Kỹ Thuật Thực Hành Trong Phẫu Thuật Ghép Vạt Da

492
Tips
Selection of anastomosis vessel when reconstructing the lower leg and method of anastomosis.
Selecting end-to-side anastomosis of the posterior tibial artery in the lower leg reconstruction produces good results
with few spasms. As the anastomosis method to the posterior tibial artery, there are two methods, which are the Godina
method, conducted in the popliteal region, and the method conducted in the medial malleolus region.


16 Reconstruction of Distal 1/3 of Lower Leg

493
Tips
What is correct end-to-side anastomosis?


Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)

494
Tips
Godina Method: End-to-side anastomosis to posterior tibial artery in the popliteal region
An incision is made in the center of the distal popliteal region.
The medial and lateral sides of the gastrocnemius muscle are separated, and when the soleus muscle is also split,
the posterior tibial blood vessels and nerve can be identifi ed.
This is dissected from the surrounding area and an end-to-side anastomosis performed to the posterior tibial artery.
If there are two comitant veins, an end-to- end anastomosis can be performed without problem, however because they
are suffi ciently thick an end-to- side anastomosis can also be performed. If the anastomosis is performed at a position
that is too proximal, reverse vascular fl ow into the fl ap from the posterior tibial comitant veins can occur, so caution is
required.


16 Reconstruction of Distal 1/3 of Lower Leg

495
Tips
End-to-side anastomosis to the posterior tibial blood vessels in the lower medial malleolus region
As the other method, an end-to-side anastomosis is performed to the posterior tibial blood vessels in the lower
medial malleolus region. Surgery is performed in the supine position.


Free Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)

496
Cross Leg Flap Method (Level of Diffi culty: 2)
Information
Pedicle fl ap method that involves elevating the fl ap from the unaffected lower leg and stitching it to the affected lower
leg and then separating 2 weeks later. In recent times with the development of arterial fl aps and free skin fl aps, this is
no longer a fi rst choice method, but for various reasons, there are times when it must be conducted. The principle indi-
cation is when the main blood vessels of the affected side have been damaged, and the limb cannot be used as an arte-
rial fl ap pedicle or graft bed anastomosis vessel.
The fl ap used is either the gastrocnemius muscle fl ap or the calf fascia fl ap (mainly superfi cial sural artery). External
skeletal fi xation is recommended for holding both legs in place.


16 Reconstruction of Distal 1/3 of Lower Leg

497
Operation Procedures
Fig. 16.39 Procedure 1: Loss of skin accompanying exposure of plate
on distal 1/3 of medial lower leg
Fig. 16.40 Procedure 2: Musculocutaneous fl ap with lateral head of
the gastrocnemius muscle is raised from unaffected side. Achilles ten-
don is retained
Refer to Section of “Patella region reconstruction/Gastrocnemius
fl ap” in Chap. 14
Fig. 16.41 Procedure 3: The elevated muscle fl ap is placed over the
exposed plate area and sewn in place. A skin graft is performed on the
donor site, and a tie-over bolster dressing applied



Cross Leg Flap Method (Level of Diffi culty: 2)

498

Fig. 16.42 Procedure 4: An external fi xation device is attached
between both tibia, and the legs are fi xed in place with care taken not to
apply tension to the fl ap. After about 2 weeks the skin fl ap is separated

