Soft tissue sarcomas of the foot are rare malignant tumors that often present diagnostic and reconstructive challenges due to limited soft tissue coverage and proximity to critical structures. An 84-year-old male presented with a chronic ulcerative lesion over the right heel which was histologically confirmed as a malignant spindle cell neoplasm. Imaging demonstrated a lobulated soft-tissue mass confined to the subcutaneous plane without bone invasion, and staging work-up revealed no distant metastasis. The patient underwent limb-sparing surgery consisting of wide local excision of the heel lesion with right superficial inguinal lymphadenectomy followed by reconstruction using a reverse sural artery flap and split-thickness skin grafting. Histopathology confirmed malignant spindle cell sarcoma with negative margins and absence of nodal metastasis. This case highlights the feasibility of limb-salvage surgery with appropriate oncologic resection and reconstructive techniques in elderly patients with foot sarcomas.

The Reverse Sural Artery Flap (RSAF) supplied by distal peroneal perforators is a versatile local flap option for distal limb coverage. We describe perforator distribution in cadaveric dissections, and our clinical experience with four novel modifications (perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, proximal peroneal artery ligation) to allow greater reach for the RSAF. 38 cadaveric legs were dissected to study the peroneal perforators. 12 patients from 5-73 years-old underwent RSAF and the proposed modifications for a variety of defects, including the medial foot and distal forefoot. From the cadaveric study, terminal peroneal perforator was at a mean distance of 10.96±3.67 cm above the malleolus. Only 10.6% of distal-most perforators were within the last 20% of the fibular length, or 6.76 cm from the malleolus. Clinical series findings were comparable, with adult distances of 9.31±1.80 cm. However, the pivot point was lower, at 6.67±1.59 cm, owing to perforator skeletonization and dissection off the Achilles in all cases, tunneling under the Achilles in four, and proximal peroneal artery ligation in one. Two had subsequent <10% distal tip necrosis and one 50% superficial epidermolysis, which healed with local care. The terminal peroneal perforator may lie higher than the 5 cm pivot point generally recommended for the RSAF. For these cases, perforator skeletonization, dissection off and/or tunneling under the Achilles tendon, and even proximal peroneal artery ligation can allow further reach of the RSAF to reliably cover distal defects including the medial foot and forefoot.

The relevance of the topic is determined by the growing need for the implementation of effective and low-traumatic methods of reconstruction of soft tissue defects of the distal part of the lower limb and foot, which is associated with a significant number of mine-explosive injuries among military personnel. The aim is to conduct a meta-analysis of the clinical results of studies and our own research among servicemen of the Armed Forces of Ukraine on the use of the reverse sural artery flap with an assessment of the structure and nature of injuries, age and gender characteristics of patients, time from injury to surgery, length of hospital stay, frequency of complications, flap survival, as well as functional and aesthetic results, and to determine the optimal indications for its use. Materials and methods. The work was performed by meta-analysis of foreign scientific studies, content analysis of publications in the Scopus and PubMed scientific databases, along with materials from professional publications. Our own research was conducted among 33 servicemen of the Armed Forces of Ukraine who underwent reconstruction of distal defects of the lower limb with the reverse sural flap. The literature search was conducted using keywords and phrases reflecting the research topic: reverse sural artery flap, soft tissue reconstruction, distal lower limb, foot, blast injury, vascular integrity, plastic surgery. The search covered the period from 2005 to 2025. Results. The reverse sural artery flap demonstrated high efficiency: in 78.79 % of cases, healing occurred without complications. The average flap parameters (227.21 cm2, pedicle length of 24.09 cm) corresponded to the optimal technical characteristics. A moderate positive correlation was found between the defect area and the flap size (r = 0.68; p &lt; 0.01) and a weak correlation between the pedicle length and the defect area (r = 0.32; p &lt; 0.05). Complications (21.21 %) were mainly caused by venous stasis, thrombosis, or violation of the postoperative regimen. Conclusions. The use of the reverse sural artery flap is a reliable method for reconstructing distal defects of the lower extremities in military personnel, ensuring a high flap survival rate and good functional and aesthetic results.

