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Reconstructive Surgery - Lower Extremity Coverage

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Reconstructive Surgery - Lower Extremity Coverage

neligan plastic surgery 4th edition vol 4-5

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SECTION I • Lower Extremity Surgery

Reconstructive surgery: Lower

5
extremity coverage
Joon Pio Hong

tissue and bone defects. If the extremity cannot be salvaged,

SYNOPSIS
the next goal would be to maintain maximal functional length
with good soft-tissue coverage on the stump to bear the
■ Reconstructive surgery for the lower extremity has evolved from
prosthesis for functional gait.
staged approach to proving best solutions for functional and cosmetic
outcome.
Extremity salvage is a long and complex process for the
■ This chapter covers from the classical approach to the gradual change
medical professionals as well as patients. Patients and family
members must be educated and included in the decision-
towards the principle that advocates a one-stage elevator approach.
■ Special considerations are required to overcome the complexities of
making process and made aware of the expected prognosis.
Patient’s motivation and compliance along with family’s
lower extremity reconstruction, such as diabetes and chronic infection.
support will be critical during physical and psychological
■ Finally, introduction of perforator flaps, the use of multiple flaps by
recovery.
combination, and supermicrosurgery will help you design and widen
Although early amputation and prosthetic treatment was
the reconstructive choices for the lower extremity.
thought to offer the potential for faster recovery and lower
cost, recent reports have provided different views. A multi-
center, prospective, observational study to determine the
Access the Historical Perspective section online at functional outcome of 569 patients with severe leg injuries
http://www.expertconsult.com resulting in reconstruction or amputation has provided infor-
mation based on Sickness Impact Profile, a measure of self-
reported health status.1 Although reconstruction may be faced
with more challenging processes, the Lower Extremity Assess-
ment Project (LEAP) showed no significant difference in
Introduction outcome at 2 years. Costs following amputation and salvage
were also derived from data in a study that emerged from
Lower extremity reconstruction following severe trauma, LEAP concluding that amputation is more expensive than
cancer ablation, and chronic infections remains challenging. salvage and amputation yields fewer quality-adjusted life-
The involvement of multiple structures from bone, muscle, years than salvage.2 Other reports have shown similar find-
vessel, nerve, to skin makes it difficult to achieve the goals ings where projected lifetime healthcare costs for amputation
of lower extremity reconstruction where restoration of may be as high as three times.3,4
limb function, coverage for vital structures, and satisfactory Treatment of salvage evolves as with the coverage strategy.
appearance is achieved. But still this process can be long and complicated. Despite that
In the recent years, the management of the lower extremity normal function and appearance can be difficult to achieve,
has evolved with numerous new techniques and innovations it may be warranted to support successful reconstruction
and thus extremities are salvaged that would have been leading to successful salvage of the extremity.
amputated in the past. Introduction of vascularized bone
grafting, Ilizarov lengthening, bone matrix, and growth
factors to manage the bone defects along with new ideas for Principles
coverage like perforator flaps, propeller flaps, and negative
pressure therapy as well as increased knowledge for anatomy The primary goal of surgical reconstruction of the lower
have led to successful management of lower extremity soft extremity wound is to restore or maintain function. Function

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Historical perspectives 118.e1

on this principle, and advances made in the new millennium,

Historical perspectives treatment for infected wounds like osteomyelitis, complicated
wounds such as diabetic foot ulcers and ischemic limb, and
The early history of lower extremity reconstruction dates back large defects after cancer ablation now turns routinely to soft-
to Hippocrates (460–370 BC) and amputation and procedures tissue coverage using microsurgery. With respect to function,
trying to improve the success of amputation and survival free functioning muscle transfer using rectus femoris muscle
have been the main practice up to WWI.5 and gracilis muscle and composite free flaps such as dorsalis
Although the term flap originated in the 16th century from pedis with extensor tendons or fibula osteocutaneous flaps
the Dutch word flappe, meaning something hanging by one may achieve acceptable functional results in the extremity
side, and the concept dates back as far as 600 BC when Sush- with composite defects.12–15 Innervated flaps utilizing micro-
ruta Samhita described nasal reconstruction using a cheek surgical coaptation of nerves may help regain early protective
flap, it was not until WWI and II that pedicled flaps were used sensation for sole reconstruction.16–18 Tissue expansion tech-
extensively for reconstruction of the extremity. The next nique combined with or without microsurgery may allow
evolution came as surgeons started to use axial pattern flaps. coverage for large chronic defects or healed scars minimizing
The term “axial pattern” as used to describe flaps with named donor morbidity.19 The most recent advances in flap surgery
pedicles was presented by McGregor and Morgan and this came in the 1990s with the introduction of perforator flaps.
concept, along with contributions from many surgeons, Koshima and Soeda described the use of an inferior epigastric
led to the understanding of the hemodynamic aspect of flap artery skin free flap without rectus abdominis muscle for
circulation.6–8 The first muscle flap for lower extremity cover- reconstruction.20 This implied reduction in donor site morbid-
age was first described by Stark for coverage of debridement ity, ability to tailor with regard to thickness, and increased
sites for osteomyelitis, but went unnoticed until Ger reported freedom of orientation of the pedicle allowing more flexibility
that the leg muscles were reliable for leg coverage with abun- while providing coverage of the defect.21,22 Advances in
dant blood supply.9,10 These progresses led to the distinction wound healing science have synergistically made closure of
between axial and random flaps and muscle and musculocu- lower extremity wounds more successful. The vacuum-
taneous flaps that led to the introduction of free tissue assisted closure may provide a stable temporary dressing that
transfer. allows increased blood flow and decreased bacterial counts to
Prior to the introduction of microsurgery, limitations enable a better environment for flap coverage.23,24
existed for the reconstruction of large and extensive wounds Currently, state-of-the art technologies in tissue engineer-
including bone defects. Entry into the era of microsurgery, ing, genetic engineering, diagnostic technology, wound
with tissue coverage for extensive and complex defects, even healing, limb transplantation, and supermicrosurgery will
after severe trauma and radical debridement, truly allowed widen the possibility for increased salvage with better func-
advances in lower extremity coverage. In 1986, a landmark tion and appearance. Nevertheless, the concept of soft-tissue
publication on reconstructive microsurgery of the extremity coverage with or without microsurgery will remain an essen-
was presented by Marko Godina and established the principle tial part of functional and cosmetic recovery for lower extrem-
of early debridement, free tissue transfer, and aggressive ity reconstruction.
rehabilitation to achieve functional limb after salvage.11 Based

is addressed through a well-vascularized extremity, a skeletal loss, increased medical cost, and even amputation. Thus to
structure able to support gait and weight-bearing, and an provide optimal form and function, we jump up and down
innervated plantar surface to provide protective sensation. the rungs of the ladder. The reconstructive elevator requires
Without proper function, the value of reconstruction will be creative thoughts and consideration of multiple variables to
reduced, which significantly increases emotional and financial achieve the best form and function rather than a sequential
burden to the patient. climb up the ladder (Fig. 5.2B). This paradigm of thought does
An evaluation of the patient as a whole allows proper not eliminate the concept of the reconstructive ladder but
decisions to be made with regard to systemic conditions, replaces it with a ladder of wound closure that makes its mark
socioeconomic status, and rehabilitative potential. Extremity in the field where a variety of advanced reconstructive proce-
injuries are best approached by teams of surgeons with dures and techniques is not readily available. Based on the
knowledge of skeletal, vascular, neurological, and soft-tissue reconstructive elevator, the method of reconstruction should
anatomy. Although evaluations such as the Mangled Extrem- be chosen based on procedures that result in optimal function
ity Severity Score (MESS), the Predictive Salvage Index, and as well as appearance.
the Limb Salvage Index can assist the team in making a deci-
sion for amputation, they must not be the sole criteria and
the decision to amputate must be individualized for each
Skin grafts and substitutes
patient.19,25–28 Autologous skin grafts are used in a variety of clinical situa-
tions. They can be full or partial thickness and require a
recipient bed that is well vascularized and free of bacterial
The value of autologous tissue contamination. The split-thickness grafts are usually used as
Whether acute or chronic, evaluation of lower extremity the first line of treatment where wounds cannot be closed
wounds and the eligibility for soft-tissue reconstruction primarily or undue tension is suspected. In the extremity with
begins with vascular status evaluation. If clinical and diagnos- complex wounds, bone exposure and/or avascular beds,
tic examination reveals inadequate perfusion and the value of infected wounds, and wounds with dead space and poorly
reconstruction is minimal, amputation should be individually coagulated beds, skin grafts should be avoided. Autologous
decided. An amputated or avulsed tissue should never be cultured keratinocytes can be used where split-thickness
disregarded, especially in acute traumas, unless severely donor sites are limited. However, the use of cultured epithelial
contaminated or lacks vascular structure. Nothing can mimic autograft has been hampered by reports that show it to be
the superiority of an autologous tissue, and all tissues from more susceptible to bacterial contamination, have a variable
amputated parts should be considered as potential donor take rate, and be costly.37
tissues for reconstruction. The skin harvested from the A skin substitute is defined as a naturally occurring or
degloved or amputated part can be utilized as biologic dress- synthetic bioengineered product that is used to replace the
ings to permanent skin grafts (Fig. 5.1A–E).29 The leg length skin in a temporary, semipermanent, or permanent fashion.38
can be preserved using soft tissue distal form the zone of Temporary epidermal replacements may be beneficial in
injury as fillet pedicled or free flaps.30–33 Amputated bones can superficial to mid-dermal depth wounds. In deeper wounds,
be banked or used as a flap to reconstruct the leg.34,35 dermal replacements are of primary importance. Bioengi-
neered products for superficial wounds are porcine products
such as EZ Derm and Mediskin (Brennen Medical, LLC, Saint
The reconstructive elevator Paul, Minnesota), which help to close the wound, decrease
Once the wound is evaluated to have good vascular supply, pain, and improve the rate of healing.38 Biobrane (UDL Labo-
stable skeletal structures, and a relatively clean wound, soft- ratories Inc., Rockford, Illinois) is a bilaminate skin substitute
tissue coverage is then considered. The concept of a recon- that is used temporarily. The outer layer is formed with a thin
structive ladder was proposed to achieve wounds with silicone layer with pores that allow removal of exudates and
adequate closure using a stepladder approach from simple to penetration of antibiotics. The inner layer is composed of a 3D
complex procedures (Fig. 5.2A). Although still valued and nylon filament weave impregnated with type I collagen to
widely taught, the reconstructive ladder comes from the adhere to the wound. Bioengineered products that are used
concept of the wound-closure ladder that dates back beyond for deep wounds are allograft, Alloderm (Life Cell Corpora-
the era of modern reconstructive surgery.36 In the era of tion, Woodlands, Texas), Integra (Integra Life Sciences,
modern reconstructive surgery, one must consider not only Plainsboro, New Jersey), and Apligraf (Organogenesis Inc.,
adequate closures but also form and function. A skin graft Canton, Massachusetts). The gold standard for temporary
after mastectomy can still provide coverage, but a pedicled skin coverage is cadaver skin or allograft. Allograft is used to
TRAM (transverse rectus abdominis muscle) flap will provide cover extensive partial- and full-thickness wounds. It prevents
superior results in addition to coverage. Now with the intro- tissue desiccation; decreases pain and insensible loss of water,
duction of DIEP (Deep Inferior Epigastric Perforator) flaps the electrolytes, and protein; suppresses the proliferation of bac-
reconstructive ladder approach seems to show more flaws. teria; and decreases the hypermetabolic component of thermal
Other techniques including tissue expansion, skin stretching, injuries.39,40 Alloderm is an acellular dermal matrix engineered
and vacuum-assisted closure have made new changes in from banked human cadaver skin. It can also provide single
approaching reconstructive options. A simpler reconstructive stage reconstruction when used with a split-thickness
option may not necessarily produce optimal results. This is skin graft.41 Alloderm is known to improve functional and
especially true for lower extremity coverage, where conse- cosmetic results in deep burn wounds (Fig. 5.3).42 Integra is
quences of inadequate coverage will lead to complications an acellular collagen matrix composed of type I bovine col-
such as additional soft-tissue loss, osteomyelitis, functional lagen cross-linked with chondroitin-6-sulfate and covered by

