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

VASCULARIZED FIBULA BONE GRAFT
279
VASCULARIZED FIBULA BONE GRAFT
Incision (Fig. 7–4)
The patient is placed in a supine position with the knee
bent. A straight incision is m ade along the posterior
edge of the bula.
Approach to the Posterior Crural
Septum (Fig. 7–5)
After cutting through the deep fascia and ligating
the septocutaneous branches, the space between the
peroneus longus (2) and soleus muscles (1) is entered.
Figure 7–5
Approach to the posterior crural septum.
1. Soleus and gastrocnemius mm.
2. Peroneus longus and brevis mm.
Figure 7–4
Incision.
1. Soleus and gastrocnemius m.
2. Peroneus longus and brevis mm.
3. Extensor digitorum and hallucis longus m.
4. Flexor hallucis longus m.
5. Fibula bone
6. Common peroneal n.
7. Interosseous membrane
8. Posterior tibialis m.
9. Peroneal a. and v.
10. Posterior tibial a., v., and n.

Extraperiosteal Exposure of the
Lateral Aspect of the Fibula (Fig. 7–6)
The sharp and extraperiosteal dissection is perform ed
anteriorly to detach the peroneus longus and brevis (2)
and the extensor digitalis and hallucis longus muscles
(3) from the anterolateral aspect of the bula, leaving a
minimal muscle cuff to the bone up to the interosseous
m em brane (7). Posteriorly, the soleus m uscle (1) is
separated from the bula (5) in the same way to expose
the exor hallucis longus (4).
If a longer segment of the bula is required, reaching
toward its neck, the com mon peroneal nerve (6) should
be identi ed and meticulously preserved.
280
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–6
Extraperiosteal exposure of the lateral
aspect of the bula.
1. Soleus and gastrocnemius mm.
2. Peroneus longus and brevis mm.
3. Extensor digitorum and hallucis longus mm.
4. Flexor hallucis longus m.
5. Fibula bone
6. Common peroneal n.
7. Interosseous membrane

VASCULARIZED FIBULA BONE GRAFT
281
Osteotomy (Fig. 7–7)
Although the peroneal artery has not been visible up to
this point, to facilitate further exposure, the bula
(5) should then be cut at its proximal and distal ends
with a Gigli saw and measurements made according to
the length needed. This segm ent m ust include the
middle third of the bula, so that the nutrient artery is
kept intact to nourish the bone.
Figure 7–7
Osteotomy.
4. Flexor hallucis longus m.
5. Fibula bone
7. Interosseous membrane
8. Posterior tibialis m.

Identi cation of the Peroneal Vessels
(Fig. 7–8)
Using sm all bone hooks, the graft is gently retracted
anteriorly and the soleus muscle retracted posteriorly.
The peroneal vessel (9) can be seen at the upper inner
border of the origin of the exor hallucis longus (4),
passing into its deeper substance.
282
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–8
Identi cation of the peroneal vessels.
4. Flexor hallucis longus m.
8. Posterior tibialis m.
9. Peroneal a. and v.
10. Posterior tibial a., v., and n.

VASCULARIZED FIBULA BONE GRAFT
283
Dissection of Vascular Bundle and
Completion of Harvesting (Fig. 7–9)
Separating the exor hallucis longus (4), the peroneal
bundle (9) is seen passing along the posterior aspect of
the bula. It is then ligated and sectioned at the severed
distal level of the bula.
After the interosseous membrane (7) is divided, the
posterior tibialis (8) is severed from below upward,
between the peroneal vascular bundle (9) and the
lateral side of the posterior tibial nerve (10), leaving a
0.5- to 1.0-cm muscle fringe to the bula.
At this point, the whole graft is freed from the
donor site except for the peroneal vascular pedicle (9),
which can be dissected further toward the bifurcation
of the posterior tibial artery (10) to obtain a pedicle
length of less than 3 cm.
Figure 7–9
Dissection of vascular bundle and
completion of harvesting.
4. Flexor hallucis longus m.
5. Fibula bone
7. Interosseous membrane
8. Posterior tibialis m.
9. Peroneal a. and v.
10. Posterior tibial a., v., and n.

Cross-Sectional Diagram (Fig. 7–10)
This is a diagram of a cross section of vascularized bular
bone graft.
284
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–10
Cross-sectional diagram.
1. Soleus and gastrocnemius mm.
7. Interosseous membrane
2. Peroneus longus and brevis mm.
8. Posterior tibialis m.
3. Extensor digitorum and hallucis longus mm.
9. Peroneal a. and v.
4. Flexor hallucis longus m.
10. Posterior tibial a., v., and n.
5. Fibula bone

PERONEAL FLAP (LATERAL LEG SKIN FLAP)
285
PERONEAL FLAP (LATERAL LEG
SKIN FLAP)
Flap Design (Fig. 7–11)
A line is drawn as the axis of the ap, from the head of
the bula along its posterior edge to the malleolus. A
point 2 cm above the midpoint of this line is marked as
the center of the ap. The largest ap size reported is
32
10 cm .
Approach to the Septum and
Identi cation of Perforators
(Fig. 7–12)
The posterior portion of the ap, along with the deep
fascia, is elevated toward the posterior crural septum,
corresponding to the axial line of the ap. The lesser
saphenous vein and the lateral sural nerve are preserved
while the proximal edge of the ap is being dissected.
The septocutaneous or musculocutaneous perfora-
tors (2) can be found near the septum, usually at levels
9, 15, or 20 cm below the head of the bula.
Figure 7–11
Flap design.
1. Soleus and gastrocnemius mm.
2. Septocutaneous perforators
3. Flexor hallucis longus m.
4. Fibula bone
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.
7. Extensor m.
8. Peroneus longus and brevis mm.
Figure 7–12
Approach to the
septum and identi cation of
perforators.
1. Soleus and gastrocnemius mm.
2. Septocutaneous perforators

Tracing the Perforator to the Peroneal
Vessels (Fig. 7–13)
A meticulous dissection is performed on the cutaneous
perforators separating the soleus (1) and the exor
hallucis longus m uscles (3) from the perforators and
the bula (4), to expose their origins from the peroneal
vesssels (5).
286
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–13
Tracing the perforators to the
peroneal vessels.
1. Soleus and gastrocnemius mm.
3. Flexor hallucis longus m.
4. Fibula bone
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.

