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The cross-leg flap: still a useful flap in children
British Joumal ofPlastic Surgery (1992), 45, 14&149 0 1992 The Trustees of British Association of Plastic Surgeons
The cross-leg flap: still a useful flap in children D. A. Hudson and K. Millar Division of Plastic and Reconstructive Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa SUMMARY. Reconstruction of the distal lower limb and foot is a difficult problem, especially where large areas of skin loss have occurred. The cross-leg flap is a safe and reliable alternative to free tissue transfer in paediatric lower limb trauma. By incorporating fascia or muscle the versatility of the flap can be enhanced. Our experience with the cross-leg flap in children during the last 5 years is discussed.
Large soft tissue defects of the distal part of the lower extremity and foot can present a difficult reconstructive problem to the plastic surgeon (Serafin et al., 1977; Noever et al., 1986). Local musculocutaneous or fasciocutaneous flaps are not always possible, and the highest incidence of free flap failure also occurs in this difficult region (Godina, 1986). The cross-leg flap should be considered as a viable alternative to free tissue transfer. It is a safe and reliable procedure for resurfacing large defects of the lower limb and foot (Morris and Buchan, 1978; Barclay et al., 1983). Furthermore, by incorporating fascia (Barclay et al., 1983) or muscle (Orticochea, 1978), the versatility of the cross-leg flap may be enhanced. The flap is easy to perform and does not require the sophisticated equipment and expertise of a micro-anastomosis-an obvious advantage in developing countries (Thatte et al., 1986). This paper reports our experience with the cross-leg flap in the management of paediatric lower limb trauma during the last 5 years.
cross-leg flaps were employed in 7 children and musculocutaneous cross-leg flaps in 3. In all cases both limbs were immobilised by means of a Hoffman exoskeleton. Division of the flap was performed in patients after a mean of 15.7 days (range 1l-21 days). Preliminary delay was performed in 3 flaps, one at 10 days, another at 13 days and another had two delay procedures, at 9 and 12 days respectively. The mean follow-up period was 18 months (range 4541 months). Patients were evaluated at follow-up for both functional and cosmetic outcome. The most recent patient was involved in a train accident + months previously. A degloving injury was sustained to part of the heel of the left foot and this was treated with a split skin graft. The dorsum of the right foot was completely degloved, but leaving the paratenon intact. In addition, the entire sole of the right foot was also degloved at the level of the plantar fascia. A medial gastrocnemius cross-leg flap was applied to the sole of the foot, while the dorsum was treated with a split skin graft. At present the patient is able to walk on the flap. Follow-up is continuing.
Material and methods The records of all patients who had a cross-leg flap for trauma at Red Cross War Memorial Children’s Hospital between 1986 and 1991 were reviewed. During this period, 10 children (6 males and 4 females) with an average age of 7.2 years, (range 4-11 years) were seen. Motor vehicle accident as a pedestrian was the predominant cause and occurred in 8 patients. One patient caught his foot in an electric lawnmower, while another was involved in a train accident. The dorsum of the foot was the most commonly involved site (7 patients). In all these the soft tissue loss exceeded half the surface area of the dorsum of the foot. There was associated extensor tendon loss in 5 patients (all tendons in 2, partial loss in 3) and the dorsalis pedis artery was also avulsed in these 5. The sole of the foot was involved in 2 patients and the distal lower limb in one other. Underlying bony injuries to the foot occurred in 8. Associated injury to other sites occurred in 5 patients. Fasciocutaneous
