441
Fig. 14.13 Procedure 13: A split-thickness skin graft is conducted
over the muscle fl ap
Fig. 14.14 Procedure 14: The muscle fl ap is soft and doesn’t obstruct
the bending and stretching of the knee. The title photo shows range of
motion after 6 months
Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
442
Tips
Use of hydroxyapatite is effective in preventing osteomyelitis
When covering exposed bone surface with a fl ap, insertion of beads with antibiotic and sustained release antibiotic
hydroxyapatite (Boneceram-P ®, Product No.: B-1-10,11) on the bone surface can prevent osteomyelitis. Material
placed on top of the bone surface can be removed after 4–6 weeks, however hydroxyapatite placed in the bone defect
area can be left as it is, or can be removed secondarily and a bone graft carried out.
14 Patella Region Reconstruction
443
Saphenous Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Saphenous artery which is a branch of the descending genicular artery. The descending genicular
artery branches off from the femoral artery about 15 cm above the knee, running along the posterior sartorius muscle,
branching off at muscular branches and articular branches before turning into the saphenous artery. Venous return is
accomplished by the comitant vein and saphenous vein. Saphenous nerve is sensory nerve of fl ap (medial thigh cutane-
ous nerve is proximal to knee)
Size About 12 × 7 cm. A length of 30 cm is possible as an extension fl ap
Advantage Vascular pedicle is thick (2 mm), and long (10 cm). It is possible to obtain a comparatively thin skin fl ap
Disadvantage There is a limit to the width that is possible for primary closure, and in cases where a skin graft is neces-
sary, the scar becomes obvious.
Saphenous Flap (Level of Diffi culty: 3)
444
Operation Procedures
Fig. 14.15 Procedure 1: In the case of creating an island fl ap, a 12 cm
longitudinal incision is made to the upper medial knee joint
Note The photo shows the inside of the left knee.
Fig. 14.16 Procedure 2: The sartorius muscle, saphenous vein and
cutaneous nerve are detected subcutaneously and retained. By pulling
the front margin of the sartorius muscle downwards it is possible to
confi rm the saphenous artery/nerve on the reverse side
Fig. 14.17 Procedure 3: While confi rming the saphenous blood ves-
sels/nerve, the proximal end of the descending genicular blood vessels
and the distal end of the saphenous blood vessels on the reverse side of
the fl ap are dissected
14 Patella Region Reconstruction
445
Fig. 14.18 Procedure 4: The area where the saphenous blood vessels
enter the fl ap is confi rmed
Note The saphenous blood vessels generally divide into two branches
before entering the skin. The diameter of the vascular pedicle is suffi -
ciently thick at 2 mm. It is possible to secure a vascular pedicle of
around 10 cm in length upwards of the knee.
Fig. 14.19 Procedure 5: The skin fl ap is designed with that area at the
center
Fig. 14.20 Procedure 6: It is possible to elevate an extended skin fl ap
10–15 cm distally along the fascia from the most distal point where the
saphenous blood vessels enter the skin fl ap
Note However, immediately after raising the skin fl ap, the distal end
of the skin fl ap is a little pale, and it takes about 10 min before the blood
fl ow stabilizes.
Saphenous Flap (Level of Diffi culty: 3)
446
Fig. 14.21 Procedure 7: Case: A vascular pedicle fi bula graft with a
peroneal fl ap was transferred for osteomyelitis of the left tibia, however
part of the proximal skin fl ap became necrotic and a loss of skin
occurred
Note The photo shows skin defect accompanying exposure of the bone
for the proximal 1/3 anterior tibia heading toward the knee.
Fig. 14.22 Procedure 8: An extended saphenous fl ap was transferred
to the anterior tibia to cover the exposed bone. A mesh skin graft was
conducted for the donor site
Note It is possible to create a saphenous fl ap of 30 cm in length, which
can cover 1/3 of the proximal anterior surface of the leg.
