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

RECIPIENT SITE EXPOSURES
329
EXPOSURE OF THE ROOF OF THE ADDUCTOR
CANAL (FIG. 7 – 6 0 )
While undermining, the greater saphenous vein can be
seen posterior to the incisions. The deep fascia is divided
anterior to the sartorius m uscle (1), which is then
retracted posteriorly. The saphenous vessels and nerve
(5) are beneath the m uscle, piercing the aponeurosis
roof of the adductor canal and running over the adductor
tendon (3). The saphenous nerve should be preserved.
Figure 7–60
Exposure of the roof of the
adductor canal.
1. Sartorius m.
2. Vastus medialis m.
3. Adductor tendon
4. Adductor tubercle
5. Saphenous a. and n.

IDENTIFICATION OF THE POPLITEAL
ARTERY (FIG. 7 – 61 )
The vastus m edialis m uscle (2) is retracted anteriorly
and the adductor tendon (3) is divided. The popliteal
artery (6) is identi ed posterior to the femur (7); it is
the most super cial (medial) vessel in the neurovascular
structure in the fossa. The m edial superior genicular
artery and medial sural artery may arise from the medial
aspect of the popliteal artery.
330
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–61
Identi cation of the
popliteal artery.
1. Sartorius m.
2. Vastus medialis m.
3. Adductor tendon
4. Adductor tubercle
5. Saphenous a. and n.
6. Popliteal a. and v.
7. Posterior edge of femur

RECIPIENT SITE EXPOSURES
331
Medial Approach to the Middle Portion
of the Popliteal Artery
INCISION (FIG. 7 – 6 2 )
The patient is placed in the supine position and the
affected foot is placed on the contralateral shin, with
the knee exed. The skin incision used for the proximal
portion of the artery is extended distally to the medial
condyle of the tibia.
Figure 7–62
Incision.
1. Sartorius m.
2. Vastus medialis m.
3. Medial head of gastrocnemius m.
4. Common tendon of gracilis,
semimembranosus, and semitendinosus
5. Saphenous a. and n.
6. Greater saphenous v.
7. Popliteal a. and v.
8. Tibial n.

EXPOSURE OF THE M EDIAL HAMSTRING
(FIG. 7 – 6 3 )
After the greater saphenous vein (6) and sartorius muscle
(1) are identi ed, the deep fascia is divided between the
sartorius and medial hamstring tendons (4). The gracilis
(4), semimembranosus (4), and sem itendinosus (4) ten-
dons are usually combined to form a com mon tendon
(4). While dissecting between them , the saphenous
vessels and nerve (5) are seen emerging between the
sartorius and gracilis at the knee joint at a subcutaneous
level and running distally with the greater saphenous
vein.
332
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–63
Exposure of the medial
hamstring.
1. Sartorius m.
2. Vastus medialis m.
3. Medial head of gastrocnemius m.
4. Common tendon of gracilis,
semimembranosus, and semitendinosus
5. Saphenous a. and n.
6. Greater saphenous v.

RECIPIENT SITE EXPOSURES
333
APPROACH TO THE POPLITEAL ARTERY
(FIG. 7 – 6 4 )
After the sartorius (1) is retracted anteriorly and the
medial ham string tendons (4) are divided, the medial
head of the gastrocnnem ius (3) is identi ed and
detached from the medial condyle of the fem ur. One
centim eter of the tendinous attachment is left to facili-
tate later suturing and to avoid injuring the synovial
membrane of the knee joint.
While turning the m edial head of the m uscle
downward to expose the popliteal fossa, care should
be taken not to injure the neurovascular bundle to the
muscle.
The sheath of the popliteal artery (7) is incised. It
m ay be necessary to divide venous tributaries that
cross the artery. The tibial nerve (8) is deep to the
popliteal vein and well out of the way.
Figure 7–64
Approach to the popliteal
artery.
1. Sartorius m.
2. Vastus medialis m.
3. Medial head of gastrocnemius m.
4. Common tendon of gracilis,
semimembranosus, and
semitendinosus
5. Saphenous a. and n.
6. Greater saphenous v.
7. Popliteal a. and v.
8. Tibial n.

Medial Approach to the Distal Portion of
the Popliteal Artery
INCISION (FIG. 7 – 6 5 )
The patient is placed in the supine position. The
affected foot is placed on the contralateral shin, with
the knee exed. An incision is made from the adductor
tubercle of the femur via the m edial condyle of the tibia
and extending distally along the posteromedial border
of the tibia.
334
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–65
Incision.
1. Capsule of the knee joint
2. Tendon of sartorius
3. Common tendon of medial hamstring
4. Medial head of gastrocnemius m.
5. Soleus m.
6. Popliteal a. and v.
7. Anterior tibial a. and v.
8. Tibial n.

