Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

LATERAL THIGH FLAP
229
Dissection of Vascular Pedicle (Fig. 6–28)
Retracting the vastus lateralis (5) anteriorly and ligating
the muscular branches to the vastus lateralis and biceps
femoris (6), the vascular pedicle is dissected toward the
linea aspera. The fasciocutaneous branches from the
second and fourth perforating branches are then ligated.
Elevation of the Posterior Portion of the Flap
(Fig. 6–29)
Once the vascular pedicle is isolated, the posterior part
of the ap is raised, and the entire ap is isolated on its
vascular pedicle. The origin of the short head of the
biceps (6) is detached from the femur.
Figure 6–28
Dissection of the vascular pedicle.
2. Third perforator
5. Vastus lateralis m.
6. Short head of biceps femoris m.
Figure 6–29
Elevation of the posterior portion of the ap.
2. Third perforator
5. Vastus lateralis m.
6. Short head of biceps femoris m.
7. Long head of biceps femoris m.

230
II.6 LOWER EXTREMITY: THIGH REGION
Further Dissection of the Vascular Pedicle
(Fig. 6–30)
After detaching a part of the origin of the short head of
the biceps (6) from the femur around the vascular pedi-
cle and retracting the biceps femoris (7) from the other
ham string m uscles, the vascular pedicle of the third
perforator (2) can be traced up to the deep fem oral
vessels (8) by windowing the adductor magnus muscle
(9). The pedicle length can reach 10 cm.
If a sensory ap is required, the lateral cutaneous
nerve of the thigh is preserved at the superoanterior
edge of the ap.
Figure 6–30
Further dissection of the vascular
pedicle.
2. Third perforator
5. Vastus lateralis m.
6. Short head of biceps femoris m.
7. Long head of biceps femoris m.
8. Deep femoral a.
9. Adductor magnus m.

ANTEROMEDIAL THIGH FLAP
231
ANTEROMEDIAL THIGH FLAP
Anatomy (Fig. 6–31)
An unnamed branch (8) arises directly from the LCFA
(5) and runs inferomedially along the medial aspect of
the rectus femoris (1) and between the sartorius (2) and
vastus medialis (3), emerging from the intermuscular
space form ed by the sartorius (2), rectus femoris (1),
and vastus medialis (3) at the level of the midpoint of
the thigh.
The diameter of the branch at its origin is 2 mm,
and the length of the pedicle can reach 12 cm.
Venous drainage is provided by the venae com i-
tantes and by the super cial tributary of the anterior
fem oral vein that drains into the greater saphenous
vein.
Innervation
Sensibility is provided by the medial cutaneous femoral
nerve.
COMMENT AND INSIGHTS
Experience with this ap is growing slowly. Cadaver
dissection of these vessels is recom m ended prior to
clinical application.
The skin of the anteromedial aspect of the thigh is
generally uniformly thin and hairless, and it might be
provided with sensibility through the medial femoral
cutaneous nerve.
As a septocutaneous ap, the anteromedial thigh
ap may include the deep fascia. When the fasciae is
used, increased blood supply m ay be obtained by
em ploying the vascular plexus of the deep fascia, so
that the skin territory of this ap could be quite large.
The maximal ap size reported is 10
25 cm.
This ap has also been reported for repair of herni-
ation of the abdominal wall and for reconstruction of a
defect of the cerebral dura, incorporating the strong
fascia lata in the ap.
Donor-site m orbidity is m inim al, but a resulting
linear scar or skin graft m ay create som e cosm etic
problems.
Figure 6–31
Anatomy of the anteromedial thigh ap.
1. Rectus femoris m.
5. LCFA
2. Sartorius m.
6. Ascending branch
3. Vastus medialis m.
7. Descending branch
4. Deep femoral a.
8. Unnamed branch

232
II.6 LOWER EXTREMITY: THIGH REGION
Harvesting Technique
Flap Design (Fig. 6–32)
A line is drawn from the ASIS to the adductor tubercle of
the femur. The midpoint of the line corresponds approx-
imately to the emergence of the unnamed branch of the
LCFA. The ap is designed using the line as an axis.
Elevation of the Anterior Portion of the
Flap (Fig. 6–33)
The anterior part of the ap, with or without deep
fascia, is raised from the rectus femoris (1). The lower
medial border of the rectus femoris (1) and upper lat-
eral border of the sartorius (3) are identi ed and traced
to nd the narrow triangular interm uscular space
form ed by the sartorius, rectus femoris, and vastus me-
dialis. Careful dissection should be undertaken to reveal
the emergence of the fasciocutaneous perforator (2).
Figure 6–32
Flap design.
1. Rectus femoris m.
2. Unnamed branch
3. Sartorius m.
4. Vastus medialis m.
Figure 6–33
Elevation of the anterior portion of
the ap.
1. Rectus femoris m.
2. Unnamed branch
3. Sartorius m.

ANTEROMEDIAL THIGH FLAP
233
Dissection of the Vascular Pedicle
(Fig. 6–34)
After assessing its position, the fasciocutaneous
perforator (2) is dissected as a vascular pedicle toward
its origin at the LCFA. Then, the rectus fem oris (1) is
retracted laterally and the sartorius (3) medially, and
the muscular branches ligated.
Flap Completion (Fig. 6–35)
The m edial portion of the ap is elevated from the
sartorius (3) and vastus medialis (4), preserving the su-
per cial vein on the upper border of the ap. The entire
ap is isolated on its vascular pedicle.
If a sensory ap is required, the m edial cutaneous
fem oral nerve is dissected on the upper m edial ap
border.
Figure 6–34
Dissection of the vascular pedicle.
1. Rectus femoris m.
2. Unnamed branch
3. Sartorius m.
4. Vastus medialis m.
Figure 6–35
Flap completion.
1. Rectus femoris m.
2. Unnamed branch
3. Sartorius m.
4. Vastus medialis m.
AQ1