16 Reconstruction of Distal 1/3 of Lower Leg

499
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_17
Reconstruction of Achilles Tendon Area
Basic Principles
Materials for reconstructing skin defects in the Achilles tendon area need to form thin and
strong skin flaps. There is no need for sensory function.
The first consideration is reconstruction with a local flap using skin from the area sur-
rounding the defect, but in many cases this is difficult because of crushing injury to the
surrounding tissue.
As an arterial island flap, medial pedis flap, a reverse peroneal flap and a lateral calcaneal
flap using a V-Y shape are the most practical. This can mean that the operating area becomes
much larger, but combining the lower calf fascia as a turn-over fascial flap and a skin graft
is a simple and stable procedure. As the free tissue transfer, either of a temporal fascia flap
or a combination of a muscle flap and a skin graft, that decreases in by atrophy, is an excel-
lent choice. A free musculocutaneous flap is too thick and not suitable. If a free skin flap is
chosen, a flap should be selected where thinning is possible.
In the case of transplanting free tissue, end-to-side anastomosis is performed to the pos-
terior tibial blood vessels in the medial malleolus region.
Selectable Flaps and Surgical Procedures
Medial pedis flap • Lateral calcaneal flap (conventional method) • Lateral calcaneal sliding
flap • Reverse flow peroneal flap • Reverse turn-over fascial flap • Reverse flow sural artery
skin flap • Supra malleolar flap • Free temporal fascia flap • Free abdominal perforator flap
• Free latissimus dorsi musculocutaneous flap (serratus anterior muscle flap) transfer

The difficulty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Difficulty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
17

500
Lateral Calcaneal Flap (Conventional Method) (Level of Difficulty: 2)
Information
Vascular pedicle Lateral calcaneal artery (Mostly distal end of peroneal artery. At times the distal end of the posterior
tibial artery is used, but it is always available)
Size width 4–5 cm, length 8–15 cm
Advantage Similar texture, has sensory function
Disadvantage Skin graft is required for donor site closure but it is difficult to take.
Donor site scar is obvious
(Reproduced from Yuichi Hirase, et al.: Long-term follow-up of a patient with lateral calcaneal flaps for bilateral
posterior heel necrosis. Ann Plast Surg 26: 474–478, 1991)

17  Reconstruction of Achilles Tendon Area

501
Operation Procedures
Fig. 17.1  Procedure 1: The position of the lateral calcaneal artery is
confirmed prior to surgery using the Doppler blood flow measurement,
and the skin flap is designed slightly longer than the necrotic area
between the lateral malleolus of the fibula and the Achilles tendon
Note  When the reconstruction area for the Achilles tendon extends to
the heel, a longer skin flap that curves slightly forward is designed. The
patient is often in the equinus position when the design is being con-
ducted, so a ruptured suture can easily occur at the flap edge following
surgery. Therefore it is essential to create a longer skin flap in consider-
ation of correction of the position of the feet.
Note  The lateral calcaneal artery runs above the periosteum. Because
it runs along the thick part of the tissue and not directly underneath the
skin flap, it gives an impression that the distal part of the flap is com-
paratively thick, but if the artery is not fully included then an arterial
flap cannot be created.
Fig. 17.2  Procedure 2: Patient is placed in the lateral recumbent posi-
tion or abdominal position. Incision is made from the distal end of the
flap, and the flap dissected from above the periosteum. The skin flap is
elevated towards the proximal end while confirming the blood vessels
and nerves on the reverse side of the flap
Lateral Calcaneal Flap (Conventional Method) (Level of Difficulty: 2)

502
Fig. 17.3  Procedure 3: The skin flap is transferred above the necrotic
area and sewn in place. Care is taken to make sure the ankle joint is not
in the equinus position
Note  Although there are few problems with the flap itself following
surgery, with regard to the skin graft to the donor site, because the graft
is conducted directly onto the periosteum, hematoma tends to occur
beneath the skin graft, and occasionally it is difficult to take. It is prefer-
able to leave the cast on for 2–3 weeks following surgery. In the case
that it doesn’t take, multiple skin grafts can at times be required.
Fig. 17.4  Procedure 4: A split-thickness skin graft is conducted on the
donor site, and a tie-over bolster dressing applied. A cast is applied to
the lower leg
17  Reconstruction of Achilles Tendon Area

503
Tips
The disadvantage of the lateral calcaneal flap is the donor site
• Grafting is conducted directly above the periosteum, and if there is incomplete pressure, a hematoma can tend to
occur.
• A small hole is opened in the skin graft so that hematomas can be discharged, pressure applied and plaster left on
for longer than usual.
• Although the depression that forms at the donor site improves over the longterm, a comparatively obvious scar
remains. For small skin defects of the Achilles area, a lateral calcaneal sliding flap using a V-Y form is preferred.