RECIPIENT SITE EXPOSURES
335
EXPOSURE OF THE M EDIAL HEAD OF THE
GASTROCNEMIUS (FIG. 7 – 6 6 )
The deep fascia is incised along the posterior edge of
the tibia. The tendons of insertion of the sartorius (2)
and other m edial hamstring (3) muscles are divided to
expose the medial head of the gastrocnemius (4).
Figure 7–66
Exposure of the medial head of
the gastrocnemius.
1. Capsule of the knee joint
2. Tendon of sartorius
3. Common tendon of medial hamstring
4. Medial head of gastrocnemius m.

IDENTIFICATION AND DISSECTION OF
POPLITEAL VESSELS (FIG. 7 – 6 7 )
The medial head of the gastrocnemius (4) is retracted
posteriorly away from the tibia; the origin of the soleus
(5) on the posterior aspect of the tibia is exposed. Along
the superomedial edge of the soleus, the popliteal vein
(6) is rst identi ed, then dissected and retracted to
expose the popliteal artery (6).
Dissecting the medial origin of the soleus m uscle
and tracing the popliteal vessel distally, the origin of
the anterior tibial artery (7) is found on the opposite
side of the popliteal artery at the lower border of the
popliteus muscle.
336
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–67
Identi cation and dissection of
popliteal vessels.
4. Medial head of gastrocnemius m.
5. Soleus m.
6. Popliteal a. and v.
7. Anterior tibial a. and v.
8. Tibial n.

RECIPIENT SITE EXPOSURES
337
Posterior Approach to the Popliteal Artery
INCISION (FIG. 7 – 6 8 )
The patient is placed in a prone position. An S-shaped
incision is m ade along the tendons of the m edial
hamstring vertically and the skin crease of the popliteal
fossa transversely, turning toward the lateral head of
the gastrocnemius.
Figure 7–68
Incision.
1. Medial hamstring
2. Biceps femoris
3. Medial head of gastrocnemius
4. Lateral head of gastrocnemius
5. Lesser saphenous v. and medial sural n.
6. Popliteal a. and v.
7. Peroneal n.
8. Tibial n.
9. Soleus m.
10. Popliteal m.

EXPOSURE OF SUPERFICIAL STRUCTURES
IN THE POPLITEAL FOSSA (FIG. 7 – 6 9 )
After undermining, the skin aps are retracted and the
deep fascia is incised in the midline. The lesser saphenous
vein and medial sural nerve (5) should be preserved,
especially if the vein is to be used as a recipient.
338
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–69
Exposure of super cial structures in
popliteal fossa.
1. Medial hamstring
2. Biceps femoris
3. Medial head of gastrocnemius
4. Lateral head of gastrocnemius
5. Lesser saphenous v. and medial sural n.

RECIPIENT SITE EXPOSURES
339
IDENTIFICATION AND DISSECTION OF
PROXIM AL PORTION OF POPLITEAL VESSELS
(FIG. 7 – 7 0 )
For exposure of the proximal portion of the artery, the
biceps femoris (2) is retracted laterally and the ham-
string (1) m edially. The tibial nerve (8) and com m on
peroneal nerve (7) are identi ed and protected in the
lateral wall of the fossa. The popliteal vein (6) is
exposed, following the lesser saphenous vein (5), and
retracted laterally. The popliteal artery (6) is located
behind and medial to the vein.
Figure 7–70
Identi cation and dissection of
proximal portion of popliteal vessels.
1. Medial hamstring
2. Biceps femoris
5. Lesser saphenous v. and medial sural n.
6. Popliteal a. and n.
7. Peroneal n.
8. Tibial n.

EXPOSURE OF DISTAL PORTION OF THE
POPLITEAL VESSELS (FIG. 7 – 71 )
For exposure of the distal portion, the heads of the
gastrocnemius (3,4) are retracted. The tibial nerve (8)
and the m edial sural nerve (5) are encountered rst,
then isolated and retracted laterally with nerve tape.
There may be two popliteal veins (6) behind them, and
the artery (6) may be located at the deepest level and
between the two veins.
340
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–71
Exposure of distal portion of the
popliteal vessels.
3. Medial head of gastrocnemius
4. Lateral head of gastrocnemius
5. Lesser saphenous v. and medial sural n.
6. Popliteal a. and v.
8. Tibial n.
9. Soleus m.
10. Popliteal m.

RECIPIENT SITE EXPOSURES
341
Lateral Approach to the Popliteal Artery
(Proximal Portion)
INCISION (FIG. 7 – 7 2 )
The patient is placed on the norm al side, with the
normal lim b straight. The affected knee joint is exed
30 to 60 degrees. A longitudinal incision is made along
the posterior edge of the iliotibial tract for 15 cm to
the head of the bula.
Figure 7–72
Incision.
1. Iliotibial tract
2. Vastus lateralis m.
3. Fibular collateral ligament
4. Tendon of biceps femoris
5. Short head of biceps femoris
6. Popliteal a. and v.
7. Peroneal n.
8. Tibial n.
9. Femur

APPROACH TO THE LATERAL INTERMUSCULAR
SEPTUM (FIG. 7 – 7 3 )
The deep fascia is divided along the posterior edge of the
iliotibial tract (1). Then the lateral intermuscular septum
between the biceps femoris tendon (4) and the vastus
lateralis muscle (2) is identi ed.
342
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–73
Approach to lateral
intermuscular septum.
1. Iliotibial tract
2. Vastus lateralis m.
3. Fibular collateral ligament
4. Tendon of biceps femoris
5. Short head of biceps femoris

