66 Local Perforator Flap Reconstruction in the Surgical Mission Setting
677
aps were used follow ing contracture release for technically
graftable beds.
The majority of patients had a single ap perform ed at one
procedure. Multiple aps were performed at one operation in
two cases: one child had three aps and an adult two aps. One
adult patient required a second ap after partial ap loss follow-
ing the rst intervention.
The perforators were fully skeletonized in six aps and left
with a very minimal adipofascial cu in 11 aps. For one re-
verse sural artery perforator ap, the standard 3-cm adipofascial
bridge was preserved without individual perforator dissection.
The majority of aps were based on a single perforator and trans-
posed as propeller aps (mean angle of rotation for the aps was
118 degrees, range 40 to 180 degrees). The majority of donor
sites closed directly for over 80% of their length requiring only
small areas of grafting.
Harvesting scar tissue within the ap did not increase our
revision rate (Table 66.4). Epiderm olysis occurred within two
dorsal metacarpal perforator aps but only within the ap com -
ponent that carried mature skin graft as part of the ap com -
position (Fig. 66.5). These healed without surgical management
or long-term sequelae. There were no cases of full-thickness ap
loss or total ap necrosis.
When raising either a ap within the zone of trauma or a
ap that contains scar tissue, a careful stepwise m obilization is
undertaken to leave as many perforators as possible, dissecting
vessels only as much as necessary to prevent torque or tension on
ap transposition. A skin bridge (Fig. 66.4) or adipofascial bridge
was incorporated according to the perforator plus ap design
where appropriate.
Workhorse Flaps
A brief audit was undertaken over four m issions to de ne
com m on perforator aps used and their outcom e. This is sum -
m arized in Table 66.3 and outlines 18 of the aps com m only
applied. All wounds were chronic, presenting on average 26
m onths after injury (range 6 to 60 m onths). We docum ent the
parent artery the perforator originates from , the degree of scar
tissue w ithin the ap composition, the degree of vessel skele-
tonization, ap islanding, and transposition. Out of the 18 aps,
11 were used to reconstruct ungraftable beds including: (1) ex-
posed bone (four aps: two cases associated w ith osteomyeli-
tis); (2) exposed tendons and open joints ( ve aps); and (3)
exposed tendons (two aps). Seven interpositional perforator
Fig. 66.4 Illustrates a perforator plus ap raised in the zone of trauma of a
lower limb. (a) Seven-month-old compound tibial fracture from a missile
injury. All local tissues are in the zone of trauma. The lateral aspect of the
leg has scarring from an axial laceration. The blue marks indicate two Dop-
pler signals from proximal anterior tibial perforators. (b) Shows the per-
forator dissection. (c) Shows that the skin bridge of a perforator plus ap
has been retained and at day 4, the ap shows no congestion or necrosis.
b
a
c
678
III Masterclasses in Reconstructive Flaps
(continued)
Table 66.3 Summary of source of perforator artery, ap composition, movement, and outcome for 18 perforator aps
undertaken during missions
Patient
Perforator
Flap
composition
Flap movement
Degree
rotation
Closure donor
site
Complication and outcome
Flap
Skeletonized (S)
1: Normal tissue
Direct closure
(DC)
Parent vessel
Adipofascial cu
(AFC)
2: Zone trauma
scar tissue (ST)
Direct closure
and graft
Perforator plus
ap
Grafted tissue
(GT)
100% split skin
graft (SSG)
Skin bridge (SB)
Adipofascial
bridge (AFB)
Patient 1 (2 aps)
Posterior tibial artery
1 perforator: AFC
1 1 2 (ST)
Propeller
transposition
180
SSG
Partial patchy necrosis within
scarred area ap: ap debrided
and replaced before mission
ended to endure fracture cover
before mission exit
Anterior tibial artery
2 perforators: S
1 1 2 (ST)
Propeller
transposition
90
SSG
Nil
Patient 2
Anterior tibial artery
1 perforator: AF
1 1 2 (ST)
Perforator plus
transposition ap
40
SSG
Nil
SB: perforator plus
Patient 3
Sural artery and peroneal
perforators
1 perforator: S
1
Propeller
transposition
180
DC
Partial skin loss after discharge
(compliance issues with weight
bearing)
Secondary SSG; no further
problems
Patient 4
Sural artery and peroneal
perforators
3 peroneal
perforators: AFB
1
Propeller
transposition
180
Direct close
50% defect
Nil
SSG 50% defect
Patient 5 (2 aps)
Left angular artery
1 perforator: S
1 1 2 (ST)
Propeller
transposition
90
Direct closure
Nil
Right angular artery
1 perforator: AFC
1 1 2 (ST)
Propeller
transposition
90
Direct closure
Nil
Patient 6
Lateral intercostal artery
1 perforator: AFC 2 (ST)
Perforator plus
80
Direct closure
Nil
SB: perforator plus
Intact skin bridge
Patient 7
First dorsal metatarsal
artery
1 perforator: AFC
1
Propeller
transposition
90
Direct closure
80%
Nil
Full-thickness
skin graft
(FTSG) 20%
Patient 8
First dorsal metatarsal
artery
1 Perforator: AFC
1
Propeller
Transposition
90
Direct closure
Minor epidermolysis in donor site
Z-plasty raised in formally grafted
tissue; no long-term sequelae
66 Local Perforator Flap Reconstruction in the Surgical Mission Setting
679
Initial Planning
Time
Consider the following questions:
1. Duration of the surgical procedure: Decide whether you will
prioritize major cases or treat a greater number of minor
cases. This mission has a nite duration. The number of pa-
tients who present will be great.
2. Duration of the mission: Is there time for revision surgery
should complications occur? Do major cases early in the
mission.
3. “Timing” of staged procedures: Will the members of the mis-
sion nd “time” to come back, or can only single-stage pro-
cedures be done? Will the patient be repatriated elsewhere
before the mission returns?
Re ections and
Considerations
The reconstructive ladder applies the simplest technique rst
and progresses to m ore complex procedures. As emphasized by
Mardini in 2005, the simplest technical solution m ay neither
have the lowest complication rate nor be the best solution to
restore form and function. In the developing world, a recon-
struction m ust m axim ize function and surgical complications
m ust be kept to a m inim um irrespective of the complexity of
the case.
Managing chronic wounds in the developing world is truly a
di erent beast to managing them in the comfort of our developed
world hospitals. We would like to add some re ections, observa-
tions, and the lessons learned for consideration.
Table 66.3 Summary of source of perforator artery, ap composition, movement, and outcome for 18 perforator aps
undertaken during missions (continued)
Patient
Perforator
Flap
composition
Flap movement
Degree
rotation
Closure donor
site
Complication and outcome
Patient 9 (3 aps)
1) Third dorsal metatarsal
artery right foot
1 perforator: AFC
1 1 2 (GT)
Propeller
transposition
90
Direct closure
Epidermolysis ap tip; no
sequelae long-term
2) First dorsal metatarsal
artery left foot
1 perforator: AFC
1 1 2 (GT)
Propeller
transposition
90
Direct closure
Epidermolysis proximal edge;
no sequelae long-term
3) Radial artery
perforator ap
1 perforator: S
1
Propeller Islanded
perforator
180
Direct closure
50%
FTSG 20%
Intraoperative arterial spasm.
Flap returned. 48-hour delay.
Partial distal loss (skin only).
Corrected with SSG.
Patient 10
Fourth dorsal metatarsal
artery left foot
1 perforator: AFC
1 1 2 (ST)
Propeller
transposition
90
Direct closure
80%
Nil
FTSG 20%
Patient 11
Posterior tibial artery
2 perforators: S
1
Propeller
transposition
110
Direct closure
80%
Nil
FTSG 20%
Patient 12
Thoracodorsal perforator
artery ap
1 perforator: AFC
1
Propeller
transposition
180
Direct closure
Nil
Patient 13
Radial artery
1 perforator: S
1
Propeller
transposition
180
Direct closure
80%
Lost to long-term follow-up
SSG over
adipofascial
pedicle
Patient 14
Second dorsal metacarpal
artery
1 perforator: AFC
1
Propeller
Transposition
90
Direct closure
Lost to long-term follow-up
680
III Masterclasses in Reconstructive Flaps
Contracture and Bony Deformity
Pediatric patients m ay have bony deformity caused by restricted
grow th secondary to delayed treatment of a contracture
(Fig. 66.6). In such cases, one has to accept that contracture re-
lease simply prevents further grow th deformity rather than ful-
ly correcting the presenting bony deform ity (unless a com bined
case is possible with orthopaedic colleagues).
Compliance
Patient compliance can be a challenge. Sm oking is a common
issue. These are young people who have been through war and
the concept of long-term future gain for a short period of disci-
pline can be hard. Field hospitals give opiates liberally. The med-
ical team needs to be aware that an opiate addiction may not be
declared preoperatively for cultural reasons. This can adversely
a ect the patient’s anesthetic care, ward behavior, and postoper-
ative compliance.
Facilities
1. Surgical equipment: What is available? How does this limit
the scope of my practice?
2. Anesthetic support: Can a prolonged procedure be done
safely? Day-care surgery only?
3. Aftercare support: In recovery and on the ward? Is it safe to do
what I would at home?
4. Rehabilitation: Any physiotherapist? Splintage? Who will do
this when I’m gone?
Patient Characteristics
The patients presenting in the developing world are m ainly
young people and children. This has the advantage that, despite
comorbidity, poor diet, and smoking, they have good tissues and
are physiologically t enough to withstand the challenge of sur-
gery and anesthesia.
Table 66.4 The outcome of nine local perforator aps raised in the zone of trauma and containing scar tissue within
the ap substance
Flap type
Scar tissue component of ap and
etiology scar
Degree of dissection
of perforator
Complication
Outcome
Patient 1
Posterior tibial artery
7-month-old missile injury
Flap raised in zone of trauma
Visible scar tissue around perforator
Adipofascial cu left
around vessels
Patchy full-thickness
necrosis throughout ap
Debrided and further
ap raised
Patient 1
Anterior tibial artery
7-month-old missile injury
Flap raised in zone of trauma
Visible scar tissue within ap distal
one-third
Three perforators
skeletonized to allow
advancement and
rotation
Nil
No long-term problem
Patient 2
Anterior tibial artery
Missile injury middle one-third tibia
Osteomyelitis compound tibial fracture
Flap raised completely in areas of
previous injury
Flap: 100% within scarred area
Proximal skin bridge
left (perforator plus ap)
Adipofascial cu left
around perforator
Nil
No problems to date
Monitoring bone union
Patient 5
Right angular artery
Burn contracture/missile blast
Flap raised completely in areas previous
injury
Flap: 10% SSG, 90% normal tissue
Adipofascial cu left
around perforator
Nil
No long-term sequelae
Patient 5
Left angular artery
Burn contracture/missile blast
Flap raised completely in areas previous
injury
Flap: 20% SSG, 80% normal tissue
Perforator skeletonized
Nil
No long-term problems
Patient 6
Lateral intercostal
perforator ap
Burns contracture breast
No primary treatment so chronic scar
tissue
Flap 100% in zone trauma
Proximal skin bridge
left (perforator plus ap)
Adipofascial cu left
around perforator
Nil
No long-term problems
Patient 9
First dorsal metatarsal
artery left foot
Burn contracture
Flap: 20% normal skin, 80% mature SSG
Adipofascial cu left
around vessels
Epidermolysis 40%
mature SSG
No revision necessary
No recurrent contracture
Patient 9
Third dorsal metatarsal
artery right foot
Burn contracture
Flap: 80 % normal skin, 20% mature SSG
Adipofascial cu left
around vessels
Epidermolysis of 10%
mature SSG
No revision necessary
No recurrent contracture
Patient 10
First dorsal metatarsal
artery left foot
Degloving injury treated with SSG
Extension contracture from mature SSG
Flap: 80% normal skin, 20% scar tissue
(not SSG)
Adipofascial cu left
around vessels
Nil
No long-term problems
66 Local Perforator Flap Reconstruction in the Surgical Mission Setting
681
Cultural Sensitivities: Amputation
May Be Considered an
Unacceptable Option
Cultural sensitivities and beliefs can result in patients refusing
certain interventions even at the risk of life-threatening sepsis.
Amputation can be refused for functionless, insensate limbs with
chronic osteomyelitis. Clear and realistic preoperative discus-
sions must take place explaining the potential outcomes of sur-
gery as well as the risks of rejecting surgery. Amputation must be
clearly discussed if it is a possible outcom e. Appropriate trans-
lators are a crucial part of the surgical team so that nothing is
omitted or lost in translation. For such patients, the surgical focus
may have to shift to debridem ent, irradiation of osteomyelitis,
and closure, even though function cannot be restored. This con-
trasts to the developed world, where an appropriate amputation,
quality prosthetics, and rehabilitation services restore health and
function.
Injury Considerations
Severe Contractures
Contractures are severe and not limited to a cutaneous cicatrix.
Capsulotomy and tendon lengthening may be necessary, so al-
ways be prepared for the ungraftable defect following contrac-
ture release; have a plan for vascularized tissue transfer.
Composite Flaps: Scar Tissue and
Mature Graft
Harvesting scar tissue as a ap component did not in uence the
revision rate. Rather than considering raising a perforator ap in
a zone of trauma, or having scar tissue within the ap, as relative
contraindications, we would urge carefully applying the “cut as
you go” technique to m axim ize the vascular input. As m any per-
forators as possible were kept and the perforator plus ap tech-
nique applied where necessary.
Share With Your Team and Teach
Training the team is important. Raising a local perforator ap re-
quires the sam e degree of respect for the tissues as raising a free
perforator ap. This can be very di erent to the surgery the local
team routinely performs. For the immediate aftercare, there may
not be any ward sta and the family may be the ones who have to
supervise bedrest and elevation. At least twice-daily supervision
on the ward by the surgeon is mandatory and instructions must
be repeated without impatience.
Continuity of Care: Global Care
Continuity of care can be established despite the short duration
of a surgical mission. This encompasses implementing a staged
reconstructive program, following the patient in the early post-
operative period and handing the patient over to a colleague from
Fig. 66.5 (a) A 3.5-year-old boy with previous burn injury to the dorsum of his right foot treated acutely with split skin grafting. Progressive devel-
opment of extension contractures with growth of rst to third toes. (b) Release of toe extension contracture, application of dorsal metatarsal artery
perforator ap; 80% of the ap is normal skin, 20% mature skin graft on adipofascial base. (c) Zone of epidermolysis corresponds to area of mature graft.
This healed spontaneously without recurrence of the contracture.
a
b
c
682
III Masterclasses in Reconstructive Flaps
reliable and versatile flaps w hen perform ed in a challenging
environm ent.
The nature of the population and the environment m eans
the surgeon and team m ust adapt. Local perforator aps achieve
functional and aesthetic results but complications must be kept
to a minimum. Flaps can be planned in the zone of trauma and
contain scarred tissue in their substance but arterial input and
venous drainage m ust be kept to a maximum without compro-
mising the ap’s transposition. Tim ing is the key consideration
for successful surgery in an austere environment: time to execute
the surgery, time to revise if necessary, follow-up time, and time
to rehabilitate the patient.
In an environm ent where free tissue transfer is not gener-
ally feasible, local perforator aps com e into their ow n. Their
application can be for both acute and chronic wounds and the
quality of tissue transferred can be both a functional and cos-
m etic solution in the complex, ungraftable wound. Raising
these aps in the zone of traum a or incorporating scar tissue
as part of the ap does not necessarily increase the risk of ap
necrosis as long as the ap is raised, preserving the m axim al
blood supply.
another mission if required. Long distance, online dressing clinics
are run immediately after each mission until patients’ wounds
are healed and rehabilitation complete. This allows communi-
cation with nursing colleagues and therapists in the eld ad-
dressing any problems early. Teaching continues despite distance
thanks to the Internet.
Local situations can change, preventing the return of the
mission or the patients can be displaced as refugees. With the
patients’ consent, electronic clinical records can be complied
using photography of both written notes and patient images. The
patient can keep an electronic copy and surgeons all over the
globe can communicate as necessary via the Internet to discuss
procedures done to date.