A B

C D

Fig. 5.1 (A) This 67-year-old patient was involved in a pedestrian traffic accident,
which left her with ≈90% degloving injury of the entire left leg. (B,C) The injury
involved major artery and nerve defects making salvage impossible and resulting
in below knee amputation. The skin was harvested and defatted from the
degloved tissues and grafted in hope for primary take as well as biologic dressings.
(D,E) Only about 15% of the initial graft was taken, but healthy granulation was
E noted underneath the biologic dressing and made a favorable bed for secondary
graft procedure.

a thin silicone layer that serves as an epidermis.43 It is readily skin substitute. The epidermal layer is formed by human
available, does not require a donor site, coverts open to keratinocytes with a well-differentiated stratum corneum.
closed wounds, and decreases metabolic demand on the The dermal layer is formed with bovine type I collagen lattice
patient. However, Integra must be used on clean wounds impregnated with human fibroblasts from neonatal foreskin.
and requires a two-stage procedure later for the graft. Simul- Apligraf is not antigenic, and the dermal layer incorporates
taneous use with negative wound pressure therapy may into the wound bed. Apligraf has been shown to significantly
accelerate the vascularization. Apligraf is a bilaminate human decrease the time of venous ulcer healing compared to
epidermal and dermal analogue that can act as a permanent compression.44

Reconstructive ladder
any perforator can be chosen as a source of vascular supply
to the skin flap and be rotated to cover a defect. This is known
as the propeller flap.45–47 When the use of local flaps is not
Complex feasible due to the complexity of the wound, free tissue
Free flaps transfer is indicated.
The midthigh wound, due to the anatomic character where
Distant flaps femur is surrounded by a thick layer of soft tissue, rarely
requires reconstruction using free tissue transfer and often is
Local flaps sufficiently reconstructed by skin graft or local flap. Local
muscle or musculocutaneous flaps based on the lateral or
Skin grafts medial femoral circumflex artery can be used when available.
Also, any perforator can be chosen as a source of vascular
Simple
Direct closure, secondary intension supply to the skin flap and rotated to cover a defect. However,
if the patient has undergone massive resection or has special
A considerations such as postoperative radiation therapy, it may
Reconstructive elevator warrant free tissue coverage.
The wounds of the distal thigh (supracondylar knee) can
be very difficult due to the limit of rotation from previously
Complex described local muscle or musculocutaneous flaps from the
Free flaps thigh. Pedicled medial gastrocnemius muscle or musculocu-
taneous flap from the lower leg can be extended to cover this
Distant flaps region. However, extensive or complex defects may require
free tissue transfer or coverage using a perforator-based rota-
tion (propeller) skin flap (Fig. 5.4).
Local flaps
Lower leg
Skin grafts
The traditional planning for reconstruction of the lower
Direct closure, secondary intension, extremity has been approached according to the location of
Simple negative pressure wound therapy the defect. Divided into thirds: gastrocnemius muscle flap for
proximal third, soleus muscle flap for middle third, and free
B

Fig. 5.2 The reconstructive elevator requires creative thoughts and considerations
of multiple variables to achieve the best form and function rather than a sequential
climb up the ladder. This paradigm of thought does not eliminate the concept of a
reconstructive ladder, but replaces it as a ladder of wound closure and makes its
mark in the field where variety of advanced reconstructive procedures and
techniques are not readily available. Based on the reconstructive elevator, method of
reconstruction should be chosen based on procedures that result in optimal
function as well as appearance.

Approach by location (local flaps)

Thigh
The thigh can be divided into 3 parts: proximal thigh,
midthigh, and distal thigh (supracondylar knee). The proxi-
mal thigh wounds can result from various causes such as
complications from hip fractures, infected bypass vascular
grafts, after tumor resection, and trauma. The medial portion
of the proximal thigh can be especially challenging due to
location of vital structures and the likely formation of dead
space. Local lower extremity muscle or myocutaneous flap
options include using the flaps based from the lateral circum-
flex femoral artery such as tensor fascia lata, vastus lateralis,
and rectus femoris flaps. Vertical rectus abdominis muscle or
myocutaneous flap using the deep inferior epigastric artery
can allow stable coverage of the proximal thigh. The gracilis
muscle or myocutaneous flap based on the medial femoral Fig. 5.3 A 10-year-old patient was seen 3 years after reconstruction of one-stage
circumflex artery may lack muscle bulk but is a good option dermal allograft, an acellular dermal matrix engineered from banked human cadaver
when the dead space is not extensive. With the increased skin, and split-thickness skin graft. The patient is seen to have good elasticity and
knowledge of perforator and perforator-based flaps, basically acceptable cosmetic results.

A B C

Fig. 5.4 (A) A 70-year-old patient is noted with chronic drainage after failed total knee replacement. (B) After complete debridement, a perforator-based flap was elevated
and advanced using a perforator (dissected until just beneath the fascia) with visible pulse. (C) Long-term follow-up shows no recurrence of any infections, allowing her to
undergo total knee replacement.

flap transfer for the distal third of the leg. Like the reconstruc- socioeconomic status, rehabilitative potential, and patient’s
tive ladder concept, this traditional approach can be useful, motivation and compliance.
but the surgeon must individualize each wound and choose After the decision is made to reconstruct the lower extrem-
the initial procedure that can yield the best chance of success ity, the first preoperative evaluation should start with vascular
and avoid morbidity. status. Physical examination of palpable pulse, color, capillary
refill, and turgor of the extremity allows assessment of the
Microvascular free tissue transfer initial status, and Doppler examination can provide additional
information.49 The use of preoperative arteriography for lower
One must choose a proper surgical plan to achieve optimal extremity reconstruction is considered when physical/
function and cosmesis. Flaps are selected based on accessibil- Doppler exam reveals inconclusive vascular status or chronic
ity of local tissue and donor morbidity. Frequently, lower vascular disease is suspected (Fig. 5.5). The use of computed
extremity trauma due to high-energy impact results in exten- tomography angiography may obtain vascular information of
sive and complex wounds. Workhorse for soft-tissue coverage the recipient region without the risk of complications from
includes muscle or musculocutaneous flaps such as latissimus arterial puncture of the groin and can also provide vascular
dorsi, rectus abdominis, and gracilis. The perforator flap information of the donor flap facilitating the planning and the
where a skin flap is based on a single or multiple perforators,
such as the anterolateral thigh flap or thoracodorsal artery
perforator flap, can be added to the list.
Whichever flap you select, the guideline for lower extrem-
ity reconstruction using free flaps remains the same: anasto-
mose the vessel outside the zone of injury, make end-to-side
arterial anastomosis and end-to-side or end-to-end venous
anastomosis, and reconstruct the soft tissues first and then
restore the skeletal support.48