RECIPIENT SITE EXPOSURES
343
IDENTIFICATION AND DISSECTION IN THE
POPLITEAL FOSSA (FIG. 7 – 74 )
Ligating the perforating branches to both muscles, the
iliotibial tract (1) and vastus lateralis (2) are retracted
anteriorly and the biceps (5) posteriorly.
A gap between the short head of the biceps (5) and
the posterolateral edge of the fem ur (9) is reached
above the lateral condyle. The gap is enlarged by de-
taching the attachment of the short head on the fem ur
proxim ally, and the popliteal fossa is approached by
blunt nger dissection. At rst, the comm on peroneal
and tibial nerves (7,8) are encountered in the front of
the fossa; they should be carefully protected. The
popliteal artery (6) is located behind the popliteal vein
(6). There are som e branches arising from the lateral
aspect of the artery: the lateral superior genicular artery
and the lateral sural artery.
Figure 7–74
Identi cation and
dissection in the popliteal fossa.
1. Iliotibial tract
2. Vastus lateral m.
5. Short head of biceps femoris
6. Popliteal a. and v.
7. Peroneal n.
8. Tibial n.
9. Femur

Tibioperoneal Trunk
Medial Approach to the Tibioperoneal Trunk
INCISION (FIG. 7 – 7 5 )
The patient is placed in the supine position, with the
thigh abducted and externally rotated and the knee
exed and supported. The skin incision begins from
the medial condyle of the tibia, running distally parallel
to and 3 cm posterior to the posteromedial edge of the
tibia for 10 cm.
344
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–75
Incision.
1. Tibia
2. Medial head of gastrocnemius m.
3. Soleus m.
4. Popliteus m.
5. Popliteal a. and v.
6. Tibial n.
7. Tibioperoneal trunk
8. Posterior tibial a. and v.
9. Anterior tibial a. and v.
10. Peroneal a. and v.
11. Tibialis posterior m.
12. Flexor digitorum longus m.

RECIPIENT SITE EXPOSURES
345
EXPOSURE OF THE SOLEUS (FIG. 7 – 76 )
The deep fascia is divided, and the medial head of the
gastrocnem ius (2) is retracted posteriorly; then the
soleus muscle (3) is identi ed.
Figure 7–76
Exposure of the soleus.
1. Tibia
2. Medial head of gastrocnemius m.
3. Soleus m.
4. Popliteus m.
5. Popliteal a. and v.
6. Tibial n.

IDENTIFICATION AND DISSECTION
OF THE ARTERY (FIG. 7 – 7 7 )
The longitudinal attachment of the soleus (3) is detached
from the medial edge of the tibia (1), and the tibioper-
oneal trunk (7) appears between the soleus (3) and the
tibialis posterior (11).
Detachm ent continues proximally, until the medial
pier of the soleus arch is divided. At this stage, this
segment of the artery is suf ciently exposed. Dissection
proceeds deeply, to isolate the tibial nerve (6) and to
identify the takeoffs of the anterior tibial and peroneal
arteries (9,10), which are usually located 2.5 and 5 cm,
respectively, below the medial condyle of the tibia.
346
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–77
Identi cation and dissection of
the artery.
1. Tibia
3. Soleus m.
6. Tibial n.
7. Tibioperoneal trunk
8. Posterior tibial a. and v.
9. Anterior tibial a. and v.
10. Peroneal a. and v.
11. Tibialis posterior m.
12. Flexor digitorum longus m.

RECIPIENT SITE EXPOSURES
347
Posterior Approach to
the Tibioperoneal Trunk
INCISION (FIG. 7 – 7 8 )
The incision begins at the level of the knee joint, for
10 cm along the posterior midline of the calf.
Figure 7–78
Incision.
1. Medial head of gastrocnemius m.
2. Lateral head of gastrocnemius m.
3. Popliteal a. and v.
4. Tibial n.
5. Lesser saphenous v. and medial sural n.
6. Soleus m.
7. Popliteus m.
8. Tibioperoneal trunk
9. Anterior tibial a. and v.
10. Posterior tibial a. and v.
11. Peroneal a. and v.
12. Tibialis posterior m.

APPROACH TO THE SOLEUS
(FIG. 7 – 7 9 )
After isolating the lesser saphenous vein (5) and m edial
sural nerve (5), the lateral and m edial heads of the gas-
trocnem ius (1,2) are split apart along the groove
between them. The superior edge of the soleus (6) and
neurovascular bundle of the popliteal vessel (3), as well
as the tibial nerve (4), are exposed.
348
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–79
Approach to the soleus.
1. Medial head of gastrocnemius m.
2. Lateral head of gastrocnemius m.
3. Popliteal a. and v.
4. Tibial n.
5. Lesser saphenous v. and medial
sural n.
6. Soleus m.
7. Popliteus m.

