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Soleus Muscle Flap

- Discussion: 
- soleus is a bipiniform (double feather) shaped muscle; 
- its width encompasses the posterior two thirds of the calf; 
- it originates from the upper one third of the dorsum & medial surface of the fibula and mid-posterior tibia; 
- it inserts into the achilles tendon over a 5 cm area just anterior and distal to the insertion of the Gastrocnemius muscle; 
- soleus muscle, when freed from its insertion on achilles tendon and based proximally, covers defects into the mid tibia; 
- because its most distal portion is narrow the coverage is smaller than one would like; 
- it has become flap of choice for middle, & some distal, tibial defects; 
- little function deficit occurs when hemi-soleous flap is raised; 
- blood supply can be unreliable, especially w/ tibial fractures; 
- soleus may be split into two independent segments, a maneuver that allows one hemisoleus muscle to be used as a flap and the other to be retained in situ for donor motor preservation; 
- this muscle may also be reversed on a distal blood supply to cover ankle defects, however, this may not be reliable; 

- Contra-indications:
- crushing tibial injury which disrupts blood supply to soleus;

- Flap Harvest: 
- skin incision proceeds from the medial aspect of tibial plateau to a point above the medial malleolus;
- excise any small skin bridges that might be created; 
- dissection should begin at the midpoint of the flap, where the soleus is is easily separated from the more superficial gastrocnemius
- subsequent separation of the deep surface of the soleus from FDL is easily performed; 
- w/ a medial hemi-soleus flap, split the soleus longitudinally just lateral to the midline, to ensure that the intermuscular artery is not transected; 
- the posterior neurovascular bundle is identified; 
- the superficial and deep surfaces are cleared of soft tissue attachments; 

- ligation of distal perforators:
- for a proximally based soleus flap, distal perforators from posterior tibial artery are ligated and divided until the muscle can be transposed to cover the defect; 
- following ligation of the distal perforators, it is important to look for distal flap necrosis; 
- the distal muscle is relased from the Achilles, but a small portion of tendon should be left attached to the muscle

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