is Assistant

Professor of Surgery, Division

of Plastic and
Reconstructive
Surgery,
at the University
of Pittsburgh
School of Medicine.
After graduating
from Dartmouth
Medical School in 1970 and the University
of Colorado
School of Medicine in 1972, he trained in general surgery
at the Dartmouth
Hitchcock Affiliated
Hospitals and concluded his plastic surgery training
at Brown University
Affiliated
Hospitals.
His fellowship
training
in microvascular surgery was taken with Dr. Harry Buncke at the
Ralph K. Davies Hospital at San Francisco. Dr. Swartz is
a diplomat
of the American
Board of Plastic Surgery, and
consulting
editor for the Journals
of Reconstructive
Microsurgery
and Microsurgery.
His clinical
interests
include hand surgery and reconstructive
microsurgery.

is Assistant
Professor of Plastic and Reconstructive
Surgery at the University
of Pittsburgh.
A graduate
of Oxford University,
he trained
in general surgery in Great
Britain
and then completed a residency in plastic and reconstructive
surgery
at the University
of Michigan
in
Ann Arbor. Dr. Jones continued
training
in plastic surgery at the Regional Plastic Surgical Unit at the London
Hospital
in England,
followed by a further fellowship
in
hand surgery
and microsurgery
at the Massachusetts
General
Hospital
in Boston. His major field of clinical
practice is hand surgery and microsurgery.

TREATMENT
of the injured lower extremity has been improved
significantly
by recent advances in reconstructive
surgical techniques. Chief among these are the development
of muscle and
musculocutaneous
flaps and the parallel development
of microvascular surgical techniques
for free tissue transfers. Each of
these techniques
brings an augmented
blood supply into the
area of injury, thereby improving
the conditions for primary
healing of soft tissues and underlying
fractures. The approach to
the management
of significant soft tissue and osseous injuries to
the lower extremity
outlined in this monograph
represents the
4 JUNE CPS

combined efforts of the plastic surgeons and the orthopedic surgeons at the University
of Pittsburgh.
It is essential that the
plastic surgeon and the orthopedic surgeon have a common understanding
of the priorities of wound management
and work
toward a common goal from the time of the initial injury. Although the management
of osseous defects, including fractures,
nonunions, and segmental bone loss, is beyond the scope of this
monograph, the techniques of soft tissue coverage have a direct
bearing on these more complex wounds.
Briefly, the principles of wound care include (1) a thorough
assessment of the magnitude of the injury, including a detailed
examination
of motor and sensory function and vascular status;
(2) anatomical alignment of fractures with appropriate fixation
techniques; (3) thorough debridement
of all nonviable tissues,
followed by a second or third reassessment and additional debridement if necessary; and (4) definitive wound repair consisting of soft tissue coverage and bone reconstruction
in selected
patients. When these principles are carried out it is possible to
achieve wound closure and primary reconstruction
within 5-7
days of the original injury.
Within the f&t few days of injury, the surgeon and patient
alike should have a thorough understanding
of the magnitude of
the injury, the reconstructive
procedures required, and the likelihood of restoring the patient to an ambulatory status within a
reasonable period of time. It is our opinion that for this plan to
be successful, efficient management
of these problems should restore the patient to a functional status within 1 year of injury.
Patients with protracted disability beyond this period of time
generally have not resumed their preinjury
way of life and
might be better served by amputation.
Despite the most careful initial management
of traumatic and
other injuries to the lower extremity, chronic problems such as
unstable burn scars, chronic osteomyelitis,
and fracture nonunions present additional special problems that may be resolved
by the application of soft tissue based on a safe vessel network.
A common theme in the following discussion on the techniques
of soft tissue coverage is preservation of blood supply and the
reliable application of this new supply to ischemic or chronically
infected wounds.
This monograph outlines principles in the management of soft
tissue injuries of the lower extremity
and delineates the techniques that have been most efficacious in their treatment.
The
general methods of soft tissue coverage, including skin grafts,
muscle flaps, and free tissue transfers, will be discussed, with
particular
emphasis on their relevance in the lower extremity.
Finally, specific procedures for coverage of defects beginning in
the upper leg and extending to the foot and ankle will follow,
with emphasis on those procedures that have been most successJUNE CPS 5

ful in our experience. This discussion is neither encyclopedic nor

esoteric. Its purpose is to provide surgeons with a practical and
rational basis for flap selection for a variety of common clinical
problems.
EVALUATION

OF THE INJURED

LOWER EXTREMITY

Evaluation
of the patient begins with a complete understanding of the mechanism of injury. Previous classifications of lower
extremity injuries are of benefit in predicting the severity of the
injury. Gustillo and Anderson classified fractures into three
types: type I is an open fracture with a wound less than 1 cm
long, type II is an open fracture with extensive soft tissue damage, and type III is either an open fracture or segmental fractures with extensive soft tissue damage that may require vascular repair.l Type III fractures have been further
classified
based on the energy involved to cause them. It is possible to
make recommendations
for the treatment
based on this classification2 Type III-A fractures are those in which there is an accurate demarcation
between injured and noninjured tissues. The
extent of injury is limited to the area of the defect. Local muscle
flaps or free tissue transfers with a short vascular pedicle can be
employed to treat these open wounds. Type III-B fractures are
those in which abrasion injury produces more significant soft tissue damage and a less distinct line of demarcation between normal and injured tissues. While the application
of a larger flap
may be required, the deeper structure, notably the principal vessels supplying the region, are not severely injured. Type III-C
fractures are high-energy
crush injuries involving
widespread
damage to soft tissue, bone, and microvasculature.
These injuries necessitate the use of flaps with long vascular pedicles, so
the vascular anastomoses can be performed well outside the zone
of injury. The use of local muscle flaps in such wounds is contraindicated.

EVALUATION OF VASCULAR INJURIES

The initial evaluation
of the traumatized
lower extremity requires a careful examination
of major blood vessels. Injuries to
these vessels portend a significant risk for subsequent tissue necrosis or limb loss. It is therefore of the utmost importance that
an early diagnosis of major arterial injuries be made and appropriate treatment
provided at the outset. A delay of more than 6
hours in the management
of the arterial injury may render an
otherwise salvageable extremity
incapable of functional
recovery. Even after a successful arterial repair has been performed,
prolonged ischemia may result in diminished or absent capillary
flow, which in turn prevents reestablishment
of nutrient
blood
6 JUNE CPS

flo~.~ Most arterial injuries can be diagnosed on physical examination.

The cardinal signs of an arterial injury include diminished or absent pulses, loss of nerve function, hematoma,
bruit at the site of injury, and persistent arterial bleeding. In
addition to these findings, the presence of an injury in close
proximity to a major vessel is justification
for further arterial
evaluation. In several recently reported series4-6 the absence of
pulses distal to the site of the soft tissue injury had a high correlation with a proximal
vascular impairment.
The dorsalis
pedis and posterior tibia1 pulses should be easily palpable in a
patient without a vascular injury. Diminished or absent pulses,
compared to the opposite uninjured extremity, should raise the
suspicion of vascular compromise and is an indication for arteriography. The presence of distal pulses does not rule out a major arterial injury. The dorsalis pedis pulse may be reconstituted
from the first dorsal metatarsal artery communication
with the
posterior tibia1 artery through the plantar arch. The reconstitution of pulses distally through collateral circulation about the
knee has been documented in popliteal artery injuries.7
Transcutaneous
ultrasonic Doppler imaging is useful for evaluating the acute vascular injury, particularly
when peripheral
pulses are difficult to assess. By using the flow-directed device,
the examiner may detect reversed flow through collateral circulation in the foot. Hard copy tracings allow a comparison of normal and abnormal flow patterns indicative of complete and/or
partial obstructions.8 Low flows on Doppler imaging without
palpable pulses may indicate spasm or external compression, in
which case the flow should improve over time. In most cases of
acute traumatic
injury, the Doppler examination
confirms the
clinical findings.
Careful examination
of the sensory distribution
of nerves in
the lower extremity will give clues to potential arterial injuries
immediately
adjacent to these nerves. In the popliteal region,
the tibia1 nerve lies immediately
adjacent to the popliteal artery. Sensory loss in both the dorsal and the plantar aspect of
the foot as well as motor paralysis below the knee would be expected in a patient with complete nerve injury at this level. In
the anterior compartment
the anterior tibia1 artery lies immediately adjacent to the deep peroneal nerve, whose sensory distribution
includes the dorsum of the foot. Injuries below the
take-off of the anterior tibia1 artery may be diagnosed by the
finding of sensory loss only on the plantar aspect of the foot,
indicating a potential posterior tibia1 artery injury. Serious arterial injuries ma7 be anticipated in 14%-33% of patients with
nerve deficits.4, , Major hemorrhage or hematoma should alert
the surgeon to the probability
of major arterial injury in addition to nerve deficits.
Displaced fractures or dislocation of the knee and ankle are
JUNE CPS 7

frequent causes of vascular compromise. Prompt reduction of the

fracture or correction of the dislocation will result in restoration
of normal pulses, precluding the need for operative intervention.
Vasospasm associated with these problems generally resolves in
a short period of time. Failure of the pulses to return suggests
significant lacerations or intimal tears of the vessel and requires
further intervention.
Angiography
is an important
adjunctive procedure that provides the surgeon with the information
necessary to make a decision about vessel injury. Primary indications for angiography
include the presence of the clinical signs of vascular injury,
namely, weak or absent pulses, neurologic deficits, bruits, or expanding hematomas. Even when the decision is made to explore
an extremity
for a probable vascular injury, angiography
may
help in identifying
the exact location of the injury and aid in
planning an approach to the vesseL7, lo Arteriography
should be
performed expeditiously
so as not to prolong the ischemia time
unnecessarily. Percutaneous transfemoral
arteriography
may be
performed while the patient is on the operating table and being
prepared for operation. Done by the surgeon, it is rapid and provides satisfactory
films. Patients without
significant
signs of
ischemia may undergo arteriography
under more ideal circumstances in the radiology suite without detrimental
effects. It is
our practice to perform angiography
whenever physical findings
suggest an acute arterial injury; otherwise we observe the patients with satisfactory distal pulses and circulation.
All patients undergoing
acute or delayed microvascular
reconstructive procedures should undergo femoral arteriography
before reconstruction
is performed. It is of utmost importance that
the surgeon have a clear understanding
of the vascular status of
the extremity before undertaking
dissections of local or regional
muscles or attempting
free tissue transfers that depend on the
presence of intact vessels. Failure to appreciate the extent of
vascular injury is the most frequent cause of flap necrosis when
local muscle flaps are used in the severely injured extremity.
Intraoperative
problems of vasospasm, vascular occlusion, and
unrecognized
damage to the vessels can be expected if these
basic tenets are not observed.

SIGNIFICANCE OF NERVE INJURIES

Injuries to the major branches of the popliteal nerve below the
knee have additional significance, beyond the potential injury of
vascular structures. Accurate diagnosis of nerve injuries allows
the surgeon to repair these at the time of initial operative intervention, with the potential for partial motor reinnervation
and
partial restoration of sensation. Isolated nerve injuries are generally compatible
with limb salvage and preservation
of func8 JUNE CPS

TABLE

l.-FINDINGS

ARTERY

IN PATIENTS WITH ISOLATES INJURIES OF POPL~TEAL NERVE BRANCHES

LOCATlON

Superficial
femoral artery
Popliteal artery
Anterior
artery

tibia1

Posterior
artery

tibia1

Adductor

ADJACENT
NERVE

Saphenous

CXId

Popliteal
fossa region

Tibia1

Anterior
compartment
lower leg
Posterior
compartment
lower leg

Deep peroneal
IlelTe
Posterior
nerve

tibia1

SENSORY

LOSS

Anteromedial
lower leg
Plantar foot
dorsum oi
foot
Dorsum of foot
Plantar
surface
foot

MOTOR LOSS

NOM
Plantar flexion
dorsiflexion of
foot, toes
Dorsiflexion
of
foot

of

tion. Table 1 lists the findings in patients with isolated injuries

of the branches of the popliteal nerve. In our experience patients
with absence of plantar sensation in combination
with severe
osseous and soft tissue injuries have a poor prognosis for restoration of function.
In these patients,
serious consideration
should be given to primary amputation.
Injuries to the anterior
tibia1 nerve with paralysis of extensors of the foot and ankle can
be successfully treated with appropriate
tendon transfers or orthosis and are compatible with a functionally
useful extremity.
A more complete discussion of the role of soft tissue restoration
where sensation is desirable is found later in this monograph.

