Incision is performed and must include the dermis and underlying adipose tissue until it reaches the fascial layer that is also delicately incised. During subcutaneous dissection, care is made to identify perforator to the skin, from the saphenous branch, that could include a small skin island if a chimeric flap is planned. The muscular fascia is incised, and the vastus medialis muscle is dissected from its septal fascial attachments and retracted anteriorly (Fig. 12.2).

The main pedicle, the DGA, is identified with the osteoarticular perforators. It’s better to Start the dissection distaly, on the medial condyle. There is a layer of connective tissue on top of the vessels on the medial femoral condyle that must be remove to identificate the osteoarticular perforators. The proximal descending genicular artery, with its comitant veins, lies deep to the roof of the adductor canal and proceeds distally dividing into three branches: the muscular branches, the osteoarticular branch, and the saphenous branch. The branches of the artery are identified and isolated as they enter the periosteum of the femur. Retrograde dissection then begins over the DGA back to its origin at the adductor canal. The tendon of adductor magnus lies on the floor of the dissection. The osteoarticular branch is identified and traced distally along its course adjacent to the adductor magnus tendon, while all collateral vessels are ligated or cauterized (Fig. 12.3).