Decreasing Complication Of Distally Based Sural Fasciocutaneous Flap: Sugical Techniques

Objective:To explore the different influence on flap-viability-related complications (hereinafter referred to as complications) due to different surgical technique groups (containing anterograde-retrograde approach or retrograde approach to harvest distally based sural fasciocutaneous flap,anastomosing Lesser Saphenous Vein to the vein of recipient site or not,the using of oblique design or general design), and to summarize the clinical experience to decrease complications of the flap.Methods:Retrospective research and analysis on data and operative pictures of 201 distally based sural fasciocutaneous flaps in 196 consecutive patients (bilateral flaps were performed in 5 patients) between April 2001 and March 2011. The average age of the patients was 32.8 (range,3-78) years. Etiology of 201 defects included trauma (n=165), soft tissue tumor (n=4), unstable scarring (n=9), osteomyelitis with chronic ulcer (n= 11) or sinus (n=5), chronic ulcer with paraplegia (n=3), venous insufficiency (n=3) or peripheral arterial disease (n=1). The flaps were conducted to reconstruct soft-tissue defects in the distal lower leg, heel and foot. All the defects combined with exposion of the bones, joints, tendons, and/or internal fixation hardware. The pivot point lay in 4cm～19cm above tip of the lateral malleolus, and the size of the flaps ranged from 5 cm×4cm to 20 cm×15 cm. The flaps are divided into three groups according to outcomes of flap survival and complications:no complication(complete survival) flaps, major complication (including complete and partial necrosis) flaps, and minor complication (including marginal necrosis, de-epithelialization and wound dehiscence) flaps. Forty-two flaps were harvested by retrograde method (Retrograde group) and 159 flaps by anterograde-retrograde approach that the peroneal arterial perforators nearby the pivot point were explored initially before the flap was elevated retrograde (Anterograde-retrograde group). There were 51 flaps conducted to reconstruct the soft-tissue defects in plantar heel, consisting of 8 flaps whose Lesser Saphenous Vein were anastomosed to the vein of recipient site (vein anastomosed group) and 43 flaps whose Lesser Saphenous Vein were not anastomosed (vein not anastomosed group). There were 76 flaps conducted to reconstruct the soft-tissue defects in foot and ankle horizontal wounds or distal lower leg longitudinal wounds, consisting of 50 flaps using the method of oblique design (oblique group) and 26 flaps using the method of general design (general group). All data analyses were performed using the SPSS (version 17.0) statistical software package.Results:Of the 201 flaps,147 flaps survived completely with wound healing uneventfully. Partial necrosis occurred in 25 (12.4%) flaps, of which remaining defects were covered successfully by changing dressings(n=1),skin grafting(n=11), secondary suture(n=5) or transferring other local flaps(n=5), and were eliminated by amputation(n=3). Marginal necrosis developed in 16 flaps, and residual defects were re-surfaced by changing dressings(n=10) or secondary suture(n=6). De-epithelialization and wound dehiscence presented in 9 and 4 flaps, respectively, whose remanent defects were re-epithelialized spontaneously without further surgical treatment and through secondary suture, respectively. We achieved successful closure of the defects using the flap alone, or in combination with a simple salvage treatment in 193 (96.0%) flaps. Follow-up ranged from 2 weeks to 72 months (mean follow-up was 6.4 months).Of the anterograde-retrograde group,both pivot point and skin island were adjusted in 9 (proximally in 6 and distally in 3) flaps. Of the nine adjusted flaps, six flap survived completely, one flap developed partial necrosis and two flaps de-epithelialization. Major complication rate and minor complication rate in anterograde-retrograde group(10.7%,17/159; 11.9%,19/159) was lower than that in retrograde group(19.1%,8/42; 21.4%,9/42), respectively, but both of the two differences were not statistically significant(P>0.05).However, the accumulative complication (including major and minor complications) rate in anterograde-retrograde group (22.6%,36/159) was significantly lower than that in retrograde group (40.5%,17/42) (P<0.05).Major complication rate in vein anastomosed group and vein not anastomosed group were 0 and 11.6%, respectively; Minor complication rate in that were 37.5% and 16.3%, respectively; Accumulative complication rate in that were 37.5% and 27.9%, respectively, but all of the three differences were not statistically significant(P>0.05). Major complication rate and accumulative complication rate in oblique group and general group were (6.0% and 22.0%) and (23.1% and 26.9%),respectively, but both of the two differences were not statistically significant(P>0.05).Conclusions:(1) The anterograde-retrograde approach to harvest distally based sural fasciocutaneous flap can locate accurately the peroneal arterial perforators around the pivot point, and if necessary, pivot point and skin island can be unobstructively adjusted, so as to improve the reliability of the flap; (2) When the flap is conducted to reconstruct the soft-tissue defects in plantar heel,the difference of anastomosing Lesser Saphenous Vein of the flap to the vein of recipient site or not is not obvious. (3) When the flap is conducted to reconstruct the soft-tissue defects in foot and ankle horizontal wounds or distal lower leg longitudinal wounds, Oblique design can reduce the transverse diameter of the flap, so as to decrease the probability of complications of the flap.