391
Tips
In cases where mediastinitis extends across the entire chest area, combine two musculocutaneous fl aps
Mediastinitis with an area or depth that can’t be covered using only the pectoralis major muscle fl ap will require
selection of either the latissimus dorsi muscle or the rectus abdominis muscle fl ap, but for mediastinitis that extends
the entire chest area, sometimes it won’t be possible to cover the area with just one fl ap. In such cases, two musculo-
cutaneous fl aps are combined, with the latissimus dorsi musculocutaneous fl ap used for the upper chest and the rectus
abdominis musculocutaneous fl ap used for the lower chest.
Mediastinitis: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
392
Pyothorax: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Timing of pyothorax operation
In the case that the entire thorax fi stula is contaminated, the thorax fi stula is cleaned and administered with antibiotics.
After wound culture and sputum culture become negative, surgery is performed to fi ll the wound using musculocutane-
ous fl ap.
In the case that discharge of bacteria from a specifi ed area cannot be stopped, fi lling of the entire thorax is avoided,
and only the area with the bacteria discharge is covered with a skin fl ap in the fenestration state. When the bacteria
discharge is controlled, surgery is re-performed to fi ll the fi stula or to close the wound.
How to avoid creating dead space
In many cases it is diffi cult to fi x certain musculocutaneous fl aps to the bronchial margin by fi lling from the bottom
upwards. Therefore, a powerful continuous suction drain is inserted at the back of the muscle fl ap, and drainage con-
tinued for a considerable time.
If a non-infectious dead space is left despite conducting continuous suction drainage is conducted, or there is an air
leak from the bronchial margin, another way of treating is the conduct embolization from within the bronchial tube.
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
393
Operation Procedures
Fig. 11.19 Procedure 1: A large fi stula caused by a pyrothorax is pres-
ent, running diagonally upward from the back
Pyothorax: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
394
a
b
Fig. 11.20 ( a , b ) Procedure 2: Fistula is also confi rmed by X-ray and
CT scan
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
395
Fig. 11.22 Procedure 4: Appearance with the latissimus dorsi muscu-
locutaneous fl ap elevated
Fig. 11.21 Procedure 3: The latissimus dorsi musculocutaneous fl ap is
designed for the surface of the fi stula, in the lateral recumbent position
Pyothorax: Latissimus Dorsi Musculocutaneous Flap (Level of Diffi culty: 4)
396
Note If necessary, a continuous suction drain is inserted at the deepest
part of the fi stula.
Fig. 11.23 Procedure 5: The musculocutaneous fl ap is transferred into
the fi stula through the subcutaneous tunnel. The edge of the muscle fl ap
is sutured, using an absorbable suture, to the deepest part of the fi stula
to avoid making a dead space. A drain is inserted to the raised part of
the skin fl ap and the wound closed
Fig. 11.24 Procedure 6: The latissimus dorsi musculocutaneous fl ap is
raised/transferred, the muscle fl ap section used to fi ll the fi stula, and a
continuous suction drain inserted for more than 3 weeks, however from
the CT scan a dead cavity remained at an even deeper section, and there
was an air leak from the continuous suction drain. Fibrin adhesive was
then injected into the bronchial margin under a microscope. The air leak
was then eliminated. The drain was removed 6 weeks after the latissi-
mus dorsi transfer surgery
Note The arrow indicates the muscle fl ap used to fi ll the area.
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
397
Abdominal Incisional Hernia: Components Separation Method (Level of Diffi culty: 3)
Information
Even if detaching from the area around the hernia region, a laparotomy is not necessitated. The abdominal external
oblique muscle is dissected, the hernia region is pushed into the thorax, and both sides of the rectus abdominis muscle
are brought together and sutured.
