J Reconstr Microsurg 2019; 35(07): 505-515
DOI: 10.1055/s-0039-1679955
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cross-Leg Flaps for Lower Extremity Salvage: A Scoping Review

Melody Scheefer Van Boerum
1   Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
Thomas Wright
1   Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
Mary McFarland
2   Eccles Health Sciences Library, University of Utah Health, Salt Lake City, Utah
Michelle Fiander
3   College of Pharmacy, University of Utah Health, Salt Lake City, Utah
Christopher J. Pannucci
1   Division of Plastic Surgery, University of Utah Health, Salt Lake City, Utah
› Author Affiliations
Further Information

Publication History

21 May 2018

14 January 2019

Publication Date:
05 March 2019 (online)


Background Lower extremity trauma with soft tissue loss presents a challenge to the reconstructive surgeon. Cross-leg flaps, first described by Hamilton in 1854, are still used to salvage traumatized lower extremities in patients not suitable for free tissue transfer, or those who are receiving care in locations with limited resources.

Methods A scoping review methodology was used to examine the evidence supporting the use of cross-leg flaps in modern healthcare.

Results There have been 409 cases of cross-leg flaps reported in the modern literature, with the majority of flap cases occurring outside the United States in Turkey, India, and Japan. The most common indication was trauma, mentioned in 93.2% of patients (n = 353 of 379), and anatomic limitation, including inadequate vasculature, was the main reason for not performing free tissue transfer (52.8% of patients; n = 170 of 322). The majority are cross-leg fasciocutaneous flaps (85.8%, n = 273 of 318), based off the posterior tibial artery (27.5%, n = 50 of 182) and peroneal artery (26.9%, n =  49 of 182) and, covering defects of the distal third of the leg (55.5%, n = 151 of 272), or the foot (27.9%, n = 76 of 272). The pedicles are typically divided at 3 weeks (mean 20.9 days) after external fixation is used as the immobilization method (57.7%, n = 184 of 319). Flap survival was 100% across all publications except one (n = 349 of 350 patients), making cross-leg flaps a robust and reliable reconstructive option.

Conclusion In resource-limited environments or in patients who are unsuitable for microvascular free tissue transfer, the cross-leg flap remains an impactful and reliable option for limb salvage.

