Local Flap of Lower Extremity.pptx

LOCAL FLAP IN LOWER
EXTREMITY
RECONSTRUCTION

INTRODUCTION
Khundkar, R. 2019. Lower Extremity Flap Coverage Following Trauma. Journal of Clinical Orthopedics and Trauma, 10, 839-844, doi: https://doi.org/10.1016/j.jcot.2019.08.007
Defects of lower extremities can
be the results from a trauma,
malignancy or oncology resection,
diabetes, peripheral arterial disease,
and chronic venous stasis. Some
trauma in lower extremities can be
severe which often involving any
lesion of soft tissue and bone. This
condition can lead to a limb-
threatening condition.

INTRODUCTION
Gabriel, A., Pfaffenberger, M., Eldenburg, E. 2020. Succesfull Salvage of a Llower Extremity Local Flap Using Multiple Negative Pressure Modalities. Plast Reconstr Surg Glob Open, 8(6), doi:
10.1097/GOX.0000000000002801
Gyori, E., Fast, A., Resch, A., Rath, T. Radtke, C. 2022. Reconstruction of Traumatic and non-Traumatic Lower Extremity defects with Local of Free Flaps. Eur Surg, 54, 44-49, doi: https://doi.org/10.1007/s10353-
021-00704-0
Local
Flap
Is a reconstructive surgery where its provide a similar
type, characteristic, thickness, and weight bearing
capacity to the planted area. It is said, that local flap
should be technically, simple to follow, single stage
procedure, minimizing donor site morbidity, and
having a good outcome in function and aesthetic.

Flap reconstruction can be
described by their
specification, for example
their blood supply to the flap,
the location of the donor-site,
and the type of tissue being
used.
Flap and Local Flap
Deldar, R., Merie,C., Attinger, C.E., Evans, K.K. 2022. Soft Tissue Coverage of Lower Extremity Defects: Pearls and Pitfalls in The Chronic Wound Population. Plast Aesthet Res, 9(3), doi: 10.20517/2347-
9264.2021.100
Saber, A.Y., Hohman, M.H., Dreyer, M.A. 2022. Basic Flap Design. StatPearls Publishing, diakses pada: 14 Juni 2023, tersedia di: https://www.ncbi.nlm.nih.gov/books/NBK563252/

The lower extremity can be
divided into four anatomic
subregions: (1) gluteal, (2) hip
and thigh, (3) knee and leg,
and (4) ankle and foot.
Within these regions, there
are 21 cutaneous vascular
territories
Anatomical Consideration

Etiology
Gyori, E., Fast, A., Resch, A., Rath, T. Radtke, C. 2022. Reconstruction of Traumatic and non-Traumatic Lower Extremity defects with Local of Free Flaps. Eur Surg, 54, 44-49, doi: https://doi.org/10.1007/s10353-021-00704-0
Cause of
Defect
Trauma (high or
low intensity
injury)
Diabetes
Vasculitis
Infection
Peripheral
vascular disease
Post-operative
Polyneuropathy
Tumor resection

Closure possibilities are assessed beginning with the
simplest and proceeding up the "reconstructive ladder" to
the more complex. This transition from primary closure to
skin graft, local tissue transfer, regional tissue transfer, and
free tissue transfer provides a foundation for every
reconstructive circumstance.
Flap Modality
Azoury, S. C. et al. (2021) ‘Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?’, Journal of Reconstructive Microsurgery, 37(1), pp. 42–50. doi: 10.1055/s-0039-1695753.
Reconstruction Ladder in
Plastic Surgery

Flap
Modality
Fleming, M. E. et al. (2014) ‘Application of the Orthoplastic reconstructive ladder to preserve lower extremity amputation length’, Annals of Plastic Surgery, 73(2), pp. 183–189. doi: 10.1097/SAP.0b013e3182a638d8.
Simman, R. and Abbas, F. T. (2021) ‘Foot Wounds and the Reconstructive Ladder’, Plastic and Reconstructive Surgery - Global Open, 9(12), pp. 1–7. doi: 10.1097/GOX.0000000000003989
Are several techniques available? Do they
provide solutions with varying levels of quality?
What is the degree of difficulty? Do the
techniques entirely/partially solve the problem?
these include cardiovascular health, body mass index, and
smoking. Complication risks and consequences must also
be considered.
is the problem's
anatomical/pathological
complexity, and what
structures are involved?
Would the patient accept a
partial remedy or a
compromise to the
problem? It is critical to
evaluate compliance, social
support, and emotional
stability.

