Giacomini's vein - a report on the invaluable importance of an anomalous short saphenous vein.

Variations in the drainage (termination) and course of the lower limb veins are not uncommon. When dissecting the left lower limb of the adult male cadaver in the vascular case described herein, a unique kind of unilateral short saphenous vein (SSV) termination was observed. It was found that the SSV had normal origin and course in the dorsum of the foot and the back of the leg, respectively. Most often the SSV terminates in the popliteal vein at the popliteal fossa. In this case, it extended upward into the back of the thigh, passing behind the sciatic nerve and then deep to it and the biceps femoris, and finally ended in the veins of the thigh. The SSV did not penetrate any structures along its course to the end, so this unusual vein appears unlikely to be associated with SSV varicose veins. For general, plastic, cardiothoracic, and vascular surgeons, our case would be of significant value.

Variações na drenagem (terminação) e curso das veias dos membros inferiores não são incomuns. No caso vascular relatado, ao dissecar o membro inferior esquerdo de um cadáver adulto do sexo masculino, foi observado um tipo único de veia safena parva (VSP) unilateral. Verificou-se que a VSP tinha origem e curso normais no dorso do pé e na traseira da perna, respectivamente. É mais comum a VSP terminar na veia poplítea, localizada na fossa poplítea. No caso relatado, ela se estendia para cima até a parte posterior da coxa, passando por trás e profundamente no nervo ciático e no músculo isquiotibial, finalizando nas veias da coxa. A VSP não penetra nenhuma estrutura no seu curso; portanto, não é provável que esta veia incomum esteja associada a veias varicosas da VSP. Para cirurgiões gerais, plásticos, cardiotorácicos e vasculares, nosso caso é de extrema importância.

Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap.

Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.

[Local flaps as a last attempt to avoid lower extremity amputation: an overview]. / Lokale Lappenplastiken als letzter Versuch vor der Unterschenkelamputation: eine Übersicht.

BACKGROUND: Soft tissue reconstruction in aged patients is challenging. Free tissue transfer can be carried out in healthy patients with a high success rate despite old age. When free tissue transfer is contraindicated in multimorbid patients, local flaps are often chosen, which are associated with a high complication rate. Such salvage interventions must be selected so that an amputation is not disadvantageously influenced by the selection of the donor site or is even impossible. METHODS: The three distally based local flaps the sural artery flap, peroneus brevis muscle flap and perforator-based propeller flaps are discussed with respect to placement of the donor site as well as wound healing disorders. RESULTS: The sural artery flap is disadvantageous as the donor site because the proximal dorsal calf region is affected, which in the case of a below the knee amputation enables soft tissue covering of the stump. CONCLUSION: If a local flap is to be used as a salvage surgery in an attempt to prevent a below the knee amputation in a patient who is not suitable for free tissue transfer, special emphasis must be placed on the donor site of this flap. The proximal dorsal aspects of the distal calf are required for covering a potential stump and should not be violated by harvesting a local flap.

Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint.

The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.

Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction.

INTRODUCTION: Soft tissue defects of foot and ankle are challenging due to the susceptibility of the area to trauma and the complexity of the region. Several flaps have been described for wound coverage after surgical debridement at this location. The purpose of this study is to present the reverse sural flap for covering soft tissue defects at the ankle and foot. MATERIALS AND METHODS: From July 2014 to November 2017, ten patients with soft tissue defect at the ankle and foot were retrospectively reviewed. There were nine men and one woman with a mean age of 40.5 years (range 17-71 years). Seven patients were smokers and five were diabetics. The mean size of the defect was 50.5 cm2. All operations were performed by the same microsurgical team. At a mean follow-up of 21 months (range, 18 to 24 months), we evaluated wound healing and complications. RESULTS: In nine patients, the soft tissue defect was successfully covered. In four patients, venous congestion was noticed, whereas in one patient, there was total necrosis of the flap. In all cases, the donor site was healed uneventfully. CONCLUSION: The reverse sural artery flap is a reliable alternative for wound coverage at the ankle and foot, with low complication and morbidity rate. Nevertheless, it is a demanding microsurgical operation that requires knowledge of the anatomy and surgeons' experience.

Outcome Of Distally Based Sural Artery Flap For Distal Third Of Leg And Foot Defects.

