- Email: [email protected]
An inferiorly based soleus muscle flap
AN INFERIORLY BASED
SOLEUS
MUSCLE
FLAP
By I’. L. G. TOWNSEND, F.R.C.S., F.R.C.S.C. Department of Plastic and Jaw Surgery, Frenchay Hospital, Bristol BS16 ILE, England
SINCE Ger (1968, 1971) first introduced and popularised the use of split skin grafted transposed muscle flaps, a wide variety of these have been described (Pers and Medgyesi, 1973; McHugh and Prendiville, 1975). The area least well served by the flaps so far described is the lower third of the lower leg. Here many muscles become tendons and the muscle bulk available for transposition is small. The soleus muscle has been used as a flap based proximally on its origin, but it retracts proximally when cut, the distal portion is fairly tenuous and it is only useful in the upper part of the lower leg (Fig. I). The soleus muscle, however has an extensive blood supply not just for nutrition but because of its function as a venous pump. The vessels reach it segmentally (Figs. 2 and 3). In the cadaver shown, there were at least 4 vascular plexuses between 6 and 12 cm above the tip of the medial malleolus. When these plexuses are retained and the rest divided, the muscle, detached from its origin, can be rotated as far as the calcaneum (Fig. 4). The flap is bulkier than is desirable on the lower leg but it was felt that if its nerve supply was divided, its subsequent degeneration would shrink it to an acceptable size and it would not contract on walking. It is supplied by 2 branches of the posterior tibia1 nerve which enter its upper third. The muscle may be exposed through an incision over its medial or lateral border whichever is more convenient to the defect to be filled. The thick layer of fascia which covers it makes its dissection from the gastrocnemius straightforward.
FIG. I.
When the soleus is detached distally it retracts proximally and the tip of the flap is thin and tenuous. It is thus mainly suitable for defects of the upper part of the lower leg.
FIG. 2.
The segmental blood supply of the soleus which comes from the posterior 210
tibia1 vessels.
AN
INFERIORLY
BASED
SOLEUS
MUSCLE
FLAP
211
It remained to discover whether such a flap in vivo would have sufficient blood supply to survive. It has been used in 4 patients as shown in Figures 5 to 16. Successful closure was obtained in all 4 although some necrosis at the tip of the muscle flap occurred in 2. The transposition of the muscle did not appear to interfere with function, which was taken over by the gastrocnemius; it is to be remembered however that these were patients with long-standing defects in whom normal walking was not to be expected for some time if ever.
FIG. 3.
The soleus has been detached from its origin and al: vessels entering it divided except the lower 4 plexuses which reach a distance about 12 cm above the medial malleolus. FIG. 4.
FIG. 5.
FIG. 6.
Case
I.
The detached proximal Old compound
part of the muscle will reach as far as the calcaneum.
tibia1 fracture with recurrent old man.
breakdown and several sinuses in a 4r-year-
Case I. The soleus muscle detached to a distance 12 cm above the medial malleolus and rotated distally to show the transposition that is possible. The medial malleolus is outlined in ink.
212
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FIG. 7. fibula.
Case I. The thickness of the end of the muscle flap, i.e. its origin from the back of the tibia and The longitudinal vessels on the undersurface of the muscle which are supplied segmentally from the posterior tibia1 vessels are also shown.
FIG. 8.
Case I. The healed result FIG. g.
Case 2. This
FIG. IO. FIG. II.
IO days postoperatively.
rq-year-old
had a compound
There fracture
was no necrosis
of his tibia 18 months
Case 2. The soleus flap raised and about to be transposed
Case 2. Although
there was infection with pseudomonas wound healed well.
in the muscle flap. before.
subcutaneously.
there was no muscle necrosis
and the
FIG. 12. Case 3. This 76-year-o!d man had a pathological fracture of his tibia plated wtthout success. He had angina at rest, marked peripheral vascular disease and no peripheral pulses. The skin around the fracture area was of poor quality. The incision to expose the soleus is also seen.
AN
INFERIORLY
BASED
SOLEUS
MUSCLE
213
FLAP
Fro. 13.
Case 3. Only the lower half of the muscle was used. After being transposed parts which were directed upwards and downwards as shown.
FIN. 14.
Case 3. Despite
it was split into 2
some delay because of some loss of the tips of the flaps, complete tibia and stable healing was obtained.
cover of the
FIG. 15. Case 4. An unstable Pott’s fracture with exposure of the capsule of the anterior aspect of the ankle joint. Access to the soleus was limited to the window in the plaster and the length of muscle obtained The muscle flap was oedematous and this interfered with rotation. was barely adequate. FIG. 16.
Case 4. Some necrosis
of the muscle flap occurred but sufficient and obtain healing.
remained
to cover the defect
CONCLUSION
This is a useful and reliable flap and is particularly valuable for closing the larger defects on the lower part of the lower leg, providing that the lower segmental blood supply has not been impaired by comminuted fractures around the ankle joint. REFERENCES The management of pretibial skin loss. Surgery, 63, 757. GER, R. (1968). The technique of muscle transposition in the operative treatment of GER, R. (1971). traumatic and ulcerative lesions of the leg. Journal of Trauma, II, pz. MCHUGH, M. and PRENDIVILLE, J. B. (1975). Muscle flaps in the repair of skin defects over British 3ournal of Plastic Surgery, 28, 205. the exposed tibia. PERS, M. and MEDGYESI, S. (1973). Pedicle muscle flaps and their applications in the British Journal of Phtic surger_v, 26, 313. surgery of repair.