RECIPIENT SITE EXPOSURES
349
IDENTIFICATION AND DISSECTION OF THE
VASCULAR BUNDLE (FIG. 7 – 8 0 )
The brous band between the tibia and bula that arches
over the popliteal vessels (3) and the tibial nerve (4) is
identi ed and divided. From this point, the soleus
muscle (6) is split longitudinally, and the underlying neu-
rovascular bundle (8) is then revealed. Below the lower
border of the popliteus muscle (7), the takeoffs of the an-
terior tibial and peroneal arteries (9,11) are dissected out
on the lateral aspect of the tibioperoneal trunk.
Figure 7–80
Identi cation and dissection of
the vascular bundle.
3. Popliteal a. and v.
4. Tibial n.
5. Lesser saphenous v. and medial sural n.
6. Soleus m.
7. Popliteus m.
8. Tibioperoneal trunk
9. Anterior tibial a. and v.
10. Posterior tibial a. and v.
11. Peroneal a. and v.
12. Tibialis posterior m.

Lateral Approach to the Tibioperoneal Trunk
INCISION (FIG. 7 – 81 )
The incision begins at the popliteal fossa, curving via
the posterior aspect of the head of the bula and
running distally along the posterior edge of the bula
for 10 cm.
350
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–81
Incision.
1. Head of bula
2. Lateral head of gastrocnemius m.
3. Peroneus longus m.
4. Soleus m.
5. Popliteus m.
6. Popliteal a. and v.
7. Tibial n.
8. Peroneal n.
9. Tibioperoneal trunk
10. Anterior tibial a. and v.
11. Peroneal a. and v.
12. Flexor hallucis longus m.
13. Tibialis posterior m.

RECIPIENT SITE EXPOSURES
351
APPROACH TO THE SOLEUS (FIG. 7 – 8 2 )
The common peroneal nerve (8) is identi ed between
the lateral head of the gastrocnemius (2) and the biceps
fem oris tendon and should be carefully protected.
Retracting the lateral head of the gastrocnem ius (2)
posteriorly, the lateral proximal portion of the soleus
(4) appears in the wound.
Figure 7–82
Approach to the soleus.
1. Head of bula
2. Lateral head of gastrocnemius m.
3. Peroneus longus m.
4. Soleus mm.
5. Popliteus m.
6. Popliteal a. and v.
7. Tibial n.
8. Peroneal n.

IDENTIFICATION AND DISSECTION OF
NEUROVASCULAR STRUCTURES (FIG. 7 – 8 3 )
The soleus (4) is detached from the posterior aspect of
the head and the proxim al third of the bula and
retracted posteriorly with the gastrocnemius. The ante-
rior tibial and peroneal arteries (10,11) are identi ed.
The tibioperoneal trunk (9) lies deeply behind the tibial
nerve (7). For better exposure, the lateral head of the
gastrocnemius can be detached from the lateral condyle
of the femur.
352
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–83
Identi cation and
dissection of neurovascular structures.
3. Peroneus longus m.
4. Soleus m.
7. Tibial n.
8. Peroneal n.
9. Tibioperoneal trunk
10. Anterior tibial a. and v.
11. Peroneal a. and v.
12. Flexor hallucis longus m.
13. Tibialis posterior m.

RECIPIENT SITE EXPOSURES
353
Exposure of the Arched Segment of
the Anterior Tibial Artery by
Resection of the Fibula
INCISION (FIG. 7 – 8 4 )
An incision is made from the lateral wall of the popliteal
fossa along the m edial border of the biceps fem oris
tendon to the head of the bula. It then runs distally
along the shaft of the bula for 8 cm.
Figure 7–84
Incision.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Fibula
4. Peroneus longus m.
5. Biceps femoris tendon
6. Tibialis anterior m.
7. Extensor digitorum longus m.
8. Common peroneal n.
9. Tibialis posterior m.
10. Popliteal a. and v.
11. Tibioperoneal trunk
12. Tibial n.
13. Articular facet on tibia
14. Anterior tibial a. and v.
15. Deep peroneal n.

EXPOSURE OF THE NECK
OF FIBULA (FIG. 7 – 8 5 )
The common peroneal nerve (8) is rst identi ed be-
hind the biceps femoris tendon (5). The peroneus longus
(4) is detached from the head of the bula; then the
nerve can be mobilized from the neck of the bula. The
soleus (2) and peroneus longus (4) are stripped from
the bula, and the interosseous m embrane is exposed
from the posterior and anterior aspects.
354
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–85
Exposure of the neck of bula.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Fibula
4. Peroneus longus m.
5. Biceps femoris tendon
6. Tibialis anterior m.
7. Extensor digitorum longus m.
8. Common peroneal n.
9. Tibialis posterior m.

