Utility of proximally based sural fasciocutaneous flap for. Figure 6 a a 22yearold male presented with a left foot degloving injury with exposure of the. The most accessible flap is the reverse sural artery flap, which can be harvested as a fasciocutaneous flap or an adipofascial flap. Pdf versatility of the medial sural artery perforator flap. May 24, 2015 oral and extremity defect reconstruction can often require a flap that is thin, and traditionally, the radial forearm free flap has been used, however, this has significant donor site morbidity. Comparison of reverse sural artery flap healing for. It can be extended anteriorly to 23rd of the distance from the. Sural artery article about sural artery by the free dictionary. It has the largest arc of rotation of all the regional flaps and does not require sacrifice of any major artery, and moderatetolargesized defects can be covered adequately. Adipofascial flap with wide pedicle in the late group.
The distally based island superficial sural artery flap. Small superficial defects of the lower onethird of the leg can be treated by a sural artery flap if the defect size is smaller than 6. Preoperatively, the medial calf was examined with the handheld doppler. Complete flap survival was observed in all four children which implies that reverse sural artery flap is equally applicable and is safe in paediatric patients. The aim of this study was to report our experience with this flap for reconstruction throughout the body, highlighting its potentially increasing role as a. We evaluated the versatility of this flap and provide further evidence on its use for covering small. Three to six perforating arteries were identified in the medial part of the pedicle and four to five perforating arteries in the lateral part of the pedicle. The reverse flow island sural flap is presented as an alternative to flaps currently used for reconstruction of small and medium substance losses in the distal third of the leg, ankle, and heel. Pdf the reverse superficial sural artery flap revisited. Anatomically, the proximally based sural fasciocutaneous island flap consisted of an islet of skin and subcutaneous fat, the superficial and deep fascia, sural nerve, lesser saphenous vein, and the superficial sural artery. There are numerous anastomosis between the peroneal artery and the vascular axis of the flap. Reconstruction of chronic lower extremity wounds remains challenging. Pdf versatility of the medial sural artery perforator.
The distally based sural artery flap for ankle and foot. The venous network of the superficial sural vein, the short saphenous vein, and the associated veins of the peroneal artery provide the venous return for. The rotation point is 5 cm above the lateral malleolus the limit for dissection of the pedicle. A outline of the flap and the calcaneal defect before debridement. The distally based superficial sural artery flap, first described as a distally based neuroskin flap by masquelet et al.
Infected lateral malleolar bursitis occurring as a diabetic complication requires debridement and flap surgery because it cannot be treated by conservative methods. The medial sural artery flap is a type a fasciocutaneous flap based on the sural artery, a direct cutaneous branch of the popliteal artery. A pragmatic evaluation of the role of the medial sural artery. Peroneal artery perforator flap for the treatment of. Download as an information leaflet pdf medial sural artery perforator free flap msap a medial sural artery perforator free flap is also known as an msap flap. Donorsite morbidity was minimal because the muscle was not included in the flap. Peroneal artery perforator flap plastic surgery key. The preferred perforator was the one figure 1 the medial sural artery divides into two. The reverse sural fasciocutaneous flap for the treatment. The reverse sural artery rsa flap is popular among trauma surgeons to cover the distal third of the leg to the foot.
Since its description, the distally based superficial sural artery flap sural flap has gained popularity for these indications. The main perforators of the medial sural artery are located on a line drawn from the midpoint of the popliteal crease to the midpoint of the medial malleolus. Medial sural artery perforator free flap msap british. A total of 71 patients were operated on with this technique, some of them with.
This is a thin, pliable flap with a lengthy reliable pedicle. Medial sural artery perforator flap plastic surgery key. Jun, 2016 the distally based sural artery flap, which is perfused by reverse flow through the anastomosis between the superficial sural artery and the lowermost perforator of the peroneal artery, forms part of this group. Reverse flow superficial sural artery fasciocutaneous flap. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. The purpose of this study is to describe our experience in harvesting the reversed large sural flap from the proximal of the leg for large defects on the foot. In an attempt to find a more ideal alternative, we present our initial experience using the medial sural artery perforator msap flap in intraoral reconstruction.
