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

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elevation reaches the region of the adductor tendon insertion, the vessels become intimately invested in the
periosteum of the medial condyle. Three large branches are encountered: the transverse branch, the longitudinal
branch, and the superomedial geniculate artery (SGA).
The SGA courses deep into the popliteal fossa in the retrocondylar sulcus of the femur. In approximately 10% of
patients, the DGA may be absent and the SGA may serve as the pedicle, requiring dissection of this vessel from
its origin off the popliteal artery. The longitudinal branch serves as the pedicle for the non-cartilage-bearing MFC
flap and is ligated when harvesting the MFT. The perpendicular transverse branch typically traverses the
metaphyseal region and densely supplies the periosteum surrounding the MFT both on its
medial aspect and proximal aspect (Fig. 504.4). This branch is preserved and elevated with its attachments to
the trochlea. As the dissection approaches the trochlea, it is performed subperiosteally to protect the small
vessels.
FIGURE 504.3 Full-length exposure of the DGA pedicle demonstrated. Vastus medialis muscle is retracted
anteriorly. Origin of DGA from SFA in adductor hiatus is shown proximally (left). Periosteal vessels of the medial
femur are shown. At the distal femur (right), the DGA is seen in continuity with its longitudinal and transverse
branches. The transverse branch can be seen coursing toward the patellofemoral joint and medial trochlea.
FIGURE 504.4 Close-up view of the periosteal vessels approaching the medial trochlea from both medial and
proximal aspects. The segment of osteochondral harvest is outlined with surgical marker.
The flap is then harvested using a saw and/or osteotomes. The most difficult maneuver is the sagittal cut
because the patella remains in anatomic position during harvest. Knee extension permits passage of a small
precise right angle sagittal saw into position (Fig. 504.5). Alternatively, the surgeon may make all of the other
saw cuts and perform the sagittal osteotomy via a small curved osteotome from proximal to distal.

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FIGURE 504.5 View of convex osteochondral trochlea and surrounding periosteal vessels. With the knee in
slight flexion, the patella permits little access for saw or osteotome harvest. The knee should be brought into
extension to facilitate harvest.
The joint capsule is closed, a drain is placed in the subcutaneous plane, and the skin is closed. No
immobilization is required. The patient is permitted to ambulate immediately after surgery. It is common for the
patient to have some discomfort with ambulation that will resolve over 2 to 4 months.
The osteochondral segment and attached vascular pedicle can then be inset into the wrist to recreate the
proximal scaphoid or lunate as described in published clinical series (Fig. 504.6) (1, 2).
FIGURE 504.6 Representation of the MFT flap vascular pedicle and use of the flap in advanced Kienböck
disease. 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
the harvested segment as it relates to the area of lunate reconstruction. ©The Curtis National Hand Center.

FIGURE 504.7 Preoperative AP (above) and postoperative AP and lateral x-rays (below) of cases of scaphoid
nonunion MFT reconstructions. X-rays on the left demonstrate a case using a dorsal approach showing
preoperative nonunion (above) and postoperative healed reconstruction (below) in a 1-year postoperative x-ray.
X-rays on the right demonstrate a case using a volar approach showing preoperative nonunion (above) and
postoperative healed reconstruction (below) on 1-year postoperative x-ray.
CLINICAL RESULTS
Two clinical series have been reported on the use of this flap. Bürger et al. (2013) (1) reported on 16
patients who underwent MFT transfer for proximal pole scaphoid nonunion with an average of 14 months'
follow-up (minimum 6 months). Fracture union was confirmed by CT scan in 15 of 16 patients. Twelve of
sixteen patients reported complete pain relief, whereas 4 of 16 reported improvement without complete pain
relief. Preoperative and postoperative ranges of motion were similar (Fig. 504.7).
Bürger et al. (2014) (2) also reported on a series of 16 cases of osteochondral MFT flap transfers for lunate
reconstruction for advanced Kienböck disease with mean follow-up of 19 months (minimum 12 months).
Healing was confirmed in 15 of 16 reconstructed lunates. Lichtman staging remained unchanged in 10
patients, improved in 4 patients (3a/b-2), and worsened in 2 patients (3a-3b). All but 1 patient experienced
improvement in wrist pain (12 of 16 had complete relief; 3 of 16 had incomplete relief). Wrist motion at
follow-up averaged 50 degrees of extension and 38 degrees of flexion, similar to preoperative
measurements. Grip strength at follow-up was 85% of the contralateral side (Fig. 504.8).

FIGURE 504.8 Preoperative AP (above) and postoperative AP and lateral x-rays (below) of cases of
advanced Kienböck disease lunate MFT reconstructions. On the left is a 30-year-old patient with stage 3A
Kienböck disease (top left). At 19.5 months after MFT reconstruction (bottom left), she has achieved
improved carpal height and lunate substance, converting to stage 2 disease. On the right is a 23-year-old
patient with stage 3A Kienböck disease. Initial treatment with radial shortening osteotomy provided pain
relief until he experienced recurrence of pain and coronal fracture of the lunate (top right). At 13 months
after MFT reconstruction, he has achieved improved carpal height and lunate substance, converting to
stage 2 disease, and he is pain free (bottom right).
SUMMARY
The MFT flap provides vascularized osteochondral bone for reconstruction of small convex articular
defects. Promising early clinical reports suggest that it may provide a novel solution to articular problems
requiring replacement of damaged cartilage surfaces.
References
1. Bürger HK, Windhofer C, Gaggl AJ, et al. Vascularized medial femoral trochlea osteocartilaginous flap
reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 2013;38(4):690-700.
2. Bürger HK, Windhofer C, Gaggl AJ, et al. Vascularized medial femoral trochlea osteochondral flap
reconstruction of advanced Kienböck disease. J Hand Surg Am 2014;39(7):1313-1322.
3. Higgins JP, Bürger HK. Proximal scaphoid arthroplasty using the medial femoral trochlea flap. J Wrist Surg
2013;02(03):228-233.
4. Higgins JP, Bürger HK. Osteochondral flaps from the distal femur: expanding applications, harvest sites,
and indications. J Reconstr Microsurg 2014;30(7):483-490.
5. Hugon S, Koninckx A, Barbier O. Vascularized osteochondral graft from the medial femoral trochlea:
anatomical study and clinical perspectives. Surg Radiol Anat 2010;32(9):817-825.

6. Iorio ML, Masden DL, Higgins JP. The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg
2011;36A:1592-1596.
7. Iorio ML, Masden DL, Higgins JP. Cutaneous angiosome territory of the medial femoral condyle
osteocutaneous flap. J Hand Surg 2012;37A:1033-1041.

Chapter 505
Cross-Leg Skin Flap
A. M. MORRIS
The cross-leg flap, a direct bridge flap from one lower extremity to the other, is a standard method of providing
flap skin to resurface defects of the lower limb (1, 2, 3, 4, 5, 6, 7). The development of alternative procedures
recently in the form of new, longer local flaps, for example, the fasciocutaneous flap (8), musculocutaneous flap
(9, 10), muscle flap covered by a free skin graft (11), reversed dermis turnover flap (12), and free-flap transfer by
microvascular anastomosis (13, 14) may provide more comfortable methods of achieving the necessary repair
but have not rendered the cross-leg flap obsolete.
The discovery of these new flaps has given rise to much greater flexibility in planning safer cross-leg flaps, in
addition to the traditional random-pattern cross-leg flap. Cross-leg musculocutaneous (15), axial-pattern (16),
and reverse dermis (6, 17) flaps already have been reported.
INDICATIONS
The main indication for a cross-leg flap is the need for flap coverage over a defect on the knee, shin, ankle,
or foot with exposed bone (see Fig. 505.5), tendon, or joint or over an unstable scar in a weight-bearing
area (see Fig. 505.4). Because it is a method requiring meticulous planning and technique, involving the
patient in 3 weeks of immobilization, several weeks of hospitalization, and a minimum of two operative
stages, it is used only when there is no suitable alternative. Provided there is no stiffness or prejudicial
scarring of the donor leg (see Fig. 505.5), the amount of skin available for the flap is so large and variable in
extent that a cross-leg flap can be used for most defects of the lower limb.
The cross-leg is contraindicated when stiffness in either leg prevents a suitable position of the two lower
limbs from being obtained. Age, old (4) or young (5), is not a contraindication per se, but the use of a cross-
leg flap in elderly patients may give rise to unacceptable discomfort. The stasis caused by the
immobilization also may give rise to thromboembolic problems in older patients or in those with a history of
thromboembolic disease.
ANATOMY
The arterial supply of the skin of the calf is derived from the underlying arteries and muscles in perforating
branches, apart from a few specific skin arteries, for example, the saphenous artery (16). It is arranged in two
principal layers, the fascial plexus and the subdermal plexus (17). The venous drainage is by means of the
venae comitantes of the arterial supply and the longitudinal subcutaneous venous system.
FLAP DESIGN AND DIMENSIONS
The principal donor site for the random-pattern cross-leg flap transfer is the calf (Figs. 505.1 and 505.2). The
thigh is not frequently used, but it affords a less visible donor scar in the female patient. To cover a weight-
bearing defect of the sole, a cross-foot flap (18, 19) gives excellent appropriate skin, but the size is limited to a
flap 8 × 6 cm (Fig. 505.3).
Some of the perforating branches are divided in raising a random-pattern skin flap in the lower limb, which
therefore has to be raised with a broad base. Flaps raised to include the underlying fascia have a better blood
supply and can be raised on a narrower base (8).