BACKGROUND: Due to precarious blood supply, skin coverage for defects of leg, heel, dorsum of foot and the ankle has been a complicated task for plastic surgeons & orthopaedic surgeons. The present study aimed to prospectively evaluate the outcome of distally based sural flap for coverage of defects distal third of leg, ankle & foot. METHODS: In this study 15 patients with soft tissue defects on distal third of leg in (n=2), heel (n=4), medial malleolus (n=3), lateral malleolus (n=1), Achillis tendon (n=2), anterior ankle (n=2) and in dorsum of foot (n=1) were operated for coverage of defect by distally based sural flap. All the cases were done as secondary procedures. RESULTS: All the flaps showed good results except five minor complications. Three flaps showed superficial skin necrosis and two showed partial tip necrosis. CONCLUSIONS: Distally based sural artery flap is very useful in covering the defects of lower leg, heel and dorsum of foot. It is reliable, easy to raise with minimal morbidity to the patient. This flap does not sacrifice any of the major vessels of the limb and hence it is very safe flap.

De-epithelialized fasciocutaneous turnover flap for recurrent calcaneal wound with osteomyelitis.

Recurrent ulcerations of the foot and ankle almost always present a challenge to lower extremity surgeons. Recalcitrant heel ulcerations with osteomyelitis are especially difficult to treat because of the lack of soft tissue coverage. The turnover flap is a simple, fast, and effective treatment method for lower extremity wounds. It is a de-epithelialized fasciocutaneous flap harvested from the adjacent area of the wound. We believe it is an underused technique for advanced wound closure in the lower extremity. It offers several advantages compared with traditional, more difficult to perform, flaps. We have seen an excellent result 18 months after using the turnover flap in a patient with recurrent posterior heel ulceration with calcaneal osteomyelitis.

The reverse sural artery flap for the reconstruction of distal third of the leg and foot.

Soft tissue defects around the distal third of the leg and the foot present a major reconstructive challenge. There is limited expertise with free tissue transfers in many developing countries, necessitating consideration of other options for the closure of such defects. The versatility and reliability of sural artery flap have made it an emerging popular option for the reconstruction of such defects. Twenty patients comprising of 13 males and 7 females with soft tissue defects of the lower third of the leg and foot requiring soft tissue cover were treated between January 2006 and December 2010. The age range was 7-58 years with a mean age of 30 years. Nineteen (95%) of the defects were post-traumatic while one (5%) was post-infective. All the defects were covered with reversed sural artery flaps, which were raised on the posterior aspect of the junction of the upper and middle third of the leg. The smallest flap was 4 × 4 cm(2) while the largest measured 20 × 12 cm(2). The donor defect was closed directly in 7 (35%) patients, while split skin graft was applied in the remaining 13 (65%) patients. There was satisfactory flap healing in 17 patients (85%), while 3 patients (15%) had complete flap necrosis. Two of these patients had significant comorbidities of haemoglobinopathy and poorly controlled diabetes mellitus. Sural artery flap remains a viable option for the reconstruction of soft tissue defects of the distal third of the leg and foot. Caution should, however, be exercised in patients with some significant systemic diseases.

Sural flap reconstruction of lateral malleolus following undifferentiated pleomorphic sarcoma resection with 1-year follow-up.

We report a case of a 54-year-old female who presents with a gradually expanding mass at the right lateral malleolus. The diagnosis of undifferentiated pleomorphic sarcoma was made after a histopathological examination of the mass following a wide tumor excision. The defected soft tissue area was reconstructed using a local flap, reverse sural artery flap. Following the surgical management, multiple radiotherapy sessions were completed. The patient's follow-up result showed no signs of local recurrence or metastasis, and the wound was well-healed with no complications other than paresthesia in a small area at the posterolateral aspect of the ankle under the lateral malleolus. This case represents a rare form of malignant neoplasm and emphasizes the effectiveness and safety of the reverse sural artery flap reconstruction technique, especially in places where microsurgery is unavailable or when the patient's status does not allow for prolonged anesthesia.

Surgical delay in reverse sural artery flap prevents congestion of the flap: a case report of the stepwise delay method.

We performed reverse sural artery flap (RSAF) with the stepwise delay method, cutting the vascular pedicle step by step, as the patient had a high risk of flap necrosis. Surgical delay in RSAF is anticipated to prevent not only flap cyanosis but also flap congestion.

Post-traumatic Aeromonas hydrophila Osteomyelitis caused by an Infected Gustilo-Anderson Grade 3B Tibial Fracture: A Case Report with a 7-year Follow-up.

