Introduction:

• The Reverse Sural is a fasciocutaneous flap occupying space overlying gastroc raphe between popliteal fossa and midportion of leg
• Commonly used for defects of the distal third of the leg, calcaneal wounds, and sometimes thought of as an alternative to a free flap in these settings

Anatomy:

• Anatomy of the lower leg 
• 4 compartments
• Superficial posterior compartment contains gastroc, soleus, plantaris
• Distally, the lesser saphenous vein and sural nerve run…
• Between the achilles tendon and the lateral malleolus at the ankle
• Ascend proximally along the medial raphe of the gastroc
• Dive below the fascia in the proximal third of the leg
• Peroneal artery runs within DEEP posterior compartment 

Flap Basics:

• Fasciocutaneous flap of the posterior leg overlying gastroc raphe between popliteal fossa and midportion of the leg
• Axis of flap – along gastroc raphe, lesser saphenous and sural nerve run along this axis and are included in the flap
• Blood supply – reverse flow supplied by peroneal and PT artery perforators (more commonly peroneal)
• Venous drainage actually thought to be through subdermal plexus and the fasciocutaneous pedicle of this flap, as the lesser saphenous has VALVES and is unlikely the primary drainage source 

Complications:

• MOST COMMON complication is venous congestion

• Poor venous outflow
• Kinking
• Management:
• Avoidance:
• Modifications like delay procedures, interpolated vs. islandized flaps, adding adipofascial extension
• Management:
• LEECHES
• Supercharging lesser saphenous
• Venous cannulation at bedside