Conclusion
A user’s guide is proposed in this chapter for the application of
local perforator flaps w hen perform ed in a post-conflict set-
ting. The environm ent, planning, and patient characteristics
have to be considered to enhance the outcom e of these
Fig. 66.6 Growth deformity secondary to untreated contracture and bony injury. (a) Crush and degloving injury was treated acutely with skin grafting
5 years previously. (b) Soft tissue contracture and forefoot shortening have resulted in deformity and dorsal extension contracture of all toes. (c,d) First
dorsal metacarpal artery perforator ap corrects extension contracture but does not correct foreshortening of foot from existing bony deformity.
a
b
c
d
66 Local Perforator Flap Reconstruction in the Surgical Mission Setting
683
Ozdem ir R, Kocer U, Sahin B, Oruc M, Kilinc H, Tekdem ir I. Exam ination
of the skin perforators of the posterior tibial artery on the leg
and the ankle region and their clinical use. Plast Reconstr Surg
2006;117:1619–1630
Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery ap:
Caveats for success. Ann Plast Surg 2002;48:496–504
Qassemyar Q, Havet E, Sinna R. Vascular basis of the facial artery perfora-
tor ap: Analysis of 101 perforator territories. Plast Reconstr Surg
2012;129:421–429
Quaba O, Quaba A. Pedicled perforator aps for the lower limb. Semin
Plast Surg 2006;20:103–111
Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator aps: History, con-
troversies, physiology, anatomy and use in reconstruction. Plast
Reconstr Surg 2009;123:132e–145e
Schaverien MV, Hamilton SA, Fairburn N, Rao P, Quaba AA. Lower limb
reconstruction using the islanded posterior tibial artery perforator
ap. Plast Reconstr Surg 2010;125:1735–1743
Schaverien M, Saint-Cyr M. Perforator aps of the lower leg: Analysis of
perforator locations and clinical application for pedicled perforator
aps. Plast Reconstr Surg 2008;122:161–170
Taylor GI, Doyle M, McCarten G. The Doppler probe for planning
aps: Anatom ical study and clinical applications. Br J Plast Surg
1990;43:1–16
Tsai FC, Yang JY, Mardini S, Chuang SS, Wei FC. Free split-cutaneous per-
forator aps procured using a three-dimensional harvest technique
for the reconstruction of post-burn contracture defects. Plast Re-
constr Surg 2004;113:185–193
Verhaegen PDHM, Stekelenburg CM, Trier AJM, Schade FB, Van Zuijlen
PPM. Perforator-based interposition aps for sustainable scar
contracture release: A versatile, practical and safe technique. Plast
Reconstr Surg 2001;127:1524–1532
Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style aps: A further
step forward for perforator ap surgery. Plast Reconstr Surg
2009;124:419–426
Waterston SW, Quaba O, Quaba AA. The ad hoc perforator ap for con-
tracture release. J Plast Reconstr Aesthet Surg 2008;61:55–60
Chapter Credit
This chapter and its tables are adapted with the kind permission of
Elsevier from an earlier version published as Godwin Y, Righi B, Robotti E.
A User’s Guide to local perforator ap reconstruction in a post-con ict
setting. J Plast Reconstr Aesthet Surg 2016;69:e57–e60
Suggested Further Reading
Al-Qattan MM. A modi ed technique for harvesting the reverse sural artery
ap from the upper part of the leg: Inclusion of a gastrocnemius mus-
cle “cu ” around the sural pedicle. Ann Plast Surg 2001;47:269–278
Brunetti B, Tenna S, Aveta A, Segreto F, Persichetti P. Freestyle local perforator
aps: Versatility of the V-Y design to reconstruct soft-tissue defects
in the skin cancer population. Plast Reconstr Surg 2013;132:451–460
Chaput B, Garrido I, Pluvy I, Grolleau JL, Mojallal A. Free style local
perforator aps: Versatility of the V-Y design to reconstruct
soft-tissue defects in the skin cancer population. Plast Reconstr
Surg 2014;133:432e–433e
Chen SL. Thoracodorasal artery perforator ap for extremity reconstruc-
tion. Sem in Plast Surg 2006:20;112–120
Fodor L, Horesh Z, Lerner A, Ramon Y, Peled IJ, Ullm ann Y. The distally
based sural musculocutaneous ap for the treatment of the distal
tibial osteomyelitis. Plast Reconstr Surg 2007;119:2127–2136
Geddes CR, Morris SF, Neligan PC. Perforator aps: Evolution, classi ca-
tion, and application. Ann Plast Surg 2003;50:90–99
Godwin Y, Righi B, Robotti E. A User’s Guide to local perforator ap re-
construction in a post-con ict setting. J Plast Reconstr Aesthet Surg
2016;69:e57–e60
Gottleib LJ, Krieger LM. From the reconstructive ladder to the reconstruc-
tive elevator. Plast Reconstr Surg 1994;93:1503–1504
Hamdi M, Landuyt VK, de Frene B, Roche N, Blondeel P, Monstrey S. The
versatility of the inter-costal artery perforator (ICAP) aps. J Plast
Reconstr Aesthet Surg 2006;59:644–652
Lecours C, Saint-Cyr M, Wong C el al. Freestyle pedicle perforator
aps: Clinical results and vascular anatomy. Plast Reconstr Surg
2010;126:1589–1603
Maciel-Miranda A, Morris SF, Hallock GG. Local aps, including pedicled
perforator aps: anatomy, technique and applications. Plast Recon-
str Surg 2013;131:896e–911e
Mardini S, Wei FC, Salgado CJ, Chen HC. Reconstruction of the reconstruc-
tive ladder. Plast Reconstr Surg 2005;115:2174
Matros E, Disa JJ. Uncommon aps for chest wall reconstruction. Sem in
Plast Reconstr Surg 2011;25:55–59
Mehrotra S. Perforator-plus concept: Adding versatility to traditional
aps. Plast Reconstr Surg 2009;123:219e–220e
Mehrotra S. Perforator-plus aps: A new concept in traditional ap
design. Plast Reconstr Surg 2007;119:590–598
Misra A, Niranjan NS. Fasciocutaneous aps based on fascial feeder
and perforator vessels for defects in the patellar and peripatellar
regions. Plast Reconstr Surg 2005;115:1625–1632
684
Peroneus Brevis Muscle Flaps for Lower
Limb Reconstruction in Burns or Trauma
Dilnath Gurusinghe, David Bell, and Kayvan Shokrollahi
67
Technique: Case Example
A patient with 75% body surface area, full-thickness, accelerant-
derived ame burns with necrosis of the anterior compartment
of the right leg required reconstruction of approximately 15 cm
of the lateral surface of the tibia (Fig. 67.1).
Early burn wound excision and grafting of the lower lim bs
was complete. The obvious challenges of lim b salvage included
the local fasciocutaneous and free tissue options being in-
volved in the areas of full-thickness burn; proxim al recipient
vessel sites being w ithin the zone of injury; the absence of
adjacent anterior compartm ent m usculature; and m inim izing
complex procedures on a patient w ith such signi cant concom -
itant injury w ith heavy bacterial colonization. Even traditional
last-resort m ethods such as cross-leg aps were not feasible
due to the bilateral and extensive nature of the burns to both
lower lim bs.
A proximally based peroneus brevis muscle ap is a versa-
tile and easily accessible option in the adjacent lateral compart-
ment with an acceptable donor site and functional de cit with
peroneus longus intact.
The procedure is perform ed under tourniquet control with
the patient supine and foot in plantar exion in order to relax the
peroneal compartment and maximize ap length for harvest. In
this case, the lateral compartment was accessed via the overly-
ing intermuscular septum separating it from the open anterior
compartm ent. Alternative access to the compartm ent is gained
via a skin incision made just behind and parallel to the posterior
border of the bula. Peroneus brevis is identi ed by its anterior
and deep position in relation to the overlying peroneus longus,
which has a musculotendinous junction beginning more proxi-
mally. The super cial peroneal nerve is visualized and protected
at a proximal level.
Peroneus brevis is delineated within the compartment
and freed distally along its tendinous portion. Extra precaution
should be taken to preserve the paratenon and therefore the use-
ful, graftable length of the distal extent of this ap. With traction
on the brevis tendon in a proximal direction, it can be divided as
distally as possible either from within the wound or via a sepa-
rate incision over its insertion into the fth metatarsal. Similar
to gastrocnemius, the tendinous portion of the ap is useful to
anchor the inset (Fig. 67.2). Tenodesis of the peroneus brevis and
longus tendons has been described in order to limit any loss in
ankle stability during locomotion.
Dissection is continued from distal to proximal initially in
the subperiosteal plane (Fig. 67.3). It is important to note that
this periosteal portion of the ap should rem ain on the deep
Introduction
Reconstruction of the distal third of the tibia has long been a
reconstructive challenge for the plastic surgeon, frequently re-
quiring the use of free tissue transfer or local options when the
zone of injury allows. The numerous options attempted are a
testament to surgeons’ and patients’ frequent dissatisfaction
with the cosmetic and functional result of both the donor and
recipient sites.
However, in the speci c scenario of the major burn, the
locoregional options, recipient vessel quality, systemic suitability
of the patient, availability of less bulky fasciocutaneous free aps,
as well as acceptable donor site morbidity may all be unsuitable
or unavailable. Loss of all or part of a compartment will further
compound this challenge by rem oving go-to, regional, pedicled
muscle ap options.
Planning
As detailed in the excellent cadaveric studies by Chambers and
Larson, the peroneus brevis is a thin, fusiform muscle located
within the lateral compartment of the leg that contributes to
plantar exion and eversion of the foot. It takes its origin from the
distal two-thirds of the bula and adjacent intermuscular septa,
lying deep and anterior to peroneus longus. It can be muscular
up to and even beyond the level of the lateral malleolus, behind
which its tendon passes to eventually insert into the styloid pro-
cess on the lateral side of the base of the fth metatarsal. Innerva-
tion is derived from the common peroneal nerve. The muscle has
a rich blood supply, receiving muscular perforators from all three
major vessels of the leg with a consistent, dominant, proximal
pedicle from the peroneal artery being one of an average of four.
This greatly increases its versatility, as based upon these, it may be
transposed on either proximal or distal pivot points. The vascular
structure of peroneus brevis appears to allow complete lling of
the muscle from all three isolated source arteries and the addi-
tional, consistently observed presence of an axial vessel running
throughout the length of the muscle and connecting these source
arteries prompts suggestion that it might be classi ed a novel type
VI muscle ap rather than type II or IV as previously reported.
The reconstructive uses of the proxim ally based peroneus
brevis muscle ap were rst described in the literature by Pers
and Medgyesi. Eren et al. further detailed its distally based mer-
its for defects of the lateral ankle and tendo-Achilles region. The
most signi cant series reported to date is by Schmidt and Giessler
with over 100 cases.
67 Peroneus Brevis Muscle Flaps for Lower Limb Reconstruction in Burns or Trauma
685
Fig. 67.1 Right leg with absent anterior compartment structures, 15 cm of exposed lateral tibia, and healed meshed
autograft over the lateral compartment. An extending incision has been made posterior to the lateral malleolus where
the peroneus brevis tendon is visible.
Fig. 67.2 Peroneus brevis identi ed anterior and deep to peroneus longus before dividing its tendon distally; the tendon
of peroneus longus can be seen immediately beneath the raised muscle.
surface after inset as there is a possibility of heterotopic ossi ca-
tion interfering with graft take if left super cial.
Branches passing to the peroneus longus are ligated with
care taken to preserve the axial vessel running posteriorly within
peroneus brevis over the posterior intermuscular septum. Four
peroneal artery muscular perforators are described passing
through the septum to supply peroneus brevis, one of which is
illustrated in Fig. 67.4. The dominant distal perforator is encoun-
tered within 6–8 cm of the lateral malleolus and ligated as neces-
sary to allow a proximal pivot point of the ap. Similarly, extra care
686
III Masterclasses in Reconstructive Flaps
Fig. 67.3 Peroneus brevis raised from distal to proximal allowing identi cation of perforators; muscle not completely
detached from its origin proximally; bula identi ed with forceps.
Fig. 67.4 One of the perforators passing from the peroneal artery through the posterior intermuscular septum
indicated by yellow arrow.
67 Peroneus Brevis Muscle Flaps for Lower Limb Reconstruction in Burns or Trauma
687
Fig. 67.5 Peroneus brevis muscle raised with tendon and paratenon, proximal attachment preserved.
Fig. 67.6 Peroneus brevis muscle fanned out and tendon used to secure inset to medial border of defect; donor site
closed without tension.
is required to preserve the attachment of the proximal 4–6 cm of
muscle and the dominant proximal perforator therein (Fig. 67.5).
By careful release of the epimysium, particularly parallel to
the tendon, the m uscle may be fanned out to increase its sur-
face area for inset (Fig. 67.6). The defect covered here measured
approximately 15 3 5 cm , with the donor site being covered by
the rem aining contents of the lateral compartm ent and prim ary
closure of the extensile incision. Meshed split skin graft from un-
burned skin was used to cover the entire muscle and paratenon
(Fig. 67.7).
688
III Masterclasses in Reconstructive Flaps
Conclusion
The peroneus brevis m uscle ap provides a relatively easy re-
constructive option allowing lim b salvage in challenging cases,
as well as an alternative to other more traditional reconstruc-
tive choices for a variety of other lower lim b defects. Moreover,
increased awareness of this ap highlights the availability and
versatility of this ap for a range of less complex reconstruc-
tions with potentially less morbidity than other muscle aps of
the region. Rapid graft take and stability alludes to the robust
vascularity throughout the length of the ap when based proxi-
mally (Fig. 67.8). The donor site is cosmetically and functionally
Fig. 67.7 Meshed autograft laid over muscle and paratenon.
Fig. 67.8 Reconstruction healed at 3 weeks postop with complete graft take.
67 Peroneus Brevis Muscle Flaps for Lower Limb Reconstruction in Burns or Trauma
689
of the lower leg: Postoperative ankle function and stability evalua-
tion. J Plast Reconstr Aesthet Surg 2010;63(9):1523–1533
Lyle G, Colborn G. The peroneus brevis muscle ap for lower leg defects.
Ann Plast Surg 2000;44(2):158–162
Mathes S, Nahai F. Peroneus brevis ap. In: Mathes S, Nahai F, eds. Recon-
structive Surgery: Principles, Anatomy and Techniques. New York:
Churchill Livingstone; 1997:1437–1445
Ng Y, Chong K, Tan G, Rao M. Distally pedicled peroneus brevis m uscle
ap: a versatile lower leg and foot ap. Singapore Med J 2010;
51(4):339–342
Pers M, Medgyesi S. Pedicle muscle aps and their applications in the
surgery of repair. Br J Plast Surg 1973;26(4):313–321
Sabapathy S, Bajantri B, Bharathi R, Ramkumar S, Latheef L, Dhane S.
Experience with peroneus brevis m uscle aps for reconstruction of
distal leg and ankle defects. Indian J Plast Surg 2013;46(1):48
Schm idt A, Giessler G. The muscular and the new osteom uscular compos-
ite peroneus brevis ap: experiences from 109 cases. Plast Reconstr
Surg 2010;126(3):924–932
Taylor I, Pan W. Angiosom es of the leg: anatom ic study and clinical impli-
cations. Plast Reconstr Surg 1998;102(3):599–616
Yang Y, Lin T, Lee S, Chang K, Lai C. The distally pedicled peroneus brevis
muscle ap anatomic studies and clinical applications. J Foot Ankle
Surg 2005;44(4):259–264
acceptable with no appreciable loss of contour or ankle stability.
Carefully m aintaining the paratenon and releasing the epimysium
are recommended to substantially increase the useful surface
area of the ap for coverage of defects of the distal tibia.
Suggested Further Reading
Chambers G, Larsen A. Characterization of the peroneus brevis m uscle
for closure of lower extremity defects: A cadaveric study and
case report. Available at: /pdfs/
Update_2002/2002_41.pdf
Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus bre-
vis m uscle ap: a new ap for the lower leg. Plast Reconstr Surg
2001;107(6):1443–1448
Kneser U, Brockmann S, Le er M, Haeberle L, Beier J, Dragu A, et al. Com -
parison between distally based peroneus brevis and sural aps for
reconstruction of foot, ankle and distal lower leg: An analysis of
donor-site m orbidity and clinical outcome. J Plast Reconstr Aesthet
Surg 2011;64(5):656–662
Lorenzetti F, Lazzeri D, Bonini L, Giannotti G, Piolanti N, Lisanti M, et al.