Background: Sural-based flaps, including the reverse/distally based sural artery flap (RSAF) and the medial sural artery perforator (MSAP) flap, remain widely used for distal lower-extremity and selected head-and-neck reconstruction due to reliable anatomy and acceptable morbidity. Methods: A focused narrative review of systematic reviews, pooled analyses, large clinical series, and key anatomic studies was performed to summarize indications, outcomes, risk factors, and technical considerations. Results: RSAF shows survival rates of approximately 95–97%, with venous congestion and partial necrosis as the most common complications. Smoking, venous insufficiency, advanced age, larger flap size, and heel location increase complication risk, whereas diabetes and peripheral vascular disease are not consistently associated with total flap loss. MSAP flaps provide thin, pliable tissue with low donor-site morbidity and survival rates near 96%. In head-and-neck and lower-extremity reconstruction, MSAP outcomes are comparable to other free flaps, with superior donor-site aesthetics but persistent risk of venous congestion. Conclusions: RSAF remains a reliable workhorse for distal leg and foot defects, while MSAP offers a versatile perforator alternative with favorable donor-site outcomes when anatomy and expertise allow.

Background: Achilles tendon is the most commonly ruptured tendon in the human body. Injury may occur due to accidental slippage of foot, accidental cut by sharp household, machinery tools, spontaneous rupture, road traffic accidents, etc., In rural India, another common mechanism of injury is slippage of foot in Indian type lavatory pans. Skin over tendoachilles is thin and pliable to facilitate smooth tendon excursion and aid in dorsi and plantar flexion of foot. However, soft tissue defects of this region are difficult to reconstruct because of paucity of skin, soft tissue, and poor vascularity. Aim: To evaluate the use of various fasciocutaneous flaps for tendoachilles defects. Patients and Methods: This retrospective study was conducted in the Department of Plastic and Reconstructive Surgery, Siddartha medical college, Andhra Pradesh, from May 2023 to May 2025 for a period of two years. Fifteen patients with soft tissue defects over tendoachilles were studied. The etiology, size of defect, and the various reconstructive flaps used and postoperative course were evaluated. Results: Out of 15 patients, 13 were male and two were female. The age group ranged from three to 60 years. Most of the defects are due to road traffic accidents. Reverse sural artery flap, lateral calcaneal artery flap, lateral supramalleolar flap, keystone flap, and peroneus brevis muscle flap were used to cover these defects. Conclusion: Fasciocutaneous flaps play a major role in reconstruction of defects over the tendoachilles region. Long-term follow-up with physiotherapy is essential to achieve good function of tendoachilles.

BACKGROUNDEarthquakes stand as the most devastating form of natural disaster. Türkiye, situated within a fault zone, has witnessed numerous catastrophic earthquakes throughout its history. On February 6, a powerful earthquake severely impacted eleven cities in the southeastern part of the country. The purpose of this study is to evaluate the treatment management of a specific group of patients who were initially advised amputation but rejected this procedure and were referred to our clinic for reconstruction.METHODSThis single-center retrospective analysis included 15 patients (8 female, 7 male) with 17 flaps. Cases not requiring microsurgery were excluded. Data on admission conditions, time spent under debris, debridement surgeries, flap surgeries, anastomosis details, lab values, angiography, reoperations, wound closure times, complications, flap outcomes, hospitalization duration, and amputations or death were collected.RESULTSThe average age of the 15 patients was 30.67±18.51, with 5 patients being pediatric (33.33%). Patients spent an average of 41.77±40.68 hours under debris, with an 11.40±5.80-day admission delay. They underwent an average of 4.41±3.02 debridement surgeries before flap surgery, which occurred around 21.06±18.24 days post-admission. Wound closure took about 37.93±37.58 days on average, with an average hospital stay of 77.33±36.67 days. Forty-six percent received hyperbaric oxygen treatment. Various flap types were used, with no failures in anterolateral thigh (ALT) or sural artery flaps. Latissimus dorsi + serratus anterior chimeric flaps were used for larger defects, required more blood product replacements, and were fraught with difficulties. In total, 4 of the flaps failed, 3 patients required amputation despite all efforts, and 1 patient died.CONCLUSIONEarthquake victims with injuries that are “worse than they seem” due to vascular and infectious concerns require careful microsurgery. Proximal anastomosis, venous complication monitoring, meticulous debridement, VAC therapy, and adjuvant treatments such as hyperbaric oxygen therapy are crucial in managing these complex cases.

