Revisiting the Reverse Sural Artery Flap in Distal Lower Extremity Reconstruction A Systematic Review and Risk Analysis

Background The reverse sural artery flap (RSAF) is a popular option for patients with distal lower extremity defects who are not ideal candidates for free flap reconstruction. This is the first systematic review and pooled analysis of surgical characteristics, risk factors, and outcomes of the RSAF. Methods A systematic literature review was conducted. All studies reporting on patients undergoing RSAF reconstruction and their outcomes were included. Outcomes were pooled and analyzed using Fisher exact or chi(2) test. Results Forty-three studies (479 patients, 481 flaps) were analyzed. The majority of patients were male (70.3%), and average +/- SD age was 46.9 +/- 16.7 years. Rates of smoking, diabetes mellitus (DM), and peripheral vascular disease (PVD) were 34.6%, 35.4%, and 12.3%, respectively. Defect etiologies were largely traumatic (60.4%). The most common defect location was the heel (40.8%). Flap modifications were reported in 123 flaps (25.6%). The most common modification was adipofascial extension (20.3%). Overall, the partial and total flap loss rates were 15.4% and 3.1%, respectively. Partial flap loss was significantly increased in smokers (28.9% vs 12.2% in nonsmokers, P = 0.0195). Technical modifications decreased the odds of partial necrosis by almost 3-fold compared with traditional RSAF reconstruction (7.2% vs 17.9%; odds ratio, 2.8 [1.4-5.8]; P = 0.0035). Patient age, DM, and PVD were not significantly associated with flap loss. Conclusions The RSAF remains a safe salvage option for patients with DM or PVD but should be used with caution in smokers. Technical modifications to minimize pedicle compression significantly reduce rates of partial necrosis.