RECONSTRUCTIVE SURGERY
Distally Based Saphenous Nerve-Greater Saphenous Venofasciocutaneous Flap for Reconstruction of Soft Tissue Defects in Distal Lower Leg Zhaohui Cheng, MD,* Weigang Wu, MD,Þ Pengfei Hu, MD,Þ and Min Wang, BS* Background: To this day, the reconstruction of soft tissue defects in the distal lower leg is still a challenge for reconstructive surgeons. At present, free f lap, musculocutaneous f lap, anterior and posterior tibial artery flap, cross-leg f lap, and distally based neurocutaneous f lap are the main surgical alternatives. However, these methods are not always satisfactory. This article describes our experience with the distally based saphenous nerve-greater saphenous venofasciocutaneous f lap method to reconstruct soft tissue defects in the distal lower leg. Methods: A total of 27 patients (17 men and 10 women) underwent reconstructive surgery in our department from October 2009 to July 2012. Their mean age was 44.8 years (range, 16Y62 years). The mean follow-up period was 18 months (range, 12Y30 months). The only etiology was acute traumatic injury. Defects were located in the distal tibia around the ankle joint and the foot. The fasciocutaneous pedicle was 3 to 4 cm wide and the anatomical structures consisted of the superficial and deep fascia, the saphenous nerve, the greater saphenous vein, and their accompanying vessels together with an islet of subcutaneous cellular tissue and skin. The pivot point was approximately 5 cm proximal to the tip of medial malleolus. The size of skin islands ranged from 7 5 to 14 10 cm2. Results: All f laps survived without any partial necrosis and no arterial crisis occurred postoperatively in any case. Severe venous congestion occurred only in 1 case; however, the flap got better gradually and survived eventually after limb raise and interrupted bloodletting. All donor sites were 1-stage closed with split-skin grafting. Conclusions: The reverse saphenous neurocutaneous island f lap is a reliable and efficient method to reconstruct soft tissue defects in the distal lower leg. Both this f lap and the classic sural flap provide valuable alternative coverage of such defects. Key Words: island flap, saphenous nerve, distal lower leg, soft tissue defects (Ann Plast Surg 2016;77: 102Y105)
M
anagement of soft tissue defects in the distal lower leg remains difficult.1 Flaps of cutaneous nerve with nutrient vessels have been widely applied for reconstruction of soft tissue defects in these regions since the initial report by Masquelet et al in 1992.2 Most of the empirical literature on this type of f lap has focused on distally based sural nerve-lesser saphenous venofasciocutaneous f laps and their modified f laps.3Y9 There have been far fewer reports on distally based saphenous nerve-greater saphenous venofasciocutaneous f lap.10,11Here, we present our experiences with the distally based Received April 11, 2014, and accepted for publication, after revision, July 23, 2014. From the *Department of Orthopedic Surgery, Huangyan Hospital, Wenzhou Medical College, Huangyan, Zhejiang; and †Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Conflicts of interest and sources of funding: none declared. Supported by the National Natural Science Foundation of China (81101371). Reprints: Zhaohui Cheng, MD, Department of Orthopedic Surgery, Huangyan Hospital, Wenzhou Medical College, Huangyan, Huangyan District, Taizhou 318020, Zhejiang Province, China. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7701-0102 DOI: 10.1097/SAP.0000000000000338
102
www.annalsplasticsurgery.com
saphenous nerve-greater saphenous venofasciocutaneous island f lap method (ie, reverse saphenous neurocutaneous f lap) to reconstruct soft tissue defects in distal tibia around the ankle joint and foot. The final clinical outcomes have been satisfactory and encouraging.
PATIENTS AND SURGICAL TECHNIQUE Reverse saphenous neurocutaneous f laps were performed from October 2009 to July 2012 in our department. All patients gave written, informed consent and this study obtained an approval of our hospital’s ethical committee. We tracked outcomes from 27 surgical cases (17 men and 10 women; mean age, 44.8 years; age range, 16Y62 years). Follow-up measures were taken on average at 18 months after the procedure (range, 12Y30 months). Defects were located in the distal tibia, around the ankle joint, and the foot. The only etiology was acute traumatic injury. Associated risk factors in the patients were diabetes (2 cases), cigarette smoking (6 cases), and high blood pressure (4 cases). The patients were positioned supine for the procedure. A tourniquet was placed on the proximal thigh and pressurized without exsanguination, and venous congestion facilitated the identification and dissection of the neurovascular structures. The recipient region was radically debrided before the flap transplantation. The reverse saphenous neurocutaneous island f lap consisted of superficial and deep fascia, the saphenous nerve, the greater saphenous vein, and their accompanying vessels, together with an islet of subcutaneous cellular tissue and skin. Flap irrigation depended on the lower perforators of the posterior tibial artery, which anastomoses with the neurovascular axial network. We initially outlined the trajectory of the saphenous nerve and closely adjacent greater saphenous vein, typically using a dotted line extending from the medial condyle of the tibia to approximately 1 cm anterior to the medial malleolar tip; this line roughly marked the course of the pedicle. We usually drew the pivot point of the pedicle along the line approximately 5 cm proximal to the medial malleolar tip. Then we measured the dimensions of the defect and drew the skin islet to be transferred in the form of a paddle with enlargement of the defect by 15% and pivot point-centered reversion. The anterior margin of the f lap was strictly kept 1 to 1.5 cm medial to the tibial crest and the posterior margin usually did not across the midline. The entire f lap was dissected and elevated from proximal to distal. We first incised and dissected proximally to incorporate the deep fascia, ligated greater saphenous vein, and the saphenous nerve together. Anatomically, the greater saphenous vein is always superficial and is easily identified. The saphenous nerve is always very close to the vein, either anterior or posterior and crosses or overlaps it.10 Therefore, we always adjusted the central axis of the flap according to the visual actual course of the saphenous vein regardless of the initial marked dotted line (ie, an imaginary neurovascular axis). Because of strict restriction of the anterior margin, the neurovascular axis in the flap was sometimes eccentric and the posterior border was beyond the posterior midline. Subcutaneous dissection on the medial aspect of the tibia should be very careful to avoid injuring the tibial periosteum. Interrupted sutures between the skin and the subcutaneous deep fascia were mandatory to prevent the sliding of both Annals of Plastic Surgery
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
&
Volume 77, Number 1, July 2016
Annals of Plastic Surgery
& Volume 77, Number 1, July 2016
layers. The f lap was elevated along the marked border line until the pivot point. The width of the pedicle was 3 to 4 cm. The subcutaneous dissection of the pedicle (especially near the pivotal point) had to be done very carefully so as not to injure the incorporated saphenous nerve, vein, and the perforators. Only when the pedicle length was not long enough, we dissected and exposed the lowermost perforator to increase the rotation arc. When the f lap was entirely evaluated, the tourniquet was def lated and the circulation of the f lap was carefully checked. Sometimes a hot pack with warm, normal saline was used to relieve the vascular spasm. After verifying good circulation, an open tunnel was incised and the f lap was transposed to the recipient site, by careful rotation over its pedicle with no tension or compression. The donor sites were all 1-stage closed. We usually interruptedly sutured with low tension to reduce the surface and then grafted with split-skins. Vacuum sealing drainage dressings were routinely used. Lots of drainage strips were put around the flap to allow bleeding, especially beneath the rotated pedicle, then the wounds were dressed with thick sterilized gauzes. Generally, a plaster support was used for 1 week and any compression of the plaster support on the flap was absolutely prohibited.
