Skin Cover Options

Basic Concepts


Proximal tibia

- gastrocnemius local muscle flap

- gracilis free muscle flap if gastroc damaged


Middle tibia

- soleus local muscle flap

- gracilis free muscle flap


Distal tibia

- posterior tibial fasciocutaneous local flap

- gracilis free muscle flap


Distal Tibia Skin Graft


Hip / Thigh

- TFL musculocutaneous local flap



- FHB / Abductor Hallucis Longus

- dorsalis pedis fasciocutaneous local island flap

- gracilis free muscle flap


Types of coverage


1.  Split skin grafts


2.  Local flaps

- muscle (gastrocneumius / soleus / T Anterior / EDB)

- musculocutaneous (gastroc / TFL)

- fasciocutaneous (dorsalis pedis /


3.  Free flaps

- muscle

- fasciocutaneous


1.  SSG



- on bed of healthy muscle

- must not be infected



- graft taken with harvestor

- set desired thickness

- usually from anterior thigh

- meshing increase coverage

- stitched to rim of wound

- pressure dressing applied

- takes 5 - 7 days to take


2.  Local Flaps


A.  Muscle Flaps 



- high blood supply 

- deliver ABx to fight infection

- excellent bulk for eliminating dead space




Type 1 

- single pedicle, easiest to transfer

- tensor fascia lata, gastrocnemius


Type 2 

- one or more dominant pedicles, plus minor pedicles

- soleus


Type 3 

- 2 dominant pedicles




The muscle flap mobilises about the vascular pedicle, not the muscle itself


Preserving the neuro pedicle can be disadvantageous

- muscle twitching can compromise the flap

- however this can be advantageous i.e. in bracial plexus surgery


These never have an independent blood supply and are always dependent on the pedicle

- can raise the flap

- must be aware of and preserve pedicle

- check old notes

- plastics review

- ultrasound


Gastrocnemius flaps




Lateral and medial

- Workhorse of the leg

- Cover between the knee prox tibia

- Need to check sufficient muscle bulk and that muscle has not been damaged in accident



- most commonly used

- close to anterior tibia & larger



- can use, but must remove fibula and tunnel under anterior compartment

- putts pedicle at risk


Blood supply

- each head is supplied by a single sural artery 

- branch of the popliteal artery just below the joint line

- need only do angio if severe trauma, knee dislocation or previous vascular procedure




Type 2 flap

- Useful for the middle third of the tibia

- More difficult to raise as must beware the posterior tibial artery

- Muscles can easily be damaged by the tibia in high velocity trauma


Tibialis Anterior 


Occasionally used if not too damaged




Local to ankle


B.  Musculocutaneous flap



- skin is taken also to extend the flap

- SSG used to cover skin defect of donor site

- Gastrocenumius / TLF



- TFL, skin and deep fascia

- Pedicle is branch of lateral femoral circumflex

- Used for hip and thigh

- Need SSG to skin defect


C.  Fasciocutaneous flap


These have independent blood supply after 2 weeks


Posterior tibial artery flap

- Distal Tibia but greater than 10 cm from ankle

- Based on Great saphenous vein for drainage


Dorsalis Pedis Island Flap

- Used to cover heel


Sural artery flap


3.  Free Flaps


- taking tissue with vascular pedicle 

- transferring it to a distal site and re-anastomosing it

- select flaps that have a long pedicle for ease of reimplantation and positioning



- 95 - 98% success with good surgeons

- Nil evidence that smoking or age affect flap

- CRF / DM / atherosclerosis do


A. Muscle


For when muscle is required to bony cover or to fill dead space



- For defects 10 - 15 cm

- Based on medial circumflex artery

- Reasonable thin


Latissmus dorsi

- Workhorse

- For larger defects up to 25 x 40 cm 

- Based on thoracodorsal artery


Rectus Abdominus

- Less commonly used as hernias are a problem


Serratus anterior

- Used for small defects


B. Fasciocutaneous


For when skin cover only is required, not muscle bulk i.e. over ankle joint


Radial free flap

- Workhorse flap