Abdominal Incisional Hernia: Components Separation Method (Level of Diffi culty: 3)
398
Operation Procedures
Fig. 11.26 Procedure 2: Using an electric scalpel, the lateral section of
the abdominal external oblique muscle is cut and severed. The same
action is repeated on both sides
Fig. 11.25 Procedure 1: The peritoneum of the hernia region or sec-
tion to be reefed is subcutaneously opened up. The area surrounding the
abdominal external oblique muscle is detached across a wide area
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
399
Fig. 11.27 Procedure 3: This makes it easier to close the hernia orifi ce.
The section strangulated by the hernia orifi ce is pushed inside, and both
sides of the rectus abdominis muscle are brought together and sutured
tightly in place using a non-absorbable suture. A continuous suction
drain is inserted and the wound closed
Abdominal Incisional Hernia: Components Separation Method (Level of Diffi culty: 3)
400
Abdominal Incisional Hernia: Tensor Fascia Latae Musculocutaneous Flap (Level of Diffi culty:
4)
Information
Vascular pedicle Terminal branch of lateral circumfl ex femoral vessels, with 4 cm length and 2 mm diameter
Size It is possible to obtain a width of 15–20 cm, and a length of 40–50 cm if the iliotibial band is included, but in order
to perform temporary closure, the width is limited to within 10 cm.
Advantage It is possible to obtain a large skin fl ap with a sensory nerve (lateral femoral cutaneous nerve).
Disadvantage The vascular pedicle is short, and the proximal muscle section of the skin fl ap is bulky, causing a depres-
sion in the donor site.
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
401
Operation Procedures
Fig. 11.28 Procedure 1: Caused after multiple operations due to intes-
tinal tuberculosis
Note Abdominal incisional hernia gradually increased in size over a
10 year period.
(Photos reproduced from “Surgical Method for Abdominal
Incisional Hernia” by Yuichi Hirase et al. The Journal of Plastic Surgery
41:S157–S162, 1998)
Abdominal Incisional Hernia: Tensor Fascia Latae Musculocutaneous Flap (Level of Diffi culty: 4)
402
Fig. 11.30 Procedure 3: Line drawn from anterior superior iliac spine
to lateral condyle of tibia indicates the anterior border of tensor fasciae
latae muscle. It is possible to obtain a 15–20 cm wide skin fl ap from this
line. The vascular pedicle enters the skin fl ap from medial side at 6 cm
from the anterior superior iliac spine, and at 10 cm it is possible to con-
fi rm the lateral femoral cutaneous nerve
Fig. 11.29 Procedure 2: Diameter of hernia is 20 cm
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
403
Fig. 11.32 Procedure 5: Leaving a monitoring fl ap in place, the skin is
resected and the hernia orifi ce closed at the fascia level
Fig. 11.31 Procedure 4: Making an incision at the periphery of the
fascia makes it possible to easily peel off and raise the fl ap under the
fascia. The entire fl ap is elevated while paying attention to the sections
6 and 10 cm from the anterior superior iliac spine
Note When using for reconstructing the abdominal wall, it is not nec-
essary to cut the muscle ends, but it is possible to cover a larger area by
creating an island skin fl ap.
Abdominal Incisional Hernia: Tensor Fascia Latae Musculocutaneous Flap (Level of Diffi culty: 4)
404
Fig. 11.33 Procedure 6: Appearance immediately after transferring
the skin fl ap. The proximal region of the musculocutaneous fl ap is used
as a monitoring fl ap
Fig. 11.34 Procedure 7: Appearance 6 months after surgery. There
was no recurrence of abdominal hernia. Patient wore abdominal ban-
dage for 6 months after surgery
11 Reconstruction of Mediastinitis/Pyothorax/Abdominal Incisional Hernia
405
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_12
Reconstruction of Inguinal Region
Basic Principles
The inguinal region has an excess of skin so there are few cases with insuffi cient skin. However
the femoral blood vessels run beneath the inguinal ligament, so in the case of a large and deep
skin or soft tissue defect, the reconstruction of this region becomes extremely important. This is
because insuffi cient tissue directly above the femoral blood vessels can cause the femoral blood
vessels to rupture, and such an event may prove fatal. Therefore, in the case of tissue lost above
the femoral blood vessels it is essential to reconstruct healthy tissue as soon as possible.
