Sural and Reverse Sural Flaps in Reconstruction: A Concise Review

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.