Brifish Journal tf Plastic Surgery (1986) 39. 321-331 :i; 1986 The Trustees of British Association of Plastic Surgeons

Reconstruction of the lower leg and foot with the reverse- pedicled anterior tibia1 flap: preliminary report of a new fasciocutaneous flap

J. T. K. WEE

Queen Mary Hospital, Hong Kong

Summary-The blood supply to the skin of the anterior leg was studied in 10 fresh cadavers. Particular attention was paid to the intermuscular septal blood vessels, which emerge in the cleft between tibialis anterior and extensor hallucis longus and extensor digitorum longus muscles. With this anatomical knowledge, the reverse-pedicled anterior tibia1 fasciocutaneous flap was designed and transferred clinically to cover lower leg and foot defects in 6 patients. Three case reparts are detailed. The factors which allow a distally based flap to be raised in the lower leg against the direction of venous valves are also described. The versatility of this new flap in the reconstruction of defects of the lower leg and foot is discussed.

While microvascular techniques have enabled tremendous strides to be made in the reconstruc- tion of the leg and foot, these techniques have not gained universal application. Not every surgeon has the training to perform these operations, nor is it easy to assemble a team of trained personnel or organise equipment and operating time, especially where resources are limited. Techniques which are simple would have greater appeal, especially in de- veloping countries.

A new reconstructive procedure has been devised based on the anterior tibia1 artery and its venae comitantes. The vascular pedicle, based distally, supplies a skin flap raised from the extensor region of the upper leg. This island flap pivoting on the lower leg or ankle may be used to cover the lower third of the leg, the ankle and all parts of the foot. The flap is simple, convenient and versatile. It does not require the mastery of microvascular tech- niques.

Anatomical studies

Ten fresh cadavers were dissected to study the blood supply of the skin of the extensor compart- ment of both legs. The anterior tibia1 artery was exposed between the tibia1 tuberosity and the fibu- lar head, and ligated. The dorsalis pedis was then exposed at the ankle and cannulated. 4Occ of Indian ink was injected into the dorsalis pedis artery in a retrograde direction. The area of stain-

ing of the skin of the extensor compartment was defined.

The skin of the extensor region of the leg was then elevated from a lateral to a medial direction by incising over the whole length of the fibula, A flap of skin and fascia was raised by developing the sub- fascial plane. The flap was elevated until the inter- muscular cleft between tibialis anterior (TA) and extensor digitorum longus (EDL) in the upper third, and between TA and extensor halluci$ longus (EHL) in the middle third, was reached. In the lower third the space between the tendons of TA and EHL was studied. The two muscles, EDL and EHL, were retracted laterally to expose the inter- muscular septal arteries which spring from the anterior aspect of the anterior tibia1 artery. The purely muscular pedicles to TA and EDL a$ well as those pedicles which course towards the deep fascia to supply the overlying skin were studied. The number of pedicles supplying the deep fascia and skin (fasciocutaneous vessels) in each third of the leg was counted.

Results

In each of the 20 limbs dissected, the dorsalis pedis artery was a direct continuation of the anterior tibia1 artery. The area of staining of the anterior leg extended from the level of the head of the fibula to the lateral malleolus, and from the line of the fibu- lar shaft to 2cm medial to the anterior border of

331

328 BRITISH JOURNAL OF PLASTIC SURGERY

the subcutaneous surface of the tibia (Fig. lA, B). The intermuscular septal vessels were of two types. There were muscular pedicles which supplied TA and EDL (conforming to the Type IV pattern of muscle blood supply of Mathes and Nahai (1979)) as well as fasciocutaneous pedicles which, after giv- ing off collateral muscular branches, continued on to supply the deep fascia via a fascial plexus which in turn supplied the overlying skin (Fig. 2).

The average number of fasciocutaneous vessels in each third of the leg were as follows: upper third-3 vessels, middle third-7 vessels, lower third-3 vessels. The vessel diameters were usually less than OSmm. Each artery was usually accom- panied by two venae comitantes.

