Reconstructive

Surgery
Anatomy,
Anatomy, Technique,
Technique, and Clinical Applications
and Clinical Applications

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This page intentionally left blank
 Reconstructive
Surgery
Anatomy,
Anatomy, Technique,and
Technique, andClinical
Clinical Applications
Applications

Michael R. Zenn, MD, FACS

Vice Chief, Division of Plastic and Reconstructive Surgery,
Duke University Medical Center,
Durham, North Carolina

Glyn Jones, MD, FACS

Professor of Surgery, Department of Surgery,
University of Illinois College of Medicine,
Peoria, Illinois

Quality Medical Publishing, Inc.

St. Louis, Missouri
2012

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CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2012 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20140402

International Standard Book Number-13: 978-1-4822-5792-2 (eBook - PDF)

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 To my mother, Renee Schwam,
who has inspired me to dream big, then work hard to achieve.
She came to this country at the end of World War II,
not speaking the language, in search of a new life without persecution.
Despite the barriers that confronted her, she made a life for herself in America.
Throughout my life, whenever challenges faced the family
and things seemed bleak, she was the Rock of Gibraltar
and made certain her children were her priority.
I know that without her guiding light and example,
I could not be the surgeon I am today.
For all of her sacrifice and delay of gratification,
I wish to dedicate this book to her.

Michael R. Zenn

To my wife, Hilarie, for her constant love and cheerful support,

and our treasured children, Christy, Vanessa, and Stephen,
who are the source of my greatest pride
and by far my best contribution in life.

Glyn Jones

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 Experts Providing Commentary
and Clinical Cases

Louis C. Argenta, MD, FACS Hung-Chi Chen, MD, MHA, FACS

Professor, Experimental Surgery and Professor, Department of Plastic Surgery, China
Translational Medicine, Department of Plastic Medical University/China Medical University
and Reconstructive Surgery, Wake Forest Hospital, Taichung, Taiwan
Medical Center, Winston-Salem, North Carolina
Ming-Huei Cheng, MD, MBA, FACS
Christopher E. Attinger, MD, FACS Professor and Chief, Division of Reconstructive
Professor of Plastic Surgery, Chief, Division Microsurgery, Department of Plastic and
of Wound Healing, Georgetown University Reconstructive Surgery, Chang Gung Memorial
Hospital, Washington, DC Hospital, Taoyuan, Taiwan

Basem Abdulla Attum, MS, MD Pierre M. Chevray, MD, PhD

Resident, Department of Orthopedics, Institute for Reconstructive Surgery, The
University of Louisville, Louisville, Kentucky Methodist Hospital, Houston, Texas; Associate
Professor of Plastic Surgery, Weill Cornell
Phillip N. Blondeel, MD, PhD, FCCP Medical College, New York, New York; Adjunct
Professor in Plastic Surgery, Department of Associate Professor of Plastic Surgery, Baylor
Plastic and Reconstructive Surgery, University College of Medicine, Houston, Texas
Hospital Gent, Gent, Belgium
Ernest S. Chiu, MD, FACS
Benjamin J. Brown, MD William Henderson Chair in Surgery, Depart-
Resident in Plastic and Reconstructive Surgery, ment of Plastic Surgery, Tulane University School
Georgetown University Hospital, of Medicine, New Orleans, Louisiana
Washington, DC
Lawrence Colen, MD, FACS
Rudolf F. Buntic, MD Associate Professor of Surgery (Plastic & Recon-
Chief, Division of Microsurgery, California structive), Department of Surgery, Eastern
Pacific Medical Center, Department of Plastic Virginia Medical School, Norfolk, Virginia
Surgery, San Francisco, California; Clinical
Associate Professor in Surgery, Stanford Peter G. Davison, BSc(Eng), MD
University Medical School, Palo Alto, California Resident Physician, Department of Plastic
Surgery, Dalhousie University, Halifax,
Charles E. Butler, MD, FACS Nova Scotia, Canada
Professor with Tenure, Department of Plastic
Surgery, The University of Texas M. D. Anderson Frank J. DellaCroce, MD, FACS
Cancer Center, Houston, Texas Director, Center for Restorative Breast Surgery,
New Orleans, Louisiana
David W. Chang, MD, FACS
Professor, Deputy Chairman of Clinical Gregory Ara Dumanian, MD, FACS
Operations, Director of Plastic Surgery Clinic, Chief of Plastic Surgery, Division of Plastic
Department of Plastic Surgery, The University Surgery, Northwestern Feinberg School of
of Texas M. D. Anderson Cancer Center, Medicine, Chicago, Illinois
Houston, Texas

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 viii Experts Providing Commentary and Clinical Cases

Matthew Endara, MD Geoffrey C. Gurtner, MD, FACS

Resident in Plastic and Reconstructive Surgery, Professor of Surgery, Professor of Materials
Georgetown University Hospital, Science and Engineering, Division of Plastic
Washington, DC and Reconstructive Surgery, Department of
Surgery, Stanford University School of Medicine,
Detlev Erdmann, MD, PhD, MHSc Stanford, California
Associate Professor, Division of Plastic, Recon-
structive, Maxillofacial, and Oral Surgery, Geoffrey G. Hallock, MD, FACS
Department of Surgery, Duke University Consultant, Division of Plastic Surgery, Sacred
Medical Center, Durham, North Carolina Heart Hospital, Allentown, Pennsylvania;
Consultant, Division of Plastic Surgery, St. Luke’s
Karen Kim Evans, MD, FACS Hospital, Bethlehem, Pennsylvania
Assistant Professor, Department of Plastic
Surgery, Georgetown University Medical Center, Moustapha Hamdi, MD, PhD
Washington, DC Professor and Chairman, Department of Plastic
and Reconstructive Surgery, Brussels University
Jeffrey D. Friedman, MD Hospital; Professor, Department of Plastic
Chief, Plastic Surgery, Department of Surgery, Surgery, Edith Cavell Medical Institute,
The Methodist Hospital, Houston, Texas; Brussels, Belgium
Associate Professor of Surgery, Department of
Plastic and Reconstructive Surgery, Weill Cornell Matthew M. Hanasono, MD, FACS
Medical College, New York, New York Associate Professor, Department of Plastic
Surgery, The University of Texas M. D. Anderson
Guenter Germann, MD, PhD, FACS Cancer Center, Houston, Texas
Professor of Plastic Surgery-Hand Surgery,
University of Heidelberg, Ethianum Clinic for James P. Higgins, MD, FACS
Plastic and Reconstructive Surgery, Aesthetic and Chief, The Curtis National Hand Center, Union
Preventive Medicine at Heidelberg University Memorial Hospital, Baltimore, Maryland
Hospital, Heidelberg, Germany
Jung-Ju Huang, MD
Lawrence J. Gottlieb, MD, FACS Assistant Professor, Division of Reconstructive
Professor of Surgery, Director of Burn and Microsurgery, Department of Plastic and Recon-
Complex Wound Center, Department of structive Surgery, Chang Gung Memorial
Surgery, Section of Plastic and Reconstructive Hospital, Taoyuan, Taiwan
Surgery, University of Chicago, Chicago, Illinois
Marco Innocenti, MD
Adriaan O. Grobbelaar, MBChB, Director, Reconstructive Microsurgery Division,
MMed(Plast), FRC(Plast), FRCS(Plast), Department of Oncology, Careggi University
FRCS(ad eundem) Hospital, Florence, Italy
Department of Plastic and Reconstructive
Surgery, Royal Free Hospital; Honorary Senior Ian T. Jackson, MD, DSc (Hon),
Lecturer, Division of Surgery, University College FRCS, FRACS (Hon)
London, London, United Kingdom Professor Emeritus, Beaumont Health Systems,
Royal Oak, Michigan
Amit Gupta, MD, FRCS
Associate Clinical Professor, Department of Leila Jazayeri, MD
Orthopedic Surgery, University of Louisville; Resident in Plastic and Reconstructive Surgery,
Louisville Arm and Hand, Louisville, Kentucky Division of Plastic and Reconstructive Surgery,
Department of Surgery, Stanford University
School of Medicine, Stanford, California

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 Experts Providing Commentary and Clinical Cases ix

Glyn Jones, MD, FACS Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Professor of Surgery, Department of Surgery, Professor of Surgery, Director, Center for Recon-
University of Illinois College of Medicine, structive Surgery, University of Washington
Peoria, Illinois Medical Center, Seattle, Washington

Sebat Karamürsel, MD Michael W. Neumeister, MD, FRCSC, FACS

Associate Professor, Department of Plastic Professor and Chairman, Division of Plastic
and Reconstructive Surgery, Ankara Diskapi Surgery, Southern Illinois University School of
Hastanesi, Ankara, Turkey Medicine, Springfield, Illinois

Joshua L. Levine, MD Norbert Pallua, MD, PhD

Chief of Surgical Services, Department of Plastic Professor, Chairman, Department of Plastic
and Reconstructive Surgery, New York Eye and Surgery, Hand Surgery, Burn Center, RWTH
Ear Infirmary, New York, New York Aachen University Hospital, Aachen, Germany

Samir Mardini, MD William C. Pederson, MD, FACS

Professor of Surgery, Department of Surgery, Adjunct Professor, Department of Surgery,
Mayo Clinic College of Medicine, Division of Plastic Surgery, The University of
Rochester, Minnesota Texas Health Science Center at San Antonio;
President and Fellowship Director, The Hand
Frederick J. Menick, MD Center of San Antonio, San Antonio, Texas
Chief, Division of Plastic Surgery,
St. Joseph’s Hospital, Tucson, Arizona Julian J. Pribaz, MD
Professor of Surgery, Harvard Medical School,
Steven L. Moran, MD Brigham and Women’s Hospital,
Professor and Chairman of Plastic Surgery, Boston, Massachusetts
Professor of Orthopedic Surgery, Division of
Plastic Surgery, Division of Hand Surgery, Lee L.Q. Pu, MD, PhD, FACS
Mayo Clinic, Rochester, Minnesota Professor of Surgery, Department of Surgery
(Plastic Surgery), University of California,
Steven F. Morris, MD Davis, Sacramento, California
Professor of Surgery, Professor of Anatomy
and Neurobiology, Department of Surgery, Justin M. Sacks, MD, FACS
Department of Anatomy and Neurobiology, Assistant Professor, Department of Plastic and
Dalhousie University, Halifax, Reconstructive Surgery, Johns Hopkins School
Nova Scotia, Canada of Medicine, Baltimore, Maryland

Edwin J. Morrison, MBBS, LLB, Michel Saint-Cyr, MD, FRCSC

BComm(Eco) Associate Professor, Department of Plastic
Resident, Department of Plastic Surgery, Surgery, University of Texas Southwestern
St. Vincent’s Hospital, Melbourne, Medical Center, Dallas, Texas
Victoria, Australia
Luis R. Scheker, MD
Wayne A. Morrison, AM, MD, BS, FRACS Associate Professor of Plastic Surgery,
Professorial Fellow, Department of Surgery, Department of Surgery, University of Louisville,
St. Vincent’s Hospital, University of Melbourne, Louisville, Kentucky; Associate Consulting
Victoria, Australia; Director, O’Brien Institute, Professor of Surgery, Department of Surgery,
Melbourne, Australia Duke University, Durham, North Carolina

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 x Experts Providing Commentary and Clinical Cases

Minoru Shibata, MD, PhD Fu-Chan Wei, MD, FACS

Professor and Chief, Department of Plastic and Professor, Department of Plastic Surgery, Chang
Reconstructive Surgery, Niigata University, Gung Memorial Hospital, Chang Gung Medical
Graduate School of Medicine and Dental College and University, Taipei, Taiwan
Sciences, Niigata Prefecture, Japan
Timm P. Wolter, MD, PhD
Roger L. Simpson, MD, MBA, FACS Attending, Department of Plastic Surgery,
Assistant Professor of Surgery, State University Hand Surgery, Burn Center, RWTH Aachen
of New York Stony Brook, Stony Brook, University, Aachen, Germany
New York; Long Island Plastic Surgical Group,
Garden City, New York Peirong Yu, MD, MS, FACS
Professor, Department of Plastic Surgery, The
Aldona J. Spiegel, MD University of Texas M. D. Anderson Cancer
Director, Center for Breast Restoration, Center, Houston, Texas
Assistant Professor, Weill Cornell Medical
College, Institute for Reconstructive Surgery, Michael R. Zenn, MD, FACS
The Methodist Hospital, Houston, Texas Vice Chief, Division of Plastic and
Reconstructive Surgery, Duke University
Milan Stevanovic, MD, PhD Medical Center, Durham, North Carolina
Professor of Orthopaedics and Surgery,
Department of Orthopaedic Surgery, Keck Ronald M. Zuker, MD, FRCSC, FACS,
School of Medicine of University of Southern FRCS(Ed)(Hon)
California, Los Angeles, California Professor of Surgery, Department of Surgery,
University of Toronto; Attending Plastic
Robert L. Walton, MD, FACS Surgeon, The Hospital for Sick Children,
Professor of Surgery, Department of Surgery, Toronto, Canada
Division of Plastic Surgery, Northwestern
University Feinberg School of Medicine,
Chicago, Illinois

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 Foreword

This book fulfills a promise that Steve Mathes and I made in February 1987 when we
planned the first edition of  Reconstructive Surgery: Principles, Anatomy, & Technique with
Karen Berger at QMP. At that time we contracted to produce a third work that would
build upon the flap anatomy in the initial two-volume book while adding new techniques
and specific clinical applications for each flap. In the intervening years, the project stalled
when Steve became ill and I became more involved with aesthetic surgery. Now, however,
I am delighted and honored to be able to write a foreword for this new book: Reconstructive
Surgery: Anatomy, Technique, and Clinical Applications, written by two master surgeons, Michael
Zenn and Glyn Jones, who have taken up the mantle and completed what we began so
many years ago.
Drs. Zenn and Jones have produced a landmark work that fulfills the legacy of the first
book. It captures the detailed flap anatomy, design and markings, and basic technique of
the initial work while adding valuable new information on flap dissection technique, flap
variants and options such as perforator flaps, clinical applications, pearls and pitfalls, and
expert commentary.
This long-anticipated book does not disappoint. The artwork is rendered in a simple yet
elegant style that clearly depicts key structures and techniques. Helpful icons and opening
outlines enhance the learning experience, as do the summary boxes, which focus on pearls
and pitfalls for each flap. The expert commentary at the conclusion of each chapter is a ter-
rific addition; it provides valuable perspective on these flaps by leading experts in the field.
This superb text provides today’s reconstructive surgeons with the tools to solve com-
plex reconstructive problems with new surgical options. It is destined to become the stan-
dard for young and experienced surgeons alike as they seek optimal solutions for difficult
reconstructive problems. We owe a debt of gratitude to the authors and to the publisher
for making this book a reality after so many years and for providing our specialty with a
classic textbook to guide us.

Foad Nahai, MD, FACS

Paces Plastic Surgery
Atlanta, Georgia

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 Foreword

In 1961, President Kennedy’s inaugural speech referred to “the torch being passed” to a new
generation. The torch of plastic surgery has been reconstructive techniques that treat myriad
afflictions of the human condition: congenital deformities, traumatic injuries, oncologic
conditions, and infections. Our toolbox has expanded exponentially in the past half-century.
Sixteen years ago, the first edition of Reconstructive Surgery became the bible for recon-
structive surgeons. The ability to move tissue on vascular pedicles and perform autogenous
tissue transplantation using the operating microscope welcomed the modern era of recon-
structive surgery. The first edition demonstrated the anatomy of flaps and the basic techniques
and applications. Now the torch has been passed from masters of modern reconstructive
surgery, Foad Nahai and Stephen Mathes, to two outstanding leaders in reconstructive
surgery, Michael Zenn and Glyn Jones. Dr. Michael Zenn served with distinction as my
partner at Duke, and I observed his passion for reconstructive surgery, education, and clinical
excellence with pride and respect. Dr. Jones’s path to authorship of this book is a wonderful
testimony to America and American medicine. A native of Zimbabwe, he emigrated to
the United States and has made his mark in reconstructive plastic surgery and as an author/
editor. For any educational event that I was fortunate to organize relating to reconstruc-
tive surgery, Glyn was always on the top of my list as a faculty member. Both authors have
a keen sense of organization, clear expression of thought, and attention to detail to create
excellence in everything they do. This book is a written testimony to these attributes.
It is essential that the reconstructive plastic surgery community have a definitive refer-
ence delineating anatomy, applications, and the limitations of these techniques. This new
landmark publication fulfills that need; it is superbly organized, beautifully illustrated, and
is authored by two reconstructive surgeons who are internationally recognized for their
innovation and contributions to the field. There is such a wealth of information that this
text will serve us well for the future, providing information that will allow further develop-
ment of reconstructive surgery and new applications using the time-honored anatomy that
is our compass in surgery. It will be embraced not only by the new generation of students,
residents, and fellows, but will also inspire the practicing plastic surgeon to establish the
foundation of a procedure correctly each day in the operating room by laying down the
principles of reconstructive surgery.

L. Scott Levin, MD, FACS

Paul D. Magnuson Professor of Bone and Joint Surgery
Chair, Department of Orthopaedic Surgery
Penn Orthopaedics
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

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 Preface

Progress is never achieved in isolation. To advance any field, we need to acknowledge those
who have come before us and recognize how their contributions have enhanced our under-
standing. We must then stand on the shoulders of those giants who have preceded us and
move the specialty forward. In the area of reconstructive flap surgery, there are no broader
shoulders than those of Stephen Mathes and Foad Nahai. The original Mathes-Nahai text
on muscle flaps was epic, ushering in a new era of reconstructive surgery. For many of us
students of plastic surgery, this was the first text that we purchased in the field, guiding us
on our path to becoming competent plastic surgeons. It was a detailed guide to safe flap
dissection as well as an inspiration to generations of plastic surgeons.
Years ago, Glyn Jones’s former partner at Emory, Foad Nahai, and colleague Steve
Mathes invited Glyn to contribute to a new clinical applications book that they were plan-
ning; it was intended as a comprehensive replacement for their landmark flap book. Un-
fortunately, this project was shelved when Steve became ill, but the idea persisted. As time
passed, it became increasingly obvious that, while the earlier book was still an invaluable
resource, it was in serious need of an update, both in the scope of flaps covered and in the
style that has become the standard for our times. The new text you are holding fulfills that
need and the dream of the original authors.
In preparing this book, we are very much aware of how quickly plastic surgery is
changing, particularly in the area of flap surgery. Advances in microsurgical techniques and
applications, combined with the explosive growth of perforator surgery, make any attempt
at writing a “complete” text on flap surgery daunting. These volumes are intended to be
as inclusive as possible, given our current knowledge of the field and our best guess as to
which flaps will prove most valuable in the future.
We have planned this text to be a helpful companion for the reconstructive surgeon,
both in flap selection and in flap execution. To accomplish that goal, it is organized into two
major Parts: Fundamentals and Regional Flaps (Anatomy and Techniques). Part I is intro-
duced by a Reader’s Roadmap that explains how the book’s chapters and flap descriptions
have been organized and helps the reader navigate its pages. Following this introduction
are four key chapters. The first focuses on decision-making and surgical principles while
the second by Drs. Steven Morris and Peter Davison presents invaluable information on the
vascular basis and classification of flaps. Further guidance is provided in Chapter 3 with its
regional treatment of flaps. This chapter outlines the possible flap options in each area of the
body and serves as a useful starting place for finding the ideal flap for a particular problem.
The final chapter in this section discusses complications, why they occur and what we can
do to avoid them.
Part II is divided into separate chapters for each anatomic region. Within those chapters,
the basic anatomy of each of the commonly used flaps is carefully outlined in a consis-
tent format to make this text a quick and easy reference for locating critical information.
Throughout, we have provided many useful dissections, pairing photographs and radiographs
with detailed medical illustrations to depict dissection technique and other technical points
emphasized in the text. Clinical cases demonstrate applications for each of these procedures,
showing their versatility wherever possible. We are particularly grateful to the experts who
have joined us in this endeavor for their sage comments and the cases they have contributed.

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 xvi Preface

This enormous reservoir of pooled information and expertise will benefit us all as plastic
surgeons and make a useful and timely contribution to our exciting field.
Our collaboration has been a delightful experience as we each have had a wide ex-
perience of reconstructive and aesthetic plastic surgery and we both enjoy microsurgical
reconstruction. A long-standing friendship and deep personal respect for one another has
fueled a collaborative effort that has made this project a particularly rewarding endeavor.
Working together for several years as instructors at the renowned Duke Flap Workshop and
seeing the innovative advances demonstrated by an international faculty of experts have
provided further fuel for the text. It has allowed us to refine concepts and provide the most
up-to-date advances and modifications to many of these flaps that have been reported by
our colleagues throughout the world.
As this project comes to fruition, we sincerely hope that it will enrich the lives of our
patients. We also hope that generations of plastic surgeons to come will benefit from the
wealth of collective knowledge outlined in these two volumes. We are both humbled and
grateful to have been given this extraordinary opportunity.

Michael R. Zenn
Glyn Jones

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 Acknowledgments

It was quite by accident that I was introduced to plastic surgery. I was a rotating fourth-year
medical student from Cornell who signed up for a month of general surgery subinternship
at the Massachusetts General Hospital with my friend, Andy Kenler. His brother-in-law,
an MGH resident, got him on the premiere surgical oncology service while I got stuck on
the thyroid service. After a week of seemingly endless thyroidectomies I was bored, and got
my friend Andy to appeal to his brother-in-law to get me on another service. That brother-
in-law was Louis Bucky, now on faculty in plastic surgery at the University of Pennsylvania;
then, he was a senior general surgery resident rotating on the plastic surgery service. He
got me on the service for my remaining time, and my life path was forever changed. The
hustle and bustle of the plastic surgery service, the variety and complexity of the surgeries,
and the iconic James W. May, Jr., were all it took to plant the seed that would take root
after my training in general surgery.
Ironically, some 5 years later, I would end up at Massachusetts General again, this time
as a plastic surgery resident. The intensity of that training could not be replicated today
(without violating multiple ACGME rules), but the experience became the crucible that
molded me into the plastic surgeon I am today. My mentors at MGH included one of the
greatest teachers I have ever met and emulate daily—James W. May, Jr. I was also fortunate
to train side by side with Gregory Gallico, Michael Yaremchuk, Michael Lewis, Peggy
Howrigan, Matthew Donnelan, and W.P. Andrew Lee, just a first-year attending at the
time. The training was intense and grounded in traditions dating back to Bradford Can-
non, one of the founders of our specialty and a regular at our weekly conferences. I was
heavily influenced at the time by my co-residents, who included Lou Bucky (then my chief
resident), Craig Johnson (our hand fellow), Jeffrey Ditesheim, Neal Chen, Matt Concan-
non, and Fred Duffy.
Some early experiences at Memorial Sloan-Kettering Cancer Center while a Cornell
general surgery resident introduced me to the world of microsurgery, so it only seemed ap-
propriate that I study under the master himself, David Hidalgo, as a MSKCC microsurgery
fellow. While working with David, I saw first hand the amazing power that microsurgery
had to solve difficult problems and to transform lives. Most of all, it was his artistry and
attention to the smallest details that stuck with me and torture my current residents on a
daily basis. I was fortunate at that time to also work with Peter Cordeiro, now the chief at
MSKCC, who has remained a good friend.
Early in my practice, I was fortunate to meet the man who would have the greatest
influence on my career, L. Scott Levin. As Chief of Plastic Surgery, Scott welcomed me to
Duke with open arms. I was not a competing microsurgeon, but a partner in what would
be an incredible 10-year voyage of discovery, growth, friendship, and the creation of some-
thing special in the Duke Flap Course.
I have always known I would be an educator. Second only to operating and caring for
patients, teaching residents and fellows the art and science of plastic surgery has been my life’s
work. It is true that the bond between teacher and student is a special one, and I would be
remiss if I did not also give thanks and acknowledgment to the residents and fellows I have
had the honor to train. We in academics are fortunate to be exposed to bright, energetic
minds on a daily basis. One source of annoyance when training residents is their constant

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 xviii Acknowledgments

questioning of the status quo. However, I must admit that it has been this pressure that has
allowed my practice to evolve continually and stay at the cutting edge of plastic surgery.
It has been an incredible honor to co-author this text with Glyn Jones. As a young
surgeon, I always looked up to Glyn as someone in academic surgery to emulate. He is a
bright, talented surgeon who, like me, has always had a passion for teaching and enriching
the lives of patients. Our long weekends at QMP in the “dungeon” will be fondly remem-
bered. Our shared passion in creating this text has cemented a friendship for life.
I would also like to thank and congratulate the invited experts who wrote commentaries
and provided additional clinical cases for a job well done. Our specialty is full of incredibly
talented people, and this has been ably demonstrated through their insights.
We learn early in our surgical careers that success comes with a price. The time required
to care for patients and even write this book has to come from somewhere and all too often
it is our own family who suffers. I have been fortunate to have an incredible family who
support my endeavors and have never complained when I have been called away or missed
an event. My wife and soulmate, Susan, my son, Andrew, and my daughter, Erica, are
a continual source of joy and encouragement. My other “family,” my nurse of 15 years,
Jo Ann Garofalo, also deserves my special thanks for helping me to hone my craft and care
for our patients, many of whom are demonstrated in this book.
Last, but certainly not least, I want to thank Karen Berger at Quality Medical Publishing,
without whom this text would not exist. Her decades of experience in medical publishing
have given her a true understanding of the needs of the plastic surgeon and the plastic sur-
gery educational market. Once she decides to take on a project, she has the uncanny ability
to take an author’s vision and make it a reality, often surpassing expectation. To know her
is to love her, but make sure you meet your deadlines! The family that Karen has built at
QMP is a special one and includes Amy Debrecht, Michelle Berger, Taira Keele, Andrew
Berger, Suzanne Wakefield, Carolyn Reich, Brett Stone, Ngoc-Thuy Khuu, Carol Hol-
lett, Rebecca Sweeney, and Lane Wyrick. The artistry of  Brenda Bunch, Amanda Behr,
Amanda Tomasikiewicz, Eric Olson, Jennifer Darcy, and Jennifer Gentry has raised the
bar for medical illustration in a reconstructive text. My sincere thanks to all at QMP for
your hard work and the passion you displayed creating this text. It is my hope that over the
years, plastic surgeons will continue to thank you for this job well done.

Michael R. Zenn

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 Acknowledgments

Just over 34 years ago I completed my internship and was called up to a year of National
Service during the bloody and tragic civil war in my former homeland of Rhodesia, now
Zimbabwe. Committed as I was to a career in surgery, I spent a year dealing with combat
casualties as well as the usual run of civilian surgical pathology. It was during that life-
changing year that I was drawn repeatedly to the finesse of facial and hand reconstruction
and the dilemma of closing large defects inflicted by warfare. Those early experiences were
to become the stepping stones that would lead to a career in plastic surgery. Although general
surgery enthralled me, a rotation through plastic surgery at the University of Cape Town
convinced me that it was here where my future lay. After completing my general surgery
residency in Cape Town, I was fortunate to be accepted to the plastic surgery program in
Cape Town. While training there, Guy Trengrove Jones and Roger Strover inspired me
to seek further fellowship training in the United States, and in 1988-1989 I spent 2 years
undergoing postgraduate plastic surgical training at Norfolk, Virginia, Atlanta, Georgia, and
then St. Louis, Missouri.
My time at Emory University in Atlanta was probably the most life-changing experience
of my entire career. It was here that I came under the tutelage of Josh Jurkeiwicz, a born
teacher and inspiration to several generations of surgeons. Josh was a man who regarded the
transmission of knowledge to his residents as his life’s work and a God-given responsibility,
not only for the benefit of the surgeons on his watch, but for the patients those surgeons
would ultimately treat. He had attracted a dynamic faculty and trained more future chair-
men of plastic surgery than any other plastic surgeon in this country’s history. It was as a
fellow at Emory that I was exposed to the dynamism of Foad Nahai, John Bostwick, Rod
Hester, and their fellow trainees John McCraw, P.G. Arnold, Steve Mathes, Luis Vasconez,
and Leonard Furlow. You cannot be in the presence of these men without having your life
seared by the flame of their contagious enthusiasm. They changed my entire perspective
on plastic surgery, retooling the way I approached problems, and kindled within me an
undying love for breast surgery and complex reconstruction that remains with me today.
My relationship with John Bostwick became a lifelong friendship curtailed by his untimely
death, but it allowed me the privilege of rewriting his famous text on breast surgery for
future generations, a privilege I will always cherish.
While still a fellow at Emory, I spent a weekend in St. Louis with Foad Nahai and Steve
Mathes, meeting Karen Berger for the first time as we discussed contributing to a clinical
companion text to the original Mathes-Nahai reconstructive books. The “flap book” was a
must-have text for any plastic surgeon embarking on reconstructive procedures, and despite
its age, it has remained a landmark text that has helped countless surgeons better perform
the reconstructions from which so many patients have benefited over the years. As time
wore on and innovations emerged, however, it became clear that a companion text was
needed—one that incorporated the information from the previous reconstructive work
while adding important clinical applications and expert commentary. It has been a privi-
lege to be involved in writing this monumental text. Foad Nahai has been tremendously
supportive of our efforts, and I will always be grateful to him for his support, friendship,
and encouragement over the years.

xix

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 xx Acknowledgments

Karen Berger is a remarkable woman who has left an indelible mark on the plastic
surgery publishing world. As Mike Zenn said in his acknowledgments, “to know her is to
love her,” and having known and worked with her for over 20 years, I can wholeheartedly
affirm that statement. Karen is an extraordinarily motivated publisher who drives us hard
as a team but delivers far more than one could have hoped for. The quality of her work
and the books she produces are unmatched in the world of plastic surgical publishing. No
publisher can achieve what she has without the support of an outstanding team. Karen has
put together an excellent team at QMP with whom it has been both a pleasure and privi-
lege to work. Amy Debrecht, Michelle Berger, Taira Keele, Suzanne Wakefield, Carolyn
Reich, Brett Stone, Ngoc-Thuy Khuu, Carol Hollett, Rebecca Sweeney, Lane Wyrick, and
Andrew Berger are a formidable publishing team who spend countless hours preparing the
text for publication and marketing it to the world, and we are indebted to them for their
meticulous efforts.
This book could not exist without the remarkable artistry of the medical illustrators
who have infused its pages with beautiful imagery. The quality of the artwork reflects the
skill of Brenda Bunch, Amanda Behr, Jennifer Gentry, Jennifer Darcy, Eric Olson, and
Amanda Tomasikiewicz, whose combined efforts have created a visually stunning body
of art to accompany the text. The QMP team is to be congratulated for a job well done.
In preparing something as monumental as this two-volume book, Michael Zenn and
I have had to work together for hours as a team. It has been a privilege to know Michael
as a colleague and a friend, and this book has been a catalyst in strengthening an enduring
friendship and mutual respect. We both love to teach, and we hope that the pages of this
book will help generations of plastic surgeons to come.
Works such as this do not come to fruition without considerable sacrifice. We are both
busy clinical surgeons with mature practices, and time is always at a premium. In embarking
upon such a project, we were acutely aware that the time commitment would be enormous.
That time is garnered at night and on weekends, and it comes at the expense of time with
our wives and families. I want to pay tribute to my wife, Hilarie, for her enduring support
and encouragement during this second tour de force in my writing career, for without it,
the project would never have matured.
It is my hope and prayer that this book will be an invaluable tool in plastic surgical
training, not only as a resource for surgeons, but above all, for the benefit of our patients,
without whom the need for this book would never exist.

Glyn Jones

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 Contents

VOLUME ONE
 Part I Fundamentals
Reader’s Roadmap  3

  1 Surgical Decision-Making: Options, Principles,

and Techniques  7

  2 Vascular Basis of Flaps and Flap

Classification  35
Steven F. Morris and Peter G. Davison

  3 Guide to Flap Selection   81

  4 Complications: Avoidance and Treatment   153

Part II Regional Flaps: Anatomy and Basic Techniques

  5 Head and Neck   169
A. Paramedian Forehead Flap   170
B. Scalp Flap  192
C. Nasolabial Flap  232
D. Temporoparietal Fascia Flap   262
E. Temporalis Flap  288
F. Masseter Flap  316
G. Orbicularis Oris Flap   334
H. Tongue Flap  368
I. Submental Flap  388
J. Facial Artery Myomucosal (FAMM) Flap   410

xxi

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 xxii Contents

  6 Anterior Thorax  431
A. Deltopectoral Flap  432
B. Pectoralis Minor Flap   454
C. Lateral Intercostal Artery Perforator (LICAP) Flap  474
D. Serratus Flap  492
E. Pectoralis Major Flap   518
F. Supraclavicular Artery Flap   546

  7 Posterior Trunk  583
A. Gluteus Maximus and IGAP/SGAP Flaps   584
B. Gluteal Thigh Flap   620
C. Scapular/Parascapular Flap  646
D. Lumbar Perforator Flap   676
E. Trapezius Flap  694
F. Latissimus Dorsi Flap   726
G. Paraspinous Flap  758

  8 Upper Extremity  777
A. Lateral Arm Flap   778
B. Brachioradialis Flap  806
C. Posterior Interosseous Flap   820
D. Radial Forearm Flap   842
E. Flexor Carpi Ulnaris Flap   880
F. Ulnar Forearm Flap   894

Credits  C-1

Index  I-1

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  Contents xxiii

VOLUME Two
  9 Hand  913
A. Abductor Digiti Minimi Flap   914
B. Great Toe (Hallux) Flap   926
C. Homodigital Neurovascular (Littler) Island Flap   958
D. Second Toe Flap   976
E. Dorsal Metacarpal Artery Flap   1010
F. Cross-Finger Flap  1046
G. Kleinert-Atasoy V-Y Flap   1074
H. Moberg Advancement Flap   1090

10 Abdomen  1107
A. Deep Circumflex Iliac Artery (DCIA) Flap   1108
B. Rectus Abdominis and TRAM/DIEP Flaps   1136
C. External Oblique Flap   1192
D. Superficial Inferior Epigastric Artery (SIEA) Flap   1218
E. Groin Flap  1242
F. Thoracoepigastric (Transverse Abdominal) Flap   1268
G. Pudendal-Thigh (Singapore) Flap   1280

11 Abdominal Viscera  1297
A. Jejunal Flap  1298
B. Omental Flap  1324

12 Thigh  1349
A. Anterolateral Thigh (ALT) and Anteromedial Thigh
(AMT) Flaps  1350
B. Saphenous and Medial Condylar Flaps   1392
C. Gracilis and TUG/TMG Flaps   1418
D. Sartorius Flap  1466
E. Biceps Femoris (Hamstring) Flap   1482
F. Tensor Fascia Lata (TFL) Flap   1506
G. Vastus Lateralis Flap   1534
H. Rectus Femoris Flap   1552

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 xxiv Contents

13 Leg  1583
A. Fibula Flap  1584
B. Soleus Flap  1628
C. Sural Artery Flap   1654
D. Gastrocnemius Flap  1682
E. Anterior Tibial Flap   1706

14 Foot  1733
A. Abductor Digiti Minimi Flap   1734
B. Flexor Digitorum Brevis Flap   1754
C. Abductor Hallucis Flap   1772
D. Dorsalis Pedis Flap   1788
E. Medial Plantar Artery Flap   1812
F. Lateral Calcaneal Flap   1834

Credits  C-1

Index  I-1

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 Reconstructive
Surgery
Anatomy,
Anatomy, Technique,
Technique, and Clinical Applications
and Clinical Applications

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This page intentionally left blank
 Part I

Fundamentals



Reader’s Roadmap
Surgical Decision-Making:
 Options, Principles, and
Techniques
Vascular Basis and Flap
 Classification
Guide to Flap Selection
Complications: Avoidance
  and Treatment

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This page intentionally left blank
 Reader’s Roadmap



Successful outcomes in reconstructive surgery depend on the interplay of a number of key fac-
tors. A comprehensive understanding of anatomy is of primary importance. Once mastered,
this must be combined with surgical training, clinical judgment, and technical skill. Equally
important, a surgeon must be able to effectively analyze the problem at hand, identify all po-
tential options for its solution, and select the reconstructive approach that most effectively and
aesthetically restores the lost form or function while minimizing donor site deformity. Com-
pared with our predecessors, who could not have foreseen our current concept of angiosomes
or the advent of perforator flaps, our choices are greater and the range of deformity treated is
wider. With this knowledge also comes complexity and an increased level of technical difficulty
that our teachers never had to contend with. That said, with our improved understanding of
human anatomy, coupled with advances in flap design, we are able to steadily move forward,
accomplishing more with better outcomes.
This book should be thought of as a roadmap for navigating the wide range of reconstruc-
tive problems we see throughout the body. It is a tool for selecting the best solutions for these
problems. It has been formatted to be a quick, easy-to-read reference guide that surgeons can
use when determining options for a particular problem, delineating the appropriate anatomy,
and showing the step-by-step dissection technique for the chosen flap. Clinical examples fur-
ther demonstrate what is possible with each flap, and insights from invited experts ensure that
you know their tricks.
Building on the systematic approach established in earlier books authored by the iconic
Mathes and Nahai, our book employs a similarly structured format. The text has been orga-
nized into two distinct sections: Part I: Fundamentals, and Part II: Regional Flaps: Anatomy
and Basic Techniques.

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 4 Part I  Fundamentals

The text begins with a section on fundamentals that includes four key chapters. The
first chapter is “Surgical Decision-Making: Options, Principles, and Techniques.” It presents
the essential building blocks for understanding and using the flap concepts and designs that
follow. It also contains basic information on the subset of free tissue transfers and guidelines
on flap monitoring.
The second chapter, contributed by Steven Morris, discusses the vascular basis of flaps
and the justification for flap classification. As the complexity and number of flaps grow, it
is important that we can communicate clearly what tissues are involved and how they are
vascularized and innervated.
The third chapter in this section is entitled “Guide to Flap Selection.” This unique
chapter will be the one you will turn to again and again as a logical starting point when
assistance is needed with clinical problem-solving. Once you know where the problem is
located, a series of tables and regional maps, organized by anatomic area, will guide you
to all the potential reconstructive solutions. Page numbers are keyed into these charts to
quickly direct you to the appropriate chapters and the specific flaps of interest. These charts
also highlight the commonly used recipient vessels in that area, which may influence the
specific flap choice. This section is also ideal for determining a fall-back plan for your case
or a secondary choice in addressing a complication.
Chapter 4, “Complications and Treatment,” considers patient selection, surgical plan-
ning, intraoperative factors, and postoperative care.
Part II: Regional Flaps provides the detailed information on anatomy, basic technique,
and clinical applications required for planning and successful execution of your reconstruc-
tive procedure. An overview of the pertinent anatomy is provided in a list format that is
comprehensive yet easy to grasp. For simplicity and ease of use, this part is divided into 10
individual chapters: Head and Neck, Anterior Thorax, Posterior Trunk, Upper Extrem-
ity, Hand, Abdomen, Abdominal Viscera, Thigh, Leg, and Foot. For this atlas only the
most commonly used flaps are identified in each body region. Individual sections are then
dedicated to each flap, providing everything the surgeon needs to know about its execu-
tion and application. Each section in the chapter follows a distinct and consistent format,
beginning with a list of clinical applications, and a succinct summary of anatomic features,
as shown on p. 5.

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   Reader’s Roadmap 5

ANATOMY
Landmarks Specific anatomic guideposts that assist the surgeon to identify all important
structures to define the local anatomy and design each flap.
Composition Classification of anatomic components: (1) fascia, (2) fasciocutaneous, (3) muscle,
(4) myocutaneous, (5) bone, and other specialized tissues.
Size Flap dimensions to aid in flap selection and assess whether primary closure
will be possible.
Origin/Insertion Bony connections of all muscle flap origins and insertions.
Function The intended purpose and role that these tissues play in situ. This is impor-
tant in selecting a flap while ensuring that as much tissue as needed is taken.
Even more important, this allows the surgeon to evaluate potential morbidity
from alteration of the donor site, including functional loss (range of motion or
strength) and aesthetic loss after flap elevation. Synergistic muscles that retain
local motor function after flap elevation are identified.

Arterial Anatomy (Pattern of Circulation)

Dominant Pedicle  Source of arterial inflow to the flap and circulation to maintain tissue vi-
ability. As noted by Mathes and Nahai, different tissues have different sources of vascularization.
Practically, the type of blood supply will dictate the way the flap can be used.
Regional Source  Major vessel located in the region of the flap that represents the source of
circulation to dominant pedicle.
Length  Distance from point of entry of pedicle into flap and regional source of circulation. This
information will help determine the adequacy of that flap choice based on distance to the defect
or recipient site.
Diameter  Measurement of external lumen diameter to assist in planning for microvascular flap
transplantation and vessel match at the recipient site.
Location  Anatomic site of the vascular pedicle relative to the flap and its landmarks.
Minor Pedicle  Smaller pedicles in relation to dominant vascular pedicle of flap that also help
to vascularize the flap but may not reliably maintain tissue viability on its own. Also listed for
minor pedicles are regional source, length, diameter, and location.

Venous Anatomy
The accompanying and auxiliary vessels that provide venous drainage for the flap.

Nerve Supply
Motor Source and location of motor nerve to the muscle flaps. Important data especially
for design of a functional muscle flap. Also important when muscle function is
not required and the surgeon wishes to avoid undesirable muscle contractions
or enhance muscle atrophy at the recipient site.
Sensory Source and location of sensory nerves that have an anatomic relationship to the
flap. These data will assist in design of cutaneous components of the flap with
potential for sensory innervation. This information also helps to predict potential
sensory deficits at the flap donor site.

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 6 Part I  Fundamentals

The discussion proceeds to flap design and markings, patient positioning, and operative
technique. The basic flap design is described, as well as known flap variants. The principal
flap design is described first; description of the common variants follows. Wherever pos-
sible, we have included technical points invaluable to achieving success. The sections on
flap transfer, flap inset, and donor site closure summarize the technical aspects necessary
for safe completion of the reconstructive procedure after flap elevation.
All too often, operative descriptions fail to mention key procedural tips that make or
break the success of a surgery. The Pearls and Pitfalls section has been written in bulleted
form with this in mind, to provide the reader with as comprehensive a list as possible, thereby
reducing the potential for failure. This is also an excellent way to reinforce important flap
details when returning to the chapter. Augmenting this section, our expert commentators
provide further insights into the successful execution of the procedures described. Their
contributions and presentation of clinical cases bring the utility of the flaps into focus,
demonstrating a broad range of possible applications for each flap or variant. Although case
presentations have had to be limited by space constraints, they are intended to expose the
reader to the many clinical applications available and are not intended to be comprehensive
or exclusive.
The annotated bibliography includes a selection of the most relevant literature on each
flap. Although the articles cited are not intended to be all-inclusive, every attempt has been
made to briefly summarize publications that support the use of a flap or provide data relevant
to its applications in reconstructive surgery.
Each section has been liberally illustrated with high-quality anatomic drawings and
cadaveric photographs. The diagrams have been rendered in a combination of black and
white line and color to clearly identify key anatomic elements important to flap design and
execution. Extraneous detail has been downplayed for the sake of clarity. Color correction
and artistic standardization has been maintained throughout.
We hope that this text will aid trainees as well as experienced surgeons in the selection
and performance of a wide range of commonly used flaps. The format has been designed
for ease of use, and its visual presentation will easily imprint critical flap details on the
reader’s memory.

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 Chapter 1
Surgical Decision-Making:
Options, Principles, and
Techniques

Reconstructive surgery combines science, anatomic knowledge, and surgical artistry to ac-
complish the goals of preserving life and restoring form and function. As plastic surgeons,
we are called upon to treat defects ranging from small to large that often have a significant
impact on function and on the patient’s sense of self-esteem. Accordingly, reconstruction of
these defects may require anything from simple direct suturing to complex composite free
tissue transfers in multiple stages. The selection of the most appropriate reconstructive modal-
ity requires a careful assessment of the risks and benefits of each procedure in the light of the
patient’s clinical status. Procedures should be tailored to the individual’s needs in providing a
safe and expeditious recovery with minimal morbidity. In some instances, that may require a
simple skin graft, such as for a fasciotomy wound in a leg. Other defects may be solved most
easily with a free composite tissue transfer, the most extreme example being a face transplant
for massive facial soft tissue loss. Although complex in execution and postoperative manage-
ment, the procedure provides a one-stage restoration of facial structures unparalleled by any
other techniques to date.

THE RECONSTRUCTIVE PARADIGM

Surgical decision-making in general surgery has been simplified to some extent by outcomes-
based algorithms that lead to clear-cut approaches and procedures suitable for dealing with a
wide range of problems. By contrast, surgical decision-making in plastic surgery is complicated
by the vast array of procedures suitable for a given problem, each one offering advantages and
disadvantages. While this text attempts to provide the reader with an atlas of flaps to assist with
the execution of a given procedure, the choice of procedure can be bewildering, especially
for the neophyte.

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 8 Part I  Fundamentals

In the past, the reconstructive ladder became a much-publicized tool to aid surgeons
in decision-making.

Complex Distant flap

Local flap

Skin grafts

Simple Direct closure

Reconstructive ladder

Fig. 1-1 

In recent years, the ladder has been dismissed by many as being simplistic and outdated.
Although this may be partially true, the ladder simply attempted to provide surgeons with a
progressive approach to wound management, beginning with simple solutions such as direct
wound closure, progressing to grafts, adjacent flaps, and then distant or free flaps. There
is nothing inherently wrong with this approach, other than to say that it is not necessary
to progress in a stepwise fashion from a simple operation to a more complex one, only to
end with a free flap because the previous option failed. In other words, free flaps are not a
last resort. The reconstructive ladder never attempted to suggest that. It merely suggested a
progressively more complex approach, using the simplest technique possible if it was feasible
and best for the patient. The problem with maintaining the hierarchy of the reconstructive
ladder is that although a skin graft is appropriate management for a granulating fasciotomy
wound of the leg, it is clearly not a viable proposition for a composite hemimandibulectomy
defect. Similarly, while a split-thickness skin graft could be placed over viable tissues across
a joint flexion crease, flexion contracture would be a certainty, and the patient would be
better served with a full-thickness graft or flap procedure.

When considering reconstructive options, it is imperative to bear in mind that safe

wound closure should be based on the selection of the most appropriate technique,
whether simple or complex, to achieve effective wound-healing, while taking into
account local wound requirements and complexity.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 9

In an attempt to clarify some of these issues, the reconstructive triangle was proposed.

Flaps

Microsurgery Tissue expansion

Reconstructive triangle

Fig. 1-2 

Rather than suggesting a stepwise progression from simple to complex, the triangle
concept allowed for a free flow between pedicled flaps, tissue expansion and free tissue
transfer. Although attractive in some respects, this model does not give the surgeon any
guidance other than to suggest that any of the above options may be useful (which we al-
ready know), and it does not allow for the use of direct closure or grafts. Also, it overstated
the role of tissue expansion in daily reconstructive surgery. As such, it fails to provide a
clinically useful roadmap.
Rather than this simplistic procedural triangle, it may be preferable to conceive of a
triangle housing several interdependent components leading to wound closure.

Defect

Wound
closure
technique

Systemic Local
factors factors

Interdependent components concept

Fig. 1-3 

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 10 Part I  Fundamentals

When assessing a wound for closure, the reconstructive surgeon needs to evaluate a
multiplicity of factors to determine which procedure is most appropriate. These include
the patient’s general health, the location and size of the defect, concomitant systemic risk
factors such as tissue irradiation, and the availability of tissue donor sites.

Systemic Factors
A patient’s pathology may result from either congenital or acquired conditions. Acquired
problems may arise from trauma, infection, radiation therapy, neoplasia, or vascular or
autoimmune causes. Defects may be stable or unstable and may range from physically
deforming to life threatening. The patient’s underlying health plays an important role in
determining when and what, if anything, should be done. Although some procedures are
simple and can be performed under local anesthesia on an outpatient basis, others require
lengthy general anesthetics with postoperative intensive care. A seriously ill patient may not
tolerate such a complex intervention. It should be remembered that organ failure or major
medical morbidity takes precedence over defect reconstruction. In recent years the use of
negative-pressure wound therapy (NPWT) has allowed temporary wound control while
other more serious medical and surgical emergencies are dealt with. Once the patient’s
condition is stable, definitive wound closure can be performed.
A second group of patients includes those with functional disability or severe deformity
without concomitant life-threatening illness. Patients may be severely incapacitated by
these problems and require complex reconstructions. A patient with a grossly disfiguring
facial burn may be socially stigmatized and suffer severe psychological sequelae without
life-threatening consequences. The problem may be salvageable with a face transplant or a
series of more standard operations.
Patients with severe neurologic impairment or a limited lifespan as a result of organ
failure are not good candidates for complex reconstructions, particularly when such pro-
cedures rely on normal physiologic function as part of a successful recovery.
Systemic factors that impact wound-healing and flap survival include smoking, obesity,
immunocompromised states, steroid usage, and cardiopulmonary impairment. When flaps
are planned in high-risk patients, one should consider maneuvers to increase blood supply
and improve the safety of the procedure.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 11

Organ System Derangements That Contraindicate Surgery and Require

Treatment Before Management of Complex Defects

Neurologic System Gastrointestinal and

Space-occupying lesion with Pancreaticobiliary Systems
  impending herniation Infarction
Acute infarction Obstruction
Cardiovascular System High-output fistulas
Acute myocardial infarction Kidney
Acute cardiac failure Acute obstruction
Acute peripheral vascular Acute failure
 insufficiency Hematopoietic System
Compartment syndrome Shock (acute blood loss)
Respiratory System Bleeding disorder
Upper airway obstruction Endocrine System
Acute respiratory insufficiency Acute adrenal insufficiency

Local Factors
Patients may be in good general health but have local wound conditions that place them at
high risk for failure. Wound contamination, infection, radiation therapy, poor vascularity,
extensive scarring, or exposure of underlying tissues such as bone, joint, tendons, viscera,
or body cavities require widely differing approaches to reconstruction.

Defect Analysis
Analysis includes an evaluation of:
• Size
• Location
• Wound characteristics
• Adjacent tissue
• Potential donor sites
The wound bed should include an assessment of all tissue components, including:
• Tissue quality
• Skin
• Subcutaneous tissue
• Mucosa
• Vasculature
• Nerve supply
• Cartilage
• Bone
Wound characteristics include assessment of:
• Vascularity to the region
• Infection
• Desiccation
• Tissue viability and presence of slough or eschar
• Quality of granulation (if any)
• Presence or absence of radiation injury
• Degree of fibrosis and scarring
• Presence or absence of malignancy

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 12 Part I  Fundamentals

Timing of Closure
The timing of wound closure is critical to a successful outcome. Operating on an unstable
patient with hypoperfusion may result in potential flap loss. Godina demonstrated that
performing a free tissue transfer to a lower extremity compound fracture 5 to 21 days after
injury tends to be associated with higher flap failure rates and increased infectious com-
plications. For severe contamination or overt infection, the wound should be adequately
debrided and reassessed carefully, allowing time for inflammation to resolve before a complex
reconstructive procedure is undertaken. With the advent of multidisciplinary approaches
to treatment, early closure of wounds has become increasingly frequent. If surgery has to
be delayed because of patient instability or organ failure, NPWT has played a major role
in maintaining a temporary safe and clean environment before definitive coverage. Tumor
extirpation followed by immediate reconstruction in cancer treatment has allowed primary
closure with functional reconstruction in complex situations, with improvement in patient
outcomes and reduced morbidity.

A SYSTEMATIC APPROACH TO WOUND

CLOSURE: SURGICAL OPTIONS
Split-Thickness Skin Grafts
Split-thickness skin grafts are invaluable in the management of superficial, granulating clean
wounds overlying stable surfaces. They are simple, easily performed, and take rapidly on
a vascularized bed by imbibition and inosculation. They tend to shrink, contracting the
original wound size in both area and depth, and can produce quite good aesthetic outcomes.
Their inherent tendency to contract makes them a poor choice for use across joints and
for correcting contractures. Because of their thin nature, they tend not to maintain their
characteristic color and texture. Their donor sites are painful and leave potentially large
surface area scars. Wounds with irregular surfaces often benefit from NPWT as the bolster
over the skin graft to improve graft-to-bed apposition.

Full-Thickness Skin Grafts

Full-thickness grafts, by contrast, are more aesthetically pleasing and are widely used to
correct or limit contractures. They provide better texture on the face and hands but produce
large, full-thickness donor site defects requiring direct donor site closure, a factor precluding
the harvest of very large grafts. Given their thickness, they are slower to develop a blood
supply, and take is correspondingly slower. To succeed, these grafts require a freshly pre-
pared, well-vascularized bed. Graft-to-bed apposition has to be meticulously maintained
with bolster dressings to achieve complete take. Color match and contour are often better
than those achieved with split-thickness grafts.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 13

Thin

Split-thickness depth

Thick

Full-thickness

Depth of skin elevation for split-thickness and full-thickness skin graft

Subepidermal
Dermal

Subdermal
Plexuses
Subcutaneous
Fascia
Prefascial and
subfascial
Muscle
Musculo-
cutaneous
artery
Regional
artery Septo-
cutaneous
artery

Skin circulation

Fig. 1-4

Local Cutaneous Flaps

Flaps are full-thickness blocks of tissue perfused by regional source vessels with varying
patterns of supply. The nature of flap blood supply is the topic of Chapter 2. Traditionally,
flaps were considered random in terms of blood supply, until the axial nature of the groin
flap was discovered. The random concept led to complex tubed pedicle transfers in multiple
stages to bring a given piece of tissue to its final destination, distant to its origin.

Random Pattern Flaps

The term random flaps has historically been used to refer to skin flaps raised without a known,
named blood supply leading to more tenuous flap survival rates. The term has also been
applied to flaps with a known blood supply at their bases, but that have been designed to
include more distant areas of skin with the hope that these will survive on random extensions
of the known supply into the distal tissue. This led to a somewhat hit-and-miss approach
to reconstructive surgery.

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 14 Part I Fundamentals

With the discovery of the groin flap’s axial blood flow, reconstructive surgery took a
major leap forward in both predictability and creativity. Axial pattern flaps refers to the supply
by a named, identifiable source vessel. Taylor’s pioneering studies of skin vasculature, built
on the concepts of Michel Salmon, demonstrated that all skin is perfused from perforators
arising from or between the underlying muscles and fascial septa. As such, although these
flaps are perfused by an unnamed vessel, they are in fact perforator variants of one sort or
another, arising from named vessels.

RanDom patteRn flap

A B

Subdermal plexus
(note outline of flap design with Standard arc of rotation
2:1 length/width ratio)

Fig. 1-5

Propeller Flaps
It is not uncommon for a surgeon to raise a flap based on Doppler identification of a small,
unnamed perforator derived from a known regional source artery, which provides axial blood
supply to the overlying skin island. When the design is an ellipse and the flap is transposed
based on that perforator, the term propeller flap has come in vogue. Propeller flaps are a type
of perforator flap. They are called propeller flaps because the flaps rotate around the pedicle
in the same way a propeller rotates around its hub. They can be designed freestyle, meaning
that the surgeon can identify a perforator and design a propeller flap based on it to cover an
adjacent defect. The term also describes the technique by which the flap is rotated into the
defect. Propeller flaps can be used anywhere, but are probably used most often in the lower
limb. It used to be taught that a free flap was required for defects of the lower limb. Now,
however, many of these defects can be closed with a propeller flap, replacing the need for
a free flap and making things much simpler for the surgeon and the patient.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 15

Propeller flap

A B
Perforator
artery

Defect

Skin island

Design of propeller flap Flap advancement

Fig. 1-6 

Based on these observations, use of the word random, as applied to flap blood supply, is
rapidly becoming obsolete. Although it is true that a flap may have a perforator in its base,
so-called random flaps are usually designed with a length that may outrun the axial blood
flow, thereby leaving the terminal part of the flap as a random extension. It is in this situa-
tion that length-to-breadth ratios come into play: the greater the length-to-breadth ratio,
the greater the risk of necrosis. The ideal ratio is 1.5:1, with a maximum of 2:1. If an axial
blood flow enters the base of the flap, ratios of 3:1 to as much as 6:1 have been described in
fasciocutaneous flaps such as the supraclavicular flap. This is also related to Taylor’s angio-
some concept of blood flow, in which an adjacent vascular territory may be captured fairly
reliably but more distant angiosomes will be more prone to necrosis. These local flaps can
be either transposition or rotation advancement flaps and while invaluable in many situa-
tions, their usefulness is limited by their arc of rotation. Examples of such procedures are
Limberg flaps in facial skin cancer closures and gluteal rotation advancements for pressure
sore closure.

Rotation flap Advancement flap

A B

Design of rotation flap Flap advancement

Design of V-Y flap Flap advancement

Fig. 1-7 

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 16 Part I Fundamentals

Axial Perforator–Based Cutaneous Flaps

Cutaneous flaps with a known axial or perforator inflow often have a longer arc of rota-
tion, and some have the option of being converted to free flaps. Typical examples include
the groin, radial forearm, and supraclavicular flaps. These flaps are usually cutaneous, but
some may be raised as adipofascial alternatives. The effectiveness of these flaps should not
be underestimated. For example, the supraclavicular flap, an axial perforator–based flap,
has often led its proponents to abandon their free flap options entirely for head and neck
reconstruction in favor of this reliable and easy-to-use local pedicled flap.

Muscle and Myocutaneous Flaps

Muscle flaps are based on axial or segmental vascular supplies. This discovery in the clini-
cal context led to the next major advance in plastic surgery after axial pattern flaps had
evolved. The classification of the various blood flow patterns is described in Chapter 2.
Those flaps with dominant axial inflows can be raised as pedicled or free flaps, such as the
rectus abdominis or latissimus flaps, whereas those with segmental supplies, such as the
sartorius, external oblique, or biceps femoris, are used only as transposition flaps. Muscle
flaps are bulkier, have excellent blood flow, and can fill large defects. Many can be raised
with an overlying skin paddle. Their vascularity makes them useful carriers of oxygen,
growth factors, and antibiotics into the wound-healing milieu. Some are used as functional
transfers, such as the latissimus dorsi, pectoralis minor, and gracilis flaps.

Design of muscle flap

B C

muscle flap arc of rotation myocutaneous flap arc of rotation

Fig. 1-8

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 17

Prediction of Arc of Rotation

The extent that a muscle may be elevated from its anatomic location and its subsequent abil-
ity to reach adjacent defects without devascularization determines its arc of rotation. The
dominant vascular pedicle’s entrance site into the muscle determines the point of rotation.
(See Mathes and Nahai Classification, Chapter 2.)
Only muscle distal to the point of rotation is used as a transposition flap. For muscle
types I, II, III, and V, the point of rotation is usually at one end or the proximal third of the
muscle. For type IV, however, only the proximal or distal third of the muscle can be safely
elevated because of the segmental vascular pattern; therefore type V muscle has a limited
arc of rotation.
In type II muscle, the two dominant vascular pedicles are positioned at opposing ends
of the muscle; thus the arc of rotation is smaller, because the whole muscle may not survive
transposition on one vascular pedicle.
Type V muscle has two arcs of rotation; the total muscle can be safely elevated on
the dominant vascular pedicle that enters adjacent to the muscle insertion in the shoulder
girdle. Division of this dominant vascular pedicle permits safe transposition (a reverse arc
of rotation) on the secondary segmental pedicles entering the muscle adjacent to the origin
in the midline of the trunk.

A
Regional pedicle Origin
artery and vein

Dominant
vascular pedicle

Insertion

B C D

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.

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 18 Part I Fundamentals

Fascial and Fasciocutaneous Flaps

Before the discovery of the importance of fasciocutaneous blood supply, skin flaps had been
raised in the subcutaneous plane at the suprafascial level. Cormack, Lamberty, and Ponten,
among others, discovered the enhanced blood flow to flaps achieved by simply incorpo-
rating the underlying fascial layer which carried with it fascial blood flow. The resulting
fasciocutaneous flaps became a new vascular basis for flap design with considerably improved
flap reliability. Fascial vessels were identified as running on the surface of the fascia, perfo-
rating either from the underlying muscles or from within the fascial septa between muscle
groups. This important discovery, coupled with the earlier understanding of muscle flap
blood supply, formed the basis of modern flap design based on an understanding of tissue
perfusion and altered the entire course of modern reconstructive plastic surgery. Fascial and
fasciocutaneous flaps play a major role in reconstructive surgery today. Examples of such
workhorse flaps include the pedicled radial forearm flap and temporoparietal fascia flap.

A B

fascial flap arc of rotation fasciocutaneous flap arc of rotation

Fig. 1-10

Composite Flaps
Complex defects often require multicomponent flaps to achieve closure. A full-thickness
mandibular defect may require skin, bone and intraoral lining, all of which can be supplied
with a fibular or iliac crest composite free flap. Although usually used as free flaps, compos-
ite flaps can be used as pedicled procedures, as in a fibular translocation into an ipsilateral
tibial defect or a pedicled iliac crest bone graft to treat osteomyelitis of the symphysis pubis.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 19

Free Flaps
Microsurgical reconstruction has become a mainstay of modern plastic surgery. Although
pedicled flap reconstructions carried reconstructive surgery well into the 1970s, micro-
surgery represented the next major course change in the development of modern plastic
surgery. It completely transformed our ability to reconstruct defects by bringing the most
appropriate tissue components into the field rather than being limited by what local tissues
had to offer. Where in the past, a pedicled pectoralis major flap with incorporated anterior
rib could be used for mandibular reconstruction, it was now possible to bring a vascular-
ized, osteotomized iliac crest or fibular graft complete with skin coverage into the mouth.
The potential for complex three-dimensional reconstruction advanced exponentially as a
consequence of the microsurgical revolution.

Perforator Flaps
The analysis of cutaneous perforator blood supply and the concept of chimeric flaps has
fueled an explosion of interest in perforator-based cutaneous flaps, many of them suitable
for microsurgical transplantation, as discussed by Drs. Morris and Davison in Chapter 2.
Not only do these flaps contain a reliable blood supply, but they also spare the underlying
musculature from being violated. The quintessential example is the deep inferior epigastric
perforator (DIEP) flap in breast reconstruction.

A Muscle perforator

Direct
cutaneous
perforator Septocutaneous perforator

Fig. 1-11  A, Three major variants of perforator flap blood supply. B, Skin island based on a myocu-
taneous perforator, with complete muscle sparing.

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 20 Part I Fundamentals

While perforator flaps have in some respects transformed the landscape of microsurgical
options, many of the traditional free flaps, including muscle, myocutaneous, and various
forms of composite bone flaps remain in play today. Microsurgery was once considered the
option of last resort, whereas now it is often viewed as the first and best option for a complex
reconstruction. Forty years ago, a thumb loss may have been reconstructed by wrapping a
corticocancellous bone strut with a groin flap to achieve a static post for opposition; today
that same reconstruction would be achieved with a free toe-to-thumb transfer, producing
a more functional, sensate outcome. Under these circumstances, the reconstructive ladder
has been sidestepped in favor of the more versatile reconstructive triangle suggested earlier.

A B

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.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 21

Tissue Expansion
Although tissue expansion is not a flap procedure per se, it would be inappropriate to ig-
nore the role of tissue expansion in reconstruction. While the utility of tissue expansion
has receded in recent years with the advance of microsurgical reconstruction, it still plays
an important role in breast, scalp, and burn reconstruction. Tissue expansion has also been
invaluable in the management of congenital nevi in pediatric surgery patients. The original
concept devised by Radovan incorporates the insertion of an inflatable silicone balloon into
the subcutaneous tissues adjacent to a given defect. The healthy skin is sequentially expanded
and stretched until the desired surface area is attained, then the expander is removed and
the stretched skin is advanced into the defect. Recruitment of adjacent skin coupled with
a direct increase in epithelium and improved vascularity to the skin all contribute to ex-
pansion’s success. More recently, the use of acellular dermal matrices (ADM) allows tissue
expansion in areas that are thin and otherwise would have required muscle coverage over
the expander. This approach has revolutionized breast reconstruction with the placement
of ADM over tissue expanders in skin-sparing and nipple-sparing breast reconstruction.
Distraction osteogenesis is a modern adaptation of tissue expansion, allowing lengthening
of bone and expansion of the surrounding soft tissues.

tISSUe eXpanSIon

A B Defect
Defect Excised tissue

Skin island

Expander
Expander
Skin island
Burow’s triangle

Fig. 1-13 A, expander placement. the dashed line shows the planned flap. B, the flap is now ex-
panded 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.

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 22 Part I  Fundamentals

PRINCIPLES OF CLOSURE
Simple Linear Wounds
Clean linear wounds, such as excisions for small skin cancers or benign lesions, are often best
closed with direct linear suturing. Large-diameter wounds, such as for an open fasciotomy,
can be sutured as delayed primary closures or be skin grafted. The use of wound approxima-
tion devices can reduce wound diameter by progressive, continuous wound-edge traction
over days or weeks, obviating the need for more extensive procedures. NPWT devices are
also immensely helpful in reducing wound surface area before closure.

Fresh Lacerations
Clean, freshly lacerated tissues are best treated with primary closure, assuming adequate
tissue volume to achieve closure safely without tension.

Clean Granulating Wounds

Larger surface granulating wounds are usually closed with split-thickness skin grafts, de-
pending on surface area involvement. Grafting should be deferred if wounds are draining
excessively or are associated with heavy growths of bacteria, particularly staphylococci,
pseudomonal strains, or beta-hemolytic streptococci, the latter tending to dissolve skin
grafts within days of application.

Contaminated Traumatic Wounds

All contaminated wounds must be thoroughly debrided and lavaged to remove impacted
dirt and debris. It is usual for the wound to be packed and the patient brought back for a
second-look procedure 24 or 48 hours later to evaluate wound cleanliness and stability
before a complex reconstruction is undertaken. All contaminated or devitalized tissue must
be removed before definitive closure is contemplated.

Infected Wounds
Infected wounds should be drained of all pus, and all necrotic material should be debrided
back to healthy bleeding. Antibiotic therapy is never a substitute for adequate surgical drain-
age and debridement. For example, the treatment of osteomyelitis includes resection of any
necrotic bone back to healthy punctate bleeding. Wound closure should be delayed until
a stable, clean wound bed has been achieved and surrounding inflammation has resolved.

Necrotic Wounds
Wound necrosis creates an ideal milieu for bacterial proliferation. Because necrotic tissue
is avascular, antibiotics cannot penetrate the mass of dead tissue. Adequate debridement is
essential to achieving a clean, stable wound before closure. When assessing wounds contain-
ing necrotic tissue, the regional blood flow should be assessed carefully; a revascularization
procedure before reconstruction may make the difference between success and failure. The
classic example is of a diabetic with chronic foot ulceration with a monophasic waveform
of the distal circulation on Doppler evaluation. Revascularization with femorodistal bypass
may convert such a patient’s Doppler readings to a biphasic or triphasic waveform that is
more likely to be compatible with improved tissue perfusion and oxygenation and chances
for a more successful reconstructive outcome.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 23

RECONSTRUCTIVE GOALS
Once the defect has been assessed and surgical options reviewed, reconstructive goals should
be established based on safety and restoration of form and function.

Fu
m

n
ctio
For

n
Safety

Guiding principles of reconstructive surgery

Fig. 1-14 

Safety
Safety in plastic surgery involves achieving the fine balance between effective wound cover-
age and maintenance of patient health. Flap selection forms the basis of an entire chapter in
this text (Chapter 3). Focusing on flap safety, it is clear that a well-vascularized flap placed
into the defect without tension and with good primary healing and complete flap survival
are all keys to success. For example, the transfer of a poorly vascularized sural flap onto the
sole of the foot under tension with resulting flap loss does not meet the goal of a healed
wound and demonstrates poor planning and execution.
When performing pedicled flaps, the surgeon should carefully assess the arc of rotation
before committing to the procedure. If a flap cannot easily reach its destination, an alterna-
tive or a free flap should be sought. If an unusually large skin island is necessary, a vascular
delay can always be added to improve and enhance flap vascularity.
Similarly, safe free flap surgery is measured by an excellent microsurgical anastomosis
and a resultant viable free flap that achieves a healed wound without flap loss. It is intuitive
that a successful outcome requires not only good donor vessels, but also excellent recipient
vasculature. Small, damaged vessels in a radiated, scarred bed are unlikely to deliver adequate
inflow for success. Current microsurgical success rates for elective free flaps should be in
the 96% to 98% range, given current equipment and training standards. These percentages
decline in surgical repair of traumatic injuries.

Form
When breast reconstruction first began with the advent of first-generation silicone implants,
success was measured by the creation of a breast mound on the chest wall. The resultant
structure was often a poor facsimile of the natural breast. Fifty years later, breast reconstruc-
tion has evolved into a discipline that allows near-perfect restoration of form, sometimes
exceeding the appearance of the preoperative breast shape and size.

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 24 Part I Fundamentals

This evolution of technique epitomizes the concept of restoration of form and should
be applied to all forms of reconstructive plastic surgery, whether one is dealing with a face,
a breast, or an extremity. Closure of a wound by a bulky muscle flap is a worthy goal, but
not an ideal one. An approach that allows an aesthetically pleasing outcome in addition to
achieving the goal of closure is far more laudable. With the expanding array of perforator-
based skin flap options, we are also in a better position to choose thin skin flaps that are
more tailored to the defect, rather than being forced to rely on a few bulky options, as we
were in the past.
Another concept that has come to our aid has been that of prelamination. This involves
staging the creation of the flap at the donor site by delay incisions, lining the flap with grafts
such as skin or mucosa, adding cartilage constructs, and even preplacing osteointegrated
implants. This ensures viability and structural soundness before transfer, speeding the healing
process at the recipient site and increasing the chances of ultimate success. When an entirely
new flap is created by a first-stage placement of a vascular pedicle under the area of desired
skin, the term prefabrication is used. Such flaps may also be prelaminated.

Chimeric Flaps
The use of chimeric flaps has also expanded our arsenal of potential resources in recon-
struction of difficult wounds. The term chimera refers to a beast in Greek mythology that
was a composite of a lion, a goat, and a serpent. In similar fashion, the chimeric approach
can provide a multiplicity of tissues on one vascular pedicle. A classic example of this is the
anterolateral thigh (ALT) flap, whose vascular axis, the lateral circumflex femoral artery, can
supply multiple muscles, fascial tissue, multiple cutaneous skin paddles, and vascularized bone
all on one vascular pedicle for reconstruction of complex maxillary and mandibular defects.

cHImeRIc flapS

A a

c
s B
t Superficial anterior
b epigastric flap

Scapular flap

Serratus
anterior Standard groin flap
e
Latissimus dorsi

ci f

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.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 25

When considering restoration of form, it is appropriate to consider donor site sacrifice as

well. If providing a sound closure comes at the expense of unacceptable donor site morbidity,
the procedure is hardly justifiable. Perforator flaps epitomize the concept of harvesting tissue
with little or no donor site morbidity. Although the ultimate form at the flap recipient site
is the primary basis of flap selection, deformity resulting from loss of form and/or function
at the donor site should be minimized and acceptable to the patient.

Preserve Restore
donor site defect

Form and function

Fig. 1-16  Reconstructive balance: Preservation versus restoration.

Function
The ultimate goal of a successful procedure is a durable, stable, and functional result at the
reconstructive site. Although a lesser procedure such as a skin graft may achieve closure, it
may not be as durable or aesthetically pleasing as a more complex flap procedure.
While many defects require a simple closure, some require specialized functional res-
toration. These include:
• Skeletal support (bone and joints)
• Sensibility
• Animation (facial or hand)
• Hair growth (scalp and face)
• Conduit function (aerodigestive tract, bladder)
Both pedicled and free flaps can be used to meet these requirements, although microsurgery
has certainly expanded our options. Bony restoration for skeletal stability is most critical in
the face and extremities. We are fortunate to have available a plethora of bone and osteo-
cutaneous flaps, some with additional muscle extensions for soft tissue bulk. These flaps are
invaluable for the reconstruction of massive mandibular and maxillary defects. Traumatic
hand injuries are always a source of bone and soft tissue loss, and creative options available
for their restoration include functional joint transfers, toe transfers, and composite osteo-
cutaneous flaps, some incorporating tendon (dorsalis pedis or radial forearm flaps).
Restoration of sensation is not normally included in reconstruction with a cutaneous
skin island based on a muscle flap, such as the transverse rectus abdominus myocutaneous
(TRAM) flap or latissimus dorsi myocutaneous flap. However, a cutaneous branch may be
included in the flap design to allow anastomosis to a recipient cutaneous nerve for sensory
input. In thumb reconstruction, a staged groin flap wrapped around a static bone peg will
not provide sensation, whereas a single-stage free toe-to-thumb transfer will and is there-
fore preferable.

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 26 Part I  Fundamentals

Regional sensation plays an important role in flap outcomes. A sensate individual with
a wound over a pressure point is well served with a muscle or cutaneous flap, with little
likelihood of recurrent breakdown, whereas a low lumbar paraplegic will be more prone
to recurrent ischial ulceration with a nonsensate flap than a sensory flap (a vascular delayed
neurosensory tensor fascia lata flap incorporating sensory components from T12 to L1).
Functional muscle transfer can be accomplished by pedicled muscle flaps or free inner-
vated muscle transfers. Examples include transfers for facial reanimation or forearm flexion
following Volkmann’s ischemic contracture. A pedicled latissimus dorsi or pectoralis major
flap can help restore elbow flexion, and a temporalis turndown with a masseter transfer
can help with facial reanimation. Similarly, free pectoralis minor or gracilis transfers to the
face and gracilis transfers to the forearm can produce some outstanding results in carefully
selected patients. When performing functional muscle harvest, careful attention should be
paid to maintaining function at the donor site; adjacent muscles should be able to accom-
modate the muscle loss so as not to impair regional function.
Tissue expansion can be used strategically to bring additional hair-bearing skin into a
defect on the scalp for alopecia, as well as providing wound closure. Today the art of hair
transplant has advanced significantly enough to replace many of the hair-bearing flaps of
the past.
Conduit function can be restored using preexisting natural conduits or by creation of
conduits by tubing skin flaps. Jejunum and colon free flaps have been described for replace-
ment of the cervical esophagus and for creation of a neovagina. Tubed free skin flaps using
radial forearm, ALT, and regional pedicled pectoralis muscle have been described for the
esophagus, while regional flaps such as TRAM, gracilis, gluteal thigh, and internal pudendal
have been used for vaginal reconstruction.

PRINCIPLES OF RECONSTRUCTION
Flap Design
Flap design should take into account the size of the defect in relation to the tissue available
from a given flap as well as the arc of rotation of the flap when pedicled flaps are used. Flaps
should be designed slightly larger than the defects they are designed to close, given that
tissues rarely stretch as much as anticipated. Where skin flaps are used, every effort should
be made to make use of the lines of maximum extensibility (relaxed skin tension lines) to
facilitate donor site closure. Skin flaps designed to fit a particular anatomic defect should
be designed around a template of the defect. When using expanded skin flaps in delayed
closures, the flaps should be raised first before re-creating the defect in case there is not
enough flap available for closure, necessitating further expansion in the future.

Flap Selection
The details of flap selection are the basis of Chapter 3. However, some basic principles of
flap selection are pertinent at this stage of discussion.

TECHNICAL CONSIDERATIONS
Precise anatomic knowledge is essential if many of these complex reconstructive procedures
are to be accomplished successfully. External anatomic landmarks that can guide the surgeon
should be identified beforehand.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 27

Pedicle Identification and Elevation

Based on external landmarks, flap elevation is commenced and dominant pedicle identifica-
tion should be performed and confirmed before any minor pedicles are divided. Doppler
studies or preoperative multidetector CT (MDCT) scans or magnetic resonance angiography
(MRA) can be very helpful in confirming the presence or absence of pedicles. Intraop-
eratively, indocyanine green fluorescence imaging is very helpful in locating perforators
as well as delineating zones of perfusion. Once a pedicle has been identified, every effort
should be made to preserve its integrity during flap elevation and to prevent twisting or
kinking during flap transfer. The use of topical vasodilators (20% lidocaine or papaverine
solution) can help to prevent or reverse the spasm induced by dissection of the pedicle.
Hypotension, hypothermia, and the use of pressors should be avoided at all costs. When
elevating perforator flaps such as the DIEP flap, attempts should be made to incorporate
alternative venous outflow sources such as the superficial inferior epigastric vein (SIEV) to
prevent venous congestion.

Flap Delay
There are times when a flap’s design will extend beyond its usual boundaries, and these
extensions are needed for the reconstructive problem. One can improve the vascularity of
such tissues by “delaying” the needed tissues, effectively training the tissues to live off the
blood supply selected. This process requires time for vessels to dilate to increase the primary
angiosome. Taylor demonstrated that each delay requires 3 to 7 days to achieve maximal
effect, depending on the area of the body and its local vascularity.

A B C
w

w
Incision
completed

Area undermined Area undermined

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 3 1, 2 3 2, 3 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 3 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.

01_DecMaking_r3b_bs_0007-0034.indd 27 1/27/2012 1:36:37 PM

 28 Part I  Fundamentals

Tunneling Flaps for Transfer

Subcutaneous tunneling can allow a flap to reach its destination without severing the inter-
vening skin bridge. Unfortunately, postoperative swelling within the tunnel or overlying
skin bridge can result in pedicle compression, causing thrombosis and flap loss. If tunnels
are being considered, they should be patulous and generous, never tight. Hemostasis should
also be carefully checked within the tunnel to prevent development of a tunnel hematoma
that could cause catastrophic flap loss.

Tension
Tension is another common cause of partial or complete flap loss. In pedicled flaps, tension
bands running across the flap from the pivot point may cause necrosis of all tissue distal
to the tension band. In free flaps, tension can result in either avulsion of the anastomosis
or stretching of the pedicle, which predisposes to vascular thrombosis. Tension may also
develop postoperatively from swelling, activity, or a hematoma or seroma that may develop
under the flap. Drains effectively reduce seroma collections in the postoperative period.

Hemostasis
Ensuring meticulous hemostasis should be standard operating procedure for any surgeon.
Hematomas cause flap or pedicle compression, with serious consequences for both the
patient and surgeon. For dissecting extremity flaps, it is helpful to use a tourniquet for ac-
curate visualization of neurovascular structures and to minimize blood loss. Tourniquets
should be released at the end of the dissection, and hemostasis should be carefully achieved
before flap transfer and to ensure that blood flow to the flap is adequate and reaches all
components of the flap.

Blood Loss and Transfusion

Blood loss can be minimized with careful dissection technique and the use of cautery dissec-
tion. Excessive blood loss resulting in hypotension must be avoided. The question of transfu-
sion in a patient with anemia has been the subject of debate in recent years, particularly in
cancer patients, where even small-volume transfusions have been shown to slightly increase
the risk of recurrence as a result of immune compromise induced by transfusion. In terms of
postoperative hematocrit levels, slight hemodilution down to a hematocrit of 35% seems to
reduce the likelihood of intravascular thrombosis, both within anastomoses and in the deep
venous system. Patients should only receive a transfusion if they are symptomatic (syncope,
dyspnea, hypotension). Low hemoglobin values will reduce oxygen delivery to the tissues.

POSTOPERATIVE MANAGEMENT
Positioning
Although every effort may have been made to prevent intraoperative compression within
tunnels or around pedicles, incorrect postoperative positioning can induce similarly disas-
trous results. A head and neck free flap may be compressed because of neck flexion; the
problem could be avoided by using a neck roll instead of a large pillow to provide cervical
support. A Trach-Tie supporting a tracheostomy can occlude the pedicle of any flap travers-
ing the neck. A free TRAM or DIEP flap anastomosed to the vessels within the axilla may
be compressed if the patient’s arm is adducted completely or she is allowed to lie slightly
onto the operative side. An abdominal reconstruction using a free flap anastomosed to the
femoral vessels may kink when the patient sits in a chair. When performing flaps for de-
cubitus ulceration in paraplegics, the use of air-fluidized beds dramatically unload the flap
and buttocks to maintain perfusion above critical closing pressures of 32 mm Hg or more.

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 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 29

Dressings
Dressings tightly applied to an extremity can strangulate flaps or digit transplants by acting
like a tourniquet. This is particularly true at the base of the flap or digit where the vessels
enter the tissue. Plaster splints, tight bras, and aggressive binders can also compress tissues
either within the flap or adjacent, causing postoperative complications. It would be a failure
of postoperative care if a surgeon performed a flap to salvage a diabetic extremity, only to
have the splint create a pressure point over the heel, leading to heel necrosis and ultimately
amputation of the limb. Extremity flaps and replants should be elevated to reduce edema.
Patients with flaps of the head and neck should be placed in an upright position to promote
venous return and minimize swelling, since inadequate venous return and edema may
compromise flap circulation.

Suction Drains
Closed suction drains are always used after flap surgery. Although they will not necessar-
ily prevent hematomas, they reduce fluid accumulation and prevent seromas, which can
increase pressure on the flap or pedicle and lead to infection. Drain management should
be individualized to each patient situation. In general, drainage should be less than 20 to
30 ml per 24-hour period before drains are removed. Drains are usually contaminated
within 24 hours of insertion, and if at all possible, they should not be left in immediate
proximity to an implant. Fully fluted channel drains seem to be more effective and have
less tendency to block than do perforated drains. Hubless channel drains are also much less
painful for the patient when removed.

Perioperative Antibiotics
Administration of perioperative antibiotics is considered the standard of care for most major
procedures. However, postoperative antibiotics have not been shown to be beneficial be-
yond the first 24 hours and may in fact increase complication rates. Antibiotics should only
be given postoperatively if a wound is contaminated or frankly infected. In such circum-
stances, it is not usual to perform a flap; reconstruction should be delayed until sepsis has
been controlled. There are no substantive data to show that the presence of drains warrants
administration of long-term antibiotic cover.

Mobilization
Prolonged bed rest is rarely indicated after reconstruction, other than for paraplegics un-
dergoing repair of a decubitus ulcer or patients having lower extremity or perineal recon-
structions. Elevation and immobilization of upper and lower extremities for 7 to 10 days
is invaluable to reduce edema and prevent high venous back-pressures clotting off venous
anastomoses. In the lower extremities this is followed by non-weight-bearing for 6 weeks
postoperatively. Range of motion exercises can be instituted by 7 to 10 days after surgery
unless upper extremity tendon repairs have been performed in which case early motion
protocols are instituted within 24 to 48 hours of surgery.

Rehabilitation
Extremity reconstructions usually require a period of occupational and physical therapy
rehabilitation to optimize functional recovery. In upper extremity surgery, good compli-
ance with physical therapy may account for up to 50% of the final functional outcome.
Customized splint fabrication is important to support joints in their best functional posi-
tions to prevent deforming contractures. Paraplegic patients require careful instruction on
pressure relief, both when in bed and when in their wheelchairs, because failure to relieve
weight can cause recurrent ulceration in a matter of weeks or months, completely negating

01_DecMaking_r3b_bs_0007-0034.indd 29 1/27/2012 1:36:37 PM

 30 Part I  Fundamentals

the benefits of a reconstructive procedure. Careful inspection of wheelchairs and pressure-

relieving cushions for malfunction is essential. As always, rehabilitation to a functioning
position in society remains the ultimate goal of any reconstruction.

CONCLUSION
Surgical decision-making is complex and must be individualized for each patient and each
clinical problem. Equal weight should be given to patient assessment, surgical planning,
intraoperative execution, and postoperative care, because a deficiency in any one area may
mean ultimate failure of the reconstruction. Although this text focuses on flap selection
and execution, the importance these other areas cannot be overstated.

Bibliography With Key Annotations

Argenta LC, Morykwas MJ, Marks MW, et al. Vacuum-assisted closure: state of clinic art. Plast
Reconstr Surg 117(7 Suppl):127S-142S, 2006.
Treatment of wounds has been the cornerstone of plastic surgery since its inception. Vacuum-assisted
closure provides a new paradigm that can be used in concert with a wide variety of standard existing
plastic surgery techniques. It was originally developed as an alternative treatment for debilitated patients
with chronic wounds. It has rapidly evolved into a widely accepted treatment of chronic and acute
wounds, contaminated wounds, burns, envenomations, infiltrations, and wound complications from
failed operations. The ease of technique and a high rate of success have encouraged its adaptation by
thoracic, general, trauma, burn, orthopedic, urologic, as well as plastic surgeons. This article discussed
multidisciplinary advances in the use of the vacuum-assisted closure technique over the past 10 years
and its status as of 2006. Creative surgeons continue to regularly adapt the system to difficult problems.
This technique in trained surgical hands greatly enhances the scope and safety of wound treatment.
Bakhach J, Peres JM, Scalise A, et al. The quadrifoliate flap: a combination of scapular, para-
scapular, latissimus dorsi and scapula bone flaps. Br J Plast Surg 49:477-481, 1996.
A short arm stump was lengthened with a composite flap with four different tissue units based on the
subscapular artery.
Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent” consensus on perforator flap
terminology: preliminary definitions. Plast Reconstr Surg 112:1378-1383; discussion 1384-
1387, 2003.
Because of the increasing popularity of perforator flaps, many articles on their use have been published
during the past few years. Because the area of perforator flaps is new and rapidly evolving, there are
no definitions and standard rules on terminology and nomenclature, which creates confusion when
surgeons try to communicate and compare surgical techniques. This article attempts to represent the
opinion of a group of pioneers in the field of perforator flap surgery. This consensus was reached after
a terminology consensus meeting held during the Fifth International Course on Perforator Flaps in
Gent, Belgium, on September 29, 2001. It stipulated not only the definitions of perforator vessels and
perforator flaps but also the correct nomenclature for different perforator flaps. The authors stated that
this consensus is a foundation that can stimulate further discussion and encourage future refinements.
Cormack GC, Lamberty BG. Fasciocutaneous vessels. Their distribution on the trunk and
limbs, and their clinical application in tissue transfer. Anat Clin 6:121-131, 1984.
Erba P, Ogawa R, Vyas R, et al. The reconstructive matrix: a new paradigm in reconstructive
plastic surgery. Plast Reconstr Surg 126:492-498, 2010.
Erdmann D, Drye C, Heller L, et al. Abdominal wall defect and enterocutaneous fistula treat-
ment with the vacuum-assisted closure (VAC) system. Plast Reconstr Surg 108:2066-2068, 2001.
This article describes the successful treatment of an abdominal wall defect with a high-output enterocu-
taneous fistula associated with Crohn’s disease in a female patient using the wound vacuum-assisted
closure system.

01_DecMaking_r3b_bs_0007-0034.indd 30 1/27/2012 1:36:37 PM

 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 31

Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast

Reconstr Surg 78:285-292, 1986.
Gonyon DL Jr, Zenn MR. Simple approach to the radiated scalp wound using Integra skin
substitute. Ann Plast Surg 50:315-320, 2003.
The chronic irradiated scalp wound remains one of the most difficult reconstructions for the plastic
surgeon. With its inherent radiodermatitis and poor healing potential, chronic ulcers down to bone will
result if coverage cannot be achieved. Reconstructive procedures as simple as a skin graft have a high
complication rate in the irradiated wound and often fail. Local tissue transfer also has a high failure
and complication rate because of the decreased vascularity of the wound bed and radiation damage to
the surrounding scalp tissue, limiting one’s ability to manipulate it. The authors reported two cases
using a simple method with Integra bilaminate skin substitute for repair of difficult wounds of the
radiated scalp. Both patients were successfully treated using Integra. This simple method resulted in
complete healing of the irradiated scalp wound and an acceptable, functional, and cosmetic outcome
with minimal morbidity to the patients.
Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast
Reconstr Surg 93:1503-1504, 1994.
Descriptions of the reconstructive ladder permeate the literature and discussion of plastic surgery. The
reconstructive ladder is a flawed concept, however. The principles and practice of plastic surgery may
be better reflected in the phrase reconstructive elevator. The reconstructive elevator implies that in the
era of form and function, simplest is not necessarily always best. To think sequentially about the best
reconstruction options no longer suffices; technology and advanced techniques have made this type of
thought obsolete. Reconstructive surgery calls for parallel, creative thought rather than simple sequential
thought. One must be free to skip a rung of the ladder and take the elevator up to the next floor.
Hallock GG. Further clarification of the nomenclature for compound flaps. Plast Reconstr
Surg 117:151e-160e, 2006.
Compound flaps can be partitioned into two major classes that in turn are further differentiated into
various subtypes according to their inherent pattern of circulation. Although many technical modifica-
tions have improved and will improve the reliability and versatility of compound flaps, these maneuvers
alone should not be confused with creating distinct flap types but rather should be acknowledged as
only important variations. With this understanding, this revised nomenclature system for compound
flaps detailed by the author is intended to be a means of standardizing communication and to fa-
cilitate research agendas on a common ground, fully realizing its primary role still only to serve as a
convenient guideline.
Hallock GG. Simplified nomenclature for compound flaps. Plast Reconstr Surg 105:1465-1470,
2000.
The unique niche for compound flaps is their potential role for the repair of massive defects that demands
the simultaneous restoration of multiple, missing tissue types. These complex flaps can be sorted into
two major classes, and their subtypes on the basis of their means of vascularization are described. (1)
Solitary vascularization, the composite flap: “multiple tissue components with a single vascular supply
and dependent parts.” (2) Combined flaps: (a) Siamese flaps: “multiple flap territories, dependent
as a result of some common physical junction, yet each retaining their independent vascular supply”;
(b) conjoint flaps: “multiple independent flaps, each with an independent vascular supply, but linked
by a common indigenous source vessel”; and (c) sequential flaps: “multiple independent flaps, each
with an independent vascular supply, and artificially linked by a microanastomosis.” Many technical
modifications that have improved or will improve the reliability of these flaps should not be confused
as distinct flap types, but rather acknowledged as variations that can be more conveniently classified
for the purposes of improved communication and research by using this basic schema as a guideline.

01_DecMaking_r3b_bs_0007-0034.indd 31 1/27/2012 1:36:37 PM

 32 Part I  Fundamentals

Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 44:53-54,
1991.
The authors reported a method of elevating and rotating a flap like a propeller for the release of scar
contractures. They obtained satisfactory results in the repair of scar contractures in the cubital and axil-
lary regions. This flap may be applied to the flexor side in other regions, such as the groin, popliteal
fossa, and fingers, where burn contractures are common.
Koshima I, Yamamoto H, Hosoda M, et al. Free combined composite flaps using the lateral
circumflex femoral system for repair of massive defects of the head and neck regions: an intro-
duction to the chimeric flap principle. Plast Reconstr Surg 92:411-420, 1993.
Chimeric composite flaps, combined using microanastomoses, consist of two or more flaps or tissues,
each with an isolated pedicle and a single vascular source. Free combined chimeric flaps using the lateral
circumflex femoral system were used to treat massive composite defects of the head and neck in 10 cases.
Combined anterolateral thigh flap and vascularized iliac bone graft based on the lateral circumflex
femoral system and the deep circumflex iliac system was the most commonly used combination. An
anteromedial thigh flap and a paraumbilical perforator-based flap were also combined with this prin-
cipal combination. The advantages of this chimeric flap over other osteocutaneous flaps were reviewed.
Lamberty BG, Cormack GC. The antecubital fascio-cutaneous flap. Br J Plast Surg 36:428-
433, 1983.
Milton SH. Pedicled skin-flaps: the fallacy of the length: width ratio. Br J Surg 57:502-508, 1970.
The author discussed how the old concept of a length/width ratio for estimating skin flap length has
gradually evolved into a new one: that flaps made under similar conditions of blood supply survive to
the same length regardless of width. The steps of this change in concept were presented.
Morykwas MJ, Simpson J, Punger K, et al. Vacuum-assisted closure: state of basic research and
physiologic foundation. Plast Reconstr Surg 117(7 Suppl):121S-126S, 2006.
A tremendous amount of research has been conducted in recent years investigating the mechanisms
of action by which the application of subatmospheric pressure to wounds increases the rate of healing.
Similarly, numerous studies have also been conducted examining the physiologic response of wounds
to the applied subatmospheric pressure. However, many more need to be conducted. A series of basic
studies examining the use of subatmospheric pressure to treat wounds was presented, including the
original studies on which the vacuum-assisted closure device was based (on blood flow, granulation
tissue formation, bacterial clearance, and survival of random-pattern pedicle flaps). Subsequent stud-
ies analyzing removed fluids, envenomation/extravasation, burns, grafts, and in vitro tissue culture
studies were also reviewed. Two broad mechanisms of action were proposed: removal of fluid and
mechanical deformation. Fluid removal both decreases edema—thus decreasing interstitial pressure
and shortening distances of diffusion—and removes soluble factors that may affect the healing process
(both positively and negatively).
Moscatiello F, Masià J, Carrera A, et al. The ‘propeller’ distal anteromedial thigh perforator flap.
Anatomic study and clinical applications. J Plast Reconstr Aesthet Surg 60:1323-1330, 2007.
Sixteen cryopreserved inferior limbs were latex-injected in the femoral artery and the skin perforators
of the distal anteromedial thigh and their source vessels were studied. In addition, from December
2000 to June 2005, skin islands from the distal anteromedial aspect of the thigh of six patients
were transferred as local perforator flaps to reconstruct the peripatellar region and upper leg soft tissue
defects. Every flap was based on a single adequate perforator vessel. The tissue was rotated, like a
propeller, through 180 degrees. The authors called the flap the “propeller distal anteromedial thigh
perforator flap.” This flap can be reliably transferred based on only one adequate perforator vessel. It
reduces morbidity and improves the availability of the distal anteromedial thigh as a flap donor site
and represents an additional reconstructive option for knee and upper leg defects.

01_DecMaking_r3b_bs_0007-0034.indd 32 1/27/2012 1:36:37 PM

 Chapter 1  •  Surgical Decision-Making: Options, Principles, and Techniques 33

Pignatti M, Ogawa R, Hallock GG, et al. The “Tokyo” consensus on propeller flaps. Plast
Reconstr Surg 127:716-722, 2011.
The authors reported the consensus on the definition and classification of propeller flaps reached at
the First Tokyo Meeting on Perforator and Propeller Flaps in June 2009. Some peculiar aspects of
the surgical technique were discussed. A propeller flap can be defined as an “island flap that reaches
the recipient site through an axial rotation.” The classification is based on the nourishing pedicle
(subcutaneous pedicled propeller flap, perforator pedicled propeller flap, supercharged propeller flap),
the degrees of skin island rotation (90 to 180 degrees) and, when possible, the artery of origin of the
perforator. A flap should be called a propeller flap only if it fulfils the definition above. The type of
nourishing pedicle, the source vessel (when known), and the degree of skin island rotation should be
specified for each flap.
Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plast Re-
constr Surg 69:195-208, 1982.
Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology,
anatomy, and use in reconstruction. Plast Reconstr Surg 123:132e-145e, 2009.
Perforator flaps have these advantages: reduced donor site morbidity, the versatility to accurately re-
place the components required at the recipient site, a longer pedicle than is achievable with the parent
myocutaneous flap, and freedom from orientation of the pedicle. Their development has followed our
understanding of the blood supply from a source artery to the skin, which has been achieved because
of landmark studies by Manchot, Salmon, Milton, Taylor, and others. Many articles now attest to
the safety and reliability of perforator flaps. This review outlined the history and controversies sur-
rounding perforator flaps and described the anatomy of the workhorse perforator flaps and their use in
microsurgical reconstruction. These flaps include the deep inferior epigastric artery, anterolateral thigh,
thoracodorsal artery, and superior and inferior gluteal artery perforator flaps.
Scherer SS, Pietramaggiori G, Mathews JC, et al. The mechanism of action of the vacuum-
assisted closure device. Plast Reconstr Surg 122:786-797, 2008.
The data in this article provide profound insights into the mechanism of action of the vacuum-assisted
closure device, providing an explanation for the increases in wound bed vascularity and cell prolifera-
tion based on its components. Results suggest that the vascular response is related to the polyurethane
foam, whereas tissue strains induced by the vacuum-assisted closure device stimulated cell proliferation.
Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome) and clinical territories
of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast
Reconstr Surg 127:1447-1459, 2011.
Taylor GI, Razaboni RM, eds. Michel Salmon Anatomic Studies. Book I: Arteries of the
Muscles of the Extremities and the Trunk. Taylor GI, Razaboni RM, eds. Anatomic Studies,
vol I. St Louis: Quality Medical Publishing, 1994.
Wei FC, Celik N, Jeng SF. Application of “simplified nomenclature for compound flaps” to
the anterolateral thigh flap. Plast Reconstr Surg 115:1051-1055; discussion 1056-1057, 2005.
The authors proposed a new terminology for classification of the anterolateral thigh flap based on
the “simplified nomenclature for compound flaps” introduced by Hallock. The intention of this new
terminology is to describe both tissue components and skin vessel type. Anterolateral thigh flaps can be
classified into two subgroups according to the tissue components, as follows: cutaneous or compound.
The skin vessel types can also be classified into two subgroups according to the course they traverse:
septocutaneous vessel or myocutaneous perforator. This classification may bring a consensus on the
nomenclature of anterolateral thigh flaps and would be applicable to other perforator flaps.

01_DecMaking_r3b_bs_0007-0034.indd 33 1/27/2012 1:36:38 PM

 34 Part I  Fundamentals

Wei FC, Demirkan F, Chen HC, et al. The outcome of failed free flaps in head and neck
and extremity reconstruction: what is next in the reconstructive ladder? Plast Reconstr Surg
108:1154-1160; discussion 1161-1162, 2001.
The indications for free flaps have been more or less clarified; however, the course of reconstruction
after the failure of a free flap remains undetermined. Is it better to insist on one’s initial choice, or
should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, the au-
thors analyzed the outcome of 101 failed free tissue transfers of 3361 head and neck and extremity
reconstructions performed by free tissue transfers. The authors concluded that a second free tissue
transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap
failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of
the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps
for soft tissue coverage in extremities with partial and even total losses.
Wong CJ, Niranjan N. Reconstructive stages as an alternative to the reconstructive ladder. Plast
Reconstr Surg 121:362e-363e, 2008.
Various paradigms have been offered to describe the increasingly sophisticated methods of wound
closure. The most established is, of course, the reconstructive ladder. The reconstructive ladder implies
that the simplest technique should be explored before progressing up the rungs, and that should be done
only when required. It has been dismissed by the champions of the second paradigm, the reconstruc-
tive elevator. The floors are equivalent to the rungs of the ladder, but with an elevator we can jump
several floors and go straight to the floor/technique desired. The authors propose a new paradigm, the
reconstructive stages. Instead of rungs or floors, they equate surgical techniques to stages. The next
stage can only be attempted after the preceding one has been completed often enough so that one does
not fail. Unlike the ladder or elevator, the reconstructive stages reflect the skill and effort required as
the more difficult technique is adopted.

01_DecMaking_r3b_bs_0007-0034.indd 34 1/27/2012 1:36:38 PM

 Chapter 2
Vascular Basis of Flaps
and Flap Classification
Steven F. Morris
Peter G. Davison

Since the times of ancient civilizations, physicians have struggled to close traumatic wounds.
The initial attempts were hampered by inadequate anesthesia, lack of antisepsis, and crude in-
struments. More recent challenges have included incomplete anatomic understanding and poor
surgical technique. However, over the course of time, surgical ingenuity has resulted in a gradu-
ally improved ability to move tissues around the body to close wounds.
A flap may be defined as a vascularized tis-
sue transfer. It can consist of skin, muscle, fascia,
subcutaneous tissue, tendon, nerve, or any com-
bination of these. It may be either pedicle based
on an attachment to the donor site, or the flap
may be detached completely and its vessels re-
anastomosed at the recipient site. The history of
the development of flaps in reconstructive surgery
has been fairly haphazard and random.1 Initially,
wound closure was achieved by primitive suturing
techniques. Later, methods of skin grafting and
local, regional and distant tissue transfers evolved.
Often, excellent reconstructive techniques were
identified but not effectively communicated so the
surgical technique never became widely accepted.
For example, Sushruta2 of India described nasal re-
construction using a delayed forehead rotation flap
about 600 bc. This yielded excellent results and
is a procedure that is still used with good results.

Fig. 2-1  Sushruta nasal reconstruction. Sushruta

described this nasal reconstruction about 600 bc in
the book Sushruta Samhita.

02_VasBasis_r4_bs_0035-0080.indd 35 2/2/2012 2:11:08 PM

 36 Part I  Fundamentals

About 2200 years later, Gaspare Tagliacozzi described a delayed, tubed arm flap for nasal
reconstruction in 1597. Survival of this multistage reconstruction relied on a random blood
supply and yielded worse results than the forehead flap technique. It is interesting that the
ancient “Indian rhinoplasty” technique was lost and replaced by an inferior random-pattern
flap technique.

Fig. 2-2  Gaspare Tagliacozzi nasal reconstruction, 1597.

Study of Vascular Anatomy

An understanding of vascular anatomy is crucial to the design of flaps of any kind. However,
flap design in the early days of reconstructive surgery was hampered by an inadequate knowl-
edge of vascular anatomy. Carl Manchot in the late
1800s and Michel Salmon in the 1930s were the first
researchers to take an interest in the vascular anatomy
of the skin and soft tissues.3,4 Manchot’s work5,6 from
1889 was largely unrecognized by the surgical commu-
nity until it was translated from German into English.
This was the first major study to describe the vascular
supply to the integument; it also described in detail 40
cutaneous territories.

Fig. 2-3  Carl Manchot’s illustration from his 1889 publication

depicts the territories supplied by the cutaneous arteries of the
human body.

02_VasBasis_r4_bs_0035-0080.indd 36 2/2/2012 2:11:08 PM

 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 37

In 1936, Salmon’s publications expanded on this work.7,8 On the basis of a large number of
angiographic studies using lead oxide, he defined more than 80 vascular territories through-
out the body. Ironically, the research work of Manchot and Salmon provided important
information regarding the vascular basis of flaps, yet this information was not recognized by
surgeons of the era.

A chematic summary of the cutaneous arterial territory of the ventral surface

S
of the body.
1.0 Occipital artery 21.0 Internal mammary artery
2.0 Superficial temporal artery 22.0 External mammary (lateral thoracic)
3.0 Ophthalmic artery and subscapular arteries
4.0 Sternocleidomastoid artery 23.0 Intercostal arteries
5.0 Facial artery 24.0 Superficial superior epigastic artery
6.0 Thyroid arteries 25.0 Lumbar arteries
7.0 Transverse cervical and 26.0 Inferior superficial epigastric artery
suprascapular arteries 27.0 Deep epigastric artery
8.0 Deltoid branch of the 28.0 External superior pudendal artery
acromiothoracic trunk 29.0 External inferior pudendal artery
9.0 Circumflex humeral arteries 30.0 Superficial circumflex iliac artery
10.0 Small thoracic branches of the 31.0 Femoral artery
acromiothoracic trunk 32.0 Artery to the vastus lateralis muscle
11.0 Profunda brachii artery 33.0 Superficial femoral artery
12.0 Brachial artery (muscular branches) 34.0 Artery to the adductor muscles
13.0 Brachial artery (direct branches) 35.0 Lateral articular branches
14.0 Epicondylar arteries 36.0 Medial articular branches
15.0 Epitrochlear arteries 37.0 Genus descendens artery
16.0 Radial artery 38.0 Anterior tibial artery
17.0 Ulnar artery 39.0 Posterior tibial artery
18.0 Deep palmar arch 40.0 Peroneal artery
19.0 Superficial palmar arch 41.0 Dorsalis pedis artery
20.0 Anterior interosseous artery 42.0 Medial plantar artery
Anterior view

B Schematic summary of the cutaneous arterial territories of the dorsal surface

of the body.
1.0 Superficial temporal artery 20.0 Posterior interosseous arteries
2.0 Occipital artery  21.0 Deep palmar arch
3.0 Posterior auricular artery 22.0 Digital arteries
4.0 Deep cervical artery 23.0 Intercostal arteries (perforating
5.0 Sternocleidomastoid artery branches)
6.0 Deep branch of the transverse 24.0 Lumbar arteries (dorsospinal branches)
cervical artery 25.0 Lumbar arteries (perforating branches)
7.0 Suprascapular artery 26.0 Superficial circumflex iliac artery
8.0 Dorsospinal branch of the 27.0 Superior gluteal artery
intercostal artery 28.0 Internal pudendal artery
9.0 Subscapular artery 29.0 Inferior gluteal artery
10.0 Posterior circumflex humeral artery 30.0 Artery to the adductors
11.0 Brachial artery (medial collateral 31.0 Artery accompanying the sciatic nerve
branches) 32 and 33. Perforating arteries
12.0 Profunda brachii artery 34.0 Popliteal artery
13.0 Posterior recurrent ulnar artery 35.0 Gastrocnemius arteries
14.0 Radial recurrent artery 36.0 Small saphenous artery
15.0 Ulnar artery 37.0 Posterior tibial artery
16.0 Posterior interosseous artery 38.0 Peroneal artery
17.0 Anterior interosseous artery 39.0 Dorsalis pedis artery
18.0 Dorsal branch of the ulnar artery 40.0 Medial plantar artery
19.0 Dorsal carpal artery

Posterior view

Fig. 2-4  Michel Salmon’s vascular territories of the human body, from his book Artères de la Peau.
The vascular territories are numbered and indexed.

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 38 Part I  Fundamentals

Ian Taylor and colleagues9-15 refined the lead oxide injection technique and used it to
produce a vast body of anatomic work. This resulted in dozens of publications on vascular
and neurovascular territories of the body and the vascular basis of flaps. This work was very
closely related to surgical breakthroughs including the use of free tissue transfers,16,17 vascular-
ized bone transfers,18 and the use of the Doppler for flap design.19
Cormack and Lamberty20-22 also contributed significantly to our current understanding
of the vasculature of the human body. They provided detailed descriptions of the skin’s vascu-
lature and differentiated between anatomic, dynamic, and potential territories. Cormack and
Lamberty also used the lead oxide injection technique, which Salmon had initially reported.
This injection technique was further defined by Taylor, Bergeron, and Tang.23,24

I II III

Anatomic
Dynamic
Potential

Fig. 2-5  Cormack and Lamberty’s simplified concept of the underlying vasculature of anatomic,
dynamic, and potential territories for flap design.

More recently, computerized axial tomography and advanced software have allowed
three dimensional analysis of the vascular anatomy of regions of interest.25-27 This technique
has allowed layer-by-layer analysis of the vasculature without disrupting the anatomy as in
dissections. Three-dimensional vascular anatomic techniques and clinical imaging modalities
provide a vast amount of useful anatomic information to the surgeon planning a reconstruc-
tive procedure.

Fig. 2-6  A three-dimensional reconstruction that demonstrates the vascular anatomy of a deep cir-
cumflex iliac artery (DCIA) osteocutaneous perforator flap.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 39

Evolution of Flap Design

Initially, surgeons used flaps almost exclusively to reconstruct soft tissue defects, so the flaps
were usually skin-only flaps and were designed in a random fashion; that is, no effort was
made to identify the vascular basis of the flap or to include vessels at the base of the flap. In
fact, it was assumed at the time that the width of the flap determined the surviving length of
the flap; the so-called length-to-width ratio. Stuart Milton28 disproved this theory with an
elegant study using a porcine flank skin flap in which he compared flaps of differing widths
and found equivalent survival. McGregor29-31 is credited with recognizing the importance of
the distinction between random and axial flaps, which are supplied by major vessels running
within the skin along the axis of the flap. In the 1960s and 1970s, the concept of the axial flap
was used to design the deltopectoral flap based on the internal mammary perforators and the
groin flap based on the superficial circumflex femoral vessels. When it was generally appreci-
ated that the vascular anatomy of a flap influenced its survival, there was a flurry of activity in
both the study of the anatomy of flaps and in the development of a wide array of skin, muscle,
and bone flaps. Other axial flaps, including the forehead flap based on the supraorbital vessels,
the postauricular flap based on postauricular vessels, and the dorsalis pedis flap based on the
dorsalis pedis vessels were described.

A B

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.

Once axial-pattern flaps became widely used, the limits of viability of the flaps were tested.
In efforts to improve the viability of axial-pattern flaps, surgeons sought to include fascia in
the flaps. Several descriptions and classifications of fasciocutaneous flaps emerged, including
those by Cormack and Lamberty20 and Nakajima et al.32 A variety of fasciocutaneous flaps
were subsequently described including the radial and ulnar artery forearm flaps, the circumflex
scapular artery flap, the medial plantar artery flap and the saphenous flap. With the careful
attention to the vascular supply of tissues, it was soon noted that the vascular supply to muscles
was far larger and more consistent than the skin vasculature. Muscle and myocutaneous flaps
were subsequently introduced by McCraw, Arnold, Mathes, and Nahai to take advantage
of this robust blood supply, bulk, and minimal donor site scarring.33-39 Muscle flaps became
very popular and widely used in the 1970s and 1980s.
The introduction of free autologous tissue transfer using microsurgical vessel anastomoses
marked a momentous innovation that opened a new landscape of possibilities for the recon-
structive surgeon. Taylor and Daniel16,40 in 1973 published the first clinical application of a
free composite tissue transfer with reanastomosis at a distant site and thereby coined the term

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 40 Part I  Fundamentals

free flap. This first free flap was a groin flap based on the superficial inferior epigastric artery
(SIEA) used for a large medial ankle defect. Defect reconstruction was no longer limited to
the donor sites within an arc of rotation or by a multistaged delayed pedicled tube flap recon-
struction. The emergence of free flap reconstruction was possible because of the simultaneous
development of the operating microscope, microinstruments, and sutures.
The most recent development in flap surgery has been the use of perforator flaps. Perforator
flaps are strictly defined as pedicled or free flaps based on myocutaneous perforators; however,
the term perforator flaps has evolved to encompass the variety of skin flaps based on skeletonized
vessels supplying the skin flap directly, whether the vessel is myocutaneous, septocutaneous, or
fasciocutaneous in origin. We have previously documented the approximately 400 cutaneous
perforators that provide the basis for perforator flap design.4 The rapid expansion of our under-
standing of the vascular anatomy of perforator flaps and their applications has highlighted the
continued need for detailed anatomic knowledge for intelligent flap design. There has been a
steady evolution of flap design based on ever-improving anatomic understanding, which has
led to more sophisticated and elegant solutions for clinical problems.

Perforator flaps

Free flaps

Fasciocutaneous flaps
Anatomic understanding

Muscle flaps

Axial flaps

Skin grafts

Random flaps
• Rotation
• Advancement

Pedicled tube flaps

Forehead flap

600 BC 1600 1900 1970 1990

Timeline

Fig. 2-8  A timeline that represents the evolution of wound reconstruction since the beginning of
plastic surgery (not to scale).

Angiosome Concept
The angiosome concept describes the vascular supply to specific three-dimensional blocks of
tissue, including skin and deeper tissue layers. The concept was first described and named in
1987 by Taylor and Palmer, 9 in “The vascular territories (angiosomes) of the body.” The term
angiosome originates from the juxtaposition of the Greek words angeion (“blood vessel”) and
somite (“sector of the body”). Taylor et al3,9 described the angiosome concept as an “anatomic
concept with clinical implications.” The angiosome concept has significantly enhanced the
understanding of the blood supply of tissue and has stood the test of time.
Angiosomes are three-dimensional composite blocks of skin and deep tissue that are sup-
plied by a single source artery. The angiosomes are interconnected by smaller-caliber choke
anastomotic vessels and true anastomotic vessels to form a continuous vascular network that

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 41

encompasses the entire body, broken up into distinct units, arranged in a distribution that
resembles a jigsaw puzzle. The original work of Taylor and Palmer9 described 40 source
arteries bilaterally. They indicated that many of these territories could be further subdivided,
depending on the definition of a main source vessel. A recent study by Morris et al4 identified
61 distinct vascular territories, based on the analysis of three-dimensional CT angiography of
lead oxide–injected cadavers. Others have further subdivided the vascular territories into smaller
subunits.12,14,41-43 The important observation to keep in mind regarding vascular territories is
that the architecture of the vascular territory influences the behavior of tissue transfers. It is
also crucial to note that the detailed vascular anatomy of different vascular territories varies
dramatically from individual to individual. The main source vessels remain constant; however,
the individual perforators are highly variable when compared from side to side in the same
individual and between individuals.

5
4 39
9
6 3 38
7 2 16
11 8 1 15
9
10 14
11 13
12 12 11
13
37
14 36
17
35
15 18
16 19 34
33

20 32

40
21 31
28
22 27 21 22

22A 22A
23 23

30
24 26

25 29

Fig. 2-9  Taylor and Palmer’s vascular territories (angiosomes) of the body, based on 40 source ves-
sels. 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, acromio-
thoracic; 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.

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 42 Part I  Fundamentals

Each angiosome is supplied by a source artery. Some source arteries give off a single cu-
taneous perforator that supplies the complete angiosome, such as the SIEA.3,4,44 Nevertheless,
most cutaneous territories are supplied by source arteries that branch into multiple variable
cutaneous perforators, such as the deep inferior epigastric artery (DIEA).45-47 Therefore each
angiosome may often be further subdivided into numerous cutaneous territories, supplied
by cutaneous perforators branching from their associated source vessel. More recently, these
subunits of angiosomes, the anatomic territories associated with cutaneous perforators, have
been termed both a cutaneous angiosome and a perforator angiosome, which can be shortened to
perforasome.48-50 This is consistent with the angiosome theory, which initially stated that an-
giosomes can be subdivided.9

Clavicle
A B
STHA
TCT

ITA
LTA LTA

TDA TDA
Nipple

SEA LPIA
LPIA

DIEA

DCIA SIEA
SIEA
SCIA
SCIA

SEPA

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 perfora-
tors 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 ex-
ternal pudendal artery; SIEA, superficial inferior epigastric artery; STHA, superior thyroid artery; TCT,
thyrocervical trunk; TDA, thoracodorsal artery.)

Adjacent cutaneous territories are connected by anastomotic vessels in all directions

around the perimeter of angiosome. Taylor and Palmer3,9 found an average of 376 cutaneous
perforators in the human body with a diameter of 0.5 mm or greater. Each of these vessels is
interconnected with adjacent arterial territories by either smaller-caliber choke anastomoses
or true anastomoses.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 43

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).

In the integument, the choke anastomotic vessels are generally of smaller caliber, with
a narrow lumen, the so-called choke vessels. However, these connections can alternatively
be “true” anastomoses without any reduction in caliber; these are seen primarily in deeper
tissues such as muscles or nerve trunks, or with the vessels that accompany cutaneous
nerves. The latissimus dorsi muscle connections between the thoracodorsal and intercostal
territories are an example. There is an analogous arrangement on the venous side, where
adjacent territories are connected by oscillating, bidirectional veins. These avalvular veins
regulate the flow and pressure to maintain venous drainage equilibrium between neighbor-
ing venosomes (venous territories).

Angiosome territory
of cutaneous perforator

Angiosome skin territory of source artery

Fig. 2-12  True versus choke anastomoses between neighboring vascular territories.

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 44 Part I  Fundamentals

The most likely area for necrosis in an elevated flap is at the junctional anastomotic
zone of the territories supplied by adjacent cutaneous perforators from adjacent vascular
territories. However, it has been shown in animal studies and correlated with clinical data
that one adjacent anatomic territory, radially in any direction, supplied by an independent
cutaneous perforator, may be reliably included in the dissection of a cutaneous perforator
flap.3,51 In some instances, a second territory beyond the junctional zone can be supported,
particularly if there are “true” anastomoses instead of choke vessels present at the interface.
Interestingly, this can be extended with a vascular delay procedure to allow recruitment
of additional vascular territories in the flap.51-54 Cormack and Lamberty20 referred to these
different descriptions of flaps as the anatomic, dynamic, and potential territories (see p. 38).

Arterial Vasculature
The arterial system supplies the entire body through a three-dimensional continuous network
of interconnected vessels, divided into many vascular territories. The vascular territories
are mostly interconnected through smaller-caliber choke anastomotic vessels, and to a
much lesser extent, true anastomoses. The boundaries of cutaneous territories are gener-
ally marked by the junctional zones of smaller-caliber choke vessels on the arterial side and
with bidirectional oscillating veins in the venous system. The interconnections between
the vascular arcades also occur in the deeper tissues, including muscle, bone, and nerve.
Blood vessels that supply the integument can be classified as either direct or indirect
cutaneous arteries. Direct vessels supply the skin directly from the source artery, piercing
through the deep fascia or traveling to the skin via an intermuscular septum, and they often
travel directly into the subdermal plexus as an axial vessel. The direct cutaneous arteries
vary in length, caliber and density over different areas of the body. The indirect vessels
(septocutaneous and myocutaneous perforators) primarily supply muscle and deep tissues,
after which terminal branches give off cutaneous perforators to the skin. The classification
of perforator arteries as direct or indirect is less clinically applicable than their ability to sup-
port a flap, based on the source vessel. The caliber, direction, and pattern of perforators to
the skin are most relevant, because they affect flap viability.4 The distribution of individual
vessels varies from subject to subject; hence preoperative evaluation of the size, direction,
and territory of individual vessels will be important for flap survival.

MATHES-NAHAI CLASSIFICATION OF FASCIA/FASCIOCUTANEOUS FLAPS

Type A Type B

Fig. 2-13  Patterns of blood supply to the in-

tegument: 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 cuta-
neous pedicles.

Type C

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 45

There are numerous cutaneous perforators within each vascular territory that supply
the skin. The source vessels that supply an angiosome are the named main vessels, which
are predictable and relatively consistent between individuals. However, there is great inter-
individual variability in the number and arrangement of the specific perforator vessels that
supply the skin of each territory, composed of both direct and indirect vessels.4
Taylor described a number of general principles that guide the clinical use of the angio-
some theory, as follows.3,9,10

Law of Equilibrium
A balance or equilibrium of blood supply to adjacent territories is maintained so that a
dominant supply from one cutaneous perforator is balanced by a smaller size of a neighbor-
ing perforator within an angiosome or in adjacent angiosomes.7 In other words, there is an
inverse relationship between adjacent individual perforators that supply the same region.7,8
When small vessels are found in one area, larger vessels are present adjacently.9 This law of
equilibrium was initially recognized by Salmon in 19367 and was put into clinically relevant
terms by Taylor.9 For example, the calibers of the SIEA and DIEA tend to be inversely pro-
portional, as seen when elevating a DIEA flap (see p. 42). This becomes important clinically
when evaluating which potential perforator or source vessel to include in a flap. For example,
if the SIEA is particularly large, the DIEA perforators may be correspondingly smaller.

Vessels Move From Fixed to Mobile Skin

Perforators pierce the deep fascia at areas of fixed skin and then are oriented from areas of
fixed to mobile skin.
• Areas of fixed skin correspond to the locations at which the deep fascia is “anchored
to bone or to the intermuscular and intramuscular septa.”
• Vessels flow toward the convexities of the body.
• In areas with fixed skin, such as the palms and soles, there will be a higher density
of short perforator branches.
• Areas of mobile skin are supplied by fewer, longer perforator branches; for example,
in the torso—the deltopectoral flap. Other regions with fewer, longer perforators
include the arm, thigh, head, and neck.
Arterial vessels are also long when they travel in association with a cutaneous nerve. In
general, cutaneous vessels in areas of loose skin have a larger vascular territory.

Vessels Follow Connective Tissue Framework

The body is composed of a continuous framework of rigid and loose connective tissue,
including bone and fascia. The network of arteries and veins follows these connective tissue
planes as they radiate from the heart to the periphery. Proximally, vessels generally travel
close to the axial skeleton, then branch into the intermuscular septa, then give off smaller
branches to supply the muscles and other deep tissue. It is noteworthy that the vessels may
travel next to but not truly within the septa as they perforate a muscle. The terminal branches
of the arteries and their associated venae comitantes take off from their source vessels and
pierce the deep fascia as they follow the superficial fascial planes up to the integument.

Growth and Development

During the early stages of human embryonic development, the mesoderm forms the mesen-
chyme—connective tissue that further differentiates into bone, cartilage, fascia, the lymphatic
system, and the vascular system. Therefore, after completion of growth and differentiation,
the blood vessels are left in the surroundings and tissue planes of the rigid and loose connec-
tive tissue, including the intermuscular and intramuscular septa. This intuitively explains the

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 46 Part I  Fundamentals

vascular anatomy of vessels that follow the connective tissue framework. Hunter56 posited a
fixed number of arteries in the body. The cutaneous perforators in the fetus branch off in a
stellate pattern. In the regions where there has been longitudinal growth in that direction,
these will develop into axially oriented vessels in adults.

Venous Vasculature
The study of the venous structures of the body has attracted less interest and is more dif-
ficult than the study of the arterial anatomy. Generally, it is assumed that venous structures
mirror the arterial anatomy; however, there are important differences. Our understanding
of the venous vasculature was significantly advanced from the landmark study on venous
territories published by Taylor et al in 199010 (see p. 41). This study outlined the entire
venous system with meticulous detail throughout the human body’s integument and deep
tissues. Using refined techniques of retrograde intravenous injection of chlorocresol and lead
oxide, six cadavers were precisely dissected and radiographed. All perforating veins of the
integument were identified and tagged. Additionally, the superficial and deep veins were
microscopically dissected to classify valvular and avalvular veins and thereby understand the
patterns of venous drainage. The authors found that analogous to the arterial vasculature,
the venous system throughout the body is made up of venous territories (venosomes) that
form a vast, three-dimensional, interconnected network of veins. These arcades of veins
exist within and between all tissues. They are the link between adjacent vascular territories.
The flow of venous drainage is directed from the capillary level, with increasing caliber of
vessels as they converge at the superior and inferior venae cavae.

Network of Arcades
The venous vasculature comprises superficial and deep systems. Superficial veins are gen-
erally independent of the arterial vasculature, and their territory of drainage may cross
multiple angiosomes. Superficial veins are located in the subdermal plexus, are larger than
venae comitantes, and flow axially in the limbs. Examples include cephalic, basilic veins
in the upper extremity; and the saphenous vein in the lower extremity.57 Veins in the deep
system, venae comitantes, generally parallel their associated source artery and its perfora-
tors. In some regions, venae comitantes are paired; in other regions, they are single.10 The
horizontal superficial veins are connected to the deep system throughout their course either
via the venae comitantes or the larger-caliber valvular venae communicantes. Contrary to
earlier findings by Schafer,58 Taylor et al10 found that the integument is primarily drained by
venous vasculature that parallels the arterial system, the venae comitantes. Certain regions
of the limbs are the exception.

Valvular and Avalvular Connections

The veins throughout the body are either valvular or avalvular, which thereby determines
the possible direction of blood flow. The superficial veins that make up the horizontal
channels in the limbs and veins are arranged in a stellate pattern. The venae comitantes that
collect blood from a vascular territory parallel to the arterial system, such as a cutaneous
perforator or muscle pedicle, are also directional, valved veins. These veins are arranged in
a treelike pattern that has valves along the branches, at the branching points off the trunk,
and at the entry of the pedicle into the parent vein.10 However, the distalmost tips of these
venous branches have no valves and are therefore bidirectional. These smaller collecting
veins will be continuous with those of the adjacent venous tree, whose venous branches
will have valves oriented in the opposite direction.10

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 47

A
S

D D

D D

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 drain-
age 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).

One of the key concepts discovered by Taylor et al10 in their venosome study was the
presence of interconnected valvular and avalvular channels within the venous system that
maintain an equilibrium of flow (and possibly pressure) between adjacent vascular territories.
Analogous to the choke vessels that mark the perimeter of cutaneous territories, there are
oscillating, bidirectional veins that maintain equilibrium in the vascular drainage. These
avalvular vessels define the boundaries between adjacent venous territories.

Veins Converge From Mobile to Fixed Areas

The deep veins travel within the connective tissue framework, along with their accompany-
ing arteries from the heart to the integument. Generally, veins are oriented parallel to the
plane of mobility and only cross mobile tissue planes at areas where the skin is adherent to
underlying fascia or bone.10 Mobile tissue planes are relatively avascular.
Veins course from areas of mobile skin to fixed skin. Similar to arteries, they will per-
forate the deep fascia from the subcutaneous tissue at locations where the two structures
are anchored together. Taylor et al10 mapped the common locations of venous perforators,
which include the perimeter of muscles, intermuscular septa, flexor surfaces of joints, dorsal
and ventral midline, base of the skull and orbital margins (where the galea is anchored), and
areas of deep fascia fixation to bone.

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 48 Part I  Fundamentals

Muscles Propel Venous Return

Similar to the arterial system, the venae comitantes may drain the integument directly or
indirectly, based on their course either through intermuscular septa or intramuscular septa,
respectively. When paired, the venae comitantes are generally connected with their mirrored
vein via avalvular channels in a stepladder pattern. Venae comitantes are efferent veins; they
drain the muscles toward the venae cavae. Afferent veins drain blood into nearly all muscles
of the body from the surrounding tissues, which may include the overlying integument,
adjacent muscles, and the bone or bones of the muscle’s insertion or origin. The venous
cutaneous perforators are generally directional and valvular, whereas the intermuscular ve-
nous arcades are primarily avalvular. Muscle contraction is of prime importance for venous
blood return, because this “pumps” the blood back toward the heart.

Neurovasculature
The high volume of trauma from the two world wars resulted in many peripheral nerve
injuries. At the time the management of these injuries was limited, largely because of an
incomplete understanding of peripheral nerve anatomy and physiology. A lifetime of produc-
tive research by Sir Sydney Sunderland59-61 greatly advanced our knowledge of the subject.
One of the key anatomic concepts noted by Taylor et al3,10 during their studies on arte-
rial and venous vasculature to the integument is that there is a close relationship between
vessels and nerves; as they described it: “Vessels hitchhike with nerves.” This relationship
was evaluated in detail in subsequent work, in which the neurovascular territories of the
skin and muscles were described.11 Human cadavers underwent total body injection of a
radiopaque lead oxide mixture into either the arterial or venous system. The integument
and many of the muscles were removed and radiographed. Second, the cutaneous nerves
and extramuscular and intramuscular course of motor nerves were dissected. Labeled with
multifilament computer wire, the nerves could then be radiographed. Subtraction radiog-
raphy allowed the wire-labeled nerves to be isolated from the injected vasculature.11

Cutaneous Nerves
Taylor et al11 found that all cutaneous nerves were accompanied by an artery—either one
continuous artery or a chain-linked system of arteries. However, the reverse is not always
the case; some major cutaneous arteries had no accompanying cutaneous nerve. It was also
noted that nerves are economical: they travel the shortest distance between two points.
Arteries and cutaneous nerves often travel together as they course from the deep tissue,
pierce through the deep fascia, and enter the integument, generally at areas of fixed skin.
However, multiple patterns were noted of the relative locations that a cutaneous nerve and
the associated artery pierce the fascia.11 At certain locations, the nerve and artery traverse the
fascia at a distance from one another and unite distally. Alternatively, a nerve may diverge
from its accompanying artery after emerging through the fascia and travel with another
artery more distally.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 49

A B C D E

Fig. 2-15  The neurovascular patterns of the integument. A, A long

artery courses with the nerve (note the true anastomosis to the adja-
cent vessel). B, A system of arteries “hitchhiking” 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 to-
ward the main trunk of another artery. E, A nerve crosses the primary
and secondary vascular arcades and travels parallel to another artery.

Motor Nerves
Taylor et al11 evaluated the neurovascular patterns of 80 different muscles in their cadaver
study. They noted several key concepts about motor nerves:
1. Nerves follow the connective tissue framework. From the nerve origin, the motor
nerve travels within a connective tissue sheath until it reaches the neurovascular
hilum of the muscle. Within the muscle, the nerves follow the intramuscular con-
nective tissue.
2. Nerves are economical. Analogous to the cutaneous nerves, motor nerves travel the
most direct extramuscular and intramuscular route, from their origin at the spinal
cord to their target muscle that permits functional muscle contraction. Nerves ap-
proach the proximal aspect of the muscle, with respect to the nerve origin at the spinal
cord. Intramuscular nerve fibers are oriented parallel to the muscle bundles.
3. Nerves enter the muscles in the direction of their geometric center. This was first
noted by Schwalbe62 in 1879, who also described a morphologic muscle classification
with three groups, based on muscle shape. The neurovascular relations vary based
on the muscle and the extramuscular and intramuscular nerve architecture. Muscles
may have a single nerve supply or multiple motor nerves. There were several key
findings by Taylor et al:
A. Motor nerves have an accompanying vascular pedicle. However, many vessels
have no associated nerve.
B.  Generally, the motor nerve accompanies the dominant vascular pedicle
C. The nerve may branch just before entering the muscle, forming a neurovascular
hilum, or afterward.
D. A motor nerve divides early after entering the muscle, and its branches rapidly
orient themselves parallel to the muscle fibers.
4. The law of equilibrium, as discussed earlier, states that a reciprocal relationship exists
between adjacent territories with respect to vessel caliber. Analogously, there is a
reciprocal relationship between multiple motor nerve branches that supply a muscle
in terms of the size and the number of nerve branches to the muscle from the same
nerve trunk.

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 50 Part I  Fundamentals

Muscle Classification
Muscles can be classified based on several features, including shape, morphology, func-
tion, blood supply, and nerve supply. It is important to understand the pattern of motor
innervation of muscles to harvest functioning muscle transfers or to maintain function in
a muscle after harvesting a segment of this muscle. For example, biceps femoris has two
separate nerve branches and is therefore suitable for segmental harvest, leaving the remain-
ing portion innervated.

Muscle Nerve Classification

Taylor et al11 described the following muscle innervation types:
•  Type I  Muscle supplied by single motor nerve that divides after entering the muscle
• Type II  Muscle supplied by a single motor nerve that divides before entering the
muscle
• Type III  Muscle supplied by multiple nerve branches that originate from the same
motor nerve trunk
• Type IV  Muscle supplied by multiple motor nerves that originate from different
nerve trunks
Types II, III, and IV can be subdivided into separate neurovascular units and partially har-
vested as a flap for local or distant transfer, leaving a functional muscle in situ. Especially
for types III and IV, this dissection is relatively straightforward; the multiple neurovascular
pedicles can be isolated before entering the muscle. However, with a meticulous intramus-
cular dissection of the motor nerve branches, it is also possible to elevate a portion of a type I
muscle as a flap without denervating the residual fibers.

Type I Type II Type III Type IV

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.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 51

Delay Phenomenon
During World War II, the tubed pedicle flap was used increasingly to transfer tissues to
distant sites. This technique is based on a random-pattern flap where the tissue is rotated
about the pedicle base and attached distally to a new site, possibly an arm carrier. The delay
of these random flaps relied on the subdermal vasculature to adapt and revascularize from
the new site of attachment. The delay of these random-pattern flaps improved the survival
of the flaps. Later, the flap would be rotated again, based on the opposite flap tip. With the
use of multiple delays or an arm carrier, complex reconstructions of distant sites were possible
long before the introduction of microvascular free flaps. Today this reconstructive approach
is essentially of historical interest only. However, the tubed flaps led to an awareness and
understanding of the delay phenomenon, which is the basis for delayed flaps.
The delay phenomenon is based on the physiologic events that follow a partial restriction
in blood flow to tissue. It is possible to delay both skin and muscle flaps.54,63,64 For example, a
flap may be partially elevated or its blood supply partially ligated, which stimulates vascular
events within the flap that lead to increased flap vascularity based on the planned pedicle.
The purpose of the delay technique is to increase the size of flap and/or its vascularity and
reliability. It has been shown that a flap can be safely raised in one cutaneous territory, and
one adjacent territory can generally be recruited.3,9,54 The delay phenomenon is the only
documented technique that can reproducibly extend the zone of perfusion to a second
or third cutaneous vascular territory beyond that supplied by the cutaneous perforator at
the base of the flap. When an undelayed flap is raised, the demarcation line of necrosis has
generally been in the junctional choke zone at the outer perimeter of the adjacent vascular
territory.54 Therefore the limiting factor of viable flap dimensions depends on the spacing of
cutaneous perforators. Areas of fixed skin have a high density of vessels emerging from the
deep fascia; mobile areas have a much greater distance between perforators. For example,
the deltopectoral flap based on the internal mammary perforators has a large, reliable area
of vascular supply without delay.

1 2 3

1 2 3

1 2 3

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 di-
vided at the second stage to allow a long pedicled flap based on the base of the flap.

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 52 Part I  Fundamentals

Delay Technique
There are many variations on techniques for surgical delay. The flap may be partially incised,
partially elevated, or one or more adjacent vessels can be ligated.52,54 If the surgical margins
of the planned flap are partially incised, the planned vascular supply of the flap is left intact.
As a result, the choke vessels of the first junctional zone irreversibly dilate. The caliber of
vessels increases so that they become more like true anastomoses across the choke zone.
This process results from hyperplasia of the blood vessel wall cells, as well as hypertrophy
and elongation.51,53 The maximal dilation is seen by 48 to 72 hours after the delay.63
Clinically, delaying the elevation of a pedicled transverse rectus abdominis myocutane-
ous (TRAM) flap is an effective way to safely raise a large skin paddle.65 In the first stage,
the superficial and deep inferior epigastric vessels are ligated. This provides a more robust
vascular supply to the flap for the second stage, when the pedicled flap is raised definitively
based on the superior epigastric vessels. The delay procedure is a reliable method for aug-
menting flap survival in challenging situations.

A B

D1 D1

Ligation
D2 D2 of D2 Ligation
of D3
Ligation
of D3

Fig. 2-18  Strategic delay of a pedicled TRAM flap, shown here for intended left breast reconstruc-
tion. 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.
Dominant pedicles to rectus muscle: Superior deep epigastric artery and associated
venae comitantes (D1); deep inferior epigastric artery and associated venae comitantes (D2)
Dominant pedicle to fasciocutaneous inferior abdominal region: Superficial inferior
epigastric artery and associated venae comitantes (D3)

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 53

Flaps/Skin Flaps
A flap is a vascularized tissue transfer. It may include any tissue type and may be based on
a pedicle as a local or regional flap or may be transferred distantly microsurgically by mi-
crovascular anastomoses. A skin flap is a vascularized skin transfer. Vascularity is intrinsic
and may be maintained at the flap base, as in a pedicled skin flap, or reconnected to vessels
at the recipient site using microsurgical techniques, as in a free microvascular skin flap. A
comprehensive summary of skin flap surgery including the history and anatomy was pub-
lished by Cormack and Lamberty in 1986.20

Local Flaps
Random
The earliest flaps were random-pattern flaps.29 These flaps are considered random because
their maintained vascular supply is not based on a named vessel; they are supported by a
random arrangement of subdermal vasculature. They were so-named because of a lack of
understanding of the vascular supply to the flap. Random-pattern flaps are useful for the
reconstruction of small defects but have several inherent limitations:
•  Proximity of the defect must be the within arc of rotation
• There may be compromised vascularity in the associated zone of injury surrounding
the wound
•  Unpredictable survival
Rotation, transposition, advancement, and other geometric flaps are generally considered
random-pattern flaps, although outcomes are improved by maintaining small perforating
vessels in the base of the flap. The survival of small local flaps can be improved by the sur-
geon’s knowledge of the underlying vascular anatomy.

Rotation Flaps
Rotation flaps are local skin flaps in which skin and subcutaneous tissue is elevated and ro-
tated in an arc from a pivot point at the flap base. The flap must be designed such that there
is sufficient flap length to cover the most distal aspect of the defect, limited by the skin ten-
sion from the pivot point at the flap base to its tip. One must plan for the flap tip to extend
beyond the arc of rotation of the distal defect to account for the length that will be lost due
to the rotation. The donor site may be closed by primary closure, a local flap or a skin graft.

A B C

n
tensio
f maximal
Line o

Area of greatest risk

Semicircular flap is designed after Flap is undermined and advanced into Tension-bearing part of random flap
triangular resection defect; mobilization of the surrounding is most ischemic and most at risk for
tissues allows closure of defect necrosis or dehiscence
created by flap advancement

Fig. 2-19 

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 54 Part I  Fundamentals

Transposition Flaps
There are several versatile geometric patterns of transposition flaps that are commonly
used for small defect closure, such as following skin cancer excision. The bilobed flap is an
example of a transposition flap, where a smaller secondary flap is rotated to fill the defect
from the primary flap that is used to reconstruct the defect. The Limberg or rhomboid flap
is another useful transposition flap.

B x
y

120°
60° x y

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
Advancement flaps are accomplished by moving a flap of skin directly into a defect by the
use of undermining but without any rotation, relying on the skin elasticity. The single
pedicle advancement flap remains attached at its base and the skin is stretched forward di-
rectly into the defect. Excising burrow’s triangles at each side of the flap base simplifies the
closure along the sides of a rectangular advancement flap. The V-Y advancement flap is a
common modification that can be useful for various wound reconstructions, such as volar
fingertip soft tissue injuries.66,67

Fig. 2-21  The skin is elevated as a triangu-

lar island flap and advanced forward to fill the
defect.

V-Y advancement flap

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 55

Axial Flap
An axial-pattern skin flap is designed according to the trajectory of the vessels supplying the
flap. In 1973, McGregor and Morgan29 proposed the differentiation of skin flaps into two
types, the random- and axial-pattern flaps. They defined an axial flap as “a single pedicled
flap which has an anatomically recognized arteriovenous system running along its long
axis.” The flap is designed such that the pedicle axis is aligned with the arc of rotation. This
allows much greater sized skin flaps to be used. A workhorse flap for nasal tip reconstruction
is the paramedian forehead flap. This axial flap is based on the dominant supratrochlear,
and minor supraorbital vessels. The deltopectoral flap is an example of a remarkably large
axial skin flap that has many uses for skin coverage in the neck and lower face.68,69 The
deltopectoral flap is based on the second and third anterior intercostal perforators.

Arc to inferior abdomen

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

Flap Vascular Supply Size (cm)
Deltopectoral69,72 First to third rib perforators from internal 10 3 20
mammary artery and venae comitantes
Paramedian Supratrochlear artery and venae comitantes 836
forehead2
Abbé or reverse Superior or inferior labial artery and venae One fourth
Abbé comitantes of lip?
Nasolabial Transverse facial artery and venae comitantes 235
Standard forehead Superficial temporal artery and venae 22 3 7
comitantes
SIEA Superficial inferior epigastric artery and vein 15 3 30
Groin Superficial circumflex iliac artery and vein 10 3 25
Dorsal metacarpal Dorsal metacarpal artery 134
Digital Digital artery 631

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 56 Part I  Fundamentals

Fascia and Fasciocutaneous Flaps

Esser70 in 1917 and Gillies71 in 1920 had both suggested that including deep fascia in a
random-pattern skin flap would be beneficial. Unfortunately, for many years this hypothesis
was overlooked. In the decades that followed, skin flap design was guided by the now obso-
lete concept of length to width ratio limitations. Distant reconstruction was accomplished
with delayed flaps and pedicled-tubed flaps, which comprised of skin and subcutaneous
fatty tissue only. In the 1960s, Bakamjian et al69,72,73 reported good success with head and
neck reconstruction using the large, pedicled deltopectoral flap. Reminiscent of earlier
surgeons such as Esser70 and Gillies,71 Bakamjian et al73 advised the inclusion of deep fascia
in deltopectoral flaps. In 1974, Bowen74 described including the deep fascia in ipsilateral
lower leg flaps for large full thickness leg defects. Similarly, McGregor31 in 1975 noted that
the deltopectoral flap could be extended by including the fascia. However, the generalized
concept of the fasciocutaneous flap was not described until 1981, by Ponten.75,76 Ponten
published a series of 23 lower leg defect reconstructions using an undelayed fasciocutane-
ous flap. They were successful in all but three patients, who had flap failure. Thereafter,
fasciocutaneous flaps gained popularity as a reliable technique to cover bone and tendon
in the lower leg and elsewhere.77 The clinical implications of the fasciocutaneous flap were
further elaborated by Tolhurst et al77 in 1983, with a clinical series of 27 consecutive and
successful reconstructions of a variety of defects on the lower leg and trunk. The following
year, the classification of fasciocutaneous flaps based on their vascular pattern was estab-
lished by Cormack and Lamberty.76 In 1997, Mathes and Nahai55 described a different
fascial and fasciocutaneous flap classification based on the vascular anatomy of the pedicles
to the integument.
A fascial or fasciocutaneous flap is elevated based on the deep fascial layer and its as-
sociated blood supply. A fasciocutaneous flap, which includes the skin, subcutaneous tissue,
and the underlying fascia, provides a sturdier construct than an isolated fascial flap. The
circulation of the deep fascia is based on the vascular pedicles that enter its deep surface
and form a vascular plexus within the fascial plane that subsequently supply the overlying
integument. The venous component of the pedicle is usually the paired venae comitantes
that accompany the artery from the source vessels.
A major benefit of a fasciocutaneous flap in comparison to a myocutaneous flap is that
it provides a robust vascularized skin flap without the expenditure of a functional muscle
from the donor site, and without the often unnecessary bulk of a myocutaneous flap. Fas-
ciocutaneous flaps are preferred in reconstructing areas in which the skin or mucosa at the
wound is thin; for example, the lower leg, dorsum of the hand, nasal lining, and orophar-
ynx. Similar to muscle flaps, fasciocutaneous flaps provide large blocks of tissue for defect
reconstruction without the need for prior delay but are limited by the arc of rotation of the
vascular pedicle, unless transferred as a free flap.
With our improved knowledge of vascular anatomy today, the indications for using a
true fasciocutaneous flap in wound reconstruction are limited and depend on the donor
site anatomy. Where the skin is relatively fixed to the underlying fascia, the integument is
best raised as a fasciocutaneous flap because there will be many small perforators through-
out the territory, supplying the skin. Conversely, where the skin is mobile with respect to
the underlying connective tissue, then there will be sparse cutaneous perforators piercing
through or traveling within the deep fascial plane. In the latter, there is negligible benefit
to include the fascial layer when raising a cutaneous flap.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 57

Cormack and Lamberty Classification of

Fasciocutaneous Flaps
Cormack and Lamberty21,76,78,79 conducted a series of injection studies to further outline the
vascular anatomy at the fascial level, identify the locations of fasciocutaneous perforators and
fascial vascular plexuses, and postulate potential new fasciocutaneous flaps. They applied
these anatomic findings clinically, with the implementation of fasciocutaneous flaps. Based
on their combined experimental and clinical observations, they proposed a classification
with four distinct types of fasciocutaneous flaps, differentiated by their vascular anatomy.

Vascular plexus of the

deep fascia supplying
overlying skin

Fasciocutaneous perforators Subcutaneous vein draining

lying in intermuscular the skin through the
fascial septum superficial venous system
Muscle belly—generally long, thin muscles

Major regional artery Venae comitantes of regional artery

May also receive veins draining down
along fascial septum

Type A —
Type A subcutaneous
pedicle

Type B
Type B—modified

Type C Type D

Fig. 2-23  Cormack and Lamberty’s classification of fasciocutaneous flaps. Type A flaps have mul-
tiple 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 fascio-
cutaneous 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.

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 58 Part I  Fundamentals

Type A
The flap is supported by multiple fasciocutaneous perforator vessels at the flap base and
orientated along the longitudinal axis of the flap, which is determined by the arterial plexus
within the deep fascia. This pedicled flap may be based either proximally or distally, or as an
island flap; for example, upper arm flaps based on the medial or lateral intermuscular septum.

Type B
The flap depends on a single dominant fasciocutaneous perforator that supplies the deep
fascial vascular plexus. These perforators generally have a consistent location and may be
raised as a pedicle or free flap; for example, antecubital forearm flap.

Type C
The flap is based on the fascial plexus supplied by multiple small perforators along the length
of a fascial septum. The supplying artery is taken in continuity with the fascial septum
and integument. It may be pedicled, based distally or proximally or used as a free flap; for
example, the radial forearm flap.

Type D
Similar to type C, the type D flap is based on multiple small perforators, but it is raised
as an osteomyofasciocutaneous flap. The fascial septum and the source artery are taken in
continuity with the bone and adjacent muscle; for example, the radial forearm flap with
half of the radius longitudinally.

Nakajima Classification of Fasciocutaneous Flaps

Nakajima et al32 described a classification of six types of deep fascia perforators based on
patterns of perfusion. They conceptualized a three-dimensional framework of the fascial
plexus and showed the various patterns of vascularization of the fascia. They reported
that the body’s fascial vascular supply could be divided into these types: (1) direct cutane-
ous branch of muscular vessel, (2) septocutaneous perforator, (3) direct cutaneous vessel,
(4) myocutaneous perforator, (5) direct septocutaneous and, (6) perforating cutaneous
branch of muscular vessel.

A B C D E F

Fig. 2-24  The six distinctive deep fascia perforators according to Nakajima et al. A separate type of
A Direct cutaneous branch of a muscular vessel
fasciocutaneous flap could be named after each different perforator. (A, Direct cutaneous branch of
B Septocutaneous perforator
a muscular vessel;CB,Direct
septocutaneous
cutaneous perforator; C, direct cutaneous; D, myocutaneous perforator;
E, direct septocutaneous; F, perforating cutaneous branch of a muscular vessel.)
D Musculocutaneous perforator
E Direct Septocutaneous
F Perforating cutaneous branch of a muscular vessel

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 59

Mathes and Nahai Classification

of Fasciocutaneous Flaps
In 1997, Mathes and Nahai55 published a different classification of fascial flaps, also based
on the pattern of vascular supply to the integument overlying the fascia. The three distinct
types of vascular pedicles are direct cutaneous, type A; septocutaneous (intermuscular),
type B; and myocutaneous (intramuscular), type C. The dominant vascular pedicles to the
deep fascial plexuses of specific flaps were identified on anatomic dissections of deep fascia
in humans using regional vascular injections of colored barium–latex solution.55 This is the
classification that is used in this book.

Examples of Useful Fascial Flaps

Pattern of
Flap Vascular Supply Circulation Size
Temporoparietal fascia Superficial temporal artery and Type A 12 3 9
vein
Reverse sural80 Superficial sural artery and vein Type A 8 3 12
(retrograde)
Scapular Circumflex scapular artery and Type B 20 3 7
venae comitantes
Radial forearm81 Radial artery and cephalic vein Type B 10 3 40
and venae comitantes
Lateral arm Radial collateral and venae Type B 20 3 7
comitantes
Anterolateral thigh82 Descending branch of lateral Type B 9 3 22
circumflex femoral artery and and C
venae comitantes
Submental artery Submental artery and vein Type C 7 3 18

Type A: Direct Cutaneous Pedicled Flap

The vascular pedicle enters the fascia from the deep surface and then travels for a variable
distance in this plane. Distally, the vessels will pierce the fascia, branch out into the subdermal
plexus and subsequently supply the integument. Along the length of the pedicle, multiple
perforators supply the skin. The pedicle itself is generally long and superficial, traveling in
a radial fashion, similar to that of an axial flap. Its course can often be readily identified by
palpation and Doppler probe; for example, the deep external pudendal artery, digital artery,
dorsal metacarpal artery, gluteal thigh, great toe, groin, lateral thoracic (axillary), pudendal-
thigh, saphenous, scalp, second toe, standard forehead, superficial external pudendal artery
(SEPA), superficial inferior epigastric artery (SIEA), sural artery, and temporoparietal fascia.

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 60 Part I  Fundamentals

Type B: Septocutaneous (Intermuscular) Pedicled Flap

The vascular pedicle that supplies this fasciocutaneous flap courses from the source vessel to
the skin either within a recognized intermuscular septum or in the space between adjacent
muscles. This category was designed to encompass a broader range of fasciocutaneous flaps
than the Cormack and Lamberty classification to simplify flap classification. The largest
septocutaneous pedicles are dominant pedicles to specific fasciocutaneous flaps; for example,
the anterior lateral thigh (ALT), anterior tibial artery, deltoid, dorsalis pedis, inferior cubital
artery, lateral arm, lateral plantar artery, lateral thigh, medial arm, medial plantar artery,
medial thigh, peroneal artery, posterior interosseous, posterior tibial artery, radial forearm,
radial recurrent, scapular, and ulnar recurrent.

Type C: Myocutaneous (Intramuscular) Pedicled Flap

The vascular pedicle for type C flaps originates from a large myocutaneous perforator that
provides the blood supply to the muscle, en route from the source vessel to the deep fascial
plexus and the integument. These dominant perforating vessels are therefore defined as
indirect cutaneous perforators. The overlying skin can be supported by a fasciocutaneous
flap with or without inclusion of the underlying muscle. Adequate pedicle length for a
type C fasciocutaneous flap will generally require dissecting the pedicle back through its
intramuscular course to the source vessel, ligating the side branches that supply the muscle.
Unlike the other two fasciocutaneous flap types, these flaps have much greater variability
in perforator locations and caliber; for example, ALT, deltopectoral, nasolabial, median
forehead, thoracoepigastric, transverse back, and DIEA.

Muscle Flaps
The discovery of muscle and myocutaneous flaps was a major advance in reconstructive
surgery.33-39 Iginio Tansini described the latissimus dorsi flap in 1906 for postmastectomy
reconstruction35; however, muscle flaps were not widely implemented clinically until the
1970s.35,83,84 Muscle and myocutaneous flaps were found to have a robust blood supply and
were used to reliably reconstruct challenging soft tissue defects. It was noted that the vas-
cular supply of skin transferred with a myocutaneous flap was very reliable. In comparison
to the limited number of skin flaps available at the time, the introduction of muscle flaps
provided a vast range of possibilities for wound reconstruction.
The major benefit of a muscle or myocutaneous flap is the reliable blood supply based
on the main source vessel, often measuring 2 to 4 mm in diameter. Some early reports
suggested that this conferred an improved ability to clear infections in the wound. Muscle
flaps can be transferred as pedicled local or regional flaps or distantly as free tissue transfers.
In the initial reports, the muscle flaps were generally used as pedicled flaps. Wounds with
a significant dead space, in particular, are ideally suited for muscle or myocutaneous flaps.

Muscle Flap Classification

Muscles are supplied by a dominant, minor, or segmental vascular pedicle (or pedicles), or
any combination thereof. Muscles are typically classified based on their vascular supply, as
described by the Mathes and Nahai classification, Types I through V.85 This classification
was originally published by Mathes and Nahai in 1981 in a landmark study of the vascular
anatomy of muscles. The pattern of vascular supply to each muscle guides how the muscle
flap may be safely elevated and transferred. The patterns are based on several variables in the
anatomic configuration of vascular pedicles entering the muscle: (1) the regional source of
the arterial pedicle (or pedicles) entering the muscle, (2) the size of the artery supplying the
muscle, (3) the number of pedicles, (4) the location in relation to the origin and insertion,
and (5) the patterns of the internal muscle vessels.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 61

MATHES-NAHAI CLASSIFICATION OF MUSCLE/MYOCUTANEOUS FLAPS

Type I Type II Type IV

Type V
Type III

Gluteus maximus

Tensor fascia lata Gracilis Sartorius Latissimus dorsi

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

Pattern of
Flap Vascular Supply Circulation Size
Gastrocnemius Medial or lateral sural artery and venae comitantes Type I 8 3 20
Gracilis Dominant: Medial circumflex femoral artery and venae comitantes Type II 8 3 15
Minor: Superficial femoral artery
Gluteus Dominant: Superior gluteal artery Type III 24 3 24
maximus Dominant: Inferior gluteal artery
Rectus Dominant: Superior deep epigastric artery and venae comitantes Type III 25 3 6
abdominis Dominant: Inferior deep epigastric artery and venae comitantes
Serratus Dominant: Lateral thoracic artery and venae comitantes Type III 15 3 20
Dominant: Branch of thoracodorsal artery and venae comitantes
Sartorius Segmental: Six or seven branches of superficial femoral artery and vein Type IV 5 3 40
Extensor Segmental: Eight to ten arterial muscular branches and venae Type IV 4 3 35
digitorum longus comitantes from anterior tibial artery
Latissimus dorsi Dominant: Thoracodorsal artery and venae comitantes Type V 25 3 35
Segmental: Posterior intercostal arteries and veins (lateral row
perforators)
Segmental: Lumbar artery and vein (medial row perforators)
Pectoralis major Dominant: Thoracoacromial artery and vein Type V 15 3 23
Segmental: First through sixth internal mammary artery perforators
Segmental: Fifth through seventh rib intercostal perforators
Minor: Pectoral branch of lateral thoracic artery

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 62 Part I  Fundamentals

Mathes-Nahai Classification

PATTERNS OF VASCULAR SUPPLY TO MUSCLEs

Type I: One Vascular Pedicle

Type I muscles have a single vascular pedicle that
enters the muscle.
Examples: Gastrocnemius, rectus femoris,
tensor fascia lata, abductor digiti minimi, ab-
ductor pollicis brevis, anconeus, first dorsal
interosseus, genioglossus, hyoglossus, vastus
lateralis.

Type I muscles

Fig. 2-26  The medial and lateral gastrocnemius muscles are each supplied by a single vascular
pedicle from the popliteal artery.

B
1
Type II: Dominant Vascular P edicles
2 and M inor P edicles
Type II muscles have one or more large vascular
pedicles that enter the muscle near the origin,
or less commonly, at the insertion, and one or
3 more small pedicles that enter the muscle belly.
The minor pedicles supplying type II muscles are
not able to support the muscle, after ligation of
the dominant pedicle. This pattern is the most
common.
Examples: biceps femoris, abductor digiti
minimi, brachioradialis, coracobrachialis,
flexor carpi ulnaris, flexor digitorum brevis,
gracilis, peroneus brevis, peroneus longus,
platysma, rectus femoris, soleus, sternoclei-
domastoid, trapezius, triceps, vastus lateralis.
Type II muscles

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).

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 63

T ype III: T wo Dominant Pedicles

Type III muscles have two large vascular pedicles
that arise from separate regional arteries. The two
pedicles fill the intramuscular vasculature equally,
and either one could independently support the
muscle or myocutaneous flap.
Examples: Gluteus maximus, rectus abdomi-
nis, serratus anterior, temporalis, pectoralis
minor.

Type III muscles

Fig. 2-26  The rectus abdominis is supplied by the superior (A) and inferior (B) epigastric arteries.

B T ype IV: Segmental Vascular Pedicles

Type IV muscles have multiple pedicles of similar
size that enter the muscle throughout its course,
from origin to insertion. These segmentally lo-
cated pedicles equally fill the muscle vasculature.
Examples: Sartorius, extensor digitorum
longus, extensor hallucis longus, external
oblique, flexor digitorum longus, flexor hal-
lucis longus, tibialis anterior.

Type IV muscles

Fig. 2-26  The sartorius muscle has a segmental vascular supply from the lateral circumflex femoral
artery (A) and the superficial femoral artery (B)

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 64 Part I  Fundamentals

T ype V: One Dominant Vascular Pedicle and Secondary Segmental

Vascular Pedicles
Type V muscles have a single large pedicle that enters the muscle near its insertion and
multiple segmental pedicles that enter the muscle close to its origin. Both systems provide
significant vascular supply to the muscle, and a flap could be elevated based on either system.
Examples: Pectoralis major, internal oblique, latissimus dorsi.

Type V muscles

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

The use of a muscle flap results in the loss of function of the muscle used. Although this is
usually not a significant loss of function, there will be varying degrees of morbidity and
functional loss, based on the selected donor muscle and the patient’s occupation and life-
style. The latissimus flap, for example, is a workhorse flap for reconstruction of defects to
the trunk, chest, back, and head and neck. It is generally accepted that there are minimal
clinical implications in sacrificing this muscle, unless the patient is an avid climber or swim-
mer, has an occupation that involves climbing ladders, or is a paraplegic and self-transfers
with his or her arms.

Free Microvascular Tissue Transfer

The introduction of free autologous tissue transfer using microsurgical vessel anastomoses
marked a momentous innovation, which opened a new landscape of possibilities for the
reconstructive surgeon. As noted earlier, in 1973 Taylor et al16,40 published the first clinical
application of a free composite tissue transfer with reanastomosis at a distant site and thereby
coined the term free flap. This first free flap was a groin flap based on the superficial inferior
epigastric vessels used for a large medial ankle defect. The emergence of free flap recon-
struction was possible because of the concurrent development of the operating microscope,

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 65

microinstruments, and sutures and knowledge of the cutaneous vasculature. It heralded

the beginning of an era of greatly improved ability to transfer tissues throughout the body.
Free flaps have become a versatile and instrumental component of the reconstructive
surgeon’s armamentarium. The requirements for free flap transfer include an adequate and
reliable vascular pedicle that supplies a dependable segment of tissue.86 Ideally, the selected
donor site should incur minimal morbidity and leave an inconspicuous defect. A multitude of
free flap variations have continued to evolve over the years, including microvascular transfers
of skin, muscle, bone, tendon, nerve, functional muscle transfers, sensate skin free flaps,
and a wide variety of combinations of the tissues (Siamese, conjoint, sequential).4,18,21,44,87-90

Perforator Flaps
A perforator flap can be strictly defined as a tissue transfer nourished by a myocutaneous
perforator. Practically, however, the perforator flap technique has expanded to any perfora-
tor to the skin, including both myocutaneous and septocutaneous vessels. Myocutaneous
and fasciocutaneous free flaps are the predecessors of perforator flaps. There was great
enthusiasm for myocutaneous flaps during the 1970s and 1980s, and free flaps were being
more widely used for wound reconstruction. An abundance of flaps were described, and
our understanding of vascular anatomy continued to expand. It was proposed that any
muscle with a blood supply that could be isolated as a pedicle could be raised as a flap.91
The principle advantage of perforator flaps initially was the large and reliable pedicle size
of a muscle flap without the disadvantage of the sacrifice of muscle function. It is possible
to base perforator flaps on many of the body’s approximately 400 cutaneous perforators.4
As experience with perforator flaps grew, it became clear that perforator flap technique was
being used to develop many new and useful flaps.44

Examples of Useful Perforator Flaps

Pattern of
Flap Vascular Supply Circulation Size
DIEP Deep inferior epigastric Indirect Zones I to III
artery perforators (sometimes IV) of
lower abdomen
SGAP Superior gluteal artery Indirect 10 3 26
perforator
IGAP Inferior gluteal artery Indirect 10 3 26
perforator
LCFAP Lateral circumflex Direct  9 3 22
(anterolateral thigh) femoral artery perforator
TDAP Thoracodorsal artery Indirect 14 3 25
perforator
Lateral arm flap Posterior radial collateral Direct  8 3 12
artery
Medial groin Medial circumflex Indirect  8 3 15
femoral artery perforator

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 66 Part I  Fundamentals

The early pioneers of perforator flaps demonstrated that with meticulous dissection of
the vascular pedicle through the intramuscular course, the inclusion of a portion of muscle
to act as a carrier for integument was unnecessary.89 In 1988 Koshima et al92 described a
medial thigh perforator flap, and Kroll and Rosenfield91 described several cases of success-
ful midline back defects reconstructed with laterally based rotation myocutaneous flaps.
The pedicled TRAM and subsequently the free TRAM flap were the gold standards
of autologous breast reconstruction in the 1980s and 1990s.46,93,94 However, postoperative
abdominal muscle weakness, contour abnormalities, and possible abdominal hernias were
acknowledged as risks of rectus abdominis muscle and fascia harvest.94,95 Koshima and Soeda96
successfully performed two completely muscle-sparing DIEA skin flaps for wound recon-
structions in 1989. The clinical application of DIEA perforator flaps was further described
and refined by others in the years that followed, for breast reconstruction as well as other
defects.93,94,97-99 Multiple studies have investigated the differences in donor site morbidity
after a TRAM flap breast reconstruction compared to a DIEP flap.100-103 There is good
evidence that the DIEP flap donor site is superior to a pedicled TRAM flap donor site and
there is some evidence that abdominal donor site function after DIEP flap harvest is supe-
rior to muscle sparing TRAM flap; however, this has not been definitively documented.104
Myocutaneous perforator flaps are generally based on the territory’s dominant blood
vessel. Following flap dissection, the underlying muscle will survive on the remnant vascular
supply from the source artery of the angiosome and/or collateral vessels.105 Interestingly,
the underlying muscle of a perforator flap can sometimes be used if necessary to salvage a
compromised pedicled perforator flap. Hallock105 reported a failed pedicled medial sural
artery perforator flap salvaged with a pedicled medial gastrocnemius flap.

Vascular Basis of Perforator Flaps

The clinical use of perforator flaps requires a thorough understanding of the cutaneous
vasculature and the cutaneous perforators in the region of interest. There are approximately
400 cutaneous perforators to the skin that can be divided into 61 vascular territories.4,44
Each cutaneous perforator could potentially be used for a local, regional, or free perforator
flap transfer. Knowledge of the patterns of perforator architecture will allow a reconstruc-
tive surgeon the opportunity to customize the reconstruction using the optimal skin type
in an expendable donor site region. However, the individual perforators to the skin are
highly variable in diameter and location; therefore a method for identifying the perfora-
tor preoperatively is advantageous. Initially a handheld Doppler was used to identify the
perforators preoperatively19; however, this method has some associated inaccuracy and has
been largely supplanted by duplex or color Doppler,106,107 CT angiography MRA, and ICG
laser angiography.

Advantages and Disadvantages of Perforator Flaps

Myocutaneous perforator flaps offer several advantages over a traditional myocutaneous flap.
Perforators take advantage of the robust blood vessels that supply the underlying muscle,
without the need to sacrifice the muscle. Perforator flaps incur no functional deficit, have
less donor site morbidity, improved postoperative recovery, and allow for greater versatility
in flap design.89,94,100,103,109 Without the need to incorporate the muscle, a perforator flap
may be tailored to fit the recipient site precisely.89 However, perforator flaps require careful,
delicate dissection of the vascular pedicle, which may translate to a longer operative time.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 67

Because of the variability of the cutaneous vascular anatomy, it may not be technically pos-
sible to perform the planned perforator flap of a specific territory. A planned DIEP flap can
be converted to a muscle-sparing free TRAM flap if the patient’s anatomy is not favorable.
If there are small perforators or if the perforators are damaged, alternative flaps, including
a muscle-sparing free TRAM or SIEA flap, can be used.110

STA
OPA STA
OCA
IOA OCA OPA
PAA TFA
FA PAA TFA
MA
SMA FA
TCT
STHA STHA MA
TAA SMA
TTA
PCHA ITA
CSA PCHA
BA
LTA SUCA CSA
PBA
PRCA BA BA TDA
IUCA PBA
RRA TDA
PRCA PRCA
SEA BA
PIOA RRA DPIA
LPIA  UA RRA
SUCA
UA IUCA PIOA
LA  RA LA 
DIEA RA LPIA  RA
RA DCIA  UA LSA AIOA
SGA  SIEA DPAA DCIA 
AIOA
SCIA SPA  SGA  UA
DCA IGA  SGA  DCA 
EPA
IGA 
DPAA  LCFA  DPAA
SFA IPA IGA 
DPA SPA
SPA  SPA
PFA  MCFA LCFA 
MCFA

PFA PFA 
PFA
MSGA
SFA
LSGA  LSGA 
DGA
MIGA
MSGA MSGA
PA 
LIGA PA PA DGA

PA ATA
PTA ATA
PTA

PNA ATA PTA PTA

PNA

DPA
DPA MCA PNA PNA
DPA DPA
LCA MPA
LPA MPA
LCA LCA
MCA
LPA

Fig. 2-27  The vascular territories of the body that correspond to sources arteries providing myocu-
taneous or septocutaneous perforators to the skin.

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 68 Part I  Fundamentals

Local Perforator Flaps

A local perforator flap can be defined as a cutaneous flap based on a single perforator that
is raised and transferred locally.44 Local perforator flaps have been reported by Taylor et
al19 using a Doppler probe to assist in detection of the position of the perforator. Other
radiographic techniques such as color Doppler and CT angiography give a more detailed
view of the underlying perforator anatomy. The surgical technique involves identification
of the perforator and dissection of the perforator below the fascial level to completely free
the perforator for transfer of the flap. Teo111 described the propeller flap, which is an elegant
local perforator used for reconstruction of defects throughout the body. Local perforator
flaps represent a significant improvement over conventional local random or geometric
flaps, since the inclusion of a perforator in the base of the flap provides a much more reli-
able vascularity to the flap.

Nipple
A B

SEA LICA

Perforator of
lateral intercostal artery

Perforator of
inferior epigastric artery  DIEA

SIEA
SCIA

Iliac crest

Fig. 2-28  Design of a local perforator flap. A, A local perforator flap is planned on the upper abdo-
men 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).

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 69

C D

Perforator of
lateral intercostal
artery

Perforator of
inferior epigastric
artery 

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
The quest to reliably transfer tissues throughout the body has stimulated surgeons to re-
examine the vasculature of the human body. The byproduct of the quest has been the
description of hundreds of different flaps. The evolution continues as surgeons gradually
determine optimal approaches to specific clinical challenges. However, major questions
remain, such as “How much tissue can be based on specific sized pedicle vessels?” and “How
can we increase the diameter of flap vessels?” Clear, unbiased descriptions of results and
good communication about the vascular basis of different flaps will assist in determining
the best flap for the job. This evolution of flap choice should and will continue to improve
results in reconstructive surgery.

Bibliography With Key Annotations

  1. McDowell F. Logs vs harpsichords, blobby flaps vs finished results. Plast Reconstr Surg
64:249, 1979.
  2. Sushruta, Bhishagratna K. An English Translation of the Sushruta Samhita, Based on
Original Sanskrit Text. Calcutta, 1907.
  3. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomic (angiosome) and clinical
territories of cutaneous perforating arteries: development of the concept and designing
safe flaps. Plast Reconstr Surg 127:1447, 2011.
Island “perforator flaps” have become state of the art for free skin flap transfer. Recent articles
by Saint-Cyr et al and Rozen et al have focused on the anatomic and the clinical territories of
individual cutaneous perforating arteries in flap planning, and it is timely to compare this work
with our angiosome concept. The angiosome concept, first published in 1987, was reviewed and
correlated with key experimental and clinical work by the authors, published subsequently at

02_VasBasis_r4_bs_0035-0080.indd 69 2/2/2012 2:11:22 PM

 70 Part I  Fundamentals

different times in different journals. In addition, new data are introduced to define these anatomic
and clinical territories of the cutaneous perforators and to aid in the planning of safe skin flaps
for local and free flap transfer. The anatomic territory of a cutaneous perforator was defined in
the pig, dog, guinea pig, and rabbit by a line drawn through its perimeter of anastomotic vessels
that link it with adjacent perforators in all directions. The safe clinical territory of that perfora-
tor—seen not only in the same range of animals but also in the human using either the Doppler
probe or computed tomography angiography to locate the vessels—was found reliably to extend
to include the anatomic territory of the next adjacent cutaneous perforator, situated radially in
any direction. The data provided by Saint-Cyr et al and Rozen et al, coupled with the authors’
own original work on the vascular territories of the body and their subsequent studies, reinforce
the angiosome concept and provide the basis for the design of safe flaps.
  4. Morris SF, Tang M, Almutari K, et al. The anatomic basis of perforator flaps. Clin Plast
Surg 37:553, 2010.
The recent enthusiasm for perforator flaps underlines the need for a detailed understanding of
the cutaneous vasculature. The principle determinant of success in perforator flap surgery is the
inclusion of an adequately sized cutaneous perforator in the flap. Therefore the size, distribu-
tion, and variability of cutaneous perforators of the human body are crucial to the design and
execution of successful perforator flap surgery. Based on numerous anatomic studies, the authors
found that the main source arteries supplying the skin are fairly constant, but the individual
cutaneous perforators are quite variable. Knowledge of the overall architecture of the vasculature
and an awareness of the variability, combined with a flexible operative plan, will enable the
perforator flap surgeon to take advantage of the most appropriate perforators to execute a suc-
cessful operative plan.
  5. Manchot C. Die Hautarterien des Menschlichen Körpers. Leipzig: FCW Volgel, 1889.
  6. Manchot C. The Cutaneous Arteries of the Human Body. Translated by Ristic J, Morain
WD. New York: Springer-Verlag, 1983.
  7. Salmon M. Artères de la Peau. Paris: Masson, 1936.
  8. Salmon M. Arteries of the Skin. In Taylor GI, Tempest MN, eds. First English Edition.
Edinburgh: Churchill Livingstone, 1988.
  9. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental
study and clinical applications. Br J Plast Surg 40:113, 1987.
The blood supply to the skin and underlying tissues was investigated by ink injection studies,
dissection, perforator mapping and radiographic analysis of fresh cadavers and isolated limbs.
The results were correlated with previous regional studies done in this department. The blood
supply is shown to be a continuous three-dimensional network of vessels not only in the skin
but in all tissue layers. The anatomic territory of a source artery in the skin and deep tissues
was found to correspond in most cases, giving rise to the angiosome concept. Arteries closely
follow the connective tissue framework of the body. The primary supply to the skin is by direct
cutaneous arteries that vary in caliber, length, and density in different regions. This primary
supply is reinforced by numerous small indirect vessels, which are “spent” terminal branches
of arteries supplying the deep tissues. An average of 374 major perforators was plotted in each
subject, revealing that there are still many more potential skin flaps. The arterial roadmap of the
body provides the basis for the logical planning of incisions and flaps. The angiosomes defined
the tissues available for composite transfer.
10. Taylor GI, Caddy CM, Watterson PA, et al. The venous territories (venosomes) of the
human body: experimental study and clinical implications. Plast Reconstr Surg 86:185,
1990.
The venous architecture of the integument and the underlying deep tissues was studied in six
total-body human fresh cadavers and a series of isolated regional studies of the limbs and torso. A
radiopaque lead oxide mixture was injected, and the integument and deep tissues were dissected

02_VasBasis_r4_bs_0035-0080.indd 70 2/2/2012 2:11:22 PM

 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 71

and radiographed. The sites of the venous perforators were plotted and traced to their underlying
parent veins that accompany the source (segmental) arteries. A series of cross-sectional studies
were made in one subject to illustrate the course of the perforators between the integument and
the deep tissues. The veins were dissected under magnification to identify the site and orienta-
tion of the valves. Results revealed a large number of valveless (oscillating) veins within the
integument and deep tissues that link adjacent valved venous territories and allow equilibration
of flow and pressure throughout the tissue. Where choke arteries define the arterial territories,
they are matched by boundaries of oscillating veins in the venous studies. The venous architec-
ture is a continuous network of arcades that follow the connective-tissue framework of the body.
The veins converge from mobile to fixed areas, and they “hitchhike” with nerves. The venous
drainage mirrors the arterial supply in the deep tissues and in most areas of the integument in
the head, neck, and torso. In the limbs, the stellate pattern of the venous perforators is modified
by longitudinal channels in the subdermal network. However, when an island flap is raised,
these longitudinal channels are disconnected, and once again the arterial and venous patterns
match. The venous studies add strength to the angiosome concept. Where source arteries supply
a composite block of tissue, we have demonstrated radiologically and by microdissection that the
branches of these arteries are accompanied by veins that drain in the opposite direction and return
to the same locus. Hence each angiosome consists of matching arteriosomes and venosomes.
The clinical implications of these results were discussed with particular reference to the design of
flaps, the delay phenomenon, venous free flaps, the pathogenesis of flap necrosis, the “muscle
pump,” varicose veins, and venous ulceration.
11. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories of the skin and
muscles: anatomic study and clinical implications. Plast Reconstr Surg 94:1, 1994.
In 1987 the results of a series of total-body investigations of the arterial system of the skin
and underlying deep tissues were published. This resulted in the angiosome concept. In 1990
a similar series of studies of the venous network was published. In both investigations, it was
noted that “vessels hitchhike with nerves.” This anatomic study analyzed these neurovascular
relationships in the skin and in the underlying muscles. Seven fresh human cadavers and nine
animals were studied over a 2-year period. The entire integument of each and a total of 538
human and 72 animal muscles were removed and analyzed. Either the arterial or the venous
system was injected with a radiopaque lead oxide mixture, and the dissected nerves were labeled
with fine wires and were segregated later by a subtraction radiography technique. The authors
presented the results of these investigations, with special emphasis on the design of long axial
skin flaps placed along neurovascular systems and their relationship with the current design of
skin flaps. The muscles were classified according to their extrinsic and intrinsic neurovascular
supplies and suggestions made as to how they may or may not be subdivided into functional
units for local and distant transfer. The cutaneous nerves, as well as the motor nerves of the
muscles, were invariably accompanied by a longitudinal system of arteries and veins that often
was the dominant supply to the region. Whether the nerves appeared together with the vessels,
whether the nerves crossed them at an angle, or whether they approached the vessels from opposite
directions, in each case the main trunk of the vessel or some of its branches soon “peeled off”
to course parallel to the nerve. This information provides the basis for the design of long skin
flaps placed along neurovascular systems. Indeed, it reveals that many of the current “axial” or
“fasciocutaneous” skin flaps used in clinical practice are in fact neurovascular flaps.
12. Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and clinical implica-
tions. Plast Reconstr Surg 98:195, 1996.
13. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications.
Plast Reconstr Surg 102:599; discussion 617, 1998.
14. Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic
study and clinical applications. Plast Reconstr Surg 105:2287, 2000.

02_VasBasis_r4_bs_0035-0080.indd 71 2/2/2012 2:11:22 PM

 72 Part I  Fundamentals

15. Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Re-
constr Surg 89:181, 1992.
16. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses.
A clinical technique. Plast Reconstr Surg 52:111, 1973.
17. Daniel RK, Williams HB. The free transfer of skin flaps by microvascular anastomoses.
An experimental study and a reappraisal. Plast Reconstr Surg 52:16, 1973.
18. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of
microvascular techniques. Plast Reconstr Surg 55:533, 1975.
19. Taylor GI, Doyle M, McCarten G. The Doppler probe for planning flaps: anatomical
study and clinical applications. Br J Plast Surg 43:1, 1990.
The Doppler probe was used to identify the dominant cutaneous perforating arteries in a series
of 10 patients. The results were compared with our previous total body fresh cadaver anatomic
studies and a close correlation was found. The instrument was used in a series of patients to
plan the base, the axis and the dimensions of skin flaps for local, distant and free transfer. A
dominant perforator was located at the base of the flap, the surrounding skin was scanned to
identify the next dominant perforator in each direction and the appropriate axis was chosen
by drawing a line between two nominated perforators. Often the flap was based distally or its
axis departed from the main course of the supplying vessel. The technique proved to be simple
and reliable and in many cases flaps of unusual dimensions and directions were transferred
successfully. The instrument provides a useful link between the anatomic dissecting room and
the operating theater.
20. Cormack G, Lamberty B. The Arterial Anatomy of Skin Flaps. Edinburgh: Churchill
Livingstone, 1986.
21. Cormack GC, Duncan MJ, Lamberty BG. The blood supply of the bone component
of the compound osteo-cutaneous radial artery forearm flap—an anatomical study. Br J
Plast Surg 39:173, 1986.
22. Lamberty BG, Cormack GC. The antecubital fascio-cutaneous flap. Br J Plast Surg 36:428,
1983.
23. Bergeron L, Tang M, Morris SF. A review of vascular injection techniques for the study
of perforator flaps. Plast Reconstr Surg 117:2050, 2006.
24. Rees MJ, Taylor GI. A simplified lead oxide cadaver injection technique. Plast Reconstr
Surg 77:141, 1986.
25. Tang M, Ding M, Almutairi K, Morris SF. Three-dimensional angiography of the sub-
mental artery perforator flap. J Plast Reconstr Aesthet Surg 64:608, 2011.
26. Tang M, Mao Y, Almutairi K, Morris SF. Three-dimensional analysis of perforators of
the posterior leg. Plast Reconstr Surg 123:1729, 2009.
27. Tang M, Yin Z, Morris SF. A pilot study on three-dimensional visualization of perforator
flaps by using angiography in cadavers. Plast Reconstr Surg 122:429, 2008.
28. Milton SH. Pedicled skin-flaps: the fallacy of the length:width ratio. Br J Surg 57:502,
1970.
29. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg 26:202, 1973.
30. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 25:3, 1972.
31. McGregor IA. Fundamental Techniques in Plastic Surgery, 6th ed. Edinburgh: Churchill
Livingstone, 1975.
32. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and clas-
sification of skin flaps according to their vascularization. Ann Plast Surg 16:1, 1986.
The success of fasciocutaneous flaps is based on the existence of epifascial vascular networks and
reliable blood supply. However, there has been no thorough classification of the vascular anatomy
of the fascia and skin and there is some confusion in regard to cutaneous vascular nomencla-
ture. The authors divided the vascular systems involved in the cutaneous circulation into four

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 73

categories. This permits classification of skin flaps into five types (cutaneous, fasciocutaneous,
adipofascial, septocutaneous, and myocutaneous flaps). Fasciocutaneous flaps can be further
divided into six types, according to the patterns of the vascular input to the fasciocutaneous
plexus. This classification has been demonstrated to be related to clinical effects. Nine new free
and island flaps were discussed.
33. Mathes SJ. The muscle flap for management of osteomyelitis. N Engl J Med 306:294,
1982.
The author observed that the effectiveness of the muscle flap in the management of osteomyelitis
is related to two factors: (1) wound debridement is less restricted because of the ability of the
muscle flap to provide coverage in one operation, and (2) well-vascularized muscles are applied
directly to the bone defect, bringing a new source of antimicrobial defense.
34. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experi-
mental and clinical correlation. Plast Reconstr Surg 69:815, 1982.
The authors reviewed the cases of 11 patients with chronic osteomyelitis involving the distal
tibia and foot who were successfully treated with a combination of debridement and immediate
microvascular muscle transplantation. Diagnosis of chronic osteomyelitis was confirmed by dem-
onstration of radiographic and histologic abnormality, along with positive bone culture results.
Experience data were presented to support the effectiveness of muscle flap coverage of the infected
wound. The authors introduced two useful concepts in muscle transplantation to leg defects:
(1) selection of receptor vessels to the leg defect based on arteriographic evaluation of suitable
receptor vessels, and (2) use of end-to-side venous anastomosis as well as established techniques
of end-to-side arterial anastomosis. A comparison of long-term results notes improved contour
of the muscle flap with a skin flap as compared with a myocutaneous flap. All patients in this
series demonstrated resolution of chronic bone infection at an average follow-up of 1.8 years.
35. Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap.
Plast Reconstr Surg 65:686, 1980.
36. McCraw JB. The recent history of myocutaneous flaps. Clin Plast Surg 7:3, 1980.
37. McCraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 60:212, 1977.
Experimental studies were undertaken in dogs to determine whether useful island myocutane-
ous flaps could be based on the gracilis, sartorius, biceps femoris, trapezius, or rectus abdominis
muscles. Dissection and injection studies on these muscles were also undertaken in human
cadavers to determine the contributions of these muscles to the blood supply of the overlying skin.
In most instances it was considerable. The use of island myocutaneous flaps seems promising
in many situations. Such transfers can be done in one operation, without delay procedures, and
result usually in a better blood supply with the transfer of a thicker amount of tissue. Clinical
research on such flaps in patients was to be described in a subsequent paper.
38. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous
vascular territories. Plast Reconstr Surg 60:341, 1977.
A number of myocutaneous flaps are described for the first time. This article includes a description
of 13 myocutaneous flaps. The size of each unit and its vascular basis are described.
39. Mathes S, Nahai F. Clinical Atlas of Muscle and Musculocutaneous Flaps. St Louis: Mosby,
1979.
40. Taylor GI, Daniel RK. The free flap: composite tissue transfer by vascular anastomosis.
Aust N Z J Surg 43:1, 1973.
41. Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SF. The posterior thigh
perforator flap or profunda femoris artery perforator flap. Plast Reconstr Surg 119:194;
discussion 201, 2007.
42. Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery
perforator flaps. Plast Reconstr Surg 120:1551, 2007.

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 74 Part I  Fundamentals

43. Morris SF, Yang D. Gracilis muscle: arterial and neural basis for subdivision. Ann Plast
Surg 42:630, 1999.
44. Blondeel P, Morris S, Hallock G, Neligan P. Perforator Flaps: Anatomy, Technique and
Clinical Applications. St Louis: Quality Medical Publishing, 2006.
45. Drever JM. The epigastric island flap. Plast Reconstr Surg 59:343, 1977.
46. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal
island flap. Plast Reconstr Surg 69:216, 1982.
A rectus abdominis myocutaneous island flap for breast reconstruction following mastectomy
was presented. The vascular anatomy of the abdominal wall was clinically studied in patients
undergoing abdominal lipectomy. Cadaver dissections were shown, demonstrating the anatomy,
arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique was
demonstrated and representative patients were shown.
47. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the
deep inferior epigastric systems. Plast Reconstr Surg 73:1, 1984.
The vascular territories of the superior and the deep inferior epigastric arteries were investigated
by dye injection, dissection, and barium radiographic studies. By these means it was established
that the deep inferior epigastric artery was more significant than the superior epigastric artery
in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric
system pass upward and outward into the neurovascular plane of the lateral abdominal wall,
where they anastomose with the terminal branches of the lower six intercostal arteries and the
ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple nar-
row “choke” vessels. Similar connections are seen between the superior and the deep inferior
epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many
perforating arteries emerge through the anterior rectus sheath, but the highest concentration of
major perforators is in the paraumbilical area. These vessels are terminal branches of the deep
inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from
the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent
territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the su-
perficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery.
The dominant connections, however, are superolaterally with the lateral cutaneous branches
of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the
deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin
on a superiorly based rectus abdominis myocutaneous flap. The vascularity of this flap would
be further increased by positioning some part of the skin paddle over the dense pack of large
paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior
and deep inferior epigastric arteries with respect to local and distant tissue transfer using various
elements of the abdominal wall are discussed in detail.
48. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory:
vascular anatomy and clinical implications. Plast Reconstr Surg 124:1529, 2009.
49. Rozen WM, Ashton MW, Le Roux CM, et al. The perforator angiosome: a new concept
in the design of deep inferior epigastric artery perforator flaps for breast reconstruction.
Microsurgery 30:1, 2010.
The previously described “perfusion zones” of the abdominal wall vasculature are based on
filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With
the advent of the DIEA perforator flap, only a single or several perforators are included in the
supply to the flap. As such, a new model for abdominal wall perfusion has become necessary.
The authors explored the concept of a “perforator angiosome.” They undertook a clinical and
cadaveric study of 155 abdominal walls. This comprised the use of 10 whole, unembalmed
cadaveric abdominal walls for angiographic studies and 145 abdominal wall CT angiograms in

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 75

patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation
of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators
was explored, particularly exploring differences between medial and lateral row perforators.
Fundamental differences exist between medial row and lateral row perforators, with medial
row perforators larger (1.3 mm versus 1 mm) and more likely to ramify in the subcutaneous
fat toward the contralateral hemiabdomen (98% of cases versus 2% of cases). A model for the
perfusion of the abdominal wall based on a single perforator is presented. The “perforator
angiosome” is dependent on perforator location, and can be mapped individually with the use
of preoperative imaging.
50. Rozen WM, Grinsell D, Koshima I, et al. Dominance between angiosome and perforator
territories: a new anatomical model for the design of perforator flaps. J Reconstr Microsurg
26:539, 2010.
51. Morris SF, Taylor GI. Predicting the survival of experimental skin flaps with a knowledge
of the vascular architecture. Plast Reconstr Surg 92:1352, 1993.
Experimental skin flaps have been used by researchers for almost a century to investigate many
of the perplexing questions in plastic and reconstructive surgery, yet the underlying vascular
anatomy of these flaps is addressed infrequently. The purpose of this study was to predict the
survival of experimental skin flaps before their elevation in guinea pigs and rabbits, planned on
a knowledge of the underlying vascular anatomy. On the basis of the authors’ previous anatomic
studies, 17 guinea pigs and 15 rabbits were used in separate experiments. In experiment 1,
two parallel flank flaps of identical dimensions were compared on one side of each guinea pig.
The dorsal flap encompassed the vascular territories of multiple perforators, while the ventral
flap embraced two perforators (two-territory flap). Viability was assessed on days 3 and 7 by
inspection and fluorescein dye injection. All ventral flaps survived to a greater extent than the
dorsal flaps. Whole-body fresh cadaver lead oxide injections were performed to provide cutaneous
angiograms. It was found in each flap that the area of skin viability corresponded to the capture
of one to two adjacent vascular territories on the artery at its base. In the second experiment, a
multiple-territory osteocutaneous flap was designed on one side of the torso of the rabbit using
the Doppler probe. It was based on the thoracodorsal artery and embraced the skin and a 1 by
2 cm segment of iliac crest bone in the adjacent deep circumflex iliac artery angiosome. Using
the same criteria as in experiment 1, the authors found that one to two adjacent viable skin
territories were captured on the thoracodorsal artery. In addition, viability of the iliac bone was
confirmed in every case by angiography, fluorochrome labeling, and india ink injection studies
indicating the capture of deep structures of the deep circumflex iliac artery angiosome. This
study reinforces the angiosome concept and indicates that one adjacent vascular territory may
be captured reliably in experimental guinea pig and rabbit skin flaps. The authors described a
reliable osteocutaneous flap model in the rabbit.
52. Callegari PR, Taylor GI, Caddy CM, et al. An anatomic review of the delay phenomenon:
I. Experimental studies. Plast Reconstr Surg 89:397; discussion 417, 1992.
A number of experiments were conducted to study the anatomic changes in a flap following
a surgical delay using the Doppler probe to add precision to the technique. After scanning the
integument of a series of anesthetized animals with the probe, each was sacrificed; a total-body
arterial injection was performed with a lead oxide mixture, the integument and deep tissues
were radiographed separately, and the results were correlated and compared with our previous
human studies. The dog was selected from the range of animals examined, and the arterial
networks of a number of skin and muscle flaps were studied with and without a surgical delay.
The study included the use of a tissue expander. Results revealed that an adjacent cutaneous
perforator could be captured with safety on the artery at the base of an undelayed flap; that the
survival length of that flap was related to the distance between perforators; that the necrosis line

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 76 Part I  Fundamentals

of the flap usually appeared in the zone of choke vessels connecting adjacent territories; that a
surgical delay results in a dilatation of existing vessels with maximal effect in the zone of choke
arteries; that the most effective delay was obtained by elevating the flap in stages from the base,
leaving detachment of the tip until last; that tissue expansion is a form of surgical delay, with
particular emphasis on vessel hypertrophy; and that similar changes occur when a muscle is
delayed. The clinical applications of this investigation were presented in part II of this anatomic
review of the delay phenomenon.
53. Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg
104:2079, 1999.
54. Taylor GI, Corlett RJ, Caddy CM, et al. An anatomic review of the delay phenomenon:
II. Clinical applications. Plast Reconstr Surg 89:408; discussion 417, 1992.
55. Mathes S, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. London:
Churchill Livingstone, 1997.
56. Hunter J. A Treatise on Blood, Inflammation and Gunshot Wounds. London: John
Richardson, 1794.
57. Lockhart R, Hamilton G, Fyfe F. Anatomy of the Human Body. London: Faber & Faber,
1959.
58. Schafer K. [The subcutaneous vascular system (lower extremity): studies on micro-
preparations] Gegenbaurs Morphol Jahrb 121:492, 1975.
59. Sunderland S. Nerves and Nerve Injuries, 2nd ed. London: Churchill Livingstone, 1978.
60. Sunderland S. Nerve Injuries and Their Repair: A Critical Appraisal. London: Churchill
Livingstone, 1991.
61. Sunderland S. Nerves and Nerve Injuries. Baltimore: Williams & Wilkins, 1968.
62. Schwalbe G. Ueber das Gesetz des Muskelnerveneintritts. Arch Anat Physiol Anat Abt
167, 1879.
63. Morris SF, Taylor GI. The time sequence of the delay phenomenon: when is a surgical
delay effective? An experimental study. Plast Reconstr Surg 95:526, 1995.
The authors previously showed that when a flap is delayed, the maximal anatomic effect
on the arterial side of the circulation is focused at the level of the smaller-caliber choke vessels
that link adjacent vascular territories. These anastomotic vessels were noted to increase in size
to the dimension of true anastomoses. However, we did not define when this occurred. The
present experiment therefore was designed to elucidate the chronologic sequence of events that
occur in the “choke” vessels using a rabbit flank skin flap as the experimental model. A long
two-territory osteocutaneous flank flap was designed on one side of each rabbit (n 5 30), with
the opposite unoperated side serving as a control. The flap was elevated and sutured back in
place. At various times postoperatively, namely, 1 (n 5 2), 2 (n 5 2), 3 (n 5 2), 4 (n 5 2),
6 (n 5 2), 8 (n 5 2), 12 (n 5 2), 24 (n 5 2), 48 (n 5 2), and 72 (n 5 2) hours and 7
days (n 5 10), the animals were sacrificed, and total-body arteriograms were obtained using
a lead oxide mixture. The density and size of the choke arteries between the territories in the
flap and their counterparts on the control side were assessed by histologic analysis (n = 3). The
authors observed a sequential dilation of choke vessels during the delay period. In particular, the
authors found that the vessels increased rapidly in size between the 48- and 72-hour studies.
64. Morris SF, Yang D. Effect of vascular delay on viability, vasculature, and perfusion of
muscle flaps in the rabbit. Plast Reconstr Surg 104:1041, 1999.
65. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps
based on the deep superior epigastric system. Plast Reconstr Surg 82:815, 1988.
66. Jackson IT. Local Flaps in Head and Neck Reconstruction, 2nd ed. St Louis: Quality
Medical Publishing, 2007.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 77

67. Ma GF, Cheng JC, Chan KT, et al. Finger tip injuries—a prospective study on seven
methods of treatment on 200 cases. Ann Acad Med Singapore 11:207, 1982.
68. Mendelson BC, Woods JE, Masson JK. Experience with the deltopectoral flap. Plast
Reconstr Surg 59:360, 1977.
69. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a
primary pectoral skin flap. Plast Reconstr Surg 36:173, 1965.
70. Esser J. Studies in Plastic Surgery of the Face. Leipzig: FCW Vogel, 1917.
71. Gillies H. Plastic Surgery of the Face. London: Oxford University Press, 1920.
72. Bakamjian VY. Total reconstruction of pharynx with medially based deltopectoral skin
flap. N Y State J Med 68:2771, 1968.
73. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap
in reconstructuve surgery of the head and neck. Br J Plast Surg 24:174, 1971.
74. Bowen J, Meares A. Delayed local leg flaps. Br J Plast Surg 27:167, 1974.
75. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast
Surg 34:215, 1981.
76. Cormack GC, Lamberty BG. A classification of fascio-cutaneous flaps according to their
patterns of vascularisation. Br J Plast Surg 37:80, 1984.
77. Tolhurst DE, Haeseker B, Zeeman RJ. The development of the fasciocutaneous flap and
its clinical applications. Plast Reconstr Surg 71:597, 1983.
78. Cormack GC, Lamberty BG. The anatomical vascular basis of the axillary fascio-cutaneous
pedicled flap. Br J Plast Surg 36:425, 1983.
79. Cormack GC, Lamberty BG. The blood supply of thigh skin. Plast Reconstr Surg 75:342,
1985.
80. Follmar KE, Baccarani A, Baumeister SP, et al. The distally based sural flap. Plast Reconstr
Surg 119:138e, 2007.
81. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 9:21, 1982.
82. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the
septocutaneous artery. Br J Plast Surg 37:149, 1984.
83. Taylor GI, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical
technique. Plast Reconstr Surg 72:751, 1983.
84. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus
abdominis) flap. Br J Plast Surg 37:330, 1984.
85. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and
clinical correlation. Plast Reconstr Surg 67:177, 1981.
The authors described five patterns of muscle circulation, based on studies of the vascular
anatomy of muscle. Clinical and experimental correlation of this classification was determined
by the predictive value of the vascular pattern of each muscle currently useful in reconstructive
surgery in regard to the following parameters: arc of rotation, skin territory, distally based flaps,
microvascular composite tissue transplantation, and design of muscle-delay experimental models.
This classification was designed to assist the surgeon both in choice and design of the muscle
and myocutaneous flap for its use in reconstructive surgery.
86. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg
56:243, 1975.
87. Hallock GG. Simplified nomenclature for compound flaps. Plast Reconstr Surg 105:1465,
2000.
The unique niche for compound flaps is their potential role for the repair of massive defects that
demands the simultaneous restoration of multiple missing tissue types. These complex flaps can
be sorted into two major classes; the author described their subtypes on the basis of their means

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 78 Part I  Fundamentals

of vascularization: (1) solitary vascularization, the composite flap: “multiple tissue components
with a single vascular supply and dependent parts” and (2) combined flaps: (a) Siamese flaps:
“multiple flap territories, dependent due to some common physical junction, yet each retain-
ing their independent vascular supply”; (b) conjoint flaps: “multiple independent flaps, each
with an independent vascular supply, but linked by a common indigenous source vessel”; and
(c) sequential flaps: “multiple independent flaps, each with an independent vascular supply, and
artificially linked by a microanastomosis.” Many technical modifications that have improved or
will improve the reliability of these flaps should not be confused as distinct flap types, but rather
acknowledged as variations that can be more conveniently classified for the purposes of improved
communication and research by using this basic schema as a guideline.
88. Hallock GG. Muscle perforator flaps: the name game. Ann Plast Surg 51:630, 2003.
89. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and ap-
plications. Ann Plast Surg 50:90, 2003.
The authors reviewed the literature regarding perforator flaps. Myocutaneous perforator flaps
have evolved from myocutaneous flaps and offer several distinct advantages. By sparing muscle
tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for
a number of clinical problems. The versatility of the perforator flap makes it ideal for the recon-
struction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing
shallow wounds when bulk is considered a disadvantage. The authors reviewed the historical
development of the perforator flap and discuss the advantages and disadvantages of perforator
flaps compared with free and pedicled myocutaneous flaps. The nomenclature traditionally used
for perforator flaps is confusing and lacks a standardized anatomic basis. The authors presented
a method to describe all perforator flaps according to their artery of origin.
90. Taylor GI, Watson N. One-stage repair of compound leg defects with free, revascularized
flaps of groin skin and iliac bone. Plast Reconstr Surg 61:494, 1978.
91. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast
Reconstr Surg 81:561, 1988.
A new type of flap was described based on unnamed perforators located near the midline of the
lower back region. Such flaps combine the superior blood supply of the myocutaneous flap with
the lack of donor-site morbidity of a skin flap. Five clinical cases were presented, showing how
such perforators can augment skin flaps or create custom-designed island flaps. The dissection
of the flap was described, and further possibilities for its use were suggested.
92. Koshima I, Soeda S, Yamasaki M, et al. The free or pedicled anteromedial thigh flap.
Ann Plast Surg 21:480, 1988.
The anteromedial thigh flap first described by Song is a septocutaneous artery flap based on
the septocutaneous perforator originating from the lateral circumflex femoral vessels and long
saphenous vein. The authors reported the use of this flap for three patients who required soft
tissue coverage. The most important advantage of this flap is that it can be used not only as a
skin flap but also as a vascularized fascia graft and fasciocutaneous free flap for the full-thickness
defect of the abdominal wall and cranial region.
93. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann
Plast Surg 32:32, 1994.
The ideal material for reconstruction of a breast is fat and skin. Most current methods of autolo-
gous reconstruction use myocutaneous flaps. The authors investigated the feasibility of transfer
of skin and fat from the lower abdomen without muscle sacrifice. The flap is based on one,
two, or three perforators of the deep inferior epigastric vessels. Their study demonstrated both
experimentally and clinically this original technique for breast reconstruction. Fifteen breasts
were successfully reconstructed with this technique. This technique has all of the advantages of
the free TRAM flap with a decreased possibility of ventral hernia or muscle weakness.

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 Chapter 2  •  Vascular Basis of Flaps and Flap Classification 79

94. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience.
Br J Plast Surg 52:104, 1999.
The TRAM flap has been the gold standard for breast reconstruction until recently. Not only
autologous but also immediate reconstructions are now preferred to offer the patient a natural
and cosmetically acceptable result. This study summarized the prospectively gathered data of
100 free DIEP flaps used for breast reconstruction in 87 patients. Primary reconstructions were
done in 35% of the patients. Well-known risk factors for free flap breast reconstruction were
present: smokers 23%, obesity 25%, abdominal scarring 28% and previous radiotherapy 45%.
Free DIEP flaps vascularized by a single (52%) perforator, two (39%) perforators, or three
(9%) perforators were preferentially anastomosed to the internal mammary vessels at the level
of the third costochondral junction. Of 74 unilateral DIEP flaps, 41 (55%) flaps were well
vascularized in zone IV. Two flaps necrosed totally. Partial flap loss and fat necrosis occurred
in 7% and 6% of all flaps, respectively. One patient presented with a unilateral abdominal
bulge. Mean operating time was 6 hours 12 minutes for unilateral reconstruction and mean
hospital stay was 7.9 days. These data indicate that the free DIEP flap is a reliable and safe
technique for autologous breast reconstruction. This flap offers the patient the same advantages
as the TRAM flap and avoids the most important disadvantages of the myocutaneous flap by
preserving the continuity of the rectus muscle. The donor site morbidity is reduced, a sensate
reinnervation is possible, postoperative pain is less, recovery is quicker and hospital stay is
reduced. The more complex nature of this type of surgery, leading to increased operating time,
is balanced by the permanent and gratifying results achieved.
95. Mizgala CL, Hartrampf CR Jr, Bennett GK. Assessment of the abdominal wall after
pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients. Plast
Reconstr Surg 93:988; discussion 1003, 1994.
96. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle.
Br J Plast Surg 42:645, 1989.
97. Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: anatomic study and
clinical application. Plast Reconstr Surg 91:853; discussion 864, 1993.
98. Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical perforator-based flaps.
Ann Plast Surg 29:12, 1992.
99. Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral
deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br
J Plast Surg 47:495, 1994.
Besides the enormous advantages of reconstructing an amputated breast by means of a conven-
tional TRAM flap, the main disadvantage remains the elevation of small (free TRAM) or
larger (pedicled TRAM) parts of the rectus abdominis muscle. To overcome this disadvantage,
the free deep inferior epigastric perforator (DIEP) skin flap has been used for breast mound
reconstruction with excellent clinical results. After achieving favorable results with eight unilateral
DIEP flaps, the authors were challenged by an abdomen with a midline laparotomy scar. By
dissecting a bilateral DIEP flap and making adjacent anastomoses to the internal mammary
artery, they were able to achieve sufficient flap mobility for easy free flap positioning and breast
shaping. Intraoperative segmental nerve stimulation, postoperative functional abdominal wall
tests, and CT scan examination showed normal abdominal muscle activity. On the basis of a
case report, the technical considerations and advantages of anastomosing the bipedicled DIEP
flap to the internal mammary artery were discussed.
100. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free
DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 50:322, 1997.
101. Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and func-
tional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruc-
tion. Plast Reconstr Surg 117:737; discussion 747, 2006.

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 80 Part I  Fundamentals

102. Futter CM, Webster MH, Hagen S, et al. A retrospective comparison of abdominal muscle
strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg
53:578, 2000.
103. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormalities of the abdomen after
breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr
Surg 109:91, 2002.
104. Pribaz JJ, Chan RK. Where do perforator flaps fit in our armamentarium? Clin Plast Surg
37:571, 2010.
105. Hallock GG. Sequential use of a true perforator flap and its corresponding muscle flap.
Ann Plast Surg 51:617; discussion 621, 2003.
106. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in the planning of per-
forator flaps. Br J Plast Surg 51:202, 1998.
107. Hallock GG. Doppler sonography and color duplex imaging for planning a perforator
flap. Clin Plast Surg 30:347, 2003.
108. Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row computed tomography in
the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 59:594, 2006.
109. Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruction using an
inferior gluteal artery perforator (IGAP) flap. Br J Plast Surg 55:83, 2002.
110. Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a
prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 114:1077;
discussion 1084, 2004.
111. Teo TC. The propeller flap concept. Clin Plast Surg 37:615, 2010.
The propeller flap, based on a single vascular pedicle supplying a fasciocutaneous island of
skin, is a very useful technique for reconstructing soft tissue defects and has wide applications
throughout the body. The use of this unique flap is pushing the boundaries of local flap recon-
struction and bringing up intriguing questions about our understanding of the vascular basis of
fasciocutaneous flaps.

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 Chapter 3
Section Title
Guide to Flap Selection
Sect Title 2nd Line
Sect Title 3rd

The practice of plastic and reconstructive surgery is as much art as it is science. This explains
why different plastic surgeons can successfully solve similar clinical problems with different
reconstructive flaps and techniques. Both can be successful. This makes it hard to teach as
dogma that one flap or another is the best or should be the standard. It is even harder for the
student, whose life is made easier by dogma and repetition. This is especially true in residency,
which is effectively an apprenticeship in which the tools of the trade are passed down and one
learns the “right” way to solve problems.
To be truly successful in reconstructive surgery, one needs to be flexible, and able to adapt to
a given situation—in essence, one needs to be “plastic.” Any worthwhile guide to flap selection
will best serve its students by teaching them how to think about the reconstructive problem at
hand and to generate a list of possible solutions. Each solution would have its own list of pros
and cons. The true art would then be the application of those solutions to a particular patient.
And the same clinical problem in a different patient might produce a different list of solutions
for that individual.
Although there are unifying principles in plastic surgery, such as “replace like with like” and
“mark twice, cut once,” it is best to break down the reconstructive problem into its component
parts: patient factors, local factors, and flap factors (see the box on p. 150).
In this way, one can avoid the knee-jerk response of doing the same reconstructive flap in
varying clinical situations in dissimilar patients. Time spent breaking down the problem and
considering all options preoperatively will pay off by reducing time in the operating room,
lowering patient morbidity, and solving the problem at hand.

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 82 Part I  Fundamentals

PATIENT FACTORS
The category of patient factors can be further broken down into the physical and the emo-
tional. As a physician, one’s first and overriding concern is for the patient’s well-being. The
event that has led the patient to present to you (such as trauma, cancer, or disease) may in
the end limit the choices you have for reconstruction. The physical state of the patient, the
multisystem traumatic injury, the metastatic cancer currently being treated, or the medical
comorbidities of the patient may severely limit options for long operative procedures or
long recoveries. Shorter local or regional procedures may prevail.
The patient’s emotional state and his or her insight into the situation can also weigh
heavily on your decision. Is the patient willing to accept scars, and where? What is the desired
recovery time? A patient who owns his or her own small business is less able to dedicate
the necessary 6 weeks of recovery that a free flap might entail and less able to tolerate a
lengthy complication. The patient’s reliability should also factor into the decision-making
process. If lengthy follow-up or therapy will be required and the patient is not motivated,
the chances of success may be doomed before the incision is made.

LOCAL FACTORS
Location, location, location. Where you are operating will present different reconstructive
opportunities. Some anatomic locations, such as the top of the head and the bottom of the
feet, offer fewer local and regional options. Previous surgery may affect options for incisions,
available tissues, and available recipient vessels. A history of radiation therapy or a plan for
postoperative radiation can also alter one’s surgical plans toward more durable flap choices.
The concept of “zone of injury” is an important one, not only in trauma cases, but also in all
reconstructions. One must strive to be aggressive in the resectioning of involved, infected,
poorly vascularized, and poor-quality tissues, and, as much as possible, to use uninjured,
well-vascularized, expendable tissues from the region or from distant sites with free tissue
transfer. Recipient vessels for such transfers should be clearly out of the involved area to
reduce the chances of thrombosis caused by damaged vessels. Finally, the patient’s body
habitus can alter one’s choices in flap selection; for example, obesity can change the donor
site and has an impact on vascularity, ease of dissection, and ease of flap inset, in addition
to an increased potential for donor site morbidity.

FLAP FACTORS
Once the requirements of the reconstruction are clearly delineated, the search for the best
solution begins. Each flap has certain characteristics to offer, and these expectations must
be confirmed by examining the patient. The concept of “replacing like with like” usually
means local tissues. Regional choices are considered first to provide good color and texture
match and ease of transfer and to avoid a lengthy microsurgical procedure. The right flap
will have the right combination of components needed for the job: muscle, skin, fascia,
bone. The best choices for skin supply the needed surface area and allow primary donor
site closure. If skin grafting is required for donor site closure, comparison with other flaps
is warranted. The character of the transferred skin must also be assessed for texture and
color match, durability, and other special features, such as hair and sensibility. If fascia is
required, the amount needed and the desire to vascularize the fascia will point to certain

03_GuideFlapDis_r8_bs_0081-0152.indd 82 2/9/2012 1:25:10 PM

 Chapter 3  •  Guide to Flap Selection 83

choices. Many flaps can contain muscle, but we also now know that the muscle is a carrier
for blood supply and can be left in situ, carrying the skin of the flap via its perforating ves-
sels. One must decide whether the muscle is needed, and if so, how much, and whether a
functional transfer of the muscle is required.
All flaps, whether muscle containing or perforator of muscle containing, have some
associated donor morbidity, and this again is where the patient’s desires and the art of ap-
plication come into play. Bone requirements differ with different flaps, and there are always
choices. Complex defects that require bone and other tissues may sometimes require more
than one flap to solve the problem at hand because of the geometry or sheer size of the de-
fect; this can also be true of defects not requiring bone. Although the natural tendency of
surgeons is to solve all problems with one reconstructive flap and the desire of all patients is
to have one surgery, the surgeon must be careful not to extend the applicability of a flap or
put at risk the reconstruction by trying to do too much with too little. Sometimes a second
flap, a delayed inset, or a surgical revision is not a sign of failure, but a good plan.

SURGEON FACTORS
Ultimately, it comes down to you—your skill, your creativity, and your judgment. The
good news is that each of these things can improve over time with experience. You will be
a better surgeon in the future than you are now. It is true of us all. This book is meant to
guide you on that path, to open the door of possibilities and options to you, and to allow
you to successfully select flaps to treat patients.

A Guide to Flap Selection by Area

This chapter is organized by anatomic area and is a good starting place in the initial planning
process. The anatomic illustrations and accompanying boxes will show you which flaps
are available locally, which are the workhorse flaps for that area, and which free flaps are
commonly used. If microsurgery is being considered, the most commonly used recipient
vessels are listed. Finally, each area of the body has its own special considerations or traps,
and a list of suggestions for that area of the body is included. Each flap and each recipient
vessel choice is labeled with the page number where the detailed description and dissection
guide can be found. Good luck, and much success with your case!

03_GuideFlapDis_r8_bs_0081-0152.indd 83 2/9/2012 1:25:10 PM

 Free Flaps Scalp Reconstruction Options

Scalp flap

Omental

Latissimus dorsi

ALT
Trapezius flap

Rectus abdominis

Free muscle/skin

03_GuideFlapDis_r8_bs_0081-0152.indd 84 2/9/2012 1:25:17 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   2nd
Guide Line
to Flap Sect
Selection  Title
•  Scalp
3rd 85

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Scalp (p. 192) Implies artery and vein unless otherwise noted.
1.  Superficial temporal
2. Temporoparietal fascia (TPFF)
(p. 262) 2.  Facial
3.  Trapezius (p. 694) 3.  Occipital
4.  Omental (p. 1324) 4.  External jugular vein
5.  Latissimus dorsi (p. 726) 5.  Internal jugular vein
6.  Anterolateral thigh (ALT) (p. 1350)
7.  Rectus abdominis (p. 1136)
8.  Free muscle/skin

Things to Consider When Reconstructing the Scalp

1.  Alopecia may occur with skin grafts and scars.
2.  Tissue expansion may be useful.
3.  Superficial temporal vessels are larger with proximal dissection beyond the deep temporal branch.
4.  Recipient vessels may require an A-V loop to the neck.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 85 2/9/2012 1:25:21 PM

 Free Flap Nose Reconstruction Options

Radial forearm

Nasolabial flap

Paramedian forehead flap

Scalp (Washio) flap

03_GuideFlapDis_r8_bs_0081-0152.indd 86 2/9/2012 1:25:24 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   2nd
Guide Line
to Flap Sect
Selection  Title
•  Nose
3rd 87

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Paramedian forehead (p. 170) Implies artery and vein unless otherwise noted.
1. Facial/angular branch
2.  Nasolabial (p. 232)
2. Superficial temporal
3.  Radial forearm (p. 842)
3. External jugular vein
4. Scalp (Washio) (p. 192)
4. Internal jugular vein

Things to Consider When Reconstructing the Nose

1. Facial tissues offer the best color match.
2. A free flap may be used for lining and structure, saving the forehead flap for the best resurfacing option.
3. Secondary thinning of flaps is often required to alleviate airway obstruction.
4. Superficial temporal vessels are larger with proximal dissection beyond the deep temporal branch.
5. Recipient vessels may require an A-V loop.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 87 2/9/2012 1:25:24 PM

 Free Flaps Ear Reconstruction Options

Temporoparietal fascia flap (TPFF)

TPFF

Free fascia

03_GuideFlapDis_r8_bs_0081-0152.indd 88 2/9/2012 1:25:25 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 2ndtoLine
3   Guide Sect  Title
Flap Selection •  Ear
3rd 89

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Temporoparietal fascia (TPFF) Implies artery and vein unless otherwise noted.
(p. 262) 1. Superficial temporal
2.  Temporoparietal fascia (TPFF) 2. Facial
(p. 270) 3. Lingual
3.  Free fascia 4. Superior thyroid
5. External carotid
6. Occipital
7. External jugular vein
8. Internal jugular vein

Things to Consider When Reconstructing the Ear

1. Thin flaps are best.
2. The TPFF with skin grafting is useful.
3. Deep temporal fascia should be avoided for best coverage of the construct and contour of the ear.
4. If TPFF is unavailable because of trauma or cancer, a TPFF may be considered as a free flap from
the contralateral side.
5. Tissue expansion can be advantageous.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 89 2/9/2012 1:25:25 PM

 Free Flaps Tongue Reconstruction Options
Tongue flap

Radial forearm

VRAM

ALT

Supraclavicular
flap

Deltopectoral
flap

Ulnar forearm
Pectoralis major
flap

Free muscle/skin

03_GuideFlapDis_r8_bs_0081-0152.indd 90 2/9/2012 1:25:29 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   Title
Guide to2nd Line Sect
Flap Selection  •  Title
Tongue
3rd 91

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Tongue (p. 368) Implies artery and vein unless otherwise noted.
1. Superficial temporal
2.  Radial forearm (p. 842)
2. Facial
3.  Vertical rectus abdominis
myocutaneous (VRAM) (p. 1136) 3. Lingual
4.  Anterolateral thigh (ALT) (p. 1350) 4. Superior thyroid
5. Pectoralis major (p. 518) 5. External carotid
6. Deltopectoral (p. 432) 6. Transverse cervical
7. Supraclavicular (p. 546) 7. External jugular vein
8.  Ulnar forearm (p. 894) 8. Internal jugular vein
9.  Free muscle/skin

Things to Consider When Reconstructing the Tongue

1. Maintaining mobility is important for swallowing and speech.
2. Innervated tissue should be used when possible (to the lingual nerve).
3. Bulk is important after a total glossectomy (ALT, VRAM).

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 91 2/9/2012 1:25:29 PM

 Free Flaps Lip Reconstruction Options

Facial artery
myomucosal Orbicularis oris flap
(FAMM) flap

Radial forearm

Tongue flap

Submental

Supraclavicular
Temporoparietal fascia flap (TPFF)

Deltopectoral

03_GuideFlapDis_r8_bs_0081-0152.indd 92 2/9/2012 1:25:33 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 2ndtoLine
3   Guide Sect  Title
Flap Selection •  3rd
Lip 93

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Orbicularis oris (p. 334) Implies artery and vein unless otherwise noted.
1. Superficial temporal
2.  Facial artery myomucosal
(FAMM) (p. 410) 2. Facial
3.  Tongue (p. 368) 3. Lingual
4.  Radial forearm (p. 842) 4. Superior thyroid
5. Temporoparietal fascia (TPFF) 5. External carotid
(mustache) (p. 262) 6. Transverse cervical
6.  Submental (p. 388) 7. External jugular vein
7.  Supraclavicular (p. 546) 8. Internal jugular vein
8.  Deltopectoral (p. 432)

Things to Consider When Reconstructing the Lip

1. Microstomia must be avoided.
2. Color match is best with local tissues.
3. A mustache can camouflage the lip deformity after reconstruction in men (TPFF or free hair grafts).
4. Tendon or fascial support of the lip is recommended with free flaps (palmaris, plantaris, fascia lata).
5. One should plan for adequate vertical height to anticipate flap shrinkage over time.
6. V-Y advancement of intraoral mucosa can provide vermilion reconstruction, thereby avoiding the need
for additional flaps.
7. The surgeon must beware of constricting postoperative dressings or ties that could obstruct vascular
pedicles, resulting in flap loss.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 93 2/9/2012 1:25:33 PM

 Free Flap Cheek Reconstruction Options

Free muscle/skin

Submental flap
Nasolabial flap

Trapezius flap

Masseter flap

Temporalis flap

Supraclavicular
flap

Deltopectoral
flap

03_GuideFlapDis_r8_bs_0081-0152.indd 94 2/9/2012 1:25:39 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3  Title
Guide2nd
to FlapLine Sect
Selection  • Title
Cheek
3rd 95

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Nasolabial (p. 232) Implies artery and vein unless otherwise noted.
1. Superficial temporal
2.  Submental (p. 388)
2. Facial
3. Deltopectoral (p. 432)
3. Lingual
4. Supraclavicular (p. 546)
4. Superior thyroid
5. Temporalis (p. 288)
5. External carotid
6. Masseter (p. 316)
6. Transverse cervical
7.  Free muscle/skin
7. External jugular vein
8. Trapezius (p. 694)
8. Internal jugular vein

Things to Consider When Reconstructing the Cheek

1. When possible, the surgeon should respect the aesthetic subunits of the cheek.
2. Local tissues will give the best color and texture match for reconstruction, and one should take advan-
tage of the natural tissue redundancy in the cheek and neck (for example, the Mustarde advancement
rotation flap; see Chapter 1).
3. Care should be taken when importing hair-bearing skin into non-hair-bearing areas.
4. It is imperative when reconstructing the cheek that there be no tension on the neighboring lower
eyelid, creating ectropion.
5. One should have a low threshold for providing lower lid support.
6. The surgeon must beware of constricting postoperative dressings or ties that could obstruct vascular
pedicles, resulting in flap loss.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 95 2/9/2012 1:25:39 PM

 Free Flaps Intraoral
Reconstruction Options

Tongue flap

Radial forearm
Nasolabial
flap

Facial artery
myomucosal
(FAMM) flap

Free muscle/skin

Submental flap

Supraclavicular
flap

Deltopectoral
flap

Pectoralis major
flap

Masseter flap

03_GuideFlapDis_r8_bs_0081-0152.indd 96 2/9/2012 1:25:44 PM

 Chapter Title  •  3 : Section TitleSect Titleto Flap
Chapter 3   Guide 2ndSelection
Line Sect
•  Title
Intraoral
3rd 97

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
  1.  Pectoralis major (p. 518) Implies artery and vein unless otherwise noted.
1. Superficial temporal
  2.  Radial forearm (p. 842)
2. Facial
  3. Tongue (p. 368)
3. Lingual
  4. Supraclavicular (p. 546)
4. Superior thyroid
  5. Deltopectoral (p. 432)
5. External carotid
  6. Submental (p. 388)
6. Transverse cervical
  7. Facial artery myomucosal (FAMM)
(p. 410) 7. External jugular vein
  8. Nasolabial (p. 232) 8. Internal jugular vein
  9. Masseter (p. 316)
10.  Free muscle/skin

Things to Consider When Reconstructing the

Intraoral Region
1. A watertight closure should be confirmed to prevent fistula.
2. Tongue mobility should be maintained for swallowing and speech.
3. Hair-bearing skin can be problematic.
4. A feeding tube is placed at the time of flap inset.
5. Complete intraoral reconstruction is not always necessary, because use of an obturator improves
cancer follow-up.
6. A clear liquid diet is given until all suture lines are healed.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 97 2/9/2012 1:25:44 PM

 Free Flaps Skull Base
Reconstruction Options

Temporalis flap

Free muscle/skin

Omental

Temporoparietal fascia
flap (TPFF)

03_GuideFlapDis_r8_bs_0081-0152.indd 98 2/9/2012 1:25:46 PM

 Chapter Title  •  3 : SectionChapter
TitleSect Title
3   Guide 2nd
to Flap Line
Selection  • 
SectSkull
TitleBase
3rd 99

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Temporalis (p. 288) Implies artery and vein unless otherwise noted.
1. Superficial temporal
2.  Temporoparietal fascia (TPFF)
(p. 262) 2. Facial
3.  Free muscle/skin 3. Lingual
4.  Omental (p. 1324) 4. Superior thyroid
5. External carotid
6. Transverse cervical
7. External jugular vein
8. Internal jugular vein

Things to Consider When Reconstructing the Skull Base

1. Nonskin, well-vascularized, nonirradiated flaps are best.
2. A lumbar drain helps dural leaks to heal with the flap in place.
3. Free tissue transfer of muscle (rectus abdominis, latissimus dorsi, and ALT) is the most common
approach for skull-based reconstruction, because this provides ample tissue fill without the constraints
of local pedicle options.
4. Sealing the dural defect should be the top priority in these situations. This is best accomplished with
muscle flaps.
5. The surgeon must beware of constricting postoperative dressings or ties that could obstruct vascular
pedicles, resulting in flap loss.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 99 2/9/2012 1:25:46 PM

 Free Flaps Neck Reconstruction Options

Free muscle/skin

Submental flap

ALT Supraclavicular
flap

Deltopectoral
flap

Pectoralis major flap

Radial forearm

Trapezius
flap

Latissimus
dorsi flap

Jejunal

03_GuideFlapDis_r8_bs_0081-0152.indd 100 2/9/2012 1:25:51 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   2nd
Guide Line
to Flap Sect
Selection  Title
•  Neck
3rd 101

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
  1.  Pectoralis major (p. 518) Implies artery and vein unless otherwise noted.
  1. Superficial temporal
  2. Supraclavicular (p. 546)
  2. Facial
  3. Deltopectoral (p. 432)
  3. Lingual
  4. Submental (p. 388)
  4. Superior thyroid
  5. Trapezius (p. 694)
  5. External carotid
  6. Latissimus (p. 726)
  6. Transverse cervical
  7.  Anterolateral thigh (ALT) (p. 1350)
  7. Thoracoacromial
  8.  Radial forearm (p. 842)
  8. Cephalic vein turnover
  9. Free muscle/skin
  9. External jugular vein
10.  Jejunal (p. 1298)
10. Internal jugular vein

Things to Consider When Reconstructing the Neck

1. The intraoral space should be separated and sealed from the neck.
2. The neck is a highly mobile area, so one must take into account the full neck motions.
3. Use of a shoulder roll facilitates neck exposure.
4. Microsurgery should be performed with the neck turned toward the opposite side to prevent
postoperative tension on the microsurgery site.
5. Postoperative compression of the neck should be prevented by avoiding any circumferential
tracheostomy ties or oxygen masks.
6. The head of the bed should be elevated at all times for best venous drainage.
7. In esophageal reconstruction, skin flaps (ALT and radial forearm) provide better speech outcomes
than can be achieved with intestinal (jejunal) flaps.
8. When using a buried flap for esophageal reconstruction, an external monitoring segment
(such as a perforator skin island or an exteriorized segment of jejunum) should be considered.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 101 2/9/2012 1:25:51 PM

 Free Flap Shoulder
Reconstruction Options

Free muscle/skin Pectoralis

major flap

Latisimus dorsi flap

Trapezius Serratus
flap anterior flap

Scapular flap

Parascapular flap

Intercostal artery perforator (ICAP) flap

Lateral arm flap

Intercostal
artery
perforator
(ICAP) flap

Intercostal artery
perforator (ICAP) flap

03_GuideFlapDis_r8_bs_0081-0152.indd 102 2/9/2012 1:25:57 PM

 Chapter Title  •  3 : Section Chapter
TitleSect Title
3   Guide 2ndSelection
to Flap Line  Sect
•  Shoulder
Title 3rd 103

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Latissimus dorsi (p. 726) Implies artery and vein unless otherwise noted.
1. Thoracodorsal
2.  Pectoralis major (p. 518)
2. Thoracoacromial
3.  Scapular/parascapular (p. 646)
3. Lateral thoracic
4. Trapezius (p. 694)
4. Axillary
5. Serratus anterior (p. 492)
5. Circumflex scapular
6. Intercostal artery perforator (ICAP)
(p. 474) 6. Transverse cervical
7. Lateral arm (p. 778) 7. Cephalic vein
8.  Free muscle/skin

Things to Consider When Reconstructing the Shoulder

1. Local flaps and skin grafts are most commonly used.
2. The shoulder is a highly mobile area, so shoulder motion must be factored into the flap design.
3. A latissimus dorsi flap can reach to the elbow, even when tunneled.
4. One must beware of previous lymph node dissections, because some vessels may have been divided;
dilated veins should be explored before use.
5. Use of a sling will prevent unintended postoperative motion.
6. Radiation may cause pedicle damage to axilla-based flaps.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 103 2/9/2012 1:25:57 PM

 Free Flap Axilla Reconstruction Options
Scapular flap

Free skin

Parascapular flap

Intercostal artery perforator (ICAP) flap

Latissimus dorsi flap

Intercostal
artery
perforator
(ICAP) flap
Serratus anterior flap

Intercostal artery
perforator (ICAP) flap

Lateral arm flap

03_GuideFlapDis_r8_bs_0081-0152.indd 104 2/9/2012 1:26:02 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   Guide2nd Line
to Flap Sect
Selection  • Title
Axilla
3rd 105

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Scapular/parascapular (p. 646) Implies artery and vein unless otherwise noted.
1. Thoracodorsal
2.  Latissimus dorsi (p. 726)
2. Axillary
3. Intercostal artery perforator (ICAP)
(p. 474) 3. Circumflex scapular
4.  Free skin 4. Lateral thoracic
5. Lateral arm (p. 778) 5. Brachial
6. Serratus anterior (p. 492) 6. Transverse cervical
7. Cephalic vein

Things to Consider When Reconstructing the Axilla

1. One should not underestimate the amount of surface area the axilla requires. A template should
be created with the patient’s arm completely extended.
2. The parascapular design is favored over the scapular design, because less rotation is necessary to reach
the recipient site.
3. A modified sling that keeps the arm abducted will prevent postoperative motion and compression
of the flap.
4. Thinner flaps allow the best unencumbered motion.
5. The surgeon should beware of previous lymph node dissections, because some vessels may have been
divided; dilated veins should be explored before use.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 105 2/9/2012 1:26:02 PM

 Free Flap Upper Arm
Reconstruction Options

Free muscle/skin

Latissimus dorsi flap

Scapular flap

Lateral arm flap

Parascapular flap

Radial forearm flap

03_GuideFlapDis_r8_bs_0081-0152.indd 106 2/9/2012 1:26:06 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   GuideTitle
to Flap 2nd Line
Selection  • Sect
Upper
TitleArm
3rd 107

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Latissimus dorsi (p. 726) Implies artery and vein unless otherwise noted.
1. Brachial
2.  Scapular/parascapular (p. 646)
2. Posterior circumflex humeral
3. Lateral arm (p. 778)
3. Superior ulnar collateral
4. Radial forearm (p. 842)
4. Radial collateral
5.  Free muscle/skin
5. Cephalic vein
6. Basilic vein

Things to Consider When Reconstructing the Upper Arm

1. A sling should be used to prevent unintended postoperative motion.
2. End-to-side anastomoses with the brachial artery will maintain distal perfusion.
3. The surgeon should beware of previous lymph node dissections, because some vessels may have been
divided; dilated veins should be explored before use.
4. Cephalic and basilic veins are easiest to use for venous outflow.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 107 2/9/2012 1:26:06 PM

 Free Flap Elbow Reconstruction Options

Lateral arm (reverse) flap

Free skin

Radial forearm flap

Flexor carpi
ulnaris (FCU) flap Ulnar forearm flap

Latissimus dorsi flap

Groin flap

03_GuideFlapDis_r8_bs_0081-0152.indd 108 2/9/2012 1:26:10 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3  Title
Guide2nd
to FlapLine Sect
Selection  • Title
Elbow
3rd 109

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Lateral arm (reverse) (p. 778) Implies artery and vein unless otherwise noted.
1. Brachial
2.  Radial forearm (p. 842)
2. Radial
3. Latissimus dorsi (p. 726)
3. Ulnar
4. Ulnar forearm (p. 894)
4. Cephalic vein
5. Flexor carpi ulnaris (FCU) (p. 880)
5. Basilic vein
6. Groin (p. 1242)
7.  Free skin

Things to Consider When Reconstructing the Elbow

1. The elbow is a highly mobile area, so one must be sure to account for elbow flexion and extension.
2. One should not underestimate the amount of surface area the elbow requires for full range of motion.
A template should be created with the patient’s elbow completely flexed.
3. Use of a sling will prevent unintended postoperative motion.
4. End-to-side anastomoses with the brachial artery will maintain distal perfusion.
5. The ipsilateral groin should not be used for skin or vein grafts, because the area should be preserved for
potential groin flap salvage in case of a complication or flap failure.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 109 2/9/2012 1:26:10 PM

 Free Flap Antecubital Fossa
Reconstruction Options

Lateral arm (reverse) flap

Free skin/fascia

Radial forearm flap

Flexor carpi Ulnar forearm flap

ulnaris (FCU) flap

03_GuideFlapDis_r8_bs_0081-0152.indd 110 2/9/2012 1:26:13 PM

 Chapter Title  •  3 :Chapter
Section TitleSect
3   Guide Title 2nd
to Flap Selection  •  Line
Antecubital
Sect Title
Fossa
3rd 111

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Lateral arm (reverse) (p. 778) Implies artery and vein unless otherwise noted.
1. Brachial
2.  Radial forearm (p. 842)
2. Radial
3. Ulnar forearm (p. 894)
3. Ulnar
4. Flexor carpi ulnaris (FCU) (p. 880)
4. Cephalic vein
5.  Free skin/fascia
5. Basilic vein

Things to Consider When Reconstructing the

Antecubital Fossa
1. One should not underestimate the amount of surface area the antecubital area requires. A template
should be created with the patient’s arm completely extended.
2. A modified sling that keeps the elbow between 90 and 180 degrees will prevent postoperative motion
and compression of the flap.
3. Thinner flaps allow the best unencumbered motion.
4. A gliding surface should be considered in flap choice when tendons are exposed.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 111 2/9/2012 1:26:13 PM

 Free Flap Forearm
Reconstruction Options

Radial forearm flap

Brachioradialis flap

Free muscle/skin/
fascia/bone

Ulnar forearm flap

Lateral arm (reverse) flap

Posterior interosseous flap

Groin flap

03_GuideFlapDis_r8_bs_0081-0152.indd 112 2/9/2012 1:26:18 PM

 Chapter Title  •  3 : Section TitleSect Titleto 2nd
Chapter 3   Guide Line  Sect
Flap Selection •  Title
Forearm
3rd 113

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Radial forearm (p. 842) Implies artery and vein unless otherwise noted.
1. Radial
2. Ulnar forearm (p. 894)
2. Ulnar
3. Lateral arm (reverse) (p. 778)
3. Cephalic vein
4. Posterior interosseous (p. 820)
4. Basilic vein
5. Groin (p. 1242)
6. Brachioradialis (p. 806)
7.  Free muscle/skin/fascia/bone

Things to Consider When Reconstructing the Forearm

1. Postoperative elevation limits edema.
2. A sling will prevent unintended postoperative motion.
3. A preoperative Allen’s test should be performed before the ulnar or radial arteries are sacrificed.
4. End-to-side anastomoses should be considered with either artery when possible to maintain
distal perfusion.
5. The radial artery is easier to dissect and reduces the known complications of ulnar neurapraxias
that can occur with ulnar artery dissection.
6. Cephalic and basilic veins should be used for primary or secondary venous anastomosis.
7. A gliding surface should be considered in flap choice when tendons are exposed.
8. The ipsilateral groin should not be used for skin or vein grafts, because the area should be preserved
for potential groin flap salvage in case of a complication or flap failure.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 113 2/9/2012 1:26:18 PM

 Free Flap Wrist Reconstruction Options

Radial forearm (reverse) flap

Brachioradialis flap

Free skin/fascia/
bone
Ulnar forearm (reverse) flap

Posterior interosseous flap

Groin flap

03_GuideFlapDis_r8_bs_0081-0152.indd 114 2/9/2012 1:26:22 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   Guide2nd Line
to Flap Sect
Selection  • 
Title
Wrist
3rd 115

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Radial forearm (reverse) (p. 842) Implies artery and vein unless otherwise noted.
1. Radial
2.  Posterior interosseous (p. 820)
2. Ulnar
3. Groin (p. 1242)
3. Cephalic vein
4.  Ulnar forearm (reverse) (p. 894)
4. Basilic vein
5. Brachioradialis (p. 806)
6.  Free skin/fascia/bone

Things to Consider When Reconstructing the Wrist

1. Postoperative elevation limits edema.
2. Use of a sling will prevent unintended postoperative motion.
3. A preoperative Allen’s test should be performed before the ulnar or radial arteries are sacrificed.
4. A gliding surface should be considered in flap choice when tendons are exposed.
5. The ipsilateral groin should not be used for skin or vein grafts, because the area should be preserved
for potential groin flap salvage in case of a complication or flap failure.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 115 2/9/2012 1:26:22 PM

 Free Flaps Hand Reconstruction Options
Posterior interosseous flap

Medial plantar

Radial forearm flap (reverse)

Free muscle/skin/
fascia
Ulnar forearm flap (reverse)

Abductor digiti
minimi (ADM)
flap

Groin flap

03_GuideFlapDis_r8_bs_0081-0152.indd 116 2/9/2012 1:26:26 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   Guide2nd Line
to Flap Sect
Selection  • 
Title
Hand
3rd 117

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1. Posterior interosseous (p. 820) Implies artery and vein unless otherwise noted.
1. Radial
2. Radial forearm (reverse) (p. 842)
2. Ulnar
3. Ulnar forearm (reverse) (p. 894)
3. Cephalic vein
4.  Groin (p. 1242)
4. Basilic vein
5. Abductor digiti minimi (ADM)
(p. 914)
6.  Medial plantar (p. 1812)
7.  Free muscle/skin/fascia

Things to Consider When Reconstructing the Hand

1. Function takes priority over cosmesis.
2. One should prefer sensate flaps in the hand.
3. A preoperative Allen’s test should be performed before the ulnar or radial arteries are sacrificed.
4. Postoperative physical therapy is as important as flap choice.
5. Postoperative elevation limits edema.
6. Use of a sling will prevent unintended postoperative motion.
7. The ipsilateral groin should not be used for skin or vein grafts, because the area should be preserved
for potential groin flap salvage in case of a complication or flap failure.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 117 2/9/2012 1:26:26 PM

 Free Flap Digit Reconstruction Options
Kleinert-Atasoy
V-Y flap

Homodigital
neurovascular
(Littler) island flap

Second toe

Cross-finger
flap
Dorsal metacarpal
flap

Posterior interosseous flap

03_GuideFlapDis_r8_bs_0081-0152.indd 118 2/9/2012 1:26:30 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   2nd
Guide Line
to Flap Sect
Selection  Title
•  Digit
3rd 119

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1. K leinert-Atasoy V-Y (p. 1074) Implies artery and vein unless otherwise noted.
1. Radial
2. Dorsal metacarpal (p. 1010)
2. Ulnar
3. Cross-finger (p. 1046)
3.  Cephalic vein
4. Homodigital neurovascular (Littler)
island (p. 958) 4.  Basilic vein
5. Posterior interosseous (p. 820)
6.  Second toe (p. 976)

Things to Consider When Reconstructing the Digit

1. Postoperative elevation limits edema.
2. Use of a sling will prevent unintended postoperative motion.
3. Postoperative physical therapy is as important as flap choice.
4. Isolated transverse pulp defects often achieve superior aesthetic and functional outcomes when
allowed to heal secondarily.
5. Nail bed injuries should be meticulously repaired to prevent nail deformities.
6. The advantage of augmenting tip defects is to prevent parrot-beaking of the nail.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 119 2/9/2012 1:26:30 PM

 Free Flaps Thumb
Reconstruction Options

Moberg advancement
Great toe flap

Second toe

Posterior interosseous flap

Dorsal metacarpal
flap

Groin flap

03_GuideFlapDis_r8_bs_0081-0152.indd 120 2/9/2012 1:26:34 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   Title
Guide to2nd
Flap Line
SelectionSect
  •  Title
Thumb3rd 121

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1. Moberg advancement (p. 1090) Implies artery and vein unless otherwise noted.
1. Radial
2. Posterior interosseous (p. 820)
2. Princeps pollicis
3. Dorsal metacarpal (p. 1010)
3.  Cephalic vein
4. Groin (p. 1242)
5.  Great toe (p. 926)
6.  Second toe (p. 976)

Things to Consider When Reconstructing the Thumb

1. Postoperative elevation limits edema.
2. Use of a sling will prevent unintended postoperative motion.
3. Postoperative physical therapy is as important as flap choice.
4. A functional thumb is essential to a functional hand.
5. The ipsilateral groin should not be used for skin or vein grafts, because the area should be preserved
for potential groin flap salvage in case of a complication or flap failure.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 121 2/9/2012 1:26:34 PM

 Free Flap Anterior Chest
Reconstruction Options
Deltopectoral
flap
Pectoralis major flap

Free muscle/skin/
fascia

Serratus anterior flap

Rectus abdominis
flap
External oblique flap

Latissimus dorsi flap

Omental flap

Intercostal artery
perforator (ICAP) flap

03_GuideFlapDis_r8_bs_0081-0152.indd 122 2/9/2012 1:26:39 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   Title
Guide to Flap 2nd  Line
Selection •  Anterior
Sect Title
Chest
3rd 123

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Pectoralis major (p. 518) Implies artery and vein unless otherwise noted.
1. Internal mammary
2.  Rectus abdominis (p. 1136)
2. Transverse cervical
3.  Latissimus dorsi (p. 726)
3. Thoracodorsal
4. External oblique (p. 1192)
4. Thoracoacromial
5. Intercostal artery perforator (ICAP)
(p. 474) 5. Axillary
6. Serratus anterior (p. 492) 6. External jugular turndown
7. Deltopectoral (p. 432) 7. Cephalic turnover
8. Omental (p. 1324) 8. Lateral thoracic vein
9.  Free muscle/skin/fascia

Things to Consider When Reconstructing the

Anterior Chest
1. Reconstruction can affect pulmonary dynamics postoperatively, so aggressive pulmonary toilet is indicated.
2. If more than three rib segments are missing, a flail segment may result that warrants structural recon-
struction.
3. For intrathoracic reconstructions, more chest wall should be resected to allow direct passage of the flap
from its vascular pedicle.
4. Careful flap planning allows multiple flaps to be harvested in the same patient (supraclavicular,
deltopectoral, and pectoralis major).
5. The combination of vertical rectus abdominis, external oblique, and/or latissimus flaps can close almost
any anterior chest wound.
6. The mammary recipient site has fewer problems than the axillary recipient site relating to motion
and compression postoperatively.
7. One should beware of previous lymph node dissections, because some vessels may have been divided;
dilated veins should be explored before use.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 123 2/9/2012 1:26:39 PM

 Free Flaps Breast
Reconstruction Options

Rectus abdominis
(TRAM) flap
Rectus abdominis
IV II I III

Gracilis/TUG

Latissimus
dorsi flap

Gluteus/GAP

Pectoralis
major flap

Lumbar perforator

Intercostal artery
perforator (ICAP) flap
DCIA (Rubens) Tram/DIEP/SIEA

03_GuideFlapDis_r8_bs_0081-0152.indd 124 2/9/2012 1:26:44 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   Guide2nd Line
to Flap Sect
Selection  • Title
Breast
3rd 125

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Rectus abdominis (TRAM) Implies artery and vein unless otherwise noted.
(p. 1136) 1. Internal mammary
2.  Latissimus dorsi (p. 726) 2. Thoracodorsal
3. Pectoralis major (p. 518) 3. Serratus branch, thoracodorsal
4.  TRAM/DIEP/SIEA (pp. 1136, 1218) 4. External jugular turndown
5.  Gracilis/TUG (p. 1418) 5. Cephalic turnover
6.  Gluteus/GAP (p. 584) 6. Transverse cervical
7.  Lumbar perforator (p. 676) 7. Thoracoacromial
8.  Deep circumflex iliac artery (DCIA) 8. Axillary
(Rubens) (p. 1108) 9. Lateral thoracic vein
9. Intercostal artery perforator (ICAP)
(p. 474)

Things to Consider When Reconstructing the Breast

1. Adequate vascularity of the breast skin envelope must be ensured before removal of flap skin,
especially in immediate reconstruction cases.
2. The mammary system can be successfully used both anterograde and retrograde, accommodating
two arterial and two venous anastomoses.
3. Securing the flap to the chest wall is important to prevent unintended postoperative tension
on the flap when the patient is moving or standing erect.
4. One must beware of previous lymph node dissections, because some vessels may have been divided;
dilated veins should be explored before use.
5. Use of the axillary vessels should be reconsidered if a lymph node dissection is contemplated for
the future.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 125 2/9/2012 1:26:44 PM

 Free Flap Intrathoracic Region
Reconstruction Options

Pectoralis major flap

Free muscle/skin

Serratus anterior flap

Rectus abdominis
flap

Latissimus dorsi flap

Omental flap

03_GuideFlapDis_r8_bs_0081-0152.indd 126 2/9/2012 1:26:47 PM

 Chapter Title  •  Chapter
3 : Section
3   GuideTitleSect Title
to Flap Selection  • 2nd
Intrathoracic
Line Sect Title
Region
3rd 127

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Latissimus dorsi (p. 726) Implies artery and vein unless otherwise noted.
1. Internal mammary
2.  Serratus anterior (p. 492)
2. Thoracodorsal
3.  Pectoralis major (p. 518)
3. Thoracoacromial
4.  Omental (p. 1324)
4. Transverse cervical
5. Rectus abdominis (p. 1136)
5. Cephalic vein turnover
6.  Free muscle/skin
6. Lateral thoracic vein

Things to Consider When Reconstructing the

Intrathoracic Region
1. The rib segment nearest to the vascular pedicle should be removed to maximize the flap length
and volume available for reconstruction.
2. There is not enough tissue to completely obliterate a pneumonectomy defect without thoracic
cage modification (thoracoplasty).
3. Flap position can be maintained with sutures and tissue glues.
4. One must beware of previous lymph node dissections, because some vessels may have been divided;
dilated veins should be explored before use.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 127 2/9/2012 1:26:47 PM

 Free Flap Abdomen
Reconstruction Options

Free muscle/skin/
fascia

Thoracoepigastric flap

External oblique flap Superficial

inferior epigastric
artery (SIEA) flap
Rectus abdominis
flap

Groin (SCIA) flap

Tensor fascia
lata (TFL) flap

Anterolateral
thigh (ALT) flap

Rectus femoris flap

Omental flap

03_GuideFlapDis_r8_bs_0081-0152.indd 128 2/9/2012 1:26:52 PM

 Chapter Title  •  3 : SectionChapter
TitleSect Title
3   Guide to Flap2nd Line
Selection  •  Abdomen
Sect Title 3rd 129

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
  1.  Tensor fascia lata (TFL) (p. 1506) Implies artery and vein unless otherwise noted.
1. Deep inferior epigastric
  2.  Rectus femoris (p. 1552)
2. Superficial epigastric
  3.  Anterolateral thigh (ALT)
(p. 1350) 3. Superior epigastric
  4. Rectus abdominis (p. 1136) 4. Superficial circumflex iliac
  5. Groin (SCIA) (p. 1242) 5. Deep circumflex iliac
  6. Superficial inferior epigastric artery 6. Right and left epiploic
(SIEA) (p. 1218) 7. Greater saphenous vein turnover
  7. External oblique (p. 1192)
  8. Thoracoepigastric (p. 1268)
  9. Omental (p. 1324)
10.  Free muscle/skin/fascia

Things to Consider When Reconstructing the Abdomen

1. Abdominal integrity at closure is critical to a successful postoperative course and prevention
of future hernias and bulges.
2. Mesh should be used as needed to ensure a dependable fascial closure.
3. Postoperative binder use can limit edema and support flaps as they heal.
4. Six to 8 weeks should be allowed before stressing an abdominal fascial closure.
5. Because of the lack of bony confines, one can take advantage of the horizontal excess present in all
abdomens and close surprisingly large donor sites.
6. Bowel management and avoidance of postoperative bloating and constipation will limit unnecessary
tension on abdominal wall reconstructions.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 129 2/9/2012 1:26:52 PM

 Free Flap Groin Reconstruction Options

Free skin

Tensor fascia
lata (TFL) flap

Anterolateral Gracilis flap

thigh (ALT) flap

Rectus femoris flap

Vastus lateralis flap Sartorius flap

Thoracoepigastric flap

Rectus abdominis
flap

03_GuideFlapDis_r8_bs_0081-0152.indd 130 2/9/2012 1:26:55 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   Guide2nd Line
to Flap Sect
Selection  • 
Title
Groin
3rd 131

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Sartorius (p. 1466) Implies artery and vein unless otherwise noted.
1. Deep inferior epigastric
2.  Tensor fascia lata (TFL) (p. 1506)
2. Superficial epigastric
3.  Rectus femoris (p. 1552)
3. Superficial circumflex iliac
4. Anterolateral thigh (ALT) (p. 1350)
4. Deep circumflex iliac
5. Vastus lateralis (p. 1534)
5. Femoral
6. Rectus abdominis (p. 1136)
6. External iliac
7. Thoracoepigastric (p. 1268)
7. Greater saphenous vein turnover
8. Gracilis (p. 1418)
9.  Free skin

Things to Consider When Reconstructing the Groin

1. Flaps should obliterate dead space.
2. Because of the presence of lymphatics that are often violated, the groin should be drained well;
the drains are kept in place until the flap−recipient site interface has sealed.
3. Further lymphatic dissection and injury should be avoided to prevent postoperative lymphedema.
4. If a vascular repair has been performed or vessels have been divided, inflow to the planned flap
may be insufficient.
5. Fascial replacement may be needed if the inguinal ligament has been taken down to avoid hernia
postoperatively. Plan a flap with fascia (tensor fascia lata, rectus femoris, rectus abdominis) or use
synthetic mesh under a well-vascularized flap.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 131 2/9/2012 1:26:55 PM

 Vaginal Vault
Reconstruction Options

Pudendal-thigh
(Singapore) flap

Gracilis flap

Rectus abdominis
flap

Anterolateral Gluteal
thigh (ALT) flap thigh flap

Jejunal flap

Groin flap

Superficial inferior
epigastric artery
(SIEA) flap

03_GuideFlapDis_r8_bs_0081-0152.indd 132 2/9/2012 1:27:03 PM

 Chapter Title  •  3 : Section
ChapterTitleSect
3   Guide toTitle 2nd  Line
Flap Selection •  Vaginal
Sect Title
Vault
3rd 133

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Rectus abdominis (p. 1136) Implies artery and vein unless otherwise noted.
1. Deep inferior epigastric
2.  Pudendal-thigh (Singapore)
(p. 1280) 2. Superficial epigastric
3. Gracilis (p. 1418) 3. Superficial circumflex iliac
4. Gluteal thigh (p. 620) 4. Deep circumflex iliac
5. Anterolateral thigh (ALT) (p. 1350) 5. Femoral
6. Jejunal (p. 1298) 6. External iliac
7. Groin (p. 1242) 7. Greater saphenous vein turnover
8. Superficial inferior epigastric
artery (SIEA) (p. 1218)

Things to Consider When Reconstructing the

Vaginal Vault
1. Because of the tendency of flap shrinkage in this area, the surgeon must ensure that a flap of adequate
length is used.
2. The anterior vaginal remnant that is often preserved after resection should be incorporated in the
reconstruction.
3. The introitus should be made as patulous as possible to prevent postoperative stenosis.
4. When possible, sensate flaps (pudendal, thigh, gluteal) are preferred for reconstructing the vaginal
vault.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 133 2/9/2012 1:27:03 PM

 Free Flap Upper Back
Reconstruction Options

Free muscle/skin

Scapular flap

Intercostal artery
perforator (ICAP) flap Latissimus
dorsi flap

Lumbar perforator flap

Trapezius flap

Paraspinous flap

03_GuideFlapDis_r8_bs_0081-0152.indd 134 2/9/2012 1:27:08 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   GuideTitle
to Flap 2nd Line
Selection  • Sect
Upper
TitleBack
3rd 135

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Latissimus dorsi (p. 726) Implies artery and vein unless otherwise noted.
1. Thoracodorsal
2.  Scapular (p. 646)
2. Circumflex scapular
3.  Paraspinous (p. 758)
3. Intercostal artery
4. Trapezius (p. 694)
4. A-V loop (axilla, neck)
5. Intercostal artery perforator (ICAP)
(p. 474)
6.  Free muscle/skin

Things to Consider When Reconstructing the Upper Back

1. The midline of the upper back is one of the hardest areas to reconstruct because there are a limited
number of flaps that will reach this area.
2. There are no convenient recipient sites for free flaps.
3. The surgeon’s options may be limited to an intercostal artery recipient, which is small and has poor
venae comitantes.
4. Tissue expansion can be a helpful adjunct procedure.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 135 2/9/2012 1:27:08 PM

 Free Flap Lower Back
Reconstruction Options

Free muscle/skin

Latissimus dorsi
(reverse) flap

Lumbar perforator flap

Gluteus maximus flap

Paraspinous flap

External
oblique flap
Omental flap

03_GuideFlapDis_r8_bs_0081-0152.indd 136 2/9/2012 1:27:12 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   Guide Title 2nd Line
to Flap Selection  • Sect
Lower
TitleBack
3rd 137

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Latissimus dorsi (reverse) (p. 726) Implies artery and vein unless otherwise noted.
1. Superior gluteal
2.  Paraspinous (p. 758)
2. Inferior gluteal
3. Lumbar perforator (p. 676)
3. Intercostal artery
4. Gluteus maximus (p. 584)
4. A-V loop (groin, thoracodorsal)
5. External oblique (p. 1192)
6.  Free muscle/skin
7. Omental (p. 1324)

Things to Consider When Reconstructing the Lower Back

1. The midline of the lower back is one of the hardest areas to reconstruct because there are limited
flaps that will reach this area.
2. There are no convenient recipient sites for free flaps; an A-V loop should be considered.
3. Tissue expansion can be a helpful adjunct procedure.
4. When available, the paraspinous flap offers the simplest means of closure for reconstruction of midline
defects. Its utility decreases toward the sacrum.
5. Omentum may be tunneled through the paracolic gutter when other back flaps are unavailable.
6. The gluteal artery perforator (GAP) flap should be considered as a pedicle option for difficult back
wounds.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 137 2/9/2012 1:27:13 PM

 Free Flap Buttock Reconstruction Options

Gluteus
maximus flap

Free muscle/skin

Gluteal
thigh flap Tensor fascia
lata (TFL) flap

Biceps femoris
(hamstring) flap

Vastus lateralis flap

Gracilis flap

Lumbar perforator flap

03_GuideFlapDis_r8_bs_0081-0152.indd 138 2/9/2012 1:27:17 PM

 Chapter Title  •  3 : Section TitleSect Titleto2nd
Chapter 3   Guide Line Sect
Flap Selection  •  Title
Buttock
3rd 139

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Gluteus maximus (p. 584) Implies artery and vein unless otherwise noted.
1. Superior gluteal
2.  Biceps femoris (hamstring)
(p. 1482) 2. Inferior gluteal
3. Gracilis (p. 1418) 3.  A-V loop (groin)
4. Tensor fascia lata (TFL) (p. 1506)
5. Gluteal thigh (p. 620)
6. Vastus lateralis (p. 1534)
7. Lumbar perforator (p. 676)
8.  Free muscle/skin

Things to Consider When Reconstructing the Buttock

1. For decubiti, dead space fill is as important as skin resurfacing.
2. The patient is instructed to avoid sitting directly on the reconstruction for 4 to 6 weeks.
3. Muscle sacrifice should be avoided in an ambulatory patient.
4. The surgeon should exercise great care to prevent any tension on the closure.
5. Deepithelization of the leading edge of the flap should be considered to provide additional bulk and fill
to the reconstructed defect.
6. The gluteal artery perforator (GAP) flap should be the pedicle flap of choice for ambulatory patients.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 139 2/9/2012 1:27:17 PM

 Free Flap Thigh Reconstruction Options

Free muscle/skin
Gracilis
Sartorius flap flap

Saphenous flap

Tensor fascia
lata (TFL) flap

Anterolateral
thigh (ALT) flap

Rectus femoris flap

Vastus lateralis flap

Gluteus
maximus flap

Rectus abdominis
flap

Biceps femoris
(hamstring) flap

03_GuideFlapDis_r8_bs_0081-0152.indd 140 2/9/2012 1:27:20 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   Guide2nd
to FlapLine Sect
Selection  • Title
Thigh
3rd 141

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
  1. Sartorius (p. 1466) Implies artery and vein unless otherwise noted.
1. Superficial femoral
  2. Gracilis (p. 1418)
2. Lateral circumflex femoral
  3. Tensor fascia lata (TFL) (p. 1506)
3. Medial circumflex femoral
  4. Rectus femoris (p. 1552)
4. Superficial epigastric
  5. Vastus lateralis (p. 1534)
5. Superficial circumflex iliac
  6.  Biceps femoris (hamstring) (p. 1482)
6. Profunda femoris
  7. Anterolateral thigh (ALT) (p. 1350)
7. Greater saphenous vein
  8. Rectus abdominis (p. 1136)
  9. Saphenous (p. 1392)
10. Gluteus maximus (p. 584)
11.  Free muscle/skin

Things to Consider When Reconstructing the Thigh

1. The use of local muscles is often the best option.
2. The need for free flaps is rare.
3. For free flaps, consider end-to-side anastomoses to the major vessels to preserve distal blood flow.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 141 2/9/2012 1:27:20 PM

 Free Flap Knee Reconstruction Options

Gastrocnemius flap
Free muscle/skin

Rectus femoris
flap
Anterolateral
thigh (ALT)
(reverse) flap
Saphenous flap

Vastus lateralis
flap (reverse)

Tibialis
anterior flap

03_GuideFlapDis_r8_bs_0081-0152.indd 142 2/9/2012 1:27:24 PM

 Chapter Title  •  3 : Section TitleSect Title
Chapter 3   2nd
Guide Line
to Flap Sect
Selection  Title
•  Knee
3rd 143

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Gastrocnemius (p. 1682) Implies artery and vein unless otherwise noted.
1. Popliteal
2. Anterolateral thigh (ALT) (reverse)
(p. 1350) 2. Sural
3. Vastus lateralis (reverse) (p. 1534) 3. Genicular
4. Saphenous (p. 1392) 4. Descending lateral circumflex
5. Rectus femoris (p. 1552) 5. Superficial femoral
6. Tibialis anterior (p. 1706) 6. Greater saphenous vein
7.  Free muscle/skin 7. Lesser saphenous vein

Things to Consider When Reconstructing the Knee

1. The knee is a highly mobile area, so one must take range of motion into account in designing a flap.
2. The surgeon should not underestimate the amount of surface area the knee requires; a template
should be created with the knee completely flexed.
3. A splint should be placed postoperatively to minimize motion with no pressure on flap.
4. The knee must remain elevated to reduce the inevitable swelling.
5. The medial gastrocnemius is preferred over the lateral gastrocnemius because it is larger and easier
to transpose.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 143 2/9/2012 1:27:24 PM

 Free Flap Popliteal Fossa
Reconstruction Options

Free muscle/skin Sural artery flap

Gastrocnemius flap

Tibialis anterior flap

Saphenous flap

03_GuideFlapDis_r8_bs_0081-0152.indd 144 2/9/2012 1:27:27 PM

 Chapter Title  •  3 : Section TitleSect
Chapter 3   Title
Guide to Flap 2nd  Line
Selection •  Popliteal
Sect Title
Fossa
3rd 145

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1. Gastrocnemius (p. 1682) Implies artery and vein unless otherwise noted.
1. Popliteal
2. Saphenous (p. 1392)
2. Sural
3. Sural artery (p. 1654)
3. Genicular
4. Tibialis anterior (p. 1706)
4. Descending lateral circumflex
5.  Free muscle/skin
5. Superficial femoral
6. Greater saphenous vein
7. Lesser saphenous vein

Things to Consider When Reconstructing the

Popliteal Fossa
1. The surgeon should not underestimate the amount of surface area the popliteal fossa requires;
a template should be created with the leg completely extended.
2. A modified splint to keep the knee straight will prevent postoperative motion and allow elevation.
The splint should prevent compression of the flap.
3. Thinner flaps allow the best unencumbered motion.
4. End-to-side anastomoses to the popliteal artery should be considered to preserve distal blood flow.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 145 2/9/2012 1:27:27 PM

 Free Flap Leg Reconstruction Options

Sural artery
(reverse) flap

Free muscle/skin/ Soleus flap

fascia/bone
Gastrocnemius
flap

Anterior tibialis
flap

Fibula
flap

Saphenous
flap

Dorsalis pedis
flap

03_GuideFlapDis_r8_bs_0081-0152.indd 146 2/9/2012 1:27:35 PM

 Chapter Title  •  3 : Section TitleSect
ChapterTitle 2ndtoLine
3   Guide Sect Title
Flap Selection •  Leg
3rd 147

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Gastrocnemius (p. 1682) Implies artery and vein unless otherwise noted.
1. Posterior tibial
2.  Soleus (p. 1628)
2. Anterior tibial
3. Sural artery (reverse) (p. 1654)
3. Peroneal
4. Anterior tibialis (p. 1706)
4. Popliteal
5. Saphenous (p. 1392)
5. Dorsalis pedis
6. Dorsalis pedis (p. 1788)
6. Greater saphenous vein
7. Fibula (p. 1584)
7. Lesser saphenous vein
8.  Free muscle/skin/fascia/bone

Things to Consider When Reconstructing the Leg

  1. The upper two thirds of the leg is amenable to local muscle flaps.
  2. The lower third has some local options but is well reconstructed with free flaps.
  3. Recipient vessels for free flaps should be sought outside the zone of injury, either proximally
or distally.
  4. When possible, two venous anastomoses should be performed for each arterial anastomosis,
taking advantage of deep and superficial venous systems.
  5. End-to-side anastomoses to the popliteal artery should be considered to preserve distal blood flow.
  6. A preoperative arteriogram should be done when the clinical pulse examination is abnormal or
a doubt exists about potential injury to the vessels.
  7. An A-V loop to the popliteal vessels should be considered when the distal vessels are inadequate.
  8. In a dysvascular patient, a revascularization procedure may be considered before or in combination
with the flap surgery.
  9. Fasciocutaneous and muscle flaps are equally effective for treating open wounds and resected
osteomyelitis.
10. The leg should remain elevated, and ambulation should be limited in the early postoperative period.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 147 2/9/2012 1:27:35 PM

 Free Flap Foot Reconstruction Options

Free muscle/skin/
fascia
Sural artery
(reverse) flap

Tibialis anterior
flap

Dorsalis pedis
flap

Lateral calcaneal
flap

Medial plantar
artery flap

Abductor Flexor
digiti minimi digitorum brevis
(ADM) flap (FDB) flap Abductor
hallucis flap

03_GuideFlapDis_r8_bs_0081-0152.indd 148 2/9/2012 1:27:41 PM

 Chapter Title  •  3 : Section TitleSect
ChapterTitle 2nd
3   Guide Line
to Flap Sect  Title
Selection •  Foot
3rd 149

Flap Choice Recipient Vessels

Flaps are listed in order of popularity. Recipient vessels are listed in order of popularity.
1.  Sural artery (reverse) (p. 1661) Implies artery and vein unless otherwise noted.
1. Dorsalis pedis
2. Tibialis anterior (p. 1706)
2. Anterior tibial
3. Dorsalis pedis (p. 1788)
3. Posterior tibial
4. Lateral calcaneal (p. 1834)
4. Peroneal
5. Medial plantar (p. 1218)
5. Greater saphenous vein
6. Abductor digiti minimi (ADM)
(p. 1734) 6. Lesser saphenous vein
7. Flexor digitorum brevis (FDB)
(p. 1754)
8. Abductor hallucis (p. 1772)
9.  Free muscle/skin/fascia

Things to Consider When Reconstructing the Foot

1. The foot is one of the hardest areas to reconstruct because of the distant nature of the blood supply,
the increased venous pressure, and the impressive postoperative swelling that occurs at the surgical site.
2. Division of one of the three vessels to the leg and foot should only be performed when an alternative
blood flow to the foot is confirmed.
3. An arteriogram is recommended if pulses are not palpable.
4. The specialized plantar surface requires durable reconstructive choices for areas of weight-bearing.
5. Muscle free flaps with skin graft are equal to free skin flaps in regard to wound healing, postoperative
complications, and the patient’s resultant ability to ambulate.
6. Foot elevation with no weight-bearing is recommended for at least 4 weeks for most flap surgeries.
7. An external fixator should be placed at the time of surgery to maintain leg and foot position
postoperatively, even if no bony injury exists.

Red type denotes a workhorse flap.

Italic type denotes a free flap.

03_GuideFlapDis_r8_bs_0081-0152.indd 149 2/9/2012 1:27:41 PM

 150 Part I  Fundamentals

Considerations in Flap Selection

Patient Factors Flap Factors

Medical comorbidities Surface area and volume
Concurrent adjuvant therapy Color and texture match
Ability to undergo surgery Structural integrity and durability
Willingness to accept scars Component parts (muscle, skin,
Desired recovery time   fascia, bone)
Patient reliability Pedicle length
Local Factors Arc of rotation
Location on the body Need for sensibility
Previous surgery Need for function (functional muscle,
Previous or anticipated radiation therapy   toe transfer)
Tissue quality Special characteristics (hair, mucosa)
Local tissue availability

Workhorse Flaps

Fasciocutaneous Flaps Bone

Temporoparietal fascia Fibula (fibula flap)
Radial forearm Iliac (deep circumflex iliac artery [DCIA] flap)
Scapular/parascapular Radius (radial forearm flap)
Groin Scapula (scapular or trapezius flap)
Lateral arm Femur (saphenous/medial femoral condyle flap)
Deltopectoral Humerus (lateral arm flap)
Supraclavicular Rib (pectoralis major, serratus anterior,
Muscle   or latissimus dorsi flap)
Rectus abdominis Perforator
Latissimus dorsi Deep inferior epigastric perforator (DIEP)
Gracilis Superficial inferior epigastric artery (SIEA)
Pectoralis major Anterolateral thigh (ALT)
Gluteus maximus Anteromedial thigh (AMT)
Gastrocnemius Superior gluteal artery perforator (SGAP)
Inferior gluteal artery perforator (IGAP)
Thoracodorsal artery perforator (TDAP)
Tensor fascia lata (TFL)

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 Chapter 3  •  Guide to Flap Selection 151

Vascularized Bone Flaps

  1.  Fibula (p. 1584)

  2. Deep circumflex iliac artery (DCIA) (iliac) (p. 1108)
  3.  Radial forearm (radius) (p. 842)
  4.  Scapular/parascapular (scapula) (p. 646)
  5.  Lateral arm (humerus) (p. 778)
  6.  Saphenous (medial femoral condyle) (p. 1392)
  7. Temporoparietal fascia (TPFF) (cranium) (p. 262)
  8.  Dorsalis pedis (second metatarsal) (p. 1788)
  9.  Tensor fascia lata (TFL) (iliac) (p. 1506)
10.  Anterior lateral thigh (ALT) (iliac) (p. 1350)
11.  Trapezius (scapula) (p. 694)
12.  Tibialis anterior (fibula) (p. 1706)

03_GuideFlapDis_r8_bs_0081-0152.indd 151 2/9/2012 1:27:41 PM

This page intentionally left blank
 Section 44
Chapter
Complications: Avoidance and Treatment
Complications:
Complications:
Avoidance and Treatment
04_Complications_r2_0153-0166
Revised 12/7/2011

Complications are an ever-present part of reconstructive surgery. The more experience we

gain in the practice of our art, the less likely these complications become. Unfortunately, we
can only gain this experience by encountering these problems and learning from them. Only
by studying our own patients, facing up to our shortcomings, and dealing with them in an
open and academic way will we reduce or eliminate potential complications.
Although the causes of surgical complications are numerous, they can be grouped into
four broad categories: patient selection and preparation, selection of reconstructive procedure,
CLINICAL APPLICATIONS
intraoperative execution, and postoperative care. While many of these etiologic factors are
common to all
Regional Use surgical procedures, we will review those relating particularly to flap recon-
structive surgical procedures.
Head and neck
Thorax
INFORMED CONSENT
Upper
No chapter extremity would be complete without a discussion of informed consent.
on complications
Abdomen
A famous surgeon once said, “When you explain the possibility of a complication before the
surgery, it is called informed consent. When you explain a complication after it has happened,
Distant Use
it is called an excuse.” Medicine in general, and reconstructive surgery in particular, are not
Head and
exact sciences, neck
and complications happen. The real mistake is in not preparing the patient
Trunk
appropriately for a less than optimal outcome of a surgical procedure and not owning up to a
Upper
postsurgical extremity
complication when it occurs. A well-prepared patient understands the reconstruc-
tive procedure he or she
Lower extremity is about to undergo and the possible complications associated with that
procedure. A well-prepared surgeon has thought about these complications and how to avoid
themSpecialized Use
and has an established plan for treating them. Then, when a complication does occur, it
Intrathoracic
is our duty as caregivers toreconstruction
ensure that our patients know that we can be relied on to get them
throughFunctional muscle
this problem. It transfer
is important to avoid minimizing the problem and to explain carefully
how you and the patient will get through this together, and will face any future problems that
(upper extremity, facial reanimational)
may arise. You must become the patient’s advocate, directing and guiding care to achieve a
successful outcome.

04_Complications_r2_0153-0166.indd 153 1/27/2012 3:32:18 PM

 154 Part I  Fundamentals

PATIENT SELECTION AND PREPARATION

Often in reconstructive surgery we cannot choose our patients. They may present with
a problem such as a traumatic injury or cancer that requires immediate attention, and the
responsibility of care falls on our shoulders. With such cases, there is little time to optimize
the patient’s status to ensure the best possible outcome. We accept morbidity, and we care for
complications as they occur. In cases in which the surgeon is consulted for a reconstructive
problem and there is the luxury of time, it is important to take the opportunity to optimize
the patient’s condition for the upcoming surgical procedure.
As consultants, we are often not the primary caregiver for a prospective patient. The
referral itself should not be construed as a clearance for surgery or an understanding on the
part of the referring physician of what the surgical procedure actually entails. Determining
a patient’s candidacy for surgery should be the first step in planning the procedure.
The surgeon must first assess any comorbidities or patient-specific considerations that
could interfere with the healing process (see the box below). For patients undergoing adju-
vant therapies for cancer or who are debilitated by recent trauma or illness, these problems
may require resolution before the reconstructive procedure. Smokers should be instructed
to stop smoking; both the literature and clinical experience show the detrimental effects of
nicotine on the reconstruction as well as on donor site morbidity. A patient who is unwill-
ing to stop smoking may be a patient who is unwilling to follow postoperative instructions
and may be difficult to manage. The best approach is to make that individual a partner in
the reconstructive effort. If you explain that a preexisting condition must be resolved or
the patient must stop smoking to promote proper healing and to avoid complications or the
need for secondary surgeries, the patient will often agree to comply with these requirements.

Medical Issues Affecting Healing

•  Ongoing adjuvant chemotherapy

•  History of radiation therapy
•  Ongoing medical conditions
  – Diabetes
  –  Cardiovascular disease
  –  Cerebrovascular disease
  –  Recent trauma
•  Smoking/nicotine use
•  Nutritional state
•  Steroid use
•  Anticoagulant use
•  Hypercoaguable state
• Obesity
•  Psychosocial factors

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 Chapter 4  •  Complications: Avoidance and Treatment 155

Although our surgical training encompassed basic medical care and management, we
are surgical specialists, and prolonged medical care that extends postoperatively out of the
hospital is out of our area of expertise and practice. For some conditions, it is appropriate
to partner with the patient’s other caregivers to provide comprehensive perioperative care.
Metabolic conditions such as diabetes need to be under strict control, preoperatively as well
as perioperatively. In some cases, consultation with an endocrinologist may be advisable.
Patients who have been debilitated by their illness should have albumin, prealbumin, and
transferrin assays as a rough gauge of their nutritional status. Deficiencies should be fur-
ther investigated to ensure that the patient’s metabolic status is optimal for reconstructive
surgery. Consultation with a nutritional specialist may be indicated. Patients on an aspirin
or anticoagulant regimen should be evaluated by their prescribing physician to determine
whether these can safely be discontinued during the perioperative period. Patients with
previously failed flaps should undergo a workup by a hematologist for a hypercoagulable
state. Patients receiving steroidal agents for medical conditions should receive vitamin A
supplementation to aid in the healing process. When possible and if time permits, issues
of obesity should be addressed. Ideally, the patient should be at a stable weight for elective
reconstructive procedures. Equally important in patient selection and preparation is the
patient’s emotional state and emotional preparation for surgery. The individual’s support
network and the level of postoperative family support must be assessed. Patients are worried
about time away from work, so a specific return-to-work plan can assuage this concern.
Patients need to be confident that there is a well-thought-out recovery plan in place that
will allow them to undergo reconstructive surgery, recover successfully, and return to work
in a timely fashion. Helping to relieve the stressors the patient faces preoperatively will aid
in the healing process postoperatively.

SELECTION OF RECONSTRUCTIVE
PROCEDURE
Most complications related to flap selection and the reconstructive plan can be avoided by
proper planning and prevention. Once the surgeon is armed with the knowledge of which
flaps or reconstructive techniques are available to solve the problem (see Chapter 3), he or
she examines the patient to determine which would be most appropriate. It is in taking
the history and examining the patient that some common errors can be made, resulting in
complications (see the box on p. 156). A complete history of past surgical procedures is
essential and must be confirmed by a careful physical examination. Determining how the
patient healed after previous surgeries and what complications occurred offers insight into
potential healing issues. It is not uncommon for patients to forget previous surgical proce-
dures or not admit to past laparoscopic or cosmetic procedures, but physical examination
will show telltale signs that should be noted and documented. This may help to prevent a
situation in which the surgeon begins to harvest a flap, only to encounter the signs of pre-
vious surgery that were not revealed in the patient’s history. Such an unforeseen discovery
can have a significant impact on the reconstructive outcome.

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 156 Part I  Fundamentals

History and Physical Examination

History
•  Complete surgical history
  –  Minimally invasive
  – Cosmetic
•  Past complications and their management
•  Risk factors for DVT
Physical Examination
Examination of all previous scars
  –  Hypertrophic or keloid
  –  Hernias or bulges
  –  Related neurovascular changes
•  Examination of recipient site
  –  Accurate evaluation of needs
  –  Underestimation of ultimate defect
  –  Related preexisting neurovascular changes
  –  Preexisting physical limitations
•  Examination of donor sites
  –  Amount and quality of tissues available
  –  Vascular examination
•  Angiogram/CT/MRA if indicated 

Physical examination of potential donor sites can sometimes yield equivocal findings,
with absent pulses or old scars, and further study might be warranted, with tests such as
CT angiography, MRA, or angiography. Underestimation of the recipient site’s needs is
also a common cause of postoperative complications. This can occur from poor planning
or unanticipated changes in the recipient site defect. For this reason, a preoperative plan is
essential, but once in the operating room, some flexibility is beneficial. We strongly recom-
mend that the surgeon not commit early in the reconstructive process to a particular flap
before the final size and characteristics of the defect are known. Even the most experienced
surgeons have encountered unforeseen problems intraoperatively. Sometimes a second flap
or additional surgical procedures are necessary that could have been avoided. Flaps that are
too small, too thick, or have an inadequate arc of rotation or inadequate pedicle length are
all avoidable with sufficient planning. One of the most common and avoidable postopera-
tive complications is deep vein thrombosis. A plan should be in place for every patient who
is having reconstructive surgery. This is especially true in long reconstructive flap cases,
where the risk of DVT goes up exponentially and patients should be considered at increased
risk. Sequential compression boots are used in all cases, and the addition of anticoagulants
should be considered, depending on the particular clinical situation.

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 Chapter 4  •  Complications: Avoidance and Treatment 157

INTRAOPERATIVE EXECUTION
Many things are under the surgeon’s control in the operating room that need attention to
prevent postoperative complications (see the box below). Fluid resuscitation and temperature
are critical, and homeostasis is achievable with attention to detail. The operative surgeon
should be personally responsible for preventing pressure-related injury from inadequate pad-
ding, excessive retractor use, or inappropriate patient positioning. Reconstructive surgeries
can often be lengthy, and anything that can reduce time in the operating room can translate
into lower complication rates. As the surgeon develops a routine for certain procedures, it is
important to continually look for ways to be more efficient and reduce time in the operat-
ing room. Increased operative time means more tissue edema, more bleeding, and more
cardiopulmonary issues, and an increased risk of coagulopathy. Furthermore, the risk of
stress ulcers, pressure ulcers, and neurapraxia is increased.

Intraoperative Considerations

•  Appropriate fluid resuscitation

•  Maintenance of normothermia
•  DVT prophylaxis
•  Hemostasis
•  Padding of pressure points
•  Avoidance of excessive retractor use
•  Minimizing length of surgery
•  Accurate assessment of recipient site
•  Accurate flap design and performance
•  Ensuring that dressings are not tight/compressive

Despite a well-thought-out, appropriate operative plan, you will sometimes encounter

unexpected anatomic variations. It is important not to be rigid in your surgical plan but to
assess the variation and decide whether a secondary or tertiary flap should be chosen. All
too often a good surgeon will perform a good operation, yet end up with an inadequate
result because of an unrecognized anatomic variation. It is important to inspect not only the
reconstructive flaps but also the recipient bed for adequacy for reconstruction. Vascularity
can be evaluated by clinical examination or by imaging techniques such as laser angiog-
raphy to help determine whether further debridement is required or other maneuvers are
necessary to provide the best chance for successful reconstruction. If the surgeon encounters
potential ischemia or venous congestion of a reconstructive flap or recipient site tissues, the
time to react is in the operating room. Options include returning the pedicled flap back to
its donor site and evaluating it for pedicle compression, kinking, or torsion; microscopically
evaluating the vascular anastomoses and the lay of the pedicle for compression, kinking, or
thrombosis; performing additional inflow or outflow procedures if possible; delaying the
reconstructive flap, with inset at a later time; and debriding ischemic or congested tissues
before they can cause a dehiscence, infection, or flap necrosis. The enemy of all reconstruc-
tive surgery is tension. Tension on closure is ischemic in nature and can predispose tissue to
breakdown. Tension in closure can cause compression on the vascular pedicle, especially
as the reconstructive flap and surrounding tissues swell postoperatively. Tension on a mi-
crovascular anastomosis or pedicle will predispose to thrombosis. Every effort should be
made to reduce tension and to anticipate postoperative tension by changes in swelling, body
position, or postoperative dressing. In mobile areas such as the extremities or the head and
neck, tension should be checked intraoperatively in positions of movement to ensure that

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 158 Part I  Fundamentals

postoperatively a change in position will not create a problem. If tension is unavoidable when
closing skin incisions, maneuvers such as support with acellular dermal matrix (ADM) or
secondary closure should be considered. Many a situation has been salvaged by leaving the
wounds open and performing dressing changes for 48 hours, allowing borderline tissues a
chance to recover. Closing the donor or recipient site by skin grafting is another alternative,
with the option of coming back secondarily to excise the graft, if desired.
There are certain errors of planning that are specific to microsurgery. Identification of
trauma to the vasculature of the donor flap or the recipient vessels is crucial. The concept
of zone of injury, popularized in cases of trauma, extends to all surgical procedures. Injured
vessels from any cause, even iatrogenic, are predisposed to thrombosis. Size and mismatch
between vessels can also predispose to thrombosis and flap failure. The surgeon must feel
comfortable evaluating free flaps for arterial inflow and venous egress, the discussion of
which is beyond the scope of this text.
In both pedicle and free flap reconstruction, the use of drains is important for preven-
tion of compression of the vascular pedicle by seroma or hematoma. Although drains do
not prevent these complications, they can buy time and prevent compression while the
complication is being managed.
The final and sometimes most important part of any reconstructive procedure is the
placement of appropriate splints and dressings and proper patient positioning. Constricting
dressings, inadequate splinting, and poor positioning of the patient can place inappropriate
tension or pressure on the reconstructive tissues and lead to postoperative complications.
When leaving the operating room, the patient should be warm, comfortable, and well
hydrated. A clearly defined plan for dressings, use of splints, postoperative positioning, and
postoperative activity should be confirmed and communicated to everyone caring for the
patient postoperatively.

POSTOPERATIVE FACTORS
Once the surgical procedure has been successfully performed, the surgeon must be vigilant
in postoperative management of the patient to prevent the common problems that are seen
in reconstructive procedures (see the box below). The concerns regarding positioning,
movements in the area of surgery, and avoidance of pressure on the flaps is carried forward
in the postoperative period. Attention to metabolic homeostasis, fluid balance, pulmonary
toilet, stress gastritis prophylaxis, and DVT prophylaxis are also critical in combating known
and common problems relating to surgery.

Postoperative Considerations

•  Fluid balance and maintenance of urine output

• Normothermia
•  Pain control
•  Pulmonary toilet
•  Avoidance of pressure on reconstruction site
•  Avoidance of excessive movements
•  Flap monitoring
•  Appropriate dressings/splints
•  Early treatment of infection
•  Aggressive treatment of hematoma and seroma
•  DVT prophylaxis
•  Stress ulcer prophylaxis

04_Complications_r2_0153-0166.indd 158 1/27/2012 3:32:19 PM

 Chapter 4  •  Complications: Avoidance and Treatment 159

One area that is specific to reconstructive flap surgery is postoperative monitoring of

the patient’s tissues. Both pedicle flaps and free tissue transfers need vigilant nursing care to
avoid flap loss and dehiscence. In pedicle flaps, this relates primarily to avoiding hematomas
and seromas at the recipient and pedicle sites. Prevention of trauma to the reconstructed
area, both when the patient is in bed and during transfers out of bed, is critical. Prolonged
pressure on a reconstructive flap or vascular pedicle by improper positioning can also cause
partial and total flap failure. Monitoring of free tissue transfers is more critical in the early
postoperative period, because an arterial or venous thrombosis must be identified imme-
diately so that salvage is possible. Free tissue transfers should be monitored by experienced
staff, and a standardized monitoring plan should be in place.
Lengthy reconstructive procedures may be complicated by infection. General surgical
principles apply, and areas of suspected infection should be managed aggressively. When
infection or abscess is suspected near a vascular pedicle, the area should be explored immedi-
ately, washed out, and drained widely to prevent the risk of vascular thrombosis. Appropriate
perioperative antibiotics should be used for such long procedures, and active infections should
be treated with antibiotics directed by culture-specific data. Any contaminated foreign
body should be removed. Negative-pressure wound therapy (NPWT) has been extremely
helpful in the management of postoperative problems; it acts as an open dressing while
maintaining moisture in the wound, minimizing edema, and preventing the spreading or
separation of the surrounding tissues. It is an effective bridge to secondary surgery. When
dealing with partial necrosis or a failed flap in a sick patient, the surgeon’s decision to go
back to the operating room can be difficult. No one wants to put a patient’s life at risk to
reconstruct a defect that is not life threatening. There are some advantages to consider in
not taking the patient back immediately to the operating room. The ischemic tissue acts
as a biologic dressing, encouraging surrounding tissue revascularization or ingrowth. This
principle, called the Crane principle, can sometimes be used to avoid a second flap surgery.
The term has its origin in thinking of the flap as an engineering crane, dropping in tissue
and later removing it, as necessary. If the patient is stable and there are no vital structures
exposed, the surgeon can wait until there is clear wound separation or evidence of infection.
Once there is evidence of eschar separation, the patient can be returned to the operating
room for debridement of all nonviable tissues. It is sometimes possible at that point, with
enough ischemia-mediated tissue ingrowth, to simply perform a skin graft and close the
wound, discarding the flap completely. If this is not possible, sometimes further NPWT
can salvage the situation to a point at which a skin graft is possible. With that said, it is rare
in a stable patient with evidence of a flap-related problem to regret taking the patient back
to the operating room.
If a second flap is required, the same systematic assessment should be performed for
options and solutions to the problem. It is equally important that the patient be mentally
and physically prepared for this second surgery. The surgeon must be honest and open with
the patient about the surgical procedure and its potential complications and be positive and
confident that a solution is at hand.
As stated at the outset, complications are an ever-present part of reconstructive surgery
and cannot be avoided completely. The occurrence of complications relates to more than
just surgical skill, and many of these factors are out of our control. We can reduce our own
complication rates only by studying our patients, facing up to our shortcomings in planning
and execution, and modifying our own practices.

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 160 Part I  Fundamentals

Bibliography With Key Annotations

Alderman AK, Wilkins EG, Kim HM, et al. Complications in postmastectomy breast recon-
struction: two-year results of the Michigan breast reconstruction outcome study. Plast Reconstr
Surg 109:2265-2274, 2002.
In this study, the effects of procedure type, timing, and other clinical variables on complication rates
in mastectomy reconstruction were prospectively evaluated. Using a prospective cohort design, women
undergoing first-time, immediate, or delayed breast reconstruction were recruited from 12 centers and
23 plastic surgeons. Data on complications for expander/implant, pedicle transverse rectus abdominis
myocutaneous (TRAM) flap, and free TRAM flap procedures were evaluated 2 years after surgery
in 326 patients.
Aly A. Prone positioning precautions in plastic surgery. Plast Reconstr Surg 117:1584-1588, 2006.
Prone positioning carries with it risks associated with neural and vascular compression. Meticulous
attention to avoiding compression will protect against the risks associated with improper positioning,
particularly for plastic surgeons.
Beahm EK, Walton RL. What is done when free flaps fail? Plast Reconstr Surg 116(3 Suppl):
116-118, 2005.
The authors reviewed their experience with secondary reconstruction following failed free flaps and
presented an algorithm for decision-making.
Bluman LG, Mosca L, Newman N, et al. Preoperative smoking habits and postoperative pul-
monary complications. Chest 113:883-889, 1998.
The authors reported their prospective cohort study examining the effect of preoperative smoking
on postoperative pulmonary complications in 410 patients scheduled for noncardiac elective surgery.
Current smoking was associated with a nearly sixfold increase in risk for a postoperative pulmonary
complication. Reduction in smoking within 1 month of surgery was not associated with a decreased
risk of postoperative pulmonary complications.
Braithwaite SS, Robertson B, Mehrotra HP, et al. Managing hyperglycemia in hospitalized
patients. Clin Cornerstone 8:44-57, 2007.
Cavallini M, Baruffaldi Preis FW, Casati A. Effects of mild hypothermia on blood coagulation
in patients undergoing elective plastic surgery. Plast Reconstr Surg 116:316-321, 2005.
The authors presented a prospective, controlled study that evaluated the effects on coagulation function
of active patient warming during elective plastic surgery.
Coskunfirat OK, Chen HC, Spanio S, et al. The safety of microvascular free tissue transfer in
the elderly population. Plast Reconstr Surg 115:771-775, 2005.
This study evaluated the safety and thus the efficacy of microvascular free tissue transfer in the elderly
patient population. Free flaps for different types of reconstructions were analyzed to verify whether
free tissue transfer is feasible in the elderly. The authors performed 102 free flaps in 94 patients 70
years of age or older (range 70 to 87 years). The study found that neither operation time nor age was
predictive of postoperative complications. Microvascular free tissue transfer is a safe and reliable option
in the elderly population. The success rate of free flaps is not different from that for other age groups.
The rate of postoperative medical complications was 31% (29 of 94 patients); most complications were
in American Society of Anesthesiologists class III and IV patients.
Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue
transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Surg 10:97-101, 1999.
Conventional free flap monitoring techniques (clinical observation, hand-held Doppler ultrasonography,
surface temperature probes, and pinprick testing) are proven methods for monitoring free flaps with
an external component. Buried free flaps lack an external component; thus, conventional monitoring
is limited to hand-held Doppler ultrasonography. Free flap success is enhanced by the rapid identi-
fication and salvage of failing flaps. The purpose of this study was to compare the salvage rate and

04_Complications_r2_0153-0166.indd 160 1/27/2012 3:32:19 PM

 Chapter 4  •  Complications: Avoidance and Treatment 161

final outcomes of buried versus nonburied flaps monitored by conventional techniques. The authors
retrospectively reviewed 750 free flaps performed for reconstruction of oncologic surgical defects. There
were 673 nonburied flaps and 77 buried flaps. All flaps were monitored by using conventional tech-
niques. Both buried and nonburied flaps were used for head and neck and extremity reconstruction.
Only nonburied flaps were used for trunk and breast reconstruction. Buried flap donor sites included
jejunum (50), fibula (16), forearm (8), rectus abdominis (2), and temporalis fascia (1). Overall flap
loss for 750 free flaps was 2.3%. Conventional monitoring of nonburied free flaps was highly effective
in this series. These techniques have contributed to rapid identification of failing flaps and subsequent
salvage in most cases. As such, conventional monitoring has led to an overall free flap success rate
commensurate with current standards. In contrast, conventional monitoring of buried free flaps has not
been reliable. Failing buried flaps were identified late and found to be unsalvageable at reexploration.
Thus, the overall free flap success rate was significantly lower for buried free flaps. To enhance earlier
identification of flap compromise in buried free flaps, alternative monitoring techniques such as im-
plantable Doppler probes or exteriorization of flap segments are recommended.
Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postoperative infec-
tious complications. Arch Surg 141:375-380, 2006.
The authors performed a study of 647 diabetic patients who underwent major noncardiac surgery. The
study patients were predominantly nonblack men with a median age of 71 years. Primary outcomes
were infectious complications, including pneumonia, wound infection, urinary tract infection, or sepsis.
An HbA(1c) level of less than 7% was significantly associated with decreased infectious complications
with an adjusted odds ratio of 2.13 (95% confidence interval; 1.23-3.70) and a p value of 0.007.
Good preoperative glycemic control (HbA[1c]) levels (less than 7%) is associated with a decrease in
infectious complications across a variety of surgical procedures.
Dybec RB. Intraoperative positioning and care of the obese patient. Plast Surg Nurs 24:118-
122, 2004.
Perioperative nurses involved in the intraoperative care of obese patients are faced with numerous issues
and challenges. As a growing number of these patients present for medical care, nurses must consider
the special positioning needs for surgery and the equipment needed to promote the safest environment
for these patients.
Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces
the incidence of morbid cardiac events. A randomized clinical trial. JAMA 277:1127-1134, 1997.
The authors conducted a randomized, controlled trial to assess the relationship between body tem-
perature and cardiac morbidity during the perioperative period. They compared routine thermal care
(hypothermic group) to additional supplemental warming care (normothermic group) in operating
rooms and the surgical intensive care unit at an academic medical center. The outcome measure was
the relative risk of a morbid cardiac event (unstable angina/ischemia, cardiac arrest, or myocardial
infarction) according to thermal treatment. Cardiac outcomes were assessed in a double-blind fashion.
The mean core temperature after surgery was lower in the hypothermic group (35.4 6 0.18 C) than
in the normothermic group (36.7 6 0.18 C) and remained lower during the early postoperative pe-
riod. Perioperative morbid cardiac events occurred less frequently in the normothermic group than in
the hypothermic group (1.4% versus 6.3%). Hypothermia was an independent predictor of morbid
cardiac events by multivariate analysis (relative risk 2.2; 95% confidence interval; 1.1-4.7), indicating
a 55% reduction in risk when normothermia was maintained. Postoperative ventricular tachycardia also
occurred less frequently in the normothermic group than in the hypothermic group (2.4% versus 7.9%).
Genden EM, Rinaldo A, Suárez C, et al. Complications of free flap transfers for head and neck
reconstruction following cancer resection. Oral Oncol 40:979-984, 2004.
The reported success rate of microvascular free flap reconstruction ranges from 95% to 97%. However,
when complications occur, they must be identified early and managed efficiently, because there is a
narrow window of opportunity to salvage a potentially failing flap. Complications of microvascular

04_Complications_r2_0153-0166.indd 161 1/27/2012 3:32:19 PM

 162 Part I  Fundamentals

free tissue transfer may occur at the recipient site or at the donor site. Complications occurring at the
recipient site are largely a result of vessel thrombosis, whereas complications occurring at the donor site
may result from many causes, ranging from infection to those related to the harvesting of the flap. Ir-
respective of the site of the complication, it is essential that complications be recognized and addressed
early in their course to prevent or minimize devastating consequences.
Goldman L, Caldera DL, Southwick FS, et al. Cardiac risk factors and complications in non-
cardiac surgery. Medicine 57:357-370, 1978.
To assess cardiac risk in noncardiac surgery, 1001 patients over 40 years of age who were undergoing
major operative procedures were examined preoperatively, observed through surgery, studied with at
least one postoperative electrocardiogram, and followed until hospital discharge or death. Documented
postoperative myocardial infarction occurred in only 18 patients; although most of these patients had
some preexisting heart disease, there were few preoperative factors that were statistically correlated
with postoperative infarction. Postoperative pulmonary edema was strongly correlated with preopera-
tive heart failure, but 21 of the 36 patients who developed pulmonary edema did not have any prior
history of heart failure.
Kroll SS, Miller MJ, Reece GP, et al. Anticoagulants and hematomas in free flap surgery. Plast
Reconstr Surg 96:643-647, 1995.
A review of systemic anticoagulant use in 517 free flap procedures was performed to determine the as-
sociated risk of hematoma formation. A cause-and-effect relationship between the use of anticoagulants
and flap loss or prevention of thrombosis could not be established. The authors concluded that the use
of low-dose heparin does not increase significantly the risk of hematoma or intraoperative bleeding.
Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle thrombosis and flap loss after
free tissue transfer. Plast Reconstr Surg 98:1230-1233, 1996.
A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred,
when it occurred, and if the timing of thrombosis detection had any relationship to the probability of
flap salvage. The authors concluded that arterial monitoring is most critical immediately after surgery.
Beginning on the second postoperative day, venous monitoring becomes progressively more important
to flap success. The cost-effectiveness of postoperative monitoring of free flaps is greatest during the
first 2 days, after which it decreases significantly.
Kuri M, Nakagawa M, Tanaka H, et al. Determination of the duration of preoperative smoking
cessation to improve wound healing after head and neck surgery. Anesthesiology 102:892-896,
2005.
One hundred eighty-eight consecutive patients who underwent reconstructive head and neck surgery
were included in this retrospective study. Information on preoperative smoking habits was obtained from
the patients’ medical records. Smokers were defined as having smoked within 7 days before surgery.
Late, intermediate, and early quitters were defined as patients whose duration of abstinence from
smoking was 8 to 21, 22 to 42, and 43 days or longer before the operation, respectively. Patients who
required postoperative debridement, resuture, or reconstruction of their flap before hospital discharge
were defined as having had impaired wound healing. The incidences of impaired wound healing
among the late, intermediate, and early quitters and nonsmokers were 67.6%, 55.0%, 59.1%, and
47.5%, respectively, and the incidence of impaired wound healing was significantly lower among the
intermediate quitters, early quitters, and nonsmokers than among the smokers (85.7%). Preoperative
smoking abstinence of longer than 3 weeks reduces the incidence of impaired wound healing among
patients who have undergone reconstructive head and neck surgery.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical
wound infection and shorten hospitalization. N Engl J Med 334:1209-1215, 1996.
Mild perioperative hypothermia, which is common during major surgery, may promote surgical wound
infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen ten-
sion. Hypothermia itself may delay healing and predispose patients to wound infections. Maintaining

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 Chapter 4  •  Complications: Avoidance and Treatment 163

normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients

undergoing colorectal resection and to shorten their hospitalizations.
Monfrecola G, Riccio G, Savarese C, et al. The acute effect of smoking on cutaneous micro-
circulation blood flow in habitual smokers and nonsmokers. Dermatology 197:115-118, 1998.
The authors conducted a study to assess the effect of smoking a single cigarette on cutaneous blood
flow in habitual smokers as well as in nonsmokers. A laser Doppler flowmeter was used to measure
cutaneous microcirculation. Flowmetric data were recorded before smoking, inhaling from an unlighted
cigarette, during cigarette smoking, and 2 and 5 minutes after smoking. Results showed that smoking
a single cigarette acts on the cutaneous microcirculation, reducing blood flow in both groups of subjects
(38.1% reduction in smokers and 28.1% reduction in nonsmokers). Interestingly, the recovery phase
was faster in nonsmoker subjects than in smokers; in fact, recovery is complete 2 and 5 minutes after
cigarette smoking in nonsmokers and in smokers, respectively. Smoking a single cigarette decreases the
cutaneous blood flow in habitual smokers as well as in nonsmokers. Moreover, the slower recovery
phase of smokers suggests that their microcirculation becomes inured to smoke.
Pasquina P, Tramer MR, Granier JM, et al. Respiratory physiotherapy to prevent pulmonary
complications after abdominal surgery: a systematic review. Chest 130:1887-1899, 2006.
To examine the efficacy of respiratory physiotherapy for prevention of pulmonary complications after
abdominal surgery, the authors searched in databases and bibliographies for articles in all languages
through November 2005. Randomized trials were included if they investigated prophylactic respira-
tory physiotherapy and pulmonary outcomes and if the follow-up was at least 2 days. Efficacy data
were expressed as risk differences and number needed to treat, with 95% confidence intervals (CIs).
There were only a few trials that supported the usefulness of prophylactic respiratory physiotherapy.
The routine use of respiratory physiotherapy after abdominal surgery does not seem to be justified.
Reus WF, Colen LB, Straker DJ. Tobacco smoking and complications in elective microsurgery.
Plast Reconstr Surg 89:490-494, 1992.
This study assessed the risk for complications in patients who chronically smoke but who have quit in
the perioperative period of an elective free tissue transfer, compared with patients who do not smoke.
The study’s findings suggest that cigarette smokers are at increased risk for complications, not at the
site of the anastomosis in free tissue transfer, but rather at the flap’s interface with the wound or
overlying skin graft.
Scott JD, Forrest A, Feuerstein S, et al. Factors associated with postoperative infection. Infect
Control Hosp Epidemiol 22:347-351, 2001.
Serletti JM, Higgins JP, Moran S, et al. Factors affecting outcome in free tissue transfer in the
elderly. Plast Reconstr Surg 106:66-70, 2000.
Free tissue transfers have become the preferred surgical technique to treat complex reconstructive defects.
Because these procedures typically require longer operative times and recovery periods, the applicability
of free flap reconstruction in the elderly continues to require ongoing review. The authors performed
a retrospective analysis of 100 patients aged 65 years and older who underwent free tissue transfers
to determine preoperative and intraoperative predictors of surgical complications, medical complica-
tions, and reconstructive failures. One hundred four flaps were transferred in these 100 patients. The
overall flap success rate was 97%, and the overall reconstructive success rate was 92%. There were
6 additional reconstructive failures related to flap loss, all of which occurred more than 1 month after
surgery. Patients with a higher ASA designation experienced more medical complications but not
surgical complications. Increased operative time resulted in more surgical complications. All 8 cases of
reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral
vascular disease.
Shestak KC, Jones NF. Microsurgical free tissue transfer in the elderly patient. Plast Reconstr
Surg 88:259-263, 1991.

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 164 Part I  Fundamentals

Smetana GW, Lawrence VA, Cornell JE, et al. Preoperative pulmonary risk stratification for
noncardiothoracic surgery: systematic review for the American College of Physicians. Ann
Intern Med 144:581-595, 2006.
The authors reviewed the literature on preoperative pulmonary risk stratification before noncardio-
thoracic surgery. They included English-language studies that reported the effect of patient- and
procedure-related risk factors and laboratory predictors on postoperative pulmonary complication rates
after noncardiothoracic surgery and that met predefined inclusion criteria. For certain risk factors and
laboratory predictors, the literature provides only unadjusted estimates of risk. Prescreening, variable
selection algorithms, and publication bias limited reporting of risk factors among studies using mul-
tivariable analysis. Selected clinical and laboratory factors allow risk stratification for postoperative
pulmonary complications after noncardiothoracic surgery.
Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound
infection: a randomized controlled trial. Ann Surg 238:1-5, 2003.
The authors studied 78 healthy subjects (48 smokers and 30 who had never smoke) and followed them
for 15 weeks. In smokers, the wound infection rate was 12% (11 of 93 wounds), compared with 2%
(1 of 48 wounds) in individuals who had never smoked. Wound infections were significantly fewer in
abstinent smokers compared with continuous smokers 4, 8, and 12 weeks after randomization. No
difference between the use of the transdermal nicotine patch and placebo was found.
Spear SL, Ducic I, Cuoco F, et al. The effect of smoking on flap and donor site complications
in pedicled TRAM breast reconstruction. Plast Reconstr Surg 116:1873-1880, 2005.
The detrimental effects of smoking on pedicled and free flap reconstruction are well documented. The
purpose of this study was to examine the effect of smoking on the flap, donor site, and other individual
and multiple complications in pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast
reconstruction. A retrospective review was carried out of 224 pedicled TRAM flaps in 200 patients
over a 10-year period. Three subgroups of patients were identified: active smokers, former smokers
(defined as patients who had stopped smoking at least 4 weeks before reconstruction), and nonsmokers
(patients with no history of smoking). Active smokers made up 15.5% of the study population; former
smokers and nonsmokers made up 17.5% and 67%, respectively. There were no statistically significant
differences in age, weight, radiation/chemotherapy history, distribution of flap pedicle types, timing
of reconstruction, or percentage of delay procedures performed among the smoking subgroups. Logistic
regression analysis was used to identify significant risk factors and determine their odds ratios. This
identified active smoking as a statistically significant risk factor for developing multiple flap complica-
tions and TRAM infection, while former smoking was a risk factor for multiple flap complications
and TRAM delayed wound healing. Thus pedicled TRAM flap breast reconstruction should be
considered contraindicated in active and former smokers, unless the patient has stopped smoking for
more than 4 weeks before surgery.
Ungern-Sternberg BS, Regli A, Schneider MC, et al. Effect of obesity and site of surgery on
perioperative lung volumes. Br J Anaesth 92:202-207, 2004.
Although obese patients are thought to be susceptible to postoperative pulmonary complications, there
are only limited data on the relationship between obesity and lung volumes after surgery. The authors
studied how surgery and obesity affect lung volumes measured by spirometry. Considering patients
according to BMI (less than 25, 25 to 30, and greater than 30), VC decreased after surgery by 12%,
24% and 40%, respectively.
Wilson M, Weinreb J, Hoo GW. Intensive insulin therapy in critical care: a review of 12 pro-
tocols. Diabetes Care 30:1005-1011, 2007.
The authors systematically identified and compared 12 protocols and then applied the protocols to
generate insulin recommendations for the management of patients with hyperglycemia. The lack of
consensus in the delivery of intravenous insulin infusions is reflected in the wide variability of practice
noted in this survey. This mandates close attention to the choice of a protocol. One protocol may not
suffice for all patients.

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 Chapter 4  •  Complications: Avoidance and Treatment 165

Yii NW, Evans GR, Miller MJ, et al. Thrombolytic therapy: what is its role in free flap salvage?
Ann Plast Surg 46:601-604, 2001.
Thrombolytic agents have been demonstrated to improve free flap salvage in animal models. However,
clinical evidence regarding their efficacy has been scant. The authors reviewed their experience with
flap salvage using thrombolytic therapy in 1733 free flaps.
Young VL, Botney R, eds. Patient Safety in Plastic Surgery. St Louis: Quality Medical Pub-
lishing, 2009.
Young VL, Watson ME. The need for venous thromboembolism (VTE) prophylaxis in plastic
surgery. Aesthet Surg J 26:157-175, 2006.
Plastic surgeons have generally been reluctant to use antithrombotic agents because of the increased
risk of bruising or hematoma and the possible need for blood transfusion. However, numerous studies
have found little or no increase in the frequency of clinically important bleeding associated with their
use. Some plastic surgeons now routinely use chemoprophylaxis in patients undergoing abdomino-
plasty, combined procedures, or procedures lasting more than 4 hours. The authors also recommend
postoperative chemoprophylaxis in circumferential body contouring, thighplasty, surgery requiring open
space dissection, transverse rectus abdominus muscle (TRAM) procedures, and surgical procedures
likely to contribute to venous stasis or compression. It is impractical and expensive to screen every
patient for asymptomatic DVT. A patient history focusing specifically on VTE risk factors should
be performed within a few weeks of surgery. Patient education should include information about the
symptoms of DVT and PE (including the fact that most patients with VTE are asymptomatic) and
a full explanation of the risks and benefits of anticoagulant prophylaxis.
Young VL, Watson ME. Prevention of perioperative hypothermia in plastic surgery. Aesthet
Surg J 26:551-571, 2006.
Although inadvertent perioperative hypothermia has received serious attention in many surgical special-
ties, few discussions of hypothermia have been published in the plastic surgery literature. This article
reviewed the physiology of thermoregulation, described how both general and regional anesthesia alter the
normal thermoregulatory mechanisms, indicated risk factors particularly associated with hypothermia,
and discussed the most effective current methods for maintaining normothermia.

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 Part II

Regional Flaps:
Anatomy and Basic
Techniques

Head and Neck

Anterior Thorax
Posterior Trunk
Upper Extremity
Hand
Abdomen
Abdominal Viscera
Thigh
Leg
Foot

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This page intentionally left blank
 Chapter 5
Head and Neck

The head and neck present unique challenges in reconstruction. It is one area in which
an understanding of three-dimensional anatomy is essential to planning and execution
of a successful result. In no other region of the body is so much going on in such a small
space. The surgeon must consider such issues as airway maintenance, speech, mastica-
tion, swallowing, vision, and facial expression. Reconstruction can affect each of these
functions negatively, impinging on the patient’s quality of life. The consequences of
failure can be devastating in terms of form and function. In no other part of the body
is it more critical to replace like with like—to replace what has been taken away with
as exact a copy as possible. As if that weren’t enough, it has to look good: aesthetic out-
comes are vital, since there is no way to hide what the plastic surgeon has reconstructed.
It is the one area of the body where a beautiful reconstruction is one that should not be
immediately apparent to others.

Paramedian Forehead Flap

Scalp Flap
Nasolabial Flap
Temporoparietal Fascia Flap
Temporalis Flap
Masseter Flap
Orbicularis Oris Flap
Tongue Flap
Submental Flap
Facial Artery Myomucosal (FAMM) Flap

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 ANATOMIC LANDMARKS
Landmarks Central forehead.
Size 3 cm wide with primary closure; 8 3 6 cm with skin grafting of
donor site; larger flaps with delay procedure or tissue expansion.
Composition Skin with inclusion of frontalis, corrugator, and procerus muscles
in its base.
Flap Type Fasciocutaneous, type B.
Dominant Pedicle Supratrochlear artery.
Minor Pedicle Supraorbital artery.
Nerve Supply Supratrochlear.

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 Section 5A
Head and Neck

Paramedian Forehead Flap

CLINICAL APPLICATIONS
Regional Use
Cheek
Eyelid
Nose
Specialized Use
Nose

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 ANATOMY OF THE ParaMedian Forehead Flap

A
B
Frontalis
muscle
Supraorbital
Corrugator artery
muscle
Supraorbital
artery Supratrochlear
artery Ophthalmic
Supratrochlear artery
artery Procerus
muscle

Relationship of vascular pedicles to skull

Vascular supply

Supraorbital
nerve

Supratrochlear
nerve

Neural anatomy of forehead

Fig. 5A-1 

Dominant pedicle: Supratrochlear artery

Minor pedicle: Supraorbital artery

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 Head and Neck  •  5A: Paramedian Forehead Flap 173

Anatomy
Landmarks This flap uses the forehead tissues for local reconstruction of the upper face. The
redundant blood supply in this area allows great flexibility in flap design, using
a small portion of the central forehead, or potentially the entire forehead.
Composition Fasciocutaneous; this is a resurfacing flap. Although the base of the flap will
contain portions of the frontalis, corrugator, and procerus muscles, it provides
little muscle for reconstruction. The muscles function merely as carriers of the
supplying blood vessels.
Size 3 cm width can be closed primarily; an 8 3 6 cm flap can be reliably taken
without delay. Larger flaps can be taken with delay procedures, including tissue
expansion.

Arterial Anatomy
Dominant Pedicle  Supratrochlear artery
Regional Source  Terminal branch of the ophthalmic artery.
Length  3 cm.
Diameter  1 mm.
Location  Exits the orbit superior to the medial canthal ligament, passes through the orbital sep-
tum, and enters the glabellar region 2 cm from the midline. It then courses cephalad beneath
the frontalis muscle.
Minor Pedicle  Supraorbital artery
Regional Source  Ophthalmic artery.
Length  4 cm.
Diameter  1 mm.
Location  Exits the supraorbital notch, or foramen, approximately 3 cm from the midline in the
midpupillary axis, then courses beneath the frontalis muscle.

Venous Anatomy
Accompanying venae comitantes to the supratrochlear and supraorbital vessels.

Nerve Supply
Sensory Supratrochlear and supraorbital nerves.

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 174 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Paramedian Forehead Flap

A

Vertical flap design

B C

m D m
D

Deep surface of flap Radiographic view

Fig. 5A-2 
Dominant pedicle: Supratrochlear artery (D)
Minor pedicle: Supraorbital artery (m)

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 Head and Neck  •  5A: Paramedian Forehead Flap 175

Flap Harvest
Design and Markings
The middle third of the forehead, with some extension laterally (6 cm wide), can survive
without delay procedures based on the dominant vascular pedicle. The height of the flap
will depend on the height of the forehead and the desire to carry hair-bearing scalp with
the reconstruction; 7 to 8 cm of height without including hair is common. The orientation
of the flap can be made more oblique to carry more hairless skin for reconstruction. The
narrower the flap base, the easier the rotation of the flap will be. A minimum width of 1.5
cm, including the supratrochlear vessels, is required for flap viability.

A B

Vertical flap design Oblique flap design

Fig. 5A-3

Accurate measurement of the recipient site will help guide placement of the incisions for
the reconstruction. A 1:1 template design should be transposed to the forehead. Simulation
of the pedicle arc and reach with a sponge will help determine the adequacy of the pedicle
length to reach the reconstructive site.
Doppler examination of the supratrochlear vessels is recommended to ensure their
inclusion in the flap, guaranteeing an axial flap for best perfusion.

Patient Positioning
The patient is placed in a supine position. If the hair is to be shaved as part of the procedure,
it is important to take note of the hairline so that inclusion of hair-bearing skin is intentional
and not accidental.

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 176 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

Once the flap is designed and the location of the supratrochlear vessels is confirmed, inci-
sions can be made throughout, down to the periosteum. In cases of nasal reconstruction in
which inclusion of the frontalis muscle is not required, the distal and superiormost portion
of the flap can be elevated in a subcutaneous plane for approximately 20% of its length. The
subdermal plexus is spared.