Results Nine of the 10 flaps were completely viable after division. One musculocutaneous flap applied to the entire heel was divided at 10 days and underwent 25% necrosis. The necrotic part of the flap was debrided and then the wound allowed to heal by secondary intention. All 6 patients with fasciocutaneous flaps on the dorsum of their feet wear normal shoes and are able to participate in sport. In each case the flap was considered cosmetically acceptable by both parent and surgeon (Figs 1, 2). In 5 patients the donor site was considered cosmetically acceptable by parent and surgeon. One patient developed hypertrophic scarring of the skin grafted donor site. No patients developed either knee or ankle stiffness as a result of immobilisation prior to division of the cross-leg flap. One patient who suffered extensive lower limb 146
The Cross-lea Flan : Still a Useful Flan in Children
147
Fig. 1 Figure l--Successful
cross-leg flap on dorsum of foot. Figure 2-Cross-leg
trauma had a fasciocutaneous flap applied to the distal aspect of the leg. He also developed septic arthritis of the knee secondary to knee trauma, and subsequent ankylosis of the knee joint. He now wears a built up shoe. He also has extensive scarring of the limb. Two patients had musculocutaneous flaps applied to the plantar surface of the foot; one to the heel and one had his entire sole replaced. Both patients are able to walk on their flaps, although one patient has only been followed up for 43 months. No ulceration or hyperkeratosis of the flaps have occurred. One patient wears specially padded shoes. No ankle or knee stiffness has occurred. The donor areas have been considered cosmetically acceptable by both parent and surgeon. Secondary procedures were performed in 3 patients. Two patients who had lost all their extensor tendons on the dorsum of the foot during the initial injury had tendon transfers performed through the cross-leg flap 6 months after the initial injury. One patient underwent debulking of the cross-leg flap, which was performed a year after the initial injury.
Discussion In the last decade, the transfer of flaps with the aid of microvascular anastomosis has dramatically altered reconstructive surgery (Thatte er al., 1986), but their
Fig. 2 flap on antero-lateral
aspect of foot.
use is limited in crushing or vascular injuries (Uhm et al., 1985). The dorsalis pedis artery was completely avulsed in 5 of our patients and all had a crush component as part of their injury, making microsurgical reconstruction potentially more hazardous. In a recent report describing their experience of microsurgery in children, Devaraj ef al. (1991) found that the only free flap failures occurred following trauma. The cross-leg flap is a viable and versatile alternative to free tissue transfer in paediatric lower limb trauma. The safety and reliability of the flap has long been established (Serafin et al., 1977; Morris and Buchan, 1978; Hodgkinson and Irons, 1979; McGregor, 1982; Barclay et al., 1983). Barclay et al. (1983) felt that the safety and certainty of success of this flap outweigh its disadvantages, and Serafin et al. (1977) reported that the cross-leg flap had a greater success rate than either jump flaps or free flaps. However, more recent studies report a much greater success rate with free tissue transfer. Parry et al. (1988) reported a success rate at all sites in children of 96% and Banic and Wulff (1987) reported complete success in 13 out of 15 free tissue transfers on the traumatised lower limb in children. While microsurgery now offers many advantages in reconstructive surgery, the process is relatively time consuming. Parry et al. (1988) and Devaraj et a/. (1991) reported an average operative time of 6.1 and 5.5 h respectively. In addition, a microsurgical anastomosis also requires sophisticated postoperative monitoring. Devaraj et al. (1991) recommended that
148 patients be ventilated overnight in an Intensive Care Unit or be carefully monitored in a High Care Unit. The cross-leg flap requires neither of these measures. While the cross-leg flap in adults is associated with the problems of thrombo-embolism and joint stiffness, these complications do not occur in children (Greer, 1975). By incorporating the fascia in the flap a much greater area of skin can be transferred and more freedom of leg position is possible (Barclay et al., 1983). The inclusion of muscle in the flap, when required, further enhances its versatility (Orticochea, 1978; Landra, 1982). Although various methods have been described to imrnobilise the limbs for cross-leg flaps (Stark, 1947; Randall and Shilling, 1978; Schwartz et