double free - flaps are technically challenging due to the complex nature of the defect , harvest of two flaps and use of two pairs of recipient 's vessels . in such limb defects more further the risk of distal limb ischaemia is imminent when collateral circulation is not adequate . double fasciocutanous flaps either perfused independently or as chimeric flaps fulfil the requirements provided suitable recipient vessels are available . the risk of distal limb ischaemia is minimal when a single vascular axial limb vessel is used as the recipient . harvest of such flaps from a common donor site avoids the morbidity of distant second donor site . we report successful resurfacing of large bimalleolar defects in a 14-year - old boy using the anterolateral and anteromedial fasciocutanous perforator flaps harvested independently and anastomosed to the proximal and distal cut ends of the anterior tibial vessels . a 14-year - old boy presented to us with a 2 weeks old infected bimalleolar defect with dimensions of 12 cm  7 cm medially and 8 cm  4 cm laterally [ figure 1 ] at the ankle . the patient was treated with cast application elsewhere for swelling of the ankle following a fall and had no bony injury . he developed severe pain in the ankle soon after and fever a week later , . on removal of the cast , necrosis of the skin was noted over the both malleoli which was debrided at the referral hospital and then he was referred to our institute for further management . malleoli and the adjacent lower ends of tibia and fibula were exposed with open ankle joint - draining frank pus . the foot was sensate and well vascularised with good dorsalis pedis and posterior tibial pulsations . considering the dimensions and proximity of the two defects , a chimeric fasciocutanous anteromedial thigh ( amt ) and anterolateral thigh ( alt ) flap [ figure 2 ] based on the lateral circumflex , femoral vessels was planned and their perforators marked with hand held doppler . the flaps were raised based on these perforators and the pedicles traced proximally for their confluence . it was found to be very close to the origin of the lateral circumflex femoral artery precluding chimeric flap design and due to gross vessel size mismatch and excess pedicle length . the vessels were healthy and amenable for the use with good pulsatile flow from both the proximal and distal cut ends of the recipient artery . both flap vessels were anstomosed to the proximal and distal cut ends of the anterior tibial artery , in an end to end fashion . the corresponding flap veins were anastomosed to the available two vena comitans of the anterior tibial artery in an antegrade direction . at 11 months follow - up , the patient is ambulatory with a stiff ankle in slight varus position with x - ray showing extensive post - septic arthritic sequale of the ankle joint [ figure 4 ] . medial and lateral malleolar defect chimeric anterolateral thigh and anteromedial thigh flaps settled anterolateral thigh and anteromedial thigh flaps x - ray showing post arthritic sequele distal lower limb defects requiring double flaps can be resurfaced by a combination of two separate distally based flaps laterally and medially , a single pedicled flap with de - epithelisation of intervening skin bridge and use of chimeric free flaps . chimeric free flaps resurface more than one defect based on single pedicle by innovation in the flap design . lin et al . have demonstrated the feasibility of harvesting more than one skin and muscle components on the lateral circumflex femoral system . two separate skin paddles based on the anterolateral and anteromedial perforators of the descending branch of the lateral circumflex femoral artery can be harvested as a chimeric flap . however , the pedicle of the amt flap can arise from the lateral circumflex femoral artery or the femoral artery . when the chimeric anterolateral and anteromedial flap is harvested in such circumstances , the confluence would be in a much more proximal position which was the case in our patient . routine imaging has not been advocated for the harvest of these flaps by however , when chimeric flap harvest is planned , imaging can be helpful in assessing the location of the confluence . the harvest of both the flaps did not incur additional morbidity in our case though the potential exists . lin et al . in their preference for choosing chimeric flaps over double free - flaps have observed the following difficulties in advocating double free - flaps for limb defects namely , ( 1 ) the need for more than one pair of recipient vessels or a flow - through flap ( 2 ) morbidity of the second flap harvest and ( 3 ) the additional time for second anastomosis . the choice of the recipient vessel for a free flap in the limb will depend on the location and the vascular status of the limb . collateral circulation maintains distal limb perfusion and hence its intactness and adequacy are vital when one of the major limb axial vessels is utilised . this is possible because of presence of collaterals at multiple levels between the anterior tibial , posterior tibial and peroneal vessels . in 3 of the 50 cases of park et al . reverse flow from anterior tibial was used as the recipient vessel , and they suggested angiography and pulsatile flow intra - op to be usable criteria for the vessel . thus , if both the proximal and distal cut ends have good flow , they can be utilised for perfusion of two flaps assuming that collateral circulation is adequate . both superficial and deep park et al . have found the vena comitans to be better suited than superficial veins as they are less vulnerable to injury and located in the same operative field . even though patency rates are similar to that of an end to end anastomosis , it has technical difficulties ( angle of vessel take off , arteriotomy , difficulty in diseased vessels ) and flow problems ( turbulence , insufficient flow , thrombosis ) . although it gives a safer and more satisfactory outcome in size discrepancy , it is not feasible when flap vessel is larger than the recipient vessel which was the situation in our case . thus , in a properly selected patient double free - flaps can be done safely with minimal additional morbidity as demonstrated in this case .