INITIAL

WOUND

MANAGEMENT

Initial management
of a patient with a severely traumatized
lower extremity is carried out in the operating room under general anesthesia. Tetanus prophylaxis
is provided according to
the guidelines of the Trauma Care Committee
of the American
College of Surgeons.ll
Patients in whom a history of tetanus
prophylaxis
is unclear are given 500 units of human hyperimmune globulin
(Hyper-Tet)
along with an initial immunizing
dose of 0.5 cc of adsorbed tetanus toxoid. A broad-spectrum
antibiotic with activity
against penicillinase-resistant
staphylococci is begun, generally a cephalosporin.
In the operating room
thorough and complete wound debridement
is carried out. Skin
flaps may be evaluated for capillary refill and any questionable
skin may be further evaluated with the use of intravenous
fluorescein dye. One to 2 gm of dye are injected after a test dose of
1 cc to ensure that there is no allergic reacti0n.l
While the use
of fluorescein is helpful in determining
skin viability, its value
in the determination
of muscle viability is less certain. At present there is no clinically useful vital dye that delineates necrotic
from living muscle tissue. In the future the use of the magnetic
resonance imaging techniques may be useful in this regard.
Debridement
is based on clinical judgment.
Viable muscle
JUNE CPS 9

blood supply muscles with a single dominant vessel and one or

more secondary vascular pedicles are most safely transferred,
with the dominant vessel being the point of rotation. If the dominant vessel is divided and the muscle is rotated on its distal
vascular supply, significant
muscle necrosis may occur. This
method is less reliable but occasionally useful-for
example, a
vastus lateralis muscle flap based on its distal blood supply may
be used for knee coverage, and a soleus muscle flap based on the
posterior tibia1 artery may be used for distal tibia1 coverage.
Functional
Considerations
It is important
to understand
the functional
loss incurred
when a muscle is chosen for a rotation flap. Frequently
more
than one muscle contributes to a given motion. For example, the
soleus and gastrocnemius
muscles both contribute
to plantar
flexion, and the use of either for soft tissue coverage does not
result in a functional
deficit. The use of both, however, would
result in inability
to flex the foot in a plantar direction and
would not be suitable for reconstruction.
When a muscle has a
special function, as in the case of the tibialis anterior, and its
use for reconstruction
is indicated, the muscle belly may be dissected away from the tendon to the musculotendinous
insertion
and rotated to cover the defect. In this manner the integrity of
the muscle tendon unit is preserved. Additionally,
a larger muscle such as the soleus may be split and only a portion of it used
to cover the defect, leaving the remaining
muscle functionally
intact.24
Muscle Flaps
When muscle flaps are used for soft tissue coverage along with
split-thickness
skin grafting,
some muscle atrophy may be expected, due to muscle denervation
and division of insertion and/
or origin. Flaps that are initially
bulky at the time of reconstruction ultimately
settle into an acceptable contour over the
injured tibia and malleolar areas. Latissimus
and gracilis free
flaps, for example, show a 30%~50% decrease from the initial
flap thickness. Skin grafts placed directly over muscle have been
shown to be quite durable in the lower extremity.25 We and others have found this to be an acceptable method of coverage over
non-weight-bearing
areas, with long-term durability.
This technique is especially useful in extensive defects where the harvesting of a skin flap of necessary dimension would create an
unacceptable donor site deformity.
Occasionally it is possible to use local muscle flaps for soft
tissue coverage and preserve their function aa well. With the
nerve supply to the muscle preserved and its tendon reattached
in a new location, the muscle will continue to function, providing its length has been maintained.
The vastus medialis muscle
may be rotated anteriorly
for coverage of defects about the su18 JUNE CPS

compartment
may be released through a midline posterior incision, an extension of the incision used for vascular access to the
popliteal space. Further release of the deep posterior compartment may be carried out through this incision. Fibulectomy
for
complete compartment
decompression,
advocated by Ernst and
Kauper,15 while affording adequate decompression, is contraindicated when severe fractures or segmental bone loss are present. Following release of the fascial compartments,
temporary
coverage of the wound is carried out with moist dressings, biologic dressings, or skin grafts where indicated. Our preference is
to use adaptic gauze covered with a thick layer of bacitracin
ointment
on all exposed wounds. This prevents wound desiccation and provides a bacteriostatic
atmosphere.
Following this initial debridement
the patient is returned to
the operating room in 24 or 48 hours for wound inspection and
further debridement
as needed. Any remaining devitalized muscle or bone is removed. A thorough
inventory of the wound is
carried out and plans for definitive
reconstruction
are made.
Further debridement
is carried out as necessary, should the first
reoperation not be sufficient.
DEFINITIVE

SOFT TISSUE

COVERAGE

Definitive wound closure is the first step in the reconstructive

process, ultimately
leading to full rehabilitation
of the patient
with lower extremity
trauma. Wound closure is achieved only
after thorough debridement
and control of bacterial contamination have been achieved.
REQUISITES OF SOFT TISSUE COVERAGE
The goal of soft tissue replacement
on the lower extremity
is
to provide a well-healed,
stable wound in the most expeditious
manner. For anatomical areas with little or no padding, such as
the anterior tibia1 region, the malleoli, and the patella, the tissues chosen must provide durable coverage. In addition, the tissues must be supple and able to conform to such regions as the
knee and the ankle joints. In weight-bearing
areas, tissues must
be able to withstand
the trauma imposed by ambulation
or the
wearing of shoes. In each of these conditions, the blood supply to
the tissues must be adequate to prevent long-term
ischemic
changes and eventual tissue breakdown.
A second requirement
is the restoration of contour. The choice
of reconstruction
must take into account the necessity of providing thin conforming
tissue for coverage in the regions of the
malleolus and the foot so that shoes may be worn comfortably.
In addition,
the cosmetic aspects with respect to leg contour
should be taken into account when one chooses tissue. While
JUNE CPS

11

aesthetics may not be the primary consideration

in lower extremity reconstruction,
if other factors are equal, acceptable contour is achievable.
Third, tissue chosen for reconstructive
purposes should preserve function whenever possible. It is unacceptable to sacrifice
a functionally
important
muscle or muscle skin flap merely because of its proximity to the wound. Only those muscles or musculocutaneous
units that are not essential for normal function
should be utilized. By preserving
the musculotendinous
junctions, a muscle like the tibialis anterior, an essential dorsiflexor
of the foot, can be used for covering the anterior tibia while preserving its functional
integrity.
Similarly,
the function of the
latissimus dorsi can be preserved by intramuscular
dissection
that preserves the remaining
nerve and blood supply to the
functional
portion of the muscle. These technique will be described later in greater detail. These factors take into consideration the appropriate
reconstructive
method for each patients
wound and may be chosen on the basis of a broad armamentarium of reconstructive
methods.
CONDITION

OF THE WOUND

In choosing the appropriate

reconstructive
method for soft tissue coverage, the surgeon must take into consideration
the
wound itself. The nature of the injury plays a great role in determining
the amount of soft tissue and bone destruction that is
present. To a variable degree the tissues in the area of trauma
will have become relatively
devascularized.
If the devascularization is minor, the underlying
soft tissue vasculature
may be
well maintained,
thereby allowing
the application
of a splitthickness skin graft as the method of choice. Degloving injuries
also generally provide a suitable wound base for split-thickness
skin grafts. More severe trauma, such as crush avulsion injuries
or grade III open fractures with crushing injuries to the underlying muscle, significantly
decrease the local blood supply, particularly
in the area of fracture. The choice of reconstructive
method here must take into account these vascular changes.
The surgeon must also consider the desirability
of increasing
the blood supply to an ischemic wound. The use of a highly vascularized muscle tissue in a free tissue transfer satisfies this reconstructive
requirement.
Finally, the patients overall condition, age, and concomitant
medical and surgical problems may
dictate whether the simplest possible method of reconstruction
or a more complicated endeavor is attempted.
Temporary wound
closure with a biologic dressing or skin grafts will allow the surgeon to further evaluate the patient before undertaking
more
complex procedures.
12 JUNE CPS

BACTERIOLOGIC CONTROL
Bacterial contamination
or gross infection may be adequately
controlled
with serial debridement
and systemic antibiotics.
Continued wound infection reflects residual necrotic tissues, either muscle or bone, and their complete debridement
is essential. Topical antimicrobials
such as Sulfamylon or the less painful silver sulfadiazine may be used to treat the open wound prior
to coverage. The use of biologic dressings allows the surgeon to
further assess bacterial contamination.
An initial take of porcine heterografts
or the actual take of homografts indicates successful control of bacterial proliferation.
The suitability
of a heavily contaminated
wound for grafting
may be determined by quantitative
bacterial analysis. The rapid
slide technique is a useful method for determining
whether the
bacterial count is less than lo5 per cubic millimeter
of tissue.16
TIMING OF COVERAGE
Coverage of open wounds of the lower extremity
is basically
divided into three time periods. Immediate
coverage means closure of the wound within 24 hours of the time of injury. Definitive coverage at this time depends on a thorough evaluation of
the wound and confidence that the underlying
tissues have not
sustained severe trauma or further necrosis.
Delayed primary closure is performed a short period of time
following injury, generally within 5-7 days. This technique is
the most useful and allows a more thorough
evaluation
of the
wound, including serial debridement,
complete vascular assessment with arteriography,
and a thorough plan of reconstruction
that the surgeon and the patient have had time to consider
along with its alternatives.
Delayed primary
closure may be
combined with definitive
bone reconstruction
or other reconstructive procedures as needed with a greater measure of safety
than one might have in the acute setting immediately
following
injury.
The third category of wound closure is secondary closure.
Many patients in whom secondary closure is necessary have incurred severe injury with major soft tissue loss, crush injuries,
or segmental bone loss. These wounds have been treated open
for a period of time and frequently
are heavily contaminated
with bacteria, if not grossly infected. Coverage of these wounds
presents a significant
problem in infection control, particularly
if bone is involved. Soft tissue coverage alone might be chosen
rather than definitive bone and soft tissue reconstruction
in order to prevent the loss of bone grafts or nerve grafts due to secondary infections.
Additional
difficulties
encountered
in these
JUNE CPS 13

wounds are significant

fibrosis and induration
of tissues with
loss of normal tissue planes. In general, the simpler the method
of soft tissue closure in these wounds, the more successful it has
been.
METHODS

OF SOFT TISSUE COVERAGE

In evaluating
a wound that needs soft tissue coverage, the
surgeon should consider methods in order of simple to complex.
The simplest method that meets the reconstructive
goals should
be chosen in preference to more complex, risky methods. In increasing order of complexity, the reconstructive
methods are primary closure, skin grafts, local muscle flaps, free tissue transfers, and cross-leg flaps.
SKIN GRAFTS

Split-thickness
skin grafts taken from the thigh or the buttock
may be safely applied to most wounds in the lower extremity
with a high degree of success. They have been used successfully
for closure of fasciotomy wounds and for skin loss over underlying muscles and the periosteum. They take well over the paratenon and on granulating
wound beds. An essential requirement
is an adequate blood supply to the underlying
tissues. Skin
grafts have also been used in less ideal locations, such as over
the Achilles tendon and over bare bone. A time-honored
technique for grafting over bone is to drill holes through the bone
cortex and allow granulation
tissue to cover the bone before
placing the skin graft. In the Achilles tendon region as well,
granulation
tissue is required to support a skin graft. These
techniques require meticulous wound care and patience on the
part of both surgeon and patient for successful completion of
wound closure. Skin grafts are indicated for closure of heavily
contaminated wounds, particularly
in the chronic wound setting.
The use of a meshed split-thickness
skin graft over freshly debrided tissue is particularly
useful. Meshing permits wound exudate and bacterial accumulation to be collected in the overlying
cotton dressing, passing through the interstices of the graft
without lifting it from its bed.
A special indication for the use of split-thickness
skin grafts
is in degloving injuries of the extremities
(Fig 1). Replacing
these full-thickness
skin flaps on the traumatized
wound is uniformly unsuccessful and most of the time results in necrosis of
the skin flap and infection of the underlying tissues.17 If the tissue is available, split-thickness
skin grafts may be taken from
the degloved specimen with an electric dermatome. Skin grafts
may be used to close extensive wounds as a temporary measure
14 JUNE CPS

