11. • Incision taken down to muscle complex
• Locate and preserve sural nerve and locate lesser saphenous vein
• Heads divided sharply
• Dissection over medial head to deep surface
• Distal muscle dissected off achilles tendon ()
• Tunnelling under skin to insert
• Closure of donor site and placement of suction drain
• Skin Graft coverage
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15. Post op
• Monitor for haematoma
• If flap looks good by day 5, light weight bearing could be initiated.
• Complications
• Flap loss from kinking of pedicle
• Tight tunnel
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16. Soleus flap
• The proximal part of soleus is supplied by the popliteal artery and
this constitutes the basis of the proximally based soleus flap
• The main blood supply of the medial part of the muscle is from the
posterior tibial artery through large and constant perforators and this
constitutes the basis of the medial hemisoleus flap.
• The main blood supply of the lateral part of the muscle, its overlying
skin and the fibula is from vascular pedicles of the peroneal artery
and this constitutes the basis of the soleus–fibula free transfer flap.
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17. SOLEUS FLAP
• Indications – middle 1/3 of leg
• Type II flap
• Position – supine with tourniquet
• Hip roll under contralateral hip improves access to medial side of limb
• Incision on posterior lip of tibia
• From origin of achilles tendon to 6 cm below knee
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18. INDICATIONS:
• Subcutaneous tissue opened down to posterior compartment
• Plane between gastrocnemius and soleus opened
• Dissection taken far proximally enough to allow coverage
• Lateral release of soleus from tibia can improve arc of rotation
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20. Plantar Flaps
• INDICATION
• Need for sensate coverage
• CONTRAINDICATIONS
• Absent flow in dorsalis pedis and posterior tibial artery
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21. • The presence of Dorsalis Pedis and Posterior Tibial pulse is essential
• Ankle to arm blood pressure ratio of 0.8 acceptable
• Preop doppler or Angiography if in doubt
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22. • Position : supine or prone with tourniquet
• Skin island created based on the planter artery
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23. • Abductor Hallucis muscle could be included as a myocutaneous flap
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24. GENERAL COMPLICATIONS
• Seroma formation
• Haematoma formation
• Venous congestion
• Infection
• Superficial skin necrosis
• Wound separation with eventual partial and/or complete flap
loss
• Fat necrosis
• Donor site infection
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25. INVESTIGATIONS BEFORE FLAP
SURGERY
• Doppler: to assess blood supply of selected donor area
• MRI angiogram
• CT angiogram
• Routine tests
• FBC, blood gp, LFT, RFT
• Urine tests
• ECG
• CXR
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26. MONITORING OF THE FLAP
0 Clinical (hourly for 1st 24hrs)
0 Tissue colour, swelling, warmth and turgor, assess blanching,
CRT
0 Instrumental
0 Doppler studies (hand held doppler)
0 Fluorescein dye test
0 Sensors for tissue Oxygen saturation
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27. Postop care
0 Chest physiotherapy
0 DVT prophylaxis
0 Analgesics
0 Antibiotics (if indicated)
0 Elevation of affected part
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