Flaps Practical Reconstructive Surgery

178
II Reconstructive Flaps A-to-Z
4. When transferring the pedicled ALT to the perineum, it is im -
perative to create a submuscular window under both rectus
femoris and sartorius muscle along with a w ide subcutaneous
medial thigh tunnel.
Suggested Further Reading
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:
2211–2116; discussion 7–8
Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site m or-
bidity after anterolateral thigh fasciocutaneous and myocutaneous
free ap harvest in 220 patients. Plast Reconstr Surg 2010;125:
209–214
Koshim a I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh ap;
variations in its vascular pedicle. Br J Plast Surg 1989;42:260–262
Koshim a I, Yam amoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H.
Free combined composite aps using the lateral circum ex femoral
system for repair of massive defects of the head and neck regions:
an introduction to the chimeric ap principle. Plast Reconstr Surg
1993;92:411–420
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
Sacks JM, Broyles JM, Baum ann DP. Considerations in abdominal wall
reconstruction. Sem in Plast Surg 2012;26:5–7
Song YG, Chen GZ, Song YL. The free thigh ap: a new free ap con-
cept based on the septocutaneous artery. Br J Plast Surg 1984;37:
149–159
Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an
ideal soft-tissue ap? An experience with 672 anterolateral thigh
aps. Plast Reconstr Surg 2002;109:2219–1126; discussion 27–30
Yu P, Youssef A. E cacy of the handheld Doppler in preoperative identi-
cation of the cutaneous perforators in the anterolateral thigh ap.
Plast Reconstr Surg 2006;118:928–933; discussion 34–35
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
Fig. 13.15 (continued) (c) Transposed ALT myocutaneous  ap through a 
subrectus femoris, subsartorius muscle, and subcutaneous tunnel. Prior 
to inset, the  ap is de-epithelialized. While insetting the  ap, care is taken 
to ensure there is no tension on the proximal vascular pedicle. (d) Inset 
of  ap showing reconstructed postural vaginal wall and perineum. (e) Six-
month follow-up of healed perineum.
c
d
e

179
Deep Circum ex Iliac Artery Flaps
Russell J. Corlett and G. Ian Taylor
14

Classi cation

●
Axial: to bone

●
Musculocutaneous perforators to skin

Vascular Pedicle
The deep circum ex iliac artery (DCIA) and vein provide the
dominant blood supply to the ilium with a series of ne skin per-
forators passing above the iliac crest to supply the skin with usu-
ally one large perforator 8 to 10 cm beyond the anterior superior
iliac spine (ASIS) representing the termination of the DCIA.

●
Mean arterial caliber: 2 mm

●
Mean venous caliber: 5 mm

●
Length: approximately 5 cm

Patient Positioning
The patient is placed supine with a sandbag under the con-
tralateral hip as this allows easier access to the inside of the
pelvis, particularly in the m ale w ith a narrower pelvis. This
maneuver m ay, however, be a disadvantage in gaining access
posterolaterally.

Anatomy and
Surface Markings
See Figs. 14.1 and 14.2.
Pedicle
The ASIS and the pubic tubercle are m arked out and a line drawn
between them. The femoral artery is palpated and marked where
it crosses that line as this locates the origin of the DCIA.
Skin Flap
A ap of su cient size to repair the defect or of a maximum
size that will permit direct closure of the donor site is marked,
centered over the iliac crest with two-thirds above the crest and
one-third below. It is important to note that the skin perforators
pierce the abdominal muscles 1 to 2 cm above the crest and from
2 to 10 cm lateral to the ASIS and the ap should be centered over
these. If the ap is to be raised as a bone-only ap, the sam e tech-
nique is used but with a straight incision to expose the relevant
structures.

Raising the Flap
Step 1
An incision is made along a line just above the inguinal ligament
and extending onto the upper margin of the skin ap if this is
Fig. 14.1 (a) Exposure and dissection of DCIA: 1, External iliac artery and
vein; 2, DCIA; 3, inguinal ligament; 4, iliacus muscle; 5, iliac bone; 7, fringe
of three layers of abdominal muscle.1 (continued)
a

180
II Reconstructive Flaps A-to-Z
Step 3
If a skin ap is required, the upper margin is dissected down to
the abdominal muscles. If possible, the skin perforators are iden-
ti ed and preserved retaining a 2-cm cu of abdom inal m us-
cles attached to the iliac crest. Since the DCIA pierces the three
abdominal wall muscles and then crosses the iliac crest around
10 cm along the iliac crest, there is no point in keeping muscle
attached to the ap beyond that point as it only increases the
bulk of the ap, unnecessarily damages the abdominal wall, and
makes wound closure di cult. At this point in the dissection, the
iliac crest is passing directly backward and it is a common mis-
take to continue too far superiorly. The pedicle passes obliquely
across the inside of the pelvis in a fascial tunnel and lying on
iliacus muscle. This muscle can be incised medial to the pedicle
and swept farther medially by blunt dissection to preserve the
periosteal vessels on the surface of the ilium.
Step 4
The remainder of the ap is incised along its inferior edge and
deepened to the thigh muscles. An incision is made along the outer
lip of the iliac crest down to the bone and the gluteal muscles dis-
sected from the outer aspect of the ilium. This is quite bloody par-
ticularly in the posterior part, and good hemostasis and a rm pack
may be required. On occasion, only the inner aspect of the iliac
crest is required, in which cases the crest is split with an osteotome
with one hand inside the pelvis to ensure that an adequate thick-
ness of bone is maintained, particularly where the ilium is thin.
Step 5
The m edial dissection between the ASIS and the anterior inferior
iliac spine (AIIS) requires some care so as to avoid inadvertent
damage to the pedicle. The inguinal ligament is usually detached
from the ASIS, the iliacus muscle is divided, and the rectus femoris
tendon attached to the AIIS identi ed and incised, leaving a cu
of tendon attached to the AIIS. This cu of tendon is important
Fig. 14.1 (continued) (b) Note the DCIA passing on the inside of the iliac crest with the
perforating branches passing through the three layers of the abdominal wall. (c) The design
of the neomandible from the ipsilateral iliac crest.
b
c
being used. The external oblique is incised a centimeter above
and parallel to the inguinal ligament from the ASIS to just medial
to the external iliac vessels, taking care to preserve the spermatic
cord in the m ale and the ilioinguinal nerve. The conjoined tendon
of internal oblique and transversus abdominis is incised along
the sam e line toward the ASIS. At this point the DCIA can usu-
ally be palpated with the tip of the index nger directed back
toward the inner aspect of the inguinal ligament. The vessels lie
in a brous tunnel at this point that needs to be incised, and are
sometimes not readily palpable. An alternative approach is to lo-
cate the ascending branch as it passes in the layer between inter-
nal oblique and transverses muscles, 1 cm anterior and superior
to the ASIS, and follow this to the main pedicle. The origin of the
artery is usually best located by rst nding the deep circum ex
iliac vein (DCIV) as it characteristically crosses the external iliac
artery (EIA) usually around 1 cm above the DCIA forming a tri-
angle bordered by the EIA medially, the DCIA inferolaterally, and
the deep inferior epigastric vein (DIEV) superolaterally. The DCIV,
however, frequently crosses behind the EIA. The DCIV is quite
large, often 1 cm or greater.
Step 2
The pedicle is dissected from medial to lateral dividing the vari-
ous branches with particular care of those arising from the deep
surface of the pedicle as they are quite short. There is usually a
connection to the super cial circum ex iliac artery (SCIA) system
near the origin of the DCIA. The ascending branch, which is often
quite large, arises from the lateral side of the pedicle at a variable
distance from the origin and pierces the transversus muscle to
course upward between it and the internal oblique. It needs to
be identi ed from the main pedicle, which passes inside the iliac
crest. As it does so, it crosses the lateral cutaneous nerve of the
thigh, which is usually di cult to separate from the vessels. The
nerve is divided well proximal to avoid a neuroma in the wound
and the patient needs to be warned preoperatively that he or she
will have a patch of anesthesia on the thigh. The unbranched in-
trapelvic portion of the nerve can be useful as a graft if required.

