Flaps Practical Reconstructive Surgery

378
II Reconstructive Flaps A-to-Z
Fig. 32.6 Magni ed view of intercostal perforating branches of the right 
internal mammary vessels.
Fig. 32.7 (a) Marking of proposed myotomy site for split pectoralis
muscle  ap. (b) Myotomy performed.
a
b
composite myocutaneous pectoralis m ajor ap o the underly-
ing chest wall (Fig. 32.9). In order to increase muscle excursion,
the surgeon m ay raise the skin aps o the anterior surface of
the muscle.
Step 10: Insetting the
Advancement Flap
Medially advance and inset the myocutaneous ap(s) into
the sternal defect. Secure the ap(s) with absorbable suture
(Fig. 32.10).
Step 11: Drain Placement
Place 19-French round channeled drains in the donor site defect.
Bring the drain out through a separate stab incision and secure it
with a standard drain suture.
Step 12: Split-Thickness Skin
Grafting
Perform split-thickness autografting at this stage if there is no
dermal coverage of the newly inset muscle ap.

32 Pectoralis Major Muscle Flaps
379
Step 13: Donor Site Closure
Close the incision in multiple layers (Fig. 32.11).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required muscle ap

●
Dominant supplying vascular pedicle(s)

●
Overlying skin if utilizing a myocutaneous ap
Identi ed and preserved:

●
Identify and divide branches of medial and lateral pectoral
nerves

●
Pectoralis minor

●
Lateral thoracic artery

●
Cephalic vein in deltopectoral groove (identify and ligate
if performing pectoralis major turnover ap) (Fig. 32.12).

Clinical Perspectives
The pectoralis m ajor ap is one of the m ost com m only employed
aps in plastic surgery. It is a well-described ap option for coverage
of head and neck defects and chest wall closure. It is usually
transferred as a pedicled muscle ap. Variations are discussed
Fig. 32.8 Split turnover pectoralis major muscle  ap is rotated into defect.
Fig. 32.9 Pectoralis major myocutaneous  ap raised o  chest wall.
Fig. 32.10 Pectoralis major myocutaneous  ap is advanced into wound.

380
II Reconstructive Flaps A-to-Z
Fig. 32.11 Wound is primarily closed with closed suction drains placed.
Fig. 32.12 The cephalic vein courses in the deltopectoral groove: 1, deltoid muscle; 2, sternal head of
pectoralis major; 3, clavicular head of pectoralis major; 4, cephalic vein.1

32 Pectoralis Major Muscle Flaps
381
above and include: advancement aps, turnover aps, split turn-
over aps, and osteocutaneous aps. Other common indications
for the pectoralis muscle ap use include: breast reconstruction,
breast augmentation, thoracic reconstruction, tracheopharyngeal
reconstruction, pacemaker coverage, intrathoracic defects, and
upper extremity reconstruction (Fig. 32.13).
Flap Variations
1. Pectoralis myocutaneous advancement aps are employed
for m idline sternum reconstruction and head and neck re-
construction. The patients undergoing this type of chest wall
reconstruction have generally previously undergone a mid-
line sternotomy for cardiac surgery. In cases of head and neck
reconstruction, large soft tissue and skin defects can be re-
constructed with these reliable aps. The aps are raised as
myocutaneous aps o of the underlying chest wall. This ap
is a good option for critically ill patients, because the aps can
be raised expeditiously. Furthermore, the aps are depend-
able, because the skin is not separately elevated o the muscle.
2. Pectoralis major turnover aps are employed for midline sternum
reconstruction. The indications are similar for which advancement
aps are utilized; however, prior thoracic surgery can preclude
this procedure’s use. Speci cally, use of the internal mammary
vessels for cardiac bypass grafting implies the perforating blood
supply to the muscle ap has been disrupted. Harvesting a turn-
over muscle ap requires dividing the humeral insertion of the
muscle and ligating the dominant pedicle. Transferring a turnover
muscle ap in a patient with previous ipsilateral internal mam-
mary vessel harvest would result in a vascularly compromised
ap. Split muscle turnover aps are described.
3. The pectoralis major osteomyocutaneous ap is well de-
scribed for reconstructing composite defects of the mandible.
This ap is a good option for patients who cannot undergo
free tissue transfer, for defects too large for nonvascularized
bone grafts, and for salvage of free tissue transfer (Fig. 32.14).

Hints and Tips

●
This m uscle is generally not transferred as a free tissue
transfer due to a short pedicle length and is not generally
used in women (i.e., aesthetic considerations due to prox-
imity to the breast).
Fig. 32.13 Pectoralis major osteomyocutaneous  ap: 1, pectoralis major muscle; 2, pectoralis
minor muscle; 3,  fth rib; 4, lateral thoracic artery and vein; 5, pectoral branch of thoracoacro-
mial artery and vein; 6, clavicular head; 7, deltoid muscle; 8, pleura; 9, intercostal muscle.1

382
II Reconstructive Flaps A-to-Z
b
d
Fig. 32.14 A 45-year-old diabetic man with left internal mammary vessel sacri ce after cardiac bypass surgery. (a) Patient presented with postopera-
tive wound infection and sternal dehiscence. (b) Sternal debridement. (c) Disinsertion of right pectoralis major muscle. (d) Turnover and inset of  ap 
into sternal wound. (continued)
a
c

●
The surgeon should wear a headlamp.

●
Autom atic vascular clip appliers facilitate e cient
hemostasis.

●
The loss of the pectoralis m uscle has m inim al functional
consequences, especially if any segm ent of the m uscle is
preserved. It is not entirely dispensable, however, and the
surgeon should forewarn the patient of som e resultant
functional disability. Mobilization of the entire muscle as
a standard ap with division of the insertion will result in
the loss of the anterior axillary fold, resulting in a possi-
ble aesthetic deformity. Flap modi cations that preserve
the anterior axillary fold may also preserve som e m uscle
function.

