Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

covered with a vascularized free flap.
The largest flap I have transferred was 27.5 × 39 cm, which is approximately the limit of the abdomen as a donor
site.
OPERATIVE TECHNIQUE
Delay of the flap is achieved by first making parallel incisions over the length of the flap, then elevating the
proximal end of the flap, and then dividing the large perforating vessels to the midline if it can be done safely.
The possibilities can be checked with intravenous fluorescein. The next step is elevation and attachment to the
arm. These steps should all be accomplished at intervals of 10 to 14 days from each other.
The inset into the arm carrier should be done about 4 weeks after the initial delay. As much of the forearm as
possible is used, and the underside of the flap is lined with the turned-back portion of the forearm skin. Split-
thickness skin grafts are used to cover the donor defect at this time. In 3 weeks, the distal end of the flap is
divided but not elevated. Two weeks later, the distal end is elevated, but the flap is not transferred, because
there are often perforating vessels through the abdominal fascia, either over the rectus muscle or just lateral to
this, that may still be the principal blood supply to the distal end of the flap. Judgment will dictate how far the
distal end should be elevated.
The entire flap should be ready for transfer 10 to 14 days after the previously described delay. Judgment may
dictate one further delay if circulation in the flap appears compromised after elevation. If transfer is
accomplished, as much of the flap is inset as comfort of the arm carrier will allow. At least one half to two thirds of
the flap should be inset. The remaining portion of the recipient defect can be closed at the time of final
separation. The donor defect must be skin-grafted.
FIGURE 493.1 A: The extent of the flap is shown. The flap is actually thoracoabdominal, with approximately
one-half the flap across the midline. Note that the entire forearm is used as a carrier. B: Lower extremity defect
in a 19-year-old soldier as a result of an exploding land mine while on duty in Vietnam. C: The flap, after transfer
to the leg, must rest comfortably and without tension. No fixation other than suture to the recipient defect is
required if the flap is well planned. D: Ample flap has been transferred to accommodate later lengthening of the
leg with a bone graft. The arm carrier defect has been repaired by replacement of the turnover flap.

Usually 2 to 4 weeks and perhaps one delay are necessary before division of the flap. This is easily ascertained
by occluding the circulation in the arm with a blood pressure tourniquet and administering intravenous
fluorescein. When detaching the flap from the forearm, care must be taken not to disrupt the superficial venous
circulation or unduly thin the turnover flap. This turnover flap will then be replaced to close the arm carrier defect.
Usually, the plane of separation is well defined (see Fig. 493.1).
CLINICAL RESULTS
The major risk or complication with this procedure is flap necrosis, the hazard of all large random flaps. The
whole process takes about 3 to 4 months from inception to completion. Approximately eight separate
procedures are required to complete the delays and transfer steps necessary, and these must all be about
10 to 14 days apart. Attempts to shorten the time have threatened substantial loss of the flap, at least in my
hands. If one were to lose all or at least a large part of the flap, it would be difficult to find another suitable
donor site for such a large flap.
My experience is limited to young patients. No flaps were lost, nor were any reconstruction efforts
compromised by tissue loss. A well-planned flap of adequate size, and delayed as described in young
patients, should produce similar results.
SUMMARY
The open-jump skin flap can be transferred from the abdomen to the thigh using the forearm as a carrier.
This flap may be rarely indicated but, if used properly, can cover larger areas than the standard
musculocutaneous or free flaps.
References
1. Jones HT. Replacement of scar over the tibia and os calcis by tube pedicle transplant from abdomen. Surg
Clin North Am 1929;9:936.
2. Cannon B, Lischer CE, Davis W, et al. The use of open-jump flaps in lower extremity repairs. Plast
Reconstr Surg 1947;2:336.
3. Cannon B, Lischer CE, Brown JB. Open-jump flap repairs of the lower extremity. Surgery 1947;22:335.
4. Converse JM. Plastic repair of the extremities with nontubulated skin flaps. J Bone Joint Surg
1948;30A:163.
5. Edwards S. Evaluation of the open jump for lower extremity soft-tissue repair. Ann Surg 1948;128:1131.
6. Soderberg BN. The massive combined tube and open flap used as a unity rotation pedicle: transplant for
repairs of certain deep surface defects. Plast Reconstr Surg 1948;3:407.
7. Jayes PH. The design of flaps for major repairs: the open-jump flap method. In: Transactions of the first

international congress of plastic surgeons. Baltimore: Williams & Wilkins, 1957;514.
8. Morgan SC, Zbylski JR. Repair of massive soft-tissue defects by open-jump flaps. Plast Reconstr Surg
1972;50:265.

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Chapter 494
Free Microvascular Posterolateral Thigh Flaps
T. R. HEINZ
L. O. VASCONEZ
EDITORIAL COMMENT
This is a dependable flap that can be harvested relatively easily. The quality of the skin is reasonably thin.
The free lateral thigh flap offers the possibility of harvesting a very large (up to 20 × 30 cm) pliable, thin, and
generally hairless fasciocutaneous free flap for practically any type of requirement.
INDICATIONS
This flap has the advantage of incorporation in a chimeric fashion with the iliac bone, vastus lateralis, tensor
fasciae latae muscles, or TRAM-flap territories, for very extensive combined defects. The term “lateral thigh
flap” is misleading, since two flaps based in the lateral thigh territory have been described based on quite
different arterial systems. A cutaneous posterolateral thigh flap, based on the third perforator of the
profunda femoris artery (1), will be described first. A second flap, which can be called the anterolateral thigh
flap, is based on the cutaneous branch of the descending branch of the lateral circumflex femoral system (1,
2, 3, 4, 5, 6) and is described in Chapter 553. Either of these flaps may be innervated, typically with a
branch of the lateral or posterior femoral cutaneous nerve.
FIGURE 494.1 Vascular anatomy and usual flap orientation of the posterolateral thigh flap. Note that vastus
lateralis may be harvested.

ANATOMY
The posterior thigh flap is based on a branch of the profunda femoris artery, which gives off four perforating
arteries that supply the muscles and skin of the posterolateral aspect of the thigh. The third cutaneous perforator
is generally the largest, usually approximately 1.0 to 2.0 mm in diameter. It traverses the space between the
iliotibial tract and the biceps femoris muscle, giving muscular branches to each, and emerges from that space
immediately distal to the adductor brevis. This branch pierces the origin of the vastus lateralis muscle along the
linea aspera, about half the distance from the greater trochanteric to the lateral femoral condyle.
The artery continues on to give a muscular branch to the biceps femoris muscle and is approximately 2 mm in
diameter at this point. It then traverses the muscle fibers of the short head of the biceps femoris to become a
cutaneous branch of about 1.0 to 1.5 mm in diameter (Fig. 494.1).
The artery is accompanied by a vena comitans, usually of good caliber and quality. The length of the vascular
pedicle that can be used is about 5 cm.
The nerve supply to this portion of the thigh is derived from the posterior and lateral femoral cutaneous nerves,
and one or both may be used, as needed, according to the design of the flap.
FLAP DESIGN AND DIMENSIONS
The vascular pedicle can be located by the Doppler flowmeter and marked (Fig. 494.1). These vessels should
be large and are easily identified. Since the pedicle emerges between the iliotibial tract and the biceps femoris,
these may be identified with the patient in the supine position, the knee slightly flexed, and the hip internally
rotated.
With the pedicle approximately half the distance from the greater trochanter to the lateral epicondyle of the
femur, an oval flap of up to 20 × 30 cm may be outlined in this area. The flap is typically incised superiorly and
subfascial dissection is used, with care toward the center of the flap at the point of fascial penetration of the
pedicle vessels. The deeper fascia is incised at this point, and careful dissection is used to expose the vascular
pedicle fully. A portion of the intermuscular septum on both sides of the vascular bundle should be taken with this
structure.
OPERATIVE TECHNIQUE
The patient is placed in the lateral decubitus position for exposure of the lateral and posterior thigh. The pedicle
is located with the Doppler flowmeter at one-half the distance from the greater trochanter to the lateral femoral
epicondyle, along the line of the posterior border of the iliotibial tract. The lateral femoral cutaneous nerve of the
thigh in the anterior portion of this flap territory emerges from behind the inguinal ligament near the anterior
superior iliac spine and descends inferolaterally to innervate the anterior portion of this thigh skin territory.
The posterior femoral cutaneous nerve of the thigh emerges just below the gluteal fold at one-half the distance
from the ischium to the trochanter. It then descends almost longitudinally caudally, to provide sensation to the
posterior thigh. These points may be marked and the skin flap raised from superior centrally in the subfascial
plane. As one approaches the pedicle, care is taken to avoid injury, as the deep fascial layer is penetrated for
better definition of the pedicle itself. With this under control, the remainder of the flap may be safely raised quite
rapidly, to include the iliotibial tract fibers. Muscular branches will be ligated as the deeper dissection of the
pedicle proceeds. Splitting the linea aspera is also helpful to allow identification of the accompanying vein.
The donor site may be closed directly to up to 15 cm in width or skin-grafted, as required.
SUMMARY

The posterolateral thigh free flap is quite useful. It is relatively easy to harvest, has a long pedicle and
vessels of good diameter, can be frequently closed primarily, and may be harvested with the patient supine.
References
1. Song Y, Chen G, Song Y. The free thigh flap: a new free flap concept based on the septocutaneous
artery. Br J Plast Surg 1984;37:149.
2. Baek SM. Two new cutaneous free flaps: the medial and lateral thigh flaps. Plast Reconstr Surg
1983;71:354.
3. Kajiyama K, Kawashima T. Experience with anterolateral thigh flaps. Jpn J Plast Reconstr Surg
1986;29:398.
4. Koshima I, Eudoh T, Uchida A, et al. Clinical experience with free anterolateral thigh flaps. J Jpn Soc Plast
Reconstr Surg 1986;6:260.
5. Xu D-C, Zhang S-Z, King J-M, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg
1988;82:305.
6. Koshima I, Fukudo H, Utonomiya R, Soeda S. The anterolateral thigh flap: variation in vascular pedicles.
Br J Plast Surg 1989;42:260.