RESULTS Soft tissue defects were located in the distal tibia, around the ankle joint, and the foot. The size of defects ranged from 6 4 to 12 8 cm2. The size of skin islands ranged from 7 5 to 14 10 cm2. The pivot point was approximately 5 cm proximal to the medial malleolar tip. The upper border of the flap reached the knee. The mean operation time was 90 minutes (range, 70Y120 minutes). This reverse saphenous neurocutaneous f lap method yielded satisfactory coverage in all 27 cases. All f laps survived with no partial necrosis and no arterial crisis occurred postoperatively in any case. Severe venous congestion occurred only in 1 female case. However, the f lap got better gradually and survived eventually after limb raise and interrupted bloodletting. All donor sites were 1-stage closed with split-skin grafting and successfully healed. No further surgery was preformed for any case in this series. The presence of adverse risk factors such as diabetes, high blood pressure, and
Reconstruction of Soft Tissue Defects in Lower Leg
cigarette smoking seemed to have few adverse effects on the final clinical outcomes. A representative case is shown in Figure 1.
DISCUSSION Even to this day, reconstruction of soft tissue defects in distal lower leg still presents a challenge for reconstructive surgeons.11 Several f lap techniques have been developed for repairing these defects. Free f lap, musculocutaneous f lap, anterior and posterior tibial artery f lap, cross-leg f lap, and distally based neurocutaneous f lap are the main alternatives.12Y16 Free-tissue transfers are usually considered the best method for reconstruction of these defects. Free f laps provide reliable singlestage soft tissue coverage.11 However, free f laps are always not the first choice because of their disadvantages of increased operative time, increased medical cost and hospitalization, sacrificing a major vessel of the leg, the need of a remote donor site, and the need of special instruments and microsurgical expertise. Consequently, free f laps are advised for extensive skin defects or in cases where poor distal vascularity of the leg or local trauma precludes the reliability of a distally based fasciocutaneous f lap.17 Musculocutaneous f laps are usually reliable, but their appearances are always bulky and fatty. They cannot meet aesthetic requirements at all and normal muscular function is damaged. These disadvantages dictate that distally based musculocutaneous f laps are not the optimal choice. The anterior and posterior tibial artery island f laps are also reliable and have been successfully transferred to the ankle and foot.18,19 But this method is not very popular because it requires the sacrifice of a major artery in the lower leg; tissue reconstruction with sacrifice of any major artery is commonly unacceptable. The peroneal artery f lap is an alternative20 but the peroneal artery is hard to dissect because of the obstruction of the fibula, making this method technically limited. The cross-leg f lap brings about inevitable uncomfortability of immobile position. This technique needs 2-stage pedicle division, which prolongs the hospitalization. In summary, these methods are not always satisfactory. However, the distally based cutaneous nerve island f lap with nutrient
FIGURE 1. A 32-year-old female patient with perimalleolar soft tissue defects and who had a road traffic accident received satisfactory coverage using a reverse saphenous neurocutaneous f lap. A, Foot and ankle wound with exposed tendon requiring f lap coverage. B, After debridement, area of skin loss was determined to be optimal for f lap coverage. C, The reverse saphenous neurocutaneous f lap was marked on the skin with dimensions of 12 7 cm. The dotted line extends from the medial condyle of the tibia to approximately 1 cm anterior to the medial malleolar tip. We drew the pivot point of the pedicle along the line approximately 5 cm proximal to the medial malleolar tip. D, The reverse saphenous neurocutaneous f lap was rotated through a 180-degree arc on its pedicle. E, The f lap was inset into the defect after rotation with excellent coverage in the immediate postoperative period. F, Final result, after covering the defect with a reverse saphenous neurocutaneous and a partial graft on the donor site. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
103
Annals of Plastic Surgery
Cheng et al
vessels does present some advantages for reconstruction of such defects. This kind of f lap always has a long arc of rotation and a thin and pliable skin islet with aesthetic superiority over other available f laps. In addition, the anterior and posterior tibial (major) artery in the leg will never be damaged; even the minor peroneal artery can be preserved based on septal perforators. Thus far, the reverse sural neurocutaneous f lap and the reverse saphenous neurocutaneous f lap techniques have been the most widely applied types in clinical situations. For these 2 f laps, various modifications of fasciocutaneous, fasciosubcutaneous, adipofascial, fasciomyocutaneous, osseouscutaneous, or myo-osseouscutaneous f laps have been gradually introduced and are all widely considered to be reliable.21Y23 Comparatively speaking, the reverse saphenous neurocutaneous f lap has less clinical application than the reverse sural neurocutaneous f lap for reconstruction of soft tissue defects in the distal lower leg. This is the case for multiple reasons. The former always presents a superior alternative to the latter, especially when the wound is located at the medial aspect of the distal limb. An additional advantage is that the Achilles tendon is not exposed in the reverse saphenous neurocutaneous f lap. Anatomically, the vascular axis of this reverse saphenous neurocutaneous f lap is formed