Reconstructive Surgery: Anatomy Technique and Clinical Applications 2Vols (4 DVDs)

VOLUME ONE
Part I Fundamentals
Fundamentals
Reader's Roadmap
ANATOMY
Arterial Anatomy (Pattern of Circulation)
Venous Anatomy
Nerve Supply
Chapter 1 Surgical Decision-Making: Options, Principles, and Techniques
THE RECONSTRUCTIVE PARADIGM
Fig. 1-1
Fig. 1-2
Fig. 1-3
Systemic Factors
Organ System Derangements That Contraindicate Surgery and Require Treatment Before Management of Complex Defects
Local Factors
Defect Analysis
Timing of Closure
A SYSTEMATIC APPROACH TO WOUND CLOSURE: SURGICAL OPTIONS
Split-Thickness Skin Grafts
Full-Thickness Skin Grafts
Fig. 1-4
Local Cutaneous Flaps
Random Pattern Flaps
Fig. 1-5
Propeller Flaps
Fig. 1-6
Fig. 1-7
Axial Perforator뺹ased Cutaneous Flaps
Muscle and Myocutaneous Flaps
Fig. 1-8
Prediction of Arc of Rotation
Fig. 1-9 A, Flap anatomy. B, Arc of rotation with flap elevation to the point of entrance of the vascular pedicle to the
flap. Applications of the flap are based on standard arcs of rotation. C, Extended arc of rotation based on flap elevation
with dissection of the pedicle to its regional source. D, Extended arc of rotation based on flap elevation with pedicle
dissection and release of proximal fascia and/or muscle origin or insertion.
Fascial and Fasciocutaneous Flaps
Fig. 1-10
Composite Flaps
Free Flaps
Perforator Flaps
Fig. 1-11 A, Three major variants of perforator flap blood supply. B, Skin island based on a myocutaneous perforator, with
complete muscle sparing.
Fig. 1-12 A, Fasciocutaneous flap elevated on its vascular pedicle. B, Remote donor site debrided with exposure of
appropriate adjacent recipient vessels. C, Inset of the revascularized skin island showing microvascular anastomosis to
recipient vessels. D, Closeup view.
Tissue Expansion
Fig. 1-13 A, Expander placement. The dashed line shows the planned flap. B, The flap is now expanded on top of the tissue
expander and will be advanced into the defect. This creates redundancy at the base, excised as Burow's triangles. C, Flap
advancement and closure.
PRINCIPLES OF CLOSURE
Simple Linear Wounds
Fresh Lacerations
Clean Granulating Wounds
Contaminated Traumatic Wounds
Infected Wounds
Necrotic Wounds
RECONSTRUCTIVE GOALS
Fig. 1-14
Safety
Form
Chimeric Flaps
Fig. 1-15 Chimeric flap modification. A, Common vascular connections between subscapular artery and vein to dominant pedicle
to latissimus dorsi, serratus anterior, and scapular flaps. a, Axillary artery and vein; b, crossing branch for serratus
muscle; c, circumflex scapular artery and vein; s, subscapular artery and vein; t, thoracodorsal artery and vein. B, Common
vascular connections between superficial circumflex iliac artery and groin flap, and superficial inferior epigastric artery
and inferior abdominal flap. ci, Superficial circumflex iliac artery and vein; e, superficial inferior epigastric artery and
vein; f, superficial femoral artery and vein.
Fig. 1-16 Reconstructive balance: Preservation versus restoration.
Function
PRINCIPLES OF RECONSTRUCTION
Flap Design
Flap Selection
TECHNICAL CONSIDERATIONS
Pedicle Identification and Elevation
Flap Delay
Fig. 1-17 A, Designing a delayed flap is straightforward and relies on the concept that a flap with an equal base and height
can survive anywhere on the body (such as 1 ?1, 2 ?2, 3 ?3). For example, for a normal flap design that is certain to
survive, if one adds an extension to the design based on the width of the flap, this is effectively planning a 1 ?1 flap
based on a random blood supply away from the flap, which would survive on its own. B, Next, the sides of the normal flap and
the extensions are incised, leaving the base of the design and the end of the design intact. The area between the cuts is
completely undermined, so the only blood supply to the undermined tissue comes from the base and end of the flap. C, After 7
to 10 days, the end of the flap is incised. If further length is required, further extensions are created every 7 to 10 days
before division of the end of the flap. It is advisable to wait 7 to 10 days before moving the flap to maximize perfusion
before twisting and turning the flap and potentially compromising flow. This scheme generally means a minimum of 2 weeks to
perform the initial delay incisions (day 0), incise the end of the flap, completing the delay (day 7), and rotate the flap
(day 14). This technique can fail if extensions are aggressively long, the tissues are not completely undermined, and the
timing of the entire delay is compressed.
Tunneling Flaps for Transfer
Tension
Hemostasis
Blood Loss and Transfusion
POSTOPERATIVE MANAGEMENT
Positioning
Dressings
Suction Drains
Perioperative Antibiotics
Mobilization
Rehabilitation
CONCLUSION
Bibliography With Key Annotations
Chapter 2 Vascular Basis of Flaps and Flap Classification
Fig. 2-1 Sushruta nasal reconstruction. Sushruta described this nasal reconstruction about 600 BC in the book Sushruta
Samhita.
Fig. 2-2 Gaspare Tagliacozzi nasal reconstruction, 1597.
STUDY OF VASCULAR ANATOMY
Fig. 2-3 Carl Manchot's illustration from his 1889 publication depicts the territories supplied by the cutaneous arteries of
the human body.
Fig. 2-4 Michel Salmon's vascular territories of the human body, from his book Art?es de la Peau. The vascular territories
are numbered and indexed.
Fig. 2-5 Cormack and Lamberty's simplified concept of the underlying vasculature of anatomic, dynamic, and potential
territories for flap design.
Fig. 2-6 A three-dimensional reconstruction that demonstrates the vascular anatomy of a deep circumflex iliac artery (DCIA)
osteocutaneous perforator flap.
EVOLUTION OF FLAP DESIGN
Fig. 2-7 Evidence that the viable length of a skin flap is not determined by the base width. Skin pedicles are 2, 4, 1, and
3 cm wide. (The animal's head is to the left.) A, 30 minutes after infusion of disulphine blue. B, Survival after 1 week.
Fig. 2-8 A timeline that represents the evolution of wound reconstruction since the beginning of plastic surgery (not to
scale).
ANGIOSOME CONCEPT
Fig. 2-9 Taylor and Palmer's vascular territories (angiosomes) of the body, based on 40 source vessels. Vascular territories
of the integument of the skin are delineated according to the source vessel of the perforator. The angiosomes are numbered:
1, Thyroid; 2, facial; 3, buccal internal maxillary; 4, ophthalmic; 5, superficial temporal; 6, occipital; 7, deep cervical;
8, transverse cervical; 9, acromiothoracic; 10, suprascapular; 11, posterior circumflex humeral; 12, circumflex scapular;
13, profunda brachii; 14, brachial; 15, ulnar; 16, radial; 17, posterior intercostals; 18, lumbar; 19, superior gluteal; 20,
inferior gluteal; 21, profunda femoris; 22, popliteal; 22a, descending geniculate saphenous; 23, sural; 24, peroneal; 25,
lateral plantar; 26, anterior tibial; 27, lateral femoral circumflex; 28, adductor profunda; 29, medial plantar; 30,
posterior tibial; 31, superficial femoral; 32, common femoral; 33, deep circumflex iliac; 34, deep inferior epigastric; 35,
internal thoracic; 36, lateral thoracic; 37, thoracodorsal; 38, posterior interosseous; 39, anterior interosseous; 40,
internal pudendal.
Fig. 2-10 A, Angiogram of the integument of the anterior trunk of a fresh human cadaver specimen injected with lead oxide
and gelatin. Lead wires indicate important landmarks including the clavicles, nipples, and inferior boundary of the
pectoralis major muscle. Note the anastomoses between the superficial lateral thoracic artery and the large second internal
thoracic artery perforators around the nipple. This angiogram shows the abundance of significant (0.5 mm or more)
myocutaneous perforators in the abdominal region from the deep inferior epigastric artery. Lateral to these perforators are
the large, vertically oriented superficial inferior epigastric territories. B, Angiogram of the integument of the anterior
torso of a fresh cadaver specimen injected with lead oxide and gelatin. Cutaneous vascular territories are shown in
different colors to facilitate identification. (DCIA, Deep circumflex iliac artery; DIEA, deep inferior epigastric artery;
ITA, internal thoracic [mammary] artery; LCFA, lateral circumflex femoral artery; LPIA, lateral branches of posterior
intercostal arteries; LTA, lateral thoracic artery; SCIA, superficial circumflex iliac artery; SEA, superior epigastric
artery; SEPA, superficial external pudendal artery; SIEA, superficial inferior epigastric artery; STHA, superior thyroid
artery; TCT, thyrocervical trunk; TDA, thoracodorsal artery.)
Fig. 2-11 Sites of an average of 374 dominant cutaneous perforators of 0.5 mm or greater as they emerge from the outer layer
of the deep fascia, colored to match their source vessels. The majority of perforators are myocutaneous on the torso,
piercing the muscles near their fixed attachments, whereas they are most often fasciocutaneous in the limbs, piercing the
deep fascia between muscles, tendons, or bone (compare with Fig. 2-9).
Fig. 2-12 True versus choke anastomoses between neighboring vascular territories.
ARTERIAL VASCULATURE
Fig. 2-13 Patterns of blood supply to the integument: direct and indirect vessels. Patterns of blood supply to integument.
Type A is a direct cutaneous pedicle; type B (septocutaneous) and type C (myocutaneous) are indirect cutaneous pedicles.
Law of Equilibrium
Vessels Move From Fixed to Mobile Skin
Vessels Follow Connective Tissue Framework
Growth and Development
VENOUS VASCULATURE
Network of Arcades
Valvular and Avalvular Connections
Fig. 2-14 A, Interconnected venous networks draining the integument and underlying muscle (shaded) in a limb. Note the
horizontal superficial veins (S), with the valved venae communicantes (C) to the deep system (D). The venae comitantes are
also noted here, which provide secondary drainage in the limbs. B, Representation of venous networks elsewhere in the body.
The venae comitantes provide the primary venous drainage from the integument to the deep system (D).
Veins Converge From Mobile to Fixed Areas
Muscles Propel Venous Return
NEUROVASCULATURE
Cutaneous Nerves
Fig. 2-15 The neurovascular patterns of the integument. A, A long artery courses with the nerve (note the true anastomosis
to the adjacent vessel). B, A system of arteries 밾itchhiking?with a nerve. C, A nerve and artery pierce the fascia at
separate sites but unite distally D, A nerve diverges from its accompanying artery and descends toward the main trunk of
another artery. E, A nerve crosses the primary and secondary vascular arcades and travels parallel to another artery.
Motor Nerves
Muscle Classification
Muscle Nerve Classification
Fig. 2-16 Muscle classification based on motor nerve supply. Type I: single unbranched motor nerve; type II: single motor
nerve branched before entering muscle; type III: multiple motor nerve branches from same nerve trunk; Type IV: multiple
motor nerve branches from different nerve trunks.
DELAY PHENOMENON
Fig. 2-17 The area of necrosis (shaded) if the flap is raised based on isolated vascular supply with A, no delay; B, single-
stage delay of vessel 1; C, delay of vessels 1 and 2. In C, vessel 3 will be divided at the second stage to allow a long
pedicled flap based on the base of the flap.
Delay Technique
Fig. 2-18 Strategic delay of a pedicled TRAM flap, shown here for intended left breast reconstruction. A, The original
anatomy is shown, with the identified DIEA and SIEA vessels that supply the skin island of the designed TRAM flap. B,
Ligation of the DIEA vessels bilaterally and the ipsilateral SIEA vessels.
FLAPS/SKIN FLAPS
Local Flaps
Random
Rotation Flaps
Fig. 2-19
Transposition Flaps
Fig. 2-20 A, Simple transposition. If transposed over a larger distance, a small triangle may be excised at the tip of the
donor site to facilitate primary closure. B, Rhomboid flap. Note that any of the four corners could be elevated and rotated
to fill the defect.
Advancement Flaps
Fig. 2-21 The skin is elevated as a triangular island flap and advanced forward to fill the defect.
Axial Flap
Fig. 2-22 Axial-pattern groin flap rotated to the lower abdomen, based on the superficial circumflex iliac artery (SCIA).
Examples of Useful Axial Flaps
FASCIA AND FASCIOCUTANEOUS FLAPS
Cormack and Lamberty Classification of Fasciocutaneous Flaps
Fig. 2-23 Cormack and Lamberty's classification of fasciocutaneous flaps. Type A flaps have multiple fasciocutaneous vessels
entering at the base of the flap that are oriented longitudinally within the flap and parallel to the direction of the
arterial plexus. Type B flaps are based on a single fasciocutaneous perforator. Type C flaps are supported by multiple small
perforators that arise from a main source vessel, passing along a fascial septum between muscles. Type D flaps are
osteomyofascial cutaneous free tissue transfers.
Type A
Type B
Type C
Type D
Nakajima Classification of Fasciocutaneous Flaps
Fig. 2-24 The six distinctive deep fascia perforators according to Nakajima et al. A separate type of fasciocutaneous flap
could be named after each different perforator. (A, Direct cutaneous branch of a muscular vessel; B, septocutaneous
perforator; C, direct cutaneous; D, myocutaneous perforator; E, direct septocutaneous; F, perforating cutaneous branch of a
muscular vessel.)
Mathes and Nahai Classification of Fasciocutaneous Flaps
Examples of Useful Fascial Flaps
Type A: Direct Cutaneous Pedicled Flap
Type B: Septocutaneous (Intermuscular) Pedicled Flap
Type C: Myocutaneous (Intramuscular) Pedicled Flap
MUSCLE FLAPS
Muscle Flap Classification
Fig. 2-25 Patterns of vascular anatomy: type I, one vascular pedicle; type II, dominant pedicle(s) and minor pedicle(s);
type III, two dominant pedicles; type IV, segmental vascular pedicles; type V, one dominant pedicle and secondary segmental
pedicles.
Examples of Useful Muscle Flaps
Mathes-Nahai Classification
Fig. 2-26 The medial and lateral gastrocnemius muscles are each supplied by a single vascular pedicle from the popliteal
artery.
Fig. 2-26 The vastus lateral is mainly supplied by the lateral circumflex femoral artery (1, transverse branch and 2,
descending branch) and by perforating arteries from the profunda femoral artery as minor pedicles (3).
Fig. 2-26 The rectus abdominis is supplied by the superior (A) and inferior (B) epigastric arteries.
Fig. 2-26 The sartorius muscle has a segmental vascular supply from the lateral circumflex femoral artery (A) and the
superficial femoral artery (B)
Fig. 2-26 The latissimus dorsi muscle has a dominant pedicle from the thoracodorsal artery and several secondary segmental
pedicles from the posterior intercostal arteries (dots).
Donor Site Morbidity
FREE MICROVASCULAR TISSUE TRANSFER
PERFORATOR FLAPS
Examples of Useful Perforator Flaps
Vascular Basis of Perforator Flaps
Advantages and Disadvantages of Perforator Flaps
Fig. 2-27 The vascular territories of the body that correspond to sources arteries providing myocutaneous or septocutaneous
perforators to the skin.
Local Perforator Flaps
Fig. 2-28 Design of a local perforator flap. A, A local perforator flap is planned on the upper abdomen in the territory of
the deep inferior epigastric artery, extending into the territory of the lateral intercostal artery. B, An angiogram of the
human skin of the abdomen showing a number of vascular territories including the deep inferior epigastric artery (DIEA),
lateral intercostal artery perforators (LICA), superior epigastric artery (SEA), superficial circumflex iliac artery (SCIA),
and superficial inferior epigastric artery (SIEA).
Fig. 2-28 C, The perforators in the region of the planned flap are identified using a Doppler probe. D, The local perforator
flap is designed to include two major perforators.
CONCLUSION
Bibliography With Key Annotations
Chapter 3 Guide to Flap Selection
PATIENT FACTORS
LOCAL FACTORS
FLAP FACTORS
SURGEON FACTORS
A Guide to Flap Selection by Area
Free Flaps
Scalp Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Scalp
Free Flap
Nose Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Nose
Free Flaps
Ear Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Ear
Free Flaps
Tongue Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Tongue
Free Flaps
Lip Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Lip
Free Flap
Cheek Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Cheek
Free Flaps
Intraoral Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Intraoral Region
Free Flaps
Skull Base Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Skull Base
Free Flaps
Neck Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Neck
Free Flap
Shoulder Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Shoulder
Free Flap
Axilla Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Axilla
Free Flap
Upper Arm Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Upper Arm
Free Flap
Elbow Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Elbow
Free Flap
Antecubital Fossa Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Antecubital Fossa
Free Flap
Forearm Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Forearm
Free Flap
Wrist Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Wrist
Free Flaps
Hand Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Hand
Free Flap
Digit Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Digit
Free Flaps
Thumb Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Thumb
Free Flap
Anterior Chest Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Anterior Chest
Free Flaps
Breast Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Breast
Free Flap
Intrathoracic Region Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Intrathoracic Region
Free Flap
Abdomen Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Abdomen
Free Flap
Groin Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Groin
Vaginal Vault Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Vaginal Vault
Free Flap
Upper Back Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Upper Back
Free Flap
Lower Back Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Lower Back
Free Flap
Buttock Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Buttock
Free Flap
Thigh Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Thigh
Free Flap
Knee Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Knee
Free Flap
Popliteal Fossa Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Popliteal Fossa
Free Flap
Leg Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Leg
Free Flap
Foot Reconstruction Options
Flap Choice
Recipient Vessels
Things to Consider When Reconstructing the Foot
Considerations in Flap Selection
Workhorse Flaps
Vascularized Bone Flaps
Chapter 4 Complications: Avoidance and Treatment
INFORMED CONSENT
PATIENT SELECTION AND PREPARATION
SELECTION OF RECONSTRUCTIVE PROCEDURE
History and Physical Examination
INTRAOPERATIVE EXECUTION
Intraoperative Considerations
POSTOPERATIVE FACTORS
Postoperative Considerations
Bibliography With Key Annotations
Part II Regional Flaps: Anatomy and Basic Techniques
Regional Flaps: Anatomy and Basic Techniques
Chapter 5 Head and Neck
Section 5A Paramedian Forehead Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5A-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 5A-2
FLAP HARVEST
Design and Markings
Fig. 5A-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5A-4
Fig. 5A-4
Fig. 5A-4
FLAP VARIANTS
Tissue Expansion-Assisted Flap
Fig. 5A-5
Delay Flap Procedure
Fig. 5A-6
Fig. 5A-6
ARC OF ROTATION
Standard Flap
Fig. 5A-7
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 5A-8 A, Residual angiosarcoma of the left cheek. B-D, The reconstruction was designed using a forehead flap with a
template guide, cheek advancement flap, and upper eyelid flap. E, The left cheek defect is shown after surgical excision. F
and G, The immediate and long-term postoperative results are shown.
Fig. 5A-9 A, The preoperative defect and the planned forehead flap. The dots denote Doppler points of the supratrochlear
vessels. B, Lateral view of the defect after lining flaps and cartilage grafts placed. C, Worm's-eye view showing the degree
of tissue loss and the cartilage necessary to buttress the reconstruction. D, Flap after inset with primary closure of the
donor site. E, AP view of the patient at 6 month follow up. The patient was satisfied with the result and refused any
revisional surgery. F, Oblique view. G, Lateral view.
Fig. 5A-10 A, The preoperative defect. B, The forehead flap is elevated and skin grafts are used to laminate the flap where
lining is needed. C, The flap is inset and primary closure of the donor site has been accomplished. D, Flap at 2 weeks
postoperatively, ready for division and inset. E, AP view, 8 months postoperatively. F, Lateral view.
Fig. 5A-11 A, The nasal defect has been skin grafted as the plan involves delaying the closure for two weeks. The flap
design shows that the most ischemia prone lateral tissues has a maintained skin bridge to vascularize the area until the
flap becomes more robust. B, Lateral view of the skin bridge. This bridge was sutured closed in the office under local
anesthesia at one week. C, At 2 weeks postoperatively, the flap is ready for transfer, without evidence of ischemia, and is
supplied only by the supratrochlear vessels.
Fig. 5A-12 A, The flap design has been made more oblique to allow primary closure of the forehead Mohs defect after the flap
is elevated. Also, the remaining glabellar skin will be used as a turnover flap to line the defect. The donor and recipient
sites will be connected. B, Turndown of the glabellar flap for lining. C, Forehead flap directly transposed and inset with a
small glabellar dog-ear left in place. The donor site is closed primarily with the Mohs defect. D and E, Oblique views of
the result at 4 months postoperatively. No revision of the dog-ear was required.
Fig. 5A-13 A, Defect with proposed forehead flap. B, AP view of the flap inset. C, Oblique view. Since the flap design
abutted the defect, a direct transposition was possible. Care should be taken to avoid ischemia and delay any debulking
procedures to a later date.
Fig. 5A-14 A and B, The defect of the ala was closed as a subunit, with a right paramedian forehead flap. The result is
excellent. The fine vertical forehead donor scar does not distort adjacent tissues, nor draw attention to the nasal
reconstruction.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Recommendations
Complications
Bibliography With Key Annotations
Section 5B Scalp Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5B-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 5B-2
FLAP HARVEST
Design and Markings
Fig. 5B-3
Fig. 5B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5B-4
Fig. 5B-4 E, Initial incisions and flap undermining. F, Completion of delay at 7 days.
FLAP VARIANTS
Three- or Four-Flap Technique
Fig. 5B-5 A, Bipedicle flap oriented parallel (1?) to the defect on the left temporal frontal scalp. B, Bipedicle flap
divided to form two flaps. The flap based on occipital artery (1) will advance to the anterior scalp; the flap based on the
parietal branch of the superficial temporal artery (2) will advance to the posterior scalp; the flap based on the
contralateral occipital artery (3) will close the donor defect as an advancement flap. C, Parallel incisions through the
galea at 1 to 2 cm intervals allow flap expansion without interruption of vascular pedicles superficial to galeal layer. D,
Final closure with flaps inset.
Fig. 5B-6 The four-flap technique is particularly applicable in a child.
Temporoparietal Flap
Occipitoparietal (Juri) Flap
Fig. 5B-7
Washio Flap
Fig. 5B-8
Tissue Expander뺹ased Flaps
ARC OF ROTATION
One-, Two-, Three-, and Four-Flap Techniques
Temporoparietal Flap
Occipitoparietal (Juri) Flap
Fig. 5B-9
Washio Flap
Tissue Expansion
FLAP TRANSFER
One-, Two-, Three-, and Four-Flap and Temporoparietal, Occipitoparietal, and Washio Flap Techniques
Tissue-Expanded Flaps
Fig. 5B-10
Fig. 5B-10
FLAP INSET
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 5B-11 A, The patient is seen prone with the forehead down. The T incision used for the neurosurgical procedure lends
itself to the creation of three flaps. Most of the expansion through scoring and advancement will have to come from the two
posterior flaps to limit forehead advancement and eyebrow elevation. B, The bone plate and hardware are seen centrally and
must be covered. The posterior flaps have been scored transversely to allow advancement into the defect. The entire scalp
has been undermined to allow closure. This is almost always performed, because it does not affect the blood supply in the
subgaleal plane. C, Flaps advanced and closed. The wound healed without complication.
Fig. 5B-12 A, Preoperative oblique view of the wound with exposed bone. B, A wide-based flap of similar dimension to the
wound was created, with the occipital and superficial temporal vessels in its base. The periosteum was left at the donor
site to allow skin grafting. C, The flap was easily transposed and a large dog-ear was created. One should resist the
temptation to fix the dog-ear, because it contains the blood supply to the flap. The donor site was skin grafted. D, Two
months postoperatively, the graft and flap are well healed. Note how small the dog-ear has become without revision. E, AP
view at 2 months.
Fig. 5B-13 A, The defect after skin grafting. B, Three tissue expanders were planned to maximize scalp expansion. The
proposed left lateral site is marked. C, The posterior and right lateral sites are marked.
Fig. 5B-13 D, After completion of expansion. Measurements before and after expansion were used to determine adequate
expansion. One can sometimes get further expansion of the area to be resected. This relates to the proximity of expander
placement and is quite common, but cannot be counted in measurements for reconstruction. E, The priority of the
reconstruction was to reestablish the anterior hairline so a large posterior flap based on the occipital artery was
fashioned to accomplish this on the right, while straight advancement of the left flap formed the left hairline. The large
dog-ear was left in place, and the hairline closure was delayed, because the flap turned white with full inset. Some
spanning sutures are seen. This area was closed in the office 1 week postoperatively. An area of the vertex could not be
closed at this procedure and was left, emphasizing the importance of waiting until the end to resect the lesion or area of
alopecia to avoid the need for more skin grafting. F, One week after closure of the anterior hairline. G, Four months
postoperatively, the patient has a nice hairline. It is not uncommon to have some postoperative alopecia until the hair-
growth cycle reestablishes itself. This patient went on to have forehead expansion to remove the forehead skin graft and
further scalp expansion to remove the vertex skin graft.
Fig. 5B-14 A, Preoperative view of the lip. Skin from sites distant from the face often provides a poor color and texture
match. Mustache reconstruction is a good camouflage procedure, although not helpful in women, who often can use cover
makeup. B, The planned flap. Allowance was made for loss of some of the arc of rotation because the rotation and placement
were through a tunnel. A Doppler probe identified the vessels marked. It is critical to plan the flap with hair growth in
the desired direction. The flap was first incised, partially elevated, and delayed. C, Two weeks after delay. The flap was
passed through a subcutaneous plane. The outer skin of the lip reconstruction was resected and replaced with the scalp flap.
D, The result is seen 1 week postoperatively and E, 4 months postoperatively.
Fig. 5B-15 A, Flap design based on superficial temporal vessels. B, Elevation of flap with backcut (dashed lines) to allow
flap reach. C, Flap elevated in a subfascial plane. The flap is transposed easily, reaching the nose without scoring of the
galea. D, Superficial temporal vessels shown. It is important to maintain these vessels as an axial supply during elevation.
E, Flap inset. The scalp is temporarily grafted at 2 weeks. After division and inset, the Washio flap is returned to the
scalp and the skin graft is excised.
Fig. 5B-16 A, Malformation on the right forehead and orbit. B, Plan for surgical resection and a forehead rotation flap. C,
Excision of the vascular lesion. D, The flap was elevated, with scoring of the pericranium to enlarge the flap.
Fig. 5B-16 E, Surgical plan of closure. The flap was rotated with excess scalp medially and the excess was resected. F, The
excision was completed and the flap rotated into the residual defect. G and H, The patient is seen 6 months postoperatively
with no revisions. The right front orbital area has healed well, but there is some asymmetry. The eyebrow is elevated, and
there is excess eyelid skin. The patient was pleased and did not want further surgery.
Fig. 5B-17 A and B, The basal cell carcinoma had eroded the frontal bone but had not invaded the dura. C and D, The
resection was outlined; the planned reconstruction was with a large scalp transposition flap from the posterior area of the
scalp. E, A full-thickness resection of the basal cell carcinoma was performed; this included the scalp and underlying
cranium. The dura was exposed.
Fig. 5B-17 F and G, The defect was reconstructed with bone dust harvested from the posterior skull and was covered with
Surgicel. A large transposition flap based on the left temporal vessels was raised posteriorly and used to cover the defect.
The defect was reconstructed with a split-thickness skin graft. H, Good anterior closure was achieved. The lateral dog-ear
was trimmed later. The message from this case is to carefully plan the flap and its rotation using a sponge or swab. Basing
the flap on a secure blood supply is essential. I-K, The postoperative result. Further reconstruction will be carried out by
scalp expansion to reconstruct the skin grafted area.
Fig. 5B-18 A and B, The technique has been applied to the right hemiforehead and upper eyelid nodular hemangioma, as
illustrated in this patient. C and D, The surgical plan called for resection of the lesion and reconstruction with a
forehead rotation flap. The diagram shows the proposed surgical approach and illustrates mobilization of the forehead
rotation flap, as well as the planned dog-ear resection. E, The vertical height of the forehead in the midline is
approximately equal to the horizontal width of the hemiforehead just above the eyebrows.
Fig. 5B-18 F, An incision completely within the hairline, or one initially in front of the hairline and then down to the
temporal region, will allow rotation of the whole of the remaining forehead. It can be seen that to achieve good coverage of
a secondary defect after excision of the lesion, scoring has begun. As can be seen in later photographs, this allows a flap
that seems inadequate to easily close the defect that has been created and to achieve a nice reconstructive result. G-J, The
vertical edge of the flap becomes the horizontal suture line. In this technique, two rotational movements are being used:
the loose scalp of the temporal area is being stretched, and the lateral scalp areas on both sides are being advanced. A
full-thickness scalp graft is used to provide an eyebrow. K, Some asymmetry of the eyebrows and the hairline may occur, but
this is usually acceptable when compared with the original problem.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
Complications: Avoidance and Treatment
EXPERT COMMENTARY
Advantages and Limitations
Recommendations
take-Away Messages
Bibliography With Key Annotations
Section 5C Nasolabial Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5C-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 5C-2
FLAP HARVEST
Design and Markings
Superiorly Based Nasolabial Flap
Fig. 5C-3
Inferiorly Based Nasolabial Flap
Fig. 5C-4
Patient Positioning
GUIDE TO FLAP DISSECTION
Superiorly Based Nasolabial Flap
Fig. 5C-5 A, The flap is based high on the side of the nose and consequently has a smaller transposition. B and C, The high-
based flap avoids the nose-cheek concavity but creates another problem. D, This flap almost always pincushions and may take
time to resolve.
Fig. 5C-5 E-G, The nasolabial transposition flap is useful for closure of defects of the upper cheek. The donor site of the
nasolabial fold is plentiful, and this tissue excess increases with age. The flap is based superiorly and is transposed at
90 degrees to close the defect. The donor site is close directly.
Inferiorly Based Nasolabial Flap
Fig. 5C-6 A, A basal cell carcinoma is excised and reconstruction is planned with an inferiorly based nasolabial flap. B-D,
The flap is elevated above the facial muscles, taking care not to damage the underlying facial nerve branches. It is
transposed to the lower lip and sutured into position. The donor defect is closed directly.
FLAP VARIANTS
V-Y Advancement Flap
Fig. 5C-7
One-Stage Flap
Two-Stage Flap
Fig. 5C-8
ARC OF ROTATION
Fig. 5C-9
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 5C-10 A, In a Mohs resection, a full-thickness resection of the entire ala and alar base with some cheek loss is not
uncommon for a basal cell carcinoma in this area of the face. The amount of tissue loss should not be underestimated, but a
forehead flap is not necessary and can be saved for future cancers. The nasolabial flap is an excellent choice for isolated
alar reconstruction or in combination with other local flaps for complex defects. B, Internal nasal flaps provide lining,
and conchal cartilage provides structure to the reconstruction. A template of the defect is transposed to the cheek for
transfer as a superiorly based nasolabial flap. The arrows denote the nasolabial fold and her marionette line so the flap
can be designed to abut the line and leave the donor scar in these lines. C, Basal view shows the amount of tissue needed to
re-create the ala.
Fig. 5C-10 D, Stage one inset of the flap with cheek undermining to close the donor site (lateral view). E, Basal view
following closure. F, One month later, the patient underwent division and inset of the flap, with some thinning. She is seen
here 7 months after the division and inset (oblique view). G, Basal view.
Fig. 5C-11 A, It can be seen that the alar base was removed, with a significant portion of the hair-bearing upper lip. The
vermilion was preserved. B, First, a wedge excision of 20% of the upper lip was performed. This lessens the reconstructive
burden so there is a smaller wound, allowing a V-Y nasolabial advancement. The flap design abuts the nasolabial fold for the
best donor scar. C, After flap advancement and inset. The cheek was undermined and closed, and a small skin graft was placed
at the base of the columella. The excess in this area of the cheek allowed significant advancement (to midline) without much
Y component to the V-Y. D, Basal view. E, Four months postoperatively, the hair-bearing nature of the flap has allowed
mustache growth to camouflage the area even further.
Fig. 5C-12 A, The two-stage nasolabial flap is ideally suited for reconstruction of a defect resulting from excision of a
basal cell carcinoma of the upper lip. B, The flap was based superiorly and made long enough and wide enough to resurface
the lip defect. C, The flap was lifted just above the facial muscles. Deep dissection should be avoided to ensure that
facial nerve branches are not divided. D, The flap was transposed medially to close the lip defect; the nasolabial defect
was closed directly. A small Burow's triangle was removed to eliminate the dog-ear skin excess. E, This photo shows how well
this flap provides hair-bearing skin for an individual who wears a mustache.
Fig. 5C-13 A and B, This basal cell carcinoma of the lower lip was excised and reconstruction planned with an interiorly
based nasolabial flap. C-E, The flap was elevated above the facial muscles, taking care not to damage the underlying facial
nerve branches. It was transposed to the lower lip and sutured into position. The donor defect was closed directly. F and G,
A good result is shown: the mouth is symmetrical, the lip level is horizontal, and only slight pincushioning of the flap is
present. The patient has no desire to have the latter corrected.
Fig. 5C-14 One-stage nasolabial flap. A, A significant defect of the left ala and sidewall was present after a Mohs
excision. A pattern of the defect was designed lateral to the left nasolabial fold. Superiorly, a dog-ear excision was
marked to create a space into which the cheek flap will advance. Another dog-ear excision was marked interiorly along the
nasolabial fold. B, The medial aspect of the cheek flap was incised along the nasolabial fold, and the cheek was undermined
with 2 to 3 mm of subcutaneous fat. The cheek flap was advanced and fixed deeply along the nasofacial groove with permanent
or slowly dissolving sutures to the underlying soft tissue. The one-stage nasolabial flap skin extension, which is an
extension of the advancing cheek flap, can be cut out of the flap initially or from its excess leading edge after the cheek
flap is fixed in its advanced position. The nasolabial fold donor incision was closed in layers. A primary cartilage graft
was fixed to the underlying lining to support the nostril margin. C and D, The nasolabial extension was draped over the
nostril margin without tension. The excess skin (of the inferior dog-ear) was excised and all incisions closed. Fine sutures
can be placed from the deep surface of the flap into the underlying, ideal alar crease to reestablish its position if flap
vascularity is good. E and F, The patient is shown postoperatively, without revision. There is mild nasolabial fold
asymmetry.
Fig. 5C-15 Two-stage nasolabial flap. A, The defect was limited to the alar subunit. The nasal subunits were marked. An
exact foil template of the contralateral normal right ala was drawn to abut the left nasolabial fold at the approximate
level of the commissure. A distal dog-ear excision was marked. The proximal pedicle was tapered so that the final superior
donor scar will be short and will not lie on the nasal surface or extend onto the cheek. B, A subunit of residual normal
tissue within the left ala was excised. A primary conchal cartilage graft supported the nostril margin. The nasolabial flap
was elevated distally with 2 mm of subcutaneous fat. The superior dissection was deepened to include perforators from the
facial artery, based lateral to the ala. The inferior cheek dog-ear had not yet been excised. C, The nasolabial flap was
inset with a single layer of fine suture. The cheek was closed in layers. D, Three weeks postoperatively the medial and
inferior inset had a good contour. The pedicle required division. E and F, The superior (above the dotted line) and lateral
aspects of the inset were debulked at pedicle division. The flap skin was elevated with 2 mm of subcutaneous fat, and the
underlying convex contour of the ala and the depth of the alar crease were re-created by soft tissue excision. Excess skin
was trimmed and the flap inset.
Fig. 5C-15 G and H, Final intraoperative scars were along the margin of the alar subunit and directly in the nasolabial
fold. I and J, The patient is shown postoperatively, without revision. Alar contour is excellent. The donor scar is barely
visible, although the nasolabial folds are asymmetrical.
