an atlas of flap in limb reconstruction

Intermetacarpal and
dorsocommissural
flaps
A These flaps are raised from
the dorsum of the metacarpal
region of the hand. They are
distally based pedicle island flaps.
The intermetacarpal flaps are
theoretically based on the dorsal
intermetacarpal arteries. In fact,
these arteries are constant only for
the first and second space, so
such flaps are not reliable for the
third and fourth space.
The dorsocommissural flaps are
raised between the metacarpal
heads at the tip of the webs. The
vascular anastomoses between the
dorsal and palmar systems should
be ligated and divided. The flap is
distally supplied by the anasto-
moses between the dorsal vascu-
lar network of PI and the palmar
digital artery. These anastomoses
are located just proximal to the
proximal interphalangeal
(PIP)
joint.
I ntermetacarpal and dorsocommisural flaps
A
1
irtermetacarpal flaps
2 dorsocommissural flaps

Transfers from the upper limb
B An intermetacarpal flap is
elevated from the second inter-
metacarpal space. The flap is
outlined just distal to the bases of
the adjacent metacarpal bone.
The subcutaneous fascia which
covers the interosseous muscle is
raised
in
the
pedicle,
fascia
included.
The pivot point is
located at the tip of the web. The
arc of rotation allows coverage of
the dorsum of the first phalanx of
the adjacent fingers.
B
1 extensor tendons
2 interosseous muscle
3 subcutaneous fascial pedicle of the
flap
C
3
3
2
C For the elevation of a dorso-
commissural flap, all the webs can
be involved, and the pedicle of a
flap can be raised on either the
radial side or the ulnar side of the
two adjacent fingers.
An incision is made on the
lateral aspect of Pl. The skin
edges are retracted by a subder-
mal dissection and a subcutaneous
pedicle is raised until the pivot
point just proximal to the PIP
joint. The arc of rotation allows
coverage of the palmar aspect of
the first phalanx, and the dorsum
1
dorsal expansion
of the second phalanx distal
2 subdermal dissection
interphalangeal
(DIP)
joint
3 subcutaneous pedicle of the flap
included.

5
Transfers from
the lower limb

Transfers from the lower limb
Thigh
Introduction
The surgery of coverage in the pelvic girdle is indeed
dominated by the treatment of pressure sores; but
this treatment is not limited to the knowledge of the
surgical procedures available, especially in the case
of neurological patients who require particular and
specialized care and very advanced techniques. We
do not want to describe all the possibilities of flaps
for the treatment of sores, but only to offer a techni-
cal description of the most currently used flaps in
this region.
Gluteus maximus and biceps femoris are island
pedicled flaps and they are employed usually for local
indications. Tensor fasciae latae myocutaneous and
gmcilis flaps also have a wide range of applications in
free transfer surgery. In our view, the lateral thigh flap
is only to be used as an island pedicled flap for knee
coverage.
Vastus lateralis flap
Introduction
The vastus lateralis flap is important for coverage of
defects of the pelvic girdle. The muscle is one of the
four parts of the quadriceps. The functional deficit
following its elevation is of little importance.
However, it constitutes a very large vascular bypass
between the profunda femoris artery and the
popliteal artery when the femoral artery is obliter-
ated. An arteriogram is required in arteriosclerotic
patients before its elevation.
Indications
• Proximally based island flap: coverage of the proxi-
mal
portion
of the thigh (femoral vessels,
trochanteric sore); coverage of the pubis and the
lower ipsilateral abdominal wall.
• Distally based pedicled flap: coverage of the knee.
This procedure is not routinely advocated.

A
1
lateral circumflex artery
2 the great artery of the vastus
lateralis (according to Salmon)
3 femoral artery
4 deep femoral artery
5 popliteal artery
Vastus lateralis flap
Vascular supply
A The muscle is type II in the
Mathes and Nahai classification. It
is richly vascularized by numerous
pedicles which arise mainly from
the profunda femoris.
Proximally, the muscle receives
two
well identified arteries.
The most proximal comes from
the lateral circumflex artery
and runs for a short distance
close to the femoral insertion
of the muscle. The second one
arises either from the lateral
circumflex artery (transverse
descending branch) or from a
common trunk arising from the
profunda femoris. This huge
vessel is called `the great artery
of the vastus lateralis' (Salmon).
The middle third of the muscle
is nourished by the perforating
arteries of the profunda femoris.
The distal third receives a
sizeable muscular branch from
the first collateral artery of the
popliteal artery.
The two proximal branches are
sufficient to supply the muscle in
its entirety. The distal group of
arteries comprising the last perfo-
rating artery and the collateral of
the popliteal artery is not reliable
enough to undertake a distally
based pedicle flap.
The motor nerve accompanies
the descending branch of the
lateral
circumflex
artery
and
enters the muscle in its proximal
third. The neurovascular pedicle
is thus defined.
The pedicle transfer is based on
the two proximal arteries.

