Lateral retromalleolar perforator-based flap: anatomical study and preliminary clinical report for heel coverage.
BACKGROUND
Repair of heel soft-tissue defects remains a challenging problem in reconstructive surgery. The distally based sural neurofasciocutaneous flap is among the flaps of choice for coverage of this difficult region. The authors describe a modified lateral retromalleolar perforator-based neurocutaneous flap with a lower pivot point.


METHODS
This study was divided into two parts: anatomical study and clinical application. In the anatomical study, 12 cadavers were injected with red gelatin, and all fasciocutaneous perforators between the lateral malleolus and Achilles tendon (called the lateral retromalleolar space) were identified. Clinically, based on the anatomical study, five cases of heel soft-tissue defects were reconstructed with the modified lateral retromalleolar perforator-based sural neurofasciocutaneous flap.


RESULTS
The anatomical study showed that there are usually two to three retromalleolar cutaneous perforators arising from the terminal part of the peroneal artery in the lateral retromalleolar space. Their outer diameters range from 0.1 to 0.8 mm. A direct venous communicator, usually accompanied by the larger perforator, connected the superficial lesser saphenous vein and the deep peroneal venae comitantes. Five patients with heel soft-tissue defects were treated with flaps ranging from 3 x 6 cm to 5 x 12 cm. The distal pivot point was designed at 1 to 3 cm above the tip of the lateral malleolus. All flaps survived without complications.


