The cross-leg soleus muscle flap

Reconstruction of the lower limb can be a difficult problem, especially when located over the lower third of the leg, or when a large soft-tissue defect exists. When local flap coverage is not possible, a distant flap--free or pedicled--is indicated. There are, however, circumstances that preclude the use of a free flap, and in these situations cross-leg flaps remain a viable alternative. They have been proved to be safe, are usually quick to perform, and do not require specialized facilities for postoperative monitoring. A new variation of the soleus muscle flap--the cross-leg soleus muscle flap--is described. Using this modification, the authors successfully closed large defects of the lower limb in 9 patients. The donor site defect that is left on the contralateral limb is far more acceptable than that left by conventional cross-leg fasciocutaneous or musculocutaneous flaps. The authors prefer the cross-leg soleus flap to conventional cross-leg flaps in these situations.     

Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report

Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.     

The use of the photoplethysmograph to monitor the training of a cross-leg free flap prior to division.

The cross-leg free flap is an important, although rarely used, option in the reconstruction of lower limb trauma. We report the use of photoplethysmography in the assessment of such a flap's training and the time of pedicle division.     

Cross-leg tibial posterior perforator flap

BACKGROUND: In the lower leg posttraumatic pathology, we are frequently confronted with tissue defects that are difficult to cover by local or distance means, because of either the poor tissue quality or the precarious local vessels. One of the still available methods for solving these cases remains the cross-leg flap. The authors will try to demonstrate the advantages of this method, by using the cross-leg flap based on perforator vessels. METHODS: We are presenting two cases for which we practiced a cross-leg perforator flap, based on perforator vessels emerging from the posterior tibial artery. RESULTS: The results were favorable, demonstrated by immobilization in a comfortable position, perfect flap integration, pedicle flap's division at 14-21 days, early postsurgery ambulation. CONCLUSIONS: The cross-leg perforator flap diminishes many of the disadvantages created by the classic cross-leg flap and can be successfully used in cases in which other procedures are prohibited.     

Repair of bilateral lower limb injuries using a free latissimus dorsi cross-leg flap

Current microsurgical techniques are used in single stage repair of distal lower limb defects. The previously popular cutaneous and fasciocutaneous flaps have been practically shelved. However, in selected cases, the vessels of a lower limb can still be employed to vascularize a harvested flap for the repair of a contralateral defect. In cases where the vessels of a traumatized leg are severely damaged or jeopardized, vascular components of the opposite limb can be exploited to provide the blood supply for the flap chosen to cover the defect. There are times when trauma to both legs may require a single large flap (latissimus dorsi) which if properly vascularized can bridge a bilateral defect. This could bring about the revival of the cross-leg flaps. Four cases are reported: in one, the flap was vascularized from a healthy limb to cover a contralateral exposed fracture and an avulsed heel. In three other cases, the latissimus dorsi was utilized to fill large post-traumatic bilateral defects at the distal lower limb level. In these cases the limb with the best vascular system was chosen for flap anastomoses and fixation was then applied. Received: 2 June 1998 / Accepted: 12 August 1998     

Newer applications of the cross-leg flap

Five recent examples of the cross-leg flap are presented. Its applications and design have been altered and its versatility widened by using muscle. In all cases the use of a Hoffmann apparatus facilitated not only fixation of the flap but also patient comfort, since ropes attached to side-arm rods can be put over pulleys and weights attached to take the strain off potential pressure points. The technetium scan was helpful in determining when flap division should be done. Flaps were rarely in place more than three weeks before division: often, especially in children, division is possible by two weeks. By clamping the flap with a soft clamp and giving an intravenous bolus of fluorescein, circulation can be ascertained unequivocally. Cross-leg flaps remain a useful and highly reliable tool for the reconstruction of difficult wounds of the lower limb.     

