ISSN 0972-978X 

  About COAA








The Reverse Sural Artery Island Flap For Defects Of The Lower Third Of The Leg A Clinical Series Of 16 Cases

*Jimmy Mathew, # Saramma Varghese **Jagadeesh

*MCh trainee, Plastic surgery,  Medical college, Calicut.
#Professor, Plastic surgery, Medical college, Calicut
** Associate Professor, Plastic surgery, Medical college, Calicut

Address for Correspondence

Dr. Jimmy Mathew,
Final year Mch Plastic surgery trainee, Medical College, Calicut


Sixteen cases of reverse sural artery flap done in our institution are reviewed. Eleven were done under combined femoral and sciatic nerve block. All were done for lower third leg defects. Three flaps underwent necrosis. The rest achieved their objective with minimum complications and donor site morbidity. We conclude that this flap is a reliable alternative to free tissue transfer for lower third defects of the leg. The anatomical basis and operative technique is also briefly outlined

J.Orthopaedics 2006;3(1)e3



Soft tissue coverage of the lower third of the leg is a challenge, especially if microvascular expertise is not available. Although we have started doing free tissue transfer, our case load makes it impossible to do it in every case. We have found the recently introduced sural artery neurocutaneous flap to be extremely useful for lower third defects. Here we present a series of 16 cases of sural artery flap done in the past 2 years.

Material and Methods :

All the case records of patients who underwent this procedure during the past 2 years were reviewed. Patients were personally followed up whenever possible. The patient details, flap size, type of defect, necrosis and other relevant details were recorded.

Technique: first, the sural nerve is marked, from the mid-calf between the two heads of the gastrocnemius to the midpoint between the Achilles tendon and the lateral malleolus. The appropriately sized flap is marked out on this line with the pivot point kept at least 5 cm above

the lateral malleolus. The flap is elevated in the sub-fascial plane including the sural nerve, the short saphenous vein, and the vessels accompanying the nerve. We always keep a 2 cm skin pedicle, which is kept after incising the path to the defect. Drains are always kept. The donor site is skin grafted.

Results :

Sixteen patients underwent the procedure in the last 2 years. All of them were referred from the orthopedics department. All were done electively. Seven

patients underwent the procedure for defects in the region of the Achilles tendon either immediately for inadequate soft tissue cover, or for later skin necrosis post repair. Nine patients underwent the procedure for exposed tibia in the lower third of the leg.

Out of the 16 patients, 2 were females and the rest,

males. The ages ranged from 14 years to 65 years, the average being 36.8. Two people were diabetics and 2 had peripheral vascular disease as demonstrated by color Doppler.

The sizes of the flaps ranged from 4 X 3 cm to 12 X 10 cm. Three of the flaps underwent complete necrosis. One flap had minimal rim necrosis. All the rest survived totally and provided satisfactory cover. One patient complained of excessive bulk and underwent flap thinning twice. There were no cases of florid infection, hematoma or total graft loss at the donor site.

Four of the cases were done under spinal anesthesia and 1 under general anesthesia. Ten cases were done under combined sciatic and femoral nerve block, which made the prone positioning and the position changes needed during graft harvest and inset of the flap, very simple.

Discussion :

Coverage of wounds of the lower third of the leg are usually best treated using microvascular free tissue transfer. These flaps provide for reliable single stage coverage of these wounds. There are certain disadvantages to free flaps. These are: the need for a remote donor site, increased operative time, use of a major vessel to the leg, and the need for microvascular expertise. The alternative for coverage of these defects has traditionally been pedicled fasciocutaneous flaps, as described by Ponten1. but the distalmost portion is often random in its blood supply and the lower third of the leg is difficult to cover.

The design of these fasciocutaneous flaps has undergone a revolution on the basis of the discovery of neurocutaneous territories2. The cutaneous nerves of the body are frequently accompanied by small arteries and veins that supply the nerve and send small perforators to the overlying skin. Experience subsequently demonstrated that the skin overlying these territories could be elevated based on this blood supply, even in a retrograde fashion, to cover defects as distal as the forefoot. These kinds of flaps were first described in the foreaem3. The best described of these flaps is the sural artery flap.

The medial sural nerve descends in close association with the lesser saphenous vein, passing posterior to the lateral malleolus to supply the lateral side of the foot and the great toe. It is also accompanied by the median sural artery, a branch of the poplitial artery. This artery communicates with perforators from the peroneal artery 5-10 cm above the lateral malleolus. The blood supply courses in a retrograde fashion from these perforators when the nerve and artery are cut proximally. The exact technique of elevation is described in materials and methods.           

Mustafa Y et al in 1998 described 17 cases of sural artery flap done for various defects of the ankle, malleolus and the heel4. The largest flap used was 12 X 15 cm in length. He observed partial necrosis of the flap in 2 patients. He also noted the reliability of the flap and the importance of taking a skin extension along with the pedicle of the flap.

Hollier L et al in 2002 studied the same flap done in 11 patients5. He described partial necrosis in one patient. He also emphasized a broad inferolateral pedicle and the importance of including the short saphenous vein. Our series of 16 patients, notes 3 total necrosis and 1 minimal rim necrosis. But all these cases occurred early in our series and 2 of the patients were complicated by long standing diabetes and peripheral vascular disease. Our largest flap measured 12 X 10cm. We were also maintaining a 2 cm skin paddle over the pedicle instead of totally islanding it. We also note the ease of doing the flap under combined sciatic and femoral nerve block, which makes the positioning of the patient very easy6. Intra-operative change of position especially for anterior defects is made very simple. We also used tumescent solution (dilute lignocaine and adrenaline) for infiltrating the margins of the flap, which made a pneumatic tourniquet unnecessary7.

The disadvantages of the flap include ugly donor site in the calf, and loss of sensation in the lateral foot and leg5.


To conclude, the distally based sural artery flap is our flap of choice for reconstruction of the lower third of the leg, when the lower lateral aspect of the leg is relatively uninjured. It is a reliable one-stage procedure when properly done. It can be safely done under combined femoral and sciatic nerve block.

Reference :

  1. Ponten B. The fasciocutaneous flap. Its use in soft tissue defects of the lower leg. Br. J. Plast surg. 34: 215.1981.
  2. Masquelet A C, Ramana M C, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: Anatomic study and clinical experience in the leg. Plast.Reconstr.surg. 89: 1115, 1992.
  3. Beretelli JA and Khoury Z. Neurocutaneous island flaps in the hand: Anatomical basis and preliminary results. Br. J. Plast.surg. 45: 586, 1992.
  4. Yilmaz M, Karatas O, Baruteu A. The distally based superficial sural artery island flap: clinical experiences and modifications. Plast.Recostr.Surg. 102: 2358, 1998.
  5. Hollier L, Sharma S, Babigumira E, Klebuc M. Versatility of the sural fascocutaneous flap in the coverage of lower extremity wounds. Plast.Reconstr.Surg. 110: 1673, 2002.
  6. Khoo ST and Brown STK. Femoral nerve block- The anatomical basis of a single injection technique. Anesthesia and critical care. 11: 40, 1983.
  7. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/ kg for liposuction. Dermatol Surg oncol. 16: 248, 1990.



 This is a peer reviewed paper 

Please cite as : Jimmy Mathew: The Reverse Sural Artery Island Flap For Defects Of The Lower Third Of The Leg A Clinical Series Of 16 Cases

J.Orthopaedics 2006;3(1)e3





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.