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Reply: Distally Based Superficial Sural Artery Flap Excluding the Sural Nerve

Mojallal, Ali M.D., Ph.D.; Shipkov, Christo M.D., Ph.D.; Wong, Corrine M.R.C.S.; Brown, Spencer Ph.D.; Rohrich, Rod J. M.D.; Saint-Cyr, Michel M.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1750-1751
doi: 10.1097/PRS.0b013e31820a65ca
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Department of Plastic, Reconstructive, and Aesthetic; Edouard Herriot Hospital; University of Lyon, and; Department of Plastic Surgery; University of Texas Southwestern Medical Center; Dallas, Texas (Mojallal)

Department of Plastic, Reconstructive, and Aesthetic; Edouard Herriot Hospital; University of Lyon; Lyon, France (Shipkov)

Department of Plastic Surgery; University of Texas Southwestern Medical Center; Dallas, Texas (Wong, Brown, Rohrich, Saint-Cyr)

Correspondence to Dr. Mojallal, Department of Plastic, Reconstructive, and Aesthetic Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, University of Lyon, 5 Place d'Arsonval, 69437 Lyon, Cedex 03, France, dr.mojallal@gmail.com

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Sir:

We would like to thank Drs. Orbay, Ogawa, Ono, Aoki, and Hyakusoku for their pertinent comment on our recent publication on the vascular anatomical basis of the distally based sural flap.1 The notion that the sural nerve is not indispensable for the vascularization of the distally based sural flap was shown in several reports1–3 and supported by our clinical study.4 This would mean that the distally based sural flap could be considered as a perforator flap rather than a neurocutaneous flap, based on distal peroneal perforators (and tibialis posterior artery perforators to a lesser extent). In this sense, as for all perforator flaps, two questions arise: (1) What would be the territory vascularized by a single perforator? (2) What would be the direction of the blood flow from this perforator? These questions can be answered only after static and dynamic assessment of the blood supply using three-dimensional/four-dimensional computed tomographic angiography in a cadaveric model or using multidetector-row computed tomography in an in vivo model as mentioned by Orbay et al.

To give answers to these questions, we have performed anatomical studies and have recently presented the “perforasome theory,”5 which is based on four major principles concerning the suprafascial distribution of the perforator vascular branches. A perforasome was defined as a suprafascial territory supplied by a single perforator and its vascular network.5

According to the first principle of the perforasome theory, adjacent perforasomes are connected by means of both direct and indirect linking vessels. According to the second principle, flap design and skin paddle orientation should be based on the direction of the linking vessels, which is axial in the extremities and perpendicular to the midline in the trunk. This coincides with the suggestions of Ono et al. and their study on the occipital artery perforators and corresponding flaps.6 The third principle suggests that preferential filling of perforasomes occurs within perforators of the same source artery first, followed by perforators of other adjacent source arteries.

Furthermore, vascularity of a perforator found adjacent to a joint is directed away from that same joint [e.g., the direction of the blood flow of the distally based sural flap is away, that is, proximal from the ankle joint (fourth principle of the perforasome theory)]. This supports the statement of Ono et al. that “the blood flow of lower limb perforators after penetrating fascia tends to go proximally,” which makes them “believe that the distally based superficial sural artery flap is the reasonable design of the flap.” However, if the perforator is located near a proximal joint (e.g., a sural perforator distal to the knee joint), the flow will be longitudinal but distally directed. We thank Orbay et al. again for their comment, which will add further details in understanding of the vascularization of the distally based sural flap.

Ali Mojallal, M.D., Ph.D.

Department of Plastic, Reconstructive, and Aesthetic

Edouard Herriot Hospital

University of Lyon, and

Department of Plastic Surgery

University of Texas Southwestern Medical Center

Dallas, Texas

Christo Shipkov, M.D., Ph.D.

Department of Plastic, Reconstructive, and Aesthetic

Edouard Herriot Hospital

University of Lyon

Lyon, France

Corrine Wong, M.R.C.S.

Spencer Brown, Ph.D.

Rod J. Rohrich, M.D.

Michel Saint-Cyr, M.D.

Department of Plastic Surgery

University of Texas Southwestern Medical Center

Dallas, Texas

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REFERENCES

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. Mojallal A, Shipkov C, Braye F, Breton P. Distally based adipofascial sural flap for foot and ankle reconstruction. J Am Podiatr Med Assoc. 2011;101:41–48.
5. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124:1529–1544.
6. Ono S, Ogawa R, Hayashi H, Takami Y, Kumita SI, 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. 2010;63:1602–1607.

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