Technique to re-establish continuity of the recipient artery after end-to-end anastomoses in cross-leg free flap procedure

In this report, a simple technique is described to restore the continuity of the recipient artery in cross-leg free flap procedure after end-to-end anastomoses. In the first stage, the latissimus dorsi flap was revascularized by end-to-end anastomosis between the posterior tibial artery of the noninjured leg and the thoracodorsal artery of the flap. After 4 weeks of neovascularization period, in the second stage when the pedicle was to be divided, the thoracodorsal artery was dissected until its bifurcation in the muscle, transected, and rerouted to the distal ligated end of the posterior tibial artery, accomplishing a simple end-to-end anastomosis between these two vessel ends. Thus, the continuity of the recipient artery was re-accomplished by replacing the normally discarded segment of the flap's arterial pedicle as an arterial graft, the patency of which was demonstrated clinically and by Doppler examination. The authors believe that this technique provides further benefit to the patient by accomplishing vascular flow through a major lower limb artery when the reconstructive pathway involves an end-to-end anastomosis in a cross-leg free flap procedure.     

小腿前外侧的皮瓣及筋膜瓣的临床应用

目的 介绍小腿前外侧的皮瓣筋膜瓣的应用解剖、手术方式、方法及临床应用。方法 在１４侧成人下肢标本及１条断腿上,观察了腓浅血管的起始部位、行程及皮支的分布情况,设计了小腿前外侧组织瓣的４种术式。１９９８年以来,临床应用２６例。结果 术后皮折筋膜全部成活,切口Ⅰ期愈合２３例,Ⅱ期愈合３例,２０例随访４个月到５年,情况稳定良好,无复发。结论 手术操作简单、安全可靠,对供区影响小,是修复小腿及对侧踝及跟部     

Cross-leg free flap for emergency extremity salvage: case report

The use of a cross-leg free flap and consequent limb salvage was successfully performed in a 10-year-old boy with a compound open fracture of the tibia, involving extensive skin and soft-tissue loss. This method should be kept in mind, as it may sometimes, in an emergency situation, lead to lower-extremity salvage, as in the case reported.     

Cross-leg latissimus dorsi free flap with chimeric serratus anterior bridge for lower extremity trauma: Case report and reconstructive algorithm

Gustilo Grade IIIB and IIIC open fractures of the lower extremity often involve complex wounds requiring bony fixation and soft tissue reconstruction. We present a case of a 32 year-old male who suffered a traumatic Gustilo Grade IIIB open fracture of the tibia and fibula with an extensive soft tissue defect. Reconstruction was first attempted with a turbocharged anterolateral thigh flap that failed due to venous thrombosis. Due to vascular injury, limited reconstructive options were available from the ipsilateral leg. Limb salvage was subsequently achieved with a chimeric cross-leg latissimus dorsi-serratus anterior (LD-SA) free flap based off the contralateral healthy leg, using the serratus for pedicle bridge coverage so that the latissimus could be fully used for defect coverage. Though not extensively described in the literature, this flap is a versatile reconstructive option for limb salvage in patients with Gustilo IIIB or IIIC injuries to the lower extremity.     

扩张的交腿皮瓣修复足背皮肤缺损

目的探讨虚用皮肤软组织扩张术与交腿皮瓣相结合，修复足背皮肤缺损骨外露的临床效果。方法共已采用扩张的交腿皮瓣修复对侧足背皮肤缺损骨外露10例。结果本方法对供皮瓣区及受皮瓣区均能得到良好的修复，供区不需移植皮片，修复后遗留的体表痕迹少，皮瓣较薄外形佳。结论虚用扩张的交腿皮瓣为足背皮肤缺损骨外露提供一种简单易行、损伤小、皮瓣供受区外形均佳的修复方法。     

The repair of soft tissue defects in the lower leg. A comparison of different flap techniques

The results following reconstruction of soft tissue defects in the lower leg in 102 patients with 19 cross-leg flaps, 49 muscle flaps, 17 dorsalis pedis island flaps and 26 free composite island flaps were compared regarding the pattern of primary healing, time taken to heal and costs. The cross-leg flap appeared to be the least dependable method of reconstruction and most expensive way of reestablishing stable soft tissue coverage. Muscle flaps and dorsalis pedis island flaps appeared to be preferable and equal alternatives to cross-leg flaps in the proximal and distal part of the lower leg, respectively. Free composite island flaps also appeared advantageous compared to cross-leg flaps, and seem to be indicated when simpler means of reconstruction are inadequate or would yield a similar result at higher overall costs.     