Transfers from the lower limb
Operative procedure
The patient is supine, with a
sandbag
under the ipsilateral
buttock;
the
whole limb is
included in the operative field.
B The incision is made along a
line from the anterior superior
iliac spine to the lateral angle of
the patella, beginning between 10
and 15 em distal to the spine. If a
trochanteric sore is to be resur-
faced, the incision starts from the
margin of the defect and runs
obliquely towards the patella.
C
The fascia lata is opened, care
being taken in the proximal third
to preserve the vascular pedicle to
tensor fasciae latae. The space
between rectus femoris and vastus
lateralis
is
identified
and
cautiously opened in its middle
third.
C
1 tensor fasciae latae
2 rectus femoris
3 vastus lateralis
B

2
Vastus lateralis flap
D Care should be taken to
preserve the vascular pedicle to
vastus lateralis which runs deep to
rectus femoris and crosses the
operative field in the proximal
third. The branch that descends
along the medial border of the
muscle must also be protected. It
lies in thin fatty tissue that should
be left in continuity with the
muscle.
D
1 minor vascular bundle (from the
lateral circumflex artery)
2 vastus lateralis
3 rectus femoris
4 major vascular pedicle to vastus
lateralis
5 motor nerve to vastus lateralis
E
In the distal third, the tendon
is
incised
to
separate
rectus
femoris and vastus lateralis. The
distal
end of the muscle is
separated
from the extensor
apparatus of the knee and the
muscle is then released from
vastus intermedius
which lies
beneath it. The aponeurosis on
the deep aspect of vastus lateralis
should be included to facilitate
the dissection between the two
muscles.
E
1 vastus laterals, retracted
2 vastus intermedius
3 rectus femoris

Transfers from the lower limb
F vastus lateralis and vastus
intermedius are divided
F
Vastus intermedius and vastus
laterally insert into the linea
aspera and they are not easily
separated at that level. The muscle
flap is raised in the distal to proxi-
mal
direction,
being
carefully
G The arc of rotation allows
coverage of the pubis and the
lower abdomen, medially, and the
area of the greater trochanter,
laterally.
G
released from its insertion into the
linea aspera. The muscle can be
isolated on its two proximal
vascular pedicles, as a true island
flap, by releasing its femoral inser-
tion.

Tensor fasciae latae
myocutaneous flap
I ntroduction
The tensor fasciae latae myocuta-
neous flap is one of the earliest
described free flaps. It comprises
en bloc the tensor muscle, the
fascia lata and the skin overlying
the fascia. It is little used as a free
flap but it retains some indica-
tions as a pedicled flap, especially
for the coverage of pressure sores
in
the region of the greater
trochanter.
Indications
Use as a free flap is indicated
when it is also necessary to
resurface a skin defect and to
restore
the
continuity
of
avulsed tendons.
Coverage of pressure sores of
the trochanteric area and repair
of the lower abdominal wall.
Vascular supply
This flap is type I in the classifi-
cation of Mathes and Nahai. The
muscle is supplied by a single
pediele issued from the lateral
circumflex artery. The diameter of
the artery at its origin is 2 mm and
the length of the pediele is about
8 cm. The muscle is nourished via
the fascia lata and the overlying
skin. The flap must include en
bloc the three above components.
Sensory nerve supply is ensured
by the lateral cutaneous nerve of
the thigh.
Tensor fasciae latae myocutaneous flap
Operative procedure
A pedicled flap is used to resur-
face a pressure sore in the region
of the greater trochanter.
A
The landmark of the pediele is
about 10 em distal to the anterior
superior iliac spine. The flap is
outlined on the lateral aspect of
the thigh; the anterior border
corresponds to the line which
joins the anterior iliac spine to the
patella.
10W
A, I
~l
yJ!rY4~
lly !~°~ f! til,,
~n;r!Ln. ie
U~Im(ir%!0
A
1
trochanteric defect

Transfers from the lower limb
B In the upper part of the
incision the plan between sarto-
rius
and tensor fasciae latae is
identified and developed. Deeper,
rectos femoris is exposed. In the
lower part, the fasciocutaneous
flap is raised, exposing the under-
lying vastus lateralis muscle.
B
1 tensor fasciae latae
2 vastus lateralis
3 sartorius
4 lateral cutaneous nerve of thigh
C The medial border of the
fascia is incised distal to proximal
until
the
pedicle is exposed.
Medially,
sartorius
and rectos
femoris are retracted.
C
2
1 supplying pedicle to tensor fasciae
latae
2 incision of the fascia
4
3

D When a pedicled flap is
required, it is not necessary to
pursue the dissection further
proximally. A proximal hinge of
skin tissue is maintained.
Tensor fasciae latae myocutaneous flap
The extremity of the flap is
rotated to cover the defect. The
dog's ear on the lateral side of the
flap will be corrected later. The
donor site can rarely be primarily
sutured.
A split-thickness skin
graft is applied.

Transfers from the lower limb
Gracilis flap
Introduction
This is a very useful transfer
which does not cause functional
impairment for the limb. The
applications
are numerous and
various.
I ndications
Gracilis can be used as a free or
an island pedicled flap.
The free flap may be used for:
• Coverage of defects. The muscle
is well vascularized by its proxi-
mal pedicle. If needed, a small
portion of the muscle can be
raised.
• Functional transfer. Gracilis is
probably the best free transfer
muscle to restore paralysed
functions
such
as
elbow
flexion,
finger
extension
or
finger flexion. In this indication
the procedure usually requires a
skin island to ensure a good
quality of skin overlying the
transfer.
The pedicle flap is used locally
to treat limited defects of the
groin and ischiatic regions.
Vascular and nerve
supply
The gracilis is type 11 in the classi-
fication of Mathes and Nahai. The
dominant pedicle is proximal and
is accompanied by the motor
nerve. The artery arises from the
medial
circumflex
artery
or
directly from the femoral artery.
The pedicle is 6 cm in length.
The diameter of the artery at its
origin is 1.5 mm. A secondary
pedicle can be of importance at
the middle of the thigh. In some
cases of free transfer the vein of
this
pedicle can be used to
improve the venous return.
Operative procedure
Gracilis is elevated with dissection
of the pedicle (this is not neces-
sary when the muscle is used
locally).
A
The incision is outlined on the
medial aspect of the thigh. It is
not always easy to identify the
body of gracilis. The identification
of the muscle requires the dissec-
tion of the distal tendon. A slight
traction on the tendon allows the
precise definition of the course of
the
muscle and the eventual
repair of the skin incision.
A

