The Sural Flap: Anatomical Basis, Technical Refinements, And Clinical Applications in Lower Extremity Reconstruction

Background: Reconstruction of soft tissue defects in the distal lower extremity remains a complex surgical challenge due to limited local tissue availability, poor vascularity, and the frequent need to cover exposed critical structures. The sural flap, particularly the reverse-flow sural neurocutaneous flap, offers a reliable, technically straightforward, and cost-effective solution for these defects. Objective: This manuscript provides a comprehensive review of the anatomical basis, technical considerations, surgical refinements, clinical indications, outcomes, and complications associated with the sural flap. It also explores its role in modern reconstructive algorithms and compares its efficacy to alternative reconstructive options. Methods: A thorough literature review was conducted using PubMed, Scopus, and Embase databases to evaluate studies from 1983 to 2025 related to the sural flap, including anatomical studies, clinical trials, cohort studies, and case series. The data were analyzed to provide an evidence-based review of the flap’s performance in reconstructive surgery. Results: The sural flap consistently demonstrates high success rates (85–95%) across various indications, with low donor site morbidity and acceptable aesthetic and functional outcomes. Technical modifications, including the supercharged and adipofascial variants, have expanded its indications and minimized complications such as venous congestion and partial flap necrosis. Conclusion: Despite advances in microsurgical free tissue transfer, the sural flap remains a fundamental option for lower limb reconstruction, particularly in patients with comorbidities, resource-limited settings, or when free flaps are contraindicated. Its anatomical reliability, ease of harvest, and versatility underscore its continued relevance in modern reconstructive surgery.