Leg Defects Research Articles

Post road traffic accident one-month old, extra-large heel defect coverage by delayed reverse sural artery flap: an interesting case report

Post road traffic accident (RTA) complete heel avulsion injury is not very common, but once it happened, it is very challenging to plastic and reconstructive surgeon to reconstruct the total heal avulsion defect. There is paucity of soft tissue in the region of foot, ankle and lower one third of leg. Although the micro vascular free flap reconstruction is gold standard for reconstruction of large heel defect but not feasible most of the time. Reverse sural artery flap (RSAF) is a workhorse flap for reconstruction of heel and lower 1/3rd leg defect. Here we reported a case of 28 years old young man, who had road traffic accident and sustained complete right heel avulsion injury with calcaneal and right tibia bone fracture. Patient was presented to author one month later after the injury with extra-large infective right heel defect size 15×12 cm with k-wires in exposed calcaneal bone. Patient’s surgery was done in two stages. Delayed RSAF survived completely and well settled in our case.

A Thin and Short Muscle Flap Acted as a Savior for A Child’s Calcaneal Defect: A Case Report

Managing, a distal leg defect is reconstructive challenge for any plastic surgeon. With the advent of microsurgery, the work hose flap for this area shifted from cross leg to free and local perforator flaps. Children with such defects pose a bigger problem because of smaller caliber of vessels, difficult immobilization and poor compliance. We, hereby, report a case of a 12 year old child who had an exposed distal half of calcaneum, which warranted a cross leg or free flap, but was managed successfully by distally based peroneus brevis muscle.

THE APPLICATION OF THE DISTAL POSTERIOR TIBIAL ARTERY PERFORATOR FLAPS IN CHRONICS WOUNDS

INTRODUCTION: The reconstruction of lesions in the distal third of the leg is one of the challenges for surgeons. In this scenario, the use of posterior tibial perforator flaps is being used more and more in surgical practice due to their versatility and aesthetic results. MATERIALS AND METHODS: This research consists of an integrative review carried out from a bibliographic survey in the PUBMED and Virtual Health Library (BVS) search platforms. After reading the full 20 articles in total, an overlap of four articles present in the two searches was observed, thus resulting in a total of 16 articles included in this review. RESULTS: The treatment of chronic lower limb wounds caused by infection, diabetes mellitus and osteomyelitis has always been a formidable task. Perforator-free flaps are generally recommended as the therapy of choice in the treatment of chronic lower limb wounds. DISCUSSION: The advantages of the application of the posterior tibial artery skin flap is ideal for small leg defects to reconstruct the exposed bone and tendon. As it is local tissue, it substitutes as tissue. The distal posterior tibial artery perforator flap is a beneficial technique, in the plastic and reconstructive surgery field, especially for the treatment of chronic lower extremity wounds. Keyword : CHRONIC WOUNDS, DISTAL POSTERIAL TIBIAL ARTERY, PERFORATOR FLAP, PLASTIC SURGERY

Modified S-Reinforced Suture in Dermatologic Surgery: A Novel Alternative for Lower Leg Defects

Modified S-Reinforced Suture in Dermatologic Surgery: A Novel Alternative for Lower Leg Defects

Efficacy of the Free-Style, Perforator-Plus Flaps in the Reconstruction of the Soft Tissue Defects at the Lower Leg and Ankle Regions

ABSTRACTBackground: Reconstruction of the lower leg and ankle soft tissue defects is not that the convenient task, due to the unique anatomy and its variation. Aim of Study: Evaluation efficacy of the Free-Style, Perforator-Plus flap concepts in the reconstruction of the soft tissue defects at lower two-thirds leg, tendo-Achilles and ankle regions.Method: A Prospective (Case Series) Study, was carried on 20 consecutive patients, which performed at the Plastic and Reconstructive Surgery Unit, of General Surgery Department, of Benha University Hospitals, and Department of Plastic and Reconstructive Surgery at Nasser Institute for Research and Treatment in the period from June 2020 to June 2021. Results: 20, consecutive, exclusively males, patients, aged from 3 to 57 years old (Mean 28 ± 12 SD years), had a “Free-Style, Perforator-Plus Flap” reconstructive surgery, to cover defects presented at lower Leg two-thirds (75% of cases), Tendo-Achilles (10%) and Ankle (15%) regions. Flap complications were encountered in 4 cases (20%): 2 cases (10%) had distal congestion, the other 2 cases had distal ischemia, which one of them developed full-thickness distal loss. The final recipient outcome “Defect Coverage” was achieved in all cases (100%). Conclusion: The Free-Style, Perforator-Plus Flap is reliable with relative efficiency, versatile, and has a modest rate of failure and need for secondary surgery. It capable to reconstruct small to relatively large, complex defects (exposed bone or hardware and chronic osteomyelitis) in the distal Leg two-thirds, Tendo-Achilles, and Ankle regions.

