Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

568.e4 PART 4 — CONVENTIONAL WORKHORSE FLAPS
This patient had bilateral skin-sparing mastectomy for breast
carcinoma. The flap is designed. The upper transverse incision
is always made, the septum between the adductor longus and
gracilis muscles is identified. The fascia overlying the adductor
longus is elevated from anterior to posterior. The caudal portion
of the gracilis muscle can be maximally harvested in order to
provide additional volume, and this portion of the muscle can
also be fat grafted in situ in order to augment volume. The
patient is shown postoperatively with a good outcome and
minimal donor site morbidity in Figure 49.16.
CASE 49.7  Bilateral Skin-Sparing Mastectomy with Immediate Reconstruction with Bilateral
Transverse Upper Gracilis Flaps
Figure 49.16  (A) Preoperative view of 24-year-old woman with left breast carcinoma. (B) Anterior view of bilateral TUG flap skin paddle
design. Note limited anterior extension of flap skin paddle design, as there is limited tissue anterior to the adductor longus and taking
lymphatics can create lymphedema. (C) Posterior view of bilateral TUG flap skin paddle design. Note that the posterior extension of the
TUG flap should not extend past the vertical mid-posterior axis of the thigh. (D) Intraoperative view demonstrating TUG flap pedicle and
dissection, with preservation of additional subcutaneous tissue and fascia over the gracilis muscle in order to maximize perfusion of the
skin paddle. Note that the fascia overlying the adductor longus has been harvested to facilitate septum opening between the gracilis and
the adductor longus and better identify the medial circumflex femoral vessels. Flap dimensions can vary from 5–12 cm (in width), and
20–30 cm (in length). The superior transverse incision is kept within 1 cm of the groin and infragluteal crease in order to better conceal
the scar. (E) Postoperative view at 2 weeks following fat grafting and revision after initial bilateral immediate breast reconstruction with
TUG flaps. (F) Postoperative view of bilateral TUG flap donor sites at 6 months.
A
D
E
F
B
C

CHAPTER 49 — Gracilis Flap 568.e5
This is a 44-year-old patient prior to bilateral skin-sparing mas-
tectomy for biopsy-proven breast carcinoma. Donor site included
a bilateral trilobe TUG flap design to maximize both horizontal
and vertical skin laxity of the inner thigh. The patient healed
well and had an aesthetic benefit at the donor site. Some
methods to increase tissue harvested included the E-TUG
(extended transverse upper gracilis flap), where additional
adipose tissue is harvested caudally. Modifying the skin paddle
design as a “T-shaped” or “L-shaped” or “V” (vertical) and
“S-shaped,” can all be performed based on recruitment of
maximal donor site volume and characteristics (horizontal vs
vertical laxities). A common design in our practice is the S-shaped
TUG design (Fig. 49.17).
CASE 49.8  Bilateral Mastectomies Through Reduction Patterns, Reconstructed with
Extended Transverse Upper Gracilis Free Flap
A
B
C
D
E
F
E
Figure 49.17  (A) Preoperative view of a 44-year-old patient prior to bilateral skin-sparing mastectomy for biopsy-proven breast carci­
noma. Donor site included a bilateral trilobe TUG flap design to maximize both horizontal and vertical skin laxity of the inner thigh. (B)
Intraoperative view demonstrating vertical extension of TUG flap for recruitment of additional skin and subcutaneous tissue. (C) A 12-month
postoperative view following bilateral immediate breast reconstruction with trilobe TUG flaps, fat grafting, and mastopexy. Vertical exten­
sion of the TUG flap should be kept just anterior to the anterior border of the gracilis flap in order to avoid an anterior visible scar. (D)
Coning of TUG flap provides optimal projection for re-creating breast shape. (E) Extended TUG flap design using an S-shaped TUG flap
skin paddle design. This provides the advantage of recruiting maximal volume in the donor site by addressing both the horizontal and
vertical thigh soft tissue laxities. The final donor site closure is vertical oblique, and avoids a “T” junction, which is more prone to wound
breakdown. (F) Intraoperative harvest of the “S” TUG flap, with early identification of the gracilis muscle so that any skin paddle design
and location can be modified as needed.

CHAPTER 49 — Gracilis Flap
569
31. Hoang NT, Staudenmaier R, Feucht A, et al. Effectiveness of free
gracilis muscle flaps in the treatment of chronic osteomyelitis with
purulent fistulas at the distal third of the tibia in children. J Pediatr
Orthop 2009;29(3):305–11.
32. Kay S, Pinder R, Wiper J, et al. Microvascular free functioning
gracilis transfer with nerve transfer to establish elbow flexion.
J Plast Reconstr Aesthet Surg 2010;63(7):1142–9.
33. Terzis JK, Kostopoulos VK. Free muscle transfer in posttraumatic
plexopathies: part III. The hand. Plast Reconstr Surg 2009;124(4):
1225–36.
34. Doi K, Sakai K, Ihara K, et al. Reinnervated free muscle transplan­
tation for extremity reconstruction. Plast Reconstr Surg 1993;91(5):
872–83.
35. Zuker RM, Bezuhly M, Manktelow RT. Selective fascicular coapta­
tion of free functioning gracilis transfer for restoration of inde­
pendent thumb and finger flexion following Volkmann ischemic
contracture. J Reconstr Microsurg 2011;27(7):439–44.
36. Fattah A, Borschel GH, Manktelow RT, et al. Facial palsy and recon­
struction. Plast Reconstr Surg 2012;129(2):340e–352e.
37. Papadopoulos O, Konofaos P, Georgiou P, et al. Gracilis myocuta­
neous flap: evaluation of potential risk factors and long-term
donor-site morbidity. Microsurgery 2011;31(6):448–53.
38. Carr MM, Manktelow RT, Zuker RM. Gracilis donor site morbidity.
Microsurgery 1995;16(9):598–600.

570
Gastrocnemius Flap
Alain-Charles Masquelet  |  Paolo Sassu  |  Marco Innocenti
50 
Figure 50.1  Gastrocnemius Flap.
Medial head of
gastrocnemius
Lateral head of
gastrocnemius
Popliteus
Calcaneal
(Achilles) tendon
Tibial nerve
Tibial nerve
Posterior
tibial artery
Peroneal artery
Tibial nerve
Popliteal artery
Plantaris
Lateral sural artery
and nerve
Medial sural artery
and nerve
INTRODUCTION
The gastrocnemius flap is one of the most useful flaps.
Described very early, it has been proven to be easy to raise
and very reliable. Typically, it can be used by non-specialized
reconstructive surgeons, since its field of application con­
cerns the area of the knee and upper part of the leg, which
is frequently involved in injury and is an area in which pros­
thetic surgery is frequently performed. As is the latissimus
dorsi flap for the upper limb, the gastrocnemius is the main­
stay of the armamentarium of flaps that can be used for
lower extremity reconstructions and should be known by
surgeons in orthopedic and plastic surgery. Although the
musculocutaneous flap has significant potential as a func­
tional muscle transplant to restore elbow flexion, the main
indication is the use of the medial head as a proximally
based pedicled muscle flap for reconstructing defects
around the knee. With the increasing number of knee pros­
theses and the existing risk of skin disunion or infection,
especially in the elderly, the medial gastrocnemius flap is
the “cornerstone” of the strategy for dealing with problem
cases of prosthetic knee replacement.
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

CHAPTER 50 — Gastrocnemius Flap
571
LATERAL GASTROCNEMIUS MUSCLE
Dominant:  lateral sural artery
Length: 4.8 cm (range 1.8–9 cm)
Diameter: 2.2 mm (range 1.2–3.7 mm)
Minor:  branches from the medial sural artery
These branches have variable length and diameter. They
are located in the distal half of the muscle.
VENOUS DRAINAGE OF THE FLAP
All arteries to these flaps are accompanied by venae
comitantes.
Primary:  venae comitantes of the medial and lateral sural
artery
Two venae comitantes are found with each artery. The
diameter of the veins is approximately 3.5 mm (range
3–4 mm).
Secondary:  superficial veins such as the lesser saphenous
vein (Fig. 13.19)
This vein can be included with the flap to augment
drainage or to serve as primary drainage of the flap. This is
particularly useful when a large skin island is included with
the flap.
FLAP INNERVATION (see Fig. 50.1 and
Figs 13.9, 13.10, 13.11, 13.19)
Motor:  medial and lateral sural motor nerves that come
off the tibial nerve
These nerves are approximately 4–5 cm in length and
enter the muscle on its deep proximal surface with the
sural vascular pedicle. As the gastrocnemius is a rapid-
contraction muscle, it is preferable to cut the nerve when
raising a pedicled flap to avoid muscle contraction on the
donor site.
Sensory:  skin overlying the medial gastrocnemius muscle
Posterior femoral cutaneous nerve and saphenous nerve
(L3–L4) innervate this area. The saphenous nerve follows
the course of the greater saphenous vein and can be found
near the medial side of the gastrocnemius muscle.
Sensory:  skin overlying the lateral gastrocnemius muscle
The sural nerve (S1–S2) supplies the skin in this part of
the calf and the nerve can be found running along the lesser
saphenous vein. The nerve runs in a subfascial plane and
pierces the fascia in the posterior calf to travel more super­
ficially and supply the skin.
FLAP COMPONENTS
The gastrocnemius flaps are harvested as muscle flaps. They
can include the overlying fascia and skin. A strip of tendon
can be included with the flap. The flap can be harvested as
a chimeric flap with the skin island and muscle harvested
based on the same common pedicle.
FLAP ANATOMY (Figure 50.1 and see Ch. 13
and Figs 13.3, 13.6, 13.9, 13.10, 13.11, 13.19)
The gastrocnemius muscle has two heads: medial and
lateral. The medial head originates on the posterior surface
of the femur superior to the medial condyle and posterior
to the insertion of the adductor magnus muscle. The lateral
head originates in the lateral epicondyle of the femur. Both
insert into a long common muscle aponeurosis that forms
the Achilles tendon with the aponeurosis of the soleus.
• The proximal part of the muscle forms the lower triangle
of the popliteal fossa, the upper triangle being formed by
the diverging hamstring muscles.
• The muscle bellies extend from the popliteal fossa to the
mid- to distal third of the leg.
• The plantaris muscle and tendon lie between the medial
gastrocnemius and the soleus muscle and can be used to
clearly identify the plane of separation.
• The medial and lateral head run side by side and are
separated by a fibrous septum.
• The gastrocnemius muscles contribute to plantar flexion
of the foot through their pull on the Achilles tendon.
These muscles also contribute to knee flexion.
ARTERIAL SUPPLY OF THE FLAP (Figs 50.1 and
13.3, 13.6, 13.9)
The vascular supply is type I in the Mathes and Nahai clas­
sification, and each head, lateral or medial, can be mobi­
lized individually on its own neurovascular pedicle.1 One
muscle head can survive totally based on the vascular com­
munications between the two muscle bellies. The dominant
vessel in most patients is the medial sural artery.
MEDIAL GASTROCNEMIUS MUSCLE
Dominant:  medial sural artery
Length: 5.1 cm (range 1.6–9.5 cm)
Diameter: 2.5 mm (range 1.8–4 mm)
Minor:  branches from the lateral sural artery
These branches have variable length and diameter. They
are located in the distal half of the muscle and communicate
between the two muscle heads.
Minor:  branch from the posterior tibial artery
The branches have variable length and diameter. The
distal part of the medial head receives a vascular pedicle
from a musculocutaneous artery issuing from the tibialis
posterior artery at the midleg. This pedicle gives off a
direct skin branch and a muscular branch that divides
into two small branches, one for the soleus and the other
for the distal part of the medial aspect of the medial
head. Not infrequently, this branch is well developed and
permits the raising of an inferiorly based portion or the
entire muscle based only on this pedicle. It provides an
elegant solution to cover the middle or the distal third of
the leg.

572
PART 4 — CONVENTIONAL WORKHORSE FLAPS
is performed and the skin vessels are located; then the skin
island design is adjusted as necessary.
DIFFERENCES IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
No difference exists when the muscle is harvested as a free
flap or pedicled flap. In order to extend the arc of rotation
Advantages
• Muscle dissection is rapid in case of a proximally based
pedicled flap.
• The external diameter and length of the pedicle are suit­
able for microsurgical transplantation.
• Contour deformity following the use of one head is
acceptable.
• When only one head is raised, functional loss is negligi­
ble, compared with the benefit of the procedure.
• The medial or the lateral head can be transposed distally
by extending the pedicle length. However, this technique
is no longer so popular after the recent description of
fasciocutaneous flaps for covering the distal leg.
• The length of the distal tendon, the length of excision of
the body muscle, and the strength of contraction make
functional transfer an interesting possibility.
Disadvantages
• In case of a free transfer, the prone position is more suit­
able for dissecting the pedicle but makes transplantation
to an anterior recipient site more difficult.
• The posterior incision is not desirable in females.
• The elevation of a pedicled flap in supine position can
be difficult in case of stiffness in hip or knee.
• The donor site following the transplantation of an
extended musculocutaneous flap is not cosmetically
acceptable.
FLAP DESIGN AND FLAP MARKINGS
ANATOMIC LANDMARKS (Fig. 50.2)
A transverse line is marked in the posterior knee crease; this
coincides with the level of the takeoff of the medial and
lateral sural vessels. The midline raphe separating the
medial and lateral heads and the distal ends of the muscles
are marked. These landmarks can be palpated in most
patients.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The skin over the calf can be harvested in its entirety,
encompassing the entire width of the calf and from the
popliteal fossa to approximately 10 cm past the distal end
of the muscle bellies. In order to close the defect primarily,
<6 cm of skin can be included.
Skin grafting is required for defects >8 cm and should be
performed without hesitation in order to prevent the occur­
rence of compartment syndrome.
The proximal part of the skin island should be at least
4 cm beyond the popliteal crease in order to avoid discom­
fort with knee motion.
Many of the branches off the sural artery, supplying the
overlying skin, exist in the distal medial half of the muscle
bellies. Therefore, when harvesting an overlying skin island,
it is preferable to design the island to include this region.
SPECIAL CONSIDERATIONS
If a small skin island is to be included with the flap, a hand­
held Doppler can be used to map the location of the skin
vessels prior to beginning the surgery. The medial incision
Figure 50.2  Anatomic landmarks. Lower calf: 1. Gastrocnemius.
2. Soleus. 3. Lateral malleolus. 4. Medial malleolus. 5. Calcaneus
tendon (Achilles tendon). 6. Calcaneus. Upper thigh: 1. Biceps
femoris. 2. Semimembranosus. 3. Semitendinosus. 4. Gracilis. 5.
Sartorius. 6. Gastrocnemius, medial head. 7. Gastrocnemius, lateral
head. Marking of the flap. Medial gastrocnemius (black dashed line):
the incision is marked parallel to and 2 cm behind the posterior
border of the tibia. Lateral gastrocnemius (blue dashed line): the inci­
sion is marked parallel to and 2 cm behind the posterior border of
the fibula. Free gastrocnemius flap (red dashed line): the incision is
marked longitudinally in the midline and curved proximally toward the
muscle that is being harvested. Each incision has a length of about
10 cm, should form an angle as it crosses the popliteal fossa, and
can be extended either proximally or distally as necessary. (Adapted
with permission Lumley JSP. Surface anatomy. 3rd ed. Churchill
Livingstone, 2002).
1
2
3
4
5
7
6
2
3
6
4
5
1

CHAPTER 50 — Gastrocnemius Flap
573
ANESTHETIC CONSIDERATIONS
If the defect to be reconstructed is in the same extremity,
spinal or epidural anesthesia may suffice; otherwise, general
anesthesia is instituted. Generally speaking, we prefer
general anesthesia as it is more comfortable for the patient.
In cases where the flap is to be transferred to the upper
extremity, the procedure can be performed under regional
blocks with sedation of the patient.
TECHNIQUE OF FLAP HARVEST
Elevation of the medial and lateral heads is discussed
separately.
PROXIMALLY BASED PEDICLED MEDIAL
GASTROCNEMIUS MUSCLE FLAP (Figs 50.3, 50.4)
The incision starts at midcalf, 2 cm behind the posterior
border of the tibia on the medial aspect of the leg, and
curves proximally to reach the popliteal fossa that it crosses
by an angulated incision. Care should be taken to avoid
injury to the great saphenous vein and saphenous nerve.
The crural fascia is incised in line with the skin incision and
the fascia and overlying skin of the calf are elevated off the
muscle as far laterally as the plane between the two heads of
the gastrocnemius. It is advised to begin the elevation by
separating the two heads in the midline. The sural nerve
and lesser saphenous vein are identified on the lateral
border of the medial head in the aponeurotic sheet between
the two heads and are usually covered by a thin layer of
muscle fibers from the medial head. The nerve and vein are
dissected and retracted posterolaterally. The aponeurotic
plane between the two heads is identified and progressively
incised while separating the two muscle bellies from distal
to proximal. The space between the proximal part of both
heads is identified, taking care to preserve the neurovascu­
lar pedicle, which lies on the lateral aspect of the medial
gastrocnemius muscle. Before detaching any part of the
muscle, the plane between the soleus and the gastrocnemius
muscle is identified on the medial border of the gastrocne­
mius and developed with a finger. This plane houses the
plantaris tendon, which lies between the gastrocnemius and
soleus muscles. Skin vessels traversing this plane must be
ligated or cauterized and cut. Finally, the distal tendon is
severed and the flap is raised from distal to proximal. Usually
the distal tendon of the gastrocnemius can be split for a few
centimeters from the soleus component in the context of
the Achilles tendon and included in the flap if necessary for
patellar or quadriceps tendon reconstruction. The muscular
body of the medial head is long and the arc rotation of the
transfer allows easy coverage of the proximal third of the leg
and the medial and anterior aspects of the knee.
Several points should be emphasized to maximize the arc
of rotation in order to reach the defect to be reconstructed
and to optimize outcomes:
• The tendons of gracilis and semitendinosus muscles can
render the transposition of the gastrocnemius muscle dif­
ficult; therefore, it is advisable to perform wide tenolysis
of a myocutaneous gastrocnemius flap, the skin island can
be designed more distally.
FLAP DIMENSIONS
MUSCLE DIMENSIONS
MEDIAL HEAD
Length: 15 cm (range 13–20 cm)
Width: 7 cm (range 5–9 cm)
LATERAL HEAD
Length: 12 cm (range 11–16 cm)
Width: 5 cm (range 4–7 cm)
SKIN ISLAND DIMENSIONS
Length: 10–15 cm (maximum 20 cm)
Width: 6–10 cm (maximum 15 cm)
The skin over the medial and lateral head is supplied by
musculocutaneous perforators that can each supply a large
area of skin. Most perforators exist in the proximal part of
the calf, over the muscle; however, the skin can be included
based on some of the skin vessels that supply the skin distal
to the muscle heads. The dimensions for skin islands over
the lateral gastrocnemius muscle are adjusted to be slightly
smaller than described above. However, depending on the
actual size of the musculocutaneous branch, large flaps can
be harvested.
PATIENT POSITIONING
The best compromise is the supine position with the knee
flexed and the hip abducted, flexed, and externally rotated.
In this position, even a free transfer of the medial head can
be raised. Free transfer of the lateral head requires the
prone position but this procedure is not often used.
The prone position is used when the defect requires this
position. The harvest of the flap is simple and straightfor­
ward in this position.
If the patient suffers from severe hip stiffness, the prone
position may be chosen or the patient can be placed in a
lateral decubitus position with the flap donor leg down.
PREOPERATIVE PREPARATION
In case of previous injury to the lower extremity with suspi­
cion of injury to the popliteal vessels or its branches, an
arteriogram, magnetic resonance angiogram, or computed
tomography (CT) angiogram are performed to assess the
permeability of the main vessels and the presence of the
sural arteries.
The contour of the muscle can be assessed clinically by
asking the patient to flex the ankle against resistance. This
allows an evaluation of the length and chiefly the volume of
the body of the muscle. One should keep in mind that the
thinner the muscle, the easier transplantation will be. A
thick-bodied muscle is always more difficult to mobilize.