234
II.6 LOWER EXTREMITY: THIGH REGION
ANTEROLATERAL THIGH (ALT) FLAP
Since this ap was rst reported by Song and colleagues
in 1984, anatom ic investigations and clinical applica-
tions of this donor site have been widely expanded. It
has becom e one of the most applicable donor sites in
reconstructive microsurgery.
According to the anatomic investigations, the main
cutaneous blood supply is by myocutaneous perforator
in about an 84% incidence. Some authors have referred
to it as a perforator ap, to remind surgeons to take care
in following the same principles as in other perforator
aps, such as preoperative Doppler detection and intra-
muscular dissection.
Anatomy
Blood Supply (Figs. 6–36, 6–37)
The skin territory on the anterolateral aspect of the
thigh is supplied by the following arterial system s:
deep femoral artery (5), LCFA (1), descending branch (2)
or transverse branch (4), and myocutaneous perforator
or septocutaneous vessel.
The LCFA (1) is given off from the lateral side of the
deep femoral artery (5), passes inferolaterally behind
the sartorius (11) and the rectus fem oris (9), and
between the divisions of the femoral nerve (6). Shortly
thereafter, it divides into ascending (3), transverse
(4), and descending (2) branches.
The transverse branch (4) passes laterally in front
of the vastus intermedius muscle (8), and then pene-
trates the vastus lateralis m uscle (7) to anastom ose
with the medial circum ex femoral and inferior gluteal
arteries.
The descending branch (2) passes dow n behind
the rectus fem oris m uscle (9), and then travels with
the m uscular branch of the fem oral nerve along the an-
terior border of the vastus lateralis m uscle (7) toward
the knee joint, to anastom ose with the lateral superior
genicular artery. At tim es, the descending branch (2)
m ay arise directly from the deep fem oral artery (5), or
even from the trunk of the fem oral artery (6).
As to the cutaneous blood supply to the skin of
the anterolateral aspect of the thigh, there are som e
variations regarding the pattern of the cutaneous
vessels. According to the anatomic studies and clinical
applications, there are four types:
A. Myocutaneous perforator from the descending
branch (2) of the LCFA (1), penetrating the vastus lat-
eralis with an intramuscular length of 5 cm in 57%
of cases.
B. Myocutaneous perforator from the transverse branch
of the LCFA, penetrating the vastus lateralis with an
intramuscular length of 7 cm in 27% of cases.
Figure 6–36
Anatomy of lateral circum ex femoral artery
(LCFA) and its branches.
1. LCFA
2. Descending branch of LCFA
3. Ascending branch of LCFA
4. Transverse branch of LCFA
5. Deep femoral a.
6. Femoral a., v., and n.
7. Vastus lateralis m.
8. Vastus intermedius m.
9. Rectus femoris m.
10. Vastus medialis m.
11. Sartorius m.
12. TFL m.
13. Lateral femoral
cutaneous n.

ANTEROLATERAL THIGH (ALT) FLAP
235
C. Septocutaneous perforator from the descending
branch of the LCFA, penetrating the intermuscular
septum between the vastus lateralis and rectus
fem oris with a length of 4 cm in the septum in 11%
of cases.
D. Septocutaneous perforator from the transverse
branch of the LCFA, penetrating the intermuscular
septum formed by the rectus femoris, vastus later-
alis, and TFL with a length of 8 cm in the septum in
5% of cases.
Generally, the vascular pedicle length can be 10 cm
to 13 cm, and the diameter of the artery is 2.0 mm to
2.5 m m . There are two accom panying veins with a
diam eter of 1.8 mm to 3.0 mm .
Most of the cutaneous vessels are located in a circle
with a 3-cm radius centered at the midpoint of a line
drawn from the ASIS to the superolateral corner of the
patella. Usually, the most proximal among those discov-
ered myocutaneous perforators may be more acceptable
because of its relatively larger diameter.
Figure 6–37
Patterns of the anatomic variations of LCFA system for anterolateral thigh (ALT) ap.
1. LCFA
3. Ascending branch of LCFA
2. Descending branch of LCFA
4. Transverse branch of LCFA

236
II.6 LOWER EXTREMITY: THIGH REGION
Sensory Innervation (Fig. 6–38)
The lateral cutaneous nerve of the thigh (1) originates
from the lum bar plexus (L2–3), and passes behind the
inguinal ligament 1 cm medial to the ASIS and in front
of the sartorius into the thigh. It then divides into
anterior and posterior branches.
The anterior branch penetrates the fascia lata
10 cm below the ASIS, and it supplies the skin of the
anterolateral aspect of the thigh.
The posterior branch pierces the fascia lata higher
than the anterior one, and it supplies the skin of the
lateral aspect of the thigh.
The anterior cutaneous nerve of the thigh (2) is a
branch of the femoral nerve. It penetrates the fascia lata
8 cm below the midpoint of the inguinal ligament,
and it supplies the skin of the anterior aspect of the
thigh.
For the anterolateral thigh perforator ap, the
anterior branch of the lateral cutaneous nerve of the
thigh is the dominant sensory supply.
Figure 6–38
Sensory distribution of the cutaneous
nerves on the anterolateral aspect of the thigh.
1. Lateral femoral cutaneous n.
2. Anterior femoral cutaneous n.

