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Anatomy of the Leg
By:
Mohamed Amin
Plastic Surgery Department-Shebin Elkom Teaching Hospital
Zgl.mohamedamin@gmail.com
Anatomy of the leg includes:
1-Skin and subcutaneous tissue
2-Fascia
3-Bones
4-Muscles
5-Nerves(motor,sensory)
6-Arterial ...
1-Skin
The skin consists of two layers :
Stratified squamous epithelium called
the epidermis and a deeper connective
tiss...
Layers of the Epidermis:
1. stratum basale
2. stratum spinosum
3. stratum granulosum
4. stratum lucidum
5. stratum co...
Layers of skin
The Dermis
 It is composed mainly of collagen,elastic and
reticular fibers, fibroblasts, and the other cells. It is
well ...
Fascia
a-Superficial fascia:a layer of loose areolar connective
tissue
b-Deep fascia:is a sheet of connective tissue that ...
Leg compartments and fasciae
Leg intermuscular septa
Bones:
A-Tibia:
 It provides 85% of the weightbearing capacity of the leg.
 It articulates with the femur proximally and...
B-fibula
 It is the second bone of the leg.
 It serves as a structure for muscle and
fascial attachments.
Tibia and Fibula
Nerve supply in the leg:
A-motor supply:
 Sciatic nerve (largest and thickest nerve in the
body) arises from sacral plexu...
Tibial Nerve:
 It is present on the Posterior Compartment of the
leg and supplies all it’s muscles on(gastrocnemius,
plan...
Tibial Nerve(Cross section of leg)
Common peroneal nerve
 At the lateral side of the neck of fibula, it divides into the
deep and superficial peroneal nerve...
Deep peroneal nerve
 Is present in the anterior compartment of the leg and supplies
all the anterior leg muscles(peroneus...
 The nerve ends in front of the ankle by dividing into the
lateral and medial terminal branches.
 The lateral terminal b...
Deep peroneal nerve(cross section of leg)
superficial peroneal nerve
 It is present in the lateral compartment of the leg and
supplies all the lateral leg muscles ...
 It gives cutaneous branches that supply the skin of the lower
one third of the lateral side of the leg and dorsum of the...
Superficial peroneal nerve
B-sensory supply:
 The sensory supply of the leg is mainly from:
 saphenous nerve(anteromedial,posteromedial areas)
 su...
Saphenous nerve(longest cutaneous nerve of the body)
 It is a branch of posterior division of femoral
nerve. It pierces t...
Saphenous Nerve
Sural nerve:
 It is a branch of the tibial nerve in the popliteal fossa.
 It pierces deep fascia in the middle of the le...
Sural Nerve
Sural Nerve Harvest
2cm posterior to lateral malleolus
Or midway between lat.malleolus
and tendoachilles
what is the name ...
Nerve Extractor
Areas of Sensory distribution along the Leg
Muscles:
 The fleshy mass of the leg is formed by a group of
crural muscles
 These muscles are tightly bound by fasciae ...
Compartments of the leg:
1-Anterior Compartment of the Leg . (4muscles)
2-Posterior Compartment of the Leg. (7muscles):
a-...
1-Anterior Compartment of the Leg(4muscles)
1-peroneus tertius.
2-extensor digitorum longus.
3-extensor hallucis longus.
4...
3-Lateral Compartment of the Leg
(2muscles):
1-Peroneus(fibularis) longus.
2-Peroneus Brevis.
Nerver supply: superficial p...
Peroneus Longus
 Origin: Head and lateral surface of proximal
two-thirds of fibula
 Insertion: lateral side of the base ...
Peroneus brevis
Origin:Lateral surface of distal two-
thirds of fibula
Insertion: Base of metatarsal V
Action:it everts...
Peroneus Brevis
Posterior Compartment of the Leg (7muscles):
 a-superficial muscle groups(3 muscles).
 1-gastrocnemius
2-soleus
3-planta...
Gastrocnemius
 It has 2 heads : medial and lateral heads
 Origin: Condyles and popliteal surface of femur; lateral
supra...
Gastrocnemius
Soleus
 Origin:Posterior surface of head and proximal one-
fourth of fibula; middle one-third of
tibia;interosseous membr...
Soleus
Plantaris
 Origin:the lower end of the femur close to the
lateral head of gastrocnemius(lateral supracondylar
line)
 Ins...
