The Lateral Supramalleolar Flap A.C. Masquelet, M.D., J. Beveridge, M.D., C. Romana, M.D., and C. Gerber, M.D. ris, France, Sasatoon, Cade, ond Bern, Suitzesland An anatomic study (40 fresh dissected specimens) and linical experience (14 patients) have shown the reliability ‘of a skin flap designed on the lower third of the lateral aspect of the leg. It is supplied by a cutaneous branch from the perforating branch of the peroneal artery. Th perforating branch continues distally deep to the fascia along the anterior ankle and into the foot. This can be used as a reversed pedicle, giving the flap an arc of rotation that allows coverage of the dorsal, lateral, and plantar aspects of the foot, the posterior heel, and the ower medial portion of the leg, Many procedures have been described to re- surface foot and ankle defects. The most com- monly used include skin grafts, local pedicle flaps," distally and proximally based islands flaps,"®cross-leg flaps," and free skin and muscle flaps.!'? The aim of this article is to present an anatomic study and clinical experience relating toa new skin flap for use in the lower leg and foot. This flap, the lateral supramalleolar flap, is, raised on the lateral aspect of the lower third of the leg and is supplied by a terminal branch of the peroneal artery. MATERIALS AND METHODS ‘The anatomic study was carried out on 40 fresh cadaver legs injected with colored latex by means of the femoral artery. The vascular anas- tomotic circle of the lateral malleolar area and the blood supply to the skin of the lateral aspect, of the distal part of the leg were studied. Clinical cases include 14 patients who presented with soft- tissue defects of the foot, ankle, or lower third of the leg. Resurs Our anatomic findings demonstrated a con- stant pattern of arterial distribution on the lateral Fic. 1. The general pattern of the arterial distribution fon the lateral walleolar area! (J) retinaculum extensorum superius, (2) proximal col- lateral branch from the anterior tibial artery, (3) anterior tibial artery. (4) extensor hallucis longus, (5) dorsalis pedis artery. (6) tibialis anterior nerve, (7) lateral tarsal artery, (8) sinus tars artery, (9) lateral malleolar artery, (20) exten sor digitorum longus, (1) superficial peroneal nerve, (12) cutaneous branch for the flap issued from the perforating branch of the peroneal artery, (13) descending branch of the perforating branch of the peroneal artery, (14) periostic vessels from the descending branch of the peroneal artery, (15) anastomotic branch to the posterior peroneal artery. (Z6) peroneus brevis, and (17) anastomotic branch to the Tateral plantar artery. rom the Department of Orthopedic Surgery at Trovsscau Hospital in Pars, Prance: the Department of Plastic Surgery atthe University ‘of Saskatchewan in Saskatoon, Coad publication Seperaber 11, 1986; revised January 7, 1987, rad the Department of Orthopedic Surgery athe tmelspital in Bern, Switzerland. Revelved ForVol. 81, No. I / THE LATERAL SUPRAMALLEOLAR FLAP 75 malleolar area (Fig. 1). The perforating branch issuing from the posterior peroneal artery is the key to this system. This branch is well demon- strated in standard anatomic textbooks, but the descriptions are not detailed enough to allow their use clinically. The perforating branch of the posterior pe- roneal artery is constant and always emerges from the groove between the tibia and fibula just proximal to the distal tibiofibular ligaments, where it perforates the interosseous membrane, The perforating branch is located 5 cm above the lateral malleolus and always divides into two branches just after it perforates the interosscous membrane: a superficial cutaneous branch and a deep descending branch The first (cutaneous) branch is included in the intermuscular septum between the extensor dig- itorum longus and the peroneus brevis. Then it perforates the fascia and divides in the subcuta- neous tissue to supply the skin over the lower lateral half of the leg. The ascending portion of this artery continues within the subcutaneous Fic. 2. The design of the lateral supramalleolar flap on the lateral aspect of the leg. ‘The posterior margin must not overlap the crest of the fibula. The lower incision allows the discovery of the reverse pedicle of the fap, tissue of the lateral aspect of the leg. It supplies a skin territory whose size is approximately 12.0 to 18.0 cm in length and 9.0 cm in width. This can be demonstrated by injections of methylene blue: the skin territory corresponds to the lower half of the leg from the tibial crest to the poste- rior border of the fibula. ‘The second (deep descending) branch contin- ues distally below the deep fascia within a loose connective tissue, following the anterior aspect of the lateral