635journal of wound care vol 22, no 11, novEMBER 2013
Hemisoleus muscle flap in the
reconstruction of exposed bones
in the lower limb
l objectives: To evaluate the efficacy of soleus muscle flap for covering complex defects of the middle
and lower leg. The study also outlines functional gain after the reconstructive procedure, the donor site
morbidity and the technical details of the operative procedure.
l Method: This prospective study consists of a total of 40 patients with middle and lower third defects
with exposed bone present in the leg. In all cases, a proximally-based hemisoleus flap was used. All patients
were between 15–65 years of age. Depending upon the position of the defect and ease of rotation, either
the medial or lateral hemisoleus was used to cover the defects. In 7 patients with large defects, both the
hemi-gastrocnemius and hemisoleus flap were used.
l results: Most of the patients studied (52.5%) had defects in the middle third of their leg. A further
12(30%) patients had defects over the upper part of the lower third of the leg and 7(17.5%) cases involved
large defects exposing bones comprising both the middle and lower thirds of the leg. All the flaps survived
well except 5 which developed partial skin graft loss, and 1 where complete flap loss was observed. out
of 5 patients who developed partial graft loss, 3 patients achieved complete healing by regular dressings
and 2 required regrafting. The patient who developed complete flap loss required below knee
amputation. no donor site morbidity was observed, except minimal depression in the posterior leg.
l conclusion: Due to a high degree of reliability, versatility, minimal donor site morbidity, less operating
time, low cost and good functional gain, this procedure is highly suitable for the treatment of complex
middle and lower leg defects.
l declaration of interest: There were no external sources of funding for this study. The authors have no
conflicts of interest to declare.
a challenge to plastic surgeons. The use of local skin
flaps and fasciocutaneous flaps may become limited
especially if their pedicles come within the zone of
injury. Cross leg flaps may be another option but is
difficult to use in the presence of fixators, with 3
weeks immobilisation being an additional problem.
Free flaps may be a good solution,1 yet they are not
available in all centres and have a higher rate of fail-
Parrett and Pribaz3 described the changing trend of
lower extremity trauma management from microv-
ascular to local flaps, skin grafting and vacuum-
assisted closure. According to the authors, microvas-
cular free-tissue transfer increases the ability to close
wounds, transfer vascularised bone, and prevent
amputation, yet remains a complex, invasive proce-
dure with significant complication rates, donor site
morbidity, and failure rates.
Reconstruction of the soft tissue defect of exposed,
soleus muscle; tibial defects; perforators; posterior compartment
evere lower limb traumas are common
among victims of road accidents. The
relatively unprotected anteromedial
portion of the tibia is at risk of bone
exposure following trauma. Because of
complexity of the defect, soft tissue coverage remains
fractured and osteomyelitic lower leg bone remains a
difficult task. In these cases, muscle flaps are a good
option to cover these defects in order to combat
infection and to provide good vascularity to the
exposed area of bone for better healing. In addition,
the muscle flap provides bulk to the bony defect.
Local muscle flaps were first reported by Stark4 and
have become an established procedure for the soft
tissue coverage of pretibial skin defects, especially
when associated with osteomyelitis.5 Mathes et al.
described the proximally-based soleus muscle flap,6
which has been used for the soft tissue coverage of
the middle third of the leg. It has also been widely
employed for the treatment of chronic osteomyelitis
of the leg bones.4,6,7
To further investigate the use of the proximally-
based soleus muscle flap for the treatment of com-
plex wounds of the lower legs, this study aimed to
treat specifically patients with defects in the middle
and lower third of the leg using the hemisoleus mus-
cle flap. In cases involving large soft defects, both
hemisoleus and hemi-gastrocnemius flaps were used.
The study also strived to determine the rate of flap
survival, donor morbidity and functional outcomes
of the patients receiving surgery.