Flap
Movement
Subtypes Illustration
Rotation
Flap rotates
around pivot
point
Back cut →
Releasing too
tight flap
Rotation
Advancement
Flap moves
forward with no
lateral
movement
V-Y
Bipedicled
Single
pedicle
Movement of Flaps Classification
FLAP CLASSIFICATION
Pribaz JJ, Huber KM. Principles of Flap Design and Application. In: Chung KC. Grabb and Smith’s Plastic Surgery Eighth Edition. Wolters Kluwer 2020;4:25-38.

Flap Movement Subtypes Illustration
Transposition
Rectangle or
square flap
moves laterally in
relation to pivot
point
Z-plasty
Limberg flap
Bilobed
Islandization
Flap rotates
around pivot point
to be positioned
to defect, forming
a skin bridge
Propeller
Pedicled
FLAP CLASSIFICATION

Flap Modality
Mathes and Nahai Classification
Type Vascular Pedicle Examples Description
I Single Vascular
Pedicle
Abductor digiti minimi, abductor policis brevis,
dorsal interosseous, gastrocnemius
Single vascular pedicle to muscle to safely
elevated from pedicle
II Dominant vascular
pedicle and minor
vascular pedicle
abductor digiti minimi (foot), abductor hallucis,
brachioradialis, coracobrachiora·
dialis, flexor carpi ulnaris
Division of minor pedcile while preserving
dominant pedicle
III Dominant pedicles gluteus maximus,intercostal, orbicularis oris,
pectoralis minor, rectus abdominis, serratus, and
temporalis
Two large vascular pedicles, each support
entire muscle
IV Segmental vascular
pedicles
extensor digitorum longus, extensor hallucis
longus, external oblique, flexor digitorum longus,
flexor hallucis longus, sartorius, and tibialis
anterior
Series of segmental pedicles entering the
muscle. Each pedicle provides circulation
of the mucle
V Dominant Vascular
pedcile and
secondary segmental
vascular pedicles
internal oblique, latissimus dorsi. pectoralis
major
Large vascular pedicle to provide
circulation to muscle, and secondary
vascular pedicle

Flap Modality
Mathes and Nahai Classification
Fleming, M. E. et al. (2014) ‘Application of the Orthoplastic reconstructive ladder to preserve lower extremity amputation length’, Annals of Plastic Surgery, 73(2), pp. 183–189. doi: 10.1097/SAP.0b013e3182a638d8.
Simman, R. and Abbas, F. T. (2021) ‘Foot Wounds and the Reconstructive Ladder’, Plastic and Reconstructive Surgery - Global Open, 9(12), pp. 1–7. doi: 10.1097/GOX.0000000000003989

SPLIT THICKNESS SKIN GRAFT
IN LOWER EXTREMITY
05

Skin grafts can be used to cover exposed muscle
or soft tissue, and they can also be utilized to cover
the bone with healthy periosteum or the tendon
with healthy paratendon.
SKIN GRAFT IN LOWER EXTREMITY
Adelman, D. et al. (2016) Grabb and Smith’s Plastic Surgery. 7th edn. Philadelphia: Lippincott Williams & Wilkins.
Ramanujam, C. L. et al. (2013) ‘Impact of diabetes and comorbidities on split-thickness skin grafts for foot wounds’, Journal of the American Podiatric Medical Association, 103(3), pp. 223–232. doi: 10.7547/1030223.
Rose, J. F. et al. (2014) ‘Split-thickness skin grafting the high-risk diabetic foot’, Journal of Vascular Surgery, 59(6), pp. 1657–1663. doi: 10.1016/j.jvs.2013.12.046.
Skin grafts used for: Gustilo grade IIIA open tibial fractures, IIIB or IIIC injuries,
Diabetic foot wounds.

LOCAL FLAPS OF LOWER
EXTREMITIES
06

LOCAL FLAPS IN LOWER EXTREMITY
Gastrocnemius Muscle Flap Although the gastrocnemius
is capable of carrying a skin
paddle, the donor-site
deformity that is formed is
undesirable. Detaching the
muscle's origin from the
femur, carefully dissecting
the pedicle, and either
scoring or eliminating the
muscle fascia can improve
the arc of rotation
The lateral or medial gastrocnemius flap is beneficial for
proximal third of the leg abnormalities.
Left: Open knee wound. Right: Gastrocnemius rotational flap

Paro, J., Chiou, G. and Sen, S. K. (2016) ‘Comparing Muscle and Fasciocutaneous Free Flaps in Lower Extremity Reconstruction--Does It Matter?’, Annals of plastic surgery,
76(May), pp. S213–S215. doi: 10.1097/SAP.0000000000000779.
Left: Pre-op appearances. Right: Hemisoleus flap to cover tibial fracture
Soleus Muscle Flap
The soleus muscle
flap can be raised
and translated into
wounds in the
proximal, middle,
and distal thirds of
the leg.

