On “Use of Soleus Muscle Flaps for Coverage of Distal Third Tibial Defects” (J Reconstr Microsurg 2004;20:593-597)

In their article describing their series of soleus muscle flap reconstructions,[1] Kauffman and coauthors used a previous study[2] from our unit as a foil for their findings. I believe that the authors do not clearly present our findings or their own.

The authors note that we reported a “100 percent success rate using soleus muscle flaps for coverage of defects in the distal third of the lower extremity.” They should note that we used the soleus very selectively, and our success rate was based on eight of 28 patients treated for lower extremity defects. Twenty of the 28 patients underwent other reconstructions (including 14 microsurgical flaps). Our 100 percent success rate of soleus reconstruction in eight patients was therefore coincident with careful selection of patients for this procedure, and utilization of alternatives when soleus flap coverage did not seem optimal because of muscle damage or wound characteristics.

The authors then present their series with the intent of showing that the soleus flap is not a universally successful procedure for distal third lower extremity defects. This point should be an obvious one based on our paper and the general principals of lower extremity reconstruction.[3] The failures reported by the authors, however, do not so much show limitations of the soleus flap as demonstrate that these patients had problems beyond the scope of flap reconstruction. One patient had arterial insufficiency of the affected lower extremity. A soleus flap cannot treat arterial insufficiency. A second patient underwent late below-the-knee amputation (with a closed wound) because of complications of radiation therapy. A soleus flap cannot treat late radiation-related scarring and contractures. The third patient underwent amputation (with a closed wound) because of failure of the underlying skeletal reconstruction. A soleus flap cannot treat a failed skeletal reconstruction. Two of these three patients actually had closed wounds at the time of amputation, so the soleus flaps succeeded as soft-tissue coverage.

The authors state that on the basis of their study, “we would emphasize that patients with trauma and with comorbid conditions represent a relatively high-risk population for this type of soft tissue coverage, and free flap coverage is likely a better choice under these circumstances.” This statement makes no sensible point related to the authors' cases. A free flap cannot treat a leg wound based on arterial insufficiency, late radiation complication, or a failed skeletal reconstruction any better than a soleus flap.

Our presentation of soleus flap reconstruction was made within the context of our overall strategy for treatment of distal third of the leg defects. Our strategy included careful analysis of the lesion, careful patient evaluation (including angiography when vascular injury was a possibility), and ready use of other procedures (including microsurgical flaps) when a soleus reconstruction did to appear likely to succeed. Within this context, our soleus success rate was 100 percent, but this success was based on highly selective use.

Kauffman and his coworkers are not presenting limitations of the soleus flap in their paper. They are reporting failure related to untreated or untreatable associated lesions and progressive radiation complications; therefore, they are reporting problems of patient selection and disease progression that set limits on the likelihood of success of any method of flap reconstruction. Their report does not offer any specifically useful information about soleus flap use.

REFERENCES

• 1 Kauffman C A, Lahoda L, Cederna P S, Kuzon W M. Use of soleus muscle flaps for coverage of distal third tibial defects.  J Reconstr Microsurg. 2004;  20 593-597
• 2 Beck J B, Stile F, Lineaweaver W C. Reconsidering the soleus muscle flap for coverage of wounds of the distal third of the leg.  Ann Plast Surg. 2003;  50 631-635
• 3 Gayle L B, Lineaweaver W C, Oliva A et al.. Treatment of chronic osteomyelitis of the lower extremities with debridement and microvascular muscle transfer.  Clin Plast Surg. 1992;  19 895-903