I. ahmad,I MS,
S. akhtar,1 MS,
MCh(Plast Surg), Senior
e. rashidi,1 MS,
MCh(Plast Surg), Senior
M.f. Khurram,1 MS,
MCh(Plast Surg), Assistant
Department of Burns,
Jawaharlal nehru Medical
College, Aligarh Muslim
journal of wound care vol 22, no 11, novEMBER 2013
This prospective study conducted between October
2010 and January 2013 involved patients between
the ages of 15–65 with defects present in the mid-
dle and upper part of the lower third of the leg. For
division of the leg into upper middle and lower leg,
reference points were taken as the femorotibial
joint above and the lateral malleolus below. Pre-
operative Doppler ultrasound was used to locate
Prior to the reconstructive procedure, the wound
was thoroughly debrided aseptically, with dressing
applied on a daily basis. An external fixator was
applied to stabilise the fractured segment. In all cas-
es, a proximally-based hemisoleus flap was used,
with the flap size harvested dependent upon the size
of the wound after debridement. Depending upon
the position of the defect and ease of rotation, either
the medial or lateral soleus was used to cover the
defects. In 7 patients with large defects, both hemi-
gastrocnemius and hemisoleus flaps were used.
The fibrous interosseous membrane connecting the
tibia to the fibula divides the leg into anterior and
posterior compartments. The anterior compartment
is further divided into anterior and lateral compart-
ments by an intermuscular fascia. The posterior
compartment is divided into superficial and deep
compartments by a thin intermuscular fascia. The
superficial compartment contains the gastrocnemi-
Table 1. Patient distribution in various age group
S.no age group in yrs. no. of patients % of total patients
1 15-25 8 20
2 26-35 12 30
3 36-45 10 25
4 46-55 6 15
5 56-65 4 10
Table 2. aetiology of wounds
Mode of injury
no. of patients
% of total
1 Road traffic accident 28 70
2 Train Injury 6 15
3 Fall from height 2 5
4 Gunshot 4 10
us, soleus, and plantaris muscles.3 The gastrocnemi-
us and soleus join together to become the Achilles
tendon that inserts into the calcaneal bone. The
soleus muscle is vascularised by the posterior tibial
and peroneal arteries, which delivers blood supply
through several perforators along its course.3
The soleus muscle is a large, broad, bipennate
muscle consisting of a lateral and a medial head with
independent neurovascular supply.8 It is categorised
as a type II muscle flap. The muscle is supplied by
large and small vascular pedicles.6 The lateral and
medial hemisoleus muscles are separated in the mid-
line by a septum, which is present in the distal part
of the muscle. Intramuscular septum has a distinct
watershed in the blood supply of the proximal half
of the muscle and many fine vascular communica-
tions between intramuscular vascular territories.8
The two muscle heads join together to form the dor-
solateral and dorsomedial component of the Achilles
tendon. This tendon, which is formed by the soleus
and gastrocnemius muscles, inserts on the calca-
The soleus muscle was harvested through a medial
and lateral approach. The most reliable perforator
consistently found during the study using colour
Doppler imaging was located around 8–9cm below
the joint line. This was taken as the upper limit of
Medial approach: First, the incision was drawn
from the medial malleolus up to the proximal part of
the leg located about 1.5cm posterior to the medial
aspect of the tibia. If the skin defect was in the leg,
the line was usually continuous with the defect. The
saphenous nerve and the great saphenous vein were
identified, and a longitudinal incision was made pos-
terior to these two structures. Dissection between the
gastrocnemius and soleus was performed by bluntly
separating the two muscles. By sharp dissection, the
medial head of the soleus (medial hemisoleus) was
separated from its tibial attachments. Care was taken
not to damage the deep fascia covering the posterior
tibial neurovascular bundle. During this dissection,
the posterior tibial neurovascular pedicle became
visible and was preserved. For harvesting of a proxi-
mally-based soleus flap, the dissection was contin-
ued by releasing the aponeurosis of the soleus mus-
cle from the aponeurosis of the gastrocnemius
(separate the component of each muscle within the
Achilles tendon), and at last the distal part of the
soleus with its aponeurosis component was cut.