Distally based peroneus brevis muscle ap in reconstructive surgery
(Trang không có chữ)
691
Index
thrombogenic factors in, 35, 35t
triangulation technique of, 34, 34f
Angiography
in breast reconstruction, 62–64, 64f–65f
in lower limb reconstruction, 109–110
preoperative, 32, 44, 45–48
Angiosome, 267
Angiotome, 267, 268f
Ankle defects, 109
burn injuries, 669–670
Antecubital fossa
access, 116–117, 118f
anatomy, 116, 116f
burn injuries of, 669
Anterior tibial artery, 120
access, 120, 122f
anatomy, 120, 121f–122f
Anterograde ow, 29
Anterolateral thigh (ALT) ap
for abdominal wall reconstruction, 171, 173, 175, 176
for cheek reconstruction, 92
free, 163–168
classi cation of, 163
clinical perspectives on, 167
fasciocutaneous, raising, 163–165, 164f–165f
for head and neck reconstruction, 167, 168f
hints and tips on, 167–168
important anatomical structures and, 167
patient positioning for, 163
suprafascial, raising, 165–167, 166f–167f
surface markings for, 163, 163f
vascular pedicle of, 163
for lip reconstruction, 96
for lower limb reconstruction, 109, 110, 111
for oropharyngeal reconstruction, 98, 100f–101f
pedicled, 169–178
anatomy and, 169–170, 169f–170f, 176
classi cation of, 169
clinical perspectives of, 176
closure of donor site, 175
dissecting perforators of, 171
fasciotomy for, 171, 172f
harvest of, 173
hints and tips on, 176–178
identifying perforators for, 171, 172f
lateral incision for, 172, 173f
medial incision for, 171, 171f
muscle taken with, 173, 173f
patient positioning for, 169
postoperative management of, 175
preparing limb for, 171
raising, 171–176
split-thickness allograft for, 175
subcutaneous tunnel for, 173–175, 174f–176f
A
Abbé or lip switch, 95, 553, 553f, 576, 576f
Abdomen, keystone aps for, 303–309, 309f, 311, 314f
Abdom inal flap. See also Rectus abdom inis m uscle flap;
Transverse rectus abdom inis m usculocutaneous
(TRAM) flap
for breast reconstruction, 59–64, 502–524
for perineal reconstruction, 69–71, 540–545
Abdominal muscle function, TRAM ap and, 511–512
Abdominal wall reconstruction
ALT ap for, 171, 173, 175, 176
rectus femoris muscle ap for, 423
Abdominoperineal wound dehiscence, SGAP ap for, 446–448,
448f–450f
Acellular dermal matrix (ADM), in breast reconstruction, 53, 56,
57f–59f
Acland’s technique, for end-to-side anastomosis, 37f
Adjunctive wound healing techniques, 26–28
Advancement aps, 15, 15f–17f
bipedicle, 15, 16f–17f
for burn injuries, 664–665
cheek, for nasal reconstruction, 587–590
for cheek reconstruction, 89, 90f–91f, 95
dorsal, for nasal reconstruction, 592–593
keystone, 268, 269f
for lip reconstruction, 95
pectoralis major muscle, 377–378, 378f, 381
single pedicle, 15, 16f
for upper face reconstruction, 82, 85
V-Y, 15, 17f, 70, 71
Y-V, 15
Aesthetic reconstruction, facial. See Facial reconstruction,
aesthetic
Alar crease restoration, 598–600, 600f
Allograft, skin, 10
Alloplastic implants, for ear, 88
ALT. See Anterolateral thigh (ALT) ap
Amputation
lower limb
free ap loss and, 112
reconstruction vs., 104–107, 107t
in mission setting, 681
Anastomosis, 33–35. See also speci c aps and procedures
alignment of, 29
closure procedure for, 35
de nition of, 29
diameter discrepancies in, 35, 36f–37f
end-to-end, 35, 36f
end-to-side, 35, 37f
sh-mouth technique of, 35, 36f
patency test of, 35, 38f
preparing vessels for, 33, 33f
successful, healing of, 40
technical principles of, 34–35
Note: Italic f and t indicate gure and table, respectively.
692
Index
Breast reconstruction, 52–67
adjuvant therapy and, 66
algorithms for, 53t, 54f–55f, 62, 64t
assessment for, 52
autologous, 53, 53t, 58–66
abdominal aps for, 59–64
advantages of, 59
algorithm for selecting aps in, 62, 64t
alternative donor sites for, 64–66
clinical cases of, 206, 207f–208f
DIEP ap for, 55f, 59, 60–62, 61f–63f, 62t, 64t, 194–203,
206, 207f
gracilis ap for, 239–240, 240f
IGAP ap for, 64
intraoperative imaging in, 62–64, 65f
latissimus dorsi ap for, 55f, 58–59, 359, 360f, 363–365,
365f–366f
latissimus dorsi ap for, muscle-sparing, 650–656, 656f
morbidities associated with, 60–62, 62t
pectoralis major muscle ap for, 55f
preoperative imaging for, 62, 64f
SGAP ap for, 64, 66f, 205–206, 206f, 208f, 434, 437–439,
437f–445f, 448–451
SIEA ap for, 55f, 59, 62, 63f, 64t, 205–206, 208f
TDAP ap for, 474–475, 477f
TMG/TUG ap for, 55f, 64–66, 491, 491f
TRAM ap for, 52, 55f, 59–62, 60f–61f, 62t, 64t
TRAM ap for, free, 514–524, 523f–524f
TRAM ap for, pedicled, 502–513
bene ts of, 52
bilateral, 512
burn injuries, 668
decision making in, 53t, 54f–55f, 66
delayed-immediate, 66, 512–513
expander/implant (prosthetic), 53–58, 53t
acellular dermal matrix in, 53, 56, 57f–59f
complications of, 56–58
device location in, 56, 57f–58f
one-stage, 53, 56, 56f
partial muscle coverage in, 53f, 56, 58f
total muscle coverage, 56, 57f
two-stage, 53–56, 53f–54f, 58f–59f
keystone aps for, 309–310, 310f
options for, 52–65, 54f–55f
recipient vessel in, internal mammary, 129–140, 194–196,
516, 517f
anastomosis setup for, 131, 135f, 196, 197f
controlled posterior perichondrial elevation for exposure,
131, 134f
for DIEP ap, 194–196, 196f
dissection with rib cartilage excision, 129–131, 130f–135f
important considerations and pitfalls, 140
intercostal muscles in, 137, 137f–138f
intercostal space for, 131–137, 135f–136f
perforator dissection, 137, 140f
rib-sparing dissection, 131–137, 135f–138f, 194–196, 196f
for SIEA ap, 205–206
surgical technique, 129–137
recipient vessel in, thoracodorsal, 141–146
axillary dissection for exposure, 142, 142f–143f
axillary microsurgical platform and setup, 144, 144f–145f
experience and philosophy, 141
nesting of abdominal ap on chest wall, 144–146, 145f–146f
surgical technique, 141–146
thoracodorsal dissection and transection, 142
triangular exposure, 142, 144f
surgeon’s goal in, 53
Bridge ap, for eyelid reconstruction, 87–88
surface markings for, 169–170, 170f–172f
tension-free zone for, 175
vascular pedicle of, 169, 169f, 172, 176, 177f
for perineal reconstruction, 69–71, 70f–75f, 169–178, 174f,
176f–178f
for scalp reconstruction, 82
for temple reconstruction, 85
Anticoagulation, in microsurgery, 38, 39t
Approximators, microsurgical, 30f
Arc ap. See Keystone aps
Areolar sparing mastectomy, 53, 56
Arm free ap, lateral. See Lateral arm free ap
Arm reconstruction, keystone aps for
clinical perspectives on, 327, 327f–329f
design of, 322–323, 322f–323f
vascular pedicle and blood supply for, 319–320, 319f
Articulated arm technique, in stereotaxy, 48–49
Aspirin, for anticoagulation, 39t
Auricular ap, posterior, 88, 89f
Autogenous transplantation, 29
Autograft, skin, 10
Axial pattern aps, for burn injuries, 665
Axilla, blood supply of, 301
Axillary burn injuries, 669
B
Back, keystone flaps for, 302, 306f–308f, 313f,
315f–317f
Behan, Felix, 267
Bilateral rotation aps, 19, 20f–21f
Bilobed aps, 19, 22f–24f
for nasal reconstruction, 22f–24f, 92, 93f, 582–584
anatomy and, 584
classi cation of, 582
clinical perspectives on, 583f, 584
donor site closure, 583f, 584
rst lobe placement, 584
graft site preparation for, 582, 583f
hints and tips on, 584
patient positioning for, 582
raising, 582–584, 583f
second lobe placement, 583f, 584
surface markings of, 582, 583f
vascular pedicle of, 582
Bilobed split latissimus dorsi ap, 353
Bipedicle advancement ap, 15, 16f–17f
Bishop-mitre ap, 92
Blood ow measurement, for ap monitoring, 149–150
Bolster dressing, 9, 11f
Bone grafts, free vascularized, for spinal reconstruction,
644–649
approaches in, 644
cervical spine, 645–646, 646f
cervicothoracic and thoracic spine, 646–647, 646f–647f
double barrel bula strut for, 645, 645f, 647f
indications for, 644, 644f
lower thoracic and thoracolumbar spine, 647
lumbar spine, 647–648, 647f–648f
osteotomy for, 645, 645f
planning for, 644–645
postoperative monitoring of, 648–649
surgical technique for, 645, 645f
vascular pedicle of, 645
Brachial artery, 115–116
access, 116, 116f, 117f
anatomy, 115, 115f
Brachioradialis tendon, vascularized graft, 626
Breast conservation therapy (BCT), 52
Index
693
patient age and, 88–89
radial forearm ap for, 558–561, 559f–560f
rotation advancement ap for, 89, 90f–91f
rotation ap for, 19, 22f
submental artery ap for, 92
temporoparietal scalp ap for, 558, 558f
Chemical leeching, of TRAM ap, 513
Chest
anterior
blood supply of, 297
keystone aps for, 309–310
upper lateral, blood supply of, 301
Chimeric aps, 41
Chin, as facial subunit, 549, 549f
Chin, subunits of, 5, 6f–7f
Circulation, for aps, 12
Circum ex scapular artery
access, 128
anatomy, 128, 427–428, 427f, 428f
in parascapular cutaneous axial ap, 621
Circum ex scapular artery perforator (CSAP) ap, 427–433
anatomy and, 427f, 428, 428f
classi cation of, 427
clinical perspectives on, 433
patient positioning for, 428–429
raising, 429–432, 432f–433f
size of, 429
surface markings of, 428, 429f
vascular pedicle of, 427–428, 427f
Clamps, microsurgical, 31
Clinical bedside monitoring, of aps, 147, 149, 149t
Closure, direct, 5–9. See also Suture(s)
Coaptation
de nition of, 29
microneural, 38
Color Doppler ultrasound, for ap monitoring, 150
Composite graft, conchal
anatomy and, 605
classi cation of, 605
clinical perspectives on, 605–607, 606f
donor site closure, 605, 606f
graft site preparation for, 605
hints and tips on, 605
for nasal reconstruction, 605–607, 606f
patient positioning for, 605
raising, 605, 606f
surface markings of, 605
vascular pedicle of, 605
Computed tomographic angiography (CTA), 44, 45–47, 45f
for breast reconstruction, 62, 64f
for lower limb reconstruction, 109–110
Computed tomography, multidetector, 45
Conchal cartilage graft, 597, 597f–598f
Conchal composite graft
anatomy and, 605
classi cation of, 605
clinical perspectives on, 605–607, 606f
donor site closure, 605, 606f
graft site preparation for, 605
hints and tips on, 605
for nasal reconstruction, 605–607, 606f
patient positioning for, 605
raising, 605, 606f
surface markings of, 605
vascular pedicle of, 605
Contiguity, of aps, 13
Continuous sutures, 6, 9, 9f
Contour, of aps, 13, 550
Buoy aps, jejunal, 265, 266f
Burn injuries, 664–672
ankle and foot, 669–670
antecubital fossa, 669
axillary, 669
breast, 668
debridement of, 671
epidemiology of, 664
aps for, 664–672
advancement, 664–665
axial pattern, 665
complications and failure, reducing rates of, 671
free, 665–666, 667f–668f
indications for, 664, 665
pedicled, 665–666, 666f
postoperative monitoring of, 671
Quaba, 642, 643, 643f
timing for, 670–671
Z-plasty, 664–665
hand, 642, 643, 643f, 669
head and neck, 666–668
hip, knee, and lower leg, 669–670
lower limb, 669–670, 684–689
microvascular surgery for, applications of, 665
in mission setting, 673f
peroneus brevis muscle aps for, 684–689
primary and secondary reconstruction in, 665, 670–671
thrombosis in, 671
upper limb, 669
vascular preoperative imaging in, 671
Buttocks
blood supply of, 301
keystone aps for, 301, 315f–317f
C
Carotid artery, external
anatomy of, 125–127, 125f
dissection of, 127, 127f
Cartilage grafts
conchal, 597, 597f–598f
for ear reconstruction, 88
for nasal reconstruction, 92, 94f
Celsus, 104f
Cervical spine, free vascularized bone graft for, 645–646, 646f
Cervicosubmental island (CSI) ap, 330, 334f, 338f–339f
Cervicothoracic spine, free vascularized bone graft for, 646–647,
646f–647f
Cheek, as subunit of face, 5, 549, 549f
Cheek advancement ap
anatomy and, 590
classi cation of, 587
clinical perspectives on, 590
donor site closure, 589f, 590
graft site preparation for, 587
hints and tips on, 590
for nasal reconstruction, 587–590
patient positioning for, 587, 588f
raising, 588f–589f, 589–590
surface markings for, 587, 588f
vascular pedicle of, 587
Cheek reconstruction, 88–92
anterior-based angle rotation cheek ap for, 557–558, 557f–558f
bula ap for, 569–579, 569f–570f
free tissue transfer for, 92
illustrative case reports of, 550–562, 569–579
lip reconstruction with, 95
local aps for, 88–92
median forehead ap for, failed, 573–579, 574f
694
Index
Dental implants, osteointegrated, 570, 570f, 573, 573f
Dermis, 4–5, 4f
Desault, Pierre-Joseph, 104f
Dextrans, 39t
DIEP. See Deep inferior epigastric artery perforator (DIEP) ap
Direct closure, 5–9. See also Suture(s)
DIRT. See Dynamic infrared thermography
Distant aps
free, 13
for head and neck reconstruction, 79
pedicled, 18
Dog ears, in suturing, 6, 9, 10f
Doppler owmetry, laser, for ap monitoring, 150
Doppler probe, Cook–Swartz implantable, 154–155, 154f
Doppler ultrasound, 44–45, 44f, 45f
handheld, for ap monitoring, 149–150
Dorsal advancement ap
anatomy and, 592
classi cation of, 592
clinical perspectives on, 593, 593f
donor site closure, 592, 593f
graft site preparation for, 592, 593f
hints and tips on, 593
for nasal reconstruction, 592–593
patient positioning for, 592
raising, 592
surface markings of, 592, 593f
vascular pedicle of, 592
Dorsalis pedis artery, 122–124
access, 124, 124f
anatomy, 124, 124f
in dorsalis pedis ap, 628
Dorsalis pedis aps, 628–632
anatomy and, 631
classi cation of, 628
clinical perspectives on, 631
donor site reconstruction, 631
fascial, 632
for hand reconstruction, 628, 629f, 631
for head and neck reconstruction, 628
hints and tips on, 632
innervation of, 628, 631f
for lower limb reconstruction, 628
osteocutaneous, 632
for palate defects, 631
patient positioning for, 628
raising, 628–631, 630f–631f
surface markings of, 628, 630f
variations in, 632
vascularized tendon graft with, 632
vascular pedicle of, 628
Dorsal metacarpal artery (Quaba) ap, 641–643
Dorsal metatarsal ap, 642–643, 642f
Dorsal scapular vessels, in trapezius flaps, 526, 527,
529, 533
Double barrel bula strut, 645, 645f, 647f
Double barrel ap, for mandible reconstruction, 96
Double keystone aps, 268, 269f
Dufourmentel ap, 17f, 19
Dynamic infrared thermography (DIRT), 49–51, 50f, 151
E
Ear reconstruction, 88, 89f
burn injuries, 668
temporoparietal fascial ap for, 500, 500f
EFACS. See Extended facial artery cheek (EFACS) ap
Elbow reconstruction, keystone aps for
design of, 323–324, 324f–325f
vascular pedicle and blood supply for, 320
Contrast-enhanced ultrasound (CEUS), for ap monitoring, 155
Contrast medium, 46
Cook–Swartz implantable Doppler probe, 154–155, 154f
Cormack and Lamberty classi cation, of fasciocutaneous aps, 14t
Crane principle, 13
Creep, 12, 275, 275f, 293, 331
Critical ischemia time, 39
Cross leg ap, 112
CSAP. See Circum ex scapular artery perforator (CSAP) ap
CSI. See Cervicosubmental island (CSI) ap
CTA. See Computed tomographic angiography
Cultural sensitivity, in mission setting, 681
Cutler–Beard ap, for eyelid reconstruction, 87–88
D
DCIA. See Deep circum ex iliac artery (DCIA) aps
Deep circum ex iliac artery (DCIA) aps, 179–183
anatomy and, 179, 179f–181f, 181
classi cation of, 179
clinical perspectives on, 182