574
PART 4 — CONVENTIONAL WORKHORSE FLAPS
is adducted and internally rotated. The lateral head is raised
through a posterior midline incision or a lateral incision.
The lateral incision is placed 1–2 cm posterior to the fibula
bone and prolonged in the popliteal fossa by an angulated
design (Fig. 50.5). The incision is taken to and through the
crural fascia. The fascia and overlying skin are elevated from
lateral to medial until the midline raphe is reached. The
lesser saphenous vein and sural nerve are identified and
retracted posteriorly and medially. The two muscle bellies
are separated, the lateral head is separated from the soleus
muscle, the tendon is divided from the Achilles tendon, and
the dissection of the muscle is completed from distal to
proximal, taking care not to injure the pedicle of the flap
at the proximal part of the calf. The reach of the flap can
be extended by transecting the origin of the muscle.
The arc of rotation is less than that of the medial head
due to the more limited size of the muscle body and the
obstacle of the fibula. The area of coverage involves the
lateral aspect of the knee and the lateral aspect of the upper
third of the tibia. The anterior aspect of the knee cannot
be entirely covered by the muscle. The arc of rotation
can be increased by all the procedures already mentioned
for the medial head and by passing the muscle beneath
the common peroneal nerve. However, this “trick” remains
of such tendons to create a large tunnel and allow free
passage of the flap. Care should be taken that the proxi­
mal part of the muscle and the pedicle will not be too
much tightened by the tendons, chiefly in full extension
of the knee. Another solution is to sever both tendons
since the functional prejudice will be negligible. This
procedure of decrossing is useful to gain arc of rotation
for covering the upper anterior aspect of the knee.
• The origin of the medial head of the gastrocnemius
muscle can be transected in order to advance the flap
distally. The maneuver is effective in providing coverage
to the junction between the proximal and medial thirds
of the leg. Care is taken to visualize the pedicle and avoid
placing it on stretch.
• The neurovascular pedicle of the medial gastrocnemius
muscle should be identified at the level of the popliteal
fossa, on the lateral side of the muscle. The nerve is then
separated from the artery and vein and transected.
PROXIMALLY BASED PEDICLED LATERAL
GASTROCNEMIUS MUSCLE FLAP (Fig. 50.5)
The principles of elevation of the lateral head are similar to
those of the medial head. The knee is flexed, and the hip
Figure 50.3  Flap harvest of the medial gastrocnemius muscle: 1.
Medial head of
gastrocnemius
Semitendinosus
Sural nerve
Perforator of the
sural artery and vein
Gracilis
Saphenous vein
Sartorius
Soleus

Figure 50.4  Flap harvest of the medial gastrocnemius muscle: 2.
Vascular pedicle to the medial
head of gastrocnemius
Tibial nerve
Popliteal artery
Plantaris

CHAPTER 50 — Gastrocnemius Flap
575
Figure 50.5  Flap harvest of lateral gastrocnemius muscle.
Tibial nerve
Popliteal artery
Neurovascular pedicle
to the medial head
Common peroneal nerve
(retracted)
Sural nerve
(retracted)
controversial because of the risk of stretching the nerve and
exposing it by a more superficial location.
Both heads can be simultaneously harvested to cover a
defect involving the medial anterior and lateral aspect of
the knee or the upper leg.
PROXIMALLY BASED PEDICLED MEDIAL OR LATERAL
GASTROCNEMIUS MUSCULOCUTANEOUS FLAP
The skin island is incised down to and through the crural
fascia and elevated with the muscle in the same way as
described earlier. Care is taken not to shear the skin off the
muscle and injure the blood supply. If the skin island is
small, using a Doppler to map the location of the skin vessels
may aid in ensuring adequate vascularity to the skin. Most
of the musculocutaneous perforators in the medial gastroc­
nemius musculocutaneous flap are located 7–18 cm from
the popliteal crease, and at or within 1 cm from a midline
traced on the medial gastrocnemius muscle. The lesser
saphenous vein can be included with the flap to augment
venous drainage or it can be used as the sole outflow for the
flap.
FLAP MODIFICATION/FLAP HANDLING
MEDIAL SURAL ARTERY PERFORATOR FLAP
(Video 50.1)
An imaginary line is marked from the mid-point of the
popliteal crease to the central point of the medial malleolus.
A Doppler is used to find the perforators, which are located
mostly over this line, the first being usually at 8 cm from the
popliteal crease. The skin island can be as large as that of
the musculocutaneous version of the flap. The lateral inci­
sion is performed to the subfascial plane and the dissection
continues medially until the perforator is located. The
design of the flap is adjusted based on the exact location
of the perforator and the rest of the skin incisions are
performed. Intramuscular dissection is performed until the
perforator length and diameter are adequate to suit the
defect. For a pedicled flap, the dissection of the perforator
continues until the flap can reach the defect. During the
dissection, as in other perforator flap dissection, it is useful
to inflate the tourniquet without full exsanguination of the
leg. The pedicle length can reach 15 cm and the flap can
achieve an extended length by placing the perforator in an
eccentric position. The flap can be converted to a musculo­
cutaneous flap if the perforator cannot be found. Other­
wise, the dissection can continue past the midline and, if a
perforator is found from the lateral sural artery, the flap can
be performed as such.
LATERAL SURAL ARTERY PERFORATOR FLAP
When a perforator is found by Doppler, the flap can be
harvested using the technique described for the medial
sural artery perforator flap. Perforators of the lateral sural
artery are often not present and therefore this flap is not
commonly performed.
DISTALLY BASED FLAP
The origin of the flap is transected proximally and the flap
is elevated from proximal to distal and rotated into the
defect. The vascular supply to the flap is based on either/
or communications between the lateral and medial head
and on the branch to the muscle from the tibialis posterior
artery at the midleg.
In an anatomic study performed on 30 fresh legs by the
first author (A-CM), a nutrient artery from the posterior
tibialis artery to the medial gastrocnemius muscle was always
found but its diameter had great variability, being >1 mm
in 9 legs, <1 mm in 14 legs, and a microscopic artery in the
remaining 7 legs. Therefore, basing a pedicled flap on this
artery can be helpful in several situations, but its consistency
must be carefully assessed.

576
PART 4 — CONVENTIONAL WORKHORSE FLAPS
fusiform course and despite the strong power they can gen­
erate, the muscle has a rather short excursion capability,
which limits its use. The gastrocnemius has been used as a
pedicled functional muscle flap for correction of foot drop.
As a free functional muscle transfer it has been used
especially for restoration of finger flexion after Volkmann’s
contracture, but it is not usually a first choice since the
gracilis offers a much greater excursion. Furthermore the
first requires some planning for the position of the patient
whether the latter is easily harvested in a supine position.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• The flap should be firmly fixed on the recipient site by
small resorbable inverted stitches. The short distal apo­
neurotic portion should be buried into the edge of the
recipient site by a U-shaped stitch, which provides a solid
attachment for the flap.
• Particularly when a skin island is used or when the flap is
harvested as a perforator flap, inclusion of superficial
veins, particularly the lesser saphenous vein, can improve
the venous drainage of the flap and can often be used as
the primary source of drainage.
EXTENSION OF THE EFFECTIVE FLAP LENGTH
Transverse linear incisions in the thick deep aponeurosis of
the muscle increase the length of the flap by stretching the
muscle fibers. On the other hand, longitudinal linear inci­
sions allow expansion of muscle width. Care must be taken
not to injure the main vascular supply that enters the muscle
in its deep anterior surface.
Reconstruction of the middle and distal thirds of the leg
can be achieved by lengthening the vascular pedicle by
interpositional vein grafts. After a longitudinal midline skin
incision in the posterior calf, the gastrocnemius muscle is
elevated in a standard fashion and its proximal insertion is
detached from the femoral condyle. The sural artery and
vein are identified and transected at about 2 cm from their
origin. The lesser saphenous vein is isolated along its course
in the posterior leg and the distal portion is harvested,
reversed, and anastomosed to the sural artery in order to
reach the required length. The proximal portion of the lesser
saphenous vein, still in continuity, is anastomosed to the sural
vein so as to provide adequate venous outflow to the muscle.
For a gastrocnemius musculoadipofascial flap, a standard
cutaneous incision is made and prolonged distally for about
10 cm. The gastrocnemius muscle (either the lateral or
medial component) is identified and elevated proximally in
a standard fashion. Dissection of the distal musculotendi­
nous portion is carried out, including the deep fascia and
the subcutaneous fat layer, so as to increase the overall flap
length of about 10 cm, and its width of 7 cm. Vascular
supply to the distal adipofascial layer is provided by the
fascial plexus and musculocutaneous perforators arising
from the sural artery.
Presurgical tissue expansion is an option for either
increasing the flap’s skin dimensions or for better closure
of the donor site.
CHIMERIC FLAP
As mentioned above, the medial head of the gastrocnemius
is often used in knee reconstruction after exposure of previ­
ous knee arthroplasty or post-traumatic skin defects. When
the patellar bone is also exposed, a conventional pedicled
muscle flap might not be adequate for coverage. In such a
situation, a conventional myocutaneous flap is elevated and
rotated 90° to the recipient area. Then a propeller flap is
raised on a perforator of the medial sural artery previously
identified by Doppler investigation. The muscle component
is used to cover the tibial tuberosity and the skin paddle may
be rotated up to 180° to reach the patellar region (Fig.
50.6). This technique expands the potential territory of the
flap and provides a cutaneous coverage of the patella, thus
improving the functional outcome (see Cases 50.2, 50.4).
Another possibility is offered by harvesting a Y-shaped vas­
cular pedicle and two different components, muscle and
skin, that have enough freedom to cover different types of
defects (Fig. 50.7).
FREE OR PEDICLED FUNCTIONAL MUSCLE TRANSFER
The gastrocnemius is a type 1 muscle according to the
Mathes and Nahai classification, and its motor nerve runs
together with the sural artery.1 The muscular fibers have a
Figure 50.6  A propeller fasciocutaneous skin flap can be designed
based on a single perforator rising from the medial sural artery and
previously detected with a Doppler. The skin flap can be rotated in
any direction so as to extend its potential for skin reconstruction. It
is ideal in patellar bone coverage, but it can also reach the tibial
diaphysis if needed.

CHAPTER 50 — Gastrocnemius Flap
577
that the muscle should be moved aside to place the pros­
thesis, and all incisions through the muscle flap are com­
pletely avoided.
• Inclusion of the distal tendon for the gastrocnemius flap
allows, in the same operating time, the reconstruction of
the patellar ligament or the quadricipital tendon as well
as soft tissue coverage of the defect.
• A skin territory can be included in the flap since the
medial and lateral skin of the posterior calf receives mus­
culocutaneous perforators chiefly located at the proximal
part of both heads. But the technique is not advocated if
the skin width required is more than 5 or 6 cm because
it leads to a large defect at the donor site that can only
be covered by a split-thickness skin graft directly applied
on the soleus muscle.
• Another possibility is to raise a distal skin island to
increase the arc of rotation of the flap. At least half of
the skin island should be placed on the distal muscle to
be correctly supplied by some distal perforators; the
lower half of the skin island is firmly attached to the
aponeurosis.
• Elevation of both heads of the gastrocnemius is possible
by two separate incisions and a wide posterior subfascial
dissection without risk of skin necrosis.
ATYPICAL INDICATIONS
• Other uses include the distally based pedicled flap sup­
plied by a sufficient pedicle issued from the tibialis pos­
terior artery at the midleg, by a remaining attachment to
the lateral head or by an arterial anastomosis. All these
procedures are not very reliable, and other procedures to
cover the middle and distal thirds of the leg offer better
alternatives.
• Free microsurgical transfer of gastrocnemius flaps is used
for soft tissue coverage or as functional muscle transfers
to restore finger flexion of the forearm in Volkmann’s
contracture cases.
• Pedicled functional muscle transfer for reconstruction of
foot drop as described by Ninković.2
• It is advocated to sever the motor nerve, which provides
two benefits:
• it avoids contraction of the muscle when it is attached
on the recipient site
• it allows the flap to shrink over time, essentially serving
as a debulking procedure
• When elevating the lateral gastrocnemius flap, attention
should be paid to the common peroneal nerve at the
most proximal part of the muscle.
USE OF THE FLAP
MEDIAL HEAD
TYPICAL INDICATIONS
• The medial head is longer and thicker than the lateral
head. The area of coverage of the pedicled flap is the
medial and anterior aspect of the leg and knee for the
medial head and the lateral aspect for the lateral head.
The excursion of the lateral head is limited by the pres­
ence of the fibula.
• The proximally based pedicled flap is the most commonly
used. The arc of rotation is circular and the areas likely
to be covered are the proximal third of the tibia (medial
aspect and anterior crest), the anterior aspect of the knee
beyond the lateral border of the patella, the distal third
of the posterior aspect of the thigh, and the popliteal
fossa. One of the main applications of the medial head
gastrocnemius flap is its inclusion in the two-stage proce­
dure of prosthetic knee replacement. In case of skin
necrosis and infection, the prosthesis should be removed
and temporarily replaced by a spacer. Several weeks later,
after resolution of the infection and healing of the soft
tissues, another prosthesis is placed. The defect created
in these patients is always an anterior skin defect, and the
medial gastrocnemius flap can be used when the infected
prosthesis is removed or preferentially at the same time
as the definitive replacement. One should bear in mind
Figure 50.7  Chimeric flap based on a Y-shaped vascular pedicle which supplies two different components, muscular and cutaneous. As
described by Han, these have great freedom of movement depending on the recipient site.

