Abstract
Background
The reverse sural artery flap (RSAF) is widely used for soft-tissue reconstruction of distal lower extremity defects. However, outcomes may vary based on the defect site. This study aimed to compare clinical, functional, and aesthetic outcomes of RSAF performed at the ankle, heel, and lower leg, and to identify predictors of postoperative complications.
Methods
A retrospective analysis was conducted on 60 patients who underwent RSAF for soft-tissue reconstruction in the lower extremity. Patients were stratified by defect location: ankle, heel, or lower leg. Clinical data, complication rates, functional outcomes (Foot and Ankle Ability Measure [FAAM]), aesthetic outcomes (Vancouver Scar Scale), and predictors of complications were analyzed.
Results
The heel group exhibited the highest complication rate (50%) compared to the ankle (33.3%) and lower leg (6.2%) (p = 0.019). Functional outcomes were poorest in the heel group, with a mean FAAM score of 76.8, while the lower leg group had the best outcomes (mean FAAM, 91.2). Aesthetic satisfaction was also lowest in heel reconstructions. Smoking, elevated body mass index (BMI), longer pedicle length, and heel defect location were significantly associated with higher complication rates in univariable analysis. However, in multivariable analysis, smoking (odds ratio [OR], 5.29; p < 0.001), increased BMI (OR, 1.653; p = 0.001), and pedicle length (OR, 1.241; p = 0.030) remained independent predictors, whereas the defect site did not reach statistical significance (p = 0.083, p = 0.155).
Conclusions
While heel reconstructions demonstrated the highest raw complication rates and poorest functional outcomes, multivariable analysis suggests that patient factors—particularly smoking, obesity, and longer pedicle length—are stronger independent predictors of adverse outcomes than defect location itself. These findings underscore the importance of preoperative optimization and careful patient selection and highlight the need to interpret the influence of heel location with caution due to confounding factors such as the high prevalence of smoking in this subgroup.
Keywords: Surgical flaps, Lower extremity, Reconstructive surgical procedures, Foot, Soft tissue injuries
Soft-tissue reconstruction of the distal lower extremity presents a unique set of challenges due to the region’s limited vascularity, subcutaneous tissue, and exposure to mechanical stress, particularly in weight-bearing areas such as the heel and ankle.1) Traumatic injuries, chronic ulcers, diabetic foot complications, and tumor excisions often necessitate complex reconstructive procedures to preserve limb function and prevent amputation.2) In this context, the reverse sural artery flap (RSAF) has emerged as a reliable and versatile option for addressing small- to mediumsized defects in the lower leg, ankle, and heel.3,4)
The RSAF is a fasciocutaneous flap based on the vascular axis of the sural nerve, typically incorporating the median superficial sural artery, lesser saphenous vein, and accompanying perforators.5) It offers several advantages over free flaps, including technical simplicity, shorter operative time, and the absence of microvascular anastomosis, making it especially valuable in resource-limited settings or in patients with significant comorbidities.6) Despite its widespread use, concerns regarding complications—such as partial flap necrosis, venous congestion, and delayed wound healing—remain, particularly in distal foot reconstructions where perfusion is more tenuous.7,8)
While numerous studies have reported the clinical success of RSAF in lower limb reconstruction, limited data exist on how outcomes may differ according to the defect location—namely, the ankle, heel, or lower leg.9) These anatomical subregions differ significantly in terms of soft-tissue characteristics, vascular supply, biomechanical demands, and risk of pressure-related complications.10) Therefore, a comparative analysis based on defect location could provide more nuanced insights into optimizing surgical planning and patient counseling.11)
This study aims to assess the clinical and functional outcomes of RSAFs in lower extremity reconstruction, with a focus on comparing outcomes among ankle, heel, and lower leg defects. In addition to evaluating postoperative complication profiles, this study also assesses functional recovery using the Foot and Ankle Ability Measure (FAAM), aesthetic results via the Vancouver Scar Scale (VSS), and overall patient satisfaction. By leveraging a multicenter retrospective design encompassing diverse healthcare settings in Jordan, this work seeks to provide a comprehensive evaluation of RSAF outcomes and contribute to evidence-based surgical decision-making in reconstructive lower limb surgery.
METHODS
Ethical approval for this study was obtained from the Institutional Review Board (IRB No. 86/7/2024/2025), in addition to ethical clearance from each of the participating hospitals as required. Given the retrospective nature of the study and the use of de-identified data, informed consent was waived. Confidentiality and data privacy were strictly maintained throughout the study by anonymizing all personal identifiers and securely storing data.
Study Design
This study employed a retrospective multicenter case series design to evaluate the clinical and functional outcomes of patients who underwent RSAF procedures for soft-tissue reconstruction of the lower extremity. Data were collected from 4 major healthcare sectors in Jordan—military, academic, governmental, and private institutions—ensuring a diverse and representative patient population. The study period spanned from January 1, 2015, to July 31, 2024. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies to ensure methodological rigor and transparent reporting.
Study Population and Sample
The study population included all patients who underwent RSAF for soft-tissue coverage of defects in the distal lower extremity, specifically involving the foot, ankle, heel, or lower leg. A census sampling method was used, in which all eligible patients who met the inclusion criteria within the defined study period were included. Patients were eligible if they had undergone RSAF as the primary method of reconstruction and had a minimum postoperative follow-up period of 6 months. Cases were excluded if RSAF was not used as the primary reconstructive technique or if postoperative records and follow-up data, functional or aesthetic outcome was incomplete, preventing reliable outcome assessment.
Data Collection
Data were collected retrospectively using a standardized data abstraction form specifically developed for this study. Information was extracted from institutional surgical databases, operative reports, inpatient and outpatient medical records across participating centers. The dataset included patient demographics (age, sex, body mass index [BMI]), relevant comorbidities (diabetes mellitus, smoking status, peripheral vascular disease, and neuropathy), and surgical indication (trauma, infection, tumor resection, or chronic ulcer). Defect characteristics such as location (ankle, heel, or lower leg), size (measured in cm2), and laterality were recorded. Operative details, including duration of surgery, use of a delay procedure, and flap dimensions, were also documented.