PERONEAL FLAP (LATERAL LEG SKIN FLAP)
287
Flap Completion (Fig. 7–14)
Then, the anterior portion of the ap is raised from the
extensor (7) and peroneus m uscles (8) toward the
septum . The septocutaneous or m usculocutaneous
perforators are dissected from the peroneus m uscles
and the bula, ligating the peroneal vessels (5) just
distal to the origin of the lowest cutaneous perforators
of the ap. The peroneal ap is isolated on the proximal
peroneal pedicle.
Reversed Pattern of the Flap (Fig. 7–15)
If a reversed skin ap is required, the peroneal vessels
(5) are severed proxim al to the origin of the upper
cutaneous perforators of the ap. The distal pedicle can
be dissected up to the ankle region. However, the proximal
ends of the peroneal vein should be anastomosed to the
veins in the recipient site. If the lesser saphenous vein
has been taken with the ap, this can serve as additional
venous drainage.
Figure 7–14
Flap completion.
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.
7. Extensor m.
8. Peroneus longus and brevis mm.
Figure 7–15
Reversed pattern of the ap.
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.

Cross-Sectional Diagram (Fig. 7–16)
This is a diagram of the cross section of the peroneal ap.
288
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–16
Cross-sectional diagram.
1. Soleus and gastrocnemius mm.
2. Septocutaneous perforators
3. Flexor hallucis longus m.
4. Fibula bone
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.
7. Extensor m.
8. Peroneus longus and brevis mm.

FIBULAR OSTEOCUTANEOUS FLAP
289
FIBULAR OSTEOCUTANEOUS FLAP
Flap Design (Fig. 7–17)
The skin ap is designed and the bula m arked, as in
the peroneal ap and vascularized bula bone graft
procedures. The size and shape of the skin markings,
the length of the bula, and the relationship of the skin
and bone should follow requirements at the recipient
site. Usually, the skin ap should be about one fth
larger than the size of the defect, and the bular graft
should be 4 cm longer than the defect, for proper xation
of both ends.
Approach to the Posterior Crural
Septum (Fig. 7–18)
The posterior and anterior portions of the ap, along with
the deep fascia, are elevated toward the posterior crural
septum, near to where the septocutaneous or musculo-
cutaneous perforators (2) can be seen emerging from the
septum or muscles into the subcutaneous layer.
Figure 7–17
Flap design.
1. Soleus and gastrocnemius mm.
2. Septocutaneous perforators
3. Flexor hallucis longus m.
4. Fibula bone
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.
7. Extensor m.
8. Peroneus longus and brevis mm.
9. Interosseous membrane
Figure 7–18
Approach to the posterior crural septum.
1. Soleus and gastrocnemius mm.
2. Septocutaneous perforators
7. Extensor m.
8. Peroneus longus and brevis mm.

Osteotomy and Dissection of the
Peroneal Vessels (Fig. 7–19)
The bula (4) is divided at each end with a Gigli saw,
according to the length needed. The severed fibula
can then be rotated on its long axis to facilitate further
dissection.
The septocutaneous branches are traced and
dissected toward their origins from the peroneal
vessels (5) while the soleus muscle is being detached
from the bula (leaving a 0.5-cm m uscle fringe to
the bula), and the exor hallucis longus muscle (3) is
separated.
The peroneal vessels (5) are ligated distally and
cut, with the proxim al side vessels kept intact as a
pedicle.
290
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–19
Osteotomy and dissection
of the peroneal vessels.
3. Flexor hallucis longus m.
4. Fibula bone
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.

FIBULAR OSTEOCUTANEOUS FLAP
291
Completion of the Osteocutaneous
Flap (Fig. 7–20)
Subsequent procedures on the anterior and medial
aspects of the bula are similar to a free bula transfer.
However, special attention should be paid to keep the
bone and skin ap intact, with the peroneal vessels (5)
and their circular arteries and the posterior crural
septum; the cutaneous perforators should not be injured.
The entire bular osteocutaneous ap is then
isolated, connected to the lower leg only by its vascular
pedicle (5).
Figure 7–20
Completion of the osteocutaneous ap.
5. Peroneal a. and v.
6. Posterior tibial a., v., and n.
8. Peroneus longus and brevis mm.
9. Interosseous membrane

Cross-Sectional Diagram (Fig. 7–21)
This is a diagram of the cross section of a bular osteo-
cutaneous ap.
292
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–21
Cross-sectional diagram.
1. Soleus and gastrocnemius mm.
6. Posterior tibial a., v., and n.
2. Septocutaneous perforators
7. Extensor m.
3. Flexor hallucis longus m.
8. Peroneus longus and brevis mm.
4. Fibula bone
9. Interosseous membrane
5. Peroneal a. and v.

