Pedicled Fillet of Leg Flap for Extensive Pressure
Shareef Jandali, MD, and David W. Low, MD
Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia
Published October 27, 2009
Objective: Multiple large decubitus ulcers present a reconstructive challenge to the
plastic surgeon. When stage IV pressure sores become recurrent or extensive, traditional
flaps either have already been exhausted or would not be sufficient to cover the defect.
Methods: A retrospective review was performed on all paraplegic patients who had
chronic, extensive, and stage IV decubitus ulcers, and underwent reconstruction using
a pedicled continuous musculocutaneous flap of the entire leg between 1998 and 2007.
The extent and size of the debrided pressure sores, number of previous flap reconstruc-
tions, intraoperative blood loss, postoperative complications, and years of follow-up
were all recorded. A description of the operative technique is also given. Results: Four
patients underwent a total leg fillet flap in the study period, with follow-up ranging from
2 to 7 years. Indications included extensive and bilateral trochanteric, sacral, and ischial
pressure sores. Complications included intraoperative blood loss and postoperative het-
erotopic calcification. Conclusions: The total leg fillet flap is a very large and robust
flap that offers paraplegic patients coverage of extensive stage IV pressure sores of the
trochanteric, sacral, and ischial areas.
Multiple large decubitus ulcers present a reconstructive challenge to the plastic surgeon.
They are a recurrent and pervasive problem in patients who are either immobilized or
insensate in the lower trunk and extremities. Various local and regional flaps from the
buttock and thigh are routinely used to close primary ulcerations of modest size. However,
when stage IV pressure sores become recurrent or extensive, these flaps either have already
been exhausted or would not be sufficient to cover the defect. Reconstruction is aimed at
improving hygiene and quality of life, prevention of osteomyelitis and sepsis, prevention
of fluid and protein loss through the wound bed, and prevention of future malignancy
(Marjolin’s ulcers) in these chronic wounds with sinus tracts. We present a method of
reconstruction, using a pedicled continuous musculocutaneous flap of the entire leg to fully
cover such defects that was performed on 4 patients from 1998 through 2007.
No funds were used supporting this work and the authors have no financial interest.
SHAREEF JANDALI AND DAVID W. LOW
Figure 1. Illustration of incisions for pedicled
fillet of leg flap.
and stage IV decubitus ulcers, and underwent reconstruction using a pedicled continuous
musculocutaneous flap of the entire leg between 1998 and 2007. The extent and size of the
debrided pressure sores, number of previous flap reconstructions, intraoperative blood loss,
postoperative complications, and years of follow-up were all recorded.
All patients selected were highly motivated to be compliant with future wound care
and prevention of recurrent pressure sores. They had all been serially debrided by either the
plastic surgery team or the orthopedic team at our institution. At the time of flap coverage,
the multiple pressure sores were debrided a final time, connected into a single wound, and
pulse-lavaged. The incision along the thigh was made laterally between the quadriceps
muscles and the hamstring muscles so as to avoid dissection of any major muscle groups
thigh incision was carried transversely across the patella and then along the bare area of
the tibia (Fig 1). Using a periosteal elevator, the tibia was exposed in a subperiosteal
fashion. Care was taken to avoid injury to the interosseous membrane to preserve flow to
the anterior tibial vessels. To facilitate dissection, the foot was amputated just above the
ankle by making a circumferential incision and then identifying and ligating the posterior
tibial, anterior tibial, and peroneal vessels. After dissection of the tibia, the knee joint
was entered and the meniscus was removed from the surrounding soft tissues of the knee
capsule. The patella was dissected away from the quadriceps and patellar tendons. The tibia
was then removed after separating it from the head of the fibula. The fibula was approached
pulled through the muscle tunnel so that the leg was completely void of any bony support
underneath the flap (Fig 3). Closure was obtained with interrupted deep absorbable sutures
between parts of the muscle fascia and the deep bed of the ulcer, followed by a standard
skin closure (Fig 4). No attempts were made to innervate these flaps with sensory input
from above the level of the spinal cord injury. All patients were kept on an air-fluidized bed
for the remainder of their hospital stay and were seen by physical and occupational therapy.
The patient is a 25-year-old woman with a history of paraplegia secondary to transverse
myelitis, complicated by scoliosis and chronic vertebral osteomyelitis, who had undergone
multiple previous orthopedic procedures for her spine and 2 pedicled flaps for her pressure
sores. She had undergone left hip disarticulation and excision of the proximal femur for an
extensive hip pressure sore. She had open wounds on the left side of the ischium and along
thesacrum, whichafter debridementmeasuredabout 600 cm2, andwere reconstructedwith
a left total leg fillet flap. She lost an estimated 1 L of blood and got transfused with 2 units
of packed red blood cells. The flap healed well without complication with follow-up lasting
The patient is a 60-year-old man with a history of T4 paraplegia for 21 years from a boating
accident. He had not undergone any previous flap surgeries for coverage of his pressure
sores. He had exposure of his right posterior iliac wing and the posterior portion of his right
hip along with small pressure sores on the left ischium. Three weeks after a colostomy, the
patient underwent debridement of all of his wounds, resulting in a defect that measured
about 650 cm2, requiring a right total leg fillet flap for coverage. He lost an estimated 1 L
of blood and got transfused with 2 units of packed red blood cells. The flap healed well
without complication with follow-up lasting 6 years.
flap reconstructionsfor pressure sores of her right ischium. She still had a large right ischial
pressure sore. She underwent a right total leg fillet flap for coverage of a debrided surface
area of 550 cm2. She lost an estimated 500 mL of blood and got transfused with 1 unit of
SHAREEF JANDALI AND DAVID W. LOW
packed red blood cells. At her 3-month follow-up, she was found to have some breakdown
of the distal end of the flap overlying the ischium without bone exposure and was taken
back to the operating room for revision of the flap. Within 4 years of follow-up after the
revision, she had no further flap complications.
Figure 2. Pedicled leg flap void of any bony support.
Figure 3. Drain placement prior to insetting of leg flap.
The patient is a 48-year-old man with a history of paraplegia who developed right
trochanteric, sacral, and bilateral ischial pressure sores. He had previously undergone
one flap surgery, which was a left gluteal V-Y advancement flap to try to cover a left ischial
pressure sore. This patient underwent a right total leg fillet flap for a defect that measured
about 800 cm2. He lost an estimated 1 L of blood and got transfused with 2 units of packed
red blood cells. The flap remained extremely robust postoperatively but a large portion of