Lateral Calcaneal Flap (Conventional Method) (Level of Difficulty: 2)

504
Lateral Calcaneal Sliding Flap (Level of Difficulty: 3)
Information
Vascular pedicle Lateral calcaneal artery
(Mostly distal end of peroneal artery. At times the distal end of the posterior tibial artery is used, but it is always
available)
Size Width 3–5 cm, length 5–8 cm
Advantage Similar texture, has sensory function. Skin graft is not required.
Disadvantage The transfer distance for the flap is short, and is not suitable for covering large areas.

17  Reconstruction of Achilles Tendon Area

505
Operation Procedures
Fig. 17.5  Procedure 1: A triangular flap is designed adjacent to the
skin defect area on the Achilles tendon
Note  This is to be kept in mind when deciding the width of the flap for
enabling the nutrient vessel to run between the Achilles tendon and the
lateral malleolus of the fibula. It is possible to determine for certain if
confirmed using a Doppler blood flow measurement.
Note  In many cases the sural nerve also runs alongside. The vascular
pedicle is deep and runs above the periosteum.
Fig. 17.6  Procedure 2: An incision is made surrounding the flap, and
the lateral calcaneal artery & vein running above the periosteum con-
firmed. The proximal and distal sections of the vascular pedicle of the
skin flap are confirmed and retained and the skin flap completely dis-
sected from the surrounding area
Lateral Calcaneal Sliding Flap (Level of Difficulty: 3)

506
Fig. 17.7  Procedure 3: The skin flap is transferred laterally in accor-
dance with the V-Y plasty technique, and sutured to the surrounding
area
17  Reconstruction of Achilles Tendon Area

507
Tips
The first choice skin flap when reconstruction areas are not too large
In this case the skin texture with the surrounding skin is extremely good, and the inconspicuousness of the scar tis-
sue after reconstruction is striking. The area of surgery is small, and the volume of blood loss is also minor. However
the vascular pedicle is at a deep layer above the periosteum, so it is necessary to elevate a thick skin flap. Do not dissect
the thinner layer.

Lateral Calcaneal Sliding Flap (Level of Difficulty: 3)

508
Reverse Peroneal Flap (Level of Difficulty: 4)
Information
Vascular pedicle Peroneal artery and its skin perforator
Pivot joint Difficult to increase to a more distal position than 5–6 cm proximal of the lateral malleolus of the fibula
Size width 10 cm; length 20 cm
Advantage Skin texture is similar. Can perform surgery in same operating area.
Disadvantage If skin flap is large, skin graft becomes necessary and is obvious.

17  Reconstruction of Achilles Tendon Area

509
Operation Procedures
Fig. 17.8  Procedure 1: In prone position, prior to surgery, Doppler
measurement is conducted of the perforators of the peroneal artery
positioned at the rear margin of the fibula, distal of the middle of the
lower leg, and the peroneal flap is designed with that cutaneous branch
included. Surgery is performed under a tourniquet
Fig. 17.9  Procedure 2: An incision/detachment is made to the anterior
margin of the skin flap (front of fibula) including the deep fascia and the
front section of the skin flap elevated. It is then possible to confirm the
perforators heading toward the skin through the thin fascia at the rear
margin of the fibula
Note  Ordinarily 3–4 perforators to be included in the skin flap, are
located at intervals of 2–3 cm from the middle of the fibula. Perforators
proximal from the middle of the fibula are perforators for the muscle
and not for the skin, so even if they are picked up by Doppler measure-
ment, they cannot be used for a vascular pedicle for the skin flap.
Note  The skin perforators rise up from behind the skin, so it is pos-
sible to confirm the perforators when starting to elevate the front margin
of the flap.
Fig. 17.10  Procedure 3: An incision is made in the posterior margin of
the flap, and the flap dissected from the soleus muscle with the soleus
fascia attached on the flap side. When the soleus muscle is moved aside
the flexor hallucis longus muscle can be seen. The fibula blood vessels
that become the vascular pedicle for the skin flap, are located in this
flexor hallucis longus muscle, so with care, the vascular pedicle on the
posterior side of the fibula are detached
Note  To harvest without damaging the vascular pedicle, it is neces-
sary to harvest with part of the flexor hallucis longus muscle included.
Also, perforators from the posterior tibial artery perforate the soleus
muscle and the flexor hallucis longus muscle, and these should be
ligated.
Reverse Peroneal Flap (Level of Difficulty: 4)

