Comparison of the outcomes of adipofascial and two-staged fasciocutaneous reverse sural flap in patients with lower leg trauma

Abstract

Background: Distal one - third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature.

Material & methods: In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months.

Results: The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment.

Discussion: Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity.

Conclusion: Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.

Keywords: Adipofascial flap; Distal one - third leg defect; Lower limb reconstruction; Reverse sural flap; Two-staged fasciocutaneous reverse sural flap.

Fig. 1

Stepwise plaanning of two-staged fasciocutaneous reverse sural flap.A Flap marking in a patient. B Showing point A which is the perforator marked with hand-held doppler and point B which is the pivot point. C.Showing elevated flap with sural nerve and saphenous vein included in the flap. D. Flap before inset. E. Donor site covered with STSG and flap inset over the defect. E. Bulky dressing with window for monitoring.

Fig. 2

Fasciocutaneous reverse sural flap with long term results.A. Tendoachilles (TA) defect with previous scar of failed TA repair. B. Flap Planning. C. Flap elevation. D. Flap inset. E. Long term results showing well settled flap.F Cosmetically less appealing donor site can be seen in the long term

Fig. 3

Adipofascial reverse sural flap with long term results.A. TA defect in a 17 year old female. B Flap planning. C. Incision with subcutaneous tissue exposure. D. Flap elevation. E. Flap inset with primary closure of the donor site and coverage of the adipofascial flap with STSG. F. Long term results with better donor site cosmetic outcome.