CROSS-LEG TIBIAL POSTERIOR PERFORATOR FLAP

ALEXANDRU V. GEORGESCU, M.D., Ph.D.,* CAPOTA IRINA, M.D., and MATEI ILEANA, M.D.

Background: In the lower leg posttraumatic pathology, we are frequently confronted with tissue defects that are difficult 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 flap. The authors will try to demonstrate the advantages of this method, by using the cross-leg flapbased on perforator vessels. Methods: We are presenting two cases for which we practiced a cross-leg perforator flap, based on perforatorvessels emerging from the posterior tibial artery. Results: The results were favorable, demonstrated by immobilization in a comfortableposition, perfect flap integration, pedicle flap’s division at 14–21 days, early postsurgery ambulation. Conclusions: The cross-leg perforatorflap diminishes many of the disadvantages created by the classic cross-leg flap and can be successfully used in cases in which other pro-cedures are prohibited. VVC 2007 Wiley-Liss, Inc. Microsurgery 27:379–383, 2007.

The covering of soft tissue defects of the lower leg presents

a notable challenge for the reconstructive surgeon, first of all

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

especially in posttraumatic conditions.1–4 For these reasons,

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

problem: cross-leg flaps,2–6 proximally7 or distally2–4,8–10

based fascial or fasciocutaneous flaps, distally based muscle

flaps,11–13 and free flaps.14–16 The new era of perforator flaps

determined an improvement in the possibilities to use both

local/regional17–20 or free21–25 perforator flaps in covering

these difficult 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 flaps 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 flap. We consider that this method offers

some advantages over the classical cross-leg flap and,

more, brings the advantages of a perforator flap.

CASE REPORTS

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 five 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 fistulized septic pseudarthrosis (Fig. 1A). We decided

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

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

the surgery, we found an extensive fibrosis 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

flap 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 flap.

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

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

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

We identified a very nice perforator coming through the tibi-

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

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

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

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

forator was completed, keeping a 2-cm adipofascial cuff

around it (Fig. 1C). The flap was rotated 908 and applied on

the 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 flap, before or after the pedicle division, was

observed. The patient used elastic compression support for 4

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

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

Case 2

A 58–year-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: geordv@hotmail.com

Received 28 February 2007; Accepted 5 March 2007

Published online 7 June 2007 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20375

VVC 2007 Wiley-Liss, Inc.

After revascularization and other complex surgical proce-

dures (local and free flaps), 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 flaps, and so we

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

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

blood supply was ensured through two septocutaneous

perforators identified 8 cm above the tibial maleola and

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

The dimensions of the flap 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 flap of 18/8 cm was designed and a musculocutaneous tibial posterior artery perforator was identified. C: The flap was harvested by

keeping a 2-cm adipofascial tissue cuff around the perforator. D: The flap was rotated 908 and applied to the defect. Free split skin graft

one the donor site. E: 21 days later, after sectioning the pedicle. F: 7 months after surgery. [Color figure can be viewed in the online issue,

which is available at www.interscience.wiley.com.]

380 Georgescu et al.

Microsurgery DOI 10.1002/micr

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

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

cm length, 9-cm width proximally and 4 cm distally) was completed. D: After the flap was rotated 908, about 90 cm2 of its proximal part

was de-epidermised and filled 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 figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

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

mised in the attempt to fill the dead space (Fig. 2D). Theflap 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 flap survival was complete. Thepedicle was divided in the 14th day (Fig. 2H), and theambulation was permitted 1 week later.

DISCUSSION

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 flap.

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 flap

to be used less and less.4

Since Ponten7 introduced the concept of fasciocutane-

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

achievements in the knowledge of the leg blood supply

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

again this procedure increased.

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

pedicled flaps5,6,28–30 or neurocutaneous flaps,2–4,10 but

also as free cross-leg flaps.31–33

But all these procedures do not completely avoid the

well-known disadvantages (especially the immobilization

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

the risks of vascular anasthomosis.

Because of the local conditions, in both our patients,

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

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

avoid part of the traditional procedure’s disadvantages

(especially the immobilization in uncomfortable positions

and the knee fixation in some degree of flexion or exten-

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

It is better to base the flap 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 flap.

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 flap more than 908 is generally

not necessary so will be no chance to compromise the

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

sels. Because sometimes deep defects are to be covered,

some surgeons harvest together with the distally based

pedicle flap a segment of the gastrocnemius muscle that

improves the blood supply of the flap and facilitates the

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

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

dermised flap. 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 flexion 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 flap 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.

REFERENCES

1. Fraccalvieri M, Verna G, Dolcet M, Fava R, Rivarossa A, Robotti E,Bruschi S. The distally based superficial sural flap: Our experiencein reconstructing the lower leg and foot. Ann Plast Surg 2000;45:132–139.

2. Quarmby C, Skoll PJ. The distally based cross-leg sural artery islandflap. Plast Reconstr Surg 2001;108:798–799.

3. Yildirim S, Akan M, Giderodglu K, Akoz T. Use of distally basedsaphenous neurofasciocutaneous and musculofasciocutaneous cross-leg flaps in limb salvage. Ann Plast Surg 2001;47:568–574.

4. Atiyeh B, Al-Amm CA, El-Musa KA, Sawwaf AV, Musharafieh RS.Distally based sural fasciocutaneous cross-leg flap: A new applica-tion of an old procedure. Plast Reconstr Surg 2003;111:1470–1474.

