Distal lower extremity coverage by distally based sural flaps: Methods to increase their vascular reliability

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.

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.

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.

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.