by a rich network of vessels around the saphenous nerve that anastomoses with the lower perforators of the posterior tibial artery. The lowermost anastomosis is approximately 5 cm proximal to the tip of medial malleolus. The accompanying arteries of the greater saphenous vein may be considered as an additional source of cutaneous branches for the irrigation of the f lap.24 Some surgeons have observed the reverse f lap (including the greater saphenous vein) became extremely engorged and the venous pressure elevated much higher than the capillary pressure. Thus, these surgeons have advocated routinely dividing and ligating the vein at the base of the f lap.25,26 In our procedures, we did not ligate the greater saphenous vein at the base of the pedicle. As a result, there was no apparent venous congestion except for 1 case. The involved flap improved with treatment and eventually survived without any necrosis. Actually, most surgeons do not ligate the vein in the pedicle. We also determined that ligation was unnecessary and inversely increased the risk of disrupting other vascular structures. In addition, we designed the pedicle along the line between the medial condyle of the tibia and 1 cm anterior to the medial malleolar tip, which was modified instead of a conventional axial line from the medial condyle of the tibia to the posterior edge of the medial malleolus.11,27 This modification ensured the inclusion of the saphenous vein in the pedicle and the skin islet, avoiding any possible damages to the vein and the close accompanying nerve. We believe that satisfactory irrigation could be first explained by good preservation of the neurovascular axial network. The second explanation for the success in our series was related to the choice of a relative proximal pivot point. The septocutaneous perforator of the posterior tibial artery is concentrated near the crus distal 1/3 and to the supramalleolar region. Some authors have suggested the lower perforators are approximately 4 to 6.5 cm proximal to the medial malleolus.28 We always chose approximately 5 cm proximal to the medial malleolar tip as the pivot point, although other surgeons have technically modified to lower the point as possible. In our series, we often found a large septocutaneous perforator at 6 to 7 cm proximal to the medial malleolus when dissecting the pedicle from proximal to distal. Our experience was to preserve this perforator and trace to its origin on the posterior artery for greater mobility, which can make up for the loss of rotation arc for this more proximal pivot point in most cases. We considered the tactic of incorporating more than 1 perforator into the pedicle to ensure good irrigation of the flap and to reduce any tension in the pedicle, which we found it not negligible. Only in 6 cases we proceeded distally to dissect along the pedicle because of high tension in the pedicle for rotation and coverage. We always found another more distal septocutaneous perforator at 104
www.annalsplasticsurgery.com
& Volume 77, Number 1, July 2016
approximately 4 cm proximal to the medial malleolus. We then deflated the tourniquet and carefully checked the circulation of the flap by blocking the proximal perforator using a vascular clamp. After making certain that the flap could be well irrigated by the single distal perforator, the proximal perforator vessel was ligated. Fine dissection for this lowermost perforator to its origin was absolutely unnecessary so as to avoid any possible damages to the vessels. Most surgeons suggest that a Doppler ultrasound probe should be used to precisely localize the distal perforators of the posterior tibial artery on which the f lap should rotate.11,27 However, we were successful in simply carefully palpating the medial tarsal tunnel before operation to determine the presence of the posterior tibial artery and to exclude its congenital absence. We did not perform a Doppler test for any of our patients because of no obvious lesions and no suspected abnormalities of the posterior tibial artery. We used this simple preoperative palpation instead of the fussy Doppler test and achieved successful results. The size of our reverse saphenous neurocutaneous f laps ranged from 7 5 to 14 10 cm2. Usually, reverse f laps can extend from the medial edge of the tibia to the posterior midline of the calf between the knee and the lowermost perforator.27,29,30 We strictly restricted the anterior margin of the f lap 1 to 1.5 cm medial to the tibial crest. It was always a little difficult to dissect between the subcutaneous fascia and periosteum in the medial aspect of the tibia. Preservation of the intact tibial periosteum was mandatory so as to ensure the survival of subsequent split-skin grafting. Because of strict restriction of the anterior margin, the posterior margin of the f lap sometimes was inevitably beyond the posterior midline. Nonetheless, we did not experience any adverse effects. Generally, these reverse saphenous neurocutaneous f laps can be elevated up to the insertion of the sartorius, where the nerve dips deeper to the deep fascia and reaches up to the distal part of the midfoot. In addition, associated risk factors (even diabetes) did not adversely affect the survival of the f laps, so we also advise that diabetes was not an absolute contraindication.31 An external fixation device was recommended to provide better postoperative patient compliance to prevent complications.32 We routinely use a plaster support to immobilize the leg for 1 week. We believe this immobilization was beneficial to the patients. With respect to complications, scars at the donor site and loss of sensation on the medial aspect of the leg were generally well tolerated by the patients and did not affect the final clinical outcomes.
