Flaps Practical Reconstructive Surgery

128
I Planning and Decision Making in Reconstructive Surgery
Anatomy
Branching o the second part of the axillary artery, the lateral
thoracic artery travels along the lateral border of pectoralis m i-
nor and sends perforating branches to it. It travels inferiorly and
winds around the distal part of the pectoralis minor and passes
deep to the pectoralis major before anastomosing to the internal
mammary, subscapular, and intercostal vessels. The vessels tend
to be larger in women as this forms one of the major sources for
perfusion of breast tissue.
Access
The same approach as to the thoracodorsal vessels is used. The
lateral thoracic vein is the rst vessel seen when dissecting pos-
terior the pectoralis major in the axillary fat. The artery is seen
posterior to the vein. The vessels can be traced proximally to the
origin to create length and to nd a segment with a larger diame-
ter. Again, if this vessel is not satisfactory, the thoracodorsal, sub-
scapular, and circum ex scapular arteries are in close proximity
and are an alternative.
Suggested Further Reading
Ashraf T1, Panhwar Z, Habib S, Memon MA, Shamsi F, Arif J. Size of
radial and ulnar artery in local population. J Pak Med Assoc
2010;60(10):817–819
Cham i HA1, Keyes MJ, Vita JA, Mitchell GF, Larson MG, Fan S, et al.
Brachial artery diam eter, blood ow and ow-m ediated di-
lation in sleep-disordered breathing. Vasc Med 2009;14(4):
351–360
Chen TH, Chen CH, Shyu JF, Wu CW, Lui WY, Liu JC. Distribution of the
super cial temporal artery in the Chinese adult. Plast Reconstr Surg
1999;104(5):1276–1279
Fazan VP, da Silva JH, Borges CT, Ribeiro RA, Caetano AG, Filho OA. An
anatomical study on the lingual-facial trunk. Surg Radiol Anat
2009;31(4):267–270
Ge XZ, Huang GK. Use of distal arteries for microvascular reconstruc-
tion in forearm and hand surgery. Microsurgery 1996;17(4):
180–183
Guay NA. The thoracodorsal vessels are advantageous, reliable, and safe
recipient vessels for free abdominal ap breast reconstruction. Ann
Plast Surg 2012;68(5):539–541
Morris-Sti G, Haynes M, Ogunbiyi S, Townsend E, Shetty S, Winter
RK, et al. Is assessm ent of popliteal artery diameter in patients
undergoing screening for abdominal aortic aneurysm s a worth-
while procedure. Eur J Vasc Endovasc Surg 2005;30(1):71–74
Ozgur Z, Govsa F, Celik S, Ozgur T. Clinically relevant variations of the
superior thyroid artery: an anatomic guide for surgical neck dissec-
tion. Surg Radiol Anat 2009;31(3):151–159
Pinar YA, Govsa F. Anatomy of the super cial temporal artery and its
branches: its importance for surgery. Surg Radiol Anat 2006;28(3):
248–253
Sabatier MJ, Stoner L, Reifenberger M, McCully K. Doppler ultrasound as-
sessment of posterior tibial artery size in hum ans. J Clin Ultrasound
2006;34(5):223–230
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Operative
Approaches. 2nd ed. New York, NY: Thieme; 2006
Access
The vessels can be accessed using an axillary approach (hockey
stick incision). Dissection through axillary fat identi es the pec-
toralis muscle anteriorly and the latissimus dorsi posteriorly and
proceeds medially to identify the serratus anteriorly. The tho-
racodorsal vessels are identi ed in the axillary fat posterior the
lateral thoracic vein which is encountered rst. The vessels are
dissected free from fat and the thoracodorsal nerve which crosses
anterior to them.
Alternatively, the thoracodorsal vessels can be identi ed en-
tering the latissimus dorsi (10 cm distal to its insertion on the
medial surface) and traced proxim ally until an adequately sized
vessel is found for anastomosis.
If the thoracodorsal artery is not suitable, the subscapular
and circum ex scapular arteries are alternatives with little fur-
ther dissection required.
Circum ex Scapular Artery
Diameter: 2.5–4 mm
Anatomy
The circum ex scapular artery is one of the term inal branches of
the subscapular artery (branches o the third part of axillary ar-
tery). The artery w inds around the lateral border of the scapula
and passes through the triangular space and enters the infraspi-
nous fossa beneath teres minor. Here it divides into descending
and transverse branches. The descending branch travels along
the lateral border of the scapula between the teres m ajor and
minor and anastomoses with the dorsal scapular artery at the
angle of the scapula. The transverse branch enters the infraspi-
nous fossa and anastom oses w ith the dorsal scapular artery at
the m edial border of the scapula. This transverse branch gives o
an ascending branch that travels superiorly toward the supraspi-
nous fossa.
Access
The circum ex scapular vessels lie posterior to the thoracodor-
sal vessels and are approached through the same access (see
previous). The vessels are traced to their entrance into the trian-
gular space, and ligated to ip them medially into the axilla for
anastomosis.
Lateral Thoracic Artery
Diameter: 1.5 mm

129
the subcostal groove. Sm aller side branches arise from the inter-
nal mammary vessels to supply the intercostal muscles and peri-
osteum of the rib and sternum.

Internal Mammary System
as Recipient Vessels
Three options are available: dissection of the internal mammary
vessels with rib excision (traditional), dissection of the internal
mammary vessels with rib preservation, and dissection of the in-
ternal mammary perforators. The preferred level for rib cartilage
excision is the third rib, as the vessels here are consistently large.
More distally, the vein narrows and bifurcates, generally becoming
unsuitable below the fourth space. We have found that removal of
rib cartilage does not result in noticeable contour deformities, as the
ap and pectoralis muscle provide adequate cover. As the rib carti-
lage is removed with the cranial and caudal intercostal muscles, this
technique provides excellent exposure and vessel length of 3 to 4 cm.
For the past 2 years, we have adopted the rib-sparing ap-
proach, usually at the third intercostal space. Donor site morbid-
ity and pain are reduced at the expense of exposure and pedicle
length (1 to 2 cm). Nevertheless, we have found that dissection
of the internal mammary vessels and microanastomosis could
be successfully accomplished in 90% of cases without having to
rem ove cartilage. In the remaining patients, the cranial portion
of the caudal rib cartilage may be partially excised to provide an
additional 0.5 to 1 cm of length.
Internal mammary perforators, which typically emerge from
the second and third intercostal spaces, may be preserved to pro-
vide an additional source of venous out ow. This is particularly
useful on the left side where there often tends to be one internal
mammary vein. Depending on their caliber, the internal mammary
perforators can be used as an alternative to the main internal mam-
mary vessels as recipient vessels for free ap breast reconstruction.

Surgical Technique
Internal Mammary Vessel Dissection
With Rib Cartilage Excision
Step 1: Subpectoral Dissection to
Expose Rib Cartilage
The third rib is palpated (Fig. 9.1a) and the overlying pectoralis
muscle is split along its bers (Fig. 9.1b) entering the subpectoral
plane, exposing the third rib from the sternocostal junction to

Introduction
The ideal recipient vessels for m icrovascular breast reconstruc-
tion are the internal m am m ary system . These vessels have m any
advantages over the thoracodorsal system:

●
Ideal for inset as it allows the ap to be positioned medi-
ally. Avoids the lateral displacement seen when the tho-
racodorsal vessels are used. Especially important during
bilateral breast reconstructions with small hemiabdominal
aps and aps with short pedicles, such as superior gluteal
artery perforator (SGAP).

●
Constant anatomy.

●
Strong pressure head.

●
Technical advantages: good exposure without needing to
extend incisions, com fortable position for assistant during
microsurgery, no need to reposition upper limbs.

●
If sentinel lymph node returns as positive, then formal
axillary dissection may proceed safely.
As a result, the internal mammary vessels have all but com -
pletely replaced the thoracodorsal vessels as the primary choice
for recipient vessels in our practice.

Anatomy
The internal mammary artery and vein arise from the subclavian
artery and brachiocephalic vein, respectively, and descend 0.5 to
2 cm lateral to the sternum, deep to the costal cartilages and inter-
costal muscles to bifurcate into the phrenic and superior epigastric
vessels at the sixth intercostal space. The vessels are enclosed with-
in a fatty connective tissue sheath along with the internal mam-
mary lymph nodes. The artery and vein become narrow distally,
and vessels on the left tend to be smaller than on the right. The
typical dimensions of the internal mammary vessels at the level of
third intercostal space are right internal mammary artery (2.52 6
0.58 mm), left internal mammary artery (2.30 6 0.55 mm), right
internal mammary vein (2.89 6 0.56 mm), and left internal mam -
mary vein (2.31 6 0.48 mm). The internal mammary vein typically
bifurcates between the level of the third and fourth ribs.
Internal mammary perforators arise from the main vessel at
the second and third intercostal levels. They pierce through the
respective intercostal muscles and then through the pectoralis
major m uscle and breast. They have an average caliber of 1 m m
(0.5 to 1.3 mm) for the artery and 1.7 mm (1 to 3 mm) for the
vein. The anterior intercostal vessels also arise from the internal
mamm ary vessels at each intercostal space to run laterally along
The Internal Mammary System as
Recipient Vessels for Breast
Microsurgical Reconstruction
Moustapha Ham di and Moham ed Zulf kar Rasheed
9

130
I Planning and Decision Making in Reconstructive Surgery
Fig. 9.1 (a,b) The third rib is palpated and marked. Retractors are applied.
(c) The pectoralis major is split along the bers and elevated o the third
rib cartilage.
c
b
a

9 The Internal Mammary System as Recipient Vessels for Breast Microsurgical Reconstruction
131
Fig. 9.2 Internal mammary artery perforators are ligated; their location
serves as a guide to the approximate location of the internal mammary
vessels. Self-retraining retractors are applied to maintain the exposure.
the costochondral junction, and the second and third intercostal
spaces (Fig. 9.1c). Internal m am m ary perforators course through
the intercostal and pectoralis m uscles and serve as a guide to the
location of the internal mammary vessels (Fig. 9.2). These are li-
gated with clips. Self-retaining retractors and elastic hooks are
applied, making it possible for the surgeon to perform the expo-
sure unassisted.
Step 2: Subperichondrial Rib Cartilage
Excision
The anterior perichondrium of the third rib cartilage is incised.
Subperichondrial dissection of the third rib cartilage is performed
all around with a periosteal elevator (Fig. 9.3). A narrow rongeur
is then used to progressively excise the segm ent of rib (Fig 9.4a,b).
Every e ort is m ade to leave the posterior perichondrium
intact throughout this part of the procedure so that nal expo-
sure of the vessels is controlled and deliberate (Fig 9.4c).
Step 3: Controlled Posterior
Perichondrial Elevation to Expose
Internal Mammary Vessels
From this stage forth, the dissection is perform ed under loupe
or microscope magni cation. The posterior perichondrium is
incised laterally with a blunt tip scissor away from the internal
mamm ary vessels (Fig. 9.5). The perichondrium and attached in-
tercostal muscles are elevated medially toward the sternum with
a cotton-tipped applicator and ne bipolar forceps (Fig. 9.6).
This exposes the internal m am mary vessels which are enclosed
within a fatty connective tissue sheath.
Step 4: Internal Mammary Vessel
Dissection
The fascia covering the fatty connective tissue sheath is incised.
A cotton-tipped applicator is used to spread the fat and dissect
the vessels. The artery is usually located lateral to the vein, and
where the vein has bifurcated, the artery lies in the middle. Inter-
vening fat or lymph nodes are excised. Side branches are ligated
with clips so that the internal mammary vessels are completely
freed along the exposed length. Great care should be taken when
dissecting the vein, which is thin walled (Fig. 9.7).
Step 5: Setup for Microsurgical
Anastomosis
When the surgeon is satis ed with the length and caliber of
the dissected vessels, the distal ends are clipped, m icrovascular
clamps applied proximally, and the vessels cleanly transected with
a pair of microscissor. A “spurt test” con rms adequate out ow
from the internal mammary artery. Blood is aspirated and the
vessel lum ens irrigated with heparinized saline. A narrow-gauge
suction drain placed in the deepest part of the microsurgical eld
helps to remove any irrigation uid or blood, keeping the eld
clear during anastomosis (Fig. 9.8).
Rib-Sparing Internal Mammary
Vessel Dissection
Step 1: Selecting the Appropriate
Intercostal Space
The intercostal spaces are rst assessed by palpation through the
pectoralis muscle (Fig. 9.9). The ideal intercostal space has the
following attributes:

●
Su ciently wide (1.5 to 2 cm)

●
Adjacent ribs run parallel without a tendency to converge
acutely at the sternum

●
Easily accessible through the available m astectomy
approach
This usually corresponds to the third intercostal space.
Step 2: Exposure of the Chosen
Intercostal Space
The pectoralis m uscle is split in the m anner described above
(Fig. 9.10). The chosen intercostal space with its cranial and cau-
dal ribs is exposed from the sternocostal junction to the costo-
chondral junction. The exposure is m aintained with self-retaining
retractors and hooks (Fig. 9.11).

132
I Planning and Decision Making in Reconstructive Surgery
d
a
b
c
Fig. 9.3 The perichondrium on the anterior surface (a) of the rib cartilage is incised and lifted o the cartilage with a periosteal elevator. Subperichondrial
dissection continues all around the (b) superior and (c) inferior edges and (d) undersurface of the rib cartilage.

9 The Internal Mammary System as Recipient Vessels for Breast Microsurgical Reconstruction
133
Fig. 9.4 (a–c) The segment of rib cartilage is resected with a rongeur,
keeping the posterior perichondrium intact.
a
b
c

134
I Planning and Decision Making in Reconstructive Surgery
Fig. 9.5 The subperichondrial space is approached by incising the peri-
chondrium with a blunt tip scissors, away from the internal mammary ves-
sels, taking care not to damage the underlying pleura.
Fig. 9.6 The perichondrium (and the intercostal muscles that attach to
it) are carefully elevated in a medial direction toward the sternum with a
cotton-tipped applicator.
Fig. 9.7 (a,b) Medially, 1 to 2 cm from the sternal edge, the fat pad is seen. The internal mammary vessels lie within this fat pad, with the
vein usually being quite visible through the fat. The thin fascia over the fat pad is incised and the vessels can then be dissected. Here two
veins are seen with the artery in between.
a
b

9 The Internal Mammary System as Recipient Vessels for Breast Microsurgical Reconstruction
135
Fig. 9.8 The internal mammary vessels are ready for anastomosis.
Fig. 9.9 The intercostal spaces are assessed by palpation through the pectoralis major muscle. The widest, accessible
intercostal space is selected. This usually corresponds to the third intercostal space.

136
I Planning and Decision Making in Reconstructive Surgery
Fig. 9.10 The pectoralis major muscle is split over the selected intercostal space and its sternal attachments are
partially divided.
Fig. 9.11 The intercostal space and adjacent ribs are exposed from the sternocostal to costochondral junctions and a
self-retaining retractor applied. An internal mammary perforator that emerges through the intercostal muscle is ligated
after a short length.

