Eur J Plast Surg (1998) 21:290±292
P.G. Vico ´ R. Deraemaecker
Achilles tendon cover using a free lateral arm fascial flap
Received: 30 April 1997 / Accepted: 29 January 1998
P.G. Vico (
) ´ R. Deraemaecker
Department of Surgery, Institut Jules Bordet Tumor,
Center of the Free University of Brussels, 1, rue HØger-Bordet,
B-1000 Brussels, Belgium
Tel.: +32-2-374-1600; Fax: +32-2-374-3425
Abstract Cover of an exposed Achilles tendon is a rare
but difficult surgical problem. Two cases are presented
in which a free lateral arm fascial flap covered with a
split-thickness skin graft was used. The morbidity of the
donor site was very low, and the functional result was
good. Surgical techniques and results are presented.
Key words Achilles tendon ´ Flap
Exposure of the Achilles tendon is rare. It may be encoun-
tered after lower limb trauma with soft tissue loss, infec-
tion, failed tendon repair, or as a pressure sore. It is fre-
quently associated with vascular problems, such as dia-
betic arteriopathy or venous stasis. The possibilities for
local closure are usually very limited, difficult and unre-
liable. A free flap may be a good option, but muscular or
fasciocutaneous free flaps are usually too bulky for this
region. A fascial free flap covered with a skin graft may
provide the advantages of a free flap, i.e. cover of the ex-
posed tendon, preservation of a gliding surface for the
tendon, in addition to the ideal thickness required for shoe
Materials and methods
Two patients presenting with an exposed Achilles tendon were op-
erated on in September 1993 and in July 1994, respectively. The first
patient was a 51-year-old man, who was operated on for a right
Achilles tendon rupture. The plaster cast was removed after 6 weeks
and a pressure sore was seen in relation to the incision. The soft tis-
sue loss was 7.54 cm. The tendon was healed and non necrotic
(Fig. 1). Bacterial cultures samples were negative.
After wide surgical debridement, a reconstruction with a free lat-
eral arm fascial flap was performed. End-to-side anastomoses were
performed on the posterior tibial vessels. The flap was wrapped
around the tendon, and covered with a split thickness skin graft.
The patient had one minor complication, a seroma at the donor
site, which resolved after evacuations. The wound healed after
two weeks and he was discharged from hospital three weeks postop-
eratively. One month later, he was able to wear his usual shoes.
There have been no problems after 33 months follow-up (Fig. 2),
there was no donor site morbidity and a full range notion of flex-
ion/extension of the elbow.
A second patient, a 69-year-old man, was operated on following
a similar operative procedure for a single pressure over the left
Achilles tendon which appeared in relation to a stroke. The tendon
was intact and the soft tissue loss was 54 cm, with an undermined
area measuring 84 cm. Cultures of the area showed no bacterial
This patient died of a cardiac arrest on the second postoperative
day. The flap progressed uneventfully until his sudden and unex-
Anatomy and surgical procedure
The lateral arm flap was first described by Song et al.  in 1982,
and its anatomy and indications were confirmed by Katsaros et al.
. The flap is based on the posterior radial collateral artery, a ter-
minal branch of the deep brachial artery. This constant branch, with
a caliber suitable for microanastomosis, lies in the lateral intermus-
cular septum between the brachialis and the triceps muscles. It gives
off several branches to the skin of the lateral aspect of the arm, mus-
cular branches to the brachialis, triceps, and brachioradialis muscles,
and also branches supplying the humerus.
The flap is centered on a line drawn from the insertion of the del-
toid to the lateral epicondyle. This line marks the lateral intermuscu-
lar septum between the triceps and the brachialis muscles. The skin
incision is carried out along that mark, as a straight line, a lazy S
line, or a H. The skin flap is elevated posteriorly and anteriorly
above the muscular fascia, leaving a layer of fatty tissue on it.
The muscular fascia is incised according to the size of the defect,
and elevated until the lateral intermuscular septum is reached. There
is no size limit to this flap, and almost the entire brachial fascia may
be harvested. Previous cadaver studies showed the cutaneous area of
the lateral aspect of the arm that is vascularized by the posterior ra-
dial collateral artery varies in size from 810 to 1514 cm [3±5].
The thickness and the size of the flap are thus adaptable to most clin-
ical situations. The pedicle is easily identified within the lateral in-
termuscular septum and divided distally. The flap is elevated from
distal to proximal, until the origin of the pedicle is visualized, taking
care not to damage the radial nerve.