Introduction: Post-traumatic osteomyelitis (OM) is often caused by Staphylococcus aureus. However, occasionally, it is caused by an infection with a rare bacterium. A case of OM caused by Aeromonas hydrophila was first reported in 1975. Since then, only nine cases have been reported, making it a rare disease. Here, we report a case of rare A. hydrophila OM that developed following open tibial fracture (classified as Gustilo-Anderson 3B) caused by an injury in a river. Case Report: The patient was a 50-year-old male who got injured in a river and was diagnosed with open tibial fracture. Debridement in the first surgery happened at a leisurely pace. Purulent discharge from the wound persisted despite external fixation; however, no bacterium was detected in the bacterial culture. The patient underwent multiple debridement procedures; A. hydrophila was detected in the bone marrow. Despite the appropriate administration of antibacterial drugs and debridement, infection persisted until radical bone resection and tissue reconstruction were performed. In the present case, OM following an open fracture caused by an injury in a river was suspected, which was caused by the rare bacterium A. hydrophila. Conclusion: In cases of OM occurring after underwater trauma, A. hydrophila should be considered as a causative pathogen. In addition, in cases of post-traumatic OM accompanied by bone and soft-tissue defects, the orthoplastic approach is required.

Reconstruction of the weight-bearing heel with nonsensate reverse sural artery flaps.

BACKGROUND: The reverse sural artery flap (RSAF) is widely used to reconstruct foot and ankle defects. Although it is commonly used in a nonsensate type, there has been controversy as to whether it provides sufficient stability and durability when applied to weight-bearing heels. The aim of this study was to evaluate patient outcomes after weight-bearing heel coverage using a nonsensate RSAF. METHODS: Twenty-three patients who underwent reconstruction surgery of the weight-bearing heel with RSAF from 2004 to 2018 in a tertiary hospital were retrospectively reviewed. All surgeries were performed without a sensate procedure. The patients' experience of pressure sore on the flap area and the ability to use normal footwear were investigated. Light touch, Semmes-Weinstein test (SWT), and two-point discrimination tests were assessed, along with postoperative wound complications. RESULTS: Heel damage etiologies included malignant tumors in 14 (61%), trauma-related in 7 (30%) and diabetic ulcers in 2 (9%) patients. Patient mean age was 58 years (range, 18-93 years) and the mean follow-up period was 57 months (range, 12-185 months). The mean size of the flap was 64.1 cm2 (range, 20-169 cm2). All flaps healed without major complications. All returned to daily living activities and 20 (86%) patients were able to use normal footwear. Of the 11 patients who had available measurement records, 8 (73%) showed a light touch sense. The mean SWT value was 4.31 (range, 3.61- 4.56). Two-point discrimination was not observed in any of the patients. Two patients had experienced superficial ulcers on the flap within a one-year postoperative period, which spontaneously healed and did not recur. No full-thickness ulcers were observed during the follow-up period. CONCLUSIONS: The results of this study suggest that patients who underwent nonsensate RSAF for the reconstruction of the heel could expect to maintain the property for stable weight-bearing without pressure sore.

Resurfacing the donor sites of reverse sural artery flaps using thoracodorsal artery perforator flaps.

BACKGROUND: The reverse sural artery (RSA) flap is widely used for lower extremity reconstruction. However, patients sometimes suffer from donor site complications such as scar contracture and paresthesia, resulting in dissatisfaction with the aesthetic outcomes. This study investigated the characteristics of donor site morbidity associated with RSA flaps and described our experiences of dealing with complications by performing resurfacing surgery using thoracodorsal artery perforator (TDAP) flaps. METHODS: From April 2008 to August 2018, a total of 11 patients underwent contracture release and resurfacing surgery using TDAP flaps due to donor morbidity associated with RSA flaps. All affected donor sites were covered with a skin graft, the most common of which was a meshed split-thickness skin graft (six cases). RESULTS: Eight of the 11 patients (72.7%) suffered from pain and discomfort due to scar contracture, and seven (63.6%) complained of a depression scar. The donor sites were located 6.3±4.1 cm below the knee joint, and their average size was 140.1 cm². After resurfacing using TDAP flaps, significant improvements were found in the Lower Extremity Functional Scale (LEFS) scores and the active and passive ranges of motion (AROM and PROM) of the knee joint. The LEFS scores increased from 45.1 to 56.7 postoperatively (P=0.003), AROM increased from 108.2° to 118.6° (P=0.003), and PROM from 121.4° to 126.4° (P=0.021). CONCLUSIONS: Planning of RSA flaps should take into account donor site morbidity. If complications occur at the donor site, resurfacing surgery using TDAP flaps achieves aesthetic and functional improvements.

Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience.

BACKGROUND: Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area. METHODS: In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel. RESULTS: Out of 40 patients' medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group. CONCLUSION: Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

The chimeric medial sural artery perforator flap as the ideal for partial tongue reconstruction: A case series and technical refinements.

BACKGROUND: The medial sural artery perforator free flap (MSAP) has gained increasing popularity in head and neck reconstruction. Its slightly bulkier nature than the radial forearm flap, combined with negligible donor site morbidity, makes it an ideal candidate for the reconstruction of partial glossectomy defects. The ability to harvest the MSAP as a chimeric flap with a portion of the medial gastrocnemius muscle gives it greater flexibility in soft tissue reconstruction. METHODS: A retrospective study of patients with partial glossectomy defects reconstructed using the MSAP by a single surgeon was performed. Perioperative data, donor and recipient site characteristics, complications, and outcomes were analyzed. A video is included to show technical points for the harvest of the flap. RESULTS: A total of 10 patients were included. The average age was 59.1 years, with a mean of 43.5% of the tongue resected. All flaps survived, with no major complications. At follow-up, the patients had regained an average of 86.5% of original speech, with none requiring NG feeding. The average MSAP skin flap thickness was 7.8 mm, with 6 flaps being harvested as chimeric fasciocutaneous muscle flaps. Five flaps incorporated 2 perforators. Two case examples are presented. CONCLUSION: The chimeric MSAP perforator allows for more robust partial glossectomy reconstruction with improved postoperative functional outcomes. It should be considered as the workhorse flap for partial tongue reconstruction.

Long-Term Clinical and Functional Outcomes of Distally Based Sural Artery Flap: A Retrospective Case Series.

BACKGROUND: Reconstruction of soft tissue defects around the lower leg, foot and ankle is a challenge for orthopedic surgeons. These defects commonly occur as a result of trauma, infection and tumor excision. Sural artery neurovascular island flap is a relatively thin, pliable and insensate flap with minimum donor-site morbidity and acceptable aesthetic outcome. METHODS: A retrospective analysis of a case series was conducted, all operated by a single surgeon over a period of 25 years from July 1996 to February 2020. Data were collected through a structured proforma; the variables included were as follows: demographic data, mechanism of injury, defect site and size, size of flap, hospital stay, complications, outcome of flap and functional status of limb. Data analysis was performed by using SPSS version 25.0. RESULTS: We included 89 patients out of 106, with 92 distally based sural artery flaps. The flap coverage was divided in two groups: group I for leg (n=41) and group II for foot (n=51). The mean flap dimension in leg was 9.98 ± 2.2 cm and 12.15 ± 3 cm in foot. Postoperatively functional outcomes were assessed using a self-designed tool and graded as excellent in 79 cases (leg=38; foot=41), good in 10 cases (leg=2; foot=8), fair in 3 cases (leg=1; foot=2) and poor in zero cases. All flaps survived uneventfully. CONCLUSION: The reverse sural artery flap is versatile and reliable, and can be performed easily with good knowledge and using a microsurgical technique. It is useful for the reconstruction of soft tissue defects around the lower third of the leg, dorsum of the foot, malleoli and hind foot. The functional range of motion of the ankle is not compromised because of the flap's supple and pliable nature. The reverse sural artery flap is ideal for the coverage of the foot, ankle and lower one third of the leg. This flap is insensate and not suitable for the weight-bearing area of the heel.

The reverse sural artery flap- How do modifications boost its reliability? A systematic analysis of the literature.

The reverse sural artery flap (RSAF) was first described approximately four decades ago and has since been used frequently for reconstruction of soft tissue defects in the distal part of the leg. Although the popularity of this flap never reached the extent of that of free perforator flaps, it still serves as a reliable alternative. This has been demonstrated by the increased rate of publication on the technique in recent years. The number of authors reporting data has risen up to 20 reports a year. During this time, several new modifications of the flap were inaugurated in order to boost the efficiency and reliability of the flap. The goal of this systematic analysis of the literature was to gain information on the influences of the modifications of the RSAF with regard to consistency and complication rates. An overall survival rate of 95% and a rate of complications of 14% were reported in all the analyzed cases. Some modifications were able to improve flap viability but not at a statistically significant extent. Venous supercharging and the adipofascial variant of the RSAF provided the best results. The RSAF is still a remarkable flap design, especially as a backup solution or in circumstances without a microsurgical skilled surgeon. Further investigation with controlled randomized prospective trials is vital to confirm this finding with more evidence.

