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

Ease of dissection
−
++
+
+++
Position
Prone
−
−
−
+++
Supine
++
++
++
+
Size
++
++++
++
+
Vascular pedicle
Length
+
++++
+
++
Caliber
+++
++++
++
++
(+), asset; (−), liability; LCFAP-tfl, lateral circumflex femoral artery perforator—tensor fascia lata;
LCFAP-vl, lateral circumflex femoral artery perforator—vastus lateralis; MCFAP-g, medial circumflex
femoral artery perforator—gracilis; MSAP, medial sural artery perforator.
Among the disadvantages: (a) anomalies may be found: usually, at least a single medial sural perforator exists,
but not necessarily at the point marked for the first or second major perforator; and (b) even if primary donor-site
closure is possible, a conspicuous scar results that may not be acceptable, especially for women.
SUMMARY
Lower-extremity muscle perforator flaps offer many advantages for lower- extremity coverage by using
similar tissue, not only as straightforward local flaps but also as versatile free flaps. As with any muscle
perforator flap, anatomic variations are the norm and must be anticipated; the dissection can be tedious;
and the flap will be bulky and perhaps inappropriate in the very obese patient. Venous congestion is also
always a concern with muscle perforator flaps, but those from the lower extremity have a distinct advantage
in that a superficial vein can be included, and even should be sought out, to allow augmentation of venous
outflow, if later found to be necessary.
The LCFAP-vl flap, better known as the “anterolateral thigh flap,” remains the “ideal” donor site for soft-
tissue flaps of the lower extremity, with which all others must be compared (Table 524.1). The LCFAP-tfl
flap is a superb option for trochanteric defects. The MCFAP-g flap leaves the least donor-site residue. The
MSAP flap is typically the thinnest available and is the only one of this group that can be harvested with the
patient in a prone position. The lower-extremity muscle perforator flaps have allowed a whole new
approach, not only for lower-extremity reconstruction but also throughout the body.
References
1. Hallock GG. Lower extremity muscle perforator flaps for lower extremity reconstruction. Plast Reconstr
Surg 2004;114:1123.

2. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114:910.
3. Song TG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous
artery. Br J Plast Surg 1984;37:149.
4. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast
Surg 2003;50:90
5. Wei FC, JainV, Celik N, et al. Have we found an ideal soft-tissue flap? An experience with 672
anterolateral thigh flaps. Plast Reconstr Surg 2002; 109:2219.
6. Yildirim S, Gideroglu K, Akoz T. Anterolateral thigh flap: ideal free flap choice for lower extremity soft tissue
reconstruction. J Reconstr Microsurg 2003;19:225.
7. Lutz DA, Hallock GG. Territories of perforator flaps by source vessel and subtype. (Appendix). In: Blondeel
PN, Morris SF, Hallock GG, et al., eds. Perforator flaps: anatomy, technique, and clinical applications. St.
Louis, MO: Quality Medical Publishing, 2006;1045.
8. Demirkan F, Chen HC, Wei FC, et al. The versatile anterolateral thigh flap: a musculocutaneous flap in
disguise in head and neck reconstruction. Br J Plast Surg 2000;53:30.
9. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap for extremity reconstruction: clinical
experience and functional assessment of donor site. Plast Reconstr Surg 2001;107:1766.
10. Koshima I, Yamamoto H, Moriguchi T, Orita Y. Extended anterior thigh flaps for repair of massive cervical
defects involving pharyngoesophagus and skin: an introduction to the “mosaic” flap principle. Ann Plast Surg
1994;32:321.
11. Koshima I, Kawada S, Etoh H, et al. Flow-through anterolateral thigh flaps for one-stage reconstruction of
soft-tissue defects and revascularization of ischemic extremities. Plast Reconstr Surg 1995;95:252.
12. Pan SC, Yu JC, Shieh SJ, et al. Distally based anterolateral thigh flap: an anatomic and clinical study.
Plast Reconst Surg 2004; 114:1786.
13. Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical application of the thin
anterolateral thigh flap. Plast Reconstr Surg 1996;97:985.
14. Koshima I, Soeda S, Yamasaki M, Kyou J. The free or pedicled anteromedial thigh flap. Ann Plast Surg
1988;21:480.
15. Chen Z, Zhang C, Lao J, et al. An anterolateral thigh flap based on the superior cutaneous perforator
artery: an anatomic study and case reports. Microsurgery 2007;27:160.
16. Kimura N, Satoh K, Hosaka Y. Tensor fasciae latae perforator flap. Clin Plast Surg 2003;30:439.

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17. Ishida LH, Munhoz AM, Montag E, et al. Tensor fasciae latae perforator flap: minimizing donor-site
morbidity in the treatment of trochanteric pressure sores. Plast Reconstr Surg 2005;116:1346.
18. Koshima I, Urushibara K, Inagawa K, Moriguchi T. Free tensor fasciae latae perforator flap for the
reconstruction of defects in the extremities. Plast Reconstr Surg 2001;107:1759.
19. Deiler S, Pfadenhauer A, Widmann J, et al. Tensor fasciae latae perforator flap for reconstruction of
composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg 2000;106:342.
20. Thione A, Valdatta L, Buoro M, et al. The medial sural artery perforators: anatomic basis for a surgical
plan. Ann Plast Surg 2004;53:250.
21. Lykoudis EG, Spyropoulou GC, Vlastou CC. The anatomic basis of the gracilis perforator flap. Br J Plast
Surg 2005;58:1090.
22. Kappler VA, Constantinescu MA, Buchler U, Vogelin E. Anatomy of the proximal cutaneous perforator
vessels of the gracilis muscle. Br J Plast Surg 2005;58:445.
23. Hallock GG. The gracilis (medial circumflex femoral) perforator flap: a medial groin free flap? Ann Plast
Surg 2003;51:623.
24. Hallock GG. Further experience with the medial circumflex femoral gracilis perforator free flap. J Reconstr
Microsurg 2004;20:115.
25. Hallock GG. The medial circumflex femoral gracilis local perforator flap: a local medial groin perforator
flap. Ann Plast Surg 2003;51:460.
26. Hallock GG. The conjoint medial circumflex femoral perforator and gracilis muscle free flap. Plast
Reconstr Surg 2004;113:339.
27. Hallock GG. Free-flap monitoring using a chimeric sentinel muscle perforator flap. J Reconstr Microsurg
2005;21:351.
28. Hallock GG. Sequential use of a true perforator flap and its corresponding muscle flap. Ann Plast Surg
2003;51:617.
29. Shim JS, Kim HH. A novel reconstruction technique for the knee and upper one third of lower leg. J Plast
Reconstr Aesthet Surg 2006;59:919.
30. Chen SL, Chen TM, Lee CH. Free medial sural artery perforator flap for resurfacing distal limb defects. J
Trauma 2005;58:323.
31. Hallock GG. Anatomic basis of the gastrocnemius perforator-based flap. Ann Plast Surg 2001;47:517.

32. Hallock GG, Sano K. The medial sural medial gastrocnemius perforator free flap: an “ideal” prone
position skin flap. Ann Plast Surg 2004; 52:184.
33. Kim HH, Jeong JH, Seul JH, Cho BC. New design and identification of the medial sural perforator flap: an
anatomical study and its clinical applications. Plast Reconstr Surg 2006; 117:1609.
34. Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la Camara A, et al. The medial sural artery perforator
free flap. Plast Reconstr Surg 2001; 108:1609.
35. Hallock GG. The medial sural medial gastrocnemius peforator local flap. Ann Plast Surg 2004;53:501.

Chapter 525
The Medial Sural Artery Perforator Flap
GEOFFREY G. HALLOCK
EDITORIAL COMMENT
The medial sural artery perforator flap provides a thin flap for reconstruction. It is most useful as a free flap.
The anatomy of the medial sural artery is variable. The length of the scar may also be a problem.
INDICATIONS
If a cutaneous flap is preferable, and muscle function preservation desirable, the medial sural artery
perforator (MSAP) flap represents yet another perforator flap option from the lower extremity. As a long
pedicled island flap, reach as a local flap is possible even to the patella (1). It has even been described
using Y-to-V pedicled reverse flow for defects distal to the gastrocnemius muscle (2). More often, though,
the MSAP flap has been used as a free flap throughout the body (3, 4, 5). In this role, the advantages
include a relatively thin flap even in the obese individual (5), which allows avoidance of use of the
comparable contour of forearm flaps, which sacrifice a major artery to the hand. Access to this donor site is
possible with the patient in either the prone or supine position (6). A tourniquet can be used to facilitate
harvest unobscured by any blood staining of the typical long pedicle of large caliber (5). Epidural
anesthesia only is possible if the reconstruction is limited to the lower extremity (5).
Even if primary closure of the calf donor site is possible, the resulting conspicuous scar is unacceptable for
some female patients. In these scenarios, it is recommended then that other donor sites be sought out. Few,
however, could argue that the MSAP free flap is most legitimate as a solution for the ipsilateral distal lower
extremity defect, as the morbidity caused at the donor site is limited to the same region that already is
compromised, if the aesthetic result alone is a major consideration (7).
ANATOMY
The MSAP flap captures the angiosome of the medial calf, an area similar to the archaic medial gastrocnemius
musculocutaneous flap. The source vessel is the medial sural artery (MSA), which is a branch of the popliteal
artery, originating at or about the knee joint. Numerous anatomical studies in both cadaveric and clinical series
have caused great confusion as to the expected location of dominant musculocutaneous perforators that arise
from the MSA (3, 4, 5, 8, 9, 10). This conundrum is nicely summarized in a classification schema proposed by
Dusseldorp et al. (11). They reported that the MSA has three intramuscular branching patterns, called type I, II,
or III depending on the number of branches observed (11). Type I (31% frequency) has a single deep branch.
Type II (59%) has dual branches, bifurcating above the tibial plateau (subtype 2A), or else below (subtype 2B)
(11). Type 2A has one branch running very superficial to the posterior margin of the medial gastrocnemius
muscle, whereas type 2B branches are always deeper. Type III (10%) has three branches with at least one
superficial in the muscle. A major MSAP perforator was found by Dusseldorp et al. (11) on average, vertically 13
± 2 cm from the popliteal crease and 2.5 ± 1 cm from the posterior midline. Others have stated that this vertical
distance is 8 to 10 cm from the popliteal crease, which is a good starting point (3, 6, 10). Wong et al. (10) found a
dual configuration in