Chapter 495
Slide-Swing Skin Flap
J. SCHRUDDE
V. PETROVICI
See Chapter 112 and Figure 495.1.
FIGURE 495.1 A: Loss of skin and soft tissue on the left calf from pressure necrosis. B: Healed wound 3 weeks
after coverage by a slide-swing plasty type III.

Chapter 496
Bipedicle Crural Skin Flap
S. W. HARTWELL JR.
EDITORIAL COMMENT
The safety of this procedure is increased if the bipedicle flap is elevated beneath the fascia and if it is not
extended beyond 10 cm above the malleolar area.
Absent or defective coverage of the pretibial area, with or without underlying chronic osteomyelitis, may be
remedied by large local flaps of skin, subcutaneous fat, and crural fascia (1).
INDICATIONS
Unstable, easily injured pretibial skin coexisting with or without a chronic underlying osteomyelitis provides
the best indication for this operation. The blood supply to the affected lower limb should be uncompromised.
Arterial insufficiency, for whatever reason, may force a decision to correct the problem with alternative
methods. The point is that a precarious circulation to the leg probably will not adequately supply leg skin
that is as extensively undercut as this operation requires. The patient should be ambulatory at the time of
operation. A stable, weight-bearing leg is easier to work with than an unstable limb that needs fixation. The
fixing devices, internal or external, may complicate the preparation and transfer of a bipedicle crural flap.
ANATOMY
Branches of the anterior and posterior tibial arteries at the knee (forming the lower part of the genicular
anastomotic system) and at the ankle (forming the malleolar network) enter the two ends of the crural flap to
supply the detached skin of the leg.
FLAP DESIGN AND DIMENSIONS
There is no vertical mobility of skin above or below pretibial defects, and skin that serves to cover them must be
brought in from the medial and lateral areas. Although the medial and lateral adjacent skin may seem abundant,
a sufficient amount to cover the pretibial defect requires the mobility of the entire circumference of skin and
subcutaneous tissue of the leg at the level of the defect. A long vertical posterior incision through skin, fat, and
fascia on the leg allows the circumferential skin to move anteriorly. The middle of the flap moves; the two
pedicles are fixed, one above the ankle and the other below the knee. An anterior crural defect is thus covered at
the expense of creating a posterior crural defect that a split-thickness skin graft will resurface.
The long posterior incision in the calf becomes a Y at both superior and inferior ends (Figs. 496.1 and 496.2).
The two cuts that veer away from the central incision are simply back-cuts that allow more anterior
circumferential movement of the middle of the flap than otherwise would be possible. Like all backcuts, they
encroach upon the pedicle. Beware! These Y extensions at either end of the posterior calf incision should be just
long enough to permit closure of the anterior defect.
OPERATIVE TECHNIQUE

There are two stages: The first is a delay, undercutting the crural fascia enveloping the posterior, lateral, and
anterior muscular compartments. Much of this can be done by blunt dissection. The septa that divide the
compartments must be incised. The sural nerve and lesser saphenous vein, both readily seen, are not easily
spared in the dissection. Their loss is inconsequential.
Whether or not any preliminary preparation of the anterior tibial problem is appropriate depends on the
circumstances. Debridement or curettage of bone may be done now or deferred until the second stage. Flexing
the knee (with the patient prone) brings the anterior aspect of leg into view and thereby makes all surfaces of the
leg approachable.
One week after the delay, the final stage involves the ultimate preparation of the anterior defect to be closed;
movement of the flaps of skin, fat, and fascia around from behind; and closure of the new posterior defect with a
skin graft. More than one full drum (10 × 20 cm) of skin may be necessary. In cases of osteomyelitis with
cavernous tibial defects, small plastic catheters can irrigate these spaces in the postoperative period. The
anterior closure should be thick and tight, affording both protection and a seal.
FIGURE 496.1 Raising the two bipedicle flaps on the leg. (Left) Note the Y at the upper and lower ends of the
posterior incision. (Center) The flaps are raised between the crural fascia and the muscles. (From Hartwell and
Evarts, ref. 1, with permission.)
FIGURE 496.2 (Left) The two bipedicle flaps are moved anteriorly and are sutured, one to the other, to close the
defect. (Right) The resulting posterior defect is covered with a split-thickness skin graft. (From Hartwell and
Evarts, ref. 1, with permission.)

CLINICAL RESULTS
Progressive ambulation (all patients were ambulatory preoperatively) begins 3 weeks after the final
operation. A custom-fitted elastic stocking, below the knee, is prescribed. The loss of the rural nerve makes
the lateral aspect of the foot numb. Results of up to 16 years have been followed and there have been
neither complications nor functional deficits (Fig. 496.3).
SUMMARY
If carefully executed, bipedicle crural skin flaps can provide cover for pretibial defects.
FIGURE 496.3 A: Persistent osteomyelitis in an area of chronically exposed tibia. B: Anterior view of
resurfaced tibia. C: Posterior aspect of reconstructed leg. (From Hartwell and Evarts, ref. 1, with
permission.)
Reference
1. Hartwell SW Jr, Evarts CM. Secondary coverage of pretibial skin defects. Plast Reconstr Surg
1970;46:39.

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Chapter 497
Island Flap in Reconstructive Surgery of The Legs
F. C. BEHAN
EDITORIAL COMMENT
The design versatility of fasciocutaneous flaps, particularly in the lower extremity, is due to our knowledge
of the blood supply through the septocutaneous vessels. As long as the surgeon maintains one
septocutaneous perforator vessel, he or she can outline a flap either proximally or distally based or as a
turnover flap, or as the authors demonstrate, in an elegant way, with what they call the “keystone flap.”
The keystone-design perforator island flap (KDPIF), used to reconstruct soft-tissue defects and to avoid complex
reconstruction, is described.
INDICATIONS
The principle of island-flap repair has a long history (1, 2, 3, 4, 5). The KDPIF is a curvilinear trapezoidal
flap. It is essentially
two V-Y end-to-side flaps (see Fig. 497.3). The curvilinear shape of the flap fits well into various body
contours. This chapter describes the use of an island flap that is effective in many areas of the body,
provides effective skin coverage, and achieves excellent aesthetic results.
FIGURE 497.1 Keystone design perforator island flaps designed along the dermatomal segments. The
longitudinal axis of the flap sits along the dermatomal segment and superimposes on septocutaneous,
musculocutaneous and fasciocutaneous perforator vessels that ensure the viability of the flap.

