Cross-leg tibial posterior perforator flap

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    Background: In the lower leg posttraumatic pathology, we are frequently confronted with tissue defects that are difcult to cover by local ordistance means, because of either the poor tissue quality or the precarious local vessels. One of the still available methods for solvingthese cases remains the cross-leg ap. The authors will try to demonstrate the advantages of this method, by using the cross-leg apbased on perforator vessels. Methods: We are presenting two cases for which we practiced a cross-leg perforator ap, based on perforatorvessels emerging from the posterior tibial artery. Results: The results were favorable, demonstrated by immobilization in a comfortableposition, perfect ap integration, pedicle aps division at 1421 days, early postsurgery ambulation. Conclusions: The cross-leg perforatorap diminishes many of the disadvantages created by the classic cross-leg ap and can be successfully used in cases in which other pro-cedures are prohibited. VVC 2007 Wiley-Liss, Inc. Microsurgery 27:379383, 2007.

    The covering of soft tissue defects of the lower leg presentsa notable challenge for the reconstructive surgeon, rst of all

    because of the poor availability of local tissues to be used,

    especially in posttraumatic conditions.14 For these reasons,

    a lot of various methods were used in the attempt to solve the

    problem: cross-leg aps,26 proximally7 or distally24,810

    based fascial or fasciocutaneous aps, distally based muscle

    aps,1113 and free aps.1416 The new era of perforator aps

    determined an improvement in the possibilities to use both

    local/regional1720 or free2125 perforator aps in covering

    these difcult defects.

    Unfortunately, in the clinical practice, we are some-

    times confronted with cases in which, because of the

    local anatomical conditions, the local resources or the

    free aps cannot be used. In such cases, one of the best

    surgical alternatives remains the cross-leg procedure.

    We will present two cases in which we used a cross-

    leg perforator ap. We consider that this method offers

    some advantages over the classical cross-leg ap and,

    more, brings the advantages of a perforator ap.


    Case 1

    A 32-year-old man sustained a severe crush trauma of

    the right lower leg, with open fracture of both the tibia

    and peroneum bones in the middle third and interruption

    of the tibial posterior and peroneal arteries. He was oper-

    ated ve times in an orthopedic surgery clinic (centrome-

    dulary ostheosynthesis, numerous debridements). Finally,

    the patient developed a septic pseudarthrosis of the tibia

    and was referred to our service 8 months later presenting

    a stulized septic pseudarthrosis (Fig. 1A). We decided

    to perform a large debridement and to use a free latissi-

    mus dorsi muscle ap to cover the defect. But, during

    the surgery, we found an extensive brosis in the poste-

    rior muscle compartment and both the posterior tibial and

    peroneal arteries, with no pulse proximal to the level of

    the previous rupture.

    So, because of the local situation (multiple vicious post-

    operative scars and very poor skin quality), we decided to

    cover the 12/4 cm defect by using a bipedicled transposition

    ap of 15/6 cm, harvested from the anteroextern aspect of

    the lower leg in a subfascial plane.

    Because of the poor local vascular conditions, 10

    days later, a wound dehiscence occurred. In these condi-

    tions, we decided to cover the defect by using a perfora-

    tor cross-leg ap.

    An 18/8-cm ap was designed in the distal half of the

    anteromedial aspect of the left lower leg. We rst incised the

    anterior border, and the distal and proximal ends of the ap.

    We identied a very nice perforator coming through the tibi-

    alis posterior muscle 20 cm above the tibial maleola (Fig.

    1B). The dissection of the ap was started on the anterior

    border and was done in a subfascial plane. The posterior bor-

    der of the ap was then incised and the dissection of the per-

    forator was completed, keeping a 2-cm adipofascial cuff

    around it (Fig. 1C). The ap was rotated 908 and applied onthe exposed tibial bone of the right lower leg (Fig. 1D). The

    remaining defects were covered with split-skin grafts. The

    immobilization was obtained using plaster casts in a very

    comfortable position. The pedicle was divided after 21 days

    (Fig. 1E), and the ambulation was possible after 1 week. No

    suffering of the ap, before or after the pedicle division, was

    observed. The patient used elastic compression support for 4

    months. Seven months after the surgery, the ap was com-

    pletely integrated with no septic relapse (Fig. 1F).

    Case 2

    A 58year-old man sustained a severe crush trauma

    with subtotal amputation of his lower leg, 15 years ago.

    Clinic of Plastic Surgery and Reconstructive Microsurgery, University of Med-icine Iuliu Hatieganu, Cluj-Napoca, Romania

    *Correspondence to: Alexandru Georgescu, Spitalul Clinic de Recuperare,Str.Viilor Nr.46-50, 400347 Cluj-Napoca, Romania.E-mail:

    Received 28 February 2007; Accepted 5 March 2007

    Published online 7 June 2007 in Wiley InterScience ( DOI 10.1002/micr.20375

    VVC 2007 Wiley-Liss, Inc.

