Reverse Sural Flap for Reconstructive surgery in Siliguri

What is Reverse Sural flap?

Reverse sural flap utilizes a flap composed of skin, subcutaneous tissue and fascia from over the raphe between the two heads of the gastrocnemius muscle. This flap is commonly utilized in distal leg reconstruction when there is inadequate tissue for soft tissue coverage. Blood supply of the flap is based on distally based reverse sural artery based on peroneal artery perforators in distal leg.

When is Reverse Sural flap utilized?

1. Ankle defects with exposed tendons or bone

2. Posterior heel defects with exposed tendons or bone

3. Dorsum of foot defects with exposed tendons or bone

4. Anterior leg defects in lower leg with exposed tendons or bone

Reverse sural flap for posterior leg defect

What is a delay procedure of Reverse sural flap?

A delay procedure of Reverse sural flap is usually done to preoptimize the flap against ischemia and venous congestion. This makes the flap robust with increased vascularization and makes the flap viable. It is usually done when the flap length is longer than its usual size, when the patient has diabetes, peripheral vascular disease, and increased risk of complications. This procedures involves harvesting of the flap, ligation of sural nerve and its transection, ligation of lesser saphenous vein and transection. The flap is then resutured to surrounding calf incision. After 7-10 days, the flap is then transferred to the defect.

Delay procedure Reverse Sural flap for Heel defect

Who are at risk for increased complications?

1. Older age

2. History of smoking

3. Obesity

4. Diabetes

5. Peripheral vascular disease

Complications that can occur with Reverse Sural flap

1. Venous congestion - Most common complication usuallly occurs on 40% of the cases. In this situation, the venous blood which needs to return from flap usually does not flow back causing congestion of the flap. Kinking of pedicle or pressure over the pedicle can cause venous congestion.

2. Distal flap necrosis - Part of the flap in the most distal aspect may undergo loss of flap due lack of blood flow either due to venous congestion or ischemia. Kinking of pedicle, pressure over the pedicle can cause flap necrosis.

3. Loss of sensation over lateral aspect of foot and lateral 4th and 5th toes.

4. Skin graft contour depression on posterior calf where flap has been harvested

5. Lack of posterior flap when RSA flap has been used in case the patient will require future below knee amputation of the leg.

General Postoperative guidance

1. Limb elevation of operated leg and rest in posterior splint

2. Donor site of flap is dressed with occlussive dressings or Negative pressure vacuum dressing can be applied.

Note - Additional surgeries may be necessary to modify the flap like reduce thickness, adjust contour, detachment of pedicle, or delay procedure to make the flap viable.