Fig. 5C-16 A-C, A composite defect of the tip, ala, sidewall, lip, and cheek was present. Soft tissue within the medial
cheek and over the piriform aperture was missing. The full-thickness defect of the nose needed to be repaired. The nose had
to be rebuilt on a stable platform to avoid late soft tissue shifting and alar base distortion. D, The subunits of the nose
and lip were marked. E-G, The nasolabial fold was incised, and the cheek was elevated with a few millimeters of subcutaneous
fat. A medially based fat flap, supplied by perforators from the facial and angular arteries, was marked on the underlying
soft tissue. It was incised and transposed to supply soft tissue bulk under the future alar base. The soft tissue defect
created by its excision was obliterated by the subsequent cheek advancement.
Fig. 5C-16 H and I, A superior nasolabial skin extension (a one-stage nasolabial flap) was cut out of the advancing cheek
flap adjacent to the nasolabial fold, trimmed, and inset to resurface the future alar base. J and K, Once healed, the nasal
defect was repaired with a three-stage folded forehead flap and delayed primary cartilage grafts on a stable midface lip and
cheek platform. Postoperatively after a staged reconstruction of the lip and cheek initially, and the nose secondarily, the
complex three-dimensional contours of the nose, cheek, and lip are restored. The nose sits on a stable platform in the
correct anteroposterior midface position.
Pearls and Pitfalls
EXPERT COMMENTARY
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Bibliography With Key Annotations
Section 5D Temporoparietal Fascia Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5D-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 5D-2
FLAP HARVEST
Design and Markings
Fig. 5D-3 Once the superficial temporal artery's course is determined by handheld Doppler, a zigzag incision is planned in
the hair-bearing area to expose the flap and give the best cosmesis.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5D-4
Fig. 5D-4
Fig. 5D-4
Fig. 5D-4
FLAP VARIANTS
Fasciocutaneous (Hair-Bearing) Flap
Free Flap
ARC OF ROTATION
Fig. 5D-5
Fig. 5D-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 5D-6 A, Preoperative view of the exposed hardware. There was no evidence of cellulitis or deep infection. The skin was
thin and atrophic, consistent with his history of irradiation. B, This radiograph shows the extent of the metallic
cranioplasty. C, The location of the prosthesis relative to the open wound. The plan was a wound debridement and removal of
a small portion of the cranioplasty that was placing pressure on the overlying skin. Coverage with a rotational
temporoparietal fascial flap was felt to be necessary to promote uncomplicated healing. X's mark the location of the
superficial temporal artery.
Fig. 5D-6 D, The temporoparietal fascial flap was elevated and the modified metal cranioplasty noted. E, The turnover flap
easily covered the prosthesis. The deep temporal fascia was left in situ. F, Although a skin graft was initially planned,
primary closure was possible. G, At the 2-month follow-up, the wound was healed and the edge of the prosthesis was not
palpable.
Fig. 5D-7 A, Through a vertical temporal incision, the temporalis fascia was elevated, based interiorly. It is important in
such cases that a generous amount of fascia be elevated, because it is always possible to sacrifice any excess during the
reconstructive process. The scalp wound was closed with suction drainage. B, A portion of costal cartilage was harvested and
carved to the dimensions of the missing portion of the ear, together with the three-dimensional anatomy. This was sutured to
the remaining ear cartilage with nonabsorbable sutures. The fascial flap, which was tunneled under the bridge of skin
beneath the donor site and ear, was placed over the ear cartilage graft. C, The temporalis fascia flap was trimmed and then
used to cover the cartilage graft. The skin of the edge of the ear defect was gently elevated and a temporalis fascia flap
sutured into position with the skin of the ear overlapping the sutured area.
Fig. 5D-7 D, A thick split-thickness skin graft was harvested and placed over the reconstruction and sutured into position.
Several small punctures were made with a No. 11 blade to allow drainage of blood from under the graft. The temporal area was
drained with a small suction drain and a light dressing was applied. E and F, At the 6-month follow-up, the ear is slightly
short in the vertical dimension, but the contours of the ear are satisfactory.
Fig. 5D-8 A, The defect at initial presentation. B, The patient was treated with a rotational scalp flap and grafting of the
scalp donor. She did well and presented 2 years after the scalp flap for ear reconstruction. C, A rib cartilage construct
was planned, but no local tissues were available for coverage. D, A free temporoparietal fascia flap was planned from the
uninjured contralateral side, initially covering a tissue expander.
Fig. 5D-8 E, The free flap after harvest. F, The flap was inset over a tissue expander and skin grafted. The area was
grafted, and 3 months later the cartilage construct was placed. G, The cartilage construct, based on a template of the
normal ear on the right. H, The patient is seen 9 months after placement of the cartilage with good ear definition. The
patient is seen undergoing tissue expansion of her scalp and will undergo reconstruction of the area of alopecia.
Fig. 5D-9 A, The patient is seen preoperatively. B, A temporoparietal fasciocutaneous flap was designed. C, The flap was
exposed via a classic T-shaped incision and raised in the manner described.
Fig. 5D-9 D-F, The deep lamina of the flap is also shown. Once the flap was elevated, it was skin grafted in situ, and the
skin-grafted temporoparietal fascia flap was tunneled into the orbit through a lateral orbitotomy. G, The patient is shown
postoperatively.
Fig. 5D-10 A, The superficial temporal vessels were identified by Doppler probe. B and C, The fasciocutaneous flap was
raised as an island at the distal part of this flap and then tunneled across into the eyebrow region. The flap was very
robust. D, Hair growth was abundant from this flap, and regular trimming is required. Care should be taken to avoid injury
to the frontal branches of the facial nerve with a superficial dissection to the eyebrow region.
Fig. 5D-11 A and B, A zigzag approach was designed for harvesting the temporoparietal fascia flap. The cartilaginous
construct in this older adult was semiossified and therefore difficult to carve. C, Some postauricular skin was used to
provide posterior coverage and allow projection of the constructed ear. D, The temporoparietal fascial flap covered the
anterior and upper posterior aspect of the construct, and a full-thickness skin graft was placed over this. E and F, The
postoperative result is shown.
Fig. 5D-12 A, The patient is shown preoperatively with the flap design. B and C, A free temporoparietal fascial flap was
elevated and transferred to the hand, anastomosing the superficial temporal vessels to the radial vessels. D, A full-
thickness skin graft was then applied. E, The postoperative result is shown. A thin, pliable reconstruction with good
aesthetics was created.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Bibliography With Key Annotations
Section 5E Temporalis Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5E-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 5E-2
FLAP HARVEST
Design and Markings
Fig. 5E-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5E-4
FLAP VARIANTS
Functional Muscle Transfer
Fig. 5E-5
Segmental Transposition Flap
Vascularized Bone Flap
ARC OF ROTATION
Fig. 5E-6
FLAP TRANSFER
Fig. 5E-7
FLAP INSET
DONOR SITE CLOSURE
Fig. 5E-8
CLINICAL APPLICATIONS
Fig. 5E-9 A, A gold loader was placed in the patient's left upper eyelid soon after tumor resection to protect the cornea.
Six months after her neuroma resection, a static fascial sling was placed for the left lower eyelid. An early dynamic
temporalis transfer was performed, creating a Mona Lisa type of zygomaticus-dominant smile. The anterior portion of the
masseter was used to balance the strong dynamic upward pull of the temporalis muscle. B, Two years postoperatively, she
demonstrates a balanced smile. No revision surgery was required.
Fig. 5E-10 A, The patient demonstrates her only function through a portion of the marginal mandibular nerve. She underwent
placement of a gold loader and a static fascial sling for the right eyelids. B, A dynamic transfer of the temporalis muscle
was performed to the right commissure and upper lip. At 9 months postoperatively, the patient shows excellent excursion of
the upper lip and commissure, demonstrating complete relaxation.
Fig. 5E-11 A, The paralysis affected her commissure and upper lip. At the time, a partial temporalis transfer was performed
directly into the commissure and upper lip, creating an excellent, balanced smile. B, The photo on the right was taken
approximately 10 years after the original reanimation procedure.
Pearls and Pitfalls
EXPERT COMMENTARY
Fig. 5E-12 Design of a standard temporalis transfer, with linear exposure of the muscle and rotation over the zygomatic arch
into the commissure with its facial extension.
Recommendations
Fig. 5E-13 A partial left-sided paralysis limited to the zygomaticus major and minor and the levator labii superioris is an
ideal clinical condition that lends itself to a partial temporalis muscle transfer. Pictured here is a partial temporalis
transfer with its fascial extension to provide paralysis support for isolated loss of the levator superior.
Fig. 5E-14 A, Mona Lisa type of smile: A zygomaticus-dependent smile draws the commissures laterally and keeps the upper lip
horizontally flat. B, Canine type of smile: A combination of the zygomaticus major and levator superior muscles to produce a
gentle curvature.
Fig. 5E-15 Preparation of fascia before isolating and contouring the temporalis muscle transfer.
Fig. 5E-16 Cheek dissection creates a path for the transfer, designed to reproduce the smile pattern of the normal side.
Care should be taken not to allow the transferred muscle to roll medial to the zygomatic prominence.
Fig. 5E-17 Tension is set with overcorrection. The temporalis fascial extension is attached to the upper lip and commissure.
Fig. 5E-18 Overcorrection of the tension of the transferred temporalis muscle is essential in creating the correct balance
of dynamic excursion. Approximately 28% of patients require a minor adjustment of the tension within 2 years.
Fig. 5E-19 Polyethylene implant.
Take-Away Messages
Bibliography With Key Annotations
Section 5F Masseter Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5F-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 5F-2 A, Masseter muscle in situ with facial vessels visible crossing the mandibular line medially; these vessels give
minor blood supply to the muscle. B, The muscle is elevated off the mandible to demonstrate the dominant maxillary blood
supply. C, Closeup of the maxillary pedicle.
Exposure of the Masseteric Nerve
Fig. 5F-3
Fig. 5F-3
Fig. 5F-3
Fig. 5F-3
Fig. 5F-3
FLAP HARVEST
Design and Markings
Fig. 5F-4
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5F-5
Fig. 5F-5
FLAP VARIANT
Inferiorly Based Flap
ARC OF ROTATION
Fig. 5F-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 5F-7 A, The patient is seen before reanimation. B, Postoperatively, the lower lip on the paralyzed side is elevated,
creating a substantial asymmetry at maximum smile.
Fig. 5F-8 A, The patient is seen before reanimation. B, Postoperatively, her lower lip has excellent symmetry (slight
overcorrection) when she smiles. The maximum depression of the lower lip is medial to the commissure.
Fig. 5F-9 A, He had marked limitation of his smile on the right side. A temporalis and partial masseter transfer was
performed. B, Note the normal expected downward reanimation of the lower lip in conjunction with excellent excursion of the
right commissure and upper lip. He is shown 26 years after surgery.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Fig. 5F-10 A, The anterior third of the masseter muscle acts as a complement to help balance the upward-directed pull of the
temporalis transfer. Insertion of the masseter medial to the commissure stabilizes the lower lip position with a slight
downward pull, re-creating lower lip depression. B, Strong overcorrection of the upper lip and commissure through the
temporalis transfer distorts the position of the lower lip in an upward direction. The partial masseter transfer is
essential in reproducing lower lip balance.
Recommendations
Take-Away Messages
References
Bibliography With Key Annotations
Section 5G Orbicularis Oris Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5G-1
Fig. 5G-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 5G-2
Fig. 5G-2
FLAP HARVEST
Design and Markings
Abb?Flap
Fig. 5G-3
Estlander Flap
Fig. 5G-4
Gillies Flap
Fig. 5G-5
McGregor Flap
Fig. 5G-6
Karapandzic Flap
Fig. 5G-7
Patient Positioning
GUIDE TO FLAP DISSECTION
Abb?Flap
Fig. 5G-8
Estlander Flap
Fig. 5G-9
Gillies Fan Flap
Fig. 5G-10
McGregor Flap
Fig. 5G-11 Design and dissection of the McGregor flap. a, Height of lip defect; a?= a and becomes the new vertical
component; b, vertical height of flap that will become the new lip once relined with a mucosal graft or FAMM flap.
Fig. 5G-12 A and B, The flaps are based on an inferior medial pedicle; they are full-thickness cheek flaps that include the
mucosa. Considerable care is required at the pedicle area to avoid traumatizing the vessels around the commissures. A
conscious effort is made to maintain a subcutaneous pedicle that is wider than the skin or mucosal pedicle. C and D, After
the flaps have been incised, they are rotated medially to form the upper lip. The donor defect is closed directly after
excision of superior dog-ears of excess skin. E, The mucosa is reconstructed by advancement. Use of a tongue flap is too
hazardous in this situation; it would probably become detached.
Fig. 5G-13 A, Planned resection and flap design. B, Defect with flaps incised. C, Flaps rotated without tension. D, Flaps
inset with primary closure of donor sites. E, Bilateral fan flaps provide a lip of adequate bulk; the vermilion is supplied
by a tongue flap, which is divided after 2 weeks (see Section 5H). The donor defect can be closed directly without
difficulty.
Karapandzic Flap
Fig. 5G-14 A, Karapandzic flap design. B, Arc of orbicularis oris muscle flap and associated subcutaneous tissue with
preservation of the neurovascular pedicles. C, Arc of bilateral myocutaneous flap and direct donor site closure.
Fig. 5G-15 A, The plan for the procedure is outlined for a carcinoma of the lower lip, consisting of resection followed by
reconstruction with bilateral modified Karapandzic flaps. B, The resection is completed. C, Incisions are made transversely
from the base of the postexcisional defect on both sides. These extend around the commissures into the upper lip and
equidistant from the free lip margin. The orbicularis muscle fibers are spread apart longitudinally in the line of the skin
incision, down to the submucosal layer. The nerves and vessels are maintained intact. The mucosa is incised for 1 to 2 cm
from the edge of the defect. D, After this maneuver the edges of the defect can be approximated without tension. E, The lip
reconstruction is sutured in layers.
FLAP VARIANTS
ARC OF ROTATION
Fig. 5G-16
FLAP TRANSFER
FLAP INSET
All Flaps
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 5G-17 A, The patient's full-thickness upper lip defect is seen after radical resection of a Merkel cell tumor. B, A
closeup of the defect shows that it extended from the base of the nasal tip to the white roll. C, Basal view of the
columellar defect.
Fig. 5G-17 D, Design of the Abb?flap and bilateral perialar crescentic advancement flaps. The shaded areas represent areas
of full-thickness skin resection to allow advancement of the perialar flaps. E, Abb?flap and perialar flaps prepared for
advancement. F, Flaps sutured in place with inset of the Abb?flap. G, Postoperative staged result 2 weeks before division
of the Abb?flap. H, Final result 1 year postoperatively with no revision.
Fig. 5G-18 A, The defect after Mohs surgery, which extends to the philtrum medially and onto the maxilla superiorly B,
Planned Abb?flap using 25% of the lower lip. C, Lateral view showing the Mustard?flap design and the Abb?design relative
to the commissure.
Fig. 5G-18 D, Abb?flap, based on the medial labial artery, rotated superiorly into the defect. E, The flap is rotated and
inset. The inset of the cheek flap has also been completed. F, Lateral view of the inset with back-grafting of the cheek to
allow cheek rotation. G, AP view at 8 months postoperatively. H, Lateral oblique view. The patient has excellent opening and
functional result. He has refused any revisions of his scars.
Fig. 5G-19 A, The patient's Mohs defect encompassed 70% of the upper lip, some full-thickness, and the ala and columella of
the nose. B, Planned Abb?flap to the central upper lip and columella and superiorly based nasolabial flap for alar
reconstruction. Closure of the nasolabial donor site also allowed some advancement of the commissure medially. C, Abb?
rotated and nasolabial flap elevated and ready to inset.
Fig. 5G-19 D, All flaps inset with primary donor site closure. Note how the Abb?donor avoided the chin pad subunit for best
aesthetics. E, Lateral oblique view. F, The patient is seen in repose at his 7-month follow-up. Note how normal the scars
appear within the nasolabial fold and around the chin pad subunit. G, Lateral oblique view. Without cartilage support, the
nasolabial flap to the ala has vanished. H, The patient shows maximal mouth opening, evidencing some microstomia. The
patient was functional and desired no further surgery.
Fig. 5G-20 A, The patient's Mohs defect encompassed 25% of the lower lip and the left commissure. B, Because he had more
upper lip to donate, an Estlander flap was planned from the upper lip to reconstruct the defect and re-create his
commissure. C, Flap elevated and rotated into position. D, Inset and donor site closure. Care was taken to avoid tight
closure around the pedicle. E, AP view at 1?years postoperatively. F, Lateral oblique view. Although the patient has been
offered commissuroplasty, he is happy with the final result.
Fig. 5G-21 A, Preoperative view. B, Proposed resection and flap design. C, Defect after resection. D, Bilateral Karapandzic
flaps elevated. E, After flap inset. F, The patient is seen 1 year postoperatively. G, The patient demonstrates good
muscular function of the oral sphincter.
Fig. 5G-22 A-C, A full-thickness excision of two thirds of the lip was done, with the lip mucosa resected from the residual
third. A unilateral fan flap with a small base of the upper lip that contained the labial vessels was used to reconstruct
the defect.
Fig. 5G-22 D and E, The flap is seen rotated into place; note the narrow pedicle. F, The flap was raised from the
undersurface of the tongue to increase the length of the tongue flap. G, The donor defect was closed, and the flap provided
a nice reconstruction of the lip. H and I, Early and late photographs show that the lip is perfectly adequate in size and
shape as well as function. The tongue flap used to reconstruct the lower lip is of a slightly different color and texture
compared with the normal upper lip.
Fig. 5G-23 A, The plan for the procedure was outlined, consisting of resection followed by reconstruction with bilateral
modified Karapandzic flaps. B, The resection was completed and the position of the vessels noted. C, The vascular supply to
these flaps is well illustrated. This flap can also be made as an island flap.
Fig. 5G-23 D, Incisions were made transversely from the base of the postexcisional defect on both sides. These extended
around the commissures into the upper lip; with the use of scissors they were maintained equidistant from the free lip
margin. The orbicularis muscle fibers were spread apart longitudinally in the line of the skin incision, down to the
submucosal layer. The nerves and vessels were maintained intact. The mucosa was incised for 1 to 2 cm from the edge of the
defect. E, After this maneuver, the edges of the defect could be approximated without tension. F, The lip reconstruction was
sutured in layers. G and H, The result is a competent, sensate, fully functional lower lip with a slightly reduced oral
stoma. If necessary, these flaps can be used as islands based on the vessels that supply them.
Pearls and Pitfalls
EXPERT COMMENTARY
Personal Experience and Insights
Complications and Avoidance
Take-Away Message
Bibliography With Key Annotations
Section 5H Tongue Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5H-1
Fig. 5H-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 5H-2
FLAP HARVEST
Design and Markings
Fig. 5H-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Dorsally Based Flap
Fig. 5H-4
Laterally Based Flap
Fig. 5H-5
Ventral Tongue Flap
Fig. 5H-6
ARC OF ROTATION
Dorsally Based Tongue Flap
Fig. 5H-7
Anteriorly Based Lateral Tongue Flap
Posteriorly Based Lateral Tongue Flap
Fig. 5H-8
Ventral Tongue Flap
Fig. 5H-9
FLAP TRANSFER
All Variants
FLAP INSET
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 5H-10 A, Preoperative view of an infiltrative lesion of the lower lip. B, Defect of the lower lip after a Mohs
resection. The mistake in planning at this point would be to underestimate the actual bulk of tissue resected and the
functional need for adequate replacement. The large size of the overall wound that crosses the anatomic zones of the lip and
chin dictates separate handling of each area. C, A ventral tongue flap was chosen and the design drawn for an anteriorly
based flap.
Fig. 5H-10 D, The flap was inset to the lip subunit only with extra bulk from the tongue. E, A skin graft was chosen for
reconstruction of the chin subunit. A full-thickness graft was taken from the supraclavicular area. F, Appearance of the
skin graft and tongue flap 2 weeks later, just before division and inset. G, Appearance immediately after division and inset
of the tongue flap. The donor site was closed primarily and the tongue flap is viable on the lip. H, The patient is seen in
repose, 3 months postoperatively. I, View with maximal opening. The patient has excellent postoperative speech, no drooling,
and can tolerate a regular diet.
Fig. 5H-11 A-D, The postexcisional defect may be part or all of the length of the lower lip. It consists of mucosa,
submucosa, and often a layer of orbicularis. E-H, A suture was placed on either side of the tongue, and the required flap
was outlined on the undersurface. A flap of the required size was elevated, based anteriorly. The thickness of the flap is
that required to reconstruct the lip.
Fig. 5H-11 I and J, The posterior edge of the flap was brought forward and sutured to the cutaneous border of the defect and
was also sutured laterally. The raw area on the undersurface of the tongue remained, with no attempt at closure. K and L,
The tongue flap was left attached to the lip for 10 days and was then divided. At this point it is important to make certain
that enough tongue mucosa is transferred to generously close the residual defect. In this way adequate resurfacing is
obtained. Failure to transfer sufficient mucosa will result in a thin, pincushioned ridged of tongue mucosa. The incision on
the tongue is closed with a continuous absorbable suture. If there is significant induration, causing difficulty in closure,
the defect may be left unsutured and will close spontaneously. M, A reasonably normal looking vermilion can be obtained.
Scaling of the mucosa because of drying can be seen in this case.
Pearls and Pitfalls
EXPERT COMMENTARY
Personal Experience and Insight
Recommendations
Postoperative Care
Take-Away Messages
Bibliography With Key Annotations
Section 5I Submental Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5I-1
ANATOMY
Arterial Anatomy (Type C)
Venous Anatomy
Nerve Supply
Fig. 5I-2 A, The undersurface of a left-sided submental flap is shown. The dissection plane on the right is subplatysmal
until the left digastric muscle is encountered. Perforators on each side of the muscle are investigated. As shown here, both
perforators are included by taking the section of digastric muscle within the flap territory. The submandibular gland, an
important dissection landmark, is also shown. B, The flap is isolated on the submental vessels, based off the facial
vessels. C, The reach of the flap is extended by dividing the facial artery proximal to the take-off of the submental
artery. Flow in this 뱑everse?flap is retrograde through the facial system.
FLAP HARVEST
Design and Markings
Fig. 5I-3 A line 1 cm posterior to the jawline is marked with the patient sitting. The width is determined by the pinch
test. The design extends only to the mandibular angles.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5I-4
Fig. 5I-4
Fig. 5I-4
FLAP VARIANTS
Island Flap
Fig. 5I-5 Design of submental island flap
Free Flap
Perforator Flap
ARC OF ROTATION
Fig. 5I-6 A, Arc to the lip, nose, and cheek exteriorly and buccal mucosa and floor of the mouth interiorly. B, Division of
the facial pedicle proximal to the submental takeoff extends the arc, creating a 뱑everse flow?flap.
FLAP TRANSFER
Pedicle Flap
Free Flap
FLAP INSET
Pedicle Flap
Free Flap
DONOR SITE CLOSURE
Pedicle Flap
CLINICAL APPLICATIONS
Fig. 5I-7 A, This patient underwent a full-thickness excision of a squamous cell carcinoma that included the muscles of
facial expression. The flap design is shown.
Fig. 5I-7 B and C, A functional submental flap was elevated and transferred through a subcutaneous tunnel, with the platysma
muscle fibers oriented to facilitate facial expression. D and E, The postoperative result after radiation therapy.
Fig. 5I-8 A, This 69-year-old with squamous cell carcinoma of the inner cheek had a large buccal defect. After confirming
the size of the defect, a submental flap was designed on the ipsilateral side to allow a pedicle flap to reach the recipient
site. B, Flap elevated on the submental pedicle. The dissection across the midline is just below the platysma, and on the
pedicle side it included the digastric muscle. The submandibular gland is also seen after its feeding vessels were divided.
C, The flap was passed through the subcutaneous tunnel and marked for areas to be deepithelialized. The flap was then
secured to the cheek. D, Flap well healed at 2 weeks postoperatively. E, The donor site scar at 2 weeks.
Fig. 5I-9 A, This 51-year-old man had a poorly differentiated carcinoma of the right cheek. Resection included the anterior
maxillary wall and excision of the infraorbital nerve. Because this was close to his eye, it was felt a pedicle submental
flap would apply too much downward pressure on the lid, so a free submental flap was performed based on the contralateral
pedicle. B, The flap was elevated with a nice pedicle length and good perfusion over the midline. C, The flap after inset,
with anastomosis to the ipsilateral facial artery and vein, effectively lengthening the pedicle. The patient had a
protective canthopexy at the initial surgery, underwent two revisions for a debulking cheek lift, and finally, a
canthoplasty and placement of a tendon graft for lower lid support. D, The final result is seen 1 ?years after the initial
surgery.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
Complications: Avoidance and Treatment
Bibliography With Key Annotations
Section 5J Facial Artery Myomucosal (FAMM) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 5J-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
FLAP HARVEST
Design and Markings
Fig. 5J-2
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 5J-3
Fig. 5J-3
ARC OF ROTATION
Superiorly Based Flap
Fig. 5J-4
Inferiorly Based Flap
Fig. 5J-5
FLAP TRANSFER
Both Variants
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 5J-6 A, An alveolar gap allowed a superiorly based flap to be raised to traverse from cheek to palate without risk of
injury from the teeth. B, The flap was dissected, as described in the chapter. It was fairly thick and well perfused to its
distal tip. The dissection was continued as far as necessary to transpose the flap into the defect. C, At the palatal
defect, local turn-in flaps were used for nasal lining and then the flap was positioned to restore the oral coverage.
Fig. 5J-7 A, The patient is seen preoperatively. B and C, A contralateral superiorly based FAMM flap was raised and inset
into the defect. The incision was made at the junction between the wet and dry mucosa, allowing the rim of dry mucosa to
rotate externally and the flap to be inset at this junction. D, The postoperative result is shown.
Fig. 5J-8 A, The patient had a complex palatal defect and intact dentition. B, A one-stage procedure was achieved by raising
an additional flap that extended from the base of the FAMM flap in the retromolar area to near the margin of the defect
itself. C, The flap was based on blood supply through its base, and thus was raised to within 1 cm of the palatal fistula
and turned over to repair the nasal lining. The residual donor defect creates a large furrow to accommodate the
transposition of the inferiorly based FAMM flap so that it no longer protrudes and is not at risk from injury when the
patient bites down. D, The result is shown 6 months postoperatively.
Fig. 5J-9 A, The lower lip defect is seen after Mohs excision, with removal of 90% of the lip, along with lip bulk. B, An
inferiorly based FAMM flap was planned. A Doppler probe was used intraorally to trace the facial artery's course, and the
flap was designed around it. C, The FAMM flap was elevated. Some early sutures were placed near the base to prevent
inadvertent pulling on the flap and separation from the artery. The donor site was closed primarily. D, The FAMM flap is
seen inset; it is pink and viable. E, One-month postoperative view. The FAMM flap has nicely reestablished the vermilion and
replaced some lost bulk in the lower lip.
Fig. 5J-10 A, The defect consisted of a superficial upper lip defect, a deeper complex defect of the commissure, and 50% of
the lower lip. B, A FAMM flap was planned for the lower lip defect. A Doppler probe was used intraorally to show the course
of the facial artery and angular branch. The flap was then planned around this. C, The inferiorly based FAMM flap was
raised. Some distal sutures were placed to prevent separation of the mucosal surface from the artery. D, The FAMM flap was
inset, reestablishing the vermilion and providing appropriate bulk. The upper lip defect was grafted with a full-thickness,
hair-bearing graft from the submental area, and the commissure and associated defect was reconstructed with a V-Y
advancement flap. E, The patient is seen in repose at his 3-month follow-up with a good aesthetic result. The skin graft is
already growing hair; the V-Y advancement flap still has some pincushioning, but the FAMM flap has already settled nicely.
F, With the mouth opened slightly, one can appreciate the added bulk and the color and texture difference between oral
mucosa and normal vermilion. The patient was happy with the result and requested no revisions.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Recommendations
Postoperative Care
Bibliography With Key Annotations
Chapter 6 Anterior Thorax
Section 6A Deltopectoral Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 6A-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 6A-2
FLAP HARVEST
Design and Markings
Fig. 6A-3 A, Design for a standard flap. B, A deltopectoral flap is possible with delay (see Fig. 6A-5).
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 6A-4 A, Elevation of the deltopectoral flap from lateral to medial in the subfascial plane. B, Flap elevation is
discontinued when the perforators of the internal mammary artery are encountered.
Esophageal Reconstruction
Prefabrication for Tracheal Reconstruction
FLAP VARIANTS
Delayed Flap
Fig. 6A-5 A, In stage one of the delay procedure, the superior and inferior incisions of the proposed delayed flap are made
and the flap is completely undermined. The distal edge of the flap is not incised. B, In stage two, 7 to 10 days later, the
distal edge is incised. The flap is now surviving only on the mammary perforators. Transfer of the flap may be done 7 to 10
days later.
Internal Mammary Artery Perforator Flap
Fig. 6A-6 Once perforators to the skin paddle are identified, dissection follows the vessels through pectoralis major
muscle, which is removed to show the underlying ribs. Removal of the intervening rib is required to include more than one
perforator. Additional ribs are removed to lengthen the pedicle and improve the arc of rotation, or if longer vessels are
needed for a free tissue transfer.
ARC OF ROTATION
Standard Flap
Fig. 6A-7
Delayed Flap
Fig. 6A-8
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 6A-9 A, The thoracic surgeons resected the area of erosion and replaced the stent. B, A delayed deltopectoral flap was
placed between the esophagus and trachea.
Fig. 6A-10 A, The preoperative defect is seen, with the shortened tracheal stump and neck skin defect. B, After a one-stage
deltopectoral flap reconstruction and skin grafting of the donor site. The flap easily reached the lower neck and allowed
tension-free closure around the deeper tracheal stoma.
Fig. 6A-11 A, Preoperative view 2 weeks after the patient's initial injury. The full-thickness defect of the cheek is seen,
but the tongue sutured to the cheek obscures the deficiency in the floor of the mouth. B, The planned deltopectoral flap,
delayed as described above. C, The tongue was released and the deltopectoral flap inset into the floor of the mouth,
allowing normal tongue mobility. The donor site was skin grafted. D, The deltopectoral flap was then folded and used to line
the inner cheek and was sutured to the outside of the cheek, closing and relining the defect. The flap was tubed for wound
control of the exposed pedicle, and a bolster was placed over the skin graft. E, Two weeks postoperatively, the pedicle was
divided and returned to the chest to replace some of the skin graft. There was lining for the cheek, inside and out. F,
After free fibular mandible reconstruction, two serial excisions of the skin paddle were performed, and the external skin
paddle was completely removed, leaving the internal cheek and floor of the mouth lining and a more aesthetic appearance.
Fig. 6A-12 A, The patient presented 9 months after her pectoralis major muscle salvage procedure. Her plate was stable, and
there was no intraoral exposure. She was bothered by the bandlike neck contracture from her reconstruction. B, Debridement
of the pectoralis muscle and skin graft superiorly released the contracture, but a skin defect remained. The previous skin
graft caused contracture, so a deltopectoral skin flap was chosen to resurface the area. A standard deltopectoral flap would
not reach the wound without tension, so a delay procedure was planned. C, The standard deltopectoral flap was outlined.
Lines were incised, and the flap was completely undermined except in the area of the mammary perforators. A second delay was
performed, extending the incisions above and below and undermining the distal flap. D, The distal end of the flap was
divided under local anesthesia in the office 1 week later. The patient is shown 1 week after the final distal delay, ready
for flap transfer.
Fig. 6A-12 E, The flap was elevated. Note the length that was attained, with excellent vascularity if delayed correctly. F,
The flap was rotated to the cheek. The arc of rotation could be extended by backcutting the flap, sacrificing one of the
distal internal mammary artery perforators. G, The flap was tubed and inset. The large donor site required a skin graft. H,
Four months after the division and inset, the contracture band is resolved and the patient has improved neck mobility. She
is a candidate for further aesthetic revisions.
Fig. 6A-13 A, The skin defect is seen after laryngopharyngectomy and free jejunal cervical esophageal reconstruction. The
proposed deltopectoral flap is outlined. B, The neck defect was resurfaced with the deltopectoral flap and the donor site
was partially closed. The remainder was skin grafted. C, At 6-month follow-up, the flap remains well healed over the
functional jejunal reconstruction, and the skin grafted donor site is acceptable to the patient.
Fig. 6A-14 A, The patient is seen before resurfacing. B, This was achieved with bilateral obliquely oriented IMAP
transposition flaps. C, These were pedicled using the second IMAP, without the need for mobilization of the internal mammary
artery. D, Stable closure was achieved, as well as direct closure of the secondary defect.
Fig. 6A-15 A, Design of the IMAP flap. B, Three perforators were harvested with this flap, necessitating the removal of the
two intervening costal cartilages to mobilize the internal mammary artery and lengthen the pedicle. C, The flap was pedicled
to the neck and inset as a patch onto the esophagus. D, Direct closure of the donor site was achieved.
Pearls and Pitfalls
EXPERT COMMENTARY
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Fig. 6A-16 In this patient, in whom a pectoralis major flap is being elevated, the deltopectoral skin territory is preserved.
Complications: Avoidance and Treatment
Take-Away Messages
References
Bibliography With Key Annotations
Clinical Series
Flap Modifications
Complications
Section 6B Pectoralis Minor Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 6B-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 6B-2
Fig. 6B-2
FLAP HARVEST
Design and Markings
Fig. 6B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 6B-4 A, Exposure of the pectoralis minor muscle.
Fig. 6B-4 B, Exposure of the lateral thoracic pedicle lying lateral to the pectoralis major on the serratus and entering the
pectoralis minor's deep surface.
Fig. 6B-4 C, Division of the pectoralis minor insertion to the coracoid.
Fig. 6B-4 D, Pectoralis minor muscle divided from the origin and insertion, attached to only vessels and nerves.
FLAP VARIANTS
Free Microvascular Flap
Pedicled Flap
ARC OF ROTATION
Fig. 6B-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 6B-6 A, The patient is seen preoperatively. B, Results are seen 18 months postoperatively, with good symmetry when
smiling and good depressor function from the three-slip inset.
Fig. 6B-7 A, The patient is seen preoperatively. B, Results of the pectoralis minor transfer are seen 2 years
postoperatively. Note the slight excess bulk in the cheek of the transferred muscle.
Fig. 6B-8 A, The patient is seen preoperatively. B, Twenty years later, she has good symmetry, with excellent elevation of
the upper lip but a slightly excessive depressor function on the nonparalyzed side. The muscle function did not deteriorate
over time.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Fig. 6B-9 The axillary approach.
Anatomic Considerations
Personal Experience and Insights
Recommendations
Fig. 6B-10 The lateral edge of the pectoralis minor exposed.
Fig. 6B-11 Retraction of the tendon from the coracoid process.
Fig. 6B-12 Three slips for insertion into the alar base, upper lip, and lower lip.
Fig. 6B-13 Inset with pedicle facing anteriorly to facilitate easy microsurgical anastomosis.
Postoperative Care
Complications
Take-Away Message
References
Bibliography With Key Annotations
Section 6C Lateral Intercostal Artery Perforator (LICAP) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 6C-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 6C-2 A, Location of the lateral fat compartment captured in this flap. B, Anatomic study demonstrating the lateral fat
compartment (indicated in blue). C, Cadaver dissection showing the right back-axilla region, revealing the main vascular
pedicles. The locations of the intercostal perforators are indicated (arrows to red markers). D, A dominant intercostal
perforator is shown among other smaller ones (blue markers). (A and B, courtesy Michel Saint-Cyr, MD; C and D, courtesy
Moustapha Hamdi, MD.)
FLAP HARVEST
Design and Markings
Fig. 6C-3 After its intermuscular course, the lateral cutaneous bundle emerges in front of the latissimus dorsi muscle,
where it pierces the origin of the external oblique abdominis muscles. This branch divides after its intermuscular course
into a larger anterior and smaller posterior branch, accompanied by the sensory lateral cutaneous branch.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 6C-4 Surgical technique for the LICAP flap on the lower lateral part of the rib cage. A, After the anterior border of
the latissimus dorsi muscle is visualized, the smaller posterior branch of the lateral cutaneous branch is identified. This
branch is followed to find the bigger anterior branch. B, The origin of the external oblique abdominis muscle is elevated
and split, and the latissimus dorsi muscle belly is retracted.