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83% of cadavers, with lateral row perforators 2 ± 0.5 cm from the posterior midline and medial row about 6 cm,
with all such perforators 10 ± 2 cm below the popliteal crease.
Note that Dusseldorp et al. (11) found the same MSAP branching pattern in both legs of the same individual only
18% of the time. If two perforators were found, the more medial perforator was more likely to arise from a
superficial branch, which would simplify pedicle dissection (11). A dominant MSAP perforator was found in 92%
of anatomical specimens (11), as opposed to our original anatomical findings that showed there always was one
present (6). In 9% of cadavers, the major calf perforator arose from a substantive median sural artery (11), so
that no muscle dissection whatsoever would be necessary when harvesting the flap vasculature.
FLAP DESIGN AND DIMENSIONS
Flap design always first requires identification of a perforator adequate to sustain the desired flap dimensions.
CT angiography or MRA may be the best means for preoperative perforator mapping, but this is not available for
many. Instead, the ubiquitous handheld audible Doppler still has value. Various schematics have been
suggested to expedite finding the requisite perforator (12). With the patient supine, hip abducted, and knee
flexed 90 degrees, Kim et al. (3) drew a line from the midpoint of the popliteal crease to the apex of the medial
malleolus. A proximal perforator was usually found in the distal half of a circle of 2 cm radius, centered 8 cm
along this line away from the popliteal crease (3). A second perforator, if present, would be in a circle of 3 cm
radius, centered 15 cm distally along this line (3). Wang et al. (4) drew a second line between the medial
epicondyle of the femur and the lateral malleolus. Where these two lines intersected, this point was the center of
a circle of 4 cm radius, which in their hands would reliably encompass the desired perforator (4).
A simpler beginning point for seeking out a dominant perforator might be to use the idea of Wong et al. (10),
realizing that it is based on the dual branching pattern of the MSA, which usually is the predominant case.
Remembering that the medial edge of the medial gastrocnemius muscle head is about 1 cm posterior to the
medial tibia bone, and its decussation with the lateral head is at about the posterior calf midline, vertical lines can
be drawn from the popliteal crease to divide this encompassed region into thirds (Fig. 525.1). These lines would
roughly correspond to the medial and lateral branches of the MSA. At their intersection with a horizontal line
parallel to and 10 cm below the popliteal crease is a good starting point to use the audible Doppler, running up
and down each vertical line until a loud perforator is heard.
If a local MSAP flap is selected, to permit reach as far proximally as required, the more distal the perforator
location, the better. Eccentrically designing the flap with the perforator as far proximally as possible will also
enhance reach or, for a free flap, allow the longest possible pedicle to reach a recipient site. As Saint-Cyr et al.
(13) have shown, connections between perforasomes in the lower extremity tend to follow a longitudinal axis so
that the design of the desired flap, unless very small, should be oriented with its major axis in that direction.
The largest flap reported by Wang et al. (4) was 9 cm wide by 14 cm long. Depending on the flaccidity of the
skin, if the flap width exceeds 5 cm, or sometimes up to 8 cm, then primary closure of the donor site is not safe
and a skin graft must be used.

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FIGURE 525.1. A rough beginning point for identification of dominant medial sural artery (MSA) perforators using
the audible Doppler is to drop two vertical lines from the popliteal crease over the calf region encompassed by
the medial head of the gastrocnemius muscle. The intersection of these lines with a horizontal line 10 cm below
the popliteal crease is a good starting point for the Doppler probe. If a perforator is not found, then go up or down
each line until a loud sound is heard as here marked by the “x” on the medial vertical line, which corresponds to
a medial MSA branch.
OPERATIVE TECHNIQUE
More often than not, the patient will be supine and is best positioned as Kim et al. (3) suggest. Inflation of a thigh
tourniquet without limb exsanguination provides a bloodless field yet appropriate identification of accompanying
veins as required. The easiest and medial border of the flap is first incised down through the deep fascia to
expose the muscle. In the prone position, this might instead be the lateral border near the posterior midline. Lin
(14) has shown that through a small exploratory incision, endoscopic verification of the perforator location is
possible. Otherwise, the entire medial boundary may need to be opened to allow subfascial exploration to find
the desired perforator. Once confirmed, and if necessary, the flap is redesigned to ensure inclusion of that
perforator.
Once a desirable perforator is identified, all flap borders can then be incised to a subfascial plane about that
requisite perforator. Care must be taken next not to stretch that perforator during its tedious intramuscular
dissection. Placement on a sterile towel will support the flap. Anything that does not separate easily from the
vascular pedicle probably is a branch and should be coagulated with bipolar cautery. This dissection should
continue as proximal as needed to get the desired pedicle length, or vessel caliber if a free flap is contemplated.
A local flap must be able to reach the ipsilateral limb defect without tension. The tourniquet is then deflated and
adequate flap perfusion in situ is assessed. Antispasmodics may be necessary. If adequate, the local flap is
inset. The free flap is harvested and transferred using the customary microsurgical procedures. The donor site is
closed primarily if possible, or a skin graft is placed, which avoids the risk of a compartment syndrome from too
tight a closure (15).
CLINICAL RESULTS
Local MSAP Island Flap
This middle-aged woman weeks after a left total knee replacement could not heal the distal portion of her

orthopedic incision with exposure of the quadriceps tendon at its insertion (Fig. 525.2). By this time,
surrounding tissues were too indurated to permit simple skin advancement. Rather than resorting to a
traditional medial gastrocnemius muscle flap, instead a small 2- × 3-cm MSAP local flap was selected. Two
adjacent perforators were found on exploration and arose together from a relatively superficial medial sural
vascular branch. The latter was dissected through the medial gastrocnemius muscle until this island MSAP
flap could reach the tibial tubercle via a subcutaneous tunnel. Her wound then healed although the patient
complained that the flap was bulky. Because of the small size of the flap, primary donor site closure was
possible.
FIGURE 525.2 A: Exposed quadriceps tendon and tibia in a poorly healing distal left total knee incision. B:
Proposed design of an MSAP local flap on the medial calf about perforator “x.” Note slightly canted
posterior axis and eccentric location of the perforator used as maneuvers intended to extend reach to the
defect seen anteriorly after appropriate wound debridement. C: Two perforators seen on microgrids at
fascial level corresponding to point “x,” which quickly originated together from medial sural pedicle (red
vessel loop) that has been dissected proximally through the medial gastrocnemius muscle. D: Flap inset
over the tibial tubercle after drawn through a subcutaneous tunnel from the calf, with primary donor site
closure. E: Healed left knee wound.
Free MSAP Flap
Following Achilles tendon disruption in a construction accident, the surgical repair incision dehisced.
Ultimately, this young patient was referred to deal with a chronic, open, partially granulating, and indurated

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wound of his left posterior hindfoot (Fig. 525.3). A free flap was considered a reasonable
option and an MSAP flap chosen to keep all surgery within the ipsilateral lower extremity while ensuring
muscle preservation of his triceps surae. A 4.5- × 10-cm flap was harvested based on a single perforator
with a 10-cm vascular leash that easily reached the posterior tibial recipient site. The wound healed with
near-normal ankle range of motion eventually achieved. Primary donor site closure was possible.
FIGURE 525.3 A: Dehisced left Achilles tendon repair wound. B: Proposed MSAP free flap, designed
eccentric to perforator “x” heard using audible Doppler, with a longitudinal orientation. C: Large single
perforator confirmed; note the long vascular pedicle (microgrid) dissected as a very superficial medial sural
branch traversing the medial gastrocnemius muscle. D: MSAP free flap with solitary perforator dangling with
its more than adequate vascular pedicle length in microclamp. E: Uneventful posterior hindfoot healing.
Note the wide scar above after primary donor site closure.

SUMMARY
Although not a commonly used perforator flap, the MSAP flap does have some attributes that should be
considered. As a small local flap, it is a reasonable alternative to the medial gastrocnemius muscle for the
region of the proximal one-third of the lower leg. As a free flap option, it is a relatively thin flap even in the
more obese patient. The potential vascular pedicle can be very long and of reasonable caliber to simplify
any microanastomoses. Unless CT angiography or an equivalent is available, the actual location of major
perforators can be quite variable. A major detriment is the obvious donor site scar along the calf, which is
unacceptable for most women. Some might consider this matter irrelevant if used for an ipsilateral foot
and/or ankle wound, where actually the MSAP flap might be the free flap of choice to confine all morbidity to
the ipsilateral extremity.
ACKNOWLEDGMENTS
David C. Rice, B.S., Physician Extender, Sacred Heart Hospital, Allentown, Pennsylvania, assisted with the
clinical cases.
References
1. Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la Camara A, et al. The medial sural artery perforator
free flap. Plast Reconstr Surg 2001;108:1609-1615.
2. Persichetti P, Brunetti B, Aveta A, et al. Reverse-flow medial sural artery perforator flap—pedicle extension
for distal lower limb defects. Ann Plast Surg 2013;70:246-247.
3. Kim HH, Jeong JH, Seul JH, et al. New design and identification of the medial sural perforator flap: an
anatomical study and its clinical applications. Plast Reconstr Surg 2006;117:1609-1618.
4. Wang X, Mei J, Pan J, et al. Reconstruction of distal limb defects with the free medial sural artery
perforator flap. Plast Reconstr Surg 2013;131:95-105.
5. Xie XT, Chai YM. Medial sural artery perforator flap. Ann Plast Surg 2012;68:105-110.
6. Hallock GG, Sano K. The medial sural MEDIAL GASTROCNEMIUS perforator free flap: an “ideal” prone
position skin flap. Annal Plast Surg 2004;52:184-187.
7. Hallock GG. Medial sural artery perforator free flap: legitimate use as a solution for the ipsilateral distal
lower extremity defect. J Reconstr Microsurg 2014;30:187-192.
8. Hallock GG. Anatomic basis of the gastrocnemius perforator-based flap. Ann Plast Surg 2001;47:517-522.
9. Kosutic D, Pejkovic B, Anderhuber F, et al. Complete mapping of lateral and medial sural artery
perforators: anatomical study with Duplex-Doppler ultrasound correlation. J Plast Reconstr Aesthet Surg
2012;65:1530-1536.

10. Wong MZ, Wong CH, Tan KB, et al. Surgical anatomy of the medial sural artery perforator flap. J
Reconstr Microsurg 2012;28:555-560.
11. Dusseldorp JR, Pham QJ, Ngo W, et al. Vascular anatomy of the medial sural artery perforator flap: a
new classification system of intra-muscular branching patterns. J Plast Reconstr Aesthet Surg 2014;67:1267-
1275.
12. Hallock GG. A primer of schematics to facilitate the design of the preferred muscle perforator flaps. Plast
Reconstr Surg 2009;123:1107-1115.
13. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical
implications. Plast Reconstr Surg 2009;124:1529-1544.
14. Lin CH. Medial Sural Artery Perforator Free Flap Live Surgery Presentation, 2014 Chang Gung Mayo
Clinic Symposium in Reconstructive Surgery, May 7, 2014, Taoyuan, Taiwan.
15. Addison PD, Lannon D, Neligan PC. Compartment syndrome after closure of the anterolateral thigh flap
donor site: a report of two cases. Ann Plast Surg 2008;60:635-638.