Flap design

The dorsalis pedis and posterior tibia1 pulses are confirmed by palpation pre-operatively. The ab- sence of either pulse contraindicates this flap. The mere presence of the dorsalis pedis does not mean

Fig. 1

Figure l-(A) Retrograde injection of dorsalis pedis artery. The line of the fibula marks the lateral extent of ink staining. (B) The medial extent of ink staining lies I-2cm medial to the anterior border of the tibia.

that it comes from the anterior tibia1 artery. The latter artery may be attenuated. The dorsalis pedis may, in this situation, be derived from the perforat- ing branch of the peroneal artery. At the time of the operation, the best way to confirm that the anterior tibia1 artery is not aberrant or attenuated is to make an exploratory incision just above the ankle. In the 6 cases where this flap was raised, arterio- grams were not done pre-operatively. The course of the anterior tibia1 artery was, however, checked with a Doppler probe in each case by tracing the dorsalis pedis artery retrogradely.

The anterior tibia1 artery is marked on the skin of the leg by joining a point midway between the tibia1 tuberosity and the fibular head to another point midway between the malleoli. The artery is divided into thirds along its length. The pivot point is then marked in the lower third of the leg. If poss- ible, the pivot point should be kept at least 5cm above the ankle as this is the level at which the medial and lateral malleolar networks begin. Occa- sionally in order to obtain a longer pedicle, e.g. to cover the sole of the forefoot, the pivot point could be sited lower than 5cm above the ankle. This is achieved by dividing the extensor retinaculum. Arterial anastomoses via the medial and lateral malleolar networks must necessarily be divided. The length of the pedicle required is measured from the edge of the proposed defect to the pivot point, allowing a further 2cm for tension-free transposi- tion of the pedicle. By back-planning, the inferior edge of the planned flap is determined and out- lined. For narrow flaps, care should be taken to centre the flap on the line of the anterior tibia1 artery. The more distal the defect, the nearer will be the donor site to the knee, and the more distal will be the pivot, i.e. closer to the ankle.

Flap elevation

A bloodless field is essential. The anterior tibia1 vessels are exposed just above the extensor retina- culum by incising skin and deep fascia and retract- ing the tendons of EDL and EHL from TA. The deep peroneal nerve is encountered first, lying anterior or lateral to the vessels. The nerve is traced to the inferior margin of the flap. The flap is incised all around including the deep fascia. The lateral edge of the flap is elevated medially with the deep fascia to the intermuscular cleft where the deep peroneal nerve is again encountered. The cleft is widened by retracting EDL and EHL laterally. The

RECONSTRUCTION OF THE LOWER LEG AND FOOT 329

Fig. 2

Figure 2-Fasciocutaneous pedicles are shown emerging from the intermuscular cleft to supply tibialis anterior (TA) and the long extensors of the toes (EDL). Two fasciocutaneous pedicles supplying tibialis anterior and the deep fascia (DF) are arrowed.

delicate fasciocutaneous vessels are visualised and left undisturbed on the lateral surface of tibialis anterior. Vascular branches supplying EDL and EHL are coagulated as are communicating branches perforating the interosseous membrane. The deep peroneal nerve is separated from the ves- sels throughout the length of the cleft from the superior edge of the flap to the pivot point. The anterior tibia1 artery and venae comitantes are iso- lated at the superior margin of the flap and severed. A sliver of tibialis anterior 1 cm broad is incised through its full thickness to reach the interosseous membrane. This sliver of muscle is included with the flap and serves to prevent stretching of the fas- ciocutaneous vessels supplying the deep fascia. In the first 2 patients, 1 cm slivers of both TA and EDL were taken to protect the fasciocutaneous vessels. This necessitated the sacrifice of the deep peroneal nerve. In the next 3 cases, the deep pero- neal nerve was preserved by taking only a sliver

from tibialis anterior. In the sixth case, as: the flap was based solely on one fasciocutaneous “pedicle”, only a cuff of TA was taken around this “pedicle”. This enabled a thin flap to be raised.

