Background: In patients with extensive bone and soft-tissue defects, the inclu-sion of the hemisoleus muscle with the fibula osteoseptocutaneous flap wouldprovide the needed soft-tissue volume to the flap. This study evaluates thereliability and technical considerations for the inclusion of the hemisoleus withthe fibula and skin paddle as a chimeric, peroneal artery–based flap.Methods: The location and size of major arterial branches of the peroneal arterysupplying the lateral hemisoleus muscle were investigated in 10 cadaveric in-jected lower limb specimens. The utility of this design was demonstrated in fiveclinical cases.Results: The lateral hemisoleus was noted to be consistently supplied by largemuscle branches from the peroneal artery, soleus vessels 1 (proximal) and 2(distal). The mean diameter and distance from the origin of the peroneal arteryfor soleus vessels 1 and 2 were 1.8 mm and 2.1 cm, and 1.6 mm and 6.3 cm,respectively. The fibula osteoseptocutaneous flap incorporating the hemisoleusmuscle was performed in five clinical cases. All were successful. Either soleusvessel 1 or soleus vessel 2 can be used as the pedicle to the muscle, dependingon the specific reconstructive requirements for the reach and placement of thehemisoleus.Conclusions: The fibula osteoseptocutaneous flap incorporating the hemiso-leus muscle can reliably be raised by preserving constant muscle branches thatarise from the peroneal artery to supply the lateral hemisoleus. This flap pro-vides the additional bulk in selected cases, with little additional donor-sitemorbidity. (Plast. Reconstr. Surg. 124: 1956, 2009.)
Complex three-dimensional defects involvingthe mandible or maxilla with concomitantloss of a significant amount of soft tissue are
challenging reconstructive problems. In the mandi-ble in particular, the provision of vascularized boneis the definitive standard for reconstruction.1,2 Thefibula osteoseptocutaneous flap as described by Weiet al. can reliably transfer good quality bone and skininto the defect. It is the flap of choice for vascularizedbone transfer to the head and neck.3,4 However, thetissue bulk that is available with this flap is limited.Therefore, in defects with significant soft-tissue loss,the use of a second soft-tissue flap is often necessary
to provide the needed bulk to fill dead space andto give a more aesthetic outcome.5,6 The use of asecond free flap, however, is more technically de-manding and prolongs surgery significantly. Dou-ble free flaps are more technically demanding andprolong surgery significantly. The inclusion of thehemisoleus muscle with the fibula osteoseptocu-taneous flap provides the needed bulk, makingsimultaneous replacement of missing bone andsignificant tissue loss possible. This study revisitsthe blood supply of the lateral hemisoleus andevaluates the reliability of its inclusion into thefibula osteoseptocutaneous flap. Its versatility andutility was demonstrated in five clinical cases ofcomposite defects of the head and neck.From the Department of Plastic Reconstructive and Aesthetic
Disclosures: None of the authors has any conflictof interest regarding the content of this article.
www.PRSJournal.com1956
MATERIALS AND METHODSCadaveric lower limb dissections were per-
formed on 10 injected lower limb specimens (fivewhole cadaver specimens) to investigate the sup-ply of the lateral hemisoleus muscle. The skin overthe posterior compartment of the leg was re-moved. The gastrocnemius muscle was then re-moved, exposing the soleus muscle. The lateralhemisoleus was disinserted from its origin andinsertion. The flap was cut in the midline of thesoleus marked by the median raphe and plantaristendon. The hemisoleus was then raised lateral tomedial to identify vessels supplying the muscle. Thenumber, location, and size of muscle branchesfrom the peroneal artery supplying the lateralhemisoleus were noted. The distance of the vesselssupplying the lateral hemisoleus from the originof the peroneal artery was also noted.
