Use of the cross-leg distally based sural artery flap for the reconstruction of complex lower extremity defects

Cross-leg flaps are a useful reconstructive option for complex lower limb defects when free flaps cannot be performed owing to vessel damage. We describe the use of the extended distally based sural artery flap in a cross-leg fashion for lower extremity coverage in three patients. To maximise the viability of these extended flaps, a delay was performed by raising them in a bipedicled fashion before gradual division of the tip over 5 to 7 days for cross-leg transfer. Rigid coupling of the lower limbs with external fixators was critical in preventing flap avulsion and to promote neovascular takeover. The pedicle was gradually divided over the ensuing 7 to 14 days before full flap inset and removal of the external fixators. In all three patients, the flaps survived with no complications and successful coverage of the critical defect was achieved. One patient developed a grade 2 pressure injury on his heel that resolved with conservative dressings. The donor sites and external fixator pin wounds healed well, with no functional morbidity. The cross-leg extended distally based sural artery flap is a reliable reconstructive option in challenging scenarios. Adequate flap delay, manoeuvres to reduce congestion, and postoperative rigid immobilization are key to a successful outcome.

Keywords

Leg injuries - Sural nerve - Perforator flap - Surgical flaps - External fixators

Publication History

Received: 18 May 2017

Accepted: 24 October 2017

Article published online:
28 March 2022

• REFERENCES

• 1 Devansh S. Prefabricated recipient vascular pedicle for free composite-tissue transfer in the chronic stage of severe leg trauma. Plast Reconstr Surg 1995; 96: 392-9
• 2 Chen H, El-Gammal TA, Wei F. et al. Cross-leg free flaps for difficult cases of leg defects: indications, pitfalls, and long-term results. J Trauma 1997; 43: 486-91
• 3 Quarmby CJ, Skoll PJ. The distally based, cross-leg, sural artery island flap. Plast Reconstr Surg 2001; 108: 798-9
• 4 Atiyeh BS, Al-Amm CA, El-Musa KA. et al. Distally based sural fasciocutaneous cross-leg flap: a new application of an old procedure. Plast Reconstr Surg 2003; 111: 1470-4
• 5 Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992; 89: 1115-21
• 6 Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002; 109: 583-91
• 7 Al-Qattan MM. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg: inclusion of a gastrocnemius muscle “cuff” around the sural pedicle. Ann Plast Surg 2001; 47: 269-74
• 8 Tosun Z, Ozkan A, Karacor Z. et al. Delaying the reverse sural flap provides predictable results for complicated wounds in diabetic foot. Ann Plast Surg 2005; 55: 169-73
• 9 Tan BK, Wong CH. An anomalous septocutaneous perforator to the skin paddle of the fibula osteocutaneous flap originating from the posterior tibial artery. J Plast Reconstr Aesthet Surg 2009; 62: 690-2
• 10 Mok WL, Por YC, Tan BK. Distally based sural artery adipofascial flap based on a single sural nerve branch: anatomy and clinical applications. Arch Plast Surg 2014; 41: 709-15
• 11 Wong CH, Tan BK. Intermittent short saphenous vein phlebotomy: an effective technique of relieving venous congestion in the distally based sural artery flap. Ann Plast Surg 2007; 58: 303-7
• 12 Mojallal A, Wong C, Shipkov C. et al. Vascular supply of the distally based superficial sural artery flap: surgical safe zones based on component analysis using three-dimensional computed tomographic angiography. Plast Reconstr Surg 2010; 126: 1240-52
• 13 Fayman MS, Orak F, Hugo B. et al. The distally based split soleus muscle flap. Br J Plast Surg 1987; 40: 20-6
• 14 Pu LL. 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 2006; 56: 59-63