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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1277-1281

Comparative study between harvesting extended sural flap with and without punch of gastrocnemius muscle


1 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Plastic Surgery, Ahmad Maher Teaching Hospital, Cairo, Egypt

Date of Submission31-Jul-2018
Date of Decision26-Aug-2018
Date of Acceptance28-Aug-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Yasser E M Elsehity
2nd, Elsehity Street, Elbagour, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_244_18

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  Abstract 


Objective
To evaluate the safety of harvesting reverse-flow sural flap from the proximal one-third of the leg with the inclusion of a part of the gastrocnemius muscle with its mesentery and with the inclusion of the mesentery only.
Background
The reversed sural artery flap in standard technique is usually not harvested from the proximal third of the leg. Conversely, this study is conducted to evaluate the efficiency, safety, and success of reversed sural flap harvested from the proximal third of the leg even without the inclusion of the gastrocnemius muscle.
Patients and methods
This study included 32 patients presented with soft tissue loss of the leg or foot, from January 2015 to January 2018 with a follow-up period of 6 months. The cases were divided into two groups: group A included 17 patients, where a part of the gastrocnemius muscle and its mesentery was involved in the flap, and group B included 15 patients, where the flap was devoid of the muscle completely.
Results
Postoperative splinting by plaster of Paris with a bridge over the pedicle and the full length of the flap to avoid pressure over the flap was done. In group A, two patients had full-thickness tip necrosis, where one of them required debridement and skin grafting; two patient had superficial epidermolysis of the flap, which passed unnoticed; three patients had venous congestion; and six patients had donor site scarring. In group B, one patient had marginal tip necrosis, which required skin grafting later on; two patients had venous congestion; one patient had suture rupture; and two patients had donor site scarring.
Conclusion
The reversed sural flap can be harvested safely from proximal one-third of the leg without harvesting a part of gastrocnemius with the flap.

Keywords: gastrocnemius muscle, lesser saphenous vein, mesentery, sural artery, sural nerve


How to cite this article:
Kishk TF, Elsheikh YM, Alrahawi AM, Elsehity YE. Comparative study between harvesting extended sural flap with and without punch of gastrocnemius muscle. Menoufia Med J 2019;32:1277-81

How to cite this URL:
Kishk TF, Elsheikh YM, Alrahawi AM, Elsehity YE. Comparative study between harvesting extended sural flap with and without punch of gastrocnemius muscle. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1277-81. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1277/274244




  Introduction Top


Soft tissue defects in the distal leg, ankle, and foot are still challenging problems to solve.

Masquelet et al. [1] demonstrated neuroskin island flaps, and they published a case of a reversed-flow sural flap.

Moreover, with the description of the septocutaneous vasculature of the lower limb and the extension of the concepts of reverse flow and distally based flaps to the leg [2], many have described the anatomical and the clinical applications of the flap, which was commonly referred to as reverse sural artery island flap and has become a routine technique for lower limb reconstruction.

Many authors introduced a lot of modifications to the technique, such as delay [3],[4], exteriorizing the pedicle [5], a wider than routine technique [6], mobilizing the peroneal perforator in the intermuscular septum [7], supercharging [8], cross-leg sural flap [9], leaving a skin extension over the pedicle [10],[11], and harvesting a midline cuff of the gastrocnemius muscle with the flap [12]. In the standard, the flap is not harvested from the proximal third of the leg as the sural nerve runs deep between the two heads of the gastrocnemius muscle [13]; therefore, we are trying to evaluate the safety of harvesting reverse-flow sural flap from the proximal one-third of the leg with the inclusion of a part of the gastrocnemius muscle with its mesentery and with the inclusion of the mesentery only.


  Patients and Methods Top


All the patients involved in the study gave written informed consent. The study was approved by the ethical Committee of faculty of medicine Menoufia university. From January 2015 till January 2018, this study included 32 patients who presented with soft tissue loss at distal leg, ankle, and foot, with either large defect that necessitated proximal extension of the flap, or distal foot defect, or traumatized distal perforator or a previous scar near the lateral malleolus that necessitated inclusion of a proximal perforator with extension of the flap from proximal one-third of the leg. Patients were divided into two groups randomly.

Group A included 17 patients, where part of the gastrocnemius muscle and its mesentery was involved in the flap.

Group B included 15 patients, where the flap was devoid of the muscle completely.