Keystone Flap with Omega Variation and Sydney Melanoma Unit Modification to Cover Small- and Moderate-Sized Defects in the Anterior Lower Leg

Background: Covering a small defect on the anterior lower leg is challenging because less soft tissue is available. This study presents the application of a keystone flap (KF) with omega variation (OV) and Sydney melanoma unit modification (SMUM) for small- and moderatesized pretibial defects.Methods: This study included a series of six cases of anterior lower leg defect reconstruction with OV and SMUM KF technique by a single surgeon between December 2017 and June 2020. Records and photographs of the patients were collected and analyzed.Results: The defects’ sizes ranged from 1.5×2.5 to 6×8 cm. All defects were covered with OV KF, SMUM KF, or OV SMUM KF based on the hotspots of surrounding perforators. The flap sizes varied from 3×6 to 8×17 cm. Moreover, all flaps were completely viable. A marginal maceration developed in one case, which was mended with conservative dressing. Outcomes were favorable in all patients during the average follow-up period of 4.83±1.17 months.Conclusion: This study successfully covered small- and moderate-sized anterior lower leg defects with OV and SMUM KF. We therefore suggest the OV and SMUM KF techniques as good alternative modalities for anterior lower leg reconstruction.

Distally Based Medial Hemisoleus Muscle Flap for reconstruction of distal and middle third leg defects.

Background: Coverage of distal leg defects is quite challenging. Usually, free tissue transfer is used for the reconstruction of such defects. Lack of microsurgical team/setup or patient contraindication to undergo a lengthy procedure would divert the decision to local tissues for coverage typically using local fasciocutaneous/propeller flaps or muscle flaps. Also, those local flaps options would be the first choice for relatively small defects, with plenty of healthy tissue available for coverage. If a local fasciocutaneous flap is not feasible or desired, the distally based medial hemisoleus flap is a common reliable alternative for reconstruction of middle and/or distal third leg defects of small to moderate size. In the current series, relatively larger defects were successfully reconstructed using this flap. Intraoperative confirmation of the adequacy of the explored flap distal pedicle underly the reported high flap survival rate. PATIENTS AND METHODS: The study enrolled 13 cases (12 male & 1 female) with distal and/or middle third leg defects. Patients' age ranged from 12–51 years age (mean 37 years), with defect sizes ranging from 3.5x5cm (17.5cm2) to 8x10cm (80cm2) with a mean of 41cm2. Distally based medial hemisoleus flap was used to reconstruct all cases, based on its distal pedicle(s) from the posterior tibial vessels. A split thickness skin graft was used to cover the muscle typically one week later in a second procedure. RESULTS: All flaps survived completely except partial-thickness surficial flap necrosis in one case. This was conservatively managed by debridement and later skin grafting. All cases achieved complete healing of their wounds with successful limb salvage. CONCLUSIONS: Intraoperative confirmation of distal medial hemisoleus flap pedicle would ensure better flap survival and would allow safe reconstruction of moderately large distal leg defects in selected cases with appropriate distal pedicle size and location.

Versatility of Reverse Sural Artery Flap (RSAF) in management of lower limb defects: Our experience

Background: Wounds around the lower 1/3rd of leg and foot are difficult to manage. Treatment options like skin grafting, healing by secondary intention can result in an unstable scar. Free tissue transfers and Regional flaps has its own disadvantages. To circumvent these difficulties a fasciocutaneous flap harvested from sural angiosome was proposed. In this study, we have made an attempt to find out different scenarios in which this flap can be used as a management option and ways to minimize the complications associated with this flap. Methods: A retrospective observational study was conducted over 2 years. 30 patients were studied. Patient details was obtained from the case record, operative notes and postoperative follow-up.Results: Patients between the age of 10 years to 65 years were studied. RSA flap with adipofascial pedicle and fasciocutaneous pedicle was done in 21 and 9 patients respectively. Delaying of flap was done in 9 patients, with most common indication as distal defect. Common site of defect which were reconstructed was on the Tendoachilles region, Heel region. Various complications were loss of graft used to cover adipofascial pedicle, Venous congestion, hematoma formation and partial skin necrosis of the flap. None of the patients complained of any effect on routine activity during postoperative follow up.Conclusion: It is a versatile flap and different scenario can be managed with customization in plan. With proper selection of patients, it can be judiciously used to manage different leg defects.