malleolus. Tt anastomoses, at a variable level, with the lateral malleolar branch of the tibialis anterior artery. ‘The artery then continues into the foot, where it divides into its terminal branches, forming anastomoses with the sinus tarsi, lateral tarsi, posterior peroneal, and lateral plantar arteries. In two cases in the ana- tomic study, we have not found a well-defined artery but rather a vascular network which en- sured the continuity of blood flow. Other cuta- neous branches may originate from the tibialis anterior artery or peroneal artery to supply this Fic. 3. The elevation of the flap includes the aponeuross ‘The elevation is carried out from the anterior incision until the perforating artery and its eutancous branch are exposed, ( cutaneous branch for the flap; —> sensitive branch from the superficial peroneal nerve; «= descending branch of the peroneal artery)16 PLASTIC AND RECONSTRUCTIVE SURGERY, January 1988 territory, but they are not required in the design of the Map. The anatomic variations found in- cluded the following: 1. The inconstant presence of a proximal col lateral branch from the tibialis anterior ar- tery 2. ‘The presence of the anterior peroneal ar- tery. 3. Variations in the level of anastomosis be- tween the perforating branch of the pero- neal artery and the lateral malicolar artery arising from the tibialis anterior artery 4, The presence of a vascular network instead of a well-defined artery (2 cases) However, these variations do not affect the de- sign of the flap, FLaP DESIGN AND OPERATIVE PROCEDURE According to the way the vascular pedicle is designed, there are two types of blood supply, but the cutaneous portion of the flap remains the same. The distal end of the flap must include the emergence of the perforating branch of the pe- Fig. 4. The rotation flap. This type of flap is supplied by © perfora antegrade flow from ¢ ng branch of the peroneal artery, Incision over the lateral malleolus is not necessary if the pivot point of the flap is the perforating artery ( ‘cutaneous branch for the fap: superficial peroneal nerve). Fic. 5. Elevation of a distally based island flap. Arrow indicates cutaneous pedicle for the flap isued from the perforating branch of the peroneal artery. Double arrow Indicates the lateral malleokar artery. Sear indicates sinus reversed pedicle. Elevation of the tarsi pivor center of pedicle requires the release of the exten: (BR) over the lateral malleolus, 6. The distally bused pedicled lateral supramalleotar lap. The blood supply is ensured by retrograde low from 1 of sinus tarsi. The anastomotic vascular circle at the Te pedicle of the flap is located beneath the aponcurosis. Ee tation of the reverse sand Map requires ligature of the perforating branch under the emergence of the cutaneous sucery of the fap (© the ligature of the perforating branch of the peroncal artery). The cutancous branch (a) for the Nap ernains in continuity wth the descending branch, () The superficial peroneal nerve, itis spared, is beter Dried inthe musclesVol. 81, No. I / THE LATERAL SUPRAMALLEOLAR FLAP: 71 roneal artery, which can be located easily by digital palpation prior to the incision in the groove just above and anterior to the lateral malleolus. ‘The proximal end of the flap can extend toa level halfway up the fibula. The design of the flap must not overlap the posterior margin of the fibula (Fig. 2). Elevation of the flap should include the apo- neurosis and is carried out from the anterior incision until the perforating branch is located, ‘The superficial peroneal nerve should be spared to avoid disturbances of sensation over the dor sum of the foot. I¢is possible to include a branch of this nerve to provide sensation to the flap, but this would require a nerve anastomosis at the recipient site (Fig. 3). Rotation Flap Blood supply is provided by the perforating branch of the peroneal artery which gives off the cutaneous branch for the flap. In this type of flap, the vascular supply to the pedicle is ante- grade from the perforating branch of the pero- TABLE 1 tase Reports Set ep Oiner Cre Sex Age Bly Inpsinmese Type Fup tem Canpitions Procedures Resale TF 18 Bum (sequelae) Recirctilesear, pes “Rotation «1X5 0 Subtle Good valgus ‘ap ho desis 2 FS Bams[ecquelae) Retetilescar ofthe Roution 6X4 0 0 Excelent famterior aspectof flap Bx4 Small both ankler Pedicle distal ne ‘ap cross 3M 3-Burns(sequelae) Retractile sear of the Rotation 64 ° 0 Excellent ‘amerioraspect of fap the ankle 4M 25 Sequee of met. Uleerativescarover Rotation 125 ° 0 Excellent ‘lyse race the medial malleo- flap, ture ofthe ib- lus 5 M9 Electrical burns Softtisue defect of Rotation 8X3. ° © Excellent the dorsum ofthe fap foot 6 M2 Electrical burns Sofetisste defer of Rotation 106 ° © Excelent theanterior