ANATOMY
The KDPIF is designed within the dermatomal segments or precincts (Fig. 497.1) and straddles the longitudinal
running structures (6, 7) [e.g., the cutaneous nerves and superficial veins (8)], which are incorporated in the flap.
Aligning the flaps along the cutaneous nerve supply, when possible, incorporates the perforators that accompany
the peripheral nerves (8, 9). These are in addition to the subcutaneous, fascial, and muscular perforators that
support the viability of the flap (10). Blunt dissection allows the retention of the majority of venous
communications (8). Doppler localization techniques have not been used preoperatively or intraoperatively.
FLAP DESIGN AND DIMENSIONS
The vascular basis of this keystone flap is essentially that of a fasciocutaneous perforator and has been well
described by us and others (1, 2, 3, 4, 5). Hence, we use the terminology keystone design perforator island flap.
It is really an extension of the angiotome principle, designed as an island based on axial perforators from the
underlying structures. However, to design a flap the same width as the primary defect immediately adjacent to it,
which has essentially the same mobility characteristics, and to expect this not only to close that defect but also to
permit direct closure of its own larger secondary defect, seems empirically daring. What is it about the design
that enables this to occur when the rules of length-breadth ratio seem to be overruled? It was S. H. Milton in
1971, remarking on the experimental studies on island flaps, who said, “an island is safer than a peninsula.”
The flap has certain characteristics of a bipedicled flap (6, 7), yet this keystone flap is really two V-Y flaps side
by side, but facing in opposite directions. In a conventional bipedicled design, the secondary defect is usually
larger than the primary and is not closeable without grafting. By converting this bipedicled flap into an island with
V-Y advancement at each end, the longitudinal tension in the flap is released, thus creating laxity and
redundancy in its midportion, which can then be moved farther in a horizontal direction toward the defect.
Closure of the V-Y defects at each end narrows the whole defect complex, so that the flap does not have to
move so far horizontally. Similarly, the secondary defect on the opposite side of the flap is reduced by this
maneuver. Wide, blunt dissection preserving the neurovascular structures, and teasing of the surrounding tissue,
facilitate centripetal movement inward circumferentially around the flap. Although considerable tension exists
peripherally, the central portion of the flap does not move excessively, relative to its underlying vertical
perforators. These are consequently not subjected to the same tension.
Flap Subtypes
Type I: standard flap design and closure are suitable for defects up to 2 cm in width over most areas of the
body.
Type IIA: division of deep fascia. For larger areas of reconstruction located over the muscular compartments,
the deep fascia over the muscular compartment is divided along the outer curvature of the flap, to permit
further mobilization of the keystone flap.
Type IIB: with split-thickness skin graft to secondary defect. Where excess tension exists, the secondary
defect may be skin grafted (e.g., where tissue has limited elastic stretch on the lower third of the lower limb
and the lower third of the forearm). This retains the advantage, however, of allowing the flap to cover vital
structures while the graft allows wound healing.
Type III: double-keystone flaps. For considerably larger defects (5 to 10 cm), a double-keystone design can be
carried out, to exploit maximal laxity of the surrounding tissues. This is suitable for large defects in the calf or
sacral regions.
Type IV: rotational keystone flap. Occasionally, to facilitate rotation across joint contractures or compound

P.1330
fractures with exposed bone, the keystone flap is raised with undermining up to 50% of the flap subfascially.
The undermined fasciocutaneous part of the flap, which could be either proximally or distally based, can then
be transposed across large joint contractures of the elbow and knee, or can be used to cover the exposed
bone in compound fractures. Perforator support is derived from the attached part of the flap.
OPERATIVE TECHNIQUE
The lesion should be excised in an elliptical manner, with its axis parallel to the line of the cutaneous nerves,
veins, known
vascular perforators, or a combination of these. In the upper and lower limbs, this location is generally
longitudinally placed (Fig. 497.1). The side of the defect that has the greater laxity is chosen for the flap site. In
the lower leg, where these flaps are particularly well suited, the flap is best sited posterior to the defect, so that
the increasing laxity of skin over the posterior compartment can be exploited to close the secondary defect (e.g.,
upper, middle, and lower calf areas in the lower limb).
FIGURE 497.2 A: Mitotic lesion or traumatic defect excised with clearance; B: Keystone design perforator island
flap. The trapezoid- shaped flap is contoured along the side of the excisional defect with 90-degree angle at the
limits of the island flap.

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FIGURE 497.3 A: Blunt-dissection mobilization around the limits of the flap. Note: No dissection is done beneath
the island flap to preserve the integrity of the perforators, while retaining, if possible, all longitudinal venous and
neural structures that support the flap. The deep fascia is divided along the outer curvilinear line in types IIA, IIB,
III and IV, in which the undue tension exists. No deep fascia is divided beneath the flap canopy, the site of the
random perforator. B: The keystone island flap in position. Interrupted sutures (1-3) bring the flap into alignment,
creating lines of tension. Closure of the double V-Y apposition points at the limits of the flap creates a relative
redundancy in the central portion of the flap and relaxes the horizontal tension. The shaded areas (4 and 5) are
redundant and are excised. The wound closure is completed with the Hemming suture.
In the upper limb, these techniques are well applied to the biceps and triceps areas of the upper arm, and the
proximal flexor and extensor areas of the forearm. An incision at 90 degrees at either end of the defect meets the
curvilinear line of the flap markout. This curvature or keystone shape is then mobilized. The width of the flap
equals the width of the defect (Fig. 497.2). Its length is governed by the size of the elliptical excision.
Once the excisional defect is created after the removal of a lesion, the KDPIF has a ratio of 1:1 for the width of
the defect to the width of the flap. The length of the flap is determined by the size of the excisional defect. A right
angle is formed at the limits of the excision to create the keystone design (Fig. 497.2A and B).
Blunt dissection allows mobilization of the surrounding tissue while advancing the flap to facilitate wound
approximation (Fig. 497.3A). Careful teasing of the circumferential tissue
is performed without any flap undermining, so as to preserve the integrity of the perforators. Where possible, all
subcutaneous longitudinal venous and neural structures that support the flap should also be retained within the
limits of the surgical procedure. Any inadvertent trauma to the venous drainage system is repaired. The deep
fascia is left intact for smaller lesions up to 2 cm (type I keystone). Where increased mobilization is required, the
lateral deep fascial margin is released, particularly in the areas of the calf, thigh, forearm, and upper arm (type II
keystone).
The first step in wound closure is direct apposition of the defect with interrupted single-layer nylon sutures (Fig.
497.4C). Depending on the size of the defect, that may be two, three, or four stay sutures in this single-layer-
closure technique. Then the V-Y advancement of each end of the flap in the longitudinal axis is completed (Fig.
497.3B). This creates redundancy and laxity in the flap tissue at the right-angle points of the flap, which are
excised. This also serves to narrow the whole defect. Wound closure of the relaxed keystone flap can now be
completed, using a hemming suture advanced in the horizontal axis into the original defect and sutured. Further
undermining and release allow even distribution of tension, and facilitate circumferential wound closure. A
continuous, everting, horizontal mattress suture also helps to distribute tension evenly around the flap margins.

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FIGURE 497.4 A-D: The use of a type IIA keystone flap to reconstruct a 5- × 2.6-cm soft tissue defect on the
lower leg after a wide local excision for a level II malignant melanoma.
To close the V-Y points initially may reduce tension. However, our technique of direct closure of the midpoint
helps to determine the need for a graft, if undue tension is present. Stay sutures must be left intact for 14 to 17
days, to prevent wound dehiscence.
CLINICAL RESULTS
Since 1995, we have performed more than 300 keystone-design flaps, with only one case of partial flap
necrosis. Superficial flap necrosis occurred in the leg of a 78-year-old diabetic patient. Thus the flap-
survival rate in this whole series has
been 99.6%. The procedure has been associated with excellent healing, minimal postoperative pain,
minimal postoperative edema, and superior aesthetics.
When initially islanded, flaps appear hyperemic, perhaps because of denervation or vessel vasodilatation. It
is conjectured that this is a sympathetic response, and a sympathectomy is being performed to the small
vessels via the blunt dissection. We have observed striking vascular changes in these island flaps. This
may make them intrinsically more robust than skinbased flaps, which rely on horizontal blood flow and are
more subject to tensional forces (4, 5, 8, 10). The red-dot sign at a suture point is where arterial blood
oozes on the surface of the flap, which is not seen around the perimeter of the insert. The vascular flare is
seen consistently in those KDPIFs that have a myocutaneous base for the perforators.

To facilitate closure of the secondary defect, the flap should be sited along the side of the excision margin
that has the greater tissue laxity. This may not be significantly different at either side, but it is the tissue
beyond the flap itself that must ultimately move to close the defect. It is this progressive movement outward
into looser territory that enables direct closure of the secondary defect. In the lower limb, for instance, tissue
is mobile over the medial, and especially over the posterior, compartment. Here, the calf and thigh muscles
themselves can move with the overlying skin, compared with the tighter fascial or periosteal beds of the
anterolateral aspect, which allows very little direct advancement of overlying skin.
The perforating skin vessels of the lax muscle compartment are also longer and more stretchable than the
short tighter vessel of the anterior region. In this sense, the design is somewhat akin to the principle of the
bibbed flap, in which the first flap closes the main defect, and the smaller second flap (because it is now
taken from laxer tissues) is able to close the secondary defect. In this case, however, the second flap is
direct advancement.
Postoperative pain is negligible, and narcotics are rarely needed. When healing is complete, the
surrounding nerve supply usually returns to normal, although some patients do complain of mild
dysesthesia, particularly in the large flaps in the front of the thigh. Somewhat surprisingly, postoperative pin-
cushion-type flap edema has been minimal, despite the islanded flap design. No doubt the underlying
perforator support plays a role, as well as the relatively large size of the flaps.
SUMMARY
The reliability of this island flap design is possibly due to the fact that the circulation is based on vertically
orientated perforators and dispenses with the subdermal plexus. This could explain why lines of transverse
tension across the flap, so commonly seen on direct suturing, validate that perfusion is reliable to the limits
of the flap, because the island design is supported by such vessels. The ability to close relatively large
defects totally with flap tissue from the immediate vicinity maximizes the aesthetic appearance, compared
with grafts or distant flaps, which have poor color match, poor contour, and secondary deformity. The
nature of the curvilinear design of the keystone flap fits well into body contour dimensions (i.e., straight lines
stand out; curves fit into the creases).
References
1. Behan FC, Wilson I. The principle of the angiotome, a system of linked axial pattern flaps. In: Transactions
of the 6th International Congress of Plastic and Reconstructive Surgery. Paris: Masson, 1975.
2. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint
Surg 1956;38A:917.
3. Behan FC, Cavallo AV, Terrill P. Ring avulsion injuries managed with homodigital and heterodigital venous
island conduit (VIC) flaps. Br J Plast Surg 1998;23B:465.
4. Behan FC, Terrill PJ, Breidahi A, et al. Island flaps including the Bezier type in the treatment of malignant
melanoma. Aust N Z J Surg 1995; 65:870.
5. Behan FC. The fasciocutaneous island flap: an extension of the angiotome concept. Aust N Z J Surg

