Flaps Practical Reconstructive Surgery

428
II Reconstructive Flaps A-to-Z
The skin island should be designed to overlie this point (su-
per cial CSA) with a safe margin of a few centimeters laterally
for the scapular ap or superiorly for the parascapular ap. This
makes certain that the ap does not miss the vessels.
If a Doppler is not available, and/or if the patient has larger
habitus, then an e ective adjunct to planning a scapular ap
is to use the method of Urbaniak: points are m arked two n-
gerbreadths above the tip of the inferior angle and two nger-
breadths below spine of the scapula. These points form the upper
and lower m argins of the ap, which is a transverse ellipse drawn
from a point two ngerbreadths from the m idline of the back to a
point two ngerbreadths above the apex of the posterior axillary
fold. We have found this to be a failsafe m ethod for locating the
horizontal branch, which will be running approxim ately in the
central axis of a ap planned this way (Fig. 39.3).
The parascapular ap should be centered on the lateral bor-
der of the scapula. It can be raised with the apex of its ellipse as
low as the highest point of the iliac crest. The most distal few cen-
timeters of the ellipse are likely to be of questionable vascularity
in such a circumstance and should not be used for a crucial part
of the reconstruction.

Patient Positioning
The patient should be warned preoperatively that the scar will hy-
pertrophy and stretch. In large aps, the back feels tight and pain-
ful; physiotherapy may be needed postoperatively for the shoulder.
The scapular axis aps may be raised with the patient in
the lateral or prone position. The arm should be abducted at
The teres muscles lie close together, with the artery passing
between them. The potential space between the teres m uscles
has to be opened to dissect the pedicle.
The main CSA gives a large terminal branch to the subscapu-
laris muscle (infrascapular branch), which supplies the bone of
the scapula, including a descending branch to the lateral margin of
scapula. The super cial branch of the CSA sends multiple branches
to the teres muscles and infraspinatus. The branch to infraspinatus
is one of the rst encountered during mobilization of the pedicle.

●
Mean arterial caliber: 1.8 to 4.5 mm
Super cially there are two venae comitantes running with
the artery. More deeply, at the subscapular artery, there is usually
a single large vena comitans.

●
Mean venous caliber: 1.8 to 6 mm

●
Pedicle length: up to 14 cm if subscapular artery included

●
Nerve supply: generally, there is considered to be no useful
method of innervating the scapular aps.

Anatomy
Immediately after it reaches the deepest level of the subcutane-
ous fat, having passed between the two teres muscles, the super-
cial branch of the CSA divides into its m ain term inal branches.
The horizontal branch passes transversely across the scapula, and
the descending branch runs inferiorly and slightly medially ap-
proximately overlying the lateral border of the scapula (Fig. 39.2).
These branches supply the widely used scapular and parascapular
aps, respectively. In the early part of their course, the vascular
pedicles run just above the fascia and the muscles.
In addition, a smaller ascending branch passes superiorly
and slightly medially. This branch can be used to raise the occa-
sionally used ascending scapular ap.
A perforator arises consistently from either the super cial
CSA or the descending branch imm ediately after the bifurcation.
This perforator arborizes straight into the skin perpendicular to
the deep fascia and can be used to supply a thin ap: the circum -
ex scapular artery perforator (CSAP) ap.
The osseous ap uses the large branches at the lateral border
of scapula to supply bone from the lateral border.

Surface Markings
Good preplanning of the scapular aps enhances success. Plan-
ning should ideally take place preoperatively with the arm ab-
ducted about 90 degrees. It is more comfortable for the patient to
have the limb supported in this position during marking.
The inferior angle of the scapula is palpated and m arked. The
lateral end of the spine of the scapula is palpated and marked.
A point is marked at the midpoint of a line between these two
points. This should be at the midpoint of the lateral border of the
scapula. A handheld Doppler probe is used to con rm the pres-
ence of the signal from the super cial branch of the CSA at or
near to this point, which is then marked. Sometimes the signal
is slightly inferior, or very slightly m ore lateral, than the marked
point and marking is adjusted accordingly.
Fig. 39.2 The transverse (scapular) and descending (parascapular)
branches arising from the super cial branch of the circum ex scapular
artery at the lateral border of scapula.1

39 Scapular, Parascapular, CSAP, and Scapular Osteocutaneous Flaps
429
adrenaline solution to reduce bleeding. It is best not to in ltrate adren-
aline for free aps. Thromboembolic prophylaxis should be used.

Raising the Flap
Size of Flap
Generally, the size of ap is limited by the maximum amount of skin
that can be excised and closed directly. However, especially if the de-
scending branch is also included, a much larger ap can be harvested,
including all to the skin over the scapula below the spine of scapula
and a larger portion from the back lower down. This creates an awk-
ward donor defect requiring skin grafting over a wide area.
Another option for taking a ap to cover a large area is to har-
vest both scapular and parascapular aps in an L pattern, creating
a donor site that can be closed, and approximating one edge of
the aps so they provide a wide area of coverage (Fig. 39.4).
General Points
For relatively inexperienced surgeons raising these aps for the
rst time, there are various tips to consider:
1. It may be safest to bevel the subcutaneous incision outward
from the skin incision a little so as to include a good width
of subcutaneous tissue until the vessels are localized. Do this
when nearing the lateral border of scapula. This helps to en-
sure that the pedicle is always included with the ap. Excess fat
can be trimmed o later when the line of the pedicle is clear.
2. The thick aponeurotic fascia of the back should not be raised
with the ap (especially over the infraspinatus) but care
90 degrees during ap elevation. Care should be taken to avoid
undue pressure on nerves or vessels in positioning the patient.
Metal patient supports should be carefully protected to prevent
diathermy injury.
There is commonly quite signi cant bleeding from the dermis
and subcutaneous fat during incision of aps on the back. For pedi-
cled aps, it is reasonable to in ltrate with a modest amount of dilute
Fig. 39.3 Method of marking the upper and lower borders of the scapular
ap two ngerbreadths below the spine and two ngerbreadths above
the angle of scapula (Urbaniak). The surface marking of the super cial
branch of the CSA is marked with Doppler approximately halfway down
the lateral border of the scapula.
Fig. 39.4 Completion of elevation of a combined scapu-
lar/parascapular ap: 1, teres major muscle; 2, teres mi-
nor muscle; 3, latissimus dorsi muscle; 4, infraspinatus
muscle; 5, trapezius muscle; 6, descending branch of CSA;
7, cutaneous scapular branch; 8, cutaneous parascapular
branch.1

430
II Reconstructive Flaps A-to-Z
2. The closer to the lateral border of the scapula the dissection
reaches, the m ore circum spect it should become, and dissec-
tion may be changed to using scalpel and bipolar diathermy.
At this stage, the surgeon is looking at the deep surface of the
ap to nd the horizontal branch, or som etim es branches,
showing through the thin areolar fascia and fat. In thin pa-
tients and children, this is commonly easy to see, and if the
horizontal branch is seen, it is a matter of carefully following
it to the triangular space, looking out for the site at the later-
al border of scapula where the vessels change angle and dive
into the space (Fig. 39.5).
3. Sometimes, the horizontal branch is not readily apparent on
the deep surface of the ap. If this is the case, it is worthwhile
looking for other anatomical landmarks at the upper and low-
er borders of the ap so as to ensure that the ap is sited nei-
ther too high nor low. If the incisions at the margins of the
ap are carried laterally, bevelling outward from the skin, del-
toid, and the ascending branch may be found superiorly, and
latissimus and the descending branch inferiorly. This cautious
approach ensures that the pedicle is always found in awkward
cases.
4. Once the site of the main pedicle is identi ed, attention turns
to dissecting on the surfaces of teres m ajor and m inor from
below and above, respectively. Typically, the surface of teres
major is bare muscle, similar to the surface of latissimus dorsi.
The surface of teres minor is usually covered with strong apo-
neurotic fascia similar to that found over infraspinatus, and
this extends down into the triangular space separating the
teres m uscles from each other. Dissection continues close on
the surface of the teres muscles and aponeurosis. The sharp
end of “cat’s paw” retractors are useful for pulling the muscles
away from the triangular space to start the process of opening
and enlarging the space.
5. Around this stage of dissection, it is important to nd and di-
vide the branch of the super cial CSA and its veins that enter
the infraspinatus from lateral to medial. These branches tether
the pedicle close to the scapula and, once divided, dissection
of the pedicle is easier.
6. Once the teres muscles are identi ed and start to be separated,
a self-retaining retractor is inserted between them with the
pedicle between its arms. At this stage the aim of dissection
usually becomes clear: to enlarge the space, dividing muscle
branches of the pedicle as dissection descends into the trian-
gular space. Dissection with ne scissors, bipolar, and ligating
clips is useful at this stage.
7. Once the path of the vessels becomes obvious, it is useful to
enlarge the space laterally toward the triceps and raise the
lateral end of the skin ap. This allows access to the pedicle
on all sides, and two deeper self-retaining retractors can be
used to open the space. It is advisable to dissect close to the
vessels as clear visualization make dissection easier and safer.
The self-retaining retractors are inserted deeper and deeper
as dissection proceeds and, if a long pedicle is required, larger
branches, including the infrascapular branch, are divided.
Great care should be taken to secure the infrascapular branch
so as to prevent problematic bleeding.
8. In order to reach the subscapular vessels deeper, handheld re-
tractors such as the longest Langenbeck’s are used. If the ap
should be taken to preserve the ne areolar fascia at the base
of the subcutaneous fat so as to protect the vessels. Get right
dow n onto the m uscles, but do not take m uscle or muscle apo-
neurotic fascia w ith the ap.
3. A “siege” approach dissecting toward the super cial CSA from
medial, inferior, and superior pays dividends for the inexperi-
enced operator:
a. The rst two thirds of ap elevation is a straightforward
matter of keeping to a good plane on the surface of the
muscles or over the thick aponeurotic fascia.
b. Closer to the pedicle, m ore care should be taken. As the
surgeon works carefully toward the triangular space, he/
she can use landmarks such as the thick fascia over infra-
spinatus, the ascending branch of the super cial CSA, the
lower m argin of deltoid, and the latissim us dorsi to orien-
tate the dissection.
c. Try to have a mental picture of the anatomy, and how dif-
ferent structures relate to the site of the triangular space.
Change direction of dissection from m edial, superior, and
inferior now and then when nearing the pedicle. Avoid
committing to dissection laterally until the pedicle is seen.
d. Possibly the most e ective measure has been to identify
the descending branch when raising a scapular ap or the
horizontal branch when raising a parascapular ap at the
edge of the incised ap. This vessel, which has been divid-
ed, is then used as a guide to trace toward the CSA. This
helps to identify the location of the main pedicle.
4. Use self-retaining retractors and assistance to separate the
teres major and minor muscles. As you dissect, keep thinking
about how you can open the triangular space to improve ex-
posure of the vessels. The self-retaining retractor is one of the
reconstructive surgeon’s best assistants.
5. Multiple muscular branches have to be cauterized, clipped, or
tied when dissecting the CSA. If som ething starts bleeding sig-
ni cantly in the triangular space, pack it with a wet swab for
a few minutes and get some good exposure and suction rather
than rushing to get hem ostasis and risk dam aging the pedicle.
6. Try not to raise your rst scapular ap in a person of large
habitus: it is much more di cult to see the vessels and the
ap can be bulky and awkward for the clinical indication in
such individuals.
Raising the Scapular Flap
1. Dissection is begun medially at the distal end of the ap. Ini-
tially, it is reasonable to incise the distal two thirds of the ap
at upper and lower margins, leaving the lateral third until
there is certainty over the site of the pedicle. The incision is
carried down to trapezius and the ap is elevated laterally,
moving onto the surface of the scapula and the infraspinatus
muscle. Without adrenaline in ltration, the dissection can
be moderately bloody, and it is often best to press on and not
spend undue time trying (often unsuccessfully) to control ev-
ery sm all vessel. Use of monopolar cautery is advised at this
stage. The thick fascia over infraspinatus is fairly obvious and
it should not be elevated, but the plane of dissection should be
kept close to its surface.