RESULTSThe results of the cadaveric dissection are sum-
marized in Table 1. Two sizable muscle branches(�1 mm) usually arise from the peroneal artery tosupply the lateral hemisoleus muscle (Fig. 1). Theproximal vessel was designated soleus vessel 1 andthe more distal vessel was designated soleus vessel2. Soleus vessel 1 was present in 10 of 10 specimensand soleus vessel 2 was present in nine of 10 spec-imens. The mean diameter of soleus vessel 1 was1.8 mm (range, 1.2 to 2.4 mm) and it arose a meanof 2.1 cm (range, 0.5 to 4 cm) from the origin ofthe peroneal artery. The mean diameter of soleusvessel 2 was 1.6 mm (range, 1.2 to 2.3 mm) and itarose a mean of 6.3 cm (range, 4.6 to 8.5 cm) fromthe origin of the peroneal artery.
From July of 2007 to January of 2009, the fibulaosteoseptocutaneous flap incorporating the hemi-soleus muscle was performed on five clinical cases.Table 2 gives a summary of our clinical cases. Themean follow-up was 6 months (range, 4 to 19months). All flaps survived. In one patient (case3), necrosis of the skin island was noted on thesixth postoperative day. This was attributed to in-jury to the septocutaneous vessel supplying theskin paddle during bone osteotomies. A pedicledpectoralis major myocutaneous flap was per-formed to replace the oral lining. The fibula andsoleus muscle flap was noted to be healthy duringthe reexploration. In fact, the benefit of inclusionof the hemisoleus muscle to obliterate dead spaceand protect the neck vessels was realized in thiscase. Despite the salivary leak into the neck, thehemisoleus was effective for sealing the neck ves-sels and anastomotic site from the detrimentaleffects of the contamination. This was instrumen-tal in averting the potential loss of the entire flapand even a catastrophic carotid blowout.
Surgical Technique for Harvesting the FibulaOsteoseptocutaneous Flap Incorporating theHemisoleus Muscle
The fibula is marked and the septocutaneousvessel supplying the skin island located by hand-held Doppler on the posterior border of the fib-ula. The dimensions of the needed skin paddleand muscle are then marked (Fig. 2). The anteriorincision on the skin island is made first to identifythe location of septocutaneous vessels. The pos-terior incision is then made and the soleus and theflexor hallucis longus are then dissected off theposterior crural septum. Any musculocutaneousperforators coming through the soleus muscle tosupply the skin can be ligated safely, as the sep-tocutaneous vessels already identified can reliablysupply the skin paddle. The septocutaneous ves-sels are then traced to their origin at the peronealartery. The flexor hallucis longus muscle coveringthe posterior aspect of the peroneal artery is de-tached progressively from the posterior aspect ofthe peroneal artery. Exposure of the peroneal ves-sel is performed from distally to proximally, trac-ing the vessel up the leg. Soleus vessel 2 followedby soleus vessel 1 present as the surgeon progressesup the leg (Fig. 3). Depending on specific recon-structive requirements, either vessel can be used asthe vascular pedicle for the hemisoleus. The muscleis then transected distally and in its midline. Thesagittal septum separates the medial from the lateralhemisoleus, and its location is marked by the plan-
10 1.5 1.6 6.2 1.4*S1, soleus vessel 1(the first sizable muscle branch arising from theperoneal artery to supply the lateral hemisoleus); S2, soleus vessel 2(the second, more distal muscle branch arising from the peronealartery).