The presence of competent valves in the saphenous veins means that proximally based flaps have a more
secure blood supply than distally based flaps. To improve the blood supply of transverse flaps, the proximal edge
should be angled upward if possible (7) (see Fig. 505.2). Transverse flaps based anteriorly on the medial calf
must be based at least 3 cm behind the medial border of the tibia in order not to encroach as far as the long
saphenous vein or divide a row of important perforating vessels posterior to the tibial border.
Geometric problems in the use of a cross-leg flap occur because the flap is raised from a curved donor site and
usually has to be applied to a curved recipient site. The lack of suppleness in the cross-leg flap raised on the calf
donor site does not allow it to conform readily to sharp bends, for example, over the Achilles tendon or edge of
the foot.
Adoption of the crane-flap principle (20) allows return of the skin of the flap to the donor site, minimizing the
cosmetic defect and shortening the attachment phase to 1 week. The reverse dermis cross-leg flap (6) also
minimizes the donor defect to a shallow one while providing good cover for a plantar defect.
Precise preoperative planning is essential (2, 3) (Fig. 505.1A-C). The proposed defect is outlined, including
damaged or scarred local tissue, to give a more vascular bed and facilitate good return of sensation (7). A cloth
pattern of this defect, including a generous margin to include the bridge segment, then is used to plan the flap
with as short a bridge length as possible, avoiding any twisting or kinking of the flap and with the limbs in a
comfortable position, avoiding extreme joint flexion. Crossed-leg positions are better avoided, but if used, great
care is necessary to prevent tension in the flap.
FIGURE 505.1 Stages in planning and performing a cross-leg flap.
OPERATIVE TECHNIQUE
A delay operation is not normally necessary. The leg skin is relatively stiff and unpliable, and a delay operation
can exacerbate this by causing edema in the flap.
At operation, the defect is outlined and the flap is marked using the sterilized pattern. It is better to excise the
defect as the first stage of the operation. This allows a good check of the defect to be made first before
embarking on the flap because wider than planned excisions may be necessary. A split-thickness skin graft is
applied to the flap donor site and bridge segment of the flap. The legs are brought together, a suction drain is
inserted, and the flap is sutured in place (Fig. 505.1D-H).

FIGURE 505.2 The blood supply is improved by obliquity of the proximal edge of the cross-leg flap.
FIGURE 505.3 A cross-foot flap.
Firm, accurate fixation that avoids tension or kinking of the flap or bridge segment is essential. Methods used
include plaster of Paris casts placed preoperatively with windows or, at the time of the operation, crepe and
Elastoplast® bandages applied to knee and ankles; external evacuation splints; or skeletal fixation across both
lower limbs. It is important to avoid pressure areas and to pad bony prominences.
Division of the uncomplicated flap can be safely performed at 3 weeks. If no part of the bridge segment is
required for cover, division can be accomplished at 2 weeks. Staged division or segment insetting of the flap is
best delayed. A useful method is to insert sutures, leaving the ends long so that the knots can be tied loosely
later. Formal suturing of the inset area is often not required when the bridge segment is skin-grafted. With
dressings, the wound will rapidly flatten and reepithelialize.

FIGURE 505.4 A cross-leg flap to resurface the unstable scar over a foot stump. Three year follow-up.
FIGURE 505.5 A cross-leg flap over a defect of the right shin. A scar over the tibia of the donor leg does not
necessarily prevent an anteriorly based flap being taken from the medial calf. Scars following crush or degloving
injuries are more likely to preclude a cross-leg flap.

FIGURE 505.6 A cross-leg flap over the dorsum of the foot. Fourteen- year follow-up.
After division of the flap, the patient is started on gradually increasing limb dependency and ambulation. Elastic
compression support is essential in the early weeks. On the sole of the foot, the flap performs well after the initial
2 years of poor sensation. The footwear must be modified to distribute the weight and avoid pressure, usually by
fitting a specially prepared cushion insole into the normal shoes.
CLINICAL RESULTS
The success rate of the cross-leg flap in experienced hands is high: 95% of 60 patients in one series (1),
94% of 165 patients in another (7). In the long term, the cross-leg flap provides good-quality skin with good
return of sensation on a favorable base (Figs. 505.4 and 505.5). The cross-foot flap gives excellent weight-
bearing area cover (18, 19). The donor defect carries no functional defect (Fig. 505.6). A cosmetic and
contour defect does occur, particularly in the calf donor site, that may be of particular concern to the female
patient.
SUMMARY
The cross-leg flap is still a reliable flap for lower leg and foot defects if properly designed and transferred. It
is best used when some of the newer flaps are unavailable.
References
1. Jayes PH. Cross-leg flaps: a review of sixty cases. Br J Plast Surg 1950;3:1.
2. Stark RB. The cross-leg flap procedure. Plast Reconstr Surg 1952;9:173.
3. Gillies H, Millard DR eds. The principles and art of plastic surgery. Boston: Little, Brown, 1957;134.
4. Hayes H. Cross-leg flaps after the age of fifty. Plast Reconstr Surg 1962;30:649.

5. Argamaso RV, Lewin ML, Baird AD, Rothfleisch S. Cross-leg flaps in children. Plast Reconstr Surg
1973;51:662.
6. Clodius L, Smahel J. The reverse dermal-fat flap: an alternative cross-leg flap. Plast Reconstr Surg
1973;52:85.
7. Morris AM, Buchan AC. The place of the cross-leg flap in reconstructive surgery of the lower leg and foot:
a review of 165 cases. Br J Plast Surg 1978;31:138.
8. Pontén B. The fasciocutaneous flap: its use in soft-tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
9. Orticochea M. The musculocutaneous flap method: an immediate and heroic substitute for the method of
delay. Br J Plast Surg 1972;25:106.
10. McCraw JB, Dibbell DG, Carraway JM. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
11. Ger R. The closure of defects in the lower extremity by muscle flaps. In: Converse JM, ed.,
Reconstructive plastic surgery. Philadelphia: Saunders, 1977;549.
12. Pakiam IA. The reversed dermis flap. Br J Plast Surg 1978;31:131.
13. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr
Surg 1973;52:111.
14. O'Brien B, MacLeod AM, Hayhurst JW, Morrison WA. Successful transfer of a large island flap from the
groin to the foot by microvascular anastomosis. Plast Reconstr Surg 1973;52:271.
15. Orticochea M. Immediate (undelayed) musculocutaneous island cross leg flaps. Br J Plast Surg
1978;31:205.
16. Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular free flap. Plast Reconstr
Surg 1981;67:763.
17. Haertsch P. The surgical plane in the leg. Br J Plast Surg 1981;34:464.
18. Mir y Mir L. Functional graft of the heel. Plast Reconstr Surg 1954;14:444.
19. Mir y Mir L. Follow-up clinic: functional graft of the heel. Plast Reconstr Surg 1975;55:702.
20. Millard DR. The crane principle for the transport of subcutaneous tissue. Plast Reconstr Surg
1969;43:451.

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Chapter 506
Sartorius Muscle and Musculocutaneous Flap
M. ORTICOCHEA
EDITORIAL COMMENT
This innovative use of skin and muscle brought on a wave of enthusiasm and study for the
musculocutaneous flap. All plastic surgeons are in debt to Dr. Orticochea for introducing and clarifying the
principles of the musculocutaneous flap.
During the nineteenth and twentieth centuries, many surgeons described musculocutaneous flaps that were
used for different purposes, for example, reconstruction of the palate (1), filling of facial losses (2), and penis
reconstruction (3). I believe that two patients with different problems—a penis reconstruction and raw surfaces of
a lower extremity—were responsible for my 1972 article, in which I conceived of the musculocutaneous flap as a
substitute for delaying cutaneous flaps (3, 4, 5, 6).
INDICATIONS
The rich irrigation of the superior pedicle of the sartorius, together with its great length, provides great
versatility for transfer of skin to the lower abdominal wall, external genitalia, perineum, and opposite thigh.
ANATOMY
The sartorius muscle goes through the anterior aspect of the thigh, from superior to inferior and from lateral to
medial, extending from the anterior superior iliac spine to the medial aspect of the upper end of the tibia. The
sartorius has a segmental vascular supply but receives its proximal and principal vascular pedicle from the
profunda femoris vessels. This superior proximal pedicle is several centimeters long, giving great mobility to
musculocutaneous flaps of the sartorius muscle. At the level of Hunter's canal, the inferior pedicle of the sartorius
is formed by small vessels that are branches of the femoral vessels.
OPERATIVE TECHNIQUE
The greater saphenous vein, owing to its easy dissection, must be included in the superior proximal pedicle of
the sartorius muscle. Two additional points are stressed. The proximal edge of the cutaneous part of the flap
should overlie the vascular pedicles to the muscle. In other words, the area supplied by the vascular pedicles is
distal to their site of entry into the muscle. Second, the skin is attached to the muscle by a layer of superficial
fascia. The small perforating blood vessels pass through this layer and may easily be damaged if any shearing
stress is imparted to the skin during the operation. When the muscle is divided, therefore, the ends should be
sutured with catgut to the overlying fat (Figs. 506.1 and 506.2).
SUMMARY
The sartorius muscle can be used with or without the overlying skin for coverage of various leg defects.