510
Fig. 17.11  Procedure 4: After the vascular pedicle is completely iso-
lated, blood flow at the proximal end of the fibula blood vessels is tem-
porarily blocked using a blood vessel clip and the tourniquet taken off,
and confirmation made of color in the skin flap from reverse blood flow
Fig. 17.12  Procedure 5: The proximal end of the fibula blood vessels
are cut and ligated, the peroneal flap with reverse blood flow elevated,
and the flap transferred to the skin defect area, being careful not to bend
the vascular pedicle
Fig. 17.13  Procedure 6: After the flap is transferred and sutured to the
surrounding area, a split-thickness skin graft is conducted to the donor
area, and a tie-over bolster dressing applied. A plaster splint is applied
to the lower leg
17  Reconstruction of Achilles Tendon Area

511
Tips
The key to improving blood flow to the flap is wrapping the flap in a warm wet-to-wet dressing
In many cases, when the tourniquet is released the color doesn’t return straight away to flaps raised in the lower leg
or foot region. In particular, reverse flow flaps take more time. For that reason the author wraps the flap in a warm wet-
to-wet dressing and leaves it for around 15 min. In most cases the blood flow to the skin flap improves without requir-
ing the need for extra drugs.

Reverse Peroneal Flap (Level of Difficulty: 4)

512
Medial Pedis Flap (Level of Difficulty: 4)
Information
Vascular pedicle Medial branch of deep branch of medial plantar artery
Size width 3 cm, length 7 cm
Advantage Comparatively thin and flexible but strong. Can perform surgery in same operating area. Can retain the
lateral plantar artery
Disadvantage Size of skin flap is small. Not a sensory flap. Requires a skin graft to close the donor site. The vascular
pedicle is thin and deep. The vascular pedicle is always present, however there are variations in the path.

17  Reconstruction of Achilles Tendon Area

513
Operation Procedures
Fig. 17.14  Procedure 1: A flap is designed with the proximal concav-
ity of the scaphoid tubercle of the medial foot included
Fig. 17.15  Procedure 2: An incision is made in the lower margin of
the skin flap, and the line of incision is extended to the direction of the
tarsal tunnel. The abductor hallucis muscle is present here, so with its
fascia included, the skin flap is detached from the plantar side toward
the dorsal side. When the abductor hallucis muscle is pulled downwards
at the same time, it is possible to see the cutaneous branch from the
medial plantar artery
Refer to Section of “Medial pedis flap” (pp. 228–231)  Yuichi
Hirase, Gentle Microsurgery, Kokuseido CO., LTD. 2004.
Note  The scaphoid tubercle of the foot is easily recognizable as the
protrusion located in the upper arch of the foot. The cutaneous branch
of the flap runs from below the concavity proximal to the scaphoid
tubercle upwards, so this should also be included in the design.
Fig. 17.16  Procedure 3: An incision is made in the upper margin of
the skin flap, and after the skin flap is detached from the surrounding
area, the vascular pedicle is dissected moving toward the stem of the
medial plantar artery. The vascular pedicle is detached up to where the
medial plantar artery and the lateral plantar artery branch, and the lat-
eral branch of the deep branch and the superficial branch are severed,
and a complete island flap containing the medial plantar blood vessels
is elevated
Medial Pedis Flap (Level of Difficulty: 4)

