Distally Based Sural Flap in Treatment of Chronic Venous Ulcers

Abstract

The treatment of venous ulcers of the leg often fails to heal because venous ulcers are mostly associated with severe lipodermatosclerosis. These complicated ulcers may require correction of local hemodynamics, excision of ulcer with surrounding lipodermatosclerotic skin, and replacement of the defect with healthy tissue. We present our experience with the use of the distally based sural flaps for the reconstruction of soft-tissue defects of the distal region of the lower limb in patients with chronic venous ulcer. Between 2001 and 2003, 12 patients with venous ulceration were treated with distally based sural flaps. At operation, the ulcer and its surrounding lipodermatosclerotic skin were excised. The defects after excision ranged from 3 x 3 to 11 x 17 cm. The distally based sural artery flap was inset within the defect. In all patients, the flap survived completely, and in only 1 patient, distal venous congestion was seen and was treated successfully with leeches. There was donor site skin graft loss in 2 patients. Two flaps had minor local complications that healed with local wound care. No recurrent ulcers were identified after average 19.7 months. In conclusion, the distally based sural flaps can be used reliably for treatment of venous ulcers. Our approach in treatment of chronic venous ulcers improves venous hemodynamics and provides local flap alternative that should be considered prior to a free-flap transfer for closure of the defect.

The Reverse Flow Sural Flap in the Treatment of the Soft Tissue Defects, Distally Part of the Leg - A Preliminary Report

“…Leeches improve perfusion within congested tissue by drawing off blood and anticoagulants in their saliva injected into the bite (17). Top et al used successfully leech therapy in venous congestion treatment of a sural flap (18). In our two cases of hirudotherapy treatment we observed a reduction of venous congestion.…”

The Distally Based Sural Flap

“…69 The flap has also been shown to be useful as a cross-leg flap by a number of authors. 39,40,41 The causes of the defects needing repair that have been reported in the literature include the following: nonhealing skin wounds/ulcers, 2,13,24,42 chronic venous ulcers, 43 29 gangrene, 29 unstable scars, 48 cancer resections, 13 and electrical burns. 49…”

Complex Wounds

“…91 The importance of the role of skin grafting resilience and its potential to prevent recurrence is being evaluated, as is that of local and distant flaps used in more severe cases of recalcitrant ulcers after removal of the lipodermatosclerotic tissues. 92,93 Vein stripping and perforator ligation valvuloplasty may improve regional venous hemodynamics and are often indicated by vascular surgeons, but they do not solve the problem of the wound if there is irreversible scarring due to surrounding lipodermatosclerosis.…”

“…Fournier's gangrene occurs in male and female patients with genital abscesses, cellulitis, necrotizing fasciitis, and vascular disorders; it is more frequent in males than in females. 92 Precautionary measures are important for supporting the patient with Fournier's gangrene as are urinary and fecal diversions when necessary. Treatment with hyperbaric oxygen is still controversial as a complementary treatment to débridements, although some have claimed advantages with its use.…”