Users Online: 1343
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE: SARCOMAS AND SKIN CANCER
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 255-257

Reverse sural flap – A feasible option for oncological defects of the lower extremity, ankle, and foot: Our experience from Northeast India


Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India

Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. Jitin Yadav
Department of Surgical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sajc.sajc_11_19

Rights and Permissions
  Abstract 

Background: Soft-tissue management around the lower third of the leg and foot presents a challenge to the surgeon. To achieve local control of tumor, additional surgical margins are required, thus creating large soft-tissue defects. The reverse sural artery flap (RSAF) is a popular option for many of these defects. Materials and Methods: This is a retrospective study of 26 patients who underwent resection of tumor around the lower leg, ankle, and foot, and reconstruction with RSAF was performed at our institute from 2012 to 2018. Results: Among the 26 studied patients, aged between 22 and 71 (mean age: 50.8) years, 5 were female and rest were male. The most common site of involvement by tumor was heel (42.3%), followed by sole (26.9%). The most common histopathological diagnosis was melanoma (61.5%), followed by squamous cell carcinoma (26.9%) and soft-tissue sarcoma (11.5%). Conclusion: The distally based sural flap is a reliable flap for the coverage of soft-tissue defects following oncological defects of the distal lower extremity and foot.

Keywords: Free flap, melanoma, reverse sural flap


How to cite this article:
Talukdar A, Yadav J, Purkayastha J, Pegu N, Singh PR, Kodali RK, Kalita D, Bannoth S. Reverse sural flap – A feasible option for oncological defects of the lower extremity, ankle, and foot: Our experience from Northeast India. South Asian J Cancer 2019;8:255-7

How to cite this URL:
Talukdar A, Yadav J, Purkayastha J, Pegu N, Singh PR, Kodali RK, Kalita D, Bannoth S. Reverse sural flap – A feasible option for oncological defects of the lower extremity, ankle, and foot: Our experience from Northeast India. South Asian J Cancer [serial online] 2019 [cited 2019 Nov 12];8:255-7. Available from: http://journal.sajc.org/text.asp?2019/8/4/255/269690


  Introduction Top


Soft-tissue management around the lower third of the leg and foot presents a challenge to the surgeon. To achieve local control of tumor, additional surgical margins are required, thus creating large soft-tissue defects. Defects located in the weight-bearing areas are difficult to be reached by conventional local flaps. The ideal reconstruction should provide sufficient tissue with minimal morbidity and acceptable recovery. Free flap transfer has often been accepted as the operation of choice in cases where the local tissues of the foot and ankle were severely compromised.[1] Further progress in the studies of the microsurgery, especially the concept of angiosomes,[2],[3] neurovascular flap technique, and neuroadipofascial pedicled flaps,[4] has been alternative popular solutions. The reverse sural artery flap (RSAF) is a popular option for many of these defects. The distally based sural artery flap, first described as a distally based neurocutaneous flap by Masquelet et al.,[5] is skin island flap supplied by the vascular axis of the sural nerve.


  Materials and Methods Top


This is a retrospective study of 26 patients who underwent resection of tumor around the lower leg, ankle, and foot, and reconstruction with RSAF was performed at our institute from 2012 to 2018.

Surgical technique

The sural neurovascular flap [6],[7],[8],[9] is a fasciocutaneous flap that is raised along the course of the sural nerve [Figure 1]. Its blood supply depends on a constant sural artery that accompanies the nerve along its very proximal course. Distally, it depends on perforators coming from the peroneal artery. The flap is designed in the proximal posterior region of the leg, and the pivot point for this flap should be 5 cm posterior and superior to the lateral malleolus.[9],[10] The true pivot point was intraoperatively decided based on the direct identification of perforators. We do not use routine Doppler ultrasound to identify perforators and rely on the anatomical landmarks. Initially, we used to tunnel the pedicle, but as it causes more pressure on the pedicle, we stopped using tunneling and put split-thickness skin graft (SSG) to cover the pedicle. The donor site was closed primarily or using SSG based on the size of the defect.
Figure 1: Elevation of reverse sural flap

Click here to view


There was no plastic surgeon at our institute till June 2018, so flap reconstruction was done by surgical oncologists in 24 cases.


