UAD Flap: A Contemporary Alternative to the Conventional Sural Flap for Distal Leg Wound Reconstruction
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Abstract
Background: The reconstruction of soft tissue near the heel area is challenging, especially after wheel-spoke injuries. Different varieties of the reverse sural artery flap technique are routinely used in complex locoregional areas for reconstructive surgery.
Methods: This study proposes an innovative surgical method involving the use of a rotation-advancement fasciocutaneous flap based on peroneal artery perforators. In this study, 30 patients with soft-tissue defects in the lower third of the leg, including defects in the ankle and heel areas, were treated with this flap.
Results: The study included 19 women and 11 men. The mean age of the patients was 27.60 years. The most common cause of the defect was wheel-spoke injury due to a road traffic accident. In the authors’ experience, the flap survival rate was approximately 100%. Four patients had only marginal necrosis of the distal tip, and 2 patients had minor wound infections; these patients were managed cautiously until their healing was complete.
Conclusions: For distal leg reconstruction, the authors recommend the UAD flap over the traditional sural flap because of its lower donor-site morbidity and better aesthetic appearance.
Introduction
The skin around the ankle is distinctive because of several special features, including sensitivity, pliability, and elasticity. These characteristics are essential for the ankle to operate normally as a dynamic joint when walking. If joint function and aesthetic appearance are preserved, the reconstructive surgeon's challenge is to recreate the attributes of the original tissue. Achieving satisfactory coverage of defects involving the lower third of the leg is an endlessly challenging task. These defects are frequently associated with exposure of the underlying tendons or bone. The most common causes of such defects include tumors and trauma, particularly wheel-spoke injuries from bicycles.1 A useful classification of wheel-spoke injuries is presented in Table 1.2
The literature reports multiple options for covering the ankle and heel regions.3-5 Traditionally, the reverse sural artery flap is the most commonly applied coverage option in this area.6,7 However, this approach has certain disadvantages and potential challenges such as venous congestion, flap necrosis, bulk, poor aesthetics, donor-site morbidity, contour deformity, and problems with footwear.8,9 A free flap is another option, but it requires long periods of anesthesia and is associated with donor-site morbidity, a potential lack of available recipient vessels, and the need for highly specific skill sets and clinical backup.4
In this study, we describe a surgical technique involving a new flap named by the first author, the UAD flap, performed using peroneal artery perforators, and present the results of our retrospective analysis including the location of the defect area and the coverage of this unique flap.
Methods and Materials
A retrospective descriptive analysis was conducted from 2017 to 2019 and included a total of 30 patients with wheel-spoke soft-tissue heel defects. (Table 2) The age, gender, and postoperative outcomes (including cosmesis, footwear, and complications) of the patients were noted. Defects between 2 x 3 cm and 5 x 3 cm were chosen for coverage. X-rays were advised for all patients in the heel and ankle region.
Surgical technique
The patient was placed in the prone position, and a tourniquet was applied to the thigh. The defect was prepared by wound debridement, and the Achilles tendon was repaired when needed.
Markings
Marking was performed by identifying important local landmarks; the lateral malleolus was designated as point A, and the insertion point of the Achilles tendon into the calcaneus was designated as point B. A line was drawn from point A to point B, and this line was divided into 3 equal parts. The junction of the medial one-third and lateral two-thirds of this line was designated as point C. Then, using the handheld Doppler probe, peroneal perforators were marked just above point C in the proximal direction at distances of 3 cm, 5 cm, and 8 cm. Point D was marked slightly further proximal to the highest perforator and usually signified the limiting point of the incision toward the base of the flap. The incision line was marked starting from point D proximally and curving medially in a semicircular fashion, followed by dropping directly down toward the most superomedial margin of the defect. The size of the flap was determined by the size of the defect to be covered. A back cut may be added at point D to enhance the advancement and rotation of the flap for easy coverage of the defect (Figure 1A).
Figure: (A) The peroneal perforators were marked over the lower third of the leg. Point A is the lateral malleolus, Point B is the Achillis tendon, and Point C is between the one-third and two-thirds points on the line between points A and B. The peroneal artery and sural nerve can also be seen. (B) The defect was prepared for coverage, and the flap was designed according to the size of the defect. The flap was harvested, and rotation-advancement over the defect was achieved. (C) The back cut may be needed if the flap cannot completely cover the defect and closure.
An incision was made on the medial side of the flap, and the flap was harvested in the subfascial plane (Figure 1B). Any perforators on the medial side of the flap were coagulated while dissection continued toward the lateral side, approaching the marked peroneal perforators. The short saphenous vein was ligated and divided. Upon reaching the area of the peroneal perforators, dissection should be performed very carefully to avoid damaging the perforators while ensuring the reach of the flap over the defect. To increase the reach of the flap where needed, a perforator at 8 cm may be sacrificed, and a back cut may be made (Figure 1C). After complete harvesting of the flap, the flap may be advanced to inset. The donor site was closed primarily, and a drain may be placed if necessary.
Results
The study included 19 (63.33%) women and 11 (36.66%) men. The mean age of the patients was 27.60 years (range, 12-48 years). The average body mass index was 21.4 kg/m2. The average follow-up period was 6 months. Wheel-spoke injuries secondary to road traffic accidents were the cause of defects in 24 (80.00%) patients, ulceration in 4 (13.33%) patients, and contact burns in 2 (6.66%) patients. Three patients also had 1 or more of the following comorbidities: hypertension, diabetes, and coronary artery occlusive disease.
In the experimental group, 25 (83.33%) patients achieved complete survival of the flaps with no serious complications. However, 5 (16.66%) patients experienced minor wound-related complications, including dehiscence, infection, and distal tip necrosis.