Lateral approach: The incision was made longitu-
dinally along the fibula bone from the fibula neck
down to the lateral malleolus. The lateral incision
was outlined on the donor leg along the fibula for
the lower part and reaching the popliteal area by an
oblique extension. After incising the skin, subcuta-
journal of wound care vol 22, no 3, MARCh 2013
journal of wound care vol 22, no 11, novEMBER 2013
neous tissue and fascia, in order to achieve better
exposure of the proximal part of the fibula, lateral
soleus and surrounding vessels and nerves, the supe-
rior attachment of the lateral gastrocnemius was sev-
ered from the femur and the muscle belly was split
longitudinally. Once the flap was inset, it was secured
through absorbable suture. Raw muscle belly was
covered through split thickness skin grafts preferably
taken from non-traumatised limb. A suction drain
was placed underneath the flap to drain out collec-
tion. The flap was monitored at regular intervals.
In the case of a distal lower leg soft tissue defect,
the hemisoleus required a few relaxing incisions,
allowing it to advance more distally and cover the
Postoperatively, the limb was immobilised with a
slab. Flap immobilisation was maintained for 7 days.
During the course of treatment, the limb was kept in
an elevated position. The flap was regularly evaluat-
ed through a small rent over the skin graft. The
appropriate uptake of the graft is an indication of
survival of the flap. Once bone was found to be unit-
ed after radiological evaluation, partial weight bear-
The outcome and success of the flap surgery was
evaluated on the basis of flap survival, graft intake,
functional gain and donor site morbidity. Flap sur-
vival was graded as excellent, good or poor. A grad-
ing of excellent depicts no flap lost and survival of
the skin grafted over the flap surface, good depicts
where there is some loss of skin grafted over the flap
or marginal loss of the flap, and poor depicts the
complete loss of the flap or if there is necrosis of
more than 50% of the flap. The functional outcomes
were evaluated on the patient’s capacity to gain full
flexion and extension, to bear weight, return to work
and the requirement for assisting devices.
A total of 40 patients between the ages of 15–65
were recruited for this study (31 males and 9
females). The majority of the patients (30%) in this
study fell in the 26 to 35 years age group. Only 4
patients in this study were between 55 to 65 years
old (Table 1). Road traffic accidents accounted for
the majority of cases of the trauma wounds (70 %).
Train injury was the second most common cause
(Table 2). The majority of the defects (21 of 40
(52.5%)) were in the middle third of leg (Table 3). A
further 12(30%) patients had defects over the lower
third of the leg and 7(17.5%) cases involved large
defects exposing bones comprising both middle and
lower thirds of leg.
The success or failure of the outcome was assessed
according to flap survival, graft intake, functional
gain and donor site morbidity. The results of the flap
Table 4. location of defect and the incision used in
Site of defect
no. of patients
1 over lower third
of leg (upper part) 12 10 2
2 over middle third
of leg 21 16 5
3 over both middle and
lower third defect 7 7 nil
Total 40 33 7
Table 3. distribution of wounds (exposed bone segments)
Site of defect no. of patients %
1 Involving lower third of leg (upper part) 12 30
2 Involving middle third of leg 21 52.5
3 Involving both middle and lower third defects 7 17.5
Total 40 100
reconstruction are listed in Table 5. Out of a total of
40 flaps, 34 showed excellent results, 5 showed good
survival and 1 flap was graded as poor.
In terms of donor site morbidity, all the patients had
acceptable donor site with regard to the function
and cosmesis, except minimal depression in the pos-
Post-operative functional gain was also analysed.
