541
Fig. 18.3 Procedure 3: An incision is made around the margin of the
skin fl ap, and the skin fl ap is detached while retaining the toe nerve
beneath the plantar fascia. The tarsal tunnel is opened from the proxi-
mal end and the vascular pedicle is detached while retaining the calca-
neal branch/lateral plantar artery at the distal end of the posterior tibial
artery. The abductor hallucis muscle is retained and the vascular pedicle
is detached from beneath it. Sensory nerves are included in the skin fl ap
if they can be retained
Note The plantar fascia isn’t involved in the blood fl ow to the skin
fl ap, however it is a good technique to raise the fl ap with it included.
Medial Plantar Flap (Level of Diffi culty: 3)
542
Fig. 18.4 Procedure 4: The island fl ap is transferred to the lateral side
and the skin defect area is covered. If the fl ap elevated area cannot be
sutured closed, a non-load area skin graft is conducted
Fig. 18.5 Procedure 5: A tie-over bolster dressing is applied to the
graft area
18 Reconstruction of Calcaneal Region/Lateral Plantar Region
543
Fig. 18.6 Procedure 6: The patient is made to wear an arch support
splint for several months following surgery. The plantar reconstructed
with the adjoining skin fl ap has extremely good skin texture
Medial Plantar Flap (Level of Diffi culty: 3)
544
Tips
It is possible to combine several skin fl aps and elevate/move the entire sole as a single skin fl ap.
It is possible to combine the medial pedis fl ap and the calcaneal fl ap to the medial plantar fl ap and elevate and move
the entire sole as a single skin fl ap with the posterior tibial arterial system. The skin fl ap combination can be changed
and elevated in accordance with the skin defect area and stitching position.
18 Reconstruction of Calcaneal Region/Lateral Plantar Region
545
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Perforators of deep inferior epigastric blood vessels
Size Can create a skin fl ap from the skin beside the naval region that can be reefed in any direction horizontally, lon-
gitudinally or diagonally. It is easy to include multiple perforators if harvesting in a longitudinal direction. It is possible
to create the fl ap horizontally in order to hide the stitching beneath underwear, however this requires hollowing the
navel, detaching the skin in the surrounding area before closing the suture.
Advantage It is possible to retain the rectus abdominis muscle so there is less concern for the possibility of an abdomi-
nal hernia. The skin fl ap can be freely created. It is possible to conduct thinning by removing fat
Caution The perforators may be ruptured in patients who have had abdominal surgery, and in principle this method is
not indicated for such cases.
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
546
Operation Procedures
Fig. 18.8 Procedure 2: The skin fl ap is designed with the inclusion of
the perforators in a 3–4 cm square region around the naval area
Fig. 18.9 Procedure 3: Multiple perforators are secured in the anterior
sheath of the rectus abdominis muscle
Fig. 18.7 Procedure 1: A large skin defect spans from the Achilles
region to the medial calcaneal plantar region
Refer to Section of “Reconstruction of dorsum of hand/Free abdomi-
nal perforator fl ap” in Chap. 3
Refer to Section of “Reconstruction of palm of hand/Free abdominal
perforator fl ap” in Chap. 5
Refer to Section of “Reconstruction of Achilles tendon area/Free
abdominal perforator fl ap” in Chap. 17
18 Reconstruction of Calcaneal Region/Lateral Plantar Region
547
Fig. 18.10 Procedure 4: Following the perforators, an incision is made
in the rectus abdominis muscle in the direction of the muscle fi ber, and
the vascular pedicle is detached up to the deep inferior epigastric artery.
An incision is made in a ring shape around the navel area, being careful
not to damage the surrounding subcutaneous fat, leaving it in place
Fig. 18.11 Procedure 5: Leaving the vascular pedicle in place, excess
fat is resected from the harvested skin fl ap
Fig. 18.12 Procedure 6: The skin fl ap is transferred to the calcaneal
region, and an end-to-side anastomosis is conducted of the vascular
pedicle to the proximal end of the posterior tibial artery. A skin graft is
conducted to the skin defect area of the upper arch and a tie-over bolster
dressing applied
Free Abdominal Perforator Flap (Level of Diffi culty: 4)
548
Note If the position of the naval will be out of alignment when closed,
a new incision is made and the position of the naval adjusted.