Fig. 6C-4 C, The junction of the lateral cutaneous branch and the main bundle is exposed.
Fig. 6C-4 D, The required pedicle length is dissected and the flap elevated.
FLAP VARIANTS
Dorsal Intercostal Artery Perforator Flap
Fig. 6C-5 Paravertebral perforator source for DICAP flap
Anterior Intercostal Artery Perforator Flap
Fig. 6C-6 Vascular source for AICAP flap
ARC OF ROTATION
Fig. 6C-7 Arc of rotation of the LICAP flap. More arc of rotation is gained by extending the skin design, and more freedom
of placement is achieved with further pedicle dissection.
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 6C-8 A, Preoperative view. B, Flap design with the mapped perforators. C, The defect after the quadrantectomy. D, The
two perforators were found, one perforator (seen against green background) originated from the thoracodorsal vessels, and
one LICAP in front of the anterior border of the latissimus dorsi muscle. The intercostal nerve was included in the flap. E,
The thoracodorsal perforator was clipped. F, The flap was based on the intercostal perforator. The LICAP was totally
deepithelialized and turn 180 degrees to the breast defect. G, Postoperative view.
Fig. 6C-9 A, The patient is seen preoperatively. B, Flap design and breast reduction pattern with a lateral pedicle. The
defect measured 12 by 8 cm. C, The AICAP flap was designed over the medial part of the excised inverted-T skin pattern. D,
The defect after the radical excision. E, The flap skin was incised. F, The AICAP flap was advanced with 90-degree rotation.
G, The defect was closed with the AICAP flap, and the breast reduction was completed. H, The patient is seen postoperatively
with complete wound healing.
Fig. 6C-10 A, Preoperative view. B, The DICAP flap was designed around the mapped perforator. C, Complete wound healing was
obtained.
Fig. 6C-11 A, The defect is shown, with the designed LICAP flap. The X indicates the mapped perforator. B, The flap was
raised on two intercostal perforators. C, The flap was rotated 180 degrees, with complete defect coverage.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Recommendations
Postoperative Care
Complications
Take-Away Messages
References
Bibliography With Key Annotations
Section 6D Serratus Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 6D-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 6D-2
Fig. 6D-2
FLAP HARVEST
Design and Markings
Fig. 6D-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 6D-4
Fig. 6D-4
Fig. 6D-4
FLAP VARIANTS
Composite Serratus-Latissimus Flap
Fig. 6D-5
Serratus Fascial Flap (Lateral Thoracic Fascia)
Fig. 6D-6
Myoosseous Flap
Fig. 6D-7
Fig. 6D-7
ARC OF ROTATION
Standard Flap
Fig. 6D-8
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 6D-9 A, Thoracotomy wound following rib resection for insertion of a serratus flap to seal a bronchopleural fistula
repair. B, The pedicled serratus anterior flap tunneled into the chest through a rib resection.
Fig. 6D-10 A, Open wound of the lateral lower leg with exposed tendons and bone after sarcoma resection. B, Serratus
anterior flap anastomosed to the anterior tibial vessels proximal to the defect. C, The skin grafted serratus flap achieved
wound closure. The patient healed uneventfully.
Fig. 6D-11 A, A cross-face sural nerve graft was placed between the contralateral buccal branches of the facial nerve (left
side) to the preauricular region of the paralyzed right side of her face. B, Three inferior slips of serratus muscle were
elevated as a functional muscle flap for transplantation to the right side of her face. Note that the proximal motor nerve
fibers to the superior slips have been left intact. C, Vascular pedicle anastomosed to the facial artery and vein. Long
thoracic nerve anastomosed to the distal end of the sural cross-nerve graft. D and E, The patient is seen at 6 months
postoperatively. The innervated serratus muscle has restored facial animation with adequate symmetry and muscle support to
the lower third of the face in repose.
Fig. 6D-12 A, The preoperative defect. The entire fibrinous tract required debridement to bleeding tissue. B, The planned
serratus flap. Only the lower three slips will be taken to maintain scapular function. C, Flap dissection was easily
accomplished as the vascular pedicle lies superficially on the muscle and is readily seen and protected. D, After inset. The
muscle was left intraorally to remucosalize, and a split-thickness skin graft was placed to maximize postoperative
contraction of the graft. Note how much irradiated skin was removed to accomplish complete debridement. E, The patient is
seen 4 months postoperatively. There were no further problems with fistula or infection.
Fig. 6D-13 A, The serratus muscle was harvested in its entirety, based on the serratus branches of the thoracodorsal
pedicle. B, After intrathoracic transposition to the bronchial stump site. Normally, a rib is resected for access to the
chest, the closest rib to the pedicle origin, the better. In this case, the previously created pleural window at the fourth
rib was used and was adequate for the repair.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
Bibliography With Key Annotations
Section 6E Pectoralis Major Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 6E-1
ANATOMY
Arterial Anatomy (Type IV)
Venous Anatomy
Nerve Supply
Fig. 6E-2
Fig. 6E-2
FLAP HARVEST
Design and Markings for Standard Muscle Flap
Fig. 6E-3 Skin island designs for head and neck coverage. A, 1: a, For access to muscle for reverse flap based on the
mammary perforating vessels. b, Access incisions for muscle-only harvest for head and neck reconstruction, leaving the
deltopectoral flap available for future use. c, Deltopectoral incision to release the muscle origin for use with a and
possibly b. 2: Typical vertical skin design used in men. B, 1: Access incisions for muscle-only harvest for head and neck
reconstruction, sparing the breast and leaving the deltopectoral flap available for future use. 2: Typical skin design in
women to avoid taking breast tissue with the flap and to minimize donor site deformity.
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Muscle Flap
Fig. 6E-4 A, Typical access incisions for muscle only harvest in a, men and b, women. B, Initial dissection to expose the
anterior surface of the muscle.
Fig. 6E-4 C, Division of the pectoralis major muscle based on the thoracoacromial pedicle, sparing the mammary perforators.
D, Typical superior rotation for head and neck reconstruction, limited by the thoracoacromial pedicle. Easier rotation can
be accomplished by tapering the muscle near the pedicle.
FLAP VARIANTS
Myocutaneous Advancement Flap
Muscle Advancement (Slide)
Fig. 6E-5 A, Bilateral pectoralis major flaps for a central sternal defect. The muscle has been released at its origin along
the sternum and laterally at its insertion through separate skin incisions. This can sometimes be accomplished through the
wound. B, Both muscles have been advanced centrally to reconstruct the defect.
Reverse (Turnover) Flap
Sternal Coverage
Fig. 6E-6 A, An L-shaped incision is made in the pectoralis major muscle insertion to maintain the anterior axillary fold;
the thoracoacromial vessels are identified and cut on the deep surface of the flap. B, The muscle is turned over to expose
the divided thoracoacromial vessels. C, The pectoralis major is split into a smaller upper flap and a larger lower flap,
each based on the internal mammary perforator; the lower flap is positioned interiorly and the upper flap superiorly.
Vascularized Bone
Fig. 6E-7 Vascularized bone territory.
Functional Muscle Flap
Tissue Expansion
ARC OF ROTATION
Muscle and Myocutaneous Flap
Head and Neck
Fig. 6E-8
Intrathoracic Cavity
Fig. 6E-9
Sternum
Fig. 6E-10
Reverse Flap
Fig. 6E-11
FLAP TRANSFER
Head and Neck
Sternum
Intrathoracic
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 6E-12 A, The patient is seen before flap reconstruction, 10 days after CABG surgery, with an inflamed, draining sternal
wound. B, A bilateral partial sternectomy was performed. C, Medial edge of left pectoralis major myocutaneous advancement
flap. Note that the skin is separated only 2 cm from the muscle edge. D, Flap shown at the level of the subpectoral plane.
E, Completed closure with well-vascularized skin edges.
Fig. 6E-13 A, Debrided sternum with exposed pericardial sac. B, Left pectoralis major muscle exposed for advancement. C,
Right split turnover flap exposed. D, Right split turnover flap based on internal mammary perforator, and left advancement
flap based on the thoracoacromial artery. E, The three flaps are interlocked, with the left advancement flap spliced between
the two components of the right turnover flap.
Fig. 6E-14 A, Recurrent malignant fibrosarcoma of the chest with a previous thoracotomy, midline laparotomy scar, and
bilateral subcostal incisions. B, Resection of skin, tumor, ribs, and pleura covered with a double layer of Prolene mesh. C,
Longitudinal incision to expose the pectoralis major muscle. D, Turnover of the pectoralis major based on internal mammary
perforators showing a divided thoracoacromial pedicle. E, Healed skin grafted muscle flap.
Fig. 6E-15 A, The sizable defect and the plan for a vertically designed myocutaneous flap are shown. It is important to keep
the skin paddle directly over the pectoralis major muscle to prevent necrosis. Larger paddles can be designed but should be
delayed to ensure vascularity. B, The flap was elevated, narrowing the muscle at the level of the pedicle to facilitate
rotation. C, The flap was inset with care taken to avoid a tight subcutaneous tunnel and kinking of the pedicle. Primary
closure was attained at the cost of nipple migration. D, At 2-month follow-up, the patient is seen with uncomplicated
healing.
Fig. 6E-16 A, The muscle was isolated on its thoracoacromial pedicle, accessed through inframammary and subclavicular
incisions. The Xs mark the mammary perforators that were left in situ, preserving the option of a deltopectoral flap. The
muscle is quite narrow at the level of the clavicle to facilitate rotation and reach to the plate. B, The thoracoacromial
pedicle is visible. The muscle easily reached the plate and wrapped it completely. C, The noncompliant irradiated neck skin
would not close over the muscle without excessive tension, so a skin graft was placed. Intraoral closure was obtained in
part with mucosa and part by remucosalization of exposed intraoral muscle. D, Her donor scars at 4 months postoperatively
are well hidden. E, Although the flap, skin, and intraoral closure all healed without incident, she was left with a
contracture band of pectoralis muscle and contracted skin graft. She was a candidate for a deltopectoral flap because of the
method of pectoralis harvest (see Section 6A, Deltopectoral Flap).
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Bibliography With Key Annotations
Anatomic/Experimental Studies
Clinical Series
Flap Modifications
Section 6F Supraclavicular Artery Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 6F-1 A, Blood supply to supraclavicular artery flap. B, The supraclavicular nerves (C3, C4) arise from a common trunk,
which descends for a variable distance before dividing into medial, intermediate, and lateral supraclavicular nerves. These
supply the skin over the lower neck from near the midline to the acromioclavicular region and above the shoulder. They then
pass in front of the clavicle to innervate the skin of the anterior chest wall to the level of the sternal angle and the
second rib. The medial and lateral nerves, respectively, send twigs to the sternoclavicular and acromioclavicular joints.
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 6F-2 A, Cadaveric dissection of the supraclavicular flap demonstrating the supraclavicular artery running axially in
the flap. B, Closeup of the triangle defined by the sternocleidomastoid, clavicle, and trapezius, with the pedicle
visualized. C, A sizable pedicle is seen coming from the transverse cervical branch of the subclavian artery. D, Three-
dimensional CT angiogram of a supraclavicular flap (anteroposterior view). The flap was infused almost 100%.
FLAP HARVEST
Design and Markings
Fig. 6F-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 6F-4
FLAP VARIANT
Tissue Expansion
Fig. 6F-5
ARC OF ROTATION
All Flaps
Fig. 6F-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 6F-7 A, The 6 by 6 cm defect and open neck from lymph node dissection. B, Design of the supraclavicular artery flap.
The supraclavicular artery was localized with a Doppler probe in the dotted triangle of the SCM, trapezius, and clavicle.
(Three Doppler points are marked by Xs.) The flap was designed 3 cm distal to the deltoid insertion.
Fig. 6F-7 C, The flap was elevated up to the vessels. The dissection did not specifically identify any vessels. D, The
underside of the flap is seen; note some of the axialized vessels within the flap. E, The flap easily reached the defect.
Rather than bury the flap with the necessary 180-degree rotation and flipping of the flap, with possible compression of the
pedicle and bulk along the mandibular line, it was decided to pedicle the flap. F, After inset of the flap and primary
closure of the donor site. G, After division and inset of the flap. Some of the pedicle was returned to the chest for
aesthetics.
Fig. 6F-8 A, Before flap reconstruction. B, Tumor ablation defect. C, Supraclavicular flap elevated, with blue background
beneath the pedicle. D, The patient is seen 2 weeks postoperatively.
Fig. 6F-9 A, The patient is seen preoperatively. B, Defect after tumor ablation. C, Supraclavicular flap harvested. D, The
flap deepithelialized and ready for inset. E, The patient is seen 6 months postoperatively.
Fig. 6F-10 A, Ablation of the intraoral tumor involving the gingivobuccal sulcus left a 5 by 6 cm defect. B, The planned
flap was marked. C, The supraclavicular artery flap was elevated and D, rotated. E, The flap was tunneled into the
ipsilateral neck and F, inset. There was no leak from the reconstruction, and the patient was able to tolerate a normal diet
6 months after surgery.
Fig. 6F-11 A and B, Preoperative AP and oblique views of the patient. C, The inflated expanders are seen in place. D, The
intraoperative flap design was marked. E, The supraclavicular artery flap was raised and inset. F and G, Postoperative
appearance.
Fig. 6F-12 A and B, AP and closeup preoperative view. C, After excision of the lesion, the supraclavicular flap was outlined
and used to cover the defect. D-F, Twelve years after surgery, excellent tissue and contour reconstruction is evident, and
the donor site scar is inconspicuous.
Fig. 6F-13 A and B, The patient's keloids restricted his neck movement. C, expanders were placed preoperatively. D,
Reconstruction was done with a unilateral preexpanded supraclavicular artery flap of 32 by 5 cm. E and F, The reconstruction
resulted in improved contour and function.
Fig. 6F-14 A and B, The patient is seen preoperatively. C, Bilateral expanders were placed. D, The scar was resected and the
defect covered with the supraclavicular artery flap. E, The donor site was closed primarily. F and G, The patient is seen
postoperatively after full face reconstruction with the bilateral preexpanded supraclavicular flaps.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Recommendations
Technique
References
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
Reference
Bibliography With Key Annotations
Chapter 7 Posterior Trunk
Section 7A Gluteus Maximus and IGAP/SGAP Flaps
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7A-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 7A-2
FLAP HARVEST
Design and Markings
Fig. 7A-3 Variations of skin paddle design for the gluteal flap.
Patient Positioning
Fig. 7A-4 Lateral decubitus positioning is used for simultaneous immediate breast reconstruction. A, A bean bag is used in
combination with an axillary roll and padding of all pressure points. B, The arm is draped free, and care is taken during
surgery to avoid unnatural positions.
GUIDE TO FLAP DISSECTION
Standard V-Y Advancement Flap
Fig. 7A-5 A, V-Y design for a midline wound. The flap is as wide as the bursa, not the skin defect. B, Advancement is
possible by incising the skin down to muscular fascia and dividing the proximal and distal muscle. C, Cadaveric dissection
of the superior and inferior gluteal vessels. Either or both can be used to vascularize the flap. D, Flap after inset in V-Y
fashion, allowing tension-free closure at the midline.
FLAP VARIANTS
Semicircular Advancement Flap
Fig. 7A-6 A, Semicircular design for a midline wound. B, The flap is largely elevated at the level of the fascia, except
near the point of entry of the superior and inferior gluteal vessels. If more rotation is required, the muscle is released
from its origin medially and divided distally as shown. C, After advancement and closure. One can deepithelialize the
leading edge of the flap for fill of the bursa.
Functional Muscle Transfer Flap
Superior Gluteal Artery Perforator Flap
Fig. 7A-7 Identification of anatomic landmarks. A mark at the transition of the proximal and middle third on a dashed line
drawn from the posterior superior iliac spine to the greater trochanteric prominence represents the location where the
superior gluteal artery exits the pelvis. The line leading from the superior edge of the greater trochanter bisects the line
between the PSIS and the tip of the coccyx. This marks the position of the piriformis muscle.
Fig. 7A-8 A, Design of the SGAP flap. The location of the superior gluteal artery is confirmed by Doppler ultrasonography.
B, The flap is elevated in the subfascial plane with identification of the SGAP perforators. C, After inset of the SGAP free
flap for breast reconstruction. The superior gluteal vessels have been anastomosed to the internal mammary system.
Inferior Gluteal Artery Perforator Flap
Myocutaneous Free Flap
ARC OF ROTATION
Standard Flap
Fig. 7A-9
Transposition Flap
V-Y Advancement Flap
FLAP TRANSFER
FLAP INSET
Pedicle Flap
Transposition and V-Y Flaps
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 7A-10 A, The defect is shown with a planned large semicircular skin flap based on the inferior gluteal artery for skin
cover. B, The planned superior gluteal muscle transposition based on the superior gluteal artery to cover the exposed cauda
equina. The semicircular flap is elevated and the perforator of the IGA has been left intact. C, The defect has been closed
after transposition and rotation of the flaps. This combination is acceptable for an ambulatory patient and preserves the
contralateral side for complications or future needs.
Fig. 7A-11 A, The defect and the design for a V-Y advancement flap on the left versus a semicircular flap on the right. Only
a V-Y flap was required. Notice that the design of the V-Y is large enough to fill the underlying bursa that is always
present. A common error is to focus only on the skin defect and design the flap too small to fill the defect, leading to
failure. B, The wound closed after advancement. This required release of the medial origin of the gluteus and release of the
lateral muscle. This maneuver should only be done in nonambulatory patients. The flap should be designed over the entire
gluteus muscle so readvancement of the flap is possible if the pressure sore recurs.
Fig. 7A-12 A, The flap design, which will spare the IGA perforator but sacrifice the SGA perforator to allow advancement.
Note the wide design, which can be readvanced later if the pressure sore recurs. B, The flap advanced and closed without
tension. A larger design allows easier closure of the donor site which can be cheated closed over a longer distance.
Fig. 7A-13 A, The flap was designed to use the lower third to half of the gluteus muscle; this uses the longest portion of
the muscle, which must reach to the contralateral ischial tuberosity. The sigmoidal incision (blue dashed line) provided the
best access to the origin and insertion areas of the muscle. Care was taken to keep the incision within the buttock proper.
B, The muscle was elevated and split, one tongue to go above and one to go below the anal sphincter. Some fascia was
harvested at the insertion site to aid in fixating the muscle after transposition. C, The muscle after transposition. The
remaining gluteus effectively covers the exposed sciatic nerve to pad the area and protect against postoperative irritation.
D, The result is seen 6 months postoperatively with minimal contour deformity; the patient has normal continence.
Fig. 7A-14 A, The patient had thin skin cover, with visible ribs and inverted-T scars from her previous breast reduction
surgery. B and C, Design of the SGAP flap. Note that this patient's excess fat lies superiorly, favoring an SGAP over an
IGAP design. Her reconstruction was performed one side at a time, separated by 4 months.
Fig. 7A-14 D-G, The final result 1 year after revision. The inverted-T scars required vertical inset of the flaps, improving
their projection and shape. The Z-plasty seen on the right breast is a useful maneuver for rounding off a step-off
deformity. H, Donor scars at 1 year postoperatively.
Fig. 7A-15 A-C, Preoperative markings delineate the extent of the dissection. The mastectomy scar was to be opened and the
gluteus flap inset. Markings include the skin island and the fat harvest. D, A section of the inferior gluteus pedicle was
extended proximally to ensure adequate pedicle length. E and F, The free inferior gluteus flap was divided and prepared for
anastomosis. The flap was inset with minimal trimming to provide the best symmetry with the contralateral breast.
Fig. 7A-15 G and I, The patient is shown preoperatively and H and J, 18 months later, after flap thinning and nipple-areolar
reconstruction. Her breast symmetry and softness are acceptable. K and L, Preoperative and postoperative views of the donor
site show the scar in the right buttock crease. Liposuction of her opposite hip was performed at the time of nipple
reconstruction.
Fig. 7A-16 A, A 3 by 5 cm necrotic wound over the sacral area. B, Harvesting a pedicled SGAP flap based on one perforator.
C, The medial part of the flap was deepithelialized and used to fill the depth of the wound. D, The reconstructed result is
seen; function has not been hindered in this ambulatory patient.
Fig. 7A-17 A, The flap and perforators are marked. B, The flap was elevated on the medial perforator with a small muscle
cuff around the perforator. C, The flap was tunneled and ready for inset. D, One year postoperatively, the closure is
stable, and there is minimal donor site scarring.
Fig. 7A-18 A, The patient did not have enough abdominal volume to achieve the C cup breasts she desired. B, However, her
buttocks were ample for creating two C cup breasts. C, A bilateral SGAP breast reconstruction was performed. D and E, The
donor sites retain acceptable contour after harvest of the flaps.
Fig. 7A-19 A, The patient did not have enough abdominal tissue to create two larger breasts. B, She had ample fat in the
inferior buttock area for reconstruction and was an excellent candidate for IGAP flap reconstruction. C, She is shown after
bilateral mastectomies and IGAP breast reconstruction. D, Note the improved buttock contour in the donor sites.
Fig. 7A-20 A, The patient is shown preoperatively. B, Bilateral IGAP flaps were designed and harvested. C, Bilateral nipple-
sparing mastectomies were performed, with IGAP reconstruction of her breasts. D, Note that donor site scars lie in the
inferior buttock creases, and with the IGAP flap, there is no flattening in the upper buttock.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Fig. 7A-21 Incising the thick fascia deep to the gluteus in an SGAP flap. Note that the perforator has been dissected all
the way through the muscle, and there is now fat and fascia surrounding the pedicle.
Personal Experience and Insights
Recommendations
Fig. 7A-22 Beveling to improve the volume harvest in an SGAP flap.
Fig. 7A-23 This photo emphasizes the importance of dissecting parallel to muscle bundles so that perforators (arrow) can be
visualized as they emerge.
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Message
EXPERT COMMENTARY
Indications
Take-Away Messages
Bibliography With Key Annotations
Section 7B Gluteal Thigh Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7B-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 7B-2
FLAP HARVEST
Design and Markings
Fig. 7B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 7B-4 The gluteal thigh flap is elevated to the gluteal crease and inferior border of the gluteus maximus muscle.
FLAP VARIANT
Extended Flap
Fig. 7B-5
ARC OF ROTATION
Fig. 7B-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 7B-7 A, Initial presentation of the wound without evidence of granulation or any wound healing. B, The gluteal thigh
flap was elevated as an island flap, keeping all attachments to the underlying inferior gluteal vessels but incising the
entire skin paddle to facilitate rotation. C, The inferior gluteal artery pedicle was identified and spared. D, The patient
is seen 3 months postoperatively with a healed, sensate reconstruction. Note the skin grafting of the donor site required
for closure.
Fig. 7B-8 A, Design of the gluteal thigh flap. The inferior gluteal artery was identified with handheld Doppler, and the
length of the flap was designed to cross the midline. B, The gluteal thigh flap is elevated to the inferior edge of the
gluteus muscle. C, Identification of the inferior gluteal artery pedicle and the posterior femoral cutaneous nerve. No
gluteal muscle was elevated. D, A large amount of tissue can be carried with this flap. The tissue is viable and easily
reaches past the midline.
Fig. 7B-8 E, The flap was inset to resurface the skin defect and to provide some fill of the dead space with well-
vascularized tissue. Although two flaps were initially contemplated, one flap was adequate. Note that the proximal portion
of the flap was not incised to maintain attachment and provide improved venous egress and lymphatic connections. The cone of
rotation (dog-ear) is large but necessary initially for best blood supply to the flap. F, Oblique view shows that the flap
was transposed via a direct incision, and a skin graft was required for closure. The patient healed uneventfully and did not
require secondary revisions.
Fig. 7B-9 A, At laparotomy: there was no vaginal vault and there were no external perineal incisions. Two gluteal thigh
flaps were designed for sensate total vaginal vault reconstruction. B, The flaps were inset after passing them through a
subcutaneous tunnel and attaching them to each other to reform a vaginal vault. The flap on the left can be seen. The donor
sites were closed primarily, and no revisions were required.
Fig. 7B-10 A, The patient's condition was complicated by recurrent fistulas. B, Bilateral gluteal thigh fasciocutaneous
flaps were designed to provide coverage before postoperative radiation therapy was initiated. C, The neurovascular pedicle
was identified at the inferior border of the gluteus maximus muscle. D and E, The bilateral flaps were tunneled beneath
intact skin bridges that separated the wounds from the bases of the flaps. F, Delayed flap compression led to flap necrosis
from the pressure of the overlying skin bridge at the base of the pedicle. Complete release of the intervening skin bridge
might have prevented venous congestion and ultimate partial flap loss.
Fig. 7B-11 A, The patient's soft tissue defect is seen. B and C, Bilateral gluteal thigh fasciocutaneous flaps were designed
and elevated; the ablative procedure was performed through a perineal approach. D, Flap inset allowed primary closure. E,
Excellent healing is evident at 6 months postoperatively.
Fig. 7B-12 A, The defect is shown; the patient had undergone radiation therapy and posterior exenteration for advanced
carcinoma of the prostate. B, The patient had both urinary and fecal diversion. C and D, Gluteal thigh fasciocutaneous flaps
were designed and elevated to provide both soft tissue fill for the large pelvic defect and closure of the skin defect. E
and F, Early and late results demonstrate uneventful healing.
Fig. 7B-13 A, The defect is shown. B, Multiple local procedures had failed to correct the recurrence of the fistula. C and
D, A unilateral gluteal thigh fasciocutaneous flap was designed and elevated to provide soft tissue separation of the rectum
from the distal urinary tract and external skin replacement of the perianal skin. E, Closure of the wound.
Fig. 7B-14 A, She underwent abdominoperineal resection, a posterior vaginectomy, and wide soft tissue resection of the
perineum. B and C, A single vertical rectus abdominis myocutaneous flap was found to be insufficient to provide vaginal
reconstruction and soft tissue reconstruction of the perineal defect.
Fig. 7B-14 D-F, Bilateral gluteal thigh fasciocutaneous flaps were used to close the remainder of the perineal wound. G,
Long-term results were favorable and allowed functional vaginal reconstruction and stable wound closure despite a
postoperative course of radiation therapy.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Take-Away Messages
Bibliography With Key Annotations
Section 7C Scapular/Parascapular Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7C-1 A, The blood supply of the scapular system. B, The circumflex scapular artery is seen exiting the triangular
space. The orientations of the four major dorsal thoracic fascia flaps are outlined, each based on its discrete and usually
consistent tributary: anterior (inframammary extended circumflex scapular); ascending (ascending scapular); descending
(parascapular); horizontal (scapular). C, The subscapular artery arises from the third portion of the axillary artery on its
inferior margin. It divides into the circumflex scapular artery and the thoracodorsal artery.
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 7C-2
FLAP HARVEST
Design and Markings
Fig. 7C-3 A, Outline of the scapular and parascapular flaps based on the scapular cutaneous artery and parascapular
cutaneous artery, respectively. These are both terminal branches of the descending branch of the circumflex scapular artery,
seen exiting through the triangular space. B, The triangular space can usually be identified by palpation. An approximate
location can be marked at the lateral border of the scapula, two fifths the distance interiorly on a line connecting the
midportion of the spine of the scapula to its inferior angle.
Patient Positioning
Fig. 7C-4
GUIDE TO FLAP DISSECTION
Fig. 7C-5 A, A scapular flap is outlined with the distal portion of the flap extending to the midvertebral line overlying
the medial border of the scapula. B, Initial dissection of the scapular flap from lateral to medial, with identification of
the circumflex scapular pedicle emerging from the triangular space. Once this is identified, the remainer of the flap can be
quickly elevated.
FLAP VARIANTS
Adipofascial Flap
Osteocutaneous Flap
Fig. 7C-6 A, The teres minor muscle and a portion of the teres major muscle are excised, exposing the periosteum on the
dorsal surface of the scapula. Osteotomies are then performed, harvesting the lateral edge of the scapula. The serratus
muscle inserting on the costal surface of the lateral border is cut, preserving its attachment to the inferior angle.
Fig. 7C-6 B, The composite osteocutaneous flap is isolated on its vascular pedicle. Because of the lengthy vascular pedicle
to the bone edge and the additional pedicle length to the skin island, placement of the bone and cutaneous paddle is
facilitated by movement in three dimensions.
Fig. 7C-6 C, Initial dissection begins laterally with identification of the circumflex scapular pedicle. D, The area of bone
harvest on the medial scapula is determined and the flap in this area is left attached. Osteotomies can then be performed.
Fig. 7C-6 E, The scapular osteocutaneous flap is isolated on its vascular pedicle and is observed for continuous perfusion.
The rhomboid major and serratus anterior muscles are then reattached to the medial portion of the scapular bone through
multiple drill holes.
Bone-Only
ARC OF ROTATION
Standard Flap
Fig. 7C-7 The arc of rotation for any variant is around the circumflex scapular pedicle.
FLAP TRANSFER
Pedicle Flap
Free Flap
FLAP INSET
Pedicle Flap
Free Flap
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 7C-8 A, The preoperative defect requiring skin and some soft tissue replacement. There were no bony defects and no
intraoral communication. B, The flap was harvested and anastomosed to the facial artery and vein. A small extension of the
defect was required for the microscopic connection. C, The back donor scar is seen 1 year postoperatively. D, The final
appearance after one revision with liposuction and skin excision (lateral view) and, E, oblique view is seen 3 years
postoperatively.
Fig. 7C-9 A, Scalp wound with exposed bone. The periphery is marked for pathologic margins. Soft tissues including the outer
table of skull were resected. B, The wound was dressed with Integra matrix wound dressing, awaiting final negative margins.
C, A template of the wound was created and used in the design. Handheld Doppler was used to confirm the location of the
circumflex scapular artery; the design included this point and both the transverse and the descending branches. The dotted
line outlines the scapula for reference only.
Fig. 7C-9 D, The flap is elevated and pedicle length is maximized by following the vessels into the triangular space and
dividing the thoracodorsal vessels. E, The flap inset. Exploration of the superficial temporal vessels showed inadequate
size for anastomosis, so an A-V loop was constructed to anastomose to the facial artery and vein. A small skin graft was
placed near the pedicle to decrease the pressure on the pedicle that was experienced with primary closure. F, The donor scar
is seen 2 months postoperatively. G, The final result at 2 years. A small recurrence was resected and skin was grafted. No
revisions were required, because the flap tolerated the radiation well, improving the final contour with contraction.
Fig. 7C-10 A, This defect was complex, with the floor of the mouth, full-thickness lip, chin pad, and anterior mandible
removed. A reconstructive bar was placed before resection for correct contour, then replaced after the resection. B, Lateral
view of defect. C, A template of the defect was used to design the flap. Such a large design will encompass both transverse
and descending branches of the circumflex scapular artery so orientation is based more on areas of skin laxity. (Xs denote
Doppler points; the dotted line the scapula; FOM is the planned floor of the mouth, and the arrow indicates the planned
direction that the pedicle will go once inset.) D, The flap elevated with approximately 12 cm of lateral bone and the
relatively independent skin paddle. The angle of the scapula was not harvested.
Fig. 7C-10 E, The bone was osteotomized in two locations to conform to the reconstructive plate. The muscular soft tissue
cuff was maintained to vascularize the segments. F, A strip of fascia lata was used to support the lower lip reconstruction
to maintain oral competence postoperatively. The fascia lata was inset into the modiolus bilaterally. Such support is
required for such a large flap. G, Final inset of flap. H, The reconstruction is seen 1 month postoperatively. The patient
has oral competence and intelligible speech. I, He has good lower lip position when he opens his mouth and a good aperture.
J, The early lateral contour is good and will improve over time.
Fig. 7C-11 A, A grade III tibia-fibula fracture with exposed bony nonunion after debridement. A preoperative angiogram
showed that all vessels to the foot were patent, so the posterior tibial system was prepared for recipient vessels. B, Flap
design. The X marks the Doppler point of the circumflex scapular artery. Interestingly, laser angiography showed the
perforators perfusing the dotted areas preferentially. A template from the leg helped design the flap to encompass the
perforator and the areas it perfused best. C, Flap inset with one artery and two venous anastomoses to the posterior tibial
system. The extra triangle of the flap over the anastomosis allows a tension-free closure over the anastomosis. D, Final
flap result seen 4 months postoperatively, ready for secondary bone grafting.
Fig. 7C-12 A, Original crush injury after demarcation. B, After transmetatarsal amputation and dressing changes. No further
necrosis was evident, so soft tissue coverage was performed with a scapular flap. C, Inset of the flap with arterial
anastomosis to the anterior tibial artery and a venous anastomosis to the lesser saphenous vein. D, Back donor site, which
was skin grafted, seen 5 months postoperatively. (NOTE: Remaining bilateral back tattoo was removed from this photograph to
protect patient identity.) E, Final result at 5 months postoperatively (AP view). F, Lateral view.
Fig. 7C-13 A, Axillary defect 1 week after debridement of infected tissues and daily dressing changes. B, Parascapular flap
design. X marks the Doppler point of the circumflex scapular artery. The flap was designed to the specifications of the
defect and to allow primary closure of the donor site. C, Flap inset. Tension is borne by the donor closure. There should be
no tension on the flap skin closure. D, The result is seen 2 months postoperatively with the arm abducted; E, at 6 months
with the arm extended. F, Back donor scar at 6 months postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Personal Experience and Insights
Complications
Bibliography With Key Annotations
Section 7D Lumbar Perforator Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7D-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 7D-2 A, Arterial system and B, artery and bone are shown in these posterior views of three-dimensional reconstructions
of the pelvic region from a human cadaver angiographic injection specimen. (1 Lumbar artery; 2 superior gluteal artery.) C,
Interior view and D, angiogram of the soft tissues of the gluteal region. (L3 and L4, Third and fourth lumbar arterial
perforators; 1, anterior branch of the fourth lumbar arterial perforator; 2, posterior branch of the fourth lumbar arterial
perforator; 3, ascending branch of the superior gluteal artery; IGA, inferior gluteal artery; SGA, superior gluteal artery;
green arrow, anterior superior iliac spine; red arrow, greater trochanter; blue arrow, gluteal fold.)
FLAP HARVEST
Design and Markings
Fig. 7D-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 7D-4 Flap elevated from lateral to medial, with the perforator at the base of the flap medially and the correct
underlying muscles of the lumbar back.
FLAP VARIANT
Free Flap
ARC OF ROTATION
Fig. 7D-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 7D-6 A, Preoperative and B, postoperative views. Bilateral implant removal and capsulectomies were performed, followed
by redo breast reconstruction with lumbar artery perforator (LAP) flaps and subsequent deep inferior perforator (DIEP) flap
stacked overlay of her LAP flaps to achieve desired volume and skin replacement. C, The hip donor site is seen before and D,
after LAP flap harvest, with associated truncal contour change.
Fig. 7D-7 A, The patient is seen preoperatively and B, postoperatively after bilateral prophylactic mastectomies with
immediate lumbar artery perforator (LAP) flap reconstruction. C, Before and D, after views of the of hip donor site
following LAP flap harvest, with associated truncal contour change.
Pearls and Pitfalls
EXPERT COMMENTARY
Advantages and Limitations
Recommendations
Fig. 7D-8 CT angiography demonstrating the course of the lumbar perforator into the overlying soft tissue.
Fig. 7D-9 Preoperative markings for bilateral lumbar perforator free flaps with associated Doppler signal points.
Fig. 7D-10 Surgical exposure of the lumbar perforator.
Fig. 7D-11 Flap with both lumbar perforator and superior gluteal perforator dissected out in its base.
Take-Away Messages
References
Bibliography With Key Annotations
Section 7E Trapezius Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7E-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 7E-2
Fig. 7E-2
FLAP HARVEST
Design and Markings
Fig. 7E-3
Patient Positioning
Fig. 7E-4
GUIDE TO FLAP DISSECTION
Fig. 7E-5
Fig. 7E-5
FLAP VARIANTS
Myocutaneous Flap
Dorsal Scapular Artery Perforator Flap
Fig. 7E-6 A, Emergence of the lower trapezius cutaneous perforator. B, Dorsal scapular perforator island flap. The trapezius
muscle is split, and the rhomboid major is divided.
