Super-Drained Distally Based Neurofasciocutaneous Sural Flap: A Case Series and Review of Literature

Objective: The distally based neurofasciocutaneous sural flap is central to the armamentarium for the reconstruction of leg's distal third, ankle, and hindfoot. Despite the use of adapted techniques aimed at increasing the flap's reliability, venous congestion remains a frequently encountered problem. We present a venous super-drainage technique used by the senior author to reduce venous congestion and improve flap reliability when harvesting larger flaps. Methods: A retrospective chart review, from January 2002 to October 2008, at 2 tertiary care centers, was conducted on all cases of inferior limb reconstruction with reverse sural flaps on defects greater than 10 × 5 cm. In addition, a literature review was carried out to examine the average sural flap surface area and reported complications published from 1992 to 2012. We then compared our results with those published in the literature. Results: A total of 15 flaps were identified. Mean flap dimensions were 14 × 8.5 cm (mean area = 115.27 cm(2); 95% confidence interval, 99.28–131.26). None of the flaps developed complications (arterial or venous insufficiency, partial/complete necrosis). The average flap surface area in the literature is 55.08 cm(2), with a 22% rate of total complications. We harvested significantly larger flaps (P < .001) with a significantly lower total complication rate (P < .05) when compared with that reported in the literature. Conclusion: Anastomosing the proximal end of the lesser saphenous vein with a vein at the defect site improves venous outflow, effectively reducing the incidence of venous congestion, increases the potential flap size, and improves reliability.