  • After revascularization and other complex surgical proce-

    dures (local and free aps), he remained with a vicious

    position of the foot, well tolerated until now. Because

    some pain appeared a few months before, he decided to

    accept a tallo-crural arthrodesis in functional position.

    Because of a hematoma in the postoperative period, a

    wound dehiscence appeared (Fig. 2A). The local and re-

    gional poor quality of soft tissues and vessels made

    impossible the coverage using local or free aps, and so we

    decided to use a tibial posterior perforator cross-leg ap.

    The same procedure as in case 1 was used, but the

    blood supply was ensured through two septocutaneous

    perforators identied 8 cm above the tibial maleola and

    coming from the posterior tibial artery (Fig. 2B).

    The dimensions of the ap were 27 cm in length, 9

    cm width at the proximal part and 4 cm width at the dis-

    Figure 1. A: Right lower leg. Large soft tissue defect and osteitis of the tibia after an open fracture in a 32-year-old man. B: Left lower

    leg. A ap of 18/8 cm was designed and a musculocutaneous tibial posterior artery perforator was identied. C: The ap was harvested by

    keeping a 2-cm adipofascial tissue cuff around the perforator. D: The ap was rotated 908 and applied to the defect. Free split skin graftone the donor site. E: 21 days later, after sectioning the pedicle. F: 7 months after surgery. [Color gure can be viewed in the online issue,

    which is available at]

    380 Georgescu et al.

    Microsurgery DOI 10.1002/micr

  • Figure 2. A: Wound dehiscence after right ankle arthrodesis in a 58year-old man. B: A perforator ap is harvested from the left lower

    leg. Two septocutaneous posterior tibial artery perforators were identied 8 cm above the tibial maleola. C: The harvesting of the ap (27

    cm length, 9-cm width proximally and 4 cm distally) was completed. D: After the ap was rotated 908, about 90 cm2 of its proximal partwas de-epidermised and lled into the defect. E: 48 h after surgery. F: The immobilization was obtained by using two plaster casts secured

    to each other. G: The very comfortable position and the possibility to move the knees can be observed. H: After sectioning the pedicle.

    [Color gure can be viewed in the online issue, which is available at]

  • tal part (Fig. 2C). Its proximal 90 cm2 were de-epider-

    mised in the attempt to ll the dead space (Fig. 2D). Theap was turned 908 and applied into and on the defect(Fig. 2E). The immobilization was done using two plastercasts secured to each other, involving only the lower legsand feet; the knees mobilization was possible and theposition in bed was very comfortable for the patient(Figs. 2F and 2G). The ap survival was complete. Thepedicle was divided in the 14th day (Fig. 2H), and theambulation was permitted 1 week later.


    Sometimes, in both acute and sequelar conditions, the

    local or regional soft tissues and vascular resources are

    not available for reconstructive purposes. One of the few

    available surgical solutions in such cases remains the

    cross-leg ap.

    First described in 1854 by Hamilton,6 the cross-leg

    procedure was considered in the 70th to be the solution

    for covering the soft tissue defects in the distal third of

    the leg and foot.26

    The disadvantages of the traditional cross-leg proce-

    dure, such as random blood supply, short pedicle, limited

    rotation arch, and uncomfortable immobilization, that can

    generate frequent complications made the cross-leg ap

    to be used less and less.4

    Since Ponten7 introduced the concept of fasciocutane-

    ous aps and Masquelet et al.27 suggested that the new

    achievements in the knowledge of the leg blood supply

    could rehabilitate the cross-leg ap, the interest in using

    again this procedure increased.

    So, a lot of cross-leg aps were done as conventional

    pedicled aps5,6,2830 or neurocutaneous aps,24,10 but

    also as free cross-leg aps.3133

    But all these procedures do not completely avoid the

    well-known disadvantages (especially the immobilization

    in uncomfortable positions) and, in the free aps case,

    the risks of vascular anasthomosis.

    Because of the local conditions, in both our patients,

    the use of local or regional aps was not possible. So,

    we decided to use a cross-leg ap, but in the attempt to

    avoid part of the traditional procedures disadvantages

    (especially the immobilization in uncomfortable positions

    and the knee xation in some degree of exion or exten-

    sion), we chose to base the ap on perforator vessels.

    It is better to base the ap on perforators coming from

    the posterior tibial artery. As Koshima et al. has shown in

    1992,34 there are three types of perforators emerging from

    the posterior tibial artery: septocutaneous, musculocutane-

    ous, and periosteal. From these, the musculocutaneous per-

    forators, located in the proximal half of the leg, and the sep-

    tocutaneous perforators, located mainly in the distal third,

    are of great interest in performing a cross-leg perforator ap.

    Very important is the fact that the distribution of

    these perforators is relatively constant and that they are

    very well represented, and so they are able to blood sup-

    ply very wide areas, as we proved in our cases.

