Case 19 2026: Split Perforator Flaps for bilateral ankle defects: A modern microsurgical approach to preserve function and reduce secondary thinning operations
Luisa Lotter¹, Marta Jezierska¹, Ilja W. Käch¹, Volker J. Schmidt¹1
- 1Hospital St.Gallen, St.Gallen, Switzerland
Abstract
Keywords: Lower extremity; Orthoplastic Reconstruction; Split flap; microsurgery Authors: Luisa Lotter¹, Marta Jezierska¹, Ilja W. Käch¹, Volker J. Schmidt¹; ¹Department of Plastic Surgery and Handsurgery, HOCH, Health Ostschweiz, Cantonal Hospital St.Gallen, St.Gallen, Switzerland Abstract 46-year-old man presented with two full-thickness soft-tissue defects of the distal right lower leg (medial 7 × 4 cm, lateral 10 × 5 cm) with exposed tendons, osteosynthesis material, and bone after a Gustilo grade IIIb open tibial and fibular fracture. During initial orthopedic stabilization, interdisciplinary orthoplastic assessment and planning were performed. Because of exposed functional structures and two spatially separated defects with healthy anterior skin between them, microsurgical free-tissue reconstruction was chosen to provide stable coverage while preserving the anterior skin and preventing flap-related functional impairment. Reconstruction was achieved using a split anterolateral thigh (ALT) flap based on two independent perforators, enabling simultaneous coverage of both defects with a single vascular pedicle. Patient medical history The patient’s medical history was significant for type 2 diabetes mellitus, two-vessel coronary artery disease, and obesity. Before and After Patient examination Clinical assessment revealed two full-thickness defects at the distal lower leg: • medial defect: 7 × 4 cm with exposed tendons • lateral defect: 10 × 5 cm with exposed bone and osteosynthesis material Both wounds showed non-viable soft-tissue components requiring radical surgical debridement prior to reconstruction. An CT-angiography was performed, revealing a regular three-vessel supply to the affected lower right leg. Preoperative color-duplex-ultrasound was routinely performed to identify the ALT perforator pattern and to verify, if a two-perforator split ALT-fashion is possible. Due to our tertiary orthoplastic program final interdisciplinary reconstruction was schedule
Donor site in anterolateral thigh (ALT) free flaps: A systematic review of closure techniques and introduction of a management algorithm Chang, Chad et al. Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 105, 243 - 259Split anterolateral thigh free flaps for bilateral open fracture ankle defects: A one donor, two flap solution, Wilson, Elizabeth et al. JPRAS Open, Volume 46, 2025, Pages 61-64
BeforeAfterThe patient’s medical history was significant for type 2 diabetes mellitus, two-vessel coronary artery disease, and obesity.
After removal of the negative pressure wound therapy (NPWT) dressing, the wound was thoroughly inspected, radically debrided, and sampled for microbiology. The osteosynthesis material was largely covered except for a small exposed segment. Concurrently, ligamentous and peroneal tendon reconstruction was performed to restore ankle stability. This ensured an adequately conditioned wound bed and a stable biomechanical environment prior to definitive microsurgical soft-tissue coverage.
Concurrently, ligamentous and peroneal tendon reconstruction was performed to restore ankle stability. Through an anterior longitudinal approach, the anterior tibial artery and its concomitant veins were identified and mobilized over a length of approximately 6 cm. Side branches were clipped, and the vessels were prepared for subsequent microsurgical anastomosis.
2
Simultaneously, a bipedicled anterolateral thigh (ALT) flap was harvested from the left thigh. The flap design was centered over the two dominant perforators to allow subsequent division into two equally sized skin islands (marked in green and blue). After fascial incision, two robust perforators with a long intramuscular course (approximately 12 cm) were identified.
The descending branch of the lateral circumflex femoral artery was dissected proximally to achieve adequate pedicle length and vessel caliber. Prior to flap transfer, perfusion of both distal flap segments was confirmed using indocyanine green angiography.
3
The pedicled flap was transferred to the lower-leg defect without torsion. Venous anastomoses were performed using a 2.0-mm coupler and an additional hand-sewn anastomosis to the two venae comitantes. An end-to-side arterial anastomosis to the anterior tibial artery was completed using interrupted microsurgical sutures (Dafilon 8-0). After systemic heparinization and clamp release, the flap demonstrated immediate and stable perfusion. The anastomotic site was reinforced with fibrin sealant.
The flap was subsequently divided between the two perforators, creating two spindle-shaped skin islands. One island was inset into the medial defect, whereas the second island was rotated to cover the distal lateral defect. Care was taken to avoid torsion or traction on both pedicles during inset.
4
Both flaps were trimmed and inset tension-free using interrupted sutures. Final inspection confirmed excellent perfusion of both components. The donor site was reconstructed with a partial resorbable mesh reinforcement of the fascial defect and primary skin closure with drainage.
5
• Strict limb elevation and bed rest were maintained for five postoperative days. Flap perfusion was monitored hourly for the first 24 hours and at regular intervals thereafter.
• A structured dangling protocol was initiated from postoperative day 5 to gradually condition venous outflow.
• The patient was immobilized in a custom splint with protected partial weight-bearing of 15 kg for six weeks due to the underlying osteosynthesis. A pressure-relieving recess was incorporated over the flap to avoid compression and prevent equinus deformity.
• Low-molecular-weight heparin anticoagulation and intravenous antibiotics were administered according to institutional microsurgical protocol and adjusted to microbiological results.
• Compression therapy was continued for six months, with scheduled outpatient follow-up at regular intervals.
How to cite this article
Luisa Lotter¹, Marta Jezierska¹, Ilja W. Käch¹, Volker J. Schmidt¹. Case 19 2026: Split Perforator Flaps for bilateral ankle defects: A modern microsurgical approach to preserve function and reduce secondary thinning operations. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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