coverage of thigh
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Coverage of Thigh. Ian Maxwell. Gastocnemius Flap. Mathes and Nahai type I muscle flap Indications Most commonly upper third of leg defects and knee Exposed bone, tendon, metal Can be advanced on its pedicle as a V-Y for achilles coverage Can be used as a functional muscle free flap

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Presentation Transcript
gastocnemius flap
Gastocnemius Flap
  • Mathes and Nahai type I muscle flap
  • Indications
    • Most commonly upper third of leg defects and knee
      • Exposed bone, tendon, metal
    • Can be advanced on its pedicle as a V-Y for achilles coverage
    • Can be used as a functional muscle free flap
  • Lateral or medial heads can be taken
muscle anatomy
Muscle Anatomy
  • Origin:
    • Lateral head: Lateral epicondyle of femur
    • Medial head: Superior to medial epicondyle
    • Posterior to insertion of adductor magnus
  • Insertion
    • Calcaneal epiphysis via achilles tendon
vascular anatomy
Vascular Anatomy
  • Medial head: Medial sural artery from popliteal artery (1cm proximal to knee joint)
    • 4-5cm from origin of artery to muscle insertion
  • Lateral head: Lateral Sural artery
    • Pedicle length of 4cm (arises more distally)
  • Venous drainage via venae comitantes
innervation
Innervation
  • Tibial nerve
flap dissection
Flap dissection
  • Midcalf longitudinal or straight incision beginning a few centimeters proximal to popliteal crease
  • Sural vein and saphenous nerve retracted laterally
  • Medial and lateral heads dissected in popliteal fossa and continued distally to achilles tendon
flap dissection1
Flap dissection
  • Medial head is cut from Achilles tendon
  • Dissect through loose areolar plane proximally between soleus and medial head of gastroc
  • Dissect pedicle
  • If necessary proximally divide origin
  • Tunnel subcutaneously to defect
lateral head
Lateral head
  • More difficult
  • Common peroneal nerve at increased risk
  • Shorter pedicle length
  • Sometimes necessary of medial head flap can’t reach defect
anterolateral thigh flap
Anterolateral thigh Flap
  • A type B and C (septocutaneous and musculocutaneous perforators) fasciocutaneous flap
  • Useful for local or distant defect reconstruction
  • Flap size up to 8cm X 25cm with primary closure
  • Indications:
    • Free: anywhere
    • Local: Thin flap, large surface area wounds
      • Groin, knee, abdomen, trochanteric region
arterial supply
Arterial Supply
  • Lateral femoral circumflex artery
    • Arises from lateral side of profundafemoris
    • Runs obliquely in septum between vastislateralis and rectus femoris
    • Pedicle length is 12-16 cm
  • For retrograde, distally based flaps can base it off of the lateral superior geniculate artery
venous drainage
Venous drainage
  • From venae comitantes accompanying artery
innervation1
Innervation
  • Lateral femoral cutaneous nerve of thigh
  • Can harvest as a sensate flap
flap elevation
Flap elevation
  • Mark ASIS and lateral patella
    • This is the central axis of the flap
  • Draw a circle of radius 3cm in the middle of the line
  • This is where the perforators are
    • Doppler them
  • Base your flap around these perforators
flap dissection2
Flap dissection
  • Dissect anteriorly first down to deep fascia
  • Dissect subfascial anterior to posterior
  • Vessels near or approaching the septum are preserved
  • Dissect posterior to anterior
flap dissection3
Flap dissection
  • If vessels are perforators are all septocutaneous then elevate on these
  • If musculocutaeous then these must be dissescted out
  • Follow pedicle proximally and ligate if free or preserve if pedicled
  • If bulk is needed can preserve branches to VL or RF and take muscle with the flap
references
References
  • Microsurgeon.org
  • Serafin, d. Atlas of microsurgical tissue transplantation
  • Wei, Mardini. Flaps and reconstructive surgery
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