al., 1980) we found the Hoffman exoskeleton satisfactory (Arnander et al., 1975). The only necrosis (25% of the flap) in this series occurred in a musculocutaneous flap which was completely divided after 10 days. While there is no absolute time at which a pedicled musculocutaneous flap should be divided, 10 days is probably too early in this setting. Black et al. (1978) and Tsur et al. (1980) have shown that musculocutaneous flaps can survive without their initial axial blood supply after 7-10 days, if reset into an ideal bed. Clinically one is often dealing with less than ideal beds. Khoo and Bailey (1982) reported a number of clinical muscle-containing flaps which underwent partial necrosis when the axial vessel thrombosed more than 7 days post surgery. Millican and Poole (1985) showed that if the bed on which the flap lies is poorly vascularised, then the peripheral inset is of importance in flap neo-vascularisation. They suggested, where possible, having flap muscle abutting healthy muscle rather than scarred skin and fat. Landra (1982) reported dividing a musculocutaneous cross-leg flap at 15 days and Tauxe et al. (1970) described the use of Technetium as a guide to deciding when division of the flap is possible. Reconstruction of the weight bearing parts of the foot presents a particularly difficult problem (Chicarilli and Price, 1986; Noever et al., 1986). While a number of local flaps have been described (McGraw, 1979; Reiffel and McCarthy, 1980; Ikuta et al., 1984), none is large enough to cover a heel defect involving massive tissue loss. A number of different free flaps have been described (May et al., 1985; Stevenson and Mathes, 1986; Rautio et al., 1990) but this variety represents a continuous effort to develop satisfactory replacement for the highly specialised sole skin (Chicarilli and Price, 1986). Sommerlad and McGrouther (1978), in their much quoted study on resurfacing the sole, found that the only patients who bore significant weight on resurfaced areas of their feet were doing so on full thickness grafts or local and cross-leg flaps. While it appears that sensation is not necessary for successful reconstruction of the weight bearing surface of the foot (Sommerlad and McGrouther, 1978) continual care is necessary to prevent ulceration and other complications occurring in the flap (May et al., 1985). The cross-leg flap is a safe and reliable flap in paediatric lower limb trauma. We are not recommending that the cross-leg flap be used in preference to free tissue transfer in all cases, but rather suggest that it be considered as a potentially useful alternative, espe-
British Journal of Plastic Surgery cially when confronted with large crush/avulsion injuries of distal lower limb and foot.
References Anumder, C., ErIksson, G., Ktirlof, B. and Nylon, B. (1975). Transfixation in cross-leg flap procedures using Hoffman’s instruments. Scandinavian Jourrkl afPIastic SurgerY,9,68. Banic. A. and WuRL K. (1987). Latissimus dorsi free flans for total repair of extensive lower leg injuries in children. Plastic and Reconstructive Surgery, 79,769. Barclay, T. L., Sharpe, D. T. and Chlshokn, E. M. (1983). Cross-leg fascia-cutaneous flaps. Plastic and Reconstructive Surgery, 12,843. Black, M. J., Chait, L., O’Brien, B., Sykes, P. and Schano, L. (1978). How soon may the axial vessels of a surviving free flap be safely ligated: a study in pigs. British Journal of Plastic Surgery, 31,295. CbicariUi, Z. N. and Price, G. J. (1986). Complete plantar foot coverage with the free neurosurgery radial forearm flap. Plastic
ana'Reconstructive Surgery, 78,94. Devarqi, V. S., Kay, S. P., Batchelor, A. G. and Yates, A. (1991). Microvascular surgery in children. British Journal of Plastic Surgery, 44,276. Godina, M. (1986). Early microsurgical reconstruction of complex trauma of the extremities. Plastic and Reconstructive Surgery, 78, 285. Greer, D. (1975). The cross-leg flap. In Grabb, W. C. and Meyes, M. B. (Eds). Skin Flaps. Boston, Little, Brown & Co, p. 507. Hodgkhrson, D. J. and Irons, G. B. (1979). Newer applications of the cross-leg flap. Annals of Plastic Surgery, 4, 381. Ikuta, Y., Murakaml, T., Yoshioka, K. and Tsuge, K. (1984). Reconstruction of the heel pad by flexor digitorum brevis musculo-cutaneous flap transfer. Plastic and Reconstructive Surgery, 74,86.