CONCLUSIONS This distally based saphenous neurocutaneous island f lap is a reliable and efficient method to reconstruct soft tissue defects in the distal lower leg with more versatility. The procedure is easy to learn and this f lap, as well as the classic sural f lap, is a valuable alternative coverage of soft tissue defects. REFERENCES 1. Pinsolle V, Reau AF, Pelissier P, et al. Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg. 2006;59:912Y917; discussion 918. 2. 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;89:1115Y1121. 3. Schmidt K, Jakubietz M, Harenberg P, et al. The distally based adipofascial sural artery flap for the reconstruction of distal lower extremity defects. Oper Orthop Traumatol. 2013;25:162Y169. 4. Yang C, Li Y, Geng S, et al. Modified distally based sural adipofascial flap for reconstructing of leg and ankle. ANZ J Surg. 2013;83:954Y958. 5. Liu L, Liu Y, Zou L, et al. The distally based superficial sural flap for reconstruction of the foot and ankle in pediatric patients. J Reconstr Microsurg. 2013;29:199Y204.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 77, Number 1, July 2016
6. Dai J, Chai Y, Wang C, et al. Comparative study of two types of distally based sural neurocutaneous flap for reconstruction of lower leg, ankle, and heel. J Reconstr Microsurg. 2013;29:125Y130. 7. Hamdi MF, Kalti O, Khelifi A. Experience with the distally based sural flap: a review of 25 cases. J Foot Ankle Surg. 2012;51:627Y631. 8. Peng F, Wu H, Yu G. Distally-based sural neurocutaneous flap for repair of a defect in the ankle tissue. J Plast Surg Hand Surg. 2011;45:77Y82. 9. Rudig LL, Gercek E, Hessmann MH, et al. The distally based sural neurocutanenous island flap for coverage of soft-tissue defects on the distal lower leg, ankle and heel. Oper Orthop Traumatol. 2008;20:252Y261. 10. Zhang F, Zhang CC, Lin S, et al. Distally based saphenous nerve-great saphenous veno-fasciocutaneous compound flap with nutrient vessels: microdissection and clinical application. Ann Plast Surg. 2009;63:81Y88. 11. Kansal S, Goil P, Agarwal V, et al. Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot. Eur J Orthop Surg Traumatol. 2014;24:62Y72. 12. Wang X, Mei J, Pan J, et al. Reconstruction of distal limb defects with the free medial sural artery perforator flap. Plast Reconstr Surg. 2013;131:95Y105. 13. Chung YJ, Kim G, Sohn BK. Reconstruction of a lower extremity soft-tissue defect using the gastrocnemius musculoadipofascial flap. Ann Plast Surg. 2002;49:91Y95. 14. Kim TG, Kim IK, Kim YH, et al. Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link. Microsurgery. 2012;32:575Y579. 15. Bhattacharya V, Reddy GR. Retrograde perforator-based cross-leg fasciocutaneous flaps for distal leg and foot defects. Plast Reconstr Surg. 2006;117: 1662Y1664. 16. Hu XH, Du WL, Chen Z, et al. The application of distally pedicled peroneus brevis muscle flaps and retrograde neurocutaneous accompanying artery flaps for treatment of bony and soft-tissue 3-dimensional defects of the lower leg and foot. Int J Low Extrem Wounds. 2013;12:53Y62. 17. Rı´os-Luna A, Villanueva-Martı´nez M, Fahandezh-Saddi H, et al. Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury. 2007;38:824Y831. 18. Sharma RK, Kola G. Cross leg posterior tibial artery fasciocutaneous island flap for reconstruction of lower leg defects. Br J Plast Surg. 1992;45:62Y65.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Reconstruction of Soft Tissue Defects in Lower Leg
19. Satoh K, Aoyama R, Onizuka T. Comparative study of reverse flow island flaps in the lower extremities-peroneal, anterior tibial, and posterior tibial island flaps in 25 patients. Ann Plast Surg. 1993;30:48Y56. 20. Tharayil J, Patil RK. Reverse peroneal artery flap for large defects of ankle and foot: a reliable reconstructive technique. Indian J Plast Surg. 2012;45:45Y52. 21. Chang SM, Zhang K, Li HF, et al. Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel. Microsurgery. 2009;29:205Y213. 22. Bocchi A, Merelli S, Morellini A, et al. Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction. Ann Plast Surg. 2000;45:284Y291. 23. Yu AX, Deng K, Tao S, et al. Anatomic study and clinical application of distally-based neuro-myocutaneous compound flaps in the leg. Microsurgery. 2007;27:528Y532. 24. Nayak BB, Thatte RL, Thatte MR, et al. A microneurovascular study of the great saphenous vein in man and the possible implications for survival of venous flaps. Br J Plast Surg. 2000;53:230Y233. 25. Chang SM, Hou CL. Role of large superficial veins in distally based flaps of the extremities. Plast Reconstr Surg. 2000;106:230Y231. 26. Cavadas PC. Reversed saphenous neurocutaneous island flap: clinical experience and evolution to the posterior tibial perforator-saphenous subcutaneous flap. Plast Reconstr Surg. 2003;111:837Y839. 27. Shao X, Yu Y, Zhang X, et al. Repair of soft-tissue defect close to the distal perforating artery using the modified distally based medial fasciocutaneous flap in the distal lower leg. J Reconstr Microsurg. 2011;27:145Y150. 28. Boriani F, Bruschi S, Fraccalvieri M, et al. Leg perforators and leg length: an anatomic study focusing on topography and angiogenesis. Clin Anat. 2010;23: 593Y605. 29. Heymans O, Verhelle N, Peters S, et al. Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest. Burns. 2002;28:674Y678. 30. Lineaweaver WC, Lei MP, Mustain W, et al. Vascular endothelium growth factor, surgical delay, and skin flap survival. Ann Surg. 2004;239:866Y873. 31. Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg. 2011;128:173Y180. 32. Noack N, Hartmann B, Ku¨ntscher MV. Measures to prevent complications of distally based neurovascular sural flaps. Ann Plast Surg. 2006;57:37Y40.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
105
Distally Based Saphenous Nerve-Greater Saphenous Venofasciocutaneous Flap for Reconstruction of Soft Tissue Defects in Distal Lower Leg Zhaohui Cheng, MD,* Weigang Wu, MD,Þ Pengfei Hu, MD,Þ and Min Wang, BS* Background: To this day, the reconstruction of soft tissue defects in the distal lower leg is still a challenge for reconstructive surgeons. At present, free f lap, musculocutaneous f lap, anterior and posterior tibial artery flap, cross-leg f lap, and distally based neurocutaneous f lap are the main surgical alternatives. However, these methods are not always satisfactory. This article describes our experience with the distally based saphenous nerve-greater saphenous venofasciocutaneous f lap method to reconstruct soft tissue defects in the distal lower leg. Methods: A total of 27 patients (17 men and 10 women) underwent reconstructive surgery in our department from October 2009 to July 2012. Their mean age was 44.8 years (range, 16Y62 years). The mean follow-up period was 18 months (range, 12Y30 months). The only etiology was acute traumatic injury. Defects were located in the distal tibia around the ankle joint and the foot. The fasciocutaneous pedicle was 3 to 4 cm wide and the anatomical structures consisted of the superficial and deep fascia, the saphenous nerve, the greater saphenous vein, and their accompanying vessels together with an islet of subcutaneous cellular tissue and skin. The pivot point was approximately 5 cm proximal to the tip of medial malleolus. The size of skin islands ranged from 7 5 to 14 10 cm2. Results: All f laps survived without any partial necrosis and no arterial crisis occurred postoperatively in any case. Severe venous congestion occurred only in 1 case; however, the flap got better gradually and survived eventually after limb raise and interrupted bloodletting. All donor sites were 1-stage closed with split-skin grafting. Conclusions: The reverse saphenous neurocutaneous island f lap is a reliable and efficient method to reconstruct soft tissue defects in the distal lower leg. Both this f lap and the classic sural flap provide valuable alternative coverage of such defects. Key Words: island flap, saphenous nerve, distal lower leg, soft tissue defects (Ann Plast Surg 2016;77: 102Y105)