Selection criteria

  1. Post-traumatic soft tissue defect
  2. Age from 14 to 50 years
  3. Not known to have a peripheral vascular disease.


Methods

All patients were subjected to history taking, general and local examination of the defect (shape, site, size, and components like muscle, tendon, and bone), and photographic documentation preoperatively and postoperatively. Preoperative Doppler marking of the distal perforators was routinely done, and tourniquet was applied over mid-thigh with a pressure of 300 mmHg. Age of the patients ranged from 14 to 45 years old.

All donor sites were closed directly, except in four cases with a split-thickness skin graft; postoperative splinting with below-knee splint to keep the foot in neutral position with bridging of the specially designed splint over the flap and its pedicle to avoid pressure over the flap was done.

Operative technique

In a prone position, tourniquet was applied over the thigh with pressure of 300 mmHg, measuring the size of the defect, and drawing of the flap with the measurements with its axis to a line from the midpoint of the knee joint line to a midpoint between the lateral malleolus and tendon akheilos, our incision was started at the tip of the flap proximally, down to sup facial plane from the upper one-third of the leg over cuff area.

In group A, a punch of one-fifth of both heads of gastrocnemius with the median contents 'mesentery of the muscle with the sural nerve' was harvested with the flap.

In group B, only the mesentery and the sural nerve was harvested with the flap [Figure 1].
Figure 1: Extended sural flap with gastrocnemius muscle punch (original). (a) Defect over the heal. (b) Marking and Doppler. (c) Flap dissected. (d) Flap in place.

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Then, dissection of the flap was continued with the inclusion of short saphenous vein in the flap and its pedicle till distal perforator as determined preoperatively by Doppler.

The pedicle is only adipofacial while the flap was with skin island, settling of the flap with sutures without tension, closure of donor site either directly over a suction drain or with skin graft, dressing from the toes till above knee with splinting.

Data were collected for all patients in the form of operative details, operative time, and postoperative complications, including wound infection hematoma, seroma, function loss, flap survival, and esthetic outcome.

Statistical analysis

All data were collected, tabulated, and statistically analyzed, and were calculated by the statistical package for the social sciences, version 20, statistical software package (SPSS Inc., Chicago, Illinois, USA).


  Results Top


This study included 32 patients who presented with a soft tissue defect of distal lower limb (distal leg, heal, and foot) [Figure 2] and [Figure 3].
Figure 2: Statistical analysis SPSS, version 20, percentage of male to female and percentage of site of defects in each group.

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Figure 3: Statistical analysis by SPSS, version 20, percentage of postoperative complications in each group.

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All defects were covered by extended reversed sural flap from the upper one-third of the back of the leg, including 17 patients with gastrocnemius muscle punch in the flap and 15 patients without muscle punch [Figure 1].

In group A [Table 1], two patients had tip necrosis of the flap, where one of them was managed conservatively till secondary healing and the other one was treated with split-thickness skin graft; two patients had superficial epidermolysis; and three patients had venous congestion, which was managed with massaging of the flap and limb elevation.
Table 1: Group A harvesting the flap with gastrocnemius muscle punch

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In group B [Table 2], two patients had venous congestion, which was treated with massaging and elevation of the limb; one patient had marginal necrosis, which necessitated covering with a split-thickness skin graft, and one patient had suture rupture, which was treated with a dressing till secondary healing.
Table 2: Group B harvesting the flap without gastrocnemius muscle punch

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  Discussion Top


Soft tissue defects affecting the distal third of the leg, ankle, heel, and foot are challenging to reconstruct. The reversed sural artery flap is one of the well-described reconstructive measures [14].

Sometimes we need to harvest our flap from the proximal third of the calf to cover distant foot defects or if distal perforator is damaged, where we found tiny vessels around the sural bundle, as they passed deep to the deep fascia in the median raphe of gastrocnemius muscle, and surrounding the short saphenous vein.

These vessels are found in a fibro-adipo-areolar tissue between the two heads of the gastrocnemius muscle and look like a mesentery structure attached to deep fascia [15].

In the standard, it was the concept that the flap vascularity comes from the median sural artery, as this artery gives direct cutaneous branches only in the lower two-thirds of the leg, and so, the extension of the flap proximally was considered as a random flap and so the survival is not safe [14].

A lot of modifications were done to secure the extension of the flap to the proximal leg, like delaying [4], a wider than usual pedicle [6], and including a cuff of the gastrocnemius muscle within the flap as a result of the thought that blood supply of the upper one-third of the skin of the leg is considered musculocutaneous through muscle perforators [13].