Supratrochlear Supratrochlear
nerve artery

Markings

Fig. 5A-4 

At this point, the plane is then deepened below the frontalis muscle. The flap is elevated
in a supraperiosteal plane. At the glabellar region, within 1 cm of the orbital rim, the plane
is deepened to a subperiosteal plane. A Freer elevator is then used to elevate this window
of periosteum off the bone in the area of the radix, protecting the pedicle. At this level the
corrugator muscle is encountered, and the supratrochlear vessels are intimately associated
with it. This area is best divided with bipolar cautery, again taking care to avoid injury to
the supratrochlear vessels. These vessels may not be visualized during the procedure, but
their position can be easily confirmed with a Doppler probe.

Supratrochlear Supratrochlear
nerve artery

Thinned
subcutaneous fat

Intermediate dissection

Fig. 5A-4 

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 Head and Neck  •  5A: Paramedian Forehead Flap 177

The base of the flap is extended as needed to reach the reconstructive site; it commonly
divides the eyebrow and runs into the upper inner aspect of the orbit. This occurs frequently
in nasal reconstruction, and the eyebrow will later be returned to its normal position during
division and inset of the flap.

Periosteal
window

Supratrochlear Supratrochlear
nerve artery

Final dissection

Cut edge of
frontalis muscle

Periosteum
Thinned
subcutaneous fat

Supratrochlear
artery and nerve

Dissection cross-section

Fig. 5A-4 

Flap Variants
•  Tissue expansion–assisted flap
•  Delay flap

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 178 Part II  Regional Flaps: Anatomy and Basic Techniques

Tissue Expansion–Assisted Flap

For larger tissue requirements, a tissue expander can be used to expand the available tissues
for reconstruction. Tissue expanders are used in one of two ways. First, the expander can
be placed in the area desired for reconstruction. Expanding the central forehead can provide
a larger flap for reconstruction and aid in donor site closure. There is some evidence that
these expanded flaps can develop secondary contracture that leads to distortion, especially
in nasal reconstruction, but this is controversial. The second, more reliable technique is to
place tissue expanders in areas laterally for donor site closure, leaving the central portion of
the forehead unexpanded to be used for reconstruction. The expanded lateral forehead on
each side is used for primary closure so that a larger primary flap can be harvested. To use the
expander technique, one would have to have the elective time for expansion. In some cases,
a preliminary skin graft for wound closure can be performed to extend the time needed.

A B

Tissue Tissue
expander expanders

Expander placement under flap to Expander placement under forehead lateral flap,
expand flap and devise closure not to expand flap but to aid in donor closure

Fig. 5A-5 

Delay Flap Procedure

If a larger flap is desired or if the flap procedure is being performed in a patient who has
poor vascularity or is a smoker, a delay of transfer of the flap may be warranted. A delay
procedure can be planned, or it can be performed based on intraoperative findings. If a
primary transfer is planned and the surgeon is unhappy with the appearance of the flap
after it has been elevated, returning the flap to its bed will give the flap its best chance of
survival, because the position of the flap will afford the best venous drainage, and the lack
of rotation at the base will limit potential interference with blood flow from kinking and
postoperative edema. If the flap could not survive by simply being returned to its donor
site, it would not have survived in its reconstructive site. More commonly, a delay can be
planned in patients who are at high risk for the use of larger flap sizes. In general, the design
of the flap will include the supratrochlear vessel or vessels at its base, as confirmed by Doppler
examination. Because the plane of dissection is an areolar plane, little blood supply will be
provided by the undersurface of the flap. Therefore it is advisable to not completely incise

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 Head and Neck  •  5A: Paramedian Forehead Flap 179

the flap, leaving the areas at higher risk intact with the surrounding tissue to provide extra
blood supply and extra drainage that would otherwise compromise the flap. These small
areas of attachment allow axialization of the blood supply so that in 2 weeks, these areas
can be divided and the flap will survive.

A B

Complete
incision at
Leave intact 7 days and
transfer at
Incise, then 10-14 days
undermine
completely

Supratrochlear Supratrochlear
artery artery

Flap is undermined completely, but base Complete incision at 7 days and

and tip remain attached transfer at 10 to 14 days

Fig. 5A-6 

Another way to use forehead tissues with the delay phenomenon is to plan the flap on
the more lateral superficial temporal vessels. Blood supply based on these vessels is unreliable
across the midline, so a surgical delay is warranted. In these cases, skin grafting is required for
donor site closure, and the aesthetic forehead subunit should be respected for best cosmesis.

C D

Incise and
Complete
undermine
incision at
completely
7 days and
transfer at
10-14 days

Superficial Superficial
temporal temporal
artery artery

Forehead carried on superficial temporal Complete incision at 7 days and

vessels, not supratrochlear transfer at 10 to 14 days

Fig. 5A-6 

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 180 Part II  Regional Flaps: Anatomy and Basic Techniques

Arc of Rotation
Standard Flap
The flap will cover defects that range from the level of the eyebrow to the lip. Flaps can
be rotated either clockwise or counterclockwise based on the recipient site and particular
need of the reconstruction.

Arc to nasal tip

and columella

Fig. 5A-7 

Flap Transfer
Once the flap is elevated to the level of the orbital rim, it is worth transposing the flap and
deciding whether further elevation is needed. After the final degree of flap elevation, the flap
can be inset directly without the need for a tunnel to reach the recipient site. In eyebrow,
eyelid, and cheek reconstruction, the inset can be direct, without a secondary procedure.
For nasal reconstruction, often the flap is transferred, leaving its pedicle exposed, bridging
normal skin at the radix and upper nose to reach the more distal part of the nose. Then the
exposed base will be grafted or dressed for the intervening delay period.

Flap Inset
The flap may be directly sutured into the defect. In some cases, a partial inset is recom-
mended, especially when final stitching of the flap causes the skin to blanch because the
blood supply is poor. Partial inset with tacking sutures can be performed, and final suturing
can be done in the office 48 hours later with the use of a local anesthetic.

Donor Site Closure

Direct donor site closure is recommended, when possible. Even for the narrowest of pedicles,
wide undermining of the forehead is often required. Scoring of the galea can assist in gaining
an extra centimeter or more of advancement to allow primary closure under tension. It is
not uncommon, especially near the hairline, to have areas that cannot be closed primarily.
Simple dressing changes allow healing by secondary intention, which in most patients can
be cosmetically acceptable. The donor site can be closed with a skin graft, especially if the
exposed base of the flap is being grafted anyway. This may have cosmetic consequences,
and often secondary procedures are required to excise these grafts. Tissue expansion of the
forehead can be performed at the initial surgery before flap transfer, or as a delayed proce-
dure after unacceptable scarring has occurred from secondary healing or skin grafting of
the donor site. The timing of tissue expansion is at the surgeon’s discretion.

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 Head and Neck  •  5A: Paramedian Forehead Flap 181

Clinical Applications
This patient shows the use of a forehead flap in cheek reconstruction after radiation therapy
and surgical excision of an angiosarcoma.

A B C

D E

F G

Fig. 5A-8  A, Residual angiosarcoma of the left cheek. B-D, The reconstruction was designed us-
ing 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. (Case courtesy Julian J. Pribaz, MD.)

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 182 Part II  Regional Flaps: Anatomy and Basic Techniques

This 64-year-old man was seen after resection of a basal cell carcinoma of the nose in which
the full thickness of the left ala was excised. The patient required reconstruction of all layers,
including lining, support, and cover.

A B D

E F G

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 recon-
struction. 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. (Case supplied by MRZ.)

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 Head and Neck  •  5A: Paramedian Forehead Flap 183

This 55-year-old man had undergone a Mohs resection of a basal cell carcinoma of the nose.
This defect had bony support but needed some lining and soft tissue cover.

B
A

C D

E F

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. (Case supplied by MRZ.)

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 184 Part II  Regional Flaps: Anatomy and Basic Techniques

This is an example of how to delay a forehead flap. The 67-year-old woman had a previous
midline scar in the forehead and was an active smoker. Because of the midline scar, tissue
harvest was limited to the right side of the forehead.

B C

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 post-
operatively, the flap is ready for transfer, without evidence of ischemia, and is supplied only by the
supratrochlear vessels. (Case supplied by MRZ.)

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 Head and Neck  •  5A: Paramedian Forehead Flap 185

This 79-year-old woman had two Mohs defects, one on the dorsum of the nose and the other
on the left side of the forehead. She had adequate support but needed some midvault lining.

A B C

D E

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. (Case supplied by MRZ.)

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 186 Part II  Regional Flaps: Anatomy and Basic Techniques

This 46-year-old man had a Mohs resection of a skin cancer of the medial canthal area. The
forehead flap can be a good choice for resurfacing needs around the orbit.

A B C

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. (Case supplied by MRZ.)

This woman in her mid-forties had a Mohs defect within most of the left ala after excision
of a basal cell carcinoma. Although the defect is similar to the one in the older patient shown
in Fig. 5C-15, it was repaired with a two-stage subunit forehead flap and primary cartilage
graft, rather than a two-stage subunit nasolabial flap. The nasolabial fold in younger patients
has less available excess and often a less distinct nasolabial crease from which to harvest
donor materials; therefore a forehead flap is often preferred when resurfacing the nose to
avoid the distortion of midface donor landmarks, which frequently occurs after harvesting
tissue from the nasolabial fold. In almost all circumstances, forehead donor deformities are
less apparent than nasolabial flap deformities.

A B

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. (Case courtesy Frederick J. Menick, MD.)

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 Head and Neck  •  5A: Paramedian Forehead Flap 187

Pearls and Pitfalls

• Although the flap can survive without identifying the supratrochlear or supraorbital vessels
in its base, one should avoid injury to these vessels and maintain them for best perfusion.
• The surgeon should avoid skeletonization of these vessels and the desire to see them be-
fore transfer. In periorbital reconstructions, tunneling the flap may cause congestion and
ischemia. It is best to connect the recipient and donor sites and directly rotate the flap.
• Aggressive thinning of the flap in its area of redundancy at its rotation point should be
avoided—this is the blood supply to the flap. This can be done more safely at a later time.
• Doppler ultrasound is used to identify the supratrochlear vessels and ensure that they are
within the flap. If the supratrochlear vessels cannot be followed for a few centimeters,
delay of the flap should be considered.
• More oblique flap designs will require more random blood supply and delay should be
considered.
• These valuable tissues should not be wasted on building the substructure of nasal or
orbital reconstruction. The forehead flap should be the last finishing piece to resurface
the reconstruction, because it has the best texture and color match of all reconstructive
flaps of the face. This is especially true in nasal reconstruction, when smaller flaps may
suffice, and the forehead flap may be required at a later time.

Expert Commentary
Michael R. Zenn

Indications
The forehead flap remains the gold standard for color match and tissue consistency in facial
reconstruction. It is the most commonly used flap for nasal reconstruction but can be used
creatively for reconstruction in the periorbital area as well.

Advantages and Limitations

A central forehead flap can be elevated without identification of the blood vessels because
of the robust blood supply of the supratrochlear, supraorbital, angular, infratrochlear, and
dorsal nasal vessels. However, rotation of the pedicle flap, reach of the flap, and prevention
of kinking of the base of the flap will all benefit from as narrow a base as possible. By using
a Doppler device to identify the supratrochlear vessels, this can be accomplished. This area
of the face, especially for a nasal reconstruction, should be considered prime real estate and
should not be squandered when reconstructing significant defects of the face or complex
defects of the nose.
The forehead tissues should be the last used in reconstruction for final resurfacing and
a final aesthetic result. Reconstruction of the foundation of the orbit or of the nose should
be performed with other flaps and other tissues. Once the forehead has been used, it is pos-
sible to reharvest, depending on the previous surgery and previous incisions, although this
will be more difficult and will likely require tissue expansion or grafting of the forehead.
Continued

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 188 Part II  Regional Flaps: Anatomy and Basic Techniques

Anatomic Considerations
One should have patience when using the forehead flap for reconstruction, especially with
nasal reconstruction. The superior portion of the flap will be the most important part used
for reconstruction, but will also be the most ischemic portion of the flap. It is often appro-
priate to take a stepwise approach to preparing tissues for final reconstruction. Often the
areas reconstructed on the columella and tip of the nose require as thin a flap as possible.
Too much thinning at the initial procedure can cause loss of the flap and loss of the most
valuable tissue for reconstruction. I recommend elevating the flap and thinning its distal-
most part only to the subcutaneous level, and only for a distance of 1 to 2 cm. One should
be able to visualize the axial vessels within the subcutaneous tissues and spare them. At
10 to 14 days, one can return and reelevate the flap, thinning it a second time if thinner
tissues are needed, since the flap will have acclimated to its new blood supply and position
and will be more reliable and robust. Some may do two or more thinnings before division
of the base of the flap and final inset.

Recommendations
Planning
Cosmesis at the donor site is excellent in these median forehead flaps. A vertical design will
leave a vertical scar, which ultimately will heal best. Areas of dog-ear superiorly can be ex-
tended into the hair-bearing scalp and excised without compromising vascularity. It is not
uncommon to have fullness at the glabellar area when performing periorbital reconstruction,
from rotation of the pedicle. Fullness of this area is also a common problem after division
and inset of the pedicle. When dividing the pedicle and returning tissues to the forehead,
it is recommended to aggressively thin the glabellar area, which includes resection of the
corrugator muscles in this area. I take more tissue than I anticipate I need to take and have
been much more pleased with the resulting donor site. This has also limited the amount of
revisions that are required in this area.
In designing the flaps for the recipient site, it is important to make accurate templates
as to the need for tissue. The templates should be the exact size of the tissue requirements.

Technique
When reconstructing areas that have healed by secondary intention or skin grafting, one
must excise the area of cicatrix or skin graft and allow the tissues to resume their normal
position. This will increase the size of the recipient area and allow a more accurate recon-
struction. In smokers and patients with poor vascularity, I have a low threshold for delay-
ing the flap, leaving the flap attached distally and training the blood supply to improve the
vascularity of the flap. Completion of the delay can be performed in the clinic, with simple
suturing of the small bridges to confirm excellent vascularity and complete the delay before
the actual surgical date. Timing of the delay may depend on patient vascularity but can
safely be performed at 2 weeks. I recommend placing a tourniquet with a simple elastic in
the holding area around the pedicle at the glabella. By the time the patient is taken to the
operating room, it will be quite clear whether the flap has adequate vascularity or not. If
the flap appears to be ischemic or markedly congested, further delay is warranted.

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 Head and Neck  •  5A: Paramedian Forehead Flap 189

Complications
The main complications relating to use of the paramedian forehead flap involve ischemia,
partial flap loss, and scarring of the forehead donor site. If the surgeon upon flap inset finds
evidence of ischemia to the tip of the flap, delaying the final inset should be considered.
Tacking sutures can be placed to hold the tissue and final closure can be performed 4 to
7 days later in the office under local anesthesia. Although the forehead scar is usually ac-
ceptable, there are times when excessive tension or secondary healing leave a less than ideal
scar. I generally recommend waiting 4 to 6 months before considering scar revisions in the
forehead.

Bibliography With Key Annotations

Bruschi S, Marchesi SD, Boriani F, et al. Galea-including forehead flap for lower one-third
nasal reconstruction. Ann Plast Surg 63:67-70, 2009.
The first choice for internal mucosal restoration of the nose is a septal mucosal or vestibular local flap.
The forehead flap, raised including the galeal layer, is an alternative option for large nasal defects.
It can be used in any difficult situation in which septal or vestibular flaps are not adoptable, such as
complete loss of the lower third. The authors described the inclusion of the galea in the traditional
median forehead flap for nasal lining reconstruction. Thirteen patients treated with a forehead flap
including the galea for lower third nasal reconstruction were retrospectively reviewed. No complete flap
necrosis occurred. In one case, lining was lost to infection. In two cases, a moderate nostril stenosis was
observed as a late complication.
de Figueiredo JC, Naufal RR, Zampar AG, et al. Expanded median forehead flap and Abbé
flap for nasal and upper lip reconstruction after complications of polymethylmethacrylate.
Aesthetic Plast Surg 34:385-387, 2010.
Despite the benefits of the minimally invasive technique, complications may occur, raising doubts
about the safety of polymethylmethacrylate as an injectable filler material. The authors reported their
treatment of a patient from another institution with necrosis involving full-thickness nasal skin and
upper lip after injection of polymethylmethacrylate in the nasolabial folds and nose for augmentation.
An expanded median forehead flap was used to reconstruct the nose, and an Abbé flap was used for
the upper lip. The flaps and the skin expander allowed reconstruction with correct texture, color, and
dimensions, producing a good aesthetic and functional outcome.
Gosain AK, Zochowski CG, Cortes W. Refinements of tissue expansion for pediatric forehead
reconstruction: a 13-year experience. Plast Reconstr Surg 124:1559-1570, 2009.
A 13-year retrospective review was carried out of all pediatric patients who completed reconstruction
for lesions involving at least 25% of the forehead by a single surgeon. All lesions were classified by
the percentage of forehead involved and involvement of adjacent subunits. Twenty patients completed
reconstruction. A median of six (range 2 to 11) surgical procedures was required, with a median of three
(range 1 to 4) expansion procedures. Simultaneous expanders were placed in the scalp (16 patients)
and cheek (8 patients). Five patients underwent correction of eyebrow ptosis as a final procedure.
Reconstruction involved 25% to 70% of the forehead in 19 patients, 17 of whom were reconstructed
with serial forehead expansion and advancement flaps. One patient with a pigmented nevus occupying
more than 75% of the forehead received an expanded full-thickness skin graft from the lower abdomen.
For all groups, the entire extent of the visible lesion was excised and complete skin coverage achieved.

05a_ParamedFore_r6c_ek_0170-0191.indd 189 1/30/2012 5:39:33 PM

 190 Part II  Regional Flaps: Anatomy and Basic Techniques

Güzel MZ. The turnover subdermal-periosteal median forehead flap. Plast Reconstr Surg
111:347-350, 2003.
Kelly CP, Yavuzer R, Keskin M, et al. Functional anastomotic relationship between the su-
pratrochlear and facial arteries: an anatomical study. Plast Reconstr Surg 121:458-465, 2008.
For the previous 15 years, the authors had used a forehead flap with its pedicle based at or below the
medial canthus without any flap loss. This study described the anatomic vascular relationships that
allowed this flap design to be successful. Nine fresh-frozen cadaver heads were studied in three groups.
Six heads were injected with red latex. In group I, the supraorbital, supratrochlear, and facial arteries
of four heads were dissected out under the operating microscope. In group II, using two latex-injected
heads, the median forehead flap was elevated in the extended fashion, and the arteries within the flap
were dissected. The distal portion of the flap was elevated supraperiosteally, and the proximal por-
tion was elevated subperiosteally. In group III, the arterial systems of three heads were injected with
barium solution after the flaps had been elevated. Radiographic assessment was used to demonstrate
the vascular pattern within the flap. Group I showed an anastomotic relationship between the supra-
trochlear and facial arteries and a consistent relationship between the infraorbital and facial arteries.
Group II showed that the above-mentioned connections could be protected during the supraperiosteal
and subperiosteal flap elevation. This was confirmed by radiographic assessment in group III. The
vascular network of the flap was filled through the facial artery via the dorsal nasal and supratrochlear
arteries. Within the paranasal and medial canthal region, there is an anastomotic relationship between
the supratrochlear, infraorbital, and branches of the facial arteries, and branches from the contralateral
side, creating a rich vascular arcade. This allows a median forehead flap to be narrowly based at the
level of the medial canthus.
Kleintjes WG. Forehead anatomy: arterial variations and venous link of the midline forehead
flap. J Plast Reconstr Aesthet Surg 60:593-606, 2007.
The author reported the largest prospective cadaver study conducted over a 3-year period to investigate
the arterial variations of the forehead. The primary goal was to find anatomic support for various
previously designed forehead flaps. Thirty cadaver foreheads (60 hemiforeheads) were dissected from
deep to superficial to identify arterial variations. The arteries were filled with a latex solution before
dissection. The author detailed the findings and concluded that the significance of the central artery
and vein favors the median forehead flap as anatomically superior, and the prominent central vein is
a constant landmark on which to select the side of the pedicle.
Little SC, Hughley BB, Park SS. Complications with forehead flaps in nasal reconstruction.
Laryngoscope 119:1093-1099, 2009.
The authors reviewed the charts of their patients from 1995 to 2008 to identify those characteristics
and comorbidities that are associated with a higher rate of complications in patients undergoing nasal
reconstruction with a forehead flap. They reviewed the charts of 205 patients with a median age of
66. Three preexisting comorbidities were tracked: diabetes, smoking, and vascular disease. Major
complications (flap necrosis, nasal obstruction, alar notching) and minor adverse outcomes (partial nasal
obstruction, epidermolysis, and alar asymmetry) were recorded. Full-thickness defects were significantly
associated with higher incidences of any major complication and had higher odds of flap necrosis and
alar notching. Smokers had higher odds of developing flap necrosis. Neither the presence of diabetes,
increased age, or vascular disease was significantly associated with higher rates of major complications.
Masic T, Lincender I, Dizdarevic D. Reconstruction of total and subtotal nose defects. Med
Arh 64:110-112, 2010.
This paper reported on the management of patients with subtotal and total nasal defects with the use
of forehead and nasolabial flaps. From 2007 to 2010, 20 patients with total or subtotal nasal defects
were observed; 6 defects resulted from trauma and 14 from tumor resection. All were full-thickness
defects of the nasal mucosa, skin of the nasal antechamber, cartilage frame, and external nasal skin.

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 Head and Neck  •  5A: Paramedian Forehead Flap 191

All were appropriate for local flap reconstruction. A median forehead flap was used in 12 cases, a
nasolabial flap in six cases, and a combination of these two flaps in two cases. Satisfactory results
were achieved in all patients except for one with speech dysfunction. Nasal function was maintained
with proper porosity of the nostril. The three-dimensional appearance of the nose was reconstructed
with acceptable aesthetic results.
Mombaerts I, Gillis A. The tunneled forehead flap in medial canthal and eyelid reconstruction.
Dermatol Surg 36:1118-1125, 2010.
The midline forehead flap is used in the reconstruction of large, deep defects of the medial canthal area
and lower eyelid. Drawbacks included a cosmetically unfavorable skin bulge at the nasal bridge and
obliteration of the natural medial canthal concavity, both of which required correction in a second stage.
The authors adopted a modification of the technique to avoid these drawbacks. They reviewed the
medical records and photographs of their patients who underwent the tunneled midline forehead flap
procedure to repair medial canthal defects and anterior lamellar repair of eyelid defects. The forehead
flap was elevated in the subdermal plane, and the pedicle was deepithelialized and transferred through
a subgaleal tunnel from the pivot point of the flap into the primary defect. Nine patients had defects
of the medial canthal area, the medial part of the eyelids, or both after surgical removal of malignant
tumors. Follow-up ranged from 5 months to 6.1 years (mean 2.1 years; median 11 months). In all
cases, flap viability was maintained, the globe was protected, and the concave architecture of the medial
canthus was preserved.
Redondo P. Repair of large defects in the forehead using a median forehead rotation flap and
advancement lateral U-shaped flap. Dermatol Surg 32:843-846, 2006.
Most forehead defects that cannot be closed primarily are reconstructed with laterally based advance-
ment flaps. The author described a combination of a median forehead rotation flap and an advance-
ment lateral U-shaped flap for repair of medium to large defects in paramedian and lateral forehead.
Technically the design of the median forehead rotation flap based on supratrochlear vessels was similar
to the median forehead transposition flap used to reconstruct large defects of the nasal dorsum. The
length and movement of the flap were much smaller in this case. Approximately two thirds of the
closure of the defect was achieved by displacing the median forehead flap, whereas the remaining third
corresponded to the advancement of the lateral U-shaped flap. These flaps are simple to perform,
have minimal complications, and have good cosmetic results. A representative case was presented along
with photographs.

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 ANATOMIC LANDMARKS
Landmarks The scalp encompasses the entire hair-bearing portion of the
head and can include non-hair-bearing areas of the postauricular
area and forehead.
Size The entire scalp may be elevated. Individual flaps based on
designated pedicles may be up to 30 cm in diameter with skin
grafting of the donor or tissue expansion.
Function The scalp contains the frontalis and occipitalis muscles responsible
for brow elevation and some limited scalp movements. Muscle
may be part of flaps designed from the scalp, but the muscles are
not functional. The scalp also has a role in temperature regula-
tion.
Composition Fasciocutaneous, type A.
Dominant Pedicles Superficial temporal artery and venae comitantes; occipital artery
and venae comitantes.
Minor Pedicles Supratrochlear artery and venae comitantes; supraorbital artery
and venae comitantes; posterior auricular artery and venae co-
mitantes.
Nerve Supply Motor: Temporal branch of the facial nerve, zygomaticotemporal
branch of the maxillary nerve, and the auriculotemporal branch
of the mandibular division of the trigeminal nerve. Sensory: Su-
pratrochlear, auriculotemporal, postauricular, greater occipital,
lesser occipital, great auricular, and third occipital nerves.

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 Section 5B
Head and Neck

Scalp Flap

CLINICAL APPLICATIONS
Regional Use
Scalp
Face
Specialized Use
Scalp
Nose

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 ANATOMY OF THE Scalp FLAP

A Superficial temporal artery

Galea
aponeurotica
Frontalis muscle
Superficial
temporal nerve

Occipitalis
muscle
Temporal artery

Posterior
auricular nerve

Occipital artery

Occiptal nerve
Posterior Temporal nerve
auricular artery

Lateral view

Galea
Galea
aponeurotica
aponeurotica
B Frontalis
C
muscle
Supratrochlear
artery
Supraorbital
artery
Supraorbital
nerve Occipitalis Posterior
Supra- muscle auricular
trochlear nerve
nerve

Occipital artery Occipital nerve

Anteroposterior view Posterior view

Fig. 5B-1 

Dominant pedicles: Superficial temporal artery; occipital artery

Minor pedicles: Supratrochlear artery; supraorbital artery; posterior auricular artery

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 Head and Neck  •  5B: Scalp Flap 195

Anatomy
Landmarks This specialized area of skin covering the cranium has unique hair-growth
characteristics. The blood supply to this area is rich, and areas beyond the hair-
bearing area and the retroauricular and forehead areas can also be incorporated
into flaps.
Composition Fasciocutaneous. Specialized hair-bearing skin is unique to this part of the body.
Frontalis and occipitalis muscles incorporated in flaps are not functional.
Size Although the entire flap can be elevated on a single pedicle, flaps on designated
pedicles can have a width of up to 30 cm. Primary closure may be possible with
expansion; however, back-grafting with a skin graft is often necessary for these
large advancements.
Function Temperature regulation and facial expression.

Arterial Anatomy
Dominant Pedicle  Superficial temporal artery
Regional Source  External carotid artery.
Length  5 cm.
Diameter  2.5 cm.
Location  Originates from the external carotid and courses in the preauricular area and over the
zygomatic processes of the temporal bone. The pedicle branches into both frontal and parietal
branches, which are located superficial to the superficial temporoparietal fascia. Both vessels
then course toward the midline of the scalp.
Dominant Pedicle  Occipital artery
Regional Source  External carotid artery.
Length  4 cm.
Diameter  2.5 mm.
Location  Passes beneath the sternocleidomastoid and neck musculature. It then passes between
trapezius and sternocleidomastoid muscles into the occipitofrontalis muscles 4 cm lateral to the
occipital protuberance. The vessel then courses anteriorly.
Minor Pedicle  Supratrochlear artery
Regional Source  Terminal branch of ophthalmic artery.
Length  3 cm.
Diameter  1 mm.
Location  Exits the orbit medially as it courses through the corrugator muscles and frontalis
muscle cephalad over the epicranium.
Minor Pedicle  Supraorbital artery
Regional Source  Ophthalmic artery.
Length  4 cm.
Diameter  1 mm.
Location  Exits through the supraorbital foramen beneath the frontalis muscle and courses cephalad.
Minor Pedicle  Posterior auricular artery
Regional Source  External carotid artery.
Length  3 cm.
Diameter  0.5 mm.
Location  Arises in common either with the occipital or the superficial temporal artery.

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 196 Part II  Regional Flaps: Anatomy and Basic Techniques

Venous Anatomy
Named vessels with accompanying venae comitantes.

Nerve Supply
Motor Temporal branch of the facial nerve, zygomaticotemporal branch of the maxil-
lary nerve, and the auriculotemporal branch of the mandibular division of the
trigeminal nerve.
Sensory Supratrochlear, auriculotemporal, postauricular, greater occipital, lesser occipital,
great auricular, and third occipital nerves.

Vascular A natomy of the Scalp Flap

A

D1

D1

Entire scalp with posterior midline incision

B
m1

m2

D1
D1

D2
D2

Radiographic view

Fig. 5B-2 

Dominant pedicles: Superficial temporal artery (D1); occipital artery (D2)

Minor pedicles: Supratrochlear artery (m1); supraorbital artery (m2)

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 Head and Neck  •  5B: Scalp Flap 197

Flap Harvest
Design and Markings
The scalp has the following sources of circulation: the anterior central scalp has the supra-
trochlear and supraorbital vessels; the anterior preauricular scalp has the frontal and parietal
branches of the superficial temporal artery; the anterior postauricular scalp has the posterior
auricular vessels; and the posterior scalp has the occipital vessels. These vessels should be
localized with a Doppler probe before scalp flaps are planned and designed. For best per-
fusion, any flap design should locate one or more of these pedicles within the base of the
flap. The actual number of flaps will depend on the clinical situation and the remaining
blood supply. Simple single flaps, two-flap, three-flap, and four-flap techniques have been
described. Scalp flaps in general do not extend beyond the anterior hairline to preserve the
aesthetic subunit of the forehead.

Incision
Suture

Rotation flaps

Incision Suture

Rotation flaps

Fig. 5B-3 

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 198 Part II  Regional Flaps: Anatomy and Basic Techniques

Incision Suture

Incision Incision Suture Suture

Gillies’ tripod technique

Incision Incision Suture

Bipedicle flaps

Fig. 5B-3 

Patient Positioning
Patient positioning will depend on the area of the defect and the donor site used. In general,
the prone position will be most useful for lateral and posterior defects and defects of the
vertex. Anterior defects near the hairline are often best addressed with the patient in the
supine position. Full exposure of the head is necessary, because scalp mobilization will be
performed around the entire scalp, regardless of the size of the defect.

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 Head and Neck  •  5B: Scalp Flap 199

Guide to Flap Dissection

Flaps are incised down through the galea and flaps are quickly elevated in this areolar plane.
Expansion of the flaps is performed through the technique of galeal scoring. This is done
either with a knife or a Bovie cautery. With either technique the galea is opened across
either the width or length of the flap, depending on the reconstructive need. The galea
can be scored every 1 to 2 cm, depending on need. Care must be taken to preserve the
vasculature that lies below the galea.

Galeal Scoring

Flap elevated and scored Flap advanced

A B

Wound
Incision Suture

Scoring Scoring

Across width to increase length

C D

Incision Incision Suture

Scoring Wound Scoring

Lengthwise to increase width

Fig. 5B-4 

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 200 Part II  Regional Flaps: Anatomy and Basic Techniques

In cases in which the source blood vessel cannot be found by Doppler ultrasound or
where long thin flaps are required for reconstruction, a delay procedure should be consid-
ered. A delay would involve incision of the sides of the flap, keeping both the base and the
tip of the flap attached. The flap is undermined again in the subgaleal plane, and then the
incisions are closed. In 7 days, the distal tip of the flap can be incised, and at 10 to 14 days,
the flap is rotated.

Flap Delay

E F

Incision
Complete incision
at 7 days and
transfer at
10-14 days

Occipital Occipital
artery artery

Fig. 5B-4  E, Initial incisions and flap undermining. F, Completion of delay at 7 days.

Flap Variants
•  Three- or four-flap technique
•  Temporoparietal flap
•  Occipitoparietal (Juri) flap
•  Washio flap
•  Tissue expander–based flaps

Three- or Four-Flap Technique

For a scalp defect, coverage with a two- or three-flap technique is commonly used. This
allows expansion of each of the flaps elevated to increase the surface area to cover the de-
fect. These flaps, once scored, can be advanced or rotated into position. Not uncommonly,
back-grafting is required to completely close donor sites.

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 Head and Neck  •  5B: Scalp Flap 201

Three-Flap Expansile Technique

A B

Incision
Superficial Superficial
temporal temporal
artery artery
1 1
2 2
Incision

3 3

Occipital Occipital
artery artery
Occipital Occipital
artery artery

Scoring
C D

Suture Superficial
Superficial temporal
temporal artery
artery
Occipital
artery

Scoring
Scoring
Occipital
Occipital artery
artery
Occipital
artery

Fig. 5B-5  A, Bipedicle flap oriented parallel (1-2) 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 expan-
sion without interruption of vascular pedicles superficial to galeal layer. D, Final closure with flaps inset.

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 202 Part II  Regional Flaps: Anatomy and Basic Techniques

Four-Flap Technique

A B
4 3
Incision Scoring
4
Wound 3

1 2

2
1

C
3

Suture 2

Fig. 5B-6  The four-flap technique is particularly applicable in a child.

Temporoparietal Flap
These more centrally based flaps are based over the superficial temporal system and are
often used for more specialized purposes such as eyebrow and mustache reconstruction.
When used for these purposes, these flaps can be elevated as unipedicle flaps for unilateral
reconstruction or bipedicle flaps for mustache reconstruction. Because of the length and
narrow design of these flaps, a delayed procedure is often recommended for best viability
(see Fig. 5B-15).

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 Head and Neck  •  5B: Scalp Flap 203

Occipitoparietal (Juri) Flap

This is the most commonly used flap for alopecia surgery and reconstruction of the anterior
hairline. Based on the temporal or occipital vessels, the length and width of this flap often
requires a delay procedure to carry the entire length of the scalp to reconstruct the entire
anterior hairline. Again, both proximal and distal attachments are maintained while the
remainder of the flap is incised and elevated and then resutured. The flap may be advanced
into position at 10 to 14 days after delay. Often with the Juri flap the remaining scalp can
be advanced and closed without skin grafting.

Superficial
temporal
Incision artery

Flap drawn
B over forehead

Superficial
temporal
artery

Temporoparietooccipital flap design

Fig. 5B-7 

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 204 Part II  Regional Flaps: Anatomy and Basic Techniques

Washio Flap
This flap takes advantage of the non-hair-bearing skin in the mastoid area. Oftentimes no
other tissues are available for specific reconstructions such as nasal reconstruction where
good color and texture match are critical for a reconstruction. The Washio flap elevates the
scalp and carries this portion of non-hair-bearing skin from the postauricular area to the
nose. The defect created in the postauricular area is skin grafted while the area of exposed
scalp can be dressed during the process of revascularization of the flap. Similar to a forehead
flap, the pedicle, which supplies the skin, can be tubed for control of the wound. After 10
to 14 days the flap can be divided and the scalp tissues are returned to the scalp replacing
areas of temporary dressing although the postauricular area maintains its skin graft. Use of
this flap is limited to situations in which no other locally based flaps are available.

A B
Superficial
temporal
Superficial artery
temporal
Incision artery

Flap drawn
over eye

Flap design with superficial temporal pedicle Flap elevated with arc of rotation to nose

Suture
Superficial
temporal
artery

Flap inset of nose

Fig. 5B-8 

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 Head and Neck  •  5B: Scalp Flap 205

Tissue Expander–Based Flaps

Most commonly tissue expansion can be performed in the scalp to increase the surface area
of the specialized hair-bearing tissues. The expansion process itself can often take weeks to
months; therefore one must have the time to perform the expansion. Most commonly the
defect to be reconstructed is skin grafted or is benign in its nature such that the expansion
can be performed first. The general rule of thumb is to place as large a tissue expander as
one can fit in any one location and to place as many expanders as possible to completely
expand the scalp tissues. Once expansion is complete, flaps may be designed as straight ad-
vancement flaps or rotational flaps to move the excess tissue generated into the defect and
still allow primary closure (see Figs. 5B-10, 5B-14).

Arc of Rotation
One-, Two-, Three-, and Four-Flap Techniques
Galeal scoring of these flaps allows expansion in either length or width necessary to rear-
range these flaps for a reconstruction. These flaps generally are advanced or rotated and the
arc of rotation will depend on the designed length and the amount of advancement allowed
by scoring. Remember, any flap rotation will lose length with rotation. Defects of up to
20 cm in diameter have been closed using these techniques (see Figs. 5B-5, 5B-6, 5B-11).

Temporoparietal Flap
These flaps can safely be designed to midline and rotated safely in a single-stage procedure.
When flaps are extended past the midline, a delay procedure is recommended. By dissecting
the superficial temporal pedicle down toward the preauricular area, areas of the eyelid and
mustache can easily be reached (see Fig. 5B-14).

Occipitoparietal (Juri) Flap

The point of rotation for the Juri flap is at the top of the ear. To reconstruct an entire hairline,
the flap length must be measured from this rotation point. Because of the narrow width of
these flaps and their long length, a delay is recommended for viability of these flaps. Once
delayed, the flap should easily reach across the anterior hairline to the contralateral side.

Flap drawn Flap drawn

A over forehead B over forehead

Superficial
temporal
Superficial artery
temporal
artery

Arc to anterior scalp Arc to frontal skull

Fig. 5B-9 

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 206 Part II  Regional Flaps: Anatomy and Basic Techniques

Washio Flap
Most commonly used for nasal reconstruction, the Washio flap is elevated and easily reaches
the area of the nose without galeal scoring (see Figs. 5B-8, 5B-15).

Tissue Expansion
Actual reach of the flaps created by tissue expansion will depend on the amount of expan-
sion. Measurements from the base pedicle up and around the tissue expander will indicate
the length of reach from the base of the pedicle to the area of reconstructive need and can
guide the surgeon during tissue expansion (see Fig. 5B-13).

Flap Transfer
One-, Two-, Three-, and Four-Flap
and Temporoparietal, Occipitoparietal,
and Washio Flap Techniques
Once elevated, flaps are transposed or advanced to the defect and secured in the galeal and
dermal levels. Burying these pedicles or tunneling them is not recommended, except in
eyebrow or mustache reconstruction. If flap transposition from the donor site to the recipient
site crosses normal tissue, the flap may be tubed or dressed on its exposed side and tempo-
rized while tissue ingrowth occurs. It is usually safe to divide these flaps at 10 to 14 days,
depending on the clinical situation and return of the pedicle tissue back to its donor site.

Tissue-Expanded Flaps
One must decide, based on the tissue generated and the need for reconstruction, whether
the flap should be advanced as a transposition or pure advancement flap. Again, burying or
tunneling the flap is not recommended. It is often possible to split the area crossed by the
pedicle tissue to allow a direct one-stage inset. All rotated or transposed flaps may create a
dog-ear, which should be left and not revised immediately, because this may compromise
blood supply.

Port
A Expander B

Suture
Incision

Wound

Advancement designed in area of expansion; After inset

Burow’s triangles to be excised

Fig. 5B-10 

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 Head and Neck  •  5B: Scalp Flap 207

Port
C Expander D
Suture

Incision

Wound

Design of transposition flap within area After inset

of expanded scalp

Fig. 5B-10 

Flap Inset
Scalp flaps have a robust blood supply but can be made ischemic by too much tension on
closure. Clinical inspection of the flap is important, and if the flap appears white from ten-
sion, delayed inset of the flap is recommended. The flap may be temporarily tacked with
some tacking sutures and the patient returned to the operating room 48 hours later for final
closure. Otherwise, the flap is secured in its new position with both galeal and skin suturing.

Donor Site Closure

All Flap Variants
If flaps are planned for a primary donor site closure, this often can be accomplished once
the flap has been rotated or advanced. The remaining defect can be closed by simple galeal
scoring and advancement. Often the amount of tissue used for reconstruction dictates that
a skin graft will be required at the donor site. This allows a primary wound closure, and the
area of alopecia can be addressed at a later time through serial excision or tissue expansion
to remove the skin graft, if warranted.

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 208 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 63-year-old man underwent resection of a brain tumor after preoperative embolization.
Probably as a result of this embolization, the scalp flaps became necrotic postoperatively. He
had not received radiation therapy, and his neurosurgeon was concerned that the avascular
bone flap and hardware would become exposed and infected. Although he had been referred
for a free flap, it was thought that the defect would be amenable to local scalp flap closure.

B C

Fig. 5B-11  A, The patient is seen prone with the forehead down. The T incision used for the neu-
rosurgical 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. (Case supplied by MRZ.)

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 Head and Neck  •  5B: Scalp Flap 209

This 78-year-old man had a squamous cell carcinoma of the scalp that required Mohs
resection and had an area of exposed bone. Coverage with tissue was required to facilitate
postoperative radiation therapy. Because of the patient’s age and medical comorbidity, free
tissue transfer was not considered. In such a situation, the use of local scalp tissue and back-
grafting with a skin graft is advisable.

A B C

D E

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 con-
tains 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. (Case supplied by MRZ.)

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 210 Part II  Regional Flaps: Anatomy and Basic Techniques

This 25-year-old woman had had a traumatic amputation of the scalp that failed attempts
at replantation. Four months after skin grafting the wound, tissue expansion was scheduled.
The patient had adequate hair-bearing areas for expander placement and eventual replace-
ment of the skin graft with hair-bearing scalp.

B C

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.

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 Head and Neck  •  5B: Scalp Flap 211

D E

F G

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 re-
sected. 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 hair-
line. 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. (Case supplied by MRZ.)

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 212 Part II  Regional Flaps: Anatomy and Basic Techniques

This 42-year-old man underwent resection and reconstruction with a radial forearm free
flap for a squamous cell carcinoma of his upper lip. The reconstruction was functional but
not aesthetic. As a secondary procedure, a mustache reconstruction was planned with a
scalp flap based on the superficial temporal system.

B C

D E

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 postopera-
tively. (Case supplied by MRZ.)

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 Head and Neck  •  5B: Scalp Flap 213

This child had congenital absence of heminose; the defect was treated with a Washio flap
to avoid forehead scars.

A B C

D E

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. (Case courtesy Ian T. Jackson, MD.)

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 214 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient had a low-flow vascular malformation.

A B

C D

Galeal
scoring

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.

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 Head and Neck  •  5B: Scalp Flap 215

E F

G H

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. (Case courtesy Ian T. Jackson, MD.)

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 216 Part II  Regional Flaps: Anatomy and Basic Techniques

This 50-year-old woman had a large basal cell carcinoma.

C D

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 transpo-
sition 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.

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 Head and Neck  •  5B: Scalp Flap 217

F G

I J K

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 car-
ried out by scalp expansion to reconstruct the skin grafted area. (Case courtesy Ian T. Jackson, MD.)

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 218 Part II  Regional Flaps: Anatomy and Basic Techniques

When large unilateral defects involving virtually the whole hemiforehead result from tumor
resection, the concept advanced by Worthen may be used.

A B

C
D
E

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.

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 Head and Neck  •  5B: Scalp Flap 219

Scoring

G H

K
I J

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. (Case courtesy Ian T. Jackson, MD.)

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 220 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Defects of the scalp are best reconstructed with like scalp tissues.
• Tissue expansion provides the safest, most reliable technique for creating and providing
like tissues for scalp reconstruction. Planning the flaps in the expanded tissue is critical
for success and for best utilization of expansion.
• Most tissue expansion cases will benefit from straight advancement of flaps and excision
of Burow’s triangles.
• Although the Washio flap is rarely used, the surgeon should keep it in mind when re-
constructing a nose that has had multiple procedures or complications and no forehead
tissues are available.
• Expanded flaps can be quite thin, and care must be taken in scoring and manipulating
the flaps to avoid avulsion or ischemia.
• When there is exposed bone, a history of radiation treatment, or a wound that will not
take a skin graft, one should strongly consider advancing nearby scalp into the defect
and back-grafting the donor site with a skin graft. Flaps may be planned so that the
back-grafting can be done in a cosmetically acceptable location or far enough away from
the open wound that the skin graft should heal uneventfully. Later the skin graft can be
removed by serial excision or tissue expansion at the patient’s convenience.

EXPERT COMMENTARY
Ian T. Jackson

All plastic surgeons should be capable of performing a scalp flap. This is more significant
today, as we have become more and more involved in craniofacial surgery. We should also
know our limitations. Coronal flaps are within the range of the plastic surgeon’s training,
but intracranial procedures are in the realm of neurosurgery.

Indications
The main procedures are in the closure area to cover the dura and to protect the cranium
with vascularized material, which is mainly scalp. Skin grafts will not survive on the external
layer of the cranium minus pericranium because of a lack of blood supply, if such a flap is
desired. This can be designed so that the pericranium will be preserved. This all requires
careful planning, and it is important not to damage the lateral cranial area. This will not
allow a skin graft to survive, and thus a further problem will have been created.

Recommendations
Technique
On some occasions the flap can be expanded to provide the required cover. This may be
achieved by multiple incisions of the pericranium, which can provide maximal expansion.
Care must be taken not to injure the deep area; necrosis may result, with exposure of the
cranium. In situations in which a raw area will result, the latter will have pericranium left
in place, and the area is covered with a split-thickness skin graft.

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 Head and Neck  •  5B: Scalp Flap 221

A somewhat more hazardous approach is tissue expansion. The danger lies in the
potential for infection and expansion tension. The area to be expanded must be in such a
position that the expander does not find its way into the defect. If this happens, the treatment
should be discontinued. Sometimes there may be enough scalp tissue to use, even though
the region has only been partially expanded. In other situations, removal of the expander
and partial resection and reconstruction with the flap should be performed.
The expander should be positioned so that it is well away from the zone of injury. The
rules of expansion are as follows: (1) an area away from the defect is chosen so the wound
is not disturbed, and (2) the expansion must be very frequent, several times a day for 2 to
3 hours with small volumes (5 to 10 ml). This can prevent too much tension at each expan-
sion. If the scalp is too tight, the volume of fluid is reduced. This can be done easily and
painlessly, because the filling value is exteriorized. This situation allows expansion several
times a day. Usually the patient or a relative can be trained to do this. This can also be done
in children once they realize it is painless. (3) Once the expansion has been completed, the
scalp flap can be designed. It is important to measure the expanded area carefully. If this is
sufficient, excision and reconstruction are performed. If there is not enough skin, further
expansion is performed. It is always better to have too much than too little tissue.

Complications: Avoidance and Treatment

Most complications result from a poor blood supply to the flaps, infection or exposure
of the expanders, or exposed bone in the donor site that requires further surgery. Proper
execution using the tips above will help to limit these problems.

Expert Commentary
Michael R. Zenn

Advantages and Limitations

The scalp is perhaps one of the best vascularized areas of the body. This can be used to one’s
advantage in reconstruction as these flaps can be quite robust. That said, long, random flaps
of the scalp, especially when narrow, may necrose and foil the reconstructive effort.

Recommendations
Planning
A general rule of thumb is to design any scalp-based flaps with the aid of a Doppler device
to ensure a signal in the base of any flaps designed. It is often possible to follow these ves-
sels, mark their axial course, and create axial-based flaps that have a better blood supply
than random flaps.
When defects greater than 6 cm must be reconstructed, I prefer placement of tissue
expanders as the primary reconstructive technique. Two or three expanders can often be
placed around the area of defect, and these should be as large as possible to fit under the
existing scalp. I prefer to place these expanders through radial incisions, not longitudinally
along the defect, because these incisions may dehisce during the expansion process.
Continued

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 222 Part II  Regional Flaps: Anatomy and Basic Techniques

Measurement of the scalp preoperatively can be helpful in determining the amount of

tissue expansion required. One can compare the preoperative measurements to measure-
ments of the postexpanded scalp to determine how much extra skin has been generated.
This is then compared with the recipient site to see whether tissue expansion is complete.
One should always overexpand, because once these tissue expanders are removed, the flaps
will provide less than they measure because of the elastic nature of scalp flaps.
Although galeal scoring is a standard method for expanding flaps further, one must
be careful when scoring expanded flaps, because they are quite thin and can be easily
avulsed. Planning should rely on the expansion, and not on scoring. These expanded flaps,
once advanced or rotated, are often associated with large dog-ears. These dog-ears can be
excised as Burow’s triangles; however, clinical experience shows that these dog-ears will
often disappear over time as the scalp settles down to the cranium. Dog-ears can always be
excised later if they do not resolve on their own after 4 to 6 months.

Technique
Flaps based in the temporoparietal area on the superficial temporal vessel can be quite useful
for eyebrow and mustache reconstruction. These flaps are centered over these vessels but
can often be congested on initial elevation. If the flaps are to be passed in a subcutaneous
plane to the eyebrow or mustache,

Take-Away Messages
I strongly recommend a delay procedure with these flaps to avoid postoperative conges-
tion or ischemia from compression of the pedicle. These delays are usually accepted by the
patient, since they are correcting secondary deformities and there is the luxury of time.

Bibliography With Key Annotations

Altindas M, Yucel A, Ozturk G, et al. The prefabricated temporal island flap for eyelid and
eye socket reconstruction in total orbital exenteration patients: a new method. Ann Plast Surg
65:177-182, 2010.
Anophthalmic socket reconstruction is a challenging problem in plastic surgery. The authors had
described a prefabricated superficial temporal fascia island flap and used this technique in more than
50 enucleation patients with severe socket contraction, ending in excellent or good results for 28 years
(Altindas-1 procedure). However, the flap was not suitable for exenteration patients with complete
eyelid loss. The technique was modified and used in exenteration patients (Altindas-2 procedure). In
this two-stage procedure, the temporoparietal fascia is prefabricated with a full-thickness skin graft from
the retroauricular area, and a strip of scalp is preserved at the middle of the flap. The flap is transferred
to the orbit through a subcutaneous tunnel at the second stage. The prefabricated flap is used for the
reconstruction of eyelids and periorbital skin; a scalp island is used for the reconstruction of lid margins
and eyelashes; and the neighboring bare temporoparietal fascia is used for the augmentation of the
periorbital soft tissues. The orbital lining is elevated as a centrally based skin flap and used for the
reconstruction of the eye socket, fornices, and posterior lining of the eyelids. The technique was used
successfully in five total exenteration patients with complete eyelid loss. In one patient the ipsilateral
temporal island flap was used previously, so the flap was prepared from the contralateral site and
transferred to the anophthalmic orbit as a free flap 5 weeks later. By means of this procedure, it is
possible to reconstruct a stable eye socket that is suitable for ocular prostheses, upper and lower fornices,
periorbital skin with good color matching, naturally looking eyelids with eyelashes and lid margins,

05b_Scalp_r8_cah_0192-0231.indd 222 1/31/2012 4:35:52 PM

 Head and Neck  •  5B: Scalp Flap 223

and medial and lateral canthal areas. It is also possible to improve periorbital soft tissue atrophy, which
is a significant problem in patients who had radiotherapy previously. Free transfer of the flap provides
a new solution for reconstruction in patients who had prior surgery.
Angelos PC, Downs BW. Options for the management of forehead and scalp defects. Facial
Plast Surg Clin North Am 17:379-393, 2009.
Forehead and scalp reconstruction comprises a diverse and complex set of defects. Repair must be per-
formed with minimal disturbance to surrounding structures such as the eyelid, eyebrow, and hairline.
Care must be taken to maintain symmetry between sides. The authors addressed the options for the
management of forehead and scalp defects, including healing by secondary intention, skin grafts, local
flaps, free flaps, tissue expansion, and negative pressure treatment. They also discussed the advantages
and disadvantages of each repair option while providing a framework from which to plan scalp and
forehead reconstruction.
Blackwell KE, Rawnsley JD. Aesthetic considerations in scalp reconstruction. Facial Plast Surg
24:11-21, 2008.
This article reviewed common methods of reconstructive surgery in patients with wounds that involve
the scalp, including primary wound repair, healing by secondary intention, and the use of skin grafts,
local tissue flaps, regional myocutaneous flaps, and microvascular free flaps. The authors discussed
aspects of the reconstruction that affect the aesthetic outcome, including preservation of the hairline and
hair follicle orientation, scar camouflage, avoidance of alopecia, and secondary restoration of alopecia.
Brandy DA. Corrective hair restoration techniques for the aesthetic problems of temporoparietal
flaps. Dermatol Surg 29:230-234; discussion 234, 2003.
Temporoparietooccipital flaps (Juri flap) and temporoparietal flaps (Elliott) were commonly performed
in previous decades but have largely fallen out of favor with the development of follicular unit hair
transplantation. Besides high complication rates, these procedures created straight, abrupt hairlines,
posterior hair direction, hair density that was disproportionately thick, and blunt temporofrontal angles.
Because many patients live with cosmetic deformities created by previous flap procedures, the author
presented a series of techniques to restore these patients to normal cosmesis: (1) undulating follicular
unit grafting anterior to the hairline, (2) removal of 2 to 3 mm cylinders of hair-bearing scalp at the
anterior hairline, (3) removal of 2 to 3 mm cylinders of hair-bearing scalp from within the flap itself,
and (4) appropriate fusiform excision techniques to create a normal temporofrontal angle. The com-
bination of these techniques has restored a very natural cosmesis in patients who have poor aesthetics
after flap surgery.
Cesteleyn L. The temporoparietal galea flap. Oral Maxillofac Surg Clin North Am 15:537-
550, vi, 2003.
The temporoparietal galeal flap has been rediscovered as a useful tissue transfer technique. It is the
only single-layered fascial flap that can be transposed into the craniofacial and head and neck region
on its vascular pedicle. In the 1990s, it was used extensively in the surgical reconstruction of a wide
variety of defects in the craniomaxillofacial area, ranging from scalp and auricle defects to nasal and
maxillo-orbital repair to all types of intraoral and even mandibular and pharyngeal reconstructions.
Davison SP, Capone AC. Scalp reconstruction with inverted myocutaneous latissimus free flap
and unmeshed skin graft. J Reconstr Micro Surg 27:261-266, 2011.
Limited skin paddle size, peripheral thinning, or lack of cerebral expansion after radiotherapy may
necessitate secondary sculpting after latissimus free flap reconstruction of large scalp defects. This series
presented a novel modification of the myocutaneous latissimus dorsi free flap for use in large scalp
defects. After superficial artery isolation, titanium mesh is placed into the calvarial defect to recapitulate
the inner table. The myocutaneous latissimus flap is harvested in standard fashion, deepithelialized,
and inverted. The skin paddle is placed over titanium mesh to fill the calvarial defect, then sewn over
a drain. The inverted latissimus muscle is draped over the defect and extended peripherally beneath
the pericranium. The flap is sewn to the scalp internally using a vest-over-pants suture pattern, and

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 224 Part II  Regional Flaps: Anatomy and Basic Techniques

the thoracodorsal and superficial temporal vessels are anastomosed and left facing outward. Unmeshed
skin graft is draped over the muscle, and vessels are then sutured loosely. Patients with complex scalp
defects whose soft tissue defect exceeded the size of latissimus skin paddle available with primary closure
were considered eligible for inverted latissimus free flap reconstruction. Follow-up ranged from 6 to
12 months. Over a 2-year period, five patients underwent inverted latissimus free flap reconstruc-
tion. Scalp defects ranged in size from 10 by 8 cm to 17 by 11 cm. The calvarial defect was smaller
than the soft tissue defect in all cases. All flap donor sites were closed primarily. All five flaps took,
and donor site outcomes were acceptable. Aesthetic outcomes were satisfactory with well-contoured,
calvarial-shaped results. Cosmesis was most notably limited by skin graft joint lines. No patients
underwent secondary surgical revision. The inverted myocutaneous latissimus free flap is a safe and
effective method for reconstructing large or irradiated scalp defects.
Ducic Y. Reconstruction of the scalp. Facial Plast Surg Clin North Am 17:177-187, 2009.
The scalp provides a relatively limited amount of excess tissue that can be used in reconstructing sig-
nificant scalp defects that arise most often from oncologic resection or traumatic loss. Scalp reconstruc-
tion encompasses a broad spectrum of flaps, grafts, and techniques that should be readily available to
the facial plastic surgeon treating this patient population. Meticulous attention to detail, particularly
in the planning and early postoperative periods, is associated with gratifying results in most patients.
This article presented defect analysis and discussion of reconstruction options, as well as discussion of
successful reconstructive surgeries.
Duymaz A, Karabekmez FE, Tosun Z, et al. Reconstruction with galeal frontalis flap of de-
pressed forehead region in progressive hemifacial atrophy. J Craniofac Surg 19:1104-1106, 2008.
Parry-Romberg syndrome is characterized by progressive hemifacial atrophy that is the lack of tissue
(generally, soft tissue and, rarely, bone and muscle) in the atrophic area of the face. The cause and
incidence of this pathologic process are uncertain, but it is relatively rare and self-limited. The authors
presented a 21-year-old female patient with progressive hemifacial atrophy who underwent reconstruc-
tion with a composite galeal frontalis flap. Although many reconstructive methods have been described,
reconstruction of both eyebrow deficiency and forehead atrophy with composite galeal frontalis flap had
not been described previously.
Fan J, Liu L, Tian J, et al. The expanded “flying-wings” scalp flap for aesthetic hemiscalp alo-
pecia reconstruction in children. Aesthetic Plast Surg 33:361-365, 2009.
For a large lesion of the scalp (up to 50% scalp loss), restoration of the scalp with a hair-bearing scalp
flap to achieve a pleasing aesthetic outcome and hair growth matched to the direction of the lesion—
especially for a hemiscalp defect in children—often becomes very challenging for plastic surgeons.
Treatment was performed in 18 children with severe hemiscalp losses after burns. The technique was
carried out by initially positioning a tissue expander in the subgaleal pocket of the scalp and serially
inflating it with normal saline solution at 5- to 7-day intervals for about 3 months. Thereafter a
“flying-wings” expanded scalp flap was designed by combining the principles of advancement and
rotation flap transplantation. This design was based on at least one nominated vascular system of the
scalp used as the pedicle, with the wings often working to correct the distant part of the lesion in which
the hair direction is greatly changed. After the lesion was excised, the expanded hair-bearing flap was
advanced and rotated to the recipient site when the expander was removed. The flap used for hemiscalp
reconstruction could be transferred to repair the hemiscalp loss totally (17 patients) or mostly (1 patient)
in a single–tissue expansion process without flap necrosis. The patient with a remaining lesion was
treated completely with a secondary tissue expansion in the postauricular area. All patients showed
good aesthetic results, with the direction of hair growth well matched at the recipient site.
Floyd DC, Ali FS, Ilyas S, et al. The pedicled occipital artery scalp flap for salvage surgery of
the neck. Br J Plast Surg 56:471-477, 2003.
A small group of patients with complex head and neck cancer present with problems of wound healing
following radiotherapy and reconstructive surgery. Providing skin coverage to the neck in these cases is
often required and presents a challenge to the reconstructive surgeon. The authors presented the use of

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 Head and Neck  •  5B: Scalp Flap 225

a pedicled scalp flap based on the occipital artery for such defects. This flap is an axial patterned scalp
flap that incorporates hair-bearing skin. It may be up to 15 cm wide and can reach beyond the midline
of the chin. The anatomy of the flap was described and its use illustrated in three cases. This flap is a
useful addition to the options for reconstruction of neck defects in patients with head and neck cancer.
Frodel JL Jr, Ahlstrom K. Reconstruction of complex scalp defects: the “banana peel” revisited.
Arch Facial Plast Surg 6:54-60, 2004.
To demonstrate the use of multiple large local flaps in the reconstruction of large scalp defects, the
authors presented a retrospective review of four cases in which the “banana peel” method of scalp
reconstruction, originally described by Orticochea, was used as a method for closure of moderately
large to extensive scalp defects. In all four cases, closure of the scalp defects was accomplished. Major
morbidity included hair-bearing skin in the forehead in one patient, an inconsequential small flap
dehiscence requiring closure in the same patient, and a partial loss of a small skin graft resulting from a
donor site defect in one patient. Although other techniques may be optimal for the management of most
scalp defects, such as one- or two-flap rotation-advancement flaps in small to moderate-sized defects
and microvascular free tissue transfer and secondary tissue expansion for larger defects, the authors
concluded that the multiple-flap reconstruction method as described by Orticochea may be useful in a
small subset of patients, including older, severely debilitated patients who would be optimally treated
with microvascular tissue transfer but cannot tolerate lengthy general anesthesia, and young patients
who will not accept a significant area of alopecia that might exist with other techniques, such as healing
by secondary intention, skin grafts, or free flaps.
Furtado SV, Anantharam BA, Reddy K, et al. Repair of Chiari III malformation using cra-
nioplasty and an occipital rotation flap: technical note and review of literature. Surg Neurol
72:414-417; discussion 417, 2009.
Chiari III malformation (CM3) is rare among Chiari malformations (I-IV). Its definition has been
expanded to include caudal medullary displacement and hindbrain herniation into encephaloceles
in lower occipital and high cervical regions. Prognosis is recorded as dismal, with respect to survival
and functional outcome. The authors described the presentation, radiologic evaluation, and repair of
this malformation by means of methylmethacrylate cranioplasty and an occipital scalp rotation flap
for closure. Outcome after surgery is also addressed. Adequate closure of the defect and protection of
underlying structures was achieved without undue stress at the incision site. This method of closure
can be considered in cases of large occipital and cervical encephaloceles with poor skin coverage and
added osseous anomalies around the foramen magnum.
Gundeslioglu O, Altundag O, Altundag K, et al. Closure of large scalp defects by modified
Gillies triple scalp flaps in patients with scalp tumors. Plast Reconstr Surg 116:1813-1814, 2005.
Hafezi F, Naghibzadeh B, Nouhi A. Facial reconstruction using the visor scalp flap. Burns
28:679-683, 2002.
In male burn victims, scarring may cause grotesque disfigurement of the upper lip and lower face. There
are many ways to address the problem, ranging from simple skin grafting to complex flaps. Bipedicle
scalp flaps are used sporadically for reconstruction of the upper lip. The authors described the use of
bitemporal artery hair-bearing flaps for reconstruction of the mustache and beard area in nine cases as
a substitute for deformed facial skin. The results indicated that the scalp flap is one of the best-matched
flaps for reconstruction of the middle and lower parts of the male face. By choosing a proper-sized
flap, use of a tissue expander can be omitted, the donor site may be closed primarily, and early return
of the patient to normal life is assured. Although the width of the flap is not sufficient to cover the
entire lower face and cheeks, it is adequate to imitate a normal face and provide a pleasant appearance.
Halvorson EG, Cordeiro PG, Disa JJ, et al. Superficial temporal recipient vessels in microvascular
orbit and scalp reconstruction of oncologic defects. J Reconstr Microsurg 25:383-387, 2009.
The superficial temporal artery and vein are often considered suboptimal recipient vessels because
of anecdotal reports that they are unreliable and prone to spasm. This is unfortunate, because their
position greatly facilitates reconstruction of the scalp and orbit. The authors presented their experience

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 226 Part II  Regional Flaps: Anatomy and Basic Techniques

in 28 patients who underwent microvascular craniofacial reconstruction of oncologic defects using the
superficial temporal artery and vein as recipients over a 4-year period at a single institution. Rates of
vessel thrombosis, total flap loss, and partial flap loss were not significantly different from 282 flaps
anastomosed to neck vessels. With knowledge of the anatomy and proper technique, the superficial
temporal artery and vein are reliable and available in most patients and can facilitate microvascular
orbit and scalp reconstruction. The proximity they offer allows more flexibility in flap pedicle length
requirement and avoids the use of vein grafts. Caution should be exercised in patients with a history
of radiation therapy.
Ibrahimi OA, Jih MH, Aluma-Tenorio MS, et al. Repair of scalp defects using an H-plasty
type of bilateral advancement flap. Dermatol Surg 36:1993-1997, 2010.
Defects of the scalp often pose a reconstructive challenge in dermatologic surgery. The authors reported
their experience with the H-plasty type of bilateral advancement flap for the closure of small to
medium-sized scalp defects that cannot be closed primarily. Sixty-nine 1.5 to 3.0 cm diameter scalp
defects resulting from Mohs micrographic surgery that could not be closed primarily were identified
over the 2-year study period. All 69 defects were closed entirely with the bilateral advancement flap,
and there were no significant complications. The H-plasty type of bilateral advancement flap allows
appropriately selected scalp defects that might not be readily closed primarily to be easily repaired with
the use of local skin, providing an attractive alternative to other flap techniques, skin grafting, and
healing via secondary intention. The limitations of this study were that the results were based on a
retrospective single-surgeon experience and there was no long-term follow-up scheduled to evaluate
the final cosmetic outcome of the repair.
Jeong SH, Koo SH, Han SK, et al. An algorithmic approach for reconstruction of burn alopecia.
Ann Plast Surg 65:330-337, 2010.
The purpose of this study was to assess the appropriateness of the clinical indications for the various
reconstructive methods for burn alopecia and to suggest an algorithm for individualized reconstruction.
A review of 83 patients who underwent reconstruction for burn alopecia between 1995 and 2007 was
conducted. Demographics, associated injuries, preoperative findings, surgical techniques, and post-
operative complications were collected. From these data, the authors classified reconstructive methods
based on the area, the scar quality, and the location of the burn alopecia and investigated the clinical
outcomes. Reconstructive methods included hair grafting (13), scalp reduction (21), scalp extension (14),
and scalp expansion (37). Twenty-eight patients had surgical complications, most related to alloplastic
implants used in scalp extension and expansion. The reconstructive method should be tailored to the
conditions of the burn alopecia. Because scalp extension and expansion are associated with a high
rate of complications, the authors recommended the use of these methods for large, poor-quality burn
alopecia. On the other hand, hair grafting and scalp reduction are more appropriate treatment options
for relatively small, good-quality burn alopecia.
Kruse-Lösler B, Presser D, Meyer U, et al. Reconstruction of large defects on the scalp and
forehead as an interdisciplinary challenge: experience in the management of 39 cases. Eur J
Surg Oncol 32:1006-1014, 2006.
The authors described options and indications for different surgical reconstruction techniques after
resection of large skin tumors on the scalp, taking into account an interdisciplinary approach for
craniomaxillofacial surgeons, dermatologists, and neurosurgeons, and to evaluate complications and
postoperative outcomes. Forty-two surgical reconstructions were performed in 39 patients with large
skin tumor resections on the scalp and/or the forehead who were treated between 1995 and 2005.
The medical histories, surgical treatment, postoperative complications, follow-up, and outcome were
evaluated. The excision defects measured an average of 146 cm (range 80.6 to 546 cm). The most
common methods for defect closure were multiple rotation-advancement flaps. Six patients were treated
with split-thickness skin grafts after bone drilling for inducing granulation tissue to grow. Free latis-
simus dorsi muscle flaps were used in eight patients and radial forearm flaps in four. Postoperative
complications were rare. An algorithm for the surgical approach to large scalp defects was presented.

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 Head and Neck  •  5B: Scalp Flap 227

Kwon H, Kim HJ, Yim YM, et al. Reconstruction of scalp defect after Moyamoya disease
surgery using an occipital pedicle V-Y advancement flap. J Craniofac Surg 19:1075-1079, 2008.
Scalp necrosis is an infrequent complication of surgery for Moyamoya disease, which is more prevalent
in the parietotemporal area. Because scalp vascularity is severely compromised after Moyamoya disease
surgery, reconstruction of defects with local scalp tissue is challenging. To cover defects, a flap is needed
that is highly vascularized and has great mobility and territory to avoid existing scars. After tracing
ipsilateral occipital artery, an advancement flap that was based on occipital artery and vein was designed
to fit the defect. The flap was elevated in the subperiosteal layer and advanced without tension to
cover the defect. Occipital pedicle V-Y advancement flaps were used in seven patients who had scalp
necrosis of the parietotemporal area and a mean defect size of 8.7 cm. There were no complications
such as flap necrosis, infection, or recurrence of the defect in any of the patients during 9-month follow-
up. Occipital pedicle V-Y advancement flap is a useful alternative flap for scalp defects after surgical
treatments that compromise scalp vascularity, such as Moyamoya disease surgery.
Lee S, Rafii AA, Sykes J. Advances in scalp reconstruction. Curr Opin Otolaryngol Head Neck
Surg 14:249-253, 2006.
The authors summarized traditional and advanced techniques used to reconstruct defects of the scalp,
from small defects that can be closed primarily to significant defects that require free tissue transfer.
Increased use of tissue expanders, advancement rotational flaps, and hair transplantation has resulted
in improved cosmetic outcomes for larger defects of the scalp. Free tissue transfer has provided a revo-
lutionary method of reconstructing subtotal and total defects of the scalp, in particular those associated
with neoplasms. Advances in techniques of scalp reconstruction have provided improved cosmetic ap-
pearance and decreased morbidity for scalp reconstruction.
López-Arcas JM, Martín M, Gómez E, et al. The Guyuron retroauricular island flap for eyelid
and eye socket reconstruction in children. Int J Oral Maxillofac Surg 38:744-750, 2009.
A complete loss of palpebral tissue can occur from a congenital malformation or after tumor resection or
traumatic injury. The authors presented their clinical experience with upper eyelid reconstruction in
children using the Guyuron retroauricular island flap. Five cases of severe eyelid defects in children ages
5 days to 10 years (3 patients after enucleation and 2 with upper eyelid coloboma of approximately
two thirds of the upper eyelid surface) were treated with this technique. In all cases, optimal closure
of the eyelid fissure was achieved and corneal exposure clinically improved. On average, 15% of the
initial flap surface was lost. Only one major complication (40% flap necrosis) was reported in the
postoperative period. This reconstructive technique can provide complete eyelid reconstruction, leaving
an inconspicuous scar and causing limited morbidity at the donor zone.
Mangubat EA. Scalp reconstruction and repair. Facial Plast Surg 24:428-445, 2008.
The repair and/or removal of an existing defect is often difficult; however, the appearance of the repair
is often the most difficult challenge. Thus an understanding of normal hair morphology, anatomy, and
physiology is important to achieve long-lasting, satisfying results. We must anticipate future hair loss,
communicate that to the patient, and consider it in surgical planning. In addition, residual effects such
as radiation therapy after cancer resection may pose additional challenges. Today many extraordinary
techniques are available that allow creation of natural and almost undetectable hairlines, but these
techniques are often unsuitable for repairing large scarred areas of hair loss. By using more traditional
techniques of scalp reduction and tissue expansion, however, excision of many large, scarring defects
can be accomplished. Combining older methods with modern hair restoration surgery permits the
satisfactory treatment of many previously untreatable conditions.
Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol 94:504-508, 2006.
Scalp reconstruction after oncologic resection can be challenging. Wide surgical resections, in combination
with comorbid conditions such as infected alloplastic material, cerebrospinal fluid leak, or devascularized
bone after craniotomy necessitate healthy, vascularized tissues for reconstruction. Although primary
closure is feasible in some cases, the mainstay of treatment involves local tissue rearrangement with or
without split-thickness skin grafting. In addition, free tissue transfer is an important adjunct to therapy

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 228 Part II  Regional Flaps: Anatomy and Basic Techniques

in patients with poor local tissues. Careful analysis of the defect and local tissues can help tailor the
method of reconstruction and result in satisfactory closure in a majority of patients.
Mehrotra S, Nanda V, Shar RK. The islanded scalp flap: a better regional alternative to tradi-
tional flaps. Plast Reconstr Surg 116:2039-2040, 2005.
Michaelidis IG, Stefanopoulos PK, Papadimitriou GA. The triple rotation scalp flap revisited:
a case of reconstruction of cicatricial pressure alopecia. Int J Oral Maxillofac Surg 35:1153-
1155, 2006
Rotation flaps constitute a time-honored method for repair of small to moderate scalp defects, even
in the era of microsurgical reconstruction. A case of cicatricial pressure alopecia that was successfully
repaired using the Bardach modification of the curved tripod flap confirms the value of this flap in
scalp reconstruction. The main advantages of this method are the natural appearance of the final result
because hair orientation is preserved, and wound-closure tension is distributed uniformly over a wide
peripheral area of the scalp, although extensive undermining is generally required.
Newman MI, Hanasono MM, Disa JJ, et al. Scalp reconstruction: a 15-year experience. Ann
Plast Surg 52:501-506; discussion 506, 2004.
Finding a useful reconstructive algorithm lacking for scalp reconstruction after ablative surgery, the
authors evaluated their experience—73 procedures performed in 64 patients over 15 years—and
identified an appropriate reconstructive strategy. Reconstructive methods, independent factors, and
outcomes were analyzed. Techniques for reconstruction included primary closure, grafts, and local and
distal flaps. A correlation between reconstructive technique and complications could not be demon-
strated. However, an increased incidence of complications was correlated with a history of radiation,
chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect. Important tenets
for successful management of scalp defects are durable coverage, adequate debridement, preservation of
blood supply, and proper wound drainage. Local scalp flaps with skin grafts and free tissue transfer
remain the mainstay of reconstruction in most instances.
Nthumba P, Carter L. Visor flap for total upper and lower lip reconstruction: a case report.
J Med Case Reports 3:7312, 2009.
Noma, aptly named the “face of poverty,” is a scourge with a mortality rate of up to 90% that affects
some 140,000 people each year, predominantly children in the sub-Saharan “noma belt.” Survivors
of the acute polymicrobial attack suffer severe gangrenous facial disfigurement from loss of facial tissue
and scarring. Surgical reconstruction of noma defects is a major challenge, especially in Africa, where
most cases occur. The authors reported the case of a 40-year-old Somali man who presented with
severe facial disfigurement, including total absence of both upper and lower lips and inability to open
his mouth. After a failed initial reconstruction, a combination of platysma flaps and a left deltopec-
toral flap provided mucosal lining, while a scalp visor flap served to recreate upper and lower lips, the
beard, and the mustache. The scalp visor flap offers a simple but extremely versatile tool for use in
midfacial reconstruction, especially in men, providing neolip tissue, a mustache, and a beard. This is
the first report of a simultaneous total upper and lower lip reconstruction using a scalp visor flap in the
English literature. The authors also emphasized a process of transfer of skills to enable local surgeons
to effectively manage the challenge that noma presents.
Ogawa R, Hyakusoku H, Murakami M, et al. Clinical and basic research on occipito-cervico-
dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels. Plast Reconstr
Surg 113:1923-1933, 2004.
The authors carried out a clinical study of all their patients who underwent reconstructions with oc-
cipitocervicodorsal flaps between 1994 and 2003 and analyzed the outcomes of the surgery. The
reconstructed areas ranged from the cheek to the anterior chest. Twenty-eight patients underwent
reconstruction with microvascular augmented occipitocervicodorsal flaps, and four were reconstructed
with single pedicle occipitocervicodorsal flaps. In five cases, distal partial necrosis was observed. The
largest flap was 43 by 23 cm (with a 5 by 5 cm pedicle). In the microvascular augmented occipitocer-
vicodorsal flaps, the circumflex scapular artery and veins were used in 28 cases, and dorsal intercostal
perforators were used together with circumflex scapular artery and veins in five cases. Follow-up was

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 Head and Neck  •  5B: Scalp Flap 229

1 to 8 years. Neck scar contractures were released in all cases, and good results were obtained not only
functionally but also aesthetically. In an anatomic study, the authors used 20 preserved cadavers and
obtained angiograms of the dorsal region. Five cadavers were used to confirm the territory of each of
the vessels that are closely related to the occipitocervicodorsal flap (occipital artery, transverse cervical
artery, circumflex scapular artery, and dorsal intercostal perforator artery). Each anatomic territory
was clearly seen and its area identified.
Oh SJ, Koh SH, Lee JW, et al. Expanded flap and hair follicle transplantation for reconstruction
of postburn scalp alopecia. J Craniofac Surg 21:1737-1740, 2010.
The advent of tissue expansion began an era of aesthetically reconstructed scalp alopecia by provid-
ing a large hair-bearing scalp area with acceptable hair density. However, residual scalp alopecia and
wide visible scars still raised aesthetic problems. The hair follicle transplantation carries the possibility
of producing a more natural scalp, because both the desired hair density and the natural direction of
the hair can be reproduced using this procedure. Our study group consisted of 62 patients (41 men
and 21 women) with a mean age of 26.3 years. The median age of suffering a burn to the scalp was
3 years. The first reconstruction for all patients was the expanded flap coverage; in three patients,
two-stage expanded flaps were used. Five patients underwent hair follicle transplantation after they
had undergone expanded flap coverage. Expanders (n 5 86) were placed in 62 patients, with a total
of 9 major and 3 minor complications. The overall results after expanded flap reconstruction and
hair follicle transplantation were excellent (43 patients), good (18 patients), and poor (1 patient). The
visible remaining alopecia and marginal scar after the procedure, especially on the anterior hairline of
the forehead and the sideburns, can be refined by hair follicle transplantation. This report also sug-
gests the possibility that cicatricial scalp alopecia with intact deep tissue can be restored by hair follicle
transplantations using a hair transplanter.
Roehl K, Geoghegan J, Herndon DN, et al. Management of class IV skull burns using the
bipedicled superficial temporal artery scalp flap. J Craniofac Surg 19:970-975, 2008.
Calvarial burns are extremely rare and pose a difficult challenge for both burn and reconstructive
surgeons. Reconstruction of these injuries depends on the depth of invasion and the amount of tissue
loss. Fourth-degree burns include damage to the calvarium and the underlying dura and/or cerebrum.
Historically, these wounds have been treated conservatively. The authors detailed two cases of electri-
cal fourth-degree calvarial burns with large soft tissue defects as well as loss of calvarium and dura
with cerebral herniation. Each patient presented to Shriners Burn Hospital in a delayed fashion with
infected wounds necessitating immediate intervention. In both patients, the wounds were debrided and
covered with a bipedicle superficial temporal artery scalp flap. The donor sites of each flap, as well as
the remaining areas, were skin grafted. This flap provides immediate vascularized coverage in wounds
that could not be treated conservatively. In the presence of sepsis and other severe injuries, where more
complicated flaps are risky, this flap provides a reasonable and reliable method of calvarial coverage.
Schnabl SM, Horch RE, Ganslandt O, et al. Aplasia cutis congenita—plastic reconstruction
of three scalp and skull defects with two opposed scalp rotation flaps and split-thickness skin
grafting. Neuropediatrics 40:134-136, 2009.
Aplasia cutis congenita (ACC) is a rare congenital defect of skin and subcutaneous tissue, more rarely
of periosteum, skull, and dura. The lesions can involve any location, but most common are scalp
defects. The authors reported on the successful treatment of three large defects of the scalp with skull
involvement in a newborn girl by early debridement and defect closure with two opposed scalp rotation
flaps and an occipital split-thickness skin graft.
Sharma RK, Pandey SK. Extended posterior auricular artery flap for coverage of a large
temporo-parietal defect. J Plast Reconstr Aesthet Surg 63:e775-778, 2010.
The authors presented a case with a 5 by 8 cm full-thickness defect in the temporoparietal region that
was managed with an extended posterior auricular artery–based flap in one stage. The flap was shaped
like a “gandasa” (an axelike agricultural implement used in Punjab, India). This allowed ample
movement of the flap and permitted a V-Y closure of the donor site. The flap also received additional
blood supply from the ipsilateral superior auricular artery.

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 230 Part II  Regional Flaps: Anatomy and Basic Techniques

Sharma RK, Tuli P. Occipital artery island V-Y advancement flap for reconstruction of posterior
scalp defects. J Plast Reconstr Aesthet Surg 63:410-415, 2010.
The management of posterior scalp defects with “similar” tissue can be challenging. The currently
available techniques of transposition-rotation result in the creation of unwanted dog-ears, changes in
the direction of hair growth, and patches of skin-grafted areas with alopecia. The authors described a
new method of reconstruction of full-thickness scalp defects in the occipital region by moving the lo-
cally available scalp tissue as for a V-Y advancement flap. The island flap is based on the ipsilateral
occipital artery in the substance of occipitalis muscle. The donor sites can be closed primarily and the
operation performed in a single stage. A total of seven patients underwent reconstruction over a 2-year
period with this technique. The defects in the posterior scalp region resulted from electrical burns (2
patients), tumor excision (2 patients), encephalocele excision (1 patient), or posttraumatic loss of the
scalp (2 patients). In all the patients, the underlying bone was exposed. The remaining scalp tissue
in the vicinity of the defect was moved as a V-Y advancement flap either unilaterally or bilaterally,
depending on the size of the defect. The pedicle of the flaps contained ipsilateral occipital vessels at
the base. The flaps were raised in the subgaleal plane and the pedicle included ipsilateral occipital
artery in the substance of the occipitalis muscle. The donor area was closed primarily in all cases. All
of the flaps survived completely; one patient had postoperative superficial loss that eventually healed
with dressings. All wounds healed with luxuriant hair growth, except in one patient who had partial
alopecia in the transferred flap, although the flap survived completely.
Tellioğlu AT, Cimen K, Açar HI, et al. Scalp reconstruction with island hair-bearing flaps.
Plast Reconstr Surg 115:1366-1371, 2005.
The authors presented three cases in which reconstruction of the temporal, frontoparietal, and midline
regions was performed with the use of island hair-bearing scalp flaps. In addition, they described a
new vascularized island scalp flap design that can potentially repair large scalp defects.
Temple CL, Ross DC. Scalp and forehead reconstruction. Clin Plast Surg 32:377-390; vi-vii,
2005.
This article reviewed the surgical anatomy of the scalp and forehead and presented an algorithm for
decision-making in reconstructive surgery of the region. Nonmicrosurgical techniques were briefly
reviewed. The microsurgical reconstruction of scalp and forehead defects differs from the more common
oropharyngeal reconstructions in several ways, including flap choices, choices for recipient vessels, and
the opportunity to use conventional and microsurgical techniques simultaneously to improve outcomes.
Each of these considerations was reviewed and the authors’ preferred techniques presented.
Touré G, Méningaud JP, Vacher C. Arterial vascularization of occipital scalp: mapping of
vascular cutaneous territories and surgical applications. Surg Radiol Anat 32:739-743, 2010.
Although the vascular supply of the occipital region of the scalp is usually considered to depend on
the occipital arteries, the authors stated that in their clinical experience the importance of the poste-
rior auricular arteries seems to have been underestimated. They considered the occipital artery to be
the main artery to the vascular supply of this region. The role of the posterior auricular artery has
not been clearly investigated. To describe the cutaneous territories of these two arteries, 20 cadaver
occipital areas were dissected after bilateral injection of colored latex (40 occipital and 40 posterior
auricular arteries studied), and four occipital areas were dissected after selective injection of china ink
in the occipital and posterior auricular arteries (4 occipital and 4 posterior auricular arteries injected).
The occipital artery was deep from its origin to the arch constituted by the insertions of the trapezius
and sternocleidomastoid muscles. Then the occipital artery was becoming superficial while ascending
to the vertex. The cutaneous territory of the occipital arteries was paramedian and median (38% of
the occipital area). The posterior auricular artery was superficial in the auriculomastoid sulcus and
divided into three branches: auricular and mastoid as usually described, and a third terminal branch
that they called the “transverse nuchal artery.” The posterior auricular arteries supplied the major
part of the occipital area of the scalp (62%).

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 Head and Neck  •  5B: Scalp Flap 231

Warren SM, Zide BM. Reconstruction of temporal and suprabrow defects. Ann Plast Surg
64:298-301, 2010.
Large temple and suprabrow lesions can pose a reconstructive challenge. When the lesion extends
anterior to the hairline, aesthetically acceptable local flaps may be difficult to design. The authors
described a modified scalp flap (part Converse scalping flap and part scalp rotation flap) that can be
tailored to reconstruct a variety of difficult temple and suprabrow lesions while maintaining eyebrow
position. The modified scalp flap is raised in a subgaleal plane until approximately 2.5 cm above
the brow. At this level, dissection proceeds in the subcutaneous plane to protect the frontal branch of
the facial nerve and to keep the flap thin. (The key to the modified scalp flap is the dissection plane
change that protects the frontal branch of the facial nerve.) The extent of posterior subgaleal dissection
is dictated by the amount of anterior rotation necessary. A temporal dog-ear is removed subfollicularly
to permit modified flap rotation and preserve the superficial temporal artery. The modified scalp flap
was used to reconstruct temple and suprabrow lesions in 10 patients ranging in age from 4 months
to 22 years. There were no complications. Four typical cases were presented. Temple and suprabrow
lesions can be excised and successfully reconstructed in one stage using a modified scalp flap that is
extended from the hair-bearing scalp onto the glabrous skin of the forehead. This novel modified scalp
flap prevents eyebrow/hairline distortion and avoids facial nerve injury.
White N, Srivastava S. Tissue expanded scalp flaps in alopecia: advancement, rotation or trans-
position? J Plast Reconstr Aesthet Surg 62:281-282, 2009.
Worthen EF. Repair of forehead defects by rotation of local flaps. Plast Reconstr Surg 57:204-
206, 1976.

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 ANATOMIC LANDMARKS
Landmarks The flap occupies the area lateral to the nasolabial fold and ex-
tends from midcheek down to the mandibular line.
Size 2 3 5 cm.
Composition Cutaneous.
Dominant Pedicle Angular artery.
Minor Pedicle Alar branches of the superior labial artery.
Nerve Supply Infraorbital nerve.

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 Section 5C
Head and Neck

Nasolabial Flap

CLINICAL APPLICATIONS
Regional Use
Nose
Upper lip
Lower lip
Cheek
Intraoral
Specialized Use
Nose
Lip

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 ANATOMY OF THE NASOLABIAL FLAP

A B

Angular
Nasalis
artery
muscle
perforator
Levator labii
superioris
alaeque nasi
muscle

Angular
artery
perforator Levator labii
superioris muscle
Zygomaticus
minor muscle
Zygomaticus
major muscle

Nasolabial vascular anatomy (oblique view) Nasolabial anatomy (lateral view)

Angular
artery
perforator

Angular
artery
perforator

Elevation of flap, maintaining subcutaneous pedicle superiorly

for superiorly based flap (not visualized during dissection)

Fig. 5C-1 

Dominant pedicle: Angular artery perforator

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 Head and Neck  •  5C: Nasolabial Flap 235

Anatomy
Landmarks The tissues that compose the nasolabial flap lie directly over the angular artery,
which is the end vessel of the facial artery. These tissues lie lateral to the nasolabial
fold and extend from the midcheek above the ala down to the mandibular line.
Composition Cutaneous.
Size 2 3 5 cm.

Arterial Anatomy
Dominant Pedicle  Angular artery
Regional Source  Facial artery.
Length  1 cm.
Diameter  0.5 mm.
Location  The facial artery can be palpated along the mandibular border within 3 cm of the
mandibular angle. A line can be drawn from this point to the ala. The vessel runs below the
facial musculature in this area and sends branches to the flap throughout its length.
Minor Pedicle  Alar branches of the superior and inferior labial artery
Regional Source  Facial artery.
Length  1 to 3 mm.
Diameter  0.3 mm.
Location  These small vessels enter this area of the flap at the level of the ala.

Venous Anatomy
Paired venae comitantes accompany the major and minor pedicles.

Nerve Supply
This area is innervated by the infraorbital nerve. This is not a sensate flap.

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 236 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Nasolabial Flap

A B

C D

Superiorly based flap Radiographic view

Inferiorly based flap Radiographic view

Fig. 5C-2 

Dominant pedicle: Angular artery (D)

Minor pedicle: Alar branches of superior labial artery (m)

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 Head and Neck  •  5C: Nasolabial Flap 237

FLAP HARVEST
Design and Markings
Superiorly Based Nasolabial Flap
The flap is designed in an elliptical pattern that abuts the nasolabial fold and encompasses
the cheek tissue overlying the angular artery. Depending on the defect to be reconstructed,
a template may be placed on the cheek to guide accurate flap design. The width of the flap
is limited by the ability to mobilize the cheek tissues and close the flap donor site primarily.
When the nasolabial flap is used as a two-stage flap, one must take into account the bulk of
the pedicle and the extra tissue needed to rotate the tissue to reach the reconstructive site.

Superiorly
based flap

Angular
artery
Superiorly
based flap

C
Superiorly
based flap

Skin island design based on superior subcutaneous pedicle

Fig. 5C-3 

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 238 Part II  Regional Flaps: Anatomy and Basic Techniques

Inferiorly Based Nasolabial Flap

The skin design for the inferiorly based flap is similar to that for the superiorly based flap
but extends more superiorly. Again, a template for the site to be reconstructed can be
transposed to the cheek so that the flap dimensions are correct. Unlike the superiorly based
flap, rotation and placement of the inferior flap are made easier because of the mobility of
the cheek tissues.

Inferiorly
based flap

Inferiorly
based flap

Angular
artery

Flap is
elevated

Rotation and inset facilitated by tissue mobility

Fig. 5C-4 

Patient Positioning
For both inferiorly and superiorly based nasolabial flaps, a supine position provides optimal
exposure.

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 Head and Neck  •  5C: Nasolabial Flap 239

GUIDE TO FLAP DISSECTION

Superiorly Based Nasolabial Flap
Once the flap has been designed, a base of tissue at the superiormost aspect of the flap
that is near the alar base should be marked for preservation. This is a 1.5 by 1.5 cm area
of tissue where all subcutaneous attachments will be left intact. The vessels in this region
are underneath the facial musculature but perforate in this area. The flap may be quickly
elevated from caudal to cephalad, leaving facial musculature at the base and elevating skin
and fatty tissue. Once the flap has been elevated to the area marked as the base of the flap,
no further dissection is performed, and the flap is rotated. In some cases, flap rotation will
require incising the flap in its entirety along its design. This may aid in rotation. The flap
must not be overrotated, which would occlude the blood supply at the base.

A B

Preserve area of
attachment here

C D

Fig. 5C-5 A, The flap is based high on the side of the nose and consequently has a smaller trans-
position. 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.

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 240 Part II  Regional Flaps: Anatomy and Basic Techniques

E Preserve area of F
attachment here

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.

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 Head and Neck  •  5C: Nasolabial Flap 241

Inferiorly Based Nasolabial Flap

After the design has been marked, the base of the pedicle is marked with a 1.5 by 1.5 cm
area. A Doppler probe can be used to confirm the path of the angular vessel of the facial
artery to ensure it is within the base. The flap is quickly incised and elevated, maintaining
all subcutaneous fat with the flap and leaving all facial musculature intact. Once the flap
is elevated to the rotation point, the flap is rotated into position. Sometimes full incision
of the skin paddle is required to allow rotation. Rotation of the flap must not in any way
occlude the vascular pedicle.

A B

Preserve area of
attachment here

C D

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.

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 242 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANTS
•  V-Y advancement flap
•  One-stage flap
•  Two-stage flap

V-Y Advancement Flap

This flap lends itself to advancements to the upper lip and nose as a V-Y advancement flap
because of the mobility of the cheek tissues and the fact that the flap is supplied by perforat-
ing vessels from below the muscle that come up through the subcutaneous fat and remain
intact with advancement. This flap offers excellent color match for the facial reconstructive
site, and the donor site scars can be placed in areas that are aesthetically acceptable. The flap
design neighbors the defect and is designed in the same area as the standard nasolabial flap.
The flap is incised on all sides, and minimal spreading and dissection are performed around
the periphery of the flap. Simple release of the surrounding skin will allow advancement and
further spreading, and deeper dissection can allow even more advancement. Undermining
of the triangle of the skin of the flap should be limited to a few millimeters.

A B C

Flap design Advancement to upper lip defect Inset and donor site closure

Fig. 5C-7 

One-Stage Flap
When the nasolabial tissues border the defect area, the superiorly or inferiorly based naso-
labial flap can be directly transposed into the defect and the donor site closed primarily. No
attempt is made to revise dog-ears at this stage, because this area contributes blood supply
to the flap. This excess can settle over time or be revised 4 to 6 months later (see the Flap
Harvest section).

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 Head and Neck  •  5C: Nasolabial Flap 243

Two-Stage Flap
Often the delicate anatomic details of the commissure or alar crease have not been violated
during the trauma or cancer resection, and it is advisable to maintain these areas. The na-
solabial tissues can be used as a staged reconstruction in which the flap is transposed over
normal tissues and secured to the recipient site. This leaves the underside of the pedicle
temporarily exposed, but this can be dressed and the donor site temporarily closed. After
allowing 10 to 14 days for vascularization from the recipient site, the flap base is divided
and the flap is inset.

First Stage

A B C

Flap elevated Flap transposed Donor site closed

Second stage

D E

Flap is divided at 10-14 days and inset Some of flap is returned to cheek

Fig. 5C-8 

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 244 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Reconstructions of the upper lip, nose, and upper cheek, as well as lining flaps for the nose,
are based superiorly for the easiest arc of rotation. An entire upper lip and a midline nasal
defect can all be reached with a nasolabial flap.
Inferiorly based flaps are used for reconstruction of the lower lip, intraoral region, and
nearby cheek. Depending on the flap design, the flap easily reaches to the midline centrally
and to the preauricular area laterally.

Flap
elevated

Angular
artery
Superiorly
based flap

Arc to nose

Inferiorly
based flap Flap
elevated

Angular
artery

Arc to lower nose, upper lip, and oral cavity

Fig. 5C-9 

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 Head and Neck  •  5C: Nasolabial Flap 245

FLAP TRANSFER
Flaps are transferred as a direct transposition, a V-Y advancement, or a two-stage inset with
secondary division. Which application to use for a given reconstruction is at the surgeon’s
discretion and is often based on the defect, the desired donor scar, the arc of rotation, and
the pedicle reach.

FLAP INSET
All flap variants follow the principles of layered closure and minimizing tension on flaps.
For two-stage flaps, a dressing is required for the underside of the pedicle until division and
inset of the flap. Tubing of these small flaps is not recommended.

DONOR SITE CLOSURE

With all variants there is excess tissue in the cheek that allows subcutaneous cheek advance-
ment medially, and closure. If the flap design abuts the nasolabial fold, the advanced cheek
will leave a scar in the area of the nasolabial fold, which leaves the most aesthetic donor scar.
In a two-stage approach, the donor site is temporarily closed. On division and inset of the
flap, a portion of the flap could be returned to the cheek area. Again, the goal is to leave
a single scar within the nasolabial fold to give the best possible aesthetic to the donor site.

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 246 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 67-year-old woman had a basal cell carcinoma of the alar crease of the nose and un-
derwent a Mohs resection.

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 com-
bination 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.

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 Head and Neck  •  5C: Nasolabial Flap 247

F G

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. (Case supplied by MRZ.)

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 248 Part II  Regional Flaps: Anatomy and Basic Techniques

This 67-year-old man had a squamous cell carcinoma of the upper lip. A Mohs resection
was performed, and he required upper lip reconstruction.

B C

D E

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.
(Case supplied by MRZ.)

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 Head and Neck  •  5C: Nasolabial Flap 249

This man presented with a basal cell carcinoma of the upper lip.

B C

D E

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. (Case courtesy Ian
T. Jackson, MD.)

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 250 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient had a basal cell carcinoma of the lower lip, which had been neglected and
required an excision and reconstruction.
B

C D E

F G

Fig. 5C-13 A and B, This basal cell carcinoma of the lower lip was excised and reconstruction
planned with an inferiorly 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. (Case courtesy Ian T. Jackson, MD.)

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 Head and Neck  •  5C: Nasolabial Flap 251

This 66-year-old woman had a superficial defect within parts of the side wall and ala after
Mohs excision of a basal cell carcinoma. Because of its simplicity, a one-stage, nonsubunit
nasolabial flap was planned. The skin was transferred as a random flap. Available excess
within the adjacent cheek would be rotated and advanced to resurface the combined sidewall
and alar defect after placement of primary support along the nostril border.

A B C

D E F

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 inferiorly 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. (Case courtesy Frederick J. Menick, MD.)

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 252 Part II  Regional Flaps: Anatomy and Basic Techniques

This elderly woman had a defect of more than 50% of the ala after Mohs excision of a basal
cell carcinoma. The defect was entirely within the alar subunit. To better position periph-
eral flap border scars and to control trapdoor contraction within the subcutaneous fat on
the undersurface of a two-stage transposition flap harvested from the nasolabial fold, the

A B C

D E F

Fig. 5C-15  Two-stage nasolabial flap. A, The defect was limited to the alar subunit. The nasal sub-
units 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.

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 Head and Neck  •  5C: Nasolabial Flap 253

subunit principle was applied. Residual normal tissue within the left alar subunit was excised
to alter the defect and permit resurfacing of the entire ala as a subunit, rather than patching
the partial alar defect. The two-stage flap was vascularized through multiple vertical per-
forators that pass to the base of the flap pedicle through the underlying facial musculature
from the facial artery. The pedicle will be divided at the second stage.

I J

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. (Case
courtesy Frederick J. Menick, MD.)

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 254 Part II  Regional Flaps: Anatomy and Basic Techniques

This 45-year-old man had a composite defect of the nose, lip, and cheek after Mohs exci-
sion. The full thickness of the right ala and sidewall was missing. Adjacent cheek, lip, and
tip skin were absent. Soft tissue within the medial cheek and upper lip had been excised
down to underlying bone. Because the nose sits on the cheek and lip in an exact position,

A B

D E F

G
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 ap-
erture was missing. The full-thickness defect of the nose needed to be re-
paired. 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 el-
evated 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.

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 Head and Neck  •  5C: Nasolabial Flap 255

a stable platform had to be reestablished before formal nasal reconstruction. Skin from the
nasolabial area can be rotated as a random extension of a cheek flap to resurface the medial
cheek and upper lip. Once the skin is elevated, underlying fat is hinged over from the more
lateral cheek to fill the soft tissue defect over the medial maxilla, like the page of a book.
This soft tissue flap is based on subcutaneous perforators from the angular artery. Cheek
skin is then rotated to resurface the medial cheek and upper lip defects. A stable soft tissue
platform is re-created on which to build the nose at a later stage.

J K

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. (Case courtesy Frederick J. Menick, MD.)

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 256 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The surgeon should not attempt to visualize the perforating vessels at the base of either
the superiorly or inferiorly based nasolabial flap. Once the base of the flap is marked,
dissection in this area should be minimized.
• The nasolabial fold, alar crease, and other important facial landmarks should be marked
while the patient is awake and can animate the facial muscles. Once the patient is un-
conscious with muscles paralyzed, it will be difficult to find the natural creases. To the
degree it is possible, it is important to leave the scar within the animation lines.
• If wide undermining of the cheek is performed for closure of the donor site, a small drain
should be placed for at least 24 hours to avoid seroma formation.
• One disadvantage of island flaps such as the V-Y flap is possible pincushioning or edema
of the flap for prolonged periods. The same is true after division and inset of a two-stage
flap. At least 4 months should elapse before one considers debulking these flaps.
• Difficult-to-reconstruct areas, such as the commissure and the alar crease, should be
preserved. Two-stage flaps are favored for these areas to bypass these natural transitions
that are difficult to reproduce.
• Defects often require multiple flaps. The nasolabial flap can be used in combination with
other regional flaps for lip and nasal reconstruction. One should not always try to have
one flap do all things for all defects.

Expert Commentary
Frederick J. Menick

Named flaps develop from clinical necessity. Common defects are identified, and available
excess tissue is harvested that can be transferred on a reliable blood supply with predictable
results and few complications.
Cheek skin lateral to the nasolabial fold is commonly used to resurface defects within the
midface. The facial artery crosses the jawline and travels under the deep facial musculature
lateral to the nasolabial fold toward the alar base, where its distal branch, the angular artery,
continues toward the medial canthus. Multiple unnamed vertical perforators, primarily
positioned above and below the lateral lip commissure, arise from the facial artery to perfuse
the overlying skin. Based on the underlying perforator blood supply, excess tissue lateral
to the nasolabial fold can be elevated as subcutaneously based island flaps, with or without
a cutaneous random skin component as part of the pedicle. This medial cheek skin can be
moved to resurface the lateral nose and upper and lower lip, most often as a transposition
flap, and occasionally as a V-Y flap. Nasolabial skin can also be transferred as a random skin
extension of an advancing cheek flap.

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 Head and Neck  •  5C: Nasolabial Flap 257

Advantages and Limitations

In mature patients a modest amount of skin is available lateral to the nasolabial fold; this
can be harvested with minimal morbidity. Its color and texture match adjacent facial skin.
If its donor scar lies directly within the nasolabial crease, late scarring is minimal.
It is common, even if the scar lies directly in the nasolabial fold, to pull the fold laterally.
In all patients, the cheek is flattened, creating asymmetry. A contralateral excision of the
opposite nasolabial fold can be performed secondarily to improve symmetry.
In adults, the available excess is limited to approximately 2 cm in width, whereas chil-
dren have no excess tissue within the face, and no wrinkle in which to hide the scar. On
the male face, hair-bearing skin of the beard is problematic. The surgeon risks transferring
hair-bearing skin to a hairless recipient site, or vice versa. Although touted as a method for
reconstructing a mustache, the follicle density of a transferred flap may not be similar to that
of a normal upper lip, and the hair follicles are usually incorrectly oriented. Clinically, naso-
labial flaps have a tendency to pincushion, bulging above the plane of adjacent normal skin.
The vascularity of all nasolabial flaps is reliable but not robust. They do not tolerate
tension. Although occasionally recommended as a folded flap for covering and lining full-
thickness alar defects, their bulk and modest blood supply make them a poor choice.

Anatomic Considerations
Skin from the nasolabial fold can be moved based on a random cutaneous blood supply or
on the underlying subcutaneous perforators. The one-stage nasolabial flap can be used to
resurface defects of the nasal sidewall and ala, and upper lip and nasal base/sill. Excess skin
of the medial cheek, lateral to the nasolabial fold, is shifted as a random pattern extension
of an advancing cheek flap. Unlike traditional local nasal flaps, which only redistribute
residual nasal skin, this technique adds regional cheek skin to the surface of the nose. This
minimizes the risk of distorting the adjacent mobile tip or nostril margin and allows the
use of alar support grafts without risking collapse created by the tension of local nasal flaps.
The two-stage nasolabial flap transfers the same excess medial cheek skin, based on
multiple perforating vessels that originate from the facial and angular arteries. The sub-
cutaneous base of the flap is perfused by vessels that pass above and below the levator labia
and muscle, and travel perpendicularly through the subcutaneous fat to the overlying skin.
Although the proximal aspect of the skin flap may receive a random blood supply from
its skin pedicle, the flap survives as a subcutaneous island flap. Because of this deep axial
blood supply, a wide proximal skin pedicle is not necessary. Therefore this flap can be used
even if the skin lateral to the ala is scarred or has been excised, as long as the underlying
subcutaneous vascular base has not been significantly injured. The subcutaneous pedicle
also permits easy transposition of the flap around its pivot point, without the constraint or
twist necessitated by a wide skin pedicle.

Personal Experience and Insights

In my experience, nasolabial flaps are most effectively employed to resurface the nasal
sidewall and ala, to reconstruct the upper lip and nasal base of a composite nose-lip-cheek
defect, or as an island flap to resurface the lateral upper lip unit. But their limited size and
reliable length, high risk of pincushioning, the donor site midface scar, and the advantages
of other options—specifically, the forehead flap—limit their use to specific defects.
Continued

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 258 Part II  Regional Flaps: Anatomy and Basic Techniques

Recommendations
Technique
I perform most of my reconstructions with the patient under general anesthesia to avoid
distorting the flap and recipient tissues. This also facilitates evaluating the three-dimensional
contour and vascularity during flap elevation, and especially during suture closure, without
the fluid bulk of local anesthetic injection and without the effects of epinephrine.
The regional units of the face are marked with ink initially. Exact templates of missing
skin are designed based on the contralateral normal. It is difficult or impossible to make
these decisions once the procedure is underway.

Bibliography With Key Annotations

Borle RM, Nimonkar PV, Rajan R. Extended nasolabial flaps in the management of oral
submucous fibrosis. Br J Oral Maxillofac Surg 47:382-385, 2009.
The authors evaluated the effectiveness of extended nasolabial flaps and coronoidectomy in 47 ran-
domly selected patients with histologically confirmed oral submucous fibrosis. All had an interincisal
opening of less than 25 mm and were treated by bilateral release of fibrous bands, coronoidectomy or
coronoidotomy, and extended grafting with a nasolabial flap. All had postoperative physiotherapy and
were followed for 2 years. Their interincisal openings improved significantly from 14 mm (mean) to
41 mm (mean). The procedure was effective in managing patients with oral submucous fibrosis. The
main disadvantage was extraoral scars.
D’Arpa S, Cordova A, Pirrello R, et al. One-stage reconstruction of the nasal ala: the free-style
nasolabial perforator flap. Plast Reconstr Surg 123:65e-66e, 2009.
The nasolabial skin is the donor site of choice for nasal ala reconstruction, especially when the patient
does not want a forehead scar. Since its first description, the nasolabial flap has undergone several
modifications. Its only drawback is that it is a two-stage procedure, and even when harvested on a
subcutaneous pedicle, a second operation is required to restore an adequate nasal-cheek groove. The
authors reported on their experience using the nasolabial perforator flap for one-stage nasal ala re-
construction in eight cases with good results, comparable to those obtained with the classic technique.
Daya M, Mahomva O, Madaree A. Multistaged reconstruction of the oral commissures and
upper and lower lip with an island submental flap and a nasolabial flap. Plast Reconstr Surg
108:968-971, 2001.
The authors presented a case report on a patient in whom they used a submental flap to reconstruct
the oral commissure and partial defects involving the adjacent upper and lower lips. The same flap also
provided lining for the buccal mucosa. This is a new application for this flap. The remaining resurfac-
ing and bulk restoration for the upper and lower lips were completed with an adjacent nasolabial flap.
Deora SS, Nanjappa M, Kumaraswamy SV. Bilateral pedicled nasolabial flaps for the anterior
alveolus mandibular defect: a review. J Maxillofac Oral Surg 9:385-388, 2011.
Although the increased application of microvascular free tissue transfer techniques for oral cavity re-
construction has decreased the need for local and regional flaps, a number of them are quite useful and
should be considered for this purpose. Nasolabial flaps are versatile, easy to harvest, and can provide
coverage for a variety of facial defects. The authors discussed a case in which they successfully used a
bilateral pedicled flap to reconstruct the patient’s mandibular anterior alveolus after the wide excision
of a squamous cell carcinoma. After 21⁄2 years, there were no signs of recurrence.

05c_Nasolabial_r7_cah_0232-0261.indd 258 2/1/2012 7:51:18 PM

 Head and Neck  •  5C: Nasolabial Flap 259

El-Marakby HH. The versatile naso-labial flaps in facial reconstruction. J Egypt Natl Canc
Inst 17:245-250, 2005.
Facial defects resulting from surgical excision of tumors can be difficult to repair. Skin grafts have a
natural tendency to contract, may not take properly, and only cover superficial defects. Color mismatch
can also be problematic. Regional flaps such as the median forehead flap are usually bulky, cannot
cover a wide range of facial reconstruction, and usually require the donor area to be grafted. The authors
utilized a nasolabial flap for facial reconstruction in 20 patients. This flap offers several advantages.
It is a versatile, robust local flap that is easily elevated without delay. It can be superiorly based to
reconstruct defects of the cheek, sidewall or dorsum of the nose, ala, columella, and the lower eyelid.
Inferiorly based flaps are useful for reconstructing defects in the upper or lower lip and the anterior
floor of the mouth. The flap can be turned over and used as a lining of the nose and lip. Indications,
flap designs, technique, and complications were discussed.
Erçöçen AR, Yilmaz S, Saydam M. Bilateral superiorly based full-thickness nasolabial island
flaps for closure of residual anterior palatal fistulas in an unoperated elderly patient. Cleft Palate
Craniofac J 40:91-99, 2003.
Unoperated cleft lip and palate in an adult is typically the result of unfavorable economic and social
circumstances. The authors treated a 65-year-old patient with bilateral complete cleft lip and palate.
At the first stage, they performed a straight-line closure of the bilateral cleft lip, and a two-flap push-
back palatoplasty with superiorly based lateral port control pharyngeal flap for the wide cleft palate.
At the second stage, large, residual anterior palatal fistulas were closed using bilateral superiorly based
(retrograde flow) full-thickness nasolabial island flaps.
Iwao F. Alar reconstruction with subcutaneous pedicled nasolabial flap: difficulties, consider-
ations, and conclusions for this procedure. Dermatol Surg 31:1351-1354, 2005.
The authors used a subcutaneous pedicled nasolabial flap for reconstruction in three patients. In the
first case, a folded flap was utilized with a conchal cartilage strut sandwich. In the second case, only
a folded flap was used. For the third case, the flap covered the outer surface of the ala, and a muco-
periosteal graft from the hard palate supplied the alar lining. In the first case, the cartilage strut was
not sufficient to support the shape of the ala. Harvesting a sufficiently wide flap is important. In the
second case, the folded flap had drawbacks, including the formation of a thick alar rim. The third case
proved to be an excellent choice.
Kearney C, Sheridan A, Vinciullo C, et al. A tunneled and turned-over nasolabial flap for
reconstruction of full thickness nasal ala defects. Dermatol Surg 36:1319-1324, 2010.
Lazaridis N, Tilaveridis I, Karakasis D. Superiorly or inferiorly based “islanded” nasolabial flap
for buccal mucosa defects reconstruction. J Oral Maxillofac Surg 66:7-15, 2008.
The authors shared their experience with superiorly and inferiorly based subcutaneous pedicled flaps
for buccal mucosal defects in nine patients. They were elevated as skin islands, relying on a pedicle of
subcutaneous tissue. Nine procedures were performed on small to moderate defects of the central portion
of buccal mucosa. Four patients underwent superiorly based and five patients underwent inferiorly
based “islanded” nasolabial flap reconstruction. All flaps were successful.
Li JH, Xing X, Li P, et al. Transposition movement of V-Y flaps for facial reconstruction. J Plast
Reconstr Aesthet Surg 60:1244-1247, 2007.
V-Y flaps are sometimes limited to only rotation or advancement. To overcome this drawback, the
authors introduced a modified V-Y flap designed with a single laterally based pedicle for facial recon-
struction in six patients. It was transferred through a transposition movement. The flap was reliable,
robust, and could be moved easily with less tension. Defects were closed primarily along the nasolabial
fold or preauricular crease. All patients had satisfactory functional and cosmetic outcomes.

05c_Nasolabial_r7_cah_0232-0261.indd 259 2/1/2012 7:51:19 PM

 260 Part II  Regional Flaps: Anatomy and Basic Techniques

Moscatiello F, Carrera A, Tirone L, et al. Distally based dorsal nasal flap in nasal ala reconstruc-
tion: anatomic study and clinical experience. Dermatol Surg 37:825-834, 2011.
The nasal dorsum is a good skin flap donor site for alar reconstructions because of its appropriate
color, texture, and thickness. The authors studied the vascular anatomy of the nasal dorsum in five
fresh-frozen latex-injected cadavers. Nasal septal branches from the superior labial arteries supplied the
nasal tip. These arteries connected with lateral nasal branches (facial system) and dorsal nasal arter-
ies (ophthalmic system) to form a consistent vascular network in the dorsal nasal superficial muscular
aponeurotic system. This anatomy was the basis for safely raising distally based cutaneous flaps. The
authors also reconstructed the nasal ala with an inferiorly based dorsal nasal flap in 14 patients. All
flaps were successful.
Rohrich RJ, Conrad MH. The superiorly based nasolabial flap for simultaneous alar and cheek
reconstruction. Plast Reconstr Surg 108:1727-1730, 2001.
Patients with multiple skin cancer defects present challenging reconstructions for plastic surgeons,
often requiring more than one flap or skin graft. The authors performed an innovative reconstruction
of simultaneous medial cheek and alar base nasal defects using a nasolabial flap. Concepts in nasal
reconstruction were reviewed.
Rudkin GH, Carlsen BT, Miller TA. Nasolabial flap reconstruction of large defects of the lower
lip. Plast Reconstr Surg 111:810-817, 2003.
Although a variety of techniques have been proposed for the reconstruction of large defects of the lower
lip, none is ideal. The authors presented their experience with reconstruction of defects of more than
75% of the transverse dimension of the lower lip using unilateral or bilateral subcutaneous nasolabial
flaps. All patients had aesthetically acceptable results, complete oral competence, and normal speech. No
complications were encountered. The authors discussed common alternate methods of lip reconstruction
and their limitations. They concluded that this method of reconstruction is superior in appropriately
selected patients; it is technically simple to perform and provides a functional and aesthetic result, with
minimal donor site morbidity.
Sarifakioğlu N, Aslan G, Terzloğlu A, et al. New technique of one-stage reconstruction of a
large full-thickness defect in the upper lip: bilateral reverse composite nasolabial flap. Ann Plast
Surg 49:207-210, 2002.
Total upper lip reconstruction is one of the most challenging procedures because of the size of the tissue
and the loss of aesthetic subunits such as Cupid’s bow and the philtral columns. The authors presented
a case of one-stage upper lip reconstruction with a bilateral reverse composite nasolabial flap.
Schmidt BL, Dierks EJ. The nasolabial flap. Oral Maxillofac Surg Clin North Am 15:487-495,
2003.
In this article, the authors discussed the advantages of the nasolabial flap—both superiorly and infe-
riorly based variants—over microvascular free flaps and less-aesthetic skin grafts. They maintained
that it offers an effective means of reconstructing facial and oral defects.
Shao Y, Zhang D, Zhao Z, et al. [Reconstruction of large nasal defects with lateral nasal artery
pedicled nasolabial flap] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 24:552-555, 2010.
The authors performed lateral nasal artery pedicled nasolabial flaps in 12 patients with large nasal
tip and alar defects. Lateral nasal artery pedicled nasolabial flaps were used in nine cases and island
flaps in three. In five patients, cartilage grafts were used for alar rim support, and the distal end of the
nasolabial flap was thinned and folded to repair the nasal lining. Donor sites were closed primarily.
There was mild venous stasis at the distal end of three island flaps that resolved without intervention.
All flaps survived. Five flaps were revisions that were performed 6 to 15 months postoperatively
because of mild swelling at the pedicles of skin flaps. The follow-up period was 8 to 24 months. All
patients had satisfactory nasal appearance, flap texture and color, and ventilatory function. No obvi-
ous scar was found at donor sites.

05c_Nasolabial_r7_cah_0232-0261.indd 260 2/1/2012 7:51:19 PM

 Head and Neck  •  5C: Nasolabial Flap 261

Tei TM, Larsen J. Use of the subcutaneously based nasolabial flap in lower eyelid reconstruc-
tion. Br J Plast Surg 56:420-423, 2003.
The authors were the first to use the Hughes procedure (tarsoconjunctival flap) to reconstruct a full-
thickness squamous cell carcinoma of the lower left eyelid. The patient was a 54-year-old man. The
procedure was combined with a subcutaneously based nasolabial flap for skin coverage.
Thornton JF, Griffin JR, Constantine FC. Nasal reconstruction: an overview and nuances.
Semin Plast Surg 22:257-268, 2008.
The authors reviewed major aspects and subtle nuances of nasal reconstruction. The nasal lining,
support, skin coverage, local nasal flaps, the nasolabial flap, and the paramedian forehead flap were
discussed, as well as the subunit versus defect-only reconstruction controversy. It was confirmed that
applying a variety of options for each defect provided the best outcome. The authors also presented a
novel approach to full-thickness skin grafting, recommended for lower third reconstruction. Postopera-
tive care, including dermabrasion, skin care, and counseling, were emphasized.
Thornton JF, Weathers WM. Nasolabial flap for nasal tip reconstruction. Plast Reconstr Surg
122:775-781, 2008.
The authors reviewed a series of 80 nasolabial flaps, 38 of which were used for partial or complete
tip reconstruction. Three complications occurred, with one resulting in complete flap loss. The naso-
labial flap is a versatile, pedicled flap that, with proper modifications, careful patient selection, and
appropriate postoperative management, is an excellent option for lateral nasal wall, ala, columella,
and intraoral reconstruction.

05c_Nasolabial_r7_cah_0232-0261.indd 261 2/1/2012 7:51:19 PM

 ANATOMIC LANDMARKS
Landmarks The temporoparietal fascia flap bounded superiorly by the superior
temporal fusion line, anteriorly by the orbital rim, inferiorly by
the supramastoid crest and the zygomatic arch, and posteriorly
by the temporal fossa of the parietal bone.
Size 14 3 10 cm.
Composition Fascial, fasciocutaneous, type A.
Dominant Pedicle Superficial temporal artery.
Nerve Supply Sensory: The auricular temporal nerve (mandibular branch of
the trigeminal nerve).

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 Section 5D
Head and Neck

Temporoparietal Fascia Flap

CLINICAL APPLICATIONS
Regional Use
Ear
Orbit
Anterior cranial base
Upper face
Distant Use
Face
Contralateral ear
Upper extremity
Lower extremity
Specialized Use
Scalp
Ear
Eyebrow
Mustache

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 ANATOMY OF THE TEMPOROPARIETAL FASCIA FLAP

A Parietal bone
Temporal bone

Frontal
bone

Sphenoid
bone

Zygomatic
bone

Bony anatomy

B Temporoparietal fascia C Frontal branch

Superficial
of facial nerve Frontal branch of
temporal
artery temporal artery
Galea Frontalis
aponeurotica muscle Auriculo- Zygomatico-
temporal orbital artery
nerve

Occipitalis
muscle Temporalis Zygomatico-
muscle (under temporal branch
temporoparietal of facial nerve
fascia) Parotid
gland

Muscle and fascial anatomy Neurovascular anatomy

Fig. 5D-1  

Dominant pedicle: Superficial temporal artery

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 265

Anatomy
Landmarks The temporoparietal fascia flap occupies the temporal fossa, which is bounded
superiorly by the superior temporal fusion line (which marks the origin of the
temporalis muscle), anteriorly by the lateral orbital rim, and inferiorly by the
zygomatic arch and supramastoid crest. Fascia can be extended posteriorly beyond
the temporalis muscle, though not across the midline.
Composition Fascial, fasciocutaneous.
Size 14 3 10 cm.

Arterial Anatomy
Dominant Pedicle  Superficial temporal artery
Regional Source  External carotid artery.
Length  4 cm.
Diameter  2 mm.
Location  Superficial temporal artery originates posterior to the vertical ramus of the mandible
and extends over the zygomatic process of the temporal bone. It is located anterior and deep to
the superficial temporal vein and courses superiorly on the surface of the superficial temporal
fascia. Superior to the zygomatic arch a deep branch, the middle temporal artery, enters the
temporalis muscle; 2 to 4 cm superior to the zygomatic arch, the vessel divides into its terminal
branches. The frontal branch courses anteriorly and supplies the frontalis muscle. The parietal
branches are variable and supply the parietal scalp to the vertex and posteriorly to anastomose
with terminal branches of the occipital vessel.

Venous Anatomy
The superficial temporal vein runs with the artery generally but can be found as far as 3 cm away in
some patients. It is located anterior and superficial to the artery immediately below the subdermal
fat. Drainage from the vein joins the retromandibular vein. At the level of the zygoma the vein is
approximately 2 to 3 mm in size.

Nerve Supply
Sensory The auriculotemporal nerve (mandibular branch of the trigeminal nerve).

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 266 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Temporoparietal Fascia Flap

A

Relationship of vascular anatomy to external ear

B C

D D

Deep surface of flap Radiographic view

Fig. 5D-2 

Dominant pedicle: Superficial temporal artery (D)

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 267

Flap Harvest
Design and Markings
The flap is exposed through a T, Y, or zigzag incision, depending on the amount of fascia
required and the surgeon’s preference.

Incision

Fig. 5D-3  Once the superficial temporal artery’s course is determined by handheld Doppler, a zig-
zag incision is planned in the hair-bearing area to expose the flap and give the best cosmesis.

Patient Positioning
The patient is placed in a supine position.

Guide to Flap Dissection

Dissection starts in the preauricular area with identification of the superficial temporal artery,
vein, and the auriculotemporal nerve. A handheld Doppler probe can be used initially to
help locate these vessels and to map them out on the scalp.

A
Incision

Superficial
temporal
artery Auriculo-
temporal
nerve

Parotid
gland

Initial dissection

Fig. 5D-4 

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 268 Part II  Regional Flaps: Anatomy and Basic Techniques

Dissection then proceeds superiorly in a subcutaneous plane. The surgeon should attempt
to stay just deep to the hair follicles to prevent injury to the fascia. Hemostasis is critical
during this procedure so the layers of the temporal fascia can be easily seen and dissected.
After the skin flaps are elevated, the superficial temporal fascia can be visualized, as well as
the associated neurovascular structures. The size of the desired flap is then marked, tapering
the design down to its pedicle.

B
Deep
temporal
fascia
Frontal branch
Superficial of temporal artery
temporal
artery Frontal branch
of facial nerve
Auriculo-
temporal Zygomatico-
nerve orbital artery

Superficial Zygomatico-
temporal temporal branch
fascia of facial nerve

Superficial dissection only

Fig. 5D-4 

If desired, two layers of fascia can be harvested, both the superficial temporal fascia
and the deep temporal fascia, separately if needed, or as a combined unit, depending on
the reconstructive need.

Auriculo-
temporal
Frontal branch
nerve
of temporal artery
Superficial
temporal Frontal branch
artery of facial nerve

Deep
temporal Zygomatico-
fascia orbital artery
Zygomatico-
Superficial
temporal branch
temporal
of facial nerve
fascia
Superficial and deep dissection

Fig. 5D-4 

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 269

The periphery of the flap is then incised and the flap is elevated. The superficial fascia
can be separated from the deep temporal fascia, entering a loose areolar avascular space. As
one nears the zygomatic process, care must be taken to avoid injury to the frontal branch
of the facial nerve. As the zygomatic arch is reached and the flap is reflected, the middle
temporal branch to the deep fascia can be seen.

Frontal branch
of temporal artery

Frontal branch
of facial nerve
Auriculo-
temporal Deep
nerve temporal fascia

Superficial
temporal Superficial
artery temporal fascia

Final dissection

Fig. 5D-4 

If only the superficial temporal fascia is being taken, this vessel is ligated. If the deep
fascia is to be taken as well, dissection proceeds to the perimeter of the deep fascia, which
is then elevated off the underlying temporal muscle. This is the same dissection that one
would start if the flaps were to be maintained in a conjoined fashion. As the deep fascia is
dissected inferiorly, there is some attachment to the zygoma that must be carefully divided.
The middle temporal artery can be seen on the deep surface of the deep fascia, and further
dissection proximally will allow the two fascial flaps to remain attached, as the superficial
temporal artery and superficial temporal vein can be dissected further.

Flap Variants
•  Fasciocutaneous (hair-bearing) flap
•  Free flap

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 270 Part II  Regional Flaps: Anatomy and Basic Techniques

Fasciocutaneous (Hair-Bearing) Flap

The temporoparietal fascial flap can be carried with overlying scalp and hair-bearing skin.
This is particularly valuable for reconstruction that requires hair-bearing tissues at the
eyebrow, mustache, or other areas of facial hair in men. It is helpful when designing these
flaps to use a Doppler probe to map the branches of the superficial temporal artery so the
flaps can be placed directly over one of these branches. The surgeon must look at the hair
follicles and the direction of hair growth so that after rotation of the flap, the hair will grow
in the correct direction (see Section 5B, Fig. 5B-14).

Free Flap
The temporoparietal fascia is valuable. This thin vascularized fascial tissue can be used in
reconstructions throughout the body. When it is not available as a local flap, the contralateral
temporoparietal fascia can be transferred as a free tissue transfer for ear reconstruction (see
Fig. 5D-8). This is also a favored flap in tendon reconstruction of the hand and the foot
because of its thin coverage and its ability to allow tendon gliding within it.

Arc of Rotation
The temporoparietal fascial flap easily rotates anteriorly for coverage of the forehead, orbit,
and cheek. This is a valuable flap for dural and cranial base reconstruction as well as orbital
reconstruction. This is the flap of choice to be used in ear reconstruction, because the flap
rotates toward its pedicle, which is at the ear. The ultimate arc is limited by the viability of
extensions of the flap, which do not reasonably go beyond the temporal fusion line supe-
riorly and the midline posteriorly.

Superficial
temporal
artery

Arc to middle
third of face

Standard flap: Arc to middle third of face

Fig. 5D-5 

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 Head and Neck  •  5D: Temporoparietal Fascia Flap   271

Superficial
temporal
artery

Standard flap: Arc to external ear

Fig. 5D-5

FLAP trANSFer
The flap is transferred as a transposition flap and is either passed through a subcutaneous
tunnel or is directly transferred to the defect. If skin is not carried with the flap, skin graft-
ing is often required.

FLAP iNSet
For a pedicle flap, the pedicle must not be kinked or compressed in any way if it is to be
tunneled. The fascial component of the flap holds suture well and secures the flap in posi-
tion. When temporoparietal fascia is used as a free flap, it is important to inset and secure
the fascia before microscopic anastomosis is performed to prevent kinking and torsion of
the pedicle.

DoNor Site CLoSure

Closure of the donor site should be planned so that a primary closure can be performed.
In most cases, when skin is not taken with the flap, there is no problem closing the skin.
One must avoid cauterization of hair follicles and undue tension on the closure to prevent
healing problems and alopecia.

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 272 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 62-year-old man had a history of resection of a brain malignancy and a metallic cra-
nioplasty for reconstruction 10 years earlier. He had undergone postoperative irradiation
of the scalp and presented with exposure of his cranioplasty, but no evidence of recurrence
of cancer. The neurosurgeon wanted to preserve the cranioplasty if at all possible.

A
B

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.

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 273

D E

F G

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. (Case supplied by MRZ.)

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 274 Part II  Regional Flaps: Anatomy and Basic Techniques

This child presented with traumatic loss of the upper third of the ear. Her parents requested
reconstruction of the ear.

B C

Fig. 5D-7 A, Through a vertical temporal incision, the temporalis fascia was elevated, based inferi-
orly. 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 tempo-
ralis 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.

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 275

E F

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 dress-
ing 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. (Case courtesy Ian T. Jackson, MD.)

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 276 Part II  Regional Flaps: Anatomy and Basic Techniques

This 24-year-old woman had been assaulted with a shotgun and sustained a wound encom-
passing the left ear, mastoid, and significant overlying skin. Her immediate care involved
a scalp flap and back grafting (see Section 5B). She presented for delayed total ear recon-
struction. Because a temporoparietal fascia flap was not available as a result of the gunshot
wound, a free temporoparietal fascia flap was harvested from the contralateral side and used
for reconstruction.

A B

C D

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 recon-
struction. 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 cover-
ing a tissue expander.

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 277

G H

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. (Case supplied by MRZ.)

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 278 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient developed radiation necrosis after enucleation and irradiation of the right eye
for recurrent melanoma.

Fig. 5D-9 A, The patient is seen preoperatively. B, A temporoparietal fasciocutaneous flap was de-
signed. C, The flap was exposed via a classic T-shaped incision and raised in the manner described.

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 279

D E

F G

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. (Case courtesy Julian J. Pribaz, MD.)

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 280 Part II  Regional Flaps: Anatomy and Basic Techniques

A temporoparietal fasciocutaneous flap was planned to reconstruct this patient’s traumatic

loss of his right eyebrow.

A B

C D

Fig. 5D-10  A, The superficial temporal vessels were identified by Doppler probe. B and C, The fas-
ciocutaneous 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. (Case courtesy Julian J. Pribaz, MD.)

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 281

This man presented with a subtotal ear defect involving the upper two thirds of his ear.

A B C

D E F

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 con-
structed 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. (Case courtesy Julian J. Pribaz, MD.)

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 282 Part II  Regional Flaps: Anatomy and Basic Techniques

This woman had a burn injury on the dorsum of the hand, and a temporoparietal fascia
flap was planned.

C D

Fig. 5D-12  A, The patient is shown preoperatively with the flap design. B and C, A free temporo-
parietal 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. (Case courtesy Julian J.
Pribaz, MD.)

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 283

Pearls and Pitfalls

• The scalp is shaved and the entire vascular tree is marked with the aid of a Doppler probe
before the flap is planned. To ensure the best vascularity, the flap is centered over one
of the branches.
• Injury of the hair follicles must be avoided during dissection to prevent alopecia.
• Early identification and sparing of the auricular temporal nerve will prevent some common
postoperative problems such as numbness and sensitivity. The use of a nerve stimulator is
sometimes helpful to prevent injury to the frontal branch of the facial nerve.
• In cases of hemifacial microsomia and congenital deformities of the head, the anatomy
of the superficial temporal system as well as the temporal fascia may be abnormal and not
usable for local flap reconstruction.
• Hemostasis is essential if both the superficial temporal and the deep temporal fascia are
required as separate leaves of the flap. Once the tissues are blood stained, it is hard to
dissect them.
• When more fascia is needed than 14 by 10 cm, one should consider an alternate donor
site. Extensions of this flap have poor vascularity beyond the territory described.
• Hair transplantation techniques have largely replaced hair-bearing flaps for mustache
and eyebrow reconstruction.

Expert Commentary
Julian J. Pribaz

Indications
The temporoparietal fasciocutaneous flap is a very useful and hardy flap that can be used
to reconstruct a variety of local and distant defects. The flap is based on the rich vascularity
coming from the superficial temporal vessels and its arborizing branches. It is very versatile
and may be used as a vascularized fascial flap (both locally and as a free flap distally) and as
a fasciocutaneous flap to reconstruct hair-bearing regions of the face.

Advantages and Limitations

The flap is very well vascularized, thin, and pliable. However, the size is limited and as
mentioned in the text, it is limited to approximately 14 by 10 cm. The fact that the overly-
ing skin is hair-bearing is an advantage for repairing hair-bearing defects, but if one desires
a non-hair-bearing fasciocutaneous flap, this flap is not suitable. The flap has the added
advantage that the temporal fascia is laminated, and separate layers can be dissected and
fanned out to increase the surface area of coverage. Also, the inherent lamination of the
temporoparietal flap can be useful when this flap is used to reconstruct the dorsum of the
hand, especially after burns, where tendons can be inserted between the two layers of this
well-vascularized flap, to assist with tendon gliding.
Continued

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 284 Part II  Regional Flaps: Anatomy and Basic Techniques

Anatomic Considerations
The anatomy of this flap is well described in the chapter. In the harvesting of this flap, great
care is needed to prevent injury to the hair follicles, which are immediately above the fascia,
as well as the flap blood supply, which is on the superficial aspect of the flap.

Personal Experience and Insights

The temporoparietal fascia flap has been used quite extensively. As a local fasciocutaneous
pedicle flap, it has been used to reconstruct the eyebrow. The problem is that an eyebrow
reconstructed in this fashion will grow hair much more rapidly than the normal contra-
lateral side requiring repeated trimming (see Fig. 5D-10). For restoration of the mustache
and upper beard area in men, this flap has been used as a large bipedicle flap as a two-stage
procedure. This may be indicated especially in a burn patient. The flap is divided and inset
after about 3 weeks. However, the hair growth that occurs is profuse and is not of the same
consistency and distribution of normal mustache hair.
I have used this as a fascial flap in orbital reconstruction, especially in a contracted or
radionecrotic orbital defect that can arise after enucleation and radiation (see Fig. 5D-10).
When used in this setting, the flap is skin grafted; it is preferable to apply the skin graft to the
flap before transfer into the orbit, since it is very difficult to inset a graft within the orbital
cavity. It is much simpler to do this with the flap dissected out before transfer.
When the flap is used for ear construction (see Fig. 5D-11), the possibility of expand-
ing the reach of the flap by separating the deep and superficial layers can be a very useful
adjunct to provide maximal coverage of the cartilaginous constructs.

Recommendations
The approach to harvest the flap, although classically described as a T-shaped or Y-shaped
scar, may in fact leave a visible scar, because some alopecia can occur along the margins. It
has been found that doing this as a zigzag-type incision provides better camouflage at the
donor site. The vessels are identified by Doppler ultrasound, and the dissection commences
distally, away from where the main identified vessels are located. The dissection occurs just
deep to the fatty tissue surrounding the hair follicles. Dissection with needle-tip cautery
set at 12 to 15 cm can facilitate the dissection. When used as a free flap, the pedicle is dis-
sected proximally to the parotid, where the superficial temporal artery and vein are at least
2 mm in diameter.

Bibliography With Key Annotations

Altindas M, Yucel A, Ozturk G, et al. The prefabricated temporal island flap for eyelid and eye
socket reconstruction in total orbital exenteration patients: a new method.
Ann Plast Surg 65:177-182, 2010.
Anophthalmic socket reconstruction is a challenging problem in plastic surgery. The authors had
described a prefabricated superficial temporal fascia island flap and used this technique in more than
50 enucleation patients with severe socket contraction, ending in excellent or good results for 28 years
(Altindas-1 procedure). However, the flap was not suitable for exenteration patients with complete
eyelid loss. The technique was modified and used in exenteration patients (Altindas-2 procedure). In
this two-stage procedure, the temporoparietal fascia is prefabricated with a full-thickness skin graft from
the retroauricular area, and a strip of scalp is preserved at the middle of the flap. The flap is transferred
to the orbit through a subcutaneous tunnel at the second stage. The prefabricated flap is used for the
reconstruction of eyelids and periorbital skin; a scalp island is used for the reconstruction of lid margins
and eyelashes; and the neighboring bare temporoparietal fascia is used for the augmentation of the

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 285

periorbital soft tissues. The orbital lining is elevated as a centrally based skin flap and used for the
reconstruction of the eye socket, fornices, and posterior lining of the eyelids. The technique was used
successfully in five total exenteration patients with complete eyelid loss. In one patient, the ipsilateral
temporal island flap had been used previously, so the flap was prepared from the contralateral site and
transferred to the anophthalmic orbit as a free flap 5 weeks later. With this procedure, it is possible to
reconstruct a stable eye socket that is suitable for ocular prosthesis, upper and lower fornices, periorbital
skin with good color matching, naturally looking eyelids with eyelashes and lid margins, and medial
and lateral canthal areas. It is also possible to improve periorbital soft tissue atrophy, which is an
important problem in patients who had radiotherapy previously. Free transfer of the flap provides a
new solution for the reconstruction of cases that were operated previously.
Bauer BS. Reconstruction of microtia. Plast Reconstr Surg 124(1 Suppl):14e-26e, 2009.
After a brief review of the history of ear reconstruction in general and microtia specifically, the author
discussed issues related to the transition in popularity from techniques involving three or more stages
(Tanzer and Brent) to the current popularity of two-stage procedures (Nagata, Firmin, and Park).
Each of the popular procedures was considered in relation to timing of the reconstruction, procedure
planning, and how both the soft tissues and framework construction are handled in each of the stages.
The most significant differences included whether the autogenous cartilage framework is constructed
with or without the tragal construct (for the lobular-type microtia), whether the lobule is rotated in
the first-stage reconstruction, whether an additional cartilage block is placed behind the framework for
added ear projection, and how that added block is covered (choice of fascia flap and skin graft). Each of
the techniques has to be varied in reconstruction of auricular dystopia in light of the associated skeletal
and soft tissue hypoplasia. The author demonstrated that although there may be significant advan-
tages to the two-stage reconstructions of Nagata and Firmin, some may feel that the larger amount
of cartilage harvested, the later optimal age for beginning the reconstruction, the additional scalp scars
engendered by using the temporoparietal fascia flap in the second-stage elevation of the framework,
and even the exchange of lobule tissue (and ability to later pierce ears) to obtain better coverage of the
concha and tragus are unacceptable. Having gained experience with each of the varied approaches and
having modified them when unusual variations in deformities have required it, the author discussed
his current preferences. Clearly, the author thinks that there may be significant advantages to delaying
the reconstruction to age 10 years or older, yet experience gained over the past 25 years would seem
to indicate that as in all other aspects of plastic and reconstructive surgery, one must never be wed to
a single approach, and experience and flexibility are essential in obtaining the optimal outcome in all
variations of the deformity.
Biswas G, Lohani I, Chari PS. The sandwich temporoparietal free fascial flap for tendon glid-
ing. Plast Reconstr Surg 108:1639-1645, 2001.
Microsurgical transfer of the superficial and deep temporal fascia based on the superficial temporal
vessels has been documented. This article analyzed the functional recovery when each layer of this
facial flap is placed on either side of reconstructed or repaired tendons, to recreate a gliding environment.
This fascial flap also provided a thin, pliable vascular cover in selected defects of the extremities. Six
patients (four male and two female) with tendon loss and skin scarring of the hand (three dorsum, one
palmar, and one distal forearm) and posttraumatic scarring of the ankle with tendoachilles shortening
(one patient) underwent this procedure. No flap loss was witnessed. Good overall functional recovery
and tendon excursion were observed. Partial graft loss was observed in two patients.
Chang SC, Wu CI, Jung SM. Resolution of posttraumatic recurrent nasal fistula using tempo-
roparietal fascia. J Craniofac Surg 21:910-912, 2010.
Temporoparietal fascial grafts have been used for both nasal and facial contouring, for vascularized tissue
coverage, and to augment the nose and lip. The temporoparietal fascial graft is easily neovascularized
and provides thin, broad, pliable, adequate coverage, contour, and bulk on the cartilage dorsum of the
nose, and creates an inconspicuous donor site. A 23-year-old woman motorcyclist had an accident
with one angular laceration wound on the dorsum of the nose. There was intermittent discharge in
the dorsal nose 2 weeks after primary repair. Six months later, open-tip rhinoplasty was performed

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 286 Part II  Regional Flaps: Anatomy and Basic Techniques

to the recurrent fistula of the nose dorsum. There were two fistulous orifices and one fibrotic cavity
with hair ingrowth. After replacement of the rolled temporoparietal fascia, external nasal splinting
was applied to mold the shape for 1 week. There was no graft exposure or recurrent infection. The
procedure is a useful method to eliminate inflammatory sequelae. The smooth nasal dorsum skin was
regained with adequate nasal projection.
Chung KC, Cederna PS. Endoscopic harvest of temporoparietal fascial free flaps for coverage
of hand wounds. J Hand Surg Am 27:525-533, 2002.
The temporoparietal fascial (TPF) flap is a thin, pliable, and well-vascularized flap that is ideal
for reconstructing hand defects. However, conventionally harvested flaps result in a large scar over
the temporal fossa, which may be problematic in patients with male pattern baldness. The authors
described an endoscopic technique for harvesting the TPF flap through a 4 cm preauricular incision to
reduce donor site morbidity. Five TPF flaps were used to cover hand wounds. Three of the flaps were
successful, and there were no injuries to the frontal branch of the facial nerve in this series. Endoscopic
harvest of the TPF flap is an ideal solution for covering medium-sized hand defects without potentially
prominent scars in the temporal area.
Davison SP, Mesbahi AN, Clemens MW, et al. Vascularized calvarial bone flaps and midface
reconstruction. Plast Reconstr Surg 122:10e-18e, 2008.
Although vascularized calvarial bone grafts were originally explored for use in reconstruction of midface
hypoplasia defects, they offer significant value in application to oncologic reconstruction of the midface.
The authors reviewed eight cases of midface reconstruction using vascularized calvarial grafts to il-
lustrate the versatility and dependability of these flaps. Adequate bony and soft tissue contours were
achieved with no clinical evidence of bone graft resorption. No immediate postoperative complications
including infection and hematoma or seroma formation were noted. One patient experienced delayed
sinusitis from a blocked duct.
Kruavit A, Visuthikosol V. Temporoparietal fascial free flap for correction of first web space
atrophy. Microsurgery 30:8-12, 2010.
Fourteen temporoparietal fascial free flaps were used for correction of first web space atrophy from ulnar
nerve palsy in 13 patients; 10 had sustained ulnar nerve injuries and three had leprosy. General
anesthesia was used in 12 patients; one leprosy patient with bilateral ulnar nerve palsy had local
anesthesia and a brachial block for harvest of bilateral free flaps and recipient site preparation, respec-
tively. Follow-up ranged from 4 to 64 months. Postoperative results were satisfactory, and there was
no resorption of the free flaps. The consistency of the augmented first web space was soft and had a
compressible, natural feel. The size of the flap was more than enough for augmentation of the first web
space, and donor site morbidity was minimal and accepted by all patients. The authors concluded that
the temporoparietal fascial free flap is an ideal autologous tissue for correction of first web space atrophy.
Liu Y, Jiao P, Tan X, et al. Reconstruction of facial defects using prefabricated expanded flaps
carried by temporoparietal fascia flaps. Plast Reconstr Surg 123:556-561, 2009.
Prefabricated flaps allow transfer of a selected tissue as an axial flap to enhance the vascular supply
of a random skin flap. The prefabricated expanded flap is an effective technique for reconstruction of
facial defects in selected patients.
Parhiscar A, Har-El G, Turk JB, et al. Temporoparietal osteofascial flap for head and neck
reconstruction. J Oral Maxillofac Surg 60:619-622, 2002.
This article described the use of the temporoparietal osteofascial flap (TOF) for reconstruction of bony
defects in the midface and mandible. The authors reviewed the demographics, causes, indications,
surgical technique, radiographic evaluation, and final outcome of 11 patients with upper or lower jaw
defects who underwent reconstruction using the TOF between 1994 and 1999. The TOF was used
to reconstruct a defect of the mandible in seven patients, the hard palate in two patients, the maxilla
in one patient, and the zygoma in one patient. This vascularized calvarial bone flap can be used
for reconstruction of small to medium-sized defects of the maxilla and lateral mandible with good
functional and cosmetic results. It can be performed without special microvascular expertise and with
minimal donor site morbidity. A full-thickness bone flap can support osteointegrated dental implants.

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 Head and Neck  •  5D: Temporoparietal Fascia Flap 287

Pinto FR, de Magalhães RP, Capelli Fde A, et al. Pedicled temporoparietal galeal flap for
reconstruction of intraoral defects. Ann Otol Rhinol Laryngol 117:581-586, 2008.
The authors reviewed the charts of six consecutive patients who underwent reconstruction of intraoral
defects using the pedicled temporoparietal galeal flap. All of the defects were in the posterior oral cavity
and oropharynx. After resection of the oral cancer, the temporoparietal galeal flap, based on the super-
ficial temporal vessels, was raised and transposed to the mouth through a tunnel under the zygomatic
arch. The oral defect was repaired, and no skin graft was applied over the flap. There were no flap
losses, and the reconstructive goal was achieved in all cases. The patients’ deglutition and phonation
abilities were restored, and the donor site scars were well hidden by hair growth.
Rogachefsky RA, Ouellette EA, Mendietta CG, et al. Free temporoparietal fascial flap for
coverage of a large palmar forearm wound after hand replantation. J Reconstr Microsurg
17:421-423, 2001.
A free temporoparietal fascial flap with a split-thickness skin graft was used to cover a large palmar
forearm wound in a patient whose hand had been replanted 21 days earlier after traumatic amputation
at the distal forearm level. At 39 months’ follow-up, the patient had achieved an excellent cosmetic
and functional result, with no alopecia or facial nerve injury. This flap is advantageous for coverage
of wounds that require a large amount of thin, pliable tissue, and the donor site scar is concealed.
Stow NW, Gordon DH, Eisenberg R. Technique of temporoparietal fascia flap in ear and
lateral skull base surgery. Otol Neurotol 31:964-967, 2010.
A retrospective review of the senior author’s personal database over a 6-year period of cases in which
a temporoparietal fascia (TPF) flap was used. Sixty-five TPF flaps were used for reconstructions
of the ear and lateral skull base. Indications for surgery included cholesteatoma, chronic otitis media,
cerebrospinal fluid fistula, and meningoencephalocele. All mastoid cases were epithelialized at 6 weeks.
Complications encountered and discussed were a mastoid-cutaneous fistula, mastoid hematoma, and
canal stenosis (5%; n 5 3). The authors concluded that with appropriate technique and indications,
the TPF flap is an important reconstructive option after ear and lateral skull base surgery.
Tanaka A, Hatoko M, Kuwahara M, et al. Evaluation of scars after harvest of the temporopari-
etal fascial flap depending on the design of the skin incision. Ann Plast Surg 48:376-380, 2002.
The authors evaluated the conspicuousness of the temporal scar caused by two incision patterns after
harvesting the temporoparietal fascial flap: a straight incision and a zigzag incision. The 27 scars of
27 patients were examined; 15 patients had a straight incision and 12 had a zigzag incision. This
study showed that the zigzag incision resulted in more conspicuous scars than the straight incision,
and this effect was more evident in younger individuals than in older ones, at least among Japanese
patients. In a comparison of older patients and younger patients, irrespective of the skin incision pat-
terns, the scars were substantially more conspicuous in younger patients. A simple, short incision is
preferred when harvesting the temporoparietal fascial flap, and more careful management is required
for young patients.

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 ANATOMIC LANDMARKS
Landmarks Fan-shaped muscle that occupies the temporal fossa and extends
onto the lateral skull. It can be palpated above the zygomatic
arch and extends under the zygomatic arch to the mandible.
Size 10 3 20 cm.
Origin Temporal fossa and temporal fascia.
Insertion Anterior coronoid process and anterior ramus of the mandible.
Function One of the muscles of mastication; assists in mandibular retrac-
tion and elevation.
Composition Muscle.
Flap Type Type III.
Dominant Pedicles Anterior deep temporal artery and the posterior deep temporal
artery.
Minor Pedicle Middle temporal artery branches.
Nerve Supply Motor: Anterior and posterior deep temporal nerves (fifth cranial
nerve).

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 Section 5E
Head and Neck

Temporalis Flap

CLINICAL APPLICATIONS
Regional Use
Orbit
Maxilla
Mandible
Specialized Use
Facial reanimation

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 Anatomy of the Temporalis Flap

A
Temporalis
muscle

Muscle and bony anatomy

B
Branches Temporalis
of middle muscle
temporal
artery

Posterior deep
temporal artery
Middle
temporal
artery
Anterior deep
temporal artery

External
carotid artery

Vascular anatomy

Fig. 5E-1 

Dominant pedicles: Anterior deep temporal artery; posterior deep temporal artery
Minor pedicle: Branches of middle temporal artery

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 Head and Neck  •  5E: Temporalis Flap 291

Anatomy
Landmarks Fan-shaped muscle that occupies the temporal fossa. The muscle can be palpated
above the zygomatic arch when the teeth are clenched. Below the arch, the
muscle extends to the mandible and is not palpable.
Composition Muscle. Although the overlying skin could be carried anatomically with the
flap, it is rarely needed and would create donor site morbidity.
Size 10 3 20 cm.
Origin Temporal fossa and temporal fascia.
Insertion Anterior coronoid process and anterior ramus of the mandible.
Function The temporalis is a muscle of mastication; it assists in mandibular retraction and
elevation.

Arterial Anatomy (Type III)

Dominant Pedicle  Anterior deep temporal artery
Regional Source  Maxillary artery.
Length  2 cm.
Diameter  1 mm.
Location  Deep to the muscle at the level of the zygomatic arch.
Dominant Pedicle  Posterior deep temporal artery
Regional Source  Maxillary artery.
Length  2 cm.
Diameter  1 mm.
Location  Deep to the muscle at the level of the zygomatic arch.
Minor Pedicle  Branches of the middle temporal artery
Regional Source  Superficial temporal artery.
Length  1 cm.
Diameter  0.5 mm.
Location  Superficial surface of the middle third of the muscle.

Venous Anatomy
Paired venae comitantes accompany the named arteries.

Nerve Supply
Motor Fifth cranial nerve, mandibular division. The deep temporal branches of the
anterior trunk of the nerve enter the posterior-superior portion of the muscle.

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 292 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Temporalis Flap

A B

D2

D2
D1 D1

Deep surface of flap Radiographic view

Fig. 5E-2 

Dominant pedicles: Anterior deep temporal artery (D1); posterior deep temporal artery (D2)
Minor pedicle: Branches of middle temporal artery (m)

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 Head and Neck  •  5E: Temporalis Flap 293

FLAP HARVEST
Design and Markings
An incision that overlies the temporal muscle is placed within the hair-bearing area to
camouflage the scar. This curvilinear incision will run down to the preauricular area for
best cosmesis and exposure of the zygomatic arch. A zigzag incision may also be used to
better conceal the scar.

Incision

Marking for incision for flap elevation

Fig. 5E-3 

Patient Positioning
The flap is usually elevated with the patient in a supine position with the head turned,
depending on the needs of the case. The flap could also be harvested with the patient in a
lateral decubitus position.

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 294 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The origin of the muscle from the temporal bone is taken down sharply or with a Bovie
cautery, and the muscle is easily dissected off the temporal fossa with a periosteal elevator.
There is no danger to the pedicle until dissection reaches the level of the zygomatic arch.
At this point, the motor nerves and vascular pedicle can be identified on the deep surface
of the muscle. For most indications, no further dissection is required, and no further skel-
etonization of the pedicle or nerves is needed.

A B

Temporalis
muscle

Zygomatic
arch

Arc to middle and lower thirds of face Removal of central portion of zygomatic arch increases arc
of rotation and exposure to pedicle

Fig. 5E-4 

FLAP VARIANTS
•  Functional muscle transfer
•  Segmental transposition flap
•  Vascularized bone flap

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 Head and Neck  •  5E: Temporalis Flap 295

Functional Muscle Transfer

The temporalis muscle is an option for reanimation of the face, particularly reanimation
of the mouth, eye, and eyelid. Exposure is begun as described previously with identifica-
tion of the superficial surface of the muscle. The central third of the muscle can be taken
to minimize bulk and ease rotation of the muscle into proper position. Extensions of fascia
can be taken to help extend the muscle for insertion into the commissure.

Temporalis
muscle

Temporalis
muscle

Fascial
extension Orbicularis oris
muscle

Suture

Inset of temporalis to modiolus and orbicularis oris

Fig. 5E-5 

A second variant of this flap involves removal of the insertion of the temporalis muscle
from the coronoid process and rotation toward the commissure with insertion. When the
flap is used for reanimation of the eyelid, smaller segments of temporalis muscle can be trans-
posed to the lower eyelid with extensions of fascia to act as both a static and functional sling.

Segmental Transposition Flap

The muscle can be split into an anterior and a posterior half or can be harvested as a central
third, as described previously. It can be helpful to divide the muscle when the reconstruction
involves areas that cannot be covered by a single flap. Some degree of muscle splitting can
also be used to attempt to animate different portions of the lip or periorbital area.

Vascularized Bone Flap

Although connections are present between the muscle and the temporal bone, such com-
bined myoosseous flaps are rarely used, because free calvarial grafts covered by temporalis
muscle work just as well and provide a better donor site for bone harvest.

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 296 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
When the flap is elevated and the zygomatic arch is the point of rotation, coverage of the
orbit, upper cheek, and maxilla is possible. Extension of the rotation of the flap can be at-
tained by removal of the central section of the zygomatic arch. For facial reanimation, the
arc of rotation for periorbital or for smile reanimation can be extended by the use of fascia,
such as temporoparietal fascia or fascia lata. This allows comfortable reach of the muscle
and proper tensioning for a functional result.

A B

Arc to orbit Arc to midface

Extended arc to lower third of face (zygomatic arch divided)

Fig. 5E-6 

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 Head and Neck  •  5E: Temporalis Flap 297

FLAP TRANSFER
For orbital and skull-base defects, the flap is transferred by transposition. This can be through
the muscle bed or anteromedially into the orbit.

A B

Temporalis
muscle

Temporalis Mini plate

muscle

Flap turnover into midface Maxillary and nasal transposition

Fig. 5E-7 

For reconstruction in the palate and mandible, the muscle is transposed over the zygo-
matic arch and can rotate 180 degrees or turn over on itself. Passage of the muscle underneath
the arch without arch removal is not practical and is not recommended.

FLAP INSET
When a temporalis flap is used for reconstruction that includes skin defects of the orbit or
cheek, skin grafting is often performed after the muscle is secured to the bone. For functional
muscle transfers or deeper reconstructions such as the skull base, no skin graft is required.
For the reconstruction of defects, it is critical that the muscle be inset without tension and
without kinking or torsion of the pedicle. For facial reanimation, it is critical that the muscle
retain its proper resting length for good muscle excursion and postoperative function.

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 298 Part II  Regional Flaps: Anatomy and Basic Techniques

DONOR SITE CLOSURE

Harvest of the temporal muscle leaves a contour deformity in the temporal fossa. This is
a cosmetic concern and should be addressed at the primary operation. Most commonly,
remaining temporal muscle or temporal parietal fascia can be used to help fill this void.

A B

A A
C C

B B

Only central section of muscle is used Remaining muscle is released and centralized,
filling void and maintaining contour

Fig. 5E-8 

In some cases, implants are used at the initial procedure, depending on the surgeon’s
preference. It is not uncommon that secondary surgeries, such as placement of an implant
or fat grafting, are required to correct this deformity.

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 Head and Neck  •  5E: Temporalis Flap 299

CLINICAL APPLICATIONS
This 36-year-old woman underwent resection of a left acoustic neuroma with complete
loss of facial nerve function.

A B

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 bal-
anced smile. No revision surgery was required. (Case courtesy Roger L. Simpson, MD.)

This 34-year-old woman presented with right-sided congenital near-complete paralysis.

A B

Fig. 5E-10  A, The patient demonstrates her only function through a portion of the marginal man-
dibular 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. (Case courtesy Roger L. Simpson, MD.)

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 300 Part II  Regional Flaps: Anatomy and Basic Techniques

This young woman, as a 16-year-old girl, underwent resection of a hemangioma of her left
cheek, which resulted in partial paralysis.

A B

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 pro-
cedure. (Case courtesy Roger L. Simpson, MD.)

Pearls and Pitfalls

• The temporalis muscle is valuable for the reconstruction of defects of the orbit and skull
base, especially in elderly patients or those with significant medical comorbidities.
• The temporalis muscle can be harvested without interference with mastication.
• Harvest of the temporal muscle will leave a cosmetic deformity at the donor site that
should be addressed.
• Fullness in the area of the zygomatic arch from passage of the muscle over the arch can
be minimized by defatting the cheek in this area, or in some cases by removing the arch.
• When the arch is removed for transposition of the temporalis muscle, in most cases it
should be replaced to avoid cosmetic deformities.
• When the temporalis is used for functional muscle transfer, the surgeon should consider
a liquid or soft diet for the first 2 weeks to minimize mastication and allow healing of
the muscle on inset and to prevent local complications.

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 Head and Neck  •  5E: Temporalis Flap 301

Expert Commentary
Roger L. Simpson

The versatility of the temporalis muscle in facial reconstruction is apparent in appreciat-

ing the various arcs of rotation of this muscle transfer. Soft tissue fill for deficiencies of the
orbit and upper maxillary area are possible with the ease of rotation of the muscle and the
reliability of its blood supply. Extension of the muscle to the lower maxillary and even
mandibular cheek areas is possible by a partial resection of the zygomatic arch tracing the
blood supply deep to the muscle and inferiorly.

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
Planning
Use of the temporalis for contiguous muscle reanimation of unilateral or bilateral facial
paralysis requires attention to design, tension, and muscle innervation. A reproducible facial
reanimation using the temporalis muscle, in my experience, requires approximately two
thirds of the width of the muscle harvested through a longitudinal incision in the hair-
bearing scalp. Isolated areas of facial paralysis, such as just the levator labii superioris, can
be reconstructed by a narrower slip of extended temporalis.

Fig. 5E-13  A partial left-sided paralysis limited

to the zygomaticus major and minor and the leva-
tor 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.

Continued

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 302 Part II  Regional Flaps: Anatomy and Basic Techniques

Planning the dynamics of the transfer requires an appreciation of the type of smile pres-
ent on the nonparalyzed side. Most individuals (67%) have a zygomaticus major–dominated
smile; fewer (31%) show a combination of levator labii superioris and zygomaticus major
and minor components. It is important to design the muscle transfer that will reproduce
the form and balance of the patient’s smile.

A B

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 zygo-
maticus major and levator superior muscles to produce a gentle curvature.

Technique
The length of the muscle is variable. The transferred temporalis is turned over the zygomatic
arch (as a fulcrum) for strong fiber excursion and pull. Fig. 5E-4 shows muscle or periosteal
extensions of the transfer to the three key areas of attachment in smile restoration. However, I
have not found that the muscle can be tapered in that fashion or that the periosteum provides
a strong enough attachment to the muscle to reliably act in a functional gliding capacity.
Fig. 5E-5 shows an extension of the temporalis using fascia to insert into the orbicularis
oris on the paralyze side. I extend the temporalis using its own deep temporal fascia.

Fig. 5E-15  Preparation of fascia before isolating and contouring the temporalis muscle transfer.

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 Head and Neck  •  5E: Temporalis Flap 303

Next, the tunnel is created from donor site to the upper lip and commissure.

Fig. 5E-16  Cheek dissection creates a path for

the transfer, designed to reproduce the smile pat-
tern of the normal side. Care should be taken not
to allow the transferred muscle to roll medial to the
zygomatic prominence.

The fascial extension is carefully inset into the desired area of the commissure and lip.

Fig. 5E-17  Tension is set with overcorrection.

The temporalis fascial extension is attached to the
upper lip and commissure.

With tension exerted on the muscle, insertion of the fascia is not into the atrophic
orbicularis but into the stable vermilion of the upper lip and commissure, reproducing the
pattern of the desired smile.
Setting the tension requires painstaking care. In a dynamic transfer, the muscle must
produce a full, balanced excursion of the smile, as well as in relaxation, to produce just the
right tension at rest. The force of the temporalis pull can be balanced by a portion of the
masseter muscle transfer to hold the position of the commissure level during contraction.

Fig. 5E-18  Overcorrection of the tension of the

transferred temporalis muscle is essential in cre-
ating the correct balance of dynamic excursion.
Approximately 28% of patients require a minor
adjustment of the tension within 2 years.

Continued

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 304 Part II  Regional Flaps: Anatomy and Basic Techniques

Facial paralysis, whether partial or complete, will produce a degree of muscle atrophy
on the affected side. The subcutaneous dissection of the tunnel in the cheek also defines the
desired direction of pull of the muscle and the resulting shape of the smile. I use the broad-
est width of the temporalis that will fit into that tunnel without creating excessive bulk.
Fullness is present as the temporalis is turned over the zygomatic arch. The degree of
fullness will vary with the thickness of the muscle, the tension created, and the degree of
contraction of the muscle during function. Thinning the muscle is not suggested as decreased
contractility or nerve injury to the transfer is possible.
With the use of a wider muscle flap, I have found that the primary closure of the remain-
ing temporalis muscle donor area is not possible. Rotation and tension on the remaining
segments, as shown in Fig. 5E-8, will cause additional volume depletion of the temporal
fossa. This will further accentuate the fullness of the muscle turnover.
The use of a temporal implant, or better yet, acellular dermal matrix, will create an
excellent form at the temple region. A carved solid or porous polyethylene implant is one
solution in the wide temporalis donor area to treat the temporal hollowing seen after transfer.
These implants have been associated with capsule formation, pain, pressure, and contour
changes. Currently I prefer a rolled sheet of acellular dermal matrix to fill the temporalis
donor site, which gives ample fullness and contour. The soft consistency has reduced post-
surgical complications of capsule formation, extrusion, and contact pain.

Fig. 5E-19  Polyethylene implant.

The use of thin segments of the temporalis muscle for dynamic reconstruction of the
eyelids has been less than satisfactory in my hands. The transfer of narrow slips of muscle
and/or fascial extensions in proximity to the lash line have produced (when remaining dy-
namic) a lateral pull to the eyelids, creating a sphincter like closure. The degree of relaxation
has not been completely predictable often leaving a partial closure of the upper lid. I prefer
the combination of a gold loader placed over the tarsal plate of the upper eyelid to initiate
descent, and a well-designed static sling for the lower eyelid.
The temporalis muscle may also be transferred to the commissure and upper lip as a
lengthening myoplasty, as described by Labbé. The fascial portion attached to the coronoid
process is advanced into the cheek after mobilization of the muscle in the temporal fossa.
Tension of the muscle after transfer has a critically important role, as in the turnover proce-
dure. Loss of contour of the temporal fossa is avoided, because the muscle and its relationship
to the zygomatic arch remain intact.

Take-Away Messages
The use of the temporalis muscle for either static or dynamic reconstruction of the face and
orbital area achieves consistently good results. Its rich blood supply and well-positioned
pedicle makes it ideal for large areas of soft tissue coverage. Temporalis innervation and
options for its direction of pull make the muscle well suited for facial paralysis reanimation.

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 Head and Neck  •  5E: Temporalis Flap 305

Bibliography With Key Annotations

Abubaker AO, Abouzgia MB. The temporalis muscle flap in reconstruction of intraoral defects:
an appraisal of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:24-30,
2002.
This retrospective review reported on the use of the temporalis muscle flap for reconstruction of differ-
ent types of intraoral defects in eight patients. All patients previously wore obturators as a nonsurgical
treatment of their defects. Criteria used to evaluate the results of this technique included flap necrosis,
facial nerve deficit, limitation of mandibular range of motion, and cosmetic deformity from scarring of
the incision line or from loss of muscle volume in the temporal fossa. The patients were also evaluated
for their degree of satisfaction with their speech and mastication with the obturator preoperatively and
with the flap postoperatively. Also reviewed were the success rates and complications with use of the
temporalis muscle flap reported in the English-language literature during the past 14 years. All eight
patients in this series had their defects successfully reconstructed, which eliminated any further need
for prosthetic obturation of the defect. No flap necrosis occurred, and there were no facial nerve deficits
or long-term changes in mandibular range of motion. Slight temporal hollowing was seen in the first
three patients.
Abu-El Naaj I, Leiser Y, Liberman R, et al. The use of the temporalis myofascial flap in oral
cancer patients. J Oral Maxillofac Surg 68:578-583, 2010.
The authors presented their experience with the use of the simple, reliable, and predictable temporalis
myofascial flap (TMF) in rehabilitation and reconstructive surgery in older cancer patients whose health
was compromised in a way that precluded the use of microvascular free flaps. The series included 10
patients (8 men and 2 women) ranging in age from 62 to 85 years. A full-thickness anteroinferiorly
based TMF was used in five patients for palatal reconstruction, three patients for buccal lining re-
construction, and two patients for reconstruction after resection of facial skin and buccal mucosa. The
TMF survival rate in this study was excellent, with an 80% success rate (2 minor complications).
Complications included one case of a partial distally necrotic flap that resolved after local debridement
and did not require further flap manipulation and one case of transient, spontaneously resolved facial
nerve (temporal branch) palsy and limited mouth opening (less than 20 mm), which also resolved after
judicious physiotherapy. The TMF was found to have a fairly low complication rate, was relatively
easy to use, and had a predictable outcome.
Arribas-Garcia I, Alcalá-Galiano A. Endoscopic harvest of a temporalis flap for a maxillary
reconstruction. J Craniofac Surg 20:1049-1051, 2009.
The temporalis muscle flap for reconstruction of the maxilla is a commonly used technique at the mo-
ment. One of the disadvantages of applying this technique is the scar generated by the anesthetic in the
temporalis fossa and the depression of this area. The authors presented a new method for endoscopic
harvesting of the muscle flap through minimal incisions situated in the temporalis fossa and preauricular
region. This endoscopic technique has not been described in the literature for a hemimaxillary recon-
struction. These authors described the first case of a maxillary reconstruction with an endoscopically
assisted temporalis muscle flap with excellent results.
Balaji SM. A modified temporalis transfer in facial reanimation. Int J Oral Maxillofac Surg
31:584-591, 2002.
The authors presented a modified technique for temporalis transfer: instead of the traditional strip-
ping of the temporalis from its origin, its attachment at the coronoid is removed, and to its end, the
harvested fascia lata graft was sutured to lengthen the muscle’s action. These fibers were then passed
to the orbicularis oculi and oris to aid in reanimation and improve their tone. The procedure is less
extensive, provides a direct line of pull with good functional results, and no muscle atrophy, since
vascularity and innervation are maintained. No complaints of paresthesia, hypoesthesia, or scarring
on the donor leg were noted. None of the patients required revision surgery for unacceptable contour
or asymmetry. This simple procedure has aided in the reconstruction of a natural, symmetrical smile
with highly successful results.

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 306 Part II  Regional Flaps: Anatomy and Basic Techniques

Boahene KD. Dynamic muscle transfer in facial reanimation. Facial Plast Surg 24:204-210, 2008.
Dynamic muscle transfers offer the hope of improved facial support and symmetry, with volitional
movement. These are most commonly employed for reanimation of the oral commissure to produce a
smile. In addition, muscle transfers have been used successfully to reestablish eye closure. Long-standing
facial paralysis presents challenges quite distinct from paralysis that is managed early after onset. In this
situation, most commonly, dynamic muscle transfers are used. The alternative is free tissue transfer.
The advantages and disadvantages of each of these two options were discussed.
Boeckx WD, De Lorenzi F, van der Hulst RR, et al. Free fascia temporalis interpositioning as
a treatment for wrist ankylosis. J Reconstr Microsurg 18:269-274, 2002.
The fascia temporalis is a thin and well-vascularized tissue, and it is versatile for use in reconstructive
surgery. It can be used as an island flap in defects of the head and neck or as a free flap in reconstructions
of different anatomic regions. As a “living” spacer for treating wrist ankylosis, its use has not yet been
described. The authors discussed transfer of the free fascia temporalis into the wrist for wrist ankylosis
in patients affected by severe rheumatoid arthritis. Four flap transfers were performed in three patients.
Preoperative flexion/extension in the wrist was absent or almost absent and painful, resulting in severely
impaired daily activities. After resection of the distal ulna and radius and the proximal surfaces of the
proximal row of the carpal bones, the free fascia was used to replace the wrist joint. Postoperative wrist
flexion/extension was 45 to 50 degrees. In all patients, this procedure allowed painless movement of
the wrist and improved ability to perform daily activities. A 2-year follow-up showed no recurrence of
wrist problems, and the articular space was maintained. The use of the free fascia temporalis offers a
good alternative to arthrodesis, maintaining sufficient function for daily activities.
Borucki Ł, Wierzbicka M, Szyfter W. [Anastomosis of hypoglossal-facial nerves by modified
May technique] Otolaryngol Pol 56:39-44, 2002.
Facial palsy is an unpleasant disorder that inhibits vital movements and facial expression. There are
many surgical techniques that use the neighboring nerve fibers to reanimate the face, such as end-to-
end or side-to-end anastomosis with hypoglossal, glossopharyngeal, accessory, or mandibular nerves.
The donor fiber can be derived from the homolateral or heterolateral side. The reconstruction can be
completed by cosmetic surgery using parietal muscle or free muscular flaps. The authors presented the
modified May technique described by Darrouzet with rerouting of the facial nerve in the mastoid por-
tion of the temporal bone. This procedure elongates the facial nerve stumps with simultaneous rerouting
of the facial nerve. Three temporal bone blocks with adjacent tissues were taken from cadavers. The
length of the isolated nerve stump was measured and photographed. The length of the prolonged nerve
stump was 13 mm in each case. After adding to this the length of the trunk (the portion between the
stylomastoid foramen and pes anserinus), the fragments of rerouted nerve measured up to 21 mm. This
distance allowed facial-hypoglossal anastomosis using only one neurorrhaphy without increased tension.
Brenner E, Schoeller T. Masseteric nerve: a possible donor for facial nerve anastomosis? Clin
Anat 11:396-400, 1998.
The authors presented a preliminary anatomic analysis that could lead to a new technique for treating
facial nerve paralysis. The masseteric nerve leaves the infratemporal fossa through the mandibular notch,
accompanied by the masseteric artery. At this level the nerve consisted (in 9 of 36 cases they studied)
of only one branch (25%), in 17 cases of two branches (47%), in nine cases of three (25%), and in the
remaining case of four branches (2.8%). There are three main reasons for considering the masseteric
nerve as a possible donor for at least the orbicular branch of the facial nerve: (1) The approach to the
mandibular notch is quite simple; (2) since the nerve consists of two or more branches in 75.0% of the
cases, severe dysfunction of the masseter muscle should not occur; (3) if there is complete denervation
of the masseter muscle, its function may be taken over by the temporalis muscle.
Browne JD, Holland BW. Combined intraoral and lateral temporal approach for palatal malig-
nancies with temporalis muscle reconstruction. Arch Otolaryngol Head Neck Surg 128:531-
537, 2002.
The authors presented a retrospective chart review of 16 patients who underwent a combined approach
for resection of palatal carcinoma; 5 of the 16 were edentulous. Six types of tumors were treated:
adenoid cystic carcinoma (3 patients), low-grade mucoepidermoid carcinoma (5 patients), squamous

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 Head and Neck  •  5E: Temporalis Flap 307

cell carcinoma (3 patients), polymorphous low-grade adenocarcinoma (2 patients), osteosarcoma (1

patient), ameloblastoma (1 patient), and hyalinizing clear cell carcinoma (1 patient). Main outcome
measures were the postoperative diet, velum competence, flap viability, complications, and survival.
Fifteen (94%) of 16 patients were able to resume their preoperative diets. No velopharyngeal insuf-
ficiency was encountered. All flaps survived and none required repeated surgical intervention. Five
patients developed serous otitis media, and two patients required flap revision secondary to posterior
choanal obstruction. One patient died of complications unrelated to the procedure.
Burggasser G, Happak W, Gruber H, et al. The temporalis: blood supply and innervation. Plast
Reconstr Surg 109:1862-1869, 2002.
In this study, 60 human cadavers were investigated to identify the arteries and nerves supplying the
temporalis muscle. In all specimens, three arteries supplying the temporalis were identified: the anterior
deep temporal artery (anterior part, 30% muscle mass), the posterior deep temporal artery (central part,
51% muscle mass), and the medial temporal artery (occipital and in 25% upper part, 19% muscle
mass). Motor branches of the trigeminal nerve innervated the temporalis: the deep temporal nerves of the
mandibular nerve (98%, central part), branches of the buccal nerve (95%, anterior part), and branches
of the masseteric nerve (69%, posterior part). They noted remarkable variation in the innervating
nerve branches, and in 12% peripheral anastomoses between the motor nerve branches. The various
numbers of innervating nerve branches demonstrate the difficulty of creating innervated or selectively
denervated pedicled muscle flaps for reinnervation. Nevertheless, at least two different pedicled flaps
using the anterior or central part of the temporalis can be selectively used for reconstructive surgery.
Byrne PJ, Kim M, Boahene K, et al. Temporalis tendon transfer as part of a comprehensive
approach to facial reanimation. Arch Facial Plast Surg 9:234-241, 2007.
This paper was a retrospective review of seven consecutive patients who underwent orthodromic transfer
of the temporalis muscle insertion for the treatment of long-standing facial paralysis. The patients
underwent facial retraining physical therapy before and shortly after the procedure. Outcomes mea-
sured included patient satisfaction, objective measurements of oral commissure elevation with smiling,
and physician grading of preoperative and postoperative patient photographs. Patient satisfaction was
high, with a mean score of 8.5 (possible score of 10). Four patients were physician graded as excellent
to superb. The other three patients were rated as having good postoperative results. Movement was
identified in every patient and ranged from 1.6 to 8.5 mm, with mean movement of the oral commis-
sure of 4.2 mm. One patient developed a postoperative salivary fluid collection that required drainage.
Carrillo JF, Celis MA, Ramirez-Ortega M, et al. Osteoplastic maxillotomy for treatment of
neoplasms of the nasopharynx and infratemporal fossa. Ann Otol Rhinol Laryngol 114(1 Pt 1):
58-64, 2005.
Approaches to the infratemporal fossa and nasopharynx are difficult because of the anatomic complex-
ity of these regions. The authors described their experience with osteoplastic maxillotomy with their
own modifications and evaluated oncologic outcomes and postoperative quality of life. Ten patients
underwent osteoplastic maxillotomy; three had a diagnosis of malignancy, and seven had nasopha-
ryngeal angiofibromas (NPAs). A Weber-Fergusson incision was made to develop facial flaps and
preserve the vascularity of the maxilla. Osteotomies were performed through the facial aspects of the
maxilla, on the orbital rims, and on the malar eminence for the medial variant of the procedure. The
anterolateral variant involved descent of the temporalis muscle, with preservation of the facial nerve,
and a zygomatic osteotomy. Four craniotomies were done. Two patients had the medial variant of
the procedure, and eight had the anterolateral variant. The complications were transient and mild.
The patients with malignancies are alive with no disease; there was one recurrence among the seven
patients with NPAs. Aesthetic results were excellent in eight patients, and there was no change in
basic functions in eight patients.
Cascone P, Agrillo A, Spuntarelli G, et al. Combined surgical therapy of temporomandibular
joint ankylosis and secondary deformity using intraoral distraction. J Craniofac Surg 13:401-
409; discussion 410, 2002.
Temporomandibular joint ankylosis (TMJ) is a pathologic process caused by damage of the mandibu-
lar condyle. When this occurs during the developmental age, it results in an alteration of the entire

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 308 Part II  Regional Flaps: Anatomy and Basic Techniques

maxillofacial complex. Therefore surgical methods to remove the temporomandibular ankylosis also
require procedures to correct the secondary maxillofacial deformity. Distraction osteogenesis induced the
authors’ center to modify the surgical protocol for the treatment of patients who develop TMJ ankylosis
and secondary maxillomandibular deformity. They treated four patients with monolateral ankylosis
of the TMJ and serious deformities of the maxillomandibular complex caused by functional limita-
tions. During the same operation, arthroplasty was performed, with removal of the ankylotic block
and the interposition of a temporal muscle flap in the new articular space; an intraoral osteodistractor
was also positioned to lengthen the mandible. All patients recovered the eurhythmy of the face and
good symmetry was reestablished. At an average 12-month follow-up, the average opening of the
mouth was at least 35 mm.
Celik N, Wei FC, Chang YM, et al. Squamous cell carcinoma of the oral mucosa after release
of submucous fibrosis and bilateral small radial forearm flap reconstruction. Plast Reconstr Surg
110:34-38, 2002.
Oral submucous fibrosis is a collagen disorder that affects the submucosal layer of the upper digestive
tract. The major cause is the habit of betel quid chewing, which is common in central, southern, and
Southeast Asia. The progressive and irreversible course of the disease results in trismus, dysphagia,
xerostomia, and rhinolalia. The most serious complication of this disorder is the development of oral
carcinoma; the incidence in different series varies from 1.9% to 10%. A sufficient mouth opening can
be achieved by complete release of fibrotic tissue, and coronoidectomy and temporal muscle myotomy
is performed when needed. Reconstruction of the resultant defect can be best achieved by microsurgical
free tissue transfer because of the discouraging results with skin grafting or local flaps. The authors
reported a series of 26 patients who underwent reconstructive surgery with small radial forearm flaps
after release of submucous fibrosis with or without temporalis muscle myotomy and coronoidectomy.
All patients were men, with a mean age of 40.1 years (range 18 to 62 years) and all had a history of
betel nut chewing ranging from 8 to 40 years. Three patients developed squamous cell carcinoma of
the oral cavity 24 to 36 months after submucous fibrosis release. Two of them occurred in the release
site and the other one occurred at the soft palate. Oral cancer occurred in three of 13 patients who had
received release of submucous fibrosis and who were followed for longer than 2 years (range 24 to 48
months), which means that 23% of these patients developed squamous cell carcinoma of the intraoral
mucosa. The high risk of cancer occurrence strongly indicates the importance of an earlier and more
aggressive surgical approach toward submucous fibrosis, and regular long-term follow-up.
Chang DW, Langstein HN, Gupta A, et al. Reconstructive management of cranial base defects
after tumor ablation. Plast Reconstr Surg 107:1346-1355; discussion 1356-1357, 2001.
The authors reviewed 77 cranial base reconstructions performed by the Department of Plastic Surgery
at the University of Texas M. D. Anderson Cancer Center between 1993 and 1999. They analyzed
the impact of the location of the defect, type of reconstruction, type of dural repair, and history of pre-
operative radiation and chemotherapy on the rate of complications and patient survival. They found
that neither the type of reconstruction nor the location of defect showed a significant effect on patient
survival. In this experience, local flaps such as pericranial or temporalis muscle flaps were found to be
good choices for reconstruction of smaller anterior or lateral cranial base defects. For defects that required
larger amounts of soft tissue, free flaps were appropriate. With proper patient selection, successful cranial
base reconstruction can be performed with either local or free flaps with a low incidence of complications.
Christo S. Temporalis muscle flap and forehead flap for a single stage primary repair of the orbit
after exenteration. West Afr J Med 21:248, 2002.
Chuang DC. Technique evolution for facial paralysis reconstruction using functioning free
muscle transplantation—experience of Chang Gung Memorial Hospital. Clin Plast Surg 29:449-
459, v, 2002.
The author performed facial reanimation by using functioning free muscle transplantation in 116 cases
from 1986 to 2000. Three consecutive 5-year periods were presented in relation to each stage of the
author’s technical improvement. In the first 5 years he encountered bulkiness and asymmetrical smil-
ing with weak gum exposure that required correction. During the second 5 years there were technical

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 Head and Neck  •  5E: Temporalis Flap 309

improvements, but with residual deformities. The third 5-year period was one of technique refinement.
The author extended the utility of the gracilis for different and more challenging problems, such as the
use of a muscle plus skin two-unit composite flap connected by the septoperforator nutrient vessels,
not only for facial reanimation but also for intraoral contracture release or extraoral facial soft tissue
and skin deficits replacement.
Dallan I, Lenzi R, Sellari-Franceschini S, et al. Temporalis myofascial flap in maxillary recon-
struction: anatomical study and clinical application. J Craniomaxillofac Surg 37:96-101, 2009.
The authors described the indications and advantages of the temporalis myofascial flap in the recon-
struction of surgical defects after partial maxillectomies. This flap is thin and reliable and can be used
as an alternative to free flap tissue transfer in the reconstruction of partial defects of the upper maxilla.
The surgical steps to raise the flap are simple, but during the dissection the surgeon must be careful to
avoid damage to the frontotemporal branches of the facial nerve on the outer surface and to the feeding
vessels on the inner surface of the temporal muscle. In this series, no major surgical complications were
observed, and no injuries to the facial nerve branches were reported. Neither total nor partial flap losses
occurred. Postoperative aesthetic and functional results were satisfying.
Edwards SP, Feinberg SE. The temporalis muscle flap in contemporary oral and maxillofacial
surgery. Oral Maxillofac Surg Clin North Am 15:513-535, vi, 2003.
The continued use of the temporalis muscle flap in maxillofacial surgery for more than a century
serves as a testament to its versatility and reliability. The technical ease of its procurement and the
amount and quality of tissue available make this flap a valuable tool in the armamentarium of the
reconstructive surgeon.
Eldaly A, Magdy EA, Nour YA, et al. Temporalis myofascial flap for primary cranial base
reconstruction after tumor resection. Skull Base 18:253-263, 2008.
The authors reported on 41 consecutive patients who received primary temporalis myofascial flap
reconstructions after cranial base tumor resections in a 4-year period. Patients included 37 males and
4 females ranging in age from 10 to 65 years. Two patients received preoperative and 18 postoperative
radiation therapy. Follow-up ranged from 4 to 39 months. The whole temporalis muscle was used
in 26 patients (63.4%) and only part of a coronally split muscle was used in 15 patients (36.6%).
Nine patients had primary donor site reconstruction using a Medpor temporal fossa implant; these
had excellent aesthetic results. There were no cases of complete flap loss. Partial flap dehiscence was
seen in six patients (14.6%); only two required surgical debridement. None of the patients developed
cerebrospinal leaks or meningitis. One patient was left with complete paralysis of the temporal branch
of the facial nerve. Three patients (all had received postoperative irradiation) developed permanent
trismus. The temporalis myofascial flap was found to be an excellent reconstructive alternative for a
wide variety of skull base defects following tumor ablation. It is a very reliable, versatile flap that is
usually available in the operative field, with relatively low donor site aesthetic and functional morbidity.
Frey M, Giovanoli P. The three-stage concept to optimize the results of microsurgical reani-
mation of the paralyzed face. Clin Plast Surg 29:461-482, 2002.
From the authors’ three-dimensional video analyses they learned that the advantages of a one-stage
procedure are far outweighed by the disadvantages. A three-stage concept to a one-stage procedure was
preferred because of the safety of having a cross-face nerve graft to cover the distance from the healthy
facial nerve to the nerve of the muscle transplant without problems and without the danger of tension
on the nerve suture line because of shortage of the muscle nerve. In addition, this concept provides
independence from anatomic variations, such a very proximal muscle hilus in the latissimus dorsi
muscle, which results in too short a muscle nerve. Only face-lift incisions are necessary, without the
need of an additional incision in the nasolabial fold while using a cross-face nerve graft. This technique
allows freedom to position the muscle graft on the paralyzed side, with free choice of the position of
the transplant hilus. The superficial temporal vessels can be used for microvascular anastomoses. The
three-stage concept prevents a scar in the submandibular region, with its tendency of hypertrophy,
especially if it is connected to the preauricular incision. Different functional territories of one muscle
transplant for eye closure and for smile are only possible in combination with two cross-face nerve grafts.

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 310 Part II  Regional Flaps: Anatomy and Basic Techniques

Har-Shai Y, Gil T, Metanes I, Labbé D. Intraoperative muscle electrical stimulation for accurate
positioning of the temporalis muscle tendon during dynamic, one-stage lengthening temporalis
myoplasty for facial and lip reanimation. Plast Reconstr Surg 126:118-125, 2010.
Intraoperative electrical stimulation of the temporalis muscle, employing direct percutaneous electrode
needles or transcutaneous electrical stimulation electrodes, was used in 11 primary and four secondary
cases with complete facial palsy. The duration of the facial paralysis was up to 12 years. Postoperative
follow-up ranged from 3 to 12 months. The insertion points of the temporalis muscle tendon to the
nasolabial fold, upper lip, and oral commissure had been changed according to the intraoperative muscle
stimulation in six patients of the 11 primary cases (55%) and in all four secondary (revisional) cases.
A coordinated, spontaneous, and symmetrical smile was achieved in all patients by 3 months after
surgery by employing speech therapy and biofeedback.
Har-Shai Y, Metanes I, Badarny S, Cuzin P, Gil T, Mayblum S, Aman B, Labbé D. Lengthen-
ing temporalis myoplasty for facial palsy reanimation. Isr Med Assoc J 9:123-124, 2007.
Hayashi N, Hirashima Y, Kurimoto M, et al. One-piece pedunculated frontotemporal orbi-
tozygomatic craniotomy by creation of a subperiosteal tunnel beneath the temporal muscle:
technical note. Neurosurgery 51:1520-1523; discussion 1523-1524, 2002.
The authors developed a simple, easy modification of the orbitozygomatic approach using a one-piece
pedunculated craniotomy. This modification prevents atrophy of the temporal muscle, resulting in
temporal fossa depression and atrophy of the free bone graft resulting in the occurrence of bone pits along
the line of the craniotomy. The scalp flap is elevated in the plane between the superficial and deep
layers of the temporal fascia. The temporal muscle is dissected from the temporal plane by subperiosteal
elevation with intact insertion to the superior temporal line of the temporal muscle, which results in the
creation of a subperiosteal tunnel beneath the temporal muscle. The one-piece frontoorbitozygomatic
bone flap is hinged on the temporal muscle.
Horta RM, Barbosa R, Marques M, et al. Reconstruction of middle third defects of the face
with the temporal flap. Ann Plast Surg 63:288-291, 2009.
The temporal flap is of great interest in head and neck reconstruction when a skin graft or a local flap
cannot be used. It has shown important results in facial reanimation and in oncologic surgery. The
authors described their experience with the pedicled flap in reconstruction of middle third face defects in
eight oncologic patients. This flap allows coverage of bone and noble structures such as the periorbital,
auricular, frontal, or parotid gland areas. Few major or minor complications were seen, and good aes-
thetic results were achieved. This can be done with or without adjuvant radiation therapy. However,
the patient prognosis depends on the stage of the tumor.
Iwasawa M, Kitazawa T, Narimatsu I. Split thoracodorsal nerve funicular graft combined with
functional latissimus dorsi musculocutaneous flap transfer for immediate facial reanimation
after tumor ablation. Ann Plast Surg 48:428-430, 2002.
The authors reported a case of immediate facial reanimation resulting from functional latissimus dorsi
myocutaneous flap transfer and funicular grafting of the thoracodorsal nerve after cheek tumor ablation.
After wide excision of the tumor, including the facial nerve except the temporal branch and part of the
zygomatic major muscle and masseter muscle, the authors reconstructed the cheek skin and provided
movement by performing a small-segment latissimus dorsi myocutaneous flap transfer using Harii’s
method and the defect of the buccal and marginal mandibular branches of the facial nerve by funicular
grafting from one of the two funicles of the thoracodorsal nerve. After 6 months, the transplanted,
small-segment latissimus dorsi muscle showed good voluntary movement, and the lower orbicularis
oris and depressor oris presented good functional recovery.
Linthicum FH Jr. The fate of mastoid obliteration tissue: a histopathological study. Laryngo-
scope 112:1777-1781, 2002.
The author reported a retrospective histopathologic analysis to demonstrate the histopathologic fate of
tissues used for mastoid obliteration over 30 years by archival temporal bone microscopic sections. From
the laboratory’s database, 17 temporal bones from subjects who had undergone mastoid obliteration
procedures were identified. The microscopic appearance of the obliteration tissue was described, and

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 Head and Neck  •  5E: Temporalis Flap 311

microphotographs made of significant findings. Fat and bone chips, or paté, retained their bulk in
the obliterated space, whereas subcutaneous tissue and muscle lost bulk but seemed to promote heal-
ing. Some substances, such as bone wax, used for hemostasis and buried under obliteration tissue,
were found to produce a subclinical inflammatory reaction, but other materials, such as Surgicel and
Gelfoam, did not.
Lutz BS. Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction
of tumor-related scalp defects. Microsurgery 22:258-264, 2002.
The author reported on 11 patients (10 men and 1 woman, average age 61.3 years) who underwent
free flap reconstruction of tumor-related defects of the scalp, forehead, and temporal region. Flaps
were selected to achieve acceptable functional and aesthetic results combined with negligible donor site
morbidity. Eight patients presented with tumor recurrences after previous surgery, irradiation, and/or
chemotherapy. The average extension of defects was 169.5 (range 30 to 600) qcm. Free flaps employed
for reconstruction included anterolateral thigh flaps, a suprafascial radial forearm flap, a lateral arm flap,
a latissimus dorsi muscle flap, and a myocutaneous vertical rectus abdominis flap. The anterolateral
thigh perforator flap offers excellent coverage of tumor-related defects of the scalp that require a thin flap
for adequate contouring. The customized harvested myocutaneous anterolateral thigh flap is regarded
as an elegant option for covering defects that consist of both deep and superficial areas. Fascia lata and
nerve grafts are available at the same donor site. This easily allows additional procedures for cosmetic
and functional improvement that are highly beneficial to patients.
Mani V, Panda AK. Versatility of temporalis myofascial flap in maxillofacial reconstruction—
analysis of 30 cases. Int J Oral Maxillofac Surg 32:368-372, 2003.
In this series, the authors used the temporalis myofascial flap for the reconstruction of different types
of maxillofacial defects and as an interposing material in temporomandibular joint surgeries. They
found this flap to be very valuable in maxillofacial reconstruction.
Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free muscle
transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation. Plast
Reconstr Surg 188:885-899, 2006.
The authors presented a study of 27 patients with bilateral or unilateral facial paralysis, aged 16 to
61 years, who received 45 muscle transfers. They assessed the ability of the masseter motor nerve–
innervated microneurovascular muscle transfer to produce an effective smile in adult patients. The
operation consisted of a one-stage microneurovascular transfer of a portion of the gracilis muscle that
is innervated with the masseter motor nerve. All 45 muscle transfers developed movement. Age did
not affect the amount of movement. Patients older than 50 years had the same amount of movement
as patients younger than 26 years (p 5 0.605). Ninety-six percent of patients reported satisfaction
with their smile.
Martins WD. Report of ankylosis of the temporomandibular joint: treatment with a temporalis
muscle flap and augmentation genioplasty. J Contemp Dent Pract 7:125-133, 2006.
A case of true bilateral ankylosis of the temporomandibular joint (TMJ) was presented. A 19-year-old
male patient had a life-threatening ear infection at the age of 10, resulting in a progressive restriction
of his mouth opening. He presented with almost complete lack of mobility of the mandible. Surgi-
cal treatment included a resection of the ankylotic mass, interpositional temporalis composite muscle
flaps, early mobilization, and aggressive physiotherapy. The functional results of the interpositional
arthroplasty were excellent. After a 2-year follow-up, an augmentation genioplasty was performed
to improve facial aesthetics.
Menderes A, Yilmaz M, Vayvada H, et al. Reverse temporalis muscle flap for the reconstruction
of orbital exenteration defects. Ann Plast Surg 48:521-526; discussion 526-527, 2002.
The authors used the reverse temporalis muscle flap for orbital reconstruction after exenteration in six
patients, with successful results. This flap enables placement of highly vascularized tissue that provides
the reconstructive goals of primary healing, obliterates dead space with separation of the orbit from the
nasal cavity or sinuses, provides the potential for early postoperative radiotherapy, and offers possible
flaps that can be used in combination for complex, wide defects.

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 312 Part II  Regional Flaps: Anatomy and Basic Techniques

Menon NG, Girotto JA, Goldberg NH, et al. Orbital reconstruction after exenteration: use of
a transorbital temporal muscle flap. Ann Plast Surg 50:38-42, 2003.
Orbital exenteration is a disfiguring operation that involves the total removal of the orbital contents,
with partial or total excision of the eyelids. Common methods of orbit reconstruction include pectoralis
myocutaneous pedicled flap and free tissue transfer. The purpose of this study was to illustrate that the
entire temporalis muscle may be used by creating a large window in the lateral orbit, without resection
of the lateral orbital rim. Orbital exenteration was performed on four cadavers. A window was cre-
ated in the lateral orbit using a 4 mm pineapple burr. Three parameters were measured: the distance
between the zygomatic arch to the superior aspect of the temporalis muscle, the width of the temporalis
muscle, and the length and width of the lateral orbit window. The free edge of the transposed temporal
muscle was then sutured to the skin edge around the bony orbit. This procedure was then performed
on a 73-year-old man who had undergone right orbital exenteration for ocular melanoma and then
postoperative radiation. The patient recovered well without complications, with a well-healed skin
graft over the top of the muscle flap. An adequate bony window can be made to allow transfer of the
entire temporalis muscle for orbital reconstruction without resecting the lateral orbital rim or entering
the middle cranial fossa.
Michaelidis IG, Hatzistefanou IM. Functional and aesthetic reconstruction of extensive oral
ablative defects using temporalis muscle flap: a case report and a short review. J Craniomaxil-
lofac Surg 39:200-205, 2011.
The authors described the temporalis muscle flap (TMF) surgical technique, with attention to specific
methods for preventing facial nerve injury and donor site deformity. They presented a patient with a
malignant tumor in the upper jaw, palate, and inferior half of the nasal cavity who underwent ex-
tensive surgical excision and the resultant defect was successfully reconstructed with a TMF. During
a 5-year follow-up there were no complications associated with the flap or the temporal implant used
for donor site reconstruction, and no local recurrence or tumor metastasis.
Moharamnejad N, Bayat M, Bohluli B. Ridge augmentation with the coronoid-temporalis
muscle pedicled flap. Br J Oral Maxillofac Surg 48:656-657, 2010.
Olson KL, Manolidis S. The pedicled superficial temporalis fascial flap: a new method for
reconstruction in otologic surgery. Otolaryngol Head Neck Surg 126:538-547, 2002.
The authors described a novel fascial flap of the temporal region and its use for reconstruction in oto-
logic and neurotologic surgery. This flap was used in 15 consecutive patients to solve a wide variety of
reconstructive problems after otologic procedures. No additional morbidity was observed from the use
of this flap. There were no complications related to the reconstruction. Adequate exposure for raising
this flap was obtained using standard incisions for the otologic procedures. Follow-up ranged from 2 to
25 months. This fascial flap provides a wide surface area of tissue on a narrow-based pedicle capable
of a wide arc of rotation. It provides thin, pliable tissue that can be adapted to the needs of various
reconstructive otologic/neurotologic problems.
Rossi DC, Kappel DA. Temporalis muscle osteofascial flap reconstruction of a temporoman-
dibular joint disk in an Ehlers-Danlos patient. Plast Reconstr Surg 117:40e-43e, 2006.
Sabit I, Schaefer SD, Couldwell WT. Modified infratemporal fossa approach via lateral trans-
antral maxillotomy: a microsurgical model. Surg Neurol 58:21-31; discussion 31, 2002.
Lateral approaches have traditionally been used to gain access to lesions of the infratemporal fossa
(ITF). However, dysfunction of the facial nerve secondary to its translocation, conductive hearing loss,
and dental malocclusion because of mandibular head resection or dislocation are significant limitations
associated with some of these approaches. Although facial nerve translocation and extended maxil-
lotomy approaches avoid some of these drawbacks, they are invasive and require extensive osteotomies
and facial incisions. To avoid these potential complications and maintain an extranasal/extraoral
exposure, the authors studied the use of a lateral and posterior extension of an anterior transmaxillary
approach to the cavernous sinus on 12 cadaver specimens and two dry skulls. An initial nasolabial
fold incision, followed by an en bloc osteotomy of the anterior and lateral maxilla provides a window
into the medial ITF. After osteotomy of the pterygoid plate and the posterior maxillary wall, the

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 Head and Neck  •  5E: Temporalis Flap 313

floor of the middle fossa is exposed to reveal the mandibular and maxillary divisions of the trigeminal
nerve exiting their respective foramina. The floor of the middle fossa is then drilled posteromedial to the
foramen ovale to gain access to the course of the C3-C4 portion of the petrous carotid artery and the
Eustachian tube. The upper two thirds of the clivus and the pituitary gland are accessed after drilling
of the floor of the sella turcica and form the posterior limit of this exposure. The technique offers a
trajectory to the medial ITF and skull base that does not necessitate palatal splitting or opening of the
nasopharynx. The anterior route avoids TMJ disruption, and spares the lacrimal apparatus and all
branches of the facial nerve. In addition, the reflected pterygoid muscle can be used as a vascularized
flap for closure of the skull base defect.
Smith JE, Ducic Y, Adelson RT. Temporalis muscle flap for reconstruction of skull base defects.
Head Neck 32:199-203, 2010.
The temporalis muscle flap (TMF) is a valuable reconstructive technique that is used for a variety
of challenging defects. However, its use for repair of skull base defects is less common. A retrospective
chart review was conducted for 35 patients who underwent reconstruction of skull base defects between
1999 and 2006 at a tertiary referral hospital. Patients with skull base defects after trauma or extirpa-
tive surgery underwent reconstruction with a TMF. The measured outcomes were as follows: defect
size/location, need for additional flaps, bone necrosis, hardware exposure, dehiscence, CSF leak,
and meningitis. Forty-two patients underwent reconstruction with a TMF, and 35 of 42 patient
records were available for review. No flap failures, one transient CSF leak, three hardware exposures
distant from the temporalis recipient site, and three hydroxyapatite cement infections or foreign body
reactions were observed.
Smith JE, Ducic Y, Adelson R. The utility of the temporalis muscle flap for oropharyngeal, base
of tongue, and nasopharyngeal reconstruction. Otolaryngol Head Neck Surg 132:373-380, 2005.
The authors performed a retrospective chart review of a consecutive series of 24 patients who underwent
a total of 26 temporalis flaps (two bilateral) for reconstruction of defects of the oropharynx, nasopharynx,
and base of tongue. Variables and outcomes that were examined included defect location, size, adjunctive
therapy, complications, and ability to tolerate oral intake at follow-up. There was no evidence of flap
failure in the series. There were two cases of minor flap loss related to early prosthetic rehabilitation,
and two cases of transient frontal nerve paralysis were noted. A 30.8% rate of complication (all minor)
was noted in this study. At a mean follow-up of 12 months, 54.2% of patients were tolerating a full
diet, 37.5% were tolerating most of their nutrition by mouth, and 8.3% were G-tube dependent.
Tan O, Atik B, Ergen D. Temporal flap variations for craniofacial reconstruction. Plast Reconstr
Surg 119:152e-163e, 2007.
Good harmony of color and texture with surrounding tissues, thinness and adequate pliability, good
alignment, obliteration of the cavities, and minimal donor site morbidity are the main features of an
ideal flap to be used in the reconstruction of craniofacial defects. Despite the numerous local, regional,
and free flaps that have been described, to date, there has not yet been an ideal flap. The authors
discussed the reconstruction alternatives presented by the temporal site and its outcomes. The tempo-
ral region is a good donor site for closure of craniofacial defects, by means of its rich vascular network
and almost all types of tissue, including skin, fascia, muscle, galea, calvarial bone, and periosteum.
The attractiveness of this region for reconstruction has gradually increased as clinical experiences have
advanced and its anatomy has been better understood.
Tender GC, Kutz S, Awasthi D, et al. Vascularized temporalis muscle flap for the treatment of
otorrhea. Technical note. J Neurosurg 98:1128-1132, 2003.
Fifteen consecutive cases of CSF fistulas treated at the authors’ institution were retrospectively reviewed.
All patients presented with otorrhea. Eleven patients had previously undergone ear surgery. A middle
fossa approach was used in all cases. The authors used a thin but watertight and vascularly preserved
temporalis muscle flap that had been dissected from the medial side of the temporalis muscle and that
was laid intracranially on the floor of the middle fossa, between the repaired dura mater and petrous
bone. The median follow-up period was 2.5 years. None of the patients had recurrence of otorrhea or
meningitis. There was no complication related to the intracranial temporalis muscle flap (e.g., seizures

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 314 Part II  Regional Flaps: Anatomy and Basic Techniques

or increased intracranial pressure caused by muscle swelling). One patient developed hydrocephalus,
which resolved after placement of a ventriculoperitoneal shunt 2 months later. The thin, vascularized
muscle flap created an excellent barrier against the recurrence of CSF fistulas and avoided the risk
of increased intracranial pressure caused by muscle swelling. This technique is particularly useful in
refractory cases.
Terzis JK, Karypidis D. Blink restoration in adult facial paralysis. Plast Reconstr Surg 126:126-
139, 2010.
Eye reanimation techniques and specifically blink restoration reinstates the cornea’s protective mechanism
and recovers a more natural appearance and eye function. Both dynamic and static procedures have
been used to augment eye closure, but only dynamic procedures can lead to blink restoration. In this
study, the experience of a single surgeon was presented in a retrospective review of 95 adult patients
who underwent dynamic procedures for blink restoration. The patients were divided into two groups.
Group A (n 5 75) included patients who underwent nerve transfers, including cross-facial nerve
grafting and subsequent microcoaptations, mini-hypoglossal nerve transfers, and direct orbicularis oculi
muscle neurotization. Group B (n 5 20) included patients who underwent eye sphincter substitution
procedures, including pedicled frontalis or mini-temporalis transfers, free platysma, occipitalis, gracilis
subunits, extensor digitorum brevis, and a slip of adductor longus transfer. Objective blink ratios were
measured. Denervation time ranged from 7 months to 42.12 years; the mean denervation time was
13.02 years. Blink improvement was noted in all patients. Blink scores and ratios were consistently
better in group A than in group B.
Terzis JK, Olivares FS. Use of mini-temporalis transposition to improve free muscle outcomes
for smile. Plast Reconstr Surg 122:1723-1732, 2008.
In this study, cases of fair or moderate outcomes from a free muscle transfer received a segmental tempo-
ralis transposition to upgrade the functional and aesthetic results. From 1981 to 2007, 153 patients
received a free muscle transfer for smile restoration. Of all patients, 72% (n 5 110 patients) required
a third stage of revisions. In 41 cases, a mini-temporalis transfer was used to augment moderate out-
comes of a free muscle transfer. The exclusion criterion was less than 3 months’ follow-up; thus six
patients were not evaluated. Each patient was videotaped at three successive points (preoperatively,
following free muscle transfer, and following mini-temporalis transfer). Five independent observers
graded patients’ videos using a five-category scale from poor to excellent. The averaged scores were
higher after free muscle transfer in comparison with the preoperative scores (Wilcoxon signed-rank test;
p ,0.0001). After mini-temporalis transfer, 97.1% of the patients had scores that were increased
further and 2.8% had the same scores. Alopecia along the coronal incision was seen in four patients,
and hollowing of the infratemporal fossa was seen in five.
Walgenbach KJ, Gorospe JR, Gratas C, et al. A potential role for mast cells in the release of
bFGF from normal myocytes during angiogenesis in vivo. J Invest Surg 15:153-162, 2002.
The authors studied the events involved in neovascularization using a well-characterized model of
angiogenesis in rabbits by which neovascularization is induced by transfer of a well-perfused rectus
abdominis muscle flap to an ischemic limb. Using this model, the authors demonstrated that basic
fibroblast growth factor (bFGF) expression is induced in normal myofibers, and bFGF is released
in the wound fluid at the ischemic/nonischemic interface. The highest concentrations of bFGF were
detected on days 14 and 21 after surgery. They also showed that the number of mast cells and their
degranulation correlate with the release of bFGF from adjacent muscle tissue and the appearance of
the growth factor in the wound fluid. There appears to be a temporal correlation between number of
mast cells, their degranulation, and the release of bFGF during angiogenesis in vivo.
Warren SM, Zide BM. Reconstruction of temporal and suprabrow defects. Ann Plast Surg
64:298-301, 2010.
Large temple and suprabrow lesions can pose a reconstructive challenge. When the lesion extends ante-
rior to the hairline, aesthetically acceptable local flaps may be difficult to design. The authors described
a modified scalp flap (part Converse scalping flap and part scalp rotation flap) that can be tailored to
reconstruct a variety of difficult temple and suprabrow lesions while simultaneously maintaining eyebrow

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 Head and Neck  •  5E: Temporalis Flap 315

position. The modified scalp flap is raised in a subgaleal plane until approximately 2.5 cm above the
brow. The modified scalp flap was used to reconstruct temple and suprabrow lesions in 10 patients
ranging in age from 4 months to 22 years, with no complications. Four typical cases were presented.
Williams JV. Transblepharoplasty endoscopic subperiosteal midface lift. Plast Reconstr Surg
110:1769-1775; discussion 1776-1777, 2002.
The use of endoscopy in the transblepharoplasty midface lift is essential for preventing the complica-
tions of facial nerve injury and bleeding. Complete observation allows precise dissection and release of
all structures in the composite flap. This technique fully preserves the zygoorbicular nerve plexus and
prevents denervation of the orbicularis oculi and zygomaticus muscles. Blind dissection has a significant
probability of denervation of the entire zygoorbital muscle complex, and avulsion of the zygomaticofacial
vessels, with associated postoperative bleeding complications. The modification involving suturing of
the “vest” of the combined lateral orbital periosteal and superficial layers of the deep temporal fascia
over the elevated “pants” of the orbicularis periosteal flap provides very secure fixation for suspension
of the lower eyelid and midface. The use of slowly absorbable polydioxanone sutures for this technique
prevents the problems caused by permanent sutures beneath the very thin skin of the lateral canthal
area. Careful trimming of the prominent roll of the orbicularis muscle that often develops with suspen-
sion eliminates the uneven contour and yields a smooth lower lid appearance.
Wong TY, Fang JJ, Chung CH, et al. Restoration of the temporal defect using laser stereo-
lithography technique. J Oral Maxillofac Surg 60:1374-1376, 2002.
Yazdani J, Ali Ghavimi M, Pourshahidi S, et al. Comparison of clinical efficacy of temporalis
myofascial flap and dermal graft as interpositional material in treatment of temporomandibular
joint ankylosis. J Craniofac Surg 21:1218-1220, 2010.
The authors compared the short-term clinical consequences between these two interpositional materials
in 20 patients with operated TMJ ankylosis. The presurgical maximum incisional opening and lateral
excursion were not significantly different between the two groups. Three months after the operation,
patient evaluation did not reveal a significant difference, considering the amount of maximum incisional
opening, lateral excursion, and mandibular deviation.
Zhang HM, Yan YP, Qi KM, et al. Anatomical structure of the buccal fat pad and its clinical
adaptations. Plast Reconstr Surg 109:2509-2518; discussion 2519-2520, 2002.
Before performing plastic and aesthetic surgery around the buccal area, the authors reviewed the
anatomic structures of the buccal fat pad in 11 head specimens (22 sides of the face). The enveloping
fixed tissues and the source of the nutritional vessels to the buccal fat pad and its relationship with
surrounding structures were observed in detail, with the dissection procedure described step by step.
Based on the findings of the dissections, the authors provided several clinical applications for the buccal
fat pad, such as the mechanism of deepening the nasolabial fold and possible rhytidectomy to suspend
the anterior lobe upward and backward. They suggested that relaxation, poor development of the
ligaments, or rupture of the buccal fat pad capsules can make the buccal extension drop or prolapse to
the mouth or subcutaneous layer.

05e_TempMusc_r4_bs_0288-0315.indd 315 1/31/2012 3:06:58 PM

 ANATOMIC LANDMARKS
Landmarks Masseter muscle extends from the zygoma to the ramus, angle,
and body of the mandible.
Size 8 3 8 cm.
Origin Zygomatic arch. Superficial belly originates from the anterior
and middle arch; posterior belly arises from the deep surface of
the zygomatic arch.
Insertion Combined muscle bellies insert on the lateral surface of the ra-
mus of the mandible; includes the lower portion of the coronoid
process.
Function Muscle of mastication; it elevates the mandible to close the mouth
and to assist in chewing.
Composition Muscle.
Flap Type Type I.
Dominant Pedicle Masseteric artery.
Minor Pedicle Facial artery.
Nerve Supply Motor: Masseteric nerve, branch of the mandibular division of
the trigeminal nerve.

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 Section 5F
Head and Neck

Masseter Flap

CLINICAL APPLICATIONS
Regional Use
Head and neck
Specialized Use
Facial reanimation

05f_Masseter_r6_bs_0316-0333.indd 317 1/31/2012 3:20:50 PM

 ANATOMY OF THE MASSETER FLAP

Maxillary
artery
Masseteric
artery

Masseteric
nerve

Masseter
muscle

Lateral view of masseter

Maxillary
artery

Masseteric
nerve
Masseteric
artery
Masseter
muscle

Oblique view of masseter

Fig. 5F-1 

Dominant pedicle: Masseteric artery

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 Head and Neck  •  5F: Masseter Flap 319

Anatomy
Landmarks The masseter muscle runs from the zygomatic arch to the ramus of the mandible.
It is largely covered by the parotid gland posteriorly and by facial muscles ante-
riorly. Deep to the facial musculature but superficial to the masseter, the parotid
duct runs transversely. The facial artery and vein also run above and superficial
to the muscle, as do the branches of the facial nerve.
Composition Muscle.
Size 8 3 8 cm.
Origin The muscle has deep, middle, and superficial bellies. The superficial belly is
largest and originates from the anterior two thirds of the zygomatic arch. The
deeper bellies are smaller and originate from the posterior portion of the zygo-
matic arch.
Insertion Combined muscle bellies insert on the lateral surface of the ramus of the man-
dible; this includes the lower part of the coronoid process.
Function One of the four muscles of mastication. Because of this redundancy, it can be
used without functional deficit.

Arterial Anatomy (Type I)

Dominant Pedicle  Masseteric artery
Regional Source  Internal maxillary artery.
Length  3 cm.
Diameter  1.5 mm.
Location  Vascular pedicle enters the muscle posteriorly midway between the zygomatic arch
and the mandibular body.
Minor Pedicle  Branches of facial artery
Regional Source  External carotid artery.
Length  1 to 2 cm.
Diameter  0.5 mm.
Location  The facial artery runs on the superficial surface of the masseter muscle. It crosses the
body of the mandible approximately a third the distance from the angle toward the mentum.

Venous Anatomy
Accompanying paired veins with the named arteries.

Nerve Supply
Motor Masseteric nerve, a branch of the mandibular division of the trigeminal nerve.

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 320 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the M asseter Flap

A

B C

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.

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 Head and Neck  •  5F: Masseter Flap 321

Exposure of the Masseteric Nerve

Although exposure of the masseteric nerve is not required for muscle rotations, the nerve
is commonly dissected and exposed for use as a motor input for free flap facial reanimation,
or “babysitting” procedures after facial nerve injury. The origin of the nerve is found by
palpating the mandibular notch, below the zygomatic arch and 2 to 3 cm anterior to the
tragus. Exposure is accomplished by exposing the SMAS that overlies the area.

Fig. 5F-3 

Next a triangular flap of the SMAS is elevated over the notch, exposing the superficial
belly of the masseter muscle.

Fig. 5F-3 

05f_Masseter_r6_bs_0316-0333.indd 321 1/31/2012 3:20:55 PM

 322 Part II  Regional Flaps: Anatomy and Basic Techniques

The masseter is composed of three distinct muscle bellies. The masseteric nerve is
located between the middle and deep muscle bellies.

C
Zygomatic arch

Deep layer of
masseter muscle
Masseteric nerve

Middle layer of
masseter muscle

Superficial layer of
masseter muscle

Mandible

Fig. 5F-3 

Dissection proceeds by removing the superficial muscle belly, exposing the middle
muscle belly.

Fig. 5F-3 

Further dissection carefully removes the middle muscle belly, exposing the nerve. The
course of the nerve is oblique, running from the notch toward the commissure of the mouth.

Fig. 5F-3 

05f_Masseter_r6_bs_0316-0333.indd 322 1/31/2012 3:20:56 PM

 Head and Neck  •  5F: Masseter Flap 323

The masseteric nerve may have from one to four branches; 75% of cases have more than
one branch. This nerve redundancy or remaining function from the contralateral muscle
and temporalis muscles allows sacrifice without compromising mastication.

FLAP HARVEST
Design and Markings
The masseter muscle can be accessed through a curvilinear incision just below the mandibular
angle and the body of the mandible. When used for facial reanimation and reanimation of
the commissure, a counterincision is made in the nasolabial area for insertion and placement
of the muscle. Forced biting allows the masseter to be palpated and its origins and inser-
tions marked. The muscle is generally used with its blood supply proximal and is released
from the mandible. The muscle, based inferiorly, has been used for intraoral reconstruction,
although this is uncommon.

Incision

Facial access incisions

Fig. 5F-4 

Patient Positioning
Supine with the head turned is the most common position for use of the masseter muscle flap.

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 324 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

For the standard, superiorly based flap, an incision is made along the mandibular border in
the area over the masseter muscle.

A B
Masseteric
artery

Orbicularis
oris muscle

Masseter
muscle

Incision Incision

Facial incisions Incisions as related to muscular anatomy

Fig. 5F-5 

As the dissection is deepened through the subcutaneous tissues, the facial artery and
vein are identified. These are not critical for supply of a superiorly based flap but are help-
ful in identifying the marginal mandibular branch of the facial nerve, which needs to be
protected during this dissection. Often this muscle is used in a patient with facial palsy, and
this point is moot. The muscle can then be used in part or in whole.

C D
Masseteric Masseteric
artery artery

Orbicularis Orbicularis
oris muscle oris muscle

Masseter Masseter
muscle muscle
(split) (split)

Incision Incision

Bifurcated inset of whole muscle Split muscle with bifurcated inset

Fig. 5F-5 

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 Head and Neck  •  5F: Masseter Flap 325

If only a portion of the muscle is to be used, the inferior portion of the muscle is marked
and the muscle is released from its mandibular insertion. It is recommended in order to obtain
good purchase with sutures that some periosteum is taken as well at this time. If the muscle
is being used for reanimation, a tunnel has been made in the subcutaneous plane from the
counter incision at the commissure and nasolabial fold. The muscle is passed through this
incision and then secured through a series of sutures to the area of the commissure.

FLAP VARIANT
Inferiorly Based Flap
The successful use of an inferiorly based masseter muscle flap has been reported for intra-
oral defects and areas of exposure in the mouth. Presumably, the muscle is being carried
on branches of the facial artery; therefore these need to be spared during the dissection.
Although successful cases have been reported, this is not a first-line muscle for these small
reconstructions, because a functional muscle is being sacrificed.

ARC OF ROTATION
The masseter muscle is a short, thick muscle that does reach the area of the commissure with-
out extensions required. It would also reach intraorally for potential applications of wound
coverage in the mouth. The muscle does not reach to the midline nor beyond the tonsil.

Orbicularis
Masseteric oris muscle
artery

Masseter
muscle

Arc to commissure

Fig. 5F-6 

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 326 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP TRANSFER
The masseter muscle reaches the commissure through a subcutaneous tunnel dissected
between the neck incision and the nasolabial incision.

FLAP INSET
It is important to maintain the resting length of the muscle when insetting it for a facial
reanimation. The muscle acts by both statically positioning the commissure as well as add-
ing a functional muscle moving the commissure. Because of the excess bulk in the cheek
from movement of the masseter, some recommend excision of the buccal fat pad to alleviate
this excess. This can be performed through an intraoral or extraoral approach, avoiding
disturbance of any functional facial nerves.

DONOR SITE CLOSURE

Primary closure of the skin is obtained in all cases.

CLINICAL APPLICATIONS
This 57-year-old man underwent left-sided facial reanimation using temporalis transfer only.

A B

Fig. 5F-7  A, The patient is seen before reanimation. B, Postoperatively, the lower lip on the para-
lyzed side is elevated, creating a substantial asymmetry at maximum smile. (Case courtesy Roger L.
Simpson, MD.)

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 Head and Neck  •  5F: Masseter Flap 327

This 48-year-old woman underwent right-sided facial reanimation following resection

of an acoustic neuroma. Both temporalis and partial masseter transfers were performed.

A B

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. (Case courtesy Roger L. Simpson, MD.)

This 42-year-old man had partial right-sided facial paralysis caused by Bell’s palsy.

A B

Fig. 5F-9  A, He had marked limitation of his smile on the right side. A temporalis and partial mas-
seter 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. (Case courtesy Roger L. Simpson, MD.)

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 328 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The masseter muscle is a secondary choice for facial reanimation with local regional
muscle. The temporalis muscle has a greater excursion and therefore more function for
this purpose. The masseter muscle is thick and has limited excursion.
• Use of the masseter muscle for intraoral defect reconstruction should always be considered
carefully, since a functional muscle would be sacrificed.
• A partial masseter muscle can be a useful adjunct to a temporalis muscle reanimation
in that it can help position the commissure and provide some lateral movement to an
otherwise vertical or oblique vector.
• Reconstruction of the mandible with a myoosseous masseter flap has been described in
a limited number of patients.
• To prevent early dehiscence of the muscle in a functional case, the patient should be on
a soft diet without chewing for the first 2 weeks.

Expert Commentary
Roger L. Simpson

Indications
The masseter muscle and its innervation play an important role in reanimation of the para-
lyzed face. The muscle, innervated by the masseteric nerve (mandibular division of the
trigeminal), is well suited to partial or complete transfer to the commissure and/or lower
lip. Both the masseteric artery (branch of the external carotid) and the masseteric motor
nerve enter deep to the muscle at its mid to upper portion, making the muscle suitable
for a complete or partial 90-degree transfer. Its redundancy in mastication allows transfer
without compromising jaw motion or strength.
My concern with the masseter muscle as a stand-alone muscle transfer for facial paralysis
is in the direction and the amount of excursion when transferred to the commissure on
the paralyzed side. The muscle is 8 by 8 cm, and although a complete 90-degree rotation
maintains the integrity of the innervation, it does not permit enough excursion through
contraction to move the commissure adequately in comparison to the normal side. Its direc-
tion after rotation creates a horizontally directed pull, not taking into account the mixed
upward component of the levator labii superioris muscle.
The masseter muscle transfer plays its best role in contiguous regional muscle reanima-
tion as a complement of the temporalis transfer. The temporalis, extended by its fascia, is
transferred to the paralyzed commissure and the upper lip in a smooth, continuous fashion.
The strength of the temporalis will overcorrect the commissure in an upward direction.
Transfer of the anterior portion of the masseter to the lateral aspect of the lower lip just
anterior to the commissure will produce an active depression of the lower lip while provid-
ing a downward, stabilizing force balancing the commissure. The masseter muscle transfer
serves to reproduce the active depression of the lower lip lost in paralysis.

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 Head and Neck  •  5F: Masseter Flap 329

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
Technique
Technically, the masseter is exposed through a 2 cm incision parallel to and below the
angle and body of the mandible. The bony groove of the mandible is palpated, allowing
identification of the facial artery and the marginal mandibular nerve. The anterior half of
the muscle is incised in a cephalad direction until a 90-degree arc of rotation is comfortably
achieved. The muscle has a very thin fascia superficially and is often too short for direct
suture to the lower lip. Extension with a portion of harvested fascia allows proper tension
and a downward and lateral trajectory to the lower lip, ideal for reanimation.
The combination of two muscle transfers to the paralyzed lips creates an excellent balance
of forces to produce a symmetrical smile. The dynamic excursion of the partial masseter
transfer to the lower lip is occasionally less than expected. The retained attachment may
then serve as a sufficiently strong static force tethering the upper temporalis pull.
The motor nerve to the masseter muscle is an excellent innervation for free muscle
transfer in facial paralysis reanimation. Manktelow et al1 described 45 single-stage micro-
neurovascular transfers of the gracilis muscle to the masseteric nerve, resulting in a high
percentage of patients with a spontaneous smile, with a high degree of patient satisfaction.
Zuker et al2 performed staged, segmental gracilis transfers to masseter motor nerves in
children with Möbius syndrome, with excellent outcomes.
Klebuc3 has reported his results in facial paralysis reanimation using direct micro-
surgical transfer of the descending branch of the masseteric nerve to selected buccal and
zygomatic branches of the ipsilateral facial nerve in patients with acquired paralysis. The
use of a consistently present masseteric nerve bifurcation allowed direct nerve transfer
without an interposition graft. Selective use of a portion of the nerve diminished the
risk of masseter atrophy while providing good restoration of facial muscle excursion.
Continued

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 330 Part II  Regional Flaps: Anatomy and Basic Techniques

This technique has been used in conjunction with cross-face nerve grafting to restore the
upper face in paralysis.

Take-Away Messages
The masseter muscle and its innervation are important anatomic structures in reanimation
of the paralyzed face. The versatility of the muscle based on its deep blood supply and in-
nervation allows complete or partial transfer to the commissural region, either directly or
by fascial extension to more medial portions of the upper and lower lips. Partial transfer
of the masseter through fascial extension to the lower lip is an excellent complement to
a strong temporalis transfer to the commissure and upper lip. As a stand-alone transfer, it
can provide dynamic depression of the lower lip to restore lost function from a marginal
mandibular nerve injury.
Use of the masseter motor nerve, either complete or partial via the descending branch,
has shown excellent results in trigeminal-innervated restoration of facial motion either
through partial gracilis transfer or through direct innervation of ipsilateral buccal and/or
zygomatic branches of the facial nerve.

References
1. Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free
muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaption.
Plast Reconstr Surg 118:885-899, 2006.
2. Zuker RM, Goldberg CS, Manktelow RT, et al. Facial animation in children with Möbius
syndrome after segmental gracilis muscle transplant. Plast Reconstr Surg 106:1-8; discussion
9, 2000.
3. Klebuc MJ. Facial reanimation using the masseter-to-facial nerve transfer. Plast Reconst
Surg 127:1909-1915, 2011.

Bibliography With Key Annotations

Antoniades K, Lasaridis N, Vahtsevanos K, et al. Superiorly based and island masseter muscle
flaps for repairing oropharyngeal defects. J Craniomaxillofac Surg 33:334-339, 2005.
The authors reported their results reconstructing 22 defects after resection of retromolar and/or ante-
rior faucial pillar squamous cell carcinomas. In 12 patients they used a superiorly based or crossover
masseter muscle flap, and in 10 patients they performed an island muscle flap (a modification of the
first type). Both techniques offered a quick and reliable method for repairing oropharyngeal defects
in oncologically “safe” cases. Elaborate technique or aftercare was not required. The island masseter
muscle flap has advantages over the superiorly based masseteric flap of being more flexible and pliable
for larger defects, with no postoperative trismus.
Barry CP, Ryan WJ, Stassen LF. Anatomical study of factors contributing to zygomatic complex
fracture instability in human cadavers. Plast Reconstr Surg 119:637-640; discussion 641, 2007.
To better understand the role of the temporalis muscle in delayed collapse or relapse after reduction
of fractures of the zygomatic complex, the authors studied the origins of the temporalis muscle in six
cadaveric dissections. In all dissections, the temporalis muscle origin was not only from the floor of
the temporal fossa and temporalis fascia, but also from the lateral margin of the orbit and the frontal
process of the zygomatic bone as far down as the body of the zygoma. The authors postulated that
the functional forces exerted by this muscle on the zygomatic complex cause postoperative distraction
at the frontozygomatic suture. These findings support the belief that internal fixation of all fractures

05f_Masseter_r6_bs_0316-0333.indd 330 1/31/2012 3:21:00 PM

 Head and Neck  •  5F: Masseter Flap 331

of the zygomatic complex is important, even for those considered clinically stable, to avoid permanent
flattening of the cheekbone.
Bianchi B, Copelli C, Ferrari S, et al. Facial animation in children with Moebius and Moebius-
like syndromes. J Pediatr Surg 44:2236-2242, 2009.
Moebius syndrome is a rare congenital disorder that involves multiple cranial nerves. It is identified
predominantly as a bilateral or unilateral paralysis of the facial and abducens nerves. The authors
reported on results of 12 pediatric patients with Moebius and Moebius-like syndromes treated by
microsurgical reconstruction for restoration of facial movement. The contralateral facial nerve was used
as a motor donor nerve in four procedures, the motor nerve to the masseter muscle in eight patients,
and the gracilis muscle was used in all operations, for a total of 17 free muscle transplantations. All
free-muscle transplantations survived. Drooling, drinking, speech, and facial animation improved
significantly, and patients reported a high degree of satisfaction.
Bianchi B, Copelli C, Ferrari S, et al. Facial animation with free-muscle transfer innervated by
the masseter motor nerve in unilateral facial paralysis. J Oral Maxillofac Surg 68:1524-1529, 2010.
The authors shared their results from eight patients with unilateral facial paralysis who underwent
gracilis muscle transfer with reinnervation by the motor nerve to the masseter muscle. All free muscle
transplantations survived, and no flaps were lost. Facial symmetry at rest and while smiling was ex-
cellent or good in all patients. Speech and oral competence were significantly improved. With practice,
the majority of patients developed the ability to smile spontaneously and without jaw movement. The
authors concluded that the masseter motor nerve is a powerful and reliable donor nerve that facilitates
commissure and upper lip movement. The masseter motor nerve may offer appropriate innervation for
patients with unilateral facial paralysis who would otherwise be considered candidates for cross-facial
nerve graft innervation of the muscle transfer.
Boahene KD. Dynamic muscle transfer in facial reanimation. Facial Plast Surg 24:204-210, 2008.
Improved facial support and symmetry with volitional movement can sometimes be achieved with
dynamic muscle transfer. This is most commonly used for reanimation of the oral commissure to pro-
duce a smile. Muscle transfers have been used successfully to reestablish eye closure. Facial paralysis of
long-standing duration presents different challenges from paralysis that is managed early after onset.
Dynamic muscle transfers are typically performed in these patients. In this respect, the alternative is
free tissue transfer. The author described advantages and disadvantages of these two procedures.
Brenner E, Schoeller T. Masseteric nerve: a possible donor for facial nerve anastomosis? Clin
Anat 11:396-400, 1998.
Several methods have been employed to restore function of the facial nerve. These include ipsilateral
nerve grafting, cross-facial nerve grafting, and temporal muscle flaps or even free muscle transfers. None
of these techniques uses the masseteric nerve. This preliminary report discussed the anatomic basis,
which could lead to a new technique. The authors studied 36 cases. They found that the masseteric
nerve leaves the infratemporal fossa through the mandibular notch, accompanied by the masseteric
artery. It was accompanied by only 1 branch in 9 cases, by 2 branches in 17 cases, by 3 branches
in 9 cases, and by 4 branches in 1 case. The masseteric nerve should be considered a possible donor
for at least the orbicular branch of the facial nerve for the following reasons: (1) the approach to the
mandibular notch is quite simple; (2) the nerve consists of two or more branches in 75% of the cases;
therefore severe dysfunction of the masseter muscle should not occur; and (3) for complete denervation
of the masseter muscle, its function may be assumed by the temporalis muscle.
Chuang DC. Free tissue transfer for the treatment of facial paralysis. Facial Plast Surg 24:194-
203, 2008.
The authors performed gracilis functioning free muscle transplantation (FFMT) in 249 patients with
facial paralysis at Chang Gung Memorial Hospital. Most cases were caused by postoperative complica-
tions and Bell’s palsy. The innervating nerve comes mostly from contralateral facial nerve branches, a
few from the ipsilateral facial nerve as a consequence of tumor ablation, and from the ipsilateral motor
branch to masseter or spinal accessory nerve because of Moebius syndrome. The authors used a short

05f_Masseter_r6_bs_0316-0333.indd 331 1/31/2012 3:21:00 PM

 332 Part II  Regional Flaps: Anatomy and Basic Techniques

nerve graft (10 to 15 cm) to cross the face in the first stage; after a 6- to 9-month waiting period, a
gracilis FFMT was performed for the second stage of the reconstruction. Results were encouraging.
Demir Y, Latifoğ lu O, Yavuzer R, et al. Oral commissure reconstruction with split masseter
muscle transposition and cheek skin flap. J Craniomaxillofac Surg 29:351-354, 2001.
This article focused on the treatment of a 64-year-old man who underwent full-thickness repair of a
cheek defect involving the oral commissure after excision of a squamous cell carcinoma. A cheek skin
flap combined with split masseter muscle transposition was performed. This method was useful for
reconstructing the oral commissure, with good functional and aesthetic results.
Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free muscle
transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation. Plast
Reconstr Surg 118:885-899, 2006.
This study assessed the ability of the masseter motor nerve–innervated microneurovascular muscle
transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis. The
operation consisted of a one-stage microneurovascular transfer of a portion of the gracilis muscle that
is innervated with the masseter motor nerve. The muscle was inserted into the cheek and attached to
the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred
muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the func-
tional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years who
received 45 muscle transfers. In all 45 muscle transfers, movement developed. A spontaneous smile,
the ability to smile without thinking about it, occurred routinely in 59% and occasionally in 29% of
patients; 85% of patients learned to smile without biting. Age did not affect the degree of spontaneity
of smiling or the patient’s ability to smile without biting.
Michaelidou M, Tzou CH, Gerber H, et al. The combination of muscle transpositions and static
procedures for reconstruction in the paralyzed face of the patient with limited life expectancy
or who is not a candidate for free muscle transfer. Plast Reconstr Surg 123:121-129, 2009.
Dynamic procedures such as muscle transplantation or muscle transposition are required for long-
standing complete and irreversible facial palsy. The authors presented their results of regional muscle
transposition for reconstruction of eye closure and smile in patients with irreversible facial palsy; 29
were treated by temporalis transposition for the eye, and 8 were treated by masseter transposition for
the mouth. Assessment of the outcome was based on clinical examination and evaluation of facial
movements by three-dimensional video analysis. Their findings demonstrated that muscle transposition
improves static symmetry and provides dynamic activity to a certain degree. It is therefore a valuable
concept for patients with limited life expectancy.
Mun GH, Lim SY, Hyun WS, et al. Correction of temporo-masseteric contour deformity using
the dual paddle thoracodorsal artery perforator adiposal flap. J Reconstr Microsurg 22:335-342,
2006.
In cases of facial asymmetry with denervation atrophy of the masticatory muscles associated with head
and neck tumors involving the trigeminal nerve, facial contour depression occurs selectively over the
temple and masseteric area, separated by an uninvolved area over the zygomatic arch. The authors
developed a new thoracodorsal artery perforator flap with two separate adiposal paddles based on their
own perforators from the same mother vessel, the thoracodorsal vessel. Nearly normal temporomas-
seteric contour was achieved in two patients. By freely positioning two adiposal paddles supplied by
independent perforators based on the same vessel, separate noncontiguous regions of the face could be
reconstructed correctly with one microvascular anastomosis in a single-stage operation, without the need
for a secondary procedure to reduce the bulk over the zygomatic arch.
Papadas T, Goumas P, Alexopoulou MM, et al. Cancer patients with large defects. Reconstruc-
tional options: a case study. Braz J Otorhinolaryngol 71:87-90, 2005.
The authors described a case of a 75-year-old man with a squamous cell carcinoma that had originated
from the right external ear 4 years previously. He had undergone surgical removal of the lesion with
a combination of modified neck dissection and reconstruction with the use of a pectoralis major flap.
Furthermore, he had had radiation therapy with 6000 rads to the right temporal region. Two months

05f_Masseter_r6_bs_0316-0333.indd 332 1/31/2012 3:21:00 PM

 Head and Neck  •  5F: Masseter Flap 333

before presentation, the patient developed an extended recurrence in the temporal muscle and bone,
lithoidal bone, masseter and pterygoid muscles, the right part of the mandible, the parotid gland with
the facial nerve, and the superior bulb of the internal jugular vein. The lesion was removed surgically
with extended healthy margins, and functional and aesthetic reconstruction of the defect was performed
with a combination of metal fixed prosthesis of the condyle and the right mandible and a myocutaneous
trapezius flap. This case report underscored the reconstruction options available to provide quality of
life in cancer patients.
Shimizu M, Kurita K, Matsuura H, et al. The role of muscle grafts in temporomandibular joint
ankylosis: short-term experimental study in sheep. Int J Oral Maxillofac Surg 35:842-849, 2006.
The temporalis muscle flap can be used as an interpositional graft placed into a gap arthroplasty site
in temporomandibular joint (TMJ) ankylosis. The authors investigated the role of the muscle graft in
sheep. Five purebred adult Merino sheep were used, and ankylosis was induced in all right TMJs.
At 3 months, the ankylosis was released by gap arthroplasty and reconstructed with a masseter muscle
graft, because the temporalis muscle is short and poorly vascularized in sheep. The sheep were killed 3
months after muscle grafting. Maximal mouth opening was recorded before and after operation and at
death. The joints were examined radiologically and histologically. In 4 sheep, mouth opening remained
at the preoperative level. A clear radiolucent space remained between the smooth temporal and ramus
stumps. Histologically, the muscle graft remained vital but with some fibrous tissue formation between
the bone ends. One sheep developed an infection at the operative site following the muscle graft; this
partly resolved with antibiotics, but the TMJ developed a fibrous reankylosis that was demonstrated
clinically, radiologically, and histologically. These results indicate that an uncomplicated temporalis
muscle graft reconstruction with gap arthroplasty is a successful and stable procedure in human TMJ
ankylosis.
Shinohara H, Matsuo K, Osada Y, et al. Facial reanimation by transposition of the masseter
muscle combined with tensor fascia lata, using the zygomatic arch as a pulley. Scand J Plast
Reconstr Surg Hand Surg 42:17-22, 2008.
The authors reported a new way of reanimating the face involving transposition of the masseter muscle
combined with the tensor fascia lata and using the zygomatic arch as a trochlea to reconstruct an inferior
facial paralysis. They used the technique on five patients who had facial palsy after excision of malig-
nant parotid tumors. The wide skin defect that exposed the masseter muscle after total parotidectomy
was reconstructed with a free flap. This method differs from those of other methods of transposing
the masseter muscle in that force is applied at an upper lateral angle. The method provided dynamic
raising of the upper lip, the corner of the mouth, and the nasolabial fold in four patients. The authors
considered the technique to be useful, particularly for prompt surgical reconstruction of facial palsy after
total parotidectomy with a wide defect in the skin of the cheek.

05f_Masseter_r6_bs_0316-0333.indd 333 1/31/2012 3:21:00 PM

 ANATOMIC LANDMARKS
Landmarks Circumferential muscle encompassing the upper and lower lips.
Size 1.5 3 8 cm.
Origin Multiple origins from other facial muscles and retaining liga-
ments.
Insertion Lip skin and mucosa.
Function Oral sphincter, oral competence.
Composition Myocutaneous, myomucocutaneous.
Flap Type Type III.
Dominant Pedicles Superior labial artery; inferior labial artery.
Nerve Supply Motor: Facial nerve. Sensory: Upper lip, superior labial branches of
the trigeminal nerve, maxillary division; lower lip, buccal nerve
and medial branches of the inferior labial nerve (mandibular
division of trigeminal nerve).

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 Section 5G
Head and Neck

Orbicularis Oris Flap

CLINICAL APPLICATIONS
Regional Use
Lip
Chin
Cheek
Nose
Specialized Use
Lip and oral sphincter
reconstruction

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 ANATOMY OF THE Orbicularis Oris Flap

Levator labii
superioris muscle Zygomaticus
minor muscle

Orbicularis oris Zygomaticus

muscle major muscle

Depressor anguli Risorius muscle

oris muscle
Platysma muscle
Depressor labii
inferioris muscle Mentalis muscle

Perioral muscles

Facial artery
Zygomatic branch
Orbicularis oris of facial nerve
muscle
Superior labial artery
Inferior labial artery
Buccal branch
of facial nerve
Marginal
mandibular branch
of facial nerve

Course of superior and inferior labial vessels and facial nerve branches

Fig. 5G-1 

Dominant pedicles: Superior labial artery; inferior labial artery

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 Head and Neck  •  5G: Orbicularis Oris Flap 337

Zygomatic branch
of facial nerve

Buccal branch
of facial nerve Nerve supply to orbicularis oris

Fig. 5G-1 

Marginal mandibular
branch of facial nerve

Anatomy
Landmarks Circular muscle encompasses the upper and lower lip.
Composition Myocutaneous, myomucocutaneous.
Size 1.5 3 8 cm.
Origin Surrounding facial musculatures and retaining ligaments.
Insertion Lip skin and mucosa.
Function Oral sphincter and oral competence.

Arterial Anatomy (Type III)

Dominant Pedicle  Superior labial artery
Regional Source  Facial artery.
Length  6 cm.
Diameter  1 mm.
Location  The lateral border of the muscle at the angle of the mouth.
Dominant Pedicle (Lower Lip)  Inferior labial artery
Regional Source  Facial artery.
Length  6 cm.
Diameter  1 mm.
Location  Lateral border of the muscle at the angle of the mouth.

Venous Anatomy
Venous drainage is through accompanying venae comitantes.

Nerve Supply
Motor Facial nerve.
Sensory Upper lip, superior labial branches of maxillary division of the trigeminal nerve;
lower lip, buccal nerve and the medial branches of the labial nerve, both branches
of the mandibular branch of the trigeminal nerve.

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 338 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Orbicularis Oris Flap

Lower Third facial skin and perioral musculature

A B

D1

D2
f

Cutaneous surface of lower third of the face Deep surface of lower third of the face

D1

D1

D2

f f

Radiographic view of lower third

Fig. 5G-2 

Dominant pedicles: Superior labial artery (D1); inferior labial artery (D2)
f, Facial artery

05g_OrbOris_r6b_bs_0334-0367.indd 338 1/31/2012 5:49:47 PM

 Head and Neck  •  5G: Orbicularis Oris Flap 339

Lower Lip Abbé flap

D2

Cutaneous surface of flap

D2

Radiographic view of cutaneous surface

Fig. 5G-2 

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 340 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP HARVEST
Design and Markings
Because of the specialized nature of the orbicularis oris muscle and specialized lip tissues,
reconstruction of lip deformities is difficult. When possible, reconstructive flaps based
from other lip segments are desirable, because this will often give the most functional and
best cosmetic result. Approximately 25% of the upper lip and 30% of the lower lip can be
sacrificed without functional significance. For reconstruction, this sacrifice comes in the
form of a flap. The five basic flaps a reconstructive surgeon should have in his or her arsenal
for this region are the Abbé, Estlander, Gillies fan, McGregor, and Karapandzic flaps. The
choice of flap is based on the location and size of the defect to be reconstructed. Each flap
can be used for both upper and lower lip reconstruction. Flap designs are as follows.

Abbé Flap
In designing an Abbé flap, the surgeon should take into account the subunit of the chin and
try not to cross the chin pad. Also, since the pedicle of the Abbé flap must stay intact for
2 weeks, a pedicle that lies more lateral is easier for the patient to tolerate than a pedicle that
crosses in the middle of the mouth.

Abbé flap design

Fig. 5G-3 

Estlander Flap
The Estlander flap is essentially an Abbé flap but is positioned adjacent to the defect. This
flap is a good option in cases in which the commissure has been sacrificed, and rotation
creates a new commissure.

Estlander flap design

Fig. 5G-4 

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 Head and Neck  •  5G: Orbicularis Oris Flap 341

Gillies Flap
The Gillies flap, initially described as an extended Estlander flap, was designed for closure
of large lower lip defects (over 50% of the lower lip). Although this flap maintains the com-
missure, it does reduce the oral opening and moves the commissure medially. It is best used
for partial medial defects.

Gillies fan flap design

Fig. 5G-5 

McGregor Flap
The McGregor flap is a variation of the Gillies flap, designed to reconstruct larger defects
with loss of vermilion. It maintains the commissure in its proper position and uses cheek
skin and subcutaneous tissue to replace the lower lip substance. A mucosal graft or flap is
still required to replace missing lip skin and mucosa.

McGregor flap design

Fig. 5G-6 

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 342 Part II  Regional Flaps: Anatomy and Basic Techniques

Karapandzic Flap
The Karapandzic flap was also designed for large lip defects and can be performed unilater-
ally or bilaterally. An advantage of the Karapandzic flap is that it maintains the neurovas-
cular elements to the lip, so the oral sphincter maintains its function. The drawback to this
technique is the resultant microstomia.

Karapandzic flap design

Fig. 5G-7 

Patient Positioning
The patient is placed in a supine position.

GUIDE TO FLAP DISSECTION

Abbé Flap
Once the flap has been designed on either the upper or lower lip, the surgeon decides which
labial vessel will supply the flap. This decision is based on pedicle location and the strength
of the Doppler signal while occluding the contralateral vessel. An incision is then made on
the side opposite the source vessel. Dissection proceeds down through skin, muscle, and
mucosa as a full-thickness incision, dividing the lip. The surgeon locates the labial vessel
and cauterizes it. This is a good reference for dissecting the vessel on the pedicle side. Dis-
section on the side of the pedicle is made from inferior to superior. When the level of the
vermilion is reached, the tissues that are necessary for rotation of the flap are divided. No
incision should be made in the skin or mucosa of the lip near this vessel. A handheld Dop-
pler probe can be used to localize the vessel and spare it in the final dissection. One can
carefully divide the orbicularis muscle near the pedicle to facilitate flap rotation.

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 Head and Neck  •  5G: Orbicularis Oris Flap 343

A B

Defect and Abbé flap design Flap rotated

C D

Inferior labial
artery

Vermilion

Orbicularis
oris muscle

Flap inset and closure Cross-section of lip showing

labial artery

Fig. 5G-8 

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 344 Part II  Regional Flaps: Anatomy and Basic Techniques

Estlander Flap
Although the Estlander flap is similar in dissection to the Abbé flap, the vessel supplying
the flap is predetermined and will be medial in its position. The side of the flap that faces
the wound is freshened, and dissection proceeds along the design laterally, full thickness
through skin, muscle, and mucosa. The medial incision is made and stops at the level of
the vermilion. The blood vessel is isolated and skeletonized only enough to permit easy
transposition.

A B C

Estlander flap design Flap rotated to lower lip Flap inset and donor site closure

Fig. 5G-9 

Gillies Fan Flap

For a Gillies fan flap, the incision starts at the level of the defect and is followed around the
arc of the mouth superiorly, including skin, muscle, and mucosa, up to the level of the com-
missure. The remaining incision is only through skin and subcutaneous tissues. A backcut
allows rotation and advancement of the flap. One can increase rotation by further extending
the backcut and by mobilizing more mucosa. The width of the flap is designed to equal the
height of the lip resection. Flap advancement distorts the commissure.

A B C

Gillies fan flap design Flap rotated to lower lip defect Inset and donor site closure

Fig. 5G-10 

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 Head and Neck  •  5G: Orbicularis Oris Flap 345

McGregor Flap
The McGregor flap is a modification of the Gillies flap. Whereas the Gillies flap extends
laterally in a fan shape, the McGregor modification extends upward vertically in a rectangular
shape, with the width of the rectangular flap equal to the vertical height of the lip defect.
The vertical length of the flap is equal to the width of the defect plus the width of the flap
itself. From the bottom of the lip defect, incisions extend laterally for the full width of the
flap and then extend vertically to its full height and medially for the full width. Compared
with the Gillies fan flap, the backcut with the McGregor flap is made downward vertically
to within a few millimeters of the vermilion border of the remaining lip. The superior la-
bial artery, which supplies the flap, must be preserved. The length of the pedicle and of the
flap reach can be increased by extending the backcut and by mobilizing and dividing more
mucosa. This flap does not provide mucosa for the vermilion; this must be reconstructed
with a free buccal graft, a FAMM flap based on the contralateral side, or a tongue-based flap.

A B

Rotation
point

b b
a
a a

a
McGregor flap design Arc to lower lip defect

Inset and donor site closure; vermilion

reconstructed with flap/graft

Fig. 5G-11  Design and dissection of the McGregor flap.

a, Height of lip defect; a9 5 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.

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 346 Part II  Regional Flaps: Anatomy and Basic Techniques

Total upper lip reconstruction with bilateral fan flaps

A B

C D

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.

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 Head and Neck  •  5G: Orbicularis Oris Flap 347

Total lower lip reconstruction with bilateral McGregor fan flaps

A B

C D

Tongue
flap

Fig. 5G-13  A, Planned resection and flap design. B, Defect with flaps incised. C, Flaps rotated with-
out 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.

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 348 Part II  Regional Flaps: Anatomy and Basic Techniques

Karapandzic Flap
Of all of the orbicularis oris muscle flap procedures, the Karapandzic flap requires the most
meticulous dissection. These flaps are neurovascular flaps; the flap must be mobilized while
maintaining the muscle innervation and the vascular pedicle. The planned incisions are
made and deepened down through skin to the subcutaneous tissues that follow the nasola-
bial fold. The orbicularis muscle fibers are then spread apart longitudinally with a scissors
in the line of the incision down to the submucosal layer. The nerves and vessels that are
encountered are maintained. Mucosa is incised for 1 to 2 cm from the edge of the defect
only. To increase the length of the flaps when they do not meet easily, further dissection
can be performed in the subcutaneous tissues to allow mobilization, and all nerves and
vessels should be preserved.

A B

D D

n
n

Fig. 5G-14  A, Karapandzic flap design. B, Arc of orbicularis oris muscle flap and associated subcu-
taneous tissue with preservation of the neurovascular pedicles. C, Arc of bilateral myocutaneous flap
and direct donor site closure.
D, Angular artery supplying the inferior and superior labial artery; n, preserved motor
branches of facial nerve

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 Head and Neck  •  5G: Orbicularis Oris Flap 349

Reconstruction of 50% lower lip Defect with Karapandzic flaps

A B

C D

Fig. 5G-15  A, The plan for the procedure is outlined for a carcinoma of the lower lip, consisting of re-
section followed by reconstruction with bilateral modified Karapandzic flaps. B, The resection is com-
pleted. 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 sub-
mucosal 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.

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 350 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANTS
•  Reverse Abbé flap
•  Reverse Estlander flap
•  Reverse Karapandzic flap
Each of these flaps is identical to its upper and lower lip variants. The flaps are now based
on the opposite lip using the other dominant blood supply to the lip as their nutrient vessel.

ARC OF ROTATION
These flaps are used for lip reconstruction, and the arc of rotation is defined by the recon-
structive need. Rotations beyond the subunit of the lip are unnecessary.

Estlander flap
arc to oral commissure and lower lip
Gillies fan flap
arc to central lower lip
Abbé flap
arc to central upper lip

Rotation point:
commissure
position
maintained

McGregor flap Karapandzic flap

arc to central lower lip arc to central lower lip

Fig. 5G-16 

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 Head and Neck  •  5G: Orbicularis Oris Flap 351

FLAP TRANSFER
The Abbé flap is transferred by transposition from one lip to the other. Estlander flap is
transferred by transposition from one lip to the other to recreate the commissure. The Gillies
flap is transferred by advancement to reconstruct the lip. The commissure is moved more
medially and the size of the oral opening is decreased. The McGregor flap is transferred
through a combination of advancement and transposition. The vertical height of the flap
at the lateral end of the defect becomes the horizontal length of the lip reconstruction. The
Karapandzic flap is transferred by advancement of the neurovascular flaps either from one
side only or as a bilateral advancement, which is more common.

FLAP INSET
All Flaps
Inset is performed in layers: the muscle layer, the dermal layer, and then the skin layer are
all closed, realigning the vermilion for best aesthetics. For the McGregor flap, a secondary
procedure is required to add a mucosal surface to the lip to reestablish the vermilion.

DONOR SITE CLOSURE

In all flap modifications, primary closure of the donor site is planned for best overall aesthet-
ics. Each of the flaps takes advantage of the excess in the lip and cheek tissues to allow the
advancement and cheating closed of the donor site without excessive tension. With flaps
such as the Abbé flap and reverse Abbé flap that require a secondary division and inset,
the surgeon must be careful during closure of the primary donor site so that there is not
too much tension on the pedicle, which might cause ischemia of the flap. At the time of
division and inset, revision of any area that has healed secondarily or any scars of the lips
can be performed.

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 352 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 50-year-old woman presented to her dermatologist with a pale pink papule, 5 mm
in diameter, at the philtrum-columella junction. Biopsy confirmed a Merkel cell tumor.
Radical excision was performed using Mohs micrographic surgery, resulting in a full-
thickness defect of the upper lip from alar base to alar base transversely and from the tip of
the columella below the nasal tip to the white roll centrally. This included the oral mucosa.
Reconstruction was planned in two stages. The first stage involved re-creation of the
philtrum and columella with an extended Abbé flap based on the left lower labial artery,
while the upper lateral lip elements were to be reconstructed with bilateral perialar cres-
centic advancement flaps. Two weeks after the first stage was completed, the patient was
brought back to the operating room for division and inset of the base of the Abbé flap.
Normal contour was restored without requiring revision and the patient was recurrence
free two years later.

A B

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.

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 Head and Neck  •  5G: Orbicularis Oris Flap 353

D E

F G

Fig. 5G-17  D, Design of the Abbé 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, Abbé flap and perialar flaps prepared for advancement. F, Flaps sutured in place with inset of
the Abbé flap. G, Postoperative staged result 2 weeks before division of the Abbé flap. H, Final result
1 year postoperatively with no revision. (Case supplied by GJ.)

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 354 Part II  Regional Flaps: Anatomy and Basic Techniques

This 48-year-old smoker with a basal cell carcinoma of the upper lip and cheek had a defect
after Mohs surgery that included 50% of his upper lip. The best cosmetic and functional
result with a large defect such as this is with an Abbé flap. The cheek flap can be managed
with a Mustardé-type cheek advancement.

B C

Fig. 5G-18  A, The defect after Mohs surgery, which extends to the philtrum medially and onto the
maxilla superiorly. B, Planned Abbé flap using 25% of the lower lip. C, Lateral view showing the Mus-
tardé flap design and the Abbé design relative to the commissure.

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 Head and Neck  •  5G: Orbicularis Oris Flap 355

D E F

G H

Fig. 5G-18  D, Abbé 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. (Case supplied by MRZ.)

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 356 Part II  Regional Flaps: Anatomy and Basic Techniques

This 78-year-old man had a basal cell carcinoma of the upper lip, which was resected using
the Mohs technique and reconstructed with Abbé and nasolabial flaps.

B C

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 Abbé 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, Abbé rotated and nasolabial flap elevated
and ready to inset.

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 Head and Neck  •  5G: Orbicularis Oris Flap 357

D E

F G

Fig. 5G-19  D, All flaps inset with primary donor site closure. Note how the Abbé 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 van-
ished. H, The patient shows maximal mouth opening, evidencing some microstomia. The patient was
functional and desired no further surgery. (Case supplied by MRZ.)

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 358 Part II  Regional Flaps: Anatomy and Basic Techniques

This 42-year-old man had a squamous cell carcinoma of the left commissure requiring
resection, which was reconstructed with an Estlander flap.

A B

C D

E F

Fig. 5G-20  A, The patient’s Mohs defect encompassed 25% of the lower lip and the left commis-
sure. 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 1½ years postoperatively. F, Lateral oblique view. Although the patient has been offered commis-
suroplasty, he is happy with the final result. (Case supplied by MRZ.)

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 Head and Neck  •  5G: Orbicularis Oris Flap 359

This relatively young woman exhibits an excellent functional and aesthetic result after
full-thickness lower lip resection for squamous cell carcinoma and reconstruction with
Karapandzic flaps.

A B

C D

E F G

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 postopera-
tively. G, The patient demonstrates good muscular function of the oral sphincter. (Case courtesy Ian
T. Jackson, MD.)

05g_OrbOris_r6b_bs_0334-0367.indd 359 1/31/2012 5:50:15 PM

 360 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient presented with a squamous cell carcinoma of the lower lip infiltrating the
muscle. It involved almost two thirds of the lower lip. A McGregor-type fan flap was used
to reconstruct the defect.

A B

Fig. 5G-22  A-C, A full-thickness excision of two thirds of the lip was done, with the lip mucosa re-
sected 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.

05g_OrbOris_r6b_bs_0334-0367.indd 360 1/31/2012 5:50:17 PM

 Head and Neck  •  5G: Orbicularis Oris Flap 361

D E F

G H

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 photo-
graphs 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. (Case courtesy Ian T. Jackson, MD.)

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 362 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient presented with carcinoma of the lower lip requiring removal of more than half
of his lip. Reconstruction was done with bilateral Karapandzic flaps.

A B

Fig. 5G-23  A, The plan for the procedure was outlined, consisting of resection followed by recon-
struction 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.

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 Head and Neck  •  5G: Orbicularis Oris Flap 363

D E

G H

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 reconstruc-
tion 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. (Case courtesy Ian T. Jackson, MD.)

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 364 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Ultimately, function of the oral sphincter and size of the oral opening will determine
how successful a reconstruction of the lip is. Cases must be individualized to select the
best flap for the situation.
• Flaps such as the Abbé, Estlander, Gillies fan, and Karapandzic will reduce the size of
the oral opening and may present problems such as microstomia. Rather than leave the
patient with a problem such as this when major resection of a lip segment has been per-
formed, one might consider free tissue transfer, which does not supply like tissues, but
will allow functional wound closure and will maintain an adequate oral aperture. Free
buccal grafts can heal similar to a skin graft and provide a nice mucosal layer to the lip
without the morbidity and discomfort of a tongue flap, which must be left in place for
up to 2 weeks and then divided and inset.
• Young people without rhytids or aged skin are often poor candidates for reconstruction
of large lip defects with local flaps such as the McGregor and Karapandzic flaps.

EXPERT COMMENTARY
Ian T. Jackson

Personal Experience and Insights

Management of the muscles of the lip is controversial. There are those who advocate subcu-
taneous suturing, and others who advise freeing of the muscles sufficient enough to perform
interdigitation. I prefer the latter, to lengthen the muscles in the repair area. This makes it
possible to reduce the amount of vertical shortening. There is also strong tightening of the
lower lip. It is my opinion that the muscles of the lip should be repaired accurately in the
same position as the noninvolved side. If this is performed very carefully, the repair is more
balanced in appearance and in function. This will then result in a more balanced end result.

Complications and Avoidance

The most common reasons for flap failure fall into two categories: design fault and technical
error. The most common examples of design fault are too small a flap, extending the flap
outside its blood supply, and failing to consider previous therapy, such as old scars or areas
that have been irradiated. Examples of common technical errors are hematoma, suturing
the wound under tension, failing to make a backcut, making the pedicle too short, and
damaging the blood supply. Judgment and execution improve with experience, and this
lowers the rate of complications. The old adage “measure twice, cut once” underscores the
importance of planning to avoid many of the problems above.

Take-Away Message
It is important to remember that the lip moves and should move symmetrically.

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 Head and Neck  •  5G: Orbicularis Oris Flap 365

Bibliography With Key Annotations

Abbé RA. New plastic operation for relief of deformity due to double harelip. Med Rec 53:477,
1898.
Classic article describing the Abbé flap.
Alic B, Gurel M, Cilengir M, et al. Unilateral gate flap for reconstruction of the lower lip. Plast
Reconstr Surg 84:814-819, 1989.
A unilateral gate flap technique consisting of a nasolabial island flap was presented for reconstruction
of defects in the lower lip after excision of large, laterally located epidermoid tumors. The amount of
healthy tissue resected is optimal. The reconstructed lower lip retains sensation and muscle function
and is continent with a satisfying appearance. Temporary flap edema and a vermilion notch at the
apex of the flap are both avoidable problems. This method may be used in selected patients with large
advanced epidermoid cancers of the lower lip.
Bakamjian V. Use of tongue flaps in lower-lip reconstruction. Br J Plast Surg 17:76-87, 1964.
Hurwitz DJ. Composite upper lip repair with V-Y advancement flaps. Plast Reconstr Surg
85:120-122, 1990.
In two patients, large but superficial partial-thickness resections of lateral upper lip were repaired by
composite island cutaneous flaps. Upper lip and nasolabial fold flaps, along with the lateral vermilion,
were advanced and closed in a V-Y manner, leaving inconspicuous scars and no contour deformity.
Jabaley ME, Clement RL, Orcutt TW. Myocutaneous flaps in lip reconstruction: applications
of the Karapandzic principle. Plast Reconstr Surg 59:680-688, 1977.
The authors described their experience with reconstruction of lips with the use of innervated myocu-
taneous flaps. They presented the technique and some illustrative cases.
Jackson IT. Use of tongue flaps to resurface lip defects and close palatal fistulae in children.
Plast Reconstr Surg 49:537-541, 1972.
Jin X, Teng L, Zhang C, et al. Reconstruction of partial-thickness vermilion defects with a
mucosal V-Y advancement flap based on the orbicularis oris muscle. J Plast Reconstr Aesthet
Surg 64:472-476, 2011.
Repair of a large, trauma-induced partial-thickness vermilion defect is considered a challenging task.
Ideally, such defects should be corrected by methods that use tissues similar in color and texture to the
normal vermilion. When the length of a defect is greater than half that of the vermilion and the width
of the defect is greater than 1.5 cm, however, effective repair is not always achieved using the tradi-
tional mucosal V-Y advancement flap. This article described a modified mucosal V-Y advancement flap
containing the orbicularis oris muscle. This flap possesses the mobility sufficient to serve as the pedicle for
the transfer and repair of large vermilion defects. Between August 2006 and January 2009, vermilion
reconstruction using this modified flap was performed on eight patients, with satisfactory cosmetic and
functional outcomes obtained in all cases. This simple and useful approach to vermilion reconstruction
provides excellent outcomes with minimal injury to the donor site.
Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 27:93-97, 1974.
Classic description of Karapandzic flap for lip reconstruction.
Kashiwa K, Kobayashi S, Honda T, et al. Orbicularis oris myomucosal island flap transfer to
the nose. J Plast Reconstr Aesthet Surg 62:e341-e344, 2009.
The authors developed the orbicularis oris myomucosal island flap (OOMMIF) to reconstruct the nasal
lining in one stage. The OOMMIF blood supply derives from the intramuscular vascular network,
which communicates with the submucosal vascular plexus via the vascular network formed by the
deep ascending branches of the superior labial artery. An oral mucosal flap of approximately 2 by
3 cm can be harvested from the upper lip, pedicled solely on the orbicularis oris muscle. They transferred
this flap to a nasal lining defect located in the ala in four patients, the nasal floor in two patients,
and the columella in two patients. The flap donor site was closed primarily. All flaps took completely

05g_OrbOris_r6b_bs_0334-0367.indd 365 1/31/2012 5:50:24 PM

 366 Part II  Regional Flaps: Anatomy and Basic Techniques

with satisfactory results. Minor complications included slight asymmetry of the vermilion height as a
result of donor site contracture in one patient, and flap drooping in two patients, corrected by secondary
debulking. Upper lip functional loss was not observed, although upper lip hypesthesia occurred in one
patient, which disappeared within 6 months. An OOMMIF can be easily elevated with minimal
donor site morbidity. Thus the OOMMIF is a good candidate for one-stage reconstruction of small
nasal lining defects.
Kawamoto HK Jr. Correction of major defects of the vermilion with a cross-lip vermilion flap.
Plast Reconstr Surg 64:315-318, 1979.
The author described a method for correcting major vermilion defects with a transverse cross-lip vermilion
flap. Sizable defects can easily be filled in to obtain an upper lip with better contour and simultane-
ously reduce the unpleasant fullness of the lower lip, producing better balance between the two lips.
McGregor IA. The tongue flap in lip surgery. Br J Plast Surg 19:253-263, 1966.
Millard DR Jr, McLaughlin CA. Abbé flap on mucosal pedicle. Ann Plast Surg 3:544-548, 1979.
A difficult secondary bilateral cleft lip deformity with nasal distortion was treated with eight local flaps
specifically designed for this case. One of these was an Abbé flap in which the coronary vessel in the
pedicle was inadvertently divided. The judgment in handling this flap and its fate as a composite lip
flap based on a narrow mucosal pedicle is reported.
Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruction with the facial artery
musculomucosal flap. Plast Reconstr Surg 105:864-872, 2000.
The lips are a complex, laminated structure. When lost through injury or disease, they present a
complex reconstructive challenge. The facial artery myomucosal (FAMM) flap is a composite flap
with features similar to those of lip tissue. The authors discussed the anatomy, dissection, and clini-
cal applications for the FAMM flap in lip and vermilion reconstruction and presented a series of 16
FAMM flaps in 13 patients; 7 had upper lip reconstruction and 6 had lower lip reconstruction.
Superiorly based FAMM flaps were used in 8 patients, and 8 inferiorly based flaps were performed
in 5 patients. Three patients had bilateral inferiorly based flaps. In summary, the FAMM flap is a
local flap that can be used for lip and vermilion reconstruction. Although not identical to the lip, it has
many similar features that make it an excellent option for lip reconstruction.
Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial artery musculomucosal
(FAMM) flap. Plast Reconstr Surg 90:421-429, 1992.
By combining the principles of nasolabial and buccal mucosal flaps, the authors designed a new axial
musculomucosal flap based on the facial artery. This flap has been designated the facial artery mus-
culomucosal (FAMM) flap. The flap has proved reliable, either superiorly based (retrograde flow) or
inferiorly based (antegrade flow). The authors found it versatile and used it 18 times in 15 patients,
with 1 failure and 2 partial losses. It has been used successfully to reconstruct a wide variety of difficult
oronasal mucosal defects, including defects of the palate, alveolus, nasal septum, antrum, upper and
lower lips, floor of the mouth, and soft palate.
Robotti E, Righi B, Carminati M, et al. Oral commissure reconstruction with orbicularis oris
elastic musculomucosal flaps. J Plast Reconstr Aesthet Surg 63:431-439, 2010.
Surgical reconstruction of the oral commissure aims to restore both symmetry of the lips at rest and, what
is more important, full oral competence. Molding the lip commissure with functional and cosmetic fidelity
remains a difficult task. A possible surgical solution, the “elastic flap” principle described by Goldstein,
may be found in the wide full-thickness mobilization of the upper and lower vermilion as two com-
posite myocutaneous flaps—tissue sandwiches consisting of labial skin, orbicularis oris muscle and oral
mucosa—on the axial pattern of the superior and inferior labial arteries. Based on the contralateral
commissure, both flaps are easily stretched, accordion-like, to reach the predetermined point of the new
commissure, using to full advantage the inherent elastic potential of both vermilions. The fibers of the
orbicularis oris muscle at each end of both flaps are imbricated to reconstitute a neomodiolus, which is
anchored to the residual buccinator muscle in primary reconstructions, or to the available perioral fibrous
tissue in secondary procedures. The authors presented a select group of 22 patients, who, between
1993 and 2008, underwent this reconstruction procedure for primary or secondary defects involving

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 Head and Neck  •  5G: Orbicularis Oris Flap 367

the oral commissure. The results were generally satisfactory, both functionally and cosmetically. The
advantages of this procedure include full restoration of the dynamic function of the orbicularis ring in a
single-stage operation and avoidance of either lip-switching procedures or of mobilization of mucosa and
cheek skin. The final scars remain well camouflaged within the oral mucosa and the mucocutaneous
junction of each lip.
Turgut G, Ozkaya O, Kayali MU, et al. Lower lip reconstruction with local neuromusculocu-
taneous advancement flap. J Plast Reconstr Aesthet Surg 62:1196-1201, 2009.
Various reconstruction techniques using the remaining lip or the adjacent cheek tissue have been described
for the repair of lower lip defects. With these techniques, microstomia, commissural distortion, func-
tional insufficiency, and sensorial loss might be observed. The authors described a technique of lower
lip reconstruction with preservation of neuromuscular tissue as a single-stage procedure. Lip sensation
and orbicularis oris muscle function are preserved. Fifteen patients with lower lip defects, after tumor
ablation or after traumatic loss, were treated by this technique. The only prerequisite for the application
of this technique is the availability of at least 20% of the remaining lip tissue. Satisfactory functional,
aesthetical, and sensational results were obtained.
Urushidate S, Yokoi K, Higuma Y, et al. New way to raise the V-Y advancement flap for
reconstruction of the lower lip: bipedicled orbicularis oris musculocutaneous flap technique.
J Plast Surg Hand Surg 45:66-71, 2011.
The authors described a new way to raise the V-Y advancement flap, which is useful for reconstruction
of the lower lip. Various other methods have been reported in the past, but it has been necessary to
choose the most suitable method for each case. A V-Y advancement flap from the submandibular region
is one of the useful techniques to reconstruct the lower lip and is suitable for a wide horizontal defect.
However, the conventional V-Y flap is insufficiently mobile, and the reconstructed vermilion is thin
because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embar-
rassing defect. The authors developed a new way to raise the flap to obviate these problems by using
the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision
of the tumor, and using a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y
flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap
is then raised as a bipedicled myocutaneous flap, which has adequate movement. After the flap has
been sutured, the superior margin of the flap is deepithelialized, and used to create the volume of the
vermilion border. Functionally and cosmetically good results have been achieved.
Yavuzer R, Jackson IT. Partial lip resection with orbicularis oris transposition for lower lip
correction in unilateral facial paralysis. Plast Reconstr Surg 108:1874-1879, 2001.
Malfunction of the marginal mandibular nerve, either in combination with a generalized facial palsy
or in isolation, can cause an unpleasant and disturbing appearance around the mouth. In total palsy,
a cross-facial nerve graft combined with a free vascularized muscle transplant will usually correct this
problem successfully; however, all older procedures used in this situation are unpredictable. For an
isolated palsy, procedures such as digastric muscle transfer or sling suspension are not uniformly suc-
cessful. The authors described a method using the contralateral, nonaffected lower lip orbicularis muscle.
A wedge is removed from the paralyzed lower lip and the orbicularis is advanced to the modiolus to
provide a functional orbicularis all the way across the lower lip up to the angle of the mouth. This is a
simple outpatient procedure that has produced satisfactory results in most cases.

05g_OrbOris_r6b_bs_0334-0367.indd 367 1/31/2012 5:50:24 PM

 ANATOMIC LANDMARKS
Landmarks This large, specialized muscular structure occupies the floor of
the mouth.
Size 8 cm from tip to foramen cecum 3 5 cm transversely is available
for flap use.
Origin The tongue has five paired extrinsic muscles: (1) genioglossus,
(2) hyoglossus, (3) styloglossus, (4) chondroglossus, and (5) glosso-
palatinus. These muscles originate from the following structures:
the genial tubercle of the mandible, hyoid bone, epiglottis, soft
palate, styloid process, pharynx, and the mandible.
Insertion The tongue has four intrinsic muscles: (1) longitudinalis supe-
rior, (2) longitudinalis inferior, (3) transversus, and (4) verticalis
linguae. There is also a fibrous midline septum that extends
between the hyoid bone and the tongue base. Extrinsic muscles
insert into these structures.
Function The tongue is the principal organ of taste and speech and also
assists in deglutition and mastication.
Composition Muscle.
Flap Type Type I.
Dominant Pedicles Lingual artery, deep lingual artery.
Nerve Supply Motor: Hypoglossal nerve. Sensory: (1) lingual branch of the tri-
geminal nerve, (2) chorda tympani branch of the facial nerve,
and (3) lingual branch of the glossopharyngeal nerve.

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 Section 5H
Head and Neck

Tongue Flap

CLINICAL APPLICATIONS
Regional Use
Palate
Tonsil
Alveolar ridge
Floor of mouth
Specialized Use
Upper lip
reconstruction
Lower lip
reconstruction

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 ANATOMY OF THE Tongue Flap

Palatoglossus
muscle

Styloglossus
muscle

Stylopharyngeus
muscle

Stylohyoid Inferior orbicularis

muscle oris muscle

Middle pharyngeal
Genioglossus
constrictor muscle
muscle

Geniohyoid
Hyoglossus
muscle
muscle
Mylohyoid
muscle
Lateral tongue muscles

B Superior longitudinal
muscle of tongue

Vertical and transverse

muscle of tongue
Styloglossus
Inferior longitudinal muscle
muscle of tongue

Sublingual
salivary gland
Hyoglossus
muscle

Lingual
artery
Genioglossus
muscle
Facial
Lingual
artery
nerve

Submandibular
Hypoglossal salivary gland
nerve Facial vein
Mylohyoid
Hyoid bone muscle

Tongue cross-section: Frontal section behind first molar (anterior view)

Fig. 5H-1 

Dominant pedicles: Sublingual artery; deep lingual artery

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 Head and Neck  •  5H: Tongue Flap 371

Lingual Deep lingual

nerve artery and vein

External carotid
artery Sublingual
artery
Internal jugular
vein

Hypoglossal
nerve

Lingual
artery
Lateral vascular anatomy of tongue

Fig. 5H-1

Dominant pedicles: Sublingual artery; deep lingual artery

Anatomy
Landmarks The tongue is a specialized muscular structure that occupies the floor of the
mouth.
Composition Muscular.
Size 8 cm from tip to foramen cecum 3 5 cm transversely is available for flap use in
reconstruction.
GENIOGLOSSUS
Origin Genial tubercle of the mandible.
Insertion Inferior fibers to the hyoid bone; middle fibers to the undersurface of the dorsal
tongue; superior fibers to the apex of the tongue.
Function Inferior fibers: protrusion; anterior fibers: retraction; both fibers: depression of
the tongue.
HYOGLOSSUS
Origin The greater coronoid of the hyoid bone.
Insertion The side of the tongue.
Function Depression and retraction of the tongue.
STYLOGLOSSUS
Origin Styloid process.
Insertion The side of the tongue.
Function Retraction of the tongue in concert with the genioglossus; elevation of the tongue
in concert with the glossopalatinus muscle.

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 372 Part II  Regional Flaps: Anatomy and Basic Techniques

LONGITUDINALIS LINGUAE
Origin Superior muscle originates from submucosal fibers and the median fibrous raphé
at the base of the tongue; inferior muscle originates from the ventral surface of
the tongue between the genioglossus and the hyoglossus muscles.
Insertion Apex of the tongue.
Function The superior muscle shortens the tongue and elevates the tip and sides of the
tongue; the inferior muscle shortens the tongue and depresses the tip and sides
of the tongue.
TRANSVERSUS LINGUAE
Origin The median fibrous septum.
Insertion The side of the tongue.
Function Narrows and elongates the tongue.
VERTICALIS LINGUAE
Origin The mucous membrane on the dorsal tongue.
Insertion The ventral surface of the tongue.
Function Flattens and broadens the tongue.

Arterial Anatomy (Type I)

Genioglossus
Dominant Pedicle  Sublingual artery
Regional Source  Lingual artery.

Hyoglossus
Dominant Pedicle  Sublingual artery
Regional Source  Lingual artery.

Styloglossus
Dominant Pedicle  Sublingual artery
Regional Source  Lingual artery.

Longitudinalis Linguae
Dominant Pedicle  Deep lingual artery
Regional Source  Lingual artery.

Transversus and Verticalis Linguae

Dominant Pedicle  Deep lingual artery
Regional Source  Lingual artery.

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 Head and Neck  •  5H: Tongue Flap 373

Venous Anatomy
The lingual vein accompanies the lingual artery with venae comitantes accompanying its branches,
combining with the facial vein to drain into the internal jugular vein.

Nerve Supply
Motor Hypoglossal nerve supplies both the extrinsic and intrinsic muscles of the tongue.
Sensory (1) The lingual branch of the trigeminal nerve (third division, mandibular) pro-
vides sensation to the anterior two thirds of the tongue. (2) The chorda tympani
of the facial nerve (seventh cranial nerve) located with the lingual nerve provides
taste and sensation to the anterior two thirds of the tongue. (3) The lingual branch
of the glossopharyngeal nerve (ninth cranial nerve) provides sensation and taste
to the posterior third of the tongue.

Vascular A natomy of the Tongue

A
B
t t
t

D2
D1
D2

D2
D1

D1

Deep surface of the flap (lateral view) Radiographic view

Fig. 5H-2 

Dominant pedicles: Sublingual artery (D1); deep lingual artery (D2)

t, Lingual artery

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 374 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings
Tongue flaps can be based dorsally, laterally, or on the ventral surface of the tongue. De-
pending on the location of need, both the laterally based and dorsally based tongue flaps
can be based anteriorly or posteriorly. By their nature, tongue flaps are two-staged flaps.
The first stage involves creation of the flap and attachment to the area of concern, keeping
its pedicle intact. The second stage involves division and inset. Care is taken in the design
of the flap to avoid critical areas of taste and tactile sensation of the dorsal tongue when
possible by using laterally based or ventrally based flaps. All tongue flaps are designed so
that the donor site can ultimately be closed primarily. Because of the incredible vascular-
ity of the tongue, Doppler examination is not required for creation of tongue-based flaps.

A B C

Anteriorly based midline flap for Posteriorly based midline flap for Anteriorly based lateral flap for
palatal defect palatal defect anterior mouth floor defect

D E

Posteriorly based lateral flap for Ventrally based flap

palate and tonsillar fossa

Fig. 5H-3 

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 Head and Neck  •  5H: Tongue Flap   375

Patient Positioning
The patient is placed in the supine position with a bite block or fixed mouth retractor for
best visualization.

GUIDE TO FLAP DISSECTION

Dorsally Based Flap
The dorsally based flap is the one most commonly used for palatal defects because of its
proximity. It is not recommended that dorsally based flaps be used for other areas of recon-
struction where either a laterally or ventrally based flap will suffice, because the scarring
and cosmetic outcomes of the specialized dorsal tissues can be problematic. Once the area
to be reconstructed has been debrided and is well defined, the surgeon decides whether
an anteriorly or posteriorly based flap will provide the best reach. If either is acceptable, a
posteriorly based flap will rely more on anterograde blood flow and will allow better tongue
mobility in the interim period before division and inset. Donor site closure is also facilitated.
A suture is placed in the tip of the tongue to protrude the tongue, and the midline area of
the tongue is then marked, ensuring an adequate base that should measure at least 1.5 to
2 cm. The length should allow ease of rotation and inset. The flap mucosa, submucosa, and
superior longitudinalis linguae muscle are elevated for a depth of 5 mm. There is no easily
identifiable plane of dissection. Excessively long flaps must be avoided.

A B

Anteriorly based midline flap Posteriorly based midline flap

for palatal defect for palatal defect

Fig. 5H-4

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 376 Part II Regional Flaps: Anatomy and Basic Techniques

Laterally Based Flap

Once the area to be reconstructed has been debrided and is well defined, the surgeon de-
cides whether an anteriorly or posteriorly based flap will provide the best reach. If either is
acceptable, a posteriorly based flap will rely more on anterograde blood flow and will allow
better tongue mobility in the interim period before division and inset. Donor site closure
is also facilitated. A suture is placed in the tip of the tongue to extrude the tongue, and the
lateral border of the tongue is then marked, ensuring an adequate base that should measure
at least 1.5 to 2 cm. The length should allow ease of rotation and inset. The flap mucosa,
submucosa, hyoglossus, superior longitudinalis linguae, and styloglossus muscles are elevated
for a depth of 5 mm. There is no easily identifiable plane of dissection.
The posteriorly based flap extends to within 1 cm of the apex of the tongue. The
anteriorly based flap extends to the level of the papillae vallata. It is prudent to gradually
deepen the flap so that it is 7 mm at its base. Full mobility of the flap can be accomplished
by completely incising the mucosa at the base of the flap; however, this is rarely needed and
may limit some vascularity to the flap.

A B

Anteriorly based lateral flap for Posteriorly based lateral flap for
anterior mouth floor defect palate and tonsillar fossa

Fig. 5H-5

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 Head and Neck  •  5H: Tongue Flap   377

Ventral Tongue Flap

The ventral tongue flap is ideal for central defects of the lower lip. Traction sutures are placed
in this case, two sutures on either side of the tip of the tongue, to help splay the tongue and
present its ventral surface. The flap is designed to be based anteriorly (distally). The design
may come to within 1 cm of the tip of the tongue anteriorly. The thickness of the flap is
largely determined by the amount of tissue required to reconstruct the lip. The broad base
of this flap ensures good viability, and a minimum thickness of 5 mm should be sought.

Incision of
ventral tongue flap,
distally based

Fig. 5H-6

ARC OF ROTATION
Dorsally Based Tongue Flap
The dorsally based tongue flap will reach the palate with either an anterior or posterior
based flap.

A B

Anteriorly based Posteriorly based

midline flap for midline flap for
palatal defect palatal defect

Fig. 5H-7

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 378 Part II Regional Flaps: Anatomy and Basic Techniques

Anteriorly Based Lateral Tongue Flap

The anteriorly based lateral tongue flap will reach the lower lip, upper lip, floor of the
mouth, alveolar ridge, anterior hard palate, and commissure.

Posteriorly Based Lateral Tongue Flap

The posteriorly based tongue flap reaches the buccal sulcus, cheek, alveolar ridge, tonsillar
fossa, posterior hard palate, and posterior soft palate.

To palate

To upper half
of lip

To palate

To upper half
of lip

To lower half
of lip To lower half
of lip

Fig. 5H-8

Ventral Tongue Flap

The ventral tongue flap will reach the lower lip and anterior floor of the mouth.

A B

Ventrally based
lateral flap to
anterior mouth

Ventrally based lateral flap for anterior mouth

Fig. 5H-9

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 Head and Neck  •  5H: Tongue Flap 379

Flap Transfer
All Variants
The flap reaches the recipient site by advancement of the ventral flap or by transposition to
the recipient site with dorsal and lateral flaps.

Flap Inset
The flap is directly inset to its recipient site using simple interrupted sutures. Care is taken
to avoid excessive tension on the flap.

Donor Site Closure

All Flap Variants
Donor sites are partially closed at the first surgery, making certain that the elevated flap is
not strangulated. After a minimum of 10 days, the flap is divided at its base and inset into
the recipient site. The defect created at the donor site may be closed with a simple absorbable
suture. Areas that dehisce or remain open will remucosalize uneventfully.

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 380 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 85-year-old woman had a basal cell carcinoma of the lower lip.

A B

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.

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 Head and Neck  •  5H: Tongue Flap 381

D E

F G

H I

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 su-
praclavicular 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. (Case supplied by MRZ. )

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 382 Part II Regional Flaps: Anatomy and Basic Techniques

This patient had a hemangioma of the lower lip that had caused color change and lip en-
largement.

A B

C D

E F

G H

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.

05h_Tongue_r3b_bs_0368-0387.indd 382 1/30/2012 2:41:30 PM

 Head and Neck  •  5H: Tongue Flap   383

I J

K L

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 trans-
ferred 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. (Case courtesy Ian T. Jackson, MD.)

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 384 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Careful planning and selection of the vascular base of the flap will help to avoid unneces-
sary tension and twisting of the flap.
• The tongue is supplied only by the lingual arteries bilaterally. Care must be taken if the
patient has had previous neck surgery, such as radical neck dissection, where the lingual
artery may have been divided. In these cases one should consider alternative flaps.
• Although dorsally based midline flaps can be attractive for use in visible areas such as
the lip, they involve greater morbidity and are more likely to produce tongue deformity
and dysarthria.
• The color and texture of the dorsal tongue does not match the color and texture of the
lip and remains this way postoperatively. The lateral and ventral surfaces of the tongue,
however, can provide an excellent match in both color and texture.
• Closure of the donor site after division and inset is forgiving. It is not uncommon that the
area dehisces or is unable to be closed completely. This will remucosalize uneventfully.
• No retaining sutures are required in the interim period before division and inset, other
than sutures that inset the flap.
• Tongue mobility and drying of exposed mucosa are common issues during the period of
attachment before division and inset, and the patient should be forewarned.
• In a small subset of patients, biting of the flap with incisors can be a potential problem.
This can be prevented by using bilateral molar bite blocks. These can be customized to
the patient and cemented to the lower molars at the time of surgery.
• Because of the pincushioning and edema that can occur with these flaps, waiting a mini-
mum of 6 months before any surgical revisions is recommended. Revisions of the tongue
donor site are rarely required.

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 Head and Neck  •  5H: Tongue Flap 385

Expert Commentary
Ian T. Jackson

Personal Experience and Insight

The central anterior–based flap provides a good result in color and texture, but there is
pincushioning that tends to settle to a varying degree with time. In my experience, there
has never been an indication to provide secondary management of the tongue.
Initially there is the problem of tongue attachment. When indicated, this is divided
and patients are so relieved that they are very pleased. They should be told that there will
be further improvement in swelling, speech, and competence, but an accurate timetable
cannot be given.
Formation of a Cupid’s bow is very difficult. If the bow can be made, it suffers from
the deficiency of no white roll, with an artificial-looking junction between the skin and
vermilion.

Recommendations
Technique
Upper lip reconstruction places much more tension on the tongue flap than does lower
lip reconstruction. Suturing the lateral edges of the tongue to the lip helps to stabilize the
reconstruction and prevent separation of the flap. As long as the undersurface of the tongue
is used, the color match and mucosal texture are good.
When the defect to be reconstructed includes muscle, a bulkier reconstruction is required
and a tongue flap is indicated. Mucosal defects of the commissure can be reconstructed with
a tongue flap based anteriorly on the side of the tongue; the flap can be raised and split to be
inserted into the anterior portion of the commissural defect. In 10 days the flap is divided
and inset into the apex of the commissure. Alternatively, two long posteriorly based flaps
from the side of the tongue can be rotated and sutured in the raw areas of the commissure,
then divided in 10 days.

Postoperative Care
The lip should be massaged with whatever product the patient finds to be best. Diet is
important, so advice from a dietician can be helpful.

Take-Away Messages
For patients, the most important aspect of this somewhat frightening procedure is to have
it carefully and fully explained and discussed with the surgeon. A meeting with another
patient who has had this procedure can be most reassuring. Patients are told that a degree
of drooling and a change in speech are inevitable, but this will improve with time. Be posi-
tive. The appearance of the tongue will also improve. A degree of drooling may continue,
but this is usually minimal, and again, this improves with time. The surgeon must provide
reassurance about the outcome of the surgery, the chances of total cure, and future man-
agement of persistent issues if they should arise. Ample time must be set aside for a relaxed
question-and-answer discussion.

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 386 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Al-Qattan MM. A modified technique of using the tongue tip for closure of large anterior
palatal fistula. Ann Plast Surg 47:458-460, 2001.
Anteriorly based dorsal tongue flaps are the most commonly used flaps for closure of difficult palatal
fistulas. The author presented a patient in whom the palatal defect was thought to be too big to be
closed by the standard tongue flap. The tongue tip was divided into equal dorsal and ventral flaps,
and both flaps were used to reconstruct the palatal defect. Technical considerations and advantages
and disadvantages of the procedure were discussed.
Buchbinder D, St-Hilaire H. Tongue flaps in maxillofacial surgery. Oral Maxillofac Surg Clin
North Am 15:475-486, 2003.
The tongue provides well-vascularized tissue that can be used predictably in maxillofacial reconstruc-
tion. Pertinent surgical anatomy and the different designs and clinical applications of tongue flaps are
presented. The authors presented clinical cases.
Elyassi AR, Helling ER, Closmann JJ. Closure of difficult palatal fistulas using a “parachuting
and anchoring” technique with the tongue flap. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 112:711-714, 2011.
The tongue flap has been described in reconstructing palatal defects. Nevertheless, properly securing
the flap to the palatal defect has continued to pose a challenge, especially because the flap becomes
mobile with normal activities (speech and swallow). For this reason, alternative fixation schemes have
been discussed in the literature but do not always solve the problem. The authors proposed an alter-
native method for positioning and securing the tongue flap into the palatal defect. They stated that
the advantages of this technique include an increase in flap security and immobility and a decrease in
postoperative maxillomandibular fixation requirement. Although unanswered questions still remain
regarding improved flap retention with this method, the “parachuting and anchoring” technique provides
an alternative method that can most definitely add to the surgeon’s armamentarium.
Guerrerosantos J, Trabanino C. Lower lip reconstruction with tongue flap in paramedian
bilateral congenital sinuses. Plast Reconstr Surg 109:236-239, 2002.
The authors presented a case report of a 31-year-old woman with bilateral congenital sinuses in her
lower lip. A flap from the tip of the tongue was elevated, including mucosa and muscle. The ventral
part of the tongue flap was used to reconstruct the vermilion border of the lip and the dorsal portion
was used for lining the lower area of the lip. After 3 weeks, the flap was divided. The postoperative
period was uneventful in both stages, and the patient demonstrated a satisfactory aesthetic and func-
tional result 4 years postoperatively.
Minovi A, Ural A, Kollert M, et al. Lower lip reconstruction with the tongue flap: surgical
technique and long-term results. B-ENT 3:73-78, 2007.
The authors described a surgical technique for and long-term results of lower lip reconstruction with the
tongue flap and reviewed five cases in which this technique was used to reconstruct defects of the lower
lip, particularly the lip vermilion. All patients were followed for 2 to 10 years (mean 3.4 years). The
procedure achieved good functional and aesthetic results, with no major complications, in particular no
flap necrosis. One patient complained of paresthesias of the tongue that resolved within 24 months.
Speech was unaffected by use of the tongue flap, although eating and drinking were temporarily im-
paired before flap separation at the second and final stage of surgery. The tongue flap is a simple and
reliable technique for reconstruction of part or all of the lip vermilion. The technique is easy to perform
and provides good aesthetic and functional results.
Murthy J. Salvaging procedure for mutilated cleft palate by simultaneous tongue and pharyngeal
flap surgery. Plast Reconstr Surg 122:29e-30e, 2008.

05h_Tongue_r3b_bs_0368-0387.indd 386 1/30/2012 2:41:32 PM

 Head and Neck  •  5H: Tongue Flap 387

Sándor GK, Carmichael RP, Brkovic BM. Dental implants placed into alveolar clefts recon-
structed with tongue flaps and bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
109:e1-e7, 2010.
The authors described a case series using surgical and prosthodontic modifications of tongue flaps
necessary to adapt them for use in the reconstruction of large cleft deformities that were refractory to
customary measures using dental implants and to presented their outcomes in patients with complex
cleft lip and palate deformities. Five patients were treated with iliac crest bone grafts that were covered
by anteriorly based tongue flaps divided at 3 or 4 weeks after surgery. The patients were followed
clinically and radiographically for 3 to 12 years after placement of their dental implants to monitor
implant survival and success. One of the five patients developed a partial tongue flap detachment,
graft dehiscence, and recurrence of an oronasal fistula, which was successfully treated by shifting the
tongue flap tissue from its new location in the palate. A total of 18 dental implants were placed into
bone-grafted tissue covered by the tongue flaps. There was one implant failure. There were no cases of
periimplantitis or bone loss in the 17 surviving implants. Tongue flaps are rarely used clinical entities
with a very narrow range of indications. Tongue flaps are useful in the preprosthetic reconstruction of
select cases with large residual oronasal fistulas with soft tissue deficits due to scarring from previously
failed surgery. Tongue flaps are extremely stressful procedures for patients to endure. Patient selection
is of the utmost importance.
Yano K, Hosokawa K, Kubo T. Combined tongue flap and V-Y advancement flap for lower
lip defects. Br J Plast Surg 58:258-262, 2005.
A combined tongue flap and V-Y advancement flap were used for reconstruction of the lower lip after
radical excision of squamous cell carcinoma in two cases. This V-Y advancement flap is a useful,
simple technique, and the orbicularis oris muscle and the branch of the mental artery and nerve can
be preserved. The vermilion is reconstructed with a tongue flap, with almost no disturbance in the
patients’ speaking or eating and satisfactory cosmetic results.

05h_Tongue_r3b_bs_0368-0387.indd 387 1/30/2012 2:41:32 PM

 ANATOMIC LANDMARKS
Landmarks Occupies the submental area, bounded superiorly by the man-
dibular line and laterally by the angle of mandible. The width
of the flap depends on the amount of skin excess.
Size Muscle: 6 3 7 cm; skin: 7 3 15 cm.
Function The platysma muscle that is carried with the flap can be positioned
for facial reanimation by maintaining its facial nerve attachment.
Composition Cutaneous, myocutaneous. This is a skin flap that contains a
portion of digastric muscle and a portion of platysma muscle.
Flap Type Type C .
Dominant Pedicle Submental artery.
Nerve Supply Motor: Cervical branch of the facial nerve (platysma muscle).
Sensory: Transverse cervical nerves. These nerves are not rou-
tinely taken with the flap.

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 Section 5I
Head and Neck

Submental Flap

CLINICAL APPLICATIONS
Regional Use
Head and neck
Distant Use
Head and neck
Specialized Use
Facial reanimation

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 ANATOMY OF THE SUBMENTAL FLAP

Facial vein
Marginal mandibular
branch of facial nerve
Facial artery

Submental artery

Marginal mandibular
branch of facial nerve
Cervical branch B Facial artery
of facial nerve under and vein
platysma muscle
Submental
Digastric vein
Submandibular muscle
gland Platysma
Submental
Relevant anatomy of artery
submental flap
Digastric
muscle

Submandibular
gland
Platysma

Closeup of relevant anatomy of

submental flap

Marginal mandibular
Facial vein branch of the
facial nerve
Submental
artery

Submandibular
gland

Facial artery
Digastric muscle

Mylohyoid muscle
Inferior view of submental area

Fig. 5I-1 

Dominant pedicle: Submental artery

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 Head and Neck  •  5I: Submental Flap 391

Anatomy
Landmarks The flap is bounded superiorly by the mandibular line. A minimum of 1 cm of
distance posterior to the mandibular line is recommended to keep the scar hid-
den under the jawline. The flap can extend all the way to the mandibular angle
bilaterally. Beyond this, on the side of its pedicle, more tissue may be taken, but
the scar will be noticeable.
Composition Cutaneous, myocutaneous. This is a skin flap that contains digastric muscle and
platysma muscle. The section of platysma taken can be functional if the facial
nerve is maintained.
Size Muscle: 6 3 7 cm (platysma); skin: 7 3 15 cm with primary closure.
Function When placed properly, the platysma muscle can assist in generalized tone and
some reanimation of the face.

Arterial Anatomy (Type C)

Dominant Pedicle  Submental artery
Regional Source  Facial artery.
Length  5 cm.
Diameter  1.5 mm.
Location  The submental artery branches off the facial artery approximately 5 cm away from the
origin of the facial artery. The origin of the submental artery is 3 to 5 cm anterior to the angle
of the mandible and 7 mm away from the mandibular border. The vessel runs a tortuous course
from the facial artery and continues medially, supplying lymph nodes and the submandibular
gland. In 70% of cases the artery runs under the digastric muscle, which can be included in
the flap. Perforators to the skin can be found on both medial and lateral aspects of the digastric
muscle; their dominance is variable between patients.

Venous Anatomy
The venae comitantes of the facial artery are small in diameter. They communicate with the
posterior facial vein to form the common facial vein, which drains into the internal jugular vein.
The facial vein is 2.5 mm in diameter at its origin. The common facial vein is 3 mm in diameter.
There is also a submental vein that is separate from the submental artery and its venae comitantes,
and this vein runs a straight course superior and superficial to the submandibular gland and drains
into the common facial vein. Because there are valves in the venae comitantes, when a reverse flow
flap is performed, it is necessary to incorporate the submental vein for drainage of the flap; it may
not be sacrificed without reanastomosis in its new location.

Nerve Supply
Motor Platysma muscle is innervated by the cervical branch of the facial nerve.
Sensory Transverse cervical nerves. These nerves are not routinely taken with the flap.

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 392 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Submental Flap

A

Digastric muscle
divided

Submandibular gland
D

B C

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
“reverse” flap is retrograde through the facial system.
Dominant pedicle: Submental artery (D)

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 Head and Neck  •  5I: Submental Flap 393

FLAP HARVEST
Design and Markings
The entire skin paddle of the submental area can be carried on one pedicle, because there
is good flow across the midline. The skin design should be a minimum of 1 cm away from
the mandibular line to make the scar less noticeable. The thickness of the flap can be de-
termined by flexing the neck and performing a pinch test. Widths of up to 8 cm have been
described. In cases in which extra platysma is needed, beyond the skin incisions muscle
can be dissected and carried with the flap. In such cases, if innervation is required, dissec-
tion must proceed laterally to identify the cervical branch of the facial nerve to be spared.

Incision
Marginal mandibular
branch of facial nerve

Submental
artery

Facial artery Submandibular

gland

Fig. 5I-3  A line 1 cm posterior to the jawline is marked with the patient sitting. The width is deter-
mined by the pinch test. The design extends only to the mandibular angles.

Patient Positioning
The flap is performed with the patient in the supine position. The neck should not be
extended excessively, as is commonly performed with neck dissections, because the head
will need to be flexed for closure.

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 394 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

There are three separate approaches to the submental flap: lateral, superior, and inferior. The
lateral approach is most commonly used because it allows easy dissection, and, early on, it
shows perforators on the contralateral side as a foreshadowing of the ultimate perforators
that will carry the flap. Dissection proceeds initially on the contralateral side, where the
flap is elevated just below the platysma, and the platysma is taken with the flap. Once the
midline is crossed, care must be exercised as the digastric muscles are encountered. Digas-
tric muscles are divided on either side of the flap incisions, and dissection proceeds with
identification of the submental artery.

Platysma muscle
Digastric
muscle
Submental
perforating
artery

Lateral approach Digastric muscle

divided

Fig. 5I-4 

The inferior approach focuses on identification of the submental artery at its branch
point from the facial artery. Dissection is deepened through the platysma and down to the
submandibular gland. The gland is then retracted inferiorly, showing branches from the
submental artery that supply it. These branches are divided. Once the submental artery has
been identified, rapid dissection of the rest of the flap can be performed.

Incision

Digastric muscle

Elevation of flap
Inferior approach

Fig. 5I-4 

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 Head and Neck  •  5I: Submental Flap 395

The superior approach gives the best exposure for the submental vessel as it takes off
from the facial artery. This is facilitated by identification of the facial artery with a Dop-
pler probe, then the facial artery and vein are followed inferiorly to the submental takeoff.
This exposure also lends itself to identification of the marginal mandibular branch of the
facial nerve, which should be spared. Once the submental vessel has been identified, the
remainder of the flap dissection can be performed rapidly.

Incision Marginal madibular

branch of facial nerve

Facial artery
Digastric and vein
muscle

Superior approach

Fig. 5I-4 

In all cases, once the flap has been elevated on the submental vessels, the surgeon must
decide whether the length of the pedicle is adequate for the reconstructive need. For intra-
oral and facial uses, the flap is often passed through a tunnel, and the surgeon determines
whether there is enough length to perform the reconstructive procedure. The flap can be
lengthened by dividing the facial artery just proximal to the takeoff of the submental artery.
Flap perfusion is then retrograde through the distal facial artery. In this case, the submental
vein must be maintained, because there is poor reverse flow through the venae comitantes
of the facial system. If division of the vein is required to add length, a reanastomosis at the
site of inset is recommended, either primarily or with a vein graft.

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 396 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANTS
•  Island flap
•  Free flap
•  Perforator flap

Island Flap
Island flaps can be useful for reconstruction in the mid to lower face and for intraoral uses.
The flap is designed to incorporate the perforator of the submental artery near the digastric
muscle. This island of tissue is then attached by a long vascular pedicle that can measure
up to 6 cm, allowing placement of the islanded flap within the mid to lower face or intra-
orally. In males, one must take into account that this area is hair bearing, which could be
problematic for certain reconstructions.

Cut digastric
muscle

Platysma
muscle
Fat
Submental
artery

Cut edge of
digastric muscle

Fig. 5I-5  Design of submental island flap

Free Flap
Submental skin is an excellent color and texture match for reconstructions about the head
and neck area, especially in elderly patients, because there is excess tissue here. The flap
is harvested as described for a pedicle flap. As a free flap, the main vessel of the flap is the
facial artery, since it has a longer pedicle length and a more favorable diameter. The facial
vein also can be taken to provide a longer pedicle and a larger diameter. This scenario is
common when a reconstruction needs to be done on the same side as the cancer resection
or previous neck dissection, during which the submental artery and vein may have been
divided or made unreliable.

Perforator Flap
The submental flap may be harvested without the digastric muscle. Although there is no
functional consequence of taking the muscle, there are times when a thinner flap is preferred,
and the muscle does not add to the flap’s blood supply. There is a fair amount of variation in
the distribution of perforators, which can be either medial or lateral to the digastric muscle,
or both. In a small percentage of patients the submental vessel runs superficial to the digastric
muscle belly; in such cases, the flap will already be thin, because the muscle is not taken.
When bulk is required for the reconstruction, it is recommended that the digastric muscle
be carried with the flap.

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 Head and Neck  •  5I: Submental Flap 397

ARC OF ROTATION
Island flaps can reach the level of the upper cheek and nose. Internally, they can be used for
defects of the trachea or pharynx. The arc of rotation can be improved, as noted earlier,
by creating a reverse flap, which is based on retrograde flow. This adds an additional 1 to
2 cm to the arc of rotation.

A B

Arch of Arch of rotation

rotation
Artery divided here
for extra 1-2 cm
of rotation Incision
Incision

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 “reverse flow” flap.

FLAP TRANSFER
Pedicle Flap
The submental flap as a pedicle flap is transferred through a tunnel to its recipient site for
skin resurfacing; this is through a subcutaneous plane. For intraoral or pharyngeal defects,
this is often through the operative defect. The surgeon must exercise caution to prevent
kinking or tension on the pedicle and damage to the marginal mandibular nerve during
creation of the tunnel.

Free Flap
Once the flap is harvested and removed to its recipient site, microscopic anastomosis can
be performed, and no connecting tunnels are needed.

FLAP INSET
Pedicle Flap
Care must be taken to ensure that the tunnel has excess capacity and does not constrict the
pedicle of the flap in any way. The flap inset should be without tension, and for resurfacing
defects of the face, a standard skin closure should be performed. Intraorally and for mucosal
defects, the skin may be sutured to the mucosa in watertight fashion.

Free Flap
Inset of the flap as a free flap is facilitated by correct sizing of the flap and by some mobi-
lization of the surrounding tissues. The microvascular anastomosis must not be under any
tension, and the pedicle must not be kinked.

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 398 Part II  Regional Flaps: Anatomy and Basic Techniques

DONOR SITE CLOSURE

Pedicle Flap
There will be some fullness where the flap is passed over the mandible. The surgeon should
not attempt recontouring at the initial procedure for fear of devascularizing the flap. This
fullness often settles over time and requires no revision. If it does not settle, revision can
be safely performed 4 to 6 months later. Because closure of the neck should be considered
an aesthetic undertaking, the skills used for a face lift should be employed. With the neck
in a flexed position, it should be possible to perform closure for flaps as wide as 8 cm.
Mobilization of the inferior neck above the platysma is safe and will allow a tension-free
closure. These neck flaps dissected in this subcutaneous plane have a wide base and are well
vascularized. Maintaining the head in a somewhat flexed position postoperatively over the
first week will also ensure uneventful healing. Dog-ears should be expected and defatted
at the initial flap procedure.

CLINICAL APPLICATIONS
The submental flap is a simple yet versatile regional flap that can be used to reconstruct large
defects of the face and especially the cheek. It provides an excellent color and texture match
for facial reconstruction, with minimal donor site morbidity. The thin, pliable quality of
the skin paddle facilitates reconstruction throughout almost the entire ipsilateral face and
oral cavity. In select groups of patients, the submental flap has been used as an alternative to
free tissue transfer for reconstruction after resection of orofacial malignancies. Oral func-
tion can be satisfactorily preserved postoperatively. An additional advantage, particularly
in older patients, is the cosmetic improvement achieved by removing excess submental
subcutaneous tissue and skin redundancy.
The submental flap has been used as a functional flap by maintaining innervation to
the platysma muscle. The cervical branches of the facial nerve are kept with the flap during
elevation. Once the flap is transposed onto the facial defect, the platysma muscle fibers are
rotated to provide an upward pull on the oral commissure to assist with facial animation.
This innervated platysma myocutaneous flap is an effective way to provide static support
and augment facial animation while providing appropriate soft tissue for a moderate-sized,
full-thickness facial defect.

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.

05i_Submental_r4d_bs_0388-0409.indd 398 1/31/2012 1:23:27 PM

 Head and Neck  •  5I: Submental Flap 399

D E

Fig. 5I-7  B and C, A functional submental flap was elevated and transferred through a subcuta-
neous tunnel, with the platysma muscle fibers oriented to facilitate facial expression. D and E, The
postoperative result after radiation therapy. (Case courtesy Julian J. Pribaz, MD.) 

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 400 Part II  Regional Flaps: Anatomy and Basic Techniques

The submental flap can be excellent for reconstruction of buccal defects where resurfac-
ing of the cheek is required. This can often be accomplished as a rotational flap, and no
microsurgery need be performed.

A B

Digastric
muscle divided

Submandibular gland
Submental artery

C D

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 dis-
section 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. (Case supplied by MRZ.)

05i_Submental_r4d_bs_0388-0409.indd 400 1/31/2012 1:23:32 PM

 Head and Neck  •  5I: Submental Flap 401

There are times when the submental flap is available for reconstruction but is too far to
reach as a pedicle. A free flap based on the submental system can be performed to another
recipient site on the face.

C D

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 protec-
tive 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 11⁄2 years
after the initial surgery. (Case supplied by MRZ.)

05i_Submental_r4d_bs_0388-0409.indd 401 1/31/2012 1:23:35 PM

 402 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Careful placement of the skin paddle posterior to the mandibular line and staying within
the angle of the mandible will provide the best postoperative cosmetic result.
• Flaps more than 8 cm in width may be hard to close. In a younger patient who does not
have skin excess, this width may be limited to 5 cm.
• Aggressive and wide undermining of the lower skin flap above the level of the platysma
allows tension-free closure.
• In a patient with an intact facial nerve, early identification of the marginal mandibular
branch of the facial nerve is critical.
• When a flap is passed over the mandible for general resurfacing or for intraoral lining, it
is helpful for the surgeon to have experience with microsurgical techniques. Even when
this flap is performed as a pedicle flap, sometimes a reverse flap is required to gain extra
length to perform the reconstruction, and venous anastomosis is required.
• In select patients the submental flap may be a good alternative to free tissue transfer for
head and neck reconstruction.
• The hair-bearing nature of the flap in men can be useful for mustache reconstruction—
although it can be a disadvantage when using the flap in areas such as the nose, where
hair-bearing tissues are less desirable.
• Because the submental artery supplies cervical lymph nodes, this flap may be used to
treat lymphedema.

Expert Commentary
Michael R. Zenn

Indications
The submental flap is one of the most useful for head and neck reconstruction, although
most surgeons are not aware of this. Its advantages include having tissues that are well
matched in color and texture and its uniform availability in most patients. The submental
flap is a first-line choice for resurfacing of the face. It is also uniquely suited for resurfacing
of buccal mucosal defects by a simple pedicle rotation.

Recommendations
Planning
As with most flaps, careful planning is essential, and if the submental flap is to be used dur-
ing an oncologic procedure, one must coordinate harvesting of the flap with the cancer
resection so that the blood supply to the flap can be spared during oncologic resection. In
cases in which a neck dissection is required because of disease in the neck and the defect
is on the same side, a free flap is recommended, still using the submental tissues, but on a
contralateral pedicle. These can often be replanted back into the stump of the facial vessels
at the recipient site for a facial artery–to–facial artery anastomosis.
Although the flap is described as a perforator flap and can be dissected as such, this is a
triumph of technical expertise over clinical judgment. The perforators that would carry this

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 Head and Neck  •  5I: Submental Flap 403

flap are small, and the amount of muscle that is taken to carry all possible perforators is also
small; it does not necessarily make the flap bulky. As in most cases of tissue transfer, sec-
ondary revisions can be performed if the area needs further recontouring. One must stay
focused on the matter at hand, which is the reconstruction of a defect with the best possible
blood supply.

Technique
Of the three techniques of flap harvest described, I often use a combination of techniques
as I surround the pedicle and exclude unnecessary tissues. I uniformly mobilize the lower
neck to aid in closure and attempt to make the aesthetic improvement in the neck, one of
the bonuses of this procedure for the patient. The remaining scar can be thick and notice-
able, and it is important to perform the preoperative marking with the patient in an upright
position, using the pen to define the area under the mandible where a scar will not be seen.
This is commonly 1 cm back from the mandibular edge. It is unwise to cheat this scar closer
to the edge of the mandible to obtain more flap, because it will leave a more noticeable scar.

Complications: Avoidance and Treatment

The main complication related to the use of the submental flap is ischemia. When we read
descriptions of the old platysma flap, it is evident that its unreliability stems from the fact
that this area is largely supplied by the submental vessel. When attempts were made to carry
the platysma outside the area described for a submental flap, there were often problems with
ischemia. It is commonly accepted today that use of this flap and the platysma within it is
best and is reliably carried by the submental vessels.

Bibliography With Key Annotations

Abouchadi A, Capon-Degardin N, Patenôtre P, et al. The submental flap in facial reconstruc-
tion: advantages and limitations. J Oral Maxillofac Surg 65:863-869, 2007.
Complex defects resulting from surgical excision of facial cancer sometimes require reconstruction
using microvascular free tissue transfer. Tissue transfer from areas distant from the face can resolve
many problems, but often provides a poor cosmetic match with facial skin. The submental flap helps
surmount this problem. Cervical skin has similarities with facial skin, and because this is a regional
flap, it helps eliminate microsurgical risks. The authors reviewed a series of nine cases (eight men
and one woman), reviewed the anatomy and surgical technique, and explained the advantages and
limitations of the submental flap.
Atamaz Pinar Y, Govsa F, Bilge O. The anatomical features and surgical usage of the submental
artery. Surg Radiol Anat 27:201-205, 2005.
Skin characteristics make the submental region an available flap site for facial and intraoral reconstruc-
tions. For this reason, the anatomy of the submental region and the submental artery has gained in
importance. The submental artery branches out from the facial artery at the level of superior edge of
the submandibular gland. The submental artery runs anteromedially below the mandible and super-
ficial to the mylohyoid muscle. It gives off some perforating branches to the overlying platysma and
underlying mylohyoid muscle during its course. The terminal branches continue toward the midline,
crossing the anterior belly of digastric muscle either superficially or deep, and end at the mental region
in general. Some perforating arteries from the terminal branches supply the anterior belly of digastric
muscle. This study described the anatomic features of the submental artery and its branches to help in
the preparation of submental arterial flaps.

