soft - tissue defects around the knees are common problems in the victims of trauma , post - operative wound or after arthroplasty and excision of various lesions , which is usually associated with bone and implant exposure . currently , various reconstructive options available are gastrocnemius flap , sural fasciocutaneous flap , and saphenous flap . these flaps are harvested from the leg , which is usually involved in traumatized lower limb . in this series , therefore , inferiorly based thigh flap has been used , including anteromedial thigh fasciocutaneous flap and anterolateral thigh ( alt ) fasciocutaneous flap in 16 patients having soft - tissue defects around the knee joint for the coverage . lu et al . first confirmed the presence of at least one supragenicular fasciocutaneous perforator within 3 cm above the adductor tubercle . this perforator arises from the saphenous branch of the descending genicular artery , which accompanies two venae comitantes . inferiorly based anteromedial thigh fasciocutaneus flap can be taken from anteromedial aspect of thigh , which survives on supragenicular fasciocutaneous perforator . in 1990 , hayashi and maruyama have reported the inferiorly based alt fasciocutaneous flap based on the perforators of the lateral superior genicular artery ( lsga ) for reconstruction of defects around the knee , popliteal region , lower third of the thigh , and upper one - third of the leg . due to variable pathway of its pedicle , this flap was not used widely at that time . since its description , it was found in these publications that this flap can be very useful for soft - tissue coverage around knee joints . to the best of our knowledge , no publications are found that focus on simultaneous use of both inferiorly based anteromedial and anterolateral thigh flap for the reconstruction of defects around the knee joint . this leads to a more versatile use of inferiorly based thigh flap . in this series , we present our clinical experience with the use of inferiorly based thigh fasciocutaneous flap for the reconstruction of defects around the knee joint in 16 patients . these flaps have been potentially useful and advantageous for the coverage of these difficult regions . the sites of the soft - tissue defects included patellar region , infrapatellar region , upper one - third of leg , lower thigh , and over the knee joint [ table 1 ] . the aetiology of the defects were trauma ( n = 10 ) , burn ( n = 2 ) , infections ( n = 2 ) , tumour excision ( n = 1 ) , and post - arthroplasty wound dehiscence ( n = 1 ) [ table 2 ] . pre distribution of wound aetiology of soft - tissue defect the largest size of the defect was 28 cm  10 cm , whereas the smallest size was 17 cm  8 cm . the inferiorly based anteromedial thigh fasciocutaneous flap [ figures 1 and 2 ] was performed on 12 patients and inferiorly based alt fasciocutaneous flap on four patients [ table 3 and figure 3 ] . the size of the flaps ranged from 32 cm  11 cm to 20 cm  9 cm depending on the size of the defect . ( a ) soft - tissue defect over the knee with exposed joint after debridement . ( b ) inferiorly based anteromedial fasciocutaneous flap with supragenicular perforators identified . ( c ) follow - up photograph ( a ) soft - tissue defect over infrapatellar region before debridement . ( b ) intra - operative photograph after inferiorly based anteromedial thigh fasciocutaneous flap was raised . ( c ) long term follow - up photograph types and sizes of flap used ( a ) unstable scar lateral part of right knee with involved leg . ( b ) soft - tissue defect after debridement and arc of rotation of the inferiorly based anterolateral thigh fasciocutaneous flap . ( c ) post - operative photograph showing well set flap and skin grafted donor site the saphenous artery originates from the descending genicular artery at 9.16  1.36 cm proximal to the adductor tubercle , and it travels distally towards the knee joint within the adductor canal . saphenous artery and its venae comitantes give off supragenicular fasciocutaneous perforator and its venae comitantes , which supply the inferiorly based anteromedial thigh flap . the saphenous artery with its venae comitantes penetrates the adductor aponeurotic plate into a space formed by the sartorius anteriorly and adductor magnus posteriorly at the distal part of the adductor canal . the saphenous artery travels distally into the subcutaneous tissue between the sartorius and gracilis . in this course , saphenous artery is accompanied by the saphenous nerve and gives off 2 - 5 direct fasciocutaneous perforators and 2 - 6 musculocutaneous perforators . at least one supragenicular fasciocutaneous perforator always arises from the saphenous artery within 3 cm proximal to the adductor tubercle and it accompanies two venae comitantes . supragenicular fasciocutaneous perforator passes through the anterior margin of sartorius in 90% of cases and in remaining cases , it passes through the posterior margin of the sartorius . the