FIBULAR OSTEOMUSCULAR TRANSFER (WITH THE SOLEUS MUSCLE)
293
FIBULAR OSTEOMUSCULAR TRANSFER
(WITH THE SOLEUS MUSCLE)
Incision (Fig. 7–22)
The patient is placed in a prone position. The incision
begins from the popliteal fossa, running inferolaterally
to the back of the head of the bula, then proceeding
downward along the posterior edge of the bula.
Figure 7–22
Incision.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Popliteal m.
4. Popliteal a., v., and tibial n.
5. Flexor hallucis longus m.
6. Peroneal a. and v.
7. Tibialis posterior m.
8. Fibula bone
9. Interosseous membrane
10. Peroneotibial a. and v.
Exposure of the Soleus (Fig. 7–23)
The skin and deep fascia are incised, and the superior
attachment of the lateral gastrocnemius (1) then detached
from the femur. The gastrocnemius, with its overlying
skin as a ap, is turned medially to expose the soleus
muscle (2).
Figure 7–23
Exposure of the soleus.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Popliteal m.
4. Popliteal a. and v. and tibial n.

Splitting the Soleus and Identifying
the Neurovascular Structures
(Fig. 7–24)
The m uscle (2) is split longitudinally on its midline, and
the muscle belly (its lateral portion) is retracted laterally
to expose the peroneotibial vessels (10), accompanied
by the posterior tibial nerve (4). Tracing the vessels
downward, the peroneal vessels (6) can be seen running
obliquely toward the bula and giving off one or two
m uscular branches to the soleus w ith a diam eter of
more than 1 mm, usually 4 cm after the origin of the
peroneal artery.
294
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–24
Splitting the soleus and identifying the
neurovascular structures.
2. Soleus m.
4. Popliteal a. and v. and tibial n.
5. Flexor hallucis longus m.
6. Peroneal a. and v.
7. Tibialis posterior m.
10. Peroneotibial a. and v.

Osteotomy (Fig. 7–25)
The required length of bula (8) is divided by a Gigli
saw, and the lateral part of the soleus m uscle (2) is
severed at the sam e levels as the divided upper and
lower ends of the bula. The peroneal vessels (6) are
ligated and divided distally. It is not necessary to
separate the soleus from the bular segment if it is to
be used only for coverage of the bular graft.
Completion of Osteomuscular Flap
Harvesting (Fig. 7–26)
Subsequent steps, such as detaching the peroneus,
extensor, and tibialis posterior muscles, are similar to
those for a free bular transfer. Care should be taken
not to dam age the m uscular branches to the soleus
muscle (2).
FIBULAR OSTEOMUSCULAR TRANSFER (WITH THE SOLEUS MUSCLE)
295
Figure 7–25
Osteotomy.
2. Soleus m.
5. Flexor hallucis longus m.
6. Peroneal a. and v.
7. Tibialis posterior m.
8. Fibula bone
Figure 7–26
Completion of osteomuscular ap harvesting.
2. Soleus m.
5. Flexor hallucis longus m.
6. Peroneal a. and v.
7. Tibialis posterior m.
8. Fibula bone
9. Interosseous membrane

Cross-Sectional Diagram (Fig. 7–27)
This is a diagram of the cross section of a bular osteo-
muscular transfer.
296
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–27
Cross-sectional diagram.
1. Lateral head of gastrocnemius m.
2. Soleus m.
5. Flexor hallucis longus m.
6. Peroneal a. and v.
7. Tibialis posterior m.
8. Fibula bone
9. Interosseous membrane

GASTROCNEMIUS FLAP
Anatomy (Fig. 7–28A, B)
The origin of the m uscle involves two heads (1,2)
arising from the lateral and m edial condyles of the
femur, the adjacent capsule of the knee, and the insertion
is the calcaneal tendon (3). The gastrocnemius functions
for plantar exion of the foot and exion of the knee
joint. The two muscle heads, medial (1) and lateral (2),
unite at about the level of the head of the bula; they
join the tendon of the soleus at the m iddle level of the
leg to form the Achilles tendon (3).
6. Lateral sural a.
7. Soleus m.
8. Plantaris
9. Tibial m.
10. Common peroneal n.
Figure 7–28A, B
Anatomic diagram of the gastrocnemius and its blood supply.
1. Medial head of gastrocnemius
2. Lateral head of gastrocnemius
3. Achilles tendon
4. Popliteal a.
5. Medial sural a.
GASTROCNEMIUS FLAP
297
B
A

Measurements
Length (cm)
Width (cm)
Thickness (cm)
Muscle Belly
Medial head
23
7.0
1.7
Lateral head
23
8.1
1.7
The broadest portions of both heads are located
6 cm below the head of the bula.
Blood Supply
Each head has an independent vascular unit. The me-
dial and lateral sural arteries (5,6) arise from the
popliteal artery (4), 3 to 4 cm above the head of the
bula and, respectively, enter the m edial (1) and lateral
(2) heads of the gastrocnemius at about the level of the
bular head.
Measurements
Length of
Diameter (mm)
Pedicle (cm)
Medial sural vessels
Artery
1.4
2.6
Vein
1.4
Lateral sural vessels
Artery
1.5
2.2
Vein
1.4
Innervation
The paired m otor nerves come from the tibial nerve and
enter each head of the muscle adjacent to the vascular
pedicle.
298
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Microvascular transfer of the gastrocnemius m uscle or
myocutaneous ap is not widely applied clinically. The
vascular anatomy is, however, quite constant and the
calibers of the pedicles are adequate, but pedicle length
is som ew hat short. Rem oval of the m uscle does not
result in obvious disability or morbidity, although loss
of part of the plantar exor may lessen jumping and
running ability to a certain extent. Local transfer of the
m uscle or m usculocutaneous ap as an island ap,
applied to cover the upper half of the tibia or the knee
joint, is more commonly utilized.
For coverage of the lower half of the tibia using
m icrovascular technique, a free medial gastrocnemius
ap can be transferred by lengthening the medial sural
artery w ith a segm ent graft of the lesser saphenous
vein. (The sural vein can be directly anastomosed to the
lesser or greater saphenous.)
Myocutaneous ap transfer causes substantial
contour deformity, either from depression and scar in
the donor calf or from bulk in the recipient area. For
these reasons, the muscle ap with split-thickness skin
graft might be preferred.
COMMENT AND INSIGHTS