Plantaris
Plantaris harvest
Medial to tendoachilles
Tendon stripper
Anatomy of the Blood Vessels
 A-Arteries:
 In the leg proper, the three most significant arteries are the
anterior tibia...
 Branches
 These are divided into three groups—cutaneous,
muscular,and articular (genicular).
1. 1.Cutaneous branches:
2...
3. Genicular (articular) branches :They are
 five in number and supply the knee joint.
 (a) Superior medial and lateral ...
Anastomosis around knee joint
 It is an arterial anastomosis around the knee joint formed by the
branches of popliteal, a...
Anastomosis around knee joint
ANTERIOR TIBIAL ARTERY
 The anterior tibial artery is the main artery of the anterior
compartment of the leg.
 The anter...
 Relations
 In the upper one-third of the leg it lies between the tibialis anterior
and extensor digitorum longus.
 In ...
Branches:
1. Anterior and posterior tibial recurrent
arteries: They take part in the arterial
anastomosis around the knee ...
Anterior tibial artery
Posterior Tibial Artery
 It is the larger of the two terminal branches of the popliteal
artery because its branches not o...
Branches:
1. Peroneal (fibular) artery: It is the largest and most important branch of
the posterior tibial artery
 2. Mu...
PERONEAL ARTERY
 It is the largest and most important branch of the
posterior tibial artery. It provides blood supply to
...
Branches:
 1. Muscular branches to the posterior and lateral
compartments of the leg.
 2. Nutrient artery to the fibula....
Peroneal(fibular) artery
B-veins:
 There are deep and superficial veins with anastomoses between them
I. Superficial Veins
 1. The dorsal venous ...
Superficial,Deep veins of lower limb
C-lymphatic
 There are both superficial and deep lymphatics. The
superficial lymphatics accompany the superficial
veins. ...
9-Keys of Leg anatomy in
Reconstructive surgery
Mathes and Nahai classification:
 Type I: one main vascular pedicle (gas...
Types of Muscle flaps (Mathes and Nahai)
Radiograph of Gastrocnemius
muscle(left),Sartorius(right)
The Angiosome Concept:
 In 1987 Taylor defined the Angiosome as “a three
dimensional composite unit of tissue supplied by...
anterior aspect of the leg Red circles identify
musculocutaneous perforators
Blue circles identify septocutaneous perforat...
The posterior aspect of the leg
Red circles identify musculocutaneous
perforators Blue circles identify septocutaneous
per...
Types of perforating vessels to the skin
 1. Musculocutaneous perforators: this type of
perforator is the cutaneous vesse...
Keystone flaps
Design
Principles
 Variations
 The keystone flap was invented by Felix Behan
as early as 1995, but was first described by him
in 2003
 it was named ba...
keystone of Roman archways
Classification:
A-Degree of Islanding
B-Type of Mobilization
Islanding is the process of circumferential
division of a given piece of tissue
Islanding can refer to skin,fascia or bo...
B-Type of Mobilization
 The typical mobilization is by advancement with
V-Y closure at the two vertices of the larger arc...
Standard design of the keystone flap 1:1 ratio of defect width to flap width
Double opposing Keystone Flap design
Principles of keystone flap design
Design is perpendicular to the long axis
of the limb
1:1 width ratio or larger
Divid...
Design is perpendicular to the long axis of the
limb
Why?
due to the underlying
longitudinal septal supply
to the skin
1:1 width ratio or larger
Pinch test
Divide fascia along long arc of flap ->islanding fascia
Subcutaneous level Fascial level (multiple windows)
Utilize creep
 Creep is defined as the capacity for a material (e.g., skin)
to elongate when placed under constant tensio...
