Introduction: The reverse sural artery flap has been firmly established as a viable option for reconstruction of the distal third of the leg, ankle and heel. The major disadvantage of the flap is compression of the pedicle within the subcutaneous tunnel and venous congestion. The current study indicates that transferring the flap in two stages without the use of a tunnel improves the reliability of the flap with no venous congestion.

Methods: Seven distally based reverse sural artery flaps were performed on ambulatory patients between 2001 and 2002. Six flaps were used for traumatic defects and one flap was used for a chronic wound in a patient with rheumatoid arthritis, status post arthrodesis. All flaps were raised subfascially with a three centimeter width pedicle. After raising the flap, it was turned down to the defect and inset. The pedicle was covered with a split thickness skin graft. The pedicle was not divided until all subsequent orthopedic procedures were completed; most were divided eight to twenty months later.

Results: All seven flaps survived. Venous congestion did not occur in any of the flaps. All patients were ambulatory after surgery and did not require the use of a custom shoe. Follow up after surgery ranged from five months to one year. All flaps remained stable.

Discussion: Coverage of wounds of the lower one-third of the leg is frequently treated using free-tissue transfer. The distally based reverse sural artery flap has been used as a good alternative. Unreliability is the major disadvantage of this flap. The most common problem is venous congestion and subsequent partial flap necrosis. Others have sited a decrease in this problem by harvesting a midline cuff of gastrocnemius muscle, including more subcutaneous tissue, and using a wider than usual pedicle. With our technique, simply exteriorizing the pedicle eliminates venous congestion. No extra time is added to the procedure and there is no alteration in raising the flap. It is a two-staged operation; however, subsequent division is simple, has no associated complications, and has the advantage of providing a more reliable flap for difficult to treat wounds.

Conclusion: The major draw back of the reverse sural artery flap is its unreliability secondary to partial or total necrosis from venous congestion. Avoiding a subcutaneous tunnel and exteriorizing the pedicle with no other alterations to flap design or elevation techniques solves venous congestion problems.

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