The distally based posterolateral supramalleolar neurofasciocutaneous island flap for coverage defects over the distal third of the leg and foot

Abstract

A traditional-designed distally based sural flap centralized on the axis of the (medial) sural nerve and the lesser saphenous vein has been used widely for coverage of the distal third of the leg, ankle, malleoli, and foot. However, a variety of 5% to 47% of flap necrosis after the flap elevation and transposition were recorded in the literature. The unreliability of the distal part of the flap, especially when skin paddle located at the proximal third of the leg is at least partly due to their subfascial coursing of the median superficial sural artery and the medial sural nerve as well as the lesser saphenous vein. Based on the anatomic characteristics of the sural nerve and previous angiographic studies, a longitudinal chain-linked axial vascular network along with the sural nerve and the lateral sural nerve had been demonstrated on the posterolateral side of the leg from lateral retromalleolar gutter to the fibular head. A distally based posterolateral supramalleolar neurofasciocutaneous island flap centralized on this longitudinal neurovascular network was designed and used to reconstruct and cover the defects over the distal third of the leg, lateral malleolus, foot, and Achilles tendon. In this report we retrospectively review the clinical outcomes. This flap was used in 11 patients, including six young children aged 3 to 6 years. All flaps survived fully without complications except one flap which experienced postoperative infection which was controlled by dressing change and antibiotic application. Relevant surgical anatomy and detailed surgical techniques for elevation of the flap and its versatile usage are presented. Risks leading to flap necrosis, safe pedicle design, and manipulations etc. are discussed. In conclusion, this distally based posterolateral supramalleolar neurofasciocutaneous island flap is reliable and very useful for covering defects over the distal leg, ankle, heel, foot, and Achilles tendon, especially in young children.