ANTEROLATERAL THIGH (ALT) FLAP
237
The skin on the anterolateral side of the thigh is usually
pliable and thin. It has a good quality but is somewhat
hairy in males. The subcutaneous layer is not as thick as
in the abdominal and gluteal regions.
The vascular pedicle of the lateral circum ex femoral
vessels is suf ciently long, and usually more than 10 cm
can be obtained. The diameter of the artery and veins in
the pedicle are relatively large, usually more than 2 mm.
The skin territory supplied by the vascular pedicle
is very extensive. Flap size can be up to 15 cm in width
and 25 cm in length. The defect after harvesting can be
closed directly if the width is less than 8 cm . Otherwise,
a skin graft m ay be needed. The donor scar can be
concealed in clothing and is less noticeable than the
radial forearm ap.
Although anatomic variation is a major shortcom-
ing of this donor site, anatomic investigation and clinical
application over the past 20 years have m ade the
variations of the perforators explicit and the harvesting
procedure relatively easier and safer. In the case of a
septocutaneous perforator, dissection would be quite
convenient, whereas in the case of a myocutaneous
perforator from the vastus lateralis, the perforator can
be dissected out from the muscle by ligating the muscu-
lar branches. It can even be taken with an accompanying
m uscle cuff; in this case, the harvesting technique
would not be as complicated.
With its pliant skin and subcutaneous tissue, the
ALT perforator ap has been reported in reconstructive
applications for defects in the head, neck, and extremi-
ties, as well as the dorsum of the hand and foot. Its use
for breast reconstruction in Asia has also been reported.
Because of less available tissue and less ap thickness,
this indication may not be accepted in the West unless
a prosthesis or muscle (i.e., vastus lateralis) is utilized.
The donor site can be com bined w ith the TFL by a
com m on pedicle of the lateral circum flex fem oral
vessels through their ascending and descending
branches.
The myocutaneous ap of the vastus lateralis is one
option for this donor site in cases where more thickness
and more tissue are needed. However, removal of the
vastus lateralis m ay result in som e weakness of the
quadriceps.
Combined with a strip of fascia lata, the ap can be
used for repair of an Achilles tendon defect as a com -
posite ap with “tendon” transfer.
With the features of its vascular pedicle, the ALT
perforator ap can be “chimeric” or “ ow-through.” In
the chim eric ap, using the ascending branch, it can
combine with other kinds of revascularized grafts; for
example, as a vascularized bula graft. In the ow-
through ap, using the distal end of the descending
branch to anastomose with the vessels in an ischemic
distal portion of the extremity as a bridge, it can serve
to resume blood supply and salvage an extrem ity.
Usually, morbidity after surgery is minimal even if a
muscle cuff of the vastus lateralis is utilized. However, a
myocutaneous ap of the vastus lateralis may damage
the function of the quadriceps. In case the ap is too
wide and a split-thickness skin graft is required, this
may result in a certain limitation of the hip or knee joint.
Because it has been validated that the ALT perforator
ap is versatile in its applications and safe in the harvest-
ing procedure, the ap has become much more popular
in the last 10 years for general reconstructive purposes.
COMMENT AND INSIGHTS

238
II.6 LOWER EXTREMITY: THIGH REGION
ANTEROLATERAL LATERAL THIGH
FASCIOCUTANEOUS FLAP
This is a typical and common type of the ALT ap and,
as such, will be depicted in some detail. Doubtless, the
suprafascial vascular plexus enriches blood circulation
in the ap, especially when the size is large.
Perforator Detection and Flap Design
(Fig. 6–39)
A longitudinal line is drawn from the ASIS to the super-
olateral corner of the patella. Generally, this line repre-
sents the interm uscular septum between the vastus
lateralis and the rectus femoris. Centering on the mid-
point of this line, a circle with a radius of 3 cm is m ade.
The majority of cutaneous perforators are usually lo-
cated in this circle. Using the Doppler owmeter, the
cutaneous perforators are detected and marked out on
the skin surface.
A fusiform skin ap is designed with its center over
the detected perforator and its axis parallel to the longi-
tudinal line. Generally, the size of the ap can be 4 to
25 cm in length and 3 to 12 cm in width. If the surgeon
wishes to close the defect prim arily, the ap width
should not be over 8 cm.
For further exposure of the vascular pedicle to the
LCFA, an extended incision m ay be made from the prox-
im al pole of the ap toward the m idpoint of the in-
guinal ligament, if required.
Figure 6–39
Perforator detection and ap design.
1. Anterior superior iliac spine (ASIS)
2. Patella

ALT SEPTOFASCIOCUTANEOUS FLAP
239
ALT SEPTOFASCIOCUTANEOUS FLAP
Elevation of the Medial Portion and
Perforator Identi cation (Fig. 6–40)
The medial part of the incision is rst made and deepened
down to the subfascial layer by cutting the fascia lata over
the rectus femoris muscle (3). The dissection is continued
between the fascia lata and the rectus femoris and
extended laterally toward the intermuscular septum be-
tween the rectus femoris (3) and the vastus lateralis (4).
As soon as the septum is reached, attention should
be paid to identify the perforator(s) (2). If there is a
sizeable direct septocutaneous perforator (2) em erging
from the septum, the dissection becomes easier for a
septofasciocutaneous ap. At this point, the descending
branch of the LCFA (1) is exposed in the septum, and the
septocutaneous perforator is veri ed as branching from
it. This situation occurs in 16% of cases involving ALT
ap procedures; it was previously described in a report
by Song and colleagues in 1984.
Figure 6–40
Elevation of the medial portion and perforator identi cation.
1. Descending branch of LCFA
4. Vastus lateralis m.
2. Septocutaneous perforator
5. Muscular branch of the femoral n.
3. Rectus femoris m.
Figure 6–41
Elevation of the lateral portion.
1. Descending branch of LCFA
2. Septocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
Elevation of the Lateral Portion
(Fig. 6–41)
As soon as a sizeable septocutaneous perforator (2) is
found, the lateral portion of the ap is elevated with the
fascia lata from the vastus lateralis (4), until the inter-
muscular septum is reached. In addition to protecting
the septocutaneous perforator from damage, the entire
septum should be kept intact with the ap, as far as
possible, because the vascular plexus in the septum will
enhance the blood supply for the ap.

240
II.6 LOWER EXTREMITY: THIGH REGION
Vascular Pedicle Dissection (Fig. 6–42)
The dissection proceeds to separate the rectus femoris
m uscle (3) from the septum on the m edial aspect,
exposing the descending branch of the LCFA (1) where
it is accom panied by the m uscular branch of the
fem oral nerve (5). On the lateral aspect, the vastus
lateralis muscle (4) is dissected out from the septum.
During the dissection, the muscular branches from the
descending branch of the LCFA to the rectus fem oris
and vastus lateralis are ligated with care to preserve all
m otor branches, w hich are usually accom panied by
these vessels.
After the distal end of the descending branch of
the LCFA is ligated, the dissection continues proximally.
The rectus femoris (3) is retracted anteriorly, and the
femoral nerve and its branches are carefully protected.
The vascular pedicle can be dissected to the main trunk
of the lateral circum ex fem oral vessels (6) after its
ascending and transverse branches (7) are ligated. If
needed, an extended incision can be made toward the
midpoint of the inguinal ligament for further exposure.
The pedicle length can be 8 to 10 cm.
Figure 6–42
Vascular pedicle dissection.
1. Descending branch of LCFA
2. Septocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of the femoral n.
6. LCFA
7. Ascending and transverse branches of LCFA (ligated)
8. Vastus intermedius m.