This requires further dissecting the saphenous blood vessels proxi-
mally, as well as the descending genicular blood vessels. The area up to
the branch from the femoral artery is dissected while retaining the mus-
cular branch of the descending genicular artery (about 15 cm above the
knee), and by cutting the margin of the skin fl ap and making an island
fl ap, it is possible to transfer the skin fl ap further distally.
14 Patella Region Reconstruction
447
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Blood vessel Thoracodorsal blood vessel
Vascular pedicle Free fl ap
Size (muscle fl ap) width 40 cm; length 40 cm
Advantage Good vascularity, vascular pedicle is thick and long, and it is possible to perform free design of a muscu-
locutaneous fl ap
Disadvantage Large dissection area, and large amount of blood loss. Cases with a thick layer of fat over the latissimus
dorsi muscle cause bulkiness preventing it from being used as a musculocutaneous fl ap, and therefore a skin graft is
required
Caution The space following removal of the latissimus dorsi muscle can cause a painful seroma, so multiple continuous
suction drains should be put in place.
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
448
Operation Procedures
Fig. 14.23 Procedure 1: After resection of a knee scar contracture, a
skin defect 11 cm in width and 35 cm in length was formed
Fig. 14.24 Procedure 2: A latissimus dorsi musculocutaneous fl ap of
the same size was elevated
Fig. 14.25 Procedure 3: For the vascular pedicle, an end-to-side anas-
tomosis is performed to the posterior tibial blood vessels in the popli-
teal region or an end-to-side anastomosis performed in the tibia medial
malleolus region in accordance with the Godina method
Refer to Section of “Reconstruction of Achilles tendon area/Free
latissimus dorsi musculocutaneous fl ap (serratus anterior musculocuta-
neous fl ap)” in Chap. 17
Refer to Section of “Distal 1/3 lower leg reconstruction/Free latissi-
mus dorsi musculocutaneous fl ap” in Chap. 16
14 Patella Region Reconstruction
449
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_15
Anterior Lower Leg Reconstruction
Basic Principles
A problem requiring covering of the anterior middle lower leg is reconstruction due to tibia
exposure. The exposed tibia area can be covered by transferring the soleus muscle fl ap or
gastrocnemius muscle fl ap. In order to obtain suffi cient mobility distance for the muscle
fl ap, it is important that the proximal end of the gastrocnemius muscle fl ap is cut and a
muscle island fl ap with only the vascular pedicle is created. The main nutrient blood vessel
is not always positioned in the most proximal position of the soleus muscle, so the muscle
ends may or may not be severed based on the transfer distance of the muscle fl ap.
In the case that a broad coverage is required, consideration must be given to the distance from
the anastomotic vessel of the graft bed, so a skin fl ap with a long vascular pedicle is selected.
The latissimus dorsi muscle fl ap, anterolateral thigh fl ap and abdominal perforator fl ap
can all be used, but the easiest is a combination of the latissimus dorsi muscle fl ap and a
mesh skin graft.
The anterior tibial artery has a tendency to spasm, and the comitant veins are also often
damaged, so it is preferable to perform an end-to-side anastomosis to the posterior tibial
artery and comitant vein in the popliteal region or distal medial lower leg.
The simplest method, rather than choosing a free fl ap, is to choose a turn-over fascial fl ap
of the lower calf, but when covering a large exposure of bone, it can tend to be too thin.