Chapter 526
The Pedicled Perforator (Propeller) Flap in Lower Extremity
Defects
YOO JOON SUR
MOHAMED MORSY
MICHEL SAINT-CYR
EDITORIAL COMMENT
In the early experience with this type of axially based flap design, a more traditional skin paddle design
(such as with an intervening skin bridge for venous drainage) is encouraged. Also, smaller arcs of rotation
are advised to minimize pedicle torsion. Doppler confirmation of perforator location can help improve
reliability.
INDICATIONS
Although the pedicled perforator (propeller) flap is in line with the concept of freestyle flap surgery and is
applicable to all areas of the body (1), it is especially useful to cover soft-tissue defects of the lower
extremity where soft tissue has no redundancy and the laxity of soft tissue is oriented along the axis of the
limb. This flap offers replacement tissue to the defect site based on the “like-with-like” principle. When the
donor site is closed primarily, the morbidity is confined to the affected limb with a good aesthetic result.
Because it does not need sacrifice of the source artery and underlying muscles, its functional result is also
excellent. Furthermore, flap harvest is relatively easy and expeditious without requiring microvascular
anastomosis. This flap can be applied to a traumatic, oncologic, or ulcerative defect as long as a clinically
relevant perforator is not far away from the defect.
ANATOMY
Many anatomical studies have evaluated the location of the perforators of the arteries of the lower leg (2, 3, 4,
5), revealing a variety of locations for the reliable perforators. According to the senior author's (MSC) cadaveric
study with 20 lower limbs (6), most of the perforators of the lower leg emerge through the deep fascia in four
longitudinal rows adjacent to the intermuscular septa: (a) between the tibia and the tibialis anterior; (b) anterior
crural septum between the extensor digitorum longus and the peroneus longus—the anterior tibial artery
perforators; (c) between the flexor digitorum longus and the soleus—the posterior tibial artery perforators; and
(d) posterior crural septum between the peroneus longus and the soleus—the peroneal artery perforators.
Reliable perforators can be found in three 5-cm intervals from the intermalleolar line. These intervals are 4 to 9
cm, 13 to 18 cm, and 21 to 26 cm proximal to the intermalleolar line (Fig. 526.1). The anterior tibial artery
perforators are clustered in the 4 to 9 cm and 21 to 26 cm intervals; the posterior tibial artery perforators are
clustered in all three intervals, and the peroneal artery perforators are clustered in the 13 to 18 cm interval.
Although approximately twice as many perforators originate from the anterior tibial artery as from the posterior
tibial and peroneal arteries (anterior tibial 9.9 ± 4.4, posterior tibial 4.9 ± 1.7, peroneal 4.4 ± 2.3), they generally
have smaller diameters. To the contrary, the posterior tibial artery perforators are consistently the largest and
easiest to dissect (6).

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The superficial femoral artery perforator and the lateral superior genicular artery perforator can be used for soft-
tissue coverage around the knee and popliteal fossa (7, 8). On the medial side of the knee, the superficial
femoral artery perforator is located at an average distance of 22.79 ± 1.55 cm below the pubic tubercle on the
medial axis of the thigh (7) (Fig. 526.2). It is located between the sartorius and the gracilis muscles with a mean
diameter of 2.82 ± 0.69 mm and mean length of 4.79 ± 0.52 cm. On the lateral side of the knee, the lateral
superior genicular artery perforator can be found within 5 cm laterally and 7 cm proximally from the superolateral
corner of the patella (8) (Fig. 526.3).The distance from the bony landmark of the superolateral patella is
predictable at 5.3 cm, where the perforator usually comes between the vastus lateralis and the biceps femoris
muscles.
FLAP DESIGN AND DIMENSIONS
The feasibility of performing the pedicled perforator (propeller) flap depends on the presence of an available
perforator close to the defect. Preoperative computed tomographic angiography
and magnetic resonance angiography can be helpful but are not essential. The locations of perforators are
usually searched by handheld Doppler with the bony landmarks and the perforator's usual clustered area in
mind. The intensity of the audible Doppler signal of the perforator's flow reflects the vessel diameter. If two or
more perforators are found, the best suitable perforator is selected in terms of vessel diameter and location. A
perforator located too far from the defect makes the flap unnecessarily long, while a perforator located too close
to the defect is unreliable and surrounded by fibrotic scar tissue can cause pedicle torsion. The flap design is
based on the chosen perforator location. The flap is designed to have two blades of different lengths (propeller
blades), which can be rotated up to 180 degrees around the chosen perforator (propeller shaft) in either the
clockwise or counterclockwise direction. The flap size should be equal to or slightly greater than the measured
defect size to prevent closing tension. As for flap dimensions, it is not possible to make an exact determination of
maximum area or width-to-length ratio of a specific perforator at the present time, but flaps that are larger or
longer than believed to be safe in the past can be harvested successfully. A thorough understanding of the
vascular anatomy of a single perforator (perforasome) and interperforator flow mechanism (“the perforasome
theory”) is beneficial in flap design (9). Each perforasome is connected with adjacent perforasomes by means of
direct and indirect linking vessels (Fig. 526.4). Direct linking vessels connect multiple perforasomes to one
another. Perforasomes preferentially fill by perforators of the same source artery over perforators of other
adjacent source arteries. The axiality of linking vessels follows the axiality of the limb for the upper and lower
extremities. The perforators also have a preferential direction of vascularity according to their locations. The
vascularity of perforators adjacent to an articulation is directed away from the articulation, whereas perforators at
a midpoint between two articulations have a bidirectional flow distribution. Therefore, the flap should be
designed so that the long axis of flap is parallel to the axis of the limb and so that the long blade of the flap
should be directed away from the adjacent joint. When the flap is raised on a single perforator, hyperperfusion of
this perforator occurs, increasing the filling pressure and leading to perfusion of adjacent perforasomes. This
explains the viability of larger and longer flaps. The maximal number of perforasomes that can be safely perfused
is, however, variable (9). The location of the perforator within the flap and the width of the flap surrounding the
perforator should also be considered. The closer the perforator to the edge of the flap and the narrower the
width of the flap surrounding the perforator, the less linking vessels are included and the less vascularized the
flap becomes. This in turn increases the risk of partial flap necrosis. This follows the basics of “the perforasome
angle of perfusion theory” presented by the senior author (MSC) (10).

FIGURE 526.1 Illustration of the location of reliable perforators in the lower leg. Left: The posterior tibial artery
perforators are clustered in all 5-cm intervals. Center: The anterior tibial artery perforators are clustered in the
proximal and distal 5-cm intervals. Right: The peroneal artery perforators are clustered in the middle 5-cm
interval.
FIGURE 526.2 Illustration of location of the superficial femoral artery perforator between the sartorius forward
and the gracilis behind.

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FIGURE 526.3 Illustration of the location of lateral superior genicular artery perforator (x = horizontal distance
and y = vertical distance from the superolateral patella, units in millimeter). (Reprinted from Nguyen AT, Wong C,
Mojallel A, et al. Lateral supragenicular pedicle perforator flap: clinical results and vascular anatomy. J Plast
Reconstr Aesthet Surg 2011;64(3):381-385, with permission from Elsevier.)
FIGURE 526.4 Interperforator flow occurs by means of direct and indirect linking vessels. Direct linking vessels
communicate directly with an adjacent perforator to maintain perfusion and travel within the suprafascial and
adipose tissue layers. Indirect linking vessels communicate with adjacent perforators by means of recurrent flow
through the subdermal plexus. Communicating branches between direct and indirect linking vessels are also
seen and help maintain vascular perfusion in case of injury.

FIGURE 526.5 Peroneal artery perforator-based propeller flap. A: The initial skin incision should be made on
one side of the planned flap. With this one side incision, the flap design can be modified according to the
intraoperatively confirmed location of the perforator. B: Intraoperative use of a handheld Doppler is a reliable
method to check blood flow of perforators. It also can be used to confirm the consistency of the chosen
perforator after rotation of the flap. C: Flap was rotated 180 degrees and inset with skin grafting of donor site.
OPERATIVE TECHNIQUE
Flap harvesting is performed without tourniquet use. Exsanguination and tourniquet application makes it difficult
to identify small perforators. Instead, meticulous hemostasis with electrocautery is needed. The initial generous
exploratory skin incision is made on only one side of the planned flap (Fig. 526.5A). Dissection can be performed
either subfascially or suprafascially, but subfascial dissection is preferred because it is more straightforward. The
perforators are identified, and the best suitable perforator is selected based on its diameter, location, and
pulsatility. The perforators' flow can be checked by handheld Doppler intraoperatively (Fig. 526.5B). The
selected perforator can be different from the one that was marked preoperatively. In such a case, the flap design
should be revised. The pedicle is dissected long enough to make a lazy S turn twisting with flap rotation, but
complete skeletonization of the pedicle is not routinely performed to prevent vasospasm. The more the flap is
rotated, the longer the pedicle and the more meticulous skeletonization of the pedicle are needed. After the
pedicle dissection is completed, the rest of the flap can be raised easily. Before the flap is rotated, a time interval
is helpful to enhance proper perfusion of the flap and to prevent vasospasm of the pedicle. Subsequently, the
flap is rotated and the blood flow of the pedicle is checked again with handheld Doppler. Finally, the flap is inset
to the defect and the donor site is closed primarily if feasible. The author prefers to use peripheral progressive
tension sutures to close the donor site, which allows for reduction in size and makes primary closure possible.
However, the inset of the flap must be tension free, and the threshold for skin grafting should be low (Fig.
526.5C).
CLINICAL RESULTS
The pedicled perforator (propeller) flap for the lower extremity has gained popularity due to minimal donor

P.1424
site morbidity and relatively simple surgical technique. On the other hand, concerns about risk of pedicle
twisting have been raised. According to a systemic review (11), the overall complication rates of the
pedicled perforator (propeller) flap were 25.8% and the failure rate was 1.1%. The most common
complications were partial flap loss and venous congestion. The overall complication rate is similar to
reported rates for free flaps ranging from 16% to 38%, and the failure rate is lower than the reported failure
rates for free flaps ranging from 4% to 19% (11). Because the pedicled perforator (propeller) flap confines
the morbidity to the affected limb and preserves adjacent muscles and the source artery, functional and
aesthetic results are excellent. As mentioned above, the pedicled perforator (propeller) flap is in line with the
concept of the freestyle flap. Perforators from various source arteries can be used as pedicles (Figs. 526.5,
526.6, 526.6, 526.8, 526.9).
SUMMARY
The pedicled perforator (propeller) flap can provide excellent functional and aesthetic results for both
traumatic and atraumatic soft-tissue defects of the lower extremity. It can be safely used for a variety of
defects with complication rates comparable to free flaps and, therefore, can be considered a reliable and
useful reconstructive alternative to the latter.
FIGURE 526.6 Posterior tibial artery perforator-based propeller flap. A: A soft-tissue defect on anteromedial
surface of distal 1/3 of leg after excision of leiomyosarcoma. The locations of perforators were marked
(marked as “x”) and a flap was designed. B: The flap was elevated and rotated 180 degrees. C: Flap inset
with skin graft of donor site. D: Five months postoperatively, the flap and donor site showed excellent
healing.