05i_Submental_r4d_bs_0388-0409.indd 403 1/31/2012 1:23:36 PM

 404 Part II  Regional Flaps: Anatomy and Basic Techniques

Cartier C, Jouzdani E, Garrel R, et al. [Study of the platysma coli muscle vascularization by the
facial artery. Implication during the elevation of the musculo-cutaneous platysma coli muscle
flap] Rev Laryngol Otol Rhinol (Bord) 130:139-144, 2009.
The authors assessed the vascularity of the platysma muscle by the branches of the facial artery to
determine the best means of harvesting a myocutaneous flap while ensuring maximum vascular se-
curity. Ten platysma muscles were dissected on four fresh specimens and one formaldehyde-preserved
specimen. The dissection was performed after injection of the facial artery in four cases, while four
muscles were dissected without any previous injection. The vascular supply of the platysma muscle
comes essentially from the branches of the submental artery and from branches descending straight from
the facial artery. Other collateral branches contribute to this vascularization, but their importance is
minor. All these arteries reach the muscle, entering its visceral aspect, then proceed to the sternal notch
in a radial axis. The size of the flap has to be defined within a quadrilateral figure, with its base
formed by the mandibular edge and its apex by the inferior limit of the flap. It is essential to preserve
the maximum possible muscular thickness, especially on the medial side of the flap. If the facial artery
needs to be ligated, this has to be done as it enters the submandibular space to protect most of the col-
lateral branches destined to the muscle. The vascularization is then taken back by the ipsilateral and
contralateral facial vascularization in an inverted flow in the remaining segment of the facial artery.
Chen F, Wang L, Liang C, et al. [Clinical study on submental island flaps in repairing pharyngeal
fistula] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 23:322-324, 2009.
The authors explored the application of submental island flaps in repairing pharyngeal fistula after
total laryngectomy. Nine cases of concomitant pharyngeal fistula (including seven cases of laryngeal
carcinoma and two cases of hypopharyngeal neoplasms) were repaired with submental island flaps after
total laryngectomy. All patients were men, age 52 to 71 years (mean 61.8 years). Pharyngeal fistula
occurred 5 to 62 days (mean 14.7 days) after total laryngectomy. The diameter of medial pharyngeal
fistula ranged from 1.9 cm to 4.1 cm. All patients failed to respond to conservative therapy for 25 to
46 days. The size of the submental island flap was from 2.5 by 2.4 cm to 4.6 by 4.0 cm. After the
pharyngeal fistula was repaired with submental flap, the donor site were sutured directly. All nine
flaps survived, and no local necrosis or wound infection occurred. Incisions at the donor site healed by
first intention, and no obvious scars formed. A fistula occurred 10 days postoperatively in one patient
who had undergone preoperative radiation therapy; the fistula was treated symptomatically. Other
patients achieved satisfactory results with a one-stage repair. The gastric tube was removed 14 to 22
days after operation; no patients had a sense of obstruction to swallowing. The patients were followed
for 10 to 38 months (mean 27 months). The appearance of the neck was satisfactory.
Chen HM, Cai ZG, Zhao FY, et al. Reconstruction of a huge oral maxillofacial defect caused
by necrotic fasciitis secondary to leukaemia. J Plast Reconstr Aesthet Surg 61:e1-e5, 2008.
An 8-year-old boy who was diagnosed with acute nonlymphoblastic leukemia (M2) developed
secondary oral maxillofacial necrotic fasciitis. The wound was cleaned with a 3% hypertonic saline
solution, and then covered with iodoform gauze every day for about 3 weeks before and after necrotic
tissue debridement. The local infection was controlled, and plenty of new healthy granular tissue had
grown. When the necrotic tissue was removed, the patient was left with a huge defect, including the
floor of the mouth, submental and submandibular area, and right cheek. Reconstruction of the defect
was very difficult because of the patient’s preexisting leukemia and severe inflammatory local condi-
tion. The authors successfully reconstructed the defect by using the new healthy granular tissue and
a trapezius myocutaneous flap. Over 9 years of follow-up to improve his quality of life, the patient
underwent scar modification surgery and orthodontic treatment, and facial appearance and oral func-
tions were deemed satisfactory.
Chen WL, Yang ZH, Huang ZQ, et al. Facial contour reconstruction after benign tumor abla-
tion using reverse facial-submental artery deepithelialized submental island flaps. J Craniofac
Surg 21:83-86, 2010.
This study assessed the reliability of using the reverse facial-submental artery deepithelialized submental
island flap for reconstructing facial contour deformities. Reverse facial-submental artery deepithelial-

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 Head and Neck  •  5I: Submental Flap 405

ized submental island flaps were used for reconstructing facial contour deformities in five patients after
ablation of benign tumors. The patients (four women and one man) ranged from 29 to 36 years of
age. Recurrent pleomorphic adenoma in the cheek and inferior temple was present in three patients,
and recurrent basal cell adenoma was present in one. Adequate reconstruction was achieved in all
patients, without flap failures or complications. Satisfactory aesthetics and complete functionality were
achieved, and no donor site problems occurred.
Chen WL, Ye JT, Yang ZH, et al. Reverse facial artery-submental artery mandibular osteomus-
cular flap for the reconstruction of maxillary defects following the removal of benign tumors.
Head Neck 31:725-731, 2009.
Functional and aesthetic restoration in maxillary reconstruction remains a challenge. Although many
free flap procedures have become popular in maxillary reconstruction, these microsurgical methods have
certain limitations and risks. This study assessed the reliability of the reverse facial artery-submental
artery mandibular osteomuscular flap for reconstructing maxillary defects. Eight maxillary defects were
repaired following ablation of benign tumors with reverse facial artery-submental artery mandibular
osteomuscular flaps. The defects were classified as class 2a. Primary reconstruction of the maxilla was
carried out using a pedicled mandibular osteomuscular flap. No flap failures occurred. Dental recon-
struction was successful in all patients. Proper aesthetics and complete functionality were achieved, and
there were no donor-site problems. The patients were followed for 12 to 24 months, with an average
of 18.6 months, and there were no recurrences.
Chow TL, Chan TT, Chow TK, et al. Reconstruction with submental flap for aggressive
orofacial cancer. Plast Reconstr Surg 120:431-436, 2007.
The submental flap was described for head and neck reconstruction more than a decade ago. Its appli-
cation is confined mainly to nonmalignant diseases or low-grade malignancies, because the submental
flap resides in the level I lymphatic drainage region of the neck. The authors reported the use of the
submental flap for soft tissue reconstruction in a selected group of patients with aggressive orofacial cancer.
From March of 2003 to September of 2005, 10 patients (9 with intraoral squamous cell carcinoma
and 1 with facial angiosarcoma) underwent submental flap reconstruction after surgical extirpation
of aggressive orofacial malignancies. The indications were severe comorbidity, old age, the presence of
another incurable cancer, and/or the patient’s skepticism about undergoing a free flap operation. Of
the surviving patients, the median follow-up was 21 months (range 2 to 37 months). There were no
cases of total flap failure, but partial necrosis occurred in two cases. Three patients experienced tumor
recurrence, but in only one case this might have been related to use of the submental flap. Postoperative
oral function—swallowing and speech—was well preserved; conventional dentures were fabricated for
four patients. In selected patients with aggressive orofacial cancer, the submental flap is an expedient
alternative to free tissue transfer for reconstruction. Nonetheless, indiscriminate use might compromise
the oncologic outcome, so it cannot be regarded as a standard method of treatment.
Demir Z, Kurtay A, Sahin U, et al. Hair-bearing submental artery island flap for reconstruction
of mustache and beard. Plast Reconstr Surg 112:423-429, 2003.
Loss of the mustache and beard in an adult man caused by severe burn, trauma, or tumor resection
may cause cosmetic and psychological problems for the patient. Reconstruction of the elements of the
face presents difficult and often daunting problems for plastic surgeons. The tissue to be used should
have the same characteristics as the facial area, consisting of thin, pliable, hair-bearing tissue with a
good color match. Very limited donor sites have these characteristics. A hair-bearing submental island
flap was used successfully for mustache and beard reconstruction in 11 men during the past 5 years.
The scar was on the mentum in four patients, right cheek in two, right half of the upper lip in two, left
cheek in one, left half of the upper lip in one, and both sides of the upper lip in one. The submental
island flap is supplied by the submental artery, a branch of the facial artery. The maximum flap size
was 13 by 6 cm; and the minimum size was 6 by 3 cm (average 10 by 4 cm) in this series. Direct
closure was achieved at all donor sites. Patients were followed for 6 months to 5 years. No major
complication was noted, other than one case of temporary palsy of the marginal mandibular branch
of the facial nerve. Color and texture matches were good. Hair growth on the flap was normal, and

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 406 Part II  Regional Flaps: Anatomy and Basic Techniques

characteristics of the hair were the same as the intact side of the face in all patients. The submental
island flap is safe, rapid, and simple to raise and leaves a well-hidden donor-site scar. The authors
stated that the submental artery island flap surpasses the other flaps in reconstruction of the mustache
and beard in male patients.
Genden EM, Buchbinder D, Urken ML. The submental island flap for palatal reconstruction:
a novel technique. J Oral Maxillofac Surg 62:387-390, 2004.
Higgins KM, Backstein R. The submental island flap: a regional and free flap with a myriad
of reconstructive applications. J Otolaryngol 36:88-92, 2007.
Kim JT, Kim SK, Koshima I, et al. An anatomic study and clinical applications of the reversed
submental perforator-based island flap. Plast Reconstr Surg 109:2204-2210, 2002.
The authors presented their experience with the reversed submental perforator-based island flap for
nose reconstruction and their anatomic and clinical studies. There have been several descriptions on
the reversed pattern of the submental flap, but its anatomic background and clinical availability are
still questionable. The submental area was analyzed by anatomic dissection on four fresh cadavers that
were injected with a barium mixture. The anatomic data were accumulated with the authors’ clinical
experience, with eight patients treated with a submental island flap. On the basis of these studies, the
location of reliable perforators was constant at the lateral and/or medial border of the anterior belly of
the digastric muscle, but their locations were not always symmetrical in the submental territory. Unlike
the comitant submental vein, another larger superficial vein has a different course before reaching the
lateral border of the anterior digastric belly, and therefore it must be included in the reversed flap. The
premised anatomic results and the clinical experience prove the reliability of the reversed submental
perforator-based island flap as a versatile option in midface reconstruction, including the nose, once
the dissection has been carefully done, respecting the anatomic points that can be found in this study.
Matsui A, Lee BT, Winer JH, et al. Predictive capability of near-infrared fluorescence angiog-
raphy in submental perforator flap survival. Plast Reconstr Surg 126:1518-1527, 2010.
Perforator flaps have become increasingly popular in reconstructive surgery, because there is less donor
site morbidity than with conventional musculocutaneous flaps. Previously, the authors’ laboratory
described the intraoperative use of near-infrared fluorescence angiography for patient-specific perforator
flap design. This study evaluated the predictive capability of near-infrared fluorescence angiography for
flap survival in submental flap reconstruction. Use of near-infrared fluorescence angiography immedi-
ately after flap creation accurately predicted areas of perfusion at 72 hours, compared with the initial
clinical assessment. Identification of necrosis by histology at 72 hours correlated with near-infrared
findings of insufficient arterial perfusion immediately after flap creation. No statistically significant
differences in perfusion metrics were detected based on location or dominance of the preserved perfora-
tor; however, flaps containing central perforators had a higher percentage perfused area than those
with noncentral perforators.
Matsui A, Lee BT, Winer JH, et al. Submental perforator flap design with a near-infrared
fluorescence imaging system: the relationship among number of perforators, flap perfusion,
and venous drainage. Plast Reconstr Surg 124:1098-1104, 2009.
The submental flap is a reliable alternative to microsurgical reconstruction of facial deformities, providing
an excellent cosmetic match with the contour and color of the face. In this study, the authors evaluated
submental flap design by using near-infrared fluorescence angiography to identify perforator arteries.
The impact of the number of preserved perforator arteries on flap perfusion and venous drainage was
quantified. Indocyanine green was injected intravenously into 18 pigs. Three groups of six animals each
had one, two, or three perforator arteries preserved. The fluorescence-assisted resection and exploration
near-infrared fluorescence imaging system was used for image acquisition. Images were recorded before
and after flap creation, and every hour, for 6 hours. The time to maximum perfusion, the drainage ratio
(an indicator of venous drainage), and the percentage of perfused flap area were analyzed statistically
at each time point. Near-infrared fluorescence angiography can reliably identify submental perforator

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 Head and Neck  •  5I: Submental Flap 407

arteries for flap design and can be used to assess flap perfusion and venous drainage in real time. Flap
metrics at 6 hours were equivalent when either one or multiple perforator arteries were preserved.
Parmar PS, Goldstein DP. The submental island flap in head and neck reconstruction. Curr
Opin Otolaryngol Head Neck Surg 17:263-266, 2009.
This article reviewed the submental island flap, focusing on its relevant surgical anatomy, surgical
technique, and recent applications in head and neck reconstruction. The submental island flap is a
reliable and versatile flap for head and neck reconstruction. Its minimal donor site morbidity, excellent
cosmetic match, pliability, and relative ease of dissection and application has a definite advantage over
distant flaps, making it an excellent addition to the reconstructive armamentarium of the head and
neck surgeon.
Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral re-
construction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 137:82-87, 2011.
The authors reported their study comparing intraoperative, postoperative, and functional results of
submental island pedicled flap (SIPF) with radial forearm free flap (RFFF) reconstruction for tongue
and floor-of-mouth reconstruction. The study included 60 patients, 27 with SIPF reconstruction
and 33 with RFFF reconstruction. Donor site, flap-related, and other surgical complications were
comparable between the groups, as was speech and swallowing function. Reconstruction of oral cav-
ity defects with the SIPF results in shorter operative time and hospitalization without compromising
functional outcomes.
Pistre V, Pelissier P, Martin D, et al. Ten years of experience with the submental flap. Plast
Reconstr Surg 108:1576-1581, 2001.
The authors described their experience with the submental flap over 10 years. They provided a brief
review of the key points and some refinements in the operative technique. The results of 31 patients
with a mean age of 57 years were reviewed. All flaps were pedicled except two. One case of composite
flap with bone was used. The mean size of the flap was 11.8 by 5.5 cm, and the mean postoperative
stay was 11.1 days. Complications encountered were one case of temporary palsy of the marginal
mandibular branch of the facial nerve, one hematoma at the recipient site, and two cases of partial
flap loss. Color and texture match were good. The authors concluded that this flap has great clinical
potential and is a worthwhile addition to the existing surgical armamentarium.
Taghinia AH, Movassaghi K, Wang AX, Pribaz JJ. Reconstruction of the upper aerodigestive
tract with the submental artery flap. Plast Reconstr Surg 123:562-570, 2009.
The authors reported on a retrospective study of 21 patients who underwent upper aerodigestive tract
reconstruction with submental artery flaps. The flap was used primarily to reconstruct defects after
tumor extirpation, severe infections, and burns. In one case, the flap was used to close an esophago-
cutaneous fistula. Nine patients underwent radiation therapy. Three patients had flap prelamination
before transfer. The flaps in all 12 patients who had not undergone irradiation survived. With the
exception of a small fistula in one patient and transient marginal mandibular nerve palsy in another,
none of these patients had any major complications. In contrast, six of the nine patients who had
undergone radiation therapy experienced major complications. These included total flap loss in one,
partial flap losses in two, and scar contractures in another three. The difference in major complication
rates between these two groups was statistically significant (0% versus 67%). In nonirradiated tissues,
the submental artery flap is an excellent choice for reconstruction of moderate-sized defects of the upper
aerodigestive tract because of its reliability and versatility and the ease with which it can be applied.
Tan O, Atik B, Parmaksizoglu D. Soft-tissue augmentation of the middle and lower face using
the deepithelialized submental flap. Plast Reconstr Surg 119:873-879, 2007.
Facial contour augmentation is often encountered by reconstructive surgeons. To date, very different
autologous tissues such as fat, dermofat, dermal fascia, muscle, cartilage, and bone in the manner
of grafts or flaps according to the requirements of the defect have been used for facial augmentation.
Although many free flap procedures have become popular in facial contouring, these microsurgical

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 408 Part II  Regional Flaps: Anatomy and Basic Techniques

methods have some limitations and risks, especially in patients who are not suitable for microsurgery.
Moreover, the patient may wish to be treated with a more conservative procedure. The authors used the
submental flap in deepithelialized fashion successfully for augmentation of the face in three patients;
two had hemifacial microsomia and one had long-standing facial paralysis. Adequate augmentation
was achieved in all cases, with no complications. All donor sites were closed primarily and healed well.
Patient satisfaction was perfect in all cases. A second debulking procedure was performed in the third
case only. The average follow-up was 1 year.
Tang M, Ding M, Almutairi K, Morris SF. Three-dimensional angiography of the submental
artery perforator flap. J Plast Reconstr Aesthet Surg 64:608-613, 2011.
The authors proposed to clarify aspects of the anatomy of the submental flap to improve the utility
of this flap. Ten cadavers were injected with a modified lead oxide–gelatin mixture. Four cadavers
were selected for three-dimensional reconstruction using a spiral CT scanner and specialized volume-
rendering software. Dissection, angiography, and photography of each layer were performed to outline
the course of every perforator in the neck. The area of the vascular territory supplied by each source
vessel was calculated. Surface areas were measured using Scion Image software. The skin and muscles
on the anterior neck and mandible are nourished by several arterial perforators: facial artery, superior
thyroid artery, mental artery, lingual artery and the submental artery. The diameter of the submental
artery was 1.7 6 0.4 mm at its origin from the facial artery. It sends 1.8 6 0.6 perforators to the
skin on its course toward the chin. The average size of the territory supplied was 45 6 10.2 cm2.
Its largest perforating branch arises from behind the medial border of the anterior belly of the digastric
muscle. There were multiple anastomoses between perforators from the submental artery, facial artery
and sublingual artery.
Tassinari J, Orlandino G, Fabrizio T, et al. Submental flap in facial reconstructive surgery:
long-term casuistry revision. Plast Reconstr Surg 126:139e-140e, 2010.
Thornton JF, Reece EM. Submental pedicled perforator flap: V-Y advancement for chin re-
construction. J Oral Maxillofac Surg 66:2633-2637, 2008.
Thornton JF, Reece EM. Submental pedicled perforator flap: V-Y advancement for chin re-
construction. Plast Reconstr Surg 122:468-470, 2008.
Uysal AC, Alagöz MS, Unlü RE, et al. An anatomic study and clinical applications of the
reversed submental perforator-based island flap. Plast Reconstr Surg 112:690-691, 2003.
Varghese BT. Optimal design of a submental artery island flap. J Plast Reconstr Aesthet Surg
64:e183-e184, 2011.
Wang JG, Chen WL, Ye HS, et al. Reverse facial artery-submental artery deepithelialised sub-
mental island flap to reconstruct maxillary defects following cancer ablation. J Craniomaxillofac
Surg 39:499-502, 2011.
The authors presented their study to assess the reliability of the reverse facial artery–submental artery
deepithelialized submental island technique to reconstruct maxillary defects. The study included 13
patients (9 men and 4 women; 43 to 62 years of age) with maxillary defects resulting from cancer
ablation. Ten patients presented with maxillary gingival squamous cell carcinoma; the remaining 3
cases were hard palate squamous cell carcinomas. The maxilla was resected and the remaining defects
were classified as class 2a. Reverse facial artery–submental artery deepithelialized submental island
flaps measuring 8 to 10 cm long and 4 to 5 cm wide were used to reconstruct the defects. Twelve of
the 13 flaps survived. No donor site problems or palsy of the marginal mandibular branch of the facial
nerve occurred. The follow-up period ranged from 8 to 24 months; one patient died as a result of local
tumor recurrence, and two patients developed cervical recurrence.
Yamauchi M, Yotsuyanagi T, Ezoe K, et al. Reverse facial artery flap from the submental region.
J Plast Reconstr Aesthet Surg 63:583-588, 2010.
Of all the local flaps that allow elevation of a sufficiently large flap while also leaving an inconspicuous
donor site scar, the submental island flap is frequently used for the reconstruction of a defect in the lower
two thirds of the face. However, this flap has certain disadvantages: the technique is slightly difficult to

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 Head and Neck  •  5I: Submental Flap 409

perform and it carries a significant risk of injury to the facial nerve. The authors proposed the reverse
facial artery flap, elevated from the submandibular region. Their method creates a flap that includes
only the platysma under the skin island, without either the submental or facial artery. However, above
the superior border of the skin island, the flap includes the facial artery along with subcutaneous soft
tissue. The blood circulation of the skin island is in a random pattern and that of the subcutaneous
pedicle is in an axial pattern. The authors presented four cases treated with this method. There were
no complications cases, and the results were also cosmetically very good. The authors stated that com-
pared with the submental island flap, their method is easier to perform and carries a much lower risk
of damage to the marginal mandibular branch of the facial nerve, because the facial artery crosses over
the facial nerve at only one point. In addition, the method produces a thin flap.
You YH, Chen WL, Wang YP, et al. Reverse facial-submental artery island flap for the re-
construction of maxillary defects after cancer ablation. J Craniofac Surg 20:2217-2220, 2009.
This study assessed the reliability of the reverse facial–submental artery island flap for reconstructing
maxillary defects. Twelve patients (nine men and three women) with cancer underwent surgical resec-
tion and sequential maxillary reconstruction using a reverse facial-submental artery island flap. No
flaps failed. There were no donor site problems. The patients were followed for 16 to 30 months; there
was one local recurrence of tumor. The reverse facial–submental artery island flap is safe, quick, and
simple to elevate. The flap can be used reliably for reconstructing maxillary defects.
Zhang B, Wang JG, Chen WL, et al. Reverse facial-submental artery island flap for reconstruc-
tion of oropharyngeal defects following middle and advanced-stage carcinoma ablation. Br J
Oral Maxillofac Surg 49:194-197, 2011.
To assess the reliability of the reverse facial–submental artery island flap for reconstruction of oro-
pharyngeal defects after resection of intermediate stage and advanced carcinomas, the authors studied
13 patients with stage III and IV squamous cell carcinoma of the oropharynx. All tumors had been
excised, followed by reconstruction of the oropharyngeal defect using a facial-submental artery island
flap. There were no major flap failures, but two minor ones. The marginal mandibular branch of the
facial nerve remained intact and undamaged in all cases. All donor sites healed well, and the scars
were well hidden. The functional results of speech and swallowing after 10 to 28 months’ follow-up
were satisfactory. One patient developed lung metastases. The facial–submental artery island flap is a
simple, reliable flap that can be used for reconstructing oropharyngeal defects after resection of medium
and advanced carcinomas of the oropharynx.

05i_Submental_r4d_bs_0388-0409.indd 409 1/31/2012 1:23:36 PM

 ANATOMIC LANDMARKS
Landmarks Buccal mucosa overlying the course of the facial artery.
Size 2 3 8 cm.
Function Mucosal lining.
Composition Mucosa, myomucosa.
Dominant Pedicle Facial artery, angular branch.
Minor Pedicles Superior labial artery, infraorbital artery.

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 Section 5J
Head and Neck

Facial Artery Myomucosal

(FAMM) Flap

CLINICAL APPLICATIONS
Regional Use
Head and neck
Palate
Alveolus
Nasal lining
Maxillary antrum
Tonsillar fossa
Soft palate
Floor of mouth
Lip
Specialized Use
Nasal reconstruction
Lip reconstruction

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 ANATOMY OF THE Facial Artery Myomucosal (FAMM) Flap

Parotid gland

Buccinator muscle Zygomaticus minor muscle

Parotid duct Zygomaticus major muscle

Superior labial artery

Facial artery Risorius muscle

Orbicularis oris muscle

Marginal mandibular
branch of the facial nerve

Anatomy relevant to FAMM flap showing course of facial artery and relationship
to parotid duct and facial muscles

B C

Zygomaticus
Superior minor muscle
labial artery
Zygomaticus
major muscle
Parotid papilla Buccinator
muscle
Facial artery

Parotid duct

Risorius muscle
Facial artery
Orbicularis Facial artery
oris muscle

Mucosa and muscle Arterial supply

Fig. 5J-1

Dominant pedicle: Facial artery

Minor pedicle: Superior labial artery

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 413

Anatomy
Landmarks Buccal mucosa overlying the course of the facial artery.
Composition Buccal mucosa, submucosa, buccinator muscle. The muscle that is taken with
the flap is not functional.
Size 2 3 8 cm.
Function Mucosal lining.

Arterial Anatomy
Dominant Pedicle  Facial artery, angular branch
Regional Source  External carotid.
Length  4 cm.
Diameter  2.5 mm.
Location  Crosses the inferior border of the mandible within 3 cm of the mandibular angle. Follows
a tortuous course toward the alar base but lies superficial to the buccinator and the levator anguli
oris. It lies deep to the risorius, zygomatic major, and the orbicularis oris muscles and supplies
perforating vessels to the cheek and gives off the superior labial artery. It continues as the angular
artery and ends near the medial canthus, where it communicates with the infraorbital artery.
Minor Pedicle  Superior labial artery
Regional Source  Facial artery.
Length  1 cm.
Diameter  0.3 mm.
Location  Upper lip.
Minor Pedicle  Infraorbital artery
Regional Source  Maxillary artery.
Length  1 cm.
Diameter  0.2 mm.
Location  Midpupillary line of the maxilla.

Venous Anatomy
Accompanying venous plexus with the facial artery and angular artery. Diameter of the facial vein
at its origin is 3 mm.

Nerve Supply
There is no functional muscle and no sensory nerve taken with the flap.

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 414 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings
The facial artery myomucosal (FAMM) flap is an axial flap based on the facial artery as it
courses from the mandible to the medial canthus. The facial artery lies between the buc-
cinator muscle and the overlying muscles of facial expression. Therefore, to harvest buccal
mucosa with the facial artery, a section of the buccinator muscle must be taken. The flap
thus consists of mucosa, submucosa, and buccinator muscle and is 5 to 8 mm thick. The
flap may be used as a superiorly based flap or an inferiorly based flap.

A B

Inferiorly based flap design Superiorly based flap design

Fig. 5J-2 

The superiorly based flap is based on the retrograde flow through the angular artery,
which is a continuation of the facial artery. The inferiorly based flap is based on the facial
artery and its angular artery extension. Some vascularization of the flap probably comes
superiorly from the infraorbital artery and inferiorly from the superior labial artery and its
branches. Which design is selected, inferiorly based or superiorly based, depends on the
intended application. Although both flaps are commonly used for lip reconstruction, the
superiorly based flap can be used for reconstruction of the palate, alveolus, nasal lining,
maxillary antrum, soft palate, and floor of the mouth. The inferior flap may be used for
the floor of the mouth, lower lip, and lower jaw.
Marking of the flap begins with Doppler ultrasound examination to identify the course
of the facial artery. It is helpful to think of the FAMM flap as the mirror image of a naso-
labial flap in its direction and vascularization. The designed flap is then centered over the
facial artery with its orientation oblique, extending from the retromolar trigone to the labial
sulcus near the alar margin. The course of the facial artery is anterior to Stensen’s duct, and
care should be taken to avoid injuring it during the dissection.

Patient Positioning
The patient is placed in the supine position.

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 415

Guide to Flap Dissection

A superiorly based flap dissection begins inferiorly by incising the mucosa, submucosa, and
buccinator on either side of the facial artery. It is critical that the artery be included with
the flap for proper vascularization. At this inferiormost point the facial artery is identified
and ligated. It is useful to maintain some length on this suture to help bowstring the facial
artery and ensure its inclusion with the dissected flap. The remainder of the flap is then
incised, and dissection proceeds superiorly. Care must be taken to maintain the facial artery
within the flap, since the connections between the artery and the mucosa are fairly loose.
Once the flap has been elevated completely, it should appear pink and viable.

A
Facial artery

Superiorly based flap dissection

Fig. 5J-3 

Buccinator muscle

Orbicularis oris muscle

For an inferiorly based flap, the dissection begins superiorly with identification of the
angular artery. Again, mucosa, submucosa, and buccinator division is required to identify
the artery. It is then ligated, and dissection proceeds inferiorly toward the base of the facial
artery, which has been identified by Doppler ultrasound. Inferiorly the facial artery diverges
from the mucosa, and care must be taken to maintain its connection for proper vasculariza-
tion of the flap. The facial vein can be seen lateral to the facial artery at the base of the flap.

Buccinator muscle

Inferiorly based flap dissection

Fig. 5J-3 

Facial artery

Orbicularis oris muscle

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 416 Part II  Regional Flaps: Anatomy and Basic Techniques

Arc of Rotation
Superiorly Based Flap
A superiorly based flap may be used to reconstruct defects of the hard palate, alveolus,
maxillary antrum, upper lip, and even the orbit.

Superiorly based arc of rotation

Fig. 5J-4 

Inferiorly Based Flap

An inferiorly based flap may be used to reconstruct defects of the hard palate, soft palate,
tonsillar fossa, alveolus, floor of the mouth, and lower lip.

Inferiorly based arc of rotation

Fig. 5J-5 

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 417

Flap Transfer
Both Variants
The surgeon must exercise care when transposing the flap to its recipient site so there is no
excessive tension. In addition, the mucosal tissues must not be separated from the underlying
facial artery, which has a loose connection. When reconstructing the palate, the surgeon
must carefully plan transposition of the flap to avoid the dentition. In patients being treated
for wide cleft palates, there is often a gap in the alveolar ridge that can be used to allow a
superiorly based flap access to reconstruct the defect. When dentition is intact, an inferiorly
based flap is more commonly used. In that case, a temporary bite block is necessary, as well
as a secondary division and inset.

Flap Inset
Tension-free closure is essential for the success of a FAMM flap. An interrupted suture is
normally used—nonabsorbable for lip reconstruction, and absorbable for intraoral and nasal
reconstruction.

Donor Site Closure

Direct donor site closure can be done easily, because an area of excess is used for the flap.
At the base of the flap, the closure must be loose and not compromise the vascular pedicle.
Any areas of intraoral dehiscence can be managed conservatively and allowed to heal by
secondary intention.

Clinical Applications
This 12-year-old patient had a complex bilateral cleft lip and palate. A FAMM flap was
planned.

A B C

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. (Case courtesy Julian J. Pribaz, MD.)

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 418 Part II  Regional Flaps: Anatomy and Basic Techniques

This case demonstrates upper vermilion reconstruction. This patient had a forme fruste type
of hemifacial microsomia with a deficiency of the right upper lip vermilion. He had un-
dergone several unsuccessful procedures to attempt to add bulk.

A B

C D

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. (Case courtesy Julian J. Pribaz, MD.)

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 419

With intact dentition, it is not possible to use the FAMM flap as a superiorly based flap,
because the pedicle would have to traverse the dentition, which would result in injury to the
pedicle when the patient bit down. Designing this as an inferiorly based flap and transferring
this flap around the retromolar area is an alternative strategy that can result in a satisfactory
outcome. Even so, the flap tends to be rather thick at its base, and a bite block may require
a two-stage procedure. This case illustrates a way of repairing this defect in a single stage.

A B

C D

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 retro-
molar 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. (Case courtesy Julian J. Pribaz, MD.)

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 420 Part II  Regional Flaps: Anatomy and Basic Techniques

This 64-year-old man had a squamous cell carcinoma of the lower lip. The loss of volume
and vermilion was addressed with an inferiorly based FAMM flap.

B C

D E

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 separa-
tion 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. (Case supplied by MRZ.)

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 421

This 73-year-old man underwent Mohs resection of two squamous cell carcinomas. Aside
from skin of the cheek and commissure, he had lost lower lateral bulk and vermilion. A
V-Y advancement flap was used to address the skin defect, and the lip was reconstructed
with an inferiorly based FAMM flap.

B C

D E F

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. (Case supplied
by MRZ.)

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 422 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The FAMM flap is an excellent choice for replacement of lip mucosa in lip reconstruction.
• One-stage reconstruction can be accomplished for lip reconstruction, which can be advan-
tageous compared with the two stages that are necessary with Abbé flaps and tongue flaps.
• Although the buccinator muscle is harvested with the flap, no facial weakness has been
detected postoperatively.
• Maintaining the proper plane of dissection should avoid injury to the facial nerve, whose
branches lie directly beneath the facial artery during dissection.
• In some cases in which simple resurfacing of the lip is required, a free buccal graft may
be more effective than a FAMM flap, which can add unnecessary bulk to the lip.
• Intraorally, a FAMM flap is preferred to skin flaps; the mucosalized surface better replaces
like with like and avoids such issues as hair growth and desquamation.
• Sometimes FAMM flaps can be bright red and shiny compared with the normal lip and
can benefit from laser treatment to reduce this difference.

Expert Commentary
Julian J. Pribaz

Indications
The FAMM flap is an extremely useful and versatile flap with a wide range of possible
applications within the oral and nasal cavities. As a superiorly based flap, it can be used to
reconstruct small defects of the hard palate, alveolus, and upper lip (both the sulcus and the
vermilion). It can also be used for antral defects of the maxilla and to restore nasal lining.
As an inferiorly based flap, it can be used to reconstruct defects of the soft palate, and, with
modifications, the hard palate, as well as the tonsillar fossa, alveolus, tongue, floor of the
mouth, and lower lip vermilion and sulcus.

Advantages and Limitations

The advantage of the FAMM flap is that it uses local tissue to reconstruct local defects,
thereby permitting a like-with-like restoration. A limitation of this flap is its size. Although
larger flaps can be designed based on the facial artery, secondary donor site problems such
as contractures may arise in the cheek, so the use of flaps that are too wide is precluded.

Anatomic Considerations
The relevant anatomy has been well described in this chapter, but I would like to further
emphasize the importance of ensuring maximal axiality of this flap by including the facial
artery along its entire length. In addition, because there is no large obvious comitant vein
accompanying the artery, but mainly an extensive but tiny venous plexus throughout the
flap, it is important to leave some soft tissue around the base of the flap to ensure adequate
venous drainage. This flap should never be skeletonized on its facial artery alone, because
this will become venous congested and fair poorly.

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 423

Recommendations
Planning
As described in the chapter, it is essential to map out the course of the facial artery. This can
be done both on the outside of the cheek and intraorally, with an awareness that the facial
artery has a tortuous course. It will be noted that the facial artery runs in a course from
the angle of the mandible toward the oral commissure and then up toward the alar base.
It gives off both the inferior and superior labial vessels and has a connection to branches of
the transverse facial artery. It passes anterior to Stensen’s duct. A long flap with a maximum
width of about 1.5 to 2 cm can be designed based either superiorly or inferiorly. Again, the
key is to locate the facial artery, which is just deep to the buccinator muscle.

Technique
The operation commences at the distal end of the flap by cutting through mucosa, submu-
cosa, and buccinator muscle, and then the artery is located. The artery may also be located
near the oral commissure by cutting through the same layers, carefully dissecting out the
facial artery, and following it in a retrograde fashion to the distalmost part of the flap. Once
this is done, the distal parts of the flap can be incised and the flap elevated, taking care to
leave the tenuous attachments between the facial artery and its overlying buccinator and
submucosa or mucosa intact.
The small terminal branches of the facial nerves will be seen, and these can be gently
dissected away, leaving them intact. There is always some degree of postoperative swelling
after this procedure, which makes it difficult initially to assess the facial muscle mobility,
but once the swelling subsides, I have not found any obvious facial nerve weakness.

Postoperative Care
The postoperative course is fairly simple, with regular mouth washes and a soft diet initially,
advancing this over the first week. Complications may arise with the use of larger flaps,
because this may result in some tightness in the cheek after repair, and may require release
of the contracture with Z-plasty once everything is healed. Also, when the flap is used for
palatal reconstruction or for nasal airway reconstruction, the thickness at the base of the flap
may necessitate some revision to divide and inset the flap to restore the natural contours of
the alveolus, or in the case of the nose, to correct any nasal airway obstruction caused by
the bulk at the base of the flap as it transits from the oral cavity into the nasal cavity. Again,
I would like to reemphasize that it is essential to have the facial artery traverse the length
of this long, thin flap to avoid ischemia at the distal tip.

Bibliography With Key Annotations

Ahuja RB. Vermilion reconstruction with labia minora graft. Plast Reconstr Surg 92:1418-
1419, 1993.
Vermilion reconstruction was traditionally performed using buccal mucosa from the lip and cheek or
mucosa from the tongue. In this article, the authors presented a case in which a 20-year-old woman
with a 4.5 by 1.5 cm elliptical vermilion mucosal defect underwent reconstruction with a labia minora
graft. The inner leaf of the labia minora was used, because the tissue closely matches lip color. The
underside of the graft was shaved to remove subcutaneous tissue and sebaceous glands. The graft was
successful, with excellent return of sensation. The author discussed the technique and advantages of
using this tissue.

05j_FAMM_r4b_bs_0410-0430.indd 423 1/31/2012 9:46:59 AM

 424 Part II  Regional Flaps: Anatomy and Basic Techniques

Almast SC. History and evolution of the Indian method of rhinoplasty. Transactions of the
Fourth International Congress of Plastic and Reconstructive Surgery, Rome and Amsterdam,
Excerpta Medica Foundation, 1967.
Ashtiani AK, Emami SA, Rasti M. Closure of complicated palatal fistula with facial artery
musculomucosal flap. Plast Reconstr Surg 116:381-386, 2005.
The authors performed the FAMM flap in 22 patients having wide, scarred, recurrent palatal fistulas.
The patients ranged in age from 2 to 21 years. All patients with cleft palate had undergone previ-
ous surgery. A bilateral FAMM flap was used in one patient. Two flaps had partial necrosis and
one failed completely, probably because of twisting of the whole pedicle. The nasal lining was made
using turndown flaps of the fistula margin. Because of hanging the base of the flap (inferiorly based)
and producing bite block during mastication, the pedicle was divided and the flap inset secondarily
1 month later.
Ayad T, Kolb F, De Monés E, et al. Reconstruction of floor of mouth defects by the facial artery
musculo-mucosal flap following cancer ablation. Head Neck 30:437-445, 2008.
The authors reviewed their experience with 61 FAMM flaps used for floor of mouth reconstruction
after cancer ablation to assess the flap’s reliability, associated complications, and functional results. There
were 15 cases of partial necrosis and no total flap loss. Eight other complications occurred. Ten percent
required revision surgery; 85% resumed a regular diet; 93% had functional and/or understandable
speech, as determined by the surgeon; and 83% had successful dental restoration.
Baj A, Rocchetta D, Beltramini G, et al. FAMM flap reconstruction of the inferior lip vermilion:
surgery during early infancy. J Plast Reconstr Aesthet Surg 61:425-427, 2008.
Reconstructing lips lost as a result of injury or disease is a complex reconstructive challenge. The
FAMM flap, harvested from the lateral cheek, is a composite flap and an excellent option for lip and
vermilion reconstruction. The authors reviewed the literature and presented their experience using this
flap successfully in a 2-year-old girl with medial lower lip vermilion avulsion.
Barron JN, Emmett AJ. Subcutaneous pedicle flaps. Br J Plast Surg 18:51-78, 1965.
Bozola AR, Gasques JA, Carriquiry CE, et al. The buccinator musculomucosal flap: anatomic
study and clinical application. Plast Reconstr Surg 84:250-257, 1989.
The authors studied the facial regions in 14 cadavers and compared their findings with descriptions
published in the anatomic literature. Their results are presented. They also performed the buccinator
muscle mucosal flap in 38 patients—24 to close primary cleft palates that required palate lengthening,
12 to close palatal fistulas, one to treat a mandibular osteitis, and one to repair the palate after tumor
resection. Three small fistulas were reported.
Carstens MH, Stofman GM, Hurwitz DJ, et al. The buccinator myomucosal island pedicle
flap: anatomic study and case report. Plast Reconstr Surg 88:39-50, 1991.
Technical caveats and pitfalls of the buccinator myomucosal island pedicle flap were presented, based on
cadaver studies and clinical cases. A relatively large amount of vascularized mucosa can be introduced
into the oral cavity via this flap.
Carstens MH, Stofman GM, Sotereanos GC, et al. A new approach for repair of oro-antral-
nasal fistulae. The anteriorly based buccinator myomucosal island flap. J Craniomaxillofac
Surg 19:64-70, 1991.
Oral-antral-nasal (OAN) fistula is a common clinical problem. Numerous publications are avail-
able that describe closure of a persistent OAN. Minor to moderate defects can be closed using local
flaps. Larger fistulas present more challenging reconstructions. The authors described a method using
an anteriorly based buccinator myomucosal island pedicle flap for reconstructing the oral cavity. An
extensive literature review, the anatomy of the buccinator, its reconstructive capabilities, and two case
reports were discussed.
Dolderer JH, Hussey AJ, Morrison WA. Extension of the facial artery musculomucosal flap to
reconstruct a defect of the soft palate. J Plast Surg Hand Surg 45:208-211, 2010.
Reconstruction after resection of a large oropharyngeal tumour poses a difficult challenge. The authors
presented a case illustrating an extension of the previously described FAMM flap, whereby a defect

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 425

of the soft palate is replaced with a similar trilaminar structure in the form of irradiated, redundant
lower lip. This allows not only the treatment of the palatal defect, but also management of dribbling
secondary to a marginal mandibular palsy.
Duffy FJ Jr, Rossi RM, Pribaz JJ. Reconstruction of Wegener’s nasal deformity using bilateral
facial artery musculomucosal flaps. Plast Reconstr Surg 101:1330-1333, 1998.
Wegener’s granulomatosis is a progressive disease that leads to saddle-nose deformity. The authors
presented their experience reconstructing this deformity in a 45-year-old man with quiescent Wegener’s
granulomatosis. A costal cartilage graft fashioned as struts and used to provide dorsal and columellar
support. Bilateral FAMM flaps were used to replace nasal lining. Three months postoperatively, a
debulking procedure was performed. Donor sites healed uneventfully, and there was no facial nerve
weakness. The authors discussed flaps previously used for this purpose and the advantages of FAMM
flaps in this setting.
Dupoirieux L, Plane L, Gard C, et al. Anatomical basis and results of the facial artery muscu-
lomucosal flap for oral reconstruction. Br J Oral Maxillofac Surg 37:25-28, 1999.
The FAMM flap was first described in 1992. The long rotational arc of this flap is particularly suit-
able for anterior palatal defects that are otherwise difficult to treat with local flaps. However, after the
first clinical reports, some controversies arose about the reliability of this flap, so the authors conducted
an anatomic study of the vascular pattern with a latex preparation in 10 cadavers. They studied the
variations of the course of the facial artery and focused on the relationship between the facial artery
and vein within the pedicle. They concluded that the flap is more an arterialized flap than an axial-
pattern flap, and have given anatomic landmarks to optimize the survival rate. Their preliminary
clinical results (five good results, one complete failure) are acceptable.
Elliot RA Jr. Use of nasolabial skin flap to cover intraoral defects. Plast Reconstr Surg 58:201-
205, 1976.
Several fresh surgical defects of the maxillary alveolus, palate, and tonsillar area, resulting from the
excision of cancer, were repaired in a single operation by pulling through an inferiorly based nasolabial
flap with a subcutaneous pedicle. Patient rehabilitation was rapid.
Esser JF. Deckung von gaumenderfekten mittels gestielter naso-labial hautlappen. Dtsch Z
Chir 57:280, 1918.
Filiberti AT. Plastic closure of a septal perforation. Ann Chir Otorhinolaryngol 96:1, 1965.
Friedlander AH. Modified lip stripping with reconstruction of a new vermilion border. N Y
State Dent J 42:27-29, 1976.
Frommer J. The human accessory parotid gland: its incidence, nature, and significance. Oral
Surg Oral Med Oral Pathol 43:671-676, 1977.
The author presented observations on 96 dissections of human parotid glands, noting the incidence,
size, location, and histologic features of accessory parotid glands. Twenty-one percent of the dissections
revealed clearly detached accessory glands at variable distances from the main gland. There were no
appreciable histopathologic differences between the accessory gland and the main gland in the same
facial half. Aging changes, such as decreased glandular elements, increased fat, and increased fibrous
connective tissue, were not more extensive in the accessory gland than in the main gland. Because of
the histologic similarity, pathologies of the main gland could also involve the accessory parotid gland.
Failure to remove a distantly separated accessory gland during parotidectomy could be a cause of tu-
mor recurrence. Radiographs and sialograms were examined for the accessory parotid glands and their
ducts. Routine diagnostic radiographs were limited in their usefulness, whereas sialograms provided
visualization of accessory glands for diagnostic purposes.
Georgiade NG, Mladick, RA, Thorne FL. The nasolabial tunnel flap. Plast Reconstr Surg
43:463-466, 1969.
Hatoko M, Kuwahara M, Tanaka A, et al. Use of facial artery musculomucosal flap for closure
of soft tissue defects of the mandibular vestibule. Int J Oral Maxillofac Surg 31:210-211, 2002.
The authors discussed the use of the inferiorly based FAMM flap to repair a defect of the mandibular
vestibule and the advantages and disadvantages of this procedure. The FAMM flap effectively covers

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 426 Part II  Regional Flaps: Anatomy and Basic Techniques

defects of the mandibular vestibule and other regions of the oral cavity, and its softness, toughness,
and minimal shrinkage allow the use of dental prostheses.
Heller JB, Gabbay JS, Trussler A, et al. Repair of large nasal septal perforations using facial
artery musculomucosal (FAMM) flap. Ann Plast Surg 55:456-459, 2005.
The FAMM flap was studied in six patients with large symptomatic nasal septal defects measuring
at least 20 mm in their greatest dimension and related symptoms of nasal crusting, discharge, dryness,
obstruction, epistaxis, pain, or whistling. Causes of septal perforation included blunt trauma, cocaine
abuse, and submucous resection. Ages ranged from 21 to 44 years. Follow-up ranged from 10 to 30
months. Septal perforations ranged in size from 3.1 to 4 cm. At the last follow-up, all patients had
closure of their septal defect. The overall discomfort score was 0 (range 1 to 10) for all patients, and
all had complete resolution of symptoms. This single-stage technique resulted in no visible external
scar and minimal donor site morbidity.
Iwahira Y, Yataka M, Maruyama Y. The sliding door flap for repair of vermilion defects. Ann
Plast Surg 41:300-303, 1998.
Soft tissue defects of the lower lip may be amenable to reconstruction with the sliding door flap raised
on the surface of the vermilion to the oral mucosa. The bilateral inferior labial artery nourishes this
flap. Bilateral flaps allow safe, easy transfer of the vermilion tissue to partial defects of the red lip.
These flaps have been used successfully in patients with lower lip defects. The sliding door flap has
increased mobility by at least 1 cm more than the other style of flap reported by Goldstein. Moreover,
this flap contributes to excellent cosmetic results. The authors presented their technique and clinical
experience using this flap.
Jackson IT. Closure of secondary palatal fistulae with intra-oral tissue and bone grafting. Br J
Plast Surg 25:93-105, 1972.
Joshi A, Rajendraprasad JS, Shetty K. Reconstruction of intraoral defects using facial artery
musculomucosal flap. Br J Plast Surg 58:1061-1066, 2005.
The FAMM flap is technically a combination of the nasolabial flap and buccal mucosal flap. It has
been a reliable, versatile flap, either superiorly or inferiorly based, for reconstructing a wide variety of
intraoral mucosal defects resulting after cancer excision, including defects of the palate, alveolus, lips
and floor of mouth. The authors performed 17 flaps in 16 patients. There were no failures, and one
flap had terminal necrosis. Most flaps developed venous congestion that resolved with conservative
management.
Kawamoto HK Jr. Correction of major defects of the vermilion with a cross-lip vermilion flap.
Plast Reconstr Surg 64:315-318, 1979.
The author described a method to correct major vermilion defects using a transverse, cross lip vermilion
flap. With this technique, large defects were easily filled to improve upper lip contour and reduce
unpleasant lower lip fullness.
Kazanjian VH, Roopenian A. Median forehead flaps in the repair of defects of the nose and
surrounding areas. Trans Am Acad Ophthalmol Otolaryngol 60:557-566, 1956.
Kolhe PS, Leonard AG. Reconstruction of the vermilion after “lip-shave.” Br J Plast Surg
41:68-73, 1988.
The authors reconstructed 12 lip-shave defects (three were extended) using orbicularis oris myomucosal
flaps. They described planning a V-Y plasty for myomucosal advancement and presented some results.
Lahiri A, Richard B. Superiorly based facial artery musculomucosal flap for large anterior palatal
fistulae in clefts. Cleft Palate Craniofac J 44:523-527, 2007.
An anterior hard palate fistula for which more than one attempt at repair using local tissue has failed
is a difficult complication in cleft surgery. Before alveolar bone grafting, cleft patients have an open
anterior maxillary arch that allows passage of a pedicled flap from cheek to hard palate. The superiorly
based FAMM flap passed through the clefted alveolus is one of the newer techniques to solve this
difficult problem. The authors assessed the validity of using a FAMM flap with an anterosuperiorly
based pedicle with retrograde blood flow to correct a large anterior hard palate fistula when a lack of
adequate local soft tissue precludes a local flap closure, and the patient otherwise would need a tongue

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 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 427

flap. They performed 16 FAMM flaps in 14 children. Twelve were successful, two had partial flap
loss following venous congestion, and two had complete flap failure. One small wound dehiscence
occurred, resulting in a small posterior fistula. The authors concluded that this flap obviates the need
for a staged tongue flap repair for patients with an open maxillary arch.
Lejour M. One-stage reconstruction of nasal skin defect with local flaps. Chir Plast 1:254, 1972.
Lew D, Clark R, Jimenez F, et al. The bipedicled lip flap for reconstruction of the vermilion
border in the patient with a severe perioral burn. Oral Surg Oral Med Oral Pathol 63:526-529,
1987.
For patients with a severely burned lip, both reconstitution of the tissue bulk and an increase in size
of the vermilion may be required. The authors performed a bipedicled lip flap in two patients to trans-
pose both bulk and vermilion from the relatively normal donor lip to the atrophic burned lip. They
discussed their results.
Lexer E. Wangenplastik. Dtsch Z Chir 100:1909, 1909.
Maeda K, Ojimi H, Utsugi R, et al. A T-shaped musculomucosal buccal flap method for cleft
palate surgery. Plast Reconstr Surg 79:888-896, 1987.
In addition to closing the cleft palate, cleft palate surgery is performed to push back the palate by repo-
sitioning the levator muscle to ensure normal speech. This pushback operation is an effective method
for velopharyngeal closure; however, postoperative fistula can occur, especially when the cleft palate is
wide. Postoperative maxillary deformity can also result, possibly because elevating the mucoperiosteal
palatal flap is extremely troublesome. To push back the nasal mucosa, the authors applied the Kaplan
buccal flap method, which is also applicable for reestablishing the levator muscle sling. The other buc-
cal flap was covered on the hinged flap of the pared cleft margins. This resulted in far less maxillary
growth disturbance. The authors called it the T-shaped buccal flap method and applied it in more
than 30 patients with various cleft palates. Their results were satisfactory.
Matros E, Swanson EW, Pribaz JJ. A modification of the facial artery musculomucosal flap for
palatal reconstruction in patients with intact dentition. Plast Reconstr Surg 125:645-647, 2010.
The advantages of the FAMM flap for reconstruction of midface defects have been well appreciated
since 1992, when the flap was first described. In this article, the authors presented their results using
this flap to reconstruct a large palatal defect in a 61-year-old woman. She had undergone excision of
a recurrent histiocytoma. A modified inferiorly based FAMM flap supplied by the left facial artery
was utilized. A medially based mucoperiosteal flap provided nasal lining. No revisions were required.
The authors discussed their technique and reasons for choosing it.
Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin Plast Surg 11:583-617, 1984.
The authors performed an extensive review of literature pertaining to the repair of upper and lower lip
defects. They found that the many procedures used today had already been developed by the middle
of the nineteenth century. There is little that can be defined as original after that time. Most of the
so-called new methods for labial reconstruction are modifications of old ideas. The authors emphasized
that only a few concepts should be regarded as decisive to achieve a good final result. The use of lip
tissue to repair lip defects should be one of the aims of modern cheiloplasty. Following this principle,
it is possible to reestablish interrupted sphincteric functions of the orbicularis oris and, simultaneously,
most of the expression of emotions. When insufficient material is available for reconstruction, full-
thickness local cheek flaps can be considered the alternative solution.
McDowell F. Ancient ear lobe and rhinoplastic operation in India. (From the Sushruta Samhita
c 600 BC. Translated from the Sanskrit and published by KKL Bhishagratna, Calcutta, 1907).
Plast Reconstr Surg 43:515, 1969.
Niranjan NS. An anatomical study of the facial artery. Ann Plast Surg 21:14-22, 1988.
The authors dissected 50 facial arteries in 25 adult, preserved cadavers and presented anatomic varia-
tions. The facial artery was symmetrical in 17 dissections. It terminated as an angular facial artery in
34 cases, as a lateral nasal vessel in 13, as a superior labial vessel in 2, and in 1, the artery terminated
at the alar base. Five facial arteries had a longer course. They discussed the use of a nasolabial flap (skin,
full-thickness, and oral mucosa) raised as an island flap based on the facial artery or one its branches.

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 428 Part II  Regional Flaps: Anatomy and Basic Techniques

Ono I, Gunji H, Tateshita T, et al. Reconstruction of defects of the entire vermilion with a
buccal musculomucosal flap following resection of malignant tumors of the lower lip. Plast
Reconstr Surg 100:422-430, 1997.
The authors reconstructed a defect of nearly the entire lower vermilion using a buccal myomucosal
flap following resection of a malignant tumor of the lower lip. Results were satisfactory. The flap was
semispindle shaped and pedicled at the angle of the mouth. A flap as large as 1.5 by 5 cm could be
raised while ensuring that fibers of the buccinator muscle extended over its entire length. Reconstruction
with this technique is a two-stage operation, and a secondary, minor touch-up operation is performed
on the angle of the mouth at the same time the dog-ear of the pedicle is repaired. Postoperative drooling
is minimized with this flap, and food can be taken orally soon after this operation. Hemodynamics
are maintained, because the flap contains fibers of the buccinator muscle. Aesthetically, the vermilion
is given a natural eminence and its sensation returns early postoperatively.
Park C, Lineaweaver WC, Buncke HJ. New perioral flaps: anatomic study and clinical applica-
tions. Plast Reconstr Surg 101:268-276, 1994.
The authors studied the vascular anatomy of the perioral region in fresh cadaver dissections. The
anatomy of perioral branches of the facial artery consistently confirmed the existence of a septal branch
and an alar branch to the upper lip, and a vertical labiomental branch to the lower lip. New regional
flaps supplied by these perioral arterial branches were proposed. The mucosal flap from the upper lip
supplied by the deep septal branch or the alar branch of facial artery can be used to restore lower lip
defects. A composite flap from the lower lip supplied by the vertical labiomental branch of the facial
artery can be used safely to restore combined defects of the upper lip and nose or partial defects of the
lower lip.
Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruction with the facial artery
musculomucosal flap. Plast Reconstr Surg 105:864-872, 2000.
A series of 16 FAMM flaps in 13 patients was presented. Seven patients had upper lip reconstruc-
tion, and six had lower lip reconstruction. Superiorly based FAMM flaps were used in eight patients,
and eight inferiorly based flaps were performed in five patients. Three patients had bilateral, inferiorly
based flaps. The FAMM flap is a local flap that can be used for lip and vermilion reconstruction.
Pribaz JJ, Stephens W, Crespo L, et al. A new intraoral flap: facial artery musculomucosal
(FAMM) flap. Plast Reconstr Surg 90:421-429, 1992.
This paper introduced the authors’ FAMM flap, combining the principles of nasolabial and buccal
mucosal flaps. The flap has proved reliable either superiorly based (retrograde flow) or inferiorly based
(antegrade flow). It was used 18 times in 15 patients. One flap failed, and two had partial loss. It was
used successfully to reconstruct a wide variety of difficult oronasal mucosal defects, including defects of
the palate, alveolus, nasal septum, antrum, upper and lower lips, floor of the mouth, and soft palate.
Rayner CR. Oral mucosal flaps in midfacial reconstruction. Br J Plast Surg 37:43-47, 1984.
The author shared his experience using oral mucosal flaps in 18 patients. The viability of the flap
was good if drying was prevented and the blood supply enhanced either by muscle inclusion in the
pedicle or by insertion into a vascular bed.
Rayner CR, Arscott GD. A new method of resurfacing the lip. Br J Plast Surg 40:454-458, 1987.
The whole lip can be resurfaced with sensate myomucosal flaps taken from the cheeks. These flaps
can be combined with major resection of the entire lip curtain. Recovery of sensation was particularly
beneficial to elderly patients, who made up the greatest number of patients in the series.
Robotti E, Righi B, Carminati M, et al. Oral commissure reconstruction with orbicularis oris
elastic musculomucosal flaps. J Plast Reconstr Aesthet Surg 63:431-439, 2010.
Restoration of symmetry and full oral competence are goals of surgical reconstruction of the oral com-
missure. The“elastic flap” principle, described by Goldstein, may provide a solution in the wide full-
thickness mobilization of the upper and lower vermilion as two composite myocutaneous flaps—tissue
sandwiches consisting of labial skin, orbicularis oris muscle and oral mucosa—on the axial pattern of
the superior and inferior labial arteries. Based on the contralateral commissure, both flaps are easily
stretched in accordion-like fashion, to reach the predetermined point of the new commissure. The fibers

05j_FAMM_r4b_bs_0410-0430.indd 428 1/31/2012 9:46:59 AM

 Head and Neck  •  5J: Facial Artery Myomucosal (FAMM) Flap 429

of the orbicularis oris muscle at each end of both flaps are imbricated to reconstitute a neomodiolus,
which is anchored to the residual buccinator muscle in primary reconstructions, or to the available
perioral fibrous tissue in secondary procedures. The authors presented a select group of 22 patients
who underwent this procedure for primary or secondary defects involving the oral commissure. The
results were generally satisfactory, both functionally and cosmetically. The advantages of this procedure
were discussed.
Rose EH. One-stage arterialized nasolabial island flap for floor of mouth reconstruction. Ann
Plast Surg 6:71-75, 1981.
A one-stage nasolabial island flap isolated on the facial artery and vein was described for floor of
mouth reconstruction. The donor site was closed primarily, with acceptable aesthetic results. This was
a one-stage procedure. The arterialized flap carried its own blood supply to the irradiated area. In
elderly patients, the donor site provided a large amount of redundant skin that stretched easily across
the midline or to the roof of the palate. Transient upper lip palsy and drooling occurred for several
weeks after surgery.
Rosenthal W. Verschluss traumatsicher Gaumendefekte durch Weichteile des Gesichts. Zentralbl
Chir 43:596, 1916.
Sakai S, Soeda S, Terayama I. Bilateral island vermilion flaps for vermilion border reconstruc-
tion. Ann Plast Surg 20:459-461, 1988.
Large defects of the vermilion border of the lip pose difficult reconstructive problems. Vermilion border
deformity and a reduced buccal cavity can result. The authors used bilateral island vermilion flaps
pedicled by labial arteries to reconstruct the vermilion border of the lower lip (a modification of Ka-
petansky’s double-pendulum flaps). Their technique was a very reliable and versatile alternative to
other local flaps.
Schuchardt K. Plastiche Operatione im Mund-und Kiefer-Bereicht. Berlin: Urban & Schwar-
zenberg, 1959.
Schulten MV. En methodatt erstta en defekt af ena lappen medelst en bryggformad lamba fran
den anra. Fin Lakaresallsk Handl 35:859, 1894.
Sinha RN. The story of plastic surgery. Patna Med J 7:173, 1950.
Spira M, Stal S. V-Y advancement of a subcutaneous pedicle in vermilion lip reconstruction.
Plast Reconstr Surg 72:562-564, 1983.
In three patients with lip cancer, the authors used a one-stage V-Y advancement method for reconstruc-
tion. Without sacrificing the primary principle of adequately removing the cancer, they were able to
excise the lesion and reconstruct the defect by means of a subcutaneous pedicle that might otherwise
have been discarded with the usual wedge resection. With this method, there is a slight tendency for the
healed skin flap to exhibit trapdoor scarring; however, in older patients, in whom this technique has
its greatest applicability, this has not been a permanent problem. The technique was easy to perform
and resulted in minimal morbidity.
Standoli L. Cross lip flap in vermilion reconstruction. Ann Plast Surg 32:214-217, 1994.
The authors devised a surgical technique for reconstructing the vermilion that used a large portion of the
mucosa vestibularis and of the underlying musculus orbicularis. The mucosa and muscle were taken
from one lip and rotated to cover the quantitative and qualitative defect of the opposite prolabium.
This was achieved in two stages.
Strahan RW, Sorosky R, Williams D. Vascular pedicled island flaps. Use in head and neck
reconstructive surgery. Arch Otolaryngol 92:588-595, 1970.
Thiersch C. Vershluss eines Loches im harten Gaumen durch die Weichtheile der Wange.
Arch Heilkunde 9:159, 1868.
Tipton JB. Closure of large septal perforations with a labial-buccal flap. Plast Reconstr Surg
46:514-515, 1970.
Trevaskis AE, Rempel J, Okunski W, et al. Sliding subcutaneous-pedicle flaps to close a circular
defect. Plast Reconstr Surg 46:155-157, 1970.

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 430 Part II  Regional Flaps: Anatomy and Basic Techniques

Upton J, Ferraro N, Healy G, et al. The use of prefabricated fascial flaps for lining of the oral
and nasal cavities. Plast Reconstr Surg 94:573-579, 1994.
Twelve temporoparietal fascial flaps were prefabricated to line the oral and/or nasal cavities in 10
patients. Bilateral flaps were used in one patient suffering from lye ingestion and in one patient un-
dergoing bilateral lip reconstruction. All reconstructions were performed in two stages separated by 3
to 4 weeks. In the first stage, an epithelial lining was created by placing a non–hair-bearing skin graft
over the temporoparietal fascia. In the second stage, the fascial flaps were raised as vascular islands and
transferred as either pedicled or free flaps. All flaps survived and improved function for the patients.
This procedure may be useful in refined reconstructions of moderately sized intraoral and nasal defects.
Van Lierop AC, Fagan JJ. Buccinator myomucosal flap: clinical results and review of anatomy,
surgical technique and applications. J Laryngol Otol 122:181-187, 2008.
The authors retrospectively reviewed all patients who had had buccinator myomucosal flap procedures
at the Groote Schuur Hospital between 1999 and 2004. Patients were also recalled to assess flap
sensation and to record reduction of mouth opening as a consequence of donor site scarring. Of 14
patients, there was one flap failure. Sensation was present in 71% of flaps, and there was no trismus
from donor site scarring.
Winslow CP, Cook TA, Burke A, et al. Total nasal reconstruction: utility of the free radial
forearm fascial flap. Arch Facial Plast Surg 5:159-163, 2003.
Total nasal defects present daunting reconstructive challenges. The nasal skeleton can be successfully
fabricated with bone and cartilage. A forehead flap produces an excellent color match for nasal skin.
The internal lining is the most difficult of the three layers to reconstruct. Local tissue is often unsat-
isfactory in amount and/or vascular supply. The authors presented results from one patient with a
total nasal defect. They used a paramedian forehead flap to resurface the external defect. The nasal
skeleton was reconstructed with split calvarium and conchal cartilage. A fascial flap harvested from
the forearm replaced the intranasal lining. Turbinate grafts were placed to line the flap. Postoperative
breathing was excellent.
Zhao Z, Li S, Yan Y, et al. New buccinator myomucosal island flap: anatomic study and clinical
application. Plast Reconstr Surg 104:55-64, 1999.
The authors studied the vascular anatomy of the buccinator muscle in fresh cadavers. Based on results,
two patterns of buccinator myomucosal island flaps supplied by buccal arterial branches were proposed.
The buccal myomucosal neurovascular island flap (posteriorly based), supplied by the buccal artery,
its posterior buccal branch, and the long buccal nerve, can be passed through a tunnel under the ptery-
gomandibular ligament for closure of mucosal defects in the palate, pharyngeal sites, the alveolus, and
the floor of the mouth. The buccal myomucosal reversed-flow arterial island flap (superiorly based),
supplied by the distal portion of the facial artery through the anterior buccal branches, can be used to
close mucosal defects in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum,
lip, and orbit. The authors used the flaps in 12 patients. There was no flap necrosis, and all had
satisfactory aesthetic and functional results.

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 Chapter 6
Anterior Thorax

The anterior thorax presents a reservoir of tissue available for head and neck recon-
struction, thoracic reconstruction, and breast reconstruction. Before microsurgery,
deltopectoral flaps and pectoralis flaps were the mainstay of reconstruction, and they
remain important today. In thoracic applications, flaps in this area are incredibly helpful
in solving difficult complications of intrathoracic procedures, including mediastinitis,
bronchopleural fistulas, and empyema. Equally important, the anterior thorax presents
the platform on which breast reconstruction is based.

Deltopectoral Flap
Pectoralis Minor Flap
Lateral Intercostal Artery Perforator (LICAP) Flap
Serratus Flap
Pectoralis Major Flap
Supraclavicular Artery Flap

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 ANATOMIC LANDMARKS
Landmarks The flap is located in the upper portion of the anterior chest, from
the sternum onto the deltoid muscle. Specific landmarks are the
sternal edge, infraclavicular line, and deltopectoral groove.
Size 10 3 20 cm 3 10 cm diameter.
Composition Fasciocutaneous.
Dominant Pedicles Perforating branches of the internal mammary system.
Nerve Supply Anterior intercostal nerves.

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 Section 6A
Anterior Thorax

Deltopectoral Flap

CLINICAL APPLICATIONS
Regional Use
Middle and lower thirds
of the face
Neck
Intraoral cavity
Distant Use
Head and neck
Specialized Use
Esophageal reconstruction

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 ANATOMY OF THE DeltoPectoral Flap

A
Thoracoacromial
artery

Perforating
branches
of internal
mammary
artery

Pectoral
branch of
thoracoacromial
artery

Internal mammary perforators to deltopectoral flap

Anterior
intercostal
nerves

Nerve supply

Fig. 6A-1

Dominant pedicles: Perforating branches of internal mammary artery

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 Anterior Thorax  •  6A: Deltopectoral Flap 435

Anatomy
Landmarks The deltopectoral flap is located in the upper portion of the anterior chest, from
the sternum onto the deltoid muscle. Specific landmarks are the sternal edge,
infraclavicular line, and deltopectoral groove.
Composition Fasciocutaneous.
Size 10 3 20 cm.

Arterial Anatomy
Dominant Pedicles  First, second, and third perforating branches of the internal mammary artery
The flap will survive on only one of these vessels. The second or third perforators are usually largest.
Regional Source  Internal mammary artery.
Length  1 to 2 cm.
Diameter  1 to 2 mm.
Location  Within 4 cm of the midsternal line.

Venous Anatomy
Single veins accompany the arterial perforators; the average venous diameter is 1 to 2 mm.

Nerve Supply
Sensory The second through the fourth intercostal nerves provide segmental sensory
innervation.

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 436 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Deltopectoral Flap

B

Anterior view of flap Closeup view of flap base demonstrating

dominant vascular pedicle

D3

Radiographic view

Fig. 6A-2 

A and B: Dominant pedicles: First, second, or third perforating branch of internal mammary
artery (D)
C: Dominant pedicle: Third perforating branch of internal mammary artery (D3)

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 Anterior Thorax  •  6A: Deltopectoral Flap 437

Flap Harvest
Design and Markings
The flap is designed diagonally upward across the upper chest and shoulder. The base lies
over the second, third, and fourth costal cartilages. The upper border follows the infra-
clavicular line to the deltopectoral groove. The lower border runs parallel to the upper
border and usually lies a few centimeters above the undisplaced nipple. The distal extent
of the standard flap is just beyond the deltopectoral groove. However, the flap can be safely
extended to the tip of the shoulder and beyond with a vascular delay, although this must
be accomplished in two surgical stages.

A B

Fig. 6A-3  A, Design for a standard flap. B, A deltopectoral flap is possible with delay (see Fig. 6A-5).

Patient Positioning
The patient is placed in the supine position for both flap harvest and inset. The ipsilateral
arm should be adducted to prevent distortion of anatomic landmarks.

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 438 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

Incisions are made through the skin and subcutaneous tissues down to the underlying
pectoralis or deltoid muscle. The fascia overlying the muscles must be included with the flap. Fas-
ciocutaneous perforating vessels through the pectoralis muscle enter the flap medially on
its deep surface within 4 cm of the midsternal line.

Standard Flap
Flap elevation proceeds from lateral to medial. The distal end is incised through skin and
subcutaneous tissues down to and including the fascia over the deltoid muscle. The dis-
section then proceeds rapidly through a relatively bloodless plane across the deltoid, across
the deltopectoral groove, and onto the pectoralis major. The axially oriented vessels can
sometimes be seen within 6 cm of the midline just above the fascia. The dissection is con-
tinued until the perforators can be seen emerging through the pectoralis major muscle. Any
cutaneous branches of the thoracoacromial vessels that are encountered are ligated below
the clavicle as dissection proceeds proximally.

A B Pectoral branch
Pectoral
of thoracoacromial
fascia
artery

Pectoral
fascia
Pectoral
branch of Internal
thoracoacromial mammary
artery artery
perforators

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
Deltopectoral flaps are often used to provide skin coverage for underlying esophageal re-
construction using free vascularized jejunal flaps. The flap provides a large area of pliable
thin skin through which a tracheal stoma can be passed to provide a stable tracheostomy
site without the risk of soft tissue prolapse into the airway. For staged reconstruction of
the esophagus with a tubed deltopectoral flap, the flap is tubed with the cutaneous surface
inside to provide lining for the neoesophagus. The upper border of the tubed flap is ap-
proximated to the esophagus, and the lower border is kept open as a temporary controlled
salivary fistula. At the second stage (usually 2 to 3 weeks later), the attached base of the
deltopectoral flap is divided, the tubing is completed, and the distal esophageal anastomosis
is completed. Alternatively, the tubed distal end of the flap can be inset into the esophagus as
a complete tubed conduit attached on its cutaneous pedicle for blood supply. A nasogastric
tube is placed through the construct before insetting the flap into the proximal and distal
esophageal ends. Three weeks later, the cutaneous pedicle can be divided.

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 Anterior Thorax  •  6A: Deltopectoral Flap 439

Prefabrication for Tracheal Reconstruction

A multistaged approach has been described in which rib cartilage or other engineered scaffold
with palatal or buccal mucosa can be placed beneath the distal end of the flap at the time of
vascular delay. Once this tissue has achieved an adequate blood supply at 3 to 4 weeks after
surgery, the flap can be raised, and the attached and integrated chondromucosal elements
can be spliced into the airway for tracheal reconstruction, using the remaining skin pedicle
for external soft tissue cover. At a third procedure, the skin bridge can be resected as needed.

Flap Variants
•  Delayed flap
•  Second and/or third intercostal perforator (IMAP) flap, as pedicled or free flap
Delayed Flap
The delayed flap is outlined beyond the deltopectoral groove and onto the anterior border
of the shoulder—almost to the tip. The superior and inferior incisions are made and the flap
is undermined below the fascia. All perforating vessels other than the mammary perforators
must be divided at this stage, including the branches of the thoracoacromial artery. The
distal incision is left intact and allows blood supply to the tip. This will be divided in 7 to
10 days. Superiorly, the incision should be carried proximal enough to identify and ligate
the cutaneous branches of the thoracoacromial vessels. This simple maneuver dramatically
improves the delay effect. A Silastic sheet or a tissue expander may be placed beneath the
area of the delayed flap, or the back of the flap may be skin grafted, with the graft extending
onto the deltoid donor site. The flap may be transferred safely 7 to 10 days after division
of the distal edge.

A B

Scar at 1 week
postoperatively

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.

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 440 Part II  Regional Flaps: Anatomy and Basic Techniques

Internal Mammary Artery Perforator Flap

Although rarely used for microvascular transplantation, the deltopectoral flap can be trans-
ferred on the second and/or third perforating branch from the internal mammary artery as
a perforator flap (IMAP). The vascular pedicle is the IMA. The flap is elevated as described
for the standard flap or the delayed flap, and dissection is continued from lateral to medial
until the perforators are isolated. Next pectoral muscle and a small section of rib(s) are re-
moved to allow harvest of the IMA intact with its perforators. The flap may then be used
as a pedicle flap or be transferred as a free tissue transfer.

Pectoralis
major muscle
Second rib

Internal mammary
artery and vein

Third rib

Fourth rib

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
The deltopectoral flap reaches the neck, lower face, oral cavity, and mediastinum. Flexion
of the neck can improve the reach of the flap.

A B C

Standard flap design Arc to lower face Tubed flap arc to oral cavity

Fig. 6A-7 

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 Anterior Thorax  •  6A: Deltopectoral Flap 441

Delayed Flap
The delayed version of the deltopectoral flap has a longer reach and may be folded for
intraoral reconstruction or for an extended arc of rotation to the midface or deep within
the mediastinum.

A B

Extended area over shoulder Arc to midface

after flap delay

Fig. 6A-8 

Flap Transfer
The flap is transferred to its recipient site by rotation or transposition. For local neck uses,
such as parastomal defects, one-stage transfer is possible. For remote defects such as the
face or neck, or when tunneling is not possible, the flap is often used as an external tubed
pedicle flap and divided in stages at 3 weeks after transfer. The base and midportion of the
flap can be easily tubed to avoid dessication during the delay period and to simplify dress-
ing care. If tubing constricts the flap at all and causes ischemia or congestion, tubing should
be avoided and the open part of the flap should be skin grafted or dressed with a synthetic
dermal substitute. The staged transfer of a deltopectoral flap is rarely performed because of
the wide array of free flaps available for facial reconstruction. For chest wall and mediastinal
defects, the flap can be folded down onto the defect, and, once healed, the dog-ear at the
base of the rotation point can be revised or resected and the flap inset appropriately.

Flap Inset
A tension-free closure is the goal for a rotational or transposed flap. Any dog-ears at the
rotation point should be revised secondarily. The second stage, dividing the tube and in-
setting the flap, is performed after the appropriate delay period. This can be tested with a
tourniquet before division.

Donor Site Closure

The donor site is rather obvious and almost always requires a skin graft for distal closure,
although the proximal portion of the wound may be closed directly. In women, elevation
of the breast can allow primary closure. Tubed pedicles can be returned to their original
site and replace the proximal part of the skin graft.

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 442 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 70-year-old man developed erosion of his esophageal stent into the back of the trachea
below his tracheostomy site. An uncontrolled salivary fistula caused difficulty with breath-
ing. Thoracic surgeons resected the area of erosion and replaced the stent. A deltopectoral
flap that was previously delayed was placed between the esophagus and trachea to reinforce
the repair and close the superior dead space created when he was converted to a mediastinal
tracheostomy site. He went on to heal without requiring revision of the flap.

A B

Fig. 6A-9  A, The thoracic surgeons resected the area of erosion and replaced the stent. B, A de-
layed deltopectoral flap was placed between the esophagus and trachea. (Case supplied by GJ.)

This 65-year-old man with a squamous cell carcinoma of the head and neck had a stomal
recurrence of the tumor that required wide excision of the stoma and resection of previ-
ously irradiated skin, leaving a skin resurfacing requirement. This was an ideal case for a
primary deltopectoral flap.

A B

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.
(Case supplied by MRZ.)

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 Anterior Thorax  •  6A: Deltopectoral Flap 443

This 25-year-old man was shot in the cheek, which resulted in a full-thickness defect of the
cheek and segmental mandibular loss. Initial lifesaving care included ligation of the carotid
artery to prevent exsanguination and suturing of the tongue to the cheek defect to control
the wound. Once the patient was stable, a reconstruction was planned: first, soft tissue re-
construction with a deltopectoral flap, to be followed later with a mandible reconstruction
with a free fibular flap anastomosed to the contralateral neck.

A C
B

D E F

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 postopera-
tively, 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 in-
ternal cheek and floor of the mouth lining and a more aesthetic appearance. (Case supplied by MRZ.)

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 444 Part II  Regional Flaps: Anatomy and Basic Techniques

This 52-year-old woman had squamous cell carcinoma and underwent resection of her
right cheek and mandibular body. The defect was reconstructed with a free osteocutaneous
fibula flap, which failed. A pectoralis muscle flap and skin graft was performed as a salvage
procedure. She subsequently presented with a neck contracture and band. Because the
pectoralis muscle had been raised on the thoracoacromial system and the internal mam-
mary perforators were intentionally left in situ, a deltopectoral flap was still possible and
was transferred to resurface the neck and relieve contracture.

A B

C D

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.

06a_Deltopec_r5_bs_0432-0453.indd 444 1/31/2012 6:14:57 PM

 Anterior Thorax  •  6A: Deltopectoral Flap 445

E F

G H

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. (Case supplied by MRZ.)

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 446 Part II  Regional Flaps: Anatomy and Basic Techniques

This 69-year-old man required a laryngopharyngectomy for squamous cell carcinoma of

the larynx. He underwent a cervical esophageal reconstruction with a free jejunal flap. As is
often the case, the patient had previously had irradiation of his neck, and after the resection
and flap reconstruction, a large skin defect remained. Rather that select another free flap,
a deltopectoral flap was an easy solution for resurfacing at the end of an already long case.

A B

Fig. 6A-13  A, The skin defect is seen after laryngopharyngectomy and free jejunal cervical esopha-
geal 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. (Case supplied by MRZ.)

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 Anterior Thorax  •  6A: Deltopectoral Flap 447

This 58-year-old man had T4 squamous cell carcinoma of the floor of the mouth; this was
resected. Surgery included mandibular resection, and his surgical defect was reconstructed
with a fibula osteocutaneous flap. He had bilateral neck dissections, followed by a course of
radiation. Subsequently he had breakdown of the skin of his neck, which was treated with
skin grafts. This resulted in unstable skin in his neck, characterized by recurrent breakdown.
The plate fixing his fibula intraorally was exposed, so he needed resuspension of his lip.
However, the tightness of the tissues in his neck, in addition to causing this problem, was
preventing its resolution. Clinically, the neck felt stiff and hard. He required resurfacing
but was not a good candidate for free tissue transfer because of the condition of the soft
tissues of his neck and the anticipated difficulty in dissecting recipient vessels for a free flap.

A B

C D

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. (Case courtesy Peter C. Neligan, MD.)

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 448 Part II  Regional Flaps: Anatomy and Basic Techniques

This 62-year-old man had carcinoma of the pharyngoesophagus. His resection included
a partial pharyngectomy as well as a laryngectomy. The posterior half of the pharyngeal
mucosa was preserved, so that he needed reconstruction with an anterior patch to recon-
stitute his esophagus. Surgical margins were clear. A postoperative course of radiation was
planned. The patient had peripheral vascular disease and was not an ideal candidate for free
tissue transfer because of comorbidities: in addition to his peripheral vascular disease, he was
also diabetic, hypertensive, and had a history of previous myocardial infarction.

C D

Fig. 6A-15  A, Design of the IMAP flap. B, Three perforators were harvested with this flap, necessitat-
ing 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. (Case courtesy Peter C. Neligan, MD.)

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 Anterior Thorax  •  6A: Deltopectoral Flap 449

Pearls and Pitfalls

• When transposing the flap to the head and neck, skeletonization of the perforating ves-
sels should be avoided.
• A preliminary delay is necessary for flaps extending beyond the deltopectoral groove.
Delay should be accompanied by division of the cutaneous branches of the thoracoacro-
mial vessels as well as elevation of the distal end of the flap.
• The donor site in women distorts the ipsilateral breast, but primary closure is possible
in select cases.
• As a free flap, the sacrifice of ribs and the IMA is necessary but is well tolerated by patients.
• The supraclavicular flap has largely supplanted the deltopectoral flap as a regional flap for
head and neck defects, because it has a more favorable point of rotation, is easier to close
primarily, and largely captures the area over the deltoid (see Section 6F).

Expert Commentary
Peter C. Neligan

The deltopectoral was a workhorse flap in head and neck reconstruction in the 1960s and
1970s, before flaps such as the pectoralis major and others were described. The deltopectoral
flap has now largely fallen into disuse as traditionally described because of our better under-
standing of the vascular anatomy of the region and of this flap. In his original description,
Bakamjian1 described the blood supply of this flap as coming from the first four perforating
vessels from the internal mammary artery. At that time, the term perforator was not used,
and of course, the concept of perforator flaps as we know them today was not yet conceived.

Advantages and Limitations

The main advantage of this flap is its proximity to the neck and the fact that the skin of
the upper thorax is usually relatively thin and pliable. Another advantage is that it can be
raised very quickly.
However, there are many disadvantages. The first is that the flap needs to be delayed if
the skin overlying the deltoid is required, and in almost all situations, it is needed to reach
the lower face. This significantly limits its usefulness. The donor site is also a major prob-
lem, because it invariably needs to be grafted, leaving a very unsightly scar in the upper
thorax and shoulder. Furthermore, revisionary surgery is often required, particularly if the
flap has been tubed. But even if it has not been tubed, there is often a dog-ear at the pivot
point that requires revision secondarily. However, although the original design of the flap
precluded correction of the dog-ear at the time of rotation, with improved understanding
of the vascular anatomy, we know that this is not necessarily the case.

Anatomic Considerations
As I have already indicated, we now know more about the anatomy of the internal mam-
mary artery and its perforators than Bakamjian did when he first described the flap. We
also know that it is perfectly safe to skeletonize perforators, and we know more about the
relative contributions of the first four internal mammary perforators to the perfusion
Continued

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 450 Part II  Regional Flaps: Anatomy and Basic Techniques

of the skin of the anterior chest. So, for example, we now know that in most cases, the
second internal mammary perforator (IMAP) is dominant.2 Furthermore, the length of
the pedicle can be significantly increased by removing costal cartilage and mobilizing the
internal mammary vessels. This yields a pedicle length of up to 8 or 9 cm,3 which is more
than enough to reach the neck, greatly increasing the arc of rotation. We also know that
in general, one perforator can perfuse its own territory as well as the adjacent one. What
that means is that we can usually harvest the amount of tissue we need based on just one
perforator. Also, there is more flexibility in the axiality of the flap than Bakamjian realized.
This allows us to design the flap in different ways—vertically, obliquely, or horizontally.

Personal Experience and Insights

I haven’t done a deltopectoral flap since the 1980s, because I have found the pectoralis
major flap to be more useful, and using it avoids the necessity for skin grafting the donor
site. More recently, I have converted to the IMAP flap, since this avoids the necessity of
harvesting the pectoralis muscle while still allowing me to close the donor defect directly.

Recommendations
Planning
The only time I plan a deltopectoral flap is when I am harvesting a pedicled pectoralis
major flap for head and neck reconstruction. In that case, I like to preserve the traditional
deltopectoral territory in case something happens and I might need it. If I did need it, I
would harvest it as an IMAP flap.

Fig. 6A-16  In this patient, in whom a pectoralis

major flap is being elevated, the deltopectoral skin
territory is preserved.

Technique
I mentioned that harvest of the traditional deltopectoral flap is quick. The pedicle is medial,
so most of the dissection can be done suprafascially with cautery. In fact, in the traditional
deltopectoral flap, one doesn’t necessarily even need to see the pedicles. If I am harvesting
an IMAP flap, this is also quick. The dissection can be done up to the pedicle with cautery,
and once the pedicle is identified, it can be dissected with scissors in the standard manner
of perforator dissection. If extra length is required, the internal mammary artery is exposed
and mobilized.
Preoperative CT angiography can identify the dominant pedicle, or this decision can be
made with the use of indocyanine green angiography. If neither of these options is available,
an exploratory incision can be made medial to the perforators, allowing direct visualiza-
tion to determine which is the biggest perforator. Alternatively, the flap can be mobilized
on multiple perforators; this requires that the costal cartilage between these perforators be
removed so that the internal mammary can be mobilized.

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 Anterior Thorax  •  6A: Deltopectoral Flap 451

Complications: Avoidance and Treatment

If the flap is being used as a traditional deltopectoral flap, it is important to decide whether
the dimensions of the flap demand delay. If the flap extends beyond the deltopectoral groove,
delay will be necessary. It is also important to avoid tension.
In the chapter it is mentioned that flexion of the neck may help with tension-free clo-
sure. This is a maneuver that makes acceptance of the flap very difficult for the patient and
increases the risk of tip necrosis of the flap.

Take-Away Messages
The principal take-away message is that this flap is, by and large, obsolete. There are many
better flaps available. If this skin territory is to be used as a flap, it is much better used as an
IMAP flap.

References
1. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary
pectoral flap. Plast Reconstr Surg 36:173-184, 1965.
2. Schellekens PP, Paes EC, Hage JJ, et al. Anatomy of the vascular pedicle of the internal
mammary artery perforator (IMAP) flap as applied for head and neck reconstruction. J Plast
Reconstr Aesthet Surg 64:53-57, 2011.
3. Vesely MJ, Murray DJ, Novak CB, et al. The internal mammary artery perforator flap: an
anatomical study and a case report. Ann Plast Surg 58:156-161, 2007.

Bibliography With Key Annotations

Clinical Series
Bakamjian VY. A two-stage method of pharyngoesophageal reconstruction with a primary
pectoral skin flap. Plast Reconstr Surg 36:173, 1965.
This is the original description of the deltopectoral flap. The flap was used as a tube for reconstruc-
tion of the cervical esophagus in a two-stage procedure. The results were successful in 9 of 10 cases.
Bakamjian VY, Holbrook LA. Prefabrication techniques in cervical pharyngo-oesophageal
reconstruction. Br J Plast Surg 26:214, 1973.
Four cases were presented to illustrate the evolution of the deltopectoral flap in Dr. Bakamjian’s unit.
The delay procedure and prefabrication of the tube for esophageal reconstruction were demonstrated.
Bakamjian VY, Long M, Rigg B. Versatility of the deltopectoral flap in reconstructive surgery
of the head and neck. Br J Plast Surg 24:174, 1971.
Further refinements and extensions of the application of this flap for reconstruction in the head and
neck were described.
Bey E, Hautier A, Pradier JP, Duhamel P. Is the deltopectoral flap born again? Role in postburn
head and neck reconstruction. Burns 35:123, 2009.
The authors highlighted the resurgent importance of this flap for postburn head and neck reconstruc-
tion. They reported on five cases of head and neck reconstruction using the deltopectoral flap: one
perioral reconstruction after ballistic trauma, one nasal reconstruction after burn, and three cases of
neck reconstruction after burn contractures. Technical simplicity and reliability are the main features
of this flap. They emphasized the thin, pliable skin quality and the ability to extend the surface of
the skin paddle with a flap delay. Previous tissue expansion can minimize donor site morbidity. The
flap division necessitates a second surgical procedure.

06a_Deltopec_r5_bs_0432-0453.indd 451 1/31/2012 6:15:07 PM

 452 Part II  Regional Flaps: Anatomy and Basic Techniques

Feng GM, Cigna E, Lai HK, et al. Deltopectoral flap revisited: role of the extended flap in
reconstruction of the head and neck. Scand J Plast Reconstr Surg Hand Surg 40:275, 2006.
This paper revisited the utility of the deltopectoral flap in a 34-case series of head and neck reconstruction
performed between 1987 and 2004. Twenty-nine had had one or more failed attempts at microsurgi-
cal reconstruction after excision of cancer. Five were treated primarily. The flap was divided at least 3
weeks after the primary operation. All 34 flaps survived, and there were no donor site complications.
Twenty-seven patients had an uncomplicated outcome, but the remaining seven required later closure
or skin grafting, usually with a local anesthetic, for complications. They commented on the value of
this flap as a backup procedure for microsurgeons treating large head and neck defects.
Guerrissi JO. Lateral deltopectoral flap: a new and extended flap. J Craniofac Surg 20:885, 2009.
Tissues of the pectoral area such as skin and pectoralis major muscle are used in safe and extended
flaps for cervical and neck reconstructions. As blood supply is derived from medial vessels (internal
mammary artery) or lateral (thoracodorsal and lateral thoracic arteries), two different flaps can be con-
structed: medial and lateral deltopectoral. The medial deltopectoral flap was developed by Bakamjian
as an axial-pattern skin flap, and its blood supply depends on perforating branches from the internal
mammary artery. When either parasternal skin or pectoralis major muscle must be resected, this flap
obviously cannot be used. In this article, the author described a new lateral deltopectoral flap based on
lateral pedicles (from the axilla and lateral thoracic area). The successful use of this lateral deltopectoral
flap in an extended cervical and thoracic reconstruction after resection of a giant basal cell carcinoma
demonstrates that it must be considered as an alternative technique.
McCarthy CM, Kraus DH, Cordeiro PG. Tracheostomal and cervical esophageal reconstruc-
tion with combined deltopectoral flap and microvascular free jejunal transfer after central neck
exenteration. Plast Reconstr Surg115:1304; discussion 1311, 2005.
Combined defects of the skin, larynx, pharynx, and esophagus after central compartment exenteration
of the neck can be extremely difficult to reconstruct. The authors evaluated the reconstruction of the
central compartment using a combination of free jejunal transfer for pharyngoesophageal reconstruction,
together with regional deltopectoral flaps for tracheostomal reconstruction and cutaneous resurfacing.
Myocutaneous flaps such as the pectoralis major and latissimus dorsi have been used previously for
external coverage but can be bulky, causing obstruction of the tracheostoma. Seven patients were re-
constructed with seven jejunal and nine deltopectoral flaps. Five patients required resection for massive
pharyngocutaneous fistulas. Mean age was 68.7 years and mean follow-up was 1.9 years. Overall
free jejunal and deltopectoral flap survival was 100%, with no partial loss. All patients maintained an
adequate airway with stomal patency. The authors concluded that complicated defects can be effectively
repaired with free jejunal transfers to restore continuity of the alimentary tract and deltopectoral flaps
to reconstruct the tracheostoma and surrounding cutaneous defects. They emphasized the large volume
of well-vascularized, thin, pliable tissue which allows suturing of the tracheal remnants to skin edges
without tension, avoiding intraluminal prolapse of excess soft tissues.
Mendelson BC, Woods JE, Masson JK. Experience with the deltopectoral flap. Plast Reconstr
Surg 59:360, 1977.
The authors presented an extensive review of 63 deltopectoral flaps. Six flaps were used for hand
coverage and the remainder for head and neck reconstruction, including skin cover; lining of the oral
cavity, pharyngeal wall, or tubed for esophageal reconstruction; and full-thickness defects of the oral
cavity and pharyngeal wall. Forty percent of the patients had complications: 9.5% had major com-
plications and the remainder were described as minor complications. Recommendations to minimize
complications included flap design and technical aspects of flap transfer.

Flap Modifications
Harii K, Ohmori K, Ohmori S. Successful clinical transfer of ten free flaps by microvascular
anastomoses. Plast Reconstr Surg 53:259, 1974.
Microvascular transplantation of the deltopectoral flap was described. This article is of historical inter-
est in that it presented the first successful microvascular transfer of multiple tissues, including the groin
flap, myocutaneous flaps, and scalp transfers.

06a_Deltopec_r5_bs_0432-0453.indd 452 1/31/2012 6:15:07 PM

 Anterior Thorax  •  6A: Deltopectoral Flap 453

Krizek TJ, Robson MC. Split flap in head and neck reconstruction. Am J Surg 126:488, 1973.
The authors presented various modifications of the flap, including a vertical split, a tangential split,
and deepithelialization of portions of the flap for tunneling. The tangential split allows the “carrying”
portion of the flap to be buried permanently beneath the skin of the neck, thus obviating a second
procedure for division of the pedicle following definitive flap inset. The vertically split flap will allow
simultaneous coverage of both lining and external surface defects.
McGregor IA, Jackson IT. The extended role of the deltopectoral flap. Br J Plast Surg 23:173,
1970.
The authors proposed extending the role of the flap in reconstructive surgery of the head and neck, with
the arc of rotation to include the posterior triangular mastoid, ear, parotid, cheek, angle of mouth, and
chin. The use of the flap for coverage of the hand as a tubed pedicle flap was also presented.
Shinohara H, Yuzuriha S, Matsuo K, et al. Tracheal reconstruction with a prefabricated del-
topectoral flap combined with costal cartilage graft and palatal mucosal graft. Ann Plast Surg
53:278, 2004.
The authors presented a new surgical procedure using a deltopectoral flap combined with a costal carti-
lage graft and mucosal graft for tracheal reconstruction. In one case, a tracheostenosis was reconstructed
with a deltopectoral flap combined with a costal cartilage graft. In the other case, a tracheal defect was
reconstructed with a deltopectoral flap combined with a costal cartilage graft and a palatal mucosal
graft. Although the operation is a multistage procedure, the technique provides a satisfactory clinical
solution for a potentially devastating clinical complication.
Tomono T, Hirose T, Matsuo K, et al. A denuded “turn-over” deltopectoral flap combined
with a latissimus dorsi myocutaneous flap in the repair of extensive radionecrosis of the chest
wall. Br J Plast Surg 35:63, 1982.
The skin overlying the territory of the deltopectoral flap is elevated at the dermal level based on the
superior transverse edge of the standard deltopectoral flap. Subsequently, the underlying deltopectoral
flap is elevated as a turnover flap for coverage of contralateral chest wall radionecrotic wounds. Skin-
graft coverage is required for the exposed deep surface of the deltopectoral flap, whereas the preserved
skin flap based on the superior clavicular edge of the deltopectoral flap is returned to the donor site.
The inferior portion of the radiation defect of the chest wall was covered with a latissimus dorsi myo-
cutaneous flap. This technique was successful in three patients with postmastectomy radiation defects
measuring 20 by 20 cm.

Complications
Gingrass RP, Culf NK, Garrett WS, Mladick RA. Complications with the deltopectoral flap.
Plast Reconstr Surg 49:501, 1972.
Three major immediate complications of the flap were discussed: necrosis, infection, and separation.
Seven cases of partial flap necrosis were described, and etiologic factors, including a narrow base, exces-
sive length, and kinking of the pedicle, were identified. Infection occurred in three cases, resulting in
flap loss. One case of flap separation occurred. Recommendations were made for minimizing the risk
of complications with the use of this flap.
Krizek TJ, Robson MC. Potential pitfalls in the use of the deltopectoral flap. Plast Reconstr
Surg 50:326, 1972.
The use of 57 deltopectoral flaps in 53 patients was reviewed. No complications were observed in 37
of the 57 flaps. Of the remaining 20 flaps, 6 had major complications and 14 had minor complica-
tions. Major complications included total flap loss in one patient and sufficient partial loss in five other
patients to require alternate flaps. Etiologic factors were discussed, and recommendations for minimizing
complications were made. The authors concluded that this is a safe and reliable flap.

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 ANATOMIC LANDMARKS
Landmarks A thin, triangular muscle on the anterior chest wall deep to the
pectoralis major.
Size 15 3 8 cm.
Origin Third, fourth, and fifth ribs near the costochondral junction.
Insertion Coracoid process of the scapula.
Function Stabilization of the scapula and protraction of the scapula and
shoulder.
Composition Muscle.
Flap Type Type III.
Dominant Pedicles Branches of the thoracoacromial and lateral thoracic vessels, both
of which are derivatives of the axillary artery.
Minor Pedicle Direct branch of axillary artery to pectoralis minor.
Nerve Supply Motor: The pectoralis minor is innervated by the medial and
lateral pectoral nerves. The lower two digitations of the muscle
are innervated by the medial pectoral nerve, and the uppermost
digitation is innervated by a branch of the lateral pectoral nerve.

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 Section 6B
Anterior Thorax

Pectoralis Minor Flap

CLINICAL APPLICATIONS
Regional Use
Axilla
Shoulder
Breast
Distant Use
Head and neck
Forearm and hand
Lower extremity
Specialized Use
Facial reanimation

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 ANATOMY OF THE Pectoralis Minor Flap

Origin and insertion of pectoralis minor

B C

Lateral
Thoracoacromial pectoral
artery nerve

Pectoral branch Medial

of thoracoacromial pectoral
artery nerve
Lateral Thoracodorsal
thoracic nerve
artery
Lateral
Branch of thoracic
lateral nerve
thoracic
artery

Vascular supply Nerve supply

Fig. 6B-1 

Dominant pedicles: Pectoral branch of thoracoacromial artery; branch of lateral thoracic

artery

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 457

Anatomy
Landmarks A thin, triangular muscle on the anterior chest wall deep to the pectoralis major.
Composition Muscle.
Size 15 3 8 cm.
Origin Third, fourth, and fifth ribs near the costochondral junction.
Insertion The fibers converge on the coracoid process of the scapula.
Function Stabilization of the scapula and protraction of the scapula and shoulder.

Arterial Anatomy (Type III)

Dominant Pedicle  Pectoral branch of thoracoacromial artery
Regional Source  Axillary artery.
Length  8 to 10 cm.
Diameter  2 mm.
Location  The branch from the thoracoacromial vessel passes down on the deep aspect on the
pectoralis major with the lateral pectoral nerve from beneath the middle third of the clavicle to
enter pectoralis minor on its deep surface proximally.
Dominant Pedicle  Lateral thoracic artery
Regional Source  Lateral thoracic artery.
Length  8 to 10 cm.
Diameter  1.5 mm.
Location  The lateral thoracic artery runs down the anterolateral chest wall and enters the pec-
toralis minor at its lateral border, supplying the muscle distally.
Minor Pedicle  Direct branch of the axillary artery to pectoralis minor
Regional Source  Axillary artery.
Length  4 to 5 cm.
Diameter  0.5 to 1 mm.
Location  On the deep surface of the muscle, close to its insertion, located centrally behind the
muscle. This minor pedicle lies halfway between the two dominant pedicles.

Venous Anatomy
Single veins accompanying the arterial circulation; average venous diameter is 1.5 to 3 mm.

Nerve Supply
Motor The pectoralis minor is innervated by the medial and lateral pectoral nerves.
(Medial and lateral refer to cords of the brachial plexus, not anatomic position
within the muscle.) The lower two digitations of the muscle are innervated by
the medial pectoral nerve, and the uppermost digitation is innervated by a branch
of the lateral pectoral nerve.

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 458 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Pectoralis Minor Flap

A B

D1

taa
axa
D1

D2
D2
lta

C D

D1

D1

D2

Elevation of flap after release of origin

Fig. 6B-2 

Dominant pedicles: Pectoral branch of thoracoacromial artery (D1); branch of lateral thoracic
artery (D2)
Minor pedicle: Branch of axillary artery (m)
axa, Branch from axillary artery; lta, lateral thoracic artery; taa, thoracoacromial artery

06b_PectMin_r5_bs_0454-0473.indd 458 2/1/2012 12:47:52 PM

 Anterior Thorax  •  6B: Pectoralis Minor Flap 459

E F D1
D1

D2
D2

Deep surface of flap Radiographic view

Fig. 6B-2 

Dominant pedicles: Pectoral branch of thoracoacromial artery (D1); branch of lateral thoracic
artery (D2)

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 460 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings
The patient is marked in the erect position with the arm at the side. The clavicle and out-
line of pectoralis major are marked emphasizing the position of the inferolateral border of
pectoralis major. The coracoid process is marked and the potential position of pectoralis
minor is drawn within the confines of the pectoralis major outline. The third, fourth, and
fifth ribs are marked anteriorly.

A B
Coracoid process
Clavicular
border

Pectoralis
minor
muscle
borders

Third, fourth,
Pectoralis and fifth ribs
major border Incision site

Markings for incision for flap elevation

Fig. 6B-3 

Patient Positioning
The patient is placed in the supine position for both flap harvest and inset.

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 461

GUIDE TO FLAP DISSECTION

The flap is exposed through an anterolateral chest wall incision, exposing the lateral bor-
der of pectoralis major muscle. The pectoralis major is retracted to expose the underlying
pectoralis minor muscle.

Lateral
thoracic
artery

Pectoralis
major muscle

Serratus
anterior
muscle

Fig. 6B-4 A, Exposure of the pectoralis minor muscle.

The lateral thoracic vessels are also identified along the lateral border of the pectoralis
major muscle lying over the serratus anterior muscle. The lateral thoracic vessels are then
traced under loupe magnification to the undersurface of the pectoralis minor muscle.

Pectoralis
major muscle Pectoral
Pectoral branch of
branch thoracoacromial
of lateral artery
thoracic artery Pectoralis
minor muscle

Lateral
thoracic
artery Serratus
anterior
muscle

Fig. 6B-4 B, Exposure of the lateral thoracic pedicle lying lateral to the pectoralis major on the ser-
ratus and entering the pectoralis minor’s deep surface.

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 462 Part II  Regional Flaps: Anatomy and Basic Techniques

The insertion of the pectoralis minor into the coracoid process is divided and the muscle
retracted downward. This should expose the entire vascular and motor nerve supply of the
pectoralis minor.

C Thoracoacromial
artery

Pectoralis
Pectoral major muscle
branch Pectoral
of lateral branch of
thoracic artery thoracoacromial
Pectoralis
artery
minor muscle

Lateral
thoracic
artery

Fig. 6B-4 C, Division of the pectoralis minor insertion to the coracoid.

The thoracoacromial trunk and its pectoral branch to the pectoralis minor are identified.
If there is a minor pedicle, a direct branch of the axillary artery, it also is identified. The
two or three vessels are then evaluated and a decision is made to base the flap on the largest
vessel. The veins will follow the arteries and are dissected along with the artery. The other
two vessels are then divided. The lateral and medial pectoral nerves are identified, and the
branches to each of the three digitations of the pectoralis major isolated and dissected free.
The nerves are then traced proximally—the lateral pectoral nerve to the lateral cord of the
brachial plexus and the medial pectoral nerve to the medial cord of the brachial plexus. The
origin of the muscle from the third to the fifth ribs is then divided and the flap is prepared
for microvascular transplantation. Pedicle dissection can be carried to the source vessel for
additional length.

D Pectoral branch of
thoracoacromial artery
Lateral pectoral nerve

Medial pectoral nerve

Pectoral branch of
lateral thoracic artery

Pectoralis
minor muscle

Fig. 6B-4 D, Pectoralis minor muscle divided from the origin and insertion, attached to only vessels
and nerves.

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 463

FLAP VARIANTS
•  Free microvascular flap
•  Pedicled flap
Free Microvascular Flap
The pectoralis minor flap has become useful primarily for facial reanimation. Its value lies
in its thin profile and broad belly, allowing it to be split around the oral commissure. The
pedicle is reliable and of a workable diameter and length for facial reanastomosis.

Pedicled Flap
The value of the pedicled flap in breast reconstruction has dwindled now that acellular
dermal matrices have become the material of choice for lower pole implant coverage. The
muscle can be used to augment muscle bulk for intrapleural applications, but these situations
are few and far between. Its arc of rotation onto the anterior shoulder makes it helpful for
the coverage of small shoulder wounds.

ARC OF ROTATION
Because of its short pedicle length, the arc of rotation in a pedicled flap is limited to the an-
terior shoulder and clavicle. The flap has little value in breast or intrathoracic reconstruction.

Arc to anterior thorax

Fig. 6B-5 

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 464 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP TRANSFER
The flap is transferred to its recipient site based on the location of the defect.

FLAP INSET
When performing this flap for facial animation, particular attention has to be paid to ap-
propriate tensioning of the flap to achieve adequate animation. The coracoid insertion of
the muscle is sutured to the zygomatic fascia, and the terminal leaflets from the origin of
the muscle are split around the oral commissure and nasolabial fold and are tensioned appro-
priately to achieve sufficient pull on these structures to create smile. The muscle should be
sutured into the dermis of the nasolabial fold to achieve this goal. Microvascular anastomosis
is performed to the facial artery over the body of the mandible, and nerve anastomosis is
performed to the appropriate recipient motor nerve graft.

DONOR SITE CLOSURE

A simple linear closure of the lateral chest wall skin is done over a muscle placed between
the pectoralis major muscle and the ribs at the site of the pectoralis minor donor site.

CLINICAL APPLICATIONS
This 29-year-old woman presented with facial paralysis 2 years after removal of an acoustic
neuroma. Facial reanimation was planned with a two-stage free functional muscle transfer
of the pectoralis minor.

A B

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. (Case courtesy
Adriaan O. Grobbelaar, MD.)

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 465

This 38-year-old man had developed Bell’s palsy 3 years previously; his recovery was
minimal. Facial reanimation was planned with a two-stage functional muscle transfer of
the pectoralis minor.

A B

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. (Case
courtesy Adriaan O. Grobbelaar, MD.)

This patient had complete congenital facial paralysis. At age 18, she underwent functional
muscle transfer using the pectoralis minor muscle.

A B

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. (Case courtesy Adriaan O. Grobbelaar, MD.)

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 466 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• When this flap is harvested for microvascular transfer, care should be taken to prevent
injury to the axillary-subclavian vessels and the medial cord of the brachial plexus.
• When transplanting the muscle as a free flap for reanimation, the surgeon must pay
particular attention to achieving the correct tension in the face to provide adequate cor-
rection of the smile.

Expert Commentary
Adriaan O. Grobbelaar

Indications
The main indication for use of the pectoralis minor muscle flap is facial reanimation, al-
though it has been used for anterior shoulder reconstruction1 as well as implant coverage
in immediate breast reconstruction.2

Advantages and Limitations

I prefer the pectoralis minor for facial reanimation because of its size; it does not need much
reduction. Its fanlike shape and good tendinous insertion are ideal for facilitating perioral
insertion. The muscle has been primarily employed because its function is relatively un-
important, and its removal causes minimal donor site problems.3 The muscle is approached
through a curved incision in the axilla, and the scar does not seem to cause concern to
patients (Fig. 6B-9).

Fig. 6B-9  The axillary approach.

The main limitation associated with the pectoralis minor flap is its pedicle length. It
has to be used in conjunction with a cross-facial nerve graft and is not suitable for cases in
which a longer pedicle will be required. Contraindications for use of this muscle include
the following:
• Congenital absence of the muscle
• Donor vessel access in the neck because facial vessels are not available (such as when
there has been previous surgery in the face)
• Need for one-stage surgery

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 467

• Bilateral facial paralysis in which a branch of the fifth cranial nerve to the masseteric
muscle will be used as the donor nerve and a long nerve pedicle will be required
• Patient choice
Anatomic Considerations
We documented the anatomy of the pectoralis minor in 97 consecutive cases.4 The dominant
blood supply to the muscle was from a single artery in 77% of cases and took the form of an
artery arising directly from the axillary vessel in 72% of cases. This pattern is supported by
two cadaveric studies of the pectoralis minor arterial tree.5,6 That places the muscle in the
Mathes and Nahai type II category (see Chapter 2), though it was not formally described
in the original article. The venous drainage of the muscle primarily involves a single vessel
draining directly into the axillary vein. The innervating roots are C6 through C8, with
the traditional description of two nerves, the medial and lateral pectoral nerves wrapping
themselves around the axillary artery and innervating the muscle from its dorsal surface.
However, recent descriptions of the nervous anatomy are more complex.7

Personal Experience and Insights

We have used the muscle in more than 528 cases of unilateral facial reanimation. It has
always been used in conjunction with a cross-facial nerve graft in a two-stage procedure.

Recommendations
Planning
The patient is draped in the supine position. A two-team approach can shorten the operat-
ing time to approximately 4 hours if the contralateral side of the trunk is used and the flaps
harvested at the same time as the facial dissection. Free draping of the arm on that side
facilitates access to the flap.

Technique
The lateral edge of the muscle is identified and followed to the coracoid process of the
scapula (Fig. 6B-10). Careful dissection around the tendinous insertion enables division of
the tendon.

Fig. 6B-10  The lateral edge of the pectoralis minor exposed.

Continued

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 468 Part II  Regional Flaps: Anatomy and Basic Techniques

The muscle is then retracted toward the origin with the help of a single 3-0 silk suture
through the tendon (Fig. 6B-11). The vascular pedicle is identified, isolated, and divided.
The axillary incision is closed over a suction drain.

Fig. 6B-11  Retraction of the tendon from the

coracoid process.

The pectoralis minor muscle is split into three slips, and the tendinous insertion is
anchored into the alar base and upper and lower lip (Fig. 6B-12). The upper fibers of the
muscle are arranged well forward on the zygoma to emulate the zygomaticus muscle and
elevate the upper lip.

Fig. 6B-12  Three slips for insertion into the alar

base, upper lip, and lower lip.

The muscle is positioned in the face with the pedicle facing anteriorly for ease of mi-
crosurgical anastomosis (Fig. 6B-13). The facial vessels are used as recipient vessels and are
prepared well up into the face to permit easy transposition.

Fig. 6B-13  Inset with pedicle facing anteriorly

to facilitate easy microsurgical anastomosis.

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 469

Postoperative Care
We use a compression dressing over the operated side of the face. All blood-thinning
medications are avoided.

Complications
Hematomas in the immediate postoperative period should be promptly evacuated, because
they can compress the vascular pedicle and interfere with the blood supply, or they may
be a symptom of venous flow problems, with blood leaking from the cut muscle edges.
Meticulous hemostasis during the entire procedure is a very high priority. The incidence
of hematomas in our series was 5.3%. Debulking of the muscle was required in 9.7% of
cases. If the muscle is to be thinned at a later stage, it can be raised with the skin and the
posterior part of the muscle reduced.

Take-Away Message
The anatomic variation of the pedicle and small vascular structures of the pectoralis minor
flap require an experienced microsurgeon.

References
1. Palmer RS, Miller TA. Anterior shoulder reconstruction with pectoralis minor muscle flap.
Plast Reconstr Surg 81:437-439, 1988.
2. Manstein CH, Manstein G, Somers RG, et al. Use of the pectoralis minor muscle in im-
mediate reconstruction of the breast. Plast Reonstr Surg 76:566-569, 1985.
3. Scevola S, Cowan J, Harrison DH. Does the removal of pectoralis minor impair the func-
tion of pectoralis major? Plast Reonstr Surg 112:1266-1273, 2003.
4. MacQuillan A, Horlock N, Grobbelaar A, et al. Arterial and venous anatomical features of
the pectoralis minor muscle flap pedicle. Plast Reconstr Surg 113:872-876, 2004.
5. Moriya A, Takafuji T, Sato Y. Arterial supply in the human pectoralis minor. Okajimas
Folia Anat Jpn 69:321-333, 1993.
6. Stook F, Zonnevijlle, Groen G. A reappraisal of the blood supply of the pectoralis minor
muscle. Clin Anat 7:1-9, 1994.
7. Aszmann OC, Rab M, Kamolz L, et al. The anatomy of the pectoral nerves and their sig-
nificance in brachial plexus reconstruction. J Hand Surg Am 25:942-947, 2000.

06b_PectMin_r5_bs_0454-0473.indd 469 2/1/2012 12:47:58 PM

 470 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Bourdais L, Bellier-Waast F, Perrot P, et al. Coverage of clavicular area by a pectoralis minor
pedicle flap: anatomical study and description of three clinical cases. Ann Plast Surg 63:409-
413, 2009.
Because there were conflicting data in the literature concerning the vascularization of the pectoralis
minor, the authors conducted an anatomic study on cadavers preliminary to clinical application of a
pedicle flap for clavicular coverage in three patients. Twenty flaps were dissected, yielding numerous
anatomic variations. In all cases, the principal arteries penetrated the muscle in its upper part, either
posteriorly or posterolaterally. This anatomic study justified the use of the pectoralis minor as a pedicle
flap, with turnover just below the coracoid process. Accordingly, the three cases of clavicular defects
were treated successfully. Reports in the literature propose an adipofascial turnover flap or a pectoralis
major flap for clavicular coverage. The pectoralis minor pedicle flap is easy to dissect and reproducible,
involving minor aesthetic sequelae and no functional complications. This flap, which has never been
described in this application, would appear to be suitable for first-line treatment in this indication.
Grützenmacher S, Steinmeier E, Hosemann W. [The use of the platysma myocutaneous flap
for reconstruction in the head-neck area—a retrospective study] Laryngorhinootologie 84:733-
737, 2005.
Following extensive tumor resection in the head-neck area, options for immediate defect reconstruc-
tion are needed to reduce healing time and improve rehabilitation. Reconstruction of significant areas
of mucosal defects is best accomplished by introduction of a pliable regional transplant. The platysma
myocutaneous flap has been used for defect reconstruction in the head and neck for more than 20
years; however, its popularity is limited. The authors reported on 25 patients who underwent surgical
reconstruction with the platysma mucocutaneous flap for tumors of the oropharynx, hypopharynx,
or oral cavity. The platysma flap is easy to harvest and has a generally low risk level. Complications
are usually minor and may be avoided by precise preoperative planning. Necrosis of the skin-muscle
flap occurred only after resection of the external carotid artery in two patients for whom a revision was
necessary (stenting of the pharynx or secondary reconstruction by pectoralis major flap). Resection of
the facial artery (three cases) did not lead to serious complications. Special attention must be given to
the ipsilateral vascular supply and the length of the muscular pedicle. It is a cost-effective procedure,
requiring less operative time.
Harrison DH. The treatment of unilateral and bilateral facial palsy using free muscle transfers.
Clin Plast Surg 29:539-549, vi, 2002.
The author reported a 25-year experience in the treatment of unilateral and bilateral facial palsies.
The advent of cross-facial nerve grafts and revascularized muscle grafts gives a high proportion of facial
reanimation. The choice for the muscle graft is the pectoralis minor. The latissimus dorsi can be used
in unfavorable circumstances or in bilateral facial palsies. Although recovery of movement is high, the
search for refinement and symmetry continues. This article encapsulated the author’s philosophy in
trying to achieve these goals.
MacQuillan A, Horlock N, Grobbelaar A, et al. Arterial and venous anatomical features of the
pectoralis minor muscle flap pedicle. Plast Reconstr Surg 113:872-876, 2004.
The pectoralis minor muscle has been used as an innervated, vascularized, free muscle graft for facial
reanimation for 20 years. Throughout this period, several centers have demonstrated consistent success
with functional muscle transfer; however, opinions have varied regarding the arterial pedicle of the flap.
The lateral thoracic and thoracoacromial arteries have been proposed as the predominant arterial sources.
The authors stated that they had found that a vessel (not described in anatomy textbooks) arising
directly from the axillary artery and entering the muscle from its dorsal surface provides the dominant
supply to the flap and is capable of sustaining it for free tissue transfer. The vascular pedicle encountered
was recorded and photographed in 97 consecutive cases in which the pectoralis minor muscle flap was

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 471

raised. The findings demonstrated that the dominant supply to the muscle was from a single artery in
77% of cases and took the form of an artery arising directly from the axillary vessel in 72% of cases.
More than one major arterial source was noted in the remainder of their cases. The venous outflow
was usually through single or multiple veins running directly from the muscle into the axillary vein.
Manaswi A, Mehrotra N. Use of pectoralis major with or without pectoralis minor muscle flap
to fill lumpectomy in the breast. Ann Plast Surg 65:23-27, 2010.
Breast cancer treatment has undergone a major change with breast conservation surgery (consisting of
lumpectomy and axillary dissection or sentinel lymph node biopsy), which now forms a major propor-
tion of the total number of breast cancer surgeries. Reconstructing an aesthetically pleasing breast has
been a challenge. Various techniques to fill the breast defect or reconstruct the partial mastectomy defect
are presently used, such as local wedge closure, local tissue rearrangement, the local advancement flap,
thoracodorsal perforator flap, latissimus dorsi flap, silicone implant, and reduction mammaplasty. The
authors described the use of the pectoralis major muscle with or without the pectoralis minor muscle as
an innovation to fill the lumpectomy defects in the upper quadrants of the breast. Ten patients with
breast cancer in whom the cancer measured between 2 and 4 cm were identified for the study, the
prerequisite being that the tumor should be present in the upper quadrants of the breast. Patients with
severe ptosis (grade 3) were excluded from the study. After lumpectomy, using the same incision, a
pectoralis major muscle flap was harvested based on a thoracoacromial pedicle, rolled over like a ball,
and used to fill the defect. A pectoralis minor muscle flap was supplemented in two patients in whom
additional volume was required. After 9 months, cosmesis was evaluated by three independent judges
using the visual analog scale. No patient had any flap necrosis; one patient had a minor wound infec-
tion. None of the patients had positive surgical margins for malignancy.
Nomori H, Horio H, Hasegawa T, et al. Intrathoracic transposition of a pectoralis major and
pectoralis minor muscle flap for empyema in patients previously subjected to posterolateral
thoracotomy. Surg Today 31:295-299, 2001.
The latissimus dorsi muscle flap cannot be used to eliminate an empyema cavity in patients who have
previously undergone posterolateral thoracotomy, because of the division of this muscle. Moreover,
thoracoplasty alone cannot sufficiently eliminate an empyema cavity that includes the thoracic apex,
where space remains between the clavicle and the first rib. The authors constructed a flap from the
pectoralis major and pectoralis minor muscles to eliminate empyema cavities in five patients who had
undergone lobectomy or pneumonectomy via posterolateral thoracotomy from 3 months to 40 years
previously. All five patients had bronchopleural fistulas, and because of the previous upper lobectomy
or pneumonectomy, they had large empyema cavities including the thoracic apex. Open drainage
thoracotomy was performed for severe infection, and intrathoracic transposition of the muscle flap with
simultaneous thoracoplasty was carried out 7 to 124 weeks later. The pectoralis major and pectoralis
minor muscle flap easily reached the apex space with sufficient obliteration of the empyema cavity.
All patients remained free of empyema 12 to 85 months after thoracic closure.
Scevola S, Cowan J, Harrison DH. Does the removal of pectoralis minor impair the function
of pectoralis major? Plast Reconstr Surg 112:1266-1273, 2003.
The authors treated more than 300 patients during the past 20 years who had long-standing unilateral
facial palsy with a cross-facial nerve graft and a free pectoralis minor muscle flap to the face. In this
study the authors assessed the residual postoperative donor site morbidity in the chest. During the
second stage of the operation, the medial and lateral pectoral nerves were divided at a proximal level
from the plexus. Because of the common innervation of the two pectoral muscles, a consequent change
in pectoralis major muscle function could be expected, but no study had been performed to determine
whether this occurs. They performed a subjective and an objective study on a voluntary sample of 38
patients previously operated on for facial palsy with pectoralis minor muscle transfer. Cosmetic and
functional outcomes were recorded. The subjective evaluation was obtained through a questionnaire;
the objective evaluation was obtained through physical examination (inspection and palpation). They

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 472 Part II  Regional Flaps: Anatomy and Basic Techniques

assessed the following quantitative parameters: thickness of the muscle, arm muscle circumference,
power produced at contraction, and muscle fiber activity. Subjectively, 6 patients reported a reduction
in the force of the muscle and 10 patients noticed a change in muscular thickness at the site of the
operation. Objectively, the results of the electromyogram were almost normal in all of the muscles
sampled (17 patients). Occasionally, minor changes from the normal pattern were seen in the lower
half of pectoralis major. The dynamometer adduction test showed a significant reduction in the force
developed on the operated side when it was the dominant side, whereas no difference was shown in
the group of patients who underwent operations on the nondominant sides. For the pectoral fold and
the arm muscle circumference, no difference was found between the operated and nonoperated side.
Shah R, Kang N. Reconstruction in the axilla with a pedicled pectoralis minor muscle flap.
Ann R Coll Surg Engl 88:W9-W11, 2006.
Covering large defects in the axillary fossa can be challenging because of its complex shape. A variety
of local skin, fasciocutaneous, and myocutaneous flaps have been described, with a number of inher-
ent advantages and disadvantages. The use of the pectoralis minor muscle as a pedicled transposition
flap has been described for immediate reconstruction of the breast, anterior shoulder reconstruction and
the treatment of bronchopleural fistula. The authors described the use of a pedicled pectoralis minor
muscle flap for soft tissue coverage of the axillary contents after wide excision of the axilla, which had
not been previously reported.
Shipkov CD, Uchikov AP. Pectoralis major and pectoralis minor muscle flap for postpneumo-
nectomy empyema. Surg Today 40:285, 2010.
Song HK, Guy TS, Kaiser LR, et al. Current presentation and optimal surgical management
of sternoclavicular joint infections. Ann Thorac Surg 73:427-431, 2002.
Infection of the sternoclavicular joint is unusual, and treatment of this entity has not been standardized.
The authors sought to characterize the current presentation and optimal management of this disease
by retrospectively reviewing the records of the last 7 patients undergoing operation for suppurative
infections of the sternoclavicular joint. The authors concluded that aggressive surgical management
including resection of the sternoclavicular joint and involved ribs with pectoralis flap closure would
appear to be the preferred treatment for all but the most minor infections of the sternoclavicular joint.
This approach has minimal impact on upper extremity function.
Tehrani H, Srinivasan JR. The pectoralis minor pedicled muscle flap in axillary reconstruction.
Ann Plast Surg 62:405-406, 2009.
The authors described the case of a patient undergoing resection of a large axillary and chest wall tumor
that resulted in exposure of the brachial plexus and axillary vessels. They detailed their experience of
the use of the pectoralis minor pedicled flap for the reconstruction of such a defect, providing excellent
postoperative mobility of the axilla and minimal donor site morbidity.
Terzis JK, Tzafetta K. “Babysitter” procedure with concomitant muscle transfer in facial pa-
ralysis. Plast Reconstr Surg 124:1142-1156, 2009.
The “babysitter” procedure, introduced by Terzis in 1984, combines cross-facial nerve grafting with
segmental transfer of the hypoglossal to the affected facial nerve and can produce satisfactory to excellent
results. In long-lasting paralysis, nonetheless, the babysitter procedure may need to be combined with
a muscle flap (or flaps) for outcome upgrading, which was the focus of this study. Thirty-eight patients
underwent the babysitter procedure over a 20-year period (1984 to 2003). Twenty patients had only
the babysitter procedure, whereas 18 needed additional muscle flaps (up to three) to enhance function
and cosmesis. These muscles included nine free (gracilis, pectoralis minor) and 20 regional (frontalis,
mini-temporalis, platysma, digastric) muscles for distinct target needs: eye closure, smile restoration, and
lower lip depression. All free muscles were transferred at the second stage of the babysitter procedure;
regional muscles were also transposed later. All patients had upgrading of overall aesthetics and smile,
whereas four maintained similar scoring for eye closure, and one maintained similar scoring for lip
depression. All but two had secondary procedures to further enhance facial symmetry.

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 Anterior Thorax  •  6B: Pectoralis Minor Flap 473

Zhuang YQ, Xiong HT, Fu Q, et al. Functional pectoralis minor muscle flap transplantation
for reconstruction of thumb opposition: an anatomic study and clinical applications. Micro-
surgery 31:365-370, 2011.
The authors performed anatomic study of the dimensions of the pectoralis minor muscle and its neuro-
vascular supply in 10 adult human cadavers to evaluate the feasibility of microsurgical transplantation
of a part of the muscle for thumb opposition reconstruction. Subsequently, a series of five patients
underwent thenar reconstruction with the pectoralis minor muscle flap from December 2004 to October
2006. The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve.
Follow-up assessment showed that the patients recovered functional opposition of the carpometacarpal
joint, with 24 degrees of pronation and a muscle power of M4 to M5. All patients were satisfied with
the appearance of the reconstructed thenar eminence.

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 ANATOMIC LANDMARKS
Landmarks The lateral intercostal artery perforator (LICAP) flap is a fascio-
cutaneous island based on the posterior intercostal neurovascular
bundle.
Size 24 3 14 cm.
Composition Fasciocutaneous.
Flap Type Fasciocutaneous (type A).
Dominant Pedicle Intercostal vessels.
Nerve Supply Sensory: Intercostal nerves.

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 Section 6C
Anterior Thorax

Lateral Intercostal Artery

Perforator (LICAP) Flap

CLINICAL APPLICATIONS
Regional Use
Thorax
Breast
Sternum
Axilla
Distant Use
Head and neck
Upper extremity
Lower extremity

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 ANATOMY OF THE LATeral Intercostal Artery Perforator (LICAP) flap

A Dorsal branch of intercostal artery

Posterior intercostal artery

Lateral cutaneous branch

of intercostal artery

Lateral cutaneous branch

of intercostal nerve

Internal mammary artery

Anterior intercostal artery

Anterior cutaneous branches

of intercostal nerve

Intercostal perforator and cutaneous supply of LICAP flap and variants

B
Dorsal intercostal artery perforator (DICAP) flaps

Lateral intercostal artery

perforator (LICAP) flaps

Anterior intercostal artery perforator (AICAP) flap

Flap options based on chest hemicircumference

Fig. 6C-1

Dominant pedicle: Posterior intercostal vessels

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 477

Anatomy
Landmarks The lateral intercostal artery perforator (LICAP) flap is a fasciocutaneous island
based on the posterior intercostal neurovascular bundle.
Composition Fasciocutaneous.
Size 24 3 14 cm.

Arterial Anatomy
Dominant Pedicle  Posterior intercostal vessels
Regional Source  Aorta.
Length  Vertebral segment: 8 cm; intercostal segment: 15 cm; intermuscular segment: 12 cm;
rectus segment: 8 cm.
Diameter  1 to 1.5 mm.
Location  There are nine pairs of intercostal arteries within the lowermost nine ribs. The ves-
sels arise from the aorta and course beneath the inner aspect of each rib running anteriorly to
then communicate with the anterior intercostal circulation arising from the internal mammary
arteries. The vessels are divided for technical purposes into an 8 cm vertebral segment that runs
from the aorta to the angle of the rib. Within this course this segment gives rise to a dorsal
branch to the skin and a nutrient branch to the rib, as well as a minor collateral branch. The
second segment is the intercostal component, which begins at the costal groove beyond the costal
angle and extends around the chest to the insertion of the abdominal musculature on the ribs
anterolaterally. At this point the vessels lie deep to the external and internal intercostal muscles,
but superficial to the innermost intercostal and parietal pleura. This segment gives rise to five
to seven myocutaneous perforators at 1 to 3 cm intervals along its course, each with a diameter
of 0.8 mm. The main trunk of the vessel is 1.5 cm at the midaxillary line and gives off a large
lateral cutaneous branch at this point. This exits anterior to the latissimus dorsi muscle. The
lateral cutaneous branch divides into a large anterior and smaller posterior branch accompanied
by sensory nerves. In 40% of patients this lateral cutaneous branch divides early, with the large
anterior component running deep to external oblique for several centimeters before it emerges
into the overlying skin. Damage to this can lead to flap compromise. A third segment of the
intercostal artery is the intermuscular segment, 12 cm in length, which begins at the costal at-
tachment of the abdominal musculature, extending to the lateral border of rectus abdominis.
It passes between the internal oblique and transversus abdominis muscles. The final segment is
the rectus portion, which lies superficial to the posterior rectus sheath, anastomosing with the
deep epigastric circulation.

Venous Anatomy
Venous drainage is an exact mirror of the arterial circulation as venae comitantes accompanying
the arteries. The vessels may be single or paired. They are 1 mm or less in diameter.

Nerve Supply
Motor The intercostal nerves send muscular branches to the intercostal muscles.
Sensory Intercostal nerves follow the perforating branch up into the skin posteriorly,
laterally, and anteriorly.

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 478 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the LICAP Flap

A B

Lateral fat
compartment

TDAP Intercostals

C D

Thoracodorsal Serratus anterior Latissimus

artery branch dorsi

Fig. 6C-2  A, Location of the lateral fat compartment captured in this flap. B, Anatomic study dem-
onstrating 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.)

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 479

FLAP HARVEST
Design and Markings
The lateral intercostal artery perforator (LICAP) flap can be designed at any portion along
the course of the posterior intercostal artery or from the anterior intercostal artery. The
most common donor vessels are the posterior intercostals. Any perforating branch from
the posterior intercostal artery can be used to supply the flap; the most common location is
on the lateral chest. The flap is designed with the patient standing and is most often raised
over the ninth to eleventh ribs. Doppler ultrasound is used to identify the perforator. The
skin island is drawn with the posterior border of the flap lying at least 5 cm behind the
posterior axillary line to ensure that the lateral cutaneous branch is incorporated within the
flap. Although injection studies have demonstrated that flaps as large as 20 to 25 cm may be
raised safely, 12 cm in diameter tends to be the limit that can be closed primarily. The flap
is centered on the midaxillary line; the pedicle length ranges from 8 to 15 cm.

Fig. 6C-3  After its intermuscular course, the lateral cutaneous bundle emerges in front of the latis-
simus 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
The patient is placed in the lateral decubitus position with the arm free-draped into the field.

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 480 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

Loupe magnification is used for all dissections. The posterior incision is made first to allow
for perforator identification. The incision is deepened to expose the latissimus dorsi muscle
and incorporate the deep fascia to safeguard the contained vessels. Once the anterior border
of the latissimus dorsi has been reached, the smaller posterior branch of the larger cutaneous
branch can usually be found. This is followed to its bifurcation within the larger anterior
branch. The flaps are usually designed spanning two or three ribs; this allows the segment of
the largest of any of the lateral cutaneous branches to be chosen as the primary flap inflow.
The vessels tend to gap slightly posteriorly beneath the anterior border of the latissimus
dorsi muscle, and the latissimus must be retracted to follow the vessel down through the
serratus anterior or the external oblique muscles, which have to be divided to gain access
to the intercostal space.

Latissimus
dorsi

Fig. 6C-4  Surgical technique for the LICAP flap on the lower lateral part of the rib cage. A, Af-
ter 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.

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 481

These intercostal muscles are freed from the lower border of the rib, thereby exposing
the juncture of the lateral cutaneous branch with the posterior intercostal main trunk.

Posterior
intercostal
neurovascular
bundle

Fig. 6C-4  C, The junction of the lateral cutaneous branch and the main bundle is exposed.

The periosteum is incised along the undersurface of the rib as it curves posteriorly. The
anterior extension of the posterior intercostal beyond the junction of the lateral cutaneous
branch is ligated, leaving the lateral intercostal vessel in continuity with its posterior inter-
costal main trunk. The flap is then ready for transfer. The remaining skin island is incised
around the lateral cutaneous perforator.

Fig. 6C-4  D, The required pedicle length is dissected and the flap elevated.

FLAP VARIANTS
•  Dorsal intercostal artery perforator (DICAP) flap
•  Anterior intercostal artery perforator (AICAP) flap

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 482 Part II  Regional Flaps: Anatomy and Basic Techniques

Dorsal Intercostal Artery Perforator Flap

The dorsal intercostal artery perforator (DICAP) flap is based on the dorsal cutaneous branch
of the posterior intercostal artery between the aorta and the angle of the rib posteriorly. The
dorsal branch is 1.5 mm in diameter, and the largest vessel is found beneath the seventh rib.
The next largest is the sixth rib; it is recommended that the flap be based overlying these
two ribs. The perforator is located with Doppler ultrasound or indocyanine green (ICG)
fluorescence imaging. The flap has a much shorter pedicle than the LICAP flap but can
be useful for midline back defects. Dissection usually commences laterally and progresses
medially. The pedicle length can be increased by dissecting through the paraspinal muscles.

Paravertebral perforator source for DICAP flap

Fig. 6C-5 

Anterior Intercostal Artery Perforator Flap

The anterior intercostal artery perforator (AICAP) flap is based on the perforator arising
from the anterior intercostal artery, the source vessel being the internal mammary (see
the IMAP variant of the deltopectoral flap in Section 6A). The perforator is located with
Doppler ultrasound or ICG fluorescence and lies 1 to 3 cm lateral to the sternum. The
skin island is dissected in the subfascial plane until the perforator is identified. Depending
on its location in the chest wall, the pectoralis major or rectus abdominis muscle is split,
and the perforator is followed down to the source vessel. The largest internal mammary
branches are found in the second to third interspaces. Pedicle lengthening can be achieved
by harvesting the main internal mammary trunk with the perforator. A sensate flap can
be elevated by including the intercostal nerve. Pleural damage must be avoided at all costs.

Vascular source for AICAP flap

Fig. 6C-6 

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 483

Arc of Rotation
The LICAP flap can be rotated onto the chest, axilla, or breast based on its available pedicle
length. The DICAP and AICAP flaps have a much more limited arc of rotation because
of their short pedicle lengths.

Fig. 6C-7   Arc of rotation of the LICAP flap. More arc of rotation is gained by extending the skin de-
sign, and more freedom of placement is achieved with further pedicle dissection.

FLAP TRANSFER
Pedicle flaps are either tunneled or transposed into their adjacent defects. Free tissue transfers
are transferred and anastomosed to their recipient vessels as dictated by the defect.

FLAP INSET
The flaps are inset using a two-layer closure. In free flap transfer it is imperative to ensure
that there is no tension, kinking, or rotation of the pedicle after anastomosis.

DONOR SITE CLOSURE

The donor site is usually closed directly, particularly when the skin island diameter is less
than 12 cm on the lateral chest. On the anterior or posterior chest, this becomes difficult
when the defect is wider than 7 cm.

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 484 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 59-year-old patient was admitted for a quadrantectomy with partial breast reconstruc-
tion for cancer of the right breast located at the superolateral quadrant.

A B

D E

F G

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 latis-
simus 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. (Case courtesy Moustapha Hamdi, MD.)

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 485

This 76-year-old woman had already undergone a large mastectomy and a latissimus dorsi
flap reconstruction followed by radiation therapy. She developed a local recurrence that
extended over the sternal region, so a radical excision and flap coverage were planned. She
requested reduction of the contralateral breast. An AICAP flap was designed over the breast,
part of which is usually incorporated in an inverted-T incision.

A B

D E F

G H

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. (Case courtesy Moustapha Hamdi, MD.)

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 486 Part II  Regional Flaps: Anatomy and Basic Techniques

This 56-year-old man was referred for defect closure after a large resection for dermatofi-
brosarcoma. The closure was performed using a DICAP flap.

A B C

Fig. 6C-10  A, Preoperative view. B, The DICAP flap was designed around the mapped perforator.
C, Complete wound healing was obtained. (Case courtesy Moustapha Hamdi, MD.)

A patient underwent scar release after an axillary burn. The resulting defect was closed
using a LICAP flap.

A B C

LICAP

Fig. 6C-11  A, The defect is shown, with the designed LICAP flap. The X indicates the mapped perfo-
rator. B, The flap was raised on two intercostal perforators. C, The flap was rotated 180 degrees, with
complete defect coverage. (Case courtesy Moustapha Hamdi, MD.)

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 487

Pearls and Pitfalls

• The major advantage of the LICAP flap is its thin, pliable consistency and long vascular
pedicle with adequate but small vascular diameter for anastomosis.
• The flap can be designed as a sensate island with two or three fascicles of the intercostal
nerves supplying the entire flap.
• Venous drainage is usually good, but for larger flaps, additional segmental veins can be
dissected to improve venous outflow.
• The thin nature of the flap makes it particularly useful for the neck, face, and dorsum
of the hand.

Expert Commentary
Moustapha Hamdi

This chapter provides an overview of the anatomy and surgical technique of the intercostal
perforator flaps. Most of these can be used as pedicled as well as free flaps. The use of the
intercostal neurovascular pedicle to supply a sensory skin flap was first suggested by Esser1
and later by Daniel and Williams.2 The clinical use of such flaps was then described by many
others as myocutaneous, with random extensions beyond the thoracic cage.3,4 Badran and
colleagues5,6 were the first to describe the harvesting of a lateral intercostal fasciocutaneous
free flap based on one neurovascular bundle, sparing the abdominal musculature—this
being the first perforator-based intercostal free flap. I have been using this flap since 2000,
but as pedicled intercostal perforator flaps for many clinical indications.7-10

Indications
Many patients with breast or thoracic defects who were traditionally treated with a latis-
simus dorsi myocutaneous flap are suitable candidates for pedicled intercostal perforator
flaps. The indications are summarized as follows:
1.  Breast surgery
• Partial breast reconstruction, whether immediate or after wider excision in cases
of histologically involved margins for tumors located at the lateral quadrants
• Correction of breast deformity after breast-conserving surgery (tumorectomy
and radiation therapy)
• Salvage procedure after significant partial necrosis of a free flap for breast recon-
struction
• Postmastectomy breast reconstruction in combination with an implant
• Autologous breast augmentation; in particular, for patients after massive weight
loss11,12
2.  Axillary defects (such as burn contractures and hidradenitis)13
3.  Skin coverage of sternal and paramedial defects
4.  Upper dorsal defects
Continued

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 488 Part II  Regional Flaps: Anatomy and Basic Techniques

Advantages and Limitations

The flap provides sizable skin and fat flaps based on a single perforator; furthermore, there
is only a minimal decrease in flap volume postoperatively as opposed to the latissimus dorsi
myocutaneous flap which can lose up to 30% of volume secondary to muscle atrophy. The
donor site can be closed primarily after harvesting up to a 20 by 10 cm flap, depending on
skin laxity. Significantly there has been no seroma formation at the pedicled perforator flap
donor site, and patients have a more rapid rehabilitation course. Patients are also less likely
to complain of pain, and subjectively, they appear more comfortable after pedicled flaps.
Another important consideration in selecting pedicled perforator flaps is the potential to
harvest the latissimus dorsi muscle flap at a later date.
Perforator flaps are not usually indicated in cases of postmastectomy autologous breast
reconstructions because of a lack of sufficient volume, nor can pedicled flaps easily reach
three-dimensional defects located in the medial quadrant. However, additional volume can
be obtained by fat injection in the flap or an implant behind the flap. Perforator flap harvest
is initially more difficult than traditional myocutaneous latissimus dorsi flap harvesting and
necessitates some training with the attendant learning curve.

Anatomic Considerations
The basic anatomy of the intercostal bundle was extensively described in the study of Ker-
rigan and Daniel.4 However, the perforator anatomy, their locations, and distribution have
not been investigated until recently. Depending on their origin, the intercostal perforator
flaps can be classified as posterior (dorsal), lateral, or anterior intercostal artery perforator
(DICAP, LICAP, AICAP) flaps.
In our cadaver study,10 the anatomy of LICAP flap was investigated. All intercostal per-
forators located between the lateral border of the pectoralis major muscle and the anterior
border of the latissimus dorsi muscle were identified. A mean value of 7.83 perforators per
cadaver and 3.91 perforators per side were found. The highest concentration of intercostal
perforators was found between the fifth and the eighth intercostal spaces (88.4%). The mean
distances of intercostal perforators from the anterior border of the latissimus dorsi muscle
varied from 2.67 to 3.49 cm. A dominant perforator was identified in 93.6% dissected sides.
No dominant perforators were identified in the third intercostal space. Retrograde dissection
of the dominant perforator revealed that it travels obliquely under a slip of the origin of the
serratus anterior muscle into the intercostal space deep to the internal and external intercostal
muscles. Once deep to the intercostal muscles, it emerges from the subcostal groove. The
dominant perforator typically had a smaller posterior branch, which bifurcated above the
serratus anterior muscle. This branch was found to communicate with the thoracodorsal
perforators or serratus anterior vessels. When it bifurcated under the serratus anterior muscle
(in 10% of cases), it had a similar diameter to the anterior branch.

Recommendations
Planning
The intercostal island flap is typically based on the posterior intercostal vessels, but the flap
can be designed on any segment of the course of the posterior intercostal artery or from the
anterior intercostal artery. Obviously, this flap can be harvested as a perforator flap, sparing
the muscle and fascia. The largest perforator is based on the lateral branch of the posterior
intercostal artery, but an intercostal perforator flap can be dissected on any located perforator
arising from the intercostal vessels. The flap can be used as a pedicled flap to reconstruct a
distant defect of the thorax, sacrum, and axillary region or as a free flap.

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 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 489

This flap is designed on the lateral side of the flank with the patient standing or side-
lying. Perforators are located with greater ease with Doppler. In a planned pedicle flap, its
position is based on the location of the recipient defect. Depending on the indications and
the location of the defect, the flap is designed as a transposition, rotation, or V-Y advance-
ment flap. The width of the flap should allow primary closure of the donor site.

Technique
Dissection of this flap should be done using loupe magnification. A posterior incision is
made first, with an anterior extension at its lower end to explore the perforators and allow
easy elevation of the flap. The incision is deepened to expose the latissimus dorsi muscle.
It is safer to include the deep fascia in the flap to avoid accidental injury to the posterior
branches of the bundle. After visualization of the anterior border of the latissimus dorsi
muscle, the surgeon identifies the smaller posterior branch of the lateral cutaneous branch.
This branch is followed to find the bigger anterior branch. Dissection proceeds by retract-
ing the deep muscle (the external oblique muscle or the serratus anterior, depending on the
location of the defect and flap). The external and internal intercostal muscles are then cut,
and the junction of the lateral cutaneous branch with the main bundle is found.
If a longer pedicle is required, the intercostal vessels should be dissected within the
costal groove. At this level, the dissection is more difficult and necessitates great care to
avoid injury to the vessels in the costal groove; therefore the dissection of the pedicle usually
stops at this level. The lateral cutaneous nerve can be stripped from the main intercostal
nerve for any desired distance to make the flap sensate. The superior border of the flap is
then marked and incised, taking into consideration both the width to cover the defect and
primary closure of the donor site. The rest of the flap is elevated easily above the muscle
fascia until the dissection is close to the entrance of the lateral branch into the skin. The
plan is then changed to include the fascia in the flap for safer dissection.

Postoperative Care
No dressing is required on the flap. Pressure should be avoided on the area at which the
perforator enters the flap. All our patients receive intravenous piracetam 12 g for 24 hours
and as a 20% solution orally 25 ml four times a day for an additional 5 days. This drug acts
to increase the viability of the distal parts of the flap by increasing capillary blood flow.

Complications
Intercostal perforator flaps have usually robust blood supply. On the other hand, extend-
ing the flap beyond the angiosome territory may lead to partial flap necrosis. Although an
intercostal perforator flap could be designed in a different direction, horizontal flap’s design
provides a larger flap because of the interconnection between consequent perforators that
arise from the same vascular intercostal arcade. Therefore the intercostal perforator flap is
better designed parallel to the rib direction when a large skin flap is needed.
The flap has enough venous drainage but if a large flap is needed, additional venous
drainage may be required through another intercostal bundle above or below the chosen one.
Flap hypersensitivity has been reported by some patients after harvest of the intercostal
perforator flap. This hypersensitivity may last 3 to 6 months before resolving.
Continued

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 490 Part II  Regional Flaps: Anatomy and Basic Techniques

Take-Away Messages
Flap dissection is quick and easy. This flap is large and usually quite thin, or it can be thinned
preoperatively. The pedicle is short; however, a longer pedicle can be obtained with intra-
costal groove dissection. It has several indications for trunk reconstruction, depending on
the level of the costal bundle. The flap is sensate through the lateral intercostal nerve, which
has two to four fascicles to supply the entire flap.

References
  1. Esser J. [Biological or artery flaps of the face] Institut Esser de Chirurgie Structive Monaco
1931.
 2. Daniel RK, Williams HB. The free transfer of skin flaps by microvascular anastomoses.
An experimental study and a reappraisal. Plast Reconstr Surg 52:16-31, 1973.
  3. Dibbell DG. Use of a long island flap to bring sensation to the sacral area in young paraple-
gics. Plast Reconstr Surg 54:220-223, 1974.
  4. Kerrigan CL, Daniel RK. The intercostal flap: an anatomical and hemodynamic approach.
Ann Plast Surg 2:411-421, 1979.
  5. Badran HA, El-Helaly MS, Safe I. The lateral intercostal neurovascular free flap. Plast
Reconstr Surg 73:17-26, 1984.
  6. Badran HA, Youssef MK, Shaker A. Management of facial contour deformities with
deepithelialized lateral intercostal free flap. Ann Plast Surg 37:94-101; discussion 101-105,
1996.
  7. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast
reconstruction: a new concept. Br J Plast Surg 57:531-539, 2004.
  8. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel P, Monstrey S. The versatility
of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 59:644-652,
2006.
  9. Van Landuyt K, Hamdi M, Blondeel P, Monstrey S. Autologous breast augmentation by
pedicled perforator flaps. Ann Plast Surg 53:322-327, 2004.
10. Hamdi M, Spano A, Van Landuyt K, D’Herde K, Blondeel P, Monstrey S. The lateral
intercostal artery perforators: anatomical study and clinical application in breast surgery.
Plast Reconstr Surg 121:389-396, 2008.
11. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N, Monstrey S. Autologous
breast augmentation with the lateral intercostal artery perforator flap in massive weight
loss patients. J Plast Reconstr Aesthet Surg 62:65-70, 2009.
12. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight
loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg 57:361-365, 2006.
13. Stillaert FB, Casaer B, Roche N, Van Landuyt K, Hamdi M, Blondeel PN, Monstrey S.
The inframammary extending lateral intercostal artery perforator flap for reconstruction
of axillary contractures: a case report. J Plast Reconstr Aesthet Surg 61:e7-e11, 2008.

06c_LatThora_LICAP_r4b_bs_0474-0491.indd 490 1/30/2012 4:57:27 PM

 Anterior Thorax  •  6C: Lateral Intercostal Artery Perforator (LICAP) Flap 491

Bibliography With Key Annotations

Hamdi M, Spano A, Van Landuyt K, et al. The lateral intercostal artery perforators: anatomical
study and clinical application in breast surgery. Plast Reconstr Surg 121:389-396, 2008.
Lateral intercostal artery perforator flaps are based on intercostal perforators that arise from the costal
groove. The intercostal perforators were dissected in 24 fresh cadavers and evaluated in a field that
extended between the third and the eighth intercostal spaces and between the latissimus dorsi and
pectoralis major muscles. Their relationship with the anterior border of the latissimus dorsi muscle and
the serratus anterior vessels was investigated. A mean of 3.91 perforators per side was found; 88.4%
of the intercostal perforators were found between the fifth and eighth intercostal space level. Mean
distances of intercostal perforators to the anterior border of the latissimus dorsi muscle ranged from 2.67
and 3.49 cm. The largest or dominant perforator was most frequently found in the sixth intercostal
space (38.6%) at an average of 2.5 to 3.5 cm from the anterior border of the latissimus dorsi muscle.
In 10 of 47 sides (21%), vascular connections were found between the serratus anterior branch and
the intercostal perforators. The connection was observed more frequently in the seventh and the sixth
intercostal spaces, in 38% and 30% of cases, respectively. This vascular connection enables harvest
of a serratus anterior artery perforator flap.
Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the intercostal artery perforator
(ICAP) flaps. J Plast Reconstr Aesthet Surg 59:644-652, 2006.
The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different
pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They
are classified as following: dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery
perforator (LICAP); and anterior intercostal artery perforator (AICAP) flap. Between 2001 and
2004, 20 pedicled (ICAP) flaps were harvested in 16 patients. The indications were immediate
partial breast reconstruction in eight patients who had a quadrantectomy for breast cancer; midline
back and sternal defects in three patients who had radical excisions for a dermatofibrosarcoma or
malignant melanoma; and autologous breast augmentation (four bilateral and one unilateral flap) in
five postbariatric surgery patients. The average flap dimension was 18 by 8 cm2 (range 8 by 5 to 24
by 12 cm2). There were two DICAP flaps, two AICAP flaps, and 16 LICAP flaps. All but two
flaps were based on one perforator. Mean harvesting time was 45 minutes for a single flap. Bilateral
breast augmentation with a LICAP flap necessitated a longer operative time (range 2 to 3 hours),
depending on whether it was combined with mastopexy. Complete flaps survival was obtained. All
donor sites were closed primarily.
Munhoz AM, Montag E, Arruda E, et al. Immediate conservative breast surgery reconstruction
with perforator flaps: new challenges in the era of partial mastectomy reconstruction? Breast
20:233-240, 2011.
Thirteen patients underwent conservative breast surgery (CBS) reconstructions with an ICAP flap.
These flaps were raised from adjacent tissue located on the lateral and thoracic region and based on
perforators originating from the costal and muscular segment of the intercostal vessels. The technique
was indicated in patients with small to moderate volume breasts. The mean time of follow-up was
32 months. Flap complications were evaluated, and information on patient satisfaction was collected;
61.5% had tumors located in the lower-outer quadrants, and 69.2% had tumors measuring 2 cm or
less (T1). Complications occurred in three patients (23%), including wound dehiscence in two and
fat necrosis in one. All cases were treated by conservative approach with a good result. No flap loss or
wound infection were reported; 90% of patients were either satisfied or very satisfied with their result.

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 ANATOMIC LANDMARKS
Landmarks The serratus anterior is a thin, broad muscle on the lateral chest
wall between the ribs and the scapula. The usable portion of the
muscle lies between the anterior free border of the latissimus dorsi
and the inferolateral border of the pectoralis major, extending
inferiorly as low as the ninth rib.
Size 20 3 15 cm.
Origin Broad origin consists of multiple leaflets, each arising from a
separate rib, passing obliquely upward posteriorly before blend-
ing into a wide muscle belly that inserts into the anteromedial
edge of the scapula.
Insertion Medial border of the anterior surface of the scapula.
Function Protracts the scapula forward and stabilizes the scapula against
the chest during arm motion. Paralysis of the muscle creates
unsightly winging of the scapula.
Composition Broad, flat sheet of muscle arising from the ribs and inserting
onto the scapula. The muscle is usually raised in isolation, but
its blood supply can support fascial, cutaneous, and bony com-
ponents.
Flap Type Type III.
Dominant Pedicle Lateral thoracic artery.
Dominant Pedicle Serratus branches of thoracodorsal artery.
Nerve Supply Motor: C5-C7 roots of long thoracic nerve. Sensory: T2-T4 seg-
mental intercostal nerves.

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 Section 6D
Anterior Thorax

Serratus Flap

CLINICAL APPLICATIONS
Regional Use
Thorax
Breast
Intrathoracic cavity
Axilla
Posterior trunk
Distant Use
Head and neck
Upper extremity
Lower extremity
Specialized Use
Functional muscle
Facial reanimation

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 ANATOMY OF THE SERRATUS ANTERIOR FLAP

Muscle origin and insertion

B C

Lateral thoracic
artery Serratus
branches of
thoracodorsal
artery

Long
thoracic
nerve

Arterial supply to flap area Nerve supply to flap area

Fig. 6D-1 

Dominant pedicles: Lateral thoracic artery; serratus branches of thoracodorsal artery

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 Anterior Thorax  •  6D: Serratus Flap 495

Anatomy
Landmarks The serratus anterior is a thin, broad muscle on the lateral chest wall between the
ribs and the scapula. The usable portion of the muscle lies between the anterior
free border of the latissimus dorsi and the inferolateral border of pectoralis major,
extending inferiorly as low as the ninth rib.
Composition Broad, flat sheet of muscle arising from the ribs and inserting onto the scapula.
The muscle is usually raised in isolation, but its blood supply can support fascial,
cutaneous, and bony components.
Size 20 3 15 cm.
Origin Broad origin consisting of multiple leaflets, each arising from a separate rib,
passing obliquely upward posteriorly before blending into a wide muscle belly
that inserts into the anteromedial edge of the scapula.
Insertion Medial border of the anterior surface of the scapula.
Function Protracts the scapula forward and stabilizes the scapula against the chest during
arm motion. Paralysis of the muscle creates unsightly winging of the scapula.

Arterial Anatomy (Type III)

Dominant Pedicle  Lateral thoracic artery
Regional Source  Arises from the axillary artery.
Length  6 to 8 cm.
Diameter  2 to 2.5 mm.
Location  Direct branch of the axillary artery that runs along the anterolateral surface of the
muscle and descends to the level of the fifth intercostal space.
Dominant Pedicle  Serratus branches of thoracodorsal artery
Regional Source  Axillary artery.
Length  6 to 8 cm.
Diameter  2 to 3 mm.
Location  The thoracodorsal artery, a continuation of the subscapular trunk, sends two to four
branches to the serratus just before entering the latissimus dorsi. The thoracodorsal pedicle to
the serratus muscle lies 6 to 7 cm posterior to the lateral thoracic pedicle.

Venous Anatomy
Single veins accompany the arterial circulation; the average venous diameter is 1.5 to 3 mm.

Nerve Supply
Motor C5-C7 roots of long thoracic nerve.
Sensory T2-C4 segmental intercostal nerves.

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 496 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Serratus Flap

A

D1

n1

D2
t

s n2

Deep surface of serratus anterior and latissimus dorsi flaps

Fig. 6D-2 

Dominant pedicles: Lateral thoracic artery (D1); serratus branches of thoracodorsal artery (D2)
d, Latissimus dorsi muscle; n1, long thoracic nerve; n2, thoracodorsal nerve; s, serratus muscle;
t, thoracodorsal artery

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 Anterior Thorax  •  6D: Serratus Flap 497

D2

D1

D2

Radiographic view

Fig. 6D-2 

Dominant pedicles: Lateral thoracic artery (D1); serratus branches of thoracodorsal artery (D2)
d, Latissimus dorsi muscle; s, serratus muscle; t, thoracodorsal artery

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 498 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP HARVEST
Design and Markings
The serratus muscle is approached either through an oblique lateral chest wall incision or a
vertical incision down the lateral chest wall. The anterolateral chest skin between the anterior
and posterior axillary lines is included in the territory of this flap. In a muscular individual,
the muscle interdigitations can be clearly seen on the lateral chest wall. In most women, the
lateral breast mound obscures these features. It is usual to harvest only the lowermost three
or four segments of the muscle, leaving the upper fibers for scapula stability.

Marking for serratus flap

Fig. 6D-3 

With forceful contraction of the latissimus muscle, the anterior margin of the latissimus
at the posterior axillary line can be seen or palpated and is marked. With forceful contraction
of the pectoralis muscle, the lateral borders of the pectoralis at the anterior axillary line are
visualized and marked. The anterolateral portion of the serratus muscle and its skin island
lie in this triangle. The remainder of the muscle lies deep to the latissimus and extends pos-
teriorly to insert onto the deep surface of the medial border of the scapula, which is marked
to denote the posterior extent of the muscle. Skin is almost never harvested with this flap.

Patient Positioning
The patient is placed in the lateral decubitus position on a beanbag support with an axil-
lary roll placed to the dependent axilla. The ipsilateral upper extremity is free draped into
the field using an impervious stockinette wrap to allow intraoperative manipulation of the
arm during dissection. It is possible to harvest the anterior portion of this muscle with the
patient in the supine position and the arm abducted to 90 degrees at the shoulder.

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 Anterior Thorax  •  6D: Serratus Flap 499

GUIDE TO FLAP DISSECTION

The skin is incised either vertically or obliquely along the side of the chest between the
anterior border of latissimus dorsi and the inferolateral border of the pectoralis major muscle.

Skin incision

Fig. 6D-4 

Dissection is carried directly down to the muscle, which is easily seen subcutaneously.
The surgeon must avoid damaging either of the two vascular pedicles during exposure,
because both sets of vessels lie on the superficial surface of the muscle. The long thoracic
nerve should be identified early in the dissection to prevent injury. The thoracodorsal pedicle
is identified posteriorly, and the number of slips to be elevated is marked. In general, the
upper slips of the serratus are best based on the lateral thoracic pedicle; the lower portion is
based on the thoracodorsal pedicle.

Identification of thoracodorsal pedicle and long thoracic nerve

Fig. 6D-4 

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 500 Part II  Regional Flaps: Anatomy and Basic Techniques

It is easier to elevate a flap based on the thoracodorsal pedicle, and most of the lower
slips (four to nine) will survive on this pedicle. To preserve function and eliminate winging
of the scapula, only the lower three or four slips should be harvested as a flap. The pedicle
of choice for elevation of the flap either as a standard muscle flap or for microvascular
transplantation is the thoracodorsal pedicle. With the thoracodorsal pedicle identified, the
muscular digitations are dissected anteriorly from their rib origin using cautery as the at-
tachments are densely adherent, and separation can be bloody. The plane of dissection is
supraperiosteal and is never well defined.

Serratus muscle elevation

Fig. 6D-4 

Dissection is continued from anterior to posterior toward the scapula. Posteriorly the
muscle segment is divided and the flap elevated from below upward. The lateral thoracic
nerve, the motor nerve of the muscle, is found on the superficial surface of the serratus.
It joins the thoracodorsal pedicle at the level of the sixth rib and runs distally with it. It
is important to preserve this nerve and its innervation of the upper digitations to prevent
winging of the scapula. Once the muscle has been isolated, the vessels are dissected from
below upward, preserving the long thoracic nerve.

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 Anterior Thorax  •  6D: Serratus Flap 501

FLAP VARIANTS
•  Composite serratus-latissimus flap (chimeric flap)
•  Serratus fascial flap
•  Myoosseous flap

Composite Serratus-Latissimus Flap

A very large combined serratus-latissimus flap can be elevated based on the thoracodorsal
vessels. The standard skin incision for the serratus or latissimus muscle is made. Both muscles
are identified and elevated in the customary fashion. The branches of the thoracodorsal
artery to the serratus are preserved so that the thoracodorsal artery serves as the vascular
pedicle for both flaps. An even larger extension can incorporate the scapular or parascapular
skin islands based on the circumflex scapular branches arising from the subscapular axis.

Composite serratus-latissimus dorsi flap

Fig. 6D-5 

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 502 Part II  Regional Flaps: Anatomy and Basic Techniques

Serratus Fascial Flap (Lateral Thoracic Fascia)

A flap based on the serratus branches of the thoracodorsal artery and the fascia overlying the
serratus anterior and deep to the latissimus dorsi is elevated. This is a very useful thin fascial
flap for distant coverage. The standard incision for elevation of the serratus flap is made,
and the lateral edge of the latissimus dorsi muscle identified. This edge is elevated and the
underlying fascia and serratus muscle are exposed. The thoracodorsal artery is identified
proximally, and branches coursing medially toward the serratus are identified and preserved.
The fascial flap to be elevated is then outlined and incised.
This very thin flap is dissected off the underlying serratus anterior muscle. Dissection
continues from distal to proximal and includes the branches of the thoracodorsal artery.
Branches extending into the serratus muscle are cauterized with the bipolar electroco-
agulation unit. Larger branches are isolated, clamped, divided, and ligated. Separating the
fascia from the underlying serratus muscle can be a bloody dissection. The dissection is
best performed from distal to proximal. The branches of the thoracodorsal to the latissimus
muscle are ligated and divided. Care should be taken to preserve the long thoracic nerve.
The fascia is dissected away, leaving the nerve intact.

Serratus fascial flap

Fig. 6D-6 

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 Anterior Thorax  •  6D: Serratus Flap 503

Myoosseous Flap
Portions of the ribs at the site of the origin of the muscle may be elevated as an osteomus-
cular flap. Most commonly the fifth or sixth rib is included with the serratus muscle for
such an osteomuscular flap. Flap elevation proceeds as described for the standard flap, but
an extrapleural dissection of the fifth or sixth rib is done, leaving the muscle slip attached
to the elevated portion of rib.

Vascularized muscle flap

Fig. 6D-7 

In addition to vascularized rib, it is possible to harvest a portion of the inferolateral bor-

der of the scapula. There is a distinct vascular pedicle, the angular branch, as described by
Coleman and Sultan, which originates from the branch of the thoracodorsal vessel crossing
to the serratus in 42% of patients and from the thoracodorsal directly in 58% of patients.
This angular branch and associated veins supply the inferolateral border of the scapula,
which can be included with the serratus as vascularized bone. However, this variant is not
commonly used, because other flaps have less morbidity.

B C

Subscapular artery
Circumflex subscapular artery
Thoracodorsal artery
Pedicle to latissimus Pedicle to latissimus
dorsi muscle dorsi muscle
Angular branch of Pedicle to serratus Angular branch of Pedicle to serratus
thoracodorsal artery anterior muscle thoracodorsal artery anterior muscle

Osteofasciocutaneous flap

Fig. 6D-7 

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 504 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Standard Flap
Based on the thoracodorsal pedicle, the flap has a long arc of rotation reaching the chest
wall, shoulder, axilla, and back. It will also reach the intrathoracic cavity. Division of the
thoracodorsal branch to latissimus dorsi will increase the anterior arc of rotation based on the
thoracodorsal vessels. Division of the lateral thoracic pedicle will increase the posterior arc.

A B

Anterior arc to neck and thorax Arc to posterior trunk

Lateral arc into thoracic cavity

Fig. 6D-8 

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 Anterior Thorax  •  6D: Serratus Flap 505

FLAP TRANSFER
The flap is transferred to its recipient site based on the location of the defect. When pedicled
into the thoracic cavity, it is helpful to remove at least one or two rib segments as close as
possible to the origin of the vascular pedicle to allow easy passage into the pleural space
without risking kinking or compression of the flap’s blood supply.

FLAP INSET
The muscle is inset based on the requirements of the recipient site. Given the tendency
of the muscle fibers of the origin to become frayed during elevation, sutures should be
placed using a taper needle and should be tied down gently to prevent further damage to
the muscle fibers.

DONOR SITE CLOSURE

A linear or curvilinear skin closure is usually performed at the donor site, with appropriate
drainage to the wound bed.

Clinical Applications
This 65-year-old woman underwent right lower lobectomy for lung cancer. She developed
a stump leak with bronchopleural fistula. She was returned to the operating room for fistula
repair and coverage of the stump with a pedicled serratus flap to help seal the bronchial
stump closure. She healed successfully with no recurrent fistula formation or empyema.

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. (Case supplied by GJ.)

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 506 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old woman developed a dermatofibrosarcoma protuberans of her left lateral

leg above the ankle. She was referred for radical resection and free flap closure. At the time
of resection, her distal fibula and extensor tendons were exposed. Coverage was performed
using a free serratus anterior flap anastomosed to the anterior tibial vessels proximal to the
defect. The flap was skin grafted to complete closure. She healed primarily and had had no
recurrence at 2 years after surgery.

B C

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. (Case
supplied by GJ.)

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 Anterior Thorax  •  6D: Serratus Flap 507

This woman required a functional muscle transplantation for reconstruction of the para-
lyzed right side of her face. A two-stage facial reanimation with a serratus flap was planned.

A B C

D E

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. (Case supplied by GJ.)

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 508 Part II  Regional Flaps: Anatomy and Basic Techniques

This 59-year-old man had a history of squamous cell carcinoma of the oral cavity. He
presented with a persistent salivary fistula 6 months after surgical resection, cervical lymph
dissection, and postoperative radiation therapy. These difficult cases are best reconstructed
with aggressive debridement and muscle flaps to add needed vascularity and fill dead space
to allow healing. A serratus flap was chosen, because it would supply a small amount of
muscle with low morbidity.

A B

C D

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 remucosal-
ize, 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. (Case supplied by
MRZ.)

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 Anterior Thorax  •  6D: Serratus Flap 509

This 65 year-old man had a history of lung cancer and presented with a bronchopleural
fistula after a pneumonectomy and irradiation. Not surprisingly, once the old thoracotomy
was reopened and explored, the latissimus dorsi muscle had been completely divided and
was not available for reconstruction. Fortunately, the serratus muscle was still intact and
available for intrathoracic transposition to bolster the bronchopleural fistula repair.

A B

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. (Case
supplied by MRZ.)

Pearls and Pitfalls

• Early identification and preservation of the thoracodorsal vessel, lateral thoracic vessels,
and long thoracic nerve are essential. Once the vessel and its branches to the serratus
muscle have been identified, the rest of the dissection proceeds rapidly.
• Winging of the scapula will result if the entire muscle is harvested or denervated. How-
ever, segments of the muscle can be elevated to avoid functional deficits and winging of
the scapula. Lower digitations are preferred.
• Any tunnel that is formed must be large enough to avoid vascular compromise.

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 510 Part II  Regional Flaps: Anatomy and Basic Techniques

Expert Commentary
Glyn Jones

Indications
The serratus anterior muscle has most commonly been used as a minor addition to breast
reconstruction at the time of placement. The muscle has a reliable blood supply, particularly
when it is based on the thoracodorsal crossing branch. It is extremely important to protect
the long thoracic nerve supply to the uppermost leaflet of the muscle to prevent winging of
the scapula. Dissection of the anterior portion of the muscle at its costal origins is less than
satisfying, because the fibers often fray during dissection. Dissection is certainly best per-
formed with cautery rather than with scissors. Using this flap as a myoosseous variant does
not provide very well vascularized bone, although inclusion of the tip of the scapula on the
angular artery can give a more reliable reconstruction for mandibular bridging. Elevation
of the serratus fascia can provide useful lateral coverage of an expander or implant placed
at the time of immediate breast reconstruction, but the use of acellular dermal matrices is
rapidly replacing this technique.

Recommendations
Use of the serratus anterior is particularly valuable during intrathoracic reconstruction,
when the latissimus muscle has often been transected by a previous thoracotomy. Thoracic
surgeons are increasingly attempting to preserve the serratus anterior muscle during thora-
cotomy to leave it as a viable reconstructive option for the future. When using the muscle
within the pleural space, it is usually necessary to resect a ­­portion of one or two ribs laterally
to provide an adequate-sized window through which the muscle may pass without causing
compression of the pedicle.

Bibliography With Key Annotations

Botianu PV, Botianu AM, Dobrica AC, et al. Intrathoracic transposition of the serratus ante-
rior muscle flap—personal experience with 65 consecutive patients. Eur J Cardiothorac Surg
38:669-673, 2010.
The authors reported a retrospective analysis of 65 consecutive patients. Intrathoracic transposition of
the serratus anterior (SA) muscle flap was used alone or in association with other flaps and/or thora-
coplasty in patients not amenable to lung resection and/or decortication. The SA was used alone in
16 patients and in combination with other flaps in 49 patients. In 62 patients, the flap was mobilized
using both the thoracodorsal branch and the lateral thoracic vessels. Associated limited rib resection
was performed with an average of 4.9 resected ribs per patient. Mortality was 5% (three patients);
two other patients (3%) developed recurrence of the intrathoracic infection and required reoperation.
Minor local complications were encountered in three patients (skin necrosis, two cases, and external
thoracic fistula, one case). Hospitalization ranged from 4 to 172 days. There was mild impairment of
shoulder mobility in five patients, but no case of true winged scapula. Analysis of the preoperative and
postoperative values of the vital capacity and forced expiratory volume (FEV1) showed no statistically
significant difference.

06d_Serratus_r4_cah_0492-0517.indd 510 1/31/2012 11:42:01 AM

 Anterior Thorax  •  6D: Serratus Flap 511

Chang DW, Miller MJ. A subperiosteal approach to harvesting the free serratus anterior and
rib myo-osseous composite flap. Plast Reconstr Surg 108:1300-1304, 2001.
The serratus anterior and rib myo-osseous composite flap provides vascularized muscle and bone on
a single long pedicle, and because the flap is thin and easily contoured, it is ideal for reconstruction of
defects such as full-thickness defects of the calvaria. The authors report on a modified subperiosteal
technique that minimizes donor site mobility while still maintaining the vascularity to the ribs.
Chun JK, Sterry TP. Latissimus dorsi musculocutaneous flap based on the serratus branch with
microvascular venous augmentation. J Reconstr Microsurg 17:95-98, 2001.
The authors reported a case of a latissimus dorsi myocutaneous flap with microvascular venous super-
charging in an acute ligation of the thoracodorsal vascular pedicle. Through their experience with this
case, they have questioned a common belief that the flap will survive without the thoracodorsal vessels
intact. They noted that risk is minimized when rotation of the flap takes place several weeks after liga-
tion of the vessels. However, they did not think it is prudent to transfer a latissimus flap of significant
size immediately after ligation of the thoracodorsal vessels, unless the vascular supply is enhanced.
Deune EG, Manson PN. Use of the serratus anterior free flap to treat a recurrent oroantral
fistula. J Craniofac Surg 15:335-340, 2004.
The authors discussed the successful use of the serratus anterior free muscle flap to obliterate a recurrent
oroantral fistula in a 39-year-old mane who had sustained a high-velocity impact to the right side of
his face 19 years previously and had undergone multiple corrective surgeries. There was no complica-
tion from the serratus anterior free flap surgery, and no postoperative scapular winging. The serratus
anterior muscle is a versatile flap and ideal for various defects. It should be considered for obliteration
of oroantral fistulas when no local or regional tissue is available because of previous surgery or trauma.
Flügel A, Kehrer A, Heitmann C, et al. Coverage of soft tissue defects of the hand with free
fascial flaps. Microsurgery 25:47-53, 2005.
Coverage of exposed functional structures such as tendons, bones, vessels, or nerves at the dorsal and
palmar surface of the hand requires thin, supple tissue to provide adequate range of motion and a
satisfying aesthetic result. This retrospective study evaluated the functional and aesthetic results after
coverage of the hand with free fascial flaps. From 1994 to 2002, 14 patients underwent free fascial
flap coverage of the hand with four temporoparietal fascia flaps and 11 serratus fascia flaps. Eight
patients were available to be reexamined and answered a questionnaire about their satisfaction with
the functional and aesthetic results. Mean follow-up was 41.7 months. Average active range of motion
of the hand, functional improvement, and the aesthetic result were satisfying in all follow-up patients.
No secondary debulking or other contouring procedures were required. We recommend the use of free
fascial flaps as a valuable alternative to fasciocutaneous or muscle flaps, since the functional results are
excellent, no additional procedures were necessary, and the aesthetic results are appealing.
Fotopoulos P, Holmer P, Leicht P, et al. Dorsal hand coverage with free serratus fascia flap.
J Reconstr Microsurg 19:555-559, 2003.
In reconstructing a defect on the dorsum of the hand, with the extensor tendons exposed or even miss-
ing, functional as well as cosmetic goals are of major importance. The authors presented three cases of
extensor tendon reconstruction, combined with soft tissue reconstruction, with the free serratus fascia
flap, the connective tissue over the serratus muscle, for dorsal hand coverage. The flap consists of thin
and well-vascularized pliable tissue, with gliding properties excellent for covering exposed tendons.
It is based on the branches of the thoracodorsal artery, which are raised in the flap, leaving the long
thoracic nerve intact on the serratus muscle. Coverage of the flap with split-thickness skin graft is done
immediately. The free serratus fascia flap is an ideal flap for dorsal hand coverage when the extensor
tendons are exposed, especially because of low donor-site morbidity.

06d_Serratus_r4_cah_0492-0517.indd 511 1/31/2012 11:42:01 AM

 512 Part II  Regional Flaps: Anatomy and Basic Techniques

Georgescu AV, Ivan O. Serratus anterior-rib free flap in limb bone reconstruction. Microsur-
gery 23:217-225, 2003.
The authors presented their experience in surgical reconstruction of bone lesions in posttraumatic bone
defects, pseudarthrosis, and osteitis by using the free serratus anterior rib flap. The flap was used
in 12 cases: 7 in the upper limb and 5 in the lower limb. The overall immediate success rate in our
series was of 91.7%. They had only one failure, from venous thrombosis. In all successful cases, the
rib showed good integration. This procedure seems to be very useful in the reconstruction of small and
medium bone defects, especially in the upper limb.
Groth SS, Whitson BA, D’Cunha J, et al. Serratus anterior transposition muscle flaps for bron-
chial coverage: technique and functional outcomes. Ann Thorac Surg 88:2044-2046, 2009.
Because of its consistent anatomy, long vascular pedicle, malleability, low complication rate, and low
donor site morbidity, the authors prefer serratus anterior transposition muscle flaps for prophylactic
coverage of irradiated bronchi and treatment of bronchopleural fistulas. They described surgical technique
and outcomes. Serratus anterior transposition muscle flaps can be performed with minimal morbidity
and minimal impairment of upper extremity function.
Halim AS, Wan Z. Anomalous arterial supply to the muscles in a combined latissimus dorsi
and serratus anterior flap. Clin Anat 17:358-359, 2004.
The combined latissimus dorsi and serratus anterior flap has been employed for large defect recon-
struction and has been shown to be reliable. These flaps are based on the subscapular-thoracodorsal
vascular pedicle that usually supplies both muscles. In the case reported, serratus anterior possessed
an anomalous arterial supply totally independent of the subscapular pedicle. The latissimus dorsi
and serratus anterior muscles were used as a combined flap to reconstruct a massive thigh defect. The
combined flap required two arterial anastomoses.
Hallows MR, Parikh DH. Surgical management of children with pyopneumothorax: serratus
anterior digitation flap. J Pediatr Surg 39:1122-1124, 2004.
Spontaneous bronchopleural fistula after childhood empyema remains a surgically challenging condition
to treat and is associated with high morbidity. Four children with pyopneumothorax and associated
spontaneous infective bronchopleural fistula are reported. Drainage of the empyema by thoracotomy
was performed, as well as limited decortication and suturing of a raised digitation of serratus anterior
around the fistula to achieve a successful outcome. The surgical technique of raising a serratus anterior
digitation flap was described.
Ilankovan V, Ramchandani P, Walji S, et al. Reconstruction of maxillary defects with serratus
anterior muscle and angle of the scapula. Br J Oral Maxillofac Surg 49:53-57, 2011.
Large maxillary defects ideally require reconstruction with a free flap. Varied classifications have been
reported to describe maxillary/orbital defects. The authors reported their experience with free flaps in
treating large maxillary defects using composite tissue of serratus anterior muscle and the angle of the
scapula. Eleven patients (six men and five women; age range 42 to 69 years) were studied retrospec-
tively and the outcome recorded. The authors concluded that the composite flap is versatile enough to
reconstruct maxillary defects of various sizes.
Kalavrezos N, Hardee PS, Hutchison IL. Reconstruction of through-and-through osteocu-
taneous defects of the mouth and face with subscapular system flaps. Ann R Coll Surg Engl
87:45-52, 2005.
Major ablative surgery in the head and neck region may create composite defects involving the oral
mucosa, bone, and the overlying facial skin. The large surface area and the three-dimensional nature
of these defects pose a difficult reconstructive challenge requiring adequate bone and large, positionally
versatile skin flaps. From September 1993 to May 2000, 19 patients with through-and-through
osteocutaneous defects of the mouth and face underwent reconstruction with composite subscapular
artery system flaps. Ten variants of scapular osteocutaneous flaps, eight latissimus dorsi with serratus

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 Anterior Thorax  •  6D: Serratus Flap 513

anterior and rib osteomyocutaneous flaps, and one combination of an osteocutaneous scapular and
myocutaneous latissimus dorsi flap were used. Mean dimensions were skin 54.4 cm2, mucosa 56.2 cm2,
and bone 8.2 cm. Ischemic complications occurred in three patients, including one total flap failure and
one failure of the bony component, both in patients who had previously undergone radiation therapy.
The third flap was successfully salvaged. No significant long-term donor site morbidity was noted.
Kim PD, Blackwell KE. Latissimus-serratus-rib free flap for oromandibular and maxillary
reconstruction. Arch Otolaryngol Head Neck Surg 133:791-795, 2007.
Through a retrospective medical record review, the authors assessed complications and outcomes as-
sociated with latissimus-serratus-rib free flap oromandibular and midface reconstruction. Twenty-eight
patients with segmental resection of the mandible were identified, and one patient with combined
resection of the mandible and maxilla after excision of neoplasms of the oral cavity, who were poor
candidates for fibula free flap reconstruction. Twenty-seven latissimus-serratus-rib osteomyocutaneous
free flap reconstructions and two serratus-rib osteomuscular free flap reconstructions were performed.
There were no perioperative free flap failures. Delayed partial rib graft resorption occurred in one
patient 33 months after free flap transfer for maxillary reconstruction. Among 28 cases of mandibular
reconstruction, one case of bone graft nonunion was noted after 57 months. All other cases achieved
successful restoration of mandibular continuity. Donor site morbidity was well-tolerated in all patients.
Lin CH, Yazar S. Revisiting the serratus anterior rib flap for composite tibial defects. Plast
Reconstr Surg 114:1871-1877, 2004.
This article reported the benefits of the serratus anterior flap, with or without latissimus dorsi muscle. It
can provide a large composite osteomyocutaneous flap for one-stage reconstruction of three-dimensional
bilateral tibial-fibular defects.
Lipa JE, Chang DW. Lateral thoracic artery as a vascular variant in the supply to the free ser-
ratus anterior flap. J Reconstr Microsurg 17:413-415, 2001.
The authors described a case in which the dominant blood supply to a subperiosteally harvested ser-
ratus anterior muscle and rib composite myoosseous free flap came from the lateral thoracic artery.
There were no other associated features in this patient to warn of the vascular variant. Reconstructive
surgeons should be aware of possible variations in the vascular anatomy of this flap.
Meyer AJ, Krueger T, Lepori D, et al. Closure of large intrathoracic airway defects using ex-
trathoracic muscle flaps. Ann Thorac Surg 77:397-404; discussion 405, 2004.
The authors reported a prospective assessment of pedicled extrathoracic muscle flaps for the closure of
large intrathoracic airway defects after noncircumferential resection in situations in which an end-to-end
reconstruction seemed risky (defects of less than 4 cm length, desmoplastic reactions after previous infec-
tion or radiochemotherapy). From 1996 to 2001, 13 intrathoracic muscle transpositions (6 latissimus
dorsi and 7 serratus anterior muscle flaps) were performed to close defects of the intrathoracic airways
after noncircumferential resection for tumor, large tracheoesophageal fistula, delayed tracheal injury,
and bronchopleural fistula. In two patients, the extent of the tracheal defect required reinforcement of
the reconstruction by use of a rib segment embedded into the muscle flap followed by temporary tracheal
stenting. Patient follow-up was by clinical examination bronchoscopy and biopsy, pulmonary function
tests, and dynamic virtual bronchoscopy by CT scan during inspiration and expiration. The airway
defects ranged from 2 by 1 cm to 8 by 4 cm and involved up to 50% of the airway circumference.
They were all successfully closed using muscle flaps with no mortality, and all patients were extubated
within 24 hours. Bronchoscopy revealed epithelialization of the reconstructions without dehiscence,
stenosis, or recurrence of fistulas. The flow-volume loop was preserved in all patients and dynamic
virtual bronchoscopy revealed no significant difference in the endoluminal cross surface areas of the
airway between inspiration and expiration above, at the site, and below the reconstruction. Intrathoracic
airway defects of up to 50% of the circumference may be repaired using extrathoracic muscle flaps when
an end-to-end reconstruction is not feasible.

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 514 Part II  Regional Flaps: Anatomy and Basic Techniques

Mohammed F, Romany S, Bissoon D, et al. Latissimus dorsi muscle flap based on arterial branch
to serratus anterior as salvage of a failed bipedicled transverse rectus abdominis muscle flap. A
case report. West Indian Med J 52:68-70, 2003.
The authors presented a case of a failed bipedicled (unilateral rectus flap with superior epigastric pedicle
preserved and inferior epigastric vessels anastomosed to the thoracodorsal trunk as the second pedicle)
transverse rectus abdominis muscle flap that had compromised the dominant pedicle of the latissimus
dorsi muscle. A salvage procedure was possible using this muscle as a pedicle flap based on the back-
flow from the serratus anterior arterial branch with success. The use of the reconstructive ladder was
highlighted.
Nava MB, Ottolenghi J, Pennati A, et al. Skin/nipple sparing mastectomies and implant-based
breast reconstruction in patients with large and ptotic breast: oncological and reconstructive
results. Breast 2011 Mar 22. [Epub ahead of print]
The authors performed 77 procedures on 65 patients with large or medium-sized breasts, fulfilling
the oncologic criteria for skin-sparing mastectomy. All operations were performed as a single-stage
procedure, with an anatomic prosthesis inserted into a compound pouch formed from the pectora-
lis major, serratus anterior fascia, and a lower dermal adipose flap. The median size of the ana-
tomic implants was 444.3 cc. The implant removal rate was 14.2%. At a median follow-up of
36 months, the authors reported a 0.5% local recurrence rate per year. The overall specific survival rate
was 98.2%. This study confirmed the safety and effectiveness of this technical variation of skin and
nipple-sparing mastectomies. All breast, irrespective of mammary shape and size, can be reconstructed
with medium-sized implants and, if necessary, contralateral adjustments. The overall complication
rate was in keeping with previous studies.
Ozçelik D, Uğurlu K, Turan T. Reconstruction of the replanted hand with latissimus dorsi
muscle and serratus anterior fascia combined flap. J Reconstr Microsurg 19:153-156, 2003.
Reconstruction with the latissimus dorsi muscle flap, combined with the serratus anterior fascia flap,
was performed to cover two large and separate palmar and dorsal forearm skin defects in a patient whose
hand had been replanted 20 days earlier after traumatic amputation at the distal forearm level. As
a result, a total forearm amputation was salvaged by microsurgical replantation and a free combined
flap of the subscapular system. This new application of the combined flap allowed the reconstruction
of large and separate wounds of the replanted hand and provided gliding surfaces for tendons.
Patrick J, Frank W, Theodora M, et al. The pedicled serratus anterior muscle wrap-around
flap: a treatment option in the management of posttraumatic axillary neuroma and neuropathic
pain. Ann Plast Surg 65:170-173, 2010.
The authors discussed a new field of application of the pedicled serratus anterior muscle flap. Severe
axillary neuropathic pain and distress from neuroma formation were treated by wrapping the pedicled
serratus anterior muscle flap around the brachial plexus. Covering the fascicles by well-vascularized
muscle tissue results in significant postoperative pain relief. They described a new method in the treat-
ment of severe neuropathic pain syndromes originating from the brachial plexus, with good result.
Pittet B, Mahajan AL, Alizadeh N, et al. The free serratus anterior flap and its cutaneous compo-
nent for reconstruction of the face: a series of 27 cases. Plast Reconstr Surg 117:1277-1288, 2006.
The serratus anterior flap is commonly used without its cutaneous component and is covered with
a skin graft. The authors successfully used the free serratus anterior flap along with its skin paddle
and found it to be valuable for reconstruction of the face. Fresh cadaveric dissections and arteriography
were performed to identify perforator vessels to the skin overlying the muscle. Clinically, free transfer
of the musculocutaneous flap to the face was carried out in 27 patients, mostly for severe noma (infec-
tion) sequelae. Anatomic dissection and arteriography revealed no cutaneous perforator vessels directly
communicating with the vascular pedicle of the muscle. However, large perforators from the intercostal
vessels were found passing through the muscle to reach the skin. In the clinical cases, flap survival was
100% in 24 patients.

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 Anterior Thorax  •  6D: Serratus Flap 515

Riboh J, Nigriny J, Chong A, et al. Optimization of microsurgery: improved coverage of the

latissimus dorsi vascular pedicle with vascularized serratus fascia. Ann Plast Surg 58:109-111, 2007.
The latissimus dorsi free flap is a workhorse for extremity reconstruction. One of its benefits is a long
vascular pedicle that spans the zone of injury. However, it may be difficult to adequately cover this
pedicle. Direct closure may be too tight, and skin grafting over the pedicle risks exposure if graft take is
poor. We report a technique in which the serratus branch of the thoracodorsal artery and its overlying
fascia are harvested en bloc with the thoracodorsal artery and latissimus muscle. This provides 2 flaps
on a common pedicle that can easily be rotated to allow positioning and insetting. We successfully used
this technique in the reconstruction of both upper and lower extremities. The serratus fascia provides
excellent padded covering and is a good bed for skin grafting. The versatility of this hybrid flap will
allow its use in a range of complex reconstructive procedures.
Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus
anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg 125:1057-
1064, 2010.
Postmastectomy partial submuscular tissue expander placement can prevent the upper pole fullness
commonly seen with complete submuscular prosthesis placement. The resultant inferior and lateral
margins require coverage to prevent prosthesis exposure. The fascial layer overlying the serratus ante-
rior muscle can be used as an alternative to previously defined techniques to provide composite lateral
coverage. This method offers adequate coverage, prevents expander lateralization, and minimizes
use of allogenic material. This study reported the anatomy, surgical procedure, clinical outcomes, and
aesthetics following use of the serratus anterior fascial flap for lateral expander coverage in postmastec-
tomy expander-based breast reconstruction. Twenty-two patients (31 breasts) who underwent breast
reconstruction with serratus fascia were included in a retrospective case-note analysis after approval
by the institutional review board. Demographics, perioperative factors, postoperative complications,
patient satisfaction, and aesthetics were recorded as relevant endpoints. Ten fresh cadaver hemichests
were dissected, and the serratus fascia for each was measured for length and width. At a mean follow-
up of 197 days (range 71 to 370 days), seroma occurred in two breasts, wound infection occurred in
one breast, partial mastectomy skin flap necrosis occurred in four breasts, and minor wound dehiscence
occurred in one breast. There was no incidence of capsular contracture or hematoma. Four patients (five
breasts) reported very mild tightness or banding in the lateral chest wall. The mean length of cadaver
serratus fascia was 164.3 mm and the mean width was 122.8 mm.
Saint-Cyr M, Nagarkar P, Wong C, Thakar H, Dauwe P, Rohrich RJ. The pedicled subpectoral
fascia flap for expander coverage in postmastectomy breast reconstruction: a novel technique.
Plast Reconstr Surg 125:1328-1334, 2010.
In expander-based breast reconstruction, providing adequate tissue coverage of the prosthesis is neces-
sary to prevent complications. The authors previously described the use of the serratus anterior fascia
for this purpose, but when this fascia is unavailable or inadequate, the subpectoral fascia can be used.
This study described the anatomy of the subpectoral fascia, the surgical technique for harvesting it, and
an algorithm for choosing between the serratus and subpectoral fascia flaps. Clinical and functional
outcomes following use of the subpectoral fascia in expander-based breast reconstruction were reported.
Seify H, Mansour K, Miller J, Douglas T, Burke R, Losken A, Culbertson J, Jones G, Nahai
F, Hester TR. Single-stage muscle flap reconstruction of the postpneumonectomy empyema
space: the Emory experience. Plast Reconstr Surg 120:1886-1891, 2007.
Postsurgical chronic empyema continues to present a complicated treatment scenario for thoracic and
reconstructive surgeons. Muscle flaps are an important option in the management of complex thoracic
wounds. This study was designed to report the Emory experience with muscle flaps for the management
of complex postsurgical empyema. The authors also presented their treatment algorithm for managing
empyema thoracis. They retrospectively reviewed the charts of 55 patients requiring different treatment
modalities, including muscle flap transposition. Patients were divided into four groups according to the

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 516 Part II  Regional Flaps: Anatomy and Basic Techniques

initial thoracic procedure: no surgical resection; postpneumonectomy; postlobectomy; and prophylactic

postpneumonectomy or postlobectomy. The study included 42 men (76.4%) and 13 women with a
mean age of 62 years (range 39 to 77 years). Fifty-one muscle flap procedures were performed in 42
patients (serratus anterior flaps, 16 patients and 23 flaps; latissimus dorsi flaps, 16 patients and 18
flaps; pectoralis major muscle flaps, intercostal muscle flaps, and rectus abdominis flaps, three patients
each: omental flap, one patient). The mean number of ribs resected before flap intervention, usually
during the open window thoracostomy, was three. The average time from initial thoracic operation
to flap intervention was 4 months. Average time from flap intervention to discharge was 12.5 days.
Average hospital stay was 26.6 days. The 51 muscle flaps represented an average of 1.2 procedures
per patient. The authors concluded that because of the excellent blood supply of extrathoracic muscle
flaps and their ability to reach any place in the pleural cavity, they represent an ideal tissue with which
to fill the contaminated pleural space.
Takeishi M, Ishida K, Makino Y. The thoracodorsal vascular tree-based combined fascial flaps.
Microsurgery 29:95-100, 2009.
In this study, combined fascial flaps pedicled on the thoracodorsal artery and vein were raised and used
for thin coverage of dorsal surfaces of the fingers and the dorsum of hand and foot with favorable results.
The combined flaps consisted of the serratus anterior fascia and the axillary fascia at the entrance of the
latissimus dorsi. These flaps were used for reconstruction of the hand, fingers, wrist and palm, forearm,
lower leg, or foot in nine patients. Reconstruction was performed for burn or burn scar contracture,
after resection of malignant tumors, posttraumatic skin defects, and chronic regional pain syndrome.
The flaps were used in various configurations, including two independent fascial flaps, two-lobed
fascial flap with separate feeding vessels, and composite fascial and thoracodorsal artery perforator flap.
The fascial and skin flaps survived in all nine patients, with favorable results both functionally and
aesthetically. Good coverage of soft tissue defects and good recovery of range of motion in resurfaced
joints were achieved. There were no complications. The scars at the sites of harvest were not noticeable.
Tsukada H, Osada H. Reconstruction of the hemidiaphragm and hemipericardium using com-
bined reversed latissimus dorsi and serratus anterior muscle flaps. Surg Today 36:291-293, 2006.
The authors used autologous tissue for reconstruction of intrathoracic structures after extrapleural
pneumonectomy in six patients. The resected areas of the hemidiaphragm and hemipericardium were
reconstructed using combined reversed latissimus dorsi and serratus anterior muscle flaps. Based on
their results, they concluded that the combined reversed latissimus dorsi and serratus anterior muscle
flaps are broad enough to cover any defect within the hemithorax, and that this technique is the best
choice for multisite reconstruction after extrapleural pneumonectomy.
Ulrich D, Fuchs P, Bozkurt A, et al. Free serratus anterior fascia flap for reconstruction of hand
and finger defects. Arch Orthop Trauma Surg 130:217-222, 2010.
Reconstruction of the dorsal surface of hand defects requires thin, pliable, well vascularized tissue with
a gliding surface for the extensor tendon course. Also, defects of the palmar hand and degloved fingers
need nonbulky soft tissue for reconstruction. The authors presented a retrospective analysis of nine
patients with free serratus anterior fascia flaps used to cover defects of the palmar and dorsal hand
and of degloved fingers. Three of the patients had limited range of hand motion from full-thickness
burns; one patient had defects of the dorsum of one hand after an acute burn injury; two patients had
an acute trauma of the dorsum of the hand with extensor tendon injury; one patient had a soft tissue
defect of his thumb and dorsal hand from an avulsion injury; one had a dorsal defect of three fingers
after degloving injury; and one had a palmar defect after an industrial crush injury with exposed
tendons, vessels, and nerves. The flaps were applied as pure fascial flaps with an immediate partial-
thickness skin graft. One patient developed partial necrosis of less than 10% of his flap. All other
flaps survived completely. Two of the patients presented wound healing problems of the skin graft that
healed secondarily. All patients recovered useful hand function without a bulky contour of their hand
or fingers. Except for the scar, no donor-site morbidity was reported.

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 Anterior Thorax  •  6D: Serratus Flap 517

Ulrich D, Pallua N. Treatment of avulsion injury of three fingers with a compound thoracodor-
sal artery perforator flap including serratus anterior fascia. Microsurgery 29:556-559, 2009.
Complete degloving injury of three digits not amenable to revascularization may leave poor cosmetic
and functional results. The authors used a compound thoracodorsal artery perforator (TDAP) flap
in a 34-year-old, right-handed man with a traumatic degloving injury. The flap consisted of a thin,
nonbulky skin component isolated on two perforators in combination with serratus fascia, both pedicled
on the thoracodorsal vessels. The mobility of the two flap components allowed the palmar and dorsal
part of the fingers to be reconstructed without relying on multiple flaps or anastomoses. The skin
component of the TDAP flap was transferred to the palmar defect, the serratus fascia flap to the
dorsal part of the fingers and sutured loosely. Coverage of the serratus anterior fascia was done with
split-thickness skin graft. Both components of the flap survived completely. One month after the first
operation, the surgical syndactyly between the middle and ring finger was separated, one month later
the syndactyly between the ring and little finger. Good coverage of the soft tissue defects with good
function could be achieved. There were no donor site problems.
Van Landuyt K, Hamdi M, Blondeel P, et al. The compound thoracodorsal perforator flap in
the treatment of combined soft tissue defects of sole and dorsum of the foot. Br J Plast Surg
58:371-378, 2005.
Nine cases of massive soft tissue loss of the foot were reconstructed by means of a compound (chimera)
thoracodorsal artery perforator (TDAP) flap, which reconstituted the different functional units (dorsum,
heel, instep, weight-bearing surface). In each case, the flap consisted of a skin component isolated on its
perforator in combination with a portion of latissimus dorsi muscle and/or serratus fascia, all pedicled
on the thoracodorsal vessels. The pedicle length allows up to 4 to 6 cm of independent mobility of the
skin island. The mobility of the various flap components allows the various functional units of the foot
to be reconstructed without relying on multiple flaps or anastomoses. The pedicle length was sufficient
to be able to perform the anastomosis out of the zone of injury. In some cases the skin island was
harvested along with intercostal nerve branches, this provided the potential to develop a sensate flap.
Woo E, Tan BK, Lim CH. Treatment of recalcitrant air leaks: the combined latissimus dorsi-
serratus anterior flap. Ann Plast Surg 63:188-192, 2009.
Pleural space problems after lung resection and persistent air leaks are among the most common chal-
lenges posed to thoracic surgeons. Surgical repair of air leaks is indicated when conventional tube tho-
racostomy has failed to solve the problem. The authors proposed the novel application of the combined
latissimus dorsi–serratus anterior transposition flap for selected cases of air leaks that are recalcitrant
to conventional treatment. Five male patients between 32 and 70 years of age underwent the proce-
dure between 2004 and 2007. Four patients had alveolar-pleural fistulas resulting in persistent air
leaks; the fifth patient also had a space problem following lung volume reduction surgery. All patients
had undergone prolonged treatment with chest drains without success. With the patient in a lateral
decubitus position, a lazy-S incision was used to expose the entire latissimus dorsi and the proximal
slips of the serratus anterior muscles. They were raised as pedicled flaps and transferred in tandem.
The latissimus dorsi was introduced into the pleural cavity through a thoracic window and used to
reinforce the fistula repair. The serratus anterior muscle closed the rib window. In all cases, the lungs
reexpanded and chest drains were removed within 5 days after surgery. There were no recurrent air
leaks at 1-year follow-up.

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 ANATOMIC LANDMARKS
Landmarks A flat, trapezoidal muscle on the superficial anterior chest wall.
Related superiorly to the clavicle and deltoid muscle and infe-
riorly to the rectus abdominis and external oblique muscles.
Size 23 3 15 cm.
Origin The clavicle, the sternum, and the fifth and sixth ribs.
Insertion The lateral lip of the bicipital groove of the humerus.
Function Adducts and medially rotates the arm.
Composition Muscle, myocutaneous.
Flap Type Type IV.
Dominant Pedicle Pectoral branch of thoracoacromial artery.
Minor Pedicles Pectoral branch of lateral thoracic artery and internal mammary
perforating arterial branches from first to sixth intercostal spaces.
Nerve Supply Motor: Medial pectoral nerve. Sensory: Anterior intercostal nerves.

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 Section 6E
Anterior Thorax

Pectoralis Major Flap

CLINICAL APPLICATIONS
Regional Use
Face
Oral cavity
Head and neck
Anterior chest
Sternum and mediastinum
Axilla
Upper extremity (shoulder)
Distant Use
Head and neck
Functional muscle
Specialized Use
Mandible
Esophagus
Breast
Functional muscle

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 ANATOMY OF THE pectoralis Major Flap

A B
Lateral thoracic artery Thoracoacromial
Pectoralis artery
Deltoid muscle Pectoral branch of
major muscle
thoracoacromial artery

Perforating
branches
of internal
mammary
artery

Pectoral
branch of
Latissimus lateral thoracic
dorsi muscle artery

Serratus
anterior muscle

External
oblique muscle
Pectoralis musculature Pectoralis major vascular anatomy

C Medial or inferior
pectoral nerve Lateral or superior
pectoral nerve

Intercostal
sensory
nerves

Lateral
thoracic
nerve

Motor and sensory innervation

Fig. 6E-1 

Dominant pedicle: Pectoral branch of thoracoacromial artery

Minor pedicles: Perforating branches of internal mammary artery

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 Anterior Thorax  •  6E: Pectoralis Major Flap 521

Anatomy
Landmarks A flat, trapezoidal muscle on the superficial anterior chest wall. It is related su-
periorly to the clavicle and deltoid muscle and inferiorly to the rectus abdominis
and external oblique muscles. Deep to it lie the pectoralis minor, serratus anterior,
intercostal muscles, and ribs.
Composition Muscle, myocutaneous.
Size Muscle: 23 cm long 3 15 cm wide; skin: 6 3 12 cm.
Origin The medial half of the clavicle, the anterior surface of the sternum, the fifth and
sixth ribs, and the aponeurosis of the external oblique muscle
Insertion The muscle fibers converge toward the axilla, and the tendon inserts into the
lateral lip of the bicipital groove of the humerus.
Function The pectoralis major adducts and medially rotates the arm.

Arterial Anatomy (Type IV)

The thoracoacromial pedicle enters the muscle on its deep surface at approximately the junction
of the middle and lateral third of the clavicle. The perforating branches of the internal mammary
artery enter on the deep surface in each intercostal space approximately 1.5 to 2 cm from the ster-
nal edge. They vary in size from space to space; however, the pedicle in the second interspace is
consistently larger than the others.
Dominant Pedicle  Pectoral branch of thoracoacromial
Regional Source  Subclavian artery.
Length  4 cm.
Diameter  2 to 2.5 mm.
Location  Emerges below the clavicle and enters the deep surface of the upper border of the
muscle approximately at the junction of the middle and lateral third of the clavicle.
Minor Pedicle  Pectoral branch of lateral thoracic artery
Regional Source  Subclavian artery.
Length  3 to 4 cm.
Diameter  1 to 2 mm.
Location  Emerges below the clavicle and enters the deep surface of the upper border of the
muscle 3 or 4 cm lateral to the thoracoacromial branches.
Minor Segmental Pedicle  Internal mammary perforating arterial branches through first to
sixth intercostal spaces

Venous Anatomy
Single veins accompanying the arterial circulation; the average venous diameter is 1 to 2 mm.

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 522 Part II  Regional Flaps: Anatomy and Basic Techniques

Nerve Supply
Motor The lateral or superior pectoral nerve originates from the lateral cord of the brachial
plexus and is located lateral to the axillary artery. It enters the muscle on its deep
surface in close proximity to the dominant vascular pedicle. It innervates the
clavicular and anteromedial portions of the sternal heads of the muscle. The medial
or inferior pectoral nerve originates from the medial cord of the brachial plexus and
lies medial to the axillary artery. It passes between the axillary artery and vein
to enter the pectoralis minor muscle on its deep surface. It supplies the pectoralis
minor muscle, and then two or three branches pass into the pectoralis major to
supply the posterolateral portions of the muscle.
Sensory The second through seventh intercostal nerves provide segmental sensory in-
nervation to the overlying skin.

Vascular A natomy of the Pectoralis M ajor Flap

A

Deep surface of right-sided pectoralis major flap

Closeup view of flap base

Fig. 6E-2 

Dominant pedicle: Pectoral branch of thoracoacromial artery (D)

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 Anterior Thorax  •  6E: Pectoralis Major Flap 523

Deep surface of right reverse (turnover) flap

demonstrating segmental mammary
perforating vessels

D E
D

s
s

Deep surface of flap Radiographic view

Fig. 6E-2 

Dominant pedicle: Pectoral branch of thoracoacromial artery (D)

Minor pedicles: Perforating branches of internal mammary artery (s)

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 524 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings for Standard Muscle Flap
The cutaneous territory of the pectoralis major lies between the parasternal line and the
anterior axillary line and extends from the clavicle to the sixth intercostal space.
The clavicle marks the upper border of the muscle and the sternum its medial border,
extending down to the seventh rib. The anterior axillary fold marks the anterolateral border.
It is useful to outline these landmarks preoperatively in a standing patient. All or portions
of the muscle and the overlying skin may be included, depending on the design of the flap
and the requirements of the defect.
The entire overlying skin on the muscle or smaller islands of skin may be elevated. A
variety of skin islands have been designed on the pectoralis major. The exact design, size,
shape, and position of the skin island will vary with the requirements of the defect. For
head and neck reconstruction in women, the breast can interfere with flap design. The
skin island is located below the breast at or just above the inframammary crease to main-
tain aesthetics and not carry breast tissue into the reconstruction. In men, the skin island is
located anywhere over the muscle and is usually vertically oriented.
In certain situations, the skin island should be designed and the flap elevated with
preservation of the deltopectoral flap for possible later use in head and neck reconstruction.
However, aesthetic considerations can prevail and dictate avoiding vertical scars and using
a horizontal skin island design.

A 1 2 B 1 2
b

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 inci-
sion 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.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 525

For sternotomy wounds, turnover and advancement flaps are usually exposed through
the midline incision or the existing wound. Occasionally, a counterincision in the delto-
pectoral groove is required for muscle release. Ideally, the skin island design should not
extend below the inferior border of the pectoralis major muscle, because its blood supply
then becomes increasingly random. Flap delay should be considered if more flap is needed.

Patient Positioning
The patient is positioned in the supine position for both flap harvest and inset.

Guide to Flap Dissection

Standard Muscle Flap
The muscle can be dissected from an overlying incision, midline scar, or wound. The
overlying skin is dissected off the muscle, and the entire superficial surface of the muscle
is exposed. Submuscular dissection is facilitated by use of a lighted mammary retractor.
When a head and neck flap is planned, the lateral free border of the pectoralis major
is elevated to expose the underlying pectoralis minor muscle, and the muscle is divided
laterally to release it from its humeral insertion.
The thoracoacromial pedicle is visualized on the deep surface of the muscle located
laterally at the junction of the medial two thirds and lateral third of the clavicle and is spared.
The segmental perforating branches from the internal mammary artery are visualized within
5 to 6 cm of the midline and are left in situ in case a deltopectoral flap is required later. The
medial muscle is divided lateral to these mammary perforators, and the muscle division is
tapered proximally to the thoracoacromial pedicle to improve rotation.

A B

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.

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 526 Part II  Regional Flaps: Anatomy and Basic Techniques

C D

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)
•  Reverse (turnover) flap
•  Vascularized bone
•  Functional muscle flap
•  Tissue expansion
Myocutaneous Advancement Flap
The myocutaneous flap is based on the thoracoacromial blood supply. Only a central strip
of muscle carrying the vascular pedicle needs to be harvested, unless muscle is also required
for the reconstruction. The skin island is incised around its periphery, and dissection is taken
down to the muscle fascia. The intervening skin between the clavicle and the proximal end
of the harvested skin island is elevated to expose the underlying pectoralis major muscle belly.
With a Doppler probe the exact location of the thoracoacromial vessels can be identified,
although they consistently lie at the junction of the mid and lateral thirds of the clavicle. The
distal end of the muscle underneath the skin island is elevated from the chest wall and the

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 Anterior Thorax  •  6E: Pectoralis Major Flap 527

subpectoral plane is entered. Gentle submuscular finger dissection frees it up in a cephalad

direction, allowing insertion of a lighted fiberoptic retractor to visualize the thoracoacro-
mial vessels beneath the muscle. A suitable narrow strip of muscle containing the pedicle is
then incised with cautery from either side of the skin island up to the clavicle, taking care
to protect the pedicle. The narrower the muscle segment at the clavicle, the easier the flap
rotation. The flap is then delivered through the infraclavicular incision in preparation for
tunneling or directly transposing the flap up into the neck, face, or oral cavity.

Muscle Advancement (Slide)

If the flap is to be used as an advancement muscle flap for central defects based on the
thoracoacromial pedicle, the origin is divided through the dissection field with division of
mammary perforators. The thoracoacromial pedicle is visualized on the undersurface of
the muscle, and the muscle is advanced centrally, either unilaterally or bilaterally. If more
muscle advancement is required, the insertion of the muscle can be divided lateral to the
thoracoacromial pedicle, either unilaterally or bilaterally. This technique may not cover
lower sternal wounds well (see Reverse flap).

A B

Fig. 6E-5   A, Bilateral pectoralis major flaps for a central sternal defect. The muscle has been re-
leased 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.

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 528 Part II  Regional Flaps: Anatomy and Basic Techniques

Reverse (Turnover) Flap

Sternal Coverage
Better coverage of the sternum can sometimes be obtained by using the muscle based on its
internal mammary supply. This significantly reduces blood flow to the overlying skin, ren-
dering it more susceptible to marginal necrosis at the midline. Once the muscle is exposed,
the distal insertion to the humerus is cut within the anterior axillary line. This results in
loss of the anterior axillary fold’s definition, unless the distal pectoral stump from the hu-
meral insertion is sutured to the more medial pectoralis minor muscle belly. An alternative
approach is to make an L-shaped cut in the distal muscle, leaving a thin caudal strip still
attached to the chest wall. This preserves the anterior axillary fold contour. The superior
border of the muscle is then freed off the clavicle as the distal cut end is turned over and
retracted medially to expose the undersurface of the pectoralis major. The surgeon will
encounter the thoracoacromial vessels at the junction of the lateral and middle thirds of the
muscle just below the clavicle. These vessels should be securely suture-ligated or clipped,
because they are sizable. Once the muscle is fully delivered into the mediastinal wound, its
undersurface is superficial and the medial internal mammary perforators are clearly visible
between the costal cartilages.

A B

Fig. 6E-6   A, An L-shaped incision is made in

the pectoralis major muscle insertion to maintain
the anterior axillary fold; the thoracoacromial ves-
sels are identified and cut on the deep surface
of the flap. B, The muscle is turned over to ex-
pose 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
inferiorly and the upper flap superiorly.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 529

Because this turnover flap has a segmental blood supply, it may be split into two or
three separate medially based flaps. The muscle is split in the direction of the fibers, later-
ally to medially. This allows an improved arc of rotation for these turnover flaps to provide
complete sternal coverage and is particularly useful for enabling some muscle to reach the
problematic inferior portion of the sternal wound.

Vascularized Bone
Vascular communications are present between the fibers of the muscle and the periosteum
of the fifth and sixth ribs at its costal origins, permitting transposition of the pectoralis
muscle with rib. This vascularized flap will reach intraoral defects and may be used for
mandibular reconstruction. A portion of the sternum may also be elevated with this flap
as vascularized bone.
The rib is divided at the costochondral junction. The intercostal muscles are then divided
and the rib mobilized off the underlying pleura. Dissection or injury to the periosteum
must be avoided. When a sufficient length of rib has been mobilized, the rib is divided
laterally and the rest of the dissection continues as described for standard flap elevation. In
a similar fashion, the outer table of the sternum may be mobilized with the fibers of origin
of the pectoralis.

A B

Fig. 6E-7  Vascularized bone territory.

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 530 Part II  Regional Flaps: Anatomy and Basic Techniques

Functional Muscle Flap

The pectoralis major is a tertiary choice for functional transfer. Based on the dominant
thoracoacromial pedicle and lateral (superior) pectoral nerve, it may be transferred to the
upper arm for elbow flexion.
The pectoralis is a useful functional muscle transfer for elbow flexion. The incision is
made along the anterior axillary line; through that incision the pectoralis is visualized and
the skin and subcutaneous tissue are dissected off the muscle for complete muscle expo-
sure. An innervated portion of the muscle is then outlined. The origin is taken down and
the muscle mobilized from its origin toward its insertion, preserving the thoracoacromial
blood supply and the motor nerves. The muscle is tunneled through the axilla onto the
upper extremity and sutured to the biceps tendon while stretched to an appropriate tension.

Tissue Expansion
Preliminary expansion of the adjacent skin or the muscle may be helpful in enlarging the
flap or minimizing the donor defect. Expansion is helpful and often necessary for the place-
ment of submuscular implants in breast reconstruction. However, the usual transpositions
of the flap do not require prior expansion.

Arc of Rotation
Muscle and Myocutaneous Flap
Head and Neck
Based on the single dominant thoracoacromial pedicle, the muscle will provide coverage
for the head and neck up to the level of the inferior orbital rim. Division of the muscle is
required at both origin and insertion, taking care to preserve the thoracoacromial pedicle.
Tapering the muscle division near the pedicle improves the flap’s arc of rotation. Extension
of the skin paddle will increase the arc of rotation, but a delay procedure may be required.

A B

Standard arc to middle third of face Extended arc to zygomatic arch

Fig. 6E-8 

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 Anterior Thorax  •  6E: Pectoralis Major Flap 531

Intrathoracic Cavity
An island pectoralis muscle flap based on the dominant thoracoacromial pedicle will provide
intrathoracic filling for the upper part of the thoracic cavity. To place the muscle into the
intrathoracic cavity, portions of the second, third, or fourth ribs closest to the pedicle are
resected to allow the island muscle flap to be placed in the chest cavity.

A B

Arc to intrathoracic cavity

Fig. 6E-9 

Sternum
A standard island pectoralis flap based on the thoracoacromial vessels will easily advance to
cover anterior chest defects and provide sternal fill.

Arc to sternum

Fig. 6E-10 

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 532 Part II  Regional Flaps: Anatomy and Basic Techniques

Reverse Flap
The turnover flap based on the minor segmental pedicles is used predominantly for cover-
age of the sternum and mediastinum and easily reaches across the midline. This modified
flap will preserve the anterior axillary fold.

Turnover flap based medially on internal

mammary perforator

Fig. 6E-11 

Flap Transfer
Head and Neck
Once the flap is isolated on the thoracoacromial pedicle, the flap is transferred to the head
and neck by direct transposition or subcutaneous tunnel. Care must be taken to ensure that
there is no tension or compression on the pedicle.

Sternum
Both direct and reverse flaps are directly transposed into the sternal defect. When possible,
sternal fill is provided by advancing the muscles fully into the defect. One must be care-
ful to cover the inferiormost part of the wound, because this is the area of highest failure.

Intrathoracic
A window in the thorax created by rib and muscle removal allows the muscle to be directly
transposed into the chest. The window should be located near the pedicle origin.

Flap Inset
For head and neck reconstruction, the muscle and the skin island are sutured into the defect
without tension. For sternal coverage, the muscle is sutured into the sternal wound over
suction drains. Given the tendency of muscle to tear when sutured, it is helpful to use 2-0
or 3-0 Vicryl horizontal mattress sutures to minimize muscle fraying. The muscle can be
stabilized for intrathoracic use by sutures at the entry to the chest as well as intrathoracic
tacking sutures or fibrin glue.

Donor Site Closure

The donor defect is usually closed directly for small skin islands. Larger skin islands require
a skin graft or a secondary flap to close the donor area. The donor site can be closed directly
for sternal wound coverage by wide skin undermining. When rib is harvested with overly-
ing skin, an abdominal flap is preferable for closure of the donor defect if direct closure is
not possible.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 533

Clinical Applications
This patient developed suppurative mediastinitis. She underwent debridement of the ster-
num back to healthy, bleeding bone. The pectoralis major muscles were elevated as bilateral
myocutaneous advancement flaps. No release of the muscle insertion was required. The
muscles were approximated in the midline with overlying skin repair bolstered with reten-
tion sutures. The patient healed without physical deformity and no recurrence of sternal
wound sepsis.

C D

E
Fig. 6E-12 A, The patient is seen before flap re-
construction, 10 days after CABG surgery, with an
inflamed, draining sternal wound. B, A bilateral par-
tial 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. (Case supplied by GJ.)

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 534 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient underwent a four-vessel coronary bypass procedure, complicated by hematoma

requiring reexploration. A methicillin-resistant Staphylococcus aureus (MRSA) deep sternal
wound infection supervened, necessitating debridement and flap closure. The wound was
excised with a partial hemisternectomy on the right and a complete hemisternectomy on
the left. The wound was closed with a left pectoral advancement flap based on the tho-
racoacromial vessels and a right pectoral turnover based on the right internal mammary
vessels. The patient healed well, although with some hollowing at the site of the turnover
flap donor site.

A B C

D E

Fig. 6E-13 A, Debrided sternum with exposed pericardial sac. B, Left pectoralis major muscle ex-
posed 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. (Case supplied by GJ.)

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 Anterior Thorax  •  6E: Pectoralis Major Flap 535

This patient had a sarcoma of the right anterior chest wall. The tumor was resected and
polypropylene mesh was placed to repair the chest wall. The resection site was covered with
a pectoralis major transposition flap covered with a split skin graft. The patient is shown
well healed at 6 months postoperatively.

A B

C D E

Fig. 6E-14 A, Recurrent malignant fibrosarcoma of the chest with a previous thoracotomy, mid-
line 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. (Case supplied by GJ.)

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 536 Part II  Regional Flaps: Anatomy and Basic Techniques

This 30-year-old man had a sarcoma resected from the right clavicular area. He underwent
reconstruction with a myocutaneous pectoralis major flap based on the thoracoacromial
pedicle.

A B

C D

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 ne-
crosis. 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. (Case supplied by MRZ.)

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 Anterior Thorax  •  6E: Pectoralis Major Flap 537

This 52-year-old woman had a failed fibular free flap after composite resection of a squa-
mous cell carcinoma. After removal of the flap, the mandibular reconstruction plate was
salvaged with a pectoralis major muscle flap.

A B C

D E

Fig. 6E-16 A, The muscle was isolated on its thoracoacromial pedicle, accessed through inframam-
mary and subclavicular incisions. The Xs mark the mammary perforators that were left in situ, preserv-
ing 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). (Case supplied by MRZ.)

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 538 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The pectoralis major is not entirely dispensable, and some functional disability may result
from its use.
• Mobilization of the entire muscle as a standard flap with division of the insertion will
result in the loss of the anterior axillary fold, causing a significant aesthetic deformity.
• Flap modifications that preserve the anterior axillary fold may also preserve some muscle
function.
• The vascularized bone included with the flap may not always be reliable.
• Problems associated with the pectoralis major muscle include the bulk of the flap over
the clavicle and in the intraoral area, as well as the donor area deformity.
• Performing muscle turnover and advancement flaps requires elevating the chest wall skin,
which predisposes it to necrosis of the skin edges.
• Subpectoral donor sites should be drained aggressively for a long time to reduce seroma
formation.
• To create a tubed pectoralis myocutaneous flap for esophageal reconstruction, a large skin
island is designed on the pectoralis and the muscle and skin elevated. The flap is tubed so
that the skin surface is on the inside, representing the lumen of the neoesophagus. The
flap is then sutured into the esophageal defect, and a skin graft is required for coverage
of the outer muscular surface of the tubed flap.

Expert Commentary
Glyn Jones

Indications
The pectoralis major remains one of the most versatile flaps for mediastinal reconstruc-
tion. Its robust blood supply and its ability to be advanced on the thoracoacromial supply
or turned over on the internal mammary supply make it invaluable for treating wounds
resulting from suppurative mediastinitis. It can also be swung down onto anterior chest
wall defects after tumor resection.
With pedicles on the thoracoacromial vessels, it can be tunneled beneath the neck skin
to reach the floor of the mouth, mandible, and chin. It has proved itself as a workhorse flap
in head and neck reconstruction.

Advantages and Limitations

Recent modifications to the way in which the flap is raised have reduced donor site mor-
bidity as well as skin edge necrosis. When it is used as a turnover flap, the overlying skin
is significantly devascularized, resulting in a higher risk of skin edge necrosis when used
to reconstruct mediastinal wounds. The use of a composite myocutaneous design, leaving
the skin attached to the muscle, dramatically improves the cutaneous blood flow and reli-
ability of this flap. Its use in the head and neck is limited by its arc of rotation to floor of
the mouth and mandibular defects only. Although it can reach the base of the ear, tension
on the flap can be problematic.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 539

Personal Experience and Insights

The use of pectoralis major myocutaneous flap advancement dramatically improved both
operative time and reduced donor site morbidity in my management of suppurative me-
diastinitis following coronary artery bypass procedures. Although the advancement flaps
do not completely fill the underlying dead space as effectively as a turnover and island ad-
vancement had done previously, effective suction drainage beneath the flaps can be shown
to collapse the dead space when viewed on CT scans. When the flap is used in head and
neck surgery, volume in the neck can be reduced by raising only a strip of muscle over
the proximal pedicle, expanding this to incorporate a larger skin island inframedial to the
nipple for use within the recipient site.

Recommendations
Planning
For mediastinal use, the entire flap is advanced from its sternal origin into the wound. Use
in the head and neck requires a narrow base to reduce bulk within the subcutaneous tunnel
in the neck, with a large skin paddle and a broader sheet of muscle for intraoral placement.
In men, a skin island is usually designed from the level of the fourth costal cartilage to below
the nipple, and about 20% of the skin can be harvested beyond the inferior most limit of
the muscle origin. In women, it is preferable to try and use skin medial to and below the
breast, but great care has to be taken not to outrun the blood supply.

Technique
When using the flap as a myocutaneous advancement for sternal closure, I do not divide
the insertion into the humerus, which preserves the anterior axillary fold. The medial
skin edge is elevated for only 1 cm off the cut edge of the muscle’s origin from the ster-
num, and this usually allows very adequate medialization of the flap to the midline. Great
care should be taken to ensure excellent control of internal mammary perforators before
closure. For head and neck reconstruction, subpectoral dissection is carried up along the
access of the thoracoacromial vessels to the clavicle, and under direct vision, a thin strip of
muscle on either side of this can be preserved for several centimeters before extending the
muscle harvest to supply the distal skin island. This dramatically reduces bulk in the neck
and again preserves the anterior axillary fold. The pedicle must not be twisted when the
flap is tunneled into the facial recipient site.

Postoperative Care
Long-term suction drainage is essential after myocutaneous advancement into the me-
diastinum. Patients undergoing head and neck reconstruction with pectoralis major flaps
should be nursed with the neck slightly extended and not flexed for fear of kinking the
blood supply. Similarly, patients with tracheostomies should have their tracheostomy tapes
tied loosely around the neck to prevent compression. Feeding tubes should be used until
intraoral suture lines are well healed.

Complications: Avoidance and Treatment

Myocutaneous advancement flaps have a significant risk of submuscular seroma forma-
tion. The bed of the donor site should be sprayed with fibrin glue, and subpectoral drains
should be inserted and maintained until drainage is less than 30 ml per drain per day. If
long-term drainage becomes problematic, installation of steroids or doxycycline can be
helpful. Mediastinal skin edge necrosis can be reduced dramatically by maintaining the
Continued

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 540 Part II  Regional Flaps: Anatomy and Basic Techniques

relationship between the muscle and the overlying skin as a composite myocutaneous flap.
The more the skin is elevated from its underlying muscle-based blood supply, the more
likely it is to necrose. In head and neck reconstruction, the rotation from chest to neck
must be performed under direct vision to ensure that the vascular pedicle is not twisted or
alternatively kinked over the clavicle. If a turnover flap into the mediastinum does have
to be performed, the supralateral slips of the muscle should be left attached between chest
wall and humerus to preserve the axilla fold. Loss of this fold, particularly in men, creates
a very unattractive deformity.

Bibliography With Key Annotations

Anatomic/Experimental Studies
Appiani E, Almada H, Garlando C, et al. Potential myocardial revascularization and mechani-
cal effects of pectoral muscle transplant. Ann Plast Surg 10:252, 1983.
This experimental study demonstrated that the pectoral muscle wrapped around the heart revascular-
ized the myocardium with establishment of circulation through the muscle flap into the myocardium
in 12 dogs.
Freeman JL, Walker EP, Wilson JSP, et al. The vascular anatomy of the pectoralis major myo-
cutaneous flap. Br J Plast Surg 34:3, 1981.
The authors reported the results of their anatomic dissections of 17 cadaver specimens to delineate the
vascular anatomy of the pectoralis major and the overlying skin. They described a rich anastomosis
between the internal mammary artery and the pectoral branch of the thoracoacromial artery and the
pectoral branch of the lateral thoracic artery. They concluded that the lateral thoracic artery, in addition
to the pectoral branch of the thoracoacromial artery, contributed significantly to the vascularity of the
pectoralis major and was the main blood supply of the female breast.
Marin-Guzke M, Sanchez-Olaso A, Fernandez-Camacho FJ. The alternative supply of the
pectoralis major flap based medially in cases with previous surgical use of the internal thoracic
artery: an anatomical study. Surg Radiol Anat 27:340, 2005.
In this study the authors analyzed the anatomic basis for the use of the pectoralis major muscle based
on alternative pedicles to evaluate its clinical applications in cases of potential impairment of more distal
internal mammary artery. The patterns of blood supply depending on the internal mammary artery,
previously dissected for coronary bypass surgery, were studied in both sides of five embalmed cadavers
and five anterior thoracic walls taken from autopsies. The secondary vascular pedicles, depending on
the internal thoracic artery for the pectoralis major muscle, were dissected and injected with physiologi-
cal saline–stained solution in the embalmed cadavers. Studies of intravascular injection by means of
radiopaque contrast and physiologic saline–stained solution were carried out in the anterior thoracic
walls in autopsy specimens. The results showed that complete injection of the pectoralis major muscle
was achieved based exclusively on the two proximal perforating branches of the two first intercostal
spaces, in cases with previous dissection of the internal mammary artery for coronary bypass. This
may represent collateral flow from the anterior branches of the intercostal arteries.
Tobin GR. Pectoralis major segmental anatomy and segmentally split pectoralis major flaps.
Plast Reconstr Surg 75:814, 1985.
Anatomic studies, animal studies, and clinical experience demonstrated splitting of the pectoralis major
muscle and myocutaneous units based on the thoracoacromial pedicle. Three major independent seg-
ments (clavicular, sternocostal, and external) were identified and demonstrated. Segmental splitting
techniques allow utilization of the muscle as a flap while preserving form and function.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 541

Wei WI, Lam KH, Wong J. The true pectoralis major myocutaneous island flap: an anatomical
study. Br J Plast Surg 37:568, 1984.
This is a detailed anatomic study of the acromiothoracic trunk and its four main branches. The dis-
tribution of these vessels was described in detail, and the authors’ experience with 52 pectoralis major
myocutaneous flaps for head and neck reconstruction was presented.

Clinical Series
Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the
head and neck. Plast Reconstr Surg 63:73, 1979.
This is the original description of the pectoralis major myocutaneous flap for head and neck reconstruc-
tion. A narrow strip of the pectoralis major muscle based on the thoracoacromial pedicle together with
an overlying island of skin was used successfully in four patients.
Ariyan S. The pectoralis major for single-stage reconstruction of the difficult wounds of the
orbit and pharyngoesophagus. Plast Reconstr Surg 72:468, 1983.
Reconstruction of difficult wounds in 20 patients was described, including reconstruction of orbital and
pharyngoesophageal defects.
Baek SM, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast
Reconstr Surg 69:460, 1982.
The authors reviewed their experience with 133 pectoralis major myocutaneous flaps for head and
neck reconstruction. Of the 133 flaps used, 11 flaps (8%) failed to accomplish the intended purpose
and a second operation was necessary. Of the five patients who underwent reconstruction with the
osteomyocutaneous flap, three were treatment failures. This is an important article with an excellent
review and analysis of results.
Baek SM, Lawson W, Biller HF. Reconstruction of hypopharynx and cervical esophagus with
pectoralis major island myocutaneous flap. Ann Plast Surg 7:18, 1981.
The authors described their technique and experience with 14 hypopharyngeal and cervical esophageal
reconstructions using the flap. All flaps survived, but three patients developed suture line separations.
Brown RG, Fleming WH, Jurkiewicz MJ. An island flap of the pectoralis major muscle. Br J
Plast Surg 30:161, 1977.
Bilateral island pectoralis major flaps are used for reconstruction of a full-thickness anterior chest wall
defect. The flaps are based on the dominant thoracoacromial artery and covered with split-thickness
skin graft.
Erez E, Katz M, Sharoni E, et al. Pectoralis major muscle flap for deep sternal wound infection
in neonates. Ann Thorac Surg 69:572, 2000.
This paper reported on the use of pectoralis major flap usage to treat deep sternal wound infections in
neonates. Seven hundred twenty consecutive pediatric cardiac operations performed in 108 neonates and
612 infants were reviewed. Six neonates and 3 infants developed deep sternotomy wound infections
and underwent PMF reconstruction. The incidence of sternal wound complications in the neonatal
patients (5.5%; 6 of 108) was significantly higher than in the infantile group (0.5%; 3 of 612).
Five neonates were treated with a unilateral, turnover PMF reconstruction. One patient was treated
by a bilateral rotational PMF. All sternal wounds healed successfully, and all patients survived. In a
follow-up period ranging from 6 to 31 months (mean 16.5 months), the growth and development of
all operated neonates was as expected for their age. There were no signs of chronic sternal infection.
Early recognition of sternal wound complications and treatment utilizing the PMF resulted in early
stable wound closure with no long-term growth implications.
Freedlander E, Lee K, Vandervord JG. Reconstruction of the axilla with a pectoralis major
myocutaneous island flap. Br J Plast Surg 35:144, 1982.
Three cases of axillary reconstruction with the pectoralis major myocutaneous island flap were reported.
The authors suggested this flap as an alternative if the latissimus dorsi is not available.

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 542 Part II  Regional Flaps: Anatomy and Basic Techniques

Gil Z, Gupta A, Kummer B, et al. The role of pectoralis major muscle flap in salvage total
laryngectomy. Arch Otolaryngol Head Neck Surg 135:1019, 2009.
The authors assessed the utility of the pectoralis major muscle flap (PMMF) in patients undergoing
salvage total laryngectomy in a retrospective analysis of 461 patients who underwent laryngectomy.
Eighty of them underwent salvage surgery with primary pharyngeal closure; 69 (86%) underwent
primary pharyngeal closure alone and 11 (14%) underwent a PMMF to buttress the pharyngeal
suture line. Two hundred thirty-six variables were recorded for each patient. Complications related
to pharyngeal closure were measured. Sixty-four percent of the patients who underwent PMMF
also underwent chemoradiation therapy as the initial definitive treatment, compared with 25% in
the non-PMMF group. Multivariate analysis demonstrated that chemoradiation therapy was the
only independent predictor of pharyngocutaneous fistula formation (relative risk, 1.82; 27%) and
the non-PMMF (24%) groups. Furthermore, similar durations of tube feeding, days to oral feed-
ing, and hospitalization period were recorded in both groups, leading the authors to conclude that the
PMMF should be used judiciously as a surgical adjunct in high-risk patients to minimize the risk of
a pharyngocutaneous fistula.
Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z J Surg 38:61, 1968.
This is the original description of the pectoralis myocutaneous flap as a delayed procedure to reconstruct
a full-thickness defect of the anterior chest wall following the resection of a fibro­sarcoma.
Hugo NE, Sultan MR, Ascherman JA, et al. Single-stage management of 74 consecutive sternal
wound complications with pectoralis major myocutaneous advancement flaps. Plast Reconstr
Surg 93:1433, 1994.
This landmark paper represented a paradigm shift in thinking about the management of sternal wound
infection. Rather than performing total sternectomy, the authors debrided back to healthy bleeding
bone. Instead of filling the defect with muscle, the authors used bilateral pectoralis major advancement
myocutaneous flaps for closure, resulting in less skin edge of the chest.
Jones G, Jurkiewicz MJ, Bostwick J III, et al. Management of the infected median sternotomy
wound with muscle flaps: the Emory 20-year experience. Ann Surg 225:766, 1997.
The authors presented the Emory University experience with sternal wound closure using a variety
of muscle flaps, most commonly the pectoralis major advancement-turnover combination in treating
409 patients. Mortality was reduced and hospital stay declined from 18 days to 12 days using these
techniques. Pectoral flaps had a much lower morbidity than did rectus abdominis flaps for the treat-
ment of deep sternal wound infections. The authors subsequently moved to using bilateral pectoralis
major advancement myocutaneous flaps for closure rather than the turnover-advancement combination.
Jurkiewicz MJ, Bostwick J III, Hester TR, et al. Infected median sternotomy wound: successful
treatment by muscle flaps. Ann Surg 191:738, 1980.
The use of bilateral pectoralis major omental or rectus abdominis muscle flaps for the treatment of the
infected median sternotomy wound was presented. A dramatic decrease in the mortality and morbid-
ity associated with infected median sternotomy wounds was documented and attributed to the use of
muscle flaps.
Mendelson BC. The pectoralis major island flap: an important new flap for head and neck
reconstruction. Br J Plast Surg 33:318, 1980.
In this case report the author predicted that the pectoralis major myocutaneous flap will eventually
replace the deltopectoral flap as the preferred flap for head and neck reconstruction. He also suggested
modification of the incision below the clavicle to preserve the ipsilateral deltopectoral flap for future use.
Merve A, Mitra I, Swindell R, et al. Shoulder morbidity after pectoralis major flap reconstruc-
tion for head and neck cancer. Head Neck 31:1470, 2009.
This paper evaluated shoulder function in 22 patients who underwent PMF reconstruction. The con-
trol group comprised 35 patients with neck dissection (without PMF). The data suggested that much
of the morbidity after head and neck procedures with neck dissection arises from the neck dissection.
There is minimal or low shoulder morbidity caused by PMF reconstruction in head and neck surgery.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 543

Milenović A, Virag M, Uglesić V, et al. The pectoralis major flap in head and neck reconstruc-
tion: first 500 patients. J Craniomaxillofac Surg 34:340, 2006.
The authors review their experience with a total of 506 pectoralis major flaps used for head and neck
reconstruction in 500 patients. In all cases the flap was used after surgical resection of an advanced
malignant tumour of the head and neck. The tumors were intraoral in 387 cases (77%), pharyngeal
in 78 cases (15%) and on the skin in 10 cases (5%). The defect was located in the mucosal lining
in 407 (81%), skin in 43 (8%), both intraoral and extraoral in 53 (10%) patients. Bone defects
occurred in 65 patients. In 31 patients (6%), the pectoralis major flap was used in combination with
other flaps (deltopectoral, tongue, trapezius, and free flaps). Complications occurred with 168 flaps
(33%), but total flap necrosis was seen in only 10 patients (2%). Surgical treatment of complications
was necessary in 87 patients (17%). They conclude that despite the increasing use of microvascular
reconstruction, the pectoralis major myocutaneous flap continues to be the most reliable major flap in
head and neck reconstruction with acceptably low complication rates.
Nahai F, Rand RP, Hester TR, Bostwick J III, Jurkiewicz MJ. Primary treatment of the in-
fected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr
Surg 84:434, 1989.
A review of 211 patients who had undergone muscle flap closure of infected median sternotomy wounds
is described. When compared to closed irrigation and open granulation techniques, flap closure was
shown to result in a fourfold decrease in mortality and significantly decreased length of hospitalization
following treatment. The authors concluded that debridement and flap closure is the primary therapy
for patients with poststernotomy mediastinitis.
Neifeld JP, Merritt WA, Theogaraj SD, et al. Tubed pectoralis major musculocutaneous flaps
for cervical esophageal replacement. Ann Plast Surg 11:24, 1983.
The authors described their experience with five patients undergoing laryngopharyngectomies and
cervical esophagectomies who underwent reconstruction with tubed pectoralis major flaps. Two patients
had pinpoint fistulas that healed rapidly. One patient died of myocardial infarction, and the fifth
patient had a partial flap breakdown requiring secondary flap closure. Despite this high complication
rate the authors advocate the tubed pectoralis major flap for total esophageal reconstruction and they
recommend this method over colon interposition, gastric pull-through, or even jejunal free grafts.
Rees RS, Ivey GL, Shack RB, et al. Pectoralis major musculocutaneous flaps: long-term follow-
up of hypopharyngeal reconstruction. Plast Reconstr Surg 77:586, 1986.
The authors reviewed their experience with 25 patients who had undergone major head and neck
resections for stage III and IV carcinoma, all of whom required hypopharyngeal reconstruction with
the pectoralis myocutaneous flap. Only six patients were alive 1 year after reconstruction, and five
were available for study. Postoperative strictures were found in two patients.
Robb GL, Swartz WM. Pharyngocutaneous fistulas: management with one-stage flap recon-
struction. Ann Plast Surg 16:125, 1986.
Nine patients who had postoperative pharyngocutaneous fistulas underwent one-stage correction using
a variety of flaps. These included four pectoralis major, two latissimus dorsi, and three jejunal free
grafts. The indications for each flap were clearly discussed.
Robertson GA. A comparison between sternum and rib in osteomyocutaneous reconstruction
of major mandibular defects. Ann Plast Surg 17:421, 1986.
The author reviewed his experience with six patients who underwent mandibular reconstruction using
a pectoralis major osteomyocutaneous flap including rib and 22 patients undergoing similar reconstruc-
tion with an osteomyocutaneous flap including the sternum. Five of 6 patients in the rib group had
major complications. Loss of bone occurred in only 2 of 22 patients in the sternal group. The author
stated that an osteomyocutaneous pectoralis major flap with sternum is more reliable and results in
more functional and aesthetic reconstructions.

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 544 Part II  Regional Flaps: Anatomy and Basic Techniques

Rosenberg L, Mahler D. Extended rotation-transposition of the pectoralis major myocutaneous

flap in the repair of lesions over the shoulder. Br J Plast Surg 34:322, 1981.
Case reports of the use of a pectoralis major myocutaneous flap for coverage of an extensive area of
radionecrosis over the shoulder were presented.
Ryan RF, Krementz ET, Cardona-Loya O. One-stage cervical esophageal and pharyngeal
reconstruction for a fourth primary cancer. Plast Reconstr Surg 67:224, 1981.
This case report described the use of the tubed pectoralis myocutaneous flap for one-stage reconstruction
of the pharynx and esophagus.
Su WF, Chen SG, Sheng H. Speech and swallowing function after reconstruction with a radial
forearm free flap or a pectoralis major flap for tongue cancer. J Formosan Med Assoc 101:472,
2002.
This study compared the tongue function outcome in Mandarin-speaking patients obtained using two
methods of tongue reconstruction, radial forearm free flap transfer and pectoralis major flap transfer.
Twenty-five patients with carcinoma of the tongue underwent tumor resection with reconstruction
using a pectoralis major flap in 6 patients and a radial forearm flap in 19 patients. Swallowing and
speech function were evaluated 6 months to 5 years after the reconstruction. Speech intelligibility and
a Mandarin articulation test were used to evaluate the articulation proficiency before and after surgery.
Clinical evaluation of deglutition included a questionnaire on dietary habits and a swallowing rating
of 1 to 7. Patients with free flap reconstruction had more intelligible speech (p 5 0.014) even after
total glossectomy. Assessment of data obtained by clinical questionnaire showed no significant differ-
ence between the two groups in swallowing function. Motility from flap pliability increased speech
intelligibility but had little effect on swallowing function. The results suggest that radial forearm flap
transfer is better than pectoralis major flap transfer in preserving speech function, but there is no sig-
nificant difference between the two methods of reconstruction in their impact on swallowing function.
Theogaraj SD, Merritt WH, Acharya G, et al. The pectoralis major musculocutaneous island
flap in a single-stage reconstruction of the pharyngoesophageal region. Plast Reconstr Surg
65:267, 1980.
The authors described their experience with the pectoralis major myocutaneous unit in single-stage
reconstruction of the pharyngoesophageal region in seven patients. All reconstructions were successful,
with one patient experiencing salivary leak temporarily. Most of their patients were able to swallow
within 9 to 10 days. The advantages of the flap include predictable anatomy, long arc of rotation,
one-stage reconstruction, and viable muscle to protect the carotid vessels. The disadvantages are the
scarring of the chest wall and distortion and dysfunc­tion of the pectoralis major because of the procedure
and a prominent bulge in the neck because of the pedicle.
Withers EH, Franklin JD, Madden JJ, et al. Immediate reconstruction of the pharynx and cervi-
cal esophagus with the pectoralis major myocutaneous flap following laryngopharyngectomy.
Plast Reconstr Surg 68:898, 1981.
The authors described their experience with the flap for immediate pharyngeal reconstruction in nine
patients. In two patients the flap was used for total hypopharyngeal reconstruction and in the remainder
for partial reconstruction. They reported a high success rate with minimal complications.

Flap Modifications
Bell MSG, Barron PT. The rib–pectoralis major osteomyocutaneous flap. Ann Plast Surg
6:347, 1981.
The authors described their experience with 14 mandibular reconstructions using the pectoralis major
osteomyocutaneous flap incorporating the fifth or sixth rib. One of the 14 flaps was lost, and the rib
was removed in three others. Therefore in 10 of the 14 patients the rib survived and bony reconstruc-
tion was satisfactory.

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 Anterior Thorax  •  6E: Pectoralis Major Flap 545

Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a

regional osteomusculocutaneous flap. Plast Reconstr Surg 65:477, 1980.
This is a case report of a patient who had a pectoralis major osteomyocutaneous flap procedure that
incorporated a segment of the fifth rib for immediate reconstruction of a composite mandibular defect.
The rib was vascularized through the periosteal circulation. The authors presented tetracycline labeling
and technetium scanning documentation of bone survival.
Green MF, Gibson JR, Bryson JR, et al. One-stage correction of mandibular defects using
a split sternum pectoralis major osteomusculocutaneous transfer. Br J Plast Surg 34:11, 1981.
Mandibular reconstruction was performed using a pectoralis major osteomyocutaneous flap. The outer
table of the sternum was included as vascularized bone. Six successful cases were reported.
Jones NF, Sommerlad BC. Reconstruction of the zygoma, temporo-mandibular joint and
mandible using a compound pectoralis major osseomuscular flap. Br J Plast Surg 36:491, 1983.
The authors described the reconstruction of the zygoma, temporomandibular joint, and hemimandible
with a compound pectoralis major osteomyocutaneous flap that included portions of the sternum, sternal
costal joint, and rib. The result of this successful reconstruction was compared to the movement of the
normal temporomandibular joint.
Lam KH, Wei WI, Siu KF. The pectoralis major costomyocutaneous flap for mandibular re-
construction. Plast Reconstr Surg 73:904, 1984.
Experience with 14 pectoralis major osteomyocutaneous flaps for reconstruction in patients who had
undergone mandibulectomy for carcinoma was described. They reported three failures that they at-
tribute to technical errors. In an attempt to improve the blood supply by means of the perichondrium
they included a portion of the costal cartilage.
Little JW III, McCulloch DT, Lyons JR. The lateral pectoral composite flap in one-stage re-
construction of the irradiated mandible. Plast Reconstr Surg 71:326, 1983.
The authors described a modification of the pectoralis major osteomyocutaneous flap. Their modifications
spare more of the muscle, resecting only a lateral segment of muscle in eight patients, seven of whom had
successful reconstructions. This is a useful modification that spares a significant amount of the muscle.

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 ANATOMIC LANDMARKS
Landmarks Large rectangular flap covering the area above and below the
clavicle laterally to the mid-deltoid.
Size 12 3 35 cm (primary closure with 7 cm width).
Composition Fasciocutaneous.
Dominant Pedicle Supraclavicular artery.
Nerve Supply Supraclavicular nerves (C3, C4).

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 Section 6F
Anterior Thorax

Supraclavicular Artery Flap

CLINICAL APPLICATIONS
Regional Use
Head and neck
Pharynx
Anterior chest
Specialized Use
Facial resurfacing

06f_SupraClav_r7_cah_0546-0582.indd 547 2/1/2012 11:07:24 AM

 ANATOMY OF THE supraclavicular artery Flap

Transverse
cervical
artery

Supraclavicular
arteries
Subclavian
artery

Supraclavicular
nerves (C3, C4):
medial, intermediate,
and lateral

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, inter-
mediate, 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.
Dominant pedicle: Supraclavicular artery

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 549

ANATOMY
Landmarks Large rectangular surface covering from the base of the neck to the mid-deltoid,
extending above and below the clavicle.
Composition Fasciocutaneous.
Size 12 3 35 cm (primary closure with 7 cm width).

Arterial Anatomy
Dominant Pedicle  Supraclavicular artery
Regional Source  Transverse cervical artery.
Length  1 to 7 cm.
Diameter  1 to 1.5 mm.
Location  The supraclavicular artery is reliably found in the triangle composed of the sternoclei-
domastoid muscle anteriorly, the trapezius muscle posteriorly, and the clavicle inferiorly. The
supraclavicular artery is found 8 cm lateral to the sternoclavicular joint, 3 cm above the clavicle,
and 2 cm posterior to the sternocleidomastoid muscle belly. In studies, the vessel is present 80%
to 100% of the time. When the vessel is less than 1 mm in diameter, the surface area of the flap
perfusion can be diminished.

Venous Anatomy
Venae comitantes run with the supraclavicular artery, draining into the transverse cervical vein.
The diameter of the transverse cervical vein at its origin is 2.5 mm.

Nerve Supply
Sensory The supraclavicular nerves (C3, C4). There are three distinct branches of the
supraclavicular nerve: (1) the medial branch supplying the area of the sterno-
clavicular joint and onto the chest, (2) the middle branch supplying the area of
the supraclavicular fossa extending onto the chest, and (3) the lateral branch
extending to the acromial clavicular joint area.

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 550 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Supraclavicular A rtery Flap

A

B C

Injected
supraclavicular
artery

Fig. 6F-2  A, Cadaveric dissection of the supraclavicular flap demonstrating the supraclavicular ar-
tery 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%.

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 551

FLAP HARVEST
Design and Markings
Pencil Doppler ultrasound is used to locate the supraclavicular artery. The flap is designed
laterally, extending toward the acromioclavicular joint. Dye studies have shown that in two
thirds of cases the artery runs above the clavicle, although many clinical cases have shown
that anastomosis with the nearby thoracoacromial artery and nearby perforating vessels
explained perfusion below the clavicle. The design extends all the way to the area of the
mid-deltoid muscle. Primary closure is obtainable if the flap is 7 cm wide or less.

Flap design, extending to mid-deltoid

Fig. 6F-3 

Patient Positioning
The patient is placed in the supine position, with a shoulder bump pillow or towel creating
an angle of as much as 45 degrees. The neck and the entire arm and hand are circumfer-
entially prepared into the field.

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 552 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The flap is dissected from distal to proximal in a subfascial plane. The initial dissection
proceeds quickly. Care is taken as the area of the pedicle is approached. This can be con-
firmed by handheld Doppler. It is often helpful in the middle portion of the flap to use a
transillumination technique to identify the location of the vessel. Once the pedicle is iden-
tified, the skin island incision can be completed if required. This can aid in transposition
and rotation of the flap.
A B

Transverse
Transverse Supraclavicular
cervical artery
cervical artery arteries
Supraclavicular
artery
Subclavian
artery Subclavian
Deltoid muscle artery
fascia (cut)
Deltoid muscle
fascia (cut)

Flap halfway dissected, taking fascia of deltoid Flap nearly completely elevated with vessels showing at its base

Fig. 6F-4 

FLAP VARIANT
Tissue Expansion
The supraclavicular flap has been used successfully in difficult cases requiring neck and
cheek resurfacing, such as in extensive burns or cancer resections. Although large flaps can
be harvested in this area with skin grafting of the donor site, great success has been dem-
onstrated using tissue expansion. For this, the tissue expander is placed subfascially beneath
the area of desired expansion in the supraclavicular region. The expansion process and the
undermining from placing the expander tend to improve the vascularity of this area as a
form of delay procedure. The amount of expansion is limited by tissue need and patient’s
ability to tolerate expansion. The other advantage of tissue expansion is that the donor site
is expanded; thus, even for large flaps, primary closure can be achieved.

Tissue
expander
Tissue expander placed subfascially

Fig. 6F-5 

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 553

ARC OF ROTATION
All Flaps
The flap can reach the lower third of the face for resurfacing the neck or the area of the
pharynx for pharyngeal reconstruction and lower third intraoral mucosal defects. The flap
is also well suited for reconstruction of chest defects. The length of the flap may be extended
by a vascular delay procedure down the arm (see Chapter 1).

A B

Arc for tracheostomal reconstruction Arc for facial contour/intraoral restoration

Fig. 6F-6 

FLAP TRANSFER
Once the flap is isolated on the supraclavicular pedicle, transfer can be performed through
a subcutaneous tunnel or by direct connection to the defect. Surgical judgment must be
used to see which of these options best accomplishes the reconstructive goal without com-
promising the pedicle.

FLAP INSET
In most cases, the inset will be at the level of the skin, which should be closed without ten-
sion. If the harvested flap is larger than the defect to be reconstructed, it may be helpful to
deepithelialize the unneeded areas before inset to add vascularity and help bolster the closure.

DONOR SITE CLOSURE

Primary closure is obtainable with defects up to 7 cm wide. Larger areas can be closed
primarily with extensive undermining; this will depend on the laxity of the patient’s skin.
The internal mammary artery (IMA) perforators should be left intact so that the deltopec-
toral flap remains a secondary reconstructive option. One should consider skin grafting
the donor site if there is too much tension on the closure. Tissue expansion is an option as
an initial step to expand both the flap and the donor site, or as a secondary procedure to
remove a skin graft.

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 554 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 69-year-old man had an invasive squamous cell carcinoma of the cheek. He required
a composite resection of the cheek with parotidectomy and cervical lymph node dissec-
tion. The remaining mucosa was mobilized for intraoral closure. This left a large soft tissue
defect. The previous neck surgery and the lymph node dissection precluded the use of a
submental flap. Free flaps would bring in nonmatching tissue. The other local tissue choices
with best skin match were the supraclavicular and deltopectoral flaps. The deltopectoral
would require at least one delay procedure and require a skin graft to the donor site. A
supraclavicular flap was chosen as the best local choice. The lower neck incision was from
the lymph node dissection and did not extend lateral to the sternocleidomastoid muscle.

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.

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 555

C D

E F

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 rota-
tion 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.
(Case supplied by MRZ.)

06f_SupraClav_r7_cah_0546-0582.indd 555 2/1/2012 11:07:33 AM

 556 Part II  Regional Flaps: Anatomy and Basic Techniques

This 60-year-old man presented with recurrent squamous cell tumor burden adjacent to
the tracheostomal site.

A B

C D

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. (Case
courtesy Ernest S. Chiu, MD.)

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 557

This 90-year-old man presented with persistent jaw pain and recurrent cheek squamous
cell carcinoma, with cheek tissue radiation fibrosis.

A B

C D E

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 post-
operatively. (Case courtesy Ernest S. Chiu, MD.)

06f_SupraClav_r7_cah_0546-0582.indd 557 2/1/2012 11:07:43 AM

 558 Part II  Regional Flaps: Anatomy and Basic Techniques

This 65-year-old man had an intraoral tumor that had failed radiation therapy. He also de-
veloped TMJ fibrosis that impaired the intercisal opening, thus requiring coronoidectomy
and tumor resection.

A B

C D

E F

Fig. 6F-10  A, Ablation of the intraoral tumor involving the gingivobuccal sulcus left a 5 by 6 cm de-
fect. 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 reconstruc-
tion, and the patient was able to tolerate a normal diet 6 months after surgery. (Case courtesy Ernest
S. Chiu, MD.)

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 559

This patient sustained burns to the right side of the face and neck that were covered with
skin grafts. A contralateral preexpanded supraclavicular artery flap was planned.

A B

C D E

F G

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. (Case courtesy Norbert Pallua, MD.)

06f_SupraClav_r7_cah_0546-0582.indd 559 2/1/2012 11:07:49 AM

 560 Part II  Regional Flaps: Anatomy and Basic Techniques

This woman had a squamous cell carcinoma on the chin. After excision of the lesion, a
supraclavicular artery flap was required for defect coverage.

A B

D E F

Fig. 6F-12  A and B, AP and closeup preoperative view. C, After excision of the lesion, the supra-
clavicular 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. (Case courtesy
Norbert Pallua, MD.)

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 561

After sustaining a burn, this man developed keloids that severely restricted his neck move-
ment. A unilateral preexpanded supraclavicular artery flap was planned for reconstruction.

C D

E F

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. (Case courtesy
Norbert Pallua, MD.)

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 562 Part II  Regional Flaps: Anatomy and Basic Techniques

This boy sustained severe burns to the face that had primarily been reconstructed with skin
grafts. A bilateral preexpanded supraclavicular artery flap was planned.

A B

C D E

F G

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. (Case courtesy Norbert Pallua, MD.)

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 563

Pearls and Pitfalls

• The supraclavicular artery flap is a local flap that has the functionality of a free tissue
transfer.
• Advantages include excellent skin color match, thinness, and pliability.
• CT angiography can be used to confirm the presence of the supraclavicular vessel before
surgery, although this is not essential.
• A contralateral supraclavicular artery flap should be considered if, for one reason or an-
other, the initially elevated flap cannot perform the reconstructive function.
• Because the flap is composed of skin and subcutaneous tissues only, the morbidity to the
shoulder with this procedure is remarkably small.
• This flap can be compared to the deltopectoral flap, in which skin grafting of the donor
site is often required.
• If care is taken in elevating the supraclavicular artery flap and a second flap is required,
careful undermining at the time of closure of the supraclavicular artery flap will leave the
deltopectoral flap and its territory as an option for a second flap for salvage. This would
most likely require skin grafting but provides a valuable and viable salvage flap option.

Expert Commentary
Ernest S. Chiu

Indications
The supraclavicular artery island flap is my flap of choice for most lower third face and
neck oncologic defects. Its use has been described for reconstruction of neck burn scar
contracture and wounds. The flap can be successfully used despite various comorbidities,
including obesity, poor nutrition, diabetes, and smoking. Flap survival is no different than
for any traditional flap.
Relative contraindications have been limited to patients who have had previous bilateral
neck dissections and/or radiated necks. Still, our group routinely performs supraclavicular
flap harvest successfully in these challenging clinical settings. An alternative flap is always
planned but rarely used (less than 2%).

Advantages and Limitations

The supraclavicular artery island flap is a thin, pliable, reliable, regional, axially based, in-
nervated, fasciocutaneous flap with good color match for many head or neck reconstructive
defects. There is minimal shoulder donor site morbidity. The limitation of the flap is the
pedicle vessel diameter and length, which determines its perfusion zone. As in all flaps, this
can only be determined after the flap is elevated.
Continued

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 564 Part II  Regional Flaps: Anatomy and Basic Techniques

Anatomic Considerations
Personal Experience and Insights
Complications were encountered in several of our cases but did not dampen our enthusiasm
for trying again with this flap, since the results were very acceptable as judged by me as well
as board-certified ENTs and plastic surgeons.1 Most of the major complications occurred in
pharyngeal reconstruction cases (20% to 30%).2,3 All of these patients had prior failed chemo-
radiation therapy protocols. Patients with fistulas had comorbidities such as advanced tumors,
poor nutrition, significant smoking history, radiation therapy, and previous tracheotomies.
Although this rate seems high, it is similar to other reported fistula rates (5% to 53%) using
fasciocutaneous and myocutaneous flaps. All leak cases resolved without further surgical
intervention. Patients were able to drink and eat using their neopharynx and continue with
daily routines. All patients agreed they would undergo the same procedure again. Suturing
any vascularized tissue to poorly perfused, irradiated tissue is worrisome; therefore adequate
debridement and removal of nonvascularized tissue is advised. Supraclavicular flap distal
tip necrosis has been observed, but this rarely jeopardizes final outcome. Regional muscle
flaps have more bulk but will atrophy and cause fibrosis. Unfortunately, excessive scarring
and muscle fibrosis can lead to oropharyngeal stricture formation.

Recommendations
Planning
As with many perforator flaps, preoperative CT angiography is routinely performed so
that the reconstructive surgeon can determine whether the pedicle is present or was pre-
viously injured.4,5 This is not always necessary but is helpful. It is paramount to have good
preoperative planning discussions with the head and neck oncologic surgeon. A radical
neck dissection (level V lymph node) is rarely performed today; therefore the thyrocervi-
cal trunk is usually preserved on the ipsilateral side. When one side of the neck has been
previously irradiated or surgically operated on, the contralateral shoulder is used to avoid
the challenge of scar tissue dissection. In every patient with a central neck problem, there
are two potential shoulder flaps.

Technique
At the beginning of each case, folded towels are placed beneath the patient’s shoulder to
serve as a bump to improve exposure. The area is prepared with Betadine, including the
neck and the entire arm and hand circumferentially. Intraoperatively, a skin Doppler signal is
confirmed in the triangular fossa bordered by the clavicle as well as the sternocleidomastoid
and trapezius muscles.
A 6 to 7 cm wide elliptical island flap can be designed over the shoulder and supracla-
vicular region to include the proximally detected signal. The flap is dissected from distal to
proximal in a subfascial plane toward the pedicle using electrocautery. In my early operative
experience, I was not able to harvest a supraclavicular artery flap because the pedicle was
inadvertently injured when an anterior-to-posterior harvest direction was attempted. The
pedicle was very small, tortuous, and difficult to identify. Today a distal-to-proximal flap
harvest approach is recommended to decrease risk of pedicle injury. Since converting to
this technique, pedicle injury has not been observed.
Once in the Doppler-confirmed signal vicinity, I switch to blunt bipolar forceps as in
a perforator flap dissection. Frequently, a Doppler signal can be detected (3 to 10 cm away
from its origin) on the subfascial surface well before approaching the pedicle origin. After
the pedicle has been identified, the proximal skin island is divided so that the island flap has
ample room to rotate. The length, vessel diameter, and location of the pedicle entering the

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 565

flap island are the limiting factors determining the tissue volume that can be transferred.
During flap harvest, multiple infraclavicular nerves (C4-C5) may be encountered.6 They
are sensory nerves that can be divided to allow an increase in pedicle length. If the sensory
nerves are not divided, referred sensation can be noted in the skin paddle when touched.
The spinal accessory nerve runs posterior and medial to the main pedicle and should not be
encountered during flap dissection. Still, the surgeon must be aware of anatomic variations.
Intraoperatively, the distal tip is trimmed until healthy bleeding tissue is noted. We
routinely design the distal flap tip to include skin from the mid-deltoid area. All flaps are
deepithelialized and reduced in size to fit the ablative defect proportionally. The skin paddle
perfusion originates through the dermal plexus; therefore it is important to minimize in-
advertent holes in the deepithelialized proximal dermis. Defatting on the flap underside
can be done judiciously.
Other groups have recommended a tunneled technique to minimize scarring and donor
site morbidity with acceptable results. However, since many of these patients already have
neck incisions from prior surgery, we do not hesitate to connect the proximal skin island
flap to this previous incision. Tunneling of the supraclavicular flap under irradiated tissue or
areas of previous scarring is not recommended; the scar band may impair blood flow to the
distal flap where the transferred tissue is often needed the most. Flap insetting and pedicle
visualization also becomes easier. Skin necrosis at trifurcation sites has not been observed.
Flap inset technique is the surgeon’s preference. Buried flaps are not monitored, since the
flap has both an artery and vein originating from its parent vessels.
The donor site is closed after flap inset. Both anterior and posterior wide undermining is
usually required. A shoulder drain is not necessary, because the dead space is closed snuggly.
Any flap designed wider than 8 cm may be difficult to close, and skin grafting should be
performed without hesitation. Although a scar may be noticeable when the patient is shirt-
less or in a patient wearing a tank top (especially women), compromised shoulder function
has not been observed in our series.
Other investigators have stated that the vessel caliber and pedicle length are variable
and that these are not always present. Even though the supraclavicular flap has been used
previously as a free tissue transfer flap, we advise planning the use of a contralateral supra-
clavicular artery island flap or more traditional regional or free flaps as a second option,
because these vessels can be small, injured, scarred, or absent.

References
1. Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck
oncologic reconstruction: indications, complications and outcomes. Plast Reconstr Surg
124:115, 2009.
2. Chiu ES, Liu PH, Baratelli R, et al. Circumferential pharyngoesophageal reconstruction
using supraclavicular artery island flap. Plast Reconstr Surg 125:161, 2010.
3. Liu PH, Chiu ES. Supraclavicular artery flap: a new option for pharyngeal reconstruction.
Ann Plast Surg 62:497, 2009.
4. Chan JW, Wong C, Ward K, Saint-Cyr MD, Chiu ES. Three- and four-dimensional
computed tomographic angiographic studies of the supraclavicular artery island flap. Plast
Reconstr Surg 125:525, 2010.
5. Adams A, Wright MJ, Chiu ES. The use of multi-slice CT angiography: preoperative study
for supraclavicular artery island flap harvesting (accepted for publication by Ann Plast Surg).
6. Martin J, Sands Chiu ES. Innervation of supraclavicular artery island flap: anatomical studies
and clinical implications (accepted for publication by J Plast Reconstr Aesthetic Surg).

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 566 Part II  Regional Flaps: Anatomy and Basic Techniques

EXPERT COMMENTARY
Norbert Pallua, Timm P. Wolter

Indications
The supraclavicular artery flap has become a workhorse in head and neck reconstruction.
Since the original 1997 description of the flap, we have published our experience with tun-
neling and preexpanding the flap. Its use in burn reconstruction of children is well docu-
mented. Originally thought to be only used for limited indications in severe mentosternal
contracture, the supraclavicular flap is now used for a wide variety of applications, and an
increasing number of publications report its use.
The supraclavicular artery flap allows reconstruction of an enormously important area
for social interaction and permits restoration of full range of motion for neck movement.
Indications include scar reconstruction or tumor-related defect coverage in the head, neck,
and postauricular or jugular area. As an ultrathin, preexpanded flap it can be used for
hemifacial resurfacing. Intraoral defects often encountered in maxillofacial surgery can be
covered using this flap.

Advantages and Limitations

The main advantage of the supraclavicular artery flap is its soft, pliable tissue with very
good color and texture match for the head and neck region. This sensate and mostly hair-
less tissue is ideal for facial reconstruction. Because more distant regions have less color and
texture match, it is often superior to free flaps in these indications. Also, without the need
for microsurgery, the procedure is safe and faster, making it suitable for patients with com-
promised health, such as those in the early postburn period. The donor site at the shoulder
allows the scar to be inconspicuous.
The downside of the flap includes the surgeon’s learning curve, as in every new proce-
dure. Also, in most cases it requires a staged surgery. When using the flap as a pedicled flap,
good patient compliance is essential. Using preexpansion, expander filling can be associated
with problematic patient compliance, possible infection, and expander failure.

Anatomic Considerations
In my experience (N.P.), the vessel is constant in 100% of cases. I have never lost a flap
because of an absence of the supraclavicular artery. In contrast to the description in the
chapter, I use the external jugular vein as a landmark as opposed to the trapezius muscle.
The pivot point can be reliably located in the triangle between the external jugular vein,
the clavicle, and the lateral head of the sternocleidomastoid muscle.

Personal Experience and Insights

The indications for the supraclavicular artery flap have expanded and evolved since the
original description. Preexpansion allows much larger areas to be reconstructed, easier clo-
sure of the donor site and a better vascularization of the flap. Another variation of the flap
was the inclusion of an osseous chip from the clavicle. This made tracheal reconstruction
possible and offered a solution for the complex reconstruction of tracheocutaneous fistulas.1
Another exciting possibility is the use of the supraclavicular as a free flap.
A change in my technique is that I am now raising the flap not over the shoulder, as in
most publications, but using a more anteriorly lying skin island. The tissue in the acromial
fossa is even more pliable than the shoulder area. Also, surgical preparation is facilitated.

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 567

It should be noted that ancillary or secondary procedures are quite common, including
lipofilling, thinning of the flap by liposuction, and suspension of the flap by bone anchors
or by a palmaris tendon strip.

Recommendations
Planning
Because the vessel is constant, preoperative CT angiography is unnecessary in most cases.
Handheld Doppler examination will confirm the presence of the vessel in cases of doubt
(such as in patients who have had previous surgeries).
The shoulder without preexisting scarring should be chosen. However, when both
shoulders are burned or bilateral supraclavicular artery flaps are planned, the flap can even
be raised with some scarring. The scar can be excised during a later procedure.

Technique
As described in this chapter, the flap is raised from lateral to medial using a Doppler probe
or transillumination to identify the vessel. I recommend placing the patient in a supine posi-
tion with a freely movable arm. A surgical table with a removable shoulder piece facilitates
access. Closure of the donor site can almost always be performed primarily.

Postoperative Care
The flap must be carefully monitored. It is most important to reduce any tension on the
pedicle; therefore the arm should be held elevated. In select cases (such as children and
agitated patients), a postoperative Omega-type cast should be applied to immobilize the
arm and the head.

Complications: Avoidance and Treatment

In very large flaps, the flap can develop venous congestion at the distal end. Leech therapy
can be helpful. The most important factor for optimal blood flow is the position of the
arm. I routinely use perioperative and postoperative antibiotic prophylaxis to prevent flap
loss from infection.

Take-Away Messages
The flap has unique possibilities for reconstruction or resurfacing of the head and neck area.
It can be safely used in adults, children, and patients with compromised health. The flap
can be embedded in a reconstructive treatment plan with multiple procedures. When one
is defining this treatment plan, the surgical sequence should consider placement of tissue
expanders and adjunctive procedures. Refinements include lipostructuring, flap thinning,
and flap suspension.

Reference
1. Pallua N, Wolter TP. Defect classification and reconstruction algorithm for patients with
tracheostomy using the tunneled supraclavicular artery island flap. Langenbecks Arch Surg
395:1115, 2010.

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 568 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Abe M, Murakami G, Abe S, et al. Supraclavicular artery in Japanese: an anatomical basis for
the flap using a pedicle containing a cervical, nonperforating cutaneous branch of the superficial
cervical artery. Okajimas Folia Anat Jpn 77:149, 2000.
The authors investigated the morphology of the nonperforating cervical cutaneous branch in the lateral
cervical triangle using 65 (130 sides) donated cadavers. They found the branch in 104 of the entire 130
sides (80.0%). In the majority (72.1%), the cutaneous branch did not cross the clavicle or acromion but
supplied the dorsolateral cervical area. The branch was originated from the superficial cervical artery
close to the posterior belly of the omohyoideus muscle and immediately lateral to the external jugular
vein. The comitant vein, if present, drained into the external jugular vein. Their observations and
measurements (length and diameter) suggested that the nonperforating cutaneous branch is useful for
a pedicle of the dorsolateral cervical flap in Japanese people. However, detailed morphologies differ
from the previous studies published in western countries.
Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning the anterolateral thigh flap on the
blood supply to the skin. Br J Plast Surg 56:401, 2003.
The anterolateral thigh (ALT) flap has become a popular option for reconstructing a variety of soft
tissue defects, especially in the head and neck. Thinning of the flap may extend its usefulness to situ-
ations requiring less bulk; the successful use of this technique has previously been described in Asia.
However, similar results have not yet been produced in the West. To investigate this, the authors
proposed that “one-stage thinning of the ALT flap does not disrupt the blood supply to any area of
the flap skin.” A series of 10 ALT flaps were raised from Western European cadavers. The arteries
of the flaps were injected with india ink and latex rubber, and six of the flaps were cleared by the
Spalteholz technique. Patterns of dye filling were compared in full-thickness and thinned specimens,
and the arterial organization within the subcutaneous fat was studied. The authors saw 14 perforators
in 10 ALT flap dissections. These arose from the descending branch of the lateral circumflex femoral
artery in eight cases and from the transverse branch in two cases. Large branches from the perforator
were seen to form an arterial plexus at the level of the deep fascia, which communicates with the sub-
dermal plexus supplying the skin. Further branches arose from the perforator and traveled obliquely
through the fat to reach the subdermal plexus. In the thinned cadaver ALT flaps, dye perfusion did not
reach the distal portions of the subdermal plexus. There was reduced dye filling in comparison to the
full-thickness specimens. Thinning of the ALT flap reduces arterial perfusion in cadaver specimens.
This allows rejection of the null hypothesis. The fascial plexus and the oblique vessels supplying the
subdermal plexus are likely to be damaged or removed during thinning. This may explain the observed
reduction in subdermal-plexus filling in the thinned specimens. In the clinical setting, disruption of the
arterial supply in this manner could lead to ischemia and skin necrosis in thinned flaps. One-stage
thinning of the ALT flap may not be advisable in the Western population.
Andrades P, Pehler SF, Baranano CF, et al. Fistula analysis after radial forearm free flap recon-
struction of hypopharyngeal defects. Laryngoscope 118:1157, 2008.
Patients undergoing radial forearm free flap for hypopharyngeal reconstruction were retrospectively
reviewed; 104 patients underwent this procedure between 2001 and 2007. Fistulas were classified
as mild or severe, depending on the response to conservative management. Demographics, operative
details, pathology, and postoperative course were recorded as the prognostic variables. Univariate analy-
sis and a logistic regression model were used to identify associated factors. Pharyngocutaneous fistula
developed in 30 (28.8%) patients. Recurrence, cancer stage, cancer location, type of ablative surgery,
and the addition of other oncologic procedures were identified as significant predictors of fistula forma-
tion. Fistula significantly increases hospital stay and recipient site complications such as flap survival,
infection, and bleeding. Functional results such as diet, deformity, and socialization were also negatively
affected by fistula development. One third of the cases responded to conservative management, and
20 cases required a surgical procedure to definitively close the fistulous tract. Fistula formation remains

06f_SupraClav_r7_cah_0546-0582.indd 568 2/1/2012 11:07:53 AM

 Anterior Thorax  •  6F: Supraclavicular Artery Flap 569

a significant cause of morbidity associated with hypopharyngeal reconstruction. Postoperative course

and successful preventive strategies are discussed.
Angrigiani C. Aesthetic microsurgical reconstruction of anterior neck burn deformities. Plast
Reconstr Surg 93:507, 1994.
Eighty-six patients with anterior neck burn sequelae underwent scar resection up to the limits of the
aesthetic unit of the neck and immediate resurfacing with a scapular-parascapular free flap (the extended
scapular flap). The flap was raised in all patients above the deep fascia as a thin skin-subcutaneous
tissue flap, providing an initially acceptable aesthetic result. The flap was anastomosed to the facial
artery and vein. The donor area was closed directly, or a 4 to 5 cm wide skin graft was used that could
be completely removed in a secondary procedure if the patient requested it. There were 4 failures early
in the series, but no losses in the last 70 patients. To improve the final aesthetic result, 45 patients
underwent complementary defatting procedures (average three) and Z-plasties initiated 30 days after the
initial surgery at intervals of 1 month. Analysis revealed 96% good aesthetic results (as determined by
the cervicomental angle obtained and the subjective opinion of the patients). There were no recurrences
of scar contractures, and good function of the neck was regained in the majority of the patients. Thus
anterior neck burn sequelae can be safely treated with en bloc resection and resurfacing using this flap.
Angrigiani C, Grilli D. Total face reconstruction with one free flap. Plast Reconstr Surg
99:1566, 1997.
A bilateral extended scapular (scapular-parascapular) free flap was used in five patients with severe
facial burn sequelae for complete resurfacing of the face with the exception of the nose, which was
reconstructed in a separate operative procedure. All flaps survived. Four were used for complete face
resurfacing and one for neck and partial face resurfacing. The results were classified subjectively accord-
ing to both patient and surgeon opinion. Good to fair results were obtained. The authors stated that
this method might be further explored to obtain better results in these difficult cases.
Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the
head and neck. Plast Reconstr Surg 63:73, 1979.
The author described a compound flap that uses skin from the anterior chest on a narrow segment of
pectoralis major muscle, with its underlying axial neurovascular bundle. This flap was used success-
fully to reconstruct large defects in four consecutive patients. The author’s experience with this flap
suggests that it may be more versatile than the deltopectoral flap.
Ariyan S, Ross DA, Sasaki CT. Reconstruction of the head and neck. Surg Oncol Clin North
Am 6:1, 1997.
The collaboration of surgeons, radiation oncologists, chemotherapists, dentists, oral surgeons, prosth-
odontists, and speech therapists has led to major advances in the management of the difficult cancers
of the head and neck area. The advent of myocutaneous flaps and the facilitation of microsurgical free
flaps have ushered in an era of one-stage reconstructions to shorten the hospital stay and improve the
overall therapeutic, functional, and cosmetic results.
Bardsley AF, Soutar DS, Elliot D, et al. Reducing morbidity in the radial forearm flap donor
site. Plast Reconstr Surg 86:287, 1990.
The radial forearm flap, although widely used, has been criticized for the poor quality of its donor site.
To investigate the causes of morbidity, 100 radial artery free flap donor sites were reviewed. Sixty-
seven patients required skin grafting (group 1), and the remaining 33 patients were closed directly
(group 2). Seventeen patients in the series had compound osteocutaneous flaps (group 3). Wound
healing proved to be a significant problem in groups 1 and 3, and fracture of the radius occurred in 4
of the 17 patients in group 3 and was the most significant cause of morbidity. The radial artery was
reconstructed in 12 patients, but only 6 of the arteries (50%) were patent at the time of review. In
light of this experience, the authors no longer reconstruct the radial artery as a matter of routine. The
donor defect is closed directly wherever possible using an ulnar artery-based transposition flap when
required. A “boat-shaped” osteotomy is used in preference to right-angled bone cuts when harvest-
ing a segment of radius to avoid the complications and sequelae of fracture. These changes in surgical
technique have improved the acceptability and minimized the problems associated with this donor site.

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 570 Part II  Regional Flaps: Anatomy and Basic Techniques

Barthélémy I, Martin D, Sannajust JP, et al. Prefabricated superficial temporal fascia flap com-
bined with a submental flap in noma surgery. Plast Reconstr Surg 109:936; discussion 941, 2002.
The authors reported their experience with a new procedure: the combination of a prefabricated su-
perficial temporal fascia flap and a submental flap performed in an African hospital on five patients
with cheek deformities caused by noma. The prefabricated superficial temporal fascia flap makes
the inner lining of the cheek, which is anchored on the peripheral scar tissue. The submental flap is
released during the second operation and makes the outer lining. The main advantages are the excel-
lent aesthetic color of this last flap and the short distance between the donor site and the recipient site.
Moreover, the submental flap is positioned in a single operation (when the outer-lining reconstruction
is performed with a deltopectoralis flap, a third operation is necessary to cut the pedicle). None of the
flaps failed, and the functional results were good. The prefabricated superficial temporal fascia flap
and submental flap are versatile and reliable flaps, with reasonably long vascular pedicles, that can
be used successfully, even under suboptimal conditions in weak patients with huge defects of the face.
Blevins PK, Luce EA. Limitations of the cervicohumeral flap in head and neck reconstruction.
Plast Reconstr Surg 66:220, 1980.
The cervicohumeral flap has proven useful in head and neck reconstruction. The limitation of the flap
appears to be its length. Its major disadvantage is a lack of predictability of length of survival beyond
the deltoid insertion.
Bootz F, Preyer S. [Microvascular tissue transplantation in plastic reconstruction of the external
head-neck area] Laryngorhinootologie 73:538, 1994.
Free tissue transfer is under certain circumstances an ideal reconstructive method for skin and soft
tissue defects of the head and neck region. These are large multilayered defects, recurrences after previ-
ous reconstructive methods, in aesthetic disturbances resulting from the use of local flaps, in difficult
reconstructive areas associated with chronic infection and radiotherapy, and when local tissue is not
available. From 1987 to 1993 the authors performed 30 reconstructions of the surface of the head
and neck region with free flaps, mainly the forearm flap and the scapular flap, but also the latissimus
dorsi flap, and in one case the rectus abdominis flap were used. There were no flap failures. In only
one case of a forearm flap the authors saw delayed healing of the donor defect. There was no functional
impairment of the donor defect. All cosmetic results were acceptable. Flaps from the trunk mainly
showed considerable differences in color and texture to the surrounding skin.
Carlson GW, Schusterman MA, Guilamondegui OM. Total reconstruction of the hypopharynx
and cervical esophagus: a 20-year experience. Ann Plast Surg 29:408, 1992.
The authors reviewed 145 patients who underwent 148 total reconstructions of the hypopharynx and
cervical esophagus between 1970 and 1989. The types and numbers of reconstruction included 45
deltopectoral flaps, 35 myocutaneous flaps, 19 colon interpositions, 23 gastric transpositions, and 26
free jejunal transfers. Median hospitalization was 51 days for deltopectoral flaps, 24 days for myocu-
taneous flaps, 28 days for colon, 30 days for gastric, and 14 days for jejunum. Median resumption
of oral intake was 92 days for deltopectoral flaps, 19 days for myocutaneous flaps, 12 days for colon,
13 days for gastric, and 9 days for jejunum. Functional failure, defined as the inability to maintain
adequate nutrition without tube feedings, was 40% for myocutaneous flaps, 42% for colon interposition,
17% for gastric transposition, and 20% for free jejunal transfer. Microvascular free jejunal transfer has
become their method of choice for reconstruction of the hypopharynx and cervical esophagus. Gastric
transposition is an alternative when resection of the thoracic esophagus is necessary.
Chan JW, Wong C, Ward K, et al. Three- and four-dimensional computed tomographic an-
giography studies of the supraclavicular artery island flap. Plast Reconstr Surg 125:525, 2010.
The supraclavicular artery island flap is a useful regional option in head and neck reconstruction.
Previous studies recorded pedicle length, caliber, and ink injection studies of the supraclavicular artery.
This study presented a three- and four-dimensional appraisal of the vascular anatomy and perfusion
of the supraclavicular artery island flap using a novel computed tomographic technique. Ten supra-
clavicular artery island flaps were harvested from fresh cadavers. Each flap was injected with contrast
media and subjected to dynamic computed tomographic scanning using a GE Lightspeed 16-slice

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 571

scanner. The entire skin paddle was perfused in the majority (nine of 10) of flaps. One of the flaps
was perfused only 50%. In this case, the pedicle artery was found to be much smaller than the other
flap pedicles. Direct linking vessels and recurrent flow by means of the subdermal plexus were found
to convey the flow of contrast between adjacent perforators. This explains how perfusion extends to
adjacent perforators by means of interperforator flow, and how perfusion is maintained all the way
to the distal periphery of the flap. Using this imaging technique, the authors elucidated the vascular
anatomy of the supraclavicular artery island flap. This study confirmed previous clinical findings that
the supraclavicular artery island flap is a reliable option, giving surgeons new information for future
flap refinement.
Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic
reconstruction: indications, complications, and outcomes. Plast Reconstr Surg 124:115, 2009.
The supraclavicular island flap has been used successfully for difficult facial reconstruction cases, pro-
viding acceptable results without using microsurgical techniques. The authors use this regional flap in
reconstructing various head and neck oncologic defects that normally require traditional regional or free
flaps to repair surgical wounds. A pedicled supraclavicular artery flap was used to reconstruct head/
neck oncologic defects. Complications and functional outcomes were assessed. Head and neck oncologic
patients underwent tumor resection followed by immediate reconstruction using a supraclavicular artery
island flap. Ablative defects included neck, tracheal-stomal, mandible, parotid, and pharyngeal walls.
All flaps (18) were harvested in less than 1 hour. All ablative wounds and donor sites were closed
primarily and did not require additional surgery. Major complications included a complete flap loss
when the vascular pedicle was inadvertently divided and pharyngeal leaks. The leaks resolved with-
out surgical intervention, and both patients regained the ability to swallow using their neoesophagus.
Minor complications included donor site wound dehiscence and cellulitis. None of the patients reported
functional donor site morbidity. This thin flap is easy and quick to harvest, has a reliable pedicle, and
has minimal donor site morbidity. It is now the authors’ flap of choice for many common head and
neck reconstructive problems.
Clark JR, Gilbert R, Irish J, et al. Morbidity after flap reconstruction of hypopharyngeal de-
fects. Laryngoscope 116:173, 2006.
Laryngopharyngeal reconstruction continues to challenge in terms of operative morbidity and optimal
functional results. The primary aim of this study was to determine whether complications can be
predicted on the basis of reconstruction in patients undergoing pharyngectomy for tumors involving
the hypopharynx. In addition, the authors detail a reconstructive algorithm for management of partial
and total laryngopharyngectomy defects. A retrospective review was performed of 153 patients (118
men, 35 women) undergoing flap reconstruction for 85 partial and 68 circumferential pharyngectomies
at a single institution over a 10-year period. The total operative morbidity and mortality rate was
71% and 3%, respectively. Pharyngocutaneous fistula was increased in patients undergoing salvage
pharyngectomy for radiation failure compared with primary surgery. Tracheoesophageal speech was the
method of voice restoration in 44% of patients. Oral diet was achieved in 93% of patients however,
16% required gastrostomy tube feeds for either total or supplemental nutrition. The operative morbidity
associated with pharyngeal reconstruction is substantial in terms of early and late complications. The
authors were able to predict morbidity by defect extent and reconstruction type and initial treatment
modality. Swallowing function was acceptable; however, less than half of the patients undergoing
pharyngectomy had tracheoesophageal puncture voice restoration.
Conley JJ, Clairmont AA Jr. Regional flaps in ablative surgery in the head and neck. Am Fam
Physician 15:100, 1977.
Nondelayed regional skin flaps for reconstruction following radical ablative surgery in the head and neck
have become a significant advance. Radical extirpation of large, recurrent, or postirradiation persistent
cancer would be prohibitive without the use of regional skin flaps in reconstruction. The incorporation
of portions of rib, clavicle, or scapula within a skin flap has allowed reconstruction of the mandible for
both functional and cosmetic improvement.

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 572 Part II  Regional Flaps: Anatomy and Basic Techniques

Cordeiro PG. The tunneled supraclavicular island flap: an optimized technique for head and
neck reconstruction. Plast Reconstr Surg 105:852, 2000.
Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure.
The methods range from local, mostly myocutaneous flaps and skin grafts to free microsurgical flaps.
To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always
essential. Moreover, the donor site defect needs to be reduced, with no resulting functional or aesthetic
impairment. The authors found that the shoulder provides an optimal skin texture match to the neck
and face. In cadaver dissection, a vascular pedicle extending from the transversal cervical artery with two
accompanying veins was found to vascularize a defined region around the shoulder cap. In line with
these findings, the previously described fasciocutaneous island flap, nourished by the supraclavicular
artery, was developed further and used purely as a subcutaneously tunneled island flap. The tunneling
maneuver significantly improves the donor site by reducing scarring. The flap is characterized by a
long subcutaneous pedicle of up to 20 cm. The pivot point is in the supraclavicular region and allows
the flap to be used in the upper chest, neck, chin, and cheek. The authors introduced the anatomic
features and presented clinical cases underlining the surgical possibilities of the flap in reconstructive
procedures with expanded indications.
DiBenedetto G, Auinati A, Pierangeli M. From the “charretera” to the supraclavicular fascial
island flap: revisitation and further evolution of a controversial flap. Plast Reconstr Surg 115:70,
2005.
Wide tissue defects on the face and neck often require distant flaps or free flaps to achieve a tension-
free reconstruction and an acceptable aesthetic result. The supraclavicular island flap is a versatile and
useful flap that can be used in large tissue defects. Because of its wide arc of rotation, which ensures
a 180-degree mobilization anteriorly and posteriorly, the flap can reach distant sites when harvested
as a pure island flap. The main vascular supply of the flap, the supraclavicular artery, a branch of
the transverse cervical artery, or, less frequently, of the suprascapular artery, although reliable, is not a
very large vessel. In some particular cases, when there is too much tension or the angles are too tight,
the vascular supply of the flap can be difficult, and special care must be taken to avoid flap failure. To
avoid this problem, the authors started harvesting the flap not as a pure island flap but with a fascial
pedicle, thin and resistant, which ensures good reliability. When a higher tension rate is present, it
avoids the risk of excessive traction or kinking of the vessels. Twenty-five consecutive patients with
various defects located on the head, neck, and thorax area were treated in the past 2 years using the
modified supraclavicular island flap. There was no flap loss or distant necrosis of the flap, and there
was marginal skin deepithelialization in only two cases, which only required minor surgery. Post-
operative morbidity was low, similar to the classic supraclavicular island flap, with primarily closed
donor sites, except for one case, and tension-free scars. The authors demonstrated that the modified
supraclavicular island flap is a reliable and safe flap that gives a good aesthetic result with low risk
concerning the viability of the transferred skin. The technique, similar to supraclavicular island flap
harvesting, is easy to perform and is attractive in patients at risk for poor or delayed healing, such as
smokers or patients with complex medical histories.
Disa JJ, Pusic AL, Hidalgo DA, et al. Microvascular reconstruction of the hypopharynx: defect
classification, treatment algorithm, and functional outcome based on 165 consecutive cases.
Plast Reconstr Surg 111:652, 2003.
The objectives of this study were threefold: to develop a scheme for classification of hypopharyngeal
defects, to establish a reconstructive algorithm based on this system, and to assess the functional
outcome of such reconstruction. The authors performed a retrospective review of their 14-year experi-
ence with 165 consecutive microvascular reconstructions of the hypopharynx in 160 patients. The
treatment algorithm for microvascular hypopharyngeal reconstruction was based on the type of defect
with partial defects with radial forearm flaps, circumferential defects reconstructed with free jejunal
flaps, and extensive, multilevel defects reconstructed with rectus abdominis myocutaneous flaps. The
authors concluded that microvascular reconstruction of pharyngeal defects is highly successful with few
postoperative complications. With appropriate flap selection, functional outcome can be optimized.

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 573

Dufresne C, Cutting CB, Valauri F, et al. Reconstruction of mandibular and floor of mouth
defects using the trapezius osteomyocutaneous flap. Plast Reconstr Surg 79:687, 1987.
This investigative study examined the anatomy of 20 osteomyocutaneous flaps in 10 fresh cadavers
and in 8 clinical patients. In the authors’ series, 80% (type I) of the major vascular pedicle arose from
the thyrocervical trunk. In 20% (type II), the major pedicle arose separately from the subclavian artery.
The regions perfused by the vascular trunk were further examined with micropaque and Prussian
blue injections through the transverse cervical artery. Consistent areas of cutaneous staining as well
as bony staining were noted over the shoulder, arm, and back and into the scapula itself. Experience
with eight clinical applications of this osteomyocutaneous flap resulted in successful healing with an
excellent aesthetic and functional result. Long-term follow-up was maintained on the patients for up
to 36 months. Panorex radiographs and biopsies of the grafted bone were obtained on several patients.
These disclosed evidence of bony remodeling and viable bone tissue. Tetracycline labeling also revealed
evidence of active bony turnover.
Hallock GG. The role of local fasciocutaneous flaps in total burn wound management. Plast
Reconstr Surg 90:629, 1992.
This review of 182 consecutive burn patients needing surgery found that they underwent 233 separate
episodes for skin grafting. Appropriately, only a fraction of this number required some form of vascular-
ized flap, with 14 patients having 21 local fasciocutaneous flaps. Six were elevated in previously skin
grafted regions, which is an advantage peculiar to this flap type. Three flaps (14%) suffered major
complications requiring a second surgical intervention. Only six of all flaps were used for acute burn
wounds, but two of the three complications accrued in this subset, with one directly attributable to
wound infection. Because most flaps were required for either coverage or release of contractures about
joints, it has been recommended that the initial surgical approach for treatment of the acute wound in
these regions be altered to preserve the fascial plexus whenever possible to permit the use of this simple
and expedient alternative if it is needed later.
Heinz TR, Cowper PA, Levin LS. Microsurgery costs and outcome. Plast Reconstr Surg
104:89, 1999.
Reliable information on cost and value in microsurgery is not readily available in the literature. Driving
factors for cost, determinants of complications, and cost-reduction strategies have not been elucidated in
this population, despite such progress in other areas of medicine. Clearly, the time-consuming and costly
nature of this endeavor demands that appropriate indications and patient management be delineated to
operate proactively in this cost-conscious time, financial and outcome determinations are critical. One
hundred seven consecutive free tissue transfers performed from 1991 to 1994 by a single microsurgeon
were studied. Retrospective chart review for clinical parameters was combined with analysis of hospital
costs and professional charges. Operating room and anesthesia costs were based on a microcost analysis
of actual operating room time, materials, labor, and overhead. Other patient level costs were gener-
ated by Transition 1, a hospital cost-accounting system. The following issues were addressed: (1) flap
survival, (2) total costs and length of stay for all free flaps, (3) payments received from various insurers,
(4) breakdown of operating room costs by labor, supplies, and overhead, (5) breakdown of inpatient costs
by category, (6) additional costs of complications and takebacks, (7) factors associated with complications
and flap takebacks, and (8) cost-reduction strategies. Mean free flap operating room costs (exclusive
of professional fees) ranged among case types from $4439 to $6856 and were primarily a function of
operating room times. Elective patient cases lasted a mean 440 minutes. There was a large disparity
in reimbursement: private insurers covered hospital costs (not charges) completely, whereas Medicare
paid 79% and Medicaid only 64%. Length of stay, operative procedures, and complications had the
greatest influence on inpatient costs in this group of free flap patients. Potential cost savings as a result
of possible practice changes (such as shortening intensive care unit stays and avoiding staged operations)
can be predicted. This analysis caused a revision in these institutions’ practice patterns and laid the
foundation for planned outcome studies in this population.
Hyakusoku H, Gao JH. The “super-thin” flap. Br J Plast Surg 47:457, 1994.
The so-called super-thin flap was devised in China, and these flaps have been in general use since
about 1982. However, detailed descriptions of the flaps have rarely appeared in English-language

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 574 Part II  Regional Flaps: Anatomy and Basic Techniques

journals. The authors presented the development of their use of these flaps in clinical cases and dis-
cussed some factors that seem to contribute to the increase of the survival area of the distal portion of
these so-called super-thin flaps.
Hyakusoku H, Pennington DG, Gao JH. Microvascular augmentation of the super-thin occipito-
cervico-dorsal flap. Br J Plast Surg 47:465,1994.
The super-thin flap technique was first devised in China. Flaps thinned by this technique are especially
useful in the neck, face, or hands of patients with extensive burn scarring, where the combination of
thinness and suppleness is needed. However, some of these radically thinned flaps may develop su-
perficial or full-thickness necrosis because of the unpredictability of survival of the super-thinned area.
The authors presented a technique of microvascular augmentation of the blood supply of the thinned
flap, an example of so-called supercharging.
Hyakusoku H, Takizawa Y, Murakami M, et al. Versatility of the free or pedicled superficial
cervical artery skin flaps in head and neck burns. Burns 19:168, 1993.
The usefulness of the free or pedicled superficial cervical artery skin flap in reconstructive surgery of
head and neck burns is reported. This flap can be made with the pivot point near the cervical region.
Moreover, it can be elevated as a free or long vascular pedicled flap. Therefore, it is widely applicable
in reconstructing the scar contractures of the head and neck, particularly in extensively and deeply
burned patients.
Jones NF, Johnson JT, Shestak KC, et al. Microsurgical reconstruction of the head and neck:
interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305
cases. Ann Plast Surg 36:37, 1996.
A team of two head and neck surgeons and two plastic surgeons performed 305 microsurgical free
flaps for defects of the head and neck over a 9-year period, with a success rate of 91.2%. The authors
reviewed their technique and complications. The radial forearm flap and free jejunal transfer have become
the preferred choices for intraoral reconstruction and pharyngoesophageal reconstruction, respectively.
Khouri RK, Ozbek MR, Hruza GJ, et al. Facial reconstruction with prefabricated induced
expanded (PIE) supraclavicular skin flaps. Plast Reconstr Surg 95:1007, 1995.
The prefabricated induced expanded (PIE) supraclavicular flap refers to the staged transfer of an ex-
panded supraclavicular skin with a fascia flap used as the carrier. In three patients, the authors used
PIE supraclavicular flaps to successfully reconstruct a total forehead and two major nasal defects. Their
first PIE flap confirmed the feasibility of the method but necessitated two microvascular free flaps. In
the ensuing two patients, the authors reduced the need for microvascular anastomoses by using simple
pedicled flap transfers in either or both stages. Whenever feasible, the preferred method consists of
transferring a temporoparietal fascia flap to a subcutaneous pocket in the ipsilateral supraclavicular fossa
and simultaneously placing a skin expander under both the fascia flap and the supraclavicular skin.
After adequate expansion, the fascia becomes incorporated within the capsule of the expander, and
the composite capsulofasciocutaneous flap can be safely transferred to the facial defect as the PIE flap.
Krause CJ. A conceptual approach to local flaps. Otolaryngol Head Neck Surg 87:491, 1979.
Few procedures offer the surgeon a greater opportunity to exercise surgical and aesthetic judgment than
the design and implementation of local flaps about the head and neck. Considerations include skin
color and texture match; adequacy of flap blood supply; size, location, and characteristics of the donor
site defect; functional capability of the proposed flap; nature of skin tension lines created; and number
of surgical procedures required. The author presented a systematic approach to local flap design and
implementation and illustrations of the geometric principles involved.
Kuran I, Turan T, Sadikoglu B, et al. Treatment of a neck burn contracture with a superthin
occipito-cervico-dorsal flap: a case report. Burns 25:88, 1999.
Postburn neck contractures still represent a surgical challenge because of their exposed location and
early operative treatment is necessary for both functional as well as aesthetic reasons. An excellent
functional result was obtained by using a supercharged super-thin occipitocervicodorsal flap, as described
by Hyakusoku et al, to repair a large defect of the anterior neck following a very wide neck burn

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 575

contracture release. In this case report, the technique and its advantages among the other reconstructive
modalities were discussed briefly.
Lamberty BG, Cormack GC. Misconceptions regarding the cervico-humeral flap. Br J Plast
Surg 36:60, 1983.
Various authors have reported different failure rates for the cervicohumeral flap. The authors attempted
to explain these occurrences in light of recent experimental and clinical work, which has increased their
knowledge of the detailed blood supply of the supraclavicular fossa and shoulder region. In particular, the
role of a fasciocutaneous vessel in the supply of a proximally based shoulder flap was stressed. Division
of this vessel may occur during proximal mobilization of the cervicohumeral flap. This fundamentally
alters the nature of the flap and may be the key to the varying failure rates. The implications of this
for fasciocutaneous flaps in general were discussed.
Ma X, Zheng Y, Xia W, et al. An anatomical study with clinical application of one branch of
the supraclavicular artery. Clin Anat 22:215, 2009.
The supraclavicular flap is an important method for reconstruction of the neck. The authors attempted
to clarify the mechanism of blood flow into the supraclavicular flap based on the thoracic branch of
the supraclavicular artery. Additionally, they discussed the clinical application of such anatomy. The
authors stated that the pectorally extended supraclavicular flap could be used to repair defects on the
ipsilateral or contralateral face, neck, and anterior thorax.
Mäkitie A, Aitasalo K, Pukander J, et al. Microvascular free flaps in head and neck cancer
surgery in Finland 1986-1995. Acta Otolaryngol Suppl 529:245, 1997.
Microvascular free tissue transfer has in many cases replaced classic flap techniques and is now an
established workhorse for head and neck reconstructions. The authors reported a retrospective study
of over 300 patients who had microvascular free flap reconstructions in head and neck cancer surgery
in Finland during a 10-year period. The operations were performed in the University Hospitals by
plastic surgeons, ENT specialists, or maxillofacial surgeons. The most reliable flap in terms of survival
was the radial forearm flap. The ever-improving success of microvascular free tissue transfer has made
it a useful procedure for head and neck reconstructions. There is also a growing need for microvascular
team surgery in the field of head and neck cancer therapy.
McCraw JB, Magee WP Jr, Kalwaic H. Uses of the trapezius and sternomastoid myocutaneous
flaps in head and neck reconstruction. Plast Reconstr Surg 63:49, 1979.
Both of these myocutaneous flaps can supplant forehead and deltopectoral flaps in certain indications.
They are additional arterialized flaps for the armamentarium of the reconstructive surgeon, and can
be useful in many repairs in the head and neck region.
Mimoun M, Kirsch JM, Faivre JM, et al. Rebuilding the cervico-mandibular angle: correcting
a deformity of neck burns. Burns Incl Therm Inj 12:264, 1986.
Repairing the cervicomandibular angle following neck burns is a major problem. Several artistic
landmarks show its aesthetic importance. From a functional point of view, the authors showed the
positive consequences of rebuilding using the results from 101 patients with neck burns. In principle,
the treatment involves maximal use of healthy skin, and the separate reconstruction of the horizontal
and vertical parts of the neck.
Mitz V. The fasciocutaneous flap as an alternative solution in difficult reconstructive problems.
Ann Plast Surg 17:206, 1986.
Fasciocutaneous flaps are available anywhere in the body—literally from head to foot. Some hair-bearing
flaps, the parasternal flap, and some forearm and lower extremity flaps may be useful for coverage of
soft tissue defects when a relatively simple one-stage procedure is preferred. The fasciocutaneous flaps
described here are long and narrow, with a length to width ratio of up to 5:1. Although these flaps are
not the ultimate solution to all reconstructive problems, they are especially useful in the treatment of
burn scar contractures and chronic ulcerations such as those that result from the extravasation caused
by chemotherapeutic agents. Of particular importance is the fact that the use of these flaps does not
preclude the use of other flaps later, should this be necessary. Specific indications for these flaps must
always be kept in mind in relation to other reconstructive alternatives.

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 576 Part II  Regional Flaps: Anatomy and Basic Techniques

Mizerny BR, Lessard ML, Black MJ. Transverse cervical artery fasciocutaneous free flap for
head and neck reconstruction: initial anatomic and dye studies. Otolaryngol Head Neck Surg
113:564, 1995.
The bilateral transverse cervical arteries of 16 fresh cadavers were exposed by an infraclavicular midline
approach. Each artery was cannulated, and methylene blue dye was infused to delineate the skin ter-
ritory subserved by the vessel. The two major infusion skin patterns obtained allowed fashioning of a
thin fasciocutaneous flap incorporating supraclavicular skin, which was based on the transverse cervical
artery or a larger flap additionally incorporating upper back skin and varying amounts of trapezius
muscle, when the artery had a dorsal scapular artery branch. Depending on the skin pattern, either
scapula or clavicle could be transferred with the other soft tissues. The skin territory of the transverse
cervical artery is caused to vary by the presence or absence of its dorsal scapular artery branch. The
supraclavicular portion of the flap is recommended for repair of facial and nasal lesions because of its
close match in color and texture to facial skin. Oral lesions can also be reconstructed with this flap
because of its pliability. The free flap based on the transverse cervical artery pedicle appears to be a
useful addition to the armamentarium of flaps for head and neck reconstruction. Clinical use of the
flap is ongoing and will be subsequently reported.
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based
on the deep superior epigastric system. Plast Reconstr Surg 82:815, 1988.
Radiographic studies of the deep superior epigastric artery (DSEA) and its connections within the
soft tissues of the abdominal wall were performed in 64 fresh cadavers. The patterns of anastomosis
between the deep superior epigastric artery and the deep inferior epigastric artery (DIEA) were noted.
Type I (29%) revealed a single deep superior epigastric artery and deep inferior epigastric artery, type
II (57%) revealed a double-branched system of each vessel, and type III (14%) revealed a system of
three or more major branches. In each case, the two systems were united by choke vessels in the seg-
ment of muscle above the umbilicus. The supply to the various transverse and vertical skin flaps from
the deep superior epigastric artery was defined as a series of captured anatomic territories bounded by
choke vessels. The upper transverse and vertical flaps had the best supply, and the TRAM flap had
the most tenuous supply. Midline crossover occurs predominantly in the subdermal plexus and on
the surface of the rectus sheath. Modifications of the design of the TRAM flap, the case for a delay
procedure, the wisdom of including a strip of anterior rectus sheath, and the risks of splitting the muscle
with respect to its nerve supply and vascular patterns are discussed on an anatomic basis.
Pallua N, Demir E. Postburn head and neck reconstruction in children with the fasciocutane-
ous supraclavicular artery island flap. Ann Plast Surg 60:276, 2008.
Postburn deformities or scar contractures in the head and neck region of children are a challenge with
unique problems compared with the rest of the body. Fourteen children presented with neck contractures
following burns, and four children required reconstruction following panfacial burn deformities. The
authors reported their experience of late-phase secondary burn reconstruction in the head and neck
region of these 18 pediatric patients (age range 9 to 17 years) with 22 fasciocutaneous supraclavicular
island flaps, including 5 preexpanded flaps. Clinical follow-up 10 to 29 months. High functional
and aesthetic requirements could be fulfilled in all patients. Flap complications occurred in 9%, with
low donor site morbidity (9%). The fasciocutaneous supraclavicular artery island flap is reliable and
safe for immediate or late resurfacing of facial defects and to release cervical contractures. Customized
flap design with tissue expansion without the need for microsurgery allows extended indications and
optimized skin use, although good texture and color match is generally difficult to achieve in the head
and neck region of severely burned children.
Pallua N, Machens HG, Liebau J, et al. [Treatment of mentosternal contractures by flap-plasty]
Chirurg 67:850, 1996.
Mentosternal contractures represent a surgical challenge because of their exposed location. They require
early operative treatment for both functional as well as aesthetic reasons. Careful clinical examination
of scar location and traction forces both in the resting and functional moving state, including proper
evaluation of the surrounding soft tissue, is essential for exact preoperative planning of the reconstructive

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 577

surgical procedure required. In general, the technically most feasible operation is favored, if functional
and aesthetic results are good and the postoperative risk of recurrent mentosternal contractures is low.
Between 1987 and 1994, 21 patients with cervical, mentosternal and mentothoracic contractures
underwent operative procedures at their clinic. Eight patients underwent a surgical reconstruction with
local flaps, and 13 patients received a free microvascularized flap.
Pallua N, Machens HG, Rennekampff O, Becker M, Berger A. The fasciocutaneous supra-
clavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr
Surg 99:1878, 1997.
Mentosternal contractures are a surgical challenge to the plastic and reconstructive surgeon. The authors
added the supraclavicular artery island flap to their armamentarium of surgical procedures to improve
the function and cosmesis of disfigured patients. Since July 1994, they have used the supraclavicular
artery island flap for releasing postburn mentosternal contractures in eight patients. The flap was
planned to be 4 to 10 cm in width and 20 to 30 cm in length with the supraclavicular vessels running
axially. All donor defects could be closed primarily without significant postoperative complications in
seven of the eight patients. All flaps healed primarily, achieving a good functional result by complete
removal of contracting scar tissue for all patients one donor site healed by secondary intention. The
authors found the supraclavicular artery island flap both reliable and safe for immediate resurfacing
after resection of cervical scars. The anatomy, operative procedure, and postoperative results of the
supraclavicular artery island flap were outlined.
Pallua N, Magnus Noah E. The tunneled supraclavicular island flap: an optimized technique
for head and neck reconstruction. Plast Reconstr Surg 105:842, 2000.
Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure.
The methods range from local, mostly myocutaneous flaps and skin grafts to free microsurgical flaps.
To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always
essential. Moreover, the donor site defect needs to be reduced, with no resulting functional or aesthetic
impairment. The authors have found that the shoulder is a region providing an optimal skin texture
match to the neck and face. In cadaver dissection, a vascular pedicle extending from the transversal cervi-
cal artery with two accompanying veins was found to vascularize a defined region around the shoulder
cap. In line with these findings, the previously described fasciocutaneous island flap, nourished by the
supraclavicular artery, was developed further and used purely as a subcutaneously tunneled island
flap. The tunneling maneuver significantly improves the donor site by reducing scarring. The flap is
characterized by a long subcutaneous pedicle of up to 20 cm. The pivot point is in the supraclavicular
region and allows the flap to be used in the upper chest, neck, chin, and cheek. The authors introduced
the anatomic features and presented clinical cases underlining the surgical possibilities of the flap in
reconstructive procedures with expanded indications.
Pallua N, von Heimburg D. Preexpanded ultra-thin supraclavicular flaps for (full-) face re-
construction with reduced donor site morbidity and without the need for microsurgery. Plast
Reconstr Surg 115:1837, 2005.
The expanded supraclavicular island flap, as described in 1997 by Pallua, is a useful tool for total
facial reconstruction, providing satisfactory results without microsurgical prefabrication. The authors
reported the use of this technique in 12 patients requiring large flaps who presented with extensive
facial scarring that had been previously reconstructed using disfiguring, pigmented skin grafts. On
the basis of their anatomical dissection studies and knowledge of the constant anatomy of the supra-
clavicular artery and two draining veins, the authors carefully inserted tissue expanders under the
supraclavicular island flaps. After the flaps were expanded, all scars were removed and the covering
flaps were transferred into place. Sixteen preexpanded supraclavicular island flaps were used in 11
patients. There were no complications. The authors presented a method of facial reconstruction that
has the advantages of creating a large amount of thin tissue of both good color and texture, without
the disadvantages of donor site morbidity, lengthy operative time, and high cost. In their opinion, this
is the method of choice for total facial reconstruction.