Selectable Flaps and Surgical Procedures
Soleus muscle, gastrocnemius muscle fl ap • Free latissimus dorsi musculocutaneous fl ap •
Free abdominal perforator fl ap • Turn-over fascial fl ap • Bi-pedicle skin fl ap
The diffi culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Diffi culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
15
450
Soleus Muscle and Skin Graft (Level of Diffi culty: 3)
Information
Vascular pedicle Popliteal artery or several muscle nutrient branches from posterior tibial artery
Size The entire soleus muscle can be used
Indication If it is possible to completely elevate the whole soleus muscle it is possible to cover the proximal 2/3 of the
anterior lower leg, however it is most suitable for reconstructing loss tissue for the middle lower leg. Surgery is per-
formed in the lateral recumbent position or the prone position
15 Anterior Lower Leg Reconstruction
451
Operation Procedures
Fig. 15.1 Procedure 1: Osteomyelitis of tibia midsection. The infected
granulation tissue is debrided
Fig. 15.2 Procedure 2: An incision is made along the center of the
posterior lower leg, and an incision is made between the medial and
lateral heads of the gastrocnemius muscle, exposing the soleus muscle
Fig. 15.3 Procedure 3: The branches from the popliteal artery and the
tibial nerve from the proximal end of the soleus muscle are confi rmed
Note Performed in the lateral recumbent position
Soleus Muscle and Skin Graft (Level of Diffi culty: 3)
452
Fig. 15.4 Procedure 4: The reverse side of the soleus muscle can be
easily dissected manually
Fig. 15.5 Procedure 5: The muscle is dissected while being careful not
to damage the posterior tibial blood vessels, running behind the soleus
muscle, which are retained
Fig. 15.6 Procedure 6: The muscular branch from the posterior tibial
artery can be seen at the proximal end of the muscle. Suffi cient muscle
can be dissected up to that point. There are multiple muscular branches,
but only the thickest branch needs to be retained
15 Anterior Lower Leg Reconstruction
453
Fig. 15.7 Procedure 7: The muscle fl ap is dissected from the distal end
to the proximal end and elevated
Fig. 15.8 Procedure 8: The muscle fl ap is transferred to the anterior
surface of the leg through the tunnel created on the medial tibia
Fig. 15.9 Procedure 9: A bolster suture is done to pull the muscle fl ap
into the subcutaneous layer
Note Sustained release antibiotic hydroxyapatite is inserted into the
tibia marrow.
Soleus Muscle and Skin Graft (Level of Diffi culty: 3)
454
Fig. 15.10 Procedure 10: A split-thickness skin graft is performed on
top of the muscle fl ap. Light pressure is applied using a gauze, and then
fi xed in place with a cast
Fig. 15.11 Procedure 11: Appearance after 3 months. Muscle fl ap/skin
graft have taken well, and no recurrence of osteomyelitis
15 Anterior Lower Leg Reconstruction
455
Soleus Muscle Flap and Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Sural artery (there are multiple, however the branch at the proximal end is thick, and is capable of
becoming the vascular pedicle for the muscle fl ap) that branches off from the popliteal artery.
Size Gastrocnemius fl ap is about 8 cm in width; 15–18 cm in length. The soleus muscle is about 2/3 the length of the
lower leg.
If the gastrocnemius fl ap is created as a complete muscle island fl ap with only the vascular pedicle, it can cover a
large area from the middle of the lower leg to the knee. Because the soleus muscle is long, it is possible to cover the
proximal 2/3 of the lower leg without cutting the muscle ends and making a muscle island fl ap.
Soleus Muscle Flap and Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
456
Operation Procedures
Fig. 15.12 Procedure 1: Pus discharge and subcutaneous fi stula pres-
ent due to osteomyelitis of the tibia for several decades. Area is dyed
with gentian violet and the fi stula and sequester completely resected
15 Anterior Lower Leg Reconstruction
457
Fig. 15.13 Procedure 2: Evidence of chronic osteomyelitis is recog-
nized within the tibia. The osteomyelitis region is completely debrided
Soleus Muscle Flap and Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
458
Fig. 15.14 Procedure 3: An incision is made along the center of the
posterior lower leg, the medial head of the gastrocnemius is detached
from the distal end, the sural artery that enters the muscle fl ap is con-
fi rmed and the muscle ends cut, and a complete muscle island fl ap is
elevated
Refer to Section of “Patella region reconstruction/Gastrocnemius
fl ap” in Chap. 14
Refer to Section of “Distal 1/3 lower leg reconstruction/Free gastroc-
nemius fl ap” in Chap. 16
Refer to Section of “Reconstruction of anterior lower leg/soleus mus-
cle fl ap + Skin graft” in Chap. 16
As there is insuffi cient muscle volume with just the gastrocnemius
fl ap only, the soleus muscle is detached from the distal end and raised.
