an atlas of flap in limb reconstruction

Abductor hallucis
flap
Introduction
Abductor hallucis has limited but
specific indications. It is worthy
of interest for soft-tissue coverage
of the medial aspect of the heel.
Indications
The arc of rotation of the transfer
is very short when the muscle is
isolated
on its main proximal
pedicle. The arc of rotation can be
increased by releasing the medial
plantar artery until the division of
the
posterior
tibial
artery.
However, even with this manoeu-
vre, the transfer cannot reach the
medial
malleolus.
In fact, the
distal portion of the transfer is
tendinous and not suitable for
covering an exposed bone. The
elective indications for the abduc-
tor
hallucis
flap
are
limited
defects of the medial aspect of the
heel.
Anatomy and blood
supply
Abductor hallucis lies along the
foot's medial border; it is attached
proximally to the flexor retinacu-
tum and to the medial process of
the
calcaneal
tuberosity.
The
muscle fibres end in a tendon
attached distally to the medial side
of the proximal phalangeal base in
the hallux.
The blood supply is derived
from the medial plantar artery via
several arterioles. The most proxi-
mal pedicle is sufficient to supply
the
entire
muscle
body.
The
muscle can be either isolated on
its proximal pedicle or raised on
the medial plantar artery.
Abductor hallucis flap
Operative procedure
A
A long, lazy curved incision is
made on the medial side of the
foot.
A

Transfers from the lower limb
B
The retraction of skin edges
and the incision of the fascia
allow exposure of abductor hallu-
cis.
One should take care to isolate
the
distal
tendon of abductor
hallucis
without including the
tendon of flexor hallucis brevis.
B
1
abductor hallucis
2 medial plantar artery
3 flexor hallucis brevis
C The distal tendon of the
muscle is divided. The muscle is
progressively released,
exposing
the
medial plantar artery.
The
transfer can be isolated on its
proximal
pedicle
or
entirely
pedicled on the medial plantar
artery.
C
1
lateral plantar artery
2 medial plantar artery, common trunk
3 medial plantar artery, deep branch
4 medial plantar artery, superficial
branch
5 flexor hallucis brevis

D
Abductor hallucis flap
D
The arc of rotation allows the
muscle to cover the medial aspect
of the heel distal to the medial
malleolus.
Only the poorly vascularized
tendinous portion of the transfer
can reach the malleolus. This type
of coverage is not advocated.

Transfers from the lower limb
Second toe transfer
The operation for toe transfer may
be done using either the big or the
second toe. There is not much
difference in the dissection apart
from the terminal phases. We shall
describe the second toe dissection,
which is most commonly used.
Vascular anatomy
A,B
The vascularization of the
second toe comes from a vascular
network based on both plantar
and dorsal pedicles. The dorsal
network is usually predominant.
The dorsalis pedis artery plunges
into the first web to give the
plantar
arch
and the plantar
interosseous artery (PIA). It gives
off a dorsal branch, the dorsal
interosseous artery (DIA), which
runs dorsally and reaches the
web, where it branches into the
collateral arteries of the first and
second toe (type IA). The varia-
tions of the DIA are important to
know,
as
they influence the
dissection. In type IB the anatomy
is almost the same, the artery
running through the superficial
part of the interosseous muscle.
In types HA and IIB, the artery
is either duplicated or deep to the
muscle. The dissection is more
tedious but still possible through
a dorsal approach.
In type III the artery is absent or
very hypoplastic. The only possi-
bility lies in the PIA which can be
dissected by a plantar approach. In
more than 80 per cent of cases the
artery is a type I or II.
B
1
supplying branch to great toe
2 supplying branch to second toe
3 dorsal interosseous artery
4 common plantar digital artery
5 plunging branch of dorsalis pedis
artery
6 dorsalis pedis artery
A Variations of dorsal
interosseous artery
plantar
dorsal

Second toe transfer
Preparation and
positioning
The patient is supine and the
operation is performed using a
tourniquet. The knee is flexed and
the foot is flat on the table.
I ncisions
C,D
A racket-type incision is
made on the dorsum of the foot
(C) and another one on the
plantar aspect (D).
A curved
dorsal incision
will allow the
dissection of the dorsal vessels.