Treatment approach
Preoperative evaluation
The initial evaluation of the lower extremity wound involves
visual and manual examination. An examination on the loca-
tion, size, depth, and character of the wound is made. Neuro-
logical evaluation as well as vascular and skeletal evaluation
is made to develop a plan for reconstruction. Also, presence
of comorbidities including smoking, diabetes, obesity, and Fig. 5.5 Preoperative computed tomographic angiogram revealing collateral flows
peripheral vascular disease should be accounted for. The on bilateral femoral arteries for a patient with diabetes and poor pedal pulses. The
use of computed tomography angiography may obtain vascular information of the
initial evaluation enables assessment of the overall function recipient region without the risk of complications. The preoperative is selectively
and consideration of the possible outcome. One must not recommended in patients who have loss of one or more peripheral pulses, a
make the mistake of addressing the wound locally but rather neurological deficit secondary to the injury, or a compound fracture of the extremity
approach the patient as a whole and take into consideration that has undergone reduction and either external or internal fixation.

foot trauma, and anticipated protracted course to obtain soft-

Complete disruption of Yes tissue coverage and tibial reconstruction.
posterior tibial n. Ischemic leg Amputation
(ischemic time greater than 6 h) In these cases where limb salvage is not possible, an attempt
should be made to salvage as much limb length as possible.
No Every effort should be made to save the functional knee joint
as below-knee amputation results in far superior ambulatory
outcome and up to 2–3 times more full mobility compared to
Vascular supply
above knee amputation.58 The energy consumption is far less
for below-knee amputation, and this allows these patients
to walk significant daily distances, thus maintaining good
Inadequate Adequate
quality of life.59 Though the ideal stump length below the knee
is greater than 6 cm, any length of tibia should be preserved.60
The stump may be closed primarily if adequate soft tissue
Bypass graft Debridement and
exists, and where local tissue is inadequate then microsurgery
Angioplasty establish bone stability enables preservation of the maximum length of the stump. If
the tissue distal to the amputation is usable, a fillet flap can
be performed. Other flaps, such as muscle, musculocutane-
ous, fasciocutaneous, and perforator, can be used for micro-
Inadequate Adequate surgical reconstruction and achieve the same goal as well.
wound bed wound bed Muscle flaps may have a tendency to heal slowly and to
shrink due to muscle atrophy while skin flaps may provide
better contours and sensibility.61
Conservative wound care Serial debridement Elective
reconstruction
Negative pressure wound therapy
Hyperbaric oxygen therapy
Negative pressure
Wound therapy
Debridement
Bony stability is first established using external or internal
fixation devices. An external device is usually preferred if
there is significant bone loss or bone revascularization and
Inadequate Adequate may facilitate coverage procedure. Debridement must cover
wound bed wound bed devitalized soft tissue and bone and be performed until fresh
bleeding is noted. Multiple stages of debridement may be
needed to achieve adequate wound bed prior to soft-tissue
Amputation Skin graft coverage.
Cross leg flap The vacuum-assisted closure can be used to optimize the
wound bed and minimize dressing changes until definitive
Fig. 5.6 Algorithm of approach for soft-tissue reconstruction of the lower extremity. reconstruction. It must be used with caution and in conjunc-
tion with serial debridement. It does not replace surgical
surgical procedure.50–52 In association with prior injuries to the debridement and should not be used in heavily contaminated
lower extremity, the routine preoperative use of angiogram wounds with necrotic tissues. If a lower extremity wound is
is controversial.24,49,50,53–55 It is selectively recommended in clean, bony stability is present, and no vital structures are
patients who have loss of one or more peripheral pulses, a exposed, application may be indicated.54 This device facilitates
neurological deficit secondary to the injury, or a compound dressing of the wound and often promotes healing.
fracture of the extremity that has undergone reduction and
either external or internal fixation.54 Timing of reconstruction
Nerve injuries that are irreversible may require special
considerations. Peroneal nerve injury results in foot drop and Regardless of the degree of contamination and extent of injury
loss of sensation of the dorsum of the foot. Thus lifelong when indicated for salvage, there is no need to delay definitive
splinting or tendon transfers may be required. Complete loss coverage provided that the general condition of the patient
of tibial nerve function results in loss of plantar flexion and is and the status of the wound are appropriate. General consen-
an absolute contraindication for reconstruction.56 The loss of sus favors early aggressive wound debridement and soft-issue
plantar sensation can be devastating and may hinder the need coverage. Byrd et al. described acute, subacute, and chronic
for reconstruction but is not an absolute contraindication.57An phases of an open tibial fracture.62 Ideally, the wound is
algorithm of approach is outlined in Fig. 5.6. covered in the first 5–6 days after injury at the acute phase of
the wound. In severe Gustilo type IIIB and type IIIC injuries,
free muscle transplantation obtained the best results. At 1–6
Primary limb amputation weeks the wound enters the subacute phase where wounds
A study by Lange describes absolute and relative indications have a higher tendency for infections and flap failures. Between
for primary amputation of limbs with open tibial fractures.56 4 and 6 weeks, the wound enters the chronic phase and clear
Absolute indications include anatomically complete disrup- demarcation between viable and non-viable bone becomes
tion of the posterior tibial nerve in adults and crush injuries apparent. Godina further demonstrated that radical debride-
with warm ischemia time greater than 6 h. Relative indica- ment and coverage within 72 h results in the best outcome
tions include serious associated polytrauma, severe ipsilateral where only 0.75% of flaps fail, 1.5% are infected, and 6.8

months are needed for union of the bone.11 The failure rate
compares remarkably well to that of 12% when reconstructed Special considerations
from day 3 to 3 months and 9.5% when reconstructed after 3
months of injury. Yaremchuk et al. recommended early cover- Osteomyelitis
age between days 7 and 14 after several debridements to allow
better identification of zone of injury.63 The common idea Osteomyelitis often follows severe open leg fractures with
behind early intervention is that it minimizes the risk for massive contamination or devascularized soft tissue and
increasing bacterial colonization and inflammation leading to bone. Inadequate debridement or delayed coverage of the
complications. Acute coverage by day 5–7 is generally accepted wound increases the chance for osteomyelitis, and early
as having a good prognosis in terms of decreased risk of debridement remains the key to prevention.69 Osteomyelitis
infection, flap survival, and fracture healing.11,24,62,63 If the should be seen as a spectrum of disease and should be indi-
patient condition does not allow prolonged surgical proce- vidualized and managed accordingly. Factors known to be of
dures, then the wound should be debrided as early as possible prognostic significance include the duration of infection, the
and a clean and well-vascularized recipient bed maintained extent of bony involvement, the presence of associated frac-
until conditions allow definitive reconstruction.64 ture or nonunion, and overall immune status of the patient.70
The wound is composed of exposed bone, infected bone,
devitalized bone, and scarred tissue surrounding the bone.
Selection of recipient vessel These components have diminished vascular supply making
Many lower extremity wounds resulting from trauma are antibiotics difficult to reach. Thus to achieve the goal of infec-
high-energy injuries with a substantial “zone of injury”. This tion control and the restoration of function, treatment prin-
thrombogenic zone is known to extend beyond what is mac- ciples for chronic osteomyelitis are debridement including the
roscopically evident, and failure to recognize the true extent complete resection of involved bone, flap coverage with vas-
of this zone is cited as a leading cause of microsurgical anas- cularized tissue, and a brief course of antibiotic treatment (Fig.
tomotic failure. Within the zone, perivascular changes such as 5.7). Local methods of antibiotic delivery can be used when
increased friability of vessels and increased perivascular scar complete debridement of bone is not possible. Although there
tissue may lead to difficult dissection of recipient vessels and has been controversy over selecting the type of flap for cover-
higher incidence of thrombosis after anastomosis.65 The extent age, muscle flaps, rather than fasciocutaneous flaps, have
of this is very difficult to realize clinically. Thus Isenberg and been shown experimentally to have increased blood flow
Sherman demonstrated that clinical presentation of the recipi- and antibiotics delivery, increased oxygen tension, increased
ent vessel (vessel wall pliability and the quality of blood from phagocytic activity, and decreased bacterial counts.71–73 Clini-
the transected end of the vessel) is more important than the cally, complete debridement and obliteration of dead space
distance from the wound.66 Park et al. also concluded that are the most important steps in treating osteomyelitis and the
site of injury and vascular status of the lower extremity are type of flaps seems less crucial.74,75 Bone defects can be
the most important factors in choosing a recipient vessel.67 managed with vascularized bone flap, secondary bone graft-
This was further supported by successful anastomosis of ing, bone distraction lengthening, or a combination of these
perforator to perforator adjacent to or within the zone of techniques.
injury.68 Based on these findings, one of the most important Not all chronic osteomyelitis can be salvaged. As with the
factors in selecting the recipient vessel may be the vascular indication for amputation, legs with nerves too damaged
quality itself. after osteomyelitis should not be salvaged. The general and

A B C

Fig. 5.7 (A) A patient with chronic osteomyelitis is noted with soft-tissue defect. (B) Complete debridement including resection of the involved bone was performed.
(C) Flap coverage with well-vascularized anterolateral thigh flap combined with vastus lateralis muscle tissue was used with 6 weeks of antibiotic treatment.