Fig 1.-A
and 6, a large thigh flap resulting
from a degloving
injury. The flap was
debrided
and a split-thickness
skin graft harvested
from the flap was used to cover
the wound.
Additional
skin grafting
was necessary.
Replacing
such a flap in its
wounded
bed generally
results in necrosis
of the flap and underlying
infection.

when the patients condition does not allow a complicated surgical procedure to be carried out safely. Use of a skin graft under
these conditions allows homeostasis to be regained and gives the
surgeon and patient added time to plan more definitive complex
reconstructive
procedures.
LOCAL MUSCLE FLAPS
Significant improvements
in soft tissue coverage of the lower
extremity have been achieved with the development of muscle
flaps in reconstructive
procedures.18-20 This work has renewed
interest in studying the blood supply to the muscles and has
increased our knowledge of and ability to use muscles in reconstructive procedures.21-23 Local flaps are indicated for soft tissue
coverage of important
structures such as the patella, the knee
joint, the exposed tibia1 bone, and weight-bearing
areas of the
foot. Generally these are areas in which split-thickness
skin
grafting does not provide stable wound coverage or preservation
of joint mobility. A necessary condition for the use of local muscle tissues is an adequate blood supply to these tissues. A thorough understanding
of this blood supply allows the surgeon to
make a judgment with regard to the use of these procedures.
Vascular trauma in the region of the major blood supply to the
intended muscle is a contraindication
to the use of a local muscle
flap. Similarly,
an extensive crush injury to the region would
JUNE CPS 15

make the transfer of local muscle hazardous. In sections to follow, individual muscle and myocutaneous flaps will be described
in detail for specific regions.
Principles

of Muscle Flap Transposition

The reconstructive
surgeon must be familiar with the basic
principles of muscle flap transposition.
These include an understanding of the blood supply to the individual
muscles concerned, the location of that blood supply with regard to the muscles arc of rotation, and the functional deficits incurred with the
use of the muscle for soft tissue coverage. Finally, in using muscle flaps, preservation of function is an essential part of the reconstructive plan.
Classification

of Muscles by Their Blood Supply

Mathes and Nahai have classified the blood supply of the muscles after extensive dissections and radiographic
study with injection of contrast material.23 This information
is extremely important in planning the transfer of local muscle tissues either as
a pedicle transfer or a free tissue transfer. A summary of this
classification is presented here, along with a brief discussion of
the more useful muscles for reconstruction
of lower extremity
defects (Fig 2).
Type I blood supply to muscle is defined by the presence of a
single vascular pedicle as the primary blood supply for the muscle or muscle skin unit. In general, the dominant blood vessel
enters the muscle proximally.
In the lower extremity
muscles
with a type I blood supply include the medial and lateral gastrocnemius muscles, supplied by the sural arteries, and the rectus femoris muscle and tensor fascia lata, both supplied by the
lateral femoral circumflex artery. A type II blood supply is that
in which there are two vascular pedicles to the muscle, a dominant more proximal pedicle and a smaller minor pedicle, generally in its distal portion. This blood supply is the most frequent
vascular type in human anatomy. The dominant blood supply is
used in transfer of the flap, and the entire muscle survives division of the minor distal pedicle. Muscles with a type II blood
supply include the gracilis, the vastus lateralis, the soleus, the
biceps femoris, and the peroneus longus and brevis. The type III
blood supply to muscle is defined by two equally dominant pedicles. The muscle may be transferred
on either of its vascular
pedicles. Generally there is a rich anastomotic network between
the two pedicles. The rectus abdominis muscle, based on the
deep inferior epigastric or the superior epigastric artery, is a
muscle with a type III blood supply. A type IV blood supply is
found in muscles which have a multiply segmented blood supply
over the length of the muscle belly. Division of more than two
or three of these blood vessels results in necrosis of that segment
of the muscle. These muscles are generally unreliable as flaps
16 JUNE CPS

II soLEt.

*r?rer/iYr

tibia/ - wt.

Ip

TIBIALIS

ANTERIOR

P LATISSIMUS

Fig 2.-Classification
of the blood supply
to muscles
and musculocutaneous
flaps: type I, single proximal
dominant
pedicle;
type II, proximal
dominant
pedicle
and distal minor pedicle;
type Ill, two equally
dominant
pedicles;
type IV, mdtiple
segmental
pedicles;
type V, one dominant
proximal
pedicle
and segmental
secondary vascular
pedicles.

when based on their more proximal segmental blood supply.

Muscles with a type IV blood supply include the tibialis anterior, the flexor digitorum longus, and extensor digitorum longus.
Lastly, muscles with a type V blood supply have one dominant
vascular pedicle and segmental secondary vascular pedicles.
These muscles are exemplified by the latissimus dorsi muscle
and the pectoralis muscle. The significance of this blood supply
is that a portion of the muscle may be transferred using one of
the dominant blood vessels while the remainder of the muscle
will survive, based on the lesser segmental blood supply.
Arc of Rotation

The use of muscles in rotation flaps depends on an understanding of the point at which the major blood supply enters the
muscle. This pivot point is fixed. Tissue distal to this point is
rotated into the defect, preserving that blood supply. Additional
arc of rotation may be achieved by releasing the muscle from its
origin and carefully mobilizing the vascular pedicle. The gastrocnemius muscle, for example, will reach farther around the
knee or above the knee when this technique is used. Type II
JUNE CPS 17

blood supply muscles with a single dominant vessel and one or

more secondary vascular pedicles are most safely transferred,
with the dominant vessel being the point of rotation. If the dominant vessel is divided and the muscle is rotated on its distal
vascular supply, significant
muscle necrosis may occur. This
method is less reliable but occasionally useful-for
example, a
vastus lateralis muscle flap based on its distal blood supply may
be used for knee coverage, and a soleus muscle flap based on the
posterior tibia1 artery may be used for distal tibia1 coverage.
Functional
Considerations
It is important
to understand
the functional
loss incurred
when a muscle is chosen for a rotation flap. Frequently
more
than one muscle contributes to a given motion. For example, the
soleus and gastrocnemius
muscles both contribute
to plantar
flexion, and the use of either for soft tissue coverage does not
result in a functional
deficit. The use of both, however, would
result in inability
to flex the foot in a plantar direction and
would not be suitable for reconstruction.
When a muscle has a
special function, as in the case of the tibialis anterior, and its
use for reconstruction
is indicated, the muscle belly may be dissected away from the tendon to the musculotendinous
insertion
and rotated to cover the defect. In this manner the integrity of
the muscle tendon unit is preserved. Additionally,
a larger muscle such as the soleus may be split and only a portion of it used
to cover the defect, leaving the remaining
muscle functionally
intact.24
Muscle Flaps
When muscle flaps are used for soft tissue coverage along with
split-thickness
skin grafting,
some muscle atrophy may be expected, due to muscle denervation
and division of insertion and/
or origin. Flaps that are initially
bulky at the time of reconstruction ultimately
settle into an acceptable contour over the
injured tibia and malleolar areas. Latissimus
and gracilis free
flaps, for example, show a 30%~50% decrease from the initial
flap thickness. Skin grafts placed directly over muscle have been
shown to be quite durable in the lower extremity.25 We and others have found this to be an acceptable method of coverage over
non-weight-bearing
areas, with long-term durability.
This technique is especially useful in extensive defects where the harvesting of a skin flap of necessary dimension would create an
unacceptable donor site deformity.
Occasionally it is possible to use local muscle flaps for soft
tissue coverage and preserve their function aa well. With the
nerve supply to the muscle preserved and its tendon reattached
in a new location, the muscle will continue to function, providing its length has been maintained.
The vastus medialis muscle
may be rotated anteriorly
for coverage of defects about the su18 JUNE CPS

perior portion of the knee, and the tendon may be reattached to

the patella tendon for preservation
of terminal knee extension.26
MUSCULOCUTANEOUS FLAPS
The principles of the musculocutaneous
flap were developed b&
McGraw and Dibbell
from work that dates back to Manchot.
They recognized the importance
of perforating
blood vessels
from underlying
muscle as a principal means of blood supply to
the overlying skin. There are, of course, other routes by which
blood vessels enter the skin, including the direct cutaneous arteries and fasciocutaneous
arteries; these routes will be described in greater detail later. From experimental
injections in
human cadavers and extensive clinical use, the vascular territories of underlying
muscles have been well described.20, 22 Musculocutaneous
units in the upper thigh include the rectus femoris muscle and the skin overlying the anterior portion of the
thigh,28 the tensor fascia lata muscle, including a long fasciocutaneous extension covering the anterior lateral thigh, and the
gracilis muscle with the skin overlying the proximal muscle.22
These muscles will safely supply the overlying skin when they
are transferred
for reconstructive
purposes. Below the knee the
most useful myocutaneous
flap is the medial and lateral gastrocnemius musculocutaneous
flap. The skin overlying the medial
and lateral aspect of the calf may be elevated based on the perforating
vessels through
the gastrocnemius
muscle.30 31 Frequently the skin territory
extends beyond the muscle itself to a
variable degree. This area is considered to be the random skin
territory of the musculocutaneous
flap. These flaps share certain
advantages over underlying
muscle flaps alone. They include an
extended
territory
for greater
coverage, and a potentially
greater durability
and, in certain circumstances,
sensibility
(e.g., the tensor fascia lata musculocutaneous
flap). A potential
disadvantage
with the use of these flaps is that often skin grafts
are required on the donor sites, leaving a less than acceptable
donor site deformity. The skin and subcutaneous tissues do not
undergo atrophy as do muscle tissues with split-thickness
skin
grafts. In such areas as the ankle and distal third of the tibia,
the use of musculocutaneous
flaps require secondary defatting
procedures for an acceptable contour.
FASCIOCUTANEOUS FLAPS
As our understanding
of the blood supply to the skin has increased, a wide variety of flaps have been developed, based on
this new information.3
33 Flaps based on blood vessels emerging
from between muscles giving circulation
to the overlying subcutaneous tissue and skin have recently been developed on the
JUNE CPS 19

medial and lateral thigh.34 The skin of the medial aspect of the
knee, based on the sural artery,35 is another example. This flap,
however, has not found wide acceptance owing to significant donor site deformity. Finally, the skin on the posterior calf, also
supplied as a musculocutaneous
flap, may be elevated on a fasciocutaneous vessel emerging from between the two heads of the
gastrocnemius muscle.36 The success of many of our reconstructive efforts has probably been due to the redundancy in blood
supply of the skin envelope. As our study of these flaps progresses, new methods of transferring
tissue will be developed.
FREE TISSUE TRANSFERS
Free tissue transfers are indicated when local flaps are unavailable or additional specialized reconstructive
procedures are
required, such as bone reconstruction
and transfer of composite
tissues. Free flaps have wide application in a variety of reconstructive problems and have been shown to significantly
shorten
hospitalization
and reduce the number of operative procedures
required as compared to conventional
techniques in the lower
extremity.37* 38 For problems of soft tissue coverage, these include the use of muscle flaps alone with split-thickness
skin
grafts, musculocutaneous
flaps, and free skin flaps.
Evaluation of Recipient Vessels
Successful reconstruction
using free tissue transfers requires
healthy recipient arteries and veins for microvascular
anastomoses. A thorough evaluation of the vascular system must be
carried out before such procedures are undertaken.
Initial evaluation includes palpation of the dorsalis pedis, posterior tibial,
and popliteal pulses. Doppler ultrasound imaging may aid in determining the suitability of these vessels for free tissue transfer,
particularly
in obese individuals.
At the ankle, the dorsalis
pedis and posterior pulses should be palpable; if they are not,
the vasculature will probably be inadequate. Since the dorsalis
pedis artery may be reconstituted
by collateral circulation from
the posterior tibia1 and peroneal vessels and vice versa, arteriography is performed with the use of intra-arterial
vasodilating
agents prior to using these vessels. In the severely traumatized
extremity major distal vessels may be injured, and circulation to
the foot may depend on a single vessel. Knowledge of this situation will prevent the sacrifice of that vessel and influence the
selection of an end-to-side vascular anastomosis.3g 4o Flow studies in the extremity will also determine which of the patent vessels in the distal extremity has the greater flow and therefore
the least chance of intraoperative
complications.
The venous system must also be evaluated prior to the use of
free tissue transfers. Venography has been helpful in identifying
20 JUNE CPS

unsuspected deep vein thrombosis which may occur in both the

acute and the chronic posttraumatic
situation. In long-standing
deep vein thrombosis, lower leg edema is generally observed and
the superficial venous system would be chosen as a recipient
vein for transferred
tissues. Impedence plethysmography
is useful in identifying
this condition. Finally, intraoperative
evaluation of the vessels must show them to be free of fibrosis and
scarring. Vessels encased in fibrotic tissues frequently
undergo
severe irreversible
vasospasm when dissection of the vessels is
carried out. This situation can be avoided by more proximal dis-

section of the vessels in healthy

uninjured

tissues. An alterna-

tive strategy is to use a flap with a long vascular pedicle, such

as the latissmus dorsi flap, in order to place the vascular anastomoses in the popliteal fossa, where vasospasm is less of a problem.
Flap Selection
To meet the requirements
for soft tissue coverage in lower extremity defects, the appropriate
flap must be selected. Large defects requiring
substantial
bulk may be treated successfully
with the latissimus dorsi myocutaneous
flap, the scapular flap,

the tensor fascia lata flap, and the groin flap. Each of these flaps
has specific advantages

and disadvantages.

