Best Local Flaps for Lower Extremity Reconstruction

Abstract

The ideal reconstruction of lower limb defects should replace like with like and minimize morbidity to the donor site, achieving the best possible esthetic and functional outcome. The goal is to obtain stable healing and to resume daily life in an efficient manner. Although the classical local flaps such as gastrocnemius, soleus muscle flap, and the reverse sural flap have allowed to achieve those goals, perforator flaps are now added on to the armamentarium in lower extremity reconstruction using local flaps. A perforator-based local flap, such as a propeller or keystone flap, has made reconstruction efficient while further reducing donor-site morbidity. This article aims to provide a useful review of the best available local flaps for lower limb defects.

Fig. 1.

Algorithm to approach the lower extremity defect and to select appropriate flaps for reconstruction. STSG, split thickness skin graft.

Fig. 2.

Flap selection by the zones of the leg.

Fig. 3.

Reconstruction algorithm of approach and to select appropriate flaps for each zone of the leg.

Fig. 4.

Commonly found perforator flaps from all 3 major vessels on the lower extremity. Illustration of the lower leg revealing the location of reliable perforators from the peroneal artery (A), anterior tibial artery (B), and posterior tibial artery (C).

Fig. 5.

A large defect on the lower lateral thigh and upper region of the knee is noted (A). Using a handheld Doppler, potential perforators are marked and initial design is based on the perforator most likely from the geniculate system (B). One side of the flap is first approached to identify the perforator and then the design is modified accordingly based on the final finding of the perforator. After elevation of the flap, status of the flaps is checked to see if there is any compromise and then insetting is performed (C). The patient at 12 months shows good functional and esthetic results (D).

Fig. 6.

An unstable wound is noted after multiple repair and dehiscence (A). Anticipating a propeller flap will be needed after debridement, multiple perforators are identified using a handheld Doppler. After complete debridement including the necrotic tissue underneath the skin, a propeller flap is designed based on a perforator near the defect and most likely from the peroneal artery (B). During the final design, pinch test on the donor site was performed to allow primary closure. The flap is elevated, rotated, and the donor site is closed primarily (C). The patient at 12 months shows good functional and esthetic results (D).

Fig. 7.

An elliptical defect on the lateral mid-thigh is noted (A). A keystone flap is designed to close the defect (B). Incision was made all the way to the deep fascia allowing the flap to advance without tension. Because of the laxity of the thigh, the flap did not need to be closed with a V-Y but rather just an advancement and a tensionless reposition of the flap (C). The thigh at postoperative 6 months shows good functional and esthetic results (D).