Kheo, C. T. K. and Bailey, B. N. (1982). The behaviour of free muscle and musculo-cutaneous flaps after early loss of axial blood supply. British Journal of Plastic Surgery, 35,43. La&a, A. P. (1982). Salvage of a seriously injured lower limb with a musculo-cutaneous cross-leg flap. British Journal of Plastic Surgery, 35,40.
McGraw, J. B. (1979). Selection of alternative local flaps in the leg and foot. Clinics in Plastic Surgery, 6,227. McGregor, S. (1982). Soft tissue repair in compound defects of the lower leg. Journal of the Royal College of Surgeons of Edinburgh, 27,93.
May, J. W., Halls, M. J. and Simon, S. R. (1985). Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot : a clinical and gait analysis study. Plastic and Reconstructive Surgery, 75,627. Millican, P. G. and Poole, M. D. (1985). Peripheral neovascularization of muscle and musculo-cutaneous flaps. British Journal of Plastic Surgery, 38,369. Morris, A. M. and Buchan, A. C. (1978). The place of the cross-leg
flap in reconstructive surgery of the lower leg and foot: a review of 165 cases. British Joumalof Plastic Surgery, 31, 138. Noever, G., Briiser, P. and Kiihler, L. (1986). Reconstruction of heel and sole with free flaps. Plastic and Reconstructive Surgery, 78, 345. Orticochea, M. (1978). Immediate (undelayed) musculo-cutaneous island cross-leg flaps. British Journal of Plastic Surgery, 31,205. Parry, S. W., Toth, B. A. and Elliot, L. F. (1988). Microvascular free-tissue transfer in children. Plastic and Reconstructive Surgery, 81,838. Randall, P. and Sbilliq, B. B. (1978). The use of tumbuckles for adjustable positions of cross-leg flaps. Plastic and Reconstructive Surgery, 62,804. Rautio, J., Asko-Seljavaara, S., Laasonen, L. and Harma, M. (1990).
Suitability of the scapular flap for reconstruction
of the foot.
Plastic and Reconstructive Surgery, 85,922. Reilfel, R. S. and McCarthy, J. G. (1980). Coverage of heel and sole defects : a new subfascial arterialized flap. Plastic and Reconstructive Surgery, 66,250. Schwartz, B. M., Truppman, E. S. and Ellenby, J. D. (1980). Preoperative orthoplast splinting in cross-leg flaps. Plastic and Reconstructive Surgery, 66,459.
The Cross-leg Flap : Still a Useful Flap in Children Seralin, D., Georgiade, N. G. and Smith, D. H. (1977). Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot. Plastic and Reconstructive Surgery, 59,492. Sommerlad, B. C. and McGrouther, D. A. (1978). Resurfacing the sole: long term follow up and comparison of techniques. British Journalof Plastic Surgery, 31, 107.
149 Tarn, H., Daniller, A. and Strauek, B. (1980). Neovascularisation of skin flaps: route and timing. PZastic and Reconstructive Surgery, 66,85.
Uhm, K., Shin, K. S. and Lew, J. D. (1985). Crane principle of the cross-leg fascia-cutaneous flap: aesthetically pleasing technique for damaged dorsum of foot. Annals of Plastic Surgery, 15,257.
Stark, R. B. (1947). Preoperatively applied mated, plaster of paris casts as an aid in the migration of open pedicle cross-leg flaps. Plastic and Reconstructive Surgery, 2,443.
Stevenson, T. R. and Mathes, S. J. (1986). Management of foot injuries with free muscle flaps. Plastic and Reconstructive Surgery, 78,665.
Tauxe, W. N., Siiona, J. N., Lipscomb, P. R. and Hanuunoto, K. (1970). Determination of vascular status of pedicle skin flaps by use of radioactive pertechnetate (99m Tc). Surgery, Gynecology and Obstetrics, 130, 87. Thatte, R. L., Yelikar, A. D., Chhajlani, P. and That@ M. R. (1986). Successful detachment of cross-leg fascia-cutaneous flaps on the tenth day: a report of 10 cases. British Journal of Plastic Surgery, 39,491.