Smaller

defects are

best treated with a gracilis muscle or musculocutaneous

flap, an

internal oblique muscle flap, or a rectus abdominis muscle flap.

When used with a split-thickness
skin graft, these muscles atro-

phy to give the most acceptable

contour for distal third defects.

Planning and Execution of Free Tissue Transfers in the Lower

Extremity
The success of free tissue reconstruction
requires an orderly,
planned approach to the recipient vessel dissection and flap dis-

section, with planned

alternatives

should conditions

prevent

use

of the first selection. Both the surgeon and the patient should be
prepared for the use of alternative
flaps or vein grafts for extending vascular pedicles, should this become necessary. When
possible, two teams simultaneously
dissect the recipient vessels

and the flap. It is our practice

initially

to identify

the recipient

vascular bundle before the flap dissection and decide whether it

is an acceptable vessel for free tissue transfer. Further preparation of the vascular pedicle with meticulous dissection of the ar-

tery and vein is performed

while the second team is raising

the

flap. Once recipient vessels are adequately prepared, the wound

is temporarily
closed with skin clips after the vessels are bathed
in a solution of 2% lidocaine to relieve vasospasm. After the flap
is isolated on its vascular pedicle, the flap is allowed to perfuse
for 20 minutes prior to division of the vessels. If there is any

question
sutured

about the viability

of the flap at this time, it may be

back into place and the wound temporarily

closed until
JUNE CPS 21

the flap may be safely transferred.

At each step along this path
a planned retreat is still possible.
When it is clear that the flap is well perfused on its vascular
pedicle, the defect in the lower extremity is thoroughly
debrided
of all marginally
viable tissue in preparation
for the transfer of
the flap. This is the point of no return. The vascular pedicle of
the flap is then divided and the flap transferred
into the defect.
The second team closes the donor site while the first team insets
the flap, ensuring adequate vessel length and positioning before
the microvascular
anastomoses are begun. If vein grafts are required to extend the vascular pedicle, anastomosis of the vein
graft to the flap vessels may be carried out prior to insetting the
flap or passing the vascular pedicle beneath skin bridges.
Finally, the vascular anastomoses are performed.
Conservation of major vessels of the lower extremity is an essential part
of the planning in microvascular
procedures.40 The end-to-side
anastomosis is routinely chosen for arterial anastomosis into the
anterior tibia1 and posterior tibia1 vessels. This maintains
optimal blood flow to the remainder
of the lower extremity. Venous
anastomoses are generally
performed
end to end. In selected
cases the superficial veins, such as the greater or lesser saphenous vein, may be utilized when deep vein thrombosis is suspected. To ensure proximal patency, gentle irrigation of the vein
is performed prior to vascular anastomosis. Recent evidence suggests that end-to-side venous anastomoses may be preferable in
preventing
venous thrombosis at the anastomotic site.41
Postoperative Care of Patients Undergoing Free Tissue
Transfers
Unlike muscle flaps and skin grafts in the lower extremity,
free tissue transfers require hour-by-hour
observation
in the
first 5 postoperative
days to detect vascular thromboses. Thrombosis in the flap vessels means certain flap necrosis unless immediate measures are taken to correct the problem. The monitoring of microvascular
free tissue transfers is primarily carried
out by the surgeon and specially trained nursing personnel.
Changes in the appearance of the flap with regard to capillary
refill and color are extremely important
signs of partial or complete vascular occlusion. An additional clinical sign is the color
of bleeding from a small wound made by a No. 11 blade scalpel.
Recently developed monitoring
techniques such as surface temperature monitoring,
transcutaneous
Po2 sensors, plethysmography, and quantitative
IV fluorescein analysis are useful in
monitoring
the flap postoperatively.41-44
Each of these methods
indirectly measures the circulation at the anastomotic site. More
direct monitoring
of the flap vessels, both artery and vein, by
pulsed Doppler ultrasound,
currently under investigation,
may
ultimately
prove to be the optimal method.45
22 JUNE CPS

Pharmacologic
Manipulations
and Free Tissue Transfers
The essential ingredient
of successful free tissue transfers is
the technically
perfect anastomosis.
The skill is developed
through
progressive
laboratory
exercises in animal models.
Careful attention
to selection of recipient vessels, prevention of
vasospasm, and meticulous
surgical technique
will assure a
thrombosis-free
anastomosis. In most cases vascular thrombosis
is the result of technical errors due to inadequate
resection of
the injured vessel segment, preexisting
vascular disease resulting in elevation of an intimal flap, or improper placement of sutures. Despite the best of technique,
occasionally
vascular
thromboses continue to occur. Low-dose aspirin given as a 5grain rectal suppository at the beginning
of the operation and
continued on an alternate-day
basis is the only prophylactic
antiplatelet
medication
employed in our free tissue transfers.
There is no general agreement as to the appropriate
dose of aspirin to give for this purpose. Experimental
evidence suggests
that doses in the range of 1.7 mg/kg inhibit platelet aggegation
without
depressing prostacycline
on the vessel wall.
Higher
doses inhibit both prostacycline and thromboxane.
To date there
is no conclusive experimental
evidence that the routine use of
antithrombotic
medication is beneficial.47 When platelet thrombi
are seen to occur intraoperatively,
however, a full anticoagulant
dose of heparin is given IV.48 Reoperation for thrombosed vessels
is also managed by heparinizing
the patient following exploration and repair of the thrombosed vessels. Continuous
IV heparin at the rate of 1,000 units/hour
in a 70-kg adult is carried out
for 5 days and the dose tapered over a 2-day period.
Postoperative
elevation is maintained
for 7 days, after which
time gradual, progressive leg dependency is allowed. The flap
must be monitored carefully for signs of venous congestion during this period. When ambulation
is finally permitted,
gentle
support with stockings or ace bandages is maintained
for 6-12
weeks postoperatively.
SOFT TISSUE

COVERAGE

OF DEFECTS ABOUT

THE KNEE

Exposure of the knee joint and patella as a result of trauma

or wound complications
following prosthetic knee replacement
requires flap closure for the preservation
of knee motion. Occasionally reconstruction
of the extensor mechanism or ligaments
that provide medial and lateral knee stability will depend on
adequate soft tissue coverage. Requirements
of tissue in this
area are that it be supple, allowing full range of motion, and be
able to withstand
the pressure from underlying
structures as
well as external pressure during routine activities. In general,
muscle flaps with skin grafts and cutaneous flaps satisfy these
requirements.
JUNE CPS 23

For coverage of smaller defects in the suprapatellar

,region
when the rectus femoris muscle and its attachment
to the patella have been destroyed, the vastus medialis muscle, based on
its proximal blood supply, may be rotated to the defect and covered with a split-thickness
skin graft. The tendinous
attachments to the medial aspect of the extensor mechanism of the
knee may be rotated and reattached
in the central portion,
thereby functionally
reconstructing
the extensor mechanism.26
SOFT TISSUE COVERAGE OF THE KNEE
For coverage of soft tissue defects about the knee, the gastrocnemius muscle is the most versatile reconstructive
unit in the
region. 30731, 4g-51 The medial and lateral heads may be used independently,
based on their respective sural arteries, for limited
coverage of the anteromedial
aspect or anterolateral
aspect of
the knee. For more extensive defects, the medial head of the
gastrocnemius
muscle is used as the vascular basis for the extended myofascial flap, including the skin to within 5 cm of the
medial malleolus. This flap is useful for covering extensive defects of the knee extending
to the lateral aspect. Finally, this
flap may be developed as a fasciocutaneous
flap only, based on
the perforating
vessels of the gastrocnemius
muscle for a crossleg flap. A thorough knowledge of the vascular anatomy, the arc
of rotation, and the extent of coverage of this flap is mandatory
in planning a successful operation.
MEDIAL GASTROCNEMIUS MUSCLE FLAP AND SKIN GRAFT
Indications for this flap are soft tissue defects about the knee
and anterior tibia in the proximal one third. Coverage of anteromedial knee defects with the muscle flap and skin graft is
achieved with primary donor site closure and minimal flap bulk.
Before this flap is selected, an intact proximal blood supply must
be verified. A midline posterior incision is made and the gastrocnemius muscle is split in its medial raphe. Medial and lateral
sural arteries enter the respective medial and lateral heads of
the gastrocnemius
proximally
near their origin on the femoral
condyles. Unless excessive mobilization
of this muscle is necessary, these vessels should not be approached.
The muscle is
bluntly dissected from the underlying
soleus muscle and then
sharply divided at its insertion in the Achilles tendon. An extension of the anterior wound will allow full mobilization
of the
muscle belly and rotation of the muscle into the defect. For more
extensive defects the origin of the muscle may be divided from
the femoral condyle, with care taken to preserve the vascular
pedicle. Approximately
3 cm more may be gained by this maneuver. The myofascia on the underside of the muscle may be
24 JUNE CPS

Fig 3.-Medial
gastrocnemius
muscle
alone on its proximal
vascular
pedicle
third of the tibia. A meshed
split-thickness

flap. The gastrocnemius

muscle
is elevated
and used to cover defects
of the proximal
skin graft is placed directly
on the muscle.

scored to allow further stretching of the muscle unit and direct

application of the highly vascular muscle to the underlying
defect. The muscle is sutured in place and the donor incision closed
over suction drains. A meshed split-thickness
skin graft is then
used to cover the muscle (Figs 3 and 4).

USE OFTHE LATERAL HEAD OFTHE GASTROCNEMIUS

The lateral head of the gastrocnemius
muscle may be used for
coverage of lateral and anterolateral
defects of the tibia and
knee joint. The muscle is 2-3 cm shorter than the medial head
and, as a result, has a more limited arc of rotation. Dissection
and elevation are performed in a manner similar to that for the
medial gastrocnemius,
with care taken to avoid the common peroneal nerve in the region of the fibular head. Again, additional
pedicle length may be obtained by detaching the muscle origin
from the lateral femoral condyle, carefully preserving the lateral
sural artery.
JUNE CPS 25

Fig 4.-A
medial gastrocnemius
muscle
flap used to treat chronic
osteomyelitis
of the proximal
third of the tibia of 10 years duration.
A, chronic
osteomyelitic
cavity.
B, muscle flap elevated.
C, closure
of the wound prior to split-thickness
skin grafting.
D, final result at 1 year.

