Reverse Superficial Artery Flap for Lower Extremity and Foot Reconstruction—As Reliable as Reported?

The reverse superficial sural artery flap is currently used for tissue loss in the distal third of the leg, ankle, and foot from traumatic injuries, pressure ulcers, ischemic ulcers, osteomyelitis coverage, and other chronic wounds. The flap is supplied by reverse flow from the superficial sural artery, dependent on perforators of the peroneal artery. This type of flap has been purported to be safe, quick, and relatively easy to perform.

The authors retrospectively examined the experience of four surgeons trained in microvascular surgery from two different centers using the reverse superficial sural artery flap on distal lower extremity, ankle, heel, and foot tissue defects from acute and chronic wounds over a 3-year period.

Twelve patients, 19 to 91 years old, were treated with the reverse sural flap between August 2001 and July 2004. Seven wounds were from recent traumatic injury, three from pressure ulcers, one secondary to osteomyelitis, and one a nonhealing wound from prior traumatic injury. Eight patients had a fracture in the affected limb. The recent traumatic injuries were repaired an average of 39.6 days after injury (range: 4 to 91 days). The average size of the repaired defects was 7.4 cm by 7.4 cm, with flaps averaging 7.8 cm by 8.0 cm. All donor sites were closed with split-thickness skin grafts. Average operating time was 136 min with no intraoaperative complications. Six of the 12 patients healed successfully with the flap, with half of these patients experiencing delayed healing. Three patients experienced venous congestion requiring leech therapy, with 95% loss of one flap and successful healing of the other two. Flaps that healed successfully, on average, had shorter operative time, smaller defects, and were performed on younger patients.

The authors were enthusiastic to try a new reconstructive option for distal lower extremity reconstructions, given optimistic reports in the literature. However, given the flap's 50% overall success rate in experienced hands, they have become less enthused with its benefits over more complex options. In their hands, it was most beneficial in small wounds without a history of fracture, and in younger patients. They will use the flap judiciously in the future.