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"Revisiting the Reverse Sural Artery Flap: Anatomic Study and Novel Modifications for Extended Flap Reach".

Xiao Zhu1, Sydney R Verrett2, Jacqueline A Oh2

  • 1. University of Pittsburgh Medical Center Department of Plastic Surgery, Pittsburgh-PA, 15261.

Plastic and Reconstructive Surgery
|April 8, 2026
PubMed
Summary

The Reverse Sural Artery Flap (RSAF) may need modifications like perforator skeletonization to cover distal limb defects, as perforators are often higher than expected. These techniques extend the flap's reach for reliable coverage.

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Area of Science:

  • Plastic Surgery
  • Orthopedic Surgery
  • Vascular Surgery

Background:

  • The Reverse Sural Artery Flap (RSAF) is a versatile local flap for distal limb coverage, supplied by peroneal perforators.
  • Understanding perforator distribution is key to optimizing RSAF use.

Purpose of the Study:

  • To describe peroneal perforator distribution in cadaveric dissections.
  • To evaluate novel modifications of the RSAF for increased reach in clinical cases.
  • To assess the efficacy of these modifications for covering distal limb defects.

Main Methods:

  • 38 cadaveric legs were dissected to map peroneal perforator locations.
  • 12 patients underwent RSAF with modifications including perforator skeletonization, Achilles tendon release/tunneling, and proximal peroneal artery ligation.
  • Defects included medial foot and distal forefoot injuries.

Main Results:

  • Cadaveric dissections showed terminal peroneal perforators at a mean of 10.96 cm above the malleolus.
  • Clinical RSAF pivot points were lower (6.67 cm) due to modifications.
  • Minor distal tip necrosis (<10%) occurred in 2 patients; one had superficial epidermolysis.

Conclusions:

  • The terminal peroneal perforator's location often exceeds the traditional 5 cm pivot point.
  • Perforator skeletonization, Achilles tendon manipulation, and proximal peroneal artery ligation significantly extend RSAF reach.
  • These techniques enable reliable coverage of challenging distal foot and forefoot defects.