Transfers from the lower limb
Dissection
E The skin is incised and
elevated superficially in order to
protect the dorsal veins.
E
1
deep peroneal nerve
2 superficial vein
3 branches of superficial peroneal
nerve
2
3
F
One large vein is selected and
preserved, and the transverse arch
is ligated.
F
1
first dorsal interosseous
2 dorsalis pedis artery and veins
3 tendon of extensor digitorum brevis

2
G
k\11
1 deep peroneal nerve
2 tendon of extensor digitorum brevis,
retracted
3 dorsalis pedis artery and veins
4 superficial peroneal nerve
5 plunging branch of dorsalis pedis
artery
6 dorsal interosseous artery
7 supplying branch to second toe
Second toe transfer
G The dorsalis pedis artery is
then identified and the dissection
proceeds distally. Very rapidly it is
possible to confirm the size and
position of the DIA and confirm
the dorsal approach.
H The DIA is followed over or
through the interosseous muscle
and dissected free. The dissection
should not be too close to the
artery, but a fat cuff should be
kept around the pedicle in order
to avoid spasm.
The dorsal terminal branches of
the anterior tibial nerve are also
dissected and the extensor digito-
rum longus and brevis isolated.

Transfers from the lower limb
I
The dissection proceeds to the
first
web,
over
the
inter-
metacarpal ligament.
1
extensor tendon, from extensor
digitorum brevis
2 extensor tendon, from extensor
digitorum longus
3 intermetatarsal ligaments, to be cut
J
The artery receives a deep
component from the plantar
vessels
and
divides
into
two
branches of unequal size for the
first and second toe. The large
branch, supplying the big toe, is
ligated.
J
1 dorsal interosseous artery and its
supplying branches to second toe
2 deep peroneal nerve
3 communicating branch of dorsalis
pedis artery, to be ligated
4 superficial peroneal nerve, branch
5 supplying branch to great toe, to be
ligated

Second toe transfer
K The plantar incision is then
made in order to dissect the
vessels and the nerves. On each
side of the toe, the plantar nerve
is located and followed for 2-3
cm. It usually branches with the
nerve of the next toe but this
division can be dissected over
another 10-15 cm. The nerves are
then cut.
The flexor tendon sheath is
approached and opened. The
tendons are pulled out and cut at
8-10 cm of length. The volar plate
is excised.
The extensor tendons are then
cut and the articular capsule is
opened circularly.
The dorsal vein is dissected for
6-8 cm and ligated.
K
1
flexor tendons
2 common plantar digital nerve
3 proper plantar digital nerve
4 common plantar digital artery
L
The toe is then completely
free
except
for
the
arterial
pedicle.
The tourniquet is released and
the vascularity is checked.
The dorsalis pedis artery is then
lifted; its deep perforating branch
is ligated and the artery itself is
then ligated.
L
t
dorsal interosseous pedicle
2 dorsalis pedis artery, stumps
3 plunging branch of dorsalis pedis
artery, ligated

Transfers from the lower limb
M The toc is ready for trans-
plantation.
M
1
branch of superficial peroneal nerve
5 flexor tendons
2 extensor tendons
6 deep peroneal nerve
3 superficial vein
7 proper digital nerve
4 proper digital nerve
8 dorsal interosseous pedicle

6
Transfers from
the thorax,
abdomen and
pelvis

Transfers from the thorax, abdomen and pelvis
Shoulder girdle
Introduction
Tissue defects of the shoulder are not uncommon.
High-velocity injuries, sequelae of burns, and soft
tissue sarcomas are the most frequent aetiologies.
Numerous pedicled flaps are available in the area
and there are no indications for free flaps.
Muscle flaps and fasciocutaneous flaps have their
respective indications according to the site of the
defect.
The most useful flaps (latissimus dorsi, serratus
anterior,
scapular
and
parascapular
flaps)
are
supplied
by the same vascular trunk, i.e. the
subscapular artery.
Other flaps, such as the pectoralis minor and
pectoralis major flaps, are not described. Their indica-
tions are unusual in reconstructive surgery of the
shoulder girdle.

