Published online: 2019-05-20 THIEME Review Article 117 Review of Cross-Leg Flaps in Reconstruction of Posttraumatic Lower Extremity Wounds in a Microsurgical Unit Ravi K. Mahajan1 Krishnan Srinivasan1 Harish Ghildiyal2 Mahipal Singh1 Adish Jain1 Taha Kapadia1 Ankush Tambotra1 1Department of Plastic and Reconstructive Surgery, Address for correspondence Krishnan Srinivasan, Department of Amandeep Hospital and Clinics, Amritsar, Punjab, India Plastic Surgery, Amandeep Hospital and Clinics, GT Road, Model 2Department of Plastic and Reconstructive Surgery, Kailash Hospital, Town, Amritsar 143001, Punjab, India (e-mail: [email protected]). Dehradun, Uttarakhand, India Indian J Plast Surg 2019;52:117–124 Abstract Since the advent of microsurgery, and expanding expertise in the field, extensive traumatic wounds of leg have been managed successfully with free tissue transfer. Various patient-related factors may preclude the use of free flaps even in units with available expertise and infrastructure. It is in such situations that the “cross-leg flap” comes into play. In these cases, instead of attempting complicated anastomotic techniques or anastomosis in the zone of trauma, it is better to perform the simpler and more reliable cross-leg flap. In this study, we try to show the utility of a cross-leg flap based on a retrospective study of 198 patients who underwent cross-leg flap in our institute over a period of 15 years extending from November 2003 to March 2018. Materials and methods: Case sheets of all patients who underwent cross-leg flap from November 2003 to March 2018 were reviewed. The location of defect in the leg, the indication for cross-leg flap, the pattern of cross-leg flap, and perioperative complications were noted. Results: A total of 198 patients underwent cross-leg flap for traumatic soft tissue injury of leg during this period. The most common reason for performing cross-leg flap was poor pulsatility of the recipient artery as seen intraoperatively, followed by the economics of the procedure wherein the initial cost of free flap was found significantly Keywords higher compared with cross-leg flap. All flaps survived with partial necrosis occurring in ► cross leg flap 23 patients. All flaps settled well by 2 years’ time. Bony union/fracture healing evaluation ► leg defect was not a part of this study. Conclusion: Cross-leg flap is still a useful tool for leg wound ► free flap coverage even in microsurgical unit in situations precluding free flap coverage. Introduction The success of microsurgical free flaps depends on the presence of healthy recipient vessels. Free flaps cannot be used Cross-leg flap was first described by Hamilton in 1854, and has in patients who have extensive lower extremity injury with subsequently been used for the coverage of leg and foot defects axial vessel damage, vessel thrombosis, severe peripheral vessel 1 in almost all possible locations. Many varieties of the cross- disease, and patients with poor general condition. Further leg procedure have been reported, such as the cross-leg pos- electrical injury, single vessel extremities, and extremities 2 terior tibial artery perforator flap, distally based sural artery receiving radiotherapy after tumor resection are relative 3 fasciocutaneous cross-leg flap, the saphenous neurofascio- contraindications for free flap. The risk of free flap failure 4 cutaneous flap, and the whole leg cross-leg flap described increases in patients who have had previous failed free flap. In 5 by Bajaj and colleagues in 2000. These varieties profoundly these conditions, the cross-leg flap could be a good alterna- increase the flexibility and versatility of cross-leg flap. tive reconstructive option. published online DOI https://doi.org/ ©2019 Association of Plastic May 20, 2019 10.1055/s-0039-1688521 Surgeons of India ISSN 0970-0358. 118 Cross-Leg Flap in Microsurgical Unit Mahajan et al. Performing microsurgical anastomosis could be challeng- allows knee and ankle mobilization. Donor site was skin grafted ing in pediatric patients below 6 years of age when compared and dressed with bolster dressing. with the simpler cross-leg flap. This study is aimed to review Flap insetted on three sides in a tension-free manner keeping the utility of a cross-leg and technical details to minimize the bridging segment as short as possible. There should be no complications and improve flap survival. kinking of the bridge segment. This can happen if the segment is long and excess of flap has been raised. In such a situation, Materials and Methods the fixator needs to be adjusted appropriately to make sure the bridging segment remains straight and there is no acute bend. In This study was performed in conformity with the Declaration of addition, adequate space is left between two legs to provide free Helsinki and was performed after obtaining institutional ethical circulation of air to keep the area dry. committee clearance. First delay of the flap was done at 2 weeks. Flap was divided This is a retrospective study of 198 patients who in stages with a 50% division of flap base in the first delay. If the underwent cross-leg flap at our institute, over a period of length-to-breadth ratio is large or if the flap inset is less than 15 years extending from November 2003 to March 2018. 