Care is taken to include as much of the soft tissue around the vascular pedicle as possible and not to separate the veins from the artery. The fledicle is elevated from the interosseous membrane till the pivot point is reached. The flap is then transferred to the defect and inset. The intervening skin is incised and undermined to allow the pedicle to be buried.

The donor defect is closed by loose coaptation of tibialis anterior to the lateral two exten$ors and skin grafted. No attempt should be made t!o reduce the size of the donor defect by suturing Ithe skin edges closer together as this manoeuvre may com- press the deep veins of the leg.

This flap has been used successfully in 6 patients (Table 1). Three case reports are described.

330

Table 1 Clinical details of 6 patients

BRITISH JOURNAL OF PLASTIC SURGERY

Patient Pathology Flap Flap complications Ambulation

A. 74-year female L.M.Y.

Acral lentiginous melanoma of right heel. Stage I. Wide excision

B. 36-year male T.T.C. (Case 1)

C. 56-year female W.S.M. (Case 2)

D. 76-year female Y.Y.L.

Chronic venous ulcer 2cm diam. of left ankle. Surrounding fibrosis

Stage III acral lentiginous mela- noma right heel. Liver secondaries. Palliative

Neurotrophic ulcer of left heel pene- trating to calcaneum. Diabetic

E. 66-year female Post-phlebitic syndrome. Chronic H.C.Y. left ankle ulcer

F. 62-year male C.K. (Case 3)

Stage III malignant melanoma right forefoot. Palliative excision

12x 12cm TA, EDL slivers D.P.N. sacrificed

7x6cm TA, EDL slivers D.P.N. sacrificed

IOx7cm TA sliver D.P.N. intact

6x4cm TA sliver D.P.N. intact

10xScm TA sliver D.P.N. intact

11.5 x 1Ocm One fasciocuta- neous perforator TA cuff D.P.N. intact

Venous congestion. Marginal necro- sis 3 cm. Subcutaneous tissues sur- vived. Skin graft

Nil

Venous congestion, complete survi- val

Nil

Venous congestion. 2 cm marginal necrosis. Subcutaneous tissues sur- vived. Skin graft

Nil

6 weeks

3 weeks

3 weeks

3 weeks

5 weeks

2 weeks

TA-Tibialis anterior EDL-Extensor digitorum longus D.P.N.-Deep peroneal nerve

Case reports

Case 1

measured about 7cm in diameter. The ulcer had been grafted on three occasions in the previous 2 years but broke down repeatedly.

A 36-year-old Chinese man presented with a chronic The ulcer and fibrotic skin were excised down to ankle venous ulcer 2cm in diameter on the antero-medial as- tendons (Fig. 3B) and repaired with an anterior tibia1 pect of the left ankle. There was a surrounding area of flap measuring 7 x 6cm. Tibialis anterior and extensor fibrotic change around the ulcer (Fig. 3A) which digitorum longus muscle slivers were taken with the

Fig. 3

Figure 3+A) Chronic venous ulcer of ankle with surrounding induration and pigmentary change. (B) The defect created after exci- sion of the ulcer and surrounding skin. (C, D) Flap and donor site well healed at 3 months.

RECONSTRUCTION OF THE LOWER LEG AND FOOT 331

anterior tibia1 artery to protect the fasciocutaneous ves- sels. The deep peroneal nerve was thus sacrificed. The flap was thin and when transposed to the defect matched the surrounding skin very well. The procedure took 3f hours.

Post-operative recovery was uneventful, with primary healing (Fig. 3C, D). The ankle contour was preserved by the thinness of the flap. Ankle and toe extension re- covered within 3 weeks.