39 Scapular, Parascapular, CSAP, and Scapular Osteocutaneous Flaps
431
run close under the areolar fascial layer at this level. In thin-
ner patients and children, it is often easily visualized showing
through in the fat. If the descending branch is identi ed, it can
then be traced to the super cial CSA.
3. In individuals of large habitus, the descending branch can be
di cult to see in the fat, and in this instance, it has proved
helpful to raise the medial border of the ap o the infraspi-
natus, nd the horizontal branch (often by cutting it), and use
this to trace back toward the CSA, helping to con rm precisely
the level of the CSA. The direction of dissection is m oved be-
tween the inferior and medial sides to approach the super -
cial CSA by working up the surface of infraspinatus and teres
major. The lateral border of the scapula m ay be palpated to
help to identify the site of the CSA.
4. Clari cation of the line of the descending branch and the level of
the super cial CSA allows continued safe dissection to be com-
menced up the surface of the teres major to the main pedicle.
5. The superior end of the ap is then elevated and dissection is
carried down over infraspinatus and teres m inor to reach the
medial end of the triangular space, and approach the super -
cial CSA from above.
6. Once the CSA is identi ed, dissection continues as for the
scapular ap (see Step 5, above).
Raising the Circum ex Scapular
Artery Perforator Flap
The CSAP is a thin ap based on a perforating vessel that leaves
either the super cial CSA or its descending branch at or very
close to its em ergence of the CSA from the triangular space. A skin
island of up to 14 3 7 cm can be harvested. The skin island can be
is to be raised on the subscapular, the artery and vein of the
thoracodorsals have to be ligated and divided.
9. If the ap is to be passed through the triangular space for
anterior axillary or chest reconstruction, the space can be en-
larged inferiorly by incising toward latissimus dorsi and open-
ing the plane between teres major and latissimus. Care should
be taken to avoid the nerve supply to teres major if this is done.
Raising the Parascapular Flap
Commonly, a signi cantly larger ap can be harvested as a paras-
capular rather than scapular ap. An elliptical ap is centered over
the lateral border of the scapula with its superior end overlapping
the site of the super cial CSA halfway down the lateral border.
As m uch skin as can be closed directly will readily be sup-
plied by the descending branch, with the inferior extremity of the
ellipse reaching the highest point of the iliac crest. The point of
the ellipse near the crest w ill be of dubious vascularity once the
ap is elevated.
1. Dissection starts inferiorly, and the rst two thirds to three
quarters of the dissection are very straightforward. It is simply
a m atter of incising to the surface of the m uscle and elevating
the ap o the latissimus dorsi. Usually, monopolar cautery is
used at this stage. The full thickness of the subcutaneous fat
should be taken with the ap.
2. When dissection reaches the inferior angle of the scapula and
proceeds up over the scapula, care should be taken to dissect
very close on the surface of the infraspinatus fascia and the
teres m ajor so as to preserve the ne areolar fascia in the base
of the ap. It is often best to dissect with a ne scalpel and
bipolar cautery at this stage. The descending branch tends to
Fig. 39.5 Elevation of scapular ap: 2, teres major; 3, teres minor; 5, super cial branch of CSA; 6, infraspinatus;
7, trapezius; 8, rhomboid major.1

432
II Reconstructive Flaps A-to-Z
Disadvantages in comparison to the typical ap designs in-
clude a signi cantly more challenging dissection (the perforator is
fairly sm all and has to be visualized for ap thinning), and signi -
cantly smaller safe size of ap. Accordingly, it has not achieved
w idespread use in comparison to the typical aps.
The method is as follows:
1. Precise Doppler m arking of the strongest signal of the CSA is
useful.
2. Dissection is comm enced superiorly and the ascending branch
is identi ed and divided.
3. Dissection is carried inferiorly down the surface of infraspina-
tus and teres m inor to identify the m ain pedicle of the super-
cial CSA. Most of the dissection is undertaken with scissors,
separating the tissue plane to identify the vessels without
damaging them.
4. The branches of the super cial CSA are carefully dissected out
using ne scissor dissection and usually the perforator can be
identi ed arborizing directly into the skin.
5. A thin ap is elevated based on the perforator. The ap is
raised just deep to the subdermal fat and is slightly thicker
near the perforator.
6. If there is anxiety over the quality of the perforator, the de-
scending or horizontal branches can be included to augment
orientated in any direction from the super cial CSA, but it must
substantially overlap the surface marking of the CSA (Figs. 39.6
and 39.7)
The advantage of the CSAP ap over scapular or parascapular
is that the ap is much less bulky, especially around the pedi-
cle. Furtherm ore, it can be used as a ow-through ap using the
super cial CSA and horizontal or descending branches as arterial
grafts (Figs. 39.6, 39.7, 39.8, 39.9, 39.10, and 39.11).
Fig. 39.6 A posttraumatic defect (after explosion and burn injury) of
left antecubital fossa with thrombosis of brachial artery. Planned recon-
struction with CSAP ap using the transverse branch to reconstruct the
brachial artery.
Fig. 39.7 Early stage of elevation of a CSAP ap. The star shows the site of
the perforator, which has been marked with a Doppler, and the arrowhead
marks the scapular angle. Dissection commences superiorly to identify
the ascending branch, which is used as a guide to reach the CSA and its
branches.
Fig. 39.8 The branches of the super cial circum ex artery have been ex-
posed showing the main super cial CSA superiorly, the transverse branch
to the left, and the CSAP and the descending branch to the right. The
teres muscles are separated by the self-retaining retractor with the thick
aponeurosis over the teres minor above.

39 Scapular, Parascapular, CSAP, and Scapular Osteocutaneous Flaps
433
4. A segment of bone up to 12 3 3 cm may be harvested.
5. Large amounts of bone harvest may involve a relatively bloody
dissection and signi cant donor site morbidity with weakness
and shoulder sti ness. Great care should be taken to repair
muscles. Postoperative physiotherapy is crucial.
Chimeric Flap Options
As above, the scapular and parascapular aps m ay be used in
com bination, and with bone, fascia, or ow-through vessels. In
addition, the common pedicle with the thoracodorsal enables
the design of chim eric aps including latissim us dorsi, serratus
anterior, various blood vessels, and scapular bone from the infe-
rior angle supplied by the thoracodorsal angular branch.

Clinical Perspectives
As pedicled aps, the scapular axis aps m ay be used for defects
of the axilla, shoulder, lateral chest, and upper arm. By passing
the aps through the triangular space, the pedicled aps m ay
reach the anterolateral chest and supraclavicular fossa. The aps
have widespread use as free aps for head and neck or limb
reconstruction. Patient positioning (either lateral or prone) may
in uence ap selection for free ap procedures.
Suggested Further Reading
Gilbert A, Teot L. The free scapular ap. Plast Reconstr Surg 1982;69(4):
601–604
Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular ap: a new cutane-
ous microsurgical free ap. Plast Reconstr Surg 1982;69(4):591–600
Urbaniak JR, Kom an LA, Goldner RD, Armstrong NB, Nunley JA. The
vascularized cutaneous scapular ap. Plast Reconstr Surg 1982;
69(5):772–778
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
the ap with that portion of the ap taken with full thickness
of subcutaneous fat.
7. The main pedicle of the super cial CSA is dissected as for
scapular/parascapular aps.
Raising the Scapular
Osseocutaneous Flap
The infrascapular branch of the m ain circum ex scapular pedicle
may be used to support a large bone segm ent from the lateral
border of the scapula.
1. After elevation of the chosen skin ap, the triangular space
is dissected and the infrascapular branch visualized. Further
branches to the scapular bone can be seen both superiorly and
in particular descending inferiorly toward the angle.
2. The site of bone harvest is chosen and the teres minor, infra-
spinatus, and teres major are incised as required to preserve
both the vessels and the periosteum.
3. If the inferior angle is included, teres major will have to be
detached and repaired after bone harvest.
Fig. 39.9 A very thin ap has been raised based on the CSAP and the
descending branch which can be seen entering the ap. The ap has been
raised almost entirely in the plane of the subdermal fat. The transverse
branch was also raised with the ap (not seen here) to reconstruct the
brachial artery (see Fig. 39.10). For a larger ap, it would be necessary to
harvest much of the ap at a deeper plane.
Fig. 39.10 Flap partially inset and vessels anastomosed. The brachial ar-
tery has been reconstructed with the CSA owing through to the trans-
verse branch distally. The skin ap is supplied by the descending branch
and the CSAP.
Fig. 39.11 Free CSAP ap inset to the defect.

434
Superior Gluteal Artery Perforator Flaps
Phillip Blondeel, Koenraad Van Landuyt, John W. Antonetti, and Richard Young
40
Superior cluneal nerves provide sensory innervation to the
SGAP ap. SGAP innervation by the superior cluneal nerves de-
rives from terminal branches of the dorsal primary rami of seg-
mental lumbar nerves L2 and L3. The superior cluneal nerves
can be identi ed above the muscle fascia at the superior incision
margin of the SGAP ap. When a sizeable branch is encountered,
the sensory nerve can be dissected centrally and preserved for
ap innervation. For breast reconstruction, the preferred re-
cipient nerve is the fourth intercostal. During closure of sacral
wounds in patients who are neurologically intact, the superior
cluneal nerves can be dissected proximally to allow sacral wound
coverage with a sensate ap.

