Skip to main content
SpringerLink
Log in
Book cover

Regenerative Medicine and Plastic Surgery pp 429–458Cite as

Soft Tissue Reconstruction of the Lower Limb

  • Chapter
  • First Online:

  • 727 Accesses

Abstract

The authors discuss and review current and past thoughts on reconstruction of the lower limb and in particular the options of soft tissue coverage. Discussion of the lower limb, its reconstruction and why it is needed, the available options and difficult choices in regard to amputation, as well as physical examination of the wound, patient assessment, rehabilitation and functional end point are included.

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Schulte E, Schumacher U. The lower limb. In: Schuenke M, Schulte E, Schumacher U, Ross LM, Lamperti ED, Voll M, editors. General anatomy and musculoskeletal system. NY: Thieme Atlas of Anatomy, Thieme; 2006. p. 360.

    Google Scholar 

  2. Taylor SM, Kalbaugh CA, Blackhurst DW, Hamontree SE, Cull DL, Messich HS, Robertson RT, Langan EM 3rd, York JW, Carsten CG 3rd, Snyder BA, Jackson MR, Youkey JR. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg. 2005;42(2):227–35.

    PubMed  Google Scholar 

  3. American College of Surgeons Committee on Trauma: Resources for Optimal Care of the Injured Patient. https://www.facs.org/quality-programs/trauma/vrc/resources Accessed 1 Oct 2017.

  4. British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb, a short guide. Guidelines 2009. www.necn.nhs.uk/wp.../05/Open-Fractures-of-the-Lowerlimbp-Guidelines-BOA.pdf. Accessed 1 Oct 2017.

  5. Rodriguez ED, Bluebond-Langner R, Copeland C, Grim TN, Singh NK, Scalea T. Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma. 2009;66(5):1311–4.

    PubMed  Google Scholar 

  6. Kolbenschlag J, Hellmich S, Germann G, Megerle K. Free tissue transfer in patients with severe peripheral arterial disease: defects. J Reconstr Microsurg. 2013;29(9):607–14.

    PubMed  Google Scholar 

  7. Ponten B. Events leading to the rediscovery of the fasciocutaneous flap. In: Hallock GG, editor. Fasciocutaneous flaps. Boston: Blackwell ScientIfic Publications; 1992. p. 10–2.

    Google Scholar 

  8. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg. 1981;34:215–20.

    CAS  PubMed  Google Scholar 

  9. Taylor GI, Chubb DP, Ashton MW. True and 'choke' anastomoses between perforator angiosomes: part i. anatomical location. Plast Reconstr Surg. 2013;132(6):1447–56.

    CAS  PubMed  Google Scholar 

  10. Igari K, Kudo T, Toyofuku T, Jibiki M, Inoue Y, Tanaka K, Okazaki M. Combined arterial reconstruction and free tissue transfer for patients with critical limb ischemia. Ann Vasc Dis. 2013;6(4):706–10.

    PubMed  PubMed Central  Google Scholar 

  11. Briggs SE, Banis JC Jr, Kaebnick H, Silverberg B, Acland RD. Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity. J Vasc Surg. 1985;2(6):806–11.

    CAS  PubMed  Google Scholar 

  12. Greenwald LL, Comerota AJ, Mitra A, Grosh JD, White JV. Free vascularized tissue transfer for limb salvage in peripheral vascular disease. Ann Vasc Surg. 1990;4(3):244–54.

    CAS  PubMed  Google Scholar 

  13. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67:177–87.

    CAS  PubMed  Google Scholar 

  14. Cormack GC, Lamberty BGH. The arterial anatomy of skin flaps. 2nd ed. London: Churchill Livingstone; 1994.

    Google Scholar 

  15. Biglari B, Büchler A, Reitzel T, Swing T, Gerner HJ, Ferbert T, Moghaddam A. A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients. Spinal Cord. 2014;52(1):80–3.

    CAS  PubMed  Google Scholar 

  16. Mackenzie DJ, Seyfer AE, Harvey EJ, Levin LS, Colen L, Uroskie T Jr. Reconstructive surgery: lower extremity coverage; skeletal reconstruction; foot reconstruction. In: Mathes SJ, editor. Plastic surgery. Philadelphia: WB Saunders; 2006. p. 1355–453.

    Google Scholar 

  17. Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg. 2013;29(4):233–40.

    PubMed  Google Scholar 

  18. Sheena Y, Jennison T, Hardwicke JT, Titley OG. Detection of perforators using thermal imaging. Plast Reconstr Surg. 2013;132(6):1603–10.

    CAS  PubMed  Google Scholar 

  19. Chubb DP, Taylor GI, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: Part II. Dynamic thermographic identification. Plast Reconstr Surg. 2013;132(6):1457–64.