Full flexion and extension were reported at the ankle
joint in 30 patients. A further 9 patients had restrict-
ed movement at ankle joints. The average time for
partial weight gain was 3 months for a patient hav-
ing a non-fractured tibia. Most of the patients (34
out of 40), which included patients having both frac-
tured and non-fractured tibia, started full weight
bearing at 6 months. Some of the patients com-
plained of pain while walking, which reduced with
time. Two patients required support for walking
even after 6 months. These two patients exhibited
severe trauma with fracture of both bones. Some of
the patients required dressing for one month; again,
these were the cases with severe trauma. Return to
normal work with full mobilisation and weight bear-
ing was achieved in 34 of the 40 patients.
Soft tissue reconstruction of the middle and lower
leg region is difficult and remains a challenge to plas-
tic surgeons. There are many possible reconstructive
journal of wound care vol 22, no 11, novEMBER 2013
options for these regions, such as local flaps, cross leg
flaps9 and free flaps10. Local flaps include random
pattern flaps, fasciocutaneous flaps,11 reverse sural
fasciocutaneous flaps,12 and muscle flaps.6 Random
pattern flaps have high incidence of failure. The use
of cross-leg flaps has been limited by the difficulty of
immobilising both legs for 3 weeks, joint stiffness,
and concern about donor site cosmetic deformity in
the normal leg. Free flaps are costly, with significant
donor site morbidity, long operating time and a high
In this study, we have successfully used the proxi-
mally-based hemisoleus flap for the coverage of soft
tissue defects over the middle and distal lower leg.
Along with the hemisoleus muscle, we have used
gastrocnemius in some cases with large soft tissue
defects. Importantly, proximally-based hemisoleus
muscle flaps have been found to be suitable for the
distal lower leg using a few relaxing incisions, which
is one of the most difficult regions to reconstruct.
Other groups have previously explored the grafting
potential of the hemisoleus muscle flap.
Fatih et al13 studied the arterial blood supply of the
soleus muscle in 45 cadaveric lower limbs, where
they showed the distribution of the arteries entering
the soleus muscle; this knowledge of the blood sup-
ply of the soleus was critical for harvesting the soleus
muscle flap. Furthermore, Ata-ul-Haq et al14 conclud-
ed in their study that the hemisoleus muscle flap was
a valuable local option for soft tissue coverage of
middle third of lower leg for preserving the function
1 harii, K., ohmori, K. Free
skin flap transfer. Clin Plast
Surg 1976; 3: 1, 111–127.
2 Yajima, h., Tamai, S.,
Mizumoto, S. et al. vascular
tissue transfer: outcome
and salvage technique.
Microsurgery 1993; 14: 3,
3 Parrett, M.B., Pribaz, J.J.
Reconstruction, Rev Med
Clin Condes 2010; 21: 1, 66
4 Stark, W.J. The use of
pedicled muscle flaps in the
surgical treatment of
resulting from compound
fractures. J Bone Joint Surg
1946; 28: 343–350.
5 Ger, R. The management
of pretibial skin loss.
Surgery 1968; 63: 757.
6 Mathes, S.J., nahai F. (eds).
Clinical applications of
musculocutaneous flaps. St.
louis, Mosby, 1982.
7 Yajima h., Tamai, S.
Yamaguchi, T. Use of the
muscle flap covering in the
treatment of chronic
osteomyelitis of tibia.
Seikeigeka 1988; 39:
1594–1597 [in Japanese].
Quoted from 8
8 Tobin, G.R. hemisoleus
and reversed hemisoleus
flaps. Plast Reconstr Surg
1985; 76: 1, 87–96.
9 Barclay, T.l., Cardos, E.,
Sharpe, D.T. Cross leg
fasciocutaneus flaps. Plast
Reconstr Surg 1983; 72:
10 May, J.W., Gallico, G.G.,
lukash, F.n. Microvascular
transfer of free tissue for
closure of bone wounds of
the distal lower extremity.
n Engl J Med 1982; 306: 5,
11 Tolhurst, D.E., haeseker,
B., Zeeman, R.J. The
fasciocutaneus flap and its
clinical application. Plast
Reconstr Surg 1983; 71: 5,
12 Akhtar, S., hameed, A.
versatility of the sural
fasciocutaneous flap in the
coverage of lower third leg
and hind foot defects. J
Plast Reconstr Aesthet Surg
2006; 59: 8, 839–845.