The term applies to any of four or five arteries arising from the popliteal artery, with distribution to the muscles and integument of the calf, and with anastomoses to the posterior tibial. The longitudinal axis of the flap was a line from the midpopliteal point to the midpoint between the achilles tendon and lateral malleolus fig. The reverse superficial sural artery flap rssaf is a distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot. Neurological deficit caused by division of nerve is minimal and tends to improve with time.
The lateral sural artery was identified in two dissections and the medial and lateral arteries in one. Satoh subsequently described the sural artery fasciocutaneous flap in 1989, publishing on 17 clinical cases of mostly pedicled. Sep 22, 2015 adipofascial flap with wide pedicle in the late group. In this study, we discuss our experiences with peroneal artery perforator flaps in 55 patients who had. Flap vascularization is accomplished by distal reverse flow of the superficial sural artery dependent on perforators of the peroneal arterial system. More recently, the medial sural artery perforator msap flap has been described for such defects, although may necessitate skin grafting of the donor. Once this pivot point is determined, the length of the pedicle can then be determined with suture or a paper ruler. A reverse superficial sural artery flap rssaf raised as an adipofascial flap was used for coverage of the wound. Figure 6 a a 22yearold male presented with a left foot degloving injury with. This is a random type of flap, based on the reverse flow of the superficial sural artery, which mainly depends on the anatomy of the perforators of the.
Flap territory the medial sural artery perforator msap fasciocutaneous flap was first described by cavadas 2001 as a refinement of the medial gastrocnemius flap. Surgical anatomy of the medial sural artery perforator flap wong et al. Reverse sural artery flap has been proven to be an effective option to cover such defects. The flap consists of superficial and deep fascia, the sural nerve, lesser saphenous vein, and superficial sural artery. This is a case report of a 24 years old male who had gustillo and anderson. Caveats for successful performance of the reverse sural artery flap. The inferiorly based fasciocutaneous flap with sural artery incorporation, which is perfused by peroneal perforators is an excellent modification and is more reliable. Aug 11, 2009 an defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. Offloading large posterior heel defects after sural artery. Twenty patients comprising of males and 7 females with soft tissue defects of the lower third of the leg and foot requiring soft tissue cover were treated between january 2006 and december 2010.
Pedicled medial gastrocnemius flaps are the traditional reconstructive approach, but late contractures related to skin grafted muscle may affect knee function. We present an advantageous modification of the standard positioning. Using an audible doppler probe to locate a distal perforator over the medial calf, a template of the defect was then centered about this point to create a 6. This flap is based on perforators of the peroneal artery system. The reverse sural fasciocutaneous flap offers the surgeon a straightforward procedure that minimizes donorsite morbidity and preserves the major. The aim of this paper is to refine the surgical technique in order to establish the reliability of this flap. The distally based superficial sural artery flap for coverage. Reconstruction of composite defects of the posterior thigh and knee is challenging.
The routine sacrifice of the sural nerve with its consequential temporary loss of sensation on the lateral aspect of the foot can be of concern to early rehabilitation of some patients. The advantage of distally based fasciocutaneous sural flap is that it can reach the ankle and the calcaneal areas due to long pedicle and is easy and relatively quicker to. The superficial sural artery flap in distal lower third extremity reconstruction. The term applies to any of four or five arteries arising from the popliteal artery, with distribution to the muscles and integument of the calf, and with anastomoses to the posterior tibial, medial and lateral inferior genicular arteries. The versatility and reliability of sural artery flap have made it an emerging popular option for the reconstruction of such defects. This pedicle is 5cm proximal to the tip of the fibula posteriorly and will be the pivot point of the pedicle. Surgical anatomy of the medial sural artery perforator flap. Distally based sural fasciocutaneous flap was used for coverage in all cases and its survival, successful coverage of the defect and donor site morbidity studied.