MEDIAL GASTROCNEMIUS MUSCLE FLAP
Incision (Fig. 7–29)
With the patient in a prone or semilateral position, a
midposterior S-shaped incision is made starting 5 cm
above the popliteal crease and extending down to the
distal end of the muscle belly.
MEDIAL GASTROCNEMIUS MUSCLE FLAP
299
Exposure of the Neurovascular
Structures in the Popliteal Fossa
(Fig. 7–30)
The lesser saphenous vein and medial sural nerve (3)
are identi ed and retracted laterally. The m edial and
lateral heads of the muscle (1,2) are then separated to
expose the tibial nerve (4) and the popliteal vessels (4).
Figure 7–30
Exposure of the neurovascular
structures in the popliteal fossa.
1. Medial head of gastrocnemius m.
2. Lateral head of gastrocnemius m.
3. Lesser saphenous v. and medial sural n.
4. Popliteal a. and v. and tibial n.
Figure 7–29
Incision.
1. Medial head of gastrocnemius m.
2. Lateral head of gastrocnemius m.
3. Lesser saphenous v. and medial sural n.
4. Popliteal a. and v. and tibial n.
5. Soleus m.
6. Medial sural a. and v. and muscular
branch of tibial n.
7. Plantaris m.

Identifying the Neurovascular Bundle
to the Medial Head of the Muscle
(Fig. 7–31)
Tracing along the m edial and anterior surfaces of the
medial head of the muscle (1), the medial sural vessels
(6) and accom panying nerve (6) are identi ed and
dissected from the entrance of the m uscle (1) to the
origins of the popliteal vessels (4) and tibial nerve (4).
300
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–31
Identifying the neurovascular bundle to the
medial head of the muscle.
1. Medial head of gastrocnemius m.
4. Popliteal a. and v. and tibial n.
5. Soleus m.
6. Medial sural a. and v. and muscular branch of tibial n.
7. Plantaris m.

MEDIAL GASTROCNEMIUS MUSCLE FLAP
301
Isolating the Muscle (Fig. 7–32)
The super cial surface of the medial head (1) is exposed,
and the plane between the gastrocnemius (1) and soleus
(5) is developed by blunt dissection, with care being
taken to protect the neurovascular bundle (6).
Figure 7–32
Isolating the muscle.
1. Medial head of gastrocnemius m.
5. Soleus m.
6. Medial sural a. and v. and muscular branch
of tibial n.
7. Plantaris m.

Completion of Muscle Flap Harvesting
(Fig. 7–33)
Detaching its origin on the medial condyle of the femur
and separating its lower m uscle bers from the Achilles
tendon, the m edial gastrocnem ius m uscle ap (1) is
isolated on the medial sural neurovascular pedicle (6)
with a length of 3 cm.
302
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–33
Completion of muscle ap harvesting.
1. Medial head of gastrocnemius m.
5. Soleus m.
6. Medial sural a. and v. and muscular branch of tibial n.
7. Plantaris m.

LATERAL GASTROCNEMIUS MUSCLE FLAP
303
LATERAL GASTROCNEMIUS MUSCLE FLAP
Incision (Fig. 7–34)
The lateral gastrocnem ius m uscle ap can be raised
with a m aneuver sim ilar to the m edial ap, but the
incision is Z-shaped.
Figure 7–34
Incision.
1. Medial head of
gastrocnemius m.
2. Lateral head of
gastrocnemius m.
3. Lesser saphenous v.
and medial sural n.
4. Popliteal a. and v.
and tibial n.
5. Soleus m.
6. Lateral sural a. and v.
and muscular branch
of tibial n.
7. Plantaris m.
8. Common peroneal n.
9. Biceps femoris
tendon

Completion of Harvesting (Fig. 7–35)
Since the common peroneal nerve (8) passes between
the lateral head of the gastrocnem ius (2) and the
tendon of the biceps femoris (9), particular attention
should be paid to preserve the nerve during isolation of
the origin of the lateral head during harvesting. This is a
similar procedure to that for the medial gastrocnemius
muscle ap.
304
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–35
Completion of harvesting.
1. Medial head of gastrocnemius m.
2. Lateral head of gastrocnemius m.
3. Lesser saphenous v. and medial sural n.
4. Popliteal a. and v. and tibial n.
5. Soleus m.
6. Lateral sural a. and v. and muscular branch of
tibial n.
7. Plantaris m.
8. Common peroneal n.
9. Biceps femoris tendon