ascending branch anastomoses with subcutaneous branches arising from other perforators of the saphenous artery , thus , forms a subcutaneous vascular plexus to supply the skin overlying inferiorly based anteromedial thigh flap . it travels superolaterally and gives branches to the knee joint , vastus lateralis , and biceps femoris . then , it penetrates through the deep fascia proximal to the knee joint just above the lateral condyle of the femur and terminates as a skin perforator in this region . the cutaneous perforators of lsga penetrate through the deep fascia 5 cm proximal to the femoral condyle . the terminal branches of these perforators anastomose with musculocutaneous / septocutaneous perforators of the lateral circumflex femoral artery and perforator of profunda femoris and popliteal artery . the saphenous artery originates from the descending genicular artery at 9.16  1.36 cm proximal to the adductor tubercle , and it travels distally towards the knee joint within the adductor canal . saphenous artery and its venae comitantes give off supragenicular fasciocutaneous perforator and its venae comitantes , which supply the inferiorly based anteromedial thigh flap . the saphenous artery with its venae comitantes penetrates the adductor aponeurotic plate into a space formed by the sartorius anteriorly and adductor magnus posteriorly at the distal part of the adductor canal . the saphenous artery travels distally into the subcutaneous tissue between the sartorius and gracilis . in this course , saphenous artery is accompanied by the saphenous nerve and gives off 2 - 5 direct fasciocutaneous perforators and 2 - 6 musculocutaneous perforators . at least one supragenicular fasciocutaneous perforator always arises from the saphenous artery within 3 cm proximal to the adductor tubercle and it accompanies two venae comitantes . supragenicular fasciocutaneous perforator passes through the anterior margin of sartorius in 90% of cases and in remaining cases , it passes through the posterior margin of the sartorius . the ascending branch anastomoses with subcutaneous branches arising from other perforators of the saphenous artery , thus , forms a subcutaneous vascular plexus to supply the skin overlying inferiorly based anteromedial thigh flap . it travels superolaterally and gives branches to the knee joint , vastus lateralis , and biceps femoris . then , it penetrates through the deep fascia proximal to the knee joint just above the lateral condyle of the femur and terminates as a skin perforator in this region . the cutaneous perforators of lsga penetrate through the deep fascia 5 cm proximal to the femoral condyle . the terminal branches of these perforators anastomose with musculocutaneous / septocutaneous perforators of the lateral circumflex femoral artery and perforator of profunda femoris and popliteal artery . the axis of the flap is delineated by drawing a line between the medial femoral epicondyle and midpoint of the inguinal ligament on the anteromedial aspect of the thigh . supragenicular fasciocutaneous perforator arises from the saphenous artery within 3 cm above the adductor tubercle , which is the pivot point of the flap . pre - operatively , location of these perforators is confirmed using hand - held doppler , recipient site is prepared , and the size of the defect is measured . the size and location of the flaps were designed by following basic principle of the plastic surgery of planning in reverse . first of all , the lateral border of the flap was incised and dissection was performed in the subfascial plane towards the medial side . during this process , intermuscular septum between vastus medialis and sartorius was identified and incised . after visualisation of perforator , superior and medial borders of flap were incised and dissection continued proximodistally . first of all , a line was drawn on the anterolateral aspect of thigh between the anterior superior iliac spine and the lateral border of the patella . using hand - held doppler , again , similar to anteromedial thigh flap , by following the principle of planning in reverse , flap was designed . dissection was performed proximodistally in the subfascial plane and intermuscular septum between rectus femoris and the vastus lateralis muscle was incised . during the process of dissection , perforators were identified at the pre - operatively marked sites in the space between vastus lateralis and biceps femoris just proximal to the lateral condyle of femur . after identification of the perforators , flap was rotated about 5 cm above the patella and transferred at the recipient site . the axis of the flap is delineated by drawing a line between the medial femoral epicondyle and midpoint of the inguinal ligament on the anteromedial aspect of the thigh . supragenicular fasciocutaneous perforator arises from the saphenous artery within 3 cm above the adductor tubercle , which is the pivot point of the flap . pre - operatively , location of these perforators is confirmed