socioeconomic condition of the patient should also be consid- Coverage after tumor ablation
ered, and they should be offered the option of amputation and
early rehabilitation. As with any reconstructive procedure, the aim of reconstruc-
tion after tumor ablation is to maintain quality of life by
Diabetes preserving function and achieving acceptable appearance. In
addition, coverage must be able to withstand adjuvant treat-
Patients with diabetes provide additional concerns ranging ment with radiation therapy and/or chemotherapy and play
from chronic renal failure, nutrition, to blood sugar control. a role in achieving long-term local control of the disease.
These multiple issues are best approached by a multidisci- Surgeons should have close cooperation with the oncologists
plinary team.76–79 Patients will frequently have chronic and must acquire adequate knowledge of tumor characteris-
bacterial colonization, osteomyelitis, complex wounds, bone tics, behavior, and adjuvant treatment in order to plan and
deformity, local wound ischemia, and vascular disease. The choose the type of reconstructive procedure. Knowing that
etiology behind these complicated wounds is from macrovas- reconstruction is feasible allows the oncologic surgeon to
cular angiopathy, bony deformities leading to pressure points, achieve a comfortable and satisfactory excision margin and
neuropathy, and poor metabolic control. When patients with may lead to a better outcome. Skin grafts are always an
diabetes are required to undergo a reconstructive procedure option especially for very extensive defects where flap cov-
of the extremity, vascular status must be evaluated to ensure erage is not available. But for wounds scheduled for postop-
success.80,81 Any vascular problems must be addressed first erative radiation therapy or located over joints and high
and corrected. If not correctable, the surgeon may be faced friction regions, skin grafts should be avoided and recon-
with a high risk of failure. One must consider the probability struction should be with a durable flap.82 Special consider-
of successful reconstruction based on eliminating the underly- ation should be given to preoperative radiation therapy
ing problems of the diabetic wound and also take into account where skin would become fibrotic and ischemic around the
long-term ambulation after reconstruction. In a retrospective cancer and thus will not allow local coverage. Regarding
study by Hong, only 71 patients out of 216 were deemed adjuvant chemotherapy, free flap procedures will not inter-
functionally salvageable using a microsurgical approach and fere with chemotherapy nor will chemotherapy have an
a successful outcome was reported for 66 patients (Figs. 5.8 & impact on free flap survival.83,84 Overall success rate was
5.9).80 Large and composite diabetic wounds must be aggres- shown to be 96.6% in a series of 59 free flaps in 57 patients
sively debrided, including the necrotic bone, and covered undergoing lower extremity reconstruction after tumor abla-
with well-vascularized tissue. tion, with 12% major and 7% minor complications.83 Various
flaps such as omentum, muscle with skin graft, musculocu-
taneous, and perforator can be used for reconstruction
depending on location, size, depth, adjuvant therapy, func-
tion, and cosmetic appearance (Fig. 5.10).
Systemic condition
and wound evaluation
Exposed prosthesis
The traditional method to manage exposed hardware includes
Small/shallow Large/deep irrigation, debridement, antibiotics, and likely removal of
hardware. However, several factors should be taken into
account to manage exposed hardware before considering
Conservative Failure Surgical No benefit removal that may set back the treatment plan. Factors such as
care (salvage) care location of the hardware, infection (type of bacteria and dura-
tion of infection), duration of exposure of hardware, and
hardware loosening should be considered as important prog-
Simple Complex
nostic factors for successful management of exposed hard-
ware.85 In the retrospective review by Viol et al. they concluded
that if hardware is clinically stable, time of exposure is less
Skin graft/ Failure Evaluate
than 2 weeks, infection is controlled, and the location of the
local flap vascular status hardware is for bony consolidation, then there is an increase
in the likelihood that hardware can be salvaged using surgical
soft-tissue coverage (Fig. 5.11).85
Exposed vascular grafts present life and limb threatening
Reliable Unreliable complications. They should be managed with early debride-
ment and muscle flap coverage to salvage the graft. Synthetic
grafts can be susceptible to bacterial colonization, and consid-
Free flap Bypass surgery eration should be given to replacement with an autologous
Failure graft. Local muscle flaps such as gracilis, sartorius, and tensor
fascia lata are very useful in providing adequate coverage for
exposed groin synthetic vascular prosthesis. If the defect is
Outpatient program Amputation extensive, then an inferiorly based vertical rectus abdominis
musculocutaneous flap can be considered. The management
Fig. 5.8 Algorithm for diabetic foot reconstruction. of exposed vascular grafts requires close cooperation with the

A B

Fig. 5.9 A diabetic patient after partial

amputation of the foot was noted with
poorly healing stump. (A,B) The angiogram
revealed poor flow to the lower leg, and
femoral popliteal bypass was performed.
(C,D) With improved circulation, the patient
underwent reconstruction with anterolateral
C D thigh perforator flap and the foot was
salvaged.

vascular surgeon, aggressive debridement, and coverage with use in the lower extremity has been associated with a high
a well-vascularized tissue. rate of infection and extrusion of the implant. Wound infec-
tion and dehiscence are the most common complications, but
seroma, implant displacement, neurapraxia, hematoma, and
Soft tissue expansion contour defects can also occur. The technique can be reserved
The use of tissue expansion in the lower extremity has not for unstable soft tissues or scars of moderate size. The implant
been as successful as in other areas of the body, such as the is placed in a suprafascial position in the subcutaneous pocket
breast and scalp. The potential advantages of using expanded of the lower extremity, and application on the ankle and
skin in the lower extremity include improved contours, cover- foot region must be avoided. Transverse expansion has a
age with like tissue, and improved aesthetic result. However, lower failure rate compared to longitudinal advancement. For

A C D

Fig. 5.10 (A) A patient with soft-tissue sarcoma of the knee region was noted. (B,C) After wide excision including the bone, a hemi-gastrocnemius muscle was elevated to
resurface the knee joint. (D) Long-term results show good contour with acceptable function and appearance.

avoidance of wound dehiscence, neurapraxia, and fat necro- monitoring. Emergent re-exploration should be performed
sis, expansion should proceed slowly, stopping before the once pedicle compromise is noted.
onset of pain or, if it is measured, before intraexpander pres-
sure exceeds 40 mmHg.86 Flap prefabrication with tissue
expansion may have a role in select reconstructions of the
Management of flap complications
lower extremity.87 Although there are no clinical reviews that conclusively show
any agents that increase flap survival rate, about 96% of the
106 microsurgeons surveyed use some form of prophylactic
Postoperative care antithrombotic treatment, such as heparin, dextran, and alone
or in combination with other agents.89–91 The routine use of
Monitoring dextran should be carefully approached due to allergic reac-
tion and pulmonary edema, but aspirin, heparin, or low
During the postoperative period the patient as a whole and molecular weight heparin can be considered based on theory
the flap should be closely monitored. It is especially important and related studies from different disciplines. Thrombolytics
to monitor hemodynamic and pulmonary function as adequate such as urokinase can be used when flow is not immediately
hydration and oxygenation are critical to flap survival. Input reestablished after pedicle rearrangement or revision anasto-
and output of fluid should be monitored closely as distal mosis.91 But no agent can replace the meticulous surgical
perfusion is primarily affected by hypotensive episodes. This technique and early diagnosis of flap compromise.
can be a problem for patients with chronic renal failure who Leeches have a role in the postoperative care of jeopardized
require dialysis that often removes large volumes of fluid. flaps. In cases of venous congestion, by injecting a salivary
Limiting range of motion may be needed for flaps covering component called hirudin, which inhibits platelet aggregation
the joints as extension or flexion may increase the tension of and coagulation cascade, leeches can decongest by extracting
the pedicle. Monitoring flaps, especially free flaps, in the first blood directly and by the oozing that occurs after it detaches.
24 h is essential as the majority of thromboses occur during The use of leeches for 5–7 days can sometimes help salvage
this time. According to Chen et al., up to 85% of the compro- the flaps that do not resolve despite re-exploration of the
mised flaps can be salvaged when the first sign of vascular venous flow.
compromise is clinically noted during the first 3 days after
microsurgery.88 There is no ideal method of flap monitoring,
but recent techniques such as tissue oxygen measurement,
Secondary operations
implantable Doppler device, laser Doppler flowmetry, and Bone grafts are usually placed 6 weeks after soft-tissue recon-
fluorescent dye injections may assist the judgment made from struction to allow time for transferred tissue to settle in and
clinical evaluation, which remains the golden standard of sterilize the wound.19 Cancellous autograft or vascularized

impossible, a reasonable endpoint should be set and efforts to

minimize scars and achieve good contours should be made.
Debulking by surgical excision or liposuction can improve the
contour of the flap, and fat grafts can be added to elevate
depressed scars. Scar revision by Z-plasties or expanders
can help to alleviate not only physical but psychological
problems.