Salvage of the lower extremity free flap using cross-leg venous repair.

This retrospective study was designed to evaluate a salvage technique for free flaps suffering venous congestion by using a cross-leg vein repair in patients with venous-impaired lower extremities. Four free flap reconstructions were performed using the latissimus dorsi muscle to reconstruct soft tissue defects in the lower extremity. The recipient artery was confined to the ipsilateral leg and the venous anastomosis was performed with a long saphenous vein from the contralateral side. The legs were immobilised together by means of an external fixator. All patients were males with a mean age of 31 years. The mean time of pedicle division was 8.8 days (7-10). The mean size of the free flap was 186.5 cm(2). All flaps survived after pedicle division without venous congestion. There were no complications such as joint stiffness or donor site morbidity except for a linear scar. The cross-leg venous repair is a refinement of a salvage procedure for compromised free flaps used in the reconstruction of severe soft tissue defects in vascularly compromised lower extremities.     

Large transverse fasciocutaneous leg flap: whole leg flap.

Large defects of leg and sole often need massive tissue transfer. As an alternative to microvascular transfer, we have developed a fasciocutaneous flap in which almost the whole of the skin of the opposite leg is transferred based just on the septocutaneous perforators of the posterior tibial artery. The flap has been used as a cross-leg fasciocutaneous flap with potential for use as a free flap by taking a segment of the posterior tibial artery. Our experience with 11 cases is presented. Two patients suffered marginal necrosis while donor site problems were seen in another two patients. We have found this flap to be safe, technically easy and with minimal donor-site morbidity.     

Cross-foot island instep flap: a new use of instep skin flap for management of persistent wounds after complex plantar foot reconstruction

When presented with an extensive soft-tissue defect involving the sole of the foot, reconstruction with free muscle flaps covered by a split-thickness skin graft is the proposed method of treatment. However, persistent graft breakdown and a chronic wound of the weight-bearing flap is a challenging problem during the late postoperative period, as experienced by the authors in their patients with high-energy-induced lower extremity injuries. The authors used the instep flap as an island cross-foot flap to manage persistent graft breakdown that involved skin-grafted muscle flaps transferred previously to the heel in 3 patients and to treat a chronic wound involving an amputation stump in 1 patient. The vascular pathology of the injured extremities indicated a cross-leg procedure instead of a free flap transfer. Pedicles were wrapped with split-thickness skin grafts and flaps were harvested superficial to the plantar fascia. Pedicles were divided during postoperative week 3, and no complications related to the operation or to immobilization have been encountered during the postoperative follow-up. During the 1-year follow-up, durable coverage, free from development of open wounds, has been achieved, and patients have expressed their satisfaction. In the case of complicated, high-velocity foot injuries, the authors suggest that this procedure be kept in mind as an alternative treatment option because it has some advantages over conventional cross-leg procedures.     

桥式交叉逆行股前外侧皮瓣转移修复对侧小腿中下段软组织缺损

目的 报道以桥式交叉逆行股前外侧皮瓣转移修复对侧小腿软组织缺损的方法和效果.方法 对于小腿中下段皮肤软组织缺损伴对侧小腿软组织损伤或胫后动脉破坏5例,采用对侧逆行股前外侧皮瓣桥式交叉转移予以修复. 结果 术后皮瓣血运良好,6周后断蒂,皮瓣均存活.术后随访12～15个月,皮瓣质地优良、外形美观,伴骨骼、肌腱缺损者均顺利完成二期修复手术.供区愈合良好,供侧肢体无明显影响. 结论 对于小腿中下段较大面积皮肤软组织缺损伴周围软组织受损,且对侧小腿血管质量不佳的病例,以对侧逆行股前外侧皮瓣桥式交叉转移修复是一种优良的手段.     