13 Fathi, M., hassanzad
Azar, M., Arab Kheradmand,
A., Shahidi, S. Anatomy of
arterial supply of the soleus
muscle. Acta Med Iran 2011;
49: 4, 237–240.
14 Ata-ul-haq, Tarar, M.n.,
of the muscle.
In the present study, we used both medial and lat-
eral approaches for hemisoleus flap harvesting. The
lateral approach required dissection of an additional
peroneal compartment; the risk of damaging the
common peroneal nerve is always present. The most
difficult dissection involved cases of large wound
size, long standing and severe cases of trauma. Addi-
tionally, chronic inflammation resulted in dense
fibrosis. The bulk available for the covering flap was
insufficient in some cases; atrophy of the muscle was
significant in these type of defects.
Pu,15 in his series of four patients with an extensive
mid-tibial wound of the leg, successfully used the
combined medial gastrocnemius and medial hemi-
soleus muscle flaps for soft-tissue reconstruction.
Limb salvage was achieved in all four patients during
follow-up. In a subsequent study,16 14 patients with
an open tibial wound in the junction of the middle
and distal thirds of the leg underwent a soft tissue
coverage using the proximally-based medial hemiso-
leus muscle flap, demonstrating positive results.
In our study, 7 patients suffered from large defects
involving both the middle and lower third of the leg.
These types of exposed bones could not be covered
by the soleus muscle flap alone. In these cases, both
hemisoleus and hemi-gastrocnemius flap was used
to cover the exposed bone, where a medial incision
was used to harvest medial hemisoleus and hemi-
Recently, there has been a movement towards
fig 1a. defect involving the lower and
middle third of the leg. The lateral
incision approach was used for raising
both hemi-gastrocnemius and
hemisoleus flap simultaneously.
fig 1b Hemisoleous and hemi-
gastrocnemius flap raised. relaxing
incision given over the hemisoleus
to advance more distally and cover
the lower third more easily (not
shown in the figure).
fig 1c. Post op. day 7. Skin graft
fig 2a. defect over middle and lower third of leg.
dead bone devoid of periosteum was debrided.
fig 2b. Post op photograph after applying hemigastro-
cnemeus and hemisoleus followed by skin grafting.
journal of wound care vol 22, no 11, novEMBER 2013 Download full-text
using the free anterolateral thigh flap (ALTF) for
reconstructive surgery. Song first described the free
ALTF17 for reconstruction of simple and complex
soft tissue defects in difficult regions, especially the
distal lower leg.18 It has successfully and widely been
used for the coverage of post-traumatic lower and
upper limb open fractures and degloved foot dor-
sum.19 Free ALTF can be used as a combined chimer-
ic flap for the reconstruction of combined complex
defects in the lower extremity.20 Disadvantages of
this flap include the need for specialised staff,
knowledge of its anatomical variations and a well-
equipped microsurgical setup.
Most of the cases in this study had long standing
exposed wounds. Prolonged tibia exposure resulted
in dead periosteum and outer cortex. In some
instances, the inner medulla was also decayed.
Thorough cleaning and debridement of wound
was performed before insetting of the flap and
utmost care was taken in removal of all dead tis-
sues as retention of dead sequestrum and osteomy-
elitis segment causes long-standing sinus and fis-
tula. The defects created by debridement of
necrotic bone were covered by the muscle flap,
owing to its bulkiness.
This study outlined not only the flap uptake and
wound conditions but also the functional gains in
terms of weight bearing, return to normal work, use
of assist devices, mobility of the affected limb,
donor site morbidity and movement at the ankle
joint i.e. dorsiflexion and planter flexion. A majori-
ty of the patients in the study began full weight
bearing after 6 months, and eventually returned to
normal work with full mobilisation, highlighting
Malik, F.S. et al. hemisoleus
muscle flap, a better option for
coverage of open fractures
involving middle third of tibia. J
Ayub Med Coll Abbottabad 2009;
21: 4, 154–158.
