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Hemisoleus Muscle Flap - Operative Steps

Overview & Indications

The hemisoleus flap uses the medial (or lateral) half of the soleus muscle for soft tissue coverage of the middle third of the leg (proximally based) or the distal third (distally based). It is the preferred local option when the gastrocnemius cannot reach and free flap transfer is not available or indicated.

Key advantage over whole soleus: Harvesting only half the muscle preserves plantar flexion strength and reduces donor morbidity significantly.

Surgical Anatomy

The soleus is a Type II muscle (Mathes & Nahai), with:

A dominant proximal pedicle from the popliteal artery (superior pedicle)
Middle pedicles from the posterior tibial artery (supply medial half)
Lateral pedicles from the peroneal artery (supply lateral half)
An inferior pedicle from the posterior tibial artery for distally based flaps

Soleus muscle anatomy - medial and lateral views showing gastrocnemius, soleus, posterior tibial artery and peroneal artery

Anatomy of the lower leg: soleus, gastrocnemius, posterior tibial artery and peroneal artery - Rockwood & Green's Fractures in Adults, 10th ed.

Coverage zones and vascular anatomy of hemisoleus flap variants

Figure 19-16 (Rockwood & Green's): A - Coverage zones: proximally based hemisoleus (middle third), whole soleus flap, distally based hemisoleus (distal third). B - Vascular anatomy showing superior, middle, and inferior pedicles supplying the medial hemisoleus.

Preoperative Planning

Patient position: Supine with the hip externally rotated and abducted, knee slightly flexed (a sandbag under the ipsilateral hip helps)
Tourniquet: Applied to thigh; helps identify pedicles during dissection
Anesthesia: General or spinal
Mark the incision: 2 cm posterior and parallel to the medial border of the tibia; the existing wound is incorporated into the incision proximally and distally
Doppler: Optional but useful to confirm perforators preoperatively

Step-by-Step Operative Technique (Medial Proximally Based Hemisoleus)

Step 1 - Skin Incision

Make a longitudinal skin incision 2 cm posterior to the medial border of the tibia, extending proximally and distally as needed. The incision runs parallel to the tibia through the deep fascia.

Step 2 - Identify and Mobilize the Gastrocnemius

Open the deep fascia in line with the incision. The gastrocnemius is the most superficial muscle. Identify the intermuscular plane between the medial gastrocnemius and the soleus. Blunt dissection with a finger or scissors develops this plane.

Retract the gastrocnemius posteriorly to expose the anterior surface of the soleus.

Step 3 - Identify the Midline Raphe of Soleus

The soleus has a distinct midline fibromuscular raphe separating the medial and lateral halves. This is the key landmark for splitting. Visualize it on the posterior face of the muscle.

Surgical exposure showing gastrocnemius flap planning, flap mobilization with preservation of saphenous vein (asterisk), and wound coverage steps

Intraoperative views: wound debridement and flap planning (left); mobilization of muscle flap with preserved neurovascular structures (asterisk, right) - Rockwood & Green's Fractures in Adults.

Step 4 - Separate Soleus from Deep Flexors

On the deep (anterior) surface of the soleus, develop the plane between the soleus and the deep flexors (flexor digitorum longus, posterior tibialis, flexor hallucis longus). This plane is relatively avascular. Continue this elevation from distal to proximal.

Step 5 - Identify the Vascular Pedicles

Perforators from the posterior tibial artery enter the medial half of the soleus along its medial border. Identify all perforators carefully:

Preserve as many perforators as possible to maximize flap vascularity
Only ligate the most distal perforators that restrict the arc of rotation
Preserve the dominant middle and superior pedicles

Step 6 - Split the Muscle Longitudinally

Using electrocautery, split the soleus along its midline raphe from distal to proximal. This divides the muscle cleanly into medial and lateral halves. The medial half forms the hemisoleus flap.

Step 7 - Distal Division

Divide the distal attachment of the medial half of the soleus from the Achilles tendon/calcaneus. This is done sharply, leaving a cuff if needed. The flap is now based proximally on the posterior tibial artery pedicles.

Step 8 - Test Arc of Rotation

Gently rotate the mobilized medial hemisoleus flap anteriorly toward the defect. Check that it reaches without tension. If arc of rotation is insufficient, carefully ligate one or two additional distal perforators to extend reach.

Step 9 - Transfer and Inset the Flap

Rotate the flap anteriorly (the medial route passes superficial to the tibia) to cover the tibial defect. The flap is tunnelled subcutaneously if needed. Inset with absorbable sutures (e.g., 2-0 Vicryl) anchoring the muscle to the wound edges.

Step 10 - Skin Graft

The muscle surface is covered with a split-thickness skin graft (STSG), typically harvested from the anterior or lateral thigh at 0.012-0.015 inch thickness. Apply the graft with tie-over bolster dressing or negative-pressure wound therapy (NPWT) to maximize graft take.

Step 11 - Donor Site Closure

The donor site (posterior medial leg) is closed in layers over a suction drain. The skin is approximated if possible; if not, a small STSG may be required.

Step 12 - Splinting / Immobilization

Apply an above-knee plaster of Paris (POP) slab or backslab for approximately 1 week to prevent skin graft loss due to shear from ankle movement.

Distally Based Hemisoleus (for Distal Third Defects)

The technique is similar except:

The proximal pedicles are ligated and the flap is based on the inferior pedicle from the posterior tibial artery
Reliability is reduced compared to the proximal variant - careful Doppler assessment preoperatively is mandatory
Not recommended in smokers or patients with peripheral vascular disease
The same exposure is used as for posterior tibial vessel dissection (useful as a bail-out if the flap proves unreliable - allows conversion to free flap on the same exposure)

Postoperative Care

Timepoint	Action
Immediate	Limb elevation, above-knee slab, wound monitoring
Day 5-7	First dressing change, check graft take
Week 1-2	Remove slab, initiate gentle mobilization
Week 6+	Weight bearing as permitted by fracture fixation

Key Points & Pitfalls

Do not sacrifice both the gastrocnemius AND the whole soleus in the same leg - this causes severe functional deficit
Zone of injury matters - if the pedicle has been crushed or the muscle belly is contused, the flap will fail; examine muscle actively bleeding and contractility under stimulation before committing
Arc of rotation is limited - best for defects directly over the middle third tibia; larger or more proximal/distal defects may need free tissue transfer
Preserve the saphenous vein during medial dissection
The flap has been shown to cover defects of varying size with high success rates (>90% in most series) and does not significantly impair ankle plantar flexion

Sources: Rockwood & Green's Fractures in Adults, 10th ed. 2025, Hemisoleus Muscle Flap study - JAMC 2009, PMC Lower Limb Salvage Case, Plastic Surgery Key - Soleus Flap

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