Infection after Achilles tendon (AT) repair can lead to defects in both the tendon and the surrounding soft tissue. In such cases, a two-stage surgical approach is generally adopted, with soft tissue reconstruction performed initially, followed by secondary tendon reconstruction. A reverse sural artery flap (RSAF) after AT repair is not commonly performed due to potential damage to the flap pedicle. This study aims to evaluate the clinical outcomes of simultaneous flexor hallucis longus tendon (FHLT) transfer and RSAF to treat soft tissue and tendon defects resulting from infection after AT repair.We reviewed 20 patients who had undergone one-stage reconstruction of AT and soft tissue defects resulting from infection after AT repair using FHLT transfer and RSAF between October 2012 and October 2022, with a minimum of a 1-year postsurgical follow-up. Surgical outcomes were assessed based on the success of the flap, recurrence of infection, and tendon re-rupture. Clinical evaluation included visual analog scale (VAS) score, ankle range of motion, and patient-reported components of the American Orthopaedic Foot and Ankle Society (AOFAS) score (maximum of 68 points).All flaps were successful. The mean size of the flap was 7.2×4.1 cm2. There was no recurrence of infection or tendon re-rupture. The mean VAS and AOFAS scores were 0.5 and 64.6, respectively. The mean ankle joint range of motion was 13.5° for dorsiflexion and 35° for plantar flexion.One-stage reconstruction with FHLT transfer and RSAF is a safe and effective surgical method in patients with tendon and soft tissue defects after AT repair.

BackgroundWar-related injuries present significant challenges to the health system, notably during the conflict period. The study aimed to evaluate the demographics, anatomical distribution, plastic intervention, immediate complications, and outcomes of war-injured patients presenting to our plastic surgery unit.MethodsThis retrospective, cohort, single-center study was conducted from January 2024 to December 2024 and included 300 war-injured patients treated in the plastic surgery unit, Atbara Hospital. The patients' demographic data, site of injuries, surgical management, and complications were documented.ResultsThe commonly affected age group was 20–30 (51.3%), followed by 30–40 (38.3%). The most common site of war injuries was the extremity: upper limb in 171 patients (57%), and lower limb in 108 patients (36%). The total number of surgical operations performed was 306, with split thickness skin grafts being the most common procedure in 104 (34%) patients. Local fasciocutaneous flaps were used in 60 (19.6%) patients, whereas muscle flaps were used in only 23 (7.5%) patients. The Reverse sural artery flap was the commonly used fasciocutaneous flap, used in 23 patients (7.5%). Surgical operations for nerves and tendons were performed in 63 (20.6%) and 56(18.3%) patients, respectively. The complication rate was 13%, with a wound infection rate of 8.5%.ConclusionsThe study highlights the predominance of extremity-related injuries and the reliance on simple reconstructive methods (split thickness skin grafts and pedicled flaps) to reconstruct war injuries in limited resource areas, in the absence of microsurgery services. Furthermore, the report highlights the crucial role of plastic surgery in conflict settings.

BackgroundThe 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.MethodsThis 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.ResultsA 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.ConclusionsRSAF 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).

Efficacy of venous supercharged reverse sural artery flap for reconstruction of severe limb trauma: comparative study including high-risk patients.

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus, often leading to prolonged morbidity and limb amputation. Successful management involves early debridement, infection control, and appropriate soft tissue coverage. The present study is a retrospective case series conducted from March 1 to August 31, 2024, involving seven patients with chronic DFUs at Sree Balaji Medical College and Hospital. Each case underwent individualized reconstruction strategies, including split-thickness skin grafts (STSGs), reverse sural artery flaps, medial plantar artery flaps, cross-leg flaps, and conservative healing, depending on wound location, depth, and vascular status. All patients demonstrated favorable outcomes in terms of graft/flap viability and wound healing. Functional recovery was satisfactory in each case. No major complications or recurrences were observed during follow-up. Early and tailored multimodal reconstructive approaches yield positive outcomes in DFUs. Strategic planning based on anatomical site and biomechanical load is crucial for effective limb salvage.

Is it possible to perform reverse sural artery flap on lower limbs where the main trunk of the peroneal artery is interrupted?

Objectives: To determine the efficacy of intermittent controlled phlebotomy in reverse sural artery flap surgery in terms of flap congestion and flap survival. Study Design: Quasi-experimental study. Place and Duration of Study: Department of Plastic Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Mar 2021 to Feb 2022. Methodology: A total of 76 patients with lower limb skin defects requiring reconstruction were included in our study. Patients who suffered from neoplastic disease, those who had active infections or had received previous surgery for the defect were excluded. All patients underwent reverse sural artery flap repair. Patients in Group A received intermittent controlled phlebotomy by inserting 18 Gauge IV cannula in short saphenous vein during initial phase of flap harvest, while those in Group B did not. All patients were followed up for six-weeks post-surgery for the development of complications such as venous congestion. Results: Our patients had a mean age of 46.32±19.06 years, of whom 43(56.6%) were women. Venous congestion occurred in 2(5.3%) cases with intermittent phlebotomy versus 10(26.3%) without it, (p=0.012). Flap necrosis also occurred at a lower rate: 2(5.2%) versus 8(21.1%) in those without it, (p=0.042). Remaining complications such as surgical site infections, paraesthesias, limitation of mobility and donor site complications had similar incidences across the two groups, (p&gt;0.05). Conclusion: Cases undergoing intermittent controlled phlebotomy have better outcomes in terms of the occurrence of complications versus those patients who do not receive the intervention.