permanent continuous sutures
Continous sutures to distribute tension along entire flap
Quiz 1
Quiz2
Quiz3
Venous malformation
Quiz4
Thank you
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
Anatomy of the Leg
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Anatomy of the Leg

  1. 1. Anatomy of the Leg By: Mohamed Amin Plastic Surgery Department-Shebin Elkom Teaching Hospital Zgl.mohamedamin@gmail.com
  2. 2. Anatomy of the leg includes: 1-Skin and subcutaneous tissue 2-Fascia 3-Bones 4-Muscles 5-Nerves(motor,sensory) 6-Arterial Supply 7-Venous Drainage 8-Lymphatic Drainage 9-Keys of Leg anatomy in Reconstructive surgery
  3. 3. 1-Skin The skin consists of two layers : Stratified squamous epithelium called the epidermis and a deeper connective tissue layer called the dermis
  4. 4. Layers of the Epidermis: 1. stratum basale 2. stratum spinosum 3. stratum granulosum 4. stratum lucidum 5. stratum corneum
  5. 5. Layers of skin
  6. 6. The Dermis  It is composed mainly of collagen,elastic and reticular fibers, fibroblasts, and the other cells. It is well supplied with blood vessels, cutaneous glands, and nerve endings.The hair follicles and nail roots are embedded in the dermis.  Two zones of dermis :papillary and reticular layers  papillary layer is a thin zone of areolar tissue, The reticular layer consists of dense irregular connective tissue
  7. 7. Fascia a-Superficial fascia:a layer of loose areolar connective tissue b-Deep fascia:is a sheet of connective tissue that separates muscle groups from each.The deep fascia of the leg is very strong. It divides the leg into three fascial compartments each having its own muscles, arteries, and nerves : anterior, lateral, and posterior. In the posterior compartment, the muscles are divided into three layers by the superficial and deep transverse fascial septa
  8. 8. Leg compartments and fasciae
  9. 9. Leg intermuscular septa
  10. 10. Bones: A-Tibia:  It provides 85% of the weightbearing capacity of the leg.  It articulates with the femur proximally and joins fibula to articulate with the talus distally.  It is connected to fibula in the midportion with the interosseous membrane.  It has medial,lateral and posterior surfaces.  The medial surface is subcutaneous and thus most prone to exposure during injury.the lateral and posterior surfaces are well protected by muscles.
  11. 11. B-fibula  It is the second bone of the leg.  It serves as a structure for muscle and fascial attachments.
  12. 12. Tibia and Fibula
  13. 13. Nerve supply in the leg: A-motor supply:  Sciatic nerve (largest and thickest nerve in the body) arises from sacral plexus (L4-S3).  In the lower part of the back of thigh, sciatic nerve divides into tibial and common peroneal nerves.
  14. 14. Tibial Nerve:  It is present on the Posterior Compartment of the leg and supplies all it’s muscles on(gastrocnemius, plantaris, popliteus and soleus). At the ankle,behind medial malleolus, it divides into medial and lateral plantar nerves, which together supply all the muscles of the sole.  It gives sensory branches to the knee joint and a large cutaneous branch, which passes into the calf to form the sural nerve
  15. 15. Tibial Nerve(Cross section of leg)
  16. 16. Common peroneal nerve  At the lateral side of the neck of fibula, it divides into the deep and superficial peroneal nerves.  It arises in the lower third of the thigh just above the popliteal fossa.  It runs over the fibular attachment of the soleus to wind around the lateral aspect of the neck of fibula to reach deep to peroneus longus where it divides into two terminal branches—deep and superficial peroneal nerves limb
  17. 17. Deep peroneal nerve  Is present in the anterior compartment of the leg and supplies all the anterior leg muscles(peroneus tertius,extensor digitorum longus,extensor halluces longus,tibialis anterior).  It begins on the lateral side of the neck of fibula  It enters the anterior compartment of the leg by piercing the anterior intermuscular septum. It pierces extensor digitorum longus and descends in this compartment with the anterior tibial artery  The nerve lies lateral to artery in its upper one-third and lower one-third and anterior to artery in the middle one-third.Hence, deep peroneal nerve is also referred to as nervus hesitans.