Fig. 18.13 Procedure 7: The cut rectus abdominis muscle is sutured
and repaired using an absorbable suture
Fig. 18.15 Procedure 9: The wound of the naval area is sutured and
closed while confi rming that it is in the correct position
Fig. 18.14 Procedure 8: The anterior sheath of the rectus abdominis
muscle is sutured and closed using a non-absorbable suture
18 Reconstruction of Calcaneal Region/Lateral Plantar Region
549
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_19
Reconstruction of the Plantar Forefoot
Basic Principles
The plantar MP joint is a weight bearing area, and a thick tissue is required for reconstruc-
tion. However, taking into consideration comfort when walking, there are limited options
when selecting skin flaps based on tissue characteristics and thickness.
It is not necessary to pro-actively pursue a sensory reconstruction, but if a similar tissue
is used for reconstruction, it is easier to obtain protective sensation.
••
For reconstruction of the plantar forefoot, in principle, plantar flap transfer from the
unaffected foot is not an option.
••
First option: Distal transfer of medial plantar flap from affected side. In order to increase
the transfer distance, if the vascular pedicle is detached from the tarsal tunnel and trans-
ferred forward, it is possible to reconstruct a more distal area.
••
Free flap:
– Small defect
• Abdominal perforator (DIEP) flap
• Combination with medial plantar island flap
– Large defect
• Bi-lobed scapular flap
• Latissimus dorsi muscle flap + skin graft
• Anterolateral thigh flap
Selectable Flaps and Surgical Procedures
Medial Plantar Flap • Free abdominal perforator flap • Free scapular flap (Bi-lobed scapular
flap) • Extensor digitorum brevis muscle flap • Anterolateral thigh flap
19
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.
550
Information
Vascular pedicle Dissected and harvested from circumflex scapular artery to subscapular artery. Length of vascular
pedicle 10 cm and diameter 2 mm
Size The size of a scapular flap that can be sutured closed is around 20 cm long with a width of 8–10 cm, and this can
be combined with a flap of longitudinal length 15–20 cm and width 10 cm
Indication For large skin defects
Advantage Has thickness. Technique is simple and has stable blood flow. It is possible to create a large flap
Disadvantage Can require change of body position. Not possible to reconstruct sensory function
Bi-lobed Scapular Flap (Level of Difficulty: 4)
19 Reconstruction of the Plantar Forefoot
551
Operation Procedures
Fig. 19.1 Procedure 1. Case of necrotic skin on plantar forefoot
weight-bearing region
Fig. 19.2 Procedure 2: Patient is placed in the lateral recumbent posi-
tion. The circumflex scapular artery emerges from almost the center of
the acromial process and the inferior angle of the scapula and passes
through the scapular triangular space (area in between the teres minor
muscle, teres major muscle and long head of triceps brachii muscle),
emerging subcutaneously. Therefore, this area must be included in the
skin flap design
Note In order to create a bi-lobed flap, an additional skin flap is added
running longitudinally along the lateral border of the scapula.
Fig. 19.3 Procedure 3: An incision is made in the distal margin of the
skin flap, and the skin flap is detached moving from the medial side of
the back to the lateral side
Note The individual fascia of the back muscles such as the infraspina-
tus muscle and the rhomboid major muscle are left as is, and the skin
flap is elevated with the hazy fascia tissue above that included.
When the skin flap is turned over and detached close to the scapular
triangular space, it is possible to confirm the vascular pedicle through
the thin fascia. Blood vessels comprise both an ascending branch and a
descending branch, so an incision is also made in the lateral border of
the scapula and detachment conducted.
Bi-lobed Scapular Flap (Level of Difficulty: 4)
552
Fig. 19.4 Procedure 4: Confirming the path of the vascular pedicle, it
is dissected from above the individual fascia of the infraspinatus mus-
cle, teres major muscle and teres minor muscle, securing the stem of the
circumflex scapular artery, with dissection continued inside the scapu-
lar triangle
Note Even if it is not possible to confirm/detach the vascular pedicle
of the parascapular flap, if the flap was harvested as a fascia flap along
the lateral border of the scapula then it will have been automatically
included. If wanting to include part of the scapula, confirmation is made
of the descending branch of the circumflex scapular artery, and the lat-
eral border of the scapula is harvested with the teres minor muscle
attached.
Fig. 19.5 Procedure 5: The circumflex scapular artery is cut from the
thoracodorsal artery, and detached up to the subscapular artery
19 Reconstruction of the Plantar Forefoot
553
Note Obese patients may require a skin graft. A seroma can tend to
occur in the dissected area, so several continuous suction drains can be
inserted, or inserted for a slightly longer period.