5
4
Gracilis flap
B The fascia is incised, taking
care with the saphenous vein.
Gracilis
lies
between
vastus
medialis and adductor magnus.
Care should be taken with the
saphenous nerve, which arises
from the femoral nerve.
B
1 gracilis
2 adductor magnus
3 saphenous vein
4 vastus medialis
5 saphenous nerve
C The pedicle should be
dissected to divide the insertion
of the muscle. Gracilis is slightly
retracted posteriorly to open the
space where the neurovascular
pedicle lies.
C
1
motor nerve (from obturator nerve)
2 vascular pedicle
3 gracilis
4 adductor magnus
5 saphenous vein
6 saphenous nerve
7 vastus medialis

Transfers from the lower limb
D
1 origin of the pedicle on the medial
circumflex artery
2 motor nerve (from obturator)
2
D
The vascular pedicle gives off
a
branch to vastus medialis,
which is ligated. Before entering
gracilis, the pedicle divides into
three or four very short branches
of small diameter, the integrity of
E Elevation of flap
which should be respected. The
retraction
of
vastus
medialis
allows isolation of the pedicle as
far as its origin from the femoral
artery or the medial circumflex
artery. The nerve comes from the
obturator nerve and divides into
two branches before entering the
muscle. It can be dissected for a
considerable distance proximally.

Biceps femoris flap
(long head)
Introduction
This flap is very useful for the
treatment of ischiatic sores. The
biceps femoris is not essential for
the function of the knee. The
muscle transfer can be done with
a skin island.
I ndications
• Ischiatic sores.
The flap can be used in two differ-
ent ways:
An advancement of the muscle,
usually with a skin island, after
releasing the proximal and the
distal insertion.
A rotation of the distal end of
the muscle on the pivot point,
which is formed by the proxi-
mal pedicle.
Vascular supply
The muscle belongs to type II in
the classification of Mathes and
Nahai. There are some variations
in the vascular distribution but,
schematically, the proximal source
comprises two important arteries
which arise from the profunda
femoris. This proximal vascular
pole is sufficient to supply the
whole muscle. The other pedicles
are smaller and not worthy of
interest.
Operative procedure
The rotation flap can be used for
an ischiatic sore.
A The skin incision crosses the
thigh from the lateral border of
the defect to the distal insertion of
long head.
Biceps femoris flap (long head)
A
1 defect (ischiatic sore)
2 line of incision

Transfers from the lower limb
B The skin edges are retracted
and undermined to identify the
limits of the biceps femoris. The
plane
is
developed
medially
between
biceps
femoris
and
semitendinosus muscles and, later-
ally between biceps femoris and
vastus lateralis muscles.
The posterior cutaneous nerve
of the thigh, which lies in the
subcutaneous tissue, should be
spared.
B
1
semitendinosus
2 posterior cutaneous nerve of thigh
3 biceps femoris
4 vastus lateralis
2
3
C
The distal part of the muscle
is isolated and the distal insertion
is divided. The muscle is released
distal to proximal. At mid-thigh,
an important pedicle arising from
the profunda femoris is IIgated.
C
1
adductor minlmus
2 semitendinosus
3 posterior cutaneous nerve of thigh
( with vessels)
4 biceps femoris (short head)
5 vastus lateralis
6 pedicle from the deep femoral artery
(to be ligated)
7 biceps femoris (long head)

Biceps femoris flap (long head)
D,E
The dissection is pursued
until
the
proximal
pedicle is
exposed.
Then the muscle is
rotated as a page of a book to fill
up the defect easily.
D
1 proximal pedicle supplying biceps
femoris

Transfers from the lower limb
F
In cases of very large defects
in paraplegic patients, the two
muscles, semimembranosus and
biceps femoris, can be used in
association.
They are advanced
with a skin paddle, after releasing
their
distal
and proximal inser-
tions.
F

Lateral and distal
thigh flap
Introduction
The lateral and distal thigh flap is a
cutaneous
flap
with
an
axial
pattern vascularization. It is reliable
and only used as a pedicle flap.
I ndications
This flap is raised on the distal
third of the lateral aspect of the
thigh, the arc of rotation depend-
ing on the choice of pedicle
according to the variations of the
vascular network.
The flap, the measurements of
which are 18 x 7 cm, is indicated
for coverage of the lateral aspect
of the knee joint and the anterior
aspect of the femoral epiphysis.
In the case of a large lateral
defect of the knee, it can be
combined with a myocutaneous
flap of the lateral head of gastroc-
nemius. The flap is also useful for
repair of popliteal defects.
Vascular supply
The skin territory is supplied by
a large cutaneous branch arising
from the first collateral artery of
the popliteal artery. This artery
arises from the popliteal artery,
just distal to the adductor hiatus,
and
delivers
via
muscular
branches to vastus lateralis and
biceps. The terminal cutaneous
branch emerges in the subcuta-
neous
tissue
between
the
inferior border of Maissiat's band
and the distal portion of biceps
femoris, 10 cm proximal to the
knee
joint.
The
cutaneous
branch is the pedicle of the flap
and its emergence constitutes
the pivot point. Sometimes, but
not always, the main trunk or the
cutaneous branch anastomoses
Lateral and distal thigh flap
with the lateral superior genicu-
lar artery of the knee. The flap
can be distally based on this
artery by ligating the vessels
arising from the popliteal artery.
Thus the pivot point of the
pedicle is more distal, as far as it
is possible to isolate the proxi-
molateral
genicular
artery. In
these conditions the flaps can
reach the epiphysis of the tibia.
Operative procedure
A The flap is outlined on the
lateral aspect of the thigh. The
emergence of the pedicle is
marked 10 cm proximal to the
articular space, in the depression
between the posterior border of
Maissiat's band and the relief of
biceps femoris. This depression
can be found with the finger.
The design of the flap should
include
the landmark of the
pedicle.
A
a landmark of the emerging pedicle