SAPHENOUS FLAP
305
SAPHENOUS FLAP
Anatomy (Fig. 7–36)
The territory of the skin ap is nourished by the saphe-
nous artery (6), a branch of the descending genicular
artery (5), which arises from the femoral artery (4) 15
cm above the knee. This is just proximal to the opening
in the adductor magnus in the lower part of the adductor
canal (3). The descending genicular artery (5) immediately
divides into two equal branches, the musculoarticular
branch (7) and the saphenous artery (6). The diam eter
of the latter ranges from 1.2 to 1.8 mm.
The saphenous artery (6) pierces the aponeurosis
roof of the adductor canal (3) within 2 cm of its origin
and then runs downward between the sartorius (1) and
vastus medialis (2) muscles and the adductor tendon
for a distance of 12 to 15 cm. It then gives off one to four
important cutaneous branches to supply a large area of
skin m edially above the knee. Som e branches pass
anterior to the sartorius, and others posterior to it.
The term inal (distal) saphenous artery passes
between the sartorius (1) and gracilis (8) tendons and is
distributed to the skin of the upper and medial portions
of the leg below the knee.
There are two system s for venous drainage: the
paired venae com itantes and the greater saphenous
vein that lies 1.5 cm posterior to the course of the
saphenous artery.
Figure 7–36
Anatomy of the saphenous artery.
1. Sartorius m.
2. Vastus medialis m.
3. Adductor canal
4. Femoral a.
5. Descending genicular a.
6. Saphenous a.
7. Musculoarticular branch
8. Gracilis m.

306
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
The donor site provides a sensory skin ap innervated
by two nerves that can be easily identi ed during ap
dissection. The skin of the ap is quite thin, less than
1 cm in thickness. Anatomically, the length and caliber
of the vascular pedicle are generally adequate, but there
can be anatomic variation of the saphenous vessels and
their cutaneous branches. It is som etim es necessary
that nal ap design m ust follow a tedious vascular
dissection and exploration.
A split-thickness skin graft should be used when-
ever the w idth of the donor defect is m ore than 7 cm .
Postoperatively, there is no resultant m orbidity, but
the scar left after skin graft m ay not be cosm etically
acceptable.
COMMENT AND INSIGHTS
Variations
In 5% of cases, the artery is absent and in 6.7% of cases,
there is an additional unnam ed cutaneous artery from
the popliteal artery or musculoarticular branch of the
descending genicular artery.
Innervation
The medial femoral cutaneous nerve supplies the skin
territory above the knee. It runs near the anterior
border of the sartorius close to the deep fascia.
The saphenous nerve supplies the anterom edial
aspect of the leg below the knee. It courses sequentially
in close proximity to the femoral artery, the descending
genicular artery, the saphenous artery, and the greater
saphenous vein.

SAPHENOUS FLAP
307
Harvesting Technique
Flap Design (Fig. 7–37)
The anatomy of the saphenous artery and its cutaneous
branches is intim ately involved with the sartorius
m uscle. Therefore, a line is drawn from the anterior
superior iliac spine (ASIS) to the medial supracondyle of
the tibia to follow the course of the sartorius. The ap
can be designed primarily along the distal part of this
line as an axis, with its proximal edge 12 cm above the
knee joint. The largest aps reported are 29 8 cm and
15 11 cm.
Figure 7–37
Flap design.
1. Vastus medialis m.
2. Gracilis m.
3. Greater saphenous v.
4. Medial femoral cutaneous n.
5. Sartorius m.
6. Saphenous a., v., and n.
7. Anterior cutaneous branch
8. Roof of adductor canal

Identifying the Super cial Structures
Proximal to the Flap (Fig. 7–38)
A 10-cm incision is made along the course of the sartorius
above the designed ap. The medial femoral cutaneous
nerve (4) and greater saphenous vein (3) are rst
isolated near the anterior and posterior borders of the
sartorius (5).
308
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–38
Identifying the super cial
structures proximal to the ap.
1. Vastus medialis m.
2. Gracilis m.
3. Greater saphenous v.
4. Medial femoral cutaneous n.
5. Sartorius m.

SAPHENOUS FLAP
309
Approach to the Saphenous Vessels
(Fig. 7–39)
The deep fascia is incised and the sartorius (5) is bluntly
dissected in the upper part of the incision and separated
from the vastus medialis (1) to expose the saphenous
neurovascular bundle (6).
Tracing the saphenous vessel (6) distally, the
cutaneous perforators (7) can be found passing over the
anterior or posterior border of the sartorius (5) to
supply the overlying skin. If it is necessary to expose
and dissect the cutaneous perforators (7) more easily
and safely, the sartorius (5) can be divided or even a
segment of the m uscle can be included in the ap.
Figure 7–39
Approach to the saphenous vessels.
1. Vastus medialis m.
3. Greater saphenous v.
4. Medial femoral cutaneous n.
5. Sartorius m.
6. Saphenous a., v., and n.
7. Anterior cutaneous perforator
8. Roof of adductor canal

Completion of Flap Harvesting
(Fig. 7–40)
The designed ap is adjusted anteriorly or posteriorly,
according to the major cutaneous perforators uncovered.
The greater saphenous vein (3) is ligated at the
distal ap m argin and the saphenous ap, including
deep fascia, is raised based on the saphenous neurovas-
cular pedicle (6), the greater saphenous vein (3), and
the medial femoral cutaneous nerve (4). The saphenous
neurovascular bundle can be further dissected to
achieve a length varying from 4 to 16 cm.
310
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–40
Completion of ap harvesting.
1. Vastus medialis m.
3. Greater saphenous v.
4. Medial femoral cutaneous n.
5. Sartorius m.
6. Saphenous a., v., and n.
7. Anterior cutaneous perforator
8. Roof of adductor canal

