Reverse Flow Superficial Sural Artery Fasciocutaneous Flap: A Comparison of Outcome between Interpolated Flap Design versus Islanded Flap Design

Abstract

Background: Complex soft-tissue defects of the distal third of the leg, proximal third of foot and similar wounds around the ankle represent formidable foes for plastic surgeons. This study compared the outcome of 2-staged interpolated flap design versus single stage islanded flap design of reverse flow superficial sural artery flap.

Methods: Thirty-four patients were enrolled, while half randomly underwent interpolated flap design (group A) and for half, islanded flap design (group B). The outcome measures were frequency of epidermolysis, flap-tip necrosis, partial flap loss, total flap loss and number of secondary procedures required for addressing these complications.

Results: Among patients, 79.41% were male and 20.58% were females. The age range was 12-51 years (mean: 28.82±10.76 years). The wound locations were hind foot (50%), ankles (17.64%), heel (14.70%), distal third of leg (11.76%) and dorsum of proximal third of foot (5.88%). In group B, epidermolysis was noted in 35.29% of flaps, and flap tip necrosis and partial flap necrosis in 17.64%. In group A, 5.88% were tip necrosis with no other problems. In group B, 76.47% of secondary procedures were done to address various flap related complications, whereas in group A, 5.88% additional procedures were required to address the flap tip necrosis.

Conclusion: The reverse flow superficial sural artery flap constituted a practical solution to address complex defects of the distal leg, ankle, heel and proximal foot. The 2-staged interpolated flap design considerably enhanced the flap reliability and reduced the frequency of venous congestion and resultant flap necrosis of variable proportions.

Keywords: Flap; Interpolated; Islanded; Necrosis; Reverse flow; Superficial sural artery.

Fig. 1

Schematic illustration of the flap on posterior aspect of left leg. The relevant surgical anatomy is elaborated

Fig. 2

The custom made back slab of plaster of Paris was designed to protect the flap and avoid any compression or pressure on the pedicle

Fig. 3

(A): An adult male with post-traumatic hind-foot defect of the left foot. It is of three months duration. There was exposed tendo-Achilles and unhealthy tissue around the chronic defect. (B): Intraoperative photograph of the same patient as in Figure 3A following thorough debridement of the wound. (C): Intraoperative photograph of the same patient as in Figure 3A and B showing flap markings. (D): Same patient as in Figure 3A, B and C showing elevated interpolated flap. (E): Same patient as in Figure 3A through D showing elevated flap and the target defect. (F): Same patient as in Figure 3A through E with interpolated flap transposed onto the defect. (G): Intraoperative photograph of the same patient as in Figure 3A through F, a close up view of the flap. (H): 5^th postoperative day of the same patient as in Figure 3A through G. (I): One month postoperative status of the same patient as in Figure 3A through G

Fig. 4

(A): An adult female with hind-foot defect of four weeks duration. There was exposed tendo-Achilles. (B): Same patient as in Figure 4A, the markings for planned islanded flap. (C): Same patient as in Figure 4A and B islanded flap has been elevated on the adipofascial pedicle. (D): A close up view of the islanded flap and its adipofascial pedicle. (E): Flap transposed. (F): Completion photograph of the same patient as in Figure 4A through E