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Fig. 8.10. Gracillis flap.

artery and vein are ligated immediately distal to their junction with the splenic artery and vein. The omentum is mobilized within 3 cm of the gastric pylorus.

If the omentum will be based on the left gastroepiploic artery and vein, then the right gastroepiploic vessels will be divided and ligated along the greater curvature of the stomach immediately proximal to the pylorus. The greater omentum is mobilized from the greater curvature of the stomach to a point 5-7 cm proximal to the gastrosplenic ligament where standard flap elevation is completed.

A nasogastric tube is inserted for 24-48 hours after the operation to decompress the stomach. This prevents gastric distention that among other things might dislodge any of the vascular ligations along the greater curvature.

Fig. 8.11. Omentum flap. Postoperative Care

Postoperative care of free tissue transfer patients requires that patients be adequately hydrated. Maintenance of proper body temperature and hematocrit is also important Routine heparinization and anticoagulation is not utilized.

Flaps are usually monitored for a minimum of 5 days with a laser Doppler in addition to clinical observation. While the immediate postoperative period of 24-48 hours is critical, there have been late occasional failures; thus, laser Doppler monitoring should be continued for 4 or 5 days.

Extremities should be elevated at all times to augment venous return. Lower extremity patients are not allowed to ambulate postoperatively for a minimum of three weeks. The inosculation and the healing of the flap to the wound bed, the selection of muscle or skin, and the "take" of the skin graft, are factors that go into the timing to determine dependency of the lower extremity. Those patients that

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