Fig. 19.6 Procedure 6. Length of vascular pedicle is 10 cm with diam-
eter 2–3 mm. The comitant vein is thicker
Fig. 19.7 Procedure 7. The two flaps are combined to cover a large
skin defect area. Anastomosis is conducted of the blood vessels to the
distal posterior tibial blood vessels
Fig. 19.8 Procedure 8. The skin flap donor site is directly sutured
closed
Bi-lobed Scapular Flap (Level of Difficulty: 4)
554
Fig. 19.9 Procedure 9. Although it appears bulky at first, over time the
skin flap decreases in size. If it still appears too large after 6 months
then subcutaneous fat can be resected. In order to avoid formation of a
callus or a sore, an arch support splint (for the shoe) matching the shape
of the upper plantar arch should be provided to the patient
19 Reconstruction of the Plantar Forefoot
555
Information
Vascular pedicle Superficial branch of medial plantar artery
Size: From the upper arch area to the periphery of the scaphoid tubercle
Advantage Suitable for reconstruction of plantar weight bearing area.
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 flap harvest area and stitching post-surgery does not
occur in the load bearing area.
For reconstruction exceeding the size of the instep region, it is better to examine the possibility of using other free
flaps. 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.
Medial Plantar Flap (Level of Difficulty: 3)
Medial Plantar Flap (Level of Difficulty: 3)
556
Fig. 19.10 Procedure 1. A skin graft has been conducted on the weight
bearing area above the plantar MP joint, and a callus has formed
Operation Procedures
19 Reconstruction of the Plantar Forefoot
557
Fig. 19.11 Procedure 2: The medial plantar flap is elevated as an
island flap, and the abductor hallucis muscle is temporarily detached at
the joint. The skin flap neurovascular pedicle is dissected from the tar-
sal tunnel and transferred forward of the abductor hallucis muscle. The
abductor hallucis muscle is then resutured
Note This method enables the skin flap to be easily transferred
distally.
Medial Plantar Flap (Level of Difficulty: 3)
558
Fig. 19.12 Procedure 3: A split-thickness skin graft is conducted on
the donor area
19 Reconstruction of the Plantar Forefoot
559
Fig. 19.13 Procedure 4: Stitches are removed around 2 weeks later,
and the patient is provided with an arch support to use for several
months
Note By detaching the neurovascular pedicle from the tarsal tunnel it
is possible to obtain sufficient transfer distance for this flap for covering
the load-bearing area of the plantar forefoot. However, if the recon-
struction of the abductor hallucis muscle is insufficient it can cause hal-
lux valgus, so care is required.
Medial Plantar Flap (Level of Difficulty: 3)
560
Information
The weight bearing area is reconstructed using the medial plantar flap and the tip of the foot and dorsal area is recon-
structed using a free abdominal perforator flap
Medial Plantar Flap and Free Abdominal Perforator Flap (Level of Difficulty: 4)
19 Reconstruction of the Plantar Forefoot
561
Fig. 19.15 Procedure 2: The free abdominal perforator flap is elevated
for reconstructing the dorsal area
Fig. 19.16 Procedure 3: The plantar region is covered using the
advanced medial plantar flap
Fig. 19.14 Procedure 1. The medial plantar flap is designed with the
objective of reconstructing the load-bearing area of the MP joint
Operation Procedures
Medial Plantar Flap and Free Abdominal Perforator Flap (Level of Difficulty: 4)
562
Fig. 19.17 Procedure 4: The dorsal region is covered using the thinned
free abdominal perforator flap
Fig. 19.18 Procedure 5: Appearance after surgery
19 Reconstruction of the Plantar Forefoot
563
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 primarily close the donor site
Disadvantage High risk in cases of advanced obesity cases
Free Abdominal Perforator Flap (Level of Difficulty: 4)
Free Abdominal Perforator Flap (Level of Difficulty: 4)
564
Fig. 19.19 Procedure 1. A skin defect is present on the plantar region
Fig. 19.20 Procedure 2: For the abdominal perforator flap, several
skin perforators located laterally to the navel were secured in the direc-
tion of the muscle fiber
Refer to Section of “Reconstruction of dorsum of hand/Free abdomi-
nal perforator flap” in Chap. 3
Refer to Section of “Reconstruction of palm of hand/Free abdominal
perforator flap” in Chap. 5
Refer to Section of “Reconstruction of Achilles tendon area/Free
abdominal perforator flap” in Chap. 17
Operation Procedures
19 Reconstruction of the Plantar Forefoot
565
Fig. 19.21 Procedure 3: The skin flap can be thinned to a thickness
of 1 cm
Fig. 19.22 Procedure 4: The skin perforators are detached up to the
deep inferior epigastric artery, and the skin flap harvested
Free Abdominal Perforator Flap (Level of Difficulty: 4)
566
Fig. 19.23 Procedure 5: The skin flap is sutured in place and anasto-
mosis conducted of the deep inferior epigastric blood vessels to the
posterior tibial blood vessels in the proximal tarsal tunnel
Fig. 19.24 Procedure 6: After removal of the flap, the anterior sheath
of the rectus abdominis muscle is sutured and repaired
19 Reconstruction of the Plantar Forefoot
567
Fig. 19.25 Procedure 7: The wound is closed
Free Abdominal Perforator Flap (Level of Difficulty: 4)
568
Tips
The patient is provided with an arch support splint following reconstruction of the plantar region
If this is not worn it can lead to callus forming in the plantar region.
