SLR - July 2018 - Ashley N. Arzadon

Distally Based Sural Neuro-Fasciocutaneous Perforator Flap for Foot and Ankle Reconstruction: Surgical Modifications for Flap Pedicle and Donor Site Closure Without Skin Graft

Zhenglin C, Yiheng C, Tinggang C, Weiyang G, Zhijie L, Hede Y, Yonghuan S. Distally Based Sural Neuro-Fasciocutaneous Perforator Flap for Foot and Ankle Reconstruction: Surgical Modifications for Flap Pedicle and Donor Site Closure Without Skin Graft. Journal of Plastic, Reconstructive & Aesthetic Surgery. Oct 17; 71, 224–231.

Scientific Literature Review

Reviewed By: Ashley N. Arzadon, DPM
Residency Program: HealthAlliance Hospital, Kingston, NY

Podiatric Relevance: Wound care is a vital component of podiatric practice. Podiatrists frequently encounter wounds of variable sizes in the foot and ankle and struggle with closure. In cases where wounds are much larger, we are limited in different wound care modalities and products that assist in wound closure. A common method for closure in especially larger wounds is a skin graft. However, this can lead to complications, such as hyperpigmentation and hypertrophic scarring at graft-recipient interface, and a second wound at the donor site.

Methods: Twelve patients underwent the modified sural neuro-fasciocutaneous perforator flap reconstruction between 2014 and 2016. Prior to the procedure, patients underwent debridement of the wound bed. The pedicle contained a peroneal-base perforator, a superficial vein and the vascular axis of the sural nerve. A large Z-shaped incision was utilized as an exploratory type of incision instead of the traditional straight longitudinal incision. A relaying island perforator flap was used to close the donor site. No skin graft was performed in this study. Patients' follow-up period ranged between six and 18 months.

Results: There were no reported cases of total flap necrosis in this study. Two cases demonstrated marginal flap necrosis but were resolved with simple dressings. Measurements of flaps utilized in this study ranged from 16 x 8 cm to 30 x 15 cm. The perforated pedicle ranged from 4.0 to 9.0 cm in length. A relaying perforated island flap was used in 10 cases for donor site closure. Mild swelling was observed in three cases a few days postoperatively, and no severe venous congestion was noted. The average follow-up period was 10.7 months.

Conclusions: Wounds localized to the foot and ankle often create challenges for both the surgeon and patient. Surgeons most commonly utilize split thickness skin grafts (STSGs) for coverage, but these can create secondary problems at the donor site. Previous studies utilizing the modified surgical technique have obtained satisfactory results. In the traditional distally based sural neurofasiculocutaneous flap, it often requires a wide and thick adipofascial pedicle, which can affect the flexibility of the flap as it is more likely to be compressed. This can compromise the blood supply and venous return. With this modification, authors described that using a “thin and ‘naked’ pedicle” will allow for better rotation and flexibility. The modification combines the advantage of both the sural neuro-fasciocutaneous flap and the perforator-based flap, which allows the perforating artery to increase viability within the flap. Additionally, the modification includes a superficial vein in the pedicle that helps prevent venous congestion at the wound site. Overall, the distally based sural neuro-fasciocutaneous perforator flap should be considered as an alternative method for foot and ankle reconstructive surgery. The modification combines the advantages of both the perforator-based island flap and a neuro-fascicutanous flap. The Z-incision is beneficial for exploration of the perforator vessels, relieves compression on the pedicle and improves flap survival. This not only is aesthetically pleasing to the patient, but it avoids a secondary donor site. 

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