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FIGURE 526.7 Lateral supragenicular artery perforator-based propeller flap. A: A 10 × 12 cm soft-tissue
defect on the lateral aspect of the knee (perforator marked as “x”). B: A 10 × 27 cm flap was elevated. C:
Flap inset with primary closure of donor site. (Reprinted from Nguyen AT, Wong C, Mojallel A, et al. Lateral
supragenicular pedicle perforator flap: clinical results and vascular anatomy. J Plast Reconstr Aesthet Surg
2011;64(3):381-385, with permission from Elsevier.)
FIGURE 526.8 Superficial femoral artery perforator-based propeller flap. A: A soft-tissue defect on the
medial side of the knee after excision of high-grade myxoid fibrosarcoma. B: A 24 × 9 cm flap was elevated
and rotated. C: Flap inset with skin graft. D: Fifteen months after the operation.

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FIGURE 526.9 Dorsal metatarsal artery perforator-based propeller flap. A: The flap was harvested based
on the fourth dorsal metatarsal artery. B: Flap inset with primary closure of the donor site. C: Six weeks
after the operation. (Reprinted from van Alphen NA, Laungani AT, Christner JA, et al. The distally based
dorsal metatarsal artery perforator flap: vascular study and clinical implications. J Reconstr Microsurg 2015
Jul 10. [Epub ahead of print], © Georg Thieme Verlag KG.)
References
1. Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and vascular
anatomy. Plast Reconstr Surg 2011;126(5): 1589-1603.
2. Panagiotopoulos K, Soucacos PN, Korres DS, et al. Anatomical study and colour Doppler assessment of
the skin perforators of the anterior tibial artery and possible clinical applications. J Plast Reconstr Aesthet
Surg 2009;62(11):1524-1529.
3. Heitmann C, Khan FN, Levin LS. Vasculature of the peroneal artery: an anatomic study focused on the
perforator vessels. J Reconstr Microsurg 2003;19(3):157-162.
4. Tanaka K, Matsumura H, Miyaki T, et al. Anatomical study of the intermuscular septum of the lower leg;
branches from the posterior tibial artery and potential for reconstruction of the lower leg and the heel. J Plast
Reconstr Aesthet Surg 2006;59(8):835-838.
5. Martin AL, Bissell MB, Al-Dhamin A, et al. Computed tomographic angiography for localization of the
cutaneous perforators of the leg. Plast Reconstr Surg 2013;131(4):792-800.
6. Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical
application for pedicled perforator flaps. Plast Reconstr Surg 2008;122(1):161-170.

7. Mojallal A, Boucher F, Shipkov H, et al. Superficial femoral artery perforator flap: anatomical study of a
new flap and clinical cases. Plast Reconstr Surg 2014;133(4):934-944.
8. Nguyen AT, Wong C, Mojallal A, et al. Lateral supragenicular pedicle perforator flap: clinical results and
vascular anatomy. J Plast Reconstr Aesthet Surg 2011;64(3):381-385.
9. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical
implications. Plast Reconstr Surg 2009;124(5): 1529-1544.
10. Laungani AMD, Lachman N, Primus J, et al. Abstract 125: towards a safer design of perforator flaps: the
perfusion angle theory. Plast Reconstr Surg 2013;131(5S):96.
11. Gir P, Cheng A, Oni G, et al. Pedicled-perforator (propeller) flaps in lower extremity defects: a systematic
review. J Reconstr Microsurg 2012;28(9): 595-601.
12. van Alphen NA, Laungani AT, Christner JA, et al. The distally based dorsal metatarsal artery perforator
flap: vascular study and clinical implications. J Reconstr Microsurg 2015 Jul 10. [Epub ahead of print].

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Chapter 527
The Profunda Femoris Artery Fourth Perforator Island Flap
WARREN M. ROZEN
SIMON DONAHOE
JEREMY L. WILSON
EDITORIAL COMMENT
Preoperative imaging is important to assist with flap design. Deep harvesting in a lateral thigh may be
difficult. It is useful for defects of the upper knee.
INDICATIONS
The fourth perforator of the profunda femoris is able to supply a locoregional flap for coverage of the trunk
and lower extremity (1). The four perforators of the profunda femoris artery have long been known to supply
the skin of the lateral thigh. However, descriptions of the lateral thigh flap do not highlight the significance of
each of these individual perforators in flap design. The original description of the lateral thigh flap by Baek
highlighted the third perforator of the profunda femoris artery as the basis of the lateral thigh flap (2), and
subsequent descriptions of the lateral thigh flap described both the first and third perforators of the profunda
as being dominant (3, 4, 5). Despite the utility of the lateral thigh flap, perforator flaps based on this axis
have been scarcely described. This flap may also be considered as a free flap.
ANATOMY
The anatomy of the region has been described previously (1). The profunda femoris artery, the major artery
supplying the thigh musculature, distributes four major perforating arteries, which perforate the adductor magnus
to exit through the lateral intermuscular septum or through the posterior thigh musculature to supply the lateral
and posterolateral thigh. They are thus identifiable operatively or on imaging through or immediately posterior to
the lateral intermuscular septum. Perforators are variably sized, but there is uniformly at least one perforator over
1.5 mm in diameter. The first perforator is given off above the adductor brevis, between it and the pectineus. The
second perforator courses anterior to the adductor brevis, and the third perforator runs immediately below it. The
fourth perforator is described as the least constant in its cutaneous supply and is considered the terminal branch
of the profunda femoris artery (6, 7, 8). Much like the other three perforators, it can course as a septocutaneous
perforator through the lateral intermuscular septum or as a musculocutaneous perforator.
FLAP DESIGN AND DIMENSIONS
The flap is planned based on the fourth perforator's emergence from the deep fascia, similar to other “freestyle”
perforator flaps. As such, a computed tomographic angiogram (CTA) is commonly
performed to define the anatomy. An additional benefit of imaging is the ability to map the subcutaneous course
of the perforator, and thus, an axial flap is able to be planned. Given these considerations, the flap design and
dimensions are highly individualized.

FIGURE 527.1 A 6- × 4-cm neglected basal cell carcinoma of the lateral knee. A: Prior to excision, and residual
8- × 6-cm defect. B: After pathologic clearance. (Reproduced with permission from Rozen WM, Donahoe S,
Wilson JL. The profunda femoris artery “fourth perforator” island flap: a new perforator flap in lower-limb
reconstruction. J Reconstr Microsurg 2011;27(4):273-276.)
OPERATIVE TECHNIQUE
As in the planning of a “freestyle” perforator flap, a CTA is commonly performed, enabling identification of all
major perforators within the vicinity of the defect (Fig. 527.1). As demonstrated in Figure 527.2, a large perforator
is seen emerging from immediately posterior to the lateral intermuscular septum (blue arrow), found to arise as
the fourth perforating branch of the profunda femoris artery on three-dimensional reconstructions. In this
example, the perforator emerged from the deep fascia 6 cm above the proximal margin of the defect (black arrow)
and was planned as the basis of a local perforator flap to reconstruct the defect.
Preoperative and intraoperative Doppler probe findings confirm the location and course of the perforator
identified on CTA, and a profunda femoris artery fourth perforator flap can thus be designed and undertaken
(see Fig. 527.3A). Once the perforator is identified intraoperatively (see Fig. 527.3B), the flap can be islanded
and transposed into the defect. Direct closure of the donor site is achieved (see Fig. 527.4), although skin
grafting of the secondary defect is an option.
CLINICAL RESULTS
In our clinical series, we have had no flap failures and no partial flap losses. We feel that this success is
based on flap design being templated on the axial subcutaneous course of selected perforators, facilitating
an axial, single territory flap.
SUMMARY
Perforator flaps based on the perforating branches of the profunda femoris artery have not been widely
described, largely due to the perceived variability in perforator anatomy between individuals. With the
advent of CTA for preoperative perforator mapping, the “freestyle” nature of such flaps is eliminated, and
rather, planned perforator flaps can be undertaken with confidence and designed as axial flaps. The
profunda femoris artery fourth perforator flap is a worthwhile example, particularly as the reconstruction of
defects around the knee can be difficult, with relatively few local options.

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FIGURE 527.2 Computed tomographic angiogram of the lower limb vasculature, demonstrating a large
perforator emerging from immediately posterior to the lateral intermuscular septum (blue arrow), and found
to arise as the fourth perforating branch of the profunda femoris artery on three-dimensional
reconstructions. This perforator emerged from the deep fascia 6 cm above the proximal margin of the defect
(black arrow). (Reproduced with permission from Rozen WM, Donahoe S, Wilson JL. The profunda femoris
artery “fourth perforator” island flap: a new perforator flap in lower-limb reconstruction. J Reconstr
Microsurg 2011;27(4):273-276. )
FIGURE 527.3 A: Planning of a profunda femoris artery fourth perforator flap, designed as a local island
flap. B: Perforator location is based on CTA and Doppler ultrasound findings. The perforator was identified
intraoperatively at the precise location identified on preoperative imaging. (Reproduced with permission
from Rozen WM, Donahoe S, Wilson JL. The profunda femoris artery “fourth perforator” island flap: a new
perforator flap in lower-limb reconstruction. J Reconstr Microsurg 2011;27(4):273-276.)