578
PART 4 — CONVENTIONAL WORKHORSE FLAPS
UNTOWARD OUTCOMES
With a musculocutaneous flap that does not allow for
primary closure of the donor site, the cosmetic outcome is
unfavorable.
The most common early complication is a large hema­
toma in the posterior superficial compartment of the leg. It
should not be mistaken for a venous thrombosis. Delayed
treatment can lead to very severe anemia, skin necrosis,
compartment syndrome, and infection.
When the motor nerve is left intact, some patients will
experience persistence of a cumbersome contraction of the
flap at the recipient site, possibly for many years. This has
led us to resect the nerve in all patients.
LONG-TERM OUTCOMES
After follow-up of many years, we have not noted growth
disturbances of the proximal extremity of the tibia (or distal
extremity of the femur) in children.
CONCLUSION
The gastrocnemius flap is reliable, easy to raise, and
very useful in repairing defects around the knee and the
upper leg.
The gastrocnemius is a versatile flap that adapts well in
reconstructing different types of soft tissue defects most
often in the knee area. It can be used as a free flap (Case
50.1) in repairing a soft tissue defect of a widely open frac­
ture of the leg; as a myocutaneous propeller flap (Cases
50.2, 50.4), extending so its ability to cover a wider anatomic
area; and as a pedicled flap to fill a defect and improve the
vascularization in a scarred region (Cases 50.3, 50.5).
LATERAL HEAD
TYPICAL INDICATIONS
• Indications are similar to those of the medial head, but
the smaller dimensions of this portion of the muscle
make the medial head the first choice as a pedicled
muscle transfer.
• Reconstruction of soft tissue defects of the distal third
of the thigh or proximal third of either the tibia or fibula
when the location and dimensions of the defect are better
fitted by the lateral head than the medial head of the
gastrocnemius.
ATYPICAL INDICATIONS
These are the same as for the medial head.
POSTOPERATIVE CARE
A suction drain is placed at the donor site; this is mandatory
in order to obliterate the dead space created by the eleva­
tion of the flap. The drain must be left in place for at least
1 week. Early mobilization of the ankle is encouraged to
avoid adhesions and stiffness. Gentle mobilization of the
knee joint in pedicled muscle transfer can be started a week
after surgery, avoiding excessive tension on the suture site,
and progressed according to wound healing in order to
achieve full range of motion within 4–6 weeks.
OUTCOMES
EXPECTED OUTCOMES
The proximally based pedicled muscle flap is a very reliable
procedure. Complications are very rare and the functional
and aesthetic prejudices are not significant.
CASE 50.1  Gastrocnemius Muscle Free Flap for Covering a Lower Extremity Defect
(Fig. 50.8)
Figure 50.8  (A) Large lateral defect with stage 3C open tibia fracture. On presentation a few days before, the patient underwent recon­
struction of the tibialis posterior artery and coverage with a soleus muscle pedicle flap. (B) The homolateral medial head of the gastroc­
nemius was harvested as a free flap (C) the flap was revascularized on the recipient site by a short vein graft anastomosed to the stump
of the tibialis anterior artery followed by skin grafting.
A
B
C

CHAPTER 50 — Gastrocnemius Flap
579
CASE 50.2  Wide Knee Defect Reconstructed By a Gastrocnemius Propeller Myocutaneous
Flap, Used as a Chimeric Flap (Fig. 50.9)
Figure 50.9  The patient underwent wide knee resection and replacement following sarcoma excision. Postsurgical radiotherapy resulted
in severe infection that required removal of the prosthesis and replacement with a silver-coated nail. (A) A wide portion of the overlying
skin became necrotic and needed reconstruction. The thigh and the detached patellar tendon are seen on the right side of the picture.
(B) The design of the skin paddle based on two possible perforator arteries previously detected by color Doppler. (C) Rotation of the
myocutaneous flap in a conventional way was performed. (D) It was noted that the coverage was inadequate, so the skin island was raised
off the muscles as a perforator flap, rotated 90°, and used to reconstruct the remaining defect. (E) Immediate postoperative result with
good vascularization of the skin component. (F,G) Recipient and donor site, respectively, at 4 months.
A
D
E
F
G
B
C

580
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Access Figures 50.10, 50.11, and 50.12, as well
as case examples 3, 4, and 5 and further
reading and video online at http://
expertconsult.inkling.com
REFERENCES
1. Mathes S, Nahai F. Clinical atlas of muscle and musculocutaneous
flaps. St Louis: Mosby; 1979.
2. 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–45e.
Expert Commentary 
Geoffrey G. Hallock, MD
The heads of the gastrocnemius muscle truly are “work-
horse” flaps traditionally used as pedicled flaps for coverage
of the region of the knee and proximal third of the leg. The
anatomy is consistent, execution of flap harvest straightfor-
ward, and reliability predictable making this indeed a funda-
mental flap not just for the beginner, but also the expert
reconstructive surgeon.
Nevertheless, here it should be emphasized more that the
medial head is not only wider than the lateral head but also
longer by a few centimeters, which allows greater reach and
more versatility. The distal decussation of the two heads
requires a sharp dissection for their separation, while being
careful to protect the medial sural cutaneous nerve that runs
between them and serves as a good reference point for
delineating the extent of each.
Raising both heads simultaneously does lead to some
function loss not sufficiently replaced by the soleus muscle
itself. Other flap options would therefore usually be prefer-
able. Similarly, a distal-based version relying on branches of
the posterior tibial artery, since so anatomically variable as
the authors have discussed, should have limited consider-
ation as again other flap options will be superior.
During inset of the flap, tunneling of either head through a
subcutaneous or subfasical pathway in order to reach a
defect could result in its compression, leading to ischemia
and ultimately necrosis. Although cosmetically inferior, it is
always better to bring the muscle over the skin surface with
de-epithelialization as required. If additional reach is needed,
the intervening skin, fat, and/or fascia can be more safely
divided.
The use of the gastrocnemius muscle as a microsurgical
tissue transfer, although technically possible, is rarely
selected as better options exist. The exception may be the
paraplegic patient where recidivism is common and local flap
options often exhausted. Although a leg fillet is always an
alternative, patient resistance is typically highly against such
a seemingly drastic idea. Yet the paralyzed limb still is a
warehouse of potential flaps, with the gastrocnemius mus-
culocutaneous flap a safe version that can provide coverage
of a large surface area. Since the muscle itself is invariably
atrophic, its value is as a carrier of the integument, which
avoids the need to tediously dissect musculocutaneous per-
forators as strictly necessary for a perforator flap.
Although stated but not emphasized in this chapter, if skin
restoration only is required in the knee region, a sural artery
perforator flap could instead suffice with essentially total
function preservation, which may be important as for an
athlete. Almost always a dominant medial head musculocu-
taneous perforator exists to permit a medial sural artery per-
forator flap as an advancement or island flap, whereas often
an adequate perforator is absent emanating through the
lateral head. Another advantage of selecting a perforator flap
is that if it proves to be insufficient for any reason, conversion
to using its underlying muscle flap as a back-up maneuver
either synchronously or metachronously is usually still pos-
sible. Of course, the reality is that muscle flaps are more
malleable, so a 3-dimensional or irregularly surfaced wound
will be better and more intimately covered by a gastrocne-
mius muscle flap from the outset.

CHAPTER 50 — Gastrocnemius Flap 580.e1
Figure 50.10  (A) Post-radiotherapy fibrous constriction of the sciatic nerve at the lower third of the thigh. (B) Neurolysis of the sciatic
nerve by incising the skin and fibrous tissue en bloc, resulting in a long defect. (C) The defect was filled with the medial head of the
gastrocnemius turned 180°.
A
B
C
CASE 50.3  Pedicled Gastrocnemius Myocutaneous Flap for Covering a Posterior Thigh and
Popliteal Defect (Fig. 50.10)
CASE 50.4  Soft Tissue Defect After Radiotherapy in the Knee Treated By Gastrocnemius
Propeller Myocutaneous Flap (Fig. 50.11)
Figure 50.11  (A) Extra-articular resection of the knee for pleomorphic sarcoma and subsequent total knee replacement. AP view, the
thigh is on the right side of the picture. (B) Design of the flap based on a distal perforator. Medial view (C) A myocutaneous flap rotated
90° anteriorly AP view. (D) The perforator supplying the propeller flap dissected after the rotation of the muscle. (E) The skin paddle, now
free of movement, can be placed as needed over the prosthesis. (F) Result at 2 months.
A
B
C
D
E
F

580.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
CASE 50.5  Large Leg Defect Reconstructed with a Pedicled Medial and Lateral
Gastrocnemius Muscle Flaps (Fig. 50.12)
Figure 50.12  (A) Tissue necrosis due to infection following a lateral tibial osteotomy. The knee joint was intact but the medial anterior
and lateral aspects of the upper tibia were largely exposed. (B) The plate was removed and the site of osteotomy was curetted. The deci­
sion was to place a similar plate and to cover with both heads of gastrocnemius. (C) Exposed area covered with a medial and lateral
gastrocnemius flap. (D) Final result following muscle coverage and skin grafting.
A
B
C
D

CHAPTER 50 — Gastrocnemius Flap 580.e3
Video 50.1 Medial sural artery perforator flap
FURTHER READING
Atchabahian A, Masquelet AC. The distally based medial gastrocnemius
flap: a case report and anatomic study. Plast Reconstr Surg 1996;98:
1253.
Chen HC, Tang Y, Noordhoff MS. Distally based gastrocnemius myocu­
taneous flap augmented with an arterial anastomosis. A combination
of myocutaneous flap and microsurgery. J Trauma 1988;28:110.
Cheng H, Rong G, Yin T, et al. Coverage of wounds in the distal lower
leg by advancement of an enlarged medial gastrocnemius skin flap.
Plast Reconstr Surg 1984;73:671.
Dibbel D, Edstrom LE. The gastrocnemius myocutaneous flap. Clin
Plast Surg 1980;7:45.
Elghamry AH. The medial gastrocnemius muscle with an Achilles
tendon sheath extension flap as a versatile myo-tendon sheath flap
for coverage of the upper two-thirds of the tibia and pre-tibial area:
a preliminary report. J Plast Reconstr Aesthet Surg 2014;67(2):
252–6.
Feldman J, Cohen B, May JW. The medial gastrocnemius myocutaneous
flap. Plast Reconstr Surg 1978;61:531.
Hallock GG. Anatomic basis of the gastrocnemius perforator-based
flap. Ann Plast Surg 2001;47(5):517–22.
Han SE, Lee KT, Mun GH. Muscle-chimeric medial sural artery perfora­
tor flap: a new design for complex three-dimensional knee defect.
J Plast Reconstr Aesthet Surg 2014;67(4):571–4.
Keller A, Allen R, Shaw W. The medial gastrocnemius flap: a local free
flap. Plast Reconstr Surg 1984;73:974.
Kroll J, Marcadis A. Esthetic considerations on the medial gastrocne­
mius myocutaneous flap. Plast Reconstr Surg 1987;79:67.
Innocenti M, Cardin-Langlois E, Menichini G, et al. Gastrocnaemius-
propeller extended miocutanous flap: a new chimaeric flap for soft
tissue reconstruction of the knee. J Plast Reconstr Aesthet Surg
2014;67(2):244–51.
Jepegnanam TS, Boopalan PR, Nithyananth M, et al. Reconstruction
of complete knee extensor mechanism loss with gastrocnemius flaps.
Clin Orthop Relat Res 2009;467(10):2662–7.
Liu XY, Ge BF, Win YM, et al. Free medial gastrocnemius myocutaneous
flap transfer with neurovascular anastomosis to treat Volkmann’s
contracture of the forearm. Br J Plast Surg 1992;45:6.
McCraw JB, Fishman JH, Sharzer LA. The versatile gastrocnemius myo­
cutaneous flap. Plast Reconstr Surg 1978;62:15.
Masquelet AC, Beveridge J, Romana MC, et al. The lateral supramalleo­
lar flap. Plast Reconstr Surg 1988;81:74.
Masquelet AC, Romana MC, Wolf G. Skin island flap supplied by the
vascular axis of the sensitive superficial nerves: anatomic study and
clinical experience in the leg. Plast Reconstr Surg 1992;89:1115.
Robbins TH. Use of fascio-muscle flaps to repair defects in the leg. Plast
Reconstr Surg 1976;57:460.
Rhomberg M, Schwabegger AH, Ninkovic M, et al. Gastrocnemius myo­
tendinous flap for patellar or quadriceps tendon repair, or both. Clin
Orthop Relat Res 2000;377:152–60.
Salibian AH, Meniak FJ. Bipedicle gastrocnemius myocutaneous flap
for defects of the distal one third of the leg. Plast Reconstr Surg
1982;70:17.
Salibian AH, Rogers FR, Lamb RC. Microvascular gastrocnemius
muscle transfer to the distal leg using saphenous vein grafts. Plast
Reconstr Surg 1984;73:302.
Withney T, Heckler F, White M. Gastrocnemius muscle transposition to
the femur: how high can you go? Ann Plast Surg 1995;34:415.

581
INTRODUCTION
The soleus muscle, one of the components of the superficial
posterior compartment of the leg, was used initially as a
local flap, as described by Ger and later, by Mathes and
Nahai.1,2 Since then, multiple surgical modalities have been
described that have approached this flap in different ways
and used it for different purposes, as both a local and a free
flap. Its use requires precise anatomic knowledge to gain
the utmost benefit from its versatility. It deserves to be more
extensively used due to its wide coverage potential and
minimal negative effects at the donor site. The soleus muscle
is often harvested as part of the fibula flap (see Ch. 52).
FLAP ANATOMY (see Figs 50.1, 2, 4 and
Figs 13.3, 13.6, 13.9, 13.10, 13.11, 13.19)
The soleus muscle is a large, broad, and rather long muscle
located at the posterior aspect of the leg. It is a bipenniform
muscle consisting of a lateral and a medial head. The lateral
head originates from the fibula head and body and the
medial head originates from the medial side of the middle
third of the tibia. The lateral and medial soleus muscles are
separated in the midline by a septum, which is present in
the distal part of the muscle. The two muscle heads join
together to form the dorsolateral and dorsomedial compo­
nent of the Achilles tendon. This tendon, which is formed
by the soleus and gastrocnemius muscles, inserts on the
calcaneum tuberosity (Fig. 51.5).
The anatomic findings presented in this chapter are
based on a study by Caix, in an article by Baudet and col­
leagues published in 1982.3 This study was performed on 22
fresh cadavers.
We will use the following terms to describe the soleus
muscle in this chapter:
• Soleus muscle (implying the entire muscle)
• Medial head of the soleus muscle
• Lateral head of the soleus muscle.
ARTERIAL SUPPLY OF THE FLAP (Figs 51.2–51.4
and Figs 13.3, 13.6, 13.9)
THE LATERAL SOLEUS
The vasculo-nervous (neurovascular) pedicles to the lateral
soleus muscle are usually found at three levels, providing
Soleus Flap
Jacques Baudet  |  Philippe Pelissier  |  Vincent Casoli  | 
Philippe Caix  |  Félix J. Farías  |  Wieslawa De Pawlikowski 51 
Figure 51.1  Soleus flap.
Tibial nerve
Posterior
tibial artery
Peroneal artery
Medial head
of soleus
Lateral head
of soleus
Gastrocnemius
Tibial nerve
Popliteal artery
Plantaris
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

582
PART 4 — CONVENTIONAL WORKHORSE FLAPS
what we term the “upper, middle, and inferior pedicles” of
the lateral soleus muscle. These three pedicles are mainly
derived from collateral branches of the peroneal vessels
and, in some cases, the inferior pedicle is derived from the
posterior tibial artery. The middle pedicle provides the main
blood supply to the muscle and is made up of two (76%);
or three (24%) branches.
Dominant:  branch from the popliteal artery (“upper
pedicle”)
Length: 2.3 cm (range 1.2–5 cm)
Diameter: 1.3 mm (range 0.5–2 mm)
This branch is part of what is considered the “upper
pedicle”; it is constant and is accompanied by venae comi­
tantes. It penetrates the muscle 2.2 cm below the fibula
head. One nerve branch emerging from the medial popli­
teal nerve joins this arterial branch.
Dominant:  branch from the tibioperoneal artery or pero­
neal artery (upper branch of the “middle pedicle”)
Length: 1.4 cm (range 0.5–3.5 cm)
Diameter: 1.9 mm (range 1–3 mm)
This branch is part of what is considered the “upper
branch” of the “middle pedicle.” In 45% of cases, this
branch comes from the peroneotibial artery and in 55% of
cases, from the peroneal artery. The distance of origin of
Figure 51.2  (A) Cadaver dissection showing the soleus elevated proximally-based. (B) The gastrocnemius muscle is pedicled to cover the
proximal leg and the soleus muscle is pedicled to cover the middle third of the leg. Labels: A. Flexor digitorum longus muscle; B. posterior
tibial artery and vein; C. tibial nerve; D. tibialis posterior muscle; E. flexor hallucis longus muscle.
A
B
Figure 51.3  Schematic cross-section relative to soleus–fibula transfer. (After Pelissier.)
Peroneal artery and veins
Medial soleus muscle
Lateral soleus muscle
Medial gastrocnemius muscle
Lateral gastrocnemius muscle
this branch from the anterior tibial artery is 3.3 cm. The
point of penetration into the muscle is 7.5 cm from the
head of the fibula.
Dominant:  branch from the peroneal artery (lower branch
of the “middle pedicle”)
Length: 1.6 cm (range 0.3–4.0 cm)
Diameter: 1.73 mm (range 0.5–3.5 cm)
This is termed the “lower branch” of the “middle pedi­
cle.” It is always derived from the peroneal artery. The dis­
tance of origin of this branch from the anterior tibial artery
is 5.68 cm and the point of penetration into the muscle is
9.9 cm from the head of the fibula. This lower branch is
absent in 9% of the population (two out of 22 in our study).
In 13.6% of cases (three out of 22 in our study) a third
branch of the middle pedicle was present.
Minor:  branch from the peroneal artery (50%) or from
the posterior tibial artery (50%) (“inferior pedicle”)
Length: 2.4 cm (range 1.2–3.5 cm)
Diameter: 1.1 mm (range 0.5–2 mm)
This branch is considered part of the “inferior pedicle”
of the flap and is an accessory pedicle. In half of the cases
it originates from the peroneal artery and in the other half
from the posterior tibial artery. The distance of origin from
the anterior tibial artery is 11.5 cm and the point of