Muscle/musculocutaneous flaps
Tensor fascia lata
The tensor fascia lata is a small, thin, and short muscle with
A a long fascial extension from the iliotibial tract of the facia lata
to the lateral aspect of the knee. The muscle originates at the
anterior 5–8 cm of the external lip of the anterior superior iliac
crest, immediately behind the satorius, and inserts to the
iliotibial tract. It abducts, medially rotates, and flexes the hip,
acting to tighten the fascia lata and iliotibial tract but is an
expendable muscle. Its flat shape, excellent length, and reli-
able type I circulation pattern (dominant pedicle is the ascend-
ing branch of the lateral femoral circumflex artery and venae
comitantes) make it useful in many reconstructive scenarios,
both as a pedicled flap for local and regional coverage and as
a free, composite unit that incorporates skin, muscle, and iliac
bone. Motor innervation is from the superior gluteal nerve
entering the deep surface between the gluteus medius and the
gluteus maximus. Sensation is derived from T12, which
innervates the upper skin territory, and the lateral femoral
cutaneous nerve of the thigh (L2–3), which innervates the
lower skin.
When based on the dominant pedicle, located 8–10 cm
below the anterior superior iliac spine, the anterior arc of
location will reach the abdominal areas, groin, and perineum
while the posterior arc can reach the greater trochanter,
ischium, perineum, and sacrum (Fig. 5.12).92,93 The flap can
also be advanced superiorly as a V–Y flap to cover trochanteric
wounds.94 The skin overlying the muscle and fascia lata can
be harvested as a unit with the flap and can extend to within
B
10 cm above the knee.
The marking begins by identifying the major landmarks:
Fig. 5.11 A patient with total knee replacement, after contraction of the knee due
to a traffic accident, presented with unstable skin and pending exposure of the knee
the anterior superior iliac spine, lateral condyle of femur, and
implant for 1 month. (A) The unstable region of the skin was completely debrided the pubic tubercle. A line from the anterior superior iliac spine
and irrigated. (B) Upon debridement there were no apparent signs of infection. A straight down the thigh to a point 10–12 cm above the knee
large anterolateral thigh perforator flap including the deep fascia was taken to joint presents the anterior border of the flap, and a parallel
resurface the exposed prosthesis and showed stable recovery after 2 years. line 12–15 cm posterior to the first line is drawn straight down
the thigh, curving anteriorly as it crosses posterior to the
lateral epicondylar area, to meet at the same point. The skin
bone transfers can be chosen depending on the length of the island can be designed within this long strip, according to the
bone gap. In addition, the bone transfer mechanism can be an needs and distance to the recipient defect. The distal margin
alternative to free bone transfer for bone defects longer than of the flap is entered, carrying the incision through the fascia
6 cm. lata and dissecting deep to the fascia lata and iliotibial tract.
To achieve optimal motion of tendons of the lower extrem- The pedicle is located approximately 10 cm below the anterior
ity, secondary tenolysis procedure may be needed. The risk iliac spine along the line drawn. One must modify the flap
for adhesion may increase when skin graft is performed over when composite tissues are taken for reconstruction.
granulated tissue directly above the tendons and may warrant
flap coverage.
The final stage to consider after reasonable functional
Rectus femoris
recovery is appearance of the extremity. Patients after recovery The rectus femoris is located superficially on the middle of
frequently show scars, depression, bulky flaps, and donor the anterior thigh extending between ilium and patella. It is
site morbidities. Although complete restoration is nearly a central muscle of the quadriceps femoris extensor muscles

rectus femoris muscle to be identified and separated from the

Tensor fascia lata vastus medialis and lateralis. The skin island is then incised
circumferentially down to the fascia of the muscle. The rectus
Branch from
superior gluteal is elevated from distal to proximal and from medial to lateral
nerve so that the pedicle and nerve can be identified and protected
medially along the underside of the muscle. The dominant
pedicle enters the posterior medial muscle at a variable dis-
tance of 7–10 cm below the symphysis pubis and care must
be given to preserve the motor branches from the femoral
“Transverse” nerve to the adjacent vastus lateralis and tensor fascia lata.
branch of lateral The donor area should be repaired by careful suturing together
femoral circumflex of the tendinous fascia of the vastus medialis and lateralis
artery to TFL above the patella in an effort to preserve full knee extension.

Biceps femoris
This large, well-vascularized posterior muscle of the mid- and
Vastus lateralis
lateral thigh is useful for coverage of ischial pressure sores.
Rectus femoris The muscle has two heads; the long head originates on the
ischial tuberosity and the short head originates on the linea
aspera of the femur and both insert to the head of the fibula.
The long head extends the hip, and both heads flex the leg at

Fig. 5.12 Tensor fascia lata flap elevation. When based on the dominant pedicle,
located 8–10 cm below the anterior superior iliac spine, anterior arc of location will
reach the abdominal areas, groin, and perineum while the posterior arc can reach
the greater trochanter, ischium, perineum, and sacrum. TFL, tensor fascia lata.
Rectus femoris

group and acts to extend the leg at the knee. The muscle
originates with two tendons, one from the anterior inferior
iliac spine and one from the acetabulum, and inserts to the
patella. It is a thigh flexor and a leg extensor that is important Pectineus
in stabilizing the weight-bearing knee and thus is not consid- Lateral circumflex
artery (descending
ered expendable. It has a type II pattern of circulation (the
and transverse
dominant pedicle is the descending branch of the lateral cir- branches)
cumflex femoral artery with minor pedicles from the ascend- Adductor longus
ing branch of the same vessel, as well as from muscle branches
of the superficial femoral artery) and can reach to cover the
inferior abdomen, groin, perineum, and ischium.95,96 Motor Vastus medialis
innervation is from the femoral nerve, and muscle branches
enter adjacent to the dominant pedicle. The motor innerva-
Vastus lateralis
tions and the adequate dimension of the flap allows it to be
used as a functional muscle flap (Fig. 5.13).97 In addition, the
intermediate anterior femoral cutaneous nerve (L2–3) pro-
vides sensation. The skin perforators are most reliable over
the midanterior two-thirds of the muscle itself in the central
strip up to 12 × 20 cm.
A longitudinal incision is marked from 3 cm below the
anterior superior iliac spine to just above the superior margin
of the patella. With the anterior thigh muscle contraction, the
lateral border of the vastus medialis and the medial border of
the vastus lateralis are visualized creating a depression of
skin. The tendon of the rectus femoris can be easily noted
Fig. 5.13 Rectus femoris muscle flap elevation. It is a type II pattern of circulation
below the depression and above the patella. The skin island (the dominant pedicle is the descending branch of the lateral circumflex femoral
should be designed on the middle third of the thigh as the artery with minor pedicles from the ascending branch of the same vessel as well as
majority of the perforators are located in this region. Incision from muscle branches of the superficial femoral artery) and can reach to cover the
at the distal edge of the skin island, along the axis, allows the inferior abdomen, groin, perineum, and ischium.

Branch from Medial femoral

obturator nerve circumflex artery Adductor longus
Adductor brevis
Abductor magnus

Sartorius
Gracilis
tendon (cut)

Semimembranous Fig. 5.14 Gracilis muscle flap elevation. It is a type II

Gracilis circulation pattern (the dominant pedicle is the terminal branch
of the medial circumflex femoral artery and one or two minor
pedicles arise as branches of the superficial femoral artery) and
can reach to cover the abdomen, ischium, groin, and perineum
as a muscle or musculocutaneous flap.

the knee and thus are not expendable. The pattern of circula- from abductor longus and magnus muscle. The muscle has a
tion is type II (the long head has dominant and minor pedicles type II circulation pattern (the dominant pedicle is the termi-
from the first and second perforating branches of the profunda nal branch of the medial circumflex femoral artery and one or
femoris artery, respectively, and the short head receives two minor pedicles arise as branches of the superficial femoral
the second (or third) perforating branch of the profunda and artery) and can reach to cover the abdomen, ischium, groin,
a minor source from the lateral superior geniculate artery) and perineum as a muscle or musculocutaneous flap (Fig.
and can be turned over to cover the ischial regions based on 5.14). Motor innervation is from the anterior branch of the
the dominant pedicle.98 The long head derives its motor obturator nerve and enters the gracilis on its deep medial
innervations from the tibial division of the sciatic nerve, and surface immediately superior to the entry of the dominant
the short head from the peroneal division of the sciatic nerve. pedicle. The motor nerve allows gracilis to be used as a func-
The postcutaneous nerve of the thigh (S1–3) supplies the tional muscle flap for facial reanimation and upper extrem-
sensation. ity.100 The sensory innervation is from the anterior femoral
The entire skin of the posterior thigh can be elevated and cutaneous nerve (L2–3) that provides sensation to the anterior
advanced in V–Y fashion as a musculocutaneous unit. The medial thigh.101
upper base of the skin flap is horizontally marked along When skin is harvested with the gracilis muscle, the flap is
the buttock crease and the apex just above the popliteal fossa. generally oriented longitudinally, centered over the proximal
The relatively short pedicles make the flap unsuitable for third of the muscle, where the majority of the musculocutane-
wide rotation flaps but serve well in sliding the muscle proxi- ous perforators are located. A proximal transversely oriented
mally along the femur toward the pelvis. The medial thigh skin flap is optional, and the bulky fat of the medial thigh
skin may also be left uncut, preserving skin as a rotation even makes this flap suitable for breast reconstruction.102–104
advancement modification of the flap.99 The symphysis pubis and the medial condyle of the femur are
With the skin island isolated, the tendon is divided distally. major landmarks. The muscle extends the full length of the
The tendon is sectioned, and the dissection proceeds from the medial thigh and averages about 6 cm in width proximally
distal thigh toward the ischium, freeing the muscle on its deep and tapers to about 2–3 cm in the distal third of the muscle.
aspect from the femur and from the adductor group of muscles Although the width may be narrow, the muscle can be fanned
medially until enough mobility is attained so that the defect out to provide coverage over larger defects. With the patient
can easily be filled. The flap should be inset and sutured with in lithotomy position and slight extension of the knee will
the patient in a jackknife position and the hips flexed to allow the gracilis to be seen and felt, and it tends to be more
prevent dehiscence of the flap. posterior than expected.
For muscle elevation, an incision is made 2–3 cm posterior
to the line drawn connecting the symphysis pubis and medial
Gracilis condyle of the knee. The muscle is identified posterior to the
The gracilis is located on the medial thigh extending between adductor longus. If a skin flap is planned, the skin territory
the pubis and the medial knee. It is a thin, flat muscle that lies should be designed on the proximal part of the inner thigh.
anteriorly bordered by adductor longus and sartorius and Usually the dissection is easily approached by a distal incision
posteriorly by adductor magnus and semimembranosus identifying the tendon of the gracilis posterior to the saphe-
muscles. It originates on the pubic symphysis and inserts onto nous vein and the distal sartorius muscle. The tendinous
the medial tibial condyle. The gracilis functions as a thigh insertion of semimembranous and semitendinosus muscle
adductor but is expandable from the compensation made can be identified posterior to the gracilis. Traction on the