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FIGURE 506.1 A: Defect of the medial malleolus. B: Sartorius flap sutured to the defect. C: At the time of
division of the flap, both the muscle (m) and the third arterial pedicle (a) (arising from the superficial artery)
can be seen. (From Orticochea, ref. 5, with permission.)
FIGURE 506.2 A: Defect just medial and superior to the knee. B: Defect outlined and flap designed. The
proximal border of the skin flap lies at the level of the vascular pedicle. The distal border may extend
beyond the insertion of the muscle if required. C: Flap elevated. Note the sartorius muscle and skin paddle.
The two vascular pedicles to the sartorius muscle from the profunda femoris are displayed. The proximal
end of the sartorius is also divided. D: Flap sutured to the defect. The flap may be rotated through 90
degrees without occluding the vessels. (Continued.)

FIGURE 506.2 (Continued) E: Four weeks later, the flap is ready to be divided. F: Donor site skin-grafted.
G: Final result. (From Orticochea, ref. 5, with permission.)
References
1. Bakamjian V. A technique for primary reconstruction of the palate after radical maxillectomy for cancer.
Plast Reconstr Surg 1963;31:103.
2. Owens N. A compound neck pedicle designed for the repair of massive facial defects: formation,
development and application. Plast Reconstr Surg 1955;15:369.
3. Orticochea M. A new method of total reconstruction of the penis. Br J Plast Surg 1972;25:106.
4. Orticochea M. The musculocutaneous flap method: an immediate and heroic substitute for the method of
delay. Br J Plast Surg 1972;25:106.
5. Orticochea M. Immediate (undelayed) musculocutaneous island cross-leg flaps. Br J Plast Surg
1978;31:205.
6. Orticochea M. The musculocutaneous flap: personal history. Plast Reconstr Surg 1981;67:258.

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Chapter 507
Gastrocnemius Muscle and Musculocutaneous Flaps
B. E. COHEN
M. E. CIARAVINO
EDITORIAL COMMENT
Use of both lateral and medial gastrocnemius flaps has achieved the greatest prominence in the salvage of
exposed knee prostheses. Generally the muscle alone is transposed, and if any further skin coverage is
required, it is accomplished with a split-thickness skin graft. This leaves a relatively insignificant donor-site
contour deformity, as contrasted with a large skin-grafted midcalf.
Use of the gastrocnemius as either a muscle or musculocutaneous flap has proven to be highly effective in the
management of knee and upper leg wounds. The constant dominant proximal vascular pedicle that runs down
the length of the muscle makes this one of the most reliable flaps in the body. The muscle can be raised easily,
quickly, and safely if attention is paid to the relevant technical and anatomic details. It is generally unnecessary
to operate in the vicinity of its high vascular
pedicle, thereby decreasing the possibility of inadvertent damage to the flap's blood supply. Transposition of the
gastrocnemius results in little or no functional deficit, providing that the soleus and the other head of the
gastrocnemius are left intact and functioning. If necessary, subsequent bony procedures can be carried out by
elevating the healed flap with the assurance of a good vascular supply.
FIGURE 507.1 The gastrocnemius muscle and its neighboring structures are depicted in posterior and medial
views of the leg. Its tendon joins with that of the soleus to form the Achilles tendon.

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INDICATIONS
Because of their separate anatomic characteristics and locations within the leg, the two muscle heads are
not completely interchangeable. Since the medial head is larger, longer, and more optimally positioned
along the tibial border, it is used much more often for coverage of defects in the leg and knee.
As a muscle flap, the medial head can cover wounds of the knee and upper third of the tibia. Because of its
smaller size and the intervening muscles of the anterior and lateral compartments, the lateral head has a
smaller reach. It can be applied to upper lateral leg and knee wounds of somewhat lesser dimensions.
As a musculocutaneous flap, the medial gastrocnemius range of coverage is expanded to include the lower
thigh, knee, and upper two-thirds of the tibia. The lateral gastrocnemius musculocutaneous flap can cover
defects of the lower thigh, lateral knee, and upper third of the tibia.
Although a longer and broader flap can be created by elevating the gastrocnemius as a musculocutaneous
flap, the major disadvantage is the obligatory skin graft on the flap donor site and the resultant deformity of
the leg contour. Because of the lessened donor deformity, as well as its greater ability to fill three-
dimensional defects, the gastrocnemius muscle alone is generally preferred.
ANATOMY
The gastrocnemius is the most superficial muscle within the posterior compartment of the leg (Fig. 507.1) (1, 2,
3). It is comprised of two heads that arise separately from the lower femur, the femoral condyles, and the
posterior knee capsule. The anterior edge of the medial head lies along the medial border of the tibia, while that
of the lateral head is separated from the tibia by the muscles of the anterior and lateral compartments.
Posteriorly, the muscle bellies converge in the midline of the calf, intermingling and running together inferiorly.
The tendon of the gastrocnemius joins with that of the soleus to form the Achilles tendon. These muscles act in
concert to plantar flex the foot. Because it crosses the knee, the gastrocnemius contributes to the flexion of that
joint.
The medial and lateral sural arteries provide independent blood supply to the two muscle heads (Fig. 507.2).
These vessels arise from the popliteal artery above the level of the knee joint (4). Each courses a few
centimeters with its venae comitantes before entering the anterior aspect of the proximal muscle belly with the
innervating branches of the tibial nerve. The vessels then pass down the longitudinal axis of the muscle bellies.
This vascular arrangement is constant and effectively constitutes the sole supply of the muscle (Mathes and
Nahai Type 1) (2),
making it ideally suited for use as a flap. The independent neurovascular supply of the two muscle bellies allows
them to be used as separate muscle and musculocutaneous flaps.

FIGURE 507.2 The medial and lateral heads are retracted to show their neurovascular supply by the sural
vessels and branches of the tibial nerve. The plantaris and soleus muscles lie immediately deep to the
gastrocnemius.
FIGURE 507.3 The potential dimensions of the medial and lateral gastrocnemius muscle (solid line) and
musculocutaneous (dashed line) flaps are shown. The medial flap is larger and can be made longer than the
lateral one.
FLAP DESIGN AND DIMENSIONS (FIGS. 507.3 AND 507.4)
Muscle Flap
The position of the muscle in the leg can readily be determined by inspection and palpation in most instances.
One entire muscle belly or the other is chosen, depending on the clinical situation (1, 2, 3).

FIGURE 507.4 The areas of coverage of the medial and lateral muscles (solid line) and musculocutaneous
(dashed line) flaps are shown.
Musculocutaneous Flap
The medial head can support a skin flap that extends in width from the medial border of the tibia to the posterior
midline of the calf. The point of rotation is the midline popliteal fossa, near the origin of the muscle and its blood
supply. The level of the defect determines the length of the flap. This always includes the skin overlying the
muscle and often a “random” extension of skin and subcutaneous tissue distal to the muscle. This extension is
quite safely included with the flap when its length-to-width ratio is 1:1 or less. Generally, this reaches to a point
approximately 10 cm above the malleolus. The age of the patient, the state of the peripheral vascular circulation,
and the degree of trauma to the leg will determine the safety of extending the flap past this point. If unsure, a
delay of this distal portion should be done prior to the flap transfer.
The lateral gastrocnemius supports a flap of smaller dimensions. Its width extends from the posterior midline to a
point over the lateral muscle compartment. In addition to the skin over the muscle, some skin distal to the muscle
may be carried with the flap. The same constraints for the distal extension of the medial head apply here.
Generally speaking, it is safe to extend this flap to within 10 to 15 cm of the lateral malleolus (Figs. 507.3 and
507.4).
OPERATIVE TECHNIQUE
Medial Gastrocnemius Muscle Flap
The posterior dissection is generally done first through a posterior midline incision or a longitudinal incision
between the midline and the defect (Figs. 507.5 and 507.6). The posterior anatomy is clear and unlikely to have
been damaged or obscured by the anterior trauma. The sural nerve and lesser saphenous vein are two key
landmarks which are seen superficial to the muscle bellies and preserved. These structures are in the midline
and help to locate the natural cleavage between the two upper muscle bellies, a distinction not so easily made
more distally. The muscle fascia is split, and the junction of the two heads is incised. Gentle blunt finger
dissection is used to seek the plane between the gastrocnemius and the underlying soleus muscle and plantaris
tendon. The loose avascular areolar tissue can be progressively swept through with the finger down to the
tendinous junction of the muscle with the soleus. The superficial dissection is then performed, and the muscle is
transected distally with a cuff of tendon attached for use in fixation to the wound edge. Anteriorly, incisions
extend the defect superiorly and inferiorly as needed for adequate exposure. The tunnel through which the
muscle is passed should be of adequate size so as not to constrict the blood supply of the flap. The superficial