Case 2 A 56-year-old Chinese woman presented with a stage III acral lentiginous melanoma of the right heel. A liver scan confirmed space-occupying deposits in the left lobe of the liver. The primary lesion was 6mm thick (Breslow) and had infiltrated to Clarke’s level IV. The patient refused a below knee amputation.

The lesion of the heel was confirmed by excision bi- opsy (Fig. 4A). The resulting ulcer was then widely excised with a 4-5cm margin all around. The whole thickness of the heel pad was excised down to abductor hallucis muscle, plantar fascia, calcaneal periosteum and the fascia on the abductor digiti minimi (Fig. 4B).

An anterior tibia1 flap 10 x 7 cm was raised at the junc- tion of the middle and upper thirds of the leg (Fig. 4C, D). By retracting extensores digitorum longus and hallu- cis longus laterally (Fig. 4E), three fasciocutaneous ves- sels to the flap were identified and preserved. A 1 cm broad sliver of tibialis anterior muscles was taken to pro- tect the septocutaneous vessels (Fig. 4F). Retraction of EDL and EHL enabled the preservation of the deep peroneal nerve.

The flap was transferred to the heel and inset (Fig. 4G, H). The procedure lasted 4 hours. Post-operatively the flap suffered from venous congestion but recovered rapidly on releasing a few stitches. The flap survived completely.

The patient began weight bearing on the flap at 3 weeks and was able to return home after a further week of physiotherapy.

At last review, at 8 months, the flap and donor site re- mained well healed and stable although no nerve anasto- mosis was performed (Fig. 41, J, K). There was proprioceptive sensation and the ability to detect deep pressure. Footprints are shown (Fig. 4L). Recovery of ankle and toe dorsiflexion was complete except for a 30 lag of extension at the metatarso-phalangeal joint of the big toe. This did not hamper walking. The ankle and heel contours were preserved and the patient was able to use ordinary footwear.

Case 3 A 62-year-old Chinese male presented with stage III malignant melanoma of the right foot. The primary tumour was an ulcerative lesion 5cm in diameter over- lying the metatarsals of the right foot, with a few satellite nodules (Fig. 5A). Chest X-rays revealed metastases in the lungs. The patient refused a below knee amputation.

As the patient was in otherwise good health and the tumour of the foot was a source of pain, discharge and intermittent bleeding, a palliative excision of the primary lesion together with the satellite nodules was performed.

The lesions of the foot were excised with a margin of I-2cm clearance. Clearance in depth necessitated the excision of part of flexor digitorum brevis as the tumour had penetrated the plantar fascia (Fig. 5B).

An anterior tibia1 flap 11.5 x 1Ocm based on qnly one fasciocutaneous perforator was raised. A cuff ofl tibialis anterior was taken around the perforator ratheq than a sliver of the muscle. The pedicle of the flap was $levated to 3 cm below the superior border of the extensor retina- culum. This extent of pedicle mobilisation was necessary for the flap to reach the plantar surface of the forefoot. The operation took 3 hours.

Post-operatively the flap healed primarily and the patient began weight bearing at 2 weeks. Ankle ‘and toe dorsiflexion was preserved fully. The healed flap and footprints are shown (Fig. 5C, D) at one month.

At the latest follow-up 3 months post-operatively, the flap remained well healed without trophic ulceration.

The anterior tibia1 flap is an example of a’type C fasciocutaneous flap (Cormack and Lamberty 1984). The blood vessels supplying the flaplare de- rived from the anterior tibia1 vessels and sqbply the muscles straddling the cleft (Fig. 6A, B)i. Some branches course towards the deep fascia ta supply the skin. These vessels were not identified in Haertsch’s study (198 1). He found only twoi lines of perforating vessels in the anterior leg--cpne line along the anterior border of the tibia and the other along the line of the anterior peroneal septum. There is in fact a third line between the tviro men- tioned by Haertsch. Admittedly the fascial septum between the two muscles, TA and EDL, is not as well developed as the anterior peroneal sepltum but nevertheless a definite fascial septal space with fasciocutaneous vessels exists.