Attention must be paid to the narrow arteries entering the muscle fl ap
when elevating the soleus muscle, however it’s not necessary to cut the
muscle ends.
15 Anterior Lower Leg Reconstruction
459
Fig. 15.15 Procedure 4: The two muscle fl aps are transferred to the
posterior lower leg through the tunnel created in the lateral tibia (soleus
muscle fl ap below and gastrocnemius muscle fl ap above). The muscle
fl ap is inserted tightly so as to avoid creating dead space in the debrided
tibia
Soleus Muscle Flap and Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
460
Fig. 15.16 Procedure 5: A bolster suture is done in the surrounding
subcutaneous layer. A mesh skin graft is conducted on the muscle fl ap,
and a tie-over bolster dressing applied
15 Anterior Lower Leg Reconstruction
461
Fig. 15.17 Procedure 6: The muscle fl ap and skin graft have com-
pletely taken, and there is no recurrence of osteomyelitis
Soleus Muscle Flap and Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
462
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Thoracodorsal blood vessel – Subscapular artery
Size (muscle fl ap) width 40 cm; length 40 cm; vascular pedicle about 15 cm
Advantage Good vascularity, vascular pedicle is thick and long, and it is possible to conduct free design of a muscu-
locutaneous fl ap
Disadvantage Large dissection area, and large amount of blood loss. Cases with a thick layer of fat over the latissimus
dorsi muscle cause bulkiness preventing it from being used as a muscle fl ap, therefore a skin graft is conducted
Caution The space following removal of the latissimus dorsi muscle can cause a painful seroma, so multiple continu-
ous suction drains should be put in place.
15 Anterior Lower Leg Reconstruction
463
Operation Procedures
Fig. 15.18 Procedure 1: There is a large skin defect from the thigh to
the middle of the lower leg, and a large area of bone is exposed in the
middle of the lower leg
Fig. 15.19 Procedure 2: Large-scale debridement was carried out. A
free skin graft is planned for the thigh region, and the middle of the
lower leg is planned to be covered using a free latissimus dorsi muscu-
lar fl ap. An end-to-side anastomosis is planned with the posterior tibial
artery at the distal end of the lower leg
Fig. 15.20 Procedure 3: The size of the latissimus dorsi is indicated,
and the skin fl ap designed on top
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
464
Fig. 15.21 Procedure 4: Continuing through to the subscapular artery,
the latissimus dorsi musculocutaneous fl ap with a 15 cm vascular pedi-
cle is removed
Fig. 15.22 Procedure 5: Sustained release antibiotic hydroxyapatite
(Boneceram-P ®) is inserted into the area surrounding exposed tibia for
which infection was a concern, and the muscle fl ap placed over the top
Fig. 15.23 Procedure 6: End-to-side anastomosis is conducted of the
subscapular artery to the posterior tibial artery in the upper tibia medial
malleolus region, and the entire lower leg covered with the muscle fl ap
Refer to Section of “Distal 1/3 lower leg reconstruction/Free latissi-
mus dorsi musculocutaneous fl ap” in Chap. 16
Refer to Section of “Reconstruction of Achilles tendon area/Free
latissimus dorsi musculocutaneous fl ap (serratus anterior musculocuta-
neous fl ap)” in Chap. 17
Note End-to-side anastomosis resembling side-to-side anastomosis is
conducted for the artery. One vein is used for end-to-end anastomosis,
and one of the posterior tibial comitant veins retained as a deep vein.
If there is suffi cient thickness, it is possible to conduct end-to-side
anastomosis of the vein to avoid bending.
15 Anterior Lower Leg Reconstruction
465
Fig. 15.24 Procedure 7: A mesh skin graft (×1.5) is conducted on top
of the muscle fl ap
Fig. 15.25 Procedure 8: The mesh skin graft on the muscle fl ap doesn’t
require strong pressure, so it is suffi cient to wrap with light pressure
using a cotton bandage
Note A mesh skin graft of around 1.5 times will be aesthetically pleas-
ing, but at 3 times, the scar will be obvious.