M
anagement of soft tissue defects in the distal lower leg remains difficult.1 Flaps of cutaneous nerve with nutrient vessels have been widely applied for reconstruction of soft tissue defects in these regions since the initial report by Masquelet et al in 1992.2 Most of the empirical literature on this type of f lap has focused on distally based sural nerve-lesser saphenous venofasciocutaneous f laps and their modified f laps.3Y9 There have been far fewer reports on distally based saphenous nerve-greater saphenous venofasciocutaneous f lap.10,11Here, we present our experiences with the distally based Received April 11, 2014, and accepted for publication, after revision, July 23, 2014. From the *Department of Orthopedic Surgery, Huangyan Hospital, Wenzhou Medical College, Huangyan, Zhejiang; and †Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Conflicts of interest and sources of funding: none declared. Supported by the National Natural Science Foundation of China (81101371). Reprints: Zhaohui Cheng, MD, Department of Orthopedic Surgery, Huangyan Hospital, Wenzhou Medical College, Huangyan, Huangyan District, Taizhou 318020, Zhejiang Province, China. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7701-0102 DOI: 10.1097/SAP.0000000000000338
102
www.annalsplasticsurgery.com
saphenous nerve-greater saphenous venofasciocutaneous island f lap method (ie, reverse saphenous neurocutaneous f lap) to reconstruct soft tissue defects in distal tibia around the ankle joint and foot. The final clinical outcomes have been satisfactory and encouraging.
PATIENTS AND SURGICAL TECHNIQUE Reverse saphenous neurocutaneous f laps were performed from October 2009 to July 2012 in our department. All patients gave written, informed consent and this study obtained an approval of our hospital’s ethical committee. We tracked outcomes from 27 surgical cases (17 men and 10 women; mean age, 44.8 years; age range, 16Y62 years). Follow-up measures were taken on average at 18 months after the procedure (range, 12Y30 months). Defects were located in the distal tibia, around the ankle joint, and the foot. The only etiology was acute traumatic injury. Associated risk factors in the patients were diabetes (2 cases), cigarette smoking (6 cases), and high blood pressure (4 cases). The patients were positioned supine for the procedure. A tourniquet was placed on the proximal thigh and pressurized without exsanguination, and venous congestion facilitated the identification and dissection of the neurovascular structures. The recipient region was radically debrided before the flap transplantation. The reverse saphenous neurocutaneous island f lap consisted of superficial and deep fascia, the saphenous nerve, the greater saphenous vein, and their accompanying vessels, together with an islet of subcutaneous cellular tissue and skin. Flap irrigation depended on the lower perforators of the posterior tibial artery, which anastomoses with the neurovascular axial network. We initially outlined the trajectory of the saphenous nerve and closely adjacent greater saphenous vein, typically using a dotted line extending from the medial condyle of the tibia to approximately 1 cm anterior to the medial malleolar tip; this line roughly marked the course of the pedicle. We usually drew the pivot point of the pedicle along the line approximately 5 cm proximal to the medial malleolar tip. Then we measured the dimensions of the defect and drew the skin islet to be transferred in the form of a paddle with enlargement of the defect by 15% and pivot point-centered reversion. The anterior margin of the f lap was strictly kept 1 to 1.5 cm medial to the tibial crest and the posterior margin usually did not across the midline. The entire f lap was dissected and elevated from proximal to distal. We first incised and dissected proximally to incorporate the deep fascia, ligated greater saphenous vein, and the saphenous nerve together. Anatomically, the greater saphenous vein is always superficial and is easily identified. The saphenous nerve is always very close to the vein, either anterior or posterior and crosses or overlaps it.10 Therefore, we always adjusted the central axis of the flap according to the visual actual course of the saphenous vein regardless of the initial marked dotted line (ie, an imaginary neurovascular axis). Because of strict restriction of the anterior margin, the neurovascular axis in the flap was sometimes eccentric and the posterior border was beyond the posterior midline. Subcutaneous dissection on the medial aspect of the tibia should be very careful to avoid injuring the tibial periosteum. Interrupted sutures between the skin and the subcutaneous deep fascia were mandatory to prevent the sliding of both Annals of Plastic Surgery
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
&
Volume 77, Number 1, July 2016
Annals of Plastic Surgery
& Volume 77, Number 1, July 2016
layers. The f lap was elevated along the marked border line until the pivot point. The width of the pedicle was 3 to 4 cm. The subcutaneous dissection of the pedicle (especially near the pivotal point) had to be done very carefully so as not to injure the incorporated saphenous nerve, vein, and the perforators. Only when the pedicle length was not long enough, we dissected and exposed the lowermost perforator to increase the rotation arc. When the f lap was entirely evaluated, the tourniquet was def lated and the circulation of the f lap was carefully checked. Sometimes a hot pack with warm, normal saline was used to relieve the vascular spasm. After verifying good circulation, an open tunnel was incised and the f lap was transposed to the recipient site, by careful rotation over its pedicle with no tension or compression. The donor sites were all 1-stage closed. We usually interruptedly sutured with low tension to reduce the surface and then grafted with split-skins. Vacuum sealing drainage dressings were routinely used. Lots of drainage strips were put around the flap to allow bleeding, especially beneath the rotated pedicle, then the wounds were dressed with thick sterilized gauzes. Generally, a plaster support was used for 1 week and any compression of the plaster support on the flap was absolutely prohibited.