The Authors Donald Anthony Hudson, FRCS(Kd), Registrar.
Kevin Millar, MB, CLB, Registrar. Division of Plastic and Reconstructive Surgery, Ward F16, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa. Requests for reprints to Dr K. Millar. Paper received 30 July 1991. Accepted 30 September 1991, after revision.
The cross-leg flap: still a useful flap in children D. A. Hudson and K. Millar Division of Plastic and Reconstructive Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa SUMMARY. Reconstruction of the distal lower limb and foot is a difficult problem, especially where large areas of skin loss have occurred. The cross-leg flap is a safe and reliable alternative to free tissue transfer in paediatric lower limb trauma. By incorporating fascia or muscle the versatility of the flap can be enhanced. Our experience with the cross-leg flap in children during the last 5 years is discussed.
Large soft tissue defects of the distal part of the lower extremity and foot can present a difficult reconstructive problem to the plastic surgeon (Serafin et al., 1977; Noever et al., 1986). Local musculocutaneous or fasciocutaneous flaps are not always possible, and the highest incidence of free flap failure also occurs in this difficult region (Godina, 1986). The cross-leg flap should be considered as a viable alternative to free tissue transfer. It is a safe and reliable procedure for resurfacing large defects of the lower limb and foot (Morris and Buchan, 1978; Barclay et al., 1983). Furthermore, by incorporating fascia (Barclay et al., 1983) or muscle (Orticochea, 1978), the versatility of the cross-leg flap may be enhanced. The flap is easy to perform and does not require the sophisticated equipment and expertise of a micro-anastomosis-an obvious advantage in developing countries (Thatte et al., 1986). This paper reports our experience with the cross-leg flap in the management of paediatric lower limb trauma during the last 5 years.
cross-leg flaps were employed in 7 children and musculocutaneous cross-leg flaps in 3. In all cases both limbs were immobilised by means of a Hoffman exoskeleton. Division of the flap was performed in patients after a mean of 15.7 days (range 1l-21 days). Preliminary delay was performed in 3 flaps, one at 10 days, another at 13 days and another had two delay procedures, at 9 and 12 days respectively. The mean follow-up period was 18 months (range 4541 months). Patients were evaluated at follow-up for both functional and cosmetic outcome. The most recent patient was involved in a train accident + months previously. A degloving injury was sustained to part of the heel of the left foot and this was treated with a split skin graft. The dorsum of the right foot was completely degloved, but leaving the paratenon intact. In addition, the entire sole of the right foot was also degloved at the level of the plantar fascia. A medial gastrocnemius cross-leg flap was applied to the sole of the foot, while the dorsum was treated with a split skin graft. At present the patient is able to walk on the flap. Follow-up is continuing.