Cross-leg Ilizarov limb-salvage technique for management of combined bone and soft-tissue distal tibial defect: a case series

Background: Management of concomitant distal tibial bony and soft-tissue defects is still a major challenge for both orthopaedic and plastic surgeons. A cross-leg flap can be used as an alternative solution, particularly when the microsurgical free flap is not a feasible or applicable option. The proposed modified bilateral Ilizarov frame with cross-connection bridges provides stability to the construct and treats both soft-tissue and bone defect. Methods: Seven patients presented with combined posttraumatic bone and soft-tissue defects in the distal part of the leg. The defects were managed by cross-leg soft-tissue flap through two-stage procedures. Ilizarov external fixators were used for fixation of both legs to provide stability to the crossing soft-tissue flap and for bone segment transfer to manage bone defects at the same time. Results: In all patients, the soft-tissue flaps were successfully taken 3 weeks postoperatively. In six patients, bone segment transfer took 9 to 12 mo to unite. One patient had defects in the distal tibia and talus that needed further ankle fusion after the completion of segment transfer. In one patient, bone marrow injection was used to enhance the union, and residual osteomyelitis and nonunion were the end results in one patient. Conclusions: The modified cross-leg Ilizarov technique is shown to be an effective and appropriate method in simultaneous management of combined bone and soft-tissue defects in the distal leg. Level of Evidence: Level IV.

Reverse flow cross leg sural flap as a reconstructive option for traumatic defects in the lower leg circumventing free flaps

Very few flaps described in the literature would be as versatile as the reverse sural flap. In spite of its few shortcomings, it is one of the most widely used flaps for lower third defects in the leg because of the paucity of tissues in the region. In a lot of situations, free tissue transfer is the only feasible option because of non-availability of local options in the involved limb. In such a scenario, a reverse sural flap from the contralateral leg can be manoeuvred in a cross leg fashion as an alternative to free flap. It employs skin and soft tissue from the opposite limb which can easily cover large defects in the lateral malleolar and tendoachilles region which would be unachievable with a traditional cross leg flap. A prospective study was developed from September 2018 to March 2020 at SMS Hospital, Jaipur. A total of 10 patients underwent flap cover. Rigid fixation with the help of external fixator was used to prevent flap avulsion, and flaps were divided at 3 weeks. All cases were done in 2 stages, fixed with external fixator and divided at 3 weeks. All 10 flaps survived without any flap failure. One flap had ischaemic changes in the distal most part of the flap which was later debrided and flap advanced to cover the defect. Successful coverage of defect was achieved in all 10 patients, and donor site healed uneventfully. In our experience, a reverse flow cross leg sural flap is a significant option for leg defects where there is a paucity of nearby tissues for stable flap cover and as an alternative to free flap. It is an excellent option for covering large defects over the lateral side of the leg where a traditional cross leg flap cannot reach. It can also circumvent the use of free flaps in patients who cannot undergo a long duration surgery. The relative simplicity of this flap makes it a very useful flap for large defects of the lower third of leg. Level of evidence: Level IV, therapeutic study.

Use of Perforator Propeller Flaps for Coverage of Soft issue Defects Around The Distal Leg and Ankle