FIGURE 527.4 Postoperative photograph, demonstrating flap inset, with complete flap survival, and direct
closure of the donor site achieved. (Reproduced with permission from Rozen WM, Donahoe S, Wilson JL.
The profunda femoris artery “fourth perforator” island flap: a new perforator flap in lower-limb
reconstruction. J Reconstr Microsurg 2011;27(4):273-276.)
References
1. Rozen WM, Donahoe S, Wilson JL. The profunda femoris artery “fourth perforator” island flap: a new
perforator flap in lower-limb reconstruction. J Reconstr Microsurg 2011;27(4):273-276.
2. Baek SM. Two new cutaneous free flaps: the medial and lateral thigh flaps. Plast Reconstr Surg
1983;71(3):354-365.
3. Bilterys L, Coopman J, Veys A. Bilobed gluteus maximus myocutaneous and lateral thigh fasciocutaneous
flap. Acta Chir Belg 1986;86(4): 253-254.
4. Maruyama Y, Ohnishi K, Takeuchi S. The lateral thigh fascio-cutaneous flap in the repair of ischial and
trochanteric defects. Br J Plast Surg 1984;37(1):103-107.
5. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous
artery. Br J Plast Surg 1984;37(2):149-159.
6. Ahmadzadeh R, Bergeron L, Tang M, et al. The posterior thigh perforator flap or profunda femoris artery
perforator flap. Plast Reconstr Surg 2007;119(1):194-200.
7. Papon X, Pasco A, Fournier HD, et al. Descriptive anatomic study of the fourth perforating artery of the
femoral system. Surg Radiol Anat 1999;21(4):277-281.
8. Salvador-Sanz JF, Torres AN, Calpena FT, et al. Anatomical study of the cutaneous perforator arteries
and vascularisation of the biceps femoris muscle. Br J Plast Surg 2005;58(8):1079-1085.

Chapter 528
Microvascular Free Transfer of A Compound Deep Circumflex
Groin and Iliac Crest Flap
G. I. TAYLOR
R. J. CORLETT
Use of free vascularized bone has greatly improved the success of large bone grafts, with bony union occurring
at a similar rate to a double fracture in the same bone (1). These vascularized grafts also provide the opportunity
to replace en bloc the involved soft tissues and to augment the blood supply to the distal part.
INDICATIONS
Large defects in the long bones of the lower limbs ideally are reconstructed with vascularized fibular grafts
(2,3). However, it is not possible, to use the fibula in every case because it may be damaged in bilateral leg
injuries or there may be a vascular anomaly that precludes its use. Furthermore, if a large skin defect exists,
it may necessitate initial cover with a local muscle or musculocutaneous flap, a cross-leg flap, or a free skin
flap. In these situations, a one-stage reconstruction using the deep circumflex iliac osteocutaneous flap may
be preferable, particularly if the bone defect is less than 8 cm (2,4,5) (see Fig. 528.1).
FIGURE 528.1 A: A 21-year-old motorcyclist presented with a defect of the distal third of the tibia and
unstable scarred soft tissues. An 8-cm segment of anterior iliac crest, together with overlying skin, was
transferred to reconstruct the soft-tissue and bone defect, performed as a secondary procedure. The skin
flap was thinned and no complications occurred. The follow- up is 6 years. B: The bone graft was united at
4 months and, as shown here, at 12 months had hypertrophied to the size of the tibia.
Size of the Bony Defect
Defects less than 5 cm can be treated with conventional nonvascularized bone grafts, provided the bed is
well vascularized. If the skin cover is poor, if the vascularity of the bed is compromised by scar or vessel
injury, or if the defect is in the distal third of the tibia, then a composite vascularized bone graft based on the
deep circumflex iliac artery (DCIA) should be considered. An alternative solution would be a free muscle or
musculocutaneous flap, combined with cancellous bone grafts.

P.1430
P.1431
Defects of 5 to 8 cm, especially if associated with soft-tissue loss, are the ideal indication for the iliac
osteocutaneous flap. The bone can be used to bridge defects up to 14 cm. In these circumstances,
however, an osteotomy is necessary to correct the curvature of the iliac crest, and a vascularized fibular
graft
is usually the better choice. The latter procedure may require initial skin cover, although the fibular flap is
currently being modified to include additional muscle or skin to provide a one stage repair. When the bone
defect exceeds 14 cm, the fibula is the flap of choice.
Associated Soft-tissue Loss
The osteocutaneous flap offers a one-stage repair of bone and skin. In some situations, the external oblique
aponeurosis may be used to provide vascularized tendon grafts (6).
Site of the Defect
The shape of the iliac crest makes it the ideal graft for reconstructing the bones of the foot and the pelvic
ring. Although the graft can be used to reconstruct the femur, it is difficult to maintain rigid fixation. The
stresses on the graft are greater, and we therefore have confined the use of the iliac bone graft to the repair
of tibial defects in most cases.
FLAP DESIGN AND DIMENSIONS
In an adult, it is possible to obtain a straight segment of bone 6 to 8 cm long from the anterior iliac crest. Beyond
this point, the bone curves in two planes, causing a significant problem when reconstructing a long bone. The
curvature of the graft extends outside the line of weight-bearing stresses, predisposing the graft to fracture. In
two of our initial patients, this resulted in late stress fracture at the center of the bone graft after union had
occurred at both ends (see Fig. 528.2).
To overcome this problem, a step or wedge osteotomy of the graft has been devised to straighten the curvature
and has resulted in a better alignment of the graft so that it lies within
the weight-bearing stresses and has provided, in addition, an improvement in the cosmetic appearance of the
limb. The largest defect bridged by this technique so far has been 14 cm (Fig. 528.3); however, the curvature of
the bone is an advantage when reconstructing the longitudinal arches of the foot and the pelvis (Fig. 528.4).

FIGURE 528.2 A,B: A 19-year-old nurse sustained a severe compound wound to her left leg in an automobile
accident. C-E: Three weeks later, a 14-cm curved iliac crest graft was used to repair the 12-cm defect in her
tibia. The skin flap measured 30 × 11 cm. The deep circumflex iliac artery vessels were anastomosed to the
posterior tibial vessels at the ankle. (Continued)

FIGURE 528.2 (Continued) F: The bone graft was secured in position with an external fixation frame shown at 6
weeks. G: At 6 months, bone union was evident, but at 13 months, a stress fracture occurred in the center of the
graft that united spontaneously over a 1-month period. Unfortunately, the curvature of the graft had increased,
and an osteotomy was required to straighten the bone. The graft united rapidly and by 2 years had
hypertrophied to the size of the tibia. From left to right: union of the graft at 12 months, stress fracture that had
united over 4 weeks (13 months), osteotomy and plate fixation to straighten the graft (18 months), hypertrophy
and remodeling of the graft (2 years). H: The leg length is normal, there is a full range of knee and ankle
movement, and the patient participates in all sporting activities.
OPERATIVE TECHNIQUE
Angiographic studies are recommended to define the suspect arteries (2). Any segment of artery without side
branches, especially if tapered or irregular in outline, must be regarded as abnormal and avoided at the affected
level. In practice, this is achieved by dissecting the vessels in normal tissue and progressing toward the injured
area. Angiograms also may show damaged vessels with a segmental block. In this situation, the vessel may be
repaired at the same operation. The ascending branch of the DCIA is useful for this purpose.
As with the jaw (see Chapter 208), we use a model of an articulated pelvis with detachable iliac crests to select
the hip whose curvature is best suited to the bone defect in question. This also helps to orient the vascular

P.1432
pedicle, and wherever possible, we prefer to perform the anastomoses end-to-side to the posterior tibial vessels
at or above the ankle.
FIGURE 528.3 A: A young motorcyclist presented with a compound leg wound and a 14-cm defect of the right
tibia. B: Because of the complication of graft fracture seen in Fig. 528.2, it was decided to straighten the iliac
crest graft at the time of transfer. This was achieved with a step osteotomy, with care taken to preserve the blood
supply to the distal graft segment. C: The skin flap measured 32 × 12 cm. D,E: The result is shown at 6 and 18
months.
CLINICAL RESULTS
Most bone defects of the lower limb are the result of severe trauma, and the zone of tissue damage
surrounding the defect may be quite extensive. Our early experiences using recipient vessels in this zone
were disastrous. A high rate of complications awaits the uninitiated: vessel spasm, the difficult suture of
edematous fragile vessels, and unrecognized venous thromboses. The long pedicle of the DCIA may bridge
some of these injured areas but, if extensive, vein grafts are essential to permit anastomoses to normal
vessels.

P.1433
P.1434
FIGURE 528.4 A: Another case of a 19-year-old motorcyclist in whom a 6-cm segment of iliac crest was
used to reconstruct the medial cuneiform bone and the proximal half of the first metatarsal bone, lost in a
compound injury to the foot. The patient presented with a flail, shortened big toe, a limp, and an unstable
split-thickness skin graft to the area. B: The revascularized graft was secured with transfixation wires. A
skin flap was not included in the design, and closure was obtained by placing a split-thickness skin graft
over the revascularized muscle. In this way, a bulky graft was avoided. C-E: The bone graft was united at 6
months. Note how the iliac graft conforms to the longitudinal arch of the foot.
Our experience with vascularized iliac bone transfer to the lower limb currently totals 18 patients. The first
four of these transfers were designed on the superficial circumflex iliac artery. Although this vessel supplies
a large area of skin, its bone supply is limited. The vessels are small and the pedicle is short. The remaining
14 transfers all have been designed on the DCIA, and we now use this pedicle exclusively.
Most of the patients referred to us had been considered for amputation, and the composite flap was

therefore performed as a salvage procedure. Of the 18 transfers, two failed in the first quarter of our series
as a result of avoidable anastomotic complications. One resulted from inadequate three-dimensional
planning, and the other followed the selection of a traumatized recipient vessel.
Union of the bone was generally observed between 4 and 6 months. Our regimen has been to commence
partial weight bearing at 6 weeks and to remove the external fixation at approximately 6 months. A
protective caliper is worn for a further 6 months.
A supplementary bone graft was required in one patient for delayed union, and late stress fracture was
seen in another two patients. Both fractures united rapidly, but one required an osteotomy for malunion.
SUMMARY
There are now a number of techniques available for the reconstruction of composite defects in the lower
limb. The task of the reconstructive surgeon is to match the appropriate graft to the patient's needs. For
defects less than 5 cm long, nonvascularized bone grafts may suffice if soft-tissue cover is adequate.
The deep circumflex iliac osteocutaneous flap offers a one-stage repair and is best suited for bone defects
of up to 8 cm that are associated with large areas of soft-tissue loss. Beyond this size defect, the fibula is
usually the graft of choice, although we have successfully bridged tibial defects of up to 14 cm with
vascularized ilium.