  Results Top


Among the 26 studied patients, aged between 22 and 71 (mean age: 50.8) years, 5 were female and rest were male. The most common site of involvement by tumor was heel (42.3%), followed by sole (26.9%), lower leg, and medial aspect of the foot [Figure 2]. The most common histopathological diagnosis was melanoma (61.5%), followed by squamous cell carcinoma (26.9%) and soft-tissue sarcoma (11.5%) [Figure 3]. Out of these, 3 cases of recurrent melanoma were there [Table 1]. Surgical site infection occurred in 2 patients (7.6%) that was treated by antibiotics and dressing. Partial necrosis occurred in 4 patients (15.4%) that was managed by debridement and dressing and it was healed by secondary intention. Venous congestion occurred in 10 patients mostly with tunneling of flap and it was managed conservatively using limb elevation. One patient developed a chronic ulcer due to some trivial trauma that was not noticed because of numbness. It was managed conservatively and took 3 months to heal [Table 2].
Figure 2: Defect over medial aspect of tumor after tumor excision and after 6 months

Click here to view
Figure 3: Melanoma over the heel, after flap reconstruction, after 6 months of follow-up

Click here to view
Table 1: Clinicopathological factors

Click here to view
Table 2: Complications

Click here to view



  Discussion Top


Reconstruction of defects in the lower leg, ankle, and foot is a big challenge for a surgeon. Resection of tumor with oncological safe margins in this area creates a large defect with very few options available for reconstruction. Free flaps are an acceptable but complex reconstructive option.[11] It is costly, needs special instruments and microsurgery training, and is also time-consuming. These factors are very important while choosing reconstructive options at many centers, especially in developing countries, because resource constraint always an issue there.

The reverse sural flap is a good and viable option for reconstruction of these defects. Advantages of the RSAF over more complex options include ease of dissection, high reliability, low profile and bulk, and preservation of the major lower extremity arteries.[8],[10],[12] Compared with other local and regional flaps, the reverse superficial sural artery flap has a larger arc of rotation than the extensor digitorum brevis and peroneus brevis muscle flaps,[13],[14],[15] and long periods of immobilization and difficult positioning are avoided unlike the cross-leg flap.[16],[17],[18] On reviewing the available literature, we can find many authors who recommend the use of the reverse sural flap,[19],[20],[21],[22],[23] while others inform poor results.[24]

In our study, most of the flaps were done by surgical oncologists and not by a plastic surgeon. The rate of complications in our study was similar as given in literature. In our opinion, it is a very useful and easy to learn procedure that can be done by a surgical oncologist at peripheral centers also where a plastic surgeon is not available. Many authors believe that the RSAF is not suitable for the weight-bearing area due to the numbness of the heel. One of our patients developed chronic ulcer because of numbness. Proper counseling of the patients before surgery helps the patients to overcome this problem, which finally becomes less problematic in few months. It is also very important for patients in India where many people walk barefoot in many regions of the country. Hence, they should use slippers while walking and check the area even for trivial trauma.

On reviewing the literature, we found that most of the RSAFs were done in cases of trauma and other nonmalignant causes [25],[26] though some authors [21],[27] have described it for melanoma of the foot. We have done RSAF for soft-tissue tumor and squamous cell carcinoma as well.

Tips

  1. Raise the short saphenous vein with the flap
  2. Pedicle width should be at least 4 cm
  3. Raise the flap using meticulous dissection
  4. Avoid tunneling and cover the pedicle with SSG to decrease the pressure
  5. Preoperative counseling to overcome the issue of numbness.



  Conclusion Top


The distally based sural flap is a reliable flap for the coverage of soft-tissue defects following oncological defects of the distal lower extremity and foot. It is an easy to learn flap and can be done in resource constraint scenario.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Li X, Cui J, Maharjan S, Lu L, Gong X. Reconstruction of the foot and ankle using pedicled or free flaps: Perioperative flap survival analysis. PLoS One 2016;11:e0167827.  Back to cited text no. 1
    
2.
Taylor GI, Pan WR. Angiosomes of the leg: Anatomic study and clinical implications. Plast Reconstr Surg 1998;102:599-616.  Back to cited text no. 2
    
3.
Cormack GC, Lamberty BG. Cadaver studies of correlation between vessel size and anatomical territory of cutaneous supply. Br J Plast Surg 1986;39:300-6.  Back to cited text no. 3
    