SOLEUS
MUSCLE
FLAP
By I’. L. G. TOWNSEND, F.R.C.S., F.R.C.S.C. Department of Plastic and Jaw Surgery, Frenchay Hospital, Bristol BS16 ILE, England
SINCE Ger (1968, 1971) first introduced and popularised the use of split skin grafted transposed muscle flaps, a wide variety of these have been described (Pers and Medgyesi, 1973; McHugh and Prendiville, 1975). The area least well served by the flaps so far described is the lower third of the lower leg. Here many muscles become tendons and the muscle bulk available for transposition is small. The soleus muscle has been used as a flap based proximally on its origin, but it retracts proximally when cut, the distal portion is fairly tenuous and it is only useful in the upper part of the lower leg (Fig. I). The soleus muscle, however has an extensive blood supply not just for nutrition but because of its function as a venous pump. The vessels reach it segmentally (Figs. 2 and 3). In the cadaver shown, there were at least 4 vascular plexuses between 6 and 12 cm above the tip of the medial malleolus. When these plexuses are retained and the rest divided, the muscle, detached from its origin, can be rotated as far as the calcaneum (Fig. 4). The flap is bulkier than is desirable on the lower leg but it was felt that if its nerve supply was divided, its subsequent degeneration would shrink it to an acceptable size and it would not contract on walking. It is supplied by 2 branches of the posterior tibia1 nerve which enter its upper third. The muscle may be exposed through an incision over its medial or lateral border whichever is more convenient to the defect to be filled. The thick layer of fascia which covers it makes its dissection from the gastrocnemius straightforward.
FIG. I.
When the soleus is detached distally it retracts proximally and the tip of the flap is thin and tenuous. It is thus mainly suitable for defects of the upper part of the lower leg.
FIG. 2.
The segmental blood supply of the soleus which comes from the posterior 210
tibia1 vessels.
AN
INFERIORLY
BASED
SOLEUS
MUSCLE
FLAP
211
It remained to discover whether such a flap in vivo would have sufficient blood supply to survive. It has been used in 4 patients as shown in Figures 5 to 16. Successful closure was obtained in all 4 although some necrosis at the tip of the muscle flap occurred in 2. The transposition of the muscle did not appear to interfere with function, which was taken over by the gastrocnemius; it is to be remembered however that these were patients with long-standing defects in whom normal walking was not to be expected for some time if ever.
FIG. 3.
The soleus has been detached from its origin and al: vessels entering it divided except the lower 4 plexuses which reach a distance about 12 cm above the medial malleolus. FIG. 4.
FIG. 5.
FIG. 6.
Case
I.
The detached proximal Old compound
part of the muscle will reach as far as the calcaneum.
tibia1 fracture with recurrent old man.
breakdown and several sinuses in a 4r-year-
Case I. The soleus muscle detached to a distance 12 cm above the medial malleolus and rotated distally to show the transposition that is possible. The medial malleolus is outlined in ink.
212
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FIG. 7. fibula.
Case I. The thickness of the end of the muscle flap, i.e. its origin from the back of the tibia and The longitudinal vessels on the undersurface of the muscle which are supplied segmentally from the posterior tibia1 vessels are also shown.
FIG. 8.
Case I. The healed result FIG. g.
Case 2. This
FIG. IO. FIG. II.
IO days postoperatively.
rq-year-old
had a compound
There fracture
was no necrosis
of his tibia 18 months
Case 2. The soleus flap raised and about to be transposed
Case 2. Although
there was infection with pseudomonas wound healed well.
in the muscle flap. before.
subcutaneously.
there was no muscle necrosis
and the
FIG. 12. Case 3. This 76-year-o!d man had a pathological fracture of his tibia plated wtthout success. He had angina at rest, marked peripheral vascular disease and no peripheral pulses. The skin around the fracture area was of poor quality. The incision to expose the soleus is also seen.
AN
INFERIORLY
BASED
SOLEUS
MUSCLE
213
FLAP
Fro. 13.
Case 3. Only the lower half of the muscle was used. After being transposed parts which were directed upwards and downwards as shown.
FIN. 14.
Case 3. Despite
it was split into 2
some delay because of some loss of the tips of the flaps, complete tibia and stable healing was obtained.
cover of the
FIG. 15. Case 4. An unstable Pott’s fracture with exposure of the capsule of the anterior aspect of the ankle joint. Access to the soleus was limited to the window in the plaster and the length of muscle obtained The muscle flap was oedematous and this interfered with rotation. was barely adequate. FIG. 16.
Case 4. Some necrosis
of the muscle flap occurred but sufficient and obtain healing.
remained
to cover the defect
CONCLUSION
This is a useful and reliable flap and is particularly valuable for closing the larger defects on the lower part of the lower leg, providing that the lower segmental blood supply has not been impaired by comminuted fractures around the ankle joint. REFERENCES The management of pretibial skin loss. Surgery, 63, 757. GER, R. (1968). The technique of muscle transposition in the operative treatment of GER, R. (1971). traumatic and ulcerative lesions of the leg. Journal of Trauma, II, pz. MCHUGH, M. and PRENDIVILLE, J. B. (1975). Muscle flaps in the repair of skin defects over British 3ournal of Plastic Surgery, 28, 205. the exposed tibia. PERS, M. and MEDGYESI, S. (1973). Pedicle muscle flaps and their applications in the British Journal of Phtic surger_v, 26, 313. surgery of repair.