using hand - held doppler , recipient site is prepared , and the size of the defect is measured . the size and location of the flaps were designed by following basic principle of the plastic surgery of planning in reverse . first of all , the lateral border of the flap was incised and dissection was performed in the subfascial plane towards the medial side . during this process , intermuscular septum between vastus medialis and sartorius was identified and incised . after visualisation of perforator , superior and medial borders of flap were incised and dissection continued proximodistally . first of all , a line was drawn on the anterolateral aspect of thigh between the anterior superior iliac spine and the lateral border of the patella . using hand - held doppler , again , similar to anteromedial thigh flap , by following the principle of planning in reverse , flap was designed . dissection was performed proximodistally in the subfascial plane and intermuscular septum between rectus femoris and the vastus lateralis muscle was incised . during the process of dissection , perforators were identified at the pre - operatively marked sites in the space between vastus lateralis and biceps femoris just proximal to the lateral condyle of femur . after identification of the perforators , flap was rotated about 5 cm above the patella and transferred at the recipient site . all the patients were evaluated post - operatively in terms of viability of flap , the matching of flap with the recipient site and donor site morbidity . all flaps survived completely except one in which distal flap loss was noted and three in which minor complications occurred , including mild venous congestion in two patients and wound dehiscence in one patient [ table 4 ] . one patient with alt flap with suture line dehiscence achieved healing by regular dressings and antibiotics . the donor site healed well without major complications in all patients except acceptable minimal scar line and donor site skin graft . skin colour and texture of the flap matching well with the recipient site was also observed . majority of the patients ( 38% ) were in the age group of 20 - 30 years and male : female ratio was 4:1 [ table 5 ] . the aim of coverage of soft - tissue defect around the knee joint is to provide aesthetically acceptable appearance and maintain the function of joint . the gastrocnemius flap is one of the good alternatives , but the low volume of the distal part of the muscle is a disadvantage , which is incapable of providing good coverage in large defect in suprapatellar region . the sural artery flap can also be used due to its thin and pliable nature , but its size is limited . free flap is one of the good options that provide good coverage in one stage , but its use is difficult as it requires expertise , long operating time , and deep location of recipient vessels in this region . local advancement or rotation flaps is useful only for very small defects around the knee joint . used skin islands from the distal anteromedial aspect of the thighs of six patients as local perforator flaps in order to reconstruct the peripatellar region and upper leg soft - tissue defects . they concluded that the propeller distal anteromedial thigh perforator flap can reliably be transferred based on the only one adequate perforator vessel , but the disadvantage is that it becomes a microsurgical technique where the dissection of the pedicle is performed by using binocular magnifying glasses . since thigh is usually spared in the traumatised limb , and due to pliable and relatively lax skin , it is convenient to harvest flap from this region . depending upon the location of the defect around the knee joint performed their study on cadavers and confirmed the presence of supragenicular fasciocutaneous perforator within 3 cm above the adductor tubercle . they performed their study on 11 patients with skin defects over the popliteal fossa , proximal 1/3 leg , and amputation stump below knee . using distally based anteromedial thigh flaps , they successfully covered these defects and showed acceptable functional and cosmetic results in terms of movement at the knee joint and matching of skin paddle with the recipient site respectively . chou et al . described the distally based anteromedial thigh fasciocutaneous island flap for patellar soft - tissue reconstruction in seven patients . these island flaps were based on cutaneous feeders vessels and perforator vessels in the muscle septum and deep fascia of the saphenous artery . in their series , all flaps survived uneventfully with only one having venous congestion . in our series , we performed inferiorly based anteromedial thigh flap on 12 patients with a size ranging from 32 cm  11 cm to 24 cm  8 cm ( length to width ratio 2.9:1 - 3:1 ) . all the flaps survived well except two , out of which , one developed mild venous congestion , which subsided after removing compressive dressings , whereas other developed distal flap marginal necrosis