19 Reconstruction of the Plantar Forefoot
569
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_20
Reconstruction of Dorsum
and Amputated Foot Stump
Basic Principles
The dorsum of the foot has a large number of tendons, and is a difficult place for a skin graft
to take. The method of creating granulation tissue using artificial dermis and then conduct-
ing a skin graft is available as an option, but fixing the foot in place for long periods
decreases the range of movement of the ankle and can induce contracture such as equinus
foot.
For the reconstruction of an amputation stump using a free flap, a comparatively thin
skin flap is chosen. The dorsal artery of the foot is close to the reconstruction position and
muscle spasms tend to occur, so anastomosis (if possible end-to-side) to the posterior tibial
artery is the preferred option.
Selectable Flaps and Surgical Procedures
Extensor digitorum brevis muscle flap (normal/reverse) + skin graft • Temporal fascia
flap and skin graft • Free abdominal perforator (DIEP) flap • Artificial dermis and skin flap •
Groin flap • Combined free scapular/parascapular flap • Free anterolateral thigh flap
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.
20
570
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
Information
Vascular pedicle Lateral tarsal blood vessels (branches from the dorsal pedis artery beneath the extensor
retinaculum)
Size 4.5 × 6 cm
Advantage Blood flow is stable, it is not bulky and there is no loss of function due to harvesting. Suitable for covering
exposed tendons or bone of the dorsum. The vascular pedicle is beneath the extensor retinaculum of the ankle, and
some distance from the area to be covered, so is often not damaged.
Disadvantage Size of muscle flap is small. Requires skin graft
Caution Incision is made slightly medial along the dorsal artery
20 Reconstruction of Dorsum and Amputated Foot Stump
571
Operation Procedures
Fig. 20.1 Case 1 Procedure 1: Due to a large loss of skin from the
dorsum, the extensor digitorum longus muscle is exposed.
Note However, damage doesn’t extend to the layers below the exten-
sor digitorum longus muscle tendon. Also, there is no damage to the
extensor retinaculum. Therefore the extensor digitorum brevis muscle
and lateral tarsal artery are retained and an inference is made that eleva-
tion of an extensor digitorum brevis muscle flap is possible.
Procedure 2: The extensor digitorum brevis is found beneath the exten-
sor digitorum longus muscle tendon (extensor hallucis brevis muscle
and extensor digitorum brevis muscle), and the muscle flap is dissected
and elevated above the periosteum from the distal part of the muscle
flap on the lateral dorsum, and dissected in the direction of the dorsal
artery of the foot. Following the path of the dorsal artery, when the
extensor retinaculum is cut at about 2 cm, it becomes possible to see the
lateral tarsal artery branching off and entering the muscle flap
Note Turning over the muscle flap it is possible to clearly confirm the
vascular pedicle on the reverse side.
