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Distally Based Superficial Sural Artery Flap Excluding the Sural Nerve

Orbay, Hakan M.D.; Ogawa, Rei M.D., Ph.D.; Ono, Shimpei M.D., Ph.D.; Aoki, Shimpo M.D., Ph.D.; Hyakusoku, Hiko M.D., Ph.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1749-1750
doi: 10.1097/PRS.0b013e31820a6551

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, Tokyo, Japan,

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We read with great interest the article entitled “Vascular Supply of the Distally Based Superficial Sural Artery Flap: Surgical Safe Zones Based on Component Analysis Using Three-Dimensional Computed Tomographic Angiography” by Mojallal et al.1 and would like to congratulate the authors on their impressive work.

The possibility of excluding the sural nerve during the dissection of distally based superficial sural artery flaps was first reported by Hyakusoku et al.2 in 1994. This concept was further supported by a cadaver study by Aoki et al.3 In our hospital, we have been using distally based superficial sural artery flaps without sural nerve for the reconstruction of distal leg defects since the late 1980s (Figs. 1 and 2) and have already presented a clinical series,3 as Mojallal et al.1 also referred to in their article.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

The three-dimensional computed tomographic angiography data presented by Mojallal et al.1 in their article are largely consistent with the data presented previously by Aoki et al.3 Moreover, Aoki et al.3 have documented that the diameters of extrinsic vessels around the sural nerve were larger than those around the lesser saphenous vein; however, the sural nerve had fewer intrinsic vessels. A very close connection in between the extrinsic vessels of the sural nerve and the lesser saphenous vein was also observed on angiography.3 The results of the study by Mojallal et al.1 together with our previous data2,3 verify our clinical hypothesis that the sural nerve itself is not so important in terms of survival of distally based superficial sural artery flaps and can be spared during flap elevation.

However, the prediction of the flap survival area and appropriate design are still challenging. We believe it is important to determine the suprafascial perforator directionality4 using multidetector-row computed tomographic analysis. Multidetector-row computed tomographic analysis might be used to reveal the characteristics of suprafascial perforator directionality in all parts of the body.4,5 Our results from previous multidetector-row computed tomographic studies have suggested that the direction of the blood flow in peripheral perforators is toward the central portion. In contrast, the perforators originating near the median line of the body have laterally directed blood flow. In other words, blood flow of lower limb perforators after penetrating fascia tends to flow proximally. Thus, we now believe the distally based superficial sural artery flap is the reasonable design of the flap.

Hakan Orbay, M.D.

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

Shimpei Ono, M.D., Ph.D.

Shimpo Aoki, M.D., Ph.D.

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

Department of Plastic and Reconstructive Surgery

Nippon Medical School Hospital

Tokyo, Japan

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The authors have no financial interest to declare in relation to the content of this communication.

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1. 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;126:1240–1252.
2. Hyakusoku H, Tonegawa H, Fumiiri M. Heel coverage with a T-shaped distally based sural island fasciocutaneous flap. Plast Reconstr Surg. 1994;93:872–876.
3. Aoki S, Tanuma K, Iwakiri I, et al. Clinical and vascular anatomical study of distally based sural flap. Ann Plast Surg. 2008;61:73–78.
4. Ono S, Ogawa R, Hayashi H, Takami Y, Kumita S, Hyakusoku H. Multidetector-row computed tomography (MDCT) analysis of the supra-fascial perforator directionality (SPD) of the occipital artery perforator (OAP). J Plast Reconstr Aesthet Surg. 2009;63:1602–1607.
5. Ono S, Hayashi H, Ogawa R, Hyakusoku H. MDCT analysis of systemic suprafascial perforator directionality (SPD) for perforator flaps designing: The possibility of application for upper limb reconstruction. Paper presented at: 2010 Meeting of the Federation of European Societies for Surgery of the Hand; June 2010; Bucharest, Romania.

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