British Journal of Plastic Surgery (,97~), 2,5, z o - 2 [

C R O S S - L E G F L A P S IN P A T I E N T S O V E R 50 Y E A R S OF AGE

By RICHARD B. STARK, M.D., and JOSHUA M. KAPLAN, M.D.

Department of Surgery (Plastic), St. Luke's Hospital Center, New York, New York.

THE first successful cross-leg flap procedure was performed on 2 I s t January x854 by Dr Frank H. Hamilton of Buffalo, N.Y., who was professor of surgery at the University of Buffalo and was later to become an eminent Civil War surgeon. The patient, a 3o-year-old Irish labourer named Horace Driscoll, very nearly succumbed to the surgery and required more than a year to recover from it. Subsequently, this procedure was successfully performed by Billroth in r874 and Maas in I885.

However, the cross-leg and the cross-thigh flap procedures did not acquire the degree of technical sophistication that they enjoy today until during and after World War II, which produced so many patients requiring leg reconstruction. This resulted in refinement of the technique with respect to design, location, size, blood supply and delay of the flaps.

There is still doubt, however, about the effect of the necessarily prolonged im- mobilisation of the legs in the older age-groups. Letterman et aL (r96z) stressed the hazard of vascular and thromboemboli¢ accidents. They emphasised that age, obesity, bed rest, auricular fibrillation, cardiac enlargement, occlusive arterial disease, poly- cythemia, varicosities, dehydration and anaemia all predispose to thromboembolism. Moreover, 82 per cent of patients exhibiting thromboembolic phenomena are over the age of 4o. They did not, however, commit themselves on the advisability of cross-leg flaps in the over-forties.

Hayes (I962) presented a series of 24 cross-leg flaps in patients over 5 ° years of age ; the results were satisfactory without any permanent joint damage in I7. However, he did conclude arbitrarily that this procedure could be done up to, but not beyond the age of 60.

On the other hand Crikelair (z966) reported a series of 23 patients with osteomye- lifts of the lower limb treated with a cross-leg flap ; eight were over the age of 50, and one was 69. He stated that hip and knee flexion of less than 45 degrees could be tolerated for 3 weeks by most patients if joint disease did not preclude it.

Klingenstr6m and Nylen (I966) discussed the timing of transfer of various pedicles. They presented five patients with cross-leg flaps, two of whom were over 50. Both were uncomplicated.

Our thesis is that age per se should not be used as a criterion for patient selection for this procedure. In support of this, we should like to add our own series of nine patients who have undergone a cross-leg flap. All were over 5o at the time of flap construction and three were over 60.

The flap donor site was the thigh in three cases, based proximally in two, distally in one. The remaining six cases had the donor site on the calf; four were based proximally or anteriorly and two distally.

Flaps were delayed in six cases. The number of delays ranged from two to four. Three were transferred directly ; two of these were cross-thigh flaps, and both patients developed the only complications in the series. In the first case decubitus ulcers developed over the greater trochanter and over the sacrum ; in the second there was deep thrombo- phlebitis. Both responded to therapy and recovered completely ; transplantation of the flap was successfully accomplished. This demonstrated that complications are more

CROSS-LEG FLAPS IN PATIENTS OVER 5 ° YEARS OF AGE 2I

likely with a limb in acute flexion, as in the cross-thigh position. I f at all possible, extreme positioning should be avoided and generous padding used under casts applied pre-operatively. These complications were in no way related to inadequate flap circula- tion which might have resulted from direct rather than delayed flap transfer.

The procedure was done for unstable scarring over bone or tendon with repeated breakdown, in all cases. The recipient areas were the anterior leg over the tibia in four cases, the Achilles' tendon area in two, the heel in one, the lateral malteolus in one and a transmetatarsal amputation stump in one.

Patients were maintained in the cross-leg position mostly for 3 weeks, the longest period being 27 days in one case. In all cases the flaps remained viable and were divided and inset successfully. Again in all cases flaps were serially divided under local anaesthesia on alternate days using an electric cutting current. There were either two or three partial divisions prior to complete division.

There was a variable degree of discomfiture from the immobilisation of the legs in the crossed position, which lessened with time. All nine patients tolerated the immobilisation and were walking without sequelae within 2-3 months of cast removal.

It is neither the scope nor intent of this paper to discuss the relative merits of various techniques of skin replacement in the lower leg and we readily acknowledge such alternative methods of management as MiUard's Crane Principle, Crawford's local flap, Hynes' reversed dermis graft and dermal overgrafting.

In conclusion, we wish to re-emphasise that while there are certainly many valid reasons for withholding this procedure, age per se is not a contra-indication.

SUMMARY

Nine cross-leg flaps in patients over 50 years of age are reviewed. Our experience confirms that of others, that the complications of permanent joint changes and thrombo- embolic phenomena were found to be virtually non-existent. As a result, age per se should not be used as a criterion for patient selection for this procedure.

REFERENCES

CRAWFORO, B. S. (1958). The repair of defects of the lower limbs using a local flap. British Journal of Plastic Surgery, 1o, 32-35 .

CRIKELAIR, G. F. and SYMONDS, F. (1966). The cross-leg pedicle in chronic osteomyelitis of the lower limb. Plastic and Reconstructive Surgery, 38, 4o4-4o9 •

HAMILTON, F. H. (1854). "Elkoplasty, or Anaplasty applied to the Treatment of Old Ulcers, New York: Holman, Gray and Co.

HAYES, H. (1962). Cross-leg flaps after the age of fifty. Plastic and Reconstructive Surgery, 3 ° , 649-650.

HYNES, W. (1954). T he skin-dermis graft as an alternative to the direct or tubed flap. British Journal of Plastic Surgery, 7, 97-1o7.

KLINGENSTROM, P. NYLEN, B. (1966). Timing of transfer of tubed pedicles and cross-flaps. Plastic and Reconstructive Surgery, 37, I - I I .

LETTERMAN, G. S., SCHURTER, i . and PRANDONI, A. (1961). Prophylactic anticoagulation in the cross-leg flap procedure. Plastic and Reconstructive Surgery, 27, 52o-526.

MILLARD~ D. R. (1969). The Crane principle for the transport of subcutaneous tissue. Plastic and Reconstructive Surgery, 43, 451-462.

STARK, R. B. (1952). T he cross-leg flap procedure. Plastic and Reconstructive Surgery, 9, 173-2o4.

WEBSTER, G. V., PETERSON, R. H. and STEIN, H. L. (1958). Dermal overgrafting of the leg. Journal of Bone and Joint Surgery, 4oA~ 796-802.