GASTROCNEMIUS MUSCULOCUTANEOUS FLAP

The medial gastrocnemius musculocutaneous

flap is indicated
for soft tissue defects over the middle third of the tibia and for
extensive defects about the knee. Since a skin graft is required
at the donor site, there is a significant cosmetic deformity. The
flap extends from the midline posteriorly to within 2 cm of the
anterior tibia1 crest. Its maximum length is to within 5 cm of
the medial malleolus. The flap is elevated by including the underlying fascia to the level of the gastrocnemius muscle. This is
necessary because the blood supply to the skin is from fasciocutaneous vessels derived from the last perforating vessel through
the gastrocnemius muscle. Once the skin flap is elevated to the
edge of the gastrocnemius,
the skin-muscle unit is elevated as
previously described for elevation of the muscle alone. The muscle is mobilized until coverage of the defect is achieved, and the
donor site is closed with a split-thickness
skin graft (Fig 5). The
lateral head of the gastrocnemius muscle may also be used as a
musculocutaneous
flap. Its skin territory
extends to within 10
cm of the lateral malleolus and therefore is somewhat limited in
its arc of rotation compared to the medial flap (Fig 6).
Several additional
maneuvers are available to increase the
usefulness of the gastrocnemius muscles for coverage of knee defects. These include division of the origin of the muscle and mobilization of the vascular pedicle to allow more proximal exten26 JUNE CPS

Fig S-Medial
gastrocnemius
musculocutaneous
flap. The flap may be elevated
to within 5 cm of the medial malleolus.
The gastrocnemius
muscle
is included
with
the flap and provides
perforating
vessels
that connect
with the fascial extension.
A
skin grafl is necessary
for closure
of the donor site.

sion

of

the

muscle,

splitting

the

muscle

longitudinally

and

placing portions of the muscle within small osseous defects or

marrow cavity defects, and advancing the gastrocnemius
muscle
and overlying skin as a V-Y advancement
flap to cover belowknee amputation
stumps (Fig 7).30

THE TURN-DOWN VASTUS LATERALIS FLAP

The vastus lateralis muscle, based on a distal blood supply,
may be turned down to cover lateral defects of the knee in its
superior portion. Because the major blood supply to this muscle
is the descending branch of the lateral femoral circumflex artery, the most proximal portion of this muscle is subject to necrosis when the muscle is based on its more tenuous distal blood
supply. Nevertheless,
the muscle regularly covers the superior
lateral portion of the knee when the more reliable gastrocnemius muscle flap is unavailable
(Fig 8). A longitudinal
incision
is made over the anterior aspect of the upper thigh and the tensor fascia lata is divided. The vastus is mobilized with blunt and
JUNE

CPS 27

Fig B.-Lateral
gastrocnemius
musculocutaneous
flap. Because
of the shorter
length of the lateral head of the gastrocnemius
muscle,
the cutaneous
territory
of
this flap extends
only to within 10 cm of the lateral malleolus.
It is useful for coverage
of defects
in the proximal
and middle thirds of the tibia. The donor site requires
splitthickness
skin grafting.

sharp dissection. Sharp dissection is required to divide it from

the attachments to the femur and the rectus femoris muscle. The
muscle must be left attached in its distal one-fourth to prevent
disruption of the branches of the lateral geniculate artery entering the muscle in its distal insertion. The proximal vascular
pedicle and muscular origin attachments
are then divided and
the muscle is rotated into the defect. It is our practice to delay
split-thickness
skin grafting until the partial muscle necrosis,
frequently observed, is resolved and healthy underlying tissue
remains (Fig 9).
FREE TISSUE TRANSFERS
Free tissue transfers have added a dimension to soft tissue
coverage of defects about the knee. These techniques are indicated when local muscle flaps are unavailable, for example when
a popliteal artery injury precludes the use of the gastrocnemius.
They are also indicated when the soft tissue coverage required
is larger than local muscle flaps might provide for. The latissimus dorsi muscle, or musculocutaneous,
flap provides a large
area of soft tissue and a long vascular pedicle for easy passage
into the popliteal fossa. An additional potential use of the latis28 JUNE CPS

Fig 7.-Gastrocnemius
muscle
may be split longitudinally
and used to fill cavities
within the knee joint. A, Charcot
joint in a paraplegic
patient with septic arthritis
and
chronic
osteomyelitis.
B, medial head of the gastrocnemius
muscle
is split longitudinally.
C, after the knee joint has been thoroughly
debrided,
the muscle
is passed
through
the joint and covered
with a split-thickness
skin graft. D, final result at 6
weeks.
Long-term
healing of the wound resulted.

Fig E.-Turned-down
vastus
lateralis
supply to this muscle,
the lateral femoral
basing the muscle
on its distal secondary
arteries.

muscle
flap. The proximal
dominant
blood
circumflex
artery, must be sacrificed
when
blood supply,
branches
of the geniculate
JUNE CPS 29

Fig 9.-A
turned-down
vastus
lateralis
muscle
flap used for coverage
of lateral
defects
of the tibia. A, cornminuted
fracture
of the proximal
tibia with fixation
plate
exposed.
Cancellous
bone grafts
are packed
into the depth of the wound.
B, the
muscle
flap is left attached
in its distal one quarter
to ensure
its blood supply.
C,
fullness
in the lateral aspect of the knee at the muscle
pedicle requires
closure
with
a split-thickness
skin graft. D, result at 6 months
with primary
healing and a united
fracture.

simus is as an innervated muscle flap when medial knee stability is desired (Fig 10) or for dynamic reconstruction
of the quadriceps muscle (Fig 11). Alternatives
include the scapular flap or
groin flap, which can carry cutaneous flaps of large dimensions.
Vascular access for these procedures is generally from the
popliteal fossa. This necessitates a graft with a vascular pedicle
of adequate length to prevent kinking of the pedicle due to tension and still provide adequate coverage of the knee region.
SOFT TISSUE
STUMPS

COVERAGE

OF BELOW-KNEE

AMPUTATION

A recurrent problem in patients with below-knee amputations

is breakdown
of skin overlying the bone ends when soft tissue
padding is not adequate. Coverage of these defects presents a
considerable
problem, often challenging
the ingenuity
of the
30 JUNE CPS

Fig lo.-Innervated
latissimus
dorsi musculocutaneous
free flap for coverage
and
stability
of the knee. A, traumatic
injury of the leg and loss of stable soft tissue in
the medial and posterior
aspects
of the knee. B, latissimus
dorsi musculocutaneous
free flap used to provide
both soft tissue coverage
and innervated
muscle
stability
to the region.

surgeon. When shortening the bone is not a satisfactory option,

several others are available. These include turn-down
muscle
flaps from the thigh, V-Y advancement
of the remnant of the
gastrocnemius
muscles and overlying skin, free tissue transfers,
and cross-leg flaps. Each of these procedures may have particular indications in individual
patients.

The vastus

lateralis

muscle,

based on its precarious

distal

blood supply, is occasionally useful in covering below-knee amputation stumps, particularly

in the prepatellar
and lateral aspect. This muscle used in this fashion with overlying skin grafts

has proved to be durable

(Fig 12).

V-Y ADVANCEMENT OF THE GASTROCNEMIUS REMNANT

The proximal

portion

tached from its origins

of the gastrocnemius

on the femoral

muscle may be de-

condyles and the muscle

and overlying
skin advanced in a V-Y fashion.30 Use of this
technique allows advancement
of the full-thickness
muscle and
skin approximately
3 cm, with primary
closure of the distal
wound beyond the area of pressure, and V-Y closure of the donor
site in the popliteum.
Sensation to the skin is maintained
with
this procedure, which is a significant advantage. It is important
JUNE

CPS 31

Fig 11 .-innervated
latissimus
dorsi musculocutaneous
free flap.
matic osteomyelitis
of the femur with loss of rectus femoris
muscle.
provides
both coverage
and dynamic
extension
of the knee.

ascertain that the sural arteries,

tery, have not been damaged.

to

A, chronic
B, muscle

trauflap

branches of the popliteal

ar-

FREE TISSUE TRANSFERS

When local muscles are not available for distal coverage of the
amputation
stump, free tissue transfers have provided a reliable
method of obtaining adequate soft tissue coverage. The latissimus dorsi muscle, or musculocutaneous,
flap can provide stable

Fig 12.-Distally
based vastus
lateralis
muscle
used for coverage
of
below-knee
stump.
A, chronic
recurring
wound breakdown
on the
weight-bearing
surface
of the
amputation
stump.
B, flap, based on
its distal blood supply,
reaches
to the
tibia1 area. C, stable wound achieved
.-.:a. -2 --..-.--A-1:-^
32 JUNE CPS

Fig 13.-Latissimus
dorsi muscle
free flap used for coverage
of below-knee
amputation
stump.
A, exposed
tibia and chronic
nonhealing
wound
in a patient
with
bilateral
amputations.
B, healed
wound
with adequate
padding
over amputation
stump. The vascular
anastomoses
were performed
in the popliteal
fossa.

soft tissue coverage. The length of the vascular pedicle allows

vascular anastomoses to be created in the popliteal fossa. This
flap, however, does not provide cutaneous sensation, and patients must be diligent in preventing
pressure ulceration. The
tensor fascia lata flap, when used as a free flap, allows sensory
reinnervation,
utilizing the lateral femoral cutaneous nerve sutured to the saphenous nerve.52 Free tissue transfers may be indicated in patients with bilateral
leg amputations,
in whom
cross-leg flaps would be unavailable and local muscle flaps unreliable (Fig 13).
USE OF CROSS-LEG FLAPS

Finally, the medial gastrocnemius

fasciocutaneous
flap may
be utilized as a cross-leg flap for below-knee amputation
stump
coverage in situations where free tissue transfers are not possible and local muscles are damaged. As in other applications of
the cross-leg flap, this requires a 3-week period of flap attachment to the stump followed by careful flap pedicle division. In
lower extremity wounds with poor vascularity, cross-leg flaps do
not allow improved nutrition to the area and do not provide cutaneous sensibility. Nevertheless, they may be useful in selected
patients.
SOFT TISSUE

COVERAGE

OF TIBIAL

DEFECTS

Soft tissue coverage of the lower leg may be conveniently

divided into three regions, the proximal third, the middle third,
and the distal third of the tibia. Local muscle flaps are useful for
coverage of proximal and middle third defects when their blood
supply is intact. Free tissue transfers are recommended for distal third defects.
JUNE

CPS 33

PROXIMALTHIRD

The gastrocnemius
muscle flap described above is the flap of
choice in the proximal third of the tibia. When it is covered with
a split-thickness skin graft the muscle provides a minimal donor
site defect. The medial head of the gastrocnemius
has a longer
muscle belly than the lateral head; however, both will cover defects of the anterior tibia. For lateral proximal tibia1 defects, the
lateral head of the gastrocnemius
muscle is chosen (see Fig 5).
The soleus muscle, discussed below, will also reach the proximal
third of the tibia. However, this is a second choice.
MIDDLE THIRD
The Soleus Muscle

The soleus muscle is most useful for covering soft tissue defects in the middle third of the tibia. It is a broad muscle which
extends from the popliteal fossa to the Achilles tendon in the

. proximd b&d
sup & peroned

arPery

Fig 14.-Vascular
supply of the soleus
OOmes from branches
on either its proximal
34 JUNE CPS

anatomy
of the soleus
muscle.
The proximal
dominant
blood
muscle
is the peroneal
artery. A secondary
distal blood supply
of the posterior
tibia1 artery. The muscle
may be transferred
or its distal blood supply.

posterior calf and lies immediately

beneath the gastrocnemius
muscles. Its blood supply comes from branches of the peroneal
artery in its proximal portion and the posterior tibia1 artery in
its distal portion (Fig 14). When based proximally,
the distal
vascular pedicles must be divided prior to rotating the muscle
for coverage of the middle third of the tibia. Following rotation
and inset, it is covered with a split-thickness
skin graft. The
muscle will cover the middle third of the tibia, and with more
extensive dissection, the proximal third (Fig 15). The primary
advantage of using this muscle is that its use does not cause a
significant contour deformity such as may occur when the gastrocnemius muscle is employed. Also, because of its rich vascular supply the muscle is frequently available for transfer in the
injured extremity. The muscle is best approached from the medial aspect of the leg through an incision from the medial condyle of the tibia to just above the medial malleolus. The muscle
is identified immediately
beneath the gastrocnemius muscle. In
the proximal third of the leg, there is an avascular plane separating the gastrocnemius
from the soleus. In the distal portion
of the leg, however, these muscles fuse to form the Achilles tendon. Additionally,
the deep surface of the soleus muscle must be
sharply divided from the flexor digitorum muscle in the middle
third of the leg. The minor vascular pedicles arising from the
peroneal artery are divided only to the point at which the muscle can be rotated into the defect. If a small area is to be covered,
the soleus muscle may be split longitudinally
in the midcalf and
only a portion of the muscle transferred
(Fig 16). In larger defects, the entire soleus muscle may be used. The muscle is skin

