The Soleus Muscle Flap

Abstract

Lower extremity reconstruction often poses several challenges for the reconstructive surgeon. Because of limited local tissue options, patients who sustain extensive middle to distal third tibia fractures used to be at higher risk of limb loss without adequate soft tissue coverage. The traditional principle of reconstructing middle and distal third leg wounds with free tissue transfer is being challenged by advances in understanding of local muscle flap anatomy and surgical techniques to improve the efficacy of local flaps. In this article, we examine contemporary considerations, developed by the authors, for the appropriate indications of free tissue transfer versus use of local flaps such as the soleus muscle flap. We review the versatility and reliability of the soleus muscle as a local muscle option once the technique is mastered on how to safely and effectively design and execute this flap. We highlight the importance of an algorithmic approach to soft-tissue reconstruction of the lower extremity based on the best surgical option for the patient. This includes factors such as medical history, appropriate surgical candidacy, as well as the size and mechanism of injury to decide the most viable option for lower extremity reconstruction. We show that the medial hemisoleus muscle flap is a reliable local option, both by itself or in conjunction with other local flaps, to reconstruct less extensive wounds in the middle to distal third of the leg. Ultimately, such a local muscle flap must be mastered by the reconstructive surgeon to augment his or her armamentarium to provide a well-rounded reconstructive plan in managing the soft-tissue wound, while minimizing donor-site morbidity and potentially be more cost-effective in nature.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma

“…The soleus muscle flap is a good choice for middle-third tibial defects, as well as defects in the junction of the proximal and middle third or middle and distal third [ 63–65 ]. The medial hemisoleus flap can be used to successfully cover many middle-third wounds if the defect is not too large, usually <50 cm 2 if approaching the distal third [ 64 ]. Small distal third tibia wounds can be covered with a reverse hemisoleus flap [ 63 , 65 , 66 ].…”

Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects

“…Several types of local flaps, such as muscle, 24,25 fasciocutaneous, 26 adipofascial, 19 perforator, and propeller skin flaps 27,28 have been described. The sural flap, first described by Donski et al, 26 is one of the most common and simple choices for distal leg reconstruction.…”

“…Muscle flaps, such as soleus 25 or peroneus brevis flap, 24 were also described for distal extremity reconstruction. The soleus muscle, as a distally based pedicled flap, has been described as capable of covering defects of the distal third of the leg; the flap receives its supply from the distal perforator of the posterior tibial vessels.…”

How to get the most out of your gastrocnemius and soleus flaps

“…1,[14][15][16] Multiple techniques have been described for the soleus flap, which include a proximally based flap, a distally based flap (reverse flap), and then determining whether to transpose the entire soleus muscle or only half of it as a hemisoleus flap. 17,18 When considering the extent of flap coverage for a soleus flap, one needs to understand 2 concepts. First, one must balance the arc of rotation with the preservation of perforator arteries.…”