title: Distal lower extremity coverage by distally based sural flaps: Methods to increase their vascular reliability.
abstract: BACKGROUND
  Although using distally based sural flaps is old and common, the described harvesting methods vary and often depend on unclear vascular anatomical data. We wanted, through a review of the existing harvesting techniques and our clinical experience, to synthesize these aspects in order to provide an optimal, safe and customized use of distally based sural flaps.
  
  
  METHODS
  Fifty-eight sural flaps were performed in 53.4-year-old patients in average, presenting in 81% of the cases one or more vascular comorbidities. The mean cover surface was of 30cm2. The flaps were mainly fasciocutaneous. The tunneling of the pedicle was performed in 34.5% of the cases. A skin blade was preserved above the pedicle in 37.9% of flaps. The short saphenous vein was anastomosed in 27.6% of the cases at the recipient site and ligatured distally in 19% of the cases. The mean follow-up was 18.9months.
  
  
  RESULTS
  In 31% of cases, the skin paddle presented an obvious venous congestion during flap inset successfully treated with an anastomosis or a distal ligature of the short saphenous vein. We noticed in six other flaps (10.3%) a postoperative venous congestion having led to a skin paddle partial necrosis, of which five (8.6%) were treated without compromising the quality of the reconstruction. One patient required a coverage using another flap.
  
  
  CONCLUSIONS
  When the microsurgery is not required or possible, the distally based sural flaps represent a safe level of the reconstructive armamentarium. Managing the pedicle's dissection and the venous drainage needs to be discussed case-by-case and adapted to peroperatory observations. The anastomosis or ligation of the small saphenous vein, as the existence of a thin skin blade under the skin paddle appear to increase vascular reliability of these flaps.
authors.affiliation: Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier cedex 5, France. Electronic address: drchristianherlin@gmail.com.
authors.forename: C
authors.initials: C
authors.lastname: Herlin
authors.affiliation: Service de chirurgie plastique, reconstructrice et esthétique, CHRU Picardie, 80000 Amiens, France.
authors.forename: R
authors.initials: R
authors.lastname: Sinna
authors.affiliation: Service d'orthopédie et de traumatologie, CHRU Lapeyronie, Montpellier, France.
authors.forename: M
authors.initials: M
authors.lastname: Hamoui
authors.affiliation: Service d'orthopédie et de traumatologie, CHRU Lapeyronie, Montpellier, France; Laboratoire d'anatomie, faculté de médecine, université de Montpellier, Montpellier, France.
authors.forename: F
authors.initials: F
authors.lastname: Canovas
authors.affiliation: Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier cedex 5, France; Laboratoire d'anatomie, faculté de médecine, université de Montpellier, Montpellier, France.
authors.forename: G
authors.initials: G
authors.lastname: Captier
authors.affiliation: Service de chirurgie plastique, reconstructrice et esthétique, CHRU Rangueil, 31400 Toulouse, France.
authors.forename: B
authors.initials: B
authors.lastname: Chaput
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D004210:Dissection / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D035002:Lower Extremity / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply*; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation; D017695:Soft Tissue Injuries / Q000601:surgery*; D016896:Treatment Outcome
keywords: Adipofascial flaps; Distally based sural flaps; Fasciocutaneous flaps; Lambeau adipofascial; Lambeau fasciocutané; Lambeau neurocutané; Lambeau sural à pédicule distal; Neurocutaneous flaps