tendon will highlight the proximal outline of the muscle and Gastrocnemius
allow accurate estimation of the location. This is an important
step to minimize faulty elevation of the skin component as the The gastrocnemius muscle is the most superficial muscle of
medial thigh is mobile and makes it easy to incorrectly predict the posterior calf and has two heads, medial and lateral, that
the skin position over the muscle. Dissection of the anterior form the distal boundary of the popliteal space. Each head can
and posterior skin borders then precedes proximally approxi- be used as a separate muscle or musculocutaneous unit based
mately half the length of the muscle, whereby the distal on its own pedicle. The medial head originates from the
tendon is divided and the distal muscle elevated. During the medial condyle of the femur and the lateral from the lateral
elevation of the middle and distal third of the flap, one or two condyle of the femur, and both heads insert to the calcaneus
minor perforators from the superficial femoral artery will be through the Achilles tendon. It contributes to the plantar
identified and ligated. Retraction of the adductor longus flexion of the foot, and either or both heads of the gastrocne-
muscle will expose the major pedicle passing over the deep mius are expandable if the soleus is intact. The pattern of
adductor magnus approximately 10 cm below the pubic circulation is type I (the medial muscle is supplied by
symphysis. the medial sural artery, and the lateral muscle is supplied by
the lateral sural artery) and provides reliable coverage to the
upper third of the tibia, suprapatellar thigh, and knee regions
Soleus (Fig. 5.16). Both heads receive a minor source across the raphe
The soleus is a very broad, large bipenniform muscle lying that joins them as anastomotic vessels within the muscle
deep to the gastrocnemius muscle. The muscle has two muscle substance. Motor innervation derives from branches of the
bellies, medial and lateral, separated by a midline intramus- tibial nerve. The sensation to the skin overlying the medial
cular septum in the distal half. The lateral belly originates head is from the saphenous nerve and that to the lateral and
from the posterior surface of the head of the fibula and pos- distal skin overlying the lateral head is from the sural nerve.107
terior surface of the body of the fibula, and the medial belly The arc of rotation of the medial head after complete eleva-
originates from the middle one-third of the medial border of tion can cover the inferior thigh, knee, and upper third of the
the tibia. Both bellies of the soleus insert into the calcaneus tibia. When the origin of the muscle is divided, an extended
bone through the Achilles tendon and contribute to the plantar arc of rotation by 5–8 cm can be achieved to extend to the
flexion of the foot. The soleus is expandable taken that at least upper part of the knee. The lateral head can be elevated to
one head of the gastrocnemius is intact with function. The cover the suprapatellar region, knee, and proximal third of
pattern of circulation is type II (with dominant pedicles from the tibia. It can also be extended with the division of the
the popliteal, posterior tibial, and peroneal arteries and minor muscle origin. Both heads can be inferiorly rotated based on
pedicles from the posterior tibial and peroneal arteries sup- the vascular anastomosis across the raphe between the two
plying the distal medial and lateral bellies, respectively) and muscle heads to reach the middle third of the leg. A skin
can cover the middle and lower third of the leg (Fig. 5.15A). paddle can be designed, based on the perforating vessels,
The motor nerve is derived from the posterior tibial and with the following dimension: 10 × 15 cm for the medial and
popliteal nerves.105 8 × 12 cm for the lateral head. But the use of a skin paddle
The arc of rotation for a proximally based soleus flap after leaves an unsightly donor scar.
division of minor pedicles and elevation of the distal two- A line is drawn either 2 cm medial to the medial edge of
thirds of the muscle can cover the middle third of the tibia. the tibia or along the posterior midleg. If the muscle alone is
Hemisoleus flaps may improve the arc of rotation and pre- employed, a midline posterior incision affords excellent access
serve soleus function while sacrificing flap coverage area. The to both heads. During elevation care is taken to protect the
medial reversed hemisoleus pivots around the most superior neurovascular structures, especially the more superficial
distal minor perforator of the posterior tibial artery, approxi- saphenous and sural nerves. In the proximal third, the medial
mately 7 cm above the malleolus; the lateral reversed hemi- surface of the medial head is easily separated from the soleus.
soleus has a tenuous blood supply through minor perforators The dissection starts at the medial edge of the gastrocnemius
from the peroneal and a shorter arc of rotation. The distal half muscle, and the plantaris can be easily noted below the gas-
of the muscle can be reversely transposed based on minor trocnemius and above the soleus. The midline muscular raphe
segment pedicles and cover the distal third of the leg.106 is located and, with finger dissection, the underlying soleus
The medial border of the tibia is the landmark for medial muscle is separated from the gastrocnemius proximally and
exposure, and the fibula itself is the landmark for lateral distally. The musculotendinous raphe is then separated
exposure. A line can be drawn 2 cm medial to the medial edge sharply. Distally, the thick tendinous layer is sharply dissected
of the tibia or laterally along the fibula. Subcutaneous neuro- free from the remaining calcaneal tendon. The transaction of
vascular structures are identified and preserved, and the the origin of the muscle allows increased freedom. If a tunnel
posterior compartment fascia is opened. The plane between is made over the lateral proximal leg, care must be given not
the soleus and the gastrocnemius is usually well defined to violate the deep peroneal nerve.
superiorly, but sharp scalpel dissection is needed to separate
the tendons and maintain the gastrocnemius contributions to
the Achilles tendon. For proximally based flaps, distal perfo- Fasciocutaneous/perforator flap
rators are divided in the deep plane, and the tendon is divided
distally. The dominant pedicle is usually located on the upper A perforator flap is defined as a flap based on a musculocu-
one-third of the muscle for both bellies of the soleus. Identifi- taneous perforating vessel that is directly visualized and dis-
cation and dissection of the midline raphe allow a hemisoleus sected free of surrounding muscles and an adequate pedicle
flap to be developed (Fig. 5.15B–D). length is achieved.108 This concept may still be confusing

B
A

C D

Fig. 5.15 Soleus muscle flap elevation. (A) It is a type II circulation pattern (with dominant pedicles from the popliteal, posterior tibial, and peroneal arteries and the minor
pedicles rise from posterior tibial and peroneal arteries supplying the distal medial and lateral bellies, respectively) and can cover the middle and lower-third of the leg.
(B–D) A patient with chronic osteomyelitis of the middle-third of the tibia is reconstructed using a hemisoleus flap.

because the same flap can be a septocutaneous flap when aesthetic results. The report by Chang et al. showed that eleva-
it is based on a vessel traveling intermuscular septum and tion can be made above the deep fascia on the radial forearm
becomes a perforator flap if the pedicle is from a direct mus- free flap.110 Recent reports now show that elevation can be
culocutaneous perforator. However, despite the confusion in made safely between the layers of deep and superficial fat
nomenclature, this approach helps to achieve better accuracy based on a perforator able to achieve harvesting thinner flaps
by alleviating concerns of anatomic variations and minimiz- for resurfacing (Fig. 5.17).111,112 Thus the term fasciocutaneous
ing donor site morbidity. This kind of flap that may be based flap can depict the flaps elevated with the deep fascia and the
on any perforator, “freestyle free flap”, allows the freedom of term skin flap or suprafacial perforator flap can be used for
flap selection from anywhere on the body.108 This principle is flaps elevated above the deep fascia. The natural evolution of
used in local flaps as well where a flap can be rotated based skin flaps is now moving toward achieving minimal donor
on a single perforator to cover the defect as well as minimize site morbidity. Koshima et al. showed that the flap and the
donor site morbidity.47 This flap can also be rotated based on pedicle can be taken above the deep fascia as a perforator flap
the perforator to allow maximal arc of rotation and is also allowing decreased donor site.113,114 But anastomosis can be
known as a propeller flap.109 With the introduction of free difficult with a vessel diameter of less than 1 mm, hence this
style elevation of perforator flaps, different layers are now technique is known as supermicrosurgery. Hong et al. have
being used to elevate the flap. The classical fasciocutaneous also stretched the boundaries of microsurgery by introducing
flap is the elevation of flaps beneath the deep fascial layer. the possibility of using perforators as recipient vessels and
The subfascial elevation allows easiest dissection and clear the concept of “freestyle reconstruction”.115 Since the basic
identification of the perforator. However, elevation of the approach may be similar, septocutaneous and perforator flaps
deep fascia may result in muscle herniation and suboptimal will be discussed together when necessary.

Medial sural artery,

nerve, and vein

Medial head of
gastrocnemius (cut) Common
peroneal nerve

Lateral head of
gastrocnemius (cut)

Lateral sural nerve,

vein, and artery

Small saphenous
vein and sural
Gastrocnemius cutaneous nerve
insertion (cut) retracted

Soleus

Fig. 5.16 Gastrocnemius flap elevation. It is a type I circulation pattern (the medial
muscle is supplied by the medial sural artery, and the lateral muscle is supplied by
the lateral sural artery) and provides coverage to the upper-third of the tibia,
suprapatellar thigh, and knee regions.