14 Deep Circum ex Iliac Artery Flaps
181
Fig. 14.2 (a) Flap design (anteroposterior view): 1, External iliac artery and vein; 2, DCIA; 3, inguinal ligament; 4, iliacus muscle; 5, iliac bone; 6, glutei
muscle and TFL muscle; 7, fringe of three layers of abdominal muscle. (b) Dissection of DCIA in the groin: 4, Internal oblique muscle; 5, DCIA; 6, trans-
versus abdominis muscle; 7, lateral cutaneous nerve of the thigh; 9, iliacus; 10, ascending branch. (c) Osteotomy for whole layer of ilium: 2, DCIA; 5, iliac
bone; 7, fringe of three layers of abdominal muscle. (d) Note the skin ap is centered over the iliac crest with two-thirds above the crest and one-third
below as the perforating vessels pierce the abdominal wall above and lateral to the ASIS.1
a
b
c
d

182
II Reconstructive Flaps A-to-Z
as it represents the future ligaments of the temporomandibular
joint and is used to secure the new head of the mandible (AIIS) in
place after transfer. It is useful to leave a small amount of iliacus
muscle around the pedicle for protection while the bone ap is
mobilized.
Step 6
The bone ap is divided using a reciprocating saw. For jaw recon-
struction, this includes the AIIS and m ost of the crest. A useful
trick is to drill a hole at the angle between the vertical and hor-
izontal segments of the ilium to allow the point of the saw to be
inserted and to cut in each direction; otherwise, it can be awk-
ward to turn the corner. It is also important to be aware that the
crest turns directly backward as it passes posteriorly (Fig. 14.3).
After division of the bone, it is left for 15 to 20 minutes on its
pedicle to overcome any spasm in the vessels and the ap su-
tured to the wound m argin to prevent any kinking or avulsion of
the pedicle.
Step 7
The pedicle is divided and the bone is reshaped on a side table
using a bone bur to produce the required shape. Another team
repairs the donor site. It is vital to reconstruct the lateral ab-
dominal wall to prevent a hernia, and this requires repair of the
transversus m uscle to the pelvis as the iliacus m uscle is too weak
to hold the sutures. Holes are drilled along the cut edge of the
iliac bone and heavy nylon sutures are passed through these, the
transversus m uscle, and the deeper gluteal m uscles. The rest of
the m uscles are sutured in layers nishing with external oblique
sutured to gluteus maximus. Drains are inserted to minimize
hematoma formation. The skin is closed directly.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required bone and, if skin ap used, skin, fat, and portion
of the three muscle layers of the abdominal wall

●
DCIA pedicle
Identi ed and preserved:

●
Ilioinguinal nerve

●
Spermatic cord

Clinical Perspectives
The DCIA ap is the ideal reconstruction for defects of the body
and ramus of the mandible as the shape of the ipsilateral iliac
bone closely matches the mandible, and the DCIA pedicle sits
com fortably over the branches of the external carotid vessels in
the neck and is long enough to reach these without the need for
vein grafts. The tendon of rectus fem oris can be used to suspend
the head of the neom andible from the m eniscus of the temporo-
mandibular joint and the bone is ideal for insertion of osseointe-
grated implants (Fig. 14.4).
The skin ap for head and neck reconstruction is not ideal as
it is bulky and of poor color match for the face if used externally.
The skin ap is unsuitable for intraoral reconstruction unless the
patient is thin as again it is too bulky and the skin pedicle is on
the outside of the bone. A better option for lining is to attach the
DCIA ap to the distal end of a radial forearm free ap on a side
table and then there is complete mobility of the thin, potentially
sensate skin ap independent of the bone.
The curvature of the bone lim its its use to reconstruct long
bones of the limbs unless the defect is shorter than 6 to 8 cm,
but is bene cial for situations such as arthrodesis of the wrist or
elbow particularly if a large skin ap is required.

Flap Variations

●
Bone only

●
Split iliac bone: inner layer only

●
Bone and skin ap

●
Skin ap only (Rueben’s ap)

Hints and Tips

●
Ensure care with short branches from the deep surface of
the pedicle.

●
Remember that the iliac bone curves sharply posteriorly so
as to avoid taking too much muscle, reduce the bulk, and
when cutting the bone to avoid making it too short.
Fig. 14.3 The bone is shaped prior to division of the pedicle. A plastic
model is used to assist in matching the size and shape of the bone ap.
Note the nerve graft used to repair the inferior alveolar nerve harvested
from the lateral cutaneous nerve of the thigh.

14 Deep Circum ex Iliac Artery Flaps
183
Fig. 14.4 (a) Preoperative marking for resec tion of
hemimandible for ameloblastoma. (b) Postoperative re-
sult after DCIA bone ap and osseointegrated implants.
(c) Postoperative X-ray.
a
b
c
Suggested Further Reading
Bitter K. Bone transplants from the Iliac crest to the maxillo-facial re-
gion by the m icrosurgical technique. J Maxillofac Surg 1980;8(3):
210–216
Taylor GI, Corlett RJ, Ashton MW. The evolution of free vascularized
bone transfer: a 40-year experience. Plast Reconstr Surg 2016;
137(4):1292–1305
Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical
extension of m icrovascular techniques. Plast Reconstr Surg 1975;
55(5):533–544
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

184

Classi cation

●
Deep inferior epigastric artery perforator (DIEP) ap: type A
(Cormack and Lamberty), type C (Mathes and Nahai)

●
Super cial inferior epigastric artery (SIEA) ap: type B
(Cormack and Lamberty), type B (Mathes and Nahai)

Vascular Pedicle
The blood supply to the lower abdom inal wall, which is of inter-
est in free abdom inal ap breast reconstruction, arises prim arily
from the external iliac artery. A variety of elliptical aps can be
harvested from the tissue between the umbilicus and the pubis.
However, the abdominal region is traditionally divided into four
zones (I, II, III, VI) depending on an ipsilateral blood supply. Zone
IV is most remote from the pedicle and usually is not included in
the ap (Fig. 15.1).
Primary Blood Supply
Primary blood supply is from the deep inferior epigastric artery,
which is a branch of the external iliac artery arising 1 cm cranial
Deep Inferior Epigastric Artery Perforator
Flaps and Super cial Inferior Epigastric
Artery Flaps for Breast Reconstruction
Moustapha Ham di and Ali M. Ghanem
15
to the inguinal ligament. The pedicle traverses deep to the trans-
versalis fascia in a superom edial direction and com es into close
contact with the posterior surface of the rectus abdom inis m us-
cle as it passes super cial to the arcuate line. In m ost patients
the pedicle bifurcates into a lateral and m edial branch prior to
penetrating the rectus muscle (Fig. 15.2). There is no bifurcation
in about 28% of patients, and in these cases, the vessel takes a
central course. An average of two to eight “major” perforators, de-
ned as those being greater than 0.5 m m in diam eter, penetrate
the anterior rectus sheath per side in an area extending between
2 cm cranial to the umbilicus and 6 cm caudal to it, and 1 to 6 cm
lateral to the umbilicus.
The lateral branch, or lateral row, perforators m ay be larger
and easier to dissect, but the midline perforators supply better
blood ow to zone IV, which is farthest from the vascular pedicle.

●
Mean arterial caliber: 3.5 m m (3 to 4 m m ) at the origin of
the vessel

●
Mean venous caliber: 4 mm (3.5 to 4.5 mm)

●
Mean pedicle length: 16 cm (14 to 18 cm)

●
Sensory innervation: branches of the intercostal nerves

Secondary Blood Supply
The secondary blood supply com es from the super cial inferior
epigastric artery (SIEA), which arises from the com mon femoral
artery 2 to 3 cm below the inguinal ligament in 17% of cases or
from a common origin with the super cial circum ex artery in
48% of cases. The artery is entirely absent in 35% of specimens.
The artery is usually accompanied by two venae com itantes,
which drain into the deep femoral vein or occasionally into the
saphenous bulb (Fig. 15.2). In addition, there is a constant super-
cial inferior epigastric vein (SIEV) draining the lower abdom inal
skin and fat.

●
Mean arterial caliber: 1.6 mm (0.75 to 3.5 mm) at the level
of the inguinal ligament

●
Mean venous caliber: 4 mm (3 to 5 mm)

●
Mean pedicle length: 5 cm (4 to 7 cm)

●
Sensory innervation: branches of the intercostal nerves T7
to T12

Patient Positioning
Supine throughout the dissection of the ap. Flex the hip up to
90 degrees to facilitate closure of donor sites if necessary.
IV

II

III
I
Fig. 15.1 Vascular territory of the lower abdominal wall as related to
DIEA. Zone I: skin over the rectus abdominis (RA) muscle irrigated directly
by DIEA branches. Zone II: skin overlying the contralateral RA muscle.
Zone III: skin lateral to the lateral border of the RA muscle. Zone IV: skin
lateral to the contralateral RA muscle.1

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
185
3. The lower border is marked so that the scar would be hidden
in the underwear leaving at least 6 cm superior to the vulva
(Fig. 15.4)
4. In the SIEA ap, the vascular territory is limited to the ipsilat-
eral lower abdom en with som e extension to half of the con-
tralateral zone III (Fig. 15.1). In the senior author’s experience,
the SIEA can support less tissue across the midline than a free
transverse rectus abdominis (TRAM) or DIEP ap. Therefore,
the ap is designed exclusively over zones I and II, with any
extension being lateral over the iliac region. Using this meth-
od, a ap of up to 32 3 13 cm can be harvested. Mark the low-
er incision as a line placed more inferiorly toward the pubic
tubercle compared to the DIEP ap in order to better visualize
the vessels at this level.

Raising the Flap
DIEP Flaps
Step 1: In ltration of Abdominal
Incisions
A solution of 1% lidocaine with epinephrine is used to in ltrate
the entire superior edge of the ap and the inferior edge of the
ap except for the region of the super cial inferior epigastric veins,
approximately midway between the ASIS and the pubis (Fig. 15.5).

Preoperative Perforator
Assessment
It is advisable to mark all available perforators, with the domi-
nant perforators distinguished and clearly marked on the abdom -
inal skin. Color Duplex imaging is a reliable and valuable m eth-
od to assess the arterial and venous trees of the lower abdomen.
Nevertheless, preoperative m ultidetector row CT (MDCT) scans
are useful to determine the location of “dominant” perforators
(Fig. 15.3). Unidirectional Doppler allows us to verify the exact
location of the SIEA, generally located midway between the ante-
rior superior iliac spine (ASIS) and pubis.