Plastic surgeons continue to face considerable challenges while reconstructing exposed Achilles tendon. Several alternatives for repairing such defects include the reverse sural artery flap, peroneus brevis flap, propeller flap, lateral calcaneal artery flap, and peroneal artery perforator flap. However, each of these techniques has its pros and cons. This study compares our clinical experience to various reconstructive techniques for exposed Achilles tendon. Fifteen individuals had their exposed Achilles tendon reconstructed between October 2023 and July 2024. These fifteen cases were classified based on the origin of the wound, comorbidities, operational results, and complications, which were analyzed using a prospective study. The average age of the patients was 40. All 15 patients tolerated the flap procedure well without significant complications; however, one patient with a reverse sural flap developed complete flap necrosis and required secondary split-thickness skin grafting. One more patient had distal tip necrosis and healed with secondary intention. One patient developed an infection, which was resolved by debridement and consecutive dressings. None of the patients had any functional deficits in their lower extremities. The flap based on the lateral calcaneal artery is the most common and useful flap for coverage of exposed Achilles tendon with respect to aesthetic appearance, good functional outcome, minimal donor morbidity, and time of surgery; it is the flap of choice for small- to medium-sized exposed Achilles. Our study's second most commonly used flap was based on the sural artery. This flap can cover medium to larger defects. Similarly, other techniques also had their advantages and disadvantages.

Objective: Emphasize the importance of a comprehensive and aggressive management with surgical debridement and flap-based reconstruction of defects in patients with diabetic foot ulcers (Ganga Class 3), and in turn, focusing on limb salvage. Methods: A retrospective cohort analysis was conducted on 40 patients with Ganga Class 3 diabetic foot submitted to flap surgeries between 2019 and 2022. These surgeries included both free and local flaps, and patients were followed postoperatively to monitor complications such as flap necrosis, infection, and the need for amputation. A pedobarogram was performed after wound healing to assess the risk of ulcer recurrence.Results: The mean age of the study population was 58.5 years, with 75% being male. Most ulcers (60%) were located in the hindfoot, with large hindfoot ulcers often requiring anterolateral thigh-free flaps, which showed excellent long-term outcomes. While effective for smaller defects, local flaps demonstrated higher complication rates, particularly flap necrosis in reverse sural artery flaps. Despite these complications, flap surgeries were largely successful, with only one patient requiring amputation, achieving significant success in limb salvage. Conclusion: Given that India is considered the diabetic capital of the world, with 85% of amputations preceded by foot ulcers, this study highlights the potential for surgical management of diabetic foot ulcers, regardless of size or location,n emphasizing the importance of limb salvage in improving patient outcomes. Level of evidence IV.

Bilateral degloving injuries of the feet are rare and challenging to reconstruct due to the extent of tissue loss and extensive exposed surface area. This case study describes the successful treatment of a 58-year-old male with bilateral foot degloving injuries using staged reconstruction with reverse sural artery flaps and split-thickness skin grafting. The surgical approach included vacuum-assisted closure therapy followed by large reverse sural artery flap harvests to restore plantar surfaces, complemented by split-thickness skin grafts for dorsal defects. Both flaps achieved full viability without complications, and the patient regained functional mobility after 12 months of rehabilitation. This report aimed to highlight the effectiveness of reverse sural artery flaps as a reliable alternative to free flaps in high-risk cases. It underscores the simplicity of this technique in achieving successful complex foot reconstruction while delivering favorable functional and esthetic outcomes.