conversion to TRAM ap, 203
hints and tips for, 182
for mandible reconstruction, 182, 183f
patient positioning for, 179
raising, 179–182, 182f
skin ap of, 179
surface markings for, 179, 181f, 183f
variations in, 182
vascular pedicle of, 179
Deep inferior epigastric artery, 301
in rectus abdominis muscle ap, 405–406, 405f
in TRAM ap, 514
Deep inferior epigastric artery perforator (DIEP) ap, 184–203, 514
for breast reconstruction, 55f, 59, 60–62, 61f–63f, 194–203
additional venous drainage for, 196–197
algorithm for selecting, 62, 64t
anastomosis setup for, 196, 197f
clinical case of, 206, 207f
inset of, 197–199, 198f–200f
morbidities associated with, 60–62, 62t
preparation of recipient area for, 194, 195f–196f
recipient vessel exposure for, 194–196, 196f
caudal dissection of pedicle for, 192, 192f–194f
classi cation of, 184
donor site closure, 199, 201f–203f
inferior incision and SIEV identi cation for, 186–189, 189f
in ltration of abdominal incisions for, 185, 187f
optimization of, 203
patient positioning for, 184
perforator identi cation and dissection for, 189–191, 190f–192f
for perineal reconstruction, 72
preoperative angiography for, 45–46, 47f
preoperative perforators assessment for, 185, 186f
raising, 185–203
surface markings for, 185, 187f
umbilical, superior, and lateral incisions for, 186, 188f
vascular pedicle of, 184, 184f–185f
Deep inferior epigastric perforator, 301
Deglutition, mandible reconstruction and, 96
Delayed-immediate breast reconstruction, 66, 512–513
Deltopectoral aps
classi cation of, 210
clinical perspectives on, 213
delayed, 210
for head and neck reconstruction, 210–213, 213f
patient positioning for, 210
raising, 210, 211f–212f
surface markings for, 210
vascular pedicle for, 210
Index
695
aesthetic, 549–581
contour in, 550
defect analysis for, 549–550
goals of, 549
ideal donor tissues for, 550
illustrative case reports of, 550–579
principles of, 549–550
reconstructive “elevator” for, 550
single- ap, limitations of, 550
staging of, 550
burn injuries, 667–668
as cornerstone of plastic surgery, 549
facial artery perforator aps for, 550–553, 551f–553f,
614–617, 616f–617f
aps for, 28f
gracilis ap for, 242f
historical perspective on, 549
keystone aps for, 330–342
lower face, 93–96
middle face, 87–93
upper face, 82–85
Facial subunits, 5, 6f–7f, 549, 549f
FACS. See Facial artery cheek subunit (FACS) ap
Failure, ap
burn injuries, reducing rate of, 671
free ap, management of, 42–43
lower limb, and amputation, 112
median forehead, in cheek reconstruction, 573–579, 574f
radial forearm, in for nasal reconstruction, 567–573, 569f
success vs., 147
FAMM. See Facial artery musculomucosal (FAMM) aps
FAP. See Facial artery perforator (FAP) ap
Fascial ap. See also speci c procedures
dorsalis pedis, 632
lateral arm, 347
temporoparietal, 493–500
Fasciocutaneous aps, 25, 28f. See also speci c aps
anterolateral thigh, raising, 163–165, 164f–165f
circulation for, 12
Cormack and Lamberty classi cation of, 14t
for forehead reconstruction, 82
keystone, 267–281
for lower leg reconstruction, 104, 108, 109, 111
radial forearm, 394–404
ulnar artery forearm, 535–539
Fat necrosis, TRAM ap and, 512
Fibronectin, 4
Fibula aps
double barrel strut, 645, 645f, 647f
for mandible reconstruction, 79, 96, 97f–98f, 221, 222f
for oromandibular full-thickness defects, 657–660
double skin paddle, 658, 659f, 660
perforators of, 658–660, 659f–660f
postoperative morbidity with, 661–662
single skin paddle, 657, 657f, 658
single skin paddle with de-epithelialized bridge, 657, 658,
658f
soleus inclusion in, 659–660, 660f
osteomyocutaneous
for nasal and cheek reconstruction, 569–579, 569f–570f
surface markings of, 569, 569f
osteoseptocutaneous, 214–223
anatomy and, 221
anterior incision for, 217f, 219–220
classi cation of, 214
clinical perspectives on, 221
dissection order for, 214, 214f–216f
donor site closure, 221
hints and tips on, 221
End-to-end anastomosis, 35, 36f
End-to-side anastomosis, 35, 37f
Epidermis, 4, 4f
Estlander–Abbe ap, 557–558, 557f–558f
Extended facial artery cheek (EFACS) ap, 330, 331, 333
Extensor tendon, vascularized graft, 632
External carotid artery
anatomy of, 125–127, 125f
dissection of, 127, 127f
Eye(s), subunits of, 5
Eyelid reconstruction, 87–88
facial artery perforator ap for, 617
large defects
anterior lamella, 87–88
posterior lamella, 88
small defects, 87
F
Face transplantation, facial allo aps for, 608–613
classi cation of, 608
clinical perspective on, 612
composite craniomaxillofacial disjunction of, 611
donor preparation for, 609
facial nerve dissection for, 610
hints and tips for, 612–613
lateral and inferior incisions for, 610
neurovascular pedicle for, 608
osteotomies for, 611, 611f
patient positioning for, 608
perfusion and preservation of, 612
raising, 609–612
superior incision, for midfacial aps, 609–610
superior incision, for pan-facial aps, 609
surface markings of, 608–609, 609f
vascular pedicle dissection for, 610, 610f
vascular pedicle ligation for, 612, 612f
Facial artery, 125–126
access, 125–126, 126f
anatomy, 125, 126f
Facial artery cheek subunit (FACS) ap, 330, 331, 333, 335f–337f,
339, 339f–341f
Facial artery musculomucosal (FAMM) aps, 618–620
anatomy and, 620
classi cation of, 618
clinical perspectives on, 620
hints and tips on, 620
patient positioning for, 618
raising, 618–620, 619f
surface markings of, 618, 618f
variations in, 620
vascular pedicle of, 618
Facial artery myomucosal ap, for nasal lining, 92
Facial artery perforator (FAP) ap
anatomy and, 615
classi cation of, 614
clinical perspectives on, 615, 616f–617f
donor site closure, 615, 616f
for eyelid reconstruction, 617
hints and tips on, 617
inset of, 615, 616f
for lip reconstruction, 550–553, 551f–553f
patient positioning for, 614
for perioral soft tissue defects, 614–617
raising, 614–615, 614f, 615f
surface markings of, 614
variations in, 617
vascular pedicle of, 614
Facial nerve dissection, 610
Facial reconstruction. See also speci c facial anatomy
696
Index
groin/SCIP ap for, 246–247, 247f–249f
keystone aps for, 291, 292f
reverse sural ap for, 467–468, 467f–468f
Forceps, microsurgical, 29, 30f
Forearm aps
radial, 394–404, 624–627
anatomy and, 399, 605, 625–626
for cheek reconstruction, 92, 558–561, 559f–560f
classi cation of, 394, 603, 624
clinical perspectives on, 399, 604f, 605, 626, 626f
donor site closure, 399, 401f, 605
graft site preparation for, 603, 604f
for hand reconstruction, 626, 626f, 627f
hints and tips on, 605, 626
incision and suprafascial harvest, 395, 396f
for lip reconstruction, 96
for mandible reconstruction, 96
for nasal reconstruction, 558–566, 559f–560f, 564f–565f,
603–605, 604f
for nasal reconstruction, failed, 567–573, 569f
for oral cavity reconstruction, 98–102, 99f–100f
patient positioning, 395
patient positioning for, 603, 624
for phallus reconstruction, 72, 77f
raising, 395–399, 395f–400f, 604f, 605, 624–625, 625f
recipient vessels for, 603
for scalp reconstruction, 82, 626, 626f
surface markings of, 395, 395f–396f, 558–559, 559f,
563–564, 564f, 605, 624, 624f
for temple reconstruction, 85, 86f–87f
for tongue reconstruction, 401, 402f–403f
variations in, 626, 627f
vascularized tendon graft with, 626, 627f
vascular pedicle of, 394, 394f, 395–399, 397f–400f, 603, 624
ulnar artery fasciocutaneous, 535–539
anatomy and, 538
classi cation of, 535
clinical perspectives on, 538, 538f
donor site closure, 538
hints and tips on, 539
innervation of, 535
limb preparation for, 535–536
patient positioning for, 535
radial forearm ap vs., 538
radial incision for, 536
raising, 535–538, 536f–538f
retrograde pedicle dissection for, 537, 537f
surface markings of, 535, 535f–536f
ulnar incision for, 536, 536f–537f
variations in, 539
vascularity of, checking, 538, 538f
vascular pedicle of, 535
Forearm reconstruction
bilateral rotation ap for, 21f
burn injuries, 669
keystone aps for
design of, 323–324, 324f–325f
vascular pedicle and blood supply for, 319–322, 320f
Forehead, as facial subunit, 5, 549, 549f
Forehead ap
failed median, 573–579, 574f
for nasal reconstruction, 553–555, 553f–556f, 565–567, 565f–567f
paramedian (See Paramedian forehead ap)
Forehead reconstruction, 82
bilateral advancement ap for, 16f–17f
fasciocutaneous ap for, 82
rotation ap for, 19, 21f
skin grafts for, 82, 84f–85f
Forehead w-plasty, 26f
interosseous membrane division for, 217f–218f, 220
intramuscular vessels for, 220
limb preparation for, 219
muscle detachment for, 217f–218f, 220
osteotomies for, 218f, 220
patient positioning for, 214
posterior incision for, 217f–218f, 220
raising, 219–221
retrograde pedicle dissection for, 218f–219f, 221
surface markings for, 214–219, 217f–219f
vascularity of, checking, 219f, 221
vascular pedicle of, 214, 214f–215f
for spinal reconstruction, 644–649
Fibular (peroneal) artery, reverse sural ap, 460, 460f
Fiducial marking, in stereotaxy, 48–49, 48f
Fish-mouth technique, of anastomosis, 35, 36f
Five- ap plasty, 25
Flap(s), 12–28. See also speci c aps and procedures
advancement, 15, 15f–17f
bilobed, 19, 22f–24f
circulation for, 12
classi cation of, 12, 14t, 15f
composition of, 12–13
contiguity of, 13
contour of, 13, 550
Crane principle for, 13
de nition of, 12
facial, various, 28f
failure, success vs., 147
fascicutaneous, 25, 28f
ve- ap plasty, 25
four- ap plasty, 25
free, 25–26, 29, 40–43, 41t
interpolation, 19–25
jumping man, 25, 27f
in mission setting, 673–683
monitoring of, 42, 147–160
blood ow measurement for, 149–150
challenges in, 148, 149
clinical bedside, 147, 149, 149t
history of, 147f
implantable probes for, 152–155
injectable agents for, 155
invasive techniques for, 147, 148f, 152–155
microdialysis for, 152, 152t, 153f
noninvasive techniques for, 147, 148f, 149–152
oxygenation measurement for, 150–151
routine for, 149
skin paddle for, 148
temperature measurement for, 151, 152
variations in, 147–148
visual assessment for, 151–152
muscle, 25–26
perforator, 26, 41
planning, preoperative imaging for, 44–51
rotation, 19, 20f–22f
transposition, 15–19, 17f–19f
types of, 15–26
workhorse, 677, 678t–679t
W-plasty, 25, 26f
Z-plasty, 25, 25f, 26t, 664–665
Flow, anterograde or retrograde, 29
Flowmetry, laser Doppler, for ap monitoring, 150
Flow-through, 29
Fluorescent angiography, in breast reconstruction, 62–64, 65f
Fluorometry, for ap monitoring, 155
Foot reconstruction
burn injuries, 669–670
dorsal metatarsal ap for, 642–643, 642f
Index
697
Glabellar ap
anatomy and, 592
classi cation of, 590
clinical perspectives on, 592, 592f
donor site closure, 591f, 592
graft site preparation for, 590
for nasal reconstruction, 567, 568f, 590–592
patient positioning for, 590
raising, 590–592
surface markings of, 590, 591f
vascular pedicle of, 590
Gluteal arteries, 301
Gluteal artery aps. See Inferior gluteal artery myocutaneous
ap; Superior gluteal artery perforator (SGAP) ap
Gluteal thigh aps, 376–377, 389–390
anatomy and, 377, 390
for breast reconstruction, 64, 66f
donor site closure, 376, 389
patient positioning for, 376, 389
for perineal reconstruction, 69–71
raising, 376, 377f, 389, 390f
surface markings of, 376, 389
vascular pedicles of, 376, 389
Godina, Marco, 104f, 107–108
Gracilis muscle ap, 230–242
anatomy and, 239
for breast reconstruction, 239–240, 240f
classi cation of, 230
clinical perspectives on, 239–240, 240f–242f
donor site closure, 237–238, 239f
for facial reconstruction, 242f
hints and tips on, 240
incision for, 231–232, 234f–236f
limb preparation for, 231
for lip reconstruction, 96
for lower limb reconstruction, 110
muscle detachment for, 233–234, 238f
myocutaneous, 70–71, 72f, 73f, 240
patient positioning for, 230, 231f
perforator vessels for, 230
raising, 231–238
retrograde pedicle dissection for, 232–233, 237f
skin paddle techniques for, 238–239
surface markings for, 230–231, 231f–233f
transverse myocutaneous (See Transverse myocutaneous
gracilis (TMG) ap)
for vaginal reconstruction, 241f
vascularity of, checking, 234
vascular pedicle for, 230
vessel ligation for, 234–237, 238f
Groin ap, 243–249
anatomy and, 246
assessing and preparing recipient site for, 244–245
classi cation of, 243
clinical perspectives on, 246–247, 247f–249f
donor site closure, 246
elevation in deep fascial plane, 245, 245f
hints and tips on, 250
for lip reconstruction, 96
for oromandibular full-thickness defects, 660–661, 661f
patient positioning for, 243
for perineal reconstruction, 70, 71, 72
raising, 244–246
retrograde pedicle dissection for, 246, 246f
surface markings for, 244, 244f
vascular pedicle of, 243, 243f
vessel identi cation in, 246, 246f
Gustilo–Anderson classification, of tibial fractures, 106,
106t
Four- ap plasty, 25
Free aps, 25–26, 29, 40–43. See also speci c aps and procedures
chimeric, 41
clinical observation of, 42
distant, 13
failing, management of, 42–43
failure, success vs., 147
free style, 42
innervated, 42
monitoring of, 42, 147–160
blood ow measurement for, 149–150
challenges in, 148–149
clinical bedside, 147, 149, 149t
history of, 147f
implantable probes for, 152–155
injectable agents for, 155
invasive techniques for, 147, 148f, 152–155
microdialysis for, 152, 152t, 153f
noninvasive techniques for, 147, 148f, 149–152
oxygenation measurement for, 150–151
routine for, 149
skin paddle for, 148
temperature measurement for, 151, 152
variations in, 147–148
visual assessment for, 151–152
perforator, 41
prefabrication, 42
workhorse, 40, 41t
Free skin graft, 10f–11f
Free style aps, 42
Free tissue transfer, 29, 40–43. See also Free aps
endoscopic techniques in, 42
historical milestones in, 40, 40t
improving design and reducing morbidity in, 41–42
monitoring in, 42
patient selection criteria for, 41
re nements in, 41–42
supramicrosurgery in, 41–42
Free vascularized bone grafts
advantages of, 644
for spinal reconstruction, 644–649
approaches in, 644
cervical spine, 645–646, 646f
cervicothoracic and thoracic spine, 646–647, 646f–647f
double barrel bula strut for, 645, 645f, 647f
indications for, 644, 644f
lower thoracic and thoracolumbar spine, 647
lumbar spine, 647–648, 647f–648f
osteotomy for, 645, 645f
planning for, 644–645
postoperative monitoring of, 648–649
surgical technique for, 645, 645f
vascular pedicle of, 645
FTSG. See Full thickness skin graft
Full thickness skin graft (FTSG), 10, 10f
G
Gastrocnemius ap
anatomy and, 224, 225f–227f
classi cation of, 224
clinical perspectives on, 228
hints and tips on, 228–229
for lower limb reconstruction, 109, 228–229, 229f
medial, 224, 228f
patient positioning for, 224
raising, 224, 228f
surface markings for, 224
variations in, 228
vascular pedicle of, 224
698
Index
I
ICAP. See Intercostal artery perforator ap
Iliac crest ap
for mandible reconstruction, 96
for orom andibular full-thickness defects, 660–661, 661f,
662f