Transfers from the lower limb
B The raising of the flap
commences anteriorly,
without
including the fascia and its areolar
tissue.
The plane of dissection is easy
to find.
B
1
fascia lata (Maissiat band)
3
C,D
The fascia lata and the vastus
medialis are retracted, exposing
the vascular pedicle, arising from
the popliteal artery. The pedicle is
isolated and released from the
surrounding tissues.
D
1
pedicle
C
1
fascia lata
2 vastus lateralis
3 pedicle

F Release of the posterior
border of the flap
Lateral and distal thigh flap
2
E,F
After the pedicle is identi-
fied, the posterior hinge of the
flap is divided, taking care with
the pedicle.
E
1 biceps femoris
2 pedicle

Transfers from the lower limb
G Rotation of the flap allows
coverage
of the anterior, the
lateral and the posterior aspects of
the knee.
It can be interesting to explore
the
pattern
of
vascularization
around the lateral condyle. If there
is
an anastomosis between the
artery of the pedicle and the lateral
superior genicular artery, the flap
can be distally based on the former,
after ligature of the artery arising
from the popliteal artery.

Osteoperiosteal flap
(from the femur)
Introduction
Many studies have shown the
formation of bone from vascular-
ized periosteum. The association
of a vascularized periosteal flap
with a conventional cancellous
bone graft allows us to recon-
struct long bone defects or to
obtain the healing of a recalcitrant
non-union. The raising of small
cortical chips
which remained
attached
to
the
periosteum
increases the osteogenetic capac-
ity of the flap. Thus these proce-
dures may be an alternative to
other vascularized bone transfers,
such as the fibula or the iliac
crest. However, they are not yet
widely used and well accepted.
The donor site of the distal
third of the femur is described.
Indications
• Reconstruction of long bone
defects. The flap is tubulized
and filled up with cancellous
bone graft.
• Healing
of recalcitrant
non-
union. The flap is wrapped
Osteoperlosteal flap (from the femur)
around the non-union, and the
bone defect is filled up with
cancellous bone.
Repair of skull defects. The
versatility of the flap allows it
to be matched with any defect
of the skull, especially in areas
where there is a high risk of
recurrent infection.
Most of the time the flap is used
as a free flap. Nonetheless, the arc
of
rotation
provided
by the
pedicle allows coverage of the
midshaft of the ipsilateral femur.
Vascular supply
The flap is vascularized by the
articular branch of the descending
genicular artery. This artery arises
from the femoral artery just proxi-
mal to the adductor hiatus. The
common trunk is rather short (on
average 2 em) and divides into
three branches:
A muscular branch to vastus
medialis.
A cutaneous branch which joins
the saphenous nerve and passes
beneath sartorius.
An articular branch
which
courses
along the adductor
magnus tendon as far as the
femoral insertion on the medial
condyle. At this level the artic-
ular branch anastomoses with
the medial superior genicular
artery and runs upwards to
reach the metaphysis of the
femur. It divides into multiple
branches
which nourish the
periosteum and the articularis
genus muscle.
The pedicle is raised at the
origin of the descending genicular
artery.
The
muscular
and
cutaneous
branch
(saphenous
artery)
need to be ligated.
Different flaps can be raised:
Periosteal flap.
Osteoperiosteal flap with small
chips of cortical bone or with a
compact piece of bone raised
from the medial aspect of the
femur.
Musculo-osteoperiosteal flap by
including the articular is genus
muscle.
Operative procedure
A The patient is supine, the
lower limb externally rotated. A
tourniquet is applied at the root of
the thigh. The skin incision is
outlined on the relief of adductor
magnus tendon.

Transfers from the lower limb
B The deep fascia is incised,
exposing the posterior border of
vastus medialis and the tendon of
adductor magnus.
B
1 adductor magnus tendon
2 vastus medialis
C Vastus medialis is released
from the
distal aponeurosis
of
adductor magnus.
The articular branch is often
included in a fibrous tunnel,
which should be incised to
expose the origin of the descend-
ing genicular artery.
C
1 articular branch of the descending
genicular artery
2 adductor magnus tendon
3 vastus medialis
4 incision
5 femur (lower third)

Osteoperiosteal flap (from the femur)
E
1 descending genicular artery
D
1 articular branch of
descending genicular artery
2 saphenous branch of
descending genicular artery
3 descending genicular artery
4 femoral artery
5 pedicle to vastus medialis
6 vastus medialis
7 osteoperiosteal flap
D
The metaphysis and the lower
part of the shaft of the femur are
exposed.
The vascular pattern of the
region is identified. The distal end
of the articular branch is ligated at
the level of its anastomoses with
the
medial
superior
genicular
artery.
The periosteal flap is
outlined on the femur and the
periosteum is incised with a knife.
Pieces of cortical bone remaining
attached to the flap are raised
with a curved chisel.
E
The flap is raised (10 x 5 cm).
It can be modelled according to
the indication.
The saphenous artery and the
muscular branch to vastus medial
should be ligated to raise the
pedicle. Then the flap can be
tubutized to reconstruct a long
bone defect (no more than 10 cm).