Introduction: Perforator propeller flap is a suitable option to cover soft tissue defects in the distal leg and ankle which preserves the main vascular arteries of the lower extremity and muscle function. The aim of this study is to evaluate the use of perforator propeller flaps for coverage of soft tissue defects around the distal leg and ankle.
 Methods: This prospective study was donebetween December 2018 to November 2019in the Department of Burn & Plastic Surgery of National Institute of Traumatology and Orthopedic Rehabilitation ( NITOR), Dhaka. Total 32 patients with small to medium sized soft tissue defect over distal leg and ankle underwent reconstruction with perforator propeller flaps. Sixteen patients had defect over tendo achilles area, 6 had defect over lateral malleolus,7 over medial malleolus and medial aspect of distal third leg and only 3 had defect in front of ankle. Average Flap length and width were 12.72 (+4.19) & 5.63 (+1.78) cm respectively. Flap rotation was measured 180 degrees in 84.37% of the cases. The propeller flaps were based on a single perforator and it was observed from the posterior tibial artery in 62.5% and peroneal artery in 37.5% of the cases.
 Results: 81.25% of the flaps completely survived. Total flap loss was observed in one case (3%) while partial flap loss occurred in 6.2% cases. Marginal flap necrosis and epidermolysis were observed in 6.2% and 3% cases respectively.
 Conclusions: Propeller flapshavereliable vascular pedicle as well as greater freedom in design and arc of rotation that extend the possibility ofreconstructing difficult wounds with local tissues and minimal donor-site morbidity.
 J Bangladesh Coll Phys Surg 2021; 39(2): 87-93

A STUDY ON DIFFERENT SURGICAL OPTIONS OF LOWER THIRD LEG DEFECTS AND ITS OUTCOME

Background: The bones of the lower third are vulnerable to injury. Due to the paucity of soft tissues around them, the fractures that occur are often open. Most muscles become tendons at that level and in the case of soft tissue loss, skin graft may not sufce and flap cover becomes mandatory. Conventional teaching recommends gastrocnemius muscle and myocutaneous aps and fasciocutaneous aps for the upper third leg defects, soleus aps for the middle third defects and free aps for the lower third defects. Aim: Different surgical options in management of lower third leg defects. Material And Method: The study was conducted from JANUARY 2018 to December 2019, in the Department of Plastic & Reconstructive Surgery Institute of Post Graduate Medical Education and Research (IPGME&R) and SSKM Hospital, KOLKATA. Result: 70 patients admitted to the Department of Plastic & Reconstructive Surgery and referred patients from Department of General Surgery & Orthopaedic Surgery, IPGME&R and SSKM Hospital, KOLKATA. Association of FLAP LOSS with Pedicled ap was statistically signicant (p=0.0259). We found that association of DONOR SITE MORBIDITYwith Pedicled ap was not statistically signicant (p=0.7679). Conclusion: We consider that perforator propeller aps are ideal in reconstructing small-medium defects of the middle and distal third of the leg, being safe, easy to perform, providing similar tissue in texture and thickness of damaged tissues, with low donor-site morbidity.

Perforator-based propeller flap for coverage of lower leg: Single centre experience.

This study was conducted to assess outcomes of propeller flaps for reconstruction of small- to medium-sized defects in the distal third of the leg. Of 53 lower third leg defects covered using the propeller flap, 43 survived without complications. Only minor complications were seen and no flap was lost completely. The propeller flap is thus a safe option for medium-sized defects of the lower leg.

Lower limb salvage in patients older than 75 years old affected of soft tissue sarcoma: beyond the limits

Microsurgical procedures were initially believed to be feasible only in younger patients. On the one hand, operative times may be prolonged, and on the other, older patients usually present with other comorbidities. However, without the option of microsurgical reconstructive procedures, the only curative treatment for patients with bone and soft tissue sarcomas in the lower extremity is limb amputation. This was a retrospective observational study of two cohorts of patients (group A, > 75 years old, n = 20; and group B, < 75 years old, n = 21) to compare their outcomes after lower limb salvage surgery. Selection criteria included all patients who underwent free flap reconstruction after sarcoma resection in the lower limb between 2017 and 2019. Exclusion criteria included smoking, severe comorbidities, inability to ambulate, or inadequate vessels in the preoperative image studies. Length of stay, complications, and rates of flap failure, recurrence, and amputations were compared. Average age, BMI, and presence of other comorbidities for groups A and B were 80 and 61 years old, 26 and 24 kg/m2, and 50 and 45%, respectively. Most patients (53%) had leg defects and were reconstructed with an ALT flap (60%) anastomosed to the anterior tibial artery (60%). Flap failure was observed in one group A patient. The average surgical time was 9 h. The patients followed 10 days of total bed rest and a dangling protocol was started on day 11. The mean hospital stay was 16 days and patients underwent physical therapy afterward. Postoperative surgical and medical complications in groups A and B occurred in 7/20 and 2/21, and 5/20 and 5/21 patients (25%), respectively. Age or ASA status had no effect on the incidence of complications. Radiotherapy was given postoperatively in all patients. At 1-year follow-up, all patients were alive; 27% had a recurrence or metastatic disease. The amputation rate was 25% and 0% in groups A and B, and was the only variable that reached statistical significance (p = 0.021). Based on our findings, limb salvage surgery can be performed successfully in selected old patients with lower limb sarcomas. It should be considered as a treatment option in this group of patients as it offers a safe alternative to amputation with an acceptable risk of complications, good flap success rates, and functional outcomes. Level of evidence: Level III, therapeutic; risk/prognostic study.

