British Journal ofPlastic Surgery (1991).

44,459462

Technical refinement of the lateral supramalleolar flap

Ph Valenti, A. C. Masquelet, C. Romana and J. Y. Nordin

Departments of Orthopaedic and Reconstructive Surgery, Trousseau Hospital and Avicenne Hospital, Paris,
France

SUMMARY. The lateral supramalleolar flap has proved to be versatile for managing a variety of skin defects of the
foot, ankle and lower third of the leg. An anatomical study has shown the reliability of a subcutaneous vascular
network, supplied by termhtal branches of the perforating branch of the peroneal artery.
Our technical refinement consists in designing the skin flap more proximally on the lateral aspect of the leg, and
mobilishtg it on its vascular fascia-subcutaneous pedicle. The flap provides considerable possibiities for covering
more distal skin defects of the lower extremity.

The lateral supramalleolar flap described by Masquelet
et al. (1988) is a fasciocutaneous flap supplied by the
perforating branch of the posterior peroneal artery.
An anatomical study and clinical experience showed
the reliability of this flap when distally based for
managing a variety of skin defects of the lower
extremity. Further experience has indicated some
potential problems and has led us to propose a
technical refinement in the design of the flap.
The original flap cannot be used to cover skin
defects very far distal on the foot when the descending
branch of the peroneal artery, which runs anterior to
the ankle, is destroyed. We have been able to show
that it is possible to design the skin paddle more
proximally on the lateral aspect of the leg, mobilised
on a subcutaneous pedicle including the deep fascia.
The aim of this paper is to present this technical
refinement and our clinical experience of 13 cases in
resurfacing skin defects of the foot and the lower third
of the leg.
Surgical anatomy
The skin of the lateral aspect of the leg is supplied by
terminal branches arising from the perforating branch
of the posterior peroneal artery. It has been demon-
strated (Masquelet et al., 1988) that this perforating
branch is constant, always emerges 5 cm above the
lateral malleolus in the groove between the tibia and
the fibula, and gives two or three ascending cutaneous
branches. These branches perforate the fascia and
continue as a vascular network in the lateral aspect of
the leg. It is possible to isolate this subcutaneous
vascular network to provide the blood supply to the
skin flap on the lateral aspect of the leg. With this
subcutaneous pedicle, it is not necessary to site the
skin paddle over the origin of the perforating branch
of the peroneal artery under the skin paddle, as
described by Masquelet et al. in their initial paper.
The skin territory of the flap can therefore be
459
designed more proximally on the lateral aspect of the
leg but should not go above the middle third or extend
beyond the tibia1 crest medially and the posterior
border of the fibula laterally. The point of rotation is
the origin of the perforating branch of the posterior
peroneal artery. If needed, the subcutaneous pedicle
can be elongated by dissecting the descending branch
of the peroneal artery which runs anterior to the ankle
to the sinus tarsi, giving the flap a wide arc of rotation.
Operative procedure
After outlining an appropriate island, the skin is
incised over the pedicle and thin skin flaps are
reflected, sparing the rich subcutaneous vascular
network to be included in the fascia-subcutaneous
pedicle which is 2-3 cm wide (Fig. 1).
Dissection is then carried out between tibialis
anterior and extensor digitorum longus where the
perforating branch of the peroneal artery is easily
located and the elevation of the flap is completed
(Fig. 2). The superficial peroneal nerve should be
included in the pedicle to avoid an extensive dissection,
and is severed as it enters the flap. The vertical incision
is closed primarily without tension and the donor site
grafted.
clinical cases (Table 1)
Thirteen island lateral supramalleolar flaps were
carried out between October 1987 and June 1989. The
average follow-up is 1 year.
In 12 cases the point of rotation was the origin of
the perforating branch of the peroneal artery. The
pedicle was passed beneath a skin bridge into the soft
tissue defect without sacrificing healthy skin, which is
an added advantage over the standard lateral supra-
malleolar flap.
 British Journal of Plastic Surgery

Fig. 1 Fig. 2
Figure l-The design of the skin flap. Dissection of the subcutaneous pedicle should remain very superficial to spare the rich vascular
network. The pedicle includes the deep fascia. Figure Z-The flap is elevated with its subcutaneous pedicle. The point of rotation is the
emergence of the constant perforating branch of the peroneal artery. The length of the pedicle can be extended by dissecting the pre-
malleolar artery as far as the level of the sinus tarsi.