All RSAF procedures followed a consistent surgical technique centered around the sural vascular axis, incorporating the sural nerve, lesser saphenous vein, and accompanying arterial perforators, with the pivot point located 5–7 cm proximal to the lateral malleolus. Postoperative data captured included hospitalization duration and flap monitoring protocol. Outcome measures were categorized as primary and secondary. Primary outcomes included the presence and type of postoperative complications such as partial or total flap necrosis, venous congestion, donor site complications (e.g., dehiscence, infection), and the need for revision surgery. Venous congestion was evaluated intraoperatively and postoperatively based on standardized clinical criteria, including flap color, capillary refill, turgor, and venous engorgement and was classified as mild, moderate, or severe according to the clinical severity. Postoperative complications were further categorized as major or minor based on their clinical impact and need for intervention: major complications included total flap loss, partial flap necrosis requiring surgical revision, and deep wound infection, whereas minor complications included superficial flap necrosis not requiring surgery, minor wound dehiscence, and superficial infection managed conservatively. These classifications were based on standard reconstructive surgery literature.12)
Secondary outcomes focused on functional and aesthetic parameters. Functional outcomes were assessed using the FAAM, encompassing both the activities of daily living and sports subscales. Aesthetic outcomes were evaluated using the VSS for both the flap and donor sites. Patient satisfaction was gauged using a 5-point Likert scale ranging from “very dissatisfied” to “very satisfied.” All outcome data were retrospectively extracted from medical records by a trained investigator who was not involved in the primary surgical care of the patients, to reduce potential bias in data collection.
Data Analysis
Data were analyzed using Jamovi version 2.5.4. Descriptive statistics, including means, medians, standard deviations (SDs), and proportions, were used to summarize baseline characteristics and surgical outcomes. Comparisons between the 3 groups were performed using chi-square tests for categorical variables and analysis of variance for continuous variables. Associations between patient factors (such as age, comorbidities, defect location, and flap type) and flap outcomes were analyzed using chi-square or Fisher’s exact tests for categorical variables, and independent t-tests for continuous variables. A p-value of < 0.05 was considered statistically significant. To identify predictors of postoperative complications, a multivariable logistic regression analysis was performed.
RESULTS
Clinical Outcomes
The clinical and functional outcomes of patients undergoing RSAF at the ankle, heel, and lower leg regions were analyzed. The mean age of the study population was 31.3 years (SD, 13.6), with no significant difference between the groups (p = 0.569). The majority of the patients were male (86.7%), and the distribution of sex did not differ significantly among the groups (p = 0.805). Smoking status showed a significant difference (p = 0.001), with a higher proportion of smokers in the heel group (80.0%) compared to the ankle group (54.2%) and lower leg group (18.8%). The mean BMI was 25.4 kg/m2 (SD, 3.9 kg/m2), with no statistically significant differences among the groups (p = 0.109). The presence of comorbidities was noted in 10% of the cases, with a trend toward fewer comorbidities in the lower leg group (p = 0.065). The primary indications for surgery were trauma (51.7%), infection (26.7%), and war injuries (21.7%), with no significant differences among the groups (p = 0.345) (Table 1).
Table 1. Clinical Outcomes of Patients Undergoing Reverse Sural Artery Flap at the Ankle, Heel, and Lower Leg.
| Variable | Ankle (n = 24) | Heel (n = 20) | Lower Leg (n = 16) | Total (n = 60) | p-value | |
|---|---|---|---|---|---|---|
| Age | 0.569* | |||||
| Mean ± SD | 33.2 ± 16.8 | 31.3 ± 13.3 | 28.4 ± 7.5 | 31.3 ± 13.6 | ||
| Range | 18.0–67.0 | 7.0–68.0 | 18.0–42.0 | 7.0–68.0 | ||
| Sex | 0.805† | |||||
| Female | 4.0 (16.7) | 2.0 (10.0) | 2.0 (12.5) | 8.0 (13.3) | ||
| Male | 20.0 (83.3) | 18.0 (90.0) | 14.0 (87.5) | 52.0 (86.7) | ||
| Smoking | 0.001† | |||||
| No | 11.0 (45.8) | 4.0 (20.0) | 13.0 (81.2) | 28.0 (46.7) | ||
| Yes | 13.0 (54.2) | 16.0 (80.0) | 3.0 (18.8) | 32.0 (53.3) | ||
| BMI (kg/m2) | 0.109* | |||||
| Mean ± SD | 24.9 ± 3.2 | 26.9 ± 4.8 | 24.4 ± 3.0 | 25.4 ± 3.9 | ||
| Range | 21.0–33.8 | 18.0–32.9 | 19.5–28.5 | 18.0–33.8 | ||