    CAS  PubMed  Google Scholar 

  20. Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled perforator (propeller) flaps in lower extremity defects: a systematic review. J Reconstr Microsurg. 2012;28(9):595–601.

    PubMed  Google Scholar 

  21. Andrei R, Popescu SA, Zamfirescu D. Lower limb perforator propeller flaps-clinical applications. Chirurgia (Bucur). 2014;109(3):299–309.

    CAS  Google Scholar 

  22. Lei LG, He RX, Cheng P, Zhang JL, Qi DB. Free perforating flap of peroneal artery for repairing the forefoot skin defects. Zhongguo Gu Shang. 2013;26(8):634–6.

    PubMed  Google Scholar 

  23. Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high? Microsurgery. 2013;33(7):578–86.

    PubMed  Google Scholar 

  24. Hauben DJ. Ernst Blasius’s contributions to plastic surgery. Plast Reconstr Surg. 1984;74:561–70.

    CAS  PubMed  Google Scholar 

  25. Niran NS, Price RD, Govilkar P. Fascial feeder and perforator based V-Y advancement flaps in the reconstruction of lower limb defects. Br J Plast Surg. 2000;53(8):679–89.

    Google Scholar 

  26. Granzow JW, Li A, Suliman A, Caton A, Goldberg M, Boyd JB. Bipedicled flaps in posttraumatic lower-extremity reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(10):1415–20.

    PubMed  Google Scholar 

  27. Chaput B, Herlin C, Espié A, Meresse T, Grolleau JL, Garrido I. The keystone flap alternative in posttraumatic lower-extremity reconstruction. J Plast Reconstr Aesthet Surg. 2014;67(1):130–2.

    CAS  PubMed  Google Scholar 

  28. Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg. 1990;43:28–39.

    CAS  PubMed  Google Scholar 

  29. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114:910–6.

    PubMed  Google Scholar 

  30. Quaba O, Quaba A. Pedicled perforator flaps for the lower limb. Semin Plast Surg. 2006;20(2):104–11.

    Google Scholar 

  31. Gayle LB, Lineaweaver WC, Buncke GM, Oliva A, Alpert BS, Billys JB, Buncke HJ. Lower extremity replantation. Clin Plast Surg. 1991;18(3):437–47.

    CAS  PubMed  Google Scholar 

  32. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:3–16.

    CAS  PubMed  Google Scholar 

  33. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37(2):149–59.

    CAS  PubMed  Google Scholar 

  34. Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus muscle: experimental and clinical considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg. 1987;40:1–10.

    CAS  PubMed  Google Scholar 

  35. Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SF. The posterior thigh perforator flap or profunda femoris artery perforator. Plast Reconstr Surg. 2007;119(1):194–200.

    CAS  PubMed  Google Scholar 

  36. Tobin GR. Hemisoleus and reversed hemisoleus flaps. Plast Reconstr Surg. 1985;76:87–96.

    CAS  PubMed  Google Scholar 

  37. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102:599–616.

    CAS  PubMed  Google Scholar 

  38. Albu E, Aldea EA. Soft tissue reconstruction in the sacro-gluteal region after excision of a large verrucous carcinoma. Chirurgia (Bucur). 2013;108(5):729–31.

    CAS  PubMed  Google Scholar 

  39. Louer CR, Garcia RM, Earle SA, Hollenbeck ST, Erdmann D, Levin LS. Free flap reconstruction of the knee: an outcome study of 34 cases. Ann Plast Surg. 2015;74:57–63.

    CAS  PubMed  Google Scholar 

  40. Arnold P, Mixter R. Making the most of the gastrocnemius muscles. Plast Reconstr Surg. 1983;2:38–4.

    Google Scholar 

  41. Ahmad I, Akhtar S, Rashidi E, Khurram MF. Hemisoleus muscle flap in the reconstruction of exposed bones in the lower limb. J Wound Care. 2013;22(11):635.. 638–40, 642

    CAS  PubMed  Google Scholar 

  42. Venkatramani H, Sabapathy SR, Nayak S. Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle. J Plast Reconstr Aesthet Surg. 2014;67(1):93–8.

    CAS  PubMed  Google Scholar 

  43. Pu LL. Soft-tissue coverage of an extensive mid-tibial wound with the combined medial gastrocnemius and medial hemisoleus muscle flaps: the role of local muscle flaps revisited. J Plast Reconstr Aesthet Surg. 2010;63(8):e605–10.

    PubMed  Google Scholar 

  44. Pu LL. Further experience with the medial hemisoleus muscle flap for soft-tissue coverage of a tibial wound in the distal third of the leg. J Plast Reconstr Aesthet Surg. 2008;121(6):2024–8.