Surface Markings
The design of the DIEP ap is an ellipse approximately 13 cm high
and 35 to 40 cm in width; the amount of fat available is estimated
by the “pinch” test.
1. Mark all available perforators with the dominant perforator
clearly distinguished using black indelible pen (see above).
2. Mark the superior border of the ap at or just above the um -
bilicus. Taper the upper edge of the ap laterally just above
the anterior superior iliac spines to facilitate closure without
dog ears.
Fig. 15.2 Blood supply. (a) The DIEA originates from the external epigastric artery. It runs in front of the posterior sheath of rectus abdominis (RA) mus-
cle. It gives usually two main branches, medial and lateral, which anastomose with branches from the superior epigastric artery. (b) Doppler detection:
1, DIEA; 2, deep superior epigastric artery; 3, lateral branch of DIEA; 4, medial branch of DIEA; 5, paraumbilical perforator; 6, rectus abdominus muscle;
7, sheath of rectus; 8, external oblique muscle; 9, super cial inferior epigastric vein; 10, branches of the 10th and 11th intercostal nerve.2
a
b

186
II Reconstructive Flaps A-to-Z
Fig. 15.3 Preoperative mapping of the perforators is done using multidetector CT scan. The images show the dominant perforator, its location, and
course. A three-dimensional image is then created and the perforator is transferred to the abdominal wall.
Step 2: Umbilical Incisions and
Superior and Lateral Incisions
The um bilicus is delivered by connecting three perium bilical
stab incisions at 10 o’clock, 2 o’clock, and 6 o’clock. The um bilicus
stalk is then freed until the rectus fascia (Fig. 15.6). An orienting
suture is placed at the 6 o’clock position. The upper abdominal
incision is then m ade and carried down through skin, Scarpa’s
fascia, and fat to the anterior rectus sheath. It may be bevelled
cranially if a greater ap volume is desired.
The upper abdominal ap is then elevated until the sternal
xiphoid. The undermining is limited to a 3 to 4 cm width in the
midline to preserve the lateral blood supply. In patients with in-
su cient abdominal wall laxity, the area of undermining may
be extended laterally up to the costal margins for tension-free
closure (Fig. 15.7).
Step 3: Inferior Incision and SIEV
Identi cation
The lower incision is m ade w ith scalpel dow n to the deep
derm is. It is recom m ended that 3.53 plus surgical loupe is
used throughout the dissection of this ap. Dissection then

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
187
Fig. 15.4 Preoperative markings for secondary breast reconstruction
with DIEP Flap. Perforators are mapped with CT angiography and marked
(with black crosses) taking reference from the umbilicus. The dominant
perforator is marked with a red dot.
Fig. 15.5 In ltration of a solution of lidocaine with adrenaline along incision lines. Avoid injecting in the region
of the super cial inferior epigastric vessels to prevent hematoma.

188
II Reconstructive Flaps A-to-Z
Fig. 15.6 The umbilicus is incised circumferentially and freed from the abdominal ap down to the rectus fascia.
A temporary orienting suture is applied.
Fig. 15.7 The upper abdominal ap is undermined on the rectus fascia up to the level of the xiphisternum. The under-
mining is limited to around the midline to preserve the lateral blood supply (intercostal and thoracolumbar vessels) to
the upper abdominal ap and to minimize dead space.

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
189
Step 4: Suprafascial Dissection of
Marked Perforators and Dominant
Perforator Identi cation
Flap dissection starts from lateral to m edial w ith electrocau-
tery just above the anterior rectus sheath w ith careful con-
trol of secondary sm all perforators encountered by clipping
proceeds w ith a m onopolar pin diathermy (Colorado needle) to
deepen the incision into the super cial subcutaneous fat w ith
care taken to identify and preserve the SIEV bilaterally. Once
identi ed, use bipolar diathermy to dissect the SIEV for ap-
proxim ately 3 to 5 cm caudally before clipping distally to allow
for anastom osis should additional venous drainage be required
later (Fig. 15.8).
Fig. 15.8 (a) The super cial inferior epigastric vein is identi ed approximately 7 cm lateral to the midline in the
subcutaneous tissue deep to Scarpa’s fascia. Skin hooks placed caudally aid dissection. (b) The super cial infe-
rior epigastric vein has been dissected for 4 cm and preserved in case additional venous drainage is required,
particularly in cases of super cial venous dominance.
a
b

190
II Reconstructive Flaps A-to-Z
Step 5: Intramuscular Dissection of
Perforators
The fascia is then opened from directly in a cranial and caudal di-
rection for several centim eters (Fig. 15.11). Any loose connective
tissue around the base of the perforator is dissected with a
or cautery (Fig. 15.9). Once the chosen perforator is visual-
ized from its lateral aspect, it is carefully inspected to ensure
that the artery is pulsatile and that the vein is of adequate
caliber. The selected perforator is dissected free of surround-
ing connective tissue for 360 degrees in a suprafascial plane
(Fig. 15.10).
Fig. 15.9 The ap is elevated o the rectus fascia using monopolar diathermy in a lateral to medial direction, ligating
or cauterizing small secondary perforators.
Fig. 15.10 The chosen perforator is inspected to ensure that the artery is pulsatile and that the vein is of adequate
caliber. It is then dissected free of surrounding connective tissue for 360 degrees in a suprafascial plane.

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
191
by splitting the muscular bers. The medial aspect of the perfo-
rator is left undissected until the main pedicle is developed at
the posterior aspect of the rectus m uscle. A valuable strategy we
have employed in the past is to follow the largest side branch for
1 to 2 cm before ligating it to provide an additional vessel that the
SIEV can be anastomosed to if the ap appears congested later in
the procedure.
microbipolar diathermy forceps allowing the surgeon to identify
the cleavage plane in the rectus muscle through which the perfo-
rator traverses (Fig. 15.12). The motor branches of the intercos-
tal nerves can be encountered passing super cial to the pedicle
(Fig. 15.13). They must be preserved. Dissection of the perforator
is continued along its lateral aspect “unroo ng the perforator” to-
ward the m ain pedicle while longitudinally splitting the m uscle
Fig. 15.11 The fascia is carefully incised to expose the perforator.
Fig. 15.12 Hooks and self-retaining retractors are strategically placed for exposure and to provide gentle traction.
Vessel dissection with micro DeBakey forceps and cotton-tipped applicator is safe and expedient. A dissecting
microscissor and ne-tipped bipolar forceps are also used.

192
II Reconstructive Flaps A-to-Z
until adequate length is obtained, generally continuing dissection
until the lateral edge of the rectus muscle is reached (Fig. 15.15).
This portion of the dissection is very similar to that in the free TRAM
dissection. When the donor site is ready, the pedicle is transected
and pulled through the longitudinal split in the rectus muscle and
under the preserved motor nerves to deliver the ap while preserv-
ing the entire muscle and its innervation (Fig. 15.16).
Step 6: Caudal Dissection of the
Pedicle
Once the main pedicle is identi ed, self-retaining retractors are used
to hold open the rectus muscle while muscular branches from the
perforator and the main pedicle are clipped or coagulated (Fig. 15.14).
The pedicle is followed caudally releasing it from surrounding fat
Fig. 15.13 Side branches are ligated with clips. The segmental intercostal motor nerves that innervate the rectus
cross super cial to the perforator and are preserved.
Fig. 15.14 The perforator has been traced to the deep inferior epigastric vessel running deep to the rectus muscle.
The fascial incision is extended and rectus muscle split along its bers. The cranial continuation of the DIE vessels
is ligated.

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
193
a
Fig. 15.15 (a) The deep inferior epigastric vessels are traced caudally to their origin. (b) When the pedicle is of su cient
length and caliber, the deep inferior epigastric vessels are ligated.
b

194
II Reconstructive Flaps A-to-Z
Fig. 15.16 (a) The pedicle is then passed cranially deep to the preserved segmental intercostal nerves. (b) Undersurface
of the DIEP ap.
a
b
also be undermined to partially bury the DIEP ap when there
is insu cient abdominal skin, particularly in cases of bilateral
breast reconstruction. The upper mastectomy ap is undermined
o the pectoralis muscle (Fig. 15.18).
Step 9: Exposure of Recipient Vessels
The ideal recipient vessels for microvascular breast reconstruc-
tion using perforator aps are the internal m am m ary system .
We typically prepare the internal mammary vessels via a rib
Step 7: Preparation of the
Recipient Area
(Note that this step could be done simultaneously in a two-team
approach.) In delayed reconstruction, the level of the inframam -
mary fold is m arked m ore superiorly than the nal desired posi-
tion. The skin between the m astectomy scar and infram am m ary
fold is either excised full thickness or de-epithelialized to increase
the overall volum e and lower pole projection of the reconstructed
breast (Fig. 15.17). However, this caudal m astectomy ap can

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
195
Fig. 5.17 Recipient site preparation: The mastectomy scar is excised full thickness. The dermis at the desired inframa-
mmary fold is incised and the intervening lower mastectomy skin ap is de-epithelized.
Fig. 15.18 (a,b) The upper mastectomy skin ap is elevated o the pectoralis major muscle to the limits of the breast
footprint. (continued)
a