Common causes for the loss of subcutaneous soft tissue in the inguinal region are wound
dehiscence following a lymphadenectomy and lymph fl uid rhea.
Muscle fl ap is often chosen for use as the tissue fl ap because it has ample tissue and is
resistant to infection.
Selectable Flaps and Surgical Procedures
Rectus abdominis musculocutaneous fl ap • Tensor fascia latae fl ap • Rectus femoris muscle
fl ap • Gracilis muscle fl ap • Anterolateral thigh fl ap
12
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.
406
Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)
Information
Vascular pedicle Deep inferior epigastric blood vessels
Size All of rectus abdominis muscle for muscle fl ap section. For the skin fl ap section, if the perforator of the navel fl ank
can be included, a suffi cient amount can be obtained so that the skin fl ap can be reefed in all directions.
Advantage It is possible to obtain a stable blood circulation using a long and thick vascular pedicle. Highly suited to
reconstruction requiring that needs to be covered using muscle.
Disadvantage Abdominal hernia following removal of the rectus abdominis muscle is a major problem. Various meth-
ods have been reported, however reconstruction using the Components Separation Method is the most stable and
simple method.
12 Reconstruction of Inguinal Region
407
Operation Procedures
Fig. 12.1 Procedure 1: Raw surface after lymphoma resection in right
inguinal region
Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)
408
Fig. 12.2 Procedure 2: Following tumor resection, damage is assumed
to have occurred to the right deep inferior epigastric blood vessels.
Therefore the rectus abdominis musculocutaneous fl ap was designed
using the contralateral deep inferior epigastric blood vessels as the vas-
cular pedicle
12 Reconstruction of Inguinal Region
409
Fig. 12.3 Procedure 3: The fl ap is designed in a longitudinal direction
directly above and in line with the rectus abdominis muscle, with an
incision made in a longitudinal direction in the anterior rectus sheath.
Turning the muscle tissue inwards, the deep inferior epigastric blood
vessels pedicle is confi rmed on the opposite muscle surface from the
lateral side. After severing the proximal and peripheral muscle tissue,
the required amount of muscle tissue can be removed as the musculocu-
taneous fl ap. The vascular pedicle is detached in the direction of the
femoral blood vessels, creating a complete island fl ap
Rectus Abdominis Musculocutaneous Flap (Level of Diffi culty: 4)
410
Note The donor site must be closed in a way that prevents a hernia
from occurring following surgery. The application of the Components
Separation Method, which involves cutting in a straight line along the
outside of both sides of the abdominal external oblique muscle and con-
ducting a direct suture using a non-absorbable suture of the contralat-
eral rectus abdominis muscle and the abdominal external oblique
muscle, is simple and provides a stable result.
Refer to Section of “Reconstruction of mediastinitis, pyothorax,
abdominal incisional hernia/Abdominal incisional hernia: Components
Separation Method” in Chap. 11
Refer to Section of Tips of “Apply the Components Separation
Method to close up the donor site” in Chap. 11
Fig. 12.4 Procedure 4: The musculocutaneous fl ap is transferred to the
right inguinal region, a drain is inserted and the wound closed. A con-
tinuous suction drain is also inserted in the donor site
12 Reconstruction of Inguinal Region
411
Rectus Femoris Muscle Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Nutrient branch from lateral circumfl ex femoral artery
Size Can use entire rectus femoris muscle
Advantage Technique is simple. Highly suited to purpose of fi lling inguinal region
Disadvantage This is the largest muscle of the quadriceps, so cannot be used in young people or sportsmen.