RECIPIENT SITE EXPOSURES
355
AFTER OSTEOTOMY, IDENTIFICATION AND
DISSECTION OF NEUROVASCULAR
STRUCTURES (FIG. 7 – 8 6 )
The shaft of the bula is divided 8 cm below the head of
the bula with a Gigli saw. Then the interosseous mem-
brane, the biceps tendon, and the capsule ligaments of
the upper tibio bular joint are detached from the bula
and its head. The upper portion of the bula is then re-
sected.
The arch of the anterior tibial artery (14) generally
lies 3 to 4 cm below the articular facet (13) on the
lateral condyle of the tibia. In searching for it, it is bet-
ter to identify the deep peroneal nerve (15) rst; this is
a branch of the com mon peroneal nerve, joining the an-
terior tibial artery 6 to 7 cm below the facet. Tracing
the anterior tibial artery proximally, the arched segment
can be securely exposed.
Figure 7–86
After osteotomy, identi cation
and dissection of neurovascular structures.
2. Soleus m.
4. Peroneus longus m.
5. Biceps femoris tendon
6. Tibialis anterior m.
7. Extensor digitorum longus m.
8. Common peroneal n.
9. Tibialis posterior m.
10. Popliteal a. and v.
11. Tibioperoneal trunk
12. Tibial n.
13. Articular facet on tibia
14. Anterior tibial a. and v.
15. Deep peroneal n.

Exposure of the Anterior Tibial Artery
INCISION (FIG. 7 – 8 7 )
A line is drawn from the anterior border of the head of the
bula to the midpoint between the lateral and medial
malleoli. Any part of the anterior tibial artery of the leg
can be approached by making an incision on this line.
EXPOSURE OF THE UPPER THIRD (FIG. 7 – 8 8 )
For exposure of the upper third, a dissection divides the
deep fascia and proceeds between the tibialis anterior
(6) and extensor digitorum longus (5). Thus, the ante-
rior tibial artery (1) with vein and the deep peroneal
nerve (2) can be identi ed in front of the interosseous
membrane (7).
356
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–87
Incision.
1. Anterior tibial a. and v.
2. Deep peroneal n.
3. Peroneus longus m.
4. Peroneus brevis m.
5. Extensor digitorum longus m.
6. Tibialis anterior m.
7. Interosseous membrane
8. Tibia
9. Extensor hallucis longus m.
10. Fibula
Figure 7–88
Exposure of the upper third.
1. Anterior tibial a. and v.
2. Deep peroneal n.
3. Peroneus longus m.
4. Peroneus brevis m.
5. Extensor digitorum longus m.
6. Tibialis anterior m.
7. Interosseous membrane

RECIPIENT SITE EXPOSURES
357
EXPOSURE OF THE M IDDLE THIRD
(FIG. 7 – 8 9 )
For exposure of the middle third, dissection divides the
deep fascia and proceeds between the tibialis anterior
(6) and extensor hallucis longus (9). Then the neurovas-
cular bundle (1,2) can be isolated in front of the
interosseous membrane (7).
Figure 7–89
Exposure of the middle third.
1. Anterior tibial a. and v.
2. Deep peroneal n.
3. Peroneus longus m.
5. Extensor digitorum longus m.
6. Tibialis anterior m.
7. Interosseous membrane
8. Tibia
9. Extensor hallucis longus m.

EXPOSURE OF THE LOW ER THIRD
(FIG. 7 – 9 0 )
For exposure of the lower third, the deep fascia and
superior extensor retinaculum are divided. Retracting
the tibialis anterior tendon (6) medially and the extensor
hallucis longus tendon (9) laterally, the anterior tibial
neurovascular bundle (1,2) appears lying on the tibia (8).
358
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–90
Exposure of the lower third.
1. Anterior tibial a. and v.
2. Deep peroneal n.
5. Extensor digitorum longus m.
6. Tibialis anterior m.
7. Interosseous membrane
8. Tibia
9. Extensor hallucis longus m.
10. Fibula

RECIPIENT SITE EXPOSURES
359
Exposure of the Posterior Tibial Artery
INCISION (FIG. 7 – 91 )
A line is drawn from the medial condyle of the tibia,
keeping 3 cm posterior to the posterom edial edge of
the tibia, and longitudinally to a point 1 cm posterior to
the m edial malleolus. The proximal third of this line is
employed for the exposure of the tibioperoneal trunk
(see sections on exposure of the tibioperoneal trunk).
Figure 7–91
Incision.
1. Tibial n.
2. Posterioir tibial a. and v.
3. Gastrocnemius m.
4. Soleus m.
5. Tibialis posterior m.
6. Flexor digitorum longus m.
7. Tibia
8. Flexor hallucis longus m.
9. Achilles tendon

EXPOSURE OF THE M IDDLE THIRD
(FIG. 7 – 9 2 )
For exposure of the posterior tibial artery (2) at the
level of the middle third, the deep fascia is divided and
the greater saphenous vein and saphenous nerve are
located anterior to the incision (not shown in the draw-
ing). They can be protected while underm ining. The
soleus muscle (4) is detached from the posterior surface
of the tibia (7), with care taken not to injure the neu-
rovascular structure (1, 2). The muscle is then retracted
with the gastrocnemius (3) posteriorly. The posterior
tibial artery (2), accompanied by two veins, is identi ed
behind the tibialis posterior (5), and it is isolated. The
tibial nerve (1) is located deep to the artery.
360
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–92
Exposure of the middle
third.
1. Tibial n.
2. Posterior tibial a. and v.
3. Gastrocnemius m.
4. Soleus m.
5. Tibialis posterior m.
6. Flexor digitorum longus m.
7. Tibia