Volume 124, Number 6 • Repair of Complex Head and Neck Defects
1957
taris tendon. Proximal division of the muscle is de-layed until the end of the procedure. This preventstraction on the pedicle from the weight of the flapduring the remaining part of the dissection (Fig. 4).The remaining muscle over the posterior aspect ofthe peroneal artery is separated from the vessel. Atthis juncture, the entire posterior aspect of the per-oneal artery, the septocutaneous vessel supplying theskin island, and the muscle branch to the lateralsoleus muscle can be visualized. Dissection is thenmoved to the front. The peroneus longus and brevis,the anterior crural septum, the extensor digitorumlongus and extensor hallucis longus, and the inter-osseus membrane are separated progressively fromthe fibula. The proximal and distal osteotomies areperformed and the bone is rotated laterally to facil-itate dissection. The distal end of the peroneal arteryis medial to the distal end of the bone and is ligated.In the proximal two-thirds, the peroneal artery iscovered by the tibialis posterior muscle and a fasciallayer. This is opened to expose the artery. The re-maining medial attachments of the vessel are dividedfrom distal to proximal up to the tibioperonealtrunk. It is important with this technique to cleanlystrip the surrounding muscles from the peronealpedicle, as doing so enables the surgeon to clearlyvisualize all vessels supplying the muscle and skincomponents. Care should be taken when approach-ing the muscle branch to the soleus muscle to pre-vent its injury. Once the pedicle is ready, the re-
maining attachment of the muscle component tothe soleus can be completely divided. The weight ofthe hemisoleus dangling on the muscle branch mayirreversibly damage the vessel. To prevent this, twoor three temporary sutures are placed hitching themuscle to the periosteum of the bone with the vesselin a relaxed position. These sutures are dividedwhen one is finally ready to inset the flap. The fibulaosteoseptocutaneous flap incorporating the hemi-soleus muscle can then be harvested when the re-cipient site is ready (Fig. 5).
ILLUSTRATIVE CASEA 63-year-old man presented with a T4N0M0 squamous cell
carcinoma of the floor of the mouth invading into the sub-mental area and his chin skin (Fig. 6). Wide resection andbilateral neck dissection were performed. The resultant defectinvolved the loss of the mandible (angle to angle), total glos-sectomy, and the entire chin and part of the submental skin(Fig. 7). For reconstruction, a fibula osteoseptocutaneous flapincorporating the hemisoleus muscle was harvested. A largeskin island measuring 24 � 11 cm was harvested based on asingle septocutaneous vessel to simultaneously reconstruct thetongue/floor of mouth and the external skin defect (Fig. 8).The hemisoleus was used to replace tissue loss in the submentalarea. As the submental area is located in the neck close to theexpected site of microanastomoses, soleus vessel 1 was used asthe pedicle to the muscle component. Recovery was uneventful,and the patient was discharged home on the twelfth postop-erative day. Radiation therapy was commenced 1 month later.At 2-month follow-up, all his wounds were healed and the ad-ditional bulk provided by the hemisoleus gave significantlymore fullness to the submental area than was possible with an
Fig. 1. The lateral hemisoleus is usually supplied by two large branchesthat arise from the peroneal artery. Soleus vessel 1 is defined as the first,most proximal muscle branch from the peroneal artery supplying thelateral hemisoleus, and soleus vessel 2 is the second muscle branch. Thelateral hemisoleus flap can be based on either one of these vessels.
Plastic and Reconstructive Surgery • December 2009
1958
Fig. 3. From the posterior incision, the flexor hallucis longus(FHL) is separated from the posterior crural septum and the sep-tocutaneous vessel is traced to the posterior aspect of the pero-neal artery. The dissection is then continued up the leg followingthe peroneal artery. Large muscle branches from the peronealartery to the soleus muscle [soleus vessel 2 (S2) and soleus vessel1 (S1) higher up] will be seen and these can be used to vascularizethe lateral hemisoleus muscle. At this juncture, all vascular supplyof the fibula osteoseptocutaneous flap incorporating the hemi-soleus muscle chimeric can be visualized from posteriorly; theseptocutaneous vessel to the skin paddle and the muscle branchto the hemisoleus (soleus vessel 2).Ta
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Volume 124, Number 6 • Repair of Complex Head and Neck Defects
1959
osteocutaneous flap alone (Fig. 9). Donor-site morbidity wasacceptable, and there were no issues with ambulation (Fig. 10).