  18. 18.  The nerve ends in front of the ankle by dividing into the lateral and medial terminal branches.  The lateral terminal branch runs laterally and ends in a pseudoganglion deep to the extensor digitorum brevis.  The medial terminal branch runs forward and ends by supplying the skin of the adjacent sides of big and second toes (first interdigital cleft) and the first dorsal interosseous muscle
  19. 19. Deep peroneal nerve(cross section of leg)
  20. 20. superficial peroneal nerve  It is present in the lateral compartment of the leg and supplies all the lateral leg muscles (peroneus longus,peroneus brevis)  It arises in the substance of peroneus longus on the lateral side of the neck of fibula  It begins on the lateral side of the neck of the fibula and descends for a short distance between the peroneus longus and peroneus brevis, and then lies in a groove between the peroneus brevis and extensor digitorum longus. At the junction of the upper two-third and lower one-third of the leg, it pierces the deep fascia, and soon divides into a medial and a lateral terminal branches which reach the dorsum of the foot
  21. 21.  It gives cutaneous branches that supply the skin of the lower one third of the lateral side of the leg and dorsum of the foot, except for the territories supplied by the saphenous, sural, and deep peroneal nerves.  The medial terminal branch of the superficial peroneal nerve crosses the ankle and divides into two dorsal digital nerves, one for the medial side of the big toe and the other for the second interdigital cleft.  The lateral terminal branch of the superficial peroneal nerve also divides into two dorsal digital nerves for the third and fourth interdigital clefts
  22. 22. Superficial peroneal nerve
  23. 23. B-sensory supply:  The sensory supply of the leg is mainly from:  saphenous nerve(anteromedial,posteromedial areas)  sural nerve(posterolateral)  superficial and deep peroneal nerves(anterolateral)
  24. 24. Saphenous nerve(longest cutaneous nerve of the body)  It is a branch of posterior division of femoral nerve. It pierces the deep fascia on the medial side of the knee and accompanies the long saphenous vein, either in front or behind it. It supplies the skin on the medial side of the knee, leg, and medial border of the foot up to the ball of the big toe.
  25. 25. Saphenous Nerve
  26. 26. Sural nerve:  It is a branch of the tibial nerve in the popliteal fossa.  It pierces deep fascia in the middle of the leg and runs along the short saphenous vein.  After passing behind the lateral malleolus, the nerve runs forward along the lateral border of foot, and ends in the skin on the lateral side of the little toe. It supplies the skin of the lower lateral part of the back of the leg, lateral border and adjoining part of the dorsum of the foot, and the lateral side of the little toe
  27. 27. Sural Nerve
  28. 28. Sural Nerve Harvest 2cm posterior to lateral malleolus Or midway between lat.malleolus and tendoachilles what is the name of this tool?
  29. 29. Nerve Extractor
  30. 30. Areas of Sensory distribution along the Leg
  31. 31. Muscles:  The fleshy mass of the leg is formed by a group of crural muscles  These muscles are tightly bound by fasciae that compress them and aid in the return of blood from the legs.  The fasciae separate the crural muscles into anterior, lateral, and posterior compartments.
  32. 32. Compartments of the leg: 1-Anterior Compartment of the Leg . (4muscles) 2-Posterior Compartment of the Leg. (7muscles): a-superficial muscle groups(3 muscles). b-deep muscle groups(4 muscles). 3-Lateral Compartment of the Leg. (2muscles):
  33. 33. 1-Anterior Compartment of the Leg(4muscles) 1-peroneus tertius. 2-extensor digitorum longus. 3-extensor hallucis longus. 4-tibialis anterior. Nerve Supply: Deep Peroneal nerve
  34. 34. 3-Lateral Compartment of the Leg (2muscles): 1-Peroneus(fibularis) longus. 2-Peroneus Brevis. Nerver supply: superficial peroneal nerve
  35. 35. Peroneus Longus  Origin: Head and lateral surface of proximal two-thirds of fibula  Insertion: lateral side of the base of the first metatarsal and the adjacent first cuneiform  It everts and plantar flexes foot, Maintains concavity of sole during toe-off and tiptoeing
  36. 36. Peroneus brevis Origin:Lateral surface of distal two- thirds of fibula Insertion: Base of metatarsal V Action:it everts foot
  37. 37. Peroneus Brevis
  38. 38. Posterior Compartment of the Leg (7muscles):  a-superficial muscle groups(3 muscles).  1-gastrocnemius 2-soleus 3-plantaris  b-deep muscle groups(4 muscles). 1-flexor digitorum longus 2-flexor hallucis longus 3-tibialis posterior 4-popliteus Nerve supply: Tibial nerve
  39. 39. Gastrocnemius  It has 2 heads : medial and lateral heads  Origin: Condyles and popliteal surface of femur; lateral supracondylar line  Insertion:The aponeuroses of gastrocnemius and soleus form the tendo-achilles, which attaches to the middle third of the posterior surface of the calcaneus .  With soleus muscle,they are the main plantar flexor of the foot at ankle joint, flexes knee; active in walking,running, and jumping
  40. 40. Gastrocnemius
  41. 41. Soleus  Origin:Posterior surface of head and proximal one- fourth of fibula; middle one-third of tibia;interosseous membrane  Insertion:The aponeuroses of gastrocnemius and soleus form the tendo-achilles, which attaches to the middle third of the posterior surface of the calcaneus .