Peroneus Brevis Muscle Flap as a Tissue Cover for Defect over Lower Mid Leg and Ankle Defects: A Case Series

Mid leg and ankle area are more vulnerable for post-traumatic full thickness soft tissue loss. Implants used in osteosynthesis in this region are also at risk of exposure as its placement is in subcutaneous plane as well as precarious blood supply in shin region. Various options like local flap to free flap are described for reconstruction of small and medium size defects in this region. Peroneus brevis is also well described in literatures. In this case series which was done over the period of six years that includes 10 patients with post-traumatic as well as post orthopaedics surgical intervention defects in lower mid leg and ankle region. Patients were selected for proximally and distally based peroneus brevis muscle flap according to the location of defects. Data regarding age, sex, aetiological factor, size of defect, type of flap, survival of flap, donor site complications were recorded. Out of 10 patients, eight were males and two were females. Major aetiological factor was two wheeler road traffic accident. Majority of the patient had orthopaedic surgical intervention for fracture fixation prior to or along with flap surgery. Only one patient, in this series had marginal flap necrosis. Rest of flaps survived well without any donor site complications. In authors experience peroneus brevis muscle flap is dependable for medium size defects over lower leg and ankle.

Use of Adipofascial Reverse Sural Artery Flap for Distal Leg and Ankle Region Reconstruction- A Prospective Cohort Study

Introduction: Though distally based sural artery fasciocutaneous flap is a good choice for distal leg and ankle reconstruction, shortcomings like venous congestion and flap bulkiness are matters of concern. Aim: To assess the utility of adipofascial flap for distal leg and ankle reconstruction, complications, and long-term functional results with range of motion at ankle joint. Materials and Methods: A prospective cohort study (January 2018 to December 2019) was conducted at Safdarjung Hospital, New Delhi, India on patients having distal leg defect and ankle defects reconstructed with Distally Based Sural Artery Adipofascial Flap (DBSAAF). Participants of any age and aetiology were included in the study while polytrauma patients, life-threatening injuries, mangled extremity patients were excluded. Postoperatively flap survival, complications and functional outcome were assessed. Results: Total 21 patients with above defects had undergone DBSAAF reconstruction. Fifteen (71.4%) patients were males and 6 (28.6%) were females, with mean age of 34.85 years. Causes of defect were road traffic injury in 6 (28.6%) patients, additional Tendoachilles tear was repaired in 5 (23.8%) patients. Four (19%) patients had avulsion injury, 3 (14.3%) patients had postburn unstable scar, and chronic ulcer was found in 3 (14.3%) patients. The maximum defect size was 8.5×7 cm (mean of 5.24×4.34 cm). The width of flap pedicle was kept at 4 cm maximum (mean=3.04 cm). All flaps were transported to the defect site by incising the intervening bridge, tunneling was not done. Fourteen patients did not have any co-morbidity, whereas four patients were chronic smokers, and three were diabetics. Flap survived completely in all patients. Three patients had partial graft loss and one patient had chronic discharge. Follow-up for maximum of six months (mean=4.04 months) were done. Conclusion: DBSAAF is a reliable flap for defects of distal leg and ankle region. Advantages are aesthetically better donor area, normal contour, and minimal scarring. It does not require a secondary debulking making it a one stage procedure and allowing patients to use their normal footwear.

Reconstruction of Tibia Fracture With Soft Tissue Defect.