Transfers from the lower limb
Leg
I ntroduction
The leg is probably the most exposed segment of the
limbs, with the exception of the hand. Direct injuries
are frequent, especially on the middle third, and the
tibia is vulnerable on its anterior aspect, protected
merely by the skin. Open fractures of the leg are
always a challenge for the surgeon and imply differ-
ent problems in terms of viability, function, cost of
treatment and the hope of the patient.
However, many advances have been made in the
last decade in the management of soft-tissue defects
of the leg. Numerous fasciocutaneous and muscular
flaps have been described and widely used with
success, even by non-specialist surgeons.
The concept of the fasciocutaneous flap was first
elaborated in the leg. On the other hand, the proce-
dure of reverse arterial flow in distally based pedicled
flaps which has been used in the hand is more diffi-
cult to apply to the lower limb: first, because it is
more prejudicial to sacrifice a main vascular axis at
the leg than at the forearm; second, because the
reverse arterial flow provided by an artery of the leg
implies venous congestion, as was observed in the
attempts at a reversed flap based on the anterior and
posterior tibial arteries or even on the peroneal artery.
The reason is probably that the system of valves in
the veins of the lower limb is different from that in
the upper limb. Thus, skin flaps based on a non-
dominant vascular axis or supplied by the vascular
network of the superficial sensitive nerves are worthy
of interest. In fact, any superficial nerve of the leg can
be raised without great impairment in relation to the
benefit of coverage.
Another important feature is specific to the leg.
Practically all the potential muscle transfers are
located in the posterior compartment. Most of the
time they are intact after an anterior injury and are
available. Moreover, all the muscles of the deep and
superficial posterior compartment participate in the
plantar flexion of the foot. This implies that the
raising of one muscle does not lead to an important
functional impairment.
Fasciocutaneous saphenous
artery flap
I ntroduction
This flap is the prototype fasciocutaneous flap. It is
raised on the medial aspect of the calf. The inclusion
of the deep fascia allows the preservation of the
suprafascial vascular network and of the multiple
anastomoses between cutaneous, fascial and muscular
vessels.
Vascular supply
The skin of the medial aspect of the calf is supplied
by three groups of arteries:
1 The saphenous artery, which accompanies the
saphenous
nerve,
providing
numerous small
branches to the skin. It can be considered as the
axial artery of the flap.
2 The arteries arising from the posterior tibial artery,
emerging from the intermuscular space between
the superficial and deep flexor compartments of
the leg.
3 The short branches arising from the deep surface
of the muscles, particularly the medial head of
gastrocnemius.
Indications
Coverage of the infrapatellar region of the knee and
the proximal two-thirds of the tibia.
The cross leg flap.

A
Operative procedure
The patient is supine, with the
knee semi-flexed and the limb in
external rotation.
Fasciocutaneous saphenous artery flap
A The anterior border of the
flap includes the long saphenous
vein to preserve the saphenous
artery. Posteriorly, the incision is
slightly medial to the midline of
the calf. The distal end of the flap
should not extend further than
the union of the middle and distal
thirds of the tibia.
Proximally,
a fasciocutaneous
bridge is preserved at the distal
border of sartorius.

Transfers from the lower limb
B,C
The deep fascia is incised
strictly
in line
with the skin
incision. The long saphenous vein
is ligated and divided, and the
saphenous nerve divided. The flap
OEM
is raised from distal to proximal,
the dermis being sutured to the
fascia.
Cutaneous arteries from
the tibia] or muscular vessels
should be ligated or cauterized.
Frequently,
a
large
proximal
branch arising from the medial
head of gastrocnemius can be
preserved.
B
1 saphenous vein and nerve
a line of fascia incision
C
1 medial head of gastrocnemius

D
Care should be taken to spare
the
vascularized
areolar
tissue
which lies on the aponeurosis of
gastrocnemius. In the medial and
upper part of the donor site, the
E
The saphenous flap is useful
for the cross leg procedure to
cover soft tissue defects on the
opposite leg or foot. When possi-
ble, the proximal hinge of the
flap is sutured like a tube. The
inner portion of the flap which
is neither sutured nor attached
Fascocutaneous saphenous artery flap
hollow is filled up with the medial
head of gastrocnemius, which is
sutured to the medial subcuta-
neous edge.
to the recipient site, is covered
with a split-thickness skin graft
to
avoid infection.
Both legs
should be fixed with plaster or
an external device to avoid
stresses on the flap. The release
is usually performed three weeks
later.
D

Transfers from the lower limb
Gastrocnemius
flaps
Introduction
The gastrocnemius flap is proba-
bly the most useful for coverage of
the leg and
the
knee.
The
technique of elevation is easy and
the blood supply is reliable. The
elevation of both parts of the
muscle is possible
with
two
separate incisions
and
a wide
posterior
subfascial
dissection,
without risk to the skin in non-
arteriosclerotic patients.
Vascular supply
A Gastrocnemius
comprises
both medial and lateral heads and
is supplied by the sural arteries,
which arise from the popliteal
artery and are accompanied by
the motor nerves.
Each head can be mobilized
individually on its own neurovas-
cular pedicle. The vascular supply
is type I in the Mathes and Nahai
classification.
A
1 sural artery
2 medial head
3 lateral head
4 popllteal artery