Rectus Femoris Muscle Flap (Level of Diffi culty: 3)
412
Operation Procedures
Fig. 12.5 Procedure 1: Case: A subcutaneous fi stula due to lymphor-
rhea was confi rmed in the left inguinal region, and debridement was
carried out, but because it was wrapped in scar tissue, it was necessary
to use a muscle fl ap in the fi stula to avoid closing the fi stula with a dead
space (Photo reproduced from Rectus femoris muscle fl ap by Mizuko
Matsui, Yuichi Hirase, MB Orthorp 21: 148–152, 2008)
Fig. 12.6 Procedure 2: An incision is extended in an arc along the
anterior surface of the thigh, continuing until it is possible to confi rm
appearance of the entire rectus femoris muscle
12 Reconstruction of Inguinal Region
413
Fig. 12.8 Procedure 4: A muscle island fl ap of the rectus femoris
muscle is created
Fig. 12.7 Procedure 3: The vascular pedicle entering the muscle tissue
from the fascial septum between the rectus femoris muscle and the sar-
torius muscle is easily recognized. After severing the peripheral end of
the muscle tissue, the rectus femoris is cut proximal to the vascular
pedicle entering the muscle
Rectus Femoris Muscle Flap (Level of Diffi culty: 3)
414
Fig. 12.9 Procedure 5: Turning the muscle fl ap inwards, the fascia on
the opposite surface is detached and resected
Fig. 12.10 Procedure 6: It is now total muscle tissue. Appearance with
the muscle fl ap turned inwards
12 Reconstruction of Inguinal Region
415
Fig. 12.11 Procedure 7: It is then pressed into the subcutaneous
fi stula
Fig. 12.12 Procedure 8: The wound is then closed using a skin suture
Note If necessary, a continuous suction drain is inserted.
Rectus Femoris Muscle Flap (Level of Diffi culty: 3)
416
Column
The loneliness of a long distance runner or that of a surgeon.
A long distance runner runs all alone. However, in order to win they must take into consideration a large number of
factors. The cheers from the crowd and advice from their coach helps to support them, but they must make their own
decisions and the responsibility is all their’s.
It is the same for a surgeon. They must make all of the decisions on their own, and the responsibility for the results,
the praise, the appreciation and the jeering is all their’s to own. After all an assistant is no more than an assistant, and
dividing responsibility is not an option. Nobody can save the surgeon except the surgeon themself. That’s why it is
tough being a surgeon.
There is no guarantee that God’s plan is going to be the same as the surgeon’s plan, or that every surgery is going to
be a great experience. Some surgery involves no more than removing a necrotic skin fl ap. However, regrets are proof
of pride in your work, and worrying is proof that you haven’t given up. Feeling hardship is proof of your empathy with
the patient. A good conscience is a thing of inconvenience. It is sad to say, but in the end, humans can only learn from
their mistakes. Success can intoxicate a surgeon and cloud their vision. It is only those people who can withstand the
loneliness and who don’t look away from their mistakes who can arrive at the truth, and for that they require
endurance.
12 Reconstruction of Inguinal Region
417
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_13
Reconstruction of the Gluteal, Sacral,
and Trochanteric Regions
Basic Principles
Surgical treatment methods for pressure sores have undergone a number of changes over
the years, from the use of a local fl ap to a musculocutaneous fl ap, then to a fascial fl ap and
perforator fl ap, with methods chosen today that minimize loss of muscle. The reason
behind this is that there is no guarantee that the use of muscle in a musculocutaneous fl ap
is useful in preventing recurrence, and that there is no difference in the recurrence rate
whichever surgical method is used. Therefore, the fi rst option is always conservative ther-
apy, and when selecting surgery, the method with the least invasion is chosen wherever
possible.
Selectable Flaps and Surgical Procedures
Lumbosacral back fl ap • Gluteal musculocutaneous fl ap • Posterior thigh fl ap • Gluteal
perforator fl ap • Distal based latissimus dorsi musculocutaneous fl ap • Tensor fascia lata
musculocutaneous 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.
13
418
Information
Vascular pedicle Dorsolateral branches of 3 & 4 lumbar artery.
Size A skin fl ap elevated from the middle of the back that exceeds the contralateral side by 4–5 cm still has good
circulation.
Indication Sacral region pressure sore, congenital spina bifi da.