196
II Reconstructive Flaps A-to-Z
sparing approach at the third intercostal space (Fig. 15.19). This
and other techniques of internal mammary system recipient
vessel preparation are described in Chapter 9 of this book.
Step 10: Microvascular Anastomosis
Setup
In settings where two teams are available, the patient’s legs can be
raised to facilitate donor site closure during the microvascular anas-
tomosis expediting the procedure. The ap is turned 180 degrees and
xed to the chest with a moist laparotomy pad and staples (Fig. 15.20).
For technical reasons, the medial vessel is anastomosed before the
lateral vessel. The microvascular technique is dependent upon the
training and practice of the surgeon. It is our practice to perform
end-to-end anastomoses in the vast majority of cases (Fig. 15.21).
Step 11: Additional Venous Drainage
Once the microanastomoses of the DIEA/DIEV to the internal mam-
mary artery (IMA)/internal mammary vein (IMV) are completed,
the ap is evaluated. If the ap appears totally congested despite a
patent venous anastomosis, this is an indication that the patient’s
lower abdominal wall is dominantly drained by the SIEV rather
than the DIEV (which occurs in 2% of our cases). Frequently in these
patients, the SIEV is noted to be large during the initial ap dis-
section. If an approximately 5 cm length of the SIEV is available, it
would usually reach the internal mammary (IM) vessels easily and
the SIEV could be anastomosed to either a second IMV (Fig. 15.3) or
to an internal mammary perforating vein (Fig. 15.4). Alternatively,
the SIEV can be anastomosed to a preserved large side branch of
the DIEA/DIEV pedicle as described above. If the SIEV is too short,
a graft (usually the contralateral DIEA) is used to bypass the gap
Fig. 15.19 The internal mammary recipient vessels are prepared for anasto-
mosis. A narrow gauge suction drain keeps the eld clean during anastomosis.
Fig. 15.18 (continued)
b

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
197
supporting the ap to ensure that there is no traction of the ped-
icle, the towel that was used to wrap the ap is carefully removed
(Fig. 15.22). The ap is inset in the same position as the anasto-
mosis—that is, upside down with the um bilicus facing 6 o’clock.
The mastectomy ap is retracted to visually con rm that there is
no twisting, kinking, or extrinsic compression of the pedicle. A
piece of fat may be introduced to support the pedicle within the
intercostal space.
between the SIEV and the recipient vein. An additional indication
for using the SIEV is when a large ap (which includes most of zone
III or a part of zone IV) is transferred (8% of our cases).
Step 12: DIEP Flap Inset
All accessories (background, drains, staples, hooks, etc.) are
removed and returned to the scrub nurse. With an assistant
Fig. 15.20 The ap (upside down with the umbilicus facing caudally) is held in place with a wet laparotomy towel and staples.
Fig. 15.21 Completion of microscopic end-to-end anastomosis between the deep inferior epigastric and internal
mammary vessels.

198
II Reconstructive Flaps A-to-Z
Fig. 15.22 The ap being inset, ensuring that the pedicle is not twisted.
Fig. 15.23 The inferior aspect of the ap is temporarily stapled to the inframammary fold. Notice the gentle ptosis that
is achieved.
The superolateral tip of the ap is sutured to the pecto-
ralis tendon anterior to the axilla. The patient is now placed in
a 45-degree sitting position for the rest of ap inset. Next, the in-
ferior aspect of the ap is anchored to the chest along the desired
inframammary fold, allowing the ap to drape gently, thus re-cre-
ating a natural ptosis (Fig. 15.23). Next the medial aspect of the
ap is marked and resected accordingly to t the mastectomy
pocket (Fig. 15.24). This area corresponds to zone 4 of the DIEP
ap, which is most likely to be congested being farthest away from
the pedicle. Every e ort is made to preserve the SIEV with the
ap, should an additional venous drainage be required. The su-
perior aspect of the ap is then inset and the portion of the ap

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
199
a
b
Fig. 15.24 (a,b) The medial aspect of the ap is excised (zone 4) preserving the super cial inferior epigastric vein with
the ap.
under the upper mastectomy ap is de-epithelized (Fig. 15.25).
Two drains are placed away from the pedicle, and the skin is
closed with Vicryl 3-0 and Monocryl 3-0 (Ethicon, Somerville, NJ).
Step 13: Donor Site Closure
This can be done before perform ing the microanastom osis to
allow a two-team approach. Therefore, the abdomen should be
prepared for closure before setting the ap on the thorax for the
microanastom oses. The anterior rectus sheath is closed with a
nonabsorbable braided 0 suture (Fig. 15.26). It is absolutely crit-
ical that both layers of the anterior rectus sheath be visualized
and included within the closure to m inim ize postoperative ab-
dominal bulging, particularly below the arcuate line. We rou-
tinely in ltrate ropivacaine, a long-acting local anesthetic, upon
closure (Fig. 15.27). Two drains are inserted and the abdom en is
then closed as an abdominoplasty with transposition of the um -
bilicus (Fig. 15.28).

200
II Reconstructive Flaps A-to-Z
a
Fig. 15.25 (a,b) The upper ap is buried under the upper mastectomy aps and held with temporary staples. The mar-
gins are marked, the staples removed, and the buried portion of the ap is de-epithelized. Drains are applied, and the
nal inset is done with Vicryl sutures to the dermis and subcuticular Monocryl.
b

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
201
a
b
Fig. 15.26 (a,b) The incision in the rectus sheath. Below the arcuate line, the anterior sheath has two leaves, which
must be included in the closure. The umbilicus is sutured to the rectus fascia to shorten the stalk. Two Vicryl 4-0 sutures
are also applied to the dermis of umbilicus at 12 and 6 o’clock and held with mosquito forceps to aid inset later.

202
II Reconstructive Flaps A-to-Z
Fig. 15.27 Injection of a long-acting local anaesthetic around the fascial incision prior to closure. Two drains are also
applied.
a
Fig. 15.28 (a) Closure of the abdomen is done with the hips exed to reduce tension. The opening for the umbilicus is
marked. (continued)

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
203
Conversion of a DIEP ap to a TRAM ap or muscle-sparing
TRAM is often safer and easier than dissecting three or more
perforators, which may cause similar damage to the rectus
muscle when compared with a muscle-sparing free TRAM
ap. Fortunately, these situations are rarely encountered.
SIEA Flaps
Step 1: Inferior Incision and
Identi cation of the SIE Vessels
Dissection begins with surgical exploration of the SIE vessels: the
initial incision is made along the inferior ap markings, but at this
stage not deepened to the subcutis. The SIE vessels are identi ed
at a point between the pubic tubercle and ipsilateral ASIS corre-
sponding with the markings of the Doppler ndings. The SIEA is
found usually in association with two venae comitantes directly
above the Scarpa’s fascia (Fig. 15.29). The SIEV is usually located
2 to 3 cm medial to the SIEA. Side branches are m eticulously co-
agulated or ligated. It is easier to dissect close to the vessels and
dissection is performed including a limited amount of the sur-
rounding fatty tissue (Fig. 15.30). The vessels cross the inguinal
ligament and at this point, the artery descends vertically in the
Important Consideration for
DIEP Flap Optimization
The use of the DIEP ap for breast reconstruction provides a
breast with a natural appearance and texture. The following
points are valuable to achieve a safe and reproducible technique.

●
The DIEP ap, like other perforator aps, relies on spe-
cialized techniques in ap harvesting. For beginners or
trainees, the learning curve is obviously the m ajor chal-
lenge as in any new technique.

●
Using im aging technology such as Duplex or MDCT scan
in the preoperative planning of perforator aps is essential
to making this technique more reliable in inexperienced
hands.

●
Perforator selection is the key point of the technique. How-
ever, when no single perforator meets guidelines (a clearly
pulsatile artery and a vein that is at least 0.5 mm in diam -
eter), it may be necessary to dissect more than one perfo-
rator in a given row without sacri cing muscle or nerves
(Fig. 15.20).

●
Finally, there are situations where a lack of pulsatile perfo-
rator arteries or the presence of multiple very small perfora-
tors simply requires conversion to a muscle-sparing TRAM.
b
Fig. 15.28 (continued) (b) Immediate postoperative photo.

204
II Reconstructive Flaps A-to-Z
Fig. 15.29 SIEA ap dissection. The SIEA is found usually in association with two venae comitantes directly above the
Scarpa’s fascia.
Fig. 15.30 The dissection is performed including a limited amount of the surrounding fatty tissue.

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
205
form of a loop toward its origin, while the venae comitantes con-
tinue distally to join the femoral or saphenous veins (Fig. 15.31).
The venae comitantes join the SIEV in almost 50% of cases before
entering the deep venous system . The super cial circum ex ves-
sels can be included with the SIEA ap if a larger skin territory
is required. If the diameter of the SIEA is over 1 mm, the ap can
be safely harvested based on these vessels. If not, the contralater-
al SIE vessels should be explored. The ap m ust remain attached
to the deep fascia to retain the ability to convert to a DIEP ap
until the SIE vessels are explored and an appropriately sized ar-
tery is located. The pedicle length varies between 4 and 7 cm
(Fig. 15.32). If no suitable-sized arteries can be identi ed, then
the ap is converted to a conventional DIEP ap, and dissection of
the perforators through the rectus abdominis is performed.
Step 2: Exposure of Recipient Vessels
The IM vessels are dissected and prepared as described above. The
IM vessels are dissected distally to gain maximum recipient vessel
length; this makes microanastomosis more comfortable and at a
level above the pectoralis muscle, thereby allowing the SIE vessels
to lie on the PM without kinking. If a sizeable internal mammary
artery (IMA) perforator is encountered above the pectoralis major
(PM) muscle, these perforators are preferred in keeping with our
algorithm in choosing recipient vessels for breast reconstruction.
The IMA perforators are usually a better size match with the SIE
vessels and also create an ideal situation where the recipient site
morbidity is minimized as well as the donor site morbidity.
Fig. 15.31 The vessels cross the super cial fascia. The artery (arrow) descends vertically in the form of a loop toward its
origin, while the venae comitantes continue distally to join the femoral or saphenous veins.
Fig. 15.32 The SIEA ap is completely harvested.

