Preoperative Planning

Introduction
When the patient is seen for the first time, it is very important to spend enough
time with him. Usually the patient has had several procedures, some of which
have failed and his attitude towards the surgeon may show a hint of defiance.
Listening to the complete story is the first step. The psychological state of the
patient is critical. His cooperation is needed. And he must have coplate
confidence in the surgeon.
The defect is then assessed : is size, depth, infectious status, duration, expose
bone and neighbouring scars.
At the time several options are possible, and very often the best choice is not
possible right away. He choice of local flap, microvascular flap or cross leg flap.
Microvascular flap or cross leg flap based on multiple factors. The joint of both
legs must be supple, as the otherwise a cross leg flap is not possible. Several
deep scarsor previous operations preclude the use of focal flap.
A microvascular flap needs a good recipient vascular pedicle. It may be
necessary to perform an arteriogram before decision can be made.
Age, sex and occupation are assessed. Of great importance is the existence of
smoking habit. Complex lower leg reconstruction should not be undertaken in a
heavy smoke, especially if he needs microvascular sutures. The patient should
be made aware of the higher rate of complication s in smokers, and shoul be
ready to stop smoking at least 3 weeks before the operation. We will not to carry
out microvascular transfer in patient who is not willing to stop smoking.
Quite often necessity for more investigations (x-rays, arteriograms, blood test)
will not allow definitive choice at the first consultation and the patient will have
to be seen again.
When the dicision is taken it is very important to inform the patient fully and in
depth, he has to understand:

The technique used, with details of donor site, the duration of operation,
and the postoperative immobilization.
The postoperative course: time in bed, when he will be allowed to walk
and the possibilities of complications.

The patient also has to know about the cosmetic aspects of the operation:
how long the flap will stay bulky and the possibilities of secondary debulking.

The operation
The day before the operation, the operative plan is reviewed with the patient, it
is necessary to check that he has stopped smoking.

The donor and recipient areas are prepared widely. In case of doubt a second
donor area will also be prepared.
It is necessary to re-explain to he patient weather he has to stay in bed for
several days postoperatively (free flap) or in a special uncomfortable position
(cross leg flap). The rule is that the average patient is always surprised by the
post operative course.
The operation always starts with the recipient area. It would be a serious mistake
to start with the flap dissection . during the preparation of he recipient area a
problem may arise, and there may be change in the site of the shape of the
defect.
It is necessary to allow for two different possibilities:

Replacing a scar. The is excised completely before measuring the defect, as retraction may
make it larger. The borders must be excised until the skin is supple and can be undermined,
allowing appropriate suture of the flap.
Covering a defect. The aims are different and the most important is to cover the important
structures such as bone, tendon and nerve; determining the size of the defect does not
therefore automatically give the size of the flap. In large defect where large areas are covered
by granulating tissue, the flap does not need to cover the whole defect. It is possible to
simultaneously use a flap to cover the important structures and skin graft on the granulating
tissue, thus reducing the size of the flap. This is a better solution than putting a flap on
granulating , which can lead to infection.

The main problem is, of course, the size of the defect, but the depth may also present problems. In
some instances the defect is almost a deep hole, such as in the treatment of osteomyelitis. The choice
of the flap will be critical.
Infection has to be minimized by a very thorough excision. It can usually be done as one stage with
the flap, but, in some instances of severe infection, a two stage debridement is necessary.
One the recipient area is prepared, it is carefully measured, wet antiseptic gauze is applied and the flap
is raised with a new set of instrument. Raising the flap has peculiarities according to the type of flap
island, fasciocutaneous, muscle or free flap.

Raising an island flap

The raising of a fasclocutaneous island flap needs to follow very strictly the principles os flap design,
pedicles of the flap design, pedicle dissection and length and rotation axis

Design of the flap

This is based on the knowledge of the vascular territory of the arterial the defect, depending on the
retractility of the skin. Some flaps (supramalleolar flap). Contract more than others (medial plantar
flap). In general the flap should be slightly larger than the recipient area, but not excessively, so that
the placement will be done with some tension.

Anatomy of the pedicle

Only the axial pattern flaps have a fixed pedicle length, determined by the distance between the origin
of the artery and its penetration into the subcutaneous tissue. In contrast, a septal pattern flap may be
raised at different levels of the artery, according to the number of cutaneous branches. A radial flap
may be raised at various levels of the forearm, but the more extensive the flap, the shorter the pedicle.
We can say that:

In axial flaps, the pedicle is a fixed factor but the size of the flap may vary
In septal flaps, the vascular axis is constant but the size of the flap and the length of the
pedicle vary in opposite directions.

Dissection of the vascular pedicle

Each artery is accompanied by two venae comitantes which are sufficient to
ensure a satisfactory venous outflow. Dissection must proceed away from
vessels, keeping a perivascular protective sheath and avoiding coagulation. The
branches are ligated with clips. If dissection is too lose, spasm may occur.
Haematoma should also be avoided by a careful haemostasis.
Raising a muscle flap
The design and raising of a muscle flap must obey several rules. It is essential to
understand the vascular anatomy of the muscle. According to one of the five
group classified by Mathes and Nahal. Each muscle has specific characteristics
and its dissection will be determined by the situation of the neovascular hila, the
number and size of the muscular heads, and the individual variations in length
and thickness. The extent of dissection will fary with these factors; in some
patients, gastrocnemius have a muscle belly 30 per cent longer than in others.
Several techniques may be useful in dissection of the muscle flap:

When using some small leg muscle such as flexor halluces longus or even
tibialis anterior, the distal part of the muscle may be detached from the
tendon and used as a rotation flap without interrupting the contunity of
tendon.
Some muscles (gastrocnemius) have a very thick and extensive deep
fascia. It is possible to length then the flap by excessing the fascia or by
incising it at different levels.
This exicision of the deep fascia also allow and Immediete skin grafting.
Mobilization of the flap may be done in several ways- simple rotation,
advancement, or turning it upside down. It is possible in some case to cut
both extrimities of the muscles in order to move it better.
When possible, the motor nerve of the muscle should be cut in order to
avoid contraction of the muscle and sometimes pain in long term

Insetting the flap

Quite often the flap and its pedicle are distant from the defect. They may be
separated by a narrow skin bridge or larger one with poor quality skin or several
scars. In both cases the kin bridge should be opened and the pedicle left
superficial, covered only by its own skin or skin graft.
If the skin bridge Is large, there are two possibilities:

Tunnelling the flap can be done either subcutaneously, which causes a risk
to the skin vascularization or subfacially, in which case there may be
fascia subcutaneously, which allow better space for the pedicle
If there is risk of compression it is preferable to split the skin band and let
the pedicle lie exposed.

The skin flap may be closed partially over the pedicle. A skin graft is usually
necessary.