  42. 42. Soleus
  43. 43. Plantaris  Origin:the lower end of the femur close to the lateral head of gastrocnemius(lateral supracondylar line)  Insertion:posterior surface of the calcaneus medial to the tendo-achilles.  It’s commonly used as tendon graft.
  44. 44. Plantaris
  45. 45. Plantaris harvest Medial to tendoachilles
  46. 46. Tendon stripper
  47. 47. Anatomy of the Blood Vessels  A-Arteries:  In the leg proper, the three most significant arteries are the anterior tibial, posterior tibial, and Peroneal(fibular) arteries  Popliteal Artery:  It is the continuation of femoral artery. It begins at the adductor hiatus (an osseo-aponeurotic opening in the adductor magnus at the junction of middle one-third and lower one-third of the thigh), crosses the floor of popliteal fossa from the medial to lateral side to reach the lower border of the popliteus where it terminates by dividing into anterior and posterior tibial arteries
  48. 48.  Branches  These are divided into three groups—cutaneous, muscular,and articular (genicular). 1. 1.Cutaneous branches: 2. 2. Muscular branches: They are large and several in number.  The upper branches (two or three in number) supply adductor magnus and hamstring muscles  The lower muscular branches supply the triceps surae muscles (i.e., two heads of gastrocnemius and soleus)and plantaris (sural arteries 4-5 arteries)
  49. 49. 3. Genicular (articular) branches :They are  five in number and supply the knee joint.  (a) Superior medial and lateral genicular arteries: They wind around the corresponding side of the femur immediately above the corresponding femoral condyles  (b) Inferior medial and lateral genicular arteries: They wind around the corresponding tibial condyles and pass deep to the corresponding collateral ligaments  (c) Middle genicular artery: It pierces the oblique popliteal ligament of the knee to supply the cruciateligaments and synovial membrane of the knee joints.
  50. 50. Anastomosis around knee joint  It is an arterial anastomosis around the knee joint formed by the branches of popliteal, anterior tibial and posterior tibial, femoral, andprofund  The anastomosis takes place as follows :  1. Superior medial genicular artery anastomosis with the descending genicular branch of the femoral artery and inferior medial genicular artery.  2. Inferior medial genicular artery anastomosis with the superior medial genicular artery and saphenous artery—abranch of the descending genicularartery (a branch of femoral artery).  3. Superior lateral genicular artery anastomosis with the descending branch of the lateral circumflex femoral artery and inferior lateral genicular artery.  4. Inferior lateral genicular artery anastomosis with the superior lateral genicular artery, anterior and posterior recurrent branches of the anterior tibial artery, and circumflex fibular branch of posterior tibial artery.a femoris arteries
  51. 51. Anastomosis around knee joint
  52. 52. ANTERIOR TIBIAL ARTERY  The anterior tibial artery is the main artery of the anterior compartment of the leg.  The anterior tibial artery is accompanied by two venae comitantes  It begins in the back of the leg at the lower border of popliteus, enters the anterior compartment by passing forward between the two heads of the tibialis posterior, through an opening in the upper part of the interosseous membrane.  In the anterior compartment, it runs vertically downward to a point midway between the medial and lateral malleoli, where it enters the foot and changes its name to dorsalis pedis artery, which ends near the web between the big and second toes
  53. 53.  Relations  In the upper one-third of the leg it lies between the tibialis anterior and extensor digitorum longus.  In the middle one-third of the leg it lies between the tibialis anterior and extensor hallucis longus.  In the lower one-third of the leg it lies between extensor hallucis longus and extensor digitorum longus. It is crossed from the lateral to medial side by the tendon of extensor hallucis longus. As a result, the deep peroneal nerve lies lateral to it in its upper one- third and lower one-third, and anterior to it in its middle one-third
  54. 54. Branches: 1. Anterior and posterior tibial recurrent arteries: They take part in the arterial anastomosis around the knee joint. 2. Muscular branches to adjacent muscles. 3. Anterior medial and anterior lateral malleolar arteries: They take part in the anastomosis around the ankle joint