The medial head
I ndications
The medial head is more often
employed than the lateral head.
The muscular body of the medial
head is longer and the arc of
rotation of the transfer allows easy
coverage of the proximal third of
the tibia and the anterior and
medial aspect of the knee.
Some techniques are useful to
increase the arc of rotation. These
are:
• The multiple transverse incision
in the aponeurosis which lies
on the deep aspect of the
muscle.
The division of the proximal
tendon insertion.
These two procedures allow
increase of the territory of cover-
age distally over the junction of
the proximal and middle third of
the leg.
Association with a skin paddle
located on the distal part of the
muscle and on the distal aponeu-
rosis permits a longer flap which
can cover a portion of the middle
third of the leg. The rotation over
the knee is improved by decross-
ing the muscle with the tendons
of semitendinosus and gracilis.
The medial head
Operative procedure
B
The patient is supine, the limb
in external rotation and the knee
slightly flexed. The incision starts
at mid-calf,
2
em behind the
posteromedial border of the tibia,
and curves proximally to reach
the
popliteal fossa. It can be
extended along the thigh if neces-
sary.

Transfers from the lower limb
C
Care should be taken to avoid
injury to the saphenous vein and
nerve. The deep fascia is incised
in line with the skin incision, and
a large skin flap, including the
aponeurosis, is retracted posteri-
orly as far as the plane between
the two heads of gastrocnemius.
D The intermuscular plane is
developed with a forger between
soleus and the medial head after
incision of the thin aponeurosis.
Often the plantaris tendon is
found in this space. 'fhe sural
nerve is identified on the poste-
rior aspect of gastrocnemius. It
lies between the two heads on an
aponeurosic sheet and is covered
by a thin layer of muscle fibres
from the medial head. It is
dissected free and retracted poste-
riorly.
D
1
medial head of
gastrocnemius
2 sural nerve
3 semitendinosus
4 gracilis
5 saphenous vein
6 sartorius
7 soleus

E
1
aponeurosis between the two heads
of gastrocnemius
2 sural nerve, retracted
The medial head
E
The space between the two
heads is identified,
with care
being taken to preserve the
neurovascular pedicle. The distal
tendon of the medial head is
divided. The muscle is progres-
sively raised in a distal to proximal
direction by cutting the aponeu-
rotic sheet that
joins the two
heads.
F The motor nerve should be
divided to avoid postoperative
pain caused by muscle contrac-
tion. It accompanies the vascular
pedicle and is found on the lateral
side of the proximal part of the
muscle.
F
1 vascular pedicle to the medial head
of gastrocnemius
2 tibial nerve
3 popliteal artery
4 plantaris

Transfers from the lower limb
G
G The arc of rotation may be
increased by releasing the origin
of the muscle from the femur. The
skin incision, extended over the
lower part of the thigh, allows the
exposure
of
the
tendons
of
semitendinosus,
sartorius
and
gracilis.
The
medial
head
of
gastrocnemius, isolated
on its
vascular pedicle, must be passed
deep to the tendons of semitendi-
nosus and gracilis in order to
reach the anterior aspect of the
knee.

The lateral head
I ndications
The lateral head is less employed
than the medial head because the
muscular body is smaller and the
fibula constitutes an obstacle to
the passage of the flap to the
knee. Nonetheless, the lateral head
is indispensable for coverage of
the lateral aspect of the metaph-
ysic of the tibia (e.g. after a partial
necrosis of tibialis anterior follow-
ing a compartment syndrome).
The muscle flap alone does not
cover the anterior aspect of the
knee but covers the lateral aspect
of the joint without difficulty. The
myocutaneous flap allows cover-
age of the patella. With a rotation
of 180 ° the muscle covers the
distal quarter of the femur.
The lateral head
Operative procedure
The patient is supine with a sand-
bag under the ipsilateral buttock
to maintain the limb in slight
internal rotation and the knee
semiflexed.
A
The skin incision is just poste-
rior to the fibula. It can be
extended proximally, crossing the
popliteal fossa.

Transfers from the lower limb
B
1 biceps femoris
2 medial head of
gastrocnemius
3 sural nerve, retracted
4 lateral head of
gastrocnemius
5 soleus
6 lateral sural nerve
7 common peroneal
nerve
8 head of fibula
B,C
The plane under the fascia
is
developed,
exposing
the
muscle. The sural nerve and the
lateral
sural
nerve should be
identified and spared.
When an extensive mobilization
of the muscle is required, the
biceps tendon and the common
peroneal
nerve
are
exposed.
Medially,
the
sural
nerve
is
dissected and retracted and the
aponeurotic sheet between the
two heads is incised. Laterally, the
plane between soleus and gastroc-
nemius is developed.
C
1 popliteal vessels
2 tibia[ nerve
3 medial head of gastrocnemius
4 sural nerve, retracted
5 lateral head of gastrocnemius
6 head of fibula
7 biceps tendon
8 common peroneal nerve
3
4