    The need to rotate the ap more than 908 is generallynot necessary so will be no chance to compromise the

    perforator, especially if the ap is based on two such ves-

    sels. Because sometimes deep defects are to be covered,

    some surgeons harvest together with the distally based

    pedicle ap a segment of the gastrocnemius muscle that

    improves the blood supply of the ap and facilitates the

    defect lling.3,35 But, as we have shown in case 2, it is

    also possible to ll the defect by using a partially de-epi-

    dermised ap. Our method also requires both extremities

    immobilization but, by using plaster cast applied only on

    the lower leg and foot in a comfortable position, we

    avoided the need to maintain the knees in exion or

    extension. So, it is very easy for the patient to care for

    himself and to mobilize his legs and all the body.

    Despite the fact that, to our knowledge, the use of a

    pedicled cross-leg perforator ap has not been previously

    reported, we think that this procedure could be consid-

    ered in the armamentarium of lower leg and foot defects

    coverage in very well-selected cases.


    1. Fraccalvieri M, Verna G, Dolcet M, Fava R, Rivarossa A, Robotti E,Bruschi S. The distally based supercial sural ap: Our experiencein reconstructing the lower leg and foot. Ann Plast Surg 2000;45:132139.

    2. Quarmby C, Skoll PJ. The distally based cross-leg sural artery islandap. Plast Reconstr Surg 2001;108:798799.

    3. Yildirim S, Akan M, Giderodglu K, Akoz T. Use of distally basedsaphenous neurofasciocutaneous and musculofasciocutaneous cross-leg aps in limb salvage. Ann Plast Surg 2001;47:568574.

    4. Atiyeh B, Al-Amm CA, El-Musa KA, Sawwaf AV, Musharaeh RS.Distally based sural fasciocutaneous cross-leg ap: A new applica-tion of an old procedure. Plast Reconstr Surg 2003;111:14701474.

    5. Seran D, Georgiade NG, Smith D. Comparison of free with pedi-cled aps for coverage of defects of leg or foot. Plast Reconstr Surg1977;59:492499.

    6. Long CD, Granick MS, Solomon MP. The cross-leg ap revisited.Ann Plast Surg 1993;30:560563.

    7. Ponten B. The fasciocutaneous ap: Its use in soft tissue defects ofthe lower leg. Br J Plast Surg 1981;34:215220.

    8. Masquelet A, Beveridge J, Romana C, Gerber C. The lateral supra-malleolar ap. Plast Reconstr Surg 1988;81:74.

    9. Carriquiri CE. Heel coverage with a deepithelialized distally basedfasciocutaneous ap. Plast Reconstr Surg 1990;85:116119.

    10. Gozu A, Ozyigit T, Ozsoy Z. Use of distally pedicled sural fasciocu-taneous cross-leg ap in severe foot and ankle trauma: A safe alter-native to microsurgery in very young children. Ann Plast Surg2005;55:374377.

    11. Faynan MS, Orak P, Hugo B, Berson SD. The distally based splitsoleus muscle ap. Br J Plast Surg 1987;40:2026.

    12. Bashir AII. Inferiorly based gastrocnemius muscle ap in the treat-ment of war wounds in the middle and lower third of the leg. Br JPlast Surg 1983;36:307309.

    382 Georgescu et al.

    Microsurgery DOI 10.1002/micr

  • 13. Tsetsonis CT, Kaxira OS, Laoulakos DH, Spiliopoulou CA, Koutse-linis AS. The inferiorly based gastrocnemius muscle ap: Anatomicaspects. Plast Reconstr Surg 2000;106:13121315.

    14. Swartz WM, Mears DC. The role of free tissue transfer in lower ex-tremity reconstruction. Plast Reconstr Surg 1985;76:364373.

    15. Godina M. Early microsurgical reconstruction of complex trauma ofthe extremities. Plast Reconstr Surg 1986;78:285.

    16. Georgescu AI, Ivan O. Emergency free aps. Microsurgery 2003;23:206216.

    17. Lees V, Townsend PLG. Use of a pedicled fascial ap based on sep-tocutaneous perforators of the posterior tibial artery for repair of dis-tal lower limb defects. Br J Plast Surg 1992;45:141.

    18. Venkataramakrishnan V, Mohan D, Villafare O. Perforator basedVY advancement aps in the leg. Br J Plast Surg 1998;51:431.

    19. Shaw AD, Ghosh SJ, Quaba AA. The island perforator calf fasciocu-taneous ap. An alternative to the gastrocnemius muscle for cover ofknee and tibial defects. Plast Reconstr Surg 2000;101:15291536.

    20. Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforatorbased V-Y advancement aps in the reconstruction of the lowerlimb defects. Br J Plast Surg 2000;53:679.

    21. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have wefound an ideal soft tissue ap? An experience with 672 antero-lateralthigh aps. Plast Reconstr Surg 2002;109:2219.

    22. Stussi JD, Aboualtout Y, Bean P, Meley M. Anterolateral thigh apfor limb reconstructive surgery: Four case reports. Revue de ChirurgieOrthopedique et reparatrice de lAppareil Moteur 2002;88:298305.

    23. Kuo YR, Jeng SF, Kuo MH, Huang MNL, Liu YT, Chiang YC, Yeh...


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