Material and methods The records of all patients who had a cross-leg flap for trauma at Red Cross War Memorial Children’s Hospital between 1986 and 1991 were reviewed. During this period, 10 children (6 males and 4 females) with an average age of 7.2 years, (range 4-11 years) were seen. Motor vehicle accident as a pedestrian was the predominant cause and occurred in 8 patients. One patient caught his foot in an electric lawnmower, while another was involved in a train accident. The dorsum of the foot was the most commonly involved site (7 patients). In all these the soft tissue loss exceeded half the surface area of the dorsum of the foot. There was associated extensor tendon loss in 5 patients (all tendons in 2, partial loss in 3) and the dorsalis pedis artery was also avulsed in these 5. The sole of the foot was involved in 2 patients and the distal lower limb in one other. Underlying bony injuries to the foot occurred in 8. Associated injury to other sites occurred in 5 patients. Fasciocutaneous
Results Nine of the 10 flaps were completely viable after division. One musculocutaneous flap applied to the entire heel was divided at 10 days and underwent 25% necrosis. The necrotic part of the flap was debrided and then the wound allowed to heal by secondary intention. All 6 patients with fasciocutaneous flaps on the dorsum of their feet wear normal shoes and are able to participate in sport. In each case the flap was considered cosmetically acceptable by both parent and surgeon (Figs 1, 2). In 5 patients the donor site was considered cosmetically acceptable by parent and surgeon. One patient developed hypertrophic scarring of the skin grafted donor site. No patients developed either knee or ankle stiffness as a result of immobilisation prior to division of the cross-leg flap. One patient who suffered extensive lower limb 146
The Cross-lea Flan : Still a Useful Flan in Children
147
Fig. 1 Figure l--Successful
cross-leg flap on dorsum of foot. Figure 2-Cross-leg
trauma had a fasciocutaneous flap applied to the distal aspect of the leg. He also developed septic arthritis of the knee secondary to knee trauma, and subsequent ankylosis of the knee joint. He now wears a built up shoe. He also has extensive scarring of the limb. Two patients had musculocutaneous flaps applied to the plantar surface of the foot; one to the heel and one had his entire sole replaced. Both patients are able to walk on their flaps, although one patient has only been followed up for 43 months. No ulceration or hyperkeratosis of the flaps have occurred. One patient wears specially padded shoes. No ankle or knee stiffness has occurred. The donor areas have been considered cosmetically acceptable by both parent and surgeon. Secondary procedures were performed in 3 patients. Two patients who had lost all their extensor tendons on the dorsum of the foot during the initial injury had tendon transfers performed through the cross-leg flap 6 months after the initial injury. One patient underwent debulking of the cross-leg flap, which was performed a year after the initial injury.
Discussion In the last decade, the transfer of flaps with the aid of microvascular anastomosis has dramatically altered reconstructive surgery (Thatte er al., 1986), but their
Fig. 2 flap on antero-lateral
aspect of foot.
use is limited in crushing or vascular injuries (Uhm et al., 1985). The dorsalis pedis artery was completely avulsed in 5 of our patients and all had a crush component as part of their injury, making microsurgical reconstruction potentially more hazardous. In a recent report describing their experience of microsurgery in children, Devaraj ef al. (1991) found that the only free flap failures occurred following trauma. The cross-leg flap is a viable and versatile alternative to free tissue transfer in paediatric lower limb trauma. The safety and reliability of the flap has long been established (Serafin et al., 1977; Morris and Buchan, 1978; Hodgkinson and Irons, 1979; McGregor, 1982; Barclay et al., 1983). Barclay et al. (1983) felt that the safety and certainty of success of this flap outweigh its disadvantages, and Serafin et al. (1977) reported that the cross-leg flap had a greater success rate than either jump flaps or free flaps. However, more recent studies report a much greater success rate with free tissue transfer. Parry et al. (1988) reported a success rate at all sites in children of 96% and Banic and Wulff (1987) reported complete success in 13 out of 15 free tissue transfers on the traumatised lower limb in children. While microsurgery now offers many advantages in reconstructive surgery, the process is relatively time consuming. Parry et al. (1988) and Devaraj et a/. (1991) reported an average operative time of 6.1 and 5.5 h respectively. In addition, a microsurgical anastomosis also requires sophisticated postoperative monitoring. Devaraj et al. (1991) recommended that