1992;62:874.
6. Onizuka T, Akagawa T, Kondo S, et al. The length: breadth ratio of skin flaps on the trunk: two new long
narrow flaps. Br J Plast Surg 1975;28:123.
7. Schwabegger A, Ninkovic M, Wechselberger G, Anderl H. The bipedicled flap on the lower leg, a valuable
old method? Its indications and limitations in 12 cases. Scand J Plast Reconstr Surg Hand Surg 1996;30:87.
8. Shalaby HA, Saad MA. The venous island flap: is it purely venous? Br J Plast Surg 1993;46:285.
9. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries of the cutaneous veins and cutaneous
nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial
pedicled fasciocutaneous flap. Plast Reconstr Surg 1998;102:779.
10. Braverman IM. The cutaneous microcirculation. J Invest Dermatol Symp Proc 2000;5:3.

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Chapter 498
Sliding Transposition Skin Flap
S. H. HARRISON
M. N. SAAD
The use of local flaps in the leg has long been known to be hazardous (1, 2, 3, 4), partly because of the limited
collateral circulation in that area but also due to faulty design. A basic but neglected factor that has been
responsible for the large percentage of failed flaps in the leg is the convexity of its surface.
FIGURE 498.1 A: The standard bipedicle flap frequently fails because the midportion of the flap, which is
already under considerable tension, must reach over the convex surface of the leg. B: Note, however, that the
long axis of the sliding transposition flap drapes easily over the convex surface of the leg. (From Harrison and
Saad, ref. 6, with permission.)
INDICATIONS
The lateral movement of a standard transposition flap across the convex surface of the leg results in
transverse tension across the pedicle and embarrassment of its blood supply (5). The bipedicle or “strap”
flap is similarly at risk (Fig. 498.1A). The transverse excursion of both pedicles across the convex surface
results in tension, thus depriving the central part of the flap of its blood supply, causing necrosis at the very
site where skin cover is required. Use of the sliding transposition flap in the leg obviates transverse tension
by insetting the distal oblique edge of the flap into the contralateral side of the defect (Fig. 498.1B), thus
draping the long axis of the flap loosely across the convex surface (6).
FLAP DESIGN AND DIMENSIONS
A suitable donor site is selected medial or lateral to the defect (Fig. 498.2A). From the lower end of the defect, an
oblique line is drawn, this being the distal edge of the flap. Its length should be equal to the contralateral side of
the defect. From the end of this line, the lateral edge of the flap is drawn proximally toward its base. The width of
the base of the flap should be adequate to sustain the circulation of the flap, bearing in mind that excess width
will limit mobility. A length-to-width ratio of 3:2, in our experience, has been more than adequate.

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FIGURE 498.2 A: A leg defect with the sliding transposition flap outlined. B: The flap easily reaches the defect
without tension. Because the anatomy of the blood supply to the fascia and skin of the leg has been recently
clarified, the fascia is now included with the flap. (This illustration depicts the older method of including just skin
and subcutaneous tissue.) C: The donor site is covered with a split-thickness skin graft. (From Harrison and
Saad, ref. 6, with permission.)
OPERATIVE TECHNIQUE
In our earlier patients, the flaps were raised superficial to the deep fascia, but more recently, we have included
the deep fascia in our flaps (7) (see Chapter 502). After raising the flap (Fig. 498.2B), the recipient site is
prepared and the flap is inset so that its long lateral edge is sutured to the contralateral side of the defect (Fig.
498.2C). The flap donor site is grafted. For larger defects, two flaps can be used (Figs. 498.3 and 498.4), both
being proximally based. The degree of excursion of the flap results in an obvious dog-ear, which usually
regresses with time.
CLINICAL RESULTS
In the first 13 patients reviewed in 1969, none of the flaps using this technique was lost in part or in whole,
and the principle for establishing full-thickness skin cover using this method can be accepted as one
available in selected patients.
SUMMARY
The sliding transposition flap is a reliable method of covering defects of the leg in selected patients.

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FIGURE 498.3 A larger defect can be closed with two sliding transposition flaps. Note that both are
proximally based. (From Harrison and Saad, ref. 6, with permission.)
FIGURE 498.4 An upper tibial defect has been covered with two sliding transposition skin flaps. Split-
thickness skin grafts have been applied to the donor defects. (From Harrison and Saad, ref. 6, with
permission.)
References
1. Crawford BS. The repair of defects of the lower limbs using a local flap. Br J Plast Surg 1957;10:32.

2. Harrison, SH. Fractures of the tibia complicated by skin loss. Br J Plast Surg 1968;21:262.
3. Connelly JR. Reconstructive procedures of the lower extremity. In: Grabb WC, Smith JW, eds. Plastic
surgery. Boston: Little, Brown, 1968;784.
4. Saad MN. The problems of traumatic skin loss of the lower limbs, especially when associated with skeletal
injury. Br J Surg 1970;57:604.
5. Patterson TJS. The effects of tension on the survival of skin flaps. In: Transactions of the fifth
international congress of plastic and reconstructive surgery. Melbourne, Australia: Butterworth, 1971;807.
6. Harrison SH, Saad MN. The sliding transposition flap: its application to leg defects. Br J Plast Surg
1977;30:54.
7. Pontén B. The fasciocutaneous flap: its use in soft-tissue defects of the lower leg. Br J Plast Surg
1981;34:215.

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Chapter 499
Saphenous Venous Flap
R. L. THATTE
M. S. WAGH
M. R. THATTE
EDITORIAL COMMENT
This flap usually works, but it is not the first line of defense for this location.
The saphenous venous flap is useful for covering defects on both the anterior and posterior surfaces of the leg,
including the popliteal fossa and knee joint.
INDICATIONS
This flap has been used most frequently for compound fractures of the tibia in emergency procedures, or for
the same type of defect at a later stage after fixation of fractures has been achieved. It also has been used
for dense adherent scars over the tibia, as a prelude to secondary bone surgery, or to hasten union in tardy
healing of fractures. When swung to the posterior surface of the leg (Figs. 499.1 and 499.2) and also to the
popliteal fossa, it has been used to fill defects created by release of post-traumatic or post-burn
contractures (Figs. 499.3 and 499.4). In addition, it has been found to be extremely useful in coverage of
the knee joint (Figs. 499.5, 499.6, 499.7).
ANATOMY
The saphenous venous flap (1) is a unipedicled type-1 venous flap (2) based on the saphenous vein in the
upper two-thirds of the leg. The long saphenous vein ascends for 2.5 cm anterior to the medial malleolus of the
tibia and then crosses medial to the tibia, lying about 1 to 2 cm medial to the medial border of the bone, until it
reaches the medial condyle of the tibia (Fig. 499.8). It then courses on the medial surface of the thigh, ultimately
draining into the femoral vein. A vertical
rectangular territory on either side of the vein is available for the flap.

FIGURE 499.1 Defect in popliteal fossa and flap design inferior to defect for postero-superior rotation. (From
Thatte and Thatte, ref. 1, with permission.)
FIGURE 499.2 Late photograph with healed flap shown in Figure 499.1. (From Thatte and Thatte, ref. 1, with
permission.)

FIGURE 499.3 Flap designed for burn contracture in the middle third of the leg. (From Thatte and Thatte, ref. 1,
with permission.)
FIGURE 499.4 Healed flap. Upper defect has been grafted and lower defect has been covered by the flap.
(From Thatte and Thatte, ref. 1, with permission.)

FIGURE 499.5 Defect over anterior aspect of the knee. (From Thatte and Thatte, ref. 1, with permission.)
FIGURE 499.6 Flap design to cover defect. (From Thatte and Thatte, ref. 1, with permission.)