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Chapter 529
The Functional Free Innervated Medial Gastrocnemius Flap
DAMIEN GRINSELL
SCOTT FERRIS
EDITORIAL COMMENT
The use of this functional muscle flap can provide a thick, bulky muscle to reconstruct a variety of defects.
Neurotization can readily be accomplished.
INDICATIONS
Any defect with critical functional muscle loss requiring replacement is a potential indication for the free
functioning gastrocnemius flap. The authors' experience includes use after tumor resections and brachial
plexus palsy. Tumor excisions have included total glossectomy, total deltoid resection, and total loss of
anterior compartment of arm function. Indications in brachial plexus injuries include late referred cases,
salvage secondary reconstruction, and primary complete plexus injury reconstruction by functional free
muscle transfer.
The characteristics of the flap allow use in situations where a strong muscle of moderate to long proportions
is required. The neurovascular pedicle is at one extreme end of the flap. It is suited to defects requiring
muscle only or composite muscle and skin for reconstruction (1).
ANATOMY
The medial gastrocnemius muscle is a large bipennate muscle of the leg, which arises from the medial condyle of
the femur and inserts to form the Achilles tendon with the lateral gastrocnemius and soleus muscles. The blood
supply is from the medial sural artery, which arises from the popliteal artery high in the popliteal fossa. The artery
is single in 85% of patients and duplex in 15%. The venous drainage is by the accompanying sural veins, which
travel together with the artery. The nerve supply also arises high in the popliteal fossa, from the tibial nerve as a
single motor branch (2). The vascular pedicle averages 5 cm in length but has a broad range of lengths between
2 and 9 cm (3) (Fig. 529.1). Some authors report a small vessel caliber, but in our experience, the artery and
veins are usually 1.5 mm in diameter or greater. The nerve can be extended by
retrograde intraneural dissection of the tibial nerve as described by Feldman et al. (4), should this be required.

FIGURE 529.1 Gastrocnemius pedicle, with nerve in blue loupe, superior to vessels.
The overlying skin is supplied by multiple musculocutaneous perforators. The tendon of origin is quite narrow but
very strong and quickly fans out to a bulky muscle, which tapers inferiorly before terminating in a long tendon of
insertion (5). The strong, suturable tendon facilitates inset of the functioning free muscle transfer (6).
FLAP DESIGN AND DIMENSIONS
The medial gastrocnemius muscle belly contour can be readily seen and palpated in the proximal calf, as can the
medial femoral condyle from which it arises and the Achilles tendon of insertion. The skin island can reliably be
designed over the muscle. Placing the lateral border of the skin flap in the midline of the leg preserves the
musculocutaneous perforators as well as facilitates dissection of the short saphenous vein and sural nerve (Fig.
529.2).
FIGURE 529.2 Surface markings for left medial musculocutaneous gastrocnemius flap.
The long distal tendon allows functional reconstruction very distant from recipient nerve and vessels.
Alternatively, the tendon of insertion can be used short, where it is still of excellent quality, and reliably be
repaired for reconstruction of shorter musculotendinous defects.
OPERATIVE TECHNIQUE
The lateral border of the skin flap (midline of posterior leg) is incised directly down to the muscle, taking care to
preserve the short saphenous vein and sural nerve. The lateral border of the medial gastrocnemius is readily
separated from the lateral gastrocnemius, and the plane deep to the medial gastrocnemius is identified and
bluntly developed (7). The plantaris tendon is a good landmark in this plane. The incision is taken sufficiently
distally to divide the tendon long enough for the particular reconstruction. Next, the medial margin of the skin
paddle is incised and the skin paddle is islanded.
The musculocutaneous flap is easily elevated from distal to proximal, taking care when approaching the pedicle.

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By reflecting the muscle superiorly, one can identify and protect the pedicle or pedicles entering the deep
surface of the flap. Frequently, this is a convenient time to divide the tendon of origin, as it can facilitate access
to the neurovascular pedicle. The pedicle(s) are then carefully dissected, dividing the lateral sural artery in the
case of a common sural artery origin (3), to the origin from the popliteal vessels. The motor nerve is similarly
dissected, with intraneural extension if this is required (4). Once any remaining attachments have been divided,
the flap is observed for good perfusion before being harvested (Fig. 529.3).
If no skin paddle is required, flap harvest is performed through a vertical linear incision up the leg, curving into
the popliteal fossa.
CLINICAL RESULTS
The cases described below illustrate several of the clinical indications and outcomes of this versatile flap.
FIGURE 529.3 Left medial musculocutaneous gastrocnemius flap observed for perfusion prior to
transection of the pedicle.
FIGURE 529.4 Healed free gastrocnemius flap for total glossectomy defect.
A 72-year-old woman underwent total glossectomy, with laryngeal preservation, for T4N1M0
mucoepidermoid carcinoma. Her flap was inset by repair of the gastrocnemius muscle from the hyoid bone
to the anterior mandible, with the lateral muscle being attached to palatoglossus and palatopharyngeus
bilaterally. The skin paddle was inset into the floor of the mouth, cranial to the muscle (Fig. 529.4). At 2
years postoperatively, she has a full oral diet, no percutaneous endoscopic gastrostomy (PEG) tube, and
normal laryngeal movement with intelligible speech.
A 58-year-old male underwent complete left deltoid muscle resection for recurrent fibrosarcoma (Fig. 529.5).

His reconstruction was with a musculocutaneous gastrocnemius flap with vascular repair to the profunda
brachii and venae comitantes. Reinnervation was using the native axillary nerve. At 1 year postoperatively,
he demonstrates shoulder abduction and flexion to 175 degrees, which was comparable to the contralateral
side and Medical Research Council (MRC) grade 5/5 (Fig. 529.6).
A 74-year-old woman underwent complete resection of her right biceps muscle and denervation of her
brachialis muscle for synovial sarcoma. She had a musculocutaneous gastrocnemius flap to replace her
missing biceps, innervated by the native musculocutaneous nerve branch to the biceps. She also
underwent a nerve transfer from the ulnar fascicle predominantly supplying the flexor carpi ulnaris to the
native brachialis nerve. At 2 years postoperatively, she had elbow range of 30 to 120 degrees, with power
of MRC grade 5/5.
FIGURE 529.5 Left deltoid complete resection prior to reconstruction.
FIGURE 529.6 Postoperatively after left deltoid reconstruction with free gastrocnemius flap.
A 26-year-old male with a complete left brachial plexus palsy was having his second planned free muscle
transfer for finger flexion. During his original motor vehicle trauma, the pedicle to his planned gracilis had
been injured and was unavailable. He underwent a free musculocutaneous gastrocnemius flap, innervated
by multiple intercostal nerves and vascularized by the thoracodorsal pedicle. His postoperative result was
MRC grade 4/5, providing adequate short range finger flexion for hook grip, as is expected in an intrinsic
minus hand.
SUMMARY

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The functioning free medial gastrocnemius flap is an extremely valuable flap in patients requiring
replacement of muscle missing through either tumor resection or trauma. It also plays a role in replacing
critically denervated muscles with poor chances of successful primary native muscle reinnervation or
previous failed attempt to reinnervate the native muscle. Donor morbidity after flap harvest is minimal (2).
The medial gastrocnemius has reliable neurovascular anatomy, it is relatively straightforward to harvest,
and it provides a musculotendinous unit of moderate to long proportions, which will accommodate the
reconstructive requirements in many clinical situations.
References
1. Grinsell D, Ying-Ting BY. The functional free innervated medial gastrocnemius flap. J Reconst Microsurg
2014;30(7):451-456.
2. Ninković M, NInković M. Neuromusculotendinous transfer: an original surgical concept for the treatment of
drop foot with long-term follow-up. Plast Reconstr Surg 2013;132(3):438e-445e.
3. Potparić Z, Colen LB, Sućur D, et al. The gastrocnemius muscle as a freeflap donor site. Plast Reconstr
Surg 1995;95(7):1245-1252.
4. Feldman JJ, Cohen BE, May JW Jr. The medial gastrocnemius myocutaneous flap. Plas Reconst Surg
1978;61(4):531-539.
5. Fan C, Jiang P, Fu L, et al. Functional reconstruction of traumatic loss of flexors in forearm with
gastrocnemius myocutaneous flap transfer. Microsurgery 2008;28(1):71-75.
6. Manktelow RT, Zuker RM. The principles of functioning muscle transplantation: applications to the upper
arm. Ann Plast Surg 1989;22(4):275-282.
7. Katsumura T, Hirase Y, Fukumoto K, et al. Use of free ipsilateral gastrocnemius flap for coverage of distal
third tibial defect after Gustilo type III open fracture. J Reconstr Microsurg 2013;29(2):113-116.

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Chapter 530
Internal Oblique Muscle and Osteomuscular Flap
W. M. SWARTZ
S. S. RAMASASTRY
EDITORIAL COMMENT
This is one of the earliest examples of the use of separate muscle and bone in which the muscle can be
moved independently of the bone. This technique was applied most recently to the scapular and
parascapular flaps, where a separate segment of the scapula is taken with its own independent blood
supply branches.
The internal oblique muscle flap has a thin, flat shape with excellent vascularity. The muscle has a blood supply
independent of the iliac crest bone, an advantage in composite reconstruction (1). The vascular pedicle is 6 to 7
cm long and 1.5 to 3 mm in diameter, making the flap extremely reliable for free-tissue transfer. The donor site is
well concealed, and there has been no morbidity following its use.
INDICATIONS
The internal oblique muscle is best used for medium-sized surface defects requiring a minimum of
thickness. Such locations as the malleoli, pretibial areas, and dorsum of the foot requiring flaps of up to 10
× 15 cm are suitable for the internal oblique muscle. When covered with a split-thickness skin graft, this
muscle atrophies to form thin, durable, well-vascularized soft-tissue cover.
ANATOMY
Based on the continuation of the deep circumflex iliac artery (DCIA), the iliac crest bone may be included with the
internal oblique muscle flap, either intimately attached to the muscle or separated from it, depending on the
presence of the ascending branch. It is this latter characteristic that makes the osteomuscular flap extremely
versatile in composite-tissue reconstructions (Figs. 530.1 and 530.2) (1, 2, 3) (see Chapter 424).
FLAP DESIGN AND DIMENSIONS
For small defects such as an osteomyelitis cavity, the muscle flap can be positioned directly over the ascending
branch to ensure maximal vascularity. Compound defects requiring up to 14 cm of iliac crest bone can be
covered with the internal oblique osteomuscle flap, simultaneously providing both bone and soft-tissue coverage
with minimal bulk (Fig. 530.3). An additional advantage of this procedure is that the muscle may be positioned
independent of the bone, owing to its separate blood supply, the ascending branch.
OPERATIVE TECHNIQUE
An incision is made parallel to and slightly above the inguinal ligament and extended laterally beyond the anterior
superior iliac spine. After incising the external oblique fascia, the internal oblique muscle is readily identified. Flap
dissection is begun superiorly, splitting the muscle in the direction of its
fibers. Care is taken to identify the transversus abdominis muscle, and this is easily noted by a change in the

direction of the muscle fibers. Sharp dissection is required because muscle fibers interdigitate, particularly at its
insertion along the rectus fascia.
FIGURE 530.1 The osteomuscular composite flap. The internal oblique muscle may be positioned independent
of the iliac crest bone when the ascending branch is present.
FIGURE 530.2 Internal oblique muscle flap. A: Surface osteomyelitis with exposed bone over distal tibia in a 20-
year-old man. B: An 8 × 10 cm internal oblique muscle flap based on the deep circumflex iliac artery. C: Muscle
flap transferred to defect. Vascular anastomoses performed end-to-side to anterior tibial artery and vena
comitans. D: One-year follow-up shows stable coverage with excellent contour. (From Ramasastry et al., ref. 1,
with permission.)
The medial extent of the internal oblique muscle is reached, and dissection then is carried inferiorly. The muscle
is then elevated, and the ascending branch of the DCIA is identified on the underside of the internal oblique