ANTERIOR TIBIAL FLAP
311
ANTERIOR TIBIAL FLAP
Anatomy (Fig. 7–41)
The anterior tibial artery (2) arises from the popliteal
artery (1) at the lower border of the popliteus muscle. It
passes through the tibialis posterior m uscle and the
interosseous mem brane to the anterior compartment
medial to the neck of the bula, then descends in front
of the interosseous m em brane and the tibia in the
lower part of the leg, accompanied by the deep peroneal
nerve (7). In front of the ankle, it appears m idway
between the malleoli.
In its course, the artery gives off two septocutaneous
branches into the anterior crural intermuscular septum
between the anterior and peroneal compartments.
The superior lateral peroneal artery (3) origi-
nates 8 cm below the head of the fibula. Accom pa-
nying the superficial peroneal nerve, it runs
dow nward and superficially in the septum in the up-
per third of the leg, under the fascia in the m iddle
third, and above the fascia in the lower third, giving
off a cutaneous perforator in the m iddle third. The
artery, w ith an average diam eter of 1.6 m m , is pres-
ent in 100% of cases.
The inferior lateral peroneal artery (4) originates
17 cm below the head of the fibula, that is, at the
level of the fibular m idpoint. Accom panying the
superficial peroneal nerve (6), it com m unicates w ith
the superior lateral peroneal artery (3). The artery,
w ith an average diam eter of 1.4 m m , is present in 70%
of cases.
Figure 7–41
Anatomy of the anterior tibial ap.
1. Popliteal a.
2. Anterior tibial a.
3. Superior lateral peroneal a.
4. Inferior lateral peroneal a.
5. Common peroneal n.
6. Super cial peroneal n.
7. Deep peroneal n.

Harvesting Technique
Flap Design (Fig. 7–42)
A line is drawn from the anterior edge of the head of
the bula to the anterior edge of the lateral malleolus.
The ap is designed on the middle and lower thirds of the
leg, with this line as an axis. Maximum size may be as
large as 10 cm wide and 20 cm long.
312
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
The anterior tibial ap is a septocutaneous ap, and its
septocutaneous perforators come from the anterior tibial
artery through the anterior crural intermuscular septum
between the anterior and peroneal compartments.
There have been relatively few cases of revascular-
ized anterior tibial aps reported because use of the
ap demands sacri ce of the anterior tibial artery, even
though the arterial anatomy is quite constant. For this
reason, arteriography should routinely be done to con-
rm the existence of both the posterior and anterior
tibial arteries if the ap is to be used.
There are several case reports indicating that the
superior or inferior lateral peroneal artery can provide
an independent vascular pedicle for this ap in a local
transfer, to cover soft-tissue defects of the knee or ankle
joint. Because there may be no communication between
the superior and inferior lateral peroneal arteries in
40% of cases, these kinds of pedicle aps are not
introduced here.
The skin in the anterior aspect of the lower leg has
m oderate thickness and is quite hairy in m ales. The
donor site generally needs a split-thickness skin graft
after rem oval of a skin ap more than 3 cm wide.
Compared with other donor sites, the anterior
tibial ap is not a prim ary choice for revascularized
transfer; local transfers as island aps are acceptable.
COMMENT AND INSIGHTS
Figure 7–42
Flap design.
1. Anterior tibial artery and deep peroneal n.
2. Inferior lateral peroneal a.
3. Superior lateral peroneal a.
4. Extensor digitorum longus m.
5. Tibialis anterior m.
6. Interosseous membrane
7. Peroneus longus and brevis mm.
8. Soleus m.
9. Super cial peroneal n.

ANTERIOR TIBIAL FLAP
313
Anterior Elevation and Identi cation of
Neurovascular Bundle (Fig. 7–43)
The anterior portion of the ap with deep fascia is
raised from the extensor muscles (4,5) toward the ante-
rior crural intermuscular septum between the anterior
and peroneal compartments. Usually, the neurovascular
bundle is rst found at the distal margin of the ap. The
super cial peroneal nerve (9) is large, but the septocu-
taneous artery is small. The nerves are traced to identify
the inferior lateral peroneal (2) and the anterior tibial
arteries (1), and the latter is ligated distal to the origin
of the artery.
Figure 7–43
Anterior elevation and
identi cation of neurovascular bundle.
1. Anterior tibial a. and deep peroneal n.
2. Inferior lateral peroneal a.
4. Extensor digitorum longus m.
5. Tibialis anterior m.
9. Super cial peroneal n.

Further Dissection of the Vascular Bundle
(Fig. 7–44)
Detaching the extensors digitorum and hallucis longus
from the bula and interosseous m em brane (6), the
dissection is continued to identify the superior lateral
peroneal artery (3). The super cial peroneal nerve (9) is
separated from the septocutaneous vessels, leaving it
intact. Meanwhile, the posterior portion of the ap is
developed gradually, from distal to proximal.
314
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–44
Further dissection of the vascular
bundle.
1. Anterior tibial a. and deep peroneal n.
2. Inferior lateral peroneal a.
3. Superior lateral peroneal a.
4. Extensor digitorum longus m.
5. Tibialis anterior m.
6. Interosseous membrane
7. Peroneus longus and brevis mm.
8. Soleus m.
9. Super cial peroneal n.

ANTERIOR TIBIAL FLAP
315
Completion of Flap Harvesting (Fig. 7–45)
The superior lateral peroneal artery (3) is dissected to
its origin on the anterior tibial artery (1).
The entire ap is raised, based on the superior and
inferior lateral peroneal vessels and the anterior tibial
vessels, with a pedicle length ranging from 6 to 9 cm,
depending on the location of the designed ap.
Figure 7–45
Completion of ap harvesting.
1. Anterior tibial a. and deep peroneal n.
2. Inferior lateral peroneal a.
3. Superior lateral peroneal a.