Indirect linking vessels

Superficial fat Skin Superficial Superficial fascia
vein

Fig. 5.17 The elevation for fasciocutaneous flaps is made

Deep fascia underneath (subfascial dissection) and including the deep
Deep Femoral vein fascia. The skin flap can be harvested over the deep fascia
Direct linking vessels
Femoral artery (suprafascial dissection) or between the deep and the
Sartorius Superficial circumflex superfical fat (superficial fascia dissection). Note the
iliac artery distinctive layers for elevation

to 180°. In addition, although the extent of survival associated

with the concept of angiosome is not clearly understood,
venous charging of the flap may help to decrease the chance
of congestion when the flap extends beyond two or three
angiosomes.109
The propeller flap in the lower extremity is very useful.
When the donor site is able to be closed after the rotation, it
provides excellent coverage and a superb donor site. The
thigh region can easily resurface moderate sized defects and
close primarily. The use of the freestyle concept allows basing
on any perforator around the defect (Fig. 5.19A–D).

Groin/superficial circumflex iliac perforator

The groin flap may be elevated extending between the femoral
vessels and the posterior iliac spine. This flap was one of the
early introduced fasciocutaneous flaps. The dominant pedicle
is the superficial circumflex iliac artery, with venae comitantes
and superficial circumflex iliac vein. A variation in anatomy
with superior inferior epigastric artery have been reported,
but Harii et al. conclude either source can supply the flap
efficiently (Fig. 5.20).116 The pedicle is very short: up to only
3 cm. Koshima defined that the superficial circumflex iliac
perforator flap is different from the groin flap in that it is
nourished by only a perforator of the superficial circumflex
A
femoral system (Fig. 5.21).117 The T12 sensory innervation is
at the lateral margin of the flap away from the pedicle, pre-
cluding use as a sensate flap.
The long axis of the flap is centered over a line parallel and
3 cm inferior to the inguinal ligament with a flap width of
6–10 cm. The flap can be used as a free or pedicled flap. For
pedicled flaps, the dissection should proceed from lateral to
medial and distal to proximal. Elevation is begun in a plane
superficial to the fascia lata and, when the sartorius muscle is
visualized, the flap is elevated deep to the fascia and superfi-
cial to the muscle. The perforator flap is elevated suprafascially
until a sizable perforator is located and is used either as a
pedicled or free flap.
The groin flap as a septocutaneous flap may provide a large
amount of skin and soft tissue and may need debulking where
excess tissue is not needed. However, the perforator flap
enables elevation with the thin skin above the fascia. The
donor site is well tolerated and well hidden, but the pale skin
and frequent hair growth of the donor site make for a poor
match, particularly with head and neck reconstructions.
B
Medial thigh/anteromedial perforator and
Fig. 5.18 Note the propeller flap rotated up to 180° based on the perforator.
gracilis perforator
The medial thigh skin is supplied by musculocutaneous as
well as septocutaneous perforators. The medial thigh flap is
Propeller flaps located at the midthigh, and the dominant blood supply for
A propeller flap can be defined as an “island flap that reaches this fasciocutaneous flap is the anterior septocutaneous artery,
the recipient site through an axial rotation”. Every skin island and venae comitantes are from the superficial femoral artery
flap can become a propeller flap. However, island flaps that and vein at the apex of the femoral triangle (Fig. 5.22).118 The
reach the recipient site through an advancement movement coverage extends to the abdomen, groin, and perineum. The
and flaps that move through a rotation but are not completely saphenous vein may be elevated with the flap for improved
islanded are excluded from this definition (Fig. 5.18).109 When venous drainage. The sensory innervations are from medial
a perforator propeller flap is being elevated, the perforator is anterior cutaneous nerve of the thigh (L2–3). When the flap is
dissected free from the fascial and fat adhesions to minimize based more anteriorly, it is termed the anteromedial thigh flap
the chance of kinking. Although less rotation reduces the and is based on a branch of the lateral femoral circumflex
chance for kinking, the skin island may be safely rotated up artery emerging from the lateral border of the sartorius. Minor

B
A

D
C

Fig. 5.19 (A) 45-year old patient with cancer on the thigh. (B) After the cancer resection, a perforator was found near the defect and enabled a free style propeller flap to
be designed. (C) A near 180° rotation was made based on this perforator. (D) The patient at 2-year follow-up shows good contour and reconstruction results.

pedicles are contributed by musculocutaneous perforating trochanteric and ischial areas. The third perforator arises
vessels of the sartorius and gracilis muscles. When the flap is between the vastus lateralis and the biceps femoris muscles,
moved proximally to the groin, a perforator from the gracilis midway between the greater trochanter and the lateral condyle
muscle is found originating from the profunda femoris vessel of the femur, and the flaps based on second or third perforator
or the medial femoral circumflex vessel. All these flaps men- are for use as microvascular transplantation because of the
tioned can be elevated as a perforator-based flap and named long pedicle. The flap is innervated from the lateral cutaneous
medial thigh perforator flap, anteromedial thigh perforator nerve of the thigh (L2–3).
flap, and gracilis perforator (medial circumflex femoral artery
perforator) flap, respectively.119–122
For the medial thigh septocutaneous flap, the dominant Anterolateral thigh perforator
pedicle is typically located at the apex of the femoral triangle The anterolateral thigh perforator flap is one of the most
approximately 6–8 cm below the inguinal ligament and is widely used perforator flaps. This flap was first reported as a
bordered medially by the adductor longus and laterally by the fasciocutaneous flap by Baek and Song et al.118,123 The skin can
sartorius. A proximal incision is made to locate the vessels at be elevated from a septocutaneous or musculocutaneous
the apex of the femoral triangle. The remainder of the flap is perforator. Numerous perforators are found along the region
then incised and elevated subfascially. of intermuscular septum between the vastus lateralis and
rectus femoris. These perforators usually drain into the
descending branch of the lateral femoral circumflex artery,
Lateral thigh/profunda femoris perforator flap then proximally to the lateral circumflex artery, and then to
The lateral thigh flap located along the lateral aspect of the the profunda femoris artery (Fig. 5.24). When perforators are
thigh between the greater trochanter and the knee can be traced to the source vessel, it allows the pedicle to have long
based on the three perforating branches of the profunda length and thicker diameter. Innervation of the anterolateral
femoris (Fig. 5.23).118 The first perforator arises just below the thigh region is from the lateral femoral cutaneous nerve
insertion of the gluteus maximus, and flaps based on this (L2–3). The perforator frequently dissected is usually located
perforator are used for proximally based flaps to reach the on the midpoint of the line drawn between the anterior

Superficial
circumflex
Inguinal ligament
iliac artery

Sartorius

Saphenous vein

Superficial Sartorius
circumflex fascia B
iliac artery
and vein
Fig. 5.21 The superficial circumflex iliac perforator flap is nourished by only a
perforator of the superficial circumflex iliac system. A large dimension of skin from
the inguinal region can be sufficiently supplied by a single perforator.

along with the perforator to the skin flap. The flap can be
harvested either as a perforator flap including only the perfo-
rator branch to the skin or combined with the vastus lateralis
B muscle as a musculocutaneous flap. According to the need,
the skin paddle may be defatted up to a 3–4 mm thickness
except for the portion that the perforator branch enters. The
Fig. 5.20 Groin flap elevation. The dominant pedicle is the superficial circumflex
motor branch of the femoral nerve running medial to the
iliac artery (A), with venae comitantes and superficial circumflex iliac vein (B).
Superficial femoral artery
Perforating branch to
fasciocutaneous flap
superior iliac spine and the superior lateral border of the
patella. The perforator branches are identified with Doppler
near the midpoint of this line. According to our clinical experi-
ence, about 90% of perforators are found within a 3 cm
diameter drawn at the midpoint of the line. The skin flap is
designed to include the perforator and is then elevated from
the medial border. The flaps can be as large as 35 × 25 cm
based on a single perforator.124 The incision is made through
the deep fascia and raised subfascially until the intermuscular
septum between the rectus femoris and the vastus lateralis
muscle is reached. Now with increased knowledge of the Fig. 5.22 The medial thigh flap located at the midthigh. The dominant blood
perforator flap anatomy, flaps can be easily elevated suprafas- supply for this fasciocutaneous flap is the anterior septocutaneous artery, and venae
cially taking just a small cuff of fascia. At that point, the comitantes are from the superficial femoral artery and vein at the apex of the
descending branch of the lateral femoral circumflex is explored femoral triangle.

tissue transplantation, proximal superficial veins should be

dissected and preserved for possible anastomosis because the
venae comitantes are small.
Gluteus
Thoracodorsal artery perforator
Profunda femoral This flap was first described by Angrigiani et al.128 The vascu-
artery (deep)
lar territory lies on top of the latissimus dorsi muscle. The
Vastus lateralis main perforators are located along the course of the descend-
ing branch of the thoracodorsal artery or from the lateral
IIiotibial tract branch. The most proximal perforator reaches the subcutane-
Biceps femoris ous tissue at a point located 2–3 cm posterior to the lateral
edge of the muscle and 8 cm below the posterior axillary
fold.129 The patient is positioned in a lateral decubitus position
3rd perforating
with the upper arm in 90° abduction and 90° flexion at the
branch of profunda elbow. The lateral border of the latissimus is palpated and
femoral artery marked. Doppler can be used to identify potential perforators
for the flap, and the most proximal perforator can be antici-
pated as mentioned above. Once perforators are identified,
the flap can be designed based on the perforator. Although
larger flap dimensions have been reported, flap dimensions
under 255 cm2 within its vascular territory are safe from
partial necrosis.130 Incision is made from the anterointerior
border of the flap allowing the identification of the anterior
border of the latissimus dorsi muscle. The dissection is
performed between the fat and the deep fascia covering
the muscle. This plane is easy to dissect as it is in a loose
areolar plane. While dissecting for the perforator, care should
be given when dissecting the proximal portion as direct

