Distally-Based Sural Flap

Step-by-step approach for general orthopedist

Presenting in "Regional Hand Meeting 2015" at Ubon Ratchathani, THAILAND

1. Distally-Based
Sural Flap
Nattakul Yamprasert, MD
Department of Orthopaedics,
Maharat Nakhon Ratchasima Hospital
Regional Hand Meeting 2015 “The Diversity of the Hand and Upper Extremity Surgery”
August 20th - 21st, 2015 At Ubon Ratchathani, THAILAND

2. Anatomy
•Vascular supply:
•Median superficial sural artery (along with
medial sural nerve)
•Lesser saphenous vein and its arteries
•Pivot Point : about 5 cm proximal to lateral
malleolus

3. Midpoint between posterior
border of lateral malleolus
and Achilles tendon
Midpoint between 2 heads
of Gastrocnemius muscle

4. Pivot point : 5 cm proximal to lateral malleolus

5. Indication
Resurfacing of soft tissue defect in
•Middle third of leg
•Distal third of leg
•Anterior ankle
•Heel
•Dorsal foot

6. Preoperative Planning
•Posterolateral skin
•Flap size (Max. diameter 15 cm)
•Flap composition (including/excluding skin)
•One-stage/ two-stage (delayed) procedure

7. Patient Position

8. Prone

9. Lateral Position

10. Flap Composition
•Fasciocutaneous flap
•Fasciomusculocutaneous flap
•Adipofascial flap
•Adipofasciomuscular flap

11. Flap Dissection
Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ

12. Pedicle Dissection
Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ

13. Assessment of Vascularity
•Deflate tourniquet
•Observe bleeding from elevated flap

14. Subcutaneous Tunnelling

15. Subcutaneous Tunnelling

16. Subcutaneous Tunnelling

17. Avoid Subcutaneous
Tunnelling?
•Not necessary unless there are certain risk
factors such as HT, DM, peripheral vascular
disease, and vasculitis.
F. Uygur et. al., Annals of Plastic Surgery, July 2009

18. Donor Site Closure
•Primary wound closure

19. •Close by skin graft
Donor Site Closure

20. Flap Modification
•Venous supercharged flap
•Delayed flap procedure
•Megahigh flap

21. Postoperative Care
•Splint
•Dressing
•Flap monitoring

22. Complications
•Flap congestion
•Partial flap lost
•Total flap lost
•Infection

23. My Experience…

24. Case 1

25. 65 years old man:
Chronic ulcer on dorsum & anterior ankle

26. Scar excision

27. Flap
elevation

28. Flap rotation

29. Flap inset

30. 5 years postop.
D14 PO Y5 PO

32. Case 2

33. 39 year-old woman:
Skin necrosis after ORIF with screw at the calcaneus

34. X

36. D14 Y1 PO Y4 PO

37. Case 3

38. 28 year-old woman :
Open fracture-dislocation of left ankle
with loss of anterior soft tissue

39. STSGFlap
D7 PO M3 PO

40. Y7 PO

41. Case 4

42. 8 year-old boy :
Posterior heel injury with skin loss

43. X
Pivot
Flap
Primary
Defect
Flap slightly larger than defect

47. Primary closure

48. D3 PO

49. Case 5

52. Intact posterolateral skin

54. Fascia sutured to skin as one unit during flap elevation

55. Flap elevation including cuff of muscle

56. Passing elevated flap
thru subcutaneous tunnel

60. Case 6

63. Intact posterolateral skin

64. Patient positioning

65. Flap Elevation

66. Wide pedicle

67. Sural nerves and vessels
including in elevated flap

68. Tunneling and flap inset

69. Donor site closing with meshed skin graft

70. D3 PO

71. Case 7

72. Soft tissue defect with
pre-existing wound infection

74. Residual infection after flap coverage

75. M2 PO
D3 PO
Donor Site

76. Complication:
Partial Flap Necrosis

77. D1 PO D2 PO D3 PO D4 PO
D5 PO D6 PO M1 PO
After debridement

78. Take Home Messages
•If possible, design the longer side of flap along
the vascular axis.
•Flap death began from superficial layer.
•When in doubt about pedicle compression,
never hesitate to open the tunnel.
•Preexisting infection should be treated prior to
flap procedure.