The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction.
BACKGROUND
Soft-tissue defects of the distal lower extremity and foot present significant challenges to the reconstructive surgeon. The reverse superficial sural artery flap (RSSAF) is a popular option for many of these difficult wounds. Our initial experience with this flap at multiple institutions resulted in a 50% failure rate, mostly because of critical venous congestion. To overcome this, we have modified our operative technique, which has produced a more reliable flap.


METHODS
All patients reconstructed with an RSSAF between May 2002 and September 2013 were retrospectively reviewed. In response to a high rate of venous congestion in an early group of patients, we adopted a uniform change in operative technique for a late group of patients. A key modification was an increase in pedicle width to at least 4 cm. Outcomes of interest included postoperative complications and limb salvage rate.


RESULTS
Twenty-seven patients were reconstructed with an RSSAF (n = 12 for early group, n = 15 for late group). Salvage rate in the early group was 50% compared with 93% in the late group (P = 0.02). Postoperative complications (75% vs. 67%, P = 0.70) were similar between groups. Venous congestion that required leech therapy was 42% in the early group (n = 5) and 0% in the late group (P = 0.01).


CONCLUSIONS
Venous congestion greatly impairs the survival of the RSSAF. A pedicle width of at least 4 cm is recommended to maintain venous drainage and preserve flap viability.
Section of Plastic Surgery, University of Michigan, Ann Arbor, Mich.; Department of Orthopaedic Surgery St. Joseph's Hospital and Medical Center, Phoenix, Ariz.; Division of Plastic and Reconstructive Surgery, Department of Surgery, Concannon Plastic Surgery, Columbia, Mo.
Kristoffer B
KB
Sugg
Section of Plastic Surgery, University of Michigan, Ann Arbor, Mich.; Department of Orthopaedic Surgery St. Joseph's Hospital and Medical Center, Phoenix, Ariz.; Division of Plastic and Reconstructive Surgery, Department of Surgery, Concannon Plastic Surgery, Columbia, Mo.
Timothy A
TA
Schaub
Section of Plastic Surgery, University of Michigan, Ann Arbor, Mich.; Department of Orthopaedic Surgery St. Joseph's Hospital and Medical Center, Phoenix, Ariz.; Division of Plastic and Reconstructive Surgery, Department of Surgery, Concannon Plastic Surgery, Columbia, Mo.
Matthew J
MJ
Concannon
Section of Plastic Surgery, University of Michigan, Ann Arbor, Mich.; Department of Orthopaedic Surgery St. Joseph's Hospital and Medical Center, Phoenix, Ariz.; Division of Plastic and Reconstructive Surgery, Department of Surgery, Concannon Plastic Surgery, Columbia, Mo.
Paul S
PS
Cederna
Section of Plastic Surgery, University of Michigan, Ann Arbor, Mich.; Department of Orthopaedic Surgery St. Joseph's Hospital and Medical Center, Phoenix, Ariz.; Division of Plastic and Reconstructive Surgery, Department of Surgery, Concannon Plastic Surgery, Columbia, Mo.
David L
DL
Brown