CHAPTER 51 — Soleus Flap
583
transfer. Two clinical cases will be presented in further
detail, below.
VENOUS DRAINAGE OF THE FLAP
Primary:  venae comitantes running along the arterial
branches
The venae comitantes all drain into the peroneal, postero-
tibial and finally, the popliteal veins. There are some cross-
anastomoses with the superficial subcutaneous vein. Each
main pedicle and collateral branches have two venae comi­
tantes, their diameter being larger than that of the adjacent
artery. They drain finally into the popliteal vein but there
are some cross-anastomoses with the superficial subcutane­
ous vein. Including a skin paddle with the muscle flap can
help to solve the venous drainage by anastomosing one or
several veins (main trunk or collateral branches from the
long saphenous vein or short saphenous vein).
FLAP INNERVATION (Figs 51.1, 51.5 and 51.6
and see Figs 13.9, 13.10, 13.11, 13.19)
According to Taylor’s classification, the soleus should be
classified as a type 3 muscle in terms of nerve supply: mul­
tiple motor nerve branches derived from the same nerve
trunk.4
Lateral Soleus Muscle
Motor:  branches from the medial popliteal and tibial
nerves:
• An upper branch which originates from the medial pop­
liteal nerve, ranging from 0.5 mm to 2 mm
• Two middle branches emerging from the tibial nerve
• An inferior branch which is not constant.
Medial Soleus Muscle
Motor:  Three branches from the posterior tibial nerve;
usually there are three nerve branches.
Sensory:  If a skin paddle is included in the flap and a
sensory branch supplying the skin (e.g., branches of the
sural nerve) can be included and anastomosed with the
recipient site (Figure 13.19).
FLAP COMPONENTS
The soleus flap is harvested as a muscle flap. It can include
fascia overlying the muscle, tendons such as part of the
Achilles tendon, bone by including the fibula based on
branches from the peroneal artery which supply the fibula
and lateral soleus muscle, and skin by including the lateral
skin overlying the fibula.
If necessary, a skin paddle can be harvested with the
medial head of soleus. It is supplied by musculocutaneous
perforators.
Advantages
• Bipenniform morphology with independent neurovascu­
lar pedicles supplying the medial and lateral soleus, allow­
ing for separate transfer of each muscle.
• Constant blood supply.
penetration into the muscle is 10.7 cm. The inferior pedicle
is absent in 18% of cases.
THE MEDIAL SOLEUS
The medial soleus is supplied by several pedicles emerg­
ing from the peroneotibial and posterior tibial vessels
(Fig. 51.6C).
Dominant:  upper pedicle, division of the upper branch
supplying the lateral soleus
Dominant:  middle pedicle, most often three branches
emerging from the posterior tibial artery
Dominant:  inferior pedicle common with the lateral
soleus supply
Minor:  perforating vessels from both gastrocnemius
muscles emerging from the perifibular peroneal artery
arcade
Minor:  intramuscular cross-anastomoses between the
lateral and medial soleus
These branches were elucidated from our anatomic study
and they are very important in clinical application since the
whole soleus can be harvested on a single branch from the
peroneal pedicle and used as a regional or even free flap
Figure 51.4  Arterial anatomy of the region. (From Standring et al.,
eds. Gray’s anatomy. 39th edn. Elsevier, Churchill Livingstone, 2005.)
Lateral superior
genicular artery
Sural artery
Gastrocnemius
Lateral inferior
genicular artery
Soleus
Anterior
tibial artery
Fibula
Peroneal
artery
Nutrient
artery to
fibula
Flexor
hallucis
longus
Flexor
digitorum
longus
Flexor hallucis
longus
Communicating
branch
Calcanean
branch
Posterior
tibial nerve (cut)
Posterior
tibial artery
Peroneal artery
Posterior
tibial artery
Nutrient artery
to tibia
Popliteus
Medial inferior
genicular artery
Gastrocnemius
Sural artery
Medial superior
genicular artery
Popliteal
artery

584
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 51.7)
• Lateral approach (Fig. 51.10A): the posterolateral edge
of the fibula.
• Medial approach (Fig. 51.8A): the posteromedial aspect
of the tibia.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The design depends upon whether the whole soleus, the
lateral, or the medial soleus is to be harvested, and on the
need for inclusion of adjacent components (i.e., fibula bone
and/or a skin paddle).
A skin paddle can be included with the soleus or lateral
soleus muscle. Musculocutaneous perforators supply the
skin in the upper third of the lateral aspect of the leg
while a larger skin island can be harvested based on both
musculocutaneous perforating vessels and septocutaneous
branches from the peroneal artery.
The distal extent and size of the soleus muscle are vari­
able. Occasionally, if the muscle reaches the malleoli and its
size is large enough at that position, the muscle can be
transposed, based proximally, to cover distal third leg
defects. This decision can be made preoperatively using
magnetic resonance imaging (MRI) or clinical examination,
or during intraoperative exploration. The size and location
of the defect are major factors in the success of this type of
transposition.
In cases where a distally-based hemi-soleus is planned for
coverage of a distal leg defect, the exposure is the same as
that for dissection of the posterior tibial vessels as recipient
vessels for a free flap; therefore, if it is felt that the distally-
based flap is not reliable, the same exposure is used to dissect
the posterior tibial vessels and a free flap is performed.
• Minimal functional and cosmetic donor site morbidity
since the soleus muscle contributes to a minor degree to
the motion of the ankle in conjunction with the lateral
and medial gastrocnemius. The gastrocnemius muscles,
flexor hallucis longus, flexor digitorum longus, and tibi­
alis posterior compensate for the loss of the soleus muscle.
• The muscle can reach the distal third of the leg when
transposed based on the distal blood supply.
• It can be used as a functional muscle.
Disadvantages
• The complexity of vascular and nervous supply requires
a thorough anatomic knowledge in order to achieve
muscle dissection and inclusion of as many vessels as pos­
sible during the transfer.
• The distally-based medial soleus muscle flap, which is
useful for coverage of distal third defects of the leg, may
not have a reliable inferior pedicle to support the flap
and, also, may not be reliable in smokers.
PREOPERATIVE PREPARATION
A routine preoperative work-up is performed for all patients
undergoing general anesthesia (the most comfortable for
the patient). A preoperative consultation by the anesthesi­
ologist is mandatory. According to the past medical history
of the patient, further studies are performed if necessary.
In elderly patients, who may present with vascular risks or
post-traumatic injury, an echo Doppler of the lower limb
vessels and, if needed, an angiogram are recommended at
the donor and recipient sites. Preoperative examination
depends upon age of the patient, cardiovascular back­
ground, and vascular damage of the recipient site vessels by
a previous injury. Doppler and an angiogram are recom­
mended in a large percentage of patients.
Figure 51.5  Dissection of the calf through a vertical incision with individualization of vessels and nerve supply to the lateral and medial soleus.
(A) Left leg. (B) Right leg.
Lateral soleus
Medial soleus
Peroneal artery
Nerve pedicles
from the
popliteal
and posterior
tibial nerves
Division of the
superior branch
supplying the
lateral soleus
Arterial pedicle
from the
posterior
tibial artery
Arterial pedicle
from posterior
tibial artery
Arterial pedicles
from the
peroneal
artery
Nerve pedicles
from the
popliteal
and posterior
tibial nerves
A
Lateral soleus
Medial soleus
Nerve pedicles
from popliteal
and posterior
tibial nerves
Superior pedicle
from popliteal
artery
Peroneal artery
Middle arterial
pedicle from
peroneal artery
Superior nerve
pedicle from
posterior tibial
nerve
Arterial pedicles
from posterior
tibial artery
B

CHAPTER 51 — Soleus Flap
585
PTA
PTT
Popl A
Med Popl N
SP 1 mm
LS
MP 1.2 mm
IP 1–1.5 mm
OPA
Lateral soleus
Per A
A
PTA
PTT
Popl A
Med Popl N
SP 1 mm
LS
MP 0.5–0.7 mm
IP 1 mm
Per A
OPA
MP
SP
MS
Popl A
PTN
Per A
ATA
IP
PTA
Medial soleus
C
Lateral soleus
B
Figure 51.6  (A) The lateral soleus. A less
common vasculo-nervous pattern. The
superior pedicle (SP) comes from the pop­
liteal artery and the middle pedicle (MP)
from the peroneotibial trunk (PTT). The
peroneal artery (Per A) gives rise to the
inferior pedicle (IP) and finally the osteo­
periosteal artery (OPA). The posterior tibial
artery (PTA) does not supply the lateral
soleus (LS). In black, are seen the nerve
pedicles to the LS. (B) The most common
vascular and nerve supply to the lateral
soleus. SP, superior pedicle comes from
the popliteal artery (Popl A). The middle
pedicle (MP) is double and comes from
the Per A. The inferior pedicle (IP) origi­
nates from the Per A. The OPA emerges
from the Per A a few millimeters from its
origin from the PTT. In this case, the PTA
does not supply the lateral soleus. In
black, are seen the nerve pedicles to the
LS. Med Popl N, medial popliteal nerve.
(C) Medial head of the soleus (MS). ATA,
anterior tibial artery; PTN, posterior tibial
nerve. (After Caix.)

586
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The muscle has significant variations in dimensions,
which should be taken into account when reconstructing a
defect. Because a flap used with a rotational arc loses some
length, these variations have to be well known. The width
can be increased by longitudinal parallel incisions along the
superficial aponeurosis of the muscle.
SKIN ISLAND DIMENSIONS
Length: 7.5 cm (range 5–11 cm). Maximum to close primar­
ily: depends on the width
Width: 6 cm (range 4–8 cm). Maximum to close primarily:
7 cm
Thickness: 1.5 mm (range 0.5–3 mm)
FLAP MARKINGS (Figs 51.8A, 51.10A)
The soleus muscle is harvested through a medial, lateral or
posterolateral approach:
• Medial approach: the incision is drawn from the medial
malleolus up to the proximal part of the leg located about
1.5 cm posterior to the medial aspect of the tibia. If the
defect is in the leg, this line is usually continuous with
SPECIAL CONSIDERATIONS
If fibula bone is included in a composite flap, it is important
to preserve the head of the fibula with the adjacent superior
peroneotibial joint, as well as the common peroneal nerve
and to stay away from the inferior peroneotibial joint, in
order to avoid ankle instability.
The most common location for defects is proximally in
the upper two-thirds of the leg. In this case, a proximally-
based medial soleus flap is indicated or even the whole
soleus if the defect is wider (up to 13 cm).
If the defect is in the lower third of the leg, a distally-based
soleus can be harvested, provided that the medial soleus is
supplied by an inferior pedicle. This point will be discussed
later in the chapter.
FLAP DIMENSIONS
SOLEUS MUSCLE
Length: 22.3 cm (range 20–25 cm)
Width total soleus muscle: 13 cm (range 11–17 cm)
Width lateral soleus muscle: average 7–8 cm
Thickness: 2.7 cm (range 2.0–3.6 cm)
Figure 51.7  Anatomic landmarks. (A) 1. Biceps femoris. 2. Semimembranosus. 3. Semitendinosus. 4. Gracilis. 5. Sartorius. 6. Gastrocnemius,
medial head. 7. Gastrocnemius, lateral head. 8. Adductor hiatus. 9. Popliteal artery. 10. Anterior tibial artery. 11. Peroneal artery. 12. Posterior
tibial artery. 13. Tibial nerve. 14. Common peroneal nerve. (B) 1. Gastrocnemius medial head. 2. Soleus. 3. Distal peroneal malleolus. 4. Distal
tibial malleolus. 5. Achilles tendon. 6. Calcaneum posterior tuberosity. (With permission from Lumley JSP. Surface anatomy. 3rd edn. Churchill
Livingstone, 2002.)
1
2
3
4
5
7
6
8
9
12
11
13
14
10
1
2
3
4
5
6
A
B

CHAPTER 51 — Soleus Flap
587
Figure 51.8  (A) Medial approach to the soleus. (B) Technique of dissection of a proximally based soleus flap. To mobilize the muscle, the
distal pedicles emerging from the peroneal artery have to be ligated. 1. Achilles tendon. 2. Gastrocnemius. 3. Soleus. (C) The mobilization of
the flap. (D) Coverage of the middle third of the leg. (After Masquelet and Gilbert.)
A
Distal minor pedicles from the
peroneal arteries which have been ligated
Gastrocnemius muscle
Soleus
muscle
B
1
2
3
C
D

588
PART 4 — CONVENTIONAL WORKHORSE FLAPS
aponeurosis of the gastrocnemius (separate the component
of each muscle within the Achilles tendon), and finally the
distal part of the soleus with its aponeurosis component is
cut (Fig. 51.8B).
The soleus muscle can be found as low as the malleoli.
The muscle is freed from distal to proximal by ligating
several pedicles supplying the muscle and by freeing the
lateral soleus muscle from its attachment to the fibula and
fascia (lateral aponeurosis of the leg). All vessels supplying
the lateral soleus from the peroneal artery are carefully
ligated (Fig. 51.8C) to the upper part of the muscle where
the main pedicles are, until the muscle is mobile enough to
reach the defect on the medial aspect of the leg. The whole
soleus is completely mobile in its distal part and its rotation
will be able to reach any defect on the anterior aspect of the
leg, mainly in its middle third (Fig. 51.8D).
PROXIMALLY-BASED MEDIAL SOLEUS MUSCLE
The soleus is identified and separated on both sides in the
same manner as for the standard flap. The median raphe
that separates the medial and lateral soleus is identified
distally. The medial soleus muscle is cut distally and dissected
away from the lateral soleus through the midline raphe.
DISTALLY-BASED MEDIAL SOLEUS MUSCLE FLAP
(Fig. 51.9)
This method is useful for coverage of small defects in the
lower third of the leg. The existence of lower pedicles from
the posterior tibial artery is confirmed preoperatively using
an arteriogram or magnetic resonance angiography (MRA)
and intraoperatively by identifying the perforators prior to
proceeding with the dissection. In the middle third of the
leg, the medial soleus muscle is separated from the gastroc­
nemius muscle posteriorly and the tibia and flexor digito­
rum anteriorly. After confirmation of the presence of distal
pedicles, the proximal part of the medial soleus is tran­
sected at the level of the proximal and middle thirds of the
muscle. The medial soleus is separated from the lateral
soleus by ligation of the upper and middle pedicles. The
distal dissection is stopped at the junction between the
middle and distal thirds of the muscle. It is critical during
this dissection to preserve the main pedicle supplying the
distal muscle. The arc of rotation is limited by this pedicle
and dissection should stop as soon as the defect could be
covered or when this vessel is reached.
LATERAL APPROACH
The lateral approach is the most suitable for harvesting a
composite transfer (fibula + lateral soleus + skin paddle).
The lateral incision is outlined on the donor leg along
the fibula for the lower part and reaching the popliteal area
by an oblique extension. After incising the skin, subcutane­
ous tissue, and fascia, in order to achieve better exposure
of the proximal part of the fibula, lateral soleus, and sur­
rounding vessels and nerves (Fig. 51.10A), the superior
attachment of the lateral gastrocnemius is severed from the
femur and the muscle belly is split longitudinally. The fascia
between the soleus and peroneal muscles is opened, allow­
ing exposure of the lateral aspect of the fibula.
Then, the underlying soleus muscle is split longitudinally
and the septum separating the peroneal muscles and the
the defect. A lazy S-shaped incision can be performed for
the harvest of this flap.
• Lateral approach: the incision is drawn longitudinally along
the fibula bone from the fibula neck down to the lateral
malleolus.
• Musculocutaneous flap: if the fibula is to be harvested with
this flap, a skin island is marked along the lateral aspect
of the leg, centered over the posterior border of the
fibula (the location of the septum, which contains the
skin vessels) (Fig. 51.6C).
• Posterolateral approach: a skin island at the upper two-thirds
of the leg is supplied by musculocutaneous perforators;
if harvested at the lower third, it is supplied by septocu­
taneous perforators, which can be identified by Doppler
examination.
PATIENT POSITIONING
For harvesting the soleus muscle (medial and lateral soleus)
or medial soleus only, the patient is placed in the supine
position with the hip in slight flexion and external rotation
and the knee in 30° of flexion. A roll can be placed under
the hip.
For harvesting the soleus muscle through the lateral
approach or a composite transfer of muscle, skin, and bone,
the patient is positioned supine with the hip in flexion and
internal rotation with the knee slightly flexed.
ANESTHETIC CONSIDERATIONS
In the event of contraindications to general anesthesia or
according to the wish of the patient, if the defect is in the
same extremity, the operation can be performed under an
epidural block with sedation.
TECHNIQUE OF FLAP HARVEST
The leg is exsanguinated and the tourniquet inflated.
MEDIAL APPROACH (Fig. 51.8)
PROXIMALLY-BASED SOLEUS MUSCLE FLAP (MEDIAL
AND LATERAL AS ONE UNIT)
The incision is taken down to the level of the crural fascia.
After identification of the saphenous nerve and great saphe­
nous vein, a longitudinal incision is performed posterior to
these structures. Dissection between the gastrocnemius and
soleus is easily performed by bluntly separating the two
muscles. By performing sharp dissection, the medial soleus
is separated from its tibial attachments. The muscle is then
separated anteriorly from the flexor digitorum longus, tibi­
alis posterior, and flexor hallucis longus muscles. The neu­
rovascular bundle is located between the soleus and flexor
digitorum. Care is taken not to damage the deep fascia
covering the posterior tibial neurovascular bundle. During
this dissection, the posterior tibial neurovascular pedicle
becomes visible and should be protected. For harvest of a
proximally-based soleus flap, the dissection should continue
by releasing the aponeurosis of the soleus muscle from the