Table 1 Clinical cases

Case no. Aetiology Skin defect Islandflap (cm) Other procedure Complications Result

Grade III compound Medial aspect distal 10x6 Periosteal flap and Nil Excellent
fracture third leg cancellous bone graft
Grade III compound Medial aspect distal 4x4 Cancellous bone graft Nil Excellent
fracture third leg
Pseudarthrosis of 5th Lateral 5th metatarsal 4x4 Cancellous bone graft Nil Excellent
metatarsal
Open calcaneal fracture Lateral calcaneal 6x4 Subtalar arthrodesis Small distal Good
necrosis
Bone tumour of tarsus Lateral tarsal 8x6 Cancellous bone graft Nil Excellent
Crushing of tarsal Lateral tarsal 6x6 Cancellous bone graft Nil Excellent
Direct trauma of Exposure of insertion 5x5 Nil Excellent
Achilles tendon of Achilles tendon
Ankle fracture 12 years Anterior aspect ankle 10 x 8 Debridement Nil Excellent
before, with infection
Compound Grade III Anterior aspect distal 6x6 Cancellous bone graft Haematoma Excellent
fracture distal third leg third leg
with bony defect
10 Compound calcaneal Medial aspect ankle 8x 10 Reduction and fixation Venous Good
fracture with subtolar by pins congestion of
dislocation flap
11 Severe foot trauma, Resurfacing of 8x 12
transmetatarsal transmetatarsal (extended
amputation, dystrophic amputation pedicle)
skin
12 Grade III fracture Anterior and medial 6x8 External fixation soleus GOOd
middle third leg aspects of lower third flap in same procedure
leg
13 Necrotic skin with Lateral aspect ankle 3x5 Debridement Excellent
infection after ankle
arthrodesis
Technical Refinement of the Lateral Supramalleolar Flap 461

In Case 11 the descending branch of the peroneal
artery was dissected as far as the sinus tarsi to elongate
the pedicle and allow the flap to cover the defect of a
trans-metatarsal amputation. The result was excellent,
without any congestion.
casereports
Case 2
This 40-year-old man sustained a compound fracture of the
lower end of the tibia in a car accident. After bony union, a
small skin defect persisted over the medial aspect of the
lower tibia (Fig. 3A). To cover this defect, we used a small
island supramalleolar flap, 4 x 4 cm (Fig. 3B), passed be-
neath a subcutaneous tunnel over the tibia1 crest. Healing
was uneventful (Fig. 3C).
Case 5
This 25year-old woman presented with a synovial sarcoma
of the tarsal bones which had recurred after radiotherapy.
Many surgeons had proposed amputation of the foot but the
tumour had been excised and the defect reconstructed with
a bone graft. A few days after the operation, skin necrosis
exposed the bone graft (Fig. 4A). The descending branch of
the peroneal artery had been destroyed and the local
condition of the skin forbade a local flap.

Fig. 3
Figure 3-Case 2. (A) Chronic ulceration after a compound fracture of the lower end of the tibia. (B) Elevation of a small skin flap on its
subcutaneous pedicle. (C) Final result 6 months later.

