Flaps for Lower

Extremity
Reconstruction
AMIRA DANILA
  Divided into 5 zones: thigh, knee, middle leg,
Lower Limb lower leg, and foot & ankle
 Classic reconstructive armamentarium:
Zones  Local muscle flap for upper two-third of the
leg
 Free tissue transfer for distal leg and foot
THIGH
Thigh
 • Dominant pedicle: Six or seven segmental
branches of superficial femoral artery and
vein enter the muscle on its deep or medial
surface

Sartorius Flap
  Dominant Pedicle Medial circumflex femoral artery
 Minor Pedicle Smaller branches of the deep femoral artery or superficial femoral artery

Gracilis Flap
Tensor Fascia • Dominant: transverse branch of the lateral circumflex
Lata (TFL) Flap femoral artery
• The transverse branch supplies the TFL muscle entering the
anteromedial belly of the muscle 8–10 cm inferior to the
anterior superior iliac spine.
 Dominant Pedicle Lateral circumflex femoral
artery

Minor Pedicle Muscular branches of the

superficial femoral artery

Rectus
Femoris Flap

A transverse line marked from the level of the

pubis shows the approximate path of the
lateral circumflex femoral artery.
  Dominant Pedicle Descending branch of
the lateral circumflex femoral artery
 Minor Pedicle Transverse branch of the
lateral circumflex femoral artery,
Posterior branches from the profunda
femoris artery, Superficial branch of the
lateral superior genicular artery

Vastus
Lateralis Flap
KNEE
Knee
  MEDIAL GASTROCNEMIUS MUSCLE

Dominant: medial sural artery

Minor: branches from the lateral sural artery

Gastrocnemius  LATERAL GASTROCNEMIUS MUSCLE

Flap Dominant: lateral sural artery

Minor: branches from the medial sural artery
Gastrocnemius
Flap
  Dominant: branches of the
descending branch of the LCFA
 Minor: perforator of transverse
branch of LCFA

Anterolateral  Important landmarks for the

flap include the anterior
Thigh (ALT) superior iliac spine (ASIS) and
the superior lateral border of
(reverse) the patella.
 • The flap rotated inferiorly around a point
just proximal (distal pivot point) to the
anastomotic site of the descending
Anterolateral branch of the LCFA with the lateral
superior genicular artery.
Thigh (ALT) • By maintaining 6 cm of connection above
the patella, the superior genicular artery
(reverse) need not be visualized.
Vastus
Lateralis Flap
(reverse)

Dominant pedicle: Descending branch of lateral circumflex femoral artery

Minor pedicles: Transverse branch of lateral circumflex femoral artery;
posterior branches from profunda femoris artery; superficial branch of lateral
superior genicular artery
  The distal part of the muscle can be
Vastus elevated based on its minor pedicle, the
superior lateral genicular artery, and
Lateralis Flap veins that enter the distal posterior muscle
belly.
(reverse)
 Dominant Pedicle Saphenous artery

Saphenous
Flap

• the anterior or “early” cutaneous branches of the saphenous artery

predominate  designed more anteriorly and proximally
• anterior branches of the saphenous artery are deficient  must encompass the
posterior branches and the distal continuation
LEG
Popliteal Fossa
Leg

Things to Consider
1.The upper two thirds of the leg is
amenable to local muscle flaps.
2.The lower third has some local options
but is well reconstructed with free flaps.
  Dominant pedicles: Muscular branches of
popliteal artery; proximal two branches of
peroneal artery; proximal two branches of
posterior tibial artery
 Minor pedicle: Three or four segmental
branches of the posterior tibial artery

Soleus Flap

Can be approached either through an

incision 2 cm posterior to the medial
edge of the tibia or through a lateral
incision 2 cm posterior to the fibular
border.
Soleus Flap
  The most common usage of the flap is for distal-third defects of
the leg
 The distally based reverse sural artery flap is based on the
fasciocutaneous blood supply of the distal posterior lateral leg.