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surface of the muscle may remain so or be rotated to lie deeply, depending on how it best transfers. Drains are
left in the muscle bed and the muscle is skin grafted.
Medial Gastrocnemius Musculocutaneous Flap
The midline posterior incision is made in the upper calf, and after identifying the sural nerve and lesser
saphenous vein,
the deep dissection is done as described above for the muscle flap. The remainder of the peripheral skin incision
is then made, and the compound muscle and skin flap is elevated (Fig. 507.7). The peritenon over the exposed
soleus fascia and Achilles tendon should be carefully preserved in this dissection to provide a suitable bed for
application of skin grafts. The greater saphenous vein is generally, although not necessarily, transected during
elevation of the distal portion of the flap. In dissecting the distal skin and subcutaneous portion of the flap toward
the muscle, the tendinous contribution to the Achilles tendon is encountered and incised, thus converting the
subcutaneous plane at this point to the previously dissected submuscular one. Backcuts of the proximal skin and
subcutaneous tissue may be made as needed to allow for easier rotation to the defect. A suction drain is
generally placed beneath the flap. The flap is then sewn into the periphery of the prepared wound. Split-
thickness skin grafts are applied to the flap donor site and are held in place with a tie-over dressing.
FIGURE 507.5 Posterior midline approach with lesser saphenous vein and sural nerve landmarks. Once the
fascia is incised, blunt dissection is used to develop the submuscular plane.
FIGURE 507.6 A 34-year-old man with a large left upper leg defect A: Muscle flap elevated through separate

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longitudinal incision. Muscle passed through tunnel to defect. B: Muscle sutured in place and ready for skin
graft. (Courtesy of Dr. David Buchanan).
Lateral Gastrocnemius Muscle and Musculocutaneous Flaps
Techniques and approaches outlined for the medial side are generally applicable here. Again, the lesser
saphenous vein and sural nerve are used as landmarks and should be preserved. In dissecting superiorly, one
must be aware not to injure the peroneal nerve, which crosses from medial to lateral over the upper portion of the
muscle belly (Fig. 507.8).
FIGURE 507.7 A 27-year-old man with an exposed fracture of the right midtibia 4 months after injury. A: The
defect has been debrided and the musculocutaneous flap elevated and reflected with landmarks noted. B:
Transposed flap with skin graft applied to donor site (posterior grafts not visible).
FLAP MODIFICATIONS
Local Coverage
Transposition Flap
In most instances, the muscle or musculocutaneous flap will be used as described above, as a transposition flap
to cover a local defect (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). Various techniques for improving wound
coverage and aesthetics have been described. Making the flap into an island by detaching the origin of the
muscle head will result in extra reach for either flap. However, the proximity of the origin to the vascular supply
adds a degree of complexity and risk to this latter maneuver. Additional length and improved contour may also be
achieved by incising the muscle fascia. The appearance of the gastrocnemius musculocutaneous flap may be
improved by placing the skin paddle over the distal edge of the muscle and limiting its dimensions to that
required by the defect. These modifications help to minimize the contour deformity and may obviate the need for
skin grafting (15).

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FIGURE 507.8 A 20-year-old man with a lateral leg wound. A: Lateral gastrocnemius dissected prior to
transposition to exposed tibial defect. B: Muscle flap transposed to defect and sutured into place. (Courtesy of
Dr. David Buchanan.)
Advancement Flap
By undermining in the submuscular plane, with or without opening the posterior midline, enough advancement of
the musculocutaneous unit may be achieved to cover certain upper tibial defects (16).
Posterior Flap in Below-Knee Amputation
Both heads are left in the posterior skin flap, which is then turned up for closure as a musculocutaneous flap
(17).
Fasciocutaneous Flap
In this modification, the skin, subcutaneous tissue, and muscle fascia are elevated as a flap, while the muscle is
left in situ (18, 19). This is further described in Chapter 502.
FIGURE 507.9 The gastrocnemius musculocutaneous flap produces a considerable cosmetic deformity when
used to cover a knee defect (A) compared to a midtibial defect (B).

Distant Coverage
Cross-Leg Flap (12, 13, 14)
Generally, the medial head is chosen and used as a musculocutaneous flap for this purpose. The flap may not
be as well oriented as a random cross-leg flap and must usually undergo some torsion to reach the defect in the
opposite leg or foot. This is compensated for by the long and reliably robust flap that can be elevated without a
preliminary delay procedure. External bony fixation devices may be used to hold the flap donor leg in a fixed
position relative to the recipient leg while healing. Most authors have recommended that this well-perfused flap
be divided in stages in order to stimulate neovascularization adequate to nourish the transposed tissue—a
clinical concept supported by experimental evidence (20). However, the inherent disadvantages of prolonged
immobilization and the need for staged procedures make cross-leg flaps primarily useful as a salvage operation.
Free Flap
Although either head is anatomically suited, there is no obvious situation in which the flap would be chosen over
the many other available sites.
CLINICAL RESULTS
The gastrocnemius flap has provided reliable local soft-tissue coverage for traumatic defects, reconstruction
following tumor resection, and the salvage of exposed knee prostheses. In cases where the muscle alone is
employed, there is relatively little contour deformity, although a skin graft must be placed anteriorly over the
muscle flap. The gastrocnemius musculocutaneous flap, in contrast, produces a considerable contour
deformity. This latter effect is most obvious when the musculocutaneous flap is used for a high defect in an
obese patient. In this instance, a rather large amount of tissue is added to the pretibial or knee area and a
simultaneous loss of posterior bulk occurs (Fig. 507.9A). This deformity is least obvious when the
musculocutaneous flap is used in a thin patient for a middle or low tibial defect (Fig. 507.9B).
SUMMARY
The medial and lateral gastrocnemius muscle flaps and, to a lesser extent, the gastrocnemius
musculocutaneous flaps are effective flaps to use when confronted with an upper leg or knee defect.
References
1. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
2. Mathes S, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
3. Mathes S, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.
4. Whitney T, Heckler F, White M. Gastrocnemius muscle transposition to the femur: how high can you go?
Ann Plast Surg 1995;34:415.

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5. Robertson IM, Barron JS. A method of treatment of chronic infective osteitis. J Bone Joint Surg
1946;28B:19.
6. Barford B, Pers M. Gastrocnemius plasty for primary closure of compound injuries of the knee. J Bone
Joint Surg 1970;52B:124.
7. Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions
of the leg. J Trauma 1971;11:502.
8. Pers M, Pedgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;26:313.
9. Mathes SJ, McCraw JB, Vasconez LO. Muscle transposition flaps for coverage of lower extremity defects.
Surg Clin North Am 1974;54:1337.
10. Vasconez LO, Bostwick J III, McCraw JB. Coverage of exposed bone by muscle transposition and skin
grafting. Plast Reconstr Surg 1974; 53:526.
11. Feldman JJ, Cohen BE, May JW. The medial gastrocnemius myocutaneous flap. Plast Reconstr Surg
1978;61:531.
12. McCraw JB, Fishman JH, Sharzer, LA. The versatile gastrocnemius myocutaneous flap. Plast Reconstr
Surg 1978;62:15.
13. Furnas DW, Anzel SH. Two consecutive repairs of the lower limb with a single gastrocnemius
musculocutaneous cross-leg flap. Plast Reconstr Surg 1980;66:137.
14. Dibbell DG, Edstrom LE. The gastrocnemius myocutaneous flap. Clin Plast Surg 1980;7:45.
15. Kroll J, Marcadis A. Aesthetic considerations of the medical gastrocnemius myocutaneous flap. Plast and
Reconstr Surg 1987;79:67.
16. Riley WB Jr, Garren S, Ramey SJ. Variations in gastrocnemius and solus flap surgery (Abstract). Plast
Surg Forum 1981;4:128.
17. Dellon AL, Morgan RF. Myodermal flap closure of below the knee amputation. Surg Gynecol Obstet
1981;153:383.
18. Ponten B. The fasciocutaneous flap: its use in soft-tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
19. Reeder RC. The medial gastrocnemius skin-fascia flap (Abstract). Plast Surg Forum 1981;4:185.

20. Cohen BE. Beneficial effect of staged division of pedicle in experimental axial-pattern flaps. Plast
Reconstr Surg 1979;64:366.

