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The Distally Based Sural Flap

Ogawa, Rei M.D., Ph.D.; Aoki, Shimpo M.D.; Hyakusoku, Hiko M.D., Ph.D.

Plastic and Reconstructive Surgery: February 2008 - Volume 121 - Issue 2 - p 689-690
doi: 10.1097/01.prs.0000298537.96722.9d

Department of Plastic and Reconstructive Surgery, Nippon Medical School Hospital, Tokyo, Japan

Correspondence to Dr. Ogawa, Department of Plastic and Reconstructive Surgery, Nippon Medical School Hospital, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan,


We would like to make a critical comment on the article by Fodor and colleagues entitled “The Distally Based Sural Musculoneurocutaneous Flap for Treatment of Distal Tibial Osteomyelitis” (Plast. Reconstr. Surg. 119: 2127, 2007). Their opinion that “although there are reports of raising the flap and sparing the sural nerve, we consider this maneuver dangerous, especially for patients with comorbid conditions and scars because of previous orthopedic procedures” is based on little evidence and could potentially cause misunderstanding among the readers of the Journal.

In the results of our anatomical study (submitted data), we found by angiography using cadavers that the small extrinsic vessels around the sural nerve and lesser saphenous vein were important structures, especially in the distally based sural flap, and that those located around the sural nerve were particularly important for flap survival. However, compared with the numerous extrinsic vessels of the sural nerve and lesser saphenous vein, the sural nerve has relatively few intrinsic vessels.

Moreover, we have successfully harvested 28 distally based sural flaps that possessed the deep fascia and lesser saphenous vein but not the sural nerve as a means to prevent complications. In all of these cases, there was no instance of necrosis resulting from preservation of the sural nerve (submitted data). Thus, we consider that the sural nerve itself is not a critical factor for flap survival. The sural nerve can easily be detached from the flap by making a meticulous dissection from the deep fascia. This procedure causes less bleeding1 and means that the sural nerve can be preserved without severely damaging its small extrinsic vessels.

Harvesting of the sural nerve is not without disadvantages. These include the development of a small sensory defect in the lateral aspect of the foot and the possibility of neuroma formation or reflex sympathetic dystrophy.2 We do not deny the utility of reconstructions using ordinally3 or modified distally based sural flaps4,5 containing the sural nerve, because the purpose of these operations is different in each case. In cases where there is a large and distal lower leg soft-tissue defect that needs to be reconstructed without a free flap for some reason, the importance of preservation of the sural nerve should be reconsidered.

Rei Ogawa, M.D., Ph.D.

Shimpo Aoki, M.D.

Hiko Hyakusoku, M.D., Ph.D.

Department of Plastic and Reconstructive Surgery, Nippon Medical School Hospital, Tokyo, Japan

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1. Hyakusoku, H., Tonegawa, H., and Fumiiri, M. Heel coverage with a T-shaped distally based sural island fasciocutaneous flap. Plast. Reconstr. Surg. 93: 872, 1994.
2. Walsh, P. C. Nerve grafts are rarely necessary and are unlikely to improve sexual function in men undergoing anatomic radical prostatectomy. Urology 57: 1020, 2001.
3. Donski, P. K., and Fogdestam, I. Distally based fasciocutaneous flap from the sural region: A preliminary report. Scand. J. Plast. Reconstr. Surg. 17: 191, 1983.
4. Amarante, J., Costa, H., Reis, J., and Soares, R. A new distally based fasciocutaneous flap of the leg. Br. J. Plast. Surg. 39: 338, 1986.
5. Shalaby, H. A., Higazi, M., Mandour, M. A., et al. Distally based medial island septocutaneous flap for repair of soft-tissue defects of the lower leg. Br. J. Plast. Surg. 44: 175, 1991.
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