Abstract Objectives: The restoration of an intact covering is the primary surgical requisite following trauma of the lower extremity because deep healing can be no better than the surface covering. The present article is about our experience of lower limb reconstruction using fasciocutaneous flaps. Methods: 20 fasciocutaneous flaps in 15 males and 5 females were used for the wound / defect of lower limbs following trauma. Results: Fasciocutaneous flaps provided stable wound cover in 20 patients for leg wound/defect. 2 patients developed wound infection, 2 developed partial graft loss and 1 patient had partial flap necrosis. Conclusion: In the armamentarium of lower limb reconstruction fasciocutaneous flaps remains one of the useful methods of skin cover for leg wound/defects

Assoc Professor

Chittoria R

Mishra Sm

CiteSeerX

 344
Original Article  
Fasciocutaneous flaps in reconstruction of lower extremity: our 
experience 
Chittoria R1 Mishra SM2 
1Assoc. Professor, Dept. of Plastic Surgery, 2Prof. & HoD, Dept. of General Surgery 
 
Abstract 
Objectives: The restoration of an intact covering is the primary surgical requisite following trauma of the lower 
extremity because deep healing can be no better than the surface covering. The present article is about our 
experience of lower limb reconstruction using fasciocutaneous flaps. Methods: 20 fasciocutaneous flaps in 15 males 
and 5 females were used for the wound / defect of lower limbs following trauma. Results: Fasciocutaneous flaps 
provided stable wound cover in 20 patients for leg wound/defect. 2 patients developed wound infection, 2 developed 
partial graft loss and 1 patient had partial flap necrosis. Conclusion: In the armamentarium of lower limb 
reconstruction fasciocutaneous flaps remains one of the useful methods of skin cover for leg wound/defects. 
 
Key Words: Fasciocutaneous flap, lower limb reconstruction, leg defect/wound.  
 
 
ower limb trauma predominantly involves skin, 
muscle and bone. Infection doesn’t loom large as 
hazard if the skin is not involved, but it has to be 
added to the list of possible complications when there 
is a break in the skin barrier, and this can be 
particularly serious when a fracture is part of injury. 
It is for this reason that the effective provision of skin 
cover becomes a matter of urgency, though its 
provision has to be coordinated with the management 
of the other damaged structures, each of which 
carries its own imperative. Before contemplating the 
use of fasciocutaneous flap, it would be essential to 
gauge the damage to the overall vascularity of the 
skin, which it is proposed to use as the flap1. 
 
The aim of the present study is to highlight the role of 
fasciocutaneous flap in the reconstructive 
armamentarium of lower limb wounds/defects. 
 
Materials and methods 
A total of 20 patients admitted during the period of 
sept’ 2001 to May’ 2004 with lower limb 
defect/wound with exposed bone (tibia/fibula) and/or 
fracture site (Type IIIb), following trauma were 
selected for the study. The study was conducted in 
the dept of Plastic Surgery, PGI, Chandigarh, India 
and Nepalgunj Medical College Teaching Hospital 
Kohalpur, Banke, Nepal. 
 
Before embarking onto the procedure patients were 
carefully examined clinically. Basic investigations 
(HB, TLC, DLC etc.) for fitness for surgery were 
done. X ray of the injured limb was done to rule out 
underlying fracture and osteomyelitis. Wound pus 
was sent for culture and sensitivity. Local and 
systemic antimicrobials were used according to 
culture and sensitivity to control the wound infection. 
Once the wound was free of infection, 
fasciocutaneous flap was planned. For planning the 
fasciocutaneous flap, leg defect was divided into 
upper 1/3, middle 1/3 & lower 1/3. Based on the 
septocutaneous perforator of posterior & anterior 
tibial artery and peroneal artery skin with fascia as 
fasciocutaneous flap was raised as superiorly 
(proximally) based, inferiorly (distally) based & 
transversally based fasciocutaneous flap from the 
same leg (ipsilateral) or from the opposite 
(contralateral) leg (cross leg flap). In the doubt of 
vascularity flap was delayed before actual raising and 
insetting the flap. Donor site from where the flap 
raised, was covered with skin graft harvested from 
the thigh. Graft and the limb were immobilized with 
Plaster of Paris Slab. Graft dressing was done on 7th 
post-op day and flap sutures were removed on 10th 
post-op day. In case of cross leg flap, flap division 
and inset was done on 21st day. Patients were 
followed up bi-weekly and all the complications were 
recorded. 
 