| Comorbidity | 0.065† | |||||
| No | 19.0 (79.2) | 19.0 (95.0) | 16.0 (100.0) | 54.0 (90.0) | ||
| Yes | 5.0 (20.8) | 1.0 (5.0) | 0 | 6.0 (10.0) | ||
| Indication | 0.345† | |||||
| Infection | 7.0 (29.2) | 3.0 (15.0) | 6.0 (37.5) | 16.0 (26.7) | ||
| Trauma | 11.0 (45.8) | 14.0 (70.0) | 6.0 (37.5) | 31.0 (51.7) | ||
| War injury (explosion injury) | 6.0 (25.0) | 3.0 (15.0) | 4.0 (25.0) | 13.0 (21.7) | ||
| Preoperative perforator marking | 0.523† | |||||
| No | 22.0 (91.7) | 16.0 (80.0) | 14.0 (87.5) | 52.0 (86.7) | ||
| Yes | 2.0 (8.3) | 4.0 (20.0) | 2.0 (12.5) | 8.0 (13.3) | ||
| Defect length | 0.014* | |||||
| Mean ± SD | 9.5 ± 3.3 | 7.2 ± 1.7 | 8.2 ± 1.8 | 8.4 ± 2.7 | ||
| Range | 4.0–15.0 | 5.0–12.0 | 5.0–12.0 | 4.0–15.0 | ||
| Defect width | 0.923* | |||||
| Mean ± SD | 6.7 ± 1.4 | 6.5 ± 2.0 | 6.7 ± 1.2 | 6.6 ± 1.6 | ||
| Range | 4.0–10.0 | 4.0–10.0 | 4.0–8.0 | 4.0–10.0 | ||
| Defect size | 0.129* | |||||
| Mean ± SD | 66.0 ± 32.6 | 48.9 ± 26.0 | 56.2 ± 20.5 | 57.7 ± 28.2 | ||
| Range | 24.0–120.0 | 20.0–120.0 | 25.0–96.0 | 20.0–120.0 | ||
| Pedicle length | < 0.001* | |||||
| Mean ± SD | 18.6 ± 2.7 | 18.7 ± 2.4 | 13.8 ± 1.8 | 17.4 ± 3.2 | ||
| Range | 13.0–23.0 | 16.0–24.0 | 10.0–17.0 | 10.0–24.0 | ||
| Flap length | 0.035* | |||||
| Mean ± SD | 10.5 ± 2.8 | 8.9 ± 2.0 | 8.8 ± 1.5 | 9.5 ± 2.3 | ||
| Range | 5.0–15.0 | 6.0–13.0 | 6.0–12.0 | 5.0–15.0 | ||
| Flap width | 0.936* | |||||
| Mean ± SD | 8.0 ± 1.3 | 8.0 ± 1.7 | 7.8 ± 1.9 | 7.9 ± 1.6 | ||
| Range | 6.0–10.0 | 6.0–11.0 | 5.0–12.0 | 5.0–12.0 | ||
| Flap size | 0.250* | |||||
| Mean ± SD | 84.9 ± 31.9 | 73.7 ± 30.6 | 70.1 ± 24.3 | 77.2 ± 29.8 | ||
| Range | 40.0–150.0 | 42.0–143.0 | 35.0–120.0 | 35.0–150.0 | ||
| Pedicle type | 0.181† | |||||
| Adipofascial | 8.0 (33.3) | 10.0 (50.0) | 10.0 (62.5) | 28.0 (46.7) | ||
| Fasciocutaneous | 16.0 (66.7) | 10.0 (50.0) | 6.0 (37.5) | 32.0 (53.3) | ||
| Operation time (min) | 0.024* | |||||
| Mean ± SD | 141.4 ± 43.5 | 173.9 ± 51.4 | 132.0 ± 50.3 | 149.7 ± 50.5 | ||
| Range | 85.0–225.0 | 80.0–270.0 | 75.0–245.0 | 75.0–270.0 | ||
| Anticoagulation use | 0.900† | |||||
| No | 10.0 (41.7) | 7.0 (35.0) | 6.0 (37.5) | 23.0 (38.3) | ||
| Yes | 14.0 (58.3) | 13.0 (65.0) | 10.0 (62.5) | 37.0 (61.7) | ||
| Intraoperative venous congestion | 0.062† | |||||
| No | 3.0 (12.5) | 1.0 (5.0) | 6.0 (37.5) | 10.0 (16.7) | ||
| Mild | 9.0 (37.5) | 10.0 (50.0) | 7.0 (43.8) | 26.0 (43.3) | ||
| Moderate | 12.0 (50.0) | 9.0 (45.0) | 3.0 (18.8) | 24.0 (40.0) | ||
| If yes, venous congestion postoperative | duration | 0.059† | ||||
| 24 hr | 6.0 (28.6) | 2.0 (10.5) | 6.0 (60.0) | 14.0 (28.0) | ||
| 48 hr | 5.0 (23.8) | 8.0 (42.1) | 4.0 (40.0) | 17.0 (34.0) | ||
| 72 hr | 8.0 (38.1) | 6.0 (31.6) | 0 | 14.0 (28.0) | ||
| Persisted with partial loss | 2.0 (9.5) | 3.0 (15.8) | 0 | 5.0 (10.0) | ||
| Hospital stay | 0.653* | |||||
| Mean ± SD | 9.5 ± 4.6 | 8.6 ± 7.8 | 7.8 ± 4.6 | 8.8 ± 5.8 | ||
| Range | 3.0–18.0 | 3.0–32.0 | 3.0–16.0 | 3.0–32.0 | ||
| Stage of surgery | 0.523† | |||||
| 1 Stage | 22.0 (91.7) | 16.0 (80.0) | 14.0 (87.5) | 52.0 (86.7) | ||
| 2 Stages | 2.0 (8.3) | 4.0 (20.0) | 2.0 (12.5) | 8.0 (13.3) | ||
| Postoperative complications | 0.019† | |||||
| No | 16.0 (66.7) | 10.0 (50.0) | 15.0 (93.8) | 41.0 (68.3) | ||
| Yes | 8.0 (33.3) | 10.0 (50.0) | 1.0 (6.2) | 19.0 (31.7) | ||
| Severity of complications | 0.034† | |||||
| Minor | 8.0 (33.3) | 8.0 (40.0) | 1.0 (6.2) | 17.0 (28.3) | ||
| Major | 0 | 2.0 (10.0) | 0 | 2.0 (3.3) | ||
| Superficial wound infection | 0.357† | |||||
| Yes | 2.0 (8.3) | 4.0 (20.0) | 1.0 (6.2) | 7.0 (11.7) | ||
| No | 22.0 (91.7) | 16.0 (80.0) | 15.0 (93.8) | 53.0 (88.3) | ||
| Minor wound dehiscence | 0.089† | |||||
| Yes | 3.0 (12.5) | 5.0 (25.0) | 0 | 8.0 (13.3) | ||
| No | 21.0 (87.5) | 15.0 (75.0) | 16.0 (100.0) | 52.0 (86.7) | ||
| Partial necrosis | 0.033† | |||||
| Yes | 5.0 (20.8) | 7.0 (35.0) | 0 | 12.0 (20.0) | ||
| No | 19.0 (79.2) | 13.0 (65.0) | 16.0 (100.0) | 48.0 (80.0) | ||
| Flap success | 0.126† | |||||
| Fail | 0 | 2.0 (10.0) | 0 | 2.0 (3.3) | ||
| Success | 24.0 (100.0) | 18.0 (90.0) | 16.0 (100.0) | 58.0 (96.7) | ||
| Wound healing time | < 0.001* | |||||
| Mean ± SD | 20.1 ± 5.1 | 28.8 ± 6.9 | 14.4 ± 4.5 | 21.5 ± 7.9 | ||
| Range | 13.0–32.0 | 19.0–43.0 | 8.0–25.0 | 8.0–43.0 | ||
| Donor site morbidity | 0.874† | |||||
| No | 18.0 (75.0) | 16.0 (80.0) | 13.0 (81.2) | 47.0 (78.3) | ||
| Yes | 6.0 (25.0) | 4.0 (20.0) | 3.0 (18.8) | 13.0 (21.7) | ||
| Late revision procedures | 0.918† | |||||
| Yes | 6.0 (25.0) | 6.0 (30.0) | 4.0 (25.0) | 16.0 (26.7) | ||
| No | 18.0 (75.0) | 14.0 (70.0) | 12.0 (75.0) | 44.0 (73.3) | ||
Values are presented as number (%) unless otherwise indicated.