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FIGURE 499.7 Healed flap. (From Thatte and Thatte, ref. 1, with permission.)
Earlier reports of unipedicled venous flaps (3, 4, 5) postulated a to-and-fro flow pattern in the vein, seemingly
supported by experimental and mathematical models. This explanation of venous flow has been contradicted
more recently (6). The survival of unipedicled type-1 venous flaps has now been attributed to either the
perivenous or perineural capillary network.
FLAP DESIGN AND DIMENSIONS
The flap consists of a rectangular fasciocutaneous island, longer at the vertical axis along the vein, and shorter
in the transverse dimension across the vein (Fig. 499.8). It can be based only on a patent, long, saphenous vein.
It is preferable not to use this flap when adherent, deep scars are seen in the area of the surface markings of the
vein. Vein patency can be gauged by tying a tourniquet in the
lower third of the thigh. If the vein is not visible during this maneuver, palpation can assist in demonstrating a
turgid, full vein. In the event of difficulties with both these techniques, a small incision at the proposed base of the
flap and dissection through the deeper layers of the subcutaneous fat will demonstrate vein patency. The
saphenous venous flap island can be designed as a 1: 3 proportioned rectangle, the vein remaining in the middle
along the length of the fasciocutaneous island.

FIGURE 499.8 Schematic diagram showing anatomy and design of the saphenous venous flap. A unipedicle flap
can be raised based proximally at location 1 or 2. Dotted area shows the largest flap possible. (From Thatte and
Thatte, ref. 1, with permission.)
The base of the flap in our series has never been below the midpoint of the leg, and the lowermost limit of the
flap has never extended into the lower third of the leg. The medial extension of the flap usually stops around the
area of the subcutaneous portion of the tibia, which is approximately 3 to 5 cm from the long saphenous vein in
the upper two-thirds of the leg. An equal breadth is available on the posteromedial surface of the leg.
Total flap dimensions of 8 cm in width and 24 cm in length are therefore available in the upper two-thirds of the
leg to cover defects by medial, superior, lateral, or posterior transfer of the saphenous venous island. The base
of the island consists of only the long saphenous vein, with its adventitia and surrounding areolar tissue. This
narrow base allows for flap mobility in an arc from 0 to 170 degrees. The flap is an island, and therefore seals
and covers the defect on all sides.
OPERATIVE TECHNIQUE
The dissection is performed under tourniquet. The skin is incised down to and including the deep fascia in the
vertical dimension on either side of the saphenous vein after a small incision has confirmed the patency and
exact location of the vein at the flap base. A fasciocutaneous rectangle is then completed by making a transverse
incision at the lower end and extending the exploratory incision at the upper end. Only the saphenous vein with
its intact adventitia and surrounding areolar tissue is preserved at both ends.
After tourniquet release and achievement of hemostasis, heparin 100 U/kg is given subcutaneously and, after a
further check of hemostasis, the vein at the lower end is clamped, ligated, and cut. The flap is transposed to the
defect, and a split-thickness skin graft is applied to the donor site from which the flap was raised.

CLINICAL RESULTS
Seven of eight flaps in our series were successful, with five surviving completely without complication. One
flap that was entirely lost was utilized in an elderly hypertensive patient who developed a large hematoma
underneath the flap, due to a clotted suction drain. In this case, the saphenous vein had been teased off its
fatty envelope over a length of about 3 cm, which may have contributed to thrombosis. The patient had
received intraoperative heparin intravenously.
Two flaps had marginal distal loss, one also following a hematoma under the flap. This patient also had
received intraoperative intravenous heparin, leading to excessive oozing. The defect resulting from flap loss
required a small skin graft, but the flap fulfilled its original purpose of coverage.
The other marginal loss in one corner of the flap was anticipated, because the vein entered the distal
(caudal) end of the flap eccentrically. The contralateral part of the distal end was probably not perfused by
the venous network. Again, this flap also fulfilled its purpose in coverage of the defect.
SUMMARY
The saphenous venous flap can be raised at any level along the saphenous vein in the upper half of the
leg. It provides a versatile technique for extensive scarring following extremity burns or trauma and is an
improvement over previously used methods.
References
1. Thatte RL, Thatte MR. The saphenous venous flap. Br J Plast Surg 1989; 42: 399.
2. Thatte MR, Thatte RL. Venous flaps. Plast Reconstr Surg 1993; 91: 747.
3. Thatte RL, Thatte MR. The cephalic venous flap. Br J Plast Surg 1987; 40:16.
4. Thatte MR, Kamdar NB, Khakkar DV, et al. Static and dynamic computerized radioactive tracer studies,
vital dye staining, and theoretical methematical calculations to ascertain the mode of survival of single
cephalad channel venous island flaps. Br J Plast Surg 1989; 42: 405.
5. Thatte MR, Healy C, McGrouther DA. Laser Doppler and microvascular pulsed Doppler studies of the
physiology of venous flaps. Eur J Plast Surg 1993; 16:134.
6. Smith RJ, Fukuta K, Wheatley M, Jackson IT. Role of perivenous areolar tissue and recipient bed in the
viability of venous flaps in the rabbit ear model. Br J Plast Surg 1994; 147:10.

Chapter 500
Lateral Genicular Artery Flap
A. HAYASHI
Y. MARUYAMA
EDITORIAL COMMENT
This is a useful and reliable flap for this location.
The lateral genicular artery flap allows single-stage reconstruction of soft-tissue defects around the knee.
Because of its thinness, it also provides for an excellent result in contour at the recipient site.
INDICATIONS
For reconstruction of soft-tissue defects around the knee, the goals are to preserve function and to restore
knee contour. Among possible solutions to these problems are the lateral and medial genicular artery flaps,
and the posterior popliteal thigh flap. All these flaps are distally-based cutaneous and fasciocutaneous flaps
harvested from the lower thigh (1, 2, 3). The lateral genicular artery flap is indicated for soft-tissue defects
of the distal third of the thigh, the knee, the popliteal fossa, and the proximal third of the lower leg, with the
exception of the medial aspects of these regions.
The flap has the following advantages. It allows single-stage reconstruction, as well as providing excellent
results at the recipient site. A donor site less than 10 cm in width can be closed primarily in most instances,
and no functional or sensory loss occurs in the lower extremity. The flap is certainly an effective alternative
to previously reported muscle, musculocutaneous, and fasciocutaneous flaps (4, 5, 6). Since the posterior
popliteal thigh flap and the medial genicular artery flap are also fasciocutaneous flaps based on the
septocutaneous perforators around the knee, they share the same advantages as the lateral genicular
artery flap. The choice among these flaps depends on the location of the defect and tissue availability at the
donor site.
ANATOMY (FIG. 500.1)
The superior lateral genicular artery (SLGA) usually originates from the popliteal artery. It courses
superolaterally, giving off branches to the vastus lateralis, biceps femoris, and the knee joint. After traveling in
the intermuscular space between the vastus lateralis and the short head of the biceps femoris, the SLGA
penetrates the deep fascia (or iliotibial tract) just proximal to the lateral condyle of the femur. The point at which
the cutaneous perforator of the SLGA penetrates the deep fascia is about 5 cm from the plane of the knee joint.
The cutaneous perforator of the SLGA terminates in small cutaneous branches that follow a radial pattern.
These branches anastomose freely with the rete patellae, the lateral perforator of the profunda femoris artery,
the musculocutaneous perforators from the popliteal artery, and the musculocutaneous or septocutaneous
perforators (or both) from the descending branch of the lateral circumflex femoral artery (Fig. 500.1). Among
these anastomoses, the communication between the SLGA and the lateral perforators of the profunda femoris
artery are predominant; this arterial communication is well-developed in the mid-layer of the subcutaneous
adipose tissue (1).

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FLAP DESIGN AND DIMENSIONS
The skin island is designed on the lateral aspect of the lower thigh. The distal end of the flap must cover the skin
over the lateral condyle of the femur, to include the emergence of the cutaneous perforator of the SLGA. The
proximal end of the flap can be safely extended to the mid-point between the greater trochanter and the lateral
condyle of the femur (Fig. 500.2).
OPERATIVE TECHNIQUE
The incision is begun from the proximal apex of the flap, and the plane of dissection is maintained on the loose
areolar layer over the deep fascia. Distal to the point
10 cm above the knee joint, the dissection should be carried down to the iliotibial tract for the safe dissection of
the intermuscular septum between the vastus lateralis and the short head of the biceps femoris. After division,
the vascular pedicle can be identified just above the lateral condyle of the femur.
FIGURE 500.1 Vascular anatomy of the anterior aspect of the knee showing cutaneous perforators and their
communication.
This island lateral genicular artery flap is then elevated and transferred to the defect. The flap arc of rotation
reaches the distal third of the thigh, knee, and popliteal fossa, and the proximal third of the lower leg, with the
exception of the medial aspects of these regions (Fig. 500.3).
CLINICAL RESULTS
Defects around the knee have been well-recontoured because of the thinness of the flap. However, when
the patient cannot accept the donor-site scarring on the lateral aspect of the thigh, the posterior popliteal
thigh flap might be a better alternative.