A
Flaps available at the shoulder
girdle are characterized by their -
common vascular origin.
The subscapular artery is the
key common trunk for the main
procedures employed. It is a
constant and short trunk which
usually arises at the distal border
of the subscapularis muscle. It
divides 3-4 cm from its origin into
the circumflex scapular and thora-
codorsal arteries.
26
25
24 23 22 21
20
19
Shoulder girdle
18
17
16
15
14
13
7
8
9
1 0
A
9 thoracodorsal nerve
1 8 axillary vein
1 axillary nerve and posterior
1 0 thoracodorsal artery
1 9 thoraco-acromial artery
circumflex humeral artery
11
long thoracic nerve
20 pectoralis minor tendon, cut
2
median nerve
12 lateral thoracic artery
21 acromial branch
3 medial antebrachial cutaneous nerve
13 medial pectoral nerve
22 coracoid process
4 ulnar nerve
1 4 pectoralis minor, cut
23 axillary artery
5 medial brachial cutaneous nerve
15 lateral pectoral nerve
24 cephalic vein
6 latissimus dorsi
16 upper subscapular nerve
25 musculocutaneous nerve
7 circumflex scapular artery
17 pectoral branch, from thoraco-
26 pectoralis major, cut
8 subscapular artery
acromial artery

Transfers from the thorax, abdomen and pelvis
Latissimus dorsi flap
Introduction
The latissimus dorsi flap is proba-
bly the most employed and the
most reliable flap in the whole
body. It has many indications, as it
can be used as a free or pedicled
flap, as a covering procedure or as
a
functional
transfer.
The
functional deficit associated with
its elevation is negligible.
Indications
The island pedicle flap is used for:
Coverage of defects over the
shoulder girdle and upper arm,
including the posterior aspect
of the elbow, and the anterior
chest, including the clavicle.
Restoration of elbow flexion in
the paralysed upper limb. The
proximal
insertion
of
the
muscle should be transferred to
the coracoid process.
The free transfer flap is used for_
• Coverage of large defects of the
limbs, especially in the leg.
With compound transfer, a skin
paddle can be raised with the
muscle. A segment of vascularized
rib (9th or 10th) can also be
raised with the muscle. This latter
technique is worthy of interest in
large compound defects of the
upper arm.
The flap can be used as a
distally based island pedicled flap
on secondary pedicles.
Vascular and nerve supply
A The vascular pedicle arises
from the thoracodorsal vessels.
The subscapular artery divides
into the circumflex scapular and
thoracodorsal arteries.
Before entering latissimus dorsi,
the thoracodorsal artery supplies
one or two small branches to teres
major and at least one main
branch to serratus anterior. The
motor nerve arises from the poste-
rior
cord and enters latissimus
dorsi with the vascular pedicle 10
em distal to the axillary vessels. In
the muscle, the vascular pedicle,
in most cases (94%) divides into
1
2
3
4
two branches, one horizontal and
one oblique, each supplying a
distinct
segment
of
muscle.
Numerous intramuscular anasto-
moses link the two systems.
In a few cases (6%) the main
pedicle divides into three or four
main branches. Latissimus dorsi
also receives a blood supply from
the intercostal arteries at the
point of its insertion into the
spine. The muscle can be distally
based on three of these pedicles
for covering defects of the lower
back.
The skin overlying the
muscle can be raised in its entirety
with complete confidence.
A
1 subscapular artery
2 circumflex scapular artery
3 thoracodorsal artery
4 vascular bundles from the
i ntercostal arteries

