Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Reconstructive Surgery in the Tropics
Fascio-Cutaneous Flaps (Figs. 40-46)
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Figure 40. Elevated posterior calf reverse
flow same leg fascio-cutaneous
flap.
Posterior Calf for Cross Leg Application
This flap receives an excellent blood supply proximally near the popliteal space.
It can easily extend within 10 cm of the ankle.
1. Split thickness skin grafts are taken immediately after the spinal anesthetic
is started.
2. The flap is most easily elevated with the patient in the prone position.
3. Start distally and leave the greater saphenous vein in place. Dissect beneath
the fascia by clamping and ligating the perforators.
4. The flap will include the fascia overlying the gastrocnemius and soleus
muscles.
5. A circumferential running suture where the incisions were made secures
the expanded split thickness skin graft in place after the operated area is
decreased in size.
6. The split-thickness skin graft is also attached to the back of the flap for 10
cm. By doing this no exposed tissue remains after attaching the flap to the
opposite leg.
7. At this point in the operation, the patient is best operated upon while in
the supine position.
8. If external fixators are available, they can be placed in both tibia. Firmly
secure both legs in the best position to prevent distraction, kinking or
movement of the cross the leg flap. Three weeks are needed while the
fascio-cutaneous flap is developing a new blood supply from the recipient
area. Well-padded casts with wooden struts can also be used. The knees
and ankles need to be secured in the most comfortable position. The
patient will have practiced this position many times before surgery.
9. The external fixators make the patient much more comfortable and greatly
facilitate nursing care. This is done with elevation of both legs in an orthopedic
style bed along with ropes, weights, and pulleys.
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