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muscle. In 65% of patients, the artery is found within 1 cm of the anterior superior iliac spine originating from the
DCIA. In another 15%, it is found more medially (see Fig. 530.2). If the artery is not found as a separate entity,
circulation to the muscle is maintained by identifying the DCIA at its origin with the common iliac artery and then
tracing the artery distally to ensure its being included with the muscle. Once the ascending branch is identified,
the desired muscle flap may be positioned directly over the artery to ensure its complete viability. Dissection then
may proceed along the iliac crest, finally elevating the muscle on its vascular pedicle.
The entire length of the DCIA is used for the vascular pedicle, which usually measures between 6 and 7 cm long,
with a vessel diameter of 1.5 to 3.0 mm. The vena comitans is somewhat larger and lies anterior to the artery.
Wound closure is easily obtained because the transversus abdominis muscle remains intact, and the external
oblique fascia is closed over a suction drain. No skin is excised; so direct closure of the abdominal skin is easily
performed (see Fig. 530.2).
FIGURE 530.3 Internal oblique osteomuscular flap. A: Chronic open infected nonunion following motorcycle
accident in a 19-year-old man after an initial injury that measured 6 cm in length. B: A 6 × 4-cm internal oblique
osteomuscular flap based on the deep circumflex iliac artery. The segment of the iliac crest measured 8 × 3 cm.
C: Primary healing of the flap. The muscle flap had been covered at the time of transfer with a meshed split-
thickness skin graft. (From Ramasastry et al., ref. 1, with permission.) D: Bone union achieved, 8-month follow-
up. The patient is weight bearing without external support and has a completely healed wound.
Osteomuscular Flap
When the iliac crest bone is desired for composite reconstruction, the internal oblique muscle is initially left
attached to the inner border of the iliac crest. Identification of the DCIA is carried out and traced to the anterior
superior iliac spine. The ascending branch is easily identified at this time. The muscle flap then is dissected as
previously described. The desired amount of iliac bone is cut using an oscillating saw, and the muscle and bone
are isolated on the vascular pedicle of the DCIA. At the time of transfer, the muscle may be separated from the
ilium, as reconstructive requirements dictate, provided the ascending branch is present as a separate vessel

(see Fig. 530.1). Wound closure is achieved by suturing the transversalis fascia, the transversus abdominis
muscle, the external oblique fascia, and the tensor fasciae latae to the new edge of the iliac crest after drilling
holes through the bone to anchor the sutures.
CLINICAL RESULTS
The donor site is well concealed, and there has been no associated morbidity. To date, no hernia or
abdominal wall weakness has occurred in any of our patients.
SUMMARY
The internal oblique flap can be used as a free muscle or osteomuscular flap and is particularly suited for
small to medium-sized defects where bulk is undesirable.
References
1. Ramasastry S, Tucker J, Swartz W, Hurwitz D. The internal oblique muscle flap: An anatomic and clinical
study. Plast Reconstr Surg 1984;73:721.
2. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: experimental work. Plast Reconstr Surg 1979;64:595.
3. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: clinical experience. Plast Reconstr Surg 1979;64:745.

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Chapter 531
Microvascular Free Transfer of Fibula
A. J. WEILAND
J. R. MOORE
In selected patients, free vascularized bone grafts offer significant advantages over conventional methods of
treatment. A massive segment of bone can be detached from its donor site and transferred to a distant recipient
site with preservation of the nutrient blood supply by microvascular anastomoses to recipient vessels.
INDICATIONS
With the nutrient blood supply preserved, osteocytes and osteoblasts in the graft can survive, and healing
of the graft to the recipient bed will be enhanced without the usual replacement of the graft by creeping
substitution. Thus, the surgeon can achieve a more rapid stabilization of bone fragments separated by a
large defect without sacrificing viability. This is especially significant when the defect is situated in a highly
traumatized or irradiated area with significant scarring and relative avascularity that preclude incorporation
of conventional bone grafts (1, 2, 3, 4, 5, 6, 7, 8, 9).
ANATOMY
The nutrient artery of the fibula arises as a branch of the peroneal artery, which originates from the posterior
tibial peroneal trunk. The peroneal artery gives off several periosteal branches before giving origin to the nutrient
artery that supplies the medullary nutrient blood flow with the fibula. Penetration through the fibular cortex usually
occurs at the middiaphysis, with a variation of 2.5 cm proximally or distally. The length of the nutrient artery
external to the fibula ranges from 5 to 15 mm, and its diameter is between 0.25 and 1 mm (10, 11).
The peroneal artery continues distally along the medial and posterior aspects of the fibular diaphysis and
provides direct musculoperiosteal branches. Preservation of the medullary and periosteal blood supply to this
straight cortical bone is, therefore, possible by isolation of the peroneal artery at its origin from the posterior
tibial-peroneal arterial trunk (Figs. 531.1 and 531.2).
OPERATIVE TECHNIQUE
To clarify a description of the dissection technique, harvesting the fibula has been divided into eight steps. The
procedure is performed with the patient supine and with the donor leg flexed approximately 135 degrees at the
knee.
Step 1
A straight lateral skin incision is made along the line of the fibula from the neck as far distally as needed. The
incision is carried through the skin and subcutaneous tissue to the fascia overlying the peroneus longus muscle.
Step 2
Elevation of anterior and posterior flaps is performed, as needed, to identify the interval between the peroneus
longus
and soleus muscles. The deep fascia then is incised over the entire length of the wound along this interval. The

fibula is palpated periodically during the course of the dissection. Using a blunt elevator, the interval between the
peroneus longus and soleus is developed. Using an extraperiosteal dissection technique, the peroneus longus
and soleus are reflected from the fibular diaphysis anteriorly and posteriorly, respectively.
FIGURE 531.1 Cross-section of the tibia illustrating plane of dissection (dotted line). (TA, tibialis anterior; DPN,
deep peroneal nerve; ATV, anterior tibial vessels; EDL, extensor digitorum longus; PT, peroneus tertius; SPN,
superficial peroneal nerve; PB, peroneus brevis; PL, peroneus longus; PCS, posterior crural septum; FHL, flexor
hallucis longus; PV, peroneal vessels; GA, gastrocnemius aponeurosis; P, plantaris; IS, intermuscular septum;
PTV, posterior tibial vessels; PTN, posterior tibial nerve; FDL, flexor digitorum longus; IM, interosseous
membrane.)
FIGURE 531.2 This drawing demonstrates the fibula isolated on the peroneal artery. The nutrient artery is also
illustrated.

Step 3
The lateral border of the fibula is now exposed. There are three perforators to the skin lying immediately
posterior to the fascia overlying the soleus muscle. If skin is to be harvested with the fibula, these branches must
be preserved. When the bone alone is to be transferred, these vessels should be ligated.
Step 4
Beginning proximally, the peroneus longus and brevis are elevated off the lateral border of the fibula, using a
blunt elevator until the anterior crural septum is reached, staying close to bone. A 1-cm cuff of muscle is not left
surrounding the fibula, as previously described. In the event that the vascularized graft fails, the cuff of muscle
will become necrotic and serve as a nidus for infection. In addition, it will delay replacement of the graft by
creeping substitution. The anterior crural septum is divided, and the extensor group of muscles (extensor
digitorum longus, peroneus tertius, and extensor hallucis longus) is dissected off the interosseous membrane.
The dissection continues until the anterior tibial artery and nerve have been identified and protected.
Step 5
The posterior crural membrane is divided the entire length of the graft. Using careful extraperiosteal dissection
techniques, the soleus and flexor hallucis muscles are reflected off the posterior border of the fibula. The
dissection continues until the peroneal vessels are encountered. The vessels must be left attached to the
posterior surface of the intermuscular septum. Dissection is continued anteriorly and posteriorly for the length of
graft required.
During the posterior dissection, any branches arising from the peroneal artery that will not be taken with the graft
must be coagulated. Special care is taken not to damage the artery to the graft. In the distal third of the fibula,
the peroneal artery lies directly on the posterior surface of the bone, and special care is taken to avoid damage
to the artery during the osteotomy.
Step 6
The length of graft needed is measured and marked with methylene blue. All attempts should be made to
preserve the distal 6 cm of fibula to maintain integrity of the lateral aspect of the ankle joint. If distal dissection is
required in a child, a transfixion screw to preserve the integrity of the ankle mortise and to prevent possible
proximal migration of the distal fibula should be employed. At the site of the distal osteotomy, the peroneal
vessels should be identified and pushed medially off the intermuscular septum.
A hole is made in the septum sufficient to allow a 2.5-cm malleable retractor to be placed around the bone,
protecting the vessels that lie posterior to the retractor. At this point, a Gigli saw may be passed and the distal
osteotomy performed. A similar procedure is carried out at the proximal end of the graft. At this point, the distal
limbs of the peroneal artery and veins are ligated at the site of the distal fibular osteotomy.
Step 7
Using a small bone hook in the medullary canal of the distal portion of the fibular graft to stabilize the fibula
during the remaining portion of the dissection, the graft is retracted posteriorly, and division of the interosseous
membrane is performed along the entire length of the graft. The graft then is carefully retracted anteriorly, and
the tibialis posterior is dissected off the posterior aspect of the graft in the middle third, where it has remained
attached to the fibula. This step is performed in a distal to proximal direction. The fibula is retracted anteriorly or
posteriorly during this portion of the dissection, as needed, leaving the fibular graft isolated on its vascular
pedicle proximally.
Step 8