ALT PERFORATOR FASCIOCUTANEOUS FLAP
241
ALT PERFORATOR
FASCIOCUTANEOUS FLAP
Veri cation of the Musculocutaneous
Perforator (Fig. 6–43)
After Doppler detection of the perforator and flap
design have been accom plished (as in Fig. 6–39), the
m edial portion of the ap is raised, and there is no
visible septocutaneous perforator. The dissection pro-
ceeds to search out the m usculocutaneous perforator
over the vastus lateralis m uscle (4), w ith m ore
attention paid to the m arked sites that were detected
preoperatively by Doppler flow m eter. As soon as a
sizeable m usculocutaneous perforator (2) is encoun-
tered, the descending branch (1) of the LCFA in the
septum between the rectus fem oris (3) and vastus
lateralis (4) is explored to verify the branching rela-
tionships to it. This situation occurs in 84% of proce-
dures involving ALT flaps. (On rare occasions, w hen
there is neither an existing septocutaneous nor m us-
culocutaneous perforator, the procedure can then be
switched to an anterom edial thigh ap, as described in
this chapter.)
Elevation of the Lateral Portion
(Fig. 6–44)
Once a m usculocutaneous perforator (2) is identi ed
em erging from the vastus lateralis, the lateral portion of
the ap is raised with the fascia lata from the vastus
lateralis muscle (4).
Figure 6–44
Elevation of the lateral portion.
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
Figure 6–43
Veri cation of the musculocutaneous perforator.
1. Descending branch of LCFA
4. Vastus lateralis m.
2. Musculocutaneous perforator
5. Muscular branch of femoral n.
3. Rectus femoris m.

242
II.6 LOWER EXTREMITY: THIGH REGION
Intramuscular Dissection (Fig. 6–45)
An intramuscular dissection proceeds, to ligate all the
branches to the m uscle and to isolate the musculocuta-
neous perforator (2) from the muscle. Generally, these
muscular branches are given off from the lateral and
posterior aspects of the perforator. The muscle over the
perforator is incised, and the perforator can be traced
down until the m ain vessels (1) are reached.
Vascular Pedicle Dissection (Fig. 6–46)
After the intram uscular dissection, the dissection
continues in the interm uscular septum, with care taken
to avoid any tension or traction on the perforator bun-
dle (2). The descending branch (1) of the LCFA is ligated
distal to the branching-off point of the perforator (2).
The pedicle can be dissected to the main trunk of the
lateral circum ex fem oral vessels (6) by ligating the
ascending and transverse branches (7). Once the recipi-
ent site is prepared, the vascular pedicle is divided at
the main trunk and pulled out through the cleavage of
the muscle.
Figure 6–45
Intramuscular dissection.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
Figure 6–46
Vascular pedicle dissection.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
6. LCFA
7. Ascending and transverse branches of LCFA
(ligated)

ALT CUTANEOUS FLAP
243
ALT CUTANEOUS FLAP
This ap is raised without the fascia lata. It is thin and
supple, and favorable for application in reconstruction
of the head, neck, hand, and foot.
Suprafascial Elevation of the Flap
(Fig. 6–47)
Perforator detection by Doppler ow m eter and ap
design are done in the same manner as in Fig. 6–39. A
m edial incision through the skin and subcutaneous
tissue is m ade until the fascia lata is reached (1). A
suprafascial dissection proceeds between the subcuta-
neous tissue and fascia lata (1) to search out the cuta-
neous perforator, as described previously for the ALT
septofasciocutaneous ap and the ALT perforator fas-
ciocutaneous ap. Here, an ALT perforator cutaneous
ap is proposed as a sample because of higher anatomic
incidence. After the musculocutaneous perforator (2) is
identi ed, the lateral portion of the ap is elevated
suprafascially; the deep fascia is kept intact.
Perforator and Pedicle Dissection
(Fig. 6–48)
Whether a septocutaneous perforator or a musculocuta-
neous perforator is discovered during suprafascial dissec-
tion, it is suggested that a small patch of fascia, 1 to 2 cm
in diameter, be kept intact in the ap around the vessels.
Depending on the cutaneous perforator from the
septum or m uscle substance, a sim ilar procedure
follows that of the ALT septofasciocutaneous or ALT
perforator fasciocutaneous ap, as previously described.
The goal is to dissect the septocutaneous or muscular
cutaneous perforator (2) to the descending branch
(3) and main trunk of the LCFA (7).
Figure 6–47
Suprafascial elevation of the ap.
1. Fascia lata
2. Musculocutaneous perforator
Figure 6–48
Perforator and pedicle dissection.
1. Fascia lata
2. Musculocutaneous perforator
3. Descending branch of LCFA
4. Rectus femoris m.
5. Vastus lateralis m.
6. Muscular branch of femoral n.
7. LCFA
8. Ascending and transverse branches
of LCFA (ligated)

244
II.6 LOWER EXTREMITY: THIGH REGION
Flap Thinning (Fig. 6–49)
According to anatomic investigations in cadaver dissec-
tions, the septocutaneous or musculocutaneous perfo-
rator extends perpendicularly to the subdermal plexus,
so that the ALT cutaneous ap can be made thinner. The
deep layer of the subcutaneous tissue, which is gener-
ally composed of larger fat lobules, can be rem oved to
reduce the thickness of the ap. The super cial layer of
the subcutaneous tissue, which is usually composed of
smaller fat lobules, should be retained intact with the
derm is.
After thinning, the thickness of the ap with a layer
of small fat lobules can be 4 to 5 mm . However, exces-
sive thinning, especially near the entrance of the perfo-
rator, may damage the circulation and cause a marginal
necrosis.
Figure 6–49
Flap thinning.
A. Diagram of the blood supply of the cutaneous
perforator with subdermal plexus
B. Flap thinning with the subdermal plexus intact