RESULTS Soft tissue defects were located in the distal tibia, around the ankle joint, and the foot. The size of defects ranged from 6 4 to 12 8 cm2. The size of skin islands ranged from 7 5 to 14 10 cm2. The pivot point was approximately 5 cm proximal to the medial malleolar tip. The upper border of the flap reached the knee. The mean operation time was 90 minutes (range, 70Y120 minutes). This reverse saphenous neurocutaneous f lap method yielded satisfactory coverage in all 27 cases. All f laps survived with no partial necrosis and no arterial crisis occurred postoperatively in any case. Severe venous congestion occurred only in 1 female case. However, the f lap got better gradually and survived eventually after limb raise and interrupted bloodletting. All donor sites were 1-stage closed with split-skin grafting and successfully healed. No further surgery was preformed for any case in this series. The presence of adverse risk factors such as diabetes, high blood pressure, and
Reconstruction of Soft Tissue Defects in Lower Leg
cigarette smoking seemed to have few adverse effects on the final clinical outcomes. A representative case is shown in Figure 1.
DISCUSSION Even to this day, reconstruction of soft tissue defects in distal lower leg still presents a challenge for reconstructive surgeons.11 Several f lap techniques have been developed for repairing these defects. Free f lap, musculocutaneous f lap, anterior and posterior tibial artery f lap, cross-leg f lap, and distally based neurocutaneous f lap are the main alternatives.12Y16 Free-tissue transfers are usually considered the best method for reconstruction of these defects. Free f laps provide reliable singlestage soft tissue coverage.11 However, free f laps are always not the first choice because of their disadvantages of increased operative time, increased medical cost and hospitalization, sacrificing a major vessel of the leg, the need of a remote donor site, and the need of special instruments and microsurgical expertise. Consequently, free f laps are advised for extensive skin defects or in cases where poor distal vascularity of the leg or local trauma precludes the reliability of a distally based fasciocutaneous f lap.17 Musculocutaneous f laps are usually reliable, but their appearances are always bulky and fatty. They cannot meet aesthetic requirements at all and normal muscular function is damaged. These disadvantages dictate that distally based musculocutaneous f laps are not the optimal choice. The anterior and posterior tibial artery island f laps are also reliable and have been successfully transferred to the ankle and foot.18,19 But this method is not very popular because it requires the sacrifice of a major artery in the lower leg; tissue reconstruction with sacrifice of any major artery is commonly unacceptable. The peroneal artery f lap is an alternative20 but the peroneal artery is hard to dissect because of the obstruction of the fibula, making this method technically limited. The cross-leg f lap brings about inevitable uncomfortability of immobile position. This technique needs 2-stage pedicle division, which prolongs the hospitalization. In summary, these methods are not always satisfactory. However, the distally based cutaneous nerve island f lap with nutrient
FIGURE 1. A 32-year-old female patient with perimalleolar soft tissue defects and who had a road traffic accident received satisfactory coverage using a reverse saphenous neurocutaneous f lap. A, Foot and ankle wound with exposed tendon requiring f lap coverage. B, After debridement, area of skin loss was determined to be optimal for f lap coverage. C, The reverse saphenous neurocutaneous f lap was marked on the skin with dimensions of 12 7 cm. The dotted line extends from the medial condyle of the tibia to approximately 1 cm anterior to the medial malleolar tip. We drew the pivot point of the pedicle along the line approximately 5 cm proximal to the medial malleolar tip. D, The reverse saphenous neurocutaneous f lap was rotated through a 180-degree arc on its pedicle. E, The f lap was inset into the defect after rotation with excellent coverage in the immediate postoperative period. F, Final result, after covering the defect with a reverse saphenous neurocutaneous and a partial graft on the donor site. * 2014 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
103
Annals of Plastic Surgery
Cheng et al
vessels does present some advantages for reconstruction of such defects. This kind of f lap always has a long arc of rotation and a thin and pliable skin islet with aesthetic superiority over other available f laps. In addition, the anterior and posterior tibial (major) artery in the leg will never be damaged; even the minor peroneal artery can be preserved based on septal perforators. Thus far, the reverse sural neurocutaneous f lap and the reverse saphenous neurocutaneous f lap techniques have been the most widely applied types in clinical situations. For these 2 f laps, various modifications of fasciocutaneous, fasciosubcutaneous, adipofascial, fasciomyocutaneous, osseouscutaneous, or myo-osseouscutaneous f laps have been gradually introduced and are all widely considered to be reliable.21Y23 Comparatively speaking, the reverse saphenous neurocutaneous f lap has less clinical application than the reverse sural neurocutaneous f lap for reconstruction of soft tissue defects in the distal lower leg. This is the case for multiple reasons. The former always presents a superior alternative to the latter, especially when the wound is located at the medial aspect of the distal limb. An additional advantage is that the Achilles tendon is not exposed in the reverse saphenous neurocutaneous f lap. Anatomically, the vascular axis of this reverse saphenous neurocutaneous f lap is