CHAPTER 51 — Soleus Flap
589
FLAP MODIFICATIONS/FLAP HANDLING
EXPANSION OF THE WIDTH OF THE FLAP
The width can be increased by longitudinal parallel inci­
sions along the superficial aponeurosis of the muscle.
EXTENSION OF THE LENGTH OF THE FLAP
The length can be increased by multiple transverse incisions
through the epimysium of the muscle. Also, the deep surface
of the muscle can be scored to increase the effective length
of the muscle. This is performed very carefully as too much
dissection will compromise the blood supply to the flap.
FREE SOLEUS MUSCLE FLAP
Usually, when a free soleus flap is harvested, it is part of the
fibula flap based on the peroneal vessels. Several modifica­
tions of this flap can be performed, which include the soleus
muscle with or without a skin island or other tissue in the
region. We have no experience with free transfer of the
fibula and soleus without harvesting the peroneal vessels.
When soleus muscle is harvested as a free flap, it is usually
performed as part of the fibula flap harvest where a cuff of
soleus is included. The soleus muscle can be harvested as a
free flap by including the posterior tibial vessels as the
donor vessels of the flap; however, this is rarely indicated.
DONOR SITE CLOSURE
AND MANAGEMENT
We always close the recipient and/or donor site over suction
drains. If a wide skin paddle has been harvested and the
donor site was closed with excessive tension, a primary or
secondary skin graft has to be used. Careful hemostasis has
anterior compartment is incised. The peroneal artery and
its venae comitantes emerging from the peroneotibial arte­
riovenous trunk are identified and freed.
Retraction of the muscle of the anterior compartment
allows exposure of the anterior tibial vessels and retraction
of the soleus, the peroneal vessels (Fig. 51.10B).
The wide exposure makes it possible to harvest a compos­
ite fibula and lateral soleus muscle flap supplied by muscu­
lar branches emerging from the peroneal pedicle (the main
middle pedicle). A Gigli saw is used to cut the bone at its
upper and lower part at the selected point. Ligature of the
distal part of the peroneal vessels is then performed and the
whole composite transfer can be harvested after severing
the proximal peroneal pedicles (Fig. 51.10C–E).
If the lateral soleus muscle has to be reinnervated, the
nerve pedicles supplying it have to be carefully individualized
at their origin from the posterior tibial nerves and included
into the flap.
In the event of a composite fibula including the whole
soleus, the vascular pedicles originating from the posterior
artery and vein have to be severed but, as already men­
tioned, the whole muscle can survive based on the intramus­
cular cross-anastomoses with the peroneal system. Finally,
a skin graft is used to cover the muscle as a secondary
operation.
To include a skin paddle, it can be outlined on the lateral
aspect of the leg at any level, supplied by muscular perfora­
tors in the upper third of the leg and septocutaneous ped­
icles in the distal two-thirds, as already mentioned.
POSTEROLATERAL APPROACH
Taylor has advocated the use of this approach.5 We believe
that the posterolateral approach for harvesting the whole
soleus on a composite fibula + soleus flap provides better
exposure and better control of the tibia neurovascular
bundle.
Figure 51.9  (A) Technique of dissection of a distally-based soleus. (B) Coverage of the distal third of the leg. (After Masquelet and Gilbert.)
A
Medial soleus
Secondary pedicles
supplying the flap
Proximal pedicles
to the medial
soleus after ligation
B

590
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 51.10  (A) The lateral approach to the soleus. (B) Identification of proximal part of the lateral soleus and surrounding vessels and nerves.
1. Soleus. 2. Flexor hallucis longus. 3. Peronei. 4. Tibialis anterior vessels. 5. Interosseous membrane. 6. Origin of tibial and peroneal vessels.
(C) The lateral soleus is well dissected and exposed. 1. Tibial nerve. 2. Peroneal vessels. 3. Peronei. 4. Soleus. 5. The fibula. (D) The composite
fibula and soleus ready to be transferred. (E) Cross-section of the composite fibula and soleus at the midlevel of the leg. 1. Gastrocnemius
muscles. 2, 4. Lateral and medial soleus. 3. Peronei. 5. Flexor hallucis longus. 6. Fibular vessels. 7. Tibialis posterior muscle. 8. Fibula.
9. Interosseous membrane. (A,E after Strauch and Yu; B,C after Masquelet and Gilbert.)
A
4
1
2
3
C
5
2
1
6
5
4
3
7
5
1
2, 4
6
8
3
9
E
B
D

CHAPTER 51 — Soleus Flap
591
UPPER EXTREMITY
Post-tumoral or post-traumatic defects of the humerus or
radius can achieve a satisfactory solution whenever a simple
solution cannot be proposed.
Inclusion of the soleus muscle in a composite transfer
with reinnervation can be performed by anastomosis of
several motor branches to a recipient nerve, sometimes even
bridged by a nerve graft. This has been published and has
demonstrated a satisfactory result. This technique with rein­
nervation of the soleus muscle had been used mainly in the
forearm for restoration of the extension of wrist and fingers.
LOWER EXTREMITY
In the same way, composite defects of the tibia up to 20 cm
have been satisfactorily solved by fibula and lateral head of
soleus or even soleus transfer. More rarely, bone defect of
the femur have been treated by a “bipartite” fibula transfer
and adjacent components.
As a regional pedicled flap (whether proximally or dis­
tally based), the soleus muscle is commonly used for cover­
age of post-traumatic defects of the leg. It has been used as
a local proximally or distally based flap for coverage of
defects of the middle third of the leg, which is still its most
frequent indication.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
• Proximally-based soleus muscle (Fig. 51.8) approached
through a medial incision for coverage of large areas over
the middle third of the anterior aspect of the leg. The
muscle’s point of rotation is about 12 cm below the knee.
The distal pedicles from the posterior tibial artery have to
be ligated and the flap is supplied by the pedicles emerging
from the peroneal and posterotibial arteries. The muscle
can be transposed medially or laterally (Fig. 51.8D).
• Proximally-based hemi-soleus (medial or lateral) for coverage
of small defects in the middle third of the leg.
• Distally-based medial soleus muscle for coverage of distal
third of leg defects (Fig. 51.9). This flap may not be fully
reliable as the blood supply is not constant. It is based on
two or three pedicles from the posterior tibial artery and
its transposition depends upon the presence and location
of these vessels. Preoperative studies such as an angio­
gram or MRA may aid in identifying the perforators.
Otherwise, this flap is approached at the time of a planned
free flap. If reliable perforators are found, the distally
based hemi-soleus is performed. If the vessels are not
present or are small, the same incision is used to expose
the recipient vessels for a free flap.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
• Proximally-based soleus muscle approached through a lateral
incision for coverage of medial leg defects.
• Proximally-based soleus muscle free flap for coverage of con­
tralateral leg defects. The indications for this flap are
limited. Whenever a local solution cannot be found, this
flap may be considered as a free flap since the donor site
morbidity is low both functionally and cosmetically.
• Proximally-based free composite soleus + fibula + skin graft or
soleus + fibula and skin paddle is often the only available
to be achieved since any muscle dissection can be respon­
sible for postoperative bleeding or hematoma.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
The plantaris tendon can serve as a landmark as it runs
between the gastrocnemius and soleus muscles from supero­
lateral to inferomedial.
FLAP USAGE
Indications for a proximally based hemi-soleus (medial or
lateral) flap for coverage of small defects in the middle of the
leg are essentially post-traumatic exposure of bone with loss
of surrounding soft tissues or open fracture stabilized by
internal osteosynthesis or external fixator. That coverage can
be done as a primary repair or delayed repair after careful
debridement of the recipient site. Bone loss can be treated
at the same time by a conventional bone graft if the defect
does not exceed 6 cm. Some authors have described a one-
stage pedicled transfer of part of the ipsilateral fibula included
within the muscle for bone and soft tissue defect. The whole
soleus can be used in the same way for larger defects.
The pivot point for any type of proximally based soleus
flap is located between the upper and middle thirds of the
leg. A muscle harvested alone has to be skin grafted, prefer­
ably in a second stage after formation of granulation tissue.
But in some cases, a proximally-based lateral head of soleus
myocutaneous flap, instead of muscle alone, or the medial
head of the soleus can be harvested provided that the skin
defect can be closed primarily. As already mentioned, a
septocutaneous flap harvested in the lower third of the leg
can be used.
We do not feel that a proximally-based soleus muscle free
flap is indicated for coverage of contralateral defects of the
leg since many better options exist (latissimus dorsi, serratus
anterior, etc.) and it is not reasonable to jeopardize the
function of the donor leg if you cannot be certain that this
will solve the problem of the recipient leg.
FREE FLAPS
Indications for the soleus as a free flap are mainly as a com­
posite transfer (muscle, bone, skin, nerves) with many varia­
tions of each component in term of dimensions and
recipient site requirements.
HEAD AND NECK
The main indication is mandible reconstruction with even­
tual corticotomies of the fibula to fit the defect. The lateral
head of the soleus associated with a skin paddle is commonly
used and from angle to angle if necessary the mandible can
be reconstructed with this long bone component. Dental
implants can be adequately fitted in a second stage.
TRUNK
An extensive defect in the sternum area can be solved by a
revascularized composite transfer eventually with a bipartite
fibular component.

592
PART 4 — CONVENTIONAL WORKHORSE FLAPS
compression to the flap or the pedicle of the flap, as well
as the donor site, in the event of free transfer from a few
days to a few weeks, depending upon the indication and
the modality of reconstruction. Bony union may take up to
1 year.
OUTCOMES
EXPECTED OUTCOMES
If planned and executed with care based on a carefully
designed flap, total muscle survival is expected. The soleus
flap can usually successfully solve the problem of deep and
extensive defects.
Alone or as part of a composite pedicled or free transfer,
the soleus is reliable provided that the surgeon masters
the anatomy and is aware of factors which can jeopardize
the viability of the transfer: excessive tension or torsion
of the base of the pedicle, insufficient hemostasis, inade­
quate control of antithrombotic treatment.
For free tissue transfer, adequate selection of the recipi­
ent vessels and anastomoses performed by a skillful and
experienced microsurgeon are mandatory conditions to
minimize the incidence of postoperative complications and
reinterventions.
However, localized partial necrosis of the muscle does
occur. Thus, it is wise to delay coverage by a skin graft until
it can be performed on viable granulation tissue. This
occurs in about 20% of cases.
UNTOWARD OUTCOMES
With free microvascular transfer of the soleus flap (soleus
alone or most often as a composite transfer), thrombosis of
the vessels can occur in a minority of cases. Early diagnosis
and reoperation is important. Careful postoperative check­
ing is mandatory to increase the possibility of saving the flap.
DONOR SITE
As a proximally-based regional flap, some partial, superficial
or deep muscle necrosis can be expected, mostly in a small
area needing some debridement. The problem is usually
easily solved by conservative local means.
As a distally-based regional flap, if properly performed
based on reliable perforators (seen intraoperatively), the
rate of muscle necrosis is very low.
The functional deficit after hemi-soleus transfer is very
limited.
With a composite transfer, mainly soleus + fibula, one may
encounter sequelae related to free fibula transfer (impair­
ment of motion of the ankle, pain in the territory of the
lateral peroneal nerve, lack of flexion of the great toe, etc.).
When performing conventional pedicled flaps, total
muscle necrosis is rare (or is the exception). However, a free
muscle transfer can sustain total muscle necrosis in up to
20% of cases (in some series). Most of these are related to
vascular thrombosis at the anastomotic site.
As for the donor site, for pedicled or free transfer in a
few cases, some long-standing pain, even related to a
neuroma in the lateral peroneal nerve, has been reported.
We do not think that harvesting the entire soleus can be
satisfactory solution for reconstruction of extensive com­
pound defects. The length of the fibula can reach up to
25 cm and the overlying muscle 250 mm in length and
170 mm in width in extremes cases. The lower extremity,
mostly the leg, is the most common recipient site but
extensive bone defects of the upper extremity (humerus,
radius, and ulna), isolated or associated with other tissue
loss (muscle, skin), are also excellent indications for free
transfer. The first attempt at a free soleus transfer was
made in 1978 by Baudet et al.3 in the form of a composite
osteomuscular free fibula transfer including the lateral
soleus for extensive compound defect of the leg.
• Composite free reinnervated lateral soleus with overlying skin
and fibula for coverage of a defect requiring a functional
muscle with or without a soft tissue and bone defect. This
flap is rarely indicated as a functioning muscle transfer;
however, it can be used, as it has good strength. This
modification was performed by Chuang et al.6 and can be
used to reconstruct a defect which needs a functioning
muscle as well as bone and soft tissue, such as a forearm
trauma case.
POSTOPERATIVE CARE
GENERAL
In the intensive care unit, it is very important (but essential
for a free transfer) to keep the room temperature at an
adequate level, and to maintain good blood pressure to
prevent vessel spasm and thrombosis. Hemodilution is also
suitable, as well as low molecular weight heparin (LMWH)
injection to prevent thrombophlebitis in these long-standing
decubitus patients. Our only points of specific management
are visual checking of the flap color and temperature mea­
surement every half an hour compared with a control point
selected on the same leg, and control of the capillary pulse
on a skin paddle harvested with the muscle.
RECIPIENT SITE AND DONOR SITE
Dressings on the donor and recipient site have to be done
every 2 days.
The recipient site has to be immobilized by a posterior
splint for 2 weeks, with the lower extremity elevated. Phys­
iotherapy is ordered during that period to prevent edema
and joint stiffness (ankle). The drains at the donor and
recipient sites are removed at 1 week.
For a composite transfer (muscle and bone), the poste­
rior splint has to be replaced for up to 1 year by a circum­
ferential cast, including the knee, until bony union appears
on X-ray.
The patient has to remain on strict bed rest for 10 days.
In the intensive care unit, staff must carefully check the
viability of the flap, especially for a free tissue transfer, and
antithrombotic prophylactic treatment associated with vaso­
dilatation drugs is sometimes ordered.
DONOR SITE
The operated limb has to be immobilized by a posterior
splint placed carefully, so as not to create a source of

CHAPTER 51 — Soleus Flap
593
harvesting. Thus, one should always take into account the
functional and cosmetic result to be achieved and compare
it with the eventual sequelae at the donor site. We say that
the best indication in any situation is when we fulfil two
goals: “to do what is possible but also suitable.”
When the entire muscle or one of its bellies is harvested,
a visible scar is present that improves with time; a contour
deformity may be noted and asymmetry of both calves will
be seen in all patients.
No specific unfavorable outcome will be noticed if one
maintains an adequate length at the upper and lower part
of the fibula for preservation of the superior and inferior
peroneal tibial joint.
CONCLUSION
Use of the soleus muscle, either total or partial, is a very
versatile method of treatment of extensive defects in the
lower extremity. It is mostly used as a proximally based
pedicled flap for regional coverage and on occasion as a
free flap for distal wound coverage.
Its association with other components (fibula, overlying
skin) as a non-reinnervated or reinnervated muscle provides
very satisfactory results for challenging cases, mainly in the
lower extremity but also in the upper extremity.
responsible for a functional deficit since other muscles such
as the gastrocnemius can take over the motion of the ankle.
Lack of flexion of the great toe, if it occurs, is not a major
complaint.
LONG-TERM OUTCOMES
It is obvious that one cannot expect full recovery of the
muscle strength, but it is satisfactory enough to recover a
useful function (flexion of wrist and fingers), since this is
the most common indication as a composite transfer.
The main concern we have in the long term is the viability
of the transferred fibula and quality of the bony union. If a
vessel thrombosis has occurred which jeopardizes bone
viability, one can encounter stress fractures and the viability
of the bone will be called into question.
In reinnervated transfer for restoration of flexor or exten­
sor muscles of the forearm and fingers, one should not
expect full recovery in terms of strength. Even with stronger
muscles such as reinnervated pectoralis major or latissimus
dorsi, we cannot expect to recover more than half the
strength of the contralateral side.
DONOR SITE
It is obvious that an asymmetry of the calf will be noticed
and there are visible scars in cases of composite soleus
This 76-year-old male smoker, with deep venous insufficiency
presented with a chronic ulcer with exposed bone in the middle
third of the right leg. The patient had undergone previous
attempts at closure (Fig. 51.11).
CASE 51.1  Chronic Lower One-third of a Leg Wound with the Bone Exposed
Reconstructed with a Proximally-based Pedicled Medial Hemisoleus Flap
A
D
E
F
B
C
Figure 51.11  (A) Open defect in the lower third of the leg with exposed bone. (B) An incision is made 2–3 cm behind the border of the
tibia. (C) The skin flaps are elevated anteriorly and posteriorly. The soleus muscle is seen anterior to the gastrocnemius muscle and tendon.
(D) The medial head of the soleus is dissected off the Achilles tendon and away from the lateral head. (E) The medial hemisoleus muscle
is pedicled proximally and used to cover the defect. (F) The wound is well healed at 3 months postoperatively, following hemisoleus
transfer and skin grafting.

