Reverse sural artery flap for lower extremity reconstruction: a multicenter retrospective analysis of success and failure patterns

The reverse sural artery flap (RSAF) has emerged as a versatile option for soft tissue reconstruction in the distal lower extremity, particularly when microsurgical expertise or resources are limited. Despite its increasing use, comprehensive multicenter data on its survival outcomes and anatomical site-specific performance remain limited. This retrospective multicenter case series included all patients who underwent RSAF for distal lower extremity defects between 2015 and 2024 across military, governmental, private, and academic institutions. Data on patient demographics, defect characteristics, surgical technique, and postoperative outcomes were collected and analyzed using Jamovi. Kaplan-Meier survival analysis was used to assess flap survival over time, with subgroup comparisons based on defect site. A total of 60 patients were included. The overall flap survival rate was 96.7%, with a mean wound healing time of 21.5 days. Venous congestion occurred in 83.3% of cases. Persistent venous congestion occurred in 10% of cases, leading to partial flap necrosis. Flap width, pedicle length, prolonged operative time, and patient-specific factors such as body mass index (BMI) and smoking status were significantly associated with adverse outcomes. Site-specific analysis revealed that RSAFs used for ankle and lower leg defects had a 100% survival rate at 60 months, while heel-based flaps showed a decline in survival to 70.8% at 60 months. RSAF is a highly successful and reliable option for lower extremity reconstruction, especially in resource-variable settings. However, anatomical site, flap design parameters, and modifiable patient risk factors significantly impact outcomes. Long-term surveillance highlights excellent durability in ankle and lower leg reconstructions, while heel-based reconstructions require closer follow-up. Level of Evidence Level III (Retrospective Comparative Study).