RECIPIENT SITE EXPOSURES
361
EXPOSURE OF THE LOW ER THIRD
(FIG. 7 – 9 3 )
For exposure of the posterior tibial artery (2) in the
distal third of the leg, the two layers of fascia are
divided, and the soleus (4) can be easily separated from
the tibia; it is retracted with the Achilles tendon (9). The
posterior tibial artery (2), accompanied by two veins,
lies super cially between the exor digitorum longus
(6) (anteriorly) and the exor hallucis longus (8) (poste-
riorly). The tibial nerve (1) is located deep to it.
Figure 7–93
Exposure of the lower third.
1. Tibial n.
2. Posterior tibial a. and v.
4. Soleus m.
6. Flexor digitorum longus
7. Tibia
8. Flexor hallucis longus
9. Achilles tendon

Exposure of the Peroneal Artery
INCISION (FIG. 7 – 9 4 )
A line is drawn longitudinally along the posterior edge
of the bula. Any portion of the peroneal artery can be
exposed by making an incision on this line.
362
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–94
Incision.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Peroneus longus m.
4. Lateral intermuscular septum
5. Peroneal a. and v.
6. Posterior tibial a. and v. and tibial n.
7. Flexor hallucis longus m.
8. Tibialis posterior m.
9. Fibula
10. Peroneus brevis m.
11. Achilles tendon

RECIPIENT SITE EXPOSURES
363
APPROACH TO THE LATERAL CRURAL SEPTUM
FOR THE PROXIM AL PORTION (FIG. 7 – 9 5 )
In the proximal portion of the line, the skin and deep
fascia are incised. The lateral intermuscular septum (4)
between the soleus (2) and peroneus longus (3) is iden-
ti ed and entered.
Figure 7–95
Approach to the lateral crural
system for the proximal part.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Peroneus longus m.
4. Lateral intermuscular septum

EXPOSURE OF THE PROXIMAL PORTION
(FIG. 7 – 9 6 )
The soleus (2) is detached from the bula (9) to enter
the interspace between the super cial and deep groups
of the posterior crural m uscles. While detaching the
proximal part of the soleus, care should be taken not to
injure the common peroneal nerve.
Retracting the soleus (2) posteriorly, the peroneal
artery (5), accompanied by two veins, appears from its
origin to the proxim al border of the exor hallucis
longus muscle (7). The tibial nerve (6) is located between
the peroneal vessels (5) and the posterior tibial vessels (6).
364
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–96
Exposure of the proximal portion.
1. Lateral head of gastrocnemius m.
2. Soleus m.
3. Peroneus longus m.
5. Peroneal a. and v.
6. Posterior tibial a. and v. and tibial n.
7. Flexor hallucis longus m.
8. Tibialis posterior m.
9. Fibula

RECIPIENT SITE EXPOSURES
365
APPROACH TO THE FLEXOR HALLUCIS LONGUS
THROUGH THE LATERAL CRURAL SEPTUM (FOR
THE DISTAL PORTION) (FIG. 7 – 9 7 )
In the distal portion of the line, incising the skin and
deep fascia, dissection proceeds in the lateral crural
interm uscular septum . Then the soleus with Achilles
tendon (11) and peronei (3,10) are retracted posteriorly
and anteriorly, respectively, to expose the exor hallucis
longus muscle (7).
Figure 7–97
Approach to the exor hallucis
longus through the lateral crural septum for the
distal portion.
3. Peroneus longus m.
7. Flexor hallucis longus m.
10. Peroneus brevis m.
11. Achilles tendon
RECIPIENT SITE EXPOSURES
365

EXPOSURE OF THE DISTAL PORTION
(FIG. 7 – 9 8 )
The peroneal artery (5) in its middle course lies deeply
in a brous canal between the tibialis posterior and the
exor hallucis longus (7), or in the substance of the lat-
ter muscle. However, in its distal course, it lies behind
the tibio bular syndesmosis. The exor hallucis longus
(7) is therefore m obilized rst to identify the distal end
of the artery. Then, tracing it and splitting the muscle
bers, the peroneal artery can be exposed from distal to
proximal.
366
II.7 LOWER EXTREMITY: LOWER LEG AND KNEE
Figure 7–98
Exposure of the distal portion.
2. Soleus m.
3. Peroneus longus m.
5. Peroneal a. and v.
7. Flexor hallucis longus m.
9. Fibula
10. Peroneus brevis m.

