The blood supply for the skin paddle of the distal two-thirds of the leg depends on the sural arteries along its most proximal course and the peroneal artery perforators more distally.

The reverse sural artery flap receives retrograde arterial flow through septocutaneous perforators that originate from the peroneal artery and directly anastomose with the superficial sural artery.

There are typically two to five perforators located 5 to 7 cm proximal to the lateral malleolus.³

The venous drainage for this flap is composed of a venous network of the superficial sural vein, the lesser saphenous vein, and the associated veins of the peroneal artery.

Assessment of the defect begins with evaluation for missing tissues, exposed vital structures, and presence of underlying orthopedic hardware.

The reverse sural artery flap can be used to cover defects of the posterior aspect of heel and Achilles tendon, anterior and lateral ankle, dorsum of the foot, lateral aspect of the hindfoot, and the anterior crest of lower third of the leg.

Physical exam to evaluate the vascular status of the extremity, and to evaluate for peripheral artery disease or venous insufficiency, is necessary as they may influence flap survival.

Patient comorbidities of diabetes mellitus, lower extremity venous insufficiency, and peripheral artery disease have been associated with flap necrosis and represent relative contraindications.

The presence of an occluded anterior or posterior tibial artery does not represent an absolute contraindication to this flap; however, most consider occlusion of the peroneal artery to preclude its use.^4,5,6

Rarely are radiographs necessary except in the evaluation of bone abnormalities.

Preoperative angiograms are not routinely obtained but may be useful in patients with pertinent exam findings or in traumatic wounds of the lower extremity.