Fig. 4
Figure 4-Case 5. (A) Skin necrosis after excision of tumour of the foot and bony reconstruction.
Note skin changes due to irradiation. (B)
Design of skin flap and subcutaneous pedicle. (C) Elevation of skin flap and pedicle, including the deep fascia. (D) Final result 2 months
later.
462
To cover the skin defect, an island fasciocutaneous flap
measuring 8 x 6 cm was raised on the lateral aspect of the
leg, as described, with its point of rotation at the origin of
the perforating branch of the peroneal artery (Fig. 4B, C). It
was passed under a skin bridge to reach the defect, without
sacrifice of healthy skin. It successfully achieved skin cover
without infection or resorption of the bone graft (Fig. 4D).
Discussion
Since the first description of the fascia-cutaneous flap
by Ponten in 1981, several flaps have been described
recently to cover skin and soft tissue defects of the
lower third of the leg and foot: some require the
sacrifice of a main artery of the foot, e.g. dorsalis pedis
flap (MacGraw and Furlow, 1975), anterior tibia1 flap
(Wee, 1986) and peroneal island flap (Yoshimura et
al., 1986).
Other flaps with cutaneous pedicles (Donski and
Fogdestam, 1983; Amarante et al., 1986; Satoh et al.,
1988) may require sacrifice of a healthy skin bridge to
reach the defect.
The main advantages of the technical refinement of
this island flap are as follows :
(1) The length of the pedicle can often be increased
after dissection of the descending branch of the
peroneal artery.
(2) The length of the fascia-subcutaneous vascular
pedicle allows cover of very distal skin defects on
the foot, even when the descending branch of the
peroneal artery is destroyed (case 13).
It is not necessary to sacrifice healthy skin.
ii; The reliability of this island flap allows one to use
small flaps to cover small defects of the lower third
of the leg.
(5) The donor site has a muscular bed and is reliably
resurfaced with a skin graft.
Some potential problems should be pointed out.
Reliability of this flap depends on the integrity of the
external perimalleolar area, so we have not used this
flap when the groove between the fibula and the tibia
has been involved by degloving during the trauma.
The longer the fascia-subcutaneous pedicle, the
smaller the skin area of the flap. In our experience the
skin territory reaches approximately 18 cm above the
malleolus, so this flap is not suitable for large skin
defects of the foot, and other procedures such as free
flaps should be considered in these cases.
British Journal of Plastic Surgery
We have not encountered significant venous conges-
tion with this fascia-cutaneous flap; this may be due
to the low arterial flow to the flap, which contrasts
with the richly vascular anterior or posterior tibia1
flap.
We believe that this island fascia-cutaneous supra-
malleolar flap is reliable and can be used to resurface
many varieties of skin defects in the lower extremity,
and is particularly useful for small defects of the lower
third of the leg.
References
Amarante,
J., Costa, H., Rels, J. and Soares, R. (1986). A new
distally based fasciocutaneous Rap of the leg. British Journal of
Plastic Surgery, 39,338.
Donski, P. K. and Fogdestam, I. (1983). Distally based fascio-
cutaneous flap from the sural region. Scandinavian Journal of
Plastic and Reconstructive Surgery, 17, 191.
MacDraw, J. B. and Pnrlow, L. T. (1975). The dorsalis pedis
arterialized flan: a clinical study. Plastic and Reconstructive
Surgery, 55,17?
Masquelet, A. C., Reveridge, J., Romana, C. and Gerber, C. (1988).
The lateral SuDramalleolar flap. Plastic and Reconstructive Surgery,
81,74. -
Pont&n, B. (1981). The fasciocutaneous flap: its use in soft tissue
defects of the lower leg. British Journal of Plastic Surgery, 34,215.
Satoh, K., Yoabikawa, A. at~I Hayashi, M. (1988). Reverse-Flow
Arterior tibial flap type III. British Journal of Plastic Surgery, 41,
624.
Wee, J. T. K. (1986). Reconstruction of the lower leg and foot with
the reverse-pedicled anterior tibia1 flap: preliminary report of a
new fasciocutaneous flap. British Journal of Plastic Surgery, 39,
117
JL,.
Yoshimura, M., Shimada, T., Imura, S., Shimamura, K. and
Yamauchi, S. (1986). Peroneal island gap for skin defects in the
lower extremity. Journal of Bone and Joint Surgery, 67A, 935.
The Authors
Ph. Valenti, MD, Department of Orthopaedic and Reconstructive
Surgery, Trousseau Hospital, Paris.
A. C. Masquelet, MD, Professor, Department of Orthopaedic
Surgery, Trousseau Hospital, Paris.
C. Romana, MD, Department of Orthopaedic and Reconstructive
Surgery, Trousseau Hospital, Paris.
J. Y. Nordin, MD, Professor, Department of Orthopaedic and
Reconstructive Surgery, Avicenne Hospital, Paris.
Requests for reprints to: Dr. Ph. Valenti, Department of Ortho-
paedic and Reconstructive Surgery, Trousseau Hospital, Paris XII,
France.
Paper received 25 January 1990.
Accepted 15 April 1991 after revision.