DISCUSSIONThe fibula osteoseptocutaneous flap is the
flap of choice for head and neck bony defects.1,2
Its only disadvantage is that it is unable to pro-vide adequate bulk when there is significant soft-tissue loss. Wei et al. recommend that the bonebe harvested with a minimal cuff of muscle.3 Thepaper-thin posterior crural septum with the sep-tocutaneous vessel within can then be freelymoved over the bone to give more freedom inthe inset of the skin component. The fibulaosteoseptocutaneous flap incorporating thehemisoleus muscle is a chimeric design that includesthe hemisoleus with the fibula osteoseptocutaneousflap as an independent component.7 Our cadavericstudy demonstrated that sizable muscle branches,soleus vessels 1 and 2, consistently arise from theperoneal artery to supply the lateral hemisoleus.This enabled the independent bone, skin, and mus-cle components to be reliably raised as a single per-oneal artery–based chimeric flap. Selection of whichvessel to use as the pedicle of the hemisoleus musclecomponent depends on the specific requirements ofthe defect. Soleus vessel 1 is located very near theorigin of the peroneal artery and is used when themuscle flap is needed in the immediate vicinity ofthe anastomotic site. When the muscle is neededfarther away from the anastomotic site, soleus vessel2 should be used (Fig. 11).
To including more bulk with the fibula flap,some authors have advocated harvesting the flapwith at least a 1-cm cuff of the flexor hallucislongus muscle. This approach was also pur-ported to be able to include septocutaneous and
Fig. 4. The predetermined dimensions of the piece of muscleneeded are then cut except the proximal attachment of the mus-cle. This is to prevent traction on the vascular supply to the mus-cle component. Soleus vessel 2 was (S2) used as the flap pedicleand soleus vessel 1 (S1) was ligated. FHL, flexor hallucis longus.
Plastic and Reconstructive Surgery • December 2009
1960
musculocutaneous perforators supplying theskin island.8,9 However, this “blind” approachmay not always be reliable with regard to inclu-sion of vessels supplying the skin, and loss of theskin component may occur.10 –12 The excessivebulkiness of the bone/muscle/skin compositemakes inset more difficult. Furthermore, the“extra” bulk is tethered to the bone and cannotbe freely moved to the area where it is needed.It is thus of limited usefulness. Therefore, when
an additional muscle component is needed toaddress a specific area of deficiency, the fibulaosteoseptocutaneous flap incorporating the hemi-soleus muscle is far superior in terms of versatilityand reliability.
The feasibility of inclusion of the lateralhemisoleus with the fibula flap was first dem-onstrated by Baudet et al. as an osteomuscularflap.13 However, in earlier descriptions, the mus-cle and bone are harvested en bloc. The soleusremains tethered to the bone, limiting its mo-bility and freedom of movement.14,15 The fibulaosteoseptocutaneous flap incorporating the hemi-soleus muscle harvests the muscle component basedon a selected sizable muscle branch, giving the mus-cle an independent, free vascular pedicle.16,17 Thisdesign can reliably include the entire hemisoleus.This piece of well-vascularized muscle is mobile onits own muscle branch and can be inset independentof the skin and bone components. Only one set ofanastomoses is needed to revascularize the entirecomposite tissue.
Mathes and Nahai classified the lateral hemi-soleus as a type 2 muscle with a dominant pedicleand minor pedicles arising from the peronealartery.18 The dominant pedicle is located mostproximally and corresponds to soleus vessel 1noted in our study. The minor pedicle corre-sponds to soleus vessel 2. It is generally recom-mended not to harvest a flap based on minor(secondary) pedicles. This is generally not an issuewith the harvest of the conventional pedicledlateral hemisoleus muscle flap for defects of themiddle third of the leg. The more distal “minor”pedicle (corresponding to soleus vessel 2) isusually divided to increase the reach of the flap
Fig. 7. Photographs showing the tumor excised and the resultant large composite defect.
Fig. 8. Photograph showing the fibula osteoseptocutaneousflap incorporating the hemisoleus muscle harvested with the en-tire lateral hemisoleus muscle based on soleus vessel 1 (S1) and askin island measuring 24 � 10 cm.
Volume 124, Number 6 • Repair of Complex Head and Neck Defects
1961
and the muscle is perfused by the more proxi-mally located “major” pedicle (soleus vessel 1).For the harvest of the fibula osteoseptocutane-ous flap incorporating the hemisoleus muscle,
however, greater flexibility in the vessel that sup-plies the lateral hemisoleus is needed. Our ca-daver study noted that soleus vessel 1 is usuallyslightly larger than soleus vessel 2. However, as
Fig. 9. Photographs of the patient at 2-month follow-up. Note the significant filling of thesubmental and neck area by the hemisoleus muscle.