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SUMMARY
The lateral genicular artery flap is useful for reconstruction of soft-tissue defects around the knee. The flap
is thin, provides excellent results in knee contour, and produces no functional or sensory loss in the lower
extremity.
FIGURE 500.2 Design of the lateral genicular artery flap in relation to surface landmarks.

FIGURE 500.3 A: Recurrent ulcers of the anterior and medial aspects of the knee. B: Design of the lateral
genicular artery flap. C: Island flap was elevated, and donor site was closed primarily. D: Postoperative
view showing complete survival of the flap and good recontouring of the knee. (From Hayashi and
Maruyama, ref. 1, with permission.)
References
1. Hayashi A, Maruyama Y. The lateral genicular artery flap. Ann Plast Surg 1990;24:310.
2. Hayashi A, Maruyama Y. The medial genicular artery flap. Ann Plast Surg 1990;25:174.
3. Maruyama Y, Iwahira Y. Popliteo-posterior thigh fasciocutaneous island flap for closure around the knee.
Br J Plast Surg 1990;42:140.
4. Feldmann JJ, Cohen BE, May JW. The medial gastrocnemius myocutaneous flap. Plast Reconstr Surg
1978;61:531.
5. Swartz WM, Ramasastry SS, McGill JR, et al. Distally based vastus lateralis muscle flap for coverage of

wounds about the knee. Plast Reconstr Surg 1987;80:255.
6. Acland RD, Godina MSM, Eder E, et al. The saphenous neurovascular free flap. Plast Reconstr Surg
1981;67:763.

Chapter 501
Three Anteromedial Fasciocutaneous Leg Island Flaps
A. A. KHASHABA
M. M. EL-SAADI
EDITORIAL COMMENT
The versatility of the flap is increased, as the flap can be converted into an island with preservation of its
vascular pedicle.
These three fasciocutaneous island flaps (upper, middle, and lower) are based on three segments of the
anteromedial aspect of the leg. Depending on the location of the nearest flap pedicle and the size of the defect,
they can be used for reconstruction over almost any site in the lower two-thirds of the leg.
INDICATIONS
The upper and middle flaps are indicated mainly for coverage of bony and soft-tissue defects of the upper
and middle thirds of the anterolateral aspect of the leg. The use of the lowest flap, perhaps the most
important of the three, includes the difficult areas of the medial and lateral malleolus, the back of the
calcaneum, and the Achilles tendon (1, 2, 3, 4, 5, 6).
ANATOMY (7, 8, 9)
The medial septocutaneous vessels originate from the posterior tibial vessels and are enclosed in the deep
transverse fascial septum of the leg, i.e., the septum that separates the soleus and gastrocnemius from the deep
muscular compartment of the posterior leg. The upper and middle septocutaneous vessels supplying the upper
and middle flaps pierce the fascia after passing through the tibial origin of the soleus just behind the medial
border of the tibia. The lower septocutaneous vessels supplying the lower flap pierce the fascia, after passing
between the flexor digitorum longus and soleus muscles and the Achilles tendon.
The three segments along the medial side of the leg where their feeding vessels are most frequently identified lie
between 9-12 cm, 17-19 cm, and 22-24 cm, respectively, from the tip of the medial malleolus (Fig. 501.1). The
external diameter of these vessels varies from 0.5 to 1.5 mm, those with larger diameter being found at the
middle third of the leg.
FLAP DESIGN AND DIMENSIONS
The flaps are designed in accordance with the size of the defect and the site of the nearest pedicle (upper,
middle, or lower). Generally speaking, the skin of the entire calf area can be raised on any of the three pedicles,
but it is always safer not to transgress the midline posteriorly by more than 2 cm.
OPERATIVE TECHNIQUE
Raising the flap begins from its posterior edge in a subfascial plane. The pedicles will appear just before the
medial border of the tibia is reached. After identifying and dissecting the pedicle, the flap is raised from all its
edges. The greater saphenous vein will often be encountered at the anterior edge of the flap, and an effort

P.1343
should always be made to preserve it. The flap is then transferred to cover the defect, and a split-thickness skin
graft is utilized at the donor site (Fig. 501.2, 501.3, 501.4).
CLINICAL RESULTS
In a series of eight flaps utilized for patients with chronic leg ulcers, all flaps survived completely; healing
was uneventful without even minimal necrosis. The medial septocutaneous vessels are constant and are
situated at relatively fixed points. Each vessel can support a reliable island flap. All three flaps have the
following advantages. The flaps are thin, reliable, and easy to elevate. Based on the three segments
described, coverage can be provided for almost any site in the lower two-thirds of the leg. The arc of
rotation is extensive, and the flaps can fit the defect exactly and comfortably, with no axial tension or
kinking. The operating time and donor-site morbidity are kept to a minimum, and the patient remains
conveniently supine during the operation.
SUMMARY
The three anteromedial fasciocutaneous island flaps, based on the medial septocutaneous vessels of the
leg, can be used for coverage in almost any site in the lower two-thirds of the leg.
FIGURE 501.1 Diagrams of the three fasciocutaneous island flaps with anatomic landmarks and relevant
distances. A: Upper anteromedial fasciocutaneous island flap. B: Middle anteromedial fasciocutaneous
island flap. C: Lower anteromedial fasciocutaneous island flap.

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FIGURE 501.2 A: Chronic leg ulcer of 2 years' duration over the shin of the tibia. B: The defect and a flap
based on the uppermost segment (forceps point to pedicle). C: The flap rotated 90 degrees to cover the
defect. (Continued)
FIGURE 501.2 (Continued) D: Flap inset and sutured, and donor site skin grafted. E: Late postoperative
view at 2 months. (From El-Saadi and Khashaba, ref. 1, with permission.)
FIGURE 501.3 A: Chronic post-traumatic leg ulcer of 3 years' duration. B: Flap based on the middle
segment covering the defect. C: Early postoperative view. D: Late postoperative view of flap donor site.
(From El-Saadi and Khashaba, ref. 1, with permission.)

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FIGURE 501.4 A: Chronic post-traumatic ulcer of back of the calcaneum of 12 years' duration. B: Extent of
excision and flap design based on the lower segment. C: Immediate postoperative view. D: Flap and donor
site 2 months postoperatively. (From El-Saadi and Khashaba and ref. 1, with permission.)
References
1. El-Saadi MM, Khashaba AA. Three anteromedial fasciocutaneous leg island flaps for covering defects of
the lower two-thirds of the leg. Br J Plast Surg 1990;43:536.
2. Moscona AR, Govrin-Yehudain J, Hirschowitz B. The island fasciocutaneous flap: A new type of flap for
defects of the knee. Br J Plast Surg 1985;38:512.
3. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
4. Thatte RL. One stage random-pattern de-epithelialised “turn-over” flaps in the leg. Br J Plast Surg
1982;35:287.
5. Tom S, Namiki Y, Hayashi Y. Anterolateral leg island flap. Br J Plast Surg 1987;40:236.
6. Walton RL, Bunkis J. The posterior calf fasciocutaneous free flap. Plast Reconstr Surg 1984;74:76.
7. Amarante J, Costa H, Soares R. A new distally based fasciocutaneous flap of the leg. Br J Plast Surg
1986;39:338.
8. Carriquiry C, Costa MA, Vasconez LO. An anatomic study of the septocutaneous vessels of the leg. Plast
Reconstr Surg 1985;76:354.
9. Donski PK, Fogdestam I. Distally based fasciocutaneous flap from the sural region: a preliminary report.
Scand J Plast Reconstr Surg 1983; 17:191.