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 578 Part II  Regional Flaps: Anatomy and Basic Techniques

Petrovici V, Makropoulos P. [Reconstructive measures in burn injuries of the face and neck]
Handchir Mikrochir Plast Chir 18:11, 1986.
Parts of the face and neck are often affected by thermal damage, which results in particularly disfiguring
scars. Movement of the facial muscles is severely impaired, and symmetry as well as facial contours are
distorted by scarred skin, which is always of lesser quality. Particular problems arise when the trauma
results in partial loss of facial structures such as the nose, lips, or eyebrows. Plastic surgical treatment of
burned areas requires thorough knowledge of various procedures for best possible rehabilitation. Burn
scars of the facial and neck region were treated by using local flaps and free skin transplantation or com-
bination of both. The indication for the various methods was discussed and demonstrated in their cases.
Pribaz JJ, Fine NA. Prefabricated and prelaminated flaps for head and neck reconstruction.
Clin Plast Surg 28:261, 2001.
Flap prefabrication and prelamination are evolving new techniques that are useful in reconstructing
complex defects of the head and neck. Flap prefabrication involves the introduction of a new blood
supply by means of a vascular pedicle transfer into a volume of tissue. After a period of neovascular-
ization, this volume of tissue may be transferred, based only on its implanted vascular pedicle. The
transfer may be a local transposition or by microsurgical transfer. Flap prelamination refers to a tech-
nique in which additional tissue is added to an existing flap (without manipulation of its axial blood
supply) to make a multilayered flap that may be used for complex, three-dimensional, multilayered
reconstructions. This technique may be used locally or at a distance, requiring microvascular transfer.
Examples of each were described in this article.
Pribaz JJ, Fine N, Orgill, DP. Flap prefabrication in the head and neck: a 10-year experience.
Plast Reconstr Surg 103:808, 1999.
Tissue neovascularized by implanting a vascular pedicle can be transferred as a “prefabricated flap”
based on the blood flow through the implanted pedicle. This technique potentially allows any defined
tissue volume to be transferred to any specified recipient site, greatly expanding the armamentarium of
reconstructive options. The authors prefabricated 17 flaps, and 15 flaps were transferred successfully
in 12 patients. Tissue expanders were used as an aid in 11 flaps. Seven flaps were prefabricated at a
distant site and later transferred using microsurgical techniques. Ten flaps were prefabricated near the
recipient site by either transposition of a local vascular pedicle or the microvascular transfer of a distant
vascular pedicle. The prefabricated flaps were subsequently transferred as island pedicle flaps. These
local vascular pedicles can be reused to transfer additional neovascularized tissues. Common pedicles
used for neovascularization included the descending branch of the lateral femoral circumflex, superficial
temporal, radial, and thoracodorsal pedicles. Most flaps developed transient venous congestion that
resolved in 36 to 48 hours. Venous congestion could be reduced by incorporating a native superficial
vein into the design of the flap or by extending the prefabrication time from 6 weeks to several months.
Placing a Gore-Tex sleeve around the proximal pedicle allowed for much easier pedicle dissection at the
time of transfer. Prefabricated flaps allow the transfer of moderate-sized units of thin tissue to recipient
sites throughout the body. They have been particularly useful in patients recovering from extensive
burn injury on whom thin donor sites are limited.
Robson MC, Koss N, Krizek TJ, et al. The undelayed Mütter flap in head and neck reconstruc-
tion. Am J Surg 132:472, 1976.
Twenty-one mastoid-occiput–based shoulder flaps were used to reconstruct defects in patients with
head and neck cancer. When the tip of the flap does not extend beyond the midclavicle, this flap can
safely be elevated and transferred into its final position without delay procedures. Because it does not
require secondary sectioning and implantation, the Mütter flap can successfully be used to reconstruct
multiple defects within its arch. Its utility thus rivals the more commonly used medially based delto-
pectoral flap and forehead flap.
Rose EH. Aesthetic restoration of the severely disfigured face in burn victims: a comprehensive
strategy. Plast Reconstr Surg 96:1573, 1995.
Although highly specialized burn centers have significantly reduced mortality rates following extensive
total body surface area burns, survivors are often left with grotesque facial disfigurement. The strategy
of modern facial restoration emphasizes enhancement of appearance as significantly as mitigation of

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 579

functional impairment. Criteria for success are (1) an undistracted “normal” look at conversational
distance, (2) facial balance and symmetry, (3) distinct aesthetic units fused by inconspicuous scars,
(4) “doughy” skin texture appropriate for corrective makeup, and (5) dynamic facial expression.
The author successfully restored 17 severely disfigured burned faces by replacement of entire aesthetic
units with microvascular “prepatterned” composite flaps blended into the facial canvas by cosmetic
camouflage techniques. Important to outcome is extensive initial intraoperative sculpting to simulate
normal planes and contours. Seams are placed at junctions of facial components. Three-dimensional
imaging is used to assess architectural asymmetries, and bone grafts are aided by computer-generated
acrylic models. Adjunctive procedures include tensor fascia lata slings, intraoperative tissue expansion,
suction-assisted lipectomy, and scar management. Flesh-colored makeup and/or tattooing of beard,
lips, scars, and eyebrows help to hide scars and pigment the skin to harmonize with the rest of the
face. In all cases, facial integrity has been aesthetically restored and, in most instances, with makeup,
is near normal in social settings at conversational distances. Facial animation is retained and color
matches are excellent. One flap was lost early in the series.
Saint-Cyr M, Schaverien M, Arbique G, Hatef D, Brown SA, Rohrich RJ. Three- and four-
dimensional computed tomographic angiography and venography for the investigation of the
vascular anatomy and perfusion of perforator flaps. Plast Reconstr Surg 121:772, 2008.
Two-dimensional contrast radiography is the current standard for investigating the vascular anatomy
of surgical flaps. The microvascular anatomy of the perforator flap, however, is limited conceptually
by representation in two dimensions. Static three-dimensional CT angiography enables vascular
anatomy to be evaluated in the coronal, axial, and sagittal planes, and dynamic four-dimensional CT
angiography allows the vascular filling of a perforator flap to be visualized over short time intervals
in three dimensions. An anatomic study was performed using 11 fresh adult cadavers, 4 males and
7 females. Perforator flaps harvested included the anterolateral thigh, deep inferior epigastric perfora-
tor, superior gluteal artery perforator, inferior gluteal artery perforator, thoracodorsal artery perforator,
anteromedial thigh, and dorsal intercostal artery perforator. Novel techniques for acquiring both static
and dynamic three-dimensional images of macrovascular and microvascular perforator flap anatomy
using computed tomographic angiography have been described. This methodology has also allowed
the sequential investigation of adjacent vascular territories. This can provide a better understanding of
how perforator flaps and the skin are perfused and may aid in the future design of new flaps.
Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory:
vascular anatomy and clinical implications. Plast Reconstr Surg 124:1529, 2009.
The authors investigated the three-dimensional and four-dimensional arterial vascular territory of a
single perforator, termed a “perforasome,” in major clinically relevant areas of the body. A vascular
anatomy study was performed using 40 fresh cadavers. A total of 217 flaps and arterial perforasomes
were studied. Perforator flaps on the anterior trunk, posterior trunk, and extremities were studied.
Flaps underwent both static (three-dimensional) and dynamic (four-dimensional) CT angiography to
better assess vascular anatomy, flow characteristics, and the contribution of both the subdermal plexus
and fascia to flap perfusion. The perfusion and vascular territory of perforators is highly complex and
variable. Each perforasome is linked with adjacent perforasomes by means of two main mechanisms
that include both direct and indirect linking vessels. Vascular axis follows the axiality of linking ves-
sels. Mass vascularity of a perforator found adjacent to an articulation is directed away from that same
articulation, whereas perforators found at a midpoint between two articulations, or midpoint in the
trunk, have a multidirectional flow distribution. Each perforator holds a unique vascular territory
(perforasome). Perforator vascular supply is highly complex and follows some common guidelines.
Direct and indirect linking vessels play a critical part in perforator flap perfusion, and every clinically
significant perforator has the potential to become either a pedicle or free perforator flap.
Schaverien M, Saint-Cyr M, Arbique G, Brown SA, Rohrich RJ. Three- and four-dimensional
arterial and venous anatomies of the thoracodorsal artery perforator flap. Plast Reconstr Surg
2008 121:1578, 2008.
The vascular anatomy of the thoracodorsal artery perforator flap, which had not previously been
elucidated, was examined using three- and four-dimensional computed tomographic angiography

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 580 Part II  Regional Flaps: Anatomy and Basic Techniques

and venography. Twenty-five thoracodorsal artery perforator flaps were harvested from fresh cadavers
from the Western population. Dynamic static CT angiography using iodinated contrast media was
performed after cannulation of the largest perforator from the descending branch of the thoracodorsal
artery and its vena comitans in 10 flaps. Imaging was repeated subsequent to flap thinning between
the deep and superficial adipose layers. Colored latex injections and flap dissections were performed
in a further 15 flaps to establish the location, caliber, and intramuscular length of the thoracodorsal
artery perforators. Two distinct perforator complex types were described. Flap thinning can be safely
performed between the deep and superficial adipose layers without significantly affecting flap vascularity,
provided that a safety zone about the perforator is respected. The superficial venous system consisted
of large veins arranged in a polygonal pattern situated at the subdermal level and was connected to
the deep system by the venae comitantes of the thoracodorsal artery perforators. Perforators from the
descending branch of the thoracodorsal artery were found in reliable locations. Using a novel dynamic
three-dimensional imaging technique, perfusion of the arterial and venous system of the thoracodorsal
artery perforator flap was elucidated. Although the flap is inherently thin, it can be safely thinned
between the superficial and deep adipose layers.
Schaverien M, Saint-Cyr M, Arbique G, Hatef D, Brown SA, Rohrich RJ. Three- and four-
dimensional computed tomographic angiography and venography of the anterolateral thigh
perforator flap. Plast Reconstr Surg 121:1685, 2008.
The authors presented a detailed three- and four-dimensional appraisal of the arterial and venous
anatomy and perfusion of the anterolateral thigh flap using a novel computed tomographic technique.
Eighteen anterolateral thigh flaps harvested from fresh Western cadavers were used. Four-dimensional
CT angiography with injection of iodinated contrast medium into isolated perforators and their venae
comitantes was used to investigate the arterial and venous anatomy and flap perfusion. Additional
perforators were injected to investigate the vascular connections within the flap. Changes in flap per-
fusion after thinning and adipofascial flap harvest were also examined, and contrast density within
each flap plexus with respect to the perforator was examined. Large-diameter linking vessels at the
suprafascial level enabled perfusion of adjacent vascular territories and of the subdermal plexus between
angiotomes. Thinning reduced the size of the vascular territory by ligating recurrent vessels at the
level of the suprafascial plexus. Adipofascial flap harvest prevented perfusion of the recurrent vessels,
demonstrating the role of the subdermal plexus in recurrent flow. Three distinct perforator complex
patterns were found with relevance to flap thinning. A superficial venous system perfused the venae
comitantes of the descending branch of the lateral femoral circumflex artery and the long saphenous vein.
A reduction in vascular territory occurs in the anterolateral thigh flap after thinning and is attribut-
able to ligation of vessels within the suprafascial plexus. Recurrent flow through the subdermal plexus
was seen dynamically for the first time and appears to be an important mechanism for skin perfusion.
Suominen S, Ahovuo J, Asko-Seljavaara S. Donor site morbidity of radial forearm flaps. A
clinical and ultrasonographic evaluation. Scand J Plast Reconstr Surg Hand Surg 30:57, 1996.
Harvesting of a forearm flap based on the radial artery has been thought to cause functional or circula-
tory problems in the donor hand. Eighteen patients were examined three to 24 months after a radial
forearm flap had been raised. The function of both hands was studied for grip strength, mobility of the
wrist and elbow joints, and sensitivity of the area served by the superficial radial nerve. The patients
were interviewed and the cosmetic result was evaluated. Duplex ultrasonography and color Doppler
ultrasonography of both ulnar arteries were done, and the brachial arteries were measured as controls.
Angle-corrected peak flow velocity (cm/s) in the ulnar artery of the donor forearm was significantly
increased at the level of the wrist compared with the control forearm, as was the ulnar-brachial peak
flow velocity ratio. The grip strength of the donor hand was weaker by 11.9%. Ten (56%) had
areas of sensory loss over the radial nerve distribution, and 7 of the 18 patients complained of cold
intolerance. Four patients considered the donor site result so bad that they would not have chosen the
operation had they known what the result would look like. The radial forearm flap donor site is not
without problems, and the patients must be carefully selected and properly informed preoperatively.

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 Anterior Thorax  •  6F: Supraclavicular Artery Flap 581

Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study
and clinical applications. Br J Plast Surg 40:113, 1987.
The blood supply to the skin and underlying tissues was investigated by ink injection studies, dissec-
tion, perforator mapping, and radiographic analysis of fresh cadavers and isolated limbs. The results
were correlated with previous regional studies. The blood supply was shown to be a continuous
three-dimensional network of vessels not only in the skin but also in all tissue layers. The anatomic
territory of a source artery in the skin and deep tissues was found to correspond in most cases, giving
rise to the angiosome concept. Arteries closely follow the connective tissue framework of the body. The
primary supply to the skin is by direct cutaneous arteries which vary in caliber, length and density
in different regions. This primary supply is reinforced by numerous small indirect vessels, which are
“spent” terminal branches of arteries supplying the deep tissues. An average of 374 major perforators
was plotted in each subject, revealing that there are still many more potential skin flaps. Their arterial
roadmap of the body provides the basis for the logical planning of incisions and flaps. The angiosomes
defined the tissues available for composite transfer.
Teot L, Cherenfant E, Otman S, et al. Prefabricated vascularised supraclavicular flaps for face
resurfacing after postburn scarring. Lancet 355:1695, 2000.
The authors designed a technique for prefabrication of large flaps to cover the whole face reconstruction
for cervicocephalic postburn scarring. Aesthetic improvement and a better quality of life was achieved
in seven patients.
Vinh BQ, Ogawa R, Van Anh T, Hyakusoku H. Reconstruction of neck scar contractures
using supraclavicular flaps: retrospective study of 30 cases. Plast Reconstr Surg 119:130, 2007.
The supraclavicular flap is used to cover chin and neck region defects. Its main vascular supply is the
supraclavicular artery, and it can be harvested as either a skin pedicled flap or an island flap (vascular
pedicled flap). The island flap has a wide rotation arc, and both the color and texture match are better
for reconstructing contour-sensitive areas such as the chin and neck than those of free flaps harvested
from distant sites. The authors used 32 supraclavicular flaps for reconstructions in 30 patients. If
circumstances demanded it, they transferred the flaps through skin tunnels to reduce continuous scar
formation between the donor and recipient sites. Twenty-eight of the 32 flaps survived completely,
but there were 3 cases of distal necrosis and 1 case of 90% necrosis. Twenty-nine of the 30 patients
were satisfied with both the functional and aesthetic results. The benefits of the supraclavicular island
flap are clear: it is thin but reliable, and easy to harvest.
Woo SH, Seul JH. Pre-expanded arterialized venous free flaps for burn contracture of the
cervicofacial region. Br J Plast Surg 54:390, 2001.
Despite the fact that arterialized venous flaps provide thin, good-quality tissue to repair defects of the
face and neck, their clinical applications have been limited by an unstable postoperative course and
variable flap necrosis. To resolve these problems, the authors applied a tissue-expansion technique to
the arterialized venous flap before flap transfer. Three preexpanded arterialized venous free flaps were
used to treat postburn scar contracture of the cervicofacial region. The donor site was confined to the
forearm. A rectangular expander was usually placed over the fascia of the flexor muscles in the proximal
two thirds of the forearm. The mean expansion period, volume, and flap size were 44 days, 420
cm3, and 147 cm2, respectively. There were no complications. The cervicofacial region was successfully
reconstructed after excision of the postburn contractures with preexpanded arterialized venous flaps,
with no marginal necrosis or postoperative instability. Large, thin, arterialized venous flaps are well
matched with the recipient defect in the cervicofacial area, and the color and texture match obtained
with forearm tissue produced an aesthetically favorable result. Preexpanded arterialized venous flaps
are another new option for free flap reconstruction of the face and neck.
Zimman OA. Reconstruction of the neck with two rotation-advancement platysma myocu-
taneous flaps. Plast Reconstr Surg 103:1712, 1999.
A reconstruction of a neck with a defect caused by radionecrosis sequelae using two rotation-advancement
platysma myocutaneous flaps was presented. The thinness of the flaps, their accessibility, the lack of
bulk, and the primary closure of the donor site, without functional or aesthetic problems, all render
this technique an attractive option for replacing anterior neck skin.

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06f_SupraClav_r7_cah_0546-0582.indd 582 2/1/2012 11:07:54 AM
 Chapter 7
Posterior Trunk

The posterior trunk is a paradox in that it offers some of the largest soft tissue donor sites
of the body while presenting some of the most difficult reconstructive challenges. The
latissimus is one of the most versatile and widely used flaps in reconstructive surgery and
can be used for almost any area in the body. The gluteal area also provides an abundance
of options for reconstruction of decubiti, vaginal reconstruction, and breast reconstruc-
tion. Difficult wounds in the midline and lower back can be reconstructed with trapezius,
paraspinous, lumbar perforator, and gluteal-based flaps. Although these reconstructive
challenges are not common, it is important to know about the flaps required in this area
because there are few options available for solving these complex problems.

Gluteus Maximus and IGAP/SGAP Flaps

Gluteal Thigh Flap
Scapular/Parascapular Flap
Lumbar Perforator Flap
Trapezius Flap
Latissimus Dorsi Flap
Paraspinous Flap

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 ANATOMIC LANDMARKS
Landmarks A rhomboid-shaped muscle. Important landmarks for locating
the muscle include the posterior superior iliac spine (PSIS), the
tip of the coccyx, the ischial tuberosity, and the iliotibial tract.
Size 24 3 24 cm. The skin paddle design is variable, depending on
the patient. A flap 22 cm long and 10 cm wide allows primary
closure.
Origin The gluteus maximus originates from the PSIS, the coccyx, and
the bony and ligamentous structures of the lateral sacrum.
Insertion Insertion into the greater trochanter and the iliotibial tract of
the fascia lata.
Function The gluteus maximus extends and rotates the thigh laterally.
Composition Muscle-only, myocutaneous, or skin only.
Flap Type Type III.
Dominant Pedicles Superior gluteal artery, inferior gluteal artery.
Minor Pedicle First perforator of profunda femoris artery.
Nerve Supply Motor: Inferior gluteal nerve (L5 to S2). Sensory: Posterior divi-
sions of S1 to S3 medially, posterior divisions of L1 to L3 laterally.

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 Section 7A
Posterior Trunk

Gluteus Maximus
and IGAP/SGAP Flaps

CLINICAL APPLICATIONS
Regional Use
Sacrum
Ischium
Trochanter
Distant Use
Breast
Specialized Use
Anal sphincter
Meningomyelocele
Breast

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 ANATOMY OF THE Gluteus Maximus and IGAP/SGAP Flaps

Posterior superior
iliac spine

D
Superior
1 gluteal artery

Gluteus maximus
muscle

Inferior gluteal artery

Coccyx Ishcial
Ischial
tuberosity

Bony landmarks of gluteus muscle

Superior gluteal
artery

Gluteus maximus
muscle (cut)

Inferior gluteal
artery and nerve

Sciatic nerve

Undersurface of muscle with neurovascular anatomy

Fig. 7A-1 

Dominant pedicles: Superior gluteal artery; inferior gluteal artery

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 587

Anatomy
Landmarks A line drawn from the PSIS to the tip of the coccyx marks the posterior border
and origin of the gluteus maximus muscle. A second line drawn from the tip of
the coccyx through the inferior edge of the ischial tuberosity to the iliotibial tract
indicates the inferiormost extent of the gluteus muscle. A line drawn through
the posterior superior iliac spine parallel to the inferior border of the muscle
denotes the superior border of the muscle. Laterally, the border of the muscle is
at the greater trochanter and it extends inferiorly into the iliotibial tract. The
muscle is rhomboid shaped.
Composition A gluteus maximus flap provides a muscle-only flap, a myocutaneous flap, or a
perforator flap containing overlying skin and fat only.
Size The size of the gluteus maximus muscle in its entirety is 24 3 24 cm. The
skin paddle design is variable, depending on the patient, and may be as long as
22 cm, with a width of 10 cm. Primary closure is possible.
Origin The gluteus maximus muscle originates from the PSIS, the coccyx, and the bony
and ligamentous structures of the lateral sacrum.
Insertion The insertion of the muscle is into the greater trochanter and the iliotibial tract
of the fascia lata.
Function The gluteus maximus extends and rotates the thigh laterally. It is important in
running, jumping, standing, and climbing; thus it is not taken in its entirety
when used for reconstruction in an ambulatory patient. Up to half of the muscle
can be taken with minimal impact on function.

Arterial Anatomy (Type III)

Dominant Pedicle  Superior gluteal artery
Regional Source  Internal iliac artery.
Length  3 cm.
Diameter  2.5 mm.
Location  Deep to muscle origin above the piriformis.
Dominant Pedicle  Inferior gluteal artery
Regional Source  Internal iliac artery.
Length  3 cm.
Diameter  2.5 mm.
Location  Deep to muscle origin below the piriformis.
Minor Pedicle  First perforator of profunda femoris artery and venae comitantes
Regional Source  Profunda femoris artery.
Length  1 cm.
Diameter  0.6 mm.
Location  Below inferior muscle insertion.
The superior and inferior gluteal arteries communicate with transverse branches of the medial
femoral circumflex artery, lateral femoral circumflex artery, and the first perforator of the profunda
femoris artery. None of these minor pedicles alone is sufficient to carry or supply the flap.

Venous Anatomy
The superior and inferior gluteal veins are 2 to 4 mm in diameter, with the superior vein often
larger than the inferior vein. At the level of the piriformis muscle, the venae comitantes have often
combined into a single vein, with an effective usable length of 3 cm.

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 588 Part II  Regional Flaps: Anatomy and Basic Techniques

Nerve Supply
Motor The inferior gluteal nerve (L5 to S2) emerges from the sciatic foramen and runs
below the piriformis muscle, entering the gluteus maximus muscle from its
deep surface. The inferior gluteal nerve supplies motor innervation to both the
superior and inferior portions of the muscle.
Sensory The skin territory of the gluteus maximus muscle is supplied by the posterior
divisions of S1 to S3 medially and the posterior divisions of L1 to L3 laterally.
This innervation cannot be maintained for island flaps and free flaps.

Vascular A natomy of the Gluteus M aximus

and IGAP/SGAP Flaps

D1

D2

m1
Deep surface of flap
after release of insertion

B C

D1 D1

D2

D2

m1

m1
Deep surface Radiographic
of flap view

Fig. 7A-2 

Dominant pedicles: Superior gluteal artery (D1); inferior gluteal artery (D2)
Minor pedicle: Profunda femoris perforator (m1)
p, Piriformis

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 589

Flap Harvest
Design and Markings
When possible, it is best to mark the patient in a standing position; the marks should then
be confirmed with the patient prone or in a lateral position. The superior gluteal flap is
most commonly used in a V-Y fashion, or as a perforator flap. As a perforator flap, the skin
paddle design is similar to that for a buttock lift. The inferior gluteus–based flap is also used
in a V-Y fashion. Inferior-based flaps using a skin paddle are carefully designed so that the
aesthetic of the lower buttock is maintained after harvest.

A B

Superior gluteal flap design Inferior gluteal flap design

C D E

Superior V-Y segmental advancement Flap design incorporating both Inferior V-Y segmental advancement
flap skin island design superior and inferior vessels flap skin island design

Fig. 7A-3  Variations of skin paddle design for the gluteal flap.

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 590 Part II  Regional Flaps: Anatomy and Basic Techniques

When a muscle-only rotation flap is used, access incisions are made directly over the
desired portion of the muscle, or the muscle can be accessed through the nearby defect.
When using the inferior portion of the gluteal muscle to create an anal sphincter, access
incisions are directly over the muscle and are kept above the gluteal fold for best cosmesis.

Patient Positioning
For surgery on sacral, trochanteric, or ischial soft tissue wounds, prone positioning is best.
For creating an anal sphincter, a jackknife prone position is preferable. Unilateral breast
reconstruction may be performed with the patient in a lateral decubitus position for both
harvest and inset. Many surgeons prefer to transfer the patient from supine (for mastectomy
and/or recipient vessel preparation) to prone (for gluteal flap harvest), then supine again (for
inset of the flap). Bilateral flap harvest for bilateral breast reconstruction has been described.

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.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 591

Guide to Flap Dissection

Standard V-Y Advancement Flap
After marking the skin paddle that overlies the gluteus maximus muscle, the surgeon incises
the skin as marked down to the muscle fascia. Dissection proceeds from lateral to medial,
with division of the muscle laterally. Access is then gained to the submuscular space, where
the underlying piriformis muscle can be found. For advancement toward the midline, the
origin of the muscle must be carefully divided along the sacrum, taking care not to injure
the superior or inferior gluteal vessels. The flap is based off the superior vessel or the infe-
rior vessel that supplies that section of muscle being used. Once the muscle has been fully
divided around the skin island, it easily advances to the midline. Large defects can often be
closed with bilateral advancement flaps (see Fig. 7A-11).

A Superior gluteal
Defect
artery B
Gluteus maximus
muscle (medial cut)

Gluteus
maximus
muscle
(lateral cut)

C D

Superior gluteal
artery

D1 Piriformis
muscle
p Inferior gluteal
artery

D2

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.
Dominant pedicles: Superior gluteal artery (D1); inferior gluteal artery (D2)
p, Piriformis

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 592 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variants
•  Semicircular advancement flap
•  Functional muscle transfer flap
•  Superior gluteal artery perforator (SGAP) flap
•  Inferior gluteal artery perforator (IGAP) flap
•  Myocutaneous free flap

Semicircular Advancement Flap

A large semicircular advancement flap can be designed to take advantage of the excess tissue
of the buttock. Undermining of the flap should be limited in the areas of the superior and
inferior gluteal perforators. The remainder of the areas may be undermined and advanced
medially. Direct closure of this donor site is usually possible, although back-grafting is always
an option. It is not necessary to visualize the pedicle in these flaps. For added rotation, the
muscle can be divided laterally as the flap is advanced medially (see Figs. 7A-10 and 7A-12).

Superior gluteal
artery

Inferior gluteal
artery

B C

Superior gluteal
Superior gluteal
artery
artery

Perforating
Piriformis
artery
muscle

Gluteus maximus Inferior gluteal

muscle artery
(lateral cut)

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.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 593

Functional Muscle Transfer Flap

A sigmoid-shaped incision is made over the lower portion of the buttock, exposing the
inferior half of the gluteus muscle, which is the most useful for this application. For patients
without anal sphincter function, the inferior gluteal muscle will be released laterally at the
level of its fascial insertion in the iliotibial band. Some of this fascia is included with the
harvest to facilitate inset later. A third to a half of the gluteal muscle is then harvested from
lateral to medial; the muscle is split in such a way that the inferior gluteal vessels are included
in the flap. The surgeon should note a key dissection point at the posterior femoral cuta-
neous nerve (PFCN) branches as they exit from the inferior border of the gluteus muscle,
accompanying the continuation of the inferior gluteal artery. Care must be taken to preserve
the posterior femoral cutaneous nerve to maintain posterior thigh sensation. The nerve
and the inferior gluteal vessels can then be directly seen as the muscle dissection proceeds
and the muscle is split. Also, the inferior gluteal nerve must be protected; it lies lateral to
the sciatic nerve and innervates the entire gluteus muscle. Once the flap has been elevated
to the origin of the inferior gluteal vessel at the piriformis, it can be passed through two
subcutaneous tunnels, one anterior and one posterior to the anus. They are then anchored
to the contralateral ischial tuberosity. Care must be taken to leave soft tissue over the sciatic
nerve to prevent irritation postoperatively when the patient is sitting (see Fig. 7A-13).

Superior Gluteal Artery Perforator Flap

The superior gluteal artery perforator (SGAP) flap is used most commonly as a free flap but
can be used as a rotational flap. The flap is designed on the superior portion of the buttock.
One can expect the origin of the superior gluteal vessels to lie on a point a third the distance
from the PSIS to the trochanter, and this can be confirmed by a handheld Doppler device.
After incision of the skin paddle, dissection proceeds from lateral to medial, elevating the
fascia off the gluteus maximus muscle. Once the desired large perforator is encountered,
the vessels may be followed with careful intramuscular dissection to the source superior
gluteal vessel. Many side branches exist at this level, and the surgeon should invest time
in further, sometimes tedious, dissection to maximize the pedicle length or to achieve an
adequate length and diameter of vessel to match the recipient site.

Posterior superior
Superior iliac spine
gluteal artery 1/3

1/3

1/3
Greater
trochanter
prominence

Coccyx

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 promi-
nence 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.

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 594 Part II  Regional Flaps: Anatomy and Basic Techniques

After this has been adequately dissected, the flap can be used as a rotational flap for
sacral or gluteal wounds; it may also be harvested as a free tissue transfer (see Figs. 7A-14
and 7A-16 through 7A-18).

SGAP flap

Superior gluteal
B artery C

Superior gluteal
artery

Perforating
artery

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.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 595

Inferior Gluteal Artery Perforator Flap

After the skin island for the inferior gluteal artery perforator (IGAP) flap is designed, dissec-
tion proceeds down to the muscular fascia. On the inferior border of this flap, the posterior
femoral cutaneous nerve will be evident with the inferior gluteal artery as it descends down
to the thigh. The surgeon should attempt to spare this nerve to avoid numbness of the
posterior thigh. The artery will ultimately be divided as dissection of the inferior gluteal
artery proceeds through the muscle to its source inferior gluteal system. Again, many side
branches exist at this level, and time should be invested in further dissection to maximize
the pedicle length and to achieve an adequate diameter of vessel to match the recipient site.
Once this has been adequately dissected, the flap can be used as a rotational flap for sacral
or gluteal wounds; it may also be harvested as a free tissue transfer. Care must be exercised
not to injure the inferior gluteal nerve, which overlies or is lateral to the sciatic nerve and
is often in the area of the inferior gluteal artery (see Figs. 7A-15, 7A-19, and 7A-20).

Myocutaneous Free Flap

A patch of muscle can be taken that includes these perforators, making them myocutaneous
free flaps. note: Inclusion of muscle will severely shorten the pedicle length.

Arc of Rotation
Standard Flap
In a standard muscle flap, the point of rotation is the superior and/or inferior gluteal vessels
that will supply the flap. Release of the sacral origin may assist in inset but will not lengthen
the arc of rotation.

A C

Standard arc for total muscle flap Arc for inferior gluteal muscle

Arc for superior gluteal muscle

Fig. 7A-9 

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 596 Part II  Regional Flaps: Anatomy and Basic Techniques

Transposition Flap
When a flap containing a skin paddle is rotated, the arc of rotation will be limited by its
vascular supply (superior and/or inferior gluteal vessels). Arc of rotation can be improved by
dissecting the perforators that supply the flap and leaving muscle behind, which effectively
lengthens the pedicle (see Figs. 7A-16 and 7A-17).

V-Y Advancement Flap

The flap may be transposed or advanced in a V-Y fashion. Advancement centrally is limited
by the origin of the muscle at the lateral edge of the sacrum, so this must be released. Further
advancement of the flap may be possible by completely dividing the gluteus maximus lateral
to the skin island and pedicle (in nonambulatory patients) or by isolating the flap to either
the superior or the inferior vessels, depending on the reconstructive need (see Fig. 7A-11).

Flap Transfer
A standard flap may be transposed through a subcutaneous tunnel or through an access
incision—whichever path fits the reconstructive need. V-Y advancement is through direct
advancement, with closure of the donor site behind the advanced flap. In functional muscle
reconstruction, the inferior flap is split and tunneled subcutaneously both anteriorly and
posteriorly around the anus. The harvested fascia on the distal part of the elevated muscle is
then attached to the ischial tuberosity on the contralateral side through a counterincision.

Flap Inset
Pedicle Flap
The pedicle flap should be inset without placing tension on the superior or inferior gluteal
pedicle. Closure of the donor site should bear the tension of the closure, leaving the rotated
flap tension free.

Transposition and V-Y Flaps

For either a transposition flap or a V-Y flap, closure of the donor site should bear the tension
of the closure, leaving the advanced or transposed flap tension free. For inset of a functioning
muscle transfer, it is critical to maintain the functional length of the muscle; this is usually
not a concern when insetting the muscle to the contralateral ischial tuberosity.

Donor Site Closure

For a rotational or V-Y flap, direct donor site closure is recommended, because these
wounds are often deep after the flap has been moved. Planning the size of the skin paddle
component of the flap is therefore critical in ensuring primary closure of the donor site. A
width of 10 cm can usually be closed without difficulty, but this is patient dependent. Wide
undermining in a subcutaneous plane can also aid in closure. If needed, back-grafting with
a skin graft can be performed in semicircular advancement flaps. Closure of a free flap site
is more straightforward, because there is less concern about placing pressure on the pedicle.
The deep fascia is often closed as the first layer, followed by skin closure. In general, these
wounds are notorious for developing postoperative seromas, and a drain tube should be
placed at the time of harvest.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 597

Clinical Applications
This 72-year-old woman presented with osteoradionecrosis of the sacrum and exposure of
the cauda equina after tumor extirpation and radiation therapy. Debridement of bone and
necrotic tissues with muscle coverage of the cauda equina and stable skin coverage were
required. Options included gluteal muscle flaps, myocutaneous flaps, and free tissue transfer.

B C

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 supe-
rior gluteal artery to cover the exposed cauda equina. The semicircular flap is elevated and the per-
forator 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. (Case supplied by MRZ.)

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 598 Part II  Regional Flaps: Anatomy and Basic Techniques

This 28-year-old man with paraplegia had a stage 4 sacral decubitus ulcer. After maximizing
nutrition and debriding necrotic tissues, options for closure included gluteal-based rotation
or transposition flaps. In this case, a myocutaneous flap provided the best padding to guard
against future pressure sores.

A B

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 de-
sign 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. (Case supplied by MRZ.)

This 54-year-old man with paraplegia presented with a stage 4 sacral decubitus ulcer. For
this more superficial wound, a semicircular flap was chosen.

A B

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. (Case supplied by MRZ.)

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 599

This 24-year-old woman presented with anal incontinence after an excessive episiotomy
and tear from childbirth. On rectal ultrasonography, her sphincter muscle was shown to be
incomplete, and she was referred for functional muscle transfer. Although some surgeons
use a gracilis muscle wrap for this procedure, the gluteal muscle transfer is preferred. The
gracilis has little active function, since the area used is mainly tendinous. The wrapping of
the sphincter is likely bringing the remaining functional muscle into a better position to
function. A gluteal transfer has the same effect, plus a shutter effect, with active contraction
of the gluteus, a natural inclination when trying to maintain continence.

A B

C D

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 sig-
moidal 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. (Case supplied by MRZ.)

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 600 Part II  Regional Flaps: Anatomy and Basic Techniques

This 48-year-old-woman desired bilateral breast reconstruction with autologous tissue and
opted for a bilateral GAP breast reconstruction. She did not have adequate abdominal or
thigh tissue for bilateral reconstruction, a common problem necessitating the use of breast
implants.

B C

Fig. 7A-14 A, The patient had thin skin cover, with visible ribs and inverted-T scars from her previ-
ous 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.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 601

E F

G H

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. (Case sup-
plied by MRZ.)

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 602 Part II  Regional Flaps: Anatomy and Basic Techniques

This 24-year-old woman was diagnosed with infiltrating intraductal carcinoma of her
left breast. She wanted a breast reconstruction to match her unmodified opposite breast.
Although her lower abdomen was thin, scarred, and had been irradiated, she did not want
a back scar, so free flap reconstruction with the inferior gluteus flap was selected.

A B

C D

E F

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.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 603

G H

I J

K L

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. (Case supplied
by GJ.)

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 604 Part II  Regional Flaps: Anatomy and Basic Techniques

This 48-year-old ambulatory patient was referred with a chronic wound of the sacral region.
Four years earlier, the patient had undergone a sigmoidectomy for adenocarcinoma. The
patient had received adjuvant radiation to the pelvic/gluteal area and had developed a fistula,
which necessitated a temporary stoma. The patient then underwent radical debridement,
which included resection of part of the coccyx. Two previous attempts to close the wound
primarily had failed because of chronic infection and the presence of irradiated tissue.
Clinical examination revealed a 3 by 5 cm chronic wound, extending deeply in the sacral
region. After radiologic and histologic investigation, no locoregional recurrence of disease
was evident. A wide debridement was performed and a pedicled SGAP flap was designed.

A B

C D

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. (Case courtesy Phillip N. Blondeel, MD.)

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 605

The neonate shown below was born with an undiagnosed myelomeningocele. Plastic surgi-
cal consultation was obtained to assist with soft tissue closure. Because of the defect size and
location, alternative options to standard closure techniques were devised. We decided that
vascularized tissue directly over the neural tube closure would minimize both cerebrospinal
fluid leaks and the risk of infection. An SGAP flap was designed and rotated based on large
medial perforators, maximizing vascularized skin transfer and minimizing muscle damage.

A B

C D

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. (Case courtesy
Phillip N. Blondeel, MD.)

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 606 Part II  Regional Flaps: Anatomy and Basic Techniques

This 54-year-old woman had undergone failed breast implant reconstructions; she also had
a history of an emergency cesarean section via a midline incision.

A B

C D E

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. (Case courtesy Joshua L. Levine, MD.)

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 607

This 47-year-old woman presented with lobular carcinoma in situ of the right breast and
atypical ductal hyperplasia. Multiple negative biopsies had yielded negative results, but she
opted for bilateral mastectomies. For the reconstruction, she requested larger breasts than
her A cup size.

A
B

C D

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. (Case courtesy Joshua L. Levine, MD.)

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 608 Part II  Regional Flaps: Anatomy and Basic Techniques

This 36-year-old woman presented for bilateral nipple-sparing prophylactic mastectomy.

She did not want a scar on her abdomen.

C D

Fig. 7A-20  A, The patient is shown preoperatively. B, Bilateral IGAP flaps were designed and har-
vested. 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. (Case courtesy Joshua L. Levine, MD.)

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 609

Pearls and Pitfalls

• Use of the gluteus maximus muscle should be a distant second or third choice for re-
construction in an ambulatory patient. The patient may have no difficulty ambulating
with harvest of up to 50% of the muscle, but the possibility of nerve injury or functional
disability does exist. A gluteal perforator flap should be considered.
• One should favor the superior gluteal vessel when planning flap rotations, advancements,
or free flaps. This particular dissection does not put the inferior gluteal nerve or the pos-
terior femoral cutaneous nerve at risk.
• When harvesting a skin paddle, a superior paddle is favored, because this best mimics
the tissue that would be removed for a buttock lift. The scar, although thick, elevates
the buttock, which is more natural than harvesting the skin from the inferior crease and
distorting the crease. This is sometimes more difficult to hide in clothing.
• When used for breast reconstruction, the fatty tissue from the gluteal area is not comparable
to the fatty tissue one sees in the abdomen. Because of the fibrous nature of the buttock,
shaping can be more difficult and matching a natural breast more complex. Z-plasties
and fat grafting can be very helpful.
• Anal sphincter reconstruction can be performed using the gluteal muscle; in fact, it is
the preferred reconstruction. Contracting the gluteal muscle is a natural response when
forcibly contracting the anal sphincter, so it is easier for patients to learn to use this muscle
in this fashion.
• It is best to leave drains in place until the patient is fully ambulatory, because this donor
site is known for seroma formation, especially after the patient becomes more active. It
is not unusual for gluteal drains to remain in place for 2 to 3 weeks.
• It is important to maintain a soft tissue pad over the sciatic nerve when muscle is harvested,
or patients may complain of sciatica or pressure-related problems when sitting on this area.
• Treatment of meningomyelocele in children has been described using gluteal flaps, either
as a transposition flap or in continuity with advancement of the latissimus and paraspinal
muscles (see Fig. 7A-17).

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 610 Part II  Regional Flaps: Anatomy and Basic Techniques

EXPERT COMMENTARY
Joshua L. Levine

The gluteal area has long been an outstanding choice for autologous perforator flap breast
reconstruction with gluteal artery perforator (GAP) flaps. An adequate volume of tissue
can almost always be found from either the superior (SGAP) or inferior (IGAP) region in
patients for whom an abdominal deep inferior epigastric perforator (DIEP) flap may not
be the best option.

Indications
The gluteal region should be considered for any patient interested in autologous breast
reconstruction. My preference is to use the abdomen as the donor site whenever it is avail-
able. However, there are circumstances in which the abdomen is not available, or not the
best option. For example, if the patient has had an abdominoplasty, liposuction, or other
procedures that render her abdomen unusable, one must look elsewhere for donor tissue.
Also, in very thin patients, especially if they undergo bilateral mastectomy, the abdomen
may not provide enough volume for two reasonable breast reconstructions. There are situ-
ations in which the patient simply does not want a long scar across her front, and would
prefer a scar that she will not have to see in the mirror. In these situations, the GAP flaps
have the advantage of providing adequate tissue for breast reconstruction, and hiding the
scar behind the patient.
Most women who are candidates for a GAP flap breast reconstruction have tissue in both
the upper and lower buttock areas, and may chose SGAP or IGAP based on the following
advantages and disadvantages: the SGAP scar can be hidden in panties or a swimsuit, but
the removal of tissue from the upper buttock creates a flattening that is seldom favorable.
The IGAP scar is hidden in the inferior buttock crease and does not flatten the buttock,
but it may distort the curve of the infrabuttock crease.

Advantages and Limitations

Technical considerations include the fact that compared with the abdomen, gluteal fat is more
spongy and firm. Thus it can be slightly less pliable for shaping in the breast reconstruction.
Also, the amount of skin available is less than that for an abdominal flap. This poses some
limitations in delayed reconstructions, especially in patients who have had radiation therapy.
These issues are minor and can be overcome with proper planning and realistic expectations.
The major limitation is the extreme difficulty of the procedure. Of all the perforator
flaps used for breast reconstruction, most experienced surgeons agree that the GAPs are the
most challenging. As such, most surgeons offer these procedures only one at a time, so that
a staged reconstruction is done for a bilateral procedure, as described in this chapter. Bilat-
eral simultaneous GAP flap breast reconstruction has been described (by me and others). It
requires two expert microsurgeons harvesting the buttock flaps simultaneously, preferably
at the same rate, and intraoperative repositioning of the patient twice.

Anatomic Considerations
When dissecting the perforator through the muscle, branches to surrounding muscle are
divided as the pedicle is followed down into the muscle. The branches, especially the veins,
get bigger as the dissection continues. Before reaching the superior gluteal vessels (in the
SGAP), a thick layer of posterior gluteal fascia is encountered (Fig. 7A-21).

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 611

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.

At this level the branches become very large and cumbersome. The fascia must be
opened widely to fully address this area, which had been called the Medusa’s head. This
fascial layer does not exist in an IGAP dissection. If one is able to get beyond this obstacle,
the reward is the gluteal artery, which is very large in diameter (2 to 4 mm), and makes
for a much easier arterial anastomosis. If the flap is harvested too soon, the artery will be a poor
size match for the internal mammary artery. In harvesting an IGAP flap the dissection is very
similar, but the length of the perforator is usually much greater. It may take longer to get to
an artery of adequate diameter. The posterior femoral cutaneous nerve may or may not be
encountered. If it is encountered, it is separated from the artery and preserved. The sciatic
nerve is not encountered.

Personal Experience and Insights

GAP flaps take a great deal of effort and stamina to perform successfully. I have found
preoperative MRA imaging to help enormously in hastening the procedure and reducing
anxiety. Knowing where the best perforator is and its’ course through the muscle helps one
to plan the best incision and dissection. Persistence and patience at the “Medusa’s head” is
also of paramount importance. The veins are very large and thin walled, and the operative
space is deep and tight. The farther the dissection is carried, the better caliber the artery
will be, but it must be done with extreme caution.

Recommendations
Planning
Preoperative MRA imaging was introduced by my group in 2005. We were impressed by
the images from CT angiography from the group in Barcelona and wanted to obtain the
information without radiation. We have fine-tuned the technique over the years to the point
at which we are consistently getting extremely useful information. I highly recommend
preoperative imaging. I also always mark the patient the day before the procedure in my
office. This gives me the opportunity to plan and think about the details of the procedure.
I find this very helpful.
Continued

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 612 Part II  Regional Flaps: Anatomy and Basic Techniques

Technique
The entire flap is incised through the skin and subcutaneous fat. At this point it is very im-
portant to bevel as the dissection goes through the fat, so that more fat volume is captured,
if needed (Fig. 7A-22).

Fig. 7A-22  Beveling to improve the volume harvest in an SGAP flap.

Once the skin is opened, the flap is mobile, so the position of the marked Doppler signal
may change with respect to its position as it emerges from the muscle. Always be aware of the
original vessel position with respect to all landmarks. The flap can be elevated off the muscle from
any side in a subfascial plane. The most important element is to do so parallel to the muscle
bundles. Each bundle should be completely uncovered within the field before moving to the
next bundle. This makes for a very neat and predictable dissection, so that the perforators
are very visible when they emerge within the septum between two bundles (Fig. 7A-23).

Fig. 7A-23  This photo emphasizes the importance of dissecting parallel to muscle bundles so that
perforators (arrow) can be visualized as they emerge.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 613

At that point the septum is opened all the way to the extent of the operative field. These
recommendations are consistent with the surgical principal of “don’t get in a hole.” This
will be a deep dissection, and it is very important to open the field as wide as possible. I use
the Ellman bipolar forceps and a micro-DeBakey forceps for the entire dissection. Small
muscle branches are cauterized with the bipolar cautery, and larger ones are tied. Clips are
not used because they can fall off and/or get in the way during microanastomosis. Clips
are used for the final vessel harvest. Great care must be taken to avoid injury to a giant vein
when the dissection is deep in the muscle.

Postoperative Care
The patient is placed in compressive garments and a supportive bra. The Foley catheter is
removed on first day. She is out of bed and ambulating on postoperative day 1. The patient
can shower on day 3 and is discharged on day 4.

Complications: Avoidance and Treatment

If the SGAP pedicle is too short (less than 6 cm), more length can be achieved on the inter-
nal mammary vessels by removing a rib. Buttock drains are left in place for approximately
2 weeks, or until the drainage diminishes. Recontouring procedures should be expected
with SGAP reconstruction, including fat injection, liposuction, or local flap procedures to
improve upper buttock volume deficiency.

Take-Away Message
GAP flap reconstruction is a challenging procedure. Careful planning, skill, and patience
are important.

Expert Commentary
Michael R. Zenn

Indications
Decubitus Surgery
The gluteal area is the main source of reconstructive tissue for the treatment of sacral wounds,
mainly decubiti. Most reconstructive surgeons are comfortable transferring these tissues
either as a V-Y or as a semicircular advancement flap. The location of the pedicles (SGA and
IGA) is favorable because they are close to the defect to be reconstructed, facilitating ease
of transfer. My preference is to use the V-Y flap and design it large; these decubitus patients
are “patients for life,” because the decubiti will recur. The V-Y design can be reelevated
and advanced when the sacral ulcer reappears. The further extension of this logic is to not
use the gluteal tissues for other wounds, such as ischial and trochanteric decubiti. These
should be reconstructed with other flaps (ischial: biceps, gracilis; trochanteric: tensor fascia
lata), because these patients will someday present with a sacral decubitus, and the surgeon
will want the gluteal tissues to be available. Use of the island perforator flaps can be helpful
in cases in which bulk is not needed. These cases also provide valuable practice for SGAP
and IGAP free flap cases.
Continued

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 614 Part II  Regional Flaps: Anatomy and Basic Techniques

Anal Incontinence Surgery

The use of the gluteal muscle for anal incontinence was a dramatic change in my practice
from the more standard use of the gracilis. I think that in these cases, some of the sphincter
muscle may still exist, and the gracilis tendon wrapping around the sphincter was less about
adding a functional muscle to the sphincter; rather, it decreased the lumen size and brought
what little functional muscle that existed into better apposition. The motion of adducting the
knee for sphincter control is not natural and transfers poorly. I have had great success with
the gluteal transfer, especially in young women with a birthing injury that has resulted in
fecal incontinence. The muscle is functional, acting as a shutter mechanism that promotes
continence. The act of flexing the gluteus muscle while attempting sphincter control is a
natural one. The surgical procedure, with diet modification, has been life changing for
these patients.

Breast Reconstruction
Gluteal tissue for distant transfers is used mainly for breast reconstruction, and this is admit-
tedly a second or third option. The reason for this is threefold: (1) the patient positioning
or required position change is awkward, (2) the dissection is difficult, and (3) the fibrous
nature of buttock fat makes it harder to shape than other tissues. In immediate breast re-
construction, lateral positioning allows a two-team approach and saves time, but a position
change to supine is still often required for definitive flap inset. For delayed reconstruction,
I now always use supine positioning for recipient vessel identification, prone positioning
for flap harvest and closure, and return the patient to the supine position for microscopic
anastomoses and flap inset. As I have matured as a microsurgeon, I feel more comfortable
delaying the revascularization of these cutaneous flaps for up to an hour during donor site
closure. I have never seen a problem with thrombosis or necrosis as a result of this.
I only perform one side at a time in bilateral cases, separated by 4 months minimum,
but some surgeons perform bilateral GAP flaps at the same time, using the supine-prone-
supine sequence and a two-team simultaneous approach. Although the dissection may be
the hardest of all possible choices, experience and repetition are essential to making the
surgery more acceptable.

Take-Away Messages
The gluteal area is valuable for reconstruction of many difficult problems. Each application
requires excellent planning, execution, and attention to detail to accomplish the reconstruc-
tive goal and minimize morbidity in an area critical to the patient’s activities of daily living.

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 615

Bibliography With Key Annotations

Ay A, Aytekin O, Aytekin A. Interdigitating fasciocutaneous gluteal V-Y advancement flaps for
reconstruction of sacral defects. Ann Plast Surg 50:636-638, 2003.
The authors described a modification of the classic gluteal bilateral V-Y advancement flap for sacral
defect closure. After initial debridement, the V-Y design is marked on both sides of the defect. The
incision is carried down to the fascia of the underlying gluteus maximus muscle. The upper and lower
arms of the flaps are elevated and advanced on the gluteal muscle toward the midline, interdigitating
each opposing arm. The overall result is a zigzag, broken midline suture. This procedure was carried
out in 14 patients with sacral pressure sores and in 1 patient with a chronic pilonidal sinus. All flaps
survived without major problems. There were no recurrences during the 6 to 16 months of follow-up.
The interdigitating fasciocutaneous V-Y gluteal flap design is effective in breaking the midline vertical
scar and preserving the gluteus maximus muscle.
Benito P, De Juan A, Cano M, et al. Reconstruction of an extensive perineal defect using two
modified V-Y flaps based on perforators from the gluteus maximus muscle. J Plast Reconstr
Aesthet Surg 61:e1-e4, 2008.
The authors reported the case of a woman with a severe perineal defect secondary to a perianal cancer
that required reconstruction from the posterior wall of the urinary bladder to the coccyx, and that
laterally surpassed both ischial tuberosities. For this reconstructive work they used two V-Y advanced
flaps taken from the gluteal region. On the basis of these flaps, they modified the final position in the
advance of the lateral ends, crossing the tips of each flap over each other to provide a greater volume
of tissue in the central area, with no signs of vascular injury. They concluded that the use of V-Y
flaps, based on the perforating arteries of the gluteus maximus, allows the reconstruction of especially
extensive defects in the perineal region. The technique is rapid and easy to perform and produces an
acceptable clinical outcome with minimal morbidity.
Benito P, García J, De Juan A, et al. Reconstruction of a perianal defect by means of a bilateral
V-Y advancement flap based on the perforating arteries of the gluteus maximus shaped over a
cicatricial area. J Plast Reconstr Aesthet Surg 62:412-414, 2009.
Cheon YW, Lee MC, Kim YS, et al. Gluteal artery perforator flap: a viable alternative for
sacral radiation ulcer and osteoradionecrosis. J Plast Reconstr Aesthet Surg 63:642-647, 2010.
Radiation therapy has a crucial role in the treatment of cancer; however, it may cause adverse effects
to normal tissue such as radiation-induced ulcer and osteoradionecrosis. The few cases of conservative
management that were reported had a limited value and unsatisfactory results. The most reliable
method for treating sacral radiation ulcer and osteoradionecrosis is a wide excision of the affected tis-
sue, followed by coverage with well-vascularized tissue. Myocutaneous free flaps and local gluteus
maximus myocutaneous flaps have been used; however, there are many drawbacks, such as dissection
of a recipient vessel in the previously irradiated area and donor site morbidity. During a 4-year period
at their institute, the authors achieved favorable clinical results using gluteal artery perforator proce-
dure for radiation-induced ulcers and osteoradionecrosis of the sacral area. The 10 patients who were
treated with gluteal artery perforator flaps had chronic nonhealing radiation ulcers or bone exposure of
the sacrum. Intraoperatively, massive debridement of bone and soft tissue was performed, while the
well-vascularized skin with only a color change was preserved. The flap was designed to include two
or more perforators using Doppler flowmetry, and the perforators were preserved with surrounding
subcutaneous tissue during the flap elevation. The mean postoperative follow-up period was 25.7
months. There was one major complication (partial flap loss) and three minor complications (wound
dehiscence). In the patient with partial flap loss from infection and a floating flap, the contralateral

07a_GlutMax_r7_bs_0584-0619.indd 615 1/31/2012 8:49:11 AM

 616 Part II  Regional Flaps: Anatomy and Basic Techniques

superior gluteal artery perforator flap was used to treat the complication. Other complications were
conservatively treated and healed well. Gluteal perforator flaps are a valuable alternative in treat-
ing sacral radiation ulcers and osteoradionecrosis. Sufficient excision of devitalized tissue is a crucial
procedure to achieve optimal results.
Di Mauro D, D’Hoore A, Penninckx F, et al. V-Y Bilateral gluteus maximus myocutaneous
advancement flap in the reconstruction of large perineal defects after resection of pelvic ma-
lignancies. Colorectal Dis 11:508-512, 2009.
To evaluate the role of the V-Y bilateral gluteus maximus myocutaneous flap in the reconstruction of
large perineal defects after wide surgical resections for pelvic malignancies. Twelve consecutive patients
(seven women and five men) 36 to 78 years of age (mean 59 years) with primary or recurrent pelvic
malignancies (rectal, anal, and vulvar carcinoma) underwent either abdominoperineal rectum excision
with partial sacrectomy or total pelvic exenteration. The perineal defect was reconstructed with a gluteus
maximus myocutaneous flap. Intraoperative blood loss, operative time, hospital stay, postoperative
complications, and long-term outcome were retrospectively assessed. One patient died postoperatively.
All other patients had at least one early and/or late complication. After a mean follow-up of 31.2
months, seven patients were alive. No major functional impairment in daily activities was observed.
Five patients had slight discomfort in either walking, sitting, or cycling.
Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with gluteal artery perforator
flaps. J Plast Reconstr Aesthet Surg 59:614-621, 2006.
Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other
reasons are candidates for IGAP or SGAP flaps. Because of a better donor site contour and scar, the
authors now prefer to use the IGAP rather than the SGAP flap. Absolute contraindications specific
to perforator flap breast reconstruction in their practice include a history of previous liposuction of the
donor site or active smoking (within 1 month before surgery). IGAP and SGAP flaps are based on
perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected
free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibers
and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor
site closed primarily. IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the
buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site
or even as a first choice in selected patients.
Guerra AB, Soueid N, Metzinger SE, et al. Simultaneous bilateral breast reconstruction with
superior gluteal artery perforator (SGAP) flaps. Ann Plast Surg 53:305-310, 2004.
The superior gluteal artery perforator (SGAP) flap is a useful technique for restoration of the breast
after mastectomy. If appropriately planned, the soft tissue envelope supplied by the superior gluteal
artery perforator vessels can be harvested with minimal donor site morbidity and often results in a
highly aesthetic restoration of the breasts. Dissection of the flap is performed with complete preservation
of gluteus maximus muscle function. The resulting vascular pedicle obtained via dissection through
the muscle is longer than that of gluteal myocutaneous flaps and affords the surgeon the luxury of
avoiding vein grafts in the anastomotic phase of surgery. Despite these advantages, the SGAP flap
is not popular among reconstructive surgeons. Many practitioners are not familiar with the vascular
anatomy of the gluteal area and may not be comfortable with dissection of the parent vessels, or lack
the desire to practice microsurgery. The authors’ group previously reported the largest experience to
date with this method of breast reconstruction and found the SGAP flap to be a reliable and safe
method of autologous breast restoration in unilateral absence of the breast. Although the indications
for performing single-stage gluteal tissue transplantation for bilateral breast restoration are uncommon,

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 617

they do occasionally arise in clinical practice. The authors carried out concurrent bilateral breast recon-
struction using SGAP flaps on six patients, with acceptable overall morbidity. All flaps went on to
survive and resulted in highly aesthetic restorations of the breast. Although a challenging undertaking,
in-unison transfer of bilateral SGAP flaps serves as a useful option for a subset of patients desiring
one-stage bilateral breast reconstruction.
Kim JT, Kim YH, Naidu S. Perfecting the design of the gluteus maximus perforator-based
island flap for coverage of buttock defects. Plast Reconstr Surg 125:1744-1751, 2010.
The new design of the gluteus maximus perforator–based island flap for coverage of gluteal defects has
the distinct advantage of being able to use customizable tissue components for coverage and at the same
time sparing the source vessel. This adds a further option for use in reconstruction. After excisional
debridement of the lesion, a perforator adjacent to the defect is selected. The tissue of the donor region
is pinched to simulate closure. The change in shape of the recipient defect is noted and the dimen-
sions of this new shape are measured. This will serve as the new dimensions of the donor tissue. The
tissue components required to fill the defect are then analyzed and the flap is raised. It can be either
muscle-sparing, muscle-splitting, or muscle-inclusive. A 1 to 2 cm diameter of soft tissue around the
perforator is preserved. The flap is islanded and transposed, and the donor site is closed primarily,
acting as a “locking barrier” to the flap. Tension-free closure of the recipient flap is then carried out.
The authors reported on 75 patients who underwent closure of varying defects of the gluteal region
using this technique. There were three minor complications; the rest of the patients healed well, with
no recurrence at a mean follow-up of 15 months. The flap design for coverage of gluteal defects has a
great impact on recurrence and complications. This design is novel and the flap is simple to elevate.
This is an ideal flap in any high-risk patient in whom the risk of recurrence is high.
Kishi K, Nakajima H, Imanishi N, et al. Extended split superior gluteus maximus myocutaneous
flap and reconstruction after resection of perianal and lower gluteal hidradenitis suppurativa. J
Plast Reconstr Aesthet Surg 62:1081-1086, 2009.
Various modifications of the gluteus maximus myocutaneous flap have been reported. Among them,
the split gluteus maximus myocutaneous flap is easy to prepare and does not leave ambulatory insuf-
ficiency. However, the safety of extending the skin portion beyond the margin of the muscle has not
yet been clarified. In the authors’ study, angiography was performed systemically on 11 fresh cadavers,
and the distance the margin of the gluteus maximus muscle could be extended was noted. Based on
these anatomic data, reconstruction after total skin resection of perianal and lower gluteal hidradenitis
suppurativa was performed with an extended split superior gluteal maximus myocutaneous flap.
Surgery was performed on three sides of two patients. From the results, the authors found that it is
possible to extend the flap beyond the iliac crest several centimeters superiorly, and to the gluteal fold
inferiorly, and several centimeters laterally. They designed the flap so that the extended area was
situated in these areas. All flaps took well and did not show any congestion or necrosis. There were no
recurrences at least 1 year after surgery. When reconstructing the lower part of the buttock, an extended
split superior gluteus maximus myocutaneous flap is easy to raise and leaves aesthetically satisfactory
results. Thus it may be the first choice for reconstruction of the lower buttock.
Kishi K, Nakajima H, Imanishi N, et al. Three-dimensional arterial anatomy of the gluteus
maximus and the proper method of muscle splitting. Plast Reconstr Surg 126:107e-109e, 2010.
The large gluteus maximus muscle is sometimes used as a split muscle flap in reconstructive surgery.
This article presented a reconstructive method based on three-dimensional arterial anatomy. The authors
reported on six patients who underwent reconstruction with a split gluteus maximus myocutaneous
flap. In all cases, the flaps took well without any evidence of necrosis.

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 618 Part II  Regional Flaps: Anatomy and Basic Techniques

Koh PK, Tan BK, Hong SW, et al. The gluteus maximus muscle flap for reconstruction of
sacral chordoma defects. Ann Plast Surg 53:44-49, 2004.
Four patients diagnosed with sacral chordoma underwent reconstruction with the gluteus maximus
flap using an approach based on available muscle remnants and their residual blood supply. The entire
unilateral gluteus maximus muscle was turned over to fill the defect in two patients. The flap was
based on one or two gluteal vessels, depending on vessel availability following tumor resection. When
all four major pedicles had been ligated, bilateral advancement gluteal muscle flaps based on their distal
blood supply were used (patient 3). A longitudinally split flap was used for secondary reconstruction
of a partially obliterated defect (patient 4). Over a mean follow-up period of 8 months, there was no
wound breakdown, and all patients were ambulant.
Meltem C, Esra C, Hasan F, et al. The gluteal perforator-based flap in repair of pressure sores.
Br J Plast Surg 57:342-347, 2004.
The gluteal perforator-based flap is designed according to the localization of sacral perforator vessels.
These vessels penetrate the gluteus maximus muscle and reach the intrafascial and suprafascial planes,
and the overlying skin forming a rich vascular plexus. The gluteal perforator-based flaps described in
this paper are highly vascularized, have minimal donor site morbidity, do not require the sacrifice of
the gluteus maximus muscle and rarely lead to postoperative complications. The authors concluded
these easy-to-perform flaps might be considered as the first choice in the repair of gluteal pressure sores.
Tuinder S, Chen CM, Massey MF, et al. Introducing the septocutaneous gluteal artery per-
forator flap: a simplified approach to microsurgical breast reconstruction. Plast Reconstr Surg
127:489-495, 2011.
The authors retrospectively reviewed 11 consecutive septocutaneous gluteal artery perforator (sc-GAP)
flaps performed for postmastectomy breast reconstruction in 9 patients between February and July of
2008. Patient demographics, risk factors, perforator characteristics, operative technique, operative time,
and outcome were analyzed. Preoperative imaging was used for all patients. The patients ranged in
age from 44 to 60 years (mean 52 years). Their body mass index ranged from 17.2 to 29.1 (mean
22.2). Of the 11 flaps, 5 sc-GAP flaps were immediate (45%) and 6 were delayed reconstruction
(55%); 7 were unilateral (64%), and 4 were bilateral (36%). Mean operative time was 8.2 hours
(range 6.5 to 11 hours). All patients stayed in the hospital for 5 days. Mean pedicle length was 7.9 cm
(range 5 to 10 cm) and mean flap weight was 499 g (range 360 to 640 g). Vessel size ranged from
1.8 to 3 mm. Complications included one take-back, one axillary seroma, one donor site seroma,
and one donor site hematoma. There were no flap losses.
Tunçbilek G, Nasir S, Ozkan O, et al. Partially de-epithelialised and buried V-Y advancement
flap for reconstruction of sacrococcygeal and ischial defects. Scand J Plast Reconstr Surg Hand
Surg 38:94-99, 2004.
Defects in the sacrococcygeal and ischial soft tissues can be treated with gluteus maximus and pos-
terior thigh V-Y advancement flaps. However, late complications include recurrence and dehiscence
of the suture line. Increasing the amount of soft tissue over the bony prominences and multilayered
closure may have an advantage for long-term durability. The authors modified the V-Y advancement
technique by deepithelializing the medial parts of the flap and burying them under the opposing edge
of the wound or the flap. Sixteen patients with various defects of the sacrococcygeal and ischial soft
tissues were operated on using this technique. All the flaps healed well, with no partial or complete
loss of the flap. Three patients developed complications. The main advantage of the technique is the

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 Posterior Trunk  •  7A: Gluteus Maximus and IGAP/SGAP Flaps 619

use of healthy tissues to obliterate the dead spaces under the edges of the wound or the opposing flap.
In this way, not only the defect in the skin but the defect in the subcutaneous tissue, with its iceberg
tip at the surface, is treated effectively. To have an additional layer of tissue between the bone and the
superficial tissues provides an extra cushion of soft tissue and avoids putting the suture line directly
over the bony prominences. The authors used this modification safely for both unilateral and bilateral
flaps. It could also be used successfully in other parts of the body.
Zenn MR, Millard JA. Free inferior gluteal flap harvest with sparing of the posterior femoral
cutaneous nerve. J Reconstr Microsurg 22:509-512, 2006.
The free inferior gluteal flap is a major secondary choice of autologous tissue for breast reconstruction
if the TRAM flap is not an option. Loss of posterior thigh and popliteal sensibility is a frequent
sequela of harvesting the free inferior gluteal myocutaneous flap and the inferior gluteal artery perfora-
tor (IGAP) flap. The posterior femoral cutaneous nerve of the thigh lies directly on the deep surface
of the gluteus maximus muscle, having a very close anatomic relationship with the inferior gluteal
artery. The purpose of this study was to gain a better understanding of the anatomy of the posterior
femoral cutaneous nerve (PFCN), its branches, and their relationship with the inferior gluteal artery
(IGA). Eighteen fresh human pelvic halves were dissected for examination during harvesting of the
inferior gluteal myocutaneous free flap, to determine whether a nerve-sparing approach was possible
and how this information might affect an IGAP flap harvest. Seventeen of 18 pelvic halves had at
least some of the PFCN branches intact after isolation of the IGA pedicle and flap elevation. Three
of 18 of the pelvic halves had the entire PFCN and its branches intact after flap elevation. One of
18 pelvic halves required complete transection of the PFCN and its branches in order to isolate the
IGA pedicle. In 94.5% of the pelvic halve dissections, it was possible to maintain at least a portion
of the PFCN intact after isolation of the inferior gluteal artery pedicle while harvesting the free in-
ferior gluteal myocutaneous flap. These findings support a nerve-sparing approach to inferior gluteal
myocutaneous flap elevation to minimize the sequelae of posterior thigh anesthesia. These data also
emphasize the intimate relationship of the PFCN and the gluteal artery and the real possibility of
injury to the PFCN during IGAP harvest.

07a_GlutMax_r7_bs_0584-0619.indd 619 1/31/2012 8:49:12 AM

 ANATOMIC LANDMARKS
Landmarks Posterior thigh from the gluteal crease to, but not including, the
popliteal fossa. The flap is centered on the posterior thigh.
Size 12 3 30 cm.
Composition Fasciocutaneous, type A.
Dominant Pedicle Inferior gluteal artery.
Nerve Supply Sensory: Posterior femoral cutaneous nerve.

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 Section 7B
Posterior Trunk

Gluteal Thigh Flap

CLINICAL APPLICATIONS
Regional Use
Trochanter
Buttock
Perineum
Specialized Use
Vaginal reconstruction

07b_GlutealThi_r4_cah_0620-0645.indd 621 1/31/2012 9:31:56 AM

 ANATOMY OF THE GLUTEAL THIGH FLAP

Superior gluteal
artery

Gluteus maximus
muscle

Inferior gluteal
artery

Descending branch
of inferior gluteal
artery

Vascular anatomy of posterior thigh

relative to gluteal thigh flap
Posterior
femoral
cutaneous
nerve

Neural anatomy of gluteal thigh flap

Fig. 7B-1 

Dominant pedicles: Inferior gluteal artery

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 623

Anatomy
Landmarks Occupies the posterior portion of the thigh from the gluteal crease to, but not
including, the popliteal fossa.
Composition Fasciocutaneous.
Size 12 3 30 cm. Primary closure is possible in flap widths 9 cm or less.

Arterial Anatomy
Dominant Pedicle  Inferior gluteal artery
Regional Source  Internal iliac artery.
Length  3 cm.
Diameter  2.5 mm.
Location  The vessel runs with the posterior femoral cutaneous nerve, often within a sheath, in
the majority of patients. Both structures are identified as they emerge from under the inferior
border of the gluteus maximus muscle midway in the posterior thigh.

Venous Anatomy
Accompanying paired venae comitantes with the inferior gluteal artery.

Nerve Supply
Sensory Posterior femoral cutaneous nerve (S1 to S3) innervates the posterior thigh skin.
It originates at the lower border of the piriformis muscle just medial to the sci-
atic nerve. It then runs inferiorly and deeply under the fascia lata, exiting from
under the inferior border of the gluteus maximus muscle in the midline of the
posterior thigh. At the level of the popliteal fossa the nerve penetrates the fascia
and becomes subcutaneous over the posterior calf.

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 624 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Gluteal Thigh Flap

A B

D2

n D2

Gluteal thigh flap with inferior half Radiographic view

of gluteus maximus muscle

Fig. 7B-2 

Dominant pedicle: Inferior gluteal artery (D2)

n, Posterior femoral cutaneous nerve; arrows, cutaneous descending branch of inferior
gluteal artery

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 625

FLAP HARVEST
Design and Markings
The skin paddle is designed over the midline of the posterior thigh. It is marked from the
gluteal fold to the popliteal fossa. The inferior gluteal artery can supply the entire posterior
thigh, and donor sites larger than 9 to 10 cm wide will need to be skin grafted. This is
especially true as the flap approaches the popliteal fossa.

Flap design

Fig. 7B-3 

Patient Positioning
The patient is placed in the prone position for gluteal and trochanteric applications and the
lithotomy position for perineal and vaginal applications.

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 626 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

Once the flap is designed, it is dissected from distal to proximal. Medial, lateral, and inferior
incisions can be made, and dissection is deepened down through the fascia. The fascia is
then elevated from caudal to cephalad, with identification and inclusion of the posterior
femoral cutaneous nerve and the inferior gluteal pedicle. Once the level of the gluteal fold
and inferior border of the gluteus muscle is reached, some backcutting of the lateral incision
can be performed to help rotation of the flap toward the perineum, or backcutting of the
medial portion of the flap will allow more lateral rotation.

Gluteus maximus
muscle

Inferior gluteal
nerve

Inferior gluteal
artery

Posterior femoral
cutaneous nerve

Sciatic nerve

Fig. 7B-4  The gluteal thigh flap is elevated to the gluteal crease and inferior border of the gluteus
maximus muscle.

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 627

FLAP VARIANT
Extended Flap
When further extension of the flap is needed for reconstruction, dissection within the gluteus
maximus muscle can be done. Care is taken to keep the inferior gluteal artery within the
divided muscle. The lower third to half of the muscle can be elevated with the flap to give
added length to the pedicle for rotation. Caution must be exercised during this maneuver
to avoid injury to the inferior gluteal nerve, which is the motor nerve to the entire gluteus
maximus muscle.

B Descending branch of
inferior gluteal artery

Gluteus maximus
muscle

Inferior gluteal
nerve

Sciatic nerve

Posterior
femoral
cutaneous
nerve

Design of extended gluteal thigh flap

Extended gluteal thigh flap elevated

Fig. 7B-5 

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 628 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
The standard flap easily rotates to the trochanter and to beyond the midline in the perineum.
A large dog-ear is created during these rotations, which can be dealt with later.

Trochanter

Standard flap: Arc to trochanter Extended flap: Arc going past midline in perineum

Fig. 7B-6 

FLAP TRANSFER
The flap may be transposed either directly through a connection between the recipient
and donor sites or through a subcutaneous tunnel. The subcutaneous tunnel is standard
when flaps are used for vaginal reconstruction. Care must be taken to allow a large enough
subcutaneous tunnel such that the pedicle of the flap is not compressed.

FLAP INSET
The tension of the flap must be carefully adjusted to avoid tension at the inset site; it is better
to bear tension on the more proximal portion of the flap inset.

DONOR SITE CLOSURE

For more proximally based and smaller flaps with widths of 9 cm or less, primary closure
is possible. For most applications where larger amounts of tissue are needed, it is harder to
obtain primary closure, especially near the popliteal fossa, so skin grafting of the donor
site is common.

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 629

CLINICAL APPLICATIONS
This 45-year-old woman with a history of squamous cell carcinoma of the labia underwent
resection and postoperative irradiation. She presented with this deep, chronic, irradiated
wound, with no vital structures exposed. Reconstruction was performed with a gluteal
thigh flap.

A B

D
C

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. (Case
supplied by MRZ.)

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 630 Part II  Regional Flaps: Anatomy and Basic Techniques

This 50-year-old woman had a history of rectal cancer and irradiation. She now required
abdominoperineal resection for a recurrence. The perineal defect was reconstructed with
a sensate gluteal thigh flap.

B
A

C
D

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 el-
evated 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.

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 631

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 ad-
equate. 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 neces-
sary 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. (Case supplied by MRZ.)

This 44-year-old woman was undergoing a total abdominal hysterectomy with removal
of her vaginal vault for a carcinoma. She required total vaginal reconstruction. Bilateral
gluteal thigh flaps were used to perform the reconstruction.

Fig. 7B-9 A, At laparotomy: there was no vaginal vault and there were no external perineal inci-
sions. 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. (Case supplied by MRZ.)

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 632 Part II  Regional Flaps: Anatomy and Basic Techniques

This 25-year-old man had invasive squamous cell carcinoma of the perineum and a history
of Crohn’s disease. A gluteal thigh flap was planned.

C D

E F

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 pres-
sure 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. (Case courtesy Jeffrey
D. Friedman, MD.)

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 633

This 72-year-old woman underwent wide local excision of a recurrent squamous cell
carcinoma of the vulva and vagina. This resulted in a large soft tissue defect of the medial
buttock, vulva, and posterior vagina. She underwent radiation therapy to the perineum.

B C

D E

Fig. 7B-11 A, The patient’s soft tissue defect is seen. B and C, Bilateral gluteal thigh fasciocuta-
neous 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 postop-
eratively. (Case courtesy Jeffrey D. Friedman, MD.)

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 634 Part II  Regional Flaps: Anatomy and Basic Techniques

This 64-year-old man presented with a 2-year history of a chronic irradiated sacral-perineal
wound.

B
A

C
D

E F

Fig. 7B-12 A, The defect is shown; the patient had undergone radiation therapy and posterior exenter-
ation 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. (Case courtesy Jeffrey D. Friedman, MD.)

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 635

This 52-year-old man had a recurrent perianal fistula after localized radiation therapy for
carcinoma of the prostate.

A B

C D

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. (Case courtesy Jeffrey D. Friedman, MD.)

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 636 Part II  Regional Flaps: Anatomy and Basic Techniques

This young woman had a history of Crohn’s disease; she developed advanced squamous
cell carcinoma of the perineum.

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.

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 637

D E

F G

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. (Case courtesy Jeffrey
D. Friedman, MD.)

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 638 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The large cone of rotation or dog-ear that is common with these flaps should be dealt
with secondarily. Although the temptation is to remove these immediately, such removal
will make the flaps ischemic and will cause the reconstruction to fail. A minimum delay
of 4 to 6 months should be planned before any revisions are done.
• The patient should be warned about paresthesia in the posterior thigh and calf from divi-
sion of the posterior femoral cutaneous nerve.
• Although visualization of the inferior gluteal pedicle is useful, the wide based design of
the flap allows elevation and rotation of the flap without specific identification.
• Care should be taken in splitting the gluteal muscle, especially in an ambulatory patient.
Although patients can tolerate losing up to half of the gluteus muscle and still have a
normal gait, injury to the inferior gluteal nerve, which innervates the entire gluteus
muscle, could be devastating.

Expert Commentary
Jeffrey D. Friedman

Indications
The gluteal thigh flap (also called the posterior thigh flap or inferior gluteal thigh flap) remains a
useful tool for the reconstruction of various defects in the vaginoperineal region. In most
cases, this flap provides relatively thin, pliable, soft tissue that can be used for a variety of
reconstructive purposes in this area. Given the location of the vascular pedicle proximally
at the level of the gluteal crease, there is a relatively generous arc of rotation for the flap in
terms of reach within the pelvis. The gluteal thigh flap can thus be used to provide soft tissue
coverage of open defects in and around the pelvis and can facilitate functional reconstruc-
tion for both congenital and acquired deformities.
The various uses for the gluteal thigh flap are somewhat different in males and females.
Reconstruction in men tends to involve either large soft tissue defects of the perineum re-
sulting from oncologic excision of colorectal cancers, or treatment for fistulous disease after
radical prostatectomy. Female patients present many more challenges, because deformities
in women typically have a functional component that adds a level of complexity to their
treatment. The gluteal thigh flap can be used not only for soft tissue reconstruction of large
pelvic and vulvar defects, but also to provide functional restoration of partial or total defects
of the vaginal vault.

Advantages and Limitations

As described in this chapter, the flap is relatively simple to design and elevate. However, the
distal portion of the flap, which has been described to extend to the proximal flexion crease
of the knee, may be somewhat unreliable. Generally, a large amount of skin and underlying
soft tissue can be raised with this flap. Obviously, this depends on the extent of redundant
tissue in the patient’s posterior thigh. In most cases, there is an inverse relationship between
the amount of available skin and the volume of the underlying soft tissue. In thin patients,

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 639

typically there is considerable excess of skin in the posterior thigh; however, there is a limited
volume of available soft tissue. In large or obese patients, there are often moderate degrees
of available subcutaneous tissue, although the amount of available skin in these patients is
quite restricted.
Therefore, when planning a gluteal thigh flap, the surgeon must assess these factors
preoperatively in light of the patient’s reconstructive needs. For large soft tissue defects of
the perineum and for most cases of total vaginal reconstruction, one flap may be insuf-
ficient, and bilateral flaps will be required. Depending on the size of these defects and the
relative laxity of the underlying soft tissues in the posterior region of the thigh, variable
amounts of soft tissue can be harvested without the need for a skin graft at the donor site.
When primary closure is not an option, the donor site can often leave a moderate cosmetic
deformity, and this must be weighed against the patient’s reconstructive needs and other
possible flap choices.

Anatomic Considerations
In large part, the consistent neurovascular anatomy of the gluteal thigh flap means that it is
relatively straightforward to elevate and transfer the flap to the pelvis. The close proximity
of the posterior femoral cutaneous nerve to the inferior gluteal pedicle enables one to raise
the gluteal thigh flap as a sensate fasciocutaneous flap. Although the advantages of this are
readily apparent, placement of a sensate flap in the region of the perineum or along one of
the vaginal walls may, in some cases, be problematic. The sensation of stimulation along
the posterior thigh during intercourse or when pressure is applied to the perineum can be
quite bothersome for many patients. However, because of the proximity of the nerve to
the vascular pedicle, dividing the nerve at the time of initial transfer may place the vascular
pedicle at risk. Therefore I think it is safer to divide the nerve as a secondary procedure if
this sensation is disturbing to the patient. At such time, vascular ingrowth has generally
developed from the recipient bed, so compromise of the entire flap is no longer a concern.

Personal Experience and Insights

The gluteal thigh flap is a valuable tool in the reconstruction of vaginoperineal deformi-
ties—although in most cases, this flap is not the first choice when addressing these complex
reconstructions. In my experience, most perineal defects are created at the time of extir-
pative pelvic surgery. In such cases, a laparotomy is typically performed, which provides
easy access to the pelvis from the anterior abdominal region. Thus variations of the rectus
abdominis myocutaneous flap can be easily transferred to the pelvis to provide soft tissue
and skin to the region. Exceptions to this include patients who will undergo both fecal and
urinary diversion. In this situation, two stomas are required, thus making the use of the
rectus muscles problematic for abdominal wound healing. Use of the gluteal thigh flap can
avoid compromise of abdominal wall integrity.
The more common indications for the gluteal thigh flap are perineal reconstructions that
do not require laparotomy for access to the pelvis or in cases where flaps from the abdominal
wall have previously been used. While gracilis myocutaneous flaps have frequently been
used under these circumstances, I have found the gracilis flap to be relatively unreliable
because of the bulkiness of the skin paddle or the inadequate reach and poor vascularity of
the distal skin island.
Continued

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 640 Part II  Regional Flaps: Anatomy and Basic Techniques

Recommendations
Planning
Planning for the gluteal thigh flap is critical. Patients must be marked in the upright position
before surgery, since the anatomic landmarks of the posterior thigh become quite distorted
when the patient is in the dorsal lithotomy position. If findings are normal on vascular ex-
amination, use of the Doppler to identify the pedicle is generally unnecessary. However,
the Doppler probe may be useful intraoperatively in identifying the proximal pedicle.

Technique
Dissection of the flap is relatively straightforward and begins distally, extending in a proxi-
mal direction. The fascia of the posterior compartment must be included with the flap
and is best secured to the skin margins with sutures. As one nears the proximal pedicle, it
is best to extend the incision along the lateral side of the skin paddle and move medially
toward the pedicle once the inferior gluteal pedicle has been clearly identified. Creation of
an island pedicle flap is generally discouraged, because it is fraught with the potential for
early or late vascular compromise.
The critical portion of this flap procedure lies in the transfer of the gluteal thigh flap
into the pelvic region. This generally requires creation of a tunnel between the defect and
the upper thigh. If the skin bridge is to be left intact, it is imperative that the superficial
fascia of the intervening skin bridge be released to prevent excessive pressure on the flap
in situ. Should this be found to be constricting, division of the skin bridge can avoid late
necrosis of the distal skin paddle (see Fig. 7B-10, F).

Postoperative Care
Postoperatively, pressure on the vascular pedicle must be avoided. Patients are instructed
not to sit, but to lie supine, prone, or in the lateral position or to stand during the first
2 postoperative weeks. Sitting is expressly prohibited, because this causes too much pres-
sure on the flap and risks early flap loss. A gradual sitting program is recommended after
this 2-week period.

Take-Away Messages
The gluteal thigh flap is a reliable transfer flap for perineal reconstruction in selected patients.
This is particularly true in primary cases in which patients will have both urinary and fecal
diversion or when an isolated perineal approach is performed. I have also found the gluteal
thigh flap to be useful when previous abdominal-based flaps have either been used or are
no longer available for transfer. These cases are generally quite challenging because of scar-
ring and radiation effects. However, when the gluteal thigh flap is elevated and transferred
as described, these complex deformities can be reliably treated with few complications and
excellent clinical outcomes.

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 641

Bibliography With Key Annotations

Coşkunfirat OK, Islamoğlu K, Ozgentaş HE. Posterior thigh perforator-based flap: a new
experimental model in rats. Ann Plast Surg 48:286-291, 2002.
Animal research has added a great deal of understanding to flap hemodynamics. The rat is the most
commonly used animal in flap research, and various flap models have been devised. In the current
study the authors developed a single-perforator–based flap model in rats. In 30 rats, anatomic dis-
section and flap elevation based on a single myocutaneous perforator artery arising from the biceps
femoris muscle were performed. The vascular basis of this new flap was cleared by anatomic dis-
section of the posterior thigh in six rats. The survival pattern of the proposed flap was investigated
in three groups of rats. Each group consisted of eight rats and had different flap dimensions. In the
first group the flap was located in the posterior thigh and was 3 by 2 cm. All flaps survived in this
group at the end of the first week. In the second group the same flap was extended to the gluteal
region and was 3 by 4 cm. Again, all flaps survived. In the last group an oversized flap (3 by
12 cm) was planned from the posterior thigh to the scapular region based on the same perforator
artery. In this group only 61% of the flaps survived at the end of the first week. Microangiography
was performed in each group and the vascular architecture of the pedicle (perforator artery) was seen.
This new posterior thigh perforator-based flap model is simple and reliable with a constant survival
pattern. Thus it could be used in studies investigating the physiologic and pathophysiologic changes
of perforator-based flaps.
Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for complex pelvic
and perineal reconstruction. Plast Reconstr Surg 126:146-155, 2010.
In this study the authors reviewed their experience with the posterior thigh flap as an alternative to
the more commonly performed transfers for difficult wounds of the perineum and pelvic structures. A
total of 27 posterior thigh flaps were used in 19 patients for complex perineal wound closure. Suc-
cessful transfer of the posterior thigh flap was noted in 26 of 27 flaps (11 unilateral and 8 bilateral),
with only one flap failure (3.7%). Primary wound healing was ultimately achieved in all patients;
however, early wound-healing complications were common (53%). Secondary procedures were neces-
sary in seven patients (37%), with only one patient requiring a secondary flap procedure. The authors
found the posterior thigh flap to be a useful and reliable flap for coverage of complex perineal wounds.
This was particularly true for patients in whom a laparotomy was best avoided and those who had
both a urinary and a fecal diversion.
Hurwitz DJ. Closure of a large defect of the pelvic cavity by an extended compound myocu-
taneous flap based on the inferior gluteal artery. Br J Plast Surg 33:256-261, 1980.
A compound thigh flap, which includes the central portion of posterior thigh skin and deep fascia and
the inferior half of the gluteus maximus muscle, was used to close a large cavity in the perineum and
posterior pelvis. Features of this flap design include (1) a pedicle based on the inferior gluteal artery
with a direct cutaneous artery and posterior thigh flap, (2) a point of flap rotation superior to the
ischial tuberosity, (3) a sensory flap with a posterior femoral cutaneous nerve, (4) the potential for
direct donor site closure, and (5) the superior half of the gluteus maximus muscle remaining intact for
function preservation.
Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable, sensate flap for the closure
of buttocks and perineal wounds. Plast Reconstr Surg 68:521-532, 1981.
Evaluation of the vascular anatomy of the inferior gluteal artery confirms its blood supply through both
the overlying gluteal skin and the posterior thigh via a direct cutaneous artery deep to the thigh fascia.
This direct cutaneous pedicle is located in the midposterior thigh adjacent to the posterior cutaneous
nerve. The flap design is centered on a vertical line located midway between the greater trochanter and
the ischial tuberosity with the distal flap border located 8 cm superior to the popliteal fossa. With the
flap point of rotation 5 cm above the ischial tuberosity, the flap will reach pelvic, perineal, and lateral

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 642 Part II  Regional Flaps: Anatomy and Basic Techniques

trunk defects. The authors reported successful closure of 18 of 21 complex wounds of the perineum and
buttock regions. The flap dimensions ranged from 12 to 35 cm in length and 6 to 15 cm in width. In
the three patients in whom distal flap loss was observed, the flap complications were from hematoma,
pressure on the flap, and flap dehiscence, respectively. The authors recommended this flap for closure
of midline deep anal-perineal wounds and ischial-sacral pressure sores and posterior pelvic defects.
Hurwitz DJ, Walton RL. Closure of chronic wounds of the perineum and sacral regions using
the gluteal thigh flap. Ann Plast Surg 8:375-386, 1982.
The authors provided five examples of patients with complex lower midline truncal wounds successfully
reconstructed with a gluteal thigh flap. The donor sites of the flaps were closed directly. In a review of
40 patients under 65 years of age, the gluteal flaps were successfully used to treat 50 wounds.
Michlits W, Windhofer C, Papp C. Pectus excavatum and free fasciocutaneous infragluteal
flap: a new technique for the correction of congenital asymptomatic chest wall deformities in
adults. Plast Reconstr Surg 124:1520-1528, 2009.
Pectus excavatum is typically a cosmetic congenital chest wall deformity. In most cases, it does not af-
fect heart and lung function; therefore, because of their high rate of complications, extensive procedures
need not be performed. Various alternative techniques (such as reconstruction with a silicone prosthesis
or the TRAM flap) were introduced in asymptomatic pectus excavatum. All of these methods have
their advantages but also limitations. Thus the authors used a free fasciocutaneous infragluteal flap
for reconstruction of asymptomatic pectus excavatum in selected patients. Between 2001 and 2007,
six patients with asymptomatic pectus excavatum underwent correction with the free fasciocutaneous
infragluteal flap. This flap is based on a constant end artery of the inferior gluteal artery. After rais-
ing the flap and wound closure in the buttock region, the flap was adjusted to the defect using a small
skin incision in the inframammary fold, and the vessels were anastomosed. There were no flap losses
and no major complications. One patient suffered from a sensory change at the posterior thigh in
the early postoperative period that resolved completely within 2 weeks. In four cases, flap shaping or
liposuction was performed to improve the aesthetic result. In the authors’ final evaluation, all patients
were very satisfied with the result and would undergo the procedure again. The authors demonstrated
for the first time the reconstruction of asymptomatic pectus excavatum with the free fasciocutaneous
infragluteal flap. They concluded that in selected patients, this flap offers an excellent alternative to
established techniques for this problem.
Palanivelu S. Medial circumflex femoral artery flap for ischial pressure sore. Indian J Plast Surg
42:49-51, 2009.
A new axial pattern flap based on the terminal branches of the medial circumflex femoral artery was
described for coverage of ischial pressure sore. Based on the terminal branches of the transverse branch
of medial circumflex femoral artery, which exit through the gap between the quadratus femoris muscle
above and the upper border of adductor magnus muscle below, this fasciocutaneous flap is much smaller
than the posterior thigh flap but extremely useful to cover ischial pressure sores. The skin redundancy
below the gluteal fold allows a primary closure of the donor defect. It can also be used in combination
with the biceps femoris muscle flap.
Pan WR, Taylor GI. The angiosomes of the thigh and buttock. Plast Reconstr Surg 123:236-
249, 2009.
The angiosomes of the body were defined in 1987. The recent popularity of skin perforator and
muscle flaps designed in the thigh, together with significant major vessel anomaly and disease, has
necessitated a more detailed reevaluation of the blood supply to this region. Eighteen new studies,
combined with a review of 36 of the authors’ archival studies of the buttock and the thigh, have been
conducted in fresh human cadavers using arterial perfusion with a radiographic lead oxide mixture.
The angiosome territories of the lumbar, deep circumflex iliac, sacral, gluteal, common femoral, super-
ficial femoral, lateral femoral circumflex, medial femoral circumflex, profunda, descending genicular,
and popliteal source vessels that contribute to the thigh and buttock were defined between the skin

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 643

and the bone. The dominant cutaneous supply of perforators of 0.5 mm or greater emerged from the
deep fascia predominantly in longitudinal rows from the intermuscular septa or from intramuscular
septa, especially from the buttock muscles. Each muscle was supplied from two or more angiosomes,
thereby constituting important bypass shunts for potential major vessel injury or disease, by means
of their intramuscular anastomoses. These results may help surgeons in the design of skin perforator
and refined muscle, myocutaneous, and composite flaps in the thigh and the buttock. The study also
provides a better understanding of vessel anastomoses in the region.
Rosen JM, Mo ST, Liu A. Experience with the island inferior gluteal thigh flap compared with
other local flaps for the reconstruction of the pelvic area. Ann Plast Surg 24:498-509, 1990.
The authors proposed classifying patients with pelvic wound defects into three functional categories: (1)
spinal cord injury with no sensation and no motor function, (2) spinal cord injury with partial sensory
and motor function, and (3) miscellaneous injury (trauma and tumor resections). The posterior thigh
flap represents the technique of choice for both ischial and sacral wounds. Their experience with closure
of pelvic sores in 31 patients included 27 gluteal thigh flaps—19 island flaps and 8 combined gluteal
thigh flaps. There were 4 island flap complications involving partial flap loss (21%) and 1 complete
flap loss (5.3%). In the gluteal thigh or combined flap, there was 1 flap complication (13%) that
resulted in partial flap loss. In category 1 patients, the authors advocated the use of the gluteal thigh
flap for shallow defects without osteomyelitis. A standard muscle flap is preferred for more complex
defects involving bone infection. In category 2 and 3 patients, the gluteal thigh flap is preferred, since
functional muscles are not required in the flap design.
Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after
radical, extensive vulvectomy. Ann Plast Surg 54:184-190, 2005.
The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy,
relate them to tumor characteristics, and select a choice of flaps able to correct every remaining defect.
This study was a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar
reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips, and three
other flaps developed a major breakdown related to an infection or an error in flap planning. Accord-
ing to the authors, the size of the defect is the main issue that must be taken into consideration dur-
ing the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using
fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet
different needs. A flap is then chosen with the fewest potential complications. An algorithm has been
thus established: Small to medium-sized defects are closed with island V-Y flaps, island gluteal fold
flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for
vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its
very low complication rate. If the vulvar defect is large and/or reaches the vulva-crural fold, V-Y flaps
are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very
large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus
abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with
pedicled local or regional flaps can be performed easily and reliably.
Scheufler O, Farhadi J, Kovach SJ, et al. Anatomical basis and clinical application of the infra-
gluteal perforator flap. Plast Reconstr Surg 118:1389-1400, 2006.
When selecting flaps for coverage of pressure ulcers of the sacrum and perineal region in paraplegic
patients, surgeons should consider long-term recurrence rates. Therefore the authors developed an
infragluteal perforator flap to avoid “burning bridges” for future reconstruction. Infragluteal perforator
flaps were dissected in five fresh human cadavers to define the anatomy of the cutaneous branches of
the descending branch of the inferior gluteal artery and cluneal nerves and define anatomic landmarks
for clinical application. In a series of 13 paraplegic patients, the authors used perforator-based flaps
(additional skin bridge) to cover four perineal ulcers and one sacral ulcer and perforator flaps to cover
six perineal and two sacral ulcers. Donor sites were closed by direct approximation. Twelve of 13

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 644 Part II  Regional Flaps: Anatomy and Basic Techniques

flaps healed uneventfully. In all cadaver and clinical dissections, one or two cutaneous branches of the
descending branch of the inferior gluteal artery and one or two cluneal nerves were found at the lower
border of the gluteus maximus muscle supplying the infragluteal perforator flap. These direct cutaneous
branches allowed dissection of inferior gluteal perforator flaps with improved flap mobility compared
with the perforator-based flaps. The descending branch of the inferior gluteal artery could always be
spared for future flaps. The infragluteal perforator flap is a versatile and reliable flap for coverage of
ischial and sacral pressure sores. It can be designed as a perforator-based or perforator flap and could
provide a sensate flap in ambulatory patients. Donor site morbidity is minimal, and options for future
flaps of the gluteal and posterior thigh region are preserved.
Stevenson TR, Grekin RC, Friedman RJ, et al. Squamous cell carcinoma of the perineum:
management with Mohs’ surgical excision and gluteal thigh flap. Ann Plast Surg 18:248-251,
1987.
Two patients presented with squamous cell carcinoma in areas of chronic perirectal fistula and chronic
ischial pressure sores, respectively, that required surgical resection. Each patient had previously under-
gone fecal diversion and colostomy. Mohs micrographic technique was used to determine tumor margins
during the ablative procedure. Subsequent defects were successfully reconstructed with a gluteal thigh
flap in both patients.
Unal C, Ozdemir J, Yirmibesoglu O, et al. Use of inferior gluteal artery and posterior thigh
perforators in management of ischial pressure sores with limited donor sites for flap coverage.
Ann Plast Surg 2011 May 27. [Epub ahead of print]
Reconstructive surgery for ischial pressure sore defects presents a challenge because of high rates of recur-
rence. The aim of this study was to describe the use of inferior gluteal artery (IGA) and posterior thigh
perforators in management of ischial pressure sores with limited donor sites. Between September 2005
and 2009, the authors operated on 11 patients (9 men, 2 women) with ischial sores with IGAP and
posterior thigh perforator flaps. The data on patients included age, sex, cause of paraplegia, flap size,
perforator of flap, previous surgeries, recurrences, complications, and postoperative follow-up. Nine
IGAP and 5 posterior thigh perforator flaps were used. Six patients presented with recurrent lesions;
5 patients had previously undergone surgery for sacral and contralateral ischial pressure sores. In 2
patients IGAP and posterior thigh perforator flaps were used in combination. Patients were followed
for an average of 34.3 months. In two recurrent cases, readvancement of the IGAP flap and gluteus
maximus myocutaneous flap procedures were the treatment of choice. Treatment of patients with recur-
rent lesions or multiple pressure sores is challenging because flap donor sites are limited.
Windhofer C, Brenner E, Moriggl B, et al. Relationship between the descending branch of
the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery.
Surg Radiol Anat 24:253-257, 2002.
Surgeons performing flap surgery in the distal part of the gluteal region have had to contend with a
lack of detailed descriptions of the inferior gluteal artery and the posterior femoral cutaneous nerve.
The existing papers are mainly clinical studies, based on low numbers of observations. The authors’
study included 118 cadaveric gluteal regions. The descending branch was present in 91% and gave
rise to a cutaneous branch. When the descending branch was absent, this cutaneous branch came
from the medial or lateral femoral circumflex artery or as a perforator of the deep artery of the thigh.
The posterior femoral cutaneous nerve was found in a common sheath of connective tissue with the
descending branch of the inferior gluteal artery in 72% of cases. Nerve loops around the vessel were
present in 29%. The results show that a cutaneous or fasciocutaneous flap, either local or free, in
this region can be reliably lifted on a cutaneous branch of the descending branch of the inferior gluteal

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 Posterior Trunk  •  7B: Gluteal Thigh Flap 645

artery without loss of sensitivity. However, the close relationship of the artery and nerve limits the arc
of rotation in the case of a local flap.
Zenn MR, Millard JA. Free inferior gluteal flap harvest with sparing of the posterior femoral
cutaneous nerve. J Reconstr Microsurg 22:509-512, 2006.
The free inferior gluteal flap is a major secondary choice of autologous tissue for breast reconstruction
if the TRAM flap is not an option. Loss of posterior thigh and popliteal sensibility is a frequent
sequela of harvesting the free inferior gluteal myocutaneous flap and the inferior gluteal artery perfora-
tor (IGAP) flap. The posterior femoral cutaneous nerve of the thigh lies directly on the deep surface
of the gluteus maximus muscle, having a very close anatomic relationship with the inferior gluteal
artery. The purpose of this study was to gain a better understanding of the anatomy of the posterior
femoral cutaneous nerve (PFCN), its branches, and their relationship with the inferior gluteal artery
(IGA). Eighteen fresh human pelvic halves were dissected for examination during harvesting of the
inferior gluteal myocutaneous free flap, to determine if a nerve-sparing approach was possible and
how this information might impact on IGAP flap harvest. Seventeen of 18 pelvic halves had at least
some of the PFCN branches intact after isolation of the IGA pedicle and flap elevation. Three of
18 of the pelvic halves had the entire PFCN and its branches intact after flap elevation. One of 18
pelvic halves required complete transection of the PFCN and its branches in order to isolate the IGA
pedicle. In 94.5% of the pelvic halve dissections, it was possible to maintain at least a portion of the
PFCN intact after isolation of the inferior gluteal artery pedicle while harvesting the free inferior gluteal
myocutaneous flap. These findings support a nerve-sparing approach to inferior gluteal myocutane-
ous flap elevation to minimize the sequela of posterior thigh anesthesia. These data also emphasize
the intimate relationship of the PFCN and the gluteal artery and the real possibility of injury to the
PFCN during IGAP harvest.
Zhang R, Sun J, Wei X, et al. Reconstruction of defects with the posterior femoral fasciocutane-
ous flap after resection of malignant tumour of the femoral greater trochanter, sacrococcygeal
region and knee. J Plast Reconstr Aesthet Surg 62:221-229, 2009.
To determine the vascular anatomy and clinical applications of superiorly and inferiorly based posterior
thigh fasciocutaneous flaps, the authors conducted a study of 10 consecutive patients who underwent
resection of malignant tumors, five malignant fibrous histiocytomas (MFH), two synovial sarcomas,
one skin squamous cell cancer, one malignant hamartoma, and one fibrosarcoma. The average age of
the patients was 49 years (range 25 to 71 years), with 6 men and 4 women. Superior defects, includ-
ing two in the sacrococcygeal region and one lesion over the femoral greater trochanter, were closed with
superior posterior femoral fasciocutaneous flaps (SPFFCF). Seven lesions, three in the popliteal fossae
and two in the lateral and two medial knee regions, were closed with inferior posterior femoral fascio-
cutaneous flaps (IPFFCF). The average flap size was 148 cm2 (range 90 to 300 cm2). The average
follow-up period was 23 months (range 3 to 50 months). Patients were assessed by examination of the
vascular anatomy, the operation technique and the treatment outcome. In particular the fasciocutaneous
network and the descending branch of the inferior gluteal artery of the nutrient flap were analyzed.
There were no total skin flap failures and no significant complications. Tumor recurred locally in
two patients and lung metastases occurred in another two. Five patients returned to their original jobs
and daily activity without limitation, but two experienced decreased knee flexion of 30 degrees. The
larger SPFFCF is based on the fasciocutaneous branch of the inferior gluteal artery accompanied by
the posterior gluteal cutaneous nerve. The larger SPFFCF, which includes the fascia lata femoris
and the fasciocutaneous branch with the posterior femoral cutaneous nerve, does not include the first
cutaneous branch of the fasciocutaneous branch artery. Hence large defects of the sacrococcygeal region
and the femoral greater trochanter can be reconstructed using an SPFFCF. Defects around the knee
can be reconstructed with an IPFFCF, which is based on the ascending branch of the fasciocutaneous
branch of the third perforating artery.

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 ANATOMIC LANDMARKS
Landmarks This large fasciocutaneous territory extends from the midline
to the posterior axillary line and from the scapular spine to the
midback.
Size 12 3 25 cm with primary closure; larger size up to 20 3 35 cm
with skin grafting of the donor site. Size can be further increased
by tissue expansion.
Composition Fascial or fasciocutaneous.
Dominant Pedicle Circumflex scapular artery.
Nerve Supply Cervical plexus, dorsal nerve roots, circumflex nerves.

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 Section 7C
Posterior Trunk

Scapular/Parascapular Flap

CLINICAL APPLICATIONS
Regional Use
Axilla
Shoulder
Back
Upper extremity
Distant Use
Cutaneous
Head and neck
Upper extremity
Lower extremity
Specialized Use
Facial augmentation

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 ANATOMY OF THE Scapular/Parascapular Flap

A Axillary artery
Ascending branch of
circumflex scapular artery

Circumflex
Transverse branch scapular artery
of circumflex
scapular artery
Thoracodorsal
artery
Descending branch
of circumflex
scapular artery

Thoracodorsal artery

Latissimus
dorsi muscle

Circumflex
Axillary artery
scapular
B C
artery
Subscapular
Circumflex artery
Circumflex scapular
humeral artery
artery

Transverse Axillary
branch of artery
circumflex
scapular
artery
Thoracodorsal artery

Thoracodorsal artery

Serratus anterior
branch

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 cir-
cumflex 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.
Dominant pedicle: Circumflex scapular artery

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 649

Anatomy
Landmarks The triangular space must be identified to safely design the scapular flap. The space
is defined by the teres major inferiorly, the teres minor superiorly, and the long
head of the triceps laterally. It is through this space that the circumflex scapular
vessels emerge; the exact point can be found by palpation and can be confirmed
by Doppler ultrasonography. The approximate location of the triangular space
can also be palpated on the lateral scapular border, where it lies two fifths the
distance from the scapular spine to the scapular tip. The lateral extension of the
flap can be to the midaxillary line, and medially, the flap can be designed to
the vertebral column. Superiorly, the flap can be harvested from just above the
scapular spine, and inferiorly, at least to the angle of the scapula and as far as the
midback.
Composition The scapular flap can be harvested as a cutaneous flap, an adipofascial flap, an
osseous flap, or any combination of the above.
Size 12 3 25 cm with primary closure; larger size up to 20 3 35 cm with skin graft-
ing of the donor site or tissue expansion.
Although flap design is limited by the ability to close the donor site, a flap of
10 to 12 cm usually can be closed primarily and the length can be 25 cm or more,
as long as the design remains within the confines of the landmarks described
above. Larger skin paddles can be harvested but would require skin grafting to
the donor site, tissue expansion, or a delay procedure. The length of bone that
can be harvested depends on the patient’s size and can be harvested from the
lateral or medial border of the scapula, with bony length as large as 14 cm.

Arterial Anatomy
Dominant Pedicle  Circumflex scapular artery
Regional Source  Axillary artery.
Length  4 cm.
Diameter  2.5 to 4 mm.
Location  The triangular space is defined by the teres major inferiorly, the teres minor superiorly,
and the long head of the triceps laterally. It is through this space that the circumflex scapular
vessels emerge. The subscapular artery arises from the third portion of the axillary artery; after
2 to 3 cm, it divides into a circumflex scapular artery and a thoracodorsal artery. At this point
the circumflex scapular artery is 4 mm in external diameter. The circumflex scapular artery
then runs 3 to 4 cm as it passes through the triangular space; once in the space, it sends branches
to the subscapularis muscle as well as to the scapula, providing the vascularization for the lateral
bone flap. The artery divides generally into a descending branch (parascapular branch), a trans-
verse branch (scapular branch), and ascending branches. Flaps based on the descending branch
are referred to as parascapular flaps, whereas flaps based on the more transverse or superior vessels
have been called scapular flaps, although the flap composition and source vessels are the same. The
transverse vessels supply the medial osseous segment, which is largely through fasciocutaneous
connections and not direct musculoperiosteal branches, as is seen with the lateral osseous flap.

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 650 Part II  Regional Flaps: Anatomy and Basic Techniques

Venous Anatomy
Two venae comitantes accompany the artery; one vein is usually larger, measuring approximately
4.5 mm in diameter at the level of the circumflex scapular vein. The smaller vein is frequently 1.5
to 2.5 mm in diameter.

Nerve Supply
Sensory Innervation of this area is from the cervical plexus, the dorsal nerve roots, and
the circumflex nerves. There is no nerve that can be harvested with the flap to
make it sensate.

Vascular Anatomy of the Scapular/Parascapular Flap

A B

t
s D

Deep surface of flap Radiographic view

C s D t
t s
D
D

p
p

Cutaneous surface of flap with lateral segment of scapula Radiographic view

(vascularized bone)

Fig. 7C-2 

Dominant pedicle: Circumflex scapular artery (D)

p, Periosteal branch to scapula; s, subscapular artery; t, thoracodorsal artery

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 651

Flap Harvest
Design and Markings
The patient is marked in a standing or sitting position; the marks are then confirmed once
the patient is positioned on the operating table. The design begins with palpation of the
triangular space. Next, based on tissue needs, the relaxed skin tension lines of this area of
the back are determined, and the skin paddle is designed accordingly. Any skin paddle
design that incorporates the circumflex scapular vessels as they emerge from the triangular
space will be well vascularized. It is advisable to place the axis of the flap along either the
descending or transverse branches; this can be confirmed by surface Doppler ultrasonog-
raphy. If the width of the skin paddle design is kept at 10 cm or less, primary closure can
be done. For an osteocutaneous flap, the cutaneous segment is planned separately, as noted
previously. Based on the length of the desired flap and the thickness of bone stock, either a
medial or a lateral osseous segment can be harvested the width of the flap, and no further
skin incisions are necessary to facilitate this.

A B
Scapular flap

Teres minor
muscle

Triceps brachii
muscle
(long head)

Teres major
muscle

Triangular
space

Parascapular Lateral border

flap of scapula

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 inferiorly on a line connecting the midportion of the spine
of the scapula to its inferior angle.

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 652 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
Positioning for harvest of the scapular flap will depend on its clinical application. When
possible, lateral decubitus positioning is preferred, especially when the recipient site can
also be prepared in this position, either as a pedicle or free flap. For a free flap, this allows
a two-team approach.
Many head and neck applications require repositioning of the patient; therefore harvest-
ing with the patient in either the lateral decubitus or prone position depends on the surgeon’s
preference. For rotational flaps of the axilla or shoulder, a lateral decubitus position with
the arm prepared into the field is preferred.

Lateral decubitus position

Prone position

Fig. 7C-4 

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 653

Guide to Flap Dissection

Once the flap has been designed, based on identification of the triangular space and the
amount of tissue required at the recipient site, one of two approaches can be used to dissect
the skin paddle. In the first approach the superior flap border and lateral flap border are
incised, and dissection proceeds directly to the triangular space. Fascia from the deltoid and
teres muscles can be taken to allow a safe passage into the triangular space, but this fascia
must be opened to identify the sizable circumflex scapular vessels. Then the remainder of
the incisions in the flap can be made, and the flap can rapidly be raised from medial to lateral
and from inferior to superior surrounding the triangular space.

A B

Infraspinatus
Scapular flap muscle
Trapezius
muscle

Teres
minor muscle

Triceps muscle
Teres
major muscle
Circumflex
scapular artery

Fig. 7C-5  A, A scapular flap is outlined with the distal portion of the flap extending to the midverte-
bral 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.

In the second approach the pedicle is not identified immediately; rather, the medialmost
and inferiormost portions of the flap are elevated and quickly dissected toward the triangular
space. A subfascial plane is maintained as the lateral edge of the scapula is approached. Again,
the triangular space is surrounded by including the fascia from the teres major and teres
minor muscles, and once dissection is carried down into the triangular space, this fascia is
entered; the areolar tissues encountered contain the circumflex scapular vessels.
At this point, small muscle branches to the teres minor and teres major are divided, and
deep retractors can be placed, opening the triangular space and facilitating dissection of the
vessel toward the subscapular system. Branching of the circumflex scapular vessels can be
seen within the space, and the descending branch is noted to pass around the lateral border of
the scapula, with direct blood vessels to the periosteum. If a skin or adipofascial flap only is
desired, the vessel to the bone is divided and the pedicle is lengthened by further dissection.
The pedicle length is approximately 4 cm at this point; this can be further lengthened by
dividing the thoracodorsal vessels and extending the dissection into the subscapular system.

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 654 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variants
•  Adipofascial flap
•  Osteocutaneous flap
• Bone-only

Adipofascial Flap
When soft tissue lining or soft tissue fill is the reconstructive goal, as in a Romberg’s hemifa-
cial atrophy case, a scapular flap containing only fascia and overlying fat can be an excellent
choice. This can be obtained by harvesting the fasciocutaneous flap and deepithelializing
or simply removing the skin, or incisions can be designed over the area to be harvested
and thin skin flaps raised for exposure. The thickness of the elevated flap will dictate how
much subcutaneous fat remains with the flap.

Osteocutaneous Flap
The scapular flap is the flap of choice when vascularized bone is required in combination
with a large soft tissue defect. Bone stock is good and is best used straight, although osteoto-
mies are possible with a good soft tissue cuff around the bone. The fibula is the best choice
when multiple osteotomies are required. The advantage of the scapular flap over the fibula,
however, is the large skin flap that can be carried without the need to skin graft the donor
site and the relatively independent mobility of the skin and bone components, which is not
the situation with the fibular osteocutaneous flap (see Chapter 3).
If bone stock is required as part of the dissection, the lateral border is favored for its
greater diameter when compared with the medial osseous segment (3 cm thick versus
1.5 cm). A segment of bone is then marked: approximately 2 to 3 cm wide and 10 to
14 cm long is outlined.

A Teres minor muscle

Infraspinatus muscle

Circumflex scapular artery

Scapula

Lateral area of
scapula to be
harvested
Teres major muscle

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.

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 655

The segment starts just below the insertion of the long head of the triceps. The muscles
can be directly incised, which releases the teres minor muscle and the superior portion of
the teres major muscle, thus exposing the periosteum of the dorsal surface of the scapula.
Osteotomies can then be performed.

B Teres minor muscle

Infraspinatus muscle Teres minor
(cut edge)

Circumflex
scapular artery

Teres major
(cut edge)
Serratus anterior
(cut edge)
Teres major muscle

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, place-
ment of the bone and cutaneous paddle is facilitated by movement in three dimensions.

The attachment of the serratus muscle to the inferior angle of the scapula is maintained.
Once this is freed, dissection of the pedicle can be continued, as described previously. It is
important to preserve the inferior angle to ensure shoulder stability. If the serratus and teres
major muscles have been divided, they are reinserted through drill holes or suture anchors
in the remaining scapula.
If the medial osseous segment is to be harvested, dissection proceeds down to the un-
derlying muscles in this area.

C D Infraspinatus muscle

Infraspinatus muscle Teres minor muscle

Teres minor muscle

Triceps muscle

Triceps muscle Teres major muscle

Teres major muscle
Rhomboid major muscle
Vascular pedicle identified
in triangular space Medial border of scapula

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 at-
tached. Osteotomies can then be performed.

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 656 Part II  Regional Flaps: Anatomy and Basic Techniques

The distal portion of the flap that overlies the medial part of the scapula is left attached,
and the remaining more proximal portion is elevated. A medial osseous segment 10 to
12 cm long and 2 to 3 cm wide is marked, and after complete elevation of the skin paddle,
this osseous segment can be harvested. The incision is made through the infraspinatus
muscle, exposing the periosteum of the dorsal surface of the scapula. The greater rhomboid
muscle must be released from its attachment on the medial border. The subscapularis and
serratus anterior muscle attachments are also released from the anterior surface of this os-
seous segment.

E
Infraspinatus muscle

Rhomboid major muscle Teres minor muscle

(cut edge)

Erector spinae muscle

Vascular pedicle

Rhomboid major muscle (cut edge)

Serratus anterior muscle (cut edge)

Medial scapular bone

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.

The rhomboid and serratus anterior muscles must be reattached to the medial portion
of the scapula using drill holes.

Bone-Only
When only bone is required, an incision is made directly over the bone, and the dissection
then proceeds as described for the osteocutaneous variant.

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 657

Arc of Rotation
Standard Flap
The arc of rotation of the flap is generally toward the shoulder or axilla, because the cir-
cumflex scapular vessels emerge from the triangular space laterally in the back. These vessels
are the limiting point for rotation, and the reach of the flap will depend on the ultimate
size of the flap designed.

Scapular flap

Parascapular
flap

Arc for scapular flap

Arc for parascapular flap

Fig. 7C-7  The arc of rotation for any variant is around the circumflex scapular pedicle.

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 658 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Transfer
Pedicle Flap
When the scapular flap is used as a regional tissue transfer, options include direct transposi-
tion from the donor site to the recipient site or subcutaneous tunnel transposition. This is
largely based on the operating surgeon’s preference. Care must be taken when placing a
flap through a subcutaneous tunnel that there is no compression on the vascular pedicle.
With the skin flap completely elevated and side branches divided, rotation of 180 degrees
is possible. With less skeletonization of the pedicle, less rotation is safely achievable.

Free Flap
If tissues are being used as a free tissue transfer, considerations of pedicle length and vessel
diameter are crucial to determining how much dissection of the pedicle is required. Because
these flaps tolerate ischemia well, it is not uncommon to harvest the flap and place it on the
back table while the donor site is quickly closed. The patient can then be repositioned for
the microsurgical portion of the procedure, if this is necessary.

Flap Inset
Pedicle Flap
For pedicle flaps it is critical that the flap be inset without tension on the skin paddle and
without kinking or torsion of the pedicle. For axillary use, a rotation of 180 degrees is not
uncommon; it is therefore critical to dissect the pedicle of the flap into the triangular space
to allow this degree of rotation without kinking. A parascapular design would require less
rotation into the axilla and is preferred.

Free Flap
As a free tissue transfer, these considerations are less important. Once the flap and vessels
have been harvested, inset is performed at the recipient site, again ensuring a tension-free
closure without torsion, kinking, or tension on the microscopic anastomosis.

Donor Site Closure

All Flap Variants
Primary closure should be the goal in most reconstructions. Occasionally, such a large
amount of tissue is required that primary closure may not be obtainable. For these cases,
if time allows, tissue expansion can be performed within the flap or in the periphery of
the flap to assist in primary closure. Otherwise, donor sites that exceed 10 cm in width
may require skin grafting and secondary expansion or closure. Once the tissues have been
removed and the donor site requires closure, wide mobilization above the level of the fas-
cia is recommended until a tension-free closure can be achieved. Scarpa’s fascia should be
closed with sutures, and then the skin is closed. It is recommended that a drain be placed
in the donor site, because seroma formation is a concern and can be exacerbated by early
postoperative arm movements.

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 659

Clinical Applications
This 39-year-old man underwent resection of a dermatofibrosarcoma protuberans of the
cheek. In this moderately obese patient, the back provided the best donor site for the thin,
pliable tissue needed for cheek resurfacing. A free scapular flap was performed, with primary
closure of the back. One revision with liposuction and excision was required for the final
result. A drawback of most reconstructive flaps not from the facial area is the mismatch of
skin color and texture. Whereas women can often hide differences with cover makeup, men
have a harder time hiding the differences, especially with facial hair growth surrounding
the flap.

A B

C D

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.
(Case supplied by MRZ.)

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 660 Part II  Regional Flaps: Anatomy and Basic Techniques

This 75-year-old man had an extensive squamous cell cancer of the scalp. He required
wide resection and good soft tissue reconstruction so that he could undergo postoperative
irradiation. Although large defects can often be skin grafted or reconstructed with muscle
or with omental free flaps with skin grafting, any patient who will be undergoing post-
operative radiation therapy should undergo reconstruction with a skin flap. Skin grafts do
not tolerate irradiation, but skin flaps can, and often the final cosmesis is improved thanks
to the effects of irradiation on the flap. Because of a poor Allen’s test, a radial forearm flap
was ruled out and a scapular flap was performed. First, resection was performed and re-
construction was delayed until permanent clear margins were obtained. On postoperative
day 4, margins were clear and reconstruction proceeded. The scapular flap was dissected
to the subscapular system to lengthen the pedicle and reach the superficial temporal vessels.
Ultimately, an A-V loop was required to anastomose to the facial vessels. The flap healed,
and despite an area of local recurrence requiring a small skin graft, the patient and the flap
tolerated postoperative radiation well.

B C

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.

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 661

E F

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 super-
ficial 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. (Case supplied by MRZ.)

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 662 Part II  Regional Flaps: Anatomy and Basic Techniques

This 77-year-old man had recurrent squamous cell carcinoma of the chin pad requiring a
large soft tissue resection, including the lower lip and the anterior mandible with the floor
of mouth. Although the fibula is preferred for anterior mandible reconstruction because it
can be easily osteotomized, the flap does not supply enough soft tissue for these complex
reconstructive needs. Rather than use a fibula and a second flap, a scapular osteocutaneous
flap was chosen to reconstruct the entire defect. The scapula was osteotomized and the
thin, pliable skin paddle was used for the floor of the mouth, lip, and chin pad. The relative
independence of the skin and bone components allows this. The lower lip was supported
with a fascia lata graft. Wide undermining allowed primary closure of the donor site, avoid-
ing the need for a skin graft.

C D

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.

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 663

F G

H I J

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. (Case supplied by MRZ.)

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 664 Part II  Regional Flaps: Anatomy and Basic Techniques

This 29-year-old woman sustained a complex tibia-fibula fracture and had a nonunion and
open wound requiring aggressive debridement and placement of methylmethacrylate beads.
She needed a soft tissue flap to cover the beads and establish a well-healed soft tissue envelope
so future bone grafting could proceed. The radial forearm donor site is not preferred in a
woman, and she did not like the idea of an abdominal skin flap. She accepted the choice of
a scapular flap, since she would not see the donor scar. A scapular flap was performed, and
she ultimately underwent bone grafting. No flap revisions were required, and the donor
site scar was acceptable to the patient.

A B

C D

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.
(Case supplied by MRZ.)

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 665

This 34-year-old man sustained a crush injury to his foot that ultimately required open
transmetatarsal amputation. Soft tissue reconstruction was performed to maintain foot func-
tion. Although a muscle flap with skin graft was an option, it was thought that the wear
and tear of shoes on his reconstruction would be problematic and that a skin flap would be
better tolerated. A scapular flap was chosen because of the large amount of skin supplied
and the acceptable donor location. Translocation of his back tattoo was not a concern. He
underwent a large scapular flap for resurfacing of the foot. The large flap size required skin
grafting of the donor site. He currently ambulates in a shoe with an orthotic device.

A B

C D

E
F

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. (Case supplied
by MRZ.)

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 666 Part II  Regional Flaps: Anatomy and Basic Techniques

This 39-year-old man had chronic hidradenitis of the right axilla, and conservative therapies
had failed. After aggressive debridement and dressing changes, he was ready for reconstruc-
tion. It was thought that secondary healing or skin grafting would result in a functionally
disabling contracture, and a soft tissue flap was planned. A parascapular flap is a natural flap
for axillary soft tissue needs, since the tissue is readily available and the location of the vas-
cular pedicle is a favorable point of rotation. In such cases, a parascapular design is preferred
over a scapular design, because the degree of rotation of the flap is less.

A B C

D E F

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. (Case supplied by MRZ.)

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 667

Pearls and Pitfalls

• Because this flap has excellent vascularity as long as the circumflex scapular vessel is
included as it exits the triangular space, the surgeon should use the relaxed skin tension
lines to produce the best scars and allow the most tension-free closures. Aligning the
flaps on descending or transverse vessels is less critical. Laser angiography can provide
further guidance for the design.
• For the axilla, the parascapular design is favored over the more transverse scapular design
for axillary needs, because the arc of rotation is less.
• For soft tissue needs for the shoulder, a myocutaneous latissimus or thoracodorsal perfora-
tor (TDAP) flap may be a better choice, depending on the location of the defect, because
these flaps have a larger arc of rotation and reach.
• Adipofascial flaps are an excellent choice when soft tissue fill is required, such as in recon-
struction of a Romberg’s hemifacial atrophy or other conditions, such as radiation atrophy.
• The skin of a scapular flap is relatively hairless, but it will not be a good color match for
the face.
• With preservation of the periosteum and a muscular cuff, osteotomies and shaping of
the scapula can be performed. However, this is a second choice to the fibular flap for
these purposes.
• This is a straightforward flap to dissect, with the potential for a long pedicle (10 to
12 cm) with large vessel diameters (3 to 4.5 mm).
• There is minimal morbidity and quick recovery to the fasciocutaneous and adipofascial
flaps; it is important to reinsert any disinserted muscles when the bone is harvested for
an osteocutaneous flap.
• Compared with other osteocutaneous flaps, such as those from the fibula and iliac crest,
the skin paddle and the osseous segment can be manipulated separately, which allows
greater flexibility in inset, depending on the bony and soft tissue needs.

Expert Commentary
Michael R. Zenn

Indications
For distant tissue transfers, much of the use of the scapular and parascapular flaps has been
replaced by the anterior lateral thigh (ALT) and radial forearm flaps, mainly because these
flaps are easy to harvest, often in a two-team approach to reconstruction in which donor
site and recipient site surgery are performed in parallel. Also, these flaps have been shown to
have acceptably low donor site morbidity. The regional use of parascapular flaps, especially
for axillary contracture of all causes, remains unquestioned.

Advantages and Limitations

So why bother with the scapular flap as a choice for free flap reconstruction? As reconstruc-
tive surgeons, we must have many weapons in our arsenal. Although the scapular free flap
may be a second, third, or fourth choice in most cases, there are clearly times when it is the
first choice (see Clinical Applications, Fig. 7C-10). Without a doubt, the scapular donor site
Continued

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 668 Part II  Regional Flaps: Anatomy and Basic Techniques

provides the largest surface area of flap, which is thin and pliable and is not encumbered by
any muscle bulk, as is often required with the ALT flap. As a patient becomes more obese,
the thighs and abdomen become less usable, and often the upper trunk is relatively spared
from this lipodystrophy. Many of the patients requiring these free flaps are elderly, especially
for head and neck applications, so sacrifice of the radial artery is problematic and is not
recommended, discouraging the use of the radial forearm free flap. Also, donor site scarring
is an issue, especially in younger patients and in women in general. Although a scar in the
arm and leg can be noticeable and distressing to these patients, a back scar is better tolerated,
since the patient cannot see it as well. For this reason, women prefer the superficial inferior
epigastric artery (SIEA) or deep inferior epigastric perforator (DIEP) flap for reconstruc-
tion, because the donor scar is hidden in clothing. Finally, the occasional morbidity that can
occur in the arm and leg involving neuropathy, paresthesia, and contracture rarely occur
in the back, where the most common concern is poor scar quality.

Personal Experience and Insights

As I have attempted to fit the reconstruction to the patient more and more in my practice,
I have offered the scapular flap more commonly as an alternative to the ALT and radial
forearm and let the patient decide. And as I have matured as a microsurgeon, I am more
comfortable harvesting a flap with the patient in the prone position and placing it on the
back table while the donor site is closed and the patient is repositioned for the microsurgery.
A fasciocutaneous flap is ideal for this approach, and I have never seen a failure of a free
fasciocutaneous flap based on this delay of 1 hour or less.

Complications
The main complications associated with the use of this flap are ischemia of the flap and
scarring at the donor site. Although the circumflex scapular vessels are quite large, the
distribution of its perforating vessels is variable. The use of laser angiography can aid in the
design of these flaps to ensure capture of the main areas of perfusion. In general, scars on
the back can be wide, and sometimes preparing the patient for this inevitability can avoid
the need for scar revision surgery.

Bibliography With Key Annotations

Bannasch H, Strohm PC, Al Awadi K, et al. Technical refinements of composite thoracodorsal
system free flaps for 1-stage lower extremity reconstruction resulting in reduced donor site
morbidity. Ann Plast Surg 60:386-389, 2008.
A multitude of local flaps have been suggested for lower extremity reconstruction. However, the gold
standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a
well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction
of defects requiring bone and soft tissue in complex three-dimensional relationships. Composite bone
and soft tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular
flap, the “latissimus/bone flap,” and the thoracodorsal artery perforator-scapular osteocutaneous flap.
Patient outcomes after reconstruction of lower extremity defects with composite free flaps from the
thoracodorsal system were analyzed. The authors demonstrated the execution of technical refinements
on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise
reduction of donor site morbidity.
Brown J, Bekiroglu F, Shaw R. Indications for the scapular flap in reconstructions of the head
and neck. Br J Oral Maxillofac Surg 48:331-337, 2010.
Composite free flaps that are available for reconstructions of the head and neck include those from
the fibula, iliac crest, radial forearm, and scapula, but only that from the scapula precludes two-team

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 669

operating and consequently adds a further 2 to 3 hours to the operating time. The authors clarified the
indications for the subscapular system of composite flaps and discussed their unique properties in terms
of reliability of the bony segment, their resistance to atherosclerosis, and the diversity of the skin and
muscular components that are available. They have had favorable results in composite resections of the
anterior mandible that required substantial resections of the anterior tongue. The authors presented a
consecutive series of 46 patients, documenting the use of this option in routine head and neck practice.
In extensive oropharyngeal resections that require a segmental resection of the mandible, the skin
island is reliable and provides sufficient bulk to reduce the risk of dehiscence and maintains a nar-
rowed oropharynx to improve speech and swallowing. In reconstructions of the midface, a combination
of the latissimus dorsi and the scapula that is based on the angular branch of the thoracodorsal vessel
(thoracodorsal angular flap) allows a long pedicle, and adequate muscle and bone for high and low
maxillectomy defects.
Dabernig J, Ong KO, McGowan R, et al. The anatomic and radiologic basis of the circumflex
scapular artery perforator flap. Ann Plast Surg 64:784-788, 2010.
Microsurgical development has recently focused on the perforator paradigm and primary thinning.
Existing perforator flaps may require intramuscular dissection or lack reliable surface markings, whereas
traditional scapular/parascapular flaps have low donor morbidity and reliable anatomy, but can be exces-
sively bulky. Clinical application of a new flap based on a perforator from the circumflex scapular axis
(CSA) has recently been published, but the vessel’s anatomy has not been adequately characterized.
The authors dissected the CSA in 115 sites in 69 cadavers and measured the number, external vessel
diameter, and site of origin of perforators relative to the CSA bifurcation. Color Doppler ultrasound was
used to delineate the CSA and its perforators bilaterally in 40 volunteers. The number, origin relative
to CSA bifurcation, diameter, length, and flow velocity of cutaneous perforators were determined.
A CSA perforator was always present, running into the subdermal plexus, arising within 2.4 cm of
the bifurcation. The authors definitively described the anatomy of the perforator from the circumflex
scapular artery on which a new flap has been based. Its origin and dimensions are anatomically and
radiologically reliable. The flap has certain potential benefits over existing perforator flaps.
Dabernig J, Sorensen K, Shaw-Dunn J, et al. The thin circumflex scapular artery perforator
flap. J Plast Reconstr Aesthet Surg 60:1082-1096, 2007.
Based on initial clinical observations, cadaveric, and radiologic studies, the authors described a new,
thin, perforator flap based on the circumflex scapular artery (CSA). A perforator vessel was found to
arise within 1.5 cm of the CSA bifurcation (arising from the main trunk, or the descending branch).
The perforator arborizes into the subdermal vascular plexus of the dorsal scapular skin, permitting the
elevation and primary thinning of a skin flap. This thin flap was employed in five clinical cases to
reconstruct defects of the axilla. No intramuscular perforator dissection was required; pedicle length was
8 to 10 cm and vessel diameter 2 to 4 mm. There were no significant perioperative complications or
flap failures, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive
aims were achieved in all cases. Surgical technique and the vascular basis of the flap were described.
Erdmann D, Sundin BM, Yasui K, et al. Microsurgical free flap transfer to amputation sites:
indications and results. Ann Plast Surg 48:167-172, 2002.
The authors reviewed microsurgical free flap reconstructions to amputation stumps of the upper as
well as the lower extremities in seven male and two female patients. Indications included preserva-
tion of length after trauma in six patients and cure of local infection in two patients. In one patient
an extensive defect after resection of a recurrent shoulder sarcoma required use of a complete arm fillet
free flap for tumor reconstruction. Microvascular free flaps used included four scapular flaps, two fillet
flaps from the amputated extremity, one anterolateral thigh flap, and one lateral arm flap. Seven of
nine patients were fitted with a prosthesis and underwent occupational therapy resulting in ambula-
tory and improved functional status. Microvascular reconstruction is indicated in emergency settings as
well as for elective reconstruction of amputation sites. Using uninjured “spare parts” of the amputated
extremity should be considered. Elective reconstruction is performed preferably with free flaps based
on the subscapular vascular system.

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 670 Part II  Regional Flaps: Anatomy and Basic Techniques

Fairbanks GA, Hallock GG. Facial reconstruction using a combined flap of the subscapular axis
simultaneously including separate medial and lateral scapular vascularized bone grafts. Ann
Plast Surg 49:104-108; discussion 108, 2002.
The authors presented a case report in which a conjoined combined free flap consisting of four free
tissue transfers based on the subscapular axis was used in simultaneous reconstruction of a gunshot
wound to the face. This included a medial scapular osteofasciocutaneous flap for the mandible, a
lateral scapular osseous flap for the anterior maxilla, a serratus anterior muscle flap for the cheek,
and a separate latissimus dorsi musculocutaneous flap for the forehead. This flap was successful and
provides another alternative to the resolution of complex problems needing multiple areas of both soft
tissue coverage and vascularized bone graft.
Hanasono MM, Skoracki RJ. The scapular tip osseous free flap as an alternative for anterior
mandibular reconstruction. Plast Reconstr Surg 125:164e-166e, 2010.
The authors described the successful use of scapular tip osseous free flap for anterior mandibular recon-
struction in seven patients with peripheral vascular disease, which precluded fibula free flap harvest.
These cases are novel in that the inferior angle of the scapula is oriented transversely and used to re-
create the anterior mandible, obviating the need for bony osteotomies. This flap is based on the angular
branch of the thoracodorsal artery rather than the circumflex scapular artery, which is the traditional
blood supply of the scapular flap.
Hwang JH, Hwang K, Bang SI, et al. Reliability of vascular territory for a circumflex scapular
artery-based flap. Plast Reconstr Surg 123:902-909, 2009.
The authors evaluated the cutaneous vascular territories of the circumflex scapular artery and the areas
supplied by perforators from neighboring anatomic vascular territories. They also defined the safety
limits of circumflex scapular artery–based flaps by means of fresh cadaver injection studies. A total of
15 dorsal thoraxes from eight fresh cadavers were used in this study. After saline irrigation, contrast
medium was injected into the subclavian artery of each specimen. Each full-thickness specimen of the
posterior hemithorax was then radiographed to characterize vascular networks. The primary zone of
the circumflex scapular artery was calculated to be 93.8 6 16.1 cm, which occupies a region smaller
than that of the scapula. However, by capturing the secondary zone, which was composed of the ter-
ritories supplied by adjacent perforators of the thoracodorsal artery, the dorsal intercostal artery, and
the transverse cervical artery, potential flap survival dimensions extended beyond the scapular region.
In fact, the potential zone was increased to 307.7 6 55.3 cm, which extended beyond the scapular
spine, the inferior angle of the scapula, the posterior axillary line, and close to the midline of the back.
Jaminet P, Pfau M, Greulich M. Reconstruction of the second metacarpal bone with a free
vascularized scapular bone flap combined with nonvascularized free osteocartilaginous grafts
from both second toes: a case report. Microsurgery 31:146-149, 2011.
In this report, the authors presented a case of a giant cell tumor of the second metacarpal bone. The tumor
was treated by en bloc resection of the distal portion of the second metacarpal with adjacent interosseus
muscle. Reconstruction was achieved using a free vascularized scapular bone flap with nonvascularized
free osteocartilaginous grafts from both second toes. Structural integrity and metacarpophalangeal joint
motion were preserved, with good functional result. A brief review of the literature was presented.
Kannan RY, Boyce DE, Peart FC. Surface marking the vascular pedicle of scapular flaps:
“scapular triangle.” Plast Reconstr Surg 112:1196-1197, 2003.
Labow BI, Rosen H, Pap SA, et al. Microsurgical reconstruction: a more conservative method
of managing large scalp defects? J Reconstr Microsurg 25:465-474, 2009.
Scalp reconstruction is a challenging problem requiring attention to the cause, size, and condition of
the defect to formulate an optimal reconstructive plan. Although many “conservative” options have
been described even for large wounds, the use of local flaps or split-thickness skin grafts (STSGs) may
actually result in the need for multiple procedures, prolonged wound care, increased patient discomfort,
and an unsatisfactory aesthetic result. The authors reviewed 37 patients who had received a total of
38 free flaps for scalp defects of 100 cm2 or more secondary to a broad range of etiologic factors. There
were 24 males and 13 females, with a mean age of 47.4 years (range 7 to 83 years). The mean

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 671

scalp defect size was 356.2 cm2 (range 130 to 675 cm2). More than half the patients had previously
undergone local flap reconstructions or STSGs that had failed (n 5 20; 54.1%). Latissimus dorsi
muscle or myocutaneous flaps were the most commonly used free flaps in this series. Rectus abdominis
muscle, scapular, radial forearm, and omental donor sites were also used. There were a total of 10
complications among 10 patients (27%). Two patients (5.4%) had major complications, and eight
patients (21.6%) had minor complications. Four complications (40%) were in patients who had re-
ceived radiation therapy. Definitive closure was achieved using free tissue transfer in 95% of patients
who had previous attempts at closure using local options. These results demonstrate that free tissue
transfer is a safe and highly efficient reconstructive option to manage large scalp defects under a variety
of conditions. In large complex scalp wounds, especially in patients receiving radiation, microsurgical
reconstruction should be the preferred method of management.
Liu Y, Yu S, Song B, et al. Reconstruction of posterior lumbar defects in oncologic patients
using two island flaps of the back in series. Ann Plast Surg 65:326-329, 2010.
Reconstruction of the large lumbar defect is a challenge for plastic surgeons. The authors reported their
experience with the reverse latissimus dorsi myocutaneous flap for the coverage of large lumbar wounds
in two oncologic patients. Meanwhile, a pedicled ascending scapular flap was used to aid the donor
site closure of the myocutaneous flap. This allowed easy closure of both the donor sites and minimized
donor site morbidity. This procedure is highly reliable, and in the authors’ opinion, it is the first option
in reconstruction of large lumbar defects, particularly when a large surface coverage is needed.
Moukarbel RV, White JB, Fung K, et al. The scapular free flap: when versatility is needed in
head and neck reconstruction. J Otolaryngol Head Neck Surg 39:572-578, 2010.
The authors conducted a retrospective review of patients who underwent scapular free flap reconstruction
between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Defect analysis
and complications were also reviewed. Sixty procedures were performed, including 31 osteocutaneous
and 29 fasciocutaneous flaps. Most fasciocutaneous flaps were used for large defects of the lateral skull
base and face (70%). The skin paddle dimensions ranged from 4 by 3 to 15 by 10 cm. All osteocu-
taneous flaps were used for mandibular reconstruction. The length of the bony defects ranged from 4
to 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries
and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four
cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps had medical
complications, including one mortality. Scapular free flaps are reliable options. Fasciocutaneous applica-
tions are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous
flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap
complication rates were acceptable, even in medically higher-risk patients.
Nişanci M, Er E, Işik S, et al. Treatment modalities for post-burn axillary contractures and the
versatility of the scapular flap. Burns 28:177-180, 2002.
Inappropriate treatment of axillary burns frequently results in adduction contractures. In this clinical
study the authors reviewed 32 patients with different types of axillary postburn adduction contractures.
They used a variety of surgical treatments for reconstruction of axillary contracture releasing defects,
such as simple grafting, Z-plasties, and locally pedicled flaps. Among these alternatives, they used
the scapular island flap most frequently. In addition to conventional harvest of this flap, extension
of its pedicle up to the subscapular ramification by passing it through the triangular space allowed its
transfer even to the anterior axillary line defects in a vertical orientation without pedicle kinking. In
conclusion, the island scapular flap is a good choice for reconstruction of all types of axillary contracture,
releasing defects with satisfactory results in terms of function and cosmesis.
Nkenke E, Vairaktaris E, Stelzle F, et al. Osteocutaneous free flap including medial and lateral
scapular crests: technical aspects, viability, and donor site morbidity. J Reconstr Microsurg
25:545-553, 2009.
The authors presented their study in which they assessed the metabolism of the bony segments of
osteocutaneous free flaps, including lateral as well as medial scapular crests, by 18F-fluoride PET/
CT examinations and evaluated donor site morbidity. Twenty patients were included in the study; in

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 672 Part II  Regional Flaps: Anatomy and Basic Techniques

10 patients, osteocutaneous free flaps were harvested that included lateral as well as medial scapular
crests. Seven days after surgery, an 18F-fluoride PET/CT examination was performed to assess the
metabolism and viability of the bony segments. In the other 10 patients, flaps were harvested that
only included the lateral scapular crest. One and 6 months after surgery, all patients were asked to
fill in the disabilities of the arm, shoulder, and hand (DASH) questionnaire. In the 10 free flaps
that included lateral as well as medial scapular crests, 18F-fluoride PET/CT examinations revealed
metabolism and viability of both bony segments. The DASH scores for the two patient groups did not
differ significantly at 1 and 6 months after surgery. It seems that scapular osteocutaneous free flaps
adopting lateral as well as medial scapular crests are a viable option for mandibular reconstruction and
may be an alternative to the fibular double barrel.
Oyama T, Ohjimi H, Makino T. Bilayer reconstruction for Parry-Romberg syndrome: using
a free circumflex scapular artery-based adipofascial flap for both the buccal fat pad and subcu-
taneous fat. Ann Plast Surg 2011 Mar 2. [Epub ahead of print]
When using a free flap to reconstruct a facial deformity caused by Romberg’s disease, it is important to
prevent the flap from sagging after the operation. The authors reported a new method of reconstructive
surgery using a free subscapular adipofascial flap to prevent this problem. Three women (27, 28, and
34 years of age) with Parry-Romberg syndrome underwent microsurgical free scapular flap transfer for
buccal defects. This operation requires making a gingivobuccal sulcus incision and forming a pocket
for buccal fat reconstruction by dissecting over the periosteum of the maxillary bone. Preauricular and
submandibular incisions are made to create a subcutaneous pocket for flap transfer. After the subscapular
flap is elevated, the authors use its angiogram to observe its vascular pattern. The flap is separated to
preserve the main blood vessels horizontal lower branches. The subcutaneous adipose tissue layer uses
the horizontal branch, and the buccal fat pad layer the lower branch. Postoperatively, the adipofascial
flaps were in good condition and without complications. Six months after the first operation, revision
surgery was performed on one patient. No cases showed sagging of the cheek, and in every case the
overall appearance of the buccal region improved significantly.
Parrett BM, Pomahac B, Orgill DP, Pribaz JJ. The role of free-tissue transfer for head and neck
burn reconstruction. Plast Reconstr Surg 120:1871-1878, 2007.
Reconstruction of head and neck burns is challenging, traditionally involving skin grafting and local
flaps. Free flaps have improved in versatility and variability in recent years, and are now among the
techniques used for burn reconstruction. Thirty-six free flaps for 32 patients with cervicofacial burns
were reviewed retrospectively over a 17-year period (1989 to 2005) to determine indications, methods,
and outcomes. The mean patient age was 31 years. Thirteen flaps were transferred to the neck and
23 to the face. The main indication was contractures or hypertrophic scarring, followed by exposed
bone or cartilage. The majority of flaps were transferred for secondary reconstruction. The free flaps
most frequently used were the anterolateral, scapular/parascapular, and radial forearm. Fourteen were
prefabricated, 1 was prelaminated, and 15 were tissue-expanded. Thirty-four flaps were successful.
There were no deaths, two donor site complications, a 17% tip necrosis rate, and a 6% flap infection
rate. The median hospital stay was 6 days after free flap transfer. Patients were followed for at least
1 year; 64% of flaps needed further debulking or sculpting. Free tissue transfer is a valuable tool in
head and neck burn reconstruction. It can be used safely and effectively with minimal morbidity in
selected patients.
Pinsolle V, Tessier R, Casoli V, et al. The pedicled vascularized scapular bone flap for proximal
humerus reconstruction and short humeral stump lengthening. J Plast Reconstr Aesthet Surg
60:1019-1024, 2007.
The vascularized scapular bone free flap is popular in mandible reconstruction, but it is less commonly
used as a pedicled flap to reconstruct the upper humerus. The authors analyzed their experience in eight
patients with pedicled scapular crest flaps in humerus reconstruction and compared their results with
cases reported in the literature. They considered the age at surgery, time elapsed before reconstruction,
time required to obtain solid bony union, the operative indication, the osteosynthesis procedure used,

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 673

and whether circumflex scapular vessels or angular vessels were used. Flaps were pedicled either on
circumflex scapular vessels (three) or angular vessels (five). The mean size of the scapular bone used
was 9.4 cm (range 7 to 11 cm). The authors used a covering flap in seven patients. All flaps survived
and bone healed in 3 to 6 months (mean 3.75 months). There was one accidental secondary fracture
1 year after reconstruction. For a vascularized reconstruction of the upper humerus, the pedicled scapular
bone flap is a valuable option especially if a composite reconstruction is needed. For short humerus
stump lengthening, this flap seems to provide a very satisfactory solution.
Saadeh PB, Chang CC, Warren SM, et al. Microsurgical correction of facial contour defor-
mities in patients with craniofacial malformations: a 15-year experience. Plast Reconstr Surg
121:368e-378e, 2008.
Since their first review of microsurgical correction of facial contour deformities in 19 patients with
craniofacial malformations, the authors have treated an additional 74 patients (total 93). The authors
reviewed indications, choices, safety, efficacy, complications, and technical refinements. A treatment
algorithm was presented. Microsurgical flaps have markedly improved the authors’ ability to restore
craniofacial contour in patients with craniofacial malformations. In selected patients, the authors chose
primary midface augmentation with free vascularized tissue to restore form and function. Microsurgical
flaps in patients with craniofacial malformations are safe, effective, and reliable.
Sakurai H, Takeuchi M, Fujiwara O, et al. Total face reconstruction with one expanded free
flap. Surg Technol Int 14:329-333, 2005.
Deformities of a totally burned face present a profound challenge to the reconstructive plastic surgeon.
Skin grafting has been used traditionally for resurfacing with limited success, especially when the burns
were so severe the deeper structures were destroyed. Total face reconstruction, using bilateral extended
scapular free flap, has been reported previously for severe deformities following an extensive facial burn.
Although this method obtained better aesthetic and functional results than skin grafting, the donor
site morbidity was relatively high, with a large scar that extended across the entire back. In addition,
the nose needed to be reconstructed separately with a forehead flap or free radial forearm flap. The
authors presented a case in which a patient’s totally burned face was reconstructed successfully with a
single free-expanded flap. A 54-year-old man sustained a severe facial burn with gasoline. The burn
involved the face, anterior neck, anterior chest, and bilateral upper extremities. Sequential debridement
and skin grafting were required to close the burn wound. A tissue expander was inserted in his left back
before the facial reconstruction. Six months after insertion of the tissue expander, the left dorsal skin
was transferred to the face as one large flap, size 28 by 27 cm, with three sets of vascular anastomoses.
The flap totally survived with abundant tissue at the central area to reconstruct the nose. With five
complementary procedures, including a costal cartridge graft, the shape of the nose was restored, and
acceptable functional and aesthetic results were obtained. This method did not require a separate tissue
transfer for nasal reconstruction. To their knowledge, this was the first case of successful reconstruction
with one flap for total face reconstruction that included the nose.
Tachi M, Toriyabe S, Imai Y, et al. Versatility of chimeric flap based on thoracodorsal vessels
incorporating vascularized scapular bone and latissimus dorsi myocutaneous flap in reconstruct-
ing lower extremity bone defects due to osteomyelitis. J Reconstr Microsurg 26:417-424, 2010.
To treat lower extremity osteomyelitis resulting from trauma, bone and soft tissue can be grafted at the
same time using microsurgical techniques. The authors investigate the use of chimeric flaps based on
thoracodorsal vessels incorporating vascularized scapular bone and latissimus dorsi myocutaneous flap
to reconstruct bone and soft tissue defects of the lower leg due to osteomyelitis. Ten patients with lower
extremity bone and soft tissue defects from osteomyelitis were treated. Vascularized scapular bones were
raised on the angular branch of the thoracodorsal artery. Latissimus dorsi myocutaneous flaps were
elevated simultaneously to reconstruct the soft tissue defects. All patients tolerated the procedure well.
One patient developed an early venous thrombosis, which was successfully treated by thrombectomy.
Mean follow-up time was 7 years and 8 months. Bone union without refracture was observed in all
patients. The mean time required for bone union after surgery was 13.5 weeks. Donor site morbidity

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 674 Part II  Regional Flaps: Anatomy and Basic Techniques

was minimal. Chimeric flaps based on thoracodorsal vessels incorporating vascularized scapular bone
and latissimus dorsi myocutaneous are safe and effective in the repair of lower extremity bone and soft
tissue defects caused by osteomyelitis.
Tanna N, Wan DC, Kawamoto HK, et al. Craniofacial microsomia soft tissue reconstruction
comparison: inframammary extended circumflex scapular flap versus serial fat grafting. Plast
Reconstr Surg 127:802-811, 2011.
The authors investigated the use of serial autologous fat grafting to restore soft tissue contour in cranio-
facial microsomia patients. Patients with moderate to severe craniofacial microsomia were divided into
two groups. Ten microvascular free flap patients underwent reconstruction with inframammary extended
circumflex scapular flaps at skeletal maturity. Twenty-one patients had fat grafting during multiple
staged operations for mandible and ear reconstruction. Sex, age, severity of deformity (determined by
OMENS [orbital deformity, mandibular hypoplasia, ear deformity, nerve involvement, and soft tis-
sue deficiency] classification), number of procedures, operative times, and augmentation volumes were
recorded. A digital three-dimensional photogrammetry system was used to determine “final fat take”
and symmetry (affected side versus unaffected side). Physician and patient satisfaction were elicited.
Microvascular free flap and fat grafting groups had similar OMENS scores, 2.4 and 2.3, and similar
mean prereconstruction symmetry scores, 74% and 75%, respectively.
Turkaslan T, Turan A, Dayicioglu D, et al. Uses of scapular island flap in pediatric axillary burn
contractures [correction of contractures]. Burns 32:885-890, 2006.
Pediatric axillary postburn contractures one of the most challenging problems that follow treatment of
the upper extremity burns. The authors prefer to use scapular flaps for surgical treatment of pediatric
axillary contractures instead of skin grafting or Z-plasties. In this clinical study the authors presented
13 pediatric cases treated with scapular island flaps. In pediatric scapular flap cases, the technique they
used was to extend the flap’s pedicle dissection to the level of bifurcation of subscapular artery. Bypass-
ing the flap triangular space allowed them to cover the anterior part of the axillary contractures. They
observed that the scapular flap repairs have many benefits to skin grafting including no recurrence of
contracture and stable coverage of the shoulder joint. The other advantages of scapular island flap are
that the donor site is closed primarily, and it provides an adequate amount of pliable skin while not
compromising the function and range of motion of joints.
Vacher C, Lkah C. The osteomuscular dorsal scapular (OMDS) flap: an alternative technique
of mandibular reconstruction. J Plast Reconstr Aesthet Surg 63:198-204, 2010.
Free tissue transfer has become the dominant reconstructive tool for segmental defects of the mandible,
except in case of severe peripheral vascular disease. In these cases, the authors propose to use the os-
teomuscular dorsal scapular (OMDS) flap as an alternative technique. This flap is pedicled on the
dorsal scapular vessels with the harvesting of the medial border of the scapula and the lateral part of
the rhomboid muscles. The main disadvantages of the OMDS flap are the impossibility of placing
implants in the bone that have been harvested because of its thickness and the lateral position that has
to be changed to supine to allow access for resection of the tumour.
Valentini V, Gennaro P, Torroni A, et al. Scapula free flap for complex maxillofacial recon-
struction. J Craniofac Surg 20:1125-1131, 2009.
Composite tissue defects of the mandible and maxilla, after resection of head and neck malignancies,
osteoradionecrosis, malformations, or traumas, cause functional and aesthetic problems. Today micro-
vascular free flaps represent the main choice for the reconstruction of these defects. Among the various
flaps proposed, the scapula flap has favorable characteristics that make it suitable for bone, soft tissue,
or combined defects. Although the fibula flap and the deep circumflex iliac artery flap remain the first
choice for bone reconstructions of the mandible and maxilla, the scapula flap has some features that
make its use extremely advantageous in some circumstances. In particular, the authors advocated the
use of the osteomuscular latissimus dorsi–scapula flap for reconstruction of large-volume defects involv-
ing the bone and soft tissues, whereas fasciocutaneous parascapular flaps represent a valid alternative
to forearm flap and anterolateral thigh flap in the reconstruction of soft tissue defects.

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 Posterior Trunk  •  7C: Scapular/Parascapular Flap 675

Wagner AJ, Bayles SW. The angular branch: maximizing the scapular pedicle in head and neck
reconstruction. Arch Otolaryngol Head Neck Surg 134:1214-1217, 2008.
A series of 25 osteocutaneous scapular flaps was performed from August 2000 through January
2005. Of these 25 flaps, 7 procedures of scapular bone solely vascularized by the angular artery and
vein were performed to reconstruct head and neck defects. The angular vessels were used to reach the
neck for anastomosis in midfacial reconstruction (2), to carry a separate second bone flap in complex
oromandibular defects (2), and to reach the contralateral neck for anastomosis in through-and-through
oromandibular defects encompassing overlying facial skin (3). Postoperative bone scans revealed all
bone segments to be vascularized. The pedicle length originating from the circumflex scapular vessels
varied from 6.7 to 9.0 cm (mean length 7.5 cm). The pedicle length of the angular vessels varied from
13.0 to 15.0 cm (mean length 14.1 cm), a mean length of 6.6 cm longer than the circumflex scapular
flap. Vein grafts were not necessary to perform remote anastomoses with the additional pedicle length.
The angular vessels can reliably supply the scapula. Use of the angular vessels over the circumflex
scapular vessels increases the bone pedicle length by a mean length of 6.6 cm (88%) and is a useful
technique to avoid vein grafting for remote anastomosis.
Yang M, Zhao M, Li S, et al. Penile reconstruction by the free scapular flap and malleable penis
prosthesis. Ann Plast Surg 59:95-101, 2007.
Penile reconstruction has always been a challenging problem for plastic surgeons; patients present with
severe congenital deformities and gender dysphoria, or they may have suffered penile loss because of
trauma, self-amputation, malignancy, and so on. Since 1936, when Bogoras first constructed a total
penis, attempts have been made by different techniques, including skin flaps or myocutaneous flaps.
And with development of free tissue transfer and microsurgical techniques, various free skin flaps, such
as the radial free forearm flap, the superficial inferior epigastric artery flap, the superficial circumflex
iliac artery flap, have been attempted for phallic construction, with the goal of functional (including a
competent neourethra that allows voiding while standing and sexual intercourse) and cosmetic result.
The purpose of their study was to evaluate the scapular free flap and implantation of malleable penile
prosthesis for penile reconstruction. Twenty patients with penile loss underwent reconstruction with
a one-stage procedure by transferring scapular flap and implantation of a malleable penile prosthesis.
The patients ranged between 21 and 36 years old. Of these patients, 12 had penile amputation
resulting from an electric accident; the other 8 were self-amputated. All the flaps remained 100%
viable postoperatively. Follow-up ranged from 1 to 5 years. There were no cases of urethral fistula,
urethral stenosis, prosthesis extrusion, or infection. The reconstructed penis yielded satisfactory func-
tion and aesthetic appearance. The scapular free flap is an ideal flap that achieves satisfactory function
and aesthetic appearance for penile reconstruction because of its adequate amount of tissue, reliable
vascularity, acceptable donor site morbidity, and reliable blood supply.
Zhang YX, Wang D, Follmar KE, et al. A treatment strategy for postburn neck reconstruc-
tion: emphasizing the functional and aesthetic importance of the cervicomental angle. Ann
Plast Surg 65:528-534, 2010.
The authors described an algorithm for reconstruction of both the soft tissue and skeletal components of
severe postburn neck deformities. The critical functional and aesthetic importance of the cervicomental
angle is emphasized. The neck is subdivided into 3 anatomic subunits: (1) lower lip/chin subunit,
(2) submental subunit, and (3) anterior neck subunit. After release of contractures, platysmaplasty is
performed to prevent recurrence and to deepen the cervicomental angle. In cases where chin retrusion
is present, sliding genioplasty is performed. The 3 subunits are resurfaced individually by skin grafts
and free flaps. The combined scapular and parascapular bilobed free flap is an ideal flap for cases
involving 2 subunits. Fifty patients with severe postburn neck contractures were treated. After excision
and release of scar, 47 (94%) patients underwent platysmaplasty, and 12 (24%) patients underwent
sliding genioplasty. Defects were covered with skin grafts alone in 20 (40%) patients, with free flaps
only in 22 (44%) patients, and with a combination of skin grafts and free flaps in 8 (16%) patients.

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 ANATOMIC LANDMARKS
Landmarks Lumbar back, from midline to midaxillary line.
Size 15 3 24 cm; 10 cm width or less for primary closure.
Composition Fasciocutaneous.
Dominant Pedicle Lumbar perforating arteries from L1 to L5.
Nerve Supply Sensory: Lateral cutaneous branches of the dorsal rami of L1 to
L3 (superior cluneal nerves).

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 Section 7D
Posterior Trunk

Lumbar Perforator Flap

CLINICAL APPLICATIONS
Regional Use
Back
Buttock
Specialized Use
Breast reconstruction

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 ANATOMY OF THE Lumbar Perforator Flap

A B

Lumbar
perforating
arteries

Lumbar muscles and arterial perforators Lower back sensory nerves

C Cauda equina
Spinal cord
Aorta

Anterior rami
of spinal nerves
L1
Sympathetic ganglion Medial
Multifidus muscle cutaneous
branches
Quadratus lumborum muscle
L2

L3
Lateral cutaneous
branches

L4

Longissimus muscle

Cross-section of lumbar region

Fig. 7D-1 

Dominant pedicle: Lumbar perforating arteries (L1-L5)

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 679

Anatomy
Landmarks The lumbar area, defined by the lumbar spinal bodies, from the midline to the
midaxillary line.
Composition Fasciocutaneous.
Size 15 3 24 cm maximally. As with most flaps of the back, in most patients primary
closure can be obtained with a width of 10 cm or less. In patients with skin lax-
ity, this can be greater. Otherwise, the donor site can be skin grafted.

Arterial Anatomy
Dominant Pedicle  Lumbar perforating arteries
Regional Source  Aorta (L1 to L4); iliolumbar arteries (L5).
Length  2 cm.
Diameter  1 mm.
Location  Perforators from the upper three lumbar vertebral bodies run between the erector
spinae and the quadratus lumborum muscles. The last two pairs of perforators run in front of
the quadratus lumborum muscles just lateral to the erector spinae musculature. Each lumbar
artery gives off a perforating vessel. The second and fourth perforators generally are the largest.

Venous Anatomy
Accompanying venae comitantes with the perforators.

Nerve Supply
Sensory Superior cluneal nerves (L1 to L3).

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 680 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Lumbar Perforator Flap

A B

C D

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 speci-
men. (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.)

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 681

FLAP HARVEST
Design and Markings
Lumbar artery perforators are first localized using Doppler ultrasound. The flap design then
encompasses this Doppler point. The margins of the flap can run from midline to midaxil-
lary line, depending on the reconstructive need. Elliptical patterns are most common, since
they aid in closure. Depending on the location of the defect, a second lumbar perforator
is preferred for dorsal defects; the fourth lumbar perforator is preferred for sacral defects.

Lumbar flap design for second and fourth perforators

Fig. 7D-3 

Patient Positioning
The patient is placed prone or in the lateral decubitus position.

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 682 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

Dissection begins laterally at the distal end of the flap. The incision is deepened down to
lumbar fascia, which is elevated with the flap. Dissection proceeds carefully until the per-
forating vessels are identified. With identification of the perforator, the entire flap may then
be incised and dissection proceeds completely around the perforator. The muscle can then
be split and further dissection of the pedicle can be performed 2 to 3 cm to aid in mobi-
lization and the arc of rotation of the flap. Since the vessels travel obliquely and anteriorly
from the lateral edge of the rectus spinae muscle, excessive skeletonization of the pedicle
does not lengthen the flap reach. For large defects of the sacrum, bilateral perforator flaps
can be designed.

Perforating vessel

Latissimus aponeurosis

Erector spinae muscle

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
Lumbar artery perforator flaps have been described for autologous breast reconstruction,
especially when abdominal tissues are not available. Here the dissection of the pedicle is
continued until a large enough diameter of artery and vein can be exposed for coaptation
in the chest. A position change is also required, because the flap is harvested in either the
prone or lateral decubitus position, and the flap must be inset and shaped with the patient
supine. Preoperative CT angiography or MRA studies can often be helpful to determine
whether dominant vessels are available in this area for such procedures.

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 683

Arc of Rotation
The arc of rotation of flaps will depend on the location of the pedicle. Most flaps are
turned toward the midline with a rotation of 90 degrees. For rotation to 180 degrees, some
skeletonization of the pedicle must be performed to allow the torsion of the pedicle to be
distributed over a longer length.

A B

Arc based on lower perforators Arc based on superior lumbar perforators

(L4-L5) (L1-L3)

Fig. 7D-5 

FLAP TRANSFER
Flaps are transposed into the defect to be reconstructed. Although they may be tunneled
subcutaneously, it is recommended to connect the donor site and the recipient site to take
any unnecessary pressure off the pedicle of smaller perforating vessels and to allow for
postoperative edema that could compromise flow in a subcutaneous tunnel.

FLAP INSET
Lumbar flaps should be inset with a tension-free closure. All tension should be borne by
the closure at the donor site. Drains are recommended for a few days until the amount of
drainage has diminished.

DONOR SITE CLOSURE

Primary donor site closure should be possible in flaps 10 cm in width and possibly wider. In
some patients, undermining of the donor site, especially on the side away from the flap rota-
tion, will allow further subcutaneous advancement and help minimize tension on closure.

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 684 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 56-year-old woman had a history of lobular carcinoma of the left breast and had under-
gone bilateral mastectomy with tissue expander/implant reconstruction 7 years earlier. Her
complaints included chronic discomfort associated with her implants and recurrent low-grade
cellulitis on the left. Additional concerns included poor central projection, asymmetry, lack
of inframammary fold definition, and an overall poor aesthetic. Both breast implants were
removed and capsulectomies performed, and her breast volume was reconstituted with an
initial lumbar artery perforator flap. She subsequently underwent deep inferior epigastric
perforator flap addition on both sides as a stacked overlay to her lumbar artery perforator
flaps for added volume and skin paddle increase.

A B

C D

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. (Case courtesy Frank J. DellaCroce, MD.)

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 685

This 40-year-old woman had a strong family history of breast carcinoma. She was seen in
consultation for autologous reconstructive options before undergoing bilateral prophylactic
mastectomies. Lumbar artery perforator flaps were used for immediate reconstruction to
reconstitute her breast volume.

A B

C D

Fig. 7D-7 A, The patient is seen preoperatively and B, postoperatively after bilateral prophylac-
tic 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. (Case courtesy Frank J. DellaCroce, MD.)

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 686 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The second or fourth intercostal perforator should be used preferentially, because these
tend to be the largest perforators.
• For a large defect of the midline, bilateral flaps should be considered.
• Gluteal perforator flaps may be appropriate in cases in which a good lumbar perforator
cannot be found on Doppler examination.
• Sensate flaps are possible by preserving the cutaneous nerve that travels with the perforator.
• Because of variable anatomy and small vessel size, the use of the lumbar perforator flap
as a free tissue transfer is a distant third or fourth choice for reconstruction.

EXPERT COMMENTARY
Frank J. DellaCroce

Advantages and Limitations

The lumbar artery perforator flap is rarely used in the clinical setting. Its anatomy tempts
with the promise of a large composite of fatty tissue, but the underlying vascularity is
challenging to deal with. It may be used as both a regional flap and a free flap. The former
is a more practical application, because rotating the flap around the pedicle’s exit point is
a surgical exercise that may be attempted by a reconstructive surgeon with even modest
experience. Employing the lumbar perforator flap as a free tissue transfer is made difficult
by the short pedicle (2 to 3 cm) and the fact that the artery remains small (approximately
1 mm) throughout its length.
With respect to the use of the flap for breast reconstruction, it has the potential to pro-
vide a relatively large amount of fatty volume, even in individuals with a slight build. This
fact may draw the breast reconstructive surgeon to consider its use. The lordotic curvature
of the low back in this area provides a depressed deep surface to the flap harvest site and
the convexity of the “love handle” on the superficial aspect means that the fatty depth is
substantial in most patients at this level. Despite this, the overlying skin tends to be thick
and inelastic, so the ratio of skin to fat is low. This can limit utility for breast reconstruction,
particularly for delayed reconstructions. An attempt to harvest 10 cm or more of skin width
with this flap will be met with a closure that is akin to a drumhead over an underlying
valley. The need to maintain a drain tube in place for a significant period and the likelihood
of chronic seromas are other significant considerations.

Recommendations
Planning
Doppler examination, cross-referenced with angiography (CTA/MRA), provides accu-
rate determination of the location of the lumbar perforators (Fig. 7D-8). The skin pattern
and associated bevel of the underlying fat may be tailored accordingly (Fig. 7D-9). Patient
positioning may be either prone or lateral decubitus.

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 687

Erector spinae Lumbar artery

musculature perforator

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 perfo-

rator free flaps with associated Doppler signal points.

Technique
As the dissection proceeds through the subcutaneous fat, I prefer to elevate the flap superficial
to the fascia underlying the fat. Although this makes the identification and skeletonization
of the perforators more difficult, it avoids removing the lumbar fascia with the flap. Re-
moving the fascia in this region introduces the potential of a lumbar hernia, which despite
being a rare phenomenon, is best avoided.1 Therefore I prefer to think of this flap as an
adipocutaneous flap rather than a fasciocutaneous flap. As the dissection progresses around
the perimeter of the flap, the superior cluneal nerves will be encountered over the superior
border. These nerves are of impressive size, and in my experience, transection of them at
their penetration point causes substantial numbness across the donor site.
When the perforating vessels are encountered, they will be tightly bound in fascial tis-
sue, and the dissection plane under the flap will be somewhat difficult to navigate. Working
through these challenges allows skeletonization of the pedicle, which can be impressive in
its overall size. As the surgeon will soon discover, the majority of this size is a consequence
of the vein’s diameter rather than that of the artery. Preserving the fascia and splitting it
around the perforator’s surface allows the vessel to be followed through the underlying
Continued

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 688 Part II  Regional Flaps: Anatomy and Basic Techniques

musculature (Fig. 7D-10). Careful dissection in these tight confines will allow the operator
to acquire a pedicle 2 to 3 cm long with an arterial component of 1 to 1.5 mm diameter
(Fig. 7D-11). The dissection may be concluded before this point for a pedicled flap if the
rotational arc is adequate.
For free tissue transplantation, the length and diameter of the pedicle limit this flap’s
utility. The short pedicle length means that it must be located somewhere near the periph-
ery of the flap to allow for reach to the recipient vessels. The risk of fat necrosis in the areas
farther away from a peripheral feeding perforator is, of course, a resultant concern.

Lumbar perforator
Iliac crest
Gluteus
medius
Fig. 7D-10  Surgical exposure of the lumbar
Gluteus
perforator.
maximus

Superior Lumbar
gluteal artery
perforator perforator

Fig. 7D-11  Flap with both lumbar perforator

and superior gluteal perforator dissected out in
its base.

Take-Away Messages
The benefits of keeping the donor site higher up on the buttock and using the love-handle
in the breast reconstruction arena are favorable considerations (see Clinical Applications
cases, Figs. 7D-6 and 7D-7), but the technical limitations of this flap make it a less practi-
cal procedure than an SGAP flap, which is positioned high on the buttock.2 The SGAP’s
pedicle length, associated increased arc of rotation, and ease of pedicle dissection, compared
with the lumbar perforator flap, make it a more favorable pedicled flap for defects in its
periphery as well.

References
1. Salameh JR, Salloum EJ. Lumbar incisional hernias: diagnostic and management dilemma.
J Soc Laparoendosc Surg 8:391-394, 2004.
2. DellaCroce FJ, Sullivan SK. Application and refinement of the superior gluteal artery perfora-
tor flap for bilateral simultaneous breast reconstruction. Plast Reconst Surg 116:97-103, 2005.

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 689

Bibliography With Key Annotations

Arco G, Horch RE, Arkudas A, et al. Double pedicled perforator flap to close flank defects:
an alternative for closure of a large lumbar defect after basalioma excision—a case report and
review of the literature. Ann Plast Surg 63:422-424, 2009.
Large defects after resection of skin cancers are sometimes a challenge for the reconstructive surgeon.
Although skin grafts are considered as the first choice for reconstruction of large skin defects of the
trunk, pedicled or free flaps sometimes provide a superior functional and aesthetic outcome. Perfora-
tor flaps represent a valuable option for these patients. The progress in understanding the perforator
vessel system of the body facilitated the development of a plethora of novel pedicled flaps which could
be transferred over long distances with minimal donor site morbidity. The authors presented the case
of a patient with a large lumbar basalioma. The skin defect after excision was reconstructed using a
novel concept based on two independent pedicled perforator flaps, a lumbar artery perforator, and a
lateral intercostal artery perforator.
Atik B, Tan O, Mutaf M, et al. Skin perforators of back region: anatomical study and clinical
applications. Ann Plast Surg 60:70-75, 2008.
Despite numerous studies that have been performed recently on skin perforators and perforator flaps
of various regions of the body, investigations on the back region are still insufficient. The authors in-
vestigated the anatomic characteristics and clinical applications of perforating vessels in the back region.
The skin on the back region between the right and left seventh to eleventh thoracic vertebrae of 10
fresh cadavers was raised as flaps. Perforating vessels perfusing the skin with pedicle diameters of over
1 mm were included in the study. The anatomic localization, diameter, pedicle size, and the supplying
vessels of these pedicles were determined. Using this information, the defects of eight patients with large
meningomyeloceles included in the study were closed with a prepared intercostal artery perforating flap.
Perforators of the back region were seen to originate from the posterior intercostal vessels. There were
a higher number of perforators on the right side of the body. The most commonly observed perforators
were the seventh and ninth posterior intercostal perforators, and their diameters were larger. All flaps
were viable after perforator flap closure for defects in eight patients with large meningomyelocele included
in the clinical study. No problems were encountered in the postoperative 3-month follow-up. Because
of the low donor site morbidity and wide motion capabilities, the perforator flap is a new choice of flap
for the back region. Perforator pedicle flaps supplied by the posterior intercostal vessels may be safely
used in congenital tissue defects, such as meningomyelocele, tumors, and traumatic defects.
De Weerd L, Elvenes OP, Strandenes E, et al. Autologous breast reconstruction with a free
lumbar artery perforator flap. Br J Plast Surg 56:180-183, 2003.
Autologous breast reconstruction with a perforator flap has become increasingly popular. This paper
presented the free lumbar artery perforator (LAP) flap as an option for breast reconstruction. Flap
harvest is easy, no muscle is sacrificed, and donor site morbidity is minimal. Anastomosis of the sensory
nerve to the fourth intercostal nerve is possible. The successful use of a LAP flap for breast reconstruc-
tion is illustrated with a case report, and the surgical technique is described. This method may be a
good alternative for patients with relative contraindications to breast reconstruction with a DIEP flap.
De Weerd L, Weum S. The butterfly design: coverage of a large sacral defect with two pedicled
lumbar artery perforator flaps. Br J Plast Surg 55:251-253, 2002.
The treatment of sacral pressure sores in ambulatory patients presents a challenge to the reconstructive
surgeon. The authors reported the successful use of two pedicled lumbar artery perforator flaps to cover
a sacral defect measuring 12 by 25 cm. Stable coverage was provided, with protective sensibility, ac-
ceptable contour, and minimal donor site morbidity, and additional functional loss of the gluteal muscle
was avoided. The configuration of the flaps resembles a butterfly.
Duteille F, Perrot P, Floch N, et al. Advantages of using intercostal vessels as the recipients for
free flaps covering lumbar defects. J Reconstr Microsurg 20:523-526, 2004.
Anatomic conditions in the lumbar region can complicate procedures for covering defects. In particular,
a free flap is often required when the defect is large, in which case suitable recipient vessels must be

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 690 Part II  Regional Flaps: Anatomy and Basic Techniques

found to ensure revascularization. The authors described the case of a 50-year-old woman with mul-
tiple basal cell carcinomas in the lumbar radiodermatitis zone who underwent a large resection from
D10 to S2. The defect was repaired using a free latissimus dorsi flap revascularized by microvascular
anastomosis to the eighth intercostal pedicle. The advantages of using these recipient vessels were then
considered relative to reports in the literature.
Feinendegen DL, Klos D. A subcostal artery perforator flap for a lumbar defect. Plast Reconstr
Surg 109:2446-2449, 2002.
Based on a previous clinical case report in which the pedicled subcostal artery perforator flap allowed
for the closure of a large defect of the lumbar region, the authors designed a study to investigate the
anatomy of the subcostal artery perforator flap and to evaluate its potential for wider clinical use. A
series of 14 human cadavers was studied, and 28 subcostal artery perforator flaps were dissected. The
location of the perforator vessel was charted against anatomic landmarks. Measurements included the
perforator caliber, pedicle length, and flap size after injection of methylene blue. The findings were
compared by Doppler sonography in 15 volunteers. The subcostal artery perforator was present in
all dissected specimens and in all volunteers. Its caliber measured a mean 2 mm. The location was
constant at the lateral border of the latissimus dorsi muscle and between 1 and 3 cm below the lower rib
end. The pedicle length reached a mean 10.5 cm when dissected up to the border of the erector spinae
musculature. The vascular supply covered a mean flap size of 10 by 14 cm. The in vivo investigations
confirmed the constant perforator location from the anatomic landmarks.
Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the inter-costal artery perforator
(ICAP) flaps. J Plast Reconstr Aesthet Surg 59:644-652, 2006.
The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different
pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They
are classified as dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery perforator
(LICAP); and anterior intercostal artery perforator (AICAP) flap. Between 2001 and 2004, 20
pedicled ICAP flaps were harvested in 16 patients. The indications were immediate partial breast
reconstruction in 8 patients who had a quadrantectomy for breast cancer; midline back and sternal
defects in 3 patients who had radical excisions for a dermatofibrosarcoma or malignant melanoma;
and autologous breast augmentation (4 bilateral and 1 unilateral flap) in 5 postbariatric surgery pa-
tients. The average flap dimension was 18 by 8 cm2 (range 8 by 5 cm2 to 24 by 12 cm2). There were
2 DICAP flaps, 2 AICAP flaps, and 16 LICAP flaps. All but two flaps were based on one per-
forator. Mean harvesting time was 45 minutes for a single flap. Bilateral breast augmentation with
LICAP flap necessitated longer operative time (range 2 to 3 hours), depending on whether it was
combined with mastopexy. Complete flaps survival was obtained. All donor sites were closed primarily.
Harris GD, Lewis VL, Nagle DJ, et al. Free flap reconstruction of the lower back and posterior
pelvis: indications, principles, and techniques. J Reconstr Microsurg 4:169-178, 1988.
Reconstructive microsurgery can be successfully applied to major defects of the lower back and posterior
pelvis. When present, the superior and inferior gluteal vessels can be excellent free flap recipient ves-
sels. However, if they are absent as a result of trauma or tumor ablation, a wrist carrier can be used
to transfer large blocks of tissue in a staged procedure. Five patients were presented with challenging
defects for which these techniques were used.
Kato H, Hasegawa M, Takada T, et al. The lumbar artery perforator based island flap: anatomi-
cal study and case reports. Br J Plast Surg 52:541-546, 1999.
A lumbar artery island flap can be elevated based on a single lumbar artery. The authors studied the
vascular anatomy using 21 specimens of lumbar arteries in 11 cadavers and investigated the skin
territory of the artery using fluorescein injection. They observed lumbar perforators emerging through
the lumbar fascia at the lateral border of the erector spinae muscle, situated 5 to 9 cm from the midline.

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 691

The diameter of the vascular bundle at the site of perforation ranged from 1 to 5 mm. Perforators of
the second and fourth lumbar arteries were much more developed than others. The cutaneous territory
supplied by the second lumbar artery extended from the posterior midline to the lateral border of the
rectus sheath, and at least 10 cm above the anterosuperior iliac spine. The authors transferred four
clinical flaps for coverage of ulcers on the lower back. All flaps survived and their donor site defects
were closed primarily. The authors stated that the cadaver dissection, injection study, and their clinical
success confirmed the feasibility of lumbar artery island flaps.
Kiil BJ, Rozen WM, Pan WR, et al. The lumbar artery perforators: a cadaveric and clinical
anatomical study. Plast Reconstr Surg 123:1229-1238, 2009.
The lumbar region has been scarcely explored as a donor site for free tissue transfer or as a free flap
recipient site. The lumbar integument provides a versatile prospective flap site, with a potentially
well-concealed scar. Similarly, defects of this region can require recipient vessels that may be difficult
to identify. Although lumbar artery perforators have been described, the reliability of perforators in
this region remains questionable. The authors undertook an anatomic study combining both cadaveric
and in vivo analysis of the lumbar vessels. The cadaveric component comprised both dissection and
angiographic studies in fresh and embalmed cadavers (36 lumbar regions in 18 cadavers), and the clini-
cal study comprised a CT angiographic study (44 sides in 22 patients) and an operative case report.
Perforators were shown to arise from all eight lumbar arteries to enter the lumbar integument, with
their size, location, and course described. Lower lumbar perforators were more often septocutaneous
and of larger caliber. A case in which the fourth lumbar artery and concomitant vein were used as free
flap recipient vessels was described, the first such reported case in the literature.
Lecours C, Saint-Cyr M, Wong C, et al. Freestyle pedicle perforator flaps: clinical results and
vascular anatomy. Plast Reconstr Surg 126:1589-1603, 2010.
The authors reported the cumulative experience with freestyle perforator flaps from two medical
centers (Hôpital Maisonneuve-Rosemont and University of Texas Southwestern Medical Center).
Fifty-three pedicled perforator flaps were performed on 49 patients for local reconstruction of a range of
defects at various anatomic locations: head and neck, anterior trunk, posterior trunk, perineal/gluteal,
lower limb, and upper limb. Complete flap survival was obtained in 48 of 53 flaps. Complications
included three cases of partial flap necrosis and two total flap failures, the latter in high-risk patients.
Complete primary closure of the donor site was possible in 37 cases, especially in the trunk. Twelve
patients had partial primary closure complemented by skin grafting, three cases required complete skin
grafting, and one donor site required another local flap for closure. Five clinical examples were given:
anterior trunk, posterior trunk, cervical region, lower limb, and upper limb.
Lui KW, Hu S, Ahmad N, et al. Three-dimensional angiography of the superior gluteal artery
and lumbar artery perforator flap. Plast Reconstr Surg 123:79-86, 2009.
Three-dimensional angiography was first proposed by Cornelius and advanced by Voigt in 1975.
Since then, a variety of improvements have been made. Three-dimensional evaluation of perforator
flaps is no longer a clinical curiosity but an absolute necessity. By combining three-dimensional digital
imaging and angiography, the authors developed a new three-dimensional technique for visualizing
blood vessels. This method produces a digitized model of the lumbar artery and superior gluteal artery
myocutaneous perforators that enables secure elevation of the lumbar and superior gluteal artery cross-
boundary perforator flap. Two cadavers were injected with whole-body lead oxide–gelatin. Spiral
CT scanning and three-dimensional reconstructions were performed. Six fresh bodies were used
and underwent latex injection. Specimens were then dissected by layers to document the individual
perforators. An average of five superior gluteal artery myocutaneous perforators with a diameter of
0.6 mm were present in the specimens. The average diameter and area supplied by perforators from the
lumbar arteries was 0.7 mm and 30 cm, respectively. The three-dimensional reconstructed model of the

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 692 Part II  Regional Flaps: Anatomy and Basic Techniques

lumbar region can display the modality, spatial location, and adjacent relationship of the lumbar and
superior gluteal arteries. Three-dimensional modeling of lumbar and superior gluteal artery perforator
flaps could provide greater insight into perforator anatomy in combination with traditional sectional
imaging. Three-dimensional reconstructive modeling is now a clinically available process that in the
future could provide great value in basic science investigation, clinical training, preoperative design,
and virtual surgical procedures.
Minabe T, Harii K. Dorsal intercostal artery perforator flap: anatomical study and clinical ap-
plications. Plast Reconstr Surg 120:681-689, 2007.
An anatomic study was conducted on five fresh human cadavers injected with a lead oxide–gelatin
mixture as a radiopaque agent. Angiographic studies were done to map the dorsal intercostal artery
perforators in detail. Each of the fourth to twelfth posterior intercostal arteries consistently supplied the
dorsal perforators. Those derived from the fourth, fifth, sixth, tenth, and eleventh posterior intercostal
arteries were the dominant direct cutaneous perforators. They were located within 5 cm of the spinous
processes of the vertebrae and were clinically detectable by Doppler probe preoperatively. Eleven dorsal
intercostal artery perforator flaps were applied in 10 cases. In 9 cases, the muscles of the latissimus
dorsi, trapezius, or scapular circumflex artery had been sacrificed in previous operations. The maxi-
mum flap dimension was 31 by 13 cm. All flaps showed stable postoperative blood circulation and
survived completely, except for marginal necrosis in the largest flap. No functional loss attributable to
flap harvest was recognized.
Mureau MA, Hofer SO. Perforator-to-perforator musculocutaneous anterolateral thigh flap
for reconstruction of a lumbosacral defect using the lumbar artery perforator as recipient vessel.
J Reconstr Microsurg 24:295-299, 2008.
Reconstruction of large-sized lumbosacral or sacral defects often is not possible using local or regional
flaps, making the use of free flaps necessary. However, the difficulty of any microsurgical procedure
in this region is complicated by the need to search for potential recipient vessels to revascularize the
flap. The authors described the use of a free myocutaneous anterolateral thigh flap to cover a large-
sized and deep lumbosacral defect. Arterial anastomosis was performed, connecting the cutaneous
ALT perforator to the perforator of the second lumbar artery. In this fashion, the arterial circulation
through the flap was flowing in a reverse direction through the muscle. The concomitant vein of the
descending branch of the lateral circumflex femoral artery was hooked up to the thoracodorsal vein
using a long interposition vein graft, because the perforator of the second lumbar vein was too small.
Postoperative healing was uneventful. A successful reconstruction of a lumbar defect has shown that
local perforators in the lumbar area may be accessible for easier perforator-to-perforator anastomoses
and that the muscular part of the myocutaneous ALT flap can survive on retrograde arterial perfusion
from a perforator of the skin island.
Offman SL, Geddes CR, Tang M, Morris SF. The vascular basis of perforator flaps based on
the source arteries of the lateral lumbar region. Plast Reconstr Surg 115:1651-1659, 2005.
Perforator flaps based on the integument of the trunk have been well described in the literature; however,
the anatomy of many donor sites has yet to be adequately documented. The integument of the lateral
lumbar region of the trunk is supplied by a number of source arteries (lower posterior intercostal, lumbar,
superior epigastric, deep inferior epigastric, superficial inferior epigastric, superficial circumflex iliac,
deep circumflex iliac) whose large perforators may be suitable for perforator flap harvest. The purpose
of the study was to describe the vascular anatomy of these perforators in the lateral lumbar region. A
series of five fresh human cadavers were studied using a lead oxide–gelatin injection technique. The
integument of the trunk (10 sides or hemitrunk specimens) was dissected, and the perforating vessels
(diameter 0.5 mm or larger) were identified, noting vascular origin, diameter, and pedicle length.
Radiographs of tissue specimens were digitally analyzed using Scion Image for Windows software to

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 Posterior Trunk  •  7D: Lumbar Perforator Flap 693

determine vascular territories. The source vessels contributed a summed mean of 33 perforators per
hemitrunk, with a mean emerging vessel diameter of 0.7 6 0.2 mm and a corresponding mean su-
perficial pedicle length of 31 6 24 mm. The total area of skin supplied directly by these 33 perforators
was 1200 cm2, equating to a mean area of 37 cm2 per perforator.
Roche NA, Van Landuyt K, Blondeel PN, et al. The use of pedicled perforator flaps for recon-
struction of lumbosacral defects. Ann Plast Surg 45:7-14, 2000.
Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in nonparaplegic
patients. Traditional options for closure include local rotation or transposition flaps and myocutaneous
flaps. However, these flaps are not an optimal option in previously irradiated or operated areas, or in
cases of large defects. Application of the perforator principle to the traditional myocutaneous flap cre-
ates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic
patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without
sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps.
The authors presented an anatomic overview of three types of pedicled perforator flaps: the superior
gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator
flap. They also reported four patients in whom a pedicled perforator flap was used to reconstruct a
large lumbosacral defect.
Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg
30:331-342, 2003.
An angiosome is a composite block of tissue that is supplied anatomically by source (segmental or
distributing) vessels that span between the skin and bone. In addition to supplying the deep tissues,
the source vessels of these angiosomes supply branches to the overlying skin, which pass either between
the deep tissues or through the deep tissues, usually muscle, to pierce the outer layer of the deep fascia,
usually at fixed skin sites. Hence perforator flaps, when dissected to the underlying source vessels,
involve tracing vessels either between the deep tissues, whether muscle tendon or bone, or through the
deep tissues, usually muscle.
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study
and clinical applications. Br J Plast Surg 40:113-141, 1987.
The blood supply to the skin and underlying tissues was investigated by ink injection studies, dissec-
tion, perforator mapping and radiographic analysis of fresh cadavers and isolated limbs. The results
were correlated with previous regional studies done in this department. The blood supply is shown to
be a continuous three-dimensional network of vessels not only in the skin but also in all tissue layers.
The anatomic territory of a source artery in the skin and deep tissues was found to correspond in most
cases, giving rise to the angiosome concept. Arteries follow closely the connective tissue framework of
the body. The primary supply to the skin is by direct cutaneous arteries which vary in calibre, length
and density in different regions. This primary supply is reinforced by numerous small indirect vessels,
which are “spent” terminal branches of arteries supplying the deep tissues. An average of 374 major
perforators was plotted in each subject, revealing that there are still many more potential skin flaps.
An arterial roadmap of the body provides the basis for the logical planning of incisions and flaps. The
angiosomes define the tissues available for composite transfer.
Zhao JT. Free iliac skin flap transplantation by anastomosing the fourth lumbar blood vessel.
Plast Reconstr Surg 77:836-842, 1986.
The author presented a cadaveric study of 44 fourth lumbar arteries, veins, and nerves. Dye injected
to the area of perfusion included profusion to the posterior iliac bone. At the lateral margin of the
sacrospinal muscle, the diameter of the artery was 0.8 to 1.8 mm; the accompanying vein was 0.8 to
2.4 mm, with two veins present in 42 of 44 specimens.

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 ANATOMIC LANDMARKS
Landmarks A large, flat, triangular muscle located in the superior aspect of
the back. Its wide area of attachments includes the base of the
skull, lateral shoulder, and thoracic vertebral column. Superiorly,
it is superficial to the levator scapula; inferiorly, it extends over
the superior edge of the latissimus dorsi muscle.
Size Muscle: 34 3 18 cm; skin: 10 3 22 cm with primary closure.
Origin External occipital protuberance, the medial third of the supe-
rior nuchal line of the occipital bone, ligamentum nuchae, and
spinous processes of C7 through T12.
Insertion Superior fibers, lateral third clavicle; middle fibers, spine of
scapula; inferior fibers, acromion.
Function Rotates the scapula and elevates the shoulder during full arm
abduction and flexion.
Composition Muscle, myocutaneous, or cutaneous.
Flap Type Type II.
Dominant Pedicle Transverse cervical artery.
Minor Pedicles Occipital artery, dorsal scapular artery, posterior intercostal
arteries.
Nerve Supply Motor: Spinal accessory nerve (eleventh cranial nerve). Sensory:
Sensory branches from the third and fourth cervical nerves and
posterior cutaneous branches of the intercostal nerve.

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 Section 7E
Posterior Trunk

Trapezius Flap

CLINICAL APPLICATIONS
Regional Use
Scalp
Head and neck
Oral cavity
Posterior trunk
Shoulder
Anterior trunk
Specialized Use
Midline back wounds

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 ANATOMY OF THE TRAPEZIUS FLAP

A B

Transverse
cervical artery

Perforating
intercostal
arteries

Anatomic landmarks of trapezius muscle Vascular supply

C
Intercostal
perforator nerves

Nerve supply

Fig. 7E-1 

Dominant pedicle: Transverse cervical artery

Minor pedicles: Dorsal scapular artery; perforating intercostal arteries

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 Posterior Trunk  •  7E: Trapezius Flap 697

ANATOMY
Landmarks This large, flat, triangular muscle is located in the superior aspect of the back.
Its wide area of attachments include base of skull, lateral shoulder, and inferior
thoracic spine.
Composition Muscle, myocutaneous, or cutaneous.
Size Muscle: 34 3 18 cm; skin: 10 3 22 cm with primary closure.
Origin External occipital protuberance, the medial third of the superior nuchal line of
the occipital bone, ligamentum nuchae, and spinous processes of C7 through T12.
Insertion Superior fibers, lateral third clavicle; middle fibers, spine of scapula; inferior
fibers, acromion.
Function Rotates the scapula; elevates the shoulder during full arm abduction and flexion.

Arterial Anatomy (Type II)

Dominant Pedicle  Transverse cervical artery
Regional Source  Thyrocervical trunk 80%; subclavian artery 20%.
Length  4 cm.
Diameter  1.8 mm.
Location  Posterior inferior neck and superior anterior margin of the muscle.
Minor Pedicle  Dorsal scapular artery (deep branch of transverse cervical artery)
Regional Source  Transverse cervical artery or subclavian artery.
Length  4 cm.
Diameter  1.6 mm.
Location  Perforates the rhomboid muscles and enters the distal portion of the trapezius muscle.
Minor Pedicle  Branch of occipital artery
Regional Source  External carotid artery.
Length  3 cm.
Diameter  1 mm.
Location  Adjacent to the muscle origin at the external occipital protuberance.
Minor Pedicle  Posterior intercostal arteries
Regional Source  Descending aorta.
Length  1 to 2 cm.
Diameter  0.5 mm.
Location  Vascular pedicles enter the muscle along the posterior midline adjacent to the cervical
and thoracic vertebral bodies.

Venous Anatomy
The transverse cervical artery is accompanied by a transverse cervical vein whose diameter at its
base is 2 mm. The dorsal scapular artery is accompanied by dorsal scapular vein with a diameter
of 2 mm at its origin. Branches of both the occipital artery and the intercostal arteries are accom-
panied by venae comitantes.

Nerve Supply
Motor Spinal accessory nerve (eleventh cranial nerve).
Sensory Sensory branches from the third and fourth cervical nerves and posterior cutane-
ous branches of the intercostal nerves.

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 698 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Trapezius Flap

A

Trapezius muscle

Rhomboid major muscle

Latissimus dorsi muscle

Superficial surface of trapezius

B C

Elevation of flap after release Closeup view of deep surface of

of fibers of origin from vertebral superior trapezius at base of neck
column and scapula

Fig. 7E-2 

Dominant pedicle: Transverse cervical artery with descending branch (D)

m3, Dorsal scapular artery

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 Posterior Trunk  •  7E: Trapezius Flap 699

D E

D
D

m1

m2

m3 m2 m2
m3 m2

m2

m2
m2
m2

Deep surface of flap Radiographic view

Fig. 7E-2 

Dominant pedicle: Transverse cervical artery (D)

Minor pedicles: Branch of occipital artery (m1); branches of posterior intercostal arteries
(m2 ); dorsal scapular artery (m3 )

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 700 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP HARVEST
Design and Markings
A line drawn from T12 to the acromion will outline the location of the trapezius muscle
for a muscle-only flap. A vertical incision can be made directly over the muscle to allow
its release and rotation to accomplish the reconstructive goal. For midline back wounds,
access can often be gained from the wound itself by elevating the overlying skin and sub-
cutaneous tissues.

A B

Vertical skin design Extended vertical skin design

C
Transverse
cervical artery

Extended lateral (cervicohumeral) flap design based

on ascending branch of transverse cervical artery

Fig. 7E-3 

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 Posterior Trunk  •  7E: Trapezius Flap 701

Patient Positioning
For back and posterior scalp applications, a prone position is preferred to facilitate dissection
and flap inset. For reconstruction of the head and neck and anterior chest, a lateral decubitus
position is preferred to allow both harvest and inset in the same position.

Prone positioning

Lateral decubitus positioning

Fig. 7E-4 

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 702 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The skin incision is made directly down to the overlying muscle, then wide elevation of
the skin and subcutaneous tissues off the muscle is performed. In the most common ap-
plication, for midline upper back wounds, the lateral border of the muscle is identified and
undermined. The origin of the muscle is released from the spinous processes from caudad
to cephalad. Once the vascular pedicle is visualized superiorly, the muscle can be divided
lateral to the pedicle, which allows rotation of the muscle in an open book fashion to cover
midline wounds. Care is taken to preserve the superior fibers of the trapezius as much as
possible to maintain shoulder function. For applications that include head and neck recon-
struction or when a long vascular pedicle is required, dissection proceeds to the origin of
the transverse cervical vessel with division of intercostal vessels. Once the vascular pedicle
is identified, the muscular attachments to the neck and occiput can be divided to create an
island flap that can then be passed through the neck to the face for reconstruction.

A B

Paramedian skin incision design Skin opened and

with ghosted muscle underneath muscle surface exposed

Fig. 7E-5 

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 Posterior Trunk  •  7E: Trapezius Flap 703

Incised edge of
trapezius muscle Remaining portion of
trapezius muscle

Transverse cervical
artery

Flap elevated and fully released

Fig. 7E-5 

FLAP VARIANTS
•  Myocutaneous flap
•  Dorsal scapular artery perforator flap
•  Extended lateral flap
•  Osseous flap
Myocutaneous Flap
Similar to other flaps of the back, a 9 to 10 cm wide flap can be designed with primary
closure of the donor site. If the skin paddle of the flap is designed over the territory of the
trapezius muscle, it will be well perfused. Most commonly used flaps are designed with a
vertical orientation, which extends the reach of the flap to the occiput and can be useful
for head and neck reconstruction when skin is required.
The surgeon should be careful not to go beyond the location of the muscle, because
the distal muscle and skin are supplied mainly by the dorsal scapular system, which is not
routinely included with the flap. Once the skin paddle has been planned, dissection begins
with incision of the skin paddle around its circumference and freeing of the skin and sub-
cutaneous tissues off the entire surface of the trapezius elsewhere. Inferiorly and laterally,
the edge of the muscle is identified and the muscle elevated, dividing its origin from the
spinous processes from caudad to cephalad. Dissection at this point proceeds similar to that
described earlier. If an extended skin paddle is required inferiorly, one must take care to
preserve the dorsal scapular perforator, which can be found on the deep surface of the muscle
piercing the rhomboid muscle. Incorporation of this vessel, which normally is supplied by
the transverse cervical artery as a deep branch, requires division of the rhomboid muscle.
A second option to capture this territory would be to perform a formal delay procedure
on a distal portion of the flap.

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 704 Part II  Regional Flaps: Anatomy and Basic Techniques

Dorsal Scapular Artery Perforator Flap

The dorsal scapular artery (DSA) perforator flap is based on the dorsal scapular artery,
which is the deep branch of the transverse cervical artery. It runs posteriorly in the neck
through the brachial plexus and then under the trapezius and levator scapular muscles to run
directly on the rib cage. At the medial angle of the scapula, the DSA gives off a superficial
branch that is the basis of the perforator flap. This branch pierces the rhomboid muscle and
enters the deep surface of the trapezius muscle, which it supplies. It then gives off cutaneous
perforators that supply the overlying skin paddle. This perforator can be located by Dop-
pler examination and usually enters the muscle within 2 cm of its lateral edge within the
middle third of the muscle vertically. Flaps as large as 20 by 20 cm have been harvested on
this perforator, but skin grafting would be required for donor site closure. Once the flap
is designed and its skin margins incised, dissection proceeds along the lateral border of the
trapezius muscle superficial to the deep fascia. Once the cutaneous perforator is identified,
it is followed deeply through the trapezius muscle. Once through the trapezius muscle, the
emergence of the vessel from the rhomboid is identified. Dissection then proceeds through
the rhomboid muscle where the deep branch of the DSA is identified. It is ligated distally to
allow further proximal dissection. All muscular branches to the levator scapula and omohyoid
are also ligated. Dissection of the vessels proceeds superiorly until adequate pedicle length
is available. The flap is used as a pedicle flap, but its use as a free tissue transfer is possible.

A B

2 cm

Trapezius muscle
8 cm Rhomboid
major muscle

Latissimus dorsi muscle

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.

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 Posterior Trunk  •  7E: Trapezius Flap 705

C D E

Fig. 7E-6 C, Cadaver specimen focusing on the left shoulder. The lower trapezius muscle was tran-
sected 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. (Dissection courtesy Claudio Angrigiani, MD.)

Extended Lateral Flap

The extended lateral flap is based on the ascending branch of the transverse cervical artery.
The flap is located over the lateral arm between the acromial clavicular joint and the lower
lateral third of the upper arm. Myocutaneous and direct fasciocutaneous pedicles at the
level of the acromial clavicular joint are not visualized during elevation of this flap. After
detachment of the trapezius fibers, which insert to the clavicle, one may visualize the as-
cending branch of the transverse cervical artery, but this is not required for elevation. After
the flap is designed, the incision is made around the skin island and the muscular fibers of
insertion into the joint are incised. The muscle is then elevated from lateral to medial, with
visualization of the deep surface of the trapezius muscle. From this viewpoint the ascend-
ing branch of the transverse cervical artery and veins are visualized and can be preserved.
Muscular fibers originating from the spine of the scapula are divided. The trapezius muscle
is divided at its junction of the upper and middle third of the muscle. The degree of the
division of the muscle is dictated by the reconstructive need. Because there are many other
less morbid flap choices with more acceptable donor sites, this variant of the flap is rarely if
ever used (see Section 6F, Supraclavicular Artery Flap).

Osseous Flap
An osseous component to the flap has been described for both the trapezius muscular flap
and the DSA perforator flap. The muscular flap uses its origin from the scapular spine,
whereas the dorsal artery perforator flap uses a branch of the DSA to the medial border and
tip of the scapula. Although isolated cases have been described, routine use of such flaps is
not recommended, because other more reliable and less morbid flaps exist.

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 706 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Muscle Flap
With the rotation point at the posterior base of the neck, the muscle will reach the posterior
skull, cervical and thoracic vertebral column, midface, and neck. Further lengthening is
possible by division of the superior muscle fibers, which allows the flap to reach the upper
third of the face.

POSTERIOR ARC for VERTICAL STANDARD FLAP POSTERIOR ARC for VERTICAL STANDARD FLAP

A B

Arc to vertebral column, posterior neck, Arc to face and anterior neck
and occipital skull

Fig. 7E-7 

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 Posterior Trunk  •  7E: Trapezius Flap 707

Myocutaneous Flap
A vertically oriented skin design overlying the trapezius muscle will have a similar arc of
rotation of the muscle. Extension of the flap can be gained by a delay procedure or inclusion
of the dorsal scapular vessels, as described.

Dorsal Scapular Artery Perforator Flap

Significant length can be obtained on the dorsal scapular perforator flap as an island flap.
When passed anteriorly through a clavicular incision, the flap can reach the anterior chest,
axilla, and lower face.

arc for dorsal scapular artery perforator flap

Arc of rotation with its long leash

Fig. 7E-8 

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 708 Part II  Regional Flaps: Anatomy and Basic Techniques

Extended Lateral Flap

With its rotation point at the acromial clavicular joint, this flap will reach the middle and
inferior thirds of the face, ear, and oral cavity.

ARC For EXTENDED LATERAL (CERVICOHUMORAL) FLAP

A B

Arc to inferior face (anterior trapezius Arc to superior face (superior trapezius
fibers to acromioclavicular joint intact) fibers of insertion elevated with flap)

Fig. 7E-9 

FLAP TRANSFER
Muscle Flap
For posterior midline defects, simple transposition of the muscle or an open-book movement
can be performed for reconstruction. For use in the anterior neck or head and neck, the
flap must be passed through a subcutaneous tunnel. The pedicle must not be compromised
with an inadequate tunnel.

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 Posterior Trunk  •  7E: Trapezius Flap 709

Myocutaneous Flap
For most defects of the back and posterior scalp, simple transposition of the flap is performed,
with care taken not to kink or compress the vascular pedicle. For use anteriorly in the head
and neck, the subcutaneous tunnel must be adequately sized to allow passage of the bulk
of the flap without compromising its integrity.

Dorsal Scapular Artery Perforator Flap

For posterior defects, simple transposition can be performed. For use anteriorly, the flap
is tunneled, with care taken not to put excessive tension on the vessels, which have been
freed from any muscular support and are more prone to sheer injury.

Extended Lateral Flaps

These flaps are transferred by local advancement or transposition. For some uses in the head
and neck, a two-stage approach may be used whereby initial attachment to the head and
neck is performed first, and division and inset is completed as a second stage.

FLAP INSET
All Variants
The flap must be supported deeply and tension minimized on the vascular pedicles. In cases
in which muscle is included with the flap and the flap is passed through a subcutaneous
tunnel, one should prepare for postoperative swelling of the muscle and ensure that the
tunnel is adequately sized to accommodate this.

DONOR SITE CLOSURE

Muscle Flap
The large dead space created should be adequately drained. Skin closure can be performed
without tension, because no skin has been removed.

Myocutaneous Flap and Dorsal Scapular Artery

Perforator Flap
Mobilization of the surrounding subcutaneous tissues should allow primary closure of the
back in flaps 10 cm or less, depending on the patient and the degree of skin laxity. Larger
flaps have been taken that also have allowed primary closure. When primary closure is not
obtainable, skin grafting can be performed.

Extended Lateral Flap

One downside to use of this flap is the need for skin grafting for the donor site. When a
two-stage reconstruction is planned, a portion of the flap may be returned to the donor
site to remove some of this skin-grafted area. The final cosmesis of this donor site is poor
compared with that of other available reconstructive flaps.

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 710 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 70-year-old man had undergone resection of a sarcoma of the postauricular scalp and
postoperative irradiation. He presented after a failed skin graft and exposure of the dura in
the wound. A trapezius myocutaneous flap was used to reconstruct the area.

C D E

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 myocutane-
ous 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.

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 Posterior Trunk  •  7E: Trapezius Flap 711

F G

Fig. 7E-10 F, Flap transposed through a generous subcutaneous tunnel. G, Flap inset without ten-
sion. Primary closure of the back was obtained. H, The patient is seen at 1-month follow-up. (Case
supplied by MRZ.)

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 712 Part II  Regional Flaps: Anatomy and Basic Techniques

This 56-year-old woman smoker had a chronic neck wound after cervical spine surgery
and exposure of her hardware. The wound persisted even after removal of the hardware.

A B

C D

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. (Case supplied by MRZ.)

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 Posterior Trunk  •  7E: Trapezius Flap 713

This 60-year-old man had recurrent squamous cell carcinoma of the scalp, multiple surgical
excisions, and a history of scalp irradiation.

B C

D E

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. (Case supplied by MRZ.)

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 714 Part II  Regional Flaps: Anatomy and Basic Techniques

This 63-year-old woman with an unclassified sarcoma of the cervical spine had been treated
by resection, dural reconstruction, and spinal stabilization with hardware. The spinal cord
and hardware were covered with a right trapezius muscle flap to minimize the risk of hard-
ware exposure, infection, and CSF leak. The transverse cervical pedicle was not visualized
or dissected in this case, but the arc of rotation of the muscle easily reached the nuchal line of
the head superiorly.

B C

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. (Case
courtesy David W. Chang, MD.)

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 Posterior Trunk  •  7E: Trapezius Flap 715

This 45-year-old man underwent resection of a recurrent synovial sarcoma of his cervical
spine. Bilateral trapezius muscle flaps were used to cover the dural repair and to cover and
wrap the hardware to minimize the risk of CSF leak, hardware exposure, and infection. The
cervical portion of both trapezius muscles had been previously irradiated and partially resected
at the current and previous operations.

A B

C D E

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. (Case
courtesy David W. Chang, MD.)

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 716 Part II  Regional Flaps: Anatomy and Basic Techniques

A defect resulted from resection of a Ewing’s sarcoma in this 18-year-old girl.

A B

C D

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. (Case
courtesy David W. Chang, MD.)

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 Posterior Trunk  •  7E: Trapezius Flap 717

This 68-year-old man presented with a third recurrence of a spindle cell sarcoma in the cervi-
cal spine with cord compression after multiple previous resections, free flap reconstruction,
and radiation therapy. Radical resection with stabilization of the spine with hardware was
performed.

B
A

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. (Case courtesy David W. Chang, MD.)

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 718 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The trapezius is a functional muscle, and its use in reconstruction can cause functional
disability, including shoulder weakness and shoulder droop. Preservation of the superior
fibers of the trapezius can help to minimize this morbidity. Using the DSA perforator
flap leaves all muscle intact and functional.
• Caution should be exercised in patients who have undergone previous neck surgery,
including radical neck dissection, because the transverse cervical artery may have been
ligated. In such cases, a preoperative arteriogram may be warranted, or a different donor
site can be used.
• Skin paddles are reliably carried in a superior two thirds of the muscle distribution; infe-
rior third perfusion is less reliable, and if critical for the reconstruction, inclusion of the
dorsal scapular vessel should be considered or the procedure should involve a preliminary
delay procedure.
• Postoperative shoulder immobilization can be helpful in reducing tension in the donor site.
• Because of the cosmetic deformity created at the donor site, the extended lateral flap
should be considered only when all other standard options are not possible.
• Although bone may be carried with different variants of the trapezius flap, other more
acceptable donor sites are available that produce much less morbidity to shoulder func-
tion, and these should be considered first.
• For use on the face, the trapezius flap has a poor color match and has thick dermis, which
may be less desirable for facial skin reconstruction.

EXPERT COMMENTARY
Pierre M. Chevray, Peirong Yu, David W. Chang

Indications
The trapezius muscle or myocutaneous flap may be useful in the reconstruction of defects
of the upper midback, the base of the neck, head and neck, and the shoulders. The flap is
generally used as a pedicled flap, based on its dominant blood supply, the transverse cervical
artery and vein. The muscle measures about 32 by 18 cm2, and the skin island supplied by
myocutaneous perforators may extend up to 10 cm beyond the inferior edge of the muscle as
long as at least one third of the skin overlies the trapezius muscle. If primary donor site closure
is desired, the width of the skin island generally should be less than 10 cm. However, a wider
skin island may be harvested while still allowing primary closure if a bilobed flap design is
selected (Fig. 7E-17).

Recommendations
Technique
With this design, the transverse extension of the bilobed flap assists in a V-Y closure of the
defect created by the larger, vertical component of the flap. To avoid disruption of the donor site
closure, anterior rotation or abduction of the shoulder should be minimized for 4 to 6 weeks
postoperatively. The donor site morbidity with the trapezius flap is minimal if the superior
4 cm of the muscle, the acromial attachment, and the spinal accessory nerve are preserved.

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 Posterior Trunk  •  7E: Trapezius Flap 719

The trapezius muscle is the most superficial muscle of the back, which makes elevation of
a trapezius muscle flap straightforward. The skin paddle of the trapezius myocutaneous flap
should be positioned largely over the muscle, which makes design and elevation of a trapezius
myocutaneous flap straightforward.

Fig. 7E-17  Bilobed flap design.

In most cases, the trapezius flap will be elevated as a vertical strip of muscle with or
without an overlying skin paddle for reconstruction of the occiput, posterior neck, and/or
the upper back. The critical step is to identify the location of the transverse cervical pedicle
vessels and divide the trapezius muscle lateral to the pedicle in a vertical direction to create a
strip of muscle which includes the pedicle vessels. The superior half of the muscle is usually
spared to prevent a shoulder drop and surface anatomy deformity. Therefore the transverse
cervical pedicle vessels are typically visualized and identified, but usually not dissected unless
extra flap length is required.
The standard trapezius muscle flap will reach the posterior neck up to the nuchal line. Ad-
ditional division of the superior portion of the muscle and dissection of the transverse cervical
pedicle allows the arc of rotation of the flap to be extended, at the cost of potential shoulder
drop and shoulder deformity. Use of an extended skin paddle can allow defects of the upper
scalp to be reached, as shown in Fig. 7E-12.

Take-Away Messages
A routine trapezius flap is straightforward to perform, but the extended flap is more difficult
to dissect, since it has to include the dorsal scapular artery. An extended flap may be needed
to reach the oral cavity or higher; the dorsal scapular artery becomes the limiting factor for
pedicle length and needs to be divided, making this flap less reliable. Because of the wide-
spread use of free flaps for head and neck reconstruction, the trapezius flap is now rarely used
for that purpose. However, it is still a useful flap to cover defects in the upper midback, base
of the neck, and shoulders.

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 720 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Bhathena HM. The caudal trapezius musculocutaneous flap. Plast Reconstr Surg 111:1355-1356,
2003.
Bhathena HM. Extended lower trapezius island myocutaneous flap in the repair of postburn
axillary contracture. Plast Reconstr Surg 116:1556-1557, 2005.
Chen WL, Chen ZW, Yang ZH, et al. The trapezius osteomyocutaneous island flap for recon-
structing hemimandibular and oral defects following the ablation of advanced oral malignant
tumors. J Craniomaxillofac Surg 37:91-95, 2009.
This study presented an effective repair method for the hemimandibular and oral defects produced during
the ablation of advanced oral malignant tumors. Nine patients (five males and four females ranging
in age from 18 to 74 years; mean age 51.3 years) with advanced oral malignant tumors were treated.
Trapezius osteomyocutaneous island flaps, including the acromion, spine, and part of the medial scapular
border were used to repair the hemimandibular and oral defects. No major flap failure occurred. Donor
site problems were minimal, with limited shoulder motion in all patients. The functional results in
terms of speech, swallowing, and facial contour were satisfactory. The patients were followed for 6 to
24 months (average 15.2 months): six of them are alive with no disease, two alive with disease; and
one died of a lung metastasis.
Chen WL, Deng YF, Peng GG, et al. Extended vertical lower trapezius island myocutaneous flap
for reconstruction of cranio-maxillofacial defects. Int J Oral Maxillofac Surg 36:165-170, 2007.
This study explored an effective method for repairing craniomaxillofacial soft tissue defects after radical
craniofacial surgery in four patients with malignant tumors involving the skull base and frontal region.
The large craniomaxillofacial soft tissue defects were reconstructed using an extended vertical lower
trapezius island myocutaneous flap based on the transverse cervical artery. The flaps were 8 to 12 cm
long and 5 to 7 cm wide. No major flap failure occurred, and there was no shoulder dysfunction. The
patients were followed for 3 to 12 months. One patient had a local recurrence, and another died of
lung metastasis 12 months postoperatively. The extended vertical lower trapezius island myocutane-
ous flap is a large, simple, reliable flap. It is preferred for reconstructing craniomaxillofacial soft tissue
defects when a pedicled flap is used following craniofacial surgery for cancer.
Chen WL, Li J, Yang Z, et al. Extended vertical lower trapezius island myocutaneous flap in
reconstruction of oral and maxillofacial defects after salvage surgery for recurrent oral carci-
noma. J Oral Maxillofac Surg 65:205-211, 2007.
This study explored an effective repair method for oral and maxillofacial soft tissue defects after sal-
vage surgery for patients with recurrent oral carcinoma. The study included eight patients (six women
and two men; mean age 56.9 years); four with recurrent oral squamous cell carcinoma of the tongue;
two with cancer of the oral cavity floor, and two with buccal carcinoma. The patients were treated
with salvage surgery, and the oral and maxillofacial soft tissue defects were reconstructed primarily by
extended vertical lower trapezius island myocutaneous flap. No flap failure occurred. The donor sites
were closed primarily. There were no disabilities with regard to shoulder motion. The patients’ survival
period was 6 to 30 months (average 13.1 months). There was one recurrent case.
Chen WL, Li JS, Yang ZH, et al. Extended vertical lower trapezius island myocutaneous flap
for repairing extensive oropharyngeal defects. J Oral Maxillofac Surg 67:1349-1353, 2009.
Chen WL, Yang ZH, Li JS, Huang ZQ. Reconstruction of the tongue using an extended
vertical lower trapezius island myocutaneous flap after removal of advanced tongue cancer. Br
J Oral Maxillofac Surg 46:379-382, 2008.
The authors explored an effective method to repair defects in the tongue that had been produced dur-
ing removal of advanced tongue cancers. Eighteen patients with advanced squamous cell carcinoma of
the tongue were treated. Extended vertical lower trapezius island myocutaneous flaps based on the
transverse cervical artery were used to repair more than half the tongue. No flap failed completely,

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 Posterior Trunk  •  7E: Trapezius Flap 721

and no shoulder movement was affected. The lingual contours were excellent. The functional results
in terms of speech and swallowing were satisfactory. The patients were followed for 6 to 24 months.
Three of them were alive with disease and two had died of local recurrence or metastasis at 18 and
20 months, respectively. The extended vertical lower trapezius island myocutaneous flap is a large,
simple, and reliable flap that is preferred for reconstruction of defects of the tongue after removal of
advanced tongue cancer.
Chen WL, Zhang B, Wang JG, et al. Reconstruction of large defects of the neck using an
extended vertical lower trapezius island myocutaneous flap following salvage surgery for neck
recurrence of oral carcinoma. J Plast Reconstr Aesthet Surg 64:319-322, 2011.
The authors described the extended vertical lower trapezius island myocutaneous flap for reconstructing
large defects of the neck. Eleven patients with neck recurrence of oral carcinoma were treated using salvage
surgery and an extended vertical lower trapezius island myocutaneous flap based on the transverse
cervical artery was used to repair the large defect in the neck. No major flap failure occurred. No dis-
abilities were observed in terms of shoulder motion. The patients were followed for 6 to 22 months.
Four patients developed local recurrence: two of them were still alive with the disease and two had died.
Chun JK, Lynch MJ, Poultsides GA. Distal trapezius musculocutaneous flap for upper thoracic
back wounds associated with spinal instrumentation and radiation. Ann Plast Surg 51:17-22, 2003.
Upper thoracic wounds with exposed hardware from spinal instrumentation and previous radiation
present a subset of back wound coverage problems that lend themselves to a unique opportunity to use
the distal trapezius myocutaneous flap. The unirradiated, healthy skin paddle can be transposed between
the irradiated skin edges to seal and cover the exposed hardware and achieve early primary healing
of the back wound without the need for a skin graft. The authors reviewed their series of upper back
radiated wounds reconstructed with the trapezius myocutaneous flaps, immediately at the time of the
spinal surgery and secondarily after the incisional wound breakdown, to cover the exposed hardware.
Their contiguous skin flap design strategy, results, and complications were discussed.
Disa JJ, Smith AW, Bilsky MH. Management of radiated reoperative wounds of the cervico-
thoracic spine: the role of the trapezius turnover flap. Ann Plast Surg 47:394-397, 2001.
Reoperation for malignant disease of the cervicothoracic spine can lead to compromised wound healing
as a result of poor tissue quality from previous operations, heavily irradiated beds, and concomitant
steroid therapy. Other complicating factors include exposed dura and spinal implants. Introducing
well-vascularized soft tissue to obliterate dead space is critical to reliable wound healing. The authors
conducted a retrospective review of all patients undergoing trapezius muscle turnover flaps for closure of
complex cervicothoracic wounds after spinal operations for metastatic or primary tumors. Six patients
(three men and three women) were operated over an 18-month period (mean age 43 years). Primary
pathologies included radiation-induced peripheral nerve sheath tumor (two), chondrosarcoma (one),
non-small-cell lung cancer (one), paraganglioma (one), and spindle cell sarcoma (one). Trapezius muscle
turnover flaps were unilateral and based on the transverse cervical artery in every patient. Indications
for flap closure included inability to perform primary layered closure, an open wound with infection,
and exposed hardware. All patients had previous operations of the cervicothoracic spine (mean 5.8
months; range 2 to 9 months) for malignant disease and prior radiation therapy. Exposed dura was
present in all patients, and two had dural repairs with bovine pericardial patches. Spinal stabilization
hardware was present in four patients. All patients underwent perioperative treatment with systemic
corticosteroids. All flaps survived, and primary wound healing was achieved in each patient. The only
wound complication was a malignant pleural effusion communicating with the back wound, which
was controlled with a closed suction drain. All wounds remained healed during the follow-up period.
Four patients died from progression of disease within 10 months of surgery. The trapezius turnover
flap has been used successfully when local tissue conditions prevent primary closure, or in the setting
of open, infected wounds with exposed dura and hardware. The ease of flap elevation and minimal
donor site morbidity make it a useful, single-stage reconstructive option in these difficult wounds.

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 722 Part II  Regional Flaps: Anatomy and Basic Techniques

Dumanian GA, Ondra SL, Liu J, et al. Muscle flap salvage of spine wounds with soft tissue
defects or infection. Spine 28:1203-1211, 2003.
The authors retrospectively studied the results of 22 patients treated for postoperative soft tissue defects
of the spine. In the literature, the treatment of postoperative spine infections is with serial debridement,
antibiotic irrigation catheters, drains, and occasional removal of spinal implants. Muscle flaps have
received scant mention in the surgical literature for spine coverage. The 15 patients in the authors’
group 1 had postoperative wound infections or dehiscences. Group 2 (seven patients) had “prophylac-
tic” flaps at the time of their initial spine surgery. The indications for “prophylactic” closure included
multiple prior surgeries, prior infection, and previous radiation therapy. Group 1 was treated with
drainage, dressing changes, and one-stage flap closure of their wounds. Sliding paraspinal muscle flaps
were the flaps of choice. Group 2 was treated with a variety of closure techniques at the time of their
initial surgery. The average defect size was 10 vertebral bodies long. Despite the large defect size,
19 of 20 surviving patients currently have healed wounds, and all patients have maintained their
instrumentation. Two patients died of causes unrelated to their wound problems. A group 1 patient
with complete loss of a superior gluteal artery flap was salvaged with a contralateral gluteus muscle
flap. Another group 1 patient had intermittent drainage from under a trapezius flap, which covered
a cervical spine fusion. Four patients had minor wound complications. Flaps are a useful adjunct in
the treatment of patients with complex spine wounds. Sliding paraspinal muscle flaps can effectively
close wounds from the high cervical to the low lumbar area in one operative procedure. These patients
can go on to successful spine fusion.
Elshaer WM. Extended lower trapezius island myocutaneous flap in the repair of postburn
axillary contracture. Plast Reconstr Surg 113:2076-2081; discussion 2082-2084, 2004.
Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius musculocutaneous flap from pedicled
to free flap: anatomical basis and clinical applications based on the dorsal scapular artery. Plast
Reconstr Surg 113:1580-1590, 2004.
A review of the literature showed that there is no uniform nomenclature for the branches of the subclavian
artery and the vessels supplying the trapezius muscle and that the different opinions on the vessels
supplying the pedicled lower trapezius myocutaneous flap lead to confusion and technical problems
when this flap is harvested. The authors attempted to clarify the anatomic nomenclature; they also
described exactly how the flap is planned and harvested and discussed the clinical relevance of this
flap as an island or free flap. They dissected both sides of the neck in 124 cadavers to examine the
variations of the subclavian artery and its branches, the vessel diameter at different levels, the course
of the pedicle, the arc of rotation, and the variation of the segmental intercostal branches to the lower
part of the trapezius muscle. Clinically, the flap was used in five cases as an island skin and island
muscle flap and once as a free flap. The anatomical findings and clinical applications proved that
there is a constant and dependable blood supply through the dorsal scapular artery (synonym for the
deep branch of the transverse cervical artery in the case of a common trunk with the superficial cervical
artery) as the main vessel. Harvesting an island flap or a free flap is technically demanding but pos-
sible. Planning the skin island far distally permitted a very long pedicle and wide arc of rotation. The
lower part of the trapezius muscle alone could be classified as a type V muscle according to Mathes
and Nahai because of its potential use as a turnover flap supplied by segmental intercostal perforators.
The lower trapezius flap is a thin and pliable myocutaneous flap with a very long constant pedicle
and minor donor site morbidity, permitting safe flap elevation and the possibility of free tissue transfer.
Hafezi F, Naghibzadeh B, Pegahmehr M, et al. Extended vertical trapezius fasciocutaneous
flap (back flap) in face and neck burn scar reconstruction. Ann Plast Surg 61:441-446, 2008.
Elevation of the skin along with its deep fascia vascular network is a recent addition to flap design. The
longitudinal trapezius fasciocutaneous flap was first introduced in 1996; at that time it did not receive
much attention, although it has many significant benefits compared with other available procedures.
Sixteen trapezius fasciocutaneous flaps were elevated in 15 patients for reconstruction of severe scar-
ring of the neck and midface. All flaps were based on the deep branch of the transverse cervical artery
and included the overlying fascia of the trapezius muscle. Delaying was applied for very long flaps.

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 Posterior Trunk  •  7E: Trapezius Flap 723

Two flaps developed minimal distal necrosis (less than 5 cm) because of longer pedicles (more than
10 cm below the muscle border). The results indicate that an extra-long back fascia flap based on the
descending branch of the transverse cervical artery could be formed, which would be long enough to
reconstruct the entire neck and safely transfer it to the midface. The vertical trapezius fasciocutaneous
flap, with its abundant tissue, excellent blood supply, anatomic proximity, wide arc of rotation, and
hidden donor site scar, provides a simple and reliable method for primary reconstruction of various
midface and neck defects.
Halvorson EG, Avram R, Disa JJ. The lower trapezius “reverse-turnover” flap. Plast Reconstr
Surg 122:45e-46e, 2008.
Since its introduction, the reverse-turnover latissimus dorsi flap has been established as a reliable muscle
flap for coverage of lower midspinal wounds. Based on its reversed secondary segmental blood supply, a
medially based flap can be turned over for coverage of midline posterior trunk defects. This same concept
is used when turnover pectoralis major muscle flap surgery is performed. It is now recognized that the
lower trapezius muscle has a dominant dorsal scapular pedicle and secondary segment pedicles arising
from the intercostal system. This article presents a novel use of the lower trapezius muscle as a reverse-
turnover flap, based on secondary segmental posterior intercostal artery perforators, for coverage of a
midline midthoracic wound.
Ihara K, Shigetomi M, Muramatsu K, et al. Pedicle or free musculocutaneous flaps for shoulder
defects after oncological resection. Ann Plast Surg 50:361-366, 2003.
Management of soft tissue defects of the shoulder was described. Extensive defects of soft tissues with
or without overlying skin were created after resection of sarcomas in five patients. Reconstruction was
performed using myocutaneous flaps, which included three pedicle latissimus dorsi and two free ten-
sor fascia lata flaps. Simultaneous functioning replacement of the defects of the trapezius and deltoid
muscles were each achieved in two patients. Primary wound healing was achieved, and each patient
recovered good contour of the shoulder. Functional results were satisfactory in all patients with an average
score of 93.4% using the system of the Musculoskeletal Tumor Society. The four functioning muscles
recovered active contraction in the transferred position. The shoulder elevation was normal in three
patients, and was 90 degrees and 30 degrees in one patient each. All patients remained disease free
at the time of latest follow-up. Thus shoulder defects of the soft tissues can be managed appropriately
with the two representative myocutaneous flaps.
Kneser U, Beier JP, Dragu A, et al. Transverse cervical artery perforator propeller flap for re-
construction of supraclavicular defects. J Plast Reconstr Aesthet Surg 64:952-954, 2011.
Propeller perforator flaps supplied by branches from the transverse cervical artery allow transport of
skin from the back region to supraclavicular defects. This article described a soft tissue defect following
resection of melanoma metastasis that was successfully reconstructed using a propeller flap based on a
perforator originating from the anterior part of the cranial trapezius muscle. This technique should be
considered as an alternative to commonly used muscle or myocutaneous flaps in selected cases.
Lynch JR, Hansen JE, Chaffoo R, et al. The lower trapezius musculocutaneous flap revisited:
versatile coverage for complicated wounds to the posterior cervical and occipital regions based
on the deep branch of the transverse cervical artery. Plast Reconstr Surg 109:444-450, 2002.
The clinical role of the lower trapezius myocutaneous flap varies in the literature. Many describe its
use in the reconstruction of the lateral neck and facial regions, but very few refer to its use in the pos-
terior cervical and occipital regions. Different vascular pedicles have also been described and effectively
used. A retrospective analysis was conducted, reviewing the authors’ experience with 13 patients with
complex open wounds to the posterior cervical and occipital regions that were treated with a lower tra-
pezius muscle or myocutaneous flap. All flaps were based on the deep branch of the transverse cervical
artery. This pedicle was used to support a relatively large skin segment over the distal portion of the
lower trapezius muscle, a margin that, in the authors’ experience, extends at least 1 cm beyond the
muscular margin. Postoperatively, patients were evaluated based on complications, residual shoulder
function, and aesthetic outcome. In addition to the clinical study, cadaveric dissection of the trapezius
muscle was conducted on 22 specimens, and the vascular anatomy was confirmed by direct visualiza-

07e_Trapezius_r5b_cah_0694-0725.indd 723 1/31/2012 9:52:58 AM

 724 Part II  Regional Flaps: Anatomy and Basic Techniques

tion. The authors’ experience indicates that the lower trapezius myocutaneous flap, when based on
the deep branch of the transverse cervical artery, provides a reliable alternative for the reconstruction
of complicated wounds in the posterior cervical and occipital regions, with the added capability of
providing richly vascularized tissue to compromised wounds as far cephalad as the vertex of the skull.
Mardini S, Chen HC, Salgado CJ, et al. Extended trapezius myocutaneous free flap for the
reconstruction of a foot defect lacking adjacent recipient vessels. J Reconstr Microsurg 20:599-
603, 2004.
Foot reconstruction requires tissue that is durable and can withstand the extremes of pressure and stress.
The trapezius myocutaneous flap had not been used previously as a free flap for foot reconstruction.
In this report, the trapezius was used as an extended myocutaneous free flap for the reconstruction of
a foot wound lacking adjacent and adequate recipient vessels. The extended trapezius flap may be
one of the longest free flaps that can be harvested. The indications for the use of this flap are limited.
In an extremity that lacks adequate recipient vessels adjacent to the defect, this flap can be extended
so that more proximal vessels in the leg can be used as the recipient vessels without the need for vein
grafts to bridge the distance. The donor site morbidity of this flap is minimal when the superior fibers
of the trapezius muscle and its innervation are preserved.
Rasheed MZ, Tan BK, Tan KC. The extended lower trapezius flap for the reconstruction of
shoulder tip defects. Ann Plast Surg 63:184-187, 2009.
Defects of the shoulder tip expose the glenohumeral and acromioclavicular joints and lead to scarring
and contractures. Well-vascularized cover is required to restore function and appearance. The latissimus
dorsi flap is commonly employed, but its use affects glenohumeral function, which is undesirable in
a patient with a shoulder weak from an underlying pathologic condition. The authors described the
extended lower trapezius flap for reconstructing the shoulder tip defects in three patients. This pedicled
flap was based on the dorsal scapular artery and included the lower trapezius muscle and a long infe-
rior fasciocutaneous extension. All flaps healed without complications, and all patients regained good
shoulder function, with full range of motion. One patient who developed a tumor recurrence was treated
with reexcision and latissimus dorsi flap reconstruction. The extended lower trapezius flap based on
the dorsal scapular artery is well suited for reconstructing shoulder defects. With its fasciocutaneous
extension, it has a long arc of rotation that is able to reach the shoulder tip. Shoulder morbidity is
low, since only the lower trapezius is detached, minimizing disruption to scapulothoracic function.
And because the latissimus dorsi is spared, glenohumeral function is not affected, and the option of
the latissimus dorsi flap remains available for future use.
Riedel K, Kremer T, Hoffmann H, et al. [Plastic surgical reconstruction of extensive thoracic
wall defects after oncologic resection] Chirurg 79:164-174, 2008.
In defect reconstruction after radical oncologic resection of malignant chest wall tumors, adequate soft
tissue reconstruction must be achieved along with function, stability, integrity, and aesthetics of the
chest wall. The authors retrospectively evaluated the oncoplastic concept following radical resection of
malignant chest wall infiltration with an interdisciplinary approach. Between 1999 and 2005, 36
consecutive patients (9 men and 27 women; mean age 55 years, range 20 to 78) were treated with
resection for malignant tumors of the chest wall. Indications were locally recurrent breast carcinoma,
thymoma, and desmoid tumor. Primary lesions of the chest wall were spinalioma, sarcoma, and non-
small-cell lung cancer. There were distant metastases of colon and cervical cancer in one patient each.
Soft tissue reconstruction was carried out using primary closure, an external oblique flap, a pectoralis
major myocutaneous flap, latissimus dorsi myocutaneous flap, vertical or transversal rectus abdominis
myocutaneous flap, free tensor fascia lata flap, trapezius flap, serratus flap, and one filet flap. In
15 reconstructive procedures microvascular techniques were used. On average, 3.4 ribs were resected.
Stability of the chest wall was obtained with synthetic meshes. The latissimus dorsi flap is considered
the flap of choice in chest wall reconstruction; however, alternatives such as the pectoralis major flap,
VRAM/TRAM flap, free TFL flap, and serratus flap must also be considered. Low mortality
and morbidity rates allow tumor resection and chest wall reconstruction, even in a palliative setting.

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 Posterior Trunk  •  7E: Trapezius Flap 725

Stillaert FB, Van Landuyt K. Stable coverage of a cervico-thoracic defect with an extended
lower trapezius myocutaneous flap. J Plast Reconstr Aesthet Surg 62:e101-e102, 2009.
Uğurlu K, Ozçelik D, Hüthüt I, et al. Extended vertical trapezius myocutaneous flap in head
and neck reconstruction as a salvage procedure. Plast Reconstr Surg 114:339-350, 2004.
In surgical treatment of head and neck cancer, when local tumor recurrence or failure of the previ-
ous reconstruction method occurs, reoperation for reconstruction of complicated soft tissue defects can
become a challenge for the plastic surgeon. The authors described their experience with the extended
vertical trapezius myocutaneous flap for head and neck complicated soft tissue defects in nine patients
ranging in age from 17 to 72 years. The causes of the defects were squamous cell carcinoma of the
external ear, lip, larynx, and oral cavity floor; congenital hemifacial atrophy-temporomandibular
joint ankylosis; synovial sarcoma at the mandibular ramus; and malignant fibrous histiocytoma at
the posterior cranial fossa. Eight of the nine patients had previously been operated on using other flap
procedures, including free flaps and/or distant pedicled flaps (pectoralis major and deltopectoral flaps).
One patient had been operated on using a graft procedure. After failure of the previous flap procedures
in four patients and tumor recurrence in five, the extended vertical trapezius myocutaneous pedicled
flap was used as a salvage procedure. The mean flap size was 7 by 34 cm. The flap was based solely
on the transverse cervical artery. Superior muscle fibers of the trapezius were preserved and the caudal
end of the flap was extended from 10 to 13 cm beyond the caudal end of the trapezius muscle. Three
weeks postoperatively, the pedicle was separated. No flap failure occurred. The donor sites were closed
primarily. There were no disabilities with regard to shoulder motion. Tumor recurrence was observed
in two patients. In conclusion, for complicated soft tissue defects of the head and neck, the extended
vertical trapezius flap can be preferred as a salvage procedure because it is a simple, reliable, large flap
that is located far enough from the damaged area.
Ulrich D, Fuchs P, Pallua N. Preexpanded vertical trapezius musculocutaneous flap for recon-
struction of a severe neck contracture after burn injury. J Burn Care Res 29:386-389, 2008.
Preexpanded flaps are a method to replace a larger postburn contracture area. The authors described the
use of a preexpanded vertical trapezius myocutaneous flap for reconstruction of a severe mentosternal
contracture in a 10-year-old boy with second- to third-degree burn wounds. A 500 cm3 rectangular-
shaped tissue expander was inserted under the trapezius muscle via a lateral incision in first stage.
Two months later, after serial expansion of the expander, the neck scar was excised. The preexpanded
flap (27 by 9 cm) was harvested and rotated into the defect. The donor site could be closed primarily.
The flap totally survived. The hospital stay was 7 days. After 6 months’ follow-up, a significantly
improved range of motion with good aesthetic outcome was achieved. The use of a preexpanded tra-
pezius flap can provide thin, large, and pliable tissue for reconstruction of a severe mentosternal scar
contracture with excellent functional outcomes.
Vacher C. The osteo-muscular dorsal scapular (OMDS) flap. Anatomic basis of a new pedicled
flap for mandibular reconstruction. Surg Radiol Anat 30:233-238, 2008.
The fibula free flap has become the dominant free flap for all mandible reconstructions, except in case
of severe peripheral vascular disease. In these cases the authors propose to use the pedicled osteomuscular
dorsal scapular flap as an alternative technique. This flap is an original technique, it is pedicled on
the dorsal scapular vessels with harvesting of the medial border of the scapula and the lateral part of
the rhomboid muscles. They carried out an anatomic study of the scapular region on 33 subjects to
describe the surgical landmarks of the dorsal scapular pedicle. They determined the feasibility of this
technique using ten fresh cadavers and performed this flap on three patients. In most cases (58%), the
dorsal scapular artery passed very close to the superior angle of the scapula and ran lateral to the medial
border of the scapula, in 42% of cases the artery divided into a lateral branch which stayed deep to the
medial border of the scapula and a medial branch which ran deep to the rhomboid muscles. In all cases
an anastomosis between the dorsal scapular artery and the descending branch of the transverse cervical
artery was present. In this technique, after harvesting the medial border of the scapula and the lateral
part of the rhomboid muscles, the flap is transposed in the cervical region through a tunnel under the
superior part of the trapezius. This technique was used in three patients after lateral resection of the
mandible. The functional results were good, allowing preservation of the scapular elevation.

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 ANATOMIC LANDMARKS
Landmarks A large, flat, triangular muscle covering the posterior inferior
half of the trunk. It extends from the humerus to the paraspinal
and iliac area.
Size Muscle: 25 3 35 cm; skin: 10 3 22 cm with primary closure.
Origin Lower sixth thoracic vertebrae, sacral vertebrae, supraspinal
ligament, and posterior iliac crest.
Insertion Medial lip of the bicipital groove of the humerus.
Function Adducts, extends, and rotates the humerus medially.
Composition Muscle, myocutaneous.
Flap Type Type V.
Dominant Pedicle Thoracodorsal artery.
Minor Pedicles Segmental paraspinal perforators; perforator of lumbar artery.
Nerve Supply Thoracodorsal nerve.

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 Section 7F
Posterior Trunk

Latissimus Dorsi Flap

CLINICAL APPLICATIONS
Regional Use
Head and neck
Thorax
Upper extremity
Abdomen
Distant Use
Head and neck
Trunk
Upper extremity
Lower extremity
Specialized Use
Intrathoracic reconstruction
Functional muscle transfer (upper
extremity, facial reanimation)

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 ANATOMY OF THE Latissimus Dorsi flap

Thoracodorsal artery

Branches
of lumbar
artery

Branches of posterior
intercostal artery

Arterial supply to the latissimus dorsi muscle

B Subscapular C
Subscapularis artery
muscle
Circumflex
scapular artery Upper
subscapular nerve

Posterior humeral Lower

circumflex artery subscapular nerve
Thoracodorsal nerve
(motor nerve) Branches of
Teres minor posterior
Thoracodorsal artery
muscle cutaneous
Teres major Lateral thoracic artery nerves
muscle Serratus branch of
thoracodorsal artery Branches
Latissimus dorsi of lateral
muscle Long thoracic nerve cutaneous
nerves
Serratus anterior muscle

Neurovascular anatomy of axilla Sensory innervation to overlying skin

Fig. 7F-1 

Dominant pedicle: Thoracodorsal artery

Minor pedicles: Segmental paraspinal perforators; perforator of lumbar artery

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 729

Anatomy
Landmarks A large, flat, triangular muscle covering the posterior inferior half of the trunk.
It extends from the humerus to the paraspinal and iliac area, passing below the
tip of the scapula. Its medial origin is deep to the trapezius muscle. The lower
portion of the muscle is superficial to the serratus posterior inferiorly and to the
serratus anterior muscles in the midthorax.
Composition Muscle, myocutaneous. It is the largest, most expendable muscle in the body.
Although the inclusion of the tenth rib has been described, this is not reliable in
most surgeons’ hands and is not recommended.
Size Muscle: 25 3 35 cm; skin: 10 3 22 cm with primary closure.
Origin A broad aponeurosis joining the posterior layer of the thoracolumbar fascia and
attaching to the spine of the lower sixth thoracic vertebrae, sacral vertebrae,
supraspinal ligament, and posterior iliac crest. The muscle also has some small
muscular slips of origin from the tenth, eleventh, and twelfth ribs, interdigitating
with the slips of origin of the external oblique and serratus anterior muscles. The
superior border of the muscle is largely free of attachments, with the exception
of the attachment to the scapula; the lateral border is a free edge in which the
deep surface merges with the underlying muscle fibers of the serratus anterior
muscle.
Insertion The muscle fibers converge to form the posterior fold of the axilla, adjacent to
the lower border of the teres major muscle. The broad muscular tendon then
inserts into the medial lip of the bicipital groove of the humerus.
Function The latissimus dorsi muscle adducts, extends, and rotates the humerus medially.
It is an expendable muscle, since function is preserved by the remaining syner-
gistic shoulder girdle muscles.

Arterial Anatomy (Type V)

Dominant Pedicle  Thoracodorsal artery
Regional Source  Subscapular artery.
Length  8.5 cm.
Diameter  2.5 mm.
Location  Enters the deep surface of the muscle in the posterior axilla 10 cm inferior to the muscle
insertion into the humerus. The vessel then bifurcates into a transverse (upper) and a descending
(lateral) branch that can be the basis for muscle splitting.
Minor Pedicle  Segmental paraspinal perforators
Regional Source  Perforators of the posterior intercostal arteries.
Length  1 to 2 cm.
Diameter  0.5 mm.
Location  Adjacent to the site of the muscle origin into the lumbar vertebrae (paraspinal).
Minor Pedicle  Perforator of lumbar artery
Regional Source  Lumbar arteries.
Length  1 to 2 cm.
Diameter  0.5 mm.
Location  Adjacent to muscle origin at lumbar vertebrae.

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 730 Part II  Regional Flaps: Anatomy and Basic Techniques

Venous Anatomy
Accompanying paired thoracodorsal veins and paraspinal venous perforators. The average diameter
of the thoracodorsal vein is 3.5 mm.

Nerve Supply
Motor The thoracodorsal nerve (C6 to C8) enters the muscle adjacent to a dominant
vascular pedicle within the posterior axilla.
Sensory The lateral cutaneous nerves arise from the intercostal nerves at the midaxillary
line, and the posterior branches supply the skin overlying the latissimus dorsi
muscle. These nerves are divided during flap elevation.

Vascular A natomy of the Latissimus Dorsi Flap

B

i
o

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.
Dominant pedicle: Thoracodorsal artery (D)
i, Insertion; o, origin

07f_LatDor_r4_bs_0726-0757.indd 730 1/31/2012 10:53:14 AM

 Posterior Trunk  •  7F: Latissimus Dorsi Flap 731

S2

S2

S2 o
D

D S2

S2
S1
S2
D

S2 S1

S1
S2

D
S2

S1
S1
S2

S2
S1

S1
S1
S2 S1

S2 S1
S2
S1

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.
Dominant pedicle: Thoracodorsal artery and venae comitantes (D)
Minor segmental pedicles: Lateral row: branches of posterior intercostal artery and vein
(S1); medial row: branches of lumbar artery and vein (S2)

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 732 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings
The skin paddle design should overlie the muscle for reliable perfusion. There are two basic
designs, depending on tissue requirements and donor scar location. The largest skin island
can be harvested in an oblique fashion; this is most useful in large reconstructions, chest
wall applications, and free flaps. For breast reconstruction, where scar location and aesthetics
are a priority, a transverse orientation is preferred to minimize the scar and carry a natural
tissue roll within the relaxed skin tension line. A fleur-de-lis design can increase the amount
of tissue harvested and still allow primary closure. In general, its use is not recommended,
because the donor scar and contour deformity from harvest are greatly increased.
With the patient standing or sitting, forceful contraction of the latissimus dorsi muscle
allows the anterior margin of the latissimus at the posterior axillary line to be visualized or
palpated and marked. The tip of the scapula is marked with the patient’s arms at the sides;
this denotes the superior margin of the latissimus dorsi muscle. The posterior vertebral col-
umn represents the posterior flap border. The posterior iliac crest is marked to determine
the inferior margin of the flap. (note: The inferior marking of a skin island is generally
8 cm superior to the posterior superior iliac crest.) The skin design is placed over the muscle
in an oblique or transverse design, as noted earlier.

A C

Vertical Transverse

Fleur-de-lis

Fig. 7F-3 

07f_LatDor_r4_bs_0726-0757.indd 732 1/31/2012 10:53:14 AM

 Posterior Trunk  •  7F: Latissimus Dorsi Flap 733

Patient Positioning
Several options are available for positioning the patient, depending on the reconstructive
application of the latissimus flap. Most commonly, a lateral decubitus position is used, be-
cause it facilitates a two-team approach and aids in closure of the skin in the myocutaneous
variant. It is critical to evaluate all areas of possible nerve compression and stretch to prevent
nerve injuries. A beanbag is helpful for holding the torso in the proper position, and an
axillary roll will prevent compression of the axilla. The arm may be draped in the field and
rested on a Mayo stand or other support device. Alternatively, the arm may be positioned
and draped off the field, especially if skin closure will not be an issue. In bilateral cases, it
may be easier to harvest both flaps with the patient in the prone position and bank them in
the axilla while changing the patient to a supine position for bilateral inset.

Stockinette

Axillary roll

Lateral decubitus position

Fig. 7F-4 

07f_LatDor_r4_bs_0726-0757.indd 733 1/31/2012 10:53:15 AM

 734 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

The area around the skin island is incised with a bevel away from the skin island, or a
direct cutaneous linear incision is made overlying the surface of the muscle. Initial dissec-
tion exposes the superficial surface of the muscle. Elevation extends over the limits of the
planned muscle dissection superiorly to expose the vascular supply and any skin tunnels
required for rotation.

Flap design

B
Latissimus dorsi muscle

Serratus
anterior muscle
Thoracodorsal nerve

Initial pedicle identification

Fig. 7F-5

The superior fibers of the muscle are located below the tip of the scapula. The up-
permost tendinous origin can be located under the inferior trapezius muscle fibers. These
superior medial fibers of origin are divided, and the latissimus muscle is separated from the
underlying paraspinous muscle fascia. Paraspinous perforators are ligated as the dissection
proceeds laterally. The inferior extent of muscle harvest is then delineated by dividing the
muscle inferiorly, taking care to separate the latissimus from the serratus posterior laterally
where it is fused.

07f_LatDor_r4_bs_0726-0757.indd 734 1/31/2012 10:53:15 AM

 Posterior Trunk  •  7F: Latissimus Dorsi Flap 735

The entire muscle is then elevated toward the axilla. When the serratus anterior muscle
is reached, the natural plane will carry the dissection deep to the serratus. This junction is
typically denoted with a fatty layer that must be entered to maintain the dissection super-
ficial to the serratus.

Perforating branch
of intercostal artery

External oblique
muscle
Latissimus dorsi
muscle rib origins

Distal incision of flap

Fig. 7F-5

Superior elevation of the muscle exposes its deep surface in the posterior axilla. The
thoracodorsal artery and vein are identified at the point of entrance into the muscle. The
thoracodorsal nerve joins the vascular pedicle higher in the axilla; it is large and readily
identified. If required, the tendinous insertion can be safely divided, because the neuro-
vascular supply is deep at this point. This maneuver is required for free flap transfer and
increases mobility for local advancement.

D Serratus posterior E
inferior muscle Teres major
Teres major muscle
Trapezius muscle
muscle
Ligated
intercostal
artery
perforators

Thoracodorsal
nerve

Thoracodorsal
artery
Lumbodorsal
External oblique
fascia
muscle
External oblique Serratus anterior
muscle muscle

Distal flap elevation Flap fully mobilized

Fig. 7F-5

07f_LatDor_r4_bs_0726-0757.indd 735 1/31/2012 10:53:15 AM

 736 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variants
•  Reverse flap
•  Muscle-sparing flap
•  Thoracodorsal artery perforator (TAP, TDAP) flap
•  Chimeric flap
•  Functional muscle transfer

Reverse Flap
The reverse flap is designed for transposition as either a complete or a segmental muscle flap.
A skin island can be carried if positioned over the muscle, usually over the superior third
of the muscle. For a complete muscle flap design, the superficial surface of the muscle is
exposed first. The muscle insertion is then divided within the axilla. After elevation of the
fibers of insertion, the thoracodorsal artery, paired venae comitantes, and nerve are identi-
fied and divided. As the deep lateral surface of the muscle is visualized, dissection proceeds
toward the midline of the posterior trunk. At 4 to 6 cm from the midline, the segmental
pedicles from the posterior intercostal and lumbar arteries are visualized and preserved.
The superior latissimus dorsi muscle fibers of origin are divided as required to obtain an
adequate arc of rotation to the defect. With division of the superior muscle fibers of origin,
the superior segmental pedicles are also divided as required. However, it is essential to
preserve the inferior segmental pedicles to the muscle flap.

A B

Muscle insertion and thoracodorsal Muscle transposed toward papaspinal perforators

pedicle divided of posterior intercostal and lumbar arteries

Fig. 7F-6 

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 737

Muscle-Sparing Flap
One can take advantage of the major divisions of the thoracodorsal blood supply and in-
nervation into transverse and longitudinal branches within the muscle and split the muscle,
sparing viable, innervated muscle at the donor site. The location of the division can often
be determined by inspecting the undersurface of the muscle (see p. 730) and splitting the
latissimus from distal muscle up to this point. This technique is advantageous when a large,
bulky flap with excess muscle is not required.

Thoracodorsal artery

Descending branch of
thoracodorsal artery
Transverse branch of
thoracodorsal artery

Latissimus dorsi
muscle
Section of muscle
harvested with flap

B C D

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. (Case courtesy Michel Saint-Cyr, MD.)

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 738 Part II  Regional Flaps: Anatomy and Basic Techniques

Thoracodorsal Artery Perforator (TDAP) Flap

The skin island normally carried with the latissimus flap can be isolated on a perforator of
the thoracodorsal artery as a TDAP flap, sparing the latissimus muscle completely. Although
morbidity from harvest of the latissimus muscle has not been well documented, some ap-
plications requiring less muscle bulk make this variant a reasonable flap choice.
Doppler identification of the perforators is possible but can be misleading, because
perforators run a variable distance on the muscle fascia before they supply the subcutaneous
tissues. The major perforators overlie the descending branch of the thoracodorsal artery
within the muscle.
Dissection starts laterally with identification of the lateral muscle border and proceeds
over the muscle. Care should be taken to look for a direct cutaneous branch of the thora-
codorsal vessels winding around the lateral muscle border. Once a suitable perforator complex
(artery and veins) is identified, the undersurface of the muscle should be locally exposed
to determine the appropriateness of the perforator and the subsequent pedicle length. The
more distal the perforator, the longer the pedicle length, and the longer the dissection. Mo-
tor nerves can be spared in this dissection. Lateral intercostal nerves can be harvested with
the flap to make it a sensate flap. The pedicle length can be as long as 14 cm, and the flap
can be used as a local rotation flap or as a free tissue transfer. As with the latissimus flap, a
chimeric flap containing other components of the subscapular axis is possible.

Axillary vessels
A

Thoracodorsal
artery
Thoracodorsal
perforator
B

Lateral intercostal
sensory nerves/
posterior ramus

Thoracodorsal
perforator

Fig. 7F-8  A and B, TDAP design. The perforators overlie the course of the thoracodorsal artery.

07f_LatDor_r4_bs_0726-0757.indd 738 1/31/2012 10:53:17 AM

 Posterior Trunk  •  7F: Latissimus Dorsi Flap 739

C D

Subscapular
artery and vein
Thoracodorsal
artery, vein, and nerve

Thoracodorsal
artery, vein,
Branch to and nerve Branch to serratus
serratus anterior muscle
anterior muscle Myocutaneous
perforator

Latissimus
Latissimus dorsi skin flap
dorsi skin flap

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
Flaps supplied by the subscapular axis of vessels (circumflex scapular and thoracodorsal)
can be harvested as combined flaps on one vascular pedicle. Here the latissimus muscle
can be combined with the serratus muscle on the thoracodorsal pedicle or can even be
combined with scapular/parascapular flaps by extending the dissection of the pedicle to
the subscapular vessels.
The muscle is elevated similar to a standard flap elevation. With the release of the muscle
origin from the thoracic and lumbar vertebrae, posterior ribs, and lumbosacral fascia, the
muscle is elevated superiorly toward the axilla. When the muscle’s deep surface is visualized,
the thoracodorsal pedicle is easily identified, allowing proximal pedicle dissection. For a
chimeric latissimus dorsi muscle and serratus flap, the serratus branch of the thoracodorsal
pedicle is maintained, and the serratus muscle flap is elevated as described for the serratus
muscle flap (see Section 6D). Pedicle dissection proceeds into the axilla to achieve adequate
pedicle length.

07f_LatDor_r4_bs_0726-0757.indd 739 1/31/2012 10:53:19 AM

 740 Part II  Regional Flaps: Anatomy and Basic Techniques

For inclusion of the scapular/parascapular tissues in the flap, the dissection proceeds
proximally to the takeoff of the circumflex scapular vessels. The scapular/parascapular
flap having been previously dissected (see Section 7C), it must now be passed through the
triangular space, often facilitated by division of the teres major muscle. The subscapular
artery and vein may be dissected to their respective junctions with the axillary artery and
vein to achieve maximum pedicle length.

Functional Muscle Transfer

The thoracodorsal nerve enters the latissimus dorsi muscle beneath its insertion in the
posterior axilla. Release of the fibers of origin allows transposition of a functional muscle
after restoration of a normal origin-insertion length-width relationship. The muscle may be
transposed to the upper extremity with reattachment of muscle origins to the arm to restore
either elbow flexion or extension. The muscle is also suitable for transposition to the ante-
rior chest wall to replace an absent (Poland’s syndrome) or injured pectoralis major muscle.

Arc of Rotation
Standard Flap
The point of rotation is located at the posterior axilla where the thoracodorsal pedicle enters
the muscle. The muscle then has a posterior arc of rotation to the neck and occipital and
parietal skull and across midline in the upper thorax. The anterior arc of rotation includes
the ipsilateral chest and sternum, middle and lower thirds of the face, and superior abdo-
men. The standard arc of rotation is extended approximately 5 to 10 cm by division of the
latissimus dorsi tendinous insertion and mobilization of the vascular pedicle (i.e., a division
of the branch to the serratus anterior muscle and branch of the circumflex scapular artery).

Lateral Arc of Standard Flap

A B

Arc to posterior upper extremity Arc to anterior upper extremity

Fig. 7F-9

07f_LatDor_r4_bs_0726-0757.indd 740 1/31/2012 10:53:19 AM

 Posterior Trunk  •  7F: Latissimus Dorsi Flap 741

Anterior Arc of Standard Flap

C D

Arc to anterior thorax with insertion intact Arc after release of insertion

Fig. 7F-9

Posterior Arc of Standard Flap

E F

Arc to posterior thorax with insertion intact Arc after release of muscle insertion

Fig. 7F-9

07f_LatDor_r4_bs_0726-0757.indd 741 1/31/2012 10:53:20 AM

 742 Part II  Regional Flaps: Anatomy and Basic Techniques

Reverse Flap
After the dominant vascular pedicle is divided, the point of rotation is along the lateral
and/or medial row of minor pedicles. The muscle will then reach across the midline of
the posterior trunk. Standard reverse rotation involves division of the humeral insertion,
sacrifice of the thoracodorsal bundle, and transposition of the muscle like an open book.
The muscle will survive based on its paraspinal perforators from the posterior intercostal
and lumbar arteries.

Posterior Arc of Reverse Flap

A B

Reverse flap insertion divided Reverse flap rotated

Fig. 7F-10
An alternative to flap elevation when muscle requirements are not so great (such as
exposed hardware) involves midline release of the latissimus fascia only. This allows mo-
bilization of the muscle for a few centimeters without division of the thoracodorsal bundle
or paraspinal perforators, maximizing the blood supply and minimizing morbidity. It also
allows secondary use of the latissimus muscle, if needed later.

Posterior advancement standard Flap

C D

Arc to posterior trunk

Fig. 7F-10

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 743

Flap Transfer
Standard Flap
The muscle reaches the superior abdomen and anterior chest wall through a subcutaneous
tunnel between the donor and recipient sites. The latissimus muscle will reach the head
and neck region through a subcutaneous tunnel between the recipient site and the lateral
clavicle. The arc of rotation can be improved by tunneling under the pectoralis major
fibers laterally. For defects over the mediastinum, the tunnel will extend beneath the skin
and either superficial or deep to the pectoralis major muscle, if this muscle is still present.
For intrathoracic defects, resection of the second or third rib segment at the midaxil-
lary line allows the muscle to enter the superior mediastinum. A similar window in the
fifth to sixth intercostal space will allow muscle transposition into the middle and inferior
mediastinum when less muscle is available. The chimeric serratus with latissimus flap can
add needed intrathoracic volume.

Reverse Flap
The reverse flap is designed directly adjacent to the defect and does not require a separate
tunnel for transposition into the posterior trunk defect. A complete muscle flap can be used
without a skin island. The muscle is advanced like opening a book, with the superficial sur-
face of the distal muscle flap facing into the deep surface of the defect. If a complete muscle
flap is used with a skin island, it is generally necessary to rotate the flap without kinking;
planning the orientation of the skin island dictates how much rotation will be necessary.

Flap Inset
Pedicle Flap
The rotated flap should be inset without tension, evenly distributing the muscle. If the flap
reaches the defect without division of the tendinous insertion, this attachment should be
left to protect inadvertent tension on the pedicle. The tunnel must be wide enough that
there is no compression of the pedicle postoperatively. Division of the thoracodorsal nerve
should be considered if muscular contraction postoperatively would adversely affect heal-
ing. The nerve is maintained for functional transfer and in cases in which the bulk of the
muscle needs to be maintained.

Free Flap
Inset of the muscle is relative to the pedicle and the microvascular anastomosis. It is recom-
mended that the muscle be inset on some tension to re-create near-original dimensions,
which will improve blood flow through the flap. For a TDAP inset, no muscle is available
to anchor the flap, and the flap must be carefully secured to its recipient site with superficial
fascia and dermis.

Donor SiTE Closure

All Flap Variants
Direct donor site closure is recommended. Correct planning can avoid the use of skin grafts,
which result in contour defects. A skin island 7 to 9 cm wide will generally permit primary
closure. Wider islands can be closed directly in selected patients, depending on the amount
of skin laxity. The contour defect in the back is minimal after removal of the latissimus dorsi
muscle. The initial fullness seen in the reverse flap settles with time. Upper arm abduction
and medial rotation are preserved by the remaining shoulder girdle muscles, including the
pectoralis major, subscapularis, teres major, and coracobrachialis muscles.

07f_LatDor_r4_bs_0726-0757.indd 743 1/31/2012 10:53:22 AM

 744 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 44-year-old patient had a previous TRAM flap reconstruction of the left breast and
an implant reconstruction of the right breast that was contracted; her breasts did not match,
even in a bra.

A B

C D E

Fig. 7F-11  A, The patient requested autologous-only reconstruction for the right breast. B, A myo-
cutaneous 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. (Case supplied by MRZ.)

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 745

This 50-year-old woman was diagnosed with an invasive right breast cancer. She had
symptomatic macromastia and desired a contralateral reduction. She was offered an autolo-
gous reconstruction with a myocutaneous latissimus flap to match the reduced breast. The
amount of reduction was determined intraoperatively based on the amount of latissimus
tissues transferred.

A B

C D

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, maximiz-
ing 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. (Case supplied by MRZ.)

07f_LatDor_r4_bs_0726-0757.indd 745 1/31/2012 10:53:32 AM

 746 Part II  Regional Flaps: Anatomy and Basic Techniques

This 39-year-old woman had a history of right breast cancer and previous pedicle TRAM
flap reconstruction. She presented with a radiation-induced sarcoma of the chest. In this
case, all abdominal options had been exhausted. Normally, we would consider the latissimus
dorsi or the omentum as rotational options, but there was not enough tissue for such a large
defect. The largest available block of tissue was a chimeric flap, harvesting the latissimus
and the serratus on their common blood supply. A large chimeric flap from the leg would
also have been possible, but deforming. Here the chimeric flap, transferred as a free flap to
the neck vessels, provided adequate tissue, bolstered with nearby omentum in a vest-over-
pants fashion. The key in this case was supplying an adequate amount of well-vascularized
tissue to accomplish the reconstruction.

A B C

D E F

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 in-
ferior portion of the wound, all of which was skin grafted. F, Postoperative appearance at 6 months,
with no bulges or hernias. (Case supplied by MRZ.)

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 747

This 4-year-old boy was injured in a lawn-mower accident. Heel reconstruction can be
managed with regional flaps (such as sural) or free flaps. Free flaps can be skin based (for
example, the radial forearm) or muscle based, with skin or skin grafting to the muscle.
There are advantages and disadvantages to all approaches and vocal supporters for each
technique. In this case, a myocutaneous latissimus free flap was chosen to minimize donor
site morbidity and to provide as durable a reconstruction as possible. It is not uncommon
to need revisional procedures to allow normal shoes to be worn and to improve cosmesis,
especially in areas where the pedicle was left bulky at the first operation.

A B

D E

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 de-
bulked. E, Three months after debulking. (Case supplied by MRZ.)

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 748 Part II  Regional Flaps: Anatomy and Basic Techniques

This 34-year-old woman underwent tissue expander reconstruction. Although she did not
receive radiation therapy, her mastectomy skin became thin, and ultimately her expander
was exposed. Options at this point included removal of the expander and closure, with
ultimate reinsertion of a tissue expander with or without the use of acellular dermal matrix,
conversion to autologous-only reconstruction, or salvage of the expander with a latissimus
myocutaneous flap. She underwent latissimus salvage, during which we took the opportu-
nity to remove all suspect thin skin and “patch” the area with muscle cover and adequate
skin from the back. Notice how the flap design allows the donor scar to be well hidden in
her clothes. This flap is advantageous also for partial breast reconstruction when the partial
mastectomy defect can be “patched” with a rotational latissimus dorsi flap.

A B

C D E

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. (Case
supplied by MRZ.)

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 749

Pearls and Pitfalls

• The latissimus dorsi is an expendable muscle in patients with intact, synergistic shoulder
girdle muscles. However, in patients with contralateral shoulder girdle paralysis (such as
after a craniectomy for tumor extirpation) or extremity paralysis from spinal cord injury,
the latissimus dorsi muscle function may be essential. Alternative flap choices should be
considered.
• Denervated latissimus dorsi muscle has thin, pale muscle fibers, even though the intramus-
cular vascular system is intact. Dissection is initiated on the inferior aspect of the proposed
island to identify the underlying muscle. Inadvertent incision through the muscle will
not injure the proximal muscle circulation and allows the surgeon to alter the plane of
dissection to preserve the superior muscle with the flap vascular pedicle.
• The serratus branch to the latissimus dorsi should not be divided until the proximal
subscapular–thoracodorsal artery and vein are identified. If the proximal thoracodorsal
artery and vein have been divided previously, the muscle will survive transposition based
on the serratus muscle branches with retrograde blood flow. The flap will reach the an-
terior chest for chest wall or breast reconstruction if dissection is limited proximally to
this branch point.
• During the initial muscle dissection, care is taken to separate the latissimus muscle from
the superficial surface of the scapula and its associated serratus anterior muscle. Failure to
maintain the dissection superficial to the scapula may result in elevation of the latissimus
muscle with the underlying serratus anterior muscle. This zone of fusion is heralded by
a fatty plane that must be entered.
• If the tendon of insertion is divided, only the dominant vascular pedicle will limit the
arc of rotation. Excessive tension on the muscle flap may disrupt the vascular pedicle, so
the muscle and tendon must be carefully resecured after transfer.
• The tunnel should have adequate dimensions to prevent flap compression. In general, the
space available should be twice the volume of the flap located within the tunnel between
the donor site and the site of flap inset.
• Precise identification of the segmental vascular pedicles is essential during reverse latissimus
myocutaneous flap transposition. If time permits, an initial delay procedure involving
division of the thoracodorsal pedicle can be performed 2 weeks before harvest.
• A pillow holding the elbow in a position of shoulder abduction will prevent pedicle
compression postoperatively when transposition is to the anterior chest or head and neck.
• Seroma in the back donor site is common, and a minimum of two large drains is rec-
ommended for 2 weeks, or until the drainage is less than 25 ml per day. Tissue glue and
sequential sutures have been used by some to minimize this complication.
• The latissimus dorsi flap is the flap of choice when pediatric free tissue transfer is needed
for reconstructive challenges requiring a large flap with low morbidity.

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 750 Part II  Regional Flaps: Anatomy and Basic Techniques

Expert Commentary
Michael R. Zenn

Indications
The latissimus dorsi flap is one of the most versatile flaps available to reconstructive surgeons.
It is both the largest muscle and the most expendable, and has for decades proved to be a
valuable donor site both as a pedicled flap and a free flap. Although the anatomy and the
varied uses of the flap are well outlined in this chapter, variations do exist in the harvest
of the muscle. I would like to point out one of the more valuable ones I use routinely in
breast reconstruction.

Anatomic Considerations
The goal in breast reconstruction with a latissimus flap is delivery of the muscle and a skin
paddle with minimal scar morbidity in the back. In women undergoing breast reconstruc-
tion, that means a scar that will not be visible in most clothes. I favor the low transverse
pattern of skin design, centered between the scapular tip and the posterior iliac crest, along
the relaxed skin tension line. If there is a roll of excess fat in the back, it is usually here.
The problem with this skin design is that it limits exposure in the upper third dissection,
where pedicle identification is essential and full release is required for an adequate arc of
rotation to the chest.

Recommendations
Technique
In breast reconstruction I like to start the dissection of the latissimus from the chest recipi-
ent site with a lighted retractor, but certainly a headlight or endoscope would work just as
well. The subcutaneous tunnel from recipient to donor site is marked and dissected. This
dissection plane will take the dissection naturally on the serratus anterior muscle before
the lateral border of the latissimus muscle is reached. I follow this plane, which leads under
the latissimus muscle, and within 3 cm the thoracodorsal pedicle can be seen, distal to the
serratus branch of the thoracodorsal vessels.
Once past these vessels, it is an easy dissection in areolar tissue completely underneath
the latissimus to the medial border, where the subcutaneous plane is reestablished, releas-
ing the muscle medially. Next, the dissection is turned inferiorly, where the latissimus is
separated from the serratus anterior under direct vision as far as possible until visualization
becomes difficult. The lighted retractor is removed, and dissection of the anterior surface
of the muscle is quickly and easily performed. Care must be exercised not to undermine
the intended skin paddle. When a two-team approach is used, the superior skin paddle is
incised first to prevent this, and the remainder of the time is spent dissecting the distal flap
so that both teams can finish about the same time, cutting harvest time in half.

Take-Away Messages
This flap design, degree of dissection, and arc of rotation allow the flap to easily reach the
anterior chest for breast reconstruction. This also preserves the important serratus branch
of the thoracodorsal vessels, which are able to supply the flap by retrograde flow when the
thoracodorsal vessels have been divided during axillary lymph node dissection. The scar
quality and placement are excellent.

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 751

Bibliography With Key Annotations

Bailey S, Saint-Cyr M, Zhang K, et al. Breast reconstruction with the latissimus dorsi flap:
women’s preference for scar location. Plast Reconstr Surg 126:358, 2101.
The authors reported study to assess women’s preference for the latissimus dorsi donor site location,
the reasons for donor site choice, and the correlation between donor site location preference and factors
such as age, body mass index, body image, and clothing options. Two hundred fifty women between
20 and 80 years of age were surveyed. Participants analyzed patients’ pictures and ranked the scar
locations from most desirable to least desirable. The reason for their preference and additional factors
were assessed. The data were then collected and analyzed. The low and middle transverse donor sites
were the most preferred sites, 54% and 22%, respectively. The most common reasons for choosing a
donors site were ability to conceal the scar in a low-back top and contour improvement. Women younger
than 50 years were more concerned about the ability to conceal the scar (64%). Women older than 50
years were focused on contour improvement (40%) and concealing the scar while clothed (42%). No
direct correlation with age, body mass index, body image, or clothing options was seen.
Barton FE Jr, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myo-
cutaneous flap: anatomic observations and report of 60 cases. Plast Reconstr Surg 71:199, 1983.
A latissimus dorsi myocutaneous flap was used in 60 patients for immediate reconstruction following
head and neck tumor ablation. The distribution of surgical defects was as follows: floor of mouth (22),
retromolar trigone (11), pharyngeal wall (9), segmental esophagus (9), temporozygomatic (7), and
full-thickness cheek (2). The flap was routinely tunneled beneath the pectoralis major and superficial
to the pectoralis minor and clavicle to reach the head and neck defect. The authors recommend design
of the skin island on the superior two thirds of the muscle surface for best blood supply. A small skin
island located over the inferior third of the muscle may not have adequate circulation following trans-
position to the head and neck region.
Buntic RF, Horton KM, Brooks D, et al. The free partial superior latissimus muscle flap: pres-
ervation of donor-site form and function. Plast Reconstr Surg 121:1659, 2008.
The authors presented a series of 13 cases of partial superior latissimus flap, which has the following
advantages: (1) small or medium size, (2) large-caliber vessels, (3) a potentially long vascular pedicle,
(4) preservation of the majority of the latissimus muscle in situ, (5) preservation of the dorsal thoracic
silhouette of the back, (6) the potential for neurotization and sensory or functional muscle reconstruc-
tion, and (7) use as a myocutaneous flap by including the overlying skin territory.
Chike-Obi CJ, Feldman EM, Friedman JD. The extended latissimus dorsi musculocutaneous
flap in postmastectomy breast reconstruction: indications and technical considerations. Plast
Reconstr Surg 124:100, 2009.
The authors presented a study to assess a single surgeon’s technique and outcomes with the extended
latissimus dorsi myocutaneous flap. Patients who underwent unilateral or bilateral, delayed or immediate
extended latissimus breast reconstruction were included in this retrospective study. Epidemiologic data,
tumor diagnosis, mastectomy type, length of hospital stay, flap complications, donor site complica-
tions, and length of follow-up were recorded and analyzed. Flap design consisted of a near-transverse
elliptical skin paddle, the latissimus muscle, and the fat pad deep to the superficial thoracic fascia and
overlying the latissimus muscle. Twelve reconstructions were performed in 10 patients, with bilateral
reconstructions in 2 patients. Eight were immediate, and 4 delayed. Mean patient age was 60 years
(range 47 to 77 years). Mean body mass index was 33.2 kg/m2 (range 25.2 to 40 kg/m2). Four
patients received adjuvant radiation therapy before breast reconstruction. The mean skin paddle area was
22.3 by 8.6 cm (192.3 cm2). The mean follow-up was 20.6 months. Flap complications developed

07f_LatDor_r4_bs_0726-0757.indd 751 1/31/2012 10:53:45 AM

 752 Part II  Regional Flaps: Anatomy and Basic Techniques

in 2 of 12 flaps (16.7%); both were partial flap losses requiring reoperation. Donor site complications
developed in 8 of 12 donor sites (66.7%). The most common donor site complication was seroma
formation. Partial mastectomy skin flap necrosis occurred in 5 patients. The extended latissimus dorsi
myocutaneous flap can provide total autologous breast reconstruction in select cases, specifically in
women who are poor candidates for implant-based reconstruction and in those with contraindications
to an abdominal flap. Safe, large-volume breast reconstruction is possible by harvesting a flap that
includes only fat tissue directly overlying the latissimus muscle.
Durkin AJ, Pierpont YN, Patel S, et al. An algorithmic approach to breast reconstruction using
latissimus dorsi myocutaneous flaps. Plast Reconstr Surg 125:1318, 2010.
Innovative surgical techniques developed by surgical oncologists have changed the landscape of mas-
tectomy defects. Latissimus dorsi myocutaneous flap–based breast reconstruction provides a reliable
foundation for breast reconstruction. The authors presented a study evaluating differential skin island
designs with latissimus dorsi myocutaneous flap breast reconstruction and provided an algorithmic
approach to breast reconstruction that is applicable to a broad spectrum of mastectomy defects.
Elliot D, Lewis-Smith PA, Piggot TA. Case report: the expanded latissimus dorsi flap. Br J
Plast Surg 41:319, 1988.
The latissimus dorsi myocutaneous donor site was preexpanded with a 1000 mm oval tissue expander.
Expansion was completed in 12 weeks. A large skin island was subsequently used with the underly-
ing latissimus dorsi muscle for coverage of an anterior chest wall mastectomy defect with previously
placed skin grafts. The donor site was closed directly without the necessity for skin grafts. The authors
recommended preexpansion of myocutaneous flaps if direct closure of the donor site may not be possible.
Elliott LF, Ghazi BH, Otterburn DM. The scarless latissimus dorsi flap for full muscle coverage
in device-based immediate breast reconstruction: an autologous alternative to acellular dermal
matrix. Plast Reconstr Surg 128:71, 2011.
Thin patients have fewer autologous options in postmastectomy reconstruction and are frequently
limited to device-based techniques. The latissimus dorsi flap remains a viable option with which to
provide autologous coverage, although for certain patients the donor scar can be a point of contention.
The scarless latissimus dorsi flap is a way of mitigating these concerns. The authors presented their
6-year single-surgeon experience with scarless latissimus dorsi flap reconstruction. Charts from 2003
to 2009 were reviewed for demographic characteristics, nonoperative therapies, and short- and long-
term complications. Results were compared with historical data. Thirty-one patients with 52 flaps
were identified. Fifty-one flaps were immediate reconstructions; these patients had an average age
of 47 years and BMI of 22.8. Thirteen patients were treated with chemotherapy and 2 underwent
radiation therapy, 2 preoperatively. The single drain was removed, on average, at 21 days. Complica-
tions included 3 hematomas (5.8%), 2 capsular contractures (3.8%), and 2 infections (3.8%). The
average time to secondary reconstruction was 143 days. There were 5 unplanned revisions (9.6%).
There were no flap failures or tissue expander losses.
Fisher J, Bostwick J III, Powell RW. Latissimus dorsi blood supply after thoracodorsal vessel
division: the serratus collateral. Plast Reconstr Surg 72:502, 1983.
The authors studied blood flow between the serratus anterior arterial branch to the latissimus dorsi
via the thoracodorsal artery during intraoperative dissections in patients undergoing mastectomy and
in the primate model. Reversal of flow after a division of a thoracodorsal artery and vein was clearly
demonstrated in these studies. Based on their data, it appears safe to rely on the crossing branch from
the serratus anterior into the thoracodorsal artery as the dominant vascular pedicle for transposition of
the latissimus dorsi in selected patients.

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 753

Glassey N, Perks GB, McCulley SJ. A prospective assessment of shoulder morbidity and recovery
time scales following latissimus dorsi breast reconstruction. Plast Reconstr Surg 122:1334, 2008.
In this prospective study, the authors set out to define the impact on shoulder function and to assess
recovery time scales compared with preoperative values. Shoulder range of motion, strength, function,
and pain were assessed prospectively in 22 subjects who had latissimus dorsi muscle flap breast recon-
struction. Assessments were carried out preoperatively and then at 6 weeks, 6 months, and 1 year
postoperatively using standardized objective assessments. The results demonstrated no significant loss
of range of motion, strength, function, or pain at 1 year. However, strength, disability scores, neural
glide, and discomfort were still abnormal at 6 months and then normalized at 1 year. It was noted
that the extended latissimus dorsi flap tended to have poorer scores and recovery compared with a
latissimus dorsi flap and implant.
Hallock GG. The combined parascapular fasciocutaneous and latissimus dorsi muscle conjoined
free flap. Plast Reconstr Surg 121:101, 2008.
A series of eight parascapular fasciocutaneous and latissimus dorsi muscle conjoined free flaps were
reported. This combination allows the creation of an extremely large cutaneous flap from the dorsal
thorax while ensuring survival of both the muscle and skin portions in their entirety.
Hamdi M, Decorte T, Demuynck M, et al. Shoulder function after harvesting a thoracodorsal
artery perforator flap. Plast Reconstr Surg 122:1111; discussion 1118, 2008.
Between 2002 and 2004, 22 patients who had a partial breast reconstruction using a pedicled
thoracodorsal artery perforator flap were enrolled in a functional study to evaluate shoulder function
postoperatively. Latissimus dorsi muscle strength, shoulder mobility, and latissimus dorsi thickness
were measured by using the MicroFet2, a goniometer, and ultrasound examination, respectively. The
measurements of the operated and contralateral (unoperated) sides were analyzed statistically. When
comparing the operated sides to the unoperated sides, latissimus dorsi strength seemed to be maintained
after surgery. Shoulder mobility was also similar in all movements, but both active and passive forward
elevation and passive abduction were reduced significantly after surgery, and latissimus dorsi thickness
was not affected by harvesting the thoracodorsal artery perforator flaps. No seroma formation was
found in any of the donor sites.
Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicled thoracodorsal artery
perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 121:1632, 2008.
A thoracodorsal artery perforator flap was harvested in 90 cases. The perforators were unsuitable in
10 flaps. Unidirectional Doppler imaging was used exclusively in 92% of cases to map the perforator
preoperatively and was felt to add greatly to the efficiency of flap harvest. The average flap size was
20 by 8 cm. Average operative time for flap harvest was 80 minutes. Perforators were located at 8 to
13 cm from the axillary crease (average 10.8 cm).
Hammond DC. Latissimus dorsi flap breast reconstruction. Plast Reconstr Surg 124:1055, 2009.
Five technical modifications in surgical technique, including orientation of the skin island along the
relaxed skin tension lines, harvesting the deep layer of fat with the flap, cutting the thoracodorsal
nerve, partially dividing the insertion of the muscle, and using a staged expander/implant sequence,
are included in an overall surgical strategy designed to reconstruct the breast in both delayed and im-
mediate settings. As a result of these technical modifications, a thin line and smooth donor site scar
is created in the back. The flap advances completely to the breast because of the partial release of the
insertion of the muscle, and the volume provided by the flap is increased by keeping the deep layer of
fat attached to the flap. This more effectively softens the contours of the reconstructed breast. Breast
animation is minimized as a result of sectioning of the thoracodorsal nerve, and the consistency and
quality of the result are improved by using a staged tissue expander/implant strategy.

07f_LatDor_r4_bs_0726-0757.indd 753 1/31/2012 10:53:45 AM

 754 Part II  Regional Flaps: Anatomy and Basic Techniques

Hanasono MM, Silva A, Skoracki RJ, et al. Skull base reconstruction: an updated approach.
Plast Reconstr Surg 128:675, 2011.
The authors’ goal was to develop an updated and comprehensive algorithm for skull base reconstruc-
tion based on data from the 10-year period following their initial report. Reconstructive outcomes were
analyzed from 250 patients undergoing skull base reconstruction from 2000 to 2009. Thirty-nine
local or regional pedicled flap reconstructions and 211 free flap reconstructions were performed. Free
flaps were usually selected over pedicled flaps for patients with a history of prior surgery, irradiation,
or chemotherapy. Reconstructions were performed for 36 region I defects, 39 region II defects, 124
region III defects, and 51 defects involving more than one region. Complications occurred in 29.6%
of patients. There were no significant differences in the overall complication rates between pedicled and
free flap reconstructions. The recipient-site complication rate decreased from 31% in the authors’ prior
report to 18.4%. A facial nerve repair was performed in 30 patients. By 12 months, 75% of patients
had signs of reinnervation. Recovery was not significantly less likely in patients with preoperative
weakness, postoperative irradiation, or age 60 years or older.
Iblher N, Ziegler MC, Penna V, et al. An algorithm for oncologic scalp reconstruction. Plast
Reconstr Surg 126:450, 2010.
The treatment of scalp tumors was documented in 60 patients over a 10-year period. Data regard-
ing tumor type, size, and localization; reconstructive procedure; oncologic, functional, and aesthetic
outcome; and complications were collected and analyzed retrospectively. These data were correlated
to recurrence and survival rates. The findings extracted from the data were amalgamated to produce
the proposed reconstructive algorithm. Five reconstructive categories were defined and their application
described in an algorithmic approach. Indications, limitations, and adequate reconstructive procedures
for each category were identified. The most important decisions are when to use local flaps versus
primary closure and when to use free tissue transfer.
Lin CT, Yang KC, Hsu KC, et al. Sensate thoracodorsal artery perforator flap: a focus on its
preoperative design and harvesting technique. Plast Reconstr Surg 123:163, 2009.
Free sensate thoracodorsal artery perforator flaps that include the posterior divisions of the lateral
cutaneous branches of the intercostal nerves have been described. The authors used preoperative color
Doppler sonography to identify the nerves and demonstrate its clinical value. Fourteen free sensate
thoracodorsal artery perforator flaps were collected. Preoperative color Doppler sonography was used
to identify the locations of thoracodorsal artery perforators and the courses of the posterior divisions of
the lateral cutaneous branches of the intercostal neurovascular bundles. These posterior divisions were
preserved on flaps and classified into three types. Type A and B nerves sprouted cutaneous perforating
fascicles over the lateral region of the latissimus dorsi muscle. Type C nerves went through the region
without any dominant perforating fascicle. Twenty-one nerves were mapped, and 24 were found dur-
ing surgery. The sensitivity of preoperative color Doppler sonography was 87.5%. Of the 24 nerves,
nine were type A (37.5%), 12 were type B (50%), and three were type C (12.5%). Ten of the 14
patients (sensate group) showed better tactile recovery at both the center and the periphery of the flap
than the other 10 patients who underwent reconstruction with nonsensate flaps.
Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg
124:722, 2009.
Breast conservation therapy for the management of women with breast cancer continues to grow in
popularity. To preserve cosmesis or broaden the indications for breast conservation therapy in some situ-
ations, plastic surgeons are now being challenged with the reconstruction of partial mastectomy defects.
Numerous techniques exist, either at the time of resection or following radiation, and the decision of
which to use depends on breast size, tumor size, and tumor location. Women with unfavorable defects

07f_LatDor_r4_bs_0726-0757.indd 754 1/31/2012 10:53:45 AM

 Posterior Trunk  •  7F: Latissimus Dorsi Flap 755

in smaller breasts will often benefit from volume replacement techniques, such as local fasciocutaneous
or myocutaneous flaps, without the need for a symmetry procedure. Women with moderate or larger
breasts (with or without ptosis) and the potential for an unfavorable result also have the option for volume
displacement procedures using local tissue rearrangement techniques to reshape the breast mound. As
these are volume reduction procedures, they often require a contralateral procedure for symmetry. The
extent of resection (lumpectomy versus quadrantectomy) will also influence the type of reconstruction.
Patient selection, surgical technique, margin status, and appropriate follow-up are crucial to maximize
both oncological safety and cosmesis. The reconstruction of partial mastectomy defects will likely gain
popularity as we continue to demonstrate safe and effective treatment algorithms with larger series
and longer follow-up in an attempt to minimize locoregional disease and maximize cosmetic outcome.
Maia M, Oni G, Wong C, Saint-Cyr M. Anterior chest wall reconstruction with a low skin
paddle pedicled latissimus dorsi flap: a novel flap design. Plast Reconstr Surg 127:1206, 2011.
Distal anterior chest wall defects remain a challenge for the reconstructive surgeon. To reconstruct this
region, the most commonly used flaps are the pectoralis and rectus abdominis flaps. When these flaps
cannot be used, the pedicled latissimus dorsi flap and the omentum flap are suitable options. The
use of the pedicled latissimus dorsi flap for chest wall reconstruction was first described by Tansini in
1906 and was subsequently popularized by Olivari in 1976. Since then, the latissimus dorsi flap
has gradually evolved, with many modifications and refinements described in the literature. In the
traditional pedicled latissimus dorsi flap, the skin paddle is typically placed in the mid to upper back
region. With this location, the arc of rotation and reach of the skin paddle can make it difficult to cover
anterior chest wall defects. Thus when the latissimus dorsi flap is used for coverage of the anterior chest
wall, skin grafting over the muscle is often required, resulting in less than optimal cosmetic results.
To provide a latissimus dorsi flap with a wider arc of rotation and increased skin paddle reach to and
past the chest anterior midline, they designed the low skin paddle pedicled latissimus dorsi flap. The
preoperative design and vascular basis of the flap were discussed and a case report was presented.
Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular-thoracodorsal
arterial system: study of 100 cadaver dissections. Br J Plast Surg 37:574, 1984.
The results of 100 cadaver dissections of the subscapular-thoracodorsal arterial system are presented. In
94% of dissections, the thoracodorsal artery originated from the subscapular artery. In the remaining
6%, thoracodorsal arteries had an anomalous origin, although in each instance the aberrant vessels
were of satisfactory dimensions to support the latissimus dorsi flap. In 99% of dissections, significant
branches of the thoracodorsal artery to the serratus anterior muscle were found, confirming the viability
of the serratus muscle for either transposition or transplantation based on the subscapular-thoracodorsal
arterial axis. In 47% of dissections, a direct cutaneous branch from the thoracodorsal artery was dem-
onstrated, the forerunner of the TDAP.
Saint-Cyr M, Graham D, Wong C, Donfrancesco A, Colohan S, Rohrich R. The free descend-
ing branch muscle sparing latissimus dorsi flap: vascular anatomy, clinical results and comparison
with the transverse branch. Plast Reconstr Surg 127:73, 2011.
The latissimus dorsi flap holds an important role in reconstructive surgery. Despite its widespread use
as a free flap, donor site morbidity can still be problematic. A muscle-sparing version of the latissimus
dorsi free flap can help alleviate donor site morbidity while still providing an excellent tool for recon-
struction. The authors investigated the vascular anatomy and clinical results of the free muscle-sparing
latissimus dorsi flap based on the descending branch of the thoracodorsal artery. They also reported
the vascular anatomy of the transverse branch muscle sparing latissimus dorsi flap and compare this
to the descending branch version of the latissimus dorsi flap.

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 756 Part II  Regional Flaps: Anatomy and Basic Techniques

Saint-Cyr M, Nagarkar P, Schaverien M, Dauwe P, Wong C, Rohrich RJ. The pedicled de-
scending branch muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr
Surg 123:13, 2009.
The pedicled descending branch muscle-sparing latissimus dorsi flap with a transversely oriented skin
paddle presents distinct advantages in breast reconstruction, including reduced donor site morbid-
ity and greater freedom of orientation of the skin paddle. The authors reported the anatomic basis,
surgical technique, complications, and aesthetic and functional outcomes following use of this flap for
breast reconstruction in a retrospective study of 20 patients who underwent breast reconstruction with
a pedicled muscle-sparing latissimus dorsi myocutaneous flap. Indications for surgery included breast
reconstruction after mastectomy, lumpectomy, and irradiation and for correction of implant-related
complications. Case-note reviews were performed, as was a functional evaluation consisting of a patient
questionnaire, a Disabilities of the Arm, Shoulder, and Hand form, postoperative range-of-motion
analysis, and instrumented strength testing comparing the operated and nonoperated sides. Aesthetic
evaluation of the donor site was conducted by all patients. An anatomic study of 15 flaps harvested
from fresh cadavers was performed to determine the location of the bifurcation of the thoracodorsal artery
and the course of its descending branch. Twenty-four descending branch muscle-sparing latissimus dorsi
flaps were harvested. All donor sites were closed primarily, with skin paddle sizes ranging up to 25
by 12 cm. There was one case of minor flap tip necrosis and no instances of seroma. There was no
statistically significant difference in strength or range of motion of the shoulder joint when comparing
the operated to the nonoperated side. Two patients reported minor functional impact following surgery.
Seify H, Mansour K, Miller J, et al. Single-stage muscle flap reconstruction of the postpneu-
monectomy empyema space: the Emory experience. Plast Reconstr Surg 120:1886, 2007.
A series of 51 muscle flap procedures were performed in 42 patients (serratus anterior flaps, 16 patients
and 23 flaps; latissimus dorsi flaps, 16 patients and 18 flaps; pectoralis major muscle flaps, intercostal
muscle flaps, and rectus abdominis flaps, 3 patients each; omental flap, 1 patient). Because of the
excellent blood supply of extrathoracic muscle flaps and their ability to reach any place in the pleural
cavity, they represent an ideal tissue with which to fill the contaminated pleural space.
Theeuwes HP, Gosselink MP, Bruynzeel H, et al. An anatomical study of the length of the
neural pedicle after the bifurcation of the thoracodorsal nerve: implications for innervated free
partial latissimus dorsi flaps. Plast Reconstr Surg 127:210, 2011.
For innervated functional muscle transplant procedures, it is essential that the surgeon be aware of
the length of nerve pedicles available for nerve anastomosis. For the latissimus dorsi muscle, the tho-
racodorsal nerve divides into two funicles that separately innervate the medial and lateral portions of
the muscle. This suggests the possibility of a multiple, segmentally innervated latissimus dorsi muscle
transfer. The branching and length of the thoracodorsal nerve distal to the bifurcation have not been
described. This surgical-anatomic study presented anatomic data on these practical/clinical issues. Eleven
latissimus dorsi muscles were dissected in eight adult embalmed human specimens. The thoracodorsal
neurovascular bundle was dissected from insertion to proximal of the bifurcation. Measurements were
taken indirectly from standardized photographic images and analyzed with ImageJ and standard
spreadsheet software. The authors concluded that the separate neurovascular branches and its minimal
pedicle length make the latissimus dorsi muscle very suitable for single functional free muscle transfer,
using only the lateral part of the latissimus dorsi muscle, and double functional free muscle transfer
using only one vascular pedicle.

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 Posterior Trunk  •  7F: Latissimus Dorsi Flap 757

Uygur F, Sever C, Tuncer S, et al. Reconstruction of postburn antebrachial contractures using

pedicled thoracodorsal artery perforator flaps. Plast Reconstr Surg 123:1544, 2009.
Full-thickness burns involving the antecubital area result in severe contractures. Functional impairment
is inevitable if the affected areas are not managed properly. Proper treatment requires complete release
and radical excision of the scar tissue, followed by reconstruction using durable tissue that will not
contract during long-term follow-up. Nine patients with flexion contractures were reconstructed with
pedicled thoracodorsal artery perforator flaps between 2004 and 2008. All of the patients were men;
their ages ranged from 20 to 23 years (mean 21.4 years). The size and orientation of the skin islands
were planned according to the defect size and orientation. The size of the flaps varied from 6.5 to 9.0
cm in width (mean 8.0 cm) and 16.0 to 21.0 cm in length (mean 20.0 cm). All of the patients were
followed up for 6 to 12 months (mean 9.3 months). All of the flaps used on the postburn antecubital
contractures survived completely. Minimal transient venous congestion occurred in two flaps during the
early postoperative period. A complete range of motion at the elbow joint was achieved in all patients
by the end of the reconstruction period.
Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow flexion. J Bone Joint Surg 55A:
1265, 1973.
The latissimus dorsi was transferred to the anterior compartment of the upper arm based on its tho-
racodorsal neurovascular pedicle with reattachment of its origin to the biceps tendon and its insertion
into the coracoid process so that the muscle transfer functioned as an elbow flexor. This flexorplasty
technique was used in eight patients with flexor paralysis of the elbow due to brachial plexus injury
(2) and poliomyelitis (6). All patients achieved active elbow flexion with a range of 105 to 140 de-
grees. The authors recommended this technique over traditional flexorplasty techniques, including the
pectoralis major and triceps muscles.

07f_LatDor_r4_bs_0726-0757.indd 757 1/31/2012 10:53:45 AM

 ANATOMIC LANDMARKS
Landmarks The paraspinal muscles, otherwise known as the erector spinae,
consist of a complex block of muscle lying on either side of the
spinal processes of the vertebrae extending from the nuchal line
of the skull to the sacrum.
Size 60 cm long 3 6 to 8 cm wide.
Origin Muscles arise segmentally from the sacrum and iliolumbar fascia
and the transverse processes of the vertebrae and medial ribs.
Insertion Muscles insert segmentally into transverse processes of the spine,
all the way to the occiput of the skull.
Function Extension and lateral flexion of the spine.
Composition Muscle.
Flap Type Type IV.
Dominant Pedicle Segmental and segmental intercostal arteries.
Minor Pedicle Secondary lateral perforators.
Nerve Supply Segmental spinal: Cervical to lumbar.

07g_ParasFlap_r4_bs_0758-0776.indd 758 2/1/2012 8:06:05 PM

 Section 7G
Posterior Trunk

Paraspinous Flap

CLINICAL APPLICATIONS
Regional Use
Coverage of spinal wounds

07g_ParasFlap_r4_bs_0758-0776.indd 759 2/1/2012 8:06:15 PM

 ANATOMY OF THE PARASPINOUS FLAP

A Semispinalis Longissimus B
capitis muscle capitis muscle
Semispinalis Longissimus
cervicis muscle cervicis muscle
Semispinalis Longissimus
thoracis muscle thoracis muscle

Segmental
intercostal
arteries

Multifidus
muscle

Paraspinal muscles Intercostal arterial supply

Medial
Segmental
perforator
intercostal arteries
Secondary
lateral perforator

Cross-section of neurovascular anatomy Intercostal nerve supply

of paraspinal muscles
Fig. 7G-1

Dominant pedicle: Segmental and segmental intercostal arteries

Minor pedicle: Secondary lateral perforators

07g_ParasFlap_r4_bs_0758-0776.indd 760 2/1/2012 8:06:22 PM

 Posterior Trunk  •  7G: Paraspinous Flap 761

Anatomy
Landmarks The paraspinal muscles, otherwise known as the erector spinae, consist of a com-
plex block of muscle lying on either side of the spinal processes of the vertebrae
extending from the nuchal line of the skull to the sacrum. The term erector spinae
refers collectively to a large group of muscles consisting of the multifidus in the
lumbar and lower thoracic area; the semispinalis muscles extending from the
lumbar, thoracic, and cervical areas; and the longissimus in the lateral lumbar
area. The erector spinae is encased in an anterior and a posterior investing fascia
that is thickened in the lumbar area as the iliolumbar and thoracolumbar fascia.
The muscle bulk is thickest in the upper lumbar and thoracic areas. Superiorly,
it is covered by the trapezius muscle from the occiput down to T12 and from
approximately T6 to L2 it is covered by the latissimus muscle beneath the tra-
pezius.
Composition Muscle.
Size 60 cm long 3 6 to 8 cm wide.
Origin Muscles arise segmentally from the sacrum and iliolumbar fascia and the trans-
verse processes of the vertebrae and medial ribs.
Insertion Muscles insert segmentally into transverse processes of the spine, all the way to
the occiput of the skull.
Function Extension and lateral flexion of the spine.

Arterial Anatomy (Type IV)

Dominant Pedicle  Consists of segmental perforators arising from the posterior intercostal vessels
Regional Source  Aorta.
Length  2 to 3 cm extramuscular.
Diameter  1.5 to 2 mm.
Location  These branches enter the deep medial surface of the muscle between the transverse
processes 2 to 3 cm lateral to the spinous processes.
Minor Pedicle  Lateral perforator row
Regional Source  Posterior intercostals arteries.
Length  2 to 3 cm extramuscular.
Diameter  1 to 1.5 mm.
Location  Deep surface of muscle in its midportion.

Venous Anatomy
Closely parallels the arterial anatomy.

Nerve Supply
Motor Segmental intercostal.
Sensory Segmental intercostal.

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 762 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Paraspinous Flap

A Lateral perforators

Medial
perforators Right paraspinous
muscle

Cervical spine Spinal column Thoracic spine

muscle

Left paraspinous
muscle

Fig. 7G-2 A, Laser angiogram with indocyanine green of the paraspinous muscles in a patient fol-
lowing 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 me-
dial 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.

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 Posterior Trunk  •  7G: Paraspinous Flap 763

FLAP HARVEST
Design and Markings
The paraspinous flaps are used bilaterally to close midline defects of the spine. They are
accessed through a midline skin incision. The muscles can be marked between 6 to 8 cm
on either side of the midline as two longitudinal columns and are usually exposed for at
least 30 cm of their length to close a typical spinal wound.

Trapezius
muscle

Paraspinal muscles
(under trapezius superiorly)

Design and markings for paraspinous flap

Fig. 7G-3

Patient Positioning
Patients are always placed in the prone position with appropriate padding to all pressure
points.

GUIDE TO FLAP DISSECTION

These patients usually have an open midline wound to begin with; this is frequently as-
sociated with a healing or completely healed incision extending superiorly and inferiorly
down the midline of the spine. The incision is opened longitudinally to achieve a 20 to
30 cm exposure of muscle. Depending on the location of the incision, the skin is under-
mined and elevated at the level of the deep fascia overlying the paraspinal muscle mass on
either side. Undermining is performed for 6 to 8 cm and no further.
In the cervical and thoracic areas, the trapezius and latissimus muscles can be elevated
with the skin as a composite myocutaneous flap to preserve cutaneous perforators arising
from these muscles for better wound healing. In the lumbar area, these muscles are absent

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 764 Part II  Regional Flaps: Anatomy and Basic Techniques

and the dissection plane for exposure is subcutaneous. Once the dorsal fascia overlying the
paraspinal muscles has been exposed, it is incised 5 to 6 cm from the midline, extending
superiorly and inferiorly parallel to the spine. The fascia is fairly thin in the upper and mid-
thoracic levels but thickens substantially in the lumbar region. Once the fascia is opened,
the longitudinal muscle mass of the paraspinal muscles can be clearly visualized, and gentle
digital dissection stripping superiorly and inferiorly around the lateral edge of the muscle
provides good mobilization in a relatively bloodless fashion. Blunt dissection can be carried
down anteriorly and slightly medially to the lateral perforator row. It is not necessary to
specifically visualize the vessels.

Midline defect

B C
Thoracic vertebra

Medial perforator
Erector spinae muscle
Lateral perforator
Fascia

Rhomboid major muscle

Trapezius muscle Cut in fascia

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 para-
spinal 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.

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 Posterior Trunk  •  7G: Paraspinous Flap 765

ARC OF ROTATION
The muscles can be rolled medially in an arc of approximately 60 degrees.

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
Like the pages of a book, the muscle is advanced toward the midline, dividing the muscle
proximally or distally if needed for advancement.

FLAP INSET
The two paraspinal muscle blocks are sutured together in the midline using interrupted
0 PDS figure-of-eight sutures. These are placed at 1 to 2 cm intervals down the entire length
of the closure after a channel drain has been placed between the muscle and the underlying
bone and/or hardware. A second layer of continuous 2-0 PDS suture on a CT needle can
be used to imbricate and bury the original suture line. This not only provides a watertight
seal but also serves to invert the muscle mass deeper into the spinal wound centrally, thereby
helping to fill dead space. A second drain is then placed superficial to the spinal repair.

DONOR SITE CLOSURE

If the flaps have been raised in the thoracic or cervical areas, the separated edges of the la-
tissimus or trapezius muscles respectively can be repaired with a running 2-0 PDS suture,
providing additional strength to the repair. The skin is then closed using interrupted sub-
cutaneous closure, followed by a running subcuticular closure or staples. If the skin edges
are inflamed and are of poor quality, large, widely spaced 1 Prolene sutures can be placed
at 5 cm intervals to help relieve tension centrally.

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 766 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 37-year-old patient had undergone spinal fusion for severe kyphoscoliosis 20 years ear-
lier. Six months before presenting, she developed progressive erosion of her spinal hardware
through the skin of her upper thoracic region. The wound was positive for methicillin-
resistant Staphylococcus aureus (MRSA). Explantation of the hardware was planned, with
closure using bilateral paraspinal flaps.

A B

D E

Fig. 7G-6 A, Dorsal spinal wound of the thoracic region before explantation of hardware. B, Ra-
diograph 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 latis-
simus dorsi caudally. E, Lateral paraspinal perforators passing through the paraspinal muscles and
entering the medial border of the latissimus dorsi.

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 Posterior Trunk  •  7G: Paraspinous Flap 767

F G

H I

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 paraspi-
nal 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. (Case supplied by GJ.)

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 768 Part II  Regional Flaps: Anatomy and Basic Techniques

This 70-year-old man had developed erosion of portions of his spinal hardware, which
had been inserted for stabilization of pathologic fractures arising from metastatic disease.
His back had been irradiated 18 months previously. The protruding bolts were cut down
with a side-cutting burr by the neurosurgeons, and closure was performed using bilateral
paraspinal muscle flaps. The patient healed primarily without incident. He died 2 years later
from metastatic disease to the lungs.

C D

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. (Case supplied by GJ.)

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 Posterior Trunk  •  7G: Paraspinous Flap 769

This 45-year-old woman developed sepsis and exposure of her spinal fusion hardware
6 weeks after surgery. The wound was debrided and lavaged, but retention of the hardware
was seen as critical, because the patient’s spine was not fused, and removal would result in
instability and paraplegia. Closure was planned with bilateral paraspinal flaps, with long-
term antibiotic coverage. The wound healed without complication, and the patient went
on to successful spinal fusion with hardware retention.

A B

C D

Fig. 7G-8 A, The debrided wound is seen after repeated washout procedures by the neurosurgi-
cal 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. (Case supplied by GJ.)

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 770 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• To improve skin edge vascularity, it is very helpful to leave the skin attached to the tra-
pezius and latissimus muscles in the cervical and thoracic portions of the wound.
• The dorsal investing fascia must be incised roughly 5 cm parallel to the spine to allow
advancement and rotation into the defect. In the lumbar region, multiple fascial incisions
closer to the midline may also be necessary to facilitate this movement.
• It is not necessary to visualize the vascular pedicles, but care should be taken to preserve
any vessels that happen to be seen during the dissection, since the flap’s blood supply is
entirely segmental.
• Given the immense power of these muscles, medial suturing must be undertaken with
strong sutures. The use of figure-of-eight sutures helps to distribute tension, preventing
tearing of the muscle as the sutures are tightened.
• Submuscular drainage is essential to prevent seroma formation beneath and superficial
to the muscle flaps.
• Great care should be taken with drain placement if the dura is exposed when extensive
laminectomies have been performed.

EXPERT COMMENTARY
Glyn Jones

Indications
Spinal closure has been plagued in the past by the perceived paucity of available tissue donor
sites and the need for extensive undermining when transposing or advancing latissimus
flaps. The practice of undermining led to adjacent wound edge necrosis and dehiscence,
converting a problematic wound into a serious and potentially life-threatening situation.
The advent of a rapid, simple closure technique has literally transformed the surgical land-
scape in this clinical setting.

Advantages and Limitations

The paraspinal muscle mass presents us with a parallel block of muscles lining the spinal
column from occiput to lumbosacral junction. Their convenient proximity to the wound
defect and reliable, segmental blood supply make them the near-ideal wound closure option
for spinal wounds. Their ease of dissection makes them a remarkably simple choice, with
their maximal utility found between the lower cervical and upper lumbar portions of the
spine. The muscles become progressively less bulky and less mobile in the lower lumbar
sacral area and become less useful as a consequence.

Anatomic Considerations
From the occiput to the lower thoracic region, the trapezius and latissimus dorsi muscles
overlie the paraspinal muscles. They should be left attached to the overlying skin to preserve
skin blood supply. Based on their thickness and mobility, the paraspinal muscles are most
useful between C6 and L3. Blood vessels enter the deep surface of the muscles as medial
and lateral rows.

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 Posterior Trunk  •  7G: Paraspinous Flap 771

Personal Experience and Insights

Paraspinal muscle flap usage has transformed my approach to treating midline defects of
the spine. Even in aggressively debrided or irradiated wounds, there is usually an adequate
supply of residual muscle to achieve central wound closure. The flaps are extremely reliable
and simple to mobilize, and provide excellent padding even in thin patients.

Recommendations
Planning
For closing upper cervicothoracic defects, the overlying trapezius muscle should be left
attached to the skin edge to bolster wound edge blood supply. Centrally, the medial edge
of latissimus dorsi can be advanced and closed as a second layer over the underlying para-
spinous mass.

Technique
As dissection commences, the trapezius and/or latissimus muscles are identified, and the
plane of dissection is started immediately beneath these muscles, exposing the paraspinal
mass beneath.
Paraspinal muscle flap turnover is easily accomplished by releasing the overlying fascia
longitudinally, approximately 4 or 5 cm parallel to the midline on either side. Gentle, blunt
digital dissection frees up the muscles laterally, allowing medial advancement into the
midline. This release enables advancement as well as partial turnover of the muscles into
the midline defect. If further mobilization is required, it should be achieved by releasing
the deeper lateral muscle attachments up to the lateral perforator row. It is rarely necessary
to divide perforators in this operation.
Superficial wounds in which the spinous processes are still present are usually closed
with a single plication of interrupted figure-of-eight 2-0 PDS sutures placed every 2 to 3 cm
down the muscle length required. In deeper wounds it is desirable to imbricate the muscle
mass deeper into the wound, like the keel of a sailing ship. This can be accomplished by
running a second layer of inverting 2-0 PDS down the midline to invert the original stitch
line into the depths of the wound. This maneuver pushes the medial muscle mass deeper
into the defect when the spinous processes and posterior elements have been resected or
the spinal cord is exposed.
Draining these wounds is vital to success; 15 Fr hubless channel drains are placed be-
tween the flaps and the spinal cord or vertebrae, and a second drain is placed between the
muscle fascia and the overlying skin. Drains should be left in place until they are producing
less than 30 ml per drain per day. It is helpful to spray the bed of the wound with fibrin
glue before closure. Drain placement in the presence of exposed cord should be discussed
carefully with the neurosurgical team, particularly if dural repair has been performed and
a lumbar drain inserted.
These flaps are extraordinarily easy to raise but can be more difficult in the lumbosacral
region, where their bulk declines rapidly toward the L5-S1 level. They are also less bulky
in the cervical region but are buttressed in this area by the trapezius muscle.

Postoperative Care
Drains are placed between the spine and the muscle, and between the paraspinous muscles
and the skin. Given their close proximity to the spinal cord, drains should only be placed
to bulb suction rather than to electromechanical wall suction.
Continued

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 772 Part II  Regional Flaps: Anatomy and Basic Techniques

Complications: Avoidance and Treatment

Any patient at risk for pressure necrosis should be placed on a low-air-loss bed. If a CSF
leak was noted by the spine surgeon at the time of debridement, it should be repaired and
a lumbar drain inserted prophylactically. Under these circumstances, only a subcutaneous
drain is inserted by the reconstructive surgeon.

Take-Away Messages
Paraspinal flaps have become the benchmark procedure for spinal wound closure and have
relegated latissimus dorsi turnover flaps to a weak second place. Their reliability and ease of
use make them a first-choice procedure, even in irradiated spinal wounds with associated
tissue atrophy. The use of bilaminar onlay acellular dermal matrices can augment their role
as bulk additives to the midline in thin patients.

Bibliography With Key Annotations

Balogh B, Piza-Katzer H, Ritschl P, et al. Modifications of the paraspinous muscle flap: anatomy
and clinical application. Plast Reconstr Surg 97:202-206, 1996.
Soft tissue defects of the back, particularly those involving the paravertebral tissues, are generally
covered with myocutaneous, muscle, or fasciocutaneous flaps. The authors reported the case of a
64-year-old man with a paravertebral malignant fibrous histiocytoma. To ensure adequately radical
margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and
the spinous processes were resected between T9 and T12. The resulting defect was covered with a
pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case,
the authors studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was
visualized after flushing with colored latex and microsurgical dissection. Another four specimens were
subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging
from the intercostal arteries were identified. These were found to communicate in a longitudinal and
vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the
paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses
of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally
pedicled transposition or island flaps.
Casas LA, Lewis VL Jr. A reliable approach to the closure of large acquired midline defects of
the back. Plast Reconstr Surg 84:632-641, 1989.
A systematic regionalized approach for the reconstruction of acquired thoracic and lumbar midline defects
of the back was described. Twenty-three patients with wounds resulting from pressure necrosis, radiation
injury, and postoperative wound infection and dehiscence underwent successful reconstruction. The
latissimus dorsi, trapezius, gluteus maximus, and paraspinous muscles were used individually or in
combination as advancement, rotation, island, unipedicle, turnover, or bipedicle flaps. All flaps were
designed so that their vascular pedicles were out of the field of injury. After thorough debridement,
large, deep wounds were closed with two layers of muscle, while smaller, more superficial wounds were
reconstructed with one layer. The trapezius muscle was used in the high thoracic area for the deep
wound layer, and the paraspinous muscle was used for this layer in the thoracic and lumbar regions.
Superficial layer and small wounds in the high thoracic area were reconstructed with either the latis-
simus dorsi or trapezius muscle. Corresponding wounds in the thoracic and lumbar areas were closed
with latissimus dorsi muscle alone or in combination with the gluteus maximus muscle. The rationale
for systematic regionalized reconstruction of acquired midline back wounds was described.

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 Posterior Trunk  •  7G: Paraspinous Flap 773

Giesswein P, Constance CG, Mackay DR, et al. Supercharged latissimus dorsi muscle flap for
coverage of the problem wound in the lower back. Plast Reconstr Surg 94:1060-1063, 1994.
The authors described “supercharging” a latissimus dorsi muscle flap for coverage of an irradiated
nonhealing wound of the lumbar area of the back. Nonhealing wounds of the lower back pose difficult
management problems. In the presence of radiation therapy, infection, and foreign materials, nonhealing
wounds can have the potential for disastrous outcomes. Exposed bone and prosthetic materials in an
irradiated bed were covered by turning a latissimus dorsi muscle flap over its lower paraspinous origin
and anastomosing the thoracodorsal artery and vein to the ipsilateral superior gluteal vessels. Postop-
eratively, the patient’s wound healed without incident, and the muscle flap and skin graft provided
a stable and durable reconstruction. Subsequent duplex Doppler imaging demonstrated a significant
inflow to the flap from the superior gluteal artery and vein anastomosed to the thoracodorsal artery
and vein of the muscle.
Graeber GM, Seyfer AE, Shriver CD, et al. Desmoid tumor of the paraspinous muscle involv-
ing the chest wall. Mil Med 150:458-461, 1985.
Hartman JT, McCarron RF, Robertson WW Jr. A pedicle bone grafting procedure for failed
lumbosacral spinal fusion. Clin Orthop Relat Res 178:223-227, 1983.
An iliac crest bone graft with an intact quadratus lumborum muscle pedicle was devised for the surgical
repair of symptomatic pseudarthroses in failed lumbosacral spinal fusions. The graft and pedicle were
rotated into a paraspinous bed and internally fixed to the spine. The preliminary results were presented
in 12 patients in whom operations were performed under the direction of a single surgeon. Follow-up
averaged 39 months (range 8 to 68 months). Eleven patients demonstrated radiologic evidence of
union, and nine subjectively reported improvement of symptoms. Five complications occurred in four
patients. Two superficial infections quickly resolved with appropriate therapy. One patient had neural
foraminal encroachment from an internal fixation device, necessitating its early removal. In a fourth
patient, major complications of a deep infection and an incisional hernia were successfully treated.
Iliac pedicle grafting is an alternative stabilization procedure for use in a select group of patients with
disabling pain and previous failed spinal fusion.
Hultman CS, Jones GE, Losken A, et al. Salvage of infected spinal hardware with paraspinous
muscle flaps: anatomic considerations with clinical correlation. Ann Plast Surg 57:521-528, 2006.
Infected spinal stabilization devices represent a significant reconstructive challenge by threatening spinal
stability and increasing the risk of neurologic complications. The authors conducted an anatomic and
clinical investigation of posterior midline trunk reconstruction using paraspinous muscle flaps as the
primary method of repair. They retrospectively analyzed a series of 25 consecutive patients (mean age
57.2 years; range 32 to 78 years) with complex spinal wounds who underwent reconstruction with
paraspinous muscle flaps, at a single university health care system. To help define the versatility of
these muscle flaps, they also performed cadaveric dissections with lead oxide injections in 10 specimens,
with an emphasis on regional blood supply, flap width, and arc of rotation. From 1994 to 2000,
the authors successfully reconstructed complex spinal wounds in 25 patients, using 49 paraspinous
muscle flaps as the primary method of reconstruction. Hardware present in 22 patients was replaced
or retained in 17 cases. Long-term spinal fusion with preservation of neurologic status was observed
in all patients, with no cases of dehiscence or reinfection. Wound complications included a CSF leak,
skin necrosis, sinus tracts, and seroma. Mean length of stay was 24 days (range 8 to 57 days). One
postoperative death occurred. Paraspinous dissections and injections confirmed a segmental type IV
blood supply with medial and lateral perforators, arising from intercostal vessels superiorly and lumbar
and sacral vessels inferiorly. Flap width was 8 cm at the sacral base, 5 cm at the level of the inferior
scapular angle, and 2.5 cm at the first thoracic vertebra.

