British Journul of Plastic Surgery ( 1982) 35, 127-l 32 C 1982 The Trustees of British Association of Plastic Surgeons

0007.1226/X2!‘0302-0127 $02.00

Repair of lower leg injuries with fascia-cutaneous flaps

T. L. BARCLAY, E. CARDOSO, D. T. SHARPE AND D. J. CROCKETT

St. Luke’s Hospital, Bradford, West Yorkshire

Summary-Experience with sixteen consecutive cases of lower leg skin loss has confirmed the reliability of PonGn’s fascia-cutaneous or “super flap” (1981) in the management of these difficult injuries. The technique has several important advantages compared with the conventional lower leg flaps of both the ipsi-lateral and cross-leg variety.

The report by Ponttn in December 1979 of his pioneering work with fascia-cutaneous flaps stimulated us to try to reproduce his striking success. We report here our experience with 16 successive cases.

Anatomy

Cadaver dissection in 13 subjects (by E. Cardoso) has confirmed the following relevant features of the surgical anatomy: (i) On the medial side of the leg, three large

branches of the posterior tibia1 artery pierce the deep fascia at the medial border of the middle third of the tibia to form a plexus of vessels running longitudinally on the super- ficial surface of the deep fascia (Fig. 1).

(ii) On the lateral side of the leg, four or five small branches of the anterior tibia1 artery pierce the deep fascia at the anterior border of the lateral compartment of the leg and up

Fig. 1 Cadaver dissection of the medial aspect of the lower leg to show the skin (l), the deep fascia (2) and the tibia (3) and three large branches of the posterior tibia1 artery.

to five small branches of the peroneal artery’ pierce the deep fascia at the posterior border of the lateral compartment, joining to form a longitudinal plexus (Fig. 2A, B).

Fig. 2 (A, B) Cadaver dissection of the lateral aspect of the lower leg to show small branches of the anterior tibia1 and pexoneal arteries. A. Vessels issuing at anterior border of lateral compartment (marked with arrows). B. Vessels issuing at posterior margin of lateral compartment (marked with arrows).

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128 BRITISH JOURNAL OF PLASTIC SURGERY

(iii) On the posterior surface of the leg, a large and constant branch of the popliteal artery pierces the deep fascia 4 cm below the fold behind the knee, in the midline of the back of the leg and runs longitudinally as far as the lower quarter of the leg; it usually has two main lateral branches also running longi- tudinally (Fig. 3).

Fig. 3 Cadaver dissection to show a branch of popliteal artery in the posterior compartment of the leg. The arrows indicate the popliteal artery (A), a branch of the popliteal artery (B) and the level of the deep fascia (C).

Discussion

Our experience with the lower leg “super flap” has been very satisfactory. The wounds in 14 out of 16 patients have healed primarily: in two wounds in which there was marginal distal skin loss the fascia survived so that secondary skin grafting was safely accomplished over a defect that originally was not reparable by split-skin grafts alone. The layer of connective tissue overlying the muscle, underneath the fascia, is not disturbed and the skin grafts applied to the flap donor site at the same operation have taken perfectly in every case. We would like to underline four particular advantages of the “super flap” over the conventional flap:

(i) A length to width ratio of 3: 1 is safe medi- ally, laterally or posteriorly (Figs. 4, 5, 6). We did have some skin loss in the one patient with a 30 x 8 cm posterior flap (Fig. 7).

Clinical Study

Our clinical observations are based on a series of 16 successive cases in which fascia-cutaneous flaps were used to resurface defects of the lower leg. Our experience with 12 ipsi-lateral flaps is summarised in Table 1 and our experience with four cross-leg fascia-cutaneous flaps is summar- ised in Table 2. Fig. 4 “Super flap” raised medially measuring 16 x 7 cm.