9 The Internal Mammary System as Recipient Vessels for Breast Microsurgical Reconstruction
137
Fig. 9.12 The intercostal muscle lateral to the perforator, as well as the anterior perichondrium of the adjacent ribs, is
scored. The intercostal space is then unroofed in a lateral to medial direction, detaching the intercostal muscle o the
ribs and sternum with bipolar cautery. Periosteal branches of the internal mammary vessels are cauterized or ligated
with clips.
the vessel m ay be ligated as far distally as possible under the rib.
Having an assistant retract the caudal rib with a hook allows the
surgeon to visualize and dissect sm all side branches that need
to be ligated.
If further vessel length is required, the caudal rib may be par-
tially excised to provide an additional 0.5 to 1 cm . The anterior
perichondrium is incised and elevated subperichondrially with
a Josephs elevator. A narrow rongeur is then used to carefully
excise the rib edge, creating a gentle trough. The posterior peri-
chondrium can now be elevated in a craniocaudal direction thus
exposing the internal mammary vessels.
Internal Mammary Perforator
Dissection
The m astectomy skin ap is elevated o the pectoralis m ajor
muscle, observing for internal m amm ary perforators that em erge
through the pectoralis m ajor m uscle at the level of the second or
third intercostal spaces. If the caliber of vessels is appropriate, the
vessels are prepared under a microscope.
If a longer vessel length is required, the pectoralis muscle is
split along its bers around the perforator so that it can be fur-
ther dissected until its exit from the intercostal muscle.
If no internal mammary perforators are seen above the
pectoralis major muscle, the muscle is split at the level of the
fourth rib and elevated cranially until a perforator is encountered
(Fig. 9.15).
Step 3: Unroof ng the Intercostal
Muscles
If present, an internal mammary perforator that emerges through
the intercostal muscle identi es the approxim ate position of the
underlying internal m am m ary vessels; dissection starts 1 to
2 cm lateral to it (Fig. 9.12). In the absence of this perforator, the
dissection starts 3 cm from the sternal edge.
The anterior perichondrium over the cranial and caudal ribs’
edges are scored and the intercostal m uscles resected from the
rib edges using monopolar or bipolar diathermy, starting laterally
and working medially toward the sternum. This exposes the fatty
connective tissue sheath that contains the internal m amm ary
vessels (Fig. 9.13).
Step 4: Internal Mammary Vessel
Dissection
Vessel dissection proceeds in the sam e m anner described pre-
viously, but m ay be m ore challenging as the space available is
lim ited between the adjacent ribs (Fig. 9.14). In our experience,
1 to 1.2 cm of pedicle length is com fortably su cient for end-
to-end m icroscopic anastom osis w ith a single m icrovascular
clamp. However, the lim ited space will not adm it the installation
and m anipulation of m icrovascular fram es or venous coupler
devices. Pedicle length is m axim ized by extending the vessel
dissection deep to the cranial portion of the caudal rib, so that

138
I Planning and Decision Making in Reconstructive Surgery
Fig. 9.13 The intercostal space has been unroofed, exposing the parietal pleural and fatty connective tissue containing
the internal mammary vessels.
Fig. 9.14 (a) The fascia over the fatty connective tissue is incised, and a cotton-tipped applicator is used in the vessel
dissection. (continued)
a

9 The Internal Mammary System as Recipient Vessels for Breast Microsurgical Reconstruction
139
Fig. 9.14 (continued) (b) The internal mammary artery lying in between two internal mammary veins. (c) The recipient
site is ready for anastomosis. Two single microvascular clamps are on the proximal artery and vein. A narrow-gauge
suction drain keeps the eld clean during anastomosis.
b
c

140
I Planning and Decision Making in Reconstructive Surgery
result when these structures are elevated aggressively
with sharp instruments or by powerful diathermies. Care-
ful dissection is required, gently retracting the perichon-
drium and intercostal muscles, developing the plane with
a cotton-tipped applicator and ne bipolar forceps at a
low setting. If a leak is suspected, saline is instilled into
the eld, watching for bubbling as the anesthetist applies a
Valsalva maneuver. The leak is repaired accordingly and a
chest drain applied.
Suggested Further Reading
Clark CP, Rohrich RJ, Copit S, Pittman E, Robinson J. An anatomic study of
the internal mammary veins: Clinical implications for free-tissue
transfer breast reconstruction. Plast Recon Surg 1997;99(2):400–404
Darcy CM, Smit JM, Audolfsson T, Acosta R. Surgical technique: The in-
tercostal space approach to the internal mamm ary vessels in 463
m icrovascular breast reconstructions. J Plast Reconstr Aesthet Surg
2011;64(1):58–62
Feng LJ. Recipient vessels in free- ap breast reconstruction: A study of
the internal mamm ary and thoracodorsal vessels. Plas Recon Surg
1997;99(2):405–416
Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing
recipient vessels for perforator free ap in breast reconstruction:
the role of the internal m ammary perforators. Br J Plast Surg 2004;
57(3):258–265
Nahabedian M. The internal mammary artery and vein as recipient
vessels for microvascular breast reconstruction: are we burning a
future bridge? Ann Plast Surg 2004;53(4):311–316
Nahabedian M. The internal mammary artery and vein as recipient
vessels for m icrovascular breast reconstruction. Ann Plast Surg
2012;68(5):537–538
Wallace CG, Shokrollahi K. Thoracodorsal or internal m ammary recipi-
ent vessels for microvascular breast reconstruction? Ann Plast Surg
2012;68(5):536

Important Considerations,
Pitfall Avoidance, and
Management

●
The rib-sparing technique typically does not perm it the
application of large microsurgical frames (double vascular
clamps) or venous coupler devices, as there is not enough
space to install and manipulate the devices. We prefer to
perform the end-to-end suture anastomosis free-hand
with single microvascular clamps on the recipient vessels.
For technical reasons, the venous anastomosis is completed
rst as the vein lies medial to the artery.

●
Potential complications of internal m am m ary vessel har-
vest are bleeding and pneumothorax.

●
Bleeding m ay be caused by failure to visualize and li-
gate side branches, or tearing of the thin-walled internal
m am m ary vein from aggressive handling, especially in
cases w hereby the patient has previously received radi-
ation and the eld is scarred. This is avoided by careful
vessel dissection and ligation of side branches. Should
bleeding occur, it m ay be controlled by applying a vas-
cular clamp proxim ally and clipping the vessel distally,
which m ay need to be exposed by retracting or partially
resecting the caudal rib as described previously. Assess-
m ent and repair of the vessel dam age are then done
under m icroscope.

●
The pleura lies directly below the posterior perichondrium
and intercostal muscles laterally. Pneumothorax may
Fig. 9.15 A retropectoral internal mammary perforator emerging from the third intercostal space.

141
(which can be transected and rotated anteriorly as a recipient
vessel option).

Experience and Philosophy
We analyzed 195 consecutive attempts at the anastomosis of
thoracodorsal vessels to deep inferior epigastric vessels, of which
79% were delayed free ap breast reconstructions; 188/195
(96.4%) thoracodorsal vessels were suitable for anastomosis,
whereas 7/195 (3.6%) were unusable. Of them, 4/195 (2.1%) were
scarred or damaged and 3/195 (1.5%) were found to be too small
for the anastomosis. The reliability of the surgical technique and
the consistent anatomy of the thoracodorsal neurovascular ped-
icle are appreciated with this low 3.6% unusable thoracodorsal
vessel rate, compared with the rate quoted in the literature (2.6%,
6.2%, 10%, 15%, 26%). With this experience, I have been able to
explore the advantages of the thoracodorsal as a recipient vessel
and ways of negating some of its disadvantages.

●
Advances in surgical technique make the secondary dissec-
tion of the thoracodorsal vessel reliable.

●
Advances in technical exposure (see below) simplify surgi-
cal assistance during microsurgery.

●
Consistent anatomy.

●
Stout artery and vein represent a better wall thick-
ness match to the deep inferior epigastric vessels during
anastomosis.

●
Size match can be customized by varying the level of
harvest of the deep inferior epigastric vessels and zone of
transection of the thoracodorsal trunk.

●
Proxim ity of other axillary vessels (lateral thoracic and
circum ex scapular vessels) in the same surgical eld if
the thoracodorsal system inappropriate.

●
A level I axillary node dissection is suggested when an im -
mediate breast reconstruction with a free abdom inal ap
uses the thoracodorsal vessels.

●
Prevents sacri ce of the internal m am m ary system which
is essential for future optimum cardiac revascularization
procedures.

Surgical Technique
The m ain advantage of using the thoracodorsal vessels includes
the ease of preparation (average vessel preparation tim e ob-
served in 2009 was 19 minutes). Here are the steps used to e -
ciently, reliably, and safely harvest the thoracodorsal system for
breast microsurgical reconstruction.

Introduction
The thoracodorsal vessels are the original recipient vessel for
breast microsurgical reconstruction. Many surgeons have enjoyed
a long career in breast microsurgery using the thoracodorsal ves-
sels as recipients for free abdominal aps and internal mammary
vessels as recipients for shorter pedicle free aps (including the
gluteal aps). When a free abdominal ap is harvested, the au-
thor’s preference remains the thoracodorsal vessels with a pub-
lished success rate of 99.1%, a 1.9% rate of arterial thrombosis,
and a 0.9% rate of venous thrombosis. Due to the long lead times
involved, there is little controversy at the current time in relation
to sacri ce of the internal mammary artery (IMA) and its poten-
tial consequences for potential future coronary artery surgery.
This issue, and issues of consent related to sacri ce of the IMA,
are likely to increase over the next decade.

Anatomy
The thoracodorsal artery is a branch of the subscapular artery
arising from the axillary artery. It is the dominant blood supply
to the class V latissimus dorsi muscle. The neurovascular hilus is
located midway between the mid humerus and the chest wall,
or 10 cm of extramuscular distance from the axillary artery. The
range of diam eter of the thoracodorsal artery is 1.0–2.5 m m, with
an average length 8.4 cm (which facilitates an anterior anasto-
mosis). The average diam eter of the thoracodorsal vein is 3.4 mm
and average length is 9.1 cm (favorable for the anterior displace-
ment of the anastom osis with an appropriate platform). The
thoracodorsal nerve is mainly anterior and m edial to both tho-
racodorsal artery and vein. The nerve must be further medialized
after transection of the vessel to avoid pressure and impediment
on the anteriorly displaced end-to-end anastomosis. The distal
harvest of both thoracodorsal veins and arteries is limited to the
rst serratus branch so that the retrograde ow can allow for a
latissimus dorsal ap harvest to be used as a salvage procedure in
case of ap failure. Presence of the thoracodorsal system should
be con rmed by angiography solely for Poland syndrome micro-
surgical reconstruction.
Regional options in case of thoracodorsal vessels’ inap-
propriate size, scarring, or dam age include the variable lateral
thoracic vessels that arise from the axillary vessels. The lateral
thoracic vessels follow the lateral border of the pectoralis m inor
on the chest wall. The circum ex scapular artery is a branch of
the subscapular artery in 97% of cases. It is found 2.2 cm away
from the axillary vessels and has an average length of 4 cm
The Thoracodorsal System as Recipient
Vessels for Breast Microsurgical
Reconstruction
Nicolas A. Guay
10

142
I Planning and Decision Making in Reconstructive Surgery
Step 1: Axillary Dissection to
Expose Thoracodorsal System
With the patient in supine position, we m ark the anticipated
position of the thoracodorsal vessel hilus (Fig. 10.1a). Prior to
draping, three folded towels are placed under the scapula and
axilla to initiate the anterior displacem ent of the thoracodor-
sal system anastom osis (Fig. 10.1a). The prepectoral pocket
to receive the autologous tissue is precisely dissected. Under
loupe m agni cation (3.53 to 4.03 ), we expose the anterior
axillary content (Fig. 10.1b). At the level of the m arked hilus,
a nger is inserted along the chest wall to separate the latissi-
m us dorsi from the serratus at the anticipated intram uscular
level of the vessels (Fig. 10.1c). The nger is rotated cepha-
lad and anterior to place the entire axillary content/scar an-
teriorly to the nger (Fig. 10.1d). The axillary content/scar is
cauterized (Fig. 10.1e). The nger protects the extram uscu-
lar thoracodorsal vessels w hile we split the axillary content
(Fig. 10.1f).
Step 2: Triangular Exposure of the
Thoracodorsal System
The perceived awkward positioning for the thoracodorsal anas-
tomosis can be countered with advances in exposure. After the
axillary content/scar has been separated, an exposure triangle
is created with a Thompson retractor anchored to the head of
the table over the sterile drape to retract the rem aining axillary
contents. A Gelpi retractor is used to retract the split axillary
contents and create space between the latissim us dorsi and the
anterior axillary line (Fig. 10.2).
Step 3: Thoracodorsal Dissection
and Transection
We have implemented a four-component approach to breast
microsurgery reconstruction for teaching and e ciency assess-
ment. The vessel preparation component consists of six steps
that include: anterior exposure of the thoracodorsal system from
the axillary vessels to the rst serratus branch; dissection of the
thoracodorsal nerve away from the thoracodorsal vessels (m ov-
ing it medial to the vessels to avoid proximal impediment of the
anteriorly displaced anastomosis); and circumferential separa-
tion of the thoracodorsal artery and vein by clipping all branches
from the subscapular to the rst serratus branch. The selection
of the level of harvest of the vessels proximal to the rst serratus
branch is made to match the visualized deep inferior epigastric
vessels. Microsurgical bulldogs are applied to the thoracodorsal
vessels proximally. The vessels are transected and irrigated with
a heparin-diluted solution.
Fig. 10.1 (a) The anticipated position of the thoracodorsal hilus is marked. Folded towels under the axilla initiate the anterior displacement of the
anastomosis. (b) The exposed scarred axillary content. (continued)
a
b

10 The Thoracodorsal System as Recipient Vessels for Breast Microsurgical Reconstruction
143
Fig. 10.1 (continued) (c) The index nger is inserted along the chest wall at the level of the hilus (approximately 10 cm from the axillary vessel). (d) The axillary scar
is anterior to the nger. (e) The axillary scar is cauterized. (f) The thoracodorsal system is protected after the blunt dissection of the axillary scar with a cautery.
d
c
f
e

144
I Planning and Decision Making in Reconstructive Surgery
Step 4: Axillary Microsurgical
Platform and Setup
To facilitate the anterior displacement of the level of anastomosis,
an axillary microsurgical platform is created with three to ve
folded 4 3 8 soaked gauze dressings, three to four large neuro-
vascular pads, and a colored background material (Fig. 10.3a,b).
Fig. 10.2 The exposure triangle created by the Thompson retractor and the two prongs of the
Gelpi retractor.
Step 5: Nesting of the Abdominal
Flap on the Chest Wall
The ap is covered with a wet abdom inal gauze, wrapped with
the help of staples, shaped in a cone close to the deep inferior
epigastric vessels, and anchored on the chest wall distally to the
anastomosis on the anterior axillary line (Fig. 10.4a). The nesting
Fig. 10.3 (a) The axillary microsurgical platform created with three folded 4 3 8 gauze
dressings and three large neurovascular pads. (continued)
a

10 The Thoracodorsal System as Recipient Vessels for Breast Microsurgical Reconstruction
145
Fig. 10.3 (continued) (b) The axillary exposure platform with a 2- to 4-cm anterior displace-
ment of the anastomosis over a green background material.
b
Fig. 10.4 (a) Nesting of the free abdominal ap on the chest wall with a wet abdominal gauze
and staples. Coning of the abdominal tissue close to the vessels. (continued)
a

146
I Planning and Decision Making in Reconstructive Surgery
Guay N. The thoracodorsal vessels are advantageous, reliable, and safe
recipient vessels for free abdom inal ap breast reconstruction.
Ann Plast Surg 2012;68(5):539–541
Haykal S, Guay N. One hundred forty-one consecutive attempts at autolo-
gous tissue single-stage breast cancer reconstruction. Ann Plast Surg
2009;63:21–27
Moran SL, Nava G, Behnam AB, et al. An outcome analysis comparing the
thoracodorsal and internal m ammary vessels as recipient sites
for microvascular breast reconstruction: a prospective study of
100 patients. Plast Reconstr Surg 2003;111(6):1876–1882
Saint-Cyr M. Changing trends in recipient vessel selection for microvascular
autologous breast reconstruction: an analysis of 1483 consecutive
cases. Plast Reconstr Surg 2007;119(7):1993–2000
Serletti JM, Moran SL, Orlando GS, Fox I. Thoracodorsal vessels as recipi-
ent vessels for the free tram ap in delayed breast reconstruction.
Plast Reconstr Surg 1999;104(6):1649–655
Temple CL, Strom EA, Youssef A, et al. Choice of recipient vessels in
delayed tram ap breast reconstruction after radiotherapy.
Plast Reconstr Surg 2005;115(1):105–113
Wallace CG, Shokrollahi K. Thoracodorsal or internal m ammary recipi-
ent vessels for microvascular breast reconstruction? Ann Plast Surg
2012;68(5):536
of the free abdominal ap on the chest wall improves the access
to the axilla for a second microsurgeon (Fig. 10.4b).

Conclusion
These advances in thoracodorsal system preparation for breast
microsurgical reconstruction resulted in a reliable 96.4% rate of
thoracodorsal vessel suitability and a safe 99.1% free abdom inal
ap success rate.
Suggested Further Reading
Feng LJ. Recipient vessels in free- ap breast reconstruction: a study of the
internal mamm ary and thoracodorsal vessels. Plasl Reconstr Surg
1997;99:405–416
Grottina JC. Immediate breast reconstruction using the tree tram ap.
Clin Plast Surg 1994;21:207–221
Fig. 10.4 (continued) (b) Improved access to the axilla for two microsurgeons.
b

147
Postoperative Monitoring of
Microvascular Free Flaps
Zita M. Jessop, Warren M. Rozen, and Iain S. W hitaker
11

Microvascular Free Flap
Success versus Failure
In recent tim es success of m icrovascular free ap transfers has
increased to over 97%, attributed to improvem ents in preop-
erative and intraoperative assessm ent of ap vasculature as
well as in surgical technique. However, ap failure rem ains
a signi cant complication even in the hands of the m ost ca-
pable and experienced m icrosurgeons, especially in the rst
24 hours. It is attributed to arterial or venous occlusion, caused
m ost com m only by throm bosis w ithin 3 days of surgery, but
also by kinking, hem atom a, or external compression leading
to ap ischem ia. The tim e-dependent no-re ow phenom enon,
rst described in 1978, highlights that ap ischem ia becom es
irreversible after only a few hours of m icrovascular throm -
bosis and edem a. This explains w hy ap survival is increased
given tim ely detection of ap comprom ise, surgical explora-
tion, and reversal of the injury. Several groups have show n that
salvage of 70 to 80% of comprom ised aps is possible, high-
lighting the importance of reliable postoperative assessm ent of
the m icrocirculation.