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DORSALIS PEDIS FLAP
Arterial Anatomy (Fig. 8–1)
The dorsalis pedis artery (1) is the continu-
ation of the anterior tibial artery (10) distal
to the ankle joint. It passes under the
extensor retinaculum (9) at the m idpoint
between the m edial and lateral m alleoli
and usually across and beneath the exten-
sor hallucis longus (8) from its m edial to
lateral side. After em erging at the lower
border of the extensor retinaculum, it gives
off the lateral and m edial tarsal arteries
(5,6). The artery then proceeds under the
extensor hallucis brevis (7) above the tarsal
bones and toward the interspace between
the bases of the rst and second metatarsals.
This progression takes place in a muscular
arch formed by the two heads of the rst
dorsal interosseous muscle, where the ar-
tery, named as the deep plantar artery (4),
plunges to join the plantar arch in the sole of
the foot. Before this junction, the arcuate
8
Ankle and Foot
Figure 8–1
Anatomy of the arterial system of the
dorsalis pedis ap.
1. Dorsalis pedis a.
2. Arcuate a.
3. FDMA
4. Deep plantar a.
5. Lateral tarsal a.
6. Medial tarsal aa.
7. Extensor hallucis brevis m.
8. Extensor hallucis longus m.
9. Extensor retinaculum
10. Anterior tibial a.

DORSALIS PEDIS FLAP
373
Figure 8–2
Anatomy of the venous drainage and cutaneous
innervation on the dorsum of the foot.
1. Greater saphenous v.
2. Dorsal venous arch
3. Dorsal metatarsal v.
4. Median dorsal v.
5. Lesser saphenous v.
artery (2) branches out. The rst dorsal metatarsal artery
(FDMA) (3) arises just as the dorsalis pedis artery turns
into the sole.
For the lateral tarsal artery (5), see section on the
extensor digitorum brevis ap.
There are two or three medial tarsal arteries (6) on
the medial border of the foot.
The arcuate artery (2) arises from the dorsalis pedis
artery (1) on the medial cuneiform . It runs laterally over
the base of the m etatarsal bones and gives off the
second, third, and fourth dorsal metatarsal arteries that
pass distally upon each dorsal interosseous muscle. The
arcuate artery is present in 51% of cases.
The FDMA (3) generally arises from the dorsalis
pedis artery (1) after the origin of the deep plantar vessel
(4). The FDMA then runs distally, super cial or deep, to
the rst interosseous muscle toward the rst web, where
it divides into the dorsal digital arteries to the rst and
second toe. For its possible variations, see Fig. 8–4.
In addition to the FDMA serving as a direct cuta-
neous artery in supplying the dorsalis pedis ap,
cutaneous branches arise m ainly from the dorsalis
pedis artery in two other areas: beneath the retinacu-
lum and proximal to the interspace between the rst
and second metatarsals.
Venous Drainage (Fig. 8–2)
SUPERFICIAL SYSTEM
The dorsal digital veins receive communications from the
plantar digital veins to form dorsal metatarsal veins (3)
that unite in a dorsal venous arch (2) across the proximal
parts of the metatarsal bones. Then they generally drain
proximally through the lateral and medial veins that
become the lesser and greater saphenous veins (5,1),
respectively. In addition, oblique veins on the middle
dorsum of the foot may unite to form a median dorsal
vein (4) that normally joins the greater saphenous vein
(1) several centimeters above the ankle.
DEEP SYSTEM
There are a pair of venae com itantes to the dorsalis
pedis artery. Although the super cial system is the
dominant drainage and should be used preferentially
for toe transplants, the venae comitantes alone can be
adequate for an island dorsalis pedis ap.
Innervation (Fig. 8–2)
The super cial peroneal nerve (6) is a branch of the com-
mon peroneal nerve. In the distal third of the leg, it pierces
the deep fascia and bifurcates to form the medial and
lateral dorsal cutaneous nerves (8,7). The latter are located
at the front of the ankle at the anterolateral aspect of the
joint. The nerves supply almost the entire dorsum of the
foot, except for the rst web and lateral side of the foot.
The deep peroneal nerve descends along the lateral
side of the anterior tibial artery to the front of the ankle
joint. There it divides into lateral and medial terminal
branches.
The lateral term inal branch, accom panying the
lateral tarsal artery, passes deep to the extensor hallucis
and extensor digitorum brevis and supplies them.
The m edial term inal branch, accom panying the
dorsalis pedis artery, runs forward and pierces the deep
fascia at a proxim al point to the rst interspace of the
metatarsals, supplying the rst web.
6. Super cial peroneal n.
7. Lateral dorsal cutaneous n.
8. Medial dorsal cutaneous n.
9. Saphenous n.

Figure 8–3
Variations of the dorsalis pedis artery (see
text for details).
374
II.8 LOWER EXTREMITY: ANKLE AND FOOT
Variations of the Dorsalis
Pedis Artery (Fig. 8–3)
A. The artery begins as a continuation of the perforating
peroneal artery in 3% of cases.
B. The lower end of the anterior tibial artery is in the
position of the perforating peroneal artery in 1.5% of
cases.
C. It can arise about equally from the anterior tibial and
perforating peroneal arteries in 0.5% of cases.
D. The artery can be so reduced in size as to be consid-
ered almost absent in 12% of cases.