514
Note  A tie-over bolster dressing is applied.
Fig. 17.17  Procedure 4: Case of skin defect of medial calcaneal. The
flap elevated with the medial plantar blood vessels is transferred, being
careful not to bend the vascular pedicle
Fig. 17.18  Procedure 5: After the flap is transferred to the Achilles
tendon area, the abductor hallucis muscle is raised, and the scaphoid
tubercle covered, and a skin graft conducted on top
17  Reconstruction of Achilles Tendon Area

515
Tips
The posterior tibial artery splits into the medial and lateral plantar artery at the distal tarsal tunnel
The medial plantar artery further splits into the superficial branch and deep branch.
The superficial branch is included in the vascular pedicle of the medial plantar flap, however the (1) deep branch
further splits into the (2) medial branch (the vascular pedicle for this flap) and the (3) lateral branch. If the lateral
branch is located distally and communicates with the plantar or dorsal arterial arch, then it is also possible to elevate
this flap as a reverse flap.

Medial Pedis Flap (Level of Difficulty: 4)

516
Reverse Turn-Over Fascial Flap (Level of Difficulty: 2)
Information
Vascular pedicle Posterior tibial artery and peroneal artery
Size Superior margin 3–5 cm distal from popliteal crease; inferior margin 6–8 cm proximal from medial and lateral
malleolus. Fascial flap made to size required to fit 10–15 cm width from this area. An overlap of 5 cm from the wound
is secured.
Advantage Fascia is thin, flexible and strong. Can perform surgery in same operating area. Surgery is extremely
simple. No complex techniques are required.
Disadvantage A skin graft is required

17  Reconstruction of Achilles Tendon Area

517
Note  Here, if the sural nerve can be retained then it is detached from
the fascia and left in place.
Refer to Section of  “Reconstruction of distal 1/3 of lower leg/Reverse
turn-over flap” in Chap. 16
Operation Procedures
Fig. 17.20  Procedure 2: An incision is made in the fascia 3–5  cm
below the popliteal region, and a large section of fascia detached from
the tissue
Fig. 17.21  Procedure 3: The fascial flap is detached in a distal direc-
tion with a width of about 10–15 cm. Here, care is taken not to go more
than 6–8  cm from the medial and lateral malleolus. An overlap of
around 5 cm from the wound is secured
Fig. 17.19  Procedure 1: An incision is made along the major axis of
the middle of the posterior surface of the lower leg beneath a tourniquet,
and detached subdermally (above fascia)
Note  It is important not to separate too far distally in order to avoid
damaging the perforators from the posterior tibial artery and peroneal
artery.
Reverse Turn-Over Fascial Flap (Level of Difficulty: 2)

518
Fig. 17.23  Procedure 5: A split-thickness skin graft is conducted on
top of the fascia flap
Fig. 17.22  Procedure 4: The exposed Achilles tendon is covered with
the turn-over fascia flap. A bolster suture is done to pull the fascial flap
into the subcutaneous layer
Note  Here, if necessary, a continuous suction drain is inserted beneath
the fascia flap.
17  Reconstruction of Achilles Tendon Area

519
Tips
The pivot point is placed 5 cm proximal from the exposed Achilles tendon area
A rich vascular network supplies the fascia of the lower leg from the posterior tibial artery and peroneal artery.
Therefore, if a perforator from at least one of these is included in the skin flap it is possible to maintain blood flow. It
is also possible to create a skin island above the fascia flap and create a fasciocutaneous flap (gastrocnemius skin flap).
As part of the actual technique, the pivot point should be placed 5 cm proximal from the exposed Achilles tendon area.
The area 5 cm from the pivot point will overlap, so the section covering the wound area will be the fascia more proxi-
mal from there.
This should be taken into consideration when deciding the size of the fascia flap.
Reverse Turn-Over Fascial Flap (Level of Difficulty: 2)