  55. 55. Anterior tibial artery
  56. 56. Posterior Tibial Artery  It is the larger of the two terminal branches of the popliteal artery because its branches not only supply the posterior compartment but also the lateral compartment of the leg and the sole of the foot.  It begins at the lower border of popliteus, between the tibia and fibula, deep to gastrocnemius and enters the back of the leg by passing deep to the tendinous arch of soleus.  In the leg, it runs downward and slightly medially to reach the posteromedial side of the ankle, midway between the medial malleolus and the medial tubercle of calcaneum  It terminates deep to the flexor retinaculum by dividing into a large lateral plantar artery and a small medial plantar artery
  57. 57. Branches: 1. Peroneal (fibular) artery: It is the largest and most important branch of the posterior tibial artery  2. Muscular branches: To the muscles of posterior compartment.  3. Nutrient artery to tibia: It is the largest nutrient artery in the body. It enters the nutrient foramen of tibia below the soleal line.  4. Circumflex fibular artery: It encircles the lateral side of the neck of the fibula.  5. Communicating branch: It joins with the similar branch of peroneal artery about 5 cm above the ankle.  6. Medial malleolar branch: It passes toward the medial malleolus.  7. Calcaneal branch: It pierces the flexor retinaculum and supplies soft tissues of the heel.  8. Terminal branches: These are medial and lateral plantar arteries of the sole
  58. 58. PERONEAL ARTERY  It is the largest and most important branch of the posterior tibial artery. It provides blood supply to the posterior and lateral compartments of the leg.  It arises 2.5 cm below the lower border of popliteus  It runs obliquely toward the fibula and then descends along the medial crest of the fibula in a fibrous canal between tibialis posterior and flexor hallucis longus. Now it passes behind the inferior tibiofibular and ankle joints, and ends on the lateral surface of calcaneus and terminates by giving the lateral calcaneal arteries
  59. 59. Branches:  1. Muscular branches to the posterior and lateral compartments of the leg.  2. Nutrient artery to the fibula.  3. Communicating branch: It joins with similar branch of the posterior tibial artery about 5 cm above the ankle.  4. Perforating branch: It is large and pierces interosseous membrane about 5 cm above the ankle, appears in the anterior compartment of the leg, and terminates by anastomosing with the lateral malleolar branches of the anterior tibial and dorsalis pedis arteries.  5. Lateral calcaneal artery: It is a terminal branch which takes part in the formation of lateral malleolar plexus
  60. 60. Peroneal(fibular) artery
  61. 61. B-veins:  There are deep and superficial veins with anastomoses between them I. Superficial Veins  1. The dorsal venous arch is often visible through the skin on the dorsum of the foot. It collects blood from the toes and more proximal part of the foot, and has numerous anastomoses similar to the dorsal venous network of the hand. It gives rise to the following two veins.  2. The small (short) saphenous vein arises from the lateral side of the arch and passes up that side of the leg as far as the knee. There, it drains into the popliteal vein.  3. The great (long) saphenous vein, the longest vein in the body, arises from the medial side of the arch and travels all the way up the leg and thigh to the inguinal region. It empties into the femoral vein slightly inferior to the inguinal ligament.. Portions of this vein are commonly used as grafts in coronary bypass surgery. The great and small saphenous veins are among the most common sites of varicose veins
  62. 62. Superficial,Deep veins of lower limb
  63. 63. C-lymphatic  There are both superficial and deep lymphatics. The superficial lymphatics accompany the superficial veins. Those with the great saphenous vein terminate in superficial inguinal nodes,which drain into deep inguinal nodes. Lymphatics following the short saphenous vein drain into nodes in the popliteal fossa. The deep lymphatics accompany arteries in the muscle compartments.Those from the leg and foot drain into the popliteal nodes whence lymphatics ascend with the femoral artery to the deep inguinal nodes whose efferents pass to the external iliac group.