4.
Afifi AM, Mahboub TA, Losee JE, Smith DM, Khalil HH. The reverse sural flap: Modifications to improve efficacy in foot and ankle reconstruction. Ann Plast Surg 2008;61:430-6.  Back to cited text no. 4
    
5.
Masquelet AC, Romana MC, Wolf G. 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;89:1115-21.  Back to cited text no. 5
    
6.
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;103:104-20.  Back to cited text no. 6
    
7.
Le Fourn B, Caye N, Pannier M. Distally based sural fasciomuscular flap: Anatomic study and application for filling leg or foot defects. Plast Reconstr Surg 2001;107:67-72.  Back to cited text no. 7
    
8.
Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: Clinical experiences and modifications. Plast Reconstr Surg 1998;102:2358-67.  Back to cited text no. 8
    
9.
Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93:1012-20.  Back to cited text no. 9
    
10.
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;110:1673-9.  Back to cited text no. 10
    
11.
Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS, et al. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010;125:924-34.  Back to cited text no. 11
    
12.
Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007;119:138e-148e.  Back to cited text no. 12
    
13.
McHenry TP, Early JS, Schacherer TG. Peroneus brevis rotation flap: Anatomic considerations and clinical experience. J Trauma 2001;50:922-6.  Back to cited text no. 13
    
14.
Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: A new flap for the lower leg. Plast Reconstr Surg 2001;107:1443-8.  Back to cited text no. 14
    
15.
Pai CH, Lin GT, Lin SY, Lin SD, Lai CS. Extensor digitorum brevis rotational muscle flap for lower leg and ankle coverage. J Trauma 2000;49:1012-6.  Back to cited text no. 15
    
16.
Barclay TL, Sharpe DT, Chisholm EM. Cross-leg fasciocutaneous flaps. Plast Reconstr Surg 1983;72:843-7.  Back to cited text no. 16
    
17.
Ambroggio G, Oberto E, Teich-Alasia S. Twenty years' experience using the cross-leg flap technique. Ann Plast Surg 1982;9:152-63.  Back to cited text no. 17
    
18.
Sundell B, Takolander R. Repair of skin and soft tissue loss of the lower leg with cross-leg flaps. Ann Chir Gynaecol 1976;65:332-7.  Back to cited text no. 18
    
19.
Ahmed SK, Fung BK, Ip WY, Fok M, Chow SP. The versatile reverse flow sural artery neurocutaneous flap: A case series and review of literature. J Orthop Surg Res 2008;3:15.  Back to cited text no. 19
    
20.
Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: Experience of 109 clinical cases. J Orthop Traumatol 2014;15:225-9.  Back to cited text no. 20
    
21.
Kang HG, Kim JH, Cho HS, Han I, Oh JH, Kim HS. Soft tissue reconstruction of the foot using the distally based island pedicle flap after resection of malignant melanoma. Clin Orthop Surg 2010;2:244-9.  Back to cited text no. 21
    
22.
Liu JF, Zhao LR, Lu LJ, Chen L, Liu ZG, Gong X, et al. Limb salvage surgery following resection of a melanoma: Foot and ankle reconstruction using cutaneous flaps. Oncol Lett 2014;8:1966-72.  Back to cited text no. 22
    
23.
Yiacoumettis A, Mallouris A. Reconstructive options for defects after melanoma excision in the foot and ankle region. J Foot Ankle Surg 2011;50:498-503.  Back to cited text no. 23
    
24.
Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg 2009;123:1499-504.  Back to cited text no. 24
    
25.
Ebrahimi A, Nejadsarvari N, Shams Koushki E. Experience with reverse sural flap to cover defects of the lower leg and foot. Trauma Mon 2012;16:178-81.  Back to cited text no. 25
    
26.
Ignatiadis IA, Tsiampa VA, Galanakos SP, Georgakopoulos GD, Gerostathopoulos NE, Ionac M, et al. The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds: A retrospective review of 16 patients. Diabet Foot Ankle 2011;2:doi:10.3402/dfa.v2i0.5653.  Back to cited text no. 26
    
27.
Larrañaga JJ, Picco PI, Yanzon A, Figari M. Reconstruction of hind and mid-foot defects after melanoma resection using the reverse sural flap: A case series. Surg J (N Y) 2017;3:e124-7.  Back to cited text no. 27
    


    Figures

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

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed30    
    Printed0    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    

Recommend this journal