distally-based sural flap
TRANSCRIPT
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Distally-Based Sural Flap
Nattakul Yamprasert, MD Department of Orthopaedics,
Maharat Nakhon Ratchasima Hospital
Regional Hand Meeting 2015 “The Diversity of the Hand and Upper Extremity Surgery”August 20th - 21st, 2015 At Ubon Ratchathani, THAILAND
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Anatomy
• Vascular supply:
• Median superficial sural artery (along with medial sural nerve)
• Lesser saphenous vein and its arteries
• Pivot Point : about 5 cm proximal to lateral malleolus
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Midpoint between posterior border of lateral malleolus
and Achilles tendon
Midpoint between 2 heads of Gastrocnemius muscle
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Pivot point : 5 cm proximal to lateral malleolus
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IndicationResurfacing of soft tissue defect in
• Middle third of leg
• Distal third of leg
• Anterior ankle
• Heel
• Dorsal foot
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Preoperative Planning
• Posterolateral skin
• Flap size (Max. diameter 15 cm)
• Flap composition (including/excluding skin)
• One-stage/ two-stage (delayed) procedure
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Patient Position
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Prone
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Lateral Position
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Flap Composition
• Fasciocutaneous flap
• Fasciomusculocutaneous flap
• Adipofascial flap
• Adipofasciomuscular flap
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Flap Dissection
Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ
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Pedicle Dissection
Source : https://www.youtube.com/watch?v=eFwzbbYdAMQ
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Assessment of Vascularity
• Deflate tourniquet
• Observe bleeding from elevated flap
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Subcutaneous Tunneling
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Subcutaneous Tunneling
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Subcutaneous Tunneling
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Avoid Subcutaneous Tunneling?
• Not necessary unless there are certain risk factors such as HT, DM, peripheral vascular disease, and vasculitis.
F. Uygur et. al., Annals of Plastic Surgery, July 2009
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Donor Site Closure• Primary wound closure
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• Close by skin graft
Donor Site Closure
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Flap Modification
• Venous supercharged flap
• Delayed flap procedure
• Megahigh flap
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Postoperative Care
• Splint
• Dressing
• Flap monitoring
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Complications
• Flap congestion
• Partial flap lost
• Total flap lost
• Infection
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My Experience…
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Case 1
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65 years old man:Chronic ulcer on dorsum & anterior ankle
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Scar excision
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Flap elevation
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Flap rotation
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Flap inset
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5 years postop.
D14 PO Y5 PO
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Case 2
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39 year-old woman:Skin necrosis after ORIF with screw at the calcaneus
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X
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D14 Y1 PO Y4 PO
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Case 3
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28 year-old woman :Open fracture-dislocation of left anklewith loss of anterior soft tissue
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STSG Flap
D7 PO M3 PO
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Y7 PO
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Case 4
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8 year-old boy :Posterior heel injury with skin loss
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XPivot
Flap Primary Defect
Flap slightly larger than defect
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Primary closure
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D3 PO
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Case 5
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Intact posterolateral skin
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Fascia sutured to skin as one unit during flap elevation
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Flap elevation including cuff of muscle
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Passing elevated flapthru subcutaneous tunnel
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Case 6
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Intact posterolateral skin
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Patient positioning
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Flap Elevation
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Wide pedicle
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Sural nerves and vessels including in elevated flap
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Tunneling and flap inset
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Donor site closing with meshed skin graft
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D3 PO
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Case 7
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Soft tissue defect withpre-existing wound infection
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Residual infection after flap coverage
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M2 PO
D3 PO
Donor Site
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Complication:Partial Flap Necrosis
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D1 PO D2 PO D3 PO D4 PO
D5 PO D6 PO M1 PO After debridement
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Take Home Messages• If possible, design the longer side of flap along
the vascular axis.
• Flap death began from superficial layer.
• When in doubt about pedicle compression, never hesitate to open the tunnel.
• Preexisting infection should be treated prior to flap procedure.