Fig. 5.23 The lateral thigh flap. This is located along the lateral aspect of the thigh
between the greater trochanter and the knee and can be based on the three
perforating branches of the profunda femoris.

descending branch of the lateral circumflex femoral artery

should be preserved. To elevate as a sensate flap, a branch of Anterolateral thigh
the lateral femoral cutaneous nerve should be included. The flap isolated on lateral
branch of descending
donor site can be primarily closed depending on the laxity of
lateral femoral circumflex
the skin (Fig. 5.25). artery and lateral femoral
cutaneous nerve
Sural
The sural flap is located between the popliteal fossa and the
midportion of the leg over the midline raphe between the two
heads of the gastrocnemius muscle. It is one of the longest
fasciocutaneous flaps of the lower leg based on the direct
cutaneous artery (sural artery branch) in the upper central calf
and extending to the Achilles tendon distally.125,126 The lesser
saphenous vein provides venous drainage. It can cover defects
of the knee, popliteal fossa, and upper third of the leg. When
used distally, based on a reverse flow through anastomoses
between the peroneal artery and the communicating vascular
network of the medial sural nerve, it can reach difficult defect
areas in the lower leg, ankle, and heel region (Fig. 5.26).127 It
is innervated by the medial sural cutaneous nerve (S1–2).
The flap is raised from distal to proximal, in the plane
beneath the deep fascia and above the gastrocnemius muscles.
Fig. 5.24 The anterolateral thigh flap. Numerous perforators are found along the
The sural nerve and lesser saphenous vein are divided region of the intermuscular septum between the vastus lateralis and the rectus
distally and elevated with the flap. The pedicle should be femoris. These perforators usually drain into the descending branch of the lateral
visualized and protected in the popliteal fossa, with continued femoral circumflex artery, then proximally to the lateral circumflex artery, and then
dissection of the pedicle for free tissue harvesting. For free to the profunda femoris artery.

A B

Fig. 5.25 (A,B) The deep fat portion of the

anterolateral thigh can be debulked to
obtain a thinner pliable flap. (C,D) The
patient with soft-tissue defect of the ankle
C D region is seen with excellent contour after
reconstruction without further debulking.

cutaneous or perforators adjacent to the anterior borders are be maneuvered and placed in a 3D manner to achieve an ideal
easily missed. After a suitable perforator is identified, the one-stage reconstruction. Now as complex and complicated
design of the flap in accordance with the defect and pedicle defects are challenged, reconstruction using these compound
can be made. Perforators can be isolated or taken with a flaps is becoming routine for these cases.
muscle cuff reaching down to the main pedicle. Total pedicle According to Hallock’s classification, the subdivisions of
length depends on the location of perforator and the intra- compound flaps are those with a solitary source of vascular-
muscular course of the pedicle. Pedicle length can be acquired ization and those with combinations of sources of vasculariza-
up to 14–18 cm (Fig. 5.27). tion (Fig. 5.28).132 Those with a solitary source include
composite flaps, defined as multiple tissue components all
served by the same single vascular supply, and thereby con-
Compound flaps sisting of dependent parts. Those flaps with combinations of
sources of vascularization include conjoined flaps and chime-
The complexity of reconstruction has changed from simple ric flaps. Conjoined flaps are defined as multiple flap territo-
coverage to addressing the issue of function and cosmetics. ries, dependent because of some common physical junction,
Frequently a simple flap can result in adequate reconstruction yet each retaining its independent vascular supply. Chimeric
and may undergo several revisions until the final outcome flaps are defined as multiple flap territories, each with an
becomes acceptable. A compound flap consists of multiple independent vascular supply, and independent of any physi-
tissue components linked together in a manner that allows cal interconnection except where linked by a common source
their simultaneous transfer.131 These separate components can vessel (Fig. 5.29).

Fig. 5.26 The reverse sural artery flap is a fasciocutaneous flap based on the
median superficial sural artery and its communication with the perforating branch of DB of TD
the peroneal artery situated in the region of the lateral malleolar gutter. Reverse flow artery
is established after elevation of the flap and with division of the sural artery and the
nerve proximally.

Supermicrosurgery
The supermicrosurgery technique is defined as microsurgical
anastomosis of vessels, with a diameter <0.8 mm.109,129 This
technique, although reported frequently on lymphaticovenous
shunting to treat lymphedema and sporadically in soft-tissue
reconstruction with specific indications, is a relatively new
concept for lower extremity reconstruction.129–132 For the
lower extremity soft-tissue reconstruction, one of the applica-
tions can be seen in the perforator-to-perforator anastomoses
approach.68,111 With an evident pulse on the perforating artery, B
it can be successfully used as a recipient vessel to supply a
sizable flap. This approach will allow an increase in the selec-
tion of recipient pedicles. By using a perforator-to-perforator Fig. 5.27 Thoracodorsal artery perforator flap. The main perforators are located
along the course of the descending branch of the thoracodorsal artery or from the
anastomosis approach, less time is consumed to secure the lateral branch. The most proximal perforator reaches the subcutaneous tissue in a
recipient vessel as the flap can be elevated by taking just a short point located 2 or 3 cm posterior to the lateral edge of the muscle and 8 cm below
segment of the perforator pedicle, which minimizes any risk the posterior axillary fold. DB, descending branch; TD, thoracodorsal.
for major vessel injury, or can utilize collateral circulation
without apparent flow of major vessels while having accept-
able flap survival (Fig. 5.30). Further, studies on physiology and
anatomy will be needed to evaluate the extent of application.

Composite

Conjoined

Chimeric Fig. 5.28 Classification of compound flaps.

Gracilis

Descending branch of
lateral femoral circumflex

Vastus lateralis

Anterolateral thigh
perforator flap
B

Fig. 5.29 The chimeric flaps defined as multiple flap territories, each with an
independent vascular supply, and independent of any physical interconnection except
where linked by a common source vessel. Example of complex extremity
reconstruction is shown using a chimeric approach. The source vessel of the
descending branch of the lateral femoral circumflex artery feeding the vastus lateralis
C and the anterolateral thigh perforator flap. A gracilis is connected using a branch
from the source vessel.

A B

C D

Fig. 5.30 (A) The application of supermicrosurgery (perforator-to-perforator anastomosis) on the lower extremity is shown. A patient with chronic osteomyelitis is seen after
debridement. (B) A recipient perforator was located adjacent to the defect margin piercing the fascia with a good visual pulse. (C) After the elevation of anterolateral thigh
with a short perforator pedicle segment, anastomosis is performed. (D) The flap is shown to have good contour without recurrence of infection.

Access the complete reference list online at http://www.expertconsult.com

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Medical Center performed a multicenter, prospective, observational study Surg. 2010;125(2):582–588. The authors from the Duke University
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profile: a multidimensional self-reported health status to determine the that the primary goal of limb salvage is to restore or maintain function
long-term outcomes after amputation or limb reconstruction. They report based on proper patient selection, timely reconstruction, and choosing the
that at 2 years, there was no significant difference in scores for the best procedure that should be individualized for each patient. Aggressive
Sickness Impact Profile between the amputation and the reconstruction debridement and skeletal stabilization, followed by early reconstruction,
groups. They advise that patients with limbs at high risk for amputation are the current standard of practice and give better results than the more
may undergo reconstruction and will have results in 2 years that are traditional approach of repeated debridements and delayed flap cover. For
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68. Hong JP. The use of supermicrosurgery in lower extremity literature. Better accuracy in reconstruction, including the use of only
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1995;9(2):121–127. the first choice.

19. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr
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N Engl J Med. 2002;347(24):1924–1931. The authors from Carolinas best procedure that should be individualized for each patient. Aggressive
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of 569 patients with severe leg trauma and evaluated the sickness-impact are the current standard of practice and give better results than the more
profile: a multidimensional self-reported health status to determine the traditional approach of repeated debridements and delayed flap cover. For
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Reconstructive Surgery - Lower Extremity Coverage

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Reconstructive Surgery - Lower Extremity Coverage

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SECTION I • Lower Extremity Surgery

Reconstructive surgery: Lower

tissue and bone defects. If the extremity cannot be salvaged,

on this principle, and advances made in the new millennium,

Approach by location (local flaps)

foot trauma, and anticipated protracted course to obtain soft-

Fig. 5.9 A diabetic patient after partial

impossible, a reasonable endpoint should be set and efforts to

rectus femoris muscle to be identified and separated from the

Branch from Medial femoral

Semimembranous Fig. 5.14 Gracilis muscle flap elevation. It is a type II

Medial sural artery,

Lateral sural nerve,

Indirect linking vessels

Fig. 5.17 The elevation for fasciocutaneous flaps is made

to 180°. In addition, although the extent of survival associated

Groin/superficial circumflex iliac perforator

tissue transplantation, proximal superficial veins should be

descending branch of the lateral circumflex femoral artery

Fig. 5.25 (A,B) The deep fat portion of the

Chimeric Fig. 5.28 Classification of compound flaps.

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