206
II Reconstructive Flaps A-to-Z
Step 3: SIEA Flap Insetting
The shorter SIE vessels make ap insetting somewhat more di cult
than that of DIEP or TRAM aps. Also, the SIE vessels emerge from
the subcutaneous level of the inferior border of the ap rather than
from the deep surface of the ap, as in the TRAM or DIEP ap. This
can become a problem in breast reconstruction because the ap
needs to be oriented in a suitable way to achieve adequate shaping
without kinking the pedicle. We have found that vertical orienta-
tion of the ap provides the safest positioning of the vessels as they
lie almost horizontally above the pectoralis muscle (Fig. 15.33). In
the case of ipsilateral SIEA ap harvest, the ap should be oriented
in a more oblique direction with folding of the lateral part of the
ap to obtain maximal medial fullness (Fig. 15.34). The nal shape
achieved on table should be one with less lateral fullness and more
tissue bulk medially. This prevents lateral sagging due to gravity
that can become apparent during follow-up. The ap is attached to
the thoracic wall inferiorly with heavy absorbable stitches, espe-
cially in the lateral border. One or two stitches are placed between
the super cial fascia and PM fascia to ensure that there is no ten-
sion on the microanastomosis site due to the weight of the ap.
The skin is closed using interrupted deep dermal 3-0 absorbable
suture and subcuticular running mono lament absorbable suture.
Two drains are inserted between the breast skin and the ap, far
from the pedicle.
Fig. 15.33 A contralateral SIEA ap setting is performed in vertical fashion
(90 degrees counter-clockwise).
Fig. 15.34 An ipsilateral SIEA ap setting is performed in oblique fashion
(270 degrees counter-clockwise).
Step 4: Donor Site Closure
The deep fascia is repaired at the level were the SIE vessels join
the deep system using strong interrupted sutures. The abdomen
is closed as described above for a DIEP ap, and two drains are
inserted. These are removed only when drainage is less than
20 mL/24 hours.

Clinical Cases
DIEP Case
A 38-year-old patient had left mastectomy followed by radiotherapy
and chemotherapy (Fig. 15.35). She had a DIEP ap breast recon-
struction harvested from the right side (contralateral side to mas-
tectomy). Four months later, nipple reconstruction with right breast
remodelling was performed to create breast symmetry (Fig. 15.36).
SIEA Case
A 46-year-old patient who underwent left mastectomy
(Fig. 15.37). No adjuvant therapy was given. A SIEA ap was done
and, 3 months later, patient had a nipple reconstruction under
local anesthesia (Fig. 15.38).

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
207
Fig. 15.35 (a–c) Preoperative views of DIEP patient.
a
b
c
Fig. 15.36 (a–c) Postoperative views of DIEP patient.
a
b
c

208
II Reconstructive Flaps A-to-Z
Fig. 15.38 (a–c) Postoperative views of SIEA patient.
a
b
c
Fig. 15.37 (a–c) Preoperative views of SIEA patient.
a
b
c

15 DIEP Flaps and SIEA Flaps for Breast Reconstruction
209
Hamdi M, Weiler-Mitho EM, Webster MH. Deep inferior epigastric
perforator ap in breast reconstruction: experience with the rst
50 aps. Plast Reconstr Surg. 1999;103(1):86–95
Hamdi M, Wol i J, Van Landuyt K. Partial mastectomy reconstruction.
Clin Plast Surg. 2007;34:51–62
Hartrampf CR, Sche an M, Black PW. Breast reconstruction with a
transverse abdominal island ap. Plast Reconstr Surg. 1982;69(2):
216–225
Heitm ann C, Felmerer G, Durmus C, et al. Anatom ical features of perfora-
tor blood vessels in the deep inferior epigastric perforator ap. Br J
Plast Surg. 2000;53:205–208
Heller L, Feledy JA, Chang DW. Strategies and options for free TRAM ap
breast reconstruction in patients with midline abdominal scars.
Plast Reconstr Surg. 2005;116:753–759
Holm C, Mayr M, Hofter E, Ninkovic M. Perfusion zones of the DIEP
ap revisited: a clinical study. Plast Reconstr Surg. 2006;117(1):
37–43
Kikuchi N, Murakami G, Kashiwa H, et al. Morphom etrical study of the
arterial perforators of the deep inferior epigastric perforator ap.
Surg Radiol Anat. 2001;23:375–381
Koshim a I, Soeda S. Inferior epigastric artery skin aps without rectus
abdominis muscle. Br J Plast Surg. 1989;42(6):645–648
Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row computed
tom ography in the planning of abdom inal perforator aps. J Plast
Reconstr Aesthet Surg. 2006;59(6):594–599
Mehrara BJ, Santoro T, Smith A, et al. Alternative venous out ow ves-
sels in microvascular breast reconstruction. Plast Reconstr Surg.
2003;112(2):448–455
Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities
of the abdomen after breast reconstruction with abdom inal aps:
the role of muscle preservation. Plast Reconstr Surg. 2002;109(1):
91–101
Nahabedian MY, Momem B, Galdino G, et al. Breast reconstruction with
the free TRAM or DIEP ap: patient selection, choice of ap, and
outcome. Plast Reconstr Surg. 2002;110:466–475
Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the
DIEP ap or the m uscle-sparing (MS-2) free TRAM ap: is there a
di erence? Plast Reconstr Surg. 2005;115(2):436–444; discussion
445–446
Nahabedian MY. De ning the “gold standard” in breast reconstruction
with abdominal tissue. Plast Reconstr Surg. 2004;114(3):804–806
Nahabedian MY. The internal mam mary artery and vein as recipient ves-
sels for microvascular breast reconstruction: are we burning a fu-
ture bridge? Ann Plast Surg. 2004;53(4):311–316
Reardon CM, O’Ceallaigh S, O’Sullivan ST. An anatom ical study of the
super cial inferior epigastric vessels in humans. Br J Plast Surg.
2004;57(6):515–519
Taylor GI, Daniel RK. The anatomy of several free ap donor sites. Plast
Reconstr Surg. 1975;56(3):243–253
Figure Credits
1. Jones GE, Bostwick J. Bostwick’s Plastic & Reconstructive Breast Sur-
gery. 3rd ed. St. Louis, MO: Quality Medical Pub.; 2010
2. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
Suggested Further Reading
Allen RJ, Heitland AS. Super cial inferior epigastric artery ap for breast
reconstruction. Semin Plast Surg. 2002;16(1):35–44
Allen RJ, Treece P. Deep inferior epigastric perforator ap for breast recon-
struction. Ann Plast Surg. 1994;32(1):32–38
Arnez ZM, Khan U, Pogorelec D, et al. Breast reconstruction using the
free super cial inferior epigastric artery (SIEA) ap. Br J Plast Surg.
1999;52(4):276–279
Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbid-
ity of free DIEP aps and free TRAM aps for breast reconstruction.
Br J Plast Surg. 1997;50(5):322–330
Blondeel P. One hundred free DIEP ap breast reconstructions: a personal
experience. Br J Plast Surg. 1999;52:104–111
Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and
blood ow in free transverse rectus abdom inis myocutaneous
and deep inferior epigastric perforator aps. Plast Reconstr Surg.
2000;106:1295–1299
Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler owm etry in the plan-
ning of perforator aps. Br J Plast Surg. 1998;51(3):202–209
Chang DW, Reece GP, Wang B, et al. E ect of smoking on complications
in patients undergoing free TRAM ap breast reconstruction. Plast
Reconstr Surg. 2000;105:2374–2380
Chevray PM. Breast reconstruction with super cial inferior epigastric
artery aps: a prospective comparison with TRAM and DIEP aps.
Plast Reconstr Surg. 2004;114(5):1077–1083
El-Mrakby Hamdy H, Milner RH. The suprafascial course of the direct
paraumbilical perforator vessels. Plast Reconstr Surg. 2002;109:
1766–1768
El-Mrakby Hamdy H, Milner RH. The vascular anatomy of the lower ante-
rior abdom inal wall: a microdissection study on the deep inferior
epigastric vessels and the perforator branches. Plast Reconstr Surg.
2002;109:539–543
Feller AM. Free TRAM. Results and abdom inal wall function. Clin Plast
Surg. 1994;21(2):223–232
Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison
of abdom inal muscle strength following breast reconstruction with
a free TRAM or DIEP ap. Br J Plast Surg. 2000;53(7):578–583
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
Grotting JC. The free abdominoplasty ap for immediate breast recon-
struction. Ann Plast Surg. 1991;27(4):351–354
Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choos-
ing recipient vessels for perforator free ap in breast reconstruc-
tion: the role of the internal m am mary perforators. Br J Plast Surg.
2004;57(3):258–265
Hamdi M, Blondeel P, Van Landuyt K, Tondu T, Monstrey S. Bilateral au-
togenous breast reconstruction using perforator free aps: a single
center’s experience. Plast Reconstr Surg. 2004;114(1):83–89
Hamdi M, Khuthaila D, Van Landuyt K, et al. Double-pedicle abdominal
perforator free aps for unilateral breast reconstruction: new hori-
zons in microsurgical tissue transfer to the breast. J Plast Reconstr
Aesthet Surg. 2007;60(8):904–912
Hamdi M, Van Landuyt K, Van Hedent E, Duyck P. Advances in autogenous
breast reconstruction: the role of preoperative perforator mapping.
Ann Plast Surg. 2007;58(1):18–26

210
Deltopectoral Flaps for Head and
Neck Reconstruction
Rowan D. Gillies and Pouria Moradi
16

Classif cation

●
Mathes and Nahai type C fasciocutaneous ap; originally de-
scribed by Bakamjian in 1965 for pharyngeal reconstruction

Vascular Pedicle
The deltopectoral ap is based on the perforating branches of the
internal m am mary artery arising through the second, third, and
fourth intercostal spaces.

