I appreciate very much the thoughtful discussion of my article (Plast. Reconstr. Surg. 115: 245, 2005) by Drs. Uraloğlu et al. from Ankara, Turkey.1 It is still true that coverage of soft-tissue defects in the distal third of the leg is a great challenge for plastic surgeons. Unlike some other parts of the body, local tissues are not enough for coverage of a larger soft-tissue defect in the distal third of the leg. Free tissue transfer still remains a standard option for management of this complex clinical problem. The focus of my article deals with a less extensive soft-tissue defect in the distal third of the leg. The size of the soft-tissue defect is usually less than 40 cm2. For a limited soft-tissue defect in the distal third of the leg, I have tried a proximally or distally based hemisoleus muscle flap as an alternative option for soft-tissue coverage in this region for the last 3 years. I think the surgical technique described in my article would provide a more cost-effective approach, although a free tissue transfer is still the standard option of choice. Because of the volume of orthopedic traumas in our medical center, free tissue transfers have been routinely performed for soft-tissue coverage of lower extremity wounds and a number of refinements have been made by our group with good success.2,3 Given a number of previous studies and my clinical experience with more than 50 soleus muscle flaps,4–7 I believe that the proximally based hemisoleus muscle flap can be used to cover relatively smaller soft-tissue defects in the distal third of the leg. The level of insertion of the soleus muscle can be quite low and can be determined by physical examination and intraoperative exploration, although magnetic resonance imaging would be a good noninvasive study.5 With such a low level of insertion of the soleus muscle, the proximally based hemisoleus muscle flap can be used to cover the defects located in the distal third of the leg when the surgeon makes an intraoperative decision based on the size of the soft-tissue defect in the distal third of the leg and the size of the distal soleus muscle mass.
I agree with Drs. Uraloğlu et al. that use of a distally based hemisoleus muscle flap for defects in the distal third of the leg is not a brand new idea.7,8 However, the refinement of the flap dissection would represent an innovative idea to maximize the reliability of the so-called distally based hemisoleus muscle flap. Based on my experience with nine cases so far, the distally based hemisoleus muscle flap would be a reliable alternative in a healthy patient who is not a smoker. I would be cautious in using this flap in a smoker, because it has been my experience that tip necrosis of the flap may occur. However, tip necrosis of the distally based hemisoleus muscle flap can be débrided and the flap can be re-advanced to cover the defect, with ultimate success, as I described for patient 5 in my article.1
I am glad to know that Drs. Uraloğlu et al. also agree that the soleus muscle still remains a valuable option in selective cases for coverage of lower extremity wounds. The surgical procedure described in my article represents a more cost-effective approach for management of this complex problem, which is often related to orthopedic injuries.9 I will continue to refine my techniques with the soleus muscle flap for soft-tissue coverage in the distal third of the leg, so that a more cost-effective approach can be successfully developed to manage this complex clinical problem.
Lee L. Q. Pu, M.D., Ph.D.
Division of Plastic Surgery, University of Kentucky, Kentucky Clinic, K454, Lexington, Ky. 40536, firstname.lastname@example.org
1. Pu, L. L. Q. Successful soft-tissue coverage of a tibial wound in the distal third of the leg with a medial hemisoleus muscle flap. Plast. Reconstr. Surg.
115: 245, 2005.
2. Marek, C. A., and Pu, L. L. Q. Refinements of free tissue transfer for optimal outcome in lower extremity reconstruction. Ann. Plast. Surg.
52: 270, 2004.
3. Pu, L.L. Q., Medalie, D. A., Rosenblum, W. J., Lawrence, S. J., and Vasconez, H. C. Free tissue transfer to a complex wound of the lower extremity. Ann. Plast. Surg.
53: 222, 2004.
4. Hallock, G. G. Getting the most from the soleus muscle. Ann. Plast. Surg.
36: 139, 1996.
5. Hallock, G. G., Lutz, D. A., and Osborne, M. A. Non-operative estimation of the soleus musculotendinous junction using magnetic resonance imaging. Plast. Reconstr. Surg.
100: 896, 1997.
6. Beck, J. B., Stile, F., and Lineaweaver, W. Reconsidering the soleus muscle flap for coverage of wound of the distal third of the leg. Ann. Plast. Surg.
50: 631, 2003.
7. Tobin, G. R. Hemisoleus and reversed hemisoleus flaps. Plast. Reconstr. Surg.
76: 87, 1985.
8. Townsend, P. L. G. An inferiorly based soleus muscle flap. Br. J. Plast. Surg.
31: 210, 1978.
9. Thornton, B. P., Rosenblum, W. J., and Pu, L. L. Q. Reconstruction of limited soft tissue defect associated with open tibial fracture in the distal third of the leg: A cost and outcome study. Ann. Plast. Surg.
54: 276, 2005.
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