Reverse flow sural flap al azhar assiut medical journal. Pdf vascular anatomy of the medial sural artery perforator. The flap is well described for reconstruction for soft tissue defect as either a free graft or local flap in the upper of the tibia. The reverse sural artery pedicle flap is based off of a consistent perforating artery from the peroneal vessels. The proximally based lateral superficial sural artery flap is. Sural artery definition of sural artery by medical dictionary. Posterior tibial artery perforator flap series of cases. Preoperative left and postoperative right picture of the left foot of a 15yearold girl, which was repaired with reverse sural artery flap.
In recent years, the authors have favored the reverse sural artery fasciocutaneous flap in 11 patients for its ease of dissection, limited morbidity, and preservation of major vessels to the limb. The medial sural artery perforator msap flap shows advantages for reconstruction in the foot and ankle, where bulk is a liability. A comparison of fasciocutaneous and adipofascial methods. The medial sural artery muscle perforator flap would be called the msap flap using the canadian terminology 9, or the ms medial gastrocnemius muscle perforator flap if one prefers to include both the source vessel and the muscle intermediary as part of the nomenclature 10. Microsurgery medial sural artery perforator msap flap. The reverse sural artery flap is a generally accepted means of soft tissue reconstruction for defects of the distal third of the legs. The major issues which we should make a note of in determining the survival of reverse sural artery flap arereverse arterial and venous flow to be established through axial vessels and.
The sural artery flap is contraindicated in patients with destruction of the vascular pedicle or the lowermost perforator of the peroneal artery see table 292. The reverse flow superficial sural artery flap constituted a practical solution to address complex defects of the distal leg, ankle, heel and proximal foot. Main demerit of distal based sural artery flap is a scar on calf which can be reduced by making use of fascia flap wherever possible. This kind of injury commonly occurs when lower limbs get stuck in between the spokes of the wheel. These wounds are mainly associated with diabetes mellitus, infections, and osteomyelitis. Vascular supply of the distally based superficial sural.
A 47yearold man with a calcaneal defect from chronic osteomyelitis. Pdf the distally based island superficial sural artery. The 2staged interpolated flap design considerably enhanced the flap reliability and reduced the frequency of venous congestion and resultant flap necrosis of variable proportions. The success of the reverse sural flap is predicated on the ability to correctly incorporate its vascular supply which is based off the sural nerve and, to a greater extent, the sural artery which provides the true vascular network as it continues into the retromalleolar region and communicates with several anastomoses with the peroneal artery. The reverse sural artery flap is a reliable alternative for treating small to moderate size defects of the lower tibia, ankle, and heel regions. The medial sural artery perforator msap flap captures the cutaneous territory of the medial calf, and can potentially be advantageous as a thin free flap, even in the most obese individual, for. The territory approximates to the medial half of the upper third of the posterior calf, an area of about 8x12 cm. Conclusion distally based sural artery flap is reliable, safe, easy and. The medial sural artery perforator flap is a good alternative for head and neck reconstruction, with the advantages of thin and pliable skin, a long and reliable vascular pedicle, straightforward. An defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. The authors aim was to determine which components were necessary to maintain this flaps ar.
Acute vascular complications flap necrosis and congestion. The distally based superficial sural flap for reconstruction of the lower leg and foot. The distally based superficial sural artery flap for. The flap was distally based, islanded and covered the area with vascularised. Split median superficial sural artery perforator mssap. The sural artery flap is a distally based fasciocutaneous flap that has many advantages to offer for coverage in the foot and ankle area. To overcome this, we have modified our operative technique, which has produced a more reliable flap. Distally based sural artery peroneus flap dbspf for foot and ankle reconstruction article pdf available in plastic and reconstructive surgery 54. Effectiveness of reverse sural artery flap in the management of wheel spoke injuries of the heel figures etc. The posterior tibial artery perforator flap is considered a relevant option to treat small to medium size defects from the proximal third to the distal third of the leg. The sural flap acts as an axial flap and has 3 sources of nutrition. The sural reverse flap is useful in the ankle and foot soft tissues. Although the present series is short, it seems that the medial sural artery perforator flap can be a useful flap for free and pedicled transfer in lowerlimb reconstruction. The reverse flow island sural flap is presented as an alternative to flaps currently used.