Variations in Flap
Monitoring
The need for early detection of ap compromise and the importance
of monitoring of free aps postoperatively were recognized along-
side the emergence of microsurgery in the 1970s (Fig. 11.1). This
has led to a wide variety of proposed techniques, ranging from clin-
ical bedside monitoring alone to clinical monitoring together with
various adjunctive techniques, which can either be invasive or non-
invasive. Noninvasive adjuncts can measure a variety of ap features
such as blood ow, oxygenation, and temperature as well as provide
a visual assessment of color and the capillary network (Fig. 11.2).
Invasive m onitoring techniques o er the advantage of m oni-
toring buried aps, where clinical assessment is not possible. In-
jecting uorescent dyes for uorometry (see below) or contrast
agents to enhance ultrasound can be used to visualize ap perfu-
sion (Fig. 11.3). Alternatively, implantable probes can be used to
measure a num ber of variables that correlate with ap perfusion,
such as microdialysis (glucose and lactate), pH, oxygen tension,
and temperature, or monitor the anastomosed vessels directly,
such as by using implanted (Cook-Swartz) Doppler probes.
Operating microscope
introduced
(Jacobson/Suarez)
First free ‘microvascular
flap’ (Mclean and Buncke)
First free cutaneaous flap
(Daniel)
Fluometry (McGraw)
No-reflow
phenomenon (May)
Transcutaneous PO2 &
surface temperature
(Achauer 1979, Serafin
1981, Harrison 1981)
Implantable Doppler
probe (Parker)
Cook-Swartz probe
(Swartz)
Dynamic infrared
themography &
Photoplethysmography
(Wilson, Hales)
Handheld Doppler &
NIRS (Hirigoyen, Irwin)
Nuclear medicine (Aygit)
Microdialysis (Udesen)
Orthogonal polarization
spectral imaging (Olivier)
Near-infrared
spectroscopy (NIRS)
(Scheufler)
CEUS, ceMRI, PET
(Llamby, Muller), VLS
(Cornejo), SFDI (Gioux)
LROI (Mueller 2012),
Smartphone (Hwang)
Dark field imaging
(Harwicke)
Flap Monitoring Development
1960
1972
1973
1977

1978
1981
1984
1988

1989
1995
1999
2000

2003
2004
2011
2012
2014
Fig. 11.1 History of microsurgery and the emergence of free  ap monitoring.1

148
I Planning and Decision Making in Reconstructive Surgery
Despite the range of techniques available, there is no general
consensus on the type, duration, or frequency of postoperative
ap monitoring as re ected by wide interunit variability. This
may be because no one monitoring technique satis es all the cri-
teria to becom e the accepted gold standard. The essential crite-
ria include the following: for patients, that it be safe and rapid;
for clinicians, that it be simple, reliable, repeatable, recordable,
and rapidly responsive; and for hospitals, that it be inexpensive,
applicable to all kinds of aps, and with a simple display to alert
possibly inexperienced personnel.

Challenges in Flap
Monitoring
Assessment of ap perfusion remains a challenge despite the va-
riety of monitoring techniques available and the number of opti-
mal comparative m easures for evaluating them . Routine clinical
monitoring is subjective and often undertaken by junior team
mem bers, highlighting the need for reliable adjunctive m ethods
to detect early ap failure to expedite successful salvage. Clini-
cal m onitoring and most adjunctive techniques rely on a visible
cutaneous skin paddle, making buried aps extremely di cult
to assess. Even if a skin paddle is present, many monitoring tech-
niques only sample a small area of the ap and are therefore
unable to di erentiate vascular regional ap problems due to
Fig. 11.2 Noninvasive  ap monitoring techniques.
Fig. 11.3 Invasive  ap monitoring techniques.

11 Postoperative Monitoring of Microvascular Free Flaps
149
Early clinical changes can be subtle, and perception is
a ected by a variety of factors such as lighting, di erences in skin
color between donor and recipient tissues, and subjective inter-
pretation of temperature and turgor. The need for experience in
clinical monitoring of free aps may explain the variety of ranges
of salvage (40 to 80%) and overall ap success rates (94 to 99%)
reported in the literature, suggesting interunit variability in
monitoring standards.
One of the signi cant lim itations of the standard clinical
monitoring techniques is in aps that are buried or located in dif-
cult to access areas. In the literature, investigators have bypassed
this issue by creating a distal skin paddle, a chimeric ap, or an
exteriorized ap from which the usual clinical examinations can
be perform ed. These “m onitoring aps” provide an indirect indi-
cation of perfusion status of the ap of interest. However, any der-
ivation must be carefully interpreted due to the potential risk of
a false positive, reported to be 36%, or a false-negative result aris-
ing from vascular complications speci c to the “monitoring ap.”
To date, only a few techniques have been shown to improve
ap salvage rates in comparison to clinical monitoring, and all of
these case series have based their analyses on small numbers of
failing aps.

Noninvasive Adjuncts
to Clinical Bedside
Monitoring
Blood Flow Measurement
Handheld Doppler Ultrasound
Handheld Doppler ultrasound, using a low-frequency (8 MHz),
continuous-wave probe, is the most com m on adjunctive device
in use for assessing pedicle ow through auditory cues. It is a
noninvasive bedside technique that can accurately demonstrate
blood ow and ap viability and can also be useful in evaluat-
ing perfusion in buried aps. One of the major limitations is dif-
ferentiating between the pedicle and the adjacent recipient site
vessels, and it is therefore recom m ended that the position of the
Table 11.1 Clinical bedside monitoring of microvascular free aps
Clinical parameter
Normal exam
Arterial occlusion
Venous occlusion
Color
Pink
Pale/mottled
Dusky/cyanotic
Temperature
Warm
Cool
Cool
Turgor
Soft

Flaccid/“empty”
Tense
Capillary re ll time
2–3 seconds
Absent/sluggish (. 3 seconds)
Brisk (, 2 seconds)
Capillary bleeding on pinprick
Slight delay, bright red blood
Delayed, little bleeding
Immediate, dark red
ap design issues leading to territorial problems from true pedi-
cle compromise, resulting in false positives.
Another challenge is demonstrating that any one adjunc-
tive technique is better than standard clinical m onitoring. Som e
report that certain devices can alert to ap compromise earlier
than clinical m onitoring but fail to dem onstrate improvem ent in
clinically relevant outcom e m easures such as ap salvage rates,
false-positive rates, and overall ap success. This has been at-
tributed to low num bers of compromised aps in each series and
hence a di culty in proving a signi cant improvement of any
adjunctive technique over clinical monitoring. Many surgeons
therefore choose techniques based on cost, availability, and ease
of use.
It is accepted that regular ap monitoring in a specialized
microsurgical unit by well-trained and experienced nurses and
surgeons allows for early detection of vascular compromise, with
superior success (97 to 99%) and salvage rates (up to 80%) regard-
less of the speci c monitoring technique used. The routine is dif-
ferent at di erent centers but usually consists of hourly checks
for the rst 24 hours postoperatively, then every 2 hours for the
next 1 to 2 days, and then every 4 to 8 hours until discharge.
This chapter reviews the current options and evidence base for
postoperative monitoring techniques of microvascular free tissue
transfers.

Clinical Bedside
Monitoring
Clinical bedside m onitoring is noninvasive, repeatable, and re-
mains the gold standard technique for postoperative m onitor-
ing of free aps against which adjunctive techniques m ust be
compared. Clinical signs are determ ined by which vessels are
occluded (Table 11.1).
These ndings should be interpreted together with the full
clinical picture including core temperature, urine output, oxygen
saturation, blood pressure, and pulse rate to provide an indica-
tion of adequate ap perfusion. Clinical m onitoring alone has
enabled ap salvage rates of up to 80% and overall success rates
of up to 99%.

150
I Planning and Decision Making in Reconstructive Surgery
pedicle be marked with a suture intraoperatively for later ease of
locating the Doppler signal. It is also possible to be deceived by a
continuing Doppler arterial sound despite complete occlusion of
the venous anastomosis.
Color Doppler Ultrasound
Color Doppler ultrasonography enables detection of blood ow
based on the relationship between recorder Doppler frequency
shift (audible or represented as a visual display) and blood ow
velocity. A color assigned to di erent ow velocities allows cre-
ation of a color scale that enables accurate assessment of ow
characteristics to con rm anastomotic patency.
Laser Doppler Flowmetry
Laser Doppler owm etry is a simple, noninvasive technique to
give an objective measure of tissue perfusion. Light of uniform
wavelength (e.g., helium neon laser) shone on to the surface of
the ap is re ected by red blood cells m oving within the m icrocir-
culation of the ap. The frequency shift between the transmitted
and re ected light is directly proportional to the speed of blood
ow in the microcirculation (1 mm 3, 1.5 mm below surface).
It has been shown to provide a warning of ap compromise
up to several hours before the onset of clinical signs and has a
low false-positive and -negative rate. Some retrospective studies
using this device show similar ap salvage rates to clinical moni-
toring alone, while one demonstrated an increase in salvage rate
from 50% to 85% in a group of 12 complicated aps, represent-
ing level IIb evidence, the highest available for an adjunctive ap
monitoring technique.
Laser Doppler owmetry data vary depending on tissue
type, patient, and physiological variation in m icrocirculation,
and therefore, trends rather than absolute values are important,
which requires experience to interpret accurately. Laser Doppler
may be helpful in darkly pigm ented skin or pure m uscle aps
when clinical evaluation is di cult. Utility in monitoring buried
aps is limited due to depth of penetration.
Photoplethysmography
Photoplethysm ography (PPG) uses re ected spectrographic
m eans (either green or infrared light) to directly m easure ux
of red blood cells and therefore determ ine real-tim e perfusion
m ore accurately than laser Doppler ow m etry. Clinical testing
has show n high sensitivity and speci city. Im pedance-based
PPG involves passing alternating electric current through
a cutaneous free ap and m easuring the induced voltage to
give a graphical display of pulsatile ow through the ap
and hence a continuous assessm ent of perfusion. Despite
prom ising anim al studies, no comparative clinical study has
been reported.
Sidestream Dark Field Imaging
Sidestream dark eld imaging (SDFI) visualizes red blood cells
at the end-capillary bed in real-time, independent of their
oxygenation status, through illum ination of the ap by a central
light surrounded by concentrically placed stroboscopic LEDs. The
main advantages of SDFI are that it is easy to use, provides a di-
rect measure of ap blood ow in the microcirculation, and may
be a useful adjunct when capillary re ll time is di cult to assess
clinically. However, SDFI has only been reported in one clinical
case report, and further studies will be needed to assess impact
of ap salvage rate.
Oxygenation Measurement
Transcutaneous Oximetry
Transcutaneous oximetry is a simple, noninvasive technique that
assesses the percent oxygen saturation of arterial hemoglobin
(SaO2) in real time. It uses two wavelengths of light (660 and
940 nm) to distinguish between oxygenated and deoxygenated
hemoglobin through di erences in light absorption and hence
provides a measure of tissue perfusion. Decrease in oxygen sat-
uration occurs signi cantly earlier than changes in clinical signs
after both venous and arterial occlusion. Hence, several studies
have attempted to use SaO2 as a measure of perfusion in free
aps. Initial animal studies and early clinical studies showed
transcutaneous SaO2 to be a potential predictor of ap survival,
but no studies have dem onstrated clear advantages over clinical
monitoring on the basis of ap salvage rate. In addition to mon-
itoring SaO2, the use of CO2 monitoring to assist in identifying
congested aps has been proposed, but there have as yet been no
follow-up studies.
More recently, the development of a combined photoplethys-
mographic and pulse oximetry probe has allowed continuous
measurement of oxygen saturation, heart rate, and perfusion in-
dex (ratio of pulsatile arterial ow and nonpulsatile venous ow)
in real time. This technique, however, does not accurately predict
ap viability because the perfusion index and oxygen saturation
can vary enormously, even in aps that are adequately perfused.
Near-Infrared Spectroscopy
In the last decade, near-infrared spectroscopy (NIRS) has been
tested with promising results. As well as being noninvasive, con-
tinuous, and easy to use, NIRS has additional advantages over
oximetry. It uses infrared light to determine percent oxygen sat-
uration of tissue arterial hem oglobin, which is not a ected by
external factors, such as supplem ental oxygen and blood pres-
sure, or ap-speci c variables, such as the perforator size and
number, and also allows for di erentiation between arterial and
venous comprom ise. Studies have shown NIRS detects vascular
comprom ise earlier than clinical assessm ent, handheld Doppler,
and implanted Doppler probes, resulting in high ap salvage rates
(94–100%).
Visible Light Spectrophotometry
In comparison to NIRS, visible light spectrophotometry (VLS) is a
real-tim e, localized method that utilizes white light to measure
the hemoglobin saturation at capillary level. The light from the
transm itting ber is in part absorbed, re ected, and backscat-
tered. Due to varying absorption wavelengths of oxyhemoglobin

11 Postoperative Monitoring of Microvascular Free Flaps
151
In 1992 Khouri and Shaw reported the use of di erential surface
temperature in a series of 600 free tissue transfers and demon-
strated that a decrease greater than 1.8°C indicated ischemia.
A decrease in the skin surface temperature in the center of the
ap compared to the surrounding skin can provide an indication
of arterial occlusion. The major disadvantage with surface tem -
perature readings is their low speci city (75% when optimized)
because they can be in uenced not only by the microcirculation
to the skin but also core temperature, room temperature, humid-
ity, light, and vasomotor responses. Experimental studies suggest
that temperature changes were only signi cant after 15 hours of
ap ischemia, which is too long for successful revascularization.
Most would therefore recom mend use of surface temperature as
an adjunct but not a replacement to standard clinical monitoring.
Dynamic Infrared Thermography
There is a de ned relationship between the skin temperature and
the em itted infrared (IR) radiation (approxim ately 0.9 to 14 mm
in the electromagnetic spectrum) from the skin surface, which
can be used as an indicator of ap perfusion. Although more
com m only recognized for use in perforator selection and ap
planning, infrared thermography has been shown to be a feasible
noncontact technique for postoperative monitoring of perfusion
dynamics of deep inferior epigastric perforator (DIEP) aps that
is more sensitive than surface temperature. Changes in the ther-
mographic im age (pedicle hot spot) can precede clinical signs of
vascular compromise in animal models, independently of abso-
lute temperature values that are in uenced by environmental
factors. A clinical trial using emitted skin surface IR correlated
with alteration in capillary blood ow and hemoglobin oxygen-
ation demonstrating the reliability of this adjunctive method in
postoperative monitoring of free aps.
Visual Assessment
Smartphone Digital Technology
In the era of readily accessible Internet and ubiquitous smart-
phones with camera functionality, digital photography represents
an opportunity for surgeons to monitor free aps remotely, enable
rapid communication between nursing and medical sta , and po-
tentially reduce the response time to re-exploration. Comparative
studies assessing Internet messaging to share digital photographs
have demonstrated improved response time to re-exploration
(1.4 hours vs. 4 hours) and improvement in ap salvage rate (100%
vs. 50%), thus translating to higher ap survival (100% vs. 96.2%).
In 2014 Kiranantawat et al. developed a smartphone application
that analyzes digital photos for color di erence and demonstrated
high sensitivity (94%) and speci city (98%) in detecting vascular
compromise. Although smartphone digital technology continues
to show promise, technical issues, cost, misdiagnosis, and con -
dentiality issues will need to be addressed before widespread use.
Microvasculature Imaging Techniques
A variety of real-time, noninvasive techniques exist for
visualization of tissue microvasculature as a means of early
(542 and 557 nm ) and deoxyhem oglobin (556 nm), capillary
oxygenation and relative hemoglobin concentrations can be cal-
culated using backscatter spectrum (502 to 630 nm). Since visible
light is absorbed one hundred times stronger by hemoglobin than
infrared light, VLS is theoretically m ore sensitive to alterations in
tissue oxygenation than NIRS. VLS has been shown to detect ap
ischemia earlier than the implantable Doppler probe and clinical
examination, but there are no studies demonstrating impact on
ap salvage rates.
Incorporating white light spectrom etry (O2C, Lea Medizin-
technik, Giessen, Germ any) with laser Doppler owm etry has
allowed determ ination of oxygenation and relative hem oglobin
and therefore di erentiation between venous congestion and
arterial occlusion. O2C has been shown to produce salvage rates
of 80%, comparable to standard clinical monitoring.
Multispectral Spatial Frequency
Domain Imaging
Multispectral spatial frequency domain imaging (SFDI) enables
visualization of oxygenation over a large area of tissue. This elimi-
nates the limitations of the traditional pulse oximetry probe, which
assesses the global hemoglobin oxygenation status of the patient,
and the spectroscopy-based probes, such as NIRS, which assess
only small areas. Furthermore, animal and pilot human studies
have demonstrated the safety and feasibility of SFDI as well as its
ability to detect alteration in oxygen saturation secondary to par-
tial blood ow obstruction earlier than visual cutaneous changes.
Luminescence Ratiometric Oxygen
Imaging
Luminescence ratiometric oxygen imaging (LROI) measures rel-
ative transdermal oxygen consumption (RTOC) for quantitative
assessment of perfusion. LROI consists of a uorescent oxygen
sensory foil covering the cutaneous surface of a ap and a hand-
held uorescence microscope. The sensory foil contains a reser-
voir of oxygen, which is consumed by the tissue and hence gives
a measure of skin perfusion. In a prospective analysis of 52 free
aps, Meier et al. concluded that RTOC of less than 0.3 indicates
a well-perfused ap and greater than 0.3 a poorly perfused ap.
A prospective study of 15 osseocutaneous aps showed that com-
bining LROI to evaluate the skin with contrast-enhanced ultrasound
(CEUS), which assesses the deep tissues, can be complementary.
There is evidence that the use of SaO2 and/or SaCO2 moni-
toring with m athem atically derived perfusion indices or oxygen-
ation imaging could be bene cial in the monitoring of cutaneous
free aps. Further studies involving large sample groups and a
double-blinded random ized clinical trial are needed to dem on-
strate de nitive clinical bene t of these various techniques.
Temperature Measurement
Surface Temperature
Surface temperature is the oldest and simplest adjunctive m ethod
of ap monitoring that can be performed in real time using in-
expensive equipm ent, such as therm oelectric thermom eters.

