Yotsuya Medical Cube, Chiyoda-ku, Tokyo, Japan
A problem requiring covering of the anterior middle lower leg is reconstruction due to tibia exposure. The exposed tibia area can be covered by transferring the soleus muscle flap or gastrocnemius muscle flap. In order to obtain sufficient mobility distance for the muscle flap, it is important that the proximal end of the gastrocnemius muscle flap is cut and a muscle island flap with only the vascular pedicle is created. The main nutrient blood vessel is not always positioned in the most proximal position of the soleus muscle, so the muscle ends may or may not be severed based on the transfer distance of the muscle flap.
In the case that a broad coverage is required, consideration must be given to the distance from the anastomotic vessel of the graft bed, so a skin flap with a long vascular pedicle is selected.
The latissimus dorsi muscle flap, anterolateral thigh flap and abdominal perforator flap can all be used, but the easiest is a combination of the latissimus dorsi muscle flap and a mesh skin graft.
The anterior tibial artery has a tendency to spasm, and the comitant veins are also often damaged, so it is preferable to perform an end-to-side anastomosis to the posterior tibial artery and comitant vein in the popliteal region or distal medial lower leg.
The simplest method, rather than choosing a free flap, is to choose a turn-over fascial flap of the lower calf, but when covering a large exposure of bone, it can tend to be too thin.
Selectable Flaps and Surgical ProceduresSoleus muscle, gastrocnemius muscle flapFree latissimus dorsi musculocutaneous flapFree abdominal perforator flapTurn-over fascial flapBi-pedicle skin 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.
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15.1 Soleus Muscle and Skin Graft (Level of Difficulty: 3)
Vascular pedicle Popliteal artery or several muscle nutrient branches from posterior tibial artery
Size The entire soleus muscle can be used
Indication If it is possible to completely elevate the whole soleus muscle it is possible to cover the proximal 2/3 of the anterior lower leg, however it is most suitable for reconstructing loss tissue for the middle lower leg. Surgery is performed in the lateral recumbent position or the prone position
15.1.1 Operation Procedures
Procedure 1: Osteomyelitis of tibia midsection. The infected granulation tissue is debrided
Performed in the lateral recumbent position
Procedure 2: An incision is made along the center of the posterior lower leg, and an incision is made between the medial and lateral heads of the gastrocnemius muscle, exposing the soleus muscle
Procedure 3: The branches from the popliteal artery and the tibial nerve from the proximal end of the soleus muscle are confirmed
Procedure 4: The reverse side of the soleus muscle can be easily dissected manually
Procedure 5: The muscle is dissected while being careful not to damage the posterior tibial blood vessels, running behind the soleus muscle, which are retained
Procedure 6: The muscular branch from the posterior tibial artery can be seen at the proximal end of the muscle. Sufficient muscle can be dissected up to that point. There are multiple muscular branches, but only the thickest branch needs to be retained
Procedure 7: The muscle flap is dissected from the distal end to the proximal end and elevated
Procedure 8: The muscle flap is transferred to the anterior surface of the leg through the tunnel created on the medial tibia
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