Fig 15.-Cadaver
dissection
of the
soleus muscle.
A, the muscle flap is
raised, based on the proximal
peroneal
artery. One may elevate
only the lateral
or the medial half of the muscle.
8, arc
of rotation
includes
the region of the
patella. C, distal arc of rotation
includes
AL- -:

JUNE

CPS 35

Fig 16.-Left,
soleus muscle flap used for coverage of exposed tibia1 fracture
(middle third of tibia). Right, use of the soleus muscle and a split-thickness skin
graft over a midtibial fracture.

grafted primarily and the donor site is closed over suction drain
catheters. If the lateral aspect of the tibia requires coverage, a
lateral approach to the soleus muscle may be made. The interposed fibula makes difficult the visualization
of the minor pedicles, which must be divided and ligated to assure adequate mobilization of the muscle and good hemostasis.
The second choice for coverage of soft tissue defects in the
middle third of the tibia is a gastrocnemius musculocutaneous
flap. An extended skin flap based on the medial gastrocnemius

Fig 17.-Medial gastrocnemius musculocutaneous flap for coverage of the middle

third of the tibia. A, open wound of the middle third of the tibia. 6, rotation of the
gastrocnemius musculocutaneous flap. The donor site requires a split-thickness skin
graft.
36 JUNE CPS

muscle can be elevated

to within

This provides

soft tissue coverage in the middle third

excellent

5 cm of the medial

of the tibia but requires

nor defect (Fig 17).

split-thickness

Use of the Gastrocnemius

Myofascial

malleolus.

skin grafting
Flap

in the do-

as a Bipedicled

Flap

Bipedicled
gastrocnemius
musculocutaneous
flaps may be
used to cover defects of the anterior tibia in the middle and distal thirds.53 Keeping intact the distal attachment above the malleolus increases the blood supply to the fascial extension. This
attachment
limits the amount of flap mobility, however. The bi-

pedicled flap is elevated by making

a midline

posterior

incision

and splitting the raphe between the two heads of the gastrocnemius muscle. The incision is carried to within 2 cm of the malleolus. The medial or lateral head of the gastrocnemius
muscle

is separated

from the underlying

with the skin and subcutaneous

soleus muscle

and elevated

tissue along with

the underly-

ing fascia. Care is taken to preserve the posterior

vascular

bundle

as well as the short saphenous

nerve. A back cut is required

to achieve

adequate

rotation.

donor defect. In our opinion,

ther wound

healing

distally

tibia1 neurovein and sural

just above the malleolus

Skin grafts

are required

for the

these flaps risk the creation

problems

in an already

of fur-

compromised

area,

particularly
for the distal third of the tibia, and instead we prefer free tissue transfers.
In addition to the soleus muscle and the gastrocnemius musculocutaneous flap, smaller muscles may be useful in augmenting soft tissue coverage in the distal portion

The tibialis

anterior

based proximally

covering

larger

of the middle third.

muscle and the extensor digitorum

may be combined

muscle

with the soleus muscles for

defects. When using these muscles it is possible

to preserve their

function

belly from the tendon.

by separating

Caution

a portion

of the muscle

must be exercized

these muscles in the traumatized

tenuous blood supply (type IV),
quently leads to muscle necrosis.

extremity.
extensive

in selecting

Because of their
mobilization
fre-

DISTALTHIRD

The distal

third

of the tibia

presents

a difficult

the use of local muscle flaps. In this region,

flexors of the foot have largely

little

become tendinous

muscle useful for soft tissue coverage. Although

several muscles based on their segmental

problem

the extensors

for
and

and there is
the use of

distal blood supply has

been described, including the tibialis anterior, extensor digitorum longus,

and the soleus,
it must be emphasized that the

blood supply is marginal for survival of the muscle. Muscle necrosis occurs in a significant percentage of cases, rendering these
techniques

unreliable.56

Rotation

of distally

based muscle flaps

JUNE CPS 37

is contraindicated
in patients with severe local trauma to the
distal third of the leg and in patients with absent posterior tibia1
or anterior tibia1 pulses. When the proximal blood supply of
these muscles is ligated, the smaller secondary blood supply
must be adequate for survival of the muscle. Preoperative arteriography is recommended before the use of distally based muscle flaps. The technique of elevation of these muscles is similar
to that of proximally based muscles. The proximal portion of the
muscle is elevated and its major blood supply ligated. The
smaller, distal blood-supplying
vessels are ligated only as necessary to allow adequate rotation of the muscle flap.
The Distally

Based Soleus Muscle

The inferiorly
based soleus muscle derives its blood supply
from secondary segmental vessels that are branches of the posterior tibia1 artery. A muscle is exposed for incision over the
medial lateral border and is divided from the Achilles tendon
with sharp dissection. It is easily divided from the overlying gastrocnemius muscle. The distal vascular pedicles are seen approximately 12 cm from the medial malleolus and should be preserved if possible. The donor site is closed primarily
and the
muscle is skin grafted (Fig 18).55
Free Tissue Transfers

The use of free tissue transfers for distal third soft tissue coverage is particularly
appropriate for the reasons given in the
preceding paragraphs.
Because of the nature of severe local
trauma, distally based muscle flaps are generally unreliable.
Consequently we favor free tissue transfers as the primary mode
of therapy for these injuries.57
Indications

for Free Tissue Transfer

Open fractures of the distal tibia, exposure of the ankle joint,

and extensive soft tissue defects are indications for microvascu-

Fig 18.~-Distally
based soleus
muscle
flap for coverage
of defects
of the distal
third of the tibia. A, open wound of the tibia in the distal third. B, soleus muscle
has
been split and rotated
to cover the distal third. Use of this muscle
in a freshly traumatized
patient is risky because
of the precarious
nature
of the secondary
blood
supply.
38 JUNE CPS

lar free tissue transfer. The one-stage transfer of muscle on musculocutaneous

flaps has provided a reliable solution to these
problems. Muscle flaps and skin grafts provide the most desirable contour for both large and small defects. A meshed skin
graft is placed immediately
over the muscle, and with subsequent shrinkage of the muscle an acceptable contour is obtained 25, 58 A large skin island may be included for larger defects or when greater bulk is required. Advantages
of the
latissimus flap are that one can cover a distal third of the extremity defect and place the microvascular
anastomosis in the
popliteal artery well out of the zone of injury.5g Larger vessels
are not as prone to spasm as are the more distal anterior and
posterior tibia1 vessels. This has been a useful technique in our
hands. The dissection is rapid and the vessels are extremely accessible. In such cases we have been able to obtain a latissimus
flap with pedicle lengths of up to 35 cm (Fig 19).
For smaller defects, the gracilis muscle, or musculocutaneous,
flap, based on the medial femoral circumflex artery, is both convenient and reliable.20 The muscle is located in the medial thigh
between the sartorius and the vastus medialis. It originates on

Fig lg.-Use
of the latissimus
dorsi musculocutaneous
flap for coverage
fects of the distal third of the tibia. A, chronically
infected
nonunion
in the distal
Local blood vessels
were unsatisfactory
for vascular
anastomosis.
B, design
latissimus
flap based
low in the back, allowing
vascular
pedicles
up to 30
length.
C, Healed wound.
The vascular
anastomosis
was constructed
at the
cation of the popliteal
artery and vein.
JUNE CPS

of dethird.
of the
cm in
trifur39

the pubis and inserts on the medial tibia1 tubercle. The vascular
pedicle enters the muscle approximately
10 cm distal to the pubic tubercle. Its length is approximately
6-7 cm, with an arterial diameter of 1.5-2.0 mm. The flap may be used as muscle
alone with skin graft, or the skin island over the proximal half
may be safely included. For defects about the ankle and distal
tibia, muscle alone is preferred, as it gives the most acceptable
contour. The primary advantages of this muscle are its ease of
access in the supine patient, its convenient size for smaller defects, and the well-tolerated
donor scar on the medial thigh (Fig
20).
In addition to the gracilis muscle, the internal oblique and the
rectus abdominis are smaller muscles with dependable vascular
pedicles for use in the distal third of the lower extremity. The
internal oblique muscle, based on the deep circumflex iliac artery, is elevated through an extended herniorraphy
incision. The
vascular pedicle is 8-10 cm long and has an arterial diameter
of 1.5-2.0 mm. The muscle is flat and can be easily tailored to
fit difficult contours. Its primary indication is for surface defects
of the ankle. The donor scar is well hidden in brief underwear.
No patient in our experience has developed abdominal laxity
when this muscle flap has been used (Fig 21).60
The rectus abdominis muscle, based on the deep inferior epigastric artery, provides yet another useful muscle for coverage
in an extremity.
The vascular pedicle is very long (lo-12 cm)
and its external arterial diameter is 2-3 mm. The muscle is eas-

Fig 20.-The
gracilis
musculocutaneous
flap for small defects
of the distal tibia and ankle. A, open
wound following
comminuted
fracture
of
the distal tibia. 8, design of the gracilis
musculocutaneous
flap. The blood supply
is based on the medial circumflex
femoral
artery. The skin island is reliable only
over the proximal
third of the muscle.
C,
healed wound followkig
microsurgical
transfer.
Vessel anastomoses
were
constructed
in the posterior
tibia1 artery
and vein.
40 JUNE CPS

Fig 21 .-Internal
oblique muscle
free flap and skin graft for smaller
defects
about
the distal tibia and ankle. A, chronically
nonhealing
posttraumatic
wound of the distal
third of the tibia. 6, design
of the internal
oblique
muscle
free flap based on the
ascending
branch
of the deep circumflex
iliac artery. C, muscle flap elevated
on the
deep circumflex
iliac artery.
Note that the muscle
flap is centered
directly
over the
ascending
branch,
ensuring
complete
survival
of the muscle.
D, healed wound
at 1
year with acceptable
contour
of the distal third of the tibia.

ily dissected through a transverse suprapubic incision, is suited

for intermediate-sized
defects, and may be contoured
as
needed.61
With free tissue transfers, the appropriate tissue for the individual defect may be selected. These flaps are reliable in experienced hands, with a success rate of 95% or greaterIn
the distal third of the leg and foot, free tissue transfers are the resort
of choice and have largely replaced the older methods of tubed
pedicle flaps and cross-leg flaps.62
Cross-Leg Flap
The cross-leg flap may be useful in distal third coverage when
a free tissue transfer is not possible or has failed. The donor flap
must be skin grafted, as previously described. The gastrocnemius fasciocutaneous flap has provided a useful, reliable fasciocutaneous unit for use as a cross-leg flap when other methods
are not available. The advantages of this flap over the conventional cross-leg flap are that it does not require a preliminary
delay, and that because the gastrocnemius
muscle is not elevated in the procedure, it causes no impairment
of this muscle.
In the previously described musculocutaneous
flap, the distal
skin over the medial distal leg to within 5 cm of the medial
JUNE

CPS 41

Fig 22.-Gastrocnemius
musculocutaneous
flap used as an undelayed
cross-leg
flap. Inclusion
of the gastrocnemius
muscle
with its perforators
allows secure
elevation of the flap without
prior delay. The donor site requires
a split-thickness
skin
graft for closure.

malleolus is elevated in a subfascial plane. As one approaches

the border of the gastrocnemius muscle, a significant perforating
artery will be observed. This artery should be left intact and
marks the extent of the proximal dissection of the flap. The donor site is skin grafted and then the flap is set into the recipient
defect in the opposite leg (Fig 22). Division of the flap is begun
at 3 weeks by cross-clamping the vascular pedicle and injecting
fluorescein to ensure adequate vascularization
from the recipient bed. There is some concern that due to the axial-patterned
blood supply, a delay in revascularization
might occur in these
flaps. It is our preference to base the judgment for division of the
flap on the fluorescein test. If there is any question, a partial
transection of the pedicle is carried out and the procedure is repeated in 3-5 days (Fig 23). The Hoffman external fixation device is a useful adjunct for immobilizing
patients undergoing the
cross-leg flap procedure. It allows ease of access to flap dressings
and is more comfortable then the plaster and cross brace technique.57
RECONSTRUCTION
FOOT

OF SOFT TISSUE

DEFECTS ON THE

Reconstruction of soft tissue defects of the foot remains a complex and challenging problem despite the recent developments
42 JUNE CPS

Fig 23.-The
medial gastrocnemius
musculocutaneous cross-leg flap for
coverage of the middle and distal thirds
of the tibia. A, cross-leg flap can be
elevated
malleolus.

to within 5 cm of the medial

8, time of division of the

muscle pedicle is determined by use of

IV fluoroscein

dye.