formed by a rich network of vessels around the saphenous nerve that anastomoses with the lower perforators of the posterior tibial artery. The lowermost anastomosis is approximately 5 cm proximal to the tip of medial malleolus. The accompanying arteries of the greater saphenous vein may be considered as an additional source of cutaneous branches for the irrigation of the f lap.24 Some surgeons have observed the reverse f lap (including the greater saphenous vein) became extremely engorged and the venous pressure elevated much higher than the capillary pressure. Thus, these surgeons have advocated routinely dividing and ligating the vein at the base of the f lap.25,26 In our procedures, we did not ligate the greater saphenous vein at the base of the pedicle. As a result, there was no apparent venous congestion except for 1 case. The involved flap improved with treatment and eventually survived without any necrosis. Actually, most surgeons do not ligate the vein in the pedicle. We also determined that ligation was unnecessary and inversely increased the risk of disrupting other vascular structures. In addition, we designed the pedicle along the line between the medial condyle of the tibia and 1 cm anterior to the medial malleolar tip, which was modified instead of a conventional axial line from the medial condyle of the tibia to the posterior edge of the medial malleolus.11,27 This modification ensured the inclusion of the saphenous vein in the pedicle and the skin islet, avoiding any possible damages to the vein and the close accompanying nerve. We believe that satisfactory irrigation could be first explained by good preservation of the neurovascular axial network. The second explanation for the success in our series was related to the choice of a relative proximal pivot point. The septocutaneous perforator of the posterior tibial artery is concentrated near the crus distal 1/3 and to the supramalleolar region. Some authors have suggested the lower perforators are approximately 4 to 6.5 cm proximal to the medial malleolus.28 We always chose approximately 5 cm proximal to the medial malleolar tip as the pivot point, although other surgeons have technically modified to lower the point as possible. In our series, we often found a large septocutaneous perforator at 6 to 7 cm proximal to the medial malleolus when dissecting the pedicle from proximal to distal. Our experience was to preserve this perforator and trace to its origin on the posterior artery for greater mobility, which can make up for the loss of rotation arc for this more proximal pivot point in most cases. We considered the tactic of incorporating more than 1 perforator into the pedicle to ensure good irrigation of the flap and to reduce any tension in the pedicle, which we found it not negligible. Only in 6 cases we proceeded distally to dissect along the pedicle because of high tension in the pedicle for rotation and coverage. We always found another more distal septocutaneous perforator at 104
www.annalsplasticsurgery.com
& Volume 77, Number 1, July 2016
approximately 4 cm proximal to the medial malleolus. We then deflated the tourniquet and carefully checked the circulation of the flap by blocking the proximal perforator using a vascular clamp. After making certain that the flap could be well irrigated by the single distal perforator, the proximal perforator vessel was ligated. Fine dissection for this lowermost perforator to its origin was absolutely unnecessary so as to avoid any possible damages to the vessels. Most surgeons suggest that a Doppler ultrasound probe should be used to precisely localize the distal perforators of the posterior tibial artery on which the f lap should rotate.11,27 However, we were successful in simply carefully palpating the medial tarsal tunnel before operation to determine the presence of the posterior tibial artery and to exclude its congenital absence. We did not perform a Doppler test for any of our patients because of no obvious lesions and no suspected abnormalities of the posterior tibial artery. We used this simple preoperative palpation instead of the fussy Doppler test and achieved successful results. The size of our reverse saphenous neurocutaneous f laps ranged from 7 5 to 14 10 cm2. Usually, reverse f laps can extend from the medial edge of the tibia to the posterior midline of the calf between the knee and the lowermost perforator.27,29,30 We strictly restricted the anterior margin of the f lap 1 to 1.5 cm medial to the tibial crest. It was always a little difficult to dissect between the subcutaneous fascia and periosteum in the medial aspect of the tibia. Preservation of the intact tibial periosteum was mandatory so as to ensure the survival of subsequent split-skin grafting. Because of strict restriction of the anterior margin, the posterior margin of the f lap sometimes was inevitably beyond the posterior midline. Nonetheless, we did not experience any adverse effects. Generally, these reverse saphenous neurocutaneous f laps can be elevated up to the insertion of the sartorius, where the nerve dips deeper to the deep fascia and reaches up to the distal part of the midfoot. In addition, associated risk factors (even diabetes) did not adversely affect the survival of the f laps, so we also advise that diabetes was not an absolute contraindication.31 An external fixation device was recommended to provide better postoperative patient compliance to prevent complications.32 We routinely use a plaster support to immobilize the leg for 1 week. We believe this immobilization was beneficial to the patients. With respect to complications, scars at the donor site and loss of sensation on the medial aspect of the leg were generally well tolerated by the patients and did not affect the final clinical outcomes.
