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How Safe Is Reverse Sural Flap? A Systematic Review
Abstract
Background: Soft tissue reconstruction of the lower third of the leg, the ankle, and the foot is challenging for reconstructive surgeons. The options for reconstruction are limited. Reverse sural flap is relatively easy to perform and considered a good option for reconstruction. The complication rates are variable in studies. This study aims to systemically review all available articles based on reverse sural flap focusing on complications of the flap. The overall complication of the flap helps to better understand the reliability of the flap.
Methods: A comprehensive literature search was performed using MEDLINE, EMBASE, and Google Scholar to identify cases of reverse sural artery flap.
Results: A pooled analysis of 89 articles was performed, which yielded 2575 patients (2592 flaps) over a period of 19 years. Most of the cases were performed in Asian countries (1540 flaps, 59.4%) with the majority being performed in China (746 flaps, 28.8%). The most common cause for reverse sural flap surgery was trauma/postsurgical (1785/2592) followed by burn/scarring. Flap complications were recorded in 653 of 2592 flaps (25.20%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.85%) followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 participants (2.5% of all the flaps performed).
Conclusions: Reverse sural flap is reliable flap for the reconstruction of lower leg, ankle, and foot. It can give a comparable outcome as free flap when meticulously performed and, in many cases, a better result.
Introduction
Soft tissue reconstruction of the lower third of the leg and the foot is challenging for reconstructive surgeons. The major problem is limited mobility of the skin and poor vascularity. Various methods of reconstruction have been described for reconstruction such as local flap, free flap, perforator flap, etc. The distally based sural fasciocutaneous flap is a good option for the reconstruction of the lower third of the leg and the foot. The major advantage of this flap is that it does not require microsurgical skills and can be done in a minimal-resource center. The first distally based sural fasciocutaneous flap was defined by Donski et al in 1983 for Achilles tendon coverage.1 The detailed anatomy of distally based sural fasciocutaneous flap for the reconstruction of distal third of leg, foot, and ankle defect was described by Masquelet et al in 1992.2 Later, various modifications were illustrated by other studies.3-5
The distally based sural fasciocutaneous flap is the workhorse flap for many reconstructive surgeons, especially when they lack microsurgical skills or when other reconstructive options are not available. Many surgeons believe the sural flap is a good alternative to the free flap. The complication rates are variable in studies. This study aims to systemically review all available articles based on the reverse sural flap, focusing on complications of the flap. Knowing the overall complications of the flap helps us to better understand the reliability of the flap. Furthermore, this study reviews the demographics and etiologies for flap surgery.
Review and Data Extraction
We conducted a comprehensive literature search of MEDLINE, EMBASE, and Google Scholar using the keywords “sural flap, reverse sural flap, reverse neurocutaneous sural flap, reconstruction of leg and foot.” Additional articles were identified by reviewing reference lists. Various journals were searched for articles not indexed in PubMed or EMBASE. The inclusion criteria for the articles were those which studied reverse sural flap with complications from 2000-01 to 2019-20, had been published, and are in English. Articles were excluded if they failed to present the data for extraction and also if they failed to present the complications.
Data extraction and quality assessment were performed. The data were extracted from each study into an Excel spreadsheet, and further evaluation was performed. Various charts were extracted from the original data. The following variables were collected from each study: country of origin, year of publication, number of flaps, number of patients, gender, indication for reconstruction, number of complications, and type of complications.
Special care was taken to avoid the overlapping of the patient population. For this purpose, a comparison of the authorship, date of publication, and country of origin of the article were performed. If the patient population was found to overlap, the article with most comprehensive data was included in the study. This method resulted in the exclusion of 2 articles.
A formal meta-analysis was not performed due to the large degree of clinical heterogeneity among the study populations.
The database search elicited 784 articles. The process of article selection for systematic review is summarized in Figure 1.
Results
The search revealed 784 titles of interest, of which 89 articles were selected for the final review. All the articles were observational studies, with the majority being retrospective case series. The list of publications included in the review is presented in Table 1. The pooled analysis of 89 articles yielded 2575 patients (2592 flaps) over a period of 19 years (2000-01 to 2019-20).
Demographics
Most of the flap surgeries were performed in Asian countries (1540 flaps, 59.4%), with majority being performed in China (746 flaps, 28.8%). The majority of patients were male (1896 patients, 73.6%). The complication rate in China is much lower than the overall complication rate (Table 2; Figure 2).
Etiology
For the ease of classification and data extraction, the etiology has been classified into 9 groups. The most common cause for reverse sural flap surgery was trauma/postsurgical (1785 of 2592) followed by burn/scarring (Table 3).