Giacomini's vein - a report on the invaluable importance of an anomalous short saphenous vein / Veia de Giacomini: um relato sobre a importância inestimável de veia safena parva anômala

Abstract Variations in the drainage (termination) and course of the lower limb veins are not uncommon. When dissecting the left lower limb of the adult male cadaver in the vascular case described herein, a unique kind of unilateral short saphenous vein (SSV) termination was observed. It was found that the SSV had normal origin and course in the dorsum of the foot and the back of the leg, respectively. Most often the SSV terminates in the popliteal vein at the popliteal fossa. In this case, it extended upward into the back of the thigh, passing behind the sciatic nerve and then deep to it and the biceps femoris, and finally ended in the veins of the thigh. The SSV did not penetrate any structures along its course to the end, so this unusual vein appears unlikely to be associated with SSV varicose veins. For general, plastic, cardiothoracic, and vascular surgeons, our case would be of significant value.

Resumo Variações na drenagem (terminação) e curso das veias dos membros inferiores não são incomuns. No caso vascular relatado, ao dissecar o membro inferior esquerdo de um cadáver adulto do sexo masculino, foi observado um tipo único de veia safena parva (VSP) unilateral. Verificou-se que a VSP tinha origem e curso normais no dorso do pé e na traseira da perna, respectivamente. É mais comum a VSP terminar na veia poplítea, localizada na fossa poplítea. No caso relatado, ela se estendia para cima até a parte posterior da coxa, passando por trás e profundamente no nervo ciático e no músculo isquiotibial, finalizando nas veias da coxa. A VSP não penetra nenhuma estrutura no seu curso; portanto, não é provável que esta veia incomum esteja associada a veias varicosas da VSP. Para cirurgiões gerais, plásticos, cardiotorácicos e vasculares, nosso caso é de extrema importância.

Effectiveness of Reverse Sural Artery Flap in the Management of Wheel Spoke Injuries of the Heel.

OBJECTIVE: Soft tissue injuries at the level of lower extremities, plantar, and dorsal foot pose a surgical challenge for reconstructive surgeons. This kind of injury commonly occurs when lower limbs get stuck in between the spokes of the wheel. Reverse sural artery flap has been proven to be an effective option to cover such defects. The aim of this study is to analyze the demographic variables of affected individuals, technical aspects of reverse sural artery flap, quantify the effectiveness of reverse sural artery flap among various treatment options available, and to study the outcome of injury. METHODS: A total of 49 patients who presented during a period of six years from January 2010 to January 2016 were included in the study. The data was collected using patient's charts, by interviewing the patients, and from hospital records. The patients' wounds were prepared, examined, and the injury was graded depending upon the extent of tissue damage. Tendon and bone defects were repaired, and wounds were closed by either split thickness skin graft or reverse sural artery flaps. RESULTS: Children were the most commonly affected with no conclusive gender trend. The posterolateral part of the heel of the right foot was the most frequently injured part (69%). Surgical interventions together with proper postoperative care and follow-up produced very good results overall. CONCLUSION: Wheel spoke injuries of the heel can be managed without significant morbidity if the patient presents early, the wound is assessed properly, suitable surgical technique is utilized, and good postoperative care is provided.

How Much Can We do by Reverse Superficial Sural Artery Flap to Potentiate Its Effects: Introducing Spout Sural Flap as a New Modification.

BACKGROUND: Due to shortage of local donor tissue and unreliable blood supply, free flaps were the mainstay of treatment for tissue defects in the lower leg and foot region, but it requires a qualified microvascular surgeon. Recently, attention has been paid to reverse superficial sural artery flap (RSSAF) and its modifications as a good alternative to pave the way to simple and friendly techniques. METHODS: Excluding each patient with septic and severely ischemic foot, every patient with tissue defect in distal leg and proximal foot region were studied. Various methods were applied including spout technique with sufficient follow up. No imaging was used to evaluate the blood supply. RESULTS: Five patients underwent spout technique with excellent results in four cases. Spout technique in one case failed due to narrow base. In five cases, RSSAF was performed with creating skin tunnel and very good results. CONCLUSION: RSSAF is a good alternative for free flap to cover the leg and foot tissue defects. We also advise wide base pedicle (>4 cm) in every patient.