Application of Reverse Sural Flaps in Pediatric Patients: A Systematic Review

The reverse sural flap (RSF) is a random-type, pedicled flap based on sural artery perforators indicated for traumatic lower-extremity wounds. The RSF has demonstrated comparable results to free flap placement in the adult population for reconstruction of distal third defects, but few reports describe its application and outcomes in the pediatric population.

We investigated RSF application in pediatric patients (<18 years of age) through systematic review and meta-analysis. PubMed, Scopus, CINAHL, and ProQuest databases were utilized. Inclusion criteria included case series and chart studies reporting on pediatric RSF patients. Primary outcomes included overall flap survival rate, venous congestion, and necrosis. Screening of 244 initial articles yielded 16 studies for further review and statistical analysis.

There were 207 patients treated with a mean age of 9.51 ± 2.27 years and follow-up of 20.07 months. The majority of studies focus on the distal third as the primary site for RSF reconstruction, with fasciocutaneous being the most commonly used flap type. Trauma was the predominant etiology of soft-tissue defect (91.0%). Analysis of outcomes shows a 91.0% survival rate for reverse sural flaps. Approximately 13.0% of patients experienced venous congestion. Flap necrosis rate was 15.0%, although most cases were subtotal (93.1%) and successfully managed through additional skin grafting.

With comparable efficacy to free flaps for distal third defects in the pediatric population as well as similar success rates to adult RSF patients, the RSF should be considered a first-line therapy for lower-extremity soft-tissue reconstruction in pediatric patients.