Objectives. The NEUROCUTANEOUS SURAL ARTERY FLAP taken from the calf is the one of best procedures to cover defects of the lower leg, ankle, and foot. Patients alld Methods. We report our experience with 15 Patients presenting with chronIc and traumatic wounds of the ankle and foot. Results. All cases were successfully operated at our center during the five year period from 1998 to 2003. Among the complications, we encountered 3 cases of partial necrosis. Due to its good vascularity and long pedicle, this FLAP has a wide range of rotation in the dorsum, sole, heel, and malleoules, and is a dependable and versatile procedure for surgeons. Another advantage is easy and quick dissection. Donor site scar and anesthesia of the lateral side of the leg is a disadvantage of this FLAP.

The distal third of the tibia, ankle and heel area is difficult to reconstruct. For small to medium size defects, local FLAPs are often an easier alternative than free FLAP. In lower limb surgery, the SURAL FLAP is based on this principle and this FLAP is becoming increasingly popular. The distally based superficial SURAL ARTERY FLAP, first described as a distally based neuro skin FLAP by masquelet et al., is a skin island FLAP supplied by the vascular axis of the SURAL nerve. The main disadvantage of distally based SURAL ARTERY FLAP is sacrifice of the SURAL nerve because it is described the concept of neurocutaneus island FLAP. We describe one case of reverse SURAL FLAP without SURAL nerve .The aim of this paper is to establish the reliability of this FLAP even without SURAL nerve.

Background: The reversed SURAL ARTERY FLAP is a well-described method for lower limb reconstruction. However, in the standard technique, the FLAP is usually not harvested from the proximal third of the leg. We conducted this study to evaluate the efficiency, safety, and success rate of the reversed SURAL FLAP harvested from the proximal third of the leg. Methods: The authors harvested medium to very large sized FLAPs from or extended to the upper third of the calf in 28 patients to cover the defects in the distal tibia, ankle, heel, foot, and sole. Results: With proximal extension of the FLAP, we would have a longer and larger FLAP with a safer pedicle. The majority of FLAPs resulted in a good coverage of defects. Only the distal 1cm of a large FLAP developed marginal necrosis in the distal border, which was treated with a secondary skin graft. Six FLAPs developed venous congestion. In seven other patients, minor complications such as hypertrophic scar in the donor site, rupture of sutures, and superficial epidermolysis occurred. In these 13 patients, the complications did not influence the final outcome.  Conclusion: Extension of reversed SURAL island FLAP to the proximal third of the leg was safe and reliable. It was efficiently used to treat patients with large and far wounds, from the distal leg to the distal foot and the sole with more versatility and easier reach to the recipient site.

Introduction & Objective: The repair of soft tissue defect in lower leg and heel area with free FLAP is still a standard in reference books. However, there are disadvantages in the use of free FLAP like increased operative time, the damage of major vessels and the need for experienced microsurgeon. The use of local fasciocutaneous FLAP is usually impossible in these areas due to limited soft tissue, especially in moderate and large size defect.Reverse island SURAL FLAP is an island FLAP based on the vascular axis of the SURAL nerve, which gets reverse blood flow through communication with the perforating branch of the proneal ARTERY in lateral malleolar gutter. This FLAP can be a good alternative to free FLAP for the reconstruction of lower leg and heel soft tissue defect.Materials & Methods: Between 1383 and 1386,20 patients (18 male and 2 female), mean age 36 years were treated in 2 plastic and reconstructive centers for soft tissue defect of lower leg and heel area with reverse island SURAL FLAP. The mean follow up of patients was 6 months. After debridment and detection of defect size, FLAP was elevated. The FLAP was inserted in defect aria and the pedicle passed over skin in 18 patients and passed through subcutalous tunnel in 2 patients. FLAP pedicel was removed after 2 months. Results: In all patients, repair was complete, venous congestion was occurred in 16 patients. Superficial partial FLAP necrosis was present in 2 patients which were treated with conservative management. In 1patient, bleeding from FLAP border was occurred, but stopped after 12 hours.Conclusions: According to the results of our study, reverse island SURAL FLAP is a good alternative to free FLAP for coverage of lower leg and heel soft tissue defect. Short operative time, easy technique and rapid ambulation of patient are the advantages of this FLAP.

SURAL FLAP is one of the NEUROCUTANEOUS FLAPs, which was explained for the first time by Masquelet in 1992. Nowadays the distally based vascularized reverse SURAL island FLAP has eliminated the need for free FLAP with microscopic surgical procedures in repairing soft tissue defects of heel, middle and distal third of the leg. This FLAP has been located on a tiny vascular complex beneath the skin of SURAL nerve region. We have used repeatedly this FLAP for repairing soft tissue defects of the heel and leg. This question has raised in mind that regarding delicate nutrient vessels of the FLAP, can we use this FLAP for a patient with frostbite in lower limbs?In this article we have explained successful application of this FLAP in a patient with frostbite in his lower limb which led to toes amputation and had advanced sce in frostbite scar of heel.

