The “gold standard” for coverage of severe lower extremity injuries is free tissue transplantation. Free scapular flaps, such as free fasciocutaneous flaps, are suitable for many lower extremity applications and often provide excellent contour reproduction and appearance.¹ The blood circulation in the free scapular flap must be reestablished by anastomosing its pedicle to recipient vessels. In other words, there must be vessels available for anastomosis. Unfortunately, injury to a lower extremity is sometimes very serious, complicated, and prone to infection resulting in damage to recipient vessels and vascular obstruction, so there may not be vessels to be anastomosed in the recipient site. In this situation, the vessels of the contralateral lower extremity can provide temporary blood supply while neovascularization between the bed and the flap occurs. This technique was called the cross-leg pedicled free flap and has been performed for several years.^2,3 This study extends the indications and reports successful use of the cross-leg pedicled free scapular flap to cover an extensive soft tissue defect with tibial bone exposure of the lower leg in 13 patients. Good results were obtained and the cross-leg pedicled free scapular flap appears to be suitable for these wounds.

Methods

The study included 13 patients from May 2000 to October 2005. There were 11 men and 2 women. Ages ranged from 18 to 52 years with a mean age of 35 years. All patients had extensive soft tissue defects of the lower leg with tibial bone exposure and variable wound infection (Figure 1). The defects ranged in size from 8 cm x 15 cm to 15 cm x 30 cm. Wounds were caused by accident (6 patients), burn (2 patients), electrical injury (3 patients), and fall (2 patients). The soft tissue defects were so severe that there were no suitable vessels to be anastomosed in the recipient sites. All patients were treated with free scapular flaps to cover the defects and the vessels of the free scapular flaps were anastomosed with the dorsalis pedis vessels of contralateral leg in order to provide temporary blood supply.
Operative technique. The vessels of the recipient site were evaluated after wide radical debridement of all necrotic or infected tissue. If there was no suitable vessel to use, a cross-leg pedicled scapular flap was performed. The scapular flap was marked according to the defect so that the area of the scapular flap was a little larger than the defect in order to form the pedicle and cover the extensive soft tissue defect with no tension. The area of the scapular flap was from 10 cm x 15 cm to 15 cm x 35 cm (Figure 2). Dissection of the scapular flap was carried out in a routine manner (Figure 3). The local flap of the dorsum pedis was then lifted up to the contralateral limb and the dorsalis pedis vessels were dissected. The free scapular flap was transferred to cover the defect and its vessels were anastomosed with the dorsalis pedis vessels. The local flap was turned over and sutured with the pedicle part of the free scapular flap to form the skin pedicle (Figure 4). The 2 legs were in a cross-position and the knee of the donor limb was in flexion, which was fixed by plaster cast. Typically, the pedicle was divided after 4 to 5 weeks. The local flap was re-sutured and the pedicle part of the scapular flap was used to repair the secondary defect or was resected.

Results

The blood supply was re-established in all 13 patients. All free scapular flaps survived and the defects were covered completely (Figure 5). The defective lower extremities had regained function and there were no deformities in donor sites of the contralateral lower leg.

Discussion