    CAS  Google Scholar 

  45. Pu LL. The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg. Ann Plast Surg. 2006;56(1):59–63.

    CAS  PubMed  Google Scholar 

  46. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114(6):1457–66.

    PubMed  Google Scholar 

  47. Beris AE, Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Malizos KN, Soucacos PN. Vascularized fibula transfer for lower limb reconstruction. Microsurgery. 2011;31(3):205–11.

    PubMed  Google Scholar 

  48. Hameed S, Ehtesham-ul-haq RH, Ahmed RS, Majid A, Waqas M, Aslam A, Yusuf O, Butt AM, Ali G. Use of vascularised free fibula in limb reconstruction (for non-malignant defects). J Pak Med Assoc. 2013;63(12):1549–54.

    PubMed  Google Scholar 

  49. Lu S, Wang C, Wen G, Han P, Chai Y. Versatility of the greater saphenous fasciocutaneous perforator flap in coverage of the lower leg. J Reconstr Micro Surg. 2014;30(3):179–86.

    Google Scholar 

  50. Rudig LL, Gercek E, Hessmann MH, Müller LP. The distally based sural neurocutaneous island flap for coverage of soft-tissue defects on the distal lower leg, ankle and heel. Oper Orthop Traumatol. 2008;20(3):252–61.

    PubMed  Google Scholar 

  51. Meng CH, Liang G, Sun JP. Utility of different levels of perforator based sural neurofasciocutaneous flaps in repairing lower limb defects. Zhongguo Gu Shang. 2013;26(8):631–3.

    PubMed  Google Scholar 

  52. Lee YH, Rah SK, Choi SJ, Chung MS, Baek GH. Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle. Plast Reconstr Surg. 2004;114(6):1478–85.

    PubMed  Google Scholar 

  53. Kilinc H, Bilen BT, Arslan A. A novel flap to repair medial and lateral malleolar defects: anterior tibial artery perforator-based adipofascial flap. Ann Plast Surg. 2006;57(4):396–401.

    CAS  PubMed  Google Scholar 

  54. Boopalan PR, Nithyananth M, Titus VT, Cherian VM, Jepegnanam TS. Experience of using local flaps to cover open lower limb injuries at an Indian trauma center. J Emerg Trauma Shock. 2011;4(3):325–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. Sirasanagandla SR, Swamy RS, Nayak SB, Somayaji NS, Rao MK, Bhat KM. Analysis of the morphometry and variations in the extensor digitorum brevis muscle: an anatomic guide for muscle flap and tendon transfer surgical dissection. Anat Cell Biol. 2013;46(3):198–202.

    PubMed  PubMed Central  Google Scholar 

  56. Baltensperger MM, Ganzoni N, Jirecek V, Meyer VE. The extensor digitorum brevis island flap: possible applications based on anatomy. Plast Reconstr Surg. 1998;101:107–13.

    CAS  PubMed  Google Scholar 

  57. Earley MJ, Milner RH. A distally based first web flap in the foot. Br J Plast Surg. 1989;42:507–11.

    CAS  PubMed  Google Scholar 

  58. Lykoudis EG, Seretis K, Lykissas MG. Free sensate medial plantar flap for contralateral plantar forefoot reconstruction with flap reinnervation using end-to-side neurorrhaphy: a case report and literature review. Microsurgery. 2013;33(3):227–31.

    PubMed  Google Scholar 

  59. Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes of free tissue transfer to the lower extremity in children: review. J Reconstr Micro Surg. 2006;22(3):173–81.

    Google Scholar 

  60. Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg. 2013;40(5):575–83.

    PubMed  PubMed Central  Google Scholar 

  61. Demirtas Y, Kelahmetoglu O, Cifci M, Tayfur V, Demir A, Guneren E. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery. 2010;30(1):24–31.

    PubMed  Google Scholar 

  62. Fitoussi F, Bajer B, Bégué T, Penneçot GF, Masquelet AC. The medial saphenous hetero (cross leg) flap in coverage of soft tissue defects of the leg and foot. Rec Chir Orthop Reparatrice Appar Mot. 2002;88(7):663–8.

    CAS  Google Scholar 

  63. Karşıdağ S, Akçal A, Turgut G, Uğurlu K, Baş L. Lower extremity soft tissue reconstruction with free flap based on subscapular artery. Acta Orthop Traumatol Turc. 2011;45(2):100–8.

    PubMed  Google Scholar 

  64. Samir K, Shrirang P. Anurag. Double flap from amputated opposite lower limb for cover of plantar and dorsal surfaces of a crushed foot. Indian J Plast Surg. 2013;46(3):568–71.