Fig. 7E-6 C, Cadaver specimen focusing on the left shoulder. The lower trapezius muscle was transected distally and flipped
over medially. The belly of the muscle is seen, with the superficial or muscular branch of the DSA piercing the rhomboid
major muscle and attached to the undersurface of the trapezius muscle (arrow). D, The dissection was carried deeper. The
deep branch of the DSA is noted (arrow). E, The trapezius muscle has been completely elevated from its lateral insertion
(the lower and main portions). One can clearly see the independent perfusion of the lower part and main portion. The dorsal
scapular artery appears from under the omohyoid and levator scapulae muscles (arrow). The deep branch of the DSA runs on the
medial border of the scapula. The rhomboid muscle was resected.
Extended Lateral Flap
Osseous Flap
ARC OF ROTATION
Muscle Flap
Fig. 7E-7
Myocutaneous Flap
Dorsal Scapular Artery Perforator Flap
Fig. 7E-8
Extended Lateral Flap
Fig. 7E-9
FLAP TRANSFER
Muscle Flap
Myocutaneous Flap
Dorsal Scapular Artery Perforator Flap
Extended Lateral Flaps
FLAP INSET
All Variants
DONOR SITE CLOSURE
Muscle Flap
Myocutaneous Flap and Dorsal Scapular Artery Perforator Flap
Extended Lateral Flap
CLINICAL APPLICATIONS
Fig. 7E-10 A, Preoperative appearance of the wound with some residual skin graft. B, The defect after resection with no
evidence of cancer recurrence. C, Design of the vertically oriented myocutaneous flap. Note that the skin design completely
overlies the muscle for best vascularity. D, After flap elevation. Only a vertical strip of muscle that contains the
transverse cervical branches is included with the flap. The dorsal scapular perforator was divided. E, Closeup of the
feeding transverse cervical pedicle at the base of the neck. This was the limit of flap mobilization in this case.
Fig. 7E-10 F, Flap transposed through a generous subcutaneous tunnel. G, Flap inset without tension. Primary closure of the
back was obtained. H, The patient is seen at 1-month follow-up.
Fig. 7E-11 A, Site of chronic wound and sinus and markings for the trapezius muscle. B, Defect after aggressive debridement
and elevation of a vertical strip of muscle that includes the transverse cervical vascular pedicle and spares the superior
fibers of the trapezius muscle. C, Muscle transposed through a subcutaneous tunnel. D, After primary closure of both donor
and recipient sites. The patient healed uneventfully.
Fig. 7E-12 A, Preoperative view of his latest cancer recurrence with exposed irradiated scalp. The dotted line denotes the
proposed wide excision of the tumor. The patient's medical comorbidities precluded treatment with free tissue transfer. B,
Design of the extended trapezius flap to reach the scalp defect. C, Flap elevated with inclusion of the dorsal scapular
artery perforator to maximize blood supply of the distal flap. D, Demonstration of arc of rotation. E, Flap inset after
passing it through a generous subcutaneous tunnel. The donor site was closed primarily.
Fig. 7E-13 A, The inferior portion of the right trapezius muscle was released from its origins from the thoracic spinous
processes and elevated out of its bed as the most superficial muscle of the back. B, The muscle flap was transposed after
vertical division of the muscle (yellow arrow) lateral to the transverse cervical vessels. C, The muscle flap was then
transposed nearly 180 degrees clockwise and used to cover the dural reconstruction and hardware and to fill the dead space
following tumor resection.
Fig. 7E-14 A, The resection defect was reconstructed with a dural substitute patch, hardware for spinal stabilization, and
allograft bone chips. B, The lower half of the bilateral trapezius muscles were divided from their origins from the thoracic
spinal processes and elevated in an inferior to superior direction. C, The transverse cervical pedicles were not dissected,
and the muscles were divided vertically (yellow arrows) lateral to their pedicles. The arc of rotation easily allowed the
muscle flaps to reach any upper back or neck midline wounds up to the nuchal line superiorly. D, The muscle flaps were inset
over the dural patch and around the spinal rods and screws. E, The result is seen 3 months postoperatively.
Fig. 7E-15 A and B, A trapezius myocutaneous flap was elevated, preserving the upper trapezius muscle. C, The flap was
brought to the back of the neck through a subcutaneous tunnel. The donor site was closed primarily. D, Both the donor and
recipient sites healed well, with no functional deficit.
Fig. 7E-16 A and B, A pedicled trapezius myocutaneous flap was elevated, preserving the upper trapezius muscle. C and D, The
flap was rotated to cover the exposed spinal cord and hardware. E, A well-healed flap at 3-month follow-up.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
Fig. 7E-17 Bilobed flap design.
Take-Away Messages
Bibliography With Key Annotations
Section 7F Latissimus Dorsi Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7F-1
ANATOMY
Arterial Anatomy (Type V)
Venous Anatomy
Nerve Supply
Fig. 7F-2 A, Cadaveric dissection demonstrating the branching pattern of the vascular and neural supply of the latissimus
flap seen on the underside of the muscle. Understanding of the pattern can allow muscle splitting for a partial muscle
sparing approach. B, Anterior view of the dominant pedicle after release of the origin and insertion.
Fig. 7F-2 C, Posterior view of the dominant pedicle after release of the origin and insertion. D, Posterior surface of the
flap. E, Radiographic view.
FLAP HARVEST
Design and Markings
Fig. 7F-3
Patient Positioning
Fig. 7F-4
GUIDE TO FLAP DISSECTION
Fig. 7F-5
Fig. 7F-5
Fig. 7F-5
FLAP VARIANTS
Reverse Flap
Fig. 7F-6
Muscle-Sparing Flap
Fig. 7F-7 A, Schema for muscle splitting based on transverse and oblique branch pattern of the thoracodorsal pedicle. B,
Design of skin paddle on the lateral muscle. C, The muscle is exposed and marked for splitting. D, The muscle has been
split. The lateral muscle will carry the skin paddle, and the superomedial muscle is preserved.
Thoracodorsal Artery Perforator (TDAP) Flap
Fig. 7F-8 A and B, TDAP design. The perforators overlie the course of the thoracodorsal artery.
Fig. 7F-8 C and D, Pedicle dissection demonstrating the serratus branches and the thoracodorsal perforator to the skin,
which can be used to dissect the TDAP flap with no muscle included in the flap. E, Intraoperative view.
Chimeric Flap
Functional Muscle Transfer
ARC OF ROTATION
Standard Flap
Fig. 7F-9
Fig. 7F-9
Fig. 7F-9
Reverse Flap
Fig. 7F-10
Fig. 7F-10
FLAP TRANSFER
Standard Flap
Reverse Flap
FLAP INSET
Pedicle Flap
Free Flap
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 7F-11 A, The patient requested autologous-only reconstruction for the right breast. B, A myocutaneous latissimus flap
with subscarpal extended fat harvest was chosen, with the flap design in the relaxed skin tension lines. C-E, The results
are shown 6 month postoperatively. F, Donor site at 6 months.
Fig. 7F-12 A, A Wise pattern breast reduction was planned for the left breast, and a partial skin-sparing mastectomy for the
right breast. B, The skin design chosen was an oblique pattern, maximizing the amount of tissue transferred for building the
mound and not requiring an implant. C, The result is seen 9 months postoperatively with excellent symmetry in shape and
volume. D, Donor scar at 9 months. Although the thicker scar and contour deformity did not bother the patient, this
illustrates the difference from a transverse skin paddle in natural relaxed skin tension lines, which leaves a better scar
and minimal contour deformity.
Fig. 7F-13 A, Preoperative appearance. B, The chest wall and abdominal wall specimen, including diaphragm. C, Clinical
defect. The chest, abdomen, and diaphragm were first repaired with Gore-Tex mesh. D, Contralateral chimeric latissimus and
serratus flaps on their thoracodorsal pedicle. E, Flaps were inset after microsurgical revascularization to the neck. The
omentum was used to close the inferior portion of the wound, all of which was skin grafted. F, Postoperative appearance at 6
months, with no bulges or hernias.
Fig. 7F-14 A and B, Appearance of the heel with missing soft tissue and exposed calcaneus and fascia. C, Latissimus free
flap design based on a template of the foot defect. D, Latissimus free flap inset. Excess muscle was skin grafted and the
bulk was left for 4 months, when it was directly debulked. E, Three months after debulking.
Fig. 7F-15 A, The patient had threatening implant extrusion in the left breast and underwent salvage with a latissimus flap.
B, A transverse flap design was used in the relaxed skin tension line. C-E, Her result is shown 2 years postoperatively. F,
Her donor scar is seen 3 weeks postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Anatomic Considerations
Recommendations
Take-Away Messages
Bibliography With Key Annotations
Section 7G Paraspinous Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 7G-1
ANATOMY
Arterial Anatomy (Type IV)
Venous Anatomy
Nerve Supply
Fig. 7G-2 A, Laser angiogram with indocyanine green of the paraspinous muscles in a patient following explantation of
Harrington rods. Both paraspinal muscle masses are shown, indicating medial and lateral perforator rows. The lateral
perforators have been exposed after advancement of the medial edge of the muscles toward the midline following longitudinal
incision of the paraspinous fascia. B, Segmental blood supply of the paraspinous muscle demonstrated in this latex injected
fresh tissue cadaver.
FLAP HARVEST
Design and Markings
Fig. 7G-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 7G-4 A, Typical upper midline back defect amenable to repair with paraspinal muscle flaps. B, The trapezius and
latissimus muscles are elevated with the skin to expose the surface of the paraspinal muscles. C, The muscular fascia is
incised and the muscle is bluntly dissected, mobilizing it toward the midline. Here, bilateral flaps have been mobilized and
advanced centrally for total muscle coverage under the skin flap advancement and closure.
ARC OF ROTATION
Fig. 7G-5 Medial advancement of the paraspinal muscles to reach the midline occurs by freeing of the superficial, lateral,
and deep attachments and by muscle rotation centrally. Visualization of the vascular pedicle is not necessary.
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 7G-6 A, Dorsal spinal wound of the thoracic region before explantation of hardware. B, Radiograph of spinal hardware.
C, Open midline spinal wound after explantation of Harrington rods. D, Elevation of the trapezius muscle cranially and the
paraspinal fascia and medial border of latissimus dorsi caudally. E, Lateral paraspinal perforators passing through the
paraspinal muscles and entering the medial border of the latissimus dorsi.
Fig. 7G-6 F, The trapezius and latissimus dorsi muscles were elevated to reveal the length of the paraspinal muscles from
cervical to lumbar regions. G, Medial traction was placed on the paraspinal muscles after release of the dorsal muscle
fascia 5 cm parallel to the midline. H, The paraspinal muscles were closed in the midline. I, The trapezius muscles
approximated. J, Final skin closure with drains inserted.
Fig. 7G-7 A, Back wound showing extruding hardware in the lower thoracic region. B, The wound was debrided, with exposure of
the hardware in the thoracic spine. C, The wound was closed with bilateral paraspinal muscle flaps, augmented with
medialization of the right latissimus dorsi origin. D, The healed wound is seen 3 weeks postoperatively.
Fig. 7G-8 A, The debrided wound is seen after repeated washout procedures by the neurosurgical service. B, Right paraspinal
flap mobilized and advanced across the midline. C, The midline was closed with bilateral paraspinal flaps using the keel
inversion technique. D, The skin incision was closed.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
Bibliography With Key Annotations
Chapter 8 Upper Extremity
Section 8A Lateral Arm Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 8A-1
Fig. 8A-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 8A-2
FLAP HARVEST
Design and Markings
Fig. 8A-3 With the patient either standing or supine, a line is drawn from the deltoid insertion to the lateral epicondyle
of the humerus. This line represents the central axis of the flap. It also delineates the lateral intermuscular septum and
the course of the PRCA.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 8A-4 A, Flap elevation begins with a posterior incision that is carried down through the deep fascia of the arm.
Dissection proceeds from posterior to anterior in the subfascial plane until the lateral intermuscular septum is
encountered. Dissection more proximally exposes the PRCA, the posterior cutaneous nerve of the forearm, and the lower
lateral cutaneous nerve of the arm. The radial nerve is also identified as it passes through the intermuscular septum.
Fig. 8A-4 B, The anterior margin of the flap is incised down to and through the deep fascia overlying the brachialis muscle
and the brachioradialis muscle. Dissection proceeds in the subfascial plane posteriorly.
Fig. 8A-4 C, The lateral intermuscular septum with the attached cutaneous paddle is then dissected from the humerus in a
distal to proximal direction.
FLAP VARIANTS
Extended Lateral Arm Flap
Fig. 8A-5
Reverse Flap
Fascial Flap
Osteocutaneous Flap
Fig. 8A-6 A, An osseous segment may be included with the cutaneous flap. An incision is made through a portion of the
lateral head of the triceps muscle adjacent to the lateral intermuscular septum. A posterior osteotomy is then performed. B,
With the flap retracted posteriorly, an incision is made through a portion of the brachialis and brachioradialis muscles
adjacent to the lateral intermuscular septum. The anterior osteotomy is then performed. Care must be taken to avoid injury
to the radial nerve, which must first be identified and retracted.
Vascularized Nerve Graft
ARC OF ROTATION
Standard Flap
Fig. 8A-7
Extended Flap
Reverse Flap
Fig. 8A-8
FLAP TRANSFER
Standard, Extended, and Reverse Flaps
Free Flap
FLAP INSET
DONOR SITE CLOSURE
All Flaps
CLINICAL APPLICATIONS
Fig. 8A-9 A, The defect is seen after wide excision of the patient's recurrent adenoma; the excision included sacrifice of
the facial nerve. B, Flap design. The flap width was based on the defect size and the desire to close the donor primarily.
C, The flap is elevated and ready for transfer.
Fig. 8A-9 D, After flap inset with anastomosis to the facial artery and vein. E, Two months postoperatively, the patient is
seen in frontal view with good early contour. F, Lateral view. The color match on the face is not ideal. Without
postoperative irradiation, hair growth may be an issue in some patients, requiring ancillary laser treatment. G, Donor site.
The resulting scar can be unsightly but is preferable to a skin-grafted donor site.
Fig. 8A-10 A, The patient's dorsal hand avulsion injury resulted in skin and extensor tendon loss, with multiple open
metacarpal fractures. B, Open reduction and internal fixation of metacarpal fractures were performed after the wound was
debrided. C, A template of the skin deficit was designed with proper orientation of the vascular pedicle. D, A line was
drawn from the deltoid insertion to the lateral epicondyle that corresponded to the lateral intermuscular septum. The
predesigned template of the deficit was centered and marked over the main axis of the flap along the intermuscular septum.
E, Flap dissection started posteriorly, over the triceps brachii muscle and tendon. F, An easy plane of dissection was
carried out between the triceps brachii muscle epimysium and the lateral arm flap deep fascia.
Fig. 8A-10 G, The pedicle was visualized along its entire course within the lateral intermuscular septum after posterior
flap dissection. H, Anterior dissection of the flap was performed, and the pedicle was identified within the lateral
intermuscular septum. The posterior cutaneous nerve of the forearm (arrow) can be seen entering the flap and was preserved.
I, The pedicle was separated from its humeral attachment within the lateral intermuscular septum. J, The lateral arm flap
was harvested. K, The flap was inset into the dorsal hand wound after extensor tendon reconstruction. Tendon grafts were
passed through the subcutaneous layer of the flap. L and M, Range of motion 6 months postoperatively. N, The patient had
hypoesthesia in the proximal lateral aspect of the forearm from transection of the posterior cutaneous nerve of the forearm.
Fig. 8A-11 A, Preoperative image of patient's injuries. B, The first webspace was released, with pinning of the first
metacarpal. C, A lateral arm free flap was designed; note the sterile tourniquet. D, The flap after dissection; the pedicle
is located to the left. The arrow points to the radial nerve. E, The immediate postoperative result is shown. F and G,
Twelve years postoperatively, her release and motion are demonstrated.
Fig. 8A-12 A and B, The patient's burn injuries are seen preoperatively. C, The palm after release of the contracture.
Anastomoses were performed to the radial artery and cephalic vein in the anatomic snuffbox on the dorsal wrist. D and E,
Intraoperative views of the release. F and G, The results are shown at 6 months postoperatively.
Fig. 8A-13 A, Preoperative view. B, Markings for distally pedicled lateral arm flap for elbow defect. There was a strong
Doppler arterial signal in the distal vessel at the level of the lateral epicondyle. C, The flap after dissection. The
distal pedicle is shown to the left, with a microvascular clamp on the proximal pedicle to evaluate flow to the flap through
the retrograde circulation. D, The flap after inset. The donor site was closed primarily. E, Healing of the flap at 4 months
postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications
Take-Away Message
Bibliography With Key Annotations
Section 8B Brachioradialis Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 8B-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 8B-2
FLAP HARVEST
Design and Markings
Fig. 8B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 8B-4
FLAP VARIANT
Free Flap
ARC OF ROTATION
Fig. 8B-5
FLAP TRANSFER
Standard Flap
Free Flap
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 8B-7 A, The defect after resection. The area of CSF leak was in the posterior orbit after exenteration. The facial
vessels were exposed in the neck as the recipient site. B, The flap has been elevated. The larger skin paddle is for
external skin coverage, the smaller for palatal repair. The long vascular pedicle will reach the neck without vein grafts or
an A-V loop. The cephalic vein has been taken with the flap as well. C, The undersurface of the flap is shown, with the
brachioradialis muscle carried with the flap based on perforators from the radial artery. D, After flap inset. The muscle
nicely covered the area of CSF leak, which healed uneventfully. E, Two months postoperatively, the flap has settled nicely,
which is desirable if the patient will ultimately wear a prosthesis. F, Final result with external prosthesis in place.
Fig. 8B-7 A, Lateral soft tissue defect with exposed and ground-down lateral epicondyle. B, Dissection of the
brachioradialis muscle. C, The muscle was elevated and D, rotated into the defect.
Fig. 8B-7 E, The donor site incision was closed for exposure and the muscle was transposed and sutured into the recipient
bed. F, The muscle was covered with a split-thickness skin graft. G, The flap reconstruction is seen 1 month
postoperatively. H and I, At 6-month follow up, the patient has good extension and flexion of the elbow.
Pearls and Pitfalls
EXPERT COMMENTARY
Anatomic Considerations
Fig. 8B-8 The brachioradialis is shown disinserted distally. The muscle origin from the distal lateral humerus is seen on
the left side of the photo. Vascular pedicles from the radial recurrent artery are shown entering the muscle belly at the
proximal third-middle third junction.
Recommendations
Fig. 8B-9 Medial side view of the brachioradialis showing the relationship of the vascular pedicles deep to the radial nerve.
Take-Away Messages
Bibliography With Key Annotations
Section 8C Posterior Interosseous Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 8C-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 8C-2 The distally based posterior interosseous flap can be designed based on the anterior interosseous artery
perforator and is dependent on the arcade of vessels running between the anterior interosseous artery and the posterior
interosseous artery, between the extensor digiti minimi and extensor carpi ulnaris. Flaps can also be based on individual
perforators of the posterior interosseous artery.
FLAP HARVEST
Design and Markings
Fig. 8C-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 8C-4
Fig. 8C-4
Fig. 8C-4
Fig. 8C-4
FLAP VARIANT
Reverse Flap
Fig. 8C-5
Fig. 8C-5
Fig. 8C-5
Fig. 8C-5
ARC OF ROTATION
Standard Flap
Fig. 8C-6
Reverse Flap
Fig. 8C-7
FLAP TRANSFER
Standard and Reverse Flaps
FLAP INSET
All Types
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 8C-8 A and B, The tumor was resected widely to include the radial artery and radial sensory nerve and the tendons of
the abductor pollicis longus, flexor carpi radialis, and extensor pollicis brevis muscles. C and D, A reverse pedicled PIA
perforator flap was designed to cover the soft tissue defect. E, The radial artery was reconstructed with a vein graft. The
tendon defects of the abductor pollicis longus, flexor carpi radialis, and extensor pollicis brevis muscles were
reconstructed using a palmaris longus graft. A reversed posterior interosseous pedicled flap was raised. F, The PIA
perforator flap was inset in the defect. G and H, The result is seen 2 years and 10 months after surgery. There is no radial
sensory nerve irritation, the vein graft to the radial artery is patent, and the skin color and contour match are excellent.
Fig. 8C-9 A and B, The patient had undergone previous surgery for closure of the left interdigital space and separation of
the syndactyly of the two radial digits. C, The surgical plan was to widen the first interdigital space and remove the
second metacarpal bone. A PIA flap was planned for coverage of the soft tissue defect created by the widened first web
space. D and E, The PIA perforator flap was elevated and transposed into the first web space soft tissue defect. F-I, The
flap healed well, with primary closure of the donor site. The results are shown 5 months postoperatively, with improved
function, good color match, and an acceptable donor site scar.
Fig. 8C-10 A, The first web space defect is shown. B, A distally based PIA flap was designed at the junction of the proximal
and middle thirds of the extensor forearm. C, The flap was incised on the radial and ulnar sides down through the
antebrachial fascia and dissected to the pivot point approximately 5 to 6 cm proximal to the distal radioulnar joint. It was
elevated in a proximal to distal fashion, while carefully noting the cutaneous perforators within the septocutaneous fascia
between the extensor digiti minimi and the extensor carpi ulnaris muscles. The posterior interosseous artery was elevated at
the base between these muscles. The proximal end of the feeding vessel to the flap was ligated as it exited distal to the
supinator muscle. The flap was tunneled into position. D and E, The flap and donor site are shown after inset. The donor
site was closed primarily. F and G, Early postoperative results show good range of motion with adequate preservation of the
first web space.
Fig. 8C-11 A, The appearance of the wound after debridement. B, Radiograph of the amputation through the midmetacarpal
level. C, The PIA flap was designed between the distal radioulnar joint and the lateral epicondyle. Flap dimensions were 15
by 10 cm. D and E, The flap was elevated on the posterior forearm and transposed into position. F and G, The healed flap
provides complete wound closure. There were no complications.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Fig. 8C-12 The posterior interosseous flap designed in the forearm.
Bibliography With Key Annotations
Section 8D Radial Forearm Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 8D-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 8D-2
FLAP HARVEST
Design and Markings
Fig. 8D-3 A, The territory of this flap extends from below the antecubital crease proximally to the wrist flexion crease
distally. The distal width is from the extensor hallucis longus tendon radially to the extensor carpi ulnaris tendon
ulnarly. The proximal width is from the lateral to medial humeral epicondyles. B, A fasciocutaneous flap can be designed and
placed proximally centrally or more distally on the forearm. Middle positioning is useful if the recipient pedicle is of
suitable length and improves aesthetics by avoiding the wrist crease. Most perforators are in the distal half of the
forearm. Proximal positioning is useful when designing a reverse-flow flap. C, An average flap measures 5 to 8 cm wide and 8
to 10 cm long. The flap is designed so that the lateral third of the flap is located lateral to the course of the radial
artery.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 8D-4 A, An incision is made along the proximal radial margin of the flap, including the deep fascia. Branches of the
cephalic vein are identified and protected. The brachioradialis muscle is retracted toward the radius, exposing the radial
artery, its venae comitantes, and the superficial branch of the radial nerve, which lies more laterally in the lateral
intermuscular septum.
Fig. 8D-4 B, Dissection continues in an ulnar to a radial direction beneath the deep fascia until the lateral intermuscular
septum on the lateral aspect of the flexor carpi radialis is located. Dissection is then carried between the flexor carpi
radialis muscle and the lateral intermuscular septum to the anterior surface of the radius. The radial artery is visible
within the lateral intermuscular septum.
Fig. 8D-4 C, Distal dissection.
Fig. 8D-4 D, The flap is isolated on the proximal neurovascular pedicle.
FLAP VARIANTS
Reverse Radial Forearm Flap
Fig. 8D-5
Adipocutaneous Flap (Suprafascial Harvest)
Fascial Flap
Osteofasciocutaneous Flap
Fig. 8D-6
Fig. 8D-7 An osseous segment of radius may be included with the fasciocutaneous flap. A, The skin flap design is similar to
that of the fasciocutaneous flap. B, At approximately 1 to 1.5 cm medial to the lateral intermuscular septum, the bellies of
the pronator quadratus muscle and flexor pollicis longus muscles are identified and the perforators of the radial artery to
the skin are noted and spared. C, The skin incision is extended proximally to dissect the pedicle and the cephalic vein
proximally.
Fig. 8D-7 D, The pronator quadratus and flexor pollicis longus muscles are incised down to bone, and a longitudinal
osteotomy is made on both sides of the attachment to the radius, harvesting 30% of the radius while maintaining vascular
perforators from the radial artery.
Myocutaneous Flap
Tendinocutaneous Flap
Fig. 8D-8
Vascularized Nerve Flap (Superficial Radial Nerve)
Flow-Through Flap
ARC OF ROTATION
Standard, Adipocutaneous, and Fascial Flaps
Fig. 8D-9
Reverse Flap
Fig. 8D-10
FLAP TRANSFER
Standard Flap
Reverse Flap
Free Flap
FLAP INSET
Pedicle Flap
Free Flap
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 8D-11 A, Chronic open wound with exposed dead bone. Dots show the planned skin resection. B, A radial forearm free flap
(6 by 9 cm) was used to resurface the defect with microscopic anastomosis to the dorsalis pedis vessels. C, Side-by-side
donor and recipient sites at 4 months postoperatively.
Fig. 8D-12 A, After completion of the right hemiglossectomy with a lymph node dissection on the right side of the neck. B, A
3 by 7 cm radial forearm flap was elevated with the lateral antebrachial cutaneous nerve for reinnervation of the flap. C,
After flap inset and arterial anastomosis to the facial artery and venous anastomosis between the vena comitans and a branch
of the internal jugular vein. The lateral antebrachial cutaneous (LABC) nerve was anastomosed to the transected lingual
nerve. D, The result is seen 4 months postoperatively with the patient in repose, and E, with protrusion of the tongue. F,
The donor site 4 months after primary closure.
Fig. 8D-13 A, Preoperative view of the lesion. B, The resulting 80% full-thickness defect of the lower lip. C, A
tendinocutaneous flap was planned using the palmaris longus, which was not present. Instead, the flexor carpi radialis
tendon was harvested to support the skin paddle which would line the outside and inside of the lower lip. The LABC nerve was
also harvested with the flap for reinnervation. D, The flap in position for anastomosis of the vessels in the neck, tendon
into the commissure, and nerve to the mental nerve stump. E, Immediately after inset.
Fig. 8D-13 F, Flap at 1 year postoperatively, ready for revision. The patient required an aggressive debulking and a
reconstruction of the vermilion. G, The flap was debulked directly and quilting sutures were placed. A facial artery
myomucosal (FAMM) flap was thought to be too bulky for vermilion reconstruction, so a free buccal graft was harvested. H,
Immediately after debulking and buccal graft placement. I, Three months after debulking and grafting, the patient is seen in
repose and J, with an open mouth. Microstomia was avoided by adding the radial forearm flap. Lip competence was ensured by
using the vascularized tendon graft. The aesthetic of the vermilion was reestablished with a simple buccal graft.
Fig. 8D-14 A, The dorsal wound after debridement and external fixator pin placement. B, Hand radiograph showing bony loss.
C, Planned reverse radial forearm flap, centered over the radial artery. D, The flap was elevated and transposed through a
short subcutaneous tunnel. It is not unusual to have some venous congestion after transposition. E, The patient had
cancellous bone grafting at 2 months postoperatively and is seen 6 months later (dorsal view) and F, (volar view) without
any other revisions.
Fig. 8D-15 A, The preoperative defect, with loss of midface support and no separation between mouth and nasal cavity. B, The
radial forearm flap with cephalic vein and vascular pedicle isolated, attached skin paddle, and exposed radius ready for
osteotomy (dashed line). C, After bilateral bone inset to the neighboring maxilla. D, The skin paddle was first used to
reconstruct the palate by suturing to the remaining mobile soft palate. The skin was then wrapped around the bone and used
to line the nasal floor. The midportion of the flap was deepithelialized and the lip segment was inset. E, At 4 weeks
postoperatively, the intraoral view shows that the flap is viable and growing hair. F, A lateral skull radiograph
demonstrates the bony reconstruction holding out the soft tissues of the maxilla at proper length, preventing the common
postmaxillectomy appearance of a retruded midface.
Fig. 8D-16 A, The defect after resection. The area of CSF leak was in the posterior orbit after exenteration. The facial
vessels were exposed in the neck as the recipient site. B, The flap was elevated. The larger skin paddle was for external
skin coverage, the smaller for palatal repair. The long vascular pedicle will reach the neck without vein grafts or A-V
loop. The cephalic vein was taken with the flap as well. C, The undersurface of the flap demonstrating the brachioradialis
muscle carried with the flap based on perforators from the radial artery. D, After flap inset. The muscle nicely covered the
area of CSF leak, which healed uneventfully. E, Two months postoperatively, the flap has settled nicely, which is desirable
if a prosthesis will ultimately be worn. F, Final result with an external prosthesis in place.
Fig. 8D-17 A, Preoperative view of the lip. Skin taken from areas distant to the face are often a poor color and texture
match. Mustache reconstruction is a good camouflage procedure, although this is obviously not possible in women, who can use
concealing cosmetics. B, The planned flap. Allowance was made for loss of some arc of rotation because of the rotation and
placement through a tunnel. A Doppler probe localized the vessels, which were then marked. It is critical to plan the flap
with hair growth in the desired direction. The flap was first incised, partially elevated, and delayed. C, Two weeks after
delay. The flap was passed through a subcutaneous plane. The outer skin of the lip reconstruction was resected and replaced
with the scalp flap. D, The flap 1 week postoperatively and E, 4 months postoperatively the upper lip color maintained a
pink hue as a result of intraoral exposure over time, and no graft was required.
Fig. 8D-18 A and B, The patient is seen preoperatively. C, A template was marked for the flap to restore the nasal floor
lining, vestibule, and columella. The flap is oriented so that the radial vascular pedicle lies directly beneath the
posterior edge of the floor element. D and E, The flap was delayed to selectively redirect dermal perfusion from the
posterior edge of the floor element to the vestibular and columellar elements.
Fig. 8D-18 F, The nasal site was prepared by excision of all diseased and scarred nasal lining. Access to the nasal lining
was via the intraoral approach through a labial gingival sulcus incision. G, Before transfer, the component elements of the
flap were assembled anatomically. The flap was then vascularized to the facial artery and vein. H, Immediate postoperative
view of the flap inset. Additional contouring procedures were required at 3 and 6 months postoperatively. I and J, The
patient is shown 13 months after microsurgical transfer of the forearm flap.
Fig. 8D-19 A and B, The patient is seen preoperatively. C, A two-island radial forearm free flap was planned for restoration
of the nasal lining. D, After microsurgical transfer, the flap elements were assembled anatomically and inset into the
defect.
Fig. 8D-19 E and F, After inset of the radial forearm flap islands, the elements were braced with small matchstick grafts of
cadaver allograft cartilage to prevent shrinkage in the interim between lining restoration and definitive coverage with the
forehead flap. The undersurface of the vestibular flap element was temporarily covered with a full-thickness skin graft,
which was placed directly over the cartilage allografts. G and H, The patient is shown 18 months after a forehead flap
procedure (performed by Dr. G. Burget) and placement of supporting autologous rib cartilage grafts for definitive structural
support. A free anterior lateral thigh flap was also transferred to the patient's left cheek to restore soft tissue volume.
Fig. 8D-20 A and B, The patient is seen preoperatively. C and D, The initial approach to reconstruction was restoration of
the nasal vestibular lining, left nostril floor, and adjacent cheek, composing the nasal base. A two-island flap based on
the volar forearm was designed to address the missing soft tissue elements. After elevation, the flap was debulked and then
transferred to the facial site, where vascular repairs were made to the recipient facial artery and vein. E and F, Immediate
postoperative view of transferred radial forearm flap. The flap islands were articulated anatomically and the exposed
vestibular element undersurface was closed with a full-thickness skin graft.
Fig. 8D-20 G and H, The healed lining flaps are shown 8 weeks postoperatively. I, Ten weeks after microsurgical transfer,
the patient returned for the second stage of the reconstruction. The skin graft covering the vestibular element was removed
and the flap was debulked to the level of the dermis. J, After debulking, autologous costal cartilage grafts were placed to
support the dorsum, tip, ala, and nasal side wall. K-M, A paramedian forehead flap was then placed to provide external nasal
cover. The patient will return in 6 to 8 weeks for debulking of the forehead flap and selective placement of cartilage
grafts to achieve the desired final shape and contour before division of the pedicle.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Recommendations
Postoperative Care
Complications
Take-Away Messages
References
Bibliography With Key Annotations
Section 8E Flexor Carpi Ulnaris Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 8E-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 8E-2
FLAP HARVEST
Design and Markings
Fig. 8E-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 8E-4
FLAP VARIANTS
Tendon Transfer Flap
Fasciocutaneous Flap With Flexor Carpi Ulnaris and With Flexor Carpi Ulnaris and Ulna
ARC OF ROTATION
Fig. 8E-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATION
Fig. 8E-6 A, Surgical wound at presentation. B, The wound was surgically debrided. C, The flexor carpi ulnaris was
harvested. D, The muscle was rotated 180 degrees to cover the olecranon and distal prosthesis. E, The healed wound is seen 6
months postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Anatomic Considerations
Fig. 8E-7 Vascular pedicles from the ulnar artery to the flexor carpi ulnaris.
Fig. 8E-7 Proximal vascular pedicles to flexor carpi ulnaris from ulnar recurrent artery (most proximal pedicle) and ulnar
artery (second most proximal pedicle).
Recommendations
Fig. 8E-8 Fanfolded flexor carpi ulnaris muscle.
Take-Away Messages
Bibliography With Key Annotations
Section 8F Ulnar Forearm Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 8F-1 A, A common interosseous artery arises within 2 cm of the brachial bifurcation. Flap placement and dissection are
located distal to this artery, which remains intact. B, The basilic vein receives tributaries from the dorsal venous arch on
the ulnar aspect of the back of the hand. It ascends on the ulnar aspect of the forearm accompanied in the distal third by
the ulnar branch of the medial antebrachial cutaneous nerve. C, Sensory innervation of the ulnar forearm flap is based on
the medial antebrachial cutaneous nerve branches, which are associated with the basilic vein proximally.
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 8F-2 A, Dissection of the ulnar artery flap skin paddle is started from radial to ulnar and is performed in a
suprafascial plane to minimize donor site morbidity. B, The dissected ulnar artery is seen coursing within the intermuscular
septum between the flexor digitorum superficialis and flexor carpi ulnaris muscles. Note cutaneous perforators to the volar
ulnar forearm skin and multiple muscle perforators to the flexor carpi ulnaris and flexor digitorum superficialis muscle
bellies. The retracted flexor digitorum superficialis muscle belly shows multiple muscle, myocutaneous, and cutaneous
perforators originating from the ulnar artery. The ulnar artery runs within the intermuscular septum between the flexor
carpi ulnaris and the flexor digitorum superficialis and is intimately bound to the ulnar nerve. The ulnar artery
perforators are predominantly myocutaneous in the proximal forearm, and mostly septocutaneous in the distal forearm. C, The
ulnar artery flap is harvested based on five cutaneous perforators. As the ulnar artery runs deeper within the intermuscular
septum between the flexor digitorum superficialis and flexor carpi ulnaris muscle bellies, the cutaneous perforators become
longer from distal to proximal. Note the suprafascial harvest of the ulnar artery flap to minimize donor site morbidity.
FLAP HARVEST
Design and Markings
Fig. 8F-3 The location of the ulnar artery distally is marked by the line connecting the medial epicondyle of the humerus
and the pisiform bone. This is confirmed by Doppler ultrasonography. The flap design should have at least one third of the
skin paddle radial to this line and should include the basilic vein.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 8F-4 A, The flap is raised radial to ulnar, with early identification of the ulnar artery and nerve distally and the
basilic vein and medial antebrachial cutaneous nerves proximally.
Fig. 8F-4 B, The flap is further dissected to the intermuscular septum containing the perforators to the skin. The ulnar
artery is divided distally, and any branches to surrounding muscles are also divided.