The extent

of dye

penetration may be seen by the second

line drawn on the flap at 30 days. C,
complete

survival

of the cross-leg

flap

after division of the pedicle and insetting

in musculocutaneous
flap and free flap surgery. Defects of the
foot may be divided arbitrarily
into three geographic areas: the
dorsum of the foot, the medial and lateral malleoli,
and the
plantar, weight-bearing
surface. The etiology of soft tissue defects in the foot may also be divided into three general categories. Trauma is the most frequent cause and may range from
degloving injuries and burns to pressure ulcerations. In the second category, diminished
sensibility
of the plantar skin may
lead to the development
of a neurotrophic
ulcer in conditions
such as paraplegia, myelodysplasia,
and diabetes. Finally, inadequate blood flow to the foot due to peripheral vascular disease
may lead to the development
of ulcers around the malleoli and
on the plantar surface of the foot.
Plantar skin is a unique weight-bearing
surface. Eighty percent of the body weight is transmitted
through the skin overlying the calcaneus and 20% through the skin over the metatarsal
heads. The glabrous
epidermis
and dermis here are much
thicker than in other areas of the body, measuring up to 3.5 mm.
Strong vertical fibrous septa resist shearing forces and produce
a system of closed fat loculations which act as a shock absorber.
This unique anatomical
arrangement
makes it difficult to provide the same stability by any of the current forms of reconstruction. In other areas of the foot the skin is thinner and freely
mobile over underlying
bony and tendinous structures such as
the medial and lateral malleoli and the Achilles tendon. Reconstruction in these areas requires thin, conforming
tissue that
allows the use of conventional
footwear. Reconstruction
of planJUNE

CPS 43

tar tissues ideally should provide some degree of sensibility in

this area. Recent developments
in sensory free flaps have not
resolved the issue of whether sensation is indeed necessary. Additional considerations
in the choice of local tissues for reconstruction include the underlying pathologic process, particularly
in diabetes and atherosclerotic peripheral vascular disease, since
local flaps depend on an intact vasculature.
The various options available for reconstruction
of soft tissue
defects of the foot may be classified as follows:
Split-thickness
skin graft
Innervated skin graft66
Local muscle transposition flag
Flexor digitorum brevi&j7, 6
Abductor hallucis67
Abductor digiti minimi
Neurovascular pedicle musculocutaneous
flap70P7
Neurovascular pedicle fasciocutaneous flap
Medial and lateral plantar flap (instep flap)72-77
Calcaneal artery flap77
Lateral calcaneal flap7*, 7g
Neurovascular
island toe flapsoPs
Distant flap
Random cross-leg flap63
Cross-leg fasciocutaneous flap64
Cross-foot flap84* s5
Free flap
Free muscle flap with split-thickness
skin graft259 60, 61
Free innervated skin flap75, a>l, g2
RECONSTRUCTION OFTHE DOWUM OFTHE FOOT
Soft tissue defects of the dorsum of the foot may be divided
into those wounds in which there is still subcutaneous tissue
covering the extensor tendons and bony skeleton and those
wounds in which extensor tendon or bone are exposed. In the
first case, split-thickness
skin grafting is usually all that is required. If bone or tendon is exposed, a split-thickness
skin graft
may still be utilized after granulation
tissue has developed. If a
large area of bone or tendon remains exposed, flap coverage is
indicated. The conventional
fla coverage of the dorsum of the
foot has been the cross-leg flap. t3 This random pattern cross-leg
flap has been improved by Barclay et al.64 to include the deep
fascia, which protects the tenuous blood supply to the skin. This
design is the same as the fasciocutaneous gastrocnemius flap described in preceding sections. For coverage of large defects over
the dorsum of the foot, especially if there are areas of exposed
tarsal and metatarsal bone, small free muscle flaps have distinct
advantages over the cross-leg flaps. Among them are the short44 JUNE CPS

ened time of immobilization,

the ease of a one-stage procedure,
and a more aesthetic donor site. The gracilis, rectus abdominis,
and internal
oblique muscles covered by split-thickness
skin
grafts all provide acceptable contour for the dorsum of the foot.
These flaps are discussed in more detail in the section on free
tissue transfer in the lower third of the leg.
RECONSTRUCTION OF THE PLANTAR SURFACE OF THE FOOT
Split-thickness
skin grafts may be used initially in the treatment of traumatic
defects of the sole of the foot in an early attempt to provide a closed wound. They may also be the method

of choice where adequate

split-thickness

soft tissue padding

skin grafts

are usually

remains.

unstable

However,

over a long pe-

riod of time, and about 50% of cases may require further

structive

procedures.639 65 An

innervated,

recon-

full-thickness

skin

graft@j has been described for soft tissue coverage and sensation
for a defect of the heel. A full-thickness
skin flap is raised from
the skin territory
innervated
by the sural nerve and defatted,
with great care taken to preserve the branches of the sural
nerve, thereby converting it to an innervated full-thickness
skin

graft. However,
padding

this reconstruction

requires

sufficient

soft tissue

to allow take of the graft.

LOCAL MUSCLE FLAPS FOR RECONSTRUCTION OF THE HEEL AND

MALLEOLI

As has been mentioned

previously,

the skin and subcutaneous

foot precludes

the unique

easy rotation

or transposition

cover defects over the heel. Ger67 a popularized

position

architecture

tissue over the plantar

of

surface of the

of skin flaps to
the use of trans-

flaps of muscles covered by a split-thickness

skin graft

to reconstruct many of these defects. The abductor hallucis, abductor digiti minimi, and flexor digitorum
brevis are useful for
covering defects around the heel and malleoli
ANATOMY OF THE PLANTAR SURFACE OF THE FOOT
The abductor hallucis arises from the medial tubercle of the
calcaneus, flexor retinaculum,
and plantar aponeurosis and inserts into the base of the proximal phalanx of the big toe. It is
supplied in its proximal third by a branch from the medial plan-

tar artery

and medial plantar

nerve (Fig 24). The muscle may

be used to reconstruct defects on the medial aspect of the heel

up to the medial malleolus (Fig 25).
The abductor digiti minimi arises from the lateral process of
the calcaneal tuberosity and inserts into the lateral aspect of the
base of the proximal phalanx of the fifth toe. The muscle is supJUNE CPS 45

c&mea/ a & n.

Fig 24.-Anatomy

of the plantar

aspect

of the foot.

plied by a branch from the lateral plantar artery and nerve and
enters the muscle in its proximal third. Small defects of the posterolateral aspect of the heel and lateral malleolus may be covered with this muscle.
The flexor digitorum brevis originates from the medial tubercle of the calcaneus and inserts into the middle phalanges of the
second to fifth toes. The muscle lies deep to the plantar fascia
and is bordered medially and laterally by the abductor hallucis
and abductor digiti minimi muscles, respectively.
Vascular

Anatomy

The posterior tibia1 artery and posterior tibia1 nerve bifurcate

just beneath the medial malleolus to form the medial and lateral
plantar neurovascular
bundles. Both of these continue beneath
the origin of the abductor hallucis muscle. The medial plantar
artery and nerve then continue distally between the flexor digitorum brevis and the abductor hallucis muscles, giving off motor
branches to both of these muscles. The lateral plantar artery
passes from medial to lateral beneath the proximal third of the
flexor digitorum
brevis muscle and in this area provides the
main blood supply to this muscle. On the lateral aspect of the
foot the lateral plantar artery and the lateral plantar nerve pass
in a groove between the abductor digiti minimi and the flexor
46 JUNE CPS

Fig 25.-Use
of the abductor
hallucis
muscle
for coverage
of wounds
about the
medial malleolus.
A, chronic
wound of the dorsum
of the foot involving
the cuneiform
bones and first metatarsal.
B, abductor
hallucis
muscle
is divided from its tendinous
insertion
distally
and carefully
dissected
proximally
to allow adequate
transposition
into the defect.
Care is taken not to divide the proximal
blood supply.
C, donor size
is closed primarily
and the muscle is grafted with a meshed
split-thickness
skin graft.
D, final result. Wound
was healed on 3-month
follow-up.

digitorum brevis. At the level of the fifth metatarsal base, the

lateral plantar artery divides into a deep branch and a superficial branch. The superficial branch continues as the most lateral
digital plantar artery, while the deep branch passes medially to
form the deep plantar arch, giving off four plantar metatarsal
arteries. There is a communication
between the deep plantar
arch and the dorsalis pedis system on the dorsum of the foot
through
a perforating
artery that courses through the first
metatarsal space.
Flexor Digitorum Brevis Muscle and Musculocutaneous
Flaps
The flexor digitorum
brevis muscle provides the basis for a
variety of flaps useful in coverage of heel defects. It is exposed
through a midline plantar incision, with care taken that it is
not extended onto the metatarsal weight-bearing
surface. After
the incision is carried through the plantar fascia, the four distal
tendons are divided and the muscle is reflected posteriorly upon
itself. The muscle may be mobilized proximally to its neurovascular pedicle. With this degree of mobilization,
a defect on the
plantar surface of the heel may be easily covered.6s For more
proximal coverage of the insertion of the Achilles tendon, the
origin of the muscle must be divided from the calcaneus. Finally,
JUNE CPS 47

Fig P&-Flexor
digitorum
distally allows more proximal
tendon.

brevis muscle
flap. Division
of the lateral plantar artery
rotation
of the muscle
to cover the heel and Achilles

more extensive proximal mobilization

may be achieved by dividing the lateral plantar artery distally and elevating it in continuity with the overlying muscle.70 This allows coverage of the
posterior aspect of the heel, the lower Achilles tendon, and the
medial or lateral malleoli. It is imperative that the patency of
the dorsalis pedis system be confirmed preoperatively,
either by
Doppler examination
of angiography,
before ligation of the distal lateral plantar artery is considered. Consequently the flexor
digitorum brevis muscle may be used either as a muscle pedicle
flap or as a vascular island muscle flap. After transposition
of
the muscle into the defect, it is covered with a split-thickness
skin graft (Figs 26 and 27).
For coverage of very large defects of the weight-bearing
heel
in which subcutaneous padding and sensory innervation
are desired, use of the flexor digitorum brevis has been described7, 71
for a neurovascular island musculocutaneous
flap. A skin island
from the non-weight-bearing
area of the sole overlying the flexor
digitorum brevis muscle and innervated by a branch of the lateral plantar nerve is elevated in continuity with the flexor digitorum brevis muscle. The skin island must be designed on the
non-weight-bearing
surface of the foot, and care must be taken
to preserve the sensory branches to the overlying skin from the
lateral plantar nerve. The lateral plantar artery is divided distally and the muscle and overlying skin are elevated, as described previously for the flexor digitorum brevis muscle flap it48 JUNE CPS

self. Again, it is imperative that an intact dorsalis pedis arterial

system be verified preoperatively
(Fig 28).
Others have reported the use of this flexor digitorum
brevis
neurovascular
island musculocutaneous
flap for coverage of heel
defects in which both the lateral and medial plantar arteries
were ligated distally.72 Consequently
the vascular supply to the
distal foot and toes was provided only by the dorsalis pedis arterial system with its perforating
branch to the deep plantar
arch.
Reconstruction
of the Heel Using Instep Flaps
Reconstruction
of the heel has also been described utilizing
axial pattern
or island fasciocutaneous
flaps from the instep
area of the sole.73-77 The major difference between these instep
flaps and the flexor digitorum
brevis musculocutaneous
flap is
that they do not depend on the underlying
muscles for their vascular survival. Of greater importance,
these fasciocutaneous
instep island flaps are less bulky and may be transposed to cover
defects more conveniently
(Fig 29).
The instep island flap is elevated by making a transverse incision just proximal to the weight-bearing
area of the metatarsal
heads and identifying
the medial plantar neurovascular
bundle
between the abductor hallucis and flexor digitorum
brevis muscles. The distal medial plantar artery is divided, using the artery as the plane from which the flap is elevated, progressing
from its distal to the proximal portion. The medial plantar artery remains attached to the flap. The cutaneous fascicles are
peeled off the surface of the medial plantar nerve and kept with
JUNE CPS 49