Objective: To evaluate the effectiveness and outcomes of the reverse sural artery flap (RSAF) in managing wheel spoke injuries of the heel in a tertiary care setting in Pakistan, with an emphasis on its indications, postoperative complications, and functional recovery. Study Design: Cross-sectional descriptive study. Place and Duration of Study: Department of Plastic and Reconstructive Surgery, PNS Shifa Hospital, Karachi, Pakistan, conducted between August 2024 and January 2025. Methodology: Data were collected from patients treated with RSAF for reconstructive purposes following wheel spoke injuries to the heel. The study included patient demographics, details of the injury, and postoperative outcomes. The main outcomes assessed were complications such as flap necrosis, donor site morbidity, and functional recovery, along with the success rate of RSAF in covering soft tissue defects. Data analysis was performed using SPSS Version 22, with a significance level of p-value &lt; 0.05. Results: RSAF successfully covered heel defects in 90% of cases. In the remaining 10%, minor complications were observed, including partial flap necrosis and donor site issues like scar formation and sensory changes but there were no cases of osteomyelitis or major complications. Functional recovery was excellent, with all patients regaining weight-bearing ability within six months. The average hospital stay was 14–16 days, and follow-ups at 1, 3, and 6 months showed stable flap viability and satisfactory healing. Early intervention significantly improved outcomes, confirming the importance of timely surgery. Conclusion: The reverse sural artery flap is a viable and effective option for the reconstruction of soft tissue defects in wheel spoke injuries of the heel in the Pakistani population. The technique offers reliable coverage and good functional outcomes, with minimal complications when performed in a timely manner. The study highlights the importance of early intervention and appropriate postoperative care to optimize results.

The reconstruction of soft tissue near the heel area is challenging, especially after wheel-spoke injuries. Different varieties of the reverse sural artery flap technique are routinely used in complex locoregional areas for reconstructive surgery. This study proposes an innovative surgical method involving the use of a rotation-advancement fasciocutaneous flap based on peroneal artery perforators. In this study, 30 patients with soft-tissue defects in the lower third of the leg, including defects in the ankle and heel areas, were treated with this flap. The study included 19 women and 11 men. The mean age of the patients was 27.60 years. The most common cause of the defect was wheel-spoke injury due to a road traffic accident. In the authors' experience, the flap survival rate was approximately 100%. Four patients had only marginal necrosis of the distal tip, and 2 patients had minor wound infections; these patients were managed cautiously until their healing was complete. For distal leg reconstruction, the authors recommend the UAD flap over the traditional sural flap because of its lower donor-site morbidity and better aesthetic appearance.

Delayed pedicled flaps are a reliable reconstructive tool for limb salvage. Determining the optimal timing for pedicle division is critical for surgical success and minimizing complications. Assessment of optimal timing has traditionally relied on arbitrary timing or subjective measures. This study explores the use of indocyanine green (ICG) angiography in the office setting as an objective guide for timing the delayed pedicled flap pedicle division, aiming to improve surgical outcomes and resource efficiency. In the outpatient setting, ICG is administered intravenously while the flap pedicle is under tourniquet control. If the distal flap opacifies with the tourniquet still applied, appropriate revascularization has occurred, and the pedicle may be safely divided. We present the example of a 47-year-old male with multiple previous flap reconstructions who eventually required a reverse sural artery flap. Initial intraoperative ICG imaging on postoperative day (POD) 23 revealed insufficient perfusion, prompting the postponement of pedicle division. Subsequent office-based imaging on POD 47 revealed a persistent lack of neovascularization. Adequate vascularization was demonstrated on POD 81, enabling successful pedicle division in the operating room on POD 121 without complications. ICG fluorescent angiography can guide the timing of division for delayed pedicled flaps. We recommend its use in the outpatient setting to decrease unnecessary operating room usage and anesthetic events and reduce the risk of wound healing complications from early pedicle division.

Soft tissue defects around the knee and proximal leg represent a challenging clinical scenario for plastic and reconstructive surgeons. These defects can arise from a variety of causes, including traumatic injuries, such as crush injuries and road traffic accidents, thermal injuries like burns, and surgical complications such as infection. Objective of the study was to evaluate the success of proximally based sural artery flap for soft tissue defects around the knee and proximal leg in patients presenting to our tertiary care hospital. This prospective observational study was conducted at the Department of Plastic & Reconstructive Surgery, Civil Hospital, Karachi, Pakistan. The study included patients with soft tissue defects around the knee and proximal leg, excluding those with specific comorbidities, high BMI, or active smoking. Non-probability convenience sampling was employed. After ethical review committee approval and informed consent, if needed wounds were optimized with thorough debridement then patients underwent proximal-based sural artery flap surgery for soft tissue defects around knee and proximal leg. Flap survival and complications were assessed over three to six weeks. The study included 37 patients, with a median age of 30 years. The most frequent cause of defects was road traffic accidents (73%). Of the patients, 73% were male, and 27% were female. The median duration of soft tissue injury was 5 weeks, and the median duration of surgery was 90 minutes. Flap survival was 97.3%, with 28 flaps surviving without any complications. One patient with a 20-year-old chronic defect experienced partial flap failure. The use of the proximally based sural artery flap represents a promising approach for the successful reconstruction of soft tissue defects around the knee and proximal leg.