Supplementary Material

  • References

  • 1 Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 2006; 117 (04) 1315-1322 , discussion 1323–1324
  • 2 Taylor GI, Daniel RK. The free flap: composite tissue transfer by vascular anastomosis. Aust N Z J Surg 1973; 43 (01) 1-3
  • 3 Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001; 108 (04) 1029-1041 , quiz 1042
  • 4 Lee KS, Park JW. Free vascularized osteocutaneous fibular graft to the tibia. Microsurgery 1999; 19 (03) 141-147
  • 5 Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower extremity reconstruction. Plast Reconstr Surg 2008; 121 (4, Suppl): 1-7
  • 6 Agarwal P, Raza H. Cross-leg flap: Its role in limb salvage. Indian J Orthop 2008; 42 (04) 439-443
  • 7 Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989; 29 (08) 1086-1094
  • 8 Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005; 8 (01) 19-32
  • 9 Joanna Briggs Institute. Checklist for Case Reports. 2017. Available at: http://joannabriggs.org/assets/docs/critical-appraisal-tools/JBI_Critical_Appraisal-Checklist_for_Case_Reports2017.pdf . Accessed July 28, 2017
  • 10 Moher D, Liberati A, Tetzlaff J, Altman DG. ; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (07) e1000097
  • 11 Ahn SY, Cho YK. Clinical application of posterior calf fascio-cutaneous pedicle flap in leprosy foot ulcer. Nippon Rai Gakkai Zasshi 1993; 62 (03) 99-110
  • 12 Basile A, Stopponi M, Loreti A, Minniti de Simeonibus AU. Heel coverage using a distally based sural artery fasciocutaneous cross-leg flap: report of a small series. J Foot Ankle Surg 2008; 47 (02) 112-117
  • 13 Fujimura T, Tomizuka Y, Fujita M. Cross-leg fillet flap for the reconstruction of severe bilateral leg burns. J Plast Reconstr Aesthet Surg 2009; 62 (10) e405-e408
  • 14 Lu L, Liu A, Zhu L, Zhang J, Zhu X, Jiang H. Cross-leg flaps: our preferred alternative to free flaps in the treatment of complex traumatic lower extremity wounds. J Am Coll Surg 2013; 217 (03) 461-471
  • 15 Garg R, Shah S, Uppal S, Mittal R, Thakur B. External fixator immobilised cross-leg flap- our experience. J Evol Med Dent Sci 2018; 32 (07) 3617-3619
  • 16 Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg 2003; 50 (05) 498-503
  • 17 Masoodi Z, Ahmad I, Khurram F, Haq A. Management of post road traffic accident compound leg defects using fasciocutaneous flaps. J Wound Care 2013; 22 (07) 376-378 , 380–382
  • 18 Hassan FO, Jabaiti S, El tamimi T. Complete subtalar release for older children who had recurrent clubfoot deformity. Foot Ankle Surg 2010; 16 (01) 38-44
  • 19 Manrique OJ, Bishop SN, Ciudad P. , et al. Lower extremity limb salvage with cross-leg pedicle flap, cross-leg free flap, and cross-leg vascular cable bridge flap. J Reconstr Microsurg 2018; 34 (07) 522-529
  • 20 Atiyeh BS. The cross-leg flap: a new perspective. Plast Reconstr Surg 1994; 94 (01) 223-224
  • 21 Atiyeh BS, Al-Amm CA, El-Musa KA, Sawwaf AW, Musharafieh RS. Distally based sural fasciocutaneous cross-leg flap: a new application of an old procedure. Plast Reconstr Surg 2003; 111 (04) 1470-1474
  • 22 Long CD, Granick MS, Solomon MP. The cross-leg flap revisited. Ann Plast Surg 1993; 30 (06) 560-563
  • 23 Otsuka T, Udagawa A, Kaoh F, Okamura T, Takeda H, Hamajima A. Reconstruction of adactyly for 4th and 5th toes: the study of foot pressure. Br J Plast Surg 1992; 45 (08) 610-613
  • 24 George A, Cunha-Gomes D, Thatte RL. Early division of pedicled flaps using a simple device: a new technique. Br J Plast Surg 1996; 49 (02) 119-122
  • 25 Jabaiti S, Salah B, Ababneh M, El-Hadidy S, Abu-Hassan F, Younes NA. Cross-leg fasciocutaneous flaps. Still a valid option for reconstruction of traumatic lower extremity defects. Saudi Med J 2006; 27 (10) 1609-1611