The use of a distally pedicled island fasciocuta- neous flap is not new. The radial forearm flap, modified as a distally based flap, has been success- fully used in the reconstruction of the hand (Foucher et al., 1984; Soutar et al., 1984). In the lower limb, the distally pedicled peroneal attery has been used to carry an island of skin to reconstruct a heel defect (Yoshimura et al., 1984). In Africa, Landra (1984) has pedicled the posterior tibia1 artery distally, bringing with it the soleus muscle, to cover defects in the lower leg. The arterial slupply to the reverse-pedicled anterior tibia1 flap is by retro- grade flow through anastomoses between the

332 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 4

Figure 4-(A) Ulcer of heel after excision biopsy of acral lentiginous melanoma. Limits of palliative excision outlined. (B) Defect after palliative excision exposing calcaneum and plantar fascia. (C) Flap planning. The flap is centred over the junction of upper and middle thirds of the leg. The lateral margin does not cross the fibular shaft. (D) The medial margin does not cross the subcutaneous surface of the tibia (cross-hatched). The asterisk points to the line of the anterior tibia1 vessels. The pivot point is marked 5cm above the ankle joint. (E) Extensor digitorum longus muscle is retracted laterally. The asterisk points to the deep peroneal nerve. Arrows point to 2 fasciocutaneous pedicles lying on tibialis anterior (TA) and supplying flap (F). (F) Sliver of tibialis anterior (TA) being elevated off the interosseus membrane (IM). The anterior tibia1 pedicle is arrowed. (G) The island flap is transposed to the heel defect. The incision over the ankle is made to accommodate the pedicle. (H) Flap inset into heel.

anterior tibia1 artery and the dorsalis pedis artery communicating with the plantar arch. These con- on the one hand and branches of the posterior nections provide adequate perfusion of the flap tibia1 and peroneal arteries on the other. There are from a retrograde direction. many levels of anastomosis between the major The venous drainage of the flap is by the venae arterial trunks in the networks around the malleoli, comitantes accompanying the anterior tibia1 artery. in the midfoot and through perforating arteries An alternative pathway via the superficial veins of

RECONSTRUCTION OF THE LOWER LEG AND FOOT

Fig. 4 (continued)

Figure 4-(1, J) Medial and plantar views of heel at 6 months. (K, L) The donor site and footprints. The flap is marked by the dotted

the anterior leg, draining into the long saphenous vein, may also be used but this requires at least one microvascular anastomosis to a recipient vein. This may negate the attraction of this flap which does not require any microvascular anastomosis, when the venae comitantes are relied on to provide the sole venous drainage.

Drainage via the deep veins occurs in a reversed manner, against the direction of the valves. This can only occur if the valves are bypassed or ren- dered incompetent. There is some controversy as to which situation actually exists in reverse-pedicled flaps. Lin et al. (1984) have studied reversed venous flow in the radial forearm flap. They found that the valves are bypassed either by crossover channels linking the venae comitantes or by collateral super- ficial or deep veins. Timmons (1984) on the other hand believes that the valves are actually rendered incompetent, provided that each of the following three criteria is fulfilled:

(i) a pressure gradient exists across the valve from a proximal to a distal direction.

(ii) the valves are denervated. (iii) venous filling occurs (via tributaries).

These criteria should be carefully examined as it

is possible to use the criteria to advantage to enhance the venous drainage in a reversed direc- tion.

Higher proximal pressure across the valve As long as there is an adequate arterial input to the flap, a gradient of pressure, higher in the proximal part of the venae comitantes than distally3 would exist. The maintenance of a pressure gradient across the venous valves is dependent on arterial inflow.