lower flap, third of the leg, tendons and bene exposed 7 M3 Burns (sequelae) Rectactile sear of ‘bth fet 2: pes valgus xs 0 © Goo pes aductas 8x4 Sina © Excelent dla ne fap ‘rons SF 5 Burns (sequelae) Retactilescar ofthe Pedicle Ta 0 0 Excellent Smierioraapect of Mp the ankle 9 -F 15 Burns (sequelae) -Retracile sear, pes “Rotation 105 0 Swbaalse Good “sigue Map archrod 10 MSL Bectrical burns Uerative car ofthe Pedicle 94 0 © Excallene (sequelae) heel Tap LM 84 Prestesore —— Softibsue defect Rotation 104 ® ° = ‘over the lateral Tap. tralleolue 12 M45. Tralfeinjury Compound fracture Rotation 15 x8 0 © Goort ofthe Foot ap 1s M@ Glad foe Retraction ofthe me- Pedicle 154 0 Release of Good larch ofthe Tap ‘the club foot fot 1 F 20 Viceraion of the Pedide = «5X5 —Hematoma 0 Good ‘weight bearing ares of the hee78. P neal artery. The flap may be rotated as an istand flap to cover soft-tissue defects of the lower third of the leg or anterior aspect of the ankle (Fig. 4) Distally Based Island Flap rhe vascular pedicle is made up by the distal continuation of the peroneal artery, which passes anterior to the ankle and into the foot. The blood. supply is provided by retrograde flow from its distal anastomosis. The pedicle can be dissected. very distally up to its anastomosis with the lateral arsal artery at the level of the sinus tarsi (Fig. In some cases, it may be possible to continue this dissection up to the tuberosity of the fifth metatarsal; division of the lateral malleolar branch issuing from the tibialis anterior artery is, necessary. The perforating branch of the pero neal artery is ligated as well just deep to the origin of the cutaneous branch for the flap. This ligature may require a small opening in the in- terosseous membrane in order to better visualize the peroneal artery. The dissected pedicle up to the sinus tarsi averages 8.0 cm in length and allows a wide are of rotation for the lateral su- Fic, 7. (Above, lef) Compourd fr tures of the foot and dislocation of the ankle in 45-year-old ‘ofa rotation flap. (Below, left) The flap in place (arrow indicates the pedicle). (Below, righ) Pinal result 3 months later STIC AND RECONSTRUCTIVE SURGERY, January 1988 pramalleolar island flap. The distal pedicle was always accompanied by one or two large venae comitantes which ensured its venous return (Fig, 6), Case Reports (Table 1) ixteen flaps have been achieved in 14 patients from May of 1985 to June of 1986: nine rotation flaps and seven distally based iskind flaps. All flaps survived. In two patients (cases 2 and 7), there was a marginal necrosis at the proximal end of the flap, but this spontaneously healed. In one patient (case 14), a hematoma required evac- uation under general anesthesia. In two patients with rotation flaps (cases 4 and 5), we were obliged to resect a bridge of normal skin to put the flap in place. In fact, at the beginning of our experience we were not aware of the possibility of performing a distally based pedicle flap. These patients were certainly candidates for such a re- versed flap. In the reversed flaps, no venous congestion was noted, but there was edema of the flap which lasted 48 hours, At the beginning of our experi- san. (Above, righ) ElevationVol. 81, No. 1 / THE LATERAL ence, the superficial peroneal nerve was divided in order to raise the flap (cases I and 5). How: ever, these patients did not develop pain at the donor site, the flap, or on the dorsum of the foot. We now routinely spare the nerve, which can easily be dissected off the deep aspect of the flap. In all patients, the donor site was grafted with- out any functional impairment. Results were noted as excellent when function was restored ad integrum, thanks to the release and coverage with the flap. Results were noted as good when the patient required another orthopedic proce- dure to improve function. In these patients, the additional procedure was not necessary because of inadequacy of the flaps. Case 12 (Fig. 7) This 45-year-old man was involved in a car accident and sustained a compound fracture of the left foot with a large anterior softaissue defect. There were a dislocation of the tibjotarsal joint and fractures of the cuboid and the anterior process of the calcaneum. The dorsalis pedis artery, super- Ficial peroneal nerve, and common extensor tendons were severed. In the emergency room, the subtalar joint and the lateral arch (fifth metatarsal, cuboid, and calcaneum) were stabi lized with K wires. The extensor tendons were sutured. To cover the skin defect, lateral supramalleolar flap was raised (15.0 x 8.0 cm), pedicled on the perforating branch of che peroneal artery and turned a8 4 rotation flap. ‘The lap was alittle congestive for 48 hours, but the postoperative course vwas uneventfl TThe wires were removed 11 