SD: standard deviation, BMI: body mass index.
*Linear model analysis of variance. †Pearson’s chi-square test.
Preoperative perforator marking was performed in 13.3% of cases, with no significant variation across groups (p = 0.523). The defect length differed significantly among the groups (p = 0.014), with the longest defects observed in the ankle group (mean, 9.5 cm; SD, 3.3). However, defect width (p = 0.923) and total defect size (p = 0.129) were comparable among groups. Pedicle length was significantly different (p < 0.001), with shorter pedicles in the lower leg group (mean, 13.8 cm; SD, 1.8) compared to the ankle (18.6 cm; SD, 2.7) and heel (18.7 cm; SD, 2.4) groups. Flap length also differed significantly (p = 0.035), while flap width (p = 0.936) and flap size (p = 0.250) were not significantly different. The pedicle type distribution showed a higher proportion of adipofascial flaps in the lower leg group (62.5%), but this difference was not statistically significant (p = 0.181). The mean operation time was 149.7 minutes (SD, 50.5), with a significant difference between groups (p = 0.024). Anticoagulation use was reported in 61.7% of cases, with no significant difference among groups (p = 0.900) (Table 1).
Intraoperative venous congestion was observed in 83.3% of cases, with varying severity levels (p = 0.062). Among those who developed postoperative venous congestion, the duration of congestion was significantly different across groups (p = 0.059). The average hospital stay was 8.8 days (SD, 5.8), with no significant difference between groups (p = 0.653). Most surgeries were completed in a single stage (86.7%), with no significant difference across groups (p = 0.523). Postoperative complications were significantly different between groups (p = 0.019), with the lowest complication rate observed in the lower leg group (6.2%) compared to the ankle (33.3%) and heel (50.0%) groups. The severity of complications was also significantly different (p = 0.034), with major complications (partial flap loss requiring surgical intervention) occurring in 3.3% of cases. All other postoperative complications—including minor wound dehiscence and superficial infections—were considered minor and managed conservatively. Wound infection was observed in 11.7% of cases (p = 0.357), while wound dehiscence occurred in 13.3% (p = 0.089) (Table 1).
Postoperative Complications (Log Odds Ratios)
The analysis of complication rates across different anatomical sites demonstrated that the log odds of overall complications were higher for RSAF performed at the ankle (log odds ratio [OR], 2.02; 95% CI, –0.18 to 4.20; p = 0.070) and significantly higher for those at the heel (log OR, 2.71; 95% CI, 0.50–4.91; p = 0.016) compared to the lower leg. Notably, venous congestion was significantly more likely to occur at both the ankle (log OR, 2.08; 95% CI, 0.20–3.96; p = 0.030) and the heel (log OR, 2.98; 95% CI, 0.40–5.38; p = 0.020). Although the log odds of infection, wound dehiscence, and necrosis were numerically higher at the ankle and heel, these findings were not statistically significant, likely due to the wide confidence intervals (Fig. 1).
Fig. 1. Forest plot of complications across different sites of reverse sural artery flap.
Functional and Aesthetic Outcomes
Functional outcomes, assessed using the FAAM, further emphasized the differences across sites. The mean FAAM score was highest for the lower leg (91.2), followed by the ankle (88.6), and lowest for the heel (76.8). Normal function was reported in 10 cases (62.5%) for the lower leg and 12 cases (50%) for the ankle, whereas none of the heel RSAF achieved normal function. Satisfactory function was more frequently observed in heel RSAF (14 cases), but moderate dysfunction was exclusively noted in heel RSAF (6 cases), indicating a greater impact on function at this site. These findings highlight the superior aesthetic and functional outcomes associated with lower leg and ankle RSAF, while the heel remains a challenging site with higher rates of scarring, dissatisfaction, and functional impairment (Fig. 2).
Fig. 2. Functional outcomes assessed using the Foot and Ankle Ability Measure (FAAM). (A) Distribution of functional outcomes (normal function, satisfactory function, and moderate dysfunction) across sites. (B) Mean FAAM scores across sites.
The aesthetic and functional outcomes varied across reconstruction sites. Based on the VSS, the lower leg demonstrated the most favorable aesthetic results, with 11 cases classified as normal, while no normal outcomes were observed for the heel. Moderate and severe scarring were more prevalent in heel RSAF, with 11 and 3 cases, respectively (Fig. 3A). The Likert scale assessment similarly reflected better aesthetic satisfaction for lower leg and ankle RSAF, where excellent or good outcomes were more common. In contrast, the heel site had the highest number of poor and very poor aesthetic ratings (Fig. 3B).