Fig. 10. Donor-site morbidity was acceptable. The patient was able to ambulate withoutany difficulty and was able to tiptoe (right). Reattachment of the flexor hallucis longusmuscle to the interosseous membrane under the appropriate tension during closure of thedonor site ensures adequate great toe flexion (left).
Plastic and Reconstructive Surgery • December 2009
1962
demonstrated in our clinical cases, either one iscapable of adequately perfusing the entire lat-eral hemisoleus. With the free-style approach toharvesting flaps, the muscle may be based on anyvessel, provided it is of adequate size. The caveatfor the use of soleus vessel 2 as the muscle pedi-cle is therefore that it must be sizable (�1mm).16,17 Therefore, calling soleus vessel 2 a mi-nor pedicle is perhaps inaccurate and mislead-ing and should be avoided. Furthermore, itshould be noted that the muscle componentbased on the peroneal artery is almost alwaysreliable. At least one large vessel from the per-oneal artery is always present. This is in contrastto the septocutaneous vessel supplying the skinpaddle, which may be absent in 5 percent ofcases, necessitating maneuvers for skin islandsalvage.11
The advantage of the fibula osteoseptocuta-neous flap incorporating the hemisoleus muscle isthat it allows the freedom of various componentsto address the three-dimensional requirements of
the defects. Insetting the fibula osteoseptocutane-ous flap incorporating the hemisoleus muscle ismore challenging and requires greater precisionboth in its planning and in its execution. Theperoneal artery is firmly adherent to the bone, andthe septocutaneous vessel is embedded with theposterior crural septum. These are thereforeprotected from traction injury from the weightof the tissues. The muscle branch, in contrast, isunsupported and quite susceptible to tractioninjury from the weight of the soleus muscle dan-gling off its pedicle. It is our practice thereforeto suture the muscle to the periosteum of thebone immediately after raising the muscle com-ponent with the muscle branch completely ten-sion free. The muscle component is also gen-erally inset first into the defect. The suspensionsutures are removed and the muscle is partiallyinset into the defect. This is followed by skincomponents and bone with miniplates or recon-struction plates. Once the flap is secured, mi-croanastomosis can then proceed safely.
Fig. 11. The lateral hemisoleus can be based on either soleus vessel 1 or soleus vessel 2.The primary determinant of this selection is the specific defect requirements. (Left) Fibulaosteoseptocutaneous flap incorporating the hemisoleus muscle used in case 3. Soleusvessel 1 (S1) takes off very close to the origin of the peroneal artery and therefore placesthe muscle in the immediate vicinity of the anastomotic site. This is good for coverage ofneck vessels and replacement of tissue loss in the neck, submental space, and jaw areas.(Right) Fibula osteoseptocutaneous flap incorporating the hemisoleus muscle used incase 2. The use of soleus vessel 2 (S2) places the muscle component farther away from theanastomotic site and allows the muscle to reach areas such as the maxilla, cheek, and oralcavity.
Volume 124, Number 6 • Repair of Complex Head and Neck Defects
1963
As compared with the fibula osteoseptocuta-neous flap, there seems to be only minimal addi-tional donor-site morbidity by inclusion of the so-leus muscle. Patients were all able to ambulatewithout any difficulty kicking-off or tiptoeing. Thisis consistent with our experience with the use ofthe pedicled hemisoleus flap in coverage of lowerlimb defects.19 Ankle plantar flexion is adequate,provided that the gastrocnemius and the medialhemisoleus are preserved. Similar to the harvest ofthe fibula osteoseptocutaneous flap, the major po-tential morbidity in the use of the fibula osteo-septocutaneous flap incorporating the hemisoleusmuscle is the loss of great-toe flexion from dys-function of the flexor hallucis longus muscle.20–23
The flexor hallucis longus muscle is completelystripped off its origin on the fibula. Care must betaken therefore to reattach the muscle under theright tension to the interosseous membrane inclosing the donor site. This would minimize do-nor-site morbidity and ensure satisfactory great-toe flexion postoperatively.