  • 26 Largey A, Faline A, Hebrard W, Hamoui M, Canovas F. Management of massive traumatic compound defects of the foot. Orthop Traumatol Surg Res 2009; 95 (04) 301-304
  • 27 Maajid S, Mir Gh R, Akbar S. , et al. Soft tissue reconstruction of open tibial fractures. JK Sci 2002; 4 (03) 123-129
  • 28 Memon A, Memon FA, Keerio NH. Functional outcome of fasciocutaneous flap used for soft tissue coverage for open tibia fracture (gustilo type IIIB), remote area hospital of Pakistan experience. Med Forum Monthly 2017; 28 (03) 71-74
  • 29 Tevanov I, Enescu DM, Bălănescu R, Sterian G, Ulici A. Negative pressure wound therapy (NPWT) to treat complex defect of the leg after electrical burn. Chirurgia (Bucur) 2016; 111 (02) 175-179
  • 30 Yildirim S, Akan M, Giderodğlu K, Aköz T. Use of distally based saphenous neurofasciocutaneous and musculofasciocutaneous cross-leg flaps in limb salvage. Ann Plast Surg 2001; 47 (05) 568-574
  • 31 Zgonis T, Cromack DT, Stapleton JJ. Utilizing a crossover reverse sural artery flap for soft tissue reconstruction of the plantar forefoot after a severe degloving injury. Int J Low Extrem Wounds 2007; 6 (02) 114-119
  • 32 Sharma RK, Kola G. Cross-leg posterior tibial artery fasciocutaneous island flap for reconstruction of lower leg defects. Br J Plast Surg 1992; 45 (01) 62-65
  • 33 Abdali H, Kachouei AA. Distally based sural fasciocutaneous flap and cross-leg method for soft tissue reconstruction of the distal leg, ankle, and hind foot defects. J Res Med Dent Sci 2017; 5 (04) 84-89
  • 34 de Almeida OM, Monteiro Jr. AA, Neves RI. , et al. Distally based fasciocutaneous flap of the calf for cutaneous coverage of the lower leg and dorsum of the foot. Ann Plast Surg 2000; 44 (04) 367-373 , discussion 373–374
  • 35 Macedo JLS, Rosa SC, Botelho DL, Santos CPD, Queiroz MN, Gomes TGACB. Lower extremity reconstruction: epidemiology, management and outcomes of patients of the Federal District North Wing regional hospital [Article in English, Portuguese]. Rev Col Bras Cir 2017; 44 (01) 9-16
  • 36 Georgescu AV, Irina C, Ileana M. Cross-leg tibial posterior perforator flap. Microsurgery 2007; 27 (05) 379-383
  • 37 Hudson DA, Millar K. The cross-leg flap: still a useful flap in children. Br J Plast Surg 1992; 45 (02) 146-149
  • 38 Kohli JS, Pande S, Bajaj SP. Large transverse fasciocutaneous leg flap: whole leg flap. Br J Plast Surg 2000; 53 (06) 495-498
  • 39 Ladas C, Nicholson R, Ching V. The cross-leg soleus muscle flap. Ann Plast Surg 2000; 45 (06) 612-615
  • 40 Li F, Zeng B, Fan C, Chai Y, Ruan H, Cai P. Distally based extended peroneal artery septocutaneous perforator cross-bridge flap without microvascular anastomoses for reconstruction of contralateral leg and foot soft tissue defects. J Reconstr Microsurg 2010; 26 (04) 243-249
  • 41 Eser C, Gencel E, Kesiktaş E, Kokaçya Ö, Yavuz M. A convenient flap for repairing the donor area of a distally based sural flap: gastrocnemius perforator island flap. J Plast Reconstr Aesthet Surg 2016; 69 (08) 1109-1115
  • 42 Giraldo F, García MD, de Grado J, González C, Rus JA. The injured foot: cutaneous coverage with a distally based posterior tibial cross-leg flap. Br J Plast Surg 1996; 49 (02) 115-118
  • 43 Kapadia A, Cheruvu VR, John JR, Tripathy S, Sharma RK. Reconstruction in pediatric orthopedic trauma: the role of primary cross-leg flap cover. J Pediatr Orthop B 2017; 26 (02) 172-178
  • 44 Mavili ME, Erk Y, Gürsu G. Use of a subfascial pocket on the contralateral calf for salvage of an avulsed foot. Plast Reconstr Surg 1993; 92 (01) 147-150
  • 45 Melikoglu C, Eren F, Kok D. Repair of pretibial atonic wound with long cross-leg flap. Int J Low Extrem Wounds 2013; 12 (03) 223-225
  • 46 Mooney III JF, DeFranzo A, Marks MW. Use of cross-extremity flaps stabilized with external fixation in severe pediatric foot and ankle trauma: an alternative to free tissue transfer. J Pediatr Orthop 1998; 18 (01) 26-30