for spinal reconstruction, 644, 648
Illumination, in microsurgery, 29, 29t
IMA. See Internal mammary artery
Implantable probes, for ap monitoring, 152–155
Indocyanine green (ICG) dye, 64, 65f
Inferior gluteal artery, 301
Inferior gluteal artery myocutaneous ap, 251–258
anatomy and, 257
classi cation of, 251
clinical perspectives on, 257, 257f–259f
dissection of fascia lata for, 254, 254f–255f
dissection of gluteus maximus inferior edge for, 252, 253f
dissection of main inferior gluteal artery for, 254
division of descending branch for, 254, 255f
donor site closure, 254
hints and tips on, 257–258
inferior incision for, 252, 252f
inset of, 254–257, 256f, 257f
patient positioning for, 251
raising, 252–257
superior incision for, 252, 253f
surface markings for, 251–252, 252f
vascular pedicle of, 251, 251f
Inferior gluteal artery perforator (IGAP) ap, for breast
reconstruction, 64
In ammation, in wound healing, 3, 3f
Infrared thermography, dynamic, 49–51, 50f, 151
Injectable agents, for ap monitoring, 155
Innervated aps, 42
Instrumentation, microsurgical, 29–31, 29t, 30f
Intercostal arteries
in pectoralis major muscle ap, 375, 384
posterior, in trunk reconstruction, 297, 298f
Intercostal artery perforator ap (ICAP), 55f
Intercostal muscles, in internal mammary artery dissection, 137,
137f–138f
Intercostal space, in internal mammary artery dissection,
131–137, 135f–136f
Internal mammary artery (IMA), 127
access, 127
anatomy, 127, 129, 297
as recipient vessel in breast reconstruction, 129–140, 194–196,
516, 517f
anastomosis setup for, 131, 135f, 196, 197f
controlled posterior perichondrial elevation for exposure,
131, 134f
for DIEP ap, 194–196, 196f
dissection with rib cartilage excision, 129–131, 130f–135f
important considerations and pitfalls, 140
intercostal muscles in, 137, 137f–138f
intercostal space for, 131–137, 135f–136f
perforator dissection, 137, 140f
rib-sparing dissection, 131–137, 135f–138f, 194–196,
196f
for SIEA ap, 205–206
surgical technique, 129–137
as vascular pedicle in pectoralis major muscle ap, 375, 384
Internal pudendal artery, 301, 301f–302f
Internal thoracic arteries, 297–301, 298f
Interpolation aps, 19–25
Invasive monitoring, of aps, 147, 148f, 152–155
Ischemia-reperfusion injury, in microsurgery, 39–40
H
Handheld Doppler ultrasound, 149–150
Hand reconstruction
burn injuries, 642, 643, 643f, 669
dorsalis pedis ap for, 628, 629f, 631
keystone aps for
design of, 326–327, 326f
vascular pedicle and blood supply for, 321f, 322
Quaba ap for, 642, 642f–643f
radial forearm ap for, 626, 626f, 627f
Hannover Fracture Scale-97 (HFS-97), 106
Head and neck recipient vessels, 125–127
Head and neck reconstruction, 79–103. See also speci c anatom ic
structures
ALT ap for, 167, 168f
animation issues in, 79
assessment for, 79
burn injuries, 666–668
challenges of, 79
DCIA ap for, 182, 183f
deltopectoral aps for, 210–213, 213f
distant aps for, 79
dorsalis pedis ap for, 628
bula ap for, 221, 222f
free aps for, 79
groin/SCIP ap for, 246–247
keystone aps for, 278f–280f, 330–342
assessing vascularity of, 337
clinical perspectives on, 339, 339f–341f
closure and tension of, 337–338
defect and pathology in, 331
degree of islanding and ligament release in, 331–333
documentation and reoperation, 338, 338f
m arking out, creep, and m obilization of, 331,
335f–337f
preserving neurovascular structures and maintaining
venous drainage with, 333–337
technique in, 331–338
vascular pedicles and blood supply for, 330–331,
332f–335f
lateral arm free aps for, 343–347
latissimus dorsi ap for, 359, 361f
local aps for, 79
options for, 80–102
origins of plastic surgery in, 79
parascapular ap for, 623
patient factors in, 79
pedicle major muscle ap for, 96, 102, 381, 386, 387f
preoperative planning/imaging for, 79
radial forearm ap for, 399
sensory issues in, 79
static vs. dynamic tissue, 79
surgeon factors in, 79
temporoparietal fascial ap for, 500, 500f
trapezius ap for, 531, 532f–534f
Hemisoleus ap, 109, 452, 455, 458, 459f
Heparin
low-molecular weight, 39t
unfractionated, 39t
Hernia, TRAM ap and, 511
HFS-97. See Hannover Fracture Scale-97
Hinge-over ap, for nasal lining, 92
Hip, burn injuries of, 669–670
Hippocrates, 104f
Horizontal mattress sutures, 6–7, 9f
Hughes procedure, 88
Hunter’s canal, 120f, 121f
Hydrogen clearance, in ap monitoring, 152
Index
699
technique in, 291–294
thigh, 282, 288f–289f
vascular pedicle and blood supply of, 282, 283f–287f, 293
mobilization types of, 268, 269f
neurovascular structures in, maintaining, 273f, 274, 293,
333–337
postoperative splinting with, 275–276, 294
principles of, 267, 268f, 270–276
single, 268, 269f
skin grafting with, 268, 269f, 275, 276f–277f, 293–294, 338
surface markings for, 271, 271f–272f, 293
for trunk reconstruction, 297–317
abdomen, 311, 314f
anterior chest, 309–310
back, 302, 306f–308f, 313f, 315f
breast, 309–310, 310f
buttock, 310–311, 315f
hints and tips on, 311, 312f–317f
lateral trunk and abdomen, 303–309, 309f, 311
perineal, 310–311, 311f–312f
reliability and advantages of, 297
subregions and planning for, 302–311
for upper limb reconstruction, 317–329
arm, 319–320, 319f, 322–323, 322f–323f, 327, 327f–329f
clinical perspectives on, 327, 327f–329f
design of, 322–327
elbow region, 320, 323–324, 324f–325f
forearm, 319–322, 320f, 323–324, 324f–325f
hand, 321f, 322, 326–327, 326f
vascular pedicles and blood supply for, 317–322, 319f–321f
vascularity of, checking, 275, 293, 337
vascular pedicle of, 270–271, 282, 293, 317–322, 330–331
Keystone island ap (KIF), 267. See also Keystone aps
Knee reconstruction, 109. See also Lower limb reconstruction
burn injuries, 669–670
keystone ap for, 282–289, 289f
L
Lamella, eyelid
anterior, 87–88
posterior, 88
Langer lines, 5, 5f–6f
Laser Doppler owmetry, for ap monitoring, 150
Lateral arm free ap
anatomy and, 346
classi cation of, 343
clinical perspectives on, 346
donor site closure, 346, 346f
for head and neck reconstruction, 343–347
hints and tips on, 347
for lip reconstruction, 96
patient positioning for, 343, 344f
raising, 344–346, 344f–347f
surface markings for, 343, 344f
variations of, 346–347
vascular pedicle for, 343, 343f
Lateral circum ex femoral artery (LCFA)
in anterolateral thigh ap, 163, 169, 169f, 171, 172, 177f
in rectus femoris muscle ap, 417, 417f
Lateral split latissimus dorsi ap, 353
Lateral thoracic artery, 128
access, 128
anatomy, 128
in pectoralis major muscle ap, 374f, 375, 384
Latissimus dorsi (LD) aps
for breast reconstruction, 55f, 58–59, 359, 360f, 363–365,
365f–366f, 650–656, 656f
free, 348–357
Ischemia time
critical, 39
primary, 39
secondary, 39
Ischial wounds, posterior thigh perforator ap for, 391, 391f
Islanding, in keystone aps, 267–268, 271, 272f–274f, 293,
331–333
Island nasolabial ap, 584–587, 585f–586f
Isograft, skin, 10
J
Jejunal ap
anastomosis for, 260–264, 264f–265f
anatomy and, 264
bowel division for, 260, 263f
bowel transillumination for, 260, 261f
buoy, 265, 266f
for circumferential pharyngolaryngectomy defects, 259–266,
266f
classi cation of, 259
clinical perspectives on, 265
donor site closure, 264, 265f
hints and tips on, 265–266
jejunal emptying and clamping for, 260, 262f
patient positioning for, 260
postoperative care, 264
raising, 260–264
suture marking for, 260, 261f
upper abdominal midline incision for, 260, 260f
variations in, 265
vascular pedicle of, 259, 259f, 260, 262f, 263f
Jumping man ap, 25, 27f
K
Karapandzic aps, 95–96
Keystone aps, 267–281
assessing defect for, 271
classi cation of, 267
clinical perspectives on, 276–281, 296
creep and suturing in, 275, 275f, 293
degree of islanding in, 267–268, 271, 272f–274f, 293,
331–333
documentation of, 276, 294, 338
double, 268, 269f
elevation of, 270–276
design and principles of, 271–276
free ap surgery vs., 270–271
for head and neck reconstruction, 278f–280f, 330–342
assessing vascularity of, 337
clinical perspectives on, 339, 339f–341f
closure and tension of, 337–338
defect and pathology in, 331
degree of islanding and ligament release in, 331–333
documentation and reoperation, 338, 338f
marking out, creep, and mobilization of, 331, 335f–337f
preserving neurovascular structures and maintaining
venous drainage with, 333–337
technique in, 331–338
vascular pedicles and blood supply for, 330–331,
332f–335f
hints and tips on, 281, 294–296
history and development of, 267, 267f
for lower limb reconstruction, 282–296
anesthesia and tourniquet for, 291
foot, 291, 292f
knee, 282–289, 289f
leg, 289–291, 290f–291f, 294f–295f
special considerations in, 282
700
Index
skin laxity for, 640
standard geometric model of, 635, 636f
tension and landmarks for, 640
transposition of, 633–635, 635f
20-degree rule for, 636–637, 636f
Limb Salvage Index (LSI), 106
Lingual artery, 127
access, 127
anatomy, 127
Lip(s), subunits of, 5, 6f–7f
Lip reconstruction, 93–96
Abbé or lip switch for, 95, 553, 553f, 576, 576f
advancement aps for, 95
cheek reconstruction with, 95
Estlander–Abbe ap for, 557–558, 557f–558f
facial artery musculomucosal ap for, 620
facial artery perforator ap for, 550–553, 551f–553f
functional considerations in, 96
gracilis free ap for, 96
illustrative case reports of, 550–562
Karapandzic aps for, 95–96
local aps for, 93–95
radial forearm ap for, 96
Local aps, 15–19. See also speci c aps and procedures
for cheek reconstruction, 88–92
for head and neck reconstruction, 79
for lip reconstruction, 93–95
for lower limb reconstruction, 109
for nasal reconstruction, 92, 93f
for upper face reconstruction, 85
Loupes, surgical, 29, 29t
Lower face reconstruction, 93–96
Lower limb injury
algorithm for managing, 105f
assessment of, 104–106
scoring systems for, 106–107, 106t
Lower limb recipient vessels, 110, 118–124
Lower limb reconstruction, 104–114
ALT ap for, 109, 110, 111
amputation vs., 104–107, 107t
burn injuries, 669–670, 684–689
cross leg ap for, 112
dorsalis pedis ap for, 628
fasciocutaneous vs. muscle aps for, 104, 108, 109, 111
“ x and ap” concept in, 107–108
free ap loss and amputation in, 112
free tissue transfer for, 104, 108, 109, 110
gastrocnemius ap for, 109, 228–229, 229f
gracilis ap for, 110
groin/SCIP ap for, 246–247, 247f–249f
hemisoleus ap for, 109, 459f
historical perspective on, 104, 104f
keystone aps for, 282–296
anesthesia and tourniquet for, 291
foot, 291, 292f
knee, 282–289, 289f
leg, 289–291, 290f–291f, 294f–295f
special considerations in, 282
technique in, 291–294
thigh, 282, 288f–289f
vascular pedicle and blood supply of, 282, 283f–287f, 293
latissimus dorsi ap for, 110
negative pressure wound therapy in, 104, 108, 112
options for, 108–109
parascapular ap for, 110
pedicled aps vs. free aps for, 111
peroneus brevis muscle ap for, 684–689
Ponten type aps for, 109, 111
anatomy and, 353
classi cation of, 348
clinical perspectives on, 355, 356f
donor site closure, 351, 352f
hints and tips on, 356
patient positioning for, 349–350, 351f
postoperative management of, 353
raising, 350–351
sensory innervation of, 349, 349f
surface markings of, 350
variations in, 353, 354f–355f
vascular pedicle of, 348–349, 348f, 351, 352f
for head and neck reconstruction, 359, 361f
for lower limb reconstruction, 110
muscle-sparing, 475, 650–656
anatomy and, 654
classi cation of, 650
clinical perspectives on, 654–656, 656f
delivery into defect, 654, 655f
dissecting fascial ap for, 652–653, 652f–653f
dissecting skin aps for, 652
donor site closure, 654
hints and tips on, 656
muscle strip for, 653–654, 653f–655f
patient positioning for, 650, 651f
preparing eld for, 651
raising, 651–654, 652f–655f
surface markings of, 650–651, 651f
vascular pedicle of, 650, 650f
pedicled, 358–367
anatomy and, 358–359, 358f, 364–365
classi cation of, 358
clinical perspectives on, 365
donor site closure, 364, 365f
ellipse orientation of, 359, 361f
hints and tips on, 365–366
inset of, 364, 366f
patient positioning for, 359
raising, 359–364, 362f–365f
subcutaneous tunnel for, 363, 365f
surface markings of, 359, 359f, 360f
vascular pedicle and innervation of, 358
for scalp reconstruction, 82, 83f–84f, 355, 356f
for temple reconstruction, 85
LCFA. See Lateral circum ex femoral artery
LD aps. See Latissimus dorsi (LD) aps
Leg defects. See also Lower limb reconstruction
burn injuries, 669–670
keystone aps for, 289–291, 290f–291f, 294f–295f
lower third leg, 109
middle third, 109
proximal third, 109
reverse sural ap for, 467–468, 467f–468f
Limberg (rhomboid) ap, 15–19, 17f–19f, 633–640
choice, guiding principles of, 640, 640f
classic, 633, 634f
dependency and pin cushioning for, 640
drawing angles for, 633, 633f–635f
drawing lesion for, 633, 634f
excision margin for, 633, 634f
xed points lacking in, 635, 635f
four potential aps in, 633, 634f
line of maximum extensibility in, 635
modi ed, 639, 639f
orientation of, di culty with, 635–636
relaxed skin tension line in, 635, 636–637, 636f–639f
for scalp reconstruction, 81
scar vs. standing cutaneous cone for, 640
Index
701
no-re ow phenomenon in, 39–40
physiological concepts in, 38–40
planning for, 31
recipient vessels in, 115–128
recipient vessels in, choosing, 32–33, 32f
setup for and comfort in, 31, 31t
technique in, 31–35
thrombogenesis and anticoagulation in, 38, 39t
vasospasm in, 38, 38t
Microsurgical coaptation, 29
alignment of, 29
de nition of, 29
microneural, 38
Microsutures, 31
Microtia reconstruction, temporoparietal fascial ap for, 500,
500f
Microvasculature imaging techniques, for ap monitoring,
151–152
Middle face reconstruction, 87–93
Middle third leg defects, 109
Midfacial aps, 609–610
Milking patency test, of anastomosis, 35, 38f
MIP. See Maximum -intensity projection
Mission setting, 673–683
amputation in, 681
basic operative technique in, 675–677, 676f–677f
bone deformity in, 680, 681f
continuity of care in, 681–682
contracture in, 680, 681, 681f
cultural sensitivities in, 681
donor site morbidity in, 673, 673f
facilities in, 680
initial planning in, 679–680
injury considerations in, 681–682
outcomes in, 677, 680t
patient characteristics in, 680
patient compliance in, 680
post-con ict, 674–675, 674t
raising aps in, 675–677, 675t, 676f–677f
re ections and considerations, 679
scar tissue as ap component in, 681
team training for, 681
timing of procedures in, 679
user’s guide for, 674–675, 674t
workhouse aps in, 677, 678t–679t
Monitoring, bone graft, 648–649
Monitoring, ap, 42, 147–160
blood ow measurement for, 149–150
in burn injuries, 671
challenges in, 148–149
clinical bedside, 147, 149, 149t
history of, 147f
implantable probes for, 152–155
injectable agents for, 155
invasive techniques for, 147, 148f, 152–155
microdialysis for, 152, 152t, 153f
noninvasive techniques for, 147, 148f, 149–152
oxygenation measurement for, 150–151
routine for, 149
skin paddle for, 148, 149
temperature measurement for, 151, 152