Chapter 502
Fasciocutaneous Flap
B. PONTÉN
EDITORIAL COMMENT
The safety and reliability of this fasciocutaneous flap are now universally confirmed, and the editors
recommend its use for the appropriate indications. It should be mentioned that as long as a good vascular
pedicle is preserved at the base of the flap, it can be outlined with a proximal, lateral, or distal base.
It is generally assumed that arterial blood supply to the fascia, subcutaneous fat, and skin is highly dependent on
perforating vessels from the underlying muscle. Successful musculocutaneous flaps, free flaps, and many
anatomic studies demonstrate the validity of this assumption; however, experience and practical observations
have also furnished proof of another type of arterial circulatory system.
The sliding of muscles needs the loose connective tissue underneath the fascia and must not be hampered by
more vessels than are absolutely necessary. Distally, the tendons give off no vessels whatsoever. It is also well
known that after making an incision in a compartment, blunt dissection between the muscle and fascia can be
performed without any bleeding worth mentioning. In addition, a large muscle can be rotated as a flap from its
original position without any circulatory problems in the remaining overlying fascia, fat, and skin. A crush injury or
a compartment syndrome can more or less destroy a muscle through ischemia, but the circulatory system to the
superficial structures will still function. A high-tension electric current through an extremity can severely reduce or
eliminate the circulation in a muscle but still leave the skin intact.
These observations, plus many years of experience in treating skin defects below the knee, with or without
complications, made me realize that skin, fat, and fascia derive nutrition from the proximal vessels and have an
important circulatory system of their own. Thus arose the idea of including the fascia in cross-leg flaps and in
local flaps of the leg and foot (1).
ANATOMY
The arterial circulation of the fascia and the layers superficial to the fascia are usually scantily described in
anatomy textbooks. The topography of the main arteries is always well described, but the less conspicuous
superficial arteries are seldom shown, and few have names. The increasing use of free flaps, muscle, and
musculocutaneous flaps has necessitated detailed studies of the vessels from the muscle as well as of those
giving rise to the fascial plexus. Recently, investigators stimulated by the successful use of fasciocutaneous flaps
have verified in postmortem studies that the fascial plexus is much more extensive than had been assumed
earlier.
The anatomic arrangements of the circulation in the skin of the leg and probably also in that of the arm, follow
the same principles. There are long arteries following the axis of the extremity proximally under the fascia,
eventually penetrating and creating a plexus in and on the fascia. The vessels are clearly visible from
underneath when the fascia is lifted from the muscle. Some fairly large axial long vessels run parallel to the
superficial nerves: the saphenous nerve, the sural nerves, and several long branches of cutaneous nerves in the
leg and foot.
There are also shorter musculocutaneous arteries penetrating the fascia and forming a plexus, and they seem to

P.1346
adopt the same pattern; that is, they run close to the fascia before penetrating.
On the medial side of the tibia, the main axial vessel is the saphenous artery. There are also proximal vessels
from the
inferior genicular artery; further distally, constant branches from the posterior tibial artery form a longitudinal
plexus on the superficial surface of the deep fascia.
FIGURE 502.1 A 45-year-old man with an avulsion of skin exposing the proximal third of the left tibia.
On the lateral side, vessels from the anterior tibial artery pierce the anterior part of the fascia. Four or five
branches have been found at the anterior border of the lateral compartment; together with lateroposterior
branches from the peroneal artery, they form a longitudinal plexus of fascia covering the lateral compartment of
the leg.
Each one of the three arteries of the leg gives off segmented branches that perforate the fascia of the leg and
arborize on top of the fascia and form connections with the superior and inferior branch. These are the
septocutaneous vessels. If one includes at least one septocutaneous perforator, it is possible to outline and
elevate safely and reliably fasciocutaneous flaps, proximally or distally based (2, 3).
On the middle part of the posterior side, there are usually two or three longitudinal vessels deriving their blood
supply from a branch of the popliteal artery. Flaps from the posterior side are very useful because they can be
made quite broad and long. The dorsum of the foot also can be used, at least on the proximal part, the distal
border sited where the tendon sheaths begin.

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FIGURE 502.2 A fasciocutaneous flap outlined over the medial head of the gastrocnemius muscle. Note the
dimensions: 22 × 12 cm.
FLAP DESIGN AND DIMENSIONS
The arc of rotation of the fasciocutaneous flap is often quite extensive, and it is therefore important to plan the
position of the patient on the table in advance. The surgeon may have to begin with the patient face down, and it
may be necessary to turn the patient during the operation when rotating the flap.
After marking the outline of the defect, the best fasciocutaneous flap for the particular patient should be planned
and marked. Because it is easy to rotate these long flaps, I prefer to use longitudinal incisions along the axis of
the leg. The basic rules are the same as when planning other flaps: It is essential to avoid tension. I prefer to
have a long and broad flap that falls into place without being under tension (Figs. 502.1, 502.2, 502.3, 502.4,
502.5).
FIGURE 502.3 A flap transposed to cover the entire defect without any tension.
OPERATIVE TECHNIQUE
Before beginning the incision, one should remember not to touch or disturb the circulation between the fascia
and skin. This implies that the incision should go through skin, fat, and fascia. Hooks always should be used in
the fascia, and not in the skin, when handling the flap. If hooks are placed in the skin in an attempt to lift a long
and heavy flap, it is easy to destroy at least part of the delicate tissue between the fat and the fascia.

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FIGURE 502.4 A healed flap 3 months postoperatively. Patient is walking normally.
The incision should be started in an area where the fascia is easily identified and where there normally is an
adequate space between fascia and muscle. From this incision, a finger through the opening in the fascia can lift
it from the muscle underneath by blunt dissection. This maneuver is usually easy to perform, but in certain areas
there is a septum between the muscle compartments underneath the flap. In such cases, it is advisable to
undermine from both sides, after which the septum should be carefully cut after transecting the distal part. The
flap will be loose and freely mobile.
Utmost attention should be paid to preserving a segment of septum continuous with the base of the flap because
often a septocutaneous vessel is included there and it may be essential for flap survival.
It is well known that the fascia is rather tough, which might hamper flap rotation. To lengthen the flap and
facilitate rotation, a backcut in the fascia (not in the skin or fat) is useful. Even a small backcut can give an extra
centimeter that might be necessary in order to have an absolutely relaxed flap lying over the defect. It is self-
evident that cutting the vessels that can be seen in the fascia should be avoided.
The rotation can be quite extensive, and a longitudinal incision flap border can end up in a horizontal position.
Flap stability and good flap circulation make delay procedures unnecessary. All my flaps have been raised and
rotated in one stage.
Bleeding from the borders of the incision usually does not create any problems, and diffuse bleeding from the
loose connective tissue separating the fascia and muscle is generally insignificant. The area to be covered
should, of course, be surrounded by normal skin or at least skin with good circulation, but this is not mandatory.
The edges of the area to be covered are undermined, and the rotated fascia is sutured underneath the skin. As a
rule, I do not have any bandage on the flap itself, except perhaps a few tapes, especially in cases where there is
risk for bleeding under the flap. In a few cases, I have used suction for 24 hours.
The secondary defect can be covered immediately with a split-thickness skin graft, but it also can be left
uncovered.

FIGURE 502.5 A secondary defect that was mesh-grafted immediately.
Flap transposition almost inevitably results in a “pig's ear,” but this irregularity soon reduces considerably by
itself, and, if necessary, it is very easy to remove the little extra piece of skin later.
Because many of the vessels follow the cutaneous sensory nerves, the patient will lose sensation in an area
peripheral to the defect after flap transfer. This should be regarded as an insignificant sequela, considering the
effective solution of the main problem.
CLINICAL RESULTS
Previous authors have observed that circulation in a flap is better if the fascia is included. The technique
has been used when covering pretibial skin defects with delayed bipedicle flaps and as part of a delay
procedure. It has been noted that the deltopectoral flap can be extended and has better circulation if the
fascia is included. The same observations have been made in cross-leg flap surgery (Fig. 502.4).
The fasciocutaneous flap is reliable (1, 3), and it can take rotation and kinking to a surprisingly high degree.
Delay procedures are needless and it is, of course, possible to make two flaps in the same stage (Fig.
502.5).
The good circulation of the flap will make it especially useful when working with complicated cases
(fractures, nerve and vessel injuries, cut tendons, for example). The flap can be used after tumor excision,
in any kind of soft tissue defect after a trauma with or without fractures, in cases where osteosynthetic
material is exposed, in combination with bone grafting, in chronic osteomyelitis, in pressure sores, and even
in postthrombotic ulcers. There are only minor postoperative problems, even with the elderly patient,
because patients do not need any extra fixation and can be in a wheelchair the next day provided the leg is
kept in a horizontal position. The operative procedure is simple and short, the flap is safe and stable, and
the technique should always be considered when one is faced with the problem of covering a soft-tissue
defect on the lower leg.
References
1. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
2. Carriquiry C, Costa MA, Vasconez LO. An anatomic study of the septocutaneous vessels of the leg. Plast

Reconstr Surg 1985;76:354.
3. Tolhurst DE, Haeseker B. Fasciocutaneous flaps in the axillary region. Br J Plast Surg 1982;35:430.

