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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Coverage of Thigh

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Coverage of thigh

Coverage of Thigh

Ian Maxwell


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


Mathes and nahai muscle flap classification

Mathes and Nahai muscle flap classification


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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