Fig. 3. Aesthetic outcomes across the 3 sites. (A) Vancouver Scar Scale. (B) Likert scale.
The univariable analysis comparing patients who developed complications (n = 19, 31.7%) to those who did not (n=41, 68.3%) identified several significant predictors. Smoking status was significantly associated with complications (p = 0.007), with a higher proportion of smokers in the complication group (78.9%) compared to the noncomplication group (41.5%). Additionally, a higher BMI was observed among patients who developed complications (mean 28.8 vs. 23.9; p < 0.001). Pedicle length was also significantly longer in the complication group (mean, 18.7 cm vs. 16.7 cm; p = 0.023). Defect site played a notable role, as heel defects were more commonly associated with complications (52.6% vs. 24.4%, p = 0.019), whereas lower leg defects were more prevalent in the non-complication group (36.6% vs. 5.3%). While intraoperative venous congestion did not show a statistically significant difference (p= 0.366), cases with persistent venous congestion occurred exclusively in the complication group (29.4%), which subsequently progressed to partial flap necrosis. Other factors such as age, sex, comorbidity, defect size, flap dimensions, operation time, and preoperative perforator marking did not demonstrate statistically significant differences between the 2 groups. These findings suggest that smoking, elevated BMI, longer pedicle length, and heel defect location may contribute to an increased risk of complications following surgery (Table 2).
Table 2. Univariable Analysis of Factors Associated with Postoperative Complications.
| Variable | No-complication group (n = 41, 68.3%) | Complication group (n = 19, 31.7%) | Total (n = 60) | p-value | |
|---|---|---|---|---|---|
| Age (yr) | 0.753* | ||||
| Mean ± SD | 30.9 ± 14.3 | 32.1 ± 12.4 | 31.3 ± 13.6 | ||
| Range | 7.0–68.0 | 18.0–65.0 | 7.0–68.0 | ||
| Sex | 0.231† | ||||
| Female | 4.0 (9.8) | 4.0 (21.1) | 8.0 (13.3) | ||
| Male | 37.0 (90.2) | 15.0 (78.9) | 52.0 (86.7) | ||
| Comorbidity | 0.926† | ||||
| No | 37.0 (90.2) | 17.0 (89.5) | 54.0 (90.0) | ||
| Yes | 4.0 (9.8) | 2.0 (10.5) | 6.0 (10.0) | ||
| Smoking | 0.007† | ||||
| No | 24.0 (58.5) | 4.0 (21.1) | 28.0 (46.7) | ||
| Yes | 17.0 (41.5) | 15.0 (78.9) | 32.0 (53.3) | ||
| BMI | < 0.001* | ||||
| Mean ± SD | 23.9 ± 3.3 | 28.8 ± 2.7 | 25.4 ± 3.9 | ||
| Range | 18.0–32.8 | 24.0–33.8 | 18.0–33.8 | ||
| Indication | 0.157† | ||||
| Infection | 14.0 (34.1) | 2.0 (10.5) | 16.0 (26.7) | ||
| Trauma | 19.0 (46.3) | 12.0 (63.2) | 31.0 (51.7) | ||
| War injury (explosion injury) | 8.0 (19.5) | 5.0 (26.3) | 13.0 (21.7) | ||
| Preoperative perforator marking | 0.211† | ||||
| No | 34.0 (82.9) | 18.0 (94.7) | 52.0 (86.7) | ||
| Yes | 7.0 (17.1) | 1.0 (5.3) | 8.0 (13.3) | ||
| Defect length | 0.735* | ||||
| Mean ± SD | 8.5 ± 2.6 | 8.2 ± 2.9 | 8.4 ± 2.7 | ||
| Range | 4.0–15.0 | 4.0–15.0 | 4.0–15.0 | ||
| Defect Width | 0.961* | ||||
| Mean ± SD | 6.6 ± 1.5 | 6.6 ± 1.8 | 6.6 ± 1.6 | ||
| Range | 4.0–10.0 | 4.0–10.0 | 4.0–10.0 | ||
| Defect size | 0.951* | ||||
| Mean ± SD | 57.9 ± 26.5 | 57.4 ± 32.3 | 57.7 ± 28.2 | ||
| Range | 20.0–120.0 | 24.0–120.0 | 20.0–120.0 | ||
| Pedicle length | 0.023* | ||||
| Mean ± SD | 16.7 ± 3.0 | 18.7 ± 3.2 | 17.4 ± 3.2 | ||
| Range | 10.0–22.0 | 13.0–24.0 | 10.0–24.0 | ||
| Flap length | 0.542* | ||||
| Mean ± SD | 9.4 ± 2.2 | 9.8 ± 2.6 | 9.5 ± 2.3 | ||
| Range | 5.0–15.0 | 5.0–14.0 | 5.0–15.0 | ||
| Flap width | 0.456* | ||||
| Mean ± SD | 7.8 ± 1.5 | 8.2 ± 1.6 | 7.9 ± 1.6 | ||
| Range | 5.0–12.0 | 6.0–11.0 | 5.0–12.0 | ||
| Flap size | 0.366* | ||||
| Mean ± SD | 74.8 ± 27.2 | 82.4 ± 35.1 | 77.2 ± 29.8 | ||
| Range | 35.0–150.0 | 40.0–143.0 | 35.0–150.0 | ||
| Operation time | 0.376* | ||||
| Mean ± SD | 153.7 ± 48.8 | 141.2 ± 54.2 | 149.7 ± 50.5 | ||
| Range | 75.0–270.0 | 80.0–270.0 | 75.0–270.0 | ||
| Anticoagulation use | 0.121† | ||||
| No | 13.0 (31.7) | 10.0 (52.6) | 23.0 (38.3) | ||
| Yes | 28.0 (68.3) | 9.0 (47.4) | 37.0 (61.7) | ||
| Intraoperative venous congestion | 0.366† | ||||
| Moderate | 14.0 (34.1) | 10.0 (52.6) | 24.0 (40.0) | ||
| Mild | 19.0 (46.3) | 7.0 (36.8) | 26.0 (43.3) | ||
| No | 8.0 (19.5) | 2.0 (10.5) | 10.0 (16.7) | ||
| If yes, venous congestion postoperative duration | |||||
| 24 hr | 12.0 (36.4) | 2.0 (11.8) | 14.0 (28.0) | ||
| 48 hr | 12.0 (36.4) | 5.0 (29.4) | 17.0 (34.0) | ||
| 72 hr | 9.0 (27.3) | 5.0 (29.4) | 14.0 (28.0) | ||
| Persisted | 0 | 5.0 (29.4) | 5.0 (10.0) | ||
| Defect site | 0.019† | ||||
| Ankle | 16.0 (39.0) | 8.0 (42.1) | 24.0 (40.0) | ||
| Heel | 10.0 (24.4) | 10.0 (52.6) | 20.0 (33.3) | ||