520
Free Latissimus Dorsi Musculocutaneous Flap (Serratus Anterior Muscle Flap)
(Level of Difficulty: 4)
Information
Vascular pedicle Thoracodorsal blood vessel
Size (muscle flap) width 40 cm; length 40 cm
Advantage Good blood circulation, vascular pedicle is thick and long, and it is possible to conduct free design of a
musculocutaneous flap
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 flap, and therefore a skin graft is
required
Caution The space left after removal of the latissimus dorsi muscle can cause a painful seroma, so several continuous
suction drains should be put in place.

17  Reconstruction of Achilles Tendon Area

521
Operation Procedures
Fig. 17.24  Procedure 1: With the patient in the prone position, the
anastomosis area is prepared in accordance with the Godina method.
An incision is made along the center of the posterior lower leg, and
when the medial and lateral heads of the gastrocnemius muscle are cut
down the middle, the soleus muscle becomes visible
Refer to Tips of  “Selection of anastomosis vessel when ­reconstructing
the lower leg and method of anastomosis” in Chap. 16
Fig. 17.25  Procedure 2: When the soleus muscle fibers are split down
the middle, the posterior tibial blood vessels (or distal site of popliteal
blood vessel) and the tibial nerve become visible
Free Latissimus Dorsi Musculocutaneous Flap (Serratus Anterior Muscle Flap) (Level of Difficulty: 4)

522
Note  If the skin flap section is designed distally, it is possible to obtain
a longer vascular pedicle.
Fig. 17.26  Procedure 3: In the lateral recumbent position, the middle
axillary line is marked, which becomes the anterior margin of the latis-
simus dorsi muscle. The required skin flap is designed on top of the
latissimus dorsi muscle
Fig. 17.27  Procedure 4: An incision is made in the middle popliteal
line, the anterior margin of the latissimus dorsi muscle is uncovered,
and the serratus anterior muscle is identified anterior to that. The ser-
ratus anterior muscle branch of the thoracodorsal blood vessels that
pass through the fascia of the serratus anterior muscle can now be
confirmed
Note  Following this serratus anterior muscle branch proximally, the
latissimus dorsi muscle branch of the thoracodorsal blood vessels
comes into view.
17  Reconstruction of Achilles Tendon Area

523
Note  For the elevation of the serratus anterior muscle flap, the latissi-
mus dorsi muscle branch of the thoracodorsal blood vessel is ligated,
and the muscular bundle, heading toward ribs 7–9 from the serratus
anterior muscle branch of the thoracodorsal blood vessel, is elevated as
the muscle flap.
Fig. 17.28  Procedure 5: The latissimus dorsi muscle is turned over
enabling confirmation of the thoracodorsal blood vessels on the reverse
side. The vascular pedicle is confirmed and the required size of muscu-
locutaneous flap is detached from the surrounding area
Fig. 17.29  Procedure 6: With the latissimus dorsi flap elevated, head-
ing proximally along the thoracodorsal blood vessels, the serratus ante-
rior muscle branch/circumflex scapular artery are ligated, and an island
muscle flap with subscapular blood vessels is elevated/harvested
Free Latissimus Dorsi Musculocutaneous Flap (Serratus Anterior Muscle Flap) (Level of Difficulty: 4)

524
Note  Caution should be paid when restructuring skin soft tissue on the
posterior lower leg in the prone position, that the ankle joint is not in the
equinus position. The ankle joint is placed at right angles, and the flap/
skin graft sutured in place and fixed in plaster.
Fig. 17.30  Procedure 7: An end-to-side anastomosis is conducted of
the subscapular artery which is the vascular pedicle for the flap, to the
posterior tibial blood vessels. A continuous suction drain is inserted
beneath the muscle flap, and a bolster suture is done to pull the muscle
flap into the subcutaneous layer
Fig. 17.31  Procedure 8: A 1.5 time split-thickness skin graft is con-
ducted over the muscle flap, and a light pressure bandage applied. It is
fixed in plaster for 2 weeks
17  Reconstruction of Achilles Tendon Area