Reverse Sural
Flap

• The design of the distally based superficial sural

artery flap on the posterior aspect of the leg.
• The skin island can be raised anywhere in the
lower two thirds of the leg.
• The pivot point of the pedicle must be at least 5
cm above the lateral malleolus to keep the
anastomoses with the peroneal artery.
A. Skin island raised and sural pedicle identified. B. The skin island is
raised with the deep fascia. The subcutaneous fascial pedicle is
elevated, keeping a width of 2 cm to include the sural nerve and the
short saphenous vein. C. Flap transposed and donor site skin
grafted.
  Dominant pedicles: Anterior tibial artery; superolateral peroneal
artery; inferolateral peroneal artery

Anterior Tibial
Flap
FOOT
Foot
The foot and ankle consist of six angiosomes
the anterior  anterior tibial artery
the dorsum  dorsalis pedis artery

the anterolateral ankle  both the calcaneal branch and

the anterior perforating branch of the peroneal artery

the plantar heel  calcaneal branch of the posterior tibial artery

the plantar instep  the medial plantar artery
the lateral plantar midfoot and forefoot  the lateral plantar artery
  Dominant: superficial sural artery
 Minor: perforators from the
peroneal artery (retrograde flow),
the posterior tibial artery,
neurocutaneous perforators from
vasa nervorum of the sural nerve
 Components: fasciocutaneous w/o
THE SURAL muscle, or fascia only.
 Coverage: lateral, medial, and
FLAP posterior ankle defects
 skin paddle design runs from the
popliteal fossa to the mid-point of
the leg.
  Dominant: one dominant
pedicle from lateral plantar
artery (level of distal calcaneus)
 Minor: minor pedicle(s) from
ABDUCTOR the lateral plantar artery (1–2)
DIGITI MINIMI  Commonly taken as a muscle-
only flap. (Very rarely it is used
(ADM) FLAP as a musculocutaneus pedicled
flap)

Flap markings. Elevated from distal to proximal

  Dominant: proximal branch of medial plantar artery
 Minor: minor branches of medial plantar artery (2–3 branches)
 It is commonly taken as a muscle-only flap for reconstruction of the foot (can
used as a musculocutaneus pedicled flap (3 × 10 cm V-Y advancement flap))

ABDUCTOR
HALLUCIS Flap marking

(AH) FLAP

Flap elevated from

distal to proximal.
• Medial plantar region between the
great toe and the base of the heel.
• Dominant pedicle at the level of the
distal calcaneus.
  Dominant: proximal branch of the medial plantar artery & proximal
branch of the lateral plantar artery
 Minor: minor pedicle(s) from the medial plantar artery (2–3) & lateral
plantar artery (2–3)

FLEXOR  commonly taken as a muscle-only flap.

DIGITORUM
BREVIS (FDB)
FLAP

Flap marking Flap isolated on its pedicle

  Dominant: one dominant pedicle from lateral tarsal artery
 Minor: minor pedicle from dorsalis pedis artery

EXTENSOR
DIGITORUM
BREVIS (EDB)
FLAP

• lateral tarsal artery derived from dorsalis
pedis artery located at the distal edge of
the extensor retinaculum.
• The minor pedicle is located about 1–3
cm distal to the main artery
Flap markings. The length of Harvest of the extensor digitorum
the curvilinear incision brevis muscle.
depends on the location of
the wound.
  Dominant: anterior perforating branch of the peroneal artery
 supplied by the cutaneous branches of the anterior perforating branch
from the peroneal artery.
 Can be used as a rotational flap and a reversed pedicled flap.
 Most useful in coverage of bony defects that accompany loss of soft
tissue over the lateral malleolus and anterior ankle.

LATERAL
SUPRAMALLEOLAR
FLAP

Perforator is located and flap is elevate Flap rotated to cover

Flap markings. the defect.
The perforating branch of the
peroneal artery marked by a
cross; Flap width includes the
tissue between the fibula and
tibia.
New Trending Flaps
Thank You