15 Pu, l.l. Soft-tissue
reconstruction of an open tibial
wound in the distal third of the
leg: a new treatment algorithm.
Ann Plast Surg 2007; 58: 1, 78–83.
16 Pu, l.l. Soft-tissue coverage of
an open tibial wound in the
junction of the middle and distal
thirds of the leg with the medial
hemisoleus muscle flap. Ann Plast
Surg 2006; 56: 6, 639–643.
17 Song, Y.G., Chen, G.Z., Song
Y.l. The free thigh flap: a new free
flap concept based on the
septocutaneous artery. Br J Plast
Surg 1984; 37: 2, 149–159.
18 Kimura, n., Satoh, K.
Consideration of a thin flap as an
entity and clinical applications of
the thin anterolateral thigh flap.
Plast Reconstr Surg 1996, 97: 5,
19 Koshima, I. Fukuda, h.,
Yamamoto, n. et al. Free
anterolateral thigh flaps for
reconstruction of head and neck
defects. Plast Reconstr Surg 1993;
92: 3, 421–428.
20 Koshima, I., Soeda, S., Yamasaki,
M. Kyou, J. Free pedicle
anteromedial thigh flap. Ann. Plast.
Surg., 5: 480, 1988
21 Kauffman, C.A., lahoda, l.U.,
Cederna, P.S., Kuzon, W.M. Use of
soleus muscle flaps for coverage
of distal third tibial defect. J
Reconstr Microsurg 2004; 20: 8,
Table 5. results of the operation.
Site of defect.
no of patients.
1 lower 1/3 leg(upper part) 12 12 2 1
2 Middle 1/3 leg 21 16 2
3 Both middle and lower
third defect 7 6 1
Total 40 34 5 1
the high success rate of the surgery.
Kauffman et al21 reviewed the outcome of 12
patients who underwent soleus flap reconstruction
of distal third lower extremity defects. Nine of the 12
patients achieved a healed, stable wound; however,
several flaps and multiple additional procedures
were often required. One of the 12 patients experi-
enced soleus flap loss and two of the patients
required below-knee amputations. Failure of limb
salvage was related to traumatic injuries or comorbid
conditions such as peripheral vascular disease, smok-
ing, and planned radiation.
In our study, only one patient exhibited complete
flap loss, necessitating amputation to avoid chronic
morbidity. The reasons for flap failure could not be
clearly identified. Damage of pedicle during dissec-
tion, compression of pedicle, avascular bed, severe
infection and general poor condition of the patient
could contribute to flap failure. Although the failure
rate of the reconstructive grafts in our study were
low, the presence of these adverse contributors to
flap loss and eventual limb loss necessitates further
studies on how to minimise postoperative muscle
flap failure and improve muscle flap survival.
The soleus muscle flap is an excellent flap for the
reconstruction of the middle and lower third leg
defects. It is ideal for covering exposed, osteomye-
litic and dead bones. This muscle is easy to identify
and dissect. While elevating the flap, the medial
approach was found to be easier than the lateral
approach. This study showed that the functional
gain following the reconstrucive procedure, in
terms of weight bearing, early return to work,
mobility in the affected limb and movement at the
ankle joint i.e. dorsiflexion and plantar flexion,
was positive. Donor site morbidity was minimal.
Chronic inflammation and dense fibrosis in a trau-
matised limb might lead to difficulties in dissec-
tion and separation of muscle. It is thus a good
alternative to other muscle flap procedures such as
fasciocutaneous flaps, adipofascial and free flap for
lower leg defects. Due to its reliability, ease of har-
vesting, minimal donor site morbidity, reduced
operating time, low cost and good functional gain,
it is highly beneficial for the reconstruction of mid-
dle and lower leg defects. n