525
Free Temporal Fascia Flap (Level of Difficulty: 4)
Information
Vascular pedicle Superficial temporal blood vessels
Size length 10 cm, width 12 cm
Advantage Thin, so difficult to create dead cavity in reconstructed area. Possible to create greater thickness by folding
on top of each other. If the deep fascia is included it is possible to harvest two fascia flaps
Disadvantage Requires skin graft. Not possible to monitor blood flow after surgery. Tends to have high blood loss

Free Temporal Fascia Flap (Level of Difficulty: 4)

526
Operation Procedures
Fig. 17.32  Procedure 1: In the case of harvesting only the superficial
temporal fascia, a straight incision is made that extends from the auricle
anterior margin to the parietal region
Note  Here, cutting or shaving of hair is not required; wash/sterilize
hair after bundling with a rubber band.
17  Reconstruction of Achilles Tendon Area

527
Note  The vascular pedicle is dissected up until the upper margin of the
zygomatic arch and harvested.
Fig. 17.33  Procedure 2: The temporal fascia flap with superficial tem-
poral blood vessels as the vascular pedicle is elevated
Free Temporal Fascia Flap (Level of Difficulty: 4)

528
a
b
Fig. 17.34  (a, b) Procedure 3: Case: Necrotic skin on calcaneal and
Achilles tendon is exposed following debridement. Firstly, the medial
plantar blood vessels (posterior tibial blood vessels) are identified on
the Achilles tendon side
17  Reconstruction of Achilles Tendon Area

529
Fig. 17.35  Procedure 4: The fascia flap is transferred. End-to-side
anastomosis is conducted of the superficial temporal blood vessels to
the posterior tibial blood vessels in the medial malleolus region, and the
fascia flap is used to cover the skin defect with thickness adjusted by
folding the fascia flap over on itself
Free Temporal Fascia Flap (Level of Difficulty: 4)

530
Fig. 17.36  Procedure 5: A split-thickness skin graft is performed on
the fascia flap
17  Reconstruction of Achilles Tendon Area

531
Tips
The temporal fascia is a high quality reconstruction material that is thin and strong with stable blood flow
• Outside of plastic surgery, there is often resistance to the surgical method of using the cranium as reconstruction
material for reconstructive foot surgery.
• However, as a skin flap that is thin, strong and has a stable blood supply, the temporal fascia flap is a reconstructive
material worthy of special mention.
• The donor site is from an area with hair so doesn’t become obvious.
• Other fascias that can be elevated and harvested apart from the temporal fascia include the fascia of the scapula
region at the circumflex scapular artery, and the serratus anterior muscle fascia at the subscapular artery blood
vessels.

Free Temporal Fascia Flap (Level of Difficulty: 4)

532
Free Abdominal Perforator Flap (Level of Difficulty: 4)
Information
Vascular pedicle Perforators of deep inferior epigastric blood vessels
Size No restriction as long as abdominal skin containing perforators is used
Advantage Few restrictions for the shape of the skin flap Possible to remove fat and conduct thinning of skin flap.
It is possible to conduct primary closure of the donor site
Disadvantage High risk in cases of advanced obesity cases

17  Reconstruction of Achilles Tendon Area

533
Operation Procedures
Fig. 17.38  Procedure 2: Multiple perforators emerging from the ante-
rior sheath of the rectus abdominis muscle are secured, with two perfo-
rators chosen that run in line with the muscle fibers, and the anterior
sheath cut and detached up to the deep inferior epigastric blood
vessels
Fig. 17.37  Procedure 1: The abdominal skin flap containing multiple
perforators is designed next to the naval region
Note  A large number of perforators are present beneath this 4 × 4 cm
section of the naval region.
Refer to Section of  “Reconstruction of calcaneal region/lateral plan-
tar region/Free abdominal perforator flap” in Chap. 18
Note  For blood circulation, it is sufficient for one perforator to be
included in the skin flap, but it is better to include at least two perfora-
tors in order to avoid twisting of the vascular pedicle occurring. Also,
by securing two perforators that run in line with the muscle fiber, it is
possible to minimize damage to the rectus abdominis muscle, reducing
the possibility of an abdominal hernia.
Free Abdominal Perforator Flap (Level of Difficulty: 4)

