Reverse sural island flap elevated from the proximal third of the leg: its reliability and versatility in distal leg and foot reconstruction

Soft tissue loss around the distal third of the leg and foot has remained a considerable challenge. A reconstructive option providing supple tissue, while avoiding the complexity and the high technical demand of free flaps is a welcome alternative. The sural island flap largely satisfies these criteria. A number of authors have suggested raising the skin island from the junction of the middle and upper third of the leg to improve its reliability. However, raising the flap over the upper third of the leg may provide a larger amount of tissue and often makes dissection of its most distal perforator unnecessary. This study aims to assess the reliability and versatility of the reverse sural island flap elevated from the proximal third of the leg for soft tissue reconstruction of the distal leg and foot. Consecutive patients with soft tissue loss around the distal third of the leg and the ankle region requiring flap cover who met the inclusion criteria were managed using the distally based sural island flap elevated from the upper third of the leg. The outcome has been analysed. There were 15 patients, 11 males and four females with an age range of 22 to 54 years. Thirteen patients had distal third open tibial fractures while two had open calcaneal injuries. Nine resulted from motorcycle accidents, four from motor vehicular accidents while two were gunshot wounds. Flap sizes ranged from 10 × 7 cm to 22 × 12 cm. Thirteen flaps had full survival while two flaps had partial necrosis. All donor sites were skin grafted with 95% to 100% graft take. The use of the reverse sural island flap elevated from the proximal third of the leg for coverage of soft tissue defects of the distal leg and foot is safe and reliable in our experience. It provides a sizeable amount of soft tissue while maintaining a robust blood supply.