VASTUS LATERALIS MYOCUTANEOUS FLAP
245
VASTUS LATERALIS
MYOCUTANEOUS FLAP
This is virtually a type of ALT ap in which the ALT ap
is combined with the vastus lateralis muscle. Some au-
thors have described it as a musculocutaneous ALT ap.
Following classic term inology, the nomenclature of a
myocutaneous ap should use the term muscle, rather
than refer to the skin location. In this case, vastus later-
alis myocutaneous ap would be correct. The ap is in-
dicated only when bulkiness of soft tissue is required.
Approach to the Vascular Bundle
(Fig. 6–50)
The skin ap design can follow the description and
drawing in Fig. 6–39, but it is not necessary to detect the
perforator by Doppler owmeter.
After the medial portion of the skin ap is elevated
from the rectus femoris, the descending branch of the
LCFA in the intermuscular septum is dissected, and its
muscular branches to the vastus lateralis are reserved for
the vascular pedicle; the muscular branches to the rectus
femoris and the vastus intermedius are ligated out.
Flap Elevation (Fig. 6–51)
A lateral incision of the designed skin ap is m ade
through the subcutaneous layer and fascia lata down to
the vastus lateral muscle. The skin ap is kept intact
with the muscle so that there is no need for intermus-
cular dissection of the perforator or for dissection of the
septocutaneous vessels.
A portion of the vastus lateralis muscle, the volum e
of which is needed for the recipient site, is cut with the
skin ap. Then the vascular pedicle is continuously dis-
sected to the main trunk of the LCFA, with care taken
not to damage the femoral nerve and its branches, as
described previously.
Figure 6–50
Approach to the vascular bundle.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
Figure 6–51
Flap elevation.
1. Descending branch of LCFA
2. Musculocutaneous
perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of
femoral n.
6. LCFA
7. Ascending and transverse
branches of LCFA (ligated)

246
II.6 LOWER EXTREMITY: THIGH REGION
COMPOSITE ALT FLAP WITH
“TENDON” TRANSFER
This ap is, in effect, an ALT fasciocutaneous ap, in
which the skin ap is com bined w ith an extended
segment of fascia lata. It can be used for reconstruction
of defects of the Achilles tendon or patellar tendon,
together with the overlying soft tissue.
Flap Design (Fig. 6–52)
The preoperative detection of the perforator by Doppler
owm eter and the ap design can be perform ed ac-
cording to Fig. 6–39. In addition, a strip of fascia lata,
which is designated for harvesting with the skin ap, is
marked on the skin. The length of the strip should be
2 cm longer than the defect of the Achilles tendon. Its
width should be much more extended than the width
of the ap to provide strength for the tendon when it is
rolled after transfer.
Figure 6–52
Flap design.
8. Area of fascia lata to
be taken
9. ASIS
10. Patella
Figure 6–53
Elevation of the medial portion.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
8. Area of fascia lata to be taken
Elevation of the Medial Portion
(Fig. 6–53)
A m edial incision is m ade through the subcutaneous
layer to the suprafascial plane, at which point under-
mining proceeds medially to expose a wider area of the
deep fascia. The designated fascia lata on the m edial
side is cut and elevated laterally with the skin ap from
the rectus femoris muscle (3), until a sizeable septocuta-
neous or musculocutaneous perforator (2) is identi ed,
as described previously for the ALT fasciocutaneous ap.

COMPOSITE ALT FLAP WITH “TENDON” TRANSFER
247
Elevation of the Lateral Portion
(Fig. 6–54)
Once the perforator is found, a lateral incision is m ade
down to the suprafascial plane. After lateral underm in-
ing, the designated fascia lata on the lateral side is cut
and elevated with the skin ap from the vastus lateralis
muscle (4), until the identi ed perforator (2) is reached.
Flap Completion (Fig. 6–55)
By dissection in the septum or with an intram uscular
dissection, as described for the ALT fasciocutaneous
ap, the vascular pedicle with the LCFA, its descending
branch, and cutaneous perforator are dissected out.
Figure 6–54
Elevation of the lateral portion.
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
8. Area of fascia lata to be taken
Figure 6–55
Flap completion.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
6. LCFA
7. Ascending and transverse branches of LCFA
(ligated)

248
II.6 LOWER EXTREMITY: THIGH REGION
“Tendon” Formation (Fig. 6–56)
The composite ALT ap with a rolled fascia lata as a
“tendon” is ready for transfer.
Figure 6–56
“Tendon” formation.
1. Composite ALT ap with “tendon”
2. Achilles tendon (with a defect)
3. Posterior tibial a., v., and n.
4. Flexor hallucis longus m.
5. Flexor digitorum longus m.
6. Tibialis posterior m.

CHIMERIC ALT FLAP
249
CHIMERIC ALT FLAP
There are possibilities that the ALT ap can be com -
bined with other tissue transfers by the ascending or
transverse branches of the LCFA, with or without mi-
crosurgical anastomosis.
Figure 6–57
Type 1 of the chimeric ALT ap.
1. LCFA
2. Descending branch of LCFA
3. Ascending branch of LCFA
4. TFL m.
5. Vastus lateralis m.
6. Rectus femoris m.
Type 1 of the Chimeric ALT Flap
(Fig. 6–57)
Without microsurgical anastomosis, using the ascend-
ing branch (3) of the common stem of the LCFA (1), the
ALT ap can be com bined with the TFL (4) ap. The
anatomy and surgical harvesting technique for the TFL
ap can be found in this chapter.

250
II.6 LOWER EXTREMITY: THIGH REGION
Type 2 of the Chimeric ALT Flap
(Fig. 6–58)
Using microsurgical anastomosis to the branches of the
LCFA (3), the ALT ap can also be combined with most
other tissue transfers from donor sites described in this
book. Am ong them , the vascularized bula bone (1)
graft or bula osteoseptocutaneous ap can commonly
be combined with the chimeric ALT ap in reconstruc-
tion of massive composite orom andibular defects fol-
lowing tumor ablation surgery.
Figure 6–58
Type 2 of the chimeric ALT ap.
1. Fibula
2. Peroneal a., v.
3. LCFA
4. Descending branch of LCFA
5. Ascending branch of LCFA

“FLOW-THROUGH” ALT FLAP
251
“FLOW-THROUGH” ALT FLAP
The descending branch of the LCFA terminates in the
vastus lateralis m uscle, and it continues to run in
the muscle toward the knee joint, anastomosing with
the lateral superior genicular artery. After ligation
before its termination, the distal end of the descending
branch has artery and veins with suf cient diameter for
anastom osis. The vascular pedicle can be used as an
interpositional “graft” (or bridge) to save an ischemic
extremity, or as continuous recipient vessels to supply
another free tissue transfer.
Type 1 of the “Flow-Through” ALT Flap
(Fig. 6–59)
This type of ow-through ALT ap can be used for a
distal ischemic extremity resulting from a defect of the
major vessels, with massive soft-tissue loss, due to
trauma or surgical ablation of a malignant tumor. In addi-
tion to reconstruction with its soft-tissue ap, by utilizing
its vascular pedicle, this ALT ap may also resume its
blood supply by bridging the proximal and distal ends of
the major vessels. For example, a traumatic, incomplete
amputation with defects of both the ulnar and radial
arteries can be treated with this ow-through ALT ap.
Figure 6–59
Type 1 of the “ ow-through”
ALT ap.
1. Ulnar a.
2. Basilic v.
3. LCFA
4. Descending branch of LCFA