Fig. 8F-4 C, The ulnar side of the flap is incised and elevated toward the septum. Retraction of the flexor carpi ulnaris
exposes the ulnar pedicle, facilitating dissection. Muscular branches are divided.
Fig. 8F-4 D, Dissection then proceeds from distal to proximal, extending the dissection of the pedicle proximally as needed
for vessel diameter and length. The ulnar nerve is left within its bed, deep to the flexor carpi ulnaris.
FLAP VARIANTS
Fasciocutaneous Flap With Flexor Carpi Ulnaris
Fig. 8F-5 The flexor carpi ulnaris muscle is included with the cutaneous paddle.
Fasciocutaneous Flap With Flexor Carpi Ulnaris and Ulna
Fig. 8F-6 An osseous segment of ulna may be included in the flap. A portion of the flexor carpi ulnaris muscle is included
with this myoperiosteal branch, which supplies the osseous segment.
Flow-Through Flap
ARC OF ROTATION
Standard Flap
Fig. 8F-7
FLAP TRANSFER
Standard Flap
Free Flap
FLAP INSET
Pedicled Flap
Free Flap
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 8F-8 A, The wound defect is seen with exposed bone. B, Ulnar artery flap design. C, The ulnar artery flap was elevated
and the donor site skin grafted. D, The flap has been inset and wound closed.
Fig. 8F-9 A, The patient's tongue cancer is seen preoperatively. B, The ulnar artery skin flap inset is seen
postoperatively. C and D, Donor site.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Personal Experience and Insights
Recommendations
Take-Away Message
Bibliography With Key Annotations
VOLUME TWO
Chapter 9 Hand
Section 9A Abductor Digiti Minimi Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9A-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 9A-2
FLAP HARVEST
Design and Markings
Fig. 9A-3 Marking for flap incision (dashed line = alternate incision).
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 9A-4
FLAP VARIANT
Huber Opponensplasty
Fig. 9A-5 Huber abductor digiti minimi opponensplasty. Two incisions are required to expose and transfer the abductor digiti
minimi muscle. The neurovascular structures enter the muscle proximally on its deep and radial aspect. The muscle is freed
from the other hypothenar muscles, and its origin on the pisiform bone is elevated while preserving a tendinous attachment
to the tendon of the flexor carpi ulnaris. The abductor digiti minimi is then rotated 180 degrees on its long axis and
passed subcutaneously to the area of the thumb metacarpophalangeal joint. The distal attachment is to the abductor pollicis
brevis muscle.
ARC OF ROTATION
Fig. 9A-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATION
Fig. 9A-7 A, Resection of the ulnar head. B, The flap was harvested through an incision placed at the glabrous-nonglabrous
skin junction. The muscle was then used to C, obliterate the dead space and D, skin grafted with an unmeshed split-thickness
graft. E, The result is shown at 6 months with irradiation of the infection.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Recommendations
Bibliography With Key Annotations
Section 9B Great Toe (Hallux) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9B-1
ANATOMY
Arterial Anatomy (Type A)
Venous Anatomy
Nerve Supply
Fig. 9B-1
Fig. 9B-2
FLAP HARVEST
Design and Markings
Fig. 9B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 9B-4
Fig. 9B-4
Fig. 9B-4
Fig. 9B-4
Fig. 9B-4
FLAP VARIANTS
Wrap-Around Flap
Standard Wrap-Around Flap
Fig. 9B-5
Fig. 9B-6
Fig. 9B-6
Fig. 9B-6
Modified Wrap-Around Flap
Fig. 9B-7
First Dorsal Web Space Sensory Cutaneous Flap
Fig. 9B-8
ARC OF ROTATION
Standard Flap
Fig. 9B-9
Extension of Pedicle Length
FLAP TRANSFER
FLAP INSET
Standard Great Toe Transplant to Thumb Position
Bone
Fig. 9B-10
Nerve Repair
Fig. 9B-11
Vascular Repair
Fig. 9B-12
Tendon Repair
Closure
Fig. 9B-13
Wrap-Around Flap
Fig. 9B-14
First Dorsal Web Space Cutaneous Sensory Flap
Microvascular Transplantation
Transposition Flap
DONOR SITE CLOSURE
Standard Great Toe Transplant
Fig. 9B-15
Wrap-Around Flap
Fig. 9B-16
Modified Wrap-Around Flap
Fig. 9B-17
First Dorsal Web Space Cutaneous Sensory Flap
CLINICAL APPLICATIONS
Fig. 9B-18 A, Dorsal and B, volar appearance of the proximal thumb preoperatively. C, The trimmed toe was designed from the
nondominant foot. The pedicle position is easier if the toe can be harvested from the ipsilateral foot. However, it is more
important to harvest from the nondominant foot. D, Dissected trimmed toe. E, Harvested trimmed toe.
Fig. 9B-18 F, Exposed proximal stump of the amputated thumb, all structures identified for reconstruction. G, Dissected
princeps pollicis artery. H, The results are seen at 1 year postoperatively with opposition of the thumb to the ring finger,
I, the thumb's dorsal appearance and flexion, and J, the thumb's volar appearance and extension and abduction.
Fig. 9B-19 A, Distally based dorsal soft tissue avulsion. B, Volar soft tissue injury at presentation. C, Dorsal soft tissue
after debridement of necrotic tissue. D, Dorsal and E, volar appearance of the thumb after debridement. F, Dissected wrap-
around flap. G, Harvested wrap-around flap.
Fig. 9B-19 H, Dorsal and I, volar intraoperative views of reconstruction. J, At 14-month follow-up, satisfactory abduction
and extension of the thumb can be seen. K, Flexion and opposition of the reconstructed thumb. L, Comparative appearance to
the contralateral thumb in flexion, and M, comparative appearance to the contralateral thumb in extension.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
Take-Away Messages
Reference
Bibliography With Key Annotations
Section 9C Homodigital Neurovascular (Littler) Island Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9C-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 9C-2
FLAP HARVEST
Design and Markings
Fig. 9C-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 9C-4
Fig. 9C-4
FLAP VARIANT
Modified Oblique Triangular Neurovascular Island Flap (Evans and Martin Stepladder Advancement Island Flap)
Fig. 9C-5 Stepladder advancement island flap for fingertip closure.
ARC OF ROTATION
Fig. 9C-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 9C-7 A, Lateral distal tip defect involving the right long finger. B, Design and markings for a neurovascular island
digital flap for stable coverage. C, Flap dissection and island solely on the radial neurovascular bundle. D, The flap could
be advanced up to 1.5 cm following adequate neurovascular pedicle dissection. E and F, Stable coverage was obtained with
final flap inset. The patient had instant identical two-point discrimination for tip pinch.
Fig. 9C-8 A and B, This 18-year-old male patient had an avulsion crush injury to the right long finger with an exposed
distal phalanx and inadequate coverage. C-E, A neurovascular island flap was used to cover the distal tip and provide stable
coverage.
Fig. 9C-9 A-E, Littler neurovascular island flap.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
Complications: Avoidance and Treatment
Take-Away Messages
Bibliography With Key Annotations
Section 9D Second Toe Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9D-1
ANATOMY
Arterial Anatomy (Type A)
Fig. 9D-1
Venous Anatomy
Nerve Supply
Fig. 9D-2
FLAP HARVEST
Design and Markings
Fig. 9D-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap (Second Toe to Hallux)
Fig. 9D-4
Fig. 9D-4
Fig. 9D-4
Fig. 9D-4 Dominant pedicle: First dorsal metatarsal artery (D)
Fig. 9D-4
Fig. 9D-4
Fig. 9D-4
Short Transfer
Fig. 9D-5
Joint Transplantation
Fig. 9D-6
Double Transfer (Second and Third Toes)
Fig. 9D-7
Fig. 9D-7
FLAP VARIANTS
Segmental Transposition
Vascularized Bone
Sensory Flap
ARC OF ROTATION
Standard Flap
Fig. 9D-8
FLAP TRANSFER
FLAP INSET
Second Toe to Thumb
Bone
Fig. 9D-9
Fig. 9D-9
Nerve Repair
Fig. 9D-10
Vascular Repair
Fig. 9D-11
Tendon Repair
Fig. 9D-12
Closure
Second and Third Toe Transplants (Double Digit)
DONOR SITE CLOSURE
Fig. 9D-13
CLINICAL APPLICATIONS
Fig. 9D-14 A, The thumb had been amputated at the base of the proximal phalanx. B-D, The appearance and function of the
thumb is seen 4 months after reconstruction with a second toe transfer.
Fig. 9D-15 A, The patient's index, middle, and ring fingers were amputated at various levels. B, Both second toes were
harvested for replantation. C, The function and appearance of the reconstructed hand are shown 6 months after surgery. D,
The donor site is shown 3 years postoperatively.
Fig. 9D-16 A, Distal index finger amputation. B, The distal second toe was harvested. C, Appearance of the reconstructed
distal index finger 1 year after surgery. D and E, The function of the reconstructed index finger is shown.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Recommendations
Personal Experience and Insights
Complications: Avoidance and Treatment
Take-Away Messages
Bibliography With Key Annotations
Section 9E Dorsal Metacarpal Artery Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9E-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 9E-2
FLAP HARVEST
Design and Markings
Fig. 9E-3
Patient Positioning
GUIDE TO FLAP DISSECTION
First Dorsal Metacarpal Artery (FDMA) or Kite Flap
Fig. 9E-4
Fig. 9E-4 (B through E from Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY.)
Reverse Dorsal Metacarpal Artery (DMA) Flap
Fig. 9E-5
Reverse Metacarpal Artery Perforator Flap (Quaba Flap)
Fig. 9E-6 A, CT angiogram showing the dorsal metacarpal arteries and their multiple interconnections along their course. B,
Cadaver latex injection study demonstrating the dorsal metacarpal arteries and the interconnections at the metacarpal head,
the basis for the Quaba flap.
Fig. 9E-6 C, Quaba flap arterial supply. D, Extended Quaba flap arterial supply. E, Latex injected cadaver showing dissected
dorsal metacarpal artery flap. One can see the blood supply of either an anterograde or retrograde flap and the basis of a
perforator based flap. F, Closeup of the interconnection of the volar and dorsal arterial systems providing the basis for a
retrograde flap.
Fig. 9E-6
Fig. 9E-6
Extended Dorsal Metacarpal Artery Flap
Fig. 9E-7 A, Division of the usual perforator of the DMA flap, which allows shifting of the pivot point distally.
Fig. 9E-7 B, Two DMA flaps transposed, the long finger with a skin paddle and some exposed pedicle, and the ring finger with
transposed fascia and subcutaneous tissue. C, The blood supply is demonstrated in the ring finger. D, Flaps are inset with
skin grafting of the pedicle in the long finger and the flap in the ring finger.
COMPOSITE DORSAL METACARPAL ARTERY FLAPS
First Dorsal Metacarpal Artery Flap With Extensor Tendon
Fig. 9E-8
Sensate Dorsal Metacarpal Artery Flap
Fig. 9E-9 Origin and course of the first dorsal metacarpal artery and dorsal sensory branches of the radial nerve.
ARC OF ROTATION
First Dorsal Metacarpal Artery Flap
Fig. 9E-10
Reverse Dorsal Metacarpal Artery Flap
Fig. 9E-11
Dorsal Metacarpal Artery Perforator Flap
Extended Dorsal Metacarpal Artery Flap
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 9E-12 A, The wound was open and contaminated, and located on the dorsal aspect of the proximal phalanx of the left
middle finger. The EDC tendon was exposed. B, The wound was radically debrided outside the zone of injury. This allowed
immediate flap coverage and helped minimize any risk of secondary infection from residual devitalized tissue, and
contamination. Partial loss of the exposed EDC tendon was noted. C, The tendon was repaired, and the clean wound was ready
for coverage. D, A second DMA flap was designed based on a cutaneous perforator located just proximal to the juncturae
tendinum. It should not extend proximal to the dorsal wrist crease. This flap will easily cover the dorsal proximal phalanx
and proximal interphalangeal joint. The pivot point was the perforator between the second and third metacarpal heads,
located with a handheld Doppler probe. A skin pinch test was used to confirm primary donor site closure. E, The flap was
inset with loose sutures and with no tension or pressure on the flap. Stable, well-vascularized wound coverage was achieved.
This flap allowed early, active range of motion, which is especially important in a manual worker.
Fig. 9E-13 A, The flap was designed over the index proximal phalanx and MCP joint. B, The flap was elevated and transferred
to the dorsal thumb defect. C, Neurovascular pedicle showing perivascular soft tissue cuff. D, The flap was inset into the
dorsal defect and the donor site was covered with a full-thickness skin graft.
Fig. 9E-14 A, Closeup of the defect. B, A reverse FDMA flap (reverse kite flap) was designed. C, The flap was rotated into
the defect and inset. D, The donor site was closed primarily.
Fig. 9E-15 A, Closeup of the defect. B, A typical cutaneous tail was designed. The DMA was marked after Doppler
identification. C, Flap harvest was almost complete. The paratenon was left intact. All other tissues, including the
interosseous muscle fascia, were included in the flap pedicle. D, The harvested flap is shown. The supplying perforating
vessel from the common digital artery was identified in the web space (arrow). E, After the tourniquet was released,
perfusion appeared to be excellent, with no signs of venous congestion. F, The flap was rotated to fit perfectly into the
defect while excellent perfusion was maintained.
Fig. 9E-16 A, The defect in the ring finger could be skin grafted. The defect in the middle finger required flap
reconstruction. B, An extended DMA flap with a cutaneous tail was designed. C, The perforator supplying the conventional DMA
flap was clipped. The flap relied on the perforators from the proper digital artery supplying the vascular network in the
web space. D, After the tourniquet was released, the flap had excellent perfusion. E, The flap was rotated into the defect.
F, The cutaneous tail design allowed tension-free skin-skin closure. G, The flap is seen several days postoperatively with
excellent healing. H, The skin graft to the ring finger showed complete take. I, The patient demonstrates active range of
motion 10 days postoperatively.
Fig. 9E-17 A and B, Closeup views of the defect. C, The wound is shown after radical debridement. D, A long, extended DMA
flap with a cutaneous tail was designed. The tourniquet was released. The arrow shows the pivot point in the distal web
space.
Fig. 9E-17 E, The flap was sutured in place. Because of the cutaneous tail design, no tunneling was required. F, The donor
site was closed primarily. G and H, Healing was excellent 12 days postoperatively with no signs of venous congestion or
partial flap loss.
Fig. 9E-18 A, Closeup view of the defect. B and C, The defect was reconstructed with a DMA flap. Twelve weeks after surgery,
contour was excellent. No debulking was required.
Fig. 9E-19 A, A DMA flap was sutured over the exposed joint. B, The flap healed well.
Fig. 9E-20 A, Flap design. B, DMA from a grafted area. C, The donor site was reconstructed with a split-thickness skin graft.
Fig. 9E-21 A, The skin of the dorsum of the hand appeared to be too thick to use for coverage of the proximal phalanx
defect. Therefore a fascial DMA flap was designed. B, After rotation into the defect, the flap was covered with a split-
thickness skin graft.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Anatomic Considerations
Personal Experience and Insights
Take-Away Messages
References
Bibliography With Key Annotations
Section 9F Cross-Finger Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9F-1
ANATOMY
Arterial Anatomy (Type A)
Venous Anatomy
Nerve Supply
Fig. 9F-2 A, Cadaveric dissection of cross-finger flap. B, Closeup of digital bundle with perforating vessels supplying the
flap. The proximal incision showing the feeding digital bundle is for demonstration purposes only.
FLAP HARVEST
Design and Markings
Fig. 9F-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 9F-4 A, Dissection begins distal to the flap's pivot point, and the plane of dissection is kept just above the
paratenon layer of the extensor tendon. B, Dissection continues until Cleland's ligament is reached. Dorsal branches of the
proper digital artery will be visible within the flap, as well as the subcutaneous veins. Cleland's ligament can be
transected as needed to increase flap mobilization. C, The flap is inset under minimal tension to the volar aspect of the
adjacent index volar tip defect.
Fig. 9F-4 D, Cross-sectional anatomy of a standard flap and inset with relation to the neurovascular bundle and skin graft.
FLAP VARIANTS
Reverse Cross-Finger Flap
Fig. 9F-5 A, Design and B, elevation of a reverse cross-finger flap, with the plane of dissection just under the dermis to
preserve the underlying subcutaneous tissue. C, The adipofascial flap is rotated similar to the standard cross-finger flap
shown in A. This provides a vascularized bed for a full-thickness skin graft. The reverse flap, elevated at the dermis
level, is returned to its bed, effectively forming a partially vascularized full-thickness graft itself.
Fig. 9F-6 A, The reverse cross-finger flap is detached on the contralateral side and elevated off the paratenon. B,
Harvested reverse cross-finger flap in situ. C, Reverse cross-finger transfer and closure of the donor site with the
previously elevated skin flap.
Innervated Cross-Finger Flap
ARC OF ROTATION
Fig. 9F-7
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 9F-8 A, Appearance of volar aspect of the metacarpophalangeal joint with significant flexion contracture and limited
range of motion. B, Resulting soft tissue deficit after contracture release and excision of scar tissue and exposure of
neurovascular bundle. C, Cross-finger flap based on the dorsal aspect of the adjacent middle finger. Note oblique axis of
the cross-finger flap to achieve a longer arc of rotation to cover the proximal ring finger volar soft tissue defect. D, The
cross-finger flap was harvested from lateral (distal to the flap hinge point) to medial. The extensor tendon paratenon was
carefully preserved to support a skin graft for donor site closure. The plane of dissection was kept within an avascular
areolar tissue plane, which was easily defined.
Fig. 9F-8 E, The final aspect is seen after flap elevation with preservation of the extensor tendon paratenon, which next
could be covered with either a split-thickness or full-thickness skin graft. F, Before insetting the cross-finger flap, a
full-thickness skin graft was applied to the donor site for ease of insetting. The exposed pedicle was also skin grafted to
prevent desiccation, and this was excised at the time of flap division-inset. G, Final flap inset with no tension. H and I,
One week postoperatively, the patient was allowed to begin light active range of motion to minimize any joint stiffness. J,
Three weeks postoperatively, the cross-finger flap was divided and excess tissue was trimmed or rearranged, as needed.
Fig. 9F-9 A, The patient underwent flexor tendon reconstruction, pulley reconstruction, and ulnar and radial digital nerve
grafting and was left with a soft tissue defect that was resurfaced with a cross-finger flap. B, A template of the defect
was taken to better assess the cross-finger design and size required. C, The template size and orientation was placed on the
donor site for accuracy of design. note: A larger cross-finger flap should always be harvested to prevent tension and
account for soft tissue variables. The entire skin unit from the dorsal middle phalanx was harvested. D, The cross-finger
flap elevation began distal to the pivot/hinge point of the flap, and dissection was kept above the paratenon. The extensor
paratenon was kept moist during the procedure to prevent inadvertent desiccation. E, Before cross-finger flap inset, the
donor site was skin grafted with a full-thickness skin graft harvested from the ipsilateral thigh. F and G, Final aspect of
the donor site and recipient sites. H, Appearance of the cross-finger flap 3 months after division and inset, with good
contour and color match.
Fig. 9F-10 A, The injury resulted in loss of soft tissue, partial loss of the eponychial fold, and an exposed distal
interphalangeal joint. B and C, Reverse cross-finger flap and crescent dermal flap for soft tissue coverage and
reconstruction of the eponychial fold. D, The skin flap was elevated above the subcutaneous tissue layer. The base of the
raised skin flap is contralateral to the reverse cross-finger flap pivot/hinge point. E, The crescent flap was
deepithelialized and the contralateral aspect of the cross-finger flap was incised. F, The reverse cross-finger flap was
inset into the defect, and the dermal portion of the flap was used to reconstruct the eponychial fold. G, A split-thickness
skin graft was used to cover the reverse cross-finger flap.
Fig. 9F-11 A, The defect and the elevated cross-finger flap are shown. The digital vessels have not been exposed in the
base. B, The flap was inset without tension into the defect in the small finger. C, Volar view. D, The dorsum and exposed
flap were skin grafted with a full-thickness skin graft from the groin, seen here healing well at 2 weeks postoperatively.
E, Division and inset, performed 2 weeks after initial placement. F, The result is seen 4 months postoperatively, with good
cosmesis and function.
Fig. 9F-12 A, The injury is shown with flexor tendons exposed. B, Design of a conventional cross-finger flap on the dorsum
of the ring finger. C, The flap was raised under loupe magnification; a tourniquet was used. The paratenon of the extensor
tendon was preserved to guarantee graft take for donor site reconstruction. D, The flap fit perfectly into the defect and
was temporarily fixated with stay sutures. E, The flap was sutured in. After release of the tourniquet, the flap showed
excellent perfusion.
Fig. 9F-13 A, The situation is seen following debridement with exposed flexor tendon. B, Design of the cross-finger flap
over the middle phalanx of the middle finger. C, The flap had excellent perfusion at the end of the operation. D, The
patient was able to perform active motion with the flap still attached 10 days postoperatively. E, Fourteen days
postoperatively, the flap is well healed.
Fig. 9F-14 A and B, The patient's hand is seen after division of the flap. Note the ugly appearance of the donor site after
reconstruction with a thick split-thickness skin graft and the granulation tissue at the site of flap division. C, Aesthetic
appearance of the recipient site at the palmar aspect of the middle phalanx of the index finger. D, Function of the
reconstructed index finger and the middle finger 12 months postoperatively. E, The aesthetic appearance of the donor site is
excellent at the patient's 12-month follow-up.
Pearls and Pitfalls
EXPERT COMMENTARY
Advantages and Limitations
Recommendations
EXPERT COMMENTARY
Indications
Anatomic Considerations
Flap Design
Recommendations
Fig. 9F-15 A, Typical indication for a cross-finger flap: volar defect with exposed flexor tendons.
Fig. 9F-15 B, The dorsal nerve can be included to facilitate neural reconstruction. The laterodorsal cutaneous veins in the
base of the pedicle are preserved. The paratenon is preserved to guarantee skin graft take. C, A thin full-thickness graft
is used to achieve good cosmetic appearance of the donor site. D, The flap is secured with sutures or buddy taping.
Take-Away Messages
References
Bibliography With Key Annotations
Section 9G Kleinert-Atasoy V-Y Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9G-1
ANATOMY
Arterial Anatomy (Type A)
Venous Anatomy
Nerve Supply
Fig. 9G-2
FLAP HARVEST
Design and Markings
Fig. 9G-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 9G-4
FLAP VARIANT
Kutler Bilateral Advancement Flaps
Fig. 9G-5
ARC OF ROTATION
Fig. 9G-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
Fig. 9G-7
CLINICAL APPLICATION
Fig. 9G-8 A, The width of the nail bed was measured at the level of the amputation. B, The flap should be as wide as the
width of the nail bed at the level of the amputation. C, The flap was undermined distally between the flap and the distal
phalanx. D, The flap was advanced to cover the amputated fingertip. E, V-Y advancement of the lap. F and G, Final result of
the fingertip after healing of the flap, showing good contour.
Pearls and Pitfalls
EXPERT COMMENTARY
Fig. 9G-9 Vascular supply to the pulp of the digit showing the two digital arteries joining to form a common trunk and
branches coming from the common vessel supplying the pulp.
Indications
Recommendations
Advantages of the Flap
Complications
References
Bibliography With Key Annotations
Section 9H Moberg Advancement Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 9H-1
ANATOMY
Arterial Anatomy (Type A)
Venous Anatomy
Nerve Supply
Fig. 9H-2
FLAP HARVEST
Design and Markings
Fig. 9H-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 9H-4
Fig. 9H-4
FLAP VARIANTS
Cupped Moberg Flap
Extended Palmar Advanced Moberg Flap
O'Brien Modification
ARC OF ROTATION
Fig. 9H-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 9H-6 A, Transverse amputation of the right thumb. B, The Moberg thumb palmar advancement flap for reconstruction of
distal tip amputations. Midaxial lines are drawn on the ulnar and radial aspects of the thumb, and dissection is performed
from distal to proximal until enough flap advancement is possible for distal coverage. C, The Moberg flap will allow more
than 1 cm of volar advancement for distal tip coverage. Note that this advancement is done without IP joint flexion and that
further mobilization would be possible with IP joint flexion. D and E, The patient is seen 1 year postoperatively with good
contour and stable coverage of the distal thumb tip and pulp. Note the slight shortening of the amputated thumb. Range of
motion and two-point discrimination are normal.
Fig. 9H-7 A and B, The patient had right thumb pulp atrophy and constant pain with contact following a crush injury to the
thumb. C and D, The Moberg flap was elevated, incorporating both neurovascular bundles into the flap. E, The flap was
incised proximally and converted from an advancement flap to an island flap to achieve further reach for tension-free
coverage. Any closure of the flap under tension may result in a hook-nail deformity. F, The end of the Moberg flap was
cupped in shape to provide better volume, projection, and padding for the distal thumb tip. This was then left to heal by
secondary intention. G, Lateral triangular transposition flaps were used to cover the exposed neurovascular bundle following
flap advancement.
Fig. 9H-8 A, The O'Brien bipedicled flap was modified to include a V-Y advancement flap at the base. B, This allowed
advancement of the flap without the need for excessive IP joint flexion or skin grafting, so the base of the flap could be
closed primarily. C, Final appearance of the thumb 4 months postoperatively with good cosmesis and sensation, and no IP
contracture.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Recommendations
EXPERT COMMENTARY
Personal Experience and Insights
Reference
Bibliography With Key Annotations
Chapter 10 Abdomen
Section 10A Deep Circumflex Iliac Artery (DCIA) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10A-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 10A-2
FLAP HARVEST
Design and Markings
Fig. 10A-3
Patient Positioning
Fig. 10A-4 A, Positioning for a combined ipsilateral harvest and breast reduction. B, The ipsilateral buttock is elevated on
a pillow, rotating the pelvis.
GUIDE TO FLAP DISSECTION
Osseous Flap
Fig. 10A-5 A, Markings for incision of a standard osseous flap.
Fig. 10A-5 B, Division of the external oblique aponeurosis and identification of the vascular pedicle.
Fig. 10A-5 C, Division of the internal and transversus muscles with lateral dissection of the pedicle. Note the division of
the ascending branch of the DCIA.
Fig. 10A-5 D, Intrapelvic course of the deep circumflex iliac artery along the rim of the iliac crest. The line denotes the
level of the iliacus muscle division, sparing the vessel with the harvested flap.
Fig. 10A-5 E, Division of the iliacus internally, the TFL externally, and the distal end of the DCIA with muscle division to
allow elevation of the flap on its pedicle. Bone is exposed for full-thickness iliac bone harvest. F, Elevation of the flap.
FLAP VARIANTS
Osteomyocutaneous Flap
Fig. 10A-6 A, Release of the tensor fascia lata and gluteus medius for a full-thickness osseous flap. B, Dissection
completed. C and D, Variations in iliac crest bone harvest design for mandibular reconstruction.
Fig. 10A-7 A, Division of the iliac fascia and muscle. B, Retroperitoneal dissection to the deep margin of the iliac crest.
C, Deep surface of the flap within the retroperitoneal space. D, Completion of retroperitoneal dissection.
Fig. 10A-7
Myocutaneous Flap
Fig. 10A-8 A, Myocutaneous flap design. B, Division of the internal oblique and transversus muscles with lateral dissection
of the pedicle. C, Flap elevation completed, with release of the muscle origin from the iliac crest and elevation of an
inferior skin island superficial to the tensor fascia lata.
Perforator DCIA Flap
Fig. 10A-9
Internal Oblique Flap
Fig. 10A-10 A, After release of the internal oblique muscle from the iliac crest, the ascending branch of the DCIA is seen,
here as two branches running under the muscle. B, Closeup view. C, Composite osteocutaneous flap with additional internal
oblique muscle.
Fig. 10A-10 D, Anterior surface of the harvested flap. E, Posterior surface.
ARC OF ROTATION
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
Osseous and Osteomyocutaneous Flap
Fig. 10A-11 A, Approximation of the iliac muscle and fascia with the transverse muscle and transversalis fascia. B,
Approximation of the internal and oblique muscles with the gluteal and tensor fascia lata muscles. C, Repair of inguinal
ligament. NOTE: Only nonabsorbable sutures should be used to repair the muscle donor site.
Fig. 10A-11 D, Abdominal muscles sutured to the iliac crest with nonabsorbable sutures placed through a series of drill
holes in the crest. Alternatively, suture anchors can be used.
Myocutaneous Flap
Internal Oblique Flap
CLINICAL APPLICATIONS
Fig. 10A-12 A, The patient is shown preoperatively. B, The DCIA flap was designed. C, The donor site was closed. No bone was
taken. D, She is shown 9 months after a successful free left DCIA flap to the right breast, which has produced good shape
and symmetry. Her breast is soft and supple. E, The posterior view of the donor site shows minor distortion from the DCIA
harvest. Most of the deformity is from her previous inferior gluteal flaps.
Fig. 10A-13 A, A reconstruction plate was prepared before bony resection to maintain proper contour. B, Flap harvest. The
DCIA and DCIV were identified at the donor site. C, The flap consisted of 8 cm of bone stock, which was secured to the
reconstruction plate. Microscopic anastomosis to the neck vessels was performed. D and E, He is seen 1 year postoperatively
with good mandibular symmetry and contour. There were no hernias or bulges at the donor site.
Fig. 10A-14 A, Dissection of a right osteomyocutaneous DCIA flap for right hemimandibular reconstruction. B, Rigid fixation
of the DCIA flap from the mandibular symphysis to the right mandibular angle. C, DCIA skin paddle used to reconstruct the
floor of the mouth. D, Postoperative appearance. E, Postoperative donor site appearance.
Fig. 10A-15 A, Anterior mandibular defect after resection of a squamous cell carcinoma. A right DCIA flap was planned. B,
Right osteocutaneous DCIA perforator flap, with a cuff of muscle around the perforators. C, Because of the patient's body
habitus, the skin paddle was still very bulky and needed to be thinned. D, Early postoperative appearance with the mouth
open, showing the skin paddle.
Fig. 10A-16 A, The patient is seen before reconstruction, following debridement. B, Dissection of a right osseous DCIA flap.
C, Inset of bilateral osseous DCIA flaps to restore the right and left mandible. D, Postoperative appearance, including
reconstruction of the chin skin with an anterolateral thigh perforator flap.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Fig. 10A-17 A, Skin markings for the planned flap, including the location of a cutaneous perforator (indicated by an X at
the center of the flap design), localized with a handheld Doppler ultrasound probe, about 6 cm posterior to the ASIS. B, The
cutaneous perforator is visible through the fascia, indicated by the forceps. C, Fully dissected osteocutaneous DCIA
perforator flap.
Postoperative Care
References
Bibliography With Key Annotations
Anatomic Studies
Clinical Series
Flap Modifications
Complications
Section 10B Rectus Abdominis and TRAM/DIEP Flaps
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10B-1 Dominant pedicles: Superior epigastric artery; deep inferior epigastric artery
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 10B-1 D, Longitudinal cross-section of chest and abdomen showing the varied sources of blood supply to the rectus
abdominis muscle and its perforators. E, Upper abdominal cross-section demonstrating the interconnection of the superior
epigastric and lateral intercostal systems.
Vascular Anatomy
Fig. 10B-2 Anatomic variations in epigastric circulation choke vessels within the rectus muscle.
Fig. 10B-3
Fig. 10B-3 m, Myocutaneous perforating vessels from deep epigastric artery; u, umbilicus
TRAM Zones
Fig. 10B-4 A, Hartrampf's zones I through IV. B and C, Laser angiography showing superior perfusion to zone I, the area
encompassed by the primary angiosome of the rectus abdominis perforators.
FLAP HARVEST
Design and Markings
Vertical (VRAM)
Fig. 10B-5
Transverse (TRAM)
Fig. 10B-6
Thoracoepigastric
Fig. 10B-7
Patient Positioning
GUIDE TO RECTUS MUSCLE-ONLY FLAP DISSECTION
Fig. 10B-8 A and B, Superiorly based pedicle before and after dissection.
Fig. 10B-8 C and D, Inferiorly based pedicle before and after dissection.
FLAP VARIANTS
Pedicled Vertical Rectus Abdominis Myocutaneous (VRAM) Flap
Fig. 10B-9
Fig. 10B-9
Thoracoepigastric Flap
Fig. 10B-10
Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
Fig. 10B-11 A, A skin-sparing mastectomy has been performed. The upper TRAM incision has been deepened to the fascia. B, The
umbilicus is circumferentially freed. C, The flap is elevated from lateral to medial with identification of the lateral row
perforators just medial to the semilunar line. D, The row of lateral perforators is exposed. The lateral fascia is opened,
and the muscle is dissected directly. E, After division of the pubic insertion and the DIEA and DIEV vessels, the hemiflap
is transposed to the chest through a tunnel connecting the abdominal donor to the chest recipient.
Fig. 10B-11 F, The ipsilateral pedicle on the left rotates 90 to 180 degrees counterclockwise. A similar flap based on the
right would rotate clockwise. G, The contralateral flap based on the right rotates 90 to 180 degrees counterclockwise. A
similar flap based on the left would rotate clockwise.
Fig. 10B-11
Fig. 10B-11
Bipedicle TRAM Flap
Fig. 10B-12 A, Operative plan for a bipedicle flap. B, Bipedicle flap showing the relationship of midline tunnel to the
muscle attachments. C, Cross section illustrating the relationship of two muscle pedicles to the overlying skin island and
umbilicus. D, Flap donor site showing a rectus sheath defect. E, Mesh closure of a bipedicle donor site.
Midabdominal TRAM Flap
Fig. 10B-13
Free TRAM Flap
Free TRAM Flap Variants
Fig. 10B-14
Fig. 10B-14
Deep Inferior Epigastric Perforator (DIEP) Flap
Fig. 10B-15
DIEP Flap Elevation
Fig. 10B-16 A, Typical skin design for a medial row-based DIEP flap. More lateral tissue (zone III) would be included for a
lateral row-based flap. ICG angiography can help to identify the best perfused tissues after elevation of the flap before
excision of flap skin. B, Clinical case of markings for a medial perforator-based flap. C, Flap harvest and intramuscular
dissection. D, Intraoperative view of dissection demonstrating dissection of the perforator without muscle harvest.
ARC OF ROTATION
Pedicled TRAM/Rectus Flaps
Fig. 10B-17
Thoracoepigastric Flap
FLAP TRANSFER
Muscle-Only Flap
Pedicled TRAM (Unipedicle, Bipedicle, Midabdominal, Superiorly Based VRAM) Flap
Fig. 10B-18 A, The subcutaneous tunnel viewed from below showing a retractor in the mastectomy site passed through the
tunnel. B, The surgeon's hand placed from the abdominal incision into the mastectomy site.
VRAM (Inferiorly Based) Flap
FLAP INSET
Pedicled Flap
Free Rectus Flap
Free TRAM Flap
DONOR SITE CLOSURE
Fig. 10B-19
Fig. 10B-19
Free TRAM Flap
Fig. 10B-20
CLINICAL APPLICATIONS
Fig. 10B-21 A, Preoperative right breast cancer. Note that the right breast is higher than the left. B, Muscle-sparing flap
harvest. C, Muscle-sparing type II (MS-2) free TRAM flap.
Fig. 10B-21 D, Muscle-sparing free TRAM donor site before closure. E, Donor site closure. F and G, AP and oblique views of
postoperative result 1 year after surgery demonstrating excellent shape and symmetry; the right breast is at the same level
as the left breast.
Fig. 10B-22 A, Preoperative view showing paramedian scar and irradiated mastectomy. B, Intraoperative planning.
Fig. 10B-22 C, Large 2 mm DIEA perforator on right side. D, Nerve-sparing dissection. E, DIEP flap harvested with two
perforators. F, Donor site before closure. G, Healed left DIEP flap. H, Final result 1 year after right breast reduction and
left nipple reconstruction.