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 774 Part II  Regional Flaps: Anatomy and Basic Techniques

Lien SC, Maher CO, Garton HJ, et al. Local and regional flap closure in myelomeningocele
repair: a 15-year review. Childs Nerv Syst 26:1091-1095, 2010.
A trend in large myelomeningocele defect repair involves soft tissue closure with muscle and fascial flap
techniques to provide a durable, protective, and tension-free soft tissue covering. The authors proposed
that composite tissue closure yields superior outcomes regardless of defect size. They presented a retro-
spective review of their 15-year, single-institution experience using this approach. The study included
45 consecutive patients treated using combinations of muscle and fascia flaps for primary closure of a
myelomeningocele defect. Lumbosacral fascia closures were used in 18 cases with paraspinous muscle
closure and 12 cases without paraspinous closure. Fascial closure with bony pedicle periosteum and
gluteal muscle and fascial closure were used in four cases each. Other techniques included latissimus
dorsi flaps and combinations of these techniques. Postoperatively, none of our patients experienced
a cerebrospinal fluid leak, and only one patient required reoperation for skin flap necrosis. Objective
measures show that universal application of flap techniques may lead to better outcomes for soft tissue
closure during myelomeningocele repair.
Manstein ME, Manstein CH, Manstein G. Paraspinous muscle flaps. Ann Plast Surg 40:458-
462, 1998.
Coverage of midline posterior spine wounds presents a challenge to the reconstructive surgeon, especially
when spinal stabilization hardware is present and exposed in the wound. Most commonly, wounds
that involve the mid to upper thoracic spine have been covered by latissimus dorsi muscle or myocutane-
ous flaps. Lower midline wounds, especially in the thoracolumbar region, have needed more complex
means of coverage. These have included reversed latissimus dorsi flaps, free flaps, extended intercostal
flaps, or fasciocutaneous rotation flaps. The authors used a far simpler and more effective muscle flap:
the paraspinous muscle flap. They raised paraspinous muscle flaps bilaterally and were able to cover
a number of difficult wounds. The wounds were presented by eight patients with exposed Harrington
rods, three patients with cerebrospinal fluid leaks, and one patient with exposed spinous processes. The
wounds in five of these patients were in the upper thoracic region, where a latissimus flap was used
as an additional layer of muscle coverage. The other seven patients had wounds in the lower midline
region below the potential reach of the latissimus dorsi. In the latter patients, the only flaps employed
were paraspinous muscle flaps. They had only one failure in all patients, which involved a recurrent
CSF leak in which there was no decompression of the cerebrospinal fluid pressure used in the immediate
postoperative period to protect the dural repair. In that instance, a leak recurred.
Mericli AF, Mirzabeigi MN, Moore JH Jr, et al. Reconstruction of complex posterior cervical
spine wounds using the paraspinous muscle flap. Plast Reconstr Surg 128:148-153, 2011.
The paraspinous muscle flap is often overlooked for use in cervical wounds; surgeons cite the decreased
size and mobility of the muscles in the cervical region. The authors discussed the paraspinous muscle
flap technique for reconstruction of cervical spine wounds. An 11-year, single-institution, retrospective
chart review was performed on 14 consecutive patients from 1996 to 2007. All patients underwent
paraspinous muscle flap surgery to provide soft tissue coverage of the cervical spine after wound heal-
ing complications resulting in exposed hardware or bone. Variables of interest included demographics,
comorbidities, and postreconstruction wound-healing complications. The overall complication rate
after paraspinous muscle flap surgery was low, 2 of 14 (14%) and consisted of 2 minor wound infec-
tions. There was no postreconstruction seroma, a well-known complication associated with use of the
trapezius muscle flap, which is often thought of as the first-line option for posterior cervical soft tissue
reconstruction. The authors concluded that the paraspinous muscle flap is an expeditious and reliable
solution to complex cervical spine wounds.
Mericli AF, Moore JH Jr, Copit SE, et al. Technical changes in paraspinous muscle flap surgery
have increased salvage rates of infected spinal wounds. Eplasty 8:e50, 2008.
The authors presented a study to introduce modifications in paraspinous muscle flap surgery and
compare this new variation’s ability to salvage infected hardware with the classic technique. Infected
posterior spine wounds are a difficult problem for reconstructive surgeons. Hardware retention in
infected wounds maintains spinal stability, decreases length of stay, and decreases the wound-healing

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 Posterior Trunk  •  7G: Paraspinous Flap 775

complication rate. The authors conducted an 11-year retrospective office and hospital chart review. All
patients who underwent paraspinous muscle flap reconstruction for wound infections following spine
surgery during this period were included. There were 51 patients in the study, representing the largest
reported series to date for this procedure. Twenty-two patients underwent treatment using the modified
technique and 29 patients were treated using the classic technique. There was no statistical difference
between the two groups in demographics, medical history, or reason for the initial spine surgery. The
hardware salvage rate associated with the modified technique was greater than the rate associated with
the classic technique (95.4% versus 75.8%). There were fewer postreconstruction wound-healing
complications requiring hospital readmission in the modified technique group than in the classic group
(13.6% versus 44.8%). Patients in the modified technique group demonstrated a shorter mean length
of stay than the patients in the classic group (23.7 days versus 29.7). The authors concluded that the
modified paraspinous muscle flap technique is an excellent option for spinal wound reconstruction,
preservation of spinal hardware, and local infection control.
Mericli AF, Tarola NA, Moore JH Jr, et al. Paraspinous muscle flap reconstruction of com-
plex midline back wounds: risk factors and postreconstruction complications. Ann Plast Surg
65:219-224, 2010.
With increasingly complex spine surgeries now being performed on a more comorbid patient popula-
tion, the reconstruction of midline back wounds from these procedures is becoming a frequent dilemma
encountered by plastic surgeons. The purpose of this study was to examine the effect of various
preoperative risk factors on postoperative wound-healing complications after paraspinous muscle flap
reconstruction of midline back defects. An 11-year retrospective office and hospital chart review was
conducted. All adult patients who underwent paraspinous muscle flap reconstruction during the study
period were included. There were 92 patients in the study, representing the largest reported series to
date for the paraspinous muscle flap procedure. Mean follow-up was 120 days. Several wound-healing
risk factors were present in this patient population: 72% were malnourished, 41% had hyperten-
sion, 37% were obese, 34% had a history of smoking, 32% had diabetes, 16% were on a long-term
steroid regimen, 14% had a history of more than two previous spine surgeries, and 9% had a history
of radiation to the wound area. Factors significantly associated with postreconstruction wound com-
plications included a history of traumatic spine injury, prereconstruction hardware removal, a history
of more than two spine surgeries, hypertension, and lumbar wound location. This patient population
had multiple comorbidities, making complex wound healing difficult. Several specific risk factors are
associated with an increased rate of postreconstruction wound complications after paraspinous muscle
flaps. The paraspinous muscle flap remains an important tool for spinal wound reconstruction in the
reconstructive surgeon’s armamentarium.
Saint-Cyr M, Nikolis A, Moumdjian R, et al. Paraspinous muscle flaps for the treatment and
prevention of cerebrospinal fluid fistulas in neurosurgery. Spine 28:E86-E92, 2003.
A prospective clinical study was conducted to evaluate the efficacy of paraspinous muscle flap coverage
using a “vest-over-pants” closure in the prevention and treatment of cerebrospinal fluid fistulas in
high-risk patients. Previous studies had described paraspinous muscle flaps for the closure of complex
spinal wounds, but none had addressed their use for the prevention and treatment of cerebrospinal fluid
fistulas. This study evaluated nine consecutive patients who either had refractory cerebrospinal fluid
fistulas or were at high risk for CSF leaks after spinal surgery. Bilateral paraspinous muscle flaps were
used as primary flaps and were closed using an overlapping vest-over-pants technique in eight of nine
cases. The latissimus dorsi and trapezius muscles were recruited as additional muscle flaps for closure
of thoracolumbar and high thoracic deficits, respectively. Paraspinous muscle flaps provided immediate
wound coverage in seven high-risk patients undergoing spinal surgery and two patients with recurrent
CSF fistulas. Postoperative hospitalization averaged 14.4 days. There was no evidence of a cerebro-
spinal fluid fistula after an average follow-up of 176.7 days. No wound infections occurred. The only
complications were a superficial hematoma, which was drained percutaneously on postoperative day
6, and a seroma, which was drained during the follow-up period and eventually resolved.

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 776 Part II  Regional Flaps: Anatomy and Basic Techniques

Wilhelmi BJ, Snyder N, Colquhoun T, et al. Bipedicle paraspinous muscle flaps for spinal wound
closure: an anatomic and clinical study. Plast Reconstr Surg 106:1305-1311, 2000.
The authors presented a study to evaluate the vascular anatomy of the paraspinous muscles and
reviewed their clinical use as bipedicled flaps in spinal wound closure. Anatomically, through cadaver
dissections, lead oxide injections, and radiographic imaging, the blood supply to the paraspinous muscles
was determined. Clinically, 29 consecutive patients treated with spinal wounds and exposed bone
or hardware were reviewed retrospectively. Of these patients, 19 had delayed primary closure, and 10
were referred to plastic surgery for reconstruction because of the complex nature of their wounds. The
cadaver study demonstrated the paraspinous muscles to possess a segmental arterial supply through
medial and lateral perforators. Division of the medial perforators allowed medial advancement of the
muscles. Lead oxide injection of the lateral perforators demonstrated adequate medial muscle perfusion
with ligation of the medial perforators. Ten of the 29 patients (six women, four men, 32 to 62 years
of age) underwent reconstruction with paraspinous, latissimus, and trapezius muscle flaps. A higher
complication rate was found in wounds closed in delayed primary fashion (13 of 19 patients; 68%)
than those reconstructed with muscle flaps (2 of 10 patients; 20%). Follow-up of the patients who
underwent muscle flap reconstruction averaged 12 months (range 3 to 27 months). Cadaver muscle
injections predicted and clinical cases confirmed that the paraspinous muscles can be raised on lateral
perforators and advanced medially to close lumbar spine wounds reliably with fewer complications.

07g_ParasFlap_r4_bs_0758-0776.indd 776 2/1/2012 8:06:58 PM

 Chapter 8
Upper Extremity

Plastic surgery requires an intimate understanding of the anatomy of the whole body.
For hand surgeons and general reconstructive surgeons, the arm is an invaluable donor
site for reconstructive flaps; the morbidity associated with the upper extremity is low.
Although important for regional applications, arm flaps are of greatest value in distant
reconstruction, particularly the head and neck.

Lateral Arm Flap

Brachioradialis Flap
Posterior Interosseous Flap
Radial Forearm Flap
Flexor Carpi Ulnaris Flap
Ulnar Forearm Flap

08_Ch Opener_r3_0777.indd 777 1/31/2012 1:52:39 PM

 ANATOMIC LANDMARKS
Landmarks Flap occupies the lateral arm from the deltoid insertion to the
proximal third of the forearm.
Size 20 3 14 cm (6 cm for primary closure); bone 10 to 15 cm.
Composition Fasciocutaneous, osteocutaneous.
Dominant Pedicle Posterior radial collateral artery.
Nerve Supply Lower lateral cutaneous nerve of the arm (C5-C6).

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 Section 8A
Upper Extremity

Lateral Arm Flap

CLINICAL APPLICATIONS
Regional Use
Upper extremity
Shoulder
Elbow
Distant Use
Head and neck
Upper extremity
Hand reconstruction
Lower extremity

08a_LatArm_r4_cah_0778-0805.indd 779 1/31/2012 1:53:56 PM

 ANATOMY OF THE LATeral arm flap

Extensor carpi radialis longus muscle

Brachioradialis muscle

Brachialis muscle
A Long head of biceps muscle

Deltoid muscle

Lateral and long heads of triceps muscle

Muscular anatomy of lateral arm

B
Brachial artery

Posterior radial collateral artery

Anterior radial collateral artery

Middle collateral artery
Radial collateral artery

Profunda brachii artery

Arterial system of lateral arm

Fig. 8A-1

Dominant pedicle: Posterior radial collateral artery

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 Upper Extremity  •  8A: Lateral Arm Flap 781

Posterior cutaneous nerve of forearm

C
Radial nerve

Lower lateral cutaneous nerve of arm

Sensory distribution of lower lateral cutaneous nerve of arm

Fig. 8A-1

ANATOMY
Landmarks Flap occupies the lateral arm from the deltoid insertion to the proximal third of
the forearm.
Composition Fasciocutaneous, osteocutaneous. Flap is most commonly used for resurfacing.
It is possible to harvest a segment of the distal humerus from the supracondylar
ridge to the lateral epicondyle.
Size 20 3 14 cm (6 cm for primary closure); bone 10 to 15 cm.

Arterial Anatomy
Dominant Pedicle  Posterior radial collateral artery
Regional Source  Profunda brachii artery (brachial artery).
Length  7 cm.
Diameter  2.5 mm.
Location  Posterior radial collateral artery (PRCA) enters the lateral intermuscular septum, pass-
ing in between the brachialis muscles anteriorly and the lateral head of the triceps posteriorly.
Within the septum, the artery gives off periosteal and muscular branches as well as four or five
septocutaneous arterial branches. At the distal end of the spiral groove, the diameter is 2.5 mm.

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 782 Part II  Regional Flaps: Anatomy and Basic Techniques

Venous Anatomy
This flap has two drainage systems: deep and superficial. The deep system consists of the venae
comitantes that travel with the PRCA. At the distal end of the spiral groove, their diameter is
2.5 mm. The superficial system drains into the cephalic vein and communicates with the deep
system by several small branches. Either system can be used to drain the flap.

Nerve Supply
The lower lateral cutaneous nerve of the arm is a branch of the radial nerve, which perforates the
lateral head of the triceps near the deltoid insertion. It then passes anteriorly up to the elbow near
the cephalic vein and supplies the skin of the lateral arm above and below the elbow.

Vascular A natomy of the Lateral A rm Flap

A B

Elevation of island fasciocutaneous flap Deep surface of flap

Fig. 8A-2 

Dominant pedicle: Posterior radial collateral artery (D)

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 Upper Extremity  •  8A: Lateral Arm Flap 783

FLAP HARVEST
Design and Markings
A line is drawn from the deltoid muscle insertion to the lateral epicondyle that bisects the
flap. The superiormost extent of the skin design is at the deltoid insertion, and the flap can
extend distally over the lateral epicondyle of the humerus. Primary closure of the donor
site is obtainable in flaps 6 cm or less in width, and flaps as large as 20 by 14 cm have been
designed.

Insertion of deltoid muscle on humerus

Outline of flap
Axis of flap

Standard flap design

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
The patient is placed in the supine or lateral decubitus position.

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 784 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The lateral arm flap is first approached posteriorly, and the incision is deepened down to
the fascia of the triceps muscle, which is elevated with the flap. The lateral intermuscular
septum is exposed, and the branches of the vessel to the triceps are ligated. The posterior
branch of the radial collateral artery and the posterior cutaneous nerve of the forearm are
then exposed. It is helpful to retract the triceps muscle posteriorly to facilitate dissection.

Anterior branch of
radial collateral artery

Radial nerve

Radial collateral artery

Lateral intermuscular septum

Lateral head of triceps muscle

Posterior branch of radial collateral artery

Posterior cutaneous nerve of forearm

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.

At the posterior border of the flap the lower lateral cutaneous nerve of the arm is iden-
tified, and if desired, it is preserved with the flap. The incision continues anteriorly down
through muscular fascia, with elevation toward the intermuscular septum laterally.

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 Upper Extremity  •  8A: Lateral Arm Flap 785

B
Brachioradialis muscle

Brachialis muscle

Cephalic vein
Anterior branch of
radial collateral artery

Radial nerve

Radial collateral artery

Lateral intermuscular septum divided

Posterior branch of radial collateral artery

Posterior cutaneous nerve of forearm

Fig. 8A-4  B, The anterior margin of the flap is incised down to and through the deep fascia overly-
ing the brachialis muscle and the brachioradialis muscle. Dissection proceeds in the subfascial plane
posteriorly.

The PRCA can then be seen from both sides, and the septum is detached from the
humerus from distal to proximal. The anterior branch of the radial collateral artery and the
posterior cutaneous nerve of the forearm are divided. Dissection of the pedicle proceeds
proximally. Pedicle lengths of 4 to 8 cm can be obtained.

Brachioradialis muscle

Brachialis muscle

Cephalic vein

Posterior cutaneous
nerve of forearm divided
Lateral intermuscular septum
Posterior branch of
radial collateral artery
Lateral head of triceps muscle
Radial collateral artery

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.

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 786 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANTS
•  Extended lateral arm flap
•  Reverse flap
•  Fascial flap
•  Osteocutaneous flap
•  Vascularized nerve graft

Extended Lateral Arm Flap

The skin design can be moved distally to capture the thinner tissues below the elbow that
extend over the proximal third of the arm. This has the added advantage of lengthening
the vascular pedicle. Dissection distally is in the subfascial plane. Once the area of the lateral
epicondyle is passed, the dissection proceeds as described above.

Insertion of deltoid muscle on humerus

Outline of flap

Axis of flap

Extended lateral arm flap design

Fig. 8A-5 

Reverse Flap
The radial collateral artery anastomoses with the radial recurrent artery and vein posterior to
the lateral epicondyle. A reverse flap may be elevated on this distal vascular anastomosis for
coverage of elbow defects. The standard design is used, and the initial dissection is similar
to the standard flap. Once the septum is isolated from anterior and posterior, the direction
of dissection is proximal to distal. The anastomotic vessels are located in the epicondylar
area in the subcutaneous tissues near the periosteum. No attempt is made to see these ves-
sels; rather, all subcutaneous tissues and periosteum are kept en bloc as a pedicle for the flap.
The flap is then rotated directly into the defect or through a generous subcutaneous tunnel.
A width of 6 cm or less will allow primary closure of the donor site.

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 Upper Extremity  •  8A: Lateral Arm Flap 787

Fascial Flap
The fascial flap can be designed to be 10 to 14 cm wide and 14 to 10 cm long in cases in
which vascularized fascia is required. After elevating skin flaps at the subcutaneous level over
the desired fascia, the dissection proceeds as described previously. In such cases its surface
may be grafted at the recipient site, if required.

Osteocutaneous Flap
The osseus segment from the posterior lateral aspect of the humerus can be included with
the flap. The blood supply to the bone is from the periosteum and requires a small segment
of attached triceps and brachioradialis muscles for vascularization. A flap 10 to 15 cm long
and 1 cm wide can be harvested.

Cuff of lateral head Intermuscular

of triceps muscle septum
Posterior branch of
radial collateral artery Posterior
osteotomy
A
Radial nerve
Radial collateral artery
Lateral head
Posterior cutaneous of triceps muscle
nerve of forearm

Brachialis
muscle
Cephalic vein
Posterior branch of
radial collateral artery Brachioradialis
muscle
B

Radial nerve

Radial collateral artery

Posterior cutaneous
nerve of forearm Intermuscular
septum divided

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

A 10 cm segment of the posterior cutaneous nerve of the forearm can be harvested as a
vascularized nerve graft, nurtured by the PRCA and its vena comitans.

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 788 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Standard Flap
The standard flap design is based on the proximal PRCA pedicle. It can reach the posterior
shoulder and axilla.

A B

Arc to axilla Arc to shoulder

Fig. 8A-7 

Extended Flap
Extension of the flap design distally over the proximal third of the forearm will extend the
reach of the standard flap by that amount.

Reverse Flap
The reverse lateral arm flap easily reaches the lateral elbow and antecubital fossa.

Radial artery

Radial recurrent artery

Brachial artery
Posterior branch of
radial collateral artery

Arc to elbow

Fig. 8A-8 

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 Upper Extremity  •  8A: Lateral Arm Flap 789

FLAP TRANSFER
Standard, Extended, and Reverse Flaps
The flap is transferred by transposition to the neighboring defect. It is most commonly done
by direct extension connecting the donor and recipient sites. Alternatively, the flap may be
passed through a subcutaneous tunnel.

Free Flap
When the lateral arm flap is transferred as a free flap, microsurgical principles apply.

Flap Inset
Care must be taken to insert the flap without tension and without kinking or torsion of the
vascular pedicle when it is passed through a subcutaneous tunnel. Adequate room must be
allowed for flap passage and to accommodate postoperative swelling. In a free tissue transfer,
undue tension on the microvascular anastomosis must be avoided.

DONOR SITE CLOSURE

All Flaps
Primary closure can be obtained when the width of the flap is 6 cm or less; subcutaneous
undermining may be necessary to accomplish this. Larger flap designs may necessitate skin
grafting to close the donor site.

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 790 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 40-year-old man had a recurrent pleomorphic adenoma of the parotid gland; he had
undergone previous excision and irradiation.

B C

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.

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 Upper Extremity  •  8A: Lateral Arm Flap 791

E F G

Fig. 8A-9  D, After flap inset with anastomosis to the facial artery and vein. E, Two months postopera-
tively, 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. (Case supplied by MRZ.)

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 792 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient had multiple open metacarpal fractures, with extensor tendon and dorsal skin
loss of the hand. Osteosynthesis with plates and extensor tendon repair with grafts required
thin, well-vascularized coverage with fascia to facilitate tendon glide. The lateral arm flap
fulfilled these criteria.

A B C

D E

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 frac-
tures 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.

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 Upper Extremity  •  8A: Lateral Arm Flap 793

G H I

J K

L M

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 postop-
eratively. N, The patient had hypoesthesia in the proximal lateral aspect of the forearm from transec-
tion of the posterior cutaneous nerve of the forearm. (Case courtesy Luis R. Scheker, MD.)

08a_LatArm_r4_cah_0778-0805.indd 793 1/31/2012 1:54:06 PM

 794 Part II  Regional Flaps: Anatomy and Basic Techniques

This 19-year-old woman had severe crush injuries to both hands and was managed elsewhere.

A B

C D

E F G

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. (Case courtesy William C. Pederson, MD.)

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 Upper Extremity  •  8A: Lateral Arm Flap 795

This 35-year-old patient presented after burns and contracture of the palm.

A B

C D E

F G

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. (Case courtesy William C. Pederson, MD.)

08a_LatArm_r4_cah_0778-0805.indd 795 1/31/2012 1:54:16 PM

 796 Part II  Regional Flaps: Anatomy and Basic Techniques

This paraplegic patient had a chronic elbow wound. A failed primary closure and skin
grafting had been done.

B C

D E

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. (Case courtesy
William C. Pederson, MD.)

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 Upper Extremity  •  8A: Lateral Arm Flap 797

Pearls and Pitfalls

• The lateral arm flap is useful in the head and neck when both skin and segmental bone
are required for reconstruction.
• The flap can be used as a flow-through flap, especially in hand reconstruction, where the
PRCA can be used to revascularize the hand or digits.
• This flap may be too bulky for use in an obese patient. In such cases a fascial flap can be
taken and skin grafted.
• Division of the posterior cutaneous nerve of the forearm results in anesthesia of the su-
perior lateral forearm.
• The lateral arm flap is advantageous for hand reconstruction because it does not eliminate
a major arterial supply to the hand, as do radial and ulnar based flaps. Thus the lateral
arm flap can be raised from the same extremity that is being reconstructed, limiting
morbidity to one extremity.
• Anatomic variation in the lateral arm flap is minimal.
• This flap may be disadvantageous in hirsute individuals, if hair-bearing skin is not desir-
able in the reconstruction.

Expert Commentary
William C. Pederson

Indications
The lateral arm flap is indicated for smaller wounds of the hand (and body) where a reliable
small free flap is needed. I think it is ideal for placement in the first webspace after injury or
release of contracture. The flap fits this space perfectly, and although the pedicle is relatively
short, recipient vessels are available in the anatomic snuffbox. The flap has applications for
coverage and fill in small defects of the head and neck and lower extremity. It may be used
as a pedicled flap, both proximally and distally based.

Advantages and Limitations

The flap supplies a free flap with a relatively easy dissection, reliable vascular pedicle, and
reasonable donor site. Flaps up to about 7 cm in width can usually be closed primarily.
The primary limitation of the flap is that its size is limited. The pedicle is relatively short
and the artery is relatively small, but neither is a problem, as long as the flap anatomy and
limitations are understood.

Anatomic Considerations
The length of the pedicle is limited by its curving around the humerus, but the vascular
pedicle often becomes entwined around the radial nerve in my experience, and this truly
limits the length (primarily of the vein) that can be harvested. Distally based flaps may be
unreliable because the size and presence of the distal vessel are variable. The presence of this
vessel, determined by Doppler examination, will usually obviate this problem.
Continued

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 798 Part II  Regional Flaps: Anatomy and Basic Techniques

Personal Experience and Insights

I find this flap very good for coverage of the hand in injuries and prefer the ipsilateral flap. It
is my flap of choice for soft tissue fill after release of first webspace contractures. It is shaped
like a wedge, and with release of the first webspace, a wedge-shaped defect is created. The
radial artery and cephalic vein provide easy vascular access for this flap on the dorsal hand
or first webspace. It is not really a flat flap, but when placed on the dorsal hand, it will usu-
ally require later thinning and inset to avoid bulkiness. It offers an excellent choice for fill
in small soft tissue defects of the head and neck, such as temporal wasting after a temporal
craniotomy.

Recommendations
Planning
I prefer to use Doppler ultrasonography to delineate the main pedicle before elevation. A
template of the defect can be helpful in designing the flap.

Technique
The center line of the flap is marked and outlined before placing the tourniquet. A sterile
tourniquet is used so that it can be removed if needed to dissect the proximalmost portion
of the pedicle. The surgeon must be aware of the radial nerve coursing anteriorly into the
brachialis muscle at the more proximal portion of the pedicle dissection. At least a dermal
closure of the donor site should be performed before placing the flap on the recipient site.
If this is not done, swelling may make it difficult to close the donor site later.

Postoperative Care
I often place the patient in a posterior elbow splint if the donor site closure is a bit tight.

Complications
Most complications of this flap are related to microsurgery. The radial nerve can be injured
in the dissection, but with care, this is unusual. Hard retractors should not be placed on
the anterior muscles during the dissection (the radial nerve runs anteriorly in the brachialis
muscle after coming around the humerus). I had one patient develop symptoms of radial
nerve compression and compartment syndrome on the first postoperative night when the
donor site was closed primarily (and it was too tight). The closure must be carefully evalu-
ated and a skin graft placed if it appears to be too tight

Take-Away Message
This flap is ideal for the management of smaller traumatic wounds of the hand. It is possibly
the best option for reconstruction of the first webspace after contracture release.

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 Upper Extremity  •  8A: Lateral Arm Flap 799

Bibliography With Key Annotations

Akinci M, Ay S, Kamiloglu S, et al. Lateral arm free flaps in the defects of the upper extremity—
a review of 72 cases. Hand Surg 10:177-185, 2005.
Lateral arm flaps are versatile for use in upper extremity moderate-sized defects, with little morbidity
and acceptable cosmesis. In this paper the conditions were outlined in a series of 74 lateral arm flaps
performed on 72 patients, and the results were discussed. Five patients were treated emergently, 12
were operated within the first 72 hours of injury, and 57 patients were treated electively. Skin defects
were between 6 by 4 cm and 20 by 9 cm. Five (7%) flaps were lost as a result of venous thrombosis;
three had sustained a high-voltage electric burn. Two other patients that were treated for a high-voltage
electric burn had a successful revision of the anastomosis site in the early postoperative period. One
flap was abandoned because of a very thin pedicle and the patient’s obesity. A higher failure rate is
encountered most frequently with the cases of high-voltage electric burn. To deal with this problem, a
modified approach such as an extended approach and/or including the forearm skin to the flap is rec-
ommended during the flap harvest. For a longer pedicle to be anatomized more proximally, perforator
flaps with longer pedicles may be used as an alternative.
Atzei A, Pignatti M, Udali G, et al. The distal lateral arm flap for resurfacing of extensive defects
of the digits. Microsurgery 27:8-16, 2007.
The distal lateral arm flap was used to reconstruct six extensive defects of the digits: two degloving
injuries of the thumb and four major skin losses of the fingers. Two adjacent fingers were involved in
one patient. Flap size ranged from 3 by 7 cm to 9 by 14 cm. Four flaps were reinnervated using the
posterior cutaneous nerve of the forearm. All flaps survived, although one showed marginal necrosis.
Average follow-up was 53.4 months. Thumb opposition scored 5 according to the Kapandji index;
finger range of motion averaged 50.75%; pinch strength 72.5%. Protective sensation with touch
localization was restored. Patient satisfaction for resurfaced digits averaged 8.9 on a 10-point visual
analog scale. All donor sites resulted in a painless scar with good patient satisfaction. The authors
concluded that the distal lateral arm flap offers a thin, pliable skin ideal for digit reconstruction, with a
low rate of donor site morbidity, and it can be considered when toe-to-hand flap transfer is not advis-
able or is refused by the patient.
Haas F, Ensat F, Windhager R, et al. Reconstructive potential of the lateral arm flap after tumor
resection. Microsurgery 27:166-173, 2007.
The reconstruction of extended tumor-related defects in different anatomic regions requires a versatile
and reliable flap. For many surgeons, the lateral arm flap has become the technique of choice in the
reconstruction of small- to medium-sized defects. The aim of this study was to analyze the reconstruc-
tive potential of the lateral arm flap after cancer ablation in various indications. Between 1998 and
2006, 14 patients underwent reconstruction with differently composed and designed lateral arm flaps.
Complete coverage of all defects was achieved with a single surgical procedure. With a flap survival
rate of 100% in this series, excellent long-term results, and high patient satisfaction, combined with
low donor site morbidity, the authors recommended the use of the lateral arm flap in tumor patients.
Haas F, Rappl T, Koch H, et al. Free osteocutaneous lateral arm flap: anatomy and clinical ap-
plications. Microsurgery 23:87-95, 2003.
For many surgeons, the potential to reconstruct skin, fascia, tendon, or bone in a single-stage procedure
has made the lateral arm flap the technique of choice for reconstruction of complex defects. The aim
of this study was to examine more closely how the humeral bone is supplied by the posterior collateral
radial artery. To this end, the authors dissected 30 cadaver arms to determine the vascular relationship
of the lateral arm flap to the humerus. They examined the number of directly supplying vessels and
the height to the lateral epicondyle of the humerus. The reconstructive potential of the osteocutaneous
flap in different indications was analyzed in a series of five clinical cases. In all dissected extremities,
they found one or two branches of the posterior collateral artery directly and constantly supplying the
bone between 2 and 7 cm proximal to the lateral epicondyle. In five cases, combined defects, including
bone, were successfully reconstructed with lateral arm flaps, including vascularized bone.

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 800 Part II  Regional Flaps: Anatomy and Basic Techniques

Haas F, Seibert FJ, Koch H, et al. Reconstruction of combined defects of the Achilles tendon
and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap.
Ann Plast Surg 51:376-382, 2003.
The authors presented a new approach to reconstruction of the Achilles tendon and overlying soft tis-
sue. A fascia lata graft was used to reconstruct the tendon, enwrapped by the fascia that is included in
a fasciocutaneous lateral arm flap. Five patients were treated with this technique—three of them after
surgical Achilles tendon repair, rerupture, and consecutive infection; one after a full-thickness burn with
loss of the tendon; and one with a history of ochronosis and necrosis of the whole tendon and overly-
ing soft tissue. There were no anastomotic complications, and all flaps healed primarily. Functional
evaluation with the Cybex II dynamometer was done at least 49 months after reconstruction. A good
functional and cosmetic result was obtained in all patients, and donor site morbidity was acceptable.
These results are well within the results of other surgical treatment options reported in the literature.
Hage JJ, Woerdeman LA, Smeulders MJ. The truly distal lateral arm flap: rationale and risk
factors of a microsurgical workhorse in 30 patients. Ann Plast Surg 54:153-159, 2005.
The forearm part of the extended lateral arm flap may be separately raised on the distalmost septo-
cutaneous perforator of the posterior collateral radial artery. This truly distal lateral arm flap shares
most of the advantages of the radial forearm flap and is associated with less donor site morbidity. From
April 2000 to March 2004, the authors used 30 such flaps as the fasciocutaneous free flap of choice,
mostly for reconstructions in the head and neck region. The eventful postoperative course observed in
5 of these flaps motivated them to evaluate the rationale and risk factors of this procedure. They pro-
spectively analyzed the influence on the incidence of partial or complete flap loss of 19 patient-related
or procedure-related characteristics that may have been risk factors. None of these factors was found
to be of statistical significance. They found the distal lateral arm flap to have a less robust vascular
anatomy than the radial forearm flap, resulting in the need for advanced surgical expertise to raise
and handle it. As they recognized that the difficulty of this flap was associated predominantly with
the anatomy of its vascular pedicle, they stated that they now take a more liberal stand toward the
possibility of intraoperative conversion to the use of a radial forearm flap.
Hara I, Gellrich NC, Duker J, et al. Swallowing and speech function after intraoral soft tissue
reconstruction with lateral upper arm free flap and radial forearm free flap. Br J Oral Maxil-
lofac Surg 41:161-169, 2003.
Swallowing, speech, and morbidity were assessed postoperatively in 25 patients, 18 of whom had had
intraoral defects reconstructed by lateral upper arm free flaps (LUFF) and 7 by radial forearm free flaps
(RFFF). Videofluoroscopy was used to assess swallowing, the Freiburger audiometric test to assess
speech, and measurement of arm circumference to assess donor site morbidity. A questionnaire was
used to subjectively evaluate swallowing, speech, and donor site morbidity. The degree of impairment
in swallowing depended on the site of resection. Anterior and posterior resections affected swallowing
more than lateral resections. Anterior resection and the use of LUFFs reduced intelligibility. There
was no significant difference in impairment between LUFF and RFFF. The authors concluded that
the LUFFs are superior to RFFFs because they can be closed primary and the incidence of donor site
morbidity is slight.
Hennerbichler A, Etzer C, Gruber S, et al. Lateral arm flap: analysis of its anatomy and modi-
fication using a vascularized fragment of the distal humerus. Clin Anat 16:204-214, 2003.
Soft tissue injuries with associated bone defects are difficult to manage and often require prolonged
treatment with repeated interventions. Frequently a free flap is applied as a first step, and bone grafting
is carried out in a second procedure. Ideally, these two procedures are combined in one operation, using
a soft tissue flap with an attached vascularized bone fragment. The lateral arm flap can provide such
an osteoseptocutaneous flap and has been used clinically with success; however, the vascular anatomy
of the flap, especially the humeral fragment, has not been described in detail previously, and there is
broad disagreement concerning its innervation. In this study, the arteries and nerves of 24 fresh cadaver
arms were dissected after injection of colored latex. The levels of origin of the periosteal arteries of the

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 Upper Extremity  •  8A: Lateral Arm Flap 801

humerus were also documented. The lateral arm flap has a consistent arterial supply from three sep-
tocutaneous perforating branches that are arranged in a predictable pattern. The lateral supracondylar
ridge of the humerus is vascularized by direct branches of the posterior branch of the radial collateral
artery and by arteries that arise from muscular branches supplying adjacent muscles. The innervation
of the lateral arm flap is by the inferior lateral cutaneous nerve of the arm.
Hsu YC, Wu CI, Cheng HT, et al. Free chimera lateral arm flap for repair of orocutaneous
fistulae/osteoradionecrosis in oromandibular cancers. Plast Reconstr Surg 126:180e-182e, 2010.
The authors described the advantages of the free chimeric lateral arm flap for repair of orocutaneous
fistulas/osteoradionecrosis in oromandibular cancers. These benefits include (1) proper thickness of the
flap for soft tissue reconstruction in the head and neck lesions, (2) use of the minor flap to reconstruct
the intraoral lesion instead of scarifying the local tissue as a local flap, (3) relatively small caliber and
length of the pedicle of the minor flap that is well suited for the fistula tract, (4) the minor flap tunnels
through the fistula tract, with less damage to surrounding tissue, (5) a composite flap in which part of
the triceps muscle, the humeral bone, or both can be included, and (6) minimal donor site morbidity.
Hwang K, Lee WJ, Jung CY, et al. Cutaneous perforators of the upper arm and clinical ap-
plications. J Reconstr Microsurg 21:463-469, 2005.
The authors investigated the distribution of constant cutaneous perforators in the upper arm. A total
of 20 amputated upper arms of 10 fresh Korean cadavers were used for the study. Red latex was
injected into the axillary arteries of 10 specimens and lead oxide-gelatin mixture (radiopaque mate-
rial) in the other 10. The cutaneous perforators were then identified by dissection and radiography.
The upper arm had several perforating arteries (range 5.7 to 6.3) in the subfascial plane, but only
four fasciocutaneous perforators were constant: one in the medial intermuscular septum and three in
the lateral intermuscular septum. The constant medial perforators were included in a circle of 2.89
cm in diameter, the center of which was 8.9 cm above and 1.2 cm medial to the medial epicondyle.
The mean length and diameter of the extended pedicle of the medial perforator was 2.78 cm and
0.94 mm, respectively. The lowermost constant lateral perforators were included in a circle of 2.44
cm in diameter, the center of which was 16.8 cm above and 0.5 cm medial to the lateral epicondyle.
The mean length and diameter of the extended pedicle of the lateral perforator was 2.88 cm and
0.84 mm, respectively. A flap based on the perforator of the medial intermuscular septum is not as
simple as with the lateral intermuscular perforator, but direct closure of the donor site is more favorable.
The authors concluded that it is safe to design a free skin flap with knowledge of its dominant perforator.
Kalbermatten DF, Wettstein R, vonKanel O, et al. Sensate lateral arm flap for defects of the
lower leg. Ann Plast Surg 61:40-46, 2008.
Ideally, reconstruction of lower extremity soft tissue defects includes not only an aesthetically pleasing
three-dimensional shape and solid anchoring to the underlying structures to resist shear forces, but
should also address the restoration of sensation. The authors presented a prospective study on defect
reconstruction of the lower leg and ankle to evaluate the role of sensate free fasciocutaneous lateral arm
flap and the impact of sensory nerve reconstruction. Thirty patients were allocated randomly to the study
group (n 5 15) that obtained end-to-side sensate coaptation using the lower lateral cutaneous brachial
nerve to the tibial nerve using the epineural window technique, or to the control group reconstructed
without nerve coaptation. At 1-year follow-up the patients were evaluated for pain sensation, thermal
sensibility, static and moving two-point discrimination, and Semmes-Weinstein monofilament tests.
Data from both groups were compared and statistically analyzed with the Mann-Whitney U test and
the Fisher exact test. Flaps of the study group reached a static and moving two-point discrimination and
Semmes-Weinstein monofilament results nearly equal to the contralateral leg area, and significantly
better than flaps of the control group. Donor damage morbidity of the tibial nerve did not occur. The
authors recommended that resensation be carried out by end-to-side neurorrhaphy to the tibial nerve
because of the superior restoration of sensibility.

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 802 Part II  Regional Flaps: Anatomy and Basic Techniques

Karamürsel S, Bağdatlý D, Markal N, et al. Versatility of the lateral arm free flap in various
anatomic defect reconstructions. J Reconstr Microsurg 21:107-112, 2005.
The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap.
Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site
morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study,
the authors presented 18 patients operated on between January 2002 and August 2003 in whom
18 free lateral arm flaps were used. There were 4 women and 14 men; the mean patient age was
40 years. Thirteen fasciocutaneous, 3 fascial, and 2 osteofasciocutaneous flaps were used. Flaps were
employed for the reconstruction of the lower extremity in 5 patients, upper extremity in 9 patients,
and head and neck in 4 patients. Thirteen flaps were elevated under axillary block and 5 flaps under
general anesthesia. Aspirin, dipyridamole, dextran, and chlorpromazine were administered post-
operatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative
day 1. Venous thromboses were detected, anastomoses were redone, and flaps healed uneventfully.
No postoperative complications were observed in the other patients. The free lateral arm flap may be
used in various anatomic defects with various indications. It may be elevated under axillary block for
extremity reconstructions.
Kim CH, Tark MS, Choi CY, et al. A single-stage reconstruction of a complex Achilles wound
with modified free composite lateral arm flap. J Reconstr Microsurg 24:127-130, 2008.
A composite defect of the posterior aspect of the heel, including the Achilles tendon, is usually very
difficult to reconstruct because of the problems of controlling infection, resurfacing the deficient skin
defect, and restoring plantar flexion. With the latest advances in microsurgery, several free composite
flaps have been used to reconstruct the defect in the Achilles tendon region to achieve stable and func-
tional soft tissue coverage. The authors reported such a single-stage reconstruction of a complex Achilles
wound using the modified neurosensory lateral arm free flap, including the triceps tendon strip and the
posterior cutaneous nerve. Their rolled-up triceps tendon strip method was presented for the one-stage
reconstruction of the Achilles tendon and soft tissue defect, providing good contour, strong tension, and
protective sensation. The follow-up has shown a satisfactory outcome.
Levin LS. Foot and ankle soft-tissue deficiencies: who needs a flap? Am J Orthop 35:11-19, 2006.
The patient who needs a flap for a deficit of the foot or ankle soft tissues is any patient who has a break
in the integument. Although skin grafts often will suffice, if there is a full-thickness loss, particularly
over the plantar bony prominence such as the heel or metatarsal, one should strongly consider flaps.
In the author’s practice, the flap procedure most commonly performed for the metatarsal region is the
V-Y advancement; for the hindfoot, free tissue transfer; and for the Achilles region, a sural flap. If a
lesion is small and the vascular inflow is good, the author uses free tissue transfer of a thin skin flap,
such as a lateral arm flap or a radial forearm flap. For the dorsum of the foot, particularly when there
is osteomyelitis or a lesion, or a lateral sidewall lesion, he uses a muscle flap. The calcaneus is best
served by one of many muscle flaps, such as the gracilis.
Malata CM, Tehrani H, Kumiponjera D, et al. Use of anterolateral thigh and lateral arm fascio-
cutaneous free flaps in lateral skull base reconstruction. Ann Plast Surg 57:169-175; discussion
176, 2006.
Lateral skull base defects following tumor ablation are ideally reconstructed with microvascular free
tissue transfer. Although the rectus abdominis free flap is the workhorse in skull base reconstruction,
it has a number of drawbacks. Anecdotal reports have indicated that fasciocutaneous free flaps may
be useful alternatives in selected cases. Patients undergoing lateral arm (4 cases) or anterolateral
thigh (8 cases) fasciocutaneous free flap reconstruction of lateral skull base defects between 1999 and
2005 were therefore reviewed. Twelve consecutive patients (4 males, 8 females) with a mean age of
63 years (range 39 to 74) underwent such reconstruction following resection of lateral (11 cases) and
anterolateral (1 case) skull base lesions. Eight patients had squamous cell carcinoma, 3 had infection
or osteoradionecrosis, and 1 had adenoid cystic carcinoma. The duration of surgery (from induction of
anesthesia to exit from the operating room) averaged 14.5 hours (range 10 to 19.5 hours). All donor
sites were closed directly. All the flap transfers were successful, with minimal reconstructive and donor

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 Upper Extremity  •  8A: Lateral Arm Flap 803

site morbidity. During the follow-up period (average 18 months; range 2 to 48 months), 2 patients
died of metastatic disease, and 2 died of other unrelated causes. The remaining 8 patients were alive
and disease free. The authors concluded that lateral arm and anterolateral thigh fasciocutaneous free
flaps should be considered as viable reconstructive options for lateral skull base ablative defects.
Marques Faria JC, Rodrigues ML, Scopel GP, et al. The versatility of the free lateral arm flap
in head and neck soft tissue reconstruction: clinical experience of 210 cases. J Plast Reconstr
Aesthet Surg 61:172-179, 2008.
The authors presented a study of their experience with 210 free lateral arm flaps used to repair head
and neck oncologic defects over an 8-year period. Patients’ ages ranged from 4 to 83 years (average
49.7 years); 141 were male and 66 female. Three patients received two consecutive flaps each. They
were used to reconstruct the tongue, 53 cases; retromolar trigone, 42 cases; soft/hard palate, 34 cases;
skin/facial contour, 19 cases; hypopharynx, 17 cases; buccal mucosa, 12 cases; lips, 5 cases. Flap
cutaneous dimensions ranged from 4 by 2 cm to 17 by 8 cm. The flap was composed of skin and fascia,
18 cases; sensate (neurovascular) skin, 6 cases; subcutaneous fat tissue, 5 cases; skin and vascularized
nerve graft, 3 cases; and skin and partial triceps muscle, 3 cases. Nerve coaptations were performed
for all lip reconstructions. Nine flaps did not survive (success rate 95.2%). Severe postoperative clinical
complications preceded flap failure and death in 2 cases. All but 6 donor sites were closed primarily.
Complications related to the donor site were paresthesia of the forearm, 210 cases; dog ear, 16 cases;
hypertropic scar, 14 cases; weakness, 9 cases; hematoma, 6 cases; seroma, 3 cases; dehiscence, 1 case.
Radial nerve injury was not observed in this series. The authors concluded that the lateral arm flap
can be considered safe and versatile for most soft tissue head and neck microsurgical reconstructions.
The possibility of sensory recovery through neural anastomoses and low donor site morbidity enhances
its efficiency.
Mears SC, Zadnik MB, Eglseder WA. Salvage of functional elbow range of motion in complex
open injuries using a sensate transposition lateral arm flap. Plast Reconstr Surg 113:531-535, 2004.
Complex open posterior elbow injuries pose three principal challenges to the reconstructive surgeon.
First, the surgeon must provide stable soft-tissue closure over the joint/skeletal reconstruction. Second,
the coverage must be thin and supple and promote the free gliding of the underlying structures. Finally,
secondary and tertiary procedures must be anticipated beneath the flap, because a stiff, scarred, and
adherent flap will only compromise these procedures. The results of 10 consecutive fasciocutaneous
transposition lateral arm flaps for coverage of posterior elbow wounds were reported. This flap pro-
vides coverage that is thin and supple and that allows subsequent elevation for secondary procedures.
Functionally, these flaps allowed for the development of an average arc of motion of 20 to 114 degrees
and an average pronation-supination motion of 119 degrees.
Prantl L, Schreml S, Schwarze H, et al. A safe and simple technique using the distal pedicled
reversed upper arm flap to cover large elbow defects. J Plast Reconstr Aesthet Surg 61:546-551,
2008.
The reconstruction of large soft tissue defects at the elbow is hard to achieve by conventional techniques
and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate
skin. Surgical treatment should permit early mobilization to avoid permanent functional impairment.
Clinical experience with the distal pedicled reversed upper arm flap in 10 patients with large elbow
defects is presented (7 men, 3 women; age 40 to 70 years). The patient sample included 6 patients
with chronic ulcer, 2 with tissue defects resulting from excision of a histiocytoma, and 1 patient with
burn contracture. In the 2 cases of histiocytoma, defect closure of the elbow’s ulnar area was achieved
by using a recurrent medial upper arm flap. In the 8 other patients a flap from the lateral upper arm
was used, with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average
wound area from 30 to 80 cm2. Flap dimensions ranged from 15 by 8 cm for the lateral upper arm
flap to 29 by 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral
arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating
vessels were identified preoperatively using color Doppler ultrasonography. Flap failure did not occur.
Secondary wound closure became necessary because of initial wound-healing difficulties in 1 patient.

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 804 Part II  Regional Flaps: Anatomy and Basic Techniques

The mean operative time was 1.5 hours, and the mean follow-up was 12 months. Good defect cover-
age with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term
wound stability without any restriction of elbow movement. The authors concluded that lateral and
medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects.
The surgical technique is comparatively simple and quick.
Sauerbier M, Unglaub F. Perforator flaps in the upper extremity. Clin Plast Surg 37:667-676,
vii, 2010.
Perforator flaps are frequently used for defect coverage for the whole body. There are strong indications
for the use of perforator flaps in the upper extremity. This article demonstrated the possibilities for
defect coverage with perforator flaps as well as their anatomic and technical considerations. Lateral
arm, posterior interosseous artery, ulnar artery, radial artery perforator flaps, and intrinsic hand flaps
were described.
Türegün M, Nisanci M, Duman H, et al. Versatility of the reverse lateral arm flap in the treat-
ment of post-burn antecubital contractures. Burns 31:212-216, 2005.
If they are not managed with proper treatment and rehabilitation, full-thickness burns involving the
cubital fossa can result in severe contractures that may impair upper extremity functions. Later release
of these contractures discloses a large soft tissue defect that should be replaced. The authors used reverse
lateral arm flaps for coverage of the cubital fossa in 11 selected cases of antecubital contracture. Ten
flaps survived totally; there was distal partial necrosis in 1 flap, which was later treated by skin graft-
ing. The authors reported considerable functional improvement in all cases. Although fasciocutaneous
flaps offer the advantage of using regional tissue in a single stage, few versatile local flaps relying on
the vascular anatomy around the elbow joint are available for cubital fossa coverage. Because it is a
rapid, easy, and one-stage procedure with no necessities for sacrifice of a major artery or muscle and
for a long-term immobilization of the involved joints, the reverse lateral arm flap appears to be ad-
vantageous in comparison with other options for coverage of the cubital fossa defects after the release
of antecubital contractures.
Ulusal BG, Lin YT, Ulusal AE, et al. Free lateral arm flap for 1-stage reconstruction of soft
tissue and composite defects of the hand: a retrospective analysis of 118 cases. Ann Plast Surg
58:173-178, 2007.
The long-term results of hand defects after one-stage reconstruction with lateral arm flap were ret-
rospectively analyzed in a large series. Between 1990 and 2004, 118 traumatic hand defects were
reconstructed using lateral arm fasciocutaneous flap (104), lateral arm fascial flap (6), and composite
lateral arm flap (8). There were 22 females and 96 males, with an average age of 32.5 6 13.3
years. Mean follow-up was 17 6 6.2 months. The overall success rate was 97.5%. The cosmetic
outcomes were satisfactory and only 16.1% of the patients required debulking. The functional recovery
of the hand contractures secondary to crush injury were generally associated with poor results. In the
composite flap group, reconstruction of the extensor tendons with triceps tendon yielded limitation in
tendon excursion and poor functional results. However, complete bone healing without complication
was uniformly detected in all cases. Lateral arm fasciocutaneous flap endured secondary interventions
well, and no complications regarding wound healing were encountered.
Ulusal BG, Lin YT, Ulusal AE, et al. Reconstruction of foot defects with free lateral arm fas-
ciocutaneous flaps: analysis of fifty patients. Microsurgery 25:581-588, 2005.
Long-term outcomes of foot reconstruction with free lateral arm fasciocutaneous flaps were retrospectively
analyzed in 50 patients: 38 males and 12 females, ranging in age from 7 to 73 years (mean 43.5
years). Indications for surgery included trauma (32 patients), diabetes mellitus (7 patients), burns (7
patients), chronic ulcers (3 patients), and tumor (1 patient). The locations of defects were the dorsum
(21), ankle (12), medial (6), lateral (6), posterior heel (2), and distal sole (3). Concomitant bone
injury occurred in 5 cases, and the weight-bearing surface of the foot was involved in 5 patients. De-
fects ranged from 27 to 76 cm2 (mean 36.4 cm2). Successful reconstructions were accomplished in 46
cases (92%). Flap complications included total flap loss and below-knee amputation (1) and partial
flap loss (3); 75% of these patients had diabetes as a comorbid factor, and 25% (had a concomitant

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 Upper Extremity  •  8A: Lateral Arm Flap 805

bone injury. Six patients with dorsum defects required debulking of the flap (11.1%). None of the
patients required modified shoes. In the majority of cases, flaps provided stable coverage and a gain
in protective deep-pressure sensation. In long-term follow-up (up to 4 years), patients regained their
ambulation, free of pain. Even in weight-bearing areas, none of the patients developed ulceration or
skin breakdown. Free lateral arm flaps provided excellent durability, with solid bony union and suc-
cessful restoration of the contour of the foot in moderate-sized foot defects.
Windhofer C, Michlits W, Karlbauer A, et al. Treatment of segmental bone and soft-tissue de-
fects of the forearm with the free osteocutaneous lateral arm flap. J Trauma 70:1286-1290, 2011.
Complex defects of the forearm often require microvascular reconstruction with osteocutaneous free flaps
to salvage the limb. In this review, we report our experience with the use of the free osteocutaneous
lateral arm flap to reconstruct such defects in four patients. Three male patients with osseous defects
of the ulna and one defect of the radius with associated soft tissue defects were treated with a free os-
teocutaneous lateral arm flap. The indications for the procedure included three cases of posttraumatic
osteitis and one bone defect with soft tissue defects after trauma. The authors evaluated postoperative
results by evaluating the range of motion, pain, strength, and score on the disabilities of the arm,
shoulder, and hand questionnaire. Donor site morbidity was also documented. The average length of
segmental bone defects was 5.75 cm. The average dimension of the skin paddle was 99.5 cm. The
average follow-up was 43.3 months. All bone flaps healed without nonunion; the fasciocutaneous
flaps healed without complications. No problems related to microanastomoses were found. Functional
results were very satisfactory; disabilities of the arm, shoulder, and hand questionnaire scores showed
a median of 5.8 (0 to 10.8). All patients had returned to their preinjury occupations.
Wong M, Tay SC, Teoh LC. Versatility of the turn-around technique of lateral arm flap for
hand reconstruction. Ann Plast Surg 2011 Jul 5 [Epub ahead of print]
The lateral arm flap is a popular flap for hand resurfacing. Despite its many advantages, it is limited
by the available width of the flap. The authors described the application of this long and narrow flap
in a turn-around manner, greatly increasing its versatility while achieving primary closure of the donor
site. The lateral arm flap was designed with extension onto the forearm (extended lateral arm flap)
and harvested in the usual manner. During inset, the distal segment of the flap was brought through
a 180 degree U-turn to lie adjacent to the proximal segment. They analyzed the outcomes of 31
turn-around lateral arm flaps performed between 1988 and 2008. All flaps healed well without any
vascular compromise. Reconstruction of defects with a variety of configurations was performed with
a maximum flap size of 144 cm. Four patients required split skin grafting to the forearm. Primary
closure of the lateral arm donor site was achieved in all patients. The authors noted the ease, reli-
ability, and versatility of this simple modification in extending the usefulness of the lateral arm flap
in hand reconstruction.

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 ANATOMIC LANDMARKS
Landmarks Lies on the radial side of the forearm between the brachialis and
the triceps muscle.
Size 5 3 22 cm.
Origin Lateral supracondylar ridge of the humerus and lateral intermus-
cular septum.
Insertion Styloid process of the radius.
Function Arm flexion.
Composition Muscle.
Flap Type Type II.
Dominant Pedicle Radial recurrent artery.
Minor Pedicle Muscular branches of radial artery.
Nerve Supply Motor: Lateral muscular branches of radial nerve.

08b_BrachRad_r4b_bs_0806-0819.indd 806 1/31/2012 2:47:17 PM

 Section 8B
Upper Extremity

Brachioradialis Flap

CLINICAL APPLICATIONS
Regional Use
Upper extremity
Distant Use
Head and neck
Upper extremity
Specialized Use
Tendon transfer

08b_BrachRad_r4b_bs_0806-0819.indd 807 1/31/2012 2:47:18 PM

 ANATOMY OF THE Brachioradialis Flap

A
Flexor carpi radialis muscle Brachioradialis muscle

Palmaris longus
muscle
Flexor carpi Flexor carpi
superficialis muscle ulnaris muscle

Musculature of the medial forearm

B
Radial recurrent artery
Radial artery

Brachial artery
Arterial supply to the brachioradialis flap

C
Lateral antebrachial
cutaneous nerve Radial nerve

Nerve distribution

Fig. 8B-1 

Dominant pedicle: Radial recurrent artery

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 Upper Extremity  •  8B: Brachioradialis Flap 809

ANATOMY
Landmarks Lies on the radial side of the forearm between the brachialis and the triceps
muscle.
Composition Muscle.
Size 5 3 22 cm.
Origin Lateral supracondylar ridge of the humerus and lateral intermuscular septum.
Insertion Styloid process of the radius.
Function Arm flexion.

Arterial Anatomy (Type II)

Dominant Pedicle  Radial recurrent artery
Regional Source  Radial artery.
Length  3 cm.
Diameter  1 mm.
Location  Radial recurrent artery is in close proximity to the radial nerve and provides two
terminal branches to the proximal deep surface to the muscle.
Minor Pedicle  Muscular branches of radial artery
Regional Source  Radial artery.
Length  1 cm.
Diameter  0.6 mm.
Location  Segmental branches of the radial artery enter the muscle belly on its deep surface.

Venous Anatomy
Venae comitantes of the radial recurrent artery.

Nerve Supply
Motor Lateral muscular branches of the radial nerve.

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 810 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Brachioradialis Flap

A
D

Deep surface of flap

B
D

Radiographic view

Fig. 8B-2 

Dominant pedicle: Radial recurrent artery (D)

FLAP HARVEST
Design and Markings
A dorsal radial incision is made overlying the muscle.

Radial incision over muscle

Fig. 8B-3 

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 Upper Extremity  •  8B: Brachioradialis Flap 811

Patient Positioning
The patient is placed in the supine position. The arm is placed on a hand surgery table,
abducted 90 degrees at the shoulder. A tourniquet is used.

GUIDE TO FLAP DISSECTION

A dorsal radial incision is made from the level of the lateral epicondyle to the distal third of
the forearm. The posterior antebrachial cutaneous nerve and the lateral antebrachial lateral
cutaneous nerve are identified and preserved. The tendon of insertion is identified in the
distal forearm. The superficial branch of the radial nerve, which crosses dorsally, is pre-
served. The distal tendon is divided and the muscle is elevated proximally. The superficial
branch of radial nerve and radial artery are located beneath the brachioradialis muscle and
are retracted medially. The dominant vascular pedicle of the radial recurrent artery can
be seen entering the deep surface of the muscle. This marks the rotation point for muscle
transposition, and no further dissection is required.

A B

Flap after release of insertion Closeup view

C D

Flap elevated to show deep surface Closeup view

Fig. 8B-4 

Dominant pedicle: Radial recurrent artery (D)

08b_BrachRad_r4b_bs_0806-0819.indd 811 1/31/2012 2:47:20 PM

 812 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANT
Free Flap
Dissection proceeds similar to that of the standard flap. The pedicle in this case is dissected
proximally to its junction of the radial artery and venae comitantes. The radial artery and
venae comitantes are divided distal to the radial recurrent artery, and the proximal radial
artery and venae comitantes are dissected proximally until adequate pedicle length has been
obtained. The muscle is then released from its origin in the posterior humerus.
If the motor nerve is required for functional transfer, the radial nerve is dissected
proximally superior to the level of the radial condyle where the motor branch is identified
entering its deep surface.
The distal section of the brachioradialis muscle can be carried with the radial forearm
free flap (see Section 8D) based on its minor pedicle. As the radial forearm flap is dissected,
in this case muscular branches from the radial artery are preserved, providing vasculariza-
tion to the muscle.

ARC OF ROTATION
Based on its proximal vascular pedicle, the muscle will reach the antecubital fossa, upper
elbow, and distal upper arm.

Arc of rotation to elbow and antecubital fossa

Fig. 8B-5 

FLAP TRANSFER
Standard Flap
The flap is transferred by transposition to the recipient site.

Free Flap
Transfer of the brachioradialis as a free flap is performed using microsurgical principles.

FLAP INSET
The tendinous portion of the brachioradialis is used to secure the flap in place. Care is taken
to ensure that there is no excessive tension on the pedicle or kinking of the blood supply.

DONOR SITE CLOSURE

Primary closure of the donor site is obtainable in all cases.

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 Upper Extremity  •  8B: Brachioradialis Flap 813

CLINICAL APPLICATIONS
This 47-year-old woman had a maxillary tumor excised, leaving a large skin defect, a small
CSF leak, and open communication with the oropharynx. A radial forearm flap was chosen
with multiple skin paddles for this complex reconstruction, as well as some brachioradialis
muscle for repair of the CSF leak and soft tissue fill.

B C

D E F

Fig. 8B-6  A, The defect after resection. The area of CSF leak was in the posterior orbit after ex-
enteration. 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. (Case supplied by MRZ.)

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 814 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old truck driver sustained an open injury to the left elbow during a motorcycle
accident. There was soft tissue loss over the lateral epicondyle with exposed bone, open
radiocapitellar joint, and partial laceration of the triceps tendon.

Fig. 8B-7  A, Lateral soft tissue defect with exposed and ground-down lateral epicondyle. B, Dissec-
tion of the brachioradialis muscle. C, The muscle was elevated and D, rotated into the defect.

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 Upper Extremity  •  8B: Brachioradialis Flap 815

F G

H I

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. (Case courtesy Milan Stevanovic, MD.)

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 816 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Superficial and deep branches of the radial nerve are subject to injury during flap elevation.
• A tourniquet is recommended for flap dissection to maintain a bloodless field.
• Because of the size of the muscle and the paucity of perforator of the muscle to the skin,
an overlying skin island is unreliable.
• Skin grafting of the muscle is recommended when skin coverage is necessary.

Expert Commentary
Milan Stevanovic

Anatomic Considerations
The brachioradialis is a useful flap for local coverage of small to moderate soft tissue defects
on the posterior and lateral sides of the elbow. There is little functional deficit to the donor
site. Both the dominant arterial pedicle and the innervation to the muscle are proximal.
Preservation of the innervation to the muscle reduces the atrophy and fibrosis seen in de-
nervated muscle transfers.
The dominant arterial pedicle can arise from the brachial artery, recurrent radial artery,
or radial artery. All of the dominant pedicles enter the muscle in its proximal third, leav-
ing the distal two thirds of the muscle to be rotated. In addition, the muscle origin from
the lateral humerus can be released, increasing the ability to mobilize and rotate the flap.

Brachioradialis muscle

Extensor carpi
radialis longus

Extensor carpi
radialis brevis

Branches from radial recurrent artery

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.

Unique to the brachioradialis anatomy is the wide distal tendon that can be used as a
vascularized graft for reconstruction of the lateral ulnar collateral ligaments of the elbow.
It can also be used for reconstruction or augmentation of the distal triceps tendon.

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 Upper Extremity  •  8B: Brachioradialis Flap 817

Recommendations
Technique
The muscle should be dissected through a long incision over the middle of the muscle.
The distal insertion is divided from the distal radius. If tendon length is not needed, the
muscle is divided proximal to where the first extensor compartment muscles cross over
the brachioradialis tendon. The dissection can be performed with loupe magnification,
from distal to proximal. More proximally, the muscle is mobilized from lateral to medial.
The pedicles in the proximal third are all left intact until the muscle has been completely
dissected. Proximally, the radial nerve lies on the medial side of the brachioradialis muscle
between brachioradialis and brachialis.
The fascia should be completely released to allow more mobility to the muscle. After
determining the dominant pedicle, several distal branches can be ligated to allow a greater
arc of muscle rotation. If the tendon is needed for lateral ulnar collateral ligament or triceps
tendon reconstruction, the reconstruction is completed first, and the muscle belly is subse-
quently positioned to cover the soft tissue defect.

Branches from radial collateral artery

Fig. 8B-9  Medial side view of the brachioradialis

showing the relationship of the vascular pedicles deep
to the radial nerve.

Biceps Brachioradialis Radial

muscle muscle nerve

Take-Away Messages
The brachioradialis flap is ideal for small to moderate defects of the lateral, posterolateral,
and posterior elbow and can be used for lateral ulnar collateral ligament or triceps tendon
reconstruction. A greater arc of rotation can be achieved by releasing the fascia and the proxi-
mal origin and leaving only the proximal dominant pedicles. The surgeon must take care to
protect the radial nerve during proximal medial dissection. After the muscle is rotated, the
pedicles should be inspected to confirm that there is no tension or kinking of the pedicles.

Bibliography With Key Annotations

Binns M, Kueh KA, Pho RW. Brachioradialis forearm flap in a case of traumatic bone and skin
loss at the elbow. J Hand Surg Br 15:317-319, 1990.
The authors treated a patient with traumatic skin and bone loss at the elbow using a long brachioradialis
flap, which provided a thick, sensate cover and allowed early movements. Anatomic studies helped
describe the extent of this flap.
Daya M. Simultaneous total upper and lower lip reconstruction with a free radial forearm-
palmaris longus tendon and brachioradialis chimeric flap. J Plast Reconstr Aesthet Surg 63:e75-
e76, 2010.

08b_BrachRad_r4b_bs_0806-0819.indd 817 1/31/2012 2:47:34 PM

 818 Part II  Regional Flaps: Anatomy and Basic Techniques

Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and clinical implications.
Plast Reconstr Surg 98:195-210, 1996.
The authors explored the blood supply of the forearm, an area whose angiosome was not previously
described in the classic work by Drs. Taylor and Palmer in 1987. Ten upper limbs from fresh cadav-
ers were perfused with a radiopaque lead oxide solution. The arteries to the skin and the bones of the
forearm and a total of 200 muscles were examined. The angiosomes in the forearm supplied by the
brachial, radial, ulnar, and interosseous arteries were defined. The contribution from each angiosome
to the skin, muscles, radius, and ulna was identified. Territories were color coded to correspond with
source arteries. The authors reported that the connections between adjacent angiosomes occurred pre-
dominantly within tissues, not between them. The skin, bones, and most muscles received branches
from the source arteries of at least two angiosomes, explaining how circulation is maintained if a source
artery is interrupted by disease or trauma. Alternatively, several muscles were supplied within one
angiosome, explaining the variable clinical responses to interrupted circulation (for example, Volk-
mann’s ischemic contracture). Results of this study are useful for designing flaps from the forearm for
local or free transfer. Because most muscles are nourished from multiple angiosomes, techniques can be
refined to include only a part of a muscle. This anatomic information also explains how the supply
to remaining muscle groups is reconstituted when one of the source arteries is harvested with a skin
flap, a muscle, or part thereof.
Lai MF, Krishna BV, Pelly AD. The brachioradialis myocutaneous flap. Br J Plast Surg 34:
431-434, 1981.
The authors studied the vascular anatomy and defined cutaneous territories of the brachioradialis
myocutaneous flap in cadavers using intraarterial injection of methylene blue dye. They discuss treat-
ment of an exposed, open elbow joint with a proximal brachioradialis myocutanenous flap, based on
the vascular pedicle arising from the radial recurrent artery just distal to the elbow level. Advantages
and disadvantages of this flap are presented.
Leversedge FJ, Casey PJ, Payne SH, et al. Vascular anatomy of the brachioradialis rotational
musculocutaneous flap. J Hand Surg Am 26:711-721, 2001.
The authors performed a two-part vascular injection study to determine (1) the sources of blood to the
brachioradialis muscle and the distance the brachioradialis muscle flap may be rotated for local soft tis-
sue reconstruction and (2) the fasciocutaneous vascular perfusion territory associated with the vascular
pedicle of the brachioradialis muscle flap. To reveal the contribution of the isolated radial recurrent
artery (RRA) and 3 cm and 6 cm segments of radial artery (RA) to a rotation brachioradialis muscle
flap, they injected lead oxide into 16 fresh frozen human upper extremity amputation specimens.
The RRA perfused an average of 41% of the brachioradialis muscle. Selective injection of the RRA
and the proximal 3 cm segment of the RA perfused 80% of the muscle length, or at least 90% of
muscle volume. Flap rotation consistently provided adequate coverage of the antecubital fossa, lateral
elbow, and proximal third of the volar forearm. To quantify the fasciocutaneous perfusion territory of
the isolated vascular pedicle, India ink injection studies were performed in 10 fresh frozen cadaveric
specimens. Fasciocutaneous perfusion was consistent directly over the muscle belly, but no specimen
was perfused more than about 1 cm distal to the myocutaneous junction.
McGeorge DD, Arnstein PM, Stilwell JH. The distally-based brachioradialis muscle flap. J
Plast Surg Br 44:30-32, 1991.
The authors describe their experience with the brachioradialis muscle flap based distally on the radial
artery. They conclude that it can be raised quickly and provides excellent coverage for soft tissue defects
of the hand. The use of the brachioradialis tendon for extensor tendon reconstruction is also discussed.
Reece EM, Oishi SN, Ezaki M. Brachioradialis flap for coverage after elbow flexion contracture
release. Tech Hand Up Extrem Surg 14:125-128, 2010.
With careful preoperative planning, the brachioradialis muscle can provide adequate surface area for
covering the deep antecubital neurovascular structures, often required after a chronic elbow flexion con-
tracture is released. Local rotation or transposition flaps can cover skin defects, but not deeper structures.

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 Upper Extremity  •  8B: Brachioradialis Flap 819

The brachioradialis muscle is a secondary flexor of the elbow and has a robust vascular anatomy that
can support a skin paddle. Its removal causes minimal functional morbidity.
Sanger JR, Ye Z, Yousif NJ, et al. The brachioradialis forearm flap: anatomy and clinical ap-
plication. Plast Reconstr Surg 94:667-674, 1994.
To determine the blood supply to the brachioradialis muscle and skin of the forearm, the authors
performed late-injection studies. The dominant perforator to the muscle was from the brachial artery
(27.3%), radial recurrent artery (33.3%), or radial artery (39.4%). Perforators from the radial artery
were consistently present, confirming that transfer as either a muscle or myocutaneous free flap based
on this vessel is possible. The authors dissected the septocutaneous perforators from the radial artery
in 10 arms to examine the relationship between the forearm and brachioradialis flaps. It is possible to
transfer the brachioradialis muscle as a free flap or combined with the radial artery forearm flap based
on the radial artery and either the venae comitantes and/or the cutaneous veins. Four clinical cases
were presented.
Selvan SS, Chandran TC, Alalasundaram KV, et al. Extensor compartments of the forearm: a
preliminary cadaveric study. Plast Reconstr Surg 115:1447-1449, 2005.
The authors retrospectively reviewed all vascular thromboses and intraoperative technical difficulties
with free flaps performed in a 5-year period in one institution to determine whether intraoperative
vascular complications predict postoperative vascular thrombosis and flap loss. All flaps were performed
for breast reconstruction. They compared flaps with a routine intraoperative course with those that had
an intraoperative complication. They reviewed data from 173 free flaps in 804 patients and conclude
that intraoperative vascular problems increase the risk of a postoperative vascular complication and
flap loss. Postoperative vascular complications are apparently not overtly affected by specific surgical
intervention or choice of anticoagulation during an intraoperative problem.
Shen S, Pang J, Seneviratne S, et al. A comparative anatomical study of brachioradialis and
flexor carpi ulnaris muscles: implications for total tongue reconstruction. Plast Reconstr Surg
121:816-829, 2008.
The authors compared the neurovascular anatomy of the brachioradialis and flexor carpi ulnaris muscles
to evaluate their possible use as donor muscles, together with overlying skin, for functional total or
subtotal tongue reconstruction. They examined 88 brachioradialis and 80 flexor carpi ulnaris muscles
from a total of 120 dissected specimens. They also performed 18 arterial studies, two venous studies,
20 histologic studies, and eight neurovascular studies. In the brachioradialis muscle, the major pedicle
arose from the radial (38%), radial recurrent (42%), and brachial arteries (20%). The muscle had
no single neurovascular pedicle. With the flexor carpi ulnaris muscle, the ulnar artery consistently
supplied the dominant pedicle in 86% of cases. The entry point of motor innervation is near that of
the vascular pedicles. The main vascular pedicle was accompanied by a minor distal nerve in 65% of
cases. The overlying skin was supplied by myocutaneous perforators. The skin over the brachioradialis
was innervated by the lower lateral cutaneous nerve of the arm. Sensation over the flexor carpi ulnaris
was from the medial cutaneous nerves of the arm and forearm. In conclusion, the flexor carpi ulnaris
has anatomic advantages over the brachioradialis for total or subtotal tongue reconstruction.
Takada K, Sugata T, Yoshiga K, et al. Total upper lip reconstruction using a free radial forearm
flap incorporating the brachioradialis muscle: report of a case. J Oral Maxillofac Surg 45:959-
962, 1989.
The authors presented a case of upper lip reconstruction with a free radial forearm flap. The procedure
was performed in one stage, with excellent aesthetic and functional results. In conclusion, the free
radial forearm flap, including the vascularized and innervated brachioradialis muscle, is useful for a
variety of lip defects.

08b_BrachRad_r4b_bs_0806-0819.indd 819 1/31/2012 2:47:34 PM

 ANATOMIC LANDMARKS
Landmarks Flap is centered on a line between the lateral humeral epicondyle
and distal radial joint in the midforearm, between the radial and
ulnar bones.
Size 15 3 7 cm.
Composition Fasciocutaneous.
Dominant Pedicle Posterior interosseous artery (PIA).
Minor Pedicle Anterior interosseous artery (AIA).
Nerve Supply Sensory: Lower branch of the dorsal antebrachial nerve (C5 to
C8). Medial antebrachial cutaneous nerve (C8 to T1).

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 Section 8C
Upper Extremity

Posterior
Interosseous Flap

CLINICAL APPLICATIONS
Regional Use
Elbow
Forearm
Wrist
Hand

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 ANATOMY OF THE Posterior Interosseous Flap

A Extensor carpi radialis longus muscle

Extensor carpi radialis brevis muscle Extensor digitorum muscle

Abductor pollicis longus muscle

Extensor pollicis brevis muscle 

Brachial artery
Interosseous artery Extensor digiti minimi muscle

Extensor carpi ulnaris muscle

Vascular and muscular anatomy

B Radial artery Posterior interosseous nerve

Radial nerve
Posterior interosseous artery
Anterior interosseous artery

Brachial artery
Ulnar artery Perforators of posterior
interosseous artery
Interosseous artery

Nerve distribution

Fig. 8C-1 

Dominant pedicle: Posterior interosseous artery

Minor pedicle: Anterior interosseous artery

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 Upper Extremity  •  8C: Posterior Interosseous Flap 823

ANATOMY
Landmarks Flap is centered on a line between the lateral humeral epicondyle and distal radial
joint in the midforearm, between the radial and ulnar bones.
Composition Fasciocutaneous.
Size 15 3 7 cm.

Arterial Anatomy
Dominant Pedicle  Posterior interosseous artery
Regional Source  Common interosseous artery or ulnar artery.
Length  5 cm.
Diameter  1.5 mm.
Location  Posterior interosseous artery; 1 cm after origin from the ulnar artery, the common
interosseous artery divides into the anterior and posterior interosseous arteries. The PIA, which
is smaller than the AIA, passes between the oblique cord in the upper border of the interosseous
membrane. It emerges at the lower border of the supinator in the lower forearm. It descends in
the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi. In the
proximal third of the forearm, the PIA lies deep with the posterior interosseous nerve. More
distally, it becomes superficial on the extensor pollicis longus and the extensor indicis muscles.
The PIA receives an anastomotic branch from the AIA 3 cm proximal to the distal radial ulnar
joint and then extends to join a dorsal carpal arch. In the intermuscular septum between the
extensor carpi ulnaris and extensors digiti minimi, the PIA gives off four to seven septocutane-
ous perforators as well as muscular branches. In its middle third, the PIA consistently gives off
a middle cutaneous perforator, the vena comitans of which is a communicating vein between
the superficial and deep veins of the flap. Because of this, this perforator should be included in
the flap to improve drainage.
Minor Pedicle  Anterior interosseous artery
Regional Source  Common interosseous artery or ulnar artery.
Length  4 to 5 cm.
Diameter  1.5 to 1.7 mm.
Location  Pedicle courses on the palmar surface of the interosseous membrane deep to the flexor
digitorum profundus and flexor pollicis longus muscles. At the superior border of the pronator
quadratus the pedicle pierces the interosseous membrane to anastomose with the PIA.

Venous Anatomy
There are one or two venae comitantes that accompany the PIA, with diameters of 2 to 3 mm.

Nerve Supply
Sensory Lower branch of the dorsal antebrachial nerve (C5 to C8), pierces the deep fascia
beneath the level of the deep deltoid. The nerves course along the lateral side of
the upper arm and elbow and enter the flaps on the dorsal forearm. The medial
antebrachial cutaneous nerve (C8 to T1) courses medially to the basilic vein and
anterior to the medial epicondyle.

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 824 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Posterior Interosseous Flap

Anterior interosseous artery perforator Posterior interosseous artery

Extensor digiti minimi Lateral epicondyle

Fig. 8C-2  The distally based posterior interosseous flap can be designed based on the anterior in-
terosseous 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. (Dissection courtesy Steven F. Morris, MD.)

FLAP HARVEST
Design and Markings
The PIA flap is drawn centered on a line from the lateral epicondyle of the humerus to the
distal radial ulnar joint. The flap is centered at the middle and distal thirds of the line with
a width of 5 to 7 cm. Distally, the flap ends 4 cm above the wrist joint to avoid damaging
the dorsal branch of the ulnar nerve. The flap may extend superficially 2 to 3 cm above the
emergence of the PIA.

Flap design

Fig. 8C-3 

Patient Positioning
The patient is placed in a supine position with the arm on a hand table.

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 Upper Extremity  •  8C: Posterior Interosseous Flap 825

GUIDE TO FLAP DISSECTION

The radial border of the flap is incised through the deep fascia and is then elevated toward
the intermuscular septum. Once the extensor digiti minimi is reached, the septocutaneous
perforator of the PIA can be visualized.

A Extensor digiti minimi muscle

Extensor digitorum muscle

Perforators of
posterior interosseous artery

Elevation of radial portion of flap

Fig. 8C-4 

These perforators are traced to the intermuscular septum between the extensor carpi
ulnaris and the extensor digiti minimi. After the muscular branches are ligated, retraction
of the extensor digiti minimi radially exposes the PIA. With further dissection, the com-
municating branch with the AIA can also be identified.

B Posterior interosseous artery

and venae comitantes
Extensor digitorum muscle
Communicating branch
Extensor digiti minimi muscle with anterior interosseous artery

Posterior interosseous nerve Perforators of

posterior interosseous artery

Approach to PIA

Fig. 8C-4 

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 826 Part II  Regional Flaps: Anatomy and Basic Techniques

The ulnar border of the flap is incised, carefully preserving the dorsal branch of the ulnar
nerve after the PIA and its perforating branches are visualized. The anastomotic branch of
the AIA is ligated, and the flap is elevated from distal to proximal.

C Extensor digiti minimi muscle

Extensor digitorum muscle
Posterior interosseous nerve
Communicating branch
with anterior interosseous artery

Posterior interosseous artery Dorsal branch

and venae comitantes of ulnar nerve

Elevation of ulnar portion of flap

Fig. 8C-4 

Pedicle dissection occurs between the extensor carpus ulnaris and the extensor digiti
minimi. The posterior interosseous nerve lies radial to the artery and the nerve should
be protected. After ligation of the interosseous recurrent artery the posterior interosseous
vascular pedicle is dissected proximally beneath the supinator muscle.

D Posterior interosseous nerve

Extensor digiti minimi muscle
Extensor digitorum muscle

Supinator muscle
Posterior interosseous artery
and venae comitantes

Pedicle dissection

Fig. 8C-4 

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 Upper Extremity  •  8C: Posterior Interosseous Flap 827

FLAP VARIANT
Reverse Flap
The flap design is positioned more proximally compared with that of the standard flap.
The design is mainly in the middle third of the forearm, again on a line from the lateral
epicondyle of the humerus to the distal radial ulnar joint.

Point of rotation

Flap design

Fig. 8C-5 

The rotation point for the flap is 3 cm proximal to the distal radial ulnar joint. The
radial border of the flap is incised and raised with the deep fascia toward the intermuscular
septum. Dissection proceeds in the septum to expose the PIA and nerve in the midpoint
of the PIA. The surgeon carefully identifies the middle septocutaneous perforator, which
contains the communicating vein between the superficial and deep system in the forearm.
This perforator should be included in the flap to improve venous drainage.

B Extensor carpi
ulnaris muscle
Extensor digiti minimi muscle
Supinator muscle
Extensor digitorum muscle

Posterior interosseous artery Perforators of

and venae comitantes posterior interosseous artery

Elevation of radial portion and approach to PIA

Fig. 8C-5 

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 828 Part II  Regional Flaps: Anatomy and Basic Techniques

The skin incision is then extended distally along the line of the intermuscular septum.
The cutaneous perforator is identified and preserved. Retraction of the forearm muscles
exposes the posterior interosseous vessels. Dissection proceeds distally to identify the anas-
tomotic branch with the AIA, which comes from beneath the extensor indicis proprius.
All branches that join the dorsal carpal arch distally must be preserved.

C Extensor carpi ulnaris muscle

Posterior interosseous nerve

Supinator muscle Extensor digiti minimi muscle

Extensor digitorum muscle

Posterior interosseous artery Anastomotic branch with

and venae comitantes anterior interosseous artery

Dissection of distal portion of pedicle

Fig. 8C-5 

After flap elevation, the surgeon may clamp the proximal vessels and release the tour-
niquet to assess perfusion of the flap through this retrograde supply. After this is confirmed,
the proximal end of the vascular pedicle is ligated.

D Extensor carpi ulnaris muscle

Posterior interosseous nerve
Extensor digitorum muscle
Supinator muscle
Extensor digiti minimi muscle

Posterior interosseous artery Anastomotic branch with

and venae comitantes anterior interosseous artery

Complete raising of flap

Fig. 8C-5 

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 Upper Extremity  •  8C: Posterior Interosseous Flap 829

ARC OF ROTATION
Standard Flap
The standard flap covers defects on the antecubital fossa and proximal volar forearm.

Arc to antecubital fossa and proximal forearm

Fig. 8C-6 

Reverse Flap
A reverse flap will cover defects of the distal wrist, hand, first web space, and proximal thumb.

Point of rotation

Arc to hand

Fig. 8C-7 

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 830 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP TRANSFER
Standard and Reverse Flaps
Flaps are transferred by transposition to the recipient site with direct incision or through a
subcutaneous tunnel.

FLAP INSET
All Types
The flap is inset without tension; the vascular pedicle must not be compressed.

DONOR SITE CLOSURE

With a skin island of less than 6 cm, primary closure is possible. A larger skin island requires
skin grafting.

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 Upper Extremity  •  8C: Posterior Interosseous Flap 831

CLINICAL APPLICATIONS
This 51-year-old man developed a malignant fibrous histiocytoma in the distal forearm and
wrist area. A reverse PIA flap was chosen for reconstruction. This flap is available locally,
with good color and texture match.

A B

C D

E F

G H

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. (Case courtesy Minoru Shibata, MD.)

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 832 Part II  Regional Flaps: Anatomy and Basic Techniques

This boy, 3 years and 4 months old, presented with brachysyndactyly of the left thumb. A
reverse PIA flap is as excellent choice for reconstruction of first web defects, such as the one
created by this secondary reconstruction.

A B

C D

E F G

H I

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. (Case courtesy Minoru Shibata, MD.)

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 Upper Extremity  •  8C: Posterior Interosseous Flap 833

This 32-year-old man had injured the first web space of his right hand. He developed a
contracture of the first web space that required release of soft tissue, fascia, and joint capsule
to restore function. A distally based PIA flap was used to close the defect.

B C

D E

F G

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. (Case courtesy
Guenter Germann, MD.)

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 834 Part II  Regional Flaps: Anatomy and Basic Techniques

This 25-year-old farmer caught his right hand in the power take-off on a farm tractor,
resulting in amputation of four fingers of his right (dominant) hand. They were nonreplant-
able. The wound was reconstructed with a distally based PIA flap.

A B C

D E

F G

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. (Case courtesy Steven F. Morris, MD.)

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 Upper Extremity  •  8C: Posterior Interosseous Flap 835

Pearls and Pitfalls

• The flap is most commonly used as a reverse flap to cover defects of the hand or wrist.
• Use of a tourniquet is recommended for flap elevation and identification of the posterior
interosseous pedicle and motor nerve branches in the vicinity.
• For the reverse flap, a wide tunnel is required to avoid compression of the minor pedicle
beneath the skin bridge.
• If there is inadequate venous drainage of the flap, anastomosis may be performed between
the superficial vein at the distal flap edge and the hand.
• Whether reverse or free, the posterior interosseous flap is advantageous in that it does
not require division or sacrifice of a major artery of the hand.
• This donor site provides a skin flap with good texture, thinness, and color match for
hand reconstruction.

Expert Commentary
Michael W. Neumeister

The PIA flap was first described by Angrigiani and Zancolli in 1986, and by Penteado and
Masquelet in the same year. The flap is versatile because of its long pedicle, location, and
ability to cover the dorsal or volar aspect of the hand, forearm, and elbow. It can also be
harvested as a free flap and used for recipient sites throughout the body.

Indications
The main indication for the PIA flap is coverage of dorsal hand and first web space defects.
The flap is typically harvested as a reverse-flow pedicled flap based at the wrist, with direct
communications with the anterior interosseous artery on the volar aspect of the forearm. The
reverse-flow PIA flap is also indicated for volar forearm and hand defects. As an antegrade
flap, it be used to cover more proximal forearm defects, including those on the anterior and
posterior aspects of the elbow.

Advantages and Limitations

The main advantage of the PIA flap is that it can be used as a regional pedicled flap for
coverage of elbow, forearm, wrist, and hand defects. It can be harvested as a fascial flap,
fasciocutaneous flap, or osteocutaneous flap. As noted previously, it can be harvested as an
antegrade or retrograde flap, allowing versatility in its design and application. Microsur-
gery is not required, although occasionally venous outflow can be augmented through an
anastomosis with superficial veins within the skin paddle.
Continued

08c_PostInter_r4_cah_0820-0841.indd 835 1/31/2012 3:17:17 PM

 836 Part II  Regional Flaps: Anatomy and Basic Techniques

The flap has numerous limitations. The artery itself can be extremely small, particularly
at its most distal aspect. The main perforator into the skin paddle can also be too distal to
provide optimal pedicle length for skin coverage in the hand. The dissection can be rather
tedious where the vessel courses between the extensor carpi ulnaris and the extensor digiti
quinti muscles. The pedicle can be somewhat more superficial toward the distal forearm and
wrist, so caution is warranted as the dissection proceeds distally. The blood supply to the
skin paddle can be somewhat precarious, especially if larger amounts of tissue are required
for a given defect. Flap necrosis and partial necrosis can occur. If the donor site is wider
than 6 to 7 cm, it cannot be closed primarily. Flaps designed with a smaller width can be
closed primarily; otherwise, a split-thickness skin graft is required for closure.

Anatomic Considerations
The main perforator for the PIA flap arises just distal to the supinator muscle in the junc-
tion between the proximal third and distal two thirds of the extensor forearm. The flap
can be designed distally or proximally around this middle third. The posterior interos-
seous artery communicates with the anterior interosseous artery at a level approximately
5 cm proximal to the ulnar styloid. This is the pivot point for the flap if it is distally based.
A Doppler study should be performed preoperatively to help locate the perforators within
the skin paddle.

Personal Experience and Insights

For dorsal hand or first web space defects, the flap is islandized on its pedicle and can be
tunneled into the first web space quite easily. Taking an extended skin paddle distally in the
shape of an ice cream cone can also aid in the flap inset if tunneling seems too constrictive.
The flap is usually quite narrow; therefore the posterior interosseous artery flap should be
used for smaller defects only. The skin paddle is usually not very bulky, but the donor site
can often leave significant scars, which limits the use of this flap, in my experience. I find
this flap to be rather tedious in its dissection, limiting its use. The major benefit of this flap
is that it is a regional flap located close to the zone of injury, and it does not utilize one of
the major arteries to the hand. The pedicle can be rather small near the pivot point at the
wrist; therefore, care must be taken not to avulse or place tension on the pedicle, which
would compromise the skin paddle.
If the flap is tunneled, the surgeon must not place undue pressure on the pedicle, because
this will result in vascular compromise and flap necrosis. Many surgeons opt not to tunnel
the flap but instead divide the bridge from the pivot point of the flap to the defect on the
hand. Flap congestion can occur; therefore the superficial vein should be preserved within
the flap so that venous outflow can be reestablished through a microsurgical anastomosis.
Better donor flaps are available for larger defects on the hand or first web space. The
skin paddle can be as wide as 10 cm based on the posterior interosseous artery, but the donor
site would require skin grafting, and in my opinion, that creates too much scar tissue and
is extremely unsightly. This flap should not be used if the defect is large.

Recommendations
Planning
To design the flap, the pedicle is identified first. The arm is positioned in pronation and a
line drawn from the lateral epicondyle to the distal radioulnar joint. This line is divided into
thirds, and Doppler ultrasonography is used to identify the perforator, which should emerge
around the level of the junction of the proximal third and distal two thirds of that line.

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 Upper Extremity  •  8C: Posterior Interosseous Flap 837

This is located approximately 7 to 10 cm distal to the lateral epicondyle. Fig. 8C-12 illustrates
the design of the skin paddle and a reverse posterior interosseous artery flap.

Fig. 8C-12  The posterior interosseous flap designed in the forearm.

Technique
The radial incision is made and the dissection carried down through the antebrachial fas-
cia toward the intermuscular septum between the extensor carpi ulnaris and the extensor
digiti quinti. The posterior interosseous artery should be identified between these muscle
bellies at the level of the interosseous membrane. The posterior interosseous nerve should
be preserved at this level. As this nerve enters the dorsal compartment of the forearm, it
supplies the extensor carpi ulnaris, extensor digiti quinti, and extensor digitorum commu-
nis. The nerve and artery may crisscross in the more proximal aspect of the forearm. The
nerve is usually more radial and deeper than the artery. Before becoming a sensory nerve,
the posterior interosseous nerve innervates the abductor pollicis longus, extensor pollicis
brevis, extensor pollicis longus, and extensor indicis proprius, which is the last muscle belly
innervated by the nerve. Care must be taken not to denervate the extensor muscles while
dissecting the pedicle of the posterior interosseous artery flap. The dorsal cutaneous branch
of the ulnar nerve should also be preserved as the dissection is carried from proximal to
distal. The dorsal cutaneous branch of the ulnar nerve is often found 6 cm proximal to the
ulnar carpal joint.
It is often easier to raise the flap from radial to ulnar until the septum is identified be-
tween the extensor carpi ulnaris and the extensor digiti quinti muscles. The muscles are then
retracted as the flap is elevated from proximal to distal. The posterior interosseous artery is
ligated as it emerges from the distal aspect of the supinator. The posterior interosseous nerve
is dissected to free up the pedicle, at least until the final branches to the extensor indicis
proprius have been located. The flap is then transferred into the defect on the dorsum of
the hand or first web space. A Penrose drain is placed for drainage from below the flap, and
the donor site is closed primarily. A volar wrist splint is applied for approximately 2 weeks
after the surgery, and subsequently, range of motion exercises are initiated.
The PIA flap can also be harvested as a sensate flap, preserving branches of the posterior
cutaneous nerve of the forearm. Other variations of the flap elevation include harvesting
the flap as a fascial flap or osteocutaneous flap. The small portion of the extensor pollicis
longus muscle belly must be harvested with the ulna to preserve the vascularity, because a
small segment of bone is required with the flap.

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 838 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Agir H, Sen C, Alagöz S, et al. Distally based posterior interosseous flap: primary role in soft-
tissue reconstruction of the hand. Ann Plast Surg 59:291-296, 2007.
The authors reviewed a series of 15 consecutive patients with various hand defects covered with a
distally based posterior interosseous flap. Twelve flaps survived completely. Partial distal necrosis oc-
curred in three flaps; no surgery was required. One patient developed radial nerve palsy that resolved
after 3 months. In flaps 4 cm wide or less, the donor site was closed directly, and larger flaps were skin
grafted. Main indications were presented.
Akinci M, Ay S, Kamiloglu S, et al. The reverse posterior interosseous flap: a solution for flap
necrosis based on a review of 87 cases. J Plast Reconstr Aesthet Surg 59:148-152, 2006.
The goal of this report was to better understand the relationship between flap necrosis and the place-
ment of the flaps on the forearm. The authors reviewed 87 consecutive posterior interosseous island
flaps used for hand and wrist reconstruction. Fifty-eight flaps were from the middle and proximal
thirds of the forearm. In 24 of these, the distal edges were within the middle third of the forearm, and,
in 34 the distal edges were within the distal third of the forearm. Twenty-nine flaps were harvested
within the boundaries of the distal two thirds of the forearm. Seventy-eight flaps completely survived.
Superficial necrosis occurred in the distal part of three flaps. Three flaps failed. Partial necrosis appeared
to be related to the donor site. The authors concluded that the reverse posterior interosseous flap should
include the septocutaneous perforators in the distal third of the forearm. To cover distant defects by a
flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece
of skin with numerous perforators.
Balakrishnan G, Kumar BS, Hussain SA. Reverse-flow posterior interosseous artery flap re-
visited. Plast Reconstr Surg 111:2364-2369, 2003.
The authors shared their experience using the reverse-flow posterior interosseous artery flap in 53
patients. Defects included small defects on the dorsum of the hand, first web, and volar aspect of the
wrist, as well as combined defects on the dorsum of the hand and forearm, palm, and first web, ex-
tending onto the dorsum of the hand. They discussed modifications in how they raised the flap and in
the shape and route of transposition to avoid pedicle compressions. Tip necrosis occurred in four flaps,
and the pincushion effect occurred in 10 flaps. One patient developed a hypertrophic scar. Advantages
and disadvantages were described.
Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction.
Plast Reconstr Surg 108:897-901, 2001.
The authors shared their results using the posterior interosseous free flap with an extended pedicle
in nine patients with hand defects. All flaps were designed over the dorsal distal forearm, and donor
sites were closed directly. All transfers were successful, and donor site morbidity was minimal. The
authors concluded that, despite the tedious dissection required, the vascular pedicle was suitable for
microanastomosis. The skin island was thin, though hairy. The posterior interosseous free flap with an
extended pedicle may be a good choice when thin skin is limited and a long vascular pedicle is needed.
Cavadas PC, Ibañez J, Landin L, et al. Use of the reversed posterior interosseous flap in staged
reconstruction of mutilating hand injuries before toe transfers. Plast Reconstr Surg 122:1823-
1826, 2008.
The authors presented results from nine patients who underwent reconstruction following metacarpal
hand amputations. In the primary reconstructions (six), the posterior interosseous pedicled flap provided
skin coverage to the metacarpal stumps. In the three delayed cases, the flap provided extra skin for
operations performed at a later date. All flaps survived. One required venous supercharging because
of venous supercharging. Advantages and disadvantages of this flap were discussed.

08c_PostInter_r4_cah_0820-0841.indd 838 1/31/2012 3:17:17 PM

 Upper Extremity  •  8C: Posterior Interosseous Flap 839

Cheema TA, Lakshman S, Cheema MA, et al. Reverse-flow posterior interosseous flap: a
review of 68 cases. Hand (N Y) 2:112-116, 2007.
Over the course of 10 years, the authors performed a reverse-flow posterior interosseous flap in 68
patients. Sixty-six flaps were fasciocutaneous, and two were osteofasciocutaneous. These flaps were
used for volar and dorsal traumatic hand defects, first web space defects, thumb reconstruction, and repair
of congenital anomalies. Sixty flaps survived uneventfully. Four flaps developed partial necrosis, and
four flaps completely necrosed. The authors concluded that the most important factor for flap survival
was the inclusion of at least two perforators to supply the skin paddle.
Coban YK, Gumus N, Cetinus E. Triangular design and V-Y closure of donor site of posterior
interosseous artery flap. Plast Reconstr Surg 114:264-266, 2004.
Costa H, Pinto A, Zenha H. The posterior interosseous flap: a prime technique in hand recon-
struction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr
Aesthet Surg 60:740-747, 2007.
Based on their results of 102 clinical cases and 100 anatomic dissections, the authors reported the
indications for the posterior interosseous flap for reconstructing hand defects. Even when the radial or
ulnar pedicles were damaged, large fasciocutaneous island flaps could be harvested. One advantage
is that the posterior interosseous artery is a vessel of secondary importance for hand vascularization.
Fasciocutaneous and osteofasciocutaneous island distally based flaps could be tailored. The major indica-
tions for this flap are reconstruction of the first web space up to the interphalangeal joint of the thumb,
dorsal hand defects up to the metacarpal joints, and large defects on the palm-ulnar border of the hand.
Ishiko T, Nakaima N, Suzuki S. Free posterior interosseous artery perforator flap for finger
reconstruction. J Plast Reconstr Aesthet Surg 62:e211-e215, 2009.
The authors presented their experience of successfully transplanting two free posterior interosseous
artery perforator flaps that had been harvested simultaneously from a single posterior interosseous
artery system to the index and middle fingers of a 19-year-old man.
Koch H, Kursumovic A, Hubmer M, et al. Defects on the dorsum of the hand—the posterior
interosseous flap and its alternatives. Hand Surg 8:205-212, 2003.
The authors performed the posterior interosseous flap in 30 patients to close defects on the dorsum of
the hand. In four other patients, free lateral arm and temporoparietal fascial flaps were used because
of severe trauma to the wrist and distal forearm with potential impairment of the pedicle, a complex
defect requiring a composite flap, or an anatomic variation. All flaps survived. Marginal flap necrosis
developed in two posterior interosseous flaps. Flaps based on the main vessels of the forearm were not
used because of their significant donor site morbidity.
Lim YJ, Sebastin SJ, Fong PL, et al. Extending the reverse posterior interosseous artery flap
using a de-epithelised bridge segment. J Plast Reconstr Aesthet Surg 63:e111-e113, 2010.
Lu LJ, Gong X, Lu XM, et al. The reverse posterior interosseous flap and its composite flap:
experience with 201 flaps. J Plast Reconstr Aesthet Surg 60:876-882, 2007.
The authors reported their experience using the reverse posterior interosseous flap and its composite
flap in 201 cases. The fasciocutaneous flap was used to cover skin defects over the distal third of
the forearm, wrist, and hand. The composite flap with the vascularized ulna bone graft was used to
reconstruct thumbs in 11 cases, and the composite flap with vascularized tendon graft was used to
repair tendon defects with skin defects in 16 cases. One flap failed completely. Of the 200 flaps that
survived, 16 had venous congestion and partial necrosis at the distal end. Six months postoperatively,
in all patients who were followed, the flap generally matched surrounding skin. However, 10 cases had
a lipectomy. The sensibility did not recover or achieved S1 within 6 months. For the extensor tendon
defect, the function of finger extension was nearly normal, and tenolysis was not required. In contrast,
tenolysis was required after the flexor tendon reconstruction, but these patients refused surgery. Bone

08c_PostInter_r4_cah_0820-0841.indd 839 1/31/2012 3:17:17 PM

 840 Part II  Regional Flaps: Anatomy and Basic Techniques

grafts healed within 3 months. The reconstructed thumb looked abnormal, but lacked normal sensi-
bility, although the patients used them. The authors concluded that the reverse posterior interosseous
flap was a reliable method to cover skin defects over the distal third of the forearm, wrist, and hand.
Page R, Chang J. Reconstruction of hand soft-tissue defects: alternatives to the radial forearm
fasciocutaneous flap. J Hand Surg Am 31:847-856, 2006.
In this article, the authors focused on the surgical technique, specific limitations, and indications for the
radial forearm fascial flap, the posterior interosseous artery flap, the retrograde radial artery perforator
flap, and the dorsal ulnar artery flap. They proposed a reconstructive algorithm for flap selection.
Pan ZH, Jiang PP, Wang JL. Posterior interosseous free flap for finger re-surfacing. J Plast
Reconstr Aesthet Surg 63:832-837, 2010.
The authors performed 12 posterior interosseous free flaps, including two dual-paddle flaps, and
reported their clinical experience and surgical methods. The posterior interosseous vessels were ligated
below the level where the motor branch to the extensor carpi ulnaris crossed the vessel superficially. All
donor sites were closed directly. All flaps survived completely. Results were cosmetically acceptable in
all but one patient in whom defatting of the flap was performed in the late postoperative period. Static
two-point discrimination scores averaged 11 mm. Seven patients had normal joint flexion and exten-
sion. Two patients with fracture and flexor injuries recovered near-normal flexion and extension after
flexor release. The other patients had partial preoperative joint stiffness and recovered partial flexion.
Puri V, Mahendru S, Rana R. Posterior interosseous artery flap, fasciosubcutaneous pedicle
technique: a study of 25 cases. J Plast Reconstr Aesthet Surg 60:1331-1337, 2007.
The authors attempted to improve the versatility of the posterior interosseous artery (PIA) flap to
decrease flap complication rates. They used this flap to resurface 25 cases of distal forearm, hand, and
finger defects. Flap types were: 23 adipofascial, 1 fascial, and 1 osteocutaneous. Doppler analysis
was part of the preoperative planning. The anatomy and distal reach of the flap were noted. Flaps
were raised from the zone of injury if Doppler confirmed the presence of good perforators. A large
amount of fascia and subcutaneous tissue was included with the flap, which may have explained the
survival of larger flaps, absence of venous congestion, and the low complication rate. To improve the
distal reach of the flap to the distal interphalangeal joint, they exteriorized the pedicle, bowstringing
it across the extended wrist. The pedicle was covered with a split-thickness skin graft and divided 3
weeks later under local anesthesia. Three minor complications occurred.
Rozen WM, Hong MK, Ashton MW, et al. Imaging the posterior interosseous artery with
computed tomographic angiography: report of a rare anomaly and implications for hand re-
construction. Ann Plast Surg 65:300-301, 2010.
Anatomic variations in the posterior interosseous artery have been widely described and, in some cases,
are the reasons cited for flap failures or conversion to alternative salvage procedures. The authors reported
on a new technique, CTA, for imaging this artery preoperatively. This noninvasive method can be
used to highlight anatomy to facilitate safe planning for alternative reconstructive options in complex
cases. The authors described a unique case in which the posterior interosseous artery was completely
absent throughout its course. With preoperative imaging, they were able to achieve a good outcome.
Sauerbier M, Unglaub F. Perforator flaps in the upper extremity. Clin Plast Surg 37:667-676,
2010.
In this article, the authors reported on the possibilities for defect coverage with perforator flaps, and
discussed anatomic and technical considerations. Lateral arm, posterior interosseous artery, ulnar artery,
radial artery perforator flaps, and intrinsic hand flaps were described.

08c_PostInter_r4_cah_0820-0841.indd 840 1/31/2012 3:17:18 PM

 Upper Extremity  •  8C: Posterior Interosseous Flap 841

Tan O. Reverse posterior interosseous flap in childhood: a reliable alternative for complex hand
defects. Ann Plast Surg 60:618-622, 2008.
Treatment choices for restoring complex hand defects in children are limited. The reverse posterior
interosseous flap is a versatile flap, with successful results shown in adults. The authors used this flap
to repair complex hand defects in 10 children. Their average age was 9.1 years. Fasciocutaneous and
osteofasciocutaneous flaps were used in 7 and 3 children, respectively. All flaps survived completely.
The average time of bone union was 3 months. This flap was safe and versatile, with easy and rapid
harvest. The diameter of the vessels was not a handicap in the flap dissection, and the operation time
was short.
Xu G, Lai-jin L. Coverage of skin defects in spaghetti wrist trauma: application of the reverse
posterior interosseous flap and its anatomy. J Trauma 63:402-404, 2007.
In this article, the authors introduced the reverse posterior interosseous flap for spaghetti wrist trauma.
They performed the flap in 12 patients with skin defects over the volar wrist. The size of the skin
defects ranged from 5 by 4 cm to approximately 10 by 6 cm. Donor sites were covered by a split-
thickness skin graft. The follow-up period was at least 3 months. All flaps and skin grafts survived
uneventfully. The texture, color, and thickness of the skin paddle matched the surrounding skin. The
sensation of the flap recovered from S0 to S1 on a five-point scale. The functional recovery of the hand
and fingers was dependent on the original injuries to the tendons and nerves. The authors concluded
that the pedicle should include 2 cm of fascia and septum between the extensor carpi ulnaris and
extensor digiti quinti proprius, and the subcutaneous tunnel should be wide enough to avoid venous
congestion. They recommended temporarily blocking the proximal end of the posterior interosseous
artery to observe the blood supply of the flap before completing the procedure.

08c_PostInter_r4_cah_0820-0841.indd 841 1/31/2012 3:17:18 PM

 ANATOMIC LANDMARKS
Landmarks Large, well-vascularized fasciocutaneous flap primarily on the
ventral aspect of the forearm that extends from the wrist crease
to the antecubital fossa.
Size 10 3 40 cm.
Composition Fasciocutaneous; muscle and bone.
Flap Type Fasciocutaneous, osteocutaneous, myocutaneous.
Dominant Pedicle Radial artery.
Nerve Supply Sensory: Lateral and medial antebrachial cutaneous nerves.

08d_RadialFore_r6d_bs_0842-0879.indd 842 2/27/2012 11:19:41 AM

 Section 8D
Upper Extremity

Radial Forearm Flap

CLINICAL APPLICATIONS
Regional Use
Forearm
Elbow
Wrist
Hand
Thumb
Distant Use
Head and neck
Upper extremity
Lower extremity
Specialized Use
Esophageal
reconstruction
Penile reconstruction

08d_RadialFore_r6d_bs_0842-0879.indd 843 2/27/2012 11:19:44 AM

 ANATOMY OF THE RADIAL FOREARM FLAP

A Brachioradialis muscle
Radial artery

Brachial artery

Flexor carpi Palmaris longus

radialis muscle muscle
Arterial anatomy

B Lateral antebrachial
Cephalic vein cutaneous nerve Medial cubital vein
Cephalic vein

Medial
antebrachial vein Basilic vein Medial antebrachial Basilic vein
cutaneous nerve
Venous anatomy

C
Lateral antebrachial
cutaneous nerve

Medial antebrachial
cutaneous nerve
Nerve distribution

Fig. 8D-1

Dominant pedicle: Radial artery

08d_RadialFore_r6d_bs_0842-0879.indd 844 2/27/2012 11:19:45 AM

 Upper Extremity  •  8D: Radial Forearm Flap 845

ANATOMY
Landmarks This thin, well-vascularized fasciocutaneous flap can encompass nearly all tis-
sues of the lower forearm; the size of the flap is limited only by morbidity at the
donor site. Almost any part of the skin and fascia, from the wrist crease to the
antecubital fossa, can be elevated based on the radial artery and its branches.
Composition Fasciocutaneous. A segment of the radius can be elevated with the flap as an
osteocutaneous flap, and the distal brachioradialis can be taken with the flap for
additional muscle. A fascia-only flap can also be used.
Size 10 3 40 cm skin; bone 15 cm; muscle 6 cm.

Arterial Anatomy
Dominant Pedicle  Radial artery
Regional Source  Brachial artery.
Length  20 cm.
Diameter  2.5 mm.
Location  Just below the elbow crease and distal to the bicipital aponeurosis, the brachial artery
divides into the radial and ulnar arteries. The radial artery courses between the brachioradialis
and the pronator teres muscles in the upper forearm, in between the brachioradialis and the
flexor carpi radialis in the lower forearm. The artery originates deep to the brachioradialis and
becomes more superficial distally in the arm. At the level of the wrist, the vessel passes deep to
the tendons of the abductor pollicis longus and extensor pollicis brevis and continues into the
anatomic snuff box (the radial fossa), where it forms the deep palmar arch. The majority of the
fasciocutaneous perforators from the radial artery are in the distal half of the forearm, where
the vessel is more superficial. Although most perforators directly supply the overlying fascia and
skin, there are some small perforators that are supplied through the brachioradialis, also based
off of the radial vessel.

Venous Anatomy
There is both a deep and a superficial drainage system to the radial forearm flap. The superficial
system is based off the cephalic vein, which is 20 cm long and 2.5 mm in diameter. The cephalic
vein drains the radial portion of the dorsum of the hand. It courses around the radial border of the
forearm, then runs on the ventral aspect of the forearm toward the antecubital fossa, where it joins
the basilic vein. The deep system is based on paired venae comitantes that accompany the radial
artery. The diameter of these comitantes is 1 to 1.5 mm. They run with the radial vessels and play
an important role in drainage for any distally based flap. Depending on the location of the skin
paddle, the venae comitantes may be the more dominant drainage system.

Nerve Supply
Sensory The medial and lateral antebrachial cutaneous nerves of the forearm supply
the skin territory of the radial forearm flap. The lateral antebrachial cutaneous
nerve supplied by C5-C6 is the distal continuation of the myocutaneous nerve.
This nerve arises from between the biceps brachii and the brachialis muscles. It
pierces the fascia lateral to the biceps tendon in the cubital fossa, passes posterior
to the cephalic vein, and divides into anterior and posterior branches. The larger
anterior branch accompanies the cephalic vein into the forearm and supplies the
skin of the radial half of the anterior surface as far as the thenar eminence. The
smaller posterior branch supplies the skin of the radial border and posterior aspect
of the forearm as far as the wrist.

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 846 Part II  Regional Flaps: Anatomy and Basic Techniques

The medial antebrachial cutaneous nerve (C8 to T1) arises from the medial
cord of the brachial plexus and accompanies the brachial artery. At the junc-
tion of the middle and distal thirds of the arm, it passes with the basilic vein
and divides into an anterior and ulnar branch. The anterior branch supplies
the anterior medial surface of the forearm to the wrist; the ulnar branch passes
anterior to the medial epicondyle and supplies the skin of the forearm on its
posteromedial surface.

Vascular A natomy of the Radial Forearm Flap

A

Deep surface of flap

Radiographic view

Fig. 8D-2 

Dominant pedicle: Radial artery (D)

n, Lateral antebrachial cutaneous nerve; v, cephalic vein

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 Upper Extremity  •  8D: Radial Forearm Flap 847

FLAP HARVEST
Design and Markings
Positioning of the skin flap on the forearm depends on the nature of the defect to be recon-
structed. For a pedicle flap to be used proximately on the arm, the skin paddle is positioned
more distally to allow adequate arc of rotation to reach the reconstructive site. A Doppler
probe is used to mark the location of the radial artery. A tourniquet can be placed on the
arm preoperatively and the cephalic vein demarcated, because it is advantageous to include
this in the design of the flap. For distally based reconstruction, the flap is designed more
proximally in the forearm to allow adequate arc of rotation. Multiple skin islands can also
be planned; these are centered along the axis of the radial artery.

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 avoid-
ing 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.

08d_RadialFore_r6d_bs_0842-0879.indd 847 2/27/2012 11:19:49 AM

 848 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
The patient is placed in the supine position, with an armboard and a tourniquet around
the upper arm.

GUIDE TO FLAP DISSECTION

When the surgeon is contemplating a radial forearm flap, it is important to test the vas-
cularization of the hand based on the ulnar and radial vessels. A preoperative Allen’s test
should establish that the hand will be well vascularized on the ulnar artery alone. The flap
is incised first on the radial aspect, with incision down to the fascia of the forearm. The
cephalic vein is identified and spared if it will be included in the flap. Dissection proceeds
centrally until the septum containing the radial artery is found. The surgeon will find the
superficial radial nerve branches a helpful landmark. The plane of dissection should be above
the nerve branches to spare them and preserve distal sensitivity.

A Superficial radial Radial artery and

Brachioradialis
nerve branches venae comitantes
muscle
Cephalic vein

Fig. 8D-4  A, An incision is made along the proximal radial margin of the flap, including the deep fas-
cia. 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.

Next, the ulnar side of the flap is incised and again elevated just under the fascia. Care
is taken to keep the peritenon on tendons in the area so that a skin graft closure is possible.
Again, the septum containing the radial artery is approached.

B Lateral intermuscular
Pronator quadratus septum
muscle

Cephalic vein

Flexor carpi
radialis muscle

Flexor policis Median

longus muscle nerve

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 an-
terior surface of the radius. The radial artery is visible within the lateral intermuscular septum.

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 Upper Extremity  •  8D: Radial Forearm Flap 849

The distal incision is made and the deeper fascia of the wrist is opened, exposing the
radial artery and its venae comitantes. These are divided.

C Radial artery and

venae comitantes Brachioradialis
tendon

Flexor carpi Flexor digitorum

radialis tendon superficialis tendon

Fig. 8D-4  C, Distal dissection.

The upper border of the flap is incised, with care taken to preserve the cephalic vein. The
lateral antebrachial cutaneous nerve is also identified at this point running with the cephalic
vein and should be spared if a sensate flap is desired. Once the flap is dissected proximally,
perforating branches from the radial artery to the brachioradialis muscle are ligated. Once
the flap is elevated to its proximal margin, dissection of the cephalic vein is performed
proximally. The skin is opened in an area overlying the radial artery and cephalic vein so
both can be easily accessed. Once the vein has been dissected for the appropriate length,
deeper dissection can be performed, isolating the radial artery and its venae comitantes.

D
Radial artery and
venae comitantes

Cephalic vein
Brachioradialis muscle
Superficial radial nerve

Flexor carpi
radialis muscle

Lateral intermuscular Median nerve

septum

Fig. 8D-4  D, The flap is isolated on the proximal neurovascular pedicle.

08d_RadialFore_r6d_bs_0842-0879.indd 849 2/27/2012 11:19:50 AM

 850 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANTS
•  Reverse radial forearm flap
•  Adipocutaneous flap
•  Fascial flap
•  Osteofasciocutaneous flap
•  Myocutaneous flap
•  Tendinocutaneous flap
•  Vascularized nerve flap (superficial radial nerve)
•  Flow-through flap
Reverse Radial Forearm Flap
The reverse variant is based on retrograde flow through the deep palmar arch and associated
venae comitantes. To produce appropriate arc of rotation, the flap design is placed more
proximally in the forearm. One should be careful not to place the design too proximal as
there are fewer perforators from the radial artery at this level because of the arteries’ depth.
Also, venous outflow from this flap is based on reversed flow in the veins, and often the
flap is initially congested. This reversed flow may lead to some flap loss. Occasionally, extra
cephalic vein is harvested with the flap proximally and is used to decompress the venous
system, with vascular anastomosis at the recipient site. Incisions are made along the upper
proximal and distal borders of the flap down through fascia. The radial vessel is identified,
and perforators emanating from the vessel to the skin paddle are preserved. An incision must
then be made distally over the course of the radial artery identified by Doppler examina-
tion. The radial artery and associated venae comitantes are then mobilized along with the
flap from proximal to distal, the rotation point being the level of the wrist.

Design of reserve flap

Fig. 8D-5 

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 Upper Extremity  •  8D: Radial Forearm Flap 851

Adipocutaneous Flap (Suprafascial Harvest)

Fascia of the arm may be preserved and elevation of the flap limited to the skin and sub-
cutaneous tissues. Care must be taken to include perforators of the radial artery and flap
vascularity will not be compromised. The advantage of this flap would be to maintain fascia
over the tendons of the arm to prevent adhesion formation and to maximize a skin graft
take by not attempting to graft peritenon.

Fascial Flap
When skin is not required and there is a desire to improve the donor site skin graft deformity,
a radial forearm flap can be harvested as a fascia-only flap. This is advantageous when thin
fascia is required for reconstructive purposes, such as tendon reconstruction. An incision is
made along the central axis of the radial vessel and skin and subcutaneous tissues are elevated
along each side of the area of flap to be harvested. The fascia can then be incised, and flap
elevation proceeds as described for the standard flap.

Osteofasciocutaneous Flap
A segment of radial bone may be included with the radial forearm flap. A segment of bone
10 cm long, which encompasses no more than 30% of the cross-section of the radius, may
be harvested. A keel-shaped bone harvest is recommended to reduce the possibility of
radial fracture.

Vascularized bone territory

Fig. 8D-6 

08d_RadialFore_r6d_bs_0842-0879.indd 851 2/27/2012 11:19:51 AM

 852 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap elevation is similar to that described for the standard flap until the radial vessel is
reached on either side of the septum. Retraction of the brachioradialis and the flexor carpi
radialis muscles exposes the muscle bellies of the flexor pollicis longus and pronator qua-
dratus. The area of bone to be harvested is marked, and the muscle bellies are then divided
down and through the periosteum. Bone cuts can be made with a saw for bony harvest.

A
Brachioradialis tendon Radial artery and
venae comitantes

Flexor carpi
radialis tendon

B
Radial artery and
venae comitantes Cephalic vein Lateral antebrachial
cutaneous nerve

Flexor digitorum
superficialis muscle Flexor carpi
radialis muscle

C Radial artery and

venae comitantes
Pronator quadratus
muscle Cephalic vein

Flexor pollicus Flexor digitorum

longus muscle superficialis muscle Brachioradialis muscle

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.

08d_RadialFore_r6d_bs_0842-0879.indd 852 2/27/2012 11:19:52 AM

 Upper Extremity  •  8D: Radial Forearm Flap 853

D Radial artery and

venae comitantes

Brachioradialis Cephalic vein

muscle

Pronator
Flexor digitorum
quadratus muscle Flexor carpi
superficialis muscle
radialis muscle

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
The brachioradialis and flexor carpi radialis muscles can be harvested with the flap to include
muscle. For reconstructive purposes one must visualize the perforating branches to these
muscles if attempting to keep them vascularized with the flap. Of the two, the brachiora-
dialis is the more commonly harvested, because there are fewer functional sequelae (see
Clinical Applications in Section 8B).

Tendinocutaneous Flap
The palmaris longus tendon and tendon of the flexor carpi radialis can be harvested with
the flap as vascularized tendon grafts. These are often helpful in reconstruction of the eyelid,
cheek, and lip in the head and neck, as well as reconstruction of the hand and foot. Again,
small vascular connections between the radial artery and these tendons must be maintained
if a truly vascularized structure is desired (see Fig. 8D-13).

Palmaris longus tendon

Brachioradialis muscle
Flexor carpi radialis tendon
Cephalic vein
Radial artery and venae comitantes
Superficial branch
Brachioradialis muscle
of radial nerve

Pronator
quadratus Cephalic vein
muscle

Flexor pollicis Flexor carpi radialis muscle

longus muscle
Palmaris longus muscle
Flexor digitorum superficialis muscle
Completion of tendinocutaneous flap dissection

Fig. 8D-8 

08d_RadialFore_r6d_bs_0842-0879.indd 853 2/27/2012 11:19:53 AM

 854 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascularized Nerve Flap (Superficial Radial Nerve)

The superficial branch of the radial nerve may be harvested based on the radial vessels as a
vascularized nerve graft. This can be the nerve alone or in combination with the overlying
skin paddle.

Flow-Through Flap
Because of the large caliber of the radial vessels, the radial forearm flap can be used both for
coverage and for revascularization of a dysvascular part of the anatomy. This distal vessel can
also provide a recipient site for a second free flap. This is most commonly seen for revascu-
larization of the extremities and for multiple free flap reconstruction in the head and neck.

ARC OF ROTATION
Standard, Adipocutaneous, and Fascial Flaps
The arc of rotation includes anterior and posterior forearm, elbow, and upper arm.

Standard arc to antecubital fossa and below

Fig. 8D-9 

Reverse Flap
Based on retrograde flow through the deep palmar arch and associated venae comitantes,
the rotation point of this flap is at the level of the wrist and will allow coverage of defects
of the palm and the dorsal surface of the hand and thumb.

Arc of reverse flap to palmar and dorsal surface of hand

Fig. 8D-10 

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 Upper Extremity  •  8D: Radial Forearm Flap 855

FLAP TRANSFER
Standard Flap
Flaps are transferred proximally through direct incision connecting the recipient and donor
sites or through a subcutaneous tunnel. Care must be taken to prevent compression within
the subcutaneous tunnel. Postoperative splinting is also critical for preventing compression
of the pedicle for uses that cross the elbow joint.

Reverse Flap
The reverse flap is transposed directly to the hand for reconstruction. Management of the
exposed pedicle must be painstaking; it can be buried under mobilized skin for skin cover-
age. Sometimes skin grafting is required because of the bulk of the pedicle tissues as they
cross the thin wrist, which does not tolerate subcutaneous tunnels. In this case, secondary
revisions may be necessary.

Free Flap
A free flap is transferred using standard microvascular principles, avoiding tension on the
pedicle. With long radial artery and cephalic vein pedicles, one must maintain proper
orientation of the pedicles throughout. This can be accomplished by marking the artery
and vein before division and using this visual guide to prevent kinking of the flap at inset.

FLAP INSET
Pedicle Flap
It is essential to inset the flap without tension. In a reverse flap, where congestion may oc-
cur, a temporary inset is sometimes appropriate to prevent excessive tension on an already
compromised flap. Secondary closure can be performed in 48 hours or later.

Free Flap
Insetting a free flap requires careful placement of the pedicle. For bone-containing flaps,
the osteosynthesis is often performed first to prevent tension or damage to the vessels after
reanastomosis. The surgeon must ensure that there is no tension on the closure of the flap.

DONOR SITE CLOSURE

Primary closure is possible only for flaps less than 4 cm in diameter. Although it is technically
possible to achieve skin closure, the amount of compression of the arm, which is now relying
only on the ulnar vessel, can be limiting and will have a tourniquet-like effect, especially
with postoperative swelling. In most cases a skin graft is required for donor site closure.

08d_RadialFore_r6d_bs_0842-0879.indd 855 2/27/2012 11:19:54 AM

 856 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 26-year-old man had a crush injury to his foot; the wound became chronic, and he
had nerve pain. At exploration and debridement, dead bone was identified and resected,
and a neuroma in continuity was resected and repaired.

A B

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 anastomo-
sis to the dorsalis pedis vessels. C, Side-by-side donor and recipient sites at 4 months postoperatively.
(Case supplied by MRZ.)

08d_RadialFore_r6d_bs_0842-0879.indd 856 2/27/2012 11:19:56 AM

 Upper Extremity  •  8D: Radial Forearm Flap 857

This 43-year-old woman had a squamous cell carcinoma of the tongue. A hemiglossectomy
was performed. Although much of the defect could have been closed or allowed to heal
secondarily, the addition of a radial forearm flap improved tongue mobility and limited
distortion from secondary healing and scarring.

C D E

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. (Case supplied by MRZ.)

08d_RadialFore_r6d_bs_0842-0879.indd 857 2/27/2012 11:20:00 AM

 858 Part II  Regional Flaps: Anatomy and Basic Techniques

This 61-year-old had a squamous cell carcinoma of the lower lip. The large defect was
reonstructed with a radial forearm flap, supported by vascularized fascia. Microstomia was
avoided by adding tissue to the area.

A B

D E

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.

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 Upper Extremity  •  8D: Radial Forearm Flap 859

F G

I J

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 su-
tures 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. (Case supplied by MRZ.)

08d_RadialFore_r6d_bs_0842-0879.indd 859 2/27/2012 11:20:07 AM

 860 Part II  Regional Flaps: Anatomy and Basic Techniques

This 35-year-old man sustained a gunshot wound to his palm that resulted in loss of the
fourth metacarpal and produced a large dorsal exit wound. The affected area was debrided
and initially stabilized with an external fixator and a methylmethacrylate spacer for staged
bony reconstruction. The patient had a normal Allen’s test, and a reverse radial forearm
flap was used for soft tissue coverage.

A B

D E

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. (Case supplied by MRZ.)

08d_RadialFore_r6d_bs_0842-0879.indd 860 2/27/2012 11:20:11 AM

 Upper Extremity  •  8D: Radial Forearm Flap 861

This 45-year-old man had undergone a maxillectomy for squamous cell carcinoma. A
radial forearm flap was planned for bony reconstruction as well as palate and nasal floor
reconstruction.

A B

C D

E F

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 sutur-
ing 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. (Case
supplied by MRZ.)

08d_RadialFore_r6d_bs_0842-0879.indd 861 2/27/2012 11:20:15 AM

 862 Part II  Regional Flaps: Anatomy and Basic Techniques

This 47-year-old woman had a maxillary tumor excised, leaving a large skin defect. There
was also a small CSF leak and open communication with the oropharynx. A radial forearm
flap was chosen with multiple skin paddles for this complex reconstruction as well as some
brachioradialis muscle for repair of the CSF leak and soft tissue fill.

B C

D E F

Fig. 8D-16  A, The defect after resection. The area of CSF leak was in the posterior orbit after exen-
teration. 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.
(Case supplied by MRZ.)

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 Upper Extremity  •  8D: Radial Forearm Flap 863

This 42-year-old man had a squamous cell carcinoma of the upper lip; he underwent re-
section and reconstruction with a radial forearm free flap, supported with a vascularized
palmaris longus tendon. This was a functional reconstruction, but not an aesthetic one. As
a secondary procedure, a mustache reconstruction was planned with a scalp flap based on
the superficial temporal system.

B C

D E

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. Al-
lowance 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. (Case supplied by MRZ.)

08d_RadialFore_r6d_bs_0842-0879.indd 863 2/27/2012 11:20:22 AM

 864 Part II  Regional Flaps: Anatomy and Basic Techniques

This 29-year-old woman presented with loss of her nasal columella and vestibular lining.

A B

D E

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.

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 Upper Extremity  •  8D: Radial Forearm Flap 865

F G

I J

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 pa-
tient is shown 13 months after microsurgical transfer of the forearm flap. (Case courtesy Robert L.
Walton, MD.)

08d_RadialFore_r6d_bs_0842-0879.indd 865 2/27/2012 11:20:29 AM

 866 Part II  Regional Flaps: Anatomy and Basic Techniques

This 39-year-old man had a traumatic loss of the distal portion of his nose, including the
vestibule, left nostril floor, and caudal septum/columella.

A B

C D

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 as-
sembled anatomically and inset into the defect.

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 Upper Extremity  •  8D: Radial Forearm Flap 867

E F

G H

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 ele-
ment was temporarily covered with a full-thickness skin graft, which was placed directly over the car-
tilage 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. (Case courtesy Robert L. Walton, MD.)

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 868 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old man presented with composite nasal/maxillary defect following surgical
excision of a recurrent basal cell carcinoma, followed by radiation therapy.

A B

C D

E F

Fig. 8D-20  A and B, The patient is seen preoperatively. C and D, The initial approach to reconstruc-
tion 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.

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 Upper Extremity  •  8D: Radial Forearm Flap 869

G H

I J

K L M

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. (Case
courtesy Robert L. Walton, MD.)

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 870 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Good perfusion to the hand must be ensured by performing a preoperative Allen’s test
before deciding to use a radial forearm flap.
• Harvesting bone in elderly patients and women should be avoided, because the incidence
of fracture is much higher in these populations.
• To help prevent radial fracture, plating of the radius and casting of the forearm including
the elbow should be considered for 3 to 5 weeks postoperatively when bone is harvested.
• Paresthesia and dysesthesia distal to the flap can be avoided by carefully preserving the
branches of the radial sensory nerve during flap elevation.
• The flap is advantageous because it allows a two-team reconstruction, especially in head
and neck surgery.
• The radial artery is rarely involved with any systemic atherosclerosis that may be present.
• There is limited postoperative pain and immobilization from harvesting this flap.
• The biggest disadvantage of the radial forearm flap is the conspicuous donor deformity
of the forearm, especially in women.

Expert Commentary
Robert L. Walton

Indications
I have found the radial forearm flap to be very useful for reconstruction of a variety of facial/
nasal defects and it is particularly useful in conditions that require multi-island fabrications.

Advantages and Limitations

The radial forearm flap is a very robust flap with consistent anatomy. Elevation is straight-
forward. Limitations of the flap lie primarily in its relatively small bulk and size. Donor site
scarring can be a problem, especially in women.

Anatomic Considerations
A critical issue in the use of the radial forearm flap is prior catheterization of the radial artery.
I have had two cases in which partial flap loss occurred in flaps harvested from forearms
that previously underwent radial artery arterial line catheterization. Despite palpable pulses
and a positive Allen’s test, these flaps exhibited compromised perfusion after the flap was
elevated. I suspect that the arterial catheterization may have resulted in thrombosis of the
small radial arterial perforators into the overlying subcutaneous tissue and skin.
For complex flap shapes, I have found that delay of the radial forearm flap is advantageous
for augmenting dermal perfusion and do this routinely 10 to 14 days before flap transfer.
In a case a number of years ago, we performed an immediate external cover flap using a
suprafascial radial forearm flap in a 16-year-old girl. The alar element of the flap that lay

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 Upper Extremity  •  8D: Radial Forearm Flap 871

over the ulnar side of the volar forearm necrosed following transfer, necessitating use of a
second free flap from the abdomen. With surgical delay, I have not observed flap necrosis
in any patient, including those with flaps having very complex configurations.
I think the primary venous drainage of the flap is through the paired venae comitantes
coursing with the radial artery, and this has been recently verified by Selber et al.1 The
cephalic vein is a secondary conduit, as evidenced by the sparse branching in the volar
forearm. As noted in the excellent article by Gottlieb et al,2 the venae comitantes coalesce
into a single vein at the level of the brachial artery bifurcation. The profundus cubitalis vein
(vena anastomotica) connects this coalesced (deep) vein to the cephalic vein at the level of
the cubital fossa. Both the deep and superficial venous systems are drained via one large
anastomosis, situated proximal to the profundus cubitalis interconnection.
Advantages of this technique include the following: (1) venous drainage of the radial
artery forearm free flap is improved; (2) the venous anastomosis is rendered technically easier
because of its larger size; and (3) the technique offers greater versatility in designing the
venous portion of the vascular pedicle. Deep systems join in the proximal forearm, allow-
ing for single outflow vessel anastomosis. This configuration is reserved for large flaps that
wrap the radial forearm distally and extend the greater length of the forearm to the wrist.

Recommendations
Planning
It is preferable to harvest the flap from the nondominant upper extremity. Use of the Allen’s
test is important to ensure adequate inflow into the hand from the ulnar artery (although
I have not encountered a case in which a radial forearm flap could not be used because
perfusion was inadequate). The flap is centered over the radial artery whenever possible,
depending on flap size, except in cases of surgical delay, where flap design is such that the
radial artery and its perforators are aligned to the edge of the flap, “out of harm’s way,”
to facilitate ease of inset and to avoid pedicle compression when using bone or cartilage
grafts. With multiple islands, I have found it helpful to create templates of foil connected
by Steri-Strips to mimic the radial pedicle. The foil templates are then articulated in space
to ensure correct size and configuration and to allow easy positioning without kinking of
the pedicle. The old adage “measure twice, cut once” is quite apropos in these situations.

Technique
As noted earlier, I do not routinely use the cephalic vein in flap design unless the flap is
inordinately large such as is encountered in penile reconstruction. Before making the skin
incision, I identify the brachioradialis and flexor carpi radialis tendons at the volar wrist
and trace these proximally. These structures will form the boundaries of the “no-fly zone”
defining the traverse of the radial pedicle and its perforators to the overlying skin paddle.
In most cases I prefer to harvest the flap in the suprafascial plane, preserving the deep fascia
for coverage of the volar tendons and nerves. This results in less donor site morbidity and
allows selective thinning of the flap as necessary for the reconstruction at hand.
When one is harvesting multiple islands, magnification (loupe or operating microscope)
should be used to identify the radial perforators to each island. After the islands have been
dissected, care must be exercised to protect each island from shear or twisting forces that
might injure the perforating vessels.
Continued

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 872 Part II  Regional Flaps: Anatomy and Basic Techniques

The thickness of this flap should not be underestimated despite its apparent thinness
in situ. This is especially relevant when transferring the flap to the face for use in nasal
lining reconstruction or external nasal cover. Direct debulking of the flap before transfer
can be effectively accomplished by using operative magnification to visualize the fat glob-
ules, allowing for their lysis and direct suction removal with care to avoid injury to the
radial pedicle perforators and the subdermal vascular plexus. In obese patients, pretransfer
debulking/delay of the flap is essential for avoiding the typical “meatball” configurations that
result from transfer of the whole thickness of the flap. In certain reconstructions in which the
flap is tubed for reconstruction of the columella, it is important not to coapt the opposing edges
under tension, because this will compromise the blood flow. In these cases, it is helpful to
apply a small full-thickness skin graft to the folded edges of the flap to ease the tension. These
grafts do quite well if adequate hemostasis is achieved before application of the skin graft.
I rarely advocate use of the reverse configuration of the radial forearm flap, since it
frequently leads to a “sick” flap, with venous congestion and unreliable perfusion of the
skin island. In these situations, a straightforward antegrade radial forearm free flap vascular-
ized to the radial or ulnar pedicle foregoes the adverse risks inherent to the reverse radial
forearm flap.
Similarly, use of the osteofasciocutaneous radial forearm flap makes little sense, because
the procedure carries considerable risk for radius fracture, and the donor defect has consid-
erable morbidity. In my opinion, this flap design totally disregards the importance of the
forearm/upper extremity for function and should be abandoned.
Closure of the radial forearm donor site is generally straightforward. I routinely employ
a full-thickness skin graft harvested from the inguinal region. A full-thickness skin graft
provides very stable coverage for the distal volar forearm donor site; it is pliable, exhibits
minimal contraction, and is aesthetically quite acceptable. A template of the forearm defect
is transferred to the inguinal region, where it is incorporated within the confines of an
ellipse, the longitudinal axis of which is aligned with the inguinal fold. For large defects,
the graft may need to be applied as articulated segments derived from the confines of the
ellipse. The graft is inset with 4-0 silk sutures that are used to secure a sponge stent.

Postoperative Care
After application of the stent dressing, the forearm and hand are wrapped in a light compres-
sion bandage composed of Kerlix fluffs, Reston foam, cling wrap, and an Ace wrap secured
with staples. The bandage is kept in place for 1 week. (I do not use arm slings, since these
tend to produce shoulder stiffness, especially in older patients. I have the patient carry the
bandaged arm upright, and encourage overhead stretching on postoperative day 1). The
stent dressing is removed and graft take is assessed at 1 week. The graft is redressed with a
petrolatum dressing and a light gauze wrap and Ace bandage. At 2 weeks postoperatively,
the sutures are removed and moisturizing creams are applied. The forearm is kept wrapped
with an ace bandage by the patient for the next 3 months to stifle hypertrophic scarring and
promote contouring of the forearm donor site.
The flap reaches maximal swelling at 48 hours. Close observation must be maintained to
ensure that this swelling does not interfere with flap perfusion, especially if multiple islands
are used. If there is any concern about flap perfusion as the swelling ensues, release of several
inset sutures may be all that is necessary to relieve the compromised perfusion. These can be
replaced once the swelling subsides, usually within 3 to 4 days. If the flap is transferred to the

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 Upper Extremity  •  8D: Radial Forearm Flap 873

face, care must be taken to avoid the use of cool mist face masks or blow-by oxygenation as
these may result in excessive cooling of the flap, vasospasm, and thrombosis. To avoid this
complication, the surgeon should insist on the use of warm (steam) humidification for all
oxygenation adjuncts and be certain to check this to ensure that no cool mist is contacting
the flap.

Complications
Complications inherent to the radial forearm flap are few; this is a very robust flap with
large-caliber vessels and an infinite assortment of configurations and applications. As noted
earlier, one must be wary of using the radial forearm flap if prior catheterization of the
radial artery has been performed, even if the Allen’s test demonstrates robust perfusion via
both radial and ulnar systems. When using the flap around hardware, the surgeon must
be aware that hardware can very quickly occlude the pedicle, especially as the flap swells.
In these cases, judicious placement of the pedicle away from any restricting hardware or
bone graft will be good insurance against middle of the night phone calls. If the pedicle is
oriented toward the edge of the flap, as in nasal reconstruction, it is often helpful to delay
the flap to ensure adequate perfusion of the skin island.

Take-Away Messages
This is a very reliable flap. Careful planning and execution will result in successful recon-
struction.

References
1. Selber JC, Sanders E, Lin H, et al. Venous drainage of the radial forearm flap: comparison
of the deep and superficial systems. Ann Plast Surg 66:347-350, 2011.
2. Gottlieb LJ, Tachmes L, Pielet RW. Improved venous drainage of the radial artery forearm
free flap: use of the profundus cubitalis vein. J Reconstr Microsurg 9:281-284, 1993.

Bibliography With Key Annotations

Bardsley AF, Soutar DS, Elliot D, et al. Reducing morbidity in the radial forearm flap donor
site. Plast Reconstr Surg 86:287-292; discussion 293-294, 1990.
The authors reviewed their experience with 100 radial artery free flap donor sites. Sixty-seven patients
required skin grafting, 33 patients underwent direct closure of their defects, and 17 patients had com-
pound osseocutaneous flaps. Wound healing was a significant problem in patients who had skin grafts
and harvested radial bone. Fracture of the radius occurred in 4 of 17 of those patients and represented
the most significant postoperative morbidity. In 12 patients the radial artery was reconstructed, but
only six of these vessels were patent at the time of review. The authors reported that the donor site
was relatively pain free. The aesthetic result was more acceptable in men than women, and was even
less acceptable in patients who had a radial fracture. Based on this experience, the authors no longer
recommended routine reconstruction of the radial artery. The donor defect was closed directly when
possible, including an ulnar artery transposition flap if necessary. The osteotomy to harvest the bone
was made in a “boat shape” rather than right-angle bone cuts. These changes significantly improved
the donor site results and minimized complications.

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 874 Part II  Regional Flaps: Anatomy and Basic Techniques

Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg
40:207-212, 1987.
This was a retrospective analysis of complications in the donor limb in 27 patients who underwent
forearm flap procedures. Of 13 patients whose flaps contained bone, four had fractures of the radius.
This led to a 50% loss of power of grip and pinch and limited pronation and supination. Cold in-
tolerance and clinical signs of hand ischemia were not reported. Of 12 radial arteries reconstructed,
only seven remained patent.
Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr
Surg 74:251-258, 1984.
This was an initial report of seven cases of penile reconstruction with a radial forearm flap. A “tube
within a tube” was created to reconstruct the urethra and the shaft of the penis with this neurosen-
sory flap. A segment of rib cartilage was used to provide firmness for the reconstructed penis. In two
patients the medial cutaneous nerve of the forearm was included to provide sensation. The authors
emphasized that the less-hair-bearing ulnar border of the flap should be used for the urethral portion
of the reconstruction.
Chen H, Ganos DL, Coessens BC, et al. Free forearm flap for closure of difficult oronasal
fistulas in cleft palate patients. Plast Reconstr Surg 90:757-762, 1992.
The authors shared their experience treating four patients with recalcitrant oronasal fistulas after all
other attempts at closure had failed. In three patients one-stage reconstruction was successful using the
radial forearm free flap. In a fourth patient a secondary procedure was necessary for complete fistula
closure. All patients had excellent results, with improved speech and no nasal regurgitation. The au-
thors pointed out that the radial forearm flap, with its extremely long pedicle and large vascular pedicle
lumen diameter, provided a flap with thin, hairless skin ideally suited for palatal closure in patients
with difficult or recalcitrant fistulas.
Chen H, Tang Y, Noordhoff MS. Patch esophagoplasty with free forearm flap for focal stricture
of the pharyngoesophageal junction and the cervical esophagus. Plast Reconstr Surg 90:45-52,
1992.
This report described six patients who underwent patch esophagoplasty with a free radial forearm
flap to relieve focal strictures in the cervical esophagus. The authors enumerated the advantages of this
method, which produced less morbidity and a superior aesthetic result compared with other techniques,
including pedicle and myocutaneous flaps.
Chicarilli ZN, Price GJ. Complete plantar foot coverage with the free neurosensory radial
forearm flap. Plast Reconstr Surg 78:94-101, 1986.
In this case report the free radial forearm flap was transferred as an innervated free flap to resurface the
entire weight-bearing plantar surface of the foot. At the 10-month follow-up protective sensation was
present on the lateral two thirds of the plantar surface of the flap, corresponding to the distribution of
the medial antebrachial cutaneous nerve.
Cormack GC, Duncan MJ, Lamberty BG. The blood supply of the bone component of the
compound osteocutaneous radial artery forearm flap—an anatomical study. Br J Plast Surg
39:173-175, 1986.
The authors investigated the blood supply to the radius through fresh cadaver injection studies of the
radial artery. They concluded that a segment of the lateral part of the distal radius, usually incor-
porated with the radial forearm flap as a compound otseocutaneous flap, was supplied through two
fascioperiosteal branches of the radial artery and a myoperiosteal plexus at the site of attachment of
the flexor pollicis longus muscle.

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 Upper Extremity  •  8D: Radial Forearm Flap 875

Elliot D, Bardsley AF, Batchelor AG, et al. Direct closure of the radial forearm flap donor defect.
Br J Plast Surg 41:358-360, 1988.
There are problems associated with delayed wound healing when the donor site of the radial forearm
is skin grafted. The authors described an ulnar fasciocutaneous flap that is advanced distally to cover
the radial forearm donor site, and the donor defect resulting from the advancement of the ulnar flap
closed in a V-Y fashion. This method of closure had several disadvantages. It is limited to flaps with
dimensions of 8 by 4 cm or less. A V-shaped incision in the proximal forearm denervates the skin
of the volar aspect of the forearm; however the authors reported that this was not a problem. Because
the incision may also interrupt the lymphatic drainage of the ulnar flap, gentle flap compression with
bandages was recommended postoperatively.
Emerson DJ, Sprigg A, Page RE. Some observations on the radial artery island flap. Br J Plast
Surg 38:107-112, 1985.
The authors investigated the venous drainage of standard and distally based radial artery island flaps.
Radiographic studies were performed on 12 upper limbs after barium sulfate injection. Injection of
one of the radial artery vena comitans in retrograde fashion resulted in perfusion of both of the venae
comitantes through cross-communicating branches in a stepladder fashion. Histologic studies demon-
strated valves in both the venae comitantes and the vessels lying in the mesentery between the venae
comitantes. Retrograde flow of barium sulfate in the cephalic vein was obstructed. They postulated
that venous drainage in the retrograde or distally based flap improves gradually as the venous valves
become incompetent as a result of high venous pressure.
Gilbert DA, Jordan GH, Devine CJ Jr, et al. Microsurgical forearm “cricket bat–transformer”
phalloplasty. Plast Reconstr Surg 90:711-716, 1992.
The authors described their modification of the “cricket bat” concept of phalloplasty in which a
longitudinal and transverse rotation of the linear forearm tissues was used to create the phallus. A
coronoplasty was added to complete the reconstruction.
Govila A, Sharma D. The radial forearm flap for reconstruction of the upper extremity. Plast
Reconstr Surg 86:920-927, 1990.
The authors presented their experience with 14 radial forearm flaps for upper extremity defects.
Eleven of these flaps were reverse-flow flaps, and two were transferred on an extracorporeal vascular
pedicle. If there was not enough space to accommodate the vascular pedicle, as under the palmar skin,
or if the flap would not reach the defect when the pedicle was buried, the authors simply inset the
flap and wrapped the pedicle vessels with a skin graft. They called this an “extracorporeal pedicle.”
This pedicle was excised at 3 weeks. A variety of traumatic injuries of the upper extremity were
reconstructed with the flap.
Hallock GG. Refinement of the radial forearm flap donor site using skin expansion. Plast Re-
constr Surg 81:21-25, 1988.
The author advocated the use of tissue expanders to improve the radial forearm flap donor site. Tissue
expanders were placed immediately at the time of flap harvest in 9 of 10 patients. A 40% minor
complication rate was reported. These included wound dehiscence, expander puncture, valve exposure,
and postadvancement wound dehiscence. This modification did not result in significant improvement
of the donor site defect.
Hallock GG. Simultaneous bilateral foot reconstruction using a single radial forearm flap. Plast
Reconstr Surg 80:836-838, 1987.
In this very interesting flap modification, two separate flaps were harvested from the same forearm
and then transferred to bilateral foot defects.

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 876 Part II  Regional Flaps: Anatomy and Basic Techniques

Hallock GG, Rice DC, Keblish PA, et al. Restoration of the foot using the radial forearm flap.
Ann Plast Surg 20:14-25, 1988.
The authors reported their experience with five patients in whom a radial forearm flap was transferred
to reconstruct the Achilles’ insertion, heel, instep, forefoot, and dorsum of the foot. They emphasized
the quality of the results in terms of restoration of normal foot contour, durability, and excellent aesthetic
appearance. The advantages of the flap included its long pedicle, potential sensory innervation, and
appropriate thickness for foot reconstruction.
Harii K, Ebihara S, Ono I, et al. Pharyngoesophageal reconstruction using a fabricated forearm
free flap. Plast Reconstr Surg 75:463-476, 1985.
The authors summarized their experience with 12 patients in whom the pharynx and cervical
esophagus were reconstructed with a tubed radial forearm free flap. They emphasized the advantages
of this method of reconstruction over the use of the jejunum, especially because it eliminated the need
for an intraabdominal procedure. Of the nine patients who underwent circumferential reconstruction,
five developed fistulas and two developed strictures at the esophageal anastomosis.
Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and clinical implication.
Plast Reconstr Surg 98:195-210, 1996.
The authors examined the blood supply to the skin and bones of the forearm in 10 upper limbs from
fresh cadavers. They were perfused with a radiopaque lead-oxide mixture. A total of 200 muscles were
also studied. The specimens were dissected, the vessels were tagged with metal clips and radiographed,
and branches were mapped with colored pins corresponding to the respective source arteries. The bones
were replaced with radiolucent balloons to facilitate visualization of the forearm vasculature. Then
the muscles were removed one by one from the muscle mass and radiographed again. Angiosomes in
the forearm provided by the brachial, radial, ulnar, and interosseous arteries could then be defined.
Similarly, the contribution from each angiosome to the skin, each muscle, and the radius and ulna
was identified, and the territories were color-coded to correspond with source arteries. Connections
between adjacent angiosomes mostly occurred within tissues, not between them. The source arteries
from at least two angiosomes supplied skin, bones, and most muscles. This anastomotic pathway
becomes extremely important if a source artery is interrupted by disease or trauma. Several muscles
were nourished within one angiosome, explaining the variety of responses to interrupted circulation,
as with Volkmann’s ischemic contracture. This study presented information to help design flaps from
the forearm for local or free transfer.
Ismail TI. The free fascial forearm flap. Microsurgery 10:155-160, 1989.
To minimize donor site complications after harvesting a forearm flap, the author advocated harvesting
it as a fascial flap to preserve the forearm skin. He presented eight cases in which the free fascial flap
was transferred as a free flap for lower extremity reconstruction and then covered with a skin graft.
The advantages of this fascial flap over other fascial flaps were enumerated. These included a longer
vascular pedicle, a larger fascial donor area, and the possibility of combining fascia with tendon and bone.
Jeng SF, Wei FC. The distally based forearm island flap in hand reconstruction. Plast Reconstr
Surg 102:400-406, 1998.
A distally based forearm island flap was performed in 12 patients with soft tissue defects of the hand.
The skin flap was supplied by the perforators of the distal radial artery, and the pivot point of its sub-
cutaneous pedicle was approximately 2 to 4 cm above the radial styloid process. Eight skin flaps, two
adipofascial flaps, and two sensate flaps were performed. The flaps ranged from 6 by 4 cm to 14 by
6 cm. The donor site wound was closed primarily in five patients. Advantages of the flap were discussed.
Jones BM, O’Brien CJ. Acute ischaemia of the hand resulting from elevation of a radial forearm
flap. Br J Plast Surg 38:396-397, 1985.
The authors shared their experience performing a radial forearm flap in a patient with a positive
Allen test preoperatively. Acute ischemia of the hand resulted, and circulation was reestablished by a
vein graft. The importance of ensuring hand circulation after harvesting this flap was emphasized.

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 Upper Extremity  •  8D: Radial Forearm Flap 877

Koshima I, Moriguchi T, Etoh H, et al. The radial artery perforator-based adipofascial flap for
dorsal hand coverage. Ann Plast Surg 35:474-479, 1995.
This article discussed the usefulness of the radial artery perforator–based adipofascial flap for resurfacing
dorsal hand defects. It is a distally based septocutaneous flap supplied by the dorsal superficial branch
of the radial artery. The numerous advantages of the flap were presented.
Koshima I, Tsutsui T, Nanba Y, et al. Free radial forearm osteocutaneous perforator flap for
reconstruction of total nasal defects. J Reconstr Microsurg 18:585-588; discussion 589-590, 2002.
The radial forearm osteocutaneous perforator flap comprises vascularized radial bone and superficial
adiposal tissue, nourished by a single perforator of the radial artery. The authors transferred this flap
in a one-stage reconstruction in a patient with total nasal loss.
Lin SD, Lai CS, Chiu CC. Venous drainage in the reverse forearm flap. Plast Reconstr Surg
74:508-512, 1984.
The authors studied the venous drainage on venograms in three patients who had undergone reverse
forearm flap reconstruction. They described two patterns of venous drainage: the “crossover pattern”
of the communicating branches between the two venae comitantes and the “bypass pattern” of the
collateral branches of each vein. These provided effective retrograde venous drainage. The crossover
pattern allowed communication between the two venae comitantes, thereby establishing a method for
bypassing the valves in each of the vena comitans. Drainage through small collateral branches of each
vein effectively bypassed the valves in the same vein. These crossover and bypass patterns explained
the reverse drainage of venous blood even if the valves in the veins were intact.
Masser MR. The preexpanded radial free flap. Plast Reconstr Surg 86:295-301; discussion
302-303, 1990.
The author presented two cases in which the ankle and heel area were resurfaced with innervated
preexpanded radial flaps. The advantages of preexpansion included minimizing the donor defect,
which was closed directly, and the potential for enlarging the size of the flap for transfer. However,
the major advantage of preexpansion was that a large flap could be harvested when the small amount
of remaining forearm skin was not suitable for secondary expansion to minimize the donor defect.
McGregor AD. The free radial forearm flap—the management of the secondary defect. Br J
Plast Surg 40:83-85, 1987.
The author presented his experience with the free radial forearm flap in 16 patients. To minimize
complications associated with skin grafting the donor site, he applied the graft with the wrist extended
and the gutter between the flexor carpi radialis and brachioradialis carefully packed to ensure adequate
contact between the graft and underlying tendons and muscles. The extremity was then immobilized
in a plaster cast for at least 10 days. The graft was inspected and the forearm splinted for an additional
10 days to prevent tearing of the skin graft by underlying flexor carpii radialis tendon motion. The
author emphasized that, with the wrist extended, the flexor carpii radialis tendon was flat on the
flexor pollicis longus, and the depth of the gutter and thus the dead space were minimized. Full wrist
extension was preserved by grafting with the wrist in extension.
Reid CD, Moss ALH. One-stage flap repair with vascularised tendon grafts in a dorsal hand
injury using the “Chinese” forearm flap. Br J Plast Surg 36:473-479, 1983.
A distally based reverse-flow radial forearm flap, including the palmaris longus tendon and part of
the tendinous portion of the brachial radialis, was used to provide coverage for the dorsum of the hand
and to reconstruct extensor tendons that had been lost as a result of the injury.
Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the com-
posite radial forearm–palmaris longus free flap. Plast Reconstr Surg 88:209-214, 1991.
Four patients underwent total lip and chin reconstruction. In three patients a composite flap, including
the radial forearm and palmaris longus, were used to reconstruct the chin and lip. The cut end of the
palmaris longus tendon was sutured to the modiolus bilaterally. This modification led to aesthetically
acceptable reconstructions with this innervated flap, including the palmaris longus tendon. Lip seal

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 878 Part II  Regional Flaps: Anatomy and Basic Techniques

and speech were good, and there were no problems with drooling. With this excellent modification,
reconstructive surgeons can reestablish continence of the oral sphincter.
Safak T, Akyurek M. Free transfer of the radial forearm flap with preservation of the radial
artery. Ann Plast Surg 45:97-99, 2000.
The authors presented their technique of preserving the radial artery in a free transfer of the radial
forearm flap. Their 42-year-old patient had undergone excision of a mandibular osteosarcoma and
developed neck contracture after subsequent radiation therapy. They elevated the flap as a distal row
perforator-based fasciocutaneous flap, including a short segment of the radial artery in the inverted-
T–shaped arterial pedicle. The cephalic vein, with accompanying veins of the radial artery that were
left behind, provided venous outflow. The donor radial artery was repaired primarily. The superior
thyroid artery and one limb of the arterial pedicle were anastomosed end to end (the other limb was
ligated). The cephalic vein and the external jugular vein were anastomosed. The result was satisfactory,
and the radial artery was patent long after surgery (Allen’s test and Doppler examination).
Soutar DS, McGregor IA. The radial forearm flap in intraoral reconstruction: the experience
of 60 consecutive cases. Plast Reconstr Surg 78:1-8, 1986.
The authors reviewed their extensive experience performing the radial forearm flap in 60 consecutive
patients who had had intraoral reconstruction. They reported six microvascular failures. Thirty-nine
patients had early postoperative radiation therapy, without flap viability or wound-healing problem.
The authors emphasized the need for a preoperative Allen test before flap reconstruction. In their first
10 patients the radial artery was reconstructed with a reversed vein graft. However, in the last 10
patients arterial reconstruction was performed only in exceptional circumstances. Dividing the radial
artery did not harm any patients, though this was a concern preoperatively. Direct closure of the donor
defect was possible in seven patients, with no wound-healing complications. The rest had skin grafts,
and some had difficulty with graft take. Exposure of the tendon of flexor carpii radialis was reported.
This was thought to be related to failure to preserve the peritenon. Remarkably, only one patient
required a second skin-graft procedure to obtain complete closure of the donor area. For patients in
whom the radius is harvested, the authors recommended at least a 3-week period of immobilization
in an above-elbow plaster cast.
Swanson E, Boyd JB, Mulholland RS. The radial forearm flap: a biomechanical study of the
osteotomized radius. Plast Reconstr Surg 85:267-272, 1990.
The authors used preserved human radii to study the effect of osteotomy on the radius. Twenty bones
were osteotomized, and 20 nonosteotomized bones served as controls. The osteotomy group included
10 bones with squared-corner osteotomies and 10 with beveled-corner osteotomy. The bones were
then tested for breaking using a four-point bending apparatus. Osteotomized radii were significantly
weakened with breaking strengths of only 24% of that in the control group. The beveled-osteotomy
group appeared stronger than the squared-osteotomy group, although the difference was not significant.
To reduce the incidence of fractures, the authors recommended excising no more than a third of the
radial diameter of the bone, with postoperative immobilization of the forearm for 8 weeks.
Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg 77:80-92, 1986.
This is an excellent and exhaustive review of the vascular basis of the radial forearm flap. The arterial
and venous anatomy of the flap was studied in dissections of 56 cadavers. A variety of techniques, such
as ink, latex, and barium sulfate injections, were used to determine the arterial inflow. The location
and number of perforators in the overlying skin and vascular connections with the tendons and muscles
and distal radius were well described. Venous drainage through the superficial and deep systems and
the basis for the reversed venous flow in the distally elevated flap were discussed.

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 Upper Extremity  •  8D: Radial Forearm Flap 879

Timmons MJ, Missotten FEM, Poole MD, et al. Complications of radial forearm flap donor
sites. Br J Plast Surg 39:176-178, 1986.
The authors reviewed complications from radial forearm flaps in 15 patients from two centers. In all
patients the flap was transferred as a free flap. Complications included skin-graft failure, hand swelling
and stiffness, reduced sensibility and strength, cold-induced symptoms, and fractures of the radius. In
seven patients the flap included bone, and three of these patients had a radius fracture. Recommenda-
tions for minimizing complications at the donor site were discussed.
Yamada A, Harii K, Itoh Y, et al. Reconstruction of the cervical trachea with a free forearm
flap. Br J Plast Surg 46:32-35, 1993.
The authors described a totally new method of reconstructing the entire cervical trachea with a free
forearm flap. An inverted tube was made from the forearm flap and placed between the subglottic
trachea and an adjacent cutaneous fistula at the upper portion of the tracheal stoma. A permanent
tracheal stoma was preserved, and an L-shaped silicone tube was inserted in the reconstructed cervical
trachea and tracheostoma as a stent. The authors reported their experience with two patients who were
able to speak following this procedure.

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 ANATOMIC LANDMARKS
Landmarks The most superficial muscle on the ulnar side of the forearm.
Size 20 3 5 cm.
Origin Two heads of origin: humeral and ulnar. Humeral head arises
from the medial condyle of the humerus; ulnar head arises from
the posterior border of the ulna.
Insertion Pisiform.
Function Flexion and ulnar deviation of the wrist.
Composition Muscle.
Flap Type Type II.
Dominant Pedicle Posterior ulnar recurrent artery.
Minor Pedicle Ulnar artery perforating branches.
Nerve Supply Motor: Ulnar nerve.

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 Section 8E
Upper Extremity

Flexor Carpi Ulnaris Flap

CLINICAL APPLICATIONS
Regional Use
Elbow
Distant Use
Head and neck
Specialized Use
Tendon transfer
Elbow coverage

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 ANATOMY OF THE Flexor Carpi Ulnaris Flap

A
Branches of ulnar artery Posterior ulnar recurrent artery

Flexor carpi ulnaris muscle Ulnar artery Brachial artery

Arterial supply to flexor carpi ulnaris

Ulnar nerve
Flexor carpi ulnaris muscle

Motor nerve to flexor carpi ulnaris

Fig. 8E-1 

Dominant pedicle: Posterior ulnar recurrent artery

Minor pedicle: Branches of ulnar artery

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 Upper Extremity  •  8E: Flexor Carpi Ulnaris Flap 883

ANATOMY
Landmarks The most superficial muscle on the ulnar side of the forearm.
Composition Muscle.
Size 20 3 5 cm.
Origin Two heads of origin: humeral and ulnar. The humeral head arises from the
medial condyle of the humerus; the ulnar head arises from the posterior border
of the ulna. The ulnar nerve and posterior ulnar recurrent artery run between
the two heads of origin.
Insertion Pisiform.
Function Flexion and ulnar deviation of the wrist.

Arterial Anatomy (Type II)

Dominant Pedicle  Posterior ulnar recurrent artery
Regional Source  Ulnar artery.
Length  2 to 3 cm.
Diameter  1 to 2 mm.
Location  On the deep surface of the muscle, close to its origin.
Minor Pedicle  Distal ulnar perforating branches
Regional Source  Ulnar artery.
Length  2 to 3 cm.
Diameter  0.5 to 1 mm.
Location  Along the radial border of the muscle and the middle and distal third of the forearm.

Venous Anatomy
Venae comitantes accompany the arterial supply.

Nerve Supply
Motor Ulnar nerve.

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 884 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Flexor Carpi Ulnaris Flap

A B

Superficial surface of flap after release of insertion Deep surface of flap base

Deep surface of flap

D
D

Radiographic view

Fig. 8E-2 

Dominant pedicle: Posterior ulnar recurrent artery (D)

Minor pedicle: Branches of ulnar artery (m)

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 Upper Extremity  •  8E: Flexor Carpi Ulnaris Flap 885

FLAP HARVEST
Design and Markings
The line drawn from the medial epicondyle of the humerus to the pisiform bone of the
forearm outlines the location of the flexor carpi ulnaris (FCU) muscle. The dominant pedicle
of the muscle, the posterior recurrent artery, enters the deep surface close to its origin from
the medial epicondyle of the humerus. Incision is made along the line extending from the
medial epicondyle to the pisiform bone.

Incision of flexor carpi ulnaris

Fig. 8E-3 

Patient Positioning
The patient is placed in the supine position with the upper arm abducted on an arm board.

GUIDE TO FLAP DISSECTION

An incision is made along the middle third of the line drawn from the medial epicondyle to
the pisiform bone. The FCU muscle is easily identified. It is the most superficial and most
ulnar of the forearm muscles. Proximally, the muscle belly is in close contact with the muscle
belly of the palmaris longus and the flexor carpi radialis. Deep to it lies the flexor digitorum
profundus. The fleshy muscle fibers of the flexor carpi ulnaris extend only to within 7 or
8 cm of the wrist. This easily denotes the distal extent of flap dissection. Once identified, the
flexor carpi ulnaris muscle fibers are dissected off the tendon and mobilized from distal to
proximal. This allows for function preserving elevation of this muscle. Dissection proceeds
from distal to proximal. Deep to and just radial to the tendon and muscle belly run the ulnar
artery and nerve, which are protected during dissection. Dissection stops once sufficient
muscle has been elevated for rotational coverage to the antecubital fossa or elbow region.

Flexor carpi ulnaris flap dissection

Fig. 8E-4 

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 886 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANTS
•  Tendon transfer flap
•  Fasciocutaneous flap with flexor carpi ulnaris
•  Fasciocutaneous flap with flexor carpi ulnaris and ulna

Tendon Transfer Flap

The flexor carpi ulnaris has been described for reconstruction of the triangular fibrocartilage
complex in transfers for cerebral palsy, radial nerve palsy, and medial nerve palsy. These
topics are beyond the scope of this atlas.

Fasciocutaneous Flap With Flexor Carpi Ulnaris

and With Flexor Carpi Ulnaris and Ulna
As a variant of the ulnar forearm flap, the FCU can be harvested with the overlying skin
paddle with or without a segment of ulna. The FCU is required in the bone flap variant to
provide blood supply to the bony segment near the muscle origin. (See ulnar forearm flap
variants in Section 8F.)

ARC OF ROTATION
The arc of rotation extends posteriorly to the elbow, and anteriorly to the antecubital fossa.

Arc to elbow and antecubital fossa

Fig. 8E-5 

FLAP TRANSFER
Flap transfer is by direct transposition or through a short subcutaneous tunnel.

FLAP INSET
The flap is inset by direct suturing of the flap to its surrounding bed. The muscle is usually
skin grafted when used for soft tissue coverage.

DONOR SITE CLOSURE

The skin opened for exposure can be closed primarily.

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 Upper Extremity  •  8E: Flexor Carpi Ulnaris Flap 887

CLINICAL APPLICATION
This 40-year-old patient with rheumatoid arthritis had undergone total elbow arthroplasty
3 weeks earlier. The patient presented with a nonhealing surgical incision with serous
drainage.

A B

C D

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. (Case courtesy Milan
Stevanovic, MD.)

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 888 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The FCU muscle is the most powerful flexor of the wrist; therefore it should rarely be
used for reconstruction.
• When this muscle is sacrificed, it is generally for preservation of function, or transfer to
improve loss of function.
• Muscle harvest can be performed, keeping the tendon intact, which limits morbidity.
• Although the ulna can be taken in conjunction with the ulnar forearm flap, other bone
donor sites do not require sacrifice of a functional muscle and offer better bone stock for
reconstruction. Therefore this variant is rarely used.

Expert Commentary
Milan Stevanovic

Indications
The flexor carpi ulnaris is a bipennate muscle that can be used to cover small- to moderate-
sized defects about the elbow. It can reach all surfaces (anterior, posterior, medial, and lateral)
of the elbow. It has a strong, wide tendon that can be used for vascularized elbow ligament
or triceps tendon reconstruction. The dual innervation of the humeral and ulnar heads of
origin makes it possible to spare the humeral head of origin to retain flexor carpi ulnaris
function while using the ulnar origin head for local soft tissue coverage of very small defects.

Anatomic Considerations
Both the dominant arterial pedicle and the innervation to the muscle are proximal. Preser-
vation of the innervation to the muscle reduces the atrophy and fibrosis seen in denervated
muscle transfers. In most patients there are two to seven vascular pedicles; the dominant
pedicle typically lies within the first 5 cm from the medial epicondyle. There is a small
possibility that the ulnar artery is absent. A Doppler study of the arm and forearm should
be completed before planning to use this muscle.

Flexor carpi ulnaris

Fig. 8E-7  Vascular pedicles from the ulnar artery to the flexor carpi ulnaris.

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 Upper Extremity  •  8E: Flexor Carpi Ulnaris Flap 889

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
Technique
The muscle should be dissected through a long incision along the medial side of the muscle,
starting at the wrist flexion crease and extending proximally along the medial side of the
muscle. The incision should extend to the medial epicondyle or to the soft tissue defect.
The muscle belly extends nearly to the wrist flexion crease, which increases the surface area
of defect that can be adequately covered with this flap. If tendon is needed for ligament or
triceps tendon reconstruction, the distal portion of the muscle can be stripped away from the
tendon. The dissection can be performed with loupe magnification from distal to proximal.
The vascular pedicles are identified coming from the ulnar artery. More proximally, the
dominant pedicle may arise from the ulnar artery or ulnar recurrent artery. After identifying
the vascular pedicles, the muscle is elevated from lateral to medial off the ulnar periosteum.
The more distal vascular pedicles can then be ligated, leaving the proximal two pedicles
intact. If the most proximal pedicle has a smaller caliber, then both pedicles are left intact.
If a greater arc of rotation is needed for soft tissue coverage, the adequacy of the muscle
perfusion can be assessed. With the tourniquet released, the more distal pedicle is tempo-
rarily clamped with a bulldog clamp. If the muscle retains adequate circulation, then the
second pedicle can be safely divided.
To achieve a wider extent of soft tissue coverage, the muscle fascia can be longitudinally
incised to allow the muscle to be spread out to cover a greater surface area. In addition, the
long length of the muscle belly of the flexor carpi ulnaris allows the muscle to be fanfolded
on itself.

Fig. 8E-8  Fanfolded flexor carpi ulnaris muscle.

Continued

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 890 Part II  Regional Flaps: Anatomy and Basic Techniques

If the tendon is needed for ligament or triceps tendon reconstruction, the reconstruc-
tion is completed first, and the muscle belly is then positioned to cover the soft tissue defect.

Take-Away Messages
A greater arc of rotation can be achieved by releasing the fascia and the proximal origin, as
well as leaving only the proximal dominant pedicle. The flexor carpi ulnaris has a greater
arc of rotation than the brachioradialis and can usually reach all surfaces of the elbow.
The surgeon must pay special attention to protecting the ulnar nerve. Compression or
traction on the ulnar nerve must be avoided when insetting the muscle. After the muscle
is rotated, the pedicles should be inspected to ensure that there is no tension or kinking of
the pedicles.

Bibliography With Key Annotations

Ang GG, Rozen WM, Vally F, et al. Anomalies of the flexor carpi ulnaris: clinical case report
and cadaveric study. Clin Anat 23:427-430, 2010.
The flexor carpi ulnaris is an ever-present muscle of the anterior flexor compartment of the forearm.
Variations of this muscle are uncommon, with additional slips or heads of muscles described, and only
one reported case of an accessory muscle. The authors described a unique clinical case report in which
an accessory flexor carpi ulnaris was identified and described the findings of 5000 cadaveric dissec-
tions of the forearm, performed as part of an ongoing institutional study of anatomic variations. An
aberrant accessory forearm flexor muscle was identified incidentally at the wrist during surgery for an
anterior interosseous to ulnar nerve transfer for management of ulnar nerve palsy. This muscle was
seen running superficial to the ulnar nerve and radial to the FCU proper, arising from the common
flexor origin and inserting at the triquetral carpal bone. This was therefore suitably acknowledged as
an “accessory flexor carpi ulnaris.” The anomaly was identified as bilateral using ultrasound imag-
ing, and was found to be anomalously innervated by the median nerve with nerve conduction studies.
Chen G, Jiang H, Liu AT, et al. Neurovascular details about forearm muscles: applications in
their clinical use in functional muscular transfer. Surg Radiol Anat 32:3-8, 2010.
The concept of muscle subunits has been introduced for limb reconstruction and functional conservation
of donor site, yet it requires thorough understanding of neurovascular anatomy of muscles. The present
study provides neurovascular details of forearm skeletal muscles. Twenty-eight forearms were totally
dissected, 10 to observe extramuscular nerve distribution, 10 to observe intramuscular nerve distribu-
tion by a modified Sihler’s technique, and 8 to observe intramuscular artery distribution by aqueous
barium sulfate infusion. The forearm muscles were classified into three different types according to
Lym’s classification. Numbers of extramuscular and intramuscular nerves were counted and compared
between the types. Intramuscular vascular distribution was also classified into three different types
according to Mathes’s method. Intramuscular vascular distribution was compared with nerve distribu-
tion. There were some variations in the composition of muscular branches. Numbers of intramuscular
nerve branches were significantly higher in muscle types IIa and III. Morphology and intramuscular
neurovascular distribution of type II muscles are easy to split into two independent parts for functional
muscular flap transfer according to morphology and intramuscular neurovascular distribution.
Fridén J, Lovering RM, Lieber RL. Fiber length variability within the flexor carpi ulnaris
and flexor carpi radialis muscles: implications for surgical tendon transfer. J Hand Surg Am
29:909-914, 2004.
The authors reported their study to assess the detailed architectural properties of the human flexor carpi
radialis and flexor carpi ulnaris muscles and their implications for tendon transfer surgery. Muscle fiber
length was measured in six separate regions of the flexor carpi ulnaris and flexor carpi radialis from 10
cadaveric specimens. Sarcomere length was measured by laser diffraction for normalization. Moment

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 Upper Extremity  •  8E: Flexor Carpi Ulnaris Flap 891

arms were estimated by measuring tendon excursion with respect to joint angle. The position of entry
of the motor nerve branches into each muscle also was measured to establish limits for the safe length
of muscle mobilization. Muscle fiber length varied significantly along both the FCU and FCR. Fiber
length variability in the FCU was twice that of the FCR. Although the average fiber length for both
muscles across all regions was similar, the proximal fibers of the FCU were longer compared with the
proximal fibers of the FCR, and the distal fibers of the FCU were shorter compared with the distal
fibers of the FCR. The 99% confidence interval for the second nerve branch entry into the muscles
was located approximately 69 mm distal to the medial epicondyle for the FCU and approximately
73 mm distal for the FCR.
Gousheh J, Arasteh E. Transfer of a single flexor carpi ulnaris tendon for treatment of radial
nerve palsy. J Hand Surg Br 31:542-546, 2006.
The authors reported their experience with 108 patients with isolated and persisting radial nerve palsy
who underwent transfer of the flexor carpi ulnaris tendon alone to extensor digitorum communis, ex-
tensor indicis proprius, and extensor pollicis longus. Only patients with sufficient flexor carpi ulnaris
muscle power (grade M5) underwent this procedure. Long-term functional results were reviewed at
a mean postoperative follow up of 48 (range 3 to 120) months. In comparison with the contralateral
hand, the range of extension of the wrist was less but extension of the fingers and the MCP joints
were similar to that of the normal hand. All patients improved functionally and could cope with their
routine activities. Most were able to return to their previous jobs. There was no obvious difference in
the end result of using this single transfer from our previous results using the three tendon transfers
which are commonly used to treat radial nerve palsy. The single flexor carpi ulnaris tendon transfer has
some advantages in terms of simplicity, shorter operation time, less morbidity and less surgical scars.
Kalaci A, Doğramaci Y, Sevinç TT, et al. Unusual origin of the motor branch of the ulnar
nerve to the flexor carpi ulnaris. J Shoulder Elbow Surg 18:e38-e39, 2009.
Kreulen M, Smeulders MJ. Assessment of flexor carpi ulnaris function for tendon transfer
surgery. J Biomech 41:2130-2135, 2008.
Active and passive length-force curves of spastic flexor carpi ulnaris muscles were measured intra-
operatively in 10 patients with cerebral palsy to study the variability in measured muscle function.
Maximum active FCU force was in general situated near the neutral position of the wrist and varied
between 40 and 135 N. Passive forces varied between 1 and 8 N at maximum active force. The
potential active excursion varied between 4 and 7 cm, while patients moved their wrists from flex-
ion to extension along different parts of the active length-force curve. The authors measured a large
inter-individual variety of spastic flexor carpi ulnaris muscle function in this group of patients. Thus
tailoring the surgical technique of tendon transfer to the specific needs of the desired function requires
the assessment of muscle-specific data for each individual patient.
Lemon M, Belcher HJ. An anomalous flexor carpi ulnaris. J Hand Surg Br 27:194-197, 2002.
The authors reported on a muscle with features suggesting an anomalous conjoined palmaris longus
and flexor carpi ulnaris. To their knowledge this had not been described previously. In light of improved
imaging techniques, the authors questioned the previously published view that surgery is indicated for
swellings suspected as forearm muscle anomalies that are clinically benign and otherwise asymptomatic.
Lim AY, Kumar VP, Sebastin SJ, et al. Split flexor carpi ulnaris transfer: a new functioning
free muscle transfer with independent dual function. Plast Reconstr Surg 117:1927-1932, 2006.
A functioning free muscle transfer is a well-established modality of restoring upper limb function in
patients with significant functional deficits. Splitting the neuromuscular compartments of the free muscle
based on its intramuscular neural anatomy and using each compartment for a different function would
allow for restoration of two functions instead of one at the new distant site. The authors previously
reported on the clinical use of a pedicled split flexor carpi ulnaris muscle transfer. In this report they
described the use of this muscle as a functioning free split muscle transfer to restore independent thumb
and finger extension in a patient with total extensor compartment muscle loss in the forearm and a
concomitant high radial nerve avulsion injury. Nine months postoperatively, the patient was able to
extend his thumb and fingers independent of each other.

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 892 Part II  Regional Flaps: Anatomy and Basic Techniques

Lingaraj K, Lim AY, Puhaindran ME, Kumar PV. Case report: the split flexor carpi ulnaris as
a local muscle flap. Clin Orthop Relat Res 455:262-266, 2007.
The flexor carpi ulnaris is a useful local muscle flap in the forearm and elbow. However, it is an
important palmar flexor and ulnar deviator of the wrist, and functional loss may arise from the use
of this muscle in its entirety. The flexor carpi ulnaris is made up of two distinct neuromuscular com-
partments. This arrangement allows splitting of the muscle and the potential use of the larger ulnar
compartment as a local muscle flap while maintaining the humeral compartment as an ulnar deviator
and palmar flexor of the wrist. The authors reported two cases illustrating the clinical use of the split
flexor carpi ulnaris as a local muscle flap.
Marur T, Akkin SM, Alp M, et al. The muscular branching patterns of the ulnar nerve to the
flexor carpi ulnaris and flexor digitorum profundus muscles. Surg Radiol Anat 27:322-326, 2005.
The branching pattern of the ulnar nerve in the forearm is of great importance in anterior transposition
of the ulnar nerve for decompression after neuropathy of cubital tunnel syndrome and malformations
resulting from distal end fractures of the humerus. In this study, 37 formalin-fixed forearms were
used to demonstrate the muscular branching patterns from the main ulnar nerve to the flexor carpi
ulnaris muscle and ulnar part of the flexor digitorum profundus muscle. Eight branching patterns
were found and classified into four groups according to the number of the muscular branches leaving
the main ulnar nerve.
Payne DE, Kaufman AM, Wysocki RW, et al. Vascular perfusion of a flexor carpi ulnaris muscle
turnover pedicle flap for posterior elbow soft tissue reconstruction: a cadaveric study. J Hand
Surg Am 36:246-251, 2011.
The authors evaluated the vascular perfusion of a flexor carpi ulnaris turnover flap, based on the
most proximal primary vascular pedicle that would permit a proximal turnover flap reconstruction to
include the olecranon tip. In 12 fresh-frozen, proximal humeral human amputation specimens, the
flexor carpi ulnaris flap was elevated from distal to proximal, preserving the most proximal primary
vascular pedicle to the muscle belly that would permit flap coverage of the olecranon tip. The axillary
artery was injected with india ink after ligation of radial and ulnar arteries at the wrist. After injec-
tion, each specimen was sectioned transversely at 0.5 cm increments to assess vascular perfusion of the
muscle using loupe magnification. The authors concluded that use of a proximally based, pedicled
flexor carpi ulnaris muscle turnover flap provides a reliable option for soft tissue reconstruction at the
posterior elbow. The authors observed consistent arterial perfusion of the muscle flap when preserving
a proximal vascular pedicle 5.9 cm distal to the olecranon tip.
Roukoz S. Musculocutaneous flexor carpi ulnaris flap for reconstruction of posterior cutane-
otricipital defects of the elbow. Plast Reconstr Surg 111:330-335, 2003.
The author described the successful use of a proximally based flexor carpi ulnaris myocutaneous flap
to reconstruct a distal tricipital myocutaneous defect for four patients. The flap is recommended for
patients who have undergone multiple operations, for active reconstruction of the distal third of the
triceps muscle in association with medium-sized cutaneous defects on the posterior aspect of the elbow.
Shen S, Pang J, Seneviratne S, Ashton MW, Corlett RJ, Taylor GI. A comparative anatomical
study of brachioradialis and flexor carpi ulnaris muscles: implications for total tongue recon-
struction. Plast Reconstr Surg 121:816-829, 2008.
Total or subtotal glossectomy following resection of intraoral tumors causes significant morbidity. Recent
surgical endeavors have focused on the creation of a neotongue with both sensory and motor innerva-
tion. Although various local or regional free flaps have been used for this purpose, the optimal donor
site remains undecided. The authors compared the neurovascular anatomy of the brachioradialis and
flexor carpi ulnaris to assess their suitability as donor muscles together with overlying skin for functional
total or subtotal tongue reconstruction. Eighty-eight brachioradialis and 80 flexor carpi ulnaris muscles
were studied, composing 120 dissected specimens, 18 arterial studies, two venous studies, 20 histologic
studies, and eight neurovascular studies. The authors delineated the anatomic advantages of the flexor
carpi ulnaris over the brachioradialis for total or subtotal tongue reconstruction.

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 Upper Extremity  •  8E: Flexor Carpi Ulnaris Flap 893

Slullitel MH, Andres GE. New technique of reconstruction for medial elbow instability. Tech
Hand Up Extrem Surg 14:266-269, 2010.
The authors reported a new substitution technique as a choice for repairing both acute and chronic injuries
of the ulnar collateral ligament of the elbow. Different researchers have described different techniques to
reconstruct the medial ligament complex with similar results (with the use of grafts). There is a shared
variable in the latest reports, the interpretation of the anterior bundle as the most important structure,
for medial elbow stability and the only structure to be repaired as well. The approach to the medial
structures of the elbow is similar to most of the surgical techniques. It consists of an incision on the
medial aspect of the elbow, centered on the epicondyle, 4 inches long. The reconstruction uses a strip
of the aponeurosis of the flexor carpi ulnaris reinforced with Krakow stitches. The graft is harvested
using the strong aponeurosis of the flexor carpi ulnaris, a vascularized structure, a viable option and
with sufficient resistance to bear the tension of the inner aspect of the elbow. The surgical morbidity
is also reduced as the graft is not taken from other zones. As the distal insertion of the neoligament,
the proximal fixation of the flexor carpi ulnaris is used in the sublime tubercle, inverting the direction
of the fibers of this strip from distal to proximal. The proximal fixation of this ligament is an osseous
tunnel in the epitroclea secured with an interference screw. Common complications are those resulting
from the approach and the ulnar nerve manipulation. Because of the satisfactory stability outcome
achieved by this technique, early rehabilitation may start without inconvenience.
Wysocki RW, Gray RL, Fernandez JJ, et al. Posterior elbow coverage using whole and split
flexor carpi ulnaris flaps: a cadaveric study. J Hand Surg Am 33:1807-1812, 2008.
Seventeen fresh-frozen cadaveric upper extremities were used to evaluate the coverage patterns of whole
and split flexor carpi ulnaris pedicle muscle flaps for posterior elbow soft tissue defects. The whole FCU
was raised to the dominant vascular pedicle and transposed proximally over the olecranon. The widths
of coverage at 2 cm distances about the posterior elbow were measured. Widths were also measured
after making three longitudinal cuts in the fascia and after suturing the muscle to adjacent soft tissue
under tension. The FCU was also split into its ulnar and humeral heads along the central tendon.
The larger ulnar head was transposed and the widths again measured. Midforearm circumference, elbow
circumference, and ulnar length were assessed for ability to predict flap width. The whole muscle under
no tension provided an average of 2.7 cm width coverage at the tip of the olecranon process. Cutting
the fascia provided approximately 15% additional width and suturing the muscle to the surrounding
soft tissue an additional 25%, to approximately 4 cm. The isolated flexor carpi ulnaris ulnar head
provided approximately 75% of the width of the entire muscle. Midforearm circumference was the
most predictive of flap width, and divisors were generated that improved the accuracy of predicting the
width for outlier specimens. The dominant pedicle was a consistent distance relative to the end of the
central tendon and the olecranon tip.

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 ANATOMIC LANDMARKS
Landmarks A line from the medial epicondyle of the humerus to the lateral
edge of the pisiform bone marks the mid and distal forearm
course of the ulnar artery, which should bisect any skin design.
The flap occupies the medial aspect of the forearm along the
middle and lower thirds. Its distal limit is at the wrist crease.
Size Skin: 8 3 12 cm; muscle: 5 3 20 cm; bone: up to 12 cm.
Composition Fasciocutaneous, myocutaneous, osteomyocutaneous.
Dominant Pedicle Ulnar artery.
Nerve Supply Medial antebrachial cutaneous nerve (C8 to T1).

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 Section 8F
Upper Extremity

Ulnar Forearm Flap

CLINICAL APPLICATIONS
Regional Use
Upper extremity
Distant Use
Head and neck reconstruction
Upper extremity
Lower extremity
Specialized Use
Penile reconstruction

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 ANATOMY OF THE ULNAR FOREARM FLAP

A Flexor digitorum
superficialis muscle Flexor carpi radialis muscle
Common interosseous artery

Ulnar artery
Ulnar nerve
Flexor carpi ulnaris muscle Largest perforator
Brachial artery
of ulnar artery
Palmaris longus muscle

Vascular anatomy of ulnar forearm flap

B
Cephalic vein Median cubital vein
Cephalic vein

Basilic vein
Basilic vein
Basilic venous outflow of ulnar forearm

C
Lateral antebrachial cutaneous nerve

Medial antebrachial cutaneous nerve

Sensory nerves of ulnar forearm flap

Fig. 8F-1 A, A common interosseous artery arises within 2 cm of the brachial bifurcation. Flap place-
ment 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 an-
tebrachial 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.
Dominant pedicle: Ulnar artery

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 Upper Extremity  •  8F: Ulnar Forearm Flap 897

ANATOMY
Landmarks The flap occupies the medial aspect of the forearm along a line drawn from the
medial epicondyle of the humerus to the lateral edge of the pisiform bone.
Composition Fasciocutaneous, myocutaneous, osteomyocutaneous. The flap compares well
with the radial forearm flap for both application and tissue quality.
Size Skin: 8 3 12 cm; muscle: 5 3 20 cm; bone: up to 12 cm.

Arterial Anatomy
Dominant Pedicle  Ulnar artery
Regional Source  Brachial artery.
Length  4 cm.
Diameter  3 mm proximally; 2.5 mm distally.
Location  The ulnar artery is the larger of the two terminal branches of the brachial artery. The
most proximal septocutaneous perforator of the ulnar artery arises 4 cm distal to its common
interosseous branch. Proximally on the forearm, the ulnar artery joins the ulnar nerve on its
lateral surface deep to the flexor carpi ulnaris (FCU) muscle. The ulnar artery is closely associ-
ated with the ulnar nerve in the distal two thirds of the forearm; it is found on the lateral side
of the ulnar nerve. At the wrist, the ulnar artery passes superficial to the flexor retinaculum and
enters the hand between the pisiform bone and the hook of the hamate bone. The ulnar artery
continues distally to form the superficial palmar arch. It also sends a smaller branch to form the
deep palmar arch with the terminal portion of the radial artery.

Venous Anatomy
The ulnar forearm flap has both a superficial and a deep venous system. The basilic vein runs in the
ulnar aspect of the forearm and is accompanied in the distal third by the ulnar branch of the medial
antebrachial cutaneous nerve, which is often deep to the vein. At the antecubital fossa, the basilic
vein is joined by the median cubital vein and ascends in the bicipital groove, where it is closely as-
sociated with the ulnar branch of the medial antebrachial cutaneous nerve, which is located medial
to the vein, and the anterior branch of the medial antecutaneous nerve, located lateral to the vein.
The deep venous system comprises paired venae comitantes that travel with the ulnar artery. The
basilic vein is often chosen as the main vein that drains the flap.

Nerve Supply
Sensory The medial antebrachial cutaneous nerve (C8 to T1) arises from the medial cord
of the brachial plexus, accompanies the brachial artery, and exits the fascia of
the arm, with the basilic vein dividing into anterior and ulnar branches. The
anterior branch supplies the anteromedial surface of the forearm. The ulnar
branch, which passes anterior to the medial epicondyle, supplies the skin on the
posteromedial surface of the forearm to the wrist.

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 898 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Ulnar Forearm Flap

A

Fig. 8F-2  A, Dissection of the ulnar artery flap skin paddle is started from radial to ulnar and is per-
formed 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 per-
forators 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 digi-
torum 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. (Dissection courtesy Michel Saint-Cyr, MD.)

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 Upper Extremity  •  8F: Ulnar Forearm Flap 899

FLAP HARVEST
Design and Markings
The flap is designed on the proximal or central forearm; a distally placed flap would have
less vascularity, because there is a paucity of septocutaneous perforating vessels in the distal
forearm. A line drawn from the medial epicondyle of the humerus to the lateral edge of
the pisiform bone mirrors the course of the ulnar artery; this can be confirmed by Doppler
ultrasound. A third of the flap should be located radial to the ulnar vessel. A tourniquet can
aid in marking the basilic vein, which is included in the flap.

Fig. 8F-3  The location of the ulnar artery distally is marked by the line connecting the medial epi-
condyle 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
The patient is placed in the supine position with an armboard and a tourniquet on the arm.

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 900 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

An incision is made on the radial margin, including the deep fascia of the forearm. The
distal margin is incised and the ulnar artery is identified. At this point, the ulnar artery can
be temporarily occluded with a clamp and the tourniquet deflated to confirm perfusion if
the Allen’s test has not been performed. The ulnar artery is transected and the proximal
margin is incised, again with careful identification of the ulnar artery and measures to avoid
injury to the basilic vein. If a sensate flap is desired, the anterior and ulnar branches of the
medial antebrachial cutaneous nerves are identified and spared.

Ulnar artery

Ulnar nerve
Basilic vein
Medial antebrachial cutaneous nerve

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.

Dissection continues from radial to ulnar beneath the deep fascia toward the inter-
muscular septum, which separates the flexor digitorum sublimis and the flexi carpi ulnaris
muscles. All septocutaneous vessels that run in the intermuscular septum to the deep fascia
are preserved.

B Median nerve Flexor digitorum superficialis muscle

Ulnar artery

Ulnar nerve
Basilic vein
Flexor digitorum profundus muscle
Medial antebrachial cutaneous nerve
Medial antebrachial vein

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.

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 Upper Extremity  •  8F: Ulnar Forearm Flap 901

Dissection continues on the ulnar surface of the septum. Muscular branches to the
flexor carpi ulnaris and flexor digitorum profundus are divided.

C Median nerve Flexor digitorum superficialis muscle

Ulnar artery
Basilic vein
Medial antebrachial cutaneous nerve
Ulnar nerve
Flexor carpi ulnaris muscle

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.

Dissection proceeds from distal to proximal, separating the ulnar artery from any soft
tissue attachments until the flap is attached proximally only by the ulnar artery pedicle, the
basilic vein, and the accompanying nerves.

D Flexor digitorum superficialis muscle

Flexor digitorum profundus muscle Medial antebrachial vein
Median nerve
Ulnar artery

Medial antebrachial
cutaneous nerve
Ulnar artery
Basilic vein
Ulnar nerve Flexor carpi ulnaris muscle

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
•  Fasciocutaneous flap with flexor carpi ulnaris and ulna
•  Flow-through flap

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 902 Part II  Regional Flaps: Anatomy and Basic Techniques

Fasciocutaneous Flap With Flexor Carpi Ulnaris

The flexor carpi ulnaris muscle can be included in the fasciocutaneous flap. Dissection is
similar to that described for the standard flap. The FCU is a class II muscle with a larger
dominant pedicle and smaller minor pedicles. It is noteworthy that when the FCU is dis-
sected with the ulnar forearm flap, it includes only the minor pedicles. The nerve supply
to the muscle is a branch of the ulnar nerve, which is found proximally near the elbow.
After the fasciocutaneous portion of the flap is isolated, the flexor carpi ulnaris muscle is
detached proximally from its two heads of origin, the medial condyle of the humerus and
the posterior border of the ulna. This distal tendinous insertion is cut proximal to its inser-
tion into the pisiform bone. After the muscle is elevated, the motor nerve is identified and
further dissected if the muscle will be used as a functional transfer.

Intermuscular septum
Flexor digitorum superficialis muscle Ulnar artery

Ulnar artery
Ulnar nerve
Flexor carpi ulnaris muscle

Fig. 8F-5  The flexor carpi ulnaris muscle is included with the cutaneous paddle.

Fasciocutaneous Flap With Flexor Carpi Ulnaris

and Ulna
An osseous segment of the ulna, up to 12 cm, can be included with flap. It is important
to include the proximal portion of the flexor carpi ulnaris muscle with its myoperiosteal
branch, which supplies this osseous segment. The width of the bony segment should be
0.75 cm thick.

Donor ulnar defect Ulnar artery

Flexor digitorum superficialis muscle

Flexor carpi
ulnaris muscle

Basilic vein and

Ulnar artery medial antebrachial nerves

Flexor digitorum profundus muscle

Ulnar nerve Ulnar artery

Fig. 8F-6  An osseous segment of ulna may be included in the flap. A portion of the flexor carpi ul-
naris muscle is included with this myoperiosteal branch, which supplies the osseous segment.

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 Upper Extremity  •  8F: Ulnar Forearm Flap 903

Flow-Through Flap
The caliber of the ulnar vessels proximally and distally makes the ulnar forearm ideal for
use as a flow-through flap. This is most commonly used in the extremities to revascularize
a dysvascular segment or to incorporate multiple free flaps in reconstruction, as is often
performed in the head and neck.

ARC OF ROTATION
Standard Flap
The arc of rotation of the standard flap easily reaches the antecubital fossa, the elbow, and
the forearm.

Point of rotation

Arc to elbow and forearm

Fig. 8F-7 

FLAP TRANSFER
Standard Flap
The flap is transposed into the recipient site either by direct communication or through
a subcutaneous tunnel. There must be no compression of the pedicle or kinking on its
transposition.

Free Flap
Standard microsurgical principles are employed to avoid tension on the flap or on the pedicle.

FLAP INSET
Pedicled Flap
The flap must be inset without tension, with adequate space provided for the pedicle. It is
essential to allow for postoperative swelling.

Free Flap
The flap should be inset without tension; the vascular pedicle is positioned carefully to
avoid tension or kinking. In bone harvest, the bone inset is performed before microsurgical
reanastomosis to prevent injury to the pedicle from unnecessary tension. In a muscle harvest
in which a functional muscle is required, the resting muscle length must be reestablished
for best function.

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 904 Part II  Regional Flaps: Anatomy and Basic Techniques

DONOR SITE CLOSURE

All Flap Variants
Direct donor site closure can be accomplished in most cases. When primary closure is not
possible, a skin graft can be used. The donor site must not be closed under too much ten-
sion to avoid a tourniquet-like effect, which can compromise the blood supply to the hand,
especially when postoperative swelling is taken into account.

CLINICAL APPLICATIONS
This 60-year-old man had a 3 by 3 cm nonhealing elbow wound and forearm hardware.
An ulnar artery flap reconstruction was planned.

A B

C D

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.
(Case courtesy Ernest Chiu, MD.)

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 Upper Extremity  •  8F: Ulnar Forearm Flap 905

This 56-year-old man had a lateral tongue squamous cell carcinoma.

A B

C D

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. (Case courtesy Ernest S. Chiu, MD.)

Pearls and Pitfalls

• The ulnar forearm flap supplies tissue similar to that of the radial forearm flap; an advantage
of the ulnar flap is a more aesthetically favorable, well-hidden donor site that is relatively
hairless and can include a functional muscle, the flexor carpi ulnaris.
• Postoperative pain and immobilization are minimal with the forearm ulnar flap.
• The flap allows elevation and recipient site dissection to be carried out by two teams.
• Sacrifice of the ulnar artery is less likely to result in ischemic consequences to the hand
than sacrifice of the radial artery. However, this flap does require sacrifice of a major
artery supplying the forearm.
• The ulnar forearm flap is more proximally based than the radial forearm flap and therefore
has a shorter vascular pedicle.
• When bone is harvested with the flap, the patient should be placed in a cast for a mini-
mum of 3 weeks to prevent fracture of the ulna.
• Transient postoperative paresthesias can occur postoperatively in the ulnar two digits.

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 906 Part II  Regional Flaps: Anatomy and Basic Techniques

Expert Commentary
Ernest S. Chiu

Indications
The ulnar artery forearm flap can be used in all situations in which the radial artery forearm
flap is being considered for reconstruction.

Advantages and Limitations

The thin fasciocutaneous flap is reliable and easy to harvest. It can be used as a pedicled or
free tissue transfer flap with an excellent robust blood supply to the skin paddle. The donor
site can be well concealed on the ulnar aspect of the forearm and tends to have less hair on
its skin surface. Also, the donor site does not have the raised, tendinous flexor carpus radialis,
which can be difficult to heal, even when inadequately skin grafted. Its limitations are that
an important blood supply to the hand is sacrificed; therefore the flap is contraindicated if
the result of the Allen’s test is abnormal. The color match is suboptimal for reconstruct-
ing visible anatomic head or neck defects. Although a small segment of ulnar bone can be
harvested with the flap, this is not recommended—thin ulnar bone is prone to fracture.
The flap harvest must be performed with utmost attention, because the ulnar nerve is vul-
nerable to injury, since it runs directly on the ulnar side of the ulnar artery. The donor site
frequently requires skin grafting, which may be disfiguring.

Personal Experience and Insights

The ulnar artery is located between the ulnar nerve and the flexor digitorum tendons. When
the anterolateral thigh flap is found to be too bulky, the ulnar artery flap is my preferred
thin, fasciocutaneous flap for both upper extremity regional flap reconstruction as well as
lower extremity and head and neck free flap reconstruction.

Recommendations
Planning
During the initial consultation, an Allen’s test is performed in the patient’s nondominant
arm. If the result is normal, blood is not drawn from that donor site arm, nor are intravenous
lines placed in the arm. Before induction of anesthesia, an Allen’s test is confirmed by placing
an oxygen saturation pulse oximeter on the patient’s middle finger and manually occluding
both the radial and ulnar arteries. After releasing the radial artery occlusion, the oxygen
saturation curve should return to baseline within 3 to 5 seconds. If the flap is to be used for
free tissue transfer, a temporary upper extremity tourniquet is placed to promote forearm
basilic vein engorgement. These veins can be marked and used as an alternative venous
drainage choice if the venae comitantes size match to the recipient vessels is unfavorable.
After the defect size has been determined, the skin paddle is designed one and a half to
two times larger than the defect, centered over the ulnar artery.

Technique
The skin paddle design will allow the redundant proximal forearm flap skin to be used as
a full-thickness skin graft to the donor site. A more favorable texture, contour, and color
match will result. The upper extremity is prepared in sterile fashion to the axilla, and a
sterile tourniquet is applied to the upper arm. When possible, the surgeon sits during the
flap harvest.

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 Upper Extremity  •  8F: Ulnar Forearm Flap 907

After the arm is exsanguinated, the tourniquet is placed at 100 mm Hg above systolic
pressure.
The flap is harvested by completing ulnar, radial, and proximal wrist crease skin inci-
sions. The ulnar artery is identified and ligated, and the flap is harvested in a distal-to-
proximal fashion. There are small perforating branches that run between the ulnar pedicle
to the overlying skin; these should be preserved. Dissolvable sutures are used to tack the
skin paddle to the underlying pedicle to prevent flap avulsion. Because the ulnar artery
is in close proximity to the ulnar nerve, nerve identification is important, and the nerve
should not be skeletonized. Unlike a radial forearm flap, the muscle bellies of the flexor
digitorum tendons are wide and flat, allowing a more uniform and favorable surface for
grafting. When available, a basilic vein entering the proximal aspect of the flap should be
maintained as an alternative vein choice. Dissection of the ulnar artery pedicle is continued
proximally until adequate pedicle length is obtained. The tourniquet is released to check
for skin flap perfusion. A marking pen is used to identify pedicle orientation to minimize
the risk of pedicle twisting or kinking. When the recipient vessels are ready, the flap harvest
can be performed.
The forearm skin around the flap harvest location should be undermined and sutured
to underlying fascia and muscle to decrease the size of the donor site defect. Dissolvable
sutures are selectively placed in the donor site area to promote a flat favorable recipient skin
graft location. Extra skin harvested from the flap skin paddle can be separated from the skin
paddle, thinned, and sutured to cover the donor site. Meshing of the skin graft creates an
unattractive gridlike pattern at the donor site. Pie-crusting of the skin graft and irrigation
with saline solution under the graft to flush out blood and fluid will decrease the risk of
incomplete skin graft take. An Adaptec or Xeroform dressing is applied over the skin graft
site, and a 125 mm Hg VAC negative pressure dressing is applied. An ulnar gutter splint is
used to minimize skin graft shearing. Skin graft take is checked 3 to 5 days later.

Take-Away Message
This is a practical, reliable, thin fasciocutaneous flap with a robust blood supply that can be
used in many reconstructive cases.

Bibliography With Key Annotations

Arnstein PM, Lewis JS. Free ulnar artery forearm flap: a modification. Br J Plast Surg 55:356-
357, 2002.
The authors described a modification of the free ulnar artery forearm flap that has the benefit of the
anastomosis of large-caliber vessels and the reassurance of a reconstructed ulnar artery for perfusion of
the donor hand.
Bhatt V, Hall TJ. Anatomical variations in forearm vascular anatomy. J Craniomaxillofac Surg
38:244, 2010.
Cavusoglu T, Ozden H, Comert A, et al. Topographical anatomy of the dorsal branch of the
ulnar nerve and artery: a cadaver study. Surg Radiol Anat 33:229-233, 2011.
The surgical anatomy of the dorsal branch of the ulnar nerve and artery on the dorsal aspect of the
hand is important in the design of neurocutaneous flaps for reconstructive surgery and serves as a donor
site for nerve grafts. The authors studied the course, location, and diameter of the dorsal branches of
the ulnar nerve and artery from anatomic and reconstructive perspectives. The upper limbs of 14 (7
left and 7 right) and 22 formalin-preserved adult cadavers (15 left and 7 right) were dissected in two

08f_UlnarFore_r3b_bs_0894-0912.indd 907 1/31/2012 3:41:13 PM

 908 Part II  Regional Flaps: Anatomy and Basic Techniques

different centers. The distances to specific anatomic landmarks were also measured from the proximal
forearm toward the middle phalanges of the fourth and fifth fingers. These data may help the surgeon
to design neurocutaneous flaps nourished from the dorsal branches of the ulnar nerve and artery, aid in
harvesting nerve grafts from the dorsal branch of the ulnar nerve, and provide a safe surgical approach
to the dorsum of the hand.
Gabr EM, Kobayashi MR, Salibian AH, et al. Role of ulnar forearm free flap in oromandibular
reconstruction. Microsurgery 24:285-288, 2004.
The ulnar forearm flap is not frequently used for oromandibular reconstruction. This retrospective study
of 32 patients evaluated the usefulness of the ulnar free flap for reconstruction. The ulnar forearm flap
was combined with an osseous flap in 24 patients. Nine women and 23 men with a mean age of
58.15 years composed the study population. Squamous cell carcinoma was the diagnosis in 93.75%
of cases (56.25% T4), of which 20% were recurrent cases. Functional evaluation of swallowing was
based on the University of Washington Questionnaire (UWQ). The mean hospital stay was 9.8
days. The external carotid (100%) was the recipient artery, and the internal jugular (74.07%) was
the main recipient vein. Overall flap survival was 96.8%. One flap was lost to unsalvageable venous
thrombosis. Major local complications were seen in 9.4% of cases and included partial flap loss, he-
matoma, and an orocutaneous fistula. Twenty-one patients were available for functional evaluation.
Speech was rated excellent and good in 33.3% of patients. Swallowing was found good in 28.6% of
patients. Chewing was rated excellent and good in 47.6% of patients. Cosmetic acceptance was rated
good in 71.4% of cases. The ulnar forearm is a useful free flap in oromandibular reconstruction. It is
available when the radial artery is the dominant artery of the hand. Because it is more hidden, it may
be more cosmetically accepted. It affords pliable soft tissue for lining and/or covering of oromandibular
defects, and can be used as a second choice after other free flaps have failed.
Lee HB, Hur JY, Song JM, et al. Long anterior urethral reconstruction using a sensate ulnar
forearm free flap. Plast Reconstr Surg 108:2053-2056, 2001.
Liu DX, Zheng CY, Li XD, et al. Clinical application of the flap based on the distal cutaneous
branch of the ulnar artery. J Trauma 70:E93-E97, 2011.
The authors presented their experiences with the ulnar flap based on the distal cutaneous branch of
the ulnar artery. Twenty-four patients underwent surgery for soft tissue defects of the hand between
January 2003 and December 2008. Fifteen cases had a soft tissue defect on the palmar aspect of the
hand, and nine cases had defects on the dorsal aspect. The size of the flaps ranged from 5 to 12 cm
long and 4 to 8 cm wide. Two flaps developed partial necrosis (25% to 35% of their area). In the other
cases, both the donor and recipient sites healed successfully. No patient complained of cold intolerance
of the hand or any altered sensation in the forearm. The range of motion of the wrist and hand joints
was within normal limits in most cases: 14 cases with excellent, 8 cases with good, 2 cases with fair,
and 0 case with poor results according to the total active motion (TAM) criteria. None of the patients
had limitations in activities of daily living. Because the flap does not compromise the dominant hand
arteries and provides a reliable blood supply, it is a good choice for soft tissue reconstruction of defects
in the dorsal and palmar aspects of the hand.
Lorenzetti F, Giordano S, Suominen E, et al. Intraoperative hemodynamic evaluation of the
radial and ulnar arteries during free radial forearm flap procedure. J Reconstr Microsurg 26:73-
77, 2010.
The authors conducted this prospective study to assess the blood flow of the radial and ulnar arteries
before and after radial forearm flap raising. Twenty-two patients underwent radial forearm microvas-
cular reconstruction for leg soft tissue defects. Blood flow of the radial, ulnar, and recipient arteries was
measured intraoperatively by transit time and ultrasonic flowmeter. In the in situ radial artery, the
mean blood flow was 60.5 6 47.7 ml/min before, 6.7 6 4.1 ml/min after raising the flap, and 5.8
6 2.0 ml/min after end-to-end anastomosis to the recipient artery. In the ulnar artery, the mean blood
flow was 60.5 6 43.3 ml/min before harvesting the radial forearm flap and significantly increased
to 85.7 6 57.9 ml/min after radial artery sacrifice. A significant difference was also found between

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 Upper Extremity  •  8F: Ulnar Forearm Flap 909

this value and the value of blood flow in the ulnar and radial arteries pooled together. The vascular
resistance in the ulnar artery decreased significantly after the radial artery flap raising (from 2.7 6
3.1 to 1.9 6 2.2 peripheral resistance units). The forearm has a conspicuous arterial vascularization,
not only through the radial and ulnar arteries, but also through the interosseous system. Raising the
radial forearm flap increases blood flow and decreases vascular resistance in the ulnar artery.
Martin MC, Machado GR, Wong WW, et al. Transverse ulnar forearm flap. J Craniofac Surg
21:1741-1744, 2010.
The transverse ulnar forearm flap (TUFF) was used to reconstruct different recipient sites in five
consecutive cases based on the specific requirement for a small thin, hairless flap with a long pedicle.
Recent studies have clarified the benefits of the ulnar forearm flap: a less inconspicuous donor site and
a primary donor site closure with a radially based fasciocutaneous flap. The TUFF is designed with
its long axis transverse and distal margin parallel with a wrist flexion crease. An incision is extended
proximally along the ulnar artery pedicle as far as the takeoff from the brachial artery, if needed. After
elevating the ulnar forearm flap in the standard fashion, transverse primary closure of the donor site is
obtained by elevating a large volar forearm fasciocutaneous flap based on the radial artery and advanced
distally with a V-Y advancement. Any dog-ear is tailored, and the wrist is flexed at 30 degrees. In
the authors’ series, all TUFF and radial fasciocutaneous flaps survived completely without partial or
total losses or ischemic hand complications. One patient had a wide scar at the proximal forearm Y
junction that was revised. Two-point fingertip discrimination and range of motion were satisfactory.
They noted that the TUFF is a synthesis of variations of previously described forearm flap techniques
and provides a specialized flap in situations where small, thin, pliable, hairless fasciocutaneous flap
with a long vascular pedicle are necessary. These characteristics make it appropriate in orbital recon-
struction and palatal surgery.
Mateev MA, Trunov L, Hyakusoku H, et al. Analysis of 22 posterior ulnar recurrent artery
perforator flaps: a type of proximal ulnar perforator flap. Eplasty 10:e2, 2009.
The proximal ulnar artery has several branches, including perforators that are directly derived from
the ulnar artery and anterior/posterior recurrent arteries. There are only a few reports of flaps that
use the anterior/posterior recurrent arteries, and flaps employing their perforators as a main pedicle
are yet to be reported. In this study, 22 posterior ulnar recurrent artery perforator (PURAP) flaps
were employed for elbow and forearm reconstruction; all flaps were vascular pedicled island flaps. The
flaps were analyzed in terms of the cause of injury, recipient site, vascular pedicle of the flap, flap size
and survival, and quality of the outcome. Donor site morbidity, including the development of scars
and numbness, was also evaluated. The perforator used was the medial and posterior perforator in
14 (63.6%) and 8 (36.4%) cases, respectively. The average flap size was 10 by 5 cm. Six months
after the operation, the outcomes were judged to be excellent in 15 cases (68.2%), good in 6 cases
(27.3%), and poor in 1 case (4.5%) because of partial necrosis of the distal part of the flap. The
authors stated that PURAP flaps can be harvested with two types of perforator pedicles (the medial
or posterior perforator) and offer greater safety and flexibility, and less donor site morbidity than exist-
ing flaps used for elbow and forearm reconstruction. The ability to close the donor site primarily is a
significant benefit of this flap.
Porter CJ, Mellow CG. Anatomically aberrant forearm arteries: an absent radial artery with
co-dominant median and ulnar arteries. Br J Plast Surg 54:727-728, 2001.
A radial artery free flap was dissected from a traumatically amputated forearm. During dissection
the arterial tree was found to be abnormal, with no radial artery. The arterial supply was based on
co-dominant median and ulnar arteries. This description raises issues regarding anatomic vascular
aberrations when planning forearm flaps.
Rodriguez ED, Mithani SK, Bluebond-Langner R, et al. Hand evaluation following ulnar
forearm perforator flap harvest: a prospective study. Plast Reconstr Surg 120:1598-1601, 2007.
Shoaib T, Van Niekerk WJ, Morley S, et al. The ulnar artery perforator based islanded V-Y flap
closure of the radial forearm flap donor site. J Plast Reconstr Aesthet Surg 62:421-423, 2009.

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 910 Part II  Regional Flaps: Anatomy and Basic Techniques

Sieg P, Bierwolf S. Ulnar versus radial forearm flap in head and neck reconstruction: an ex-
perimental and clinical study. Head Neck 23:967-971, 2001.
To consider the pros and cons of the microvascular ulnar forearm flap compared with its radial counter-
part, this study compares the use of these two flaps for head and neck reconstruction. In 75 patients,
51 ulnar and 24 radial forearm flaps were used. Both groups were compared regarding flap dissec-
tion, suitability of the flap for the recipient region, complication rate, and secondary morbidity in the
donor region. Furthermore, in 40 healthy volunteers, the thickness of the subcutaneous tissue layer
was measured by ultrasonography. The flap survival rate and wound healing in the recipient region
showed no differences. Clinical and experimental results demonstrated a thinner subcutaneous layer
in the ulnar aspect of the forearm. Compared with its radial equivalent, closure of the ulnar donor side
by skin grafting resulted in a significantly lower complication rate.
Van Cann EM, Koole R. The ulnar forearm free flap for the reconstruction of soft tissue defects
in the head and neck area: free flap outcome and donor site outcome. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 108:851-854, 2009.
The authors conducted a study to evaluate the outcome of reconstruction with the ulnar forearm free
flap (UFFF). The UFFF was used to reconstruct soft tissue defects in the head and neck area in 15
patients. The outcome was registered from the patient notes, clinical examination, and from interviews
with patients. All 15 UFFFs appeared successful. Thirteen donor sites healed without complications.
Two donor sites showed minor wound-healing problems. No patient had abnormal sensation in the
distribution area of the ulnar nerve. All patients were satisfied with the appearance of the scar and
shape of the donor site. The authors stated that the UFFF should be considered as a reconstruction
method for soft tissue defects in the head and neck area instead of the radial forearm free flap, as the
donor site of the UFFF is barely noticeable, which makes patient acceptance more likely.
Vergara-Amador E. Anatomical study of the ulnar dorsal artery and design of a new retrograde
ulnar dorsal flap. Plast Reconstr Surg 121:1716-1724, 2008.
The author described a new flap that resulted from a study of the vascular distribution of the ulnar
dorsal artery, with a focus on the distal and proximal branches with their anastomoses. Green latex
was injected into the brachial artery of the proximal limbs of 25 cadavers. After 48 hours, the vessels
were dissected beginning at the ulnar dorsal artery and following its descending and ascending branches.
In two of the specimens, an injection of methylene blue was administered in the ulnar artery to look
for reverse flow from the descending branch. The ulnar dorsal artery was located in all injected limbs
with a constant distribution. It had two branches: a descending one that distributed under the abductor
digiti quinti muscle and anastomosed with a deep branch of the ulnar artery, and an ascending one
supplying the proximal third of the forearm. Retrograde flow in the descending branch was found by
injecting dye. Based on these findings, a flap with reverse flow that the author called a “retrograde ulnar
dorsal flap” was designed at the expense of the descending branch by ligating the ulnar dorsal artery
where it originates. This makes it possible to cover soft tissue defects that are more distal on the hand.
Wax MK, Rosenthal EL, Winslow CP, et al. The ulnar fasciocutaneous free flap in head and
neck reconstruction. Laryngoscope 112:2155-2160, 2002.
The radial forearm fasciocutaneous free flap has become the reconstructive tissue of choice for the ma-
jority of soft tissue defects in the head and neck. The forearm skin has many of the ideal soft tissue
characteristics that optimize reconstruction and rehabilitation in these patients. The tissue is malleable,
supple, and moldable in three dimensions; has a reliable pedicle; and can be harvested with a two-team
approach. In some patients, the radial forearm cannot be used. An alternative is to use the adjacent
tissue, which shares identical tissue characteristics. This tissue gets its vascular supply from the ulnar
artery. The purpose of the report was to describe the authors’ experience with the ulnar fasciocutaneous
free flap in head and neck reconstruction. The authors presented a retrospective review of all patients
undergoing ulnar fasciocutaneous free tissue transfer by a group of microvascular surgeons was performed.
Thirty patients underwent free tissue transfer using the ulnar fasciocutaneous free flap. The male-to-
female ratio was 3:1. Defects were located in the oral cavity, oropharynx, neck skin, and soft tissue of

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 Upper Extremity  •  8F: Ulnar Forearm Flap 911

the lateral skull. The average size of the skin paddle that was transferred was 7 by 10 cm (range 3 by
5 to 9 by 12 cm). The mean area of tissue that was transferred was 70 cm2 (range 15 to 108 cm2).
Vessel sizes were somewhat smaller than the comparable radial forearm. One patient had complete
loss of the skin graft on the donor site. There were no median nerve or other wound-healing problems.
Two flaps were lost in the postoperative period. Indications for use of the ulnar fasciocutaneous free flap
were a failed Allen’s test (23), use of a less hairy part of the forearm (3), and surgical preference (4).
Zen N, Ueda K, Oba S. Urethral reconstruction for hypospadias using the ulnar forearm flap.
J Reconstr Microsurg 22:353-356, 2006.

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 Credits

Fig. 2-1  From the Gentleman’s Magazine of Calcutta, October 1794.

Fig. 2-2  From Gaspare Tagliacozzi, De Curtorum Chirurgia per Insitionem Libri Duo.
Fig. 2-4  From Salmon M. Artères de la Peau. Paris: Masson et Cie, 1936.
Fig. 2-5  Adapted from Cormack G, Lamberty B. The Arterial Anatomy of Skin Flaps.
Edinburgh: Churchill Livingstone, 1986.
Fig. 2-6  Reprinted from Clinics in Plastic Surgery, Volume 37, Morris SF, Tang M,
Almutari K, Geddes C, Yang D. The anatomic basis of perforator flaps, pp. 553-570.
Copyright 2010; with permission from Elsevier.
Fig. 2-7  From Milton SH. Pedicled skin-flaps: the fallacy of the length: width ratio.
Br J Surg 57:503, 1970.
Fig. 2-9  Reprinted from British Journal of Plastic Surgery, Volume 40. Taylor GI,
Palmer JH. The vascular territories (angiosomes) of the body: experimental study and
clinical applications, pp. 113-141. Copyright 1987; with permission from Elsevier.
Fig. 2-12  Adapted from Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomi-
cal (angiosome) and clinical territories of cutaneous perforating arteries: development
of the concept and designing safe flaps. Plast Reconstr Surg 127:1449, 2011.
Fig. 2-14  Adapted from Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous
territories (venosomes) of the human body: experimental study and clinical implications.
Plast Reconstr Surg 86:189, 1990.
Fig. 2-15  Adapted from Taylor GI, Gianoutsos MP, Morris SF. The neurovascu-
lar territories of the skin and muscles: anatomic study and clinical implications. Plast
Reconstr Surg 94:7, 1994.
Fig. 2-16  Adapted from Taylor GI, Gianoutsos MP, Morris SF. The neurovascu-
lar territories of the skin and muscles: anatomic study and clinical implications. Plast
Reconstr Surg 94:20, 1994.
Fig. 2-17  Adapted from Taylor GI, Corlett RJ, Caddy CM, Zelt RG. An anatomic
review of the delay phenomenon: II. Clinical applications. Plast Reconstr Surg 89:409,
1992.
Fig. 2-23  Adapted from Cormack CG, Lamberty BGH. The Arterial Anatomy of
Skin Flaps. Edinburgh: Churchill Livingstone, 1986, p. 107. Reproduced with permis-
sion from Elsevier Health Sciences.
Fig. 2-24  Adapted from Nakajima H, Fujino T, Adachi S. A new concept of vascular
supply to the skin and classification of skin flaps according to their vascularization. Ann
Plast Surg 16:1-19, 1986.
Fig. 2-25  Adapted from Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg 67:178, 1981.

C-1

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 Chapter 9
Hand

The hand is a unique fusion of form and function. Deficits in the hand run the gamut
from congenital deformity to traumatic injuries. When reconstructing defects within
the hand, the surgeon must remember that maintenance or improvement of hand func-
tion should always take precedence over form or aesthetics. These reconstructive flaps
limit morbidity and address quality of life by affording rapid return to work and to
normal activities. Many of these procedures will allow the replacement of like with like
tissues, the toe-to-hand transfer representing the pinnacle of this concept. One should
remember always that a fully functional hand is a cosmetic hand.

Abductor Digiti Minimi Flap

Great Toe (Hallux) Flap
Homodigital Neurovascular (Littler) Island Flap
Second Toe Flap
Dorsal Metacarpal Artery Flap
Cross-Finger Flap
Kleinert-Atasoy V-Y Flap
Moberg Advancement Flap

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 ANATOMIC LANDMARKS
Landmarks The muscle forms the bulk of the volar border of the palm, ex-
tending from the distal wrist crease to the distal palmar crease.
Size 5 3 1 to 2 cm.
Origin Pisiform bone of the distal carpal row.
Insertion Ulnar-volar base of the proximal phalanx of the small finger
and dorsal aponeurosis of the extensor digiti minimi.
Function Small finger abduction.
Composition Muscle.
Flap Type Type I.
Dominant Pedicle Deep palmar artery.
Nerve Supply Motor: Deep branch of the ulnar nerve.

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 Section 9A
Hand

Abductor Digiti Minimi Flap

CLINICAL APPLICATIONS
Regional Use
Wrist
Specialized Use
Functional (Huber) transfer

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 ANATOMY OF THE Abductor Digiti Minimi Flap

Muscle showing origin and insertion

B C

Deep palmar
artery

Branch of deep
palmar artery

Ulnar nerve

Arterial supply to flap Nerve supply to flap

Fig. 9A-1

Dominant pedicle: Deep palmar artery

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 Hand  •  9A: Abductor Digiti Minimi Flap 917

ANATOMY
Landmarks The muscle forms the bulk of the volar border of the palm, extending from the
distal wrist crease to the distal palmar crease. The muscle also forms the main
bulk of the hypothenar eminence.
Composition Muscle.
Size 5 3 1 to 2 cm.
Origin Pisiform bone of the distal carpal row.
Insertion Ulnar-volar base of the proximal phalanx of the small finger and dorsal aponeu-
rosis of the extensor digiti minimi.
Function Small finger abduction; expendable.

Arterial Anatomy
Dominant Pedicle  Deep palmar artery
Regional Source  Ulnar artery.

Venous Anatomy
Venae comitantes of the ulnar artery.

Nerve Supply
Motor Deep branch of the ulnar nerve, which penetrates the muscle on its radial deep
aspect with the vascular pedicle.

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 918 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the A bductor Digiti Minimi Flap

A B

D
D

Deep surface of flap Radiographic view

Fig. 9A-2

Dominant pedicle: Deep palmar artery (D)

FLAP HARVEST
Design and Markings
The muscle forms the bulky prominence of the hypothenar emi-
nence, extending from the pisiform bone of the distal carpal row to
the volar base of the small finger radially. Skin is not included in the
flap to reduce the risk of painful hypothenar scarring. Incisions are
linear or curvilinear.

Fig. 9A-3  Marking for flap incision

(dashed line = alternate incision).

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 Hand  •  9A: Abductor Digiti Minimi Flap 919

Patient Positioning
The patient is placed in the supine position.

Guide to Flap Dissection

The standard flap is raised by incising skin and subcutaneous fat until the volar aspect of the
muscle is visualized. Dissection is continued distally to its tendinous insertion, taking care
to preserve the neurovascular supply on the deep radial surface of the proximal end of the
muscle. The muscle has to be separated from the flexor digiti minimi. Transposition can
be performed into the palm or wrist.

A B C

Flap after release of insertion Deep surface of flap Closeup view of flap base

D E

Coverage of palm (opponens transfer) Coverage of wrist

Fig. 9A-4 

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 920 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANT
•  Functional muscle transfer: Huber opponensplasty

Huber Opponensplasty
The flap is dissected as for the standard approach, but once isolated on its insertion, the
muscle has to be tunneled across the palm subcutaneously for insertion into the base of the
thumb. A subcutaneous tunnel is made along the proposed axis of pull of the muscle in its
new position. The tunnel is made immediately subcutaneously, communicating through
a counterincision at the ulnar base of the thumb at the metacarpophalangeal joint. The
tendinous insertion of the abductor is woven into and sutured to the tendon of the abductor
pollicis brevis only, tensioning the repair to maintain the thumb abducted 90 degrees from
the flat plane of the hand to achieve functional opposition of the thumb to the fingers. Lax
tension will result in poor opposition.

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.

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 Hand  •  9A: Abductor Digiti Minimi Flap 921

ARC OF ROTATION
The muscle can be rotated almost 180 degrees onto the wrist or across the palm.

A B

Arc to palmar wrist Arc to dorsal wrist

Fig. 9A-6 

FLAP TRANSFER
The standard muscle is raised and transposed into a palmar or wrist defect and can be skin
grafted to complete closure. The functional Huber transfer for thumb opposition must be
tunneled across the palm into its new attachment to the base of the thumb to achieve op-
position.

FLAP INSET
For a simple transposition, the muscle is sutured in place with absorbable sutures to anchor
the muscle belly in place before skin grafting. For functional muscle transfer, the muscle
insertion has to be anchored into the ulnar border of the thumb metacarpophalangeal joint
to achieve the direction of pull, facilitating opposition of the thumb.

DONOR SITE CLOSURE

Primary skin closure is possible in all cases.

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 922 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATION
This 65-year-old farmer had undergone resection of the ulnar head for the treatment of
osteomyelitis of the distal ulna. The dead space and proximal ulnar bone were covered
with the use of the ADM flap.

A B C

D E

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 irradia-
tion of the infection. (Case courtesy Steven L. Moran, MD.)

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 Hand  •  9A: Abductor Digiti Minimi Flap 923

Pearls and Pitfalls

• The flap is short and narrow and cannot be used for large palmar or wrist defects.
• Functional transfer requires careful preservation of the neurovascular bundle.
• Careful adjustment of tension is necessary in functional transfer to achieve functional
benefit.
• Functional transfer must always be preceded by attainment of full passive range of motion
in the recipient thumb’s metacarpophalangeal joint to achieve a useful functional outcome.
• A functional Huber transfer creates a visible thick ridge across the palm initially; this will
always be visible to some extent.

EXPERT COMMENTARY
Steven L. Moran

Indications
The adductor digiti minimi muscle is most frequently used as a functional muscle transfer
for restoration of thumb opposition in children; this has historically been referred to as the
Huber transfer.

Advantages and Limitations

Benefits of adductor digiti minimi muscle transfer have included the ease of dissection and
a scar that is well hidden at the glabrous-nonglabrous border of the hand. Other options
for opponensplasty in children include the transfer of the superficialis tendon of the ring
or long finger to the thumb. For adult patients, oppositional transfer using the superficialis
tendon has been shown to more closely approximate the excursion and strength of the na-
tive thumb musculature.
However, the muscle suffers from several shortcomings in that the transfer tends to
create more thumb flexion than true opposition because of the vector of pull on the thumb.
Second, in many cases the muscle with attached tendon is not long enough to adequately
reach the thumb metacarpophalangeal joint (specifically, the insertion point of the native
abductor pollicis brevis) to allow ideal oppositional tendon insertion. In such cases, an in-
tercalary tendon graft can be harvested from the palmaris longus or another donor tendon.
To avoid tendon grafting one can harvest a portion of the small finger extensor mecha-
nism during muscle harvest to enhance the muscle’s reach.

Recommendations
Technique
Use of the adductor digiti minimi for coverage of open wounds is somewhat antiquated
because of the many perforator flaps that can be raised from the wrist and forearm; how-
ever, knowledge of its use is still valuable in situations of ulnar head osteomyelitis or where
obliteration of the ulnar carpal space is required (see Fig. 9A-7). The majority of the muscle’s
bulk is located proximally, limiting its use to defects that lie in the immediate vicinity of
the pisiform bone. Additional motion may be obtained by detaching both the insertion
and origin of the muscle; however, one must exercise care in these situations, because the
pedicle is small and may kink or twist during flap inset.

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 924 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Harvie P, Patel N, Ostlere SJ. Ulnar nerve compression at Guyon’s canal by an anomalous
abductor digiti minimi muscle: the role of ultrasound in clinical diagnosis. Hand Surg 8:271-
275, 2003.
Anomalous variations of abductor digiti minimi are commonly found at Guyon’s canal but rarely cause
ulnar nerve compression. The authors reported such a case, with particular emphasis on the effective-
ness of ultrasound for detecting and delineating anatomic structures in this region.
Iconomou T, Tsoutsos D, Spyropoulou G, et al. Congenital hypertrophy of the abductor digiti
minimi muscle of the foot. Plast Reconstr Surg 115:1223-1225, 2005.
Soft tissue masses of the foot are rare and present a difficult diagnostic problem. These unusual lesions
can be congenital or acquired. The diagnosis is made by imaging and histological examination. When
the mass is clinically solid, there is concern about the possibility of a malignant soft tissue tumor. The
indication for surgical intervention is based on functional impairment and usually involves ruling out
malignancy or ameliorating pain and discomfort. One case of a rare, isolated, congenital hypertrophic
abductor digiti minimi of the foot was presented with reference to its clinical picture and treatment.
Ishida O, Ikuta Y, Sunagawa T, et al. Abductor digiti minimi myocutaneous island flap as an
opposition transfer: a case report. J Hand Surg Am 28:130-132, 2003.
The authors reported on the use of the abductor digiti minimi myocutaneous (ADM) island flap as
an opposition transfer. They concluded that the procedure is easy and safe, and, compared with the
Huber transfer, provides more bulge in the thenar area. This procedure may be useful for patients with
Blauth grade 2 and 3A hypoplastic thumb.
Kelleher JC. Abductor digiti minimi opponensplasty in hypoplastic thumb. Plast Reconstr
Surg 81:648, 1988.
The authors reported on 10 cases of hypoplastic thumbs treated by abductor digiti minimi opponens-
plasty. The results of only 9 patients were discussed, however. This operation was combined with
Z-plasty to correct narrowing in the thumb-index web space. Adductorplasty using extensor indicis
propius was performed in 6 cases to restore metacarpal phalangeal joint stability in the thumb. The
authors’ opponensplasty procedure was modified by transferring the origins of the abductor digiti minimi
muscle to the palmaris longus tendon. Follow-up was 1 to 8 years, with excellent results.
Latimer J, Shah M, Kay S. Abductor digiti minimi transfer for the restoration of opposition in
children. J Hand Surg Br 19:653-658, 1994.
Abductor digiti minimi transfer was used to restore opposition in 20 patients, the majority of whom
had congenital anomalies of the hand. The transfer was shown to be effective in restoring abduction,
but less effective in restoring the rotational component of opposition in these patients. The donor site
was critically reviewed and found to be acceptable. The surgical techniques and benefits of this transfer
were reviewed.
Netscher D, Cohen V. Ulnar nerve compression at the wrist secondary to anomalous muscles:
a patient with a variant of abductor digiti minimi. Ann Plast Surg 39:647-651, 1997.
Three patients with aberrant muscles passing through Guyon’s canal were described. Each of the three
patients had, among other symptoms, dysesthesias on the volar aspects of the little and ring fingers.
The anomalous muscle in two of these patients arose from the antebrachial fascia just proximal to
Guyon’s canal, traveled through the canal, and inserted with the abductor digiti minimi muscle. This
anomaly was bilateral in both patients. In the third patient, the abductor digiti minimi muscle originated
radially from the transverse carpal ligament, and this variant too was bilateral. Symptoms in each of
the three patients resolved after surgery. Ulnar nerve compression at Guyon’s canal is discussed and
the literature is reviewed. Although anomalous muscles occur frequently in this location, the anatomic
variant found in the third patient had not previously been described in the literature.

09a_AbdDigi_r5_bs_0914-0925.indd 924 2/3/2012 3:55:33 PM

 Hand  •  9A: Abductor Digiti Minimi Flap 925

Reisman NR, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for
palmar wrist pain. Plast Reconstr Surg 72:859-863, 1983.
In a series of 12 patients incapacitated by persistent or recurrent pain in the palmar aspect of the hand
and wrist, successful rehabilitation was aided by employing an abductor digit minimi muscle flap. It
was emphasized that this muscle flap was used as an adjunct to microsurgical internal neurolysis and
neuroma resection. Eleven of the 12 patients achieved good to excellent results in terms of relief of
pain, plus either return to their previous job or vocational rehabilitation. The “salvage” nature, donor
site morbidity, and technical demands of the procedure were emphasized.
Spiess AM, Gursel E. Entrapment of the ulnar nerve at Guyon’s canal by an accessory abductor
digiti minimi muscle. Plast Reconstr Surg 117:1060-1061, 2006.
Upton J, Taghinia AH. Abductor digiti minimi myocutaneous flap for opponensplasty in
congenital hypoplastic thumbs. Plast Reconstr Surg 122:1807-1811, 2008.
Although abductor digiti minimi transfer is a common form of opponensplasty for congenital hypoplastic
thumbs, the inclusion of hypothenar skin with this flap, to create a myocutaneous flap, has not been
well described. From a series of over 600 index pollicizations and hypoplastic thumb reconstructions
performed from 1977 to 2007, the authors presented 14 patients with congenital thumb hypoplasia
who had abductor digiti minimi myocutaneous flap transfer to improve thumb opposition. The primary
indications for transfer were inadequate thumb opposition and aplastic palmar and thenar soft tissues.
follow-up ranged from 1 to 22 years. all 14 transfers survived and were successful in improving thumb
opposition. Key pinch strengths averaged 40% of normal. The inclusion of the skin paddle eliminated
routing the muscle through tight palmar soft tissues while improving thenar bulk and appearance.

09a_AbdDigi_r5_bs_0914-0925.indd 925 2/3/2012 3:55:34 PM

 ANATOMIC LANDMARKS
Landmarks May be used in its entirety or as a partial composite tissue trans-
plantation for thumb reconstruction. It extends from the middle
of the first metatarsal to the tip of the great toe and to the mid-
portion of the first web space of the foot.
Size Variable; on average, 4 to 5 cm long and 2 to 3 cm wide.
Function Plantar flexion of the distal foot for push-off during ambulation
and jumping.
Composition Osteocutaneous, fasciocutaneous.
Flap Type Type A.
Dominant Pedicle Common digital artery arising from the first dorsal metatarsal
artery.
Minor Pedicle First plantar metatarsal artery.
Nerve Supply Three sources: the digital nerves, the medial dorsal cutaneous
nerve of the superficial peroneal nerve, and the terminal branch
of the deep peroneal nerve.

09b_GrToe_r6_bs_0926-0957.indd 926 2/6/2012 5:55:22 PM

 Section 9B
Hand

Great Toe (Hallux) Flap

CLINICAL APPLICATIONS
Regional Use
Coverage of plantar surface of foot
Distant Use
Reconstruction of thumb and
distal phalanx of finger
Specialized Use
Sensate soft tissue coverage in hand

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 ANATOMY OF THE Great Toe (Hallux) Flap

A B
First
dorsal
metatarsal First plantar
artery metatarsal
artery

Dorsal
D digital
Dorsalis arteries
pedis
artery Distal
perforating
artery

First dorsal
metatarsal
artery

First plantar
metatarsal
artery
Plantar
arch
Dorsalis pedis arterial supply to great toe First plantar metatarsal Plantar
via first dorsal metatarsal artery artery flow to great toe Lateral digital
plantar arteries
artery
Deep
Dorsalis
plantar
C pedis artery
artery
First dorsal
metatarsal artery Medial
plantar
artery
Posterior
tibial
artery

First plantar
metatarsal artery
Metatarsal arterial communication Arterial anatomy for free toe and
via the distal perforating artery toe tissue transfers

Fig. 9B-1 

Dominant pedicle: First dorsal metatarsal artery

Minor pedicle: First plantar metatarsal artery

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 Hand  •  9B: Great Toe (Hallux) Flap 929

ANATOMY
Landmarks May be used in its entirety or as a partial composite tissue transplantation for
thumb reconstruction. It extends from the middle of the first metatarsal to the
tip of the great toe and to the midportion of the first web space of the foot.
Composition Osteocutaneous, fasciocutaneous.
Size Variable; on average, 4 to 5 cm long and 2 to 3 cm wide.
Function Plantar flexion of the distal foot for push-off during ambulation and jumping.

Arterial Anatomy (Type A)

Dominant Pedicle  First dorsal metatarsal artery (FDMA)
Regional Source  Dorsalis pedis artery and associated venae comitantes and saphenous vein.
Length  5 cm.
Diameter  1.5 mm.
Location  Immediately distal to the heads of the first and second metatarsal bones, the dorsalis
pedis artery bifurcates into the first metatarsal artery and a deep branch into the plantar aspect
of the foot. The first metatarsal artery then provides branches to the medial great toe and a com-
mon digital branch that bifurcates to the lateral great toe and medial second toe.
Variations of the First Dorsal Metatarsal Artery
Variations in the course, origin, and size of the FDMA have been observed in anatomic studies.
The following classification describes the anatomy and frequency of these variations.
Type A (superficial) (49%)  The FDMA originates directly from the dorsalis pedis or from
the superficial part of the deep communicating branch. This vessel then courses distally in a
superficial plane dorsal to the transmetacarpal ligament.
Type B (40%)  In these patients the FDMA arises from the lower part of the deep communicating
branch, or it may arise from the deep plantar arch. It lies deep or within the first interosseous
muscle and runs distally and dorsally, eventually becoming superficial between the heads of the
first and second metatarsal and coursing dorsal to the transmetacarpal ligament.
Type C (11%)  In these patients the vessel is very narrow or totally absent, and the blood supply
of the great and second toe depends largely on the plantar metatarsal artery.
In type A and type B patients, the FDMA is available for use as the dominant vascular pedicle. In
type C patients, the great toe transplant requires use of the first plantar metatarsal artery.
Careful identification of both vessels before pedicle division may obviate the need for preoperative
arteriography; however, preoperative arteriography is recommended for evaluation of the great toe
circulation if there is a history of prior trauma or congenital anomalies of the foot.
Minor Pedicle  First plantar metatarsal artery (FPMA); the FPMA may represent the dominant
arterial pedicle to the great toe
Regional Source  Deep plantar arch.
Length  6 cm.
Diameter  1 mm.
Location  The deep plantar arch is formed by the junction of the lateral plantar artery with the
deep plantar branch of the dorsalis pedis artery that courses through the first interosseous space.
At the level of the base of the first metatarsal, the FPMA arises from the medial aspect of this
plantar arch. The FPMA then sends digital branches to the medial and lateral great toe.

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 930 Part II  Regional Flaps: Anatomy and Basic Techniques

Variations in the Dorsal and Plantar Arterial Circulation to the Great Toe
Two communications exist between the dorsal and plantar arterial circulations. Between the heads
of the first and second metatarsals, the deep plantar artery communicates with the dorsalis pedis
artery and the plantar arch. A dorsal distal perforating artery joins the dorsal and plantar metatarsal
arteries near their bifurcation.
Several variations of the distal perforating artery exist. In the most common variant (46%), it arises
from the FDMA and splits into two plantar digital arteries (PDAs). In 24% of patients, the distal
perforating artery communicates between the bifurcations of the FDMA and FPMA. In 15% of
patients, the FPMA gives rise to two PDAs, one of which is joined by the distal perforating artery.
In a small percentage of patients, the distal perforating branch may be absent or small communicat-
ing branches will exist between the dorsal digital arteries (DDAs) and PDAs.

Venous Anatomy
Venae comitantes follow the arterial branches. Associated superficial veins that drain the first web
space and great toe join to form the saphenous vein.

Nerve Supply
Sensory Three sources: the digital nerves, the medial dorsal cutaneous nerve of the su-
perficial peroneal nerve, and the terminal branch of the deep peroneal nerve.

E FDMA F FDMA

Distal perforating Distal perforating

artery artery

Dorsal
PDA FPMA FPMA venous
arch

G FDMA

Greater
PDA saphenous
FPMA
vein

H DDA FDMA I DDA FDMA

Lesser
Distal perforating saphenous
artery vein

PDA FPMA PDA FPMA

Variations of distal perforating artery

Identification of superficial
venous system

Fig. 9B-1 

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 Hand  •  9B: Great Toe (Hallux) Flap 931

Vascular A natomy of the Great Toe (H allux) Flap

A

First dorsal interosseous space

B C
D

e
v n2

f
D
n1 n2

Dorsal surface of flap Radiographic view

Fig. 9B-2 

Dominant pedicle: First dorsal metatarsal artery (D)

Minor pedicle: First plantar metatarsal artery (m)
e, Extensor pollicis longus; f, flexor pollicis longus; n1, dorsal digital nerve; n2, plantar digital
nerve; v, superficial vein

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 932 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP HARVEST
Design and Markings
The great toe is examined for size and shape and compared with the second toe. If it is
excessively wide or curved, this may affect its suitability for transplantation as a composite
flap for thumb reconstruction.
The medial first web space and dorsalis pedis flap (10 by 8 cm) may be included with
the great toe transplant, but this is rarely necessary. Generally, minimal foot skin is included
with the great toe to ensure direct donor site closure. A dorsal triangular flap measuring 4
by 3 cm and a smaller plantar triangular flap with the base of the flap oriented at the level
of the first metatarsophalangeal (MTP) joint may be included with the great toe transplant.
A chevron-shaped incision is designed with a longer dorsal than plantar skin island.
At the apex of the dorsal incision proximally, the marking is extended up the dorsum of
the foot as a curvilinear incision, with its long axis over the first metatarsal and web space.
The most proximal limit of the marking is at the level of the distal extent of the extensor
retinaculum. With the foot in a dependent position over the edge of the operating table,
the dorsal venous system is allowed to fill and the dorsal venous arch and saphenous system
can be accurately marked.

Incision at dorsal aspect Incision at plantar aspect

Fig. 9B-3 

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 Hand  •  9B: Great Toe (Hallux) Flap 933

Patient Positioning
The patient is placed in the supine position with the lower donor extremity prepared to
the midthigh to allow knee flexion and external hip rotation for exposure of the plantar
surface of the foot during this portion of the foot dissection.

GUIDE TO FLAP DISSECTION

All dissection is done under tourniquet control, because a bloodless field is essential. A
circumferential incision is made at the level of the MTP joint, with the dorsal and plantar
triangular flaps that connect with a long dorsal vertical incision extending to the midtarsal
region and a shorter plantar incision extending to the level of the MTP joint. A separate
medial posterior plantar incision is necessary to expose the proximal flexor hallucis longus
tendon.
The proximal incision is extended over the dorsum of the foot to expose the dorsal
venous arch and greater saphenous vein. The branches to the second toe and communi-
cating branch to the deep venous system are ligated, isolating the venous outflow to the
superficial system only.

Dorsal
metatarsal
Extensor hallucis vein
longus tendon

Greater Extensor hallucis

saphenous brevis muscle
vein

Dissection of superficial veins

Fig. 9B-4 

09b_GrToe_r6_bs_0926-0957.indd 933 2/6/2012 5:55:36 PM

 934 Part II  Regional Flaps: Anatomy and Basic Techniques

The extensor hallucis brevis tendon is identified and divided lateral to extensor hal-
lucis longus. The extensor hallucis brevis is reflected laterally to expose the dorsalis pedis
vessels and deep peroneal nerve. The dorsalis pedis artery is traced distally to identify the
FDMA at the proximal limit of the first intermetatarsal space. The caliber of the FDMA is
evaluated, and if it is greater than 1 mm, the flap can be raised on this vessel. If the vessel is
diminutive, however, it will be necessary to use the FPMA.

B C Extensor
pollicis
longus
tendon
Dorsal
digital Superficial
artery draining vein
(saphenous system)
Deep Extensor
peroneal First dorsal hallucis
nerve metatarsal brevis
artery Dorsalis
pedis
artery

First dorsal
metatarsal
Dorsalis
artery
pedis artery
Deep
Greater
peroneal
saphenous
nerve
vein

Extensor
hallucis
brevis
Division of extensor hallucis brevis tendon for exposure
Identification of vascular pedicle of first dorsal metatarsal artery

Fig. 9B-4 

09b_GrToe_r6_bs_0926-0957.indd 934 2/6/2012 5:55:38 PM

 Hand  •  9B: Great Toe (Hallux) Flap 935

Assuming an adequate FDMA, the deep plantar artery is then ligated, isolating the
great toe on the dorsalis pedis–FDMA pedicle. The extensor hallucis longus tendon is
then divided proximally, depending on the length requirement for extensor tendon at the
recipient site. The dorsal interosseous muscle is divided to allow further distal dissection
of the vascular pedicle based on the FDMA. The branch to the second toe is divided, and
the deep transverse metatarsal ligament between the MTP joints of the great and second
toes is divided.

DorsalB D
digital
artery

Deep
peroneal First dorsal
nerve metatarsal Deep
Dorsal
artery plantar DorsalB E
digital
artery digital
artery
artery
First dorsal
Deep
metatarsal Deep
transverse
artery peroneal
Dorsalis First dorsal metatarsal
pedis artery nerve metatarsal ligament
artery
Greater
saphenous First dorsal
vein metatarsal
artery
Extensor Dorsalis
hallucis pedis artery
brevis
Greater
saphenous
vein

Extensor
hallucis
brevis

Dissection of first dorsal metatarsal artery

Further dissection of vascular pedicle

Fig. 9B-4 

09b_GrToe_r6_bs_0926-0957.indd 935 2/6/2012 5:55:49 PM

 936 Part II  Regional Flaps: Anatomy and Basic Techniques

Plantar dissection begins with a chevron incision that is extended for a short distance
proximally between the first and second metatarsal heads. The lateral and medial plantar
digital nerves and the plantar digital arteries to the lateral aspect of the great toe and medial
aspect of the second toe are found lying deep to the divided transverse metatarsal ligament.
The flexor hallucis tendon is identified and dissected proximally. Once an adequate length
has been exposed, it is divided together with the plantar digital nerves and vessels. At this
point the MTP joint can be disarticulated; the toe is now attached only by its dorsal arterial
inflow and venous outflow structures. The tourniquet is released, the adequacy of perfusion
to the toe can be assessed, and hemostasis is secured at the donor site.

F
Plantar digital
artery and nerve

Deep
transverse
metatarsal
ligament
G

Flexor hallucis Extensor

longus tendon Dorsal hallucis
digital longus
artery tendon

Flexor
hallucis
longus
First dorsal tendon
Dissection on plantar side
metatarsal
artery

Disarticulation of metatarsophalangeal joint

and completion of harvesting

Fig. 9B-4 

09b_GrToe_r6_bs_0926-0957.indd 936 2/6/2012 5:55:52 PM

 Hand  •  9B: Great Toe (Hallux) Flap 937

H I J

n1 n2
m1
n1
f n2

m1
n1

m1 f
n2

Identification of tendon and Closeup view Tendon released

plantar digital nerve

Fig. 9B-4 

f, Flexor hallucis longus tendon; m1, first plantar metatarsal artery; n1, medial plantar
digital nerve; n2, lateral plantar digital nerve

If the patient has a loss of first metacarpal length in the recipient site in the hand, the
surgeon will need to harvest additional metatarsal bone proximal to the MTP joint. This
is usually done with an osteotomy through the metaphysis of the first metatarsal proximal
to the metatarsal head. It is usually performed obliquely at a 60-degree angle from dorsal
to plantar, taking more dorsal bone than plantar bone. The angle is important to allow
further flexion of the thumb reconstruction, because the great toe has more extension than
flexion function compared with the function of the thumb metacarpophalangeal joint. By
canting the joint reconstruction into a more volar position on the recipient metacarpal, the
reconstructed thumb is better able to achieve opposition and flexion into the palm.

FLAP VARIANTS
•  Wrap-around flap
•  First dorsal web space sensory cutaneous flap
Wrap-Around Flap
Standard Wrap-Around Flap
The wrap-around flap concept includes elevation of lateral great toe skin and toenail, with
preservation of medial toe skin and underlying phalangeal bones for hallux reconstruction.
The flap involves harvest of the lateral three-quarter circumference of the toe skin together
with an appropriate width of nail and nail bed. The nail of the great toe is usually substan-
tially wider than that of the thumb nail, and this procedure allows a smaller amount of nail
width to be harvested to give a better cosmetic match to the normal thumb.

09b_GrToe_r6_bs_0926-0957.indd 937 2/6/2012 5:55:53 PM

 938 Part II  Regional Flaps: Anatomy and Basic Techniques

Design and M arkings

The width of the required nail is measured and the medial limit of the flap is drawn proxi-
mally as a straight line along the dorsum of the great toe at the juncture of its medial third
and lateral two thirds. At the level of the MTP joints, marking is extended transversely
laterally to the midpoint of the dorsum first webspace. The markings are then carried down
the middle of the first web space onto the plantar aspect of sole until the level of the MTP
joint is reached again. The markings are next carried medially transversely over the sole at
the level of the MTP joint to the midlateral line. Markings continue forward around the
tip of the great toe on its volar aspect and are curved upward to meet the lateral edge of
the nail fold. They are then carried transversely across the distal edge of the nail bed until
they reach the demarcation point of the planned longitudinal split in the nail. As with a
great toe transfer, a proximal curvilinear incision is extended up the dorsum of the foot.

A B

Flap design Flap design

(dorsal view) (oblique-lateral view)

Fig. 9B-5 

Flap Dissection A Skin flap

Dorsal
As with great toe harvest, the dorsal greater saphe- overlying digital
nous vein, dorsalis pedis, and FDMA arterial circula- second toe artery
tion and the deep peroneal nerve are dissected after Dorsal
dividing and reflecting the extensor hallucis brevis digital
tendon. vein
Extensor
hallucis Deep
longus peroneal
tendon nerve

Extensor
hallucis
brevis
Dissection of neurovascular muscle
pedicle and dorsal
elevation of flap

Fig. 9B-6 

09b_GrToe_r6_bs_0926-0957.indd 938 2/6/2012 5:55:57 PM

 Hand  •  9B: Great Toe (Hallux) Flap 939

Because the tissue is being used as a soft tissue cover without requiring bone or tendon,
the extensor hallucis longus tendon is not divided. The first dorsal interosseous muscle
is divided and the deep perforating branch is preserved, allowing distal dissection of the
FDMA to the level on the deep transverse metatarsal ligament.
Dissection then commences on the plantar aspect. The medial plantar digital artery
and nerve are identified and preserved to supply the medial skin bridge which has been left
attached to the phalanges of the great toe. The lateral PDA and digital nerve are dissected
proximally. The plantar skin is then raised from medial to lateral toward the first web space,
leaving a vascularized layer of fat to cover the bones and tendons of the toe. The lateral PDA
can be divided as proximally as possible once release of the tourniquet has confirmed that
perfusion is adequate to the wrap-around harvest.

B Skin flap
overlying
second toe Medial and lateral
plantar digital
artery and nerve
Flexor
hallucis
tendon
Common
plantar digital
artery and nerve

Plantar dissection and flap elevation

Fig. 9B-6 

When dissecting the FDMA, the deep transverse C Distal

Lateral
perforator
metacarpal ligament is left intact. Care should be nerve
plantar
taken at this point to ensure that communication is digital
Deep artery
preserved between the distal perforating artery and transverse
its dorsal and plantar derivatives. Lateral
metatarsal
dorsal
The flap can then be harvested and its donor site ligament
digital
covered with a full-thickness skin graft. The segment artery
of retained medial nail and nail bed at the donor site
should be resected before grafting.

Completion of flap harvesting

Fig. 9B-6 

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 940 Part II  Regional Flaps: Anatomy and Basic Techniques

Modified Wrap-Around Flap

The technique for the modified wrap-around flap is the same as that described earlier, with
the addition of the following maneuvers.
Having isolated the medial skin on its neurovascular pedicle, it remains attached to the
underlying bony structures. The modified wrap-around flap incorporates the addition of the
distal phalanx within the construct. The proximal skin can be dissected off the paratenon
of the extensor hallucis longus and the proximal phalanx that is left adherent to the distal
phalanx that is disarticulated through the interphalangeal joint capsule.

Greater
saphenous
vein

Deep
peroneal
nerve

Dorsalis B
pedis
artery
Greater
saphenous
vein
Deep
Deep transverse peroneal
metatarsal ligament nerve

Dissection in first web

Dorsalis
pedis Extensor
artery hallucis
longus
tendon

Elevation of medial flap from distal phalanx

Fig. 9B-7 

The medial nail fragment and its associated nail bed and germinal matrix are completely
resected. The medial skin is dissected off the front of the toe down to the midportion of the
proximal phalanx, preserving its medial PDA and digital nerve content intact.
The distal half of the proximal phalanx is then resected and the proximally based medial
skin flap is draped over the osteotomy site and sutured down to the plantar skin. The dorsal
defect is covered with a small split-thickness skin graft, as needed.

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 Hand  •  9B: Great Toe (Hallux) Flap 941

First Dorsal Web Space Sensory Cutaneous Flap

The web space between the great and second toes may be elevated as a neurosensory flap
based on the FDMA and associated venae comitantes and branches of the superficial and
deep peroneal nerves.
The proposed web space flap is outlined. An initial dorsal incision is made between
the first and second metatarsal bones to the level of the midtarsal region. Superficial drain-
ing veins to the lateral dorsal great and second toes are preserved. An incision through the
extensor retinaculum inferior to the extensor hallucis brevis muscle readily reveals the deep
peroneal nerve and first dorsal metatarsal artery. If the FDMA is absent, the flap dissection
is stopped and alternate donor sites are selected. If the pedicle is available, distal dissection
is completed to the area of the proposed web space flap. The flap edges are incised. At the
plantar edge of the flap, the plantar digital artery and nerves are not included with the flap.
The flap is elevated superficial to the proximal phalangeal periosteum and to the level of the
first transmetacarpal ligament. The flap dissection is connected to the previous dissection of
the FDMA and associated venae comitantes, lateral dorsal metatarsal nerve, and superficial
draining veins. The tourniquet is released and flap perfusion confirmed. The island flap is
ready for transposition to the defects on the plantar surface of the foot or for transplantation
as a neurosensory fasciocutaneous flap.

A B

Dorsalis
Greater pedis
saphenous artery
vein

Deep
peroneal
nerve

Flap design Elevation of flap

Fig. 9B-8 

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 942 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Standard Flap
The web space flap based on the FDMA with associated branches of the superficial and
deep peroneal nerve may be elevated to the level of the dorsalis pedis artery and associated
venae comitantes and superficial veins and transposed with a wide arc of rotation to the
plantar surface of the foot or ankle.
Plantar skin elevated on the FPMA has an arc of rotation to the plantar aspect of the foot.

A B C

Web space flap arc to Web space flap arc to Extended arc to heel
medial foot and ankle lateral foot and ankle

Fig. 9B-9 

Extension of Pedicle Length

The FDMA is dissected superior to the level where the extensor hallucis brevis muscle
and tendon cross the proximal second metatarsal bone. The deep communicating branch
to the plantar arch is located in the proximal first metatarsal space. The FDMA continues
superiorly at the division of the communicating branch as the dorsalis pedis artery. At the
ankle level the dorsalis pedis artery continues superiorly as the anterior tibial artery. Proxi-
mal dissection of the anterior tibial–dorsalis pedis–first dorsal metatarsal arterial system is
performed as required to obtain an adequate pedicle length for great toe transplantation or
transposition of the first dorsal web space neurosensory flap.

09b_GrToe_r6_bs_0926-0957.indd 942 2/6/2012 5:56:04 PM

 Hand  •  9B: Great Toe (Hallux) Flap 943

If the FDMA is rudimentary or absent, the great toe transplantation is based on the
dominant FPMA. This artery is initially isolated in the distal plantar first metatarsal space.
The artery may be dissected proximally beneath the flexor hallucis longus tendon and then
laterally between the head of the flexor hallucis brevis muscle, where the artery joins the
deep communicating branch from the dorsalis pedis artery to form the deep plantar arch.

FLAP TRANSFER
The first dorsal web space neurosensory flap is rotated 90 to 180 degrees, as required, to
cover the defect. A wide tunnel is necessary, particularly if the flap is designed to reach the
plantar surface of the posterior foot.

FLAP INSET
Standard Great Toe Transplant to Thumb Position
Bone
The proximal phalanx or the first metatarsal head of the great toe is initially fixed to the
proximal phalanx or first metatarsal bone in the hand. Volar angulation of the metacarpal
head allows better opposition and flexion angle. Osteosynthesis is accomplished with cross
Kirschner wires, longitudinal Kirschner wires, interosseous wire loops, bone pegs, mini-
plates, or a combination of the above.

B
90°
A

Osteotomy technique:
Metatarsal level

Great toe transplant technique for

osseous osteosynthesis

C D

Osteosynthesis with cross Kirschner wire Osteosynthesis with longitudinal Kirschner wire
and interosseous wire

Fig. 9B-10 

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 944 Part II  Regional Flaps: Anatomy and Basic Techniques

Nerve Repair
Medial and lateral dorsal sensory nerves are repaired with the dorsal branches of the radial
nerve. Medial and lateral plantar sensory nerves are repaired with the digital nerves. If the
volar digital nerves are not present at the thumb position, other recipient sensory nerves
include the sensory branches of the radial nerve, palmar cutaneous branch of the median
nerve, and dorsal sensory branch of the ulnar nerve.

A B

Neurorrhaphy: Dorsal digital sensory to Neurorrhaphy: Plantar digital sensory to

radial sensory nerve median digital nerve

Fig. 9B-11 

Vascular Repair
An arterial anastomosis is performed between the first dorsal metatarsal or dorsalis pedis
artery and the radial artery or princeps pollicis branch. A venous anastomosis is performed
between the superficial draining vein and appropriate dorsal veins at the hand recipient site.

A B

Dorsal metatarsal artery end-to-end anastomosis Medial plantar artery end-to-end superficial arch
to princeps pollicis branch and dorsal vein anastomosis and dorsal vein end-to-end
end-to-end to wrist vein to wrist vein

Fig. 9B-12 

Tendon Repair
The flexor hallucis longus tendon is repaired with a flexor pollicis longus tendon. The
repair is performed proximal to the transverse carpal ligament within the distal wrist. The
extensor hallucis longus tendon is repaired with the extensor pollicis longus tendon. A
weave tendon repair is used for both the flexor and extensor tenorrhaphies. The tension is
adjusted to ensure thumb flexion with passive wrist extension and thumb extension with
passive wrist flexion.

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 Hand  •  9B: Great Toe (Hallux) Flap 945

Closure
The skin is closed using the dorsal and volar triangular flaps interposed with skin flaps on
the recipient hand. Skin grafts may be required to complete closure, particularly on the
lateral and medial aspects of the transplanted toe.

A B

Tenorrhaphy: Extensor hallucis longus to Tenorrhaphy: Flexor hallucis longus to

extensor pollicis longus tendon flexor pollicis longus tendon

Fig. 9B-13 

Wrap-Around Flap
The wrap-around flap is inset as described for the standard flap. If this flap is designed as
an onychocutaneous flap, an iliac bone graft is initially inset in the hand metacarpal bone.
The wrap-around flap is loosely sutured in place over the bone graft. The subsequent repair
sequence inset is similar to the previous description for standard great toe transplantation.

A B

Iliac bone graft before wrap-around flap Composite wrap-around flap inset over bone graft

Closure technique

Fig. 9B-14 

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 946 Part II  Regional Flaps: Anatomy and Basic Techniques

First Dorsal Web Space Cutaneous Sensory Flap

Microvascular Transplantation
The web space flap is sutured into the defect. A suitable recipient nerve is isolated for re-
pair with the dorsal lateral metatarsal nerve. An arterial vascular anastomosis is performed
between the FDMA and the recipient artery and superficial draining vein and appropriate
recipient veins.

Transposition Flap
The first dorsal web space flap is sutured into the defect, avoiding excessive tension on its
vascular pedicle, the dorsalis pedis artery, and associated venae comitantes.

DONOR SITE CLOSURE

Standard Great Toe Transplant
With preservation of medial foot skin over the first MTP joint region, the donor site can
generally be closed directly. If a dorsal defect persists, skin grafts are used. If a plantar defect
persists, a second cross-toe flap is required.

A B

Donor site defect Closure technique

Fig. 9B-15 

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 Hand  •  9B: Great Toe (Hallux) Flap 947

Wrap-Around Flap
A combination of skin graft and second cross-toe flap are used to close the defect on the
dorsal and lateral aspect of the remnants of the great toe.
A B C D

Donor site defect with distal Design of second Flap inset and split-thickness Closure with inset
phalangeal preserved cross-toe flap skin graft cross-toe flap

Fig. 9B-16 

A B

Modified Wrap-Around Flap

The distal medially based flap is wrapped over the
proximal phalangeal base stump, and a full-thickness
skin graft is used to cover the lateral aspect of the
defect.

Fig. 9B-17 
Donor site defect without Closure technique with
distal phalangeal preservation full-thickness skin graft
to cover proximal toe

First Dorsal Web Space Cutaneous Sensory Flap

The donor site requires skin grafts for closure.

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 948 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 40-year-old carpenter had a traumatic amputation of the left thumb 2 years before he
presented for reconstruction.

A B

C D E

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, Dis-
sected trimmed toe. E, Harvested trimmed toe.

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 Hand  •  9B: Great Toe (Hallux) Flap 949

F G

H I

Fig. 9B-18  F, Exposed proximal stump of the amputated thumb, all structures identified for recon-
struction. 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. (Case courtesy Milan Stevanovic, MD.)

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 950 Part II  Regional Flaps: Anatomy and Basic Techniques

The right hand of this 27-year-old machinist was caught in a machine belt. He sustained a
crush-avulsion injury, with avulsion of the soft tissue and nail of the distal phalanx of the
thumb.

A B

C D E

F G

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.

09b_GrToe_r6_bs_0926-0957.indd 950 2/6/2012 5:56:16 PM

 Hand  •  9B: Great Toe (Hallux) Flap 951

H I

J K

L M

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, com-
parative appearance to the contralateral thumb in extension. (Case courtesy Milan Stevanovic, MD.)

09b_GrToe_r6_bs_0926-0957.indd 951 2/6/2012 5:56:18 PM

 952 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Variations in the FDMA must be taken into account in planning the flap.
• A type C variation of the first dorsal metatarsal artery is a contraindication to the use of
a first dorsal web space flap. Preliminary identification of the FDMA is required before
flap elevation.
• The use of a tourniquet during flap elevation is recommended. Before division of the
vascular pedicle to the great toe or first web space flap, the tourniquet is released and
great toe or flap perfusion observed for 15 to 20 minutes to ensure that circulation is
adequate before transplantation.
• The first metatarsal head or plantar aspect of the metatarsal head should be preserved to
improve donor site function by maintaining bone length for push-off during ambulation.
• Length and positioning of the great toe are important for function and appearance. The
average thumb length extends to the proximal interphalangeal joint of the index finger.
Exact length measurements can be obtained from the contralateral thumb, if present. The
great toe is rotated for pulp contact with the index and little fingers on thumb abduction
and opposition.
• In a child, the proximal phalangeal epiphyses are preserved to ensure finger growth.
• If the MTP joint is included with the great toe, bone fixation with the hand metacar-
pal bone should avoid hyperextension at the great toe MTP joint. This is avoided by
performing an oblique 45- to 60-degree angle osteotomy at the distal metatarsal bone,
depending on the degree of flexion available in the donor MTP joint. A lesser degree of
flexion at the joint requires a 45-degree osteotomy to tilt the joint into a more palmar
angle for flexion on the hand.
• Alternate recipient structures in the hand include use of the extensor indicis proprius if
the extensor pollicis longus tendon is unavailable; use of the long or ring finger digitorum
sublimis if the flexor pollicis longus is unavailable; and use of the volar digital nerve of
the long or ring finger if the thumb volar digital nerves are unavailable.
• If possible, the sensory nerves should be repaired before great toe revascularization to
allow optimal visualization of the nerve ends in a bloodless field.
• Appropriate balance between the extensor and flexor tendon repair is essential. Initial
repair of the extensor tendon is accomplished to allow thumb extension with 90-degree
wrist flexion. The subsequent flexor pollicis longus tendon repair is adjusted to provide
mild great toe interphalangeal and MTP joint flexion with passive wrist extension.

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 Hand  •  9B: Great Toe (Hallux) Flap 953

Expert Commentary
Milan Stevanovic

Indications
The first successful thumb replantation was reported by Tamai, Komatsu, and colleagues
in 1967,1 and today surgeons make every effort to save an amputated thumb. When the
thumb cannot be salvaged, transfer of the great toe to the thumb provides the best func-
tional and cosmetic restoration of this critical part of the hand anatomy. There are several
techniques of great toe transfer, depending on the level and extent of thumb loss. The dif-
ferent techniques include great toe transfer, trimmed toe transfer, partial toe transfer, and
a wrap-around procedure.

Recommendations
Planning
The great toe transfer provides the best pinch and grip power of any reconstruction. How-
ever, this procedure is now rarely used because of the cosmetic appearance of the recon-
structed thumb, which appears overly large and bulbous. Although the size of the pulp can
be reduced, the transferred toe always appears much larger than the contralateral thumb.
The trimmed toe transfer is now the most commonly performed reconstruction. This
procedure provides nearly the same functional outcome as the great toe transfer, but it
produces a markedly improved cosmetic appearance.
Partial toe transfers are indicated only for reconstruction of the distal phalanx and
interphalangeal joint.
The wrap-around procedure was widely performed after its introduction. It was com-
monly used to cover nonvascularized iliac crest bone graft. At its best outcome, it provided a
good cosmetic outcome, but the result was not as functional as a great toe or trimmed great
toe transfer. The complications of bone resorption and nail deformity were common and
led to the recommendation that the wrap-around only be used in cases of skeletonization
of the thumb with intact bone and tendon, but absent skin and nail.
With great toe, partial toe, and trimmed toe transfers, the flexor and extensor pollicis
longus should be reconstructed along with three sensory nerves: two plantar nerves for
reconstruction of the radial and ulnar digital nerves, and one dorsal nerve to reconstruct a
branch of the superficial radial nerve.

Technique
The incision for harvest of the great toe should begin in the first web space. I prefer a
V-shaped incision around the great toe rather than a racket incision. This minimizes the
constriction of circumferential scarring of the newly created thumb.
The princeps pollicis artery should always be used as the recipient artery for the first
dorsal metatarsal artery, which supplies the great toe. Approximately 50% of the time, the
first dorsal metatarsal artery lies on the dorsal side of the foot within the first intermetatarsal
space and first web space. The other 50% of the time, the first dorsal metatarsal artery dives
plantarward and follows the intermetatarsal space plantar to the midaxis of the metatarsal.
This anatomy requires more difficult dissection and a plantar incision to expose and harvest
this vessel.
The best veins for the great toe are located medially. The veins are better identified
when the leg has not been exsanguinated with an Esmarch tourniquet, but rather exsan-
guinated with gravity elevation.
Continued

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 954 Part II  Regional Flaps: Anatomy and Basic Techniques

The dissection of the great toe, including division of tendons, nerves, and bone (or cap-
sule), should be completed. The artery and veins are left intact. The tourniquet is released
and the toe is allowed to perfuse for at least 20 minutes before completing the toe harvest.

Take-Away Messages
The toe from the nondominant foot should be selected for transfer. A Doppler study of the
first dorsal metatarsal artery should be done to confirm an adequate pedicle to the great toe.
The great toe should not be used if the patient has had a previous injury to that foot.
The length needed for the reconstructed structures must be measured to avoid using grafts
(plantar nerves, first dorsal metatarsal artery, and tendons).

Reference
1. Masuhara K, Tamai S, Fukunishi H, Obama K, Komatsu S. [Experience with reanastomosis
of the amputated thumb] Seikei Geka 18:403-404, 1967.

Bibliography With Key Annotations

Dellon AL. Sensory recovery in replanted digits and transplanted toes: a review. J Reconstr
Microsurg 2:123-129, 1986.
A review of replanted digits indicated that excellent sensory function can be recovered in replants that
are distal, in which the mechanism of injury has been a sharp cut, in which the patient is young, and
in cases in which the patient receives postoperative sensory reeducation. It appears that poor sensory
recovery in replanted digits is most directly attributable to crush or avulsion-type injuries and lack of
sensory reeducation in the postoperative period.
Ellis PR, Hanna D, Tsai TM. Vascularized single toe joint transfer to the hand. J Hand Surg
Am 16:160-168, 1991.
The authors reported a retrospective review of their series of 31 single joints harvested from the toe
in 26 patients and transferred to the metacarpophalangeal or proximal interphalangeal joint of the
finger. Twenty-six cases were traumatic and 5 were congenital. Follow-up averaged 22.6 months.
The authors concluded that vascularized joint transfer provides a reasonable alternative to arthrodesis
and with further refinement in technique may become a reliable treatment option.
Heitmann C, Levin LS. Alternatives to thumb replantation. Plast Reconstr Surg 110:1492-
1503, 2002.
The traumatic amputation of the thumb is an absolute indication for attempted replantation. The
profound disability of the hand resulting from absence of the thumb, with loss of pinch and grasp,
obliges the surgeon to make every attempt to replant the amputated thumb and preserve hand func-
tion. However, not all attempts at replantation result in survival of the amputated portion, and unre-
constructable damage to or complete loss of the amputated part may preclude attempted replantation.
In such situations, the surgeon must have alternative methods of dealing with the sequelae of thumb
loss. This article discussed nonmicrosurgical and microsurgical techniques for thumb reconstruction.
Koshima I, Etoh H, Moriguchi T, et al. Sixty cases of partial or total toe transfer for repair of
finger losses. Plast Reconstr Surg 92:1331-1338; discussion 1339-1341, 1993.
The authors presented their experience with partial or total toe transfers for the reconstruction of finger
deficits. Sixty-one toes were transferred to reconstruct finger deficits in 60 patients. The transfers from
the big toe consisted of vascularized whole-nail grafts, onychocutaneous flaps that included the nail
and a skin flap from the toe tip, thin osteoonychocutaneous flaps, wrap-around flaps, and combined
wrap-around and dorsalis pedis flaps. The transfers from the second toe consisted of trimmed toe tips

09b_GrToe_r6_bs_0926-0957.indd 954 2/6/2012 5:56:18 PM

 Hand  •  9B: Great Toe (Hallux) Flap 955

including the nail, second toes, a combined second toe and dorsalis pedis flap, and a second toe and
third toe. The other transfers mainly consisted of other flaps, including a hemipulp flap and a first
web space flap. Regarding the transfers from the big toe, vascularized nail grafts and onychocutaneous
flaps were found to be most suitable for the treatment of total nail loss, thin osteoonychocutaneous
flaps for distal phalangeal loss of the thumb, wrap-around flaps with a vascularized iliac bone graft
for thumb loss above the metacarpal joint, and the combined wrap-around and dorsalis pedis flaps for
a total thumb deficit. For transfers from the second toe, the trimmed toe tips including the nail were
most suitable for claw nail deformities, the second toe was most suitable for finger loss, except for the
thumb with the proximal interphalangeal joint, and the combined second toe and dorsalis pedis flap
was most applicable for a total thumb deficit, including thenar skin loss.
Lutz BS, Wei FC. Basic principles on toe-to-hand transplantation. Chang Gung Med J 25:568-
576, 2002.
Toe-to-hand transplantation has become a well-established method for function and appearance
reconstruction after trauma and in congenital hand anomalies. An otherwise healthy and cooperative
patient is the ideal candidate for toe transplantation after trauma. In such a patient, even primary toe
transplantation is possible, if the stump is clean and viable. If secondary reconstruction after completed
wound healing is considered, emphasis should be laid on tissue sacrifice during the acute management
of nonreplantable amputations of the hand. Specific considerations regarding selection of toes to be
transplanted, technique of toe harvest and inset, sequence of transplantations if more than one digit
is to be reconstructed, such as in the metacarpal hand, and postoperative regimen are important to
achieve satisfying functional and aesthetic results on both recipient and donor sites. A trimmed great
toe is ideal for thumb reconstruction if the amputation is located at or distal to the middle metacarpal
shaft. However, in more proximal amputations, a second toe may be more suitable, because it allows
transmetatarsal harvest without increasing donor site morbidity. Distal finger reconstruction with
partial toe or second toe wrap-around flap gives the most gratifying result to those patients who are
critically concerned about their body image and also those who need distal fingers for their occupations
or recreational activities. Combined second and third toe or third and fourth toe transplantations are
particularly useful in metacarpal hand reconstruction to provide tripod pinch.
May JW Jr, Chait LA, Cohen BE, et al. Free neurovascular flap from the first web of the foot
in hand reconstruction. J Hand Surg Am 2:387-393, 1977.
To identify an anatomically reliable and functionally acceptable neurovascular free flap for use in hand
reconstruction, 50 fresh cadaver feet were dissected under the operating microscope, with particular
attention to the anatomy of the first web area. A distal communicating artery was seen in 100% of
dissections, allowing either dorsal or plantar donor artery inflow to nourish the entire flap area. Because
of the ease of dissection, the first dorsal metatarsal or dorsalis pedis is suggested as the donor artery,
and a dorsal branch of the greater saphenous venous system is suggested as the donor vein. The deep
peroneal nerve was seen to consistently innervate the first web and, along with the plantar digital
nerves, is suggested as an anatomically identifiable donor nerve. Either part of the foot first web may
be used alone or together as a free flap. When indicated further dorsal skin may be incorporated into
the web flap to expand its application. Two-point discrimination studies of the lateral plantar surface
of the great toe in 50 normal individuals showed an average of 11.2 mm. This was significantly better
as a potential donor flap than the medial dorsum of the foot where the average was 32 mm. A single
case demonstrating the application of this flap in hand reconstruction was presented.
Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular
wrap-around flap from the big toe. J Hand Surg Am 5:575-583, 1980.
Thumb reconstruction requires accurate functional and aesthetic approximation to the original. Accepted
methods generally have some deficiencies, particularly in appearance, and frequently the secondary
morbidity is unacceptable. A method of thumb reconstruction with the use of an iliac crest bone graft
and a free neurovascular wrap-around flap from the great toe was described that combines the attributes
of previous methods without their secondary morbidity.

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 956 Part II  Regional Flaps: Anatomy and Basic Techniques

Ortiz CL, Mendoza MM, Sempere LN, et al. Reconstruction of a degloved thumb. Scand J
Plast Reconstr Surg Hand Surg 42:274-279, 2008.
The authors presented two cases of degloving injuries of the thumb, with amputation of the distal
phalanx. In the first case, an osteocutaneous flap was transferred from the first toe, providing effective
thumb function. In the second case, a fasciocutaneous interosseous flap was placed around the segment
of the exposed thumb, with a satisfactory result.
Pan YW, Zhang L, Tian W, et al. Donor foot morbidity following modified wraparound flap
for thumb reconstruction: a follow-up of 69 cases. J Hand Surg Am 36:493-501, 2011.
The authors examined and evaluated the reconstructed thumb and donor foot morbidity of 69 pa-
tients who had thumb reconstruction with a modified wrap-around flap. Donor morbidity was as-
sessed subjectively and objectively using the Foot Function Index verbal rating scales in 34 patients,
the American Orthopaedic Foot and Ankle Society’s hallux metatarsophalangeal-interphalangeal
(MTP-IP) scale in 34 patients, and gait analysis and dynamic pedodynographic measurements in
20 patients. Follow-up ranged from 6 months to 5 years. The aesthetic appearance of the reconstructed
thumbs was good. The full length or most of the length of the donor toes was preserved in 67 patients.
The FFI-5pt total score was 3.1, and the total hallux MTP-IP score was 87.9. No significant
difference was measured in any of the five biomechanical parameters (timing, trajectory, symmetry,
average peak force, and peak pressure between donor foot and the contralateral foot). The function of
the donor foot was well preserved, with only mild pain and disability. Foot function in gait was not
affected. Restriction in interphalangeal joint motion was almost negligible.
Ray EC, Sherman R, Stevanovic M. Immediate reconstruction of a nonreplantable thumb
amputation by great toe transfer. Plast Reconstr Surg 123:259-267, 2009.
When replantation of an avulsed/amputated thumb is not feasible, toe-to-hand transfer may be considered
as a reconstructive option in appropriately chosen patients. Although selection criteria are purposefully
restrictive, immediate one-stage transfer, as opposed to a delayed procedure, provides many advantages.
Primary reconstruction reduces hospitalization and operative and recovery time. It also may expedite
return of function and allow patients to return to work sooner. The ability of the patient to undergo
extensive microvascular reconstruction at the time of injury, the psychological preparation required, and
the need to understand potential risks are important factors to consider. Six patients with thumb amputa-
tions underwent immediate great toe-to-hand transfer. The overall results of these thumb reconstructions
were evaluated retrospectively with regard to function, outcome, length of stay, complications (infection,
contracture, or need for reexploration), and time to return to work/normal activity. All patients were
laborers who sustained work-related avulsion-amputations. No complications were reported during
initial hospitalization, lasting an average of 12 days. Donor site morbidity was minimal. The data
suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the
initial presentation in selected patients. The economic and therapeutic advantages should be weighed
against the risks associated with this approach when evaluating thumb avulsion-amputations.
Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruction with toe transfer:
selection of various techniques. Plast Reconstr Surg 93:345-351; discussion 352-357, 1994.
Microsurgical toe transfer is an established method for reconstruction of missing thumbs. However, there
is little agreement on which of the various techniques represents the ideal transfer. Basically, selection
of technique requires balancing the patient’s functional needs, appearance of the reconstructed thumb,
and donor site cosmesis. Based on their experience with 103 toe-to-thumb transfers performed over
the past 9 years, the authors provided guidelines for appropriate selection among the four most com-
monly employed toe transfer techniques (second toe, total great toe, great toe wrap-around, trimmed
great toe) so that optimal results and patients’ acceptance can be achieved.
Wei FC, Chen HC, Chuang DC, et al. Aesthetic refinements in toe-to-hand transfer surgery.
Plast Reconstr Surg 98:485-490, 1996.
Techniques for aesthetic refinement are as important as those for functional improvement in toe-to-
hand transfer. The appearance of the thumb reconstructed using various types of great toe transfer can
be improved by reduction of the soft tissue, bone, interphalangeal joint, and nail and by secondary

09b_GrToe_r6_bs_0926-0957.indd 956 2/6/2012 5:56:18 PM

 Hand  •  9B: Great Toe (Hallux) Flap 957

pulp reduction and contouring procedures. Finger and thumb reconstructions using lesser toes can be
improved aesthetically by minimal inclusion of adipofibrous tissue under the plantar skin flap, especially
at the metatarsophalangeal joint region, thus decreasing the anterior-posterior bulkiness. Tight extensor
repair and temporary K-pin fixation of the proximal and distal interphalangeal joint in extension,
followed by prolonged use of a nighttime extension splint and secondary pulp reduction, will help to
avoid the claw and drumstick appearances of the transferred lesser toe. Adequate soft tissue coverage,
cruciate skin incisions, extensive mobilization, and thinning and trimming of the skin flaps of the
digital amputation stump lead to a smooth junction between the amputated digit and the transferred
toe. In the distal digital reconstruction, skeletonization of medial and lateral neurovascular bundles of
the harvested toe helps primary closure of the digital wound, thus avoiding the unsightly skin graft on
the sides of the reconstructed digit. Regarding the donor foot, preservation of the proximal 0.5 to 1 cm
of the proximal phalangeal stump of the great toe maintains the span of the foot, thus improving donor
site appearance. In single lesser toe or combined second and third toe transfer, the proximal phalanx
should not be preserved but an optimal web space should be reconstructed. Primary closure without a
skin graft is essential for aesthetic appearance of the donor foot.
Wei FC, Jain V, Chen SH. Toe-to-hand transplantation. Hand Clin 19:165-175, 2003.
In a mutilated hand, microsurgical toe-to-hand transplantation provides thumb and finger reconstruc-
tion that is superior to conventional techniques in appearance and function. Hand reconstruction using
toe transplantation should be individually planned and carefully executed to obtain optimal results
and minimal disability in the donor foot.
Wei FC, Yim KK. Pulp plasty after toe-to-hand transplantation. Plast Reconstr Surg 96:661-
666, 1998.
Pulp plasty is a simple procedure that is used to debulk the bulbous-appearing pulp of a transplanted
digit after toe-to-hand transplantation. A retrospective review of the effect of pulp plasty on the ap-
pearance and function of the debulked digit was conducted of 82 digits on 51 patients. Pulp plasty
was performed on average of 14 months after toe-to-hand transplantation. The average follow-up
was 20 months. Subjective improvement in appearance and function was reported in 67.1% and
63.4%, respectively, of the debulked digits. Painful scarring was rare, and hypersensitivity was not
reported. Sensation was not affected adversely by pulp plasty. The procedure was considered to be
worthwhile in 87.8 percent of the cases. Pulp plasty is a simple and effective procedure after toe-to-
hand transplantation that enhances the appearance and function of the transplanted digit. Patient
satisfaction with the procedure is high.
Xu L, Gu YD, Xu JG, et al. Microsurgical treatment for bilateral thumb defect: five case reports.
Microsurgery 23:547-554, 2003.
The authors introduced a single-stage method of reconstructing bilateral defective thumbs with various
toe-tissue configurations in five patients. These include two bilateral second-toe transfers, one bilateral
hallux wrap-around flap transfer, one bilateral modified hallux wrap-around flap transfer, and one
combination of second toe with island flap and neurovascular pedicles from the proximal and dorsal
aspect of the index finger. Eight transferred tissues survived uneventfully, and two had temporary
circulation problems. After 1 year, the appearance was satisfactory and function was excellent in all
cases. The authors stressed the importance of a double artery supply and venous return flow system.
Zhang L, Pan Y, Tian G, et al. [Thumb reconstruction with modified free wrap-around flap]
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 24:309-314, 2010.
Thumb and donor foot function were evaluated in 65 patients who had thumb reconstruction with a
modified wrap-around flap. Twelve patients had skin-degloving injuries and late class IB defects, 44
patients had class II defects, and 9 had class IIIA defects. Function was evaluated in 20 patients using
the Foot Function Index verbal rating scales (FFI-5pt), the American Orthopaedic Foot and Ankle
Society’s hallux metatarsophalangeal-interphalangeal (MTP-IP) score, and gait analysis and dynamic
pedobarography. Follow-up ranged from 6 to 60 months. The reconstructed thumbs had an aesthetic
appearance and satisfactory range of motion. The authors concluded that the modified wrap-around
flap can achieve aesthetic and functional thumbs, preserving most of the function of the donor feet.

09b_GrToe_r6_bs_0926-0957.indd 957 2/6/2012 5:56:18 PM

 ANATOMIC LANDMARKS
Landmarks Ulnar or radial aspect of the digit based ipsilateral to the longest
fingertip amputation flap. Flap extends from the distal tip of
the finger to the proximal digital crease. Flap is designed over
the volar lateral aspect of the digit. A straight midaxial line is
marked on the side of the finger with the longest skin flap relative
to the distal amputation. The base of the triangle corresponds
to the width of the amputation tip, and the oblique arm of the
flap is carried in a volar oblique and proximal direction to reach
the midaxial line. This point forms the apex of the flap, which
is found either at the proximal interphalangeal joint or more
proximally at the proximal digital flexion crease. When used
to resurface the thumb, the skin island is usually based on the
ulnar aspect of the ring finger.
Size Length of the flap is 2.5 times the width; varies according to
how much advancement is required to cover the defect.
Flap Type Type A.
Dominant Pedicle Digital artery.
Minor Pedicle Includes small perforators from the digital artery, which can be
seen along the length of the digital artery.
Nerve Supply Digital nerve is incorporated within the flap.

09c_HomodigNeuro_r3b_cah_0958-0975.indd 958 2/8/2012 2:35:44 PM

 Section 9C
Hand

Homodigital Neurovascular
(Littler) Island Flap

CLINICAL APPLICATIONS
Regional Use
Resurfacing of the thumb pulp
or the radial surface of the
index finger with sensate
glabrous skin

With contributions by Michel Saint-Cyr, MD.

09c_HomodigNeuro_r3b_cah_0958-0975.indd 959 2/8/2012 2:35:47 PM

 ANATOMY OF THE Homodigital Neurovascular (Littler) island FLap

Bony architecture
of hand

Digital artery

B C

Relationship of blood supply to Nerve supply to hand

underlying skeleton

Fig. 9C-1 

Dominant pedicle: Digital artery

09c_HomodigNeuro_r3b_cah_0958-0975.indd 960 2/8/2012 2:35:48 PM

 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 961

Anatomy
Landmarks Ulnar or radial aspect of the digit based ipsilateral to the longest fingertip ampu-
tation flap. Flap extends from the distal tip of the finger to the proximal digital
crease. The flap is designed over the volar lateral aspect of the digit. A straight
midaxial line is marked on the side of the finger with the longest skin flap relative
to the distal amputation. The base of the triangle corresponds to the width of
the amputation tip, and the oblique arm of the flap is carried in a volar oblique
and proximal direction to reach the midaxial line. This point forms the apex
of the flap, which is found either at the proximal interphalangeal joint or more
proximally at the proximal digital flexion crease. When used to resurface the
thumb, the skin island is usually based on the radial aspect of the ring finger.
Composition Fasciocutaneous.
Size Length of the flap is 2.5 times the width; varies according to how much advance-
ment is required to cover the defect.

Arterial Anatomy
Dominant Pedicle  Digital artery
Regional Source  Superficial palmar arch.
Length  4 to 6 cm.
Diameter  1 mm.
Location  The digital artery can be found on the ulnar and radial aspects of the finger between
Grayson’s and Cleland’s ligaments and is dorsal to the digital nerve. The superficial arch is
formed primarily by the ulnar artery and completed by the superficial palmar branch of the
radial artery. In approximately 80% of hands, this arch is complete, whereas in 20%, there is no
communication between the ulnar artery and the superficial branch of the radial artery. Classi-
cally the superficial arch or anastomosis between the radial and ulnar arteries is formed by the
superficial volar branch of the radial artery (the smaller of the two vessels) and the much larger
ulnar artery. The hands with a complete arch in this classic arrangement are seen 50% of the
time; in the remaining half, the entire superficial arch is formed by the ulnar artery, with no
contribution from the radial artery. The arch lies anterior (superficial) to the branches of the
median nerve. Its branches include a palmar digital artery to the ulnar side of the small finger
and three common palmar digital arteries running to the three web spaces between the fin-
gers. As they course distally, they become dorsal through the median and ulnar sensory nerve
branches. In the web spaces, they divide into palmar digital arteries for adjacent sides of the
fingers. The palmar digital artery to the radial side of the index finger is a branch to the radial
artery. Variations in this arrangement can occur. The palmar digital arteries represent the major
blood supply to the fingers and form the basis for numerous homodigital flaps. They run dorsal
and deep to the digital nerves and give off three dorsal branches that continue into the dorsum
of the finger and anastomose with branches from the contralateral side. These dorsal branches
represent the major source of blood supply to the dorsum of the fingers, and finally, at the level
of the distal phalanx, each vessel ends in three to four anastomotic branches that join branches
from the contralateral side of the fingertip and dorsum.
Minor Pedicle  Includes small perforators from the digital artery, which can be seen along the
length of the digital artery
Regional Source  Digital artery.
Length  5 to 10 mm.
Diameter  0.2 to 0.3 mm.
Location  Extending in a volar direction into the pulp of the fingers.

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 962 Part II  Regional Flaps: Anatomy and Basic Techniques

Venous Anatomy
Venous drainage is through venae comitantes accompanying each digital artery, as well as venous
plexus within the subcutaneous tissue of the flap.

Nerve Supply
Sensory Ipsilateral digital nerve is incorporated within the flap.

Vascular A natomy of the Homodigital Neurovascular

(Littler) Island Flap
A

C D

D
n

Pedicle dissection for neurovascular

(Littler) island flap
n
B
n

D
D

Cutaneous surface of flap Radiographic view

Fig. 9C-2 
D
n Dominant pedicle: Digital artery (D)
n, Digital nerve

Closeup view of flap base

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 963

FLAP HARVEST
Design and Markings
A midlateral or zigzag incision is carried dorsal to the neurovascular bundle to incorporate
the neurovascular bundle. Dissection is continued under the flap and over the periosteum
and flexor tendon sheath. An oblique volar incision is then made spanning from the base of
the distal tip amputation to the apex, which is found either at the proximal interphalangeal
(PIP) joint, or more proximally at the proximal digital flexion crease, depending on how
much advancement is required. Smaller triangular flap designs tend to atrophy and contract
over time, so larger flaps are favored to minimize any risks of contracture and flap atrophy.
To minimize postoperative flexion contractures, the oblique volar incision should be made
using small Brunner zigzag incisions or using modified stepladder incisions, as described
by Evans and Martin.

Neurovascular (Littler) island

flap design

Fig. 9C-3 

Patient Positioning
The patient is placed in the supine position, with the upper extremity abducted and in
extension over a hand table. The hand is kept in supination.

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 964 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The Brunner zigzag volar incision is made through subcutaneous tissue until herniating fat
is observed. Dissection proceeds from distal to proximal and is carried down to the flexor
tendon sheath. Planar dissection is superficial to this. Dissection is very similar to elevation
of a Moberg flap, in which the flap is dissected off of the periosteum and the flexor tendon
sheath. All fibrous septa are detached. A midlateral incision is then performed to delineate
the dorsal extent of the flap. Dissection is carried dorsal to the neurovascular bundle, con-
tinuing under the flap and over the periosteum and flexor tendon sheath. The neurovascu-
lar bundle, which is included within the flap, is identified distally. It is carefully inspected
throughout the flap elevation, which is carried from distal to proximal. The contralateral
neurovascular bundle is identified and protected at all times, and the flap is detached from
distal to proximal, freeing up and releasing all fibrous septa and soft tissue attachments. The
dorsal branches of the digital artery are ligated as required for proper flap advancement.

A B C

Neurovascular
pedicle

Flap design Incision Flap mobilization

D E

Flap advancement and closure

Fig. 9C-4  (Adapted from Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville,
KY.)

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 965

If adequate advancement is achieved without ligating the dorsal branches, these are
kept intact. Proper flap elevation as an island can yield more than 1 cm of advancement
onto the distal finger.
If the flap is being used to resurface an adjacent digit or thumb, proximal dissection
of the pedicle is carried down into the palm, taking care not to induce vasospasm. The
surgeon must be careful to preserve a generous cuff of fibrofatty tissue around the pedicle
throughout its length to minimize any risk of vasospasm or arterial ischemia.

F G

Volar wound
of thumb

Flap design from radial side of ring finger Tunneled flap inset with full-thickness
to resurface volar thumb wound skin graft to donor site

Fig. 9C-4 

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 966 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANT
Modified Oblique Triangular Neurovascular
Island Flap (Evans and Martin Stepladder
Advancement Island Flap)
This modification uses step-cut incisions instead of a longitudinal volar incision or Brunner
zigzag incision to avoid potential flexion contractures and longitudinal scarring.
The first surface landmarks and flap designs are identical to those for the standard neu-
rovascular island flap, with the exception that the flap is designed based on three triangles
of increasing size to minimize the risk of flexion contracture postoperatively. The width
of the flap is equal to half of the peripheral length of the amputated surface, and the apex is
located at or just proximal to the PIP joint crease. The flap design incorporates three triangles
of increasing size, the distalmost being the widest and just crossing the midline. The lateral
arm of the flap is marked just dorsal to the neurovascular bundle and curves gently dorsally.
Volar incisions are made first down through subcutaneous tissue, and lateral finger flaps are
developed to provide better exposure of the vascular pedicle. The dorsal incision is then
carried down to the periosteum with care to preserve all dorsal digital sensory branches.
The flap is elevated just above the periosteum and the flexor tendon sheath, and all fibrous
septa are detached to free up the flap. The flap is advanced by interdigitating each major
triangle, and the donor site is closed in a V-Y fashion. If mobilization is inadequate, more
proximal mobilization of the pedicle is performed.

A B

Neurovascular
pedicle

Fig. 9C-5  Stepladder advancement island flap for fingertip closure. (Adapted from Christine M.
Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY.)

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 967

ARC OF ROTATION
The neurovascular island flap is typically used as an advancement island flap for distal tip
coverage but can be rotated up to 180 degrees to cover defects on the thumb and adjacent
digits as well as the palmar and dorsal aspects of the hand.

Arc to volar aspect of distal phalanx of thumb

Fig. 9C-6 

FLAP TRANSFER
For fingertip coverage, the flap is simply advanced into the defect without tension. When
used to resurface the thumb, the flap is dissected proximally into the palm to the level of
the proximal palmar crease and is then tunneled subcutaneously into the thumb. If there
are any concerns about tunnel compression or pedicle twisting, the entire palm should be
opened from the base of the donor site incision across the palm to the base of the thumb,
permitting precise placement of the pedicle.

FLAP INSET
The flap is inset and can be advanced in excess of 1 cm. The donor site is closed in a V-Y
fashion to provide better support for the flap. The flap is inset with minimal tension over
the distal tip defect and with some excess above the eponychial fold to account for postop-
erative contracture.

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 968 Part II  Regional Flaps: Anatomy and Basic Techniques

Donor Site Closure

Simple sutures are used for closure under minimal tension and care is taken to interdigitate
the three triangles in the Evans and Martin modification. If this modification is not used,
we tend to use simple, smaller, zigzag Brunner incisions, which interdigitate very easily
without any measuring or requirements of the stepwise triangles. When the flap is used to
resurface the thumb, the donor site will require full-thickness grafting with either glabrous
skin from the instep of the foot or a full-thickness skin graft from the upper inner arm.

CLINICAL APPLICATIONS
This patient presented with a degloving injury of the radial side of the pulp of the right
middle finger. Sensate reconstruction is critical in this area, since the finger is used in fine
manipulations. A homodigital neurovascular island flap was planned.

A B C

D E F

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. (Case courtesy Michel Saint-Cyr, MD.)

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 969

This right-hand-dominant patient presented with traumatic amputation of the distal pha-
lanx. A homodigital neurovascular island flap was designed.

A B

C D E

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. (Case courtesy Michel Saint-Cyr, MD.)

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 970 Part II  Regional Flaps: Anatomy and Basic Techniques

The ulnar aspects of the long or ring fingers are selected as the usual donor sites when the
flap is required on another digit, because these areas are less critical for fine manipulations.
The neurovascular island flap should include skin of the distal segment of the donor fin-
ger for two reasons: (1) to transfer the area of critical sensibility, and (2) to avoid a painful
neuroma at the distal pulp donor site. Whereas the palmar margin of the flap corresponds
to the palmar digital midline, the dorsal limit can extend up to the dorsal midline. Dorsal
digital nerve branches should also be included in the flap if their corresponding dorsal skin
territory is included in the flap design. Final dimensions of the flap, including its proximal
extension, will be determined by the size of the recipient digit or thumb defect. In general,
larger flaps are usually favored, because they encompass a larger sensory field and risk less
injury and spasm to the pedicle during transfer.

A B

C D

Fig. 9C-9 A-E, Littler neurovascular island flap. (From Christine M.

Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY.)

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 971

Pearls and Pitfalls

• It is important not to skeletonize the neurovascular bundle and create spasm and problems
with venous congestion. Leaving a generous cuff of fibrofatty tissue around the pedicle
helps to minimize any risk of vasospasm or venous congestion.
• Straight oblique incisions incorporated in the flap design should be avoided to minimize
any risk of flexion contracture. Incisions should not pass at 90 degrees across the proximal
interphalangeal joint or any other joint in the hand at a 90-degree angle.
• The contralateral neurovascular bundle should be protected at all times so the remaining
portion of the digit is not devascularized.
• It is easier to dissect from distal to proximal and from lateral to medial.
• The volar incision can be made first, and dissection is taken down to the flexor tendon
sheath. The flap can be elevated off the flexor tendon sheath, enabling easy identification
of the neurovascular bundle.
• The flap must be inset under minimal tension, and flexion of the PIP joint and metacar-
pophalangeal (MCP) joint should be performed as needed to minimize any tension on
the closure. Flexion contracture can be avoided by progressive static extension splinting
worn at night and during the day as tolerated. Patients should wear the splint nightly for
up to 6 months to minimize any risk of flexion contracture.

Expert Commentary
Michel Saint-Cyr

Indications
The homodigital neurovascular island flap is an extremely useful flap for digital tip cov-
erage when local flaps are not suitable or available. This flap provides instant two-point
discrimination once it is harvested and does not rely on peripheral neural ingrowth for
two-point discrimination. It has all of the characteristics of the ideal tissue match, which
includes color, texture, sensibility, and durability.

Recommendations
Technique
The volar oblique incision should be performed using small Brunner incisions, not a straight
linear incision, to minimize any risk of future flexion contracture. I favor larger rather than
smaller flaps and always try to have the skin paddle cover the entire neurovascular bundle so
that it is not exposed and at risk for vasospasm. The skin paddle typically extends to either
the PIP joint or more proximally in the vicinity of the proximal digital flexion crease, and
the digital artery and nerve are dissected more proximally as needed to provide better flap
advancement.
Once elevated, the flap is inset very loosely, and the tourniquet is released to confirm
adequate blood flow into the flap. Care must be taken to preserve dorsal branches of the
digital artery. If the flap is advanced sufficiently without having to divide the dorsal branches,
then these are maintained. If not, these are cauterized, ensuring that the contralateral dorsal
digital artery branch is preserved and maintains adequate blood supply to the dorsum.
Continued

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 972 Part II  Regional Flaps: Anatomy and Basic Techniques

Complications: Avoidance and Treatment

Flexion contractures are least likely to occur with a modified oblique triangular neuro-
vascular island flap design or using small Brunner incisions instead of a standard straight
oblique flap incision. Nevertheless, we place all of our patients in nighttime splints to avoid
any flexion contracture, even when using Brunner zigzag incisions.

Take-Away Messages
When the flap is used to resurface the thumb, the patient should be warned that sensory
retraining is required. This is more difficult to achieve in older patients, because sensory
imprinting on the brain is so strongly established with advancing age.

Bibliography With Key Annotations

Adani R, Busa R, Scagni R, et al. The heterodigital reversed flow neurovascular island flap
for fingertip injuries. J Hand Surg Br 24:431-436, 1999.
The authors reported the results of pulp reconstruction with a new heterodigital reverse-flow island
flap. A dorsolateral flap from the middle phalanx, based on the digital artery is raised from the adja-
cent uninjured finger. The common digital artery, between the injured finger and the donor finger, is
ligated and transected just before its bifurcation. The two converging branches of the digital arteries can
be entirely mobilized as a continuous vascular pedicle for the flap. Thus the vascularization is now
supplied by reverse flow through the proximal transverse digital palmar arch of the injured finger. To
provide sensation the dorsal branch of the proper digital nerve from the donor finger can be included
in the flap. Six reverse heterodigital island flaps were used in patients. In five patients the flap was
used for pulp reconstruction and in one case for covering a dorsal digital defect. In one case mild venous
congestion occurred. Good skin coverage with supple and well-vascularized skin was obtained in each
patient. Static two-point discrimination over the flap was between 6 and 15 mm. This new procedure
is indicated for extensive pulp defects in fingers in which reconstruction cannot be done using other
flaps and as an alternative to microsurgical reconstruction.
Adani R, Marcoccio I, Tarallo L, et al. The reverse heterodigital neurovascular island flap for
digital pulp reconstruction. Tech Hand Up Extrem Surg 9:91-95, 2005.
The authors described a heterodigital neurovascular reverse-flow flap island flap for extensive pulp
defects. A dorsolateral flap from the middle phalanx, based on the digital artery, is harvested from
the adjacent uninjured finger. The common digital artery between the injured finger and the donor
finger is ligated and transected just before its bifurcation. At this point the two converging branches of
the digital arteries can be entirely mobilized as a continuous vascular pedicle for the flap. The vascu-
larization is now supplied by reverse flow through the proximal transverse digital palmar arch of the
injured finger; to provide sensation, the dorsal branch of the digital nerve from the donor finger must
be included in the flap. This technique is indicated for large pulp defects with bone exposure of index
and middle finger pulps, which are important for sensation.
Huang SH, Wu SH, Lai CH, et al. Free medial plantar artery perforator flap for finger pulp
reconstruction: report of a series of 10 cases. Microsurgery 30:118-124, 2010.
Treatment of composite tissue loss in the finger pulp is often difficult. The authors presented their
experience with the medial plantar artery perforator flap for repair of finger pulp defects and to restore
fingertip sensation after traumatic injury. Free medial plantar artery perforator (MPAP) flaps were
performed for digital pulp reconstruction in 10 patients (8 fingertips and 2 thumb tips). The flap’s blood
supply was a perforator vessel of medial plantar artery, which was through the intermuscular septum
between the abductor hallucis muscle and the flexor digitorum muscle. The recipient vessels were the
digital artery and dorsal digital vein. The flap was not reinnervated during transfer procedures. The

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 973

donor sites were closed primarily in all cases. MPAP flaps are good in terms of general morbidity,
cosmetic results, and durability. This flap is a valuable alternative method of repairing the glabrous
finger pulp and tip defects.
Omokawa S, Tanaka Y, Ryu J, et al. Anatomical consideration of reverse-flow island flap trans-
fers from the midpalm for finger reconstruction. Plast Reconstr Surg 108:2020-2025, 2001.
Primary soft tissue coverage for large palmar defects of the fingers is a difficult problem for cases in which
homodigital or heterodigital flaps cannot be used. The aim of this study was to explore the vascular and
neural anatomy of the midpalmar area to assess the possibility of reverse island flaps from this area.
In 24 cadaver hands perfused with a silicone compound, the arterial pattern of the superficial palmar
arch and common palmar digital artery was examined. They detailed their findings and concluded that
these flaps may be a useful reconstruction option for significant palmar soft tissue loss of the fingers.
Rose EH. Local arterialized island flap coverage of difficult hand defects preserving donor digit
sensibility. Plast Reconstr Surg 72:848-858, 1983.
Small to moderate-sized defects of the hand overlying joint surfaces, flexor tendons, Silastic implants,
and tactile surfaces require full-thickness skin and subcutaneous tissue either for primary coverage or in
anticipation of secondary reconstruction. Six difficult hand wounds were resurfaced with an arterialized
island pedicle from the lateral surface of the nearby digit in lieu of multistage distant pedicle flaps. The
Littler neurovascular island flap was modified to include only the digital artery and venae comitantes
at its pedicle, preserving digital nerve intact in the donor digit. Microsurgical separation of the digital
artery from the digital nerve minimizes the sensory loss of the donor digit. Cortical reeducation at
the recipient site is unnecessary. The lengthy pedicle allows an arc of coverage over the palm, dorsum
of the hand, and adjacent digits. Flap survival was 100%. Maximum flap size was 5.5 by 2.5
cm. Two-point discrimination of the donor defect averaged 4.5 mm. No significant donor morbidity
was noted, with the exception of one case in which there was a mild degree of hypertrophic scarring
across the volar aspect of the proximal interphalangeal joint. The one-stage procedure minimizes the
number of hospitalizations and disability time. Its proximity to the site of injury, its versatility, and
the relative speed with which it can be raised encourages its usage for primary coverage (two cases in
this series). Preservation of near-normal two-point discrimination of the donor site allows either the
radial or ulnar surface of the nearby digit to be used.
Shao X, Chen C, Zhang X, et al. Coverage of fingertip defect using a dorsal island pedicle flap
including both dorsal digital nerves. J Hand Surg Am 34:1474-1481, 2009.
Fingertip or pulp resurfacing is a challenging reconstructive problem; the treatment varies widely. The
authors reported the results of a dorsal island pedicle flap raised from an adjacent finger, including the
bilateral dorsal digital nerves, for coverage of extensive soft tissue defect in the fingertip or pulp. They
concluded that the dorsal island pedicle flap from an adjacent finger can be used for coverage of extensive
fingertip or pulp defects, with maintenance of a normal-length digit and restoration of sensation on
both the radial and ulnar sides of the finger pulp. They stated that sensation recovery in this series
was superior to dorsal island pedicle flaps previously described in the literature, which did not include
incorporation of both dorsal digital nerves.
Takeishi M, Shinoda A, Sugiyama A, et al. Innervated reverse dorsal digital island flap for
fingertip reconstruction. J Hand Surg Am 31:1094-1099, 2006.
Digital island flaps or cross-finger flaps have to be used for large defects; however, the digital artery is
sacrificed when creating conventional homodigital island flaps, and two surgeries are required for the
cross-finger flap. The authors described their experience in eight patients using an innervated reverse
dorsal digital island flap that does not require sacrifice of the digital artery. The flap was supplied by
the vascular network between the dorsal digital artery (the terminal branch of the dorsal metacarpal
artery) and the dorsal branch of the digital artery. Venous drainage was through the cutaneous veins
and the venous network associated with the dorsal arterial network. The flap was designed on either the
dorsal proximal or the dorsal middle phalangeal region. The flap was harvested with the dorsal branch
of the digital nerve (for the dorsal middle phalanx), the dorsal digital nerve (for the dorsal proximal

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 974 Part II  Regional Flaps: Anatomy and Basic Techniques

phalanx), or the superficial branch of the radial nerve (for the thumb), which was anastomosed to the
distal end of the digital nerve. After flap transfer the donor site was covered with a full-thickness skin
graft. Of the eight flaps, six survived completely, one had partial epithelial skin necrosis, and one
showed central compression skin necrosis. Three flaps showed congestive changes from the first to the
fifth day after surgery, which resolved by massage. All patients satisfactorily recovered sensation. The
advantages of this flap are that the digital artery is not sacrificed, and only one surgery is needed. A
disadvantage is the potential for venous congestion for the first 4 or 5 days after surgery.
Tan O. Reverse dorsolateral proximal phalangeal island flap: a new versatile technique for
coverage of finger defects. J Plast Reconstr Aesthet Surg 63:146-152, 2010.
All flaps described for the reconstruction of finger defects have limited indications and many disadvan-
tages. The author successfully developed a reverse digital artery flap raised from the overall side and
dorsal aspects of the proximal phalanx, excluding the digital nerve, for closure of fingertip and middle
phalangeal defects; he called this the “reverse dorsolateral proximal phalangeal island flap.” The donor
site defect was covered by another flap called the “dorsal metacarpal V-Y island flap.” The method
was used for 12 complicated phalangeal defects in 11 patients. Flap sizes ranged from 2 by 1.5 cm to
3 by 2.5 cm. The flap was applied with versatile designs including distal interphalangeal or proximal
interphalangeal anastomoses–based flaps; homodigital or heterodigital flaps from the injuries or adjacent
finger, respectively; multiple flaps from the two distinct fingers in the same hand; and a sensate flap.
The average follow-up time was 11.5 months. All reverse flaps and V-Y donor site flaps survived
completely. Finger lengths and motions were satisfactory, with favorable aesthetic results in all cases.
The mean value of static two-point discrimination was 9.3 mm. The author strongly advocates this
new flap, as a single versatile flap, for repair of different-sized or complex phalangeal defects.
Tay SC, Teoh LC, Tan SH, et al. Extending the reach of the heterodigital arterialized flap by
vein division and repair. Plast Reconstr Surg 114:1450-1456, 2004.
The heterodigital arterialized flap is ideal for nonsensory reconstruction of sizable soft tissue defects in
the proximal fingers, web spaces, and the hand. The inclusion of a dorsal vein augments the venous
drainage of this digital island flap and avoids the problem of postoperative venous congestion, which is
a common problem in digital island flaps. However, the presence of a dorsal vein pedicle inhibits flap
mobility somewhat, and the reach of the flap is mainly limited to adjacent fingers. In situations that
demand a transfer from a nonadjacent donor finger or when the reach from the adjacent donor finger is
inadequate, the dorsal vein pedicle can be temporarily divided and then anastomosed microsurgically
after flap transfer is performed. This enables the reach of the flap to be extended up to two fingers
from the donor finger. The authors performed this “partially free” heterodigital arterialized flap in
11 consecutive patients between 1991 and 2001. The average size of the defects was 4.4 by 2.3 cm.
All of the flaps survived completely, with no evidence of postoperative flap congestion. Healing of all
of the flaps was primary and did not result in any scarring. All of the donor fingers had “normal”
two-point discrimination of 3 to 5 mm. All of the donor fingers retained excellent or good total active
motion, as graded by the criteria of Strickland and Glogovac.
Teoh LC, Tay SC, Yong FC, et al. Heterodigital arterialized flaps for large finger wounds:
results and indications. Plast Reconstr Surg 111:1905-1913, 2003.
Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint,
or neurovascular structures require flap coverage. However, the location and size of the defects often
preclude the use of local flap coverage. Free flap coverage is often not desirable, because the recipient
vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled
flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the
digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap,
the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications
associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the
donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the
flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the

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 Hand  •  9C: Homodigital Neurovascular (Littler) Island Flap 975

digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also
preserves fingertip cosmesis. The authors detailed their results with 29 flaps. Ninety-seven percent of
the donor fingers achieved excellent or good total active motion according to the criteria of Strickland
and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold
intolerance of the donor finger or the adjacent finger was reported in this series.
Xarchas KC, Tilkeridis KE, Pelekas SI, et al. Littler’s flap revisited: an anatomic study, literature
review, and clinical experience in the reconstruction of large thumb-pulp defects. Med Sci
Monit 14:CR568-CR573, 2008.
Sixteen upper extremities from fresh cadavers were dissected to delineate the anatomy, vascular pattern,
and reconstructive potential of the heterodigital island flap. Fifteen heterodigital island flaps were also
performed between 1996 and 2004 in 15 patients (mean age 41.2 years) with a major trauma of
the thumb. Flap and donor site skin quality, scar contractures, finger mobility expressed in terms of
total active movement, sensibility evaluated by two-point discrimination and the Semmes-Weinstein
monofilament tests, cold intolerance, double-sensibility phenomenon, and cosmetic results were assessed.
All patients were reviewed over a postoperative follow-up period of 10 to 18 months. Good coverage
with well-vascularized skin was obtained and donor-finger full-thickness skin grafting was successful
in all cases. All flaps survived completely. Mild cold intolerance was seen in all donor fingers, but no
flap had hyperesthesia 10 months postoperatively. Total active range of motion was rated as good or
excellent in all patients for both the donor finger and the thumb. Sensation in the donor finger was
reported as “slightly altered,” and the double-sensibility phenomenon was present in all patients.