252
II.6 LOWER EXTREMITY: THIGH REGION
Type 2 of the “Flow-Through” ALT
Flap (Fig. 6–60)
Using the distal end of the descending branch (4) of the
LCFA (3) as continuous recipient vessels, this ow-
through ALT ap can supply another tissue transfer in
microsurgical reconstruction of a complex tissue loss. For
example, an oromandibular defect after surgical ablation
of malignancy can be treated by a ow-through ALT ap
combined with a vascularized bula (1) osteoseptocu-
taneous ap.
Figure 6–60
Type 2 of the
“ ow-through” ALT ap.
1. Fibula
2. Peroneal a., v.
3. LCFA
4. Descending branch of LCFA

SENSATE ALT FLAP
253
SENSATE ALT FLAP
If a sensate ap is needed, the lateral cutaneous nerve of
the thigh can be easily dissected for a fasciocutaneous
ALT ap.
Sensory Nerve Identi cation and
Dissection (Fig. 6–61)
Following elevation of the medial portion of the fascio-
cutaneous ALT ap, and nding and verifying the septo-
cutaneous or m usculocutaneous perforator (2), an
incision is made from the ASIS to the proximal pole of
the m arked ap. The deep fascia is divided 1 cm
medial to the ASIS, and the lateral cutaneous nerve of
the thigh (6) can be found on the sartorius m uscle
(7) under the deep fascia.
After the lateral cutaneous nerve of the thigh (6) is
identi ed, it is traced dow n to its bifurcation. The
posterior branch is preserved and the anterior branch is
continuously dissected to the proxim al pole of the
marked ap. Usually, the anterior branch of the lateral
cutaneous nerve of the thigh pierces the deep fascia
near or before this point.
Figure 6–61
Sensory nerve
identi cation and dissection.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
6. Lateral cutaneous n. of thigh
7. Sartorius m.

254
II.6 LOWER EXTREMITY: THIGH REGION
Flap Elevation (Fig. 6–62)
By an intraneural dissection, the anterior branch of the
lateral cutaneous nerve of the thigh is separated from
the posterior branch up to the ASIS to obtain m ore
length, and it is divided at that point. The ALT ap con-
tinues to be elevated and the vascular pedicle is dis-
sected, as described previously.
Figure 6–62
Flap elevation.
1. Descending branch of LCFA
2. Musculocutaneous perforator
3. Rectus femoris m.
4. Vastus lateralis m.
5. Muscular branch of femoral n.
6. Lateral cutaneous n. of thigh
7. Sartorius m.
8. LCFA

RECIPIENT SITE EXPOSURES
255
RECIPIENT SITE EXPOSURES
Anterior Approach to the Common
and Super cial Femoral Arteries
Incision (Fig. 6–63)
A line is drawn from the midpoint of the inguinal ligament
to the adductor tubercle of the femur. An incision is made
on the proximal part of this line for a length of 10 cm.
Figure 6–63
Incision.
1. Saphenous v.
2. Super cial circum ex iliac v.
3. Lymph node
4. Cribriform fascia
5. Common femoral a. and v.
6. Super cial femoral a.
and v.
7. Deep femoral a. and v.
8. Femoral n.
9. Sartorius m.

256
II.6 LOWER EXTREMITY: THIGH REGION
Exposure of the Super cial Structures
(Fig. 6–64)
The greater saphenous vein (1) is identi ed beneath the
super cial fascia. At the saphenous opening, it pierces
the cribriform fascia (4) to join the femoral vein 3 cm
below the inguinal ligament. The super cial circum ex
iliac vein (2) that branches from the greater saphenous
vein and runs transversely should be ligated.
Figure 6–64
Exposure of the super cial structures.
1. Saphenous v.
2. Super cial circum ex iliac v.
3. Lymph node
4. Cribriform fascia

RECIPIENT SITE EXPOSURES
257
Dissection of the Femoral Artery
(Fig. 6–65)
Dividing the deep fascia, the sartorius m uscle (9) is
mobilized and retracted laterally. The femoral sheath is
identi ed and opened to expose the common femoral
artery (5), which is located lateral to the femoral vein
(5). Further dissection proceeds to expose the proximal
portion of the super cial femoral artery (6) as its con-
tinuation. On its posterolateral aspect, the deep femoral
artery (7) originates from the femoral artery 3 to 4 cm
below the inguinal ligament.
Figure 6–65
Dissection of the femoral artery.
1. Saphenous v.
5. Common femoral a. and v.
6. Super cial femoral a. and v.
7. Deep femoral a. and v.
8. Femoral n.
9. Sartorius m.

Anterior Approach to the Super cial
Femoral Artery in Hunter’s Canal
Incision (Fig. 6–66)
An incision is m ade on the m iddle third of the line
described above in the exposure of the common femoral
artery.
Figure 6–66
Incision.
1. Super cial femoral a. and v.
2. Saphenous a., v., and n.
3. Roof of the adductor canal
4. Sartorius m.
5. Vastus medialis m.
6. Gracilis m.
7. Adductor magnus m.
8. Adductor longus m.
258
II.6 LOWER EXTREMITY: THIGH REGION

RECIPIENT SITE EXPOSURES
259
Exposure of Hunter’s Canal (Fig. 6–67)
The deep fascia is incised, and the sartorius (4) and
gracilis (6) are identi ed, m obilized, and retracted
anteriorly and posteriorly, respectively. The brous roof
of Hunter’s canal (3), which extends from the adductor
longus and m agnus (8,7) to the vastus medialis (5), is
exposed in the wound.
Figure 6–67
Exposure of Hunter’s canal.
1. Super cial femoral a. and v.
2. Saphenous a., v., and n.
3. Roof of adductor canal
4. Sartorius m.
5. Vastus medialis m.
6. Gracilis m.
7. Adductor magnus m.
8. Adductor longus m.