CONCLUSIONS
The lateral retromalleolar perforator is predictable and reliable for the design of a lower pivot point, distally based sural neurocutaneous flap. The procedures are simple and rapid, and the flap can be rotated easily without dog-ear deformity. This flap should be considered among the preferred flaps for heel reconstruction.
Chang
Shi-Min
SM
Shanghai and Guangzhou, China; and Jackson, Miss. From the Department of Orthopedic Surgery, Tongji Hospital, Tongji University; Division of Plastic Surgery, University of Mississippi Medical Center; Institute of Clinical Anatomy, Nanfang Medical University; and Department of Orthopedic Surgery, Changzhen Hospital, Second Military Medical University.
Zhang
Feng
F
Xu
Da-Chuan
DC
Yu
Guang-Rong
GR
Hou
Chun-Lin
CL
Lineaweaver
William C
WC
D000328:Adult; D000368:Aged; D002102:Cadaver; D005260:Female; D016523:Foot Ulcer / Q000601:surgery*; D006365:Heel / Q000601:surgery*; D006801:Humans; D008297:Male; D013524:Surgical Flaps / Q000098:blood supply
Hallock, G. G. Distally based flaps for skin coverage of the foot and ankle. Foot Ankle Int. 17: 343, 1996.
Hallock, G. G. Cutaneous coverage for the difficult wound of the foot. Contemp. Orthop. 16: 19, 1988.
McCraw, J. B., and Furlow, L. T. The dorsalis pedis arterialized flap: A clinical study. Plast. Reconstr. Surg. 55: 177, 1975.
Landi, A., Soragni, O., and Monteleone, M. The extensor digitorum brevis muscle island flap for soft-tissue loss around the ankle. Plast. Reconstr. Surg. 75: 892, 1985.
Morrison, W. A., Crabb, D. M., O’Brein, B. M., and Jenkins, A. The instep of the foot as a fasciocutaneous island and a free flap for heel defects. Plast. Reconstr. Surg. 72: 56, 1983.
Grabb, W. C., and Argenta, L. C. The lateral calcaneal artery skin flap. Plast. Reconstr. Surg. 68: 723, 1981.
Hartrampf, C. R., Jr., Scheflan, M., and Bostwick, J., III. The flexor digitorum brevis muscle island pedicle flap: A new dimension in heel reconstruction. Plast. Reconstr. Surg. 66: 264, 1980.
Gu, Y. D., Wu, M. M., and Li, H. R. Lateral lower leg skin flap. Ann. Plast. Surg. 15: 319, 1985.
Wee, J. T. K. Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: Preliminary report of a new fasciocutaneous flap. Br. J. Plast. Surg. 39: 327, 1986.
Liu, K., Li, Z., Lin, Y., and Cao, Y. The reverse-flow posterior tibial artery island flap: Anatomic study and 72 clinical cases. Plast. Reconstr. Surg. 86: 312, 1990.
Masquelet, A. C., Beveridge, J., Romana, C., and Gerber, C. The lateral supramalleolar flap. Plast. Reconstr. Surg. 81: 74, 1988.
Amarante, J., Costa, H., Reis, J., and Soares, R. A new distally based fasciocutaneous flap of the leg. Br. J. Plast. Surg. 39: 338, 1986.
Masquelet, A. C., Romana, M. C., and Wolf, G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerve: Anatomic study and clinical experience in the leg. Plast. Reconstr. Surg. 89: 1115, 1992.
Townsend, P. L. G. An inferiorly based soleus muscle flap. Br. J. Plast. Surg. 31: 210, 1978.
Pu, L. L. The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg. Ann. Plast. Surg. 56: 59, 2006.
Hasegawa, M., Torii, S., Katoh, H., and Esaki, S. The distally based superficial sural artery flap. Plast. Reconstr. Surg. 93: 1012, 1994.
Cavadas, P. C. Reversed saphenous neurocutaneous island flap: Clinical experience and evolution to the posterior tibial perforator-saphenous subcutaneous flap. Plast. Reconstr. Surg. 111: 837, 2003.
Chang, S. M., Zhang, F., Yu, G. R., Hou, C. L., and Gu, Y. D. Modified distally based peroneal artery perforator flap for reconstruction of foot and ankle. Microsurgery 24: 530, 2004.
Koshima, I., Itoh, S., Nanba, Y., Tsutsui, T., and Takahashi, Y. Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann. Plast. Surg. 51: 579, 2003.
Oberlin, C., Azoulay, B., and Bhatia, A. The posterior malleolar flap of the ankle: A distally based sural neurocutaneous flap. Report of 14 cases. Plast. Reconstr. Surg. 96: 400, 1995.
Jeng, S. F., and Wei, F. C. The distally based sural island flap for foot and ankle reconstruction. Plast. Reconstr. Surg. 99: 744, 1997.
Robotti, E., Verna, G., Fraccalvieri, M., and Bocchiotti, M. A. Distally based fasciocutaneous flaps: A versatile option for coverage of difficult war wounds of the foot and ankle. Plast. Reconstr. Surg. 101: 1014, 1998.
Yilmaz, M., Karatas, O., and Barutcu, A. The distally based superficial sural artery island flap: Clinical experiences and modifications. Plast. Reconstr. Surg. 102: 2358, 1998.
Tu, Y. K., Ueng, S. W. N., Yeh, W. L., and Wang, K. C. Reconstruction of ankle and heel defects by a modified wide-base reverse sural flap. J. Trauma 47: 82, 1999.
Le Fourn, B., Caye, N., and Pannier, M. Distally based sural fasciomuscular flap: Anatomic study and application for filling leg or foot defects. Plast. Reconstr. Surg. 107: 67, 2001.
Chen, S. L., Chen, T. M., Chou, T. D., Chen, S. G., and Wang, H. J. The distally based lesser saphenous venofasciocutaneous flap for ankle and heel reconstruction. Plast. Reconstr. Surg. 110: 1664, 2002.
Ayyappan, T., and Chadha, A. Super sural neurofasciocutaneous flaps in acute traumatic heel reconstruction. Plast. Reconstr. Surg. 109: 2307, 2002.
Prasad, J. S. R., Gunha-Gomes, D., Chaudhari, C., Bhathena, H. M., Desai, S., and Kavarana, N. M. The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous and muscle flaps: Anatomical basis of a new concept. Br. J. Plast. Surg. 55: 203, 2002.
Yang, D., and Morris, S. F. Reversed sural island flap supplied by the lower septocutaneous perforator of the peroneal artery. Ann. Plast. Surg. 49: 375, 2002.
Isenberg, J. S. When less is more: Revascularization and sural artery fasciocutaneous flaps in ischemic limb salvage. J. Reconstr. Microsurg. 19: 235, 2003.
Almeida, M. F., da Costa, P. R., and Okawa, R. Y. Reverse-flow island sural flap. Plast. Reconstr. Surg. 109: 583, 2002.
Zhang, F. H., Chang, S. M., Lin, S. Q., et al. Modified distally based sural neuro-veno-fasciocutaneous flap: Anatomical study and clinical applications. Microsurgery 25: 543, 2005.
Blondeel, P. N., Morris, S. F., Hallock, G. G., and Neligan, P. C. (Eds.), Perforator Flaps: Anatomy, Technique, and Clinical Applications. St. Louis: Quality Medical, 2006.
Chang, S. M., Gu, Y. D., and Li, J. F. Comparison of different management of large superficial veins in distally based fasciocutaneous flaps with a veno-neuro-adipofascial pedicle: An experimental study in the rabbit model. Microsurgery 23: 555, 2003.
Chang, S. M., Gu, Y. D., and Li, J. F. The role of the large superficial vein in survival of proximally based versus distally based sural veno-neuro-fasciocutaneous flaps in a rabbit model. Plast. Reconstr. Surg. 115: 213, 2005.
Tan, O., Atik, B., and Bekerecioglu, M. Supercharged reverse-flow sural flap: A new modification increasing the reliability of the flap. Microsurgery 25: 36, 2005.