European Journal of Plastic Surgery

, Volume 41, Issue 2, pp 165–172 | Cite as

Versatile distally based neurocutaneous saphenous flap in the era of microsurgery

  • Pradeep Goil
  • Ghisulal M. Choudhary
  • Rakesh Jain
  • Manohar K. Malviya
  • Ayush Jain
Original Paper



The reconstruction of soft tissue defects in the distal third of the leg and ankle joint remains a challenge for reconstructive surgeons. Presently, the distally based neurocutaneous flaps are the predominant surgical alternatives to free tissue transfer. In this article, we describe our experience with the distally based saphenous neurocutaneous flap for reconstructing soft tissue defects in this region.


A retrospective review of all patients who underwent reconstruction of the leg distal third and ankle joint at our department from January 1996 to June 2016 was carried out. Only patients who underwent reconstructive surgery for acute traumatic injuries were included. The fasciocutaneous pedicle was 3–4 cm wide, and the anatomical structures consisted of the superficial and deep fascia, saphenous nerve, greater saphenous vein and their accompanying vessels together with an islet of subcutaneous cellular tissue and skin. The size of skin islands ranged from 5–7 to 10–14 cm2.


A total of 170 patients (142 men and 28 women) were included in this study. The mean follow-up period was 3 months. All flaps survived with partial necrosis in three patients. Severe venous congestion occurred only in five patients. However, the flap was eventually salvaged after limb elevation and interrupted bloodletting. All donor sites were closed using split-skin grafting.


The reverse saphenous neurocutaneous flap proved to be a reliable and efficient method for reconstructing soft tissue defects in the distal third of the leg and ankle joint.

Level of Evidence: Level IV, therapeutic study


Pedicled flap Distal third-leg defects Reverse saphenous flap Cross-leg flap Neurocutaneous flap 


Compliance with ethical standards


There was no funding from either public, private or third-sector sources.

Conflict of interest

Pradeep Goil, Ghisulal Choudhary, Rakesh Jain, Manohar malviya and Ayush Jain declare that they have no conflict of interest.

Patient consent

Patients provided written consent before their inclusion in this study.

Ethical approval

For this kind of retrospective study, formal consent from a local ethics committee is not required.


