| ObjectiveTo find a best way to repair skin soft tissue defects of middle or distal foot. The rotation point of traditional sural neurofasciocutaneous flap is high.which can not be transferred to distal foot. By improving the design of sural neurofasciocutaneous flap, the rotating point of the flap could be taken in the region2-3cm above the lateral malleolar. Which can be used to repair the foot in a distant trauma.MethodsBy autopsy of lower limbs amputated due to severe trauma in13cases, we found that the peroneal artery and its terminal branches issue2～4perforating branches in the lateral post-clearance, at least one perforating branches was greater than0.5mm in diameter, and perforating branches of the constant presence was the anatomical basis of the flap rotation point down. The number and approximate location of the vessel of lateral post-clearance were snooped by Doppler vascular probe and the distribution of peroneal artery, vascular diameter and hemodynamic parameters of lateral post-clearance were detected by high-resolution color Doppler flow imaging before surgical operation. Mark the largest perforating arteries location on the skin. Careful separation of the flap to prevent it from being destroyed. Using the connection of the midpoint of the I atera I malleolus and the achilles tendon to the popliteal fossa midpoints as the axis of the flap, i. e the surface projection the small saphenous vein and the sural nerve, the rotating point is2cm～3cm to the lateral malleolus pedicle width is4cm, the edge of flap is1cm～2cm wider than the recipient site.Retrogradely cut the flap, find and confirm the sural nerve and small saphenous veins, according to the trend of the neurovascular bundle, adjust the position of the flap.If the flap needs carrying muscles, according to the defects of recipient site, cut the superficial gastrocnemius and sutures it with the fascia and subcutaneous tissue to avoid avulsion. Li gate and cut the higher perforating septum branches. Carefully dissect lateral rotating point, not need dissect the vascular bundles of the perforating branches transfer the flap in first period,12cases were repaired total ly, The flaps ranged in size from5cm*6cm to12cm*18cm.ResultsIn12cases of lower rotating point sural neurofasciocutaneous flap, two for middle foot wound repair, ten for the repair of distal foot wounds. Ten flaps survived, and distal part of one case had approximately2cm*2cm skin necrosis, but healing occurred after dressing. Distal part with a blister occurred in1flap, but dermis and deep tissue survival was not affected. The follow-up for6months to9cases revealed that the flap shape is satisfactory and part of the feeling is restored.ConclusionsThe blood vessel system of the sural nerve nutrition lies in the lateral malleolus, lateral ankle and heel, which anastomosises with the lateral malleolus artery, the lateral artery and its perforating branches around the ankle, and a large number perforating branches from the poster i or tibial artery, anterior lateral malleolus artery, dorsal artery, lateral tarsal artery, the blood comes from the distal part can offer long distance blood through the sural nerve vascular system which simi lars to the "axis of cardiovascular" structure; the blood of the distal pedicle flap may come from the combined of multiple perforating branches rather than just rely on a simple perforating branches. This is the anatomical basis of the lower rotating point. Reduce the rotating point ot the sura I nerve flap allows sufficient rotating arc, can repair the distal foot skin and soft tissue defects, and its thickness is moderate,blood supply is safe and reliable, the survival rate is high, cut and extension is easy, a wide range of repairable defects, not damage the well-known blood vessels. Therefore, the lower rotating point sural neurofasciocutaneous flap is the ideal alternative for repairing in distal defect of the foot. |
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