Reconstruction of the Soft Tissue Defects of Foot and Ankle with Neural-Island Flaps: Mono-Institutional Case Series

ABSTRACT

The aim of this report is to show the results obtained from using the neural-island flap to cover the soft tissue defects of the foot and ankle. This is the first report of the neural-island flap series since the introduction of this flap to the literature in 2003. Between 2002 and 2009 “neural-island flap” was used to treat 20 patients of various lesions on the foot and ankle. All of the patients had serious soft tissue defects that compromised tendons, bones, or joints. In 16 patients, the tissue defects were completely and successfully covered with an uncomplicated postoperative course. In 4 patients the flaps presented venous congestion and intermittent bleeding and leech application was performed for 2 to 3 days postoperatively. Two of these flaps healed completely without any flap loss. In one patient because the partial flap necrosis occurred in distal one-fourth of the flap, skin grafting was performed after 1 week of vacuum-assisted closure application. Total flap necrosis occurred in only one patient who was suffering from Buerger disease. The authors conclude that the neural-island flap is a highly versatile, easy, and reproducible flap that avoids the use of complicated and risky reconstruction options. It can be considered as an alternative reconstruction option particularly in problematic cases that are not suitable for local or free tissue transfers.

KEYWORDS

Neural-island flap - neurocutaneous flap - neuroskin flap - neuro-adipofascial pedicled fasciocutaneous flap