Surface Markings
The patient m ay be m arked in the standing position facing away
from the clinician or on the operating table.
1. The following landmarks are identi ed in the buttock region
on the side of ap harvest (Fig. 40.1).

●
Posterior superior iliac spine (PSIS)

●
Apex of greater trochanter of the femur

●
Coccyx
2. The following lines are drawn.

●
From the PSIS to the greater trochanter and divided into
equal thirds

●
From the PSIS to the coccyx and divided into half

●
From halfway between the PSIS and coccyx to the apex
of the greater trochanter (surface marking of pyriformis
muscle)
3. The SGA em erges from the pelvis at about the junction of the
medial and middle thirds of the line drawn from the PSIS to
the greater trochanter. The super cial branch then passes lat-
erally along this line giving o perforators. These perforators
lie superior to the line from the halfway point of the PSIS to
coccyx and the apex of the greater trochanter.
4. Perforators can be identi ed preoperatively with a handheld
Doppler ultrasound probe or computed tomography angiog-
raphy (Fig. 40.2). A laterally placed perforator is preferred to
give maximum pedicle length (Fig. 40.3).
5. A horizontally orientated ap is then designed around the
chosen perforator up to 13 cm in vertical height and 35 cm in
transverse length depending on local tissue laxity.
6. The lateral end of the ap axis may be placed in the natural
depression between the greater trochanter and the iliac crest

Classif cation

●
Mathes-Nahai (fasciocutaneous): type C

●
Cormack-Lamberty: type C

●
Gent consensus: muscle perforator ap

Vascular Pedicle
Perforator from the super cial branch of the superior gluteal
artery.

●
Arterial caliber: 2.0–4.5 mm

●
Venous caliber: 2.5–4.5 mm

●
Pedicle length: 8–12 cm

●
Sensory innervation: superior cuneal nerves

Anatomy
The superior gluteal artery perforator (SGAP) ap is based on the
super cial branch of the superior gluteal artery (SGA) and can be
used as a pedicled or free ap. The vascular pedicle of the SGAP
ap comprises, from distal to proximal, the muscle perforator(s),
the super cial branch of the SGA, and potentially the SGA itself if
the required pedicle length necessitates a dissection as far proxi-
mal as the source vessel.
The SGA arises as a terminal branch of the posterior division
of the internal iliac artery on the posterior pelvic wall. The SGA
exits the pelvis superior to the pyriformis muscle by piercing the
sacral fascia, which covers the greater sciatic foramen. It then di-
vides into a super cial and deep branch. The super cial branch
passes laterally supplying the overlying gluteus maximus muscle.
Between one and four perforators are generally given o by the
super cial branch passing from deep within the muscle to supply
the overlying skin. Not all of these perforating branches will be of
su cient size to adequately supply a ap. The deep branch of the
SGA passes deep to the gluteus medius muscle.
Perforator vessel length varies between 3 cm and 8 cm, with
total pedicle length varying between 8 cm and 12 cm. The SGA
diameter ranges between 2 mm and 4.5 mm, with the superior
gluteal vein ranging from 2.5 to 4.5 mm. Their angiosome is the
superolateral gluteal region. Lateral perforators provide a longer
pedicle length than medial perforators; however, they necessitate
a longer intramuscular dissection. Clinical experience has proved
that one perforator of su cient size is adequate to supply the
entire ap.

40 Superior Gluteal Artery Perforator Flaps
435
Fig. 40.1 (a) The patient can be marked in either the prone or lateral decubitus position. Landmarks for surface
markings include the posterior superior iliac spine (PSIS), apex of the greater trochanter, and coccyx. (b) Flap
design and Doppler detection: 1, Gluteus maximus muscle; 2, superior gluteal artery; 3, super cial branch of
superior gluteal artery; 4, deep branch of superior gluteal artery and superior gluteal nerve; 5, gluteus medius
muscle; 6, tensor fasciae latae muscle; 7, myocutaneous perforators.1
a
a

436
II Reconstructive Flaps A-to-Z
Fig. 40.2 Handheld Doppler identi es perforating vessels entering
the ap along the course of the super cial SGA.
Fig. 40.3 Perforators identi ed with handheld Doppler.

40 Superior Gluteal Artery Perforator Flaps
437

Patient Positioning
Flap dissection m ay be performed in either the lateral decubitus
or prone position, which will vary depending on the recipient
site. Deep vein thrombosis prophylaxis with thromboembolic
deterrent (TED) stockings and a warming blanket is used to min-
imize perioperative complications.
Unilateral breast reconstruction is performed with the
patient in the lateral decubitus position (Fig. 40.5). Lateral
if it is present. The medial end of the ap axis is placed about
5 cm down the natal cleft. An ellipse is then drawn around this
axis. To avoid a medial dog ear, the medial end of the ellipse is
angled inferiorly to create a ap that resem bles an apostrophe
(Fig. 40.4).
When elevating the SGAP for closure of sacral wounds, the
superior border of the ap is drawn in the design of a rotational
ap. This defensive approach will provide additional safety
should a suitable perforating vessel not be identi ed.
Fig. 40.5 For breast reconstruction, the pa-
tient is positioned in the lateral decubitus po-
sition allowing simultaneous mastectomy and
vessel dissection anteriorly and SGAP ap har-
vest posteriorly with a two-team approach.
Fig. 40.4 Flap is drawn to include potential perforators. Approaching the gluteal crease, the ap is curved
inferiorly to address the medial dog ear.

438
II Reconstructive Flaps A-to-Z

●
Monopolar diathermy to approach the perforator

●
Bipolar forceps and ne dissection scissors for perforator
and intramuscular dissection
Breast Reconstruction
Step 1
The ap is incised and the subcutaneous fat cut straight through
until the muscle fascia is identi ed. Some authors favor bevelling
out 1 to 2 cm to obtain additional bulk, but we caution against
this as it m ay lead to a contour deform ity at the donor site due to
inadequate subcutaneous tissue.
Step 2
Start by raising the medial end of the ap below the fascia toward
the perforator for a few centimeters.
Step 3
Raise the lateral end of the ap starting over the tensor fascia
lata super cial to the muscle fascia. We aim to excise additional
fat lateral to the tip of the ap to reduce the lateral dog ear. The
gluteus medius muscle can be distinguished from the gluteus
maxim us m uscle by the m ore vertical orientation of its m uscle
bers. As the perforator is approached, the m uscle fascia is in-
cised and the dissection proceeds in a subfascial plane toward
the preoperatively identi ed perforators. Dissection beneath the
fascia is performed by longitudinally splitting the muscular septa
to the fascia (Fig. 40.6).
positioning facilitates a two-team approach that w ill allow
for m astectomy and recipient vessel dissection anteriorly and
ap harvest posteriorly. The ipsilateral arm is prepped with
the upper body extended back 60 degrees to assist with mas-
tectomy, anterior dissection for recipient vessels, and possible
anastom osis. Microanastom osis m ay be perform ed with the pa-
tient in the lateral position for simultaneous closure of the donor
site or may be perform ed following donor site closure with the
patient in the supine position. The patient is placed supine and
upright for ap inset.
Bilateral breast reconstruction is performed in either a one- or
two-stage fashion. Single-stage bilateral breast reconstruction with
SGAP aps starts with dissection of the recipient vessels in the su-
pine position. Following dissection of the recipient vessels, moist
gauze is placed over the vessels and the skin temporarily stapled
and covered with occlusive dressing while the patient is placed in
the prone position. Two surgical teams are required for simultane-
ous ap harvest. Once the donor vessels are dissected, the aps are
harvested and placed on the back table while the donor sites are
closed. The patient is returned to the supine position for microanas-
tomosis and ap inset. Due to prolonged operative time and mul-
tiple patient positioning, a two-stage approach may be preferred.
Sacral wound closure is performed with the patient in the
prone position. Prone positioning facilitates both ap harvest and
inset. Direct pressure to the ap is avoided postoperatively.

Raising the Flap
Requirements include:

●
Loupe magni cation

●
Sharp incision of the skin
Fig. 40.6 (a) Flap harvest proceeds from lateral over the tensor fascia lata muscle and vertically oriented bers of the gluteus medius muscle
to the gluteus maximus muscle where dissection is carried out in the subfascial plane. (b) Intramuscular dissection plus pedicle dissection: 1,
Gluteus maximus muscle; 2, superior gluteal artery; 3, super cial branch of superior gluteal artery; 4, deep branch of superior gluteal artery
and superior gluteal nerve; 5, gluteus medius muscle; 6, tensor fasciae latae muscle; 7, myocutaneous perforators.1
a
b

40 Superior Gluteal Artery Perforator Flaps
439
Step 4
When the perforators come into view, they are inspected for an
arterial caliber of 1 mm or greater and two venae comitantes
of su cient size (Fig. 40.7). Usually a single perforating vessel
is selected and then dissected through the gluteal m uscle. Dis-
section of the perforating vessel proceeds by splitting the muscle
bres in a longitudinal direction to open a cleavage plane through
the gluteus m axim us without injuring m uscular function
(Fig. 40.8). Dissection proceeds toward the sacral fascia dividing
muscular side branches from the perforator as needed with bi-
polar diathermy or clips (Fig. 40.9). Occasionally ap elevation
may be performed with dissection of two perforating vessels but
a single large perforator is su cient.
Step 5
Deeper dissection is continued depending on desired pedicle
length, which will reveal the sacral fascia (Fig. 40.10). Dissection
through the sacral fascia reveals a fatty subfascial tissue plane
where multiple branches require division to provide additional
Fig. 40.7 (a) Perforating vessels are evaluated dissecting beneath the fascia of the gluteus maximus muscle.
Smaller perforators encountered may not be adequate to supply the entire ap. Care must be taken to identify
and preserve an adequate-size perforator for ap harvest. (continued)
a
pedicle length (Fig. 40.11). This is the m ost dem anding part
of ap elevation due to the delicate nature of the vessels and
di culty in determining between side branches and the source
vessels. Veins at this level have valves; therefore, m istaking a
venous side branch as the source vein could lead to venous com-
promise of the ap. At this level the pedicle length is 8 to 12 cm
and further dissection is carried out only to obtain an arterial
caliber su cient for anastomosis (2 to 4.5 mm). The vein is often
of greater size than the artery and any venous mismatch during
anastomosis will have to be handled appropriately.
Step 6
The harvested ap can be placed safely on a back table and also
weighed to compare with the mastectomy specimen if indicated
(Fig. 40.12). The donor site (Fig. 40.13a) is closed in three layers
over suction drains after elevation of the superior and inferior
aps (Fig. 40.13b). The patient has been repositioned and the
SGAP ap o ered up to the mastectomy defect. The skin paddle is
tailored for future nipple reconstruction and used to monitor the
ap postoperatively (Fig. 40.14).