| lower leg | 15.0 (36.6) | 1.0 (5.3) | 16.0 (26.7) | ||
| Wound healing time | 0.364* | ||||
| Mean ± SD | 20.8 ± 7.9 | 22.8 ± 8.0 | 21.5 ± 7.9 | ||
| Range | 8.0–40.0 | 13.0–43.0 | 8.0–43.0 | ||
| Stage of surgery | 0.663† | ||||
| 1 Stage | 35.0 (85.4) | 17.0 (89.5) | 52.0 (86.7) | ||
| 2 Stages | 6.0 (14.6) | 2.0 (10.5) | 8.0 (13.3) | ||
| Pedicle type | 0.111† | ||||
| Adipofascial | 22.0 (53.7) | 6.0 (31.6) | 28.0 (46.7) | ||
| Fasciocutaneous | 19.0 (46.3) | 13.0 (68.4) | 32.0 (53.3) | ||
Values are presented as number (%) unless otherwise indicated.
SD: standard deviation, BMI: body mass index.
*Linear model analysis of variance. †Pearson’s chi-square test.
Multivariable Analysis
In the multivariable logistic regression analysis, several factors were identified as significant predictors of postoperative complications. Higher BMI was significantly associated with an increased likelihood of developing complications (OR, 1.653; 95% CI, 1.215–2.248; p = 0.001). Similarly, greater pedicle length was also a significant predictor (OR, 1.241; 95% CI, 1.02–1.505; p = 0.030). Among defect sites, ankle and heel defects showed a trend toward increased odds of complications compared to lower leg defects; however, these associations did not reach statistical significance (ankle vs. lower leg: OR, 11.954; 95% CI, 0.721–198.240; p = 0.083; heel vs. lower leg: OR, 8.56; 95% CI, 0.443–165.441; p = 0.155). Smoking status was a strong predictor of postoperative complications, with smokers having significantly higher odds of developing complications compared to non-smokers (OR, 5.29; 95% CI, 1.495– 18.74; p < 0.001) (Table 3).
Table 3. Multivariable Logistic Regression Analysis of Predictors for Postoperative Complications.
| Predictor | Estimate | SE | Z | p-value | Odds ratio | 95% CI | |
|---|---|---|---|---|---|---|---|
| Intercept | –15.658 | 5.01 | –3.125 | 0.002 | 1.58E-7 | 8.61E-12–0.003 | |
| BMI | 0.502 | 0.157 | 3.199 | 0.001 | 1.653 | 1.215–2.248 | |
| Pedicle length | 0.216 | 0.098 | 2.19 | 0.030 | 1.241 | 1.02–1.505 | |
| Defect site | |||||||
| Ankle (lower leg) | 2.481 | 1.433 | 1.731 | 0.083 | 11.954 | 0.721–198.241 | |
| Heel (lower leg) | 2.147 | 1.511 | 1.421 | 0.155 | 8.56 | 0.443–165.441 | |
| Smoking | |||||||
| Yes-no | 1.67 | 0.646 | 2.58 | < 0.001 | 5.29 | 1.495–18.740 | |
Estimates represent the log odds of “Postop Comp = Yes“ vs. “Postop Comp = No.”
SE: standard error, BMI: body mass index.
To assess the performance of the logistic regression model, a receiver operating characteristic curve analysis was conducted. Given the small sample size, the area under the curve (AUC) was calculated to evaluate the model’s discriminatory ability. The AUC was 91.3%, indicating excellent predictive performance. These findings indicate that BMI, pedicle length, and smoking status are key determinants of postoperative complications, while defect site may also play a role.
DISCUSSION
This study provides a comprehensive evaluation of clinical and functional outcomes following RSAF reconstruction in distal lower limb defects, stratified by anatomical site: ankle, heel, and lower leg. Our findings reveal that although RSAF remains a reliable reconstructive option, significant variability exists in postoperative complications and long-term outcomes depending on the defect site, with heel reconstructions presenting the greatest challenges.
The overall complication rate in our cohort was 31.7%, consistent with prior literature reporting complication rates between 25% and 35% for RSAF procedures in the distal lower extremity.7,13,14) Notably, the heel demonstrated a significantly higher risk of both overall complications (OR, 2.71; p = 0.016) and venous congestion (OR, 2.98; p = 0.020) compared to the lower leg, which showed the most favorable outcomes. These results underscore the anatomical complexity and tenuous vascularity of the heel region, which may contribute to higher rates of flap failure, congestion, and wound breakdown. Previous studies have similarly identified the heel as a high-risk site for RSAF complications due to its limited soft-tissue envelope and high mechanical load during ambulation.15,16,17) However, the high prevalence of smoking (80%) and longer pedicle lengths in the heel reconstruction group may have confounded the observed association between defect site and outcomes. Although heel defects demonstrated an elevated OR, this effect did not reach statistical significance once smoking was accounted for, whereas smoking and pedicle length remained strong independent predictors. This suggests that heel location may not independently predict adverse outcomes.