Case 1
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
572
Fig. 20.3 Procedure 4: The muscle flap is used to cover the exposed
tendon
Fig. 20.2 Procedure 3: The elevated tissue is taken out from beneath
the extensor hallucis longus muscle tendon
20 Reconstruction of Dorsum and Amputated Foot Stump
573
Fig. 20.4 Procedure 5: A split-thickness mesh skin graft is conducted
above the muscle flap
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
574
Case 2
Fig. 20.5 Case 2: Procedure 1: Example of exposure of the extensor
tendon due to skin defect of dorsum. There is no damage to the extensor
digitorum brevis muscle beneath the extensor digitorum longus muscle
tendon
Fig. 20.6 Procedure 2: The extensor digitorum brevis muscle is cut
from the distal part of the tendon, and the bone attachment area detached
from the periosteum
20 Reconstruction of Dorsum and Amputated Foot Stump
575
Fig. 20.7 Procedure 3: The separated extensor digitorum brevis mus-
cle flap is extracted from under the extensor digitorum longus muscle
tendon
Fig. 20.8 Procedure 4: The extracted muscle flap is used to cover the
exposed tendon
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
576
Fig. 20.9 Procedure 5: A skin graft is conducted on the muscle flap,
and a tie-over bolster dressing applied
20 Reconstruction of Dorsum and Amputated Foot Stump
577
Tips
If the incision is made in the lateral dorsum to make for an easier muscle flap harvest, the blood flow to the
medial dorsum will become unstable.
The blood flow to the dorsum flows medially through the dorsal artery, and laterally through the peroneal artery. If
the dorsal artery is harvested in order to elevate this muscle flap, blood flow will be limited to the peroneal artery on
the lateral side. If the incision is made in the lateral dorsum, blood flow of the peroneal artery on the medial dorsum
will be disrupted, and a sore can occur on the dorsum. The incision should be made slightly medial of the area sur-
rounding the dorsal artery.
Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
578
Refer to Section of “Reconstruction of dorsal surface of toe/Reverse extensor digitorum brevis muscle flap”
in Chap. 21
Reverse Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
Information
Vascular pedicle Lateral tarsal blood vessels (branches from the dorsal pedis artery beneath the extensor
retinaculum)
Size 4.5 × 6 cm
Advantage Blood flow is stable, it is not bulky and there is no loss of function due to harvesting. Suitable for covering
exposed tendons or bone of the dorsum. The vascular pedicle is beneath the extensor retinaculum of the ankle, and
some distance from the area to be covered, so is often not damaged.
Disadvantage Size of muscle flap is small. Requires skin graft.
Caution Incision is made slightly medial along the dorsal artery. The connection branch between the dorsal artery and
plantar artery must be left intact
20 Reconstruction of Dorsum and Amputated Foot Stump
579
Operation Procedures
Fig. 20.10 Procedure 1: Skin defect of distal dorsum due to amputa-
tion of great toe. The X marks the path of the dorsal artery and the solid
line marks the incision line
Fig. 20.11 Procedure 2: While gradually detaching the dorsal pedis
vessels, the extensor digitorum brevis muscle beneath the extensor digi-
torum longus muscle tendon is gradually detached from the distal end
and severed
Reverse Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
580
Fig. 20.13 Procedure 4: After making a 2–3 cm opening in the proxi-
mal end of the extensor retinaculum, the lateral tarsal blood vessels that
branch from the dorsal artery can be seen entering inside the muscle
Fig. 20.12 Procedure 3: Where possible, the accompanying deep pero-
neal nerve is separated from the vascular pedicle, but if not possible,
then it is severed afterwards
Note The vascular pedicle is easier to confirm if the muscle flap is
turned over.
20 Reconstruction of Dorsum and Amputated Foot Stump
581
Note There are no problems with severing the accompanying deep
peroneal nerve, however to avoid creating a stump neuroma, electrocau-
terization should be conducted on the severed end.
Fig. 20.14 Procedure 5: Even if blood flow of the dorsal pedis artery is
temporarily blocked off using a blood vessel clip in a proximal position
to the lateral tarsal artery branch, if there is blood flow to the muscle
flap from the distal part of the dorsal pedis artery, it is possible to create
a reverse muscle flap
Fig. 20.15 Procedure 6: Dissecting of the dorsal pedis artery is con-
ducted distally continuing to the communicating branch that heads
toward the plantar area. The muscle flap is turned over distally
Note If the dorsal pedis artery is not dissected up to the communicat-
ing branch running toward the plantar area, then when the muscle flap
is turned over, the vascular pedicle can fold on itself, so care is required.