Fig 28.-Flexor
digitorum
brevis musculocutaneous
flap depends
on the
plantar
artery. The blood supply
to the skin overlying
the flexor digitorum
muscle
is derived
from perforating
blood vessels
through
the plantar fascia.

lateral
brevis

the flap. At the point at which the medial plantar

artery
emerges from the lateral border of the abductor hallucis muscle
the remainder
of the flap is incised circumferentially
down to
and including the plantar fascia and elevated as a complete island flap in the plane between the plantar fascia and the muscles. Three reported patients all had protective sensation in the
transposed flap and were able to bear weight in shoes on the
reconstructed
flap.75
A prime advantage
of the instep fasciocutaneous
flap is its
size. A flap of skin measuring up to 6 by 5 cm is quite sufficient
to resurface the central weight-bearing
area of the heel. This
skin has a similar architecture
to heel and is more likely to
withstand
the shearing forces of weight-bearing.
The deep surface of the flap, the plantar fascia, may be applied directly to
bone and so increase its stability. The flap may be raised on the
medial plantar artery alone or may be used as a free flap. The
ability to transfer the instep skin as a free microvascular
flap
expands its scope so that it may be used to reconstruct defects
in which both the heel and the instep area have been lost, or in
cases where circulation
is inadequate
due to occlusion of either
the posterior tibia1 or dorsalis pedis arteries. Hyperkeratosis
has
50 JUNE CPS

f/exor

I >,\
i

Fig 29.4nstep
island flap. The blood supply
for this skin flap is derived
from
cutaneous
vessels
that arise from the medial plantar
artery.
The flexor digitorum
brevis muscle
does not need to be elevated
to provide
this vascular
supply.

been reported as a minor problem of the donor area. Possibly

this may be avoided by not extending the flap over the lateral
aspect of the sole of the foot, which is in fact a weight-bearing
surface of the foot and, when grafted, is more vulnerable to traumatic ulceration and hyperkeratosis.
Alternative Axial Pattern
Reconstruction

and Fasciocutaneous

Flaps for Heel

The heel pad proper derives its blood supply from the calcaneal artery, which arises near the origin of the lateral plantar
artery and pierces the flexor digitorum brevis muscle and plantar aponeurosis near their origin from the OS calcis.77 A suprafascial calcaneal flap based on this artery may be utilized to
cover small defects of the heel when elevated from the surface
of the OS calcis and rotated posteriorly (Figs 30 and 31). Alternatively,
the heel skin may be transposed posteriorly
as a
broadly based pedicle by making a fishmouth
incision and elevating the skin and subcutaneous tissues after dividing the origin of the plantar fascia and flexor digitorum
brevis muscle.
The entire proximal portion of the heel supplied by the calcaneal
artery can then be advanced posteriorly and can be combined
with mobilization
of the posterior skin overlying the Achilles
JUNE CPS

51

Fig 30.-Calcaneal
artery flap. The blood
direct cutaneous
artery, the calcaneal
artery.

tendon, which is advanced

advancing heel flap.

inferiorly

supply

for this

flap

like a visor

is derived

from

to meet the

Neurovascular
Island Pedicle Flaps for Reconstruction
of the
Plantar Surface of the Foot
Sensate island flaps from either the volar surface of the big
toe or fifth toe or from the toe web spaces may be transferred
to
cover small ulcers overlying the metatarsal
heads. These flaps
are based on the plantar digital vessels and nerves. For coverage
of larger defects, the toes may be filleted and the neurovascular
pedicles carefully
dissected
until
the desired mobility
is
achieved. When dissected to the plantar arch, these toe flaps
may reach the midplantar
re ion of the sole, and even as far
proximally as the heel pad.80- 8 These neurovascular
island pedicle flaps have been used in patients with diabetic neurotrophic
ulcers. Sensibility has been maintained
following the transfer of
the flap.s2, 83
Distant Flaps for Reconstruction
of the Plantar Surface of the
Foot
The various techniques for reconstruction
of the plantar surface of the foot so far described have all been local flaps. Because
of the extensive nature of these defects, especially those due to
trauma,
in particular
avulsion or degloving
injuries, distant
flaps are frequently required. Prior to the advent of microsurgical free tissue transfers, abdominal tubed pedicle flaps and crossleg and cross-foot flaps were the only techniques available for
52 JUNE CPS

Fig 31.-Use
of the calcaneal
artery
flap for posterior
advancement
and
closure
of a chronic
heel wound.
A
previously
placed dorsalis
pedis flap
has undergone
partial necrosis.
A,
design of the flap based on the
calcaneal
artery. B, posterior
rotation of
the calcaneal
tissue provided
secure
wound coverage.
C, despite
sensation
in the flap, additional
protection
of the
weight-bearing
tissues
is achieved
with
a custom-made
shoe.

providing large areas of skin and subcutaneous tissue for reconstruction. In an analysis of heel reconstruction,
Maisels63 analyzed 16 cases of heel construction
using distant cross-leg or
cross-thigh flaps. Distant flaps do not contain the fibrous elements binding the skin to the underlying
tissues, as in the normal sole, and shearing stresses may cause instability
of the flap
on the underlying
bony skeleton. Furthermore,
these flaps require care for many months postoperatively
as they tend to develop superficial ulceration before the later development of protective sensation. More recent improvements
in the cross-leg
flap reconstruction
of foot defects include the cross-leg fasciocutaneous flap.64 This incorporates
the deep fascia on the undersurface of the cross-leg and so protects its blood supply, allowing
a greater length-to-breadth
ratio. An additional variation of this
technique is the cross-foot flap, a flap of skin based on the medial
instep of the contralateral
foots4, 85 for coverage of defects of the
heel. This technique is prone to the complications of any distant
tissue pedicle transfer, but it conforms to the concept originally
put forward by Gillies that losses must be replaced in kind.
These techniques, however, do not improve the nutrition
of the
injured area and depend on healthy surrounding
tissue for survival of the flap.

FREE TISSUE TRANSFERSFORCOVERAGE OF DEFECTS OFTHE

PLANTAR SURFACE OFTHE FOOT
The success of microsurgical
free tissue transfers over the past
decade has stimulated
surgeons to utilize these techniques in
JUNE

CPS

53

the reconstruction
of extensive plantar defects, and to provide
sensibility
to this weight-bearing
surface. The free groin
flap=> 87 has been superseded by the more reliable musculocutaneous free flaps such as the latissimus dorsi5 and tensor fascia
lata.88 While these flaps provide excellent coverage of extensive
defects, they are often too bulky to allow the patient to wear
shoes. In addition, they do not attach firmly to underlying
bony
structures, which leads to instability
of the flap in relation to
the heel. It has been demonstrated
that free muscle flaps covered
with split-thickness
skin grafts can be more precisely contoured
to match foot defects and so allow the patient to use normal footwear. The latissimus dorsi muscle free flap25 is indicated for extensive defects on the plantar surface of the foot, whereas the
gracilis muscle, rectus abdominis muscle,61 and internal oblique
muscle6 may be used for reconstruction
of smaller defects on the
plantar surface of the foot. A free muscle flap covered by a splitthickness skin graft may better withstand weight-bearing
forces
because there are two shear planes between the skin graft and
the muscle and between the muscle and the bony skeleton. The
durability
of free muscle flaps covered by split-thickness
skin
grafts for plantar surface defects was investigated
in nine patients by detailed gait analysis.8g None of the patients had any
measurable cutaneous sensation in the skin graft, but four of the
patients reported deep pressure sensation. All patients were able
to walk in normal footwear, and gait analyses revealed that all
patients were putting as much weight on the reconstructed
region as on the corresponding area of the contralateral
foot. However, two patients have experienced some skin graft breakdown.
NEUROSENSORY FREE FLAPS FOR COVERAGE OF THE WEIGHTBEARING SURFACE OF THE FOOT
The ability to include a cutaneous nerve in a free tissue transfer has led many surgeons to advocate this technique for resurfacing plantar defects in an attempt to provide better return of
sensibility to this area. The free neurosensory
flaps that have
been described for this purpose are the tensor fascia lata free
flap,88 innervated
by the lateral femoral cutaneous nerve of the
thigh; the dorsalis pedis free flap,g0 innervated by the superficial
peroneal nerve and the deltoid free flap,g1 innervated by the lateral brachial cutaneous nerve. Compared with the other two
neurosensory free flaps, the tensor fascia lata free flap has the
advantage of providing a large area of skin for reconstruction.
Results of its use as a neurosensory free flap for restoration
of
sensibility on the weight-bearing
surface of the foot have been
less than optimal, the major complication
being persistent skin
ulceration.
The deltoid flap,g1 a free fasciocutaneous
neurosensory
flap
54 JUNE CPS

Fig 32.-The
deltoid
neurosensory
free skin flap for a chronic
heel wound.
A,
chronic
unstable
scar over the OS calcis.
B, deltoid neurosensory
free flap transferred to the heel. The branches
of the posterior
humeral
circumflex
nerve were
sutured
to the sural nerve. (Courtesy
of John Franklin,
M.D.)

based on the posterior circumflex humeral artery and innervated

by the lateral brachial cutaneous nerve, has also been used for
reconstruction
of the weight-bearing
plantar surface of the foot
(Fig 32). Breakdown of the flap has not been a problem, but adherence of the flap tissue to the underlying
bone of the foot does
not result, and consequently
the flap tends to slide laterally or
medially when weight is applied, giving the patient an unsteady
feeling. Barefooted patients bear minimal
weight on the flap,
but are able to bear weight when wearing shoes.
The role of sensibility
in these free tissue transfers in preventing ulceration
still remains controversial.
Despite the re-

turn

of sensibility

of these flaps, persistent

ulceration

has oc-

curred
over
the weight-bearing
areas
and occasionally
necessitated below-knee amputation.
Normal two-point discrimination in the heel is about 20 mm and is obviously of a different
magnitude
from that in the hand, suggesting that a high degree
of sophisticated
sensibility may not be required for function of
the foot. The unique architecture
of the skin and subcutaneous
tissues of the foot, by preventing
shear forces, may be equally as
important
in preventing
ulceration.
The remaining
enigma of
reconstructing
plantar defects with similar tissue and providing
sensibility is well illustrated
by the free instep flap described by

Morrison

et a1.75 Postoperatively

the patient

of the heel and was able to bear weight

breakdown

of the flap. However,

had stable coverage

without

any evidence of

even though

he was able to

localize touch, pain, and pressure all over the flap, two-point
crimination
remained unrecordable.

At this time, therefore,

it is not possible absolutely

dis-

to define

the best method of reconstruction

of the weight-bearing
surface
of the foot. Patient selection is ultimately
the most important
factor in whether the transferred
tissues will withstand
the repeated trauma of full weight-bearing.
Equally important
is the
postoperative
education of the patient to maintain
frequent observation of the reconstructed
foot and the use of custom-molded
JUNE CPS 55

shoes with impact-absorbing

inserts to prevent future repeated
ulceration.65 Our preference is to use an innervated
instep island flap for coverage of discrete defects of the heel and a carefully contoured free muscle flap covered by a thick split-thickness skin graft for more extensive reconstruction.
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