Reverse-Flow Sural Flap Modifications for Improved Reliability in Lower Extremity Reconstruction

The reverse sural flap has been a useful alternative to free tissue transfer in the reconstruction of lower extremity wounds, but there are some concerns about its reliability. The authors presented a consecutive series of sural flaps used for lower extremity reconstruction, and their protocol for improving the reliability of the flap. Almost all their patients had co-morbidities, including diabetes, smoking, or peripheral vascular disease. The only complications included one patient with partial flap loss managed with a skin graft.

The flap was useful for coverage of wounds as far distal as the dorsum and sole of the foot. Modifications useful for improved reliability included a staged delay, inclusion of skin over the pedicle, an extended fascial cuff, and proper immobilization to prevent compression of the vascular pedicle. A staged approach not only allowed aggressive debridement of the wound on two occasions, with culture-specific antibiotic intervention, but it also allowed improved flap vascularity due to the delay. Successful coverage was achieved in all patients without the need for free tissue transfer.

Improving surgical technique and design have increased the reliability and indications for using the sural flap in lower extremity reconstruction. The authors use the sural flap as their first choice, when appropriate, for distal third lower extremity reconstructions.