REPAIR OF LOWER LEG INJURIES WITH FASCIO-CUTANEOUS FLAPS 129

Table 1 Results of ipsi-lateral fascia-cutaneous flaps in the lower leg

Dimen.sion ARC’ Date Site (cm) Flap loss Heulitq time

29 February 1980 IO May 1980 63 June 1980 30 July 1980 42 August lY80 17 September 1980

42 May 1981 38 June 1981 ?I March I980 21 July I980 33 September I980 19 Mav 1981

Medial Medial Medial Medial Medial Medial Medial Medial Lateral Lateral Lateral Posterior

13x5 14x5 13x6 16x7 11x6 13x6

18x9 16x7 14x5 12x6 II x6

30 x 8

None None None None None None None None None None I cm (skin) 6.5 cm (skin)

8 days 36 days 22 days II days I3 days 27 days 25 days 26 days 21 days 15 days 39 days 35 days

(ii) Scarring around the defect from gravitational ulceration or skin grafts on old burns do not preclude use of the flap; its viability and survival depend only on the undisturbed relationship of the mobilised fascia and integument (Figs. 8 and 9).

(iii) The “axial pattern” flap allows a much larger quantity of skin to be transferred as a cross-leg flap than would be possible with a “random pattern” conventional flap: in addition the pedicle of the flap allows considerable flexibility in the positioning of the legs, in contrast to the critical fixation required for the conventional repair (Fig. 10). Fluorescein studies in two of the patients at the time of division of the cross-leg flap pedicle, at 3 weeks, has demonstrated very adequate circulation from the recipient leg so that a separate operation to divide the arteries in the pedicle, as advocated by

many surgeons before separation of a groin flap, has not been necessary. The anatomi- cal features of the blood supply on the media1 side of the leg make a conventional shape of cross-leg flap with attached fascia perfectly safe, and doubtless much safer than a con- ventional non-fascia1 flap (Fig. 11); we feel however that the axial pattern shape is to be preferred when designing cross-leg flaps for repairs of the foot.

(iv) Although free flap repairs of the lower leg are satisfactory in expert hands, they are very demanding in operating theatre time, special skills and specialised early aftercare. The “super flap” and the cross-leg “super flap” if necessary in combination with free skin grafts, provide a relatively simple and extremely reliable repair for all but the largest injuries of the lower leg.

Table 2 Results of cross-leg fascia-cutaneous flaps in the lower leg

AXC Date Site Dimension (cm i Flap loss He&g timr

4 December 1980 Medial II x8 None 31 days I December 1980 Lateral 15x7 None 29 days

37 January 1980 Posterior 20x8 None 28 days 57 April 1981 Posterior 16x8 None 37 days

BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 5 “Super flap” raised laterally measuring 14 x 5 cm.

Fig. 6 Cross-leg “super tlap” raised posteriorly measuring IhxXcm.

A

Fig. 7 A, B. Distal skin loss in a “super flap” measuring This probably represents the limit of the method.

B

30 x 8 cm based on the posterior artery. The fascia survived.

REPAIR OF LOWER LEG INJURIES WITH FASCIO-CUTANEOUS FLAPS 131

Fig. 8 “Super flap” measuring I I x 6cm raised in heavily scarred tissue adjacent to a longstanding gravitational ulcer.

Fig. 9 lntcgument transferred from the lateral aspect of the right leg (A) to the left heel (B) by cross-leg “super flap” measuring 15 x 7 cm. Transferred tissue is fascia and old skin graft.

Fig. 10 A cross-leg “super flap” measuring 20 x 8 cm raised posteriorly on the right calf, allows some flexibility in leg fixation.

c- -

Fig. 11 Conventional design cross-leg “super flap” measuring 1 I x 8 cm

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Conclusion The Authors

We confirm the reliability of Ponttn’s “super T. L. Barclay, Cl&I, FRCS, Consultant Plastic Surgeon.

flap” in the repair of lower leg soft tissue defects E. Cardoso, FRCS, Registrar in Plastic Surgery.

and consider that he has introduced a significant D. T. sharpe, FRCS, Senior Registrar in Plastic Surgery.

addition to the options available for treatment of D. J. Crockett, FRCS, Consultant Plastic Surgeon, St. Luke’s

Hospital, Bradford. the more diffkult injuries.

Acknowledgement

Our thanks are due to Mr P. Harrison, Department of Medical Photography at St. Luke’s Hospital, Bradford.

Reference

Pontbn, B. (1981). The fascia-cutaneous flap: its use in soft Requests for reprints to: Mr T. L. Barclay, ChM, FRCS, tissue defects of the lower leg. British Journal of Plastic Consultant Plastic Surgeon, St. Luke’s Hospital, Little Surgery, 34, 215. Horton Lane, Bradford BD5 ONA, W. Yorkshire.