Risk Analysis for the Reverse Sural Fasciocutaneous Flap in Distal Leg Reconstruction

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The reverse sural fasciocutaneous flap provides the potential for simple and efficient closure of distal leg, ankle, and foot defects. In young patients with traumatic injuries, low complication rates have been reported. The authors hypothesize that extending its use to older patients with comorbidities results in a higher complication rate.


The authors retrospectively reviewed 58 consecutive reverse sural fasciocutaneous flap in 57 patients for distal leg reconstruction. Outcomes were compared between patients with no comorbidities (n = 31) and those with a history of smoking, diabetes mellitus, or peripheral arterial disease (n = 26). Standard statistical analyses were performed, including logistic regression.


Patients had a mean age of 53 years and a median follow-up of 20 months. Fifty percent of flaps had postoperative complications, with nine (16 percent) major complications (three total flap losses and six partial losses), 17 (29 percent) minor complications, and three infections. In patients without comorbidities, there were no major complications and five minor complications (16 percent). Significantly higher major and minor complication rates were seen in older patients and patients with a history of smoking, obesity, diabetes, or peripheral arterial disease. Multivariate regression analysis identified smoking as the risk factor most independently associated with any reverse sural fasciocutaneous flap complication. Importantly, surgical delay procedures were associated with decreased ischemic flap complications in patients with comorbidities.


Although the reverse sural fasciocutaneous flap is reliable in young healthy patients, it has significant complication rates in patients with comorbidities, especially smokers. In such patients, the reverse sural fasciocutaneous flap requires multiple operative revisions and a surgical delay should be considered.

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