Denervation of valves By elevating the main pedicle of anterior tibia1 artery and venae comitantes from the interosseus membrane, the pedicle is denervated. Hawever a point of technique should be stressed. The main pedicle is elevated from the surrounding tissues by severing all the branches which tether the: pedicle. This should be done systematically until the pivot point is reached ensuring that the pedicle can be transferred comfortably to reach the defect. At this stage, the pedicle elevation should continue a little farther distally beyond the pivot point to include a venous tributary or collateral which leads to a vein

BRITISH JOURNAL OF PLASTIC SURGERY

D c.K,

Fig. 5

Figure WA) Melanoma of the forefoot with satellite nodules. (B) Defect after excision. (C) Healed flap at 3 weeks. (D) Footprints. Dotted area marks the flap.

RECONSTRUCTION OF THE LOWER LEG AND FOOT 335

Fig. 6

Figure 6-(A) Transverse cross-section of flap showing fascio- cutaneous vessels running on the side of tibialis anterior to sup- ply the deep fascia and skin. Excessive traction on the delicate fasciocutaneous vessels is prevented by the sliver of muscle. (B) Side view of flap. Three fasciocutaneous pedicles are shown springing from the anterior aspect of the anterior tibia1 vessels.

with orthograde flow. Denervation beyond the pivot point ensures an alternative pathway for venous flow should the valves beyond the pivot point remain competent (Fig. 7A, B).

VenousJilling

The analogy is drawn between this criterion and a siphon where each segment must be filled with fluid for the siphon to work.

The soft tissues uniting the artery and its venae comitantes should be preserved. Arterial blood passing by segmental arterioles would supply the adventitial soft tissues and drain by venules into the venae comitantes and keep the venae com- itantes filled (Fig. 8A, B). This is the rationale for keeping the adventitial soft tissues intact and not separating the vessels from each other.

The advantages of the anterior tibia1 flap are as follows: I. Convenience and simplicity The flap can be raised in the same leg as the defect. Only general

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Fig. ‘l

Figure 7-The effect of denervation on reversed Row in the venae comitantes. The dotted area around the pedicle denotes dener- vation. Only one vena comitans is shown. (A) Incompfete dener- vation. The dissection stops at the pivot point. The s&men! of vein distal to the pivot point is not denervated and may contain competent valves. (B) Complete denervation. This is achieved if the dissection is carried beyond the pivot point and ‘includes a venous channel which leads to a vein with orthograde flow.

336 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 8

Figure 8-The effect of retaining the soft tissue around the pedicle. (A) Vessels of the pedicle are not skeletonised. Blood flows via arterioles to capillaries to venules into the venae comi- tames. Venous filling occurs. The valves are rendered incom- petent. (B) Vessels of the pedicle are skeletonised. No soft tissue is retained. No circulation occurs. There is no venous filling and the valves are not rendered incompetent.

plastic surgery techniques are required. No micro- surgical skill is needed. The whole operation can be performed in 3 to 31 hours. 2. Versatility The flap can be transferred to any part of the lower limb distal to the upper third of the leg. The anterior tibia1 artery pivoting at the ankle is long enough to reach the distal part of the plantar surface of the forefoot (Case 3). Thus any moderately sized defect of the leg, ankle, tendo Achilles region, heel, sole and the dorsum of the foot can be covered by this flap (Fig. 9). 3. Sensory potential An innervated flap may be raised if required. The skin of the anterior leg is supplied by cutaneous branches of the common peroneal nerve, the saphenous nerve and the super- ficial peroneal nerve. The flap was not innervated in the 4 patients with sole reconstructions. How- ever no problems have been encountered in the

Fig. 9

Figure 9-The range of defects within reach of the flap.

patients with follow-up periods of 13, 8, 6 and 3 months respectively.