REFERENCES

• 1 Gopal S, Majumder S, Batchelor A G, Knight S L, De Boer P, Smith R M. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.  J Bone Joint Surg Br. 2000;  82 (7) 959-966
• 2 Parrett B M, Matros E, Pribaz J J, Orgill D P. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.  Plast Reconstr Surg. 2006;  117 (4) 1315-1322 discussion 1323-1324
• 3 Vergara-Amador E. Distally-based superficial sural neurocutaneous flap for reconstruction of the ankle and foot in children.  J Plast Reconstr Aesthet Surg. 2009;  62 (8) 1087-1093
• 4 Akyürek M, Safak T, Sönmez E, Ozkan O, Keçik A. A new flap design: neural-island flap.  Plast Reconstr Surg. 2004;  114 (6) 1467-1477
• 5 Masquelet A C, Romana M C, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.  Plast Reconstr Surg. 1992;  89 (6) 1115-1121
• 6 Masquelet A C, Romana M C, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.  Plast Reconstr Surg. 1992;  89 (6) 1115-1121
• 7 Bertelli J A, Khoury Z. Neurocutaneous island flaps in the hand: anatomical basis and preliminary results.  Br J Plast Surg. 1992;  45 (8) 586-590
• 8 Bertelli J A. Neurocutaneous axial island flaps in the forearm: anatomical, experimental and preliminary clinical results.  Br J Plast Surg. 1993;  46 (6) 489-496
• 9 Bertelli J A, Kaleli T. Retrograde-flow neurocutaneous island flaps in the forearm: anatomic basis and clinical results.  Plast Reconstr Surg. 1995;  95 (5) 851-859
• 10 Cavadas P C. Reversed saphenous neurocutaneous island flap: clinical experience.  Plast Reconstr Surg. 1997;  99 (7) 1940-1946
• 11 Coşkunfirat O K, Velidedeoğlu H V, Sahin U, Demir Z. Reverse neurofasciocutaneous flaps for soft-tissue coverage of the lower leg.  Ann Plast Surg. 1999;  43 (1) 14-20
• 12 Coşkunfirat O K, Velidedeoğlu H, Küçükçelebi A. Reversed neurofasciocutaneous flaps based on the superficial branches of the radial nerve.  Ann Plast Surg. 1999;  43 (4) 367-373
• 13 Coşkunfirat O K, Ozgentaş H E. Reversed neurofasciocutaneous island flap based on the vascular supply accompanying the superficial peroneal nerve.  Plast Reconstr Surg. 2001;  108 (5) 1305-1308
• 14 Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T. Accompanying arteries of the cutaneous veins and cutaneous nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap.  Plast Reconstr Surg. 1998;  102 (3) 779-791
• 15 Nakajima H, Imanishi N, Fukuzumi S et al.. Accompanying arteries of the lesser saphenous vein and sural nerve: anatomic study and its clinical applications.  Plast Reconstr Surg. 1999;  103 (1) 104-120
• 16 Nakajima H, Imanishi N, Fukuzumi S. Vaginal reconstruction with the femoral veno-neuroaccompanying artery fasciocutaneous flap.  Br J Plast Surg. 1999;  52 (7) 547-553
• 17 Akyürek M, Safak T, Sönmez E, Ozkan O, Keçik A. A new flap design: neural-island flap.  Plast Reconstr Surg. 2004;  114 (6) 1467-1477
• 18 Ozkan O, Akyürek M, Safak T, Acar B, Ozgentaş H E, Keçik A. Neuromuscular and neuromusculocutaneous flaps in the rat.  J Plast Reconstr Aesthet Surg. 2006;  59 (3) 279-290
• 19 Sonmez E, Safak T, Kecik A. Gluteus maximus neural-island flap model in the rat.  Ann Plast Surg. 2008;  61 (3) 325-329
• 20 Sönmez E, Ozdemir H, Safak T, Keçik A. A modification of the neural-island flap: ‘split neural-island flap’.  J Plast Reconstr Aesthet Surg. 2009;  62 (1) 85-92
• 21 Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap.  Plast Reconstr Surg. 1994;  93 (5) 1012-1020
• 22 Yilmaz M, Karatas O, Barutcu A. The distally based superficial sural artery island flap: clinical experiences and modifications.  Plast Reconstr Surg. 1998;  102 (7) 2358-2367
• 23 de Almeida O M, Monteiro Jr A A, Neves R I et al.. Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot.  Ann Plast Surg. 2000;  44 (4) 367-373 discussion 373-374
• 24 Almeida M F, da Costa P R, Okawa R Y. Reverse-flow island sural flap.  Plast Reconstr Surg. 2002;  109 (2) 583-591
• 25 Imanishi N, Nakajima H, Fukuzumi S, Aiso S. Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study.  Plast Reconstr Surg. 1999;  103 (2) 494-498
• 26 Loonen M P, Kon M, Schuurman A H, Bleys R L. Venous bypass drainage of the small saphenous vein in the neurovascular pedicle of the sural flap: anatomical study and clinical implications.  Plast Reconstr Surg. 2007;  120 (7) 1898-1905
• 27 Dragu A, Bach A D, Kneser U, Horch R E. Two easy and simple modifications when using a distally based sural flap to reduce the risk of venous congestion.  Plast Reconstr Surg. 2008;  122 (2) 683-684 author reply 684
• 28 Dragu A, Bach A D, Kneser U, Horch R E. Two easy and simple modifications when using a distally based sural flap to reduce the risk of venous congestion.  Plast Reconstr Surg. 2008;  122 (2) 683-684 author reply 684
• 29 Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap.  Microsurgery. 2005;  25 (1) 36-43
• 30 Buluç L, Tosun B, Sen C, Sarlak A Y. A modified technique for transposition of the reverse sural artery flap.  Plast Reconstr Surg. 2006;  117 (7) 2488-2492
• 31 Al-Qattan M M. A modified technique for harvesting the reverse sural artery flap from the upper part of the leg: inclusion of a gastrocnemius muscle “cuff” around the sural pedicle.  Ann Plast Surg. 2001;  47 (3) 269-274 discussion 274-278 discussion
• 32 Akyürek M, Safak T, Sönmez E, Ozkan O, Keçik A. A new flap design: neural-island flap.  Plast Reconstr Surg. 2004;  114 (6) 1467-1477