Distally Based Sural Artery Adipofascial Flap based on a Single Sural Nerve Branch: Anatomy and Clinical Applications

Mok, Wan Loong James,Por, Yong Chen,Tan, Bien Keem Korean Society of Plastic and Reconstructive Surge 2014 Archives of Plastic Surgery Vol.41 No.6

Background The distally based sural artery flap is a reliable, local reconstructive option for small soft tissue defects of the distal third of the leg. The purpose of this study is to describe an adipofascial flap based on a single sural nerve branch without sacrificing the entire sural nerve, thereby preserving sensibility of the lateral foot. Methods The posterior aspect of the lower limb was dissected in 15 cadaveric limbs. Four patients with soft tissue defects over the tendo-achilles and ankle underwent reconstruction using the adipofascial flap, which incorporated the distal peroneal perforator, short saphenous vein, and a single branch of the sural nerve. Results From the anatomical study, the distal peroneal perforator was situated at an average of 6.2 cm (2.5-12 cm) from the distal tip of the lateral malleolus. The medial and lateral sural nerve branches ran subfascially and pierced the muscle fascia 16 cm (14-19 cm) proximal to the lateral malleolus to enter the subcutaneous plane. They merged 1-2 cm distal to the subcutaneous entry point to form the common sural nerve at a mean distance of 14.5 cm (11.5-18 cm) proximal to the lateral malleolus. This merging point determined the pivot point of the flap. In the clinical cases, all patients reported near complete recovery of sensation over the lateral foot six months after surgery. All donor sites healed well with a full range of motion over the foot and ankle. Conclusions The distally based sural artery adipofascial flap allowed for minimal sensory loss, a good range of motion, an aesthetically acceptable outcome and can be performed by a single surgeon in under 2 hours.

Distally Based Sural Artery Adipofascial Flap based on a Single Sural Nerve Branch: Anatomy and Clinical Applications

Wan Loong James Mok,Yong Chen Por,Bien-Keem Tan 대한성형외과학회 2014 Archives of Plastic Surgery Vol.41 No.6

Background: The distally based sural artery flap is a reliable, local reconstructive option forsmall soft tissue defects of the distal third of the leg. The purpose of this study is to describean adipofascial flap based on a single sural nerve branch without sacrificing the entire suralnerve, thereby preserving sensibility of the lateral foot. Methods: The posterior aspect of the lower limb was dissected in 15 cadaveric limbs. Fourpatients with soft tissue defects over the tendo-achilles and ankle underwent reconstructionusing the adipofascial flap, which incorporated the distal peroneal perforator, shortsaphenous vein, and a single branch of the sural nerve. Results: From the anatomical study, the distal peroneal perforator was situated at an averageof 6.2 cm (2.5-12 cm) from the distal tip of the lateral malleolus. The medial and lateral suralnerve branches ran subfascially and pierced the muscle fascia 16 cm (14-19 cm) proximal tothe lateral malleolus to enter the subcutaneous plane. They merged 1–2 cm distal to thesubcutaneous entry point to form the common sural nerve at a mean distance of 14.5 cm(11.5–18 cm) proximal to the lateral malleolus. This merging point determined the pivot pointof the flap. In the clinical cases, all patients reported near complete recovery of sensationover the lateral foot six months after surgery. All donor sites healed well with a full range ofmotion over the foot and ankle. Conclusions: The distally based sural artery adipofascial flap allowed for minimal sensory loss,a good range of motion, an aesthetically acceptable outcome and can be performed by asingle surgeon in under 2 hours.

Gracilis pull-through flap for the repair of a recalcitrant recto-vaginal fistula

Wan Loong James Mok,Ming Hui Goh,Choong Leong Tang,Bien-Keem Tan 대한성형외과학회 2019 Archives of Plastic Surgery Vol.46 No.3

Recto-vaginal fistulas are difficult to treat due to their high recurrence rate. Currently, no single surgical intervention is universally regarded as the best treatment option for rectovaginal fistulas. We present a case of recurrent recto-vaginal fistula surgically treated with a gracilis pull-through flap. The surgical goals in this patient were complete excision of the recto- vaginal fistula and introduction of fresh, vascularized muscle to seal the fistula. A defunctioning colostomy was performed 1 month prior to the present procedure. The gracilis muscle and tendon were mobilized, pulled through the freshened recto-vaginal fistula, passed through the anus, and anchored externally. Excess muscle and tendon were trimmed 1 week after the procedure. Follow-up at 4 weeks demonstrated complete mucosal coverage over an intact gracilis muscle, and no leakage. At 8 weeks post-procedure, the patient resumed sexual intercourse with no dyspareunia. At 6 months post-procedure, her stoma was closed. The patient reported transient fecal staining of her vagina after stoma reversal, which resolved with conservative treatment. The fistula had not recurred at 20 months post-procedure. The gracilis pull-through flap is a reliable technique for a scarred vagina with an attenuated rectovaginal septum. It can function as a well-vascularized tissue plug to promote healing.

Gracilis pull-through flap for the repair of a recalcitrant recto-vaginal fistula

Mok, Wan Loong James,Goh, Ming Hui,Tang, Choong Leong,Tan, Bien Keem Korean Society of Plastic and Reconstructive Surge 2019 Archives of Plastic Surgery Vol.46 No.3

Recto-vaginal fistulas are difficult to treat due to their high recurrence rate. Currently, no single surgical intervention is universally regarded as the best treatment option for recto-vaginal fistulas. We present a case of recurrent recto-vaginal fistula surgically treated with a gracilis pull-through flap. The surgical goals in this patient were complete excision of the recto-vaginal fistula and introduction of fresh, vascularized muscle to seal the fistula. A defunctioning colostomy was performed 1 month prior to the present procedure. The gracilis muscle and tendon were mobilized, pulled through the freshened recto-vaginal fistula, passed through the anus, and anchored externally. Excess muscle and tendon were trimmed 1 week after the procedure. Follow-up at 4 weeks demonstrated complete mucosal coverage over an intact gracilis muscle, and no leakage. At 8 weeks post-procedure, the patient resumed sexual intercourse with no dyspareunia. At 6 months post-procedure, her stoma was closed. The patient reported transient fecal staining of her vagina after stoma reversal, which resolved with conservative treatment. The fistula had not recurred at 20 months post-procedure. The gracilis pull-through flap is a reliable technique for a scarred vagina with an attenuated recto-vaginal septum. It can function as a well-vascularized tissue plug to promote healing.

Late Seroma in Breast Implants: A Coronavirus Disease 2019 Phenomenon?

Stephanie L.S Chan,James Wan Loong Mok 대한성형외과학회 2022 Archives of Plastic Surgery Vol.49 No.5

The coronavirus disease 2019 (COVID-19) pandemic has been challenging in all aspects of the medical field with new clinical presentations constantly arising. Plastic surgeons are not immune to this and need to be aware of their implications. There has been a recent report of late periprosthetic seroma (breast implant) as a clinical manifestation of COVID-19 infection. To our knowledge, this phenomenon has not been further reported. We present a 53-year-old immunocompromised lady who developed late seroma after COVID-19 infection. She eventually required explantation of the implant and is awaiting autologous reconstruction. It is likely that we will increasingly continue to see this phenomenon of implant complications as a result of COVID-19 infection and should be watchful, especially regarding potential immunocompromised patients.