 
 
 
 
 
 
L 
Correspondence 
Dr. Ravi Chittoria 
Associate Professor, 
Dept. Of Plastic Surgery, 
Nepalgunj Medical College Teaching Hospital, Banke, Nepal. 
E mail: drchittoria@yahoo.com 
Kathmandu University Medical Journal (2004) Vol. 2, No. 4, Issue 8, 344-348
 345
Results 
Table 1. Distribution of cases with respect to age and sex groups 
Age Male Female  Total Percentage 
< 20 years 2 1 3 15% 
20-30 years 11 2 13 65% 
>30 years 2 2 4 20% 
Total 15 5 20 100% 
 
 
Table2. Distribution of cases with respect to type of injury 
Type of Injury No. of patients Percentage 
Crush Injury 12 60% 
Run over Injury 4 20% 
Degloving Injury 2 10% 
Mixed Injury 2 10% 
Total 20 100% 
 
  
Table 3. Distribution of cases with respect to the site of the defect/wound 
Site of Defect/Wound No. of patients Percentage 
Upper 1/3 leg 3 15% 
Middle 1/3 leg 5 25% 
Lower 1/3 leg 12 60% 
Total 20 100% 
 
 
Table 4.  Distribution of cases with respect to associated fracture of Tibia/Fibula 
Type of Bone Fractured No. of patients Percentage 
Tibia Alone 3 15% 
Fibula Alone 3 15% 
Both Tibia & Fibula 12 60% 
No fracture (Only exposed) 2 10% 
Total 20 100% 
 
 
Table 5. Distribution of cases with respect to size of the defect/wound 
Size of the wound/defect No. of patients  Percentage 
< 5 cm 6 30% 
5-10 cm 12 60% 
>10 cm 2 10% 
Total 20 100% 
 
 
Table 6. Distribution of cases with respect to type of Fasciocutaneous Flap 
Type of Flap No. of patients Percentage 
Ipsilateral Superiorly based 3 15% 
Ipsilateral Inferiorly based 13 65% 
Ipsilateral Transverse based 2 10% 
Contra lateral Transverse based 2 10% 
Total 20 100% 
 
 
 
 
 346
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 7. Distribution of cases with respect to complications 
Complications No. of patients Percentage 
Wound infection 2 10% 
Partial Graft loss (<10%) 2 10% 
Partial flap Necrosis 1 5% 
Total 5 25% 
 
 
In our study for upper and middle third leg defects 
superiorly based and for lower third leg defects 
inferiorly based fasciocutaneous flaps were done. 
Overall results were satisfactory as only one patient 
developed partial flap necrosis which was managed 
conservatively. Other complications noted were: 
wound infection and partial graft loss.
 
 
Photograph – 1: Pre-operative view showing 
exposed bone (type-IIIb) 
Photograph – 2: Pre-operative X-ray 
showing fracture of tibia and fibula (type-
IIIb) of same patient 
Photograph– 3: Intra-operative view after 
debridement with flap marking & planning 
 
Photograph – 4: Post-operative view (day 15) 
showing transposed fasciocutaneous flap (based 
on perforator of posterior tibial artery) with 
donor area covered with SSG  
 
 347
Discussion 
Following unique features of the lower limb makes 
the reconstruction different from that for upper 
extremity2, 3 
 
1. The lower extremity is almost always in a 
dependent position and more susceptible for 
deep vein thrombosis, venous stasis and 
oedema. 
2. Increased incidence of peripheral vascular 
diseases. 
3. The subcutaneous location of the tibia, the 
main weight bearing bone of the leg, poses 
unique problems in the fracture healing. 
 
Before embarking on the actual reconstruction the 
defect should be assessed for soft tissue and any bony 
loss. The “Gustilo-Anderson: classification of open 
leg wounds4, 5 should be followed: 
 
Grade I - Wound less than 1cm long, no extensive 
soft tissue damage, and no crush injury. 
Grade II – Laceration greater than 1 cm, no extensive 
soft tissue damage, no flaps or skin 
avulsions and moderate skin crush. 
Grade III – Extensive soft tissue damage, including 
skin, muscle and neurovascular structure; 
highly contaminated. Further divided into 
3 groups: 
 
a) Large skin laceration or avulsed skin flaps 
that nevertheless provide for adequate soft 
tissue coverage. 
b) Extensive loss of soft tissue with periosteal 
stripping and exposed bone; massive 
contamination, severe communition and loss 
of bone. 
c) Open fracture associated with arterial injury 
requiring repair. 
In our study only those patients were selected who 
had leg defect/wound with exposed bone and/or 
fracture (Type III b). 
Fasciocutaneous flaps have been well investigated 
and tried out in the leg defect. As early as in 1901, 
Ponten7 reported the use of fasciocutaneous flaps in 
the lower leg. Ponten7 had shown that the flaps in the 
leg can measure 8 cm x 18 cm and can be raised in a 
single stage without necrosis if the deep fascia is 
included.  
The blood supply to fasciocutaneous flaps can be 
from three sources8: 
 
