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Page 2 of 9 Kondra et al. Plast Aesthet Res 2022;9:36 https://dx.doi.org/10.20517/2347-9264.2021.121

reconstructive ladder for lower extremity trauma, a rotational soleus muscle flap should not be overlooked in the
modern era of free flap tissue transfers and might be a more optimal flap choice in certain patients with multiple
comorbidities.

Keywords: Trauma, lower extremity, local flap, soleus, ambulatory status

INTRODUCTION
Hallmarks of limb salvage include hemostasis, patent vascular flow, bony fixation, infection control, and
soft tissue coverage. Accordingly, the reconstructive surgeon is presented with a complex soft tissue injury
unable to be closed primarily. Previously established treatment algorithms dictate the use of local calf
muscles for the upper two-thirds of the leg while using free tissue transfer for the lower-third of the leg and
foot . Better insight into local flap anatomy and physiology has led to some centers even reporting a
[1-3]
[4]
decreased reliance on free flaps for soft tissue coverage for traumatic lower extremity reconstruction .
Given finite flap options coupled with considerable soft tissue damage, traumatic reconstruction continues
to pose a significant challenge to the reconstructive surgeon beyond the inherent risk of limb loss associated
[5]
with limb salvage . Inclusion of muscle in flap design has historically been viewed as protective toward
postoperative infection given a robust blood supply compared to fasciocutaneous flaps . Other advantages
[6]
of muscle flaps include the ability to eliminate dead space with vascularized tissue; however, muscle flaps
can be associated with donor site morbidity and flap bulk.

While advances in microsurgical technique have allowed surgeons to utilize free flaps for soft tissue
coverage, distal lower extremity trauma is often too small to sensibly utilize free flaps but too large to close
primarily. Considerations of flap design include patient factors (medical comorbidities, surgical risk, current
adjuvant therapy), local factors (injury location, injury severity, associated fractures, tissue quality, previous
surgical sites), and flap factors (color, texture, surface area, volume, pedicle length, arc of rotation) .
[7]
Therefore, careful deliberation is vital when planning for traumatic reconstruction.

The soleus flap is known to be an optimal flap for the middle- and lower-third of the leg . Its primary
[8]
vascular pedicles include the popliteal artery and branches of both the posterior tibial (medial belly) and
peroneal arteries (lateral belly) . As a consequence of its dual blood supply, the soleus flap can
[5,9]
advantageously be split longitudinally into a hemisoleus flap with an improved rotational arc . However,
[10]
[11]
soleus muscle harvest has been associated with decreased ankle flexion and impaired venous return .
Despite these risks, soleus muscle flaps have traditionally been a reliable tool in the plastic surgeon’s
armamentarium for traumatic lower extremity reconstruction and should not be overlooked in the modern
era of free flaps. The purpose of this study is to evaluate the trends and outcomes of soleus flap
reconstruction after lower extremity injury in a large cohort at a Level 1 trauma center.

METHODS
This is an Institutional Review Board approved retrospective chart review using a prospectively maintained
database at the Los Angeles County + University of Southern California (LAC + USC) Medical Center from
2007 to 2021. Inclusion criteria were as follows: (1) patients 18 years of age or older; (2) definitive soft tissue
coverage by soleus muscle flap; (3) operation conducted by the Plastic and Reconstructive Surgery (PRS)
service at LAC + USC; and (4) available follow-up records of postoperative outcomes of the lower extremity.