[The distally based adipofascial sural artery flap for the reconstruction of distal lower extremity defects].

OBJECTIVE: Problematic tissue defects in the distal one-third of the lower leg represent a special challenge for the operative therapy. The distally based adipofascial sural artery flap is a safe and effective modification of the classical fasciocutaneous sural artery flap technique and makes the reconstruction in this problematic area more feasible. The surgical aim is soft tissue reconstruction with local tissue avoiding free tissue transfer. INDICATIONS: Complex or chronic wounds (maximum width of 8 cm) of the distal lower leg with exposed bone, joints, tendons, and/or neurovascular structures, especially in cases of missing skin perforators. CONTRAINDICATIONS: Arterial vascular disease (stage III-IV), especially peroneal artery occlusion. Postthrombotic syndrome with occlusion of the small saphenous vein. Chronic lymphedema. SURGICAL TECHNIQUE: Preparation of the vascular pedicle of the distally based flap (including small saphenous vein, sural artery and nerve), the adjacent crural fascia and the subcutaneous fat without a skin island. The pivot point is about 6 cm cranial to the malleolus lateralis. The flap can be raised proximally up to the heads of the gastrocnemius muscle. After harvesting the flap there will be a change in blood flow direction in the small saphenous vein. The donor site can be closed primarily. The flap is covered with meshed split skin graft at the end of surgery. POSTOPERATIVE MANAGEMENT: Strict elevation of the extremity for 5 days, then flap conditioning.
RESULTS: Between 1997 and 2012, this technique was used in 104 consecutive patients with soft tissue defects in the distal one-third of the lower leg. Flap survival was achieved 91 patients. In 2 patients amputation of the lower leg was necessary at the mid tibia level. In 3 cases flap necrosis occurred, requiring free tissue transfer.