Fig. 10B-23 A, Preoperative right breast cancer. Note well-developed lower abdominal pannus. B, Planned flap orientation. C,
Early postoperative result with right ipsilateral unpedicled TRAM flap. D, Final result after right pedicled TRAM flap and
contralateral vertical breast reduction for symmetry.
Fig. 10B-24 A, Irradiated chest wall after a radical mastectomy and osteoradionecrosis. B, Radical resection of the left
anterior chest, sternum, and right costal cartilages. Both internal mammary arteries were resected and the heart and both
lungs were exposed. A free TRAM flap was incised. C, One-year postoperative result showing a healed free TRAM flap with
anastomosis end-to-side with the great vessels.
Fig. 10B-25 A, Preoperative markings show her planned breast reduction and the location of the TRAM relative to her
subcostal scar. Since the design abuts the scar, no intervening areas of ischemia were created at the donor site. The
midabdominal scar created by a higher flap design did not concern the patient. An ipsilateral pedicle was used for the
rotational flap, because it avoided the areas of previous surgery and the likely transection of the superior epigastric
vessels on the right. The patient had a superomedial pedicle breast reduction in which 925 g of tissue was removed. B, The
patient is seen at her 1?year follow-up; during that postoperative period one bilateral revision was performed, with
liposuction and scar revisions. A nipple share for nipple reconstruction is pictured after completing her tattoo in the
office. C, Right oblique and D, left oblique views.
Fig. 10B-26 A, Proposed skin resection to remove all previous scars and provide access for resection. B, Wound after
resection of full-thickness abdominal wall, ASIS of pelvis, inguinal lymph nodes, and surrounding soft tissue. Note previous
midline incision. C, Abdominal hernia repaired with mesh. Proposed VRAM based on contralateral deep inferior epigastric
vessels. Abdominal tissues are a better choice than local thigh tissue because of previous radiation damage and the need to
add tissue to the area. D, After flap elevation and inset. Flap pedicle was passed above the mesh repair. Sometimes the flap
can be passed below the fascia, simplifying abdominal wall closure. Some primary closure of the thigh was performed, and
primary donor site closure was achieved.
Fig. 10B-27 A, Large chest wall resection requiring only soft tissue coverage. A contralateral VRAM was planned. The size of
the flap was based on what could be harvested and closed primarily, not on the defect size. If more tissue was required, a
second flap could be added. B, Flap inset and donor site closed primarily. Like most pedicle TRAM flaps, some congestion is
noted at the inset. One can supercharge the deep or superficial inferior epigastric veins, if indicated. C, The patient is
seen 6 weeks postoperatively (AP view). She healed uneventfully. No venous supercharge was performed. D, Oblique view.
Fig. 10B-28 A, The surgical defect is seen after removal of the tumor and reconstruction of the femoral vessels with a Gore-
Tex graft. An old skin graft donor site is seen inferior to the wound from his original melanoma surgery. The proposed VRAM
is shown. Because of the sacrifice of the femoral vessels and its tributaries, local flaps were excluded and the VRAM on a
contralateral pedicle was chosen. B, The abdominal wall defect was repaired with mesh, leaving a space for the femoral
vessels and the VRAM pedicle. The flap is seen before final inset; the mesh can be seen superior to the flap. C, The flap
was inset and the lateral portion of the wound away from the Gore-Tex graft was skin grafted. The donor site was closed
primarily. D, The patient is seen 2 months postoperatively after healing uneventfully.
Fig. 10B-29 A, The surgical defect after removal of rectum, posterior vagina, and surrounding perineal skin. The lap pad is
seen in the presacral dead space left by the removal of tissues. B, The VRAM after inset into the perineal defect. Skin of
the flap is used to resurface the perineum where the anus once was. C, VRAM skin is also used to recreate the vaginal vault,
restoring its posterior wall. The flap, when used in this transabdominal fashion, is helpful in obliterating pelvic dead
space and limiting seroma formation.
Fig. 10B-30 A, Preoperative view of the patient with macromastia and a colostomy. B, Lateral preoperative view with markings
for the midabdominal TRAM and inferior pedicle breast reduction, to be performed concurrently. C, The patient is shown 9
months postoperatively. She required no revisions; a nipple share and tattoo were performed for nipple reconstruction. Note
the midabdominal scar, which did not concern this patient. In contrast to a standard TRAM flap, very little lower abdominal
undermining is required in such a case for closure. D, Right lateral and E, left lateral views.
Pearls and Pitfalls
EXPERT COMMENTARY
Advantages
Recommendations
Complications
EXPERT COMMENTARY
Limitations
Personal Experience and Insights
Take-Away Messages
Bibliography With Key Annotations
Anatomic/Experimental Studies
Clinical Series
Flap Modifications
Complications
Section 10C External Oblique Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10C-1
ANATOMY
Arterial Anatomy (Type IV)
Venous Anatomy
Nerve Supply
Fig. 10C-2
FLAP HARVEST
Design and Markings
Skin Islands
Fig. 10C-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 10C-4
FLAP VARIANTS
Rotation Advancement/V-Y Flap
Fig. 10C-5
Tissue Expansion
Fig. 10C-6
Component Separation
Fig. 10C-7 Cross-sections of the dissection of the abdominal wall into its component sections and final flap reconstruction.
Reverse Flap
ARC OF ROTATION
Standard Flap
Fig. 10C-8
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 10C-9 A, Resection of empyema and recurrent lung cancer. B, The external oblique muscle raised for closure of the lower
thoracic wound. C, The healed result is shown.
Fig. 10C-10 A, The defect with exposed irradiated ribs and the planned external oblique flap. The design does not cross the
midline and includes all potential lateral intercostal neurovascular bundles. B, The flap has been elevated to the level of
the intercostal bundles and released from the costal margin. C, Flap inset. No inferior backcut was needed to advance the
flap. D, Patient at 2 weeks after suture removal. Convalescence was remarkably easy compared with a latissimus dorsi or
rectus abdominis flap.
Fig. 10C-11 A, Preoperative photo showing the submammary scar from her biopsy and the proposed skin resection with
mastectomy. The flap design is not affected by the previous suprapubic scar. B, The defect after resection, with some
partial rib removal. The intrathoracic space was not entered. C, The flap was elevated to the lateral intercostal vascular
bundles. A backcut was performed to allow tension-free advancement. D, Flap inset. E, The patient is shown at 1-month follow-
up. The flap design did not distort the umbilicus, a common problem with the vertical rectus abdominis myocutaneous (VRAM)
flap.
Fig. 10C-12 A, The patient's defect is seen after wide resection of full-thickness chest wall and a Marlex mesh sandwich
repair. Evidence of the previous latissimus dorsi and skin-grafted omentum are visible, as well as the previous midline
surgery. B, The planned external oblique flap. The patient was prepared for a skin graft to the donor site. C, Flap inset. A
small backcut was required to advance the flap. Because of the horizontal laxity of the abdomen, a primary closure was
obtained without the need for back-grafting. D, Patient at her 2-week follow-up for suture removal. Her recovery was
uneventful and significantly less morbid than would have been the case with the requested free flap.
Fig. 10C-13 A, Proposed wide resection of the right chest, including mastectomy and axillary lymph node dissection. B,
Defect after resection, which included all muscular fascia, but no muscle or rib resection. C, The VRAM flap has been
elevated on the contralateral pedicle and rotated to close the superior defect. The external oblique flap has been elevated
to close the lower defect. In cases in which the contralateral mammary has been divided by the chest wall resection, a
latissimus dorsi flap would be used for the superior defect. Mammary artery division does not affect the external oblique
flap. D, Flap inset with primary closure of the donor site. The patient did have some marginal necrosis at the abdominal
midline scar requiring a minor revision. She otherwise healed uneventfully.
Fig. 10C-14 A, Final defect after multiple reexcisions performed and negative margins were finally obtained. This is not
uncommon in cases of angiosarcoma, where the extent of disease is often underestimated. Note the hyperpigmentation from
previous radiation therapy. B, Planned VRAM flap to reconstruct the entire defect. C, Once the flap was elevated and
rotated, it became clear that the VRAM would not supply enough tissue, so an external oblique flap was elevated in addition.
D, Flaps inset and primary closure obtained at all sites. E, The patient had some necrosis at the tip of the VRAM flap near
the axilla that required conservative debridement in the office and secondary healing with dressing changes. She is shown at
her 9-month follow-up.
Fig. 10C-15 A, The excised tumor and marginal back tissue are shown, with exposed and partly resected spinous processes. B,
The patient was placed in the supine position for elevation of both flaps. C, She was turned to the prone position for the
flap inset. The upper right flap has a duskier color as a result of the necessary division of the uppermost perforators to
the flap. The skin graft did not take over this area. D, The incisions that preserved the periumbilical perforators to the
abdominal skin are shown.
Fig. 10C-16 An external oblique turnover flap was performed, and a skin graft to cover the left flank. A random skin flap of
right back skin was transposed to cover the spinous processes.
Pearls and Pitfalls
EXPERT COMMENTARY
Advantages and Limitations
Anatomic Considerations
Fig. 10C-17
Fig. 10C-18
Personal Experience and Insights
Recommendations
Postoperative Care
EXPERT COMMENTARY
Advantages and Limitations
Recommendations
Fig. 10C-19 The external oblique flap has been partially elevated. The intercostal bundles are seen (white dots). For
advancement, further release of the muscle will be needed interiorly (dashed line), and the contributions of the DCIA (X)
will be divided.
Take-Away Messages
Bibliography With Key Annotations
Anatomic Series
Clinical Series
Section 10D Superficial Inferior Epigastric Artery (SIEA) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10D-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 10D-2
FLAP HARVEST
Design and Markings
Fig. 10D-3 Skin island design.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 10D-4
Fig. 10D-4
Fig. 10D-4
Extension of Pedicle Length
FLAP VARIANT
Pedicle Flap
ARC OF ROTATION
Fig. 10D-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 10D-6 A, The patient's TRAM flap is marked. She had a previous lower midline incision, and it was thought that a
hemiabdomen would supply enough tissue for her reconstructive needs. Although the right side was marked, no surgery was
performed on that side. B, View from the right of the flap elevated. The patient had both a large superficial inferior
epigastric system (1.7 mm artery at its origin) and some large DIEP perforators near the umbilicus, both the lateral and
medial rows. The DIEP perforators were clamped and the blood flow from the SIEA evaluated. C, The SIEA flap elevated, with
good pedicle length. All tissue appeared well perfused before division. D, One-year postoperative view. No revisions were
required, and no symmetry procedures were performed on the right. Nipple reconstruction was done with nipple sharing and
tattooing. E, Oblique view, 1 year postoperatively.
Fig. 10D-7 A, The patient's pannus was marked preoperatively and was explored for vessels. Most of the pannus was discarded.
B, A large superficial inferior epigastric artery (1.5 mm at its origin) and two accompanying veins were found. C, Closeup
of SIEA and SIEV. The artery and vein accompanying the artery are deep. A more medial second superficial vein, seen here
engorged, is often harvested with the flap for additional venous drainage. D, Six-month follow-up photo. The patient did not
require any revision of the right reconstruction but did have a left mastopexy for better symmetry. E and F, Left and right
oblique views.
Fig. 10D-8 A, Preoperative markings. B, The patient is seen at her 1 ?year follow-up. She had a small SIEA (1.2 mm
diameter at its origin). The anastomosis was end-to-end to a second intercostal perforator. Two superficial veins were
anastomosed as well. She did not require any revisions. Nipple reconstruction was with nipple sharing; the photo was taken
on the day of her areolar tattoo. C and D, Right and left oblique views.
Fig. 10D-9 A, The patient's preoperative markings are shown. On exploration of the left side of her abdomen, she had a
significant SIEA (1.1 mm) and SIEV (2.5 mm), but only significant DIEPs on the right. B, She is seen at 10-month follow-up.
An SIEA flap was placed on the left, anastomosed to the internal mammary artery end-to-side because of vessel mismatch. The
right was reconstructed with a three-perforator DIEP. She did undergo a small touch-up procedure at 4 months consisting of
some liposuction and skin reshaping, with revision of some of her abdominal scars. Her nipple reconstructions are star flaps
with three-dimensional tattoos. C and D, Right and left oblique views.
Fig. 10D-10 A, The patient is seen preoperatively. B, A DIEP and an SIEA flap were designed and marked. C, Flap and donor
site. D, Flap (DIEP and SIEA). E, The results are seen postoperatively.
Fig. 10D-11 A, The patient is seen preoperatively. B, Preoperative markings for SIEA flaps. C, Intraoperative views of the
left SIEA flap and D, the right SIEA flap. E, The results are seen postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experiences and Insights
Recommendations
Postoperative Care
Complications
Take-Away Messages
References
EXPERT COMMENTARY
Advantages and Limitations
Recommendations
Fig. 10D-12 The SIEA and SIEV (right arrow) have been connected to the contralateral DIEA and DIEV (bottom arrow) so that
the entire flap can be vascularized on one anastomosis.
Take-Away Messages
Bibliography With Key Annotations
Clinical Studies
Anatomic/Experimental Studies
Clinical Series
Flap Modifications
Section 10E Groin Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10E-1
Fig. 10E-1
ANATOMY
Arterial Anatomy (Type A Fasciocutaneous)
Venous Anatomy
Nerve Supply
Fig. 10E-2
FLAP HARVEST
Design and Markings
Fig. 10E-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 10E-4 A, Relationship of the pedicle to fascia and sartorius. B, Relationship of flap pedicle to groin muscle and
fascial layers: standard flap with base intact. C, Exposure for island flap or free flap and isolation of the pedicle. The
medial incision is made first to locate and confirm the SCIA pedicle.
Island Flap
Fig. 10E-5
Microvascular Island Flap
Fig. 10E-6 A, Vascular anatomy of the groin flap and perforator variant. B, Vascular basis of the groin flap.
Fig. 10E-6 C, Elevation of island or free flap based on the perforators of the superficial branch of the SCIA.
Fig. 10E-6
FLAP VARIANT
Delay Flap
Fig. 10E-7 A, For a delay groin flap, standard flap elevation is performed뾵ithout the distal incision. Upper and lower
incisions are lengthened posteriorly by the width of the flap. The flap is completely undermined (green shaded area). B, Ten
to 14 days later, the flap can be extended; the delay can be repeated as needed. (1, Length of standard flap; 2, initial
delay; 3, second delay at 10 to 14 days.)
ARC OF ROTATION
Standard Flap
Fig. 10E-8
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 10E-9 A, Defect 1 week after the accident, when the patient's condition had been stabilized. B, Planned groin flap; an
SCIA pedicle is diagrammed. The extension of the flap beyond the ASIS was thought to be the largest flap possible without
employing a surgical delay procedure. C, The flap was elevated, tubed, and attached to the defect. To avoid tension at the
inset, the distal end of the tube was left open and grafted. D, Division and inset at 2 weeks postoperatively. The initial
bulk was necessary to allow healing with good-quality tissue coverage. The patient underwent revisions at 4 months and 8
months after this division. Note how the tubed flap is partially returned to the recipient site, in this case reconstructing
an open wound that developed as a partial dehiscence of the initial donor site closure. The amount of pedicle returned
should be guided by the desired appearance of the donor site scar.
Fig. 10E-10 A, The hand wound at 48 hours, ready for tendon repair and soft tissue coverage. B, The groin flap raised and
tubed, ready for inset at the recipient site. C, At inset, with primary closure of the donor site. D, Division and inset at
2 weeks. E, At the 2-month follow-up visit. Care was taken not to be too aggressive at the division and inset and to prepare
the patient for revisions at 4 months. F, After one revision, 4 months after the initial groin flap procedure. A wedge of
central skin and fat was resected and the flap thinned under direct vision. The patient is shown 3 months after the
debulking and recontouring procedure. G, Lateral view.
Fig. 10E-11 A and B, The patient developed a severe contracture of his first webspace. His donor sites were limited;
however, while his groin had been burned, it had healed without skin grafting. C and D, A pedicled groin flap was chosen for
coverage, and after release of his contracture, the flap was placed in this first webspace and palm. The flap had healed
well by 3 weeks and was divided and inset. This provided an excellent release and good hand function. E-G, The patient's
hand function is seen 3 months after release of the flap.
Fig. 10E-12 A, As a first stage, a pedicled groin flap was placed and tubed to position the toe transfer in this tubed flap.
B, The flap was divided 3 ?weeks later; the flap is shown 4 weeks after division. C, The great toe transfer was performed;
the previously placed groin flap allowed transfer of the toe without the need for an undue amount of tissue to be
transferred from the foot. D, The patient regained excellent function of his thumb, and he was able to return to duty as a
firefighter.
Fig. 10E-13 A, The patient's right hand is seen preoperatively. B, To salvage the proximal phalanges, the hand was debrided
and placed in a pedicled groin flap. C, The flap was delayed and divided at 4 weeks, with the fingers and thumb
syndactylized. D and E, The patient eventually regained reasonable metacarpophalangeal joint motion and thumb opposition
after division and insetting of the flap.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
Bibliography With Key Annotations
Anatomic Studies
Clinical Series
Flap Modifications
Section 10F Thoracoepigastric (Transverse Abdominal) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10F-1
ANATOMY
Arterial Anatomy (Type C)
Venous Anatomy
Nerve Supply
Fig. 10F-2
FLAP HARVEST
Design and Markings
Fig. 10F-3
Patient Positioning
GUIDE TO FLAP DISSECTION
FLAP VARIANT
ARC OF ROTATION
Fig. 10F-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATION
Fig. 10F-6 A, This lateral view of the patient's left hip shows the soft tissue defect that resulted from sarcoma resection.
B, An elliptical vertical rectus abdominis myocutaneous (VRAM) flap was designed over the rectus abdominis muscle, with four
perforator zones (dots) indentified. The thoracoepigastric extension (eVRAM) was marked, extending from the umbilicus toward
the costal margin at the anterior axillary line. C, The eVRAM flap was elevated. D, It was transposed through a tunnel into
the left hip soft tissue defect. E, The flap was tailored and inset into the defect, covering all vital structures. The rest
of the wound was skin grafted.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Fig. 10F-7 The thoracoepigastric flap can be used to cover a mastectomy or small chest wall defect.
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
References
Bibliography With Key Annotations
Anatomic Studies
Clinical Series
Flap Modifications
Section 10G Pudendal-Thigh (Singapore) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 10G-1
ANATOMY
Arterial Anatomy (Type A)
Venous Anatomy
Nerve Supply
Fig. 10G-2
FLAP HARVEST
Design and Markings
Fig. 10G-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 10G-4
Fig. 10G-4
ARC OF ROTATION
Fig. 10G-5
FLAP TRANSFER
Fig. 10G-6
FLAP INSET
Fig. 10G-7
DONOR SITE CLOSURE
Fig. 10G-8
CLINICAL APPLICATIONS
Fig. 10G-9 A, Appearance of the introitus on clinical examination. It was not possible to examine the introitus with a
single finger. B, A CT scan showed a significant bony component to the stenosis. C, The first stage of reconstruction
involved bony resection of the obstructive bone via a suprapubic approach. The vaginal vault was not breached. D, Four
months later, the soft tissue deficit was addressed with a pudendal thigh (Singapore) flap. The flap was designed as a
direct transposition flap, leaving the final donor scar in the groin crease. E, The release of the vaginal vault was
performed first, confirming length and width requirements. A lateral release provides easy access for the flap and is
recommended to avoid issues with the genitourinary and gastrointestinal tracts. Once the flap was transposed, primary
closure was obtained. No attempt was made to address dog-ears at this point, to preserve the vascularity to the flap. F, The
patient is seen 2 months postoperatively. She now has a three-finger introitus and has had successful intercourse.
Fig. 10G-10 A, Although the radiation therapy had been performed 2 years earlier, the damage to the skin is evident. The
damage extended to the tissues of the pudendal thigh flap. Other local options would provide too much bulk to effectively
expand a constricted, irradiated vault, so a pudendal thigh flap was attempted in a delayed fashion to maximize vascularity
in this irradiated setting. Doppler points are marked with Xs, and the initial flap to elevate is marked. The solid line
denotes what would survive primarily; the dotted lines indicate the extension for delay. The area of the pedicle was left
intact. B, Two weeks later, the initial elevation had done well and the extension was incised and undermined, leaving the
distal skin of the flap intact to support the flap during delay. This distal portion of the delay was completed in the
office with the patient under local anesthesia 1 week later. C, Two weeks after the final delay, the vaginal vault was
opened laterally and the flap inset. D, Six months postoperatively, the patient had a two-finger introitus, despite dilator
therapy. She then underwent the same series of procedures on the contralateral side without complication. She now has a
three- to four-finger introitus and is able to have intercourse.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Recommendations
Fig. 10G-11 Incisions at the base must stay superficial to avoid disruption of the pedicle. Significant undermining in the
subcutaneous plane can be performed safely, which aids in flap mobilization and rotation.
Postoperative Care
Complications
Bibliography With Key Annotations
Chapter 11 Abdominal Viscera
Section 11A Jejunal Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 11A-1 A, Relevent anatomy of the jejunal flap. The ligament of Treitz marks the point at which the duodenum becomes the
jejunum and emerges from its retroperitoneal position. B, The jejunal segment for harvest is at least 30 cm from the
ligament of Treitz and is based on the vascular arcade. Distal terminal ileum is avoided. C, Arterial supply and venous
drainage. D, Innervation of the jejunum. The flap is deinnervated when harvested, although local peristaltic reflexes
persist.
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 11A-2
FLAP HARVEST
Design and Markings
Fig. 11A-3
Patient Positioning
Fig. 11A-4
GUIDE TO FLAP DISSECTION
Fig. 11A-5
Fig. 11A-5
Fig. 11A-6
FLAP VARIANTS
Segmental Flap
Jejunomesenteric Flap
Fig. 11A-7
ARC OF ROTATION
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 11A-8 A, Preoperative view of patient with proximal esophagocolonic stricture after previous colon interposition. B,
Intraoperative view of exposed proximal colonic anastomotic stricture resection. C, Jejunal interpositional flap sewn in
with a proximal bowel segment for use as a perfusion monitor on the skin surface. D, Preoperative radiograph demonstrating
extensive tight stricture of colonic interposition segment. E, Postoperative radiographs of free barium passage down healed
jejunal interposition.
Fig. 11A-9 A, The bowel was prepared for transfer while still perfusing in the abdomen. The measurements from the defect
dictated the length. An extra segment was harvested on the same pedicle to use as an external monitoring segment. If having
this segment were to in any way compromise the transplant or put tension on the anastomosis, it could be removed. B, The
jejunum was inset and perfused. The monitoring segment was positioned laterally. The buried flap can be monitored by
observing the perfusion of the monitoring segment or by Doppler examination of the exposed pedicle. It was ligated and
removed at the bedside on postoperative day 5. C, On day 10, a gastrograffin swallow is performed. If no leaks are noted, a
definitive barium study may be performed, or the patient may be started on a soft diet. Not uncommonly, a small leak is
noted, and feeding is delayed for an additional 2 weeks, then started without further studies. Shown here is a normal
lateral barium study at 10 days postoperatively.
Fig. 11A-10 A, Preoperatively the patient had a feeding tube and a neck scar. He underwent attempted dilations without
success. He was taken to the operating room, and the neck and upper part of the substernal region were explored. The
proximal end of the cervical esophagus was located at an area with normal mucosa. B, Distally, normal-appearing colon was
identified in the substernal area. C, A free jejunal flap was harvested and used to span the defect. The jejunal artery and
vein were anastomosed to the transverse cervical artery and external jugular vein, respectively. D, The flap is shown inset
and viable. The patient healed and was eating a normal diet after 3 weeks.
Fig. 11A-10 E, The fistula tract was identified and debrided, and the tract was closed. F and G, A pectoralis major muscle
was harvested and used to reinforce the repair and obliterate the tract. H and I, The patient healed and was able to resume
a normal oral diet after 4 weeks.
Fig. 11A-11 A, A portion of the cervical esophagus was resected. B, A segment of jejunum was harvested from an area 30 cm
distal to the ligament of Treitz. C and D, The proximal and distal ends of the jejunum were anastomosed to the proximal and
distal ends of the defect, reconstituting continuity of the gastrointestinal tract. A long monitor loop was kept in place.
(We no longer use a monitor loop since we began using the implantable Doppler.) A monitor loop does not need to be more than
6 cm in length. The jejunal vessels were anastomosed to the transverse cervical artery and external jugular vein. E, Ten
hours postoperatively, a dramatic change in color and turgor was noted on the monitor loop. The patient was taken to the
operating room emergently, and the artery and vein were evaluated. There was a thrombus in the artery at the level of the
anastomosis. F, The anastomosis was revised, and the flap reperfused nicely. The patient healed uneventfully and was able to
tolerate a regular diet 3 weeks postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Fig. 11A-12 The vascular arcades within the mesenterium; a closeup view of the terminal branches, the vasa recta.
Personal Experience and Insights
Fig. 11A-13 Double-barreled jejunum.
Fig. 11A-14 Constriction and stenosis can be prevented by spatulating the anastomosis. A, End-to-end anastomosis is begun as
usual. B, Before finishing the anastomosis, the surgeon opens the jejunum longitudinally. C, This opening spreads and allows
inset of the redundant pharynx or esophagus in a Y-to-V fashion. D, The final closure has a larger diameter than the jejunum
and thus a circumferential scar that would constrict is avoided.
Recommendations
Avoidance of Complications and Postoperative Care
Reference
Bibliography With Key Annotations
Clinical Series
Flap Modifications
Complications
Section 11B Omental Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 11B-1
ANATOMY
Arterial Anatomy (Type III)
Venous Anatomy
Nerve Supply
Fig. 11B-2
FLAP HARVEST
Design and Markings
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 11B-3
Fig. 11B-3
Fig. 11B-3
Extension of Pedicle Length
Fig. 11B-4
FLAP VARIANTS
Turnover Flap
Segmental Flap
Free Flap Transfer
Gastroomental Flap
Fig. 11B-5
ARC OF ROTATION
Fig. 11B-6
FLAP TRANSFER
FLAP INSET
Fig. 11B-7
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 11B-8 A, Preoperative view of frontal sinus wound. B, Intraoperative view. C, Free omental flap with the skin graft
being sewn in place. D, Frontal view at 6 months postoperatively. E, Lateral profile at 6 months.
Fig. 11B-9 A, Preoperative view of osteoradionecrosis of the skull. B, Occipital view of the healed, skin-grafted free
omental flap to the scalp and dura. C, Lateral view of the scalp with a scar in the neck at the site of pedicle anastomosis
to the facial vessels.
Fig. 11B-10 A, Preoperative view of ulcerated right chest wall with exposed costal cartilages. B, Intraoperative defect with
chest tubes and Gore-Tex patch in place before omental coverage. C, Postoperative view at 1 year showing healed right chest
covered with the skin-grafted omental flap.
Fig. 11B-11 A, Intraoperative view of the patient's wide sternal wound after total sternectomy. B, Pedicled omental flap in
place before skin grafting.
Fig. 11B-12 A, The wound is shown at the time of omental flap closure, after debridement. B, The omental flap was tunneled
through the right paracolic gutter into the spinal wound in preparation for inset and skin grafting. C, The omental flap
inset before split-thickness skin grafting. The patient healed primarily without any recurrent breakdown until his death 14
months later from widespread metastatic disease.
Fig. 11B-13 A, The initial draining sternal incision is shown. B, The debrided wound after radical sternectomy. C, The
omental flap was elevated in preparation for transposition into the sternal wound. The flap was split along its vascular
arcades to allow a portion of the omentum to be packed into the recesses around the great vessels and hila of the lungs. The
remaining bulk was placed into the anterior superficial portion of the wound. D, The omental flap inset. E, The flap inset
and skin grafted. The patient healed uneventfully and was alive and well with stable wound coverage 2 years later.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Message
Bibliography With Key Annotations
Anatomic/Experimental Studies
Clinical Series
Flap Modifications
Complications
Chapter 12 Thigh
Section 12A Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12A-1 A, The vascular anatomy of the thigh relevant to the ALT and AMT flaps. B, Anatomy of the lateral circumflex
femoral artery and its branches and thigh vasculature.
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 12A-1 C, Sensory map of the lateral femoral cutaneous nerve and its branches. D, Sensory innervation of the anterior
thigh.
Fig. 12A-2 A, Cadaveric dissection of the ALT flap showing a proximal septocutaneous and more distal myocutaneous
perforator, which required intramuscular dissection. B, Closeup of the origin of the lateral femoral cutaneous branch
showing the two perforators combined proximally.
FLAP HARVEST
Design and Markings
Fig. 12A-3 A, With the patient in the supine position, the central axis of the flap is indicated by a line drawn from the
anterior superior iliac spine to the superolateral border of the patella. The major fasciocutaneous perforators supplying
the flap can be located at the midpoint of this line, within the lower, outer quadrant (shaded area) of a circle drawn with
a radius of 3 cm. B, The medial flap border corresponds to the central axis of the rectus femoris muscle, denoted by the
line drawn from the anterior superior iliac spine to the superior aspect of the patella. The lateral flap border extends to
the midlateral thigh. The lateral circumflex femoral artery arises from the lateral side of the profunda femoris artery. It
then passes laterally deep to the femoral nerve branches and the sartorius and rectus femoris muscles. It divides into
ascending, transverse, and descending branches (and an innominate branch). Note the lateral femoral cutaneous nerve entering
the thigh by passing under or through the lateral end of the inguinal ligament. The anterior branch can be employed to
innervate the flap.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 12A-4
FLAP VARIANTS
Thin Flap
Fig. 12A-5 A, Thigh flap elevated in a suprafascial plane on a single skin vessel. Although donor site morbidity is limited
by leaving the fascia, the visibility of landmarks that could facilitate pedicle dissection is more limited.
Fig. 12A-5 B, The blood supply of the cutaneous perforator with the subdermal plexus. C, Flap thinning with the subdermal
plexus intact.
Anteromedial Thigh Flap
Fig. 12A-6 A, Anatomy of the anteromedial thigh flap. B, The innominate branch arises directly from the lateral circumflex
femoral artery. It courses posteromedially to the rectus femoris muscle on the vastus medialis muscle, giving off multiple
muscle branches and myocutaneous branches to the vastus medialis and sartorius muscles. A dominant septocutaneous branch
usually emerges at the juncture of the rectus femoris, sartorius, and vastus medialis muscles in the middle of the thigh.
The cutaneous paddle is supplied by the anterior femoral cutaneous nerve.
Fig. 12A-6 C, Exposure of the innominate branch is facilitated by retraction of the sartorius muscle medially.
Reverse Anterolateral Thigh Flap
Fig. 12A-7 The lateral circumflex femoral artery (LCFA) arises from the profunda femoris artery (PFA) and divides into
ascending, transverse, and descending branches. The pedicled ALT flap, based on a perforator of the descending branch, could
be rotated superiorly around a point just distal to the origin of the LCFA from the profunda femoris (proximal pivot point)
or rotated inferiorly around a point just proximal (distal pivot point) to the anastomotic site of the descending branch of
the LCFA with the lateral superior genicular artery. By maintaining 6 cm of connection above the patella, the superior
genicular artery need not be visualized.
ARC OF ROTATION
Anterolateral Thigh Flap
Fig. 12A-8 Proximally based standard flap.
Reverse Flap
Fig. 12A-9 Arc of rotation for the reverse ALT flap. The pivot point for the reverse flap is shown; this can be used to
approximate the arc interiorly.
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 12A-10 A, The patient developed this open wound as a result of her second course of irradiation. Biopsies were negative
for recurrent angiosarcoma, and reconstruction was required. Advancement of the VRAM was felt to be too problematic after
the radiation treatment and the nature of the local tissues. An ALT flap was planned as a free flap to the internal mammary
system. B, The flap design after Doppler identification of the perforators and transposition of the templated defect. C,
After debridement and resurfacing with an ALT free flap. The donor site was closed primarily D, The flap healed
uneventfully, seen here at 5 months postoperatively.
Fig. 12A-11 A, The operative defect with exposed dura and maxillary sinus and a large skin defect. B, Flap elevated on the
descending lateral circumflex femoral pedicle. The blood supply to the skin was based on intramuscular perforators. C, Prior
to revascularization, the flap was partially inset with the muscle used for fill of the irradiated dead space. D, After
revascularization, the skin paddle and muscle are healthy and ready for inset. The pedicle vessels easily reached to the
neck for anastomosis with the facial artery and vein. E, Final inset. He healed uneventfully.
Fig. 12A-12 A, The defect is seen and a planned Tripier flap is marked on the upper lid for reconstruction of the lower lid.
B, The Tripier flap is transposed and inset and a porous polyethylene implant was used to replace the orbital floor. An ALT
flap was planned for soft tissue replacement. C, The design of the ALT flap was positioned over the area of maximal
fluorescence on ICG laser angiography. D, The ALT inset. The included fascia was secured to the remaining lateral zygomatic
arch with Mitek suture anchors. The donor site was closed primarily. E, AP view and F, oblique view at 1 month. He underwent
postoperative irradiation, which the flap tolerated well. He remains tumor free at 7 years.
Fig. 12A-13 A, Defect after debridement of necrotic skin and pectoralis flap. Only a posterior strip of cervical esophagus
remained. The anterior neck skin was removed, and a remnant of unusable pectoralis major muscle remained. B, Planned two-
paddle ALT flap, one for esophageal reconstruction, one for resurfacing of the neck. C, Flap after elevation, with good
viability of both skin paddles. Perforators coursed through the vastus lateralis muscle and some was included with the flap.
D, Undersurface of flap. The donor site required skin grafting for closure. E, Insetting of the flap for esophageal
reconstruction. F, After inset of the larger flap to resurface the anterior neck. Because of the added bulk of the included
vastus lateralis muscle, primary closure was not attempted, and the exposed muscle was skin grafted.
Fig. 12A-14 A, Hypopharyngeal cancer specimen including larynx, pharynx, and cervical esophagus. B, In this case, the axis
of the skin tube was oriented perpendicular to the length of the thigh. C, The skin paddle was tubed using a two-layer
closure of skin and fascia. D, Flap inset is shown with adequate volume restoration. E, An esophagram demonstrated rapid,
unobstructed passage through the skin tube.
Fig. 12A-15 A, The patient had a large defect of the left upper quadrant with infected acellular dermal matrix. B, The wound
was debrided, and an extended ALT myocutaneous flap was raised, supplied by the descending and medial (innominate) branches
of the lateral circumflex femoral artery. Thigh fascia was to be used to close the abdominal wall defect. C, The abdominal
wall defect was closed. The thigh donor site was closed with a perforator-based V-Y flap (arrow) from the posterolateral
thigh circulation.
Fig. 12A-16 A, The dashed line outlines the cutaneous portion of the radiation sarcoma. The arrow marks the fibula skin
paddle. B, The resection defect included a small mucosal defect, 5 cm of neomandible (fibula), and skin. C, A split iliac
crest chimera flap with 5 cm of split lateral iliac crest (white arrow) supplied by the ascending branch (red arrow) of the
lateral circumflex femoral vessels; the flap incorporated a portion of vastus lateralis muscle to close dead space and the
mucosal lining defect supplied by the descending branch (blue arrow) of the lateral circumflex femoral vessels and a large
skin paddle supplied by a septocutaneous branch of the lateral circumflex femoral vessels. D, The flap was inset. The split
lateral iliac crest (arrow) supplied by the ascending branch of the lateral circumflex femoral vessels is shown after
insetting. The vastus lateralis muscle was used to close dead space and the mucosal lining defect (curved arrow depicts
where the muscle flap was placed). Microvascular anastomoses were performed to the peroneal artery and vein (the old fibula
pedicle), and then the skin was inset. E, Immediate result after insetting and closure of the skin paddle.
Fig. 12A-17 A, The patient is seen preoperatively. B, He had an ulcerated tumor of the right maxilla. C, Resected specimen.
D, Thigh donor site demonstrating lateral iliac crest (white arrow), marked for the proposed line to split. E, Flap with
split lateral iliac crest (arrow) attached to the tensor fascia lata, supplied by the ascending branch (red arrow) of
lateral circumflex femoral vessels. The skin paddle (to be used as a monitor and to take tension off the neck skin closure)
was supplied by a septocutaneous vessel (blue arrow). F, Flap inset. The split lateral iliac crest (white arrow) was
osteotomized to fit the exact size and shape of the defect. The attached tensor fascia lata (red arrow) was used to
reconstruct the palate, which was left raw to remucosalize. G, Skin closure. The green nasal trumpet was left to support the
nasal floor lining, which remucosalizes on its own. Note the skin-monitoring paddle on the lower right.