152
I Planning and Decision Making in Reconstructive Surgery
occur 30 to 60 minutes after vessel occlusion and microdialysis
can therefore provide a timely indication of ap failure. Although
microdialysis has been dem onstrated to detect ap comprom ise
earlier than standard clinical m onitoring and the implantable
Doppler probe in one trial, others have shown no bene t and in-
stead found an increase in false-positive rates, which m ay result
in needless re-explorations. There is also not enough evidence to
show improvement in ap salvage. Given this is an expensive and
invasive technique, it is not routinely used for postoperative free
ap monitoring.
Hydrogen Clearance
Hydrogen gas clearance allows quantitative measurement of
tissue blood ow (m L/g of tissue/m in) using an implantable
probe. The technique uses electrodes to detect changing imped-
ance of the tissue/organ of interest due to decay in hydrogen con-
centration. It was initially used in animal models and later tested
clinically for nger replantation and in 1997 for postoperative
free ap monitoring. This technique is of interest because it is
relatively simple, safe, continuous, and useful for buried aps, but
more studies are needed to dem onstrate potential to in uence
clinical outcomes.
Temperature Probe
An implantable thermocouple probe that enables postoperative
ap temperature monitoring has been tested experimentally
and clinically. One thermocouple is placed adjacent to the ar-
tery distal to the anastomosis and one proximal. A tempera-
ture di erential of . 0.3°C between the two thermocouples was
shown to indicate thrombosis and considered as the criterion
for re-exploration. This technique showed promising early re-
sults in 18 free aps, but there have been no subsequent studies
investigating e ectiveness.
detection of ap failure. These techniques include confocal
microscopy, orthogonal polarized light, and magnetic resonance
im aging and have so far only been tested in anim al studies, m ost
likely because they are expensive and impractical for clinical
usefulness.

Invasive Adjuncts
to Clinical Bedside
Monitoring
Implantable Probes
Microdialysis
Microdialysis is a sampling technique that allows biochem ical
monitoring of speci c organs or tissues, rst described for free
ap monitoring in 2010 by Udesen et al. It is an invasive tech-
nique, which involves introducing a double-lumen microdialysis
catheter into the ap. Perfusion uid is passed through the cath-
eter that allows low molecular weight substances to equilibrate
across the semipermeable membrane from the surrounding ex-
tracellular uid, producing a dialysate. The dialysate can then
be analyzed for metabolites such as lactate, glucose, glycerol,
and pyruvate and compared with either reference values or a
reference catheter placed elsewhere to give a measure of ap
metabolic activity (Table 11.2). Several studies have shown that
measuring several m etabolites and calculating their ratios, such
as lactate:glucose and lactate:pyruvate, can permit a more ac-
curate detection of ischemia and can also di erentiate between
arterial and venous occlusion.
Microdialysis provides an accurate, objective m easure of the
ap metabolism in ischemia (Fig. 11.4). The major advantage
is its potential use in buried aps and cutaneous aps that are
di cult to assess. The metabolic changes have been shown to
Table 11.2 Microdialysis assessment of metabolic changes during ap ischemia
Metabolite
Change in ap
ischemia
Reason for change
Sensitivity
Speci city
Evidence
Glucose
Decrease

Reduced blood  ow and hence substrate 
supply
88–100%
82–100%
Henault 2014, Hara 2012 & 2012,
Sitzman 2010, Setala 2010,
Udesen 2010, Rojdmark 1998
Lactate
Increase
Reduced oxygenation leads to anaerobic
metabolism

96–98.5%
84–99.5%
Henault 2014, Setala 2010,
Udesen 2000, Rojdmark 1998
Complement 3a
Increase

Immunological changes after prolonged 
ischemia can lead to ischemia-reperfusion 
injury
–
–
Brueggemann 2008
TXA2
Increase

In ammatory changes during ischemia and 
reperfusion
–
–
Ionac 2001
Glycerol
Increase

Pronounced ischemia leads to breakdown 
of cell membrane
–
–
Udesen 2000, Brueggemann
2008, Rojdmark 1998
Pyruvate
Decrease

Glucose metabolized via pyruvate into 
lactate during ischemia (bypassing citrate 
cycle) (L:P ratio is expression of redox 
reaction in tissue)
–
–
Rojdmark 2000, Setala 2010

11 Postoperative Monitoring of Microvascular Free Flaps
153
Fig. 11.4 (a) Microdialysis  ap monitoring equipment. Pump (A) perfuses liquid 
through the semipermeable membrane in the catheter (B). The dialysate is collected 
in microvials (C) for analysis at the bedside analyzer (D). (b) Photo of deep inferior 
epigastric artery perforator (DIEP)  ap being monitored with microdialysis taken at 
the end of a re-exploration that was performed on the third postoperative day, based 
on microdialysis values.2,3
a
b
Tissue Oxygen Tension
Tissue oxygen tension measures the gradient between oxygen
delivered by the capillaries and its consumption by the cells,
therefore providing a direct index of oxygen availability. Several
studies using implanted tissue oxygen tension (PO2) probes have
reported detection of ap compromise and reduced ap loss. In
1997 Hirigoyen et al. placed sensors intraoperatively to provide
continuous monitoring of tissue oxygen tension and dem on-
strated the technique to be sensitive and rapidly responsive in
detecting circulatory impairment in buried aps. However, no
studies have adequately dem onstrated improved ap salvage rate
through direct comparison to clinical monitoring.
Tissue pH
In 1983, Raskin et al. rst introduced the use of an implanted
rem ovable pH monitor, and these have since been reported in
several small series of free tissue transfers. A fall in pH below
7.30 or a di erential of 0.35 units between ap and control site
have been suggested as criteria indicating ap comprom ise.
Tissue pH m onitoring is fast, continuous, inexpensive, and can
preempt clinical changes of ap comprom ise. However, it is not
as precise as other invasive techniques, such as uorescein in-
jection, w ith no dem onstrable improvem ent in ap salvage.
This m ay be due to a tim e lag between pedicle comprom ise and
tissue acidosis.

154
I Planning and Decision Making in Reconstructive Surgery
coupler with a removable 20-MHz ultrasound probe. This en-
ables simultaneous probe installation and vascular anastomosis,
saving intraoperative time.
A probe implanted around a ap artery will detect cessation of
arterial ow immediately but an arterial signal will persist for 3 to
4 hours after venous thrombosis. Subsequent studies have demon-
strated that a probe implanted around the out ow vein of a ap
can detect cessation of venous ow immediately and interruption
of arterial ow within minutes, shown to result in high salvage
rates of 56 to 95%. This detection of ap compromise has been
shown to occur earlier and produce higher ap salvage rates com -
pared to standard clinical monitoring (80% vs. 66%). Implantable
Doppler monitoring also has reasonable sensitivity (67 to 87%) and
high speci city (95 to 99%). Furthermore, the implanted Doppler
probes are especially bene cial in monitoring buried free aps or
cutaneous aps that are located in poorly accessible areas.
The Cook-Swartz Implantable
Doppler Probe
Implantable Cook-Swartz Doppler monitoring uses a high-
frequency (20 MHz single piezoelectric signal) pulsed ultrasound
probe (1 mm) secured to a silicone cu (5-mm width) in order to
provide real-time monitoring of ap blood ow. The cu can be
secured using microclips, sutures, brin sealant, or an elongated
cu that is wrapped around the vessel. The probe’s proximal
end exits the surgical wound as a thin wire and is connected
to a transportable monitor at the bedside (Fig. 11.5). The wire
is usually sutured to the patient in order to prevent accidental
pulling leading to false-negative results. It can be removed post-
operatively, when required, with minimal traction.
The Synovis Flow Coupler (Synovis Life Technologies Inc.,
Minneapolis, MN) is an adaptation that com bines an anastom otic
Fig. 11.5 (a) The cu  of the Cook-Swartz implantable Doppler probe wrapped 
around the venous anastomosis. (b) Doppler monitoring of a deep inferior epigastric 
perforator  ap for breast reconstruction.3
a
b

11 Postoperative Monitoring of Microvascular Free Flaps
155
video angiography, uoride positron emission tomography, and
contrast-enhanced m agnetic resonance imaging. Furtherm ore, in
2010, Sharma et al. demonstrated that CEUS is associated with
high sensitivity (100%) and speci city (86 to 100%) in predicting
ap failure. Potential pitfalls of CEUS include repeated exposure
to contrast media and the long period of time between clinical
suspicion of compromise and an ultrasound examination of a
ap. Until testing in large clinical trials, CEUS currently remains
best used as an adjunct to clinical assessment and for reassurance
in borderline cases.
Nuclear Medicine
Radioactive isotopes, which are m etabolically inactive and dif-
fuse freely into tissues, such as technetium 99m, xenon 133, and
sodium 22, can be used as direct measures of tissue perfusion
based on the Fick dilution principle. The injection of an isotope
can be later m easured by scintigraphy or positron em ission to-
mography (PET). One advantage of this technique is ability to
visualize areas of partial hypoperfusion. Several problems with
this technique m ake it ultimately unlikely to be clinically useful
in monitoring of aps; issues include access to nuclear medicine
laboratories, radiation exposure, and time between injection
of radioactive agent and scintigraphy. This substantial delay is
likely to reduce its clinical bene t and unlikely to improve ap
salvage rates.

Conclusion
The tim e of presentation of ap comprom ise is a signi cant
predictor of ap salvage outcome, and regular postoperative
ap monitoring allows early detection of vascular compromise,
early salvage, and superior success rates. Across the literature it
is well-recognized that there is signi cant variation in interunit
postoperative monitoring of free tissue transfers. For aps with a
visible cutaneous paddle, most microsurgeons would agree that
clinical m onitoring along with handheld Doppler is su cient.
The surgeon may be m ore inclined to use adjunctive techniques
in higher risk aps, di cult to monitor cutaneous aps, buried
aps, and those with vein grafts. Adjunctive techniques with
proven bene ts in ap salvage rates include laser Doppler
owmetry, uorometry, and the implantable Cook-Swartz ve-
nous Doppler. Findings from any monitoring technique should,
however, not be taken in isolation but correlated with the full
clinical picture including core temperature, urine output, oxygen
saturation, blood pressure, and pulse rate. Many of the adjunctive
techniques described are not in routine clinical use but may be of
use in the future.
Suggested Further Reading
Abdel-Galil K1, Mitchell D. Postoperative monitoring of m icrosurgical
free tissue transfers for head and neck reconstruction: a systematic
review of current techniques—part I. Non-invasive techniques. Br J
Oral Maxillofac Surg 2009;47(5):351–355
Achauer BM, Black KS, Beran AV, Huxtable RF. Transcutaneous PO2 moni-
toring of ap circulation following surgery. Birth Defects Orig Artic
Ser 1979;15(4):517–522
In addition to their clinical bene ts and despite costing
in excess of $100, the implantable Doppler probes are also the
most cost-e ective postoperative free ap monitoring technique.
Other potential bene ts include avoiding the need to wake pa-
tients at night and assisting physiotherapists with mobilization
by giving direct, real-tim e feedback regarding the venous ow.
However, the optimal use of the Cook-Swartz Doppler probe re-
quires adequately trained healthcare personnel. Initial studies
reported a low rate of probe malfunction, thought to be due to
a learning curve in probe application around the venous pedicle.
Subjective interpretation of the Doppler signal can also lead to
false positives, highlighting that this technique needs to be com-
plemented by clinical monitoring and handheld Doppler.
Injectable Agents
Fluorometry
Fluorometry involves either intravenous injection or oral admin-
istration of a uorescent agent (e.g., uorescein or indocyanine
green), which di uses across the capillary wall into the extra-
cellular uid compartment within 10 to 15 minutes. It can be
viewed with a uorom eter to determ ine ap skin perfusion. It
was initially used in the 1940s to accurately predict survival of
areas of pedicled aps. This technique was later easily adapted
for use in monitoring vascular perfusion of revascularized digits
and free aps. The introduction of beroptic uorometry by
Silverman et al. in 1981 allowed assessment with uorometry
more than once per day, previously a signi cant limitation. Fluo-
rometry, as well as being inexpensive and more speci c than pH
or temperature monitoring, is reported to have a high sensitivity
(91%) and increased ap salvage rate (85% vs. 55%) compared to
clinical monitoring.
Fluorom etry is one of the few techniques in the current
literature to provide CEBM level II evidence for an adjunctive
monitoring technique. It is likely that the potential for allergic
reactions and unfavorable pharmacokinetic properties associated
with the uorescein and ICG is the major reason why it has not
become more popular. Although ICG has better pharmacokinetic
properties and has been suggested to be safer than uorescein,
there are reports of anaphylaxis. ICG uorescence angiography
has been shown to be no better than clinical monitoring postop-
eratively and is more frequently used for intraoperative assess-
ment of free ap microvascular circulation.
Contrast-Enhanced Ultrasound
Contrast-enhanced ultrasound (CEUS) with harmonic imaging
involves a bolus injection of m icrobubbles as contrast media
(SonoVue, Bracco, Italy). Radiofrequency ltering separates the
nonlinear microbubble echoes from the linear echoes of the tis-
sue. The microbubbles act as echo-enhancing contrast media of
the intravascular space. CEUS provides a qualitative assessm ent
of the capillary perfusion in di erent ap areas as well as quan-
titative analysis using perfusion software QONTRAST (Bracco,
Italy) producing a high ap salvage rate of 85%. The perfusion
results of CEUS have been shown to correlate with uorescence