534
Note  The detached area of the skin flap donor site is sutured closed,
and a continuous suction drain inserted subcutaneously.
The area surrounding the vascular pedicle is left in place and thinning is
conducted by removing subcutaneous fat from other areas.
Note  Until the surgeon is comfortable with the technique, it is safer to
conduct defatting prior to cutting the vascular pedicle.
a
b
Fig. 17.39  (a, b) Procedure 3: A sufficient length of the deep inferior
epigastric blood vessels is detached and the skin flap harvested
17  Reconstruction of Achilles Tendon Area

535
Fig. 17.40  Procedure 4: End-to-side anastomosis is conducted with
the deep inferior epigastric blood vessels to the posterior tibial blood
vessels in the popliteal region or medial malleolus region and the skin
flap transplanted
Free Abdominal Perforator Flap (Level of Difficulty: 4)

536
Tips
Perform thinning prior to cutting the vascular pedicle until comfortable with the technique
Removal of subcutaneous fat from the abdominal perforator flap to adjust the thickness of the flap enables creation
of a highly useful flap, but until the surgeon feels comfortable with the technique, the fat should be removed prior to
cutting the vascular pedicle, while keeping a close eye on bleeding.

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537
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_18
Reconstruction of Calcaneal Region/
Lateral Plantar Region
Basic Principles
The tissue required for reconstruction of the calcaneal region is thick and must be able to
withstand weight applied. It is preferable to have sensory function, but it is not necessary to
pro-actively reconstruct sensory function, so tissue that can obtain protective sensation eas-
ily is selected.
For this reason the medial plantar fl ap is the fi rst choice. Only if for some reason it is not
possible to obtain the medial plantar fl ap from the affected foot or from the healthy foot
either, another fl ap such as an abdominal perforator fl ap should be examined.
Whichever fl ap is selected, guidance must be given for long term use of an arch support
splint.
Selectable Flaps and Surgical Procedures
Medial plantar fl ap (Normal/free) • Medial pedis fl ap • Free scapular fl ap • Free abdominal
perforator fl ap • Lateral calcaneal fl ap • Reverse peroneal fl ap • Anterolateral thigh 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.
18

538
Medial Plantar Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Superfi cial branch of medial plantar artery
Size From the upper plantar arch area to the periphery of the scaphoid tubercle
Advantage Suitable for reconstruction of plantar weight bearing area. Possible to include sensory function
Caution If the stitching is located on the weight bearing section it can produce new scar contracture. Therefore suffi -
cient examination is required prior to surgery to ensure that the fl ap harvest area and stitching post-surgery does not
occur in the load bearing area.
For reconstruction exceeding the size of the upper arch, it is better to examine the possibility of using other free
fl aps. Also, guidance should be given to the patient for the use of an arch support splint for several months after sur-
gery. This is not suited to cases where patients are required to walk on gravel roads or wear thin rubber soled shoes as
part of their work.


18 Reconstruction of Calcaneal Region/Lateral Plantar Region

539
Operation Procedures
Fig. 18.1 Procedure 1: Large skin defect present on lateral plantar
weight bearing area. A triangular fl ap with the same width as the skin
defect area is designed from the medial plantar to the upper arch

Medial Plantar Flap (Level of Diffi culty: 3)

540
Fig. 18.2 Procedure 2: Scar from around the skin fi stula is completely
removed

18 Reconstruction of Calcaneal Region/Lateral Plantar Region