594
PART 4 — CONVENTIONAL WORKHORSE FLAPS
This 45-year-old woman was involved in a motor vehicle accident
and presented with an open tibia fibula fracture with the wound
present in the middle third of the leg. The bones were stabilized
using an external fixation device. A medial hemisoleous muscle
flap was designed to cover the defect (Fig. 51.12).
CASE 51.2  Open Wound in the Middle of the Leg with Exposed Bone Reconstructed with a
Pedicled Proximally-based Medial Hemisoleus Flap
Figure 51.12  (A) Open wound in the middle third of the leg with exposed bone. (B) The medial head of the soleus muscle was dissected
free based proximally. (C) The muscle was transferred to the defect. The subcutaneous tunnel was made large enough to avoid compression
of the muscle. (D) The defect is seen 6 weeks postoperatively covered with the medial head of the soleus and resurfaced with a skin graft.
A
C
D
B

CHAPTER 51 — Soleus Flap
595
Access Figures 51.13, 51.14 and 51.15, as well
as case examples 3, 4 and 5 and further reading
online at
REFERENCES
1. Ger R. The operative treatment of advanced stasis ulcer: a prelimi­
nary communication. Am J Surg 1966;111:659–63.
2. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous
flaps. St Louis, MO: Mosby; 1979.
3. Baudet J, Panconi B, Caix PH, et al. The composite fibula and soleus
free transfer. Int J Microsurg 1982;4:10.
4. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories
of the skin and muscles: anatomic study and clinical implications.
Plast Reconstr Surg 1994;94:1.
5. Taylor GI, Miller GDH, Ham FJ. The free vascularized bone graft. A
clinical extension of microvascular technique. Plast Reconstr Surg
1975;55:533.
6. Chuang DC, Chen HC, Wei FC, et al. Compound functioning free
muscle flap transplantation (lateral half of soleus, fibula and skin
flap). Plast Reconstr Surg 1992;89:335.
Expert Commentary 
Randy Sherman, MD, FACS, Michael J. A. Klebuc, MD
While much less adaptable than its neighbor, the gastrocne-
mius, the soleus flap plays an important role in coverage of
bony defects and exposed hardware in the middle third of
the lower leg. The key to consistently successful outcomes
using the soleus muscle lies in appreciating its limitations.
Because it derives its blood supply from multiple branches
of both the posterior tibial and peroneal arteries, no one
pedicle will adequately vascularize the entire length of the
transposed muscle segment. In addition, the branch length
coming off of the parent nutrient arteries are extremely short
and further limit rotation. Use the entire soleus whenever
possible, as opposed to medial or lateral fragments, as the
latter dissections can be anatomically unfriendly. The hemi-
soleus muscle left behind will play little to no additive role in
ankle function post-recovery and rehabilitation. The ideal
defect is well within anterior to anteromedial aspect of the
mid-tibial region. While distal third lesions may be amenable
to coverage by this flap, the portion of the muscle needed
to achieve vascularized wound coverage will be, by defini-
tion, most ischemic. As mentioned in Dr Baudet’s chapter,
when considering the soleus for distal third coverage, always
prepare for a potential free flap transfer. All dissections in
this region should be done under tourniquet through gener-
ous incisional approaches to maximize exposure and ease
flap inset. Release the originating fibers from the tibial and
fibular periosteum as far proximal as necessary to ease trans-
position. Whenever possible, leave the gastro-Achilles mech-
anism intact by first incising the fusion point of the ventral
gastrocnemius fascia and dorsal soleus fascia respectively.
Slowly and meticulously separate the muscle form the Achil-
les tendon using either Bovie, scissor or knife dissection. The
frequently described midline septum is more often a fascial
invagination occurring between two-thirds and three-quarters
across from the medial edge of the muscle and must be
handled carefully if the operating surgeon wishes to use the
entire width of the distal muscle. Distally-based soleus flaps,
while anatomically alluring do not meet the test of consistent
reliability.

CHAPTER 51 — Soleus Flap 595.e1
A 45-year-old woman was referred 2 months after injury. A con-
tralateral free whole soleus was harvested and revascularized by
end-to-side anastomosis with the posterior tibial vessels. A free
iliac bone graft filled the bony defect. A meshed skin graft was
used to cover the muscle. Uneventful bony union and coverage
were achieved (Fig. 51.13).
CASE 51.3  Open Fracture of the Upper Third of the Tibia with Exposed Necrotic Bone
Figure 51.13  (A) Compound open fracture of the upper third of the leg with exposed necrotic bone of the tibia referred 2 months after
the injury in a 45-year-old woman. (B) Coverage by a proximally-based soleus free flap and a non-vascularized iliac bone graft and a
meshed skin graft over the muscle. (C) Final result.
A
C
B

595.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
This 50-year-old woman presented with a comminuted com-
pound fracture of the leg. A distally-based soleus was harvested
through a lateral approach and secondarily covered with a skin
graft, with an uneventful postoperative course (Fig. 51.14).
CASE 51.4  A Comminuted Compound Fracture of the Leg, Immobilized with an
External Fixator
Figure 51.14  (A) Delayed treatment of an extensive fracture of the tibia in a 50-year-old woman. (B) Coverage by a distally-based soleus
flap with secondary skin grafting. (C) Final result.
A
B
C

CHAPTER 51 — Soleus Flap 595.e3
Figure 51.15  (A) Extensive skin and bone defect of the left leg in a 30-year-old man following a gunshot injury to be reconstructed by
a composite fibula–soleus flap. (B) Initial preoperative X-ray. (C) Intraoperative view of the flap after elevation. Pencils indicate the three
different pedicles available for supplying the flap. (D) X-ray of the bony union achieved. (E) Good functional and cosmetic result.
This 18-year-old man sustained a serious gunshot injury 3 months
prior to admission. After temporary skin grafting, a 22 cm long
composite whole soleus and fibula transfer was performed to
solve the problem. Full weightbearing was allowed at 12 months
(Fig. 51.15).
CASE 51.5  An 18 cm Long Tibia and Overlying Soft Tissue Defect
A
B
C
D
E

595.e4 PART 4 — CONVENTIONAL WORKHORSE FLAPS
FURTHER READING
Beck JB, Stile F, Lineaweaver W. Reconsidering the soleus muscle flap
for coverage of wounds of the distal third of the leg. Ann Plast Surg
2003;50:631–5.
Cavadas P, Landin L. Reconstruction of chronic Achillesten-don defects
with posterior tibial perforator flap and soleus tendon graft: Clinical
series. Plast Reconstr Surg 2006;117:266–71.
Choudry U, Moran S, Karacor Z. Soft-tissue coverage and outcome of
Gustillo grade IIIB Midshaft tibia fractures: A 15-year experience.
Plast Reconstr Surg 2008;122:479–85.
Ger R. The management of pretibial skin loss. Surgery 1968;63:757.
Ger R. The management of open fracture of the tibia with skin loss.
J Trauma 1970;10:112–20.
Ger R. Muscle transposition for treatment and prevention of chronic
post-traumatic osteomyelitis of the tibia. J Bone Joint Surg 1977;59A:
784–90.
Ger R. Closure of defects of the lower extremity by muscle flaps. In:
Converse JM, editors. Reconstructive plastic surgery: principles and
procedures in correction, reconstruction and transplantation. 2nd
ed. Vol. 7. Philadelphia, PA: WB Saunders; 1987. p. 3558.
Gilbert A. Vascularized transfer of the fibular shaft. Int J Microsurg
1979;1:100.
Godina M. Early microsurgical reconstruction of complex trauma of
extremities. Plast Reconstr Surg 1986;78:285–91.
Gruber S, Michlits W, Papp C. The new distal soleus adiposa) pull-
through composite flap for reconstruction of defects overlying the
Achilles tendon: The anatomy and clinical experience. Surgery
2008;143:441–6.
Kauffman C, Lahoda L, Cederna P, et al. Use of soleus muscle flap
for coverage of distal tibial defects. J Reconstr Microsurg 2004;20:
593–7.
Kawamura K, Yajima H, Kobata Y, et al. Clinical Applications of free
soleus and peroneal perforator flaps. Plast Reconstr Surg 2005;115:
124.
Kawamura K, Yajima H, Kobata Y, et al. Coverage of big toe defect after
wrap-around flap transfer with a free soleus perforator flap. J Recon­
str Microsurg 2005;21:225–9.
Leclerc C, de Normandie Ph, Brunelli F Couverture cutanée du tiers
inférieur de jambe par le lambeau soléaire distal. Ann Chir Plast
Esthet 1987;32:140.
Masquelet AC, Gilbert A. An atlas of limb reconstruction. London:
Martin Dunitz; 1995.
Mathes SJ, Vasconez LO, Jurkiewicz MJ. Extensions and further applica­
tions of muscle flap transposition. Plast Reconstr Surg 1977;60:6.
Pelissier P, Casoli V, Demiri E, et al. Soleus-fibula free transfer in lower
limb reconstruction. Plast Reconstr Surg 2000;105:567.
Pers M, Medgyesi S. Pedicle muscle flaps and their application in the
surgery of repair. Br J Plast Surg 1973;26:313.
Pu LL. The reversed medial hemisoleus muscle flap and its role in
reconstruction of an open tibial wound in the lower third of the leg.
Ann Plast Surg 2006;56:59–63; discussion 63–64.
Pu LLQ. Successful soft-tissue coverage of a tibial wound in the distal
third of the leg with a media¡ hemisoleous muscle flap. Plast Reconstr
Surg 2005;115:245.
Salmon R, Dor J. Artères des muscles du tronc et des membres. Paris:
Editions Masson; 1933.
Schierle C, Rawlani V, Galiano RD, et al. Improving outcomes of the
distally based hemisoleus flap: Principles of angiosomes in flap
design. Plast Reconstr Surg 2009;123:1748–54.
Townsend PLG. An inferiorly basad soleus muscle flap. Br J Plast Surg
1978;31:210.
Vasconez LO, Bostwick J, McCraw J. Coverage of exposed bona by
muscle transposition and skin grafting. Plast Reconstr Surg 1974;53:
526–30.
Wright KJ, Watkins PR. Use of the soleus muscle flap to cover part of
the distal tibia. Plast Reconstr Surg 1981;68:957–8.
Yajima H, Tamai S, Ishida H, et al. Partial soleus muscle island flap
transfer using minor pedicles from the posterior tibial vessels. Plast
Reconstr Surg 1995;96:1162–8.
Yoshimura M, Shimada T, Hosokawa M. The vasculature of the pero­
neal tissue transfer. Plast Reconstr Surg 1990;85:917.

596
INTRODUCTION
With an outstanding length available for harvest, a solid and
sizable bone stock, a reliable blood supply, an allowance for
manipulation of the components of the flap while maintain­
ing adequate blood supply, and the ability to carry bone,
skin, muscle, and fascia, the fibula flap has become one of
the most commonly used vascularized osseous and osteocu­
taneous flaps for reconstruction of osseous defects around
the body, particularly the mandible, radius, femur, and tibia.
Ueba and O’Brien evaluated the fibula as a donor site for
free microvascular bone flap transfer prior to Taylor et al’s
report in 19751 of the first two clinical cases of microvascular
fibula flaps used for reconstruction of tibia bone gaps.
Bovet’s work, which followed, demonstrated that muscle
could be carried along with the fibula bone. It was not until
Wei and colleagues’ anatomic and clinical study in 1989,2
that surgeons were convinced of the reliability of the skin
paddle of the osteoseptocutaneous fibula flap. Since then,
the skin has served a critical role in providing a cutaneous
component when necessary, and for providing a good
monitor for the bone component. In 1989, Hidalgo3 was the
first to report on a significant series of vascularized fibula
grafts for mandibular reconstruction. Free vascularized
bone flaps were shown to heal more rapidly, with fewer
complications and earlier functional recovery, and their use
for larger defects, particularly in radiated beds, has been
found to be superior to that of non-vascularized grafts.4–6
FLAP ANATOMY (see Fig. 52.1 and Figs 13.6,
13.7, 13.8 and 13.19)
The fibula is a long, thin bone with anterior, posterior,
medial, and lateral surfaces. The head articulates with the
tibia. The biceps femoris and the lateral collateral ligament
attach to the fibula.
ARTERIAL SUPPLY OF THE FLAP (see Fig. 52.1
and Figs 13.6 and 13.7)
The arterial supply of the fibula flap is via both a dominant
nutrient endosteal and minor periosteal septal and muscu­
lar branches from the peroneal artery. The external diam­
eter of the peroneal artery is 1.5–2.5 mm and the pedicle
length is between 2 cm and 6 cm. The pedicle length varies
with the amount of bone that is resected.
Fibula Flap
Christopher J. Salgado  |  Harvey Chim  |  Steven L. Moran  | 
Fu-Chan Wei  |  Samir Mardini
52 
Figure 52.1  Fibula flap.
Fibula
Popliteal artery
Peroneal artery
Anterior tibial artery
Peroneus longus
and peroneus brevis
Flexor hallucis
longus
Soleus
Lateral sural
cutaneous nerve
Superficial
peroneal nerve
Deep peroneal nerve
Sural nerve
Tibialis posterior
Fibula flap
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION G  —  LOCAL AND FREE FLAPS IN THE LOWER EXTREMITY

CHAPTER 52 — Fibula Flap
597
anastomoses. Although not routinely performed, lateral
sural sensory or superficial peroneal nerve coaptation may
be performed, and this sensory feedback may improve oral
function or tactile penile sensation if a phalloplasty is
performed.
Motor:  Although a muscle segment can be harvested with
this flap, there are no indications for harvesting a functional
muscle with this flap.
FLAP COMPONENTS
The fibula flap is harvested as a bone flap and may include
regional musculature (soleus or flexor hallucis longus),
and/or overlying skin.
Advantages
• Provides vascularized bone that is suitable in cases of
recipient site wound contamination, scarring, radiation,
or infected bone cases following debridement.
• A long segment of straight, triangular, high-density corti­
cal bone (20–26 cm in adults) may be harvested, which is
capable of bridging long osseous defects and resisting
angular and rotational stresses, considered ideal for
extremity axial skeleton reconstruction.
• Fibula size matches the size of the radius and ulna, and
snugly fits into the medullary cavity of the humerus,
femur, and tibia.
• As an osteoseptocutaneous flap, the overlying skin con­
nected to the bone by the posterior crural septum, may
be readily manipulated, allowing greater versatility in
wound closure compared with other osteocutaneous flaps
(i.e., iliac crest and scapular osteocutaneous flaps).
• Well-defined vascular supply allows for multiple osteoto­
mies (2–3 cm bone segments), which is particularly
important in craniofacial contouring procedures.
• Suitable donor vessels (peroneal artery, 1.5–2.5 mm; vein,
2–4 mm) allow for anastomoses to large vessels in the
head and neck, and upper and lower extremities.
• Acceptable donor site morbidity due to tolerable loss of
peroneal artery and venae comitantes without the need
for reconstruction and limited functional disability in
most cases
Disadvantages
• Obvious donor scar, particularly when a skin component
>4 cm is included and skin grafting is necessary. This is
even less desirable in females.
• The technique of flap harvest requires a steep learning
curve and can be lengthy and tedious in inexperienced
hands.
• Noticeable limitations and discomfort in ankle function
and range of motion with aggressive physical activity may
result after fibula harvest, particularly if tibiofibular fusion
is performed.
PREOPERATIVE PREPARATION
Preoperative assessment to determine whether a patient is
a candidate for a vascularized fibula transfer begins with a
careful medical history to identify any conditions that could
indicate unreliability of the peroneal artery as a pedicle for
Dominant:  nutrient artery from peroneal artery
Length: 1–2 cm
Diameter: 1.0 mm
The nutrient artery arises as a branch of the peroneal
artery and enters the fibula posterior to the interosseous
membrane into the nutrient foramen approximately 15 cm
below the styloid process in the posterior medial edge of the
mid-fibula two-fifths of the way down. The vessel length is
1–2 cm and the average diameter is 1.0 mm. After traversing
a short intracortical path, the nutrient artery divides into an
ascending and a descending branch. The descending
branch is often longer than the ascending. Occasionally,
there are two nutrient arteries.
Minor:  periosteal and muscular branches from peroneal
artery
Diameter:  vessel diameters at their origin range from
0.8 mm to 1.7 mm
Periosteal and muscular branches to the fibula. They are
derived from the peroneal artery located along the fibular
origin of musculature and posterolateral septum. Musculo­
periosteal vessels course primarily through the flexor hal­
lucis longus and tibialis posterior muscle. There are typically
4–8 cutaneous arteries arising from the peroneal artery.
These vessels are segmental, consisting initially of periosteal
and musculoperiosteal branches, entering from a distance
of 4–27 cm below the fibular head and continuing within
the posterior crural septum, between the soleus and pero­
neus muscles, or back through the flexor hallucis longus
muscle to supply the lateral leg skin. The middle third
of the fibula shaft contains the greatest number of these
periosteal branches. When there are no septocutaneous
branches, musculocutaneous branches can supply adequate
circulation to the same skin area.
VENOUS DRAINAGE OF THE FLAP (see Fig. 13.19)
Primary:  venae comitantes of the peroneal artery
Length: 2–6 cm
Diameters: 2–4 mm
Comment: often there are two venae comitantes
Secondary:  superficial venous system
Length: 2–6 cm or longer
Diameter: 2–4 mm
Note: In the case of a fibular osteoseptocutaneous flap a
superficial vein (commonly the lesser saphenous) draining
the skin paddle may sometimes be used as adjunctive drain­
age of the flap. This is particularly useful when a large skin
island is harvested.
FLAP INNERVATION
Sensory:  The lateral sural nerve and terminal sensory
branch of the superficial peroneal nerve (see Figs 13.8,
13.19). Sensory innervation to the corresponding lateral
calf skin territory is largely supplied by the lateral sural
nerve, which is of adequate size to allow microscopic