months later. ‘Three months later, the patient walks normally and the range of motion of the ankle joint is 5 degrees of dorsal flexion and 25 degress of plantar flexion, Case 10 (Fig. 8) This 27-year-old man presented with a chronic ulceration fon the lateral aspect of his heel consecutive 10 an electrical bburn. After excision of the tissues, the defect was covered with a 9X 4 em reversed island flap. The postoperative course was uneventful, Six months later there is no recur renee of the uleeration Case 14 (Fig. 9) ‘This 20-year-old woman presented with neurotrophic ulceration on the anterior part of the weight-bearing 2¢¢a of her heel consecutive tS level spina bifida, Three year Ago, she was operated on for a chronic ulceration of the portcrior weight beating area of the heel, and she underwent E‘reconstruction with an instep island fap. There seas no recurrence at this place To cover the new defect, we raised reverse island lateral supramalleolar Map. A hematoma was evacuated under gen eral anesthesia 48 hours after the operation, but the Map healed uneventfully Tyra months late, the young gt] walks as she did before the occurrence of the uleeration. Follow-up is now at 6 months and there isno recurrence ofthe ulceration. SUPRAMALLEOLAR FLAP 79 Fic, 8, (Above) Chronic uleeration of the heel. Design of the distally based flap (arrow indicates the pivot point of the reversed pedicle). (Center) Elevation of the flap and dissec tion of the pedicle (arrow indicates the pedicle; double arrow indicates the superficial peroneal nerve). (Below) Final result 2 months biter. Discussion Septocutancous vessels of the leg have been well studied by Salmon" and recently by Carr quiry et al." These authors have mentioned the presence of distal anterolateral septocutaneous vessels which are enclosed in the lower half of the anterior intermuscular septum between the extensor digitorum longus and the peroneus80 PLASTIC AND RECONSTRUCTIVE SURGERY, January 1988 Fic. 9. Neurotrophic ulceration of the heel in a 20-year-old woman. (Abow, lef) The ulceration and the design of the fap the defect. (Below, right) Result 2 months later brevis. However, they do not insist on the arterial branch that comes from the perforating branch of the peroneal artery. In fact, this septocuta- neous vessel is sufficient to supply a flap designed on the lower half of the lateral aspect of the leg. Several local and regional flaps have been de scribed to resurface the foot and ankle. The dorsalis pedis flap? and the reverse-pedicled an- terior tibial flap® have a wide arc of rotation, and they are supplied by a major artery in the foot. The peroneal island flap" is versatile and reliable but requires dissection of the distal portion of the peroneal artery to reach the foot. The instep flap' provides excellent coverage of the heel. Its are of rotation is limited by the length of the medial plantar artery, and the sizes of the flap cannot overlap on the weight-bearing area of the plantar foot. The distally based fasciocutaneous flap from the sural region’ is used in recon- struction of defects in the middle and lower thirds of the leg. Portuguese authors? have re- cently described a medial distally based. fascio- (arrow indicates the instep island flap carried out 3 years ago). (Above, right) The distally based flap. (Below, left) Coverage of cutaneous flap which is the mirror image of our flap. The pivot point is centered on two perfo- rating arteries from the posterior tibial artery. The lateral calcaneal flap'isa simple procedure o cover skin defects of the posterior heel. The indications for local muscle flaps? are limited because of the shortness of their vascular pedi- cles, We believe that the lateral supramalleolar flap can now be added to this list of procedures and that the alternative would be in some cases a free flap with microsurgical anastomosis ‘The main advantages of the lateral supramal- leolar flap are as follows: 1. It may be a rather large flap (15 X 9 cm in an adult). 2. The pedicle is long (8.0 cm) and easy 10 dissect. 3. The pivot point of the pedicle is distal (sinus tarsi) and allows great local possibilities of coverageVol. 