D
2
3
4
5
2
3
The lateral head
1
popliteal artery
2 tibial nerve
3 neurovascular pedicle to the medial
head
4 common peroneal nerve, retracted
5 sural nerve, retracted
D The transfer is progressively
raised after dividing the distal
tendon. The common peroneal
nerve
is
mobilized
and the
neurovascular pedicle is identified
in
order to divide the motor
nerve.
E If the muscle is needed to
cover a defect over the anterior
aspect of the knee, the muscle
transfer is passed deep to the
peroneal nerve and if possible
deep to the biceps tendon (it
should be verified that the muscle
and
its
pedicle
are
not
compressed).
This manoeuvre is not neces-
sary when the defect is over the
proximal third.
E
1
tendon of biceps femoris
2 common peroneal nerve
3 head of fibula

Transfers from the lower limb
Soleus flap
Introduction
Soleus is a very useful transfer for
covering defects of the leg. It lies
in the superficial part of the poste-
rior compartment and frequently
is
undamaged in compound
fractures of the middle third of
the tibia.
Indications
The elective indication of soleus is
the coverage of the middle third
of the leg. However, the muscle is
subject to important variations of
length and thickness which have
a great influence on the arc of
rotation of the transfer.
Some soleus muscles are very
long and the muscular fibres may
insert directly on the calcaneum.
In this case the transfer can cover
the upper half of the distal third
of the leg. On the other hand,
some soleus muscles are short and
thick, and the rotation of the
muscle is very difficult and
sometimes, but rarely, impossible.
For these reasons it may be prefer-
able sometimes to use the medial
hemisoleus transfer,
which is
more versatile and simple than the
entire muscle transfer.
Coverage by an entire muscle is
provided by a rotation of the
transfer. Thus it is indicated for
defects
over the middle third
which are large but short in
length. In contrast, coverage by
the medial hemisoleus is provided
by an anterior advancement and is
indicated for defects which are
narrow but extended along the
tibial crest.
The morphotype of soleus can
be assessed clinically by palpation
of the contracted muscle on the
patient, but the final decision of
the precise type of transfer is
taken operatively, according to the
shape of the muscle and the
defect.
The distally based soleus flap
supplied
by the minor distal
pedicle for coverage of the distal
third is not advocated because of
the
variations
of
the
small
pedicles and the lack of reliability
after an injury.
However,
a
distally-based
medial
hemisoleus
can
be
elevated
on
the
secondary
pedicle.
A
Vascular supply
1
main proximal pedicles
2 posterior tip ial artery
3 secondary pedicle
4 small distal pedicles
5 peroneal artery
A The muscle is type lI in the
classification of Mathes and Nahai.
It
is richly vascularized by the
posterior tibia] and peroneal arter-
ies. These two arteries deliver a
similar pattern of blood supply to
the soleus. Each artery gives a
main
pedicle
proximally,
an
important pedicle at the midpoint
and smaller and variable pedicles
along the distal third. The entire
muscle can survive only on its two
main proximal pedicles, so soleus
can be mobilized without detach-
ing its origin.

Soleus flap
Operative procedure
B
The patient is supine with the
limb in external rotation and the
knee slightly flexed. The incision
commences midway between the
medial malleolus and the Achilles
tendon and ascends as far as the
proximal quarter of the leg, 1 cm
posterior to the medial border of
the tibia.
C
1 soleus
2 gastrocremius
C The deep fascia is incised in
line
with
the
skin
incision,
preserving the saphenous nerve
and vein.
Distally,
the sheath
around the Achilles tendon is
incised.
B

Transfers from the lower limb
D The plane between soleus
and
gastrocnemius
and
the
anterior border
of soleus are
identified. Several small pedicles
to the subcutaneous tissue and
skin are cauterized.
E The dissection
between
gastrocnemius
and
soleus
is
practically
avascular
and the
separation can be achieved with a
finger. Distally, the lower part of
soleus is separated from the deep
posterior
compartment.
The
intermuscular fascia separating
the two compartments should not
be incised in order to protect the
posterior
tibial
neurovascular
bundle. Numerous pedicles arise
from the main vessel and supply
the lower part of soleus; these
should be ligated and divided.
The release of the medial and
anterior aspect of the muscle is
continued. Midway between the
medial malleolus and the knee
joint, a large pedicle arises from
the posterior tibial vessels and this
should be ligated to allow the flap
to be rotated.
1
posterior tibial neurovascular axis
covered by the deep fascia
2 vascular pedicle to the muscle
midway between the knee and the
ankle
3 soleus
4 gastrocnemius

F
1 tendo Achillis
2 gastrocnemius
3 soleus
Soleus flap
3
2
F,G
The next step is the release
of the superficial aspect of soleus
distal to gastrocnemius.
In the distal two-thirds of the
muscle, the superficial aponeuro-
sis of coleus forms a deep, central,
intramuscular sheet. The superfi-
cial aponeurosis of soleus joins
the deep aponeurosis of gastroc-
nemius to form tine Achilles
tendon. The aponeurosis of soleus
is separated digitally as far as
possible from the aponeurosis of
gastrocnemius, and is then incised
to release the muscle fibres of
soleus from the Achilles tendon. It
is particularly useful to retain a
thin layer of aponeurosis in order
to avoid tearing the distal part of
the muscle.

Transfers from the lower limb
H
H
The final step is the release of
the muscle from its lateral attach-
ments. The distal portion which
has been freed is gently drawn out
from the wound, and the lateral
border is progressively released
from the fascia and the fibula.
Numerous small pedicles arise
from the peroneal artery and
should be ligated.
I
The lateral border must be
released as proximally as possible
to allow the rotation of the flap.
The distal two-thirds are hence
mobilized and, when rotated, will
cover defects of the anterior skin
of the middle third of the leg.