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Chapter 508
Vastus Medialis Musculocutaneous and Musculocutaneous-
Tendinous Flaps for Knee Reconstruction
G. R. TOBIN
EDITORIAL COMMENT
For exposure of total knee prostheses, the medial head of the gastrocnemius muscle or musculocutaneous
unit may not be enough to cover the upper portion of the defect. In these cases, the vastus medialis may
prove very handy.
The vastus medialis musculocutaneous flap is most useful for reconstruction of defects of the knee and distal
thigh. This flap is designed as a medially based advancement flap, with V-Y cutaneous donor-defect closure (1,
2) (see Fig. 508.2). An especially valuable option of this flap is its ability to carry vascularized quadriceps femoris
tendon segments for patellar or distal quadriceps femoris tendon reconstruction. Thus, the flap may be designed
as a musculocutaneous-tendinous composite flap (1, 2) (see Fig. 508.3).
INDICATIONS
Vastus medialis musculocutaneous flaps are used for defects of the anterior or medial knee joint and distal
thigh. The vastus medialis musculocutaneous tendinous composite flap is used to reconstruct segmental
defects of the distal quadriceps femoris or patellar tendons (1, 2) (see Figs. 508.3 and 508.5). If skin
overlying the muscle is missing, the muscle only can be used to cover the anterior knee (3). A vastus
medialis musculotendinous flap can be designed if knee skin cover is not needed (2).
ANATOMY
The vastus medialis muscle lies medial to the other components of the quadriceps femoris muscles and ventral
to the thigh adductor muscles. Its long origin on the linea aspera femoris extends from the intertrochanteric line to
the medial supracondylar line; its insertion is on the quadriceps femoris tendon and medial border of the patella.
The vastus medialis vascular supply usually consists of three to six segmentally arranged vascular pedicles from
the superficial femoral vessels that enter the vascular hila along the medial side of the muscle (1, 2, 4) (Fig.
508.1).
Musculocutaneous perforators from the vastus medialis supply a large musculocutaneous territory centered over
the
muscle and extending beyond the muscle borders. This musculocutaneous territory is a large triangle with a wide
base at the knee level anteriorly and an apex in the proximal medial thigh. In the midthigh, this musculocutaneous
territory lies between the rectus femoris and gracilis musculocutaneous territories. In the distal thigh, this
musculocutaneous territory occupies nearly half of the thigh circumference and covers the anterior and medial
thigh.

FIGURE 508.1 Neurovascular anatomy of the vastus medialis muscle shown on specimen angiogram.
Segmental vascular pedicles (arrows) from superficial femoral vessels enter medial muscle border. Pins show
hila of motor nerves. Muscle origin (O) and insertion (I) are indicated.
The anatomic basis for the vastus medialis musculocutaneous-tendinous composite flap is a vascular supply
from the vastus medialis muscle to the quadriceps femoris tendon along the course of the muscle-tendon
junction. A series of vessels from muscle to tendon is found in the peritenon. This allows the medial half of the
distal quadriceps femoris tendon to be transferred with the muscle as a vascularized tendon segment for distal
patellar or quadriceps femoris tendon reconstruction (see Figs. 508.3 and 508.5).
Motor supply to the vastus medialis is two muscular branches of the femoral nerve that follow the plane of the
vascular pedicle (see Fig. 508.1). The major motor branch enters a neural hilum on the ventral medial surface of
the muscle near the muscle midpoint. A second motor branch enters a neurovascular hilum on the most proximal
part of the muscle (1, 2, 4). Sensory nerves to the cutaneous paddle of the flap are branches of the medial
cutaneous and intermediate cutaneous nerves of the thigh.
FLAP DESIGN AND DIMENSIONS
Vastus medialis musculocutaneous or musculocutaneous-tendinous flaps are designed as medially based
advancement flaps with V-Y cutaneous donor-defect closure (Figs. 508.2 and 508.3). The vastus medialis
musculocutaneous flap is the largest flap available from the distal thigh. The cutaneous paddle can be made as
wide as half the distal thigh circumference. Flap length is the distal three fourths of the thigh (see Figs. 508.2,
508.4, and 508.5). The flap base is the segmental vascular pedicles from the superficial femoral vessels along
the muscle origin medially (see Fig. 508.1). The arc of transfer of this advancement flap is 12 cm, which is
sufficient to advance the flap from the upper patellar border to the tibial tubercle.
OPERATIVE TECHNIQUE
Skin paddles are incised as shown in Figure 508.2. Although this flap has been successfully transferred as a
cutaneous island, it is recommended that a medial cutaneous pedicle be maintained to preserve cutaneous
sensory nerves and subcutaneous venous drainage (Figs. 508.2A,B and 508.3).

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After the cutaneous component of the flap is incised, the vastus medialis muscle is raised in continuity with the
skin paddle by a dissection of the plane deep to the muscle. This dissection proceeds from the quadriceps
femoris tendon toward the muscle origin. If a musculocutaneous-tendinous composite flap is required, the
quadriceps femoris tendon is split along its midline to create a sufficiently long tendon segment in continuity with
the muscle to bridge the tendon defect (see Figs. 508.3 and 508.5). The muscle origin on the proximal femur may
be transected to allow greater flap mobilization for large knee defects. If a vascularized quadriceps femoris
tendon segment is transferred, the distal end of the tendon is sutured to the tibial tubercle or patellar tendon
stump and the proximal border of the tendon is sutured to the lateral half of the split quadriceps femoris tendon
that had been left in situ (see Figs. 508.3 and 508.5). The cutaneous donor defect in the proximal thigh is
managed by V-Y closure (see Figs. 508.2 and 508.3).
Closed suction drainage is routinely used. Prolonged knee immobilization is used when tendon reconstruction is
done.
CLINICAL RESULTS
This flap is highly reliable. Complete flap survival has been the result in all patients to date.
This flap is designed to avoid the functional deficit that would result from loss of this prime knee extensor.
Motor innervation is retained, and muscle insertion is restored. When the musculocutaneous flap is used,
the muscle is reinserted into the quadriceps femoris tendon and patella distally. When a musculocutaneous-
tendinous flap is used, the tendon is reinserted into the patellar tendon stump or tibial tubercle. Thus,
function is always preserved (see Figs. 508.3 and 508.5).
SUMMARY
Vastus medialis musculocutaneous flaps are highly reliable, are ideally located for reconstruction of knee
and distal thigh defects, and cause no functional deficits. Moreover, they can be designed as composite
musculocutaneous-tendinous flaps that carry vascularized quadriceps femoris tendon segments for patellar
tendon reconstruction.

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FIGURE 508.2 The vastus medialis musculocutaneous flap. A: Cutaneous paddle design. Stippled area
indicates knee defect. B: Flap advancement covers knee defect. V-Y donor defect closure. C: Flap
designed as cutaneous island. (Modified from Mathe, ref. 5.)
FIGURE 508.3 The vastus medialis musculocutaneous-tendinous composite flap. A: Distal quadriceps
femoris tendon (Q) is split to create vascularized tendon segment (T) to bridge knee defect (K). B:
Vascularized tendon segment (T) is advanced with flap and interposed between quadriceps femoris tendon
(Q) and insertion point. V-Y closure of donor defect (D). (Modified from Mathe, ref. 5.)

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FIGURE 508.4 Flap designed with medial cutaneous pedicle for cover of exposed knee joint and proximal
tibia. A: Skin loss exposes knee cartilage (arrow) and tibial fracture. B: Composite flap with medial
cutaneous base advanced. Tibial coverage supplemented by gastrocnemius muscle flap. C: Anterior view
of extended leg showing successful postoperative result. V-Y closure of cutaneous donor defect (arrow).
Note the large size of this flap.
FIGURE 508.5 Composite transfer of vascularized quadriceps femoris tendon segment. A: Medially based
flap outlined above exposed knee joint with missing patella and patellar tendon. B: Distal quadriceps
femoris tendon split. Medial half of tendon (M) transferred on flap. Lateral half (L) left in situ. (Continued.)

FIGURE 508.5 (Continued) C: Inset of vascularized medial tendon segment (M). Distal suture (white arrow)
is made end-to-end to patellar tendon stump. Proximally, the edge of the tendon is sutured (black arrow)
side-to-side to the distal quadriceps femoris tendon (L). D: Extended leg showing postoperative result with
defect closed and knee extension restored.
References
1. Tobin GR. The vastus medialis musculocutaneous flap: a comparison with other regional flaps for complex
knee defects. Plast Surg Forum 1982;5:223.
2. Tobin GR. Unpublished data.
3. Arnold PG, Prunes-Carrilo F. Vastus medialis muscle flap for functional closure of the exposed knee joint.
Plast Reconstr Surg 1981;68:69.
4. Brash JC. Neurovascular hila of limb muscles. Edinburgh: Livingstone, 1955;68-70.
5. Mathe J. Leonardo daVinci: anatomical drawings. Fribourg: Production Liber SA, 1978.

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Chapter 509
Soleus Flaps
G. R. TOBIN
EDITORIAL COMMENT
The editors question use of the musculocutaneous soleus flap. In fact, we may be dealing with a soleus
muscle and a separate fasciocutaneous flap of the leg. The use of the turndown hemisoleus is preferable to
turning down the entire soleus; however, caution should be used, because the failure rate is significant.
The soleus muscle provides several reliable flaps that are frequently first choices for repair of defects between
the knee and ankle.
INDICATIONS
These flaps are used to cover defects in the middle third (soleus and hemisoleus muscle) and distal third
(soleus musculocutaneous
and reverse medial hemisoleus muscle) of the leg that cannot be covered with skin grafts and are not so
massive as to require large free or cross leg flaps. These defects include exposed bone or open fractures of
the long bones or malleoli, exposed internal fixation devices, exposed vessels or vascular grafts, exposed
tendocalcaneus or other tendons, and surgically excised osteomyelitis, stasis ulcers, and unstable scars (1,
2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12). Compared with skin or fasciocutaneous flaps, soleus muscle flaps are more
effective for contaminated or ischemic defects, presumably because of better vascular perfusion of muscle
(13).
FIGURE 509.1 A: Medial and lateral hemisoleus flaps raised simultaneously in a cadaver leg. B: Medial
hemisoleus muscle flap raised for early cover of open midtibial fracture. Flap inset, successful skin-graft
application, and fracture union resulted. (From Tobin, ref. 19, with permission.)