DORSALIS PEDIS FLAP
375
Figure 8–4 Variations of the rst
dorsal metatarsal artery (FDMA)
(see text for details).
Variations of the FDMA (Fig. 8–4)
A. (Super cial Type) In these cases, it arises from the
beginning or upper part of the deep plantar artery
and then intermediately turns back under a lesser
m uscular arch to run on the surface of the rst dor-
sal interosseous m uscle, or in this m uscle at a
super cial level (in 49% of cases).
B. (Deep Type) In these cases, it arises from the lower
part of the deep plantar artery or originates from the
plantar arch via a comm on stem with the rst plan-
tar metatarsal artery (FPMA). It lies deep under the
rst interosseous muscle and then runs forward and
dorsally, penetrating the m uscle and appearing
super cial to the muscle between the heads of the
rst and second metatarsals. Sometimes (in 40% of
cases) there may be a narrow branch from the upper
part of the deep plantar artery running over the
interosseous muscle.
C. (Narrow or Absent Type) In these cases, there may be
a narrow FDMA with a diameter of less than 1 mm.
However, it almost disappears between the heads of
the rst and second metatarsals. The blood supply of
the big and second toes depends on the FPMA that lies
under the deep transverse ligament (in 11% of cases).

Measurements
Diameter (mm)
Dorsalis pedis
Artery
2.0 – 2.0
Vein
1.5 – 3.0
First dorsal
Artery
1.0 – 1.5
metatarsal
Greater saphenous
Vein
3.0 – 5.0
Lesser saphenous
Vein
2.2 – 3.0
Dorsal venous arch
1.2 – 3.3
376
II.8 LOWER EXTREMITY: ANKLE AND FOOT
The skin of the dorsum of the foot is extremely thin and
pliable. It is innervated by an expendable cutaneous
sensory nerve, and the two-point discrimination recov-
ered can approach 10 mm. The size of the ap avail-
able for transfer is limited, ordinarily 10
10 cm and
m axim ally 14
15 cm ; the latter requires a delay
procedure.
The length of the vascular pedicle is adequate for
reconstruction. If necessary, the vascular pedicle can be
made longer by extending it up into the lower leg. The
sizes of all the relevant arteries and veins for the vascu-
lar pedicle are quite large, which makes m icrovascular
anastomoses easy to secure.
Venous drainage of the ap is abundant and in-
cludes the greater and lesser saphenous veins, as well
as the paired venae comitantes. The ap can be drained
by only one vein—the greater saphenous—but, for
safety, it is suggested that at least two veins should be
anastomosed.
If the super cial FDMA does not exist in the subcu-
taneous layer, as a direct cutaneous artery between the
rst and second metatarsals, ap circulation (especially
in the distal portion) may be in danger; sometimes un-
expected failure may occur. Following investigation of
the distribution of the cutaneous branches from
the dorsalis pedis artery, it is advisable that the more
proximally and medially the ap is designed, the more
reliable the ap circulation should be.
The dorsalis pedis ap can be compounded as an
osteocutaneous or tendinocutaneous ap, with the
second m etatarsal or extensor tendons. In addition,
with the dorsalis pedis–FDMA system , the ap can
be com bined with free toe transfer, rst web ap,
extensor digitorum brevis muscle transfer, and so on.
The dorsalis pedis ap, including its use as a com-
posite ap, is widely applied clinically. However,
because the anatomic properties of the foot have a close
resem blance to those of the hand, the ap is ideally
suited for use in the hand.
Donor-site sequelae from split-thickness skin graft-
ing is not inconspicuous, but morbidity is low; few
patients have any discomfort in the donor foot. Occasion-
ally wound healing in the rst intermetatarsal space and
the extensor hallucis longus tendon may be troublesome,
when the skin-graft bed is not appropriately covered
with the paratenon or similar vascular bed source.
COMMENT AND INSIGHTS

DORSALIS PEDIS SKIN FLAP
377
Figure 8–5
Flap design.
1. Extensor hallucis longus tendon
2. Extensor digitorum longus tendons
3. FDMA and deep peroneal n.
4. Dorsal metatarsal v.
5. Dorsal venous arch
6. Extensor hallucis brevis m.
7. Dorsalis pedis a. and v.
8. Greater saphenous v.
9. Deep plantar a.
10. Lateral and medial dorsal cutaneous n.
DORSALIS PEDIS SKIN FLAP
Flap Design (Fig. 8–5)
The ap design is based on the dorsalis pedis– rst
dorsal m etatarsal vascular axis. If the dorsalis pedis
artery is not readily palpable, a Doppler owmeter or ar-
teriography is suggested to con rm the vasculature.
The maximum boundaries are the interdigital web
space distally, the midextensor retinaculum proximally,
and the area just beyond the m edial and lateral margins
of the venous arch. It is important to note that the distal
ap (that portion distal to the dorsalis pedis pulse) may
be a random -pattern extension. If there is no FDMA
super cial to the interosseous muscle, delay is necessary
for safe transfer. Maximum size of the average ap in
adults is 14
15 cm.