5. Serafin D, Georgiade NG, Smith D. Comparison of free with pedi-cled flaps for coverage of defects of leg or foot. Plast Reconstr Surg1977;59:492–499.

6. Long CD, Granick MS, Solomon MP. The cross-leg flap revisited.Ann Plast Surg 1993;30:560–563.

7. Ponten B. The fasciocutaneous flap: Its use in soft tissue defects ofthe lower leg. Br J Plast Surg 1981;34:215–220.

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

9. Carriquiri CE. Heel coverage with a deepithelialized distally basedfasciocutaneous flap. Plast Reconstr Surg 1990;85:116–119.

10. Gozu A, Ozyigit T, Ozsoy Z. Use of distally pedicled sural fasciocu-taneous cross-leg flap in severe foot and ankle trauma: A safe alter-native to microsurgery in very young children. Ann Plast Surg2005;55:374–377.

11. Faynan MS, Orak P, Hugo B, Berson SD. The distally based splitsoleus muscle flap. Br J Plast Surg 1987;40:20–26.

12. Bashir AII. Inferiorly based gastrocnemius muscle flap in the treat-ment of war wounds in the middle and lower third of the leg. Br JPlast Surg 1983;36:307–309.

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 flap: Anatomicaspects. Plast Reconstr Surg 2000;106:1312–1315.

14. Swartz WM, Mears DC. The role of free tissue transfer in lower ex-tremity reconstruction. Plast Reconstr Surg 1985;76:364–373.

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

16. Georgescu AI, Ivan O. Emergency free flaps. Microsurgery 2003;23:206–216.

17. Lees V, Townsend PLG. Use of a pedicled fascial flap 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 flaps in the leg. Br J Plast Surg 1998;51:431.

19. Shaw AD, Ghosh SJ, Quaba AA. The island perforator calf fasciocu-taneous flap. An alternative to the gastrocnemius muscle for cover ofknee and tibial defects. Plast Reconstr Surg 2000;101:1529–1536.

20. Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforatorbased V-Y advancement flaps 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 flap? An experience with 672 antero-lateralthigh flaps. Plast Reconstr Surg 2002;109:2219.

22. Stussi JD, Aboualtout Y, Bean P, Meley M. Anterolateral thigh flapfor limb reconstructive surgery: Four case reports. Revue de ChirurgieOrthopedique et reparatrice de l’Appareil Moteur 2002;88:298–305.

23. Kuo YR, Jeng SF, Kuo MH, Huang MNL, Liu YT, Chiang YC, YehMC, Wei FC. Free anterolateral thigh flap for extremity reconstruc-tion: Clinical experience and functional assessment of donor site.Plast Reconstr Surg 2001;107:1766.

24. Cavadas PC, Sanz Gimenez Rico JR, Gutierrez De La Camara A,Navarro-Monzonis A, Soler-Nomdedeu S, Martinez-Soriano F. Themedial sural artery perforator free flaps. Plast Reconstr Surg 2001;108:1609.

25. Schwabegger AH, Bodner G, Ninkovici M, Piza-Katzer H. Thoraco-dorsal artery perforator (TAP) flap: Report of our experience andreview of the literature. Br J Plast Surg 2002;55:390–395.

26. Morris AM, Buchan AC. The place of the cross-leg flap in recon-structive surgery of the lower leg and foot: A review of 165 cases.Br J Plast Surg 1978;31:138.

27. Masquelet A, Begue T, Pages C, Nordin JY. The vascularized cross-leg flap. Presse Med 1985;14:2013.

28. Yokoyama K, Aoki S, Ohtsuka H, Boku T, Fukushima N, ItomanM. ‘‘Slipper like avulsion injury’’ of the foot: A report of two rarecases salvaged by conventional cross-leg flaps. J Trauma 2005;59:1239–1242.

29. Ay A. An unusual contracture of the foot caused by a neglectedburn wound salvaged by a cross-leg flap. Plast Reconstr Surg 2002;110:1373.

30. Topalan M, Ermis J. Cross-leg free flap for emergency extremity sal-vage: Case report. J Reconstr Microsurg 2001;17:157–162.

31. Ninkovic MM, Schwabegger AH, Hausler JW, Ninkovic M,Schmutzhard E. Limb salvage after fulminant septicemia using afree latissimus dorsi cross-leg flap. J Reconstr Microsurg 2000;16:603–608.

32. Hamdi M, Weiler-Mithoff EM, Webster MHC. Cross-leg pedicledfree scapolar flap for neuropathic foot ulcer: Case report. J ReconstrSurg 2000;16:597–602.

33. Hallock GG. Medial sural gastrocnemius muscle perforator free flap:An immediate cross-leg flap? J Reconstr Microsurg 2005;21:217–223.

34. Koshima I, Ozaki T, Gonda K, Okazaki M, Asato H. Posterior tibialadiposal flap for repair of wide, full-thickness defect of the Achilleastendon. J Reconstr Microsurg 2005;21:551–554.

35. Al-Qattan MM. A modified technique for harvesting the reversesural artery flap from the upper part of the leg: Inclusion of a gastro-cnemius muscle ‘‘cuff’’ around the sural pedicle. Ann Plast Surg2001;47:269–278.

Cross-Leg Tibial Posterior Perforator Flap 383

Microsurgery DOI 10.1002/micr