Fig. 12A-18 A, The scalp injury is seen, with exposed, fractured cranium. B, The wound was debrided. C and D, A muscle-
sparing adipose fascial ALT flap was harvested. E, The flap was inset. F, The patient is seen at 1-year follow-up. A split-
thickness skin graft was used to cover the adipose fascial flap.
Fig. 12A-19 A, A total laryngopharyngectomy was performed, with resection of neck skin. B, A two-skin island ALT flap was
designed with a flap width of 9.5 cm to create a neoesophagus with a diameter of 3 cm. C, The proximal end of the flap was
oriented to reconstruct the nasopharynx-base of tongue region. The flap was divided between the two cutaneous perforators.
D, A Montgomery salivary bypass tube was placed in the lumen of the tubed flap and to the distal esophagus. E, The second
skin island, based on the perforator marked C was externalized to resurface the neck.
Fig. 12A-20 A, The resulting defect involved the facial skin, orbit, anterior craniobase with dural repair, the right
hemimaxilla including the palate, and the nasal sidewalk B, A multiisland ALT flap was designed for this three-dimensional
reconstruction. C, The skin island based on the perforator marked C was used to reconstruct the nasal sidewalk D, The main
flap based on perforator A was used for facial resurfacing. E, The proximal segment of the flap was used to reconstruct the
palate after deepithelializing a strip of the flap skin.
Fig. 12A-21 A, The patient had been wearing an external fixator for more than a year, with a fistula. B, The fractured left
mandible, including the condyle, was removed. C, Because of her peripheral vascular disease, a fibular flap was not
performed. Instead, a two뻮kin island ALT flap with a segment of the vastus lateralis muscle was used to reconstruct this
through-and-through mandibulectomy defect. D and E, At 6-month follow-up, the flap was well healed and the patient had good
mouth opening. She was able to tolerate a regular diet.
Fig. 12A-22 A, The patient underwent a total glossectomy. B and C, An ALT flap was harvested, with a segment of the vastus
lateralis muscle and its motor nerve and the lateral femoral cutaneous sensory nerve for both motor and sensory
reinnervation. D, The motor nerve was anastomosed to the hypoglossal nerve, and the sensory nerve to the lingual nerve. E,
The patient had excellent sensory reinnervation, although motor nerve recovery was minimal.
Fig. 12A-23 A, Defect after resection of involved cartilage. B, Tubing of the ALT around a tracheostomy tube for proper
sizing. C, The flap is inset with the endotracheal tube transferred into position. Microvascular anastomoses are completed,
and the skin is ready for closure without tension.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Fig. 12A-24 Septocutaneous medial innominate vessels (arrow) run medial to the rectus femoris and can usually be found just
distal to the point at which the sartorius crosses the rectus femoris.
Fig. 12A-25 The ascending branch of the LCFA system (arrow) running under and parallel to anterior edge of the tensor fascia
lata. Note branches of the femoral nerve (yellow vessel loops on the right), which can complicate the dissection and harvest
if multiple branches of the LCFA system are needed.
Fig. 12A-26 Branches of the femoral nerve (yellow vessel loops) going over the transverse branch, then under the first
septocutaneous vessel. In such complex relationships, care is taken to preserve the nerve. The pedicle can be passed through
after division, just before microscopic anastomosis.
Personal Experience and Insights
Recommendations
Fig. 12A-27 A, Markings for an LCF chimera flap. The red markings indicate the anticipated location of vessels; the black
line with dots indicates the initial incision. B, Extension of the initial incision to the second horizontal line. The arrow
depicts the septocutaneous vessels usually found going to the second horizontal line, approximately 17.5 cm from the ASIS.
C, After freestyle dissection of the vessels supplying the complex chimera flap.
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
EXPERT COMMENTARY
Indications
Anatomic Considerations
Fig. 12A-28 Surface locations of the cutaneous perforators of the ALT flap. Perforator B is usually located near the
midpoint of the line connecting the ASIS and the supralateral corner of the patella (the AP line), but 1.4 cm lateral to the
line. Perforators A and C are located 5 cm proximal and distal to perforator B, respectively.
Recommendations
What to Do When No ALT Perforators Are Found
Fig. 12A-29 The AMT flap is a mirror image of the ALT flap. When the ALT flap perforators are unfavorable, the AMT flap
should be explored through the same incision.
Fig. 12A-30 The blood supply to the AMT flap is the rectus femoris branch off the descending branch. By taking the
descending branch above the rectus femoris branch, both ALT and AMT flaps can be carried with one common pedicle.
References
Bibliography With Key Annotations
Section 12B Saphenous and Medial Condylar Flaps
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12B-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 12B-2
FLAP HARVEST
Design and Markings
Fig. 12B-3 A, If the anterior or 밻arly?cutaneous branches of the saphenous artery predominate, the saphenous flap skin
paddle should be designed more anteriorly and proximally to ensure that these vessels are included. B, When the anterior
branches of the saphenous artery are deficient, the skin paddle must encompass the posterior branches and the distal
continuation of the saphenous artery to ensure adequate circulation.
Patient Positioning
Fig. 12B-4
GUIDE TO FLAP DISSECTION
Fig. 12B-5 A, A 10 cm incision is made along the course of the sartorius above the planned flap. The medial femoral
cutaneous nerve and greater saphenous vein are first isolated near the anterior and posterior borders of the sartorius.
Fig. 12B-5 B, The deep fascia is incised and the sartorius muscle is bluntly dissected in the upper part of the incision and
separated from the vastus medialis to expose the saphenous neurovascular bundle.
Fig. 12B-5 C, The sartorius muscle is then retracted inferiorly and medially, exposing the subsartorius canal. The saphenous
artery and nerve are exposed and traced distally. If direct inspection reveals adequate anterior cutaneous branches, a skin
paddle is appropriately traced to include these branches. If no anterior branches are found, the skin incision is extended
more distally to within 6 cm of the knee. A flap is then outlined more distally and posteriorly on the distal saphenous
artery. D, With distal placement of the cutaneous paddle over the distal saphenous artery or its posterior branches,
division of the sartorius tendon or muscle harvest may be required to ensure an adequate blood supply.
FLAP VARIANTS
Reverse Saphenous Flap
Fig. 12B-6
Sensate Flap
Fig. 12B-7
Osteofasciocutaneous Flap (Medial Femoral Condylar Flap)
Fig. 12B-8
ARC OF ROTATION
Fig. 12B-9
FLAP TRANSFER
Standard Flap
Reverse Flap
FLAP INSET
Free Flap
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 12B-10 A, The patient had a 10 by 6 cm skin defect over the right malleolus. B, Flap design. C, The flap was elevated
on its pedicle (SM, sartorius muscle; AM, adductor magnus tendon). D, Appearance of the flap on postoperative day 5. E, The
result is seen 18 months postoperatively.
Fig. 12B-11 A, Medial approach to the distal femur. Note the length and caliber of the descending genicular artery and
veins. B, Corticocancellous bone and skin components on the descending genicular artery pedicle. C, Preoperative oblique
radiograph showing the proximal phalanx nonunion. D, The skin segment of the flap inset on the ulnar border of the hand. E,
The postoperative radiographic result is seen at 8 weeks and F, 4 months.
Fig. 12B-12 A and B, Radiographs of proximal ulnar nonunion. C and D, A large 8 cm corticocancellous segment with skin
paddle was raised; the skin was perfused by the distal cutaneous branch of the descending genicular artery. E, The result is
seen on radiographs 8 weeks and F, 12 weeks postoperatively. G and H, After the ulna healed, the patient's pronation and
supination were fully restored.
Fig. 12B-13 A and B, Preoperative radiographs demonstrate radius nonunion with plate fixation. C-E, Harvest site of the
medial femoral condyle bone flap. The skin paddle and bone component are shown on the common descending genicular artery
pedicle.
Fig. 12B-1 3 F and G, The results are seen radiographically at 4 weeks postoperatively; H and I, 8 weeks postoperatively;
and J, 14 weeks postoperatively.
Fig. 12B-14 A, The defect is seen preoperatively. B, Flap design. C, Descending genicular artery with distal cutaneous
branch at the level of the condyle (arrow). D, A large rectangular corticocancellous flap was raised (tourniquet released)
and the defect was skin grafted. E and F, AP and lateral radiographs of the knee after harvest of the large medial femoral
condyle bone segment. G-I, Radiographic views 10 weeks postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Anatomic Considerations
Reference
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications
Take-Away Messages
Bibliography With Key Annotations
Section 12C Gracilis and TUG/TMG Flaps
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12C-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 12C-2
FLAP HARVEST
Design and Markings
Fig. 12C-3
Fig. 12C-3
Fig. 12C-3
Patient Positioning
Fig. 12C-4
GUIDE TO FLAP DISSECTION
Fig. 12C-5
Fig. 12C-5
Fig. 12C-5
Fig. 12C-5
FLAP VARIANTS
Myocutaneous Flap
Fig. 12C-6 Completed dissection of a myocutaneous gracilis flap.
Medial Femoral Circumflex Artery Perforator (TUG/TMG) Flap
Fig. 12C-7
Fig. 12C-7
Functional Muscle
Fig. 12C-8
ARC OF ROTATION
Standard Flap
Fig. 12C-9
FLAP TRANSFER
Standard Flap
FLAP INSET
Pedicle Flap
Free Flap
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 12C-10 A, The defect after wide resection. Some of the pubis was saucerized and is exposed. No further urethral
reconstruction was deemed necessary. B, Design of the gracilis myocutaneous flap. The tendon has been identified and placing
tension on the tendon helps locate the skin paddle design. C, The flap has been transposed through a subcutaneous tunnel and
is inset. There was some early congestion that might have been avoided by connecting the donor and recipient sites and
directly transposing the flap. D, The patient at 4-month follow-up. Despite a well-healed wound and donor site, the patient
has difficulty with hygiene when urinating.
Fig. 12C-11 A, A multilevel injury with radiographically documented distal fractures. Three-vessel runoff was noted on a
preoperative angiogram. The proximal wound was skin grafted. B, Closeup of the wound with exposed articular surface. All
nonviable tissues were debrided. C, After inset of the gracilis free flap. Microscopic anastomosis was performed to the
posterior tibial vessels. The muscle was used to completely fill and seal the wound, and the muscle was then skin grafted.
Before the flap was placed, an external fixator was used for fracture fixation. D, The ankle at 4-month follow-up. The
contour is good, with muscle atrophy and contracture of the meshed skin graft. No surgical revision was required.
Fig. 12C-12 A, The gracilis muscle dissected and ready for transfer. Maximal length was obtained when dissecting the
obturator nerve. The full length of the distal tendon was also harvested to allow secure flap inset. B, The flap has been
partially inset with anchor sutures to the acromion. The medial femoral circumflex artery was anastomosed to the brachial
artery in end-to-side fashion while venous anastomoses were performed to the cephalic and comitans veins. It is always a
good idea to harvest a skin paddle in these cases as one tends to underestimate the skin requirement for placement of the
muscle graft. If the skin paddle is not needed, it can be discarded during closure. C, After flap inset. The extra skin has
allowed tension-free closure. The distal gracilis tendon was secured to the biceps tendon with the muscle at proper length,
compared with its length at the donor site. The skin paddle can be removed serially later, after the patient has completed
rehabilitation.
Fig. 12C-13 A, Preoperative view. Bilateral DIEP reconstruction was offered to the patient, because it was thought that she
had adequate tissue for small breast reconstruction. She preferred not to have an abdominal flap transfer. B, Intraoperative
view with the patient supine and frog-legged. This allows access for harvest and closure and still allows the surgeon to sit
the patient upright for inset and shaping. The anterior extensions of the flap were for dog-ear control only, because they
are poorly vascularized in this flap. C, The flap after harvest. The elliptical design of the flap folds into a natural
cone, with the narrow base necessary for a small breast. The flaps were anastomosed to the mammary system. D, The patient is
seen 8 months postoperatively. The patient did not want nipple reconstruction because she enjoyed not wearing bras, so a
three-dimensional tattoo was created. No revisions of the breasts or thighs were required. E, Donor site. The patient
appreciated the benefits of the thigh lift as well as the reconstruction.
Fig. 12C-14 A, There was loss of the distal Achilles tendon with complete disruption, and the patient was unable to plantar
flex with the calf muscles. B, A gracilis muscle was harvested through an 8 cm proximal incision and small counterincision
at the knee. The proximal end was sutured into the space between the gastrocnemius and soleus muscles. C, The distal tendon
was folded over on the muscle itself into a 밾ot dog in a bun?pattern to shorten the muscle tendon unit and still keep
the tendon. The distal end was stretched out and repaired directly to the calcaneus. D, The entire muscle was skin grafted.
E-G, One year postoperatively, the patient has excellent plantar flexion and is able to hop on one foot.
Fig. 12C-15 A and B, The patient is seen immediately after injury. C, In a first stage, the wound was covered with a
latissimus muscle and skin graft. She had no active finger flexion. D and E, In a second stage, a TUG flap with a transverse
skin paddle was used for functional reconstruction of the flexors of all five fingers. F, The TUG skin paddle was rotated 90
degrees to longitudinally cover the muscle. G and H, Two years postoperatively, the patient is able to flex her fingers
enough to hold a hair dryer and use the hand as an assist for activities of daily living.
Fig. 12C-16 A, The patient is seen preoperatively with complete right facial paralysis. B, A gracilis muscle was harvested
from the contralateral thigh and C, was thinned to retain the posterior aspect of the muscle and D, to increase nerve
length. The final flap measured 11 by 3 cm. E, A single-stage facial reanimation procedure was performed by coapting the
gracilis muscle to two contralateral facial nerve branches. F, One year postoperatively, she has excellent pull on her smile.
Fig. 12C-17 A and B, The patient is seen preoperatively. As a result of his injuries, he had no dorsiflexion of the foot. C,
Flap design. D, A contralateral gracilis muscle was used for anterior compartment reconstruction. E, An external fixator was
placed first to maintain the foot in the dorsiflexed position and to maintain muscle tension in the postoperative period.
The muscle was inset proximally to the tibial condyle and distally to the tibialis anterior tendon in a Pulvertaft weave. F
and G, At 9 months postoperatively, the patient is able to dorsiflex to near-neutral and can walk without an ankle-foot
orthotic.
Fig. 12C-18 A, Preoperative view at rest; note the mild right commissure droop. B, Following the second procedure, the
patient is seen at rest; note that the position of commissure has been elevated to match normal side. C, Preoperative view
with smile; note the lack of closure of the right eye, as well as minimal commissure movement. D, Postoperatively, the
patient when smiling demonstrates good excursion and fairly symmetrical nasolabial crease formation. The smile on the right
side is spontaneous; the transplanted muscle is innervated by the normal side facial nerve with the aid of a sural nerve
graft extension.
Fig. 12C-19 A-C, Preoperative appearance of the patient's neglected clubfoot deformity.
Fig. 12C-19 D, Surgical defect after midfoot osteotomies and bony repositioning. E, Intraoperative appearance with the
gracilis muscle in place filling the midfoot defect and encompassing the Achilles muscle. F and G, Postoperative appearance
after complete, satisfactory wound healing. Excellent positioning of the foot was maintained, and an adequate range of
motion of the ankle was preserved.
Fig. 12C-20 A, Preoperative appearance. B, The patient attempting a smile. C, Intraoperative appearance of the segmental
gracilis muscle transplant demonstrating origin and insertion, as well as the site of vascular anastomoses and motor nerve
repair.
Fig. 12C-20 D, Postoperative appearance at rest following staged segmental gracilis muscle transplantations to the face. E,
The patient is seen postoperatively, with a smile. Lower lip elevation has been improved, thus facilitating bilabial sound
production, and most important, facial animation. Muscle excursion is excellent, using the motor nerve to the masseter, and
reasonable symmetry was obtained.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications
Take-Away Messages
EXPERT COMMENTARY
Indications
Anatomic Considerations
Advantages and Limitations
Complications: Avoidance and Treatment
Bibliography With Key Annotations
Section 12D Sartorius Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12D-1
ANATOMY
Arterial Anatomy (Type IV)
Venous Anatomy
Nerve Supply
Fig. 12D-2
FLAP HARVEST
Design and Markings
Fig. 12D-3
Patient Positioning
GUIDE TO FLAP DISSECTION
ARC OF ROTATION
Fig. 12D-4
Fig. 12D-4
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 12D-5 A, A chronic wound with exposed graft under a fibrinous rind. B, The wound is seen after debridement and exposure
of the sartorius muscle, which was available for reconstruction. C, The muscle was divided proximally and the muscle
transposed medially to cover the exposed repair. All perforators were maintained. The reconstruction was then treated with
negative-pressure dressings for 2 months. Ultimately a small skin graft was required.
Fig. 12D-6 A, Right groin wound with an exposed graft (arrow) and some surrounding fibrinous rind. The clamps are grasping
the sartorius muscle, which is usually present laterally in such cases. B, The muscle was divided at the top and bottom of
the wound and easily transposed to cover the exposed graft.
Fig. 12D-7 A, Preoperative view of a bilateral groin condyloma and penile condyloma. B, Defects after wide excision of the
groin and partial penectomy. The femoral vessels were exposed on the right. It was decided that one of the wounds could be
closed primarily enlarging the contralateral wound, which would require a flap. C, The sartorius was transposed on the right
by dividing both above and below the required muscle and easily rotating it over the vessels. D, A primary closure was
obtained on the right, and a tensor fascia lata flap was used for closure of the left wound.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages
Recommendations
Postoperative Care
Take-Away Messages
Bibliography With Key Annotations
Section 12E Biceps Femoris (Hamstring) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12E-1
ANATOMY
Fig. 12E-1
Arterial Anatomy (Type II)
Fig. 12E-1
Fig. 12E-1
Venous Anatomy
Nerve Supply
Fig. 12E-2
Fig. 12E-3
Fig. 12E-4
FLAP HARVEST
Design and Markings
Fig. 12E-5
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 12E-6 A, Skin design with the flap width equal to the length of the bursa, not the smaller skin defect. B, The V-Y flap
is incised and advanced after muscle release superiorly, interiorly, medially and laterally. C, The V-Y closure supports the
advanced flap and allows tension-free closure. Note that some of the skin paddle has been deepithelialized and buried to add
bulk to obliterate the bursa.
Fig. 12E-6 D, Semicircular design. This can be based medially or laterally, depending on the geometry of the defect. E, The
flap is elevated and advanced after the muscles are divided superiorly and interiorly and released medially. F, Closure of
the flap is performed superiorly first, filling the bursa with tissue. The resultant defect is closed by advancement and
cheating the wound closed in typical semicircular advancement fashion.
FLAP VARIANTS
Reverse Flap
ARC OF ROTATION
V-Y Flap
Fig. 12E-7
Semicircular Flap
Fig. 12E-8
FLAP TRANSFER
V-Y and Semicircular Flap
FLAP INSET
V-Y Flap and Semicircular Flap
DONOR SITE CLOSURE
V-Y Flap
Semicircular Flap
CLINICAL APPLICATIONS
Fig. 12E-9 A, Preoperative view: the wounds are granulating, a sign of adequate nutrition. Flaps were designed to
reconstruct the deeper bursa cavity and replace the atrophic skin. B, After flap advancement as V-Y flaps. Note the large
size of the flaps, extending distally in the thigh. Also note how much of the atrophic skin could be replaced, because part
of the proximal flap was deepithelialized and used to fill the bursal cavity.
Fig. 12E-10 A, The wound had necrosis without granulation, and there was surrounding cellulitis. The first step was
aggressive debridement and treatment of the cellulitis. B, After 2 weeks of dressing changes and preoperative optimization,
a healthy, granulating wound could be seen without cellulitis. Note the true size of the defect as the thin overlying skin
was resected and the bursa exposed. C, Reconstruction of the defect with a V-Y advancement. The flap is being advanced
beyond the visible defect so some proximal deepithelialization can be performed and the cavity filled with viable tissue,
obliterating dead space. D, Flap inset. The V-Y closure has the advantage of supporting the flap in its new position, taking
tension off the inset.
Fig. 12E-11 A, A semicircular flap was planned, with the design encompassing the entire posterior thigh. The flap could have
been based medially or laterally; a medially based flap was chosen in this case, since the defect was more medial, favoring
medial rotation. B, Flap inset. Again, some of the proximal flap was deepithelialized and used to obliterate dead space.
Fig. 12E-12 A, A V-Y flap was planned. Note that the proximal width of the flap reflects the extent of the bursa, not the
skin opening. Thin overlying skin was removed to allow adequate obliteration of the cavity and resurfacing. The larger
design was used to allow for possible readvancement in case a pressure sore recurs. B, Flap inset. Some of the proximal flap
was used to obliterate space. The amount of advancement is reflected by the length of the distal donor closure.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Personal Experience and Insights
Recommendations
Bibliography With Key Annotations
Section 12F Tensor Fascia Lata (TFL) Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12F-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 12F-2
FLAP HARVEST
Design and Markings
Fig. 12F-3 A, Flap design. B, The initial incision for elevating the lateral circumflex femoral artery perforator flap
follows the upper portion of the vertical line drawn between the anterior superior iliac spine and the lateral border of the
patella. The intermuscular relationship of the source vessel to the tensor fascia lata perforator is also depicted.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 12F-4
Myofascial-Only Flap
Fig. 12F-5
FLAP VARIANTS
Osteomyocutaneous Flap
Fig. 12F-6 Osteomyocutaneous design. Note that the design is shifted more proximally than in the standard flap.
Fig. 12F-6
Fig. 12F-6
Perforator Fasciocutaneous Flap
Fig. 12F-7 A, Relationship between the tensor fascia lata muscle and its perforator. The perforator runs in a posterior
direction through the tensor fascia lata muscle and emerges at a hiatus in the deep fascia posterolateral to the central
portion of the muscle. B, Intramuscular dissection and the course of a perforator of the tensor fascia lata muscle. C, A
microdissected thin LCFA perforator free flap.
ARC OF ROTATION
Myocutaneous Arc
Fig. 12F-8
V-Y Advancement Arc
Fig. 12F-9
Anterior and Posterior Arcs of Myocutaneous Flaps
Fig. 12F-10
FLAP TRANSFER
Myofascial Flap
Myocutaneous Flap
Free Flap
Fig. 12F-11
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 12F-12 A, Preoperative view of the large left ischial decubitus and two small sacral decubiti. The patient is cachectic
and has poor soft tissue coverage of bony prominences. B, The sacral wounds are excised and closed. Aggressive debridement
of involved ischial skin and ischium were performed, and TFL flap was elevated. The width of the flap was based on the
defect, without concern for primary closure of the donor site. C, Flap rotated, providing abundant vascularized tissue for
reconstruction. D, Follow-up at 1 month with good take of the skin graft and some areas of secondary healing in the ischium
and sacrum.
Fig. 12F-13 A, Preoperative view of the bulky groin mass to be resected and the penile primary lesion. B, Large soft tissue
defect with exposed femoral vessels and one half of the scrotal skin with exposed testes. Abdominal fascia was intact. C,
Flap designed to match the 7 cm skin defect. The flap does not extend beyond the distal third to ensure good skin perfusion.
D, The flap was easily elevated until it was 12 cm distal to the ASIS, then careful dissection exposed the lateral
circumflex femoral pedicle, which was large, and forms the rotation point of the flap. E, The flap was rotated and inset
without tension. A cone of rotation (dog-ear) is left for future revisions if needed. F, Lateral view of the donor site,
which was closed primarily.
Fig. 12F-14 A, Preoperative view of condyloma of the penis and bilateral groin masses to be resected. B, Resultant defects
of the groin. The midline incision was made for the pelvic lymph node dissection. C, Flap design based on the defect width
and length. The flap is centered on the line marked from the trochanter (circle) to the lateral femoral condyle. The
anticipated location of the pedicle at 12 cm is also marked. D, Flap dissected.
Fig. 12F-14 E, Flap rotated into the defect. F, Flap inset with primary closure of the donor site. G, Flap inset with all
wounds closed. The addition of tissue on the left allowed primary closure on the right. Note the shift of the midline scar.
H, The patient is seen 3 months postoperatively after completion of postoperative bilateral radiation therapy to the groin.
I, Lateral-oblique view, including donor scar. The cone of rotation persists and does not concern the patient. Revision with
liposuction or excision would be delayed up to 1 year after irradiation, and as early as 4 months without radiation therapy.
Fig. 12F-15 A, Large full-thickness defect of the abdominal wall with resection of left rectus muscle and some oblique
musculature and overlying fascial. Peritoneal cavity is exposed. The stoma has been relocated to the right side of the
abdomen. B, The entire TFL flap with associated fascia was elevated as a myofascial unit without skin. Elevation stopped
proximally at the lateral circumflex femoral pedicle, which was spared. C, The flap is rotated and passed through a
subcutaneous tunnel to the recipient site. Repair of the fascial defect is performed with the autogenous fascia using a
permanent suture. D, Primary closure is obtained at all sites. Because the distal skin of a TFL is unreliable, abdominal
skin mobilization was favored for closure of the skin defect.
Fig. 12F-16 A, The wound on the day of surgery. There is always an associated bursa (dotted line), and all thin skin
covering the bursa should be resected before planning the flap dimensions, because the dead space needs to be filled to
prevent recurrence. The flap design and the anticipated location of the vascular pedicle are shown. B, Proper debridement
precedes all concerns about the flap. Here thin overlying skin, bursa, and prominent bone have been aggressively resected.
C, The flap easily slides posteriorly to fill the defect and provide adequate skin coverage. The donor site is closed
primarily, supporting the flap advancement. D, Two months postoperatively, the patient's wounds are healed and there is
extra padding to the trochanteric area to prevent recurrence.
Fig. 12F-17 A and B, After the requisite debridement, the patella and quadriceps tendon were exposed. C, A combined
composite LCFA-TFL perforator flap, groin flap, and LCFA-vastus lateralis perforator flap was planned to include a portion
of the iliotibial tract. D, Undersurface of this megaflap. The perforator from the descending branch of the lateral
circumflex femoral vessels (lower right) had to be divided to preserve the motor nerve to the TFL muscle, and then
reanastomosed to itself. The superficial circumflex femoral vessels (upper middle) were anastomosed to the ascending branch
of the lateral circumflex femoral vessels (lower middle). The common trunk of the lateral circumflex femoral vessels was
anastomosed to the medial sural artery and vein at the recipient site. E, The knee extended and F, flexed, 3 years later.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Recommendations
Complications
Bibliography With Key Annotations
Section 12G Vastus Lateralis Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12G-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 12G-2
FLAP HARVEST
Design and Markings
Fig. 12G-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 12G-4 A, Initial exposure reveals the dominant vessels as they enter the undersurface of the vastus lateralis muscle
after passing beneath the rectus femoris muscle.
Fig. 12G-4 B, The vastus lateralis muscle is elevated away from the vastus intermedius muscle. The two muscles are still
attached by numerous deep muscular perforators, which are ligated.
Fig. 12G-4 C, The vastus lateralis muscle is isolated on the DLCF pedicle. For local use the origin may be kept intact or
divided for improved flap rotation or use as a free flap.
FLAP VARIANTS
Distally Based Flap
ARC OF ROTATION
Standard Flap
Fig. 12G-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 12G-6 A, The defect measured 10 by 12 cm. B and C, A vastus lateralis (VL) muscle flap measuring 11 by 16 cm was
harvested from her right thigh. The recipient vessels were the superficial temporal vessels. D and E, Split-thickness skin
grafts over the muscle flap are well healed 3 weeks postoperatively.
Fig. 12G-7 A, A total pelvic exenteration was performed, with exposed, irradiated iliac vessels. B and C, The left vastus
lateralis muscle was raised as an island flap and tunneled under the groin skin to the pelvis to cover the iliac vessels and
obliterate the pelvic dead space. D, Six months later left groin metastasis was noted. Radical groin dissection was
performed, with exposed, irradiated femoral vessels. A colostomy and urostomy were present in the abdomen, and the rectus
femoris vascular pedicle had already been sacrificed; therefore the contralateral right vastus lateralis muscle was raised
as an island flap. E, The flap was tunneled under the suprapubic skin to reach the left groin. F, The area has healed
uneventfully.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Flap Selection
Flap Dissection
Fig. 12G-8
Fig. 12G-9
Donor Site Morbidity
Bibliography With Key Annotations
Section 12H Rectus Femoris Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 12H-1 A, Vascular anatomy. B, Vascular anatomy with surrounding musculature.
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 12H-2
FLAP HARVEST
Design and Markings
Fig. 12H-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 12H-4 A, Location of incision for exposing the rectus femoris. B, Dissection and elevation of the muscle from distal to
proximal with identification of the lateral circumflex femoral vessels.
Fig. 12H-4
Fig. 12H-4 Flap with skin island dissected (still connected to the origin), but with the skin divided all the way around.
The flap has been elevated and rotated but not inset.
FLAP VARIANT
Functional Muscle Transfer
Fig. 12H-5
ARC OF ROTATION
Fig. 12H-6
FLAP TRANSFER
Muscle-Only Flap
Myocutaneous Flap
FLAP INSET
Free Flap
DONOR SITE CLOSURE
All Flap Variants
CLINICAL APPLICATIONS
Fig. 12H-7 A, The groin wound was debrided and irrigated and the rectus femoris was isolated distally through a more limited
approach to minimize wound-healing issues. B, The muscle was released from its attachments distally and was dissected up to
the lateral circumflex femoral pedicle. The muscle was then rotated through 180 degrees of rotation, keeping the muscle
belly down on the exposed graft. Note the excess available flap to ensure a tension-free inset. C, The flap was inset, using
the accompanying fascia to secure the flap tension free, sealing off the graft. Primary skin closure was easily obtained.
Fig. 12H-8 A, The operative defect is shown, with missing skin, muscle, and fascia. The planned flap was marked. Proximal
skin markings were adjusted medially to assist inset of the flap laterally. B, Dissection of the flap with identification of
the lateral circumflex femoral pedicle, which was the limit of dissection on the deep surface. Note that the extra fascial
extension was taken to assist in fascial closure. C, The flap was rotated and prepared for inset. Note the clamps that show
the extent of the fascia available for repair of the defect. Release of the origin of the muscle proximally was performed to
assist in positioning of the flap. D, Final inset of the flap. The edges of the vastus lateralis and vastus medialis were
approximated for 15 cm above the patella with nonabsorbable suture. Primary skin closure was performed, as planned
preoperatively.
Fig. 12H-9 A, The patient's chronic wound is shown, with some granulations but no reepithelialization. Some of the anterior
fascia was missing, with exposed rectus abdominis muscle in the wound. B, Planned rectus femoris myocutaneous flap. C, Flap
inset. The donor and recipient sites were connected, allowing transposition without the need for tunnels and possible flap
compression under tight, irradiated skin. Resection of the irradiated skin was performed to allow flap inset. Primary donor
site closure was obtained. D, The final result after flap dehiscence requiring debridement and reinset.
Fig. 12H-10 A, A primary fascial closure was not obtainable in this area of the pubis. B, Elevation of the rectus femoris
flap with identification of the vascular pedicle. C, The flap was rotated, with tension-free reach and adequate tissue for
reconstruction. Primary fascial closure was obtained using the fascia of the rectus femoris. D, The flap inset. The donor
and recipient sites were united to allow better flap inset and no compression of the vascular pedicle. E, The patient is
shown at his 2-week follow-up. Healing was uneventful.
Fig. 12H-11 A, The defect and the proposed rectus femoris flap are shown. The large soft tissue defect required a large flap
that necessitated skin grafting of the donor site. B, The flap was elevated, the fascial defect was closed with mesh, and
the femoral vessels were covered with the sartorius muscle. C, Flap inset and donor site skin grafted. D, The patient is
shown at his 3-month follow-up. Healing was uneventful.
Fig. 12H-12 A, A chest wound from a spindle cell malignancy with necrosis and obvious subcutaneous metastases and skin
involvement. The proposed area of resection was marked. B, Operative defect with bilateral intrathoracic exposure. The local
pectoralis major and minor muscles were rotated to cover the exposed ribs and clavicle. C, Design of the rectus femoris flap
to be transferred as a free tissue transfer. The size of the flap required skin grafting of the donor site. D, The flap
inset. The lateral circumflex femoral artery was anastomosed end-to-end to the facial artery and the lateral circumflex vein
was anastomosed to an internal jugular vein branch. Purulence was present, so no mesh was placed, and complete fascial
closure was obtained with the fascia carried with the flap. Because of the purulence, the wound was left partially open
superiorly and was packed. Although the flap healed well, the patient's clinical course deteriorated.
Fig. 12H-13 A, The operative defect is shown, with an exposed dural and large skin defect. A cheek flap was elevated for
parotidectomy and lymph node dissection, providing exposure to the neck vessels as recipient vessels for free tissue
transfer. B, Lateral view of the flap elevation showing the perforators of the anterior lateral thigh to be included with
the flap. C, Medial view of the flap showing the anteromedial thigh perforators, also included with the flap. The rectus
femoris, anterior lateral thigh, and anteromedial thigh vessels share a common lateral circumflex femoral source and can be
carried together with one microvascular pedicle connection. D, View of the undersurface of the flap showing the rectus
femoris muscle divided distally and the vascular pedicle isolated up to the source profunda femoris system. E, Flap inset
with rectus femoris muscle covering the dural defect and adequate skin for closure. Microvascular anastomosis was performed
end-to-end to the superficial temporal system. The donor site was skin grafted. The flap and the donor site healed well
postoperatively.
Fig. 12H-14 A, A right thigh-based flap was planned for cutaneous coverage of the anticipated composite resection defect.
The vascular anatomy of the lateral circumflex femoral system was marked on the patient's right leg. B, The composite
resection defect included skin, subcutaneous tissue, and a 15 by 20 cm segment of abdominal wall myofascia. C, After bowel
anastomoses, the myofascial defect was bridged with an inlay of acellular dermal matrix. D, A rectus femoris myocutaneous
flap was elevated from the right leg to repair the cutaneous defect in the right lower quadrant.
Fig. 12H-14 E, The proximal portion of the flap was deepithelialized, and the flap was subsequently tunneled subcutaneously
under the groin skin. A 15 cm distal tenorrhaphy of the vastus lateralis to medialis tendons was performed. F, A
subsartorial transposition was performed to maximize the superomedial reach of the flap. The vascular pedicle was located
medial to the sartorius muscle after the flap was transposed under the sartorius muscle. This maneuver added approximately 6
cm to the flap's reach, allowing a tension-free inset. G, Intraoperative appearance of the primarily closed donor site and
flap inset. H, Appearance of the donor and recipient sites 3 weeks after reconstruction.
Fig. 12H-15 A, Preoperative appearance showing cancer recurrence. B, Computed tomography scan through the lower abdomen
demonstrating tumor recurrence involving the full thickness of the abdominal wall as well as the small bowel, large bowel,
and bladder. C, Preoperative markings for a planned rectus femoris flap to repair the planned composite resection defect.
The vascular anatomy of the lateral circumflex femoral vessels and the borders of the rectus femoris muscle are marked on
the right leg. D, The 20 by 20 cm composite resection defect. The small and large bowels were resected and reanastomosed,
and a partial cystectomy was performed.