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ANATOMY
The value and versatility of soleus-based flaps result from the following anatomic features: (1) The soleus is the
largest, longest muscle beyond the knee. (2) It extends distally on the leg. (3) Its bipennate morphology and dual
neurovascular supply permit vertical splitting of the two soleus bellies into lateral or medial hemisoleus muscle
flaps (14) (Fig. 509.1). (4) Both muscle bellies carry overlying musculocutaneous and extended fasciocutaneous
territories that permit design of wide, distally extended musculocutaneous flaps for distal leg and ankle defects
(15) (Figs. 509.2, 509.3, 509.4). (5) Distal segmental vascular pedicles permit reversal of soleus segments on
this distal vascular supply for distal leg and ankle defects (16, 17, 18) (Fig. 509.5).
The soleus lies immediately deep to the gastrocnemius and plantaris musculotendinous units in the posterior leg
compartment. It has a bipennate morphology. It originates on the proximal third of both tibia and fibula, and it
tapers to insert on the tendocalcaneus just above the ankle.
The soleus vascular supply is from popliteal, posterior tibial, and peroneal vascular pedicles to the proximal
muscle, peroneal pedicles to the distal lateral belly, and segmental posterior tibial pedicles to the distal medial
belly (see Fig. 509.2) [the basis for reversed soleus and reversed medial hemisoleus flaps (19)] (see Fig. 509.5).
FIGURE 509.2 Vascular anatomy of soleus flaps. Po, popliteal artery; PT, posterior tibial artery; Pe, peroneal
artery; M, major vascular pedicles to proximal soleus; S, segmental posterior tibial vascular pedicles to soleus
medial belly; A, longitudinal, intramuscular pedicles to lateral soleus belly; T, tendinous midline raphe separating
medial and lateral soleus bellies; MC (stippled area), extended fasciocutaneous territories of soleus
musculocutaneous flaps. (From Tobin, ref. 19, with permission.)

FIGURE 509.3 Medial soleus musculocutaneous territory (left) and lateral soleus musculocutaneous territory
(right). Soleus musculocutaneous flaps are designed within these boundaries. (Modified from O'Malley, ref. 26,
with permission.)
Cutaneous perforators from each distal soleus belly supply overlying musculocutaneous and extended
fasciocutaneous territories that extend from the posterior midline to the anterior borders of the posterior
compartment and reach distally to the malleoli (15) (see Figs. 509.2, 509.3, 509.4). These perforators provide
medial and lateral musculocutaneous flaps that extend well beyond their underlying hemisoleus muscles to cover
the most distal leg and ankle (15). Both medial and lateral soleus bellies are independently innervated by
branches of the medial popliteal and posterior tibial nerves (20).
FLAP DESIGN AND DIMENSIONS
The soleus provides the largest, longest regional flaps for the distal two thirds of the lower leg. Soleus muscle
dimensions taper from the proximal third of the leg, where the soleus constitutes approximately 45% of leg
circumference, to its narrow insertion. At the tibial midpoint, the soleus constitutes approximately 35% of leg
circumference (21). Compared with soleus muscle flaps, hemisoleus muscle flaps are slightly longer when
transposed and about half as wide (14).
The arc of rotation for fully mobilized, proximally based soleus and hemisoleus muscle flaps is the distance from
the pivot point to insertion. The pivot point is at the junction of the proximal and middle thirds of the leg (the origin
of major vascular pedicles to the proximal muscle) (19) (see Fig. 509.2). The muscle insertion is on the
tendocalcaneus 6.0 ± 1.7 cm (X ± SD) above the calcaneus (21).
Soleus musculocutaneous flaps have the same pivot point as their muscle components, but their arcs of rotation
are substantially longer when distally extending skin peninsulas are carried. Undelayed flaps extend a short
distance beyond the malleoli; delayed flaps extend well beyond the malleoli (15) (see Figs. 509.2, 509.3, 509.4).
Soleus musculocutaneous flaps also provide substantially wider flaps than their component hemisoleus muscles.
Their skin peninsulas may extend from the ipsilateral border of the tendocalcaneus to the ipsilateral margin of the
posterior compartment (the tibia or fibula) (15) (see Figs. 509.2, 509.3, 509.4). In the distal leg, medial soleus
musculocutaneous flaps comprise one third of leg circumference, and lateral soleus musculocutaneous flaps
comprise one fourth of leg circumference (15) (see Fig. 509.3).
Reversed medial hemisoleus and soleus muscle flaps have a pivot point that is the proximal of the two most
distal posterior tibial vascular pedicles. This pedicle is usually located 7 cm proximal to the malleolar flair (16)

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(see Fig. 509.5). Reversed soleus flaps reliably carry only the distal one half to two thirds of the muscle (16, 17).
Reversed transfer of the lateral hemisoleus muscle is questionable, as I find no major distal segmental peroneal
pedicles to the lateral belly and no major vascular connections from posterior tibial pedicles crossing the distal
muscle midline (19) (see Fig. 509.2).
The entire soleus muscle can be reversed by an alternative technique in which the posterior tibial vessels are
divided at their popliteal origin and the posterior tibial vessels and attached soleus are reversed together (22);
however, this technique involves major alteration of the extremity blood supply.
These flap dimensions permit coverage of leg middle-third defects with soleus and hemisoleus muscle flaps and
coverage of leg distal two thirds and ankle defects with soleus musculocutaneous and reversed muscle flaps (14,
15, 16, 17, 18).
OPERATIVE TECHNIQUE
Soleus flaps are usually approached through either medial or lateral midline incisions placed over the respective
borders of the leg posterior compartment (Figs. 509.5 and 509.6). Major subcutaneous nerves and veins, such
as saphenous and sural trunks, are preserved when possible. The calf muscles are exposed by opening the
posterior compartment deep fascia.
In the leg midsection, well-defined planes usually separate the soleus from overlying gastrocnemius tendon and
underlying vessels and deep muscles. If not present, the plane between soleus and gastrocnemius tendons must
be surgically created. The plantaris tendon transverses the superficial plane. Vascular pedicles from the
posterior tibial and peroneal vessels cross the deep plane.
FIGURE 509.4 A: Undelayed medial soleus musculocutaneous flap carried by medial hemisoleus muscle and
raised to the malleolus. Complete flap survival and successful cover of resected unstable scar and tibial
osteomyelitis resulted. B: Lateral soleus musculocutaneous flap carried by lateral hemisoleus muscle and raised
beyond the malleolus. Note the anteriorly and distally extending fasciocutaneous components of this extended
flap.
At this stage of dissection, the muscle may be designed into proximally based soleus, hemisoleus, or reversed
flaps. Proximally based soleus flaps require sharp separation of the overlying tendocalcaneus and division of
tethering distal segmental vascular pedicles. Lateral or medial hemisoleus flaps are fashioned by separating the
belly to be transferred from the belly left in situ by dissection along a midline raphe that separates them distally
(14, 19) (see Fig. 509.2). Reversed medial hemisoleus and soleus flaps are created by transversely dividing the

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muscle proximally and reversing the distal segment on the two most distal posterior tibial vascular pedicles
(16) (see Fig. 509.5). Only one half to two thirds of the muscle can be reliably reversed (16, 17).
FIGURE 509.5 A: Reversed medial hemisoleus muscle flap based on the two most distal posterior tibial vascular
pedicles (located by arrows). B: Reversed medial hemisoleus muscle flap covering exposed malleolar fracture
and internal fixation hardware. Successful skin-graft application and wound closure resulted. (From Tobin, ref.
19, with permission.)
FIGURE 509.6 Soleus muscle flap transposed through a medial midline incision. Transposition through lateral
incision permits similar coverage of lateral leg midthird defects.
Soleus musculocutaneous flaps are approached by means of incisions along a border of the skin peninsula (see
Figs. 509.2, 509.3, 509.4). Usually, this is the posterior border that overlies the tendocalcaneus ipsilateral edge.
The skin peninsula is raised deep to the underlying fascia, and the underlying hemisoleus belly is raised in

continuity with the skin peninsula. The muscle border epimysium is sutured to overlying fascia to protect
musculocutaneous perforators from shearing. Skin grafts are immediately applied to muscle flap and
musculocutaneous flap donor sites.
CLINICAL RESULTS
The anatomy and experiences described in this chapter are derived from my studies of more than 100
cadaver legs and 50 clinical flaps. Proximally based soleus, hemisoleus, and soleus musculocutaneous
flaps are exceptionally hearty and highly reliable. These flaps may fail if their proximal vascular pedicles or
the major vascular supply of the limb are compromised by trauma or arteriosclerosis obliterans (23). Soleus
musculocutaneous flaps may fail distally if the skin peninsula is extended too far or if small skin vessels are
diseased (15).
Reversed soleus flaps have reported failure rates greater than 21% (16, 17). Accordingly, reversed soleus
flaps usually are reserved for secondary salvage procedures (16, 17). This failure rate may be reduced by
transferring only the distal half of the muscle on two distal vascular pedicles and by using only the medial
hemisoleus belly (16, 19).
Although the soleus is the prime ankle plantar flexor, functional deficit following transfer is lessened by both
surgical maneuvers and synergistic muscle strengthening and alteration of gait (14, 24, 25). When
hemisoleus flaps are used, the contralateral muscle belly remains in situ to preserve soleus function (14,
25). Strengthening of gastrocnemius and deep calf muscle compensates for loss of soleus power. In
ambulation, calf muscles serve to oppose dorsiflexion and to stabilize the ankle during ipsilateral weight
bearing, thus allowing greater forward lean and stride length (24). Soleus deficit not relieved by synergistic
calf-muscle strengthening is compensated for by lessening of forward lean, earlier contralateral heel strike,
and shorter stride (24).
SUMMARY
The size, location, and anatomy of the soleus muscle allow several useful, reliable soleus-based flaps for
cover of distal leg and ankle defects.
References
1. Stark WJ. The use of pedicled muscle flaps in the surgical treatment of chronic osteomyelitis resulting from
compound fractures. J Bone Joint Surg 1946;28B:343.
2. Ger R. The operative treatment of the advanced stasis ulcer: a preliminary communication. Am J Surg
1966;11:659.
3. Ger R. The management of pretibial skin loss. Surgery 1968;63:757.
4. Ger R. Operative treatment of the advanced stasis ulcer using muscle transposition: a follow-up study. Am
J Surg 1970;120:376.
5. Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions

