Scand J Plast Reconstr Surg Hand Surg, 2006; 40: 106
/110

ORIGINAL ARTICLE

Our experience with the lateral supramalleolar island flap for

reconstruction of the distal leg and foot: A review of 20 cases
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EFTERPI DEMIRI, PERICLIS FOROGLOU, DIMITRIOS DIONYSSIOU,

ANTONIOS ANTONIOU, PARASKEVAS KAKAS, LEONIDAS PAVLIDIS &
LAMPIS LAZARIDIS

Department of Plastic Surgery, Papageorgiou Hospital, Aristotle University of Thessaloniki, Greece

Abstract
We describe our experience with, and evaluate the reliability of, the lateral supramalleolar flap that was used in 20 patients
for reconstruction of the distal leg and foot. There were 14 men and six women, age range 20
/83 years. Nine were diabetic.
The causes of the skin defects included trauma, diabetic ulcer, and deep burn. Sites of defects were the lower leg, the
Achilles tendon, the dorsal and lateral aspect of the foot, and the ankle. Nineteen flaps survived and provided satisfactory
coverage of the defect. Four flaps showed partial necrosis and required revision. We think that the lateral supramalleolar flap
For personal use only.

is a good way to reconstruct soft tissue defects of the lower extremity. Based on a secondary vascular axis, it has a large skin
paddle and a wide rotation arc that reaches the distal areas of the foot.

Key Words: Lower extremity, soft tissue defects, axial fasciocutaneous flaps, lateral supramalleolar flap

Introduction raised either as a peninsular flap with a distal skin

Reconstruction of soft tissue defects of the lower
extremity is a common and challenging problem.
Because of the limited availability of local tissues,
particularly in the lower leg and foot, the use of
distant flaps for covering those defects often looks
necessary. Cross leg flaps have been used in the past,
but have few indications nowadays. Free tissue
transfer may offer the best surgical option in most
cases; use of free flaps, however, is always associated
with risk at the anastomosis. As well as the free
transfer techniques, axial pedicled flaps harvested
from the leg can often provide good and safe
reconstructive solutions with relatively simpler tech-
niques.
The lateral supramalleolar flap is one of the series
of flaps that has been described in the last decades
and are based on the secondary arteries of the limb
[1]. It is a fasciocutaneous flap that is raised on the
lateral aspect of the lower leg and it is usually used as
a distally-based pedicled flap for covering defects on
the lower third of the leg and the foot. It can be
hinge, or as a true island flap that does not require
the dissection of the pedicle.
The aim of this retrospective clinical study was to
describe our experience with, and evaluate the
reliability of, the lateral supramalleolar island flap
that has been used in 20 patients for reconstruction
of the distal leg and foot.
Patients and methods
Patients
During the last six years, 20 patients who presented
with soft tissue defects of the lower extremity
underwent reconstruction with the lateral supramal-
leolar island flap. There were 14 men and six
women, and their ages ranged from 20 to 83
(mean 51) years. In 15 cases, the cause of the skin
loss was previous injury to the limb; four defects
were diabetic ulcers, while one patient presented
with a deep burn over the posterior aspect of the
heel. Nine patients were diabetic, and one man was

Correspondence: Efterpi C. Demiri, MD, Assistant Professor of Plastic Surgery, Department of Plastic Surgery of the Aristotle University of Thessaloniki,
100 Tsimiski St. GR-54622, Thessaloniki, Greece. Tel: /302310244180, /306945878885. Fax: /302310244180. E-mail: edemiri@med.auth.gr

(Accepted 1 December 2005)

ISSN 0284-4311 print/ISSN 1651-2073 online # 2006 Taylor & Francis
DOI: 10.1080/02844310500523740