440
II Reconstructive Flaps A-to-Z
b
c
Fig. 40.7 (continued) (b) Perforators are inspected for an arterial caliber of 1 mm or greater and two venae com-
itantes of su cient size. (c) Single perforator of adequate size is su cient to supply entire ap.

40 Superior Gluteal Artery Perforator Flaps
441
Fig. 40.8 Splitting the muscle bers facilitates dissection.
Fig. 40.9 Dissection proceeds through the muscle with ligation of side branches as needed.

442
II Reconstructive Flaps A-to-Z
Fig. 40.10 (a) Pedicle length increases as dissection proceeds through the gluteus maximus muscle. (b) The
sacral fascia is identi ed beneath the gluteus maximus muscle.
a
b

40 Superior Gluteal Artery Perforator Flaps
443
Fig. 40.11 (a) Multiple branches are encountered beneath the sacral fascia within a fatty tissue plane. Additional
dissection is required to obtain adequate pedicle length and vessel diameter. (b) Vessels beneath the sacral fascia
are fragile and care must be taken to maintain hemostasis.
a
b

444
II Reconstructive Flaps A-to-Z
Fig. 40.12 The ap is harvested, kept safely on a back table, and weighed for com-
parison to the mastectomy specimen if required.
a
Fig. 40.13 (a) Donor defect, which may require undermining for closure. (b) Flap design minimiz-
es dog ear deformities on closure.
b

40 Superior Gluteal Artery Perforator Flaps
445
Fig. 40.14 (a) Skin paddle will be used for future nipple reconstruction. (b) The patient,
2 years later, with a reconstruction of the left breast by a free SGAP ap and reconstruc-
tion of the right breast by a free DIEAP ap.
a
b

446
II Reconstructive Flaps A-to-Z
Step 3
Dissection of the perforating vessel proceeds by splitting the
muscle bers in a longitudinal direction to develop a cleavage
plane through the gluteus maximus. Motor innervation is not
disturbed during ap elevation.
Step 4
The inferior m argin of the ap is incised once it has been con-
rm ed that the perforating vessel is of su cient caliber w ith ad-
equate pedicle length (Fig. 40.16a) allowing ap advancement
toward the sacral defect (Fig. 40.16b). If there is inadequate ped-
icle length in a paraplegic patient, the gluteus maximus muscle
bers can be cut transversely to increase ap advancement. If an
adequate perforating vessel is not identi ed, a standard gluteal
rotational ap may be elevated as planned preoperatively.
Step 5
The donor site can be closed prim arily with m inim al underm in-
ing in a V-Y fashion (Fig. 40.17).
Wound Dehiscence Following
Abdominoperineal Resection
Another case of local reconstruction is demonstrated for a
wound dehiscence following an abdominoperineal resection and
Sacral Pressure Sores
Sacral pressure sores (Fig. 40.15) can be m anaged with pedicled
SGAP aps, which o er a greater range of movement of robust
and potentially sensate tissue.
Step 1
The superior border of the ap is incised rst, bevelling is not
needed, and the incision is carried down to the level of the fascia
and muscle. For patients who are neurologically intact, the
superior cluneal nerves may be identi ed above the muscle fascia
at the superomedial aspect of the incision. After identi cation,
the superior cluneal nerves can be dissected m edially toward the
sacral foramina increasing nerve length and allowing for sensate
ap advancement.
Step 2
From the superolateral ap m argin, subfascial dissection is per-
formed over the gluteus maximus muscle toward the preopera-
tively identi ed perforators. Dissection beneath the ap proceeds
parallel to the muscle following the bers when searching for
potential perforators. When perforators come into view, they are
inspected for an arterial caliber of 1 m m or greater and two venae
com itantes of su cient size. Usually a single perforating vessel is
selected and then dissected through the gluteal muscle. Use of
lateral perforators will provide longer pedicle length and allow
greater advancement toward the sacral defect.
Fig. 40.15 SGAP closure of a debrided sacral pressure sore. The ap marked with the patient in the
prone position and initially elevated as standard gluteal rotation ap.

40 Superior Gluteal Artery Perforator Flaps
447
Fig. 40.16 (a) Once a suitable perforator has been identi ed and successfully dissected, the gluteal ap is trans-
ferred to an island ap. (b) Elevating the gluteal ap isolated on an adequate perforator o ers greater advance-
ment than can be achieved with the standard gluteal ap.
a
b

448
II Reconstructive Flaps A-to-Z
Fig. 40.17 Tension-free closure of a sacral pressure sore with a pedicled SGAP ap.
radiotherapy (Fig. 40.18a). The ap and perforators are marked
in the prone position (Fig. 40.18b) and the ap islanded on the
single chosen perforator (Fig. 40.18c), which provides adequate
pedicle length (Fig. 40.18d) to post the ap into the pelvis, ll the
dead space, reconstruct the skin de cit (Fig. 40.18e), and get the
wound to heal (Fig. 40.18f).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Superior cluneal nerves if required

●
Perforator of adequate caliber
Identi ed and preserved:

●
Integrity of gluteus maximus

●
Sciatic nerve

Clinical Perspectives
For breast reconstruction, SGAP provides an alternative to
abdominal and latissimus dorsi aps for autologous breast
reconstruction. Most women, regardless of body habitus, will
have su cient subcutaneous fat in this region to provide for
breast reconstruction. The SGAP is indicated in patients who have
abdominal scaring that precludes use of a deep inferior epigastric
artery perforator (DIEP) ap, insu cient abdominal fat for DIEP,
and previous DIEP or abdominoplasty. Some patients may not
have adequate tissue in the gluteal region to immediately create
Fig. 40.18 This patient had recurrent colon cancer following resection
and radiation. (a) After abdominoperineal resection he developed wound
dehiscence and a nonhealing pelvic wound. (continued)
a

40 Superior Gluteal Artery Perforator Flaps
449
b
c
Fig. 40.18 (continued) (b) The ap is marked and the perforators identi ed in the prone position. (c) Fol-
lowing identi cation and perforator dissection, the ap is islandized. (continued)

450
II Reconstructive Flaps A-to-Z
Fig. 40.18 (continued) (d) Mobilization of the pedicled SGAP ap on a perforating vessel allows for ap
transposition into the intrapelvic space. (e) The ap is de-epithelialized and tunneled to ll intrapelvic
dead space and close the external wound. (f) Postoperative healed view following closure of pelvic
wound with a pedicled SGAP ap.
e
d
f

40 Superior Gluteal Artery Perforator Flaps
451
a breast of normal contour with the SGAP ap. For these patients
we aim to ll the lower lateral and medial quadrants with the
SGAP ap and in doing so re-create the inframammary fold and
achieve adequate projection. After 6 to 9 months, we perform
liposuction of the upper border of the ap and lipo ll as needed.
The aim of this is to re-create a sm ooth take o from the chest
wall and blend the ap/chest wall junction.
For sacral pressure sores, an SGAP ap is indicated for cover-
age of large sacral wounds. Use of the SGAP preserves the gluteus
maximus muscle and its blood supply. SGAP o ers greater ap
mobility with the use of a lateral perforator to increase pedicle
length when compared to the conventional myocutaneous glu-
teal ap. Use of the SGAP ap preserves other reconstructive
possibilities on both the ipsilateral and contralateral sides. The
SGAP is of particular importance in the ambulatory patient as
ap harvest does not impede muscle function.

Hints and Tips

●
Caution should be practiced not to injure regional structures
including the sciatic nerve, inferior gluteal artery, internal
pudendal artery, and posterior femoral cutaneous nerve
exiting caudal to the piriformis muscle. While adequate
exposure is required, excessive traction on the piriformis
muscle during dissection of the SGA below the sacral fascia
can result in injury to the sciatic nerve. General awareness
and avoidance of excessive traction during this portion of
the dissection will prevent injury to the sciatic nerve.

●
Dissection of vessels beneath the sacral fascia can result
in life-threatening bleeding. Two clips should be placed
on the superior gluteal artery for added safety. After li-
gation of the SGA, the vessel may retract into the pelvis.
Intrapelvic bleeding following harvest of the SGAP ap
may be di cult to control or require the use of interven-
tional radiology for embolization.

●
When dissecting the SGAP, ensure the ap is secured to the
wound margin once the muscle fascia has been cut so that
the perforator is not put under too much tension.

●
Avoid buttock contour deform ity by underm ining superi-
orly to the iliac crest and inferolaterally beyond the greater
trochanter. Adequate underm ining will provide for a thigh
lift and avoid depressions in the gluteal region.

●
Choosing a lateral perforator will create the longest
possible pedicle.

●
For sacral defects, the range of ap advancement can be
estimated and is usually m ore than 1.5 tim es the distance
between the SGA and the perforator.

●
Internal m am m ary artery and venae com itantes are the
preferred recipient vessels due to their anterior location
on the chest wall. Dissection of the internal m am m ary
vessels at the level of the third costochondral junction
w here the veins have larger diam eter w ill m ake it eas-
ier to anastom ose to the gluteal veins, w hich are often
larger.

●
SGAP breast reconstruction requires at least two stages.

●
Large suction drains at donor site for 2 weeks are used to
reduce seroma formation.

