distally-based sural flap
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Distally-Based Sural Flap
Nattakul Yamprasert, MD Department of Orthopaedics,
Maharat Nakhon Ratchasima Hospital
Regional Hand Meeting 2015 “The Diversity of the Hand and Upper Extremity Surgery”August 20th - 21st, 2015 At Ubon Ratchathani, THAILAND
Anatomy
• Vascular supply:
• Median superficial sural artery (along with medial sural nerve)
• Lesser saphenous vein and its arteries
• Pivot Point : about 5 cm proximal to lateral malleolus
Midpoint between posterior border of lateral malleolus
and Achilles tendon
Midpoint between 2 heads of Gastrocnemius muscle
Pivot point : 5 cm proximal to lateral malleolus
IndicationResurfacing of soft tissue defect in
• Middle third of leg
• Distal third of leg
• Anterior ankle
• Heel
• Dorsal foot
Preoperative Planning
• Posterolateral skin
• Flap size (Max. diameter 15 cm)
• Flap composition (including/excluding skin)
• One-stage/ two-stage (delayed) procedure
Patient Position
Prone
Lateral Position
Flap Composition
• Fasciocutaneous flap
• Fasciomusculocutaneous flap
• Adipofascial flap
• Adipofasciomuscular flap
Flap Dissection
Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ
Pedicle Dissection
Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ
Assessment of Vascularity
• Deflate tourniquet
• Observe bleeding from elevated flap
Subcutaneous Tunneling
Subcutaneous Tunneling
Subcutaneous Tunneling
Avoid Subcutaneous Tunneling?
• Not necessary unless there are certain risk factors such as HT, DM, peripheral vascular disease, and vasculitis.
F. Uygur et. al., Annals of Plastic Surgery, July 2009
Donor Site Closure• Primary wound closure
• Close by skin graft
Donor Site Closure
Flap Modification
• Venous supercharged flap
• Delayed flap procedure
• Megahigh flap
Postoperative Care
• Splint
• Dressing
• Flap monitoring
Complications
• Flap congestion
• Partial flap lost
• Total flap lost
• Infection
My Experience…
Case 1
65 years old man:Chronic ulcer on dorsum & anterior ankle
Scar excision
Flap elevation
Flap rotation
Flap inset
5 years postop.
D14 PO Y5 PO
Case 2
39 year-old woman:Skin necrosis after ORIF with screw at the calcaneus
X
D14 Y1 PO Y4 PO
Case 3
28 year-old woman :Open fracture-dislocation of left anklewith loss of anterior soft tissue
STSG Flap
D7 PO M3 PO
Y7 PO
Case 4
8 year-old boy :Posterior heel injury with skin loss
XPivot
Flap Primary Defect
Flap slightly larger than defect
Primary closure
D3 PO
Case 5
Intact posterolateral skin
Fascia sutured to skin as one unit during flap elevation
Flap elevation including cuff of muscle
Passing elevated flapthru subcutaneous tunnel
Case 6
Intact posterolateral skin
Patient positioning
Flap Elevation
Wide pedicle
Sural nerves and vessels including in elevated flap
Tunneling and flap inset
Donor site closing with meshed skin graft
D3 PO
Case 7
Soft tissue defect withpre-existing wound infection
Residual infection after flap coverage
M2 PO
D3 PO
Donor Site
Complication:Partial Flap Necrosis
D1 PO D2 PO D3 PO D4 PO
D5 PO D6 PO M1 PO After debridement
Take Home Messages• If possible, design the longer side of flap along
the vascular axis.
• Flap death began from superficial layer.
• When in doubt about pedicle compression, never hesitate to open the tunnel.
• Preexisting infection should be treated prior to flap procedure.
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