What is the difference between a sural (superficial sural) flap and a reverse sural (reversed superficial sural) flap?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Article Review Status
Submitted
Under Review
Approved

Last updated: March 2, 2025 • View editorial policy

From the Research

The sural flap and reverse sural flap are distinct reconstructive surgical techniques, with the reverse sural flap being more commonly used for defects in the distal third of the leg, heel, and foot due to its ability to reach these areas effectively through retrograde blood flow. The key difference between the two flaps lies in their blood supply orientation and application. The sural flap is based on the sural artery and nerve, with blood flow in its normal anatomical direction (proximal to distal), whereas the reverse sural flap relies on retrograde blood flow through the vascular connections between the peroneal artery and the sural artery, with the flap oriented in a distal-to-proximal fashion 1.

Key Characteristics of Each Flap

  • The sural flap includes skin, subcutaneous tissue, and the sural nerve, with a pedicle that contains the lesser saphenous vein and accompanying arteries.
  • The reverse sural flap also includes skin, subcutaneous tissue, and the sural nerve, with its pedicle containing the lesser saphenous vein and accompanying arteries, but it is more versatile for distal reconstruction.
  • When performing a reverse sural flap, it is crucial to identify and preserve the sural nerve and vessels, elevate the flap with adequate subcutaneous tissue, and create a pedicle of sufficient width (typically 3-4 cm) to maintain blood supply 2, 3.

Clinical Applications and Outcomes

  • The reverse sural flap is particularly useful for defects in the distal third of the leg, heel, and foot, offering a reliable option without sacrificing major arteries 4, 1.
  • However, it may result in numbness in the lateral foot due to sural nerve inclusion.
  • The standard sural flap has more limited applications due to its restricted reach to distal areas.
  • Recent studies have shown that the reverse sural flap has a complication rate of around 25%, with partial flap loss being the most common complication, followed by venous congestion 1.
  • Technical modifications, such as increasing the pedicle width and using a two-staged approach, can significantly reduce the rates of partial necrosis and improve outcomes 2, 3.

Recommendations for Clinical Practice

  • The reverse sural flap should be considered a primary option for soft tissue reconstruction in the distal lower extremity, especially in cases where free flap reconstruction is not feasible or desirable.
  • Surgeons should be meticulous in their technique, ensuring adequate pedicle width and preservation of the sural nerve and vessels to minimize complications.
  • Patient selection and preoperative assessment are crucial, taking into account factors such as smoking, diabetes, and peripheral vascular disease, which may impact flap survival 3.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.