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of the leg. J Trauma 1971;11:502.
6. Ger R. Surgical management of ulcerative lesions of the leg. Curr Prob Surg 1972;3:1.
7. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;26:313.
8. Vasconez LO, Bostwick J, McCraw J. Coverage of exposed bone by muscle transposition and skin
grafting. Plast Reconstr Surg 1974;53:525.
9. Mathes SJ, Vasconez LO, Jurkiewicz MJ. Extensions and further applications of muscle flap transposition.
Plast Reconstr Surg 1977;60:6.
10. Ger R. The management of stasis ulcers of the leg where the tendocalcaneus is exposed. Plast Reconstr
Surg 1977;60:337.
11. Ger R. Closure of defects of the lower extremity by muscle flaps. In: Converse JM, ed., Reconstructive
plastic surgery, 2d ed. Philadelphia: Saunders, 1977;3549-3560.
12. Byrd HS, Cierny G III, Tebbetts JB. The management of open tibial fractures with associated soft-tissue
loss: external pin fixation with early flap coverage. Plast Reconstr Surg 1981;68:73.
13. Pappas C, Goldich G, Cundy K, Wong W. Skin flaps vs. muscle flaps: coping with infection in the
presence of a foreign body. Plast Surg Forum 1980;3:133.
14. Tobin GR, Moberg AW, Adcock R, Gemberling RM. Hemisoleus flaps. Plast Surg Forum 1981;4:126.
15. Tobin GR, Moberg AW, Pompi-Sanders B, Bundrick L Jr. Soleus musculocutaneous flaps. Unpublished
data.
16. McGee WP, Gilbert DA, McInnis WD. Extended muscle and musculocutaneous flaps, Clin Plast Surg
1980;7:63.
17. McCraw JB. Selection of alternative local flaps in the leg and foot. Clin Plast Surg 1979;6:227.
18. Townsend PLG. An inferiorly based soleus muscle flap. Br J Plast Surg 1978;31:210.
19. Tobin GR. Hemisoleus and reversed hemisoleus flaps. Plast Reconstr Surg 1985;76:87.
20. Brash IC. Neurovascular hila of limb muscles. Edinburgh: Livingstone, 1965;88-89.
21. Tobin GR. Unpublished data, 1980.
22. Guyuron B, Dinner MI, Dowden RV, Labandter HP. Muscle flaps and the vascular detour principle: the

soleus. Ann Plast Surg 1982;8:132.
23. Riley WB Jr, Cotlar SW, Long JK. The injury-compromised gastrocnemius musculocutaneous flap:
lessons and limits. Plast Surg Forum 1980;3:136.
24. Simon SR, Mann RA, Hagy JL, Larsen L.J. Role of the posterior calf muscles in normal gait. J Bone Joint
Surg 1978;60A:465.
25. Tobin GR, Gordon JA, Smith BS, Schusterman MA. Preserving motor function by splitting muscle and
myocutaneous pedicles. Plast Surg Forum 1980;3:160.
26. O'Malley CD, Saunders JB, De CM, eds. Leonardo da Vinci on the Human Body. New York: Henry
Schuman, 1952.

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Chapter 510
Tibialis Anterior Muscle Flap
M. PERS
S. MEDGYESI
B. KIRKBY
EDITORIAL COMMENT (CHAPTERS 510 AND 511)
The use of transposition muscle flaps in the lower extremity continues to be very valuable. It is particularly
so for coverage of defects of the proximal and middle thirds of the leg. As one approaches the distal third of
the leg, particularly the foot and the ankle, microvascular surgery is most indicated.
To cover defects exposing the upper third of the tibial shaft (1, 2, 3, 4, 5, 6, 7, 8), a medial or lateral
gastrocnemius musculocutaneous flap should be the first choice; however, if the defect is located at a somewhat
lower level, between the upper and middle third (see Fig. 510.1), and if the belly of the tibialis anterior muscle is
already exposed in the defect, it may be a tempting alternative to mobilize this powerful muscle (6, 7, 8).
ANATOMY
The muscle has its bony origin from the lateral tibial condyle above to about halfway down the lateral side of the
tibia. Blood is supplied from the tibialis anterior artery by several branches entering the muscle from behind. The
vessels lie deeply on the interosseous membrane between the tibialis anterior and the extensors. The segmental
supply means that the muscle may be transected safely at any level as long as the main vessels are intact. The
cutaneous territory of this muscle is generally not useful for transfer because the donor defect may leave the
anterior tibial artery and the deep peroneal nerve exposed.
FLAP DESIGN AND DIMENSIONS
The origin and the close relationship to the tibial shaft indicate that the muscle needs to be transferred only a
very short distance to cover a fracture line or an exposed orthopedic screw in a defect located laterally between
the upper and middle thirds of the tibial shaft (Figs. 510.1 and 510.2).
The tibialis anterior muscle has an important normal function, however. Foot dorsiflexion and inversion will be
impaired
if the tendon is completely cut and the function of the tibialis anterior muscle is not taken over by other muscles
(e.g., the extensor hallucis longus or extensor digitorum longus), although they have similar innervation from the
deep peroneal nerve and are situated in the same anterolateral compartment as the tibialis anterior muscle.
When it has been decided to mobilize the tibialis anterior muscle, one should therefore use only part of it,
preserving the tendon to preserve dorsiflexion and inversion of the foot.

FIGURE 510.1 Transposition of the superficial part of the tibialis anterior muscle. Diagram shows arc of rotation.
FIGURE 510.2 A: Superficial part of tibialis anterior muscle mobilized. B: The muscle flap transferred to defect
and covered with split-thickness skin graft.
OPERATIVE TECHNIQUE
In transposing the tibialis anterior muscle, it may be feasible to chisel off the sharp anterior border of the tibia.
The muscle then is detached from its bony origin and freed from the interosseous membrane as far as necessary
for easy transfer (see Fig. 510.2B).

CLINICAL RESULTS
This muscle flap has been used to cover exposed bone following compound fracture in four patients. No
necrosis has occurred; however, in one patient, it became necessary to amputate the leg: an older woman
suffering from anterior-sclerosis in whom the additional operative trauma further impaired the blood supply
to the fracture area and foot. This was a typical case of overestimation of the possible use of muscle flaps.
Splitting the muscle has not resulted in any hematomas.
SUMMARY
The tibialis anterior muscle can be used to cover defects at the junction of the upper and middle thirds of
the tibia. Only a portion of muscle should be used because a significant functional deficit will result from use
of the complete muscle.
References
1. Ger R. The technique of muscle transposition in the operative treatment of traumatic and ulcerative lesions
of the leg. J Trauma 1971;11:502.
2. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;26:313.
3. Mathes SJ, McCraw JB, Vasconez LO. Muscle transposition flaps for coverage of lower extremity defects.
Surg Clin North Am 1974; 54:1337.
4. McHugh M, Prindiville JB. Muscle flaps in the repair of skin defects over the exposed tibia. Br J Plast Surg
1975;28:205.
5. Pers M. Muscle flaps in reconstructive surgery. In: Barron JN, Saad MN, eds. Operative plastic and
reconstructive surgery, Vol. 1. London: Churchill- Livingstone, 1981;115-135.
6. Robbins TH. Use of fasciomuscle flaps to repair defects in the lower leg. Plast Reconstr Surg
1976;57:460.
7. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby,
1979;133-261.
8. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;565, 577.