being treated with corticosteroids for connective
tissue disease.
The defect was on the Achilles tendon (n /9),
the frontal aspect of the lower leg (n /5), the dorsal
and lateral aspect of the foot (n /3), and the lateral
malleolus or posterior heel (n /3). The dimen-
sions of the skin paddle ranged from 20 to 60 cm2
(Table I).
Method
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Preoperatively, all patients had a Doppler examina-
tion to identify the site of the perforating branch of
the peroneal artery, over the inferior tibiofibular
syndesmosis. The skin paddle of the flap was out-
lined over the lateral aspect of the leg, according to
the dimensions of the defect to be covered.
After a pneumatic tourniquet had been placed
around the thigh, we debrided the recipient area
and prepared the defect for coverage. In all cases,
we used an island rotation flap based on a
subcutaneous fascial pedicle that was dissected
subdermally using a ‘‘lazy-S’’ skin incision. The
skin paddle of the flap was incised circumferentially
For personal use only.
starting from the anterior margin, and progressively
reflected including the fascia. Proximally, the
superficial peroneal nerve that runs subfascially
was divided and its proximal end buried in the
muscles. The flap was then dissected from proxi-
mal to distal, with the division of the septum
lying between the anterior and lateral compart-
ments close to the fibula. The subcutaneous
pedicle was dissected down to the emergence of
the perforating branch, which constitutes the piv-
otal point; the vascular pedicle was not exposed
and a distal hinge was maintained. The flap was
now ready to be transposed to the defect. The
vascular supply to the flap was checked after
releasing the tourniquet.
In 12 cases, we developed a wide subcutaneous
tunnel superficial to the underlying fascia to the
ulcer defect; the flap was brought through the tunnel
and sutured loosely into place (Figure 1). In the rest
of our patients, incision of the local tissues was
essential to avoid pressure over the nutrient vessels.
A split thickness skin graft was applied over the
donor defect, either primarily (n /11) or secondarily
(n /9).
A diabetic woman, who presented with extensive
tissue loss over the lateral aspect of the foot, required
a delayed procedure. Because of intraoperative
perfusion disturbances after the flap had been raised,
we bedded it on silicone foil and sutured it back in
place. It was transposed to cover the defect seven
days later (Figure 2).
Lateral supramalleolar island flap 107
Results
Nineteen of the 20 flaps in our series survived and
provided satisfactory coverage of the defect (95%).
One flap necrosed completely, which was attributed
clinically to arterial insufficiency and occurred in a
diabetic immunosuppressed man. Four patients
required revision of partial necrosis or a necrotic
tip; a split thickness skin graft was applied over the
flap margins or the pedicle. In one patient, venous
congestion developed for a few days postoperatively
but subsided, and the flap survived completely.
In seven patients, five of whom were diabetic, we
recorded a partial ‘‘take’’ of the primary skin graft, so
re-grafting was required.
Data up to 48 months after the initial operation
(mean follow up 15.5 months) show that the lateral
supramalleolar flap offered stable coverage of the
defect with no signs of recurrence of the recon-
structed ulcers.
Morbidity of the donor area was minimal. Scars
were well accepted by the patients, while the sacrifice
of the superficial peroneal nerve caused no serious
functional problems; no painful neuromas were
recorded.
Discussion
The lateral supramalleolar flap has been judged
favourably since it was first described by Masquelet
et al. in 1988 [1], and it was recommended for
managing various skin defects on the lower leg and
foot [2
/5]. It is based on a secondary vascular axis,
and has a large skin paddle, which presents a wide
range of coverage including the distal quarter of the
anteromedial aspect of the leg, the whole dorsum of
the foot, the medial and lateral malleoli, the Achilles
tendon, and the heel.
In 1991, Valenti et al. showed the reliability of the
subcutaneous vascular network of the flap, which is
supplied by the terminal branches of the perforating
branch of the peroneal artery [3]. They proposed a
more proximal design for the flap, which was
mobilised on its vascular fasciosubcutaneous ped-
icle. As a distally-based flap with a compound
vascular pedicle and subcutaneous tissues it can
reach the most distal areas of the foot, up to the
base of the toes. In addition, using this technical
variant, we avoid skin grafting over the tendinous
area of the lower leg, and so donor site morbidity is
minimised [5].
Following these technical refinements, we used
the flap as an island rotation flap based on an
adipofascial pedicle, which provided considerable
possibilities for covering distal defects of the leg and
foot successfully in most of our patients. From our
 108 E. Demiri et al.
Table I. Profiles of the 20 patients of our series.