In our study, we got a lot of special conditions pushing us to harvest the sural flap from the upper third of the leg, like far defect in the weight-bearing heel, sole, and dorsum of the foot, and in some cases, the wound itself or a previous surgical scar close to the perforator. In such patients, we designed a pivot point of our flap more proximal than usual to include proximal perforators in the flap. Moreover, the flap was harvested from proximal third.

In our study, we designed the flap from the proximal third of the leg to overcome special problems mentioned before, and we divided the cases into two groups randomly, group A with inclusion of punch of both heads of gastrocnemius muscle with the mesentery like structure in the flap, as originally prescribed in the literature, and group B where we harvested the flap with the mesentery only without the muscle to prove that there is no need to harvest the muscle with the flap to secure the skin blood supply.

The proximal end of our flap was 1.5–4 cm away from the popliteal crease.

Therefore, we believe that the low rate of failure is owing to first the reach of the flap to the defect with less tension, and second by the incorporation of more perforators from the peroneal artery in the flap pedicle, and also that vascularity is safe and reliable in the extended flap if harvested even without gastrocnemius muscle punch. As we consider the extension of a reverse sural flap is not a random pattern but axial one.

In our study, the extension of reversed sural island flaps to the proximal third of the leg even without a punch from the gastrocnemius muscle if the mesentery is dissected cautiously with the flap is safe and reliable.


  Conclusion Top


Extended reversed-flow sural artery flap can be harvested from the upper one-third of the leg safely without the inclusion of part of the gastrocnemius muscle; all we need is the inclusion of the mesentery of the vascular pedicle located between the two heads of the gastrocnemius muscle.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Masquelet AC, Romana MC, Wolf MD. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992; 89:1115–1121.  Back to cited text no. 1
    
2.
Kishk TF, Elbarah A, Elsheikh YM, Abde Elsadek WS. The assessment of clinical applications of propeller flaps of the lower leg. Menouf Med J 2016; 29:580–586.  Back to cited text no. 2
    
3.
Erdmann D, Gottlieb N, Humphrey JS, Le TC, Bruno W, Levin LS. Sural flap delay procedure: a preliminary report. Ann Plast Surg 2005; 54:562–565.  Back to cited text no. 3
    
4.
Tosun Z, Ozkan A, Karacor Z, Savaci N. Delaying the reverse sural flap provides predictable results for complicated wounds in diabetic foot. Ann Plast Surg 2005; 55:169–173.  Back to cited text no. 4
    
5.
Maffi TR, Knoetgen J III, Turner NS, Moran SL. Enhanced survival using the distally based sural artery interpolation flap. Ann Plast Surg 2005; 54:302–305.  Back to cited text no. 5
    
6.
Lo JC, Chen HC, Chen HH, Santamaria E. Modified reverse sural artery flap. Changgeng Yi Xue Za Zhi 1997; 20:293–298.  Back to cited text no. 6
    
7.
Hollier L, Sharma S, Babigumira E, Klebuc M. Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds. Plast Reconstr Surg 2002; 110:1673–1679.  Back to cited text no. 7
    
8.
Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap. Microsurgery 2005; 25:36–43.  Back to cited text no. 8
    
9.
Gozu A, Ozyigit T, Ozsoy Z. Use of distally pedicled sural fasciocutaneous cross-leg flap in severe foot and ankle trauma: a safe alternative to microsurgery in very young children. Ann Plast Surg 2005; 55: 374–377.  Back to cited text no. 9
    
10.
Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery flap: caveats for success. Ann Plast Surg 2002; 48:496–504.  Back to cited text no. 10
    
11.
Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: clinical experiences and modifications. Plast Reconstr Surg 1998; 102:2358–2367.  Back to cited text no. 11
    
12.
Al-Qattan MM. Lower-limb reconstruction utilizing the reverse sural artery flap-gastrocnemius muscle cuff technique. Ann Plast Surg 2005; 55:174–178.  Back to cited text no. 12
    
13.
Al-Qattan MM. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg: inclusion of a gastrocnemius muscle 'cuff' around the sural pedicle. Ann Plast Surg 2001; 47:269–274.  Back to cited text no. 13
    
14.
Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003; 112:129–140.  Back to cited text no. 14
    
15.
Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Fukui Y, Miyasaka T, et al. Accompanying arteries of the lesser saphenous vein and sural nerve: anatomic study and its clinical applications. Plast Reconstr Surg 1999; 103:104–120.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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