50% of the circumference of the flap, division of flap was done in Case records of all these patients were reviewed. The three stages. Two-flap delay procedures were performed in such location of defect in the leg, the indication for cross-leg cases, each 3 days apart, under local anesthesia. Delay was done flap, the type of cross-leg flap, and perioperative compli- by cutting the flap base from either side in each stage. The final cations were noted. In all patients, initial management division and inset was done under spinal anesthesia/general was as per the International Trauma Life Support protocol. anesthesia, after 1 week. Once general condition was stabilized, patients were tak- ►Table 1 mentions the technical points to consider to en up for radical debridement by the plastic surgery team improve flap survival and outcome. and bony fixation by the orthopedic team. Patients were taken up for definitive soft tissue wound coverage, within Cases 72 hours. When the condition of the patients did not allow definitive surgery for wound coverage, negative pressure 1. A 25-year-old male presented with compound trauma of the wound therapy was given, until patient was fit for surgery. left upper one-third and middle one-third leg (►Fig. 1). As this Deep vein thrombosis (DVT) prophylaxis was given for patient did not have appropriate recipient vessels close to the 3 weeks in patients who were obese and had their ankle zone of the trauma, it was decided to perform cross-leg flap immobilized due to fracture. to cover the critical area of the wound. Conventional cross-leg flap was done and a Ilizarov fixator applied after 3 months. Operative Details 2. A 39-year-old male presented with unstable scar on the heel. The pattern of cross-leg flap to be used (anteromedially based, He had been operated previously for posttraumatic leg wound superiorly based, inferiorly based) was decided based on the by split skin graft (►Fig. 2). As the entire area was scarred, dis- location of the defect. secting for a recipient vessel was difficult and unsafe. Hence, a When the defect was on the upper, or middle one-third distally based cross-leg flap was done. of the leg, we used the conventional cross-leg flap, based anteromedially. When the defect involved the lower one- Table 1 Technical considerations in cross-leg flap third or ankle and dorsum of the foot, we preferred using the distally based, posterior tibial artery perforator cross-leg Flap selection based on location flap. Hand-held Doppler was used to mark out the perforator Defect location Preferred flap type preoperatively. With an exploratory incision the perforator Knee joint–including Superiorly based, posterior tibial was identified. The base of flap raised could then be sufficient- medial aspect artery perforator flap ly narrowed. This helps to avoid kinking of the pedicle and Upper and middle Conventional cross-leg flap attain better range of rotation of flap. We have not islanded the one-third of the leg flap as it would be very difficult to manage it postoperatively. Lower one-third Conventional/distally based The weight of the flap might stretch and occlude the feeding both can be done perforator. When the defect is in the upper one-third and more Ankle, dorsum, heel Distally based, posterior tibial medially located, superiorly based flap (based on the perfora- artery perforator-based flap tor of the posterior tibial artery) provides better inset than a Technical considerations to improve outcome conventional cross-leg flap and hence was the flap of choice. 1. Appropriate flap selection as mentioned above When raised as conventional random pattern flap, we raise 2. Use of external fixator to stabilize legs it in a 1:1 ratio, and when as axial, in a 1:3 width to the length 3. Use of preop Doppler to locate perforator in cases of distally and ratio. Even longer flaps can be used when the flap is based on the proximally based axial flaps perforator, like inferiorly based, posterior tibial artery perforator 4. Bridge segment to be kept as short as possible to avoid acute bends and kink cross-leg flap. When based on perforators from major vessels of 5. Narrow pedicle in axial flaps to improve mobility 6 the leg, vascularity is robust. External fixator was used to posi- 6. Adequate space between legs to allow physiotherapy and maintain tion the legs in appropriate position as it increases the ease of hygiene postoperative care, allows proper cleansing of the wound, and 7.