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Coverage of Thigh

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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  1. Coverage of Thigh Ian Maxwell

  2. 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

  3. Mathes and Nahai muscle flap classification

  4. 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

  5. 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

  6. Innervation • Tibial nerve

  7. 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

  8. 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

  9. Lateral head • More difficult • Common peroneal nerve at increased risk • Shorter pedicle length • Sometimes necessary of medial head flap can’t reach defect

  10. 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

  11. 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

  12. Venous drainage • From venae comitantes accompanying artery

  13. Innervation • Lateral femoral cutaneous nerve of thigh • Can harvest as a sensate flap

  14. 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

  15. 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

  16. 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

  17. References • Microsurgeon.org • Serafin, d. Atlas of microsurgical tissue transplantation • Wei, Mardini. Flaps and reconstructive surgery

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