148 patients be ventilated overnight in an Intensive Care Unit or be carefully monitored in a High Care Unit. The cross-leg flap requires neither of these measures. While the cross-leg flap in adults is associated with the problems of thrombo-embolism and joint stiffness, these complications do not occur in children (Greer, 1975). By incorporating the fascia in the flap a much greater area of skin can be transferred and more freedom of leg position is possible (Barclay et al., 1983). The inclusion of muscle in the flap, when required, further enhances its versatility (Orticochea, 1978; Landra, 1982). Although various methods have been described to imrnobilise the limbs for cross-leg flaps (Stark, 1947; Randall and Shilling, 1978; Schwartz et al., 1980) we found the Hoffman exoskeleton satisfactory (Arnander et al., 1975). The only necrosis (25% of the flap) in this series occurred in a musculocutaneous flap which was completely divided after 10 days. While there is no absolute time at which a pedicled musculocutaneous flap should be divided, 10 days is probably too early in this setting. Black et al. (1978) and Tsur et al. (1980) have shown that musculocutaneous flaps can survive without their initial axial blood supply after 7-10 days, if reset into an ideal bed. Clinically one is often dealing with less than ideal beds. Khoo and Bailey (1982) reported a number of clinical muscle-containing flaps which underwent partial necrosis when the axial vessel thrombosed more than 7 days post surgery. Millican and Poole (1985) showed that if the bed on which the flap lies is poorly vascularised, then the peripheral inset is of importance in flap neo-vascularisation. They suggested, where possible, having flap muscle abutting healthy muscle rather than scarred skin and fat. Landra (1982) reported dividing a musculocutaneous cross-leg flap at 15 days and Tauxe et al. (1970) described the use of Technetium as a guide to deciding when division of the flap is possible. Reconstruction of the weight bearing parts of the foot presents a particularly difficult problem (Chicarilli and Price, 1986; Noever et al., 1986). While a number of local flaps have been described (McGraw, 1979; Reiffel and McCarthy, 1980; Ikuta et al., 1984), none is large enough to cover a heel defect involving massive tissue loss. A number of different free flaps have been described (May et al., 1985; Stevenson and Mathes, 1986; Rautio et al., 1990) but this variety represents a continuous effort to develop satisfactory replacement for the highly specialised sole skin (Chicarilli and Price, 1986). Sommerlad and McGrouther (1978), in their much quoted study on resurfacing the sole, found that the only patients who bore significant weight on resurfaced areas of their feet were doing so on full thickness grafts or local and cross-leg flaps. While it appears that sensation is not necessary for successful reconstruction of the weight bearing surface of the foot (Sommerlad and McGrouther, 1978) continual care is necessary to prevent ulceration and other complications occurring in the flap (May et al., 1985). The cross-leg flap is a safe and reliable flap in paediatric lower limb trauma. We are not recommending that the cross-leg flap be used in preference to free tissue transfer in all cases, but rather suggest that it be considered as a potentially useful alternative, espe-
British Journal of Plastic Surgery cially when confronted with large crush/avulsion injuries of distal lower limb and foot.
References Anumder, C., ErIksson, G., Ktirlof, B. and Nylon, B. (1975). Transfixation in cross-leg flap procedures using Hoffman’s instruments. Scandinavian Jourrkl afPIastic SurgerY,9,68. Banic. A. and WuRL K. (1987). Latissimus dorsi free flans for total repair of extensive lower leg injuries in children. Plastic and Reconstructive Surgery, 79,769. Barclay, T. L., Sharpe, D. T. and Chlshokn, E. M. (1983). Cross-leg fascia-cutaneous flaps. Plastic and Reconstructive Surgery, 12,843. Black, M. J., Chait, L., O’Brien, B., Sykes, P. and Schano, L. (1978). How soon may the axial vessels of a surviving free flap be safely ligated: a study in pigs. British Journal of Plastic Surgery, 31,295. CbicariUi, Z. N. and Price, G. J. (1986). Complete plantar foot coverage with the free neurosurgery radial forearm flap. Plastic
ana'Reconstructive Surgery, 78,94. Devarqi, V. S., Kay, S. P., Batchelor, A. G. and Yates, A. (1991). Microvascular surgery in children. British Journal of Plastic Surgery, 44,276. Godina, M. (1986). Early microsurgical reconstruction of complex trauma of the extremities. Plastic and Reconstructive Surgery, 78, 285. Greer, D. (1975). The cross-leg flap. In Grabb, W. C. and Meyes, M. B. (Eds). Skin Flaps. Boston, Little, Brown & Co, p. 507. Hodgkhrson, D. J. and Irons, G. B. (1979). Newer applications of the cross-leg flap. Annals of Plastic Surgery, 4, 381. Ikuta, Y., Murakaml, T., Yoshioka, K. and Tsuge, K. (1984). Reconstruction of the heel pad by flexor digitorum brevis musculo-cutaneous flap transfer. Plastic and Reconstructive Surgery, 74,86.