Patient Positioning
The patient can be positioned supine or lateral depending on re-
constructive requirements.

Surface Markings
The perforators are presumptively marked 3 to 4 cm lateral to the
anterior sternal midline in the second, third, and fourth intercostal
spaces. The upper incision is parallel and 2 cm inferior to the clav-
icle; the lower incision commences inferior to the fourth inter-
costal space. It extends to the superior border of the axillary fold,
which, due to excess skin in the area, makes the pivot point of this
ap the base of the upper incision, not the lower one when being
transposed superiorly.
The ap length is reliable to a few centim eters beyond the
deltopectoral groove, and the author routinely raises it to the tip
of the shoulder without delay, with a low rate of distal necrosis.

Raising the Flap
Step 1
Incisions are made along the upper and lower borders of the ap,
through the fascia of the pectoralis muscle (Fig. 16.1).
Step 2
The distal edge of the ap is incised, and the ap is raised in a retro-
grade fashion deep to the pectoralis fascia. This can be safely done
with monopolar diathermy until 2 cm lateral to the marked per-
forators. There is a constant perforator from the thoracoacromial
access that arises through the clavipectoral fascia that requires
division during elevation (Fig. 16.2).
Step 3
Dissection continues carefully until the perforators are identi ed.
Step 4
Extra length can be obtained by dissecting out the perfora-
tors and by extending the skin incisions toward the m idline
(Fig. 16.3).
Step 5
The ap can be tunnelled with a de-epithelized segm ent, used
as a tubed pedicle, or most commonly inset directly to the neck
defect (Fig. 16.4).
Step 6
In the elderly, with wide undermining, the defect can be closed
primarily; otherwise, it is closed with a split skin graft.
Delay
The ap can be delayed, with the best technique being to access
the constant perforator from the thoracoacrom ial access de-
scribed earlier through a short incision in line with the planned
superior incision. If this perforator is present, then its ligation is
su cient for appropriate delay. If not, the whole ap area distal
to the deltopectoral groove may need elevation.

16 Deltopectoral Flaps for Head and Neck Reconstruction
211
Fig. 16.2 Flap based on second and third space perforators.
Fig. 16.1 Superior and inferior incisions through the fascia of the pectoralis muscle.

212
II Reconstructive Flaps A-to-Z
Fig. 16.3 The body habitus of this man allowed  ap reach to the midface without delay. Flap raised to the tip of the 
shoulder.
Fig. 16.4 Flap inset to neck defect with primary closure of donor site. Note darts on  ap edge to break up vertical neck 
wound.

16 Deltopectoral Flaps for Head and Neck Reconstruction
213
Fig. 16.5 Flap tubed and inset to defect.
largest. It is an important lifeboat and should be preserved when
raising a pectoralis major ap in head and neck reconstruction.
Suggested Further Reading
Bakamjian VY. A two-stage method for pharyngoesophageal recon-
struction with a prim ary pectoral skin ap. Plast Reconstr Surg.
1965;36:173–184
Corm ack GC, Lamberty BGH. The Arterial Anatomy of Skin Flaps. 2nd ed.
London: Churchill Livingstone; 1994

Clinical Perspectives
This ap provides excellent skin for neck lining and can routinely
reach to the mastoid process (Fig. 16.5). It can be used as a tubed
pedicle for lower third of face defects; however, its reach is variable
depending on the body habitus of the patient and the employ-
ment of delay techniques. It can be raised on two of the three per-
forators, the one at the second intercostal space usually being the

214
Fibula Osteoseptocutaneous Flaps
Christopher G. Wallace and Fu-Chan Wei
17

Classif cation

●
Mathes-Nahai type V

Vascular Pedicle
The bula has a segm ental periosteal and an endosteal blood
supply from the peroneal vessels (Fig. 17.1a,b). Septocutaneous
vessels arising from the peroneal vessels pass along the posterior
crural septum to the skin of the lateral leg (Fig. 17.1a). Addition-
ally, musculocutaneous perforators that usually pass through the
soleus muscle may supply the skin paddle.

●
Mean arterial caliber: 1.5 to 2.5 mm

●
Mean venous caliber: 2 to 3 mm

●
Length: approximately 6 cm, but can be increased signi -
cantly according to ap design

●
Sensory innervation: lateral branch of the sural cutaneous
nerve can be harvested to provide a sensate skin paddle

Patient Positioning
Supine. Flex the knee to 90 degrees when marking out and dis-
secting the ap. Place a sandbag or other xed support under the
heel and sole of the foot to help maintain this position.

Order of Dissection
The parts of Fig. 17.1 (a schematic of a bula osteoseptocutane-
ous ap harvest) and Fig. 17.2 (a complete clinical photographic
series of a bula osteoseptomyocutaneous ap harvest) are re-
ferred to interchangeably for clarity when describing ap design
and ap harvest. Note that this ap can be harvested using the
anterior approach or the posterior approach, and both options
are covered herein. The surgical steps in the anterior approach
are as per the order of the clinical photographic series (Fig. 17.2);
the surgical steps in the posterior approach are as per the order
of the description in the text here.

Surface Markings
1. Mark the posterior border of the bula bone with black indel-
ible pen (Fig. 17.2a).
2. Mark the proximal and distal lim its of the bula and then
mark its anterior margin.
3. Shade the proximal and distal 6 cm of the bone; these shaded
portions of the bone will not usually be harvested so that
ankle and knee stability can be preserved safely (Fig. 17.2a).
a
Fig. 17.1 Schematic illustration of a  bula osteoseptocutaneous  ap 
design and harvest. (a) Anatomic diagram of the peroneal artery: 1, pop-
liteal artery; 2, posterior tibial artery; 3, peroneal artery; 4, anterior  tibial 
artery; 5, nutrient artery of  bula; 6, septocutaneous vessels; 7,  exor 
 hallucis longus muscle; 8, popliteal muscle. (continued)

17 Fibula Osteoseptocutaneous Flaps
215
b
c
d
Fig. 17.1 (continued) (b) Anatomic relationships of the peroneal artery: 1, popliteal artery; 
2, posterior tibial artery; 3, peroneal artery; 4, anterior tibial artery; 7,  exor hallucis lon-
gus muscle; 8, popliteal muscle; 9, tibialis posterior muscle; 10, soleus muscle; 11,  exor 
digitorum longus muscle; 12, peroneus longus. (c) Surface marking of the posterior crural 
septum. (d) Flap designed elliptically along the posterior crural septum and centered over 
dominant arterial Doppler signals. (e) Approach to the posterior crural septum: 1, soleus and
gastrocnemius muscles; 2, septocutaneous vessels; 7, extensor muscle; 8, peroneus longus 
and brevis muscles. (continued)
e

216
II Reconstructive Flaps A-to-Z
f
Fig. 17.1 (continued) (f) Proximal and distal osteotomies, 
and dissection of the peroneal vessels: 3,  exor hallucis 
 longus muscle; 4,  bula bone; 5, peroneal artery and vein; 
6, posterior tibial artery and vein, and tibial nerve. (g) Com-
pletion of the osteoseptocutaneous  ap: 5, peroneal artery 
and vein; 6, posterior tibial artery and vein, and tibial nerve; 
8, peroneus longus and brevis muscles; 9, cut interosseous
membrane. (h) Cross-sectional diagram showing the path-
way of dissection for a  bula osteoseptocutaneous  ap: 
1, soleus and gastrocnemius muscles; 2, septocutaneous 
vessels arising from the peroneal artery and vein; 3,  exor 
hallucis longus muscle; 4,  bula bone; 5, peroneal artery 
and vein; 6, posterior tibial artery and vein, and tibial nerve; 
7, extensor muscle; 8, peroneus longus and brevis muscles; 
9, cut interosseous membrane.1
g
h

17 Fibula Osteoseptocutaneous Flaps
217
a
b
c
d
e
f
Fig. 17.2 Photographic illustration of a  bula osteoseptomyocutaneous  ap design and harvest; all images are from one operation. (a) Preoperative 
markings. (b) Anterior elevation proceeds suprafascially until beyond the peroneal tendons; in this example, the surgeon continues dissection in the 
anterior incision before turning attention to the posterior margin of the  ap. (c) After reaching the lateral septum, the lateral compartment is dissected 
o  the  bula. (d) The anterior septum is incised to access the anterior compartment. (e) The posterior incision is made next; note that the sural nerve 
(under the tip of the scissors) is identi ed and protected. (f) The posterior compartment is dissected away from the posterior crural septum. (continued)

218
II Reconstructive Flaps A-to-Z
g
h
i
j
k
l
Fig. 17.2 (continued) (g) Septocutaneous vessels supplying the skin paddle. (h) The distal osteotomy is performed  rst, followed by the proximal os-
teotomy. (i) Careful incision through the interosseous membrane. (j) Ligation of the distal peroneal vessels. (k) Unroo ng the peroneal vessels. (l) The
exor hallucis longus is dissected away from the vessels while protecting the posterior crural septum with the left index  nger. (continued)

17 Fibula Osteoseptocutaneous Flaps
219
paddle because it is not guaranteed until dissection and direct
visualization that the chosen signal arises from the peroneal ar-
tery (they may arise from the posterior or anterior tibial arteries).
8. The ap can be designed in an elliptical shape with its long
axis running along the posterior crural septum (Fig. 17.1d;
Fig. 17.2a). Posteriorly, it is preferable not to include skin be-
yond the m idline of the calf. If the skin donor defect is less
than 4 cm wide, it can usually be closed without a skin graft.