variations in, 147–148
visual assessment for, 151–152
MRA. See Magnetic resonance angiography
Multidetector computed tomography (MDCT), 45
Multispectral spatial frequency domain imaging (SFDI), for ap
monitoring, 151
Muscle aps, 25–26. See also speci c m uscles and procedures
preoperative imaging for, 109–110
principles of, 108
radial forearm ap for, 399
recipient vessel choice in, 110
rectus abdominis muscle ap for, 414, 414f–415f
reverse sural ap for, 109, 467–468, 467f–468f
scapular ap for, 110
TDAP ap for, 475f
TFL-PBIF aps for, 483
timing of debridement and, 107–108
zone of injury in, 109, 110
Lower third leg and ankle defects, 109
Low-molecular weight heparin (LMWH), 39t
LSI. See Limb Salvage Index
Lumbar spine, free vascularized bone graft for, 647–648,
647f–648f
Luminescence ratiometric oxygen imaging (LROI), for ap
monitoring, 151
M
Macrophages, in wound healing, 3–4
Magnetic resonance angiography (MRA), 44, 47–48,
47f, 109
Magni cation, in microsurgery, 29, 29t
Mammary artery, internal. See Internal mammary artery
Mandible reconstruction, 96. See also Oromandibular
full-thickness defects
DCIA ap for, 182, 183f
double barrel ap for, 96
bula ap for, 79, 96, 97f–98f, 221, 222f
iliac crest ap for, 96
keystone aps for, 278f–280f
microvascular tissue transfer as gold standard in, 96
pectoralis major muscle ap for, 96, 381, 386, 387f
radial forearm ap for, 96
scapular ap for, 96
Mangled Extremity Severity Score (MESS), 106
Mastectomy
nipple areolar sparing, 53, 56
reconstruction after (See Breast reconstruction)
skin sparing, 52, 53
Mastication, mandible reconstruction and, 96
Mathes and Nahai classi cation, of musculocutaneous aps,
14t, 15f
Mattress sutures
horizontal, 6–7, 9f
vertical, 6–7, 8f
Maximum -intensity projection (MIP), 45f, 46
Medial femoral circum ex vessels, in gracilis ap, 230
Median forehead ap, failed, 573–579, 574f
MESS. See Mangled Extremity Severity Score
Metacarpal reconstruction, radial forearm ap for, 399
Microdialysis, for ap monitoring, 152, 152t, 153f
Microneedles, 31
Microneural coaptation, 38
Microscopes, operating, 29, 29t
magni cation and illumination, 29, 29t
recipient vessel selection under, 32–33
Microsurgery, 29–43
anastomosis in, 29, 33–35, 33f, 40
applications of, 40, 43
coaptation in, 29, 38
de nition of, 29
experience and disposition for, 31
future of, 43
instrumentation for, 29–31, 29t, 30f
ischemia-reperfusion injury in, 39–40
magni cation and illumination in, 29, 29t
702
Index
clinical perspectives on, 605–607, 606f
donor site closure, 605, 606f
graft site preparation for, 605
hints and tips on, 605
patient positioning for, 605
raising, 605, 606f
surface markings of, 605
vascular pedicle of, 605
covering for, 92, 94f–95f
dorsal advancement ap for, 592–593
anatomy and, 592
classi cation of, 592
clinical perspectives on, 593, 593f
donor site closure, 592, 593f
graft site preparation for, 592, 593f
hints and tips on, 593
patient positioning for, 592
raising, 592
surface markings of, 592, 593f
bula ap for, 569–579, 569f–570f
folded aps for, 92
forehead ap for, 553–555, 553f–556f, 565–567, 565f–567f
forehead ap for, failed median, 573–579, 574f
forehead ap for, paramedian, 19, 19f, 92, 94f–95f, 560–562,
561f–562f, 570–573, 570f–572f, 593–600
alar crease restoration with, 598–600, 600f
anatomy and, 600
classi cation of, 593
clinical perspectives on, 600
conchal cartilage graft with, 597, 597f
donor site closure, 596f, 597–598, 599f
rst incision, stage 1, 594, 595f
rst incision, stage 2, 598, 599f
rst stage, 594–598
graft site preparation for, 594, 594f
hints and tips on, 600
patient positioning for, 594
placement of, 596–597, 596f
raising, 594–598, 595f–596f
second stage, 598–600
surface markings of, 594, 594f–595f
thinning, 596, 596f
third stage, 598–600, 600f
vascular pedicle of, 593
glabellar ap for, 567, 568f, 590–592
anatomy and, 592
classi cation of, 590
clinical perspectives on, 592, 592f
donor site closure, 591f, 592
graft site preparation for, 590
patient positioning for, 590
raising, 590–592
surface markings of, 590, 591f
vascular pedicle of, 590
historical perspective on, 582
illustrative case reports of, 550–579
lining, 92–93
nasolabial ap for, 19, 19f, 92, 584–587
anatomy and, 587
classi cation of, 584
clinical perspectives on, 585f–586f, 587
donor site closure, 586f, 587
graft site preparation of, 584, 585f
hints and tips on, 587
patient positioning for, 584
pedicle division for, 587
raising, 584–587, 586f
surface markings of, 584, 585f
vascular pedicle of, 584
Muscle-sparing latissimus dorsi aps, 475, 650–656
anatomy and, 654
classi cation of, 650
clinical perspectives on, 654–656, 656f
delivery into defect, 654, 655f
dissecting fascial ap for, 652–653, 652f–653f
dissecting skin aps for, 652
donor site closure, 654
hints and tips on, 656
muscle strip for, 653–654, 653f–655f
patient positioning for, 650, 651f
preparing eld for, 651
raising, 651–654, 652f–655f
surface markings of, 650–651, 651f
vascular pedicle of, 650, 650f
Muscle-sparing TRAM aps, 60–62, 60f–61f, 513, 514
MS-0, 60, 60f, 514, 514f, 519, 520f
MS-1, 60, 60f, 514, 515f, 518, 519–520
MS-2, 60–62, 61f, 514, 515f, 518, 519–520, 520f, 521f
MS-3, 60–62, 61f, 514
Musculocutaneous aps
circulation for, 12
lateral arm, 347
latissimus dorsi muscle-sparing, 475
Mathes and Nahai classi cation of, 14t, 15f
oblique rectus abdominis, 70–71, 540–545
soleus, 453, 458
transverse rectus abdominis (See Transverse rectus abdominis
musculocutaneous (TRAM) ap)
transverse upper gracilis, 55f, 64–66
Myocutaneous ap. See also speci c aps
gracilis, 70–71, 72f, 73f, 240
inferior gluteal artery, 251–258
latissimus dorsi, 349, 350, 353
pectoralis major muscle, 377–378, 378f, 381, 384–388
rectus femoris muscle, 423, 424f
transverse gracilis, 486–492
trapezius, 526–529, 531, 533
vertical/oblique rectus abdominis, 69–71, 540–545
N
Nasal reconstruction, 92–93, 582–607
bilobed ap for, 22f–24f, 92, 93f, 582–584
anatomy and, 584
classi cation of, 582
clinical perspectives on, 583f, 584
donor site closure, 583f, 584
rst lobe placement, 584
graft site preparation for, 582, 583f
hints and tips on, 584
patient positioning for, 582
raising, 582–584, 583f
second lobe placement, 583f, 584
surface markings of, 582, 583f
vascular pedicle of, 582
cheek advancement ap for, 587–590
anatomy and, 590
classi cation of, 587
clinical perspectives on, 590
donor site closure, 589f, 590
graft site preparation for, 587
hints and tips on, 590
patient positioning for, 587, 588f
raising, 588f–589f, 589–590
surface markings for, 587, 588f
vascular pedicle of, 587
conchal composite graft for, 605–607, 606f
anatomy and, 605
classi cation of, 605
Index
703
NSM. See Nipple areolar sparing mastectomy
Nuclear medicine, for ap monitoring, 155
O
Oblique rectus abdominis musculocutaneous (ORAM) ap,
70–71, 540–545
anatomy and, 544
classi cation of, 540
clinical perspectives on, 544
donor site closure, 544
hints and tips on, 544–545
incision for, 540f, 541
inset of, 541–542, 543f
patient positioning for, 540, 540f, 541f
raising, 540f–545f, 541–544
surface markings of, 540–541, 540f
variations in, 544
vascular pedicle of, 540
Occipital vessels, in trapezius aps, 526
Ollier, Leopold, 104f
Omental aps, pedicled
anatomy and, 373
classi cation of, 368
clinical perspectives on, 373
hints and tips on, 373
inset of, 370, 372f
patient positioning for, 368, 369f
for pelvis reconstruction, 373
raising, 368–370, 370f–372f
for sternal reconstruction, 368–373
variations in, 373
vascular pedicle of, 368, 368f
for vesicovaginal stulas, 373
Operating microscopes, 29, 29t
magni cation and illumination, 29, 29t
recipient vessel selection under, 32–33
Oral cavity reconstruction, 98–102. See also speci c anatomic
structures
ALT ap for, 98, 100f–101f
dorsalis pedis ap for, 631
facial artery musculomucosal ap for, 618–620, 619f–620f
free bula osteocutaneous ap for, 79
pectoralis major ap for, 102
radial forearm free ap for, 98–102, 99f–100f
trapezius ap for, 531
Oromandibular full-thickness defects, 657–663
algorithms for choosing ap, 662
bula ap for, 657–660, 657f–660f
double skin paddle, 658, 659f, 660
perforators of, 658–660, 659f–660f
postoperative morbidity with, 661–662
single skin paddle, 657, 657f, 658
single skin paddle with de-epithelialized bridge, 657, 658, 658f
soleus inclusion in, 659–660, 660f
iliac crest and groin aps for, 660–661, 661f, 662f
Oropharyngeal reconstruction, 100f–101f, 102
Orticochea ap, 80, 82
Osseointegrated appliances, for ear, 88
Osteocutaneous ap
dorsalis pedis, 632
lateral arm, 346
scapular, 432–433
Osteointegrated dental implants, 570, 570f, 573, 573f
Osteomusculocutaneous aps, latissimus dorsi, 353, 355f
Osteomyelitis, tibia reconstruction in, 414, 414f–415f
Osteomyocutaneous aps
bula
for nasal and cheek reconstruction, 569–579, 569f–570f
surface markings of, 569, 569f
preauricular free ap for, 601–603
anatomy and, 602
classi cation of, 601–602
clinical perspectives on, 603
donor site closure, 602, 602f
graft site preparation for, 602
hints and tips on, 603
patient positioning for, 602
raising, 602, 602f
recipient vessels for, 602
surface markings of, 602
vascular pedicle of, 602
prelamination/prefabrication in, 92, 550
principles of, 92, 550
radial forearm ap for, 558–566, 559f–560f, 564f–565f,
603–605
anatomy and, 603
classi cation of, 603
clinical perspectives on, 604f, 605
donor site closure, 603
failed, 567–573, 569f
graft site preparation for, 603, 604f
hints and tips on, 605
patient positioning for, 603
raising, 603, 604f
recipient vessels for, 603
surface markings of, 603
vascular pedicle of, 603
septal ap for, 600–601
anatomy and, 601
classi cation of, 600
clinical perspectives on, 601
graft site preparation for, 600–601
hints and tips on, 601
patient positioning for, 600
raising, 601, 601f
surface markings of, 601, 601f
vascular pedicle of, 600
stable platform for, 550
support structures in, 93
Nasolabial ap, 19, 19f, 92, 584–587
anatomy and, 587
classi cation of, 584
clinical perspectives on, 585f–586f, 587
donor site closure, 586f, 587
graft site preparation of, 584, 585f
hints and tips on, 587
patient positioning for, 584
pedicle division for, 587
raising, 584–587, 586f
surface markings of, 584, 585f
vascular pedicle of, 584
Near-infrared spectroscopy (NIRS), for ap monitoring, 150
Neck. See Head and neck
Neck, recipient vessels in, 125–127
Needle-holder, in microsurgery, 29
Negative pressure wound therapy (NPWT), 26, 104, 108, 112
Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock,
and Age of Patient (NISSSA) Score, 106
Neurosensory ap, lateral arm, 346–347
Nipple areolar sparing mastectomy (NSM), 53, 56
NISSSA. See Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal
Injury, Shock, and Age of Patient (NISSSA) Score
Noninvasive monitoring, of aps, 147, 148f, 149–152
No-re ow phenomenon, 39–40
Nose
reconstruction of (See Nasal reconstruction)
subunits of, 5, 6f–7f, 92
NPWT. See Negative pressure wound therapy
704
Index
raising, 429–430, 429f, 431
as free ap, 621–622
as pedicled ap, 622
size of, 429
surface markings of, 428, 429f, 621, 621f
for temple reconstruction, 85
vascular pedicle of, 427–428, 427f, 621
Paravertebral region, blood supply of, 297, 298f
Pare, Ambroise, 104f
Partial muscle coverage, in breast reconstruction, 53f, 56, 58f
Patency test, of anastomosis, 35, 38f
Pectoralis major muscle aps, 374–383
anatomy and, 379, 380f, 386
arc of rotation, 377, 378f, 385–386, 385f
for breast reconstruction, 55f
classi cation of, 374
clinical perspectives on, 379–381, 386, 387f
donor site closure, 379, 380f, 386
drain placement for, 378, 386
hints and tips on, 381–383, 386–388
incision placement for, 376, 376f, 385, 385f
innervation of, 375
inset of, 377, 379f, 386
for mandible reconstruction, 96, 381, 386, 387f
myocutaneous, 377–378, 378f, 381, 384–388
for oral cavity reconstruction, 102
osteomyocutaneous, 96, 381, 381f, 382f, 386
patient positioning for, 375, 384
raising, 376–379, 376f–379f, 384–386, 385f
split-thickness skin grafting with, 378, 386
sternal debridement for, 376
for sternal reconstruction, 374–383, 379f, 382f–383f, 386
surface markings of, 375–376, 375f, 384
turnover, 376–377, 381
variations in, 381, 386
vascular pedicle of, 374–375, 374f, 384
Pedicled aps. See also speci c aps and procedures
bipedicle advancement, 15, 16f–17f
breast reconstruction, 59
distant, 13
dominant, free, 41t
lower limb reconstruction, 111
single pedicle advancement, 15, 16f
transpositional, 19, 19f
Pedicled lower lid-sharing ap, 88
Pelvis reconstruction, omental ap for, 373
Perforator aps, 26, 41. See also speci c aps and procedures
Perineal reconstruction, 69–78
algorithm for approach in, 70–71, 71f
ALT ap for, 69–71, 70f–75f, 169–178, 174f, 176f–178f
assessment for, 69
challenges of, 69
free aps for, 72
gracilis myocutaneous ap for, 70–71, 72f, 73f
inferior gluteal artery myocutaneous ap for, 254–258,
256f–258f
keystone aps for, 310–311, 311f–312f
options for, 70–72
ORAM ap for, 70–71, 540–545
pedicle aps for, 72
phallus reconstruction in, 72, 77f
rectus femoris ap for, 72, 76f
rotation aps for, 70, 71
Singapore ap for, 70, 71
tensor fascia lata ap for, 72, 76f
VRAM ap for, 69–71, 69f, 70f, 540–545
V-Y advancement aps for, 70, 71
Perineum, neurovascular supply to, 301, 301f–302f
parascapular, 623
pectoralis major muscle, 96, 381, 381f, 382f, 386
trapezius, 533
Osteoseptocutaneous bula aps, 214–223
anatomy and, 221
anterior incision for, 217f, 219–220
classi cation of, 214
clinical perspectives on, 221
dissection order for, 214, 214f–216f
donor site closure, 221
hints and tips on, 221
interosseous membrane division for, 217f–218f, 220
intramuscular vessels for, 220
limb preparation for, 219
muscle detachment for, 217f–218f, 220
osteotomies for, 218f, 220
patient positioning for, 214
posterior incision for, 217f–218f, 220
raising, 219–221
retrograde pedicle dissection for, 218f–219f, 221
surface markings for, 214–219, 217f–219f
vascularity of, checking, 219f, 221
vascular pedicle of, 214, 214f–215f
Oximetry, transcutaneous, for ap monitoring, 150
Oxygenation measurement, for ap monitoring, 150–151
Oxygen tension, tissue, in ap monitoring, 153
P
Palate defects
dorsalis pedis aps for, 631
facial artery m usculom ucosal flap for, 618–620,
619f–620f
Palmaris longus tendon, vascularized graft, 626, 627f
Pan-facial aps, 609
Papillary dermis, 4
Paramedian forehead ap, 19, 19f
alar crease restoration with, 598–600, 600f
anatomy and, 600
classi cation of, 593
clinical perspectives on, 600
conchal cartilage graft with, 597, 597f
donor site closure, 596f, 597–598, 599f
rst incision, stage 1, 594, 595f
rst incision, stage 2, 598, 599f
rst stage, 594–598
graft site preparation for, 594, 594f
hints and tips on, 600
