title: Distally based perforator propeller sural flap for foot and ankle reconstruction: a modified flap dissection technique.
abstract: BACKGROUND
  Distally based perforator propeller sural flaps that pedicled on an isolated perforator from the peroneal artery or posterior tibial artery are a versatile local reconstructive option for defects of the foot and ankle region. However, flap venous congestion is yet a difficult problem after operation. We hypothesize that containing some adipofascial tissues around the axial perforator can preserve some tiny venous return routes, improve venous drainage, and ultimately enhance flap safety in distally based sural flaps.
  
  
  METHODS
  A prospective case series of 12 patients undergoing distally based perforator sural flaps for foot and ankle coverage were included in this study from January 2008 to December 2010. There were 7 posterior tibial artery perforator flaps from the posteromedial sural region and 5 peroneal artery perforator flaps from the posterolateral sural region. After identifying the proper viable perforator during operation as the pivot point, the whole flap was designed in an eccentric propeller shape. The proximal larger blade was a fasciocutaneous flap, whereas the distal smaller blade was a subdermal vascular plexus flap, preserving at least a quarter area of adipofascial tissue intact around the perforator. Postoperatively, flap swelling was classified into a 5-grade assessment scale. Flap survival, complications, and patient functional recovery were evaluated.
  
  
  RESULTS
  The proximal fasciocutaneous flap measured 4 × 8 to 6 × 18 cm (mean, 57.8 cm), and the distal subdermal cutaneous flap measured 2 × 2 to 4 × 4 cm (mean, 9.2 cm). The flaps were rotated 160 to 180 degrees. Postoperatively, flap swelling was noted under grade 2 in 9 cases, grade 3 in 2, and grade 4 in 1 with some distal superficial skin necrosis, which occurred in the largest flap in our series. All flaps survived uneventfully. After a mean of 13 months of follow-up, the wounds were cured successfully. All patients recovered walking and shoe wearing function.
  
  
  CONCLUSIONS
  Keeping a quadrant adipofascial tissue around the distal pivot perforator to form a perforator-adipofascial-pedicle can preserve more venous return routes and relieve flap swelling. This technique should be recommended in distally perforator-pedicled propeller flaps because it enhances flap safety yet does not increase the difficulty of 180-degree rotation.
authors.affiliation: From the Department of Orthopedic Surgery, Yangpu Hospital, and Tongji Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China.
authors.forename: Shi-Min
authors.initials: SM
authors.lastname: Chang
authors.forename: Xin
authors.initials: X
authors.lastname: Wang
authors.forename: Yi-Gang
authors.initials: YG
authors.lastname: Huang
authors.forename: Xiao-Zhong
authors.initials: XZ
authors.lastname: Zhu
authors.forename: You-Lun
authors.initials: YL
authors.lastname: Tao
authors.forename: Ying-Qi
authors.initials: YQ
authors.lastname: Zhang
mesh_terms: D000328:Adult; D000368:Aged; D000842:Ankle / Q000098:blood supply / Q000601:surgery; D016512:Ankle Injuries / Q000601:surgery*; D001158:Arteries / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D002648:Child; D004210:Dissection / Q000379:methods*; D004487:Edema / Q000209:etiology; D005260:Female; D005528:Foot / Q000098:blood supply / Q000601:surgery; D018409:Foot Injuries / Q000601:surgery*; D006085:Graft Survival / Q000502:physiology; D006365:Heel / Q000098:blood supply / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply* / Q000294:innervation*; D011183:Postoperative Complications / Q000209:etiology; D019651:Plastic Surgery Procedures / Q000379:methods*; D012878:Skin Neoplasms / Q000601:surgery*; D020858:Tissue and Organ Harvesting / Q000379:methods*