Functionally, the lower leg RSAF achieved the highest FAAM scores, with over 60% of cases returning to normal function. In contrast, heel reconstructions were associated with the lowest FAAM scores and the highest proportion of moderate dysfunction. This functional disparity may reflect the biomechanical significance of the heel in gait and weight-bearing, where even minor reconstructive insufficiencies can have substantial consequences.18,19,20) From an aesthetic perspective, heel RSAFs also fared poorly, exhibiting more severe scarring and lower patient satisfaction scores. These findings reinforce the notion that flap success in lower limb reconstruction is not solely defined by flap survival but also by restoring function and achieving acceptable cosmetic outcomes.21)
The multivariable analysis identified 3 significant predictors of postoperative complications: higher BMI, longer pedicle length, and smoking status. A higher BMI has been linked to poor perfusion and increased wound tension, which may compromise flap viability.22,23,24) Similarly, pedicle length was independently associated with complications, likely due to the increased risk of venous congestion with longer pedicles. These findings align with previous anatomical and clinical analyses emphasizing the importance of optimizing flap design and minimizing pedicle length where possible.25,26,27)
Smoking emerged as the most significant modifiable risk factor, with an OR of 5.29 for postoperative complications. This finding supports existing literature on the detrimental effects of smoking on microvascular perfusion, wound healing, and overall flap survival.28,29,30,31) Preoperative counseling and smoking cessation should therefore be integral to surgical planning and perioperative optimization in candidates for RSAF. Interestingly, variables such as age, comorbidities, and defect size did not significantly impact complication rates. Although previous studies have identified these as potential risk factors,8) our exclusion of cases with incomplete data and strict site-specific comparisons may have limited variability in these parameters.
Our study has several strengths. It provides one of the few detailed analyses of RSAF outcomes stratified by defect location and incorporates both objective (complications, FAAM, VSS) and subjective (Likert satisfaction) measures. Additionally, by excluding cases with incomplete functional or aesthetic assessments, we ensured a more consistent and reliable dataset for analysis. However, several limitations must be acknowledged. The retrospective design inherently limits causality, and the modest sample size, particularly in subgroup comparisons, may reduce the power to detect certain associations. Moreover, although validated tools such as FAAM and VSS were used, the assessment of function and aesthetics remains partially subjective and may be influenced by patient expectations and rehabilitation support. Finally, the exclusion of cases without full documentation may have introduced selection bias, potentially favoring patients with better outcomes. Larger studies controlling for smoking, pedicle length, and other patient-related variables are warranted to clarify the relative impact of defect location versus patient comorbidities.
RSAF remains a valuable reconstructive technique for soft-tissue defects in the distal lower limb. However, site-specific challenges—particularly at the heel—can contribute to higher complication rates, although these may be partly confounded by patient-related risk factors such as smoking and elevated BMI. Meticulous planning, tailored flap design, and risk factor optimization remain essential. Functional and aesthetic outcomes are most favorable in lower leg defects, whereas heel reconstructions warrant heightened vigilance due to elevated complication rates. Smoking cessation, weight management, and strategic pedicle planning should be prioritized to improve outcomes. Future prospective studies with larger cohorts are needed to validate these findings and refine patient selection and perioperative care protocols.
Footnotes
CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.
References
- 1.Mansour AM, Jacobs A, Raj MS, et al. Lower extremity soft tissue reconstruction review article. Orthop Clin North Am. 2022;53(3):287–296. doi: 10.1016/j.ocl.2022.03.003. [DOI] [PubMed] [Google Scholar]
- 2.Labib A, Winters R. Complex wound management [Internet] StatPearls Publishing; 2025. [cited 2025 Dec 8]. Available from: https://pubmed.ncbi.nlm.nih.gov/35015410 . [PubMed] [Google Scholar]
- 3.Olawoye OA, Ademola SA, Iyun K, Michael A, Oluwatosin O. The reverse sural artery flap for the reconstruction of distal third of the leg and foot. Int Wound J. 2014;11(2):210–214. doi: 10.1111/j.1742-481X.2012.01075.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Johnson L, Liette MD, Green C, Rodriguez P, Masadeh S. The reverse sural artery flap: a reliable and versatile flap for wound coverage of the distal lower extremity and hindfoot. Clin Podiatr Med Surg. 2020;37(4):699–726. doi: 10.1016/j.cpm.2020.05.004. [DOI] [PubMed] [Google Scholar]
- 5.Saaiq M, Zimri FU. Reverse flow superficial sural artery fasciocutaneous flap: a comparison of outcome between interpolated flap design versus islanded flap design. World J Plast Surg. 2019;8(3):316–323. doi: 10.29252/wjps.8.3.316. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ciofu RN, Zamfirescu DG, Popescu SA, Lascar I. Reverse sural flap for ankle and heel soft tissues reconstruction. J Med Life. 2017;10(1):94–98. [PMC free article] [PubMed] [Google Scholar]
- 7.Tripathee S, Basnet SJ, Lamichhane A, Hariani L. How safe is reverse sural flap? A systematic review. Eplasty. 2022;22:e18. [PMC free article] [PubMed] [Google Scholar]