The distally based sural artery flap for ankle and foot coverage. The aim of this study was to evaluate the acute vascular complications flap necrosis or congestion of 29 patients who underwent distal base sural flap for coverage of wound around the ankle. Introduction the medial sural artery perforator msap flap was first described in 2001. The proximally based lateral superficial sural artery flap.
Walton and bunkis later reported the first posterior calf fascial free flap in 1984, based on a branch of the popliteal artery. The medial sural artery perforator flap is a relatively thin cutaneous flap which is designed over the medial head of the gastrocnemius muscle. Sural artery definition of sural artery by medical. This study compared the healing of rsa flaps performed for defects proximal to the ankle versus defects distal to the ankle. It provides similar tissue to the recipient area regarding thickness, texture and pigmentation, with little morbility in the donor site resulting in good clinical and aesthetic. A sensate lateral sural artery muscle perforator flap. Split median superficial sural artery perforator mssap flap.
The reverse superficial sural artery flap revisited for complex. Pdf distally based sural artery peroneus flap dbspf. The proximally based lateral superficial sural artery flap is not only providing thin, reliable and sen. Objective soft tissue injuries at the level of lower extremities, plantar, and dorsal foot pose a surgical challenge for reconstructive surgeons. Proximal extension of the distally based large sural flap 196 acta medica iranica, vol.
The reverse sural artery flap for the reconstruction of. Partial flap loss was found in 2 patients 8%, marginal flap necrosis in 2 patients 8% and complete loss in 1 patient 4%. The reverse superficial sural artery flap rssaf is a popular option for many of these difficult wounds. Pdf the distally based sural artery flap for ankle and foot. One of the advantages of this thin fasciocutaneous flap is that it permits skin coverage with ideal contouring. The reverse flow sural flap has been featured as a relevant option for recons truction of. Medial sural artery perforator flap msap harvesting for head and neck microsurgical reconstruction. Venous return is ensured by the minor saphenous vein3, which may be used as a distal pedicle to provide. Vascular anatomy of the medial sural artery perforator flap. Over the last decade, the medial sural artery perforator msap flap has emerged as a possible alternative with lower donor site morbidity. The reverse sural artery flap is a useful flap for defect reconstruction in the distal leg, ankle and heel. Reverse sural flap for ankle and heel soft tissues reconstruction ncbi.
Having constant anatomy, long pedicle, and pliable soft tissue, the flap was shown to be a good alternative option for soft tissue reconstruction. The reverse sural artery flap is utilized to reconstruct defects in the distal third of the lower leg, ankle, and heel. Our modification leads to a favorable engorgement of the flap pedicle and perforators, without the need of a tourniquet and also improves the surgical field accessibility for the surgeon. Postsurgical techniques used to limit pressure over the flap, pedicle, and donor site have included maintaining a prone position until fully healed20, 22, 25, 26.
Distal lower limb reconstruction remains challenging for surgeons. A new classification system of intramuscular branching patterns. Cureus effectiveness of reverse sural artery flap in the. However, flaps that inset in the foot seem to have a high necrosis rate. The reverse superficial sural artery flap revisited for. Original article the proximally based lateral superficial. Nugent m, endersby s, kennedy m, burns a 2015 early experience with the medial sural artery perforator flap as an alternative to the radial forearm flap for reconstruction in the head and neck. Reverse sural artery flap request pdf researchgate. Pdf the reverse superficial sural artery flap revisited for. Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. The aim of this study is to analyze the demographic. Although several reconstructive techniques are available, the peroneal artery perforator flap has unique advantages. Its blood supply comes from at least one, preferably the dominant myocutaneous perforator, which develops from the medial sural artery. Apr 02, 2016 the main perforators of the medial sural artery are located on a line drawn from the midpoint of the popliteal crease to the midpoint of the medial malleolus.
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