It is preferable that a transplant is conducted as a 1.5 times mesh
skin graft without stretching.
Note Fix with a plaster splint being careful to avoid causing equinus
foot, and unless there is concern for thrombus formation, avoid opening
for 1 week.
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
466
Hint!
First choice for lower leg osteomyelitis reconstruction
I.
No loss of soft tissue, infection of bone only
Debriding of sequestrum and insertion of beads with antibiotic agents. Afterwards bone transplant.
II. Slight loss of soft tissue and infection of bone
(a) Reconstruction of proximal 2/3 of lower leg : Transfer of muscle fl ap with vascular pedicle (gastrocnemius
muscle, soleus muscle) + split- thickness skin graft
(b) Reconstruction of distal 1/3 of lower leg: turn- over calf fascial fl ap + split-thickness skin graft
III. Severe loss of soft tissue and infection of bone
(a) Reconstruction of proximal 2/3 of lower leg: Transfer of muscle fl ap with vascular pedicle + insertion of
beads with antibiotic agents + skin graft
Secondary free bone graft (or vascular pedicle fi bula transplant)
(b) Reconstruction of distal 1/3 of lower leg: Vascular pedicle free muscle fl ap (latissimus dorsi, gastrocnemius
muscle etc) transfer + skin graft
Secondary free bone graft (or vascular pedicle fi bula transplant)
(c) Cases where microsurgery is unsuitable or failure cases: bone transport, cross leg fl ap method
15 Anterior Lower Leg Reconstruction
467
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_16
Reconstruction of Distal 1/3
of Lower Leg
Basic Principles
The distal 1/3 of the lower leg has a tendency for an open fracture or osteomyelitis to occur,
and it can be diffi cult to obtain skin/muscle fl ap with vascular pedicle from the affected limb
due to a lack of blood vessel length. Therefore, this is an area with good indication for use
of free muscle and musculocutaneous fl aps, but there is a higher possibility of thrombus
occurring compared to the upper limb. To address this issue, anastomosis is conducted for
the posterior tibial arterial system using end-to-side anastomosis as the method.
End-to-side anastomosis is also useful for retaining blood fl ow in the affected limb.
When performing free tissue transplant, posterior tibial artery end-to-side (side-to-side)
anastomosis is the main method of anastomosis, and is conducted in the popliteal region or
medial malleolus region.
Selectable Flaps and Surgical Procedures
Free latissimus dorsi musculocutaneous fl ap/serratus anterior muscle fl ap • Free gastrocne-
mius muscle fl ap • Reverse fl ow sural artery skin fl ap • Bi-pedicle skin fl ap • Reverse turn-
over fascial fl ap • Extensor digitorum brevis muscle fl ap • Cross leg fl ap method • Peroneal
artery fl ap • Free scapular/parascapular fl ap
The diffi culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Diffi culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
16
468
Reverse Turn-Over Fascial Flap (Level of Diffi culty: 2)
Information
Vascular pedicle Mainly superfi cial sural artery, peroneal artery and partial use of branch from posterior tibial artery
Size Superior margin 3–5 cm distal from popliteal crease; inferior margin 6–8 cm proximal from medial and lateral
malleolus. Fascial fl ap made to size required to fi t 10–15 cm width for this area. An overlap margin of 5 cm from the
wound is secured.
Advantage Fascia is thin, fl exible and strong. Can perform surgery in same operating area. Surgery is extremely easy.