●
Pressure garm ents are used postoperatively for 6 weeks to
reduce seroma formation.
Suggested Further Reading
Allen RJ, Guerra AB, Erhard HA, Levine JL. Perforator Flaps: Anatomy,
Techniques & Clinical Applications. St. Louis: Quality Medical
Publishing, Inc.; 2006
Blondeel PN. The sensate free superior gluteal artery perforator (S-GAP)
ap: a valuable alternative in autologous breast reconstruction. Br J
Plast Surg 1999;52(3):185–193
Blondeel PN, Van Landuyt KH, Monstrey SJ, Hamdi M, Matton GE, Allen
RJ, et al. The “Gent” consensus on perforator ap term inology: pre-
lim inary de nitions. Plast Reconstr Surg 2003;112(5):1378–1383
Cheong EC, Wong MT, Ong WC, Lim J, Lim TC. Sensory innervated superior
gluteal artery perforator ap for reconstruction of sacral wound
defect. Plast Reconstr Surg 2005;115(3):958–959
Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of the breast and
pectoral region by microvascular transfer of a free ap from the
buttock. Plast Reconstr Surg 1975;56(2):178–181
Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast re-
construction with gluteal artery perforator (GAP) aps: a critical
analysis of 142 cases. Ann Plast Surg 2004;52(2):118–125
Koshim a I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal
perforator-based ap for repair of sacral pressure sores. Plast
Reconstr Surg 1993;91(4):678–683
Shaw WW. Breast reconstruction by superior gluteal microvascular free
aps without silicone implants. Plast Reconstr Surg 1983;72(4):
490–501
Shaw WW. Superior gluteal free ap breast reconstruction. Clin Plast Surg
1998;25(2):267–274
Verpaele AM, Blondeel PN, Van Landuyt K, Tonnard PL, Decordier B,
Monstrey SJ, et al. The superior gluteal artery perforator ap: an
additional tool in the treatment of sacral pressure sores. Br J Plast
Surg 1999;52(5):385–391
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

452
Soleus Flaps
Sachin M. Shridharani and Devinder P. Singh
41

Classi cation
Mathes-Nahai (m uscle): The soleus m uscle is a bipenniform
muscle classi ed as a type II muscle ap.

Vascular Pedicle
The posterior tibial artery is considered to be the dominant blood
supply to the medial hemisoleus. The peroneal artery is consid-
ered to be the dominant blood supply to the lateral hemisoleus.

●
Mean arterial caliber of posterior tibial artery: 2.7 mm

●
Mean venous caliber of posterior tibial venae comitantes:
2.9 mm and 2.17 mm

●
Mean arterial caliber of peroneal artery: 1.5–2.5 mm

●
Mean venous caliber of peroneal venae comitantes: 2–4 mm

●
Length: The length of the pedicle is determined by the arc
of rotation required. For the fully mobilized, proximally
based soleus and hemisoleus muscle aps, this distance is
from the pivot point to muscle insertion on the tendocal-
caneus, ranging 6.0 6 1.7 cm (mean 6 standard deviation)
above the calcaneus. The pivot point is determined ap-
proximately by the origin of major vascular pedicles to the
proximal muscle, located at the junction of the proximal
and middle thirds of the leg.

●
Motor innervation: Both m edial and lateral soleus m uscles
are independently innervated by branches of the medial
popliteal and tibial nerves.

Patient Positioning
The positioning of the patient depends on the hem isoleus to
be harvested. To utilize a medial hemisoleus ap, the patient is
typically supine with the knee joint in a slightly exed position
and the hip in external rotation (Fig. 41.1).
To access a lateral hemisoleus, the patient is typically supine
with the knee joint fully extended or exed and the hip internally
rotated. A stack of towels can be placed underneath the hip to
assist with increasing exposure.

Anatomy and Surface
Markings
The soleus m uscle is located in the super cial posterior compart-
ment of the leg and functions to plantar ex the foot (Fig. 41.2).
The gastrocnem ius m uscle is housed in the sam e compartm ent
and is more super cial to the soleus (Fig. 41.3). The plantaris
muscle travels in a plane between the gastrocnemius and soleus.
The soleus m uscle’s bipennate m orphology and dual vascular
supply allow for vertical splitting along a midline raphe. It is the
largest and longest muscle distal to the knee. It originates from the
Fig. 41.1 The a ected extremity is positioned with the ipsilateral hip ex-
ternally rotated in order to access the medial hemisoleus.
Fig. 41.2 Cross-sectional diagram of lower extremity: 1, gastrocnemius 
(super cial) and soleus (deep) muscles; 2, septocutaneous perforators; 3,
exor hallucis longus muscle; 4,  bula bone; 5, peroneal artery and vein; 
6, posterior tibial artery, vein, and nerve; 7, extensor muscle; 8, peroneus 
longus and brevis muscles; 9, interosseous membrane.1

41 Soleus Flaps
453
proximal tibia and bula and inserts on the calcaneus. The tissue
is classically transferred as a muscle-only ap; however, there are
musculocutaneous and fasciocutaneous perforators that allow
for the design of a wide, distally extended musculocutaneous ap
for more distal leg defects.
In planning for surgery, one may use the lateral and medial
borders of the gastrocnemius muscle as a palpable and visible
landmark. These landmarks provide assistance for incision plan-
ning and to identify the cleavage plane between the gastrocne-
mius and soleus muscles.

Raising the Flap
Step 1: Prepare the Limb
Prep the extremity circumferentially. Place an extremity drape at
the level of the mid-thigh. A thigh tourniquet is optional.
Step 2: Placing the Incision
Depending on clinical indication (Fig. 41.4), ap selection, and
defect location, the surgical approach to the soleus aps is
through either m edial or lateral m idaxial incisions (Fig. 41.5).
There are reports of placing the incision on the posterior leg m id-
line; however, this maneuver is less often performed because it
requires division of the gastrocnemius m uscle in order to access
the soleus muscle.
Step 3: Elevating Skin Flaps
The surgeon conservatively elevates adipocutaneous aps o of
the underlying muscle fascia if necessary for access.
Fig. 41.3 Exposure of lateral hemisoleus with gastrocnemius cut and 
re ected: 1, lateral head of gastrocnemius muscle; 2, soleus muscle; 
3, popliteal muscle; 4, popliteal artery and vein and tibial nerve.1
a
Fig. 41.4 A clinical case. (a) Middle-third lower leg full-thickness necrotic wound. (continued)

454
II Reconstructive Flaps A-to-Z
Step 6: Dissecting the Flap
A well-de ned, relatively avascular plane allows for e cient
separation between the gastrocnem ius and underlying soleus.
Identify and preserve the plantaris tendon, w hich travels in
this plane.
Step 7: Avoiding Danger Zone
Separate the deep surface of the soleus from the underlying fascia
of the deep posterior compartment (Fig. 41.6). Take care not to
violate the deep posterior compartment fascia, the tibial nerve,
posterior tibial pedicle, and peroneal pedicle course here.
Step 4: Encountering Critical
Structures
Preserve m ajor subcutaneous nerves and veins when possible.
When raising a medial soleus ap, identify and preserve the
greater saphenous vein. When raising a lateral soleus ap, identify
and preserve the lesser saphenous vein and sural nerve.
Step 5: Fasciotomy
At this stage, perform fasciotomy to allow access to the super cial
posterior compartment musculature.
b
Fig. 41.4 (continued) (b) Wound status after debridement with exposure of vascular bypass graft.
Fig. 41.5 The medial midaxial incision line is shown.

41 Soleus Flaps
455
Step 12: Preparing the Inset
Con rm muscle ap viability. Create a subcutaneous tunnel when
necessary to allow passage of the ap. Ensure gentle delivery and
perform inset (Fig. 41.9). Be careful not to place the ap on undue
tension (Fig. 41.10).
Step 13: Split-Thickness Skin
Grafting
Perform split-thickness autografting at this stage if there is no
dermal coverage of the newly inset muscle ap (Fig. 41.11).
Step 14: Hemostasis
Copiously irrigate the donor site and obtain hemostasis (Fig. 41.12).
Step 15: Drain Placement
Place a single 19-French round channeled drain in the donor site
defect. Bring the drain out through a separate stab incision and
secure it with a standard drain suture.
Step 16: Donor Site Closure
Close the access incision in multiple layers.
Step 8: Identifying Muscle
Perforators
Distal segmental vascular pedicles from the posterior tibial and
peroneal vessels traverse this plane. Ligate and divide these
perforating vessels as needed (Fig. 41.6).
Step 9: Raising the Flap
The soleus m uscle is designed into the needed ap, such as proxi-
mally based soleus, hem isoleus, or reversed (distally based) aps.
Proxim ally based soleus aps require division of their distal
contributions to the Achilles tendon. At this stage, preserve the
overlying and remaining gastrocnemius insertion (Fig. 41.7).
Step 10: Splitting the Muscle
If utilizing a medial or lateral hemisoleus ap, identify and divide
the vertical m idline raphe, allowing for separation of the bipen-
nate muscle bellies.
Step 11: Arc of Rotation
Distal to proximal dissection allows further isolation of the mus-
cle ap on the dom inant vascular pedicle and allows for a greater
arc of rotation (Fig. 41.8).
Fig. 41.6 The medial hemisoleus muscle is dissected o  of the deep posterior compartment fascia. A vessel loop identi es a distal perforator o  of the 
posterior tibial pedicle supplying the overlying soleus.

456
II Reconstructive Flaps A-to-Z
Fig. 41.8 The full arc of rotation is established and the  ap is being prepared for inset.
Fig. 41.7 The  ap is raised on its proximal pedicle.

41 Soleus Flaps
457
Fig. 41.9 Create a subcutaneous tunnel when necessary to allow passage of the  ap.
Fig. 41.10 Ensure there is no tension on the pedicle and compression from the overlying bipedicle skin  ap.
Fig. 41.11 A skin graft is required for recipient site coverage.

458
II Reconstructive Flaps A-to-Z

Clinical Perspectives
The soleus m uscle ap is a well-described ap option for coverage
of middle-third leg defects. It is usually transferred as a
proximally based pedicled muscle ap (Fig. 41.13). Variations
are discussed below, but include hemisoleus, reverse soleus, and
myocutaneous soleus aps. With the increased reliability of free
tissue transfer techniques, the use of the soleus has decreased;
however, it is a robust ap and should not be overlooked in com -
plex lower extremity reconstructions. Prior to reconstruction,
wounds should be stable and debrided, and the patient’s nu-
trition status should be optim ized. Preoperative vascular status
should be investigated.