Case Age LSMF skin Donor site Graft take on Second operation
No. (years) Sex Site of defect Aetiology Disease paddle (cm2) grafting Result donor site (%) needed

1 65 F Achilles tendon Trauma Diabetes 30 Immediate Good 30 STSG on donor

site
2 21 M Lateral malleolus Trauma
/ 60 Immediate Very good 100
/
3 20 F Posterior heel Frostbite
/ 36 Immediate Partial ne- 80 STSG on recipient
crosis site
4 24 F Distal leg Trauma
/ 40 Immediate Very good 100
/
5 83 F Achilles tendon Trauma Diabetes 40 Delayed Superficial 100 STSG on exposed
necrosis adipofascial pedicle
and flap
6 51 M Achilles tendon Diabetic Diabetes & 54 Immediate Complete 100 Cross leg
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ulcer systemic necrosis

disease
7 78 M Distal leg Trauma Diabetes 45 Immediate Very good 60 STSG on donor
site
8 46 M Distal leg Trauma
/ 48 Immediate Very good 100
/
9 59 M Distal leg Trauma
/ 40 Delayed Very good 100
/
10 48 F Lateral aspect of Diabetic Diabetes 50 Delayed Very good 100 ‘‘Delay’’ procedure
foot ulcer for flap transfer
11 59 M Foot dorsum Trauma
/ 42 Delayed Very good 100
/
12 58 M Achilles tendon Diabetic Diabetes & 48 Immediate Venous 40 STSG on donor
ulcer arteritis stasis site
13 66 M Lateral malleolus Trauma Diabetes 20 Delayed Good 90
/
14 31 M Distal leg Trauma
/ 35 Delayed Very good 100
/
15 73 M Foot dorsum Diabetic Diabetes & 45 Delayed Very good 100
/
ulcer arteritis
16 68 M Achilles tendon Trauma
/ 45 Delayed Very good 100
/
17 45 M Achilles tendon Trauma
/ 24 Delayed Very good 100
/
18 36 M Achilles tendon Trauma
/ 42 Immediate Partial ne- 70 STSG on
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crosis recipient/donor
site
19 38 F Achilles tendon Trauma
/ 35 Immediate Very good 100
/
20 57 M Achilles tendon Trauma Diabetes & 42 Immediate Partial ne- 70 VAC-STSG on
arteritis crosis recipient/donor
site

F/female, M/male, LSMF/lateral supramalleolar flap, STSG/split thickness skin graft, VAC/Vacuum Assisted Closure.

series of 20, nine patients were diabetic. Although
diabetes is one of the most important risk factors,
and is associated with high morbidity [6], it should
not present an absolute contraindication for using
this flap, particularly in view of the extremely limited
number of options. According to our results, all
diabetic patients except one had a successful recon-
struction of the defect with this flap; minor surgical
revisions were required in only four cases to treat
partial necroses. A delayed procedure as done for
one of our patients may also be helpful for improving
vascular supply of the flap in patients with increased
comorbidity.
The findings of a recent study of Malikov et al.
[7] about the surgical anatomy of the lateral
supramalleolar flap in arteritic patients are inter-
esting. They concluded that, while the perforating
branch of the peroneal artery was found in all
cases, the vascular network of the superficial
peroneal nerve is always part of the vascularisation
of the flap. Its preservation in the distal part of the
flap therefore offers a second vascular flow to the
pedicle of the flap that is critical, particularly in
high-risk patients.
It was Salmon [8] who first introduced the idea
that the superficial nerves of the leg (the saphenous,
sural, and superficial peroneal nerves) are accom-
panied by rich arterial axes that deliver small
branches to supply the skin and support numerous
anastomoses with the suprafascial network and the
deep main vessels of the leg. Anatomical studies that
were carried out by Masquelet et al. in 1992 [2]
confirmed these observations and pointed out many
similar characteristics in the vascular supply between
the lateral supramalleolar and the sural artery flap.
The distally-based sural flap constitutes the main
local choice for covering similar defects of the foot
and the lower leg. The popularity of the sural flap
has increased throughout the years, with favourable
results reported almost uniformly [6,9
/11]. Touam
et al. in a comparative study concluded that the sural
neurocutaneous flap is much more reliable, whereas
the lateral supramalleolar flap should be used only
when the sural flap is contraindicated [11]. Based on
our experience with both flaps, we think that the
main indications for these two flaps are similar. We
agree, however, with Voche et al. [4] that for cover-
ing the medial malleolar area, the Achilles tendon,
 Lateral supramalleolar island flap 109
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Figure 1. (a ) Post-traumatic soft tissue defect over the lateral malleolus in a 21-year-old man that is exposing the underlying bones. (b ) The
For personal use only.