The distally based SURAL fasciocutaneous FLAP has become a main part of the reconstruction of the lower leg, heel and foot. However, perfusion problems and venous congestion have been reported. Over the past decade, several FLAP modifications have been reported to improve FLAP viability and to solve a myriad of reconstructive needs. The purpose of this paper is to describe our experience in harvesting the reversed large SURAL FLAP from the proximal and middle third of the leg for large defects on the foot. We applied the extended reversed SURAL FLAP from the proximal third of the leg in traumatized patients which had large defects on their foot. The technique was done in 3 parts: 1- the FLAPs were designed in the proximal third of the leg five centimeter lipofascial tissue was protected around the pedicle in distal part; 3- The pivot point was located in seven to eight cm proximal the lateral malleolus before the first fasciocutaneous perforators arising from the peroneal ARTERY. SURAL FLAPs from the proximal and middle third of the leg were designed in 13 patients who had large defects on their foot. No FLAP necrosis or split thickness skin graft loss occurred. The FLAPs healed by the 3rd week excluding two patients. This study supports the application of our technique as a safe, easy and useable method in large defects of the foot. The results showed low rates of ischemia, venous congestion, dehiscence, infection and FLAP necrosis. Proximal extended and large distally based SURAL FLAP is an alternative to free tissue transfer for large defect reconstruction of the foot.

Marjolin's ulcer following frostbite is a rare occurrence. Our review of literature revealed that only 23 cases have been reported. In most instances heel is involved and the most common associated malignancy is squamous cell carcinoma. We present a 69-year-old male patient with squamous cell carcinoma arising over a frostbite scar in heel 45 years after cold injury. This case is unique with respect to the treatment modality performed: resection of tumor with free margins and reconstruction with pedicled reverse SURAL FLAP with good result and no evidence of recurrence during the follow up period.

Background: A SURAL ARTERY FLAP is a fasciocutaneous one based on the reverse blood flow and the anastomosis between the superficial SURAL ARTERY and the perforators of peroneal ARTERY. This FLAP is used in order to reconstruct the soft tissue defects of the distal leg, ankle and heel and also to cover the vessels, tendons and bones. It is possible to cover the defects in size 10*12 cm with this FLAP, classically; as well, the design of the FLAP is being done by the limited shapes such as L and T-shaped. The purpose of this article is to introduce the new design of this FLAP to creating the most level of consistency with the shape of the defect.Method: The patient was a twelve year old girl who faced a large defect and the separation of the soft tissue of the heel and ankle of the right foot by an accident with a motorcycle about three weeks prior to her referral as her medial malleolus and Achilles tendon were exposed.Then, after the first reconstruction in the orthopedically services, she faced severe necrosis of tissue and exposition of the heel's bone and Achilles tendon. There was not a clear sensory disorder in her fingers and the movement of her ankle and toes were intact. During the first surgical operation, debridement of the necrotic tissue was occurred and preparation of the fields for the pediculate FLAP was done. Then bandage, dressing and splint–making were completed. The second operational surgery was done for designing a FLAP and during this operation, the SURAL FLAP was designed in a boot – shaped way due to the impossibility of covering the defect using the classic method and the obvious need for longer pedicle. In the end, the basis of FLAP was cut during the third operational surgery and the final reconstruction of the damage was done. Moreover, the soft tissue defect of the donor FLAP was reconstructed by the cutaneous graft from the medial surface of the thigh of the same foot. Then, the patient was followed for three months.Findings: The final result of designing the SURAL FLAP in a boot – shaped way for this area of lower limbs was remarkable because there were no side effects such as venous congestion, superficial necrosis and the bleeding from the FLAP's edge and finally, the patient could properly walk. The effects of removing the FLAP in the donor site and the sensory disorder resulted from removing the FLAP were trivial and negligible and also, the patient returned to her daily life in almost no time.Conclusion: A boot-shaped SURAL FLAP is one of the best choices for covering the defects of soft tissue of the heel and ankle. In the classic term, it is formed in a rectangular or oval shape but this FLAP was a versatile FLAP and can be designed in other shapes for increasing the efficiency of the FLAP and decreasing the side effects in terms of the shape and size of the defects.

Background: Coverage of traumatic soft-tissue defects in the lower limb is a common procedure.Objectives: The purpose of this prospective case series study was explore the capacity of the perforator-based SURAL FLAP in reconstruction surgery of patients with high velocity gunshot wounds in the distal third of the leg and heel pad of the foot.Patients and Methods: A prospective case series study was undertaken to assess the SURAL fasciocutaneous FLAP carried out in our hospital, from 2010 to 2011. This case series study comprised eight patients, seven men and one woman with an average age of 35 years (19-55) and with a mean follow-up duration of 13 months (6-24 months). All patients had a history of a gunshot wound in distal part of the leg and heel pad of the foot with large soft-tissue defects; treatment was done using the reverse SURAL FLAP.Results: We performed reverse SURAL FLAPs in eight gunshot patients, to cover the defects of the lower leg and foot. Surgical site infection observed in one patient (12.5%) was treated successfully with antibiotic therapy. The reverse SURAL FLAP provided a satisfactory coverage for gunshot defects in all the patients.Conclusions: Reverse SURAL FLAP is a useful and versatile reconstructive method in patients with gunshot wounds of the lower leg and foot.

Background: Coverage of soft tissue defects around heel and distal is difficult. Several different types of FLAPs have been designed and used for this purpose. A distally-based SURAL fascio-cutaneous island FLAP is one of such remedies for this difficult problem. We are reporting with the use of this coverage technique which has a reliable vascular supply.Material and Methods: The use of SURAL FLAP for heel or distal leg coverage in 7 cases of soft tissue defects from traumatic degloving injuries, burn and malignancy are reported. Survival of the FLAP grafts, and patients' satisfaction in terms of sensation and function are reported with a 6-24 months follow-up.Results: FLAP survival was observed in 6 cases with satisfactory outcomes. The one case of failure was seen in the member of the group with history of surgery in that vicinity and vascular calcification.Conclusion: Distally-based SURAL fascio-cutaneous island FLAP is another armamentarium for successful coverage of difficult heel and distal leg defects which does not require microsurgical techniques.