Reverse Extensor Digitorum Brevis Muscle Flap (Level of Difficulty: 3)
582
Fig. 20.16 Procedure 7. The exposed bone and tendon is covered with
the muscle flap. A drain tube is inserted in the donor area
Fig. 20.17 Procedure 8. A skin graft is conducted above the muscle
flap
20 Reconstruction of Dorsum and Amputated Foot Stump
583
Reconstruction of Dorsum: Free Abdominal Perforator Flap (Level of Difficulty: 3)
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 temporarily close the donor site
Disadvantage High risk in cases of advanced obesity cases
Reconstruction of Dorsum: Free Abdominal Perforator Flap (Level of Difficulty: 3)
584
Refer to Section of “Reconstruction of calcaneal region/lateral plan-
tar region/Free abdominal perforator flap” in Chap. 18
Operation Procedures
Fig. 20.19 Procedure 2: An abdominal perforator flap with two perfo-
rators is obtained from the deep inferior epigastric blood vessels. When
harvesting, sufficient defatting should be carried out excluding the area
around the vascular pedicle
Fig. 20.18 Procedure 1. A large skin defect is seen on dorsum with
multiple extensor tendons and bone exposed
20 Reconstruction of Dorsum and Amputated Foot Stump
585
Fig. 20.21 Procedure 4: This is fine if sufficient thinning has been con-
ducted, but if fat left in the area surrounding the perforators is obvious,
it can be removed afterwards under local anesthetic
Fig. 20.20 Procedure 3: The posterior tibial blood vessels are dis-
sected at the proximal tarsal tunnel, and if possible, an end-to-side anas-
tomosis is conducted for the artery and a side-to-side anastomosis
conducted for the vein. The skin flap is sutured to the surrounding tissue
and a drain tube inserted
Reconstruction of Dorsum: Free Abdominal Perforator Flap (Level of Difficulty: 3)
586
Groin Flap (Level of Difficulty: 4)
Information
Vascular pedicle Superficial circumflex iliac blood vessel
Size Length is twice the distance from the femoral artery to the anterior superior iliac spine (about 25 cm in adults),
and width including 4 cm of inguinal ligament is about 10 cm
Advantage No functional disorder. Donor site scar is not obvious. Closure is simple. It is possible to obtain a compara-
tively thin skin flap
Disadvantage The vascular pedicle is short and thin. In some cases there is an anatomical variation in the head of the
blood vessel that makes the procedure more complex. The medial side of the flap has hair. Not possible to conduct
thinning.
Caution Damaging the lateral cutaneous nerve of the thigh can lead to desensitization of the lateral thigh. Care should
be taken that detachment around the anterior superior iliac spine doesn’t go too deep
20 Reconstruction of Dorsum and Amputated Foot Stump
587
Operation Procedures
Fig. 20.22 Procedure 1: A large skin defect present accompanied by
rupture of the anterior tibial muscle and extensor digitorum longus
muscle tendon and bone exposure on the dorsum
Fig. 20.23 Procedure 2: Dissection is performed above the deep fascia
heading in proximal direction from the anterior superior iliac spine. If
dissection of the lateral margin of the sartorius muscle is continued
beneath the fascia, it is possible to secure the superficial circumflex iliac
blood vessel inside the skin flap. While confirming path of vascular
pedicle on the other side of the flap, dissection is continued in proximal
direction
Refer to Section of “Reconstruction of antebrachial region/Free
inguinal flap” in Chap. 2
Groin Flap (Level of Difficulty: 4)
588
Fig. 20.25 Procedure 4: Spasms tend to occur in the dorsal pedis
artery close to the damage site, so the extensor retinaculum is cut open
as far as the proximal end, and side-to-side anastomosis performed with
the anterior tibial artery
Fig. 20.24 Procedure 3: The harvested skin flap. Because the vascular
pedicle is short, it is better to harvest a slightly longer skin flap
20 Reconstruction of Dorsum and Amputated Foot Stump
589
Reconstruction of Amputated Foot Stump: 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 temporarily close the donor site
Disadvantage High risk in cases of advanced obesity cases
Reconstruction of Amputated Foot Stump: Free Abdominal Perforator Flap (Level of Difficulty: 4)
590
Operation Procedures
Fig. 20.26 Procedure 1: The skin defect from an all toe mutilation of
proximal phalanx region as far as the MP joint plantar weight-bearing
area
Fig. 20.27 Procedure 2: The free abdominal perforator flap is elevated
in the longitudinal direction from the abdominal wall
Note When obtaining the flap it is preferable to secure several perfo-
rators in the direction of the muscle fiber of the rectus abdominis
muscle.
20 Reconstruction of Dorsum and Amputated Foot Stump