Potential problems with this flap are as follows: 1. Venous insujficiency Three of the 6 flaps suf- fered from venous insufficiency with marginal losses in 2 but complete survival of the third. In both patients with marginal losses, the subcuta- neous tissues and deep fascia survived and accepted split skin grafts. The technical innovations de- scribed earlier would ensure that the valves are ren- dered incompetent with better venous drainage of the flap. 2. Foot drop Care should be exercised to preserve the branches of the deep peroneal nerve to the extensor digitorum longus and extensor hallucis longus. This can be achieved by designing the flap below the motor point of the extensor muscles, i.e. avoiding a flap centred solely on the upper third. While none of the patients developed foot drop, it was commonly found that 2 to 3 weeks were required for complete ankle dorsiflexion to be regained. 3. Arterial variation and arterial insuJj?iciency In 3.5% of limbs, the anterior tibia1 artery either fails to reach the dorsum of the foot or is reduced to a very slender channel at this level (Hollinshead, 1982). The flap is obviously not suitable in this situation. In traumatic injuries of the leg and ankle with possible injury to the anterior tibia1 artery, the flap should not be used. An obvious disqualifica- tion occurs when the anterior tibia1 artery cannot be sacrificed, e.g. in atherosclerosis or in a “one- artery leg”. 4. Donor site The donor site on the anterior leg is quite acceptable. It does not present any contour

RECONSTRUCTION OF THE LOWER LEG AND FOOT 337

problems in the leg. However, a more readily hid- den donor site for a free flap may be considered in young women.

In conclusion, the results obtained in this small series of patients show that the reverse-pedicled anterior tibia1 fasciocutaneous flap can provide an effective solution to the perennial problem of flap cover in the lower leg and foot. Simplicity and ver- satility are its main attractions. These advantages should make it universally useful especially where microvascular techniques are not practised.

Acknowledgements

I wish to thank Mr Paul Darton for the diagrams and Miss Josephine Yuen for typing the manuscript.

References

Cormack, G. C. and Lamberty, B. G. H. (1984). A classification of fascia-cutaneous flaps according to their patterns of vascu- larisation. British Journal of Plasric Surgery, 37,80.

Foucher, G., Van Cenechten, F., Merle, N. and Micbon, J. ( 1984). A compound radial artery forearm flap in hand sur- gery: an original modification of the Chinese forearm flap. British Journal qf Plastic Surgery, 37, 139.

Hnertsch, P. (1981). The blood supply of the skin of the leg: a post-mortem investigation. Brifish Journal of Plastic Surgery, 34,470.

Holbhead, W. H. (1982). Anatomy for Surgeons Vol. 3. The Back and Limbs. 3rd. Edition. Philadelphia, Harper and Row.

Landra, A. P. (1984). Q.E.D. flaps (? demonstrandum, disputdn- dum or deprecandum): three useful axial pattern flaps in tro- pical African Surgery. British Journal qf Plastic Surgery, 37, 580.

Lin, S. D., Lai, C. S. and Chiu, C. C. (1984). Venous drainage of reverse forearm flap. Plastic and Reconstructive Surgery, 74. 508.

Mathes, S. J. and Nahai, F. (1979). Clinical Atlas oficfuscle and Musculocutaneous Flaps. St Louis, Toronto, London: The C.V. Mosby Company.

Soutar, D. S. and Tanner, N. S. (1984). The radial forearm flap in the management of soft-tissue injuries of the hand. British Journal of Plastic Surgery, 37, 18.

Timmons, M. J. (1984). William Harvey revisited: Reverse flow through the valves of the forearm veins. Lancet, 2,394.

Yoshimura, M., lmura, S., Shimamura, K., Yamaucld, S. and Nomura, S. (1984). Peroneal flap for reconstruction in the extremity. Plastic and Reconstructive Surgery, 74.402.

The Author

J. T. K. Wee, MB, B!3, FRCS(Ed), FRCS(Glas), Plastic Sur- geon, Queen Mary Hospital and Lecturer in Surgery, Univer- sity of Hong Kong. Now Senior Registrar, Singapore General Hospital.

Requests for reprints to: J. T. K. Wee, Department of Hand Surgery. Singapore General Hospital, Singapore 03 16, Republic of Singapore.