598
PART 4 — CONVENTIONAL WORKHORSE FLAPS
the endosteal supply, and the periosteal branches of the
peroneal artery provide the periosteal supply. When design­
ing the flap, an attempt should be made to include the
nutrient vessels whenever possible (in most cases there is
only one). If the segment of bone required is short, and the
pedicle required is short, the flap can be centered over, or
designed to include the predicted location of the nutrient
vessel. If the bone required is long, or if the pedicle length
required is long, the majority of the bone stock may have to
come from the distal leg and therefore rely on periosteal
blood supply only.
The right leg or the left leg can be used as a source for
the fibula flap. When a bone flap is required without the
skin, there is no preference of one over the other as far as
the recipient site is concerned. Unlike the iliac crest flap,
when harvesting a fibular osteoseptocutaneous flap, the skin
paddle can be rotated over the bone due to the fact that the
septum is thin and mobile and allows for this to happen.
However, if muscle is included during the dissection of the
skin vessels, the arc of rotation of the skin paddle over the
bone may be more limited. In that situation, the side to use
for flap harvest should be carefully planned. The left side is
preferable in most patients because it is the less dominant
leg in most individuals and is used less during driving a car.
The peroneal nerve (see Fig. 13.8), lying inferior to the
head of the fibula, can be palpated during the marking of
the patient; this can more clearly identify the location of the
nerve and avoid injury to it during the dissection.
When the skin island is small, the anterior incision will
most likely lie over the lateral compartment and the subfas­
cial dissection can start at that point. However, when the
skin island is large, the anterior incision may lie over the
anterior compartment. In that case, it is easier to dissect in
the suprafascial plane posteriorly until the surgeon is over
the lateral compartment. At that point, the fascia is incised
and the dissection continues in a subfascial plane. Other­
wise, if the dissection in a posterior direction proceeds in
the subfascial plane over the anterior compartment muscles,
the surgeon will have to pass through the anterior intermus­
cular septum before reaching the lateral compartment and
eventually the posterior intermuscular septum which con­
tains the skin vessels. This will cause confusion during the
dissection and may increase the difficulty of the dissection.
When designing the skin island, it is centered over the
posterior crural septum, which contains the Dopplered per­
forators. Occasionally, the perforators do not pass through
the septum and actually pass through the FHL and/or soleus
muscles and may therefore lie posterior to the septum.
SPECIAL CONSIDERATIONS
• At least 4 cm of fibula bone is preserved proximally
(below the head of the fibula) in order to preserve the
stability of the knee. This is achieved by maintaining the
attachment of the tibia to the fibula, and the biceps
femoris muscle and the fibular collateral ligament to the
head of the fibula. The proximal portion of the fibula
hosts parts of the origins of the peroneus longus muscle,
extensor digitorum longus muscle, extensor hallucis
longus muscle, soleus muscle, and the tibialis posterior
muscle. Additionally, minimizing dissection at that level
will help avoid injury to the peroneal nerve.
free tissue transfer. These conditions include peripheral
vascular disease, deep vein thrombosis, trauma, venous stasis
disease, or arteritis. The knee and ankle joints should be
assessed for range of motion and laxity. A foot Allen’s test
should be performed with a Doppler probe ensuring a
signal for the dorsalis pedis and posterior tibial artery with
occlusion of the other vessel. Peronea magna, which is asso­
ciated with hypoplasia or absence of both the anterior and
posterior tibial arteries with the peroneal artery as the sole
arterial supply for the foot, must be ruled out and may occur
in up to 8% of the population. In most centers around the
world, in the absence of trauma to the lower extremity and
previous surgery, clinical examination is used to evaluate the
blood flow to the extremity prior to flap harvest. CT angio­
grams are used routinely in our center for evaluation of
patients’ extremities prior to fibula harvest, particularly in
patients with a history of trauma. Duplex ultrasonography
provides a potential compromise for preoperative evalua­
tion, without the invasiveness, potential risk, and expense
associated with angiography. Intraoperatively, prior to tran­
secting the peroneal artery distally, the surgeon should visu­
alize the posterior tibial artery in order to make sure it exists
and appears to be normal.
FLAP DESIGN (Figs 52.2, 52.3)
ANATOMIC LANDMARKS
The head of the fibula, the lateral malleolus, and posterior
border of the fibula connecting the head of the fibula and
the lateral malleolus are marked. The mark at the posterior
border of the fibula identifies the posterior intermuscular
septum that carries the vessels supplying the skin. A point
4 cm below the head of the fibula and a point 6 cm above
the lateral malleolus are the most superior and inferior
margins of the bony stock that can be harvested without
causing significant instability of the knee and ankle.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The fibula bone receives its blood supply from endosteal
and periosteal vessels. The nutrient artery provides
Figure 52.2  Flap markings. The head of the fibula, lateral malleo­
lus, anterior and posterior border of the fibula, including the planned
skin paddle with Dopplered perforator vessels, are included in mark­
ings for flap design.

CHAPTER 52 — Fibula Flap
599
for placing many screws into the fibula bone flap. The
plate spans the fibula flap and one or two screws only into
each fibula bone segment of 2–3 cm are adequate for
fixation.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
When using the fibula flap as a pedicled flap, the arc of
rotation can be up to 180° if care is taken during the inset
to avoid torsion of the pedicle. Careful design of the flap
allows for fewer complications during the inset. The defect
location should be measured carefully in relation to the
fibula bone. The location of the bone to be harvested
depends on the distance of the defect from the fibula bone,
on the size of the defect, and on the location of the nutrient
vessel supplying the fibula bone (the nutrient vessel is
included if possible but it is not required for a successful
reconstruction). The bone stock required for reconstruc­
tion is harvested as distal as possible to optimize pedicle
length. Proximal osteotomies on the fibula allow for a wider
arc of rotation.
FLAP DIMENSIONS
SKIN ISLAND LENGTH
Average 12 cm, maximum 32 cm
SKIN ISLAND WIDTH
Average 6 cm, maximum 14 cm
BONE LENGTH
Average 16 cm, maximum 30 cm
Note: Maximum bone length is harvested (total minus
4 cm in the upper part and 6 cm in the lower part) in most
cases in order to expose and achieve as much pedicle length
as possible. The bone to be used for the reconstruction is
later chosen based on the pedicle length required and on
the location of the nutrient vessel in relation to that.
FLAP MARKINGS
The outline of the fibula, including the lateral malleolus
and head of the fibula, is marked. This posterior aspect of
the bone marks the posterior intermuscular septum that
carries the vessels supplying the skin. A point 4 cm below
the head of the fibula and a point 6 cm above the lateral
malleolus are the most superior and inferior margins of the
bony stock that can be harvested without causing significant
instability of the ankle. When marking the skin island, it is
centered over the posterior crural septum, which contains
the Dopplered perforators.
PATIENT POSITIONING
Position the patient supine on the operating table with the
patient’s knee flexed 90° and the foot fixed to the table,
with the pelvic girdle interiorly rotated with the assistance
of a roll placed under the ipsilateral hip. A tourniquet is
used around the mid-thigh and the flap is commonly raised
under ischemia. A stack of sterile towels should elevate the
• A two-team approach is performed whenever feasible (i.e.,
head and neck and upper extremity reconstructions).
• Although not recommended, including the FHL and the
tibialis posterior can be harvested with the flap; and
including parts of the soleus muscle may lower the chance
of injury to the skin vessels. The skin vessels either travel
within the posterior intermuscular septum, or pass
through the soleus muscle on their way to the skin. In the
latter case, they can be dissected from the muscle by using
perforator techniques or a segment of the muscle can be
included with the flap.
• Preoperative CT angiography is required in patients who
have abnormal or absent pulses or Doppler signals on
physical examination, in trauma victims with severe crush
or cutting injuries, and in patients suspected of having
severe atherosclerosis. Conventional angiography can be
performed if CT angiography is inadequate.
• Although the dissection described for the osteocutaneous
flap begins with the anterior incision first, beginning the
dissection with the posterior incision is acceptable and
has the advantage of decreasing the chance of confusion
about the location of the skin vessels. Care is taken not
to injure the lesser saphenous vein and sural nerve, par­
ticularly when the skin paddle is large.
• The superficial peroneal nerve is located in the proximal
part of the peroneus longus muscle running under the
deep surface and should be avoided during the dissection
unless sensation is needed in the skin paddle (i.e., fibula
flap phalloplasty).
• There are two ways to work with the fibula after harvest.
This is performed on the back table and the segment to
be used is selected and marked. At that point, the rest of
the bone needs to be excised without injuring the pedicle.
In order to perform this excision, the bone and the
pedicle need to be separated. The separation can be per­
formed in two ways. An incision using a knife can be
performed longitudinally over the bone on the side oppo­
site the pedicle and a subperiosteal dissection can be
performed circumferentially. The bone is exposed and
cut in the appropriate location. This method will leave the
blood supply intact; however, it will leave a large periosteal
muscular segment that may be bulky during the inset. This
tissue can be used as vascularized tissue for coverage of
parts of the wound, or exposed bone, or can be wrapped
around the fibula to create a pseudo-joint. The second
method is to cut the periosteum at the level of the mark
(bone cut level), and denude the fibula circumferentially
except for over the pedicle. This is easier; however, it may
have a higher chance of injuring the pedicle.
• If an osteocutaneous flap is used to reconstruct a defect
and the vessels thrombose and cannot be salvaged, the
skin island is debrided and replaced with another skin
flap and the bone is kept in place. The patient can be
sent to hyperbaric oxygen (HBO) therapy to increase the
chance of bone revascularization.
• During inset, bone-to-bone contact of the fibula flap
bone and native bone ends at the defect should be maxi­
mized. The opposition and stability can be maximized by
creating steps, wedges, or any method that articulates
the bone ends together, or the bone is telescoped into
the recipient bone when the size is appropriate. Good
opposition will allow for bone healing without the need

600
PART 4 — CONVENTIONAL WORKHORSE FLAPS
With a reciprocating saw or Gigli saw, applying lateral
traction on the proximal and distal fibula with a bone or
towel clamp, osteotomize the fibula distally and proximally
to harvest exactly the required length of bone needed for
the reconstruction. Care should be taken to include a strip
of periosteum overlying the proximal and distal osteotomy
sites to overlap the osteotomy sites at the recipient site. Prior
to performing the osteotomy, it is important to identify the
common peroneal nerve and its superficial peroneal branch
to preserve these structures. A microvascular clamp may be
applied to the peroneal artery distal to the osteotomy site
to ensure adequate vascularization of the foot on temporary
release of the tourniquet. Section the peroneal bundle dis­
tally while the interosseus membrane is exposed and incised.
This maneuver will further expedite retraction of the fibula
laterally for better visualization of the deep posterior muscle
compartment. The flexor hallucis longus muscle is divided
along its length medial to the peroneal artery and vein. In
this way the segmental periosteal and septocutaneous vessels
that course within or adjacent to the lateral muscle surface
toward the fibula are preserved. Similarly, the tibialis poste­
rior muscle is released, leaving a small cuff of muscle on the
fibula. The vascular pedicle is dissected up to its origin at
the level of the bifurcation from the posterior tibial artery.
Care is taken to preserve the nerve running to the flexor
hallucis longus to prevent late contracture and clawing of
the great toe. The vessels are traced proximally until the
bifurcation with the posterior tibial artery is clearly visual­
ized. The tourniquet may be released at this point and
hemostasis is obtained. Once the graft is customized and the
recipient area is ready, cut the pedicle free and transfer the
flap into the defect.
OSTEOMUSCULAR FLAP
The entire lateral half of the soleus muscle can be harvested
together with the fibula flap. The dissection is similar to that
already described except that after completing the anterior
dissection of the fibula, carry this in a posterior plane
located between the lateral head of the gastrocnemius and
the soleus until the midline of the soleus is identified.
At this level, the dissection deepens laterally among the
soleus and the flexor hallucis longus7 until the peroneal
vessels are identified. The osteomuscular flap may be indi­
cated in trauma patients with extensive soft tissue damage
and a dead space that must be filled. The flap may also be
harvested as an osteomyocutaneous flap.
OSTEOCUTANEOUS FLAP
The skin island design is centered over Dopplered perfora­
tors located over the middle third of the fibula, posterior to
the long axis of the fibula, since these vessels typically course
through the posterior intermuscular septum between the
soleus and peroneal muscles (Fig. 52.3). The width of the
skin island may extend up to 14 cm; however, if primary
closure of the donor site is planned, then a maximum width
of 4–6 cm should be designed. The length of the skin island
may extend from between the fibular head proximally to
slightly above the lateral malleolus. The anterior incision is
made and the dissection proceeds superficial to the muscle
fascia in a posterior direction. Care is taken to avoid injury
heel so that the leg is not resting on the operating table,
which allows the muscles and tissues to fall away from the
fibula. The flap may also be raised with the patient in the
prone position, if necessary, using a roll under the anterior
ipsilateral hip and bending of the leg is not required.
ANESTHETIC CONSIDERATIONS
General anesthesia is commonly required for flap harvest
due to the pain involved with a thigh tourniquet, length of
the procedure, and the need for immobility during the
pedicle dissection. A regional block may be considered in
cases of lower extremity reconstructions or upper extremity
reconstructions where blocks of the lower and upper
extremities can be performed. However, due to the usual
length of the entire operative procedure and delicacy in the
steps of flap harvesting, inset, and microvascular anastomo­
ses, regional anesthesia is not advised and a general anes­
thetic is recommended.
TECHNIQUE OF FLAP HARVEST (Fig. 52.3)
OSSEUS FLAP
A line is drawn from the fibular head to the lateral malleolus
indicating the submuscular and subcutaneous course of the
fibula. The mid-point of this line is marked indicating the
approximate location of the nutrient vessel. The desired
length of fibula is typically 15–16 cm in an adult, and this is
marked using the approximate location of the nutrient
vessels as the central point of the donor osseous segment.
Fibular harvest begins by making a midlateral incision
over the fibula. A tourniquet is used to aid in dissection.
The tourniquet is placed in the mid- to upper thigh to avoid
compression over the fibular head and common peroneal
nerve. Initially skin flaps are elevated at the level of fascia.
The interval between the peroneus longus and soleus is
marked by a fat stripe. Dissection proceeds through the
facial over the lateral compartment. This incision in the
fascia is performed anterior to the posterior intermuscular
septum, through which fasciocutaneous perforators travel if
a skin paddle is to be included with the fibula. In the upper
part, identify and preserve the common peroneal nerve,
which winds around the head of the fibula and gives rise to
the superficial peroneal nerve. Dissect the peroneal muscles
off the anterior surface of the fibula reflecting the muscle
group anteriorly and incise the anterior intermuscular
septum to gain access to the anterior compartment. Dissect
the extensor digitorum and hallucis longus muscles until
the anterior tibial vessels, deep peroneal nerve, and the
interosseus membrane are identified (see Fig. 13.6). Large
arterial perforators to the soleus will require ligation for
adequate exposure of proximal peroneal vessels. The pero­
neal vessels are then mobilized from the proximal fibula.
The peroneal vessels are located between the tibialis poste­
rior and flexor hallucis longus muscles in this compartment.
Identify the peroneal vessels proximally and distally carrying
your dissection medial to the vessels and not between the
fibula and the vascular pedicle. Keep the vascular pedicle
with the fibula during the dissection.

CHAPTER 52 — Fibula Flap
601
Figure 52.3  Step by step fibula harvest. (A) Skin island is designed centered over the Dopplered perforators. (B) The anterior incision is
made down to the level of fascia. The fascia is incised over the lateral compartment and subfascial dissection proceeds posteriorly until the
posterior intermuscular septum is encountered and skin perforators are seen traveling within this septum. (C) Lateral compartment muscles
are dissected off of the fibula bone, leaving a 3 mm cuff of muscle to protect the periosteal blood supply. The anterior intermuscular septum
in this image, on the anterior border of the fibula. This septum is incised and the anterior compartment muscles are dissected off of the fibula
bone. The proximal and distal fibula bone is cut. (D) Bone clamps are placed and the fibula is retracted. The anterior compartment muscles
have been dissected off of the fibula bone and the interosseous septum is incised (see structure held in the forceps). The deep posterior
compartment muscles are exposed. (E) The posterior incision has been made and the skin island is dissected in the subfascial plane anteriorly
until the posterior intermuscular septum is met. The gastrocnemius and soleus muscles are dissected away from the skin island. (F) After
visualizing the posterior tibial vessels and nerve (seen in this image behind the retractors), the distal peroneal vessels are ligated. The FHL is
dissected away from the fibula bone from distal to proximal. The tourniquet is released for 20 min and the flap is harvested.
A
B
D
C
E
F

602
PART 4 — CONVENTIONAL WORKHORSE FLAPS
in a subfascial plane until the posterior intermuscular
septum is reached. Care is taken not to shear the thin pos­
terior intermuscular septum when turning the skin flap over
for the posterior dissection since this septum carries the
blood supply to the skin. The same posterior intermuscular
septum is visualized, from the posterior approach, with its
septocutaneous vessels coursing from the peroneal artery
and vein (Fig. 52.5). The dissection may be performed sub­
fascially at the outset; however, the superficial peroneal
nerve should be identified proximally and dissected free
from the flap tissue prior to the subfascial dissection. For the
musculocutaneous branches not coursing through the
septum the dissection of the vascular bundles must be
through the involved muscle. The intramuscular dissection
of these perforating vessels is initially carried out for a dis­
tance, which allows temporary application of a vascular
clamp and assessment of skin paddle circulation on release
of the tourniquet. If the skin flap circulation proves ade­
quate from the septocutaneous vessels traveling in the pos­
terior intermuscular septum, then the musculocutaneous
branches may be ligated. If the skin flap circulation is not
adequate or there are no vessels coursing through the pos­
terior intermuscular septum, then there should be an intra­
muscular dissection to the origins of the perforating vessels,
through the soleus muscle, to the peroneal artery (Fig. 52.6).
Once the cutaneous vessels are visualized from the poste­
rior approach, the dissection may proceed medially through
the transverse intermuscular septum, which separates the
soleus from the deep posterior compartment. At this point,
the anterior aspect is approached once again, and the pero­
neal muscles are elevated off the fibula retracting these
muscles anteriorly. A cuff of muscle (peroneus longus and
brevis) measuring around 3 mm is preserved over the fibula
to the superficial peroneal nerve and its branches, which lie
in this layer. The fascia is incised over the lateral compart­
ment 2–3 cm anterior to the posterior intermuscular septum.
The dissection is carried in the subfascial plane in a posterior
direction until the posterior intermuscular septum is
reached. Once the skin vessels are visualized running within
the septum, attention is directed toward making the poste­
rior skin incision, dissecting over the muscle fascia and pro­
ceeding in an anterior direction until the anterior margin
of the soleus muscle is visualized and the muscle fascia is
incised (Fig. 52.4). Dissection is then continued anteriorly
Figure 52.4  Posterior subfascial dissection. Care is taken to pre­
serve the posterior intermuscular septum which carries perforators to
the skin paddle.
Figure 52.5  Schematic visualizing posterior intermuscular septum from the posterior approach with its septocutaneous vessels coursing from
the peroneal artery and vein into the skin paddle of a fibula osteoseptocutaneous flap.
Osteocutaneous flap
skin paddle
Posterior intermuscular septum
Septocutaneous branches
Peroneus longus muscle
Flexor hallucis
longus muscle
Soleus muscle
Gastrocnemius
muscle