No complex techniques are required
Disadvantage A skin graft is required
16 Reconstruction of Distal 1/3 of Lower Leg
469
Operation Procedures
Fig. 16.1 Procedure 1: Based on size of skin defect area, design con-
sisted of leaving at least 5 cm of lower calf fascia without detaching,
securing an overlap of the same length, and enabling removal of fascia
the size of the skin defect area from the proximal end
Fig. 16.2 Procedure 2: An incision is made into the skin on the poste-
rior lower leg, and the fascia exposed
Fig. 16.3 Procedure 3: The fascia, based on the design and including
the overlap, is detached and elevated from the posterior lower leg. If the
sural nerve cannot be retained, then it is severed and included in the
fascial fl ap
Refer to Section of “Reconstruction of Achilles tendon area/Reverse
turn-over fascial fl ap” in Chap. 17
Reverse Turn-Over Fascial Flap (Level of Diffi culty: 2)
470
Fig. 16.4 Procedure 4: The fascia fl ap is turned over from the posterior
lower leg toward the distal anterior lower leg
Fig. 16.5 Procedure 5: The exposed bone area is covered using the
fascia fl ap, and a bolster suture conducted to pull the muscle fl ap into
the subcutaneous layer
Fig. 16.6 Procedure 6: A split-thickness skin graft is conducted over
the fascia, and a tie-over bolster dressing is applied. Fixed using a plas-
ter splint
Note Make sure not to detach areas that need to be retained.
16 Reconstruction of Distal 1/3 of Lower Leg
471
Tips
If negative pressure wound therapy is performed instead of a tie-over bolster dressing, then a splint is not required.
Reverse Turn-Over Fascial Flap (Level of Diffi culty: 2)
472
Reverse Flow Sural Artery Skin Flap (Level of Diffi culty: 2)
Information
Vascular pedicle Superfi cial sural artery accompanying the sural nerve that runs along center of posterior lower leg.
When creating a reverse skin fl ap, the sural nerve and small saphenous vein are included.
Size Width about 5 cm; length is length of sural nerve without restriction
Advantage Technique is simple and surgery time is short
Disadvantage Due to bending of broad skin fl ap and pedicle, there is tendency for vascular insuffi ciency to occur. The
skin fl ap can also become thick depending on transfer direction.
Caution Obtain blood vessels from a wide area, not only for the skin fl ap pedicle
16 Reconstruction of Distal 1/3 of Lower Leg
473
Fig. 16.8 Procedure 2: In prone position, the skin fl ap axis is estab-
lished in the center of the posterior lower leg. The fl ap pivot point is set
at 5 cm proximal from the lateral malleolus, and the skin fl ap is designed
above the sural nerve and small saphenous vein (center of posterior
lower leg) using the same distance as the distance from this point to the
skin defect area
Fig. 16.9 Procedure 3: The subcutaneous tissue is gradually exposed
while making sure that the skin fl ap is comprised of the superfi cial sural
artery accompanying the sural nerve, and is above the small saphenous
vein. The fascia pedicle of the skin fl ap is created with 3 cm width
Fig. 16.7 Procedure 1: The osteomyelitis region of the distal area of
right medial lower leg is debrided, and sustained release antibiotic
hydroxyapatite (Boneceram-P ®) inserted
Operation Procedures
Reverse Flow Sural Artery Skin Flap (Level of Diffi culty: 2)
474
Fig. 16.12 Procedure 6: The skin fl ap is transferred to the skin defect
area through the subcutaneous tunnel, and a bolster suture conducted to
pull the muscle fl ap into the subcutaneous layer
Fig. 16.10 Procedure 4: The small saphenous vein is ligated at the
proximal end, and the artery accompanying the sural nerve severed
Fig. 16.11 Procedure 5: The fl ap pedicle is detached in the distal
direction beneath the fascia and the skin fl ap elevated. The tourniquet is
released and reverse blood fl ow to the skin fl ap confi rmed
Note If the subcutaneous tunnel is not created large enough it will
apply pressure to the vascular pedicle of the skin fl ap.
16 Reconstruction of Distal 1/3 of Lower Leg
475
Fig. 16.13 Procedure 7: A split-thickness skin graft is conducted on
the donor area
Reverse Flow Sural Artery Skin Flap (Level of Diffi culty: 2)
476
Tips
Flap congestion improves after a few days, however edema persists for several weeks
Mild congestion and edema tends to occur in the skin fl ap for several days following surgery.