    PubMed  PubMed Central  Google Scholar 

  65. Vogel TR, Petroski GF, Kruse RL. Impact of amputation level and comorbidities on functional status of nursing home residents after lower extremity amputation. J Vasc Surg. 2014;59(5):1323–30.. e1.

    PubMed  PubMed Central  Google Scholar 

  66. Penn-Barwell JG. Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis. Injury. 2011;42(12):1474–9.

    PubMed  Google Scholar 

  67. Boffeli TJ, Thompson JC. Partial foot amputations for salvage of the diabetic lower extremity. Clin Pediatr Med Surg. 2014;31(1):103–26.

    Google Scholar 

  68. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924–31.

    PubMed  Google Scholar 

  69. MacKenzie EJ. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg. 2005;87A(8):1801–9.

    Google Scholar 

  70. Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. J Orthop Trauma. 1996;10:223–9.

    CAS  PubMed  Google Scholar 

  71. Johansen K, Daines M, Howey T, Helfet D, Hansen ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30(5):568–72.

    CAS  PubMed  Google Scholar 

  72. Howe HR, Poole GV, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg. 1987;53(4):205–8.

    PubMed  Google Scholar 

  73. Seekamp A, Köntopp H, Tscherne H. Hannover Fracture Scale ‘98–reevaluation and new prospects for an established score system. Unfallchirurg. 2001;104(7):601–10.

    CAS  PubMed  Google Scholar 

  74. Russell WL, Sailors DM, Whittle TB, Fisher DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven part predictive index. Ann Surg. 1991;213(5):473–80.

    CAS  PubMed  PubMed Central  Google Scholar 

  75. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma. 1994;8(2):81–7.

    CAS  PubMed  Google Scholar 

  76. Hallock GG. Evidence-based medicine: lower extremity acute trauma. Plast Reconstr Surg. 2013;132(6):1733–41.

    CAS  PubMed  Google Scholar 

  77. Joethy J, Sebastin SJ, Chong AK, Peng YP, Puhaindra ME. Effect of negative-pressure wound therapy on open fractures of the lower limb. Singap Med J. 2013;54(11):620–3.

    Google Scholar 

  78. Rybalko V, Hsieh PL, Ricles LM, Chung E, Farrar RP, Suggs LJ. Therapeutic potential of adipose-derived stem cells and macrophages for ischemic skeletal muscle repair. Regen Med. 2017;12(2):153–67.

    CAS  PubMed  PubMed Central  Google Scholar 

  79. Tan EW, Schon LC. Mesenchymal stem cell-bearing sutures for tendon repair and healing in the foot and ankle. Foot Ankle Clin. 2016;21(4):885–90.

    PubMed  Google Scholar 

  80. Andia I, Maffulli N. Muscle and tendon injuries: the role of biological interventions to promote and assist healing and recovery. Arthroscopy. 2015;31(5):999–1015.

    PubMed  Google Scholar 

  81. Foong DP, Evriviades D, Jeffery SL. Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps. J Plast Reconstr Aesthet Surg. 2013;66(12):1717–24.

    PubMed  Google Scholar 

  82. Helgeson MD, Potter BK, Evans KN, Shawen SB. Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma. 2007;21(6):394–9.

    PubMed  Google Scholar 

  83. Iorio ML, Shuck J, Attinger CE. Wound healing in the upper and lower extremities: a systematic review on the use of acellular dermal matrices. Plast Reconstr Surg. 2012;130(5 Suppl 2):232S–41S.

    CAS  PubMed  Google Scholar 

  84. Kadam D. Limb salvage surgery. Indian J Plast Surg. 2013;46(2):265–74.

    PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

Special thanks to Omar Quaba and Alex Munnoch, Consultant Plastic and Reconstructive Surgeons for use of images.

Author information

Authors and Affiliations

  1. Plastic Surgery and Reconstruction Department, Ninewells Hospital and Medical School, Tayside NHS Trust, Dundee, UK

    Mahmoud Kazem Nassar & Daniel J. Jordan

  2. Plastic Surgery & Laser Centre, Bedford Hospital NHS Trust, Bedford, UK

    Sandip Hindocha

Authors
  1. Mahmoud Kazem Nassar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel J. Jordan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sandip Hindocha
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Department for Plastic Surgery and Hand Surgery, Division of Experimental Plastic Surgery, Technical University of Munich, Munich, Germany

    Dominik Duscher

  2. Private Practice, Tustin, CA, USA

    Melvin A. Shiffman

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Nassar, M.K., Jordan, D.J., Hindocha, S. (2019). Soft Tissue Reconstruction of the Lower Limb. In: Duscher, D., Shiffman, M.A. (eds) Regenerative Medicine and Plastic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-19958-6_35

Download citation

Publish with us

Policies and ethics

Search

Navigation