156
I Planning and Decision Making in Reconstructive Surgery
Creech B, Miller S. Evaluation of circulation in skin aps. In: Grabb WC,
Myers MB, eds. Skin Flaps. Boston, MA: Little, Brown; 1975
Dagum AB, Dows AJ. Simple monitoring technique for muscle aps.
Microsurgery 1995;16(11):728–729
de la Torre J, Hedden W, Grant JH, 3rd, Gardner PM, Fix RJ, Vasconez LO.
Retrospective review of the internal Doppler probe for intra- and
postoperative m icrovascular surveillance. J Reconstr Microsurg
2003;19(5):287–290
de Weerd L, Mercer JB, Setså LB. Intraoperative dynam ic infrared ther-
m ography and free- ap surgery. Ann Plast Surg 2006;57(3):
279–284
de Weerd L, Mercer JB, Weum S. Dynam ic infrared thermography. Clin
Plast Surg 2011;38(2):277–292
de Weerd L, Weum S, Mercer JB. The value of dynam ic infrared thermog-
raphy (DIRT) in perforatorselection and planning of free DIEP aps.
Ann Plast Surg 2009;63(3):274–279
Denneny JC, 3rd, Weisman RA, Silverman DG. Monitoring free ap
perfusion by serial uorometry. Otolaryngol Head Neck Surg
1983;91(4):372–376
Dickson MG, Sharpe DT. Continuous subcutaneous tissue pH m easure-
m ent as a monitor of blood ow in skin aps: an experimental
study. Br J Plast Surg 1985;38(1):39–42
Dingwall JA, Lord JW. The uorescein test in the managem ent of tubed
(pedicle) aps. Bull Johns Hopkins Hosp 1943;73:129
Dionyssopoulos A, Odobescu A, Foroughi Y, et al. Monitoring buried
jejunum free aps with a sentinel: a retrospective study of 20 cases.
Laryngoscope 2012;122(3):519–522
Disa JJ, Cordeiro PG, Hidalgo DA. E cacy of conventional monitor-
ing techniques in free tissue transfer: an 11-year experience in
750 consecutive cases. Plast Reconstr Surg 1999;104(1):97–101
Dodakundi C, Doi K, Hattori Y, et al. Viability of the skin paddle does not
predict the functional outcome in free muscle transfers with a
second ischemic event: a report of three cases. J Reconstr Microsurg
2012;28(4):267–271
Dunn RM, Kaplan IB, Mancoll J, Terzis JK, Trengove-Jones G. Experim ental
and clinical use of pH monitoring of free tissue transfers. Ann Plast
Surg 1993;31(6):539–545
Edsander-Nord A, Rojdmark J, Wickman M. Metabolism in pedicled and
free TRAM aps: a comparison using the microdialysis technique.
Plast Reconstr Surg 2002;109(2):664–673
Edwards EA, Duntley SQ. The pigments and colour of human living skin.
Am J Anat 1939;65(1):1–33
Eles DL, Nelson RC, Herbert MD, Zubowxicz VN. Magnetic resonance
im aging for detection of arterial and venous occlusion in canine
m uscle aps and bowel segments. Ann Surg 1987;206(5):624–627
Engel H, Huang JJ, Tsao CK, et al. Rem ote real-time monitoring of free
aps via sm artphone photography and 3G wireless Internet: a
prospective study evidencing diagnostic accuracy. Microsurgery
2011;31(8):589–595
Ensat F, Schubert H, Hladik M, Reichl H, Larcher L, Wechselberger G. [Soft
tissue reconstruction in the extremities and the head and neck
area using the anterolateral thigh free ap]. Oper Orthop Traum atol
2013;25(2):176–184
Erdmann D, Sweis R, Wong MS, et al. [Current perspectives of orthog-
onal polarization spectral imaging in plastic surgery]. Chirurg
2002;73(8):827–832
Eren S, Krein R, Hafem ann B. [Objective evaluation of the microcircu-
lation in the skin with indocyanine green angiography (ICGA). A
m ethod for the clinic?]. Handchir Mikrochir Plast Chir 1995;27(6):
307–314
Eren S, Rubben A, Krein R, Larkin G, Hettich R. Assessm ent of m icrocir-
culation of an axial skin ap using indocyanine green uorescence
angiography. Plast Reconstr Surg 1995;96(7):1636–1649
Fellner C, Prantl L, Rennert J, Stroszczynski C, Jung EM. Comparison of
time-intensity-curve- (TIC-) analysis of contrast-enhanced ultra-
sound (CEUS) and dynamic contrast-enhanced (DCE) MRI for post-
operative control of microcirculation in free aps: rst results and
critical comm ents. Clin Hemorheol Microcirc 2011;48(1):187–198
Fox PM, Zeidler K, Carey J, Lee GK. White light spectroscopy for free ap
m onitoring. Microsurgery 2013;33(3):198–202
Frost MW, Nium sawatt V, Rozen WM, Eschen GE, Damsgaard TE, Kiil
BJ. Direct comparison of postoperative m onitoring of free aps
with microdialysis, implantable cook-swartz Doppler probe,
and clinical monitoring in 20 consecutive patients. Microsurgery
2015;35(4):262–271
Achauer BM, Black KS, Litke DK. Transcutaneous PO2 in aps: a new method
of survival prediction. Plast Reconstr Surg 1980;65(6):738–745
Al-Dam A, Zrnc TA, Hanken H, et al. Outcome of microvascular free aps
in a high-volume training centre. J Craniom axillofac Surg 2014;
42(7):1178–1183
Altintas MA, Altintas AA, Guggenheim M, Knobloch K, Niederbichler
AD, Vogt PM. Monitoring of microcirculation in free transferred
m usculocutaneous latissimus dorsi aps by confocal laser scanning
m icroscopy—a prom ising non-invasive methodical approach. J Plast
Reconstr Aesthet Surg 2010;63(1):111–117
Arya R, Gri ths L, Figus A, King D, Ramakrishnan V, Gri ths M.
Post-operative assessment of perfusion of Deep Inferior Epigastric
Perforator (DIEP) free aps via Pulsatility Index (PI) using a porta-
ble colour Doppler sonogram device. J Plast Reconstr Aesthet Surg
2013;66(7):931–936
Aukland K, Bower BF, Berliner RW. Measurment of local blood ow with
hydrogen gas. Cir Res 1964;14:164–187
Baldwin AJ, Langton SG. Postoperative m onitoring of aps by digital cam -
era and Internet link. Br J Oral Maxillofac Surg 2001;39(2):120–121
Bellamy JL1, Mundinger GS, Flores JM, Wimmers EG, Yalanis GC, Rodriguez
ED, Sacks JM. Do adjunctive ap-monitoring technologies impact clin-
ical decision making? An analysis of microsurgeon preferences and
behavior by body region. Plast Reconstr Surg 2015;135(3):883–892
Birke-Sorensen H, Toft G, Bengaard J. Pure muscle transfers can be monitored
by use of microdialysis. J Reconstr Microsurg 2010;26(9):623–630
Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED.
Factors that in uence the outcome of salvage in free tissue transfer.
Br J Oral Maxillofac Surg 2003;41(1):16–20
Brueggem ann A, Noltze A, Lange T, et al. Signi cant [C3a] increase in free
aps after prolonged ischemia. J Surg Res 2008;150(1):125–130
Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free ap reex-
ploration: indications, treatment, and outcom es in 1193 free aps.
Plast Reconstr Surg 2007;119(7):2092–2100
Cerny V, Turek Z, Parizkova R. Orthogonal polarization spectral imaging.
Physiol Res 2007;56(2):141–147
Chang EI, Carlsen BT, Festekjian JH, Da Lio AL, Crisera CA. Salvage rates
of comprom ised free ap breast reconstruction after recurrent
thrombosis. Ann Plast Surg 2013;71(1):68–71
Chen HC, Kuo HC, Chung KP, Chen SH, Tang YB, Su S. Quality improve-
m ent of microsurgery through telecommunication—the postoper-
ative care after microvascular transfer of intestine. Microsurgery
2012;32(2):96–102
Chen KT, Mardini S, Chuang DC, et al. Timing of presentation of the rst
signs of vascular comprom ise dictates the salvage outcome of free
ap transfers. Plast Reconstr Surg 2007;120:187–195
Chen Y1, Shen Z, Shao Z, Yu P, Wu J. Free ap m onitoring using near-
infrared spectroscopy: a systemic review. Ann Plast Surg 2016;
76(5):590–597
Chiu ES, Altman A, Allen RJ, Jr., Allen RJ, Sr. Free ap m onitoring using skin
temperature strip indicators: adjunct to clinical examination. Plast
Reconstr Surg 2008;122(5):144e–145e
Cho BC, Shin DP, Byun JS, Park JW, Baik BS. Monitoring ap for buried free
tissue transfer: its importance and reliability. Plast Reconstr Surg
2002;110(5):1249–1258
Chubb D, Rozen WM, Whitaker IS, Acosta R, Grinsell D, Ashton MW. The
e cacy of clinical assessment in the postoperative monitoring of
free aps: a review of 1140 consecutive cases. Plast Reconstr Surg
2010;125(4):1157–1166
Chubb D, Whitaker IS, Rozen WM, Grinsell D, Ashton MW, Lineaweaver
WC. Current evidence for postoperative monitoring of microvascular
free aps: a systematic review. Ann Plast Surg 2015;74(5):621–632
Clinton MS, Sepka RS, Bristol D, et al. Establishment of normal ranges of
laser Doppler blood ow in autogenous tissue transplants. Plast
Reconstr Surg 1991;87(2):299–309
Colwell AS, Wright L, Karanas Y. Near-infrared spectroscopy measures
tissue oxygenation in free aps for breast reconstruction. Plast
Reconstr Surg 2008;121(5):344e–345e
Concannon MJ, Stewart DH, Welsh CF, Puckett CL. Impedance plethys-
m ography: a new method for continuous m uscle perfusion m on-
itoring. Plast Reconstr Surg 1991;88(2):292–298
Conway H, Stark RB, Doktor JP. Vacularisation of tubed pedicles. Plast
Reconstr Surg 1949;4:133–138
Cornejo A, Rodriguez T, Steigelman M, et al.The use of visible light spec-
troscopy to measure tissue oxygenation in free ap reconstruction.
J Reconstr Microsurg 2011;27(7):397–402

11 Postoperative Monitoring of Microvascular Free Flaps
157
Holm C, Mayr M, Hofter E, Raab N, Ninkovic M. Interindividual variability
of the SIEA Angiosom e: e ects on operative strategies in breast
reconstruction. Plast Reconstr Surg 2008;122(6):1612–1620
Holzle F, Loe elbein DJ, Nolte D, Wol KD. Free ap monitoring using
simultaneous non-invasive laser Doppler owmetry and tissue
spectrophotom etry. J Craniom axillofac Surg 2006;34(1):25–33
Huang WC, Chen HC, Jain V, et al. Reconstruction of through-and-through
cheek defects involving the oral comm issure, using chim eric aps
from the thigh lateral fem oral circum ex system . Plast Reconstr
Surg 2002;109(2):433–441; discussion 442–433
Hwang JH, Mun GH. An evolution of comm unication in postoperative free
ap monitoring: using a smartphone and mobile messenger appli-
cation. Plast Reconstr Surg 2012;130(1):125–129
Iblher N, Eisenhardt SU, Penna V, Stark GB, Bannasch H. A new evaluation
tool for monitoring devices and its application to evaluate the im-
plantable Doppler probe. J Reconstr Microsurg 2010;26(4):265–270
Ionac M, Schaefer D, Geishauser M. Thromboxane A2 release in isch-
emia and reperfusion of free aps in rats, studied by m icrodialysis.
J Reconstr Microsurg 2001;17(2):139–143
Irwin MS, Thorniley MS, Dor CJ, Green CJ. Near infra-red spectroscopy:
a non-invasive monitor of perfusion and oxygenation within the
microcirculation of limbs and aps. Br J Plast Surg 1995;48(1):14–22
Issing WJ, Naumann C. Evaluation of pedicled skin ap viability by pH,
temperature and uorescein: an experim ental study. J Craniomax-
illofac Surg 1996;24(5):305–309
Jallali N, Ridha H, Butler PE. Postoperative monitoring of free aps in UK
plastic surgery units. Microsurgery 2005;25(6):469–472
Jones BM. Monitors for the cutaneous microcirculation. Plast Reconstr
Surg 1984;73(5):843–850
Jones BM, Mayou BJ. The Laser Doppler owm eter for m icrovascular mon-
itoring: a preliminary report. Br J Plast Surg 1982;35(2):147–149
Jyranki J, Suominen S, Vuola J, Back L. Microdialysis in clinical practice:
m onitoring intraoral free aps. Ann Plast Surg 2006;56(4):387–393
Kannan RY. Early detection of in ow problems during free ap monitor-
ing using digital tympanic thermometers. J Plast Reconstr Aesthet
Surg 2012;65(5):e135
Kashimura T, Nakazawa H, Shimoda K, Soejim a K. False-negative m on-
itoring ap in free jejunal transfer. J Reconstr Microsurg 2013;
29(2):137–140
Kaufman T, Granick MS, Hurwitz DJ, Klain M. Is experimental m uscle
ap temperature a reliable indicator of its viability? Ann Plast Surg
1987; 19(1):34–41
Keller A. Noninvasive tissue oximetry for ap monitoring: an initial study.
J Reconstr Microsurg 2007;23(4):189–197
Khouri RK, Cooley BC, Kunselman AR, et al. A prospective study of mi-
crovascular free- ap surgery and outcom e. Plast Reconstr Surg
1998;102(3):711–721
Khouri RK, Shaw WW. Monitoring of free aps with surface-temperature
recordings: is it reliable? Plast Reconstr Surg 1992;89(3):495–499;
discussion 500–502
Kim SC, Kim EK. Externalized monitoring of totally buried free ap in hy-
popharyngeal reconstruction. J Craniofac Surg 2013;24(2):575–578
Kind GM, Buntic RF, Buncke GM, Cooper TM, Siko PP, Buncke HJ Jr. The
e ect of an implantable Doppler probe on the salvage of m icrovas-
cular tissue transplants. Plast Reconstr Surg 1998;101:1268–1273;
discussion 1274–1275
Kiranantawat K, Sitpahul N, Taeprasartsit P, et al. The rst Smartphone
application for microsurgery m onitoring: SilpaRam anitor. Plast
Reconstr Surg 2014;134(1):130–139
Koshim a I, Fukuda H, Yam amoto H, Moriguchi T, Soeda S, Ohta S. Free an-
terolateral thigh aps for reconstruction of head and neck defects.
Plast Reconstr Surg 1993;92(3):421–428; discussion 429–430
Kraemer R, Lorenzen J, Knobloch K, et al. Free ap microcirculatory
m onitoring correlates to free ap temperature assessm ent. J Plast
Reconstr Aesthet Surg 2011;64(10):1353–1358
Kristensen DL, Ladefoged SA, Sloth E, Aagaard R, Birke-Sorensen H.
Microdialysis: characterisation of haematomas in myocutane-
ous aps by use of biochemical agents. Br J Oral Maxillofac Surg
2013;51(2):117–122
Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle throm bo-
sis and ap loss after free-tissue transfer. Plast Reconstr Surg
1996;98(7):1230–1233
Kyriacou PA. Direct pulse oximetry within the esophagus, on the surface
of abdom inal viscera, and on free aps. Anesth Analg 2013;117(4):
824–833
Futran ND, Stack BC, Jr, Hollenbeak C, Scharf JE. Green light photopleth-
ysmography monitoring of free aps. Arch Otolaryngol Head Neck
Surg 2000;126(5):659–662
Gao R, Loo S. Review of 100 consecutive microvascular free aps. N Z Med
J 2011;124(1345):49–56
Gardiner S, Hartzell TL. Telemedicine and plastic surgery: a review of its
applications, limitations and legal pitfalls. J Plast Reconstr Aesthet
Surg 2012;65(3):e47–53
Geden EM, Rinaldo A, Suarez C, et al. Complications of free fral transfers
for heand and neck reconstructon following cancer resection. Oral
Onc 2004;40(10):979–984
Geis S, Prantl L, Gehmert S, et al. TTP (time to PEAK) and RBV (regional
blood volume) as valuable parameters to detect early ap failure.
Clin Hemorheol Microcirc 2011;48(1):81–94
Geis S, Prantl L, Mueller S, Gosau M, Lamby P, Jung EM. Quantitative as-
sessment of bone microvascularization after osteocutaneous ap
transplantation using contrast-enhanced ultrasound (CEUS). Ultra-
schall Med 2013;34(3):272–279
Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of
758 DIEP aps for breast reconstruction. Plast Reconstr Surg 2004;
113(4):1153–1160
Giogivac SV, Blitz DM, Whiteside LA. Hydrogen washout technique in
m onitoring vascular status after replantation surgery. J Jand Surg
(Am ) 1982;7(9):601–605
Gioux S, Mazhar A, Lee BT, et al. First-in-human pilot study of a spatial
frequency domain oxygenation imaging system. J Biomed Opt
2011;16(8):086015
Goedhart PT, Khalilzada M, Bezem er R, Merza J, Ince C. Sidestream Dark
Field (SDF) im aging: a novel stroboscopic LED ring-based imaging
m odality for clinical assessment of the microcirculation. Opt Ex-
press 2007;15(23):15101–15114
Goldberg J, Sepka RS, Perona BP, Pederson WC, Klitzm an B. Laser
Doppler blood ow m easurements of com mon cutaneous donor
sites for reconstructive surgery. Plast Reconstr Surg 1990;85(4):
581–586
Graham BH, Gordon L, Alpert BS, Walton R, Bunckle HJ, Leitner DW. Serial
quantitative skin surface uorescence: a new method for postop-
erative monitoring of vascular perfusion in revascularised digits.
J Hand Surg (Am ) 1985;10(2):226–230
Hales JR, Stephens FR, Fawcett AA, et al. Observations on a new non-
invasive monitor of skin blood ow. Clin Exp Pharmacol Physiol
1989;16(5):403-415
Hallock GG. Sim ultaneous transposition of anterior thigh muscle and fas-
cia aps: an introduction to the chimera ap principle. Ann Plast
Surg 1991;27(2):126–131
Hara H, Mihara M, Iida T, et al. Blood glucose m easurement for ap mon-
itoring to salvage aps from venous thrombosis. J Plast Reconstr
Aesthet Surg 2012;65(5):616–619
Hara H, Mihara M, Iida T, Narushima M, Koshima I. Blood glucose m ea-
surement in ap m onitoring for salvage of aps from venous
thrombosis. Plast Reconstr Surg 2012;129(3):587e–589e
Harrison DH, Girling M, Mott G. Experience in monitoring the circulation
in free- ap transfers. Plast Reconstr Surg 1981;68(4):543–555
Harrison DH, Mott G. Impedance m onitoring for subcutaneous free ap
transfers. Br J Plast Surg 1989;42(3):318–323
Hashim oto I, Nakanishi H, Takiwaki H, Takase MT, Yamano M, Sedo H. Flap
m onitoring by transcutaneous PO2 and PCO2: importance of trans-
cutaneous PCO2 in determining follow-up treatment for compro-
m ised free aps. J Reconstr Microsurg 2007;23(5):269–274
Heller L, Levin LS, Klitzman B. Laser Doppler owm eter monitoring of
free-tissue transfers: blood ow in norm al and complicated cases.
Plast Reconstr Surg 2001;107(7):1739–1745
Henault B, Pluvy I, Pauchot J, Sinna R, Labruere-Chazal C, Zwetyenga N.
Capillary measurement of lactate and glucose for free ap monitor-
ing. Ann Chir Plast Esthet 2014;59(1):15–21
Hirigoyen MB, Blackwell KE, Zhang WX, Silver L, Weinberg H, Urken ML.
Continuous tissue oxygen tension m easurem ent as a monitor of
free- ap viability. Plast Reconstr Surg 1997;99(3):763–773
Ho MW, Cassidy C, Brown JS, Shaw RJ, Bekiroglu F, Rogers SN. Rationale for
the use of the implantable Doppler probe based on 7 years’ experi-
ence. Br J Oral Maxillofac Surg 2014;52(6):530–534
Hofer SO, Dam en TH, Mureau MA, Rakhorst HA, Roche NA. A critical
review of perioperative complications in 175 free deep inferior
epigastric perforator ap breast reconstructions. Ann Plast Surg
2007;59:137–142