Identi cation of the Femoral Artery (Fig. 6–68)
The brous roof is divided longitudinally. The saphe-
nous nerve (2) can be seen in front of the artery running
from lateral to medial; it should be carefully protected.
Then the super cial femoral artery (1) is dissected out
from the fem oral vein (1), which lies posterior to the
artery.
Figure 6–68
Identi cation of the femoral artery.
1. Super cial femoral a. and v.
2. Saphenous a., v., and n.
4. Sartorius m.
5. Vastus medialis m.
6. Gracilis m.
7. Adductor magnus m.
8. Adductor longus m.
260
II.6 LOWER EXTREMITY: THIGH REGION

RECIPIENT SITE EXPOSURES
261
Posterior Approach to the Super cial
Femoral Artery
Incision (Fig. 6–69)
The incision begins on the posterior midline of the thigh
at the top of the popliteal fossa (at the level of the junc-
tion of the middle and distal thirds of the thigh). The inci-
sion runs proximally along the semitendinosus tendon to
the medial aspect of the tuberosity of the ischium.
Exposure of the Adductor Magnus (Fig. 6–70)
The deep fascia is incised, and the semitendinosus (5),
semimem branosus (6), and gracilis (3) are identi ed to
determine the interm uscular septum between the gra-
cilis (3) and semim em branosus (6).
A dissection is perform ed to separate the sem i-
m em branosus (6) from the gracilis (3), which is re-
tracted with the sem itendinosus (5) laterally. Then, the
m edial edges and posterior surface of the adductor
magnus (2) are exposed.
Figure 6–69
Incision.
1. Popliteal a. and v.
6. Simimembranosus m.
2. Adductor magnus m.
7. Sartorius m.
3. Gracilis m.
8. Super cial femoral a. and v.
4. Gluteus maximus m.
9. Adductor longus m.
5. Semitendinosus m.
10. Roof of adductor canal
divided
Figure 6–70
Exposure of the adductor magnus.
1. Politeal a. and v.
2. Adductor magnus m.
3. Gracilis m.
4. Gluteus maximus m.
5. Semitendinosus m.
6. Semimembranosus m.

Identi cation of the Femoral Artery (Fig. 6–71)
The adductor m agnus (2) and the adductor longus
(9) are separated from the deep surfaces of the gracilis
(3) and sartorius (7) m uscles, and then retracted
with the sem im em branosus (6) and sem itendinosus
(5) laterally toward the femoral shaft.
At this stage, tracing the adductor tendon (2), the
adductor canal is identi ed along the posteromedial as-
pect of the femur in the lower half of the wound. The
aponeurosis roof of the canal (10) is incised along the
m edial edge of the adductor m agnus to expose the
femoral vessels (8). The proximal portion of the super-
cial femoral vessels (8) can be dissected out from un-
derneath the adductor longus (9).
Figure 6–71
Identi cation of the femoral artery.
2. Adductor magnus m.
3. Gracilis m.
5. Semitendinosus m.
6. Semimembranosus m.
7. Sartorius m.
8. Super cial femoral a. and v.
9. Adductor longus m.
10. Roof of adductor canal divided
262
II.6 LOWER EXTREMITY: THIGH REGION

RECIPIENT SITE EXPOSURES
263
Cross-Sectional Diagram (Fig. 6–72)
The posterior approach to the super cial femoral artery
is shown in a cross-sectional diagram.
Figure 6–72
Cross-sectional diagram.
2. Adductor magnus m.
3. Gracilis m.
5. Semitendinosus m.
6. Semimembranosus m.
7. Sartorius m.
8. Super cial femoral a. and v.
9. Adductor longus m.

Anterior Approach to the Deep
Femoral Artery
After takeoff from the m ain fem oral trunk, the deep
femoral artery lies deeply behind the thick cluster of
the thigh muscles, the branches of the femoral nerve,
and the main trunk of the super cial femoral vessels.
Incision (Fig. 6–73)
A line is drawn from a point 4 cm medial to the ASIS, to
the m edial edge of the patella. The incision is made on
the proximal and middle thirds of the line.
Figure 6–73
Incision.
1. Inguinal ligament
2. Greater saphenous v.
3. Femoral n.
4. Femoral a. and v.
5. Deep femoral a.
6. LCFA
7. Sartorius m.
8. Rectus femoris m.
9. Vastus medialis m.
10. Adductor longus m.
11. Adductor brevis m.
12. First and second perforators
13. Adductor magnus m.
14. Pectineus m.
264
II.6 LOWER EXTREMITY: THIGH REGION

RECIPIENT SITE EXPOSURES
265
Exposure of the Femoral Nerve and the
Sheath of the Femoral Vessels (Fig. 6–74)
While dividing the deep fascia along the m edial edge of
the sartorius (7), the anterior cutaneous branches of the
fem oral nerve are preserved as m uch as possible. The
sartorius (7) and rectus fem oris (8) m uscles are m obi-
lized from their m edial edge and retracted laterally. At
this stage, the m any branches of the fem oral nerve (3)
and the sheath of the fem oral vessels (4) are exposed.
Figure 6–74
Exposure of the femoral nerve and the
sheath of the femoral vessels.
1. Inguinal ligament
2. Greater saphenous v.
3. Femoral n.
4. Femoral a. and n.
5. Deep femoral a.
6. LCFA
7. Sartorius m.
8. Rectus femoris m.
9. Vastus medialis m.

Identi cation of the Deep Femoral Artery
(Fig. 6–75)
The branches of the fem oral nerve (3) are carefully
dissected from the anterior and lateral aspects of the
m ain fem oral vessels (4) and retracted laterally. The
saphenous nerve or ne branches that enter the sheath
of the artery can be divided, if required, for greater
exposure.
Retracting the nerve branches (3) and vastus medi-
alis muscle (9) laterally and the main femoral vessels
(4) m edially, the deep femoral artery (5) is identi ed
running in front of the pectineus (14) toward the
medial slope of the femur. It then disappears between
the adductor longus and brevis m uscles (10,11). If
needed, the adductor longus (10) can be detached from
the femur to obtain 3 to 4 cm m ore of distal exposure of
the deep femoral artery (5).
In the course of this segm ent, the deep fem oral
artery gives off the LCFA (6), 6 cm below the inguinal
ligam ent, and the three perforating arteries, and
terminates as a fourth perforating artery.
Figure 6–75
Identi cation of the deep femoral
artery.
3. Femoral n.
4. Femoral a. and v.
5. Deep femoral a.
6. LCFA
7. Sartorius m.
8. Rectus femoris m.
9. Vastus medialis m.
10. Adductor longus m.
11. Adductor brevis m.
12. First and second perforators
13. Adductor magnus m.
14. Pectineus m.
266
II.6 LOWER EXTREMITY: THIGH REGION