  1. 1.
    Pinsolle V, Reau AF et al (2006) Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg 59:912–917CrossRefPubMedGoogle Scholar
  2. 2.
    Masquelet AC, Romana MC, Wolf G (1992) Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 89:1115–1121CrossRefPubMedGoogle Scholar
  3. 3.
    Schmidt K, Jakubietz M et al (2013) The distally based adipofascial sural artery flap for the reconstruction of distal lower extremity defects. Oper Orthop Traumatol 25:162–169CrossRefPubMedGoogle Scholar
  4. 4.
    Yang C, Li Y, Geng S et al (2013) Modified distally based sural adipofascial flap for reconstructing of leg and ankle. ANZ J Surg 83:954–958CrossRefPubMedGoogle Scholar
  5. 5.
    Liu L, Liu Y, Zou L et al (2013) The distally based superficial sural flap for reconstruction of the foot and ankle in pediatric patients. J Reconstr Microsurg 29:199–204CrossRefPubMedGoogle Scholar
  6. 6.
    Dai J, Chai Y, Wang C et al (2013) Comparative study of two types of distally based sural neurocutaneous flap for reconstruction of lower leg, ankle, and heel. J Reconstr Microsurg 29:125–130CrossRefPubMedGoogle Scholar
  7. 7.
    Hamdi MF, Kalti O, Khelifi A (2012) Experience with the distally based sural flap: a review of 25 cases. J Foot Ankle Surg 51:627–631CrossRefPubMedGoogle Scholar
  8. 8.
    Peng F, Wu H, Yu G (2011) Distally-based sural neurocutaneous flap for repair of a defect in the ankle tissue. J Plast Surg Hand Surg 45:77–82CrossRefPubMedGoogle Scholar
  9. 9.
    Rudig LL, Gercek E, Hessmann MH et al (2008) The distally based sural neurocutanenous island flap for coverage of soft-tissue defects on the distal lower leg, ankle and heel. Oper Orthop Traumatol 20:252–261CrossRefPubMedGoogle Scholar
  10. 10.
    Zhang F, Zhang CC, Lin S et al (2009) Distally based saphenous nerve-great saphenous veno-fasciocutaneous compound flap with nutrient vessels: microdissection and clinical application. Ann Plast Surg 63:81–88CrossRefPubMedGoogle Scholar
  11. 11.
    Kansal S, Goil P, Agarwal V et al (2014) Reverse pedicle-based greater saphenous neuro-veno-fasciocutaneous flap for reconstruction of lower leg and foot. Eur J OrthopSurgTraumatol 24:62–72Google Scholar
  12. 12.
    Wang X, Mei J, Pan J et al (2013) Reconstruction of distal limb defects with the free medial sural artery perforator flap. Plast Reconstr Surg 131:95–105CrossRefPubMedGoogle Scholar
  13. 13.
    Hu XH, Du WL, Chen Z et al (2013) The application of distally pedicled peroneus brevis muscle flaps and retrograde neurocutaneous accompanying artery flaps for treatment of bony and soft-tissue 3-dimensional defects of the lower leg and foot. Int J Low Extrem Wounds 12:53–62CrossRefPubMedGoogle Scholar
  14. 14.
    Chung YJ, Kim G, Sohn BK (2002) Reconstruction of a lower extremity soft-tissue defect using the gastrocnemius musculoadipofascial flap. Ann Plast Surg 49:91–95Google Scholar
  15. 15.
    Kim TG, Kim IK, Kim YH et al (2012) Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link. Microsurgery 32:575–579Google Scholar
  16. 16.
    Rı’os-Luna A, Villanueva-Martı’nez M, Fahandezh-Saddi H et al (2007) Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury 38:824–831CrossRefGoogle Scholar
  17. 17.
    Nayak BB, Thatte RL, Thatte MR et al (2000) A microneurovascular study of the great saphenous vein in man and the possible implications for survival of venous flaps. Br J Plast Surg 53:230–233CrossRefPubMedGoogle Scholar
  18. 18.
    Chang SM, Hou CL (2000) Role of large superficial veins in distally based flaps of the extremities. Plast Reconstr Surg 106:230–231CrossRefPubMedGoogle Scholar
  19. 19.
    Cavadas PC (2003) Reversed saphenous neurocutaneous island flap: clinical experience and evolution to the posterior tibial perforator-saphenous subcutaneous flap. Plast Reconstr Surg 111:837–839CrossRefPubMedGoogle Scholar
  20. 20.
    Shao X, Yu Y, Zhang X et al (2011) Repair of soft-tissue defect close to the distal perforating artery using the modified distally based medial fasciocutaneous flap in the distal lower leg. J Reconstr Microsurg 27:145–150CrossRefPubMedGoogle Scholar
  21. 21.
    Heymans O, Verhelle N, Peters S et al (2002) Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest. Burns 28:674–678CrossRefPubMedGoogle Scholar
  22. 22.
    Lineaweaver WC, Lei MP, Mustain W et al (2004) Vascular endothelium growth factor, surgical delay, and skin flap survival. Ann Surg 239:866–873CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Satoh K, Aoyama R, Onizuka T (1993) Comparative study of reverse flow island flaps in the lower extremities-peroneal, anterior tibial, and posterior tibial island flaps in 25 patients. Ann Plast Surg 30:48–56Google Scholar
  24. 24.
    Tharayil J, Patil RK (2012) Reverse peroneal artery flap for large defects of ankle and foot: a reliable reconstructive technique. Indian J Plast Surg 45:45–52Google Scholar
  25. 25.
    Chang SM, Zhang K, Li HF et al (2009) Distally based sural fascio-myocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel. Microsurgery 29:205–213Google Scholar
  26. 26.
    Bocchi A, Merelli S, Morellini A et al (2000) Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction. Ann Plast Surg 45:284–291Google Scholar
  27. 27.
    Yu AX, Deng K, Tao S et al (2007) Anatomic study and clinical application of distally-based neuro-myocutaneous compound flaps in the leg. Microsurgery 27:528–532Google Scholar
  28. 28.
    Boriani F, Bruschi S, Fraccalvieri M et al (2010) Leg perforators and leg length: an anatomic study focusing on topography and angiogenesis. Clin Anat 23:593–605Google Scholar
  29. 29.
    Bhattacharya V, Reddy GR (2006) Retrograde perforator-based cross-leg fasciocutaneous flaps for distal leg and foot defects. Plast Reconstr Surg 117:1662–1664Google Scholar
  30. 30.
    Sharma RK, Kola G (1992) Cross leg posterior tibial artery fasciocutaneous island flap for reconstruction of lower leg defects. Br J Plast Surg 45:62–65Google Scholar
  31. 31.
    Ducic I, Attinger CE (2011) Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 128:173–180CrossRefPubMedGoogle Scholar
  32. 32.
    Noack N, Hartmann B (2006) Küntscher MV. Measures to prevent complications of distally based neurovascular sural flaps Ann Plast Surg 57:37–40PubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of Plastic SurgerySMS Hospital And Medical CollegeJaipurIndia

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