Operative procedure
The patient lies in the midlateral
position. It is also possible to
elevate the flap with the patient
lying
supine
with a carefully
positioned sandbag. The upper
limb is included in the operative
field and supported throughout to
avoid traction being applied to the
brachial plexus.
B A longitudinal incision is
made from the axilla to the poste-
rior
iliac
crest.
The eventual
desired skin paddle should be
marked out and its margin incised.
C By anterior dissection the
lateral border of the muscle is
exposed. The spinal origin of the
muscle is demonstrated by reflec-
tion of the posterior skin flap.
C
a incision on anterior border of
latissinnus dorsi
B
a incision
Latissimus dorsi flap
a

Transfers from the thorax, abdomen and pelvis
D
The key point of the
technique
is
to
dissect
the
anterior border, which should be
slightly
retracted in order to
expose the vascular distribution.
When the muscle is used as a
rotation flap, the pedicle does not
need to be dissected but the
thoracic branches of the thora-
codorsal vessels should be ligated
and divided to allow mobilization
of the muscle.
2
3
a
6
D
1 subscapularis vessels
2 circumflex scapular vessels
3 neurovascular pedicle
4 vascular pedicle to serratus anterior
5 thoracodorsal vessels
6 motor nerve to latissimus dorsi
a incision
Arrows indicate ligation of vessels
5
4

E
When a free flap is raised it
seems better to retain the distal
1
tares major
insertion of the muscle until the
2 serratus anterior
pedicle is carefully dissected.
Then the muscle is released from
its spinal origin and from the iliac
crest, beginning the dissection
distally and working proximally.
The scapular attachments are
divided. Care should be taken to
ligate the small vessels lying deep
to teres major.
Latissimus dorsi flap

Transfers from the thorax, abdomen and pelvis
F
The segmental vascular intra-
muscular
division
allows
the
surgeon to split the muscle and to
raise the medial portion only (see
A).
F
1 medial portion of the muscle

Serratus anterior flap
Introduction
Serratus anterior is essential in the stabilization and
the active motion of the scapula. Its paralysis leads to
a winging scapula. However, the three last digitations
can be raised on the thoracodorsal vessels without
functional impairment. Serratus anterior has indica-
tions as a pedicled and as a free flap.
Indications
As a pedicled flap, serratus anterior is excellent for
treatment of the difficult problems of intramediastinal
fistulae.
Some defects of the shoulder girdle, which are far
from the axilla, are also good indications for the
pedicled flap because the vascular pedicle can be
very long. The arc of rotation allows coverage of the
sternoclavicular joint and the supraclavicular region.
As a free flap, the serratus anterior flap can provide
limited coverage of defects of the limbs. The length
and the reliability of the vessels are an advantage; the
vessels can be sutured quite far from the donor site
in healthy tissues.
Vascular supply
Serratus anterior flap
Serratus anterior is type V in the classification of
Mathes and Nahai. It comprises three portions. The
upper portion and the middle portion are supplied by
several important arteries, such as the suprascapular
artery, the posterior scapular artery and the superior
thoracic artery. These two proximal portions are not
interesting as transfers. On the other hand, the distal
portion, which comprises five digitations, has an
independent vascularization. The elevation of the last
five digitations leads to a winging of the spinal border
of the scapula. Only the three most distal digitations
can be raised. The blood supply is then based on the
thoracic branch of the thoracodorsal artery. The
thoracic branch joins serratus at the level of the lower
portion and descends until the most distal digitation.
The nerve supply is the long thoracic nerve (Bell's
nerve). In the lower portion the nerve is close to the
thoracic branch and accompanies the vessel until the
last digitation.
The pedicle of the flap is composed of the thora-
codorsal vessels following ligature of the pedicle
destined to latissimus dorsi. The vessels can even be
dissected as far as the origin of the subscapular artery.
With regard to the proximal digitations of the lower
portion, which should be absolutely spared, it is
necessary to separate cautiously the nerve from the
vessels; the length of the pedicle is about 12-15 cm,
and the flaps are 8 x 5 cm.