Assessment of Complications and Outcomes in the Use of the Distally
Based Sural Lesser Saphenous Neuro-Veno-Adipo-Fascial (NVAF) Flap in
Lower Extremity Reconstruction
Samuel V. Bartholomew, MD, Michael S. Wong, MD, Kamlesh Patel, MD,
James Kim, MD, Thomas P. Whetzel, MD, Eller Sommerhaug, MD, Albert
Oh, MD, Brad Nanigian, MD, Ali Salim, MD, Thomas R. Stevenson, MD
INTRODUCTION: Wounds of the lower-third of the leg, ankle, and foot
represent a challenge to the reconstructive surgeon. These defects
may be reconstructed with a variety of local tissue flaps, cross leg
flaps, or microsurgical free tissue transfer.1
The neuro-veno-adopifascial (NVAF) flap is a distally-based
fasciocutaneous flap that has an established record of success in
reconstructing difficult defects of the lower third of the leg,
ankle, and foot.2 The aim of this paper is to report our experience
with the NVAF flap and describe the complications and co-morbid
conditions of our patient population.
METHODS: A retrospective review was conducted of all NVAF flaps
performed over a period from October 2000 through January 2007. Data
were collected in regards to patient demographics, associated comorbidities, mechanism of the lower extremity wound, technical
details of the operation(s) performed, postoperative complications,
length of follow-up, and clinical outcomes with respect to healing
and ambulation.
RESULTS: During the study period, the NVAF flap was used in the
reconstruction of lower extremity defects in 34 patients (Figures 12). The mean patient age was 40.5 years (range 4-89) at the time of
the operation. The locations of the wounds were diverse (13 wounds of
the distal one third of the lower leg, 12 ankle wounds, 3 heel
wounds, and 6 foot wounds), as were the ages of the patients at the
time of surgery (mean age 40.5 years, range 4-89 years).
Traumatic
wounds were the primary indication for reconstruction in 22 patients.
Six patients presented with chronic osteomyelitis requiring resection
of diseased bone, removal of hardware when necessary, and soft tissue
coverage with the NVAF flap. Five patients suffered from malignant
neoplasms necessitating radical resection, and 1 patient had a nonhealing wound with exposure of tibia in the face of severe peripheral
vascular disease.
Skin paddle orientation was longitudinal in 22 (64.7 %), transverse
in 8 (23.5 %), no skin paddle in 1 (2.9 %), and not specified in 3
(8.8 %).
The mean transverse skin paddle was 6.9 cm x 9.6 cm (range
4-14 cm x 7-15 cm). The mean longitudinal skin paddle was 6.6 cm x
11.9 cm (range 3-10 cm x 6-23 cm).
The mean pedicle width was 5.76
cm (Range 3.5-10 cm). The mean split-thickness skin graft used to
cover the donor site and pedicle was 114.9 cm2 (range 0-320 cm2).
Complications occurred in 15 (44.1%) of our 34 patients.
Seven major
complications occurred in 5 (14.7 %) patients. A major complication
was defined as leading to total flap loss (4) or amputation (3).
Overall, 3 (8.8%) patients with a major complication went on to
amputation. Of these, 1 had total flap loss and infection acutely; 1
had infection, total flap loss and hematoma; and the third had
chronic osteomyelitis requiring amputation 10 months after the NVAF
flap. Four patients (11.8%) had total flap loss. Two patients with
major complications were salvaged. One patient had late flap loss
secondary to radiation therapy 10 months after the index operation,
salvaged with a radial forearm free flap to the leg. One child with
traumatic wounds had post operative total flap loss and infection
salvaged by skin grafts.
Co-morbid conditions included smoking 4 (11.8 %), diabetes 3 (8.8 %),
obesity 2 (5.9 %), steroid use 1 (2.9 %), and peripheral vascular
disease 1 (2.9 %). The co-morbid conditions studied were chosen
because of their deleterious effect on wound healing. Total flap
loss occurred in 1/4 smokers (25%). One patient (2.9%) with both
diabetes and steroid use suffered partial flap loss. This represented
33% of all diabetic patients in the series. One patient (2.9%) with
both diabetes and peripheral vascular disease suffered partial loss
of the skin graft with flap survival.
Fifteen minor complications occurred in 10 (29.4%) patients, often
with multiple complications occurring in the same patient. Six
(17.6%) patients suffered from partial flap loss. Three (8.8%)
hematomas requiring evacuation were noted. Skin graft loss occurred
in 5 (14.7%) patients and 2 (5.9%) minor infections were seen.
Mean follow-up was 10.2 months (range 0 days to 48 months). One
patient expired from cardiac disease during the study period. There
is inadequate follow-up data on 4 patients to judge the success in
return of ambulation. One patient died from unrelated causes one
month after surgery. Three patients underwent amputation. Of the
remaining 26, 18 (69.2%) patients had healed wounds and were
ambulating without assistance at their last follow-up visit. An
additional 6 (23.1%) patients had healing wounds and were walking
with either a cane or walker. Two (7.7%) patients are currently nonambulatory, one has severe arthritic pain and the other has
significant bony loss of the tibia requiring bone grafting prior to
any attempts at weight bearing. The overall limb salvage rate in
patients with follow-up was 90%.
CONCLUSION: The NVAF flap remains our local flap of choice in
treating difficult wounds of the distal one-third of the lower leg,
ankle, heel, and foot. Major complications are uncommon (14.7%).
However, minor complications are seen fairly frequently(29.4%)
Despite this, healed wounds may consistently be obtained, along with
the return of ambulation in the majority of patients following
salvage of the lower extremity.
Figure 1. The NVAF flap is outlined and incised prior to elevation.
Figure 2. The elevated NVAF flap prior to rotation.
REFERENCES
1.
Kasabian AK, Karp NS. Lower Extremity Reconstruction. In: Thorne
CHM (ed). Grabb and Smith's Plastic Surgery. Philadelphia, Lippincott
Williams & Williams, 1997, pp. 676-688.
2.
Baumeister S, Spierer R, Erdmann D, et al. A realistic
complication analysis of 70 sural artery flaps in a multimorbid
patient group. Plast Reconstr Surg 112: 129-140; 2003.