Free tissue transfer remains the preferred reconstructive method for many complex lower extremity defects. Alternatives to microsurgical reconstruction may be sought for: (1) individuals unable to withstand a lengthy procedure (2) young children (3) hypercoagulable states (4) vascular trauma (5) limited soft tissue defects with simple underlying fracture patterns (6) salvage of failed free tissue transfers. The purpose of this study is to demonstrate the versatility of the reverse sural neurofasciocutaneous flap as a reconstructive option in these difficult situations.

Materials & Methods: Broad, inferiorly based fasciocutaneous flaps incorporating the median sural artery, medial sural cutaneous nerve, lesser saphenous vein and distal peroneal artery perforators were utilized to cover 19 defects in 18 patients. The group was composed of 13 males and 5 females. Ages ranged from 2 to 69 years with an average age of 32 years. The etiology of the defects included 13 open fractures (blunt trauma), 1 gun shot wound, 2 lawn mower injuries, 1 industrial crush and 1 chronic venous ulcer. All defects were isolated to the lower third of the leg and heel. The largest skin island measured 10 x 22 cm with an average dimension of 7 x 14 cm. The flaps were utilized in a variety of ways including a cross leg flap for salvage of a failed free tissue transfer (example #1) and for pediatric heal reconstruction (example #2). Delayed flaps were employed in 4 smokers with underlying vascular disease (example #3). The flap was utilized bilaterally in a single case and in one patient with a chronic venous ulcer.

Results: A closed wound was achieved in all patients, however, partial flap loss developed in 10% (2/19). Salvage was achieved utilizing local wound care and skin grafting. One partial loss was attributed to excessive subcutaneous tissue thickness and the presence of extensive lateral malleolar trauma. The second partial necrosis was attributed to the development of a yeast infection. An additional patient developed an enterococcal infection requiring removal of loose hardware. Unrestricted weight bearing was achieved in 16/18 patients. One patient failed to ambulate as a result of an occluded vascular bypass graft during the sixth postoperative week requiring a BKA while the other remained paraplegic following a spinal cord injury.

Conclusions: The reverse sural neurofasciocutenous flap can be utilized as a cross leg flap, a delayed flap and in pediatric reconstruction providing a versatile alternative to free tissue transfer in select cases.