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Now that the fibula is completely dissected, the surgeon traces the peroneal artery proximally to its junction with
the
posterior tibial artery. A vessel loop is placed around the peroneal artery and vein. The fibula then is placed back
in its bed until the recipient site is prepared. The tourniquet is deflated. Upon completion of the dissection of the
recipient bed, the fibula is harvested and placed in the defect. After stable fixation is achieved, microvascular
anastomoses of the artery and one vein are performed.
FIGURE 531.3 A 22-year-old man was involved in a motorcycle accident, sustaining a fracture dislocation of the
left hip, an intraarticular fracture of the left knee, and an open fracture of the left midtibia, with a 9-cm segmental
bone loss. A: Six months after injury, he presented with a healed wound over the left leg. B: Roentgenogram of
the left leg demonstrating the bony defect. C: After a free vascularized fibular graft was performed, the patient's
leg was placed in a Hoffmann device for 3 months, followed by a patellar tendon-bearing brace for an additional
3 months. D,E: At 6 months postoperatively, there was complete healing and hypertrophy of the vascularized
fibular graft.
CLINICAL RESULTS
Our experience with the free vascularized fibular graft has encompassed its use in reconstruction following
resection of low-grade malignant tumors and locally aggressive benign tumors, in addition to reconstruction
of limbs following trauma (Fig. 531.3). The success rate was 90%, with only three failures (10%). Bony
union occurred on an average of 3 to 5 months, with bony hypertrophy appearing in 4 to 9 months. The
patients took 5 months on average to partial weight bearing and 12 to 15 months to full weight bearing.
Of secondary procedures, three (10%) required a bone graft, three (10%) underwent subsequent
amputation, and two (6.6%) were of questionable viability. There has not been any donor-site morbidity

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associated with harvesting the fibula in any of our patients.
SUMMARY
The free vascularized fibula has dramatically altered the management of long-bone defects of the leg.
Because it is living bone, it is more easily incorporated into the leg than “dead” bone grafts.
References
1. Taylor GI, Miller GDH, Ham FJ. The free vascularized bone graft: A clinical extension of microsurgical
technique. Plast Reconstr Surg 1975; 55:533.
2. Weiland AJ, Daniel RK, Riley LH Jr. Application of the free vascularized bone graft in the treatment of
malignant and aggressive bone tumors. Johns Hopkins Med J 1977;140:85.
3. Weiland AJ, Daniel RK. Microvascular anastomoses for bone grafts in the treatment of massive defects in
bone. J Bone Joint Surg 1979; 61A:98.
4. Weiland AJ, Kleinert HE, Kutz JE, Daniel RK. Free vascularized bone grafts in surgery of the upper
extremity. J Hand Surg 1979;4:129.
5. Chin-Tang H, Chi-Wei C, Kuo-Li S, et al. Free vascularized bone graft using microvascular technique. Ann
Acad Med Singapore 1979;8:459.
6. Chung-Wei C, Zhong-Jia Y, Yean W. A new method of treatment of congenital tibial pseudarthrosis using
free vascularized fibular grafts: A preliminary report. Ann Acad Med Singapore 1979;8:465.
7. Weiland AJ, Daniel RK. Congenital pseudarthrosis of the tibia: Treatment with vascularized autogenous
fibular grafts. A preliminary report. Johns Hopkins Med J 1980;147:89.
8. Weiland AJ. Current concepts review: vascularized free bone transplants. J Bone Joint Surg
1981;63A:166.
9. Pho RWH. Malignant giant-cell tumors of the distal end of the radius treated by a free vascularized fibular
transplant. J Bone Joint Surg 1981;63A:877.
10. Gilbert A. Free transfer of the fibular shaft. Int J Microsurg 1, 1979.
11. Restrepo J, Katz A, Gilbert A. Arterial vascularization to the proximal epiphysis and the diaphysis of the
fibula. Int J Microsurg 1980;2:49.

Chapter 532
Transposition and Rotation Skin Flaps of The Sole of The Foot
J. W. CURTIN
EDITORIAL COMMENT
The procedures illustrated in this chapter are most worthwhile, because they provide coverage with similar
type of skin to a weight-bearing area.
The skin and subcutaneous tissues of the sole of the foot are unique; exact replacement of plantar skin is
impossible, and substitution is difficult. Tissue brought to the sole of the foot from other parts of the body does
not transform itself into normal plantar skin and consequently is subject to breakdown when weight bearing
resumes, usually because the substituted tissue overlies a bony prominence and the covering flap taken from a
distant site remains anesthetic. These artificially induced trophic changes lead to eventual breakdown.
When surgery is necessary to correct soft-tissue defects or lesions of the plantar aspect of the foot, the most
ideal skin covering is adjacent plantar skin (Fig. 532.1). Previously delayed laterally based plantar flaps contain a
fibrofatty pad that is specialized to resist weight bearing, and they afford protection by good permanent sensation
(1, 2).
FIGURE 532.1 A: Plantar ulcer and keratosis excised with outline of adjacent skin and subcutaneous tissue flap.
B: Immediate rotation of plantar flap with split-thickness skin graft to the donor site. C: Patient has been walking
on foot for 3 years.
INDICATIONS
When a tissue defect is encountered on the sole in an area where a bony prominence is not present,
coverage can be achieved by either a full-thickness or a split-thickness skin graft. Depending on the clinical
status, a split-thickness skin graft may be taken from the non-weight-bearing surface of the foot with good
results and no problem with the donor site (3). Intelligent care of the anesthetic skin graft is important, but
as long as some soft tissue underlies the graft, it usually will hold up quite well in weight bearing.
Past experiences with cross-leg and cross-plantar “functional flaps” have been less than satisfactory,
because of prolonged cross-leg fixation, extended hospitalizations, and the disability of the donor site on the
opposite leg or plantar surface of the foot (4, 5).

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Of patients with plantar conditions seen by me, most had ulcers of many years' duration beneath the
metatarsal heads. Their incapacity was due to prolonged overtreatment; the original plantar wart was long
gone, but painful keratosis and callus persisted. Plantar ulcerations are most commonly found in diabetic
patients with peripheral neuropathy, diabetic small-vessel disease, and other metabolic disturbances.
FLAP DESIGN AND DIMENSIONS
Although a medially based plantar flap would seem more ideally designed as an axial flap, the resulting skin graft
on the lateral donor area would be on the weight-bearing part of the foot. Therefore, laterally based flaps are
preferred. It is usually necessary to carry out delay procedures on these laterally based flaps because they must
be considered random flaps.
The bulk of the delayed laterally based plantar flap will consist of epidermis, dermis, and the specialized fibrofatty
pad overlying the plantar fascia. The size of these flaps varies but will usually measure 5 × 6 cm or 6 × 8 cm,
depending on the size of the anticipated surgical defect (Figs. 532.1 and 532.6A).
OPERATIVE TECHNIQUE
My preferred method of delay is a skin and subcutaneous incision only without undermining of the flap and
resuturing. This cuts off most of the peripheral feeders from three sides. I find that undermining the flap is a
disadvantage, as considerable fibrosis of the flap is seen by the time of transfer 2 or 3 weeks later.
If the plantar flap were completely undermined and the circulation appeared so adequate that immediate transfer
were possible, delay would not be necessary. However, my experience with the laterally based flap indicates that
primary transfer is impossible and that delay is mandatory (Figs. 532.2 and 532.3).
When ulcers or calluses underlie a metatarsal head or os calcis, it is essential that plantar skin and
subcutaneous tissue cover the surgical defect (Figs. 532.4, 532.5, 532.6). Frequently, when the plantar ulcer is
beneath the head of the metatarsal, there is hyperextension of the metatarsophalangeal joints with associated
hammer toes. The corrective operation should consist of ulcer excision, shaving or removal of the entire
metatarsal head, or shortening of the metatarsal shaft (6) (Fig. 532.6). Sectioning of the extensor and flexor
tendons to the affected toes is preferred as is closure of the surgical defect by rotation of a previously delayed
laterally based plantar flap. The donor site, which will be on a relatively non-weight-bearing surface of the foot,
will be covered by a moderately thick split-thickness skin graft (Fig. 532.6C, D).
These plantar flaps are somewhat inelastic, and the turn on the axis of rotation can be difficult. If dog-ears
develop at the base of the flap, they are best left unattended surgically and probably will flatten on weight
bearing (see Fig. 532.2B). Certainly their removal at the time of rotation would be hazardous to the vascular
supply of the flap.
CLINICAL RESULTS
Use of local plantar flaps in the weight-bearing areas of the foot brings in ideal structures of epidermis,
dermis, and subcutaneous tissue. Experience with these patients refutes the notion that local flaps can be
used only for small defects (5). Sensation returns rapidly in these local flaps, even when innervation has
been sectioned (7). Their use results in superior weight-bearing surfaces with less restriction of the patient
than when distant flaps are used.

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SUMMARY
When the surgeon is confronted with complicated and intractable conditions on the plantar aspect of the
foot, the use of local flaps, laterally based and previously delayed, affords ideal structures of epidermis,
dermis, and subcutaneous tissue.
FIGURE 532.2 A: Vascular tumor in a 3-year-old child with two previous unsuccessful operative attempts at
removal. A delay procedure of a laterally based plantar pedicle flap. B: Surgical correction by excision of
tumor, ligation of vessels, rotation of pedicle flap, and split-thickness skin graft to donor site.
FIGURE 532.3 A: A 59-year-old diabetic patient with plantar heel ulcer of 10 years' duration. B: A delay
procedure of a laterally based plantar pedicle flap. C: Surgical correction with excision of ulcer, rotation of
previously delayed laterally based plantar pedicle flap, and split-thickness skin graft to donor site.

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FIGURE 532.4 A: Delay pattern of laterally based plantar pedicle flap. B: Surgical correction of persistent
painful heel keratosis and rotation of pedicle flap to cover defect. C: Final result demonstrating primary
suture of donor site.
FIGURE 532.5 A: An 18-year-old male patient exhibiting ulcer and surrounding keratosis of heel secondary
to trauma of 5 years' duration. Note delay pattern of laterally based plantar flap. Also depicted is an
alternative (but we feel hazardous) skin flap overlying Achilles tendon. B: Postoperative result after surgical
excision of ulcer, rotation of previously delayed pedicle flap, and split-thickness skin graft to part of the
donor site.