Alternative Plans When Medial Gastrocnemius Muscle Flap Is Not Feasible
When the medial gastrocnemius muscle flap cannot be used, the lateral gastrocnemius muscle flap, combined gastrocnemius-soleus bi-muscle flap, or posterior calf fasciocutaneous flap are the primary alternatives for knee and proximal lower leg defects. 1, 2
Primary Alternative Muscle Flap Options
Lateral Gastrocnemius Muscle Flap
- The lateral gastrocnemius muscle flap serves as the most direct alternative, utilizing the same surgical principles with vascularization through the lateral sural artery rather than the medial 2
- This flap provides similar advantages of obliterating dead space, promoting healing, increasing vascular supply and oxygen tension, and augmenting antimicrobial therapy effects 1
- The lateral head offers comparable protection for exposed prosthetic material or vascular grafts 1
Gastrocnemius with Soleus Bi-Muscle Flap
- For larger defects where a single gastrocnemius head provides insufficient volume or arc of rotation, the combined gastrocnemius-soleus bi-muscle flap extends coverage capabilities 3
- This technique exploits perforators that penetrate the gastrocnemius muscle through the soleus muscle, located consistently in the distal half of the gastrocnemius 3
- The soleus muscle receives reversed flow from gastrocnemius muscle perforators, allowing both muscles to function as a single unit 3
- This combination is particularly useful for large soft tissue defects of the knee and upper third of the leg where a single gastrocnemius head would be inadequate 3
Gastrocnemius Musculoadipofascial Flap
- Adding a distal adipofascial component to the gastrocnemius muscle flap increases dimensions and arc of rotation for extensive defects 4
- This modification addresses the limitation of small distal muscle volume, especially when posttraumatic disuse atrophy is present 4
- The adipofascial extension eliminates the need for skin grafting on the donor site and reduces leg contour deformity 4
Fasciocutaneous Alternative
Island Posterior Calf Fasciocutaneous Flap
- The island posterior calf fasciocutaneous flap represents a valuable non-muscle alternative with specific advantages over gastrocnemius muscle flaps 5
- This flap offers greater flexibility in size and shape, a longer arc of rotation to reach suprapatellar defects, and provides sensate skin with protective sensation 5
- Key advantages include less bulk, avoidance of muscle sacrifice, and ease of re-elevation for subsequent orthopedic procedures 5
- The flap demonstrated 90% complete survival in clinical series (9 of 10 cases) 5
- This option is technically more demanding but particularly useful when muscle preservation is desired 5
Alternative for Distal Thigh and Lateral Knee Defects
Inferiorly Based Sartorius Muscle Flap
- When the defect is located on the distal one-third thigh or lateral aspect of the knee where gastrocnemius reach is limited, the inferiorly based sartorius muscle flap provides coverage 6
- The distal major pedicle is consistently located at approximately 35 cm from the anterior superior iliac spine (range 30.4-38.3 cm) with mean arterial diameter of 1.54 mm 6
- This flap achieves an arc of rotation between 95° and 125° for reliable coverage, though rotation beyond 155° risks distal muscle necrosis 6
- This option is particularly valuable when direct gastrocnemius muscle injury has occurred or when the wound location exceeds gastrocnemius reach 6
Critical Contraindications to Consider
- Lesions of the popliteal artery represent an absolute contraindication to proximally pedicled gastrocnemius flaps 2
- Concomitant soleus muscle injury impairs plantar flexion and may preclude gastrocnemius harvest 2
- For distally pedicled gastrocnemius flaps, unpredictable vascularization after trauma makes this technique rarely used 2