Infection occurred in 2 (6.66%) diabetic patients. Although it was skillfully controlled, the healing period was prolonged for up to 3 to 4 weeks compared with the 2 weeks in normal young patients. Additionally, venous congestion was encountered in 1 (3.33%) patient (Table 3).
Discussion
Limited mobility of the skin around the foot and ankle joints makes it difficult to reconstruct soft-tissue defects in this area. These defects are frequently associated with nearby soft-tissue injuries. The exposure of the Achilles tendon and calcaneum may result from a tumor, trauma, or a diabetic ulceration.10-12
Even minor defects need prolonged treatment to produce granulation tissue. This delay in wound healing often results in joint stiffness and other complications. It is also worth noting that only defects without any exposure to the underlying bone or tendon are amenable to such intervention. Cases involving exposure of these underlying structures require more complicated and advanced surgical procedures than non-exposure cases because of their own complication profile. Skin grafting has been an option in the treatment of these defects.13,14
Despite the potential for recovery, skin grafting alone is restricted to rare cases because it can lead to secondary graft contracture, which in turn may lead to impaired joint movement and tendon excursion. Consequently, soft-tissue reconstruction provides a pliable covering of the Achilles tendon, allowing it to maintain its function by gliding. Furthermore, it is only practical to wear normal shoes if the volume of the transferred tissue is sufficient. Additionally, the tissue must withstand pressure and shearing forces to halt periodic problems as a result of unstable scars.1,3,6,15 However, because of the lack of vascularization and poor tolerance, cross-leg flap application in low-vascularity regions, such as the ankle region, is debatable.16
Several other methods for covering soft-tissue defects near the ankle and heel have been described. Various proximally based vascular flaps from the foot have been described to cover such defects. The extensor digitorum brevis muscle flap, the flexor digitorum brevis muscle pedicle flap, the lateral calcaneal flap, the medial and lateral plantar island flaps, and the dorsalis pedis flap are some of these flaps.7,17-20 Distally based flaps are another alternative for reconstructing the heel pad.21,22 The reverse anterior tibial flap and the reverse posterior tibial flap are 2 examples of these flaps.23,24 However, these procedures result in visible contour defects at the donor site and demand the sacrifice of a crucial leg artery.25
Over the past 10 years, a variety of foot and ankle defects have been repaired using the distally based sural neurocutaneous flap, which was first described by Masquelet et al in 1992 and then by Hasegawa et al in 1994.14,19 In certain situations, this flap can be utilized in place of microsurgical flaps for reconstruction of the foot and ankle because it has a steady blood supply and is simple to harvest.14,26 Nonetheless, the relatively high pivot point of the reverse sural flap for foot and ankle coverage might result in additional trauma during flap harvest and morbidity at the lower leg donor site; wound infection with dehiscence, paresthesia, and marginal necrosis are also common complications.
The UAD flap was mostly utilized for injuries secondary to wheel spokes on bicycles, for which a conventional reverse sural artery flap was utilized. The most common feared complication of a reverse sural flap is venous congestion, which has been reported in approximately 5% to 42% of cases. In contrast, the UAD flap caused venous congestion in only 1 of our 30 patients.1,27
In many instances, sural flaps are used in 2 stages to reduce the chances of flap failure,28 whereas UAD flaps always involve a single-stage procedure. This approach helps to reduce the length of the patient’s hospital stay, relieves the stress of another surgery, and reduces the chances of anesthesia-related complications. The fasciocutaneous sural flap requires a split-thickness skin graft at its donor site, whereas the donor site of the UAD flap is closed primarily under minimal tension or healed by secondary intention for minor residual defects; therefore, the donor sites have better aesthetics, as they are exempt from problems related to skin grafting, including hyperpigmentation, hypertrophy, ulcers, and itching.1,9,22,27
In addition, the sural flap leaves a bulky contour, which prevents the patient from wearing shoes. In contrast, the UAD flap provides a natural, aesthetically pleasing, and pliable contour that provides comfort while wearing footwear.28-30 During the harvesting of the reverse sural flap, the surgeon must sacrifice the sural vascular bundle, whereas the UAD flap does not require the sacrifice of any major artery or nerve.30
Conclusions
The UAD flap is a rotation advancement flap technique based on peroneal artery perforators. It can be effectively used for heel defects, particularly for wheel-spoke injuries, in place of the reverse sural flap. It provides reconstruction with favorable contours and avoids skin grafts on the donor site without sacrificing any major structure in a single stage.
Acknowledgments
Authors: Muhammad Usman Amiruddin, MBBS, FCPS1; Ali Hassan, MBBS, FCPS2; Hafiz Saqib Sikandar, MBBS, FCPS3; Tanzeela Razzaq, MBBS4; Muhammad Siyyam, MBBS5
Affiliations: 1UA Aesthetics, Lahore, Pakistan; 2Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; 3Gujranwala Medical College Teaching Hospital, Gujranwala, Pakistan; 4Allama Iqbal Medical College, Dera Ghazi Khan, Pakistan; 5Kunri Christian Hospital, Sindh, Pakistan
Correspondence: Ali Hassan, MBBS, FCPS; alihassan2@uhb.nhs.uk
Ethics statement: The study approval was acquired from the research review committee of Hussain Surgical Hospital. The patients gave consent and permission to publish their images for the research purposes involved in this article. All the participants of this study were informed of the aim, procedure details, risks, and benefits of the surgery in simple and understandable native languages. All subject information was kept secured. Ethical Ref HSH/458; date: 03/06/2024
Disclosures: The authors disclose no relevant financial or nonfinancial interests.
References
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