158
I Planning and Decision Making in Reconstructive Surgery
Mueller S, Meier JK, Wendl CM, Jung EM, Prantl L, Gosau M. Mandibu-
lar reconstruction with m icrovascular re-anastomosed bular free
aps: two complementary methods of postoperative transplant
m onitoring. Clin Hemorheol Microcirc 2012;52(2-4):141–151
Muller S, Gosau M, Strobel D, et al. Assessment of bone microcircula-
tion by contrast-enhanced ultrasound (CEUS) and [18F]-positron
emission tom ography/computed tomography in free osseous and
osseocutaneus aps for mandibular reconstruction: preliminary
results. Clin Hemorheol Microcirc 2011;49(1-4):115–128
Nagata T, Masumoto K, Uchiyama Y, et al. Improved technique for eval-
uating oral free aps by pinprick testing assisted by indocyanine
green near-infrared uorescence angiography. J Craniom axillofac
Surg 2014;42(7):1112–1116
Nakatsuka T, Harii K, Asato H, et al. Analytic review of 2372 free ap trans-
fers for head and neck reconstruction following cancer resection.
J Reconstr Microsurg 2003;19(6):363–368; discussion 369
Newman MI, Sam son MC, Tam burrino JF, Swartz KA. Intraoperative
laser-assisted indocyanine green angiography for the evaluation of
m astectomy aps in imm ediate breast reconstruction. J Reconstr
Microsurg 2010;26(7):487–492
Nielsen HT, Gutberg N, Birke-Sorensen H. Monitoring of intraoral free
aps with m icrodialysis. Br J Oral Maxillofac Surg 2011;49(7):
521–526
Oberg PA, Tenland T, Nilsson GE. Laser Doppler owm etry: a non-invasive
and continuous method for blood ow evaluation in the m icrovas-
cular studies. Acta Med Scand 1983;687:17–24
Oliver DW, Whitaker IS, Giele H, Critchley P, Cassell O. The Cook-Swartz
venous Doppler probe for the post-operative monitoring of free tis-
sue transfers in the United Kingdom : a preliminary report. Br J Plast
Surg 2005;58(3):366–370
Olivier WA, Hazen A, Levine JP, Soltanian H, Chung S, Gurtner GC. Reli-
able assessment of skin ap viability using orthogonal polarization
im aging. Plast Reconstr Surg 2003;112(2):547–555
Ozturk CN, Ozturk C, Ledinh W, et al. Variables a ecting postoperative
tissue perfusion monitoring in free ap breast reconstruction.
Microsurgery 2015;35(2):123–128
Panchapakesan V, Addison P, Beausang E, Lipa JE, Gilbert RW, Neligan
PC. Role of thrombolysis in free- ap salvage. J Reconstr Microsurg
2003;19(8):523–530
Papillion P, Wong L, Waldrop J, et al. Infrared surface temperature m on-
itoring in the postoperative managem ent of free tissue transfers.
Can J Plast Surg 2009;17(3):97–101
Parker PM, Fischer JC, Shaw WW. Implantable pulsed Doppler cu for
long-term monitoring of free aps: a preliminary study. Microsur-
gery 1984;5(3):130–135
Paydar KZ, Hansen SL, Chang DS, Ho m an WY, Leon P. Implantable ve-
nous Doppler monitoring in head and neck free ap reconstruction
increases the salvage rate. Plast Reconstr Surg 2010;125:1129–1134
Pharaon MR, Scholz T, Bogdano S, et al. Early detection of complete vascu-
lar occlusion in a pedicle ap model using quantitative [corrected]
spectral imaging. Plast Reconstr Surg 2010;126(6):1924–1935
Poder TG, Fortier PH. Implantable Doppler in monitoring free aps:
a cost-e ectiveness analysis based on a systematic review of the
literature. Eur Ann Otorhinolaryngol Head Neck Dis 2013;130(2):
79–85
Polom K, Murawa D, Rho YS, Nowaczyk P, Hunerbein M, Murawa P. Cur-
rent trends and emerging future of indocyanine green usage in
surgery and oncology: a literature review. Cancer 2011;117(21):
4812–4822
Prasetyono TO, Adianto S. The relationship between oxygen saturation
and color alteration of a compromised skin ap: experim ental
study on the rabbit. Arch Plast Surg 2013;40(5):505–509
Pryor SG, Moore EJ, Kasperbauer JL. Implantable Doppler ow system:
experience with 24 m icrovascular free- ap operations. Otolaryngol
Head Neck Surg 2006;135(5):714–718
Raskin DJ, Erk Y, Spira M, Melissinos EG. Tissue pH monitoring in micro-
surgery: a preliminary evaluation of continuous tissue pH m onitor-
ing as an indicator of perfusion disturbances in microvascular free
aps. Ann Plast Surg 1983;11:331–339
Raskin DJ, Nathan R, Erk Y, Spira M. Critical comparison of transcuta-
neous PO2 and tissue pH as indices of perfusion. Microsurgery
1983;4(1):29–33
Repez A, Oroszy D, Arnez ZM. Continuous postoperative m onitoring of
cutaneous free aps using near infrared spectroscopy. J Plast Re-
constr Aesthet Surg 2008;61(1):71–77
Lamby P, Prantl L, Fellner C, Geis S, Jung EM. Post-operative moni-
toring of tissue transfers: advantages using contrast enhanced
ultrasound (CEUS) and contrast enhanced MRI (ceMRI) with dy-
nam ic perfusion analysis? Clin Hem orheol Microcirc 2011;48(1):
105–117
Langer S, Biberthaler P, Harris AG, Steinau HU, Messm er K. In vivo
m onitoring of microvessels in skin aps: introduction of a novel
technique. Microsurgery 2001;21(7):317–324
Laporta R, Longo B, Sorotos M, Pagnoni M, Santanelli Di Pompeo F. Diep
ap sentinel skin paddle positioning algorithm . Microsurgery
2015;35(2):91–100
Larsson L. An electrophysiological method for monitoring blood ow in
skeletal muscle. An experimental study in the rat. Scand J Plast
Reconstr Surg Hand Surg 1989;23(3):181–186
Lin CT, Chen SG, Chen TM, Tzeng YS. Is m onitor ap monitoring? Micro-
surgery 2014;34(2):164–166
Lin SJ, Nguyen MD, Chen C, et al. Tissue oxim etry monitoring in microsur-
gical breast reconstruction decreases ap loss and improves rate of
ap salvage. Plast Reconstr Surg 2011;127(3):1080–1085
Lindsey LA, Watson JD, Quaba AA. Pulse oximetry in postoperative moni-
toring of free m uscle aps. Br J Plast Surg 1991;44(1):27–29
Lineaweaver WC. The implantable Doppler probe. Plast Reconstr Surg
1988;82:1099–1100
Liu Y, Zhao YF, Huang JT, et al. Analysis of 13 cases of venous compromise
in 178 radial forearm free aps for intraoral reconstruction. Int J
Oral Maxillofac Surg 2012;41(4):448–452
Lohman RF, Langevin CJ, Bozkurt M, Kundu N, Djohan R. A prospective
analysis of free ap monitoring techniques: physical exam ina-
tion, external Doppler, implantable Doppler, and tissue oximetry.
J Reconstr Microsurg 2013;29(1):51–56
Lohman RF, Ozturk CN, Ozturk C, Jayaprakash V, Djohan R. An analysis
of current techniques used for intraoperative ap evaluation. Ann
Plast Surg 2015;75(6):679–685
Machens HG, Mailaender P, Reimer R, Pallua N, Lei Y, Berger A. Postoper-
ative blood ow monitoring after free-tissue transfer by means of
the hydrogen clearance technique. Plast Reconstr Surg 1997;99(2):
493–505
Mahoney JL, Lista FR. Variations in ap blood ow and tissue PO2:
a new technique for monitoring ap viability. Ann Plast Surg
1988;20(1):43–47
May JW Jr, Chait LA, O’Brien BM, Hurley JV. The no- re ow phenom enon
in experim ental free aps. Plast Reconstr Surg 1978;61:256–267
May JW Jr, Lukash FN, Gatico GG 3rd, Stirrat CR. Rem ovable therm ocouple
probe microvascular patency monitor: an experimental and clinical
study. Plast Reconstr Surg 1983;72:366
May JW, Halls MJ. Therm ocouple probe monitoring for free tissue transfer,
replantation and revascularization procedures. Clin Plast Surg 1985;
12:197–207
McCraw JB, Myers B, Shanklin KD. The value of uorescein in predict-
ing the viability of arterialized aps. Plast Reconstr Surg 1977;
60(5):710–719
Meier JK, Prantl L, Muller S, Moralis A, Liebsch G, Gosau M. Simple, fast
and reliable perfusion monitoring of microvascular aps. Clin
Hemorheol Microcirc 2012;50(1-2):13–24
Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free ap
take-back following postoperative m icrovascular compromise:
predicting salvage versus failure. Plast Reconstr Surg 2012;130(3):
579–589
Miyam oto S, Kayano S, Um ezawa H, Fujiki M, Sakuraba M. Vastus lateralis
m uscle aps for monitoring buried anterolateral thigh aps. J Cra-
niofac Surg 2013;24(5):1739–1740
Mo koya BO, Ugburo AO. Early experiences with microvascular free
tissue transfer in Lagos, Nigeria. Niger J Surg 2014;20(1):35–37
Morykwas MJ, Hills H, Argenta LC. The safety of intravenous uorescein
administration. Ann Plast Surg 1991;26(6):551–553
Mothes H, Donicke T, Friedel R, Sim on M, Markgraf E, Bach O.
Indocyanine-green uorescence video angiography used clin-
ically to evaluate tissue perfusion in microsurgery. J Traum a
2004;57(5):1018–1024
Mourouzis C, Anand R, Bowden JR, Brennan PA. Microdialysis: use in the
assessm ent of a buried bone-only bular free ap. Plast Reconstr
Surg 2007;120(5):1363–1366
Mucke T, Wol KD, Rau A, Kehl V, Mitchell DA, Steiner T. Autonomization
of free aps in the oral cavity: a prospective clinical study. Micro-
surgery 2012;32(3):201–206

11 Postoperative Monitoring of Microvascular Free Flaps
159
Sitzman TJ, Hanson SE, King TW, Gutowski KA. Detection of ap venous
and arterial occlusion using interstitial glucose m onitoring in a
rodent m odel. Plast Reconstr Surg 2010;126(1):71–79
Sloan GM, Renissch JF. Flap physiology and the prediction of ap viability.
Hand Clin 1985;1(4):609–619
Smit JM, Acosta R, Zeebregts CJ, Liss AG, Anniko M, Hartman EH. Early
reintervention of compromised free aps improves success rate.
Microsurgery 2007;27(7):612–616
Smit JM, Werker PM, Liss AG, et al. Introduction of the implantable
Doppler system did not lead to an increased salvage rate of com-
promised aps: a multivariate analysis. Plast Reconstr Surg
2010;125(6):1710–1717
Smit JM, Whitaker IS, Liss AG, Audolfsson T, Kildal M, Acosta R. Postoper-
ative monitoring of m icrovascular breast reconstructions using the
implantable Cook-Swartz Doppler system: a study of 145 probes
& technical discussion. J Plast Reconstr Aesthet Surg 2009;62:
1286–1292
Smit JM, Zeebregts CJ, Acosta R. Timing of presentation of the rst signs
of vascular compromise dictates the salvage outcom e of free ap
transfers. Plast Reconstr Surg 2008;122:991–992
Smith AR, Sonneveld GJ, Kort WJ, Van der Meulen JC. Clinical application
of transcutaneous oxygen measurements in replantation surgery
and free tissue transfer. J Hand Surg 1983;8:139–145
Sorensen HB. Free jejunal aps can be monitored by use of microdialysis.
J Reconstr Microsurg 2008;24(6):443–448
Stack BC, Futran ND, Ridley MB, Schultz S, Sillman JS. Signal averaging and
waveform analysis of laser Doppler owmetry of porcine myocuta-
neous aps. Otolaryngol Head Neck Surg 1995;113:550–557
Stack BC Jr, Futran ND, Shohet MJ, Scharf JE. Spectral analysis of pho-
toplethysmogram s from radial forearm free aps. Laryngoscope
1998;108:1329–1333
Stack BC Jr, Futran ND, Zang B, Scharf JE. Initial experience with personal
digital assistant-based re ectance photoplethysmograph for free
tissue transfer monitoring. Ann Plast Surg 2003;51(2):136–140
Steele MH. Three-year experience using near infrared spectroscopy
tissue oximetry monitoring of free tissue transfers. Ann Plast Surg
2011;66(5):540–545
Su Z, Ye P, Teng Y, Zhang L, Shu X. Adverse reaction in patients with drug
allergy history after simultaneous intravenous fundus uorescein
angiography and indocyanine green angiography. J Ocul Pharmacol
Ther 2012;28(4):410–413
Svaerdborg M, Birke-Sorensen H. Monitored extended secondary arteri-
al ischem ia in a free m uscle transfer. J Reconstr Microsurg 2012;
28(2):119–124
Svensson H, Pettersson H, Svedm an P. Laser Doppler owmetry and laser
photom etry for monitoring free aps. Scand J Plast Reconstr Surg
1985;19(3):245–249
Swartz WM, Izquierdo R, Miller MJ. Implantable venous Doppler micro-
vascular monitoring: laboratory investigation and clinical results.
Plast Reconstr Surg 1994;93:152–163
Swartz WM, Jones NF, Cherup L, Klein A. Direct monitoring of microvascu-
lar anastomoses with the 20-MHz ultrasonic Doppler probe: an ex-
perimental and clinical study. Plast Reconstr Surg. 1988;81:149–161
Tachakra S, Wang XH, Istepanian RS, Song YH. Mobile e-health: the unwired
evolution of telemedicine. Telemed J E Health 2003;9(3):247–257
Tan NC, Shih HS, Chen CC, Chen YC, Lin PY, Kuo YR. Distal skin paddle as a
m onitor for buried anterolateral thigh ap in pharyngoesophageal
reconstruction. Oral Oncol 2012;48(3):249–252
Tenorio X, Mahajan AL, Wettstein R, Harder Y, Pawlovski M, Pittet B. Early
detection of ap failure using a new thermographic device. J Surg
Res 2009;151(1):15–21
Udesen A, Lontoft E, Kristensen SR. Monitoring of free TRAM aps with
m icrodialysis. J Reconstr Microsurg 2000;16(2):101–106
Um GT, Chang J, Louie O, et al. Implantable Cook-Swartz Doppler probe
versus Synovis Flow Coupler for the post-operative monitoring
of free ap breast reconstruction. J Plast Reconstr Aesthet Surg
2014;67(7):960–966
Vakharia KT, Henstrom D, Lindsay R, Cunnane MB, Cheney M, Hadlock
T. Color Doppler ultrasound: e ective monitoring of the buried
free ap in facial reanim ation. Otolaryngol Head Neck Surg 2012;
146(3):372–376
van Wingerden JJ, Collins JM, Coret EH, Schroder PJ. Early monitoring of
the viability of the buried intrathoracic omental ap: a feasibility
study. Ann Thorac Surg 2010;90(4):1332–1336
Revenaugh PC, Waters HH, Scharpf J, Knott PD, Fritz MA. Suprastomal cu-
taneous monitoring paddle for free ap reconstruction of laryngo-
pharyngectomy defects. JAMA Facial Plast Surg 2013;15(4):287–291
Rim ler J, Ponticorvo A, Taydas E, et al. A critical evaluation of hum an per-
ception in conventional ap m onitoring versus spatial frequency
dom ain imaging. Plast Reconstr Surg 2014;134(4S-1 Suppl):73
Rojdmark J. Microdialysis in reconstructive surgery. Stockholm: Karolinska
Institute; 2000:19, 28
Rosenberg JJ, Fornage BD, Chevray PM. Monitoring buried free aps:
lim itations of the implantable Doppler and use of color duplex so-
nography as a con rmatory test. Plast Reconstr Surg 2006;118(1):
109–113; discussion 114–115
Rothenberger J, Amr A, Schaller HE, Rahmanian-Schwarz A. Evaluation of a
non-invasive monitoring method for free ap breast reconstruction
using laser doppler owmetrie and tissue spectrophotometry.
Microsurgery 2013;33(5):350–357
Rozen WM, Anavekar NS, Ashton MW, et al. Does the preoperative im ag-
ing of perforators with CT angiography improve operative outcom es
in breast reconstruction? Microsurgery 2008;28(7):516–523
Rozen WM, Chubb D, Whitaker IS, Acosta R. The e cacy of postoperative
m onitoring: a single surgeon comparison of clinical m onitoring
and the implantable Doppler probe in 547 consecutive free aps.
Microsurgery 2010;30(2):105–110
Rozen WM, Garcia-Tutor E, Alonso-Burgos A, et al. Planning and optimis-
ing DIEP aps with virtual surgery: the Navarra experience. J Plast
Reconstr Aesthet Surg 2010;63(2):289–297
Rozen WM, Whitaker IS, Wagsta MJ, Audolfsson T, Acosta R. Buried free
aps for breast reconstruction: a new technique using the Cook-
Swartz implantable Doppler probe for postoperative m onitoring.
Plast Reconstr Surg 2010;125(4):171e–172e
Rubben A, Eren S, Krein R, Younossi H, Bohler U, Wienert V. Infrared
videoangio uorography of the skin with indocyanine green—rat
random cutaneous ap model and results in man. Microvasc Res
1994;47(2):240–251
Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient m anage-
m ent. Plast Reconstr Surg 2009;124(6 Suppl):e295–302
Scheu er O, Exner K, Andresen R. Investigation of TRAM ap oxy-
genation and perfusion by near-infrared re ection spectros-
copy and color-coded duplex sonography. Plast Reconstr Surg
2004;113(1):141–152; discussion 153–155
Schm ulder A, Gur E, Zaretski A. Eight-year experience of the Cook-Swartz
Doppler in free- ap operations: microsurgical and reexploration
results with regard to a wide spectrum of surgeries. Microsurgery
2011;31(1):1–6
Sera n D, Lesesne CB, Mullen RY, Georgiade NG. Transcutaneous PO2
m onitoring for assessing viability and predicting survival of skin
aps: experimental and clinical correlations. J Microsurg 1981;
2(3):165–178
Setala L, Gudaviciene D. Glucose and lactate metabolism in well-perfused
and comprom ised m icrovascular aps. J Reconstr Microsurg 2013;
29(8):505–510
Setälä L, Koskenvuori H, Gudaviciene D, Berg L, Mustonen P. Cost analy-
sis of 109 microsurgical reconstructions and ap monitoring with
m icrodialysis. J Reconstr Microsurg 2009;25:521–526
Setala L, Papp A, Romppanen EL, Mustonen P, Berg L, Harma M. Microdial-
ysis detects postoperative perfusion failure in m icrovascular aps.
J Reconstr Microsurg 2006;22(2):87–96
Setälä LP, Korvenoja EM, Härmä MA, Alhava EM, Uusaro AV, Tenhunen JJ.
Glucose, lactate, and pyruvate response in an experimental model
of m icrovascular ap ischem ia and reperfusion: a microdialysis
study. Microsurgery 2004;24(3):223–231
Sharm a S, Anand R, Hickm an M, et al. Power modulation contrast
enhanced ultrasound for postoperative perfusion monitoring
following free tissue transfer in head and neck surgery. Int J Oral
Maxillofac Surg 2010;39(12):1211–1217
Siemionow M, Arslan E. Ischemia/reperfusion injury: a review in relation
to free tissue transfers. Microsurgery 2004;24(6):468–475
Silverman DG, Cedrone FA, Hurford WE, Bering TG, LaRossa DD. Moni-
toring tissue elimination of uorescein with the perfusion uo-
rom eter: a new method to assess capillary blood ow. Surgery
1981;90(2):409–417
Silverman DG, Kim DJ, Brousseau DA, Kim M, Norton KJ, Reilly CA.
Fluorescence assessm ent of skin perfusion after oral uorescein.
Surgery 1988;103(2):221–225