Kheo, C. T. K. and Bailey, B. N. (1982). The behaviour of free muscle and musculo-cutaneous flaps after early loss of axial blood supply. British Journal of Plastic Surgery, 35,43. La&a, A. P. (1982). Salvage of a seriously injured lower limb with a musculo-cutaneous cross-leg flap. British Journal of Plastic Surgery, 35,40.
McGraw, J. B. (1979). Selection of alternative local flaps in the leg and foot. Clinics in Plastic Surgery, 6,227. McGregor, S. (1982). Soft tissue repair in compound defects of the lower leg. Journal of the Royal College of Surgeons of Edinburgh, 27,93.
May, J. W., Halls, M. J. and Simon, S. R. (1985). Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot : a clinical and gait analysis study. Plastic and Reconstructive Surgery, 75,627. Millican, P. G. and Poole, M. D. (1985). Peripheral neovascularization of muscle and musculo-cutaneous flaps. British Journal of Plastic Surgery, 38,369. Morris, A. M. and Buchan, A. C. (1978). The place of the cross-leg
flap in reconstructive surgery of the lower leg and foot: a review of 165 cases. British Joumalof Plastic Surgery, 31, 138. Noever, G., Briiser, P. and Kiihler, L. (1986). Reconstruction of heel and sole with free flaps. Plastic and Reconstructive Surgery, 78, 345. Orticochea, M. (1978). Immediate (undelayed) musculo-cutaneous island cross-leg flaps. British Journal of Plastic Surgery, 31,205. Parry, S. W., Toth, B. A. and Elliot, L. F. (1988). Microvascular free-tissue transfer in children. Plastic and Reconstructive Surgery, 81,838. Randall, P. and Sbilliq, B. B. (1978). The use of tumbuckles for adjustable positions of cross-leg flaps. Plastic and Reconstructive Surgery, 62,804. Rautio, J., Asko-Seljavaara, S., Laasonen, L. and Harma, M. (1990).
Suitability of the scapular flap for reconstruction
of the foot.
Plastic and Reconstructive Surgery, 85,922. Reilfel, R. S. and McCarthy, J. G. (1980). Coverage of heel and sole defects : a new subfascial arterialized flap. Plastic and Reconstructive Surgery, 66,250. Schwartz, B. M., Truppman, E. S. and Ellenby, J. D. (1980). Preoperative orthoplast splinting in cross-leg flaps. Plastic and Reconstructive Surgery, 66,459.
The Cross-leg Flap : Still a Useful Flap in Children Seralin, D., Georgiade, N. G. and Smith, D. H. (1977). Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot. Plastic and Reconstructive Surgery, 59,492. Sommerlad, B. C. and McGrouther, D. A. (1978). Resurfacing the sole: long term follow up and comparison of techniques. British Journalof Plastic Surgery, 31, 107.
149 Tarn, H., Daniller, A. and Strauek, B. (1980). Neovascularisation of skin flaps: route and timing. PZastic and Reconstructive Surgery, 66,85.
Uhm, K., Shin, K. S. and Lew, J. D. (1985). Crane principle of the cross-leg fascia-cutaneous flap: aesthetically pleasing technique for damaged dorsum of foot. Annals of Plastic Surgery, 15,257.
Stark, R. B. (1947). Preoperatively applied mated, plaster of paris casts as an aid in the migration of open pedicle cross-leg flaps. Plastic and Reconstructive Surgery, 2,443.
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The Authors Donald Anthony Hudson, FRCS(Kd), Registrar.
Kevin Millar, MB, CLB, Registrar. Division of Plastic and Reconstructive Surgery, Ward F16, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa. Requests for reprints to Dr K. Millar. Paper received 30 July 1991. Accepted 30 September 1991, after revision.