Lumbosacral Back Flap (Level of Diffi culty: 2)
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
419
Operation Procedures
Case 1
Fig. 13.1 Case 1: Procedure 1: For a superfi cial but broad skin defect
across the sacral region, a lumbosacral fl ap that extends 4–5 cm across
the contralateral side of the middle of the back was designed
Lumbosacral Back Flap (Level of Diffi culty: 2)
420
Fig. 13.2 Procedure 2: This picture indicates the design for covering
the skin defect after transferring the skin fl ap. It is all detached from
beneath the fascia and transferred as a fascial fl ap. The dorsolateral
branch of the lumbar artery is automatically included in the skin fl ap
Fig. 13.3 Procedure 3: Final appearance immediately after surgery
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
421
Case 2
Fig. 13.4 Case 2: Procedure 1: Lumbosacral fl ap and rotation fl ap are
designed for the spina bifi da case
Fig. 13.5 Procedure 2: A fl ap raised as a fascia fl ap containing deep
fascia is transferred, and the wound closed. A continuous suction drain
is inserted
Lumbosacral Back Flap (Level of Diffi culty: 2)
422
Note Photo is 1 month after surgery.
Fig. 13.6 Procedure 3: A high standard reconstruction with sensation
and skin texture is achieved
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
423
Information
Vascular pedicle Interior gluteal vessels accompanying the posterior thigh cutaneous nerve or the perforator from the
deep femoral artery.
Size When using the skin fl ap as an island fl ap and rotating, if intending to temporarily conduct reefi ng it is possible to
elevate a skin fl ap of about 8 × 25 cm. If using as a V-Y advancement fl ap, it is possible to raise the entire posterior
surface of the thigh as the skin fl ap. It is also possible to create a combined fl ap together with the gluteal perforator fl ap.
Advantage The major axis of the skin fl ap is located in the center of the posterior thigh, and when elevating as a fas-
ciocutaneous fl ap it is easy to confi rm the neuro vascular pedicle. However, when using as a V-Y advancement fl ap, if
it is possible to confi rm several perforators, there is no need to identify the inferior gluteal vessels.
Posterior Thigh Flap (Level of Diffi culty: 3)
Posterior Thigh Flap (Level of Diffi culty: 3)
424
Fig. 13.8 Procedure 2: The fi stula area is dyed with Gentian violet,
and infectious granulation completely removed
Fig. 13.7 Procedure 1: A combined fl ap consisting of the posterior
thigh fl ap and the gluteal perforator fl ap is designed in the abdominal
position for a pressure sore in the sacral region
Operation Procedures
Note The main nutrient vessels (terminal end of inferior gluteal ves-
sels) for the posterior thigh fl ap run longitudinally along the center of
the posterior thigh, however when raising perforators from the deep
femoral artery, it is preferable to design the skin fl ap on the femoral
biceps.
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
425
Fig. 13.9 Procedure 3: Firstly, an incision is made around the border
of the fl ap, and then the fascia of the femoral biceps (or semiterdious
muscle) is cut and included in the fl ap
Fig. 13.10 Procedure 4: By dissecting the skin fl ap above the femoral
muscle (under the femoral fascia), several perforators are confi rmed
and secured
Posterior Thigh Flap (Level of Diffi culty: 3)
426
Fig. 13.12 Procedure 6: The skin fl ap is transferred forward, and the
wound closed using a V-Y formation. If necessary, a continuous suction
drain is inserted
Fig. 13.11 Procedure 5: Several small arteries perforating the femoral
biceps are easily confi rmed and secured, with the other section suffi -
ciently detached under the femoral fascia
Note Even if it is not possible to secure perforators from the femoral
biceps, if the femoral biceps fascia is raised together with the skin fl ap,
then it is easy to include the inferior gluteal vessel that runs down the
center of the posterior thigh in the fl ap.
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
427
Tips
Although a small fi stula may form , treat conservatively
Some cases involve a large amount of fat in the skin fl ap and a small fi stula around the skin fl ap margin caused by
fat necrosis, however most can be treated conservatively by cleaning. For the case shown in the photo, isodine gel was
injected into the fi stula after cleaning.