for nasal reconstruction, 19, 19f, 92, 94f–95f, 560–562,
561f–562f, 570–573, 570f–572f, 593–600
patient positioning for, 594
placement of, 596–597, 596f
raising, 594–598, 595f–596f
second stage, 598–600
surface markings of, 594, 594f–595f
thinning, 596, 596f
third stage, 598–600, 600f
vascular pedicle of, 593
Parascapular ap, 427–433
anatomy and, 427f, 428, 428f, 622
for cheek reconstruction, 92
chimeric options, 433
classi cation of, 427, 621
clinical perspectives on, 433, 623
cutaneous axial, 621–623
donor site closure, 622, 623f
for lower limb reconstruction, 110
osteomyocutaneous, 623
patient positioning for, 428–429, 621
Index
705
Q
Quaba aps, 641–643
anatomy and, 641, 642
classi cation of, 641
clinical perspectives on, 642
hints and tips on, 643
patient positioning for, 641
raising, 641–642, 641f–642f
surface markings of, 641
variations in, 642, 642f–643f
vascular pedicle of, 641, 641f
Quadriceps keystone ap, 282, 288f–289f
R
Radial artery
access, 116–117, 117f–119f
anatomy, 116–117, 116f
in radial forearm ap, 394, 394f, 395–399, 397f–400f, 624
Radial forearm ap, 394–404, 624–627
anatomy and, 399, 603, 625–626
for cheek reconstruction, 92, 558–561, 559f–560f
classi cation of, 394, 603, 624
clinical perspectives on, 399, 604f, 605, 626, 626f
donor site closure, 399, 401f, 605
graft site preparation for, 603, 604f
for hand reconstruction, 626, 626f, 627f
hints and tips on, 605, 626
incision and suprafascial harvest, 395, 396f
for lip reconstruction, 96
for mandible reconstruction, 96
for nasal reconstruction, 558–566, 559f–560f, 564f–565f,
603–605, 604f
failed, 567–573, 569f
for oral cavity reconstruction, 98–102, 99f–100f
patient positioning, 395
patient positioning for, 603, 624
for phallus reconstruction, 72, 77f
raising, 395–399, 395f–400f, 604f, 605, 624–625, 625f
recipient vessels for, 603–605
for scalp reconstruction, 82, 626, 626f
surface markings of, 395, 395f–396f, 558–559, 559f, 563–564,
564f, 603, 624, 624f
for temple reconstruction, 85, 86f–87f
for tongue reconstruction, 401, 402f–403f
ulnar artery forearm fasciocutaneous ap vs., 538
variations in, 626, 627f
vascularized tendon graft with, 626, 627f
vascular pedicle of, 394, 394f, 395–399, 397f–400f, 603, 624
Radiation, and TRAM ap, 512
Radioactive isotopes, for ap monitoring, 155
Recipient vessels, 32–33, 32f, 115–128. See also speci c vessels
breast reconstruction
internal mammary system, 129–140
thoracodorsal system, 141–146
head and neck, 125–127
lower limb, 110, 118–124
torso, 127–128
upper limb, 115–117
Reconstructive ladder, 5
Reconstructive menu, 5
Reconstructive surgery. See also speci c procedures and aps
basic principles of, 3–28
direct closure in, 5–9
functional and cosmetic aims of, 5
Langer lines in, 5, 5f–6f
patient-speci c nature of, 28
preoperative imaging for, 44–51
skin grafts in, 9–10
Perioral soft tissue defects, facial artery perforator ap for,
614–617, 616f–617f
Periorbital rotational aps, 88
Peroneal ( bular) artery, reverse sural ap, 460, 460f
Peroneal nerve, in dorsalis pedis ap, 628, 631f
Peroneus brevis muscle aps, for lower limb reconstruction,
684–689
planning for, 684
“take” of, 688–689, 688f
technique in, case example of, 684–687, 685f–688f
PET. See Positron emission tomography
pH, tissue, in ap monitoring, 153
Phallus reconstruction, 72, 77f, 399
Pharyngolaryngectomy defects, circumferential, jejunal ap for,
259–266, 266f
Photoplethysmography (PPG), for ap monitoring, 150
Pinwheel ap, for scalp reconstruction, 81
Platelet(s), in wound healing, 3
Polymorphonuclear cells (PMNs), in wound healing, 3
Ponten type aps, for lower limb reconstruction, 109, 111
Popliteal artery, 118
access, 118, 120f
anatomy, 118
Popliteal fossa, 118
Positron emission tomography (PET), 155
Post-con ict setting. See Mission setting
Posterior auricular ap, 88, 89f
Posterior intercostal arteries, 297, 298f
Posterior thigh perforator ap, 391–393
for ischial closure, 391, 391f
patient positioning for, 391
postoperative care, 392
raising, 392, 392f–393f
surface markings of, 391–392
vascular pedicle of, 391
Posterior tibial artery, 122
access, 122, 123f
anatomy, 122, 123f–124f
soleus ap, 452
Preauricular free ap
anatomy and, 602
classi cation of, 601–602
clinical perspectives on, 603
donor site closure, 602, 602f
graft site preparation for, 602
hints and tips on, 603
for nasal reconstruction, 601–603
patient positioning for, 602
raising, 602, 602f
recipient vessels for, 602
surface markings of, 602
vascular pedicle of, 602
Predictive Salvage Index (PSI), 106
Prefabrication, ap, 42, 92, 550
Prelamination, 42, 92, 550
Preoperative im aging, 44–51. See also speci c im aging
m odalities
Pressure sores
posterior thigh perforator ap for, 391, 391f
sacral, SGAP ap for, 446, 446f–448f
Primary ischemia time, 39
Profunda fem oris artery, in rectus fem oris m uscle ap, 417,
417f
Proliferation, in wound healing, 3, 3f
Proximal third leg defects, 109
PSI. See Predictive Salvage Index
Pudendal (Singapore) ap, 70, 71
Pudendal nerve, 301, 301f–302f
706
Index
patient positioning for, 460–461, 461f
perforator location for, 461
raising, 461–463, 463f–466f
split-thickness skin graft for, 463, 466f
surface markings of, 461, 461f, 462f
surgical planning for, 463
variations in, 465–467
vascular pedicle of, 460, 460f
Rhomboid (Limberg) ap, 15–19, 17f–19f, 633–640
choice, guiding principles of, 640, 640f
classic, 633, 634f
dependency and pin cushioning for, 640
drawing angles for, 633, 633f–635f
drawing lesion for, 633, 634f
excision margin for, 633, 634f
xed points lacking in, 635, 635f
four potential aps in, 633, 634f
line of maximum extensibility in, 635
modi ed, 639, 639f
orientation of, di culty with, 635–636
relaxed skin tension line in, 635, 636–637, 636f–639f
for scalp reconstruction, 81
scar vs. standing cutaneous cone for, 640
skin laxity for, 640
standard geometric model of, 635, 636f
tension and landmarks for, 640
transposition of, 633–635, 635f
20-degree rule for, 636–637, 636f
Rib cartilage
excision
internal mammary artery dissection with, 129–131,
130f–135f
subperichondrial, 130, 132f–133f
subpectoral dissection to expose, 129–130, 130f–131f
Rib–latissim us dorsi osteom usculocutaneous flap, 353,
355f
Rib-sparing dissection, of internal mammary artery, 131–137,
135f–138f, 194–196, 196f
Rintala (dorsal advancement) ap
anatomy and, 592
classi cation of, 592
clinical perspectives on, 593, 593f
donor site closure, 592, 593f
graft site preparation for, 592, 593f
hints and tips on, 593
for nasal reconstruction, 592–593
patient positioning for, 592
raising, 592
surface markings of, 592, 593f
vascular pedicle of, 592
Rotation aps, 19, 20f
bilateral, 19, 20f–21f
for cheek reconstruction, 89, 90f–91f
for eyelid reconstruction, 87–88
large, 19, 21f–22f
for perineal reconstruction, 70, 71
for scalp reconstruction, 20f, 80–82, 81f–82f
transfer of, 19, 20f
for upper face reconstruction, 85
S
Sacral pressure sores, SGAP ap for, 443–445, 445f–447f,
447–450
Saddle nose deformities, 92
Scalp reconstruction, 79–82
anterior defects, 80
assessment for, 80
burn injuries, 666–667
techniques in, 5–26
tissue expansion in, 12
wound healing in, 3–4, 3f
Rectus abdominis muscle ap, 405–416
anatomy and, 412–414
anterior rectus sheath incision for, 406–408, 407f–409f
for breast reconstruction, 52, 55f, 59–62
classi cation of, 405
clinical perspectives on, 414
completion of harvest, 409–412
dissection of muscle o posterior rectus sheath, 408, 410f
division of superior end of muscle, 408–409, 410f–411f
donor site closure, 412, 413f
hints and tips on, 415–416
oblique musculocutaneous (See Oblique rectus abdominis
musculocutaneous (ORAM) ap)
patient positioning for, 406
for perineal reconstruction, 69–71
raising, 406–412, 407f–413f
skin incision for, 406, 407f
surface markings of, 406, 406f
for tibia reconstruction, 414, 414f–415f
transverse musculocutaneous (See Transverse rectus abdomi-
nis musculocutaneous (TRAM) ap)
vascular pedicle of, 405–406, 405f, 409, 412, 412f, 413f
vertical myocutaneous (See Vertical rectus abdominis myocu-
taneous ap)
Rectus femoris muscle ap, 417–426
anatomy and, 418, 423
classi cation of, 417
clinical perspectives on, 423–424, 425f
cross-hatching fasciotomy for, 424, 425f
donor site closure, 423
hints and tips on, 424–426
incision for, 418, 419f
inset of, 422f, 423
limb preparation for, 418
myocutaneous, 423, 424f
patient positioning for, 417
for perineal reconstruction, 72, 76f
raising, 418–423, 419f–422f
skin ap elevation for, 418, 419f
stabilizing patellar tendon for, 423
surface markings of, 417, 418f
surgical planning for, 418
variations in, 423
vascular pedicle of, 417, 417f
Regional aps, 13
Relaxed skin tension line (RSTL), in rhomboid ap, 635, 636–637,
636f–639f
SPIRO (square peg in round hole), 639, 639f–640f
Remodeling, in wound healing, 3f, 4
Reperfusion injury, 39–40
Reticular dermis, 4
Retrograde ow, 29
Reverse axial dorsal metacarpal artery ap, 642
Reverse lateral free arm ap, 347
Reverse soleus ap, 455, 458
Reverse sural aps, 460–468
anatomy and, 463
classi cation of, 460
clinical perspectives on, 467–468, 467f–468f
donor site closure, 463, 465f–466f
hints and tips on, 468
incision for, 463, 463f
inset of, 463
limb preparation for, 461
for lower limb reconstruction, 109, 467–468, 467f–468f
Index
707
classi cation of, 10
donor sites for, 10
free, 10f–11f
full thickness, 10, 10f
for keystone flaps, 268, 269f, 275, 276f–277f, 293–294,
338
in mission setting, 673, 673f
for nasal lining, 92
for pectoralis major muscle ap, 378, 386
for reverse sural ap, 463, 466f
shaving of, 9, 11f
for soleus ap, 455, 457f–458f
split, 9–10, 10f–12f
“take,” 10
for temporoparietal fascia ap, 497, 497f, 499f, 500
for upper face reconstruction, 82, 84f–85f
for upper limb reconstruction, 318
Skin paddle
for ap monitoring, 148, 149
for gracilis ap, 238–239
Skin sparing mastectomy (SSM), 52, 53
Skin tension lines, 5, 5f–6f
Smartphone digital technology, for ap monitoring, 151
Soft touch registration, in stereotaxy, 49
Soleus aps, 452–459
anatomy and, 452–453, 452f, 453f, 458
arc of rotation, 452, 455, 456f
avoiding danger zone in, 454, 455f
classi cation of, 452
clinical perspectives on, 458, 459f
donor site closure, 455, 458f
drain placement for, 455, 458f
fasciotomy for, 454
hemostasis with, 455, 458f
hints and tips on, 458–459
incision placement for, 453, 453f–454f
musculocutaneous, 453, 458
patient positioning for, 452, 452f
perforators for, 455, 455f
raising, 453–455, 453f–458f
reverse, 455, 458
split-thickness skin grafting for, 455, 457f–458f
splitting of muscle, 455
surface markings of, 452–453
variations in, 458
vascular pedicle of, 452
Speech, mandible reconstruction and, 96
Spinal reconstruction, free vascularized bone grafts ( aps) for,
644–649
approaches in, 644
cervical spine, 645–646, 646f
cervicothoracic and thoracic spine, 646–647, 646f–647f
double barrel bula strut for, 645, 645f, 647f
indications for, 644, 644f
lower thoracic and thoracolumbar spine, 647
lumbar spine, 647–648, 647f–648f
osteotomy for, 645, 645f
planning for, 644–645
postoperative monitoring of, 648–649
surgical technique for, 645, 645f
vascular pedicle of, 645
SPIRO (square peg in round hole) ap, 639, 639f–640f
Split skin graft (SSG), 9–10, 10f–12f
SPY imaging, in breast reconstruction, 62–64, 65f
SSG. See Split skin graft
SSM. See Skin sparing mastectomy
STAP (superior thyroid artery perforator ap), 330
Stereotaxy, 48–49, 48f
latissimus dorsi ap for, 82, 83f–84f, 355, 356f
options for, 80–82
Orticochea aps for, 80, 82
parietal defects, 80
pinwheel aps for, 81
radial forearm ap for, 82, 626, 626f
rhomboid aps for, 81
rotation aps for, 20f, 80–82, 81f–82f
super cial temporal vessels in, 80
three- ap technique for, 80
total vs. subtotal defects, 82, 83f–84f
vertex and occipital defects, 81–82, 81f–82f
Scapula–latissimus dorsi osteomusculocutaneous ap, 353
Scapular artery, circum ex. See Circum ex scapular artery
Scapular artery, circum ex, ap. See Circum ex scapular artery
perforator (CSAP) ap
Scapular defects, keystone aps for, 302, 306f–308f
Scapular ap, 427–433
anatomy and, 427f, 428, 428f
for cheek reconstruction, 92
chimeric options, 433
classi cation of, 427
clinical perspectives on, 433
for lip reconstruction, 96
for lower limb reconstruction, 110
for mandible reconstruction, 96
osseocutaneous, 433
patient positioning for, 428–429
raising, 429–433, 429f, 431f
size of, 429
surface markings of, 428, 429f
for temple reconstruction, 85
vascular pedicle of, 427–428, 427f
Scars, placement of, 5, 5f–6f
SCIP. See Super cial circum ex iliac perforator (SCIP) ap
Scissors, microsurgical, 30f, 31
Secondary intention healing, 26–28
Secondary ischemia time, 39
Semicircular rotational ap, for eyelid reconstruction, 87
Septal ap
anatomy and, 601
classi cation of, 600
clinical perspectives on, 601
graft site preparation for, 600–601
hints and tips on, 601
for nasal reconstruction, 600–601
patient positioning for, 600
raising, 601, 601f
surface markings of, 601, 601f
vascular pedicle of, 600
SGAP. See Superior gluteal artery perforator (SGAP) ap
Shoulder reconstruction, trapezius ap for, 531
Sidestream dark eld imaging (SDFI), for ap monitoring,
150
SIEA. See Super cial inferior epigastric artery (SIEA) ap
Simple interrupted sutures, 6–7, 7f
Singapore ap, 70, 71
Single keystone aps, 268, 269f
Single pedicle advancement ap, 13, 16f
Skin
blood supply to, 4f, 5
quilted to underlying bed, 9, 12f
structure and function of, 4–5, 4f
tie-over of, 9, 12f
Skin grafts, 9–10
for anterolateral thigh ap, 175
application of, 9–10, 12f
bolster dressing for, 9, 12f
708
Index
classi cation of, 434
clinical perspectives on, 448–451
donor site closure, 438, 439, 444f, 446, 446f
hints and tips on, 451
patient positioning for, 437–438, 437f
raising, 438–446, 438f–444f, 447f
for sacral pressure sores, 446, 446f–448f
surface markings of, 434–437, 435f–437f
vascular pedicle of, 434
Superior inferior epigastric vein (SIEV), identi cation, in raising
DIEP ap, 186–189, 189f
Superior mesenteric artery (SMA), in jejunal ap, 259, 259f
Superior thyroid artery, 126–127
access, 126–127, 126f
anatomy, 126
Superior thyroid artery perforator (STAP) ap, 330
Supermicrosurgery, 41–42
Suprafascial aps, anterolateral thigh, raising, 165–167,
166f–167f
Supramicrosurgery, 41–42
Sural artery ap, 465–467, 466f
Sural aps, reverse, 460–468
anatomy and, 463
classi cation of, 460
clinical perspectives on, 467–468, 467f–468f
donor site closure, 463, 465f–466f
hints and tips on, 468
incision for, 463, 463f
inset of, 463
limb preparation for, 461
for lower limb reconstruction, 109, 467–468, 467f–468f
patient positioning for, 460–461, 461f
perforator location for, 461
raising, 461–463, 463f–466f
split-thickness skin graft for, 463, 466f