09c_HomodigNeuro_r3b_cah_0958-0975.indd 975 2/8/2012 2:36:02 PM

 ANATOMIC LANDMARKS
Landmarks Encompasses the entire second toe. The superior limit is the mid
second metacarpal; the distal limit is the end of the second toe.
Size Entire second toe.
Function Plantar flexion of distal foot for push-off during ambulation; the
second toe is expendable.
Composition Composite (second toe), fasciocutaneous (first web space).
Flap Type Type A.
Dominant Pedicle First dorsal metatarsal artery (FDMA).
Minor Pedicles First plantar metatarsal artery; second plantar metatarsal artery.
Nerve Supply Sensory: Medial dorsal cutaneous nerve, medial terminal branches
of deep peroneal nerve, common digital nerve.

09d_SecToe_r5_bs_0976-1009.indd 976 2/8/2012 2:39:47 PM

 Section 9D
Hand

Second Toe Flap

CLINICAL APPLICATIONS
Regional Use
Plantar surface of foot
Distant Use
(Microvascular Transfer)
Hand
Specialized Use
Thumb
Digits

09d_SecToe_r5_bs_0976-1009.indd 977 2/8/2012 2:39:50 PM

 ANATOMY OF THE Second Toe Flap

A B

First First plantar

dorsal metatarsal artery
metatarsal
artery
Second plantar
metatarsal artery

D
Deep
peroneal
nerve
Dorsal
Dorsalis
venous
pedis
arch
artery
Superficial
peroneal
nerve
Medial
plantar
nerve

Greater
saphenous
vein

Arterial supply to flap area

Lesser
saphenous
vein
First dorsal
metatarsal artery

Superficial venous system

First plantar metatarsal artery

First dorsal metatarsal artery

E
Arterial supply to second toe

First plantar metatarsal artery

Relationship of dorsal and

plantar metatarsal arteries in first
interosseous space

Fig. 9D-1

Dominant pedicle: First dorsal metatarsal artery

Minor pedicles: First plantar metatarsal artery; second plantar metatarsal artery

09d_SecToe_r5_bs_0976-1009.indd 978 2/8/2012 2:39:53 PM

 Hand  •  9D: Second Toe Flap 979

ANATOMY
Landmarks Encompasses the entire second toe. The superior limit is the mid second meta-
carpal; the distal limit is the end of the second toe.
Composition Composite (second toe), fasciocutaneous (first web space).
Size Entire second toe.
Function Plantar flexion of distal foot for push-off during ambulation; the second toe is
expendable.

Arterial Anatomy (Type A)

Dominant Pedicle  First dorsal metatarsal artery (FDMA)
Regional Source  Dorsalis pedis artery.
Length  5 cm.
Diameter  1.5 mm.
Location  Immediately distal to the head of the first and second metatarsal bones, the dorsalis
pedis artery bifurcates into the FDMA and a deep branch into the deep plantar arch. The first
metatarsal artery immediately proximal to the web space divides into a pair of digital arteries,
extending into adjacent sides of the great and second toe.
Variations in the Origin of the First Dorsal Metatarsal Artery
The following classification describes the anatomy and frequency of these variations.
Type A (superficial) (49%)  The FDMA takes origin directly from the dorsalis pedis or from
the superficial part of the deep perforating branch. This vessel then courses distally in a super-
ficial plane.
Type B (40%)  The FDMA arises from the lower part of the deep communicating branch or from
the deep plantar arch. It lies deep under or within the first interosseous muscle and courses distally
and dorsally, eventually becoming superficial between the head of the first and second metatarsal.
Type C (11%)  The FDMA is very narrow or totally absent. In these patients the blood supply of
the great and second toe depends largely on the plantar metatarsal artery.
In type A and B patients, the FDMA is available for use as the dominant pedicle. However, it may
be necessary to dissect the deep communicating branch of the dorsalis pedis artery and the first
metatarsal space to locate the origin of the FDMA. Distal exposure of the artery may require dissec-
tion within the interosseous muscle. In type C and selected type B patients, a second toe transplant
requires use of the first plantar metatarsal artery (FPMA). In reported series of second toe–to–hand
transplants, the FPMA is selected as the dominant donor arterial pedicle in 20% to 30% of patients.
Minor Pedicle  First plantar metatarsal artery
Regional Source  Deep plantar arch.
Length  6 cm.
Diameter  1 mm.
Location  The deep plantar arch is formed by the junction of the lateral plantar artery with the
deep branch of the dorsalis pedis artery as it extends through the first interosseous space. From
this arch the second plantar metatarsal artery courses to the first web space and bifurcates into
plantar digital arteries, entering adjacent sides of the great and second toe.

09d_SecToe_r5_bs_0976-1009.indd 979 2/8/2012 2:39:54 PM

 ANATOMY OF THE Second Toe Flap

F G H

Plantar
digital
nerves

Medial
Superficial
digital
Deep peroneal peroneal nerve
nerve
nerve

Distribution of deep peroneal nerve Relationship of superficial Distribution of medial plantar nerve
to web space and dorsum of and deep peroneal nerves to web space and plantar surface
great and second toe to flap territory of great and second toe

Dorsal digital nerve

I

Plantar digital nerve

Relationship of dorsal and plantar digital

nerves to first interosseous space

Fig. 9D-1 

09d_SecToe_r5_bs_0976-1009.indd 980 2/8/2012 2:39:57 PM

 Hand  •  9D: Second Toe Flap 981

Minor Pedicle  Second plantar metatarsal artery

Regional Source  Deep plantar arch.
Length  6 cm.
Diameter  1 mm.
Location  At the level of the second web space, the second plantar metatarsal divides into digital
arteries, entering adjacent sides of the second and third toes.

Venous Anatomy
The venous drainage is primarily through dorsal subcutaneous veins that drain into the dorsal
venous arch distally. The arch drains dorsomedially into the greater saphenous vein, whereas the
lateral border of the foot drains dorsolaterally into the lesser saphenous vein.

Nerve Supply
Sensory Medial dorsal cutaneous nerve: This sensory nerve, a branch of the superficial
peroneal nerve, extends lateral to the dorsalis pedis artery and divides into a
medial and lateral branch. The lateral branch supplies the adjacent sides of the
second and third toes.
Medial terminal branches of deep peroneal nerve: The medial terminal branch
of the deep peroneal nerve courses medial to the dorsal pedis artery along the
dorsum of the foot. It divides into two dorsal digital nerves in the first interos-
seous space; these nerves enter the adjacent sides of the great and second toe.
Common digital nerve: Branches of the medial plantar nerve provide sensation
to the plantar aspect of the second toe.

09d_SecToe_r5_bs_0976-1009.indd 981 2/8/2012 2:39:57 PM

 982 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Second Toe Flap

A

First dorsal interosseous space

B v C
e
v
f

n2

a
D

n1
D

n1

Dorsal surface of flap Radiographic view

Fig. 9D-2 

Dominant pedicle: First dorsal metatarsal artery (D)

Minor pedicle: First plantar metatarsal artery (m)
a, Dorsalis pedis artery; e, extensor digitorum longus; f, flexor digitorum longus; n1, plantar
digital nerve; n2, dorsal digital nerve; v, superficial vein

09d_SecToe_r5_bs_0976-1009.indd 982 2/8/2012 2:39:58 PM

 Hand  •  9D: Second Toe Flap 983

FLAP HARVEST
Design and Markings
The skin of the second toe and the medial aspect of the dorsum of the foot may be included
as a neurosensory flap. The skin of the dorsum of the foot may be included with the second
toe as a composite flap.

A B C D

Web space flap design Composite flap design

E F G H

Short-transfer flap design Double-transfer (second and third toe) flap design

Fig. 9D-3 

09d_SecToe_r5_bs_0976-1009.indd 983 2/8/2012 2:39:59 PM

 984 Part II  Regional Flaps: Anatomy and Basic Techniques

The second toe is examined for size and shape and compared with the great toe for
suitability for transplantation to the thumb position. The complete or second toe is used
for reconstruction of missing ulnar hand digits.
The medial first web space and dorsalis pedis flap territory measuring 10 by 8 cm may
be included with the second toe transplant (see Section 14D). Generally, minimal foot skin
is included with the second toe to ensure direct donor site closure. A dorsal triangular flap
measuring 2.5 by 3 cm in a smaller plantar triangular flap based superiorly to the second
metatarsophalangeal (MTP) joint is generally included with the second toe.
The first dorsal metatarsal artery, the dominant pedicle to the second toe, is located
between the first and second metatarsal bones lateral to the tendon of the extensor hallucis
longus. In approximately a fourth to a third of patients, the FPMA is the dominant pedicle
to the great and second toes. This pedicle courses deep to the interosseous muscles between
the first and second metatarsal bones.
A circumferential second toe incision is made that includes a dorsal and plantar trian-
gular flap based at the level of the second MTP joint. The dorsal triangular flap incision
continues as a dorsal longitudinal incision located between the first and second metatarsal
bones. A short longitudinal plantar incision may extend superior to the triangular flap as
required for exposure of plantar structures.

Patient Positioning
The patient is placed in the supine position with the lower donor extremity prepared to the
midthigh to allow knee flexion and external hip rotation for exposure of the plantar surface
of the foot during the plantar portion of the second toe flap elevation.

GUIDE TO FLAP DISSECTION

Before leg exsanguination with application of the midthigh tourniquet, a light temporary
tourniquet is placed at the midcalf level to distend superficial veins. Branches of the saphe-
nous vein into the first and second web space are identified and recorded with a marking
pen for later identification after elevation of dorsal foot skin flaps.
The superficial peroneal nerve is identified in its course superficial to the extensor
retinaculum. Branches to the second web space are identified and preserved. The deep
peroneal nerve is identified as it crosses through the extensor retinaculum between the
first and second metatarsal bone at the midmetatarsal level. Branches to the second medial
toe are preserved. Immediately inferior to the extensor hallucis brevis, as its tendon crosses
the midmetatarsal level, the dorsal metatarsal artery and associated venae comitantes are
identified between the first and second metatarsal bones. The artery is located immediately
lateral to the deep peroneal nerve.
The extensor digitorum longus tendon is exposed over the dorsum of the second MTP
joint. Division of the transmetatarsal ligament allows identification of the common plantar
digital nerve and its bifurcation into lateral great toe and medial second toe branches. The
plantar metatarsal artery is identified proximal to the second MTP joint distal to the plantar
aponeurosis. The vessel is either identified through a dorsal approach after division of the
transmetatarsal ligament or through the plantar aspect of the initial incision. Division of
the transmetatarsal ligament between the second and third toes allows identification of the
second plantar digital nerve. The tendons of the flexor digitorum longus and brevis to the
second toe are identified through the plantar incision.

09d_SecToe_r5_bs_0976-1009.indd 984 2/8/2012 2:39:59 PM

 Hand  •  9D: Second Toe Flap 985

Standard Flap (Second Toe to Hallux)

The circumferential incision around the second toe includes a triangular flap based on the
second toe at the level of the second MTP joint. This incision connects with a dorsal longi-
tudinal incision between the first and second metatarsal bones to the level of the cuneiform
bone at the midtarsal region. Medial and lateral skin flaps are elevated, preserving second
toe dorsal veins previously identified before tourniquet inflation. The superficial peroneal
nerve is identified superficial to the dorsal extensor retinaculum, with branches to the first
and second web spaces preserved.

A B C

h
h
v
v

Identification of vascular pedicle and superficial draining vein Closeup view of first dorsal
interosseous space

Fig. 9D-4 

e, Extensor hallucis longus tendon; h, extensor hallucis brevis; v, superficial draining vein
(saphenous system)

09d_SecToe_r5_bs_0976-1009.indd 985 2/8/2012 2:40:00 PM

 986 Part II  Regional Flaps: Anatomy and Basic Techniques

The extensor hallucis brevis tendon is identified as it crosses the proximal first meta-
tarsal space. The extensor retinaculum is incised. The FDMA and deep peroneal nerve are
identified between the first and second metatarsal bones. The deep communicating branch
through the plantar arch is also identified and preserved. The FDMA and medial deep
peroneal nerve branches are dissected into the first web space, where the bifurcation into
the lateral great toe (dorsal digital pedicle) and medial second toe (dorsal digital pedicle) is
identified. Nerve and arterial branches to the medial great toe are divided.

D E F

e e
v h
v
h h
p
p
p
v
n
n
h D

Release of insertion of extensor hallucis brevis tendon

Fig. 9D-4 

Dominant pedicle: First dorsal metatarsal artery (D)

e, Extensor hallucis longus tendon; h, extensor hallucis brevis; n, deep peroneal nerve;
p, dorsalis pedis artery; v, superficial draining vein (saphenous system)

09d_SecToe_r5_bs_0976-1009.indd 986 2/8/2012 2:40:00 PM

 Hand  •  9D: Second Toe Flap 987

The transmetatarsal ligament between the great toe and second toe is identified and
divided. Immediately proximal to the first and second MTP joints, the plantar metatarsal
artery and digital nerve are identified. Both are dissected to the plantar aspect of the first
web space, and the arterial and venous branches to the great toe are divided. The plantar
digital nerve is split for a 1 to 2 cm length proximal to its bifurcation, at which point its nerve
fibers to the second toe are divided, leaving the medial branches to the volar great toe intact.

Relationship of transmetatarsal ligament (t)

to dorsal and plantar arteries

H I

v
e

v e
h

p
h
p

D D

Identification of vascular Closeup view of first dorsal

pedicle and nerve interosseous space

Fig. 9D-4 

Dominant pedicle: Dorsal metatarsal artery (D)

e, Extensor hallucis longus tendon; h, extensor hallucis brevis; p, dorsalis pedis artery;
v, superficial draining vein (saphenous system)

09d_SecToe_r5_bs_0976-1009.indd 987 2/8/2012 2:40:01 PM

 988 Part II  Regional Flaps: Anatomy and Basic Techniques

The transmetatarsal ligament between the second and third toes is divided. The sec-
ond plantar digital nerve is identified proximal to the second MTP joint. The nerve and
adjacent second metatarsal artery are dissected into the second web space. Starting at the
level of the bifurcation, the second plantar digital nerve is split for 2 cm, at which point
the nerve branches to the lateral second toe are divided. Fibers to the medial aspect of the
third toe are left in continuity with the second plantar digital nerve. Arterial branches of
the second metatarsal artery to the second toe are divided, because this artery will not be
used to revascularize the second toe.

J K

Dissection of dominant Identification of dorsal digital nerve

vascular pedicle and first dorsal metatarsal artery

Fig. 9D-4 

Dominant pedicle: First dorsal metatarsal artery (D)

The extensor digitorum brevis tendon is divided at the MTP joint. A long extensor
tendon is dissected proximally to the level of the cuneiform bone to provide adequate length
for upper extremity repair.
The flexor digitorum longus and brevis tendons are identified through the plantar in-
cision and dissected proximally to the MTP joint. The interosseous muscles are separated
from their attachments to the distal second metatarsal bone.

09d_SecToe_r5_bs_0976-1009.indd 988 2/8/2012 2:40:01 PM

 Hand  •  9D: Second Toe Flap 989

L N

M n

Release of extensor digitorum longus and brevis tendons

O Q

Release of flexor digitorum longus and brevis tendons Division of flexor tendon

Fig. 9D-4 

Dominant pedicle: First dorsal metatarsal artery (D)

e, Extensor digitorum longus tendon; f, flexor digitorum longus tendon; n, dorsal digital nerve;
p, dorsalis pedis artery

09d_SecToe_r5_bs_0976-1009.indd 989 2/8/2012 2:40:02 PM

 990 Part II  Regional Flaps: Anatomy and Basic Techniques

If the MTP joint is to be included in the second toe transplant, a bone osteotomy is
performed in the distal second metatarsal shaft. If this joint is not required, the joint is dis-
articulated, with excision of the capsule and associated collateral ligaments and volar plate.
With the proximal bone divided, the previously identified FPMA may be dissected to its
junction with the deep plantar arch and communicating branch to the dorsalis pedis–first
dorsal metatarsal arterial system. Retraction or division of the head of the flexor hallucis
brevis muscle may be necessary for adequate visualization of the course of the plantar meta-
tarsal artery. If the FDMA is clearly the dominant pedicle to the second toe, the proximal
dissection of the FPMA is not required.

S U W

T V X

Osteotomy technique: Osteotomy technique: Osteotomy technique:

Metatarsal level MTP joint disarticulation Proximal phalangeal level

Fig. 9D-4  

With division of the second distal metatarsal bone, it is now possible to expose the
proximal tendon of the flexor digitorum longus and brevis to the second toe. These tendons
are divided after adequate tendon length is achieved for proximal repair in the hand after
second toe transplantation.
The tourniquet is now released, and circulation to the second toe and great toe is
observed. If the dominant pedicle to the second toe cannot be identified with certainty,
microclips are temporarily applied to the first dorsal and first plantar metatarsal arteries
consecutively to observe second toe circulation. The minor pedicle is ligated proximally or
is clipped, and a second arterial anastomosis is performed later, if required. After adequate
perfusion is established, the toe is ready for transplantation to the hand position. At this
point the second toe long extensor tendon and vascular pedicles are divided, and the second
toe is transferred to the operative field of the hand dissection.

09d_SecToe_r5_bs_0976-1009.indd 990 2/8/2012 2:40:04 PM

 Hand  •  9D: Second Toe Flap 991

Y Z

e
n2
n1
m
f

p
v
e D

Flap based on dorsal metatarsal artery Flap based on plantar metatarsal artery

e
v

n2

n1
f

Second toe composite flap with vascular dissection completed

Fig. 9D-4 

Dominant pedicle: First dorsal metatarsal artery (D)

Minor pedicle: First plantar metatarsal artery (m)
e, Extensor digitorum longus tendon; f, flexor digitorum longus tendon; n, deep peroneal
nerve; n1, plantar digital nerve; n2, dorsal digital nerve; p, dorsalis pedis artery; v, superficial
draining vein (saphenous system)

09d_SecToe_r5_bs_0976-1009.indd 991 2/8/2012 2:40:06 PM

 992 Part II  Regional Flaps: Anatomy and Basic Techniques

Short Transfer
The initial incision is performed circumferentially with small distally based dorsal and
plantar triangular flaps. The initial dissection begins on the lateral aspect of the first web
space and the medial aspect of the second web space. The dorsal and ulnar digital arteries
and nerves are identified. The superficial draining veins on the dorsum are preserved. The
toe is either divided at the midproximal phalanx or at the proximal interphalangeal joint.
The extensor digitorum brevis tendon is divided at the level of amputation. Proximal dis-
section of the long extensor tendon is performed, and the tendon is divided for an adequate
length to reach suitable extensor tendons in the hand. Similarly, the flexor digitorum brevis
tendon is divided short and the flexor digitorum longus tendon is dissected proximally to
gain a greater length. The tourniquet is released. After perfusion of the second toe is con-
firmed, the finger is ready for transplantation to the hand recipient site. Multiple digital
arterial and dorsal venous anastomoses will be performed with suitable receptor vessels in
the amputated or absent digit.

Dorsal digital
A artery and nerve

Plantar digital
artery and nerve

Short-transfer dissection

C D

Osteotomy technique: Osteotomy technique:

Proximal phalangeal level MTP joint disarticulation

Fig. 9D-5 

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 Hand  •  9D: Second Toe Flap 993

Joint Transplantation
The second MTP or proximal interphalangeal joint may be transplanted based on the dor-
sal metatarsal artery and associated venae comitantes and superficial draining veins. (The
vascularized second MTP joint is described in Section 14C.)
The dissection for the proximal interphalangeal joint is then performed as described
for a standard second toe transplant. However, a circumferential incision on the second toe
is not used. The dorsal web space incision is extended over the dorsum of the second toe.
The branch of the dorsal metatarsal artery to the second toe is dissected to the proximal
interphalangeal joint. Osteotomies are performed through the midproximal and middle
phalanges of the second toe. The long flexor and extensor tendons are retracted away from
the joint capsule, which is included in the transplant. Vascularized tendon and a dorsal skin
island may be included with the joint transplant, if necessary. Care is required to avoid disrup-
tion of the periosteal branch of the dorsal metatarsal artery to the proximal interphalangeal
joint capsule. The medial and lateral digital nerves are separated from the pedicle and are
not included in the joint transplant.

First dorsal metatarsal artery

Proximal interphalangeal joint dissection

Osteotomy technique: Proximal and middle phalangeal levels

Fig. 9D-6 

09d_SecToe_r5_bs_0976-1009.indd 993 2/8/2012 2:40:06 PM

 994 Part II  Regional Flaps: Anatomy and Basic Techniques

Double Transfer (Second and Third Toes)

A circumferential incision is made around both the second and third digits with a trian-
gular flap located on both the dorsal and plantar skin proximal to the first and third web
spaces. The technique is similar to the short transfer if the second toe alone is prepared for
transplantation. In the dissection of the dorsalis pedis artery, its branch to the dorsal arch
is identified and dissection proceeds laterally to expose the second dorsal metatarsal artery,
which is preserved. If the first and second dorsal metatarsal arteries are inadequate or ab-
sent, the first and second plantar metatarsal arteries are dissected to the deep plantar arch.
The arch will then be used as the donor artery for the paired digital transplantation. The
extensor and flexor tendons for both second and third toes are identified and included with
the transplanted double digits.

A B

d
d
n1 h
d
n2

v
p
n2 n2

Double-transfer dissection

Fig. 9D-7 

b, First dorsal metatarsal artery branch to great toe; d, plantar digital artery;
e, extensor digitorum longus tendon; f, flexor digitorum longus tendon; h, extensor
hallucis brevis; n1, deep peroneal nerve; n2, plantar digital nerve; p, dorsalis pedis
artery; v, superficial draining vein (saphenous system)

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 Hand  •  9D: Second Toe Flap 995

C E

D F

Osteotomy technique: Metatarsal level Osteotomy technique: MTP joint disarticulation

Fig. 9D-7 

The dorsal metatarsal artery is dissected proximally to the deep connecting branch to the
deep plantar arch. This branch is divided and the proximal pedicle, which is now the dorsalis
pedis artery, is dissected over the cuneiform bone. Further length is achieved by dividing
the cruciform ligament, under which the artery courses from the distal leg. The extent of
pedicle length is determined during preparation of the hand for the toe transplant. For this
reason the dominant pedicle is not divided until a satisfactory receptor vessel is identified.

FLAP VARIANTS
•  Segmental transposition
•  Vascularized bone
•  Sensory flap

Segmental Transposition
A portion of the web space or plantar aspect of the foot may be elevated as a neurosensory
flap.

Vascularized Bone
Both the interphalangeal joint and the second metacarpophalangeal joint receive vascular
communications from the FDMA and the second dorsal digital artery. Either the inner
phalangeal joint or the second MTP joint may be elevated as vascularized bone with or
without overlying dorsal skin.

Sensory Flap
The web space between the great and second toe may be elevated as a neurosensory flap
based on the FDMA and associated venae comitantes and branches of the superficial and
deep peroneal nerves.

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 996 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Standard Flap
Plantar skin may be elevated on the plantar surface of the second toe based on the second
plantar metatarsal artery. This skin has a wide arc of rotation to cover defects on the plantar
surface of the foot. The web space between the first and second toes may be elevated based
on the FDMA as a neurosensory flap. If this flap is elevated to the dorsalis pedis artery and
vein, it has a wide arc of rotation for coverage of defects on both the plantar and dorsal
surfaces of the foot. Use of this tissue necessitates amputation of the digit or skin grafting
of the resultant web space defect.

A C

Standard arc to plantar First web space flap arc to

surface of foot lateral foot and ankle

Extended arc to heel

Fig. 9D-8 

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 Hand  •  9D: Second Toe Flap 997

FLAP TRANSFER
The flap can be tunneled beneath a skin bridge if the tunnel is wide enough. Otherwise, it
is preferable to incise the intervening skin bridge and skin graft the pedicle.

FLAP INSET
Second Toe to Thumb
Bone
The distal metatarsal or proximal phalanx of the second toe is fixed to the corresponding
recipient site either for thumb or lateral digital reconstruction. Osteosynthesis is accom-
plished using interosseous monofilament wire loops, longitudinal Kirschner wire, paired
oblique Kirschner wires, bone peg, or a combination of the above. The advantage with the
longitudinal Kirschner wire is pinning the proximal interphalangeal joint in full extension
and avoiding hyperextension in the MTP joint. This will reduce the potential for excessive
proximal interphalangeal joint flexion. If oblique Kirschner wires are used, a capsulodesis
of the plantar plate may avoid hyperextension of the MTP joint.

Osteotomy technique: Metatarsal level

B C

Osteosynthesis with longitudinal Kirschner wire and interosseous wire

Fig. 9D-9 

09d_SecToe_r5_bs_0976-1009.indd 997 2/8/2012 2:40:09 PM

 998 Part II  Regional Flaps: Anatomy and Basic Techniques

Osteotomy technique: MTP joint disarticulation

E F

Osteosynthesis with oblique Kirschner wire with capsulodesis

Fig. 9D-9 

Nerve Repair
Medial and lateral dorsal sensory nerves are repaired with dorsal terminal branches of the
radial nerve. The medial and lateral plantar sensory nerves are repaired with a digital nerve
to the transplanted thumb or finger. If these recipient nerves are unavailable, other recipient
sensory nerves include the radial nerve, palmar cutaneous branch of the median nerve, and
dorsal sensory branch of the ulnar nerve.

A B

Neurorrhaphy: Dorsal digital sensory to Neurorrhaphy: Plantar digital sensory to

radial sensory nerve median digital nerve

Fig. 9D-10 

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 Hand  •  9D: Second Toe Flap 999

Vascular Repair
Arterial anastomosis is performed between the FDMA or dorsalis pedis artery and a radial
artery or princeps pollicis branch. A venous anastomosis is performed between the super-
ficial draining vein and the cephalic or appropriate superficial dorsal veins in proximity to
the toe transplant.

A B

Dorsal metatarsal–dorsalis pedis artery end-to-end Plantar metatarsal artery end-to-side

anastomosis to radial artery or princeps pollicis branch to superficial arch anastomosis and dorsal vein
and dorsal vein end-to-end to superficial vein end-to-end to superficial vein

Fig. 9D-11 

Tendon Repair
In toe to thumb transplants the long flexor tendon is approximated to the flexor pollicis
longus or alternate flexor tendon if the flexor pollicis longus is unavailable or absent.
In toe to ulnar digit transplants the long flexor tendon is repaired to the profundus ten-
don of the missing digit or alternate flexor tendon as required. The long extensor tendon is
repaired to the extensor pollicis longus of the hand or, if that is unavailable, to the extensor
indicis proprius. For transplants to ulnar digit sites, the extensor tendon is used as a recipient
tendon. Tension is adjusted to allow thumb or finger extension with passive wrist flexion
and moderate flexion with passive wrist extension.

A B

Tenorrhaphy: Extensor hallucis longus to Tenorrhaphy: Flexor hallucis longus to

extensor pollicis longus tendon flexor pollicis longus tendon

Fig. 9D-12 

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 1000 Part II  Regional Flaps: Anatomy and Basic Techniques

Closure
The skin is closed using the dorsal and volar triangular flaps interposed with skin flaps on
the recipient hand. Skin grafts may be required to complete closure, particularly on the
lateral and medial aspects of the transplanted toe.

Second and Third Toe Transplants (Double Digit)

The flap inset sequence is identical to the single digit, except that the receptor tendons and
nerves for both digits must be located.

DONOR SITE CLOSURE

The distal head and shaft of the second metatarsal bone are resected if not transplanted with
the toe. The stump of the transmetatarsal ligament of the great toe and medial third toe are
approximated with sutures. The skin is closed directly. In a double-digit transplantation,
the transmetatarsal ligaments are not approximated. Soft tissue and skin are closed directly.
In web space flaps, skin grafting is necessary to close the donor site.

A B C

Second toe Second toe Double-transfer

donor site defect closure technique closure technique

Fig. 9D-13 

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 Hand  •  9D: Second Toe Flap 1001

CLINICAL APPLICATIONS
This patient’s thumb was amputated at the base of the proximal phalanx. Reconstruction
with a second toe transfer was planned.

A B

C D

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 trans-
fer. (Case courtesy Fu-Chan Wei, MD.)

09d_SecToe_r5_bs_0976-1009.indd 1001 2/8/2012 2:40:14 PM

 1002 Part II  Regional Flaps: Anatomy and Basic Techniques

In this patient, multiple fingers were amputated, and two second toe transplantations were
planned for the index and middle finger.

A B

C D

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. (Case
courtesy Fu-Chan Wei, MD.)

09d_SecToe_r5_bs_0976-1009.indd 1002 2/8/2012 2:40:16 PM

 Hand  •  9D: Second Toe Flap 1003

This patient’s distal index finger was amputated. It was reconstructed with a distal second toe.

A B

C D E

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. (Case courtesy Fu-Chan Wei, MD.)

09d_SecToe_r5_bs_0976-1009.indd 1003 2/8/2012 2:40:21 PM

 1004 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The variability of the FDMA must be considered in planning the flap.
• Identification of both dorsal and plantar metatarsal arteries is recommended during flap
elevation. The two pedicles may be temporarily occluded in sequence to ascertain the
dominant pedicle. In general, the dorsal system is preferred because of the location of the
radial artery on the dorsal radial aspect of the hand.
• Use of a tourniquet during flap elevation is recommended. Before division of the vascular
pedicle to the second toe, the tourniquet is released and the flap observed for 15 to 20
minutes to ensure that circulation is adequate.
• Length and positioning of the second toe are critical to function and appearance, par-
ticularly in thumb reconstruction. The average thumb length extends to the proximal
interphalangeal joint of the index finger. Exact length measurements can be obtained
from the contralateral thumb. The second toe is rotated for pulp contact with the index
and little fingers on thumb abduction and opposition before osteosynthesis. In lateral
digital reconstruction the rotational deformities are avoided at the time of osteosynthesis
by appropriate alignment of the nail bed in comparison to adjacent digits.
• In a child, the proximal phalangeal epiphyses are preserved to ensure finger growth.
• For second toe to thumb transplantation, alternative recipient structures in the hand in-
clude the following: (1) use of the extensor indicis proprius if the extensor pollicis longus
is unavailable, (2) use of the long or ring finger sublimis if the flexor pollicis longus is
unavailable, and (3) use of the ulnar digital nerve of the long or ring finger if the volar
digital nerves are unavailable.
• Repair of sensory nerve should be accomplished if possible before second toe revascular-
ization. This allows optimal visualization of the nerve ends in a bloodless field.
• Appropriate balance between the extensor and flexor tendon repair is important. Initial
repair of the extensor tendon is accomplished to allow thumb extension with 90-degree
wrist flexion. The subsequent flexor pollicis longus tendon repair is adjusted to provide
mild second toe interphalangeal and MTP flexion with passive wrist extension.

Expert Commentary
Fu-Chan Wei

Indications
The toes are structurally analogous to the thumbs and fingers, and they are the best au-
tologous “spare parts” for thumb and finger reconstruction. Toe-to-hand transplantation is
indicated for thumb reconstruction to restore prehension. Such a transfer is also indicated for
finger reconstruction to restore pinch or grip. Both thumb and finger reconstruction aim
to sacrifice a toe in exchange for an increase in the functionality of the hand. However, in
select patients, partial toe-to-hand transplantation may be desired for fingertip reconstruc-
tion. Although such reconstruction restores more form than function, it can still be very
beneficial to patients, especially in cultures (such as Asian) where missing a visible body
part carries a negative connotation.

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 Hand  •  9D: Second Toe Flap 1005

Advantages and Limitations

The second toe flap has less associated donor site morbidity than the great toe flap. When
designed properly, the donor site of the second toe flap can usually be closed primarily, with
an inconspicuous scar hidden within the web space. The resulting scar is also designed to
lie on the non-weight-bearing area of the plantar foot to prevent the problem of tender scar
in the weight-bearing area. In addition, because the great toe is largely responsible for the
push-off phase of gait, sacrificing the second toe instead of the great toe ensures minimal
disruption to the gait function.
Despite its many advantages over the great toe flap, the second toe flap does have its
disadvantages. Using the second toe for thumb reconstruction will result in a less natural-
appearing construct because of its smaller size and claw appearance. However, sometimes
using the great toe for thumb reconstruction will result in a construct that appears too
large. For the most natural-appearing thumb reconstruction, the trimmed great toe offers
the best size match. Moreover, the second toe flap is limited to reconstruction of up to two
digits, even if both second toes are harvested. For reconstruction of the metacarpal hand
with finger amputation proximal to the web space, it becomes necessary to use a combined
second and third, or third and fourth, toe flap.

Anatomic Considerations
As mentioned in the chapter, either the FDMA or the DPMA may be the dominant pedicle
for the second toe flap. Its regional anatomy and variation may be confusing and challenging
for surgeons unfamiliar with the flap. To avoid this problem, the technique of retrograde
dissection is recommended.

Recommendations
Technique
Dissection of the vascular pedicle begins at the web space. The proper digital artery at the
tibial side is identified and traced proximally to the region of the transmetatarsal ligament.
At this location, the FDMA is located dorsal and the FPMA plantar to the transmetatarsal
ligament. With this technique of retrograde dissection of the pedicle, no preoperative
angiography is necessary.

Personal Experience and Insights

If the FPMA is the dominant pedicle, rather than perform extensive dissection through
the interosseous muscles in the plantar foot to obtain more pedicle length, sometimes it
is preferable to use a vein graft. Attempts to dissect extensively through the interosseous
muscles may cause significant donor site morbidity.
For digit reconstruction, the triangular flap at the base of the harvested second toe should
be carefully thinned and defatted to achieve a more aesthetic appearance and contour after
the transfer. Excessive flap thickness will create a sharp transition at the junction of the hand
and the transferred toe, making the transferred toe appear “stuck on.”
Reconstruction of a distal finger amputation (distal to the insertion of the flexor
digitorum sublimus) with a second toe or another lesser toe is most rewarding for both
function and cosmesis. It does not require complicated postoperative rehabilitation, and
sensory recovery is fast. For fingertip reconstruction, the precise length of the second toe
required for the reconstruction should be determined before surgery, so that the level of
the second toe osteotomy can be planned and performed in one attempt. Once the distal
Continued

09d_SecToe_r5_bs_0976-1009.indd 1005 2/8/2012 2:40:21 PM

 1006 Part II  Regional Flaps: Anatomy and Basic Techniques

portion of the second toe has been detached from the foot, performing an additional os-
teotomy to shorten the bone becomes more technically challenging and dangerous, with
a risk of injuring the vascular pedicle. The contralateral digit serves as a good guide when
determining the required toe length for fingertip reconstruction.

Complications: Avoidance and Treatment

Vasospasm can be problematic. Every measure should be taken to prevent or minimize the
risk of vasospasm, such as adequate patient hydration, adequate postoperative pain control,
use of a regional block, and sympathectomy by skeletonization of the vascular pedicle.

Take-Away Messages
For the best thumb reconstruction, the second toe should not be proposed as the first choice.
However, when it is used, the length of the reconstructed thumb and the amount of pulp
rotation required to achieve good opposition should be precisely decided, or should be
slightly shorter rather than longer.
When raising the flap, a retrograde dissection technique should be used to clearly
delineate the dominant vascular pedicle and save the minor vascular pedicle as the spare
(“lifeboat”) vessel. The vascular pedicle should be gently skeletonized. This not only mini-
mizes the chance of the vascular pedicle kinking or getting caught in the subcutaneous
tunnel, but also provides the sympathectomy effect to minimize vasospasm. Furthermore,
attention should be paid in designing the incision on the plantar foot to avoid placing a scar
on the weight-bearing surfaces of the plantar foot.

Bibliography With Key Annotations

Galpern DW, Tsai TM. Multiple toe transfer and sensory free flap use after a traumatic amputa-
tion of multiple digits. Surgery done in a single setting: a case study. Microsurgery 31:484-489,
2011,
The difficulties of treating crush avulsion hand injuries with amputation of multiple digits are well
known. The authors presented an alternative to the two-stage replantation procedure. In a single-stage
operation, they transplanted the second and third toes of the left foot, a sensory free flap from the left
great toe, and a microvascular free transfer from the fourth toe to the left hand to treat a patient with a
left-hand skin avulsion of the whole palm and P1 of the index, long, ring, and small fingers. The left
index finger had a complete amputation at the P2 level, and the long, ring, and small fingers all had
complete amputations at the P1 level. A 10 by 14 cm reversed radial forearm flap and a combination
of full- and split-thickness skin grafts were used to treat the rest of the defect. The authors reported
that the outcome was optimal and recommended this procedure in the emergency setting.
Jaminet P, Pfau M, Greulich M. Reconstruction of the second metacarpal bone with a free
vascularized scapular bone flap combined with nonvascularized free osteocartilaginous grafts
from both second toes: a case report. Microsurgery 31:146-149, 2011.
Ju J, Liu Y, Wei C, et al. [Reconstruction of metacarpophalangeal joint defect by the second
toe proximal interphalangeal joint with skin flaps] Zhongguo Xiu Fu Chong Jian Wai Ke Za
Zhi 23:426-429, 2009.
The authors treated 26 patients with metacarpophalangeal joint defects (22 had skin and soft tissue
components) by transplanting the toe proximal interphalangeal joint with skin flaps. Twenty-three
patients had mechanical injury (time from injury to operation 1 to 6 hours) and 3 had secondary
injury caused by trauma (time from injury to operation 3 to 12 months). The size of the joint defects
ranged from 2 by 1 cm to 4 by 2 cm. Twenty-one donor site toe amputations and 5 joint fusions

09d_SecToe_r5_bs_0976-1009.indd 1006 2/8/2012 2:40:21 PM

 Hand  •  9D: Second Toe Flap 1007

were performed. All transplanted joints and skin flaps survived, with union occurring 6 to 12 weeks
postoperatively. Flexion in the joints ranged from 30 to 75 degrees (average 45 degrees). Based on
the total active movement/total passive movement assessment criteria, 8 fingers were excellent, 13
good, 3 fair, 2 poor. Walking was not affected. The authors concluded that transferring the second toe
proximal interphalangeal joint with skin flaps to reconstruct the metacarpophalangeal joint provides
good functional recovery.
Ju J, Zhao Q, Liu Y, et al. [Repair of whole-hand destructive injury and hand degloving injury
with transplant of pedis compound free flap] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi
23:1153-1156, 2009.
The authors treated 21 patients (44 fingers) with whole-hand destructive injuries or hand-degloving
injuries by transferring pedis compound free flaps. Eleven patients had whole-hand skin-degloving
injuries, and 10 had proximal palm injuries with dorsal or palmar skin and soft tissue defects. The
defect was repaired by the thumbnail flap of dorsalis pedis flap and the second toenail flap of dorsalis
pedis flap in 5 cases, the thumbnail flap of dorsalis pedis flap and the second toe with dorsalis pedis
flap in 4 cases, and bilateral second toe with dorsalis pedis flap in 12 cases. Distal interphalangeal
joint toe amputation was conducted in the thumbnail flap donor site, metatarsophalangeal joint toe
amputation was performed in the second toenail flap donor site, and full-thickness skin grafting was
conducted in the abdomen. Forty-three reconstructed fingers survived, and one index finger repaired
by the second toenail flap was amputated. All wounds healed by first intention. The palmar and
dorsal wounds showed no apparent swelling. The appearance of the fingers was satisfactory. Walking
was apparently not affected. The authors concluded that this method is effective for recovering partial
sensation and hand function after whole-hand or hand-degloving injuries.
Kimura N. Versatility of a second toe plantar flap. J Reconstr Microsurg 25:47-53, 2009.
The second toe plantar flap is a small neurocutaneous flap used to reconstruct fingertip defects. Twenty-
seven reconstructions using this flap are reported in this article. Two types of flap are discussed. In
the first type, the second toe plantar flap is combined with an onychocutaneous flap (12 cases). In the
second type, the flap is transferred to distal digital defects or secondary defects of the palmar side of the
digits after contracture release (15 cases). The authors concluded that this flap provides nearly accept-
able functional and aesthetic results with minimal donor site morbidity and is appropriate for distal
palmar defects and skin defects of the digits. Arterial insufficiency of the pedicle must be considered as
a possible complication when planning this flap. Advantages and pitfalls were discussed.
Lee DC, Kim JS, Ki SH, et al. Partial second toe pulp free flap for fingertip reconstruction.
Plast Reconstr Surg 121:899-907, 2008.
Over the course of approximately 6 years, 929 partial second toe pulp free flaps were performed in
854 patients to preserve digital length, cover exposed bone, and replace skin over unstable fingertip
scars. The two-point discrimination test was used to assess progress in 156 patients at 1 year or more
postoperatively. The overall survival rate of the flap was 99.7%. Fifty-seven patients had two fingertip
defects covered with bilateral second toe pulp flaps, and 9 had three defects covered with bilateral second
toe pulp flaps and a third-toe pulp flap. Donor site complications occurred in 59 cases: 39 hematomas
and 20 wound separations. No gait disturbance or pain at the donor site was observed. Static two-
point discrimination averaged 8 mm (range 4 to 15 mm). Additional surgical procedures were required
in 264 patients: 154 skin grafts at the recipient site and 110 flap revisions. This procedure has the
benefits of shorter surgical time and less morbidity because of the shorter pedicle and smaller flap. In
addition, similar pulp tissue is transferred from donor site to the finger. It is the authors’ first choice
for covering fingertip wounds.
Neumeister MW, Brown RE. Mutilating hand injuries: principles and management. Hand
Clin 19:1-15, 2003.
The objectives of treating mutilating hand injuries are to ensure the patient’s survival, limb survival,
and ultimately limb function. Sound, safe principles must be followed. After patients are stabilized and
cleared of other potentially life-threatening trauma, the mangled hand is irrigated and debrided—the

09d_SecToe_r5_bs_0976-1009.indd 1007 2/8/2012 2:40:21 PM

 1008 Part II  Regional Flaps: Anatomy and Basic Techniques

cornerstone of early treatment. The initial surgery includes skeletal stabilization, revascularization,
and replantation or the transfer of spare parts to restore functions. Soft tissue is best replaced with
regional flaps and free tissue transfers. Second- or third-look surgeries may be required. Tenolysis,
joint mobilization, or toe transfers may be performed at a second procedure to restore dexterity and
function to the healed hand.
Rui Y, Mi J, Shi H, et al. Free great toe wrap-around flap combined with second toe medial
flap for reconstruction of completely degloved fingers. Microsurgery 30:449-456, 2010.
The authors presented 7 cases (10 fingers) of completely degloved fingers treated with a combined
great toe wrap-around flap and second toe medial flap free transfer, revascularized with nerve repair.
The great toe wrap-around flap with dorsalis pedis skin covered the dorsal and palmarmost side of
the finger, and the second toe medial flap covered the proximal palmar portion of the finger. Follow-
up ranged from 34 to 76 months. Rehabilitation started 2 weeks postoperatively. All fingers had a
satisfactory appearance. All flaps survived except one, which had distal phalangeal necrosis. Primary
wound healing occurred in 9 of 10 recipient areas and in all skin grafted donor sites (one had delayed
healing). There was no pain or swelling at the donor sites. Range of active motion was 60 to 80
degrees in the MCP joint and 40 to 70 degrees in the PIP joint. Two-point discrimination was 8
to 12 mm. All patients walked with no interference. The authors recommended this procedure for
patients with degloving finger injuries with intact phalanges and tendons.
Tsai TM, D’Agostino L, Fang YS, et al. Compound flap from the great toe and vascularized
joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal
metacarpal bone. Microsurgery 29:178-183, 2009.
The authors described the harvesting technique, anatomic variations, and clinical applications of a
compound flap from the great toe and vascularized joint from the second toe for thumb reconstruction.
Anatomic variations were studied in five fresh cadavers. The first plantar metatarsal artery had a larger
caliber in 40% of dissections, the first dorsal metatarsal artery was larger in 40%, and they had the
same caliber in 20%. The Gilbert classification of first dorsal metatarsal artery was 40% class I and
60% class III. In addition, this flap was performed on five patients with traumatic thumb amputation
at the level of the proximal metacarpal bone. Follow-up ranged from 11 to 24 months. Four patients
had good functional opposition and motion of transferred joints, with good pinch and grip strength.
There was one flap failure, and donor site morbidity was minimal. The authors concluded that this
compound flap has several advantages. It provides two functional joints, is useful for thumbs amputated
at the carpometacarpal joint level, and preserves growth potential in children by transferring vascular-
ized epiphyses. Disadvantages include a technically challenging harvest and longer operative time.
Zhang J, Xie Z, Lei Y, et al. Free second toe one-stage-plasty and transfer for thumb or finger
reconstruction. Microsurgery 28:25-31, 2008.
Though the free second toe transfer is a popular procedure for reconstructing thumb and finger defects,
the result is unattractive. To correct this problem in the thumb, the authors inlaid a composite tissue
strip flap from the fibula of the great toe (with the fibular proper plantar digital artery as the pedicle),
combined in some cases with the island dorsal index finger flap, with the second toe before the re-
construction. To reconstruct the fingers, they transferred a crescent double-winged dorsal metatarsal
flap, connected with the second toe and combined with the partial metatarsal bone. The study group
comprised 36 patients, and follow-up ranged from 6 months to 3 years. The appearance of the thumb
and fingers was improved, with normal caliber and length. The authors considered this an ideal method
for reconstructing the thumb and fingers.
Zhao J, Tien HY, Abdullah S, et al. Aesthetic refinements in second toe-to-thumb transfer
surgery. Plast Reconstr Surg 126:2052-2059, 2010.
The second toe is often used as an alternative to the great toe for thumb reconstruction, because function
is good and donor site morbidity is reduced; however, cosmesis is poor. This article described a modified
second toe transfer performed in six patients. To correct the narrow neck of the transferred second toe,
the authors harvested a flap from the adjacent side of the great toe and inset it into the volar aspect of

09d_SecToe_r5_bs_0976-1009.indd 1008 2/8/2012 2:40:21 PM

 Hand  •  9D: Second Toe Flap 1009

the toe to provide bulk. To reduce the bulbous tip, they made skin excisions on each side of the tip. To
make the nail appear longer, they excised the eponychium. Follow-up ranged from 6 to 36 months.
All patients had good function and cosmesis. Part of the great toe flap was lost in one case. The mean
two-point discrimination in the transferred toes was 10.1 mm, with protective sensation present in the
flaps. The range of motion of the transferred toe was 14 to 38 degrees at the MCP joint, 16 to 55
degrees at the PIP joints, and 20 to 36 degrees in the DIP joints. The authors concluded that these
techniques effectively reduce donor site morbidity and improve cosmesis in patients who have second
toe-to-thumb transfer surgery.

09d_SecToe_r5_bs_0976-1009.indd 1009 2/8/2012 2:40:21 PM

 ANATOMIC LANDMARKS
Landmarks Dorsal skin of the fingers over the proximal phalanx (FDMA/
kite), and the dorsal skin of the hand overlying the metacarpals
(DMA/Quaba).
Size 3 3 5 cm (FDMA/kite); 3 3 8 cm (DMA/Quaba).
Composition Fasciocutaneous.
Flap Type Type A.
Dominant Pedicle Dorsal metacarpal artery (DMA).
Minor Pedicle Cutaneous perforators of the DMA.
Nerve Supply Dorsal sensory branches of radial and ulnar nerves.

09e_DorsMeta_r5b_bs_1010-1045.indd 1010 2/6/2012 9:24:35 AM

 Section 9E
Hand

Dorsal Metacarpal Artery Flap

CLINICAL APPLICATIONS
Regional Use
Hand
Thumb
Digits
Specialized Use
Microvascular transplantation

Contributions to this chapter by Michel Saint-Cyr, MD,

and Guenter Germann, MD, PhD.

09e_DorsMeta_r5b_bs_1010-1045.indd 1011 2/6/2012 9:24:38 AM

 ANATOMY OF THE Dorsal Metacarpal Artery Flap

First dorsal
metacarpal
artery

First dorsal
metacarpal
artery

Second
dorsal
metacarpal
artery

Dorsal
sensory
branches
of radial
nerve
Arterial supply
Superficial
branch
Radial artery of radial
nerve

Sensory innervation

Fig. 9E-1 

Dominant pedicle: Dorsal metacarpal artery

Minor pedicle: Cutaneous perforators of dorsal metacarpal artery

09e_DorsMeta_r5b_bs_1010-1045.indd 1012 2/6/2012 9:24:39 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1013

ANATOMY
Landmarks Dorsal skin of the fingers over the proximal phalanx between the midlateral
lines and the dorsal intermetacarpal skin of the hand.
Composition Fasciocutaneous.
Size 3 3 5 cm (FDMA/kite); 3 3 8 cm (DMA/Quaba).

Arterial Anatomy (Type III)

Dominant Pedicle  Dorsal metacarpal artery
Regional Source  Dorsal carpal arch.
Length  3 to 5 cm.
Diameter  0.5 to 1 mm.
Location  The dorsal carpal arch is formed from dorsal carpal arteries arising from the ulnar
and radial arteries. The vessels anastomose across the dorsum of the distal carpal row to form a
vascular arcade that gives rise to four dorsal metacarpal arteries. Each metacarpal vessel courses
distally over the dorsal interosseous muscle bellies to supply the skin and subcutaneous tissues
covering the dorsum of each finger and its adjacent dorsal web space. The first dorsal metacarpal
artery (FDMA) tends to be a discrete terminal branch of the radial artery rather than arising
directly from the dorsal carpal arch. The fifth dorsal metacarpal artery may also arise as a ter-
minal branch of the ulnar artery.
From its origin, each vessel courses distally toward the web space and communicates through
the interosseous space with the deep palmar arch. Proximal to the web space, each of the second,
third, and fourth dorsal metacarpal arteries divides into two dorsal digital branches, one to each
adjacent side of the index, middle, ring, and little fingers. The FDMA supplies the dorsum of
the thumb and radial side of the index finger, and the fifth dorsal metatarsal artery supplies the
ulnar side of the little finger. Traveling distally along each side of the finger, the vessels divide
into terminal branches midway along the proximal phalanx. The vessels supply the dorsal skin of
the finger as far as the proximal interphalangeal (PIP) joint. Distally, the dorsal skin is supplied
by branches of the palmar digital arteries.
Minor Pedicle  Cutaneous perforators of the dorsal metacarpal artery
Regional Source  Dorsal metacarpal artery.
Location  The cutaneous perforators along the DMA are found within the proximal, middle,
and distal thirds. The perforator that forms the basis of the DMA perforator flap is found 1 cm
proximal to the metacarpal head, just distal to the junctura tendinum.

Venous Anatomy
There are two venae comitantes of 0.2 mm and 0.3 mm in diameter that follow each DMA and
provide venous drainage for the reverse dorsal metacarpal artery flap. The venous valvae develop
incompetently and will dilate after the reverse dorsal metacarpal artery is elevated and harvested.
There are also communications found between both venae comitantes; this improves venous drain-
age of the flap. A rich venous network exists in the connective tissues surrounding the cutaneous
perforator distally. The subcutaneous tissue and connective tissue harbor a venous network that
can provide adequate venous return for a perforator-based DMA flap.

Nerve Supply
Sensory The DMA flap, or Quaba flap if a cutaneous perforator is used, can be harvested
with a dorsal sensory branch of either the radial nerve or ulnar nerve to create
a sensate flap.

09e_DorsMeta_r5b_bs_1010-1045.indd 1013 2/6/2012 9:24:39 AM

 1014 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Dorsal M etacarpal A rtery Flap

A B

Deep surface of flap Closeup view of flap base

C D

D n
n
D
v n
v n

Cutaneous surface of flap Radiographic view

Fig. 9E-2 

Dominant pedicle: Dorsal metacarpal artery (D)

n, Digital nerve; v, superficial dorsal vein

09e_DorsMeta_r5b_bs_1010-1045.indd 1014 2/6/2012 9:24:39 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1015

FLAP HARVEST
Design and Markings
The flaps included in this chapter, the first dorsal metacarpal artery (FDMA) or “kite”
flap, the reverse dorsal metacarpal artery (DMA) flap, and the reverse dorsal metacarpal
artery perforator (Quaba) flap, are loosely referred to as DMA flaps, so it is important to be
specific as to which variation based on the first dorsal metacarpal artery one is referring to.
Rather than list any one as a variation, for this chapter we will simply list and refer to each
flap, leaving it to each surgeon to determine which is to be considered the primary flap.
The FDMA (kite) flap design runs from the metacarpophalangeal (MCP) joint of the
index finger proximally to the proximal interphalangeal (PIP) joint of the index finger
distally, the radial and ulnar borders being the midlateral lines on either side of the digits.
(Fig. 9E-3, A). The DMA and Quaba flaps have similar elliptical skin designs, with the
longitudinal axis centered on the intermetacarpal space, spanning the level of the metacarpal
heads to the distal wrist. The ulnar and radial borders of the skin paddle are determined by
a pinch test and by the ability to close the donor site primarily (Fig. 9E-3, B). A handheld
pencil Doppler probe can be used to identify the dorsal metacarpal artery, as well as the
cutaneous perforator emanating from the DMA in between the metacarpal heads, which
corresponds to the pivot point for both the DMA and Quaba flaps. The pivotal point of the
flap is approximately 1.5 cm proximal to the leading edge of the web space.

A B

Pivot
point

FDMA/kite flap design DMA/Quaba flap design

Fig. 9E-3 

Patient Positioning
The patient is placed in the supine position with the upper extremity abducted and placed
on the hand table.

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 1016 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

First Dorsal Metacarpal Artery (FDMA)
or Kite Flap
Dissection always starts at the dorsum of the hand, incising the proximal portion of the flap
and including one of the large subcutaneous veins. Leaving as much soft tissue envelope
around the pedicle is recommended to avoid venous congestion. For a kite flap, one does
not need to identify the pedicle. It is visualized through the thin layer of epimysium, and
one can take the entire width of the visible surface of the epimysium to secure the pedicle.
Dissection of the epimysium starts at the second metacarpal and is carried radially from
there. After the pedicle is secured, the distal part of the skin island is incised and the flap is
raised in the tissue plane above the paratenon, which has to be kept intact for perfect take
of the full-thickness graft.

FDMA/kite flap

Fig. 9E-4 

09e_DorsMeta_r5b_bs_1010-1045.indd 1016 2/6/2012 9:24:41 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1017

Flap designed over index proximal phalanx

and MCP joint

C D

Flap elevation and transfer to Neurovascular pedicle showing perivascular

dorsal thumb defect soft tissue cuff

Flap is inset into dorsal defect and donor site

is covered with a full-thickness skin graft

Fig. 9E-4  (B through E from Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louis-
ville, KY.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1017 2/6/2012 9:24:42 AM

 1018 Part II  Regional Flaps: Anatomy and Basic Techniques

Reverse Dorsal Metacarpal Artery (DMA) Flap

For harvest of a reverse DMA flap, flap dissection starts from proximal to distal. A No. 15
blade is used to make an incision on either the ulnar or radial aspect of the proximal portion
of the flap markings. Dissection is carried down through skin and subcutaneous tissue just
above the paratenon of the extensor apparatus. The axis of the flap is in the midline between
adjacent metacarpals, and the dissection plane of the skin paddle is located underneath the
epimysium of the interosseous muscle. The DMA in the intermetacarpal space is ligated
proximally and kept attached to the overlying skin paddle. The epimysium overlying the
interosseous muscles is elevated with the flap to ensure protection of the DMA. The DMA
itself often lies within or below the interosseous fascia; therefore harvesting the epimysium
with the flap protects the pedicle. Dissection is continued from proximal to distal until the
junctura tendinum is reached. The point proximal to the junctura tendinum can deter-
mine the pivot point if the arc of rotation is insufficient, and the junctura tendinum can
be transected; then dissection can continue up to the communicating branch between the
DMA and the palmar metacarpal artery. The pedicle should be surrounded by the portion
of subcutaneous tissue and a superficial vein that can be included within the flap to pre-
serve and potentially improve venous drainage, if required, with the addition of a venous
anastomosis, as needed.

Pivot
point

Reverse DMA flap

Fig. 9E-5 

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 Hand  •  9E: Dorsal Metacarpal Artery Flap 1019

Reverse Metacarpal Artery Perforator Flap

(Quaba Flap)
Quaba and Davison first described this flap in 1990. Their work followed that of Earley and
Milner, who published their results in 1987. The term perforator flap was unknown at this
time. Quaba designed a flap based on a perforating vessel in the web space that arborizes
in the subdermal plexus of the dorsal skin.
The Quaba flap is a perforator version of the first dorsal metacarpal artery flap. This
flap is an orthograde flow flap with a blood supply based on cutaneous perforators derived
from the distal portion of the DMA. Four to eight perforators originate along the proximal,
middle, and distal thirds of the DMA. A dominant cutaneous perforator lies 1 to 1.5 cm
proximal to the midinterior metacarpal head region and corresponds to the pivot point of
the DMA perforator flap. This flap was described by Quaba and is a perforator flap version
of the DMA flap. This flap does not include the main trunk of the DMA, and its vascular
supply is based solely on the cutaneous perforator emanating either directly from the DMA
or from the communicating branch between the DMA and the palmar metacarpal artery.
The perforator can be found just distal to the junctura tendinum, which allows it to have
a longer arc of rotation because of its more distal placement.

Fig. 9E-6   A, CT angiogram showing the dorsal metacarpal arteries and their multiple interconnec-
tions 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.

09e_DorsMeta_r5b_bs_1010-1045.indd 1019 2/6/2012 9:24:43 AM

 1020 Part II  Regional Flaps: Anatomy and Basic Techniques

C D

Dorsal
Dorsal
metacarpal
metacarpal
artery Perforating branch
artery

Common palmar digital artery Palmar metacarpal artery Common palmar digital artery Palmar metacarpal artery
Arterial supply to Quaba flap Arterial supply to extended Quaba flap

Dorsal metacarpal artery

Perforator from
communicating
branch of common Second dorsal
digital artery metacarpal artery
Dorsal metacarpal
E artery perforators

Communicating
branch of common
digital artery

Common
digital artery

Proper
digital arteries

Dorsal metacarpal artery perforators Skin paddle

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 interconnec-
tion of the volar and dorsal arterial systems providing the basis for a retrograde flap.

09e_DorsMeta_r5b_bs_1010-1045.indd 1020 2/6/2012 9:24:46 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1021

Flap dissection is essentially identical to the harvest of the DMA, except that the plane
of dissection initially is between the subcutaneous tissue of the flap and the paratenon. At
no point is the epimysium of the interosseous muscles violated. The flap is elevated from
proximal to distal until the junctura tendinum is reached.

Distal avulsion injuries to tips of long and

ring fingers
H

Design and elevation of Quaba flaps

Fig. 9E-6 

The flap’s cutaneous perforator can be found just distal to the junctura tendinum. The
perforator and its venous connections within the subcutaneous tissue surrounding this
perforator must not be skeletonized; this could lead to venous congestion and flap ischemia.

09e_DorsMeta_r5b_bs_1010-1045.indd 1021 2/6/2012 9:24:46 AM

 1022 Part II  Regional Flaps: Anatomy and Basic Techniques

Once a cutaneous perforator has been identified, it can be confirmed with a handheld
pencil Doppler probe. At this point, the more distal portion of the skin flap is elevated off
the surrounding subcutaneous tissue, and subcutaneous tissue and fascia surrounding the
perforator are freed up until adequate rotation can be achieved without any excessive twist-
ing or tension on the perforator.

I J

Quaba flap is raised on its distal perforator Flap perfusion is confirmed after
tourniquet release

Perforator basis of Quaba flap

Fig. 9E-6 

Extended Dorsal Metacarpal Artery Flap

The extended DMA flap was first described by Pelissier et al. The pivot point moves dis-
tally toward the distal border of the web space. The feeding vessel is no longer the palmar
perforator, but the first dorsal branch of the proper digital artery.
The DMA is usually included in the flap design. During flap dissection it is imperative
to preserve as much tissue as possible in the web space. The distal arterial feeding vessel
does not necessarily have to be identified. There are many small arterial contributions to
the rich vascular plexus in the web space. However, the major palmar perforator should be
identified and isolated.
After the flap is completely raised, the palmar perforator is temporarily occluded with
a microclamp, and the tourniquet is released. Perfect flap perfusion indicates sufficient ar-
terial flow through the perforator from the PDA and the small tributaries to the plexus in
the web space. The palmar perforator can then be clipped and transected. This maneuver
shifts the pivot point distally so that the distal interphalangeal (DIP) and the palmar aspect
of the pulp can be reached.

09e_DorsMeta_r5b_bs_1010-1045.indd 1022 2/6/2012 9:24:49 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1023

To increase the arc of rotation of the standard DMA flap, the communicating branch
between the DMA and the palmar metacarpal artery or common palmar digital artery can
be ligated to lengthen the flap’s pedicle and render the pivot point more distal.

Usual perforator for DMA flap

Palmar-based digital arteries

Fig. 9E-7  A, Division of the usual perforator of the DMA flap, which allows shifting of the pivot point
distally.

By doing so, the flap’s blood supply is maintained by communication between the dorsal
branches of the digital artery and the terminal branches of the dorsal and metacarpal artery
through retrograde flow. The surgeon must not skeletonize any of the subcutaneous tissue
in which the terminal branches of the DMA and dorsal branches of the digital arteries are
found. A zigzag incision is continued to the distal skin paddle to dissect the subcutaneous
pedicle, which is kept as wide as possible to maximize venous drainage and arterial supply
to the flap. The skin flaps overlying the pedicle are elevated with skin and dermis only to
preserve all of the subcutaneous tissue that contains the pedicle. This dissection provides
additional length to the flap pedicle and will allow the FDMA flap to easily reach the PIP
joint, and even the DIP joint. An Allen’s test must be performed to confirm the patency
of either the ulnar or radial digital artery on which this flap can be based. When raising a
Quaba flap or FDMA perforator flap based off a DMA cutaneous perforator at the inter-
metacarpal head area, an extended flap can be performed as well.

B C D

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.

09e_DorsMeta_r5b_bs_1010-1045.indd 1023 2/6/2012 9:24:53 AM

 1024 Part II  Regional Flaps: Anatomy and Basic Techniques

Again, the direct cutaneous perforator to the skin flap, which is found at the intermeta-
carpal space and on which the Quaba flap is based, can be ligated to extend the reach of the
Quaba flap. A rich subcutaneous tissue pedicle is kept intact from the flap and between the
flap and the dorsal branches of the proper digital artery. The pivot point is then distal to the
metacarpal heads and allows the flap to reach the DIP joint. Elevation of flaps of skin and
dermis only, leaving all subcutaneous tissue intact overlying the pedicle, must be performed
with care to ensure flap success and minimize the risk of venous congestion or ischemia.

Composite Dorsal Metacarpal

Artery Flaps
DMA flaps can also contain segments of tendon, bone, or nerve. Planning is the key to
success.

First Dorsal Metacarpal Artery Flap

With Extensor Tendon
Dorsal digital defects following trauma often require not only skin coverage or resurfac-
ing but also extensor tendon reconstruction. Providing a vascularized extensor tendon in
combination with well-vascularized tissue and skin coverage is beneficial to maximize
function so that patients can progress quickly into a rehabilitation program. The second
dorsal metacarpal artery (SDMA) can be harvested with a portion or all of the extensor
indicis proprius (EIP) to provide vascularized extensor tendon reconstruction. There are
multiple cutaneous perforators running along the DMA that vascularize the adjacent ex-
tensor tendons, and this forms a basis for a vascularized extensor tendon chimeric FDMA
flap. A strip of EIP can be harvested with the FDMA based on small cutaneous perforators
from the DMA. This flap can either be a traditional DMA flap or can be harvested as a
DMA perforator flap.

A B C

Defect with loss of index finger DMA flap using a segment of EIP Flap elevated with tendon segment
extensor over PIP joint as a graft

Fig. 9E-8 

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 Hand  •  9E: Dorsal Metacarpal Artery Flap 1025

D E

DMA composite flap transposed EIP tendon graft interposed into segmental extensor
defect before skin island inset

Fig. 9E-8 

Sensate Dorsal Metacarpal Artery Flap

In certain instances the dorsal branches of either the radial or ulnar nerve can be incor-
porated into the flap to provide sensate reconstruction. The sensory branch to the radial
or ulnar nerve is then anastomosed to the dorsal branch of the digital nerve or the digital
nerve proper itself, depending on how distal the flap can reach. For segmental bone loss
resulting from a traumatic injury, a corticocancellous bone graft and vascularized bone flap
can be harvested in combination with the FDMA flap because of the rich interconnection
between the DMA and the interosseous muscle and metacarpals.

First
dorsal
metacarpal
artery

Second
dorsal
metacarpal
artery
Dorsal sensory
branches of Radial
radial nerve artery

Radial
sensory
nerve

Fig. 9E-9  Origin and course of the first dorsal metacarpal artery and dorsal sensory branches of
the radial nerve. (Adapted from Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Lou-
isville, KY.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1025 2/6/2012 9:24:58 AM

 1026 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
First Dorsal Metacarpal Artery Flap
With proximal dissection of up to 6 cm, the FDMA flap will comfortably reach the distal
thumb.

Arc to thumb

Fig. 9E-10 

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 Hand  •  9E: Dorsal Metacarpal Artery Flap 1027

Reverse Dorsal Metacarpal Artery Flap

The standard point of rotation for the dorsal metacarpal artery flap is the point just proximal
to the junctura tendinum. If a further pivot point is required to allow further reach, the
junctura tendinum can be sectioned and the new pivot point becomes the communicating
branch between the DMA and the palmar metacarpal artery. This communicating branch
is usually found in the mid intermetacarpal head region. The flap can be rotated within
an upward rotation, typically ranging from 90 to 180 degrees. When pivoted proximal to
the junctura tendinum, the flap will easily reach the dorsal aspect of the proximal phalanx.
Sectioning the junctura tendinum and allowing a more distal pivot allows a greater arc of
rotation, in which case the dorsal PIP joint can be covered.

DMA or Quaba flap:

Arc with 180-degree rotation

Fig. 9E-11 

Dorsal Metacarpal Artery Perforator Flap

The arc of rotation for the Quaba flap, or first dorsal metacarpal artery perforator flap, is
located distal to the junctura tendinum where the main cutaneous perforators vascularized
in the flap are found. The perforator is usually 1 cm proximal to the intermetacarpal head
and just distal to the junctura tendinum, and the Quaba flap, or first dorsal metacarpal
artery perforator flap, is based on this cutaneous perforator. This direct cutaneous perfo-
rator determines the pivot point of this flap. The flap will easily reach the dorsum of the
proximal phalanx and dorsal aspect of the PIP joint, as well as the palmar aspect of both
of these regions.

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 1028 Part II  Regional Flaps: Anatomy and Basic Techniques

Extended Dorsal Metacarpal Artery Flap

When greater arc of rotation is required, such as to reach the DIP joint, the cutaneous per-
forator of the Quaba flap can be transected and ligated, as can the communicating branch
between the DMA and the palmar metacarpal artery in a standard DMA flap. With either
one of these maneuvers, the FDMA flap depends solely on retrograde flow from the dorsal
branches of the digital artery communicating through subcutaneous terminal connections
to the terminal branches of the DMA flap. The pivot point therefore becomes distal to the
MCP joint and just within the proximal third of the proximal phalanx. This maneuver
greatly enhances the arc of rotation and reach of the flap, which will now reach the dorsum
of the DIP joint.

FLAP TRANSFER
The flap is transposed into its recipient bed. Subcutaneous tunneling is not usually used
because of the risk of pedicle compression.

FLAP INSET
Once the flap is rotated, there should be no tethering on the proximal portion of the flap at
its pivot point. The tourniquet should be released once the flap has been rotated 180 degrees
to ensure that there is no kinking or twisting of the pedicle. The flap should be inset with
a minimum number of sutures to avoid ischemia or compression, which can lead to venous
congestion of the flap. Even the loose inset flaps remodel extremely well over their recipi-
ent site. Any skin redundancy or irregularities can be excised later, although this is rarely
indicated. By extending the distal edge of the skin paddle 1.5 cm distal to the cutaneous
perforator for a Quaba flap or the junctura tendinum for a standard DMA flap, the donor
site can be closed primarily, with no tension on the skin. Simple permanent or absorbable
sutures are used to inset the flap, again with minimal tension, making certain that there is
no new traction on the pedicle or the flap itself.

Donor Site Closure

The donor site can be closed primarily when the width is 2 to 3 cm. If the donor site can-
not be closed primarily, a split-thickness or full-thickness skin graft can be harvested to
cover the donor site. Care must be taken to always preserve the paratenon over the extensor
tendons to provide an adequate recipient bed for skin grafting. Deep dermal sutures are
used to close the dermal aspect of the donor site, followed by either a subcutaneous closure
with Monocryl or simple sutures with either 5-0 nylon or chromic suture. Usually, skin
on a skin flap measuring up to 3 cm wide and 6 to 10 cm long will allow primary closure.

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 Hand  •  9E: Dorsal Metacarpal Artery Flap 1029

CLINICAL APPLICATIONS
This 32-year-old man presented with a work-related soft tissue avulsion on the dorsal aspect
of the proximal phalanx of his left middle finger. The wound was open and contaminated,
and the extensor digiti communis (EDC) tendon was lacerated and exposed. The wound
was thoroughly debrided and the tendon repaired. A second DMA perforator flap was used
to cover the defect. The dorsal hand skin is expendable and provides an excellent flap donor
site for reconstructing soft tissue defects in the digits.

A B C

D E

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 radi-
cally 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 perfora-
tor 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. (Case
courtesy Michel Saint-Cyr, MD.)

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 1030 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient had unstable soft tissue coverage over the dorsal aspect of the left thumb proxi-
mal phalanx, resulting in pain and limited function. Well-vascularized tissue in the form
of an FDMA (kite) flap provided stable coverage and a better extensor gliding surface for
improved range of motion.

A B

C D

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. (From Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville,
KY.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1030 2/6/2012 9:25:04 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1031

This patient had a defect on the palmar aspect of the index finger over the metacarpal head.

A B

C D

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. (Case cour-
tesy Guenter Germann, MD, PhD.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1031 2/6/2012 9:25:09 AM

 1032 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient had a distal palmar defect in the middle finger of the right hand after a contu-
sion injury.

A B

C D

E F

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 har-
vested 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. (Case courtesy Guenter Germann, MD, PhD.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1032 2/6/2012 9:25:16 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1033

This patient had dorsal defects in the middle and ring finger after a contact burn.

A B C

D E F

G H I

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 demon-
strates active range of motion 10 days postoperatively. (Case courtesy Guenter Germann, MD, PhD.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1033 2/6/2012 9:25:18 AM

 1034 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient sustained an injury from a dog leash.

B C

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.

09e_DorsMeta_r5b_bs_1010-1045.indd 1034 2/6/2012 9:25:21 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1035

G H

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 postop-
eratively, with no signs of venous congestion or partial flap loss. (Case courtesy Guenter Germann,
MD, PhD.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1035 2/6/2012 9:25:23 AM

 1036 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient had a complex defect at the dorsum of the proximal phalanx of the index finger
after a crush injury.

A B C

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. (Case courtesy
Guenter Germann, MD, PhD.)

A DMA flap was used in this patient’s burned and grafted hand to cover an exposed PIP joint.

A B

Fig. 9E-19  A, A DMA flap was sutured over the exposed joint. B, The flap healed well. (Case cour-
tesy Guenter Germann, MD, PhD.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1036 2/6/2012 9:25:24 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1037

This patient had a burn injury over the PIP joint. It was reconstructed with a DMA flap.

A B C

Fig. 9E-20  A, Flap design. B, DMA from a grafted area. C, The donor site was reconstructed with a
split-thickness skin graft. (Case courtesy Guenter Germann, MD, PhD.)

A variation of a DMA flap was used in this patient to reconstruct a wound over the proxi-
mal phalanx.

A B

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. (Case courtesy Guenter Germann, MD, PhD.)

09e_DorsMeta_r5b_bs_1010-1045.indd 1037 2/6/2012 9:25:25 AM

 1038 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The skin territory should not extend over the dorsal proximal interphalangeal joint surface
to prevent scar contracture and loss of finger flexion at the donor site.
• The first dorsal metacarpal flap may not consistently reach the volar surface of the distal
phalanx of the thumb for resurfacing.
• The DMA is adherent to the interosseous muscle and deep to the dorsal sensory nerve.
Care is taken to avoid interruption of the cutaneous branches of this pedicle to the proxi-
mal phalangeal dorsal skin island.
• The DMA flap (or its perforator variant, the Quaba flap) is extremely useful for coverage
of dorsal defects involving the proximal phalanx of the PIP joint or even the DIP joint
when the flap is used as an extended variant. The second dorsal metacarpal artery and
third dorsal metacarpal artery flaps are extremely reliable flaps because of the constant
communicating branch linking the DMA with the palmar metacarpal artery. The fourth
and fifth dorsal metacarpal arteries do not always have this communicating branch but
are reliable as a cutaneous perforator variant of the DMA flap. During initial dissection,
subcutaneous veins are harvested within the flap to maximize venous drainage, and the
proximal subcutaneous vein between the flap can be dissected and clipped to provide
additional venous outflow if needed following transfer. Whether harvesting this flap as
a reverse DMA flap or a Quaba flap (cutaneous perforator DMA perforator flap), the
paratenon overlying the extensor tendon should be respected at all times in anticipation
for a skin graft for donor site closure, if required.
• A rich cuff of fibrofatty tissue should be kept around the DMA flap, especially over the
cutaneous perforator if the flap is raised as a DMA perforator flap. The pedicle should
never be skeletonized to avoid injury to any of the venous connections found within
the subcutaneous tissue. In many instances, the cutaneous perforator does not even need
to be visualized. It can be confirmed with a pencil Doppler probe, but leaving as much
subcutaneous tissue around the pedicle as possible will maximize venous drainage and
arterial supply to the flap.
• When rotating the flap 180 degrees, the tourniquet should be released before final flap
inset to confirm that there is good arterial inflow and no venous congestion to the flap.
If there is any venous congestion, the flap should be rotated and any kinking or twisting
of the pedicle should be avoided or eliminated. Subcutaneous tissue should be released
around the pivot point and perforator as needed to provide tension-free rotation and flap
inset. There should be no tension on the flap inset to avoid damage to the flap pedicle.
• Only a few tacking sutures are required to inset the flap. Insetting the flap with multiple
sutures under tension should be avoided at all costs. The flap will remodel extremely well
over time once the swelling has subsided and the flap has matured.
• When harvesting this flap as an extended DMA flap or extended Quaba flap, the surgeon
must maintain a wide pedicle to maximize connections between the dorsal branches
of the digital artery and the terminal branches of the DMA. Skeletonization should be
avoided at all costs to maximize blood supply. The skin flaps overlying the pedicle should
be elevated very thinly to preserve all of the subcutaneous tissue within the pedicle.
• Use the “cutaneous tail” to avoid a segment of solely subcutaneous pedicle, which may
have to be skin grafted. This flap design facilitates tension-free skin-skin closure.

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 Hand  •  9E: Dorsal Metacarpal Artery Flap 1039

Expert Commentary
Guenter Germann

Indications
DMA flaps are extremely versatile, not only in design, but also in clinical applicability.
With the advent of alternative flaps for coverage of the distal dorsal part of the thumb, such
as the Moschella flap or the Brunelli flap, the indication for the kite flap has shifted in our
institution. If the previously mentioned flaps are not applicable, the kite flap is still our first
choice for reconstructing dorsal thumb defects. However, restoration of sensibility has
become a major indication over the years. A sensate kite flap provides immediate protec-
tive sensibility when the pulp is reconstructed. All alternative procedures require neural
coaptation with a nonpredictable result. This is absolutely justified in younger patients with
a high likelihood of reinnervation. In older patients, we recommend a sensate kite flap to
restore sensibility. The advantages are:
• The kite flap does not have significant donor site morbidity, unlike the Littler flap.
• It is not necessary to dissect through the palm or split the common digital nerve to
increase the arc of rotation.
• There is a similar “loss of discriminative power” after flap transfer.
• The incidence of the “dual location phenomenon” is low.
• Immediate protective sensation is provided.
In addition to applications in the thumb, the kite flap can be used to reconstruct defects of
the entire dorsum of the hand because of its long pedicle and wide arc of rotation. It can
be raised as a free flap for use in the hand or to reconstruct the nasal floor in total nasal
reconstruction.
DMA flaps, as well as Quaba-type flaps, are predominantly used to reconstruct dorsal
digital defects, web space defects, and palmar defects caused by trauma, or soft tissue deficits
after the operation for Dupuytren’s contracture, burn scar release, or tenolysis.
The extended versions easily reach the palmar aspect and the dorsum of the DIP joint
and are used to reconstruct long and complex digital defects. We find an extended DMA
flap far superior to a combination of a “regular” DMA flap and a crossfinger flap in complex
digital defects.

Anatomic Considerations
Flaps from the dorsum of the hand have proved most reliable for reconstructing defects of
the digits or dorsum of the hand and for restoring sensibility in the thumb.
Anatomic dissections have shown that the dorsal metacarpal arteries usually run just
underneath the epimysium of the dorsal interosseous muscles. Cutaneous perforators branch
off the arteries to supply the overlying skin. This is predominantly important for second
through fourth DMAs, where the flaps are centered over the arteries running in the in-
termetacarpal spaces.
Not much has been written about the direction of arterial flow in the DMAs. They
arise from the dorsal carpal arch, which is formed from the dorsal carpal branches of the
ulnar and radial arteries. Distal to the junctura tendinum, they communicate with the pal-
mar vascular system through a major perforator that, in our experience, frequently comes
directly from the common digital artery.
The incidence of the DMA is 100% for first and second DMAs, and it decreases slightly
toward the ulnar border of the hand to approximately 90% for the fourth DMA.
Continued

09e_DorsMeta_r5b_bs_1010-1045.indd 1039 2/6/2012 9:25:25 AM

 1040 Part II  Regional Flaps: Anatomy and Basic Techniques

The kite flap raised on the first DMA is significantly different in its vascular anatomy.
Although the pedicle also runs below the epimysium of the interosseous muscle, the flap is
not located on the dorsum of the hand, but on the proximal phalanx of the index finger.
The artery can be safely traced with a pencil Doppler device to the proximal third of the
proximal phalanx, and is then often not detectable.

Personal Experience and Insights

Based on experience with a considerable number of kite flaps and DMA flaps, we have
modified our flap design. They are now designed only slightly larger than the defect so that
they can be sutured in place with nearly the original tension on the skin. It is our experience
that flaps that are too large tend more toward venous congestion.
The skin island design was also modified to avoid several pitfalls. With the kite flap,
tunneling the flap into the defect was always burdened with the risk of compromising the
delicate pedicle. With the “cutaneous tail design” published by our group in 2007, several
goals can be achieved:
• Tunneling of flaps to the thumb can be safely performed in the soft first web space.
Extending the defect proximally and reconstructing with the “tailed” kite flap allows
tension-free skin-skin closure.
• Skin grafts to pedicles of either the kite flap or other DMA flaps are no longer
necessary.
• The entire vascular pedicle is covered by the skin island. Subcutaneous pedicles de-
scribed in the article can be avoided; therefore more small, nonidentifiable vascular
connections to the skin island can be preserved.
• Long zigzag incisions can be avoided.
Take-Away Messages
• All variations of the DMA flap are useful for reconstructing defects in the hand and digits
if some precautions are considered during planning and dissection.
• It is important to make the pedicle as wide as possible by taking a wide strip of epimysium.
• The paratenon has to be respected at all times.
• The skin island should be designed with a cutaneous tail to benefit from the advantages
of this design.
• As much tissue as possible should be preserved in the web space to secure sufficient venous
outflow and to facilitate a distally shifted pivot point.
• The flap should be designed only slightly larger than the defect so that it is sutured under
minimal tension. In our experience, a flap that is too large has a higher tendency for
venous congestion.
• The kite flap easily reaches the thumb pulp and can restore sensibility of the thumb.

References
Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based
dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 60:731-739, 2007.
Quaba AA, Davison PM. The distally-based dorsal hand flap. Br J Plast Surg 43:28-39, 1990.
Earley MJ, Milner RH. Dorsal metacarpal flaps. Br J Plast Surg 40:333-341, 1987.
Pelissier P, Cassoli V, Bakhach J, et al. Reverse dorsal digital and metacarpal flaps: a review of
27 cases. Plast Reconstr Surg 103:159-165, 1999.

09e_DorsMeta_r5b_bs_1010-1045.indd 1040 2/6/2012 9:25:26 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1041

Bibliography With Key Annotations

Aydin A, Ozden BC. Dorsal metacarpal island flap in syndactyly treatment. Ann Plast Surg
52:43-48, 2004.
Skin graft–free web space reconstruction of syndactyly can be achieved in several ways. Previously, the
dorsal metacarpal island flap based on a direct cutaneous branch of the dorsal metacarpal artery has
been used as an island V-Y advancement for web defects. In this study, the authors raised the dorsal
metacarpal artery flap as an island but used it as a transposition flap in a series of 19 web defects.
Follow-up ranged from 1 to 5 years. Early results were good, with no recurrence or web creeping. The
authors concluded that by employing the flap as a transposition flap, the skin territory proximal to
the pedicle is used more effectively, and the result is more comfortable.
Battiston B, Artiaco S, Antonini A, et al. Dorsal metacarpal artery perforator-based propeller flap
for complex defect of the dorsal aspect in the index finger. J Hand Surg Eur 34:807-809, 2009.
Camporro D, Vidal D, Robla D. Extended applications of distally based axial adipofascial flaps
for hand and digits defects. J Plast Reconstr Aesthet Surg 63:2117-2122, 2010.
The authors reviewed a series of 18 cases of reverse axial adipofascial flaps performed in an outpatient
setting. These flaps use subcutaneous tissue of the lateral digital and dorsal metacarpal or digital areas
and are positioned on the arterial branches anastomosing the volar and dorsal arterial networks of the
fingers. They provided coverage of wide and distal defects. Proximal phalangeal defects were covered
with metacarpal flaps. Defects over the proximal interphalangeal joint, thumb, and fingers were
covered with digital flaps. Dissection was easy, fast, and preserved the collateral nerve and artery of
the finger. The flaps could be performed simultaneously with bone, joint, and tendon reconstruction.
Patients were allowed to mobilize the hand as early as possible. Partial distal necrosis occurred in one
case and partial loss of the overlying skin graft in two cases. These resolved spontaneously. Donor site
morbidity was minimal.
Chang SC, Chen SL, Chen TM, et al. Sensate first dorsal metacarpal artery flap for resurfacing
extensive pulp defects of the thumb. Ann Plast Surg 53:449-454, 2004.
The authors described a one-stage procedure in which a sensate first dorsal metacarpal artery flap is
mobilized from the dorsum of the adjacent index finger and used as an island pedicle skin flap to close
extensive pulp defects over the distal phalanx of the thumb in eight patients. All had bone, joint, or
tendon exposure. The pedicle included the ulnar branch of the first dorsal metacarpal artery, the dorsal
veins, and the cutaneous branch of the radial nerve. To overcome the anatomic variability of this very
small artery, the authors included the radial shaft periosteum of the secondary metacarpal bone and
the ulnar head fascia of the first interosseous muscle. All flaps survived completely.
Chen CC, Chang HH, Tang YB, et al. Combined first dorsal metacarpal artery flap and dor-
sal transposition flap for correction of extensive first web space contracture: a case report and
review of literature. Ann Plast Surg 67:364-366, 2011.
The authors presented a novel approach to the difficult clinical problem of releasing first web space
contracture. Their patient was a 25-year-old man with extensive contracture over the first web space
after trauma. They released the contracted structures and covered the extensive skin defect with a dorsal
transposition flap with an extension to the territory of the first dorsal metacarpal artery flap. The
functional and cosmetic results were excellent, without recurrence of contracture.
Chen C, Zhang X, Shao X, et al. Treatment of thumb tip degloving injury using the modified
first dorsal metacarpal artery flap. J Hand Surg Am 35:1663-1670, 2010.
The authors presented their experience using the modified first dorsal metacarpal artery (FDMA)
flap, including both dorsal branches of the proper digital nerve (DBPDN) to repair thumbtip deglov-
ing injuries in 11 patients (11 thumbs). Four patients had bone loss of 1 to 3 mm. The soft tissue
defects were 2.6 to 4.6 cm long and 1.8 to 2.2 cm wide. The flap size ranged from 2.7 by 2.2 cm to
4.8 by 2.1 cm. The pedicle length ranged from 6.8 to 7.5 cm. Neurorrhaphy between the DBPDN
and the proper digital nerve was performed on both sides in all cases. Follow-up ranged from 26 to
47 months. All flaps survived completely. At the final follow-up, the mean of the static two-point

09e_DorsMeta_r5b_bs_1010-1045.indd 1041 2/6/2012 9:25:26 AM

 1042 Part II  Regional Flaps: Anatomy and Basic Techniques

discrimination was 5 mm and 6 mm on the radial and ulnar sides of the distal part of the flap, respec-
tively. The mean range of motion of the metacarpophalangeal, proximal interphalangeal, and distal
interphalangeal joints of the donor fingers were 73 degrees, 101 degrees, and 70 degrees, respectively.
Clark RR, Watson SB. Pollicisation of the index metacarpal based on the first dorsal metacarpal
artery. J Plast Reconstr Aesthet Surg 59:325-330, 2006.
The authors presented two cases of complex, severe hand injuries treated with pollicization of the index
metacarpal based on the first dorsal metacarpal artery and venae comitantes. In both patients, the radial
side of the superficial palmar arch was destroyed, and there was complete loss of the thumb ray and
amputation of the index through the base of the proximal phalanx. The authors successfully created
an opposition post from vascularized index metacarpal bone, with free flap soft tissue reconstruction.
Dauphin N, Casoli V. The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled
metacarpal bone flaps. J Hand Surg Eur 2011 Jun 27. [Epub ahead of print]
Despite the variable vascular anatomy of the dorsal aspect of the hand, the first and second dorsal
metacarpal arteries (DMAs) are always present. Therefore the reliability of a metacarpal bone flap
decreases from the second to the fifth metacarpal bone. The authors examined the metacarpal segmental
vascularization and described six new vascularized bone flaps from the third and the fourth metacarpal
bones pedicled on the second or the third DMA in an anterograde or retrograde flow mode. Based on
their results, the radial and the ulnar side of the third metacarpal bone could be harvested, respectively,
on the second and third DMAs. The radial side of the fourth metacarpal bone may also be a reliable
vascularized bone donor site. Metacarpal and carpal bones or proximal phalanges may be repaired
with the flaps based proximally or distally.
Eski M, Nisanci M, Sengezer M. Correction of thumb deformities after burn: versatility of
first dorsal metacarpal artery flap. Burns 33:65-71, 2007.
Thumb reconstruction is the most crucial aspect of effectively managing burned hands debilitated by
contractures; however, flap options are limited. In this article, the authors used a neurovascular island
first dorsal metacarpal artery flap in 14 patients with thumb deformities from contracture. The time
from injury to reconstruction ranged from 5 months to 17 years. All treatments were successful, with
satisfactory functional and cosmetic results. Donor site morbidity was minimal, with an acceptable
scar on the dorsum of the index finger. Tendon gliding was adequate and without extension deficit.
The authors concluded that the first dorsal metacarpal artery flap is a reliable option for deformities
involving the thumb and/or adjacent thenar area. It provides acceptable sensation, elasticity, durabil-
ity, and skin match.
Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the hand. J Hand Surg Am
34:1148-1155, 2009.
Numerous methods are available for restoring the aesthetic appearance and function of the hand.
In this review article the authors described recent advances in soft tissue reconstruction of the hand.
Topics include skin grafts and skin substitutes, refinements in digital coverage, the expanding uses of
dorsal metacarpal artery flaps, challenges to traditional concepts of forearm-based donor tissue, and
improvements in free tissue transfer.
Gregory H, Heitmann C, Germann G. The evolution and refinements of the distally based
dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 60:731-739, 2007.
Distally based dorsal metacarpal artery (DMA) flaps have been described by Quaba, Earley, Milner,
and others. Common indications are soft tissue defects of the dorsum of the proximal phalanx and
decreased finger length. The flap had been modified for use as a pure fascial DMA flap, as dorsal
grafts for burned hands, and to avoid tunneling and permit skin-skin defect closure. The authors pro-
vided an overview of the evolution and refinements of the DMA flaps performed in a single center.
DMA flaps provide excellent coverage in one stage, with independent vascularization. Primary closure
of the recipient site is possible without sacrificing relevant arteries, such as the proper digital artery.
However, the technique is quite demanding and may result in hair growth and a visible scar on the
exposed dorsal part of the hand.

09e_DorsMeta_r5b_bs_1010-1045.indd 1042 2/6/2012 9:25:26 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1043

Gregory H, Pelzer M, Gazyakan E, et al. [Experiences with the distally based dorsal metacarpal
artery (DMCA) flap and its variants in 41 cases] Handchir Mikrochir Plast Chir 38:75-81, 2006.
In this retrospective study of dorsal metacarpal artery (DMA) flaps, the authors presented their experi-
ence with this flap in a single center. They performed 41 distally based DMA flaps: 29 distally based
DMA flaps, nine extended distally based DMA flaps, and three distally based DMA fascial flaps.
Thirty-four flaps had no complications, five had partial necrosis that was successfully treated with a
split-thickness skin graft, and two were unsuccessful because of infections. The authors concluded that
distally based second through fourth DMA flaps are reliable, but require adequate surgical experience.
They are suitable for reconstructing all defects, including burns. Defects of the entire finger can be
covered by one of the many variations of this flap.
Karunadasa KP, Beneragama TS, Dissanayake DA, et al. Dorsal metacarpal artery flap for re-
surfacing of fourth-degree electrical burns of fingers. J Burn Care Res 31:674, 2010.
Koch H, Bruckmann L, Hubmer M, et al. Extended reverse dorsal metacarpal artery flap:
clinical experience and donor site morbidity. J Plast Reconstr Aesthet Surg 60:349-355, 2007.
The authors performed extended reverse dorsal metacarpal artery (RDMA) flaps in 12 patients with
defects of the long finger. Emphasis was placed on donor site morbidity. Active and passive total range
of motion and pinch grip strength of the finger neighboring the reconstructed one were evaluated and
compared with the corresponding finger of the contralateral hand. The donor site was further evaluated
for cosmetic appearance and pain. There was no statistically significant difference for active and passive
total range of motion between the neighboring finger and the same finger on the other hand; however,
there was a statistically significant difference for pinch grip. The patients’ subjective evaluation of pain
scored a value of 1.25 (mean) on a visual analogue scale (0 5 no pain, 10 5 maximal imaginable
pain) and the mean score for cosmetic appearance was 8 (0 5 worst cosmetic result, 10 5 best cosmetic
result). The authors concluded that, compared with other flaps, the extended RDMA flap is a fast and
secure single-stage procedure for covering defects on the long fingers and has low donor site morbidity.
Muyldermans T, Hierner R. First dorsal metacarpal artery flap for thumb reconstruction: a
retrospective clinical study. Strategies Trauma Limb Reconstr 4:27-33, 2009.
Surgical treatment of extensive pulp (zone 4) defects of the thumb, with exposed tendon or bone,
has included local, regional, and free flaps. Foucher and Braun first used an island flap carried on a
neurovascular pedicle consisting of the first dorsal metacarpal artery (FDMA). The authors performed
seven innervated FDMA island flaps for thumb reconstruction. Follow-up ranged from 4 to 29 months.
In six patients the dominant hand was injured. In a retrospective clinical study, the following criteria
were evaluated: (1) cause of the defect, (2) time of reconstruction (primary versus delayed), (3) survival
rate of flap, (4) sensory function (Semmes-Weinstein monofilaments, static two-point discrimination,
pain, and cortical reorientation), (5) TAM measured with the Kapandji index, and (6) subjective
patient satisfaction measured using the SF-36). Based on these data, the authors concluded that the
FDMA flap has a constant anatomy and easy dissection, and provides good functional and aesthetic
results. Donor site morbidity is low if a full-thickness skin graft is used. This flap is their first treatment
of choice for defects of the proximal phalanx and proximal part of the distal phalanx of the thumb.
Takeishi M, Shinoda A, Sugiyama A, et al. Innervated reverse dorsal digital island flap for
fingertip reconstruction. J Hand Surg Am 31:1094-1099, 2006.
The authors described their experience using an innervated reverse dorsal digital island flap for fingertip
reconstruction that does not sacrifice the digital artery and is performed in one stage. They performed
reconstruction with this flap in eight patients. It was supplied by the vascular network between the
dorsal digital artery (the terminal branch of the dorsal metacarpal artery) and the dorsal branch of
the digital artery. Venous drainage was through the cutaneous veins and the venous network associ-
ated with the dorsal arterial network. The flap was designed on either the dorsal proximal or dorsal
middle phalangeal region. It was harvested with the dorsal branch of the digital nerve (for the dorsal
middle phalanx), the dorsal digital nerve (for the dorsal proximal phalanx), or the superficial branch
of the radial nerve (for the thumb), which was anastomosed to the distal end of the digital nerve. The

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 1044 Part II  Regional Flaps: Anatomy and Basic Techniques

donor site was covered with a full-thickness skin graft. Six flaps survived completely, one had partial
epithelial skin necrosis, and one showed central compression skin necrosis. Sensation was satisfactory
in all patients. Static two-point discrimination ranged from 3 to 5 mm, and the Semmes-Weinstein
test results ranged from 0.036 to 0.745 g. The authors concluded that this flap is a good option for
homodigital tip coverage. The digital artery is not sacrificed, and only one surgery is needed. A dis-
advantage is the potential for venous congestion for the first 4 to 5 days after surgery.
Tränkle M, Sauerbier M, Heitmann C, et al. Restoration of thumb sensibility with the inner-
vated first dorsal metacarpal artery island flap. J Hand Surg Am 28:758-766, 2003.
This study focused on the quality of sensibility from an innervated first dorsal metacarpal artery
(FDMA) island flaps and donor site morbidity at the index finger. Twenty-five patients had an in-
nervated FDMA island flap to restore sensibility of the thumb. They were divided into two groups:
age 50 years or older and age 50 or younger. The mean patient age was 48.3 years. Follow-up was
carried out at 3 years (mean). Static two-point discrimination was 10.9 in the older group and 10.8
mm in the younger patients. The average loss of two-point discrimination of the flap compared with
that of the donor area was 2.7 mm in all patients. Complete cortical reorientation occurred in seven
patients older than 50 years and in five patients younger than 50 years. Total loss of range of motion
of all donor-finger joints was 14 degrees, compared with the contralateral index finger. Twenty-two
patients were satisfied with the result. The authors concluded that there were no age-related differences
in the surgical results with the innervated FDMA island flap, and donor site morbidity was negligible.
Wang P, Zhou Z, Dong Q, et al. Reverse second and third dorsal metacarpal artery fascio-
cutaneous flaps for repair of distal- and middle-segment finger soft tissue defects. J Reconstr
Microsurg 27:495-502, 2011.
The authors evaluated the clinical efficacy of the reverse second and third dorsal metacarpal artery
fasciocutaneous flaps for repairing distal- and middle-segment finger soft tissue defects in 14 patients.
All defects had an exposed phalanx or tendon. Flaps ranged from 2 by 4.5 cm to 3 by 7 cm. Follow-
up ranged from 6 to 40 months. Two-point discrimination was 5 to 9 mm, and good finger function
was recovered. The donor site was directly sutured without dermoplasty. Pigmented linear surgical
streaks appeared at the donor site. The authors concluded that these flaps are good options for repair-
ing distal- and middle-segment finger soft tissue defects because of the convenient dissection, minimal
trauma, sufficient use of the dorsal metacarpal artery, large harvested area of the flap, and a good
dissection range.
Zhang WL, Gao SH, Chen C, et al. [The reverse flap based on two dorsal metacarpal artery
for reconstruction of degloved fingertip avulsion] Zhonghua Zheng Xing Wai Ke Za Zhi
26:175-178, 2010.
The authors performed 28 reverse flaps based on the second dorsal metacarpal artery in 28 cases of
degloved fingertip avulsions. The defects were located distal to the distal interphalangeal joints and
were 0.8 to 2.2 cm long. Ten defects were in the index finger, 13 in the middle finger, and five in the
ring finger. Twenty-four fingers were treated in an emergency surgery. Four surgeries were performed
to treat skin necrosis. Twenty-five flaps survived completely, and three had epidermal necrosis at the
distal end. Twenty-five cases were followed for 4 to 27 months. Cosmetic and functional results were
satisfactory. Two-point discrimination was 6 to 9 mm.
Zhang X, He Y, Shao X, et al. Second dorsal metacarpal artery flap from the dorsum of the
middle finger for coverage of volar thumb defect. J Hand Surg Am 34:1467-1473, 2009.
The authors shared their experience using the second dorsal metacarpal artery flap from the middle
finger in nine patients with extensive volar thumb defects. All thumbs were of normal length. In all
patients, injury precluded use of the first dorsal metacarpal artery flap. Donor sites were covered with
full-thickness skin grafts. All thumbs were immobilized postoperatively. Rehabilitation was subse-
quently performed. Follow-up ranged from 24 to 30 months. All flaps survived completely, without
complication, and provided good coverage. All patients had full active range of motion in both the donor
finger and the thumb. The mean Semmes-Weinstein sensitivity and two-point discrimination scores
of the flap were 4.02 g and 8.4 mm, respectively. Mild cold intolerance was present in all thumbs.

09e_DorsMeta_r5b_bs_1010-1045.indd 1044 2/6/2012 9:25:26 AM

 Hand  •  9E: Dorsal Metacarpal Artery Flap 1045

The authors recommended this flap for volar thumb defects in thumbs of normal length. Although its
pedicle length is limited, it is a reliable alternative for reconstructing extensive thumb-pulp defects in
one stage, especially when the first dorsal metacarpal artery flap cannot be used.
Zhang X, Yang L, Shao X, et al. Use of a bilobed second dorsal metacarpal artery-based island
flap for thumb replantation. J Hand Surg Am 36:998-1006, 2011.
Extensive traumatic defects at the level of the proximal phalanx of the thumb require challenging
replantation and reconstruction procedures. The authors reported their experience using a bilobed
second dorsal metacarpal artery–based island flap harvested from both the index and middle fingers
to treat 15 patients with completely or incompletely amputated thumbs and extensive defects in the
proximal phalanx. This flap was chosen for its ability to cover the large size of the defects. After flap
transfer, anastomoses were performed between the veins of the distal part of the thumb and the flap.
Thirteen thumbs survived, and two failed. All flaps survived completely. Follow-up ranged from 24 to
29 months. The mean active motion arcs of metacarpophalangeal and interphalangeal joints were 32
degrees (range 15 to 45 degrees) and 31 degrees (range 0 to 47 degrees), respectively. All patients had
full active range of motion in both the metacarpophalangeal and the proximal interphalangeal joints
of the donor index and middle fingers. The authors concluded that this flap is a reliable technique for
thumb replantation in patients with extensive defects in the proximal phalanx when a single-digit
dorsal metacarpal artery island flap is too small.

09e_DorsMeta_r6_bs_1010-1045.indd 1045 2/10/2012 9:57:38 AM

 ANATOMIC LANDMARKS
Landmarks Flap is designed over dorsal aspect of the middle phalanx from
radial midaxis to ulnar midaxis. The pivot point is located at
the digital midaxial level toward the affected digit.
Size 1 3 3 cm.
Composition Skin, subcutaneous fat.
Flap Type Type A.
Dominant Pedicle Dorsal digital artery.
Minor Pedicle Digital perforators.
Nerve Supply Dorsal branches of the digital nerves, which can be anastomosed
to the recipient site digital nerve for sensation (rarely done).

09f_CrossFinger_r6_bs_1046-1073.indd 1046 2/8/2012 10:55:26 AM

 Section 9F
Hand

Cross-Finger Flap

CLINICAL APPLICATIONS
Regional Use
Coverage of volar aspect of
adjacent digits’ middle
phalangeal area
Distal digital tip coverage
Volar oblique fingertip
amputations with exposed
bone or tendon

With contributions by Michel Saint-Cyr, MD.

09f_CrossFinger_r6_bs_1046-1073.indd 1047 2/8/2012 10:55:29 AM

 ANATOMY OF THE Cross-Finger Flap

Dorsal digital artery

A

Arterial anatomy

Dorsal digital nerve

B

Nerve supply to flap area; dorsal branches of digital nerve

Cleland’s ligament

Cross-sectional anatomy through middle phalanx showing Cleland’s ligament

Fig. 9F-1 

Dominant pedicle: Dorsal digital artery

09f_CrossFinger_r6_bs_1046-1073.indd 1048 2/8/2012 10:55:29 AM

 Hand  •  9F: Cross-Finger Flap 1049

ANATOMY
Landmarks Flap is designed over dorsal aspect of the middle phalanx from radial midaxis
to ulnar midaxis. Pivot point is located at the digital midaxial level toward the
affected digit.
Composition Skin, subcutaneous fat.
Size 1 3 3 cm.

Arterial Anatomy (Type A)

Dominant Pedicle  Dorsal digital artery
The vascular supply of the dorsal skin distal to the distal portion of the proximal phalanx depends
on perforating vessels from the digital arteries. These dorsal branches supply the flap. The perforat-
ing vessels course through Cleland’s ligament and anterior dorsal network, where they support a
rich dermal and subdermal plexus. This supplies a laterally based cross-finger flap. There are two
to four perforators over the proximal phalanx, midportion of the middle phalanx, and distal third
of the middle phalanx.
Regional Source  Digital artery is derived from the common digital artery.
Length  Depends on the length of the finger and does not affect flap design or length. Although
the flap is dependent initially on blood flow from the donor digital artery, this blood supply is
completely separated at the time of flap division, because the flap develops a new blood supply
from the recipient finger within 10 days after surgery.
Diameter  1 mm.
Location  Volar to the midaxial line of the finger.
Minor Pedicle  Digital perforators passing dorsally around the finger
Regional Source  Digital artery.
Length  Up to 1 cm.
Diameter  0.2 to 0.3 mm.
Location  Dorsal subcutaneous tissue.

Venous Anatomy
Dorsal subcutaneous veins accompany dorsal arterial branches. Small venules accompany the
perforators arising from the digital artery and form the basis of venous drainage during the early
phases after initial flap transfer.

Nerve Supply
Sensory Dorsal branches of the digital nerves can be incorporated with the cross-finger
flap to render it sensate. This nerve can be anastomosed to the terminal branches
of the digital nerves. Sensory nerves are divided at the time of flap inset, unless
a specific attempt has been made to anastomose a dorsal sensory nerve to the
recipient digital nerve.

09f_CrossFinger_r6_bs_1046-1073.indd 1049 2/8/2012 10:55:29 AM

 1050 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Cross-Finger Flap

A

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 demonstra-
tion purposes only.

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 Hand  •  9F: Cross-Finger Flap 1051

FLAP HARVEST
Design and Markings
The cross-finger flap is designed with the base adjacent to the injured finger. This may be
ulnar or radial, depending on the location of the injury. The proximal and distal extent
of the flap is marked transversely. The markings are joined longitudinally just behind the
midaxis of the dorsum of the finger opposite the injured digit, sparing the neurovascular
bundle to the tip. This creates a three-sided rectangle, leaving the donor site pedicle intact
on the side of the finger adjacent to the injured digit.
Incisions are made to encompass the whole surface of the middle phalanx as an aesthetic
unit, with care to protect the paratenon and underlying extensor mechanism. The finger
radial to the injured digit is usually used as a donor site, with the exception of the index
finger, in which case a flap from the middle finger is used. To maximize distal reach dur-
ing rotation, the flap can be designed to be oriented obliquely across the middle phalanx
to allow a longer projection distally once it has rotated on its pedicle.

Design over dorsum of left middle finger for

coverage of volar index distal tip amputation

Example of design to be used

for volar index finger defect

Fig. 9F-3 

09f_CrossFinger_r6_bs_1046-1073.indd 1051 2/8/2012 10:55:33 AM

 1052 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
The patient is placed in the supine position with the hand abducted and extended on an
armboard.

GUIDE TO FLAP DISSECTION

Dissection begins with an incision through the initial skin markings and is carried down
through subcutaneous fat until a loose areolar tissue plane is encountered. Elevation of the
flap at this point is relatively straightforward, as long as dissection is carried within this
areolar tissue plane. The flap is then elevated off the paratenon; the extensor apparatus is
protected at all times. All subcutaneous veins are clipped and ligated appropriately, and
dissection is carried all the way up to Cleland’s ligament at the pivot point where the flap
is facing a volar defect.
Division of Cleland’s ligament at the base of the flap may be necessary to increase pedicle
length and reduce tension during flap inset. The flap is inset under minimal tension with
permanent or nonpermanent sutures. Before flap inset, the donor site is covered with a
full-thickness or partial-thickness skin graft. A full-thickness skin graft can be harvested
from the groin to minimize any donor site scar on the volar aspect of the forearm, and this
is sewn in with simple sutures of 5-0 chromic catgut, always ensuring that the paratenon
is well protected. One strategy to minimize pedicle kinking and to augment the arc of
rotation of the flap includes making small extension cuts to the base of the flap. Finally, the
tourniquet is released. Some surgeons prefer to release the tourniquet after flap inset but
before application of the recipient bed skin graft to secure hemostasis, thereby reducing the
risk of hematoma formation beneath the graft, leading to graft loss.
The flap can be elevated as an oblique flap from proximal to midlateral. Once the flap
is inset, a bulky soft dressing is used, as well as a Xeroform flap dressing so the skin paddle
does not become dessicated. The hand and upper extremity are elevated for 10 to 14 days
after excess flap tissue is placed over the donor site. Division and inset should be done no
earlier than 2 to 3 weeks later.

A B C

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.

09f_CrossFinger_r6_bs_1046-1073.indd 1052 2/8/2012 10:55:36 AM

 Hand  •  9F: Cross-Finger Flap 1053

Full-thickness skin graft

D on donor defect

Fig. 9F-4  D, Cross-sectional anatomy of

a standard flap and inset with relation to
the neurovascular bundle and skin graft.

Cross-finger flap
covering recipient defect

Flap Variants
•  Reverse cross-finger flap
•  Innervated cross-finger flap
Reverse Cross-Finger Flap
This is a useful flap for adjacent dorsal digital wound coverage including dorsal distal avulsions
and exposure of the distal phalanx. A very thin skin flap overlying the subcutaneous tissue
is carefully elevated at the subdermal plane, hinged contralaterally just above the midaxis
line of the neurovascular bundle. Once the skin has been elevated and distally based on the
contralateral side, a reverse subcutaneous flap is elevated based on the opposite side of the
digit, adjacent to the injured digit. This adipofascial cross-finger flap can be used to rapidly
restore venous drainage and dorsal coverage for digital reimplantation of avulsion injuries
where the subcutaneous vein is used as a flow-through conduit after venous anastomosis.
Division and inset is done 14 days after surgery, with trimming and readjustment of the
flap at the donor site to maximize cosmesis. The arc of rotation of this flap is a little higher
than the traditional cross-finger flap.

A B C

Full-thickness
Large skin defect
Flap skin graft
with lacerated, Elevated thin Flap replaced over
bare extensor design full-thickness exposed paratenon
tendon skin flap and extensor apparatus

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.

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 1054 Part II  Regional Flaps: Anatomy and Basic Techniques

A B C

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

To maximize two-point discrimination in a distal tip reconstruction, optimal volar digital
skin resurfacing should not only provide good cosmesis, but should also offer improved
sensitivity to maximize function. A dorsal digital cutaneous nerve can be dissected proximal
to the flap over the proximal phalanx. Once the flap has been transposed into its recipient
bed, the donor nerve can be anastomosed to a side branch of the volar digital nerve in the
recipient finger. This is rarely performed because of the technical demands of the procedure.

ARC OF ROTATION
The flap rotates like an open book from dorsal to volar.

Dorsal Cross-Finger Flap

A B C

Flap design Arc to adjacent digit Flap inset

Fig. 9F-7 

09f_CrossFinger_r6_bs_1046-1073.indd 1054 2/8/2012 10:55:41 AM

 Hand  •  9F: Cross-Finger Flap 1055

FLAP TRANSFER
Flap transfer is performed in two stages:
• Stage One: The flap is transferred to the volar aspect of the recipient finger leaving
its entire base attached to the donor digit, usually from its radial aspect. Care should
be taken to ensure that the flap has been mobilized enough to allow for a tension-
free transfer without any kinking of the skin bridge.
• tage Two: Successful transfer depends entirely on the flap’s developing adequate
 S
vascular ingrowth from the recipient site. The longer and more secure the inset, the
more rapidly and reliably this neovascularization takes place. It may be feasible to
divide the flap pedicle as early as 10 days, but most surgeons will wait 2 to 3 weeks.

FLAP INSET
The skin bridge from the donor finger is simply divided longitudinally with a No. 15 blade
and inset into the adjacent side of the recipient finger with interrupted monofilament su-
tures. The residual base of the flap on the donor finger is similarly trimmed and inset into
the adjacent dorsal skin graft.

DONOR SITE CLOSURE

In a traditional cross-finger flap, closure is performed using a full-thickness or split-thickness
graft to the dorsum of the donor finger. This is performed with a continuous 4-0 or 5-0
chromic catgut suture. If a dorsal compression dressing is desired, it should be secured with
5-0 nylon or silk tie-over sutures to enhance graft-to-bed apposition.

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 1056 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 18-year-old had a burn scar contracture of the volar aspect of the proximal phalanx,
with limited extension of the metacarpophalangeal joint. After debridement of his contrac-
ture, stable resurfacing was provided with a cross-finger flap harvested from the adjacent
long finger.

A B

C D

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.

09f_CrossFinger_r6_bs_1046-1073.indd 1056 2/8/2012 10:55:43 AM

 Hand  •  9F: Cross-Finger Flap 1057

E F G

H I

Fig. 9F-8  E, The final aspect is seen after flap elevation with preservation of the extensor ten-
don 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 rear-
ranged, as needed. (Case courtesy Michel Saint-Cyr, MD.)

09f_CrossFinger_r6_bs_1046-1073.indd 1057 2/8/2012 10:55:45 AM

 1058 Part II  Regional Flaps: Anatomy and Basic Techniques

This 16-year-old had a degloving injury of the volar aspect of the middle phalanx of the
long finger.

A B C

D E

F G H

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. (Case courtesy Michel Saint-Cyr, MD.)

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 Hand  •  9F: Cross-Finger Flap 1059

This 14-year-old girl presented with an avulsion injury to the right ring finger.

A B

C Reversed flap covering

recipient defect and
reconstructing avulsed D
Intact eponychial defect
skin
island Defect

Thin full-
thickness
skin graft

Elevated thin
full-thickness
skin graft
Originally elevated
thin full-thickness
skin flap covering
Elevated full-thickness
donor defect
subcutaneous flap with
intact skin island

E F G

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. (Case courtesy Michel Saint-Cyr, MD.)

09f_CrossFinger_r6_bs_1046-1073.indd 1059 2/8/2012 10:55:48 AM

 1060 Part II  Regional Flaps: Anatomy and Basic Techniques

This 55-year-old woman had a schwannoma of her left small finger. After resection, there
was a significant soft tissue defect that required more than a skin graft for coverage and best
cosmesis. A cross-finger flap was planned from the dorsum of the neighboring ring finger.

A B

C D

E F

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 func-
tion. (Case supplied by MRZ.)

09f_CrossFinger_r6_bs_1046-1073.indd 1060 2/8/2012 10:55:52 AM

 Hand  •  9F: Cross-Finger Flap 1061

This patient presented for flap coverage after radical debridement of an infected perforating
injury.

A B

D E

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 tourni-
quet 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. (Case
courtesy Guenter Germann, MD, PhD.)

09f_CrossFinger_r6_bs_1046-1073.indd 1061 2/8/2012 10:55:54 AM

 1062 Part II  Regional Flaps: Anatomy and Basic Techniques

A cross-finger flap was used in this patient after a penetrating injury. The defect is shown
following tendon repair and a secondary wound infection.

A B

D E

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. (Case courtesy
Guenter Germann, MD, PhD.)

09f_CrossFinger_r6_bs_1046-1073.indd 1062 2/8/2012 10:55:55 AM

 Hand  •  9F: Cross-Finger Flap 1063

This case is an example of long-term aesthetic and functional results.

A B

D E

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. (Case courtesy Guenter Germann, MD, PhD.)

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 1064 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Never design a cross-finger flap on the volar surface of a digit. Use only a standard or
reverse flap from the dorsum, which can tolerate the loss and take a graft better.
• To maximize distal coverage, the flap can be designed obliquely, with the base of the
flap placed distally and the proximal portion of the flap found proximally once the flap
has been incorporated.
• When raising a reverse cross-finger flap, the surgeon should raise the overlying skin as an
extremely thin cutaneous flap based on the contralateral side of the finger. The subdermal
plexus should be preserved with the skin flap.
• There should be no tension on the flap inset to prevent wound dehiscence.
• The flap is immobilized without tension in a plaster cast or splint for 12 to 14 days. Af-
ter division and inset, early active range of motion exercise should be started. Vigorous
physical therapy is essential to prevent joint stiffness and flexion contractures.

Expert Commentary
Michel Saint-Cyr

Advantages and Limitations

The cross-finger flap is a very robust and dependable flap. It is useful for coverage of the volar
middle phalangeal area and the dorsal digital and distal tip. One of its major disadvantages
is the need for 2 to 3 weeks of immobilization; this places patients at risk for joint stiffness
and flexion contractures, particularly in those over 35 years of age.

Recommendations
Technique
The flap is elevated off the paratenon, and additional subcutaneous tissue can be harvested
as needed to provide better bulk for volar tip coverage from the proximal and distal por-
tions of the dorsal donor site. Also, harvesting the flap with the dorsal digital nerve branch
can provide sensate fingertip reconstruction with neurorrhaphy of the dorsal digital branch
incorporated in the cross-finger flap to a digital nerve stump of the reconstructed digit. The
entire dorsal middle phalanx skin should be harvested to accommodate some adjustments
and tearing in the flap inset.
An alternative is to design an oblique pattern of cross-finger flap to provide a pivot
point, which provides more distal coverage. One key step is to skin graft the donor site
before insetting the flap, which will make skin graft insetting much simpler.
My preferred donor site is the groin—the graft should be obtained from a non-hair-
bearing skin donor site. The graft is sewn in with continuous catgut sutures. I prefer using
a full-thickness skin graft. The flap is inset into the defect under minimal tension and with
application of a petrolatum gauze dressing. The tourniquet is released before the dressing is
applied to confirm adequate vascularity. For a reverse cross-finger flap, dorsal digital veins
can be used as the vein graft for dorsal vein neurorrhaphy.

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 Hand  •  9F: Cross-Finger Flap 1065

EXPERT COMMENTARY
Guenter Germann

Indications
Cross-finger flaps are robust and in their design modifications versatile. Main indications
for the conventional cross-finger flap are palmar defects of the middle phalanx, over the
proximal interphalangeal (PIP) joint, or the proximal phalanx. For a reversed cross-finger
flap, the indication is soft tissue defects over the dorsum of the digits.

Anatomic Considerations
In our understanding, there is no dominant pedicle in the cross-finger flaps. The flaps are
based on small perforators branching off the proper digital artery penetrating the Cleland
ligament structures. This holds true for both modifications of the cross-finger principle.

Flap Design
The flaps are designed as rectangles, or slightly oblique, or in selected cases, even with a
kite design. We have adopted the principle of selecting the most suitable finger as the donor
site, which means that the rule that the radially located finger serves as the donor site is
frequently not applied.

Recommendations
Technique
During dissection, we place the hand on a hand table and the patient in the supine position.
Dissection is performed under tourniquet control. The tourniquet is released only after the
flap has been inset and the skin graft for reconstruction of the donor site has been harvested.
Good hemostasis is achieved before the skin graft is applied.
Preservation of the paratenon of the extensor mechanism is of utmost importance
during dissection to guarantee graft take at the donor site. Subcutaneous veins are usually
coagulated with bipolar cautery, since vessel clips are too bulky, as are ligatures. Dissection
is easy and straightforward. The flap is mobilized to the digital midline, and in some cases
beyond the midline after Cleland’s ligaments have been transected. The perforators are
easily visible under loupe magnification, because we do not exsanguinate the extremity
before the tourniquet is closed.1

Fig. 9F-15  A, Typical indication for a cross-finger flap:

volar defect with exposed flexor tendons.

Continued

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 1066 Part II  Regional Flaps: Anatomy and Basic Techniques

B C D

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.

Reverse Cross-Finger Flap

This modification is raised in the “open book−closed book” technique and is used for dorsal
defects. After a skin incision at the flap border adjacent to the defect, the skin is elevated
in the subdermal plane toward the contralateral border of the donor digit (open book). All
subcutaneous tissue, which forms a very delicate flap, is raised from the remote digital bor-
der above the paratenon toward the defect and is based on the perforators from the proper
digital artery. The flap is then flipped over into the dorsal defect and fixed with some stay
sutures. The thin skin flap is then used to cover the donor defect (closed book). We find
that this delicate flap does not offer as much mechanical stability as the conventional cross-
finger flap and has an arc of rotation that is slightly smaller than the conventional flap.2,3

Take-Away Messages
Cross-finger flaps and reverse cross-finger flaps are extremely useful tools for reconstruction
of small to moderate-sized defects. However, the surgeon should always weigh the options:
whether involving a noninjured digit in the reconstruction process is indicated, or whether
a homodigital solution is preferable. It is important to make the pedicle as robust as possible
by including as many perforators as possible. The paratenon must be respected at all times.
The flap should be designed only slightly larger than the defect and must be sutured
in under minimal tension. The flap can be protected by placing a thick “holding suture”
through the pulp of the donor and recipient fingers. Any lateral movement of the fingers
by the patient will be painful and will force the patient to halt this activity. “Buddy tap-
ing” allows early active exercise of the fingers (usually after 3 to 5 days), helping to avoid
adhesions and eventual limited active range of motion.
Care should be taken when using cross-finger flaps to reconstruct defects of the pulp.
Usually the flaps are insensate, and it is often not possible to include a dorsal nerve branch
into the flap. In more proximal uses, the dorsal nerve branch can be coapted to the stump
of the proper digital nerve if a sensate flap is desired.

09f_CrossFinger_r6_bs_1046-1073.indd 1066 2/8/2012 10:56:01 AM

 Hand  •  9F: Cross-Finger Flap 1067

For defect reconstruction in the conventional cross-finger flap, a full-thickness skin

graft is recommended. This can be taken from the ulnar border of the hand, just above the
midline. This is an almost invisible donor site. The risk of problems when touching surfaces
is low, since the scar is above the hypothenar contact zone. For skin coverage of the reversed
cross-finger flap, a split-thickness skin graft is recommended.4-7

References
1. Megerle K, Palm-Bröking K, Germann G. The cross-finger flap. Oper Orthop Traumatol
20:97-102, 2008.
2. Feijal N, Belmir R, El Mazouz S, et al. Reversed cross-finger subcutaneous flap: a rapid
way to cover finger defects. Indian J Plast Surg 41:55-57, 2008.
3. Al-Qattan MM. The cross-digital dorsal adipofascial flap. Ann Plast Surg 60:150-153, 2008.
4. Shah SH, Thrumurthy SG. Re-establishing functionality and aesthetics after severe burns
over the proximal interphalangeal joint using the cross-digital dorsal adipofascial flap. Burns
37:e16-e18, 2011.
5. Ismail A, Athanasiadou M, Titley OG. Spare parts surgery: the adipofascial cross-finger
flap. J Hand Surg Eur Vol 35:239-240, 2010.
6. Zhao J, Abdullah S, Li WJ, et al. Proximally based cross-finger flap. J Hand Surg Am
36:1224-1230, 2011.
7. Nuzumlali ME, Ozturk K, Bayri O, et al. The versatile reverse-flow digital artery cross-
finger flap. Tech Hand Up Extrem Surg 11:259-261, 2007.

Bibliography With Key Annotations

Abo-hashem Azab Moosa A. Double cross-finger flaps: a novel technique for management of
ring avulsion injuries. Ann Plast Surg 64:409-411, 2010.
The author described a new approach—double cross-finger flaps—for coverage of ring avulsion injuries.
Twenty-two cases of ring avulsion injuries, with patients who met certain criteria, were operated on
by this new technique. Two cross-finger flaps were harvested, one to cover the palmar aspect and the
other to cover the dorsal aspect after being deepithelialized and turned over. A split-thickness graft
was then applied to cover the raw areas. Both functional and aesthetic outcomes were reported after a
mean of 6 months’ follow-up.
Al-Qattan MM. The cross-digital dorsal adipofascial flap. Ann Plast Surg 60:150-153, 2008.
The “homodigital distally based” dorsal adipofascial flap has been used by various authors to cover
small, complex, dorsal, digital defects. In 2004, Al-Qattan reported on 3 cases in which a distally
based dorsal adipofascial flap was used in a cross-digital fashion. This report expanded on the concept
of cross-digital adipofascial flaps in which the flaps are based not only distally but also proximally or
laterally located. A total of 14 patients with complex dorsal digital defects were reconstructed with
cross-digital adipofascial flaps. The main indication for using the cross-digital technique was a concur-
rent dorsal skin shear injury adjacent to the complex defect, which precluded the use of the homodigital
technique. There were 11 males and 3 females, with a mean age of 27 years. All defects were located
on the distal two phalanges of the digits. The adipofascial flap was based distally in 2 patients, later-
ally in 2 patients, and proximally in the remaining 10 patients. Six patients had associated extensor
tendon injury. The cross-digital flap was covered with a split skin graft at the time of transfer, and its
pedicle was divided 3 weeks later under local anesthesia. The mean follow-up time was 6 months.
All flap survived, with no dehiscence or infection. One flap required regrafting at the time of flap

09f_CrossFinger_r6_bs_1046-1073.indd 1067 2/8/2012 10:56:01 AM

 1068 Part II  Regional Flaps: Anatomy and Basic Techniques

division. The mean total range of motion of the involved distal joint of the digit varied according to
associated extensor tendon injury, from 60 degrees in patients with no concurrent tendon injury to
20 degrees in patients with segmental tendon loss requiring tendon grafts. Patients who had concur-
rent nail bed injury developed nail plate deformities such as thinning and ridging. One patient had
nonadherence of the nail plate. All other patients were happy with the aesthetic appearance of the
hand following reconstruction.
Al-Qattan MM. De-epithelialized cross-finger flaps versus adipofascial turnover flaps for the
reconstruction of small complex dorsal digital defects: a comparative analysis. J Hand Surg Am
30:549-557, 2005.
This article described a study comparing the results of two reconstructive options—the deepithelialized
cross-finger flap versus the adipofascial turnover flap—for coverage of small complex dorsal digital
defects. Of 73 patients with small, complex dorsal digital defects, 31 underwent reconstruction with
the deepithelialized cross-finger flap and 42 had reconstruction with the adipofascial turnover flap.
All flaps in both groups survived, with no infection or hematoma. Complications in the first group of
patients included flap dehiscence (1 patient), considerable skin graft loss (2 patients), stiffness of the
donor finger (5 patients), and an inclusion cyst (1 patient). The only specific complication for patients
in the second group was the occasional epidermolysis of the skin of the donor site, which occurred in 6
patients. Patient dissatisfaction with the appearance of the donor site was documented in 10 patients in
group 1 and none in group 2. The elective flap division in the cross-finger-flap group was considered a
disadvantage in children because it required general anesthesia. The versatility of both flap techniques
in digital reconstruction is confirmed; however, considering the type of complication and the need for
general anesthesia in children for cross-finger-flap division, the adipofascial flap was determined to be
superior in the following specific groups: children, older patients, and patients with osteoarthritis and
multiple defects of adjacent border digits.
Al-Qattan MM. Technical modifications and extended applications of the distally based adi-
pofascial flap for dorsal digital defects. Ann Plast Surg 52:168-173, 2004.
A series of 15 cases of distally based adipofascial flaps to cover dorsal digital defects was presented. All
flaps were raised just superficial to the dorsal veins (and hence preserving some fat with the reflected
flaps) rather than raising them at the subdermal plane. In 3 cases there was another injury proximal
to the defect that precluded the use of an adipofascial turnover flap from the injured digit, so a distally
based cross-finger adipofascial flap was used from the adjacent finger. In 4 cases, the flap was used to
cover compound fractures. The results showed complete survival of all flaps without loss of the overlying
skin graft and without epidermolysis of the donor skin, indicating that raising the flap just superficial
to the dorsal veins does not affect the reliability of its blood supply, yet it enhances the blood supply of
the reflected skin flaps. This series also showed uneventful healing of compound fractures covered by
the flap, indicating the flap’s reliability for covering exposed fractures. Finally, the study demonstrated
the feasibility of using the flap as a cross-finger flap.
Dabernig J, Schumacher O, Dabernig W, et al. The reversed dermis flap in a homodigital or cross
finger manner for soft tissue reconstruction in dorsal finger defects. Ann Plast Surg 53:299, 2004.
Dabernig J, Shilov B, Schumacher O, et al. [The deepithelialized cross-finger flap: a good
method for covering large dorsal finger defects] Unfallchirurg 109:647-651, 2006.
Injuries to the dorsum of the finger are common. When combined with exposure of important deeper
structures, flap reconstruction is necessary. The deepithelialized cross-finger flap is a good option for
covering large dorsal finger defects. The authors perform this flap on six patients (two female, four
male). No flap loss or infection occurred. All defects were covered adequately, and no donor site problems
developed. One week after flap division, the function of the involved finger joints had the same range
of motion as the contralateral finger joints. The authors concluded that the deepithelialized cross-finger
flap is a safe method for coverage of large dorsal finger defects. The good postoperative range of motion
supports the indication for this two-step reconstruction procedure.

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 Hand  •  9F: Cross-Finger Flap 1069

Fejjal N, Belmir R, El Mazouz S, et al. Reversed cross finger subcutaneous flap: a rapid way
to cover finger defects. Indian J Plast Surg 41:55-57, 2008.
Adequate coverage of dorsal finger wounds is often a challenge. The reversed cross-finger subcutaneous
flap to cover defects on the dorsum of the phalanx constitutes an excellent option for coverage of wounds
over the middle and distal phalanges of the index, middle, ring, and small fingers. It is an easy flap
to perform and represents the authors’ first choice for covering such defects.
Gokrem S, Tuncali D, Terzioglu A, et al. The thin cross finger skin flap. J Hand Surg Eur Vol
32:417-420, 2007.
Traditionally, the cross-finger flap is elevated in the plane lying superficial to the extensor tendon.
This damages the delicate subcutaneous tissues, which are important for the lengthening capacity of
the skin of the dorsum of the fingers during flexion and extension. The authors presented a modifica-
tion of elevation of the cross-finger flap in a plane superficial to the dorsal veins of the fingers. This
modification prevents donor finger complications such as poor graft take, extensor tendon adhesion to
the graft, reduced range of finger joint movement, and contour deformities. The authors reported their
use of this technique in six digits in four patients with successful results.
Hahn SB, Kang HJ, Kang ES. Correction of long standing proximal interphalangeal flexion
contractures with cross finger flaps and vigorous postoperative exercises. Yonsei Med J 51:574-
578, 2010.
The authors reviewed the results of cross-finger flaps in nine patients after surgical release and vigorous
postoperative exercises for long-standing, severe flexion contractures of the proximal interphalangeal
(PIP) joints of fingers. All contracted tissue was sequentially released and the resultant skin defect was
covered with a cross-finger flap. The cause of the contractures was contact burns in four, skin grafts
in three, and previous operations in two. The mean follow-up period was 41.2 months. The mean
flexion contracture and further flexion in the joints were improved from 73.4/87.8 degrees to 8.4/95.4
degrees at the last follow-up. A mean of 19.5 degrees of extension was achieved, with vigorous exten-
sion exercise after the operation. The mean gain in range of motion was 79.4 degrees. Near full range
of motion was achieved in three cases. There were no major complications.
Hashem AM. Salvage of degloved digits with heterodigital flaps and full thickness skin grafts.
Ann Plast Surg 64:155-158, 2010.
The author discussed the salvage of degloved digits—class III ring avulsion injuries, per the Urbaniak
et al classification—using the heterodigital neurovascular island flap originally developed by Moberg
and Littler, in addition to full-thickness grafts. Six fingers with class III ring avulsion injuries were
included. The volar surface was covered with a heterodigital island flap from the adjacent finger, and
a full-thickness graft was applied to the dorsum. All flaps survived. The mean graft take was 85%,
and mean static two-point discrimination was 8.3 mm. The mean total active range of motion in the
digits with intact tendons was 190 degrees. In the digits with absent tendons, the total active range
of motion was 90 degrees. Cold intolerance and cross-sensibility were reported in half the patients.
Follow-up was from 6 to 42 months. The technique described is useful for salvaging degloved digits
when replantation is not feasible and the patient refuses amputation despite careful counseling. How-
ever, donor finger morbidity is a major concern, and in this regard both patient and surgeon should
consider the decision carefully.
Ismail A, Athanasiadou M, Titley OG. Spare parts surgery: the adipofascial cross finger flap.
J Hand Surg Eur Vol 35:239-240, 2010.
Koch H, Kielnhofer A, Hubmer M, et al. Donor site morbidity in cross-finger flaps. Br J Plast
Surg 58:1131-11135, 2005.
Because relevant literature is scarce, this study was undertaken to assess the donor site morbidity of
cross-finger flaps. It included 23 patients who had undergone reconstruction of a finger defect with a
cross-finger flap. Any additional trauma to the donor finger was an exclusion criterion. Split-thickness
skin grafts were employed for donor site closure in 13 cases, full-thickness skin grafts were used in 10
cases. Follow-up averaged 83 months. Active and passive total range of motion of the donor finger

09f_CrossFinger_r6_bs_1046-1073.indd 1069 2/8/2012 10:56:02 AM

 1070 Part II  Regional Flaps: Anatomy and Basic Techniques

and maximal pinch grip strength in kilopascals were measured. Both parameters were compared with
the corresponding finger of the other hand. The donor site scar was evaluated for instability and pain
in the donor finger was determined subjectively with a visual analog scale. Cold intolerance and the
cosmetic appearance of the donor site were also assessed. Active total range of motion of the donor
fingers averaged 156 degrees. Average active total range of motion of the contralateral control fingers
was 173.6 degrees. There was a significant difference between the donor fingers and the control fingers,
but not between split-thickness and full-thickness grafted donor sites. Grip strength was significantly
impaired in the donor fingers, but there was no significant difference between split thickness and full
thickness grafted donor sites. Subjective cosmetic evaluation by the patients revealed significantly bet-
ter results for full-thickness grafted donor sites. Donor finger pain averaged 2.4, with a range of 0
to 8. Five of the 13 patients with split-thickness grafted donor sites and two of the 10 patients with
full-thickness grafted donor sites mentioned cold intolerance. Although the cross-finger flap is a secure
and valuable option, there is significant donor site morbidity. These results suggest that alternative
solutions should also be considered, and if a cross-finger flap is employed, donor sites should be closed
with full-thickness grafts.
Lassner F, Becker M, Berger A, Pallua N. Sensory reconstruction of the fingertip using the
bilaterally innervated sensory cross-finger flap. Plast Reconstr Surg 109:988-993, 2002.
The authors presented a prospective, nonrandomized study of 15 patients with large soft tissue defects
of the fingertips. In all cases, the fingertips were reconstructed using a bilaterally innervated sensory
cross-finger flap. This sensory fasciocutaneous flap relies on the dorsal branch of the proper digital
nerves, which branch off at the level of the head of the proximal phalanx; sensory supply to the
dorsal skin of the middle phalanx is thus ensured. The reconstructive procedure consists of two steps.
First, the contralateral dorsal branch of the proper digital nerve is elevated with the flap at proximal
interphalangeal joint level. Microsurgical coaptation is performed to the proximal nerve stump of
the injured fingertip. After 3 weeks, when the pedicle is dissected, the second nerve is dissected and
coapted. Clinical results were evaluated after 12 months. Because the regenerative distance is only
1.5 to 2.5 cm, good sensory regeneration should be expected. In nine of 16 flaps, sensory quality of
S2+ (Highet) was present in the flap after 3 weeks. After 12 months, two-point discrimination was
present in all patients, the values ranging between 2 and 6 mm (for two-point discrimination), with
an average of 3.6 mm. The rate of complications was low. With acceptable additional operative action,
a good functional result can be achieved.
Lee JY, Teoh LC, Seah VW. Extending the reach of the heterodigital arterialized flap by cross-
finger transfer. Plast Reconstr Surg 117:2320-2328, 2006.
The heterodigital arterialized island flap is a versatile flap providing robust, vascularized, nonsensate
soft tissue cover for the reconstruction of sizable digital defects. Routine inclusion of a dorsal vein aug-
ments venous drainage and minimizes postoperative congestion. The authors proposed a modification
to extend the reach and versatility of the flap in resurfacing larger digital defects and defects in awk-
ward areas such as the dorsal surface, distal fingertip, and far sides of border digits or thumb. They
reviewed their experience with this technique in 12 patients with digital soft tissue defects. Defects
ranged from 2.0 to 4.5 cm long and from 1.0 to 2.5 cm wide. By positioning the finger defect to the
flap and creating a temporary bridging tissue pocket at the base of the fingers to site the flap pedicle,
the flap was applied to defects of adjacent digits in a cross-finger fashion. Division and inset of the flap
were performed 3 weeks later. Complete survival and primary healing was achieved in all the flaps,
without evidence of venous congestion. Donor morbidity was acceptable. All donor fingers retained
normal fingertip sensation and had minimal stiffness, with return of excellent to good total active
interphalangeal joint motion.
Megerle K, Palm-Bröking K, Germann G. [The cross-finger flap] Oper Orthop Traumatol
20:97-102, 2008.
The conventional cross-finger flap is indicated for soft tissue defects in the proximal or middle pha-
langes that are not suitable for skin transplantation. The reversed cross-finger flap is indicated for soft
tissue defects in the dorsal proximal or middle phalanges that are not suitable for skin transplantation.

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 Hand  •  9F: Cross-Finger Flap 1071

Contraindications include extensive tissue defects crossing the finger joints, and concomitant injuries
of the neighboring fingers. The adipocutaneous flap is harvested from the dorsum of the finger to the
midlateral line, preserving the paratenon of the donor phalanx. The flap is transferred into the defect
of the neighboring finger, and the donor site is covered with a full-thickness skin graft. For the reversed
cross-finger flap a subcutaneous flap is prepared, with preservation of the paratenon by separating a
skin flap from the subcutaneous fat according to the “open book−closed book” technique. The flap
pedicle is transected after 14 to 21 days. Both fingers are immobilized until the pedicle is transected.
Active and passive physiotherapy exercises can be initiated after 5 to 7 days. The authors reported
uneventful healing in 18 cross-finger flaps, resulting in an average DASH score of 18 after an average
follow-up of 38 months. Twelve results were subjectively judged as very good or good; 16 patients
complained about intermittent cold intolerance.
Mishra S, Manisundaram S. A reverse flow cross finger pedicle skin flap from hemidorsum of
finger. J Plast Reconstr Aesthet Surg 63:686-692, 2010.
A reverse-flow cross-finger pedicle skin flap raised from the hemidorsum has been used that is a modi-
fication of the distally based dorsal cross-finger flap. The flap is raised from the hemidorsum at a plane
above the paratenon; the distalmost location of the base is at the level of the distal interphalangeal
joint. Thirty-two flaps were used from 32 fingers in 32 patients. Of these, 31 (97%) flaps survived
fully; there was stiffness of finger in 1 (3%) patient. Two-point discrimination was 4 to 8 mm in 14.
The patients were followed from 2 months to 3 years. The advantages of this flap are that there is
less disruption of veins and less visible disfigurement of the dorsum of the finger compared with other
pedicled cross-finger skin flaps. The disadvantage of this flap is its restricted width. It is recommended
as the cross-finger pedicle skin flap of choice when the defect is not wide.
Nuzumlali ME, Ozturk K, Bayri O, et al. The versatile reverse-flow digital artery cross-finger
flap. Tech Hand Up Extrem Surg 11:259-261, 2007.
Various flaps have been described for reconstruction of soft tissue defects of the digits, but these are
not applicable to all kinds of defects. Moreover, these techniques are mostly two-stage operations that
require long-term immobilization. In this study, reverse-flow digital artery cross-finger flap was used
to cover various volar and dorsal digital defects in nine cases. Seven of nine cases that were followed for
more than 2 years were evaluated, and all had good results. The authors recommended the reverse-
flow digital artery cross-finger flap as a universal flap that can be used for almost all types of soft tissue
defects of the digits.
Shah SH, Thrumurthy SG. Re-establishing functionality and aesthetics after severe burns
over the proximal interphalangeal joint using the cross-digital dorsal adipofascial flap. Burns
37:e16-e18, 2011.
Sica A, Dubert T. Skin graft and cross finger flap for salvage reconstruction of ring finger avul-
sion. Chir Main 24:246-250, 2005.
The authors reported an exceptional case of complete cutaneous ring finger avulsion. The distal frag-
ment was not replantable because of lack of vessels. The reconstruction restored a functional finger.
Tadiparthi S, Akali A, Felberg L. The “open book” flap: a heterodigital cross-finger skin flap
and adipofascial flap for coverage of a circumferential soft tissue defect of a digit. J Hand Surg
Eur Vol 34:128-130, 2009.
A case of circumferential digital skin loss with exposed tendons from the proximal phalanx to the distal
interphalangeal joint was presented. This was treated with a two-layer heterodigital cross-finger (open
book) flap from the adjacent digit, using a skin-only cross-finger flap to cover the palmar defect and
an adipofascial flap to cover the dorsal defect.
Ulkür E, Acikel C, Karagoz H, et al. Treatment of severely contracted fingers with combined
use of cross-finger and side finger transposition flaps. Plast Reconstr Surg 116:1709-1714, 2005.
The authors combined use of the cross-finger flap and the side-finger transposition flap to cover the skin
and soft tissue defect created by contracture release of severely contracted fingers in eight patients with
Stern type III flexion contractures of the proximal interphalangeal joints. The cause of injury was
burn in six patients and trauma in two patients. The average follow-up period was 11.6 months. All

09f_CrossFinger_r6_bs_1046-1073.indd 1071 2/8/2012 10:56:02 AM

 1072 Part II  Regional Flaps: Anatomy and Basic Techniques

operations were successful. Lack of extension of the proximal interphalangeal joint was improved by
approximately 81.2 degrees for all digits. Stern type III contracture of the proximal interphalangeal
joint can be released by transverse incision and ample resection of scarred tissue, and the resulting
palmar skin defect that cannot be covered by using the finger’s own flaps or cross-finger flap can be
covered by combined use of cross-finger and side-finger transposition flaps.
Ulkür E, Uygur F, Karagöz H, et al. Flap choices to treat complex severe postburn hand con-
tracture. Ann Plast Surg 58:479-483, 2007.
Many regions of the hand are affected seriously in patients with complex severe postburn hand
contractures. Multiple flap choices are available to treat complex severe postburn hand contractures
effectively. The authors prefer the dorsal ulnar flap for the palmar region; the cross-finger flap, side-
finger flap, and the combined use of both for flexion contracture of the fingers; and the rhomboid flap
for web contractures. Eight patients with complex severe postburn hand contractures were treated. The
maximum improvement of joint extension was 75 degrees for the metacarpophalangeal joint and 105
degrees for the proximal interphalangeal joint. The grasp function of the hand dramatically improved,
and the bulk of the flap did not interfere with grasping.
Voche P, Beustes-Stefanelli M, Pélissier P, et al. Coverage of dorsal distal skin defects of the
digits. Techniques and indications. Ann Chir Plast Esthet 53:46-58, 2008.
Distal dorsal skin defects of the digits could be considered as a surgical entity. The coverage of this area
is challenging because of the proximity of the distal interphalangeal joint, the thinness of the extensor
apparatus, and the vicinity of the nail. The authors stated that among the numerous flaps described,
the homodigital turnover pedicled flaps appear the most effective option rather than cross-finger flaps.
Wang J, Ge W, Li J. [Repair the palmar soft tissue defect of the finger with cross-finger flap
with cutaneous branch of the ulnar digital finger] Zhongguo Xiu Fu Chong Jian Wai Ke Za
Zhi 20:37-39, 2006.
The authors reported their use of cross-finger flaps to repair palmar soft tissue defects of the finger in 25
cases (32 fingers) with tendon or bone exposed. There were 18 males and 7 females; they ranged from
13 to 45 years of age. The time from injury to diagnosis was 30 minutes to 48 hours. The tissue defect
size ranged from 1.5 by 1.0 cm to 4.1 by 2.0 cm. All cases were treated with an emergent operation,
and flap sensation was recovered by anastomosing the cutaneous branch of the ulnar digital finger and
the distal digital nerve of injured finger. The flap pedicle was dissected 3 weeks later. Follow-up was
conducted for 6 to 26 months; the cross-finger flaps all survived with full digital fingertips, satisfactory
appearance, good function, and normal sensation. Two-point discrimination was 5 to 8 mm.
Woon CY, Lee JY, Teoh LC. Resurfacing hemipulp losses of the thumb: the cross finger flap
revisited: indications, technical refinements, outcomes, and long-term neurosensory recovery.
Ann Plast Surg 61:385-391, 2008.
Volar-oblique injuries of the thumb pulp are particularly disabling. Many methods have been described
to treat these injuries and provide return of sensibility. The conventional cross-finger flap is an estab-
lished technique and is well suited for intermediate-sized partial pulp losses. The authors reviewed their
experience with this flap and described technical refinements that have contributed to improved early
outcome and long-term neurosensory recovery. Thirty patients underwent 31 cross-finger flaps to the
thumb for volar-oblique pulp defects. Defect sizes ranged from 1.5 to 5 cm in length and 1.5 to 3 cm
in width. Dorsal skin of the index finger proximal phalanx was used in 26 patients, the index finger
middle phalanx in 2 patients, and the long finger middle phalanx in 3 patients. Nine patients were
available for long-term follow-up and were subjected to functional assessment (DASH questionnaire),
sensitivity testing (two-point discrimination, Semmes-Weinstein monofilament testing), and range
of motion evaluation. Thirty of 31 flaps survived. In 1 patient, trauma to the attached flap from the
long finger middle phalanx resulted in flap ischemia. This was revised with a fresh cross-finger flap
from the index finger proximal phalanx. Employed patients were able to return to their original jobs.
Recalled patients (9) were assessed at a mean of 29 months after surgery (range 12 to 70 months).

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 Hand  •  9F: Cross-Finger Flap 1073

All recalled patients regained normal sensibility on two-point discrimination testing. Functional out-
come was satisfactory in 8 patients (DASH score, 0 to 20). The last patient (DASH score, 61.67)
complained of hypersensitivity and cold intolerance that affected his work.
Xie RG, Tang JB, Cheng HB. [Application of reversed digital artery cross-finger flap with
a compound skin pedicle] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 16:181-182, 2002.
The authors reported on their experience in treating 35 fingers in 30 patients with soft tissue defects
at the dorsal side of digital interphalangeal joint and at the fingertips. These were repaired with the
reversed artery cross-finger flap with a compound skin pedicle, 1.5 by 1.0 cm to 2.0 by 2.0 cm. All
cases were followed for 1 to 6 months and evaluated clinically. All of the flaps survived, with good
texture and no swelling; there were no adverse side effects at the donor site.
Zhao J, Abdullah S, Li WJ, et al. A novel solution for venous congestion following digital
replantation: a proximally based cross-finger flap. J Hand Surg Am 36:1224-1230, 2011.
Digital replantations are often complicated by problems of venous congestion. Conservative management
is not always successful. Furthermore, the skin edge around the replanted digit is frequently inflamed
and necrotic, leading to difficulties in restoring venous flow by direct venous anastomosis or interposi-
tional vein grafts. The authors introduced a novel solution using the proximally based cross-finger flap.
They performed this flap in 10 patients who had venous congestion with inflamed, necrotic skin at
their digital replant site. Their initial injuries were amputations. The flaps averaged 3.98 by of 2.59
cm and were harvested from the dorsum of the adjacent, uninjured digit. There was only one failure in
a patient who had sustained a massive crush injury. Of the remaining 9 cases, 7 met or exceeded the
sensory threshold (Semmes-Weinstein monofilament test). Results of the two-point discrimination test
were less than 6 mm in 8 cases. Three patients complained of residual pain (based on the Michigan
Hand Outcomes Questionnaire), and only one was unsatisfied with the resulting appearance. The
proximally based cross-finger flap is pedicled and requires only a single level of venous anastomosis
distally, leading to a higher success rate. It offers a simple yet effective solution for venous congestion.

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 ANATOMIC LANDMARKS
Landmarks Volar skin and pulp of the overlying distal phalanx from the
distal interphalangeal (DIP) joint crease to the injury site.
Size 1.5 3 2 cm.
Composition Skin and volar pulp.
Flap Type Cutaneous.
Dominant Pedicle Terminal branches of both digital arteries.
Nerve Supply Terminal branches of both digital nerves.

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 Section 9G
Hand

Kleinert-Atasoy V-Y Flap

CLINICAL APPLICATIONS
Regional Use
Coverage of transverse distal
fingertip amputations

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 ANATOMY OF THE Kleinert-Atasoy V-Y Flap

Digital artery with

cutaneous branches
to digital pulp

Arterial supply to flap

Sensory nerve supply to flap

Fig. 9G-1 

Dominant pedicle: Digital artery with cutaneous branches to digital pulp

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 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1077

ANATOMY
Landmarks Volar skin and pulp of the overlying distal phalanx from the DIP joint crease to
the injury site.
Composition Skin and volar pulp.
Size 1.5 3 2 cm.

Arterial Anatomy (Type A)

Dominant Pedicle  Terminal branches of radial and ulnar digital arteries
Regional Source  Common digital arteries derived from the palmar arch.
Length  5 to 10 mm.
Diameter  0.2 to 0.3 mm.
Location  Arising from the midlateral line and extending in a volar direction distally into the pulp.

Venous Anatomy
The venous anatomy follows the arterial circulation.

Nerve Supply
Sensory Terminal branches of the radial and ulnar digital nerves arising from the com-
mon digital nerves in the palm. Source nerves are the medial and ulnar nerves,
depending on the finger involved.

Vascular A natomy of the K leinert-Atasoy V-Y Flap

A B

D D

Kleinert-Atasoy volar V-Y flap incision Vascular supply to pulp: Two digital
arteries join to form common trunk

Fig. 9G-2 

Dominant pedicle: Branches of volar digital artery (D)

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 1078 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP HARVEST
Design and Markings
The flap is designed as a triangle, with its broad base forming the proximalmost extent of
the fingertip amputation. The apex ends at the DIP joint crease, unless a more promixal
extension is deemed necessary. It is preferable not to transgress the crease in an effort to
reduce flexion contractures.

Design and markings

for Kleinert-Atasoy V-Y flap

Fig. 9G-3 

Patient Positioning
The patient is placed in the supine position, with the upper extremity extended in a supi-
nated position on a hand table.

GUIDE TO FLAP DISSECTION

This procedure is easily performed with a local anesthetic using a proximal digital block.
It is also feasible to perform this under local finger tourniquet control without having to
resort to exsanguination of the upper extremity with a proximal arm tourniquet. The skin
island is incised through the dermis until the pulp fat is visualized. With the entire skin
island incised along its periphery, medial and lateral mesentery arteries should be preserved
to maintain a robust blood supply to the flap. This is achieved by mobilizing the deep surface
of the pulp fat off the periosteum of the distal phalanx and the flexor sheath of the insertion
of flexor digitorum profundus.
At this point, the flap has been elevated off the underlying bony and tendinous struc-
tures and the skin island has been incised through the dermis, but the subcutaneous fat
within the pulp should be intact along the entire periphery and proximal end of the flap.
Although this will provide some distal movement of the flap, it does not allow adequate
translocation of the flap over the distal phalanx to complete closure of the amputation site.
To allow greater distal movement, the proximal attachments of the flap to the volar fat at
the level of the DIP joint crease need to be divided. This can be undertaken by retracting
the apex of the flap distally to expose the fat at the DIP joint crease, which is then carefully
divided with either a No. 15 blade or fine scissors down to the flexor sheath, taking care
not to damage the sheath itself.

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 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1079

The flap has now been released on its deep surface as well as proximally and is only
attached on broad medial and lateral mesentery arteries consisting of fat containing both
perforating vessels and nerve branches. These maneuvers will usually allow the flap to be
pulled distally to cover the entire amputation site without difficulty. If tension is a problem,
judicious release of the most proximal fibrofatty attachments can be performed while mak-
ing every effort to maintain an adequate blood supply to the flap from either side.

A B
Supraperiosteal
dissection

Flexor tendon

Skin flap

Relationship of skin island

and vascular mesentery arteries
V flap design to distal phalanx

Proximal division
of subcutaneous
tissue to flexor sheath

Flap advancement

Fig. 9G-4 

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 1080 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP VARIANT
Kutler Bilateral Advancement Flaps
The Kutler flaps were developed to provide lateral and medial skin and pulp for advance-
ment into larger distal amputations or slightly oblique amputations unsuitable for a single
Kleinert-Atasoy advancement. Like the Kleinert flap, each flap is based on its terminal
perforating branches from the ipsilateral digital artery. The nerve supply is similarly based
on the ipsilateral digital nerves. As described in the dissection for the Kleinert flap, Kutler
flaps require supraperiosteal mobilization to allow distal advancement. Great care should
be taken when mobilizing the base of the flap, because it is easy to impair the blood flow to
these flaps with proximal detachment. Both flaps are advanced distally, and the wide bases
are sutured together in the distal midline. One of the major disadvantages of this procedure
is that the flaps tend to be smaller than the Kleinert V-Y flap, and multiple suture lines are
present with potential for impaired sensory return and neurogenic pain.

A B

Kutler flap dissection

Fig. 9G-5 

ARC OF ROTATION
The Kleinert-Atasoy V-Y flap rarely advances more than 5 to 10 mm and can rotate over
a curve of about 60 degrees.

A B

Arc of rotation for Arc of rotation for

Kleinert-Atasoy V-Y flap Kutler bilateral flap

Fig. 9G-6 

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 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1081

FLAP TRANSFER
Having mobilized the flap, it is pulled distally with skin hooks and the distal base should
be sutured to the dorsum of the injured finger at each corner. This will allow assessment of
tension and the possible need for more proximal mobilization if necessary.

FLAP INSET
Flap inset is performed with interrupted 5-0 nylon or Prolene sutures starting with the distal
end of the flap being sutured to the dorsum or the amputation site to set the flap tension.

DONOR SITE CLOSURE

The flap should be closed distally first, then the radial and ulnar borders are sutured to the
adjacent skin. This maneuver produces a V-shaped donor site, which is closed longitudinally
in the midaxis of the finger to achieve a Y-shaped closure.

A B

V-Y closure

Fig. 9G-7 

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 1082 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATION
This 21-year-old patient presented with her finger partially amputated.

A B C

D E

F G

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 under-
mined distally between the flap and the distal phalanx. D, The flap was advanced to cover the ampu-
tated fingertip. E, V-Y advancement of the lap. F and G, Final result of the fingertip after healing of the
flap, showing good contour. (Case courtesy Amit Gupta, MD.)

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 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1083

Pearls and Pitfalls

• The flap is most useful for repair of clean, transverse guillotine type amputations of the
distal fingertip.
• Volar oblique amputations encroach too much on the distal territory of the flap design
and may require use of a Kutler flap, or a neurovascular island flap in the case of larger
defects in critically important digits.
• Undermining must be done at the supraperiosteal level, not within the pulp fat of the flap.
• Medial and lateral mesentery arteries must be of adequate size to support viable vascular
inflow. The overlying skin should only be incised through the dermis along the sides of the
flap; the incisions should not extend into the substance of the fibrofatty pulp mesenteries.
• The proximal fibrofatty restraining bands must be carefully divided to prevent necrosis,
but these bands must be adequate to allow distal advancement of the flap.
• Resection of distal bone can be considered to ensure tension-free closure.

Expert Commentary
Amit Gupta, Basem Abdulla Attum

In 1935 Ettore Tranquilli-Leali reported a description of a volar V-Y advancement flap used
for the repair of fingertip amputations.1 In 1970 Harold Kleinert and Erdogan Atasoy1 made
some modifications to this flap to further increase the indications for this procedure. The
main difference between the two flaps has to do with the vascular supply of the graft itself.
The Kleinert-Atasoy flap is classified as an axial neurovascularized island flap.1 Perfusion
of the Tranquilli-Leali flap occurs through the terminal segmental branches of the proper
digital arteries, through the superficial dorsal arch to the proximal dorsal arch, then termi-
nating through the fibroosseous hiatus branches. These flaps were created because previous
methods were able to provide good padding and coverage, but they lacked normal sensation.

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.
Digital
arteries

Continued

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 1084 Part II  Regional Flaps: Anatomy and Basic Techniques

Indications
Initially, bipedicled palmar advancement flaps were thought to be contraindicated in fin-
gertip reconstruction because the dorsal branches of the digital arteries at the proximal
interphalangeal joint level were sacrificed; sacrificing these vessels significantly increased
the risk of dorsal skin necrosis.2 This flap is used when the pulp defect is less than half the
size of the distal phalangeal segment of the finger. For the flap to be effective, the injury
should leave more pulp than nail bed.3
Fingertip amputations can be classified into three different zones:
• Zone 1 injuries occur distal to the bony structures, and the phalanx is preserved.
Most of the nail bed and the integrity of the matrix are preserved. This structure
allows normal nail contours after healing. Treatment for zone 1 injuries is usu-
ally conservative; this may include secondary healing, meticulous wound care, and
conservative debridement. Wound healing can be facilitated by the use of topical
antibiotic ointments, with frequent monitoring of the injury to prevent overgrowth
of excessive granulation tissue.
• Zone 2 injuries are typically located distal to the lunula of the nail bed. These injuries
are also accompanied by bony exposure of the distal phalanx. Management of zone
2 injuries require a local or distant pedicle flap reconstruction.3
• Zone 3 injuries involve the nail bed, with resultant loss of the entire nail bed. The
most common treatment for zone 3 injuries is amputation. Because of the amount of
trauma in zone 3 injuries, tissue reconstruction is not a reasonable treatment option.

Recommendations
Technique
It is best to perform this reconstruction under loupe magnification. This procedure can be
best performed in 12 steps:
  1. Perform a digital block using a combination of 1% lidocaine (Xylocaine) and 0.25%
bupivacaine (Marcaine), both without epinephrine. I perform a digital sheath block.
If it is felt that this injury will require extensive debridement, conscious sedation
with midazolam (Versed) or monitored anesthesia with propofol (Diprivan) could
be used. Alternatively, an axillary block anesthesia may be used.
  2. Create a tourniquet effect by either using a small Penrose drain or a commercially
available digital tourniquet at the base of the injured digit. I use a forearm tourni-
quet; I think this is less traumatic to the digital arteries.
  3. Extensively irrigate the wound with normal saline solution.
  4. Debride the devitalized tissue.
  5. If there is a portion of bone that is protruding from the wound, trim it or remove
it with the use of a rongeur. This will assist in the advancement of the V-Y flap.
  6. Create a triangular advancement flap, with the base of the flap at the cut edge
where the amputation occurred. This flap should be as wide as the widest part of
the amputation (see Fig. 9G-8, A and B). The tip of the flap will extend to the
distal finger crease (see Fig. 9G-8, B).
  7. Make a full-thickness skin incision. I stretch the flap and press the full blade of a
sharp No. 15 blade to the incision to sharply cut the pulp septa without subcutaneous
undermining. Dissection may be performed with tenotomy scissors distally between
the distal phalanx and the bone (see Fig. 9G-8, C) and proximally between the
deep part of the flap and the flexor sheath. Doing this will help in the advancement
of the flap (see Fig. 9G-8, D and E). Drs. Kleinert and Atasoy, who taught me how
to do this flap, emphasized this step: “Dissect as much as you dare in this plane,

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 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1085

and then a little more.” Under no circumstance should subcutaneous undermining

be done, because the vascular supply to this flap resides in this plane.
  8. Advance the newly created flap over the defect and use either 5-0 or 6-0 chromic
catgut to suture it to the nail bed.
  9. Place corner stitches with 5-0 nylon to avoid interrupting the blood supply.
10. Convert the V-shaped defect into a Y-shaped defect (see Fig. 9G-8, E), suturing
with 5-0 nylon.
11. Remove the tourniquet. At this point, take time to observe the capillary refill and
color of the flap. Be aware that this process may take several minutes because of
vasospasm. If 10 minutes have passed and capillary refill is still slow after that period,
check the distal sutures, because they may be sutured too tight.
12. Apply antibiotic ointment over the sutures and cover the site with a protective splint
of your choice.

Advantages of the Flap

There are many advantages of the V-Y plasty technique. First, technically it is simple to
perform. Second, it is cosmetically favored, because scarring is kept to a minimum (see Fig.
9G-8, F and G). Patients report feeling less pain with this procedure, because the flap is not
directly located over the end of the finger.4 This technique also gives the ability to preserve
the normal contours of the dorsal finger and helps preserve the finger fat pad.
One of the main clinically significant advantages of this pedicle flap is the preservation
of normal sensation and two-point discrimination.3 The V-Y plasty technique preserves
the normal sensation of the finger. The main technical advantage of the Kleinert-Atasoy
flap is that it is a bipedicled neurovascular flap. Since this flap is only attached by the neu-
rovascular bundles, it can be advanced further than the Tranquilli-Leali flap. It can also be
used for transverse and dorsal facing amputations, and palmar facing injuries that angle up
to 30 to 35 degrees.5
Postoperative management is simplified as well. Patients require only a simple finger
dressing and guard without any immobilization. Historically, flaps required long-term
immobilization.6
Finally, this technique involves only the injured finger; this results in fewer operations.
Finger stiffness that occurs with other flap techniques is prevented by the single-finger
coverage flap.4 For this flap to be effective, there cannot be any other injuries proximal to
the distal tip injury.7

Complications
As with any procedure, complications do occur. Although infection is rare because this is a
highly vascularized location, infection can occur between the distal phalanx and the flap,
which can result in bone exposure. When this occurs, resection of the distal 2 mm of bone
is performed, with readvancement of the flap in a second operation. If the dorsal branch of
the digital nerve is resected, a neuroma can develop.
The main patient complaint is pain, and unfortunately, it has been shown that this
pain does not decrease in intensity even after attempts to desensitize the nerve have been
performed. Sloughing of tissue occurs if excess tension is applied or if there is disruption in
the blood supply when undermining the flap.3 It has been reported that the nail may have
an irregular contour without hooking.6 Another rare complication is sympathetic dystro-
phy, with hypersensitivity of the fingertip that usually responds to conservative treatment
within a few weeks.6
Continued

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 1086 Part II  Regional Flaps: Anatomy and Basic Techniques

References
1. Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the ampu-
tated fingertip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am
52:921-926, 1970.
2. Gharb BB, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy flap: an anatomical
cadaveric study. J Plast Reconstr Aesthet Surg 63:681-685, 2010.
3. Braga-Silva J, Jaeger M. Repositioning and flap placement in fingertip injuries. Ann Plast
Surg 47:60-63, 2001.
4. Sherman S. Soft tissue coverage. In Cotler J, Madigan L, eds. Skeletal Trauma. Philadelphia:
Saunders-Elsevier, 2009.
5. Calandruccio JH. Amputations of the hand. In Canale ST, Beaty JH, eds. Campbell’s Op-
erative Orthopedics, 11th ed. St Louis: Mosby-Elsevier, 2008.
6. Loréa P, Chahidi N, Marchesi S, et al. Reconstruction of Fingertip Defects with the Neu-
rovascular Tranquilli-Leali Flap. J Hand Surg Br 31:280-284, 2006.
7. O’Connor D, Samuel AW. Finger flaps: using the modified neurovascular Tranquilli-Leali
Flap. Injury 29:564-566, 1998.

Bibliography With Key Annotations

Adani R, Marcoccio I, Tarallo L. Nail lengthening and fingertip amputations. Plast Reconstr
Surg 112:1287-1294, 2003.
Fingertip injuries can be treated in different ways, including shortening with primary closure, skin
grafts, and local or distant flaps. Nail bed involvement complicates fingertip reconstruction and may
influence the choice of treatment. Local flaps can usually replace the pulp and provide a satisfactory
functional and aesthetic result, whereas reconstruction of the fingernail apparatus is more difficult.
Between 1998 and 2001, 12 fingertip injuries with nail bed involvement were treated with a
combination of local flaps (Tranquilli-Leali and Venkataswami flaps) and the eponychial flap. The
eponychial flap described by Bakhach is a backward cutaneous translation flap that lengthens the nail
plate and restores a good appearance of the nail apparatus. This technique is simple to use and can be
used with different flaps for pulp reconstruction.
Brown RE, Zook EG, Russell RC. Fingertip reconstruction with flaps and nail bed grafts.
J Hand Surg Am 24:345-351, 1999.
The authors retrospectively reviewed the cases of 14 fingertips reconstructed with a combination of local
or regional flaps and nail bed grafts, some of which were placed wholly or partially over a deepithelial-
ized flap. Most of the fingertips had sustained a crushing injury and were reconstructed at the time of
the injury. Soft tissue coverage was provided by palmar V-Y flaps in 6 cases, thenar flaps in 4, lateral
V-Y flaps in 2, a Moberg flap in 1, and a cross-finger flap in 1. Split toenail bed grafts were used
in 6 cases, full-thickness nail bed grafts from the amputated part in 6, and split nail bed grafts from
the injured digit in 2. There was 1 partial graft loss and 1 partial flap loss. The remaining cases had
completely successful grafts and good soft tissue healing. Subsequent nail growth and adherence were
good in all but the 1 digit requiring secondary composite grafting.
Elliot D, Moiemen NS, Jigjinni VS. The neurovascular Tranquilli-Leali flap. J Hand Surg Br
20:815-823, 1995.
The authors presented a modification of the flap first described in 1935 by Tranquilli-Leali and
described again by Atasoy et al in 1970. The relative indications for use of the original and the modi-
fied flap were examined in the light of the authors’ experience of 116 flaps over a period of 4 years.

09g_Kleinert-Atasoy_r5_bs_1074-1089.indd 1086 2/8/2012 9:04:04 AM

 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1087

Frandsen PA. V-Y plasty as treatment of finger tip amputations. Acta Orthop Scand 49:255-
259, 1978.
V-Y plasty was performed in 28 patients who suffered from a transverse amputation of the fingertip.
Bilateral V-Y plasty was carried out in 16 cases and single volar V-Y plasty in 12 cases. The average
follow-up period was 32 months. Six patients had postoperative complications that required reopera-
tion in four patients. The follow-up results were satisfactory. The results showed that V-Y plasty is
indicated in transverse amputations through the distal third to half of the nail bed, but only in patients
to whom the length of the finger is of importance.
Gharb BB, Rampazzo A, Armijo BS, et al. Tranquilli-Leali or Atasoy flap: an anatomical
cadaveric study. J Plast Reconstr Aesthet Surg 63:681-685, 2010.
The Tranquilli-Leali and Atasoy volar V-Y advancement flaps are considered workhorse flaps in
the reconstruction of fingertip amputations. However, their description in the literature in terms of
surgical dissection and blood supply is often indistinct. This study described the differences between
the two flaps and highlighted their unique blood supply based on a thorough cadaveric study and
review of the literature. Using 16 fresh cadaveric fingers, 8 Tranquilli-Leali and 8 Atasoy volar V-Y
advancement flaps were dissected, mapping the arterial blood supply using an injectable blue resin.
In all 8 fingertips dissected as described by Tranquilli-Leali, the flap was supplied by the anastomotic
connections between the terminal branches of the palmar digital arteries and dorsal nail bed arcades
via the fibroosseous hiatus. In contrast, in all 8 fingertips dissected as described by Atasoy, the flaps
were perfused through the terminal branches of the palmar digital arteries. The Tranquilli-Leali and
Atasoy volar V-Y advancement flaps, used to reconstruct fingertip amputations, are distinct from one
another in several ways. The most obvious difference is their technique of flap dissection, which in
turn dictates a unique blood supply.
Hu HT, Chen WH, Liu WC, et al. [Fingertip reconstruction using a volar flap based on the
transverse palmar branch of the digital artery] Zhonghua Zheng Xing Wai Ke Za Zhi 21:353-
355, 2005.
Based on the transverse palmar branch of the digital artery, a flap was designed on the volar side of
a digit and reversed to repair fingertip defects; 12 fingers in 11 patients were reconstructed using this
flap. Eleven flaps survived and 1 necrosed. The contour of the reconstructed fingers was good. This
new neurovascular island flap provides excellent padding and sensation for fingertip reconstruction,
and the technique is simple.
Hu H, Zhang D. [Classification of finger flaps and its use in emergency treatment for finger
injuries] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 20:1196-1198, 2006.
From August 2001 to June 2005, 112 injured fingers were surgically treated in 108 patients (68
males, 40 females; ages 16 to 63 years). The patients underwent operations 2 hours after the inju-
ries. Nine kinds of flaps were taken from the dorsal or volar aspect of the injured fingers to cover the
defects of the distal fingers. The flaps were divided into two categories: (1) flaps that were nourished
by the main digital arterial branches, including the V-Y island flap based on the digital neurovascular
bundles, the reversed digital artery flap, the modified Moberg flap, and the twin flaps based on the
digital general neurovascular bundles; and (2) flaps that were nourished by the collateral digital arte-
rial branches, including the dorsoulnar arterial retrograde flap of the thumb and the reverse flap based
on the dorsal branches of the digital artery, the volar flap based on the transverse palmar branch of
the digital artery, and the island flap from the dorsum of the index finger and the digital local flaps.
Follow-up ranging from 2 weeks to 8 months revealed that all the flaps survived, with the exception
of flap necrosis in 3 patients and superficial necrosis in 3 patients. Sensation reached almost normal
levels in the flaps based on collateral digital arteries, and two-point discrimination was between 5
and 10 mm in the flaps based on the arterial branches. Finger motion ability was good, and finger
appearance was satisfactory.

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 1088 Part II  Regional Flaps: Anatomy and Basic Techniques

Jackson EA. The V-Y plasty in the treatment of fingertip amputations. Am Fam Physician
64:455-458, 2001.
Fingertip amputations are commonly seen by family physicians. The classification of fingertip inju-
ries corresponds with the normal anatomy of the tip of the digit. There are three zones of injury; the
V-Y plasty technique is used to repair zone II injuries. The plane of the injury can be described as
dorsal, transverse, or volar. The dorsal and transverse planes lend themselves to the use of the V-Y
plasty technique. In carefully selected injuries, the family physician can use this technique to repair
the injured digit. The use of a single V-Y plasty has replaced the original technique that repaired the
digit and restored the contour of the fingertip. Good cosmetic and functional results can be obtained.
Complications may include flap sloughing, infection, and sensory changes.
Kawakatsu M, Ishikawa K. Dorsal digital perforator flap for reconstruction of distal dorsal finger
defects. J Plast Reconstr Aesthet Surg 63:e46-e50, 2010.
The authors presented the cases of three patients in whom defects of the distal part of the dorsum of
the finger were covered with a rotation flap or V-Y advancement flap based on a single perforating
branch of the digital artery running from the volar to the dorsal side. This method is useful for the
reconstruction of the distal dorsal region of the fingers, because the flap is more mobile, has a smaller
skin island, and is less invasive compared with previous flaps. This type of flap conforms to the concept
of a perforator flap arising from the main artery.
Kim KS, Yoo SI, Kim DY, et al. Fingertip reconstruction using a volar flap based on the trans-
verse palmar branch of the digital artery. Ann Plast Surg 47:263-268, 2001.
The authors described a new homodigital neurovascular island flap for fingertip reconstruction, called
a volar digital island flap. The flap is perfused from the proper digital artery through the transverse
palmar branch and is drained through the tiny venules and capillaries contained in the perivascular soft
tissue. Between 1997 and 2000, 25 fingers from 23 patients with defects of the middle and distal
phalangeal areas were reconstructed using this flap. All flaps survived well. Patients ranged in age
from 17 to 65 years (average 32.5 years). Long-term follow-up for more than 6 months was possible
in 15 fingers from 14 patients. Light touch and temperature sensation could be detected in all the
flaps evaluated. The mean value of the static two-point discrimination test was 4.2 mm. Although
this flap requires the sacrifice of important volar skin, it provides excellent padding and sensation for
fingertip reconstruction. The authors presented this new flap as an alternative choice for coverage of
fingertip defects.
Kojima T, Kinoshita Y, Hirase Y, et al. Extended palmar advancement flap with V-Y closure
for finger injuries. Br J Plast Surg 47:275-279, 1994.
The authors described a technique of using volar advancement flaps with V-Y closure to the fingers.
It is possible to perform volar flap advancements up to 15 mm and use V-Y closures in the distal
palm, avoiding a skin graft. This method is based on knowledge of the vascular anatomy of the finger
dorsum, to avoid devitalizing dorsal skin. This method was applied to 14 fingers of 13 patients in-
cluding finger amputations, claw nail deformities, and skin defects of the middle phalanx. Favorable
results were observed.
Mehling I, Hessmann MH, Hofmann A, et al. [V-Y flap for restoration of the fingertip] Oper
Orthop Traumatol 20:103-110, 2008.
The V-Y flap is indicated for reconstruction of transverse or oblique defects of the fingertip, including
those with exposed bone of the distal phalanx. It is not suitable for larger defects of the phalanx over
the proximal interphalangeal joint, crush injury of the finger, preexisting lesions of the fingertip, or in
patients with circulatory disorders or contamination or infection of the finger. The authors described a
single volar (Tranquilli-Leali, Atasoy) or a bilateral V-Y flap (Geissendörfer, Kutler) for restoration
of the fingertip. The incision is V-shaped and is converted to a Y as the flap is advanced. The subcu-
taneous tissue of the flap contains neurovascular structures and provides sensibility and padding of the
fingertip. A distal advancement of the flap up to 10 mm is possible with this technique. The finger
is immobilized with a two-finger splint for 1 week. This approach produces good functional results.

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 Hand  •  9G: Kleinert-Atasoy V-Y Flap 1089

Meyer-Marcotty MV, Kall S, Vogt PM. [Neurovascular flaps for the reconstruction of fingertip
injuries] Unfallchirurg 110:433-446, 2007.
The fingertip is an extremely specialized end organ with a highly developed sense of touch. The
authors presented different ways of reconstructing a traumatized fingertip. They also explained the
differential indications for the techniques available. The whole spectrum of fingertip reconstruction
was discussed, starting from local neurovascular flaps (palmar V-Y Atasoy, Kutler, palmar Moberg,
lateral Venkataswami and Subramanian, palmar Hueston), distant flaps (Littler, Foucher, dorsal
metacarpal artery, cross-finger, reversed cross-finger), and free flap transfer (free toe-pulp transfer, spare-
part transplantation). The advantages and disadvantages of each flap were highlighted. The authors
presented an algorithm to help the surgeon determine the correct type of reconstruction.
Ozyigit MT, Turkaslan T, Ozsoy Z. Dorsal V-Y advancement flap for amputations of the fin-
gertips. Scand J Plast Reconstr Surg Hand Surg 41:315-319, 2007.
Amputations of the fingertip are the most common injuries to the upper limbs, and they cause the
greatest socioeconomic losses. The first choice of repair technique should be the simplest and fastest,
with rapid restoration of function and an acceptable aesthetic appearance. The repair should return
individuals to their jobs rapidly to prevent economic loss. Volar V-Y advancement flaps should therefore
be considered first, but unless the dorsal loss is greater than the volar, this first choice of flap cannot be
used because of the inadequate donor area. The authors presented a method for treatment of amputa-
tions that are proximal to the matrix of the nail. Seven volar oblique or transverse amputations were
treated with dorsal V-Y advancement flaps with or without volar V-Y advancement flaps. All flaps
survived. The procedure is simple, versatile, and a reliable way of reconstructing amputations of the
fingertip that are proximal to the nail bed.
Ren ZY. [V-Y advancement of volar skin flap in the repair of fingertip defect and cicatricial
contracture] Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 9:91-92, 1993.
The traditional Kutler and Atasoy V-Y advancement flaps have minimal range of advancement,
so they are not satisfactory for the repair of large skin defects in the fingers; hence there are limited
indications for their use. The sensory function of the repaired fingers is impaired because of injury to
sensory nerves and scar formation. From 1985 to 1991, the V-Y advancement flap with bilateral
digital arteries and nerves as the pedicle was used for the reconstruction of 33 fingertip defects and
5 digital volar cicatricial contractures. Satisfactory results were obtained in all cases.
Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction. J Hand
Surg Am 8:254-259, 1983.
The author described an operation based on anatomic studies showing the pattern of the fibrous septa
and neurovascular bundles of the distal phalanx. Lateral V-Y advancement flaps are outlined, with
the dorsal incisions going sharply to the bone. With palmar retraction of each flap, dense fibrous bands
on its underside are sharply divided. The palmar incision is made through skin only. The nerves, ves-
sels, and adipose tissue of this pedicle are preserved while the fibrous septa are carefully divided. This
technique permits 10 to 14 mm advancement of each flap. Complete division of the dorsal pedicle
permits great mobility of the flap without functionally diminishing circulation or innervation. This
procedure is particularly useful in traumatic fingertip amputations with the palmar and transverse
oblique deformities. Elective remodeling of irregular fingertips has also been aided by this operation.
Tupper J, Miller G. Sensitivity following volar V-Y plasty for fingertip amputations. J Hand
Surg Br 10:183-184, 1985.
The volar V-Y plasty is a well-accepted method of management for transverse fingertip amputations.
It has been suggested by some authors and assumed by some surgeons that fingertip sensation is nearly
normal following the procedure. Sixteen patients with 20 fingertip injuries reported an average estimate
of sensitivity of 73% of normal. There was diminished sensation to testing by two-point discrimination
and/or von Frey monofilament testing in all fingertips when compared with the contralateral digit.
Eight patients (12 fingertips) reported hypersensitivity, particularly cryalgia. The authors concluded
that sensation is not normal in almost all fingertips treated by V-Y plasty for transverse amputations.

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 ANATOMIC LANDMARKS
Landmarks Flap is designed from the distal thumb tip to just proximal to the
metacarpophalangeal flexion crease on the volar aspect of the
thumb. Lateral flap borders are the midaxial line on the ulnar
and radial aspect of the thumb.
Size 1 to 1.5 cm 3 4 to 6 cm; essentially covers the whole length of
the volar aspect of the thumb, with extension into the thenar
space as needed.
Composition Fasciocutaneous advancement or island flap.
Flap Type Type A.
Dominant Pedicle Perforating branches of the ulnar and radial digital arteries of
the thumb.
Nerve Supply Digital radial and ulnar digital nerves arising from the median
nerve sensory component.

09h_Moberg_r3_ek_1090-1106.indd 1090 2/6/2012 6:12:38 PM

 Section 9H
Hand

Moberg Advancement Flap



CLINICAL APPLICATIONS
Regional Use
Thumb

With contributions by Michel Saint-Cyr, MD.

09h_Moberg_r3_ek_1090-1106.indd 1091 2/6/2012 6:12:41 PM

 ANATOMY OF THE Moberg Advancement Flap

Digital
artery

Superficial and deep

palmar arch with
radial and ulnar
artery contribution

B C

Digital
artery

Ulnar
digital
Radial nerve
digital
nerve

Arterial supply to flap area: Perforating Nerve supply to flap area: Radial and ulnar
branches of ulnar and radial digital digital nerves arising from median
arteries of thumb nerve sensory component

Fig. 9H-1 

Dominant pedicle: Ulnar and radial digital arteries of the thumb, perforating branches

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 Hand  •  9H: Moberg Advancement Flap 1093

ANATOMY
Landmarks Flap is designed from the distal thumb tip to just proximal to the metacarpo-
phalangeal flexion crease on the volar aspect of the thumb. Lateral borders of
the flap are represented by the midaxial line on the ulnar and radial aspect of
the thumb.
Composition Fasciocutaneous advancement or island flap.
Size 1 to 1.5 cm 3 4 to 6 cm; essentially covers the whole length of the volar aspect
of the thumb, with extension into the thenar space as needed.

Arterial Anatomy (Type A)

Dominant Pedicle  Perforating branches of ulnar and radial digital arteries of the thumb
Regional Source  Superficial and deep palmar arch with radial and ulnar artery contribution.
Length  5 mm for the perforating vessels.
Diameter  1 mm for the digital arteries; 0.2 to 0.3 mm for the perforating branches.
Location  Digital arteries of the thumb lie in a more volar position than do the digital arteries
of the fingers. The same is true of the digital nerves. The vessels lie at least 5 mm volar to the
midlateral line of the thumb on either side.

Venous Anatomy
The flap is drained by venae comitantes running parallel to the digital artery as well as a subcutane-
ous venous plexus within the volar subcutaneous tissue of the thumb. The thumb can be considered
to have an independent dorsal blood supply provided by the dorsalis pollicis artery branch, which
is a branch of the radial artery. This independent blood supply allows safe mobilization of the volar
advancement flap without compromising the thumb’s dorsal blood supply, unlike the fingers, which
rely on dorsal branches of the digital artery for their dorsal blood supply. All fingers except the small
finger have an independent dorsal blood supply that terminates at the proximal phalanx. Distal to
this, the dorsal branches of the palmar proper digital arteries, which can be found at the proximal
and distal interphalangeal joints, provide the dorsal blood supply. Therefore advancement of flaps
in a digit other than the thumb must preserve at least one side of the dorsal branches of the proper
digital artery to maintain adequate skin perfusion distal to the proximal phalanx.

Nerve Supply
Sensory Digital radial and ulnar digital nerves arising from the median nerve sensory
component.

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 1094 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Moberg A dvancement Flap

A B

D
D

Deep surface of Moberg volar advancement flap Closeup view of flap base

Fig. 9H-2 

Dominant pedicle: Digital artery (D)

FLAP HARVEST
Design and Markings
The midaxial skin incisions are marked just dorsal to the neurovascular bundle on the radial
and ulnar aspects of the thumb. These markings extend from the wound edge distally up to
the metacarpophalangeal (MCP) joint flexion crease proximally on the volar aspect. For an
extended palmar advancement flap variant, the incision would follow through proximally
over the thenar eminence in a V fashion to provide additional advancement. Alternatively,
Burow’s triangles can be marked at the base of the flap to allow further distal advancement.

Moberg volar
advancement flap design

Fig. 9H-3 

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 Hand  •  9H: Moberg Advancement Flap 1095

Patient Positioning
The patient is placed in the supine position with the arm abducted, extended and stable in
supination, on a hand table.

GUIDE TO FLAP DISSECTION

Flap elevation proceeds from distal to proximal. Bilateral midaxial incisions are made dorsal
to the neurovascular bundle to incorporate the radial and ulnar neurovascular bundles within
the flap design. Distally, the midline of the flap and subcutaneous tissue is dissected off the
periosteum of the distal phalanx of the thumb and off the flexor tendon sheath of the flexor
pollicis longus tendon. Dissection continues in an areolar tissue plane just above the flexor
tendon sheath; both neurovascular bundles are identified bilaterally during the early distal
dissection. The midaxial incisions are adjusted as needed, and both neurovascular bundles
must be included in the flap for proper vascularity.
Dissection of the Moberg flap continues proximally and encompasses the entire volar skin
of the thumb, which is separated from the underlying flexor tendon sheath and periosteum.
The flap can also be converted to an island flap by cutting the base of the Moberg flap over
the volar aspect of the MCP joint. This will provide additional advancement without the
need for acute flexion of the interphalangeal (IP) joint, which can lead postoperatively to
flexion contracture and stiffness. Any dorsal branches from either the ulnar or radial digital
arteries are ligated if they interfere with advancement of the Moberg flap. The thumb has
an independent blood supply originating from the branch from the indicis pollicis and can
tolerate bilateral sacrifice of both neurovascular bundles because of its independent blood
supply from the indicis pollicis.
If the flap is elevated as a neurovascular island advancement flap, the two neurovascular
bundles are not skeletonized, and a generous cuff of fibrofatty tissue is kept surrounding the
pedicle and neurovascular bundles proximally bilaterally to minimize any risk of vasospasm.
The flap is then advanced as needed over the distal tip defect and sewn above the nail bed,
to allow for soft tissue contracture and to prevent a hook-nail deformity. Therefore over-
correction is required by 2 or 3 mm to account for postoperative contraction of the flap.

A B C

Bilateral midaxial incisions for Flap and subcutaneous

advancement flap tissue dissection

Fig. 9H-4 

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 1096 Part II  Regional Flaps: Anatomy and Basic Techniques

If the flap is advanced as a pure advancement flap, the donor site does not require closure,
and the midaxial lines are closed with either permanent or nonpermanent simple sutures
under minimal tension, so as to not create any ischemia during flap insetting. If additional
advancement is required in the form of an island flap, the proximal defect is closed with
either a split-thickness or full-thickness skin graft or a triangular transposition flap; these
are proximally based and are designed off of the ulnar and radial aspects of the thumb.

D E

Closure with straight advancement Advancement with proximal release and

closure with straight transposition flap

Fig. 9H-4 

FLAP VARIANTS
•  Cupped Moberg flap for increased volume in the digital pulp of the thumb
•  Extended Moberg flap or extended palmar advancement flap of the thumb
•  O’Brien modification of the Moberg flap

Cupped Moberg Flap

To maximize volume and tissue, the distal portion of the Moberg flap can be cupped and the
raw edge of the distal portion of the flap allowed to heal by secondary intention to provide
better padding and contouring to the reconstructed pulp of the thumb. Overprojection and
overadvancement are required to allow for secondary contraction from an open wound.

Extended Palmar Advanced Moberg Flap

If additional advancement is required, a triangular V extension is performed over the thenar
eminence and the skin of the thenar eminence in conjunction and continuity with the Mo-
berg flap. The donor site is closed in a V-Y fashion to provide support for the V-Y closure,
and the skin overlying the thenar space and thenar muscle are elevated above the fascia.

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 Hand  •  9H: Moberg Advancement Flap 1097

O’Brien Modification
In the O’Brien modification, the Moberg flap is transformed from a volar advancement
flap to a volar island flap. The donor site is closed with either lateral triangular transposition
flaps or with a full-thickness skin graft (see Fig. 9H-4, B and D).

ARC OF ROTATION
This is an advancement flap; therefore the arc of rotation is somewhat limited.

A B

Advancement flap Island flap

Fig. 9H-5 

FLAP TRANSFER
Fine single skin hooks are placed at the distal corners of the flap, and distal traction is used
to advance the flap over the distal aspect of the thumb. Further proximal release can be
performed as indicated. In addition, some degree of IP joint flexion will allow a more
tension-free closure at the risk of increasing permanent flexion contracture of the thumb.

FLAP INSET
The flap should be inset over the transverse or volar oblique amputation, with overprojec-
tion of the flap above the nail bed to minimize soft tissue contracture and to avoid any nail
bed deformities that would result in a “parrot-beak” overhang in subsequent nail growth.
The flap should be advanced and inset under minimal tension, and the IP joint can be
flexed temporarily to off load any tension on the flap insetting. This can be corrected with
progressive night splinting with the thumb in extension over the next 6 weeks after surgery.

Donor Site Closure

The donor site is closed with nonabsorbable 5-0 or 4-0 nylon or Prolene. As with all intrinsic
hand flaps, the site should not be closed under tension to minimize any risk of ischemia.

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 1098 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 56-year-old man presented with a transverse amputation of the right thumb.

A B

D E

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 as-
pects 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 mobili-
zation 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. (Case courtesy Michel
Saint-Cyr, MD.)

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 Hand  •  9H: Moberg Advancement Flap 1099

This 16-year-old patient had right thumb pulp atrophy and constant pain with contact
following a crush injury to the thumb.

A B

C D

E F G

Fig. 9H-7  A and B, The patient had right thumb pulp atrophy and constant pain with contact follow-
ing a crush injury to the thumb. C and D, The Moberg flap was elevated, incorporating both neurovas-
cular 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 neuro-
vascular bundle following flap advancement. (Case courtesy Michel Saint-Cyr, MD.)

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 1100 Part II  Regional Flaps: Anatomy and Basic Techniques

This 35-year-old man had lost the volar 1.5 cm of his thumb pulp in an accident with a
wood-splitter.

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. (Case courtesy Steven L.
Moran, MD.)

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 Hand  •  9H: Moberg Advancement Flap 1101

Pearls and Pitfalls

• The Moberg flap has an extremely robust and dependable blood supply with vascular
anatomy that is straightforward and well known to all hand surgeons. Dissection should
start from distal to proximal to better identify the neurovascular bundle distally. This
flap must be harvested with the neurovascular bundles left intact within the flap design.
• Flexion of the IP joint may be required to assist in closure of the defect and to provide
better advancement of the Moberg flap. The Moberg flap is notorious for causing IP joint
contracture of the thumb. This is particularly true in patients over age 35, in whom any
degree of prolonged joint flexion is likely to cause a permanent flexion contracture. If
flap advancement is limited and does not provide enough mobilization for thumb tip
coverage, the four following procedures can be performed to overcome this.
– The interphalangeal joint of the thumb can be flexed as necessary and may be pinned
in a position of flexion as needed to provide better flap immobilization. A progres-
sive static extension splint will be required, once the flap heals, to address any flexion
contracture of the IP joint. This is rarely a significant problem.
– The incision can be extended from the volar metacarpophalangeal crease into the
palm and thenar space. This creates a longer flap, which can be advanced. The donor
site is closed in a V-Y fashion, or it can be closed with the use of two small triangular
transposition flaps or rotation flaps.
– The two Burow’s triangles can be excised at the flap base to facilitate advancement
of both sides of the flap.
– An incision can be made on the volar aspect of the MCP joint at the base of the flap
to convert the flap into an advancement island flap with the donor site covered with
a full-thickness skin graft.

Expert Commentary
Michel Saint-Cyr

Indications
The Moberg flap or palmar advancement flap is a classic volar flap that replaces gla-
brous skin with like glabrous skin for transverse and volar oblique defects of the dis-
tal thumb. This maintains the length of the thumb and provides immediate two-
point discrimination, replacing like with like. The skin texture, color, and sensitivity
of the flap are identical to that of the native thumb skin. When considering this flap,
the surgeon can anticipate advancement of 1 to 2 cm; any larger defect needs to be
covered with either a pedicled radial forearm f lap or a free wrap-around toe f lap.

Recommendations
Technique
The midaxes of the ulnar and radial aspects of the thumb are marked dorsal to the neuro-
vascular bundle bilaterally, which in this case corresponds to the incision line and dorsal
limits of the flap. Before flap elevation, integrity of the princeps pollicis must be con­‑
Continued

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 1102 Part II  Regional Flaps: Anatomy and Basic Techniques

firmed, so as to not jeopardize the independent blood supply of the thumb. The flap is
then elevated off the periosteum of the distal phalanx and the flexor tendon sheath of
the flexor pollicis longus distally. Dissection is then carried ulnarly and radially to iden-
tify the neurovascular bundle on both sides, and the midaxial incision on both the ulnar
and radial aspects of the thumb are adjusted as needed based on location of the neu-
rovascular bundle distally. A lateral incision of the flap is made with a No. 15 blade,
which can also be used to dissect the flap off the flexor pollicis longus flexor tendon
sheath, with care taken not to damage the flexor tendon sheath.
The neurovascular bundle is irrigated with papaverine during dissection to minimize
any vasospasm, and the midline incisions are carried down all the way to the volar proxi-
mal flexion crease. A V-Y tip of the flap can be performed for smaller defects, although I
prefer using the whole volar aspect of the thumb for advancement to minimize any risk of
vasospasm of the neurovascular bundles. Once the volar base of the MCP joint has been
reached, the IP joint can be flexed slightly to see whether this is all that is needed for proper
tip coverage. If significant advancement is still required, I do not hesitate to make a transverse
incision at the volar base of the MCP joint to convert the flap from an advancement flap
into an island flap. This can provide an additional 1 cm of advancement without creating
a significant donor site deficit. A full-thickness skin graft can be used to cover the donor
site, or the donor site can be closed with lateral triangular transposition flaps.
The flap is then inset under minimal tension, which is critical, so as to not create any
ischemia, and the IP joint is kept in flexion as needed, with no forceful extension until
indicated. The flap is then immobilized for 1 week with soft dressings with the hand in the
position of function and with flexion of the IP joint of the thumb to minimize any risk of
extension and flap ischemia. The distal portion of the flap can be trimmed and contoured
to provide a nicely rounded thumb profile and distal tip.

EXPERT COMMENTARY
Steven L. Moran

Personal Experience and Insights

Clinically, I have found applications of the classic Moberg flap limited to closure of small
defects less than 1 cm in diameter. To enhance the flap’s utility and avoid the necessity of
creating an IP flexure contracture, I have opted to use a technique shown to me by David
Elliot, which is a modification of the O’Brien advancement flap.1 The proximal portion
of the flap is designed in a V fashion, extending proximal to the thenar eminence. This
then allows V-Y closure of the base of the defect without an additional skin graft or lateral
transposition flaps (see Fig. 9H-8). With this modification the flap can be advanced 1 to
2 cm without the necessity for IP joint flexion to provide wound closure. Care is taken to
position the midaxial incisions dorsal to the lateral IP joint creases to prevent the scar from
developing across the thumb pulp.

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 Hand  •  9H: Moberg Advancement Flap 1103

Other options for thumb tip coverage, such as the first dorsal metacarpal artery island
flap and the Littler flap, require reinnervation or recortication to restore thumb sensation.
The Moberg flap allows immediate sensation, restoration of glabrous skin, and a reasonable
cosmetic result.

Reference
1. Elliot D. Thumb coverage. In Moran SL, Cooney WP III, eds. Master Techniques in
Orthopaedic Surgery: Soft Tissue Surgery. Philadelphia: Lippincott Williams & Wilkins,
2009.

Bibliography With Key Annotations

Arons MS. Fingertip reconstruction with a palmar advancement flap and free dermal graft: a
report of six cases. J Hand Surg Am 10:230-232, 1985.
The palmar thumb advancement flap was first described by Moberg in 1964. This article focused on
a refinement of the palmar thumb advancement flap technique that involves augmenting the digital tip
with an autogenous dermal graft. This dermal “padding” is placed directly over the bony tuft to act as
a shock absorber, adding bulk and contour to the distal tip of the finger, increasing soft tissue stability,
eliminating direct percussive tenderness of the bone, and decreasing disability for specific occupations
such as those requiring typewriting. Six cases were reported.
Baumeister S, Menke H, Wittemann M, et al. Functional outcome after the Moberg advance-
ment flap in the thumb. J Hand Surg Am 27:105-114, 2002.
The authors reported on use of the Moberg palmar advancement flap for pulp reconstruction of the
thumb in 36 cases. No flaps were lost. Eighty-three percent of the defects were closed without ad-
ditional iatrogenic bony shortening of the thumb. At a mean of 27 months, sensory testing showed
normal sensitivity in 74% of the 25 patients studied. Minor restrictions in active range of motion in
the interphalangeal joint were mainly attributable to a loss of hyperextension. No thumbs developed
permanent flexion contracture. The flap alone did not result in a reduction in grip strength, but an
additional bony amputation resulted in decreased strength of three-point pinch grip. Seventy-two per-
cent of the patients had no or only mild subjective complaints. The Disabilities of the Arm, Shoulder,
and Hand (DASH) questionnaire, which was used for the first time as a standardized measure to
assess functional outcome after this procedure, showed only minor impairment levels. The authors
concluded that the Moberg advancement flap remains the procedure of choice for covering defects of
the distal palmar thumb.
Dellon AL. The extended palmar advancement flap. J Hand Surg Am 8:190-194, 1983.
The author presented a technique that permits resurfacing up to 3 cm of palmar skin loss from the
thumb while preserving thumb length, minimizing thumb joint flexion contracture, and providing
normal sensibility. The classic Moberg palmar advancement flap is extended proximally onto the
thenar eminence. The radial and ulnar defects created by the distal advancement of the flap are closed
by two additional local rotation flaps. Scarring is acceptable and follows natural lines. The technique
is applicable to both primary repair and secondary reconstruction.

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 1104 Part II  Regional Flaps: Anatomy and Basic Techniques

Elliot D, Wilson Y. V-Y advancement of the entire volar soft tissue of the thumb in distal re-
construction. J Hand Surg Br 18:399-402, 1993.
The commonly used variant of Moberg’s advancement flap for thumb reconstruction requires a skin graft
to reconstruct the proximal thumb defect after advancing the flap. A modification described previously
allows direct closure of this proximal defect by incorporation of the V-Y principle into the design of the
proximal part of the flap. This article presented a variant of the V-Y Moberg flap.
Foucher G, Delaere O, Citron N, et al. Long-term outcome of neurovascular palmar advance-
ment flaps for distal thumb injuries. Br J Plast Surg 52:64-68, 1999.
The authors reviewed their experience with 13 neurovascular palmar flaps for thumb tip coverage: 6
O’Brien and 7 Moberg flaps, with a mean follow-up of 81 months. Both techniques were found to
be safe and effective in preserving pulp sensibility, with a mean two-point discrimination of 5 mm and
a Semmes-Weinstein score identical to that of the contralateral side in 9 cases. The interphalangeal
joint regained a normal range of motion and did not seem to be affected by the perioperative flexion.
The main residual complaints were persistent cold intolerance (present in all cases and severe in 3),
pulp instability (present in 6 and severe in 2), and nail deformity. This last problem was more related
to the injury. Despite these drawbacks, the authors concluded that O’Brien and Moberg flaps remain
their first choice for coverage of 1 to 2 cm pulp defects of the thumb.
Gassmann N, Segmuller G. [Moberg’s neurovascular pedicled palmar moving flap. Analysis of
unsatisfactory results] Handchirurgie 8:77-80, 1976.
Large soft tissue defects of the pulp of the thumb and fingers may be successfully covered using the
palmar advancement flap described by Moberg, which is based on both neurovascular pedicles. In a
series of 21 cases, the authors found no shortcomings with regard to sensibility, padding of the distal
phalanx, or joint function. In 50% of the cases, however, there was a deformity of the nail and dys-
esthesia in the region of the hyponychium.
Macht SD, Watson HK. The Moberg volar advancement flap for digital reconstruction. J Hand
Surg Am 5:372-376, 1980.
The Moberg volar advancement flap has been used to restore normal sensation to soft tissue deficits
of the thumb. Application of this same technique for fingertip injuries was later suggested by Snow,
but differences in digital blood supply led to dorsal tip necrosis and selection of other reconstructive
techniques by many surgeons. Other methods have the disadvantages of widened two-point discrimi-
nation, a tender pulp scar, or an unacceptable donor site scar. The volar advancement flap applied
to fingers restores normal to near-normal sensation and adequate pulp with minimal deformity. The
authors stated that preservation of the dorsal perforating vessels was most important in successfully
executing this procedure. In their cases, no dorsal tip or flap necrosis occurred. Two-point discrimination
was normal or within 2 mm of contralateral values in every digit. Full range of motion, or less than
5 degrees of extension loss, was recorded in all fingers that were normal before operation. The authors
suggested that this is a safe and effective adjunct in the treatment of fingertip injuries.
Martinot V. [Forum: reconstruction of the traumatised thumb. Covering losses of cutaneous
substance of the thumb] Ann Chir Plast Esthet 38:369-75, 1993.
The authors discussed their preferential indications for repairing cutaneous loss of the thumb. The choice
of the flap depends on localization. To repair a frontal amputation, a triangular volar flap (Atazoy) was
performed; to repair a tangential distal amputation, a neurovascular island flap (O’Brien-Moberg) was
used. To repair a tangential palmar amputation, a flap with advancement and rotation (Hueston) was
performed. A free toe-to-fingertip neurovascular flap was necessary to restore sensation after complete
avulsion of pulp. The island kite flap transfer from the dorsum of the index to the thumb (Foucher)
was used to repair loss of the dorsal and palmar side of the first phalanx. For tangential dorsal amputa-
tion, cross-finger and free toe to thumb “custom-made” transfers were possible.

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 Hand  •  9H: Moberg Advancement Flap 1105

Mutaf M, Temel M, Günal E, et al. Island volar advancement flap for reconstruction of the
thumb defects. Ann Plast Surg 2011 May 27. [Epub ahead of print]
The volar advancement flap of the thumb described by Moberg has been used for pulp defects up to
1.5 cm; its mobility is limited by the stiff nature and fibrous connections of the regional skin with
underlying structures. There have been several attempts to increase the mobility of this useful flap by
adding V-Y and Z-plasty concepts into the technique. However, these modifications have provided
only a slight increase in flap advancement and achieved closure of defects up to 2 cm in length at best.
This article described the island volar advancement flap of the thumb in which all attachments except
the neurovascular pedicle of the flap are divided to provide maximum mobility and advancement. The
authors used the technique in 12 patients for reconstruction of traumatic defects of the distal thumb up
to 3.5 cm in length. The flaps healed uneventfully in all patients. There were no flap failures. All
patients were followed for 2 to 6 years. The authors concluded that the island volar advancement flap
seems to be a safe and useful procedure for thumb reconstruction.
Shah R, Cavale N, Fleming A. A modification of the V-Y Moberg advancement flap for thumb
reconstruction. J Hand Surg Eur Vol 32:357-358, 2007.
Zyluk A, Walaszek I, Puchalski P. [Reconstruction of soft tissue defects of the fingers using
homodigital V-Y flap] Chir Narzadow Ruchu Ortop Pol 69:297-300, 2004.
This article presented a series of 54 patients in which full-thickness soft tissue defects on 57 digits were
reconstructed using homodigital V-Y flaps. This is a modification of the Moberg procedure, which was
designed for coverage of injuries of the distal thumb. The V-Y flap is pedicled on two digital neuro-
vascular bundles, possible advancement is up to 2 cm, and the V-shaped base of the flap allows direct
closure of the proximal defect, without skin grafting. This technique was used for the reconstruction
of both volar and dorsal tissue defects of the fingers. All flaps healed within 2 to 4 weeks. Fourteen
patients (15 fingers) were evaluated after they recovered. In all affected fingers, active range of motion
was satisfactory, with only slight defect of extension in 2 cases. However, sensation of light touch
was decreased in 10 fingers, and two-point discrimination was abnormal in 5 fingers. The authors
concluded that the V-Y technique is versatile in various clinical occasions, is easy to learn, and has a
low risk of complications.

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 Chapter 10
Abdomen

The abdomen provides the largest volume and surface area of tissue of all areas of the
body for both local and distant reconstructive applications. Locally, it provides unique
solutions for recurrent ventral hernia and complex abdominal wounds. In particular,
the rectus abdominis complex has a wide range of uses for breast, chest wall, and pel-
vic reconstruction, and, like the latissimus dorsi flap of the back, it is one of the most
ubiquitously used flaps. In an effort to limit abdominal wall morbidity, the abdomen
has been the front line in the development of perforator-based flaps.

Deep Circumflex Iliac Artery (DCIA) Flap

Rectus Abdominis and TRAM/DIEP Flaps
External Oblique Flap
Superficial Inferior Epigastric Artery (SIEA) Flap
Groin Flap
Thoracoepigastric (Transverse Abdominal) Flap
Pudendal-Thigh (Singapore) Flap

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 ANATOMIC LANDMARKS
Landmarks The anterior superior iliac spine (ASIS), the pubic tubercle, and
the curve of the iliac crest are the major landmarks for this flap.
Size 16 3 12 cm.
Composition Osteocutaneous, osseous muscle, and myocutaneous.
Flap Type Type I.
Dominant Pedicle Deep circumflex iliac artery and vein arising from the external
iliac vessels.
Nerve Supply Sensory: T12.

10a_DCIA_r5b_tk_1108-1135.indd 1108 2/8/2012 2:47:40 PM

 Section 10A
Abdomen

Deep Circumflex Iliac

Artery (DCIA) Flap

CLINICAL APPLICATIONS
Distant Use
Head and neck
Breast
Upper extremity
Lower extremity
Specialized Use
Mandible
Breast

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 Anatomy of the Deep Circumflex Iliac Artery (DCIA) Flap

Iliac crest

External iliac artery

Deep circumflex
iliac artery

Anterior superior
iliac spine

Inguinal ligament

Femoral artery

Arterial supply

Ilioinguinal nerve

Lateral femoral
cutaneous nerve

Genitofemoral nerve

Genital branch

Femoral branch

Nerve supply

Fig. 10A-1 

Dominant pedicle: Deep circumflex iliac artery

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1111

Anatomy
Landmarks The ASIS, pubic tubercle, and curve of the iliac crest are the major landmarks
for this flap. This composite flap comprises the anterior iliac crest extending
posteriorly from the anterior superior iliac spine, with the overlying skin and
portions of contiguous muscles.
Composition The flap may be raised as a composite osteocutaneous flap or a soft tissue–only
myocutaneous or perforator flap.
Size 16 3 12 cm. A bony segment measuring up to 18 cm may be elevated; the
12 3 6 cm skin island may be included. For breast reconstruction, the skin island
is larger and extends beyond the iliac crest onto the flank.

Arterial Anatomy (Type I)

Dominant Pedicle  Deep circumflex iliac artery
Regional Source  External iliac artery.
Length  6 to 8 cm.
Diameter  2 to 2.5 mm.
Location  The deep circumflex iliac artery (DCIA) arises from the lateral aspect of the external
iliac artery near the origin of the deep inferior epigastric artery. It then courses laterally toward
the ASIS between the transversalis fascia and the transversus abdominis muscle. Just medial to
the ASIS, a large ascending branch courses superiorly through the transversus abdominis muscle
and then along the deep surface of the internal oblique muscle, which it supplies. Lateral to
the ascending branch, the DCIA courses through the transversalis fascia along the inner lip of
the iliac crest. Here it lies in the line of fusion between the iliac muscle and fascia transversalis.
During this course along the iliac crest, the branches of the DCIA supply the adjacent muscles
and the overlying skin. The artery eventually reenters the transversus abdominis muscle, where
terminal branches anastomose with branches of the iliolumbar and superior gluteal artery.

Venous Anatomy
A single vein accompanies the arterial circulation with an average venous diameter of 1.5 to 2.5 mm.

Nerve Supply
Sensory T12 (a branch of T12 supplies the skin portion of this flap).

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 1112 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the

Deep Circumflex Iliac A rtery (DCIA) Flap
A

Deep surface of osseous muscle flap

Radiographic view

C D

mc

D
D

Deep surface of osteomyocutaneous flap Radiographic view

Fig. 10A-2 

Dominant pedicle: Deep circumflex iliac artery (D)

mc, Myocutaneous perforating vessels; arrows, periosteal vascular connections

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1113

Flap Harvest
Design and Markings
The skin island is designed as an ellipse extending from the ASIS along the curvature of the
iliac crest. The island is centered along the iliac crest. For breast reconstruction, the island
extends posteriorly to the posterior axillary line. The cutaneous perforators are clustered in
an area measuring 6 by 4 cm just above the midpoint of the iliac crest some 5 cm posterior
to the ASIS. Preoperative computed tomographic angiography (CTA) can help identify
these vessels.
The skin design incorporates an extension of the incision made in the inguinal crease,
extending from the femoral pulse laterally to the ASIS. This allows exposure of the proximal
pedicle. If bone without overlying skin is to be harvested, the incision is extended laterally
along the curvature of the iliac crest for the required distance (see Fig. 10A-5, A). For breast
reconstruction, the skin island extends farther laterally and posteriorly to the posterior
axillary line. If a skin island is elevated, then the proximal border of the skin island begins
just past the ASIS.

A B

Myocutaneous flap skin island design

Fig. 10A-3 

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 1114 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
The patient is placed supine on the operating table. Elevation of the buttock on a beanbag
or slight rotation of the pelvis toward the opposite side will facilitate flap dissection. This
is particularly useful when the flap is harvested for breast reconstruction.

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.

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1115

Guide to Flap Dissection

Osseous Flap
After the inguinal crease skin incision is made, the dissection continues through the sub-
cutaneous tissues and the external oblique aponeurosis is identified. Laterally, the external
oblique muscle is identified and the tensor fascia lata is identified below the iliac crest.
The distal extent of the bone harvest depends on reconstructive requirements but usu-
ally extends to the posterior axillary line.
The external oblique aponeurosis is identified and split just above and parallel to the
inguinal ligament.
A

Fig. 10A-5  A, Markings for incision of a standard osseous flap.

The dissection is continued up to the level of the ASIS. Just proximal to the ASIS, the
lateral cutaneous nerve of the thigh is identified as it courses downward from the lateral
abdomen into the thigh.

Fig. 10A-5 B, Division of the external oblique aponeurosis and identification of the vascular pedicle.

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 1116 Part II  Regional Flaps: Anatomy and Basic Techniques

Medial and upward retraction of the spermatic cord or round ligament of the uterus
will expose the external iliac artery and vein. The DCIA can be identified as it takes origin
from the external iliac artery and is traced laterally. The fibers of the internal oblique and
transversus muscles are divided, and the vessel is followed laterally to the level of the ASIS,
where the ascending branch is easily identified and divided.

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.

The DCIA is dissected as it courses laterally along the curvature of the iliac crest. Just
below the vessel the iliac fascia and muscle are divided, thus exposing the inner surface of
the ilium.
D

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.

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1117

Dissection continues until the desired length of iliac crest is reached. The distal end of
the DCIA vessel is divided and the borders of the iliac crest to be harvested are identified.
If the full-thickness iliac crest is required, the tensor fascia lata and gluteus medius are dis-
sected from the lateral border of the iliac crest in the subperiosteal plane.

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.
Dominant pedicle: Deep circumflex iliac artery (D)

The bone is then ready for the osteotomies to complete elevation of the bone. If the
entire thickness of the bone is not required, the tensor fascia lata and gluteus medius need
not be detached, and only the inner table of the iliac bone is harvested. An oscillating saw
is used to divide the bone. The ASIS should be spared. If only the inner lip of the iliac crest
is harvested, the flap is far less bulky and the donor site deformity is less noticeable.

Flap Variants
•  Composite osteomyocutaneous flap
•  Myocutaneous flap
•  Perforator DCIA flap
•  Internal oblique flap

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 1118 Part II  Regional Flaps: Anatomy and Basic Techniques

Osteomyocutaneous Flap
When bone, soft tissue fill, and skin for lining or resurfacing are required, a composite
osteomyocutaneous flap can be harvested. The skin island is designed along the iliac crest
extending from the ASIS posteriorly for the desired length. After identification of the vas-
cular pedicle, as previously described, the skin island is incised and the upper half of the skin
flap is directed down toward the iliac crest. Approximately 3 to 4 cm above the crest, the
three layers of the abdominal musculature are divided, leaving a 2 to 3 cm cuff of muscle
with the skin flap attached to the underlying muscle and bone.
Similarly, along the inferior border the skin is incised and a portion of the tensor fascia
lata and gluteus medius muscles is included with the skin island and iliac bone. The remain-
der of the dissection is similar to that for the osseous flap.

A B

Lateral femoral
cutaneous nerve

Deep circumflex
iliac artery

External iliac
artery
Lateral femoral
cutaneous nerve

C D

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.

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1119

A B

t t

v
v
i
i
i e
e i

C D

i e i i
e
e t
t

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.
Dominant pedicle: Deep circumflex iliac artery (D)
a, Anterior superior iliac spine; e, external oblique aponeurosis; i, internal oblique muscle;
p, pubic tubercle; v, vascular pedicle to internal oblique muscle; t, iliacus muscle.

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 1120 Part II  Regional Flaps: Anatomy and Basic Techniques

v
a

Anterior view of flap

F G

D
D
a
c
c

Full-thickness iliac osteotomy Closeup of flap base

(note muscle cuff)

Fig. 10A-7

Dominant pedicle: Deep circumflex iliac artery (D)

a, Anterior superior iliac spine; c, deep circumflex iliac vein; p, pubic tubercle

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1121

Myocutaneous Flap
Also known as the Rubens flap, this variant’s skin island is larger and is designed to incor-
porate the maximum volume of lower lateral abdominal and flank fat. It can extend well
beyond the iliac crest onto the lower back.
The initial groin incision is made and the pedicle is identified and traced to the ASIS.
At this stage, a larger cuff of muscle is included with the pedicle. The skin island is then
completed and the upper half of the island dissected off the external oblique muscle down to
within 5 to 6 cm of the iliac crest. Here the upper half of the dissection extends through the
external oblique, internal oblique, and transversus muscles. This compound myocutaneous
flap contains perforating vessels into the overlying skin. These perforators are preserved and
muscle is dissected to the iliac crest below the course of the DCIA pedicle. The lower half
is then elevated off the tensor fascia lata and gluteus medius to the lower border of the iliac
crest and over the crest and down along the periosteum of the inner surface of the crest.
Perforating osseous branches of the DCIA are divided during this part of the dissection.
Laterally, the skin and fat beyond the iliac crest are elevated as a fasciocutaneous extension.
The dissection is deep to the fascia, up to the level of the iliac crest, and then deep to the
muscles, as previously described. Final muscle flap elevation is completed by dissecting the
muscles and pedicle off the inner surface of the iliac crest.

A B C

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 4 cm

The flap can be raised as a cutaneous perforator flap based 6 cm
on the variable perforator supply identified by preoperative
multidetector CT angiography (MDCTA). As many as
40% of patients do not have usable single perforators, and ASIS
the traditional myocutaneous dissection has to be used in
these cases. Perforators are centered in a 6 by 4 cm area
just above the midpoint of the crest, approximately 5 cm
posterior to the ASIS.

Fig. 10A-9

Perforator location over iliac crest rim

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 1122 Part II  Regional Flaps: Anatomy and Basic Techniques

The dissection for this flap is identical to that for a myocutaneous flap initially. Once
the ASIS is encountered, the vessels are dissected from the surrounding muscle fibers using
gentle bipolar cautery dissection. The location of the perforators will have been determined
by preoperative MDCTA. The skin island can be raised and subcutaneous dissection car-
ried out directly over the crest until the appropriate vessel is reached. The two dissections
are communicated with bipolar cautery, leaving the bulk of the muscle attachments to
the crest only minimally disturbed. Repair can be undertaken as indicated once the flap is
lifted from the wound.

Internal Oblique Flap

Based on the constant ascending branch of the DCIA near the ASIS, the internal oblique
muscle can be harvested in part to add a component of muscle to an osseous or osteocutane-
ous flap. This extra muscle can be valuable for hardware coverage, intraoral lining, or soft
tissue fill. The muscle as harvested has no muscular function.

A C
b
D

D
b a
D
c c
b

e
p e
e

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.
Dominant pedicle: Ascending branch of DCIA (D)
a, Anterior iliac spine; b, DCIA terminal branch to iliac bone; c, deep circumflex iliac artery;
e, external iliac artery; p, pubis

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1123

E
D

D
D
c

b
b
c

Fig. 10A-10 D, Anterior surface of the harvested flap. E, Posterior surface.

Dominant pedicle: Ascending branch of DCIA (D)
b, DCIA terminal branch to iliac bone; c, deep circumflex iliac artery

Using the skin design and incisions previously described, the muscles are released from
the iliac crest and the DCIA identified. Rather than divide the ascending branch, the space
between the transversalis and internal oblique muscles is developed, following the ascend-
ing branch. Next the space between the exterior and interior oblique muscles is bluntly
developed. The internal oblique muscle can then be harvested, maintaining the attachment
of the vascular pedicle.

Arc of Rotation
This composite flap is primarily used as a free flap for microvascular transplantation. Any
local flap would have its rotation point at the takeoff of the DCIA.

Flap Transfer
The flap is transferred to its recipient site and secured before microvascular anastomosis
based on the location of the defect.

Flap Inset
Following microvascular transplantation the flap is inset into the defect. When a vascularized
segment of iliac bone is included, the bone is inset and fixated with plates and screws before
completion of the microanastomosis. Muscle and skin are then sutured into the defect site.
The internal oblique flap is carefully inset with particular attention to the pedicle of
the internal oblique muscle to prevent any tension or torsion, especially around the bone.

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 1124 Part II  Regional Flaps: Anatomy and Basic Techniques

Donor Site Closure

Osseous and Osteomyocutaneous Flap
Closure of the donor site must be performed carefully to prevent postoperative deformity
and hernia formation. When full-thickness bone has been harvested, the iliac muscle and
fascia should be sutured to the transversalis muscle and fascia. The next layer, the internal
and external oblique muscles, should then be sutured to the gluteal and tensor fascia lata
muscles. The inguinal ligament should be repaired and the skin closed. If the entire thick-
ness of the iliac crest is being harvested, a n
­ oticeable contour deformity will be present.

A B C

Fig. 10A-11 A, Approximation of the iliac muscle and fascia with the transverse muscle and trans-
versalis 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.

When only the inner table of iliac crest has been harvested,
the only muscles needing reattachment and closure are the
external oblique, internal oblique, and transversalis muscles.
This is accomplished by suture anchors or drill holes through
the iliac crest. Because the outer table of bone is preserved,
muscle contour deformity is minimized.

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
Because no bone is resected, donor site closure is straightforward and there is minimal to no
deformity. The internal oblique, external oblique, and transversus muscles are reattached
to the iliac crest with permanent suture and/or suture anchors. A drain is placed.

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1125

Internal Oblique Flap

The external oblique should be carefully repaired back to the inguinal ligament and iliac
crest using nonabsorbable sutures or suture anchors. If muscle harvest has weakened the
remaining fascia and it does not hold sutures well, mesh should be added as an overlay to
secure abdominal integrity.

Clinical Applications
This woman developed cancer of the right breast for which she had a total mastectomy,
chemotherapy, and radiation. She had had a previous abdominoplasty. She underwent
breast reconstruction with a free right inferior gluteal flap that failed. A second gluteal flap
was performed, but this also failed. She was then referred for a second opinion. Despite her
abdominoplasty, she had fullness over her flanks and was deemed a suitable candidate for a
DCIA (Rubens) myocutaneous flap reconstruction from the left hip.

A B

D E

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. (Case supplied by GJ.)

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 1126 Part II  Regional Flaps: Anatomy and Basic Techniques

This 62-year-old man, an ex-smoker, developed a right intraoral squamous cell carcinoma
of the floor of the mouth. A resection was performed, including a right rim mandibulec-
tomy, followed by radiation therapy. Three years later, he developed osteoradionecrosis of
the right mandibular body, with an external draining sinus. He was referred for a right
hemimandibulectomy and composite free flap reconstruction. A composite osteocutaneous
DCIA flap was planned.

A B

C D E

Fig. 10A-13 A, A reconstruction plate was prepared before bony resection to maintain proper con-
tour. 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 sym-
metry and contour. There were no hernias or bulges at the donor site. (Case supplied by GJ.)

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1127

This man presented with squamous cell carcinoma of the right mandible. He underwent a
right segmental mandibulectomy and neck dissection. Immediate reconstruction was per-
formed with a split-thickness osteocutaneous perforator DCIA flap, using the inner table
of the iliac crest to replace the right hemimandible, from the symphysis to the angle. No
osteotomies were required to approximate the shape of the missing mandible.

A B C

Perforator

Anterior superior
iliac spine

D E

Fig. 10A-14 A, Dissection of a right osteomyocutaneous DCIA flap for right hemimandibular recon-
struction. 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. (Case courtesy Matthew M. Hanasono, MD.)

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 1128 Part II  Regional Flaps: Anatomy and Basic Techniques

This man, a bilateral below-knee amputee, presented with a floor of the mouth squamous
cell carcinoma that had invaded the anterior mandible. A segmental mandibulectomy was
performed. Mandibular reconstruction was performed with an osteocutaneous perforator
DCIA flap. The full thickness of the iliac crest was used to approximate the thickness of
the anterior mandible and to allow later placement of an osteointegrated implant. A clos-
ing wedge osteotomy was needed to restore the curvature of the left anterior mandible.
Although only a small cuff of muscle was taken around the two perforators, the skin paddle
was extremely bulky and required further thinning.

A B

C D

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. (Case courtesy Matthew M. Hanasono, MD.)

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1129

This patient presented with an orocutaneous fistula and osteoradionecrosis of his mandible,
which had already been debrided from ramus to ramus. He had severe peripheral vascular
disease affecting the lower extremities bilaterally. Bilateral split-thickness osseous DCIA
flaps were used to reconstruct the left and right hemimandibles. Reconstruction of such an
extensive defect was not possible with bone from a single DCIA flap. Because of size and
complexity, the anterior cutaneous and floor of the mouth mucosal defects were recon-
structed with an anterolateral thigh perforator flap.

C D

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. (Case courtesy Matthew M. Hanasono, MD.)

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 1130 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Meticulous layered closure of the donor defect is essential to avoid herniation of the
abdominal wall. It is preferable to drill holes in the iliac crest or use suture anchors and
sew the muscles back with large-caliber nonabsorbable sutures.
• Mesh should be considered an option to support donor site closure.
• Preservation of the outer lip of the iliac crest will help minimize the donor site deformity.
The DCIA supplies the inner lip and cortex of the iliac crest, the gluteal artery supplies
the outer lip and cortex of the iliac crest; however, the DCIA can carry both cortices.
• The lateral cutaneous nerve of the thigh courses downward medial to the ASIS. It should
be identified and preserved during flap dissection to preserve thigh sensation.
• If a perforator flap is raised, the perforators should be found clustered in an area measur-
ing about 6 by 4 cm, starting approximately 5 cm posterior to the ASIS. Preoperative
MDCTA is helpful in determining perforator caliber and location
• The DCIA is an excellent source of small, vascularized bone grafts with generous pedicles
for use in the extremities and head and neck.
• After the bone is harvested, especially in the case of a split iliac harvest, the exposed
cancellous bone is harvested and bone wax is used to aid in hemostasis. The cancellous
bone is used to pack around hardward and osteotomy sites.

Expert Commentary
Matthew M. Hanasono

Indications
The osseous deep circumflex iliac artery (DCIA) flap has most commonly been used for
mandibular reconstruction, and occasionally for maxillary reconstruction. The osteomyo-
cutaneous variant of this flap allows for simultaneous mucosal or cutaneous reconstruction
for these same defects. Use as a pedicled flap for acetabular reconstruction has also been
described. The curved nature of the iliac crest generally limits its usefulness in reconstruc-
tion to shorter defects of the spine, tibia, or humerus, although osteotomies can be done
to straighten the bone. The myocutaneous DCIA flap can be used in the reconstruction of
virtually any soft tissue defect. Although less popular than the transverse rectus abdominus
myocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP) flap, the myocu-
taneous DCIA flap (Rubens flap) is a reasonable option for breast reconstruction in patients
with ample lateral lower abdominal skin laxity and subcutaneous fat for breast reconstruction.

Advantages and Limitations

The osseous and osteomyocutaneous DCIA flap provides very thick bone stock of reasonable
length, which is particularly desirable in mandibular and maxillary reconstruction when
osteointegrated implants are planned. The natural curvature of the bone is well suited to
hemimandibular reconstruction, usually without the need for osteotomies. For flaps with
a cutaneous component, the skin paddle size can be ample, depending on abdominal and
flank laxity, which is usually desirable in breast reconstruction. The donor site can be well
concealed, even in a bathing suit, especially when bone is not removed and the skin paddle
size is not excessive relative to the patient’s body habitus.

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1131

Skin paddle thickness can also be a limitation of this flap, particularly when an intraoral
mucosal defect is being reconstructed since a bulky soft tissue reconstruction may make flap
inset challenging as well as obstruct the airway. In many cases, intraoperative or delayed flap
thinning may be necessary, particularly when a denture or implant-retained prosthesis is
planned. Obesity can also make exposure challenging during flap dissection, and in some
patients, preclude the use of this flap. Although a long length of bone can theoretically be
harvested (up to 16 to 18 cm), much of that bone is curved, limiting the osseous flap’s use-
fulness when linear defects more than about 10 to 12 cm in length are being reconstructed.

Anatomic Considerations
In addition to the anatomic considerations mentioned in the chapter, the secondary blood
supply to the cutaneous portion of the DCIA flap includes the superficial circumflex iliac
artery (SCIA) and vein (SCIV), which arise from the femoral artery and vein, respectively.
These vessels, which travel within the skin anterior to the anterior superior iliac spine (ASIS),
may be used to augment the vascularity of the DCIA skin paddle. Also, the lateral femoral
cutaneous nerve courses along the inner surface of the iliacus muscle and penetrates the
deep fascia of the thigh about 2 cm inferomedial to the ASIS. The DCIA usually crosses
over the lateral femoral cutaneous nerve near the ASIS, and care should be taken to avoid
injuring it, which could result not only in numbness but also occasionally in dysesthesias.

Personal Experience and Insights

The osteomyocutaneous DCIA flaps can be very useful for reconstruction of composite
head and neck defects. However, an excessively thick skin paddle in many patients often
makes this flap a second line choice following the fibula flap, which usually has a much
thinner skin paddle. Harvest of the cutaneous component as a perforator flap substantially
decreases the bulk of this flap and provides greater freedom with respect to inset of the skin
paddle. Experience suggests that a single skin perforator is usually adequate to support a
skin paddle of about 10 by 15 cm. Thinning of the skin paddle by careful removal of the
deeper layer of fat, below Scarpa’s fascia is usually safe, particularly if minimal thinning is
performed in the region of the perforator itself.
Anterior mandibular defects require closing wedge osteotomies of the iliac bone to
recreate the curvature of the anterior jaw. Lateral mandibular defects often do not require
any osteotomies due to the natural curvature of the iliac crest. Harvest of the bone flap as
a split-thickness flap based on the inner (deep) cortex of the iliac crest bone decreases the
donor site morbidity while still providing ample bone stock that can tolerate osteotomies
due to the robust periosteal blood supply from branches of the DCIA. If osseointegrated
implants are planned, however, either a full-thickness bone flap or a partial full-thickness
bone flap, incorporating the entire thickness of the superior “lip” of the iliac crest is preferred.
The soft tissue myocutaneous or cutaneous perforator DCIA flap is usually a secondary
option in breast reconstruction, since most patients carry greater amounts of redundant skin
and excess adipose tissue in the midline. One option for increasing the size of the soft tissue
flap is “supercharge” the flap by including and anastomosing the SCIA, either to a separate
recipient vessel or by leaving enough length on the ascending branch of the DCIA to anas-
tomose to the SCIA. The deep circumflex iliac vein (DCIV) is usually adequate to provide
drainage to the entire flap, although the SCIV can also be anastomosed to a second recipi-
ent vein, should venous congestion occur.
Continued

10a_DCIA_r5b_tk_1108-1135.indd 1131 2/8/2012 2:48:28 PM

 1132 Part II  Regional Flaps: Anatomy and Basic Techniques

Recommendations
Planning
As mentioned in the chapter, perforator anatomy can potentially be visualized preoperatively
using multidetector CT angiography (MDCTA).1 In addition to confirming the presence of
a dominant perforator and its location, the patency of the DCIA pedicle is also verified. In
the author’s experience, many patients who have peripheral vascular disease affecting their
lower extremity circulation and precluding use of the fibula flap, also have compromised
flow to the DCIA flap.
As described in the chapter, the skin paddle is centered along the superior border of
the iliac crest, beginning in the region of the ASIS. The cutaneous perforators are located
about 2 to 3 cm cephalad to the iliac crest, beginning about 5 cm posterior to the ASIS.
The largest perforator is usually the most anterior. When a dominant perforator is present,
it can be used as the sole blood supply to the skin paddle in the perforator flap variant.2,3 In
addition to MDCTA, a handheld Doppler ultrasound probe can be of assistance in locating
the perforator during operative dissection (Fig. 10A-18).

A B

Fig. 10A-17 A, Skin markings for the planned flap, including the location of a cutaneous perfora-
tor (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.

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 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1133

The internal oblique muscle can be harvested in place of an excessively bulky skin island,
with the iliac crest bone as part of a chimeric myoosseous flap, or in addition to the skin
island as a part of a chimeric osteomyocutaneous flap.4 The internal oblique component
is based on the ascending branch of the DCIA, which is found in close proximity to the
ASIS. This is usually within 1 cm, and rarely more than 2 to 4 cm away, before it enters
the DCIA into the fibroosseous tunnel formed by the line of attachment of the transversalis
fascia and the iliacus fascia on the medial surface of the iliac bone.

Technique
The external oblique muscle and fascia are incised in the direction of their fibers to expose
the internal oblique muscle. The ascending branch of the DCIA lies on the deep surface of
the muscle. Dissection is performed from superior to inferior, taking care not to divide the
intercostal neurovascular structures that supply the rectus abdominis muscle.
When a split iliac crest flap has been designed, the lateral and inferior borders of the
bone flap are cut along the inner table of the bone with a cutting burr, creating a trough that
goes full-thickness through the cortical bone. If the ASIS does not need to be included in
the flap design, the medial extent of the bone flap can also be defined with a cutting burr,
about 1 cm lateral to the ASIS, preventing disruption of the inguinal ligament. In these
cases, the pedicle must be elevated away from the medial iliac bone and protected during
the osteotomy. Next, the superior bone is osteotomized, splitting it along the upper lip of
the iliac crest with an oscillating saw and entering the medullary space.
Control of bleeding with bone wax and use of large-caliber closed suction drains is
recommended. Meticulous closure of the abdominal wall is required to prevent a hernia.
Reinforcement of the closure with bioprosthetic mesh may also be advantageous in increas-
ing the strength of the donor site closure.

Postoperative Care
Patients are mobilized within a few days of surgery and encouraged to ambulate with full
weight-bearing as tolerated.

References
1. Ting JWC, Rozen WM, Grinsell D, et al. The in vivo anatomy of the deep circumflex iliac
artery perforators: defining the role for the DCIA perforator flap. Microsurgery 29:326-329,
2009.
2. Shenaq SM, Klebuc MJ. Refinements in the iliac crest microsurgical free flap for oroman-
dibular reconstruction. Microsurgery 15:825-830, 1994.
3. Bergeron L, Tang M, Morris SF. The anatomical basis of the deep circumflex iliac artery
perforator flap with iliac crest. Plast Reconstr Surg 120:252-258, 2007.
4. Urken ML, Vickery C, Weinberg H, et al. The internal oblique-iliac crest osseomyocutane-
ous free flap in oromandibular reconstruction. Report of 20 cases. Arch Otolaryngol Head
Neck Surg 115:339-349, 1989.

10a_DCIA_r5b_tk_1108-1135.indd 1133 2/8/2012 2:48:32 PM

 1134 Part II  Regional Flaps: Anatomy and Basic Techniques

Bibliography With Key Annotations

Anatomic Studies
Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply
for free groin flaps. Experimental work. Plast Reconstr Surg 64:595, 1979.
Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply
for free groin flaps. Experimental clinical work. Plast Reconstr Surg 64:745, 1979.
These two articles included the original anatomic studies and description of the DCIA flap. The
clinical article described reconstruction of the mandible and extremities using this flap. The authors
demonstrated that the DCIA supplies the bone, surrounding muscles, and overlying skin. In fact,
these authors stated that the DCIA is a better source of blood supply for the skin over the iliac crest
than the superficial circumflex iliac artery.
Ting JW. Rozen WM. Grinsell D. Stella DL. Ashton MW. The in vivo anatomy of the deep
circumflex iliac artery perforators: defining the role for the DCIA perforator flap. Microsurgery
29:326, 2009.
This clinical-anatomic study reported on the location and size of perforators arising from the DCIA
axis. The authors noted that modifications to flaps based on DCIA perforators have been sought to
prevent donor site morbidity as a consequence of muscle cuff harvest. Previous anatomic studies have
been inconsistent in their descriptions of perforator anatomy. A cohort of 44 hemiabdominal walls in
22 consecutive patients undergoing preoperative computed tomographic angiography (CTA) before free
flap surgery was evaluated. The use of CTA was shown to demonstrate DCIA perforators with high
resolution and was able to assess vessel size and location. In 44 hemiabdominal walls, there were 44
perforators larger than 0.8 mm diameter. No suitable perforators existed in 40% of sides, with 32%
of sides having one perforator larger than 0.8 mm diameter, 16% having two perforators, less than
10% had three perforators, and only one side had over four perforators. Perforators emerged from the
deep fascia on an average of 5.1 cm cranial and 3.9 cm posterior to the anterior superior iliac spine
(ASIS). Of the 44 perforators identified, 82% were located within a 4 by 4 cm area, 3 cm superior,
and 2 cm posterior to the ASIS. The authors affirmed the usefulness of CTA in assessing which
patients are suitable candidates for perforator DCIA flaps given the variability of the vascular anatomy.

Clinical Series
Baliarsing AS, Kumar VV, Malik NA, et al. Reconstruction of maxillectomy defects using
deep circumflex iliac artery-based composite free flap. Oral Surg Oral Med Oral Pathol Oral
Radiol and Endod 109:e8, 2010.
The authors described their experience with 8 DCIA flaps for maxillectomy defect reconstruction.
The deep circumflex iliac artery (DCIA) flap has distinct advantages regarding the volume and length
of the bone in reconstruction. The contour of the iliac bone is similar to the maxilla, providing good
aesthetics, and bone volume allows placement of osseous-integrated implants for dental rehabilitation.
They presented 8 cases of maxillary reconstruction using this flap (3 osteocutaneous and 5 osseous
flaps) for benign and malignant maxillary disease, highlighting the variable vascular anatomy, dif-
ficulty of harvest, and the need for meticulous planning.
David DJ, Tan E, Katsaros J, Sheen R. Mandibular reconstruction with vascularized iliac crest:
a 10-year experience. Plast Reconstr Surg 82:792, 1988.
The authors reported on 35 patients who had undergone mandibular reconstruction with vascular-
ized iliac crest. The evolution of the technique in the authors’ hands was outlined. They had three
anastomotic failures and no donor site complications.

10a_DCIA_r5b_tk_1108-1135.indd 1134 2/8/2012 2:48:32 PM

 Abdomen  •  10A: Deep Circumflex Iliac Artery (DCIA) Flap 1135

Hentz VR, Pearl RM. The irreplaceable free flap: Part II. Skeletal reconstruction by micro-
vascular free bone transfer. Ann Plast Surg 10:43, 1983.
The role of the iliac crest as a vascularized free flap based on the DCIA for reconstruction of bony
defects in long bones and the mandible was reviewed.
Jewer DD, Boyd B, Manktelow R, et al. Orofacial and mandibular reconstruction with the
iliac crest free flap: A review of 60 cases and a new method of classification. Plast Reconstr
Surg 84:391, 1989.
This was a retrospective review of 60 vascularized iliac crest free tissue transfers for oromandibular
reconstruction. Flap survival was 95%, and the functional rehabilitation in 86% of the patients sur-
viving intraoral cancer was good. Complications were reported as general complications in 15 patients,
recipient site complications in 22 patients, and donor site complications in 21 patients. The authors
concluded that aesthetic and functional results depend largely on three factors: the extent of the surgery,
the weight of the patient, and the surgeon’s learning curve.
Peek A. Giessler GA. Functional total and subtotal heel reconstruction with free composite os-
teofasciocutaneous groin flaps of the deep circumflex iliac vessels. Ann of Plast Surg 56:628, 2006
The authors presented two cases reconstructed with this variable composite flap. One patient had
a complete heel defect produced by shrapnel injury. The complete calcaneus, soft heel, and Achilles
tendon were reconstructed. The second patient had an empty os calcis after a comminuted fracture and
a lateral crush-induced soft tissue defect. In both patients, stable wound closure, osseous integration,
and weight-bearing ambulation were achieved.
Riediger D. Restoration of masticatory function by microsurgically revascularized iliac crest
bone graft using an osseous implant. Plast Reconstr Surg 81:861, 1988.
Forty-one osteomyocutaneous flap procedures for reconstruction of the mandible and maxilla were
reported. In 38 of the patients an osseous aluminum oxide implant in the vascularized bone graft
was used to restore teeth.

Flap Modifications
Elliott LF. Options for donor sites for autogenous tissue breast reconstruction. Clin Plast Surg
21:177, 1994.
In a review of donor site options the “Rubens flap,” a modification of the DCIA flap, is presented.
It is essentially a DCIA flap with no bone. In selected patients, especially those who have had an
abdominoplasty or failed TRAM flap, this makes an excellent alternative to thigh and buttock tis-
sues. The author emphasizes suturing the external oblique, internal oblique, and transversus muscles
to the iliac crest to avoid postoperative hernias.

Complications
Forrest C, Boyd B, Manktelow R, et al. The free vascularized iliac crest tissue transfer: Donor
site complications associated with 82 cases. Br J Plast Surg 45:89, 1992.
In a retrospective summary of 78 patients who had undergone 82 free vascularized iliac crest tissue
transfers the most frequent problems were described as early postoperative pain and long-term sensory
changes. Major complications such as femoral neuropathy and incisional hernia were infrequent.
Twenty-seven percent of patients complained of pain in the early postoperative period, 27% had late
sensory changes, and 9.7% had hernias. The authors concluded that the donor site morbidity associ-
ated with the free vascularized iliac crest is well tolerated and the functional loss associated with the
procedure is acceptable.

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 ANATOMIC LANDMARKS
Landmarks A vertically oriented abdominal muscle extending between the
costal margin and the pubic region.
Size Muscle: 25 3 6 cm; 45 3 20 with skin paddle.
Origin The muscle has two tendons of origin: the crest of the pubis and
the symphysis pubis.
Insertion The muscle inserts in three fascicles into the cartilages of the
fifth, sixth, and seventh ribs.
Function The rectus abdominis muscle flexes the vertebral column and
tenses the abdominal wall, aiding in flexion of the trunk; it also
plays a role in oblique tilting and rotation of the trunk.
Composition Muscle, myocutaneous, and perforator skin only.
Flap Type Type III.
Dominant Superior epigastric artery.
Superior Pedicle
Dominant Deep inferior epigastric artery.
Inferior Pedicle
Minor Pedicle Segmental intercostal perforators (seventh through twelfth).
Nerve Supply Motor and Sensory: Seventh to twelfth intercostal nerves.

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 Section 10B
Abdomen

Rectus Abdominis and

TRAM/DIEP Flaps

CLINICAL APPLICATIONS
Regional Use
Anterior thorax
Abdomen
Groin and perineum
Distant Use
Head and neck
Upper extremity
Lower extremity
Specialized Use
Breast
Vagina reconstruction

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 ANATOMY OF THE RECTUS ABDOMINIS and Tram/DIEP Flaps

Anterior cutaneous
branches of the Internal mammary
thoracoabdominal artery
nerves (T7-T11)

Musculophrenic
artery
Lateral cutaneous Superior
branches of the epigastric artery
thoracoabdominal
nerves (T7-T11) Tenth posterior
intercostal artery
Eleventh posterior
Anterior and lateral intercostal artery
cutaneous branches
of the subcostal Subcostal artery
nerve (T12) Perforators of
Iliohypogastric superior and
nerve (L1) deep inferior
epigastric arteries
Rectus abdominis muscle Ilioinguinal
anatomy, origin, and insertion Deep circumflex
nerve (L1)
artery
Inguinal ligament Superficial
circumflex
iliac artery
Superficial
C epigastric artery
Rectus Deep inferior
Perforating abdominis epigastric artery
artery, vein, muscle Femoral artery
and sensate
branch of Vascular and neural anatomy
segmental nerve Mixed
segmental nerve

Motor branch of
segmental nerve Deep inferior
epigastric vessels

Mixed sensory supply from intercostal

nerves within rectus muscle

Fig. 10B-1 

Dominant pedicles: Superior epigastric artery; deep inferior epigastric artery

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1139

Anatomy
Landmarks This vertically oriented abdominal muscle extends between the costal margin
and the pubic region. It is a long, flat muscle with three tendinous intersections
located at the level of the umbilicus, the xiphoid process, and midway between
the xiphoid process and the umbilicus. The inscriptions are visible in thin or
muscular individuals.
Composition Muscle, myocutaneous, and perforator skin only.
Size Muscle: 25 3 6 cm; 45 3 20 cm with skin paddle.
Origin The muscle has two tendons of origin: the crest of the pubis and the symphysis
pubis.
Insertion The muscle inserts in three fascicles into the cartilages of the fifth, sixth, and
seventh ribs.
Function The rectus abdominis muscle flexes the vertebral column and tenses the abdomi-
nal wall, aiding in flexion of the trunk; it also plays a role in oblique tilting and
rotation of the trunk.

Arterial Anatomy (Type III)

Dominant Superior Pedicle  Superior epigastric artery
Regional Source  Internal mammary artery.
Length  2 to 3 cm (can be extended with proximal dissection).
Diameter  1 to 2 mm.
Location  Enters muscle on its deep surface after emerging from beneath the lowermost costal
cartilages.
Dominant Inferior Pedicle  Deep inferior epigastric artery
Regional Source  External iliac artery.
Length  6 to 10 cm.
Diameter  1 to 2.5 mm.
Location  Enters the muscle on its deep surface at the lateral border at or just below the level of
the arcuate line.
Minor Pedicle  Segmental intercostal perforators (seventh through twelfth)
Regional Source  Terminal branches of the intercostal arteries
Length  2 to 3 cm.
Diameter  0.5 to 1.5 mm.
Location  Segmental distribution passing from the linea semilunaris inferolaterally to enter the
muscle on its posterior surface at the junction of the middle and lateral thirds. Attempting to
carry the flap on its minor pedicle is not recommended, because its perfusion alone is inadequate.

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 1140 Part II  Regional Flaps: Anatomy and Basic Techniques

Venous Anatomy
Paired veins accompany both the superior and inferior epigastric vessels. Superiorly, one vein pre-
dominates as the vessel transitions to the internal mammary vein, which is 1 to 4 mm in diameter.
Inferiorly, veins combine to form a large single vein before entering the external iliac system.
Diameters range from 2.5 to 4.5 mm.

Nerve Supply
Motor Mixed segmental nerves from the seventh through twelfth intercostal nerves
enter the deep surface of the muscle at its mid to lateral aspect. Motor and sensory
branches split within the muscle to supply the muscle and skin, respectively. The
inferiormost motor branch is responsible for innervation of much of the distal
muscle. While segmental branches may be divided with some functional loss,
during perforator flap dissection it is critical to maintain the lowest branch to
minimize donor morbidity.
Sensory The ventral primary rami of the mixed seventh through twelfth intercostal
nerves provide sensation to the skin territory of the rectus abdominis muscle.
In addition, branches from the ilioinguinal (L1) and iliohypogastric (L1) nerves
provide additional supply to the lower abdomen. Intercostal branches can be
harvested with a free flap (TRAM, VRAM, DIEP) to provide a sensate flap.

Intercostal
perforators

Internal
mammary
artery

Superior Subdermal plexus

epigastric artery E
Scarpa’s fascia

Scarpa’s fascia Lateral

perforator
TRAM flap artery
perforators
Superior epigastric
perforators
Deep inferior
epigastric artery Posterior
intercostal artery

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 demon-
strating the interconnection of the superior epigastric and lateral intercostal systems.
Dominant pedicles: Superior epigastric artery; deep inferior epigastric artery

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1141

Vascular Anatomy
The superior epigastric artery may split into several branches or remain single. The superior
epigastric vessel supplies the proximally based pedicled transposition flaps. The deep inferior
system supplies free TRAM or inferiorly pedicled rectus flaps.
The superior and deep inferior systems communicate in the periumbilical area through
a system of choke vessels. Taylor has described these in detail. The superior and inferior
epigastric vessels often mirror their flow patterns. A single vessel is present in 29% of cases,
a dual system occurs in 60% of cases, and the remainder exist as multiple smaller branches,
all of the above communicating through a choke system.

A 60% C 11%

B 29%

Double vessel Multivessel

Single vessel

Fig. 10B-2  Anatomic variations in epigastric circulation choke vessels within the rectus muscle.

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 1142 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Rectus A bdominis

and TRAM/DIEP Flaps

A D1 B D1 C x

m m s

m
m

s
m m

D2 D2 e
p

Resin injection of epigastric Radiographic view Vascular injection of anterior abdominal wall
vessels supplying the
rectus abdominis muscle

x
p
m m
m m m

Elevation of abdominal skin showing

lateral row perforators from DIEA

Fig. 10B-3 

Dominant pedicles: Superior epigastric artery (D1) and inferior epigastric artery (D2)
e, Superficial inferior epigastric artery; m, myocutaneous perforating vessels from deep
epigastric artery; p, pubis; s, segmental subcostal arteries; u, umbilicus; x, xiphoid process

10b_RecAb_r4_cah_1136-1191.indd 1142 2/2/2012 5:36:19 PM

 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1143

E F
u m

m m
m

Deep surface of inferior transverse rectus Radiographic view

abdominis skin island

Fig. 10B-3

m, Myocutaneous perforating vessels from deep epigastric artery; u, umbilicus

TRAM Zones
When a lower or midabdominal flap is harvested (a TRAM flap), the blood supply will
vary, depending on the location of the tissue relative to the rectus muscle. The best blood
supply will directly overlie the rectus muscle (zone I), as this is where the perforators enter
the skin island. The areas over the contralateral rectus (zone II) and just lateral to the rectus
(zone III) are in the neighboring angiosome and have the next-best blood supply; these vary
from patient to patient. The tissue lateral to the contralateral rectus is a tertiary angiosome
and usually is the least perfused tissue in the flap.

III I II

III I II IV

III I II

Fig. 10B-4  A, Hartrampf’s zones I through IV. B and C, Laser angiography showing superior perfu-
sion to zone I, the area encompassed by the primary angiosome of the rectus abdominis perforators.

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 1144 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings
The flap may be designed as a muscle flap alone or with a vertically oriented skin island
(VRAM), a transversely oriented skin island (TRAM), or a thoracoepigastric design. The
transversely oriented island typically extends from just above the umbilicus to the pubic
crease. Moving the design more superiorly improves blood supply (midabdominal TRAM)
at the cost of a more noticeable scar. The vertical skin island can extend from the costal
margin to the pubic crease. By including an extension superiorly and obliquely above the
umbilicus (thoracoepigastric flap), even more tissue can be harvested, with primary closure
of the donor site. This design takes advantage of the communication between the intercostal
and epigastric systems. Zones I through IV designate the relationship of the skin island to
the rectus muscle flap.

Vertical (VRAM)
The skin island is designed as a tapering ellipse oriented vertically along the long axis of
the rectus muscle. The island may extend from costal margin to just above the pubic skin
crease. The width of the skin island is determined when the patient is supine, the tissues can
be pinched to determine how much tissue can be harvested while still allowing primary
donor site closure. The medial incision should remain in the midline to preserve the blood
supply to the umbilicus. The patient should be warned that the umbilicus will be pulled
to the side of harvest.

Vertical skin island design

Fig. 10B-5 

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1145

Transverse (TRAM)
The skin island extends from just above the umbilicus centrally to the pubic crease, tapering
as a horizontal ellipse laterally to end over the iliac crest, lateral to the anterior superior iliac
spine. Markings for a pedicled TRAM flap are identical to those of the free TRAM and DIEP
flaps. If more rectus perforators are desired within the flap, the skin island can be moved up
to capture more periumbilical and superior epigastric perforators (midabdominal TRAM).

Transverse inferior
skin island design

III I II IV

Fig. 10B-6 
Thoracoepigastric
Initially, the VRAM design is designed inferiorly, then an elliptical extension is designed
along an imaginary line from umbilicus to the costal margin at the anterior axillary line,
again pinching the tissues to ensure primary closure of the donor site.

Transverse superior
skin island design

Fig. 10B-7 

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 1146 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
Patients are placed supine on the operating table regardless of the type of rectus-based flap to
be harvested. Before the patient is prepared and draped, the operating table must be tested
to ensure that it can flex at the patient’s waist to facilitate closure in TRAM and DIEP flap
procedures. Failure to achieve flexion intraoperatively may seriously compromise the sur-
geon’s ability to close the abdominal donor site without tension. A pillow placed beneath
the knees to allow slight hip flexion can also be helpful during closure.

Guide to Rectus Muscle–Only

Flap Dissection
Because no skin island is required in the purely muscular version of the rectus flap, the
abdominal skin is incised as a vertical paramedian incision and dissection is carried straight
down to the anterior rectus sheath. Skin should not be undermined off the rectus sheath
to preserve cutaneous blood supply. The anterior rectus sheath is incised vertically and dis-
sected off the anterior aspect of the muscle belly from the costal margin as far inferiorly as
required. Dissection is carried laterally to the linea semilunaris and medially to the linea
alba. Care should be exercised when dissecting over the tendinous inscriptions, because
the epigastric vessels are quite superficial within the insertion and can be damaged. Later-
ally all intercostal neurovascular bundles should be divided with either cautery or sharply
between hemostatic clips to control bleeding. The eighth intercostal nerve at the costal
margin should be sought and divided specifically to prevent muscle contraction in a proxi-
mally based flap. If a superiorly based flap is to be raised, the deep inferior epigastric vessels
should be clamped and divided, following which the distal muscle belly, or preferably the
tendinous origin, is then divided with cautery.
The flap is then rotated superiorly to cover a chest or upper abdominal defect. If a distally
based muscle is raised, the proximal muscle is divided at the costal margin taking care to
secure control of the superior epigastric pedicle as it emerges from beneath the rib margin.
The muscle can then be rotated down into the pelvis or groin as needed.

A B

Fig. 10B-8  A and B, Superiorly based pedicle before and after dissection.

10b_RecAb_r4_cah_1136-1191.indd 1146 2/2/2012 5:36:21 PM

 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1147

C D

Fig. 10B-8  C and D, Inferiorly based pedicle before and after dissection.

Flap Variants
•  Myocutaneous flap
–  Vertical rectus abdominis myocutaneous (VRAM) flap
–  Thoracoepigastric flap
–  Transverse rectus abdominis myocutaneous (TRAM) flap
○ Unipedicle
○ Bipedicle
– Midabdominal TRAM flap
• Free TRAM (full muscle/muscle-sparing) flap
•  Deep inferior epigastric perforator (DIEP) flap

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 1148 Part II  Regional Flaps: Anatomy and Basic Techniques

Pedicled Vertical Rectus Abdominis Myocutaneous

(VRAM) Flap
If a skin island is incorporated, the skin island is planned in accordance with the markings
mentioned earlier. The skin island is incised as a long vertical ellipse tapering proximally
and distally. Dissection is carried down initially to the abdominal fascia. Laterally a sub-
cutaneous plane is maintained until the semilunar line is reached. Medially, the incision is
carried down directly to the linea alba. The rectus sheath is incised and the muscle is then
dissected out from within the sheath laterally and medially as described in the previous
section. The anterior rectus fascia may be spared to the level of the lateral row perforators
to aid the fascial closure (lateral fascia sparing). Great care should be taken to preserve the
relationship between the muscle, its fascia, and overlying skin island to preserve the perfo-
rator blood supply to the skin.

A B

Superior incision

Inferior incision
Fig. 10B-9 

For pelvic and vaginal reconstruction, the VRAM is an ideal flap, because it can sup-
ply a large amount of tissue with a favorable arc of rotation transabdominally. Pelvic dead
space is also obliterated and herniation formation prevented. In these cases, the pubic fascial
insertion is maintained to protect sheer of the pedicle postoperatively.

Transabdominal VRAM flap

Fig. 10B-9 

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1149

Thoracoepigastric Flap
When additional tissue is required behind the VRAM for inferiorly based flaps, a thora-
coepigastric flap can be considered (see Section 10F). This design takes into account the
anastomosis between the intercostal and epigastric systems. The extension of the flap is
centered above the line from the umbilicus to the shoulder. The flap can be extended to
the midaxillary line. Dissection starts superiorly and laterally first in the subcutaneous plane
until the semilunar line is reached. Dissection then proceeds as described for the inferiorly
based VRAM.

A B

Thoracoepigastric flap design

Flap turndown into the groin

Fig. 10B-10

Pedicled Transverse Rectus Abdominis

Myocutaneous (TRAM) Flap
The upper abdominal incision is made first and dissection is carried down to the rectus
sheath. The upper abdominal skin flap is elevated over the costal margins laterally and to the
xiphoid centrally. The patient is flexed to assess the adequacy of skin closure to the inferior
incision line. The inferior incision may need to be moved superiorly to allow for a less tight
abdominal skin closure. Tight closure can seriously compromise blood flow to the skin edges,
causing skin necrosis, particularly in the area between the umbilicus and pubis, especially
in obese patients. Preexisting Pfannenstiel incisions can be ignored, because they do not
affect the survival of suprapubic skin. The distal incision is then made, and the TRAM flap
is elevated from lateral to medial, to the lateral row of perforators passing through the rectus

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 1150 Part II  Regional Flaps: Anatomy and Basic Techniques

abdominis muscle. The decision about which side to base the flap depends on abdominal
anatomy size, the prevalence of perforators, and surgeon preference. A conventional open
cholecystectomy scar (Kocher incision) mandates a left-sided unipedicled flap, because the
approach has divided the superior epigastric system. Laparoscopic incisions and midline
incisions are rarely a cause for concern unless they perforate the rectus muscle close to the
superior pedicle. Appendectomy scars can be problematic and may require inspection of
the fascia during surgery.

C D

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.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1151

In an unscarred abdomen either the contralateral or the ipsilateral pedicle may be used
(see Fig. 10B-11). An ipsilateral transfer eliminates the problem of initial intermammary
bulging and the definition of the ipsilateral inframammary crease is excellent. Pedicle ten-
sion is reduced and flap positioning tends to be easier. Venous drainage is better with ipsi-
lateral transfer. The contralateral pedicle tends to create more medial inframammary crease
bulging and somewhat limits the ease of flap positioning in terms of more lateral motion.

III
I
II G
IV

IV
II

IV II III
I III

III I II IV

Unipedicle TRAM ipsilateral pedicle

Unipedicle TRAM contralateral pedicle

Fig. 10B-11  F, The ipsilateral pedicle on the left rotates 90 to 180 degrees counterclockwise. A simi-
lar 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.

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 1152 Part II  Regional Flaps: Anatomy and Basic Techniques

The muscle can be elevated in its entirety or with a muscle-sparing technique. Muscle-
sparing involves identifying the intramuscular course of the superior epigastric vessels with
a Doppler probe and then leaving a lateral strip of muscle some 2 cm in diameter. Theoreti-
cally, this leaves muscle innervated and vascularized by the intercostal vessels and nerves for
further abdominal wall competence postoperatively. In practice, however, the intercostal
supply penetrates the rectus muscle in its middle third, thereby leaving no innervation and
probably little, if any, blood supply to the lateral muscle strip. A medial strip of muscle may
also be left, but its functional value is questionable. As noted earlier, Harris demonstrated
an 80% reduction in pedicled blood flow by clamping the medial and lateral thirds of the
rectus muscle intraoperatively. Recent data on the diminishing size and strength of residual
upper rectus muscle after free TRAM flap harvest further call into question the validity of
performing muscle-sparing procedures. The rectus muscle is divided distally and the deep
inferior epigastric vessels are ligated with surgical clips. These vessels should be dissected
out with the flap just in case they are needed for conversion to a free flap or supercharging
in the event of vascular compromise of a pedicled flap.

III
I
II

IV

Medial and lateral

margins of rectus
muscle remain intact
IV II I III

Medial and lateral

margins of rectus
muscle remain intact

Harvest of muscle-sparing TRAM flap

Fig. 10B-11

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1153

For chest and breast applications, flap elevation is based on the superior epigastric sup-
ply. Care should be taken to divide the eighth intercostal nerve as it enters the muscle near
the costal margin. The nerve is often under the muscle and should be located and divided.
This essential maneuver facilitates muscle atrophy, reducing epigastric bulk in the long term
and eliminates the need for considering the issue of muscle sparing as a means of reducing
pedicle bulk at the costal margin.

Identification of eighth
intercostal nerve at
right costal margin

Fig. 10B-11

Bipedicle TRAM Flap

The bipedicle TRAM flap is indicated in:
•  Large-volume reconstruction
•  Patients with lower midline abdominal incisions
•  Patients who smoke
•  Obese patients
•  Patients with radiation injury to one pedicle
•  Bilateral unipedicle breast reconstruction
Most of the above represent indications for free TRAM flap transfer in many surgeons’
hands. Bipedicle flaps are robust and probably have a better blood supply than free TRAM
flaps because of the conversion of zones II and IV to additional zones I and III respectively.
They allow for more reliable survival of a greater proportion of the flap at the expense of
greater abdominal donor site muscle loss. While this affects the patient’s abdominal strength
in the short term, longer term function appears eminently compatible with activities of
daily living. Flap complications are less and the procedure enables the nonmicrosurgeon to
safely perform TRAM flap breast reconstruction in higher risk patients.
Preoperative preparation and positioning are similar to those outlined for the unipedicled
procedure. Initial flap elevation is identical in that both sides of the flap are dissected to the
lateral perforators. Medial dissection differs in that a tunnel must be fashioned down the
linea alba between the two pedicles. This leaves a fascial strip on either side of the linea for
fascial closure, because two pedicles have to pass up onto the chest wall, a more generous
tunnel has to be fashioned, causing more initial bulging; patients should be informed about
this preoperatively.

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 1154 Part II  Regional Flaps: Anatomy and Basic Techniques

Excised tissue Extent of

undermining
Fascia preserved
over upper pedicle

Skin

Deepithelialized
tissue

C Periumbilical perforators
Fascia intact

Fascia intact

Mesh

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.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1155

Midabdominal TRAM Flap

In some patients, the lower abdominal pannus is unusable because of size, edema, or previous
surgery. The midabdominal TRAM is an excellent alternative, because it takes advantage
of abdominal excess but avoids the risks of poor blood supply resulting from morbid obesity
and previous surgery. In fact, by moving the design superiorly, the blood supply becomes a
primary angiosome and is improved. The downside is a midabdominal scar. In the patients
described here, this is often not objectionable.
Although the pedicle may seem short, an ipsilateral flap reaches the chest easily. Dissec-
tion of the flap begins with deepening of incisions to fascia and elevation of the flap from
lateral to medial. The dissection is then similar to a pedicle TRAM, except the muscle is
divided at the level of the umbilicus. If deep inferior epigastric branches are encountered,
they are ligated. Unlike the lower abdominal TRAM, there is less cross-circulation and
tissue for the reconstruction should be mainly from zones I and III.

A B

Midabdominal skin island design Flap transposition

Fig. 10B-13 

Free TRAM Flap

Of all free flaps used in breast reconstruction, the free TRAM flap is by far the most com-
monly used, followed by the DIEP flap. The flap has a pedicle of adequate length with
a large vessel lumen diameter. Although a small portion of the infraumbilical part of the
rectus muscle and anterior rectus sheath must be sacrificed, it is negligible compared to the
amount that must be sacrificed with the standard superior pedicle TRAM flap.

Free TRAM Flap Variants

•  MS-0: No muscle sparing, using the full width of the rectus muscle
•  MS-1: Lateral muscle strip preserved
•  MS-2: Lateral and medial muscle strip preserved

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 1156 Part II  Regional Flaps: Anatomy and Basic Techniques

The patient is positioned supine on the operating table with both upper extremities
abducted to 90 degrees on arm boards. The arm on the breast reconstruction side is draped
to allow access to axillary vessels as well as to the internal mammary supply for the micro-
surgical transfer.
The TRAM flap skin island is marked on the abdomen similar to the markings for a
standard pedicled TRAM flap. The incision on the chest wall will vary according to local
conditions and scars. In a delayed reconstruction, the previous scars are excised, the mas-
tectomy flaps are raised, and the appropriate recipient vessels are explored. In skin-sparing
mastectomies, this component of the dissection has already been completed.

Rectus abdominis
A
muscle island

TRAM flap
skin island
Superficial
epigastric Deep inferior
artery epigastric
artery

Free TRAM skin markings Anatomy of free TRAM flap

Fig. 10B-14

The incisions are made and the skin island elevated as for the standard unipedicle TRAM
flap. It is worth preserving the superficial inferior epigastric veins for additional venous
drainage if required. These can be dissected for a length of 5 to 6 cm inferiorly to provide
length and can provide additional venous outflow to the flap. Unfortunately, these veins
are not always present or usable.
If the internal mammary vessels are used, the flap may be based on the ipsilateral DIEA
axis, because this allows a 180-degree rotation, which keeps the pedicle and zone I medial
and the periumbilical fullness inferior to mimic the natural lower pole of a normal breast.
If the thoracodorsal vessels are used, the contralateral pedicle is best used, the only disad-
vantage being that zone II is now medial, and this has a slightly less predictable blood flow.
Unlike a pedicle TRAM flap, tethered by its pedicle, a free TRAM or DIEP flap can be
based on either contralateral or ipsilateral pedicles and freely inset.
The skin island is elevated to the lateral and medial perforator rows. The deep inferior
epigastric vessels are identified at the inferolateral border of the distal rectus abdominis
muscle. Under loupe magnification, the vessels are dissected free from the surrounding
tissues and traced down to the iliofemoral junction.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1157

A pedicle of 8 to 10 cm in length can then be dissected easily. The accompanying

veins usually converge to become a single large-caliber vena comitans before entering the
iliofemoral junction or external iliac vein. Generally, the flap contains one artery and two
venae comitantes.

Pedicle dissection Flap harvest showing muscle cuff

with pedicle indicated

Fig. 10B-14

Deep Inferior Epigastric Perforator (DIEP) Flap

The DIEA or perforator flap was conceptualized in an effort to reduce abdominal donor
site morbidity while maintaining the improved blood flow associated with the free TRAM
flap. The flap incorporates the same skin elements as the TRAM flap but relies on dissecting
the perforating blood vessels through the rectus muscle, thereby leaving all of the rectus
muscle behind at the donor site and removing only the flap with its vascular pedicle. These
perforating vessels are clustered in two rows in the periumbilical area, with medial perfora-
tors being most numerous and commonly used as the basis of the DIEP flap.

Medial branch
of inferior
epigastric artery

Lateral branch
of inferior
epigastric artery

Cut in rectus
DIEP flap based on two
abdominis
medial row perforators
muscle

Fig. 10B-15

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 1158 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap markings for the DIEP flap are similar to those for the standard TRAM flap,
although care should be taken to place the bulk of the flap over the perforators. This may
require harvesting more ipsilateral tissue laterally and discarding the contralateral zone IV
completely as well as part or all of zone II.

DIEP Flap Elevation

The DIEP skin flap is elevated in a manner similar to the conventional free TRAM flap.
Every effort should be made to harvest the superficial inferior epigastric vein with the flap
to maximize venous outflow options. This vessel should be dissected distally to the femoral
vein to obtain as much length as possible. Dissection is carried from lateral to medial to
the lateral row of perforators. If preoperative Doppler or spiral CT localization of the best
perforator has been performed, dissection is carried out to that vessel. The use of indocya-
nine green (ICG) laser angiography is immensely helpful in localizing these perforators.
Immediately lateral to the desired perforator, the rectus sheath is opened longitudinally and
the lateral border of the rectus muscle is exposed and reflected medially to identify the deep
inferior epigastric vessels. These are traced through the rectus muscle following the major
cutaneous perforator into the skin island. During this dissection, it is imperative that all
intramuscular nerve branches be preserved to maintain the innervation of the abdominal
wall muscles. No muscle is removed, thereby optimizing the strength of the abdominal
wall. Following flap harvest, the sheath is closed in linear fashion.

A B
Skin Skin
excised excised

III I II IV

C Perforator D
branches from
medial branch
of deep inferior
epigastric
artery and vein
Medial branch of
deep inferior
epigastric artery
and veins
Cut in rectus
abdominis
muscle

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 dissec-
tion demonstrating dissection of the perforator without muscle harvest.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1159

Arc of Rotation
Pedicled TRAM/Rectus Flaps
The pedicled rectus, VRAM, or TRAM flaps can reach the upper manubrium superiorly
as proximally based flaps, as well as almost any area on the anterior chest. The inferiorly
based muscle and VRAM flaps can cover proximal thigh and groin defects, as well as the
pelvis, vagina, and perineum centrally.

STANDARD FLAP

A B

Arc to anterior chest Arc to groin and perineum

Arc to internal pelvis

Fig. 10B-17 

Thoracoepigastric Flap
The thoracoepigastric extension will extend the reach of an inferiorly based (deep inferior
epigastric supply) by the length of the thoracoepigastric extension. A folded sterile towel
can be used intraoperatively to simulate flap reach.

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 1160 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Transfer
Muscle-Only Flap
For a chest application, a gap in the fascial closure is necessary to allow the passage of the
muscle. This defect is best tolerated in a subxiphoid position and is worst tolerated in the
suprapubic position. Transdiaphragmatic passage allows complete primary fascial closure.
For groin defects, passage of the flap below the inguinal ligament avoids this issue, but divi-
sion of the inguinal ligament is sometimes required. If the inguinal ligament is divided for
flap passage, it must be repaired before skin closure.

Pedicled TRAM (Unipedicle, Bipedicle,

Midabdominal, Superiorly Based VRAM) Flap
A gap in the fascial closure is necessary to allow passage of the flap to the chest, avoiding
too tight a fascial closure, which can compromise blood flow in the pedicle. Two fingers
should easily pass alongside the pedicle at the fascial opening to avoid this problem.
For chest wall applications, the flap can be directly placed into the defect by incis-
ing the connecting skin, thus avoiding compression of the pedicle in a tunnel. For breast
reconstruction, a wide subcutaneous tunnel is made between the abdominal dissection
and the recipient site allowing passage of the pedicle without compression. When using a
contralateral pedicle it is tunneled adjacent to the medial border of the normal breast. Ipsi-
lateral flaps are passed straight up through the inframammary fold of the mastectomy site.
If venous congestion occurs, repositioning may be helpful. Additionally, one may remove
the surgical clip on the deep inferior epigastric vein stump and allow it to bleed for several
minutes for venous decompression. Gradually the venous flow in the flap adjusts to the new
flap location and drainage direction, and the flap assumes a healthier color. Alternatively,
Hartrampf ’s “mechanical leech” drainage system may be inserted into the deep inferior
vascular system to aid in venous decompression. This involves inserting a pediatric feeding
tube or venous cannula into the deep inferior epigastric vein and using this as a decompres-
sion valve that can be opened periodically to bleed the flap of congested, poorly oxygenated
venous blood under pressure. It mandates that the surgeon harvest a usable stump of deep
inferior epigastric vein at the time of TRAM flap harvest. The catheter can be flushed
with dilute heparin solution to maintain its patency over a period of 2 or 3 days as needed.
Alternatively, the distal cut end of the deep inferior epigastric vein may be anastomosed to
an appropriate adjacent vessel such as the internal mammary or an intercostal perforating
vein to provide adequate venous outflow.

A B

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.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1161

VRAM (Inferiorly Based) Flap

Passage of the flap for groin and thigh defects is similar to the muscle-only flap above. When
used for vaginal reconstruction, abdominoperineal resection defects, or pelvic reconstruc-
tion, the flap is transferred through the open abdomen, through the presacral space to the
perineum. Care is taken to ensure no torsion or kinking of the pedicle; this is best done
through the lithotomy approach, where the pelvic defect outside and the pelvic inlet inside
can be visualized simultaneously. The flap is first passed through the tunnel and marked
for skin resection while temporarily in place. The flap can then be passed back through the
abdomen, where deepithelialization and debulking can be performed under direct vision.
The flap is then passed back to the recipient site for inset. The fascial insertion of the muscle
to the pubis is maintained to prevent postoperative tension and ischemia but can be released
if additional length is required.

Flap Inset
Pedicled Flap
Tension-free closure is the goal for all variants of the pedicled rectus flap. Fascia carried with
the flap is useful for anchoring the flap at its recipient site, taking tension off the pedicle
and the skin closure. Areas of potential ischemia, such as TRAM zone IV and areas of the
VRAM/thoracoepigastric region not directly over muscle, should be inspected carefully
before inset. Poor vascularity should be managed by resection or delay of inset.

Free Rectus Flap

When the rectus muscle, with or without a skin paddle, is used for reconstruction, care
must be taken to secure the muscle to the surrounding bed to allow a tension-free micro-
anastomosis.

Free TRAM Flap

With the flap isolated and ready for transfer and the recipient vessels isolated, the microscope
is then brought into the operating field for final vessel preparation. The site is prepared under
microscopic magnification, the flap and deep epigastric artery and vein are divided, and
the vessel ends are irrigated with heparinized saline solution. The flap is then transferred
to the chest wall, where it is temporarily secured with sutures or staples. At this point the
pedicle length may need to be adjusted, particularly when using a TRAM flap that has a
very long pedicle that may need to be shortened, depending on the local conditions, before
end-to-side or end-to-end vascular anastomosis is performed.
If the vessels sizes are a good match, an end-to-end anastomosis is appropriate. How-
ever, if there is any size discrepancy between the flap vessel and the recipient vein (the flap
vessels usually being larger), an end-to-side anastomosis should be performed. This allows
the Venturi effect to siphon venous flow out of the flap, encouraging drainage. If end-to-
end anastomoses are performed on the vein, the use of the vein coupler saves time. If the
superficial inferior vessels are harvested with the flap or a second vena comitans is present,
they can be anastomosed as retrograde flow vessels to the distal ends of the internal mam-
mary vessels.
At this stage, the overlying skin island may be turned and modified as necessary to
inset the flap. The TRAM flap is then shaped and inset. If the internal mammary vessels
are used, the flap is oriented transversely or obliquely, with zone I medially and zone III
laterally. If the thoracodorsal vessels are used, the free TRAM flap has an inferior pedicle
directed toward the axilla, it is usually inset transversely or obliquely, with its pedicle directed
laterally. Zone I is usually placed along the lateral portion of the breast and zone II on the

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 1162 Part II  Regional Flaps: Anatomy and Basic Techniques

medial portion of the breast, particularly when the flap is inset in a transverse direction.
Zone III is used for axillary fill and can provide additional fullness to match the volume of
the opposite breast. The free TRAM flap is deepithelialized as necessary and definitively
inset over suction drains. The shaping and insetting of the TRAM flap proceed as described
for standard flap reconstruction.

Donor Site Closure

All pedicle flaps that have suprafascial recipient sites must, by definition, leave a fascial defect
to allow muscle pedicle transfer. In the TRAM and superiorly based VRAM flaps, this defect
in the xiphoid area is well tolerated. One should avoid such defects in the suprapubic area in
an ambulatory patient, because a hernia may form. Transabdominal passage and opening
the inguinal ligament are two alternatives that can be used in selected cases.
The muscle is enclosed by the anterior and posterior rectus sheaths. The anterior sheath
consists of the blended aponeuroses of external and internal oblique muscles; the posterior
sheath is composed of the blended aponeuroses of the internal oblique and transversus
abdominis muscles. At the arcuate line and inferiorly, the internal oblique contributions
to the posterior sheath run anteriorly, so the anterior sheath dominates and the posterior
sheath is diminutive.
Abdominal closure should not be relegated to the most junior member of the team,
because poor closure dramatically increases the risks of hernia formation. It is essential to
incorporate both the internal and external oblique aponeuroses into the sheath closure. If
fraying of the fascia occurs it can be darned with a suture weave or covered with an onlay
of synthetic mesh or acellular dermal matrix. In a bipedicle TRAM, the surgeon should
have a low threshold for using mesh for fascial closure. Once the abdominal fascia has been
securely closed, the upper abdominal skin flap is redraped over suction drains and closed.
An umbilicoplasty is then performed.

A B

Direct fascial closure with Prolene mesh inlay Closure

Fig. 10B-19 

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1163

Mesh

Fascial closure with mesh Fascial closure with mesh: Unilateral

Fig. 10B-19 

Free TRAM Flap

The muscle-sparing type II (MS-2) free TRAM flap harvest leaves a small rectangular
defect in the rectus muscle belly. This can be repaired directly with running 2-0 PDS or
Vicryl, and the rectus sheath is repaired with 0 Prolene. If there is any concern about ten-
sion or fascial strength, a sheet of Prolene mesh or acellular dermal matrix can be placed to
buttress the repair. Final closure then proceeds as described above.

A B

Free TRAM flap donor site Free TRAM flap closure

Fig. 10B-20 

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 1164 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 46-year-old woman was diagnosed with right breast cancer and was interested in im-
mediate free TRAM flap or DIEP flap breast reconstruction to optimize abdominal wall
strength. She was a healthy nonsmoker with mild preoperative breast asymmetry, the left
side being lower than the right. She preferred the appearance of the left breast and requested
symmetry with this side to negate any mastopexy scarring on the left. A muscle-sparing type
II (MS-2) free TRAM flap was performed, because the perforating vessels were extremely
small and unsuitable for a DIEP flap. Anastomosis was performed to the right thoracodorsal
vessels through the sentinel node biopsy site in the right axilla. Subsequently, a right nipple
reconstruction was performed using a C-V flap technique.

A
B

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.

10b_RecAb_r4_cah_1136-1191.indd 1164 2/2/2012 5:36:46 PM

 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1165

D E

F G

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. (Case supplied by GJ.)

10b_RecAb_r4_cah_1136-1191.indd 1165 2/2/2012 5:36:48 PM

 1166 Part II  Regional Flaps: Anatomy and Basic Techniques

This 55-year-old woman was referred for left breast reconstruction. She had undergone
a left mastectomy, followed by chemotherapy and radiation. Her course was complicated
by a recurrent seroma with wound breakdown at the mastectomy site after completion of
radiation therapy. Dressing therapy coupled with hyperbaric oxygen treatment was neces-
sary; the wound took 9 months to heal. She had a 40-pack-year history of smoking and
stopped smoking before her reconstruction. She had had a left paramedian incision 20 years
previously for ovarian surgery. Fifteen months after her mastectomy, a muscle-sparing free
TRAM flap was planned because of her history of smoking and radiation therapy. It was
thought that unless her vascular anatomy was exceptional, a DIEP flap would be risky in
this former heavy smoker. At operation, vascular imaging with laser-induced indocyanine
green fluorescence was performed, demonstrating a surprisingly large perforator bloom just
below and lateral to the right of the umbilicus. Intraoperative exploration confirmed the
presence of a very large (2 mm) perforator supplying a large portion of the right side of her
abdominal pannus. A DIEP flap was harvested based on this perforator, with anastomosis
to the left internal mammary vessels. After uneventful flap healing, a contralateral right
vertical breast reduction was performed, together with left nipple reconstruction using a
C-V flap. She is shown 1 year postoperatively with good symmetry and a soft, supple breast
reconstruction.

A B

Paramedian scar

III
Major perforator I
II IV

Fig. 10B-22  A, Preoperative view showing paramedian scar and irradiated mastectomy. B, Intraop-
erative planning.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1167

C D

E F

G H

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. (Case supplied by GJ.)

10b_RecAb_r4_cah_1136-1191.indd 1167 2/2/2012 5:36:54 PM

 1168 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old woman was diagnosed with right breast cancer. She had bilateral mam-
mary hypertrophy and a well-developed lower abdominal pannus. She did not exercise
regularly and was a nonsmoker. The surgical plan involved an immediate right ipsilateral,
unipedicled TRAM flap breast reconstruction, with subsequent contralateral vertical breast
reduction and right nipple reconstruction. An oblique orientation of her TRAM flap skin
island achieved a natural breast shape with good infraclavicular fill with maintenance of
the anterior axillary fold. Two months after her initial reconstruction, she underwent
contralateral left breast reduction using a vertical technique, coupled with a C-V flap right
nipple reconstruction and tattooing of the areolas. Shape and symmetry are excellent and
the abdominal contour is pleasing.

A B

C D

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.
(Case supplied by GJ.)

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1169

This 68-year-old woman had undergone a left radical mastectomy and radiation 26 years
before presenting with severe osteoradionecrosis of the chest wall. Necrosis had resulted in
exposure of the pericardium, pleura, and multiple costal cartilages. Episodes of hemorrhage
from the internal mammary vessels were occurring more and more frequently. Treatment
required a life-threatening massive chest wall resection, including the left anterior chest
wall, entire sternum, and some right costal cartilages. Both internal mammary vessels were
resected to their origin. A large free TRAM flap based on the left deep inferior epigastric
vessels was anastomosed to the origin of the right internal mammary vessels from the great
vessels. Complete coverage and stable healing was achieved. Because of the radiation-
induced stiffness of the underlying pleura and lung, no attempt was made to place Gore-Tex
or methylmethacrylate-impregnated mesh to reinforce the chest wall reconstruction. The
patient was last seen 6 years after surgery and remained well healed and functional.

A B C

Fig. 10B-24  A, Irradiated chest wall after a radical mastectomy and osteoradionecrosis. B, Radi-
cal 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. (Case supplied by GJ.)

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 1170 Part II  Regional Flaps: Anatomy and Basic Techniques

This 42-year-old woman had a history of left breast cancer and chest wall irradiation and
desired breast reconstruction. She had macromastia on the right and wanted reduction. She
also was obese and had a previous Kocher incision from a previous open cholecystectomy.
She had adequate tissue for reconstruction in both her lower abdominal pannus and her
midabdominal pannus. Normally a large subcostal scar such as hers could pose an ischemic
problem for any lower abdominal TRAM, because the tissue left between the two long
scars would be ischemic. A midabdominal TRAM was chosen to allow successful recon-
struction and to limit abdominal wall ischemia. A contralateral breast reduction was also
performed at the initial procedure.

C D

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 ische-
mia 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 11⁄ 2 -year follow-up; during that postoperative period one bilateral revi-
sion 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. (Case
supplied by MRZ.)

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1171

This 35-year-old man had a recurrent angiosarcoma of the right hip. He had previously
undergone resection, chemotherapy, and radiation therapy. He presented with recurrence
and bleeding.

A B

C D

Fig. 10B-26  A, Proposed skin resection to remove all previous scars and provide access for resec-
tion. 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 bet-
ter 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. (Case supplied by MRZ.)

10b_RecAb_r4_cah_1136-1191.indd 1171 2/2/2012 5:37:03 PM

 1172 Part II  Regional Flaps: Anatomy and Basic Techniques

This 73-year-old woman had recurrent breast cancer despite chemotherapy and chest wall
irradiation. She had a large chest wall resection, and a VRAM flap was planned for closure.
The VRAM flap provides more soft tissue than the latissimus or external oblique muscles.
The vertical design is favored over the transverse design (TRAM) to provide the best pos-
sible blood supply to all parts of the flap.

A B

C D

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 do-
nor 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. (Case supplied by MRZ.)

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1173

This 66-year-old patient had recurrent melanoma of the left leg and presented with bulky
adenopathy of the left groin involving the femoral artery and its tributaries.

A B

C D

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 ves-
sels 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. (Case supplied by MRZ.)

10b_RecAb_r4_cah_1136-1191.indd 1173 2/2/2012 5:37:09 PM

 1174 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old woman had undergone abdominoperineal resection for advanced Crohn’s
disease. The surgery created a permanent colostomy, and the rectum and associated posterior
vaginal wall were removed. This is a common defect after abdominoperineal reconstruction
for cancer. The VRAM can be harvested while the abdominal portion of the operation is
being performed and is passed through the abdomen and pelvis to the perineum, where it
can be used for reconstruction.

B C

Fig. 10B-29  A, The surgical defect after removal of rectum, posterior vagina, and surrounding peri-
neal 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. (Case supplied by MRZ.)

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1175

This 59-year-old woman had a history of diabetes and prior rectal cancer that had neces-
sitated a permanent colostomy. She was diagnosed with a right breast cancer requiring
mastectomy and desired immediate reconstruction with a TRAM flap. She had macro-
mastia and requested reduction of the normal left breast. Because of her colostomy in the
left lower quadrant, a standard pedicle TRAM reconstruction was not possible. However,
she did have ample tissue available in the midabdomen and was offered a midabdominal
TRAM breast reconstruction.

A B C

D E

Fig. 10B-30  A, Preoperative view of the patient with macromastia and a colostomy. B, Lateral pre-
operative 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. (Case
supplied by MRZ.)

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 1176 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• If the patient has had prior abdominal incisions, there is a risk of previous division of
internal muscle circulation or myocutaneous perforating vessels between the muscle and
abdominal skin. Any portion of a skin island located beyond the rectus muscle with an
intervening old incision will generally not have adequate circulation and should not be
included in the skin island design.
• In patients with impaired microcirculation (for example, those with scleroderma or
Raynaud’s disease), the skin island should not be extended for excessive distances beyond
the primary skin territory of the muscle without a surgical delay.
• Prior use of the internal mammary artery for cardiac revascularization is a relative con-
traindication for use of a superiorly based rectus muscle flap if alternative techniques are
available (such as the opposite rectus muscle). However, the muscle can survive transpo-
sition based on musculophrenic and intercostal vessel retrograde flow into the superior
epigastric artery.
• Previous major vascular surgery involving the external iliac vessels is a relative contra-
indication to the use of the inferiorly based rectus muscle or myocutaneous flap, unless
selective arteriography confirms the patency of the inferior epigastric artery. Although
both superiorly and inferiorly based flaps are commonly used successfully despite prior
radiation therapy in proximity to the flap pedicle (such as the mediastinum or groin),
an alternative flap is used when available (for example, the opposite rectus muscle flap).
• Prior pelvic surgery, especially through a Pfannenstiel incision, will generally not pre-
clude the use of a transverse skin island on a superiorly based rectus myocutaneous flap.
The deep inferior epigastric vessels are rarely violated in gynecologic surgery. However,
adhesions between the deep surface of the inferior rectus muscle and pelvic viscera may
be present. Preoperative bowel preparation is recommended in the event of colon injury
during scar lysis for flap elevation.
• The presence of a subcostal incision over the rectus muscle (Kocher incision for chole-
cystectomy) is an absolute contraindication to the use of an ipsilateral superiorly based rec-
tus myocutaneous flap. Generally, the contralateral muscle can safely be used as a flap.
Circulation to the skin between the subcostal incision and the skin island location may
be impaired after donor site closure. A complete bilateral subcostal incision for intraab-
dominal surgery is an absolute contraindication to use of a superiorly based rectus muscle or
myocutaneous flap, because the rectus muscle has been divided, causing loss of integrity
of the internal rectus muscle vascular arcade.
• Although segmental flap elevation will preserve the lateral aspect of the rectus muscle,
improvement in abdominal function and strength may not be observed. The surgeon
must accept the increased risk of injury to the muscle vascular arcade with this technique.
• If closure of the anterior rectus sheath results in tearing of the remaining fascia, the use
of a synthetic mesh or acellular dermal matrix replacement of the anterior sheath is rec-
ommended. Mesh has the added benefit of avoiding distortion of the midline position
of the umbilicus.
• Direct closure of the skin donor site is preferred whenever possible. The use of skin grafts
in the donor site results in a significant contour defect.
• When performing a DIEP flap, the surgeon should make every effort to preserve the
superficial inferior epigastric vessels as a secondary venous outflow source.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1177

Expert Commentary
Michael R. Zenn

Advantages
The rectus abdominis flap is perhaps the most versatile and most used flap in reconstruc-
tion. The reasons for this include its dual blood supply, its central location in the body, its
convenience, and its duplicity. Dual blood supply is important, because tissue flaps work
best when they are rotated toward their blood supply. When basing the flap off the superior
epigastric vessels, superior flap rotation allows the possibility of upper trunk and thoracic
applications, such as breast and chest wall reconstruction. Even intrathoracic reconstruction
is possible. When basing a flap on the deep inferior epigastric system, inferior flap rotation
makes lower trunk, groin, and thigh reconstruction possible. Even intraabdominal ap-
plications such as pelvic, perineal, and vaginal reconstruction can be done. It is the central
location of the muscle and this dual blood supply that allow such versatility.
There is acceptable morbidity from rectus abdominis harvest because of the paired
nature of the muscles and maintenance of abdominal wall function that this twofold struc-
ture allows. Even in cases of bilateral muscle harvest (such as bilateral breast reconstruction
with pedicle TRAM flaps), function is remarkably preserved through the function of the
oblique and transversalis muscles.
The rectus abdominis is also an available muscle. Midline scars do not remove the
possibility of a vertical rectus abdominis flap. In fact, reconstruction is often required at a
time when resection or repair of a problem by other surgical specialties requires a midline
incision. Good preoperative planning can allow flap harvest through the same exposure
and limit scarring and morbidity to the patient. Communication is essential, because many
a potential VRAM flap has been thwarted by a hastily placed ostomy before flap harvest.
Finally, rectus abdominis–based flaps can supply the largest amounts of soft tissue for
reconstruction while still allowing primary donor site closure; there are no bony restric-
tions to closing a vertical donor site, so abdominal circumference can be reduced to allow
closure in most patients.

Recommendations
I strongly recommend vertical (VRAM) over transverse (TRAM) flaps for reconstruction
when all the tissue is needed for the reconstructive problem at hand. The VRAM flap has
a primary angiosome blood supply to the entire flap, whereas the TRAM has a more zonal
pattern, with a less predictable angiosomal blood supply. One should not sacrifice a healed
wound at the reconstructive site for a nicer scar at the donor site. These cases are hard enough
when taking the best possible blood supply, and delayed healing can affect patient survival,
especially when adjuvant therapy awaits a healed wound.

Complications
The main complications relating to the use of the rectus flap include ischemia and partial
loss, seroma at the donor site, abdominal scar, and loss of functional muscle. When using
tissues with the rectus abdominus flap that extend beyond the muscle, tissues may be isch-
emic, because they represent secondary and tertiary angiosomes. Laser angiography can be
helpful for identifying areas of best perfusion so that areas of marginal perfusion can be
removed.
Continued

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 1178 Part II  Regional Flaps: Anatomy and Basic Techniques

Seroma is common in this area because of the large surface area that is dissected and
the mobility of the area. Multiple drains should be used as well as abdominal binders, and
the patient’s activity should be limited postoperatively. It is not uncommon for drains to
remain in place for 2 to 3 weeks.
It is important to show patients examples of the abdominal scar that they will have
after this flap is used. It is surprising to me that even when the donor scar is as nice as an
abdominoplasty scar, the patient may still be unhappy with it. There are some cases in which
patients have seen photographs of the scar and have requested that another donor site be
used. Use of the rectus abdominus muscle and even its perforator variant (DIEP) will affect
the function of the abdominal wall. Patients need to be counseled that most individuals do
not notice the degree of functional loss postoperatively. The surgeon also needs to discuss
the slight possibility of hernias or bulges that may require secondary revision. If the patient
is overly concerned about functional loss, an alternative donor site should be sought.

Expert Commentary
Glyn Jones

Limitations
Abdominal wall strength is almost certainly more compromised when compared with the
unipedicled procedure, and the bipedicle flap should be performed with caution in a younger
patient. Problems with backache, early satiety when eating, and constipation may bother
some patients. In young women, a free TRAM flap or DIEP flap is probably safer than a
bipedicled flap in terms of abdominal morbidity, but this has never been clearly proved.

Personal Experience and Insights

In the Emory review of bipedicled patient results, flap complications and abdominal wall
complications were no worse than with unipedicled flaps and flap blood supply was predict-
ably better given the dual blood supply. Our large experience with bilateral and bipedicle
flaps has confirmed our initial experience with this procedure as being safe and reliable, with
remarkably few complications, considering the higher risk patients in whom it is performed.

Take-Away Messages
Although some surgeons have voiced concern about reduced abdominal strength, this does
not appear to be as significant as initially thought, and patients cope remarkably well with
activities of daily living. While it is true that strength is initially diminished significantly,
particularly in patients’ ability to perform sit-ups, abdominal wall function improves with
time, and a remarkable number of patients report little or no negative impact on activities of
daily living. Hernia rates are not significantly higher with this procedure when compared
with unipedicled TRAM flaps if meticulous abdominal closure is performed with mesh.
It is an excellent option for the nonmicrosurgeon who performs large numbers of breast
reconstructions in higher risk patients.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1179

Bibliography With Key Annotations

Anatomic/Experimental Studies
Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep
inferior epigastric systems. Plast Reconstr Surg 73:1, 1984.
In 65 fresh cadavers the authors performed dye injections, dissections, and barium radiographic studies
to delineate the vascular territories of the superior epigastric and deep inferior epigastric vessels. Black
ink and red ink were injected into the superior and deep inferior epigastric system and the color changes
in the abdominal wall skin were noted. The authors observed that the majority of the abdominal
wall was stained through injections of the deep inferior epigastric system. Dissection of the vessels and
mapping of the perforators showed that the largest perforating vessels were in the periumbilical area.
Barium studies further confirmed the results of the dye study and dissections. The authors concluded
that the deep inferior epigastric artery supplies more of the skin of the anterior abdominal wall than
the superior epigastric artery. For breast reconstruction the authors stated that prior ligation of the
deep inferior epigastric artery would be an advantage when elevating the lower abdominal skin on a
superiorly based rectus abdominis myocutaneous flap. They further concluded that flap vascularity
would be significantly increased by positioning some part of the skin island over the dense pack of large
periumbilical perforating vessels.
Miller LB, Bostwick J III, Hartrampf CR Jr, Hester TR Jr, Nahai F. The superiorly based rectus
abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical
study. Plast Reconstr Surg 81:713, 1988.
In this anatomic and clinical study the authors reviewed 10 angiograms of the internal mammary
artery in patients who had undergone previous abdominal surgery, a median sternotomy, or mediastinal
irradiation. Twenty cadaver specimens were injected and dissected. In addition to the data gathered
from the arteriographic studies and anatomic dissections, the authors drew on their clinical experience
with 450 TRAM flaps. They concluded that the internal mammary system and intercostal vessels
have a diffuse intrathoracic collateral network with multiple intercommunications on the same side as
well as across the midline. Following the interruption of the internal mammary artery, these intercom-
munications, especially in the intercostal system, assume greater importance and continue to perfuse the
internal mammary artery beyond the area of ligation. Despite prior ligation of the internal mammary
artery, it is still possible to elevate a superiorly based rectus abdominis flap. Of particular importance
is the costomarginal artery running along the costal margin into the rectus abdominis.
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based
on the deep superior epigastric system. Plast Reconstr Surg 82:815, 1988.
The authors studied the vascular anatomy of the rectus abdominis based on the superior epigastric
system in 67 fresh cadavers. They described three patterns of anastomosis between the deep superior
epigastric artery and the deep inferior epigastric artery. In type I, 29% had a single deep superior
epigastric artery and deep inferior epigastric artery. In type II, 57% had a double branch system of
each vessel, and in type III, 14% had a system of three or more major branches. In each pattern the
two systems intercommunicated through choke vessels. These intercommunications were always located
above the level of the umbilicus. The authors also studied the vascular supply to the various transverse
and vertical skin islands based on the deep superior epigastric artery. They conclude that the upper
transverse and vertical flaps have the best supply and the TRAM flap is the least well vascularized.
Midline crossover was seen most often in the subdermal plexus and on the surface of the rectus sheath.
Based on these anatomic findings, the authors recommend harvesting the entire width of the muscle
and including some of the anterior rectus sheath for muscle harvest to enhance the circulation to the
transverse island.

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 1180 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Series
General
Bucky LP, May JW Jr. Synthetic mesh. Clin Plast Surg 21:273, 1994.
The authors described their technique for harvesting the TRAM flap and specifically the closure of
the abdominal wall with mesh. This technique has evolved over 13 years and has yielded excellent
results in the authors’ hands. Sixty-five consecutive patients at a mean follow-up of 47.4 months
were reported as having a hernia rate of 1.5% and an incidence of mesh-related infection of 1.5%.
The authors noted that the use of mesh has enabled them to harvest the entire rectus muscle, thus
preserving all of the blood supply and intramuscular vascular connections within the muscle. They
also stated that their technique allows the tightening and narrowing of the waist and abdomen, thus
enhancing the aesthetic result of the TRAM flap donor site.
Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfac-
tion following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr
Surg 126:1133, 2010.
The authors compared clinical outcomes of two matched groups of patients with either bilateral uni-
pedicle TRAM flap or bilateral DIEP flap breast reconstruction. The differences in abdominal wall
strength were insignificant between the two groups for both hernias and bulges. Fat necrosis rates were
significantly higher in DIEP flaps than in pedicled TRAM flaps. There were no significant dif-
ferences in patient satisfaction, back pain, or physical function between the two groups. The authors
concluded that although DIEP flaps represent an important technologic advance, bilateral unipedicle
TRAM flaps remain an excellent option for breast reconstruction.
Hartrampf CR Jr. Breast reconstruction with a transverse abdominal island flap. Perspect Plast
Surg 1:123, 1987.
The cases of 335 patients treated over 6 years were reviewed. The author outlined the evolution of the
operative procedure and reported an abdominal complication rate of 1.5% in his series, commenting
that the last hernia occurred in the twenty-sixth patient. Of the first 300 patients, the new breast
was completely shaped in one operation in 221 patients (58%). A total of 48% required revision of
the reconstructed breast, and a small prosthesis was placed beneath the flap as a secondary procedure
in 29 patients (7%). The overall complication rate in 335 patients was 8%, including 2 complete
flap losses. Three patients had losses of at least 50% of the flap, 4 had losses of 25% to 50%, and
13 patients had losses of less than 25%. The author concluded that this procedure is complex and
demanding. To perform the operation well, the surgeon must have a background in general surgery and
should be experienced. He warned against the poorly prepared surgeon who performs this operation
only occasionally; he predicted that these surgeons will have limited success and high complication rates.
Itoh Y, Arai K. The deep inferior epigastric artery free skin flap: an anatomic study and clinical
application. Plast Reconstr Surg 91:853, 1993.
Based on cadaver dissections of 34 rectus abdominis muscles, the authors confirmed the vascular anatomy
of the inferior epigastric artery. In 82% of the muscles studied, the inferior epigastric artery bifurcated
into two branches—medial and lateral—with the lateral artery dominant in 82% of specimens. This
bifurcation occurred in the distal lateral third of the muscle. An average of 6.5 skin perforators with an
external lumen diameter of 0.5 mm or larger was observed. The perforators were most dense in the
middle lateral aspect of the middle third of the muscle. These anatomic studies demonstrate that it is
possible to separate the muscle fibers from the dominant lateral branch of the inferior epigastric artery
and associated veins and base a skin island extending from the lateral aspect of the rectus muscle to
the inferior border of the scapula on specific myocutaneous perforating vessels. This technique has been
successfully applied in 21 patients in whom the flap was transplanted to defects using microvascular
techniques. It is advocated to preserve the continuity of the rectus abdominis muscle and avoid new
complications and also to allow use of a thin flap for specific indications in reconstructive surgery.

10b_RecAb_r4_cah_1136-1191.indd 1180 2/2/2012 5:37:14 PM

 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1181

Piza-Katzer H, Balogh B. Experience with 60 inferior rectus abdominis flaps. Br J Plast Surg
44:438, 1991.
The authors reviewed their experience with 60 patients between 1984 and 1991 who had inferiorly
based rectus abdominis flap reconstruction. Microvascular transplantation as well as pedicle flap transfer
was used for a variety of defects, including coverage of infected vascular prostheses for reconstruction of
extremities. Twenty-four flaps were transferred microsurgically and all survived. Complications in this
series were few. Of 60 patients, only two donor sites were repaired with Vicryl mesh. Four patients
required a split-thickness skin graft to the abdominal donor site, and in four patients the umbilicus
was displaced.

Abdominal Wall Reconstruction

Mathes SJ, Bostwick J III. A rectus abdominis myocutaneous flap to reconstruct abdominal
wall defects. Br J Plast Surg 30:282, 1977.
This first report of a rectus abdominis myocutaneous flap described a superiorly based myocutaneous
island flap for reconstruction of a contralateral upper abdominal wound following a shotgun blast.
The authors suggested that this myocutaneous flap could be based superiorly or inferiorly on each of
the pedicles to the rectus muscle.
Parkash S. Bilateral turn-table rectus abdominis myocutaneous flaps for an upper abdominal
recurrent dermatofibrosarcoma. Br J Plast Surg 41:322, 1988.
Following resection of an extensive dermatofibrosarcoma of the upper abdominal wall, the author used
two superiorly based rectus flaps that were rotated into the defect and a deltopectoral flap that was
rotated downward to cover the secondary defect.

Breast Reconstruction
Allen RJ, Treece P. Deep inferior epigastric perforator flap breast reconstruction. Ann Plast
Surg 32:32, 1994.
This paper represents one of the earliest reports on the anatomic basis of the DIEP flap and its use
in 15 cases of breast reconstruction. The authors presented the anatomy of the flap, its dissection, and
clinical outcomes, emphasizing the benefit of muscle-sparing harvest on abdominal wall function.
Arnez ZM, Bajec J, Bardsley AF, et al. Experience with 50 free TRAM flap breast reconstruc-
tion. Plast Reconstr Surg 87:470, 1991.
The authors from two centers, in Scotland and Yugoslavia, reviewed their experience with the first
50 patients undergoing free TRAM flap breast reconstruction. Forty percent of their patients were
chronic smokers, 26% had low abdominal scars, 16% had postoperative radiation therapy, and 54%
had postoperative chemotherapy. The average operating time was 5.6 hours and average blood loss was
2.4 units. Hospital stay averaged 11.2 days. Of significance were the complications, including three
total flap losses (6%), two partial flap losses (4%), and abdominal hernia (4%). All the flap losses
occurred in the first 20 patients. The last 30 patients experienced no flap loss or abdominal hernia.
The authors modified their abdominal wall closure technique and reduced the abdominal hernia rate.
The recipient vessels were all in the axilla. The circumflex scapular, thoracodorsal, and circumflex
humeral arteries were most commonly used.
Arnez ZM, Scamp T. The bipedicled free TRAM flap. Br J Plast Surg 45:214, 1992.
The authors reported their experience in two patients who underwent breast reconstruction with a
bipedicle free TRAM flap. The patients had a lower midline infraumbilical scar, and each half of the
lower abdomen was elevated as a free flap based on the deep inferior epigastric vessels. Both inferior
epigastric pedicles were sutured to recipient thoracodorsal and serratus vessels. Vein grafts were not used.
The authors recommended this technique for reconstruction of large-breasted patients with extensive
midline scarring below the umbilicus. They cited improved vascularity and reduced abdominal wall
morbidity as the main advantages over the conventional bipedicle TRAM flap.

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 1182 Part II  Regional Flaps: Anatomy and Basic Techniques

Berrino P, Campora E, Leone S, et al. The transverse rectus abdominis musculocutaneous flap
for breast reconstruction in obese patients. Ann Plast Surg 27:221, 1991.
The authors reported their results with TRAM flap reconstruction in 23 women who had type II
and type III obesity. The complications include fat necrosis in 20.5% of patients, skin loss of less
than 10% in 8.8% of patients, and skin loss of 10% to 20% in 2.9% of patients. Abdominal wall
complications include seroma (26.8%) and fat necrosis (11.7%). The authors concluded that despite
the increase in complications in this obese group, satisfactory reconstructions were achieved and in the
absence of other risk factors they did not think that obesity in and of itself was a contraindication to
TRAM flap reconstruction.
Chen L, Hartrampf CR Jr, Bennett GK. Successful pregnancies following TRAM flap surgery.
Plast Reconstr Surg 70:69, 1993.
Six patients who had TRAM flap reconstruction had seven normal deliveries. Unipedicle and bi-
pedicle rectus harvest was performed on all patients, and all but one had a normal vaginal delivery.
The infants were of normal weight. No abdominal revisions were required after pregnancy. They
concluded that TRAM flap reconstruction will not prevent a normal pregnancy and delivery if the
abdomen is prepared as described by Hartrampf.
Drever JM. The epigastric island flap. Plast Reconstr Surg 59:343, 1977.
In this original description of a superiorly based rectus abdominis myocutaneous flap with a vertical
skin island, a burn scar contracture was released under the breast of a 12-year-old girl. The author
speculated that this would be a useful flap for reconstruction in other areas. He suggested that resection
of the costal cartilages and dissection of the internal mammary vessels will allow this island flap to be
transposed to the head and neck area and the chest. He further speculated that the flap could be based
inferiorly with an arc of rotation that would reach the groin and upper thigh. He stated that the flap is
vascularized by arteries and veins of suitable diameter that would make it a good donor site for free flaps.
Feller AM. Free TRAM: results and abdominal wall function. Clin Plast Surg 21:223, 1994.
The author’s technique for harvesting the TRAM flap, specifically donor site closure and abdominal
wall evaluation, was described. The donor site was closed directly on the flap side and a similar plication
was performed on the opposite side. Between October 1988 and December 1992 the author performed
151 breast reconstructions in 139 patients using the free TRAM flap. Twenty-four of the 139 patients
had complications. There were three incidences of total flap loss and one incidence of partial flap loss.
One patient developed abdominal laxity. In eight patients arterial or venous anastomosis thrombosis
necessitated reexploration. In all patients the flap was salvaged without partial loss. Six patients had
problems with umbilical loss or wound healing in the area of the umbilicus.
Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free
microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 83:828, 1989.
The authors reported their experience with immediate breast reconstruction using the TRAM flap in
54 patients over 3 years. In 10 patients the flap was transferred as a free flap, and the results were
compared with those in the 44 patients who had a conventional TRAM flap. In the conventional
TRAM flap group, partial flap loss and two cases of delayed healing of the mastectomy flaps oc-
curred in six patients and abdominal relaxation in one. In the free TRAM group no flap loss and no
other complications occurred. In this early report excellent results were obtained with both techniques,
establishing that the free TRAM flap is as safe as the conventional technique and perhaps reduces the
risk of abdominal complications and flap necrosis because of the more limited rectus muscle harvest.
Larger series reported later confirmed the early findings reported by these authors.
Hartrampf CR Jr. Abdominal wall competence in transverse abdominal island flap operations.
Ann Plast Surg 12:139, 1984.
The author reported on his first 82 patients in whom breast and chest wall reconstruction was performed
using the transverse abdominal island flap. The anatomy of the abdominal wall was well described,
and the technique for muscle harvest and abdominal wall closure was presented. Prolene mesh was
used only in 3 of the 82 patients and other types of repair, including a fascial turnover and relaxing

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1183

incisions, in an additional four patients. Twenty of these patients were followed for 1 year or longer.
All returned to their preoperative activity level without discomfort and reported that the abdominal
wall appearance had greatly improved.
Hartrampf CR Jr, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal
island flap. Plast Reconstr Surg 69:216, 1982.
In this original description of the lower TRAM flap for reconstruction of the breast in eight patients,
the authors presented their anatomic cadaver studies and clinical observations on abdominoplasties in
establishing the vascular basis for this flap. In their first three patients the deep inferior epigastric ves-
sels were ligated as a delay procedure 2 weeks before reconstruction. The final five patients underwent
the operative procedure without a delay. All the flaps survived without any abdominal wall problems.
However, the authors pointed out the potential for abdominal wall problems. They also presented eight
other patients who had undergone vertical or upper transverse island breast reconstruction.
Lawrence WT, McDonald HD. Pregnancy after breast reconstruction with a transverse rectus
abdominis musculocutaneous flap. Ann Plast Surg 16:354, 1986.
A patient who became pregnant 5 months after a unipedicle TRAM flap breast reconstruction de-
veloped a small hernia through the more cephalad portion of the rectus fascia during her pregnancy,
but this had not caused her any problems and was never repaired. At the time of cesarean section, her
obstetrician noted that her abdominal wall was attenuated and weak. Even with the small hernia,
this patient was able to have a full-term pregnancy despite the TRAM flap harvest. Later reports
by Hartrampf confirmed that successful pregnancy and vaginal delivery following TRAM flap re-
construction are possible.
Marino H Jr, Dogliotti P. Mammary reconstruction with bipedicled abdominal flap. Plast
Reconstr Surg 68:933, 1981.
A very large, wide vertical skin island was elevated on both superiorly based rectus flaps for reconstruc-
tion of the breast. This was the first report of a bipedicle myocutaneous rectus flap with a vertically
oriented skin island. This was also the first report of partial muscle harvest. The authors left muscle
medially and laterally as well as fascia to facilitate donor site closure. They stated that taking both
muscles will improve the circulation to the flap, especially across the midline.
Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM flap
surgery. Clin Plast Surg 21:255, 1994.
The anatomy, vascular basis, and the authors’ technique of flap elevation and donor site closure were
presented. In a total of 662 patients the overall hernia rate was 1.4%, hernia requiring operative repair
was 0.9%, abdominal laxity was 1.8%, and abdominal laxity requiring operative repair was 0.3%.
When broken down into specific operations, unilateral single pedicle, unilateral double pedicle, and
bilateral reconstruction, the total number of hernias was similar; however, abdominal laxity was seen
in 1.7% of unilateral single pedicles as compared with 3.3% of bilateral pedicles. Abdominal laxity
was seen in 3.3% of patients who had a mesh overlay as compared with 1.5% of patients who had
direct closure. The authors attributed this acceptably low incidence of abdominal wall problems to the
muscle-sparing harvesting technique and a meticulous repair.
Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the
muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 115:436, 2005.
The authors compared breast reconstruction using the deep inferior epigastric perforator (DIEP) flap
and the muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flap (MS-2). The
study evaluated 177 women who had had breast reconstruction using muscle-sparing flaps over a
4-year period. Eighty-nine women had an MS-2 free TRAM flap procedure, of which 65 were
unilateral and 24 were bilateral; 88 women had a DIEP flap procedure, of which 66 were unilateral
and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months. For all
MS-2 free TRAM flaps (113), outcome included fat necrosis (7.1%), venous congestion (2.7%),
and total necrosis in (1.8%). For the women who had an MS-2 free TRAM flap, an abdominal
bulge occurred in 4.6% after unilateral reconstruction and in 21% after bilateral reconstruction. The

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 1184 Part II  Regional Flaps: Anatomy and Basic Techniques

ability to perform sit-ups was noted in 97% after unilateral reconstruction and 83% after bilateral
reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction
and in (95%) after bilateral reconstruction. These results demonstrated that there are no significant
differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap
reconstruction. The percentage of women who were able to perform sit-ups and the percentage of women
who did not develop a postoperative abdominal bulge were increased after DIEP flap reconstruction;
however, this difference was not statistically significant.
Robbins TH. Rectus abdominis myocutaneous flap for breast reconstruction. Aust N Z J Surg
49:527, 1979.
This is the original description of a vertical superiorly based rectus abdominis myocutaneous flap for
breast reconstruction. The author presented his experience in four patients and emphasized the ad-
vantages of sufficient muscle bulk and subcutaneous tissues to obviate the need for an implant. The
donor site was closed directly, with no reported complications in the four patients.
Scheflan M, Dinner MI. The transverse abdominal island flap: Part I. Indications, contraindi-
cations, results, and complications. Ann Plast Surg 10:24, 1983.
This was one of the early reviews of the TRAM flap and presentation of complications. The authors
reviewed their experience with 65 flaps in 60 patients. The anatomy, including the intramuscular
course of the vessels and the location of perforators, was well described. Complications included flap
necrosis (11.7%), fat necrosis (0.6%), and abdominal wall hernia (8.3%). No deep vein thrombosis
or pulmonary embolism was reported. The authors discussed these complications and made recom-
mendations to minimize these risks.
Scheflan M, Dinner MI. The transverse abdominal island flap: Part II. Surgical technique. Ann
Plast Surg 10:120, 1983.
In this second article on the transverse abdominal island flap, the authors detailed their surgical
technique. They harvested the entire width of the muscle with overlying fascia. A wide tunnel from
the abdomen to the chest was advocated. Closure of the rectus sheath with interrupted figure-of-eight
sutures was described. Positioning and tailoring of the flap to match the opposite breast was discussed.
Schusterman MA, Kroll SS, Miller MJ, et al. The free transverse rectus abdominis musculo-
cutaneous flap for breast reconstruction: one center’s experience with 211 consecutive cases.
Ann Plast Surg 32:234, 1994.
This was a prospective review of 211 free TRAM breast reconstructions performed in 163 patients.
Forty-eight patients had bilateral reconstruction. In 108 of the 211 reconstructions the muscle-
harvesting technique entailed splitting the muscle. Total flap loss occurred in 3 of 211 flaps, for a success
rate of 99%. Complications were seen in 81 of 211 reconstructions for a complication rate of 38%
overall—fat necrosis or partial flap loss (7%) and hernia or bulge (5%). The authors commented that
the bulge hernia rate tended to be lower in the group that had partial muscle harvest. Interestingly,
the fat necrosis rate was slightly higher in the group who had partial muscle harvest. However, none
of these differences reached statistical significance. The authors pointed out that a significantly higher
incidence of fat necrosis was seen in smokers.
Schusterman MA, Kroll SS, Weldon ME. Immediate breast reconstruction: why the free
TRAM over the conventional TRAM flap? Plast Reconstr Surg 90:255, 1992.
The authors reported their experience with the superior pedicle and free TRAM flap for breast recon-
struction. They reviewed 68 breast reconstructions in 63 patients. Of these, 71% were conventional
TRAM flaps and 29% were free TRAM flaps. Of the conventional TRAM flaps, 54% were
unipedicle flaps and 46% were bipedicle flaps. All patients underwent immediate TRAM flap
reconstruction. One fourth of the patients in each group were cigarette smokers. The following dif-
ferences between the two groups were noted: 44% of the patients with conventional TRAM flaps
required postoperative chemotherapy, and in 29% of those patients postoperative chemotherapy was
delayed because of complications of the TRAM flap. In contrast, only 14% of the patients in the free
TRAM flap group had chemotherapy delayed because of complications. Partial flap necrosis occurred
in 17% of the patients with conventional TRAM flaps and none in those with free TRAM flaps.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1185

This was statistically significant. Fat necrosis occurred in 23% of conventional TRAM flap patients
and in none of the free TRAM flap patients.
Selber JC, Serletti JM. The deep inferior epigastric artery perforator flap: myth and reality.
Plast Reconstr Surg 125:50, 2010.
The authors reviewed the extensive experience of the senior author (JMS), together with meta-analysis
data regarding fat necrosis rates, abdominal wall strength, amounts of muscle harvested, and flap loss
rates. The meta-analysis data suggest that fat necrosis rates are twice as high in DIEP flaps compared
with muscle-sparing free TRAM flaps. Flap loss rates were also doubled in DIEP flaps. SIEA flaps
had a higher thrombotic rate than DIEP or free TRAM flaps. Abdominal strength did not vary
among MS-2 free TRAMs, DIEP flaps, and SIEA flaps for unilateral cases, but in bilateral cases,
SIEA flaps obviously demonstrated more complete early recovery of the abdominal donor site. A useful
algorithm for selecting SIEA, DIEP, or MS-2 free TRAM flaps was presented.
Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of
236 flaps. Plast Reconstr Surg 81:189, 1988.
To improve the reliability of the skin island, the authors advocated a midabdominal transverse island.
They reviewed their experience with 236 flaps in 223 patients. They reported a 2.2% incidence of
abdominal wall hernia over 4 years; no total flap loss was seen and partial flap loss (greater than 10%
of surface area) was observed in five patients. The authors stated that the midabdominal location of the
island not only improves the vascularity of the skin island but also reduces the risk to the abdominal
wall compared with the lower transverse island. This 2% risk of abdominal wall problems and 2%
risk of partial flap loss is superior to that reported for the lower transverse island.
Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for
recurrent breast cancer. Plast Reconstr Surg 53:52, 1974.
This was the original description of the upper transverse abdominal flap for breast reconstruction. The
authors presented their experience in five patients. Their first three patients underwent a delay pro-
cedure; the final two patients underwent reconstruction without a delay. This is essentially an upper
rectus abdominis transverse island based on the perforators through the upper part of the rectus muscle.
They accurately described the basis of this flap as the perforating vessels from the superior epigastric
artery and vein through the rectus abdominis muscle.
Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle TRAM flap for unilateral breast
reconstruction. Plast Reconstr Surg 88:987, 1991.
Of 500 patients undergoing TRAM flap reconstruction, 341 patients had unilateral breast recon-
structions. In 19% of the patients a double-pedicle TRAM flap was used for a unilateral reconstruc-
tion. However, in the most recent 50 unilateral modified radical mastectomy reconstructions, the
double-pedicle TRAM flap was employed 60% of the time. Their indications for the double-pedicle
TRAM were as follows: (1) patients in whom the volume of tissue necessary to match the normal
breast exceeded that which can be reliably carried on a single pedicle and (2) patients who fell into one
of the high-risk categories, including obesity, chest wall radiation, and a history of cigarette smoking.
Patients with lower abdominal scars were also included in the high-risk group. The technique of the
operative procedure was well described.