  • 47 de Roche R, Vögelin E, Regazzoni P, Lüscher NJ. How does a pure muscle cross-leg flap survive? An unusual salvage procedure reviewed. Plast Reconstr Surg 1994; 94 (03) 540-543
  • 48 Demiralp CO, Akkaya H, Duman Y, Armangil M, Demirseren ME. Reconstruction of traumatic lower extremity soft tissue defects with the combination of ipsilateral and contralateral perforator flaps. Int J Low Extrem Wounds 2012; 11 (04) 304-306
  • 49 Duman H, Er E, Işík S. , et al. Versatility of the medial plantar flap: our clinical experience. Plast Reconstr Surg 2002; 109 (03) 1007-1012
  • 50 El-Sabbagh AH. Non-microsurgical skin flaps for reconstruction of difficult wounds in distal leg and foot. Chin J Traumatol 2018; 21 (04) 197-205
  • 51 Eser C, Kesiktaş E, Gencel E, Aslaner EE, Yavuz M. An alternative method to free flap for distal leg and foot defects due to electrical burn injury: distally based cross-leg sural flap. Ulus Travma Acil Cerrahi Derg 2016; 22 (01) 46-51
  • 52 Hill SM, Elwood ET. Pediatric lower extremity mower injuries. Ann Plast Surg 2011; 67 (03) 279-287
  • 53 Keklik B, Başaran K, Yazar S. , et al. Posterior tibial artery cross-leg perforator flap: a case report. Int J Low Extrem Wounds 2012; 11 (02) 77-79
  • 54 Li F, Cai P, Fan C, Zeng B, Chai Y, Ruan H. Distally based posterior tibial artery cross-bridge flap for reconstruction of contralateral leg soft tissue defects. J Reconstr Microsurg 2010; 26 (03) 159-164
  • 55 Newman C, Molnar JA. Achilles tendon reconstruction after electrical injury with a neurotized cross-leg fillet flap. Ann Plast Surg 2007; 59 (04) 447-450
  • 56 Nişanci M, Celiköz B, Duman H. Cross-foot island instep flap: a new use of instep skin flap for management of persistent wounds after complex plantar foot reconstruction. Ann Plast Surg 2001; 47 (02) 127-133
  • 57 Sood A, Khamsi B, Datiashvili R, Berberian WS. Use of cross-leg flap for wound complications resulting from open pilon fracture. Am J Orthop 2015; 44 (03) 131-134
  • 58 Thomas SJ, Altman DT, Lubahn JD, Hood JM. Cross-leg flap in a bilateral traumatic amputee. J Orthop Trauma 1996; 10 (07) 510-513
  • 59 Wang ZQ, Cao YL, Huang YF, Liu DQ, Li XF. Cross-leg repair of large soft-tissue defects in distal sites of the feet by distally based neuro-fasciocutaneous flaps with perforating vessels. Genet Mol Res 2014; 13 (03) 5484-5491
  • 60 Yokoyama K, Aoki S, Ohtsuka H, Boku T, Fukushima N, Itoman M. “Slipper-like avulsion injury” of the foot: a report of two rare cases salvaged by conventional cross-leg flaps. J Trauma 2005; 59 (05) 1239-1242
  • 61 Yoshimura M, Shimada T, Matsuda M, Hosokawa M, Imura S. A new method for repairing skin defects of the lower leg under unsatisfactory conditions: utilization of peroneal island flap from the opposite sound leg. Plast Reconstr Surg 1990; 85 (01) 123-126
  • 62 Zhou G, Zhang QX, Chen GY. The earlier clinic experience of the reverse-flow anterolateral thigh island flap. Br J Plast Surg 2005; 58 (02) 160-164
  • 63 Contedini F, Negosanti L, Fabbri E. , et al. Cross-leg as salvage procedure after free flaps transfer failure: a case report. Case Rep Orthop 2012; 2012: 205029
  • 64 Sano K, Ozeki S, Sugimoto I, Ogawa M. Three cross-leg flaps for lower leg reconstruction of Gustilo type III C open fracture. Indian J Orthop 2016; 50 (03) 331-334
  • 65 Gözü A, Ozyiğit T, Ozsoy Z. Use of distally pedicled sural fasciocutaneous cross-leg flap in severe foot and ankle trauma: a safe alternative to microsurgery in very young children. Ann Plast Surg 2005; 55 (04) 374-377
  • 66 Sharma GN, Nepram SS. Sural artery flap: a dependable solution in lower leg and foot soft tissue reconstruction. Int Surg 2001; 86 (03) 144-150