Cross-Sectional Diagram (Fig. 7–47)
This is a diagram of the cross section of the anterior
tibial ap.
316
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–46
Reverse pattern of ap
harvesting.
1. Anterior tibial a. and deep peroneal n.
4. Extensor digitorum longus m.
5. Tibialis anterior m.
6. Interosseous membrane
7. Peroneus longus and brevis mm.
8. Soleus m.
Figure 7–47
Cross-sectional diagram.
1. Anterior tibial a. and deep peroneal n.
2. Inferior lateral peroneal a.
3. Superior lateral peroneal a.
4. Extensor digitorum longus m.
5. Tibialis anterior m.
7. Peroneus longus and brevis mm.
8. Soleus m
REVERSE ANTERIOR TIBIAL ISLAND FLAP
Reverse Pattern of Flap Harvesting
(Fig. 7–46)
This ap is designed on the upper and m iddle thirds of
the leg. After raising the ap with the superior and in-
ferior lateral peroneal vessels and the septum isolated,
the anterior tibial vessels are ligated above the origin
of these septocutaneous vessels. They are then freed
downward from the deep peroneal nerve to reach a
suf cient pedicle length for a distal transfer. It is sug-
gested that the proxim al end of the anterior tibial vein
be anastom osed to a vein at the recipient site.

MEDIAL LEG FLAP
317
MEDIAL LEG FLAP
Anatomy of the Posterior Tibial Artery
(Fig. 7–48)
After bifurcating from the anterior tibial artery (2), the
vessel (1) runs between the soleus and exor digitorum
longus or tibialis posterior, accompanied by two veins
and the tibial nerve.
In its course, it gives off about four or more septo-
cutaneous perforators (4) along the m edial border of
the tibia, passing through the deep transverse fascial
septum . These septocutaneous perforators em erge to
the subcutaneous layer just behind the medial border
of the tibia. The diam eter of these arteries varies from
0.5 to 1.5 cm.
Figure 7–48
Anatomy of the posterior tibial artery.
1. Posterior tibial a.
2. Anterior tibial a.
3. Peroneal a.
4. Septocutaneous perforators

Harvesting Technique
Flap Design (Fig. 7–49)
The posterior edge of the tibia corresponds to the
vascular axis, but the anterior border is drawn only a
little over this line to avoid exposing the tibia and its
periosteum; the posterior border is limited to the pos-
terior midline. The ap should be sited on the midportion
of the leg, and a successful ap size of 22 9 cm has
been reported.
318
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
The m edial tibial flap is a septocutaneous flap, and
its septocutaneous perforators com e from the poste-
rior tibial artery through the deep transverse fascial
septum , em erging along the m edial border of the
tibia.
There have been relatively few cases of revascular-
ized medial leg aps reported because the ap requires
the sacri ce of the posterior tibial artery, even though
the arterial anatomy is quite reliable. For this reason,
arteriography should be routinely done to con rm the
existence of both the posterior and anterior tibial arter-
ies before harvesting the ap.
The skin in the medial aspect of the lower leg has
moderate thickness, but the donor site generally needs a
split-thickness skin graft after removal of a skin ap more
than 3 cm wide. Even so, a cosmetic problem remains.
Compared with other donor sites, the medial leg is
not a primary choice for transfer; local transfers as is-
land aps may be acceptable.
The medial leg ap also can be combined with the
m edial plantar ap on the same pedicle of the posterior
tibial artery and its continuation, as “twin” aps. (For
the harvesting technique of the medial plantar ap, see
Chapter 8).
COMMENT AND INSIGHTS
Figure 7–49
Flap design.
1. Soleus m.
2. Tibia
3. Septocutaneous perforators
4. Posterior tibial a., v., and tibial n.
5. Flexor digitorum longus m.
6. Gastrocnemius m.

MEDIAL LEG FLAP
319
Anterior Elevation of the Flap and
Identi cation of the Septocutaneous
Perforators (Fig. 7–50)
The anterior border of the ap is incised, and the dom i-
nant septocutaneous perforators (3) are identi ed
within the midportion of the leg. Detaching the soleus
muscle (1) from the tibia (2), the septocutaneous perfo-
rators are carefully dissected.
Figure 7–50
Anterior elevation of the ap and
identi cation of the septocutaneous perforators.
1. Soleus m.
2. Tibia
3. Septocutaneous perforators
5. Flexor digitorum longus m.

Posterior Elevation of the Flap and Exposure
of the Posterior Tibial Vessels (Fig. 7–51)
The posterior portion of the ap with deep fascia is
raised toward the septum behind the tibia. Tracing these
branches, the posterior tibial vessels (4) are widely
exposed. Ligating the several muscular branches, a seg-
ment of the posterior tibial vessels can be provided, in
case it should be required for graft at the recipient site.
320
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–51
Posterior elevation of the ap and
exposure of the posterior tibial vessels.
1. Soleus m.
4. Posterior tibial a. and v., and tibial n.
5. Flexor digitorum longus m.
6. Gastrocnemius m.

MEDIAL LEG FLAP
321
Completion of Flap Harvesting (Fig. 7–52)
Ligating and dividing the distal end of the vascular
segment, the entire ap is raised on the proximal pedicle
of the posterior tibial vessels (4).
If a sensory ap is needed, the saphenous nerve
should be included with the ap.
Figure 7–52
Completion of ap harvesting.
4. Posterior tibial a. and v., and tibial n.
5. Flexor digitorum longus m.
6. Gastrocnemius m.