J
1 medial hemisoleus
Soleus flap
J
A proximally based hemisoleus
flap can be released. This proce-
dure is more versatile for covering
long and narrow defects over the
tibia.
K A distally based hemisoleus
flap can be applied when the soft
tissue defect is located at the
distal third of the leg. The flap is
supplied by the midpoint pedicle
which issues from the posterior
tibial artery.

Transfers from the lower limb
L The proximal part of the
medial
hemisoleus is released
progressively from the tibia and
the lateral hemisoleus. The proxi-
mal pedicles from the posterior
tibial
artery
are
ligated
and
divided.
L
1
lateral hemisoleus
2 medial head of gastrocnemius
3 posterior tibial artery
4 medial hemisoleus, released from
tibia and lateral part
5 secondary pedicle which constitutes
the pivot point of the flap
6 neurovascular bundle in deep
posterior compartment
M The medial hemisoleus is
released as far as the secondary
pedicle which is located at the
middle of the leg. The pedicle is
spared and constitutes the pivot
point of the flap.
M
1
hemisoleus
2 vascular pedicle
'~Ef
'O'

N
N
The flap is rotated down on its
hinge. The arc of rotation allows
coverage of the distal third of the
leg. The flap is supplied mainly by
a vascular pedicle which is not
located in the injured area.
Soleus flap

Transfers from the lower limb
Flexor flaps
Introduction
The two intrinsic flexor muscles of the toes are not
routinely used. Their arc of rotation is short, the possi-
bilities of coverage are limited and, in the case of an
injury on the distal third of the leg, the muscular
bodies may be damaged. However, the flexor digito-
rum longus and the flexor hallucis longus flaps are
worthy of interest for coverage of some restricted
defects of the distal third.
Indications
Even in association, the two muscles do not cover
entirely the distal third of the leg. The most important
thing is to have a mental representation of the possi-
bilities of coverage, which are quite different for each
of them. Because of their blood supply, only the distal
half of the muscles can be mobilized and rotated.
The distal third can be divided in three parts:
1 The upper part is not usually covered by the flexors
of the toes. The extremity of a long soleus easily
covers this area.
2 The middle part is partially covered by flexor
digitorum longus, which is a very thin and narrow
muscle without possibility of expansion.
3 The lower part of the distal third is entirely covered
by flexor hallucis longus, the fibres of which
descend more distally than those of flexor digito-
rum longus.
Flexor hallucis longus has a thick and rather wide
muscular body; the most lateral of all the muscles of
the deep compartment of the leg, it is thus less
exposed by injuries of the lower tibia.
Vascular supply
The two muscles are type IV in the classification of
Mathes and Nahai. They are supplied by a series of
storeyed small pedicles which penetrate the muscle
at right angles. Only one-half of each muscle can be
raised, as vascularization of the other half is necessary
to retain viability. The origin of the vascularization of
the flexors is different.
• Flexor digitorum longus is nourished by the poste-
rior tibial artery. The lower half of the muscle,
which is usually raised, is close to the tibia and its
vascularization can be damaged by an injury.
• On the other hand, flexor hallucis longus is
supplied by the peroneal artery. Usually, the muscle
and its vascularization are spared by an anterior
injury to the tibia.
For these reasons flexor hallucis longus is more
reliable than flexor digitorum longus. Flexor hallu-
cis longus can also be raised as a distally based
island flap pedicled on the peroneal artery which is
ligated proximal to the muscle. The flap has a wide
arc of rotation but the disadvantage is the sacrifice
of one main artery of the leg. This technique,
although not widely accepted, may be an alternative
to a free flap.

A
Proximally based pedicled flexor digitorum communis flap
B In the distal portion of the
incision
the
deep
posterior
compartment is directly opened.
In
the
proximal
portion, the
incision of the fascia opens the
superficial
compartment
and
soleus is retracted to allow the
incision of the septum between
the two compartments.
Proximally based
pedicled flexor
digitorum communis
flap
Operative procedure
A
The skin incision is outlined
on the distal third of the medial
aspect of the leg close to the tibia.
B
1
soleus
2 deep fascia (to be incised)
3 flexor digtorum
4 tibial posterior vessels and nerve

Transfers from the lower limb
c
1 soleus
2 flexor digitorum
3 tibialis posterior tendon
C The neurovascular bundle
should
be identified
between
flexor
digitorum
longus
and
soleus.
The limits of flexor digitorum
longus are outlined and the termi-
nal tendon is divided. It is prefer-
able to include the tendon in the
muscular flap to avoid tearing the
muscle.
D
The distal half of the muscle
is
mobilized.
Small arterioles
issuing from the posterior tibial
artery are cauterized. The transfer
is rotated to cover the midportion
of the distal third of the leg.
D
1 tibialis posterior tendon
2 vascular pedicle
3 soleus
4 flexor digltorum
3

Proximally based
flexor hallucis
longus flap
Operative procedure
E The skin incision is the same
as for the flexor digitorum longus
flap, slightly extended proximally.
The opening of the two compart-
ments allows identification of the
tendon of tibialis posterior, close
to
the tibia,
flexor digitorum
communis and the neurovascular
bundle.
The retraction of soleus permits
in-depth exposure of flexor hallu-
cis longus.
Proximally based flexor hallucis longus flap
E
1
flexor hallucis longus
2 soleus
3 flexor digitorum
4 tibialis posterior tendon