Chapter 503
Anterior Tibial Flap
J. F. R. ROCHA
A. GILBERT
The anterior tibial artery supplies a great part of the anterolateral surface of the lower leg. It participates equally
in the vascularization of the foot and anterior compartment without being an indispensable element.
Consequently, proximally and distally based island tibial flaps can be created to cover losses of substance of the
lower leg and the calcaneal region.
ANATOMY
The flap is supplied by terminal branches of the superficial peroneal nerve satellite artery (SPA) that come from
the superior and inferior peroneus lateralis arteries. These two muscular branches of the anterior tibial artery
also participate in the cutaneous vascular supply by means of perforating twigs directly to the skin (Fig. 503.1)
(1, 2, 3, 4).
FIGURE 503.1 Anatomy of the tibial flap with its axis over one of the peroneus lateralis arteries.
Superior Peroneus Lateralis Artery (SPLA)
This vessel branches off from the anterior tibial at variable levels. We measured it at an average of 25.6 cm from
the lateral malleolus, with extremes of 20 cm in a 33-cm female lower leg to 32 cm in a 41-cm male lower leg (4).
As it runs over the interosseous membrane and the anterior surface of the fibula, the SPLA crosses the extensor
digitorum longus before reaching the space between the peroneus lateralis and the anterior peroneal septum.
The SPLA always gives some branches to the peroneus longus at this level. The caliber varies greatly from 1.2
to 2.5 mm (average, 1.63 mm), and its length ranges from 6 to 12 cm (average, 7.1 cm).
Inferior Peroneus Lateralis Artery (IPLA)

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This vessel is found in 70% of cases. It branches off from he anterior tibial artery at an average of 17.2 cm from
the lateral malleolus, with extremes of 12 cm in a 33-cm female lower leg to 20 cm in a 40-cm male lower leg. It
has a shorter course than the SPLA, although with similar anatomic references. It gives some branches to the
peroneus brevis before becoming an entirely cutaneous artery. The caliber varies from 1 to 2 mm (average, 1.4
mm), and its length ranges from 3.6 to 7.5 cm (average, 5 cm).
Superficial Peroneal Nerve Satellite Artery (SPNA)
This vessel provides vascularization to the nerve and the skin all along its descending path at the anterolateral
surface of the lower leg (Fig. 503.2). It comes from the SPLA in 30% of the cases, from the IPLA in 40%, and
from both the SPLA and IPLA in 30% of the cases.
The first cutaneous branch, at an average of 20 cm from the lateral malleolus, perforates the superficial
aponeurotic sheet directly. It supplies all the anterolateral middle third and part of the upper third of the leg. The
SPNA runs along the entire subcutaneous path of the superficial peroneal nerve at the lower leg. A second
cutaneous branch that supplies part of the anterolateral middle and lower thirds of the leg is normally seen
branching off the SPNA right after the perforating point of the superficial peroneal nerve. We measured this point
at an average of 13.5 cm from the lateral malleolus, with extremes from 9 to 17 cm. The third group of cutaneous
branches is
identified along their subcutaneous descending path where the superficial peroneal nerve gives some sensory
branches to the anterior lower third of the leg.
FIGURE 503.2 A split of the anterolateral superficial aponeurosis along the anterior peroneal septum allows
identification of interseptal cutaneous branches of the anterior tibial artery. Note the superficial peroneal nerve
attached to the flap and followed by its satellite artery.
In general, the SPNA ends by anastomosing with the dorsalis pedis artery (55% of cases), the peroneal artery
(35%), or the lateral malleolar artery (5%). In 5% of cases, there were no anastomoses evident. The caliber of
the SPNA is, on average, 0.9 mm, with extremes from 0.6 to 1.5 mm.
FLAP DESIGN AND DIMENSIONS

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The largest flap we have raised measured 20 cm long and 8 cm wide. The anterior and posterior tibial arteries
must be clinically examined before surgery to ensure the feasibility of the flap. The outline of the skin flap is
drawn inside the anterolateral middle and lower thirds of the leg. It is limited anteriorly by the tibial crest and
posteriorly by the external border of the lateral gastrocnemius (Fig. 503.3).
OPERATIVE TECHNIQUE
The anterior peroneal septum is most easily approached with the patient lying supine and the lower leg kept in a
mild internal rotation. We start raising the flap anteriorly by blunt dissection between the subcutaneous tissue
and the aponeurotic sheet of the leg. The cutaneous branches of the SPNA can be easily seen along the
anterior peroneal septum. An ascending splitting of the superficial fascia is carried out, starting from the
aponeurotic perforating point of the superficial peroneal nerve. Then the lateral peroneal muscles are separated
from the anterior peroneal septum. The SPNA and the superficial peroneal nerve are easily dissected proximally
toward the vascular trunk. When an entire dissection of the pedicle is required, detachment of the extensor
digitorum longus and extensor hallucis longus from the fibula and interosseous membrane allows exposure of the
anterior tibial bundle.
FIGURE 503.3 The tibial flap can cover losses of substance at several sites in the lower leg.
An average of five twigs to the peroneus longus and brevis must be ligated between the first cutaneous branch
and the trunk.
If an innervated skin transfer is desirable, the superficial peroneal nerve must be included in the flap. The distal
incision is performed, whether preserving the SPN or not, and the flap is entirely liberated from the donor site
according to the accurate position of the cutaneous branches and to the size of the flap (see Fig. 503.3).
Island Tibial Flap
Generally, skin coverage of the anterior tibial tubercle, the anterior and lateral surfaces of the knee joint, and the
upper third of the leg does not require the distal ligature of the anterior tibial vessels. The SPLA gives the flap a
long arc of rotation. If the loss is more extensive or in patients with a shorter pedicle, the distal portion of the
anterior tibial artery may need to be transected.
When inner surfaces are to be covered, the flap is raised more proximally and is tunneled between the anterior

compartment and the tibia. It must pass behind the anterior tibial bundle to avoid any damage to the vascular and
motor branches of the anterior muscles.
FIGURE 503.4 When inner areas of the lower leg are to be covered, the flap must be tunneled under the anterior
muscles or tendons for a looser turndown of the anterior tibial artery and the cutaneous pedicle.
Reverse Tibial Flap
The feasibility of retrograde blood flow into the anterior tibial artery and venae comitantes permits this flap to be
used for lower third, malleolar, or calcaneal skin cover (Fig. 503.4). The blood supply is provided by the plantar
perforating branch of the dorsalis pedis artery that joins together both anterior and posterior tibial systems.
The two venae comitantes drain the flap to the greater and lesser saphenous veins by means of anastomoses
with the dorsalis pedis venous arch. Venous drainage sometimes is impaired by the countless valves, thus
requiring microsuture between one of the venae comitantes at its proximal end and a vein close to the recipient
site.
If an innervated skin transfer is recommended, the reverse tibial flap must be raised, including part of the lower
third, where cutaneous branches of the superficial peroneal nerve are present. The nerve can be sutured to a
sensory branch of the posterior tibial nerve or just interposed by a nerve graft. It is equally possible to
reconstruct the posterior tibial nerve in which scar tissue is present by means of the superficial peroneal nerve
vascularized by the tibial flap.
CLINICAL RESULTS
Finally, the donor site is covered by a split-thickness skin graft over the superficial aponeurosis of the lower
leg. The unpleasant aspect of the donor site does not seem very significant when balanced against the
multiple advantages of this flap.
SUMMARY

The anterior tibial flap can be used as an island flap to cover defects about the lower knee or as a reversed
tibial flap for ankle and heel defects.
References
1. Dubreui C. Variations des artères du membre inférieure. Paris: Masson, 1933.
2. Salmon M. Les artères de muscles, des membres et du tronc. Paris: Masson, 1933.
3. Haerstch P. The blood supply to the skin of the leg: a post mortem investigation. Br J Plast Surg
1981;34:470.
4. Rocha JF, Izquierdo MP, Gilbert A, Hureau J. Les branches cutanées de l'artère tibiale antérieure.
Biomédicale de St. Pères: Service d'orthopédie et chirurgie réparatrice de l'enfant. Communication to the
Société Anatomique de Paris, October, 1984.

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Chapter 504
Medial Femoral Trochlea Osteochondral Flap
JAMES P. HIGGINS
EDITORIAL COMMENT
A useful procedure; however, there is potential donor site morbidity, that is, a long scar. In addition,
reconstructing the scapholunate ligament remains an unsolved problem.
INDICATIONS
The free medial femoral trochlea (MFT) flap provides a vascularized osteochondral segment of bone for use
in intra-articular defects requiring small convex segments of cartilage resurfacing. It has been described in
clinical series for use in recalcitrant proximal pole scaphoid nonunions and in advanced stage Kienböck
disease (avascular necrosis of the lunate) (1, 2).
FIGURE 504.1 Representation of MFT flap vascular pedicle. A, descending geniculate artery; B, transverse
branch; C, longitudinal branch; D, superomedial geniculate artery. Area of desired osteochondral harvest is
shaded in green. Inset demonstrates orientation of harvested segment as it relates to area of scaphoid
reconstruction. (©The Curtis National Hand Center.)
ANATOMY
The MFT flap is based on the same vascular network as the medial femoral condyle corticoperiosteal flap. Both
are supplied by periosteal vessels that are intimately adherent to the medial aspect of the distal femur. This
filigree of vessels represents the terminal branches of the descending geniculate artery (DGA). The DGA