Raising the Flap
Step 1: Prepare the Limb
Surgical loupes are used throughout the dissection of this ap.
Elevate the limb and exsanguinate it incompletely. If the limb is
thoroughly exsanguinated, then visualization of the small vessels
supplying the skin paddle is di cult. Apply a mid-thigh tourniquet.
Step 2: Anterior Incision
It is our preference to commence dissection at the anterior mar-
gin of the skin paddle (Fig. 17.2b). Begin the incision with a
scalpel down to deep dermis. Monopolar pin diathermy is then
In addition, the proxim al lim it to bone harvest helps protect
the peroneal nerve winding around the bula neck deep to
peroneus longus.
4. Divide the full length of the bula into equal thirds (note the
two short m arks that divide the bula into thirds on the pos-
terior border of the bone in Fig. 17.2a).
5. Apply the handheld Doppler to the posterior border of the
bula at the junction between the middle and distal thirds.
Search for arterial signals arising from immediately poste-
rior to the bula margin. Search throughout the distal third
(but not behind the shaded portion of the bone) and the mid-
dle third for arterial signals as necessary (Fig. 17.2a). If signals
are di cult to pick up, try searching slightly m ore posterior
to the bone. Note that the posterior crural septum provides
a surface m arking (indicated in Fig. 17.1c) in most patients
where it indents the lateral calf.
6. Mark the strongest arterial signals with large red spots using an
indelible marker pen and weaker signals with small red dots.
7. Select the dominant arterial signal(s) and plan the ap around it/
them (Fig. 17.1d; Fig. 17.2a). One or two sizeable septocutane-
ous branches can usually be expected to support a ap of up to
14 cm in width and up to 25 cm in length when centered at the
junction of the middle and distal thirds of the bula. It is import-
ant to incorporate more than one arterial signal within the skin
m
o
n
Fig. 17.2 (continued) (m) Muscle bulk is required for this harvest, and so 
the consistent branch to the soleus muscle (indicated by the tip of the 
scissors) from the peroneal vessels is preserved and skeletonized in chi-
meric fashion to maximize movement of the muscle strip during insetting. 
(n) The soleus within the territory of the muscular branch is harvested. 
(o) The  bula osteoseptocutaneous free  ap with chimeric soleus ready 
for transfer.

220
II Reconstructive Flaps A-to-Z
should be sacri ced without careful consideration. Temporary
tourniquet release may be required to con rm that adequate
blood supply to the skin paddle is provided by the septocutane-
ous vessels by applying microvascular clamps to the musculocu-
taneous perforators. If no septocutaneous vessels were identi ed
during dissection or their supply to the skin paddle is deemed
to be inadequate, these musculocutaneous perforators must be
dissected back farther to con rm their origins from the peroneal
vessels. The process of raising a peroneal vascularized paddle is
therefore not prescriptive and requires som e exibility during
dissection. Intramuscular perforators can be sacri ced if the sep-
tocutaneous vascular supply is adequate; this improves mobility
of the skin island during inset.
Step 5: Detach Muscles from
the Fibula
(Note: This step can instead be performed before Step 3 when
using the anterior approach.)
Return to the anterior incision and use a scalpel to elevate
the lateral (peroneal) and anterior compartment m uscles o the
bula, taking care to leave at least a 1 m m deep layer of muscle
on the periosteum (i.e., do not strip the periosteum completely of
muscle bers; Fig. 17.2c,d).
Step 6: Osteotomies
Perform the distal osteotomy rst (Fig. 17.2h). Mark the level
of the planned osteotomy and incise the periosteum perpendic-
ular to the axis of the bone. Elevate the periosteum distal and
proxim al to this incision for approxim ately 5 m m on each side.
Pass a w ide, low-pro le retractor around the bone at the level
of the planned osteotomy so that it passes from anterior to the
bula, behind the bula, and then em erges at the posterior edge
of the bula. The retractor m ust be intim ately abutted to the
cortex of the bone; otherw ise the peroneal vessels m ay be dam -
aged. Perform this osteotomy under copious irrigation and while
protecting adjacent soft tissues (Fig. 17.2h). Now complete the
proxim al osteotomy using the sam e technique. This frees the
bula so that it can be gently rotated out of the leg to facilitate
further dissection.
Step 7: Divide the Interosseous
Membrane and Continue
Detaching Muscles from
the Fibula
While rotating the fibula w ith bone graspers, the interosseous
m em brane com es into view (Fig. 17.2i). Carefully divide the
m em brane and detach the posterior tibial m uscle in sim ilar
fashion. Identify and protect the posterior tibial and peroneal
neurovascular bundles (Fig. 17.1f). Ligate the peroneal ves-
sels just distal to the distal osteotomy so that the bone can
slowly be elevated out of the lim b w ith subsequent dissection
(Fig. 17.2j).
used to deepen the incision into the super cial subcutaneous fat.
Now use bipolar diathermy to ligate suprafascial vessels at the
periphery of the skin paddle. Return to using the scalpel and
deepen the incision to the fascia, but do not penetrate the fas-
cia yet. Dissect suprafascially toward the posterior crural septum
and incise the fascia im mediately posterior to the peroneal ten-
dons so that the tendons rem ain covered (Fig. 17.2b) and to im -
prove skin graft take when required. Continue re ecting the skin
paddle subfascially until the posterior crural septum is reached.
Protect all vessels entering the skin paddle. At the posterior cru-
ral septum, the septocutaneous vessel(s) supplying the paddle
w ill com e into view, traveling within the septum . If adequate
septocutaneous blood supply to the skin paddle is identi ed
(corresponding to the handheld Doppler exam ination), turn your
attention to the posterior margin of the ap.
If a blood supply to the skin paddle is not identi ed within
the posterior crural septum, check again the position of the red
spot/dots that were m arked during Doppler exam ination. These
may correspond instead to musculocutaneous perforators enter-
ing the skin paddle from posterior to the posterior crural septum
(in which case, intram uscular dissection in Step 4 will be neces-
sary). Note that if they correspond to vessels arising anterior to
the posterior crural septum (originating from the anterior tibial
artery) they will fail to support the skin paddle in a bula osteo-
septocutaneous ap and thus should be sacri ced.
Note that, at this stage, some surgeons prefer to continue
dissecting in the anterior incision (anterior approach) according
to Step 5 and then return to Step 3 (as per the order of the parts
of Fig. 17.2). Otherwise, continue to Step 3 using the posterior
approach as below.
Step 3: Posterior Incision
Perform the incision at the posterior m argin of the skin paddle in
the sam e fashion. Protect the sural nerve (Fig. 17.2e, as indicated
by the scissor tips), short saphenous vein, and any vessels enter-
ing the skin paddle. Deepen this incision through fascia as there
are no tendons here to keep covered with fascia. Continue the
subfascial dissection in an anterior direction until the posterior
aspect of the posterior crural septum comes into view (Fig. 17.1e;
Fig. 17.2f). Do not damage intramuscular vessels if encountered
during your approach to the posterior surface of the posterior
crural septum (Fig. 17.2f,g). Do not damage or shear the septum
as the septocutaneous vessels passing within it arise from the pe-
roneal pedicle (Fig. 17.2g).
Step 4: Decide Whether
Intramuscular Vessels Are
Required to Supply the Skin
Paddle and, If So, Ensure
That They Arise from the
Peroneal Vessels
Dissect any musculocutaneous perforators in retrograde fash-
ion for at least 2 cm. Attention to con rm ing the blood supply to
the skin paddle must be m aintained at all tim es, and no vessels

17 Fibula Osteoseptocutaneous Flaps
221

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Always include a skin paddle with this ap. If the skin pad-
dle is raised purely as a monitor, make it thin enough so
that the donor site can be closed directly.

●
Harvest the entire bula bone except for the distal and
proximal 6 cm.

●
The peroneal vessels
Identi ed and preserved:

●
Fascia overlying the peroneal tendons

●
Sural and peroneal nerves

●
Do not dam age the neurovascular supply in particular to
the exor hallucis longus.

●
All muscles are preserved when harvesting a classical osteo-
septocutaneous bula ap (Fig. 17.1). If a small amount of
muscle bulk is required for the reconstruction, a strip of the
soleus can be included in chimeric fashion based on a rela-
tively constant branch from the peroneal vessels (Fig. 17.2).

