Reverse Sural Flap with Dr. Howard Levinson

Flap Cast

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  • 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 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 


  • 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 

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