Posterior Thigh Flap (Level of Diffi culty: 3)
428
Gluteus Maximus Perforator Flap (Level of Diffi culty: 3)
Information
Vascular pedicle In the gluteal region, there are more than 20 perforators from the superior & inferior gluteal arteries
that perforate the gluteal muscle.
Size The skin of the entire gluteal region can be moved as the skin fl ap.
Advantage If it is possible to secure multiple superior & inferior gluteal artery perforators, it can be used as a V-Y
advancement fl ap or rotation island fl ap for the reconstruction of the sacral region, trochanteric region or ischium
region.
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
429
Fig. 13.15 Procedure 3: The gluteal fascial fl ap is dissected and ele-
vated and multiple perforators perforating the femoral muscle
confi rmed
Fig. 13.14 Procedure 2: The necrotic subcutaneous tissue is resected,
an arc incision is made in the gluteal region for rotation and transfer
Fig. 13.13 Procedure 1: A large area of necrotic subcutaneous tissue
due to radiation damage of the sacral region
Operation Procedures
Gluteus Maximus Perforator Flap (Level of Diffi culty: 3)
430
Fig. 13.16 Procedure 4: Multiple perforators are retained
Fig. 13.17 Procedure 5: Once the perforators have been secured, the
surrounding area beneath the fascia is detached, and the skin fl ap turned
to cover the skin defect area. A continuous suction drain is inserted
beneath the fasciocutaneous fl ap
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
431
Tensor Fascia Lata Musculocutaneous Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Terminal branch of lateral circumfl ex femoral artery, with 4 cm length and 2 mm diameter.
Size It is possible to obtain a width of 15–20 cm and a length of 40–50 cm if the iliotibial tract overlying vastus lateralis
is included, but in order to perform temporary closure, width is limited to within 10 cm.
Advantage It is possible to obtain a large skin fl ap with a sensory nerve (lateral femoral cutaneous nerve).
Disadvantage Vascular pedicle is short, and central muscle section of the skin fl ap is bulky, which causes a depression
in the donor site.
Tensor Fascia Lata Musculocutaneous Flap (Level of Diffi culty: 3)
432
Fig. 13.20 Procedure 3: The skin fl ap is elevated, rotated and trans-
ferred to the trochanteric region, and the subcutaneous section of the
posterior thigh surface of the donor site is detached and the wound
closed temporarily
Fig. 13.18 Procedure 1: Pressure sore in trochanteric region. Suffi cient
debridement is conducted including for sequestrum
Fig. 13.19 Procedure 2: Line drawn from anterior superior iliac spine
to lateral condyle of tibia is anterior border of tensor fasciae latae mus-
cle. A 15–20 cm wide skin fl ap can be removed from this line
Operation Procedures
Note The vascular pedicle enters the skin fl ap from the medial side at
the 6 cm mark from the anterior superior iliac spine, and at the 10 cm
mark it is possible to confi rm the lateral femoral cutaneous nerve.
Refer to Section of “Reconstruction of mediastinitis, pyothorax,
abdominal incisional hernia/Abdominal incisional hernia: Tensor fascia
latae musculocutaneous fl ap” in Chap. 11
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
433
Fig. 13.21 Procedure 4: Because the muscle tissue to the proximal
side of the fl ap was bulky, the depression in the donor site stands out
Tensor Fascia Lata Musculocutaneous Flap (Level of Diffi culty: 3)
434
Column
“ The seagull that fl ies higher can see further ”
This comes from the book Jonathon Livingstone Seagull that was published in the United States in 1970. Jonathon
is forever trying to see how much higher and how much faster he can fl y than other seagulls so that he can eat.