Clinical Perspectives
The bula osteoseptocutaneous ap can be transferred free or
pedicled and can provide up to 25 cm of vascularized bone in
adults. It is most frequently used for composite bone reconstruc-
tion in the head and neck, such as for the m andible (Fig. 17.3)
and maxilla, and for long bone reconstruction in the extremities.

Hints and Tips
Ensure meticulous hemostasis throughout to optimize visibility
during dissection and reduce blood loss upon tourniquet de ation.
Do not strip the bula of muscle bers; this muscle cu helps pre-
serve the delicate periosteal blood supply. Always include a skin
paddle with the bula. Even when this paddle is not required for the
reconstruction, it provides a sentinel monitor of bula vascularity
and facilitates soft tissue closure at the recipient site. Take partic-
ular care to preserve the blood and nerve supplies for the exor
hallucis muscle and when reattaching it after bula harvest; other-
wise the patient may su er loss of great toe exion or, conversely,
exion contracture of the great toe. If any tension exists upon direct
closure of the donor site, opt for a skin graft closure; compartment
syndrome following bula harvest has been reported.
Step 8: Retrograde Pedicle
Dissection
The pedicle is now dissected from distal to proxim al, ligating
any branches of the peroneal vessels that do not supply the com -
posite ap tissues (Fig. 17.2k). Finally, the exor hallucis longus
muscle is dissected from the bula (Fig. 17.2l). Care should be
taken to avoid injury to the vessel supplying the skin paddle
as it may have a short intramuscular course through the exor
hallucis longus muscle. The bone and its pedicle w ill slowly rise
out of the wound as it is freed (Fig. 17.1g). It m ay be necessary
to lengthen the incision proximally to facilitate further dissec-
tion of the pedicle toward its origin if additional length is re-
quired. Note that the illustrations of Fig. 17.1 illustrate harvest
of an osteo septocutaneous ap; Fig. 17.1h shows a cross-section
of the pathway of dissection. The clinical ap harvest shown in
Fig. 17.2 proceeded to include a portion of soleus m uscle for re-
constructive purposes based on a muscular branch arising from
the peroneal vessels (Fig. 17.2m,n), which can be om itted if
muscle is not required.
Step 9: Check Flap Vascularity
Once ap elevation is complete, return the bula to its approx-
imate anatom ical location and drape the skin paddle in place.
Cover the ap with saline-damp gauze. Release the tourniquet
with the limb in supine position and check the circulation to the
skin paddle and to the distal end of the harvested bula bone.
Loosely w rap the limb with a bandage and allow the ap to rest
for at least 20 minutes; after this period, ensure ap circulation
is normal before transecting the pedicle. Ligate the pedicle ves-
sels securely at the chosen level and divide sharply with scissors
2 mm distal to this; it is not necessary to ligate the vessels on the
ap side (Fig. 17.2o).
Step 10: Donor Site Closure
Meticulous completion hem ostasis at the donor site proceeds
w hen the ap has been rem oved. Once hem ostasis has been
secured, the exor hallucis longus m uscle is reattached to the
interosseous m em brane and posterior tibialis m uscle w ith ab-
sorbable 4-0 suture. A suction drain m ay be required. The do-
nor site of a skin paddle w ith a w idth of 4 cm can usually be
closed directly w ith acceptable tension using derm al and skin
sutures. Wider skin paddle donor sites w ill usually require a
skin graft.

222
II Reconstructive Flaps A-to-Z
Fig. 17.3 Long-term outcome of compound segmental mandibular de-
fect reconstruction using a free  bula osteoseptocutaneous  ap and reha-
bilitation with secondary osseointegrated dental implants; all images are 
from one patient. (a) Right buccal cancer involving the sulcus and gingiva; 
mandibular invasion was noted on imaging. (b) Segmental mandibular re-
section, leaving a compound defect (oral lining, mandible, and dentition). 
(c) Occlusional result following complete dental rehabilitation at 2-year 
follow-up. (d,e) No  exion loss or contracture in any of the toes at 2 years. 
(f) Cosmesis at 2 years.
a
b
c
d
f
e

17 Fibula Osteoseptocutaneous Flaps
223
Wei FC, Chen HC, Chuang CC et al. Fibular osteoseptocutaneous ap:
anatomic study and clinical application. Plast Reconstr Surg. 1986;
78:191–200
Wei FC, Seah CS, Tsai YC et al. Fibula osteoseptocutaneous ap for recon-
struction of composite m andibular defects. Plast Reconstr Surg.
1994;93:294–304
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and
Operative Approaches. 2nd ed. New York, NY: Thieme; 2006
Suggested Further Reading
Hidalgo DA. Fibula free ap: a new m ethod of mandible reconstruction.
Plast Reconstr Surg. 1989;84:71–79
Lutz BS, Wei FC, Ng SH, et al. Routine donor leg angiography before vas-
cularized free bula transplantation is not necessary: a prospective
study in 120 clinical cases. Plast Reconstr Surg. 1999;103:121–127
Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clini-
cal extension of m icrovascular techniques. Plast Reconstr Surg.
1975;55:533–544
Wallace CG, Chang YM, Tsai CY, Wei FC. Harnessing the potential of the
free bula osteoseptocutaneous ap in m andible reconstruction.
Plast Reconstr Surg. 2010;125:305–314

224
Gastrocnemius Muscle Flaps for Lower
Limb Reconstruction
Duncan Atherton, Pouria Moradi, Shehan Hettiaratchy, and Jagdeep Nanchahal
18

Classif cation
The gastrocnem ius ap is a Mathes and Nahai type I ap and
was originally described by Ger (1971). Each muscle head is
considered a separate unit for the purposes of ap design and
utilization.

Vascular Pedicle
The m edial and lateral heads of the gastrocnem ius m uscle have
independent vascular supplies. The pedicle of the medial gas-
trocnem ius head is from the m edial sural artery and its venae
comitantes and the lateral head is via the lateral sural artery.
Both vessels take origin from the popliteal artery with a pedicle
length of around 2.6 cm for the medial sural artery and a caliber
of 1.4 mm for both the artery and vein. Either muscle belly can
be used; raising of the medial head is illustrated in the following
text (Fig. 18.1a).

Patient Positioning
The patient can be positioned supine or prone depending on the
required arc of rotation and nal ap location—usually in the
supine position with hip exed and externally rotated and knee
partly exed is su cient.

Surface Markings
A line is marked just medial to the midline for the medial head
(Fig. 18.1b). This approxim ates to the underlying raphe separat-
ing the two heads of the muscle, but allows easier access than a
standard midline incision and avoids the sural nerve. The m edial
malleolus and popliteal crease are also indicated.

Raising the Flap
Step 1
The incision is m ade as m arked in the posterior param idline and
carried down through the underlying fascia. The short saphenous
vein and sural nerve are also found in the m idline and should be
identi ed and protected (Figs. 18.1b-f and 18.2).
Step 2
The deep surface of the m edial gastrocnem ius m uscle is identi-
ed in the proxim al third of the leg where the m uscle is easily
separated from the underlying soleus muscle. The natural plane
between the muscles allows an easy separation of the muscles
along the medial border of the gastrocnemius.
Step 3
The deep surface of the m edial gastrocnem ius ap is inspected
to visualize the raphe between the two heads. Once that is
established, sharp dissection is perform ed to separate the
two heads and the ap is m obilized superiorly in this plane
(Fig. 18.3).
Step 4
The dissection proceeds inferiorly until the junction of the m us-
cle belly with the Achilles tendon. The m uscle belly is freed from
the Achilles tendon, leaving a 1-cm cu on the m uscle ap to aid
insetting (Fig. 18.4).
Step 5
The m obilized ap can now be passed through a subcutaneous
tunnel to cover the defect (Fig. 18.5). A split-thickness skin graft
is used over the top of the muscle for wound closure.
Step 6
The donor site is closed directly.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Medial head of gastrocnemius muscle
Identi ed and preserved:

●
Short saphenous vein

●
Sural nerve

●
Medial sural artery and venae comitantes

18 Gastrocnemius Muscle Flaps for Lower Limb Reconstruction
225
a
Fig. 18.1 (a) Anatomic diagram of the gastrocnemius and its blood supply: 1, Medial head
of gastrocnemius; 2, lateral head of gastrocnemius; 3, Achilles tendon; 4, popliteal artery;
5, medial sural artery; 6, lateral sural artery; 7, soleus muscle; 8, plantaris; 9, tibial muscle;
10, common peroneal nerve. (b) Surface markings for the gastrocnemius ap. A dorsal para-
midline incision is marked along with the medial malleolus and popliteal crease. (continued)
b

226
II Reconstructive Flaps A-to-Z
Fig. 18.1 (continued) (c) Anatomy of the popliteal fossa and neurovascular structures related to the gastrocnemius muscle: 1, Medial head of
gastrocnemius muscle; 2, lateral head of gastrocnemius muscle; 3, lesser saphenous vein and medial sural nerve; 4, popliteal artery and vein and tibial
nerve. (d) Identifying the neurovascular bundle to the medial head of the muscle: 1, Medial head of gastrocnemius muscle; 4, popliteal artery and vein
and tibial nerve; 5, soleus muscle; 6, medial sural artery and vein and muscular branch of tibial nerve; 7, plantaris muscle. (continued)
c
d