CHAPTER 52 — Fibula Flap
603
anterior and extensor digitorum longus muscles. The exten­
sor digitorum longus and the peroneus longus are sharply
detached from their proximal insertion at the level of the
emergence of the peroneal nerve into the anterior compart­
ment of the leg. The proximal muscular cuff must be left
attached to the fibular head since it contains the recurrent
epiphyseal branch of the artery. During this diaphyseal dis­
section as many periosteal branches as possible are pre­
served. It is recommended that the interosseus membrane
and a longitudinal strip of muscle be harvested as well in
order to protect the small branches from the main artery to
the diaphyseal periosteum of the proximal fibula. The pero­
neal nerve must be dissected from the anterior tibial vascu­
lar bundle. The proximal fibular epiphyseal region along
with its vascular pedicle is then harvested. The proximal
tibiofibular joint is opened and as much of the lateral col­
lateral ligament of the knee as possible is preserved. A strip
of biceps femoris tendon may be incorporated into the graft
to reinforce the soft tissue repair at the recipient site. The
artery is dissected until the origin of the anterior tibial
artery. The lateral collateral ligament along with the resid­
ual biceps femoris tendon is fixed to the lateral aspect of
the tibia to stabilize the knee. The fibula may be fixed to
the distal part of the radius stabilizing the wrist joint tem­
porarily with Kirschner wires. The strip of biceps femoris
tendon is used for soft tissue repair at the wrist by anchoring
it to the remaining distal radiocarpal capsule and ligaments.
The blood supply to the fibular head is from the descending
genicular or recurrent branch of the anterior tibial artery
and the blood supply to the diaphysis is from the peroneal
artery. The fibular head has been found to mold well to the
recipient site. The articular surface becomes more congru­
ent and growth matches that of the radius. By harvesting
the head of the fibula and lateral malleolus, the growth
plates of the fibula could be harvested with the flap for
reconstruction of bone defects in children (the growth
plates fuse in the late teen years). This will, however, increase
the morbidity at the donor site and may require including
the anterior tibial artery in order to maintain blood supply
to these growth plates. The blood supply to the growth
plates is thought to be from the lateral inferior geniculate
to ensure that the periosteal circulation is maintained.
The remainder of the dissection proceeds as that for the
osseous flap.
FLAP MODIFICATION/FLAP HANDLING
The graft may be remodeled in place before the vascular
pedicle is cut. Subperiosteal dissection at the distal and
proximal ends of the bone flap is continued as necessary to
modify bone length. Although in most cases we rely on
periosteal blood supply, endosteal blood supply is more
robust and should be preserved whenever possible. In cases
where it is preserved, the nutrient pedicle to the bone that
enters the middle third of the fibula during the osteotomies
for contouring. Depending on the type of osteosynthesis
chosen, the bone ends are rounded with the use of a rotat­
ing burr to be more easily infibulated in the tibial medullary
cavities or step cuts are performed at the fibula ends if
osteosynthesis with compression screws is planned in cases
of tibial reconstruction. Only minimal subperiosteal strip­
ping is recommended where osteotomies are made.
The fibula may be harvested as part of an osteocutaneous
flap with a large skin paddle for phalloplasty. In this case,
the superficial peroneal nerve is harvested and used to
innervate the skin paddle to create a sensate flap (Fig. 52.7).
Primary osteointegration of teeth may be performed
at the time of free fibula reconstruction in patients with
non-tumor pathologies and low malignancy tumors with
excellent prognoses and no postoperative radiotherapy
requirement. Particular attention is given to maintaining
good vascularity of the bone segments by minimizing the
number of osteotomies, unnecessary stripping of perios­
teum, and excessive placement of screws in each segment.
The proximal fibula and its epiphyseal plate (contralat­
eral side) may be used for proximal radius reconstruction
(Video 52.1).8 The proximal fibular epiphyseal region can
be transferred based on the recurrent epiphyseal branch
which originates from the anterior tibial artery 2 cm distal
to its origin. Preoperative angiography is recommended in
this type of case in order to visualize this branch. Dissection
is performed in the intermuscular plane between the tibialis
Figure 52.6  Fibula osteoseptocutaneous flap showing intermuscu­
lar septum and separate perforating vessel after intramuscular dis­
section through the soleus muscle to its peroneal artery origin.
Figure 52.7  Superficial peroneal nerve is dissected and used to
innervate the skin paddle to create a sensate flap in phalloplasty.

604
PART 4 — CONVENTIONAL WORKHORSE FLAPS
8. If the flexor hallucis longus is significantly injured or
devascularized following fibula harvest, remove the
muscle in its entirety to prevent postoperative great toe
contracture secondary to muscle fibrosis.
9. When a skin paddle is taken with the fibula graft, a
meshed skin graft is always used to cover the donor site;
attempts at primary closure have been linked to cases
of compartment syndrome in the donor leg. We have
closed defects <4 cm without morbidity but it is always
safer to skin graft. The skin graft may be excised later
if necessary or so desired.
10. Do not exsanguinate the limb excessively. Leaving a
small amount of blood in the limb vessels will aid in
visualization of the perforators. On the other hand,
inadequate exsanguination will make separation of the
peroneal pedicle from the flexor hallucis longus and
other surrounding structures difficult since the vein will
be distended.
11. We usually inflate the tourniquet to 275–325 mmHg.
12. Meticulous closure of the donor site, with particular
attention to the flexor hallucis longus muscle, is critical
to decreasing donor limb morbidity.
13. During dissection of the flexor hallucis longus muscle
off of the fibula and the peroneal vessels, care is taken
in visualizing and ligating (using hemoclips) all of the
branching vessels from the peroneal bundle. Visualizing
the pedicle at all times will avoid the potential for
damage to the pedicle and branches supplying the cuta­
neous paddle.
14. When performing a pedicled bone or bone and skin
flap, care is taken to ensure that the pedicle is not com­
pressed, twisted, or kinked. Wide exposure of the recipi­
ent site is recommended and the inset of the pedicle is
performed under clear visualization. The pedicle can
then be covered with local skin and the rest of the defect
can be skin grafted. The incisions should be planned
with this in mind. The dissection is performed with
>×2.5 loupe magnification.
15. After fibula harvest, dissect out 1–2 cm of the perios­
teum and pedicle complex off the fibula bone. This will
prevent kinking at that site and allow for a smooth
pedicle position at the recipient site.
16. When inserting plates for flap fixation at the recipient
site, unicortical screws are sufficient and prevent pedi­
cle injury. The screws are placed on the anti-peroneal
artery side, since it is smooth and will prevent vessel
injury.
17. During inset, ensure that the pedicle is not compressed
in areas that are not easily visualized in respect to the
bone.
18. Do not strip the periosteum at the bone and plate inter­
face and perform only minimal periosteal stripping at
the points of screw insertion.
FLAP USAGE
USE OF THE FLAP
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
• Segmental loss of long bones, metatarsal bones, or cra­
niofacial skeleton secondary to trauma, infection
artery, a branch of the popliteal artery, and possibly from
branches of the anterior tibial artery.
DONOR SITE CLOSURE AND MANAGEMENT
Once the fibula graft is removed, the tourniquet is released
and hemostasis obtained. The remaining flexor hallucis
longus muscle is sutured to the tibialis posterior muscle and
to the interosseous membrane to help preserve great toe
flexion. It is very important to perform this repair with the
foot in a neutral position. A suction drain may be placed
between the muscles exiting the inferior limit of the skin
incision. The skin is closed primarily or a skin graft is used
to cover the defect. We recommend the liberal use of a skin
graft, particularly if the defect is >6 cm in width. If the deci­
sion is made to close the donor defect primarily, then one
must evaluate for clinical signs of compartment syndrome
in the postoperative period. A posterior splint is used to
keep the foot in the neutral position to avoid skin graft
shearing and wound separation.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
1. Preoperative vascular studies, while controversial in the
literature, have been very useful in preoperative plan­
ning in cases of post-traumatic reconstruction and in
patients with peripheral vascular disease. A CT angio­
gram is obtained in all patients in preparation for free
fibular transfer. Unlike a formal angiogram, a CT angio­
gram adds no additional morbidity while providing
information on inflow and outflow vessels in both legs.
In 8% of the population the peroneal artery is the domi­
nant arterial supply to the leg (peroneal arteria magna)
and in such cases the contralateral leg should be con­
sidered for flap harvest.
2. We have found it helpful to always include a skin paddle
in the flap design; you never know when you will need
it and it facilitates postoperative flap monitoring.
3. Inclusion of a cuff of soleus muscle or flexor hallucis
longus (FHL) muscle can be performed if there is
concern about the perforators to the skin island.
4. In order to stabilize the ankle, 6 cm of the distal fibula
must remain intact. In the skeletally immature patients,
we always perform a syndesmosis at the lateral malleolus
following fibula harvest.
5. Once the fibula is visualized, begin dissection in a sub­
periosteal plane at the superior margin of the fibula
until one clearly identifies the peroneal nerve, then
dissection may be continued superficial to the perios­
teum. This will help prevent iatrogenic deep peroneal
nerve injury.
6. Once harvested, a portion of the distal fibula may
be removed with preservation of a vascular cuff of peri­
osteum. This cuff may be wrapped around the bone at
the recipient site to speed bony union. Removal of
excess proximal fibula allows for extension of the vascu­
lar pedicle. Care should be taken in the middle third of
the fibula not to disrupt the nutrient vessel to the bone.
7. The surgeon should always visualize the tibial nerve and
posterior tibial artery prior to ligation of the peroneal
vessels.

CHAPTER 52 — Fibula Flap
605
OUTCOMES
EXPECTED OUTCOMES
DONOR SITE
Pain with ambulation is reported in the immediate postop­
erative period in approximately 17% of patients. Almost all
patients can expect to have minimal or no discomfort with
walking by an average of 4–6 weeks after surgery. Postopera­
tive weakness of the ankle and great toe flexion is seen in
approximately 15–30% of patients. Similarly, a temporary
and mild joint stiffness about the ankle and great toe is seen
in 10–40% of patients. Toe flexion strength is expected to
be excellent when proper closure and reposition of the FHL
is performed. Clinical series have consistently shown that
with routine physical therapy, virtually all patients can
expect to resume normal ambulation close to their preop­
erative level of activity.
RECIPIENT SITE
Bone healing is expected at the recipient site in most cases
and the skin island is expected to heal without problems.
UNTOWARD OUTCOMES
DONOR SITE
Specific complications related to the donor area may be
divided into early and late complications. Other than a 2%
incidence of infection, the most common early complica­
tions reported are decreased flexion power of the big toe,
paresthesia, disesthesia of the dorsum of the foot, and, only
rarely, foot ischemia and lesions of the sciaticus popliteus
nerve with loss of foot dorsiflexion. Among the 27% inci­
dence of late complications reported, the most common are
edema, pain with ambulation, stiffness of the ankle, hyper­
trophic scarring, and rarely, instability, and tibial curvature
in children. Toe flexion contracture occurs in some cases
where the FHL has been significantly devascularized or
denervated, or the closure was not adequate.
Skin grafts to fibula donor sites consistently heal well,
usually with a satisfactory cosmetic result. Wound complica­
tions are seen as evidenced by skin graft loss, particularly
over peroneal tendons, and can occur in up to 7% of cases.
Secondary healing in these cases may be prolonged but is
usually successful.
More rare complications include heterotopic bone for­
mation at the donor site and nerve injury. Neuropraxia of
the superficial peroneal nerve is the most common nerve
injury seen with fibula harvest and is most likely related to
retraction compression. These cases are usually self-limited
and not associated with long-term sequelae.
RECIPIENT SITE
With regard to microvascular complications, the bone flap
may tolerate venous thrombosis for up to 24 h because of
spontaneous bleeding from the medullary canal before the
artery undergoes thrombosis, but vein drainage of the skin
paddle must be supported with an early return to the oper­
ating theater on detection and revision of the venous anas­
tomoses or augmentation with a second vein. In the worst
scenario of an arterial thrombosis with failed revision, the
(osteomyelitis), radiation-induced necrosis (osteoradio­
necrosis), or after tumor extirpation9–11
• Avascular necrosis of the femoral head12,13
• Pseudarthrosis (congenital or acquired) of the tibia,
radius, or ulna14,15
• Club hand (radial or ulnar)16
• Bone lengthening.17,18
ATYPICAL INDICATIONS FOR THE USE OF THIS FLAP
• Penile reconstruction19,20
• Vertebral body reconstruction21,22
• Pelvic ring reconstruction23,24
• Proximal fibular head for reconstruction of the distal
radius or proximal humerus.8
POSTOPERATIVE CARE
DONOR SITE
The donor leg is monitored postoperatively for signs and
symptoms of vascular insufficiency or compartment syn­
drome, particularly if primary closure is performed. A pos­
terior splint is applied that extends beyond the first toe. This
will hold the ankle in correct functional position during
healing and will keep the distal phalanx of the toe in an
extended position to avoid flexion contracture of the distal
phalanx of the first toe that can occur due to devasculariza­
tion or denervation of the FHL muscle. Evaluate suction
drains daily and remove them only when <30 mL of serum
is collected within a 24 h period. If a skin graft has been
applied to the donor leg, a bolster dressing is not placed;
however, adequate compression is provided by circumferen­
tially wrapping the leg with a compressive, but not too tight,
dressing. It is preferable to evaluate the skin graft the first
or second postoperative day as hematomas can be removed
or seromas can be drained. Another compressive dressing
is placed at that point and the skin graft is reevaluated at
postoperative day 4 or 5. No ambulation is allowed within
the first 2 weeks. Upon ambulation, partial weightbearing is
begun with the aid of crutches followed by full weightbear­
ing ambulation.
RECIPIENT SITE
When a skin island is harvested with the flap, clinical moni­
toring of the flap color, temperature, turgor and capillary
refill are performed every 30 min to 1 h for the first 24 h.
The handheld Doppler probe can be used for buried bone
flaps and as an adjunct to monitoring of flaps with a skin
island. More aggressive monitoring even up to the 3rd to
5th operative day, can result in salvage of some flaps that
undergo compromise. Therefore, monitoring is performed
every hour in the 2nd and 3rd postoperative days, and four
times per day thereafter until discharge, to check the micro­
anastomotic patency and to survey the skin or muscle island
perfusion.
Bone union may be evaluated with serial radiographs or
bone scans at 6 weeks, 3–6 months, and 1 year following
surgery. Radiologically, bone union is achieved when conti­
nuity is obtained in two planes and the fracture line has
disappeared.

606
PART 4 — CONVENTIONAL WORKHORSE FLAPS
been reported. Thus, a distal tibiofibular fusion may be
performed in children to avoid valgus deformity of the
ankle. Fixing the tibia to the fibula distally may, however,
impair normal movement of the ankle during flexion and
extension, further leading to diminished mobility of the
joint overall.
CONCLUSIONS
The fibula flap with its long bone stock, long and large
vascular pedicle, and its reliable skin paddle, has revolution­
ized reconstruction of bone defects throughout the body.
Its use as a pedicled flap for reconstruction of tibia defects,
and its use as a free flap for reconstruction of mandible,
humerus, femur, and other bone defects with or without soft
tissue has made it a favorite for many surgeons performing
these reconstructions.
fibula bone alone can survive in place as a simple graft. If
the recipient bed has been radiated in the past, then adjunc­
tive HBO (hyperbaric oxygen) therapy will aid in bone graft
survival. On the contrary, the skin island is very delicate
because it relies on few and small perforating vessels and is
very sensitive to circulatory changes.
LONG-TERM OUTCOMES
Patients are typically able to regain weightbearing ambula­
tion and are pain-free on average 4–6 weeks after fibula
harvest. Frequent patient complaints include pain in over
50%, sensation of ankle instability in 30%, and an inability
to run in about 20%. Walking during complex tasking and
at high velocities may reveal an incomplete restoration of
gait after partial fibulectomy; however, although not a
perfect donor site, it is the most ideal for composite tissue
transplantation requiring bone. In children, some instances
of tibial curvature and valgus deformity of the ankle have

CHAPTER 52 — Fibula Flap
607
A 65-year-old woman, with a history of tonsillar cancer under-
went resection and radiation and was admitted with osteoradio-
necrosis of the mandible with multiple oral mucosal openings.
She underwent resection of the involved mandible with closure
of oral fistulas and was scheduled for mandible reconstruction
with a fibula osteoseptocutaneous flap, several months later
(Figs 52.8–52.12).
The flap is marked and harvested (see also Fig. 52.3).
CASE 52.1  Fibula for Mandible
Figure 52.8  (A) A 65-year-old woman with a history of tonsillar cancer before procedure. (B) Lateral 3D image showing resection of
mandible using data from CT scan.
A
B
Figure 52.9  Virtual surgical planning was used in this procedure. (A) The remaining mandible was positioned in the native position. (B)
Then using CT data of the patient’s lower extremity and skull, the fibula is brought into position and osteotomized virtually. The fibula is
positioned slightly above the inferior border of the native mandible. The goal is to achieve good contour of the face while having the
implants high enough to perform dental rehabilitation.
A
B

608
PART 4 — CONVENTIONAL WORKHORSE FLAPS
CASE 52.1  Fibula for Mandible—cont’d
Figure 52.10  (A) The cutting guides are placed on the fibula bone and osteotomies are performed. The periosteum is stripped away
from the proximal fibula. (B) The fibula is inset into the pre-bent plate. (C) The skin island is inset into the oral cavity. (D) Due to lack of
good recipient vessels in the upper neck, the transverse cervical vessels were used.
A
B
C
D
Figure 52.11  (A) Patient 18 months following the reconstruction and (B) complete dental rehabilitation.
A
B
Continued