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Inclusion of an additionalInclusion of an additional
perforator to augmentperforator to augment
suralneurocutaneoussuralneurocutaneous
(SNC) flap(SNC) flap
Dr. Sumita ShankarDr. Sumita Shankar

Clinical application
Cadaveric study
Addl.perforator along the
lat. border of TA
Prologue…
The SNC flap…
as we know it

SNC flap
 Fasciocut. flap
 Pivot point
 Surface marking
 Flap size
15X5cms

(SNC) flap-Utility
Reconstructive option
for the defects
 Lower 1/3 leg
 Around ankle
 Heel
 Mid foot

Other treatmentOther treatment
modalitiesmodalities
 Free flap
 Local flaps
medial plantar artery
lateral calcaneal artery
local muscle flaps
 Premalleolar flap
 Cross-leg flap

Advantages of SNC flapAdvantages of SNC flap
 Work horseWork horse
 Ease of dissectionEase of dissection
 ReliabilityReliability
 Major limb vesselMajor limb vessel
sparedspared
 Single stage procedureSingle stage procedure

the nagging problem…
tip
necrosis…tip
necrosis…

Venous congestionVenous congestion
Use of Leeches
three months postop
Post cellulitis defectPost cellulitis defect
DiabeticDiabetic
Age >65 yrsAge >65 yrs

Cadaveric study
Addl.perforator along the
side of TA
Prologue…
The problem: edge
necrosis with SNC flap

Doppler study
 Hand held doppler, 5Mhz probe
 24 limbs studied
(7 healthy, 10 injured)
 4-6cms prox. to lat. malleolus
 Along the lateral
border of TA

Colour doppler studyColour doppler study
• Presence and
location confirmed
• Caliberation
1.0 -1.2mm sizes
1.0 & 1.2 mms perforators

Cadaveric study
Addl.perforator on either
side of TA
Prologue…
The problem: edge
necrosis with SNC flap

 10 limbs in 5 fresh cadavers
 Ant.tibial, Post.tibial & Peroneal
arteries cannulated
 Colour dye injected
 A different colour for each
artery
Dye injection…

TA
reflected
Flap base
Post. Tibial NV bundle
Communicating
vessel

Findings
 Communicating br.
between PTA and
Peroneal art.
 4-6cms. prox.l to tip of
lat.malleolus
 Along the lat. border
of TA

 SNC flap 23SNC flap 23
 SNC variant 10SNC variant 10
 Age 25-65 yrsAge 25-65 yrs
 M:F 32:1M:F 32:1
Distribution:Distribution:
 Distal 1/3 leg 11
 Medial malleolus 3
 Lat. malleolus 8

the study… ( 33 cases )the study… ( 33 cases )
Jan ‘02 – Nov ‘04Jan ‘02 – Nov ‘04

S.Saph.v
Perforator
Sural.n
SNC Variant – Flap planning

Caveats for success…
 Patent perforators onPatent perforators on
dopplerdoppler
 Inclusion of sural nerve ’n’Inclusion of sural nerve ’n’
short saphenous veinshort saphenous vein
 Inclusion of addl. PerforatorInclusion of addl. Perforator
 Inset without any tensionInset without any tension

The challanges…
Lat malleolar defect
Med. malleolar defect
heel defectLat malleolar defect

Causative factorsCausative factors
 Posttraumatic 16Posttraumatic 16
Inj.–Rx interval (<6hrs->4wks)Inj.–Rx interval (<6hrs->4wks)
 Cellulitis 3Cellulitis 3
 Chronic venous ulcers 5Chronic venous ulcers 5
 Postoperative 3Postoperative 3
 Unstable Scar 5Unstable Scar 5
 Neoplastic lesion 1Neoplastic lesion 1

Post.traumatic heel defect…
4wks
14.5x7cms
F/Pt

Post. infective
2 wks2 wks
Xposed ankle jtXposed ankle jt.
DiabeticDiabetic
14x6cms

Post traumatic
Lat malleolar defect
12x6cms

Medial reach of the flap
Med. malleolar
defect
6wks
16x7.5cms

Chronic Venous ulcer
4wks
Med. malleolar defect
19x7cms

Complications
classical variant
 Tip necrosis 8 nilTip necrosis 8 nil
 Venous congestion 2 nilVenous congestion 2 nil
 Transient infection 4 2Transient infection 4 2
 Subflap collection 1Subflap collection 1
(secondary)(secondary)
 Donor graft loss 3 2Donor graft loss 3 2
* Total flap loss nil nil* Total flap loss nil nil

ConclusionConclusion
Inclusion of an extraInclusion of an extra
perforatorperforator
 Ensures perfusion thro’ dual
axis
 Larger flaps can be raised
 Significant reduction in
complication rate
 It is a successful alternative
to free flap

Follow up:
 Followup range 4wks-18 mths
 Mean followup 6mths
 Min. followup 4wks
 Max. followup 18mths

Distribution of defect
• Distal 1/3 leg 11
• Medial malleolus 3
• Lat, malleolus 8
• Heel 7
• Dorsum foot 4

Flap
dimensions/morphology/survival
• Flap size

Findings…  Pr. of a constantPr. of a constant
perforatorperforator
 4-6cms from tip of4-6cms from tip of
lat. Malleoluslat. Malleolus
 along either side ofalong either side of
TATA
 arising fromarising from
communicating branchcommunicating branch
between post.tibial &between post.tibial &
peroneal arteriesperoneal arteries

Comorbid factors
 Diabetes 2
 Hypertension 1
 Venous insufficiency 5

Complications
(33)
 Tip necrosis 8
 Venous congestion 2
 Transient infection 2
 Sub flap collection 1
(secondary)
 Donor graft loss 4
* Total flap loss nil

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Sural Neurocutaneous Flap by Dr Sumita Shankar, Amaze MedSpa

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Sural Neurocutaneous Flap by Dr Sumita Shankar, Amaze MedSpa

Editor's Notes