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frequency and extent of tissue necrosis, reduce edema,
control infection, support healing and prevent reperfusion
injury. [9]

A recent retrospective analysis of 70 consecutive sural
flaps reported a complication rate of 59% (41 of 70
a b flaps), with complete necrosis in 19% flaps and partial
[10]
necrosis in 17%. In a series of lateral supramalleolar
flaps by Ehab et al., a total of 5 patients (20%) suffered
[6]
complications out of 25 patients. Two cases were managed
conservatively, 2 cases required revision with suturing,
c d and 1 case required alternative flap coverage. Kang et al.
[11]
Figure 4: (a) Posttraumatic soft tissue defect with exposure of the medial experienced 4 patients with partial necrosis (30%) among
malleolus and calcaneus; (b) picture following wound debridement; 13 patients where distally-based sural artery and lateral
(c) reverse sural artery flap cover performed; (d) tip necrosis of the
reverse sural flap covered with a skin graft supramalleolar flaps had been utilized for soft tissue
defects of the leg and foot. We noted complete flap
Almeida et al. experienced partial flap necrosis (22.1%), survival in patients who received HBO with flap delay in
[3]
total flap necrosis (4.2%), infection (8.5%) and venous spite of their associated co-morbidities. In the transfer
congestion (4.1%) in a total of 71 cases of transferred group without HBO treatments, 5 patients of 11 (45.4%)
reverse sural flaps. Zayed et al. experienced venous experienced flap tip necrosis, and 1 patient had partial
[6]
congestion in five out of 25 cases of lateral supramalleolar flap loss.
[2]
flap coverage. Voche et al. reported venous congestion At our institution, we have developed a strategy to
and partial flap necrosis (5-30%) in 41 cases of a lateral successfully manage patients with defects of the lower
supramalleolar flap used for ankle and foot defects. third of the leg and foot using a combined approach that
Kneser et al. suggested a delayed neurofasicocutaneous maximizes tissue perfusion and oxygenation, allowing for
[4]
sural flap, which is initially completely elevated and optimal surgical correction of such injuries. Our treatment
then fixed again at the donor site using running sutures algorithm begins with early surgical debridement and
for 7-15 days. After confirming the flap’s survival, the initiation of HBO therapy. Combination of the modalities
flap is raised again and transposed into the soft tissue allows preservation of marginal tissue, prevention of
defect. This delay procedure could be an alternative to extension of ischemia, reduction of tissue edema and
increase the reliability and viability of the distally-based congestion, and maximum preservation of the transferred
fasciocutaneous flap. However, delay procedures are not distally-based flap. In our series, no complications were
feasible in every patient as they require a significant noted in patients treated with this approach. However,
time delay for coverage of vital structures. Ulkür et al. several cases of the flap tip or partial necrosis were
[7]
demonstrated the usefulness of HBO treatment during the noted in patients who received direct flap transfer. In this
delay period of the flap which can lessen the time period series, flap delay procedures were scheduled based on
required for delay, and which can also increase the effect various factors including severity of injury, time of referral,
of flap delay. This technique of reducing the delay period co-morbid conditions, patient age, reach of the flap,
could well be utilized in the reduction of the duration of patient toleration of use of the chamber, and affordability
flap transfer in flap delay procedures. In addition, HBO of treatment. However, additional studies are required to
therapy helps to prepare the recipient and donor areas, determine any additional indications, as well as the optimal
and the flap to be transferred during the delay period. timing and dosage of HBO therapy for such procedures.
There appears to be no harm in administrating HBO The patients in the current series did not experience the
therapy during the delay period, as it reduces the edema common side effects of HBO therapy such as aural or
of the delayed tissue and provides an optimal outcome pulmonary barotrauma or a transient reversible myopia.
following transfer.
Optimal usage of HBO therapy may reduce the duration of
In our center, HBO is administered in a monoplace flap delay and increase the effect of flap delay procedure,
chamber in which a single patient is placed in a helping to an optimal outcome for the transferred tissue.
chamber, which is then pressurized with 100% oxygen. In conclusion, distally-based flaps provide effective
Vasoconstriction reduces edema and tissue swelling while coverage of variable sized soft tissue defects of the lower
ensuring adequate oxygen delivery and is thus useful third of leg, ankle and foot following trauma. Adjunctive
in acute trauma wounds as well as in delayed flaps. HBO therapy should be considered when possible for
Hyperoxygenation causes immune stimulation by restoring improved flap survival and optimal surgical outcomes.
white blood cell function and enhancing their phagocytic
capabilities and neo-vascularization in hypoxic areas by
augmenting fibroblastic activity and capillary growth. REFERENCES
[8]
Adequate shock management, debridement and repair of
soft tissues, and stabilization of bony elements are of 1. Demiri E, Foroglou P, Dionyssiou D, Antoniou A, Kakas P, Pavlidis L,
Lazaridis L. Our experience with the lateral supramalleolar island flap for
paramount importance. HBO therapy as an adjunct should reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast
be administered as early as possible to minimize the Reconstr Surg Hand Surg 2006;40:106‑10.

136 Plast Aesthet Res || Vol 2 || Issue 3 || May 15, 2015