surface markings of, 461, 461f, 462f
surgical planning for, 463
variations in, 465–467
vascular pedicle of, 460, 460f
Surface temperature, in ap monitoring, 151
Suture(s), 6–9
continuous, 6, 9, 9f
dog ears, 6, 9, 10f
horizontal mattress, 6–7, 9f
microsutures, 31
simple interrupted, 6–7, 7f
subcutaneous with buried knot, 6, 7f
subcuticular, 6–7, 8f
vertical mattress, 6–7, 8f
wound preparation for, 9
SVT. See Super cial temporal vessels
T
“Take,” skin graft, 10
Tarsal extension ap, 88
Tarsoconjunctival ap, 88
TDAP. See Thoracodorsal artery perforator (TDAP) ap
Temperature measurement, for ap monitoring, 151, 152
Temperature probe, 152
Temple reconstruction, 85
ap options for, 17f–19f, 85, 86f–87f
temporalis muscle in, 85
Temporal vessels, super cial, 80, 125, 125f
Temporoparietal fascia aps, 493–501
anatomy and, 497
auricle elevation for, 497, 498f–499f
classi cation of, 493
clinical perspectives on, 500
Sternal reconstruction
pectoralis major muscle ap for, 374–383, 382f–383f, 386
debridement for, 376
inset of, 377, 379f
split-thickness skin grafting with, 378
pedicled omental ap for, 368–373
anatomy and, 373
clinical perspectives on, 373
hints and tips on, 373
inset of, 370, 372f
raising, 368–370, 370f–372f
vascular pedicle of, 368, 368f
Stratum basale, 4
Stratum corneum, 4
Stratum granulosum, 4
Stratum lucidum, 4
Stratum spinosum, 4
Stress relaxation, 12
Subcutaneous suture with buried knot, 6, 7f
Subcuticular sutures, 6–7, 8f
Submental artery ap, for cheek reconstruction, 92
Supercharged TRAM ap, 513
Super cial circum ex iliac artery, 243–246, 245f, 246f
Super cial circum ex iliac perforator (SCIP) ap, 243–249
anatomy and, 246
assessing and preparing recipient site for, 244–245
classi cation of, 243
clinical perspectives on, 246–247, 247f–249f
donor site closure, 246
elevation in suprascarpal plane, 245, 245f
hints and tips on, 250
patient positioning for, 243
raising, 244–246
retrograde pedicle dissection for, 246, 246f
surface markings for, 244, 244f
vascular pedicle of, 243, 243f
vessel identi cation in, 246, 246f
Super cial inferior epigastric artery, 301
Super cial inferior epigastric artery (SIEA) ap, 184–185,
203–208
for breast reconstruction, 55f, 59, 62, 63f, 64t, 205–206
clinical case of, 206, 208f
inset of, 206, 206f
recipient vessel exposure for, 205–206
classi cation of, 184
donor site closure, 206
inferior incision and SIE vessel identi cation for, 203–205,
204f–205f
patient positioning for, 184
for perineal reconstruction, 72
preoperative perforators assessment for, 185, 186f
surface markings for, 185
vascular pedicle of, 184, 184f–185f
Super cial inferior epigastric vein, 301
Super cial temporal artery, 125
access, 125
anatomy, 125, 125f
in temporoparietal fascia ap, 493, 493f
Super cial temporal vessels (SVT), 125, 125f
in scalp reconstruction, 80
Superior epigastric artery, in rectus abdominis muscle ap,
405–406, 405f, 502
Superior gluteal artery, 301
Superior gluteal artery perforator (SGAP) ap, 434–450
for abdominoperineal wound dehiscence, 446–448, 448f–450f
anatomy and, 434, 448
for breast reconstruction, 64, 66f, 205–206, 206f, 208f, 434,
437–439, 437f–445f, 448–451
Index
709
Throm bosis
anastomosis and, 35, 35t
in burn injury aps, 671
microsurgery and, 38
Thumb reconstruction, radial forearm ap for, 399
Thyroid artery, superior, 126–127, 126f
Tibial artery. See Anterior tibial artery; Posterior tibial artery
Tibial fractures, open. See also Lower limb injury; Lower limb
reconstruction
classi cation of, 106, 106t
TDAP ap for, 475f
Tibial osteomyelitis, rectus abdominis muscle ap for, 414,
414f–415f
Tie-over, of skin graft, 9, 12f
Tissue expansion, 12, 13f. See also speci c procedures
advantages of, 12
clinical scenarios and technique, 12, 14f
creep and stress relaxation in, 12
disadvantages of, 12
Tissue oxygen tension, in ap monitoring, 153
Tissue pH, in ap monitoring, 153
TMG. See Transverse myocutaneous gracilis (TMG) ap
Tongue reconstruction, 98–102, 98f–100f
groin/SCIP ap for, 246–247
radial forearm ap for, 401, 402f–403f
ulnar artery fasciocutaneous ap for, 538, 538f
Torso, recipient vessels in, 127–128
Total muscle coverage, in breast reconstruction, 56, 57f
TRAM. See Transverse rectus abdominis musculocutaneous
(TRAM) ap
Transcutaneous oximetry, for ap monitoring, 150
Transposition aps, 15–19
Dufourmentel, 17f, 19
Limberg/rhomboid, 15–19, 17f–19f, 633–640
pedicle-based, 19, 19f
two (bilobed), 19, 22f–24f
Transverse cervical vessels, in trapezius aps, 525–526, 525f
Transverse myocutaneous gracilis (TMG) ap, 486–492
anatomy and, 488f, 490
for breast reconstruction, 55f, 64–66, 491, 491f
classi cation of, 486
clinical perspectives on, 491
donor site closure, 490
donor site outcome, 491, 492f
hints and tips on, 491–492
incision for, 486, 489f
patient positioning for, 486, 486f
raising, 486–490, 489f–491f
surface markings for, 486, 487f
variations in, 491
vascular pedicle of, 486
Transverse rectus abdominis musculocutaneous (TRAM) ap,
52, 55f, 59–62, 502–513
algorithm for selecting, 62, 64t
classic, 59
DCIA ap conversion to, 203
free, 514–524
abdominal incisions for, 518, 518f
before and after images, 523f–524f
anastomosis of, 522, 522f
classi cation of, 514, 514f
donor site closure, 523, 523f
fascial incision for, 518, 519f
inset of, 522–523, 523f
myotomy for, 519–520, 520f–521f
patient positioning for, 514, 516f
preparing for microsurgery, 520–522, 522f
raising, 516–520, 517f–521f
hints and tips on, 500–501
incision and exposure for, 494, 494f–495f
inset of, 497, 498f–499f
patient positioning for, 493
raising, 494–497, 494f–496f
skin graft for, 497, 497f, 499f, 500
surface markings of, 493–494, 494f
vascular pedicle of, 493, 493f
Tensor fascia lata ap, for perineal reconstruction, 72, 76f
Tensor fascia lata perforator-based island (TFL-PBIF) ap, 478–485
anatomy and, 478f, 483
classi cation of, 478
clinical perspectives on, 483
design of, 480–481, 480f–481f, 483
donor site closure, 480, 480f, 481, 482, 483f–484f
hints and tips on, 483–485
inset of, 482, 483f–484f
patient positioning for, 478
perforator location for, 479–480, 479f
radical debridement for, 479, 479f
raising, 479–482, 479f–484f
surface markings of, 479, 479f
vascular pedicle of, 478, 478f
TFL-PBIF. See Tensor fascia lata perforator-based island
(TFL-PBIF) ap
Thermography, dynamic infrared, 49–51, 50f, 151
Thigh aps. See Anterolateral thigh ap; Gluteal thigh aps;
Posterior thigh perforator ap
Thigh reconstruction, keystone ap for, 282, 288f–289f
Thoracic artery, lateral, 128
Thoracic spine, free vascularized bone graft for, 646–647, 646f–647f
Thoracoacromial artery, in pectoralis major muscle ap, 374,
374f, 384
Thoracodorsal artery, 127–128
access, 128
anatomy, 127, 141, 297, 301, 469
as recipient vessel in breast reconstruction, 141–146
axillary dissection for exposure, 142, 142f–143f
axillary microsurgical platform and setup, 144, 144f–145f
experience and philosophy, 141
nesting of abdominal ap on chest wall, 144–146, 145f–146f
surgical technique, 141–146
thoracodorsal dissection and transection, 142
triangular exposure, 142, 144f
Thoracodorsal artery perforator (TDAP) ap, 353, 469–477
anatomy and, 469, 474
for breast reconstruction, 474–475, 477f
classi cation of, 469
clinical perspectives on, 474–475
donor site closure, 473–474, 474f–475f
hints and tips on, 475–477
for lower limb reconstruction, 475f
patient positioning for, 469
raising, 470–474, 472f–474f
surface markings of, 469–470, 470f–472f
for upper limb reconstruction, 476f
vascular pedicle of, 469
Thoracodorsal vein
anatomy, 141
as recipient vessel in breast reconstruction, 141–146
axillary dissection for exposure, 142, 142f–143f
axillary microsurgical platform and setup, 144, 144f–145f
experience and philosophy, 141
nesting of abdominal ap on chest wall, 144–146, 145f–146f
surgical technique, 141–146
thoracodorsal dissection and transection, 142
triangular exposure, 142, 144f
Thoracolumbar spine, free vascularized bone graft for, 647
710
Index
back, 302, 306f–308f, 313f, 315f
breast, 309–310, 310f
buttock, 310–311, 315f
hints and tips on, 311, 312f–317f
lateral trunk and abdomen, 303–309, 309f, 311
perineal, 310–311, 311f–312f
reliability and advantages of, 297
subregions and planning for, 302–311
subregions of, 297, 302
trapezius ap for, 531
vascular pedicles and blood supply in, 297–301, 298f–302f
Tubed ap, for ear, 88
Turnover pectoralis major muscle ap, 376–377, 381
Turnover trapezius ap, 533
20-degree rule, for rhomboid ap, 636–637, 636f
U
Ulnar artery, 117
access, 117, 119f
anatomy, 116f, 117, 118f
Ulnar artery forearm fasciocutaneous aps, 535–539
anatomy and, 538
classi cation of, 535
clinical perspectives on, 538, 538f
donor site closure, 538
hints and tips on, 539
innervation of, 535
limb preparation for, 535–536
patient positioning for, 535
radial forearm ap vs., 538
radial incision for, 536
raising, 535–538, 536f–538f
retrograde pedicle dissection for, 537, 537f
surface markings of, 535, 535f–536f
ulnar incision for, 536, 536f–537f
variations in, 539
vascularity of, checking, 538, 538f
vascular pedicle of, 535
Ultrasound
contrast-enhanced, for ap monitoring, 155
conventional, 44f
Doppler, 44–45, 44f, 45f
color, for ap monitoring, 150
handheld, for ap monitoring, 149–150
Unfractionated heparin, 39t
Upper face reconstruction
advancement aps for, 82, 85
ethnic consideration sin, 82
local aps for, 85
options for, 82–85
rotation aps for, 85
skin grafting in, 82, 84f–85f
Upper limb recipient vessels, 115–117
Upper limb reconstruction
“bloodless” surgery in, 318
burn injuries, 669
function as priority in, 318
groin/SCIP ap for, 246–247, 249f
keystone aps for, 317–329
arm , 319–320, 319f, 322–323, 322f–323f, 327,
327f–329f
clinical perspectives on, 327, 327f–329f
design of, 322–327
elbow region, 320, 323–324, 324f–325f
forearm, 319–322, 320f, 323–324, 324f–325f
hand, 321f, 322, 326–327, 326f
vascular pedicles and blood supply for, 317–322,
319f–321f
parascapular ap for, 623
recipient vessel exposure for, 516, 518f
surface markings of, 515, 516f–517f
morbidities associated with, 60–62, 62t
muscle-sparing, 60–62, 60f–61f, 513, 514
MS-0, 60, 60f, 514, 514f, 519, 520f
MS-1, 60, 60f, 514, 515f, 518, 519–520
MS-2, 60–62, 61f, 514, 515f, 518, 519–520, 520f, 521f
MS-3, 60–62, 61f, 514
pedicled, 502–513
abdominal muscle function after, 511–512
anatomy and, 509–510
bilateral and contralateral, 512
chemical leeching of, 513
classi cation of, 502
clinical perspectives on, 510
complications of, 511–512
cosmetic appearance and satisfaction after, 512
delay of, 512–513
double pedicle, 513
fat necrosis after, 512
hernias and bulges with, 511
hints and tips on, 513
incision for, 503, 503f
indications and contraindications, 510
inset of, 509, 510f
ipsilateral vs. contralateral pedicle, 510
necrosis and loss of, 512
patient positioning for, 502
prior abdominal incisions and, 511, 513
Prolene mesh for harvest defect, 508, 509f
radiation and, 512
raising, 502–509, 503f–509f
sensory changes after, 512
supercharged, 513
surface markings of, 502, 503f
variations in, 512–513
vascular pedicle of, 502
venous congestion in, 513
Transverse upper gracilis (TUG) musculocutaneous ap.
See Transverse myocutaneous gracilis (TMG) ap
Trapezius aps, 525–534
anatomy and, 531
classi cation of, 525
clinical perspectives on, 531, 532f–534f
donor site closure, 530, 532f
free, 533–534
hints and tips on, 533–534
myocutaneous, 526–529, 531, 533
osteomyocutaneous, 533
patient positioning for, 526, 526f, 528
postoperative management of, 530
raising, 527–530, 528f–531f
skin paddle for, 527–529, 527f, 529f
subcutaneous tunnel for, 529, 530f
surface markings of, 526–527, 527f
tension-free zone for, 530, 531f
turnover, 533
variations in, 533
vascular pedicle of, 525–526, 525f, 529, 530f
wound assessment for, 528, 528f
Triangulation technique, of anastomosis, 34, 34f
Trochanteric defects, TFL-PBIF aps for, 483
Trueta, Joseph, 104f
Trunk
cutaneous nerves of, 302, 304f–306f
dermatomes of, 302, 303f
keystone aps for, 297–317
abdomen, 311, 314f
anterior chest, 309–310
Index
711
Vesicovaginal stulas, omental ap for, 373
Vessel dilators, microsurgical, 31
Visible light spectrophotometry (VLS), for ap monitoring, 150–151
Visual assessment, of aps, 151–152
Volume-rendered technique (VRT), 45f, 46
VRAM. See Vertical rectus abdominis myocutaneous (VRAM) ap
VRT. See Volume-rendered technique
V-Y advancement ap, 15, 17f, 70, 71
W
War, mission setting after. See Mission setting
Workhorse aps, 40, 41t, 677, 678t–679t
Wound healing, 3–4
adjunctive techniques in, 26–28
factors a ecting, 4
phases of, 3–4, 3f
secondary intention, 26–28
W-plasty, 25, 26f
Wrist reconstruction, TDAP ap for, 476f
X
Xenograft, skin, 10
Y
Y-V advancement ap, 15
Z
Zitelli’s ap, for nasal reconstruction, 582–584
anatomy and, 584
classi cation of, 582
clinical perspectives on, 583f, 584
donor site closure, 583f, 584
rst lobe placement, 584
graft site preparation for, 582, 583f
hints and tips on, 584
patient positioning for, 582
raising, 582–584, 583f
second lobe placement, 583f, 584
surface markings of, 582, 583f
vascular pedicle of, 582
Z-plasty, 25, 25f
angle of, 25, 25f, 26t
for burn injuries, 664–665
multiple, 25f
simple, 25f
Z-touch surface matching registration, 49
radial forearm ap for, 399
skin grafting in, 318
TDAP ap for, 476f
Urethral reconstruction, ulnar artery fasciocutaneous ap for, 540
V
Vacuum dressing, 26
Vaginal reconstruction, gracilis ap for, 241f
Vascular induction, 42
Vascularized bone grafts, free, for spinal reconstruction, 644–649
approaches in, 644
cervical spine, 645–646, 646f
cervicothoracic and thoracic spine, 646–647, 646f–647f
double barrel bula strut for, 645, 645f, 647f
indications for, 644, 644f
lower thoracic and thoracolumbar spine, 647
lumbar spine, 647–648, 647f–648f
osteotomy for, 645, 645f
planning for, 644–645
postoperative monitoring of, 648–649
surgical technique for, 645, 645f
vascular pedicle of, 645
Vascularized tendon graft
with dorsalis pedis ap, 632
with lateral arm ap, 347
with radial forearm ap, 626, 627f
Vascular pedicle. See speci c aps
Vascular plexus, 4–5, 4f
Vasospasm, in microsurgery, 38, 38t
Vastus lateralis muscle, taking in ALT ap, 173, 173f
Vein grafts, 32–33, 42f
Vertical mattress sutures, 6–7, 8f
Vertical rectus abdominis myocutaneous (VRAM) ap, 69–71,
69f, 70f, 540–545
anatomy and, 544
classi cation of, 540
clinical perspectives on, 544
donor site closure, 544
hints and tips on, 544–545
incision for, 540f, 541
inset of, 541–542, 543f
patient positioning for, 540, 540f, 541f
raising, 540f–545f, 541–544
surface markings of, 540–541, 540f
variations in, 544
vascular pedicle of, 540
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