flap raised with subdermal dissection of the pedicle. (c ) Coverage of the defect with the flap that was brought through a subcutaneous
tunnel. The donor area was immediately grafted. (d ) Good final result at three months.

and the distal areas of the foot, the lateral supra-
malleolar flap is the best reconstructive solution and
offers better results.
In cases of coverage of the heel, particularly when
defects are located on the weight-bearing zones,
the supramalleolar flap is not recommended [5].
Although both neurocutaneous flaps of the leg
contain sensitive nerve branches, they do not provide
the sensitive skin paddles, which are essential for
functional reconstruction of this area. The treat-

Figure 2. (a ) Composite tissue defect after wide surgical debridement of necrotic tissues in a 48-year-old diabetic woman. Design of a
10/5 cm skin paddle of a lateral supramalleolar flap. (b ) After dissection, the flap was resutured in place for seven days (delayed
procedure). (c ) Transposition of the flap for covering the defect through a wide subcutaneous tunnel. (d ) Final result at seven months.
 110 E. Demiri et al.
ment of choice is the use of the medial plantar flap
which provides tissues with similar texture and
sensate skin [12].
Healing of the donor site was a problem in our
patients, mainly because of the high rate of ‘‘non-
take’’ of the primary skin grafts. Recently, we have
preferred to graft the donor defect secondarily after
granulation, and results were much better. The flap
can also be safely used as a pure adipofascial flap
[13], which provides for a thin reconstruction with
fine contour to the recipient area, with minor
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aesthetic alterations to the donor site that does not
need to be grafted.
In conclusion, we find that the lateral supramal-
leolar flap is versatile and effective for reconstruc-
tion, and one that should certainly maintain its
position as a useful tool when dealing with recon-
structions of the distal leg and foot.
[10] Raveendran SS, Perera D, Happuharachchi T, Yoganathan
References
[11] Touam C, Rostoucher P, Bhatia A, Oberlin C. Comparative
[1] Masquelet AC, Beveridge J, Romana C, Gerber C. The
lateral supramalleolar flap. Plast Reconstr Surg 1988;81:74
/
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81.
[2] Masquelet AC, Romana MC, Wolf G. Skin island flaps
[12] Harrison DH, Morgan BDG. The instep island flap to
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supplied by the vascular axis of the sensitive superficial
nerves: anatomic study and clinical experience in the leg.
[13] Lee YH, Rah SK, Choi SJ, Chung MS, Baek GH. Distally
Plast Reconstr Surg 1992;89:1115
/21.
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[3] Valenti P, Masquelet AC, Romana C, Nordin JY. Technical
refinement of the lateral supramalleolar flap. Br J Plast Surg
1991;44:459
/62.
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[4] Voche P, Stussi JD, Merle M. Le lambeau supramalléolaire
latéral. Notre expérience de 35 cas (The supramalleolar
flap. Our experience in 35 cases). Ann Chir Plast Esthet
2001;46:112
/24.
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[5] Voche P, Merle M, Stussi JD. The lateral supramalleolar
flap: experience with 41 flaps. Ann Plast Surg 2005;54:49
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54.
[6] Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS,
Germann GK. A realistic complication analysis of 70 sural
artery flaps in a multimorbid patient group. Plast Reconstr
Surg 2003;112:129
/40.
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[7] Malikov S, Casanova D, Magualon G, Branchereau A.
Surgical anatomy of the lateral supramalleolar flap in arteritic
patients: an anatomic study of 24 amputation specimens.
Surg Radiol Anat 2003;25:89
/94. / /
[8] Salmon M. Les artères de la peau (Arteries of the skin).
Paris: Masson; 1936.
[9] Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying
arteries of the lesser saphenous vein and sural nerve:
anatomic study and its clinical applications. Plast Reconstr
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/20.
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V. Superficial sural artery flap
/ a study in 40 cases. Br J
Plast Surg 2004;57:266
/9. / /
study of two series of distally based fasciocutaneous flaps for
coverage of the lower one-fourth of the leg, the ankle, and
the foot. Plast Reconstr Surg 2001;107:383
/92.
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resurface plantar defects. Br J Plast Surg 1981;34:315
/8.
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based lateral supramalleolar adipofascial flap for reconstruc-
tion of the dorsum of the foot and ankle. Plast Reconstr Surg
2004;114:1478
/85.
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