Cross-Sectional Diagram (Fig. 7–53)
A diagram of the cross section of the medial leg ap.
322
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–53
Cross-sectional diagram.
1. Soleus m.
2. Tibia
3. Septocutaneous perforators
4. Posterior tibial a. and v., and tibial n.
5. Flexor digitorum longus m.
6. Gastrocnemius m.

POSTERIOR LEG FLAP
323
POSTERIOR LEG FLAP
Anatomy (Fig. 7–54)
There are two to three axial fasciocutaneous branches
from the popliteal artery (1) or medial and lateral sural
arteries to supply the posterior skin of the leg. One of
them , the super cial sural artery (3), accompanies the
lesser saphenous vein and the medial sural nerve (3).
However, the dominant axial artery, the lateral popliteal
cutaneous artery (2), arises at the level of the tibial
condyle in the cleft between the heads of the gastroc-
nemius. It then runs inferolaterally to accompany the
lateral sural nerve (5) under the deep fascia. Usually, it
can be identi ed at the midpoint between the posterior
midline and the bular head.
The artery pierces the deep fascia 4 cm below the
tibial condyle and continues downward, terminating at
the m edial side of the Achilles tendon. The vessel has an
average diameter of 1.2 mm, with a range from 1.0 to
1.7 m m . It is accom panied by two venae com itantes
with diameters of 2.0 mm.
Innervation
The upper portion of the ap is innervated by the
posterior cutaneous nerve of the thigh. That of the lower
portion of the ap is from the lateral sural nerve.
Figure 7–54
Anatomy of the posterior leg ap.
1. Popliteal a. and tibial n.
2. Lateral popliteal cutaneous a.
3. Super cial sural a. and medial sural n.
4. Medial popliteal cutaneous a.
5. Lateral sural n.
6. Sural n.
7. Common peroneal n.
8. Medial sural a.
9. Lateral sural a.

Variations in Origin of the Lateral Popliteal
Cutaneous Artery (Fig. 7–55)
These variations include:
A. Directly from the popliteal artery (65%)
B. From the lateral sural artery (10%)
C. From the medial sural artery (15%)
D. From another cutaneous artery (20%)
324
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–55
Variations in the origin of the lateral
popliteal cutaneous artery (see text for details).
1. Popliteal a. and tibial n.
2. Lateral popliteal cutaneous a.
8. Medial sural a.
9. Lateral sural a.

POSTERIOR LEG FLAP
325
Harvesting Technique
Flap Design (Fig. 7–56)
The patient is placed in a prone or lateral decubitus
position. The posterior midline is marked and the ap is
designed within the following boundaries: m edially
and laterally, up to each midline of the leg; superiorly,
up to the superior exion crease of the calf; inferiorly, up
to the junction of the middle and lower thirds of the leg.
The largest ap size reported is 11 19 cm.
The posterior leg ap is an axial fasciocutaneous ap;
its axial fasciocutaneous branches com e from the
popliteal artery.
Because of the variable anatomy and relatively
small size of the axial fasciocutaneous branches from
the popliteal artery, the posterior leg ap may be some-
what dif cult to harvest and therefore less reliable.
The skin on the posterior aspect of the lower leg
has m oderate thickness, but the donor site generally
needs a split-thickness skin graft after removal of a skin
ap m ore than 3 cm wide. Even so, a cosmetic problem
remains.
Compared with other donor sites, the posterior leg is
not a primary choice for transfer; local transfers as island
aps are more acceptable. The island fasciocutaneous ap
is based on the proximal fascial layer below the popliteal
fossa as the pedicle of the ap; the vascular structure is
included in the fascia and need not be dissected out.
COMMENT AND INSIGHTS
Figure 7–56
Flap design.
1. Gastrocnemius m.
2. Lateral popliteal cutaneous a.
3. Lateral sural n.
4. Sural n.
5. Lesser saphenous v., super cial sural a., and medial sural n.
6. Popliteal a. and tibial n.
7. Posterior cutaneous n. of thigh

Distal Elevation of the Flap and Identi cation
of the Cutaneous Vessels (Fig. 7–57)
The ap with deep fascia is elevated from distal to
proximal. The sural nerve (4) and lesser saphenous vein
(5) are divided at the lower border of the ap and
included with it.
Special attention should be paid to the dissection
on the superior lateral ap edge to identify the lateral
sural nerve (3) and the dom inant vessel (2) that are
located between the posterior midline and the head of
the bula under deep fascia.
326
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–57
Distal elevation of the ap and identi cation of
cutaneous vessels.
1. Gastrocnemius m.
2. Lateral popliteal cutaneous a.
3. Lateral sural n.
4. Sural n.
5. Lesser saphenous v., super cial sural a., and medial sural n.
7. Posterior cutaneous n. of thigh

POSTERIOR LEG FLAP
327
Completion of Flap Elevation and Further
Dissection of Vascular Pedicle (Fig. 7–58)
The posterior cutaneous nerve of the thigh (7), the
m edial sural nerve (5), and the lesser saphenous
vein (5) are isolated and divided on the superior border
of the ap under deep fascia. The posterior leg ap is
isolated on the lateral popliteal cutaneous vessels (2);
these can be dissected further to the vessel origin to
achieve a pedicle length of 8 to 12 cm.
Figure 7–58
Completion of ap elevation
and further dissection of vascular pedicle.
1. Gastrocnemius m.
2. Lateral popliteal cutaneous a.
5. Lesser saphenous v., super cial sural a.,
and medial sural n.
6. Popliteal a. and tibial n.
7. Posterior cutaneous n. of thigh