A case report of cross-leg free latissimus dorsi myocutaneous flap transplantation

One of the significant reconstructive challenges is closure of large soft tissue defects of the lower extremity. A patient with a large traumatic defect in the lower extremity was treated with a cross-leg free latissimus dorsi myocutaneous flap. The size of the flap was 32×12 cm. The pedicle was divided 22 days after the initial operation. The result was satisfactory after a 2-year follow-up. This technique allows the transfer of large flaps to cover compromised wounds, with the advantage of using suitable recipient vessels. Received: 4 March 1998 / Accepted: 25 March 1999     

Innervated cross-leg tensor fascia lata fasciocutaneous flap for foot reconstruction

A traumatic, extended first ray amputation in a child was treated with an innervated cross-leg tensor fascia lata fasciocutaneous flap. The flap provided thin composite tissue coverage, immobilization in a position of relative comfort, and sensory innervation to the weight-bearing surface. Consideration of this flap is recommended when dealing with large defects of the foot.     

Achilles tendon reconstruction after electrical injury with a neurotized cross-leg fillet flap

The authors present a case where a cross-leg fillet flap from an amputated limb allowed reconstruction of the contralateral disrupted Achilles tendon and provided neurotized soft tissue. Achilles tendon reconstruction of the left leg was achieved by utilizing vascularized extensor tendons from the dorsum of the right foot based on the dorsalis pedis circulation. Neurotization was accomplished end to side between a cutaneous nerve from the dorsum of the foot and the recipient sural nerve. Healing was complete and without complication. Cross-leg flaps including tendon and nerve may be used to reconstruct complex lower-extremity injuries, even when free flaps are not feasible.     

小腿外侧腓骨皮瓣交腿修复合并血管损伤的大段胫骨骨感染及缺损

 目的 探讨小腿外侧腓骨皮瓣交腿修复合并血管损伤、大面积皮肤软组织缺损的大段胫骨骨感染及缺损的疗效。方法 回顾性分析2004 年9 月至2008 年9月治疗8 例合并血管损伤的大段胫骨骨感染及缺损患者资料, 男6 例, 女2 例;年龄19~55 岁, 平均36 岁;病史2 周至3 个月, 平均2 个月;胫骨缺损长度8~20 cm, 平均13 cm;皮肤缺损面积10 cm x 7 cm~22 cm x 12 cm。彻底清创, 根据皮肤软组织缺损面积及胫骨缺损长度在健侧小腿设计外侧腓骨皮瓣的切取范围、腓骨切取长度、切取位置。切取皮瓣及腓骨, 将双下肢交叉于蒂部松弛位置, 外固定支架固定, 腓骨修复胫骨骨缺损, 外固定支架一期重建胫骨稳定性, 皮瓣覆盖创面修复皮肤软组织缺损。术后4~6 周, 二次手术断蒂。结果 8 例患者全部获得随访, 随访时间6~36 个月, 平均24 个月。术后8 例移植组织全部成活, 无一例发生感染及骨髓炎, 皮瓣均在术后2 周顺利愈合;骨折愈合时间6~15 个月, 平均11 个月;移植皮瓣外形良好;患者基本恢复负重行走功能。末次随访时, 根据Edwards 胫骨骨折评定标准, 优4 例, 良2 例, 差2 例。结论 小腿外侧腓骨皮瓣交腿修复合并血管损伤、大面积皮肤软组织缺损的大段胫骨骨感染及缺损具有手术操作相对简单、成功率高、疗效好等优点, 可恢复患者下肢行走功能。