1. Musculocutaneous perforators: For example 
via gastrocnemius. 
2. Axial vessels: Saphenous artery and 
superficial sural arteries.  
3. Septocutaneous perforators: For each of 
anterior tibial, posterior tibial and  
      Peroneal vessels. 
 
Numerous authors8, 9 have attempted to study the 
location of septocutaneous perforators in relation to 
bony landmarks and leg lengths (Table 8).
 
 
Table 8. Location of septocutaneous perforators 
Location of Perforator  Posterior tibial Artery 
Perforator 
(Distance from MM-
Medial Malleolus) 
Peroneal Artery 
(Distance from LM-
Lateral Malleolus or 
FH-Fibula Head) 
Anterior tibial Artery 
Perforator 
(Distance from origin 
of anterior tibial 
Artery) 
N1 4.5 cm (MM) 4-10cm(LM) 2-4cm 
N2 6.0cm(MM) 10-13cm(LM)  
N3 9-12cm(MM) 15-20cm(LM)  
N4 17-19cm(MM) 5-6cm(FH)  
N5 22-24cm(MM)   
 
 
Fasciocutaneous flap may be used locally in the 
ipsilateral limb or distally as a cross leg 
fasciocutaneous flap. Fasciocutaneous flap should be 
selected depending on the site of the leg defect: 
a) Upper third leg- Proximally (superiorly) 
based fasciocutaneous flaps based on the 
perforators of the post tibial, anterior tibial9 
or peroneal artery.  
b) Middle third leg- Proximally (superiorly) 
based fasciocutaneous flaps based on the 
posterior tibial or Peroneal perforators or a 
distally (inferiorly) based             
fasciocutaneous flap based on the lower 
posterior Tibial perforator10. 
c) Lower third leg- Distally (inferiorly) based 
or cross leg fasciocutaneous flap may be 
 348
used based on lower perforators of the 
posterior tibial and Peroneal arteries10, 11, 
reverse sural artery flap12, 13, posterolateral  
Malleolar flap14. 
 
In our study also, after dividing the leg defect into 
upper, middle & lower third, fasciocutaneous flaps 
were raised as superiorly (proximally) or distally 
(inferiorly) fasciocutaneous flap based on perforators 
of anterior tibial, posterior tibial artery and peroneal 
artery. In our study I (5%) patient had partial flap 
necrosis, which managed conservatively. 2(10%) 
patients developed wound infection and another 
2(10%) patients developed partial graft loss. 
 
Conclusion 
Thus it can be concluded that in the armamentarium 
of lower limb reconstruction fasciocutaneous flaps 
remains one of the useful method of skin cover for 
leg wound/defects. It is worth emphasizing that these 
fasciocutaneous flaps are also ‘superflaps’ and should 
only be practiced by super specialist. The trainee 
should learn practical skills by their supervisors 
before attempting use of such flaps.   
 
Acknowledgement 
The authors would like to thank Mr. Gautam Verma 
for the computer typing, print layout etc. done for the 
present manuscript. 
 