160
I Planning and Decision Making in Reconstructive Surgery
on 10 years of experience and 1072 aps. Int J Oral Maxillofac Surg
2014;43(9):1059–1063
Yano K, Hosokawa K, Nakai K, Kubo T, Hattori R. Monitoring by means of
color Doppler sonography after buried free DIEP ap transfer. Plast
Reconstr Surg 2003;112:1177
Yii NW, Evans GR, Miller MJ, et al. Thrombolytic therapy: what is its role
in free ap salvage? Ann Plast Surg 2001;46(6):601–604
Yuen JC, Feng Z. Monitoring free aps using the laser Doppler owmeter:
ve-year experiences. Plast Reconstr Surg 2000;105(1):55–61
Yvonne-Tee GB, Rasool AH, Halim AS, Rahm an AR. Noninvasive assess-
ment of cutaneous vascular function in vivo using capillaroscopy,
plethysm ography and laser-Doppler instrum ents: its strengths and
weaknesses. Clin Hemorheol Microcirc 2006;34(4):457–473
Zaman T, Kyriacou PA, Pal SK. Free ap pulse oximetry utilizing re ec-
tance photoplethysmography. Conf Proc IEEE Eng Med Biol Soc
2013;2013:4046–4049
Zhang T, Dyalram -Silverberg D, Bui T, Caccamese JF Jr, Lubek JE. Analysis
of an implantable venous anastom otic ow coupler: experience in
head and neck free ap reconstruction. Int J Oral Maxillofac Surg
2012;41(6):751–755
Zhang T, Lubek J, Salama A, et al. Venous anastomoses using microvascu-
lar coupler in free ap head and neck reconstruction. J Oral Maxil-
lofac Surg 2012;70(4):992–996
Figure Credits
1. Courtesy of Mr. Steve Atherton RMIP MIMI, Medical Illustrator, ABMU
Health Board.
2. Nielsen HT, Gutberg N, Birke-Sorensen H. Monitoring of intraoral
free aps with microdialysis. Br J Oral Maxillofac Surg 2011;49(7):
521–526.
3. Whitaker IS, Rozen WM, Chubb D, et al. Postoperative monitoring of
free aps in autologous breast reconstruction: a m ulticenter compar-
ison of 398 aps using clinical m onitoring, m icrodialysis, and the im -
plantable Doppler probe. J Reconstr Microsurg 2010;26(6):409–416.
Walkinshaw M, Holloway A, Bulkley A, Engrav LH. Clinical evaluation of
laser Doppler blood ow m easurements in free aps. Ann Plast
Surg 1987;18;212–217
Warner KG, Durham -Smith G, Butler MD, Attinger CE, Upton J, Khuri
SF. Comparative response of muscle and subcutaneous tissue pH
during arterial and venous occlusion in musculocutaneous aps.
Ann Plast Surg 1989;22:108–116
Wax MK. The role of the implantable Doppler probe in free ap surgery.
Laryngoscope 2014;124(Suppl 1):S1-12
Whitaker IS, Gulati V, Ross GL, Menon A, Ong TK. Variations in the
postoperative m anagem ent of free tissue transfers to the head
and neck in the United Kingdom . Br J Oral Maxillofac Surg 2007;
45(1):16–18
Whitaker IS, Oliver DW, Ganchi PA. Postoperative m onitoring of microvas-
cular tissue transfers: current practice in the United Kingdom and
Ireland. Plast Reconstr Surg 2003;111(6):2118–2119
Whitaker IS, Pratt GF, Rozen WM, et al. Near infrared spectroscopy for
m onitoring ap viability following breast reconstruction. J Reconstr
Microsurg 2012;28(3):149–154
Whitaker IS, Rozen WM, Chubb D, et al. Postoperative monitoring of
free aps in autologous breast reconstruction: a multicenter com-
parison of 398 aps using clinical monitoring, microdialysis, and
the implantable Doppler probe. J Reconstr Microsurg 2010;26(6):
409–416
Whitney TM, Lineaweaver WC, Billys JB, et al. Improved salvage of com -
plicated m icrovascular transplants m onitored with quantitative
uorom etry. Plast Reconstr Surg. 1992;90:105Y111
Wol KD, Marks C, Uekermann CB, Specht M, Frank KH. Monitoring of
aps by measurement of intracapillary haemoglobin oxygenation
with EMPHO II: experimental and clinical study. Br J Oral Maxillo-
fac Surg 1996;34:524–529
Yam am oto T, Todokoro T, Koshima I. Handheld thermography for ap
m onitoring. J Plast Reconstr Aesthet Surg 2012;65(12):1747–1748
Yang Q, Ren ZH, Chickooree D, et al. The e ect of early detection of an-
terolateral thigh free ap crisis on the salvage success rate, based

II
Section II
Reconstructive Flaps A-to-Z

(Trang không có chữ)

163
proximally and 10 cm distally from the center of the circle. If
arterial signals are di cult to pick up, try searching slightly
posterior to the line drawn in the rst step.
5. Select the most dominant arterial signal(s) and plan the ap
around it/them. A centrally placed strong single arterial signal
can usually be expected to support a ap of 8 cm by 22 cm di-
mensions. It is usually possible to incorporate more than one
arterial signal within these ap dimensions. The ap can be
designed in an elliptical shape with its long axis running along
or parallel to the line marked in the rst step.

Raising the Fasciocutaneous
Anterolateral Thigh Flap
It is recommended that surgical loupes be used throughout the
dissection of this ap. In children it may be preferable to elevate the
ap under a surgical microscope. The anterior (i.e., m edial) mar-
gin of the ap is incised rst with a scalpel down to the deep der-
mis. Monopolar pin diathermy is then used to deepen the incision
into the subcutaneous fat. Using diathermy instead of a scalpel
halts dermal bleeding and controls against blood-staining of the
tissues. Dissection continues through the subcutaneous fat to the
level of the deep fascia. Scissors are used to spread and elevate the
12
Anterolateral Thigh Free Flaps
Christopher G. Wallace and Fu-Chan Wei

Classif cation

●
Mathes-Nahai (fasciocutaneous): usually type B or C

●
Cormack-Lamberty: usually type C

Vascular Pedicle
The descending branch of the lateral circum ex femoral artery
(LCFA) provides the dominant blood supply to the anterolateral
thigh skin.

●
Mean arterial caliber: 2.1 mm

●
Mean venous caliber: 2.3 mm

●
Length: approximately 12 cm, but varies signi cantly ac-
cording to the design of the ap

●
Sensory innervation: lateral fem oral cutaneous nerve
branches

Patient Positioning
Position the patient supine, ensuring that the hip is in neutral
position and the knee is extended when marking out the ap.

Surface Markings
1. Draw a straight line with black indelible marker pen between
the anterior superior iliac spine and the lateral margin of the su-
perior pole of the patella. This roughly corresponds to the sep-
tum between the rectus femoris and vastus lateralis muscles
within which the descending branch of the LCFA lies (Fig. 12.1).
2. Draw a circle with a diameter of 6 cm centered on the mid-
point of this line. Many cutaneous vessels can usually be
found in this area. The circle is then divided into four equal
quadrants; the distal-posterior sector is where one is more
likely to nd a robust arterial signal.
3. Apply the handheld Doppler to the center of this circle and
carefully search for pulsatile signals starting in the distal-
posterior sector of the circle. Mark the strongest, m ost prom-
inent signals with a large red spot using an indelible marker
pen and weaker arterial signals with a sm all red dot. Continue
searching for and m arking arterial signals in each of the re-
maining three sectors of the circle.
4. Continue searching for and marking arterial signals along the
black line drawn in the rst step. For a ap m easuring 8 cm by
22 cm, the search should continue for approxim ately 10 cm
Fig. 12.1 Patient position for marking the anterolateral thigh  ap. The 
anterior superior iliac spine is identi ed by a cross-within-a-circle, and the 
patellar margin has been highlighted. Within the 22 cm 3 8 cm anterolat-
eral thigh  ap are marked the 6-cm circle, two dominant arterial signals, 
and two weaker arterial signals. Note that three of these lie slightly pos-
terior to the predicted position of the intermuscular septum and that one
lies outside the 6-cm diameter circle.

164
II Reconstructive Flaps A-to-Z
septocutaneous vessels. Each artery should be accompanied by
two venae comitantes taking the same course.
It is easier to dissect either side of septocutaneous vessels
rst. Branches should be dissected at least 4 m m away from the
pedicle vessel and either ligated or bipolar diathermied (depend-
ing on the size of the branch) at least 2 mm away from the pedicle
vessel. Do not ligate or diathermy any branch without ensuring
that it is not the continuation of the pedicle vessel. Once both
sides of the pedicle are dissected back to the descending branch
of the LCFA, it can be gently lifted with small retractors by an
assistant so that vessels branching underneath into the vastus lat-
eralis muscle can be divided in similar fashion.
Musculocutaneous perforators require intram uscular dis-
section (Fig. 12.5). Muscle bers overlying the vessel are gently
elevated away from the vessel adventitia and incised; meticu-
lous hemostasis is essential, as blood staining around the vessel
makes dissection much more di cult. This process is repeated
until the entire path of the intram uscular perforator is unroofed
to its origin from the descending branch of the LCFA (Fig. 12.6).
The surgeon m ay now choose to dissect additional septo-
cutaneous or musculocutaneous vessels supplying the ap from
the descending branch of the LCFA. While additional vessels pro-
vide an increased sense of safety, their dissection prolongs the
subcutaneous fat away from the immediately deeper plane so that
monopolar diathermy can continue safely without harming ves-
sels or sensory nerves running in the suprafascial plane. Sensory
cutaneous nerves should be protected and excluded if possible
when raising a nonsensate ap. The fascia is then inspected and a
5-mm diameter window is created with scissors. Pass the scissors
through this window proximally and lift the fascia away from the
underlying muscle. Do not injure any visible vessels or perforators
above or below the fascia. Spread the blades of the scissors and
incise the fascia with monopolar pin diathermy (taking care not
to touch the blades of the scissors with the diathermy). Repeat
this maneuver proximally and distally until the medial margin of
the ap is incised through fascia (Fig. 12.2).
The muscle lying more medially under this incision should
be the rectus femoris and the muscle lying more laterally should
be the vastus lateralis. The next task is to locate the intermuscular
septum between these two muscles along which septocutaneous
vessels (if present) to the anterolateral thigh ap skin will travel.
Retract the medial thigh skin medially and grasp the fascial edge of
the ap with toothed forceps. Use the forceps to lift the fascia away
from the underlying muscle and use a combination of scissors and
bipolar diathermy to incise through the loose connective tissue that
is present in the immediately subfascial plane. Do not injure or un-
duly stretch any vessels passing between the muscle and the fascia,
as these are potential pedicles. Continue dissecting in this plane un-
til as many of these vessels as possible are identi ed and protected.
Select the vessels that correspond to the preoperatively
marked large red spots within the con nes of the planned ap
territory. To facilitate the dissection of these vessels, retract the
rectus femoris m uscle medially away from the vastus lateralis
muscle. This opens the plane between the two muscles to reveal
the descending branch of the LCFA in its depths. Branching o the
descending branch of the LCFA should be the vessel(s) supply-
ing the anterolateral thigh ap (Fig. 12.3). Choose the dom inant
one and dissect it retrograde starting from the underside of the
fascia along whatever path the vessel takes. If this path is at least
partially through muscle, then it is the preference of the authors
to term the vessel a musculocutaneous perforator. Alternatively,
this vessel m ay travel exclusively between the vastus lateralis and
rectus femoris muscles to the descending branch of the LCFA and
not perforate muscle (Fig. 12.4); the authors prefer to term these
Fig. 12.2 The anterior incision has been completed through fascia to re-
veal the rectus femoris muscle lying medial to the vastus lateralis muscle.
Fig. 12.3 This time the dominant vessels supplying the  ap are septocu-
taneous (black arrow).
Fig. 12.4 The septocutaneous vessels have been dissected back to the 
descending branch of the LCFA and vein.

12 Anterolateral Thigh Free Flaps
165
continuous nonabsorbable skin suture. Wider aps can often still
be safely closed directly but a skin graft is occasionally necessary.

Raising the Suprafascial
Anterolateral Thigh Flap
A suprafascial dissection is necessary if signi cant ap thinning
is to be performed primarily. Using the same principles to mark
out the ap and arterial signals (Fig. 12.9a), raise the anterior
(i.e., medial) ap edge rst while maintaining meticulous hemo-
stasis and protecting suprafascial sensory nerves (Fig. 12.9b). A
dry surgical eld is critical to successful preservation of relevant
vessels in the suprafascial plane. An important m aneuver that
facilitates dissection in this challenging plane is controlled ap
retraction that is both rm enough to delineate the plane and
yet gentle enough not to put undue tension on the extremely
delicate suprafascial vessels (Fig. 12.9c). The fascia is incised ax-
ially where the relevant pedicles are found in order to provide
adequate access for subfascial pedicle dissection (Fig. 12.9d).
operation. The descending branch of the LCFA is then skeleton-
ized proxim ally until adequate length and diameter are achieved
for revascularization at the recipient site.
Motor innervation to the vastus lateralis courses with the
descending branch of the LCFA and m ust not be divided if at all
possible. Careful skeletonization of the vascular pedicle will allow
this nerve to be preserved (Fig. 12.7). If it is essential that this
nerve be divided, then transect and repair it microsurgically as
distally as possible.
Attention can now turn to the posterior (i.e., lateral) margin
of the ap, which is incised as described for the anterior m argin
of the ap while carefully protecting the pedicle. Any rem aining
connective tissue between the vastus lateralis muscle and the ap
fascia is now cleared. The ap circulation m ust be checked care-
fully before the pedicle is divided at the chosen level. Allow the
ap to rest for at least 20 m inutes before transecting the pedicle.
Ligate the pedicle vessels securely at the chosen level (the artery
should usually be ligated rst, then the two veins) and divide
sharply with scissors 2 m m distal to this; it is not necessary to
ligate the vessels on the ap side (Fig. 12.8).
The donor site of a ap measuring 8 cm by 22 cm can be
closed directly with dermal interrupted absorbable sutures and a
Fig. 12.5 Musculocutaneous perforator entering the vastus lateralis muscle.
Fig. 12.6 The intramuscular course of the perforator has been unroofed.
Fig. 12.7 Preserving the motor nerve to vastus lateralis by dissecting it 
o  the  ap pedicle. Note the unroofed musculocutaneous perforator sup-
plying the  ap.
Fig. 12.8 Fasciocutaneous anterolateral thigh  ap ready for free tissue 
transfer.

166
II Reconstructive Flaps A-to-Z
c
d
Fig. 12.9 Raising a suprafascial anterolateral thigh  ap. (a) Anterolateral 
thigh  ap marked with dominant arterial signals. (b) Developing the supra-
fascial plane medially. (c) Carefully controlled traction on the  ap gently 
opens the suprafascial plane. Note the meticulous hemostasis required to 
assess suprafascial vessels. (d–h) Having incised the fascia axially, two mus-
culocutaneous perforators are chosen for further retrograde dissection. 
(continued)
f
e
a
b
g

12 Anterolateral Thigh Free Flaps
167
2. Motor branch to the vastus lateralis muscle.
3. The entire vastus lateralis muscle; do not include a muscle
cu around the pedicle.

Clinical Perspectives
The anterolateral thigh fasciocutaneous ap can be transferred
free or pedicled. It is frequently used for soft tissue reconstruction
in the head and neck region (Fig. 12.10), but can be transferred to
any defect with the appropriate recipient soft tissue characteris-
tics and vessels. The thickness of the subcutaneous fat is variable
but can easily be judged by pinching and lifting the anterolateral
thigh skin and fat in the outpatient clinic. The anterolateral thigh
ap is safe to thin at the primary operation if necessary, but this
requires a suprafascial rather than a subfascial dissection.