CONCLUSIONS This distally based saphenous neurocutaneous island f lap is a reliable and efficient method to reconstruct soft tissue defects in the distal lower leg with more versatility. The procedure is easy to learn and this f lap, as well as the classic sural f lap, is a valuable alternative coverage of soft tissue defects. REFERENCES 1. Pinsolle V, Reau AF, Pelissier P, et al. Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg. 2006;59:912Y917; discussion 918. 2. 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;89:1115Y1121. 3. Schmidt K, Jakubietz M, Harenberg P, et al. The distally based adipofascial sural artery flap for the reconstruction of distal lower extremity defects. Oper Orthop Traumatol. 2013;25:162Y169. 4. Yang C, Li Y, Geng S, et al. Modified distally based sural adipofascial flap for reconstructing of leg and ankle. ANZ J Surg. 2013;83:954Y958. 5. Liu L, Liu Y, Zou L, et al. The distally based superficial sural flap for reconstruction of the foot and ankle in pediatric patients. J Reconstr Microsurg. 2013;29:199Y204.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 77, Number 1, July 2016
6. Dai J, Chai Y, Wang C, et al. Comparative study of two types of distally based sural neurocutaneous flap for reconstruction of lower leg, ankle, and heel. J Reconstr Microsurg. 2013;29:125Y130. 7. Hamdi MF, Kalti O, Khelifi A. Experience with the distally based sural flap: a review of 25 cases. J Foot Ankle Surg. 2012;51:627Y631. 8. Peng F, Wu H, Yu G. Distally-based sural neurocutaneous flap for repair of a defect in the ankle tissue. J Plast Surg Hand Surg. 2011;45:77Y82. 9. Rudig LL, Gercek E, Hessmann MH, et al. The distally based sural neurocutanenous island flap for coverage of soft-tissue defects on the distal lower leg, ankle and heel. Oper Orthop Traumatol. 2008;20:252Y261. 10. Zhang F, Zhang CC, Lin S, et al. Distally based saphenous nerve-great saphenous veno-fasciocutaneous compound flap with nutrient vessels: microdissection and clinical application. Ann Plast Surg. 2009;63:81Y88. 11. Kansal S, Goil P, Agarwal V, et al. Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot. Eur J Orthop Surg Traumatol. 2014;24:62Y72. 12. Wang X, Mei J, Pan J, et al. Reconstruction of distal limb defects with the free medial sural artery perforator flap. Plast Reconstr Surg. 2013;131:95Y105. 13. Chung YJ, Kim G, Sohn BK. Reconstruction of a lower extremity soft-tissue defect using the gastrocnemius musculoadipofascial flap. Ann Plast Surg. 2002;49:91Y95. 14. Kim TG, Kim IK, Kim YH, et al. Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link. Microsurgery. 2012;32:575Y579. 15. Bhattacharya V, Reddy GR. Retrograde perforator-based cross-leg fasciocutaneous flaps for distal leg and foot defects. Plast Reconstr Surg. 2006;117: 1662Y1664. 16. Hu XH, Du WL, Chen Z, et al. The application of distally pedicled peroneus brevis muscle flaps and retrograde neurocutaneous accompanying artery flaps for treatment of bony and soft-tissue 3-dimensional defects of the lower leg and foot. Int J Low Extrem Wounds. 2013;12:53Y62. 17. Rı´os-Luna A, Villanueva-Martı´nez M, Fahandezh-Saddi H, et al. Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury. 2007;38:824Y831. 18. Sharma RK, Kola G. Cross leg posterior tibial artery fasciocutaneous island flap for reconstruction of lower leg defects. Br J Plast Surg. 1992;45:62Y65.
* 2014 Wolters Kluwer Health, Inc. All rights reserved.
Reconstruction of Soft Tissue Defects in Lower Leg
19. Satoh K, Aoyama R, Onizuka T. Comparative study of reverse flow island flaps in the lower extremities-peroneal, anterior tibial, and posterior tibial island flaps in 25 patients. Ann Plast Surg. 1993;30:48Y56. 20. Tharayil J, Patil RK. Reverse peroneal artery flap for large defects of ankle and foot: a reliable reconstructive technique. Indian J Plast Surg. 2012;45:45Y52. 21. Chang SM, Zhang K, Li HF, et al. Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel. Microsurgery. 2009;29:205Y213. 22. Bocchi A, Merelli S, Morellini A, et al. Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction. Ann Plast Surg. 2000;45:284Y291. 23. Yu AX, Deng K, Tao S, et al. Anatomic study and clinical application of distally-based neuro-myocutaneous compound flaps in the leg. Microsurgery. 2007;27:528Y532. 24. Nayak BB, Thatte RL, Thatte MR, et al. A microneurovascular study of the great saphenous vein in man and the possible implications for survival of venous flaps. Br J Plast Surg. 2000;53:230Y233. 25. Chang SM, Hou CL. Role of large superficial veins in distally based flaps of the extremities. Plast Reconstr Surg. 2000;106:230Y231. 26. Cavadas PC. Reversed saphenous neurocutaneous island flap: clinical experience and evolution to the posterior tibial perforator-saphenous subcutaneous flap. Plast Reconstr Surg. 2003;111:837Y839. 27. Shao X, Yu Y, Zhang X, et al. Repair of soft-tissue defect close to the distal perforating artery using the modified distally based medial fasciocutaneous flap in the distal lower leg. J Reconstr Microsurg. 2011;27:145Y150. 28. Boriani F, Bruschi S, Fraccalvieri M, et al. Leg perforators and leg length: an anatomic study focusing on topography and angiogenesis. Clin Anat. 2010;23: 593Y605. 29. Heymans O, Verhelle N, Peters S, et al. Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest. Burns. 2002;28:674Y678. 30. Lineaweaver WC, Lei MP, Mustain W, et al. Vascular endothelium growth factor, surgical delay, and skin flap survival. Ann Surg. 2004;239:866Y873. 31. Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg. 2011;128:173Y180. 32. Noack N, Hartmann B, Ku¨ntscher MV. Measures to prevent complications of distally based neurovascular sural flaps. Ann Plast Surg. 2006;57:37Y40.
www.annalsplasticsurgery.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
105