Fig. 12H-15 E, The myofascial defect (which was in previously irradiated tissue) was bridged with an inlay of acellular
dermal matrix. F, A large rectus femoris myocutaneous island flap was elevated and transposed superomedially under the
sartorius muscle to increase the flap's reach. This allowed the entire defect to be repaired with a single flap without
tension on the flap inset. G, Closer view of the subsartorial transposition. The lateral circumflex femoral pedicle was
transposed superomedial to the sartorius muscle, markedly reducing the course that the pedicle traveled and thus increasing
the flap's reach. The proximal myotendinous origin of the rectus femoris muscle was tacked to the vastus lateralis myofascia
to prevent inadvertent traction on the vascular pedicle. H, The skin grafted donor site and recipient site 3 months after
the reconstruction.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
Bibliography With Key Annotations
Chapter 13 Leg
Section 13A Fibula Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 13A-1
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 13A-2
Fig. 13A-2
FLAP HARVEST
Design and Markings
Fig. 13A-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 13A-4
Fig. 13A-4
Fig. 13A-4
Fig. 13A-4
Fig. 13A-4
FLAP VARIANTS
Osteocutaneous Flap
Fig. 13A-5
Fig. 13A-5
Osteomuscular Flap
Fig. 13A-6
Epiphyseal Transfer
Fig. 13A-7
Fig. 13A-7
Fig. 13A-7 C and D, Dissection of the peroneus longus and extensor digitorum longus, which are sharply detached 1 cm distal
to their proximal insertion. The peroneal nerve is the landmark indicating the level.
Fig. 13A-7
Fig. 13A-7
ARC OF ROTATION
Bone Flap
Fig. 13A-8
FLAP TRANSFER
Standard Flap
Free Flap
FLAP INSET
Bony Inset
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 13A-9 A, This three-dimensional CT scan shows involvement from the symphysis to the mandibular angle, which was
resected. B, The design of the free fibular flap, with a skin paddle for intraoral lining and monitoring postoperatively.
This design allowed primary closure of the donor site. C, This lateral skull film shows the osteosynthesis. D and E, Lateral
and AP views 2 months postoperatively, demonstrating good cosmesis and function.
Fig. 13A-10 A, MRI revealing the destruction of the maxillary alveolus on the left by cancer. B, Partial maxillectomy
specimen. C, Fibular flap design. D, The fibular bone was double-barreled for maxillary reconstruction to replace the
resected bony hemipalate. The skin paddle was used to close the intraoral defect. Note that the initial reconstruction is
bulky. E, The reconstruction is seen 2 months postoperatively. As is often the case with the maxilla, the flap has filled in
the dead space and contoured nicely without the need for revision. F, Lateral view with normal midface projection. G, Donor
site scar at 2 months.
Fig. 13A-11 A, The intraoral defect is seen, with bone loss and a fistula. B, The fibula flap was harvested and some flexor
hallucis longus muscle was taken with the flap. Osteotomies and osteosynthesis were performed before flap inset. C, Because
this patient was going to need osteointegration for an anterior appliance, the flexor hallucis longus was used for intraoral
closure, rather than the skin paddle of the fibula flap. D, The intraoral muscle will remucosalize and atrophy
significantly, seen here at only 3 weeks postoperatively. This mucosalized surface is required for osteointegration; this
avoided the need for a procedure to debulk an intraoral skin paddle and to place a buccal graft to prepare for integration.
E, The donor site scar is acceptable.
Fig. 13A-12 A, Preoperative lateral view of the patient's lymphedema and her contracted neck, with restricted neck
extension. B, Intraoral plate exposure, with contracted and scarred mucosa. The patient underwent resection of the mandible
from angle to angle. C, Flap dissected and ready for transfer. The skin paddle was used for intraoral lining, while the
hemisoleus was used for resurfacing the neck. D, After release of the neck contracture and inset of the hemisoleus. The
muscle was skin grafted. E, Postoperative view of the healed skin graft and released neck. F, Intraoral view of the healed
fibular skin paddle at 2 months postoperatively.
Fig. 13A-13 A, An anterolateral thigh myocutaneous flap was designed and reconstruction was performed; the flap measured 22
by 8 cm. B, Subsequently the patient developed osteoradionecrosis of the right residual mandible 1 year after radiation
therapy. After a segmental mandibulectomy the defects were 4 by 2 cm of intraoral lining, 5 cm of mandible, and 7 by 4 cm of
external cheek. A fibular osteoseptocutaneous flap including 5 cm of bone and two separate skin paddles measuring 5 by 3 cm
and 8 by 5 cm was harvested for the composite mandibular reconstruction. The left superior thyroid artery and external
jugular vein were used as the recipient vessels. The soleus muscle, which was based on the myocutaneous perforator of the
proximal pedicle, was not harvested for the coverage of the fibula and plate, because it could not reach the desired inset
area. The flap survived in its entirety with an ischemia time of 194 minutes. C, At 12-month follow-up, the patient had no
symptoms or signs of osteoradionecrosis or orocutaneous fistula, but was still fed with a tube because of a previous total
glossectomy.
Fig. 13A-14 A, The patient is shown undergoing wide excision of a right buccal squamous cell carcinoma. B, A large skin
paddle was designed and split into two parts in a chimeric fashion, because more than one perforator could be recruited into
the fibular flap. The lateral subunit of soleus was elevated and based on a separate myocutaneous perforator as the
osteomyocutaneous peroneal artery combined flap.
Fig. 13A-14 C and D, When there are no sizable septocutaneous perforators during fibular flap dissection despite
preoperative Doppler mapping one may convert the osteocutaneous fibular flap to an osseous flap intraoperatively. E, A 15 by
9 cm anterolateral thigh myocutaneous flap with 12 by 8 cm of vastus lateralis was harvested for intraoral lining and
obliteration of the maxillary sinus. F, At 2-year follow-up, the patient was satisfied with the functional and cosmetic
outcome of the reconstruction. G, This Panorex view shows good reconstructed mandibular alignment with fibular bone and
reconstruction plate.
Fig. 13A-15 A and B, AP and lateral preoperative views of the patient. C, Preoperative Panorex view. Note the left
mandibular segmental defect and malocclusion that resulted from the unstable residual mandible. D, This three-dimensional CT
scan clearly demonstrates the left mandibular segmental defect and malocclusion. E, An osteomyocutaneous peroneal artery
combined flap with 12 by 5 cm of skin and 6 by 3 by 2 cm of soleus muscle was harvested for reconstruction of the left
mandible and external cheek.
Fig. 13A-15 F, Two fibular segments with a total length of 8 cm were fixed to the reconstruction plate after the temporary
intermaxillary fixation. The left superior thyroid vessels were used as the recipient site. The vessels were found to be
fibrotic and were sequentially resected until healthy intima and rigorous spurting were noted. Vein grafts of 6 cm and 7 cm
in length were used to bridge both arterial and venous anastomoses, respectively. The ischemia time was 6 hours. The soleus
muscle was flipped over on top of the reconstruction plate for plate protection and volume augmentation. The skin paddle was
used for cheek coverage. No complications were encountered. G and H, The patient underwent two revisions for
deepithelialization and fat grafting for volume augmentation and better cosmesis. At 20-month follow-up, the patient was
satisfied with the functional and cosmetic results. I, A Panorex view and J, a three-dimensional CT scan show acceptable
occlusion and good reconstructed mandibular alignment with fibular bone and reconstruction plate.
Fig. 13A-16 A and B, A radiograph and MRI showed massive involvement of the diaphysis as well. C, The wide margin resection
included the epiphysis and the proximal two thirds of the diaphysis. D, After transfer of the fibula, the joint was
stabilized using half of the biceps femoris tendon, which was woven in the residual capsule. E, Bone fixation was achieved
with a reconstruction plate and a few screws. This provides a very elastic implant that prevents stress fractures.
Fig. 13A-16 F, The overall growth of the transferred fibula after 3 years has been 2.9 cm. G and H, The patient's range of
motion is demonstrated at 3-year follow-up. Some functional impairment has resulted from oncologic muscle resection.
Fig. 13A-17 A, Involvement of the growth plate and epiphysis was evident on MRI. B, Angiography was performed to assess the
vascular supply of the proximal fibular epiphysis, and the recurrent epiphyseal branch was visualized. C, The proximal
ipsilateral fibula, including a diaphyseal segment 7 cm long, was harvested, based on the anterior tibial artery, and was
transferred to the recipient site. A step-cut osteotomy was performed and bone fixation was achieved by means of three lag
screws. The overall growth after 4 years has been 3.4 cm. D and E, Near-normal range of motion of the wrist has been
recovered in all planes.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Fig. 13A-18
Fig. 13A-19
Fig. 13A-20
Anatomic Considerations
Personal Experience and Insights
Recommendations
Fig. 13A-21
Fig. 13A-22
Fig. 13A-23
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
References
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications
Bibliography With Key Annotations
Section 13B Soleus Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 13B-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 13B-2
FLAP HARVEST
Design and Markings
Fig. 13B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 13B-4 A, Medial approach incision.
Fig. 13B-4 B, The separation between the soleus and gastrocnemius muscles is first identified in the midcalf. This
separation can also be found near the Achilles tendon, but the plane of dissection is less clearly defined. Note the
plantaris tendon on the surface of the soleus muscle, indicating that the plane of dissection between the two muscles is
correct.
Fig. 13B-4 C, A deep muscular perforator is identified passing from the soleus muscle to the undersurface of the
gastrocnemius muscle. The soleus muscle is separated from its medial attachment to the tibia starting at the point at which
the plantaris tendon crosses the distal muscle. In the area of the Achilles tendon, the soleus muscle must be sharply
separated from the gastrocnemius muscle and the Achilles tendon.
Fig. 13B-4 D, The soleus muscle is separated from the Achilles tendon. It is still attached to most of the deep perforating
branches from the posterior tibial artery. These deep perforators may be divided if it is necessary to increase the upward
excursion of the muscle. If they can be left intact, the blood supply to the muscle flap will be enhanced.
Fig. 13B-4 E, During the dissection of the fibula flap, rather than dissecting away the soleus muscle, the hemisoleus is
harvested with the flap (posterior view). F, Cross-section of the fibula flap harvested with lateral hemisoleus, all
nourished by the peroneal vessels.
FLAP VARIANT
Distally Based Hemisoleus Flap
Fig. 13B-5
ARC OF ROTATION
Medial Based Hemisoleus Flap
Fig. 13B-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 13B-7 A, The patient had a 12 by 6 cm middle third tibial wound associated with the underlying tibial fracture in the
right leg. B, The proximally based medial hemisoleus muscle flap was used to cover the entire middle third tibial wound. C,
Completion of the muscle flap inset before skin graft placement. D, Result at 3-month follow-up.
Fig. 13B-8 A, The patient had a 5.5 by 3 cm tibial wound in the junction of the middle and distal thirds of the left leg
with an exposed tibial fracture site. B, Completion of the proximally based medial hemisoleus muscle flap before placement
of a skin graft. C, Result at 5-month follow-up.
Fig. 13B-9 A, This woman had a 5.5 by 2.5 cm tibial wound in the distal third of the right leg close to the medial malleolus
with an exposed tibial fracture site and plate. B, Completion of the distally based medial hemisoleus muscle flap inset
before placement of a skin graft. C, Result at 21-month follow-up.
Fig. 13B-10 A, The patient is seen after stabilization from his other injuries, now 2 weeks after the accident. There is a
large upper and middle third of the leg skin defect with exposed devitalized bone and granulation tissue. B, His arteriogram
demonstrated intact vessels to the foot. The comminuted fracture of the fibula is seen. C, After aggressive debridement of
devitalized tissues, significant defects of the upper and middle thirds of the leg remained. Also, staged bone grafting was
desired, so muscle flaps were designed to cover the entire defect with viable muscle. The medial gastrocnemius was harvested
for the upper third defect, and the medial hemisoleus was harvested for the middle third defect. Note the scoring of the
muscular fascia to extend reach for wound coverage. D, Flaps transposed into the defect, providing total muscle coverage of
the wound. The surface of the muscle was skin grafted. E, The patient is seen at 2 weeks postoperatively with uncomplicated
healing.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Fig. 13B-11 A, Flap dissection and blood supply to the proximally based medial hemisoleus muscle flap. The flap is based
proximally and receives blood supply primarily from the posterior tibial vessels. The flap also receives additional blood
supply from one or two distal perforators of the posterior tibial vessels to its distal portion. B, Flap dissection and
blood supply to the distally based medial hemisoleus muscle flap. The flap is based distally and receives blood supply
primarily from the most distalmost two or three perforators of the posterior tibial vessels.
Personal Experience and Insights
Recommendations
Fig. 13B-12 An intraoperative view shows an adjacent perforator (indicated by forceps) from the posterior tibial vessels to
the medial hemisoleus muscle flap. Preservation of this perforator may be critical to ensure an adequate blood supply to the
distal portion of the proximally based flap.
Fig. 13B-13 An intraoperative view shows the first large perforator (indicated by forceps) from the posterior tibial vessels
to the distally based medial hemisoleus muscle flap. This perforator serves as a pivot point of the flap turnover, and
preserving it may be critical to ensure an adequate blood supply to the distal portion of the distally based flap.
Postoperative Care
Complications
Take-Away Messages
Bibliography With Key Annotations
Anatomic/Experimental Studies
Clinical Series
Flap Modifications
Section 13C Sural Artery Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 13C-1 The arterial basis for the sural flap is a branch arising either from the popliteal artery or from the lateral
sural artery. From its origin, the artery usually follows the course of the lateral sural cutaneous nerve, reaching the
overlying fascia approximately 5 cm inferior to the popliteal crease. The artery and nerve continue distally in a subfascial
course for a variable distance. Both suprafascial and subfascial plexuses are supplied by these class B fasciocutaneous
vessels. The lesser saphenous vein courses in a subcutaneous plane between the two heads of the gastrocnemius muscle. Paired
venae comitantes accompany the fasciocutaneous artery; these veins are preferentially used to establish venous drainage for
the transplanted flap. The lesser saphenous vein is usually not employed. The lateral sural cutaneous nerve arises in the
popliteal fossa from the common peroneal nerve. After giving rise to a communicating nerve, it usually penetrates the deep
fascia 5 to 10 cm distal to the popliteal crease supplying the fascia and skin of the lateral two thirds of the leg.
ANATOMY
Arterial Anatomy
Venous Anatomy
Nerve Supply
Fig. 13C-2
FLAP HARVEST
Design and Markings
Fig. 13C-3 A, Design for anterograde flap. B, The design of the distally based superficial sural artery flap on the
posterior aspect of the leg. The skin island can be raised anywhere in the lower two thirds of the leg. The pivot point of
the pedicle must be at least 5 cm above the lateral malleolus to keep the anastomoses with the peroneal artery.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 13C-4
FLAP VARIANTS
Reverse Sural Flap
Fig. 13C-5 A, Skin island raised and sural pedicle identified. B, The skin island is raised with the deep fascia. The
subcutaneous fascial pedicle is elevated, keeping a width of 2 cm to include the sural nerve and the short saphenous vein.
C, Flap transposed and donor site skin grafted.
Adipofascial Flap
Fig. 13C-6 The fascial flap supplied by the superficial sural vessels. The deep fascia without a skin island can be elevated
safely.
Delayed Flap
Fig. 13C-7 The flap is incised medially and laterally, not superiorly, and is completely undermined. The area indicated by
the dashed line is divided at 1 week and the flap moved at 2 weeks.
Supercharged Flap
ARC OF ROTATION
Anterograde Flap
Fig. 13C-8
Reverse Flap
Fig. 13C-9
FLAP TRANSFER
Standard Flap
Reverse Flap
FLAP INSET
Standard Flap
Reverse Flap
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 13C-10 A, This defect developed after tumor excision and a failed skin graft. B, The flap was designed with a distal
tail-like extension. C, The flap was completely elevated, maintaining a wide base 5 cm above the malleolus.
Fig. 13C-10 D, The flap was rotated into the defect. E and F, The flap was inset with a small-lumen angiocatheter placed in
the lesser saphenous vein. G, Before skin grafting the donor site, purse-string sutures were placed to decrease its size. H,
The healed flap is shown 4 weeks postoperatively.
Fig. 13C-11 A, Preoperative appearance of bilateral heel ulcers. B, The right heel after debridement of bone and soft
tissues, now with calcaneus exposed in the wound. C, Skin incisions and proximal flap dissection. D, After rotating the flap
into the defect site. E, The flap was sutured into the defect site, and a small skin graft was placed over the fascial
pedicle. F, The healing right ankle flap and G, left ankle flap are seen 3 weeks postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Fig. 13C-12 Design and markings for the sural flap.
Postoperative Care
Complications: Avoidance and Treatment
Take-Away Messages
References
Bibliography With Key Annotations
Section 13D Gastrocnemius Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 13D-1
ANATOMY
Arterial Anatomy (Type I)
Venous Anatomy
Nerve Supply
Fig. 13D-2
Fig. 13D-2
Fig. 13D-2
FLAP HARVEST
Design and Markings
Fig. 13D-3 Dissection of the gastrocnemius muscle using a stocking-seam incision or direct incision.
Patient Positioning
GUIDE TO FLAP DISSECTION
Medial Gastrocnemius
Fig. 13D-4 A, Medial head of the gastrocnemius muscle, with the sural nerve at its lateral border.
Fig. 13D-4 B, The medial head is converted into a true island flap by division at its origin from the femur. The fascia is
dense on the undersurface of the muscle. This fascia can be scored or completely excised to expand the area of muscle
coverage.
Fig. 13D-4 C, Both the tibial tubercle and the patella are easily covered by the medial head.
Lateral Gastrocnemius
Fig. 13D-5
FLAP VARIANTS
Myocutaneous Flap
Functional Muscle Transfer
ARC OF ROTATION
Medial Gastrocnemius
Fig. 13D-6
Fig. 13D-6
Lateral Gastrocnemius
Fig. 13D-7
Fig. 13D-7
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 13D-8 A, The defect was largely in the upper third, seen here after aggressive debridement. Methylmethacrylate spacers
were placed for two-stage bony reconstruction. A medial gastrocnemius flap was planned. B, The medial gastrocnemius was
elevated from within the wound. After scoring the muscle fascia for extended coverage, the origin did not require division.
This was preferred to protect the pedicle postoperatively from undue tension. C, The flap was transposed, completely
covering the exposed spacers. D, The leg is seen 2 months postoperatively with uncomplicated healing and a nice contour.
Fig. 13D-9 A, The wound at presentation. Although the wound appears small, it contained dead bone and was larger after
debridement, with an associated dead space. B, After elevation of the medial gastrocnemius flap and inset, obliterating the
cavity. The muscle and the surrounding bed were then skin grafted. C, Oblique and D, AP views of the leg at 4 weeks
postoperatively. The wounds healed completely without the need for revisions.
Fig. 13D-10 A, A medial gastrocnemius flap for an upper third defect. B, At inset, the surrounding skin was undermined,
allowing inset of the muscle beyond the wound edges and leveling the surface contour. This is also helpful if some skin edge
should necrose, since underlying healthy muscle will be exposed. C, Wound at 1 month postoperatively, already showing an
excellent contour. D, The patient's leg has excellent aesthetics and function at 9 months.
Fig. 13D-11 A, The wound is seen 2 weeks after the patient's accident, after stabilization from his other injuries. There is
a large upper and middle third of the leg skin defect, with exposed devitalized bone and granulation tissue. B, His
arteriogram showed intact vessels to the foot. The comminuted fracture of the fibula is seen. C, After aggressive
debridement of devitalized tissues, significant defects of the upper and middle thirds of the leg remained. Also, staged
bone grafting was desired, so muscle flaps were designed to cover the entire defect with viable muscle. The medial
gastrocnemius was harvested for the upper third defect, and the medial hemisoleus was harvested for the middle third defect.
Note the scoring of the muscular fascia to extend reach and wound coverage. D, Flaps transposed into the defect, providing
total muscle coverage of the wound. The surface of the muscle was skin grafted. E, The patient is seen 2 weeks
postoperatively, with uncomplicated healing.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Take-Away Message
Bibliography With Key Annotations
Clinical Series
Flap Modifications
Section 13E Anterior Tibial Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 13E-1
ANATOMY
Arterial Anatomy (Type IV, Muscle)
Venous Anatomy
Nerve Supply
Fig. 13E-2
FLAP HARVEST
Design and Markings
Fig. 13E-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 13E-4 A, A posterior incision is first made over the peroneal muscle through the skin and crural fascia. Dissection is
continued in its subfascial plane from a posterior to an anterior direction. Dissection continues to the anterior
intermuscular septum.
Fig. 13E-4 B, The SLPA and its venae comitantes are identified in the intermuscular septum.
Fig. 13E-4 C, The superior margin of the flap is elevated, and the SLPA and its venae comitantes are identified and traced
within the intermuscular septum to their origin from the anterior tibial artery and its venae comitantes. Note that the
superficial peroneal nerve at this deep location is lateral to the vascular pedicle within the septum.
Fig. 13E-4 D, An anterior flap incision is made and carried posteriorly to the intermuscular septum, further isolating the
flap on its vascular pedicle.
Fig. 13E-4 E, The extensor muscles are retracted medially, and the flap vessels are traced more proximally to their origin
from the anterior tibial artery and its venae comitantes. Muscle branches are ligated.
Fig. 13E-4 F, If the SLPA is thought to be inadequate in size and diameter, additional fasciocutaneous and myocutaneous
branches coursing through the tibialis anterior muscle may be included. This would by necessity make the anterior tibial
artery and its vena comitans a donor pedicle, sacrificing major limb vessels.
Fig. 13E-4 G, The fasciocutaneous flap is isolated on the proximal anterior tibial artery and its vena comitans and is
observed for continuous perfusion.
FLAP VARIANTS
Reverse Flap
Fig. 13E-5
Muscle Flap
Fig. 13E-6
Vascularized Nerve Graft
Fig. 13E-7 A, Anterior tibial vascular system and its relationship to the deep peroneal nerve. B, Clinical example of a
harvested deep peroneal nerve graft with a short segment of the pedicle vessel and a small anterior tibial artery perforator
(ATAP) monitor flap.
ARC OF ROTATION
Proximally Based Perforator Flap
Fig. 13E-8
Distally Based Perforator Flap
Fig. 13E-9
Muscle Flap
FLAP TRANSFER
Reverse Flap
Muscle
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 13E-10 A, Degloving injury at presentation. B, The wound was debrided, including the shredded fascia of the tibialis
anterior muscle (upper arrow). The tibia stripped of periosteum was exposed (lower arrow), with insufficient skin remaining
for primary closure. C, The exposed tibialis anterior muscle (arrow) was minimally split sagittally (dashed line) to allow
simple advancement to cover the bone. D, The healed right leg is seen after skin grafting of the tibialis anterior muscle
and the residual defect.
Fig. 13E-11 A, Heel defect at presentation. B, Design of the anterior tibial skin flap based on proximal perforators, with
the course of the anterior tibial artery marked. C, The elevated flap was attached to the distal anterior tibial vascular
pedicle. D, The distally based anterior tibial artery flap was turned to reach the heel defect. E, Venous congestion
developed after flap insetting, a notorious problem with this flap. F, Nevertheless, enough flap survived to allow ultimate
healing. G, A detrimental factor with the use of the anterior tibial artery flap is the unaesthetic skin grafted donor site.
Fig. 13E-12 A, Exposed plate (arrow) after open reduction surgery. B, A proximally based peninsular flap (arrow) was raised
over the anterior lower leg, carefully dissected to prevent exposure of the underlying tendons. C, Although the flap
adequately covered the plate, a large donor site defect (arrow) required skin grafting. D, This relatively simple maneuver
in this moribund patient provided adequate coverage for what later proved to be a useful limb salvage.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Take-Away Messages
References
Bibliography With Key Annotations
Chapter 14 Foot
Section 14A Abductor Digiti Minimi Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 14A-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 14A-2
Fig. 14A-2
FLAP HARVEST
Design and Markings
Fig. 14A-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 14A-4
FLAP VARIANTS
Distally Based Flap
Fig. 14A-5
Reverse Flap
Fig. 14A-6
ARC OF ROTATION
Fig. 14A-7
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 14A-8 A, The lateral calcaneal defect is seen, with exposed bone and hardware with soft tissue loss. B, The abductor
digiti minimi flap was turned over to cover the defect. C, A split-thickness skin graft was harvested and affixed over the
top of the muscle flap. D, The final result is seen.
Fig. 14A-9 A, The patient had a chronic nonhealing wound of the posterolateral heel with underlying osteomyelitis. B, The
abductor digiti minimi muscle was detached from its distal insertion and dissected to the level of its dominant vascular
pedicle. C, The muscle was turned 180 degrees and inset into the wound. D, The final result following muscle coverage and
skin grafting.
Fig. 14A-10 A, Plantar foot wound with exposed bone at the base following a cuboidectomy. B, Abductor digiti minimi muscle
elevated and tunneled underneath the lateral plantar skin to aid in obliteration of dead space. C, Design of the medial
plantar V-Y fasciocutaneous flap. D, Mobilization of the V-Y fasciocutaneous flap. E, The result is seen 1 month
postoperatively.
Fig. 14A-11 A, Chronic nonhealing wound of the anterolateral ankle with underlying osteomyelitis. B, The abductor digiti
minimi muscle detached from its distal insertion and dissected to the level of its dominant vascular pedicle. C, The muscle
was turned and inset into the wound. D, The result after muscle coverage and skin grafting.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications
Take-Away Messages
References
Bibliography With Key Annotations
Section 14B Flexor Digitorum Brevis Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 14B-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 14B-2
Fig. 14B-2
FLAP HARVEST
Design and Markings
Fig. 14B-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 14B-4
Fig. 14B-4
Myocutaneous Flap
FLAP VARIANT
Reverse Flap
Fig. 14B-5
ARC OF ROTATION
Standard Flap and Myocutaneous Flap
Fig. 14B-6
Reverse Flap (Muscle or Myocutaneous V-Y Advancement)
Fig. 14B-7
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 14B-8 A, The patient had loss of subcutaneous fat of her heel pad subsequent to a puncture injury, with resultant
infection. B, Lateral view of the heel pad contour. C, The bursal space overlying the calcaneus was opened and debrided
through a small transverse incision. The flexor digitorum brevis muscle and its overlying plantar fascia was exposed through
a midline plantar incision that stopped short of the transverse heel pad incision. D, The flexor brevis muscle, with the
attached plantar fascia, was turned over from distal to proximal after the division of the flexor digitorum brevis tendons.
It could then be inset into the debrided bursal space overlying the bone. E, Postoperatively the improved heel pad permits
painless ambulation, and plantar scars are barely visible.
Fig. 14B-9 A, The patient's recurrent plantar heel ulceration after prior closure with a heel pad rotation flap and skin
graft to the donor site. B, A plantar midline incision exposed the plantar fascia with the flexor digitorum brevis muscle
just deep to the fascia. C, The muscle flap and overlying fascia were turned over into the debrided wound and covered with a
thick split-thickness skin graft.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Take-Away Messages
Bibliography With Key Annotations
Section 14C Abductor Hallucis Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 14C-1
ANATOMY
Arterial Anatomy (Type II)
Venous Anatomy
Nerve Supply
Fig. 14C-2
Fig. 14C-2
FLAP HARVEST
Design and Markings
Fig. 14C-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Muscle Flap
Fig. 14C-4
FLAP VARIANTS
Standard Myocutaneous Flap
Myocutaneous Reverse V-Y Flap
Fig. 14C-5
ARC OF ROTATION
Standard Flap
Fig. 14C-6
Reverse Flap
Fig. 14C-7
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 14C-8 A, Following neurolysis of the tibial nerve posterior to the medial malleolus, the abductor hallucis muscle was
elevated as described. B, The muscle flap was transposed without dividing the muscle's origin and easily covered the tibial
nerve. C and D, The patient is shown 3 months postoperatively
Fig. 14C-9 A and B, Fourth-degree burn of the medial hindfoot. C, The course of the abductor hallucis muscle belly was
outlined. D, The patient is shown after debridement, abductor hallucis muscle flap transposition, and skin grafting.
Pearls and Pitfalls
EXPERT COMMENTARY
Anatomic Considerations
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Bibliography With Key Annotations
Section 14D Dorsalis Pedis Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 14D-1
ANATOMY
Arterial Anatomy (Type B)
Venous Anatomy
Nerve Supply
Fig. 14D-2
Fig. 14D-2
FLAP HARVEST
Design and Markings
Fig. 14D-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 14D-4 A, Outline of the dorsalis pedis flap, whose central axis lies along the second metatarsal bone. Note that flap
elevation begins by incising the distal margin and locating the first dorsal metatarsal artery. Dissection proceeds
proximally deep to the first dorsal metatarsal artery.
Fig. 14D-4 B, The extensor hallucis brevis tendon crosses the first dorsal metatarsal artery superficially from medial to
lateral. This muscle-tendon unit is divided, and the muscle is included with the flap.
Fig. 14D-4 C, The first dorsal metatarsal artery is traced proximally to the origin of the deep plantar artery, which is
carefully ligated distal or deep to the origin of the first dorsal metatarsal artery.
Fig. 14D-4 D, The flap, now elevated, is attached only to the anterior tibial artery and its vena comitans, the greater
saphenous vein, and the superficial peroneal nerve branches.
FLAP VARIANTS
Tendinocutaneous Flap
Sensory Flap
Fig. 14D-5
Fig. 14D-6
Osteocutaneous Flap
Fig. 14D-7
Distally Based Reverse Flow Flap
Fig. 14D-8 Similar to the dorsal metacarpal artery flap in the hand, a reverse flow flap can be based on the dorsalis pedis-
dorsal metatarsal vessels and their interconnection with the deep plantar artery.
ARC OF ROTATION
Standard Flap
Fig. 14D-9
Distally Based Reverse Flow Flap
Fig. 14D-10
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 14D-11 A, Lateral malleolar defect closed by pedicled dorsalis pedis flap. The flap was sited to span possible
perforators proximal and distal to the belly and tendon of the extensor hallucis brevis from the dorsalis pedis artery and
dorsal metatarsal arteries, respectively. B, Designing the length of the pedicle. C, Immediate postoperative result. D, The
reconstructed site in seen 10 days postoperatively. There is superficial blistering of the flap; the graft site is healing
well. This is probably the most favorable site and size for minimal morbidity from the dorsalis pedis flap.
Fig. 14D-12 A, Posterior heel-Achilles defect. B, A free dorsalis pedis flap was transferred from the opposite foot. C,
Immediate postoperative result. D and E, The patient's heel is seen 2 years postoperatively. Note the ideal, adherent thin
skin, and the acceptable size and site of secondary defect on the donor foot, with minimal morbidity.
Fig. 14D-13 A, Preoperative view of the patient's maxillary defect. The lip segment was free floating, without support. B,
The flap design was centered over the dorsalis pedis artery and included the saphenous vein. C, The elevated and skin paddle
are shown. D, The flap's undersurface with the second metatarsal. E, The inset flap; the reconstructed palate can be seen.
The lip segment was inset into a deepithelialized strip of the skin paddle. Osteosynthesis of the metatarsal was performed
to the neighboring zygoma bilaterally. F, The donor site was closed with an amputation of the second toe and closure as in a
ray section. The superficial wound was closed. The flap reconstruction healed well, and the patient was able to speak and
eat without an obturator. The donor site had some breakdown, requiring prolonged dressing changes. Donor site issues
represent the biggest drawback to the use of this flap.
Pearls and Pitfalls
EXPERT COMMENTARY
Anatomic Considerations
Indications
Advantages and Disadvantages
References
Bibliography With Key Annotations
Section 14E Medial Plantar Artery Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 14E-1
ANATOMY
Arterial Anatomy (Type B)
Venous Anatomy
Nerve Supply
Fig. 14E-2
Fig. 14E-2
FLAP HARVEST
Design and Markings
Fig. 14E-3
Patient Positioning
GUIDE TO FLAP DISSECTION
Standard Flap
Fig. 14E-4
FLAP VARIANTS
Standard Flap With Incorporated Abductor Hallucis Muscle
Reverse V-Y Advancement Flap
Microvascular Island Flap Transfer
ARC OF ROTATION
Standard Flap
Fig. 14E-5
Reverse V-Y Advancement Flap
Fig. 14E-6
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 14E-7 A, The heel defect after wide excision. B, The dotted line shows the border of the weight-bearing sole. The flap
was designed within the non-weight-bearing portion of the foot. C, The flap was elevated in the subfascial plane, exposing
the medial plantar nerve and the vascular bundle. D, The wound was closed over a silicone sheet and the recipient site was
temporarily dressed. Note that the proximal portion of the flap was maintained. E, Ten days later, the flap was elevated and
the skin incision completed. The flap was raised based on the medial plantar pedicle. F, After flap inset and skin grafting
of the donor site. The flap was congested and turned white when closure was attempted, so the flap was only partially inset
and closed with the patient under local anesthesia in the office 1 week later. G and H, Two weeks postoperatively, the flap
is viable, has a nice contour, and the skin graft is healing. The patient began ambulating at 6 weeks postoperatively and
required no further surgical interventions.
Fig. 14E-8 A, The patient had an intermediate-thickness melanoma on the weight-bearing region of his left heel. B, A wide
local excision left a defect of 6 by 4 cm over the heel. C, A 9 by 6 cm medial plantar artery flap was raised in a
subfascial plane. Intraneural dissection was performed to isolate the cutaneous medial plantar nerve and preserve sensation
to the flap. D and E, The flap was rotated to cover the defect. The donor defect was covered with a split-thickness skin
graft. F, The postoperative course was uneventful, and the flap survived completely. The patient was bearing full weight on
the sensate flap with usual footwear when seen 9 months postoperatively.
Fig. 14E-9 A and B, The patient had an intermediate thickness melanoma on the weight-bearing heel of his left foot. C, A
wide local excision left a defect of 12 by 6 cm over the heel and a portion of the weight-bearing lateral sole. D, A 10 by 5
cm island medial plantar artery flap with a neurovascular pedicle was raised in a subfascial plane. Intraneural dissection
was performed to isolate the cutaneous medial plantar nerve and preserve sensation to the flap.
Fig. 14E-9 E and F, The flap was rotated into the defect, and a split-thickness skin graft was used to cover the donor
defect. G-I, The postoperative course was uneventful, and the flap survived completely. The patient was bearing full weight
on the sensate flap with usual footwear when seen 8 months postoperatively.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications
References
Bibliography With Key Annotations
Section 14F Lateral Calcaneal Flap
ANATOMIC LANDMARKS
CLINICAL APPLICATIONS
Fig. 14F-1
ANATOMY
Arterial Anatomy (Type A)
Venous Anatomy
Nerve Supply
Fig. 14F-2
FLAP HARVEST
Design and Markings
Fig. 14F-3 Solid black curved lines depict the design of the long version of the lateral calcaneal flap, here intended to
reach a plantar heel wound. The distal end of the flap can be clamped for assessment of flap circulation before its
division, in case a delay is indicated because of unsatisfactory perfusion.
Patient Positioning
GUIDE TO FLAP DISSECTION
Fig. 14F-4
FLAP VARIANTS
Island Flap
Distally Based Flap
V-Y Advancement Flap
ARC OF ROTATION
Fig. 14F-5
FLAP TRANSFER
FLAP INSET
DONOR SITE CLOSURE
CLINICAL APPLICATIONS
Fig. 14F-6 A, The patient is seen preoperatively. B, After debridement, a proximal pedicled flap was designed with its
anterior border just posterior to the lateral malleolus. The distal flap border curved slightly forward and was longer than
the defect to compensate for the loss of reach during the rotation. C, The dog-ear rotation is seen after flap inset, with
the open donor site defect that required a skin graft. D, The flap provided satisfactory coverage, with spontaneous
flattening of the dog-ear.
Fig. 14F-7 A, Flap design. B, The flap was elevated, including the lateral calcaneal vessels. C, A split-thickness skin
graft was placed on the periosteum of the donor site, and a drain was placed. D, The healed flap and donor site are shown.
Fig. 14F-8 A and B, The wound is shown before and after debridement. C, The flap design is shown. D, The flap healed, but
despite the skin graft, the donor site took 9 months to heal because of poor surrounding blood flow.
Pearls and Pitfalls
EXPERT COMMENTARY
Indications
Advantages and Limitations
Anatomic Considerations
Personal Experience and Insights
Recommendations
Postoperative Care
Complications: Avoidance and Treatment
Fig. 14F-9 A, This lateral calcaneal flap died when it was dissected, leaving the underlying pedicle behind. B, The flap was
debrided, and the wound was treated with negative pressure until it could be skin grafted.
Take-Away Messages
References
Bibliography With Key Annotations
Back Matter
Credits
Index