The soleus muscle flap can be raised and
translated into wounds in the proximal, middle,
and distal thirds of the leg. The primary vascular
pedicles of the soleus are popliteal artery
branches, posterior tibial artery branches
(medial belly), and peroneal artery branches
(lateral belly).
Paro, J., Chiou, G. and Sen, S. K. (2016) ‘Comparing Muscle and Fasciocutaneous Free Flaps in Lower Extremity Reconstruction--Does It Matter?’, Annals of plastic surgery,
76(May), pp. S213–S215. doi: 10.1097/SAP.0000000000000779.
Soleus Muscle Flap

Because most lower leg muscles have segmental minor arterial
pedicles, they produce weak pedicles flaps. As a result, just a tiny
piece of the muscle may be transferred safely and without delay.
Lower Leg and Ankle Flaps
Simman, R. and Abbas, F. T. (2021) ‘Foot Wounds and the Reconstructive Ladder’, Plastic and Reconstructive Surgery - Global Open, 9(12), pp. 1–7. doi: 10.1097/GOX.0000000000003989.

Small defects as far distal as 2 cm above
the medial malleolus
For mild deficiencies as far as 2 cm above
the medial malleolus
For tiny defects as far as 4 cm above the
medial malleolus
can be covered by the extensor
hallucis
the extensor digitorum longus and
peroneus tertius muscles are employed
the peroneus brevis muscle can be
employed
Lower Leg and Ankle Flaps
deficiencies as far as 6 cm above the
medial malleolus
the flexor digitorum longus muscle
can be employed
the minor distal pedicles can be
detached and the muscle rotated
with an intact proximal major pedicle
to cover large (10 cm X 8 cm)
anterior lower leg defects as far as 6.6 cm
above the medial malleolus

Complication
The complication can happen in acute or chronic form. The complications include: failure of
the flap which lead to partial or total necrosis, build-up of seroma and hematoma, infection,
and wound dehiscence.
Jordan, D.J., Malahias, M., Hindocha, S., Juma, A. 2014. Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb. The Open Orthopaedics Journal, 8(2), 423-432
Acute Chronic
When the flaps are still on,
predominantly cause an acute
compromise of the blood supply and
infection. But when the flaps die, it is
usually result in vascular compromise,
veins obstruction outflow.
The chronic complications are,
aesthetic and functional dysfunction,
scarring, contracture, hair grow
disturbance, numbness, and pain

Complications
Gyori, E., Fast, A., Resch, A., Rath, T. Radtke, C. 2022. Reconstruction of Traumatic and non-Traumatic Lower Extremity defects with Local of Free Flaps. Eur Surg, 54, 44-49, doi: https://doi.org/10.1007/s10353-021-00704-0
Complications
Delayed wound healing
(19%)
Partial flap necrosis
(4.8%)
Wound dehiscence
(4.8%)
Hematoma (4.8%)
There are 66.7% samples local flaps did not get any complications. (Gyori et all,
2022)

Peroneal Artery Perforator Transpositional
Musculocutaneous Flap
Left: Open left cruris wound.
Middle: Peroneal Artery Perforator Rotational
Musculocutaneous Flap
Right: Post op appearance
A male, 17 yo, defect of left cruris region

Skin Graft
Top: Necrotic flap
Middle: Defect of left ankle region
Right: Post op appearance with STSG
A boy, 3 yo, history of diffuse flexion contracture of left
ankle region + shortened of left achilles tendon and
defect of left sural nerve
History of ALT free flap.

Conclusion
• Local flap is a reconstructive surgery which is transfers the skin donor (local tissue from a
healthy donor-site skin) around the pivot points to the wound.
• Small to moderate defects of bone-exposed arteries or tendons can be treated by
fasciocutaneous or muscle flaps.
• Local flaps in the proximal or middle portion of the leg are widely accepted, whereas
local flaps in the lower third of the leg do not exist.
• There is some type of local flaps, which are: gastrocnemius muscle flaps, soleus muscle
flaps, lower leg and ankle flaps.
• Choosing the right flaps for specific defect in lower limb is needed, not only to create a
better outcome, but also lowering any complication that could happen.

Local Flap of Lower Extremity.pptx

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