16 Reconstruction of Distal 1/3 of Lower Leg
477
Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Lateral tarsal blood vessels (branches from the dorsal blood vessels beneath the extensor retinaculum
of the ankle)
Size 4.5 × 6 cm
Advantage Has stable blood fl ow, is thin, and can be elevated either in normal or reverse. Valuable for covering
exposed tendon and bone in the ankle region. Because the extensor digitorum longus muscle tendon is still present,
even when removed, it doesn’t cause restriction in the range of foot movement.
Disadvantage Size of skin fl ap is small
Caution If an incision is made in the lateral dorsalis pedis it can cause instability in the blood fl ow of the detached skin,
so an incision is made in the medial dorsalis pedis
Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
478
Operation Procedures
Fig. 16.14 Procedure 1: A plate is exposed in the distal medial lower leg
Fig. 16.15 Procedure 2: A longitudinal incision is made above the dor-
sal artery, the section beneath the tendon of the extensor digitorum lon-
gus muscle detached and the extensor digitorum brevis muscle
identifi ed. The margin around the extensor digitorum brevis muscle is
severed. A cut is made at around 1/3 of the extensor retinaculum of the
ankle. The extensor digitorum brevis muscle is elevated as a muscle fl ap
with the dorsal blood vessels in the center. The lateral tarsal blood ves-
sels beneath the extensor retinaculum of the ankle (indicated with the
mosquito clamp) is confi rmed entering the muscle from the dorsal
blood vessels on the reverse side of the muscle
Refer to Section of “Reconstruction of dorsal and foot amputation
stump/Extensor digitorum brevis muscle fl ap” in Chap. 20
Refer to Section of “Reconstruction of dorsal surface of toe/Reverse
extensor digitorum brevis muscle fl ap” in Chap. 21
16 Reconstruction of Distal 1/3 of Lower Leg
479
Fig. 16.16 Procedure 3: The distal end of the dorsal blood vessels are
ligated and dissected, a muscle island fl ap created, and the vascular
pedicle (dorsal blood vessels) detached in the proximal direction
Fig. 16.17 Procedure 4: The muscle fl ap is transferred to the medial
malleolus of the lower leg through the subcutaneous tunnel to cover the
exposed plate and a bolster suture conducted in the surrounding area
Fig. 16.18 Procedure 5: A split-thickness skin graft is conducted
above the muscle fl ap and a tie-over bolster dressing, or a light pressure
dressing applied
Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
480
Tips
It is possible to retain the deep peroneal nerve
In the case of transferring the extensor digitorum brevis muscle fl ap proximally, it is preferable to detach and retain
the deep peroneal nerve which runs in parallel to the dorsal blood vessels. In the case of transferring distally as a
reverse muscle fl ap, it is possible to sever without problem.
Refer to Section of “Reconstruction of dorsal surface of toe/Reverse extensor digitorum brevis muscle fl ap” in Chap. 21
16 Reconstruction of Distal 1/3 of Lower Leg
481
Free Gastrocnemius Muscle Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Sural artery muscular branch, length 2 cm; diameter 1.5 mm
Size Size of the medial or lateral head of gastrocnemius (excluding Achilles tendon)
Advantage Can obtain suffi cient thickness for the muscle fl ap. Has stable blood circulation. Can obtain muscle fl ap in
same operating area
Disadvantage Short vascular pedicle. Requires skin graft
Free Gastrocnemius Muscle Flap (Level of Diffi culty: 4)
482
Operation Procedures
Fig. 16.19 Procedure 1: Skin defect accompanying exposure of bone
on distal anterior lower leg, with ongoing discharge of pus
Fig. 16.20 Procedure 2: Sustained release antibiotic hydroxyapatite
containing effective antibiotic is inserted into the wound
Fig. 16.21 Procedure 3: An incision is made along the center of the
posterior lower leg and extended subcutaneously to expose the gastroc-
nemius muscle
Note Photo shows state after debridement.
