We read with interest the article entitled “The Distally Based Sural Flap” by Follmar et al.,1 in which an excellent, comprehensive examination of all aspects of the reverse flow sural artery flap has been provided. We would like to comment on preoperative planning of the reverse flow sural island flap, which is actually considered a reliable method for covering defects of the lower third of the leg.
Various studies on cadavers have demonstrated that the anatomy of the sural nerve and its vascular axis can be inconsistent. The vascular axis of the sural nerve can be either a true artery or an interlacing network; this network of vessels connects the distal portion of the superficial sural artery with the perforators of the peroneal artery and opens up only under increased pressure conditions. We believe in the need for a preoperative study of the main vascular axis of the flap, but we consider as too invasive the use of preoperative selective angiography to locate and determine the size of perforators.
In 1994, Hasegawa et al.2 affirmed that the pivot point of the flap must be at least 5 cm above the tip of the lateral malleolus, but, as demonstrated by Zhang et al.3 in 2005, the vascular pivot point of the distally based sural flap can be safely designed even 1.5 cm proximal to the lateral malleolus. We believe that individual skin marking is fundamental in the preoperative phase because preestablished landmarks, based on previous anatomical studies, are out of date.
Yeng and Wei,4 considering the previously reported high failure rate in performing this flap because of variable vascular anatomy, advised the use of preoperative Doppler examination to identify perforators and their distance from the lateral malleolus in each clinical case. Bocchi et al.5 stated that the constant use of a Doppler probe during the preliminary evaluation provides more safety to the surgical procedure and increases the success rate of the sural artery flap. We suggest the use of preoperative Doppler examination during flap planning, with the following objectives:
- Exact determination of the most distal peroneal artery perforator(s) emergently, which is the flap pivot point. Figure 1, left, shows the Doppler determination of the most distal perforator.
- Skin marking of the course of the sural nerve accompanying vessels in the lower leg; in doing that, it is possible to encounter a mute tract at the level of the vascular network that connects the superficial sural artery and the course of the peroneal artery perforator(s) course; the Doppler signal could be found again proceeding along the course of the nerve in those specific circumstances. Figure 1, right, clearly shows the mute tract.
- Determination of sural artery skin perforators in the proximal third of the leg, when present, on which the flap island can be centered. This design makes the harvesting of the flap quicker and safer.
Fabrizio Schonauer, M.D., Ph.D.
Mariagrazia Moio, M.D.
Simone La Padula
Guido Molea, Ph.D.
Department of Plastic and Reconstructive Surgery
University “Federico II”
1. Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg.
2. Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg.
3. Zhang FH, Chang SM, Lin SQ, et al. Modified distally based sural neuro-veno-fasciocutaneous flap: Anatomical study and clinical applications. Microsurgery
4. Yeng SF, Wei FC. Distally based sural island flap for foot and ankle reconstruction. Plast Reconstr Surg
5. Bocchi A, Merelli S, Morellini A, Baldassarre S, Caleffi E, Papadia F. Reverse fascio-subcutaneous flap versus distally pedicled sural island flap: Two elective methods for distal-third leg reconstruction. Ann Plast Surg.
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