title: Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications.
abstract: The distally based sural neuro-veno-fasciocutaneous flap has been used widely for reconstruction of foot and ankle soft-tissue defects. The distal pivot point of the flap is designed at the lowest septocutaneous perforator from the peroneal artery of the posterolateral septum, which is, on average, 5 cm (4-7 cm) above the lateral malleolus. A longer neuro-veno-adipofascial pedicle would be needed to reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which may result in more trauma in flap elevation and morbidity of the donor site. In this article, we explored new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap. A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally based sural flap with lower pivot points was successfully transferred for repair of soft-tissue defects in 21 patients. The size of flaps ranged from 4 x 3 cm to 18 x 12 cm. All flaps survived without complications. Neither arterial ischemia nor venous congestion was noted. In conclusion, the vascular pivot point of a distally based sural flap can be safely designed at 1.5 cm proximal to the tip of the lateral malleolus. This modified flap provides a valuable tool for repair of foot and ankle soft-tissue defects.
authors.affiliation: Clinical Anatomic Center, General Hospital of People's Liberation Army Nanjing District, Fuzhou, China.
authors.forename: Fa-Hui
authors.initials: FH
authors.lastname: Zhang
authors.forename: Shi-Min
authors.initials: SM
authors.lastname: Chang
authors.forename: Song-Qing
authors.initials: SQ
authors.lastname: Lin
authors.forename: Yi-Ping
authors.initials: YP
authors.lastname: Song
authors.forename: He-Ping
authors.initials: HP
authors.lastname: Zheng
authors.forename: William C
authors.initials: WC
authors.lastname: Lineaweaver
authors.forename: Feng
authors.initials: F
authors.lastname: Zhang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016512:Ankle Injuries / Q000175:diagnosis / Q000601:surgery; D002102:Cadaver; D002675:Child, Preschool; D015331:Cohort Studies; D004210:Dissection; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000175:diagnosis / Q000601:surgery; D008297:Male; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods*; D012039:Regional Blood Flow; D018570:Risk Assessment; D012501:Saphenous Vein / Q000033:anatomy & histology / Q000637:transplantation; D016038:Skin Transplantation / Q000379:methods; D017695:Soft Tissue Injuries / Q000175:diagnosis / Q000601:surgery*; D013497:Sural Nerve / Q000033:anatomy & histology / Q000637:transplantation; D013524:Surgical Flaps / Q000098:blood supply* / Q000294:innervation*; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology