Tissue Coverage and Functional Reconstruction Outcomes With Use of Serratus Osteomusculocutaneous Free Flap in Lateral Malleolar Reconstruction: A Case Report

  • Ayhan Okumus
    Address correspondence to: Ayhan Okumus, MD, Private Aesthetic Plastic and Reconstructive Surgery Office, Ihsaniye Mah. Ilknur Sk. Bulvar 224 B Blok No: 1/B Kat: 6 D:10 Nilüfer, Bursa, Turkey.
    Private Aesthetic Plastic and Reconstructive Surgery Office, Bursa, Turkey
    Search for articles by this author
Published:September 18, 2021DOI:


      Currently, there is no ideal method defined in the repair of complex lateral malleolar defects, and the existing methods (i.e., bone repair, soft tissue or free flap closure) are far from producing functional results in terms of the ultimate recovery of ankle movements. Herein, an operative technique for soft tissue, ligamentous, and osseous reconstruction of fibular defect, using a free vascularized serratus anterior osteomusculocutaneous flap for reconstruction of a fibular deficit and the sixth costa for soft tissue coverage, was described in relation to tissue coverage and functional reconstruction outcome in a 31-year-old male patient with soft tissue and distal fibula defects in the lateral malleolus region caused by a traffic accident. Ankle movement was regained to almost full extent. No complications requiring further intervention was encountered in the donor site or ankle. In conclusion, the described operative technique enabled the repair of functional ligaments of the ankle joint in addition to repair of the soft tissue, lateral malleolus bone and skin defects in one session without the need for further additional operative intervention. Hence, the use of serratus osteomusculocutaneous free flap as a lateral malleolar reconstruction method seems to enable not only the tissue coverage but also to assist with functional reconstruction.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kılınç H
        • Bilen BT
        • Arslan A.
        A novel flap to repair medial and lateral malleol defects anterior tibal artery perforator-based adipofascial flap.
        Ann Plast Surg. 2006; 57: 396-401
        • Moscana RA
        • Ulmann Y
        • Hirshowitz B.
        Free composite serratus anterior muscle-rib flap for reconstruction severely damaged foot.
        Ann Plast Surg. 1988; 20: 167-172
        • Koshima I
        • Itoh S
        • Nanba Y
        • Tsutsui T
        • Takahashi Y.
        Medial and lateral malleolar perforator flaps for repair of defects around the ankle.
        Ann Plast Surg. 2003; 51: 579-583
        • Chen H
        • Yin G
        • Hou C
        • Zhao L
        • Lin H.
        Repair of a lateral malleolus defect with a composite pedicled second metatarsal flap.
        J Int Med Res. 2018; 46: 5291-5296
        • Taylor GI
        • Watson N.
        One-stage repair of compound legdefects with free, revascularized flaps of groin skin and iliacbone.
        Plast Reconstr Surg. 1978; 61: 494-506
        • Restrepo J
        • Katz D
        • Gilbert A.
        Arterial vascularization ofthe proximal epiphysis and the diaphysis of the fibula.
        Int J Microsug. 1980; 2: 49-55
        • Tanaka Y
        • Takakura Y.
        Osteoarthritis of the foot (in Japanese with English abstract).
        MB Orthop. 1995; 8: 63-72
        • Katsui R
        • Takakura Y
        • Taniguchi A
        • Tanaka Y.
        Ceramic artificial talus as the initial treatment for comminuted talar fractures.
        Foot Ankle Int. 2020; 41: 79-83
        • Yeoh JC
        • Jane C
        • Taylor BA
        • Brandon A
        Osseous healing in foot and ankle surgery with autograft, allograft and other orthobiologics.
        Orthop Clin North Am. 2017; 48: 359-369
        • Kiyokawa K
        • Tanaka S
        • Kiduka Y
        • Inoue Y
        • Yamauchi T
        • Tai Y.
        Reconstruction of the form and function of lateral malleolus and ankle joint.
        J Reconstr Microsurg. 2005; 21: 371-376
        • Spiro SA
        • Oppenheim W.
        Reconstruction of lower extremity after Grade III distal tibial injures using combined microsurgical free tissue transfer and bone transport by distraction osteosynthesis.
        Ann Plast Surg. 1993; 30: 98-104
        • Lin CH
        • Wei FC
        • Levin LS
        • Su JI
        • Fan KF
        • Yeh WL
        • Hsu DT.
        Free composite serratus anterior and rib flaps for tibial composite bone and soft-tissue defect.
        Plast Reconstr Surg. 1997; 99: 1656-1665
        • Lin CH
        • Yazar S.
        Revisiting the serratus anterior rib flap for composite tibial defects.
        Plast Reconstr Surg. 2004; 114: 1871-1877
        • Harii K
        • Yamada A
        • Ishihara K
        • Miki Y
        • Itoh M.
        A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses.
        Plast Reconstr Surg. 1982; 70: 620-629
        • Georgescu AV
        • Ignatiadis I
        • Ileana M
        • Irina C
        • Filip A
        • Olariu R.
        Long term results after muscle-rib flap transfer for reconstruction of composite limb defects.
        Microsurgery. 2011; 31: 218-222