81, No. 1 / CAN StrTcHes GET WET? create a wet-to-dry environment that would in- duce capillarity to draw the blood away from the wound. Using epinephrine, there was a period of reactive hyperemia manifested clinically by a small amount of oozing about 2 hours after the wound was closed, The capillarity resulted in a dry wound as the blood was drawn away from the wound into the dressing. ‘The dressing was constructed in such a way that with dry gauze above the wet gauze, it ensured drying of the dressing within hours after the procedure to minimize wetness causing maceration ‘The patient was advised to restrict activities for at least the first day. The morning of the day following surgery patients were asked to wash their hands with soap and water, clean under their fingernails, and then remove the dressing. ‘They were asked to wash the wound with soap and water. If the dressing was adhering to the stitches, they were advised to wet it with luke- warm water. They were asked to wash the wound gently, using their hands and not a cloth for the fear the latter could catch the stitches. Hydrogen peroxide was recommended if there were crusts which did not wash off with soap and water, Patients were asked to dry the wounds with a clean, soft towel and then dress them with either a dry, sterile dressing or an adhesive bandage. ‘The dressing was kept simple so that the patient could change it himself or herself. ‘The wound was kept dry between dressings. Patients were told they could shower and wet the stitches but were advised not to bathe. “The patients were first seen 8 to 12 days later. REsuLts ‘There were 100 patients. The average age was 51 years (range 13 to 92 years). There were 38 males and 62 females. There were 106 lesions; 45 were cancers of the skin, including basal cell skin cancer, squamous cell skin cancer, and mel- anoma. The others were benign lesions (nevi, cysts, clefts, and scars). Fighty-one were on the face, 6 were on the hand or arm, 14 were on the thorax or abdomen, and 5 were on the lower extremities; 1 was on the penis, All wounds were noted to heal primarily ‘There were no infections. There were no disrup- tions nor dehiscences of the wound. Patients were followed for an average of 6 months. Discussion In this study of 100 consecutive patients with benign and malignant lesions involving the skin 83 and soft tissues and with an average age of 51, there was a zero incidence of infection. The benefit of being able to wet stitches is obvious because of less disruption of daily activities. ‘There are no data to suggest that a wound with stitches that is kept dry heals faster, has less incidence of infection, has less pain, or has greater wound tensile strength. Infection is what is feared most if stitches are wet In the present study, monofilament nylon was used. This contrasts with silk or cotton, which because of the nature of the material is more likely to act as a “wick,” leading to an infection.® ‘A benefit to the physician was that when the wound was seen in the office it was clean so that the stitches were more visible and hence easier to remove, In this study, epinephrine was used, and as noted, there were no infections. It is probably best to wait 24 hours before washing the wound to allow the fibrin network and the process of epithelialization to be estab- lished. After that time, patients are advised to be gentle. We think that the use of their fingertips rather than a cloth facilitates this. We feel that a shower is preferable to a bath. Bath water gets easily contaminated and then may be in contact with the wound and stitches. Patients are asked to remove their dressings when showering to expose the wounds, Surgical soaps and antiseptics may have some advantage over ordinary soap and water, but they are costly, occasionally provoke allergic re- actions, and do not appear to be necessary. In an age where more procedures are being done on an outpatient basis and where more patients or their families are providing the wound care at home, it seems advantageous to allow patients to wet their wounds. There is less disruption to their daily activities. Being allowed to wash their wounds may allay any anxiety as- sociated with dealing with surgical wounds. The wound care and the dressings are simplified. As Peter Randall said, “Curiously, patients are so indoctrinated with the old dictim of ‘don’t touch it’ that they are frequently reluctant to wash a surgical wound. Actually, the patient or family members are probably in the best position to exercise the gentleness and the time-consuming thoroughness needed for simple wound care."" Joel M. Noe, M.D. 1101 Beacon Street Brookline, Mass. 0214684 PLASTIC AND RECONSTRUCTIVE SURGERY, January 1988 ACRNOWLEDOMENT 9. Noes} Mra Kali S. The mechaian of api ; oe, JM. and Kali, ‘The mechanism of copllar- “The authors would ike to acknowledge the etcisms of fe eisai ee Gece ork Dr. Willian Site ign 4. Noe, J.-M. ‘The problem of adherence in dresed REFERENCES: ‘wounds, Surg. Gynecol. Obstet. 147: 185, 1978. 1. Randall, P. Soap, water, and the surgical patients, 5. Noe, Jucard Kalish, 8. Dressing Materials ane Their YAMA. 1912347, 1965 Sciecton, In. Rudolph and J. Noe (Eds), Chronic 2 Aindt, KA. Burton, Cand Noe, M.- Minimizing Wound Problems. Bost: Lit, Brown, 1983 the pain of local anesthesia. Plast Reconstr, Surg, 72: 6. McKinney, P. Personal communication, 1986,