RECIPIENT SITE EXPOSURES
267
Posterior Approach to the Deep
Femoral Artery
Incision (Fig. 6–76)
An incision is made from the top of the popliteal fossa
(on the posterior midline and at the level of the junc-
tion of the middle and distal thirds of the thigh) to the
tuberosity of the ischium.
Figure 6–76
Incision.
1. Gluteus maximus m.
2. Semimembranosus m.
3. Semitendinosus m.
4. Long head of biceps femoris
5. Short head of bicepts femoris
6. Adductor magnus m.
7. Linea aspera
8. Sciatic n.
9. Second perforating a.
10. Third perforating a.
11. Deep femoral a. and v.

Exposure of the Sciatic Nerve (Fig. 6–77)
After dividing the deep fascia, the intermuscular septum
between the medial (2,3) and lateral (4) hamstrings is
identi ed and entered with blunt dissection to expose
the sciatic nerve.
Figure 6–77
Exposure of the sciatic nerve.
1. Gluteus maximus m.
2. Semimembranosus m.
3. Semitendinosus m.
4. Long head of biceps femoris
5. Short head of biceps femoris
6. Adductor magnus m.
7. Linea aspera
8. Sciatic n.
9. Second perforating a.
10. Third perforating a.
268
II.6 LOWER EXTREMITY: THIGH REGION

RECIPIENT SITE EXPOSURES
269
Identi cation of the Deep Femoral Artery
(Fig. 6–78)
The sciatic nerve (8) is mobilized and displaced medi-
ally or laterally. Retracting the long head of the biceps
fem oris (4) laterally and the sem itendinosus (3) and
semimem branosus (2) medially, the linea aspera (7) is
de ned. The adductor magnus muscle (6) is detached
from the medial edge of the linea aspera, between the
levels of 10 to 15 cm distal to the greater trochanter, and
the deep femoral artery (11) then appears before the
asperal aponeurosis of the adductor longus or vastus
medialis.
The second (9) and third (10) perforating arteries
arise from the deep femoral artery and pierce the inser-
tion of the adductors to the posterior and lateral as-
pects of the thigh.
Figure 6–78
Identi cation of the deep
femoral artery.
2. Semimembranosus m.
3. Semitendinosus m.
4. Long head of biceps femoris
5. Short head of biceps femoris
6. Adductor magnus m.
7. Linea aspera
8. Sciatic n.
9. Second perforating a.
10. Third perforating a.
11. Deep femoral a. and v.

Cross-Sectional Diagram (Fig. 6–79)
The posterior approach to the deep femoral artery is
shown in a cross-sectional diagram.
Figure 6–79
Cross-sectional diagram.
2. Semimembranosus m.
3. Semitendinosus m.
4. Long head of biceps femoris
5. Short head of biceps femoris
6. Adductor magnus m.
7. Linea aspera
8. Sciatic n.
11. Deep femoral a. and v.
270
II.6 LOWER EXTREMITY: THIGH REGION

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II.6 LOWER EXTREMITY: THIGH REGION

FIBULA AND ADJACENT TISSUE
TRANSFER
Anatomy of the Peroneal Artery
(Fig. 7–1A, B)
The peroneal artery (3) arises from the posterior tibial
artery (2) 3 cm below the lower border of the
popliteal muscle (8), at a level 7 cm below the head of
the bula, passing inferolaterally toward the bula
between the soleus and the tibialis posterior. It then
enters a brous canal between the tibialis posterior and
the exor hallucis longus (7) or in the substance of the
latter muscle, descending along the medial crest of the
bula toward the tibio bular syndesm osis. Finally, it
divides into the calcaneus branches.
In its course, the peroneal artery gives off the
following signi cant branches:
1. A nutrient artery (5) that originates 6.8 cm after the
origin of the peroneal artery (3) at a level 13.8 cm
below the head of the bula. The nutrient artery is
directed downward into the bula, with an average
length of 1.8 cm and a diam eter of 1.2 mm .
2. Four to six circular or arcade arteries (6) run around
the posterior aspect of the bula, segm entally
nourish it, the periosteum, and surrounding muscles,
at intervals of 3 to 5 cm, and then pass through the
posterior crural intermuscular septum as septocuta-
neous branches to supply the lateral skin of the leg.
7
Lower Leg and Knee
Figure 7–1A
Anatomic diagram of the peroneal artery.
1. Popliteal a.
2. Posterior tibial a.
3. Peroneal a.
4. Anterior tibial a.
5. Nutrient a. of bula
6. Septocutaneous branches
7. Flexor hallucis longus m.
8. Popliteal m.

The rst circular artery (6) arises m ostly from the
popliteal artery and anterior or posterior tibial arter-
ies, whereas the second, third, and fourth circular ar-
teries almost constantly originate from the peroneal
artery. These vessels have diam eters of 0.6 to 0.8
mm; they em erge through the posterior crural sep-
tum at points 9, 15, and 20 cm, respectively, below
the head of the bula.
3. Among several of the muscular branches (excepting
those from the circular artery), there usually are two
large branches with a diam eter of 1.8 m m to the
lateral part of the soleus m uscle directly from the
peroneal artery, reaching the m uscle at about its
middle part.
276
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–1B
Anatomic relationships of the peroneal artery.
1. Popliteal a.
2. Posterior tibial a.
3. Peroneal a.
4. Anterior tibial a.
7. Flexor hallucis longus m.
8. Popliteal m.
9. Tibial posterior m.
10. Soleus m.
11. Flexor digitorum longus m.
12. Peroneus longus

Variations of the Peroneal Artery
(Fig. 7–2)
A. The peroneal artery arises from the posterior tibial
artery in 90% of cases.
B. It arises from the anterior tibial artery in 1% of cases.
C. It arises from the popliteal artery in 1% of cases.
D. It takes the place of the posterior tibial artery in 8% of
cases.
FIBULA AND ADJACENT TISSUE TRANSFER
277
Figure 7–2
Variations of the peroneal artery (see text for details).