  64. 64. 9-Keys of Leg anatomy in Reconstructive surgery Mathes and Nahai classification:  Type I: one main vascular pedicle (gastrocnemius muscle)  Type II: have a dominant pedicle and a minor pedicle (soleus muscles)  Type III: have two main vascular pedicles, each arising from a separate regional vessel (example rectus abdominus and gluteus maximus muscles)  Type IV: have multiple segmental vascular pedicles (sartorius and tibialis anterior muscles)  Type V: have one main vascular pedicle and multiple secondary pedicles (Latissimus dorsi and pectoralis major muscles)
  65. 65. Types of Muscle flaps (Mathes and Nahai)
  66. 66. Radiograph of Gastrocnemius muscle(left),Sartorius(right)
  67. 67. The Angiosome Concept:  In 1987 Taylor defined the Angiosome as “a three dimensional composite unit of tissue supplied by a given source artery”.  The composite building block of tissue contains muscle, nerve, connective tissue, bone and the overlying skin. Taylor divided the body into 40 angiosomes based on named source arteries .  The angiosome concept and the idea that adjacent angiosomes are linked provide the basis for tissue transfers, particularly microsurgical tissue transfers
  68. 68. anterior aspect of the leg Red circles identify musculocutaneous perforators Blue circles identify septocutaneous perforators Anatomic territories of the cutaneous blood supply are numbered: 1) Lateral inferior genicular artery 2) Anterior tibial recurrent branch of the anterior tibial artery 3) Medial inferior genicular artery 4) Descending genicular artery 5) Anterior tibial artery 6) Posterior tibial artery 7) Peroneal artery Angiosomes and Angiotomes of the leg
  69. 69. The posterior aspect of the leg Red circles identify musculocutaneous perforators Blue circles identify septocutaneous perforators Anatomic territories of cutaneous blood supply are numbered: 1) Descending genicular artery 2) Lateral inferior genicular artery 3) Medial and lateral superficial sural arteries 4) Anterior tibial artery 5) Posterior tibial artery 6) Peroneal artery 7) Medial calcaneal artery 8) Lateral calcaneal artery Angiosomes and Angiotomes of the leg
  70. 70. Types of perforating vessels to the skin  1. Musculocutaneous perforators: this type of perforator is the cutaneous vessel after penetrating underlying muscle. Through intramuscular dissection, longer vascular pedicle can be obtained.  2. Septocutaneous perforators: this type of perforator is the cutaneous vessel after piercing the fascial septum between muscles. Through intraseptal dissection, the perforator can be traced to its deep origin from the source artery
  71. 71. Keystone flaps Design Principles  Variations
  72. 72.  The keystone flap was invented by Felix Behan as early as 1995, but was first described by him in 2003  it was named based on its similarity to the keystone of Roman archways  The keystone flap is unique among locoregional flaps because it demonstrates a high capacity for adaptation  It’s old name is Arc flap or Island flap.
  73. 73. keystone of Roman archways
  74. 74. Classification: A-Degree of Islanding B-Type of Mobilization
  75. 75. Islanding is the process of circumferential division of a given piece of tissue Islanding can refer to skin,fascia or both Islanding of the skin provides a potential benefit to cutaneous perfusion (5% increase) A-Degree of Islanding
  76. 76. B-Type of Mobilization  The typical mobilization is by advancement with V-Y closure at the two vertices of the larger arc  However, one end, or both ends, may be transposed and their shape adapted to permit rotation as required by the region  Double keystone flap closure may be by direct symmetrical apposition or by opposing transposition/advancement .  Skin grafting of the secondary defect may be undertaken if direct closure is likely to be too tight
  77. 77. Standard design of the keystone flap 1:1 ratio of defect width to flap width
  78. 78. Double opposing Keystone Flap design
  79. 79. Principles of keystone flap design Design is perpendicular to the long axis of the limb 1:1 width ratio or larger Divide fascia along long arc of flap - >islanding fascia Utilize creep /temporary mattress sutures/permanent continuous sutures
  80. 80. Design is perpendicular to the long axis of the limb Why?
  81. 81. due to the underlying longitudinal septal supply to the skin
  82. 82. 1:1 width ratio or larger Pinch test
  83. 83. Divide fascia along long arc of flap ->islanding fascia Subcutaneous level Fascial level (multiple windows)
  84. 84. Utilize creep  Creep is defined as the capacity for a material (e.g., skin) to elongate when placed under constant tension  the skin elongates along the axis of the tension through both biological and mechanical creep Temporary sutures across widest point of defect
  85. 85. permanent continuous sutures Continous sutures to distribute tension along entire flap
  86. 86. Quiz 1
  87. 87. Quiz2
  88. 88. Quiz3 Venous malformation
  89. 89. Quiz4
  90. 90. Thank you
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Anatomy of the leg and the keys of Anatomical considerations in Reconstructive surgery

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