Reference 
1. McGregor A D, McGregor I A. Limb 
trauma. In: Fundamental techniques of 
plastic Surgery and their surgical 
applications. Tenth edition. Churchill 
Livingstone.2000: 143-152. 
2. Godina M. Early microsurgical 
reconstruction of complex trauma of 
the extremities. Plast Reconstr Surg 
1986: 285-292. 
3. Thorne C H M, Siebert J W, Grotting J 
C. Reconstructive surgery of the lower 
extremity. McCarthy J G(ed); Plastic 
Surgery. Philadelphia: W.B. Saunders 
Company 1990: 4029-4092. 
4. Gustilo RB, Anderson JT. Prevention 
of infection in the treatment of one   
thousand and twenty-five open 
fractures of long bones: Retrospective  
and Prospective analysis. J bone Joint 
Surg 1976; 58: 453-458. 
5. Gustilo R B, Mendoza R M, and 
William D N. Problems in the 
management of type III open fractures: 
A new classification of type III open 
fractures. J Trauma 1984; 24: 742-746. 
6. Kumar P, Bhaskara KG, Chittoria R, 
Thomas PC. Flaps in lower limb 
trauma: Current status. IJPS 2000; 33: 
30-37. 
7. Ponten B. The fasciocutaneous flaps: 
Its use in soft tissue defects of the leg. 
Brit J Plas Surg 1981; 34: 215-220. 
8. Bhattacharya V. Fasciocutaneous flaps 
in Plastic and Reconstructive Surgery: 
current trends (proceedings of CME 
programme at national Conference of 
APSI, Calcutta) 1998:36-40. 
9. Recalde RJF, Gilbert A, Masquelct A et 
al. Anterior tibial artery flap: Anatomic 
study and clinical application. Plast 
Reconstr Surg 1987; 79: 396-404. 
10. Barklay TL, Cardoso E, Sharpe DT, 
Crockett DJ. Repair of lower leg 
injuries with fasciocutaneous flaps. Brit 
J Plast surg 1982; 35127-132. 
11. Amarante J, Costa H, Reis J, Soares R. 
A new distally based fsciocutaneous 
flap of the leg. Brit J Plast Surg 1986; 
39: 338-340. 
12. Jobe Fix RL, Vaseonez L. 
Fasciocutaneous flaps in reconstruction 
of lower extremity. Clinics in Plastic 
Surgery 1991; 18: 571-582. 
13. Yilmaz M, Karatas O, Baruteu A. The 
distally based superficial sural artery 
island flap: Clinical experience and 
modifications. Plast Reconstr Surg 
1998; 102: 2358-2367. 
14. Masquelet AC, Beveridge J, Romana 
C; Gerber C. The lateral      
supramalleolar flap. Plast Reconstr 
Surg 1988; 81:74-81. 
 
 
 
 
 
 
 
 
 
 349
 
 
16/11/2004 
To, 
Chief Editor, 
KUMJ,  
Kathmandu Medical College, 
Sinamangal, Kathmandu. 
 
Subject: “ORIGINAL ARTICLE: FASCIOCUTANEOUS FLAPS IN RECONSTRUCTION OF 
LOWER EXTREMITY: OUR EXPERIENCE” 
Sir, 
Kindly acknowledge our revised (as per your comments in the e mail sent by you) article for the category of 
‘original article’ for your KUMJ journal. I am sorry as desired by you (comment g) I could not get (On Line 
& In our Library) Photograph of Angiotomes by Ponten. Please do the needful.  
 
Sincerely 
 
Correspondence 
Dr. Ravi Chittoria 
Associate Professor, 
Deptt. Of Plastic Surgery, 
Nepalgunj Medical College Teaching Hospital, 
E mail: drchittoria@yahoo.com 
 
 
Phone: 00977-81-540406  Ext – 129 
 350
DECLARATION 
 
We hereby declare that the manuscript represents valid work and that neither manuscript nor one with substantially 
similar content under the present authorship has been published or is being considered for publication elsewhere and 
the authorships of this article will not be contested by anyone whose name(s) is/are not listed here, and that the order 
of authorship as placed in the manuscript is final and accepted by the co-authors. 
 
Dr. Ravi Chittoria       Dr. S. M. Mishra 
 
 
 
M.B.B.S, M.S., M.Ch, DNB, MNAMS, FSASMS, FAGE, PGDMLS, PGCHM 
Associate Professor 
Dept. of Plastic Surgery 
Nepalgunj Medical College Teaching Hospital 
Kohalpur, Banke 
Nepal 
Professor and HOD 
M.B.B.S, M.S. (Surgery), M.S. (Orthopedics), FRCS 
Dept. of General Surgery 
Nepalgunj Medical College Teaching Hospital 
Kohalpur, Banke 
Nepal 
 
 
ADDRESS FOR CORRESPONDENCE 
Dr. Ravi Chittoria 
Associate Professor 
Dept. of Plastic Surgery 
Nepalgunj Medical College Teaching Hospital 
Kohalpur, Banke 
Nepal 
Phone: 00977 – 81 – 540406 Ext. 129 
Email: drchittoria@yahoo.com 
 


Fasciocutaneous flaps in reconstruction of lower extremity: our experience

http://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=D2A97BE61C725D87D2897FEAED0EDB4D?doi=10.1.1.1054.2060&rep=rep1&type=pdf

Fasciocutaneous flaps in reconstruction of lower extremity: our experience

Abstract

Similar works

Full text

Available Versions

CiteSeerX