16 Reconstruction of Distal 1/3 of Lower Leg
483
Fig. 16.22 Procedure 4: In the popliteal region, confi rmation is made
of the sural artery entering the muscle between the medial and lateral
head of the gastrocnemius muscle
Fig. 16.23 Procedure 5: The Achilles tendon is retained, and the lat-
eral head of the gastrocnemius muscle is detached from the distal end
Fig. 16.24 Procedure 6: The proximal end of the muscle is severed and
a complete island fl ap with only the neuro vascular pedicle is created
Free Gastrocnemius Muscle Flap (Level of Diffi culty: 4)
484
Fig. 16.25 Procedure 7. The vascular pedicle of the sural blood vessel
is detached from the popliteal blood vessel up to the branching region,
ligated, cut and then the muscle fl ap removed
Fig. 16.26 Procedure 8: The muscle fl ap is used to cover the exposed
bone
Fig. 16.27 Procedure 9: Anastomosis of the sural blood vessels and
the posterior tibial blood vessels is conducted in the medial lower leg.
Note End-to-side anastomosis is used for the arteries and end-to-end
anastomosis to the proximal side is used for the veins
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485
Fig. 16.28 Procedure 10: When closing the wound above the vascular
anastomosis area, tension applied to the anastomosis vessel can cause it
to bend, so a skin graft is conducted
Fig. 16.29 Procedure 11: A bolster suture is done to pull the muscle
fl ap into the subcutaneous layer
Fig. 16.30 Procedure 12: A split-thickness skin graft is conducted on
top of the muscle fl ap
Free Gastrocnemius Muscle Flap (Level of Diffi culty: 4)
486
Tips
Utilize as a muscle fl ap more so than a musculocutaneous fl ap
Although there are reports of applying muscle fl aps that use the arteries, veins, skin and branches perforating the
medial gastrocnemius muscle as a free fl ap, there are also cases where the presence of the perforators is not stable, and
elevation can only be achieved as a large skin island. Therefore, using this as a muscle fl ap and conducting a skin graft
is the safer option.
16 Reconstruction of Distal 1/3 of Lower Leg
487
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Thoracodorsal blood vessel
Size (muscle fl ap) width 40 cm; length 40 cm
Advantage Good vascularity, vascular pedicle is thick and long, and it is possible to conduct free design of a muscu-
locutaneous fl ap
Disadvantage Large dissection area, and large amount of blood loss. Cases with a thick layer of fat over the latissimus dorsi
muscle cause bulkiness preventing it from being used as a musculocutaneous fl ap, and therefore a skin graft is required
Caution The space following removal of the latissimus dorsi muscle can cause a painful seroma, so several continuous
suction drains should be put in place.
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
488
Operation Procedures
Fig. 16.31 Procedure 1: Loss of large amount of skin accompanying
exposure of the bone on the posterior lower leg
Fig. 16.32 Procedure 2: The posterior tibial blood vessels are detached
in the popliteal region, and anastomosis conducted (Godina method)
Refer to Section of “Reconstruction of Achilles tendon area/Free
latissimus dorsi musculocutaneous fl ap (serratus anterior musculocuta-
neous fl ap)” in Chap. 17
Refer to Section of Tips in Section of “Free Latissimus Dorsi
Musculocutaneous Flap”
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489
Fig. 16.33 Procedure 3: The middle axillary line is marked, and the
fl ap is designed on the anterior margin of the latissimus dorsi
Fig. 16.34 Procedure 4: An incision is made around the margin of the
fl ap, and when the anterior margin of the latissimus dorsi muscle is
turned over it is possible to identify the area where the thoracodorsal
blood vessels branch into the latissimus dorsi muscle and the serratus
anterior muscle
Fig. 16.35 Procedure 5: The thoracodorsal neurovascular pedicle is
detached proximally, the circumfl ex scapular blood vessels are ligated,
with detachment continuing toward the subscapular blood vessels
Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
490
Fig. 16.36 Procedure 6. The latissimus dorsi muscle is cut at the prox-
imal section and a musculocutaneous island fl ap created
Fig. 16.37 Procedure 7: The neurovascular pedicle is cut and the vas-
cular pedicle musculocutaneous fl ap secured. A continuous suction
drain is inserted subcutaneously above the fl ap and the wound closed
16 Reconstruction of Distal 1/3 of Lower Leg