Chest Wall Reconstruction

Ishii CH Jr, Bostwick J III, Raine TJ, Coleman JJ III, Hester TR. Double-pedicle transverse
rectus abdominis myocutaneous flap for unilateral breast and chest-wall reconstruction. Plast
Reconstr Surg 76:901, 1985.
The authors presented this “new” technique using a double-pedicle transverse rectus abdominis flap
for breast reconstruction and chest wall reconstruction in 15 patients. Indications for the double pedicle
included exceptionally large soft tissue requirements, prior abdominal operations, and certain high-
risk patients, including smokers and those with irradiated chest walls. They reported complications of
partial tissue loss in two patients, abdominal flap seroma in one patient, and hernia in one patient.

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 1186 Part II  Regional Flaps: Anatomy and Basic Techniques

The double pedicle was shown to improve the vascular supply to the transverse island and allow the
transfer of extremely large and long transverse flaps for breast reconstruction.
Jones G, Jurkiewicz MJ, Bostwick J, Wood R, Trimble-Bried Jean PA, Culbertson J, Howell
R, Eaves F, Carlson G, Nahai F. Management of the infected median sternotomy wound with
muscle flaps: the Emory 20-year experience. Ann Surg 225:766, discussion 776, 1997.
The authors presented the 20-year Emory University experience with more than 350 procedures
for sternal wound closure. A majority of the cases were closed with pectoralis major flaps, but 5% of
the cases were closed with superiorly based rectus abdominis muscle flaps. Most flaps were raised as
isolated muscle flaps, although several VRAM flap were used. Although the procedures worked well
for the most part, caution was advised when using the distal portion of the muscle to reach the manu-
brial area of the sternum, because the choke system anastomosis with the deep inferior vessels may be
poor in vasculopaths, resulting in ischemic necrosis of the tip of the flap. Additionally, the donor site
in a muscle-only harvest can undergo ischemic necrosis of the skin as a result of the removal of direct
cutaneous perforators and a lack of collateral circulation. When a myocutaneous flap is raised, the skin
island should be kept fairly proximal over the muscle to again prevent tip necrosis.
Miyamoto Y, Hattori T, Niimoto M, et al. Reconstruction of full-thickness chest wall defects
using rectus abdominis musculocutaneous flap: a report of fifteen cases. Ann Plast Surg 16:90,
1986.
Extensive chest wall defects following recurrent breast cancer, radiation ulceration, or extensive chest
wall resections were reconstructed with TRAM flaps. The authors reported a high complication rate,
including 11 hernias in 15 patients. In discussing the article, Hartrampf stated that he had a hernia
rate of 0.5% in his current series of 210 patients. He noted that a hernia rate in 11 out of 15 patients
is unacceptable and pleaded that muscle- and fascia-sparing techniques for harvesting of this flap be
used to reduce abdominal wall complications.
Neale HW, Kreilein JG, Schreiber JT, et al. Complete sternectomy for chronic osteomyelitis with
reconstruction using a rectus abdominis myocutaneous island flap. Ann Plast Surg 6:305, 1981.
The authors presented three patients in whom complete sternectomy for chronic osteomyelitis was fol-
lowed by successful reconstruction with a rectus abdominis myocutaneous island flap. The volume of
the skin and muscle successfully obliterated the defect following the resection. The authors encountered
no complications and advocated this as an excellent alternative for chronic osteomyelitis of the sternum.

Groin Coverage
Brandner MD, Bunkis J. Shotgun blast injuries to the groin: reconstruction using the rectus
abdominis flap. Ann Plast Surg 18:541, 1987.
An inferiorly based rectus abdominis flap was used to cover an extensive complex defect of the groin
after a close-range shotgun injury. The femoral vessels were reconstructed with a Gore-Tex graft and
secondarily covered with an inferiorly based rectus abdominis flap.
Logan SE, Mathes SJ. The use of a rectus abdominis myocutaneous flap to reconstruct a groin
defect. Br J Plast Surg 37:351, 1984.
A large transverse upper abdominal skin island is carried on an inferiorly based rectus abdominis
muscle for coverage of a chronically infected radionecrotic wound of the right groin. This early report
demonstrated the extensive arc of rotation of the inferiorly based rectus abdominis flap and its applica-
tion for coverage of defects in the groin, perineum, and upper thigh.
Vergote T, Revol M, Servant JM, et al. Use of the inferiorly based rectus abdominis flap for
inguinal and perineal coverage—low venous pressure zone concept. Br J Plast Surg 46:168, 1993.
The authors used the inferiorly based rectus abdominis flap for groin reconstruction. They reported
successful reconstruction in eight patients. Synthetic mesh was used for reconstruction of the donor defect
in four patients. By directing the skin island diagonally from the umbilicus toward the posterior axillary
line, the authors stated that this design away from the so-called low venous pressure zones improves
the venous return of the flap by including more cutaneous and subcutaneous venous interconnections.

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1187

Head and Neck Reconstruction

Chicarilli ZN, Davey LM. Rectus abdominis myocutaneous free-flap reconstruction following
a cranio-orbital-maxillary resection for neurofibrosarcoma. Plast Reconstr Surg 80:726, 1987.
In a patient who had undergone resection of an extensive neurofibrosarcoma, a vertically oriented rectus
abdominis myocutaneous free flap was based on the deep inferior epigastric vessels for reconstruction.
In addition to the vertical island, a small transverse skin island was also elevated. The bulk of the
flap was used to obliterate the dead space and to provide skin coverage.

Hip Reconstruction
Irons GB. Rectus abdominis muscle flaps for closure of osteomyelitis hip defects. Ann Plast
Surg 11:469, 1983.
In three patients the rectus abdominis muscle was used to fill in dead space, provide soft tissue cover-
age, and to provide a reliable vascular supply for the control of chronic osteomyelitis of the hip. There
were no complications in this group of three patients. In one patient the muscle was passed through a
subcutaneous tunnel; in the other two patients the muscle was passed through a hole in the acetabulum.
The author successfully demonstrated the usefulness of this muscle in reconstruction of defects around
the upper thigh and within the hip.

Lower Extremity Coverage

Rees R, Shack B, Hulsey T, et al. A new technique for reconstruction of an open above-knee
amputation. Plast Reconstr Surg 72:882, 1993.
In this case report the authors used an inferiorly based vertical rectus abdominis myocutaneous flap
for coverage of an above-knee amputation stump. The large size of the flap and long arc of rotation
made this a suitable flap for salvage of an above-knee amputation.

Penile Reconstruction
Davies DM, Matti BA. A method of phalloplasty using the deep inferior epigastric flap. Br J
Plast Surg 41:165, 1988.
The authors presented their experience with penile reconstruction in four patients. These included
three transsexuals and a pseudohermaphrodite. A modified TRAM flap based on the deep inferior
epigastric artery was used for reconstruction.

Upper Extremity Coverage

Press BHJ, Chiu TW, Cunningham BL. The rectus abdominis muscle in difficult problems of
hand soft tissue reconstruction. Br J Plast Surg 43:419, 1990.
The authors reported their experience in six patients in whom the rectus abdominis muscle was trans-
ferred in stages as a pedicle flap or in one stage as a free flap for coverage of hand soft tissue defects. The
muscle was covered with a skin graft. Although this would not be the first choice for hand coverage,
the authors suggested that it makes a satisfactory alternative.
Sbitany U, Wray RC Jr. Use of the rectus abdominis muscle flap to reconstruct an elbow defect.
Plast Reconstr Surg 77:988, 1986.
A superiorly based rectus abdominis muscle flap was used for coverage of the elbow in a staged proce-
dure. The muscle was divided 3 weeks after the original procedure. The feasibility of using the rectus
abdominis for coverage of the elbow was demonstrated.

Vaginal Reconstruction
Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis
myocutaneous flaps. Plast Reconstr Surg 81:62, 1988.
The authors reported their experience with 11 vaginal reconstructions and nine pelvic defect reconstruc-
tions over 3 1⁄ 2 years. In their 20 patients, partial flap loss occurred in only two. There was no case of
major flap loss and no other complications, specifically those involving the abdominal wall donor site.

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 1188 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Modifications
Baroudi R, Pinotti JA, Keppke EM. A transverse thoracoabdominal skin flap for closure after
radical mastectomy. Plast Reconstr Surg 61:547, 1978.
The authors presented their experience in 34 patients who underwent coverage of extensive chest
defects following mastectomy. A large abdominal skin flap based on the rectus abdominis myocutane-
ous perforators was described. This large flap is based on perforators on the opposite rectus abdominis.
The flap elevation proceeds across the ipsilateral rectus and across the midline to the perforators on
the opposite side. Some extensive defects were closed satisfactorily with this rather large flap. These
authors first demonstrated that perforators from one rectus abdominis could easily support the skin on
the opposite side.
Berrino P, Santi P. Hemodynamic analysis of the TRAM. Clin Plast Surg 21:233, 1994.
The authors described the “recharged” TRAM flap. During this procedure a standard pedicle
TRAM flap is elevated on one side. The deep inferior epigastric vessels to this side are also dissected
and divided. On the opposite side, essentially a free TRAM flap is elevated, including division of the
muscle and vascular pedicle. Then the deep inferior epigastric vessels on each side are sutured to each
other to establish flow from the superior epigastric vessel on the pedicle side through the muscle into
the deep inferior epigastric vessel and across the anastomosis into the deep inferior epigastric system on
the opposite side. It is thought that this will increase the circulation on the opposite side and improve
the venous drainage. This flap modification is extremely useful in patients with a lower midline scar
in whom the entire lower abdomen is elevated. This is an alternative to the bipedicle TRAM. The
authors described their technique and presented their experience with this method. In 22 patients there
was a 4.5% incidence of partial flap loss, a 4.5% incidence of flap necrosis, and a 4.5% incidence of
abdominal skin loss and abdominal weakness.
Codner M, Bostwick J, Nahai F, Bried JT, Eaves FF III. TRAM flap vascular delay for high-
risk breast reconstruction. Plast Reconstr Surg 96:1615, 1995.
A series of 23 high-risk patients who underwent 30 immediate TRAM flap reconstructions was
reviewed. Flap delay was achieved by ligation of the superficial and deep inferior epigastric arteries
2 weeks before elevation and breast reconstruction. Fat necrosis occurred in only one patient (a 4.3%
incidence). A comparison of blood pressure in the proximal stump of the deep inferior epigastric artery
and vein in seven study patients and 13 low-risk undelayed patients (controls) showed an overall
increase in arterial pressure from 13.3 mm Hg (control) to 40.3 mm Hg (delayed). The data suggest
that TRAM flap delay in the high-risk patient improves flap safety.
Cronin TD, Upton J, McDonough JM. Reconstruction of the breast after mastectomy. Plast
Reconstr Surg 59:1, 1977.
The authors described the use of a very long thoracoepigastric flap based on the perforators from the
ipsilateral rectus abdominis that extends well beyond the posterior axillary line. This is a delayed
flap that can extend onto the posterior trunk. Breast reconstruction was performed using this flap and
a silicone implant.
Fernando B, Muszynski C, Mustoe T. Closure of a sternal defect with the rectus abdominis
muscle after sacrifice of both internal mammary arteries. Ann Plast Surg 21:468, 1988.
A case report of sternal wound infection after coronary artery bypass surgery was presented. The
patient had undergone bilateral internal mammary artery grafting. Despite this, the authors were
able to successfully reconstruct the defect with a vertical rectus abdominis flap basing it on the eighth
anterior intercostal vessels. A successful outcome was reported. The authors speculated that ligation of
the internal mammary may have had some “delay” effect on the rectus abdominis and improves the
circulation through the eighth intercostal vessel.
Gottlieb ME, Chandrasekhar B, Terz JJ, et al. Clinical applications of the extended deep inferior
epigastric flap. Plast Reconstr Surg 78:782, 1986.
The extended epigastric flap originally described by Taylor was used as a pedicle flap in four patients
for coverage of large wounds of the abdomen, groin, and thigh. In two patients the flap was success-

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 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1189

fully transferred microsurgically for reconstruction of the head and lower extremity. No flap loss, either
partial or complete, was reported.
Ladin DA, Smith DP, Izenberg PH, et al. Acute repair of a full-thickness right ventricular defect
with a composite myofascial pedicle flap. Plast Reconstr Surg 90:310, 1992.
A superiorly based rectus abdominis muscle flap with a patch of anterior rectus fascia was successfully
transposed for closure of the right ventricular defect. This case report underscores not only the versatility
of the rectus flap but also the useful application of reconstructive surgical procedures in life-threatening
situations.
Maruyama Y, Osafune H. Free vertical abdominal fasciocutaneous flap. Br J Plast Surg 40:27,
1987.
The authors transferred the vertical abdominal fasciocutaneous flap they described in 1986 as a free
flap. In elevating it as a free flap a portion of the anterior rectus sheath together with underlying rectus
muscle is harvested superiorly to include the superior epigastric artery. In effect, this is a myocutane-
ous flap with a fasciocutaneous extension beyond the muscle. This provided a thin flap that was
successfully used for reconstruction of facial defects. The authors reported their successful reconstruction
in three patients.
Maruyama Y, Onishi K, Chung CC. Vertical abdominal fasciocutaneous flaps in the recon-
struction of chest wall defects. Br J Plast Surg 38:230, 1985.
A superiorly based vertical abdominal fasciocutaneous flap was used for reconstruction of chest wall
defects in eight patients. The flap was based on rectus abdominis perforators in the upper part of the
muscle. The base of the flap was designed just below the costal margin, and the rectus muscle was
spared. The authors emphasized that in the proximal part of the dissection, all perforating vessels at
the level of the costal margin should be preserved and included as the pedicle to the flap.
Pernia LR, Miller HL, Saltz R, Vasconez LO. “Supercharging” the rectus abdominis muscle to
provide a single flap for cover of large mediastinal wound defects. Br J Plast Surg 44:243, 1991.
The rectus abdominis has a role in coverage of the infected median sternotomy wound. However, on
occasion the distal end of the superiorly based rectus muscle does not provide an excellent blood sup-
ply. On other occasions one or both internal mammary arteries may have been ligated. In an effort
to use a single rectus muscle to cover the entire defect, the authors advocated microsurgical anastomosis
of the deep inferior epigastric vessels to recipient vessels in the upper chest (supercharging). Thus
flow is reestablished into the muscle through the deep inferior epigastric vessels as well as the superior
epigastric vessels. The authors presented their experience in six patients. They were successful on
each attempt and recommended this procedure over the use of multiple flaps for coverage of extensive
median sternotomy defects.
De la Plaza R, Arroyo JM, Vasconez LO. Upper transverse rectus abdominis flap: the flag flap.
Ann Plast Surg 12:410, 1984.
An upper transverse island base designed just below the costal margin was described. The skin island
was based on the deep inferior epigastric vessels of the underlying rectus abdominis muscle. This proved
to be an extremely useful flap with a rather wide arc of rotation that provides a large volume of skin
subcutaneous tissue for reconstruction of defects in the lower abdomen, groin, and thigh. The authors
reported that complications were few but did not elaborate further.
Sadove R, Merrell JC. The split rectus abdominis free muscle transfer. Ann Plast Surg 18:179,
1987.
The authors successfully transferred a rectus abdominis muscle flap to the lower extremity. The flap
was then split longitudinally so that one portion covered the lateral malleolus and the other half the
medial malleolus in the same leg.
Taylor GI, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical technique.
Plast Reconstr Surg 72:751, 1983.
In this anatomic and clinical study, the authors described the extended deep inferior epigastric flap.
Based on the deep inferior epigastric artery a muscle flap with a diagonally placed upper skin island

10b_RecAb_r4_cah_1136-1191.indd 1189 2/2/2012 5:37:15 PM

 1190 Part II  Regional Flaps: Anatomy and Basic Techniques

was designed. This is a particularly long myocutaneous flap, with an arc of rotation extending down
to the knee and is available as a free flap with an extremely long pedicle.
Ueda K, Inoue T, Tanaka I, et al. Chest wall reconstruction by a rectus abdominis myocuta-
neous composite flap attached with the external oblique fascia. Preliminary report. Br J Plast
Surg 44:538, 1991.
In this brief case report the authors reconstructed an extensive chest wall defect with a superiorly based
vertical rectus abdominis flap, including the external oblique fascia from the ipsilateral side. The skin
island extended to the contralateral side of the abdomen.

Complications
Drever JM, Hodson-Walker N. Closure of the donor defect for breast reconstruction with
rectus abdominis myocutaneous flaps. Plast Reconstr Surg 76:558, 1985.
To minimize the risk of abdominal wall weakness and hernia, the authors advocated reconstruction of
the anterior rectus sheath with double Mersilene mesh extending up to the costal margin and the same
width as the fascia taken with the muscle pedicle. In essence, Mersilene mesh replaces the anterior
rectus sheath. The authors reviewed their experience with 186 TRAM flap breast reconstructions.
Of these, 31 patients underwent direct closure of the anterior rectus sheath; 43% developed weak-
ness, bulging, or hernia, five of whom required secondary repair. In 155 patients the donor defect was
closed with Mersilene mesh and only 4% developed bulging that required later repair. The authors
attributed this to technical errors. They also reported two patients with infection and three with ex-
posed mesh due to necrosis. In none of these patients was the mesh removed. In a discussion of this
article, Hartrampf vehemently disagreed with the authors and advocated a muscle- and sheath-sparing
technique. In his experience with 216 patients, he reported that 145 patients in whom unilateral
pedicle flaps were used had all undergone direct closure without synthetic mesh. Only one single
lower abdominal hernia occurred because of a technical error. He advocated the removal only of that
portion of the rectus muscle and sheath that is necessary to include the periumbilical perforators with
the superior epigastric vessels. This debate over abdominal wall closure and partial or total harvesting
of the muscle continues to this day.
Georgiade GS, Voci VE, Rief kohl R, et al. Potential problems with the transverse rectus
abdominis myocutaneous flap in breast reconstruction and how to avoid them. Br J Plast Surg
37:121, 1984.
The authors advocated preoperative evaluation, preoperative flap design, and technical modifications
to minimize the risk of complications. Patients who are obese with a large abdominal panniculus are
considered poor candidates. Smokers may have a higher risk of flap necrosis. Flap design on the con-
tralateral rectus allows a more gentle arc of rotation, thus minimizing the risk of kinking. Identification
and protection of the myocutaneous perforating vessels are emphasized. Abdominal wall reconstruction
with Prolene mesh was recommended.
Kroll SS, Marchi M. Comparison of strategies for preventing abdominal-wall weakness after
TRAM flap breast reconstruction. Plast Reconstr Surg 89:1045, 1992.
This retrospective review of 130 TRAM flaps at M. D. Anderson Cancer Center dealt specifically
with abdominal wall problems. True hernias as well as abdominal wall bulges and weakness were
included. The patients were divided into three groups: in group 1, the entire muscle was harvested
with a one-layer anterior sheath closure. In group 2, the lateral third of the muscle was preserved and
the fascia was closed in two separate layers—the deeper muscle layer and the anterior layer. In group
3, more muscle was harvested, leaving only the lateral fifth of the muscle with a two-layer closure.
The authors stated that the deep or muscle layer is a “stronger” closure, since it approximates muscle
remnants and internal oblique fascia to the midline fascia deep to the linea alba. The superiority of the
closure in group 3 was statistically significant. The incidence of bulging or weakness was 33% for group
1, 40% for group 2, and only 8% for group 3. There were four true hernias in group 1, one in group

10b_RecAb_r4_cah_1136-1191.indd 1190 2/2/2012 5:37:15 PM

 Abdomen  •  10B: Rectus Abdominis and TRAM/DIEP Flaps 1191

2, and none in group 3. The experience in these patients was neither simultaneous nor randomized;
rather, it was a chronologic evolution of abdominal wall closure in their hands. Nahai in a discussion of
this article emphasizes that experience with the TRAM flap is important in reducing complications.
Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr
Surg 87:1054, 1991.
Fifty-seven patients who had undergone breast reconstruction with the TRAM flap were evaluated.
Thirty-three patients had only one muscle harvested and 24 patients had both muscles harvested.
The patients were evaluated 6 months and 2 years after breast reconstruction. In all patients the
rectus sheath was reconstructed with Teflon mesh. A detailed and complex evaluation of the patients
included clinical examination by the surgeon at least 6 months after the operation and a questionnaire
on abdominal comfort, strength, and ability to do sit-ups and participate in sports between 6 months
and 2 years after the operation. A functional evaluation of the abdominal wall was performed by a
physiotherapist, and CT scans of the abdominal wall were obtained before and after TRAM flap
reconstruction to assess the relationship of the abdominal wall musculature. The authors reported that
Teflon mesh was well tolerated, with no hernia or bulging. Ten patients reported less back pain after
the operation than before. They also found that the ability to do sit-ups and participate in sports was
the same as preoperatively. Physiotherapeutic evaluation of the abdominal muscle did show a decrease
in function of the abdominal wall, more so in bilateral cases. CT scans demonstrated a medial migra-
tion of the lateral abdominal musculature, leaving only a small central portion of the abdominal wall
devoid of muscles.
Nesmith RL, Marks MW, DeFranzo AJ, et al. Inferiorly based rectus abdominis flaps in criti-
cally ill and injured patients. Ann Plast Surg 30:35, 1993.
The authors presented their experience with inferiorly based rectus abdominis flaps in 26 patients
between 1988 and 1993. In 17 of these patients, the flap was used as a pedicle flap, and in nine
patients it was transferred as a free flap. The authors reported that patients with multiple injuries,
especially those who had recently undergone abdominal laparotomy, had a significantly higher mor-
bidity rate. Dehiscence of the abdominal wound in three patients and a fatal donor site infection after
rectus flap transfer were reported. They recommended that alternate sources of tissue should be used
rather than the rectus abdominis in patients who are seriously ill, those on ventilators, or those with
abdominal distention and nutritional compromise.
Watterson PA, Bostwick J III, Hester TR Jr, Bried JT, Taylor GI. TRAM flap anatomy corre-
lated with a 10-year clinical experience with 556 patients. Plast Reconstr Surg 95:1185, 1995.
This was an extensive review of the first 556 patients to undergo TRAM flap breast reconstruction
at Emory University. The anatomy of the flap and operative technique were outlined. Of interest is
the classification of risk factors and the relationship of these factors to complications in the breast as well
as the abdominal donor site. Complications included partial flap loss (5%), total flap loss (0%), fat
necrosis (10.6%), and abdominal hernia (8.8%). The overall complication rate was 23.7%, includ-
ing pulmonary embolus and deep venous thrombosis (0.7%), wound infection (5%), and hematoma
(1.3%). Of interest were the association of risk factors with complications. Smokers had an overall
complication rate of 39.2% versus 21.4% in nonsmokers. This with a history of radiation therapy
led to a complication rate of 37.4% versus 21.1% in those who did not have radiation therapy. Sig-
nificant abdominal scars led to a 32.9% complication rate versus 20.6% in those without significant
abdominal scars. Obesity was associated with a 31.4% complication rate versus 20.8% in nonobese
patients. Complication rates before and after age 60 were similar. Also of interest were risk factors
and their association with fat necrosis. These included radiation, abdominal scars, obesity, smoking,
and hypertension. In all of these categories the risk of fat necrosis was higher. Smoking, history of
radiation, significant abdominal scarring, and obesity were all shown to be statistically significant
factors for overall complications, including abdominal wall problems, partial flap loss, and fat necrosis.

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 ANATOMIC LANDMARKS
Landmarks The external oblique muscle is the most superficial of the three
lateral abdominal muscles, extending between the costal margin
and the iliac crest and inguinal ligament. It is a thin, quadrilateral
muscle with an aponeurosis that blends with that of the internal
oblique muscle to form the anterior rectus sheath.
Size 40 3 20 cm.
Origin The muscle arises from the lower eight ribs laterally as fleshy
digitations combining to form a single large muscle sheet.
Insertion Anterior half of the iliac crest and a broad aponeurotic insertion
into the linea semilunaris, where it fuses with the anterior leaflet
of the internal oblique to become the anterior rectus sheath more
medially.
Function Stabilize abdominal core.
Composition Muscle, myocutaneous.
Flap Type Type IV.
Dominant Pedicle Segmental lateral cutaneous branches of the inferior eight pos-
terior intercostal vessels, with minor contributions inferiorly
from the ascending branch of the deep circumflex iliac artery
(DCIA) vessels.
Minor Pedicle Ascending branch of the deep circumflex iliac artery.
Nerve Supply Intercostal.

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 Section 10C
Abdomen

External Oblique Flap

CLINICAL APPLICATIONS
Regional Use
Chest
Posterior trunk
Abdomen

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 ANATOMY OF THE External Oblique Flap

Lateral cutaneous B
branches of inferior
eight posterior
intercostal arteries

Ascending branch
of the deep
circumflex iliac artery

Seventh through
twelfth intercostal
nerves

Vascular anatomy

Nerve supply

Fig. 10C-1

Dominant segmental pedicle: Lateral cutaneous branches of inferior eight posterior

intercostal arteries
Minor pedicle: Ascending branch of deep circumflex iliac artery

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 Abdomen  •  10C: External Oblique Flap 1195

Anatomy
Landmarks This muscle is the most superficial of the three lateral abdominal muscles, ex-
tending between the costal margin and the iliac crest and inguinal ligament. It
is a thin, quadrilateral muscle with an aponeurosis that blends with that of the
internal oblique to form the anterior rectus sheath.
The external oblique muscle is located between the linea semilunaris (palpated
at the lateral edge of the rectus muscle) and the anterior axillary line and extends
from the lateral costal margin to the iliac crest.
Composition Muscle, myocutaneous.
Size 40 3 20 cm. The flap territory extends from the midline of the abdomen to the
anterior axillary line.
Origin The muscle arises from the lower eight ribs laterally as fleshy digitations combin-
ing to form a single large muscle sheet.
Insertion Anterior half of the iliac crest and a broad aponeurotic insertion into the linea
semilunaris, where it fuses with the anterior leaflet of the internal oblique to
become the anterior rectus sheath more medially.
Function Stabilize abdominal core.

Arterial Anatomy (Type IV)

Dominant Pedicle  Segmental lateral cutaneous branches of the posterior intercostal arteries
Regional Source  Thoracic aorta.
Length  3 cm.
Diameter  0.5 to 1 mm.
Location  These segmental vessels enter the posterior muscle belly at the level of the midaxillary
line.
Minor Pedicle  Ascending branch of the deep circumflex iliac artery
Regional Source  External iliac artery.
Length  4 cm.
Diameter  0.5 to 1 mm.
Location  3 cm superior to anterior superior iliac spine.

Venous Anatomy
Venae comitantes accompanying the arterial circulation; source vessels include the azygous and
hemizygous veins.

Nerve Supply
Motor Seventh through twelfth intercostal nerves.
Sensory Seventh through twelfth intercostal nerves.

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 1196 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the External Oblique Flap

A B

Release of muscle insertion Elevation of a standard flap

C D

Closeup of flap base Radiographic view

Fig. 10C-2 

Dominant segmental pedicle: Lateral cutaneous branches of inferior eight posterior inter-
costal arteries (arrows)

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 Abdomen  •  10C: External Oblique Flap 1197

Flap Harvest
Design and Markings
Skin Islands
The external oblique muscle is most commonly used as a rotation advancement flap for chest
or hip defects or as part of a component separation procedure for hernia repair. Incorpora-
tion of a modified V-Y approach using a backcut can assist with flap advancement. The skin
island may extend over the territory of the rectus muscle to the midline of the abdomen.
The flap naturally rotates superiorly because of the direction of its fibers.

Superior skin island design

Fig. 10C-3 

The most common incision is a curvilinear incision starting below the lower rib margin
posteriorly and extending transversely across the subcostal area before turning down paral-
lel and adjacent to the linea semilunaris. This vertical limb descends until the umbilicus is
reached, at which point the incision is curved back toward the ASIS.

Patient Positioning
The patient is placed in the supine position, and if necessary, padding is placed beneath the
ipsilateral buttock to further expose the flank.

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 1198 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

Standard Flap
The skin is deepened to the fascia, and the flap is raised from medial to lateral. The dissec-
tion is in the subcutaneous plane until the semilunar line is reached. At the lateral edge of
the rectus sheath, the fibers of insertion of the external oblique muscle to the linea semi-
circularis are divided, releasing the skin island with the external oblique fascia and muscle.
The external oblique fascia is elevated, with the plane of dissection now located between
external and internal oblique muscles. In the inferior lateral abdominal wall the external
oblique fibers of origin from the anterior half of the iliac crest are divided.
The muscle is released from the costal margin to allow rotation of the flap superiorly.
Care must be taken to preserve two to four segmental vascular pedicles entering the deep
surface of the muscle adjacent to its origin from the costal margin.

Linea semilunaris

Rectus abdominis muscle

Lateral cutaneous branches of Internal oblique muscle
the posterior intercostal artery

External oblique muscle

Fig. 10C-4 

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 Abdomen  •  10C: External Oblique Flap 1199

Flap Variants
•  Rotation advancement/V-Y flap
•  Tissue expansion
•  Component separation
•  Reverse flap
Rotation Advancement/V-Y Flap
In this variant, dissection of the flap is the same as for the standard flap. This design takes
advantage of the lower abdominal excess to bear the tension of closure inferiorly while
supporting the flap superiorly. Care is taken to extend the design inferiorly. Flap elevation
is similar to that of the standard flap. Release of the muscle origin from the costal margin
superiorly and release of the muscle insertion from the iliac crest may be required to increase
the flap advancement. The V-Y variant requires an oblique inferior backcut, as illustrated
below, to allow a cephalad flap motion that creates a vertical V-Y closure.

A C

B D

Lateral chest defect with Closure with rotation

external oblique flap design advancement

Flap elevation Closure with V-Y

Fig. 10C-5

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 1200 Part II  Regional Flaps: Anatomy and Basic Techniques

Tissue Expansion
One way to increase available fascia for abdominal wall reconstruction is through tissue
expansion. An expander is placed through a remote incision (never the IMF) into the space
between the external and internal oblique muscles. Once expansion is complete, a normal
direct closure or component release can be performed after the expander is removed.

Initial expander size

External oblique
muscle Expander
B
Implant placed

Internal oblique
muscle Transverse abdominis
muscle

Cross-section shows implant between

external and internal oblique muscles

Fig. 10C-6 

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 Abdomen  •  10C: External Oblique Flap 1201

Component Separation
Since Ramirez’s description of the component separation technique, using external oblique
elevation to facilitate release of and advancement of the rectus abdominis medially has
become the flap of choice in abdominal hernia repair. The procedure involves incising
the external oblique fascia just lateral to the linea semilunaris and undermining it to the
anterior or midaxillary line. The mobilized external oblique provides relaxation for the
rectus abdominis and associated fascial support structures to advance medially, allowing
closure of the abdominal hernia centrally. Although technically not a direct use of the
external oblique as a flap for coverage, its elevation and release is integral to the success of
the component separation procedure.

Hernia
A
Rectus abdominis muscle
External oblique muscle

Midline ventral hernia between separated rectus abdominis muscles

External oblique released lateral to linea semilunaris,

allowing medialization of rectus abdominis muscles

Component separation allows medial

advancement and midline reapproximation of rectus
abdominis muscles to restore abdominal wall integrity

Fig. 10C-7  Cross-sections of the dissection of the abdominal wall into its component sections and
final flap reconstruction.

Reverse Flap
The muscle and fascia of the external oblique flap can be used for reconstructing back defects.
Based on the intercostal vessels, the muscle and fascia are released along the semilunar line,
along the costal margin, and from the ASIS. Bilateral flaps can reach the posterior midline.

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 1202 Part II  Regional Flaps: Anatomy and Basic Techniques

Arc of Rotation
Standard Flap
The point of rotation occurs at the edge of the costal margin at the anterior axillary line.
The flap will reach the anterior and posterior trunk.

A B C

Arc to superior abdomen Arc to central abdomen Arc to posterior back

Fig. 10C-8 

Flap Transfer
The flap is transferred to its recipient site, without undue tension on the segmental blood
supply. Because of the downward oblique direction of the muscle fibers, the flap will transfer
superiorly more easily than inferiorly.

Flap Inset
This myocutaneous unit is directly inset into the defect. The deep fascia beneath the skin
island may be used to reconstruct a chest wall, pelvic, or adjacent abdominal wall defect.
By insetting the flap’s fascia into the defect, tension is removed from the skin closure.

Donor Site Closure

No fascial closure is required. The large donor site requires drains postoperatively. Either
the rotational/advancement or V-Y site will close primarily. One can place a skin graft if
needed. The skin defect is closed directly by advancement of the remaining abdominal
and groin skin.

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 Abdomen  •  10C: External Oblique Flap 1203

Clinical Applications
This 70-year-old woman with lung cancer metastatic to her chest wall underwent radical
chest wall resection (rib and pleura only) with reconstruction using two Gore-Tex sheets.
She developed an infection around the Gore-Tex, with subsequent abscess formation and
wound breakdown. The cardiac service planned explantation of the mesh and requested
plastic surgical closure of the two wounds. The upper anterior wound was closed with a
pectoralis major myocutaneous flap. The lower lateral wound required an external oblique
myocutaneous rotation advancement flap to achieve closure. She had a remarkably uneventful
postoperative recovery, with complete resolution of both the sepsis and the chest wall pain.

A B

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. (Case supplied by GJ.)

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 1204 Part II  Regional Flaps: Anatomy and Basic Techniques

This 87-year-old woman had an 11-year disease-free interval from cancer of the right
breast and presented with a chest wall recurrence. Her chest wall excision included muscle
but not ribs. She had undergone radiation therapy 11 years earlier. The size and location of
the defect and the advanced age of the patient made the external oblique an ideal choice.

A B

C D

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 ab-
dominis flap. (Case supplied by MRZ.)

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 Abdomen  •  10C: External Oblique Flap 1205

This 50-year-old woman had undergone breast conservation therapy for a right breast cancer
10 years earlier. She presented with a submammary recurrence, and a wide excision of the
mass and completion mastectomy were performed. An external oblique flap was chosen
for her reconstruction. The opportunity for implant reconstruction still exists, because a
tissue expander can be placed under the flap in delayed fashion.

A B C

D E

Fig. 10C-11 A, Preoperative photo showing the submammary scar from her biopsy and the pro-
posed 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. (Case supplied by MRZ.)

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 1206 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old woman had a history of a left chest wall liposarcoma initially treated
with chest wall resection, Gore-Tex repair, and latissimus flap coverage. After accidentally
burning her insensate flap and exposing the Gore-Tex, the chest wall was salvaged with an
omentum flap and skin graft. Five years later, she had a recurrence requiring a wide chest
wall resection. She was referred for a free flap, since she was not thought to be a candidate
for a locoregional flap because of the prior surgery and her previous abdominal surgery. An
external oblique flap was planned, because the lateral intercostal blood supply was intact,
and the flap was “delayed” by her prior surgery. She tolerated the surgery with minimal
morbidity and avoided the risks of free tissue transfer.

C D

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.
(Case supplied by MRZ.)

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 Abdomen  •  10C: External Oblique Flap 1207

This is an unusual case of melanoma of the breast in a 44-year-old woman. She required
an extensive chest wall resection, and it was clear that no one flap would allow primary
closure of the resultant defect. In such circumstances, the defect is divided into an upper
and lower defect, each reconstructed with a different flap. In this case, a VRAM flap was
used for the upper portion, and the external oblique flap was used for the lower compo-
nent. This combination is advantageous because it does not require a position change, the
horizontal laxity of the abdominal area can be used to advantage, and primary closure of
the donor site can be obtained.

A B

C D

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. (Case
supplied by MRZ.)

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 1208 Part II  Regional Flaps: Anatomy and Basic Techniques

This 61-year-old woman presented with an angiosarcoma of the right chest after chest wall
irradiation for breast cancer. The patient had a wide excision and wound-VAC dressing until
negative margins were obtained. A VRAM flap was planned for the defect, but primary
closure was not obtainable. The external oblique flap could then be elevated, providing
additional tissue for a two-flap closure without a change of position or field. This strategy is
useful if the surgeon is unsure whether the VRAM or latissimus flaps will provide enough
tissue for primary closure.

C D E

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 un-
derestimated. 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. (Case supplied by MRZ.)

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 Abdomen  •  10C: External Oblique Flap 1209

This 78-year-old woman had a large, malignant fibrous histiocytoma that precluded her
lying supine; the lesion was quite painful and malodorous. Her entire back had previously
been irradiated.

A B

C D

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. (Case courtesy Gregory Ara Dumanian, MD.)

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 1210 Part II  Regional Flaps: Anatomy and Basic Techniques

This 48-year-old woman had a massive dermatofibrosarcoma protuberans excised from

her left flank. She had undergone preoperative radiation therapy. The spinous processes
were exposed.

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. (Case courtesy
Gregory Ara Dumanian, MD.)

Pearls and Pitfalls

• Prior incisions through the external oblique fascia or rectus sheath may preclude use of
this flap.
• Careful donor site closure is required. Avoiding injury to the intercostal nerves will
prevent bulges postoperatively.
• This myocutaneous flap has a limited arc of rotation that is primarily useful as an alternative
flap when a reliable flap such as the rectus abdominis myocutaneous flap is not available.
• Care should always be taken to preserve the posteriorly based vascular supply during
dissection, bearing in mind the limitation of truly segmental inflow.
• The external oblique flap is an excellent choice for lower third chest wall defects.

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 Abdomen  •  10C: External Oblique Flap 1211

EXPERT COMMENTARY
Gregory Ara Dumanian

Advantages and Limitations

The external oblique flap is a useful tool in a surgeon’s armamentarium for reconstruct-
ing lower chest/upper abdominal wounds and flank defects caused by tumor extirpation.
Radiation therapy obviates closing these wounds with simple skin grafts. Although in my
opinion the external oblique muscle is not a first-line flap choice for these wounds, it offers
certain advantages over alternatives. The choice to use the external oblique flap depends
on how the surgeon views the interplay of radiation and skin grafts.

Radiation Therapy Before Tumor Excision

Radiation therapy is commonly performed before tumor excision for tumors of the flank
and anterior chest. Sarcomas of the back and significant breast cancers are commonly treated
with preoperative radiation therapy. The defect remaining after tumor excision would po-
tentially be closeable with skin grafts and subatmospheric dressings; however, the success
rate of placing skin grafts on an irradiated bed would be lower rather than higher. Skin
grafts tend not to adhere to the periosteum of exposed, irradiated ribs. Pedicled muscle
flaps provide a reasonable option to act as an interface between the irradiated bed and the
graft. The well-vascularized muscle flap would stick to the irradiated bed, and the skin graft
would adhere to the nonirradiated muscle.
For reconstructions in the anterior chest, most surgeons would choose the latissimus
dorsi flap before an external oblique flap. The latissimus flap is well known and can treat the
entire chest, whereas the external oblique flap covers only the lower chest. The latissimus
has two significant drawbacks, however. It requires a position change that the external
oblique flap does not. For large defects, the latissimus will still require a skin graft, whereas
the external oblique flap to the anterior chest is better thought of as a myocutaneous flap and
does not require skin grafts.
For flank defects, in many circumstances pedicled latissimus flaps or large random-pattern
skin flaps can cover the irradiated site. When this is not possible, surgeons often attempt
skin grafting irradiated wound beds with no exposed bone. However, in some instances a
pedicled turnover external oblique muscle flap will provide an optimal nonirradiated soft
tissue interface for successful closure. One example is when alloplastic material is employed
for chest wall reconstruction.

Radiation Therapy After Tumor Excision

A subset of patients will undergo radiation therapy after tumor excision. In the context of
this chapter, this would be more for wound sites in the breast and anterior chest than in
the flank. Although a skin graft of the wound bed after tumor excision would successfully
close the wound in many instances, the skin graft may not be able to withstand the subse-
quent radiation therapy. Full-thickness soft tissue cover would be better able to tolerate the
postoperative radiation therapy than skin grafts.
The external oblique flap has advantages over the latissimus flap for chest coverage,
because it provides skin to cover the defect. The latissimus dorsi muscle can carry a skin
paddle, but the size of the paddle is limited based on the results of the pinch test. Because
latissimus muscle flaps are typically much larger than the size of the skin paddle, skin grafts
are often placed on the muscle to achieve closure, requiring a skin graft donor site and
leading to poorer overall cosmesis. Continued

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 1212 Part II  Regional Flaps: Anatomy and Basic Techniques

The clinical examples in this chapter illustrate some of these concepts. In Fig. 10C-9,
an alloplast of the flank is covered with an external oblique turnover flap, and the cover
for the flap is mobilized chest skin. The other examples in the chapter illustrate the ability
of external oblique pedicled flaps to cover large anterior chest wounds with full-thickness
flaps, without skin grafts.

Anatomic Considerations
The external oblique myocutaneous flap performed in V-Y fashion moves like other seg-
mentally vascularized flaps. The external oblique muscle slips have a particular orientation,
classically described by medical students as the “hands in the front pockets” direction. The
anterior abdominal skin is elevated off of the anterior rectus fascia to the level of the semi-
lunar line. Then, analogous to the components separation procedure, the external oblique
aponeurosis is incised, and the deep aspect of the muscle is elevated to the midaxillary
line, where the segmental perforators enter the muscle. The perforators are small, and are
not dissected into the internal oblique. Rather, the orientation of the muscle changes from
approximately 45 degrees sloping downward to 45 degrees pointing upward. This allows
the skin located distal to the muscle to have a much greater arc of movement superiorly
for closure of lower chest defects. Further advancement superiorly can be obtained with a
backcut of the muscle, which is done sparingly. The external oblique flap does not advance
well anteriorly or inferiorly, because the orientation of the muscle is not markedly changed
in these directions.
The segmental perforators enter the muscle at the midaxillary line, along a curved
rather than straight line (Fig. 10C-17). The upper slips of the muscle cause the perforators
to enter along the anterior axillary line, rather than at the midaxillary line. Therefore for
turnover flaps the upper perforators must be divided where the muscle is in contact with
the rib cage. This can potentially cause some relative ischemia of this aspect of the muscle.
For turnover flaps to the back, the muscle can reach the posterior midline, but it is fascia
rather than muscle that reaches this location (Fig. 10C-18). Because this would be the most
distal part of the flap, it may not be prudent to use the external oblique turnover flap to
attempt to cover spinal instrumentation.

Fig. 10C-17  Fig. 10C-18 

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 Abdomen  •  10C: External Oblique Flap 1213

Personal Experience and Insights

The external oblique muscle is commonly released in the components separation hernia
repair. Based on my observations after performing hundreds of these procedures, the loss
of function of the external oblique is truly negligible. Rarely, hernias occur at the level of
the semilunar line. These are often associated with a release that injures the internal oblique
fibers inadvertently. The shape of the abdomen changes with release of this muscle, and this
can be seen and measured on CT scans. This should be discussed with patients preopera-
tively; however, reconstruction of irradiated tumor sites is a priority over cosmesis when
making decisions.
A downside of the pedicled myocutaneous flap performed in V-Y fashion is that the
upper aspect of the flap is next to the tumor and could be irradiated or marginal in qual-
ity. Elevating the flap causes a large potential space that must be addressed in the operating
room with multiple drains and quilting sutures. During the final inset, care is taken not to
place tension on the superior (and potentially most ischemic) part of the flap.
A downside of the turnover flap is that most of the abdominal skin will require eleva-
tion to harvest the flap. Maintaining periumbilical perforators from the rectus muscle is
important to prevent ischemic necrosis of the donor site skin.

Recommendations
I recommend the external oblique myocutaneous flap for lower chest lesions when radia-
tion has been or will be given, and when thoracodorsal artery–based flaps (latissimus flap
and thoracodorsal artery perforator flaps) are unavailable. A large backcut in the lower ab-
dominal skin will ensure good superior movement, and this is best closed in V-Y fashion.
The external oblique muscle turnover flap should be used in irradiated nonmidline back
and flank defects when latissimus and large skin flaps are not available or not of good qual-
ity. Perforators leaving the chest wall along the anterior axillary line and traveling to the
superior slips of muscle may need to be sacrificed for optimal movement.

Postoperative Care
External oblique flaps do not require any special postoperative precautions. For large back
defects, pressure relief beds should be ordered so that the patient can lie on and compress
the flaps against the wound bed.

Expert Commentary
Michael R. Zenn

Advantages and Limitations

The external oblique flap is one of the best-kept secrets in chest wall reconstruction. For
most chest wall needs, one commonly sees latissimus flaps, or for larger tissue needs, the
vertically oriented VRAM flap. One common problem in these cases is that the blood supply
to the flap may have been divided during resection of the tumor, or chest wall irradiation
may affect the quality of perfusion to those flaps. The latissimus dorsi may be further com-
plicated by previous lymph node dissection and lymphedema of the arm on the same side.
Enter the external oblique flap, with abundant tissue and a robust blood supply unaffected
by surgical resection and chest wall irradiation. It is easy to raise the flap with remarkably
low morbidity. The external oblique is the flap of choice in my practice for lower third
chest wall defects. Continued

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 1214 Part II  Regional Flaps: Anatomy and Basic Techniques

Recommendations
Planning
The external oblique flap works well because it uses the circumferential excess of the ab-
domen to harvest the flap while still allowing primary closure of the donor site. For very
large defects, I combine the VRAM and the external oblique flaps and still achieve primary
closure in the abdomen (see Figs. 10C-13 and 10C-14). Only once in my practice have I
needed to skin graft the donor site.

Technique
Most reconstructive surgeons who perform component separation of the abdominal wall
are already performing an external oblique flap. The only missing piece is release of the
muscle superiorly and the cutback of the lower flap to allow advancement.
The flap is elevated, and the dissection is performed up to the intercostal neurovascular
bundles, preserving them (Fig. 10C-19). Release of the inferior muscle will divide some of
the vascular contributions of the DCIA, but this division is necessary for flap rotation. As
many of the intercostal bundles as possible should be maintained and this ultimately limits
flap advancement. Although Bogossian et al stated that the flap could reach the upper third
of the chest and clavicle, I feel this requires too much sacrifice of the segmental blood sup-
ply, and I limit the use of the flap to lower third defects only.

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 inferiorly
(dashed line), and the contributions of the DCIA
(X) will be divided.

Take-Away Messages
Two pearls that I can pass on after performing this flap for many years regard design of the
external oblique flap. First, one should not cross the midline with the flap design. The up-
per abdomen has less cross-perfusion than the lower abdomen, and tissues carried across the
midline do not survive well. Cases in which a previous midline incision exists are perfect
for the external oblique flap, since the tissues have been partially “delayed.”
Second, it is not necessary to carry tissue below the umbilicus, so the flap design should
encompass a gentle curve from just above the umbilicus to just above the ASIS. This is
where the donor site can be “cheated” closed, using horizontal laxity. The most important
reason to design the flap this way is that it prevents the umbilicus from being distorted and
pulled to the side.
The biggest surprise in using this flap is how well patients tolerate the procedure. An-
algesia requirements are much lower than with alternative flaps. There are no hernia issues,
so once the drains have been removed, there are few restrictions and patients can more
quickly resume their normal activities.

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 Abdomen  •  10C: External Oblique Flap 1215

Bibliography With Key Annotations

Anatomic Series
Yang D, Morris SF, Geddes CR, et al. Neurovascular territories of the external and internal
oblique muscles. Plast Reconstr Surg 112:1591, 2003.
This study documented the extent of the arteries supplying the external and internal oblique muscles
and the connections among the vascular territories. Ten adult human cadavers underwent whole-body
arterial perfusion (200 ml/kg) with a mixture of lead oxide, gelatin, and water, through the carotid
artery. The external and internal oblique muscles were dissected and subjected to radiography. The
vasculature of each muscle was analyzed by using the paper template technique. The areas of the
vascular territories of the individual intercostal arteries within the external oblique muscle varied from
9% to 22%. The area of the vascular territory of the muscular branch of the deep circumflex iliac
artery was 5% to 18%. The ascending branch of the deep circumflex iliac artery supplied a mean
of 35.7% of the vascular territory of the internal oblique muscle. The lower six posterior intercostal
arteries supplied a mean of 48.5%; the lateral branches of the deep inferior epigastric artery supplied
a mean of 15.8%. This information provides the basis for the design of external and internal oblique
muscle flaps for functional muscle transfer.

Clinical Series
Abdominal Wall Coverage
Hadad I, Small W, Dumanian GA. Repair of massive ventral hernias with the separation of
parts technique: reversal of the ‘lost domain.’ Am Surg 75:301-306, 2009.
This article focuses on “separation of parts hernia repair,” a technique for repairing massive ventral
hernias complicated by the “loss of domain.” Separating parts reverses domain loss by increasing
intraabdominal volume; however, because the hemidiaphragms are not raised into the thoracic cav-
ity, pulmonary complications are minimal. The authors reviewed charts of 102 patients treated by a
single surgeon. All patients had postoperative pulmonary complications. Ten patients had matching
preoperative and postoperative abdominal CT scans that were computer analyzed for intraabdominal
volume changes and diaphragm height measurements. Intraabdominal volume increased from 8600
6 2800 ml to 9700 6 2700 ml. The change in diaphragm height was not statistically significant.
The authors concluded that the separation of parts technique effectively closed large ventral hernias
without a high incidence of pulmonary complications.
Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-
wall defects: an anatomic and clinical study. Plast Reconstr Surg 86:519, 1990.
This is the paper credited with launching the current popularity of component separation in the repair
of abdominal wall hernias. The authors presented a detailed approach to the technique as well as its
outcomes. This paper is essential reading for any surgeon interested in repairing these problematic defects.
Spear SL, Walker RK. The external oblique flap for reconstruction of the rectus sheath. Plast
Reconstr Surg 90:608, 1992.
The authors reported their experience 1985 to 1990 in 33 patients who underwent breast recon-
struction with bilateral lower rectus abdominis flaps. Bilateral external oblique flaps were used for
reconstruction of the abdominal wall. These were advancement flaps of external oblique muscle and
fascia. The external oblique flaps were performed only if the rectus sheath could not be approximated
without tearing. Of the 33 patients, seven required mesh overlay because the repairs were excessively
tight. Thirty-two patients healed uneventfully with satisfactory abdominal wall integrity. One patient
developed a postoperative hernia.

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 1216 Part II  Regional Flaps: Anatomy and Basic Techniques

Breast Reconstruction
Holle J, Pierini A. Breast reconstruction with an external oblique abdominis muscle turnover
flap and a bipedicled abdominal skin flap. Plast Reconstr Surg 73:469, 1984.
A turnover flap of external oblique muscle and anterior rectus sheath is described. This is a useful
flap to provide muscle coverage inferiorly below the pectoralis in breast reconstruction. The authors
reported their experience with 11 patients. In addition to the muscle flap, they advocated a bipedicled
abdominal skin flap for skin coverage over the muscle.
Marshall DR, Anstee EJ, Stapleton MJ. Soft tissue reconstruction of the breast using an external
oblique myocutaneous abdominal flap. Br J Plast Surg 35:443, 1982.
The ipsilateral lower abdominal skin ellipse is elevated as a myocutaneous flap including the external
oblique and then transposed to the breast for autologous breast reconstruction. The authors reported
their experience with five patients. One failure resulted from compression in a subcutaneous tunnel.

Chest Wall Coverage

Bogossian N, Chaglassian T, Rosenberg PH, et al. External oblique myocutaneous flap coverage
of large chest-wall defects following resection of breast tumors. Plast Reconstr Surg 97:97, 1996.
Defects resulting from resection of advanced breast tumors can be quite large, posing a difficult recon-
structive challenge. A significant number of such patients present with local recurrences after receiving
external beam radiation and/or chemotherapy treatments. Pectoralis major, latissimus dorsi, rectus
abdominis, and omental flaps with split-thickness skin grafts have been recommended for closure of
chest wall defects. What is often excluded from the list of reconstructive options is the external oblique
myocutaneous flap. In this series of 20 consecutive patients treated at Memorial Sloan-Kettering
Cancer Center, an external oblique myocutaneous flap was used to cover these large chest-wall defects
successfully. Sixty-eight percent of patients presented with a local recurrence: 50% had external beam
radiation, and 50% had received chemotherapy; 25% of the study group had had both treatments.
The authors stated that the external oblique myocutaneous flap should be considered a safe and reliable
option when reconstruction of large chest-wall defects is contemplated.
Hodgkinson DJ, Arnold PG. Chest wall reconstruction using the external oblique muscle. Br
J Plast Surg 33:216, 1980.
These authors were the first to demonstrate that a large chest wall defect could be closed with an external
oblique myocutaneous flap.
Israeli R, Hazani R, Feingold RS, et al. Extended mesh repair with external oblique muscle
reinforcement for abdominal wall contour abnormalities following TRAM flap. Ann Plast
Surg 63:654, 2009.
This study focused on repair of abdominal wall bulges following the various forms of TRAM flap
reconstruction, whether pedicled or free. Ten patients were identified as having abdominal wall contour
abnormalities after a TRAM flap and underwent an extended Prolene mesh repair with external
oblique muscle reinforcement. The mesh was secured to the bony landmarks of the lower abdomen and
the abdominal wall fascia. All patients achieved complete resolution of abdominal wall bulging. In the
follow-up period, no recurrences, infections, or seromas were noted. One patient, who failed an earlier
repair at the inferior abdominal wall, reported symptoms consistent with a scar neuroma. Symptoms
were treated successfully with gabapentin and a nonsteroidal antiinflammatory drug.
Kuzbari R, Worseg A, Burggasser G, et al. The external oblique muscle free flap. Plast Reconstr
Surg 99:1338, 1997.
The authors presented the external oblique flap as a free flap. Anatomic studies were performed
in 35 human cadavers. In addition to the segmental arteries, one or two large branches of the deep
circumflex iliac artery contributed significantly to the blood supply of the external oblique muscle in
33 of the 35 cadavers. Based on these findings, the authors transplanted the external oblique muscle

10c_ExternOb_r5b_tk_1192-1217.indd 1216 2/3/2012 1:58:18 PM

 Abdomen  •  10C: External Oblique Flap 1217

successfully as a free flap based on the deep circumflex iliac vessels in six patients. The muscle flap is
thin, pliable, and can be combined with an iliac bone or an abdominal skin transplant. Its vascular
pedicle is long (mean 12 cm) and of adequate diameter for microvascular repair. The donor scar of the
flap is inconspicuously situated along the inguinal ligament and the iliac crest.
Moschella F, Cordova A. A new extended external oblique musculocutaneous flap for recon-
struction of large chest-wall defects. Plast Reconstr Surg 103:1378, 1999.
A new extended external oblique myocutaneous flap used in the reconstruction of chest wall defects, is
described as a V-Y rotation flap on the ipsilateral abdominal wall. The flap is described as incorporat-
ing the anterior leaflets of the rectus sheath. This flap was used in 13 patients with major anterior
chest wall excisional defects. The mean chest wall defect was about 390 cm2. Marginal necrosis was
observed in one patient. All other flaps healed without complications. The extended external oblique
myocutaneous flap differs from other external oblique flaps already described in several aspects that
allow it to obtain better functional and aesthetic results.
Sailes FC, Walls J, Guelig D, et al. Synthetic and biological mesh in component separation: a
10-year single institution review. Ann Plast Surg 64:696, 2010.
This retrospective institutional study reviewed 10 years of myofascial flap reconstruction from 1996
to 2006 at Thomas Jefferson University Hospital and revealed an 18.3% recurrence rate in 545
component separations. From this vast experience, the authors identified obesity (BMI greater than
30 kg/m2), age older than 65 years, males, and the presence of postoperative seroma and preoperative
infection as risk factors for hernia recurrence.

Elbow Coverage
Fisher J. External oblique fasciocutaneous flap for elbow coverage. Plast Reconstr Surg 75:51,
1985.
The author described a fasciocutaneous flap based on myocutaneous perforators from the external
oblique muscle into the overlying skin. The flap is based posterolaterally in the posterior axillary line.
The flap is well suited for coverage of elbow defects. The author reported five patients in whom the
flap was successfully used for elbow coverage with no flap loss. In fact, the only complication was an
infected donor site. The anatomy and blood supply of the flap are clearly illustrated through cadaver
injection studies.

Lumbosacral Coverage
Sakai S, Soeda S, Matsukawa A. External oblique musculocutaneous flap for the reconstruction
of a lumbo-sacral defect. Br J Plast Surg 41:551, 1988.
In this case report the authors reconstructed a large radiation ulcer of the lumbosacral area with a very
long external oblique myocutaneous flap. The flap successfully covered the radiation ulcer, and there
were no complications. This innovative application of the external oblique musculocutaneous flap
solved a difficult reconstructive problem in the lumbosacral area.

Pelvic Defects
Dumanian GA, Heckler FR, Bernard SL. The external oblique turnover muscle flap. Plast
Reconstr Surg 111:2344-2348, 2003.
Meland NB, Ivy EJ, Woods JE. Coverage of chest wall and pelvic defects with the external
oblique musculofasciocutaneous flap. Ann Plast Surg 21:297, 1988.
The authors demonstrated that this large flap can easily be transposed superiorly for coverage of defects
of the chest wall. However, they also demonstrated that the flap can easily be transposed inferiorly
for coverage of extensive defects. In a patient undergoing a hemipelvectomy, the resultant defect was
satisfactorily covered with a large external oblique myocutaneous flap.

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 ANATOMIC LANDMARKS
Landmarks Lower abdomen; variable across midline.
Size 30 3 15 cm.
Composition Fasciocutaneous.
Dominant Pedicle Superficial inferior epigastric vessels.
Nerve Supply Sensory: Segmental intercostal nerves T10 to T12.

10d_SIEA_r6_cah_1218-1214.indd 1218 2/3/2012 3:15:45 PM

 Section 10D
Abdomen

Superficial Inferior Epigastric

Artery (SIEA) Flap

CLINICAL APPLICATIONS
Regional Use
Abdomen
Groin and perineum
Distant Use
Head and neck
Upper extremity
Lower extremity
Specialized Use
Penile reconstruction
Vaginal reconstruction
Breast reconstruction

10d_SIEA_r6_cah_1218-1214.indd 1219 2/3/2012 3:15:46 PM

 Anatomy of the superficial inferior epigastric artery (SIEA) flap

Superficial inferior epigastric

artery and vein

Femoral artery and vein

Arterial supply to SIEA flap

B C D E

Common origin Large SCIA without SIEA Separate origins Intercostal sensory
(48%) (10% to 15%) (42% to 47%) nerve supply

Fig. 10D-1

Dominant pedicle: Superficial inferior epigastric artery and vein

10d_SIEA_r6_cah_1218-1214.indd 1220 2/3/2012 3:15:48 PM

 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1221

Anatomy
Landmarks The SIEA flap is a fasciocutaneous flap incorporating the lower abdominal skin
between the umbilicus and pubis. Vertical or transversely oriented flaps of the
lower abdominal skin may be based on the SIEA. Vertical flaps may extend up
to the costal margin and horizontal flaps extend from the ipsilateral anterior
superior iliac spine to the midline, with less-predictable flow across the midline.
Composition Fasciocutaneous.
Size 30 3 15 cm.

Arterial Anatomy (Type I)

Dominant Pedicle  Superficial inferior epigastric vessels
This vessel is not consistent and is absent in up to 15% of individuals. Its caliber is highly variable,
rendering it clinically unusable in many patients. Using the flap in the face of small-caliber vessels
increases the risk of fat necrosis and flap loss. The venous drainage is through the venae comitantes
with the SIEA or through the superficial inferior epigastric vein (SIEV), which is a large, more
medially and superficially located vein; it is vertically oriented and drains the lower abdomen. This
vein is more superficially located than the SIEA.
Length  4 to 6 cm.
Diameter  1 to 1.5 mm.
Location  The SIEA originates from the anterior surface of the femoral artery 4 to 5 cm below
the inguinal ligament. In as many as 48% of cases, it may arise from a common trunk with the
superficial circumflex iliac artery (SCIA). It courses vertically upward, crossing the inguinal
ligament at a point halfway between the anterior superior iliac spine and the pubis. It courses
deep to Scarpa’s fascia.

Venous Anatomy
Single or duplicated venae comitantes accompany the arterial circulation but often diverge from
the artery above the groin, taking a more superficial course. The average venous diameter is 1 to
1.5 mm. Medially, approximately a third the distance from the pubis to the ASIS, a large SIEV
is identified that can provide venous drainage to the entire flap. In some cases, this vein and the
combined comitans veins join before entering the femoral system.

Nerve Supply
Sensory Segmental intercostals T10 to T12.

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 1222 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the SIEA Flap

A

Exposure of femoral triangle

B C x

m s
m

m
m

m
s

m m

D
D p

Cutaneous surface of flap Radiographic view of abdominal skin

Fig. 10D-2 

Dominant pedicle: Superficial inferior epigastric artery (D)

m, Myocutaneous perforating vessels from deep inferior epigastric arcade; p, pubis;
s, segmental subcostal arteries; u, umbilicus; x, xiphoid process

10d_SIEA_r6_cah_1218-1214.indd 1222 2/3/2012 3:15:49 PM

 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1223

Flap Harvest
Design and Markings
The entire skin and subcutaneous tissues of the lower abdomen extending from the umbilicus
to the pubis and groin crease may be based on one SIEA. Although the safe skin territory
of each vessel may extend beyond the midline, most surgeons consider any cross-midline
tissue to be at high risk for development of necrosis. Perfusion studies suggest that the
SIEA perfuses a more lateral skin territory than does the DIEA. Typically the skin island is
marked lower and more lateral than a DIEP flap or TRAM flap. The umbilicus, anterior
superior iliac spine, and pubic tubercle are useful landmarks for the design and elevation
of the flap. The anterior superior iliac spine and the pubic tubercle are marked, and a line
is drawn between them. The midpoint of the line represents the deep origin of the vessel
from the femoral artery. When the line is divided in thirds, one should look for the SIEA
and vena comitans between the lateral and central third, and the medial SIEV between the
central and medial third. The vessel courses vertically upward toward the costal margin. A
Doppler probe may be useful for confirming the presence of the SIEA.

A B

Unilateral Bilateral

Fig. 10D-3  Skin island design.

Patient Positioning
The patient is positioned in the supine position for flap harvest.

10d_SIEA_r6_cah_1218-1214.indd 1223 2/3/2012 3:15:51 PM

 1224 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

A 4 to 5 cm exploratory incision is made in the groin crease, centered on the previously
marked projected location of the pedicle. Dissection is continued through the skin and
subcutaneous tissues down to Scarpa’s fascia. The SIEV lies superficially within this layer
and is encountered during this part of the dissection. It is identified and preserved. Dissec-
tion then continues deep to Scarpa’s fascia. Loupe magnification is recommended for this
dissection. Deep to Scarpa’s fascia the SIEA is identified coursing vertically; it measures ap-
proximately 1 mm in diameter at this level. It should be noted that this vessel is not constant
and is absent in 10% to 15% of patients. It is not necessary to identify the pedicle initially
for local flap transposition and tubed flaps. Once the vessels are identified, they should be
followed down over the inguinal ligament toward their origin from either the femoral
artery or a confluence with the SCIA vessels before a combined origin from the femoral
vessels. Some division of the inguinal ligament may be necessary to reach the SIEA takeoff.

A B
Superficial
circumflex iliac Superficial
artery and vein inferior epigastric
artery and vein

Femoral artery and vein

Initial exploratory incision Superficial inferior epigastric artery and vein located
two thirds the distance from the pubis to the ASIS

Fig. 10D-4 

Once the pedicle has been identified, the skin island is designed and elevated. Dissec-
tion of the skin island is then carried down to the abdominal wall. The external oblique
and anterior rectus fascia are identified, and the flap is elevated in a plane above the external
oblique fascia and anterior rectus sheath but deep to Scarpa’s fascia.
C

Initial elevation of the SIEA flap

Fig. 10D-4

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 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1225

Dissection is continued to the lateral and medial DIEA perforators which should be
isolated and preserved as a fallback if the SIEA proves inadequate. Once the entire flap is
raised it is based on both the SIEA vessels as well as the DIEA perforator rows. These latter
vessels can then be clamped with occlusive microvascular clamps to occlude their contri-
bution to flap blood flow. If the flap remains well perfused, it can be assumed that the flap
can be safely based on the SIEA vasculature. If the flap becomes congested or extremely
pale with DIEA occlusion, the flap should be raised as a DIEP flap, preserving the SIEV as
an alternative venous outflow in case congestion supervenes. Assuming the SIEA inflow is
adequate, the flap is raised as a SIEA flap, dividing the DIEA perforators to leave the flap
dependant only on its SIEA circulation. If a SIEV is present medially, it too should be dis-
sected down to the femoral vein and be clipped for possible additional venous anastomosis.
At this juncture, laser-induced indocyanine green fluorescence imaging (SPY, LifeCell
Corp., Branchburg, NJ) is helpful for assessing the exact extent to which skin may safely
be preserved within the flap. Once a well-perfused skin island is ready for transfer, the
vascular pedicle can be divided and the flap transferred to its recipient site for anastomosis.

The SIEA flap is elevated and

isolated for transfer

Fig. 10D-4 

Extension of Pedicle Length

Dissection of the vascular pedicle toward its femoral artery origin will significantly increase
the length of the pedicle and the diameter of the vessels dissected. This dissection is performed
under loupe magnification and is only necessary for microsurgical transfer. The superficial
inferior epigastric vein is traced to the saphenous or femoral vein to increase pedicle length.

10d_SIEA_r6_cah_1218-1214.indd 1225 2/3/2012 3:15:56 PM

 1226 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variant
Pedicle Flap
One can take advantage of the donor site locally by using the flap as a pedicle flap. Often the
flaps are more vertically oriented, because a rotated flap can reach the groin, perineum, or
abdomen. These flaps have been described for penile and vaginal reconstruction. Because
of its anatomic variablity, the SIEA is usually a tertiary choice as a pedicle flap, since SCIA,
DIEA, and proximal thigh flaps are more reliable.

Arc of Rotation
The vertical flap is transposed to the trochanter or perineum. The pedicle at the level of
the inguinal ligament becomes the point of rotation.

Arc to abdomen, groin, and perineum

Fig. 10D-5 

Flap Transfer
The vertical flap is transposed into the defect or through a subcutaneous tunnel. Care must
be taken not to kink or compress the pedicle.

Flap Inset
The flap may safely be trimmed deep to Scarpa’s fascia as required to reduce bulk. The flap
is sutured directly into the defect without tension. Compared with the TRAM or DIEP
flaps, no muscle or fascia exists to secure the flap at its recipient site. Often only the skin
closure provides support.

Donor Site Closure

The donor site is closed directly like an abdominoplasty when a transverse harvest is per-
formed, whether pedicled or free. The transversely oriented flap leaves the most aesthetically
acceptable donor defect. The vertical flap donor site is closed like a paramedian incision.

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 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1227

Clinical Applications
This 45-year-old woman had undergone mastectomy without radiation. She was happy
with her natural breast and asked that it be matched in her reconstruction. A TRAM flap
reconstruction was selected.

B C

D E

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 perfo-
rators 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 re-
visions 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. (Case supplied
by MRZ.)

10d_SIEA_r6_cah_1218-1214.indd 1227 2/3/2012 3:16:01 PM

 1228 Part II  Regional Flaps: Anatomy and Basic Techniques

This 52-year-old diabetic woman with a mastectomy deformity had undergone radiation
therapy to the chest wall. Six months after radiation therapy was complete, she presented
for right breast reconstruction, for which her generous abdominal pannus was used. She is
happy with her current left breast size and has no plans to lose weight intentionally.

B C

D E F

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 accompany-
ing 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. (Case supplied by MRZ.)

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 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1229

This 43-year-old woman, who had previously undergone gastric bypass surgery, presented
with this mastectomy deformity with no history of chest wall irradiation. She had a pre-
liminary left breast reduction while waiting for her weight to stabilize so as to have a target
breast to match. She had a lower midline scar, and it was felt that there was enough tissue
in her hemiabdomen to perform her reconstruction.

A B

C D

Fig. 10D-8 A, Preoperative markings. B, The patient is seen at her 11/2 -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. (Case supplied by MRZ.)

10d_SIEA_r6_cah_1218-1214.indd 1229 2/3/2012 3:16:08 PM

 1230 Part II  Regional Flaps: Anatomy and Basic Techniques

This 46-year-old woman had previous bilateral mastectomies without radiation and pre-
sented for delayed bilateral breast reconstruction using her abdominal tissues.

A B

C D

Fig. 10D-9 A, The patient’s preoperative markings are shown. On exploration of the left side of her ab-
domen, 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 in-
ternal 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 reconstruc-
tions are star flaps with three-dimensional tattoos. C and D, Right and left oblique views. (Case sup-
plied by MRZ.)

10d_SIEA_r6_cah_1218-1214.indd 1230 2/3/2012 3:16:10 PM

 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1231

This woman presented with left breast ductal carcinoma in situ and wished to have autolo-
gous reconstruction. Because of the small volume of her abdominal tissue, a bipedicled flap
was planned. On one side a DIEP flap was designed, and on the contralateral a SIEA flap
was designed that was then to be connected to a branch of the DIEP medial row perforator.
Using the entire abdominal flap allowed a volume match with the right breast.

A B

C D E

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.
(Case courtesy Aldona J. Spiegel, MD.)

10d_SIEA_r6_cah_1218-1214.indd 1231 2/3/2012 3:16:13 PM

 1232 Part II  Regional Flaps: Anatomy and Basic Techniques

This patient presented with a right-sided breast malignancy and wished to undergo a
contralateral prophylactic mastectomy. She had adequately sized SIEA diameters on both
sides and therefore was able to undergo immediate reconstruction with bilateral SIEA flaps.

A B

C D E

Fig. 10D-11 A, The patient is seen preoperatively. B, Preoperative markings for SIEA flaps. C, Intra-
operative views of the left SIEA flap and D, the right SIEA flap. E, The results are seen postoperatively.
(Case courtesy Aldona J. Spiegel, MD.)

10d_SIEA_r6_cah_1218-1214.indd 1232 2/3/2012 3:16:16 PM

 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1233

Pearls and Pitfalls

• The SIEA is not a constant vessel; it may be absent in 10% to 15% of patients. Further-
more, when present, it is usable only 10% to 15% of the time.
• Extension of the transversely oriented skin island beyond the lateral margin of the opposite
rectus abdominis is not reliable and may lead to loss of the flap or subcutaneous tissue.
When tissue is required beyond the midline, delay should be considered.
• It is considered unsafe to perform the flap if the SIEA has a caliber of less than 1.5 mm,
because the risk of fat necrosis and flap thrombosis increase twofold to threefold at smaller
vessel calibers.
• The flap deep to Scarpa’s fascia can be safely trimmed, except adjacent to the vascular
pedicle.
• With SIEA free flaps the surgeon must be prepared for a vessel mismatch, and appropriate-
sized recipient vessels should be sought.

Expert Commentary
Aldona J. Spiegel

Indications
The SIEA flap is indicated in patients with sufficient excess abdominal tissue who require
reconstruction of a soft tissue defect by either free tissue transfer or pedicled reconstruction
of pelvic defects.

Advantages and Limitations

The main advantage of the SIEA flap is that it provides all of the benefits of the traditional
lower abdominal tissue flaps without incision or excision of the abdominal wall fascia or
musculature, thereby decreasing donor site morbidity.
The SIEA flap is limited mainly by the anatomic variability of its blood supply. Since
the SIEA is not present in every patient, use of this flap is not always possible. Addition-
ally, even if the SIEA is identified, it may not be of sufficient caliber for free flap transfer.
We require the SIEA to have a 1.5 mm or greater diameter, and it must have a visible and
palpable pulsation for free flap transfer. Once these criteria are met for free flap transfer,
there may still be a constraint by size mismatch with the recipient vessels. Finally, pedicled
SIEA flaps are limited by the length of the pedicle.

Anatomic Considerations
In a study by Taylor and Daniel1 of its anatomic variation, the SIEA was found to be absent
in 35% of their subjects. In the patients who had an SIEA flap reconstruction, the origins of
the SIEA were varied, with 48% sharing a common trunk with the superficial circumflex
artery, whereas 17% were found to be direct branches of the common femoral artery. Our
clinical experience corroborated these findings,2 showing a lack of an identifiable SIEA in
42% of our 278 total patients. Further investigation of the other 58% of patients with an
identifiable SIEA showed that 54% of these patients had arteries with external diameters of
1.5 mm or greater when measured at the level of the lower abdominal incision.
Continued

10d_SIEA_r6_cah_1218-1214.indd 1233 2/3/2012 3:16:16 PM

 1234 Part II  Regional Flaps: Anatomy and Basic Techniques

This is important because our selection criteria for the SIEA flap requires such a diameter.
Therefore only 31% of all patients in our study had an SIEA sufficient for use in a free flap.

Personal Experiences and Insights

As mentioned, the main limitation of the SIEA flap is the inconsistent anatomy and size
of the arterial inflow. However, the venous outflow of this flap is excellent: there are two
pathways, the SIEV and the venae comitantes of the SIEA. This is in contrast to the DIEP
flap, where the most common limitation is the venous outflow, which may lead to conges-
tion. Therefore, when considering transfer of the lower abdominal tissue, the surgeon must
make intraoperative decisions about the reliability of the arterial and venous anatomy once
the sizes of the vessels are assessed. It may be helpful to use vascular clamps in situ during
flap harvest to determine which vessels will be more reliable.

Recommendations
Planning
When marking the flap location on the abdomen, it is important to consider the location
of the inferior abdominal incision—the lower it is, the more likely that the arterial caliber
of the SIEA will be larger as it enters the flap. Because of limited abdominal laxity, this
will also require the top abdominal incision to be more inferior, either at the umbilicus
or below, which may not be optimal for the DIEP flap, since it may not capture the larger
periumbilical perforators. Therefore the surgeon must strike a balance between making
the flap location as low as possible on the abdomen for the SIEA flap, while still capturing
the appropriate perforators should a DIEP flap be required if an SIEA flap is not possible.

Technique
Dissection of the SIEA flap is fairly simple compared with dissection of the perforator flaps.
The microsurgical challenge usually presents itself at the point of anastomosis, because there
is usually some component of vessel size mismatch with the recipient vessels. One must not
completely skeletonize the vessels as they are dissected in the groin, because they are small
and may be prone to kinking if there is not enough surrounding tissue to support the ves-
sels after inset. In addition, only a small amount of tissue should be left around the vessels,
since this requires transection of lymphatics, which may lead to increased seroma formation.
There are two choices for venous outflow; we usually choose the venae comitantes and
dissect them proximal to the point at which they unite to become one vein. We prefer this
vein to the larger SIEV, because it is close to the artery and usually the same length; therefore
the chance for kinking or twisting of the small artery is minimized. Although the SIEV is
usually larger, it is usually at a distance from the artery and may not have a similar length,
which may potentially create a tethering point.

Postoperative Care
When the flap is used for breast reconstruction, the patient is sent to the ICU for hourly
monitoring of the transplanted flap. On postoperative day 1, the patient is advanced to a
reclining chair for a 1-hour sitting trial. Because of the gravitational changes on the flap,
nurses are instructed to closely monitor the flap for any change in Doppler signal, capil-
lary refill, and skin color. If the patient has a successful sitting trial, she will slowly begin
ambulating, as tolerated, and usually can be discharged on postoperative day 3 or 4.
For anticoagulation therapy after surgery, we use low-molecular-weight heparin,
monitored with thromboelastogram viscoelastic testing. Beginning on postoperative
day 1, the patient is placed on a daily regimen of 81 mg “baby” aspirin for 2 weeks.

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 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1235

Complications
Apart from anatomic arterial limitations, the most common problem is the possibility of
developing a seroma at the abdominal donor site. This occurs mainly as a result of lym-
phatic leakage from tissue that is transected in the lower abdomen during the dissection
of the SIEA pedicle. A helpful tip is to clip the surrounding lymphatics during dissection.
We also use two drains and leave them in until there is less than 25 ml per drain per day.
This strategy has decreased seroma formation to less than 0.5% in our patient population.

Take-Away Messages
The SIEA flap is very useful for reconstruction of skin and soft tissue defects; its use avoids
transection of fascia or muscle in the lower abdomen. However, one must be cautious dur-
ing the intraoperative selection process, by critically assessing the arterial inflow and not
being lured by the ease of flap harvest.

References
1. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg
56:243-253, 1975.
2. Spiegel AJ, Khan FN. An intraoperative algorithm for use of the SIEA flap for breast recon-
struction. Plast Reconstr Surg 120:1450-1459, 2007.

EXPERT COMMENTARY
Michael R. Zenn

Advantages and Limitations

The SIEA flap is both the most desirable and the least available of lower abdominal flaps.
It is desirable because it allows harvest of the lower abdominal tissues without violation of
the abdominal fascia, avoiding most of the morbidity that comes with harvest of the lower
abdomen as a TRAM or DIEP flap. It is the least available, because appropriate vascular
anatomy is present only 5% to 10% of the time. Even then, it is a question of how comfort-
able one feels about using a flap with a 1 to 1.5 mm diameter artery.

Recommendations
Planning
With some important caveats in mind, one can use the SIEA flap with much success:
• Always look for the superficial pedicle laterally and the more prominent medial vein.
If you do not use them as your primary vessels, take them with the flap as backups
or secondary anastomoses. Practice makes perfect.
• Since the vessel is more laterally based, alter the skin design to favor the lateral tissues
 
over tissues that lie across the midline.
• Look for an artery that is 1.5 mm or larger at its femoral source. There also should
be a visible pulse in the artery as it enters the flap.
Continued

10d_SIEA_r6_cah_1218-1214.indd 1235 2/3/2012 3:16:16 PM

 1236 Part II  Regional Flaps: Anatomy and Basic Techniques

• Get comfortable with smaller anastomoses, especially end-to-side (internal mammary

artery), perforator-to-perforator (second intercostal perforator), and smaller vessels
that are a better match for end-to-end (serratus branch of the thoracodorsal artery).
• A lower midline scar may have a “delay” effect on the SIE system.
• A previous Pfannenstiel incision does not preclude the use of an SIEA flap, because
the pedicle can be quite lateral.
Perhaps the greatest use of the SIEA system in my practice comes when it can be used to
augment a DIEP or free TRAM flap, when all abdominal tissues are needed and blood
supply across the midline is not robust. Even a small vessel can be easily connected to the
contralateral DIE pedicle and needed perfusion can be added to the flap without another
fascial incision.

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
My final word of advice is to treat the abdomen as you would for an abdominoplasty, mak-
ing the patient just as pleased about the donor site as the recipient site. In some early cases,
I was so happy to find a large SIEA to carry the flap that I did not plicate the abdomen as
I would have if the patient presented for abdominoplasty. Most patients appreciate a flat
abdomen when possible.

10d_SIEA_r6_cah_1218-1214.indd 1236 2/3/2012 3:16:17 PM

 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1237

Bibliography With Key Annotations

Clinical Studies
Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective
analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg
125:1335, 2010.
Breast reconstruction using flaps from the lower abdomen can be compromised by fat necrosis. The
muscle-sparing free transverse rectus abdominis myocutaneous (TRAM), deep inferior epigastric per-
forator (DIEP), and superficial inferior epigastric artery (SIEA) flaps are techniques that have evolved
in an effort to decrease abdominal donor site morbidity. Each flap in this evolution, however, includes
fewer perforating blood vessels. The authors hypothesized that flaps with fewer perforators are less well
perfused and therefore more likely to suffer fat necrosis. They prospectively studied the incidence of fat
necrosis and number of perforators in 228 consecutive abdominal free flap breast reconstructions. The
incidence of fat necrosis was 14%, 25%, 5%, and 19% for SIEA flaps and flaps with one to two,
three to five, and more than five perforators, respectively. The incidence of fat necrosis was significantly
associated with the number of perforators, smoking, and inclusion of zone 3 of flaps. The lowest risk
of fat necrosis occurred in flaps with three to five perforators, which were predominantly muscle-sparing
TRAM flaps. The risk of fat necrosis was highest in flaps with one or two perforators, which were
predominantly DIEP flaps. SIEA flaps and flaps with poor perforators in which more than five
perforators were included had an intermediate risk of fat necrosis.
Cheng MH, Lin JY, Ulusal BG, et al. Comparisons of resource costs and success rates between
immediate and delayed breast reconstruction using DIEP or SIEA flaps under a well-controlled
clinical trial. Plast Reconstr Surg 117:2139, 2006.
Autologous abdominal breast reconstructions are favored by many reconstructive surgeons. High success
rate and cost-effectiveness are two important factors that may guide decision-making in the manage-
ment plan. The authors compared the resource costs and success rates of immediate and delayed breast
reconstructions using either DIEP or SIEA flaps. The resource cost is referred to as the cost of operation
and hospitalization. During a 12-month period, 42 patients underwent immediate (21) or delayed
(21) unilateral breast reconstruction using either a DIEP (30) or SIEA (12) flap by one surgeon.
There were no statistical differences in resource costs, success, and complication rates between DIEP
and SIEA flaps in both the immediate and delayed breast reconstruction groups.
Holm C, Mayr M, Hofter E, et al. The versatility of the SIEA flap: a clinical assessment of
the vascular territory of the superficial epigastric inferior artery. J Plast Reconstr Aesthet Surg
60:946, 2007.
After the TRAM and the DIEP, the SIEA flap is the next logical step to reduce donor site morbidity
in autologous breast reconstruction. However, the vascular axis of the SIEA flap is completely differ-
ent from the deep epigastric pedicle on which previous lower abdominal flaps were based. Therefore
mapping the vascular territory that can be reliably harvested on this pedicle seems mandatory before
this new technique can become established. The authors reported their clinical prospective study of 10
patients undergoing autologous breast reconstruction to chart the angiosome of the superficial inferior
epigastric artery with regard to breast reconstruction and to evaluate the random extension of the vas-
cular territory that can be reliably raised on this pedicle. They found that the true angiosome of the
superficial epigastric artery is located laterally on the ipsilateral hemiabdomen. Its random extension is
unreliable and ranges most frequently only to the midline. Based on the results of this study, survival
of the skin and subcutaneous fat taken laterally to the border of the contralateral rectus sheath seems
questionable. Therefore the versatility of the SIEA flap for autologous breast reconstruction seems
limited when compared with the conventional methods based on the deep inferior epigastric system.

10d_SIEA_r6_cah_1218-1214.indd 1237 2/3/2012 3:16:17 PM

 1238 Part II  Regional Flaps: Anatomy and Basic Techniques

Nasr S, Aydn MA. Versatility of free SCIA/SIEA flaps in head and neck defects. Ann Plast
Surg 65:32, 2010.
Reconstruction of head and neck defects may require replacement of the bony structures, external soft
tissue, and intraoral mucosa. Most cases, including maxillary defects, often require repair using only
soft tissue flaps. The authors used free superficial circumflex iliac artery/superficial inferior epigastric
(SCIA/SIEA) flaps for head and neck reconstruction. This was their first choice over other free flaps
because of its versatile advantages. Fifteen patients underwent head and neck reconstruction with free
SCIA/SIEA flaps. No flap loss was observed; however, emergency vascular reanastomosis was per-
formed in three cases to restore the blood supply in compromised flaps. Flap thinning and secondary
debulking procedures were performed in four cases. The functional and aesthetic results were deemed
acceptable in all patients. Based on their results, we stated that the free SCIA/SIEA flap is useful
for soft tissue defect reconstruction in the head and neck. It has the following advantages: large flap
elevation is possible for reaching distant recipient vessels, two surgical teams may work at the same
time preparing the donor and recipient regions, and the flap design uses an abdominoplasty incision,
which has minimal donor site morbidity.
Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing the functional impact of
SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part II. Bilateral
reconstruction. Plast Reconstr Surg 126:1438, 2010.
The purpose of this study was to demonstrate the impact of bilateral free flap breast reconstruction on
the abdominal wall. The authors compared bilateral combinations of the muscle-sparing free TRAM
flap, DIEP flap, and SIEA flap. A blinded prospective cohort study was performed involving 234
patients. Patients were evaluated preoperatively and for 1 year postoperatively. At each visit, patients
underwent objective abdominal strength testing using the Manual Muscle Function Test and Functional
Independence Measure and psychometric testing using the SF-36 questionnaire. At postoperative visits,
patients also completed a questionnaire specific to breast reconstruction. Statistical analysis included
the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. Of 234 patients
enrolled, 157 underwent reconstruction, 82 of which were bilateral. There was a significant decline in
upper and lower abdominal strength from bilateral free TRAM flaps compared with bilateral DIEP
flaps. Likewise, there was a significant decline in upper and lower abdominal strength from bilateral free
TRAM flaps compared with bilateral SIEA flaps. For combinations, the most muscle impairment to
least was as follows: free TRAM/free TRAM, free TRAM/DIEP, DIEP/DIEP, DIEP/SIEA,
and SIEA/SIEA. The free TRAM/SIEA data were not significant. Although psychometric testing
showed trends, there was no significant difference among treatment groups. The authors concluded
that abdominal wall strength following various combinations of bilateral free flap breast reconstruction
techniques closely adheres to theoretical predictions based on the degree of surgical muscle sacrifice.
Selber JC, Samra F, Bristol M, et al. A head-to-head comparison between the muscle-sparing
free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall func-
tion? Plast Reconstr Surg 122:348, 2008.
Attempts to limit the impact of autologous breast reconstruction on the abdominal wall have led to
the use of the muscle-sparing free TRAM, DIEP, and SIEA flaps. The authors compared the
SIEA flap with the muscle-sparing free TRAM flap to determine whether gains in abdominal wall
function are offset by flap-related complications. Seventy-two consecutive SIEA flaps were compared
with 569 consecutive muscle-sparing free TRAM flaps. Outcomes included arterial and venous
thrombosis, reoperation, abdominal hernia/bulge, seroma, hematoma, fat necrosis, delayed wound
healing, infection, partial flap loss, and total flap loss. Chi-square and Fisher’s exact tests were used
to determine significant differences. In the SIEA group, there was a higher percentage of overweight
patients, bilateral cases, and smokers. Among SIEA flaps, there were two total flap losses (2.9%)
and no abdominal morbidity. In the muscle-sparing free TRAM flap group, there was one total flap
loss (0.18%), and a hernia/bulge rate of 1.9%. The difference in flap loss rate was significant. There

10d_SIEA_r6_cah_1218-1214.indd 1238 2/3/2012 3:16:17 PM

 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1239

was a higher incidence of vessel thrombosis requiring anastomotic revision in the SIEA group: 17.4%
compared with the free TRAM group, 6.0%. The authors concluded that the SIEA flap has a
lower rate of hernia/bulge and a higher rate of thrombotic complications. Because of the emotional and
financial cost of these complications, the SIEA flap should be undertaken only if strict criteria are met.
Spiegel AJ, Khan FN. An intraoperative algorithm for use of the SIEA flap for breast recon-
struction. Plast Reconstr Surg 120:1450, 2007.
This retrospective study was conducted to assess the reliability and examine the outcomes of SIEA
flaps for breast reconstruction while considering an intraoperative algorithm established in this study.
Ninety-nine SIEA flap reconstructions were performed in 82 patients in a 31⁄2-year period. Patients
were divided into two groups (before and after algorithm implementation), and their medical records
were evaluated with respect to demographic information, tumor type, tobacco use, ischemic time, flap
weight, and complications. Potential risk factors for complications were also assessed. Only smoking at
the time of surgery was associated with increased donor site complications. The authors concluded that
their intraoperative algorithm helped decrease flap and abdominal complication rates for the SIEA flap.

Anatomic/Experimental Studies
Boeckx WD, DeConinck A, Vanderlinden E. Ten free flap transfers: use of intra-arterial dye
injection to outline a flap exactly. Plast Reconstr Surg 57:716, 1976.
This was the first report of microvascular free flap transfer of the SIEA flap, which the authors referred
to as the “superficial epigastric artery flap.” Their experience with 10 free flaps between 1973 and
1976 was presented. Nine of the 10 flaps were harvested from the lower groin-abdominal area based
on the superficial epigastric artery (3 patients), superficial circumflex iliac artery (3 patients), or both
via a common trunk (3 patients). Because of the variation in size and anatomy of the vessels the
authors started with a 5 cm groin incision and exposed the origin of the superficial inferior epigastric
artery and superficial circumflex iliac artery from the femoral artery or the common trunk if both vessels
arise from a common trunk. The largest vessel was selected and cannulated with a Teflon catheter and
2 ml of patent-blue V dye was injected into the artery. The skin territory of the vessels and its limits
immediately assumed a blue color and served as the basis for flap design. The authors stated that the
dye did not damage the intima of these small vessels.
Goldwyn RM, Lamb DL, White WL. An experimental study of large island flaps in dogs.
Plast Reconstr Surg 31:528, 1963.
In this significant article the authors elevated large island flaps on the abdomen of dogs based on a single
epigastric artery and vein. In this two-part study they not only established that flaps of significant
size can be raised on a single small artery and vein, but they also demonstrated that these large islands
of skin can be transferred through microsurgical techniques. They firmly established the principle of
island flaps and the feasibility of the microsurgical transfer of such flaps. They commented that “it is
of interest that this mass of tissue [the flap] can be maintained in a healthy, viable state by these tiny
vessels.” They further stated that “the ability to create large island flaps on the lower abdomen sug-
gests that this tissue may be rotated to supply cover for the opposite side of the abdomen, to resurface
the perineum following avulsion inju­ries, and to restore the groin after radical inguinal resection.” All
of these goals have now been achieved with the SIEA flap.
Shaw DT. Open abdominal flaps for repair of surface defects of the upper extremity. Surg Clin
North Am 24:293, 1944.
This anatomic description and clinical study demonstrated the use of this flap for coverage of surface
defects of the upper extremity, including the hand, forearm, and elbow.
Stevenson TR, Hester TR, Duus EC, et al. The superficial inferior epigastric artery flap for
coverage of hand and forearm defects. Ann Plast Surg 12:333, 1984.
The anatomy and clinical applications of this flap for upper extremity coverage were demonstrated.
The authors emphasized the large volume of tissue available and the acceptability of the donor site.

10d_SIEA_r6_cah_1218-1214.indd 1239 2/3/2012 3:16:17 PM

 1240 Part II  Regional Flaps: Anatomy and Basic Techniques

Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 56:243,
1975.
In this anatomic study of 100 cadaver dissections the authors reported the mean caliber of the SIEA
as 1.4 mm. They found that the SIEA has a common origin with the superficial circumflex iliac
artery in 48% of dissections, and the vessel is absent in 35% of dissections.

Clinical Series
Antia NH, Buch VI. Transfer of an abdominal dermo-fat graft by direct anastomosis of blood
vessels. Br J Plast Surg 24:15, 1971.
This article was perhaps the first successful report of “microsurgical free flap transfer.” Antia and Buch
transferred the dermis-fat flap from the lower abdomen based on the SIEA vessels for facial soft tis-
sue reconstruction. The flap vessels were harvested with a cuff of femoral artery and saphenous vein,
respectively, to facilitate successful suturing to the external carotid artery and internal jugular veins.
Hester TR Jr, Nahai F, Beegle PH, Bostwick J III. Blood supply of the abdomen revisited,
with emphasis on the superficial inferior epigastric artery. Plast Reconstr Surg 74:657, 1984.
The anatomy of the SIEA flap and its contributions to the total abdominal blood supply were well
reviewed. Clinical experience with the flap for coverage of pressure sores, penile reconstruction, and
microsurgical tissue transfer were presented.
Iwahira Y, Maruyama Y, Shiba T. One-stage abdominal wall reconstruction with oblique
abdominal fasciocutaneous flaps. Ann Plast Surg 19:475, 1987.
This case report demonstrated the application of the SIEA flap for abdominal wall coverage. A de-
scription of the abdominal wall blood supply and interrelationship of the SIEA and perforators from
the deep epigastric arcade was included.
Sun G, Huang J. One-stage reconstruction of the penis with composite iliac crest and lateral
groin flap. Ann Plast Surg 15:519, 1985.
The versatility of this flap was demonstrated. The authors used a combined superficial circumflex
iliac artery and SIEA pedicle flap containing both soft tissue and a segment of the iliac crest to make
an osteocutaneous flap for penile reconstruction.
Wood J. Extreme deformity of the neck and forearm. Med Chir Trans 46:151, 1863.
This was the first report of the SIEA flap being used to correct a severe burn contracture of the forearm
in an 8-year-old girl. Wood noted, “The largest and most important of these vessels are the superficial
epigastric vessels proceeding from the common femoral vessel across the inguinal ligament and upwards
and inwards toward the umbilicus.” He emphasized that it is “a matter of importance then to choose
such a position that would leave in the base of the flap the greatest amount of blood vessels running
parallel to the skin.” He believed that these vessels were the chief source of blood supply to the flap.
Zenn MR. Insetting of the superficial inferior epigastric artery flap in breast reconstruction.
Plast Reconstr Surg 117:1407, 2006.
The use of perforator flaps in breast reconstruction has gained popularity. Although a premium
has been placed on sparing muscle and fascia at the abdominal donor site, perforator flaps have less
intrinsic support for the pedicle and require additional maneuvers to support the flap and secure the
microvascular anastomosis. The superficial inferior epigastric artery flap in particular creates logistical
problems in placement of the flap for optimal shaping while preventing kinking of its superficial and
more peripheral pedicle. The author’s proposed technique secures the flap to the chest wall, maximizes
flap projection, places the best vascularized tissues in proper position, and facilitates performance of
the microsurgical anastomosis.

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 Abdomen  •  10D: Superficial Inferior Epigastric Artery (SIEA) Flap 1241

Flap Modifications
Chen Z, Chen M, Chen C, et al. Vaginal reconstruction with an axial subcutaneous pedicle
flap from the inferior abdominal wall: a new method. Plast Reconstr Surg 83:1005, 1989.
The authors presented a technique in which the unilateral lower abdominal flap is tubed and the area
of the vascular pedicle is elevated as a subcutaneous pedicle. The blood supply of this flap is based on
the SIEA, superficial circumflex iliac artery, and external pudendal vessels, all of which are included
in the rather generous subcutaneous pedicle. The authors reported their experience with 30 consecutive
patients who underwent reconstruction with this method. All flaps survived.
Dorafshar AH, Januszyk M, Song DH. Anatomical and technical tips for use of the superficial
inferior epigastric artery (SIEA) flap in breast reconstructive surgery. J Reconstr Microsurg
26:381, 2010.
This paper outlined a simple approach to the SIEA flap harvest, demonstrating that favorable results
may be achieved even for small caliber vessels. A total of 46 patients underwent 53 SIEA breast
reconstructions over a 6-year period with a modified approach for pedicle dissection and arterial inclu-
sion criteria solely on the basis of presence of a palpable pulse. Average pedicle length was 6.07 cm;
and mean arterial (0.96 mm) and venous (2.27 mm) diameters represent the lowest published values.
Three flaps (5.7%) demonstrated fat necrosis or partial flap necrosis, with one (1.9%) complete flap
loss. These results compared favorably with those of previous SIEA series employing diameter-based
selection criteria, suggesting that the presence of a palpable arterial pulse may be sufficient to permit
successful use of this flap.
Shaw DT. Tubed pedicle construction: the single pedicle abdominal tube and acromiopectoral
flap. Ann Plast Surg 4:219, 1980.
This article presented a historical review of the development of the tubed SIEA abdominal flap and
acromiopectoral flaps.
Shaw DT, Payne RL. One-stage tubed abdominal flaps. Surg Gynecol Obstet 83:205, 1946.
Shaw described the tubing of this abdominal flap for coverage of hand, forearm, and wrist defects. The
“cleanliness” of the tube was described as one of its advantages over the open flap, which Shaw had
noted in his previous article on this flap.
Stern H, Nahai F. The versatile superficial inferior epigastric artery free flap. Br J Plast Surg
95:270, 1992.
In this retrospective review of 27 successful SIEA free flaps, the anatomy and surgical technique were
described and advantages and disadvantages of this flap compared to other flaps available for soft tissue
reconstruction discussed. The safety of the flap and aesthetic donor site were emphasized.

10d_SIEA_r6_cah_1218-1214.indd 1241 2/3/2012 3:16:17 PM

 ANATOMIC LANDMARKS
Landmarks The skin of the lateral groin may be elevated as a flap extending
between the femoral vessels and the posterior iliac spine. The
long axis of the flap is centered over a line parallel and 3 cm
inferior to the inguinal ligament with a flap width of 6 to 10 cm.
Size 25 cm 3 6 to 10 cm.
Composition Fasciocutaneous.
Flap Type Type A fasciocutaneous.
Dominant Pedicle Superficial circumflex iliac artery.
Nerve Supply Sensory: Lateral cutaneous nerve of T12.

10e_Groin_r6_cah_1242-1267.indd 1242 2/3/2012 10:58:26 AM

 Section 10E
Abdomen

Groin Flap

CLINICAL APPLICATIONS
Regional Use
Abdominal wall
Perineum
Distant Use
Head and neck
Hand, upper extremity
Lower extremity

10e_Groin_r6_cah_1242-1267.indd 1243 2/3/2012 10:58:28 AM

 ANATOMY OF THE Groin Flap

Superficial circumflex
Anterior superior iliac artery (and vein)
Rectus
iliac spine Femoral
femoris muscle Sartorius muscle
artery
Perforator and vein
flap
Superficial
branch
Deep branch

Superficial
circumflex
iliac artery

Femoral artery
and vein

Perforator of
Adductor Deep Perforator of
deep branch Superficial
longus muscle branch superficial branch
branch

Sartorius muscle
Vascular anatomy of groin flap

B C

Anterior design of flap Anterolateral flap extension

Fig. 10E-1 

Dominant pedicle: Superficial circumflex iliac artery

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 Abdomen  •  10E: Groin Flap 1245

VARIATIONS OF SCIA AND SIEA

D E F

SIEA

SCIA Common origin Large SCIA Separate origins

(48%) without SIEA (42% to 47%)
(10% to 15%)

Fig. 10E-1 

Anatomy
Landmarks The skin of the lateral groin may be elevated as a flap extending between the
femoral vessels and the posterior iliac spine. The long axis of the flap is centered
over a line parallel and 3 cm inferior to the inguinal ligament with a flap width
of 6 to 10 cm. A simple, convenient technique for flap marking is to include
2 fingerbreadths above the inguinal ligament and 4 fingerbreadths below the
inguinal ligament, the dimensions of which will easily capture a safe and well-
vascularized skin flap.
Composition Fasciocutaneous.
Size 25 cm 3 6 to 10 cm. The standard flap dimensions are 10 3 25 cm, with the
flap extending from the medial edge of the sartorius muscle to a variable distance
5 to 10 cm lateral to the anterior superior iliac spine. If the width of the flap is
increased, direct donor site closure becomes progressively more difficult.

Arterial Anatomy (Type A Fasciocutaneous)

Dominant Pedicle  Superficial circumflex iliac artery
Regional Source  Superficial femoral artery.
Length  2 cm.
Diameter  0.8 to 1.5 mm.
Location  Arises from the femoral vessel deep to the deep fascia of the medial groin. The super-
ficial branch passes over the medial border of the sartorius muscle to enter the fat of the groin.
The deep branch can pass through some of the muscle bulk of the sartorius before entering the
groin flap as a musculocutaneous perforator. Either vessel can support the skin island.

Venous Anatomy
Single veins accompanying the arterial circulation, draining to the saphenous vein; the average
venous diameter is 1.5 mm.

Nerve Supply
Sensory Lateral cutaneous nerve of T12.

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 1246 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Groin Flap

B

D
s

Deep surface of standard flap Deep surface of island flap

Deep surface of flap indicating axial blood supply

Radiographic view

Fig. 10E-2 

Dominant pedicle: Superficial circumflex iliac artery (D)

s, Sartorius muscle

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 Abdomen  •  10E: Groin Flap 1247

Flap Harvest
Design and Markings
The pubic tubercle and the anterior superior iliac spine are palpated and a line is drawn
between these two landmarks. This line coincides with the location of the inguinal liga-
ment. The rule of thirds applies to marking the borders of the flap: one third above and two
thirds below the inguinal ligament. The “thirds” refers to 3 cm or 2 fingerbreadths as a
measure. One third or 3 cm above the inguinal ligament and two thirds or 6 cm below the
inguinal ligament demarcate the boundaries of the flap’s width. The vascular pedicle lies
3 cm below and parallel to the inguinal ligament. The point of origin of the vascular pedicle
is determined by palpation of the femoral artery within the femoral triangle, the depres-
sion visualized immediately inferior to the fold of the groin. This triangle is formed by
the inguinal ligament superiorly, the medial border of the sartorius laterally, and the lateral
border of the adductor longus medially. The projected course of the sartorius is marked to
define the lateral boundary of the femoral triangle.

1/3 (3 cm)

2/3 (6 cm)

Anterior superior iliac spine

Superficial circumflex iliac artery

Femoral artery and vein

Pubic tubercle
Sartorius muscle
Rule of thirds

Fig. 10E-3 

The standard flap is incised completely around the flap design. For the island flap, a
transverse incision extending from the medial edge of the adductor longus to the lateral
edge of the sartorius muscle (overlying the femoral triangle) allows identification of the
vascular pedicle. The pedicle is dissected to the medial edge of the sartorius muscle where
the superficial and deep branches penetrate the deep fascia. After identification of the
vascular pedicle, the skin incision is outlined over the lateral groin extending beyond the
anterior superior iliac spine. An incision is made around the planned skin island extending
through the deep fascia.

Patient Positioning
The patient is placed in the supine position with a beanbag or folded towel under the pos-
terior iliac spine on the side of the planned flap.

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 1248 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

Standard Flap
A Doppler probe helps to locate the pedicle over the medial edge of the sartorius and trace its
course laterally to the anterior superior iliac spine. The venae comitantes are either located
deep to the femoral artery entering the femoral vein or entering the saphenofemoral vein
junction. The superficial vein, the primary draining vein of the flap, is located superficial
to the superficial circumflex iliac artery and drains into the saphenous vein at the level of
the saphenous bulb located immediately distal to the fossa ovalis. The deep branch courses
into the medial aspect of the belly of the sartorius before perforating the anterior surface of
the muscle to enter the deep aspect of the overlying fat and skin. Dissection of this vessel
creates a perforator groin flap with a potentially longer pedicle.
The flap is elevated in a distal to proximal direction. The skin is incised around the
lateral, superior, and inferior margins. Elevation is begun in a plane directly superficial to
the fascia lata. The flap is elevated from the anterior superior iliac spine and the external
oblique fascia and inguinal ligament. When the sartorius muscle is visualized, the flap is
elevated deep to the investing fascia immediately superficial to the muscle belly. The medial
edge of the sartorius muscle denotes the proximal limit of standard flap elevation.

A
ASIS

Sartorius

SCIA

Pubis

B C

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.

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 Abdomen  •  10E: Groin Flap 1249

Island Flap
After identification of the vascular pedicle within the femoral triangle through a transverse
incision, the location of the distal skin island is outlined and incised. The distal skin island
is now elevated as described for standard flap elevation. At the medial edge of the sartorius
muscle, the flap elevation is completed with release of the deep fascia until the skin island
dissection communicates with the proximal dissection of the isolated vascular pedicle.

Elevation of flap for microvascular

transplantation

B C

Superficial circumflex
iliac artery Superficial inferior Superficial
epigastric artery inferior
epigastric
artery

Superficial
femoral
artery

Superficial circumflex
iliac artery

Identification of vascular pedicle Closeup view of femoral triangle

Fig. 10E-5 

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 1250 Part II  Regional Flaps: Anatomy and Basic Techniques

Microvascular Island Flap

The groin flap can easily be used as a free tissue transfer based on the vascular dissections
noted above. During flap elevation over the sartorius muscle, the dissection is performed
beneath the deep fascia to avoid injury to the vascular pedicle as it penetrates the deep fascia
and enters the subcutaneous tissue lateral to this muscle. If pedicle lengthening is required,
the deep branch can be dissected through the superficial aspect of sartorius.

Superficial circumflex
Anterior superior Rectus iliac artery and vein
iliac spine Femoral
femoris muscle Sartorius muscle
artery
Perforator and vein
flap
Superficial
branch
Deep branch

Superficial
circumflex
iliac artery

Femoral artery
and vein

Perforator of
Adductor Deep Perforator of
deep branch Superficial
longus muscle branch superficial branch
branch

Sartorius muscle

Perforators of the
Superficial branch of SCIA superficial branch
Perforators of superficial branch Perforators of
Perforators of the deep branch
deep branch of SCIA

Transverse
Transverse
(ascending) branch
(ascending branch of
Deep branch of SCIA deep branch of SCIA)
Sartorius muscle
Sartorius muscle

Fig. 10E-6  A, Vascular anatomy of the groin flap and perforator variant. B, Vascular basis of the
groin flap.

10e_Groin_r6_cah_1242-1267.indd 1250 2/3/2012 10:58:36 AM

 Abdomen  •  10E: Groin Flap 1251

a c

Sartorius
fascia

Perforators passing through sartorius

Fig. 10E-6   C, Elevation of island or free flap based on the perforators of the superficial branch of
the SCIA.

10e_Groin_r6_cah_1242-1267.indd 1251 2/3/2012 10:58:37 AM

 1252 Part II  Regional Flaps: Anatomy and Basic Techniques

Division of muscular branches to lengthen pedicle

Fig. 10E-6 

Flap Variant
•  Delay flap

Delay Flap
It is not uncommon that a standard groin flap would provide too little length for applications
on the hand, arm, thigh, or lower abdomen. However, the groin flap can be progressively
lengthened using a flap delay technique.
To delay a groin flap, the entire standard flap is elevated as described, except the distal
incision is not made. Instead, the upper and lower incisions are lengthened an additional
distance posteriorly, equal to the width of the flap (Fig. 10E-7, A). It is essential that the
entire flap be undermined up to the medial border of the sartorius muscle, so the only blood

10e_Groin_r6_cah_1242-1267.indd 1252 2/3/2012 10:58:38 AM

 Abdomen  •  10E: Groin Flap 1253

supply from a proximal direction is this vessel. After 10 to 14 days, the flap may be extended
further posteriorly, again by the same amount as the diameter of the flap. One way to think
about this amount of lengthening is that a 1:1 flap can be safely transferred anywhere in
the body, and in this instance a 1:1 flap is simply being added to an already viable flap (Fig.
10E-7, B). Again, the extension is completely undermined.

A B

3. Second delay at 10 days

9 cm

2. Initial delay

9
9

cm
cm

Anterior superior

m
m

iliac spine

9c
1. Standard flap
9c

Superficial circumflex
iliac artery

Pubic tubercle

Fig. 10E-7 A, For a delay groin flap, standard flap elevation is performed—without 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.)

The delay can be repeated as needed. Each time, during the delay periods, flow is
coming only from proximal and distal, and the flow within the flap is becoming more
axial. Some surgeons place a silicone sheet under the delayed segment to prevent vascular
ingrowth that can spoil the delay effect. This is not necessary for a single delay but can be
considered if more than one delay is planned.
Once the desired length has been achieved, after 1 week the distal end is divided.
Now the flap only receives arterial inflow and venous outflow from the proximal flap. It
is prudent to wait an additional week for transfer and use, although some would use the
flap immediately. If the surgeon discovers a vessel that was not divided during the delay,
but should have been, that vessel is now divided and elevation of the flap aborted, because
the delay procedure has trained the tissue, in part, on that vessel too. The delay can be
completed after 1 additional week.
Again, this delay technique, which is common for the groin flap, can be used anywhere
on the body when more than the standard flap is required and there is time to perform the
delay correctly.

10e_Groin_r6_cah_1242-1267.indd 1253 2/3/2012 10:58:39 AM

 1254 Part II  Regional Flaps: Anatomy and Basic Techniques

Arc of Rotation
Standard Flap
The point of rotation occurs over the femoral vessels beneath the inguinal ligament. The
flap will reach the abdominal wall and perineum. It is also useful for coverage of distant
upper extremity defects.

A B

Arc to inferior abdomen Coverage of ipsilateral abdomen

Fig. 10E-8 

Flap Transfer
The flap is transferred to its recipient site as either a pedicled transposition flap, a tubed
pedicled flap requiring subsequent division, or a single-stage free flap. The tubed pedicled
flap should be divided at 3 weeks or partially divided at 10 days, followed by complete
separation at 2 to 3 weeks.
The standard flap is transposed directly into the adjacent defect without use of a tun-
nel. A backcut along the inferior transverse incision over the inferior aspect of the femoral
triangle will increase the flap’s arc of rotation.
The island flap may require the use of a tunnel, since a skin flap is completely incised
from the flap base. The overlying skin tunnel will prevent exposure of the proximally
located vascular pedicle if the flap is transposed into an adjacent defect.

Flap Inset
Excess subcutaneous fat may be removed from the deep surface of the flap lateral to the lateral
edge of the sartorius muscle. The skin of the flap is sutured into the skin edge of the defect.
The proximal portion of the flap is tubed if the flap is inset into an upper extremity defect.

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 Abdomen  •  10E: Groin Flap 1255

Donor Site Closure

To avoid a contour deformity, direct donor site closure is performed whenever possible. A
tubed flap is used for upper extremity coverage, and the distal donor site is closed directly.
The midportion of the donor site beneath the tubed area of the flap will require either skin
grafts or temporary wound dressings. At the time of flap division and inset, the unused
portion of the tubed flap is returned and inset into the central donor site to complete di-
rect donor site closure. With the use of an extended wide standard flap, donor site closure
generally requires skin grafts.

Clinical Applications
This 24-year-old woman was involved in a rollover motor vehicle accident and sustained
this avulsion-type injury, leaving an exposed right elbow joint that required coverage.
She also incurred other traumatic injuries. Because of her age and the premium placed on
locating donor site scars in a hidden area, a groin flap was chosen to reconstruct the defect.

B
A

C D

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. (Case supplied by MRZ.)

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 1256 Part II  Regional Flaps: Anatomy and Basic Techniques

This 35-year-old factory worker caught her hand in machinery at work and presented with
a dorsal skin avulsion of the hand and extensor tendon, a collateral ligament injury to the
ring finger, and fractures of her middle, ring, and small fingers. Forty-eight hours after the
initial washout and debridement of nonviable tissues, the patient was returned to the operat-
ing room for fracture and tendon repair, followed by soft tissue coverage with a groin flap.

A B

C D

F G

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. (Case supplied by MRZ.)

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 Abdomen  •  10E: Groin Flap 1257

This 32-year-old soldier sustained severe burns to the majority of his body from the explo-
sion of an improvised explosive device (IED) in the Iraq conflict.

A B

C D

E F G

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. (Case courtesy William C. Pederson, MD.)

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 1258 Part II  Regional Flaps: Anatomy and Basic Techniques

This 43-year-old firefighter lost his left thumb from a thermal injury. A great toe transfer
was planned, but more tissue is always required at the hand.

B C

Fig. 10E-12 A, As a first stage, a pedicled groin flap was placed and tubed to position the toe trans-
fer in this tubed flap. B, The flap was divided 3½ 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. (Case courtesy Wil-
liam C. Pederson, MD.)

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 Abdomen  •  10E: Groin Flap 1259

This 38-year-old man developed necrosis of his hands from pneumococcal sepsis.

D E

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 reason-
able metacarpophalangeal joint motion and thumb opposition after division and insetting of the flap.
(Case courtesy William C. Pederson, MD.)

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 1260 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The groin flap was one of the first free flaps used because of its desirable donor site scar.
Today, however, it is infrequently used as a free flap because of its anatomic variability
and small vessel length and diameter.
• If microvascular transplantation is selected, the vascular pedicle is identified proximally
before skin island elevation. If the pedicle is absent or the superficial circumflex iliac artery
is diminutive or double and has an inadequate external lumen diameter, the transverse
incision over the femoral triangle is closed and the opposite groin explored. If the vas-
cular pedicle is inadequate after incision into the region of the femoral triangle, it is also
possible to identify the superficial inferior epigastric vascular pedicle and incorporate its
vascular territory in the inferior ipsilateral abdominal wall as an alternate flap design for
microvascular composite tissue transplantation.
• During flap elevation over the sartorius muscle, the dissection is performed beneath the
deep fascia to avoid injury to the vascular pedicle as it penetrates the deep fascia and enters
the subcutaneous tissue lateral to this muscle.
• If pedicle lengthening is required, the deep branch can be dissected through the superficial
aspect of the sartorius muscle.
• If greater flap length is required, a delay technique should be considered.
• The distal end of the flap can be split into short, fingerlike leaflets to reach several adja-
cent small defects.

Expert COMMENTARY
William C. Pederson

Indications
The primary indication for this flap is as a pedicled flap for coverage of hand and forearm
wounds. Probably the best indication is the first stage in thumb reconstruction with toe
transfer (to provide needed extra soft tissue). This flap is excellent for dorsal defects and
works well in thinner patients for first webspace coverage and/or release. It may also be
used for distal half forearm coverage. The flap is rarely indicated as a free flap, since many
other cutaneous flaps exist; however, it does offer perhaps one of the best donor sites for a
cutaneous free flap.

Advantages and Limitations

The primary advantage of the groin flap is that it provides excellent soft tissue coverage of
hand wounds without the need for microsurgery. This comes into play particularly when
one is planning a great toe transfer for thumb reconstruction. The use of a pedicled groin
flap as a first stage to provide adequate soft tissue can make the toe transfer simpler by
avoiding the need for a microvascular anastomosis, which might make vascular access for
the toe transfer more difficult.

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 Abdomen  •  10E: Groin Flap 1261

The pedicled groin flap has limited applicability in patients who are very obese because
of the potential thickness of the flap. Also, its dimensions are limited somewhat by the need
to close the donor site primarily. I think that any defect that requires a pedicled groin flap
that could not be closed primarily (usually about 12 to 14 cm wide) should be covered using
another technique. Although it is certainly possible to cover the donor site with a split-
thickness skin graft, I think this is suboptimal and prefer to choose a different flap. Another
disadvantage is that the hand must be placed in a dependent position while it is attached to
the groin. This delays physical therapy and can lead to more swelling.

Anatomic Considerations
I always listen with a pencil Doppler to attempt to identify the superficial circumflex iliac
artery, which one can usually hear along its course to about the level of the ASIS. I also
make a line for the center of the flap two fingerbreadths below the inguinal ligament and
make the flap width equidistant from each side of this line.

Personal Experience and Insights

The pedicled groin flap remains one of the best flaps for hand coverage of moderate to
extensive wounds. It is an excellent choice for coverage of the first webspace after release
(in thin patients) and provides excellent coverage before secondary microsurgical proce-
dures, such as toe transfers. Although microsurgical tissue transfer has perhaps delegated the
pedicled groin flap to secondary status for some, it is often the primary choice of coverage
in my hands.

Recommendations
Planning
The flap design is centered over the signal from the superficial circumflex iliac artery.
Quite wide flaps (10 to 12 cm) can be elevated in most patients, but the hip will have to be
extended and the knees flexed to facilitate closure. The flap is made longer than necessary
to allow tubing of the proximal part, which will permit some motion of the wrist, elbow,
and shoulder.

Technique
The superficial circumflex iliac artery is identified with a pencil Doppler in its usual position
2 cm below the inguinal ligament. The flap is elevated from lateral to medial, defatting the
lateral portion of the flap as it is raised (otherwise, this would have to be done later anyway).
When the lateral border of the sartorius muscle is reached, the fascia is incised and the flap
elevated in a subfacial layer to avoid damage to the superficial circumflex iliac artery. The
donor site is closed before the flap is inset on the hand, and the proximal portion of the
flap is tubed if at all possible. This will require extension (forward flexion) of the hip and
flexion of the knee. The operating table should be flexed maximally at the patient’s hips,
with several pillows placed under the patient’s knees after the flap is elevated and before
closure is attempted to remove the tension.

Postoperative Care
I place a large suture between the wrist and torso until the next morning when the patient
is fully awake to help prevent dehiscence of the flap from the hand. (I have never seen a
patient pull the flap off once he or she is fully awake, but this can occur while the patient
is thrashing around in the recovery room.) Ambulation begins 1 or 2 days postoperatively,
and usually over the first 3 or 4 days the patient will be able to stand straight.
Continued

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 1262 Part II  Regional Flaps: Anatomy and Basic Techniques

If the flap is well healed in on the hand at 3 weeks, the flap can safely be divided. The
timing of flap division is predicated on the adequacy of the new blood supply from the soft
tissues of the hand. If the wounds have dehisced a bit or do not appear to have healed in, I
usually wait another week.
Another option is to perform a “delay” procedure on the flap. At 3 weeks, the skin and
dermis of the flap can be incised or a small incision made in the flap and the deep tissues
divided (which should divide the superficial circumflex iliac vessels). This will allow safe
division of the flap a week later.

Complications: Avoidance and Treatment

Dehiscence of the flap can be avoided by the maneuvers just described. If within the first 2
or 3 postoperative days a line of ischemia is noted in the distal flap, the patient is returned
to the operating room; the nonviable portion of the flap should be debrided and the flap
reinset. Tubing of the proximal flap will usually give enough extra flap to allow this.
If an infection develops at the donor site, do not open it and leave it open! This will lead
to a wound that is extremely difficult to manage and will usually require a long course of
dressing changes and eventually a skin graft. The infected donor site should be managed
closed if at all possible, with repeated irrigation and drains. The infection will eventually
resolve and heal, with far fewer problems than if the wound is opened and left open.

Take-Away Messages
The pedicled groin flap remains one of the workhorses for soft tissue coverage of the hand.
If done carefully and extra length is taken, the flap can be tubed a bit, which will allow
some motion of the wrist, elbow, and shoulder. Although an excellent choice for soft tissue
coverage, the flap does not import a blood supply, and thus its indications are limited in
dysvascular limbs and severely contaminated wounds.

Bibliography With Key Annotations

Anatomic Studies
Ohmori K, Harii K. Free groin flaps: their vascular basis. Br J Plast Surg 28:238, 1975.
These early pioneers of microvascular surgery described their anatomic cadaver dissections and clinical
experience with the free groin flap. They clearly detailed the vascular basis of this flap and its vari-
ability. In their experience with 16 flap elevations in cadavers and 70 clinical flaps, they commented
that there were no vessels large enough to supply the flap in four cases. In all the other patients, the flap
was supplied to some extent by the superficial inferior epigastric artery and the superficial circumflex
iliac artery, and venous drainage was through the superficial axial vein running in the flap. They
noted that the superficial inferior epigastric artery and the superficial circumflex iliac artery arose from
a common trunk in 25 instances. They also pointed out that survival of the flap does not require
reanastomosis of both the superficial inferior epigastric artery and superficial circumflex iliac artery.
Either of these vessels is sufficient to carry the entire flap.
Smith PJ, Foley B, McGregor IA, Jackson IT. The anatomical basis of the groin flap. Plast
Reconstr Surg 49:41, 1972.
The authors’ anatomic studies included cadaver dissections and radiographic studies of the superficial
circumflex iliac artery. These vessels were cannulated and injected with contrast material during the
course of radical lymph node dissection. In their 14 anatomic cadaver dissections, the authors noted
that in 13 cases the vessel was a direct branch of the femoral artery and in one case a branch of the
superficial inferior epigastric artery. The course of the vessel essentially paralleling the inguinal liga-
ment was demonstrated.

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 Abdomen  •  10E: Groin Flap 1263

Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 56:243,
1975.
The vascular anatomy of potential flaps suitable for microvascular transplantation was studied in
cadavers. Specific areas evaluated included the iliofemoral, deltopectoral, axillary, chest, and popliteal
regions. The authors recommended the regional iliofemoral flap based on the superficial circumflex iliac
and superficial inferior epigastric systems as the best donor site for most regions. In their clinical series
of five patients, the largest flap from this area measured 15 by 24 cm. The deltopectoral flap designed
on the second or third perforators was recommended as the best alternate donor site region, since the
flap is thinner and provides a better color match for head and neck reconstruction.

Clinical Series
Bertani A, Riccio M, Belligolli A. Vulval reconstruction after cancer excision: the island groin
flap technique. Br J Plast Surg 43:159, 1990.
The authors reported their experience in 16 patients in whom vulval reconstruction with bilateral
island groin flaps was performed. They advocated this as a useful flap not only for reconstruction of
the vulva but also for access for groin dissection in these patients with vulvar carcinoma.
Chuang DC, Jeng SF, Chen HT, et al. Experience of 73 free groin flaps. Br J Plast Surg 45:81,
1992.
The authors reviewed their experience with 73 free groin flaps performed between 1985 and 1990.
During that 5-year interval the authors performed a total of 1096 free flap reconstructions. The groin
flaps therefore represented only 7% of their experience during that period. The complication rate was
8%. They had three complete failures and three partial failures. They stated that part of the problem
with the flap is the small diameter of the superficial circumflex iliac artery, and suggested two ways of
overcoming the small pedicle size: (1) harvest of a cuff of femoral artery with the superficial circumflex
iliac artery to facilitate microvascular anastomosis of the artery and (2) use of a longitudinal split of
the Y-shaped bifurcation of the superficial circumflex iliac artery if available. In the authors’ experi-
ence, this Y-shaped bifurcation is quite common. In their clinical series the authors demonstrated the
versatility of this thin cutaneous flap for extremity coverage.
Drabyn GA, Porterfield HW, Mohler LR, et al. Wrist-iliac crest fixation for groin flap–thumb
immobilization. Plast Reconstr Surg 70:98, 1982.
The authors described a method of fixing the wrist to the iliac crest with a Hoffman external fixation
device to immobilize the thumb during a staged thumb reconstruction using a groin flap.
Harashina T, Fujino T. Reconstruction in Romberg’s disease with free groin flap. Ann Plast
Surg 7:289, 1981.
The authors presented two cases in which the soft tissues of the face were augmented with a deepithe-
lialized free groin flap. In their first patient, a 9-year-old boy, the authors performed a flap revision
3 years later because of sagging.
Heath PM, Jackson IT, Cooney WP III, et al. Simultaneous bilateral staged groin flaps for
coverage of mutilating injuries of the hand. Ann Plast Surg 11:462, 1983.
The authors described bilateral simultaneous groin flaps for coverage of the dorsum and volar aspect
of the hand. The two flaps were elevated simultaneously and one placed over the dorsum and one on
the volar aspect. They demonstrated successful reconstruction in two patients with mutilating hand
injuries involving both the dorsal and palmar surface of the hand.
Hough M, Fenn C, Kay S. The use of free groin flaps in children. Plast Reconstr Surg 113:1161-
1166, 2004.
The authors reported their experience with 33 consecutive cases of free groin flaps in children over a
period of 9 years (1992 to 2001). Flaps were performed to provide soft tissue coverage during recon-
struction of congenital defects and tumor resection and following trauma. Twenty-six cases (79%)
involved the upper limb, six cases (18%) involved the lower limb, and one case involved the head. The
complication rate included only two failures (6%), three (9%) minor donor-site complications (super-

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 1264 Part II  Regional Flaps: Anatomy and Basic Techniques

ficial wound infection, hypertrophic scarring, and dog-ears), and nine flaps requiring debulking. The
reexploration rate was 24%, with seven of the eight flaps undergoing reexploration surviving. They
concluded that the groin flap is reliable and can be used safely in children, with minimal morbidity.
Hsu WM, Chao WN, Yang C, et al. Evolution of the free groin flap: the superficial circumflex
iliac artery perforator flap. Plast Reconstr Surg 119:1491-1498, 2007.
The authors reviewed the decline in popularity of the groin flap because of the availability of more
versatile free flaps. They highlighted some of the traditional groin flap’s inherent disadvantages, includ-
ing a short arterial pedicle, variable arterial anatomy, the small caliber of the included blood vessels,
its bulk, and numbness at the donor site. They addressed several of these criticisms by developing
alternative methods of dissection, including the use of the SCIA axis as a perforator groin flap with
extended pedicle. Clinical experience was presented, with the modified flap in 12 patients (age range
15 to 67 years) in surgical procedures involving nine recipient sites in the upper limbs, two in the
foot, and one in the mouth. They concluded that the SCIA flap overcomes most of the disadvantages
of the free groin flap and demonstrated its advantages, including (1) a concealed donor-site scar, (2)
primary closure of the donor site, (3) procurement of a large cutaneous flap (25 by 8 cm to 6 by 4 cm),
(4) non-hair-bearing skin, (5) longer arterial pedicle (3 to 13 cm), (6) typically requiring no vessel
grafting, (7) reduction in bulk, (8) a decreased area of numbness at the donor site, and (9) less time
required for flap dissection (0.5 to 1.5 hours). The SCIA perforator flap was presented as an evolu-
tion of the conventional free groin flap.
McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 25:3, 1972.
This was the original description of the groin flap. The authors stated their belief that the success and
safety of Bakamjian’s deltopectoral flap was based on a virtually closed arteriovenous system deriving
from and draining back into the perforating branches of the internal mammary system. Therefore they
attempted to identify such a vascular system in other areas. In reviewing previous anatomic descriptions
and drawings, the authors concluded that the superficial circumflex iliac arteriovenous system may well
support a flap. The area of skin supplied by the system was called the groin flap by the authors. In
this article they described the anatomic basis and clinical demonstration of the groin flap for coverage
of the hand and staged transfer to the scalp. This landmark article was the impetus for others to search
for “similar” axial flap donor sites.
Mukherjee GD. Use of groin and mid-thigh flap in reconstruction of penis with penile and
perineal urethra and a dorsal skin-lined socket for a removable prosthesis. Ann Plast Surg
16:235, 1986.
The author described a multistaged (seven-stage) reconstruction of the penis in four patients. A groin
flap and an opposite upper thigh flap were used to reconstruct a penis with a lined urethra and a
separate lined pocket into which a penile prosthesis may be placed.
O’Brien BM, MacLeod AM, Hayhurst JW, et al. Successful transfer of a large island flap from
the groin to the foot by microvascular anastomoses. Plast Reconstr Surg 52:271, 1973.
This was one of the original descriptions of a free microvascular flap transfer. The groin flap was used
for coverage of a defect of the lower third of the leg and ankle in a young man with a close-range shotgun
wound. The anatomy of the flap based on 45 cadaver dissections was presented; the anatomic basis
of the flap on the superficial circumflex iliac artery was confirmed. The feasibility of microvascular
transplantation of axial flaps was successfully demonstrated in this case, despite numerous complica-
tions and a redo of the vascular anastomosis because of thrombosis. The problems encountered in such
microvascular transplantations and the hurdles that had to be overcome before microvascular tissue
transplantation became commonplace were vividly portrayed in this early report.
Ohtsuka H, Nakaoka H, Saeki N, et al. Island groin flap. Ann Plast Surg 15:143, 1985.
The authors presented their experience with the use of an island groin flap in nine patients. The pedicle
island flap was used for reconstruction of the upper thigh, lower abdomen, and perineum. The arc of
rotation of the flap and its successful use for coverage of defects in these areas was well demonstrated.

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 Abdomen  •  10E: Groin Flap 1265

Rees MJ, Mehrotra ON. Economical use of the “groin” flap: then and now. Br J Plast Surg
40:647, 1987.
In this interesting article the authors presented two patients in whom the groin flap was used to cover
two separate anatomic areas. In the first patient the hand and neck were covered with a groin flap,
with the hand acting as a carrier for the groin flap to the neck. In a second case the distal portion of
the groin flap was used for coverage of a hand defect. When the flap was divided 3 weeks later, the
proximal portions of the flap were transferred as a free flap for coverage of a right foot defect. This
article illustrated the versatility of this flap and its practical applications based on a knowledge of the
vascular anatomy and the ability to transfer tissues by microvascular transplantation.
Santoni-Rugiu P. Review of 33 free groin flaps in the repair of complicated defects of the lower
limb. Ann Plast Surg 9:10, 1982.
The author reviewed his experience with 33 free groin flaps for coverage of complex lower extremity
defects. Of the 33 flaps, there were seven failures, including one compound osteocutaneous flap, which
represents a failure rate of 21%. Six of the 33 flaps were compound osteocutaneous flaps.
Schlenker JD. Important considerations in the design and construction of groin flaps. Ann
Plast Surg 5:353, 1980.
The author described several important steps in the elevation and tubing of the groin flap for hand
coverage. These include the preservation of the lateral femoral cutaneous nerve of the thigh and a
modification of flap design in which the upper incision is longer than the lower incision, and the flap
is tubed diagonally rather than straight across. This allows easier rotation of the tube and facilitates
donor site closure.
Schlenker JD, Robson MC, Parsons RW. Methods and results of reconstruction with free flaps
following resection of squamous cell carcinoma of the head and neck. Ann Plast Surg 6:362, 1981.
The authors reported their experience with nine patients who underwent reconstruction of head and
neck defects with free flaps. The dorsalis pedis flap was used in three patients, the groin flap in four
patients, and the latissimus dorsi flap in two patients. The authors preferred to elevate this flap from
lateral to medial and presented successful reconstructions with the flap.
Sun GC, Zhong AG, He W, et al. Reconstruction of the external genitals and repair of skin
defects of the perineal region using three types of lateral groin flap. Ann Plast Surg 24:328, 1990.
The authors described a series of patients in whom reconstruction of the vagina, penis, and groin was
performed with groin flaps and superficial inferior epigastric artery flaps. In a number of patients a
combination of flaps was used. A composite iliac crest bone and groin flap was used in 11 patients
for penile reconstruction.
Tweek AE, Manktelow RT, Zuker RM. Facial contour reconstruction with free flaps. Ann
Plast Surg 12:313, 1984.
The authors reported their experience with 11 cutaneous and musculocutaneous free flaps for facial
contour reconstruction: Romberg’s disease (4), lateral facial dysplasia (1), following tumor resection (2),
and lipodystrophy (4). In nine of their patients deepithelialized groin flaps were used. All flaps were
successful, and in every patient suitable vessels were found for microvascular transplantation. Follow-
up ranging from 6 months to 31⁄2 years showed that the flaps maintained their bulk and position.
Wray RC, Wise DM, Young VL, et al. The groin flap in severe hand injuries. Ann Plast Surg
9:459, 1982.
The authors reported their experience between 1971 and 1972 in 27 patients who underwent groin
flap reconstruction of hand injuries. All patients had severe crush-avulsion injuries with soft tissue
loss. In all patients the flap was transferred as a staged procedure. They reported an 18% incidence
of flap necrosis due to ischemia. In all cases flap necrosis occurred after the final division of the pedicle
and was more common following immediate insetting of the flap than after delaying the inset. The
authors noted that flap necrosis did not develop if the pedicle was divided in two stages.

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 1266 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Modifications
Acartürk S, Özmen E. Composite osteo-cutaneous groin flap for the reconstruction of wrist
and forearm defects. Br J Plast Surg 37:388, 1984.
The authors elevated the groin flap together with the underlying iliac crest bone for reconstruction
of complex defects of the wrist and forearm in two patients. Missing bone, skin, and subcutaneous
tissues were replaced with a pedicle groin flap in two patients. This staged procedure was successful
in reconstruction of a wrist and forearm defect. Bone scans at 8 weeks confirmed the viability of the
transferred iliac crest bone.
Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg
64:30, 1979.
To ensure the standard groin flap is uniformly thin and has a long vascular pedicle, the author places
the skin island farther laterally so that the medial border of the skin island is placed along the lateral
border of the femoral triangle. The author presented his experience with 18 free iliac flaps. Twelve
of 18 flaps were used for immediate reconstruction of intraoral defects. Thirteen of the 18 flaps were
successful, and five were failures. One failure was attributed to errors in flap elevation, one failure to
tortuosity of the arterial anastomotic site, another to intraoperative vasospasm, and two to compression
of the vascular pedicle.
Clarke JA, Rossi LFA. Two groin flaps out of one. Br J Plast Surg 33:262, 1980.
In an unusual case report, the authors split a groin flap and transferred one part as a free flap for recon-
struction of an opposite wrist and used the remainder as a pedicle flap for coverage of an ipsilateral wrist
defect. The branching pattern of the superficial circumflex iliac artery makes this modification possible.
Finseth F, May JW, Smith RJ. Composite groin flap with iliac-bone flap for primary thumb
reconstruction. J Bone Joint Surg Am 58:130, 1976.
The authors described the inclusion of the underlying iliac crest with the groin flap for primary thumb
reconstruction, thus transferring the soft tissue and bone as a composite flap in this staged reconstruction.
Katsaros J, Gilbert D, Russell R. The use of a combined latissimus dorsi–groin flap as a direct
flap for reconstruction of the upper extremity. Br J Plast Surg 36:67, 1983.
A combined latissimus dorsi–groin flap was designed with the flap located on the lateral flank extend-
ing between the axilla and groin. The flap was used to cover an extensive defect extending between
the medial upper arm and forearm. The groin pedicle was divided at 14 days and flap inset completed
1 week later. Because a vein graft had been used earlier to revascularize the upper extremity, suitable
receptor vessels for microvascular flap transplantation were not available. This technique provides a
long flap with a width of 12 cm for coverage of a large upper extremity defect with the upper extremity
maintained in an acceptable position following flap inset.
Kimura N, Saitoh M, Hasumi T, et al. Clinical application and refinement of the microdissected
thin groin flap transfer operation. J Plast Reconstr Aesthet Surg 62:1510, 2009.
The authors presented a new technique for raising a microdissected thin groin flap. The flap is
uniformly thin with a long vascular pedicle prepared by microdissection of the deep branch of the su-
perficial circumflex femoral system (SCIS). Thirty cases were reconstructed using microdissected thin
groin flaps. One flap was lost because of a venous thrombosis. A small distal area of three large flaps
became necrotic. The perforators from the deep branches were absent in five cases, and three of these
flaps were successfully elevated based on the superficial branch using the new method. The clinically
safe dimensions of the flap ranged from 5 by 2 cm to 25 by 12 cm.
Rasheed T, Hill C, Riaz M. Innovations in flap design: modified groin flap for closure of mul-
tiple finger defects. Burns 26:186, 2000.
The groin flap is usually used as a syndactylized sheet to cover multiple defects of the fingers. The
authors presented a novel technique for splitting the flap into daughter flaps based on the SCIA vessels.

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 Abdomen  •  10E: Groin Flap 1267

Taylor GI, Watson N. One-stage repair of compound leg defects with free revascularized flaps
of groin skin and iliac crest. Plast Reconstr Surg 61:494, 1978.
This was one of the early reports of microvascular transplantation of the groin flap with iliac crest bone
for reconstruction of complex leg defects. Later studies by Taylor showed that the deep circumflex iliac
artery provided a better blood supply to the iliac crest.
Wei FC, Chen HC, Chuang DC, et al. Reconstruction of Achilles tendon and calcaneus de-
fects with skin-aponeurosis-bone composite free tissue from the groin region. Plast Reconstr
Surg 81:579, 1988.
The authors reported their experience in reconstruction of complex defects of the lower leg involving the
Achilles tendon and calcaneus. Eight patients were included in this series. In patients with skin, soft
tissue, and Achilles tendon loss, a free groin flap that included sheets of external oblique aponeurosis
was transferred, and the aponeurosis was rolled to form a tendonlike structure to replace the Achilles
tendon. Coverage was provided by the overlying groin flap. In a separate group of patients the groin
flap with iliac crest bone was transferred. The bone was used for reconstruction of the calcaneus. All
reconstructions were successful. Two patients had some partial skin loss. The authors demonstrated
the feasibility of reconstruction of the Achilles tendon with a piece of vascularized external oblique
aponeurosis carried with the groin flap.

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 ANATOMIC LANDMARKS
Landmarks The flap incorporates the skin and fascia extending from the
abdominal midaxillary line laterally.
Size 25 3 7 cm.
Composition Fasciocutaneous.
Flap Type Type C.
Dominant Pedicle Myocutaneous perforators via the rectus abdominis muscle.
Minor Pedicle Two or three subcostal arteries.
Nerve Supply Anterior division of the lateral cutaneous branches of the sixth
through tenth intercostal nerves.

10f_ThoraEpi_r4_bs_1268-1279.indd 1268 2/3/2012 2:41:52 PM

 Section 10F
Abdomen

Thoracoepigastric
(Transverse Abdominal) Flap

CLINICAL APPLICATIONS
Regional Use
Anterior thorax
Breast
Abdomen

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 ANATOMY OF THE Thoracoepigastric (Transverse Abdominal) Flap

Myocutaneous
perforating arteries from
superior epigastric artery

Arterial supply to flap area

Anterior branches of
lateral cutaneous branches
of intercostal nerves

Nerve supply to flap area

Fig. 10F-1 

Dominant pedicle: Myocutaneous perforating arteries from superior epigastric artery

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 Abdomen  •  10F: Thoracoepigastric (Transverse Abdominal) Flap 1271

Anatomy
Landmarks Flap incorporates the skin and fascia extending from the abdominal midaxillary
line laterally.
Composition Fasciocutaneous.
Size 25 3 7 cm.

Arterial Anatomy (Type C)

Dominant Pedicle  Myocutaneous perforators via the rectus abdominis muscle
Regional Source  Superior epigastric artery.
Length  2 cm.
Diameter  0.5 mm.
Location  Myocutaneous perforators extending from the rectus abdominus muscle through the
anterior rectus sheath into the fat of the flap.
Minor Pedicle  Two or three subcostal arteries
Regional Source  Thoracic aorta.
Length  2 cm.
Diameter  1 to 1.5 mm.
Location  These vessels enter the midportion of the deep aspect of the rectus abdominis in
conjunction with the intercostal motor nerves. They anastomose with the superior epigastric
artery within the muscle contributing to the myocutaneous perforators entering the flap base.
The contribution from T8 is the largest segmental branch.

Venous Anatomy
The venous anatomy is via perforators that accompany the superior epigastric vein. In the subcostal
vessels, venous drainage is via the hemizygos and azygos veins.

Nerve Supply
Anterior division of the lateral cutaneous branches of the sixth through tenth intercostal nerves.

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 1272 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Thoracoepigastric

(Transverse A bdominal) Flap
A B

D
D

Deep surface of flap Flap base at lateral edge of rectus sheath

Deep surface of flap

Radiographic view

Fig. 10F-2 

Dominant pedicle: Myocutaneous perforating arteries (D)

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 Abdomen  •  10F: Thoracoepigastric (Transverse Abdominal) Flap 1273

FLAP HARVEST
Design and Markings
The skin flap is oriented either transversely or slightly obliquely across the lateral trunk.
The base of the flap extends between the xiphoid process and a point 7 cm below this.
Two parallel lines drawn from these two points extending laterally or obliquely will form
the upper and lower limits of the flap boundaries. The two parallel lines are then joined as
either an elliptical or a rectangular termination.

Standard flap design

Fig. 10F-3 

Patient Positioning
The patient is placed in a supine position.

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 1274 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The upper and lower incisions are incised, and the upper dissection is carried down over
the serratus anterior muscle; the inferior incision is extended down to the external oblique
muscle. The tip of the flap is then raised immediately superficial to the serratus and external
oblique fascial layers, moving progressively from lateral to medial. Dissection extends to
the linea semilunaris medially. Further medial dissection can be performed until the per-
forators are seen, but this dissection can be dangerous in that it may cause pedicle damage,
rendering the flap ischemic.
An inferior backcut toward the midline can expedite flap rotation superiorly. The tip
of this flap beyond the anterior axillary line is not as reliable as the more proximal com-
ponents and flap viability can be enhanced using the vascular delay procedure 3 to 7 days
before flap elevation.

Backcut to aid in rotation

Perforators are located and flap is backcut to aid in rotation

Fig. 10F-4 

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 Abdomen  •  10F: Thoracoepigastric (Transverse Abdominal) Flap 1275

Flap variant
• Extended VRAM (eVRAM) flap

ARC OF ROTATION
The flap can be rotated from 45 to 90 degrees up onto the chest or down onto the abdomen.

A B

Arc to anterior chest Arc to abdomen

Arc of rotation to groin

Fig. 10F-5 

FLAP TRANSFER
The flap is always used as a pedicled procedure, and during transposition, care should be
taken to prevent undue tension from the pivot point or kinking of the small and somewhat
fragile perforators.

FLAP INSET
The flap is sutured to the recipient bed using absorbable sutures in a two-layer closure
incorporating Scarpa’s fascia as the deep layer.

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 1276 Part II  Regional Flaps: Anatomy and Basic Techniques

DONOR SITE CLOSURE

If the donor site is too tight, it should be closed with a skin graft. Usually, however, it is
feasible to close it directly, but it is imperative that the deep layer include a competent
Scarpa’s fascia repair.

CLINICAL APPLICATION
This 72-year-old man had a sarcoma of his left hip and received neoadjuvant chemotherapy
followed by radiation therapy. Surgical resection and reconstruction were indicated.

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. (Case courtesy Justin M. Sacks, MD.)

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 Abdomen  •  10F: Thoracoepigastric (Transverse Abdominal) Flap 1277

Pearls and Pitfalls

• Care should be taken not to outrun the flap’s blood supply by extending dissection be-
yond the midaxillary line.
• Vascular delay can augment tip vascularity.
• Judicious backcutting involving the skin only can facilitate flap rotation to some degree.
When performing this maneuver, care should be taken not to damage the inferior per-
forator supply.

Expert Commentary
Justin M. Sacks

Indications
The thoracoepigastric flap provides an axial-based fasciocutaneous flap for defects of the
abdomen, anterior thorax, breast, and the ipsilateral upper extremity. This flap is appropriate
when there is a shortage of skin after mastectomy or for smaller chest wall defects. When
the thoracoepigastric flap is incorporated into an inferiorly based pedicled VRAM flap, it
can be considered an extended VRAM (eVRAM). When the flap is used in this fashion,
defects that can be reconstructed include the perineum, pelvis, groin, and hip regions.

Fig. 10F-7  The thoracoepigastric flap can be

used to cover a mastectomy or small chest wall
defect.

Based on dominant myocutaneous superior epigastric perforators from the rectus ab-
dominis muscle and minor perforators from subcostal arteries, this flap incorporates skin
and fascia from below the subcostal margin to the midaxillary line laterally. A flap measur-
ing up to 25 by 7 cm can be harvested. Using vascular delay, the flap can be lengthened.

Advantages and Limitations

This is the procedure of choice for patients requiring soft tissue for the chest wall who are
not appropriate candidates for an abdomen-based flap in the form of a free tissue transfer,
such as a free TRAM flap, muscle-sparing TRAM, or a deep inferior epigastric artery
(DIEA) flap, or if a patient is unable to have the latissimus dorsi muscle transferred, with or
without a skin paddle. If no free tissue transfer is appropriate, then the thoracoepigastric
flap can potentially provide appropriate soft tissue coverage. The advantages of this flap are
its technical ease, local donor area, and primary donor site closure. The scar can be covered
on the brassiere line, and the tissue transposed is robust.
Continued

10f_ThoraEpi_r4_bs_1268-1279.indd 1277 2/3/2012 2:42:03 PM

 1278 Part II  Regional Flaps: Anatomy and Basic Techniques

In the setting of breast reconstruction, if the inframammary fold is violated, then there
is a chance the perforators to the thoracoepigastric flap will have been violated. The flap
will not correct an infraclavicular hollow or be able to re-create an anterior axially fold.

Anatomic Considerations
The transverse thoracoepigastric flap has an axial blood supply based on lateral perforators
from the superior epigastric artery and vein. The flap is considered random when it is ex-
tended past the anterior axillary line and placed between or up to the posterior axillary line.

Personal Experience and Insights

An eVRAM flap can incorporate a portion of the thoracoepigastric flap. The terminal
portion of the eVRAM will act as the equivalent of the thoracoepigastric flap. Thus the
indications for the thoracoepigastric flap are broadened, and this flap can be considered for
reconstruction of other areas, such as the pelvis, perineum, and hip regions.

Recommendations
When raising the thoracoepigastric flap, it is important to base and center the flap over the
perforating vessels from the superior epigastric system. Transcutaneous Doppler imaging,
CT angiography, and near-infrared laser angiography using indocyanine green can help
optimize the location of the base of the thoracoepigastric flap. The flap, by definition, is
always used as a pedicled procedure. However, when it is raised with the VRAM, it can be
considered an eVRAM. In this case, the thoracoepigastric flap becomes an extension of the
VRAM, and the flap is not as limited in its rotation. This variant of the flap relies on the
anastomosis of the intercostal system and the superior epigastric system. When the flap is
solely based on the perforators of the superior epigastric flap, care must be taken to prevent
undue tension at the pivot point. The flap is sutured to the recipient bed using absorbable
sutures in a two-layer closure incorporating Scarpa’s fascia as the deep layer. Closed suc-
tion drains are recommended at all aspects of the flap donor site and inset. If the donor site
is closed too tightly, necrosis and dehiscence will ensue. In these situations the donor site
needs to be closed with a skin graft.

References
Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric
arcade. Plast Reconstr Surg 55:416-421, 1975.
Davis WD, McCraw JB, Carraway JH. Use of a direct transverse, thoracoabdominal flap to
close difficult wounds of the thorax and upper extremity. Plast Reconstr Surg 60:526-533, 1977.
Lewis VL Jr, Cook JQ. The nondelayed thoracoepigastric flap: coverage of an extensive electric
burn defect of the upper extremity. Plast Reconstr Surg 65:492-493, 1980.

Bibliography With Key Annotations

Anatomic Studies
Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flap and the deep epigastric
arcade. Plast Reconstr Surg 55:416, 1975.
The deep epigastric arcade between the superior epigastric artery and deep inferior epigastric artery
was described. A transverse abdominal flap was designed based on the perforators through the rectus
abdominis muscle. The authors shared their experience using this flap to cover an exposed upper
extremity vascular reconstruction in one patient.

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 Abdomen  •  10F: Thoracoepigastric (Transverse Abdominal) Flap 1279

Clinical Series
Bohmert H. [Experience in breast reconstruction with thoraco-epigastric and advancement
flaps] Acta Chir Belg 79:105-110, 1980.
In this French-language article Bohmert described breast reconstruction in 107 patients using the
thoracoepigastric and abdominal advancement flaps. In 76 patients with a vertical or oblique scar, a
medially based thoracoepigastric flap was used. In patients who had a transverse scar, an abdominal
advancement flap was used. In both groups, a silicone implant was placed under the flap. Satisfactory
breast reconstruction was demonstrated.
De la Plaza R. Postmastectomy reconstruction by a contralateral abdominomammary flap.
Ann Plast Surg 6:97-102, 1981.
In this modified transverse abdominal flap the author used the excess abdominal skin and subcutaneous
tissues from under the opposite inframammary crease for breast reconstruction. The flap was based on
perforators through the rectus abdominis on the same side.
Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for
recurrent breast cancer. Plast Reconstr Surg 53:52-54, 1974.
This was the original description of the transverse abdominal or thoracoepigastric flap. The authors
described a flap based on the midline and extending to the ipsilateral posterior axillary line. It was
based on the upper part of the rectus abdominis. The vascular bases of the flap were perforating ves-
sels from the superior epigastric artery through the rectus abdominis. They presented five patients. In
the first three patients the flap was delayed. In the final two patients there was no flap delay. The
only complication occurred in a patient who had a nondelayed flap and involved some distal marginal
necrosis. The utility of this flap for chest coverage was well demonstrated.

Flap Modifications
Baroudi R, Pinotti JA, Keppke EM. A transverse thoracoabdominal skin flap for closure after
radical mastectomy. Plast Reconstr Surg 61:547-554, 1978.
The authors performed a modification of a transverse abdominal flap. The flap was based on perforators
through the opposite rectus abdominis muscle. They demonstrated clearly that the perforators through
the rectus abdominis easily support a transverse flap extending across the midline. They also described
the vascular basis for this flap and clinical applications in breast reconstruction and chest coverage.
Cronin TD, Upton J, McDonough JM. Reconstruction of the breast after mastectomy. Plast
Reconstr Surg 59:1-14, 1977.
In this modification of the thoracoepigastric flap the authors extended the flap well beyond the posterior
axillary line onto the back. The flap was twice delayed before being used for breast reconstruction with
a silicone implant. The article was an early review of breast reconstruction with this flap and a silicone
implant. Techniques for nipple-areola reconstruction were also discussed.
Franco T. Axial flap from the inferior pole of the breast. Ann Plast Surg 5:260-265, 1980.
Breast reconstruction was performed using the transverse abdominal flap based high up under the
opposite breast. This flap was supplied through perforators from the superior epigastric artery. The
author also described a laterally based flap for release of burn scar contracture. Perforators from the
external oblique provided the vascular basis for this flap.
Holmström H, Lossing C. The lateral thoracodorsal flap in breast reconstruction. Plast Reconstr
Surg 77:933-943, 1986.
The authors described their experience with this flap in 114 cases of breast reconstruction. They reported
complications of partial flap necrosis in 3.5% of their cases and an infection rate of 2.5%. This was a
modification of the standard transverse abdominal flap in that it was based more laterally. In addition
to its vascular supply through the rectus abdominis, it was also supplied through the intercostal vessels
and perforators through the external oblique.

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 ANATOMIC LANDMARKS
Landmarks This flap extends from the posterior perineum obliquely along
the groin to the level of the upper pubis, between the labium
majorum or scrotum medially and the medial thigh laterally. It
abuts the groin crease.
Size 15 3 6 cm.
Composition Fasciocutaneous.
Flap Type Type A.
Dominant Pedicle Posterior labial artery.
Nerve Supply Sensory: Pudendal, S2 to S4, and perineal branches of the posterior
cutaneous nerve of the thigh, S1 to S3.

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 Section 10G
Abdomen

Pudendal-Thigh (Singapore) Flap

CLINICAL APPLICATIONS
Regional Use
Perineum
Scrotum
Genitourinary
reconstruction
Specialized Use
Vaginal
reconstruction

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 ANATOMY OF THE PUDENDAL-THIGH (singapore) FLAP

A Pubic symphysis Bulbospongiosus

Ischiocavernosus Deep transverse perineal muscle

Ischial ramus Superficial transverse

perineal muscle
Ischial tuberosity
Levator ani muscle
Gluteus maximus muscle
External anal sphincter

Muscular anatomy

B C

Posterior labial nerve Posterior femoral

cutaneous nerve,
Posterior labial artery
Perineal nerve: cutaneous branch
Transverse Superficial branch
perineal branch Deep branch

Perineal artery
Inferior rectal
nerve
Internal
pudendal artery Pudendal nerve
Inferior rectal
artery

Arterial supply Nerve supply

Fig. 10G-1 

Dominant pedicle: Posterior labial artery

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1283

Anatomy
Landmarks Fasciocutaneous flap based posteriorly in the groin creases; extends from the
posterior perineum obliquely along the groin to the level of the upper pubis
between the labium majorum or scrotum medially and medial thigh laterally. It
abuts the groin crease.
Composition Fasciocutaneous; based on the posterior labial artery as a direct axial cutaneous
vessel.
Size 15 3 6 cm.

Arterial Anatomy (Type A)

Dominant Pedicle  Posterior labial artery
Regional Source  Internal pudendal artery.
Length  10 to 12 cm.
Diameter  1 to 1.5 mm.
Location  Internal pudendal artery is the source artery to the perineum through the perineal
artery and the inferior rectal artery. The perineal arterial branch courses from posterior to an-
terior, passing from deep to superficial. At the level of the anus, the vessel gives off a transverse
perineal branch, then continues as the posterior labial artery, running from posterior to anterior
between the groin crease and the labium or scrotum, superficial to the deep fascia. Distally, the
artery anastomoses with terminal branches of the deep external pudendal artery and medial
circumflex femoral vessels.

Venous Anatomy
The venous anatomy closely follows the arterial circulation.

Nerve Supply
Sensory Pudendal, S2 to S4, and perineal branches of the posterior cutaneous nerve of
the thigh, S1 to S3. The anterior portion of the flap loses its sensation during
elevation, but the posterior half retains sensation through the posterior labial
and perineal branches, as described previously.

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 1284 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the P udendal-Thigh (Singapore) Flap

A B

Elevation of bilateral flaps Deep surface of bilateral flaps

D D

Closeup view of flap base

D E
D
D

Deep surface of flap Deep surface of flap

Fig. 10G-2 

Dominant pedicle: Posterior labial artery (D)

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1285

FLAP HARVEST
Design and Markings
The skin territory of this flap can be outlined by using Doppler ultrasound to identify the
posterior labial vessels. The flap is based posteriorly, and an oblique flap 15 cm long by
5 to 6 cm wide is designed extending from the labium majorum medially to the medial
thigh skin laterally, with the flap design abutting the groin crease.

Bilateral flap skin island design

Fig. 10G-3 

Patient Positioning
The patient is placed either in the lithotomy position or in a supported frog-leg position.

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 1286 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The incision is made around the periphery of the flap, and dissection is carried down to the
deep fascia. The deep fascia is incised, and dissection continues from anterior to posterior,
deep to the deep fascia in the subfascial plane throughout.

Flap design

Fig. 10G-4 

When dissecting over the adductor muscle mass in the medial thigh, the surgeon should
elevate the fascia and epimysium over the muscle with the flap. As dissection progresses
posteriorly toward the buttock, the subcutaneous tissues become thicker. The position of
the pedicle can be checked with Doppler ultrasound during the dissection, and judicious
subcutaneous undermining toward the base of the pedicle can be performed to facilitate
rotation, taking care not to damage the vessels. If vaginal reconstruction is planned, the
flaps can be turned into a true island.

Flaps elevated with base of flaps deepithelialized

Fig. 10G-4 

Vaginal reconstruction requires subcutaneous tunneling into the vaginal defect to allow
safe and easy transposition of the flap.

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1287

ARC OF ROTATION
The flap can easily reach the perineum and line the entire vagina, based as it is close to the
perineal body. Complete vaginal reconstruction typically requires bilateral flaps. The flap
can also reach the proximal medial thigh and the perianal area toward the coccyx.

A B

Arc to groin/thigh Arc to perineum

Arc of bilateral island flaps to vagina

Fig. 10G-5 

FLAP TRANSFER
Transfer involves transposition into the defect. When used for vaginal reconstruction, this
flap is usually used as an island flap tunneled beneath the skin bridge medially to create a
suitable introitus, but direct transposition via an incision between donor and recipient sites
is also an option.

Tunnels to vaginal defect

Fig. 10G-6 

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 1288 Part II  Regional Flaps: Anatomy and Basic Techniques

FLAP INSET
For total vaginal reconstruction, bilateral flaps are used as tunneled island flaps. The apices
of the flaps are sutured together, with each flap creating an ipsilateral hemivaginal side wall
in its final position. This creates an anterior and a posterior seam within the neovagina. A
two-layer closure should be performed, incorporating Scarpa’s fascia in the deep layer as
well as a superficial cutaneous closure. The inset into the entrance of the vagina should be
spatulated to prevent stenosis. For partial defects, such as those seen in release after introital
stenosis or partial vaginectomy, unilateral flaps should be inset without tension with absorb-
able sutures within the vaginal vault. For cutaneous defects, regular skin closure techniques
are appropriate.

A B

Flaps tunneled into defect; medial edge of flaps Flaps sutured to each other to form neovagina
approximated to form posterior surface of neovagina

Fig. 10G-7 

DONOR SITE CLOSURE

The donor sites are simply approximated in two layers as oblique linear closures within the
groin creases. For simple transplantational flaps that are not tunneled, the closure of the
donor site should not compromise the base of the flap where the pedicle lies. Undermining
of the thigh skin in the subcutaneous plane can assist in a tension-free closure.

A B

Posterior base of each flap is sutured to peroneal Final reconstruction; flap donor sites closed directly
skin to form neovagina introitus

Fig. 10G-8 

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1289

CLINICAL APPLICATIONS
This 22-year-old woman had congenital stenosis of the vaginal vault.

C
B

D E F

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 ad-
dressed 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. (Case supplied by MRZ.)

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 1290 Part II  Regional Flaps: Anatomy and Basic Techniques

This 43-year-old woman was treated with external beam radiation for advanced anal cancer.
She subsequently developed introital stenosis, with constriction of her vaginal vault. She
had a one-finger introitus and was unable to have intercourse.

A B

C D

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 op-
tions 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. Dop-
pler 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. (Case supplied by MRZ.)

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1291

Pearls and Pitfalls

• The flap is extremely versatile when used for vaginal reconstruction, but it is rendered
unavailable if a radical vulvectomy has been performed.
• If the flap is passed through a subcutaneous tunnel into the perineal wound, care must
be taken to ensure that there is no compression of the pedicle.
• If an island flap is used, great care should be taken to prevent twisting of the pedicle.
• In males, the flap can be used for scrotal and urethral reconstruction or perineal wounds.
The named vessel of the flap in the male is the inferior scrotal artery.
• Care should be taken when elevating the flap and closing the donor site to avoid inter-
ruption of the groin lymphatics. Running out of dog-ears superiorly should be done at
the subcutaneous level.

Expert Commentary
Michael R. Zenn

Indications
The pudendal thigh (Singapore) flap is indicated when sensate reconstruction is required
in the perineal area, most commonly for vaginal or labial reconstruction.

Advantages and Limitations

This flap provides thin, pliable, sensate tissues with a favorable arc of rotation for vaginal
reconstruction. The donor site is also favorable, because it leaves a donor scar in the thigh
crease that is well tolerated. The limitation of the flap is its size: it may not provide enough
surface area for the reconstructive need. Cases of total vaginal vault reconstruction have
been described using bilateral flaps. In cases in which the patient has undergone previous
radiation therapy, the use of the flap is more limited because of scarring and the decreased
vascularity of the flaps when mobilized, and the fact that the tissues are less compliant.

Recommendations
Planning and Technique
When planning the Singapore flap for vaginal vault reconstruction, one must not underes-
timate the amount of tissue that is required. In cases of introital stenosis, release should be
performed first and the defect accurately measured. A flap design slightly larger than the
defect will help combat inevitable shrinkage and restenosis.
In elevating the Singapore flap, dissection proceeds quickly, and it is not necessary to
isolate and identify the source vessel. Therefore it is critical to maintain the base of the flap
and not overdissect it. This can be accomplished by maintaining a 2 to 3 cm diameter area
of attachment at the base that does not get undermined. The area overlying this is mobilized
in the subcutaneous plane, thus preserving the pedicle.
Continued

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 1292 Part II  Regional Flaps: Anatomy and Basic Techniques

Muscle

Fascia

Posterior labial artery

Fig. 10G-11  Incisions at the base must stay superficial to avoid disruption of the pedicle. Signifi-
cant undermining in the subcutaneous plane can be performed safely, which aids in flap mobilization
and rotation.

I strongly recommend opening a path from the donor site to the recipient site so a di-
rect transposition can be performed. There is little to be gained by making a subcutaneous
tunnel other than compression of the flap. After transposition of the flap to the defect, a
gentle vaginal stent is placed within the vaginal vault to ensure proper distribution of the
flap and to prevent hematoma or seroma. Care should be taken to avoid excessive pressure
on the flap from this bolster.

Postoperative Care
It is important to keep the area clean postoperatively. I recommend bathing with direct
cleaning of the area after 48 hours and daily thereafter. For the first 2 weeks, the vaginal
stent can be removed for hygiene and then gently replaced by the patient. Because of the
high degree of bacterial colonization in this area, one should have a high index of suspicion
for cellulitis, which should be treated aggressively.

Complications
The main complications related to the Singapore flap are necrosis of the tip, wound dehis-
cence, introital stenosis, and redundancy at the rotation point. Delay of the flap can improve
vascularity and limit problems with tip necrosis, especially when larger flaps are required.
This should also be done when a Singapore flap is used in an area that has previously been
irradiated. Wound dehiscence is managed conservatively with dressing changes allow-
ing secondary healing. Introital stenosis can be managed with dilators or additional flaps.
I strongly recommend leaving the areas of redundancy at the base of the flap at the time
of initial transposition. This redundancy contains the pedicle blood supply and should be
spared. I wait 4 to 6 months before considering revision, when the pedicle blood supply is
less critical and the flap has settled.

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1293

Bibliography With Key Annotations

Ajmal S, Yusuf K. Vaginoplasty with bilateral islanded pudendal thigh flaps. J Ayub Med Coll
Abbottabad 22:1-6, 2010.
Vaginal agenesis is the most common congenital deformity of the female pelvis, and vaginal reconstruc-
tion remains a surgical challenge. There are various surgical and nonsurgical techniques described for
the reconstruction of a neovagina. The authors used pudendal thigh flaps to reconstruct the vagina
in 19 patients; 11 (58%) were diagnosed with Mayer-Rokitansky-Kuster-Hauser syndrome and 8
(42%) with isolated vaginal atresia. The flaps were raised on either side of labia and sutured to each
other in midline to form a vaginal tube. This neovagina was inserted into the space between the rectum
and bladder and anchored to the deep pelvic tissues. One year postoperatively, the patients’ mean
vaginal length and width was 9.2 and 4.3 cm, respectively. This method of vaginoplasty is simple,
safe, and reliable and has shown satisfactory functional and cosmetic results. The reconstructed vagina
has a natural angle and is sensate in its lower part. No postoperative stenting or dilation is required.
The donor site in the groin can be closed primarily, and the scar is well hidden in the groin crease.
El-Khatib HA. V-Y fasciocutaneous pudendal thigh flap for repair of perineum and genital region
after necrotizing fasciitis: modification and new indication. Ann Plast Surg 48:370-375, 2002.
Necrotizing fasciitis is an aggressive, deep-seated infection of the fascia and subcutaneous fat with
necrosis of the overlying skin, and it is a toxin-mediated disease. The aim of this study was to review
13 cases of necrotizing fasciitis of the perineum and the external genitalia with regard to the diagnosis,
treatment, and methods of reconstruction of secondary defects. The study included 11 men and 2
women, 35 to 67 years of age. All patients presented to the plastic surgery unit with huge secondary
defects of the urogenital region, upper thigh, and lower abdomen after being excised initially by general
surgeons. Eight patients were treated with bilateral flaps, and the unilateral flap was used in two
patients. The V-Y island fasciocutaneous flap, used to resurface the urogenital region after necrotizing
fasciitis, is considered a new indication. The V-Y axial-pattern design of the flap is also considered
a new modification, which enables the flap to be advanced and tailored nicely in the midline. The
idea of using the V-Y-plasty design is raised because the perineum has a pair of symmetrical anatomic
structures. In addition, this procedure conserves tissue and the flap donor site is closed primarily without
tension. Both aesthetic and functional results were satisfactory.
Ganatra MA, Ansari NU. Pudendal thigh flap for congenital absence of vagina. J Pak Med
Assoc 55:143-145, 2005.
The authors reported their experience with pudendal thigh flap reconstruction in five patients with
congenital absence of the vagina. In all patients bilateral pudendal thigh flaps based on the posterior
labial artery, a branch of internal pudendal artery, were raised on either side of labia. These were
sutured in the midline and inserted into the neovagina created by dissection between the rectum and
urinary bladder. Postoperative problems were minor, and the reconstructions achieved good anatomic
and functional results.
Huang JJ, Han CM, Lee CL, et al. Pedicled unilateral external pudendal artery perforator
flap: a new technique for reconstruction of congenital vagina agenesis. Plast Reconstr Surg
125:129e-130e, 2010.
Jin B, Hasi W, Yang C, et al. A microdissection study of perforating vessels in the perineum:
implication in designing perforator flaps. Ann Plast Surg 63:665-669, 2009.
Eleven adult cadavers (22 sides) were dissected under an operating microscope (103). Microstructures,
including perforating arteries, venae comitantes, vascular anastomoses, and cutaneous nerves, were
measured with a sliding caliper (accurate to 0.2 mm). There were four relatively constant perforating
arteries in the perineum: inguinal and perineal perforating branches of the superficial external pudendal
artery, a perforating branch of the anterior cutaneous branch of the obturator artery, and a perforat-

10g_Pud-Thigh_r7b_bs_1280-1296.indd 1293 2/3/2012 5:44:26 PM

 1294 Part II  Regional Flaps: Anatomy and Basic Techniques

ing branch of the lateral branch of the posterior scrotal (pudendal) artery. All four arteries were direct
perforating branches. These perforating arteries and accompanying veins overlapped with each other
and formed the upper, middle, and lower parts of the vascular anastomosis in the deep fascia above
the adductor wall. There were four important cutaneous nerves in the region originating from the fol-
lowing nerves: the genitofemoral nerve, ilioinguinal nerve, posterior scrotal (labial) major nerve, and
rami perineales nervi cutanei femoris posterioris. The perineum has abundant blood supply, venous
return, and innervation. Because of its covert location and maneuverability, a perforator flap from this
region is a good source of donor tissue for perineal reconstruction.
Karaçal N, Livaoglu M, Kutlu N, et al. Scrotum reconstruction with neurovascular pedicled
pudendal thigh flaps. Urology 70:170-172, 2007.
Scrotal defects resulting from many factors, including accidents, Fournier’s gangrene, and gunshot
injuries, present difficulties in management and reconstruction. Antibiotic therapy must be given
to all patients, and if necessary, vigorous debridement must be performed. Because of the abundant
vascularity of the region, local wound dressing results in dramatically rapid recovery of the wounds.
In unsuitable conditions that prevent primary closure of the scrotal skin, thigh flaps may be used.
Proximally based neurovascular pudendal thigh flaps were used in 10 scrotal defects. The maximum
dimensions of the elevated flaps were 20 by 15 cm. All donor areas were closed primarily. Satisfactory
results were achieved in all patients, especially in terms of sensitivity.
Ninomiya R, Kishi K, Imanishi N, et al. Reconstruction of vulva using pudendal thigh gluteal
fold bilobed flap. J Plast Reconstr Aesthet Surg 63:e130-e132, 2010.
To reconstruct a large defect of the vulva, the authors combined the gluteal fold and pudendal thigh
flaps and made a bilobed flap. Using this gluteal fold pudendal thigh bilobed flap, they were able to
reconstruct the vagina with sufficient depth and width. The surrounding skin defect was simultaneously
reconstructed. Sensation was intact in all areas of the reconstruction. The sutured lines of both donor
sites were hidden in the gluteal and inguinal folds. Thus the gluteal fold pudendal thigh bilobed flap
seems to be ideal for reconstructing large vulvar defects.
Oosterlinck W, Monstrey S. The pudendal thigh fasciocutaneous flap to cover deep perineal
defects, combined with reconstruction of the posterior urethra. BJU Int J 89:133-135, 2002.
Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to defect classification
and flap reconstruction. J Surg Oncol 94:515-521, 2006.
Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased
use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. Because patients
are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function
and body image are fundamental goals. The authors provided an algorithmic approach to defect clas-
sification and flap reconstruction. Careful appreciation of the specific defect facilitates flap choice. There
are two basic defect types: partial (type I) and circumferential (type II) defects. These defect types can be
further subclassified: type IA defects are partial and involve the anterior and/or lateral wall; type IB
defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential,
involving the upper two thirds of the vagina; type IIB defects represent circumferential, total vaginal
resection, most commonly following pelvic exenteration. Using this method of defect classification, three
pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal
thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary
approach to patient care, rapid wound healing, restoration of the pelvic floor, and reestablishment of
sexual function may be most reliably achieved.
Sathappan S, Rica MA. Pudendal thigh flap for repair of rectovaginal fistula. Med J Malaysia
61:355-357, 2006.
The pudendal thigh flap or the Singapore flap is a versatile flap that can be used in the repair of
rectovaginal fistulas. Apart from the potential problem of hair growth, this neurovascular flap proves
to be surprisingly simple in technique. It is robust and has a high potential to produce normal or near-
normal function.

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 Abdomen  •  10G: Pudendal-Thigh (Singapore) Flap 1295

Tham NL, Pan WR, Rozen WM, et al. The pudendal thigh flap for vaginal reconstruction:
optimising flap survival. J Plast Reconstr Aesthet Surg 63:826-831, 2010.
Although the pudendal thigh fasciocutaneous flap is reliable for perineal reconstruction when small
but is unreliable when large flaps are raised. Large flaps in particular are associated with an increased
incidence of apical necrosis. Thorough descriptions of the vascular anatomy of this flap have been lack-
ing from the literature; the authors aimed with their study to provide the anatomic basis for vascular
problems and for techniques to maximize flap survival. Five fresh human cadaveric pelvis specimens
were studied. Lead oxide injectant allowed radiographic and dissection analysis of the arterial anatomy
of the integument of the perineum. A consistent pattern of vascular supply was found in all specimens.
The blood supply to the pelvic floor was supplied sequentially by the posterior labial/scrotal arteries,
cutaneous branches from the anterior branch of the obturator artery, and branches from the external
pudendal arteries. These vessels ran close to the midline, medial to the pudendal thigh fasciocutane-
ous flap. The posterior labial/scrotal arteries were deep to Colles’ fascia and the branches from the
obturator artery and external pudendal arteries were located superficial to Colles’ fascia. The study
has demonstrated that the pudendal thigh fasciocutaneous flap is a three vascular territory flap and
that the pedicle is situated close to the midline. This could explain why regions of the pudendal thigh
fasciocutaneous flap may have a potentially precarious blood supply and suggests that the flap should
be designed more medially. Given the third territory of supply to the apex of the flap, a delay procedure
may help to avoid flap necrosis.
Yun IS, Lee JH, Rah DK, et al. Perineal reconstruction using a bilobed pudendal artery per-
forator flap. Gynecol Oncol 118:313-316, 2010.
To reconstruct the perineal region, including the urogenital and anal triangle, which differ from each
other in tissue characteristics and function, the authors applied pudendal artery perforator flaps with
a bilobed flap design. This design improved the arc of flap rotation and the mobility of the flap so it
could cover wide and deep defects. Moreover, it could preserve the characteristics of each triangle. This
study enrolled a total of 15 female patients who had undergone perineal reconstruction with pudendal
artery perforator flaps: 7 of them had vulvar cancer; 7 had extramammary Paget’s disease; and 1
had a rectovaginal fistula. Bilobed flaps were used in 9 patients, and unilobed flaps were used in 6.
All flaps survived during the entire follow-up period (average 4.6 months). Flap sizes ranged from
3 by 4 cm to 13 by 12 cm. The reconstructed areas were in good functional and aesthetic conditions.
The bilobed pudendal artery perforator flap can preserve the functional, morphologic and cosmetic
characteristics of the defect area.
Zorn KC, Bzrezinski A, St-Denis B, et al. Female neo-urethral reconstruction with a modified
neurovascular pudendal thigh flap (Singapore flap): initial experience. Can J Urol 14:3449-
3454, 2007.
Complete urethral reconstruction in women is an extreme challenge for urologists. The authors reported
a new approach using a modified neurovascular pudendal thigh (Singapore) flap for neourethral recon-
struction in two patients. A Singapore flap was raised and transposed to the vagina in two patients
whose urethras had been destroyed by several previous urogynecologic procedures. In one case, the flap
was tubularized distally and anastomosed proximally to the bladder neck. In the second case, the
flap was used to cover a urethroplasty inlay. At 24 and 27 months, respectively, the two flaps were
viable and appeared to fulfill their designated roles. The first patient developed a bladder neck stricture
2 months after surgery, and urethral dilation was performed successfully. Urinary incontinence still
remains an issue in one of these two patients, and further continence procedures have been used. It has
been found that the neurovascular pudendal thigh flap, initially described for vaginal reconstruction,
is an attractive technique to aid in complete female neourethral reconstruction. Further follow-up of
patients is necessary to address the issue of continence.

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 Chapter 11
Abdominal Viscera

Certain reconstructive situations require the use of specialized tissues for a successful
outcome, and the reconstructive surgeon has no anatomic bounds when accessing im-
portant donor sites. Surgeons’ comfort with general surgical principles allows the use
of intraabdominal-based flaps to facilitate the reconstruction of difficult defects while
minimizing donor site morbidity. Jejunal flap reconstruction has aided restoration of
esophageal continuity without compromising the stomach or the esophagogastric junc-
tion, while omental tissue, with its unique vascular and immunologic properties, has
proved to be a useful adjunct in head and neck, sternal, and even hand reconstruction.

Jejunal Flap
Omental Flap

11_Ch Opener_m1d_1297.indd 1297 2/7/2012 12:41:29 PM

 ANATOMIC LANDMARKS
Landmarks The jejunum is the segment of bowel linking the duodenum
with the ileum of the small bowel. The proximal segment should
start a minimum of 30 cm from the ligament of Treitz.
Size 7 to 25 cm 3 4 cm.
Function Absorption. Resection of a short segment of bowel will not af-
fect intestinal absorption.
Composition Bowel.
Dominant Pedicle Branches of the superior mesenteric arterial arcades.
Nerve Supply Autonomic and sensory fibers from the celiac and superior mes-
enteric plexuses.

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 Section 11A
Abdominal Viscera

Jejunal Flap

CLINICAL APPLICATIONS
Regional Use
Cervical/thoracic esophagus
Genitourinary
Distant Use
Head and neck
Thoracis
Specialized Use
Vaginal reconstruction
Bladder reconstruction

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 ANATOMY OF THE jejunAL FLAP

A B

Stomach Jejunum

Ligament
of Treitz
Jejunal
Superior segment Superior
mesenteric mesenteric Vascular
artery Vascular artery arcades
arcades

C D

Vena cava
Splanchnic
Superior nerve plexus
mesenteric
vein
Aorta

Superior
mesenteric
artery

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.
Dominant pedicle: Superior mesenteric artery

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 Abdominal Viscera  •  11A: Jejunal Flap 1301

Anatomy
Landmarks The jejunum is the segment of bowel linking the duodenum with the ileum. It
extends from the ligament of Treitz for a distance of 2.5 m (8 feet). The lumen
diameter is 4 cm. The bowel segment lies inferior to the greater curve of the
stomach and the transverse colon. It commences at the ligament of Treitz as the
duodenum passes from its retroperitoneal position to become the jejunum below
the body and tail of the pancreas. It lies in multiple folds before becoming the
ileum approximately 2.5 m from the ligament of Treitz.
Composition Bowel.
Size 7 to 25 cm 3 4 cm.
Function Absorption. Resection of a short segment of bowel will not affect intestinal
absorption.

Arterial Anatomy
Dominant Pedicle  Segmental via branches of the superior mesenteric artery
Branches of the superior mesenteric arterial arcades that originate from the source vessel in the
retroperitoneal space, passing up between the two leaflets of the mesentery. The vessels are encased
in variable amounts of fat, depending on the individual’s weight. Each artery is accompanied by a
vein. In the upper jejunum, the mesentery is short, and there is usually only one arch from which the
vasa recta radiate outward like the spokes of a wheel. Distally, there are usually at least two or three
major vascular arcades supplying the length of the jejunum. It is imperative that the interconnection
of the vasa recta be confirmed by direct examination before committing to a given flap length.
Regional Source  Superior mesenteric artery.
Length  5 to 7 cm.
Diameter  2 to 2.5 mm.
Location  At the base of the mesentery, distal to the ligament of Treitz.

Venous Anatomy
There are single veins accompanying the arterial circulation; the average venous diameter is 2 to
2.5 mm, with fragile venous walls in some patients.

Nerve Supply
Autonomic and sensory fibers from the celiac and superior mesenteric plexuses.

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 1302 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Jejunal Flap

Radiographic view

Fig. 11A-2 

Dominant pedicle: Superior mesenteric artery (D)

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 Abdominal Viscera  •  11A: Jejunal Flap 1303

Flap Harvest
Design and Markings
The flap is exposed either through a vertical upper midline abdominal laparotomy incision
or through a laparoscopic approach.

A B

Fig. 11A-3 

Patient Positioning
The patient is positioned in the supine position for both flap harvest and inset. Given the
potentially lengthy nature of these procedures, careful attention should be paid to protect-
ing pressure points. Arms are usually tucked at the patient’s sides.

Fig. 11A-4 

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 1304 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

The abdominal cavity is approached through either an open laparotomy incision in the up-
per midline, or via a laparoscopic technique. A suitable length of jejunum should be located
within the first 30 to 60 cm of the ligament of Treitz. The length of the flap is determined
by measuring the defect and the tissue need. For esophageal reconstruction, it is helpful
to add at least 2 to 3 cm of flap length to allow creation of an external monitor segment.
The bowel is held up to posterior illumination so the vascular arcades to the bowel loops
can be seen. The appropriate arcades have been identified, and the anterior and posterior
leaflets of the mesentery are carefully incised to create a wedge-shaped harvest of the con-
tained vessels. All side branches extending across the mesenteric harvest should be ligated
with vessel clips or cauterized with a Harmonic scalpel. Hemostasis must be meticulously
secured, because mesenteric bleeders can result in catastrophic postoperative hemorrhage.
Once the wedge of mesentery with its contained vessels has been isolated, the bowel is
prepared for resection. Anastomotic stapling devices are clamped across the desired tran-
section points and are fired. This results in the isolation of the jejunal flap on its vascular
pedicle. The stapled proximal and distal bowel ends are then brought together and anasto-
mosed with anastomotic staplers to reconstitute small bowel integrity within the abdomen.
The isolated bowel segment should be marked to identify the proximal and distal ends so
that a prograde direction can be maintained when the bowel is inset into the esophagus.
Once the recipient site is ready, the isolated jejunal segment can be transected at its pedicle
base and transferred to the recipient site for microvascular anastomosis. Typically the flap is
anastomosed to the internal mammary vessels. Following reestablishment of vascular flow
to the jejunal segment, it can be sewn into the ends of the pharyngoesophageal defect to
restore continuity of the esophagus. Whenever possible, it is useful to dissect a 2 to 3 cm
segment of proximal jejunum on a single vascular arcade to exteriorize as a monitor of flap
viability. Once the flap is deemed stable at 5 days, the external monitor segment can be tied
off at the bedside and resected.

Identification of proximal jejunum

Fig. 11A-5 

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 Abdominal Viscera  •  11A: Jejunal Flap 1305

B C

Exposure and isolation of mesenteric pedicle Jejunal flap design

Enteroenterostomy to reestablish bowel continuity

Fig. 11A-5 

External monitor bowel

segment Jejunal free flap

Esophagus

Jejunal free flap with external monitor bowel segment attached for postoperative monitoring

Fig. 11A-6 

11a_Jejunal_r5_cah_1298-1323.indd 1305 2/8/2012 2:56:59 PM

 1306 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variants
• Segmental flap
• Jejunomesenteric flap
Segmental Flap
The jejunum is usually used as a complete tube for pharyngoesophageal reconstruction or
vaginal reconstruction. Less commonly, it may be split along its antimesenteric border to
create a larger patch to repair a partial esophageal defect or for intraoral lining.

Jejunomesenteric Flap
The jejunomesenteric flap is a combination of a short segment of jejunum carried on a wider
segment of mesentery. Used for soft tissue coverage or fill. With this modification, a long
segment (25 cm) of bowel is harvested. The central 8 to 10 cm is maintained as a bowel loop
while the proximal and distal portions of bowel are discarded leaving mesenteric flanges
carried on the same vascular pedicle. The bowel is used for interposition as usual, while the
mesenteric components can be used for additional soft tissue cover.

A B

Split jejunal flap design Combined jejunomesenteric flap design

Fig. 11A-7 

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 Abdominal Viscera  •  11A: Jejunal Flap 1307

Arc of Rotation
Because of its short pedicle length, the arc of rotation is somewhat limited. A pedicled flap
may be used in short gut syndrome, vaginal reconstruction, or bladder reconstruction.
Pedicled Roux-en-Y jejunal flaps have been described for cervical and thoracic combined
esophageal reconstruction, often requiring additional microsurgical anastomosis in the
neck to ensure vascularity. Generally, however, the flap is used as a free flap to the pha-
ryngoesophagus.

Flap Transfer
The flap is transferred to its recipient site based on usage. For vaginal and bladder needs, one
must exercise care to avoid internal hernias by closing the mesenteric defects created. The
serosa is used to help tack and support areas of inset or suture line. For cervical esophageal
reconstruction, the flap is based on the location of the pharyngoesophageal defect. Usually
these are upper third defects of the esophagus, but the flap may be interposed at any point
along the length of the esophagus as needed. Because of pedicle length constraints, vascu-
lar anastomosis should be made within the immediate vicinity of the esophageal defect to
provide a completely tension-free bowel repair. Any tension on the anastomotic lines will
result in anastomotic leaks with the potential for mediastinitis.

Flap Inset
For esophageal reconstruction, the proximal and distal bowel anastomoses are performed
before the microsurgical anastomosis. A feeding tube should be placed before final closure.

Donor Site Closure

Before closing the abdomen, the surgeon must repair the mesenteric defect within the
donor site to prevent the risk of internal hernia formation. This is done with either catgut
or Vicryl sutures, and care must be taken not to compromise the vessels remaining within
the mesentery. Abdominal closure is performed as dictated by the surgical approach to the
peritoneal cavity: midline laparotomy incisions are closed as a mass closure with permanent
suture, whereas laparoscopic incisions are closed in layers with fascial repair.

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 1308 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 58-year-old man presented with a proximal esophageal fistula complicating colonic
interposition grafting for esophageal cancer resection.

A B

D E

Fig. 11A-8  A, Preoperative view of patient with proximal

esophagocolonic stricture after previous colon interposition.
B, Intraoperative view of exposed proximal colonic anasto-
motic stricture resection. C, Jejunal interpositional flap sewn
in with a proximal bowel segment for use as a perfusion mon-
itor on the skin surface. D, Preoperative radiograph demon-
strating extensive tight stricture of colonic interposition seg-
ment. E, Postoperative radiographs of free barium passage
down healed jejunal interposition. (Case supplied by GJ.)

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 Abdominal Viscera  •  11A: Jejunal Flap 1309

This 53-year-old man had a history of squamous cell carcinoma of the pharynx for which
he had been treated 8 years earlier by resection and reconstruction with a radial forearm
free flap. He presented with a recurrence in the pharynx and required a completion laryn-
gopharyngectomy. He underwent reconstruction with a free jejunal transfer as a free flap.

A C

Fig. 11A-9  A, The bowel was prepared for transfer while still perfusing in the abdomen. The mea-
surements 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 ob-
serving 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. (Case supplied by MRZ.)

11a_Jejunal_r5_cah_1298-1323.indd 1309 2/8/2012 2:57:04 PM

 1310 Part II  Regional Flaps: Anatomy and Basic Techniques

This 21-year-old had a corrosive injury of the esophagus after swallowing an alkaline solu-
tion. He underwent thoracic and cervical esophagus reconstruction with a pedicled colon
flap at another institution. He presented to our institution 2 years later with a stricture
spanning 7 cm at the cervical esophagus region.

C D

Fig. 11A-10  A, Preoperatively the patient had a feeding tube and a neck scar. He underwent at-
tempted 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.

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 Abdominal Viscera  •  11A: Jejunal Flap 1311

About 5 months later, the patient presented with discomfort in the upper left chest region.
A CT scan revealed a small fluid collection and a fistula tract from the cervical esophagus−
jejunum anastomosis, with no connection to the skin. The patient underwent exploration
of the area.

E F G

H I

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. (Case courtesy Samir
Mardini, MD.)

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 1312 Part II  Regional Flaps: Anatomy and Basic Techniques

This 56-year-old man underwent resection of part of the cervical esophagus, resulting in
a circumferential esophageal defect.

A B

C D

E F

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. (Case courtesy Samir Mardini, MD.)

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 Abdominal Viscera  •  11A: Jejunal Flap 1313

Pearls and Pitfalls

• The proximal division of the jejunum should be made distal enough from the ligament of
Treitz to allow creation of an easily accessible, tension-free anastomosis of the remaining
bowel following flap harvest.
• More distal harvest allows for the incorporation of more vascular arcades as the mesen-
teric length increases.
• Every effort should be made to ensure that all bowel edges, both in the abdominal donor
bowel and in the flap margins, have adequate vascular inflow. This can be greatly facili-
tated by the use of indocyanine green fluorescence imaging. Repair of poorly vascularized
bowel ends will result in anastomotic leaks with potentially life-threatening complications.
• The peristaltic direction of the donor segment of bowel should be marked to ensure
prograde peristalsis in the reconstructed esophagus once repair has been completed.
• A nasogastric feeding tube should be passed through the flap lumen before bowel anas-
tomosis.
• Leaks in the transferred segment are less likely if a stapled anastomosis can be performed
at each end. This can be difficult to achieve within the tight confines of the mediastinum
and if a hand-sewn repair is performed, it must be done meticulously, preferably with
preplacement of all sutures before these are tied down. This approach will minimize leaks.
• The mesenteric defect within the donor site must be repaired carefully to prevent internal
hernia formation.

Expert Commentary
Samir Mardini, Karen Kim Evans, Hung-Chi Chen

Indications
In the early 1900s, the jejunum was used as a pedicled flap for reconstruction of the thoracic
esophagus. Once microsurgical reconstructions became possible, surgeons began to adopt the
jejunal flap as a free flap because of its unique anatomic advantages. It is tubed, lubricated,
and has peristaltic activity; moreover, it has a reliable blood supply, and its harvest is simple
and expedient. The jejunal flap has proved successful in the reconstruction of various types
of complex defects, including the esophagus and vagina.

Advantages and Limitations

The jejunal flap provides a wealth of advantages: the tubed nature of the jejunum and its
peristaltic activity provide functional benefits when used for pharyngeal and esophageal
reconstruction. Its intrinsic peristaltic activity may help propel a food bolus, and its tubed
structure minimizes complications because of the low number of suture lines necessary
to complete the reconstruction. Flap harvest is quick and simple, and the jejunal diameter
approximates that of the esophagus.
As a free flap, the vascular pedicle can be lengthy (up to 15 to 20 cm), with vessels of
suitable external diameter (artery 1.5 to 2.5 mm; vein 2 to 4 mm). The jejunum can be
considered relatively sterile, with minimal potential of developing diseases, such as cancer
Continued

11a_Jejunal_r5_cah_1298-1323.indd 1313 2/8/2012 2:57:14 PM

 1314 Part II  Regional Flaps: Anatomy and Basic Techniques

or atypical polyps. The accompanying mesentery can be employed to cover vital neck
structures and can provide a suitable bed for skin grafting. The length of jejunum available
for transplantation ranges from 7 to 25 cm, based on one pedicle.
As a pedicled flap, the jejunum can replace the entire length of the esophagus; however,
in those cases it becomes necessary to supercharge the arterial inflow and venous outflow
in one or two places. The jejunum can be split along its antimesenteric border, creating
a flat and well-vascularized mucosal structure that can function as a patch. This patch of
jejunal tissue is suitable for reconstruction of partial circumferential defects or for provid-
ing oral lining.
A jejunal flap can be harvested based on one vascular pedicle and split into two segments
that can be used to reconstruct two different defects or to provide a monitor segment. This
flap is ideal for vaginal reconstruction, because it is lubricated and tubular.
The surgeon must also be aware of disadvantages associated with the use of this flap.
In experimental models, the jejunal flap may be more susceptible to the harmful effects of
ischemia. Clinically, an ischemic time of about 2 hours can be tolerated without permanent
effects on the outcome of the reconstruction.
The patient will require either a laparotomy or a laparoscopically assisted approach to
the abdomen—techniques that carry their own inherent risks. Reports have shown a mor-
tality rate between 2.4% and 5% when using jejunal flaps for reconstruction of esophageal
defects. This rate is similar to using gastric pull-up and colonic interposition and may be
related to the type of patient population and the nature of the disease process itself rather
than the type of flap used. Fistula rates continue to range between 1.8% and 30%, which
in many series is lower than that of skin flaps used for the same purpose.

Anatomic Considerations
The jejunum has a segmental blood supply. The overall length of the pedicle, the jejunal
artery (arising from the superior mesenteric artery), may appear to be between 15 and 20 cm,
but this length is shortened by the vascular loop configuration of the blood supply. There is a
complex branching network composed of multiple, consecutive, tiered vascular loops called
arcades (see Fig. 11A-12). The primary order arcades run parallel to one another within the
layers of the mesentery. These parallel vessels divide in two branches, one ascending and
one descending branch, that course parallel to the intestine. These branches then unite with
the adjacent branches coming from the closest jejunal arteries, thus forming an anastomotic
arcade. From the last arcade (which is the last arch parallel to the intestine) arise the vasa
recta, which form the direct and terminal blood supply to the jejunum.

Fig. 11A-12  The vascular arcades within

the mesenterium; a closeup view of the
terminal branches, the vasa recta.

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 Abdominal Viscera  •  11A: Jejunal Flap 1315

The vasa recta are terminal vessels measuring approximately 4 to 6 cm. One or two
vasa recta supply a distinct area of jejunum (approximately 1 cm per vasa recta unit). It is
very important to note that the veins within the mesentery are thin and fragile, and care
must be taken during harvest, especially in larger patients with a thick mesentery.

Personal Experience and Insights

The jejunal flap serves a distinct role in reconstructive surgery. We have used it extensively
in the reconstruction of cervical esophageal defects and total vaginal reconstructions. We
have also found it to be useful in patching a defect in the esophagus after partial resection
or after stricture release. Skin flaps provide a reasonable alternative for reconstructing de-
fects requiring a patch of tissue so that the abdominal cavity is not violated. However, if
intraabdominal surgery is performed for other reasons, we favor harvesting the jejunum,
filleting it open and using it as a patch. We have used the jejunal flap as a pedicled flap to
patch partial vaginal defects.
In patients who require total esophageal reconstruction who do not have a pedicled
stomach or colon flap available, the pedicled jejunal flap can be a great solution. When us-
ing the jejunum to reconstruct a hypopharyngeal defect, the proximal end can be double-
barreled to create a better size match to the proximal end. We have used the jejunum in
other types of reconstructions, such as creation of a voice tube and intraoral lining when
radiation has created severe intraoral dryness.

Fig. 11A-13  Double-barreled jejunum.

Controversy remains as to whether the benefits of intestinal flaps outweigh the risks
for esophageal reconstruction compared with skin flaps. In our experience, patients under-
going esophageal reconstruction with intestinal flaps have better functional outcomes in
regard to swallowing function, fistulas, and stricture formation. When a voice prosthesis
is placed between the trachea and neoesophagus (jejunum or skin) for voice rehabilitation,
patients have a less “wet” voice if skin flaps are used. Entering the abdomen is in itself a
low-morbidity procedure, particularly when laparoscopic techniques are used. However,
harvesting the anterolateral thigh perforator flap has lower donor site morbidity compared
with the jejunal flap, particularly if the patient has previously undergone major abdominal
surgery. In those cases, using the anterolateral thigh flap might be more reasonable.
We do not favor the use of the radial forearm flap in patients who do not absolutely
require us to use it, because we have found that the donor site scar is very unsightly and can
be a source of problems in areas where cold weather is predominant.
Continued

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 1316 Part II  Regional Flaps: Anatomy and Basic Techniques

We have seen many surgeons who begin performing microvascular reconstructions in

their own practice and abandon the use of jejunal flaps early in their career. We attribute
this to having one or two failures early on, which have discouraged them from continu-
ing to use this flap. We think that these failures occur from simple and avoidable technical
problems. We will attempt to outline some of them based on our experience with over 500
intestinal transfers including jejunum and colon:
• Flap harvest is simple and quick. However, it must be performed with special attention
at every step. Small bleeding vessels can create a hematoma within the mesentery that
can disturb blood supply to the jejunum and/or distort the anatomy and ultimately
create a kink in the main pedicle.
• Any traction on the pedicle must be completely avoided, because it can create unno-
ticed intimal damage and eventual spasm and thrombus formation. Therefore vessel
loops are avoided; they can produce uncontrolled pulling on the pedicle and cause
kinking when the flap is left in position in the abdomen after harvest is complete. We
have seen one flap undergo complete necrosis after the surgeon left the vessel loops in
place attached to a mosquito forceps after completely isolating the flap and the pedicle
and moving to the neck to find recipient vessels. The surgeon came back to detach
the flap 2 hours later and found the flap to be cyanotic and nonusable.
• The pedicle must not be twisted after the flap has been completely dissected and is
still in the abdominal cavity. The surgeon should pay close attention to the position
of the flap after complete isolation of it and the pedicle if it is to be left in the abdo-
men while another part of the procedure is performed.
• The proximal part of the pedicle should be dissected as the last step in the procedure,
because this will help to avoid tension on the vessels (the mesentery can take some
of the tension). Dissection of the proximal part of the vein in particular can have
bleeding, usually in a deep hole, and it is better to have everything completely ready
so that the vessels can be clamped and ligated in case bleeding is encountered.
• Abdominal donor site morbidity can be minimized by performing a meticulous
anastomosis of the proximal and distal anastomosis of the jejunum when restoring
intestinal continuity and meticulous closure of the abdominal wall.
• The defect and recipient vessels must be completely ready for inset and vascular
anastomoses before flap harvest is completed to minimize ischemic time.
• The more challenging bowel anastomosis should be performed before the micro-
vascular anastomosis is done. We have started anastomosing the proximal end first,
performing the microvascular anastomosis, then the distal anastomosis. After restoring
blood flow to the flap, the jejunum undergoes physiologic lengthening, and one can
more accurately assess the appropriate length. Now we sometimes place the jejunum
in the correct position, secure it in place using external sutures, secure the mesentery
in position using 5-0 absorbable sutures, perform the microvascular anastomosis, then
perform the proximal and distal anastomosis of jejunum to the esophagus. The key is
not to allow the pedicle to move during the bowel anastomoses; otherwise, arterial
spasm ensues, and a thrombus will form.
• When performing the microvascular anastomosis, the vein is anastomosed first,
the clamps are removed, and then the artery anastomosis is performed. The artery
can be anastomosed first; however, the clamps should not be released until the vein
anastomosis is complete. The jejunum does not tolerate venous congestion as well
as other types of tissue.

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 Abdominal Viscera  •  11A: Jejunal Flap 1317

• Strictures can be lessened by performing oblique anastomoses or inserting a segment

of vascularized tissue that widens the junction.
• We place stents that traverse the flap. One is used to decompress the stomach, and
the other is placed with the holes positioned within the lumen of the jejunum. The
key is not to allow swelling in the jejunum. If this happens, distortion of the flap
may occur, which can change the position of the pedicle and possibly create a kink.
• The closure should be very loose over the jejunum. One should not hesitate to place
a wet dressing or a skin graft (no bolster).

A B C D

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 jeju-
num 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 circumfer-
ential scar that would constrict is avoided.

Recommendations
Technique
Midline abdominal incisions are used. After entering the abdominal cavity a segment of
jejunum is identified for harvest. This segment is the second or third loop, which usually
begins 25 to 30 cm distal to the ligament of Treitz. The segment is then harvested based
on the second or third jejunal artery. The proximal and distal ends must be marked so that
the segment is transferred in the same isoperistaltic, anatomic orientation. We usually place
one suture on the antimesenteric side at the proximal end of the flap and two sutures on
the antimesenteric side at the distal end of the flap to identify the proximal and distal ends.
For reconstructions requiring a pedicled jejunum, the fourth jejunal loop is identified
as the distal part of the flap to be harvested. The third jejunal artery is ligated and divided
close to its origin from the superior mesenteric artery, and both the third and fourth vascular
pedicles can be used for supercharging. If the reconstruction does involve the third and fourth
loop and two vacular pedicles are available for supercharge, the artery and vein of one of
those pedicles are sutured first to neck vessels (transverse cervical or superior thyroid artery
and external jugular vein) or chest vessels (internal mammary artery and vein), and the color
of the flap is monitored. If color is good, one can avoid anastomosing the second vascular
pedicle. The mesentery of the jejunum is then divided at the serosal border between the
second and third jejunal artery, allowing the conduit to completely unfurl. This straightens
the sinusoid turns in the small bowel caused by a naturally foreshortened mesentery. Any
length of jejunum from 7 to 25 cm may be transferred on one vascular pedicle. The bowel
lumen diameter is 3 to 5 cm. Continued

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 1318 Part II  Regional Flaps: Anatomy and Basic Techniques

After a midline laparotomy is done, the site of jejunal transection is marked either by
sutures or with methylene blue. One must remember to identify the proximal portion of
the jejunal segment (we use sutures, as described above) to perform the inset in an iso-
peristaltic position. The mesentery is scored with electrocautery at a low setting, from the
bowel margin toward the center to expose the vascular pedicle. The mesentery is completely
divided on each side and the vasa recta are then selectively clamped, ligated, and transected.
In this way, a fan-shaped segment of mesentery attached to the jejunal segment is dissected
and attached only to the donor vascular pedicle. Special care must be taken in patients with
extensive mesenteric fat to avoid damaging branches of the mesenteric vessels. Vessel loops
are not recommended, because they produce spasm and trauma to the pedicle vessels.
The bowel is then clamped using atraumatic bowel clamps both proximally and distally
at the sites previously marked. The jejunal segment is isolated on a single jejunal artery and
vein and is observed for adequate perfusion and peristalsis. Harvest of the bowel is performed
using standard general surgery stapling devices, and intestinal continuity is reestablished
using either side-to-side or end-to-end anastomoses.
Under loupe magnification, the jejunal artery and vein, arising from the superior mes-
enteric vessels at the root of the mesentery, are identified and dissected free from the sur-
rounding tissues. Careful dissection of the jejunal vein is essential, because the wall is thin
and fragile. The dissection begins from the superior mesenteric vessel toward the mesenteric
border of the jejunal segment, at the sites of future proximal and distal bowel transection.
We reserve dissection of the artery and vein at its proximal end until the end of the flap
harvest, when the flap is completely ready for transfer and the recipient site is prepared. This
allows immediate clamping, transection, and transfer of the flap if bleeding problems occur.
When the recipient site dissection is complete, the jejunal segment is harvested from the
abdomen after dividing its blood supply at its origin from the superior mesenteric vessels.
The jejunal artery at the donor site is tied and suture ligated.

Avoidance of Complications and

Postoperative Care
Choose a large recipient vein. For head and neck reconstruction, choose a large branch off
1. 
the internal jugular, or use the external jugular. The jejunal vein can also be sutured in an
end-to-side fashion to the internal jugular vein if the other two options are not available.
2. Work fastidiously and decrease ischemic time. Expose the recipient vessels and prepare the defect
before dividing the flap pedicle. Once this is done, the jejunal flap can be transferred.
If warm ischemic time is prolonged, the detached jejunal segment can be cooled by a
double-lumen glass tube placed within the bowel lumen. Cooled saline solution (4° C) is
run continuously through the tube. (This is rarely necessary in our practice, because we
are able to maintain ischemic time at less than 2 hours.) The intestine segment is covered
with laparotomy sponges moistened with normal saline solution. We anastomose the
vein first, clamps are released, and the arterial anastomosis is performed. If the arterial
anastomosis is performed first, we prefer not to release the vascular clamps until both
the artery and vein anastomoses are completed. Damage to the intima can occur if the
vascular clamp is in place for a prolonged period (over 1 hour). The arterial clamp is not
released before performing the venous anastomosis because the jejunal mucosa does not
tolerate venous congestion very well, and permanent damage can occur.

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 Abdominal Viscera  •  11A: Jejunal Flap 1319

Create a watertight closure, especially in head and neck cases. Use a two-layered closure be-
3. 
tween the jejunal segment and pharynx and ensure proper positioning after surgery to
prevent hyperextension of the neck. After the procedure, the patient must avoid violent
coughing, which can damage the closure.
Avoid strictures. We usually increase the diameter of the esophagus by making a small cut
4. 
at the thoracic esophagus and use sutures instead of a stapling device for inset. Insert two
intraluminal drains for stenting and drainage. If a second-layer anastomosis cannot be
performed, we use excess mesentery to seal off the upper and lower anastomotic sites.
Primary healing is important for future function, and a leak will cause inflammation
and later stricture.
Avoid tight closure of the neck wound. If necessary, a local flap (deltopectoral or pectoralis
5. 
major) can be used for coverage, or the intestine is left uncovered and wet-to-dry dress-
ings are used. Alternatively, a skin graft can be placed on the exposed segment of jejunum
without a bolster dressing. External compression can compromise the blood supply.
6. Place drains. We place drains in the neck before closing the skin. Nonsuction drains are
used on the side of the recipient vessels, and bulb suction drains are used on the side
opposite the recipient vessels. In addition, we ask the nurses to pay close attention to
suctioning saliva from the patient’s mouth for the first 2 or 3 days. Saliva accumulation
can cause distention of the jejunal segment.

Reference
Chen HC, Splimbergo SS, Evans KK, Mardini S. Jejunum flap. In Wei FC, Mardini S, eds.
Flaps and Reconstructive Surgery. Philadelphia: Elsevier, 2009.

Bibliography With Key Annotations

Oki M, Asato H, Suzuki Y, et al. Salvage reconstruction of the oesophagus: a retrospective
study of 15 cases. J Plast Reconstr Aesthet Surg 63:589, 2010.
This paper reviewed the authors’ experience with 15 cases of salvage reconstruction of the esophagus
after prior cancer treatment or aortoesophageal fistula; the cervical esophagus was reconstructed in five
cases, and the cervicothoracic esophagus in 10. In four cases of cervical esophagus and six of cervico-
thoracic esophagus, free jejunal transfer was performed; a thoracic esophagus was also reconstructed
with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge
in four cases. In one case, a cervical esophageal defect was reconstructed with a latissimus dorsi myo-
cutaneous flap. A deltopectoral flap to cover the skin defect was used in three cases. In three cases, a
second salvage operation was necessary because of flap necrosis caused by unreliable recipient vessels
resulting from scar formation and persistent inflammation. Successful restoration of the esophagus and
oral alimentation was achieved in 11 cases.
Sharp DA, Theile DR, Cook R, et al. Long-term functional speech and swallowing outcomes
following pharyngolaryngectomy with free jejunal flap reconstruction. Ann Plast Surg 64:743,
2010.
This study evaluated long-term functional outcomes following pharyngolaryngectomy and free jejunal
reconstruction. Nineteen patients, each undergoing a pharyngolaryngectomy with free jejunal graft,
were included. Each had a primary tracheoesophageal puncture for insertion of an indwelling voice
prosthesis for speech. Functional outcomes of speech and swallow were assessed by a qualified speech
pathologist. The impact on patients’ quality of life was assessed under four domains: impairment,
disability, handicap, and well-being. The mean time period to follow-up was 4 years. Eighteen of the

11a_Jejunal_r5_cah_1298-1323.indd 1319 2/8/2012 2:57:16 PM

 1320 Part II  Regional Flaps: Anatomy and Basic Techniques

19 patients were tolerating an oral diet, with one patient reliant on percutaneous endoscopic gastrostomy
feeds. Seventeen patients (89%) were assessed as having no—or only a mild degree—of dysphagia,
with no evidence of aspiration. Fifteen of the 19 patients were using tracheosophageal speech for com-
munication with 11 (73%) having no—or only a mild degree—of dysphonia. Patients assessed as
having no evidence of dysphagia or dysphonia reported reduced levels of handicap and distress compared
with patients experiencing any degree of dysphagia or dysphonia. 
Yu P, Lewin JS, Reece GP, et al. Comparison of clinical and functional outcomes and hospital
costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus
the jejunal flap. Plast Reconstr Surg 117:968, 2006.
The M D Anderson Cancer Center team presented an extensive comparison of 57 circumferential
pharyngoesophageal reconstructions with an anterolateral thigh flap in 26 patients performed by a
single surgeon or a jejunal flap in 31 patients performed by six experienced surgeons between 1998
and 2004. Total flap loss occurred in one (4%) and two (6%) patients, fistula rates were 8% and 3%,
and stricture rates were 15% and 19% in the anterolateral thigh and jejunal flap groups, respectively.
Despite the limitations of comparing a single surgeon’s results with those of multiple surgeons, the
anterolateral thigh flap appears to offer better speech and swallowing functions and quicker recovery
and to be more cost effective than the jejunal flap for pharyngoesophageal reconstruction. The com-
plication rates were similar.

Clinical Series
Chang TS, Wang W, Huang OL. One-stage reconstruction of esophageal defect by free transfer
of jejunum: treatment and complications. Ann Plast Surg 15:492, 1985.
The authors presented their experience with 20 patients who underwent esophageal reconstruction
with free jejunal transfers. Sixteen were successful for a success rate of 80%. Complications included an
unusual case of balloon-like distention of the cervical portion of the transferred jejunum. The authors
provided tips to avoid complications and improve success rates.
Dean LM, Gilbert DA, Schechter GL, Baker JW. Free jejunal transfer for the reconstruction
of pharyngeal and cervical esophageal defects. Ann Plast Surg 19:499, 1987.
The authors presented their 4-year experience in 17 patients undergoing free jejunal transfer for re-
construction of the cervical esophagus and pharynx. Complications in 8 of their 17 patients included
tracheoesophageal fistula, oral cutaneous fistula, and three flap failures.
Flynn MB, Acland RD. Free intestinal autografts for reconstruction following pharyngolar-
yngoesophagectomy. Surg Gynecol Obstet 149:858, 1979.
The authors described their experience with four patients who underwent pharyngolaryngoesopha-
gectomy and reconstruction. In two patients a jejunal free flap was used and in two patients colon
was used. All the reconstructions were successful. One patient in the jejunal group developed an
intussusception in the abdominal donor site. The authors believe that the jejunum is preferable to the
colon because harvesting is simpler. However, they pointed out that their experience was too small to
reach any definite conclusions.
Hanna EA, Harrison AW, Derrick JR. Long-term results of visceral esophageal substitutes.
Ann Thorac Surg 3:111, 1967.
The authors reviewed 134 patients who underwent esophageal resection and reconstruction with
stomach, small intestine, or right transverse or left colon interposition. The reconstructions were per-
formed between 1946 and 1965. Although microsurgical reconstructions were performed, the authors
compared the results of each type of viscera. They concluded that the small bowel appeared to provide
the best long-term functional results.
Harashina T, Kakegawa T, Imai T, et al. Secondary reconstruction of oesophagus with free
revascularised ileal transfer. Br J Plast Surg 34:17, 1981.
A long length of jejunum was used to reconstruct the cervical esophagus in one patient. The recipient
vessels were the thoracoacromial artery and the cephalic vein. The jejunum was covered with a split-
thickness skin graft.

11a_Jejunal_r5_cah_1298-1323.indd 1320 2/8/2012 2:57:17 PM

 Abdominal Viscera  •  11A: Jejunal Flap 1321

Hester TR, McConnel F, Nahai F, Cunningham SJ, Jurkiewicz MJ. Pharyngoesophageal

stricture and fistula. Ann Surg 199:762, 1984.
Jejunal free grafts transferred by microsurgical techniques were used to salvage pharyngoesophageal
strictures and fistulas. The authors reported on 55 patients, the majority of whom were treated for
squamous cell carcinoma or the complications of combined radiation and operative therapy. There were
six graft failures for a success rate of 90%. There was a 5% (3 patients) operative mortality. Fourteen
patients had radionecrotic fistulas (4 patients) or strictures (10 patients).
Hester TR, McConnel FM, Nahai F, Jurkiewicz MJ, Brown RG. Reconstruction of cervical
esophagus, hypopharynx and oral cavity using free jejunal transfer. Am J Surg 140:487, 1980.
This was the first report of a “large” series of 22 cervical esophageal reconstructions in which free
jejunum was transferred via a microsurgical technique using an operative microscope and a 9-0 nylon
suture on a microsurgical needle. Seventeen procedures were performed for reconstruction of the oro-
pharynx, hypopharynx, and cervical esophagus, and five procedures were performed to provide lining
in the oral cavity. There were two failures for an overall success rate of over 90%.
Inoue T, Harashina T, Asanami S, et al. Reconstruction of the hard palate using free iliac bone
covered with a jejunal flap. Br J Plast Surg 41:143, 1988.
A patient with a hard palate defect underwent reconstruction with iliac crest bone, which was covered
with a segment of free revascularized jejunum.
Jurkiewicz MJ. Vascularized intestinal graft for reconstruction of the cervical esophagus and
pharynx. Plast Reconstr Surg 36:509, 1965.
This was a very early report on two successful esophageal reconstructions using jejunum. The artery
of the free jejunal segment was sutured end-to-side into the external carotid artery with a continuous
7-0 black silk suture. The vein was sutured end-to-side into the internal jugular vein with a similar
suture. Both reconstructions were successful.
Kato H, Watanabe H, Iizuka T, et al. Primary esophageal reconstruction after resection of the
cancer in the hypopharynx or cervical esophagus: comparison of free forearm skin tube flap,
free jejunal transplantation and pull-through esophagectomy. Jpn J Clin Oncol 17:255, 1987.
Sixty-six patients with carcinoma of the hypopharynx or cervical esophagus underwent reconstruction
consisting of a free radial forearm tubed flap, free jejunal transplantation, or a gastric pull-up procedure.
The authors concluded that the radial forearm flap is the safest, but they recommended the free jejunum
as the best method of reconstruction.
Katsaros J, Banis JC, Acland RD, et al. Monitoring free vascularised jejunum grafts. Br J Plast
Surg 38:220, 1985.
The authors described a reliable method of monitoring free jejunal flaps. A small portion of the jejunum
was isolated on a branch of the jejunal artery and placed outside the area of reconstruction so that it
could be monitored directly during the postoperative period.
Longmire WP Jr. A modification of the Roux technique for antethoracic esophageal recon-
struction. Surgery 22:94, 1947.
The author described a case of total thoracic esophageal reconstruction from the neck down to the stomach
using a length of jejunum with an intact mesenteric pedicle in the abdomen and a second “microassist
pedicle” sutured end to end to the internal mammary vessels using 5-0 silk. A remarkable single-stage
reconstruction was reported.
McConnel FM, Hester TR, Mendelsohn MS, et al. Manofluorography of deglutition after
total laryngopharyngectomy. Plast Reconstr Surg 81:346, 1988.
The authors used the new technique of manofluorography to evaluate swallowing. This technique
provides simultaneous display of manometry and videofluoroscopy to evaluate swallowing. They
studied 10 patients who had undergone total laryngopharyngectomy and reconstruction with either
a microsurgical jejunal free graft or a gastric pull-up procedure. Factors that enhanced swallowing in
these patients were the presence of a widely patent graft and an intact swallowing reflex. Conversely,
factors that impaired swallowing included stricture, jejunal peristalsis, impaired lingual coordination,

11a_Jejunal_r5_cah_1298-1323.indd 1321 2/8/2012 2:57:17 PM

 1322 Part II  Regional Flaps: Anatomy and Basic Techniques

and stenosis at the anastomotic sites. The authors noted that jejunal peristalsis is not synchronized
with the delivery of the bolus from the oral cavity; consequently this can obstruct the bolus.
Nozaki M, Huang TT, Hayashi M, et al. Reconstruction of the pharyngoesophagus following
pharyngoesophagectomy and irradiation therapy. Plast Reconstr Surg 76:386, 1985.
The authors reviewed their 5-year experience with 56 pharyngoesophageal reconstructions. Twenty-
seven patients underwent reconstruction with skin flaps with or without underlying muscle and 29
underwent reconstruction with a free jejunal graft. Two thirds of both groups received radiation therapy.
In the group with skin flap reconstruction 8 of 27 patients developed fistulas. This incidence increased
in those patients who had preoperative irradiation. In contrast, none of the patients who underwent free
intestinal segment reconstruction developed a fistula. The flaps included the pectoralis myocutaneous,
latissimus myocutaneous, and deltopectoral flaps. The free segments of bowel were exclusively jejunum.
Shaw WW. Microvascular free flaps. The first decade. Clin Plast Surg 10:3, 1983.
In this extensive review of the first 10 years of experience with microsurgical tissue transplantation,
the author covers various donor sites, including the jejunum. Historical aspects of clinical applications
were discussed.

Flap Modifications
Boyd JB, Hynes B, Manktelow RT, et al. Extensive pharyngo-oesophageal reconstruction
using multiple jejunal loops. Br J Plast Surg 40:467, 1987.
Pharyngoesophageal reconstruction was reported in two patients. In each patient two separate sets of
vascular anastomoses were required, one in the neck and the other in the midsternum, to reconstruct a
long length of the pharynx and esophagus. In the first patient, a single loop was used; in the second
patient, two separate segments were used to avoid redundancy.
Harashina T, Inoue T, Andoh T, et al. Reconstruction of cervical oesophagus with free double-
folded intestinal graft. Br J Plast Surg 38:483, 1985.
This case report demonstrated a technique for enlarging the lumen of the transferred jejunum by split-
ting the wall of the intestine longitudinally, folding it, and suturing it to double the size.
Jones NF, Eadie PA, Myers EN. Double lumen free jejunal transfer for reconstruction of the
entire floor of mouth, pharynx and cervical oesophagus. Br J Plast Surg 44:44, 1991.
The authors described an inverted J-shaped jejunal funnel that is prefabricated to enlarge the proximal
stoma of a free jejunal transfer to overcome size discrepancies between the superior pharyngeal defect
and the jejunum.
Miller M. Harvest of muscle, nerve, fascia, and vein. In Bostwick J III, Eaves FF III, Nahai F,
eds. Endoscopic Plastic Surgery. St Louis: Quality Medical Publishing, 1995.
Miller described the technique for endoscopic harvest of the jejunum. The technique is being refined
and developed.
Nahai F, Stahl RS, Hester TR, et al. Advanced applications of revascularized free jejunal flaps
for difficult wounds of the head and neck. Plast Reconstr Surg 74:778, 1984.
Reconstruction of the cervical esophagus with the jejunum and contiguous mesenteric flap was described
for the protection of vascular and mucosal anastomoses and the provision of soft tissue coverage.

Complications
Coleman JJ III, Searles JM Jr, Hester TR, Nahai F, Zubowicz V, McConnel FMS, Jurkiewicz
MJ. Ten years’ experience with the free jejunal autograft. Am J Surg 154:394, 1987.
The authors’ 10-year experience with 96 jejunal free flaps was described. Complications included
13 operative failures: arterial thrombosis (4), venous anastomotic problems (4), fistula and infection in
the neck (1), carotid blowout (1), psychosis and avulsion of the bowel (1), and unknown cause (2). In
seven patients a second attempt at salvage of jejunal flaps was successfully performed in five patients.
There were five deaths (6%) in the perioperative period. Of these, one was directly attributed to graft
failure. Eight abdominal complications required reoperation, including wound dehiscence (4), small

11a_Jejunal_r5_cah_1298-1323.indd 1322 2/8/2012 2:57:17 PM

 Abdominal Viscera  •  11A: Jejunal Flap 1323

bowel obstruction (1), Mallory-Weiss tear (1), gastrectomy tube leak (1), and acute gastric dilatation
(1). The authors concluded that significant palliation and a high rate of restoration of function are
possible with free jejunal autografts and emphasized careful patient selection to decrease operative
morbidity and mortality.
Coleman JJ III, Tan KC, Searles JM, Hester TR, Nahai F. Jejunal free autograft: analysis of
complications and their resolution. Plast Reconstr Surg 84:589, 1989.
The authors reviewed 101 patients who underwent 111 free jejunal transfers. The absolute failure rate
was 13.5%. Thirty-three patients had pharyngocutaneous fistulas; 20 of the patients had previous
radiation therapy. Of those patients with fistulas, 15 patients had a spontaneous closure and nine
other patients required surgical correction. The overall mortality rate was 5%. Eighty-three percent of
the patients had adequate restoration of swallowing.
McConnel FM, Duck SW, Hester TR. Hypopharyngeal stenosis. Laryngoscope 94:1162, 1984.
In a discussion of hypopharyngeal stenosis after total laryngectomy, the authors concluded that the
overriding factor in the incidence of hypopharyngeal stenosis appears to be the performance of partial
pharyngectomy and primary closure. They therefore advocate prevention of this complication through
the reconstruction of partial pharyngectomies with new tissue, including a free flap or other distant
tissue. They described their experience with the jejunum in 24 patients. In this group of patients they
reported a 12% incidence of fistula formation.
Stell PM, Missotten F, Singh SD, et al. Mortality after surgery for hypopharyngeal cancer. Br
J Surg 70:713, 1983.
In this extensive review the authors reported their experience in the treatment of hypopharyngeal
cancer, its complications, and mortality. They also reviewed the literature, comparing complication
rates and mortality following different methods of pharyngoesophageal reconstruction, including free
jejunal grafts. In their series of 362 patients with squamous cell carcinoma of the hypopharynx, the
hospital mortality was 25%. The mortality increased in those who had undergone previous radiation
therapy and those who were in poor general condition. The mortality was higher for visceral, stomach,
or colon transposition than for skin flap reconstruction. The hospital death rate for patients undergoing
free microvascular grafts in the literature was 17.8%.

11a_Jejunal_r5_cah_1298-1323.indd 1323 2/8/2012 2:57:17 PM

 ANATOMIC LANDMARKS
Landmarks The omentum is a well-vascularized apron of fat suspended from
the greater curve of the stomach.
Size 30 to 40 cm 3 30 to 60 cm.
Origin The omentum arises from the greater curvature of the stomach
with secondary attachments to the anterior aspect of the trans-
verse colon.
Function Adheres to and walls off areas of inflammation within the peri-
toneal cavity. It serves as a secondary fat storage area.
Composition Fat.
Flap Type Type III.
Dominant Pedicles Right gastroepiploic artery and vein; left gastroepiploic artery.
Nerve Supply Autonomic supply from the splanchnic nerve plexus.

11b_Omental_r4_bs_1324-1348.indd 1324 2/7/2012 11:07:30 AM

 Section 11B
Abdominal Viscera

Omental Flap

CLINICAL APPLICATIONS
Regional Use
Chest
Trunk
Scalp
Extremity
Specialized Use
Cheek (in Romberg’s hemifacial
atrophy)

11b_Omental_r4_bs_1324-1348.indd 1325 2/7/2012 11:07:33 AM

 ANATOMY OF THE Omental flap

A Splenic
artery and vein

Superior
mesenteric artery
Short gastric
arteries and
Gastroduodenal
veins
artery
Left gastroepiploic
Superior artery and vein
mesenteric vein

Right gastroepiploic
artery and vein

Vascular
arcades

Omental flap in situ on greater

curvature of stomach

D2
B

Right gastroepiploic
artery and vein

Vascular
arcades

Flap dissected; the omentum can

be carried on either the left or right
gastroepiploic blood supply

Fig. 11B-1 

Dominant pedicles: Right gastroepiploic artery; left gastroepiploic artery

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 Abdominal Viscera  •  11B: Omental Flap 1327

Anatomy
Landmarks The omentum is a large, well-vascularized sheet of fat suspended from the greater
curvature of the stomach. It forms the anterior wall of the lesser sac between
the stomach and transverse colon and drapes over the small bowel inferiorly
for a variable distance. Its thickness ranges from 3 to 10 mm, depending on the
person’s weight. It can extend inferiorly as far as the pelvis.
Composition Fat.
Size 30 to 40 cm 3 30 to 60 cm.
Origin The omentum arises from the greater curvature of the stomach with secondary
attachments to the anterior aspect of the transverse colon. It hangs as a pendulous
fatty apron covering the underlying small bowel to a varying extent and may
reach to the pelvis in some individuals.
Function The omentum has been called the guardian of the abdomen, an allusion to its ability
to adhere to and wall off areas of inflammation within the peritoneal cavity. It
may have a weak immune function, and it serves as a secondary fat storage area.
The attachments of the omentum between the stomach and the transverse colon
reduce the likelihood of spontaneous gastric volvulus.

Arterial Anatomy (Type III)

Dominant Pedicle  Right gastroepiploic artery
Regional Source  Gastroduodenal artery and vein.
Length  6 cm.
Diameter  2 to 3 mm.
Location  Derived from the gastroduodenal artery beneath the first portion of the duodenum.
Dominant Pedicle  Left gastroepiploic artery
Regional Source  Splenic artery and vein.
Length  4 cm.
Diameter  2 mm.
Location  Arises from the splenic artery on the proximal portion of the greater curvature of the
stomach within the splenocolic ligament.

Venous Anatomy
Single veins accompany the arterial circulation; the average venous diameter is 1.5 to 3 mm. The
right gastroepiploic vein is a branch of the superior mesenteric vein. The left gastroepiploic vein
is a branch of the splenic vein.

Nerve Supply
Autonomic supply from the splanchnic nerve plexus.

11b_Omental_r4_bs_1324-1348.indd 1327 2/7/2012 11:07:33 AM

 1328 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Omental Flap

D1

D2

Radiographic view

Fig. 11B-2 

Dominant pedicles: Right gastroepiploic artery (D1); left gastroepiploic artery (D2)

Flap Harvest
Design and Markings
The flap is exposed through a vertical upper midline abdominal laparotomy incision, a
diaphragmatic approach, or a laparoscopic approach.

Patient Positioning
The patient is placed in the supine position for both flap harvest and inset. Arms are usually
tucked at the patient’s sides. The omentum may be harvested in the lateral position during
a left thoracotomy by taking down the diaphragm anteriorly.

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 Abdominal Viscera  •  11B: Omental Flap 1329

Guide to Flap Dissection

Standard Flap
The abdominal cavity is approached through either an open laparotomy incision in the
upper midline, or through a laparoscopic technique. Laparoscopic harvest has become
increasingly important, and the flap lends itself well to this morbidity-reducing approach.
The omentum is evaluated once exposed, assessing its bulk as well the presence of adhe-
sions to unexpected areas of previous intraabdominal inflammation such as the gallbladder,
appendix, descending colon (diverticular disease), and pelvis (pelvic inflammatory disease).
The distal end of the flap is grasped and elevated to the transverse colon. The transverse
colon is inspected, and the transverse mesocolon and its contained middle colic vessels are
identified and carefully protected throughout the ensuing dissection.

Middle colic artery

Flap design (based on right gastroepiploic pedicle)

Fig. 11B-3 

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 1330 Part II  Regional Flaps: Anatomy and Basic Techniques

The posterior peritoneal reflection of the omentum is carefully dissected off the trans-
verse colon, taking care not to damage the colonic wall. Once free of the colon, the omentum
is elevated, exposing the lesser sac beneath and the greater curve of the stomach superiorly.
The right and left gastroepiploic vessels are identified, as are the short gastric vessels. At
this point the pedicle to be used as the dominant blood supply for the flap must be chosen.
If the right vessel is to be used, the left gastroepiploic vessels are ligated immediately distal
to their junction with the splenic artery and vein, adjacent to the pancreaticosplenic and
gastroepiploic ligaments.

B C
Left epiploic
artery
Right gastroepiploic
artery

Gastroepiploic
arcade

Gastroepiploic
arcade

Middle colic
artery

Division of short gastric vessels

and left gastroepiploic pedicle

Release of colon adhesions

Fig. 11B-3 

11b_Omental_r4_bs_1324-1348.indd 1330 2/7/2012 11:07:35 AM

 Abdominal Viscera  •  11B: Omental Flap 1331

The omentum is mobilized along the greater curve of the stomach, ligating all short
gastric contributions and taking care not to constrict any of the gastric wall within the
ligatures. If a pedicle flap is planned, mobilization proceeds along the greater curve of the
stomach to within 3 cm of the gastric pylorus. If a free flap is required, dissection must
proceed to the posterior pylorus to extend the pedicle length.
If the left gastroepiploic vessel is to be used to supply the flap, the vasculature on the right
is ligated first, just proximal to the pylorus. The omentum is mobilized off the greater curve
of the stomach to 5 to 7 cm from the gastrosplenic ligament, taking care not to traumatize
the spleen during retraction for exposure.

Elevation of flap

Fig. 11B-3 

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 1332 Part II  Regional Flaps: Anatomy and Basic Techniques

Extension of Pedicle Length

As mentioned previously, internal dissection within the omentum can lengthen the vas-
cular pedicle considerably. The primary vascular arch is derived from the gastroepiploic
vessels. A secondary arcade (Barkow’s arch), is formed by vascular communications along
the distal border of the omentum, allowing partial division from the gastroepiploic arcade.
The epiploic vessels within the omentum must be clearly visualized with posterior transil-
lumination to determine how the omental sheet may be split longitudinally to maintain
viable connections with the source vessels.

A B
Incise and ligate

Plan for extension of omental flap

by splitting Barkow’s arch

Omental flap is extended, maintaining its

blood supply through epiploic arcade

Fig. 11B-4 

Flap Variants
•  Turnover flap
•  Segmental flap
•  Free flap transfer
•  Gastroomental flap

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 Abdominal Viscera  •  11B: Omental Flap 1333

Turnover Flap
After release from the transverse colon, the flap may simply be turned up over the stomach
and passed through a mediastinal wound without interrupting the attachments to the stom-
ach. Care must be taken not to kink the stomach, and the width of the flap may predispose
the patient to a large paraomental epigastric hernia.

Segmental Flap
The omentum may be split down the center and one half, based on the appropriate gastro-
epiploic vessel, can be raised to cover smaller defects.

Free Flap Transfer

The flap lends itself well to large defect coverage, although it must be skin grafted if used
on a surface wound. Dissection requires skeletonization of the pedicle for anastomosis, and
the pedicle can be lengthened by unfurling some of the proximal flap along the vascular
arcades contained within the flap. This can obviate the need for vein grafting.

Gastroomental Flap
The omentum can be harvested together with the great curvature of the stomach, based
preferably on the left gastroepiploic vessels. This provides an additional cuff of vascularized
stomach wall and can be used together to patch an esophageal defect or provide additional
coverage to irradiated vessels in the neck. The omentum is then laid over the entire con-
struct to provide a vascularized bed onto which a skin graft can be placed or dead space
filled. Another indication for this rarely used flap is in esophageal reconstruction, in which
the greater curve of the stomach may be tubed as a partial esophageal reconstruction; the
omentum is then wrapped around it as a composite flap. The remaining greater curve of
the stomach is closed, creating a smaller gastric pouch while maintaining the continuity
of the alimentary tract.

Planned gastroomental flap

Fig. 11B-5 

11b_Omental_r4_bs_1324-1348.indd 1333 2/7/2012 11:07:36 AM

 1334 Part II  Regional Flaps: Anatomy and Basic Techniques

Arc of Rotation

A B C

Arc to chest and mediastinum Arc to chest and mediastinum Arc to mediastinum
(right gastroepiploic-based flap) (left gastroepiploic-based flap) (bipedicle turnover flap)

D E F

Arc to groin and pelvis Arc to groin and pelvis Arc to posterior trunk
(right gastroepiploic-based flap) (left gastroepiploic-based flap)

Fig. 11B-6 

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 Abdominal Viscera  •  11B: Omental Flap 1335

Flap Transfer
The flap is transferred to its recipient site based on the location of the defect. During inset, care
should be taken to ensure the flap is not twisted on itself, which can lead to vascular occlusion and flap
thrombosis. Any areas of dubious perfusion should be resected back to healthy flap bleeding.
Although the flap may be used to fill a defect beneath intact skin, such as in a patient with
Rhomberg’s hemifacial atrophy, it is more commonly used as a surface filler and requires
immediate skin grafting.

Flap Inset
The omentum is either tunneled over the costal margin onto a chest wall defect, or passed
through a small diaphragmatic window into the mediastinum. It can be rotated down
into the pelvis, but care should be taken to close off any potential internal hernia sites. The
omentum can also be passed through the right paracolic gutter, lateral to the right kidney,
allowing its transposition into the back for spinal coverage.

A B C

Tunnel through superior midline Tunnel through diaphragm Tunnel through posterior trunk
of abdominal wall

Fig. 11B-7 

Donor Site Closure

Before closing the abdomen, it is imperative to repair the defect in the anterior wall of
the lesser sac in the donor site to prevent the risk of internal hernia formation or gastric
volvulus. This is done with either silk or Vicryl sutures, coapting the greater curvature of
the stomach to the transverse colon. Abdominal closure is performed as dictated by the
surgical approach to the peritoneal cavity: midline laparotomy incisions are closed as a mass
closure with Prolene, whereas laparoscopic incisions are closed in layers with fascial repair.

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 1336 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 20-year-old student sustained full-thickness flame burns to the face and forehead when
he lost consciousness in a motor vehicle accident and fire. His face burned for 15 minutes
before rescuers were able to free him. He was taken to a major burn unit, where his wounds
were debrided and a skin graft was placed, but he was left with an open frontal sinus wound
with exposed bone. A free omental flap to the right superficial temporal vessels with skin
grafting was planned. The flap was harvested through an open upper midline laparotomy
with successful anastomosis to the superficial temporal vessels without vein grafts. He is
shown before, during, and 6 months after the procedure, with healed, stable forehead cov-
erage and acceptable contour.

B C

D E

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. (Case supplied by GJ.)

11b_Omental_r4_bs_1324-1348.indd 1336 2/7/2012 11:07:39 AM

 Abdominal Viscera  •  11B: Omental Flap 1337

This 56-year-old woman with postpolio syndrome developed a large basal cell carcinoma at
the vertex of her scalp. The lesion was excised and a skin graft was applied to the galea. Once
healed, she received radiation therapy. Five years later she presented with osteoradionecrosis
of the skull without any evidence of tumor recurrence. Necrotic bone was present with
visible erosion of the inner table of the skull. A wide, full-thickness resection of the skull
was planned without bony reconstruction, with coverage by a free omental flap. A latis-
simus dorsi flap would have been an excellent option, but the patient’s postpolio syndrome
precluded using any muscle flaps, and the large surface area of the defect and the need to
anastomose to vessels in the neck made the omentum an attractive option. The patient is
shown before and 1 year after resection with omental free flap coverage and skin grafting.
She was followed for 6 years, during which time her scalp remained healed and stable.

B C

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. (Case supplied by GJ.)

11b_Omental_r4_bs_1324-1348.indd 1337 2/7/2012 11:07:39 AM

 1338 Part II  Regional Flaps: Anatomy and Basic Techniques

This 62-year-old woman had undergone a radical mastectomy 20 years previously, followed
by chemotherapy and radiation therapy. She developed progressive osteoradionecrosis of the
right chest wall in the region of the costal cartilages. She then experienced a life-threatening
hemorrhage from the right internal mammary artery. Radical resection of the chest wall was
performed with chest stabilization using Gore-Tex. Soft tissue cover was obtained with a
pedicled omental transposition flap and a skin graft. She healed uneventfully, and her chest
wall was stable and well healed 3 years after surgery.

A B

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.
(Case supplied by GJ.)

11b_Omental_r4_bs_1324-1348.indd 1338 2/7/2012 11:07:40 AM

 Abdominal Viscera  •  11B: Omental Flap 1339

This 45-year-old man underwent a four-vessel coronary artery bypass complicated by

sternal wound infection. The wound was debrided by the cardiac surgeons, who excised
the sternum and splinted the chest wound open with a sternal spreader for 1 week, during
which time dressings were applied. By the time he was referred for plastic surgery, the sternal
separation had been retracted too much and was too stiff to be closed using conventional
pectoral muscle advancement flaps. A pedicled omental flap with a skin graft was performed.
The patient is shown intraoperatively, before and after transposition of the omentum flap
based on the left gastroepiploic vessels. A skin graft was subsequently applied. The patient
healed uneventfully and returned to his home state for long-term follow-up.

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. (Case supplied by GJ.)

11b_Omental_r4_bs_1324-1348.indd 1339 2/7/2012 11:07:40 AM

 1340 Part II  Regional Flaps: Anatomy and Basic Techniques

This 55-year-old man with prostate cancer metastatic to the spine developed vertebral
collapse requiring instrumentation. He had undergone radiation therapy and developed
wound dehiscence. Several unsuccessful attempts, performed elsewhere, had been made to
close the wound. The patient was referred for closure. All local options had been exhausted.

B C

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. (Case supplied by GJ.)

11b_Omental_r4_bs_1324-1348.indd 1340 2/7/2012 11:07:43 AM

 Abdominal Viscera  •  11B: Omental Flap 1341

This 57-year-old man was referred for closure of an infected median sternotomy following
coronary artery bypass grafting with bilateral internal mammary artery grafts. A radical
sternectomy was necessary to remove all infected bone and cartilage. Given the wide defect
dimensions, an omental flap was planned.

A B

D E

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.
(Case supplied by GJ.)

11b_Omental_r4_bs_1324-1348.indd 1341 2/7/2012 11:07:48 AM

 1342 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• Great care should be taken to ensure that the mesocolon is not accidentally damaged
during elevation of the flap from the transverse colon, resulting in colonic ischemia.
Similarly, direct sharp penetration of the transverse colon must be avoided at all costs.
• When retracting the costal margins to allow exposure of the left gastroepiploic vessels, the
assistant should be aware of the close proximity of the spleen and avoid retractor injuries
that can result in immediate or, more seriously, delayed splenic rupture.
• Before the flap is elevated on either of the gastroepiploic vessels, each pedicle in turn
should be clamped with a soft vascular clamp to assess pedicle dominance. Although the
flap is theoretically viable from either pedicle, there are occasions when the flap is better
perfused by one or the other of the two pedicles.
• When ligating the short gastric vessels from the main arcade of the flap, it is important
not to include portions of the stomach wall in the ligatures, because this may result in
delayed gastric perforation.
• After flap harvest is complete, the greater curve of the stomach should be tacked to the
transverse mesocolon to prevent internal herniation or gastric volvulus.
• The omentum can be used as a posterior pull-through flap for spinal wounds when passed
through a wound created in the paracolic gutter.

Expert Commentary
Glyn Jones

Indications
The omentum is usually large, soft and malleable. It can be used to resurface large surface
defects anywhere in the body and is particularly helpful as a volume filler.

Advantages and Limitations

Given its size, the omental flap can cover extremely large surfaces. Its rich blood supply
allows it to be unfurled multiple times, enabling it to be extended at least twice its original
length to provide deep fill. Its arcadelike blood supply allows it to be split into fingerlike
projections, which can be tunneled to fill multiple defects in the face, or may allow it to be
wrapped around individual digits in the hand. Its close proximity to the diaphragm allows
ready transformation into the mediastinum. It is the flap of choice for extremely large medi-
astinal defects that are too wide to be closed by the more conventional pectoralis major flaps.

Anatomic Considerations
The omentum is potentially one of the largest surface area flaps in the body and has a rich
vascular supply with a reliable, predictable vascular pedicle. As such, it can resurface unusu-
ally large defects with a relatively thin tissue mass, but always requires skin grafting when
used on surface defects.

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 Abdominal Viscera  •  11B: Omental Flap 1343

Personal Experience and Insights

The omentum is primarily used now for extremely large surface area defects or in areas
requiring large but thin coverage. The flap is exceptionally reliable but is very prone to
gravitational sagging.

Recommendations
Planning
The omentum should not be used in patients who are emaciated, because the volume can
shrink to almost unusable portions. In patients who have had previous abdominal surgery,
it should be remembered that the omentum may have been removed as part of the origi-
nal procedure (such as in a transverse colectomy for cancer or oophorectomy for ovarian
cancer). Use in the mediastinum will require substernal or transdiaphragmatic tunneling.

Technique
This flap has traditionally been raised through an open midline laparotomy. In recent years
there has been an increasing tendency to harvest the flap laparoscopically in an effort to
reduce abdominal morbidity. Before raising the flap completely, it should be transillumi-
nated to evaluate the nature and abundance of the vascular arcades within. It is helpful to
occlude the gastroepiploic artery that is not planned to be the pedicle to determine the
adequacy of inflow from the selected side. In transposing the flap, great care must be taken
not to twist the pedicle.

Postoperative Care
Patients should be treated as in any postlaparotomy case, with restriction of oral fluids and
initial bed rest. Thereafter, early ambulation will return bowel function to normal earlier.

Complications: Avoidance and Treatment

The flap’s volume tends to shrink beneath a skin graft. When used in the face or breast, it is
particularly prone to gravitational sagging over time. This problem has seen the omentum
usurped by fasciocutaneous free flaps or fat injection for the correction of Rhomberg’s hemi-
facial atrophy. Twisting of the pedicle must be avoided at all costs. In an effort to reduce the
bulk of the pedicle passing through the diaphragm into the mediastinum, the pedicle can
be skeletonized fairly easily without harm. This reduces the likelihood of subxiphisternal
hernia formation.

Take-Away Message
The ability to split the omentum based on Barkow’s secondary arcade allows the use of
split omental flaps to cover degloved fingers in devastating hand injuries. The skin grafted
fat shrinks back against the digits, providing remarkably good, thin vascularized cover.

Bibliography With Key Annotations

Anatomic/Experimental Studies
Das SK. The size of the human omentum and methods of lengthening it for transplantation.
Br J Plast Surg 29:170, 1976.
The author studied the size and vascular anatomy of the greater omentum in 200 cadavers and 100
laparotomies. He described three methods of lengthening the omentum: detachment of the omentum
from the transverse colon, detachment of the greater omentum from the stomach, and division of the
omentum according to the network of vascular arcades within the omentum itself. He stated that these
lengthening procedures will enable the omentum to reach the skull, midleg, and midforearm in all cases.

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 1344 Part II  Regional Flaps: Anatomy and Basic Techniques

Yonekawa Y, Yasargil MG. Brain vascularization by transplanted omentum: A possible treat-

ment of cerebral ischemia. Neurosurgery 1:256, 1977.
The use of the greater omentum as a pedicle flap for revascularization of the brain demonstrated the
rapid establishment of vascular connections between the transplanted omentum and the brain tissue.

Clinical Series
General
Arnold PG, Witzke DJ, Irons GB, et al. Use of omental transposition flaps for soft tissue recon-
struction. Ann Plast Surg 11:508, 1983.
The authors reported their early experience at the Mayo Clinic in 35 patients in whom the omentum
was used for difficult reconstructive problems. Twenty-two patients had radiation necrosis, and 24
patients had documented wound infections. In 26 patients the omentum was the final solution to
their difficult reconstructive problems. Complications included partial omental loss in seven patients
and secondary debridement and/or skin grafts in 14 patients. One patient required an additional
flap for closure, 2 patients had delayed gastric emptying, and there were 3 operative deaths (within
30 days of operation).
Harii K. Clinical application of free omental flap transfer. Clin Plast Surg 5:273, 1978.
In this early review of the use of the omentum for free flap transfer the author described the anatomy
and technique of omental microsurgical transplantation. Clinical case examples included coverage of
the scalp, extremity reconstruction, and soft tissue augmentation of the face.
Irons GB, Witzke DJ, Arnold PG, et al. Use of the omental free flap for soft tissue reconstruc-
tion. Ann Plast Surg 11:501, 1983.
The authors described their experience with the omentum as a free flap in 15 patients for reconstruction
of difficult wounds. They reported successful reconstruction in 11 of the 15 patients. The location of
the defects were as follows: scalp (2), face (2), thigh (2), and lower leg (9). Their rather high failure rate
of 27% (4 of 15 patients) was attributed to the use of suboptimal recipient vessels for the microvascular
anastomoses. These included vessels with scar tissue, inflammation, and arteriosclerotic changes. The
versatility of the omentum for free flap transfer to various anatomic areas is well demonstrated.
Turner-Warwick R. The use of omental pedicle graft in urinary tract reconstruction. J Urol
116:341, 1976.
The usefulness of various applications of the greater omentum in urology was described, including
wrapping the kidney following heminephrectomy, wrapping renal transplants with the greater omen-
tum, and reconstruction of various urinary fistulas.
Vineberg A. Revascularization by unilateral-bilateral ventricular mammary artery implants
and pericoronary omental grafts. Vasc Surg 7:80, 1973.
In this 10-year follow-up review, the author reported his experience with the use of the greater omentum
for revascularization of the myocardium. Direct implantation of the internal mammary vessels into the
myocardium and the transfer of the greater omentum to the myocardium were described.

Breast Reconstruction
Arnold PG, Hartrampf CR, Jurkiewicz MJ. One-stage reconstruction of the breast, using the
transposed greater omentum. Plast Reconstr Surg 57:520, 1976.
In this very early case report the greater omentum and a custom-made silicone-filled implant were
used to reconstruct the breast in a patient who had undergone a radical Halsted-type mastectomy. The
omentum was used to cover the custom implant, and the omentum itself was covered with a skin graft.
Zaha H, Inamine S, Naito T, et al. Laparoscopically harvested omental flap for immediate
breast reconstruction. Am J Surg 192:556, 2006.
The authors reported their experience of immediate breast reconstruction using laparoscopically har-
vested omental flaps (LHOF). During a 44-month period, 44 immediate breast reconstructions with
LHOF were performed. Patients were followed for complications and cosmetic results. Forty cases of
pedicled LHOF and 4 cases of free LHOF were performed after either nipple-sparing mastectomy

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 Abdominal Viscera  •  11B: Omental Flap 1345

(21) or breast-conservation treatment (23). Morbidity included 1 minor vascular injury of the LHOF,
4 wound and graft infections, and 1 epigastric hernia. Cosmetic results were mostly satisfactory, with
a soft breast that was natural in appearance. Donor site scars were minimal. However, in 5 patients,
the omental flap size was found to be inadequate during the procedure. The authors concluded that
although there is a limit of volume, LHOF is an attractive autologous flap that makes a natural soft
breast and minimal deformity of the donor site. Long-term atrophy was not addressed in this study.

Chest Wall Reconstruction

Belcher P, McLean N, Breach N, et al. Omental transfer in acute and chronic sternotomy
wound breakdown. J Thorac Cardiovasc Surg 38:186, 1990.
The authors presented their experience with 12 patients with median sternotomy wound infections
who were treated with the greater omentum transposition flap. Seven of their patients had chroni-
cally infected wounds, and 5 patients were treated acutely. The patients in the acute group had fewer
complications and a shorter hospital stay. The authors concluded that for severe sternal infections,
early radical excision of necrotic tissue, omental transposition, and direct closure will reduce morbidity
and shorten the hospital stay.
Ferron G, Garrido I, Martel P, et al. Combined laparoscopically harvested omental flap with
meshed skin grafts and vacuum-assisted closure for reconstruction of complex chest wall defects.
Ann Plast Surg 58:150, 2007
This study reviewed the authors experience with the use of vacuum-assisted closure (VAC) in com-
bination with laparoscopically harvested omental flap and meshed skin graft for treating complex
mediastinal wounds resulting from the treatment of breast cancer. Eleven patients underwent chest wall
reconstruction with a laparoscopic omentoplasty and VAC treatment of severe chest wall radionecrosis
after breast cancer treatment (10) or for locally advanced breast cancer treated first by irradiation (1).
Laparoscopic harvesting was uneventful in 10 cases. One patient had a laparoscopic transverse colic
resection because of a middle colic artery injury. Mean time of the laparoscopic procedure was 53 minutes
(range 35 to 120 minutes). Wound surface area averaged 360 cm2 (range 80 to 750 cm2). The mean
duration of VAC treatment was 9.3 days (range 6 to 16). Nine patients showed primary wound
healing without adverse events. Complications occurred in 3 patients. One developed a pulmonary
infection and died after healing during the postoperative course. One presented a partial flap loss,
leading to delayed healing after 45 days. One patient with severe radiation damage and a complete
brachial plexus paralysis required a shoulder amputation after an extensive necrosis. All but 1 patient
survived and resumed their normal daily activities.
Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruction of the
chest wall. Ann Surg 185:548, 1977.
This is an early account of the experience with the greater omentum for chest wall reconstruction. Ten
patients with extensive defects of the chest wall were included. Eight of these had previously undergone
radiation treatment and/or resection for breast cancer. The safety and feasibility of reconstructing these
difficult defects with the greater omentum were demonstrated.
Rocco G, Fazioli F, La Manna C, et al. Omental flap and titanium plates provide structural
stability and protection of the mediastinum after extensive sternocostal resection. Ann Thorac
Surg 90:e14, 2010.
The authors presented a case of massive sarcoma resection of the sternum treated with triple plate
stabilization and omental wrapping of the plates to provide stable chest wall coverage. The method
was suggested as an alternative to complete solid coverage, leaving several options open for future
tumor recurrence.
Veir Z, Smud S, Bogdanic B, et al. Combined vacuum-assisted closure treatment with lapa-
roscopic mobilization of an omental flap and meshed skin grafts for reconstruction of infected
sternotomy wounds: two cases. Coll Antropol 33:1427, 2009.
In cardiac surgery, poststernotomy wounds are life-threatening complications, with mortality up to 50%.
The authors described two patients who underwent coronary artery bypass grafting and postoperatively

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 1346 Part II  Regional Flaps: Anatomy and Basic Techniques

developed a deep sternal wound infection. Reconstruction was combined with vacuum-assisted closure
treatment, laparoscopic mobilization of an omental flap, and split-thickness skin grafts. The use of
vacuum-assisted closure treatment and laparoscopic mobilization of great omentum provided a suitable
option for treating deep sternal wounds.

Groin and Perineum Reconstruction

Bostwick J III, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or perineum with
myocutaneous or omental flaps. Plast Reconstr Surg 63:186, 1979.
Thirty-two flaps used for groin, perineum, and abdominal wall reconstruction were reviewed. Three
of these were omental flaps used for coverage of the groin and abdominal wall reconstruction, including
coverage of synthetic mesh.
Narducci F, Sonoda Y, Lambaudie E, et al. Vaginal evisceration after hysterectomy: the repair
by a laparoscopic and vaginal approach with a omental flap. Gynecol Oncol 89:549, 2003.
Two cases of vaginal evisceration using a combined laparoscopic and vaginal approach employing an
omental flap were described. The combined laparoscopic and vaginal approach with omental flap proved
effective for repair of a vaginal cuff dehiscence with bowel evisceration. The addition of laparoscopy
provides an opportunity for inspection of the small bowel, peritoneal toilet, and mobilization of an
omental flap for defect closure.

Head and Neck Reconstruction

Brown RG, Nahai F, Silverton JS. The omentum in facial reconstruction. Br J Plast Surg 31:58,
1978.
In this case report the authors used an omental free flap to revascularize rib grafts and skin grafts for
facial reconstruction in a patient with an extensive facial defect following a close-range shotgun wound.
The use of the greater omentum for reconstruction of such complex defects was demonstrated.
Carlson GW, Thourani VH, Codner MA, et al. Free gastro-omental flap reconstruction of the
complex, irradiated pharyngeal wound. Head Neck 19:68, 1997.
The authors reviewed the literature in light of a repaired pharyngeal defect that was successfully closed
after failed pectoralis major flap closure. The high pharyngeal defect in an irradiated bed was closed
with a tubed, gastric interpositional segment covered with a skin grafted omental flap.
Goldsmith HS, Beattie EJ Jr. Carotid artery protection by pedicled omental wrapping. Surg
Gynecol Obstet 130:57, 1970.
A technique was reported for transferring a pedicled omentum to the neck to cover the exposed carotid
artery following radical neck dissection. The advantages of the omentum include coverage of the exposed
carotid artery with well-vascularized tissue that will resist infection and provide a vascular bed for thin
neck flaps, especially after irradiation.
Jurkiewicz MJ, Nahai F. The use of free revascularized grafts in the amelioration of hemifacial
atrophy. Plast Reconstr Surg 76:44, 1985.
The authors reviewed their experience with free tissue transfer in hemifacial atrophy in 12 patients in
whom deepithelialized skin flaps and the greater omentum were transferred for soft tissue augmenta-
tion of the face. The greater omentum was used in 9 patients and deepithelialized skin flaps in 3
patients. Both gave satisfactory results. The authors stated that the omentum is better suited for more
extensive soft tissue defects and deepithelialized skin flap for smaller, limited defects. The long-term
sagging of the omentum and the need for resuspension were discussed. They also reported the cases of
two patients who had medical-grade liquid silicone injected into the face for amelioration of hemifacial
atrophy. In both patients late complications were observed, including chronic inflammation, indura-
tion, and sinus tracts, leading the authors to conclude that liquid silicone is not a recommended option
in the palliation of Romberg’s disease.

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 Abdominal Viscera  •  11B: Omental Flap 1347

McLean DH, Buncke HJ Jr. Autotransplant of omentum to a large scalp defect, with micro-
surgical revascularization. Plast Reconstr Surg 49:268, 1972.
In this report of the first successful microsurgical transplantation of the greater omentum, the authors
transferred the greater omentum for coverage of a skull defect following full-thickness resection for a
temporoparietal tumor. The omentum was covered with a split-thickness skin graft. The superficial
temporal artery and vein were used as the recipient vessels.
Upton J, Mulliken JB, Hicks PD, et al. Restoration of facial contour using free vascularized
omental transfer. Plast Reconstr Surg 66:560, 1980.
The authors described their experience in three patients using the free omental transfer for facial soft
tissue augmentation. Their anatomic dissections of the omentum confirmed the five patterns of vascular
distribution. They left septa along natural facial contour lines during undermining and preparation
of the face for the omental bulk. This compartmentalization was designed to minimize if not totally
prevent the sagging that is a problem with the use of the omentum for soft tissue facial augmentation.
Walkinshaw M, Caffee HH, Wolfe SA. Vascularized omentum for facial contour restoration.
Ann Plast Surg 10:292, 1983.
The authors presented their experience with the omentum for soft tissue augmentation in seven
patients. They described a method for preventing the late sagging of the omentum. Their technique
included fixing the omentum to the underlying tissues and overlying skin with multiple sutures and
using two vascular pedicles wherever possible. One end of the pedicle was sutured to the facial artery
and vein and the other end to the temporal artery and vein, forming a flow-through system with the
gastroepiploic vessels.
Wallace JG, Schneider WJ, Brown RG, Nahai F. Reconstruction of hemifacial atrophy with
a free flap of omentum. Br J Plast Surg 32:15, 1979.
This first report of microsurgical transplantation of the omentum for correction of hemifacial atrophy
involved a young patient who had extensive hemifacial atrophy of the entire left side of her face. The
advantages of the omentum include the volume of tissue available, the size of the vascular pedicle,
and the fact that “many flaps” of omentum could be developed for placement within the eyelids and
other facial regions.

Lower Extremity Coverage

Casten DF, Alday ES. Omental transfer for revascularization of the extremities. Surg Gynecol
Obstet 132:301, 1971.
A technique was described whereby an elongated omental pedicle flap was transferred into the lower
extremity. The authors included a study of the vascular anatomy of the omentum and flap-lengthening
techniques. They reported their experience in 24 patients with peripheral vascular disease who had not
benefited from other surgical methods. They reported some success and radiographically demonstrated
an increase in vascularity in extremities following the omental transfer.

Flap Modifications
Alday ES, Goldsmith HS. Surgical technique for omental lengthening based on arterial anatomy.
Surg Gynecol Obstet 135:103, 1972.
An omental-lengthening technique based on the arterial anatomy of the omentum was described and
the vascular arcades of the greater omentum were evaluated. The left gastroepiploic vessels are divided
high up on the greater curvature of the stomach and the gastroepiploic arcade is mobilized all the way
to the pylorus. Then, depending on the arterial supply within the omentum itself, the arcades are
isolated and divided to lengthen the omentum, basing it on the right gastroepiploic vessels and the
anastomotic channels within the omentum. With these lengthening procedures, the authors claimed
that the greater omentum can easily reach the scalp or even the distal lower extremity.

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 1348 Part II  Regional Flaps: Anatomy and Basic Techniques

Arnold PG, Irons GB. The greater omentum: extensions in transposition and free transfer.
Plast Reconstr Surg 67:169, 1981.
The authors presented their experience with the greater omentum as a transposition flap for coverage
of wounds of the chest, as a modified extended flap for coverage of the neck, and as a pedicle flap
for staged reconstruction of upper extremity wounds. Free flap transfer for coverage of scalp and skull
wounds as well as lower extremity defects was demonstrated.
Baudet J, Buffet M, Rivet D. Delayed excision of a defect after free omental transfer with un-
certain viability: a case report. Br J Plast Surg 40:306, 1987.
The authors transferred the omentum as a free flap for coverage of an extensive radionecrotic ulcer of
the thigh with an exposed femur. Since the gastroepiploic vessels were sutured into an irradiated set
of femoral vessels, there was considerable concern over the success of the vascular anastomosis and the
viability of the omentum. Therefore they delayed the resection of the defect for 48 hours to ensure
complete survival of the omentum before resecting the defect.
Mixter RC, Rao VK, Katsaros J, et al. Simultaneous reconstruction of cervical soft tissue and
esophagus with a gastro-omental free flap. Plast Reconstr Surg 86:905, 1990.
The omentum together with a portion of the greater curvature of the stomach was used for reconstruc-
tion of a soft tissue defect of the neck and the cervical esophagus. The gastric portion was tubed and
used for reconstruction of the esophagus and the omentum draped over for soft tissue coverage. The
authors reported on four patients, all of whom had preoperative radiation treatment and extensive neck
wounds. All were successfully reconstructed.
Saltz R, Stowers R, Smith M, et al. Laparoscopically harvested omental free flap to cover a
large soft tissue defect. Ann Surg 217:542, 1993.
In this first report of successful endoscopic harvest of the greater omentum, the authors successfully
transferred the omentum as a free flap for coverage of an extensive lower extremity wound. Through a
small subcostal incision and laparoscopic ports, the authors successfully harvested the greater omentum
using endoscopic techniques.
Spear SL, Oldham RJ. A lengthened omental pedicle in facial reconstruction. Plast Reconstr
Surg 77:828, 1986.
A soft tissue defect of the right side of the face was successfully reconstructed following basal cell carcinoma
resection. An omental-lengthening technique was used to transfer the omentum to the face without
microsurgical transplantation. The authors used several small transverse incisions to tunnel the greater
omentum from the xiphoid across the chest and neck to the defect on the right side. The reconstruction
in their patient yielded satisfactory results.

Complications
Guyuron B, McMahon J. Foreign-body granuloma following bilateral facial reconstruction
with an omental flap. Plast Reconstr Surg 81:771, 1988.
A single omental free flap was used to augment both sides of the face of a 23-year-old man. The
reconstruction was initially successful, but at 8 weeks postoperatively the patient presented with pain
and edema of the face. His face was explored, and a diagnosis of foreign body reaction was documented
by electron microscopy. The patient was successfully managed with a course of steroids. The cause of
this reaction was not established.
Hakelius L. Fatal complication after use of the greater omentum for reconstruction of the chest
wall. Plast Reconstr Surg 62:796, 1978.
A 61-year-old woman with a recurrence of breast cancer underwent chest wall resection and reconstruc-
tion with Marlex mesh and an omental flap. Two weeks after discharge from the hospital, she was
readmitted with acute abdominal pain. At operation a volvulus of the cecum was found. The cecum was
released and a cecostomy was performed. Two days later, another laparotomy was performed because
of peritonitis as a result of cecal rupture. The patient eventually died from complications related to the
cecal rupture. The authors thought that the cecal volvulus may have resulted from the release of the
omental attachments to the ascending colon, which predisposed the patient to the fatal cecal volvulus.

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 Chapter 12
Thigh

Until recently, thigh-based flaps have been relegated to the domain of locoregional
applications. They have been invaluable for covering decubitus ulcers, groin wounds,
orthopedic wounds of the hip, and vascular exposures. Although the gracilis flap saw
utility early as a free flap for lower extremity coverage, it has evolved into the most
widely used source of free innervated muscle for facial reanimation and functional muscle
transfers to the upper extremity. With the advent of the TUG flap, it has widened its
applicability to breast reconstruction. In addition, the ALT flap has become one of the
major workhorse perforator flaps in reconstruction, particularly for head and neck re-
construction. As a remote donor site with expendable muscles and a large surface area
for flap creation, the thigh has become a favorite among microsurgeons.

Anterolateral Thigh (ALT) and

Anteromedial Thigh (AMT) Flaps
Saphenous and Medial Condylar Flaps
Gracilis and TUG/TMG Flaps
Sartorius Flap
Biceps Femoris (Hamstring) Flap
Tensor Fascia Lata (TFL) Flap
Vastus Lateralis Flap
Rectus Femoris Flap

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 ANATOMIC LANDMARKS
Landmarks This myocutaneous perforator flap or septocutaneous flap provides
tissue from the anterolateral surface of the thigh from a point
10 cm inferior to the anterior superior iliac spine to a point
7 cm superior to the patella. The medial flap border is the mid-
point of the rectus femoris muscle; the lateral border is the mid-
lateral thigh.
Size 25 3 35 cm (with skin grafting of the donor site); a variable
amount of vastus lateralis muscle may also be carried with the
flap.
Composition Myocutaneous, septocutaneous.
Dominant Pedicle Septocutaneous and myocutaneous branches of the descending
branch of the lateral circumflex femoral artery.
Nerve Supply Sensory: Lateral femoral cutaneous nerve (L2-L3).

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 Section 12A
Thigh

Anterolateral Thigh (ALT) and

Anteromedial Thigh (AMT) Flaps

CLINICAL APPLICATIONS
Regional Use
Groin
Lower abdomen
Thigh
Knee
Distant Use
Head and neck reconstruction
Upper extremity reconstruction
Lower extremity reconstruction
Specialized Use
Esophageal reconstruction

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 ANATOMY OF THE Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps

Femoral artery
Profunda femoris artery
Lateral circumflex
femoral artery
Superficial femoral artery
Ascending branch
Transverse branch
Descending branch
Innominate branch
of descending Medial circumflex
branch of LCFA femoral artery
B
Septocutaneous
and myocutaneous
branches of
Femoral artery
descending/transverse
branches of LCFA Profunda femoris artery
Tensor fascia
lata muscle Superficial femoral artery
Lateral circumflex
femoral artery
Ascending branch

Transverse branch
Medial circumflex
Descending branch femoral artery

Rectus femoris muscle Sartorius muscle

Cutaneous branches
of descending
branch of LCFA
Vastus medialis muscle
Vastus lateralis muscle

Lateral superior
genicular artery

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.
Dominant pedicle: Septocutaneous and myocutaneous branches of descending branch of
lateral circumflex femoral artery (LCFA)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1353

Anatomy
Landmarks The flap occupies the anterolateral portion of the thigh from approximately
10 cm below the anterior superior iliac spine (ASIS) to within 7 cm superior
of the patella. The medial margin of the flap territory is at the midpoint of the
rectus femoris muscle. Laterally the anterolateral thigh (ALT) flap extends to
the midlateral thigh.
Composition Myocutaneous, septocutaneous.
Size 25 3 35 cm (with skin grafting of the donor site). Primary closure is usually
obtainable when the flap width is 10 cm or less. A variable amount of vastus
lateralis muscle may also be carried with the flap.

Arterial Anatomy
Dominant Pedicle  Septocutaneous and myocutaneous branches of the descending branch of the
lateral circumflex femoral artery
Regional Source  Profunda femoral artery.
Length  12 cm.
Diameter  2 mm.
Location  After its takeoff from the lateral circumflex femoral artery (LCFA), the descending
branch enters the deep fascia through the medial aspect of the vastus lateralis. Most perforators
to the skin perforate the vastus lateralis muscle, so dissection must either include some muscle or
dissect the vessels through the muscle. Less commonly the perforators are purely septocutaneous,
and this is more common in the proximal third of the thigh.

Venous Anatomy
Venae comitantes accompany the descending branch of the lateral circumflex femoral artery. The
average pedicle length is 12 cm, and the diameter at the takeoff of the descending lateral circumflex
femoral vein is 2 to 3 mm.

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 1354 Part II  Regional Flaps: Anatomy and Basic Techniques

Nerve Supply
Sensory Lateral femoral cutaneous nerve (L2-L3). It emerges from under the inguinal
ligament 1 cm medial to the ASIS, where it divides into its anterior and posterior
branches. The anterior branch runs underneath the fascia lata for approximately
10 cm before piercing it and supplying the skin of the anterolateral thigh. The
posterior branch variably pierces the fascia lata more proximally and laterally
and supplies the lateral thigh.

D
Lateral femoral
cutaneous nerve
Anterior superior
Posterior branch
iliac spine
Anterior branch
Lateral femoral
cutaneous nerve
Anterior branch Femoral nerve
Posterior branch Femoral artery
Superficial femoral artery
Tensor fascia lata muscle
Lateral circumflex
Profunda femoris artery femoral artery

Ascending branch Sartorius muscle

Transverse branch
Descending branch Innominate branch
of descending
branch of LCFA
Iliotibial tract

Rectus femoris muscle

Vastus lateralis muscle

Vastus medialis muscle

Fig. 12A-1  C, Sensory map of the lateral femoral cutaneous nerve and its branches. D, Sensory
innervation of the anterior thigh.

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1355

Vascular A natomy of the A nterolateral Thigh Flap

A

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.

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 1356 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Harvest
Design and Markings
A line is drawn from the ASIS to the superior lateral border of the patella. A circle with a
radius of 3 cm is drawn at the midway point, which should localize one of the perforators
of the ALT flap. Doppler examination is used to identify this point and any other vessels
that perforate its lower, outer quadrants. Although flaps as large as 25 by 35 cm have been
harvested on a single perforator, a skin graft is required for donor site closure. Flap widths
of 9 to 10 cm allow their donor sites to be closed primarily.

A B

Anterior superior
iliac spine
Inguinal ligament

Lateral femoral
cutaneous nerve

ALT flap
perforator

Outline of
ALT flap

Superior lateral
border of patella

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 bor-
der 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.

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1357

Patient Positioning
Patient positioning is supine with circumferential prep of the donor leg.

Guide to Flap Dissection

A medial incision is made first down to and through thigh fascia, which will expose the
rectus femoris muscle. Dissection then proceeds in a subfascial plane laterally toward the
septum between the rectus femoris and the vastus lateralis muscles. Retraction of the rectus
femoris muscle medially will help to expose the vessels as they traverse the septum. The
descending branch of the lateral circumflex femoral artery should be visualized within the
septum, or more commonly, perforating through the medialmost portions of the vastus
lateralis muscle. When a septocutaneous vessel is present and dominant, the dissection is
simplified. If vascularization of the skin is from a perforator that runs through the vastus
lateralis, an intramuscular dissection must be performed. Careful dissection will reveal the
course of the vessel. Once it emerges from the deep surface of the muscle, the remainder
of the dissection is similar to the septocutaneous case. If the surgeon does not want to
dissect the perforators through the muscle, some vastus lateralis muscle can be taken to
incorporate these perforators. In this case, the incorporated muscle acts only as a carrier
of the perforators. This limits the length of the pedicle for the flap for the distance of this
intramuscular course. Put another way, performing intramuscular dissection of the perfora-
tor will lengthen the pedicle.

A B C

Vastus
medialis
muscle

Vastus
intermedius Vastus
muscle Rectus
medialis
femoris
muscle
muscle
Rectus
femoris Vastus
muscle Descending intermedius
branch of muscle
LCFA
Descending Rectus
branch of Vastus lateralis femoris
LCFA muscle muscle
Elevation of the anterior Dissection of the vascular Flap completion
portion of the flap pedicle

Fig. 12A-4 

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 1358 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variants
•  Thin flap (suprafascial dissection)
•  Anteromedial thigh flap
•  Reverse anterolateral thigh flap

Thin Flap
When a thin flap is required for coverage or significant folding of the flap is required, thin-
ning of the ALT flap should be considered. First, an incision is made similar to that used in
a subfascial dissection; however, the depth is to the level of the fascia without dividing it.
Dissection continues above fascia, heading laterally approaching the area of the localized
Doppler signal. The suprafascial dissection involves more bleeding; care must be taken
to minimize any staining of the surrounding tissues to facilitate dissection and assist the
surgeon to visualize the perforating vessels. Cutaneous nerves that may be present can be
left in situ on the fascia. Once the vessel is identified, the lateral incision is made and a su-
prafascial dissection heading medially is performed until the same vessel is now seen from
the opposite side. The fascia is incised, and the vessel is then dissected in retrograde fashion
through muscle or in the septum until the desired pedicle length and vessel caliber are seen.

Fig. 12A-5  A, Thigh flap elevated in a supra-

fascial plane on a single skin vessel. Although
donor site morbidity is limited by leaving the
fascia, the visibility of landmarks that could fa-
cilitate pedicle dissection is more limited.

While the flap is still attached to the leg but is isolated on its pedicle, further thinning of
the flap can be performed; a circle of at least 2 cm radius is preserved around the perforating
vessel. This area is not thinned to maintain perfusion around the perforators. The remainder
of the flap may be directly thinned first by removing any deep fat that appears to have bigger
fat lobules than the more superficial fat, which has more of the smaller, round fat lobules. A
thin fascia may be found between these two fatty levels to aid dissection. Defatting before
division of the pedicle ensures viability of the flap to be transferred.

B C

Fig. 12A-5  B, The blood supply of the cutaneous perforator with the subdermal plexus. C, Flap thin-
ning with the subdermal plexus intact.

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1359

Anteromedial Thigh Flap

When no significant Doppler signal can be found in the lateral septum, the medial border
of the rectus femoris muscle should also be investigated, because some patients will have a
system that is more medially dominant. The anteromedial thigh perforator, based on the
innominate branch of the lateral circumflex femoral descending artery, exits medial to the
rectus femoris muscle and supplies branches to the vastus medialis and sartorius muscles
and a skin territory that is more anteriorly based. If this is discovered during the planning
phase, the skin design should be moved more medially, centered over the rectus femoris
muscle. Incision of the medial edge of the flap is performed first and a subfascial dissection
is performed until the medial perforator is found. This can then be dissected down to the
descending lateral circumflex femoral system.

A B

Femoral artery
Profunda femoris artery
Superficial femoral artery
Lateral circumflex femoral artery
Ascending branch
Transverse branch
Descending branch
Innominate branch of
Innominate branch
descending branch of LCFA
of descending
branch of LCFA
Sartorius muscle
Rectus femoris muscle Fasciocutaneous perforator
Vastus medialis muscle
Outline of anterior medial flap
Vastus lateralis muscle

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.

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 1360 Part II  Regional Flaps: Anatomy and Basic Techniques

When more bulk is needed for the flap or when the best vascularity is required, the
rectus femoris muscle can be included with the flap. A larger flap design can incorporate the
ALT perforators on the lateral side of the rectus femoris muscle and the AMT perforators
on the medial side. Both perforators originate from the same descending lateral circumflex
femoral arterial system.
C
Fasciocutaneous perforating
branch of innominate branch of
descending branch of LCFA

Sartorius
muscle
Rectus femoris muscle

Fig. 12A-6  C, Exposure of the innominate branch is facilitated Vastus medialis muscle
by retraction of the sartorius muscle medially.

Reverse Anterolateral Thigh Flap

The descending lateral femoral system runs the length of the thigh and maintains good
caliber distally such that a reverse flow flap is possible. For difficult knee wounds, this flap
can be considered. The skin design is more distally based. Dissection proceeds in similar
fashion with medial incision first through the fascia to the rectus femoris muscle. Once the
vessel is exposed and is thought to be of adequate size, the pedicle can be ligated superiorly
and a rotational flap created that will extend inferiorly.

Anterior superior
iliac spine
Femoral artery
Profunda
femoris artery
Superficial femoral artery
LCFA
Ascending branch
Transverse branch
Descending branch Proximal Fig. 12A-7  The lateral circumflex femoral artery (LCFA)
pivot point 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 descend-
ing branch, could be rotated superiorly around a point just
Distal distal to the origin of the LCFA from the profunda femoris
pivot point (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 supe-
Lateral superior rior genicular artery. By maintaining 6 cm of connection
genicular artery above the patella, the superior genicular artery need not
Superior lateral border be visualized.
of patella

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1361

Arc of Rotation
Anterolateral Thigh Flap
Depending on how distal the skin paddle is planned, the ALT flap can easily reach to the
groin and lower abdomen for soft tissue coverage. Large anterior thigh–based flaps have
been described for abdominal wall reconstruction with flaps extending to just above the
knee reaching the costal margin.

A B C

Flap elevation Arc to inferior abdomen Arc to posterior trunk

and ipsilateral groin and ischium

Fig. 12A-8  Proximally based standard flap.

Reverse Flap
Depending on the location of the skin paddle, the reverse flap should
easily reach to defects around the knee or popliteal fossa.

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 inferiorly. 

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 1362 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Transfer
When the ALT flap is used regionally, it is often transposed through a subcutaneous tunnel.
Care must be taken to make sure the tunnel is not restrictive and does not compromise
blood supply in any way. When used as a free tissue transfer, kinking or compression of the
vessels is less of an issue.

Flap Inset
Care is taken to secure the flap in place through either the fascia or muscle included with
the flap. Care must be taken to ensure a tension-free inset. As a free flap, often the flap is
tacked in place to ensure proper positioning of the microsurgery and prevention of redun-
dancy of such a long pedicle.

Donor Site Closure

All Flap Variants
When the skin paddle is limited to 9 or 10 cm in width, primary closure should be obtain-
able. When primary closure is not obtainable, a skin graft may be required for closure of
the donor site.

Clinical Applications
This 60-year-old woman had a history of radiation-induced angiosarcoma of the right
chest. She initially underwent reconstruction with a VRAM flap and received a radiation
boost for her recurrence.
C
A B

Fig. 12A-10  A, The patient developed this open wound as a result of

her second course of irradiation. Biopsies were negative for recurrent an-
giosarcoma, and reconstruction was required. Advancement of the VRAM
was felt to be too problematic after the radiation treatment and the nature D
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. (Case
supplied by MRZ.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1363

This 47-year-old man had a recurrent squamous cell carcinoma of the skin invading the
orbit. He required a wide excision with orbital exenteration, leaving a complex, irradiated
wound. The ALT is the flap of choice for such wounds, because it supplies ample skin for
resurfacing and well-vascularized muscle in the vastus lateralis for fill of the irradiated defect.

A B

C D

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. (Case supplied by MRZ.)

12a_AnteroThigh_r3c_bs_1350-1391.indd 1363 2/8/2012 1:17:39 PM

 1364 Part II  Regional Flaps: Anatomy and Basic Techniques

This 55-year-old man had a maxillary squamous cell sarcoma requiring radical excision,
including the maxilla and soft tissues of the cheek. The orbital contents were spared, but
the lower eyelid had outer lamella removed and lacked bony support.

A B

C D

E F

Fig. 12A-12  A, The defect is seen and a planned Tripier flap is marked on the upper lid for re-
construction 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. (Case supplied by MRZ.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1365

This 65-year-old man had a history of pharyngeal squamous cell carcinoma treated with
resection, pectoralis major flap, and postoperative radiation. He had partial necrosis of
his reconstruction, wound dehiscence, and a salivary fistula. He was referred for free flap
reconstruction.

A B

C D

E F

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 pecto-
ralis 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 reconstruc-
tion. 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. (Case supplied by MRZ.)

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 1366 Part II  Regional Flaps: Anatomy and Basic Techniques

Hypopharyngeal cancer reconstruction presents a number of challenges that favor using

an ALT flap. Following extensive resection of the pharynx, larynx, and esophagus, and a
bilateral node dissection, significant dead space remains. Although the radial forearm flap,
for example, can be easily fashioned into a skin tube, it may lack sufficient tissue bulk to
restore volume in the neck. Furthermore, the amount of skin may be inadequate to close
the neck wound, because patients have commonly received radiation as an organ-preserving
therapy. It is generally an advantage to have an ample supply of tissue available in this set-
ting, making the ALT flap a preferred treatment. An ALT flap was used to reconstruct this
pharyngoesophageal defect.

A B

C D E

Fig. 12A-14 A, Hypopharyngeal cancer specimen including larynx, pharynx, and cervical esopha-
gus. 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. (Case courtesy Fu-Chan Wei, MD.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1367

This 50-year-old woman had undergone multiple abdominal surgeries and had a history of
sepsis and recurrent fistulas. The lateral circumflex femoral vessels are versatile for provid-
ing vascularized skin, fascia, muscle, and/or bone alone or can be used in combination to
solve a wide variety of reconstructive challenges.

A B

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. (Case courtesy Lawrence J. Gottlieb, MD.)

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 1368 Part II  Regional Flaps: Anatomy and Basic Techniques

This 58-year-old man developed a postradiation sarcoma 1 year after reconstruction of his
mandible with an osteoseptocutaneous fibula flap for osteoradionecrosis.

Vastus lateralis muscle

B C

D E

Ascending
branch of lateral
circumflex
femoral vessels

Vastus
lateralis
muscle

Fig. 12A-16  A, The dashed line outlines the cutaneous portion of the radiation sarcoma. The ar-
row 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 lat-
eral 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. (Case
courtesy Lawrence J. Gottlieb, MD.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1369

This 72-year-old man had recurrent right maxillary cancer after initial treatment with
radiation. A split lateral iliac crest flap was planned.

Tensor fascia lata Rectus femoris

B C D

Tensor fascia lata Skin

E F G

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. (Case courtesy Lawrence J. Gottlieb, MD.)

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 1370 Part II  Regional Flaps: Anatomy and Basic Techniques

This 57-year-old man sustained head trauma from a mishap with fireworks.

A B

C D

E F

Fig. 12A-18  A, The scalp injury is seen, with exposed, fractured cranium. B, The wound was de-
brided. 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. (Case courtesy Lawrence J. Gottlieb, MD.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1371

This 76-year-old man presented with a recurrent squamous cell carcinoma in the larynx
following previous radiation therapy and bilateral neck dissection.

C D

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. (Case
courtesy Peirong Yu, MD.)

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 1372 Part II  Regional Flaps: Anatomy and Basic Techniques

This 61-year-old man underwent a composite maxillectomy for a recurrent maxillary cancer.

C D

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 sidewall. 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 sidewall. 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. (Case courtesy Peirong Yu, MD.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1373

This 62-year-old woman presented with a fractured left mandible that resulted from os-
teoradionecrosis after treatment for her base-of-tongue cancer.

B C

D E

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 vas-
cular disease, a fibular flap was not performed. Instead, a two–skin 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. (Case courtesy Peirong Yu, MD.)

12a_AnteroThigh_r3c_bs_1350-1391.indd 1373 2/8/2012 1:18:27 PM

 1374 Part II  Regional Flaps: Anatomy and Basic Techniques

This 48-year-old woman presented with recurrent tongue cancer.

Descending branch
of LCFA Motor nerve

B C Motor nerve
Pedicle

Anterolateral
thigh

Vastus
lateralis

Sensory
nerve

D E

Lingual nerve

Lateral femoral
cutaneous nerve
from ALT flap

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. (Case courtesy Peirong Yu, MD.)

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1375

This 36-year-old man with tracheomalacia presented for reconstruction.

A
C

Fig. 12A-23  A, Defect after resection of involved cartilage. B, Tubing of the ALT around a tracheos-
tomy 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. (Case
courtesy Peirong Yu, MD.)

Pearls and Pitfalls

• When perforating vessels appear too small for safe intramuscular dissection, a patch of
vastus lateralis muscle should be taken with the flap. In patients who are obese, avoid
overthinning of the flap initially, as it is harder to visualize blood vessels and maintain a
viable flap. A secondary flap thinning is acceptable.
• A skin-grafted donor site may not be aesthetically acceptable for the patient, and a V-Y
advancement of neighboring thigh flaps or use of tissue expansion for removal of the
skin graft can be considered.
• The caliber of the descending lateral circumflex femoral system is such that the ALT flap
is an excellent (flow-through) flap, whereby a second free flap can be attached in series.
• The descending lateral circumflex femoral artery and vein make an excellent A-V graft
in situations where an A-V loop is being considered. Which parts of the vessels are har-
vested for this A-V graft will depend on the diameters of the vessels being anastomosed.
• Overzealous closure of the donor site to prevent the use of a skin graft may result in muscle
ischemia, leg swelling, and compartment syndrome with subsequent nerve injury. One
should have a low threshold to place a skin graft when the closure appears tight.
• It is helpful to carry more than one perforator to the skin; this allows improved flow and
helps maintain proper orientation of the vessels during transfer and inset, decreasing the
likelihood of twisting or kinking.

12a_AnteroThigh_r3c_bs_1350-1391.indd 1375 2/8/2012 1:18:36 PM

 1376 Part II  Regional Flaps: Anatomy and Basic Techniques

EXPERT COMMENTARY
Lawrence J. Gottlieb

Indications
The anterior lateral thigh (ALT) flap was first described as a septocutaneous flap based on
the descending branch of the lateral circumflex femoral artery (LCFA), and subsequently
this ALT terminology was broadened to include almost any flap based on the lateral cir-
cumflex femoral system. Although initially popularized as a workhorse for head and neck
reconstruction, it has subsequently become a popular pedicle flap with a reach from the
epigastrium to the knee, and as a free flap for extremity and chest wall reconstruction.

Advantages and Limitations

The anterior lateral thigh is a storehouse of “spare parts” tissue that may be used throughout
the body. Skin, fat, fascia, muscle, and up to 10 cm of bone can be transferred indepen-
dently or in combination based off of the LCFA vascular system. The main advantages of
the LCFA-based flaps are their versatility and ability to be harvested in the supine position
usually simultaneously with tumor extirpation or wound preparation at distant sites. The
main limitations of LCFA-based flaps include body habitus (obesity) and color mismatch
when the skin of the thigh is transferred to the head and neck. The donor site can create an
unsightly scar. At best, it is a linear scar on the anterior lateral thigh; at worst, it is a depressed
split-thickness skin graft scar.

Anatomic Considerations
Most straightforward ALT flaps are based on the descending branch of the LCFA, as origi-
nally described. Anatomic variability or complex reconstructive needs may require the
use of tissue supplied by the transverse branch, innominate (medial descending) branch,
the ascending branch, or a combination of these. Invariably, there is a septocutaneous
vessel located approximately 17 to 18 cm from the anterior superior iliac spine (ASIS) in
an average-sized adult. Occasionally, this vessel is very small or covered by a small slip of
vastus lateralis muscle. Frequently, this perforator originates from the transverse branch of
the LCFA rather than the descending branch. It emerges just distal to the tensor fascia lata
(TFL) muscle, and the skin overlying the TFL can be captured with this vessel. Anterior
medial skin may be included with the ALT flap, to increase surface area or as an additional
skin paddle, by including the innominate (medial descending) branch. This vessel usually
originates from the proximal descending branch of the LCFA system, frequently having a
common origin with one of the major arteries supplying the rectus femoris muscle. The
innominate vessels are usually septocutaneous and emerge into the subcutaneous fat just
distal to where the sartorius crosses the rectus femoris muscle.

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1377

Medial

Sartorius muscle

uscle
mo ris m
Rec tus fe

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.

By including the ascending branch of the LCFA system, up to 10 cm of the iliac crest
can be included with this flap. This vessel runs just beneath the anterior edge of the TFL.
Adding vascularized corticocancellous bone to flaps based on the LCFA system provides
tremendous versatility for head and neck and extremity reconstruction.

ris
mo
tus fe
Rec

ASIS

Tensor fascia lata

Fig. 12A-25  The ascending branch of the LCFA system (arrow) running under and parallel to an-
terior 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.

As one includes more branches of the LCFA vascular system (either as a compound
or chimeric flap), it frequently becomes necessary to dissect the pedicle all the way to the
profundus femoral artery and vein. In doing so, anatomic variations become more evident.
Only 60% to 70% of legs have the “classic” three branches of the LCF artery and vein
come off of the LCF artery and vein. In some, the artery (of any one of the branches) has
an aberrant takeoff, and in others, the vein drains differently from what one would expect.
When including multiple branches of the LCFA system or even with multiple perforators
off the same branch, the surgeon must consider the branches of the femoral nerve, which
will frequently go between the branches or perforators, requiring division of either the
nerve or vessel to elevate the flap.
Continued

12a_AnteroThigh_r3c_bs_1350-1391.indd 1377 2/8/2012 1:18:38 PM

 1378 Part II  Regional Flaps: Anatomy and Basic Techniques

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

It is rare that I use the ALT free flap based on a single perforator or septocutaneous ves-
sel to transfer a single skin paddle. More frequently, I use multiple perforators to transfer
a large paddle of skin or a flap with multiple paddles of tissue as a chimera. Recognizing
the possibility of anatomic variations, I advocate a freestyle approach, usually beginning
with a midline incision in the proximal thigh to define the vessels available, tissue types
required, and length of pedicle required before committing to a particular skin paddle.
Because I usually harvest more then one perforator, I invariably have to deal with cross-
ing nerves. Occasionally a small paddle of skin or muscle with its attached vessels can be
passed under the nerve branch. When this is not possible, I usually cut the nerve close to
the muscle that it is innervating, pull it through, and then repair it after the flap is elevated.
If a large branch or multiple branches of the nerve are “in the way,” I cut the blood vessels
to reanastomose them later.

Recommendations
Planning
The first consideration in planning is to determine what tissue types (skin, fat, fascia, muscle,
bone) are needed to accomplish the reconstructive goals. In designing chimeric flaps, one
needs to be able to separate or deconstruct angiosomes (and venosomes) by their source ves-
sels or perforators so that each tissue component can be placed with special independence,
but still linked to the common source vessel (the pedicle). The approximate size of each
component, the anticipated blood supply to these tissues, and the three-dimensional details
and sequence of insetting needs to be carefully thought out. Additional relevant factors in
planning include the pedicle length needed to reach the anticipated recipient vessels in a
free flap or to reach the defect if transferred as a pedicle flap. The length of the ascending
branch, transverse branch, medial innominate branch, and first septocutaneous branch tends
to be approximately 10 cm. The descending branch with perforators through the muscle
tends to be 13 to 15 cm long.
I rarely do preoperative imaging studies and find preoperative Doppler examination
to be unreliable. With the significant number of anatomic variations of the LCFA vascular
system, it is imperative to have a lifeboat or backup plan if the vessels are not as anticipated.
This may include looking for the medial innominate vessels (as described earlier) to supply a

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1379

skin paddle if there are none suitable laterally or to perfuse a second skin paddle. Sometimes
the transverse or superior (ascending) branches going through the TFL muscle are the only
significant vessels supplying lateral thigh skin from the LCF system. Alternatively, if two
paddles of skin are required and only one perforator is found, two paddles can be fashioned
with an intervening deepithelialized area, or muscle (with or without a skin graft) can be
used as a substitute for one of the skin paddles.

Technique
I use a freestyle approach in harvesting LCF-based flaps with slightly different markings
and an initial incision that is more medial and proximal than that described in the chapter.
In addition to the standard marking of a vertical line from the ASIS to the lateral edge of
the patella, an additional vertical line is drawn from the ASIS to the midline of the patella.
Two horizontal lines are then drawn 10 cm and 17.5 cm below the ASIS. The proximal
horizontal line marks the location of the LCF vessels and the second horizontal line marks
the distal end of the tensor fascia lata, where a septocutaneous vessel is usually found. A
10 cm vertical skin incision, centered over the proximal horizontal line is made on the medial
vertical line. This incision is used primarily for orientation and for defining the anatomy
and tissue planes. It is carried down through the fascia and the rectus femoris is identified
and retracted medially revealing the underlying septum under which the LCF vessels are
found. In contradistinction to freestyle elevation of a simple perforator flap, complex chimera
flaps are best dissected from the pedicle to the various tissue components of the chimera flap
using a combination of retrograde and anterograde dissection of the perforators.

A B

ASIS

17.5 cm 10 cm ASIS
17.5
cm
10
c m
Fig. 12A-27  A, Markings for an LCF chimera
flap. The red markings indicate the anticipated
location of vessels; the black line with dots in- C
dicates the initial incision. B, Extension of the
Rectus femoris
initial incision to the second horizontal line. The
arrow depicts the septocutaneous vessels usu-
ally found going to the second horizontal line,
approximately 17.5 cm from the ASIS. C, After Ascending branch
freestyle dissection of the vessels supplying the
hnc

complex chimera flap. Tr

bra

an
sv
ng

er
se
ndi

br
an
sce

ch
es
De

Continued

12a_AnteroThigh_r3c_bs_1350-1391.indd 1379 2/8/2012 1:18:42 PM

 1380 Part II  Regional Flaps: Anatomy and Basic Techniques

Postoperative Care
If lateral thigh fascia or muscle is used in the flap, the knee is immobilized in extension for 4
to 6 weeks postoperatively. Isometric exercises are started 1 week after surgery, and aggressive
physical therapy to strengthen the quadriceps muscles is initiated 6 weeks postoperatively.

Complications: Avoidance and Treatment

When multiple branches of the LCF system are included in the flap, care must be taken to
not twist or kink the perforators, branches, or pedicle. Marking one surface of the vessels
with a marking pen in situ will help the surgeon recognize a twist sooner rather than later.
Any disruption of the fascia lata or iliotibial tract can lead to knee instability, particu-
larly in extension. This can be avoided by using a knee immobilizer, as described earlier.
Although preoperative imaging is unnecessary for most patients, it should be considered
in patients with peripheral vascular disease, because critical collateral blood flow may be
using the profunda system to perfuse the leg.

Take-Away Messages
By melding the principles and concepts of angiosomes and the freestyle technique of per-
forator flap dissection, a variety of complex flaps with multiple tissue components can
be custom designed and tailored into a chimeric flap for almost any reconstructive need.
However, in a patient who is morbidly obese and requires a long piece of bone, or in the
occasional patient who has a paucity of vessels, the usefulness of this flap may be limited.

EXPERT COMMENTARY
Peirong Yu

Indications
I have used the ALT flap as a free flap for reconstruction for a variety of defects in the head
and neck, chest wall, and extremities. It can also be used as a pedicled flap for scrotal and
perineal reconstruction, contralateral groin reconstruction, and reconstruction of pelvic
exenteration defects when the vertical rectus abdominis myocutaneous flap is unavailable
or inadequate.

Anatomic Considerations
Vascular Anatomy
Although the descending branch of the LCFA supplies the ALT flap in most cases, occa-
sionally the only perforators to the flap may arise from the transverse branch; this which
has occurred in 2% of my cases. This perforator usually travels within the vastus lateralis
muscle for its entire length, making dissection more tedious. The surgeon needs to be
aware of this variation.

Perforator Anatomy
In early years, the perforator anatomy of the ALT flap had a reputation for being inconsis-
tent. Although many early publications described the perforator as being located within
a 3 cm radius of the midpoint of the line connecting the ASIS and the supralateral corner
of the patella (AP line), careful study of the perforator anatomy has demonstrated that in
most cases there is more than one useful perforator (usually one to three), and their surface

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1381

locations follow a pattern (the ABC system). The perforator that is most consistently pres-
ent is located near the midpoint of the AP line, perforator B. Approximately 5 cm more
proximal and distal to that, a second and third perforator may be found (perforators A and
C). The average distance (longitudinally) measured from the ASIS to perforators A, B, and
C in an average adult in a Western population is 18.4 6 2.2 cm, 23.5 6 2.0 cm, and 28.6
6 2.3 cm, respectively (data from 244 ALT free flaps). On the horizontal axis, the cutane-
ous perforators are located an average of 1.4 cm lateral to the AP line. Forty-nine percent
of patients have two perforators, 26% have a single perforator (most commonly perforator
B), and 25% have three perforators.
In general, the proximal perforators are larger than distal ones (A . B . C). The proxi-
mal perforators are also more likely to be septocutaneous, whereas the distal ones are more
likely to be myocutaneous (46% of perforator A, 19% of perforator B, and 12% of perforator
C are septocutaneous). However, the proximal thigh is thicker than the distal thigh. The
thickness at the level of perforator A is 20% thicker than that at perforator B, which is 18%
thicker than that at perforator C. Therefore, when a thinner flap is needed, one should look
for more distal perforators, which are smaller and more likely myocutaneous.

Anterior midline of thigh

AP line Midpoint
1.4 cm
5 cm 5 cm
A B C

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
Planning
Leg positioning is extremely important, especially in obese patients. It is critical to position
the lower extremity neutral with the knee and foot pointing to the ceiling. Circumferential
skin preparation is not necessary. The most prominent point of the ASIS and the supralateral
corner of the patella are marked, and a straight line is drawn to connect these two landmarks.
This line is called the AP line. The presumed location of perforator B is marked 1.5 cm
lateral to and near the midpoint of the AP line. Next, the presumed locations of perforators
A and C are marked 5 cm proximal and distal to the presumed perforator B, respectively.
The estimated flap dimension is outlined, centering on perforator B. One must bear in
mind that the flap design may need to be recentered based on the actual perforator locations.
Most surgeons use a handheld Doppler device to detect the perforators. However, hand-
held Doppler examination can be inaccurate and misleading; therefore it should be used
with caution. None of the current imaging studies is accurate in identifying the perforators.
My experience suggests that the ABC system is the most accurate for locating perforators.
Continued

12a_AnteroThigh_r3c_bs_1350-1391.indd 1381 2/8/2012 1:18:43 PM

 1382 Part II  Regional Flaps: Anatomy and Basic Techniques

Technique
For an average-sized flap (6 to 10 cm wide), the medial incision usually falls along the
anterior midline of the thigh or 1.5 to 2.0 cm medial to the AP line. The medial incision,
approximately 15 cm long and spanning all three presumed perforators, is made first down
to the fascia over the rectus femoris muscle (see Fig. 12A-28). Subfascial dissection is easier
for less-experienced surgeons, because the “septum” between the vastus lateralis and rec-
tus femoris muscles can be easily identified in the subfascial plane. The fascia is retracted
laterally with three Allis clamps, with each one positioned at a perforator location. Once
the septum is identified, dissection must proceed more carefully. Since perforator B is most
consistent, it should be sought first. With the marked locations of the perforators and the
positions of the three Allis clamps, one should know exactly where to look for them. Once
the perforators are found, the descending branch is exposed. Intramuscular dissection is
carried out, if necessary, from distal (where the perforator exits the muscle) to proximal
through the muscle. All the flap dissections can be performed through the medial incision
only. It is important not to island the flap before identifying and dissecting out the perfora-
tors. The lateral incision may need to be modified based on the exact perforator locations
and the final dimensions of the defect. If a long vascular pedicle is not needed, the pedicle
can be divided below the rectus femoris branch that supplies the rectus femoris muscle. An
additional 2 cm of pedicle length can be obtained proximal to the rectus femoris branch.

What to Do When No ALT Perforators Are Found

In my early experience of 250 ALT flaps, 4.3% of thighs had no perforators in the ALT flap
territory. The contralateral thigh or an entirely different flap had to be chosen, resulting
in wasted time, additional incisions, and the potential for increased operative morbidity.
In addition, 26% had only one perforator. If a double skin island flap is needed, one may
wonder what next step is best. In our recent experience with the anteromedial thigh (AMT)
flap, the best option seems to be exploring the AMT flap perforators to either include or
convert to an AMT flap.

Fig. 12A-29  The AMT flap is a mirror image of the ALT flap. When the ALT flap perforators are unfa-
vorable, the AMT flap should be explored through the same incision.

Although the blood supply to the AMT flap has been inconsistent in the literature, our
100 AMT flap explorations suggest that it is the perforators from the rectus femoris branch
off the descending branch that descends medially along the medial border of the rectus
femoris muscle. This branch was also called the innominate branch in the past, but it is very
clear that it is the same branch that supplies the rectus femoris muscle and is always seen when

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1383

dividing the ALT flap pedicle, the descending branch. Therefore, by taking the descend-
ing branch proximal to the rectus femoris branch, one can potentially create a multi-island
ALT-AMT flap.

Anteromedial
thigh

Rectus femoris branch

Descending branch

Anterolateral thigh

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.

In our series, perforators from the rectus femoris branch to supply the AMT flap were
present in only 51% of cases. However, when there were no ALT perforators, all but one
patient had AMT perforators. When there was only one ALT perforator, the chances of
having an AMT perforator were 75%. The locations of the AMT perforators along the Y
axis are very similar to the locations of the ALT perforators, with the B perforator near the
midpoint of the AP line and A and C perforators 5 cm proximal and distal to the B per-
forator, respectively. On the X axis, the AMT perforators are located, on average, 3.2 cm
medial to the AP line, corresponding to the intermuscular space between the rectus femoris
and sartorius−vastus medialis muscles.
Therefore, when the ALT perforator anatomy is unfavorable, one should simply explore
the AMT perforators using the same incision. Since the AMT flap lies on the opposite side
of the AP line to the ALT flap, the AMT flap can be designed as a mirror image of the
ALT flap.

References
Lin SJ, Rabie A, Yu P. Designing the anterolateral thigh flap without preoperative Doppler or
imaging. J Reconstr Microsurg 26:67-72, 2010.
Ver Halen J, Yu P. Reconstruction of extensive groin defects with contralateral anterolateral
thigh-vastus lateralis muscle flaps. Plast Reconstr Surg 125:130e-132e, 2010.
Wong S, Garvey P, Skibber JM, Yu P. Reconstruction of pelvic exenteration defects with the
anterolateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg 124:1177-1185, 2009.
Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application
in head and neck reconstruction. Head Neck 26:759-769, 2004.
Continued

12a_AnteroThigh_r3c_bs_1350-1391.indd 1383 2/8/2012 1:18:45 PM

 1384 Part II  Regional Flaps: Anatomy and Basic Techniques

Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck 26:1038-
1044, 2004.
Yu P, Sanger JR, Matloub HS, et al. Anterolateral thigh fasciocutaneous island flaps in peri-
neoscrotal reconstruction. Plast Reconstr Surg 109:610-616; discussion 617-618, 2002.
Yu P, Selber J. Perforator patterns of the anteromedial thigh flap. Plast Reconstr Surg 128:151e-
157e, 2011.
Yu P, Youssef A. Efficacy of the handheld Doppler in preoperative identification of the cutane-
ous perforators in the anterolateral thigh flap. Plast Reconstr Surg 118:928-933; 2006.

Bibliography With Key Annotations

Ali RS, Bluebond-Langner R, Rodriguez ED, et al. The versatility of the anterolateral thigh
flap. Plast Reconstr Surg 124(6 Suppl):e395-e407, 2009.
In the past two decades, the ALT flap has emerged as one of the most popular reconstructive op-
tions for multiple body sites. This article summarized the anatomy, planning, flap harvest, donor
morbidity, and clinical applications of the ALT flap. The flap has proved to be extremely useful in
skin resurfacing and even functional reconstruction in traumatic wounds. The authors proposed an
algorithm to facilitate a clear, problem-based approach for the use of this versatile reconstructive option.
Amin A, Rifaat M, Civantos F, et al. Free anterolateral thigh flap for reconstruction of major
craniofacial defects. J Reconstr Microsurg 22:97-104, 2006.
Free tissue transfer has revolutionized skull-base surgery by expanding the ability to perform cranial
base resection and by improving the quality of reconstruction. The ALT flap has recently come into
use in head and neck reconstruction. Its role in craniofacial and midface reconstruction has not been
specifically defined. The authors reviewed 18 patients who were treated over a 5-year period. The
authors noted that the flap’s advantage in skull-base reconstruction is its reliable blood supply, which
can provide adequate dural cover and protection of the brain. Its size and moderate thickness are suitable
for reconstruction of scalp and calvarial defects. The abundance of reliably vascularized fat in the flap
may be an advantage in long-term maintenance of the volume of the flap in midface reconstruction.
Similar to other soft tissue flaps, additional skeletal reconstruction may still be required to achieve an
optimal functional and aesthetic result.
Boca R, Kuo YR, Hsieh CH, et al. A reliable parameter for primary closure of the free an-
terolateral thigh flap donor site. Plast Reconstr Surg 126:1558-1562, 2010.
Primary closure of the donor site after flap harvest is key to achieving a satisfactory result. This article
focused on the width of the harvested ALT flap to permit primary closure of the donor site. The flap
width­–to–thigh circumference ratio is a reliable parameter for preoperative planning of primary closure
of the ALT flap donor site. The authors concluded that primary closure can be achieved if the flap
width–to–thigh circumference ratio is less than 16%, taking body mass index and age into consideration.
Chen CY, Hsieh CH, Kuo YR, et al. An anterolateral thigh perforator flap from the ipsilateral
thigh for soft-tissue reconstruction around the knee. Plast Reconstr Surg 120:470-473, 2007.
The ALT perforator flap from the ipsilateral thigh based on the distalmost perforator can provide skin
and soft tissue coverage around the knee with a satisfactory clinical outcome. The operative procedure
is easy and reliable. This flap is an option for soft tissue reconstruction around the knee.
Chou EK, Ulusal B, Ulusal A, et al. Using the descending branch of the lateral femoral cir-
cumflex vessel as a source of two independent flaps. Plast Reconstr Surg 117:2059-2063, 2006.
Simultaneous reconstruction of two separate defects by two free flaps is time consuming and often
requires two donor sites. The anterior and lateral aspect of the thigh is an ideal donor site for free tissue
harvest without incurring significant morbidity. The authors described their recently developed tech-
nique, which allows harvesting two independent fasciocutaneous free flaps from the same descending
branch of the lateral circumflex femoral vessel as a new clinical application of the versatile ALT flap.