- 8.Dhamangaonkar AC, Patankar HS. Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases. J Orthop Traumatol. 2014;15(3):225–229. doi: 10.1007/s10195-014-0304-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kareh AM, Felder JM. Successful use of delayed reverse sural artery flap in single vessel legs with severe atherosclerotic disease and venous insufficiency. Plast Reconstr Surg Glob Open. 2023;11(1):e4740. doi: 10.1097/GOX.0000000000004740. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hamilton N, Weimar W, Luttgens K. In: Kinesiology: scientific basis of human motion, 12e [Internet] Hamilton N, Weimar W, Luttgens K, editors. McGraw-Hill; 2011. [cited 2025 Dec 8]. The lower extremity: the knee, ankle, and foot. Available from: http://accessphysiotherapy.mhmedical.com/content.aspx?aid=1100793289 . [Google Scholar]
- 11.Mahmoud WH. Foot and ankle reconstruction using the distally based sural artery flap versus the medial plantar flap: a comparative study. J Foot Ankle Surg. 2017;56(3):514–518. doi: 10.1053/j.jfas.2017.01.019. [DOI] [PubMed] [Google Scholar]
- 12.Alves AS, Tan V, Scampa M, Kalbermatten DF, Oranges CM. Complications of immediate versus delayed DIEP reconstruction: a meta-analysis of comparative studies. Cancers (Basel) 2022;14(17):4272. doi: 10.3390/cancers14174272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Park KH, Oh CW, Kim JW, Lee HJ, Kim HJ. Reliability of reverse sural artery fasciocutaneous flap in older adult patients: comparison study between older and younger patients. Injury. 2023;54(8):110915. doi: 10.1016/j.injury.2023.110915. [DOI] [PubMed] [Google Scholar]
- 14.Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg. 2009;123(5):1499–1504. doi: 10.1097/PRS.0b013e3181a07723. [DOI] [PubMed] [Google Scholar]
- 15.Fox CM, Beem HM, Wiper J, Rozen WM, Wagels M, Leong JC. Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis. J Reconstr Microsurg. 2015;31(1):59–66. doi: 10.1055/s-0034-1384674. [DOI] [PubMed] [Google Scholar]
- 16.Zakaria Y, Abdel Moktader MA, Abdel-Rahman AA. Evaluation of loco-regional flaps for heel reconstruction. Int J Med Arts. 2020;4(1):1955–1963. [Google Scholar]
- 17.Eun S, Woo SJ. Surgical outcomes of reconstruction of soft tissue defects of the heel using various free flaps. Acta Biomed. 2022;93(2):e2022048. doi: 10.23750/abm.v93i2.11353. [DOI] [PubMed] [Google Scholar]
- 18.Khai Luen K, Wan Sulaiman WA. Functional outcomes after heel pad reconstruction: a review of 7 cases. J Foot Ankle Surg. 2017;56(5):1114–1120. doi: 10.1053/j.jfas.2017.04.024. [DOI] [PubMed] [Google Scholar]
- 19.Elgohary H, Nawar AM, Zidan A, Shoulah AA, Younes MT. Functional and aesthetic outcomes of reconstruction of soft-tissue defects of the heel with free flap. JPRAS Open. 2019;19:35–44. doi: 10.1016/j.jpra.2018.10.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Krishna D, Chaturvedi G, Khan MM, Cheruvu VP, Laitonjam M, Minz R. Reconstruction of heel soft tissue defects: an algorithm based on our experience. World J Plast Surg. 2021;10(3):63–72. doi: 10.29252/wjps.10.3.63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Seyidova N, Anderson K, Abood A. Comparison of patients satisfaction with aesthetic outcomes following lower extremity reconstruction: muscle vs. fasciocutaneous free flaps. J Plast Reconstr Aesthet Surg. 2021;74(1):65–70. doi: 10.1016/j.bjps.2020.08.110. [DOI] [PubMed] [Google Scholar]
- 22.Pierpont YN, Dinh TP, Salas RE, et al. Obesity and surgical wound healing: a current review. ISRN Obes. 2014;2014:638936. doi: 10.1155/2014/638936. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Hom DB, Ostrander BT. Reducing risks for local skin flap failure. Facial Plast Surg Clin North Am. 2023;31(2):275–287. doi: 10.1016/j.fsc.2023.01.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Garg SP, Sandepudi K, Shah KV, et al. Evaluating the effect of BMIs on wound complications after the surgical closure of pressure injuries. Surgeries (Basel) 2025;6(1):5 [Google Scholar]
- 25.Hirani R, Boyd CJ. Optimizing flap surgery: the need for standardized surgical delay techniques and patient-specific approaches. Ann Transl Med. 2024;12(6):110. doi: 10.21037/atm-24-108. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Wei JW, Dong ZG, Ni JD, et al. Influence of flap factors on partial necrosis of reverse sural artery flap: a study of 179 consecutive flaps. J Trauma Acute Care Surg. 2012;72(3):744–750. doi: 10.1097/TA.0b013e31822a2f2b. [DOI] [PubMed] [Google Scholar]
- 27.Saber AY, Hohman MH, Dreyer MA. Basic flap design [Internet] StatPearls Publishing; 2025. [cited 2025 Dec 8]. Available from: https://pubmed.ncbi.nlm.nih.gov/33085399/ [PubMed] [Google Scholar]
- 28.Karamanos E, Saad N, Smith KE, Patnaik R, Wang HT, Cromack D. Not all flaps are created equal: assessing the impact of active smoking in muscle-only versus perforator flaps for patients undergoing nonelective extremity-free tissue transfer-a case control study. Microsurgery. 2021;41(6):513–521. doi: 10.1002/micr.30797. [DOI] [PubMed] [Google Scholar]
- 29.Ooms M, Puladi B, Houschyar KS, et al. Smoking and microvascular free flap perfusion in head and neck reconstruction: radial free forearm flaps and anterolateral thigh flaps. Sci Rep. 2022;12(1):13902. doi: 10.1038/s41598-022-18216-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Korompilias A, Gkiatas I, Korompilia M, Kosmas D, Kostas-Agnantis I. Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction. Eur J Orthop Surg Traumatol. 2019;29(2):367–372. doi: 10.1007/s00590-018-2330-8. [DOI] [PubMed] [Google Scholar]
- 31.Garip M, Van Dessel J, Grosjean L, Politis C, Bila M. The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis. Br J Oral Maxillofac Surg. 2021;59(3):e79–e98. doi: 10.1016/j.bjoms.2020.07.020. [DOI] [PubMed] [Google Scholar]