which , required debridement and skin grafting . venous congestion is one of the common complications in distally based flaps . in the chou et al . study , only one patients developed venous congestion which , subsided after removal of single stitch and compressive dressing . lin et al . found that venous drainage is not liable to danger in distally based flap despite the presence of valves . compression of pedicle , infection , and poor general condition of the patient could be one of the reasons . performed an anatomical and histomorphometrical study of the lateral genicular artery flap in 18 fresh cadavers and clinical results of knee reconstruction were demonstrated in four patients . they identified cutaneous perforator of the lsga in all specimens at a mean distance up to the lateral condyle of the femur of 7.40  2.77 cm and thus , they confirmed the constant location of the vascular pedicle . it was concluded that inferiorly based thigh fasciocutaneous flap on the perforators of lsga is a useful option in the reconstruction of the defects around the knee joint . performed inferiorly based thigh flap on 15 patients on the perforators of lsga for the reconstruction of defects around the knee joint . they had excellent outcome in all cases except one in which distal marginal flap necrosis was noticed that healed by debridement and dressings . the inferiorly based thigh perforator flap ( lsgap flap ) is closer than the distally based reverse flow alt flap to the knee or popliteal region , making it more versatile for coverage of defects of these regions . in our series , all the alt flap survived well except one in which suture line dehiscence was observed that achieved healing by regular dressings and antibiotics . thin tissue , adequate length of vascular pedicle with flexible arc of rotation , early ambulation , cosmetically acceptable appearance and minimal donor site morbidity makes the inferiorly based alt flap , one of the good alternatives for soft - tissue reconstruction around the knee joint . this helped in narrowing the base and increasing the length to breadth ratio of the flap . narrowing the base also helped in increased rotation of the flap , and to some extent reducing the dog ear . regarding the donor site closure , various authors suggest closure in case the size is < 8 cm . donor defect more than 8 cm has to be skin grafted . in our series , a donor defect of up to 9 cm was primarily closed , which depends upon laxity of the skin . since anteromedial thigh skin is more lax as compared with anterolateral thigh , donor site closure in former one was comparatively easier than the later . one of the advantages of this flap , especially in the indian scenario , is that the donor site is hidden as compared with the donor sites of the proximally based sural or the gastrocnemius flaps , where the donor site is on the calf , and more prone to visibility as compared to the donor site on the thigh . the inferiorly based thigh flap is a reliable flap to cover the defect over proximal one - third of the leg , patellar region , knee , and lower thigh . the main advantages of this flap are its ability to cover a large area with a hidden donor site .
background : soft - tissue defects around the knees are common in injured limbs and in the same injury the leg is often involved and the thigh is spared . furthermore due to pliable and relatively lax skin , we have used inferiorly based thigh flap to reconstruct defects around knee joint.aims and objectives : the aim of this study is to evaluate the use of inferiorly based thigh flap to cover soft - tissue defects over the proximal one - third of the leg , patellar region , knee , and lower thigh.materials and methods : this study was conducted during the period between october 2011 and february 2013 . 
 inferiorly based anteromedial thigh fasciocutaneous flap was performed on 12 patients and inferiorly based anterolateral thigh fasciocutaneous flap on four patients . 
 the sites of the soft - tissue defects included patellar regions , infrapatellar region , upper one - third of leg , lower thigh , and over the knee joint.results:patients were evaluated post - operatively in terms of viability of flap , the matching of the flap with the recipient site , and donor site morbidity . 
 all the flaps survived well except one which developed distal marginal flap loss , one in which wound dehiscence was noticed , and two in which mild venous congestion was observed . 
 venous congestion in two patients subsided on its own within 3 days . 
 one patient with wound dehiscence achieved complete healing by secondary intention . 
 patient who developed distal flap loss required debridement and skin grafting . 
 no appreciable donor site morbidity was encountered . 
 skin colour and texture of the flap matched well with the recipient site.conclusions:the inferiorly based thigh flap is a reliable flap to cover the defect over proximal one - third of the leg , patellar region , knee , and lower thigh .