If it is good enough to just solve the problems we see in front of us right now, then a large amount of fl ap surgery
would no longer become necessary. All we’d need to do is create granulation tissue by using artifi cial dermis and per-
form skin grafts. Or just amputate. But if we are seeking a higher dimension, then we need to use better techniques
today than were used yesterday. A fool learns from experience, but a wise man learns from history. A man only has one
mouth, but he has two eyes and two ears. Knowledge is knowing that we don’t know anything.
In the novel, Jonathon is treated by the other seagulls as a heretic, and banished from the fl ock. But Jonathon, who
refuses to give up trying to work out how to fl y higher and faster, is eventually visited by two seagulls with bright shiny
wings, who guide him to a world of a higher dimension.
It is only those people who are not satisfi ed with today who will uncover the glory of tomorrow, as long as they don’t
become deterred by the length of the journey and stop trying.
13 Reconstruction of the Gluteal, Sacral, and Trochanteric Regions
435
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_14
Patella Region Reconstruction
Basic Principles
Cases involving reconstruction of the knee include an open fracture with tissue loss over a
wide area, osteomyelitis cases, and cases of reconstruction after resection of a malignant
tumor. All of these cases require a fl ap with signifi cant volume, so muscle fl aps or muscu-
locutaneous fl aps are selected.
For muscle fl aps using reconstruction material from the lower leg, despite considerable
operative stress, there is only a small transfer distance, so free tissue transfer is often the
selected option. Severing the muscle ends and creating a complete island fl ap increases the
transfer distance of the muscle fl ap, enabling it to become the fi rst option. Free tissue trans-
fer is indicated for cases with losses exceeding the size of the lower leg muscles, however
in such cases, the popliteal fossa region can be used for an anastomotic vessel based on the
Godina Method.
Selectable Flaps and Surgical Procedures
Gastrocnemius muscle fl ap • Free latissimus dorsi musculocutaneous fl ap • Saphenous fl ap
• Superior medial knee fl ap • Superior lateral knee 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.
14
436
Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
Information
Vascular pedicle Sural artery
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 vascularization. Can obtain muscle fl ap in
the same operating area
Disadvantage Requires skin graft
14 Patella Region Reconstruction
437
Operation Procedures
Fig. 14.1 Procedure 1: An incision is made to the center of the lower
leg and the boundary of the medial and lateral head of gastrocnemius
confi rmed
Fig. 14.2 Procedure 2: The sural artery that emerges from the popli-
teal artery at the proximal gastrocnemius muscle is confi rmed as enter-
ing the medial and lateral head of gastrocnemius
Fig. 14.3 Procedure 3: Either the medial or lateral head is selected,
and the muscle is detached from the Achilles tendon
Note Photo shows removal of lateral head of gastrocnemius of right
lower leg.
Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
438
Fig. 14.4 Procedure 4: The separated Achilles tendon is left as it is
Fig. 14.5 Procedure 5: The muscle is detached moving towards the
proximal end
Fig. 14.6 Procedure 6: While confi rming the sural artery, other
branches are ligated and cut, and the proximal gastrocnemius muscle is
severed
14 Patella Region Reconstruction
439
Fig. 14.7 Procedure 7: The muscle fl ap is elevated as a complete mus-
cle island fl ap with the vascular pedicle only
Note If the proximal end of the muscle is not fully cut here, then it
won’t be possible to obtain suffi cient mobility.
Fig. 14.8 Procedure 8: Case: Anterior cruciate ligament rupture case
with tibia fracture and skin defect of patella region
Fig. 14.9 Procedure 9: Appearance of the medial head of the gastroc-
nemius elevated as a muscle island fl ap
Gastrocnemius Muscle Flap (Level of Diffi culty: 3)
440
Fig. 14.10 Procedure 10: The proximal end of the muscle fl ap is cut
and a muscle island fl ap with just the vascular pedicle is created
Fig. 14.11 Procedure 11: The muscle fl ap is transferred onto the
patella via a subcutaneous tunnel
Fig. 14.12 Procedure 12: The patella is covered using the muscle fl ap.
A bolster suture is done to pull the muscle fl ap into the subcutaneous
layer
14 Patella Region Reconstruction