12a_AnteroThigh_r3c_bs_1350-1391.indd 1384 2/8/2012 1:18:45 PM

 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1385

Chou LS, Chang KC, Lin TW, et al. Distally based anteromedial thigh fasciocutaneous island
flap for patellar soft tissue reconstruction. J Trauma 66:1146-1151, 2009.
Muscles used for patellar and peripatellar soft tissue construction, which include the vastus medialis,
vastus lateralis, gastrocnemius, and sartorius muscles, are often clinically inadequate for reconstruction
of the patellar and peripatellar regions. Split-thickness skin grafts are also inadequate for supporting
superficial patellar tendons and resisting perpetual shear stress. The authors reported their experience
with distally based anteromedial thigh fasciocutaneous island flaps for patellar soft tissue reconstruction in
seven patients. The authors concluded that this flap is a useful and viable option for patellar soft tissue
reconstruction because of its versatile vascular pedicle, pliable deep fascia, adequate retrograde perfusion,
and the possibility of direct closure of the donor site when no losses of the medial thigh are expected.
Chuang HC, Su CY, Jeng SF, et al. Anterior lateral thigh flap for buccal mucosal defect after
resection of buccal cancer. Otolaryngol Head Neck Surg 137:632-635, 2007.
The authors reported their experience using a free ALT flap to cover buccal mucosal defects after
buccal cancer resection. Nine patients underwent primary surgical treatment between June 2005 and
September 2006. An ALT flap was used to repair the buccal defect immediately after tumor resec-
tion. Oral function, including mouth-opening width, oral intake, and teeth cleaning, were compared
preoperatively and postoperatively. No difference was observed in the mouth-opening width between
that measured preoperatively and 3 months postoperatively. The oral intake and teeth cleaning also
remained unchanged 3 months postoperatively. The authors concluded that repair of a buccal mucosa
defect with a free anterior lateral thigh flap is a good alternative for selected patients.
Cömert A, Altun S, Unlü RE, et al. Perforating arteries of the anteromedial aspect of the thigh:
an anatomic study regarding anteromedial thigh flap. Surg Radiol Anat 33:241-247, 2011.
Because the skin of the anteromedial thigh region typically is thin, pliable, and hairless, it can be a
preferred flap based on the requirements of the recipient site. This article presented a cadaveric study
in which 204 perforators were dissected in 16 lower extremities, providing useful knowledge about
localizations and number of ALT perforators. The authors concluded that septocutaneous perforators
of the anteromedial aspect of the thigh are as important as the myocutaneous perforators, and all are
adequate to perform an anteromedial thigh flap.
Crosby MA, Hanasono MM, Feng L, et al. Outcomes of partial vaginal reconstruction with
pedicled flaps following oncologic resection. Plast Reconstr Surg 127:663-669, 2011.
Immediate flap reconstruction for partial vaginal resection is often performed with resection of colorectal,
gynecologic, and urologic malignancies. Surgical and functional outcomes have not been well described.
This article highlighted the factors associated with improved outcomes in patients undergoing im-
mediate flap reconstruction for partial vaginal resection. The authors reviewed 72 consecutive partial
vaginal resections with immediate flap reconstruction performed between 2000 and 2009. Mean
follow-up was 32 months (range 1 to 93 months). Complications were higher in patients who received
preoperative radiation therapy than in those who did not (66% versus 25%) and who had posterior
defects rather than anterior defects (66% versus 30%). Patients with postoperative complications had
higher preoperative radiation doses. Of 24 patients with available postoperative sexual function data,
68% reported successful penile-vaginal intercourse. Immediate flap reconstruction for partial vaginal
resection has a high incidence of minor complications. Preoperative radiotherapy is associated with
increased complications. Most patients able to have penile-vaginal intercourse preoperatively also could
postoperatively. The authors concluded that immediate flap reconstruction for partial vaginal resection
should be considered for patients undergoing pelvic oncologic resection; however, counseling on relevant
risks and functional outcomes is vital.
Garvey PB, Selber JC, Madewell JE, et al. A prospective study of preoperative computed to-
mographic angiography for head and neck reconstruction with anterolateral thigh flaps. Plast
Reconstr Surg 127:1505-1514, 2011.
During ALT flap harvest, inadequate perforators may necessitate modification of the flap design,
exploration of the contralateral thigh, or additional flap harvest. CT angiography (CTA) may facili-
tate perforator mapping and optimize flap design. The authors reported on 16 consecutive CTA–

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 1386 Part II  Regional Flaps: Anatomy and Basic Techniques

mapped ALT flaps for head and neck reconstruction. Perforator location, origin, caliber, and course
were compared between CTA and intraoperative findings. The relationship of patient characteristics,
imaging studies, and intraoperative factors to flap design and surgical outcomes was analyzed. CTA
identified larger perforators better than smaller ones and proximal perforators better than distal ones.
It accurately predicted the location and origin of visible perforators and less accurately predicted the
size and course of visible perforators.
Gurunluoglu R. The ascending branch of the lateral circumflex femoral vessels: review of the
anatomy and its utilization as recipient vessel for free-flap reconstruction of the hip region. J
Reconstr Microsurg 26:359-366, 2010.
The ascending branch of the lateral circumflex artery may be of value as an alternative recipient vessel
in the free flap transfer to the hip region. The author reviewed the anatomy of the ascending branch
of the lateral circumflex femoral vessels with regard to size, location, and length and on the basis of
previous anatomic and clinical studies in the literature. The ascending vessels were used in the free
flap reconstruction of the hip wounds in two case examples. The ascending vessels followed an oblique
course behind the rectus femoris muscle to reach the hilus of the tensor fascia lata muscle laterally and
superiorly. The vessels were located 7 to 12 cm from the anterior superior iliac spine in the interval
between the rectus femoris and tensor fascia latae muscles. The external diameter of the artery varied
between 2 and 3 mm, accompanied by two venae comitantes measuring 1.8 to 2.5 mm. The ascend-
ing branch has a predictable location, a consistent anatomy, and an adequate caliber, and its surgical
exposure is relatively easy.
Hanasono MM, Sacks JM, Goel N, et al. The anterolateral thigh free flap for skull base recon-
struction. Otolaryngol Head Neck Surg 140:855-860, 2009.
The authors reported the outcomes of patients undergoing reconstruction after resection of skull-base
tumors with the ALT free flap. Thirty-four consecutive patients with cancers involving the skull base
underwent reconstruction with the ALT free flap between 2005 and 2008. The ALT free flap was
successfully used to reconstruct 2, 5, and 17 anterior, lateral, and posterior skull-base defects, respec-
tively. In addition, 6 and 4 combined anterior-lateral and lateral-posterior defects, respectively, were
reconstructed. The overall complication rate was 29%. There were no flap losses. Nerve grafts (6) and
fascial slings (14) for facial reanimation were performed using the lateral femoral cutaneous nerve and
fascia lata from the same donor site as the ALT free flap. By harvesting the flap and grafts simultaneous
with the resection, an average of 3 hours per case was saved. The authors concluded that the ALT free
flap is a versatile, reliable flap that should be considered a first-line option for skull-base reconstruc-
tion. Operative time is minimized by performing a simultaneous two-team approach to resection and
reconstruction, and by harvesting nerve, vein, and fascial grafts from the same donor site as the flap.
Hanasono MM, Silva A, Skoracki RJ, et al. Skull base reconstruction: an updated approach.
Plast Reconstr Surg 128:675-686, 2011.
The authors described an updated and comprehensive algorithm for skull-base reconstruction based on
data from a 10-year period. Reconstructive outcomes were analyzed from 250 patients undergoing
skull-base reconstruction from 2000 to 2009. Based on the largest series of skull-base reconstructions
to date, the authors recommended pedicled flaps for limited defects because of minimal donor site mor-
bidity and shorter operative times and hospital stays. For extensive defects and cases involving prior
surgery, irradiation, or chemotherapy, free flaps are preferred. The authors concluded that facial nerve
repair should be attempted whenever feasible, even when in the presence of preoperative weakness,
anticipated postoperative irradiation, or advanced age.
Hong JP, Kim EK. Sole reconstruction using anterolateral thigh perforator free flaps. Plast
Reconstr Surg 119:186-193, 2007.
The goal of sole reconstruction should be functional and aesthetic. These goals can be achieved by
providing the sole with a durable and comfortable weight-bearing surface, adequate contour, protective
sensation, and solid anchoring to deep tissue to resist shearing. Various flaps such as fasciocutaneous,
myocutaneous, or split skin grafted muscle flaps have been reported for reconstruction of the weight-

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1387

bearing foot. The authors reported on 69 patients treated for soft tissue defects in the plantar areas
with ALT perforator free flaps. Sensory nerve coaptation was performed in 17 cases. The follow-up
period ranged from 4 to 38 months, with a mean of 14.7 months. Most patients regained protective
sensation by 12 months regardless of nerve coaptation, but earlier sensory recovery was noted in patients
who underwent reconstruction with sensate flaps. The authors suggested that the ALT perforator flap
is a reliable option in sole reconstruction, resulting in an acceptable functional and aesthetic outcome.
Koshima I, Fujitsu M, Ushio S, et al. Flow-through anterior thigh flaps with a short pedicle for
reconstruction of lower leg and foot defects. Plast Reconstr Surg 115:155-162, 2005.
This article highlighted new flow-through perforator flaps with a large, short vascular pedicle because of
their clinical significance and a high success rate for reconstruction of the lower legs. Of 13 consecutive
cases, the authors described 2 cases of successful transfer of a short-pedicle anterolateral or anteromedial
thigh flow-through flap for coverage of soft tissue defects in the legs. This new flap has a thin fatty
layer and a small fascial component and is vascularized with a perforator originating from a short
segment of the descending branch of the lateral circumflex femoral system. The advantages of this flap
are as follows: flow-through anastomosis ensures a high success rate for free flaps and preserves the
recipient arterial flow; there is no need for dissecting throughout the lateral circumflex femoral system
as the pedicle vessel; minimal time is required for flap elevation; there is minimal donor site morbidity;
and the flap is obtained from a thin portion of the thigh. Even in obese patients, thinning of the flap
with primary defatting is possible, and the donor scar is concealed. The authors stated that this flap
is suitable for coverage of defects in legs where a single arterial flow remains and that it is also suitable
for chronic lower leg ulcers, osteomyelitis, and plantar coverage.
Kua EH, Wong CH, Ng SW, et al. The island pedicled anterolateral thigh (pALT) flap via the
lateral subcutaneous tunnel for recurrent ischial ulcers. J Plast Reconstr Aesthet Surg 64:e21-
e23, 2011.
Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric pa-
tients. Compared to sacral and trochanteric ulcers, ischial sores are the most difficult to treat, with
a low success rate following conservative therapy and a high recurrence rate after surgical treatment.
This article reviewed the use of the pedicled anterolateral thigh (pALT) flap for reconstruction of a
chronic ischial sore. The free ALT flap has an established role in reconstruction in the head and neck
and extremities. As a pedicled flap, it has been used in the primary reconstruction of the perineum,
groin, anterior abdominal wall, thigh and ischium. The authors presented the first reported case of a
paraplegic man with a recurrent ischial sore treated successfully with an island pALT flap inset via a
lateral subcutaneous approach. The authors discussed the indications and its role as a simple and reliable
secondary reconstructive option in the treatment of recurrent ischial ulcers after first-line locoregional
surgical options have been exhausted.
Kuo YR, Yeh MC, Shih HS, et al. Versatility of the anterolateral thigh flap with vascularized
fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional
assessment of the donor site. Plast Reconstr Surg 124:171-180, 2009.
The ALT flap is commonly used for reconstruction of various soft tissue defects. The authors presented
their approach to one-stage reconstruction of composite soft tissue defects using an ALT flap with a
vascularized fascia lata; 973 patients underwent ALT flap reconstruction for various soft tissue defects
over 10 years. Various types of complicated defects in 36 patients were reconstructed with a composite
ALT flap combined with vascularized fascia lata. Functional outcomes of donor sites were measured
with a dynamometer. The overall flap survival rate was 97%. Patients achieved satisfactory results
without major postoperative complications. The study revealed that vascularized fascia may mimic a
fascial sheath but lacks the muscle-synchronized excursion properties. Apart from a mild deficiency
in quadriceps femoris muscle contraction in the donor thighs, no difficulties in daily ambulation were
reported by the patients. The authors concluded that ALT flap with vascularized fascia lata provides
a reliable fascial component for single-stage reconstruction of complex soft tissue defects.

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 1388 Part II  Regional Flaps: Anatomy and Basic Techniques

Lannon DA, Ross GL, Addison PD, et al. Versatility of the proximally pedicled anterolateral
thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg
127:677-688, 2011.
The authors evaluated their experience with consecutive cases of the pedicled ALT flap in complex
abdominal and pelvic reconstruction. A retrospective review of medical records and photographic archives
was performed on 28 proximally pedicled ALT flaps in 27 patients. The authors identified the arcs
of rotation achieved, the types of defects reconstructed, points of surgical technique that enhanced their
results, and some pitfalls of this flap. Useful points of surgical technique identified included suprafascial
flap harvesting, extended harvesting of fascia, use of fascia to protect the pedicle, harvesting as a composite
flap with the vastus lateralis, prudent preservation of large perforators that transgress the lateral aspect
of the rectus femoris, synergistic use with a sartorius “switch,” complete flap deepithelialization to fill
dead space, and simple conversion to a free flap when pedicle length is inadequate. Pitfalls identified
included the increased risk of pedicle avulsion in the morbidly obese, the risk of atherosclerotic plaque
embolization in an atheromatous pedicle, and the potential inadequacy of thigh fascia for reconstitut-
ing abdominal wall integrity.
Lee GK, Lim AF, Bird ET. A novel single-flap technique for total penile reconstruction: the
pedicled anterolateral thigh flap. Plast Reconstr Surg 124:163-166, 2009.
This was the first reported case of single-flap total penile reconstruction using a pedicled ALT flap.
Although both the ALT flap and the radial forearm free flap can create functional phallus, the distinct
advantage of the pedicled ALT flap reconstruction is that there is no need for microsurgery, and no
ischemic time. The ALT flap also produces a more aesthetic reconstruction; it provides bulk that is less
prone to atrophy, with a better color match and a donor site scar that is easier to conceal. The pedicled
ALT flap is the authors’ first choice for penile reconstruction.
Lin CH, Wei FC, Lin YT, et al. Lateral circumflex femoral artery system: warehouse for func-
tional composite free-tissue reconstruction of the lower leg. J Trauma 60:1032-1036, 2006.
Microsurgical free flap surgery has progressed from simply providing wound coverage to restoring a high
level of function. The authors used 44 free flaps to restore functional and structural defects in the lower
limbs. The versatility of the LCFA system allowed use of the anterolateral thigh, vastus lateralis, tensor
fascia lata, rectus femoris, and iliac crest. Combinations of tissues from this system were employed to
restore defects in the patellar tendon, Achilles tendon, extensor hallucis tendon, anterior compartment
with or without lateral compartment muscle, anterior compartment muscle and segmental tibial bone,
and composite calcaneus. The free flap success rate was 97.7%. Four reexplorations were performed,
with one subsequent failure. Eight patients (18.2%) developed wound infections, of which two required
secondary amputations, resulting in a limb salvage rate of 95.4%. The authors concluded that the
LCFA system provides a predictable and versatile surplus of tissue necessary to restore functional and
structural integrity of the posttraumatic lower extremity in a single stage.
Mureau MA, Posch, NA, Meeuwis CA, et al. Anterolateral thigh flap reconstruction of large
external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-
site outcome. Plast Reconstr Surg 115:1077-1086, 2005.
This article reviewed the subjective and the objective functional and aesthetic follow-up results of the
recipient and donor sites after reconstruction of extensive facial defects with the ALT flap. The ALT
flap was used to reconstruct large facial skin defects after malignant tumor resection in 23 patients. All
patients had a standardized interview, physical examination, and clinical photographs. Fasciocutane-
ous ALT flaps were used in 15 patients and myocutaneous flaps were used in eight patients with
exposed dura, open sinuses, or orbital defects. An extra free osteocutaneous fibula flap was necessary
to reconstruct the affected mandible in 10 patients. The donor site was skin grafted in 18 patients.
The flap survival rate was 96%. At follow-up, color mismatch (71%) and flap bulkiness (50%)
were encountered most often. Four of five patients with speech problems received an additional free
osteocutaneous fibula flap. Three flap contractures were seen in the neck region. A contour defect of

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1389

the upper leg was encountered in five patients. Sensory disturbances of the upper leg were observed in
12 patients. Cold intolerance occurred three times after skin grafting. No significant impairment was
found in range of motion and muscle strength of the donor leg. The authors stated that careful patient
selection may further improve aesthetic outcome of the ALT flap. They concluded that the versatility in
design and composition of the ALT flap and the low donor site morbidity and satisfactory recipient site
outcome make it a valuable option in reconstruction of external skin defects in the head and neck region.
Nojima K, Brown SA, Acikel C, et al. Defining vascular supply and territory of thinned per-
forator flaps: part I. Anterolateral thigh perforator flap. Plast Reconstr Surg 116:182-193, 2005.
The ALT perforator flap is increasingly being used for trauma and reconstructive surgical cases. With
the thinned flap design, greater survivability and a decrease in donor site morbidity are observed. This
article reviewed an anatomic study performed to determine pedicle number, location, and diameter;
accompanying veins; vascular territory; and where surgical incisions can be made safely during thin-
ning, as opposed to the danger zone. Thirteen ALT perforator flaps were harvested from seven adult
cadavers. The largest perforator arteries were cannulated, and flaps were thinned to a thickness of 6 to
8 mm, with a 2.5 cm radius from the perforator retained. Vascular territories were quantified before
and after thinning by nonradiographic and radiographic methods. A series of dyes were injected: red
dye for skin (photography) followed by Omnipaque for the whole flap (radiography) before thinning,
and blue dye for skin (photography) and lead oxide for the whole flap (radiography) after thinning.
Pedicle locations were determined by ratios of anatomic landmarks. Danger zone measurements were
derived at specific thicknesses using lateral radiographs of each flap. Four respective vascular territory
maps were drawn showing surgical territories using percentile confidence intervals (98th and 90th)
and averages. From the skin at thicknesses of 4, 6, and 8 mm, the 98th percentile danger zones were
33 to 37 mm (proximal to distal), 30 to 35 mm, and 27 to 31 mm from the pedicle in the vertical
axis, respectively; in the horizontal axis, they were 30 to 34 mm (medial to lateral), 28 to 31 mm,
and 25 to 29 mm. These data define ALT perforator flap pedicle location, number, and diameter
before harvesting, surgical danger zones during thinning, and vascular territories after thinning. The
authors’ guidelines provide surgeons with anatomic vascular territory maps to design and harvest
specific flaps for optimal results.
Rodríguez-Vegas JM, Angel PA, Manuela PR. Refining the anterolateral thigh free flap in
complex orbitomaxillary reconstructions. Plast Reconstr Surg 121:481-486, 2008.
Complex cranioorbitomaxillary reconstructions are highly demanding for the plastic surgeon; more-
over, suboptimal reconstruction can limit excisional operations because of intracranial complications or
disfiguring results. The anterolateral thigh flap can provide an acceptable one-stage reconstruction with
minimal intracranial complications. A flap design consisting of two skin islands for nasal lining and
palatal closure, a portion of vastus lateralis for dead space collapse and bulk, and a suspension of the
whole reconstruction with vascularized fascia can provide a satisfactory reconstruction with minimal
complications and donor site morbidity.
Sacks JM, Nguyen AT, Yu P, et al. Laser-assisted indocyanine green imaging optimizes the
design of the anterolateral thigh flap. Plast Reconstr Surg 127:72, 2011.
Saint-Cyr M, Schaverien M, Wong C, et al. The extended anterolateral thigh flap: anatomical
basis and clinical experience. Plast Reconstr Surg 123:1245-1255, 2009.
The ALT flap can be reliably extended to include adjacent vascular territories. The vascular basis of
this phenomenon is poorly understood. This article focused on the three- and four-dimensional arterial
and venous anatomy of the extended anterolateral thigh flap and reviews the results of a clinical series
of extended anterolateral thigh flaps. Fifteen anterior hemithigh specimens were harvested from fresh
cadavers. Four-dimensional CT angiography was used to investigate the arterial and venous anatomy
and pattern of perfusion. Injection of perforators within the lateral circumflex femoral vascular territory,
and those of the common femoral and superficial femoral arteries, was performed to investigate the
vascular connections within the extended anterolateral thigh flap. Static three-dimensional imaging and

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 1390 Part II  Regional Flaps: Anatomy and Basic Techniques

latex dissections were also performed to confirm the results. A clinical series of 12 consecutive patients
was reviewed in which extended ALT flaps were used for posttrauma or postoncologic reconstruction.
The authors highlighted the vascular basis and clinical safety of the extended ALT flap, which can be
harvested if the linking vessels between adjacent vascular territories in the anterior thigh are preserved.
The authors show that the extended flap is reliably perfused by a single dominant perforator.
Schoeller T, Huemer GM, Shafighi M, et al. Free anteromedial thigh flap: clinical application
and review of literature. Microsurgery 24:43-48, 2004.
The authors reported their series of five patients treated with the AMT flap for defects in the head and
neck region and lower extremity. They consistently found the pedicle as an emerging septocutaneous
perforator at a point at which the medial border of the rectus femoris muscle is crossed by the sartorius
muscle. In all five patients, the AMT flap provided stable coverage with no flap loss. They concluded
that the anteromedial thigh flap offers all the advantages of fasciocutaneous flaps. Therefore this flap
is a useful alternative for defects requiring coverages of thin to moderate skin thickness.
Spyropoulou GA, Lin PY, Chien CY, et al. Reconstruction of the hypopharynx with the
anterolateral thigh flap: defect classification, method, tips, and outcomes. Plast Reconstr Surg
127:161-172, 2011.
This article reviewed the authors’ experience over 5 years with reconstructions of hypopharyngeal defects
using ALT flaps. Fifty-five ALT flaps were harvested for reconstruction of hypopharyngeal defects
after tumor ablation in 54 patients. Patient age ranged from 38 to 77 years (average 54 years). In 24
cases, free flaps were used for reconstruction of circumferential defects; in 28 cases, they were used to
reconstruct partial defects; and in 3 cases, they were used to reconstruct circumferential and skin defects.
Total flap loss occurred in 1 patient and partial flap loss occurred in 3 patients. Strictures occurred in
three patients and fistulas occurred in 10. In one case, arterial occlusion was noticed postoperatively.
The arterial anastomosis was revised and the flap was salvaged. In another case, venous occlusion
was noted. The vein was reanastomosed with a vein graft and the flap was salvaged. Postoperatively,
seven patients tolerated a regular diet. The donor site was skin grafted in five cases, closed with re-
verse ALT in one case and with retrograde V-Y advancement flap in one case, and closed primarily
in the rest. There were no donor site complications. The authors concluded that reconstruction of the
hypopharynx with the ALT flap offers versatility in the coverage of large and complex defects and is
associated with minimal donor site morbidity.
Wong S, Garvey P, Skibber J, et al. Reconstruction of pelvic exenteration defects with antero-
lateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg 124:1177-1185, 2009.
The rectus abdominis may be unavailable or insufficient to reconstruct large pelvic exenteration defects.
This article reviewed the authors’ experience with the pedicled anterolateral thigh–vastus lateralis
muscle flap for such reconstructions. Eighteen patients with pelvic exenteration underwent reconstruc-
tion with this flap. When the perineal defect could be closed primarily, the vastus lateralis muscle was
tunneled over the inguinal ligament into the pelvis (inguinal route). For concomitant perineal-vaginal
reconstruction, the ALT–vastus lateralis muscle was tunneled over the medial thigh to the defect
(perineal route). All 18 patients received preoperative chemoradiation. Nine patients received intraop-
erative pelvic brachytherapy. After pelvic exenteration, a colostomy was created in all patients, and a
urostomy with ileal conduit was created in 8 patients. The inguinal route was used in 6 patients and
the perineal route was used in 10 patients. In the remaining 2 patients, the anterolateral thigh–vastus
lateralis muscle from one thigh was delivered through the perineal route and the contralateral vastus
lateralis flap was delivered through the inguinal route. Postoperative complications included five small
perineal wound dehiscences that healed spontaneously, one flap failure caused by pedicle tension in
an obese patient with a short thigh, an enterocutaneous fistula, and an ileal conduit leak that healed
spontaneously. No hernias occurred.

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 Thigh  •  12A: Anterolateral Thigh (ALT) and Anteromedial Thigh (AMT) Flaps 1391

Yang JY, Tsai FC, Chana JS, et al. Use of free thin anterolateral thigh flaps combined with
cervicoplasty for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg
110:39-46, 2002.
The authors presented their experience using free thin ALT flaps combined with cervicoplasty in a
series of seven patients who underwent reconstruction for previous burn injury. The authors used a
suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures
had resulted from flame burns in six patients and from a chemical burn in one patient. The size
of flaps ranged from 11 by 5 cm to 26 by 8 cm. The average operative time was 6 hours, and the
average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss.
The donor site was closed primarily in five cases and with a split-thickness skin graft in two cases.
At follow-up, the functional improvement included a mean increase in extension of 30 degrees, in
rotation 18 degrees, and in lateral flexion 12.5 degrees. The average cervicomandibular angle was
improved by 25 degrees. The authors concluded that the use of free thin ALT flaps combined with
cervicoplasty in a one-stage reconstruction with a thin, pliable flap achieves good cervical contour with
low donor site morbidity.
Yu P, Selber J. Perforator patterns of the anteromedial thigh flap. Plast Reconstr Surg 128:151e-
157e, 2011.
This article highlighted the perforator patterns and vascular anatomy of the ALT flap. In the authors’
investigation, 21 of 100 thighs had no anteromedial thigh perforators. For the remaining thighs,
there were two sources of perforators: the rectus femoris branch of the descending branch of the lateral
circumflex femoral artery, and the superficial femoral artery. Perforators from the latter were short and
small and thus less useful. AMT flaps based on rectus femoris branch perforators shared the same
vascular pedicle as the ALT flap and were thus clinically useful. However, these rectus femoris branch
perforators were present in only 51% of the patients. Their surface locations followed a similar pattern
as the ALT flap, with the majority of perforators near the midpoint, but an average of 3.2 cm medial
to a line connecting the anterior superior iliac spine and the superolateral patella. Forty-three thighs
had a single rectus femoris branch perforator and eight had two perforators; 66% were septocutane-
ous, and the rest traversed a thin layer of the rectus femoris muscle. The authors concluded that it is
best to plan the anteromedial thigh flap to complement the ALT rather than to be the primary flap.
Zeng A, Qiao Q, Zhao R, et al. Anterolateral thigh flap-based reconstruction for oncologic
vulvar defects. Plast Reconstr Surg 127:1939-1945, 2011.
Vulvar defects after tumor extirpation always require immediate reconstruction. Transferring a skin
flap from a distant region may be required for large defects. The authors reviewed their experience with
the ALT flap for vulvar reconstruction. Eleven patients with vulvar carcinoma underwent resection
and immediate reconstruction with the ALT flap. Based on defect type and local soft tissue quality,
four types of ALT flap reconstructions were performed: unilateral ALT flap, ipsilateral ALT flap
combined with contralateral advancement flap or local flap, fenestrated ALT flap, and split ALT flap.
Postoperative complications were recorded and clinical outcomes were evaluated. Partial flap necrosis
occurred in one patient with a fenestrated ALT flap for bilateral reconstruction. One wound dehiscence
occurred in the contralateral local flap. Two patients had prolonged serous drainage. Mean follow-up
was 8 months. One patient developed stricture of the urethral meatus and another had regional metas-
tasis. The authors concluded that with careful design, the ALT flap may provide reliable and durable
soft tissue coverage for various vulvar defects with good outcomes and minimal donor site morbidity.

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 ANATOMIC LANDMARKS
Landmarks The area of the medial knee, extending from the medial border
of the patella to the medial border of the popliteal fossa. The
flap can extend 10 cm above the knee to approximately 20 cm
below it.
Size 8 3 25 cm.
Composition Fasciocutaneous, type A.
Dominant Pedicle Saphenous artery.
Nerve Supply Sensory: Anterior femoral cutaneous nerve, saphenous nerve.

12b_Saph_r5_cah_1392-1417.indd 1392 2/7/2012 2:57:20 PM

 Section 12B
Thigh

Saphenous and Medial

Condylar Flaps

CLINICAL APPLICATIONS
Regional Use
Thigh
Knee
Popliteal fossa
Distant Use
Head and neck
Upper extremity
Lower extremity

12b_Saph_r5_cah_1392-1417.indd 1393 2/7/2012 2:57:23 PM

 ANATOMY OF THE saphenous and medial condylar flaps

A B

Pectinus
muscle

Superficial Adductor longus muscle Femoral vein

femoral artery Superficial
Adductor magnus muscle Greater saphenous vein
femoral artery
Sartorius muscle Gracilis muscle Gracilis muscle
Sartorius muscle
Descending genicular artery Descending genicular artery
Vastus
medialis muscle Vastus medialis
Saphenous artery Saphenous artery
muscle
Posterior distal branches Posterior distal branches
Anterior branches of Anterior branches of
of saphenous artery of saphenous artery
saphenous artery saphenous artery

Arterial supply Venous supply

C D

Saphenous nerve

Anterior branch Anterior branch

of medial of medial
cutaneous nerve Posterior branch of medial cutaneous nerve Posterior branch of medial
cutaneous nerve of thigh cutaneous nerve of thigh

Branches of saphenous nerve Branches of saphenous nerve

Sensory nerve supply Sensory nerve distribution to flap territory

Fig. 12B-1

Dominant pedicle: Saphenous artery

12b_Saph_r5_cah_1392-1417.indd 1394 2/7/2012 2:57:28 PM

 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1395

ANATOMY
Landmarks Flap occupies the area medial to the knee, running from the medial border
of the patella to the medial border of the popliteal fossa. The flap can extend
10 cm above the knee and 20 cm below the knee.
Composition Fasciocutaneous.
Size 8 3 25 cm.

Arterial Anatomy
Dominant Pedicle  Saphenous artery
Regional Source  Descending genicular artery from the superficial femoral artery.
Length  5 to 15 cm.
Diameter  1.5 to 2 mm.
Location  The descending genicular artery arises from the medial side of the superficial femoral
artery just proximal to where the superficial femoral artery passes into the adductor canal. The
proximal portion of the genicular artery lies deep to the roof of the canal. One of its major
branches is the saphenous artery. The saphenous artery runs in a distal, superficial direction,
and within 2 cm of its origin it pierces the adductor canal roof and courses within a loose fascial
space deep to the sartorius muscle. The artery runs distally in this plane for up to 15 cm. It then
passes into the medial aspect of the leg near the insertion of the sartorius muscle. The cutaneous
perforators supply the proximal flap and branch along the course of the artery under the sarto-
rius muscle; these branches are anterior and posterior to the sartorius muscle and vary greatly in
size and number. Fifty percent of the time, the anterior branches are the major blood supply to
the skin territory immediately anterior to the sartorius muscle. In the knee area, the saphenous
artery and the branches of the descending geniculate artery have a rich collateralization with the
superior and inferior genicular arteries. These are the basis of the reverse flow saphenous flap.

Venous Anatomy
Paired venae comitantes accompany the descending genicular artery; these combine and drain into
the superficial femoral vein. The diameter at this point is 2 to 2.5 mm. The flap is also drained by
the greater saphenous vein that runs superficially within this territory, 1 to 2 cm posterior to the
artery. The vein in this region is quite thick, measuring 3 to 4 mm.

Nerve Supply
Sensory Two nerves supply sensation to different regions of the flap. The medial femo-
ral cutaneous nerve is a branch of the femoral nerve that pierces the deep fas-
cia of the thigh in the lower third of the leg and follows the medial border
of the sartorius muscle in a plane superficial to the fascia. Its anterior branch
provides sensation to the superior portion of the flap above the knee; its pos-
terior branch continues distally beneath the deep fascia, piercing it at the level
of the knee and supplying a cutaneous distribution that is more posterior.
   The saphenous nerve is a cutaneous branch of the femoral nerve that follows
the saphenous artery in the subsartorial space and pierces the deep fascia with
the saphenous artery proximal to the sartorius insertion. The saphenous nerve
then follows the greater saphenous vein through the leg, remaining posterior
to the vein. This nerve supplies sensation to the medial knee, as well as to the
distal anterior medial leg and the medial border of the foot.

12b_Saph_r5_cah_1392-1417.indd 1395 2/7/2012 2:57:28 PM

 1396 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Saphenous and M edial Condylar Flaps

A

Flap elevated with proximal pedicle dissected

Flap after harvest

Anterior perforators Posterior perforators

Radiographic dye injection study of flap

Fig. 12B-2 

Dominant pedicle: Saphenous artery branch of descending genicular artery (D)

v, Saphenous vein

12b_Saph_r5_cah_1392-1417.indd 1396 2/7/2012 2:57:30 PM

 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1397

FLAP HARVEST
Design and Markings
The key landmark in saphenous flap design is the sartorius muscle, which runs along a line
drawn from the anterior superior iliac spine to the medial epicondyle of the tibia. Before
the skin paddle is designed, the dominant vascular pattern for that patient is identified by
handheld Doppler examination or angiography. The proximal flap margin is drawn 10 cm
above the knee joint; the distal margin will depend on the reconstructive need. Primary
closure can be obtained in flaps 6 cm wide or less.

A B

Sartorius muscle Sartorius muscle

Saphenous artery Saphenous artery

Outline of anteriorly based Outline of posteriorly based

saphenous flap saphenous flap

Fig. 12B-3  A, If the anterior or “early” 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.

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 1398 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
The patient is placed in the supine position with the knee flexed; the lateral decubitus posi-
tion is also acceptable. A tourniquet is placed on the proximal thigh.

Frog-leg positioning with pads securing ankles

Fig. 12B-4 

12b_Saph_r5_cah_1392-1417.indd 1398 2/7/2012 2:57:33 PM

 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1399

GUIDE TO FLAP DISSECTION

The first incision is made in the medial thigh over the sartorius muscle.

Sartorius muscle
Medial femoral cutaneous nerve
Greater saphenous vein

Vastus medialis muscle

Gracilis muscle

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.

The anterior border of the sartorius muscle is identified; the medial femoral cutaneous
nerve, which parallels the anterior border of the sartorius, should be identified and spared.
Deep fascia over the sartorius muscle is incised and dissected off its anterior portion. At the
posterior border, the greater saphenous vein must be carefully preserved. The muscle is then
reflected so that a blunt dissection can be performed and the saphenous artery be identified.

Sartorius muscle
Descending genicular artery
Medial femoral cutaneous nerve Greater saphenous vein

Vastus medialis muscle

Saphenous artery
Saphenous nerve

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.

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 1400 Part II  Regional Flaps: Anatomy and Basic Techniques

Next, the saphenous artery is traced distally and the locations of its cutaneous perforators
determined. Once perforators are confirmed to be within the flap design, the distal flap can
be incised and explored. Because of the variability of anatomy, there may be several op-
tions for vascularizing the flap. If the surgeon thinks the perforators anterior to the sartorius
muscle are dominant, exploration continues anteriorly, and the flap is raised from anterior
to posterior over the sartorius muscle. If it is thought that both the anterior and posterior
perforators are approximately equal, a section of sartorius muscle is taken with the flap,
and both sets of perforators are included in the flap. In some cases the anterior perforators
are not present, and the flap must be perfused by the posterior branches; then the surgeon
includes branches of the distal saphenous artery, which give off cutaneous branches below
the insertion of the sartorius tendon.
Once the source of vascularization is ensured, the skin incision is completed. If the
saphenous vein will be included as venous drainage for the flap, it is dissected proximally
until an adequate length is obtained, and it is divided. The sartorius artery can be followed
to the adductor canal, which yields a pedicle length of 15 cm.

C D
Descending Greater saphenous vein
genicular artery
Posterior branch of medial
Medial femoral cutaneous nerve of thigh Descending
cutaneous nerve genicular artery

Saphenous artery
Sartorius muscle
Saphenous
artery and venae
comitantes

Anterior flap Saphenous Sartorius

nerve muscle (cut)

Posterior flap

Fig. 12B-5  C, The sartorius muscle is then retracted inferiorly and medially, exposing the subsar-
torius 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.

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 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1401

FLAP VARIANTS
•  Reverse saphenous flap
•  Sensate flap
•  Osteofasciocutaneous flap (medial femoral condylar flap)

Reverse Saphenous Flap

As noted earlier, there is a rich collateral anastomosis between the descending genicular
artery and the superior and inferior genicular arteries. Because of this interconnection,
proximal division of the saphenous and descending genicular arteries allows continued
perfusion of the flap through this retrograde flow. In general, the skin paddle will be located
more proximally than for a standard saphenous flap to allow pedicle length for rotation.
In this case, dissection is initially posterior, with identification of the saphenous artery and
confirmation of the cutaneous perforators within the flap design. The proximal incision is
made and at this point the saphenous artery and vein are divided. The key communication
for this reverse flap is the communication of the saphenous artery with the medial inferior
genicular artery below the knee.

A B
Descending
genicular artery

Saphenous artery
branch of descending
genicular artery

Saphenous vein
Medial superior
genicular artery

Division of proximal saphenous artery and vein Flap elevation

Fig. 12B-6 

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 1402 Part II  Regional Flaps: Anatomy and Basic Techniques

Sensate Flap
By inclusion of an appropriate cutaneous nerve, a sensate flap can be used for reconstruc-
tion. Inclusion of the branches of the medial femoral cutaneous nerve will provide sensa-
tion to a proximally based flap. Sensation to a flap positioned distal to the knee joint would
require inclusion of the saphenous nerve. This does allow a long length of nerve; however,
the downside is that innervation of the saphenous distribution of the lower leg and foot is
interrupted. If sensory innervation is desired for the entire flap, both above and below the
knee, both nerves should be harvested; if a free flap is required, it is reinnervated at the
recipient site.

Medial femoral
cutaneous nerve
Saphenous nerve

Saphenous vein

Elevation of neurosensory island flap with both

medial femoral cutaneous and saphenous nerves

Fig. 12B-7 

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 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1403

Osteofasciocutaneous Flap
(Medial Femoral Condylar Flap)
A section of bone can be harvested based on the osteoarticular branch of the descending
genicular artery. This vessel supplies the periosteum and cortex of the medial supracondylar
area of the femur. A cortical-cancellous segment of bone can be carried which measures
8 by 1.5 by 1.5 cm. One advantage of this flap compared with others is the independence
of the skin and bone components and the lengthy vessels, which allows independent posi-
tioning without constraint.

A B

Descending genicular artery Saphenous

vein Descending
Osteoarticular branch of
genicular artery
descending genicular artery

Adductor magnus tendon

Superomedial genicular artery

Medial collateral ligament

Blood supply to medial Donor site medial condyle

femoral condylar flap of femur (outline)

C D

Area of bone harvest Elevation of osteofasciocutaneous flap

on medial femoral condyle for microvascular transplantation

Fig. 12B-8 

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 1404 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Proximally based flaps can cover the anterior knee and the popliteal fossa. Distally based
flaps are particularly useful for the knee and defects of the upper third of the leg.

A B C

Standard arc of rotation Reverse arc of rotation Arc to superior leg

Fig. 12B-9 

FLAP TRANSFER
Standard Flap
The standard flap can be transferred as a direct transposition or can be passed through a
subcutaneous tunnel. The tunnel must be of adequate size to prevent compression of the
vascular pedicle.

Reverse Flap
The reverse flap is usually transferred as a transposition flap by connecting the donor site
and recipient site with an incision. It is more difficult to create a subcutaneous tunnel when
crossing the knee joint, although in some cases it may be desired.

FLAP INSET
Flaps should be secured to the recipient sites without tension and without kinking or tor-
sion of the pedicle.

Free Flap
The vascular pedicle supplied with the flap is lengthy with a good diameter. Tension-free
microvascular anastomosis and adequate pedicle length must be ensured to prevent torsion
or kinking from excessive length.

DONOR SITE CLOSURE

All Flap Variants
Flaps 6 cm or less in diameter can be closed primarily, with subcutaneous undermining to
facilitate this. Otherwise, a skin graft can be used to close the donor site.

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 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1405

CLINICAL APPLICATIONS
This patient presented with a skin defect over the right malleolus.

A B

C D

AM
SM

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, Ap-
pearance of the flap on postoperative day 5. E, The result is seen 18 months postoperatively. (Case
courtesy Sebat Karamürsel, MD.)

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 1406 Part II  Regional Flaps: Anatomy and Basic Techniques

This 45-year-old man had proximal phalanx nonunion of the ring finger of his right hand.
A medial femoral condyle (MFC) corticoperiosteal flap was planned.

A B

C D

E F

Fig. 12B-11  A, Medial approach to the distal femur. Note the length and caliber of the descend-
ing 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 radio-
graphic result is seen at 8 weeks and F, 4 months. (Case courtesy James P. Higgins, MD.)

12b_Saph_r5_cah_1392-1417.indd 1406 2/7/2012 2:57:50 PM

 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1407

This 27-year-old patient had proximal ulnar nonunion.

A B

C D

E F

G H

Fig. 12B-12  A and B, Radiographs of proximal ulnar nonunion. C and D, A large 8 cm corticocancel-
lous 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 post-
operatively. G and H, After the ulna healed, the patient’s pronation and supination were fully restored.
(Case courtesy James P. Higgins, MD.)

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 1408 Part II  Regional Flaps: Anatomy and Basic Techniques

This 65-year-old patient presented with radius nonunion. An MFC flap was planned.

A B

C
Descending genicular artery

Osteoarticular branch of Muscle branches 1 and 2

descending genicular artery
Adductor magnus tendon
Distal cutaneous branch of
Transverse branch descending genicular artery

Longitudinal branch Superomedial genicular artery

Medial collateral ligament

D E

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.

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 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1409

F G

I J

Fig. 12B-13  F and G, The results are seen radiographically at 4 weeks postoperatively; H and I, 8
weeks postoperatively; and J, 14 weeks postoperatively. (Case courtesy James P. Higgins, MD.)

12b_Saph_r5_cah_1392-1417.indd 1409 2/7/2012 2:58:02 PM

 1410 Part II  Regional Flaps: Anatomy and Basic Techniques

This 55-year-old patient had an extensive carpal osteomyelitis defect after debridement.

B C
A

D E F

G H I

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 corticocancel-
lous 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, Radio-
graphic views 10 weeks postoperatively. (Case courtesy James P. Higgins, MD.)

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 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1411

Pearls and Pitfalls

• It is essential to identify the dominant blood supply for the particular patient at hand,
because there is significant variability of anatomy in this area. In other words, the surgeon
must know the location and size of the perforators before fully committing to a flap design.
• The saphenous artery may be absent in up to 5% of patients.
• This is a useful flap when a thin, neurosensory flap is required.
• The donor site scar may be undesirable in women and children.
• Two major lymphatic trunks run the length of the flap with the saphenous vein. This
may have potential uses in the future for lymphatic bypass.

EXPERT COMMENTARY
Sebat Karamürsel

Anatomic Considerations
Skin over the medial side of the knee joint was first used by Acland et al1 as a free flap. The
medial side of the knee joint provides a thin skin, especially if the flap is planned distally.
The medial femoral cutaneous nerve or saphenous nerve may be used if a sensory flap is
needed. If above-the-knee skin is elevated, the saphenous nerve must be preserved, although
it lengthens the operation. If below-the-knee skin is elevated, the medial femoral cutaneous
nerve must be preserved.
The saphenous flap has a long, wide arterial pedicle and an extraordinarily long venous
pedicle if the great saphenous vein is used. An arterialized venous flap may also be planned
based on the great saphenous vein. The donor site scar is relatively inconspicuous, especially
if the defect is closed primarily. This flap may also be suitable for knee defect coverage if
used as an island flap.

Reference
1. Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular flap. Plast
Reconstr Surg 67:763-764, 1981.

EXPERT COMMENTARY
James P. Higgins

Indications
The medial femoral condyle (MFC) corticoperiosteal flap has received increasing attention
for many applications since it was originally described in 1991. The favorable characteristics
and osteogenic capabilities of the flap have led to its use in long bone nonunions, metacarpal
and phalangeal nonunions, carpal and tarsal nonunions and avascular necrosis, and calvarial,
orbital, and maxillary/mandibular defects. It is conventionally regarded as a pliable cortico
Continued

12b_Saph_r5_cah_1392-1417.indd 1411 2/7/2012 2:58:07 PM

 1412 Part II  Regional Flaps: Anatomy and Basic Techniques

periosteal vascularized flap that may be molded and contoured around small nonunion sites
with small or no bone deficits. It can provide a solution for recalcitrant nonunions when
larger, well-established vascularized bone flaps (such as the fibula and iliac crest) would result
in higher morbidity or create difficulty in their application to small or irregularly shaped
bone defects. The MFC flap has gained attention in the treatment of recalcitrant scaphoid
nonunions when the use of other free vascularized bone flaps is not possible.
Recent studies demonstrate continued expansion of the indications for the use of this
flap to include its use as a corticocancellous semistructural flap. Literature reports have
included corticocancellous segments of up to 10 cm in length. Recent selective injection
studies have indicated that the descending genicular artery (DGA) can provide perfusion
for the distal 13.7 cm of the medial femur, suggesting that this may be the limit of this flap’s
utility for larger osseous defects.

Advantages and Limitations

This flap has provided a low morbidity alternative to vascularized bone harvest in com-
parison to other free bone harvest sites. Unlike the fibula flap, for example, this flap can
preserve the integrity of the remaining femur; avoid sacrificing a major vessel to the distal
extremity; be harvested in various thicknesses and configurations for various defects (such
as the pliable corticoperiosteal flap for onlay around nonunions without segmental bone loss
or trapezoidal corticocancellous flaps for wrist or ankle fusion defects); provide a generous
skin paddle and still permit primary closure of donor site; provide a greater proportion of
cancellous bone content; and be more conveniently harvested in the supine position during
two-team surgery.
However, the corticocancellous ratio of the fibula shaft is significantly higher (0.65
versus 0.11) than the MFC, suggesting that the MFC would not provide the same structural
characteristics if required for long bone cases. Additionally, the perfusion zone of the DGA
(13.7 cm of the medial column of the femur) limits the length of osseous defects that can
be treated with the MFC to small- and medium-length deficits.

Anatomic Considerations
Although the saphenous artery has been described as the skin-perfusing branch of the os-
teocutaneous MFC flap, the saphenous artery may originate from the superficial femoral
artery separate from the descending genicular artery in a minority of cases. Additionally,
the DGA may be absent in some cases, leaving the MFC flap perfused by the superomedial
genicular artery. In both of these situations, the use of the chimeric saphenous artery and
MFC flap would not be possible.
The skin overlying the MFC also receives perfusion from a smaller and more distal
cutaneous vessel that can be seen branching from the DGA at the level of the condyle (de-
scending genicular artery cutaneous branch: DGA-CB). This can be used as an alternative
source of skin perfusion for the osteocutaneous MFC flap.

Personal Experience and Insights

The use of the MFC bone flap has been described most often without a skin component.
In the first 100 cases described in the literature, fewer than 20 were osteocutaneous flaps. In
my experience, the routine use of the skin component of this flap provides two important
advantages: first, it permits accurate monitoring of the underlying bone perfusion, particu-
larly in the first critical days after transfer; second, an advantage is gained by tension-free
skin closure over the anastomosis. In areas around the distal extremities (hand/wrist/foot/
ankle), closure after complex reconstructive and microsurgical cases may be difficult without

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 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1413

the additional skin paddle. Routine use of the skin component requires a thorough under-
standing of the saphenous artery flap and the anatomy of the distal cutaneous skin branches
of the DGA.

Recommendations
Planning Considerations and Technique
The flap dissection is approached with the intent of harvesting a skin paddle regardless of
the variations in anatomy. A sweeping curvilinear incision is created starting at Hunter’s
canal and moving distally and anteriorly to the midpoint between the medial border of the
patella and the MFC, where it continues distally and posteriorly, stopping 2 to 3 cm below
the joint line and just posterior to the midaxis of the leg. This skin incision is continued to
the subfascial plane of the vastus medialis muscle, which allows the skin paddle to be rapidly
elevated and retracted posteriorly as the vastus medialis is dissected anteriorly. The DGA
can then be identified as the medial column of the femur is exposed.
Dissecting subfascially ensures protection of all skin vessels that may branch off the distal
DGA into the reflected skin. Through the fascial plane of the vastus medialis the branch-
ing vessels emitting from the DGA can be identified, and the presence or absence of the
saphenous artery branching from the DGA and/or DGA-CB is rapidly noted. Branches to
the vastus medialis course anteriorly (penetrating the fascial plane) and are suture ligated.
At this point, a decision is made regarding the approach for the skin paddle.
In most of my cases, the DGA-CB is selected if it is present, regardless of the presence
of the saphenous artery. This skin vessel may be preferable because of the speed with which
it can be dissected as well as the assurance that the skin and subcutaneous vasculature can
be elevated anterior to the sartorius muscle and adductor tendon, keeping the skin and
bone segments in the same dissection interval (between the vastus medialis and sartorius
muscles). If the saphenous artery is selected as the means of supplying the skin segment, a
careful distal dissection is required to determine whether the artery is supported by skin
branches that pass anterior to the sartorius muscle (45%) and in the same surgical interval as
the bone component, or posterior to the sartorius muscle (55%). If it does pass posteriorly, it
will require a distal elevation of the skin segment and careful passage deep to the sartorius
muscle to reunite it with the bone segment before flap harvest is completed.
When treating recalcitrant nonunions in closed soft tissue, the skin segment used for
MFC to permit ease of closure and monitoring is usually less than 4 by 8 cm, and primary
closure of the donor site is possible. The smaller skin paddle available from the DGA-CB
serves the surgeon well in this setting. The saphenous artery, in contrast, has a larger angio-
some and provides a greater freedom of insetting, distinct from the bone segment, because
of its proximal branching point. If the surgeon chooses to use this flap to both provide vas-
cularized bone and soft tissue coverage of extensive wounds, the extent of the angiosome
of the saphenous artery branch may make it a wiser choice for the reconstructive surgeon
than the DGA-CB.
A Doppler signal is usually easily audible over the apex of the MFC when the skin flap
is returned to its anatomic position. The initial sweeping incision allows many variations
of oblique or longitudinally oriented ellipses to be designed using the initial incision as
the anterior border of the skin component, capturing the Doppler signal for postoperative
monitoring. Care is taken to harvest this so that primary closure can be simply achieved.
The skin component is usually elevated first, then attention is turned to the bone seg-
ment. The bone segment is dissected in the width, length, and depth required, and the flap
is harvested on the common DGA origin vessel.
Continued

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 1414 Part II  Regional Flaps: Anatomy and Basic Techniques

Postoperative Care
Although patients seem to have less pain with the MFC harvest site compared with an iliac
crest harvest, caution is required with ambulation if very large corticocancellous flaps are
harvested. Even though a brace is inadequate in preventing torsional stresses on the femur,
we often require patients to use hinged knee braces after larger harvests to protect the femur.
In most smaller corticocancellous or thin corticoperiosteal harvest cases, no restriction or
protection is required.

Complications
The most concerning complication of this flap is femur fracture after larger bone harvests.
To prevent this complication, harvests are strictly limited to the cortical surface of the medial
column of the femur. Harvest depth is also limited to avoid loss of support of the medial
condyle. Excessive proximal harvest into the diaphysis of the femur is likewise avoided.
Biomechanical studies to assess the risk of torsional stresses in larger harvests are needed.

Take-Away Messages
Since the landmark description of the saphenous skin flap in 1981 by Acland et al, its use
has been limited by the substantial variation in the vascular anatomy and the later avail-
ability of more reliable donor sites. Interest in this flap has seen a rebirth with the growing
interest in the subsequently described MFC bone flap from the shared vascular pedicle. A
thorough understanding of this anatomy is critical for routine and reliable harvest of the
skin component of this valuable vascularized bone source.

Bibliography With Key Annotations

Cavadas PC. Reversed saphenous neurocutaneous island flap: clinical experience and evolution to
the posterior tibial perforator-saphenous subcutaneous flap. Plast Reconstr Surg 111:837-839, 2003.
The author reported on his further experience with the distally based saphenous flap and described a
modification of the reversed saphenous flap, used in approximately 40 cases. Advantages included that
the flap can be elevated with the patient in the supine position, it is fast and easy to execute, morbidity is
reasonably low, and the flap can reach the Achilles tendon and malleolar regions and dorsum of the foot.
The author stated that the flap should be considered among the flaps of first choice.
Chen SL, Chen TM, Chou TD, et al. The distally based lesser saphenous venofasciocutaneous
flap for ankle and heel reconstruction. Plast Reconstr Surg 110:1664-1672, 2002.
Finding an appropriate soft tissue grafting material to close a wound located over the ankle and heel can
be a difficult task. The distally based lesser saphenous venofasciocutaneous flap mobilized from the
posterior aspect of the upper leg, used as an island pedicle skin flap, can be useful for this purpose.
The vascular supply to the flap is derived from the retrograde perfusion of the accompanying arteries
of the lesser saphenous vein. These arteries descend along both sides of the lesser saphenous vein to
the distal third of the leg, either terminating or anastomosing with the septocutaneous perforators of
the peroneal artery. The authors used four variants of this flap in 21 individuals, including 11 fas-
ciocutaneous, 5 fascial, 3 sensory, and 2 fasciomyocutaneous flaps. Skin defects among all patients
were combined with bone, joint, and/or tendon exposure. They found that the flap was reliable and
technically simple to design and execute. This one-stage procedure not only preserves the major arteries
and the sural nerve of the injured leg, but it also has proved valuable for covering a weight-bearing heel
and filling a deep defect, because it potentially provides protective sensation and a well-vascularized
muscle fragment. When conventional local flaps are inadequate, this flap should be considered for its
reliability and low associated morbidity.

12b_Saph_r5_cah_1392-1417.indd 1414 2/7/2012 2:58:08 PM

 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1415

Dubois G, Lopez R, Puwanarajah P, et al. The corticoperiosteal medial femoral supracondylar

flap: anatomical study for clinical evaluation in mandibular osteoradionecrosis. Surg Radiol
Anat 32:971-977, 2010.
An ideal way to treat osteoradionecrosis of the jaws is to transfer an osteogenic, appropriately vascu-
larized flap to the affected site. The corticoperiosteal femoral medial supracondylar flap is being used
increasingly in the treatment of complex pseudarthrosis of long bones. However, robust indications
have yet to be found for use in the treatment of osteoradionecrosis of the jaw, the reasons being a lack of
anatomic data concerning its vascular supply and the local constraints of its routine harvest. The authors
presented an anatomic study and literature review to explore its potentials in clinical practice. A total of
25 legs were dissected following vascular injection of colored neoprene. The descending genicular artery
(DGA) and veins were studied with particular attention paid to anatomic variations found in their
branches. Calibers and length of the vessels were recorded. Many anatomic variations of the DGA
were found and a classification proposed. The mean caliber of the DGA at the origin was 1.9 mm,
and for the vein, 1.8 mm. The mean useful length of the pedicle was 7.9 cm. A case was reported.
Ferro A, Cadena DM. An aid to the greater saphenous vein exclusion from the posterior tibial
perforator-saphenous flap. [Comment] Plast Reconstr Surg 113:791-792, 2004.
The authors responded to Dr. Cavadas’s article (above) and related their experience with the posterior
tibial perforator–saphenous flap for Achilles tendon coverage. They concluded that the subcutaneous
180-degree turnover of the flap and exclusion of the greater saphenous vein are safer and must be
done. In their case, they preserved the skin island, performing a double twist to the pedicle because
the pedicle and tunnel were thin. They proposed ligation of the vein at the malleolus level to avoid
possible injury to the pedicle at the base of the flap.
Gideroglu K, Gunduz OH, Ofluoglu D, et al. Sensorial donor site morbidity after saphenous
neurocutaneous flap. Scand J Plast Reconstr Surg Hand Surg 39:302-307, 2005.
Neurocutaneous flaps based on the arterial network around the superficial sensory nerves are popular
for soft tissue coverage of the lower extremities and are usually preferred in reconstruction of the lower
leg and foot. Sacrifice of sensory cutaneous nerves is one of their major disadvantages, but morbidity
in the foot and at the donor site had not been well investigated. The authors investigated sensorial
morbidity in the foot and at the donor site caused by raising a saphenous neurocutaneous flap in 14 pa-
tients by using static two-point discrimination test, Semmes-Weinstein monofilament test, vibration
test, and by measuring somatosensory evoked potentials after 12 months. Their results suggest that
sensory recovery is good and protective sensation is gained in most patients.
Karamürsel S, Celebioğlu S. Use of the medial side of the knee skin as a free flap: saphenous
flap. Plast Reconstr Surg 117:1308-1314, 2006.
The knee region is a good donor site for a free skin flap; it has minimal subcutaneous tissue and
provides a hidden donor site. Acland et al first used the skin over the medial side of the knee as a
saphenous flap based on the saphenous branch of the descending genicular artery. The authors studied
the descending genicular artery and its saphenous branch in six cadaver limbs and elevated the skin
over the medial side of the knee as a free flap in six patients to reconstruct lower extremity defects. In
all clinical cases, they were able to elevate a skin flap from the skin on the medial side of the knee. All
the flaps survived and the defects healed well.
Kheradmand A, Omranipour R, Farahmand MR. Reversed saphenous fasciocutaneous island
flap in Marjolin’s ulcers. Burns 32:116-120, 2006.
The reconstruction of the heel represents a challenge because of the limited local soft tissue availability
and the special structural and functional characteristics of this region. A great number of possibili-
ties have been described; the authors presented a modified form of the sural fasciocutaneous flap for
heel reconstruction. Ten patients (two female and eight male; median age 68 years, range 48 to 76)
underwent reversed saphenous fasciocutaneous island flap after wide excision of a heel lesion. The
causes of heel lesions in all patients were squamous cell carcinoma on a chronic burn scar. In this new
technique, the sural nerve and artery were saved, and the blood supply to the flap was based on lesser

12b_Saph_r5_cah_1392-1417.indd 1415 2/7/2012 2:58:08 PM

 1416 Part II  Regional Flaps: Anatomy and Basic Techniques

saphenous vein. The mean lesion surface was 60 cm2 (range 30 to 112 cm2). Epidermolysis and flap
discoloration were seen in three patients; this was treated with intermittent wet dressing and conser-
vative management. One patient showed partial necrosis in flap circumference; this recovered with
debridement and skin grafting. Total flap necrosis was not seen in any patients. Their mean hospital
stay was 10 days (range 8 to 15 days). The mean follow-up was 12 months.
Kishi K, Nakajima H, Imanishi N. Distally based greater saphenous venoadipofascial–sartorius
muscle combined flap with venous anastomosis. Plast Reconstr Surg 119:1808-1812, 2007.
In reconstruction of the extremities, a distally based flap is useful for covering the distal parts. However,
these flaps are prone to congestion in the peripheral part of the flap, followed by necrosis because of
insufficient venous drainage as a result of resistance of the venous valves. To rescue venous congestion
of a distally based flap, venous anastomosis is effective so that the venous blood flows in the direction
of the venous valve. The authors applied this idea to a patient who had skin defects around the knee
after a wide resection of a skin tumor and covered them with a distally based greater saphenous veno-
adipofascial–sartorius muscle combined flap. The whole area of the flap took well without congestion.
Lee SH, Choi TH, Kim SW, Xu L, et al. An anatomical study of the saphenous nerve, artery,
and its perforators within the thigh using cadaveric dissection. Ann Plast Surg 67:413-415, 2011.
Although the saphenous flap has been used in reconstruction as a free flap, there has not yet been an
anatomic study about the perforators of the saphenous artery. The aim of this study was to investigate
the anatomy of the saphenous artery and the number and locations of its perforators. The authors
dissected parts of 10 legs from five cadavers. Measurements of the positions of the dissected saphenous
arteries and their perforators were taken from the medial epicondyle of the femur. They observed the
origin, endpoint, and diameter of each of the arteries and investigated the numbers and locations of
both septocutaneous and myocutaneous perforators. The average length of the saphenous artery was
14.8 cm, and it was located 12.0 cm above the medial epicondyle of the femur. The average diameter
was 1.63 mm. A median average of four perforators branched out from a single saphenous artery. On
average there were two septocutaneous perforators and two myocutaneous perforators from the saphenous
artery, mainly located about 7 cm proximal to the medial epicondyle of the femur.
Nenad T, Reiner W, Michael S, et al. Saphenous perforator flap for reconstructive surgery
in the lower leg and the foot: a clinical study of 50 patients with posttraumatic osteomyelitis.
J Trauma 68:1200-1207, 2010.
The authors presented a retrospective, noncontrolled clinical study of patients with lower leg postinjury
chronic osteomyelitis. All patients were treated with distally based saphenous neurofasciocutaneous
perforator flaps, the feeding perforators originating from the tibial artery. An endpoint survey was
conducted after flap surgery; the mean follow-up period was 4 years, the response rate 60%. Six
patients had short-term flap failure (12%), and six had flap necrosis of less than one fourth of the
flap that healed without surgical revision. Based on the endpoint data, the long-term success rate was
70% among respondents. The authors concluded that the saphenous perforator flap is a sturdy flap
with low short-term failure rates, also in high-risk patients. Their success rate compared well with
results of free flap transfers in the management of posttraumatic osteomyelitis. The saphenous flap is
a feasible option for posttraumatic reconstructions of osteomyelitis, especially in low-resource settings.
Pelzer M, Reichenberger M, Germann G. Osteo-periosteal-cutaneous flaps of the medial
femoral condyle: a valuable modification for selected clinical situations. J Reconstr Microsurg
26:291-294, 2010.
For bony nonunions with poor skin coverage, transplantation of vascularized soft tissue in addition to
bone graft is desirable. The use of the corticoperiosteal vascularized bone graft from the medial femoral
condyle has been well described, but there have only been anecdotal reports about its use as an osteo-
cutaneous flap. The authors presented results with the use of an osteocutaneous flap from the medial
femoral condyle in four patients treated with supracondylar osteocutaneous flaps for bony nonunions
(tibia, ankle, calcaneus) with concomitant soft tissue defects. The supplying cutaneous vessels were

12b_Saph_r5_cah_1392-1417.indd 1416 2/7/2012 2:58:08 PM

 Thigh  •  12B: Saphenous and Medial Condylar Flaps 1417

an unnamed perforator of the descending genicular artery (two cases) or the saphenous branch (two
cases). The first three cases healed primarily. Bony union was achieved between 32 and 170 days.
The follow-up of the fourth case was too short to achieve a bony union. There was no flap loss and
no surgery-related complications at the donor site.
Yajima H, Maegawa N, Ota H, et al. Treatment of persistent non-union of the humerus using
a vascularized bone graft from the supracondylar region of the femur. J Reconstr Microsurg
23:107-113, 2007.
Six patients with recalcitrant posttraumatic humeral shaft nonunions were treated using vascularized
bone grafts from the supracondylar region of the femur. The initial state of injury showed that four
fractures were closed, while two were open fractures. At the acute stage, five fractures were fixed using
intramedullary nailing, while one was fixed with a plate. In all patients, a bony flap was placed on
the cortex after decortication. The size of the harvested bone flap ranged between 4 by 2.5 cm and
5 by 3 cm. After fixation of the bony flap, the inferior genicular artery and vein were anastomosed
to the deep brachial artery and vein. The mean time required to obtain radiographic bone union was
3.3 months. The only graft site complication involved transient mild paresthesia in the saphenous
nerve area in one patient.
Yildirim S, Akan M, Giderodğlu K, et al. Use of distally based saphenous neurofasciocutaneous
and musculofasciocutaneous cross-leg flaps in limb salvage. Ann Plast Surg 47:568-574, 2001.
Neurocutaneous island flaps have been very popular in soft tissue coverage of the lower extremities.
These flaps are based on the arterial network around the superficial sensory nerves. The advantages
of these flaps are easy and quick dissection (hence a time-saving operation), acceptable donor site mor-
bidity, and preservation of major arteries of the leg. The authors used five neurofasciocutaneous and
three myofasciocutaneous flaps successfully as cross-leg flaps for the coverage of relatively large defects
of the lower two thirds of the leg and foot in eight patients. They concluded that reverse saphenous
neurofasciocutaneous and myofasciocutaneous flaps as a cross-leg flap in patients who cannot be
reconstructed with other flap alternatives have many advantages over traditional cross-leg procedures,
such as short vascularization time, minimal patient discomfort, wide arc of rotation, great versatility,
and a safe vascular pattern.
Zhang FH, Chang SM, Lin SQ, et al. Modified distally based sural neuro-veno-fasciocutaneous
flap: anatomical study and clinical applications. Microsurgery 25:543-550, 2005.
The distally based sural neurovenofasciocutaneous flap has been used widely for reconstruction of foot
and ankle soft tissue defects. The distal pivot point of the flap is designed at the lowest septocutane-
ous perforator from the peroneal artery of the posterolateral septum, which is on average 5 cm (range
4 to 7 cm) above the lateral malleolus. A longer neurovenoadipofascial pedicle would be needed to
reversely reach the distal foot defect when the flap is dissected based on this perforating branch, which
may result in more trauma in flap elevation and morbidity of the donor site. The authors explored
new pivot points for this distally based flap in an anatomic study of 30 fresh cadavers. The results
showed that the peroneal artery terminates into two branches: the posterior lateral malleolus artery and
lateral calcaneal artery. These two branches also send off cutaneous perforators at about 3 and 1 cm
above the tip of lateral malleolus, respectively, which can be used as arterial pivot points for the flap.
A communicating branch between the lesser saphenous vein and the peroneal venae comitantes was
found, accompanied by the perforator of the posterior lateral malleolus artery. This modified, distally
based sural flap with lower pivot points was successfully transferred for repair of soft tissue defects in
21 patients. The authors stated that the vascular pivot point of a distally based sural flap can be safely
designed 1.5 cm proximal to the tip of the lateral malleolus.

12b_Saph_r5_cah_1392-1417.indd 1417 2/7/2012 2:58:08 PM

 ANATOMIC LANDMARKS
Landmarks Inner thigh, from pubis to medial tibial condyle.
Size 30 3 5 cm 3 2 cm thick.
Origin The pubic symphysis; it can be found just below the tendon of
origin of the adductor longus muscle, which is palpable near the
pubic tubercle.
Insertion Inserts into the medial tibial condyle immediately posterior to
the sartorius muscle.
Function Adducts the thigh.
Composition Muscle, myocutaneous, or fasciocutaneous.
Flap Type Type II.
Dominant Pedicle Medial circumflex femoral artery.
Minor Pedicle Perforating vessels from the deep femoral artery or superficial
femoral artery.
Nerve Supply Motor: Obturator nerve. Sensory: Anterior femoral cutaneous
nerve.

12c_Gracilis_r7_cah_1418-1465.indd 1418 2/7/2012 3:58:37 PM

 Section 12C
Thigh

Gracilis and TUG/TMG Flaps

CLINICAL APPLICATIONS
Regional Use
Lower abdomen
Pubis
Groin
Perineum
Ischium
Distant Use
Head and neck
Upper extremity
Lower extremity
Specialized Use
Functional muscle for upper
extremity
Functional muscle for facial
reanimation
Anal sphincter reconstruction
Vaginal reconstruction

12c_Gracilis_r7_cah_1418-1465.indd 1419 2/7/2012 3:58:40 PM

 ANATOMY OF THE Gracilis Flap

Psoas muscle
Iliacus muscle
A Sartorius muscle

Adductor longus muscle

Rectus femoris muscle

Vastus medialis muscle

Pectineus muscle

Gracilis muscle
Semimembranosus muscle

Semitendinosus muscle

Muscular anatomy of gracilis flap

B
Femoral artery

Deep femoral artery

Superficial femoral artery

Perforating branches of Obturator nerve
superficial femoral artery
Medial circumflex
femoral artery

Muscular branch
of obturator nerve

Gracilis muscle
Deep femoral Perforating branch
perforating artery of medial circumflex
femoral artery

Arterial system and nerve supply of gracilis flap

Fig. 12C-1 

Dominant pedicle: Medial circumflex femoral artery

12c_Gracilis_r7_cah_1418-1465.indd 1420 2/7/2012 3:58:42 PM

 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1421

Anatomy
Landmarks The gracilis muscle lies between the pubic bone, just below the pubic tubercle,
and the medial surface of the tibia.
Composition Muscle, myocutaneous, or fasciocutaneous. The muscle is commonly used for
reconstruction because it is expendable and has a relatively large vascular bundle
for a relatively small muscle.
Size 30 cm long, 5 cm wide, 2 cm thick, depending on the size and build of the
patient. The gracilis muscle has distinct tendons of origin and insertion that can
lengthen its functional length up to an additional 8 cm.
Origin The pubic symphysis; specifically the aponeurosis originates along the pubic
arch, along the body and inferior ramus of the pubis, below the pubic tubercle.
It can be found just below the tendon of origin of the adductor longus muscle,
which is palpable near the pubic tubercle.
Insertion The gracilis muscle inserts into the medial tibial condyle immediately posterior
to the sartorius muscle.
Function The gracilis is a straplike muscle that adducts the thigh. There is no discernible
loss of adduction of the thigh after the muscle has been harvested.

Arterial Anatomy (Type II)

Dominant Pedicle  Medial circumflex femoral artery
Regional Source  Deep femoral artery.
Length  7 cm.
Diameter  1 to 2 mm.
Location  Enters lateral aspect of muscle from between adductor longus and adductor magnus.
Enters muscle in two or three terminal branches 10 cm inferior to the pubic tubercle.
Minor Pedicle  Smaller branches of the deep femoral artery or superficial femoral artery
Regional Source  Deep femoral artery or superficial femoral artery.
Length  2 to 3 cm.
Diameter  0.5 mm.
Location  Distal half of the muscle.

Venous Anatomy
There are two venae comitantes that run with the medial circumflex femoral artery. External
diameters are 1.5 to 3 mm, with a length of 6 cm. When the proximal transverse skin island is
used, one can capture the greater saphenous vein, which can be used as secondary venous outflow,
particularly in a free tissue transfer.

Nerve Supply
Motor The obturator nerve enters the gracilis muscle on its medial surface immediately
superior to the medial circumflex femoral vessels. Its course proximally diverges
from the vessels, running obliquely, then superiorly. The average nerve length
that may be taken with the flap is 7 cm.
Sensory The anterior femoral cutaneous nerve arising from L2 to L3 provides sensation
to most of the anterior medial thigh. A small cutaneous branch of the anterior
obturator nerve arises in the vicinity of the vascular pedicle and passes deep to
the adductor longus muscle. This branch must be carefully dissected to avoid
paresthesia in the distal medial thigh.

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 1422 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Gracilis Flap

A B

D
D

Deep surface of flap Radiographic view

Fig. 12C-2 

Dominant pedicle: Ascending branch of medial circumflex femoral artery (D)

Minor pedicle: One or two branches of superficial femoral artery (m)
n, Obturator nerve

12c_Gracilis_r7_cah_1418-1465.indd 1422 2/7/2012 3:58:44 PM

 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1423

Flap Harvest
Design and Markings
Muscle-only harvest is best accomplished through a linear incision overlying the muscle.
A line can be drawn from the adductor tendon at the medial pubic tubercle to the medial
femoral condyle. The gracilis muscle lies just posterior to this. In a prone position, the inci-
sion would lie more posterior to aid in wound closure.

Medial femoral condyle

Pubic tubercle

Fig. 12C-3 

For a myocutaneous flap, a longitudinal skin island is most commonly used and should
be centered posterior to this line. The skin island becomes unreliable in the distal third of
the leg and should only be used if a delay procedure is performed.

Standard flap vertical skin island design

Fig. 12C-3 

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 1424 Part II  Regional Flaps: Anatomy and Basic Techniques

The transverse skin paddle is often used in breast reconstruction; it is called the trans-
verse myocutaneous gracilis (TMG) or transverse upper gracilis (TUG) flap. The design for this
flap starts at the groin crease and extends a variable distance inferiorly to allow primary
closure, usually 10 cm long. A fleur-de-lis design is also possible, taking advantage of both
horizontal and vertical excess in the thigh, in exchange for a larger scar.

TUG flap and fleur-de-lis designs

Fig. 12C-3 

Forceful abduction of the thigh will help to visualize the adductor longus muscle; this
can be marked in the holding area. Placing the leg in a frog-leg position in the operating
room will also allow the surgeon to palpate the adductor longus muscle and tendon. After
marking a line from the adductor tendon origin to the medial femoral condyle of the femur,
a linear incision is planned for muscle harvest or an elliptical skin flap design is planned,
centered posterior to this line. The skin to be harvested is grasped to determine how much
flap can be harvested with primary closure. A flap of 9 cm in width can usually be closed
primarily.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1425

Patient Positioning
The versatility of the gracilis muscle for reconstruction is that it can be harvested in a variety
of positions, depending on need. For most anterior abdomen, pubic, and perineal applica-
tions, a lithotomy position can be used with the patient’s legs in stirrups. For most head
and neck applications, harvest can be performed in a supine position and frog-leg position.
For applications of the perineum, such as an anal sphincter or rectovaginal fistula repair, a
prone position can be used. However, although the prone position can be used to harvest
the muscle through a more posterior incision, which allows closure, harvesting of a skin
paddle and closure of the leg is not recommended in this position.

Lithotomy position

Supine with frog-leg position

Fig. 12C-4 

12c_Gracilis_r7_cah_1418-1465.indd 1425 2/7/2012 3:58:47 PM

 1426 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

With the patient supine and the knee and hip slightly flexed, an incision overlying the gracilis
muscle is made. The first, most superficial structure encountered is the greater saphenous
vein, which should be preserved if possible. Deepening the incision through muscular fascia
allows identification of the gracilis muscle. The gracilis is the posteriormost adductor of the
leg. Care should be taken in the distal half of the leg to identify the muscle with certainty,
because the sartorius muscle often overlies the gracilis in this area and has a similar appear-
ance. It can be helpful to initially make an incision over the insertion of the gracilis distally
and apply traction to the gracilis tendon to aid definitive identification. The gracilis runs
toward the pubic tubercle, whereas the sartorius runs toward the ASIS. This maneuver is
most helpful when ensuring proper placement of the skin paddle relative to the muscle.
More proximally, the muscle is readily identified immediately posterior to the adductor
longus muscle. The key to recognizing the muscle is confirming the positions of the medial
circumflex femoral pedicle and the obturator nerve, which conclusively identifies the muscle.

Anterior branch of obturator nerve

A Adductor magnus muscle
Adductor longus muscle
Minor pedicle
Sartorius muscle

Greater
saphenous vein Muscular branch
of obturator nerve
Medial circumflex
femoral artery pedicle

Gracilis tendon Gracilis muscle

Initial dissection

Fig. 12C-5 

Once the vascular pedicle and nerve have been identified, the remainder of the dissection
is more straightforward. Dissection may then quickly proceed on the medial surface of the
muscle from origin to insertion. Next, the distalmost portions of the muscle are dissected,
dividing the minor pedicles as they are encountered.

B Sartorius muscle Fascia over adductor

Ligated perforating branches of longus muscle
femoral and deep femoral artery

Greater saphenous vein

Gracilis
tendon

Gracilis muscle

Adductor
magnus muscle
Intermediate dissection

Fig. 12C-5 

12c_Gracilis_r7_cah_1418-1465.indd 1426 2/7/2012 3:58:48 PM

 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1427

It is helpful when dissecting the medial circumflex femoral vessels to take the fascia
investing the adductor longus muscle. This allows an easy dissection that both exposes and
protects these vessels.

Cutaneous branch
Adductor of obturator nerve
longus muscle

Muscular branch
of obturator nerve

Medial circumflex
femoral artery pedicle
Adductor magnus
Gracilis muscle
muscle

Deep dissection

Final dissection

Fig. 12C-5 

12c_Gracilis_r7_cah_1418-1465.indd 1427 2/7/2012 3:58:50 PM

 1428 Part II  Regional Flaps: Anatomy and Basic Techniques

To rotate the flap, the medial circumflex femoral pedicle marks the rotation point, and
the distal insertion can be divided at the tendon and the muscle rotated superiorly.

Profunda femoris Superficial

E femoral artery
artery
Adductor longus
muscle

Gracilis muscle

Adductor brevis muscle Adductor magnus muscle

Cross-section of flap

Fig. 12C-5 

For free tissue transfer, less muscle harvest may be required, and only the proximal
portion of the incision may be needed. When division of the muscle is required proximally,
division at the fascial origin is bloodless and straightforward. If further lengthening of the
arc of rotation is necessary, dissection of the medial circumflex femoral pedicle will add
an additional 2 cm of reach. Care must be taken to divide branches to the adductor longus
muscle that emanate from this pedicle. In most cases of transposition, division of the origin
will not add any further length to the arc of rotation of the flap. In rare circumstances in
which the arc of rotation is insufficient after these maneuvers, the medial circumflex femo-
ral pedicle can be divided, and the muscle may survive off perforating vessels around the
origin of the muscle. Microvascular clamps can be placed on the pedicle to test the more
proximal blood supply. However, it is preferable to always maintain the medial circumflex
femoral pedicle when possible.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1429

Flap Variants
•  Myocutaneous flap
•  Medial circumflex femoral artery perforator (TUG/TMG) flap
•  Functional muscle

Myocutaneous Flap
Early investigators thought that the skin paddle associated with the gracilis muscle was
unreliable, because the muscle is relatively small, and depending on the patient’s anatomy,
a small ellipse of skin may not be properly placed into the angiosome of the perforators of
the medial circumflex femoral vessels. The muscle also is deep distally and is based off its
minor blood supply, so the skin paddle was thought to be reliable only in the proximal two
thirds of the leg. With further anatomic study and experience, the skin paddle can now
be harvested reliably. Two maneuvers are most helpful in accounting for this reliability:
localizing perforators with Doppler ultrasound, and harvesting the investing fascia of all
surrounding muscles with the flap.
Perforators of the medial circumflex femoral artery are most commonly located 10 cm
distal to the pubic tubercle. Anatomic variation exists within this area, and more than one
perforator may be present. The perforator may run through the gracilis muscle proper or just
anterior or posterior to it. Skin paddle design should encompass these Doppler points. When
dissecting the skin flaps, dissection should proceed down to the muscular fascia overlying
adductor longus and overlying semitendinosus muscles. Dissection should proceed down
through the fascia and then inward toward the flap, along the side of the adductor longus.
This will carry the dissection directly into the septum where the medial femoral vessels and
obturator nerve reside. Posteriorly, capturing this investing fascia ensures that perforators to
the skin flap that arise posterior to the gracilis muscle will still be included. Once the flap
has been dissected onto this mesentery, it may be dissected from distal to proximal, with
care being taken not to injure the medial circumflex femoral vessels. As a rotational flap,
further lengthening can be performed as described previously.

Anterior branch of obturator nerve

Adductor longus muscle
Adductor magnus muscle

Gracilis tendon

Semimembranosus muscle
Medial circumflex
Gracilis muscle femoral artery pedicle

Distal gracilis insertion divided with muscle retracted proximally to show vascular pedicle

Fig. 12C-6  Completed dissection of a myocutaneous gracilis flap. 

12c_Gracilis_r7_cah_1418-1465.indd 1429 2/7/2012 3:58:51 PM

 1430 Part II  Regional Flaps: Anatomy and Basic Techniques

Medial Femoral Circumflex Artery Perforator

(TUG/TMG) Flap
The tissues normally removed during a medial thigh lift can be harvested as a perforator free
flap sparing gracilis muscle. Alternatively, the flap can be harvested with a variable amount
of muscle to protect perforating vessels or to add bulk to the flap. Flap design should be
similar to that of a medial thigh lift, and additional bulk may be added to this flap by creat-
ing a fleur-de-lis design. The actual design of this flap will vary, depending on the patient’s
anatomy and desire for placement of the donor site scar. When used as a perforator flap,
the perforators are identified preoperatively using a handheld Doppler probe. The design
of the flap is shifted posteriorly to capture the better-vascularized and more abundant skin
and fatty tissue that reside posteriorly and encroach upon the gluteal area. Anteriorly, there
should be minimal dissection over the femoral triangle, because there are minimal tissues
and important lymphatics that should be spared. The angiosome of these perforators from
the medial circumflex femoral system does not extend anterior to the femoral vessels.
Dissection starts anteriorly. The ellipse of skin overlying the femoral triangle, which is
marked largely for dog-ear management, is removed only in the subcutaneous plane. Once
beyond the femoral triangle, the plane is then deepened to the adductor fascia, which can
be included with the flap. For perforator flaps, careful dissection then proceeds above the
gracilis muscle, with identification of the perforator. For flaps that include muscle, anterior
dissection of the muscle can be performed. Next, attention is directed posteriorly, where
the flap may be rapidly incised and raised up to the point of the perforating vessel. If a single
perforator of large size is not found, several adjacent medium-sized perforators must be
dissected through the muscle. These perforators generally join together within the muscle.
The dominant pedicle lies directly opposite the intramuscular course of these perforators,
and careful intramuscular dissection is essential to avoid injury. Once the perforators have
been dissected, the remainder of the flap attachments can be removed. The saphenous vein
can be taken with the flap as an alternative venous outflow, although this is usually not
necessary. When muscle is harvested with this flap, especially to increase bulk, the previous
guidelines for dissecting the muscle should be used.

A Medial circumflex
femoral artery pedicle

Gracilis muscle

TUG flap design with transverse skin paddle; perforator is confirmed by Doppler

Fig. 12C-7

12c_Gracilis_r7_cah_1418-1465.indd 1430 2/7/2012 3:58:51 PM

 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1431

Deep femoral artery

Superficial femoral artery
Saphenous vein
B

Initial anterior dissection of TUG flap, superficial over femoral triangle,

sparing the saphenous or intentionally including it in flap

Posterior dissection, subfacial to gracilis; either perforator-only or

segmental muscle harvest (pictured) dissection isolates the flap on its pedicle

Flap raised from distal to proximal, isolating it completely on medial circumflex femoral pedicle

Fig. 12C-7 

12c_Gracilis_r7_cah_1418-1465.indd 1431 2/7/2012 3:58:53 PM

 1432 Part II  Regional Flaps: Anatomy and Basic Techniques

Functional Muscle
The gracilis muscle can be used as a functional muscle either as a regional rotation or as a
free tissue transfer. As a regional rotation, the dissection of the flap is performed as discussed
earlier for a standard flap. The surgeon must exercise care to avoid injuring the obturator
nerve, which is critical to the harvest of this functional muscle. When the muscle is being
used for anal sphincter reconstruction, a subcutaneous tunnel is created from the donor
site toward the recipient site, where the muscle can be passed and then wrapped around the
anus to provide sphincter function.
When the muscle is being used as a free tissue transfer, the length of the desired muscle
can be determined from the recipient site’s needs. It is important to mark the muscle at its
resting length before harvest. The muscle may be taken in its entirety, as is often the case
for upper and lower extremity uses. The muscle may also be split to a smaller size, as is
commonly done for facial reanimation. When harvested for free tissue transfer, care must
be taken not only in dissecting the vascular pedicle to its source, but also in dissecting the
nerve as proximally as can be followed. Both of these maneuvers will greatly facilitate muscle
inset. Full dissection of the medial circumflex femoral artery to its source is recommended,
because the artery tends to be quite small and enlarges in size at its origin.

Subcutaneous tunnel

Rotational flap for rectovaginal fistula, anal incontinence, and genitourinary applications

Tendon sutured
Rotational flap for anal sphincter reconstruction

Fig. 12C-8 

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1433

Arc of Rotation
Standard Flap
The muscle, based on its medial circumflex femoral blood supply, can be rotated superiorly
for defects in the lower abdomen, pubis, groin, perineum, and ischium. Depending on the
reconstructive need, it should be kept in mind that the muscle tapers at its distalmost part
and is largely tendinous at its distalmost insertion; therefore, as tissue needs require muscle
farther from the medial circumflex femoral pedicle, the less skin and less muscle bulk will
be available for reconstruction. If a greater skin flap is required, a delay procedure should
be performed. Rotation of the flap distally based on its minor pedicle is not recommended
without surgical delay.

A B

Arc to groin Arc to perineum

Arc to ischium

Fig. 12C-9 

12c_Gracilis_r7_cah_1418-1465.indd 1433 2/7/2012 3:58:54 PM

 1434 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Transfer
Standard Flap
The muscle or myocutaneous tissues will reach the recipient site either through direct
transposition through an open wound or through a subcutaneous tunnel. When rotating
the flap through a subcutaneous tunnel, the surgeon must ensure adequate space for the
flap without compression. The tunnel is located in the subcutaneous plane. The flap may
easily rotate through 180 degrees without vascular compromise. Care should be taken to
prevent tension on the vascular pedicle during closure.

Flap Inset
Pedicle Flap
The rotated flap should be inset without tension or kinking of the vascular pedicle. Divi-
sion of the origin of the muscle is not required and may add vascularity to the flap if left in
situ. Depending on the reconstructive need, the surgeon should consider division of the
obturator nerve to limit muscular contraction postoperatively as well as displacement of
the reconstructive tissues. In passing the flap through a tunnel, it is helpful to secure the
muscle to the tunnel where it emerges to prevent retraction of the muscle postoperatively.

Free Flap
For wound applications, the surgeon must ensure that the muscle used for inset has excellent
vascularity. It is appropriate to place the muscle on some tension to best distribute it. Muscle
free flaps used for wounds often require skin grafting. When skin and muscle are used for
applications such as breast reconstruction, care must be taken to anchor tissues to prevent
tension on the anastomosis postoperatively. The elliptical design of the TUG flap lends itself
nicely to contouring into a breast shape. The surgeon must ensure vascularity to all areas
of the skin paddle before insetting the flap. It is not uncommon that the extension of the
skin near the femoral triangle has poor vascularity, and this often requires removal before
inset. As a functional muscle transfer, it is critical to inset the flap at its resting length for
best postoperative function. For muscle transfer to an extremity, it is often helpful to carry
the skin paddle with the flap to allow tension-free closure. After the functional muscle has
been placed, this is often in a scarred or contracted bed, where extra skin is required for
a closure that will not put pressure on the microscopic anastomosis. The skin paddle can
often be excised at a later time if it is deemed unaesthetic or bulky.
For facial reanimation, it can be useful to carry the tendinous origin of the muscle with
the flap, because this area will hold sutures better than a cut muscle edge. Again, care must
be taken to make certain that the isolated segment of muscle being transferred has excellent
innervation and vascularity to ensure a functional result.

Donor Site Closure

Primary closure of this donor site is the norm for standard muscle flaps; simple closure with
reapproximation of Scarpa’s fascia as well as the skin is straightforward. Because of the lym-
phatic vessels in this area, it is recommended that a drain be placed in all these donor sites
of the upper thigh and to keep these in place until drainage is minimal. Harvest of a skin
paddle of 9 cm diameter can be closed primarily. Larger flaps, especially after flap delay,
may require a skin graft for donor site closure. If a larger skin paddle is required, one should
consider other flaps, such as the ALT flap, for better vascularity of a large skin paddle. Trans-
verse skin designs are closed in a manner similar to that for medial thigh lifts. Anchoring
in the Scarpa’s fascial layer is essential for taking tension off the skin closure. Any cheating

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1435

of the skin closure with wrinkling of the skin is performed posteriorly, where it is less vis-
ible. When a flap is harvested from only one leg, there is little irregularity of the donor site
contour. When a large skin paddle is harvested, there may be an asymmetry that requires
contralateral liposuction or contralateral skin excision to restore balance. Fortunately for
most patients, any such deformities can be hidden in clothes and therefore additional work
to restore symmetry is not usually required.

Clinical Applications
This 59-year-old woman had a history of vulvar cancer and had undergone radiation
therapy. She had a radical resection, leaving a complex irradiated wound with an exposed
pubic bone, and a partial vaginectomy. A myocutaneous gracilis flap was a good choice for
reconstruction in this patient, because it offers ample available tissue in a donor site with
minimal morbidity. Other options included rectus abdominis, TFL, and rectus femoris flaps.

C D

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. (Case supplied by MRZ.)

12c_Gracilis_r7_cah_1418-1465.indd 1435 2/7/2012 3:58:59 PM

 1436 Part II  Regional Flaps: Anatomy and Basic Techniques

This 19-year-old woman sustained a severe open fracture of the ankle in a motor vehicle
accident. The gracilis is a favored choice for reconstruction of a traumatic injury in the distal
third of the leg, since there are no good local muscle flap options. If the wound is too large
for a gracilis muscle, other larger muscles can be considered, such as the rectus abdominis
and latissimus dorsi.

C D

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. (Case supplied by MRZ.)

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1437

This 26-year-old man was involved in a motorcycle accident, sustaining bilateral pneumo-
thoraces, a fractured sternum and ribs, and a brachial plexus injury. He presented 2 years after
the injury and was thought to be a good candidate for reestablishment of elbow function
with an innervated gracilis transfer motored by the third, fourth, and fifth intercostal nerves.

B C

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. (Case supplied by MRZ.)

12c_Gracilis_r7_cah_1418-1465.indd 1437 2/7/2012 3:59:07 PM

 1438 Part II  Regional Flaps: Anatomy and Basic Techniques

This 54-year-old woman had undergone bilateral mastectomy for a left breast cancer
2 years earlier. She received postoperative chest irradiation on the left. She opted for delayed
reconstruction; she wanted to regain her B cup breasts and was not interested in breast
implants. Although patients may sometimes wish to have small breasts reconstructed, it
is technically difficult to shape them, especially in bilateral cases, with standard TRAM
techniques. The TUG flap is a perfect choice in these situations, because it is available, has
similar morbidity to a medial thigh lift with its benefits, and is actually easier to shape into
a small breast.

B C

D E

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. (Case supplied by MRZ.)

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1439

This 19-year-old had an Achilles tendon rupture and developed a wound infection after
repair. An Achilles tendon reconstruction with gracilis muscle and tendon was planned.

A B

C D

E F

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 gastrocne-
mius and soleus muscles. C, The distal tendon was folded over
on the muscle itself into a “hot 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.
(Case courtesy Rudolf F. Buntic, MD.)

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 1440 Part II  Regional Flaps: Anatomy and Basic Techniques

In an automobile rollover accident, this 58-year-old woman sustained a devastating crush

injury to her forearm with loss of flexor muscles. Forearm reconstruction was planned with
a functional TUG flap.

A B

C D

E F

G H

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. (Case courtesy Rudolf F. Buntic, MD.)

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1441

Resection of an acoustic neuroma resulted in complete right facial paralysis in this 58-year-
old woman. Facial reanimation with a thinned gracilis flap was planned.

B Adductor longus muscle

Pedicle

Gracilis nerve branches

C D

E F

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. (Case courtesy
Rudolf F. Buntic, MD.)

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 1442 Part II  Regional Flaps: Anatomy and Basic Techniques

This 40-year-old man presented with an anterior compartment loss after a compartment
syndrome and debridement of anterior compartment muscles. A lower extremity anterior
compartment reconstruction with a functional gracilis muscle was planned.

A B

D F G

Fig. 12C-17 A and B, The patient is seen preoperatively. As a result of his injuries, he had no dorsi-
flexion 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 or-
thotic. (Case courtesy Rudolf F. Buntic, MD.)

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1443

This child had a congenital unilateral right facial paralysis. It really had not changed signifi-
cantly since birth. Fortunately, she did not have any functional issues related to eye closure
or mouth closure. However, she was very shy and embarrassed about her facial asymmetry,
particularly with smiling or laughing. We discussed microsurgical reconstruction with a
two-stage approach. She underwent a cross-face nerve graft whereby facial nerve branches
on the normal left side were identified. An appropriate branch was selected for nerve graft-
ing, and we determined that other branches were present to preserve the innervations of the
normal side. One year after the cross-face nerve graft was carried out, a second procedure
was done in which a segment of the gracilis muscle was transplanted to the face. It was ap-
propriately positioned so that the origin and insertion would replicate the normal side as
much as possible. The muscle was revascularized through the facial vessels and reinnervated
using the previously placed cross-face nerve graft.

A B

C D

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 spontane-
ous; the transplanted muscle is innervated by the normal side facial nerve with the aid of a sural nerve
graft extension. (Case courtesy Ronald M. Zuker, MD.)

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 1444 Part II  Regional Flaps: Anatomy and Basic Techniques

This boy had an untreated severe clubfoot deformity. To correct the deformity, an open oste-
otomy was carried out to the midfoot. The Achilles tendon was also released and lengthened.
This left a complex defect with an exposed bone and joint, as well as an exposed, uncovered
Achilles tendon. The gracilis muscle was used to cover the irregular complex defect in the
midfoot. The proximal portion was split so that it would wrap around the Achilles tendon.

A B

Fig. 12C-19 A-C, Preoperative appearance of the patient’s neglected clubfoot deformity.

12c_Gracilis_r7_cah_1418-1465.indd 1444 2/7/2012 3:59:57 PM

 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1445

One portion went on the superficial aspect and one portion on the deep aspect between the
tendon and calcaneus. The muscle was revascularized through an end-to-side anastomosis
with the posterior tibial artery and an end-to-end anastomosis to the posterior tibial vein.
The muscle was inset also beneath the margin of the adjacent skin. The surface was covered
with a split-thickness skin graft.

D E

F G

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.
(Case courtesy Ronald M. Zuker, MD.)

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 1446 Part II  Regional Flaps: Anatomy and Basic Techniques

This boy was born with Moebius syndrome; thus he had bilateral and virtually complete
paralysis of his sixth and seventh nerves. He also has partial twelfth nerve involvement and
bilateral clubfeet. His development had been quite normal, and he was participating in nor-
mal activities. However, his main complaint was that he had no facial expression. He was
unable to communicate his emotions with his face, and this was affecting his psychosocial
integration. In addition, he also had some difficulty with bilabial sounds such as “P” and
“B,” because he was unable to elevate his lower lip to his upper lip. His fifth nerve func-
tion was normal, and our plan was to carry out segmental gracilis muscle transplantations,
which would be revascularized by the facial vessels and reinnervated with the motor nerve
to the masseter muscle. Each side was done separately, about 6 months apart.

A B

Fig. 12C-20  A, Preoperative appearance. B, The patient attempting a smile. C, Intraoperative ap-
pearance of the segmental gracilis muscle transplant demonstrating origin and insertion, as well as
the site of vascular anastomoses and motor nerve repair.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1447

D E

Fig. 12C-20  D, Postoperative appearance at rest following staged segmental gracilis muscle trans-
plantations 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. Mus-
cle excursion is excellent, using the motor nerve to the masseter, and reasonable symmetry was
obtained. (Case courtesy Ronald M. Zuker, MD.)

Pearls and Pitfalls

• Positive identification of the gracilis muscle is vital; it is difficult to identify in some pa-
tients, especially obese individuals.
• Identification of the tendon distally and definitive identification of the obturator nerve
and the medial circumflex femoral pedicle proximally are critical.
• The distal third of the leg should not be included in the design of the myocutaneous
gracilis flap, because it is unreliable.
• The vascular pedicle has a small-diameter artery—sometimes less than 1 mm at its origin.
• Although it is tempting to sometimes shorten the harvest time by not fully dissecting
the pedicle, it is essential in microvascular transfer to dissect the pedicle to its profunda
femoris source for the best possible arterial diameter and vessel match to the recipient site.
• On occasion, the arc of rotation of the flap does not allow the muscle to adequately
reach the reconstruction site. Division of the medial circumflex femoral pedicle should
be considered, because the muscle flap may receive adequate vascularity from smaller
vessels present around its origin.
• Transverse skin paddle designs put the patient at risk for lymphedema. Care should be
taken in harvesting these flaps to avoid deep dissections around the femoral triangle.

12c_Gracilis_r7_cah_1418-1465.indd 1447 2/7/2012 4:00:05 PM

 1448 Part II  Regional Flaps: Anatomy and Basic Techniques

Expert Commentary
Rudolf F. Buntic

Indications
The length and reliable vascular pedicle of the gracilis and its potential as a myocutaneous
flap make the gracilis flap a workhorse of reconstructive surgery. Local wounds from the
groin to the perineum can be reached, while ischial pressure sore dead space can be obliter-
ated from a posterior thigh approach. Distant reconstructions from head to toe, depending
on recipient site needs, may all be candidates for this flap. It is an excellent choice in facial
reanimation or for extensor or flexor reconstruction of the forearm. I consider the gracilis
to be the preferential functional muscle donor when great power is not needed, and the
preferred flap any time small defects in and around the distal third of the lower extremity
require coverage of vital structures.

Advantages and Limitations

The foremost advantage of the gracilis flap is the extremely consistent pedicle and nerve
that can be harvested with a patient in the supine position. The primary blood supply and
innervation of the muscle show little variability, in contrast to a perforator flap, and anatomic
variants of any significance are few. This helps to make harvest of the gracilis easy and rapid.
The length of the muscle provides excellent excursion, allowing reconstruction of defects
of extrinsic muscles of the hand and wrist and the anterior compartment of the lower leg.
Finally, the large tendon at the distal aspect of the muscle offers a significant advantage over
other functional muscle transplants. This allows direct repair to forearm and foot tendons
with strong weaves or locking looped sutures.
The long, thin nature of the gracilis does have some drawbacks. Wide defects are not
amenable to coverage. Two-bone forearm coverage or large lower extremity defects are
often best served by a latissimus muscle or other flap with a larger surface area. The power
generated by the gracilis muscle precludes its use for reconstructing foot flexion and knee
extension, where more power is needed. The power generated by muscle contraction is
proportional to the cross-sectional area of the muscle body.
In a heavier patient, the thick inner thigh fat of the gracilis skin paddle does not make
a good side-to-side match with the forearm or lower leg skin and subcutaneous tissue.

Anatomic Considerations
1. The muscle can be slipped under the adductor longus to be pedicled laterally (see Fig.
12C-5).
2. There are valves immediately at junction of the gracilis veins and the profunda femoris
vein resulting in veins that are usually a centimeter shorter than the artery.
3. The nerve splits into three branches as it enters the muscle, providing separate motor
supplies to the anterior, middle and posterior aspect of the muscle. This can be mapped
intraoperatively with a nerve stimulator and must be taken into consideration when
thinning the muscle (see Fig. 12C-16).
4. The tendon can sometimes be quite thin and is very distal on the flap (see Fig. 12C-2).
When attempting to do a Pulvertaft weave to lower or upper extremity tendons, the
surgeon immediately encounters the body of the muscle of the gracilis shortly after
pulling the tendon through the weave, limiting the passes of the weave and ability to
tighten the muscle at the distal point.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1449

Personal Experience and Insights

Although the harvest of the gracilis is simple, inset for upper and lower extremity func-
tional reconstruction is challenging and requires planning. The recipient area artery and
veins may not be adjacent to the nerve that will provide motor innervation to the muscle.
Nerve grafting should be avoided to minimize time to muscle innervation. If the nerve is
positioned well, the vessels may end up kinked to support the lie of the nerve. Likewise, if
the vessels and nerves are perfectly repaired with a good lie, further inset of the muscle and
stretching it back out to length may result in kinking or placing tension on microsurgical
repairs. It is better to consider where the nerve and vessels will lie ahead of time and then
inset the proximal and distal muscles, completing the inset of the muscle before vessel and
nerve repairs if possible, but still allowing access to the repair sites.
In functional muscle reconstruction of the forearm, the proximal gracilis needs to be
repaired above the elbow in order to achieve tendon repair in the distal wrist. Two functions
for one muscle. For flexor repair, the tendon can be split distally for weave to the thumb
and fingers in separate weaves.
For facial reanimation, great strength is not required for a smile, and the muscle can
be thinned significantly. Segmental innervation patterns should be defined with a nerve
stimulator and thinning done between innervations territories.
The proximal gracilis tendon is very short and must be taken right of the ischial origin
if a functional muscle is being used. The proximal tendon is needed to secure the new
muscle origin in the recipient site.

Recommendations
Planning
In functional reconstruction, the proximal gracilis will need to be inserted above the elbow,
and in the leg, at the tibial condyles. This brings the ulnar nerve into play in the forearm
and the peroneal nerve into play in the leg. Compression of these nerves must be avoided.
The muscle should be marked at 5 cm intervals with thin Prolene sutures before proximal
or distal transection in the thigh. This allows placement of the muscle on appropriate tension
in the recipient area when performing functional muscle transplants. The surgeon should
avoid obstructing exposure to the vessel and nerve repair, or kinking or tugging on the
vessel and nerve repair with the inset of the muscle.

Technique
Self-retaining retractors are used distal and proximal to the pedicle to widely retract the
adductor longus and magnus muscles. These retractors should be adjusted as needed to
maintain good exposure while dissecting the pedicle to the origin. One must be watchful
not to impale the nerve with the self-retaining retractors if the nerve is to be used.
If the patient is large or obese, the adductor longus muscle can be retracted medially,
and the pedicle of the gracilis can be dissected to its origin between the longus and vastus
medialis. This allows easier dissection of the root of the pedicle and a more direct lie of the
pedicle when covering groin structures.
The proximal tendon is very short and can shred easily with suturing. If needed, maxi-
mal length should be obtained by removing it directly from the origin of the ischium with
good exposure and retraction to this area.
Continued

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 1450 Part II  Regional Flaps: Anatomy and Basic Techniques

Postoperative Care
Postoperative care of a patient with a gracilis flap reconstruction is generally uncomplicated,
except in the TUG flap. The large potential space requires drains to be secured well into
position and left in place much longer than for typical gracilis flaps. Seroma formation is
common in the TUG flap, but rare in muscle-only harvest.

Complications: Avoidance and Treatment

Seroma formation can be quite a nuisance. If drains are removed too early, surgical excision
of the seroma cavity with reclosure and drainage may be needed if the patient feels bulging
pressure in the inner thigh.
It is easy to injure the small veins of the pedicle, where branches to the adductor longus
and magnus are present. These very small branches are handled by good retraction and
micro hemoclips or bipolar cautery. Countertraction is the key to exposure of the pedicle
and its branches.

Take-Away Messages
The gracilis is a workhorse flap. Along with the latissimus, ALT, fibula, and radial forearm
flaps, knowledge of this flap is a must for every reconstructive surgeon. The gracilis is a
go-to flap for many defects. The simple anatomy and ease of harvest allow the surgeon to
concentrate on the reconstruction.

EXPERT COMMENTARY
Ronald M. Zuker

Indications
The gracilis flap has a very broad application in reconstructive surgery. It can be used for
vascularized cover in very complex wounds, either through regional rotation or free tissue
transfer. It is particularly useful for coverage of small areas in poorly vascularized regions,
such as the lower extremity or in an irradiated bed. Its most dramatic use, however, is as
a functioning muscle, whereby it is not only revascularized but also reinnervated with a
motor nerve for function. This has found broad application in the upper extremities and
in the face. In the upper extremities, it has been used for finger flexion, finger extension,
deltoid replacement, and biceps replacement. In the face, it is a major workhorse for muscle
transplantation for the treatment of facial paralysis to replicate the actions of the zygomaticus
major, zygomaticus minor, and levator labii muscles. Much of this commentary will be
related to its use in facial paralysis reconstruction.

Advantages and Limitations

The gracilis muscle has a superb neurovascular anatomy that facilitates free tissue transfer.
In particular, the single motor nerve is most helpful for functioning muscle transplanta-
tion. The gracilis muscle can be harvested at the same time as recipient site dissections in
the upper extremity or in the face, facilitating a simultaneous two-team approach. The
anatomy is consistent and reliable, and the flap relatively easy to dissect. The muscle can
also be reduced in size, both lengthwise and widthwise, to suit the purpose for which it is
being applied. Last, but by no means least, the donor site leaves no functional deficit, even
when the entire gracilis is harvested. The scar is relatively well hidden in the upper inner
thigh, although it does often spread.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1451

The flap’s limitations are primarily related to its size. It is too long for easy use in the
upper extremity and often needs to be shortened. Similarly, in the face, the origin and in-
sertion are often in the muscular component rather than a fascial component. This makes
anchorage complex. It is important to avoid the pulling through of the muscle, which would
thereby disconnect it from its site of origin or insertion. Last, the gracilis muscle is too bulky
for use in the face unless it is carefully tailored. This often involves reducing the diameter
by a half or two thirds to avoid excess bulk. Care must be taken in the face to avoid placing
the muscle over bony prominences, such as the malar prominence. To avoid excess bulk in
the temple region, the muscle can be spread out over the origin in the temple.

Anatomic Considerations
The anatomy of the gracilis is quite consistent and well described in the chapter. I find iden-
tification of the myocutaneous perforator vessel a great aid in locating the pedicle. When
the perforator is found, the pedicle is directly beneath it on the deep surface of the muscle.

Personal Experience and Insights

The gracilis muscle has been the workhorse for us in functioning muscle transplantation
to the upper extremity and to the face. The anatomy is consistent, and I have never had to
switch to the other side because of aberrant anatomy. I have had experience with vascular
anomalies whereby a portion of the adductor had to be used, and this was quite feasible.
One should always be watchful for anatomic variations, but in my experience the gracilis
is extremely consistent.

Recommendations
Planning
It is essential to have a precise plan for reconstruction. The size of the defect must be smaller
than the planned flap. For wound coverage, overlapping the muscle beneath the adjacent
skin around the entire defect is very helpful. It adds a further layer of security, should there
be a minor dehiscence at one edge of the repair. In the face, it is important to reduce the
size of the muscle to avoid excess bulk. For facial paralysis reconstruction, an accurate and
secure origin and insertion are critical. The muscle also must be powered by an appropri-
ate motor nerve. This can be the ipsilateral facial nerve or the contralateral facial nerve via
a cross-face nerve graft or a regional motor nerve, such as the motor nerve to masseter. A
more powerful input will lead to a more powerful contraction and greater excursion. It
is also important to place the muscle at the appropriate tension, so that when contraction
occurs it will be most effective. In facial paralysis reconstruction, it is best to elevate the
drooping oral commissure so that it is even with the normal side and under a slight amount
of tension. Thus, when innervation does occur, it will lead to muscle contraction that will
immediately move the oral commissure.

Technique
The technical details regarding facial reanimation are extremely important. The four key
elements are appropriate and secure muscle fixation, reduction of excess bulk, provision of
a strong motor input, and placing the muscle under appropriate tension.

Postoperative Care
Wound closure of the gracilis donor site is usually straightforward. I generally do not use
drains and close the wound in layers with absorbable sutures, subcuticular sutures for the
skin and reinforced with glue. A circumferential support dressing is also used for the first
Continued

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 1452 Part II  Regional Flaps: Anatomy and Basic Techniques

2 days. In wound closure, it is important to close the deep fascia. I have had instances
of muscle herniation, which does not pose a functional problem, but is aesthetically con-
cerning. With careful closure of the deep fascia, this can be avoided.

Complications
The complications associated with the gracilis donor site include infection, hematoma, and
seroma. I now make a rule of thoroughly irrigating the wound with saline solution before
closing the wound, because it may have been open for several hours, and wound closure
may not take place until the recipient site has been effectively completed. Perioperative an-
tibiotics are also used, and with these two measures, our infection rate has been controlled.

Take-Away Messages
I have found the gracilis flap to be anatomically consistent and extremely useful and versatile,
with broad application. It can be used for vascularized cover as well as function in both the
upper extremities and the face.

EXPERT COMMENTARY
Michael R. Zenn

Indications
The gracilis flap is one of the few basic reconstructive flaps that all plastic surgeons need to
master in a successful practice. The reason lies in its versatility and low morbidity. Its uses
run the gamut from decubiti and wound closure to functional muscle transfer and free flap
breast reconstruction.

Anatomic Considerations
Anatomically the gracilis muscle is ideal, since it has a reliable and sizable vascular pedicle
that is not critical for vascularizing the leg. It has a single large motor nerve that supplies no
other muscles. The muscle can be spread out to cover a large area or pared down when the
smallest possible innervated muscle is required. Its pedicle location is favorable for rotation
when used on the most difficult problems of the perineal and groin areas, such as fistulas,
exposed vascular grafts, and issues leading to anal incontinence.

Advantages and Limitations

The general location of the upper thigh is also a plus in that it affords two-team approaches
to reconstructive problems in the head and neck, upper extremity, and lower extremity. Its
donor scar along the inner thigh is inconspicuous and well tolerated by most patients. In a
transverse design (TUG flap), the scar is identical to the scar found in medial thigh lifts, a
cosmetic procedure.
With all of those strengths, there are a few important things to remember to successfully
use this flap in reconstruction. First, identification of the muscle is key as an initial step.
More than a few sartorius and adductor longus muscles have been completely skeletonized
before the misidentification has been realized. Second, one should not rely too much on the
distal 25% of the muscle for bulk. Some patients will have mainly tendon in the terminal
portion, and that could be a big issue if muscle bulk is needed, as in repair of a fistula or
coverage of a vascular graft.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1453

In fact, if the surgeon is mere centimeters away from a successful reconstruction and
needs just a little more length, there are two maneuvers to keep in mind. First, the medial
femoral circumflex pedicle should be dissected completely to the profunda femoris, dividing
all side branches. This will generate an extra 1 or 2 cm. When that is still not enough, the
medial femoral circumflex pedicle can be divided. If the proximal portion of the muscle
has not been skeletonized, the blood supply from around the bony origin may be enough
to carry the flap. Having read about it, I have only found myself in that situation once, and
it worked like a charm. I would not recommend it routinely, and in my case, the muscle
was useless for the reconstruction if it did not reach.

Complications: Avoidance and Treatment

The last word to remember about the gracilis flap is seroma. The area has plenty of lym-
phatics and is a highly mobile area in an ambulatory patient. Drains should remain in place
longer than for other reconstructed sites, and seromas must be managed aggressively and
early to avoid the dreaded replacement of a drain. The corollary to seroma is lymphedema.
I have seen gracilis patients and medial thigh lift patients with problematic lymphedema.
The surgeon must respect the lymphatics of the groin and avoid deep and skeletonizing
dissection around the femoral system.

Bibliography With Key Annotations

Baker PA, Watson SB. Functional gracilis flap in thenar reconstruction. J Plast Reconstr Aesthet
Surg 60:828-834, 2007.
The authors described the use of a free innervated gracilis muscle flap for functional thenar reconstruction
in two unique cases following extensive traumatic loss of thenar skin and musculature. Crucially, in
each case, the recurrent motor branch of the median nerve had been destroyed at its point of insertion
into the thenar muscle remnants. To date, the main reported disadvantages of free functioning muscle
transfer in thenar reconstruction include difficult flap dissections, donor site morbidity, inadequate
strength and excursion of the transplanted muscle and excessively bulky flaps. Their aim was to address
these issues. Each thenar defect was measured and a corresponding segment of gracilis muscle, measured
in situ, was raised on the proximal neurovascular pedicle. End-side microvascular anastomosis was
performed between the medial circumflex femoral artery and the radial artery. The venae comitantes
of the pedicle were anastomosed end-to-end with those of the radial artery and also with the cephalic
vein. Epineural anastomosis was performed between the motor branch of the obturator nerve and the
recurrent motor branch of the median nerve. Each flap was covered with a split-thickness skin graft.
Both flaps survived without any complications. Both patients regained excellent voluntary thumb
opposition, sufficient to allow return to full-time employment, and had restoration of sufficient thenar
bulk. This was achieved with minimal donor site morbidity.
Camp S, Cartwright P, Siddiqi F. The prefabricated gracilis muscle flap with full-thickness skin
graft and delay for urethral channel reconstruction. Ann Plast Surg 67:59-61, 2011.
Reconstruction of complex urethral defects should provide lasting coverage, a patent tube for voiding,
and a natural appearing contour with minimal morbidity to the donor and recipient sites. Many reports
have emerged in the literature regarding complex urethral reconstruction through a variety of methods
including anterolateral thigh flaps, radial artery forearm free flap, and other simple skin and mucosal
flaps. Recently, Ozkan and Ozkan reported using a prefabricated anterolateral thigh flap for recon-
struction of a traumatic urethral defect. In this report, the authors described their experience with the

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 1454 Part II  Regional Flaps: Anatomy and Basic Techniques

use of a prefabricated gracilis muscle flap in a female-to-male transsexual with a complex proximal
urethral stricture and distal fistula. The authors stated this was the first report of a prefabricated gracilis
myocutaneous muscle flap being used for a long segment urethral stricture and distal fistula. The authors
noted that this procedure offers a unique solution to a difficult problem with decreased morbidity and
cosmetic advantages over other methods requiring microvascular anastomoses.
Cavadas PC, Sanz-Giménez-Rico JR, Landín L, et al. Segmental gracilis free flap based on
secondary pedicles: anatomical study and clinical series. Plast Reconstr Surg 114:684-691, 2004.
The gracilis muscle has been used extensively in reconstructive surgery, based on the proximal dominant
pedicle, but little attention has been paid to the secondary distal pedicles. The authors investigated
distribution of the secondary pedicles of the gracilis muscle in 20 cadaver thighs. The mean number of
secondary pedicles was 2.2. When two pedicles were present, the most common situation, they were
located at a mean distance of 12.4 and 17.5 cm from the knee joint line. The most proximal secondary
pedicle was injected with barium sulfate in five specimens, and constant and abundant connections with
the main pedicle were noted. A series of seven clinical cases of segmental gracilis free muscle flaps based
on a secondary pedicle was reported. The flaps were successfully transferred to reconstruct traumatic
defects of limited size, with one case of partial necrosis caused by a technical error. The morbidity of
this flap is minimal, the scar is well hidden, the muscle need not be sacrificed, elevation is fast and
straightforward under tourniquet control, and the pedicle was sizable. This flap should be considered
a viable option when a small, straightforward free flap is needed.
Chou EK, Cheung DC, Ko EW, et al. Functional and aesthetic approach to adult unoperated
Möbius syndrome: orthognathic surgery followed by bilateral free gracilis muscle transfers.
Plast Reconstr Surg 125:58e-60e, 2010.
Chuang DC. Free tissue transfer for the treatment of facial paralysis. Facial Plast Surg 24:194-
203, 2008.
Long-standing facial paralysis requires the introduction of viable, innervated dynamic muscle to restore
facial movement. The options include regional muscle transfer and microvascular free tissue transfer.
There are advantages and disadvantages of each. Briefly, the regional muscle transfer procedures are
reliable and provide immediate return of movement. However, the movement is not of a spontane-
ous mimetic nature. Free tissue transfer, in contrast, offers the possibility of synchronous, mimetic
movement. However, it does require a prolonged healing time in comparison with that of regional
muscle transfer. The choice is made by the physician and patient together, taking into account their
preferences and biases. Muscle-alone free tissue transfer is the author’s preferred option for reanima-
tion of uncomplicated facial paralysis without skin or soft tissue deficits. Combined muscle and other
tissue (most are skin flap) is another preferred option for more challenging complex facial paralysis
with skin or soft tissue deficits after tumor excision. Gracilis flap is the author’s first choice of muscle
transplantation for both reconstructions.
Chuang DC, Mardini S, Lin SH, et al. Free proximal gracilis muscle and its skin paddle
compound flap transplantation for complex facial paralysis. Plast Reconstr Surg 113:126-132;
discussion 133-135, 2004.
Gracilis functioning free muscle transplantation for the correction of pure facial paralysis has been a
preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis,
the deficits include facial paralysis and defects of the soft tissue, mucosa, and/or skin. No adequate
solution has been proposed. Treatment requests in such patients are not only for facial reanimation but
also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning
free muscle transplantation from 1986 to 2002, eight patients (5%) presented with complex deficits
requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects
included an intraoral defect created following contracture release (one patient), infraauricular radiation
dermatitis with contour depression (one patient), temporal depression following a temporalis muscle–

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1455

fascia transfer (one patient), ear deformity (two patients), and infraauricular atrophic tissue with contour
depression (three patients). A compound flap consisting of a gracilis muscle with its overlying skin
paddle separated into two components was transferred for simultaneous correction of both problems.
The blood supply to the gracilis and to the skin paddle originated from the same source vessel and
therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows
for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully
without complications. Satisfactory results of facial reanimation were recorded in five patients after all
stages were completed. The remaining three patients were undergoing physical therapy and waiting
for revision of the skin paddle.
Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for ac-
quired vaginal defects. Plast Reconstr Surg 110:1058-1065, 2002.
Although multiple flaps have been used for vaginal reconstruction, a logical approach to reconstruction
of these often complex defects has not been described. The objective of this study was to establish a
classification system for acquired vaginal defects and to develop a reconstructive algorithm derived from
this system. The authors presented a classification system: partial defects involving the anterior or
lateral vaginal wall were classified as type IA defects and were reconstructed primarily with pedicled
Singapore fasciocutaneous flaps. Partial defects involving the posterior wall were classified as type IB
and were reconstructed with pedicled rectus abdominis myocutaneous flaps. Circumferential defects
involving the upper two thirds of the vagina were classified as type IIA defects and were reconstructed
with a rolled rectus flap or, less commonly, sigmoid colon (one patient). Total circumferential defects,
type IIB, were reconstructed largely with bilateral gracilis flaps. Flap selection is determined on the
basis of the type of defect. Using this algorithm, immediate vaginal reconstruction with pedicled regional
flaps can be performed with minimal patient morbidity and few surgical complications.
Coskunfirat OK, Uslu A, Cinpolat A, et al. Superiority of medial circumflex femoral artery
perforator flap in scrotal reconstruction. Ann Plast Surg 2011 Feb 21. [Epub ahead of print]
Scrotal skin has unique cosmetic and functional features that make its reconstruction difficult. Cover-
age of the testicles and producing a good cosmetic appearance are major expectations from a successful
reconstruction. Usually flaps are the choice for scrotal reconstruction, but every single flap has its own
characteristics. In their series, between January 2006 and January 2010, the authors used the me-
dial circumflex femoral artery perforator flap in seven male patients for scrotal coverage after Fournier
gangrene. Six flaps were raised based on a single perforator from the gracilis muscle; in one flap two
perforators were used. Flaps were carried to the defect either by transposition or by V-Y advancement.
Donor areas were closed directly in all patients, and stable scrotal coverage was achieved with an ac-
ceptable scrotal contour and cosmesis. No major complication occurred as a result of the perforator flap
surgery; in two patients wound dehiscences were noted and they healed by secondary intention or by
secondary suturing. For scrotal reconstruction, the medial circumflex femoral artery perforator flap is a
good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and
direct closure of the donor site. All these advantages can be accomplished in one procedure.
Del Frari B, Schoeller T, Wechselberger G. Reconstruction of large head and neck deformities:
experience with free gracilis muscle and myocutaneous flaps. Microsurgery 30:192-198, 2010.
Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. The
authors described their experience with the gracilis free flap and the myocutaneous gracilis free flap for
reconstruction of head and neck defects. Eleven patients underwent 12 free tissue transfer to the head
and neck region. The reconstruction was performed with the transverse myocutaneous gracilis (TMG)
flap (7) and the gracilis muscle flap with skin graft (5). Total flap survival was 100%. There were
no partial flap losses. Primary wound healing occurred in all cases. Recipient site morbidities included
one hematoma. In their experience for reconstruction of moderate volume and surface area defects,
muscle flaps with skin graft provide a better color match and skin texture relative to myocutaneous or

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 1456 Part II  Regional Flaps: Anatomy and Basic Techniques

fasciocutaneous flaps. The gracilis muscle free flap is not widely used for head and neck reconstruc-
tion but has the potential to give good results. As a filling substance for large cavities, the transverse
myocutaneous gracilis flap has many advantages, including reliable vascular anatomy, relatively great
plasticity, and a concealed donor area.
Ducic I, Dayan JH, Attinger CE, et al. Complex perineal and groin wound reconstruction using
the extended dissection technique of the gracilis flap. Plast Reconstr Surg 122:472-478, 2008.
The authors reviewed the applications of the extended-dissection technique of the gracilis flap in a
high-risk patient population with complex wounds requiring more coverage than a standard gracilis flap
may provide. To their knowledge, this was the first study applying the extended-dissection technique
as described by Hasen et al to pedicled gracilis flaps. They conducted a chart review and identified 19
consecutive patients as having undergone an extended gracilis dissection. Once the pedicle is identified
on the medial border of the gracilis, dissection continues proximally, dividing the rich vascular network
of perforators to the adductor muscles. The gracilis is then passed beneath the adductor longus and
delivered adjacent to the sartorius, where dissection proceeds directly down to the profunda femoris. All
reconstructions were successful. There was one complication presenting as a late infection at the donor
site. Mean patient age was 66 years, and nearly all patients had multiple significant comorbidities,
including diabetes, peripheral vascular disease, and/or radiation therapy. The extended-dissection
technique for gracilis harvest has significant benefits for use in pedicled flaps, including a greater arc of
rotation and no restriction on postoperative ambulation or thigh abduction. These factors are particularly
important in the challenging patient population represented in this study and add to the reliability
and versatility of the gracilis flap.
Eom JS, Sun SH, Hong JP. Use of the upper medial thigh perforator flap (gracilis perforator
flap) for lower extremity reconstruction. Plast Reconstr Surg 127:731-737, 2011.
The upper medial thigh perforator flap is a free-style skin flap elevated suprafascially from the upper
medial thigh in a transverse manner based on any reliable perforator. A total of 40 cases were per-
formed in 40 patients with lower extremity soft tissue defects from various causes. The anatomy of
the flap, elevation technique, and results after reconstruction were evaluated. An average number of
1.3 reliable pulsating pedicles was noted entering the flap; 90% originated from the medial circumflex
femoral artery. The perforators were one third myocutaneous and two thirds septocutaneous type. The
average length of the pedicle was 6 cm; the average diameter of the artery was 0.8 mm. The flaps
were thinned according to the needs of the patient. The donor sites were closed primarily. Thirty-nine
flaps survived, and no recurrence of the original abnormality was seen during the follow-up period.
Despite the short pedicle length, small diameter of the vessel, and inconsistent perforator position, the
surgeon can use the upper medial thigh perforator flap to overcome the disadvantages by understanding
the free-style free flap approach. The flap can obtain reasonable size, well-hidden scar, preservation
of muscle function, good pliability, and superficial nerves and vein included for additional quality.
This flap, in the hands of experienced surgeons, can be reliable for reconstructing the lower extremity.
Fansa H, Schirmer S, Warnecke IC, et al. The transverse myocutaneous gracilis muscle flap: a
fast and reliable method for breast reconstruction. Plast Reconstr Surg 122:1326-1333, 2008.
Autologous breast reconstruction is predominantly performed using free transverse rectus abdominis
myocutaneous or deep inferior epigastric perforator flaps. However, some patients are not suitable can-
didates for flaps from the lower abdomen. The transverse skin island of the gracilis muscle presents an
additional option, as it includes tissue from the posterior upper thigh/lower buttock and thus delivers
the amount of tissue necessary for breast reconstruction. In 2007, the authors’ unit performed 73 free
flaps for breast reconstruction subsequent to carcinoma, implant-related capsular fibrosis, and breast
asymmetry. The transverse myocutaneous gracilis flap was used 32 times in 20 patients. The ventral
margin was the greater saphenous vein, and the posterior margin was the midline of the inferior gluteal
fold. The skin island could be harvested to a width of up to 30 cm and a height of up to 10 cm. The

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1457

donor site was closed primarily. Mean follow-up was 6 months. Mean operating time was 220 min-
utes for unilateral and 325 minutes for bilateral cases. All flaps and donor sites healed uneventfully.
An initially described “tight feeling” at the thigh ceased after 2 to 3 weeks. Persistent hypesthesia of
the dorsal thigh was not noted. A major asymmetry of the thigh in unilateral transplantations was
not apparent. After 6 months, all flaps were soft. The transverse myocutaneous gracilis flap is a safe,
fast flap for reconstruction after benign and malignant breast disease. It combines a constant vascular
pedicle with soft subcutaneous tissue that has breastlike characteristics.
Fattah A, Figus A, Mathur B, et al. The transverse myocutaneous gracilis flap: technical refine-
ments. J Plast Reconstr Aesthet Surg 63:305-313, 2010.
Autologous free tissue transfer is an ideal method for breast reconstruction. The deep inferior epigastric
perforator (DIEP) flap is considered the gold standard procedure worldwide. However, in selected
patients this flap cannot be performed to achieve satisfactory outcomes. The transverse myocutaneous
gracilis (TMG) flap is one of the most recent additions to the armamentarium of breast-reconstructive
surgeons. This flap can provide adequate autologous tissue with a hidden scar. The authors noted that
since its description for breast reconstruction in 2004, no series had been published, and its recognition
was still lacking. The main criticism of this flap was the lack of volume that can be achieved and the
potential for donor morbidity. The authors reported on a 2-year experience with the use of TMG flaps
for breast reconstruction, assessing the potential indications and introducing some technical refinements
to expand the role of this flap in breast reconstruction. Nineteen TMG flaps were performed in 12
patients (seven double procedures: five bilateral cases and two stacked flaps for unilateral breast recon-
struction). One flap was lost 9 days postoperatively. Follow-up ranged from 6 months to 2 years. The
authors detailed their surgical technique and described refinements to speed up flap harvest, increase
flap volume, optimize flap inset and minimize donor site complications.
Hallock GG. The conjoint medial circumflex femoral perforator and gracilis muscle free flap.
Plast Reconstr Surg 113:339-346, 2004.
This perforator flap could be considered an ideal skin flap, because the defined skin territory is reli-
able, harvesting can be performed with the patient supine, and the vascular pedicle has a consistent
location well known to plastic surgeons. Donor site scars in the medial groin can be readily concealed.
Hallock GG. Further experience with the medial circumflex femoral (gracilis) perforator free
flap. J Reconstr Microsurg 20:115-122, 2004.
The microsurgical transfer of the medial groin skin territory previously required this to be part of
a transverse-oriented gracilis myocutaneous free flap. As the concept of muscle perforator flaps has
evolved, avoidance of muscle bulk and/or retention of muscle function is also possible with the careful
intramuscular dissection of the gracilis myocutaneous perforators back to the usual medial circumflex
femoral source vessel. This so-called medial circumflex femoral (gracilis) perforator free flap has been
successfully used seven times in six patients with minimal complications. The gracilis muscle perforator
flap may well represent the ideal skin flap: no muscle function is sacrificed; a reliable skin territory of
large size is available; the dominant vascular pedicle is consistent in location; the flap may be harvested
with the patient in a supine position; a combined conjoint flap including the gracilis muscle is optional;
closure of the donor site leaves a medial groin scar that can be readily concealed; and flap dissection in
this region is already very familiar to most microsurgeons.
Hasen KV, Gallegos ML, Dumanian GA. Extended approach to the vascular pedicle of the
gracilis muscle flap: anatomical and clinical study. Plast Reconstr Surg 111:2203-2208, 2003.
Dissection of the proximal gracilis vascular pedicle proceeds in a dark tunnellike space deep to the
adductor longus. With the application of a previously described technique for an extended approach
to the lateral arm free flap, the authors described a novel technique that improves observation and
thus facilitates dissection of the proximal gracilis vascular pedicle. A retrospective review of data for 18
consecutive patients who underwent gracilis muscle free flap harvesting with this modified technique

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 1458 Part II  Regional Flaps: Anatomy and Basic Techniques

in 2001 was conducted to assess flap viability and patient outcomes. A cadaveric dissection was also
performed to study the anatomic features of the region in depth and to test the proposed flap modifica-
tion. After the standard incision has been made, the dominant pedicle is exposed on the medial aspect
of the gracilis muscle, running in a fascial cleft between the adductor longus and the adductor magnus.
Intramuscular branches to the adductor longus are divided. A space is bluntly created anterior and
lateral to the adductor longus by separating the fibrous connections to the surrounding adductor and
sartorius muscles on both sides of the vascular pedicle. The gracilis muscle is then divided and passed
deep to the adductor longus, into this space. With this new position, the final dissection of the pedicle
can easily be performed. The confluence of the venae comitantes is frequently encountered, providing
a larger-caliber single vein for microvascular anastomosis. The free flap survival rate was 100%. One
minor complication of a seroma at the donor site was observed. One major complication of venous
thrombosis was detected on postoperative day 3, with complete flap salvage. No other complications
were noted. This technique is safe and permits direct approach to and excellent observation of the
proximal aspect of the gracilis pedicle, without the need for headlights or deep retractors. An additional
benefit is the frequent finding of a single larger vein from the merging of the venae comitantes close to
the deep femoral vessels.
Huemer GM, Bauer T, Wechselberger G. Gracilis muscle flap for aesthetic reconstruction in
the head and neck region. Microsurgery 25:196-202, 2005.
Microsurgical tissue transfer has constantly improved the therapeutic options for reconstruction in the
head and neck region, but the ideal flap has yet to be found. The authors reported their experience
with the free gracilis muscle flap in seven patients who underwent reconstruction in the head and neck
region for a variety of indications. In all seven patients the transplanted muscle flaps healed well, with
no flap loss. Postoperative complications consisted of skin graft loss in one patient requiring a second
split-thickness skin graft. Donor site morbidity was minimal in all patients. For difficult reconstruc-
tion in the head and neck region, the free gracilis muscle flap offers a number of advantages, including
reliable vascular anatomy, relatively great plasticity, and a concealed donor area. Thus this type of
flap offers a valuable option whenever an aesthetically pleasing result is sought.
Hussey AJ, Laing AJ, Regan PJ. An anatomical study of the gracilis muscle and its application
in groin wounds. Ann Plast Surg 59:404-409, 2007.
The management of groin wounds is a common and challenging problem. The authors examined
the anatomic basis of the gracilis muscle with relation to this problem. Twelve cadaveric lower limbs
were studied to examine both the extramuscular and intramuscular vasculature of the gracilis muscle.
These underwent dissection and in three cases radiologic examination. The mean entry point of the
dominant arterial pedicle was 9.4 cm; the mean length and width of the muscle was 38.4 cm and
6.2 cm, respectively. Each gracilis muscle was then mobilized between the adductor longus and ad-
ductor magnus muscles on its dominant pedicle and transposed into the femoral triangle. In each case,
the gracilis muscle mobilized easily on its dominant pedicle to adequately cover the groin. The gracilis
muscle is a reliable muscle flap with a consistent blood supply that can be transposed easily into the
groin, based on its dominant pedicle, and offers adequate coverage of the femoral vessels.
Kappler UA, Constantinescu MA, Büchler U, et al. Anatomy of the proximal cutaneous per-
forator vessels of the gracilis muscle. Br J Plast Surg 58:445-448, 2005.
The authors analyzed the proximal perforator vessels of the gracilis myocutaneous flap. Twenty-three
cadaver legs preserved by the Thiel method were carefully dissected 24 hours after the proximal vascular
pedicle was injected with red silicone. Nine additional cadaver legs were injected with ink to visualize
the skin area supplied by the proximal perforators, clarified by a modified Spalteholz technique to
demonstrate the anatomic course of the perforators. A considerable variation in numbers and location
of the proximal cutaneous perforators was found. One to four perforators were seen within an area of 6
by 6 cm2 at the entrance of the main pedicle into the proximal gracilis muscle. Their external diameter

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1459

ranged from 0.5 to 1.0 mm. The ink injections showed an oval angiosome with a mean surface of
88 cm2 at the level of the proximal gracilis pedicle. The authors concluded from this anatomic study
that a cutaneous flap based on the medial circumflex femoral gracilis perforators can be harvested by
experienced hands, bearing in mind the unpredictable perforator anatomy.
Kay S, Pinder R, Wiper J, et al. Microvascular free functioning gracilis transfer with nerve
transfer to establish elbow flexion. J Plast Reconstr Aesthet Surg 63:1142-1149, 2010.
The loss of elbow flexion is an uncommon but devastating consequence of injury to the upper limb
and a complex problem to manage. The authors described their experience with free functioning
gracilis muscle transfer (FFGMT) to the upper limb for elbow flexion. Thirty-three patients were
followed after FFGMT for elbow flexion: 26 patients were male and 20 were children. Indications for
FFGMT included obstetric brachial palsy (13) and adult brachial plexus injury (12), arthrogryposis
(4), sarcoma, polio and radial dysplasia. Seventy percent (23) of patients had a successful outcome.
Power comparable to the other side (M5) was recorded in two patients, 19 patients scored M4, and
three scored M3. FFGMT in the obstetric brachial palsy group alone (13) was the most successful;
all had a preoperative score of M2 or less, and postoperatively 12 (92%) achieved a score of M4 or
greater. A greater increase in Medical Research Council grade for elbow flexion was achieved when
intercostal nerves were transferred to innervate the gracilis flap (mean gain three points, SD 1.3), than
ulnar fascicles (mean gain 1.75 points, SD 2.3). With a multidisciplinary team approach involving
experienced surgeons, theater staff, and therapists, a significant, reproducible, and measurable improve-
ment in elbow flexion can be achieved by FFGMT.
Kind GM, Foster RD. The longitudinal gracilis myocutaneous flap: broadening options in
breast reconstruction. Ann Plast Surg 61:513-520, 2008.
Many patients who present for autologous breast reconstruction are not suitable candidates for abdominal
wall flaps, either because of previous abdominal surgery (most commonly a transverse rectus abdomi-
nis myocutaneous flap for prior breast reconstruction) or because of the lack of enough adipose tissue.
Another donor site option is the medial thigh, which has more recently been recognized as a source
of tissue for breast reconstruction. Prior reports have described the harvest of a gracilis myocutaneous
flap through a transverse incision. The authors reported on 12 patients who underwent autologous
breast reconstruction of 15 breasts with the longitudinal gracilis myocutaneous microvascular flap. The
patients’ ages ranged from 41 to 60 years (average 48 years). In all patients the longitudinal gracilis
flap was chosen because of a desire for autologous reconstruction and a lack of available abdominal
wall tissue. Mean follow-up was 16.8 months (range 5 to 36 months). There was no microvascular
thrombosis or free flap failure in this series. Donor sites were well tolerated by all patients. Three
patients underwent suction-assisted lipectomy of five donor site areas to improve contour and/or sym-
metry. The longitudinal gracilis myocutaneous flap is a useful alternative for breast reconstruction in
properly selected patients.
Kropf N, Cordeiro CN, McCarthy CM, et al. The vertically oriented free myocutaneous
gracilis flap in head and neck reconstruction. Ann Plast Surg 61:632-636, 2008.
Oncologic resections in the head and neck can result in a variety of complex defects. Many free tissue
transfers have been described for soft tissue reconstruction in this area. The pedicled, vertical gracilis
myocutaneous flap has been well described for use in the perineum but is rarely used as a free tissue
transfer because of the previously documented unreliability of the skin island. The objective of this
study was to review a single author’s experience with reconstruction of complex head and neck defects
using the vertically oriented free myocutaneous gracilis flap. A retrospective review of all head and neck
reconstructions at a major cancer center from 2003 to 2006 was performed. Demographic, oncologic,
and reconstructive data were retrieved from a prospectively maintained clinical database. Mean follow-
up was 8 months (range 2 to 20 months). Total flap survival was 100%. There were no partial flap
losses. Primary wound healing occurred in all cases. The vertically oriented free myocutaneous gracilis

12c_Gracilis_r7_cah_1418-1465.indd 1459 2/7/2012 4:00:07 PM

 1460 Part II  Regional Flaps: Anatomy and Basic Techniques

flap is a reliable option for reconstruction of moderate volume and surface area defects in the head and
neck. It is an underutilized flap that should be more commonly considered for soft tissue reconstruction
of complex defects in the head and neck.
Lin CH, Lin YT, Yeh JT, et al. Free functioning muscle transfer for lower extremity post-
traumatic composite structure and functional defect. Plast Reconstr Surg 119:2118-2126, 2007.
From 1996 to 2004, 19 patients with lower extremity injuries whose lesions exhibited composite
soft tissue damage, with or without bone defects, and certain accompanying functional disabilities were
allocated to study groups on the basis of impression, as follows: group I, open fracture IIIB (10); group
II, neglected compartment syndromes [open IIIB (4) and open IIIC (1)]; and group III, crush injuries
(4). Free flap resurfacing was indicated for these lesions. Fifteen patients underwent free functioning
muscle transfer; source muscles were the rectus femoris (3), rectus femoris with anterolateral thigh flap
(5), and gracilis (for ankle dorsiflexion) (7). Two patients underwent composite rectus femoris and
vascular iliac crest for ankle dorsiflexion and segmental tibial defect reconstruction. Two received rectus
femoris muscle and anterolateral thigh flaps for posterior compartment defect and quadriceps defect
reconstruction, individually. Two patients required reexploration; salvage was successful in only one,
with below-knee amputation necessary in the other. Skin grafts were needed for partial skin paddle
necrosis (3) or remaining skin defect (2). Functioning muscle reinnervation failed in four cases, with
one individual undergoing ankle fusion, two people electing ambulation with stiff ankles, and one
person using an orthosis. In the sample population, range of motion varied and was related to the
severity of injury and the extent of skin grafting on the distal myotendinous portion. Less function
was exhibited in the compartment syndrome group (group II).
Lin H, Hou C, Chen A, et al. Treatment of ischial pressure sores using a modified gracilis
myofasciocutaneous flap. J Reconstr Microsurg 26:153-157, 2010.
Despite the availability of a variety of flap reconstruction options, ischial pressure sores continue to be
the most difficult pressure sores to treat. The authors described a successful surgical procedure for the
coverage of ischial ulcers using a modified gracilis myofasciocutaneous flap. The authors enrolled 12
patients with ischial sores in a study. All patients underwent early aggressive surgical debridement,
followed by surgical reconstruction with a modified gracilis myofasciocutaneous flap. Follow-up ranged
from 13 to 86 months (mean 44 months). Overall, 11 of 12 (91.7%) of the flaps survived primarily.
Partial flap necrosis occurred in one patient. Primary wound healing occurred without complications
at both the donor and recipient sites in all cases. In one patient, grade 2 ischial pressure sores recurred
13 months after the operation. There was no recurrence in the other 11 patients. A modified gracilis
myofasciocutaneous flap provides a good cover for ischial pressure sores. Because it is easy to use and
produces favorable results, it can be used in the primary treatment for large and deep ischial pressure sores.
Lykoudis EG, Spyropoulou GA, Vlastou CC. The conjoint medial circumflex femoral perfora-
tor and gracilis muscle free flap: anatomical study and clinical use for complex facial paralysis
reconstruction. Plast Reconstr Surg 116:1589-1595, 2005.
An anatomic study was initially undertaken to record the existence, consistency, and diameter of
myocutaneous perforators emanating from the proximal third of the gracilis muscle to provide blood
supply to the overlying fascia, subcutaneous fat, and skin. In a total of 20 clinical cases of gracilis
muscle harvesting, the anatomic data were recorded during flap dissection. At least one myocutaneous
perforator, consisting of one artery and two accompanying veins (vein caliber greater than 0.3 mm)
was found in 95% of cases. The anatomic study was followed by successful use of the conjoint flap
for reconstruction of long-standing facial palsy accompanied by a soft tissue defect of the cheek. In the
first stage, cross-face nerve grafting was performed. In the second stage, free transfer of the conjoint
flap, consisting of the proximal third of the gracilis muscle and the overlying subcutaneous fat, was
performed to the face. The only connection between the two components of the conjoint flap was one

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1461

myocutaneous perforator. When the flap was inset, the muscle was used for facial reanimation and
partial obliteration of the soft tissue defect, while the subcutaneous fat was used to obliterate the rest of
the defect. The technique ensures symmetry of the face, on both rest and animation, and obliteration
of the cheek deformity.
Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free muscle
transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation. Plast
Reconstr Surg 118:885-899, 2006.
The authors studied the ability of the masseter motor nerve–innervated microneurovascular muscle
transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis. The
procedure consisted of a one-stage microneurovascular transfer of a portion of the gracilis muscle that
is innervated with the masseter motor nerve. The muscle was inserted into the cheek and attached to
the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred
muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the func-
tional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years
who received 45 muscle transfers. All 45 muscle transfers developed movement; age did not affect the
amount of movement. Ninety-six percent of patients were satisfied with their smile.
Momeni A, Bannasch H. The semi-open approach to the gracilis muscle flap: aesthetic refine-
ments in gracilis muscle harvest. J Reconstr Microsurg 25:63-67, 2009.
The gracilis muscle flap is certainly among the most versatile sources of vascularized tissue available for
microsurgical reconstruction. However, the aesthetic appearance of the resultant scar has frequently been
a source of dissatisfaction. Various minimal invasive techniques have been proposed, all of which aim
to reduce scar formation. Drawbacks of endoscopic techniques, however, include a steep learning curve
as well the need for special technical equipment. A semiopen approach without endoscopic assistance
was presented, characterized by a short transverse incision in the groin area without a counterincision
distally. This technique was performed in six patients (mean age 48.8 years). Mean incision length
was 8.8 cm, and average muscle harvesting time was 49 minutes. The authors suggested the semiopen
approach to the gracilis muscle flap because it does not require special instruments and training and is
characterized by easy performance and a short incision in the inconspicuous groin area with resultant
better cosmesis.
Momeni A, Bannasch H, Lee GK. The free gracilis perforator flap: is a perforator flap really
indicated in the case of the gracilis flap? [Comment] Plast Reconstr Surg 124:1008-1009, 2009.
The authors suggested that rather than use the traditional skin island design for the gracilis flap,
orienting the skin paddle transversely avoids the large longitudinal incision, placing it inconspicuously
in the groin area.
Morasch MD, Sam AD II, Kibbe MR, et al. Early results with use of gracilis muscle flap cover-
age of infected groin wounds after vascular surgery. J Vasc Surg 39:1277-1283, 2004.
The authors described a technique for using pedicled gracilis muscle flaps to provide groin coverage,
reported a summary of their short-term and long-term results, and described why they prefer this
reconstructive technique. Twenty pedicled gracilis muscle flaps were placed in 18 patients to treat
nonhealing and infected groin wounds. Exposed prosthetic vascular reconstructions were covered with
the pedicled gracilis muscle flap in 14 wounds, and in situ autologous vascular reconstructions were
covered in four. Seven wound infections were polymicrobial, 10 had a single gram-positive organism,
and 1 had a single gram-negative organism. Pseudomonas cultured out in 4 wounds, and Candida
in 1 wound. Two patients had a virulent combination of methicillin-resistant Staphylococcus aureus
and vancomycin-resistant Enterococcus. Complete healing was initially achieved in all wounds, and
no patient died within 30 days of surgery. Two pedicled gracilis muscle flaps failed at 2 weeks and
2 months, respectively, one from tension on the flap pedicle and one from acute inflow occlusion.

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 1462 Part II  Regional Flaps: Anatomy and Basic Techniques

Underlying prosthetic reconstruction was salvaged in 12 of 14 wounds; the remaining wounds with
autologous reconstructions or exposed femoral vessels all closed successfully. At a mean follow-up of
40 6 10 months there were no recurrent groin infections. Seven patients died between 2.5 and 28
months postoperatively.
Nassar OA. Primary repair of rectovaginal fistulas complicating pelvic surgery by gracilis
myocutaneous flap. Gynecol Oncol 121:610-614, 2011.
Complex rectovaginal fistulas repair are extremely challenging. Various surgical options have been
suggested; nevertheless, none had been universally accepted as the procedure of choice. In this prospective
study the author discussed a novel surgical technique using gracilis myocutaneous flap interposition.
Eleven patients had fistulas after resection of a pelvic malignancy (10) and rectal endometriosis (1).
Primary treatment was pelvic resection; nevertheless, 6 patients had adjuvant chemoirradiation, 2
patients underwent postoperative irradiation, and 2 patients had chemotherapy only. The mean fis-
tula diameter was 2 6 0.24 cm, and in 8 patients (72.7%) their fistulas were in the middle vaginal
third. Repair consisted of wide debridement of fistula margins, followed by gracilis myocutaneous flap
interposition with synchronous diverting stomas. Success was defined as healing of fistula after stomal
closure. Five patients underwent repair with single gracilis myocutaneous flaps, 2 by simple gracilis
muscle, and 4 by double gracilis myocutaneous flaps. Patients had a mean follow-up time of 34.8 6
5.03 months, and all patients had definitive healing of their fistulas. The median time to stoma closure
was 2 months. Four women had at least one early postoperative complications including temporary
leak (3), vaginal sepsis (1), partial skin paddle necrosis (1) and donor limb deep venous thrombosis (1).
Late morbidities were seen in 3 patients, including vaginal stricture, anorectal anastomotic stricture,
and anastomotic tumor recurrence. Rectovaginal septum repair requires adequate debridement of necrotic
devascularized tissues, tissue transposition and reconstruction of vaginal wall. Gracilis myocutaneous
flaps are ideal for this repair.
Peek A, Müller M, Ackermann G, et al. The free gracilis perforator flap: anatomical study and
clinical refinements of a new perforator flap. Plast Reconstr Surg 123:578-588, 2009.
The free gracilis perforator flap is a fascioadipocutaneous flap on the medial thigh, based on perforators
of the main pedicle of the gracilis myocutaneous flap. An anatomic study was performed using 43
cadaver dissections. The vascular anatomy of the gracilis perforator flap with regard to myocutane-
ous and septocutaneous perforators was assessed. Clinical application was demonstrated in 14 cases.
Myocutaneous perforators of the gracilis muscle pedicle were present in all dissections and were 0.5 mm
or more in 93%. Septocutaneous perforators were found in 84% of the dissections, and perforators
of 0.5 mm or more were found in 63%. Most myocutaneous perforators were found in the anterior
quarter of the muscle where the pedicle enters the gracilis muscle. A constant intramuscular anastomosis
between the main and second vascular pedicles of the gracilis was demonstrated that allowed design of
an extended gracilis perforator flap.
Persichetti P, Cogliandro A, Marangi GF, et al. Pelvic and perineal reconstruction following
abdominoperineal resection: the role of gracilis flap. Ann Plast Surg 59:168-172, 2007.
Rawlins JM. Re: “Unilateral gracilis myofasciocutaneous advancement flap for single stage
reconstruction of scrotal and perineal defects.” J Plast Reconstr Aesthet Surg 61:710, 2008.
Reddy VR, Stevenson TR, Whetzel TP. 10-year experience with the gracilis myofasciocuta-
neous flap. Plast Reconstr Surg 117:635-639, 2006.
Rodríguez Lorenzo A, Morley S, Payne AP, et al. Anatomy of the motor nerve to the gracilis
muscle and its implications in a one-stage microneurovascular gracilis transfer for facial reani-
mation. J Plast Reconstr Aesthet Surg 63:54-58, 2010.
The authors presented the results of a study conducted to investigate the anatomy of the motor nerve
to the gracilis muscle to provide the anatomic basis for harvesting a one-stage gracilis transfer with a
long nerve for reanimation of the paralyzed face. An anatomic study was performed on 24 lower limb

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1463

specimens (from the pelvis down to the knee) from 12 embalmed cadavers. The motor nerve to the
gracilis muscle was dissected from the surface of the muscle to the obturator foramen. Two anatomic
regions were defined in the course of the nerve. The first region includes the part of the nerve that can
easily be reached through a standard incision in the medial aspect of the thigh; that is, from the surface
of the muscle to the posterior border of the adductor brevis muscle and the second region from there
to the obturator foramen. Measurements of both anatomic regions and the maximum length of the
nerve were taken with a calliper. The anatomic relations of the nerve were also noted and photo-
documented. The median maximum length of the motor nerve to the gracilis muscle from the surface
of the gracilis to the posterior border of adductor brevis (the first anatomic region) was 7.7 cm (range
6.3 to 10.5 cm); from there to the obturator foramen (second anatomic region), the length was 3.7 cm
(range 2 to 6 cm), giving a median length of dissection of the nerve as 11.5 cm (range 9.9 to 13.6 cm).
Intraneural dissection of the motor nerve to the gracilis muscle has to be performed proximally in the
course of the nerve (the part corresponding to the second anatomic region), just where it runs inside the
fascia over the obturator externus muscle.
Sananpanich K, Tu YK, Pookhang S, et al. Anatomic variance in common vascular pedicle of
the gracilis and adductor longus muscles: feasibility of double functioning free muscle trans-
plantation with single pedicle anastomosis. J Reconstr Microsurg 24:231-238, 2008.
Fifty thighs from fresh human cadavers were studied to evaluate the feasibility of a double functioning
free muscle transfer of the gracilis and adductor longus with single common vascular pedicle anastomosis.
Methylene blue intraarterial injection and loupe-magnified dissection were used to demonstrate three
groups of vascular patterns in these two muscles. The common vascular pedicles of 88% of their specimen
muscles were long enough for possible anastomosis. Ten percent (type B2) were quite short, making
microsurgical procedure difficult. Two percent (type A3) of their specimens were not suitable for single
anastomosis. Four percent of their gracilis muscles had two major arterial pedicles that branched from
the common pedicle in a Y-shaped configuration. If only one pedicle of this type is harvested during
a free gracilis muscle transfer, it may cause inadequate flap perfusion. Four specimens were studied
using contrast media angiography to confirm that both were Mathes-Nahai type II muscle flaps. This
study typed the common vascular pedicle of their sample of gracilis and adductor longus muscles and
confirmed the feasibility of double functioning free muscle transfer of the gracilis and adductor longus
with single vascular anastomosis.
Schoeller T, Huemer GM, Kolehmainen M, et al. A new “Siamese” flap for breast reconstruc-
tion: the combined infragluteal-transverse myocutaneous gracilis muscle flap. Plast Reconstr
Surg 115:1110-1117, 2005.
The authors presented a new combined flap composed of a fasciocutaneous infragluteal flap and a
transverse myocutaneous gracilis flap for breast reconstruction. Its main advantage lies in the extensive
tissue bulk for transplantation and the option to anastomose the flap to the recipient bed with either
of two pedicles, or both.
Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap
for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 122:29-
38, 2008.
The transverse myocutaneous gracilis (TMG) flap has received little attention in the literature as a
valuable alternative source of donor tissue in the setting of breast reconstruction. The authors presented
an in-depth review of their experience with breast reconstruction using the TMG flap. A retrospective
review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed
setting was undertaken. Of these, 26 patients underwent bilateral reconstruction, 68 underwent
unilateral reconstruction, and 17 underwent reconstruction unilaterally with a double TMG flap.
Patients ranged in age from 24 to 65 years (mean 37 years). Twelve patients had to be taken back
to the operating room because of flap-related problems, and 9 patients underwent successful revision

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 1464 Part II  Regional Flaps: Anatomy and Basic Techniques

microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted
TMG flaps. Partial flap loss was encountered in 2 patients, whereas fat tissue necrosis was managed
conservatively in 6 patients. Low donor site morbidity was an advantage of this flap, with a concealed
scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included
delayed wound healing (10), hematoma (5), and transient sensory deficit over the posterior thigh (49).
Schoeller T, Meirer R, Gurunluoglu R, et al. Gracilis muscle split into two free flaps. J Reconstr
Microsurg 19:295-298, 2003.
The authors presented a case in which the gracilis muscle was transversely split into two free flaps for
coverage of two separate defects in a patient with a multisegment fracture of the metatarsal bones and
the ankle joint.
Schoeller T, Wechselberger G. Breast reconstruction by the free transverse gracilis (TUG) flap.
Br J Plast Surg 57:481-482, 2004.
Ueda K, Oba S, Nakai K, et al. Functional reconstruction of the upper and lower lips and
commissure with a forearm flap combined with a free gracilis muscle transfer. J Plast Reconstr
Aesthet Surg 62:e337-e340, 2009.
After resection of an arteriovenous malformation of the upper and lower lips and commissure the
authors performed reconstruction with a forearm flap combined with a free gracilis muscle transfer.
First the motor nerve of the gracilis muscle was anastomosed to a buccal nerve branch in the cheek.
In a second operation, the vermilion was reconstructed with an oral mucosal graft, and the upper lip
skin was reconstructed with a local flap. The patient obtained good oral sphincter function for eating,
speaking, and inhalation.
Vega SJ, Sandeen SN, Bossert RP, et al. Gracilis myocutaneous free flap in autologous breast
reconstruction. Plast Reconstr Surg 124:1400-1409, 2009.
The gracilis myocutaneous free flap provides an alternative for autologous breast reconstruction. It
avoids abdominal donor site morbidity, allows quicker recovery, provides an alternative in a thin patient
because of its hidden and acceptable donor site, and allows supine positioning for harvest and inset
in a timely fashion. The authors conducted a retrospective review of all autologous postmastectomy
reconstructions performed between January 2005 and March 2008. All patients receiving gracilis
myocutaneous flap reconstruction for postmastectomy defects were included in the study. Office and
hospital charts were reviewed. The authors concluded that the gracilis myocutaneous free flap provides
an alternative breast reconstruction option for today’s breast cancer patient. It allows a quick harvest
in the supine setting, creation of a moderate breast volume, consistent anatomy, and acceptable donor
site morbidity with good contour.
Vyas RM, Pomahac B. Use of a bilobed gracilis myocutaneous flap in perineal and genital
reconstruction. Ann Plast Surg 65:225-227, 2010.
The gracilis myocutaneous flap has limited functional donor site morbidity and effectively contours
genitoperineal reconstructions. When harvested using a traditional vertical skin paddle, distal-tip
necrosis (secondary to inconsistent perforator anatomy) is a well-documented complication. Orienting
the skin paddle transversely provides a reliable alternative with a shorter rotational arc but results in
a more conspicuous deformity and smaller skin paddle when primary closure is desired. On the basis
of recent anatomic studies, the authors designed a pedicled gracilis myocutaneous flap with a bilobed
cutaneous paddle to maximally incorporate both the transverse and longitudinal dimensions of the
flap’s nearly circular angiosome. The bilobed design allows harvest of a larger transverse skin flap (with
a shorter arc of rotation) while a shorter, more dependable vertical skin flap is inset into the transverse
flap donor site (rather than inside the critical wound bed).
Wechselberger G, Pülzl P, Schoeller T. The transverse myocutaneous gracilis flap: technical
refinements. J Plast Reconstr Aesthet Surg 63:e711-e712, 2010.

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 Thigh  •  12C: Gracilis and TUG/TMG Flaps 1465

Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue
source in autologous breast reconstruction. Plast Reconstr Surg 114:69-73, 2004.
The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the
proximal third of the medial thigh region allows the surgeon, in selected patients, to take a moderate
amount of tissue for autologous breast reconstruction. Donor site morbidity is similar to that of a classic
medial thigh lift. The authors discussed indications for this flap in autologous breast reconstruction
and the surgical technique. From August 2002 to March 2003, 10 patients underwent autologous
breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients’ ages ranged
from 26 to 48 years (median 40 years). Of those, 2 BRCA-positive women received bilateral breast
reconstructions after prophylactic skin-sparing mastectomy, and 8 patients received immediate breast
reconstruction after skin-sparing mastectomy in early stage breast cancer. Mean follow-up of the 10
patients was 5 months (range 1 to 9 months). We had no free flap failure. Four patients had small
areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing
mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed
breasts and thigh donor site by two plastic surgeons showed good results in 9 patients and fair results
in 1 patient. There was no functional donor site morbidity caused by harvesting the gracilis flap.
The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast
reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and
inadequate soft tissue bulk at the lower abdomen and gluteal region.
Wong C, Mojallal A, Bailey SH, Trussler A, Saint-Cyr M. The extended transverse musculocu-
taneous gracilis flap: vascular anatomy and clinical implications. Ann Plast Surg 67:170-177, 2011.
The transverse myocutaneous gracilis (TMG) flap has been used in autologous breast reconstruction,
but disadvantages include a small flap volume; therefore it is only used in small to moderate breast
reconstructions. We investigated the vascular territory of this flap and the possibility of extending its
dimensions. Ten circumferential thigh adipocutaneous flaps attached to the gracilis muscle were harvested
from adult cadavers. Parameters recorded were diameter and length of pedicles, distance of pedicles
from pubis, and number and locations of cutaneous perforators. The major pedicles were injected with
contrast and subjected to three-dimensional CT scanning. Images were viewed using both General
Electric and TeraRecon systems, and the vascular territories were measured. Flaps were then incised
to include only tissue that was perfused with contrast, and measured for weight and volume. The
major pedicle had a mean length of 6.7 cm, diameter of 2.2 mm, and distance from pubis of 8.6 cm.
There was a mean of 4.3 cutaneous perforators associated with this flap. Three-dimensional images
from contrast injection of the major pedicle showed a cutaneous vascular territory that extended more
posteriorly than anteriorly, and had a vertical component. Tissue perfused with contrast had a mean
weight of 573 g and a volume of 617 ml. Two clinical cases were included to show applications of the
extended TMG flap.

12c_Gracilis_r7_cah_1418-1465.indd 1465 2/7/2012 4:00:07 PM

 ANATOMIC LANDMARKS
Landmarks Long, thin, superficial muscle that runs from the anterior superior
iliac spine diagonally to the medial tibial condyle.
Size 5 3 40 cm.
Origin Anterior superior iliac spine.
Insertion Medial tibial condyle.
Function Lateral rotation and thigh flexion.
Composition Muscle.
Flap Type Type IV.
Dominant Pedicle Segmental branches of the superficial femoral artery.
Nerve Supply Motor: Femoral nerve.

12d_Sartorius_r7_cah_1466-1481.indd 1466 2/7/2012 4:15:06 PM

 Section 12D
Thigh

Sartorius Flap

CLINICAL APPLICATIONS
Regional Use
Groin
Knee
Specialized Use
Femoral vessel and graft
coverage

12d_Sartorius_r7_cah_1466-1481.indd 1467 2/7/2012 4:15:26 PM

 ANATOMY OF THE Sartorius Flap

A B

Sartorius muscle Sartorius muscle

Femoral artery

Superficial
femoral artery

Superficial
femoral artery Gracilis
muscle

Vastus medialis
muscle

Vascular anatomy of sartorius muscle Neighboring muscular anatomy; note that sartorius
is superficial to gracilis muscle in distal third of leg

Femoral nerve

Sartorius muscle

Motor innervation to sartorius muscle

Fig. 12D-1 

Dominant pedicle: Six or seven segmental branches of superficial femoral artery and
vein enter the muscle on its deep or medial surface

12d_Sartorius_r7_cah_1466-1481.indd 1468 2/7/2012 4:15:33 PM

 Thigh  •  12D: Sartorius Flap 1469

ANATOMY
Landmarks Long, thin muscle that extends from the anterior superior iliac spine diagonally
to the medial tibial condyle.
Composition Muscle.
Size 5 3 40 cm.
Origin Anterior superior iliac spine.
Insertion Medial tibial condyle.
Function Provides lateral rotation and thigh flexion.

Arterial Anatomy (Type IV)

Dominant Pedicle  Segmental branches of superficial femoral artery
Regional Source  Superficial femoral artery.
Length  2 to 3 cm.
Diameter  1 mm.
Location  Six or seven segmental perforators enter the muscle on its deep or medial surface.

Venous Anatomy
Venae comitantes that run with the superficial femoral perforators and drain to the superficial
femoral vein.

Nerve Supply
Motor Femoral nerve.

12d_Sartorius_r7_cah_1466-1481.indd 1469 2/7/2012 4:15:33 PM

 1470 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Sartorius Flap

A B

Superficial surface of muscle (medial view) Deep surface of muscle

C D

Deep surface of flap Radiographic view

Fig. 12D-2 

Dominant pedicle: Six or seven segmental branches of superficial femoral artery and
vein (arrows)

12d_Sartorius_r7_cah_1466-1481.indd 1470 2/7/2012 4:15:34 PM

 Thigh  •  12D: Sartorius Flap 1471

FLAP HARVEST
Design and Markings
Any incision overlying the muscle will provide access to it. The incision can be along the
line from the anterior superior spine to the medial tibial condyle. However, the muscle may
be accessed through the wound it is meant to reconstruct or through longitudinal incisions
that allow access to the muscle as well as the reconstructive site.

A B

Marking for incision for superior Marking for incision for inferior
muscle elevation muscle elevation

Fig. 12D-3 

Patient Positioning
The patient is placed in the supine or frog-leg position.

GUIDE TO FLAP DISSECTION

Once the skin is incised, dissection proceeds immediately down to the superficial fascia.
The sartorius muscle is defined and the muscle is exposed along its required length. Because
the blood supply enters deeply or more medially, the surgeon must exercise care dissecting
along the medial border. For use as a standard turnover flap, the muscle is elevated from
lateral to medial, with identification of its segmental perforators. The perforators are spared
and the muscle is divided superiorly, inferiorly, or both superiorly and inferiorly to allow
the muscle to transpose over the defect. At times, with enough longitudinal dissection of
the muscle, no division is necessary, so turnover advancement can be performed.

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 1472 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
For the sartorius muscle to remain viable, its segmental perforators must be kept largely intact.
The arc of rotation must therefore be generated by release of the muscle from its origin or
insertion, or anywhere along its length, with rotation of the flap toward its vessels. Because
of this limitation and the superficial nature of the muscle, advancement superiorly to the
groin crease and inferiorly to the medial patella is the limitation of its reach. Carrying a
skin paddle with this flap is not recommended because of the limited number of perforators
emanating from the muscle and the thinness of the muscle itself.

A B C

Medial transposition, no cuts Medial transposition, Medial transposition, superior and

superior muscle divided inferior muscle divided

Fig. 12D-4 

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 Thigh  •  12D: Sartorius Flap 1473

Arc to knee

Fig. 12D-4 

FLAP TRANSFER
The flap may be transferred by simple advancement of the muscle if there is enough laxity
and the defect is close. Superior division of the muscle may aid in the arc of rotation and
length of the muscle for the reconstruction. Similarly, sometimes inferior division provides
a better release of the muscle for the reconstructive need. Both superior and inferior divi-
sion is routinely performed. The presence of multiple perforators in the segment of muscle
that is divided must be confirmed.

FLAP INSET
Absorbable sutures are used to tack the muscle in place for its reconstructive purpose. If
the muscle has not been divided either superiorly or inferiorly, there will be tension on the
muscle, especially if the patient is ambulatory, and adequate suturing should be performed
to maintain the muscle’s position. Not uncommonly, mobilization of the subcutaneous tis-
sue above the muscle rotation allows primary closure over the rotated muscle. Otherwise,
the muscle is available for skin grafting for closure.

DONOR SITE CLOSURE

Normally, primary closure of all donor sites is possible.

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 1474 Part II  Regional Flaps: Anatomy and Basic Techniques

CLINICAL APPLICATIONS
This 78-year-old woman presented with an exposed saphenous vein patch after an aneurysm
repair that resulted in a chronic wound.

A B C

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. (Case supplied by MRZ.)

This 51-year-old man presented with an exposed Gore-Tex graft in the right groin after
bypass surgery for arterial insufficiency.

A B

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. (Case supplied by MRZ.)

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 Thigh  •  12D: Sartorius Flap 1475

This 40-year-old man had condylomata, one of which developed into a squamous cell
carcinoma that required radical excision.

A B

C D

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. (Case supplied by MRZ.)

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 1476 Part II  Regional Flaps: Anatomy and Basic Techniques

Pearls and Pitfalls

• The sartorius is a first-line flap for coverage of femoral bypass grafts.
• With this flap the blood supply is maintained, even after other vascular procedures or
complications.
• The sartorius muscle should always, at a minimum, be dissected through the wound to
establish its availability.
• The overlying skin paddle is unreliable.

Expert Commentary
Michael R. Zenn

Indications
The sartorius muscle is an expendable muscle that is the primary choice for coverage of
exposed femoral prostheses or wounds of the femoral triangle.

Advantages
Despite previous vascular surgery in the area and the commonly associated fibrinous rind
one sees with infection and chronic wounds, and likely because of its diagonal course
in the thigh, the sartorius muscle is surprisingly available in most cases of exposed groin
prostheses. Usually, even when disease is present in the superficial femoral arterial system,
the collateral flow through small perforators is often adequate to perfuse the segment of
sartorius flap needed for reconstruction.

Recommendations
Technique
After an area is debrided and the vascular surgeons have decided whether to remove the
area of graft, the reconstructive surgeon starts dissection in the wound and elevates the
subcutaneous plane laterally until the sartorius muscle is encountered. Staying superficial
will help avoid injury to the segmental vessels. Sometimes a counterincision or extension
of the wound is required for visualization.
Once the lateral border of the muscle is identified, it is elevated. I prefer to keep a mini-
mum of three perforators attached to the sartorius muscle. I divide the muscle just superior
to the most proximal perforator and just distal to the most distal perforator. This segment
of muscle is then well supplied by its perforators and allows the muscle to simply transpose
like an open book over any exposed graft or difficult wound. It is rare to find perforators
through the sartorius muscle; therefore it is unwise to attempt to carry a skin island on this
muscle, because these attempts will be fraught will failure.

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 Thigh  •  12D: Sartorius Flap 1477

Postoperative Care
All of these patients are given DVT prophylaxis if they are not already on a blood thinner
therapeutically. I do try to get them out of bed and even ambulate early, but often comor-
bidities or the problem necessitating the surgery prevents this. These wounds will drain
fluid or lymph for some time, so I place a drain and leave it for 2 to 4 weeks. This is probably
a good indication for negative pressure wound therapy over the incision to secure closure
and remove weeping from the wound.

Take-Away Messages
Because of the segmental nature of the sartorius muscle, its use outside the area of the
thigh is not practical. The sartorius flap’s applicability to cover exposed vessels is often
a nice adjunct to larger soft tissue reconstructions in the pubic or groin areas, where the
reconstructive flap provides good skin coverage but not specific coverage over the vessels
(see Fig. 12H-14, Section 12H).

Bibliography With Key Annotations

Armstrong PA, Back MR, Bandyk DF, et al. Selective application of sartorius muscle flaps and
aggressive staged surgical debridement can influence long-term outcomes of complex prosthetic
graft infections. J Vasc Surg 46:71-78, 2007.
The complexity of variables associated with vascular surgical site infections (VSSI) often contribute
adversely to reinfection, limb salvage, and mortality rates. This report detailed the authors’ experience
with the selective use of a sartorius muscle flaps (SMF) as part of an overall treatment strategy focused
on staged surgical debridement (SSD) to control prosthetic graft bed infection before a graft preservation
or revision plan. They concluded that selective utilization of SMF as part of SSD treatment plan in
an attempt to achieve graft bed sterilization can effectively control the complex infectious process al-
lowing for potentially improved outcomes for in situ or preservation graft salvage techniques. Lifelong
graft surveillance is recommended.
Buckland A, Pan WR, Dhar S, et al. Neurovascular anatomy of sartorius muscle flaps: impli-
cations for local transposition and facial reanimation. Plast Reconstr Surg 123:44-54, 2009.
The sartorius muscle is a superficial muscle of the thigh that possesses highly suitable qualities for many
uses in local transposition and free muscle transfer. However, a paucity of description of the neurovascular
anatomy of the sartorius has contributed to its infrequent use in these roles. Both human and canine
studies were undertaken to delineate the neurovascular anatomy of the sartorius and to determine the
role for surgical delay clinically. Fifty-five human cadaveric sartorius muscles and 30 canine cadaveric
sartorius muscles underwent angiographic and dissection studies, and the location and course of the
vessels and nerves supplying sartorius are described. A subsequent study was undertaken in two live
canines in which the vascular supply to the sartorius was evaluated before and after surgical delay. The
sartorius is supplied by an average of six or seven vascular pedicles, the size, location, and course of
which are described. The nerve supply to the sartorius enters at its proximal end and uniformly arises
from a branch of the femoral nerve. Variations in branching patterns and course of nerves and vessels
are described. Living canine studies demonstrated the dilatation of intramuscular vessels following
surgical delay, with the contrast injection of a single remaining vascular pedicle shown to vascularize
the entire length of the sartorius muscle. The authors concluded that the sartorius is highly suitable
for local transposition and free muscle transfer for facial reanimation. The neurovascular anatomy is
reliable, and the use of surgical delay can augment its vascular supply and increase the arc of rotation
for local transposition.

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 1478 Part II  Regional Flaps: Anatomy and Basic Techniques

Clavert P, Cognet JM, Baley S, et al. Anatomical basis for distal sartorius muscle flap for recon-
structive surgery below the knee. Anatomical study and case report. J Plast Reconstr Aesthet
Surg 61:50-54, 2008.
The authors reported a case of a woman with a long-term nonhealing wound below the tibial tubercle
that underwent a successful sartorius muscle flap. They also performed an anatomic study of the vas-
cularization of the sartorius muscle. The vascular supply to the distal part of the sartorius muscle was
studied in 15 limbs by dissection and after red ink and latex injections. The artery of the sartorius
muscle flap arises most of the time from the saphenous artery or the descending genicular artery and is
supplied through anastomoses by branches of the posterior tibial artery and the medial inferior genicular
artery. The flap is useful for covering wounds around the knee, as well as the proximal and the middle
thirds of the leg. The surgical technique is relatively simple, with low morbidity from muscle harvesting.
Colwell AS, Donaldson MC, Belkin M, et al. Management of early groin vascular bypass graft
infections with sartorius and rectus femoris flaps. Ann Plast Surg 52:49-53, 2004.
Groin infections adjacent to vascular bypass grafts continue to be a source of morbidity. The authors
reviewed retrospectively nine consecutive patients with early localized groin infections treated at their
institution with sartorius or rectus femoris muscle flaps between 1998 and 2002. All wounds were
initially opened and drained. Wounds with necrotic tissue were treated with serial surgical debride-
ments, with a VAC device, or with wet-to-dry dressing changes. Two bypass grafts were excised and
replaced in the presence of marked exposure or pseudoaneurysm. Small wounds were closed with a
turnover sartorius flap and larger wounds were closed with either a muscle or myocutaneous rectus
femoris flap. Groin wounds healed in all patients without subsequent graft exposure, rupture, or
pseudoaneurysm. Local wound therapy with staged debridement and muscle flaps is effective for most
early localized graft infections.
Erba P, Wettstein R, Rieger UM, et al. A study of the effect of sartorius transposition on lymph
flow after ilioinguinal node dissection. Ann Plast Surg 61:310-313, 2008.
Ilioinguinal dissection is associated with a high rate of lymphatic complications. Prolonged lymph flow
causes greatest concern and preventive strategies are needed. The authors reported their retrospective
study of 28 consecutive patients who underwent groin dissection for melanoma metastases to evaluate
the influence of sartorius muscle transposition on lymph flow. Modification of the surgical technique
with transposition of the sartorius muscle was not associated with reduced drainage time. A two-stage
approach, with initial sentinel lymph node resection and lymph node dissection in a second operation,
led to shortened duration of the lymph flow. Prolonged lymphorrhea was more frequent in older, obese
patients affected by diabetes mellitus and hypertension.
Galland RB. Sartorius transposition in the management of synthetic graft infection. Eur J Vasc
Endovasc Surg 23:175-177, 2002.
Gravvanis A, Caulfield RH, Mathur B, et al. Management of inguinal lymphadenopathy: im-
mediate sartorius transposition and reconstruction of recurrence with pedicled ALT flap. Ann
Plast Surg 63:307-310, 2009.
Inguinal lymphadenectomy is associated with considerable morbidity, and several attempts have been
made to minimize the morbidity by well-vascularized flaps of adequate bulk to obliterate the dead
space and promote wound healing. In the case of recurrence, the overlying skin is usually involved and
the reconstructive surgeon is confronted with exposed femoral vessels and complex groin defects. The
authors reported a series of 40 patients that underwent inguinal lymphadenectomy and immediate
sartorius transposition for skin malignancies, and 4 patients with recurrence that was treated with
radical surgical excision and pedicled anterolateral thigh flap (ALT). They examined complications
such as infection, skin necrosis, lymphorrhea, lymphedema, and wound healing time. The immediate
sartorius transposition was associated with a 7.5% infection rate, 5% superficial skin edge necrosis,
0% of persistent lymph, and 27.5% of mild lymphedema. All ALT flaps survived completely

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 Thigh  •  12D: Sartorius Flap 1479

and wounds healed uneventfully within 2 weeks without any signs of infection, seroma, or wound
dehiscence. Sartorius and ALT flaps are reliable methods for reconstructing the groin after inguinal
lymphadenectomy. They ensure a low complication rate with no donor site morbidity and should be
the first-line treatment of immediate and secondary groin reconstruction, respectively.
Herrera FA, Lee CK, Kiehn MW, et al. The distal superficial femoral arterial branch to the
sartorius muscle as a recipient vessel for soft tissue defects around the knee: anatomic study and
clinical applications. Microsurgery 29:425-429, 2009.
Complex wounds surrounding the knee and proximal tibia pose a significant challenge for the recon-
structive surgeon. Most of these defects can be managed using local or regional flaps alone. However,
large defects with a wide zone of injury frequently require microvascular tissue transfers to aid in
soft tissue coverage and closure of large cavities. The authors described a unique recipient vessel for
microvascular anastomosis for free flap reconstruction involving the knee and proximal tibia through
anatomic and clinical studies.
Hong JP, Lee HB, Chung YK, et al. Coverage of difficult wounds around the knee joint with
prefabricated, distally based sartorius muscle flaps. Ann Plast Surg 50:484-490, 2003.
The coverage of soft tissue defects around the knee joint presents a difficult challenge for the reconstruc-
tive surgeon. Various reconstructive choices are available, depending on the location, size, and depth
of the defect relative to the knee joint. However, the knee joint frequently is involved in injuries to
the lower leg, which may limit the use of muscle flaps, especially the gastrocnemius muscle. The use
of a free flap is preferred for reconstruction involving obliteration of large-cavity defects, but the isola-
tion of recipient pedicle can be difficult because of the extent of injury zone and in cases of chronic
infection around the knee. To provide muscle bulk with a reliable vascular supply, the distally based,
prefabricated sartorius muscle flap was used as a last resort to reconstruct difficult wounds with chronic
osteomyelitis around the knee joint in six patients from June 1995 to May 2001. This method is
a two-stage procedure. First, the sartorius muscle is prefabricated by denervation and vascular delay.
Silicone sheets are used to increase the vascularity and dimension of the flap. Second, after 3 weeks,
the muscle is transposed based on a distal pedicle to reconstruct the soft tissue defect around the knee.
The prefabricated sartorius muscle can provide efficient bulk to obliterate the dead space and to cover
moderate-size soft tissue defects around the knee joint. This method can be considered to reconstruct
the soft tissue around the knee joint when local muscle flaps and free flaps are not feasible.
Jokuszies A, Niederbichler AD, Hirsch N, et al. [The pedicled groin flap for defect closure of
the hand] Oper Orthop Traumatol 22:440-451, 2010.
The authors presented a technique for soft tissue defect closure of the volar and dorsal aspect of the
hand and lower arm, with a maximum defect size of 10 by 25 cm. In a 3-year period, defect clo-
sure with a pedicled groin flap was performed in 14 patients. Indications for this procedure included
thumb reconstruction for lengthening and defect closure after amputation and burn injury; soft tissue
reconstruction of the dorsum of the hand after detachment and infection; soft tissue reconstruction of
the distal part of the lower arm, wrist, and palm after complex and combined trauma; and plastic
reconstructive preservation of multiple fingers with subsequent phalangealization and syndactyly
release, respectively. In all patients, complete soft tissue coverage and flap survival was achieved. The
functional and aesthetic result was satisfactory in all cases.
Kishi K, Nakajima H, Imanishi N. Distally based greater saphenous venoadipofascial-sartorius
muscle combined flap with venous anastomosis. Plast Reconstr Surg 119:1808-1812, 2007.
The authors presented the arterial and venous anatomy around the knee and provided a clinical case
that demonstrated the distally based greater saphenous venoadipofascial-sartorius muscle combined flap
with venous anastomosis so that the reverse venous flow changes to a normal flow along the direction
of the venous valves.

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 1480 Part II  Regional Flaps: Anatomy and Basic Techniques

Landry GJ, Carlson JR, Liem TK, et al. The sartorius muscle flap: an important adjunct for
complicated femoral wounds involving vascular grafts. Am J Surg 197:655-659; discussion
659, 2009.
Femoral wound complications can threaten vascular grafts. Muscle flaps can be used to facilitate soft
tissue coverage and graft salvage. The authors reported a series of sartorius flaps performed by vascular
surgeons in the treatment of complicated femoral wounds. Rotational sartorius flaps were performed to
attempt salvage of underlying vascular grafts. They reviewed a prospective database to determine the
outcomes of sartorius flaps on facilitating wound healing and graft salvage and patency. From 2005 to
2008, 21 sartorius flaps were performed in infected or threatened femoral wounds. Original operations
included femoral endarterectomy with patch repair in 8 patients, aortofemoral graft in 6, axillofemoral
graft in 4, and femoral-distal bypass in 3. Complete wound healing occurred in 18 patients. Primary
wound closure was achieved in 7 patients. Secondary wound closure was achieved in 11 patients, with
a mean healing time of 2.3 months. All vascular reconstructions remained patent at the 9.5-month
follow-up. Sartorius muscle flaps are effective at facilitating complicated femoral wound healing while
maintaining graft salvage and patency.
Liu GP, Kang B, Zeng H, et al. Treatment of femoral neck fracture with muscle-bone flap of
both tensor fasciae latae and sartorius. Chin J Traumatol 6:238-241, 2003.
The authors evaluated the effect of muscular pedicle bone grafts with sartorius or tensor fascia lata
and sartorius transfer in fresh transcervical or subcapital fractures of the femoral neck. Thirty cases of
fresh transcervical and subcapital fractures of the femoral neck were treated by tail breakable screws and
sartorius pedicle bone grafts (single muscular pedicle [SMP] group). The other 23 cases were treated
by cannulated pressure screws and bone grafts with the muscular pedicles of both sartorius and tensor
fascia latae (double muscular pedicles [DMP] group). Fifty-two patients were followed for 3 to 5 years
(mean 4 years). In the SMP group, 10 patients showed poor therapeutic results. Excellent therapeutic
effects were achieved in all patients in the DMP group. The transcervical or subcapital fractures of
the femoral neck can be treated by double muscular pedicles bone graft. The bone graft with double
muscular pedicles is more effective than single sartorius muscular pedicles for fresh transcervical and
subcapital fractures of the femoral neck.
Mojallal A, Wong C, Shipkov C, et al. Redefining the vascular anatomy and clinical applica-
tions of the sartorius muscle and myocutaneous flap. Plast Reconstr Surg 127:1946-1957, 2011.
Few studies have assessed the vascular supply of the sartorius muscle and overlying skin paddle and
its potential in reconstructive surgery. In this study the authors used three-dimensional and four-
dimensional imaging to analyze the segmental vascularity of the muscle, as well as the overlying
skin paddle, to define arcs of rotation based on its major pedicles. Thirty sartorius muscles and the
circumferential skin of the thigh were harvested from adult cadavers. Anatomic considerations such
as number of pedicles, location, diameter, and length, were recorded. Three-dimensional and four-
dimensional CT angiography was used to measure the length of muscle perfused by a single pedicle
defined as a major pedicle. Then the area of cutaneous territory supplied by each major pedicle was
calculated. The sartorius muscle is supplied by six to eight vascular pedicles. Two clusters of major
pedicles (diameter greater than 1.8 mm) were described (proximal and distal), which are located 18
to 25 cm and 35 to 44 cm from the anterior superior iliac spine, respectively. The proximal major
pedicle perfuses almost 80% of the muscle, and the distal major pedicle perfuses almost 90%. The
average area of skin perfused was 330 cm. This study indicated a greater anatomic assurance of the
potential use of the sartorius muscle and its overlying skin as a local transposition and free flap. The
vascular supply of the muscle and skin by two major pedicles allows two pivot points for muscular or
myocutaneous flaps.
Tanaka C, Ide MR, Junior AJ. Anatomical contribution to the surgical construction of the
sartorius muscle flap. Surg Radiol Anat 28:277-283, 2006.
The sartorius muscle is frequently used as a surgical flap. This study described sartorius nerve and
artery distribution in adult men. Fifty-three specimens obtained from fresh cadavers were prepared:

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 Thigh  •  12D: Sartorius Flap 1481

32 specimens were injected with a red-colored gelatin solution through the femoral artery so that in-
tramuscular arteries and nerves were dissected; 6 specimens were injected with barium sulfate solution
through the femoral artery for radiography; 7 specimens were injected with a Chinese ink solution,
also through the femoral artery, for diaphanization; 7 specimens were injected with a solution of vinyl
acetate, through the femoral artery, to obtain an arterial cast; and 1 specimen was cut and colored
by Masson’s trichrome. Sartorius branching patterns of the nerve and artery were schematized. The
authors detailed their findings. The nerve branches were divided into two or three territorial branches,
and then into four or five segmental branches, running longitudinally inside the muscle. The muscles
showed an average length of 44.81 cm. The sartorius muscle is a segmented structure that can be divided
into as many as five arterial and nervous segments. In the proximal and middle parts, the muscle has
better arterial supply. The segments can be filled by adjacent pedicles because of an elongated net of
anastomoses, which allows a longer arc of rotation in the construction of pedicled flaps.
Töpel I, Betz T, Uhl C, et al. The impact of superficial femoral artery (SFA) occlusion on the
outcome of proximal sartorius muscle transposition flaps in vascular surgery patients. J Vasc
Surg 53:1014-1019, 2011.
The authors reported a retrospective analysis of 53 patients with 56 proximal sartorius muscle flaps.
The indication for a flap procedure was postoperative recalcitrant lymphorrhea in 9 patients, graft at
risk in 13, and graft infection in 34. Preoperative and postoperative patencies of the superficial femoral
artery (SFA) and profundal femoral artery (PFA) were documented. Flap viability, wound healing,
and limb salvage were examined at follow-up. The authors concluded that biologic protection procedures
as local muscle flaps are vital adjuncts to vascular surgery techniques in the treatment of complicated
wounds in the groin. Occlusion of the SFA in the presence of a patent PFA is not associated with an
increased risk of flap loss in proximal sartorius muscle rotational flaps.
Wu LC, Djohan RS, Liu TS, et al. Proximal vascular pedicle preservation for sartorius muscle
flap transposition. Plast Reconstr Surg 117:253-258, 2006.
A variety of muscle flaps have been described to treat complex groin wounds associated with infected
and/or exposed femoral vessels or vascular grafts and persistent lymphatic leaks, and for prophylaxis
against wound breakdown following inguinal lymphadenectomy. The sartorius muscle flap has several
advantages over other muscle flaps: it is immediately adjacent to the groin, it is easy to prepare, and
the harvest causes no functional morbidity. Despite these advantages, the flap’s reliability has been
questioned because of the segmental blood supply to the muscle and the flap’s limited arc of rotation.
To improve the reliability of the flap, the authors defined the proximal vascular anatomy of the sarto-
rius muscle in 20 human cadavers and assessed the correlation with 20 clinical cases. They described
a technique for the harvest of the sartorius muscle transposition flap that preserves the proximalmost
pedicle. They dissected 40 sartorius muscles in 20 human preserved cadavers. They also performed
21 sartorius muscle transposition flap procedures in 19 patients for a variety of complex groin wound
complications, including infection (10), lymphadenectomy (4), lymphatic leak (3), exposed femoral
vessels (3), and a high-risk wound (1). The location of the proximalmost vascular pedicle with respect
to the anterior superior iliac spine was measured in each cadaveric dissection as well as in each clinical
case. Outcomes were assessed in the clinical cases with respect to wound healing. The proximal pedicle
of the sartorius muscle was consistently located 6.5 cm from the anterior superior iliac spine. Preserva-
tion of the proximal pedicle during dissection ensures the viability of the sartorius muscle transposition
flap for the treatment of complex groin wounds.

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 ANATOMIC LANDMARKS
Landmarks Posterior thigh musculature is composed of the biceps femoris, semimem-
branosus, and semitendinosus muscles, which run from the ischial tuberosity
to the tibia, occupying the posterior compartment of the thigh. The biceps
femoris is the most lateral of these “hamstring” muscles.
Size 15 3 45 cm when including all muscles; skin involves the posterior surface of
the thigh advanced only as transposition.
Origins Biceps femoris: Long head: Ischial tuberosity; short head: linea aspera of femur.
Semimembranosus: Ischial tuberosity. Semitendinosus: Ischial tuberosity.
Insertions Biceps femoris: Head of fibula. Semimembranosus: Medial condyle of
tibia. Semitendinosus: Medial condyle of tibia.
Function Three powerful flexors of the knee. The biceps femoris tightens the iliotibial
tract, important for lateral knee stabilization, and is a major external rotator
of the knee.
Composition Muscle, myocutaneous.
Flap Type Type II.
Dominant Biceps femoris: Long head: First perforating branch of profunda femoris artery
Pedicles and venae comitantes; short head: second or third perforating branch of profunda
femoris artery and venae comitantes. Semimembranosus: First perforating
branch of profunda femoris artery and venae comitantes. Semitendinosus:
First perforating branch of profunda femoris artery and venae comitantes.
Minor Biceps femoris: Long head: Second perforating branch of profunda femo-
Pedicles ris artery and venae comitantes; short head: superior lateral genicular artery
and venae comitantes. Semimembranosus: (1) Second or third perforating
branch of profunda femoris artery and venae comitantes; (2) branch of infe-
rior gluteal artery; (3) branch of superficial femoral artery. Semitendinosus:
(1) Muscular branch of inferior gluteal artery; (2) descending branch of medial
femoral circumflex femoral artery; (3) inferior medial genicular artery and
venae comitantes.
Nerve Supply Motor: Sciatic nerve branches. Sensory: Posterior cutaneous nerve of thigh (S1
to S3).

12e_BicepsFem_r7b_bs_1482-1505.indd 1482 2/8/2012 2:08:58 PM

 Section 12E
Thigh

Biceps Femoris (Hamstring) Flap

CLINICAL APPLICATIONS
Regional Use
Ischium
Thigh
Specialized Use
Pressure sores

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 ANATOMY OF THE Biceps Femoris (Hamstring) flap

A B

Composite biceps femoris, semimembranosus, Biceps femoris muscle

semitendinosus muscles

C D

Semimembranosus muscle Semitendinosus muscle

Fig. 12E-1 

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 Thigh  •  12E: Biceps Femoris (Hamstring) Flap 1485

Anatomy
Landmarks The biceps femoris is one of three posterior thigh “hamstring” muscles that
make up the posterior thigh compartment. These muscles all originate from the
ischium. The biceps femoris is the lateralmost muscle, inserting distally into the
fibula. The semimembranosus and semitendinosus muscles insert on the medial
condyle of the tibia; the semimembranosus is medialmost.
Composition Muscle, myocutaneous.
Size Muscle: 15 3 45 cm when using all muscles. Skin: Uses the posterior thigh as a
V-Y or large transposition flap with primary closure of the donor site.
Origins Biceps femoris: Long head: the ischial tuberosity; short head: the linea aspera of
the femur. Semimembranosus: Ischial tuberosity. Semitendinosus: Ischial
tuberosity.
Insertions Biceps femoris: Head of the fibula. Semimembranosus: Medial condyle of
the tibia. Semitendinosus: Medial condyle of the tibia.
Function These three muscles are powerful knee flexors. The biceps femoris tendon tightens
the iliotibial tract, which is important in stabilization of the lateral knee. The
biceps femoris is also a major external rotator of the knee, while the semimem-
branosus and semitendinosus contribute to internal rotation of the knee.

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 ANATOMY OF THE Biceps Femoris MUSCLE

Sciatic nerve

Femoral artery

Profunda femoris artery

Superficial femoral artery

Branch of inferior gluteal artery

First perforating branch

of profunda femoris artery

Biceps femoris muscle

short head

Second perforating branch

of profunda femoris artery

Third perforating branch

of profunda femoris artery

Biceps femoris muscle

long head

Superior lateral genicular artery

Biceps femoris muscle

Fig. 12E-1 

Dominant pedicle of long head: First perforating branch of profunda femoris artery
Minor pedicles of long head: Second perforating branch of profunda femoris artery; branch
of inferior gluteal artery
Dominant pedicle of short head: Second or third perforating branch of profunda femoris
artery
Minor pedicle of short head: Superior lateral genicular artery

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 Thigh  •  12E: Biceps Femoris (Hamstring) Flap 1487

Arterial Anatomy (Type II)

BICEPS FEMORIS MUSCLE
Dominant Pedicle (long head)  First perforating branch of profunda femoris artery
Regional Source  Profunda femoris artery.
Length  2 to 3 cm.
Diameter  1 to 2 mm.
Location  Medial aspect of the muscle.
Minor Pedicle (long head)  Second perforating branch of profunda femoris artery
Regional Source  Profunda femoris artery and vein.
Length  2 to 3 cm.
Diameter  0.5 to 1.5 mm.
Location  Lower part of the muscle medially.
Minor Pedicle (long head)  Branch of inferior gluteal artery
Regional Source  Inferior gluteal artery.
Length  1 to 2 cm.
Diameter  0.5 to 1 mm.
Location  At the origin of the muscle.
Dominant Pedicle (short head)  Second or third perforating branch of profunda femoris artery
Regional Source  Profunda femoris artery.
Length  2 to 3 cm.
Diameter  0.5 to 1 mm.
Location  Enters the muscle close to its origin from the femur.
Minor Pedicle (short head)  Superior lateral genicular artery
Regional Source  Popliteal artery.
Length  3 to 4 cm.
Diameter  0.5 mm.
Location  Distal into the muscle belly.

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 ANATOMY OF THE Semimembranosus MUSCLE

Sciatic nerve
Inferior gluteal artery

Femoral artery

Profunda femoris artery

Superficial femoral artery

First perforating branch

of profunda femoris artery

Second or third perforating

branch of profunda femoris artery

Semimembranosus muscle

Branch of superficial femoral artery

Semimembranosus muscle

Fig. 12E-1 

Dominant pedicle: First perforating branch of profunda femoris artery

Minor pedicles: Second or third perforating branch of profunda femoris artery; branch of
inferior gluteal artery; branch of superficial femoral artery

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 Thigh  •  12E: Biceps Femoris (Hamstring) Flap 1489

SEMIMEMBRANOSUS MUSCLE
Dominant Pedicle  First perforating branch of profunda femoris artery and venae comitantes
Regional Source  The profunda femoris artery and vein.
Length  2 to 3 cm.
Diameter  1 to 2 mm.
Location  Enters on the deep lateral surface of the muscle.
Minor Pedicle  Second or third perforating branch of profunda femoris artery and venae comitantes
Regional Source  Profunda femoris artery and vein.
Length  1 to 2 cm.
Diameter  1 to 2 mm.
Location  Enters on the deep lateral surface of the muscle.
Minor Pedicle  Branch of inferior gluteal artery and venae comitantes
Regional Source  Inferior gluteal artery and vein.
Length  1 to 2 cm.
Diameter  0.5 to 1 mm.
Location  At the origin of the muscle.
Minor Pedicle  Branch of superficial femoral artery and venae comitantes
Regional Source  Superficial femoral artery.
Length  2 cm.
Diameter  0.5 to 1 mm.
Location  At the insertion of the muscle. note: This muscle may be considered to have a type III
blood supply when its vascular pedicles from each of the perforating branches are of equal size.

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 ANATOMY OF THE Semitendinosus MUSCLE

Sciatic nerve
Inferior gluteal artery
Femoral artery
Profunda femoris artery

Superficial femoral artery

Descending branch of
medial circumflex femoral artery

First perforating branch

of profunda femoris artery

Third perforating branch of

profunda femoris artery

Semitendinosus muscle

Superior medial genicular artery

Semitendinosus muscle

Fig. 12E-1 

Dominant pedicle: First perforating branch of profunda femoris artery

Minor pedicles: Muscular branch of inferior gluteal artery; descending branch of
medial circumflex femoral artery; superior medial genicular artery

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 Thigh  •  12E: Biceps Femoris (Hamstring) Flap 1491

SEMITENDINOSUS MUSCLE
Dominant Pedicle  First perforating branch of profunda femoris artery
Regional Source  Profunda femoris artery.
Length  2 to 3 cm.
Diameter  1 to 2 mm.
Location  Enters on the deep lateral surface of the muscle.
Minor Pedicle  Muscular branch of inferior gluteal artery
Regional Source  Inferior gluteal artery.
Length  1 to 2 cm.
Diameter  0.5 to 1 mm.
Location  Enters the muscle at the origin.
Minor Pedicle  Descending branch of medial femoral circumflex artery
Regional Source  Profunda femoris artery.
Length  1 to 2 cm.
Diameter  0.5 mm.
Location  Upper portion of the muscle.
Minor Pedicle  Inferior medial genicular artery
Regional Source  Popliteal artery.
Length  1 to 2 cm.
Diameter  0.5 mm.
Location  Enters the muscle near its tendon.

Venous Anatomy
Accompanying paired venae comitantes that mirror the arterial anatomy.

Nerve Supply
Motor Branches of the sciatic nerve.
Sensory Posterior cutaneous nerve of the thigh (S1 to S3).

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 1492 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Biceps Femoris (H amstring) Flap

A

D1
D2 m2

Deep surface of flap

B C
m1

m1

D1, D2, D3

D1, D2, D3

m2
m2

Deep surface of flap Radiographic view

Fig. 12E-2 

Dominant pedicle of long head: First perforating branch of profunda femoris artery (D1)
Minor pedicles of long head: Second perforating branch of profunda femoris artery (D2);
branch of inferior gluteal artery (m1)
Dominant pedicle of short head: Second (D2) or third (D3) perforating branch of profunda
femoris artery
Minor pedicle of short head: Superior lateral genicular artery (m2)

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Vascular A natomy of the Semimembranosus Flap

A

m2

D m3
m1

Deep surface of flap

B C m2
m2

D
D

m1

m1

m3 m3

Deep surface of flap Radiographic view

Fig. 12E-3 

Dominant pedicle: First perforating branch of the profunda femoris artery (D)
Minor pedicles: Second or third perforating branch of profunda femoris artery (m1); branch
of inferior gluteal artery (m2); branch of superficial femoral artery (m3)

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 1494 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Semitendinosus Flap

A m1
B

m1

m2
m2

D
D

m3

m3

Deep surface of flap Radiographic view

Fig. 12E-4 

Dominant pedicle: First perforating branch of profunda femoris artery (D)

Minor pedicles: Muscular branch of inferior gluteal artery (m1); descending branch of medial
circumflex femoral artery (m2); superior medial genicular artery (m3)

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 Thigh  •  12E: Biceps Femoris (Hamstring) Flap 1495

Flap Harvest
Design and Markings
The skin paddle should overlie the muscles of the posterior thigh for an advancement flap,
as a V-Y or as a semicircular advancement flap. Either the biceps femoris alone or all of the
posterior thigh muscles can be included in the flap, increasing its blood supply. Incorporat-
ing the entire posterior thigh skin in the design is recommended for advancement and best
perfusion. A V-Y design allows the greatest advancement of the flap toward the ischium.
These flaps are commonly used in patients who are paralyzed and nonambulatory to
reconstruct decubitus defects. The muscles may be hard to identify because of atrophy and
may have limited bulk; therefore a wide design is helpful in capturing the blood supply.

A B

Semicircular flap design V-Y flap design

Fig. 12E-5 

Patient Positioning
Placing the patient in the prone position is most useful for treatment of the ischial or thigh
area and for harvesting this flap. The amount of flexion at the hip should be limited to al-
low maximal advancement of this flap.

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 1496 Part II  Regional Flaps: Anatomy and Basic Techniques

Guide to Flap Dissection

Once the flap is incised and deepened down to the fascia, identification of the hamstring
muscles is important. Superiorly, the bulk of the musculature originating from the ischium
is divided; this division should be kept at the bony interface to minimize injury to the
blood supply. Distally, the muscle bellies can be individually isolated as they insert into
the medial tibia and laterally into the fibular head and divided. Because the blood sup-
ply is largely segmental, the surgeon should attempt to mobilize the flap and advance this
with minimal division of the underlying attachments and therefore the blood supply. By
releasing the origin and insertion and medial and lateral attachments of these muscles, one
will generate mobility of the flap so it can be advanced upward for use with ischial defects.
Because of the segmental nature of the blood supply, one should avoid isolating muscles and
dividing distal blood supply for a proximal rotation or proximal blood supply for a distal
rotation. Although either flap rotation is possible, depending on the particular anatomy of
the patient, both are thought to be unreliable in general as isolated muscle transpositions.
For advancement and fill of an ischial defect, both muscle and deepithelialized skin paddle
should be used. By advancing the flap with the release of the muscular origin, insertions,
and lateral attachments, one can obtain up to 10 cm of advancement.

V-Y Advancement flap

A B C

Skin design Side is elevated and vessels are visible

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, inferiorly, 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.

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Semicircular flap

D E F

Fig. 12E-6 D, Semicircular design. This can be based medially or laterally, depending on the geom-
etry of the defect. E, The flap is elevated and advanced after the muscles are divided superiorly and
inferiorly 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
•  Muscle-only superiorly based flap
•  Inferiorly based (reverse) flap
Reverse Flap
The use of the biceps femoris as a distally based flap for lower thigh and superior knee re-
construction has been described; one must have an adequate distal minor pedicle to do so.
The biceps femoris can be the sole basis of a muscular flap; however, in most patients this is
not a reliable flap and is not recommended for an ambulatory patient, because it sacrifices
an essential muscle of the leg.

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 1498 Part II  Regional Flaps: Anatomy and Basic Techniques

Arc of Rotation

V-Y Flap
The V-Y flap is the most useful of the posterior thigh
myocutaneous flap designs. First, it allows advancement
of the skin muscle unit superiorly without the need for a
backcut. It also allows readvancement of the flap if pres-
sure sores recur in the ischial area. With full release of the
origin and insertion and lateral attachments of the muscle,
up to 10 cm of advancement can be obtained. In large
wounds or the need for readvancement in a paralyzed
patient, division of the sciatic nerve can offer an additional
2 cm of advancement and has no functional significance.

V-Y arc of rotation

Fig. 12E-7 

Semicircular Flap
An advantage of the semicircular advancement design is
that it encompasses the entire posterior thigh and there-
fore has an excellent blood supply; it is also easier to dissect
this flap. Although inferiorly and posteriorly muscular
release is required, similar to the V-Y variant, with the
semicircular flap design, the base of the flap is not discon-
nected, which ensures better venous drainage of the skin
and a more secure blood supply. Advancement with this
flap might be limited, depending on the backcut of the
flap for advancement. With full release of the origin and
insertion of the muscles and a healthy backcut, advance-
ment of 8 to 10 cm is possible.

Semicircular arc of rotation

Fig. 12E-8 

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Flap Transfer
V-Y and Semicircular Flap
When these flaps are used for an ischial reconstruction, the defect marks the superior por-
tion of the flap. The flap transfers through a direct transposition from the donor site into
the recipient site. Both the V-Y and semicircular designs allow advancement of the muscle
and skin for bulk for reconstruction.

Flap Inset
V-Y Flap and Semicircular Flap
With both flaps one should use the advanced muscle to secure the flap superiorly and take
tension off the skin closure. These ischial defects often have an associated bursa, and advanc-
ing the flap an additional few centimeters and deepithelializing the skin paddle will afford
even more bulk for the reconstruction. Because these flaps are inset directly, there is little
concern about compression of the pedicle.

Donor Site Closure

V-Y Flap
In typical V-Y fashion, closure distally will support advancement of the flap and bear tension
on the closure. Again, it is recommended that the design of the flap extend to the popliteal
area so that secondary readvancement of the flap can be done with further V-Y advancements.

Semicircular Flap
Once the flap has been advanced with a backcut, there should be enough mobility in the
thigh for primary closure. In rare instances, especially in reoperative cases, a skin graft may
be required to back-graft the donor site.

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 1500 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 23-year-old paraplegic man had bilateral ischial pressure sores. Preoperative care
in such patients and preparation for surgery is just as important to success as the surgical
procedure. Wounds should be clean and show evidence of granulation. This may mean a
preliminary surgery for debridement and a period of dressing changes or negative-pressure
dressings. Patients should stop smoking and a nutritional evaluation should be performed.
Atrophy of surrounding tissues is typical with paraplegia. As is also typical, the skin defect
is smaller than the underlying bursa, and flaps should be planned to reconstruct the deep
defect, removing the thin overlying skin.

A B

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 ad-
vancement 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. (Case supplied by MRZ.)

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This 58-year-old woman had diabetes, renal failure, peripheral vascular disease, and an
infected and necrotic ischial decubitus.

A B

C D

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 celluli-
tis. 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. (Case supplied by MRZ.)

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 1502 Part II  Regional Flaps: Anatomy and Basic Techniques

This 46-year-old paralyzed man had a clean ischial decubitus.

A B

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. (Case supplied by MRZ.)

This 64-year-old paraplegic man had a large ischial decubitus. The bursa in this case was
extensive, and the size of the skin opening was misleading.

A B

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. (Case supplied by MRZ.)

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Pearls and Pitfalls

• The biceps femoris flap (posterior thigh flap) is the flap of choice for ischial decubiti,
because it leaves other valuable donor sites such as the gluteal and inner and outer thigh
areas available for decubiti in these areas.
• The flap is relatively straightforward and easy to dissect, and one would be best served
by not skeletonizing or attempting to isolate the underlying blood supply.
• The surgeon must beware of excessive tension on the advancement flap and the shearing
of the skin paddle from the underlying musculature.
• Direct pressure must be avoided postoperatively on these advancements with the use of
a low-pressure bed or alternative positioning in the prone or lateral positions.
• Although reverse flaps have been described, they are unreliable as the distal minor pedicles
are variable.
• The hamstring muscles are critical in ambulatory patients and should not be used as
muscle or myocutaneous flaps.
• In a paralyzed patient, division of the sciatic nerve, when needed, will allow an additional
2 cm of advancement and has no functional significance to the patient.

Expert Commentary
Michael R. Zenn

Indications
The biceps femoris (posterior thigh flap) is an incredibly useful flap for wounds around the
ischial tuberosity and for soft tissue defects of the perineum.

Advantages and Limitations

Because of the functional importance of the muscles, these flaps should only be used in
non-ambulatory patients. Because these muscles are essentially supplied by segmental ves-
sels (some major, some minor) the most successful flap designs maintain these segmental
blood supplies. Depending on the dominance of the vessels found in a particular patient,
certainly isolated muscle advancements or rotations would be reasonable. Keep in mind
that the bulk of these muscles in the paralyzed patient is often less than desired and these
flaps are most useful as myocutaneous advancements.

Personal Experience and Insights

My personal preference is to use the biceps femoris V-Y myocutaneous flap as the primary
flap for ischial pressure sores. Its arc of rotation lends itself to this defect, as the flap is being
advanced toward its blood supply. It has a generous amount of skin, fat and muscle which
help obliterate the bursa which is often associated with these flaps, and most importantly
it spares other donor sites such as the medial thigh, lateral thigh and buttock for secondary
problems or the inevitable decubiti in other locations.
Continued

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 1504 Part II  Regional Flaps: Anatomy and Basic Techniques

Recommendations
Planning
Use of the flap as a bilateral flap advanced centrally can reconstruct remarkably large central
perineal defects as well. Although some have described the turndown of the biceps femoris
as a useful flap for supra patellar and popliteal defects, I feel that this is an unreliable flap
historically, and depending on the patient, there may be an incredibly small minor pedicle
nurturing this flap making its reliability uncertain. There are much better choices such as
the gastrocnemius flap or reverse ALT flap. This variant of the flap has not been used in
my practice. In an ambulatory patient, I also would favor a free tissue transfer for the lowest
morbidity. The primary disadvantage of the flap is its upward mobility. For extensive defects
of the ischium, this flap may require a second flap to help obliterate and close the defects.
The key to success in these patients is not only in execution of the flap, but in postoperative
management. I recommend a 2-month period of no pressure on the area of reconstruction,
either by low-pressure bed or by patient positioning. I also like the fact that the advance-
ment flap can be performed without the need for skin grafting of the donor site, which I
have never had to do in my practice.

Bibliography With Key Annotations

Cavadas PC, Sanz-Jiménez-Rico JR, Landin L, et al. Biceps femoris perforator free flap for
upper extremity reconstruction: anatomical study and clinical series. Plast Reconstr Surg
116:145-152, 2005.
Perforator flaps are an important development in reconstructive surgery. The description of new perfora-
tor flaps is an open field in anatomical and surgical research. The anatomy of the musculocutaneous
perforating vessels of the short head of the biceps femoris muscle was investigated as a possible source
for free tissue transfer in 10 fresh cadaver specimens. A series of 10 free biceps femoris perforator flaps
for upper extremity reconstruction is described. There were three constant sizable perforators, located
at 6 cm (range 5 to 6.5 cm), 11.6 cm (range 10 to 14 cm), and 15.3 cm (range 14 to 17 cm), respec-
tively, from the knee joint line. The distalmost perforator was a branch off the superior lateral genicular
artery in all anatomic specimens. The middle perforator was a direct branch off the popliteal artery in
60% of the cases and off the profunda femoris in the remaining 40%. The uppermost perforator was
usually a branch off the middle perforator. The flaps of the clinical series were based on the middle
perforator (11.6 cm). All 10 free flaps were used for upper extremity trauma coverage, with a 100%
success rate, although one flap required pedicle revision because of arterial thrombosis and developed
partial necrosis. Donor-site delayed wound healing occurred in two patients. The vascular anatomy is
relatively constant. Flap dissection is straightforward under tourniquet control, donor morbidity is low
provided a primary closure is possible, and pedicle size is appropriate for repair. When a moderate-size
free flap with moderate thickness and a medium-sized pedicle is needed, the biceps femoris perforator
flap should be considered in the first-choice group of donor areas.
Hayashi A, Maruyama Y. Lateral intermuscular septum of the thigh and short head of the biceps
femoris muscle: an anatomic investigation with new clinical applications. Plast Reconstr Surg
108:1646-1654, 2001.
The authors performed an anatomic study to reappraise the vasculature of the lateral intermuscular
septum of the thigh and the muscles associated with it; 12 preserved cadaver legs were used. Several
possible new clinical applications of the lateral intermuscular septum and the short head of the biceps
femoris were identified as follows: (1) short head of biceps femoris muscle or musculoseptal flap based on
the second and/or third profunda perforating vessels, or based on the superior lateral genicular vessels,

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 Thigh  •  12E: Biceps Femoris (Hamstring) Flap 1505

with or without the iliotibial tract and the deep fascia, and with or without the motor nerve of the short
head; (2) transverse extension of the fascial portion of the tensor fascia lata muscle or myocutaneous
flap to include the lateral intermuscular septum; (3) the combined use of items 1 and 2; and (4) free
septofascial graft using the lateral intermuscular septum and iliotibial tract. It is anticipated that the
distally based short head of the biceps femoris muscle flap will be an additional option for repairing
defects around the knee, and that a free short head of the biceps femoris muscle flap based on the
profunda femoris perforating vessels will be useful in functional reconstruction such as reanimation of
the paralyzed face. The lateral intermuscular septum can be incorporated into the short head of biceps
femoris muscle flap or into the tensor fasciae latae flap, and it also can be used as a free fascial graft.
The functional deficit resulting from harvesting the short head of the biceps femoris and the lateral
intermuscular septum is minimal, and donor wound at the lateral lower thigh seems to be acceptable.
Salvador-Sanz JF, Torres AN, Calpena FT, et al. Anatomical study of the cutaneous perforator
arteries and vascularization of the biceps femoris muscle. Br J Plast Surg 58:1079-1085, 2005.
The authors presented an anatomic study describing the distribution of the cutaneous perforators of both
heads of the biceps femoris muscle. They dissected 18 legs from 9 cadavers. The study was centered
on the biceps femoris muscle and myocutaneous perforator arteries from both muscular heads. Only
perforator arteries with comitant vein diameters greater than 0.5 mm were selected. The vascular origin
and length were also studied. In all cases, measurements were taken from the bicondylar line. The
principal vascular origin of the perforator arteries was the popliteal artery in both muscle bellies, while
the second arterial vessel in importance was the first and second profunda perforator artery. From these
results, the authors deduced that it is always possible to locate perforator arteries in both muscle bellies;
most frequently they have intramuscular distribution and are located in the proximity of the vascular
septum. Their most common origins are the popliteal artery and first and second profunda perforator
artery. Finally, it is possible to design pedicle and free flaps with less morbidity and more versatility
than with myocutaneous flaps.
Tsetsonis CH, Laoulakos DH, Kaxira OS, et al. The biceps femoris short head muscle flap: an
experimental anatomical study. Scand J Plast Reconstr Surg Hand Surg 37:65-68, 2003.
The vascular communication between the heads of the biceps femoris muscle has been established after
25 cadaveric dissections. Perfusion of dye through the long or the short head consistently showed one
or two anastomotic bundles. Outflow of dye opposite the site of the perfused head was remarkable
in most cases. Intramuscular dissections disclosed broad well-structured vascular networks in all short
heads, but this was not true for all long heads. Their observations suggest that the anastomotic vessels
alone might support the short head which, when released from its profunda femoris vessels, is adequate
to cover lateral knee defects. Depending on the level of the anastomotic vessels, the proximal or the
distal part of the short head should be used. A pedicled flap may be used as well, whereas transection
of the biceps tendon offers additional mobility.

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 ANATOMIC LANDMARKS
Landmarks This thin, bandlike muscle occupies a space laterally in the thigh
bordering the rectus femoris muscle anteriorly and the biceps
femoris muscle posteriorly. The muscle is usually palpable just
distal to the greater trochanter.
Size The muscle is 5 cm wide, 12 cm long, and 2 cm thick at its ori-
gin. Skin 15 3 40 cm can be transferred but requires skin graft
closure of the donor site.
Origin The anterior 5 cm of the outer lip of the iliac crest, extending to
the lateral surface of the anterior superior iliac spine. The muscle
also originates from the greater trochanter of the femur.
Insertion The fascia lata extension of the TFL inserts into the lateral con-
dyle of the tibia.
Function Knee stabilization.
Composition Muscle, myocutaneous, osteomyocutaneous, perforator fascio-
cutaneous.
Flap Type Type I.
Dominant Pedicle Lateral femoral circumflex artery.
Nerve Supply Motor: Superior gluteal nerve (L4, L5, S1). Sensory: Lateral cu-
taneous branch of T12; lateral femoral cutaneous nerve of the
thigh (L2, L3).

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 Section 12F
Thigh

Tensor Fascia Lata (TFL) Flap

CLINICAL APPLICATIONS
Regional Use
Groin
Abdomen
Trochanter
Ischium
Perineum
Distant Use
Head and neck
Upper extremity
Lower extremity
Abdomen
Specialized Use
Abdominal wall reconstruction
Breast reconstruction
Vaginal reconstruction

12f_TenFas_r6_cah_1506-1533.indd 1507 2/8/2012 3:33:21 PM

 ANATOMY OF THE Tensor Fascia Lata (TFL) Flap

Lateral cutaneous branch of T12

Lateral femoral cutaneous nerve of thigh

Anterior superior iliac spine
Gluteus maximus muscle
Tensor fascia lata muscle
Profunda femoris artery Femoral nerve

Superior gluteal nerve Femoral artery

Lateral circumflex femoral artery Femoral vein

Ascending branch Superficial femoral artery

Transverse branch Sartorius muscle

Descending branch

Iliotibial tract
Rectus femoris muscle

Vastus lateralis muscle

Vascular and nerve supply

Fig. 12F-1

Dominant pedicle: Lateral circumflex femoral artery

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1509

Anatomy
Landmarks This thin, bandlike muscle occupies a space laterally in the thigh, bordering the
rectus femoris muscle anteriorly and the biceps femoris muscle posteriorly. The
muscle is usually palpable just distal to the greater trochanter. A line extending
from the greater trochanter to the midlateral aspect of the knee bisects the tensor
fascia lata (TFL) muscle.
Composition Muscle, myocutaneous, osteomyocutaneous, perforator fasciocutaneous.
Size The muscle is 5 cm wide, 12 cm long, and 2 cm thick at its origin. Skin 15 3
40 cm can be transferred but requires skin graft closure of the donor site. The
osseous segment is 6 3 4 cm.
Origin The anterior 5 cm of the outer lip of the iliac crest, extending to the lateral
surface of the anterior superior iliac spine. The muscle also originates from the
greater trochanter of the femur.
Insertion The fascia lata extension of the TFL inserts into the lateral aspect of the knee.
The iliotibial tract is formed by a combination of aponeurosis of the superficial
portion of the gluteus maximus muscle and a similar aponeurosis of the TFL
muscle. The tract descends between the circular fibers of the fascia lata to insert
on the lateral condyle of the tibia.
Function The TFL acts as a knee stabilizer. When the iliotibial tract is taut, the knee is
held in extension. This tightening of the tract also stabilizes the hip and the leg
in a standing position. However, in all but the most athletic individuals, harvest
of the flap is associated with minimal functional morbidity.

Arterial Anatomy (Type I)

Dominant Pedicle  Lateral circumflex femoral artery
Regional Source  Profunda femoris artery.
Length  6 cm.
Diameter  2 to 3 mm.
Location  Leaves the lateral side of the profunda femoris artery and passes deep to sartorius and
rectus femoris muscles. Behind the rectus femoris muscle, it gives rise to three branches:
    1.  Ascending branch to the superior portion of the muscle.
    2.  A transverse branch supplying the mid and superior portions of the muscle.
    3. A descending branch running inferiorly along the muscle, supplying its lower third.
The ascending branch supplies branches to the iliac crest along its origin and is the basis for the
osseous combined flap. Multiple myocutaneous perforators measuring 1 mm or less supply the
overlying skin and are the basis for the perforator flap.

Venous Anatomy
Two venae comitantes travel with the lateral circumflex femoral artery (LCFA). These venae co-
mitantes are 2 to 4 mm in diameter and join the lateral side of the femoral vein.

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 1510 Part II  Regional Flaps: Anatomy and Basic Techniques

Nerve Supply
Motor The superior gluteal nerve. This nerve has contributions from L4, L5, and S1 and
supplies all three abductors of the hip. After exiting above the piriformis muscle,
the nerve courses laterally between the gluteus medius and gluteus minimus
muscles, entering the TFL on its deep and posterior aspect in the middle third
of the muscle.
Sensory Skin territory is innervated by two distinct sensory nerves: (1) the lateral cutane-
ous branch of T12, which supplies the upper skin territory over the muscle and
origin of the muscle, and (2) the lateral femoral cutaneous nerve of the thigh,
with contributions from L2 and L3, which innervate the remaining inferior skin
territory. The lateral cutaneous branch of T12 courses anteriorly on the external
oblique muscle in the midaxillary line, heading inferiorly and anteriorly. It crosses
the iliac crest approximately 6 cm posterior to the anterior superior iliac spine
(ASIS). The lateral cutaneous nerve of the thigh enters the thigh 2 cm medial to
the ASIS below the inguinal ligament. It remains deep to the TFL, eventually
penetrating the muscle and entering the skin 10 cm inferior to the ASIS near
the anterior border of the flap.

Vascular A natomy of the Tensor Fascia Lata (TFL) Flap

A B C

Deep surface of flap Deep surface of muscle Radiographic view

Fig. 12F-2

Dominant pedicle: Lateral circumflex femoral artery (D)

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1511

Flap Harvest
Design and Markings
The skin paddle should overly the muscle in its proximal design. This is best delineated
by a line drawn from the ASIS to the lateral condyle of the tibia. This line demarcates the
anterior border of the muscle. A line drawn 3 cm posterior to this and parallel represents
the tensor muscle; this originates in part from the trochanter, which is palpable. The vas-
cular pedicle should be anticipated 7 to 12 cm distal to the ASIS and can be confirmed
with Doppler ultrasound. A flap greater than 9 cm in width will require skin grafting for
donor site closure, although this is variable. The distal third of the skin territory is unreliable and
requires a delay procedure to ensure its vascularity. The flap design will depend on its use and is
most commonly a simple rotation flap, which can be completely incised as an island flap or
designed as a V-Y advancement flap.

Flap axis from 3 cm

lateral to ASIS
to lateral condyle
B Sartorius muscle

Rectus femoris muscle

Femoral artery
Tensor fascia lata muscle
Outline of Femoral vein
tensor fascia lata Ascending branch
myocutaneous flap perforator of lateral Iliopsoas muscle
circumflex femoral artery

Vastus lateralis
muscle

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.

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 1512 Part II  Regional Flaps: Anatomy and Basic Techniques

The patient may be marked in either a standing or supine position. The ASIS and the
lateral condyle of the femur are marked. For myocutaneous flaps, the design extends from
the ASIS to within 8 cm of the lateral femoral condyle. For a myocutaneous flap containing
bone, the design is more proximal, overlying the iliac crest and centered on the palpable
trochanter.

Patient Positioning
An advantage of the TFL flap is that it can be harvested easily in the supine position; this
is the preferred position. For some applications, including posterior rotational flaps, the
flap may be harvested in a lateral decubitus position, although this is usually not necessary.

Guide to Flap Dissection

Once designed, the flap is easily dissected from distal to proximal. After the cutaneous
paddle is incised inferiorly, the fascia lata is also incised. It is helpful at this point to suture
the skin flap to the fascia to prevent any shearing injuries. The dissection then proceeds
easily in the subfascial plane.

Fascia sutured Anterior superior

to skin paddle iliac spine

Lateral femoral
cutaneous nerve
Transverse branch
Tensor fascia lata
of lateral circumflex
muscle
femoral artery
Branch of superior
gluteal nerve

Vastus lateralis
muscle
Rectus femoris
Descending muscle
branch of
lateral circumflex
femoral artery

Initial dissection

Fig. 12F-4 

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1513

The vascular pedicle should be anticipated, starting 12 cm distal to the ASIS, and dis-
section must proceed more cautiously at this point. At this level one should also look for the
lateral femoral cutaneous nerve at the anterior margin of the flap if a sensate flap is desired.
The lateral circumflex femoral vascular pedicle is then identified on the deep surface of
the muscle and is dissected medially in the plane between the rectus femoris and the vastus
lateralis muscles. Any of the branches to the gluteus minimus and vastus lateralis muscles
are ligated. Near the origin of the lateral femoral circumflex artery, care must be taken to
avoid injury to branches of the femoral nerve. As needed for rotation, proximal muscula-
ture can be incised from its origin at the ASIS, and a complete island flap can be created.

Myofascial-Only Flap
The myofascial flap is useful when vascularized fascia only is required, such as in an abdomi-
nal wall reconstruction. Extension of the fascia lata can be taken with the flap to within a
few centimeters of the knee. Because no skin will be taken, access to the muscle is obtained
through an incision made at its anterior border, allowing visualization of the vascular hilus.
A 10 to 12 cm width of fascia can be carried. Flaps 35 to 40 cm long may be designed.

Rectus femoris muscle

Tensor fascia lata muscle

Transverse branch of lateral

Vastus lateralis muscle circumflex femoral artery

Myofascial-only flap elevation with donor site closure

Fig. 12F-5 

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 1514 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Variants
•  Myofascial-only flap
•  Osteomyocutaneous flap
• Perforator fasciocutaneous flap (lateral circumflex femoral artery–tensor fascia lata perforator
flap)

Osteomyocutaneous Flap
The osseous component of the flap, which is a segment of the iliac crest 6 cm long, is
supplied by the ascending branch of the lateral circumflex femoral artery and is supplied
through the muscle origin.

6 cm
Anterior superior
Ascending branch
iliac spine
of lateral circumflex
femoral artery 6 cm

Greater trochanter

Outline of
tensor fascia lata
osteomyocutaneous flap

Fig. 12F-6   Osteomyocutaneous design. Note that the design is shifted more proximally than in the
standard flap.

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1515

This bone can be captured with the flap with muscle only, or with its overlying cu-
taneous segment. This flap is most commonly used as a free tissue transfer, and often the
osteotomies are best performed after dissection and division of the vascular pedicle.

B C

Vascularized bone territory

Fig. 12F-6 

If skin will be carried with this flap, the design should be more proximal and centered
over the palpable trochanter, approximately 6 cm below the ASIS.

D
Donor iliac crest graft

Ascending branch
of lateral circumflex
femoral artery

Tensor fascia
lata muscle

Osteomyocutaneous flap dissected

Fig. 12F-6 

12f_TenFas_r6_cah_1506-1533.indd 1515 2/8/2012 3:33:26 PM

 1516 Part II  Regional Flaps: Anatomy and Basic Techniques

Perforator Fasciocutaneous Flap

One disadvantage of the TFL flap is that it may be bulky when it carries both skin and
muscle components. The TFL skin distribution can be carried as a thin perforator flap
based on the perforators that run through the TFL muscle. These vessels are small, and
patience and skill are required to follow these vessels through the muscle without injury.
When identifying these dominant perforators, the surgeon should keep in mind that they
have traveled through the muscle and emerge posterolateral to the central aspect of the
muscle. Wide exposure within the muscle is necessary to safely lengthen the pedicle and
ligate multiple side branches.
Once the hilum is reached, retraction of the rectus femoris and sartorius muscles help
exposure of the origin of the ascending branch of the lateral circumflex vessel, which can
be further dissected for more length and diameter. A microdissection technique has been
advocated to further thin these flaps and effectively increase pedicle length.

Anterior
Lateral

Medial

Posterior

B C

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.
(Courtesy Phillip N. Blondeel, MD.)

12f_TenFas_r6_cah_1506-1533.indd 1516 2/8/2012 3:33:27 PM

 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1517

Arc of Rotation
Myocutaneous Arc

A B

Myocutaneous flap design Flap rotated and inset

with primary closure

Fig. 12F-8 

V-Y Advancement Arc

Perhaps the best rotation for trochanteric defects, the V-Y advancement flap places the bulki-
est, best-profused tissues over the area of defect while allowing primary donor site closure.

A B

Flap design Superior advancement

to greater trochanter

Fig. 12F-9 

12f_TenFas_r6_cah_1506-1533.indd 1517 2/8/2012 3:33:28 PM

 1518 Part II  Regional Flaps: Anatomy and Basic Techniques

Anterior and Posterior Arcs of Myocutaneous Flaps

The anterior arc of rotation will cover the abdominal wall, groin, and perineum. The
posterior arc of rotation will cover the greater trochanter, ischium, perineum, and with
delay, the sacral areas.

A B

Myofascial arc to anterior trunk Myofascial arc to posterior trunk

Fig. 12F-10 

Flap Transfer
Myofascial Flap
Most common indication for this as a pedicle transfer is an abdominal wall reconstruction.
The flap is isolated on its vascular pedicle and transferred through a subcutaneous tunnel to
the abdominal wall recipient site. In cases of groin defects, direct rotation may be possible
without creation of a tunnel.

Myocutaneous Flap
Planning is key when locating the skin flap relative to its need. For more distant needs,
the proximal portion of the skin paddle may be deepithelialized or removed. This is best
determined by elevating the flap and passing it to its distant site and marking the area of
skin need. The flap may be deepithelialized once back on the thigh. For defects within the
immediate area, the donor recipient sites can be joined and the flap can be directly rotated.
This is commonly performed for groin defects requiring skin. When groin defects include
defect in the abdominal fascia, the TFL fascia can be used to patch the defect, negating the
need for synthetic mesh closure.
A conservative approach must be taken with both anterior and posterior rotations to
leave the dog-ears created by the rotation for later revision. In obese patients, these dog-
ears may be significant, and the temptation to revise them immediately should be avoided,
because these dog-ears contain valuable blood supply and venous drainage to the flaps. This
is an advantage of a V-Y advancement, because no cone of rotation is created.

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1519

Free Flap
For osteomyocutaneous and perforator flaps that are used as free flaps, the general principles
of reconstruction are followed, including no tension on the pedicle, and in the case of per-
forator flaps, no tension on the small perforators. A tension-free closure should be the goal.

Donor iliac crest graft

Ascending branch
of lateral circumflex
femoral artery

Tensor fascia
lata muscle

Osteomyocutaneous free flap dissected

Fig. 12F-11 

Donor Site Closure

Donor site closure for the TFL rotational or free flap commonly requires the use of skin
grafts and is one of the disadvantages of the flap. In select nonobese patients with skin lax-
ity, skin islands of up to 9 cm may be harvested with primary closure. These dimensional
principles also apply to flaps taken as free tissue transfer.

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 1520 Part II  Regional Flaps: Anatomy and Basic Techniques

Clinical Applications
This 30-year-old paraplegic man had undergone multiple surgical procedures for decubiti
and presented with ischial and sacral decubiti. The large left ischial decubitus was too large
for biceps advancement, so a large TFL flap was performed to provide stable coverage of
the ischium. The sacral decubiti were excised and closed primarily. The large size of the
TFL flap necessitated skin grafting of the donor site.

A B

C D

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. (Case supplied by MRZ.)

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1521

This 81-year-old man had a neglected penile squamous cell cancer with bulky metastases
to the left groin. The patient stated that he had successfully avoided doctors for more than
40 years. After a total penectomy, bilateral groin lymph node dissections, and creation of
a perineal urethrostomy, he had a residual large defect with exposed femoral vessels. He
underwent a rotational TFL flap with primary closure of the donor site. For groin defects,
it is preferable to connect the donor and recipient sites to facilitate flap placement and to
minimize pressure on the vascular pedicle, sometimes seen with tunneled flaps.

A B

C D

E F

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. (Case supplied by MRZ.)

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 1522 Part II  Regional Flaps: Anatomy and Basic Techniques

This 53-year-old man with a history of STD and condyloma of the penile shaft presented
with carcinoma arising from the condyloma, metastatic to the groin bilaterally. After resec-
tion of the groin masses, bilateral pelvic lymph adenectomy and partial penectomy, primary
closure of the right groin was obtained, but this put tension on the wound on the left side,
enlarging it and preventing primary closure. Because of exposure of the lymphatics and
femoral vessels and the likelihood that the patient would receive postoperative radiation
therapy, it was felt that a skin graft was not a durable solution, so a TFL flap was rotated
into the defect. This allowed a tension-free closure, facilitating healing. The donor site was
closed primarily.

B
A

C D

Fig. 12F-14 A, Preoperative view of condyloma of the penis and bilateral groin masses to be re-
sected. B, Resultant defects of the groin. The midline incision was made for the pelvic lymph node dis-
section. 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.

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1523

E F

H I

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. (Case supplied by MRZ.)

12f_TenFas_r6_cah_1506-1533.indd 1523 2/8/2012 3:33:44 PM

 1524 Part II  Regional Flaps: Anatomy and Basic Techniques

This 66-year-old man had a stomal recurrence after undergoing abdominoperineal re-
section for colon cancer 4 years earlier. A full-thickness wide excision of the abdominal
wall and relocation of the stoma were performed. The wound was considered dirty, and
prosthetic mesh was thought to be suboptimal for restoring fascial continuity. Autologous
fascial repair was performed with a myofascial TFL flap. Ample fascia was available, and
the flap easily reached the midabdomen for the repair. Skin carried on the distal third of
the flap would have been unreliable without delay, so primary skin closure was achieved
by mobilizing local tissue.

C D

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 el-
evated 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, ab-
dominal skin mobilization was favored for closure of the skin defect. (Case supplied by MRZ.)

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1525

This 28-year-old paraplegic man presented with a stage IV trochanteric pressure ulcer. After
he was prepared for surgery with nutritional supplementation and local dressing changes,
he underwent retroposition V-Y TFL flap closure of his wound. No pressure was allowed
on the flap for the first 4 weeks.

C D

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 primar-
ily, 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. (Case supplied by MRZ.)

12f_TenFas_r6_cah_1506-1533.indd 1525 2/8/2012 3:33:50 PM

 1526 Part II  Regional Flaps: Anatomy and Basic Techniques

The safest method for extending the size of the LCFA perforator flap is to dissect and in-
clude simultaneously the neighboring perforators for adjacent flaps. By including perforators
derived from both the ascending and descending branches of the lateral circumflex femoral
artery, and with the superficial circumflex femoral artery, an immense flap can be elevated
safely, encompassing almost the entire anterior thigh, as with this 49-year-old man with
deep peripatellar burns.

A B

C D

E F

Fig. 12F-17 A and B, After the requisite debridement, the patella and quadriceps tendon were ex-
posed. 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. (Case courtesy Phillip N. Blondeel, MD.)

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1527

Pearls and Pitfalls

• Sacrifice of the TFL muscle produces minimal functional loss in ambulatory patients but
should be avoided in high-performance athletes.
• Extended TFL flaps can be created using delay procedures, greatly increasing the skin
territory carried with the flap.
• A vascularized osseous segment can be carried with the flap, but is a distant fourth or fifth
choice to the other common osseous flaps (fibula, DCIA, scapula, radius).
• The flap can be used as a sensate flap, which gives it advantages over other nonsensate
options.
• Pedicle location is consistent and can be dissected in a supine position, facilitating a two-
team approach to reconstruction.
• The flap may be bulky in some patients; this can be reduced by removing some of the
muscle superiorly or harvesting the flap as a perforator flap.
• Excessive thinning of the subcutaneous tissue using microdissection techniques may injure
the lateral femoral cutaneous nerve supplying the flap. Similar skin territory without as-
sociated bulk can be obtained using the ALT flap and larger muscle bulk and fascia can be
carried with the rectus femoris flap. These alternatives should be considered, depending
on the reconstructive need.

Expert Commentary
Michael R. Zenn

Indications
The TFL is a workhorse flap for the reconstructive surgeon for defects of the thigh and
groin. It is the flap of choice for trochanteric decubiti and for groin defects after radical
lymph node dissections for various cancers.

Advantages and Limitations

The advantages of the TFL flap lie in its availability, its generous source of fascia and skin,
and its minimal morbidity. That said, there are always choices between the TFL and other
nearby flaps, such as the ALT, rectus femoris, gracilis, and rectus abdominis, so individu-
alization for each clinical case is important.

Recommendations
Planning
The reason the TFL is the flap of choice for trochanteric decubiti relates to the natural history
of decubitus patients and the location of the TFL. Decubitus patients are “patients for life”
and will have multiple decubiti over time; this needs to be considered in operative plan-
ning. Use of the TFL for a trochanteric defect, the biceps femoris and gracilis for an ischial
defect, and gluteal flaps for a sacral defect serves the patient best for lifetime reconstructive
planning and having enough tissue available to reconstruct future defects.
Continued

12f_TenFas_r6_cah_1506-1533.indd 1527 2/8/2012 3:33:52 PM

 1528 Part II  Regional Flaps: Anatomy and Basic Techniques

Technique
As for the favored technique of TFL use for trochanteric decubiti, the retroposition V-Y
advancement flap (see Fig. 12F-16) is superior to simple rotation flap for a few reasons.
First, the TFL flap is bulky proximally and quite thin distally. This is fine for resurfacing
the groin, but for decubiti, bulk is required for successful, durable reconstruction. The
retroposition V-Y TFL places the bulkiest tissues into the defect. Second, by crafting the
muscle as a V-Y flap, primary closure of the donor site is accomplished, avoiding one of the
biggest drawbacks of the flap: the need to skin graft the donor site. It is critical, as it is for
all flaps for decubiti, to design the flap large enough so recurrences can be dealt with by
reelevation and advancement of the flap.

Complications
The main complications relating to use of the TFL flap are donor site cosmesis, areas of tissue
excess require revision, seroma formation, and inadequate tissue to perform the reconstruc-
tive task. The most common complaint of patients who have had TFL flaps is the large skin
graft that is required at the donor site. Although this can be hidden in clothes, they still do
not like it. Using the retroposition flap for trochanteric wounds avoids this deformity. For
other uses, a skin graft is still required for flaps greater than 9 cm in width. The dog-ear
created by rotating the TFL flap can be significant. I do not recommend revising it for at
least 4 to 6 months, because it contains the blood supply to the flap.
Much of the deformity may settle over time, and resection of the dog-ear at 4 to 6
months will not endanger the blood supply to the flap. It is important to use a large-bore
drain in this area as there are surrounding lymphatics that contribute to postoperative sero-
mas. Drains may be left in for 2 to 3 weeks in some cases. Although touted as vascularized
fascial replacement for abdominal wall reconstruction, the flap may fall short in providing
adequate surface area, and the use of synthetic mesh should be considered.

Bibliography With Key Annotations

Aslan G, Tuncali D, Bingul F, et al. The “duck” modification of the tensor fascia lata flap. Ann
Plast Surg 54:637-639, 2005.
Various common locations of pressure sores require specific considerations. The most commonly used
flap for the treatment of trochanteric ulcers is the tensor fascia lata (TFL) flap. The authors noted
that in their experience with the original flap, excessive tension and eventual suture separation at the
confluence of the donor site flaps and the TFL flap are the most common problems. They presented
a new design for the TFL flap for the coverage of trochanteric pressure sores. An anterior triangular
extension was designed exactly at a point where the flaps that will cover the donor site unite after
transposition. The deepithelialized proximal part of the flap is folded into the pouch and sutured.
The “duck” flap was applied to 31 trochanteric pressure sores in 27 patients with no major complica-
tions. This modification has many advantages: the flap is reliable and easily designed; formation of
dead space and a cone-shaped dog-ear deformity resulting from rotation is prevented; better aesthetic
results are achieved; suture separation is prevented with a tension-free closure; the deepithelialized part
produces a tight attachment of the flap to the recipient bed; and because no muscle tissue is included,
the flap is more resistant to pressure.
Bulstrode NW, Kotronakis I, Baldwin MA. Free tensor fasciae latae musculofasciocutaneous flap
in reconstructive surgery: a series of 85 cases. J Plast Reconstr Aesthet Surg 59:130-136, 2006.
The use of the tensor fascia lata was first described as a rotation or island flap and evolved into a free
flap in the late 1970s. This series of 85 patients undergoing free TFL transfer included complex

12f_TenFas_r6_cah_1506-1533.indd 1528 2/8/2012 3:33:52 PM

 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1529

head and neck, abdominal wall, and lower limb reconstruction. The overall success rate was 93%
(79 patients), partial flap loss, 5% (four cases), and flap failure, 2% (two patients). Twelve patients
required unplanned return to the operating room for exploration, resulting in a 75% salvage rate.
Chevray PM, Singh NK. Abdominal wall reconstruction with the free tensor fascia lata mus-
culofasciocutaneous flap using intraperitoneal gastroepiploic recipient vessels. Ann Plast Surg
51:97-102, 2003.
The authors reported their experience with a method for definitive abdominal wall reconstruction
using the free tensor fascia lata myofasciocutaneous flap anastomosed to the intraperitoneal gastro-
epiploic vessels. This is a single-stage reconstruction capable of reconstructing reliably a full-thickness
defect involving any region of the abdominal wall. The fascial component of the flap reconstructs the
abdominal wall with like tissue, and the cutaneous portion of the free TFL provides a durable and
aesthetically acceptable external cover. The intraperitoneal gastroepiploic artery and vein were the
first-choice recipient vessels used in three patients. These intraperitoneal recipient vessels allow unin-
terrupted fascial closure, restoring structural integrity to the abdominal wall, and allow the use of free
flaps with short vascular pedicles.
Coskunfirat OK, Ozkan O. Free tensor fascia lata perforator flap as a backup procedure for
head and neck reconstruction. Ann Plast Surg 57:159-163, 2006.
Free tissue transfer is an essential part of head and neck reconstruction. Despite several flap options,
free perforator flaps have become very popular for head and neck. The anterolateral thigh perforator
flap has multiple advantages among other options and is preferred by most reconstructive microsurgeons.
Despite its advantages, sometimes it is impossible to harvest an ALT perforator flap, and the surgeon
has to select another option. Between January 2002 and June 2005, five TFL perforator flaps were
used for head and neck reconstruction because an ALT perforator flap could not be elevated because of
the absence of or insufficient myocutaneous perforators. Only one flap was reexplored and salvaged by
redoing the venous anastomosis. All flaps survived with no other problems. Donor sites were covered
by split-thickness skin grafts in four patients and closed primarily in one. Doppler examination is
important in planning the ALT perforator; if the signals of the perforators are absent or very weak,
the surgeon can shift to another flap. This decision may also be made during the operation when
insufficient perforators are seen. The authors stated that the tensor fascia lata perforator flap is a safe
alternative when anterolateral thigh perforator harvest is not possible. The TFL perforator flap can
be harvested from the same anatomic region with almost the same morbidity.
Cotrufo S, Dabernig J. Vascular supply of the tensor fasciae latae flap revised. Plast Reconstr
Surg 123:161e-162e, 2009.
The aim of this short report about the main source of the tensor fascia lata flap (as a muscular, myocu-
taneous, or perforator flap) was to invite surgeons to exercise caution during the deep dissection of the
pedicle, because its vascular supply presents a higher variability than previously reported.
Dabernig J, Shilov B, Schumacher O, et al. Functional reconstruction of Achilles tendon defects
combined with overlaying skin defects using a free tensor fasciae latae flap. J Plast Reconstr
Aesthet Surg 59:142-147, 2006.
The authors presented their experience in functional reconstruction of the Achilles tendon with large
tissue defects after trauma and infection. To cover the skin defect and reconstruct the Achilles tendon,
they used the free TFL flap. From 1997 to 2003 six men, ranging from 22 to 71 years of age
(average 38.6 years), underwent this reconstructive procedure. All of them had sustained a traumatic
loss of the tendon and the overlying tissue. After initial debridement, the reconstruction with a TFL
free flap was performed. To achieve a strong distal fascia lata attachment to the calcaneal bone, the
authors developed a special method of fixation. After vertical osteotomy in the calcaneus, the distal
part of the fascia flap was introduced between the bone segments, which were fixed together with a
spongiosa screw. For functional outcome, it was important to fix the foot in a 90-degree position,
with tension on the vascularized fascia lata. The range of motion of the ankle of the reconstructed foot
showed 93.7% in comparison to the normal foot. No flap failure occurred in any of the six patients.

12f_TenFas_r6_cah_1506-1533.indd 1529 2/8/2012 3:33:52 PM

 1530 Part II  Regional Flaps: Anatomy and Basic Techniques

Simultaneous soft tissue and function restoration of the foot with TFL free flap is an optimal one-
stage reconstructive procedure.
de Vries Reilingh TS, Bodegom ME, van Goor H, et al. Autologous tissue repair of large
abdominal wall defects. Br J Surg 94:791-803, 2007.
The authors reviewed techniques for autologous repair of abdominal wall defects that could not be
closed primarily. Medline and PubMed were searched for English or German publications using the
following keywords: components separation technique (CST), Ramirez, da Silva, fascia lata, ten-
sor fascia lata, latissimus dorsi, rectus femoris, myocutaneous flap, (auto)dermal) graft, dermoplasty,
cutisplasty, hernia, abdominal wall defect, or combinations thereof. Publications were analyzed for
methodological quality, and data on surgical technique, mortality, morbidity and reherniation were
abstracted. The CST is the best documented procedure; it is associated with a high morbidity rate of
24% and a recurrence rate of 18.2%. Although the results of the da Silva technique are good (morbid-
ity 5% to 20% and reherniation 0% to 3%), the poor methodologic quality of the studies precludes
firm conclusions. Repair with free fascia lata or dermal grafts is an alternative if the above techniques
cannot be used, but wound complications affect 42% of patients and recurrent hernia up to 29%.
Pedicled or free vascularized flaps are reserved for complex situations.
Demirseren ME, Gökrem S, Ozdemir OM. Hatchet-shaped tensor fascia lata myocutaneous
flap for the coverage of trochanteric pressure sores: a new modification. Ann Plast Surg 51:419-
422, 2003.
The tensor fascia lata flap is one of the appropriate choices for the coverage of trochanteric pressure sores.
The authors designed a new hatched-shaped TFL myocutaneous flap with distal Z-plasty closure
and applied it to four trochanteric defects in four patients. Satisfactory results were obtained in all
patients. The hatchet-shaped TFL myocutaneous flap is very safe, reliable, and practical. Designing
the flap in a hatchet shape allows one to use the proximal and well-vascularized portion of the flap
in the trochanteric pressure sore area. Another important advantage is the possibility of reuse resulting
from recurrence. Prevention of a “dog-ear” deformity at the recipient site provides a smooth contour
on the lateral aspect of the thigh. Another advantage is the tension-free Z-plasty closure of the donor
site without the need for grafting.
Gosain AK, Yan JG, Aydin MA, et al. The vascular supply of the extended tensor fasciae latae
flap: how far can the skin paddle extend? Plast Reconstr Surg 110:1655-1661; discussion 1662-
1663, 2002.
The vascular supply of the tensor fascia lata flap and of the lateral thigh skin was studied in 10 cadav-
ers to evaluate whether the lateral thigh skin toward the knee could be incorporated into an extended
TFL flap. Within each cadaver, vascular injection of radiopaque material preceded flap elevation in
one limb and followed flap elevation in the contralateral limb. Flaps raised after vascular injection were
examined radiographically to evaluate the vascular anatomy of the lateral thigh skin independent of
flap elevation. On vascular injection into the profunda femoris, the upper two thirds of the flaps was
better visualized than the distal third. On injection into the popliteal artery, the vasculature of the
distal third of the flaps was better visualized. Flaps raised before vascular injection were examined
radiographically to delineate the anatomical territory of the vascular pedicle that had been injected. In
these flaps, consistent cutaneous vascular supply was seen only in the skin overlying the TFL muscle,
confirming that myocutaneous perforators are the predominant means by which the pedicle of the TFL
flap supplies the skin of the lateral thigh. Extended TFL flaps were elevated bilaterally in one cadaver,
and selective methylene blue injections were made into the lateral circumflex femoral artery on one side
and into the superior lateral genicular artery on the contralateral side. Methylene blue was observed
in the proximal and distal thirds of the skin paddles, respectively, leaving unstained midzones. The
vascular network of the lateral thigh skin could be divided into three zones. The lateral circumflex
femoral artery and the third perforating branches of the profunda femoris artery perfuse the proximal
and middle zones of the lateral thigh skin, respectively. The superior lateral genicular artery branch
of the popliteal artery perfuses the distal zone. The middle and distal zones meet 8 to 10 cm above

12f_TenFas_r6_cah_1506-1533.indd 1530 2/8/2012 3:33:53 PM

 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1531

the knee joint, where the skin paddle of the TFL flap becomes unreliable. These data indicate that
if the aim is to incorporate the skin over the distal thigh in an extended TFL flap without resorting
to free tissue transfer, then either a carefully planned delay procedure or an additional anastomosis to
the superior lateral genicular artery is required.
Hayami S, Hotta T, Takifuji K, et al. Reconstruction of an infected recurrent ventral hernia
after a mesh repair using a pedicled tensor fascia lata flap: report of two cases. Surg Today
39:811-817, 2009.
The use of prosthetic mesh has revolutionized the repair of ventral hernias; however, the occurrence of
infection related to its use remains a notable complication that may result in fistula formation of the
skin or intestine, sepsis, or recurrence of ventral hernia. The authors presented two cases in which the
pedicled TFL flap was effective as a treatment for infected large abdominal hernias. Two men aged
61 and 78 years old underwent a ventral hernia repair using Composix Kugel mesh. They both
developed a wound infection with methicillin-resistant Staphylococcus aureus. Conservative therapy
was not successful, and the defect in the abdominal wall of the two patients measured 12 by 21 cm
and 7 by 10 cm in length, respectively. Reoperations were performed to remove the infected mesh and
reconstruct the abdominal wall with a bilateral and a left-side pedicled TFL flap, respectively. No
recurrence of the ventral hernia has been seen in 50 months and 7 months of follow-up. A review
of previous studies showed that no patients treated with a pedicled TFL flap experienced a recurrent
hernia. Therefore the pedicled TFL flap was considered to be effective for infected large abdominal
recurrent hernia.
Hubmer MG, Schwaiger N, Windisch G, et al. The vascular anatomy of the tensor fasciae latae
perforator flap. Plast Reconstr Surg 124:181-189, 2009.
The authors conducted a study to differentiate between myocutaneous and septocutaneous perforators
of the tensor fascia lata perforator flap; to evaluate their number, size, and location; and to provide
landmarks to facilitate flap dissection. An additional injection study estimated the skin area of the
flap. The anatomic study was performed on 23 fixed and injected cadavers. The injection study was
performed on 10 fresh cadavers. On one side, the ascending branch of the lateral circumflex femoral
artery was injected with methylene blue; on the other side, the septocutaneous perforators were injected
selectively. The size, location, and borders of the stained skin were measured in both studies. Forty-
five thighs were included in the study. All perforators emerged from the ascending branch of the lateral
circumflex artery. The average number of myocutaneous perforators was 2.3 (range 0 to 5), the distance
from the anterior superior iliac spine was 10.9 cm (range 4.5 to 16.1 cm), and the diameter was 0.9
mm (range 0.2 to 2 mm). Four specimens had no myocutaneous perforator. The average number of
septocutaneous perforators was 1.8 (range 1 to 3), the distance from the anterior superior iliac spine
was 10.9 cm (range 6.2 to 15.7 cm), and the diameter was 1.5 mm (range 0.5 to 3 mm). Seventy-
six percent of the septocutaneous perforators emerged between 8 and 12 cm from the anterior superior
iliac spine. The possible pedicle length of a flap based on these vessels was 8.1 cm (range 6.5 to 10
cm). In the injection study, the average skin area stained with methylene blue was 19.4 by 13.4 cm
(range 10 to 24 cm by 7 to 17 cm) in the ascending branch group. In the perforator group, the average
skin area was 19.2 by 13.7 cm (range 15 to 22 cm by 12 to 16 cm).
Jósvay J, Sashegyi M, Kelemen P, et al. Modified tensor fascia lata musculofasciocutaneous flap
for the coverage of trochanteric pressure sores. J Plast Reconstr Aesthet Surg 59:137-141, 2006.
The method most frequently used for the coverage of trochanteric pressure sores is the TFL flap. The
authors described a hatchet-shaped incision strategy for the TFL flap, which preserves the safe blood
supply of the flap and keeps the flap mobile enough. The part of the flap including the muscle is
adapted to the greater trochanter. This provides a good aesthetic result without dog-ear formation at
the rotation point of the flap. The donor site is closed in V-Y fashion; the closure does not require any
skin grafting or designing a local flap. The TFL hatchet flap was used nine times on eight patients to
cover trochanteric pressure sores. With one exception all patients healed. No recurrence was observed
during the follow-up period, and no contour difference developed on the lateral aspect of the thigh.

12f_TenFas_r6_cah_1506-1533.indd 1531 2/8/2012 3:33:53 PM

 1532 Part II  Regional Flaps: Anatomy and Basic Techniques

Kimura N. A microdissected thin tensor fasciae latae perforator flap. Plast Reconstr Surg 109:69-
77; discussion 78-80, 2002.
A new method, called “microdissection,” has been introduced to create a thin flap by elevating the ten-
sor fascia lata perforator flap to serve as a microdissected thin TFL perforator flap. In microdissection,
perforators that run in the posterolateral direction in the adipose tissue after penetrating the deep fascia
are dissected meticulously using an operative microscope, and a thin flap is elevated in a single process.
The caliber of the perforator artery and vein in the TFL muscle measures approximately 0.7 mm and
0.9 mm, respectively. When transplanting the flap, an end-to-side anastomosis to the main artery
measuring 1 to 2 mm is preferable to avoid the risk of arterial thrombosis. In contrast, an end-to-end
anastomosis of the perforator vein to the comitans vein of the main artery can be performed safely. In
this study, 11 flaps were transplanted to the sites of skin defects of the neck, hand, axilla, knee, and
foot. The author stated that the first clinical indication of this flap is reconstruction of hand skin defects.
Kobayashi MR, Brenner KA, Gupta R, et al. Functional biceps brachii reconstruction using
the free tensor fasciae latae. Plast Reconstr Surg 114:1208-1214, 2004.
Koshima I, Urushibara K, Inagawa K, et al. Free tensor fasciae latae perforator flap for the
reconstruction of defects in the extremities. Plast Reconstr Surg 107:1759-1765, 2001.
In the three cases presented in this study, free TFL perforator flaps were used successfully for the
coverage of defects in the extremities. This flap has no muscle component and is nourished by muscle
perforators of the transverse branch of the lateral circumflex femoral system. The area of skin that can
be nourished by these perforators is larger than 15 by 12 cm. The advantages of this flap include
minimal donor site morbidity, preservation of motor function of the TFL muscle and fascia lata, the
ability to thin the flap by removing excess fatty tissue, and a donor scar that can be concealed. In cases
that involve transection of the perforator above the deep fascia, the operation can be completed in a very
short period of time. This flap is especially suitable as a free flap for young women and children who
have scars in the proximal region of the lateral thigh or groin region that were caused by split-thickness
skin grafting or full-thickness skin grafting during previous operations.
Lin CH, Wei FC, Lin YT, et al. Lateral circumflex femoral artery system: warehouse for func-
tional composite free-tissue reconstruction of the lower leg. J Trauma 60:1032-1036, 2006.
Microsurgical free flap surgery has progressed from simply providing wound coverage to restoring a
high level of function. The concepts and practice of using compound, composite, and chimeric flaps
have recently further enhanced the versatility of free flaps in reconstructive surgery. A lateral circumflex
femoral arterial (LCFA) system can provide a potential single composite free tissue transfer for restora-
tion of functional and structural integrity. Between 1997 and 2003, the authors used 44 free flaps
to restore functional and structural defects in the lower limbs. The versatility of the LCFA system
allowed utilization of the anterolateral thigh, vastus lateralis, tensor fascia lata, rectus femoris, and
iliac crest. Combinations of tissues from this system were employed to restore defects in the patellar
tendon (14), Achilles tendon (13), extensor hallucis tendon (2), anterior compartment with/without
lateral compartment muscle (11), anterior compartment muscle and segmental tibial bone (3), and
composite calcaneus (1). The free flap success rate was 97.7%. Four reexplorations were performed,
with one subsequent failure. Eight patients developed wound infections, of which two required second-
ary amputations, resulting in a limb salvage rate of 95.4%.
Lin MT, Chang KP, Lin SD, et al. Tensor fasciae latae combined with tangentially split vastus
lateralis musculocutaneous flap for the reconstruction of pressure sores. Ann Plast Surg 53:343-
347, 2004.
Pressure sores in the ischial and the trochanteric regions are usually encountered in long-term bedridden
and wheelchair-dependent patients. A number of techniques have been developed for the reconstruction
of pressure sores. The tensor fascia lata myocutaneous flap has been extensively employed to close the
trochanteric defect. Despite the utility of its having a constant pedicle and proximal bulky muscle, the
relative shortness of the flap and insufficient padding in the distal portion limit the applications for
distant locations of pressure sores. From January 2001 to December 2003, eight patients with ischial

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 Thigh  •  12F: Tensor Fascia Lata (TFL) Flap 1533

and trochanteric pressure sores underwent TFL flap reconstruction in combination with a tangentially
split vastus lateralis muscle. The descending branches of the lateral circumflex femoral arteries were
also included in these flaps. All of the procedures have been successful, and no flap necrosis has been
observed. Sufficient bulk of the flap and reliable distal skin paddle constitute the advantages of this flap.
Windhofer C, Karlbauer A, Papp C. Bone, tendon, and soft tissue reconstruction in one stage
with the composite tensor fascia lata flap. Ann Plast Surg 62:665-668, 2009.
A 46-year-old patient sustained a dia-infracondylar tibial fracture from a ski accident. Open reduction
and internal fixation (ORIF) was carried out. After an initially uneventful postoperative course the
patient was readmitted because of local and systemic infection signs. Radical surgical debridement was
carried out followed by VAC therapy. The resulting defect consisted of bone defect of the tibia tuberosity,
and complete loss of the patellar tendon and the overlying soft tissue. Reconstruction was carried out
with a combined TFL flap including the TFL muscle with the iliotibial tract, the vascularized part
of the iliac crest, and the overlying soft tissue. Bone healing took place without signs of osteomyelitis
recurrence, and full weight-bearing was possible 4 months after reconstruction. Successful reconstruction
of the patellar tendon using the iliotibial tract enables the patient to have full active knee joint motion.
The soft tissue coverage was stable. The donor site showed inconspicuous healing without pain and
normal range of motion of the hip joint. This composite TFL flap is an interesting flap not only for
defects following trauma, but also for combined defects following extensive infections after knee implants.

12f_TenFas_r6_cah_1506-1533.indd 1533 2/8/2012 3:33:53 PM

 ANATOMIC LANDMARKS
Landmarks Largest of the quadriceps group of muscles, the vastus lateralis
occupies two thirds of the surface area of the lateral thigh. It
extends from the proximal femur to the patella between the
vastus intermedius and biceps femoris muscles and beneath the
tensor fascia lata.
Size 10 3 26 cm.
Origin Intertrochanteric line, greater trochanter, gluteal tuberosity, and
lateral intermuscular septum.
Insertion Superior patella.
Function It is a strong leg extensor muscle.
Composition Muscle.
Flap Type Type I.
Dominant Pedicle Descending branch of the lateral circumflex femoral artery.
Minor Pedicles Transverse branch of the lateral circumflex femoral artery; pos-
terior branches from the profunda femoris artery; superficial
branch of the lateral superior genicular artery.
Nerve Supply Motor: Muscular branch of the femoral nerve.

12g_VastLat_r4_cah_1534-1551.indd 1534 2/7/2012 5:18:13 PM

 Section 12G
Thigh

Vastus Lateralis Flap

CLINICAL APPLICATIONS
Regional Use
Groin
Perineum
Trochanter
Ischium
Knee
Abdomen
Distant Use
Head and neck
Upper extremity
Lower extremity
Specialized Use
Hip defects

12g_VastLat_r4_cah_1534-1551.indd 1535 2/7/2012 5:18:16 PM

 ANATOMY OF THE VastUS Lateralis Flap

A B
Profunda
femoris artery
Profunda
femoris artery Lateral circumflex
femoral artery Femoral nerve
Lateral circumflex Femoral
femoral artery artery Ascending branch Femoral artery
Ascending branch Transverse branch
Superficial Superficial
of lateral circumflex femoral artery
Transverse branch femoral artery femoral artery
of lateral circumflex
femoral artery Descending branch
of lateral circumflex
Descending branch
femoral artery
of lateral circumflex
femoral artery Muscular branch
of femoral nerve
Vastus lateralis
muscle Vastus lateralis
muscle
Lateral superior
Lateral superior genicular artery
genicular artery

Vascular anatomy Vascular anatomy with

surrounding musculature
C

Femoral nerve

Muscular branch
of femoral nerve

Vastus lateralis
muscle

Nerve distribution

Fig. 12G-1

Dominant pedicle: Descending branch of lateral circumflex femoral artery

Minor pedicles: Transverse branch of lateral circumflex femoral artery; posterior branches
from profunda femoris artery; superficial branch of lateral superior genicular artery

12g_VastLat_r4_cah_1534-1551.indd 1536 2/7/2012 5:18:17 PM

 Thigh  •  12G: Vastus Lateralis Flap 1537

ANATOMY
Landmarks The vastus lateralis muscle occupies two thirds of the surface area of the lateral
thigh. It is bisected by the iliotibial tract on its surface. The muscle extends from
the proximal femur to the patella. It is located between the vastus intermedius
and biceps femoris muscles and lies beneath the fascia lata.
Composition Muscle. When skin is required, this flap can be carried in combination with the
skin of the anterolateral thigh (ALT) or the skin of the tensor fascia lata (TFL)
flap.
Size 10 3 26 cm.
Origin Anteriorly, the vastus lateralis originates from the greater trochanter and the
intertrochanteric line. Posteriorly, it originates from the intermuscular septum
and the gluteal tuberosity.
Insertion Inserts into the patella with the tendon of the rectus femoris.
Function A strong leg extensor as well as a lateral knee stabilizer. Its function is expendable
if the rectus femoris and tensor muscles are intact.

Arterial Anatomy (Type I)

Dominant Pedicle  Descending branch of the lateral circumflex femoral artery
Regional Source  Profunda femoris artery.
Length  4 cm.
Diameter  1.5 mm.
Location  Superior third of the muscle, extending along the medial border of the muscle.
Minor Pedicle  Transverse branch of the lateral circumflex femoral artery
Regional Source  Profunda femoris artery.
Length  3 cm.
Diameter  1 mm.
Location  Transverse branch of the lateral circumflex femoral artery enters the muscle in the
superior fourth of the muscle from its posterior surface.
Minor Pedicle  Posterior branches from the profunda femoris artery
Regional Source  Profunda femoris artery.
Length  1 to 2 cm.
Diameter  0.4 mm.
Location  Inferior half of the muscle at the lateral intermuscular septum.
Minor Pedicle  Superficial branch of the lateral superior genicular artery
Regional Source  Popliteal artery.
Length  3 cm.
Diameter  0.5 mm.
Location  Superficial branch of this pedicle supplies the distal muscle from the area of the lateral
condyle of the knee.

Venous Anatomy
Venae comitantes accompany the dominant pedicle and minor pedicles. Both the descending and
transverse branches of the lateral circumflex femoral vein empty into the lateral circumflex femoral
vein, which has a diameter of 2.5 mm as it joins the femoral vein. The superficial branch of the
lateral superior genicular vein drains into the popliteal vein.

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 1538 Part II  Regional Flaps: Anatomy and Basic Techniques

Nerve Supply
Motor Muscular branch of the femoral nerve. The motor nerve enters the proximal
muscle at the medial border inferior and adjacent to the lateral circumflex femoral
vessels.

Vascular A natomy of the Vastus Lateralis Flap

A

m3 m2 m2
D
m1

Closeup view of major and minor pedicles supplying flap

B C

m1
m1

D D

m2 m2

Deep surface of flap Radiographic view

Fig. 12G-2 
Dominant pedicle: Descending branch of lateral circumflex femoral artery (D)
Minor pedicles: Transverse branch of lateral circumflex femoral artery (m1); posterior
branches from profunda femoris artery (m2); superficial branch of lateral superior genicular
artery (m3)

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 Thigh  •  12G: Vastus Lateralis Flap 1539

FLAP HARVEST
Design and Markings
For muscle harvest, an incision is made directly overlying the vastus lateralis muscle on a
line from the greater trochanter to the lateral patella.

Marking for incision for muscle flap elevation

Fig. 12G-3 

Patient Positioning
The patient is placed in the supine or lateral decubitus position.

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 1540 Part II  Regional Flaps: Anatomy and Basic Techniques

GUIDE TO FLAP DISSECTION

The skin incision is deepened through the fascia lata, which will include the medial edge
of the tensor fascia lata muscle proximally and the iliotibial tract distally. The rectus femoris
muscle is then retracted medially to expose the vastus lateralis muscle.

A Transverse branch of
lateral circumflex femoral artery
Tensor fascia lata muscle
Vastus lateralis muscle
Descending branch of
lateral circumflex femoral artery

Vastus intermedius muscle

Rectus femoris muscle

Vastus lateralis muscle

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.

Posteriorly, the lateral margin of the muscle is formed by the lateral intermuscular sep-
tum. The muscle fibers of insertion are then divided and the muscle is elevated from distal
to proximal. Contributions from the superior lateral genicular artery and vein are ligated.

B
Tensor fascia lata muscle

Descending branch of
lateral circumflex femoral artery
Vastus intermedius muscle
Rectus femoris muscle

Deep muscular perforating arteries

Vastus lateralis 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.

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 Thigh  •  12G: Vastus Lateralis Flap 1541

During elevation, care is taken to visualize and preserve the descending branch of the
lateral circumflex femoral vessels that enter the medial aspect of the vastus lateralis.

Vastus lateralis muscle

Descending branch of
lateral circumflex femoral artery
Rectus femoris muscle

Vastus intermedius muscle

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.

The muscle is elevated to the level of the greater trochanter. Separation from the vastus
intermedius is required, because the border is often indistinct and must be arbitrarily de-
termined. The flap can be used for transposition at this point, or the origin can be divided,
giving further mobility to the flap.

FLAP VARIANTS
•  Vastus lateralis combined with ALT flap (see Section 12A)
•  Vastus lateralis combined with TFL flap (see Section 12F)
•  Distally based flap

Distally Based Flap

The distal part of the muscle can be elevated based on its minor pedicle, the superior lateral
genicular artery, and veins that enter the distal posterior muscle belly. After the muscle is
exposed between the greater trochanter and the lateral condyle of the femur, the muscle is
separated from the vastus intermedius medially and the biceps femoris posterior laterally.
After deciding the amount of muscle needed for reconstruction, the muscle is divided and
elevated from proximal to distal. Skeletonization of the pedicle is not recommended; rather,
a few centimeters of muscle attachment should be maintained superior to the lateral condyle
of the femur. The entire muscle cannot be elevated on this pedicle.

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 1542 Part II  Regional Flaps: Anatomy and Basic Techniques

ARC OF ROTATION
Standard Flap
The standard flap can reach the trochanter, ischium, acetabular fossa, groin, perineum,
lower abdomen, and posterior iliac crest. The distally based flap can be rotated to the knee.

A B C

Arc to anterior trunk Arc to posterior trunk Arc to knee

Fig. 12G-5 

FLAP TRANSFER
The flap is transposed directly into the defect to be reconstructed or passed through a tun-
nel. If there has been previous groin dissection and irradiation, this may not be possible,
and the contralateral flap or another flap should be chosen.

FLAP INSET
The fascial component of the flap should be used to advantage and sutured into the bed at
the recipient site. There should be no tension on the pedicle or any areas of compression.

DONOR SITE CLOSURE

Primary closure of the skin should be obtainable, because skin is not taken with the flap.
When taken as part of the ALT or TFL flaps, closure should be guided by principles of
these flaps.

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 Thigh  •  12G: Vastus Lateralis Flap 1543

CLINICAL APPLICATIONS
This 72-year old woman had recurrent squamous cell carcinoma of her scalp. A free vastus
lateralis muscle flap was utilized to reconstruct the defect.

B Fascia lata (divided) Vastus intermedius fascia

C

VL

D E

Fig. 12G-6  A, The defect measured 10 by 12 cm. B and C, A vastus lateralis (VL) muscle flap measur-
ing 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 postopera-
tively. (Case courtesy Peirong Yu, MD.)

12g_VastLat_r4_cah_1534-1551.indd 1543 2/7/2012 5:18:26 PM

 1544 Part II  Regional Flaps: Anatomy and Basic Techniques

This 75-year old man presented with recurrent cancer in the pelvis. He had undergone
chemoradiation and abdominoperineal resection for a rectal cancer.

A B

C D

E F

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 me-
tastasis 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. (Case courtesy Peirong Yu, MD.)

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 Thigh  •  12G: Vastus Lateralis Flap 1545

Pearls and Pitfalls

• With the adjacent thigh muscles intact (TFL, rectus femoris), the vastus lateralis muscle
is expendable, and few functional deficits result from its harvest.
• This flap can deliver a large volume of muscle for deep defects of the hip, femur, and groin.
• The flap shares the advantages of the ALT for free tissue transfer with a long pedicle
with good proximal vessel diameter, but it is easier to dissect, because no intramuscular
dissection is required.
• The vastus lateralis muscle flap is seldom used for abdominal wall reconstruction, because
it is quite difficult to elevate, and other flaps such as the rectus femoris or TFL offer more
fascia.
• The donor site is subject to prolonged drainage; drains should be left in place until the
discharge subsides.
• If not required for reconstruction, it is prudent to leave the distal third of the muscle
intact. This avoids the bloody and imprecise dissection of the vastus lateralis where it is
fused with the vastus intermedius and biceps femoris muscles.

Expert Commentary
Peirong Yu

Indications
In addition to the indications described in the chapter, I have used this flap for reconstruction
of pelvic exenteration defects to provide volume, for scalp reconstruction, and for other areas
when a muscle is needed.

Flap Selection
The advantages of the vastus lateralis muscle flap include low donor site morbidity and main-
taining the patient in one position. It competes with the commonly used latissimus dorsi and
rectus femoris muscle flaps. Compared with the latissimus dorsi muscle, the vastus lateralis
muscle is smaller. Therefore the size of the defect should be carefully evaluated before consider-
ing the vastus lateralis muscle. If the patient is already in a lateral position, the latissimus dorsi
flap is the first choice. If the patient is in the supine position and the defect is small enough to
be covered by the vastus lateralis muscle, then this muscle would be my first choice to avoid
a position change and repreparation.
The vastus lateralis muscle is larger than the rectus femoris muscle. In most cases, either
flap is fine. However, in patients with limited pulmonary reserve (for example, patients with
COPD), avoiding an abdominal incision required for harvesting the rectus abdominis muscle
flap may be important. On the other hand, in young and athletic patients, especially run-
ners, sacrificing the vastus lateralis muscle may cause symptomatic weakness in the leg. The
gracilis muscle is much smaller than the vastus lateralis muscle and, therefore, not suitable for
larger defects.
Continued

12g_VastLat_r4_cah_1534-1551.indd 1545 2/7/2012 5:18:31 PM

 1546 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Dissection
My preferred approach to harvest the vastus lateralis muscle flap is the anterior approach. With
the patient in the supine position, a line is drawn to connect the anterior superior iliac spine and
the supralateral corner of the patella, as for an ALT flap harvest. An incision is made directly
on this line and carried down to the deep fascia. Once the fascia is opened, the intermuscular
space between the vastus lateralis muscle and the rectus femoris muscle should be in view.
This intermuscular space is entered, and the vascular pedicle to the vastus lateralis muscle, the
descending branch, is visualized (Fig. 12G-8). Next, the descending branch is dissected off
the vastus intermedius fascia, starting from its medial edge. Once the blood vessels are off the
fascia, the vastus lateralis muscle can be quickly detached from the vastus intermedius fascia
in a medial to lateral direction (Fig. 12G-9).

Descending branch Vastus lateralis

Fig. 12G-8 

Fascia lata (divided) Vastus intermedius fascia

VL

Fig. 12G-9 

Donor Site Morbidity

The donor site morbidity of the vastus lateralis muscle has not been extensively studied. In
our study with the ALT flap, we have found that fewer than 10% of the patients complained
of leg weakness when less than half of the vastus lateralis muscle was harvested. When the
entire vastus lateralis muscle was harvested, 25% of the patients complained of leg weakness,
which typically lasted 3 to 6 months. Other complaints included difficulties climbing stairs,
occasional instability of the knee joint, and seroma formation. When this flap is used for pel-
vic reconstruction after pelvic exenteration, patients are usually overwhelmed by the major
abdominal surgery, and the leg donor site is unnoticed.

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 Thigh  •  12G: Vastus Lateralis Flap 1547

Bibliography With Key Annotations

Auregan JC, Bégué T, Tomeno B, et al. Distally-based vastus lateralis muscle flap: a salvage
alternative to address complex soft tissue defects around the knee. Orthop Traumatol Surg Res
96:180-184, 2010.
Distally based vastus lateralis muscle flaps can be performed as a salvage procedure for repeated soft
tissue defects around the knee. An advantage of this flap is that it does not require microsurgical
anastomosis. The authors presented four cases of knee reconstruction with this flap. Three were in the
setting of total knee arthroplasty revision, and one was performed after a posttraumatic knee amputa-
tion. Skin closure was achieved in all cases, although distal marginal necrosis occurred in two. Final
joint mobility was consistently poor. Details of the technique were described.
Camporro D, Fueyo A, Martín C, et al. Use of lateral circumflex femoral artery system free
flaps in skull base reconstruction. J Craniofac Surg 22:888-893, 2011.
Lateral circumflex femoral artery (LCFA) system flaps are effective for skull base reconstruction,
because they provide flap design versatility, adequate tissues to fill dead space, vascularized fascia to
augment dural repairs, and a very long pedicle. The authors reviewed results of 20 LCFA system
free flaps for cranial base reconstruction performed at a tertiary center. The defects resulted either from
resections of primary or recurrent neoplasms or from secondary problems after cranial base surgery.
The types of flap transferred were: combinations of anterolateral/anteromedial thigh flaps with vastus
lateralis muscle or TFL flaps (8); anterolateral fasciocutaneous flaps (6), and muscle/myocutaneous
flaps (6). Nineteen of 20 flaps were successful. One patient died postoperatively, and one patient had
a myocardial infarction. Minor complications included partial flap loss (1), temporal CSF leaks (2),
two donor site hematomas, minor wound breakdowns (2), facial nerve weakness (3), and donor site
numbness (4). One patient had local recurrence and underwent successful ablative surgery, followed
by a forearm free flap.
Casey WJ III, Rebecca AM, Smith AA, et al. Vastus lateralis motor nerve can adversely affect
anterolateral thigh flap harvest. Plast Reconstr Surg 120:196-201, 2007.
To better understand how the anatomy of the vastus lateralis motor nerve affects ALT flap harvest,
the authors reviewed 43 ALT flap procedures. In three cases, the course of the motor nerve to the
muscle significantly modified the flap harvest. In one case, the motor nerve passed between the ve-
nae comitantes of the descending branch of the lateral femoral circumflex artery, just proximal to the
midperforator origin. In two cases, large skin islands were raised with two perforators included in each
flap. The motor nerve passed between the two perforators in these cases. The authors concluded that
two patterns of nerve anatomy could negatively affect ALT flap elevation. In one pattern, the nerve
passes through the main vascular pedicle. In the other pattern, the motor nerve passes between the
multiple perforators required for large flaps.
Cavadas PC, Sanz-Jiménez-Rico JR. Use of the extended-pedicle vastus lateralis free flap for
lower extremity reconstruction. Plast Reconstr Surg 115:1070-1076, 2005.
In a series of 12 patient, the authors demonstrated the utility of the extended-pedicle free vastus
lateralis muscle flap for lower extremity soft tissue reconstruction. This flap has a long pedicle with a
large caliber, low donor site morbidity, and versatile shape and volume. They included a segment of
the distalmost part of the muscle, distal to the entry point of the motor nerve to the vastus lateralis,
based on the descending branch of the lateral femoral circumflex vessels. The vascular pedicle was 20
cm or less, with a large caliber. All flaps were successful.
Chana JS, Chen HC, Sharma R, et al. Use of the free vastus lateralis flap in skull base recon-
struction. Plast Reconstr Surg 111:568-574; discussion 575, 2003.
The authors reconstructed cranial base defects in seven patients using a free vastus lateralis muscle
flap. In two cases, a vastus lateralis flap incorporated the ALT skin as a myocutaneous flap. In four
cases, a free flap was indicated after tumor ablation. In three cases, a free flap was indicated for wound
complications or CSF leakage following cranial base surgery. All flaps were successful. The indications
and advantages of this flap were discussed.

12g_VastLat_r4_cah_1534-1551.indd 1547 2/7/2012 5:18:32 PM

 1548 Part II  Regional Flaps: Anatomy and Basic Techniques

Chang SH, Chiu TJ, Tung KY, et al. Treatment of posterior thigh radiation ulcer by a simple
and easy technique of transferring island pedicled vastus lateralis muscle flap. J Plast Reconstr
Aesthet Surg 62:e665-e666, 2009.
Choa R, Gundle R, Critchley P, et al. Successful management of recalcitrant infection related
to total hip replacement using pedicled rectus femoris or vastus lateralis muscle flaps. J Bone
Joint Surg Br 93:751-754, 2011.
To demonstrate the effectiveness of pedicled muscle flaps for treating recalcitrant joint infections after
total hip replacement, the authors treated 24 patients with either a pedicled rectus femoris or a vastus
lateralis muscle flap. The mean patient age was 67.4 years. The mean number of attempts to close
the wound was four. Twenty rectus femoris and five vastus lateralis flaps were used. One of each type
failed, requiring revision. At 47 months (mean follow-up), 22 patients had a healed wound, and
2 had a persistent sinus. The prosthesis had been retained in 5 patients. It had been removed in all
others and subsequently reimplanted in 9 patients. At the final follow-up, 6 patients were still taking
antibiotics. Because of the numerous previous debridements, the authors recommended transferring
these flaps earlier.
Huang KC, Peng KT, Li YY, et al. Modified vastus lateralis flap in treating a difficult hip infec-
tion. J Trauma 59:665-671, 2005.
This article focused on the authors’ attempt to treat 10 patients who had challenging infections in the
hip area using a modified vastus lateralis flap transposition. The flap was chosen for its simple design
and ability to provide soft tissue coverage and dead space filler. All patients had had repeated failed
operations, including debridement, implantation of antibiotic-loaded cement spacers, and fasciocutane-
ous flap transposition. The flaps were performed immediately after radical debridement. The average
follow-up period was 17.4 months. All flaps were successful, and all wounds healed uneventfully.
No further procedures were indicated. Within 1 month, C-reactive protein returned to a near-normal,
stable level.
Lee JT, Cheng LF, Lin CM, et al. A new technique of transferring island pedicled anterolateral
thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure
sores. J Plast Reconstr Aesthet Surg 60:1060-1066, 2007.
The authors described treating 15 patients with recurrent ischial pressure sores using island pedicled
ALT and vastus lateralis myocutaneous flaps, transferred directly through the upper thigh to the ischial
defect. A total of 16 wounds were treated: 11 with pedicled island ALT flaps and five with vastus
lateralis myocutaneous flaps. The pedicle length ranged from 8.5 to 14 cm, and all transferred easily.
All donor sites were closed primarily. Fifteen of the 16 flaps survived completely. One vastus lateralis
myocutaneous flap underwent total necrosis.
Lin CH, Wei FC, Lin YT, et al. Lateral circumflex femoral artery system: warehouse for func-
tional composite free-tissue reconstruction of the lower leg. J Trauma 60:1032-1036, 2006.
Microsurgical free-flap surgery has progressed from simply providing wound coverage to restoring a
high level of function. More recently, the concepts and practice of using compound, composite, and
chimeric flaps have further enhanced the versatility of free flaps in reconstructive surgery. The authors
share their experience transferring 44 LCFA system free flaps to restore structural and functional
deficits caused by lower limb defects. Because of the versatility of the LCFA system, the ALT, vastus
lateralis, TFL, rectus femoris, and iliac crest were incorporated to provide various tissue combinations.
The following defects were treated: the patellar tendon (14), Achilles’ tendon (13), extensor hallucis
tendon (2), anterior compartment with/without lateral compartment muscle (11), anterior compart-
ment muscle and segmental tibial bone (3), and composite calcaneus (1). The success rate was 97.7%.
Four flaps required reexploration and one failed. Wound infections developed in eight patients; two
required amputation.
Lin MT, Chang KP, Lin SD, et al. Tensor fasciae latae combined with tangentially split vastus
lateralis musculocutaneous flap for the reconstruction of pressure sores. Ann Plast Surg 53:343-
347, 2004.
Limitations of the TFL myocutaneous flap for closing trochanteric pressure sores include its relative
shortness and insufficient padding in the distal portion. To overcome these shortcomings, the authors

12g_VastLat_r4_cah_1534-1551.indd 1548 2/7/2012 5:18:33 PM

 Thigh  •  12G: Vastus Lateralis Flap 1549

reconstructed ischial and trochanteric pressure sores in eight patients using TFL combined with tan-
gentially split vastus lateralis muscle. They included the descending branches of the lateral circumflex
femoral arteries. All of the procedures were successful, and no flap necrosis occurred.
Lin SJ, Butler CE. Subtotal thigh flap and bioprosthetic mesh reconstruction for large, composite
abdominal wall defects. Plast Reconstr Surg 125:1146-1156, 2010.
The authors studied results in seven patients having large, composite abdominal wall defects treated
with bioprosthetic mesh and free or pedicled subtotal thigh flap. Eight subtotal thigh flaps (five pedicled
and three free flaps with vein grafts to the femoral vessels) were reviewed. Indications for reconstruction
were tumor resection, enterocutaneous fistula, and abdominal wall osteoradionecrosis. Six patients
had had preoperative radiation therapy. The myofascial defect was repaired with 536.4 cm2 (mean) of
bioprosthetic mesh. The size of the subtotal thigh flap skin paddle was 514 cm2 (mean). The mean
follow-up was 27.7 months. Complications included partial flap necrosis in (one), a CSF leak (one),
partial split-thickness skin graft loss (two), a focal asymptomatic myofascial bulge at the surgical site
(one), and a hernia not requiring surgery (one). Bioprosthetic mesh infection, wound dehiscence, bowel
obstruction, and seroma did not occur.
Maercks RA, Runyan CM, Jones DC, et al. The vastus intermedius periosteal (VIP) flap: a
novel flap for osteoinduction. J Reconstr Microsurg 26:335-340, 2010.
The authors performed an anatomic study to confirm the vascular supply of the vastus intermedius
periosteal flap, a large periosteal free flap. They isolated the descending branch of the lateral femoral
circumflex vessels in 11 human cadavers, preserving perforators to the vastus intermedius muscle. A
cuff of vastus intermedius and approximately 75% of the circumference of the femoral periosteum were
harvested from 6 cm proximal to the knee to 8 cm distal to the greater trochanter. The pedicle length
and periosteal dimensions were measured. The pedicle arteries were injected with radiopaque dye and
radiographed. A myoperiosteal flap was elevated with visible descending perforators in each case. The
mean flap surface area was 128 cm2, and the average pedicle length was 8 cm.
Necmioglu S, Askar I, Lök V, et al. Use of the vastus lateralis muscle flap with a grooving
procedure in the surgical treatment of chronic osteomyelitis of the femur. Ann Plast Surg
53:570-576, 2004.
The authors presented a new procedure—the vastus lateralis muscle flap with grooving of the femoral
shaft—for treating chronic osteomyelitis of the femoral shaft. They discussed their experience using
this flap in 6 patients. All cases were successful at the 3.9-year follow-up.
Nelson JA, Kim EM, Serletti JM, et al. A novel technique for lower extremity limb salvage:
the vastus lateralis muscle flap with concurrent use of the vacuum-assisted closure device.
J Reconstr Microsurg 26:427-431, 2010.
The authors reported a method of free vastus lateralis muscle flap transfer for lower limb reconstruction
that uses a vacuum-assisted closure (VAC) device to reduce edema and congestion. Fourteen flaps
were performed in 13 patients. Complications included one flap failure, one superficial abscess, and
one donor site hematoma. All patients were ambulatory at 6 months.
Nelson JA, Serletti JM, Wu LC. The vastus lateralis muscle flap in head and neck reconstruc-
tion: an alternative flap for soft tissue defects. Ann Plast Surg 64:28-30, 2010.
The vastus lateralis muscle free flap is a good choice for treating soft tissue defects of the head and
neck because of its consistent anatomy, large-caliber pedicle, and low donor site morbidity. A two-
team approach is possible. The authors performed a vastus lateralis muscle free flap procedure in five
patients following head and neck tumor extirpation. All flaps survived. There were no recipient or
donor site complications.
Polykandriotis E, Stangl R, Hennig HH, et al. The composite vastus medialis-patellar complex
osseomuscular flap as a salvage procedure after complex trauma of the knee: an anatomical
study and clinical application. Br J Plast Surg 58:646-651, 2005.
To better understand the applicability of the composite vastus medialis–patellar complex osseomuscular
flap for primary knee fusion, the authors studied 12 formalin-fixated cadavers. They reported data
on vascular anatomy, pedicle reliability, arc of rotation, and their relation to sex, age, and height. The
procedure was also performed in one patient, who had a favorable outcome after 4 months.

12g_VastLat_r4_cah_1534-1551.indd 1549 2/7/2012 5:18:33 PM

 1550 Part II  Regional Flaps: Anatomy and Basic Techniques

Posch NA, Mureau MA, Flood SJ, et al. The combined free partial vastus lateralis with an-
terolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg
58:1095-1103, 2005.
The authors performed free partial vastus lateralis with ALT perforator flaps in 11 patients with large
defects. Indications for adding a muscular component were exposed bone, skull base, (artificial) dura,
or osteosynthesis material; open sinuses; and lack of muscular bulk. Flaps were planned as standard
ALT flaps, with three types of dissection: (1) a true myocutaneous flap; (2) a muscle flap with a skin
island on one perforator that could be rotated up to 180 degrees; and (3) a chimera skin perforator
flap with muscle harvested on a separate branch from the source vessel or on a side branch of the skin
perforator. No total or partial flap failures occurred. In eight patients, the skin was transferred to the
facial area, and six resulted in color mismatch. Flap bulk was excessive in eight patients at 6 weeks,
and in only two patients at 6 months. Eight patients were satisfied with the functional result, and
seven were satisfied with the cosmetic result. In all of the less-satisfied patients, the flap was performed
for external facial skin reconstruction. Donor site morbidity was minimal.
Rozen WM, le Roux CM, Ashton MW, et al. The unfavorable anatomy of vastus lateralis mo-
tor nerves: a cause of donor-site morbidity after anterolateral thigh flap harvest. Plast Reconstr
Surg 123:1505-1509, 2009.
The authors studied 36 human cadavers to better understand the motor nerve distribution to the
vastus lateralis and to explain the reason for donor site morbidity (although low) to the ALT flap.
No anatomic studies had previously described the relationship of these nerves to the vascular pedicle of
this flap. The relationship of the nerves to the descending branch of the LCFA was recorded. They
discovered that the nerve to the vastus lateralis branches extensively before entering the muscle, with
four to seven nerves identified per thigh. Two of the noted anatomic variations are more prone to
damage: the motor nerve passes (1) through the vascular pedicle or (2) between perforators supplying
the flap. At least 28% of cases had one or more unfavorable variations.
Sardesai MG, Yoo JH, Franklin JH, et al. Vastus lateralis muscle-only free flap: defining its role
in head and neck reconstruction. J Otolaryngol Head Neck Surg 37:230-234, 2008.
The authors reviewed the charts of nine patients who had had muscle-only free tissue transfer for head
and neck reconstruction after tumor ablation at one center. Distal flap vascular compromise occurred in
three patients. Advantages of this flap included versatility, ease of harvest, and a two-team approach.
Disadvantages included variable anatomy and tenuous distal circulation.
Schipper J, Boedeker CC, Horch RE, et al. The free vastus lateralis flap for reconstruction in
ablative oncologic head and neck surgery. Eur J Surg Oncol 32:103-107, 2006.
The vastus lateralis muscle was transferred as a free myocutaneous flap in six patients to reconstruct
head and neck defects after tumor removal. Five patients had a very satisfactory functional and cosmetic
outcome, without limited knee and hip movement. Immobilization was not prolonged postoperatively,
and the donor site showed no unfavorable side effects.
Shieh SJ, Jou IM. Management of intractable hip infection after resectional arthroplasty using
a vastus lateralis muscle flap and secondary total hip arthroplasty. Plast Reconstr Surg 120:202-
207, 2007.
This article reported on the successful management of two cases of intractable hip infection using a
pedicled vastus lateralis muscle transfer as an interim procedure and then a secondary total hip arthro-
plasty to restore hip function.
Spyriounis PK, Lutz BS. Versatility of the free vastus lateralis muscle flap. J Trauma 64:1100-
1105, 2008.
The free vastus lateralis muscle flap is a versatile flap with constant anatomy, a long pedicle length,
a large vessel diameter, and minor donor site morbidity. Its dissection is easy with the patient supine.
Because of these advantages, the authors used this flap in 23 patients with various defects after trauma
and cancer therapy. They transferred a total of 24 flaps. All flaps were successful, and donor site

12g_VastLat_r4_cah_1534-1551.indd 1550 2/7/2012 5:18:33 PM

 Thigh  •  12G: Vastus Lateralis Flap 1551

morbidity was minimal. Two debulking procedures were subsequently performed. Permanent partial
limb dysfunction did not occur. The authors demonstrated that this flap is valuable for difficult recon-
structions in a variety of areas, including the head and neck and lower limb.
Suda AJ, Heppert V. Vastus lateralis muscle flap for infected hips after resection arthroplasty. J
Bone Joint Surg Br 92:1654-1658, 2010.
The authors assessed results of 119 patients with 120 chronic infections after resection arthroplasty
who were treated with a vastus lateralis muscle flap. The flap was fixed with Mitek anchors in the
acetabular cavity. The mean duration of infection after resection and before the muscle flap procedure
was 6.5 months. Patients had previously undergone a mean of 4.9 operations. The infected cavity was
the origin of infection in all patients. The mean follow-up was 2.6 years. All patients had decreased
pain and an improved quality of life. Infection did not recur.
Tayfur V, Magden O, Edizer M, et al. Anatomy of vastus lateralis muscle flap. J Craniofac Surg
21:1951-1953, 2010.
The authors studied the vastus lateralis muscle in 15 adult formalin-fixed cadavers. The dominant
pedicle was the descending branch of the LCFA. Its mean diameter was 2.1 mm. The pedicle was
located 119.4 mm distal to the pubic symphysis, and it entered the muscle 155.8 and 213.7 mm from
the greater trochanter and the anterior superior iliac spine, respectively. The muscle had proximal minor
pedicles from the ascending and transverse branches of LCFA. These arteries had mean diameters of
1.8 and 2 mm, respectively. Distal minor branches were consistently present. The mean diameter of
the distal branch was 1.8 mm; it originated 83.7 mm proximal to the intercondylar line. The motor
nerve to the muscle originated from the femoral nerve and entered the muscle 194.6 mm from the
anterior superior iliac spine.
Tzeng YS, Yu CC, Chou TD, et al. Proximal pedicled anterolateral thigh flap for reconstruc-
tion of trochanteric defect. Ann Plast Surg 61:79-82, 2008.
The authors shared their experience with the proximal pedicled ALT flap in six patients with tro-
chanteric defects. A total of seven island flaps were performed: four fasciocutaneous flaps in paraplegic
patients with trochanteric pressure sores, and three myocutaneous flaps of the vastus lateralis muscle
in patients with osteomyelitis of the trochanter and implant extrusion. The mean follow-up was
7 months. All flaps survived.
Ver Halen J, Yu P. Reconstruction of extensive groin defects with contralateral anterolateral
thigh-vastus lateralis muscle flaps. Plast Reconstr Surg 125:130e-132e, 2010.
Inguinal lymphadenectomy is commonly performed for treatment of nodal metastases of primary ma-
lignancies of the lower limb, abdomen, and pelvis, often necessitating en bloc excision and producing
extensive wounds with exposure of femoral vessels. The pedicled vertical rectus abdominis myocutaneous
or anterolateral thigh fasciocutaneous and vastus lateralis muscle flaps are first choices for reconstruc-
tion of ipsilateral groin defects. The authors reported on their experience using contralateral pedicled
anterolateral thigh–vastus lateralis flaps for immediate reconstruction of radical inguinal defects when
other options were unavailable.
Wong S, Garvey P, Skibber J, et al. Reconstruction of pelvic exenteration defects with antero-
lateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg 124:1177-1185, 2009.
The pedicled anterolateral thigh–vastus lateralis muscle (ALT-VL) flap was used to reconstruct large
pelvic exenteration defects in 18 patients in whom the rectus abdominis was not available for vari-
ous reasons. For primary closure of perineal defects, the vastus lateralis muscle was tunneled over the
inguinal ligament into the pelvis (inguinal route). For concomitant perineal-vaginal reconstruction,
the ALT-VL muscle was tunneled over the medial thigh to the defect (perineal route). All patients
received preoperative chemoradiation. Intraoperative pelvic brachytherapy was performed in nine
patients. Complications included five small perineal wound dehiscences that healed spontaneously,
one flap failure caused by pedicle tension in an obese patient with a short thigh, an enterocutaneous
fistula, and an ileal conduit leak that healed spontaneously. No hernias occurred.

12g_VastLat_r4_cah_1534-1551.indd 1551 2/7/2012 5:18:33 PM

 ANATOMIC LANDMARKS
Landmarks Superficial central muscle of the quadriceps extensor muscle group
lying between the vastus lateralis and vastus medialis muscles.
Extends from the ilium to the patella of the knee.
Size Muscle: 35 3 7 cm; skin island: 9 3 30 cm with primary closure.
Origin The anterior inferior iliac spine (ASIS) and the upper border of
the acetabulum.
Insertion Patella.
Function Extension of the knee, specifically the terminal 15 to 20 degrees.
Composition Muscle, myocutaneous.
Flap Type Type II muscle.
Dominant Pedicle Lateral circumflex femoral artery.
Minor Pedicle Branches of the superficial femoral artery.
Nerve Supply Motor: Femoral nerve. Sensory: Anterior femoral cutaneous nerve
(L2-L3).

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 Section 12H
Thigh

Rectus Femoris Flap

CLINICAL APPLICATIONS
Regional Use
Groin
Perineum
Ischium
Inferior abdomen
Distant Use
Chest
Upper abdomen
Head and neck
Specialized Use
Abdominal wall reconstruction
Functional muscle transfer

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 ANATOMY OF THE rectus femoris Flap

Femoral nerve
Femoral artery
Superficial femoral artery
Profunda femoris artery
Muscular branch of femoral nerve

Lateral circumflex femoral artery

Ascending branch
Transverse branch
Descending branch

Rectus femoris muscle

Muscular branches of
superficial femoral artery

Anterior superior iliac spine

Gluteus maximus muscle
Sartorius muscle
Tensor fascia lata muscle

Femoral artery
Profunda femoris artery Superficial femoral artery

Lateral circumflex femoral artery

Ascending branch

Rectus femoris muscle

Transverse branch
Vastus medialis muscle
Descending branch

Vastus lateralis muscle

Sartorius muscle
Iliotibial tract

Fig. 12H-1 A, Vascular anatomy. B, Vascular anatomy with surrounding musculature.

Dominant pedicle: Descending branch of lateral circumflex femoral artery
Minor pedicle: Muscular branches of superficial femoral artery

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 Thigh  •  12H: Rectus Femoris Flap 1555

Anatomy
Landmarks The most superficial and central of the quadriceps extensor muscle group, the
rectus femoris muscle is a bipennate muscle that extends from the ilium to the
patella and is surrounded by the vastus lateralis and vastus medialis muscles.
Composition Muscle or myocutaneous. The rectus femoris muscle reliably carries its overlying
skin paddle. Like other flaps of the thigh, a flap design of 9 cm or less will allow
primary closure of the donor site.
Size Muscle: 35 cm long, 7 cm wide; skin island: 9 3 30 cm with primary closure.
Wider skin islands can be harvested by including perforators of the descending
lateral circumflex femoral system. Donor site would require skin grafting.
Origin Originates from the anterior and inferior iliac spine and the acetabular margin.
Posteriorly, origin has two heads, which are discontinuous.
Insertion Inserts into the upper border of the patella anterior to the continuous insertion
of the vastus medialis and vastus lateralis muscles.
Function The rectus femoris acts as an extensor of the knee, specifically powering the
terminal 15 to 20 degrees of knee extension. It also is a powerful flexor of the
hip. Therefore harvest of the rectus femoris muscle is not a primary flap of choice
in an ambulatory patient.

Arterial Anatomy (Type II)

Dominant Pedicle  Lateral circumflex femoral artery
Regional Source  Profunda femoris artery.
Length  5 cm.
Diameter  2 to 3 mm.
Location  Lateral circumflex femoral artery arises from the lateral side of the profunda femoris
artery. The major branch or branches are given off to the posterior surface of the muscle and its
upper third. The artery then continues as the transverse branch.
Minor Pedicle  Muscular branches of the superficial femoral artery
Regional Source  Superficial femoral artery.
Length  2 to 3 cm.
Diameter  1 mm.
Location  Inferior third of the muscle. This vessel is not always present.

Venous Anatomy
The lateral femoral circumflex vein joins the lateral side of the femoral vein at the level of the ori-
gin of the profunda femoris artery, approximately 3 cm inferior to the inguinal ligament. Venae
comitantes follow the course of the lateral circumflex femoral artery system.

Nerve Supply
Motor The muscular branch of the femoral nerve enters the posterior surface of the
muscle belly 6 to 13 cm inferior to the anterior superior iliac spine (ASIS).
Sensory The intermediate anterior femoral cutaneous nerve (L2-L3).

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 1556 Part II  Regional Flaps: Anatomy and Basic Techniques

Vascular A natomy of the Rectus Femoris Flap

A B

D
D

m2

m2

Superficial surface of flap Radiographic view

Fig. 12H-2 

Dominant pedicle: Descending branch of lateral circumflex femoral artery (D)

Minor pedicle: Muscular branches of superficial femoral artery (m2)

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 Thigh  •  12H: Rectus Femoris Flap 1557

Flap Harvest
Design and Markings
The skin paddle design should overlie the muscle for reliable perfusion. Unlike the tensor
fascia lata flap, where the distal third of the skin is unreliable because of its largely fascial
consistency, the rectus femoris muscle can reliably carry the skin paddle over its muscular
component, which runs the entire length of the flap. A line drawn from the palpable an-
terior superior iliac spine to the central patella bisects the rectus femoris muscle and should
be used in centering the flap design. A simple pinch test may help the surgeon decide how
much of the width of the flap can be taken with primary closure. Conservatively, a 9 cm
wide flap can be closed primarily in most patients.

Anterior superior
iliac spine

Transverse line
showing path of
lateral circumflex
femoral artery

Outline of rectus Pubis

femoris muscle
myocutaneous flap

Midline of
rectus femoris muscle

Midline of
sartorius muscle

Central patella

Landmarks for creating flap design

Fig. 12H-3 

A transverse line marked from the level of the pubis shows the approximate path of the
lateral circumflex femoral artery. These guidepoints help in the design of the flap, which
is elliptical, longitudinal, and centered over the muscle. The skin paddle can be placed
anywhere within this zone. Commonly, the entire length of the skin paddle is taken and
areas of skin not needed are deepithelialized. This helps to control the inevitable dog-ears at
the donor site. The most proximal portion of the design would have the best blood supply.

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 1558 Part II  Regional Flaps: Anatomy and Basic Techniques

Patient Positioning
This flap is most reliably designed and executed with the patient in the supine position.
Often it is used for defects of the pubis or lower abdomen in which the patient will already
be in the supine position. For use in the ischial area, the flap may be harvested with the pa­
tient in the lateral decubitus position; in this case marking in the supine position is highly
recommended.

Guide to Flap Dissection

For a muscle-only flap, an incision along the central axis of the muscle provides the best
exposure. When a skin paddle has been designed, dissection proceeds with incision of the
skin paddle down to the muscular fascia. The superficial surface of the rectus femoris muscle
is exposed from its origin to its insertion. Retraction of the sartorius muscle superiorly in the
medial direction will expose the origin of the muscle. Inferiorly, the insertion of the muscle
is exposed by freeing the vastus medialis and the vastus lateralis muscles. The tendinous
insertion of the muscle is then divided, and the muscle is dissected from distal to proximal.

Anterior superior
iliac spine
B

Rectus femoris
muscle-only flap

Skin incision for

rectus femoris Descending branch
muscle-only flap of lateral circumflex
femoral artery

Central patella

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.

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 Thigh  •  12H: Rectus Femoris Flap 1559

With a large skin paddle it is useful to suture the edges of the skin distally to the fascia
once the flap is elevated to prevent any shearing of the skin from the muscle during dissec-
tion. Dissection then proceeds superiorly, and the descending branch of the lateral circum-
flex femoral artery can be identified. Next, the surgeon encounters branches to the rectus
femoris muscle at the level of the pubis. If this is a rotational flap, this would be the limit of
the dissection superiorly. If this is a free flap, the dissection of the pedicle will then proceed
to the profunda femoris system to maximize pedicle length and diameter of the vessels.

Anterior superior
iliac spine

Transverse line
showing path of
lateral circumflex D
femoral artery Rectus femoris
myocutaneous flap

Outline of rectus Pubis

femoris muscle
myocutaneous flap

Midline of
rectus femoris muscle
Descending branch
of lateral circumflex
femoral artery
Central patella

Skin paddle design

Myocutaneous flap elevation

Fig. 12H-4 

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 1560 Part II  Regional Flaps: Anatomy and Basic Techniques

It is not always necessary to divide the origin of the muscle. In some cases, when extra
mobility of the flap and more freedom of its placement are needed, the origin can be divided.
Laterally, the muscle must be separated from the tensor fascia lata for maximum rotation.

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

Functional Muscle Transfer

When the muscle is being used as a functional muscle, it is
important to place reference marks on the flap in situ before
the origin or insertion is divided. These marks will be used Muscular branch
to tension the flap when inset. When harvesting the flap as of femoral nerve
a functional muscle, care is taken in dividing the origin; the
femoral nerve will be identified entering the deep surface
of the muscle medially, in the proximal third of the muscle.
Dissection of the nerve can be carefully performed with Descending branch
neurolysis and separation from medial femoral nerve branches of lateral circumflex
femoral artery
and the motor branches to the vastus muscles.
Because of the arrangement of its muscular fibers, the
rectus femoris muscle can only contract 4 to 5 cm. This
limited excursion makes it less useful than other more ex-
pendable muscles for functional muscle transfer. Because
there is some morbidity in harvesting the flap, one must
carefully consider other options for solving the reconstruc-
tive problem at hand.
Dissection of free flap

Fig. 12H-5 

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 Thigh  •  12H: Rectus Femoris Flap 1561

Arc of Rotation
The positioning of the proximal vasculature is favorable for arc of rotation of the flap to
the lower half of the abdomen and the groin area. Posteriorly, the flap will easily reach to
the area of the ischium. Dissection of the pedicle more proximally, because of its short size,
does not significantly increase the arc of rotation. Release of the tendon origin may assist
in flap positioning and some flap advancement medially.

Anterior arc to abdomen

Posterior arc to ischium

Fig. 12H-6 

12h_RectusFem_r8_cah_1552-1582.indd 1561 2/7/2012 5:28:09 PM

 1562 Part II  Regional Flaps: Anatomy and Basic Techniques

Flap Transfer
Muscle-Only Flap
Once elevated, muscle can be transferred to its abdominal or ischial recipient site through
a subcutaneous tunnel. The surgeon must ensure that the tunnel is wide enough that there
is no compression on the proximal pedicle and that no kinking or torsion has occurred
after transfer.

Myocutaneous Flap
A myocutaneous flap can be transferred either through a subcutaneous tunnel or by direct
extension of the donor site with the defect. For most groin defects or nearby lower abdominal
defects, extension and connection of the recipient and donor sites allow better inset of the flap
and less likelihood of compression of the pedicle or kinking or torsion on the flap pedicle.

Flap Inset
The rotated flap should be inset without tension. The advantage of the rectus femoris flap is
the generous amount of fascia with the muscle, and this fascia should be used for distributing
tension along the closure, especially for an abdominal wall fascial defect.

Free Flap
The abundant fascia present in the muscle is used to support the free tissue transfer in place
before microvascular anastomosis. The anastomosis must be tension free.

Donor Site Closure

All Flap Variants
When possible, direct donor site closure is recommended. A skin island of 9 cm or less should
permit closure, and widths of up to 15 cm have been closed primarily in select patients. Be-
cause of the potential functional morbidity of losing the rectus femoris muscle, it is advised
that distally, the vastus lateralis and vastus medialis muscles be united in the midline with per-
manent suture. Reapproximation of the vastus lateralis and vastus medialis muscles for 10 to
15 cm distally will help compensate for functional loss. Skin grafting can be unsightly but
can functionally close the donor site. Skin grafts over the patellar mechanism should be
avoided when possible.

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 Thigh  •  12H: Rectus Femoris Flap 1563

Clinical Applications
This 47-year-old woman was referred from the vascular service for an exposed Gore-Tex
graft after vascular bypass surgery. The wound was thought to be clean, and coverage
rather than removal and rerouting of a new graft was planned. Reconstructive options for
this clinical problem include the use of muscle for coverage. Skin closure is usually not an
issue. Options for local muscle flap include the sartorius, gracilis, rectus femoris, and rectus
abdominis muscles. The tensor fascia lata supplies fascia but not muscle over the graft. The
flap choice is dictated by the defect, the reconstructive need, and the remaining blood sup-
ply after bypass. In this case, a rectus femoris flap was chosen.

A B C

Fig. 12H-7  A, The groin wound was debrided and irrigated and the rectus femoris was isolated dis-
tally 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. (Case supplied by MRZ.)

12h_RectusFem_r8_cah_1552-1582.indd 1563 2/7/2012 5:28:20 PM

 1564 Part II  Regional Flaps: Anatomy and Basic Techniques

This 73-year-old woman had a liposarcoma of the abdominal wall. Resection included the
full-thickness abdominal wall, leaving both a large skin defect and a fascial defect. Options
included synthetic mesh closure and coverage with abdominal skin mobilization, or a skin-
bearing flap. One could also consider reconstruction of fascia and skin with a rotational flap
such as the tensor fascia lata, rectus femoris, or contralateral rectus abdominis. In this case,
a rectus femoris myocutaneous flap was planned for the complete reconstruction.

A B

C D

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, Dis-
section 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 vas-
tus medialis were approximated for 15 cm above the patella with nonabsorbable suture. Primary skin
closure was performed, as planned preoperatively. (Case supplied by MRZ.)

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 Thigh  •  12H: Rectus Femoris Flap 1565

This 45-year-old woman had a history of cervical cancer that had been treated with re-
section and irradiation. She remained disease free but had a chronic wound in the pubic
area from the radiation. Attempts at secondary closure and skin grafting had failed, and
the patient was referred for reconstruction. Choices for local flaps in this case include ten-
sor fascia lata, rectus femoris, and rectus abdominis flaps. In this case, a rectus femoris flap
was chosen to allow fascial reinforcement, muscle for added vascularity to the irradiated
wound, and skin for closure.

B C D

Fig. 12H-9  A, The patient’s chronic wound is shown, with some granulations but no reepithelializa-
tion. 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.
(Case supplied by MRZ.)

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 1566 Part II  Regional Flaps: Anatomy and Basic Techniques

This 62-year-old man had a bladder cancer invading the abdominal wall, requiring full-
thickness abdominal wall resection, a cystectomy, and creation of a urinary conduit. The
rectus femoris is an excellent choice for fascial replacement when there is a large skin re-
quirement.

A B

C D E

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. (Case supplied by MRZ.)

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 Thigh  •  12H: Rectus Femoris Flap 1567

This 55-year-old man had a large groin sarcoma requiring full-thickness resection of the
abdominal wall, a penectomy, and resection of the right testis. The fascial defect was repaired
with mesh, and the overlying soft tissue was repaired with a rectus femoris flap.

A B C

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. (Case supplied by MRZ.)

12h_RectusFem_r8_cah_1552-1582.indd 1567 2/7/2012 5:28:38 PM

 1568 Part II  Regional Flaps: Anatomy and Basic Techniques

This 45-year-old man had been treated for lung cancer 8 years previously with chemotherapy
and irradiation. The patient presented with a chest wound; a biopsy revealed a spindle cell
malignancy. The patient had documented metastatic disease, and a heroic chest wall resec-
tion was proposed by thoracic surgery for pain control, wound management, and possible
further adjuvant therapy.

A B

C D

Fig. 12H-12  A, A chest wound from a spindle cell malignancy with necrosis and obvious subcuta-
neous 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. (Case supplied by MRZ.)

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 Thigh  •  12H: Rectus Femoris Flap 1569

This 69-year-old man had a recurrent squamous cell carcinoma of the scalp that required
wide excision, orbital exenteration, parotidectomy, and lymph node dissection. His complex
wound required muscle for exposed dura at its base, and a large amount of vascularized
tissue for skin closure. A large flap of the anterior thigh was used, incorporating the rectus
femoris muscle with its primary blood supply, supplemented with surrounding perforators
from the descending branch of the lateral circumflex femoral system (anterior lateral thigh
and anteromedial thigh perforators).

A B C

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 ves-
sels as recipient vessels for free tissue transfer. B, Lateral view of the flap elevation showing the per-
forators 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. (Case sup-
plied by MRZ.)

12h_RectusFem_r8_cah_1552-1582.indd 1569 2/7/2012 5:28:48 PM

 1570 Part II  Regional Flaps: Anatomy and Basic Techniques

A 57-year-old man who had undergone low anterior resection for colon cancer developed
a 12 by 15 cm recurrence in the right lower quadrant of the abdominal wall at a previous
diverting colostomy site. The mass involved the small and large bowels and the full thick-
ness of the abdominal wall.

C D

Fig. 12H-14  A, A right thigh–based flap was planned for cutaneous coverage of the anticipated com-