Limitations of this present work should benoted. Our clinical experience with the use of thefibula osteoseptocutaneous flap incorporating thehemisoleus muscle is limited to five patients. Thedonor-site morbidity in particular has to be eval-uated further as more experienced is gained withits use. The flap is a little more technically de-manding, with a definite learning curve. It alsotakes slightly longer to harvest but can usually becompleted in less than one tourniquet time (un-der 2 hours).
Chin-Ho Wong, M.R.C.S., F.A.M.S.(Plast. Surg.)Department of Plastic Reconstructive and Aesthetic
5. Andrades P, Bohannon IA, Baranano CF, Wax MK,Rosenthal E. Indications and outcomes of double free flapsin head and neck reconstruction. Microsurgery 2009;29:171–177.
6. Wei FC, Demirkan F, Chen HC, Chen IH. Double free flapsin reconstruction of extensive composite mandibular de-fects in head and neck cancer. Plast Reconstr Surg. 1999;103:39–47.
7. Cheng MH, Saint-Cyr M, Ali RS, Chang KP, Hao SP, Wei FC.Osteomyocutaneous peroneal artery-based combined flapfor reconstruction of composite and en bloc mandibulardefects. Head Neck 2009;31:361–370.
8. Harrison DH. The osteocutaneous free fibular graft. J BoneJoint Surg (Br.) 1986;68:804–807.
9. Schusterman MA, Reece GP, Miller MJ, Harris S. The osteo-cutaneous free fibula flap: Is the skin paddle reliable? PlastReconstr Surg. 1992;90:787–793.
10. Urken ML. The osteocutaneous free fibula flap: Is the skinpaddle reliable? (Discussion). Plast Reconstr Surg. 1992;90:794–798.
11. Wong CH, Tan BK, Wei FC, Song C. The use of soleusmusculocutaneous perforator for skin paddle salvage inthe fibula osteocutaneous flap: Anatomic study and clin-ical confirmation. Plast Reconstr Surg. 2007;120:1576–1584.
12. Kawamura K, Yajima H, Kobata Y, Shigematsu K, TakakuraY. Clinical applications of free soleus and peroneal perfora-tor flaps. Plast Reconstr Surg. 2005;115:114–119.
13. Baudet J, Caix P, Amarante MS, et al. The composite fibulaand soleus free transfer. Int J Microsurg. 1982;4:10–26.
14. Pelissier P, Casoli V, Demiri E, Martin D, Baudet J. Soleus-fibula free transfer in lower limb reconstruction. Plast Re-constr Surg. 2000;105:567–573.
17. Mardini S, Tsai FC, Wei FC. The thigh as a model for free stylefree flaps. Clin Plast Surg. 2003;30:473–480.
18. Mathes S, Nahai F. Reconstructive Surgery: Principles, Anatomyand Techniques. Vol 2. St. Louis: Quality Medical; 1997:1473–1488.
19. Kramers-de Quervain IA, Lauffer JM, Kach K, Trentz O,Stussi E. Functional donor-site morbidity during level anduphill gait after a gastrocnemius or soleus muscle-flap pro-cedure. J Bone Joint Surg (Am.) 2001;83:239–246.
20. Shpitzer T, Neligan P, Boyd B, Gullane P, Gur E, FreemanJ. Leg morbidity and function following fibular free flapharvest. Ann Plast Surg. 1997;38:460–464.
21. Babovic S, Johnson CH, Finical SJ. Free fibula donor-sitemorbidity: The Mayo experience with 100 consecutive har-vests. J Reconstr Microsurg. 2000;16:107–110.
22. Vail TP, Urbaniak JR. Donor-site morbidity with use of vas-cularized autogenous fibula grafts. J Bone Joint Surg (Am.)1996;78:204–211.
23. Chou SW, Liao HT, Yazar S, Lin CH, Lin YC, Wei FC. Assess-ment of fibula osteoseptocutaneous flap donor-site morbidityusing balance and gait test. J Orthop Res. 2009;27:555–560.
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