Hints and Tips
1. It is important for the surgeon to recognize that the Achilles
tendon is composed of the tendinous insertions from both
the gastrocnemius and soleus muscles. By ensuring preserva-
tion of the gastrocnemius contribution to the Achilles tendon
during harvest, one can reduce donor site morbidity.
2. The surgeon should wear a headlamp.
3. Automatic vascular clip appliers facilitate e cient hemostasis.
4. Strict leg elevation is standard in the postoperative period and
a progressive dangling lower extremity protocol is initiated at
the surgeon’s discretion.
5. Repair of the fasciotomy of the super cial posterior compart-
ment can result in iatrogenic compartment syndrome.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required muscle ap

●
Dominant supplying vascular pedicle(s)
Identi ed and preserved:

●
Greater and lesser saphenous vein, if possible

●
Sural cutaneous nerve

●
Deep posterior compartment fascia

●
Plantaris muscle

●
Contributions of gastrocnemius tendon to Achilles tendon

Flap Variations
1. Distal segmental vascular pedicles permit reversal of soleus
segments on this vascular supply for distal leg and ankle
defects. Reversed (distally based) medial hemisoleus ap is
created by transversely dividing the m uscle proxim ally and
basing the distal segment on the two m ost distal posterior
tibial vascular pedicles. No more than two-thirds of the
muscle can be reliably reversed.
2. Soleus musculocutaneous aps are designed with the assis-
tance of handheld Doppler and intraoperative indocyanine
green (ICG) laser angiography to con rm perfusion to the
overlying skin paddle.
Fig. 41.12 The distal donor site wound is primarily closed and a skin graft is placed proximally. A closed suction drain is placed deep in the wound bed.

41 Soleus Flaps
459
a
Fig. 41.13 A di erent clinical case. (a) Middle-third lower leg full-thickness 
defect with exposed bone and hardware. (b) Coverage of aforementioned 
wound with medial hemisoleus  ap. (c) Split-thickness autograft placed 
on hemisoleus. Primary closure of donor site wound with placement of 
closed suction drain.
b
c
6. If elevation of skin aps is performed for access to the soleus,
the surgeon should inspect for viability prior to closure. If the
aps seem compromised, appropriate debridement should be
performed. This will increase the size of the overall dermal
defect, necessitating a larger split-thickness autograft.
Suggested Further Reading
Chan YW, Ng RW, Wei WI. Anatomical study and clinical applications of
free posterior tibial ap in the head and neck region. Plast Reconstr
Surg 2011;128:131e–139e
Ger R. Operative treatm ent of the advanced stasis ulcer using muscle
transposition. A follow-up study. Am J Surg 1970;120:376–380
Ger R. The operative treatment of the advanced stasis ulcer. A preliminary
communication. Am J Surg 1966;111:659–663
Ger R. The technique of muscle transposition in the operative treatment
of traum atic and ulcerative lesions of the leg. J Traum a 1971;11:
502–510
Guyuron B, Dinner MI, Dowden RV, Labandter HP. Muscle aps and the vas-
cular detour principle: the soleus. Ann Plast Surg 1982;8:132–140
Mathes SJ, Vasconez LO, Jurkiewicz MJ. Extensions and further applica-
tions of muscle ap transposition. Plast Reconstr Surg 1977;60:6–13
Pers M, Medgyesi S. Pedicle muscle aps and their applications in the
surgery of repair. Br J Plast Surg 1973;26:313–321
Raveendran SS, Kumaragama KG. Arterial supply of the soleus muscle: an-
atomical study of fty lower limbs. Clin Anat 2003;16(3):248–252
Schierle CF, Rawlani V, Galiano RD, Kim JY, Dumanian GA. Improving
outcomes of the distally based hemisoleus ap: principles of an-
giosomes in ap design. Plast Reconstr Surg 2009;123:1748–1754
Tobin GR. Hemisoleus and reversed hem isoleus aps. Plast Reconstr Surg
1985;76:87–96
Tobin GR, Moberg AW, Adcock R, Gemberling RM. Hemisoleus aps. Plast
Surg Forum 1981;4:126
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

460
Reverse Sural Flaps
Sachin M. Shridharani, Tom S. Potokar, Kayvan Shokrollahi, and Anthony P. Tufaro
42

Classi cation

●
Cormack-Lamberty: type A

●
Mathes-Nahai (fasciocutaneous): type A

Vascular Pedicle
Four to eight perforators arise from the bular (peroneal) ar-
tery and are considered to be the dominant blood supply to the
reverse sural ap (Fig. 42.1).

●
Mean arterial caliber, perforators from bular (peroneal)
artery: , 1.5 mm

●
Length: The length of the pedicle is determined by the arc
of rotation required. The ratio of length to width of the
adipofascial pedicle is approximately 4:1.

●
Sensory innervation: The sural nerve is the sensory
nerve supplying the skin of the lateral and posterior as-
pects of the distal third of the leg and the lateral aspect
of the foot.

Patient Positioning
The position of the patient depends to a large extent on where
the defect to be lled is located. Undoubtedly the easiest position
Fig. 42.1 (a) Anatomy of the posterior tibial ar-
tery. 1, Posterior tibial artery; 2, anterior tibial
artery; 3, peroneal artery; 4, septocutaneous per-
forators; 5, tibioperoneal trunk. (b) Contextual
anatomy of the neurovascular structures of the
proximal leg. 1, Tibia; 3, soleus muscle; 6, tibial
nerve; 7, tibioperoneal trunk; 8, posterior tibial ar-
tery and vein; 9, anterior tibial artery and vein; 10,
peroneal tibial artery and vein; 11, tibialis poste-
rior muscle; 12, exor digitorum longus muscle.1
a
b

42 Reverse Sural Flaps
461
in which to raise the ap is with the patient prone, and this is
certainly possible if the defect is on the heel or over the Achilles
tendon. For defects on the anterior ankle and foot, however, the
patient is best positioned on the appropriate side—in lateral
decubitus w ith the side opposite the a ected extremity down
(Fig. 42.2).
It is important to remember that when the patient is on their
side there is some distortion in the calf and to accurately locate
the m idline, the leg should be gently elevated to release any pres-
sure o the side of the calf that is resting on the operating table.
The supine position with the ipsilateral buttock slightly elevated
is also possible. Flexion and adduction of the hip and exion of
the knee allow raising the ap, while the whole anterior aspect
of the ankle and the medial leg remain accessible. A line can then
be drawn from the center of the Achilles to the midpoint of the
popliteal fossa, thus bisecting the calf.

Surface Markings
1. Locate a point that is three ngerbreadths (i.e., approximately
5 cm ) proximal to the lateral m alleolus and m idway between
the lateral malleolus and Achilles tendon (Fig. 42.3). This area
corresponds to where the most distal anastom osis between
the bular (peroneal) artery and the sural artery occurs. This
also demonstrates the location of the most distal perforator of
the peroneal artery.
2. Use a handheld Doppler to con rm the exact location of the
pivot point for the ap.
3. Mark this pivot point.
4. Measure the distance from the pivot point to the closest as-
pect of the defect to be lled. This corresponds to the length
of the pedicle before the skin island is elevated.
5. Mark a zigzag or “lazy S” line along the presumed course of
the sural nerve and lesser saphenous vein, which is in the line
connecting the popliteal fossa to the lateral m alleolus. Fur-
therm ore, corroborate the axis as the line from the pivot point
to the midpoint of the calf at the junction of the middle and
lower thirds of the leg (Fig. 42.2). The line is a zigzag to allow
for easy elevation of the skin aps and allow easy access for a
5-cm adipofascial pedicle, with the sural nerve at its midpoint
(Fig. 42.4).
6. The distance from the pivot point to where the elevation
of the skin and fascial ap occurs corresponds to the length of
the pedicle required.
7. Draw the outline of the defect to be lled and center this outline
on the midpoint of the axis line. It should not extend proximal-
ly beyond the point where the two heads of the gastrocnemius
come together. When outlining the ap, employ Doppler ultra-
sound to ensure inclusion of the lesser saphenous vein.

Raising the Flap
Step 1: Prepare the Limb
Prep the extremity circumferentially. Place an extremity drape at
the level of the mid-thigh. A thigh tourniquet is optional.
Step 2: Con rm Perforator
Location
Use Doppler ultrasound to con rm the location of the dom inant
perforator. The bular (peroneal) artery pierces the crural fascia,
and gives rise to several branches that join adjacent perforators,
forming an interconnecting vascular suprafascial plexus that ex-
tends from the proximal part of the leg to the posterior margin of
the lateral m alleolus. A large perforator is located approxim ately
5 cm proximal to the lateral malleolus.
Fig. 42.2 A clinical case. A zigzag line is marked along the presumed course of the sural nerve and lesser saphenous vein,
which is in the line connecting the popliteal fossa to the lateral malleolus. Furthermore, the axis is corroborated as the line
from the pivot point to the midpoint of the calf at the junction of the middle and lower thirds of the leg. In addition, the ap
design has been marked on the patient’s leg.

462
II Reconstructive Flaps A-to-Z
Fig. 42.3 A point labeled with a circled “X” is located three ngerbreadths (i.e., approximately 5 cm) proximal to the lateral
malleolus and midway between the lateral malleolus and Achilles tendon.
Fig. 42.4 The sural nerve is identi ed.

42 Reverse Sural Flaps
463
Step 3: Surgical Planning
Prepare a template of the defect with any handy sterile m a-
terial and center the template over the long axis of the pedicle
(posterior proximal calf) with its exact position determined by
the am ount of pedicle length needed. The authors advocate using
sterile paper from the surgical glove packaging as the m aterial for
the template.
Step 4: Incision
Incise the ap borders and raise the ap in a proximal to distal
fashion (Fig. 42.5).
Step 5: Identifying Critical
Structures
Perform m eticulous dissection at the lateral distal portion of
the ap w here the lesser saphenous vein and sural nerve can
be ligated. Include the proxim al segm ents of the aforem en-
tioned vein and nerve in the ap as it is raised in a subfascial
plane between the deep fascia and underlying m edial and lat-
eral gastrocnem ius m uscles. In certain instances, w here there
is concern w hether arborized vasculature has been included,
harvest a sm all cu of underlying gastrocnem ius m uscle w ith
the ap.
Step 6: Raising the Flap
Carefully preserve the subcutaneous tissue w ith the ap
base proxim al to the skin island until full arc of rotation is
achieved (Fig. 42.6). Any shearing of this tissue interface
w ill lead to overall comprom ise of the ap. Furtherm ore,
the extra subcutaneous tissue can provide increased soft
tissue coverage of the defect w ithout needing to skeletonize
the pedicle.
Step 7: Insetting the Flap
Once the inset of the ap is complete, draw attention to the new
donor site defect. Unless the ap is small, primary closure will
likely not be possible. Place a small drain in the donor site defect
(Fig. 42.7). The authors advocate for using a round, channeled
15-French closed suction drain.
Step 8: Split-Thickness Autograft
Perform split-thickness autografting at this stage if there is no
dermal coverage of the newly inset muscle ap (Fig. 42.8).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required posterior calf skin, subcutaneous fat, and fascia

●
Dom inant perforator(s), distal segm ent of lesser saphe-
nous vein, and sural nerve
Identi ed and preserved:

●
Sural nerve, if possible

●
Gastrocnemius muscle, if possible
Fig. 42.5 The ap is elevated in a proximal to distal manner.