Hints and Tips
Ensure m eticulous hemostasis throughout—this is critical to
optimize visibility during dissection, especially of the pedicle.
With careful dissection, one can almost always preserve the mo-
tor branch to the vastus lateralis. However, if it is impossible to
unravel the nerve from the pedicle, divide the nerve as distally as
In this example, two m usculocutaneous perforators are chosen,
dissected retrograde, and unroofed progressively (Fig. 12.9e–h)
until they conjoin (Fig. 12.9i). The remainder of the ap is dis-
sected suprafascially and the pedicle harvested until adequate
length and diameter are achieved (Fig. 12.9j). If the surgeon is
skilled in supramicrosurgical techniques, the pedicle dissection
need only progress at perforator level without dissecting the
source vessel. In such circumstances, it is also important that the
recipient site will tolerate a short pedicle. Finally, the donor site
is closed primarily, including the fascial layer (Fig. 12.9k) in order
to restore the compartmental envelope.

Important Anatomical
Structures
Identi ed and raised with the ap:
1. Required anterolateral thigh skin, fat, and fascia.
2. Dominant supplying pedicle, whether intramuscular or
septocutaneous.
Identi ed and preserved:
1. Sensory cutaneous branches to the anterolateral thigh skin, if
possible.
Fig. 12.9 (continued) (i) Both perforators have been dissected to where they conjoin. (j) Suprafascial anterolateral thigh  ap ready for transfer to the 
recipient site. (k) Primary closure of the fascial layer to restore continuity of the compartment.
h
i
j
k

168
II Reconstructive Flaps A-to-Z
Fig. 12.10 (a) Left buccal squamous cell carcinoma (clinically T2 N0 M0) in an 81-year-old man. (b) Ablative defect requiring only soft tissue reconstruc-
tion. (c) Revascularized fasciocutaneous anterolateral thigh free  ap following inset, microsurgical anastomoses to left neck vessels, and recipient site 
closure. (d) Immediate postoperative appearance.
b
a
c
d
Koshim a I, Fikuda H, Utumomiya R, et al. The anterolateral thigh ap:
variations in its vascular pedicle. Br J Plast Surg 1989;42:260–262
Koshim a I, Yamamoto H, Hosoda M, et al. Free com bined composite aps
using the lateral circum ex femoral system for repair of massive
defects of the head and neck regions: an introduction to the chime-
ric ap principle. Plast Reconstr Surg 1993;92:411–427
Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh ap for extremity
reconstruction: clinical experience and functional assessment of
donor site. Plast Reconstr Surg 2001;107:1766–1771
Song YG, Chen GZ, Song YL. The free thigh ap: a new free ap concept
based on the septocutaneous artery. Br J Plast Surg 1984;37:149–159
Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissue ap? An
experience with 672 anterolateral thigh aps. Plast Reconstr Surg
2002;92:421–428
possible to minimize reinnervation time, free it proximally from
vessels supplying the ap, withdraw the nerve in a proxim al di-
rection, and then coapt it to the distal stump with 9/0 suture.
Suggested Further Reading
Agostini T, Lazzeri D, Agostini V, Shokrollahi K. Anterolateral thigh ap
as the ideal ap to full-thickness cheek reconstruction. J Craniofac
Surg 2010;21(6):1897–1898
Celik N, Wei FC, Lin CH, et al. Technique and strategy in anterolateral
thigh perforator ap surgery, based on an analysis of 15 complete
and partial failures in 439 cases. Plast Reconstr Surg 2002;109:
2211–2216; discussion 2217–2218

169
Anterolateral Thigh Pedicled Flaps
Sachin M. Shridharani, Raja Mohan, and Justin M. Sacks
13

Classif cation

●
Mathes-Nahai (fasciocutaneous): usually type II or III

●
Cormack-Lamberty: usually type III

●
Mathes-Nahai (myocutaneous—when utilizing vastus lat-
eralis): type I

Vascular Pedicle
The descending branch of the lateral circum ex femoral artery
(LCFA) is the dominant blood supply to the anterolateral skin and
vastus lateralis muscle (Fig. 13.1).

●
Mean arterial caliber: 2.1 mm

●
Mean venous caliber: 2.3 mm

●
Length: Generally, this is reported as 12 cm; however, this
varies depending on the design of the ap and if perforator
A, B, or C is used.

●
Sensory innervations (Fig. 13.2): The lateral fem oral cuta-
neous nerve branches are the sensory nerves supplying the
skin of the anterolateral thigh.

Patient Positioning
The patient is routinely placed in the supine position for harvest of
the anterolateral thigh (ALT) ap under ideal circum stances. The
hip joint should be in neutral position and the knee extended. If
the ap is to be employed for perineal reconstruction, it is raised
with the patient in the lithotomy position. All pressure points
and bony prominences are appropriately padded.

Anatomy and Surface
Markings
1. Place the patient in the supine position with the hip joint in a
neutral position and the knee extended. Draw a straight line
from the anterior superior iliac spine (ASIS) to the m ost lateral
superior point on the patella (A-P line) (Fig. 13.3). Use the pal-
pable proximal cleft between the vastus lateralis and rectus
femoris to assist with centering this line.
2. Divide the A-P line in half and mark a point 1.5 cm lateral to
the halfway point. This corresponds to perforator B and may
be labeled as such (Fig. 13.4).
Fig. 13.1 Anatomy of the lateral circum ex femoral artery and its 
 branches: 1, lateral circum ex femoral artery (LCFA); 2, descending branch 
of LCFA; 3, ascending branch of LCFA; 4, transverse branch of LCFA; 5, deep 
femoral artery; 6, femoral artery, vein, and nerve; 7, vastus lateralis mus-
cle; 8, vastus intermedius muscle; 9, rectus femoris muscle; 10, vastus 
medialis muscle; 11, sartorius muscle; 12, TFL muscle; 13, lateral femoral
cutaneous nerve.1

170
II Reconstructive Flaps A-to-Z
5. Place a template of the wound requiring reconstruction over
the delineated and Doppler-accessible anterolateral thigh
perforators.
6. Convert the template into an ellipse, such that the maximum
width and length of the templated wound fall within the
3. Perforators A and C are 5 cm proximal and distal to perforator
B, respectively. Mark these points on an axis 1.5 cm lateral and
parallel to the previously marked A-P line.
4. Con rm these perforator locations with transcutaneous
Doppler examination and translocate/remark if necessary.
Fig. 13.2 Sensory distribution of the cutaneous nerves on the anterolat-
eral aspect of the thigh: 1, lateral femoral cutaneous nerve; 2, anterior
femoral cutaneous nerve.1
Fig. 13.3 Perforator detection and  ap design: 1, anterior superior iliac 
spine (ASIS); 2, patella.1
Fig. 13.4 A straight line is drawn from the anterior superior iliac spine to the most lateral superior point on the patella. This line acts as the central axis 
for the planned ALT  ap.

13 Anterolateral Thigh Pedicled Flaps
171
Fig. 13.5 The initial incision is made along the medial aspect of the  ap through the dermis, subcutaneous tissue, and super cial fascia. The deep/
overlying rectus femoris muscle fascia is visible.
boundaries of the ellipse/proposed incision. Exercise caution
in marking the incision lines so that one-third of the width of
the ap is m edial to the A-P line and the rem aining two-thirds
width of the ap is lateral to the A-P line. Example: A max-
imum width of a defect measuring 8 cm should be rounded
up to 9 cm . In an axial plane, extend the ap 6 cm lateral to
the A-P line and 3 cm m edial to the A-P line. Center the tem -
plate over the perforator long axis (line connecting perfora-
tor A-B-C, which is parallel to A-P line) and over perforator B
( lateral to medial).
7. For perineal or abdominal wall reconstruction, the patient
may require greater length of the ap so it can reach the
acquired defect. If this is necessary, extend the markings in an
elliptical fashion distally to, but not past, the knee joint.

Raising the Flap
Step 1: Prepare the Limb
Using the sterile template of the defect requiring reconstruction,
determine the geometry of the ap. Depending on the length of
the ap required to reach the defect, it is critical to place the skin
paddle as distal as possible such that the arc of rotation will allow
for tension free ap inset.
Step 2: Medial Incision
Make the entire m edial incision rst. Carry the dissection through
the skin, subcutaneous tissue, and super cial fascia and m aintain
meticulous hem ostasis throughout this dissection. At this point,
the surgeon should be at the level of the deep fascia (Fig. 13.5).
Step 3: Fasciotomy
Identify the deep fascia over the rectus femoris muscle. Using
monopolar electrocautery, incise the deep fascia both proximally
and distally. This will provide visual con rmation of the cleavage
plane between the rectus femoris muscle and the vastus lateralis
muscle (Fig. 13.6).
Step 4: Identify Perforators
Place noncrushing Alice clamps on the deep fascia correlat-
ing to the Doppler-accessible perforators. This m aneuver
assists w ith elevating the deep fascia off of both the rectus
fem oris and vastus lateralis m uscle. Proceed laterally w ith the
dissection of the deep fascia until the perforators are visual-
ized (Fig. 13.7).
Step 5: Perforator Dissection
Depending on the geom etry of the ap, choose the appropriate
perforators that correlate to the perfusion of the ap necessary
to reconstruct the defect. Once the appropriate perforator is
chosen, proceed with m onopolar and bipolar cautery dissection
and isolation of the perforator down to the pedicle (descend-
ing branch of the LCFA). The pedicle is located in the clearly de-
ned septum proxim ally between the vastus lateralis and rectus
fem oris muscles. Meticulous dissection m ust be performed when
elevating the perforator(s) through the vastus lateralis m uscle.
This must be performed in a bloodless eld. Utilize self-retaining
retractors to create an appropriate and safe surgical eld with
wide exposure.

172
II Reconstructive Flaps A-to-Z
Step 7: Lateral Incision
Once the pedicle to the ALT ap is isolated in its entirety, it is
appropriate to commit to the lateral incision. Making this incision
through skin, subcutaneous tissue, and super cial fascia commits
the ap to its elevation (Fig. 13.8). Again, perform meticulous dis-
section and ligate intramuscular branches emanating from the per-
forators or direct branches of the descending branch of LCF vessels.
Step 6: Identify the Pedicle
Ligate the small muscle branches of the LCF vessels. Carry the
dissection as proximally as possible to the origin of the pedicle.
Often, there is an ascending branch o of the LCFA that m ust
be ligated in order to create appropriate pedicle length. This
maneuver allows increased ap for potential inset into abdom en
or perineum.
Fig. 13.7 The  ap is elevated along the deep fascia until perforators are visualized emanating either from the septocutaneous plane or vastus lateralis 
muscle.
Fig. 13.6 The deep fascia is incised, giving access to the cleavage plane between the rectus femoris and vastus lateralis muscles.

13 Anterolateral Thigh Pedicled Flaps
173
lata can also be incorporated with this ap to reconstruct abdom -
inal wall fascia. When harvesting part or all of the vastus lateralis,
donor site morbidity has been shown to be minimal.
Step 10: Subcutaneous Tunnel
The vastus lateralis muscle can be harvested partially or in whole
along with the ALT ap. In this instance, intramuscular perforators
originating o of the descending branch of LCF vessels supply the
muscle. Once the ap is islandized and elevated to the pedicle ori-
gin, the surgeon may inset the ap in nearly any direction by tak-
ing advantage of a large arc of rotation (Fig. 13.10). In the setting
of abdominal wall reconstruction, tunnel the pedicled ALT ap be-
low the rectus femoris muscle proximally. Subsequently, create a
subcutaneous tunnel in the groin to allow access to the abdominal
wall. For perineal reconstruction, tunnel the ALT ap below both
the rectus femoris muscle (Fig. 13.11) and the sartorius muscle
Step 8: Flap Harvest
Once the lateral incision of the skin paddle is completed, harvest
the ap in its entirety. Typically, the ap is harvested on one to
three perforators, which routinely correspond to perforator A, B,
and/or C. By including distal perforators, the surgeon can opti-
mize adequate perfusion to the distal portion of the ap ensuring
adequate soft tissue to cover distal sites.
Step 9: Taking Muscle
Routinely, a cu of vastus lateralis muscle is included with the
pedicled ALT ap to assist with obliteration of dead space in
the perineum or recapitulation of the abdom inal wall fascia/
muscle (Fig. 13.9). The volume of muscle chosen depends on the
dead space and defect to be reconstructed. Identify and ligate
intramuscular branches from the vastus lateralis. Tensor fascia
Fig. 13.8 Once the pedicle to the ALT  ap is completely dissected, the lateral incision is made in order to isolate the  ap. This will facilitate rapid dissec-
tion proximally as the  ap can be handled freely from its intramuscular attachments.
Fig. 13.9 A portion of vastus lateralis muscle is harvested with the ALT  ap, thus converting it to a myocutaneous  ap. Harvesting the ALT  ap with a 
cu  of vastus lateralis muscle facilitates a more expeditious harvest as intramuscular perforator dissection is deemed unnecessary.

174
II Reconstructive Flaps A-to-Z
Fig. 13.10 The myocutaneous ALT  ap harvest is shown here in preparation for transposition to the perineum. The planned transposition route is below 
both rectus femoris and sartorius muscles. Furthermore, a subcutaneous tunnel through the medial thigh facilitates passage to the perineum.
Fig. 13.11 The myocutaneous ALT  ap is passed under the rectus femoris muscle. The proximal window must be made large enough so as not to 
constrict the vascular pedicle.

13 Anterolateral Thigh Pedicled Flaps
175
Step 13: Donor Site Closure
Close the donor site thigh defect in a m ultilayer fashion over
closed suction drains. Typically, use absorbable suture to close
the super cial fascia and derm is. Assure that the closure is
tension-free to avoid skin necrosis.
Step 14: Split-Thickness Autograft
When the skin cannot be closed in a tension-free manner, apply
split-thickness autograft over the underlying exposed muscle of
the anterior thigh. Hold the skin graft in place with a bolster dress-
ing or negative pressure wound therapy/vacuum-assisted closure.
Step 15: Postoperative
Management
Place the a ected extremity in a knee immobilizer and maintain
leg elevation for 5 days when a skin graft is employed. When the
leg is closed primarily, the patient may ambulate on postopera-
tive day 1 with assistance.
(Fig. 13.12). Take care to preserve the dominant blood supply to the
rectus femoris muscle. The sartorius muscle has a Mathes-Nahai
type IV blood supply. Ligate segmental perforators to create an ad-
equate submuscular tunnel for the ap. Then, create a subcutane-
ous tunnel along the medial thigh. This maneuver creates access to
the perineum for reconstruction of this area (Fig. 13.13).
Step 11: Access to Perineum
The pedicled ALT ap can be used to reconstruct defects of the
perineum and vagina. The surgeon must obtain meticulous
hemostasis in the subcutaneous tunnel. Typically, this tunnel is
four to ve ngerbreadths wide. When the pedicled ALT ap is
transposed either onto the abdominal wall or perineum , it is crit-
ical to ensure that the vascular pedicle is not under any tension.
Step 12: Tension-Free Zone
Con rm there is no tension on the ap or undue pressure from
the subcutaneous tunnel by observing the ap and proxim al
pedicle when the ap is at the point of inset.
Fig. 13.12 The myocutaneous ALT  ap is passed under the sartorius muscle. Segmental blood supply to the sartorius can be ligated to create a ten-
sion-free window for both the  ap and vascular pedicle.

176
II Reconstructive Flaps A-to-Z
the m uscle w ill be sustained on the sam e pedicle as the ALT
ap (Fig. 13.14).
This robust ap is an option for reconstruction of compos-
ite defects (fascia, subcutaneous tissue, and skin) of the abdom -
inal wall. In addition, the pedicled ALT ap can be successfully
transferred to the perineum to reconstruct both sm all and large
defects. Composite defects of the perineum including the poste-
rior and lateral walls of the vagina can be reconstructed when
using this ap (Fig. 13.15).

Hints and Tips
1. When designing the ap, draw a line from the anterior supe-
rior iliac spine to the superior lateral pole of the patella. This
line represents the cleavage plane between the rectus femo-
ris and vastus lateralis m uscle. When the patient is in litho-
tomy, palpate the cleavage plane proximally. This will aid in
con rm ing the longitudinal orientation of the planned ap
dissection.
2. The planned skin paddle needs to be centered as distal as pos-
sible over a reliable and Doppler-accessible perforator in order
to be able to reach the defect.
3. Place noncrushing Alice clamps on the deep fascia at the
site where visualized perforators are located. This maneuver
assists with safe elevation and orientation during meticulous
dissection.

Important Anatomical
Structures
Identi ed and raised with the ap:
1. Requisite anterolateral thigh skin, fat, fascia, and vastus later-
alis muscle (if needed)
2. Dominant supplying pedicle, whether it is intramuscular or
septocutaneous
Identi ed and preserved:
1. Sensory cutaneous nerves/branches to the anterolateral thigh
skin (if possible)
2. If vastus lateralis is not harvested, then the surgeon m ust be
cautious to preserve motor branch to aforementioned muscle

Clinical Perspectives
The pedicled ALT ap is a versatile ap that can also be uti-
lized as a free tissue transfer. In its pedicled form , the ap is
employed to reconstruct: inferior posterior trunk, inferior ab-
dom en, ipsilateral groin, ischium , anterior thigh, and posterior
thigh. When employed as a pedicled ap, the surgeon can
choose to harvest a sm all or large portion of the vastus
lateralis w ith the ap. By m aintaining the perforating arteries,
Fig. 13.13 Subcutaneous tunnel along the medial thigh creating access to the perineum for reconstruction. This subcutaneous tunnel must be at least 
four to  ve  ngerbreadths in width to create a tension-free environment.