Chapter 511
Flexor Digitorum Longus Muscle Flap
M. PERS
S. MEDGYESI
B. KIRKBY
The muscle may be transferred as a supplement in combination with the medial constituents of the soleus or one
of the peroneal muscles to defects in the distal third of the lower leg (1, 2, 3).
INDICATIONS
The flexor digitorum longus muscle has several qualities that make it useful for a soft-tissue reconstruction
over the middle or distal part of the tibia (Fig. 511.1). First, the muscle fibers extend very far distally, nearly
to the ankle joint. Second, its function, which is flexion of the distal phalanx of the lateral toes, is
insignificant when intact flexor digitorum brevis muscle preserves the more important function of flexion in
the proximal phalanges. With its close relationship to the medial aspect of the tibia, the flexor digitorum
longus flap occasionally may prove useful as a filling material in bony cavities or fistulas in the middle third
of the lower leg.
FIGURE 511.1 Transposition of flexor digitorum longus muscle. Diagram shows arc of rotation.
ANATOMY
The muscle is located in the medial compartment of the lower leg (Fig. 511.1). Its proximal part is felt just under
the skin along the medial border of the tibial shaft. The muscle is only about 3 cm wide and rather thin. It has a

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distal location just in front of the medial part of the soleus muscle. The muscle has an extensive origin from the
posteromedial surface of the tibial shaft, from just distal to the soleal line to within a hand's breadth from the tip of
the medial malleolus (see Fig. 511.2).
The posterior tibial artery gives off four to five branches to the muscle. Proximally, the artery is located deeply
behind the muscle, but more distally the vessels become superficial to follow the tendon on its way behind the
medial malleolus to the plantar aspect of the foot.
OPERATIVE TECHNIQUE
The flexor digitorum longus is approached through an incision close to the medial border of the tibia, followed by
sharp dissection close to the medial aspect of the tibial shaft. When the tendon is cut distally, the tibialis
posterior vessels should be carefully avoided, but one or two branches to the distal part of the mobilized muscle
have to be severed (Fig. 511.2).
CLINICAL RESULTS
We have had four opportunities to use this muscle. In one patient, the muscle necrosed, presumably from
pressure on the pedicle from the sharp anterior tibial edge. In the other patients, no necrosis occurred, and
the primarily applied split-thickness skin grafts all “took” well.
SUMMARY
The flexor digitorum longus muscle flap can be used alone for small defects but is usually combined with
either the soleus or peroneal muscles to close lower-third leg defects.

FIGURE 511.2 A: Defect following skin necrosis. Metal plate exposed on the medial surface of the fractured
tibia. B: The flexor digitorum muscle is mobilized from the medial compartment of the lower leg. C: Primary
“take” of a meshed split-thickness skin graft on the transposed muscle flap covering the metal plate. D:
Final result.
References
1. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;26:313.
2. Pers M. Muscle flaps in reconstructive surgery. In: Barron JN, Saad MN, eds. Operative plastic and
reconstructive surgery, Vol. 1. London: Churchill- Livingstone, 1981;115-135.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;563.

Chapter 512
Flexor Digitorum Longus Muscle Flap
L. C. SITA-ALB
S. DURAND
EDITORIAL COMMENT
The primary use for this flap is for small defects with exposed bone or hardware. An arteriogram should be
considered in patients over 50 years of age.
INDICATIONS
Reconstruction of the lower third of the leg is a constant challenge for surgeons. A relatively simple and
versatile procedure such as the flexor digitorum longus (FDL) muscle flap, especially for small soft-tissue
defects, has a place in our armamentarium. This medium-sized muscle with relatively low descending
muscle fibers is indicated for small (10 to 20 cm2) soft-tissue defects over the proximal portion of the distal
tibia. It is especially useful for osteomyelitic problems (Fig. 512.1) and osteosynthesis material exposure. It
is also used in association with soleus, medial hemisoleus (Fig. 512.2A and B), or medial gastrocnemius
muscles flaps to extend their reach and to increase the coverage area (1).
FIGURE 512.1 Defect of the lower leg with underlying osteomyelitis.
ANATOMY
The FDL muscle originates from the posterior surface of the tibia, just below the soleal line. The muscle fibers
descend at 2.5 to 5.35 cm (2, 3) above the medial malleolus tip (Fig. 512.3) and end in a tendon that runs on the
posterior surface of the muscle, nearly for the entire length. The muscle has an average of 10 to 13 vascular
pedicles (Fig. 512.4) (2, 4) with each of the segmental branches arising from the posterior tibial artery.
Occasionally, a large branch, with a caliber of 1.0 to 1.5 mm, is seen proximally (5). The FDL muscle is classified
as a type IV muscle. The tibial nerve branch enters the muscle in the upper third of the leg at approximately 20
cm below the apex of the fibular head. The muscle's principal action is to plantarflex the lateral four toes and,
secondarily, to plantarflex the ankle joint.
FLAP DESIGN AND DIMENSIONS

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The muscle length has been found to be approximately 24.4 cm for an average tibia length of 36 cm and the
width of 3 to 3.5 cm.
Proximally based muscle flap (Fig. 512.5) is the most frequently used. It is necessary to divide an average of six
distal pedicles (leaving six to seven proximal ones intact) (2) and dissect the muscle proximally to between 14
and 18 cm above the medial malleolus to obtain enough mobility for flap rotation (3). The average size of the
defect covered by the FDL muscle flap is 11.3 cm2. The distance between the medial malleolus and the distal
end of the flap, after flap transposition, ranges between 6 and 12 cm for an average tibia length of 38.6 cm (34 to
41 cm). The FDL muscle may be transposed leaving the tendon intact, by dissecting the muscle off the tendon,
or the tendon can be divided and the distal end can be sutured to the tendon of the tibialis posterior (3).
FIGURE 512.2 A: Skin incision marked to provide access to raise both FDL and medial hemisoleus flaps to
cover the soft-tissue defect. B: Defect covered by combining the FDL and medial hemisoleus flaps.
FIGURE 512.3 Muscle fibers of the FDL identified at their typical location 2.5 to 5.35 cm above the medial
malleolus.

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FIGURE 512.4 Segmental perforators from the posterior tibial artery seen entering the posterior surface of the
FDL muscle.
FIGURE 512.5 Proximally based muscle flap.
Inferiorly based muscle flap has been described for the coverage of small defects of the middle third of the leg,
by dividing three to four proximal perforators (4).
In the segmental muscle flap, all the direct muscle branches are preserved and a part of the tibial origin of the
FDL muscle is detached. The muscle, together with the posterior tibial vessels, is mobilized forward to cover the
exposed tibia, in the middle third and lower upper third of the leg (5).
OPERATIVE TECHNIQUE
A vertical incision is outlined just posterior to the tibia in the middle and distal third of the lower leg (Fig. 512.6).
At the distal end of the incision, the deep posterior compartment is directly opened. Proximally, the superficial
posterior compartment is first opened. After posterior retraction of the soleus muscle, the septum between the
two compartments is visualized and carefully opened. The neurovascular bundle should be identified between
the soleus muscle posteriorly and FDL muscle anteriorly and carefully dissected (Fig. 512.4).
FDL tendon is identified and divided. Then, the distal half of the muscle is mobilized, by clipping or ligating the
distal vascular pedicles, until it reaches the defect (Fig. 512.5). It is preferable to include the tendon in the
muscular flap to avoid tearing the muscle and to increase the width of the flap (2). The muscle belly can be skin
grafted during the same procedure, or a few days after to simplify flap monitoring (Fig. 512.7). Suction drainage
is established and the patient positioned with the leg elevated to facilitate venous drainage.

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FIGURE 512.6 A vertical incision is outlined just posterior to the tibia in the middle and distal third of the lower
leg.
CLINICAL RESULTS
Flap necrosis or tip flap necrosis rarely occurs and is usually attributed to venous congestion. This low
complication rate is observed in young patients with no significant comorbidities. In older patients with
comorbid conditions such as diabetes, peripheral vascular disease, autoimmune diseases, or a smoking
history, the prognosis might differ; more thorough investigations should be performed prior to the
intervention in these cases, and an arteriography should be done routinely.
The mobility at all phalangeal and metatarsophalangeal articulations for the lateral four toes has been
observed to be similar to the contralateral leg. Presumably, the flexor digitorum brevis, the substantial slip
from the flexor hallucis longus, and the quadratus plantae help to compensate for any functional loss (6).
SUMMARY
This FDL flap is an efficient and safe procedure, with reduced morbidity and good aesthetic results. It can
be used exclusively or in combination with other flaps, including the medial hemisoleus or medial
gastrocnemius.
FIGURE 512.7 The FDL muscle typically is skin grafted at the time of flap reconstruction or shortly
thereafter.
References
1. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous Flaps. St. Louis: The CV Mosby

Company, 1979;179-187.
2. Durand S, Sita-Alb L, Ang S, et al. The flexor digitorum longus muscle flap for the reconstruction of soft-
tissue defects in the distal third of the leg: anatomic considerations and clinical applications. Ann Plast Surg
2013;71(5):595-599.
3. Hugues LA, Mahoney JL. Anatomic basis of local muscle flaps in the distal third of the leg. Plast Reconstr
Surg 1993;92:1144-1154.
4. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy & Technique, Vol. II. New York:
Churchill Livingstone Ing., 1997;1371-1380.
5. Wu WC, Chang YP, So YC, et al. The anatomic basis and clinical applications of flaps based on the
posterior tibial vessels. Br J Plast Surg 1993;46:470-479.
6. Ger R. The techniques of muscle transposition in the operative treatment of traumatic and ulcerative
lesions of the leg. J Trauma 1971;11:502-510.