464
II Reconstructive Flaps A-to-Z
Fig. 42.6 (a) The pedicle is identi ed with perforators in clear view. (b) The ap is raised on its distal pedicle and positioned
to cover the defect. (continued)
a
b

42 Reverse Sural Flaps
465
c
Fig. 42.6 (continued) (c) The full arc of rotation is established and the ap is prepared for inset.
Fig. 42.7 The resultant new donor site defect may require a small drain.

Flap Variations
This flap can be used as a proxim ally based flap (sural
artery flap) (Fig. 42.9) and as a free tissue transfer. The di-
rect cutaneous artery (sural artery branch) and lesser sa-
phenous vein are the dom inant blood supply and venous
drainage to this flap, respectively. When raising the sural
(anterograde) artery flap, there are several points one m ust
consider:
1. Draw a line from the posterior midline in the popliteal fossa
to the m idportion of the calcaneus bone in the posterior heel/
ankle region.
2. Center the ap on this line in the superior two-thirds of the
posterior calf.

466
II Reconstructive Flaps A-to-Z
Fig. 42.8 A skin graft is required for donor site coverage.
Fig. 42.9 (a) Sural artery ap: 1, gastrocnemius muscle; 2, lateral popliteal cutaneous artery; 3, lateral sural
nerve; 4, sural nerve; 5, lesser saphenous vein, super cial sural artery, and medial sural nerve; 7, posterior
cutaneous nerve of thigh. (b) Completion of ap elevation and further dissection of vascular pedicle:
1, gastrocnemius muscle; 2, lateral popliteal cutaneous artery; 5, lesser saphenous vein, super cial sural
artery, and medial sural nerve; 6, popliteal artery and tibial nerve; 7, posterior cutaneous nerve of thigh.1
a
b

42 Reverse Sural Flaps
467
3. The ap has been described to have a length from 10 to 20 cm
and a proposed width of 6 to 12 cm.
4. The dominant pedicle is located in the popliteal fossa.
5. The pedicle is located entering the deep fascia between the
medial and lateral heads of the gastrocnemius muscle.
6. The pedicle usually courses slightly lateral to the posterior
midline over the lateral gastrocnemius muscle.
Furthermore, should there be a need for increased pedicle
length, the surgeon should carry his/her dissection into the
popliteal fossa. Should a sensate ap be necessary, one can pre-
serve the posterior femoral cutaneous nerve (PFCN). The PFCN
is located medial to the lesser saphenous vein in the subfascial
space in the popliteal fossa.

Clinical Perspectives
The reverse sural ap is utilized to reconstruct defects of the lower
leg, heel, and foot (Figs. 42.9a and 42.10). Venous congestion is
Fig. 42.10 The same clinical case as previous gures. (a) Resultant defect on the anterior surface of the left
ankle with exposed tendons in a 52-year-old man who sustained a traumatic degloving injury. (b) View of the
previously raised ap being placed over the exposed tendons. (c) Lateral view of the a ected extremity with ap
inset and skin graft coverage of adipofascial pedicle. (continued)
a
b
c

468
II Reconstructive Flaps A-to-Z
Fig. 42.10 (continued) (d) Anterior view of a ected extremity after healing has occurred. (e) Posterior view of a ected extremity after
healing has occurred.
d
e
often seen with this ap, but can be minimized if the pedicle is har-
vest with 2 to 3 cm of tissue on either side of the pedicle. Employ-
ing the “delay” phenomenon for 4 to 10 days and ligating the prox-
imal lesser saphenous vein and sural artery will also assist with
decreasing the probability of encountering venous congestion.

Hints and Tips
1. As one approaches the proximal portion of the dissection into
the popliteal fossa (sural artery ap), it is important to visualize
the entrance of the medial super cial sural artery into the deep
fascia. Consider employing bipolar cautery at this location.
2. Take care to preserve both medial and lateral super cial
sural arteries. Anatomic variations in pedicle location could
be encountered here. Identify the larger pedicle and utilize
the supplying vessel for the ap.
Suggested Further Reading
Akhtar S, Ham eed A. Versatility of the sural fasciocutaneous ap in the
coverage of lower third leg and hind foot defects. J Plast Reconstr
Aesthet Surg 2006;59:839–845
Almeida MF, da Costa PR, Okawa RY. Reverse- ow island sural ap. Plast
Reconstr Surg 2002;109:583–591
Buluc L, Tosun B, Sen C, Sarlak AY. A modi ed technique for transposition of
the reverse sural artery ap. Plast Reconstr Surg 2006;117:2488–2492
Cavadas PC, Sanz-Gim enez-Rico JR, Gutierrez-de la Cam ara A,
Navarro-Monzonis A, Soler-Nom dedeu S, Martinez-Soriano F.
The medial sural artery perforator free ap. Plast Reconstr Surg
2001;108:1609–1615; discussion 1616–1617
Donski PK, Fogdestam I. Distally based fasciocutaneous ap from the sural
region. A prelim inary report. Scand J Plast Reconstr Surg 1983;17:
191–196
Gill NA, Hameed A. The sural compendium: reconstruction of complex
soft-tissue defects of leg and foot by utilizing the posterior calf
tissue. Ann Plast Surg 2012;69(2):203–208
Hollier L, Sharma S, Babigum ira E, Klebuc M. Versatility of the sural fas-
ciocutaneous ap in the coverage of lower extremity wounds. Plast
Reconstr Surg 2002;110:1673–1679
Moscona AR, Govrin-Yehudain J, Hirshowitz B. The island fasciocutane-
ous ap; a new type of ap for defects of the knee. Br J Plast Surg
1985;38:512–514
Ponten B. The fasciocutaneous ap: its use in soft tissue defects of the
lower leg. Br J Plast Surg 1981;34:215–220
Raveendran SS, Perera D, Happuharachchi T, Yoganathan V. Super cial
sural artery ap—a study in 40 cases. Br J Plast Surg 2004;57:
266–269
Walton RL, Bunkis J. The posterior calf fasciocutaneous free ap. Plast
Reconstr Surg 1984;74:76–85
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

469
for creation of composite osteocutaneous aps. Similarly, the
serratus anterior muscle can be harvested as part of a composite
ap. Distally the thoracodorsal artery divides into the transverse
branch (medial) and a descending branch (lateral).
By the point of division into transverse and descending
branches, the thoracodorsal nerve from the posterior chord of the
brachial plexus has joined the thoracodorsal artery and collec-
tively is described as the neurovascular hilus. The location of the
neurovascular hilus is variable but can be expected to be located
at an average 5.1 cm (2.1 to 7.5 cm) below the posterior axillary
fold and 2.2 cm (1.3 to 3.1 cm) from the lateral border of the la-
tissimus dorsi muscle.
The transverse branch travels m edially and just inferior to
the superior border of the latissim us dorsi m uscle while the de-
scending branch travels inferiorly and just medial to the lateral
border of the latissimus dorsi muscle. The descending branch of
the thoracodorsal artery often supplies two or three reliable cuta-
neous perforators. The rst musculocutaneous perforator o the
descending branch is always dominant to distal perforators. The
rst perforator of the descending branch may be located 6.6 to
15.4 cm below the posterior axillary fold within 3 cm from lateral
edge of the latissim us dorsi m uscle. Additional perforators from
the descending branch will be spaced 2 to 4 cm apart and are not
located along the same muscle ber septum as the dominant rst
musculocutaneous perforator. Therefore, harvesting additional
perforators along the descending branch of the thoracodorsal
artery will require division of additional muscle bers, compli-
cating ap harvest and possibly increasing donor site morbidity.
After exiting the dorsal surface of the muscle, the perforat-
ing vessel will arborize to the super cial fatty and subcutaneous
layer. The skin paddle must contain the perforating vessel within
its boundaries but does not have to be centered over the perfora-
tor to provide adequate supply to the ap.

Surface Markings
As vascular anatomy of the TDAP ap is variable, basic tenants of
perforator surgery should be followed. Anatomical landmarks will
vary with patient positioning and abduction of the arm. Therefore,
preoperative marking should be performed in the position of sur-
gery (Fig. 43.1). Preoperative computed tomography and duplex
Doppler may aid in identi cation of potential perforating vessels
and delineation of vascular anatomy. Due to variability of anatomi-
cal landmarks, precise mapping of perforator location is unreliable.
1. The patient is placed in the lateral decubitus position with the
arm abducted, elbow exed at 90 degrees, and pressure points
Thoracodorsal Artery Perforator Flaps
Phillip Blondeel, Koenraad Van Landuyt, Richard Young, and John W. Antonetti
43
Classif cation

●
Mathes-Nahai (fasciocutaneous): type C, occasionally type A

●
Cormack-Lamberty: type C

●
Gent Consensus: muscle perforator ap

Vascular Pedicle
Perforator from the descending branch of the thoracodorsal
artery.

●
Arterial caliber: 1.5–4 mm

●
Venous caliber: 2.5–4.5 mm

●
Pedicle length: 14–18 cm

●
Innervation: intercostal nerves

Patient Positioning
Elevation of the ap is performed with the patient in the lat-
eral decubitus position. The ipsilateral arm is prepped into the
eld and then stabilized with arm abducted and elbow exed at
90 degrees. When used for breast reconstruction as a pedicled
ap, a two-team approach can be used. When used as a free ap,
the thoracodorsal artery perforator (TDAP) is harvested in the
lateral decubitus position, donor site closed, and patient reposi-
tioned as needed.

Anatomy
The vascular pedicle of the TDAP ap comprises a musculocuta-
neous perforator from the descending branch of the thoracodor-
sal (TD) artery, which is dissected proximally to obtain adequate
vessel size and pedicle length. The TDAP ap can also be elevated
from the transverse branch of the thoracodorsal artery or septocu-
taneous perforators emerging over the lateral border of the latis-
simus dorsi muscle. Occasionally during dissection of a TDAP ap,
proximal dissection of the chosen perforator will lead to a source
artery from the lateral thoracic or superior thoracic arteries.
The thoracodorsal artery originates from the subscapular
artery (92%) or less commonly directly from the axillary artery
(8%). Branches of the thoracodorsal artery include the angular
branch and branch to the serratus anterior muscle. The angular
branch supplies the inferolateral border of the scapula and can
be used in conjunction with the thoracodorsal artery perforator

470
II Reconstructive Flaps A-to-Z
vessels m ay run several centimeters along the muscle fascia
before entering the subcutaneous tissue. Perforators from
the intercostals or serratus arteries m ay also result in false-
positive ndings when using unidirectional Doppler for
mapping of TDAP perforators.
5. The ap is marked overlying the perforating vessels in a lon-
gitudinal (Fig. 43.3a) or horizontal direction (Fig. 43.3b). Flap
length and width dimensions are dependent on the recipi-
ent site. Flaps up to 25 3 15 cm may be safely elevated on a
single perforator. An average ap size of 8 3 20 cm has been
described.