Flap Complications
Flap complications were recorded in 653 of 2592 flaps (25.19%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.87%), followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 cases (2.51% of all flaps performed; Table 4).
Discussion
This study analyzed a total of 2592 reverse sural flaps (2575 patients) from 27 regions around the globe. No other studies of reverse sural flaps to date have included so many patients. All of the studies were observational studies, with most being case series.
The distally based sural flap is the workhorse flap for the reconstruction of the lower leg, the ankle, and the foot. Another alternative reconstructive option includes free flap. There is ongoing debate among reconstructive surgeons as to whether the free flap is better than a sural flap. When considering the reconstructive ladder, reverse sural flap, as a locoregional flap, comes earlier as a reconstructive option. The greatest advantage of a sural flap is that it is easy to perform and even non-plastic surgeons can perform the sural flap easily. It is advantageous in resource-poor centers.
This systematic review shows that most reverse sural flaps (59.4%, 1540 of 2592 flaps) were performed in Asian countries. The reason could be the larger population, lack of microsurgeons or microsurgical facilities, or higher incidence of trauma in Asian countries. A systematic review by Dijkink et al shows that 90% of all lethal traumatic injuries occur in middle- and low-income countries.95 This study classified the etiologies into 9 groups. The most common reason for surgery was trauma/post operation. Trauma and post operation were combined into a single group for the ease of date extraction, and in many cases it was difficult to extract these 2 entities separately. This group accounted for 68.86% (1785 flaps). De Blacam et al also reported trauma as most common indication for reverse sural flap surgery.96 Burn/scarring and ulcer were the other most common indication for surgery after trauma/post operation. Burn injury is one of the major causes of trauma in the world, and most cases of burn injury occur in low- and middle-income countries.97 This review shows that most of the procedures were done in a single stage. Single-stage procedures, when successful, are a win-win for both patients and doctors.
The pooled analysis shows the overall complication rate of 25.19% (653 of 2592). Total flap necrosis, the most devastating complication, was observed in only 2.5% of patients. These findings are consistent with those of a systemic review and pooled analysis done by de Blacam et al.96 Their study reported the overall complication rate of 26%, and total flap necrosis was observed in 3.2% of patients. Similarly, a meta-analysis of 50 articles including 720 flaps by Follmar et al reported complete flap necrosis in 3.3% (24 of 720) of patients.98 The findings of the study reported here are also comparable with those of Wei et al from China, with 179 flaps from 175 patients.51 That study recorded an overall complication rate of 21.22% without any complete flap loss. The findings in the study presented here compare favorably with free flap failure rates in lower limb reconstruction ranging from 7.7 to 20%.99-101
The most common complication in our pooled analysis was partial flap loss. The partial flap loss was observed in 7.87% (204) of flaps. This figure is comparable with previous a systematic review done by de Blacam et al with a rate of 6.7%.96 Follmar et al reported in his meta-analysis a slightly higher rate of partial flap necrosis of 11%.98 Similarly, Kang et al in their series of free flap reconstruction of lower limb reported a partial flap loss of 15.4%. The other most common complication was venous congestion 3.05% (79 flaps). Early detection of the flap failure or complication helps the surgeon to rescue flaps. It is always important to train the nursing staff and junior doctors to properly examine the signs of flap failure.
This study has several limitations. All included studies were retrospective in nature, hindering the identification of predictors of flap failure or complications. An analysis of the complications in respect to comorbidity of the patients was not performed because most of the studies fail to present the data systematically. Most of the studies included were case series, and pooled analysis of the data presents a result with a low level of evidence. There was considerable heterogeneity between the studies, which limited the comparison of some findings. Although a thorough search of literature on PubMed, EMBASE and Google scholar was conducted as well as a review of related and cross-referenced literature, existence of missing studies can never be excluded.
This systematic review and pooled analysis of reverse sural flaps, which includes the largest number of patients to date, will aid reconstructive surgeons in decision-making regarding the reconstruction of the lower leg, the foot, and the ankle.
Conclusions
Reverse sural flap is a reliable flap for the reconstruction of the lower leg, the ankle, and the foot. It provides an outcome comparable to that of the free flap when meticulously performed and, in many cases, a better result. The reverse sural flap will continue to evolve with various refinements to meet the reconstructive needs of the individual patients.
Acknowledgments
We would like to extend our sincere gratitude and appreciation to Ms.Sabita Kumari Chhetry for helping us with the data arrangement and statistics.
Affiliations: Nepal Plastic Cosmetic and Laser Center, Lalitpur, Nepal
Corresponding author: Sanjib Tripathee, MD; sanjibatny@gmail.com
Ethics: This study conforms to the Declaration of Helsinki ethical principles for medical research. The study is based on de-identified information and is exempt from IRB.
Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.
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