We aimed to compare different methods to treat lower leg soft tissue defects with tibia fracture using free flaps and pedicled flaps. We also highlighted the aesthetic outcome after using 1-stage secondary debulking procedure for tibia area. From December 2000 to March 2017, 83 patients with lower leg defects and tibia fractures were reconstructed using 71 free flaps and 12 pedicled flaps. One-stage secondary debulking procedures were performed for 39 patients after flap reconstruction. Infection control and aesthetic outcomes using 5-point Likert scale were reviewed after a 16-month follow-up. Twenty-five myocutaneous free flaps, 45 fasciocutaneous free flaps, 1 fibula free flap, 12 pedicled flaps of which 8 were distally based sural artery flaps, and 4 medial gastrocnemius flaps were used. The flap survival rate was 100%. There was no recurrence of osteomyelitis in any patient after reconstruction with any of these flaps. Using a 5-point Likert scale, performance of a 1-stage secondary debulking procedure showed statistically significant difference in terms of contour, color, and texture compared with the group without debulking procedure. The use of free flaps and pedicled flaps in the reconstruction of lower leg defects with tibia fracture is reliable and results in good infection control. A 1-stage secondary debulking procedure delivers excellent long-term aesthetic outcome after reconstruction of the tibia area.

Propeller flap: Orthoplastic approach for coverage of distal leg and ankle defects

BackgroundCovering soft tissue defects of the distal one-third of the leg and the Achilles tendon region and is a challenging problem for an orthopedic surgeon. With recent advancements in the anatomical knowledge of perforating vessels, perforator-pedicled propeller flaps have become increasingly popular in recent decades. We aimed to evaluate the clinical outcomes of our patients whose soft tissue defects in the distal leg were reconstructed with propeller flaps and assessed association of complications with age, gender, flap size and arc of rotation. MethodsPatients that had a reconstruction with a propeller flap at the ankle from 2013 to 2019 were retrospectively reviewed. The main indications for the propeller flap were small- and medium-sized soft tissue defects of the distal lower limb. 20 propeller flaps were applied to 19 patients (14 male, 5 female) for various lower extremity defects. ResultsThe mean follow-up duration was 2 years (range, 6 months to 6 years). The average flap size was 82 cm2 (range, 48–125 cm2). The flap was rotated 180 degrees in nine patients The source of the perforator vessel was the tibialis posterior artery in 14 cases, the peroneal artery in 4 cases, both the tibialis posterior and peroneal arteries in 1 case. Four complications (20 %) occured postoperatively. Two patients developed partial necrosis at the tip of the flap, and two patients developed superficial epidermolysis. No correlations were found between complications and flap size and the arc of rotation. ConclusionsThe propeller flap is a reliable option for reconstruction of small to moderate defects in the lower extremity with good clinical results and minimal donor-site morbidity. It is applicable for orthopedic surgeons who do not have microsurgical experience or an available microscope in the operating room.

MODIFIED SURAL FLAP TO COVER DISTAL LOWER LIMB SOFT TISSUE DEFECTS

The purpose of this study was to evaluate the outcomes of coverage of soft tissue defects of leg and foot by sural flap with preserving a lane of skin over the pedicle (cutaneous pedicle) with open passage between donor and recipient sites. A proscriptive study including thirty-six patients with distal lower limb soft tissue defects was carried out in the period between June 2018 and June 2019 at Sohag University Hospital. All these 36 patients underwent modified sural flap with preserved lane of skin over the pedicle with open passage for the pedicle between donor and recipient sites. Evaluation of viability of the flap, resistance against infection, healing of the flap, donor site healing and weight bearing, postoperative follow up to nine months. Group of patients including thirty-six patients with distal lower limb soft tissue defects underwent modified sural flap, the indication for flap cover was Motor car accident in 26 cases (72.2%) and exposed plate was in 6 cases (16.7%) crushing trauma was in 4 cases (11.1%). Infection were the common complications encountered Six cases (16.7%) three cases (8.35%) complicated by distal ischemia and One case (2.8%) was totally lost with increase in the flap viability with modified sural flap. Modified sural flap by preserving alane of skin over the pedicle and open passage between donor and recipient site increase venous return of the flap and increase flap viability.

Combined Tissue Transfer for Extensive Lower Limb Complex Defects: Flow-through Flaps, Chimera, and "Orochi" Flaps.

Perforator flaps can be raised anywhere in the body, with minimal donor-site deformity, and can be made into custom-made combined composite flaps, especially for severe complex defects such as osteomyelitis of the lower limbs. Here, we report on the representative application of the combined tissue transfers for complex leg defects. For a wide range of complex defects in the lower extremity, it is necessary to perform reliable revascularization by bypass or flow-through type or vein graft. At the same time, a chimeric or "Orochi" type combined transfer using a minimally invasive perforator flaps and a well-vascularized bone flap are useful. In the case of nerve palsy, it could be possible to combine vascularized nerve flaps. Combined tissue transfers with less invasive donor will be more available in the future.