Raising the Flap
General approach to raising the ap includes loupe magni ca-
tion, sharp incision of the skin, monopolar diathermy to approach
the perforator, and bipolar forceps and ne dissection scissors for
perforator and intramuscular dissection. Flap elevation proceeds
in an inferior to superior direction for a vertically orientated ap
(Fig. 43.4) and a posterior to anterior direction for a transverse ap.
Step 1
The skin and subcutaneous tissue are incised down to the latissi-
mus dorsi (LD) muscle fascia. The dissection can be bevelled an-
teriorly to m axim ize fat volum e and ensure that the ap extends
anterior to the anterior border of LD (Fig. 43.5). In addition, lat-
eral thoracic veins may be included and used if the ap becomes
venously congested (Fig. 43.6).
Step 2
Dissection proceeds just above the LD fascia until the preopera-
tively identi ed perforator or a good-sized (. 0.5 mm) pulsatile
perforator is visualized containing one artery and two venae
comitantes (Fig. 43.7). A perforator originating from the de-
scending branch of the TD artery is preferred as that makes the
dissection easier since it is less intim ately associated with nerve
branches; in addition, the vessel course is usually shorter within
the muscle bers. If two perforators are in the same muscular
septum, both of them can be incorporated in the ap without
cutting any additional muscle bers. In some cases, a perforator,
arising from TD vessels and passing around the anterior border of
the LD muscle, is identi ed and used preferentially as no intra-
muscular dissection is required.
Step 3
If the surgeon is satis ed with the caliber and quality of the per-
forator, a complete dissection of the perforator can be done. The
anterior and superior part of the skin paddle should be left at-
tached to the LD m uscle. The m uscle is split and the perforator
is dissected cranially. All side branches are clipped or coagulated
w ith a m icrobipolar. Nerve branches are dissected away from the
vessels, and they are preserved. The perforator, usually running
in loose areolar fatty tissue, is traced to the TD pedicle (Fig. 43.8).
padded (Fig. 43.2). The lateral border of the latissimus dorsi
muscle is palpated and marked on the overlying skin.
2. The axis of the ap will be oriented longitudinally along the
lateral border of the latissimus dorsi muscle or horizontally
along the bra line. The skin paddle must contain the musculo-
cutaneous perforator or direct cutaneous perforator; therefore,
the anterior margin of the skin paddle is placed 2 to 3 cm an-
terior to the lateral border of the latissimus dorsi muscle. The
posterior margin of the skin paddle should extend at least 3 cm
posterior to the lateral border of the latissimus dorsi muscle.
The ap does not need to be centered on the perforator. At-
tention is directed toward the rst two perforators as they are
more likely to provide the dominant vascularity to the ap.
3. A point 8 cm distal to the posterior axillary fold and 2 cm m e-
dial from the lateral border of the latissim us dorsi muscle will
mark the classic description for location of the vascular hilus.
4. From this location, a handheld Doppler m ay be used to m ap
potential perforating vessels. Handheld unidirectional Doppler
may be associated with false-positive ndings as perforating
Fig. 43.1 Markings are made with the patient in the position of surgery
as movement will change anatomic landmarks. The lateral margin of the
latissimus dorsi (LD) muscle is palpated and marked with a dashed line.
Red and blue lines represent approximate location of the thoracodorsal
artery and vein. Handheld Doppler identi ed three perforating vessels
along the lateral margin of the LD muscle.

43 Thoracodorsal Artery Perforator Flaps
471
Fig. 43.2 Care must be taken during patient positioning to avoid excess pressure and traction nerve in-
jury. The recipient site may require preparation prior to harvesting the TDAP ap in the lateral decubitus
position and positional changes are often required.
Fig. 43.3 (a) A longitudinally orientated TDAP ap is centered over the
marked lateral border of the latissimus dorsi muscle. (b) A horizontally
orientated TDAP ap incorporates two preoperatively identi ed perfora-
tors from the descending branch of the thoracodorsal artery.
a
b

472
II Reconstructive Flaps A-to-Z
Fig. 43.4 Flap elevation starts distally and proceeds anterosuperiorly to
identify the lateral margin of the LD muscle.
Fig. 43.5 During this dissection, the incision has been extended anterior-
ly to ensure the ap overlies the lateral margin of the LD muscle. If the ap
does not overlie the lateral margin of the LD muscle, you risk not including
the dominant perforator in the ap.
Fig. 43.6 Branches of the lateral thoracic vein may be encountered.
When possible the lateral thoracic vein is included with the skin paddle as
a salvage option in case of venous congestion.
Fig. 43.7 The dominant perforating vessel has been identi ed and dis-
sected proximally by splitting the bers of the LD muscle. The TD nerve
is preserved and can be seen retracted laterally in this picture with the
assistance of a white vessel loop.

43 Thoracodorsal Artery Perforator Flaps
473
Step 4
The TD vessels are dissected proxim ally to their origin from the
subscapular vessels to provide adequate pedicle length. The ser-
ratus branch is divided when it hinders adequate length of the
pedicle. Only when the dissection of the vessels is complete
should the skin paddle be completely raised from the LD muscle.
The ap is now ready to be transferred (Fig. 43.9).
Step 5
If it is being used as a pedicled ap for breast or chest reconstruction,
the skin paddle is passed through the split LD muscle and into the
breast area. Extreme care should be taken at this point so as not to
damage the perforator during the transfer of the ap. If a free ap is
being used, the amount of proximal dissection is determined by the
pedicle length required and/or the donor vessel caliber at the recipi-
ent site. A pedicle length of 14 to 18 cm can be achieved (Fig. 43.10).
Step 6
The donor site is closed in layers directly over a suction drain
using suture plication when needed (Fig. 43.11). Postoperative
seroma rates are much lower compared to the LD donor site.
Fig. 43.9 Once perforator dissection has been performed, the ap is raised from the underlying
LD and isolated on its pedicle in preparation for transfer.
Fig. 43.8 A combination of elastic stay hooks and self-retainers is used
to retract the LD muscle to allow further dissection of the perforator. The
transverse branch of the TD artery and vein must be clipped and ligated to
allow proximal dissection for increased pedicle length and vessel diameter.

474
II Reconstructive Flaps A-to-Z
Fig. 43.10 TDAP aps can provide long pedicle
length. Additional length of the lateral thoracic
vein is preserved in case additional venous out-
ow is needed.
Fig. 43.11 The donor site is closed in a three-layer fashion over a closed
suction drain.
Lateral displacem ent of the nipple can occur on the donor side
(Fig. 43.12).
Step 7
Following closure of the donor site, the patient often needs to
be repositioned to access the recipient site (Fig. 43.13a) for ap
inset or microanastomosis when used as a free ap (Fig. 43.13b).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Intercostal nerves if required

●
Perforator of adequate caliber

●
Lateral thoracic vein when present (accessory venous out-
ow if needed)

●
Portion of LD muscle when needed
Identi ed and preserved:

●
Thoracodorsal nerve

Clinical Perspectives
The TDAP ap provides a good-size ap on a reliable and lengthy
pedicle that, for many applications, would ful ll the require-
ments of a traditional LD myocutaneous ap without the poten-
tial donor site morbidity. As a free ap it can be considered as
an alternative to many other fasciocutaneous aps (Fig. 43.14).
As a pedicled ap it can provide volum e replacem ent as well as

43 Thoracodorsal Artery Perforator Flaps
475
resurfacing following breast conservation therapy for breast can-
cer or as one option for autologous augmentation (Fig. 43.15).
The ap will also reach the distal third of the upper arm , neck
shoulder, and upper back.
Adequate perforators are not always identi ed at the time
of operation despite preoperative handheld Doppler assessment.
A reliable and safe ap can still be raised by incorporating a seg-
ment of LD m uscle. These aps have been described as LD m us-
culocutaneous muscle-sparing (LD-MS) aps.

●
LD-MS 1: To protect small (, 0.5 mm) but pulsatile perfo-
rators, one side of the perforator is left attached to muscle.
A segment of LD muscle measuring , 4 3 2 cm is incorpo-
rated in the ap to protect the perforator.

●
LD-MS 2: To protect multiple nonpulsatile perforators, a
2- to 5-cm longitudinal strip of anterior LD muscle is in-
corporated in the ap.

●
LD-MS 3: Incorporates most of the LD muscle.

Hints and Tips

●
Design the ap with the patient in the operative position.

●
Switch to an LD muscle-sparing ap if there is any concern
about the adequacy of the perforators.

●
Caution must be exercised when incorporating m uscle as
it tends to ooze. This can obscure the selected perforators,
Fig. 43.12 Straight line closure may result in lateral displacement of the
ipsilateral nipple.
Fig. 43.13 (a) Open tibial fracture after crush injury. (b) The ap has been inset and anastomosed end-to-side to the poste-
rior tibial artery for coverage of a grade IIIB open tibial fracture dislocation of the right knee.
a
b

476
II Reconstructive Flaps A-to-Z
making further dissection hazardous. If a m uscle-sparing
LD is opted for preoperatively, then the perforators still
need to be displayed prior to section of the muscle.

●
Medial perforators from the transverse branch may be ab-
sent in 17% of patients, whereas a reliable lateral perfora-
tor from the descending branch of the thoracodorsal artery
has been found in almost every patient. Medial perforators
may have a longer intram uscular course and be m ore inti-
mately involved with nerve branches.

●
Lateral intercostal perforators can be confused with TD ar-
tery perforators. Check deep to the LD muscle to di eren-
tiate between the two.
Fig. 43.14 (a) Transverse skin paddles can be oriented over perforators of the descending branch of the thoracodorsal artery. The ap can be of any
shape as long as the perforator is contained within the ap. (b) Open wrist dislocation with loss of soft tissue. (c) Recipient site following free TDAP ap
with anastomosis to ulnar artery. (d) Lateral and (e) anterior view of donor site following transverse TDAP ap.
a
c
e
b
d