●
With respect to innervation, the nomenclature of the me-
dial and lateral pectoral nerves can be slightly confusing.
The names are derived from their brachial plexus anatomy,

32 Pectoralis Major Muscle Flaps
383
Fig. 32.14 (continued) (e) Primary closure of wound with drain placement. (f) Postoperative follow-up of patient at 4 months.
e
f
speci cally the nerves originating from the medial and lat-
eral cords, respectively. The lateral pectoral nerve is locat-
ed medially on the chest wall, while the m edial pectoral
nerve courses laterally. The lateral pectoral nerve has also
been referred to as the “superior pectoral nerve.” Where-
as, the medial pectoral nerve has been called the “inferior
pectoral nerve.”

●
To extend the arc of rotation of the pectoralis major mus-
cle ap in head and neck reconstruction, one can perform
a segmental ostectomy of the clavicle at the middle third.
The bony segment is resected in the subperiosteal plane.
This m aneuver ensures continuity of the periosteum which
will protect the underlying pedicle and subclavian artery
and vein. This technique allows for passage of the pedi-
cle without tethering or compression when insetting the
ap. Stabilize the resulting osseous defect with a spanning,
locking, reconstruction plate.

●
The pectoral branch of the thoracoacrom ial pedicle has
been described as a recipient vessel for free tissue trans-
fer to the thorax. Similarly, perforators from the internal
mamm ary artery and vein have been utilized as recipient
vessels for free ap breast reconstruction.
Suggested Further Reading
Ariyan S. The pectoralis major myocutaneous ap: a versatile ap for recon-
struction in the head and neck. Plast Reconstr Surg 1979;63:73–81
Ariyan S. Further experiences with the pectoralis major myocutaneous
ap for the imm ediate repair of defects from excisions of head and
neck cancers. Plast Reconstr Surg 1979;64:605–612
Ethier JL, Trites J, Taylor SM. Pectoralis m ajor myofascial ap in head and
neck reconstruction: indications and outcomes. J Otolaryngol Head
Neck Surg 2009;38:632–641
Green MF, Gibson JR, Bryson JR, Thomson E. A one-stage correction
of mandibular defects using a split sternum pectoralis major
osteo-musculocutaneous transfer. Br J Plast Surg 1981;34:11–16
Krespi YP, Wurster CF, Sisson GA. A longer muscle pedicle for pectoralis
myocutaneous ap. Laryngoscope 1983;93:1360–1361
Kroll SS, Goepfert H, Jones M, Guillam ondegui O, Schusterman M. Analysis
of complications in 168 pectoralis major myocutaneous aps used
for head and neck reconstruction. Ann Plast Surg 1990;25:93–97
McLean JN, Carlson GW, Losken A. The pectoralis major myocutaneous
ap revisited: a reliable technique for head and neck reconstruc-
tion. Ann Plast Surg 2010;64:570–573
Mehta S, Sarkar S, Kavarana N, Bhathena H, Mehta A. Complications of the
pectoralis major myocutaneous ap in the oral cavity: a prospec-
tive evaluation of 220 cases. Plast Reconstr Surg 1996;98:31–37
Netter FH. Atlas of Human Anatomy. 2nd ed. East Hanover, NJ: Novartis;
1997
Phillips JG, Falconer DT, Postlethwaite K, Peckitt N. Pectoralis major
m uscle ap with bone graft in intra-oral reconstruction. Br J Oral
Maxillofac Surg 1990;28:160–163
Shah JP, Haribhakti V, Loree TR, Sutaria P. Complications of the pectoralis
m ajor myocutaneous ap in head and neck reconstruction. Am J
Surg 1990;160:352–355
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

384

Classi cation

●
Mathes-Nahai type V

Vascular Pedicle
See Fig. 32.1.
Dominant
The pectoral branch of the thoracoacrom ial artery is considered
to be the dominant blood supply to the pectoralis major muscle.

●
Mean arterial caliber of pectoral branch of the thoracoacro-
mial artery: 2.0 mm

●
Mean venous caliber of associated venae comitantes:
3.0 mm

●
Length: The length of the pedicle is 4 cm to where it pene-
trates the deep surface of the pectoralis major m uscle, but
the skin paddle of a myocutaneous ap can be designed at
the inferior lim it of the m uscle, thus increasing e ective
pedicle length.
Secondary Segmental Vascular
Pedicles
The internal m am m ary perforating arterial branches through
rst to sixth intercostal spaces (m edial) are considered to be
secondary segm ental vascular pedicles to the pectoralis major
muscle.

●
Mean arterial caliber of internal mam mary perforating
arterial branches: 0.5 to 0.8 mm

●
Mean venous caliber of associated venae com itantes: 1.0 to
1.5 mm

●
Length: The length of the pedicle is 1 to 2 cm
The pectoral branch of lateral thoracic artery is considered
to be one of the secondary segm ental vascular pedicles to the
pectoralis major muscle.

●
Mean arterial caliber of pectoral branch of lateral thoracic
artery: 1 to 2 mm

●
Mean venous caliber of associated venae com itantes: 2.0 to
2.5 mm

●
Length: The length of the pedicle is 3 to 4 cm
The perforating branches of fth, sixth, and seventh inter-
costal arteries (lateral) are considered to be secondary segmental
vascular pedicles to the pectoralis major muscle.

●
Mean arterial caliber of perforating branches of fth, sixth,
and seventh intercostal arteries: , 0.5 mm

●
Length: The length of the pedicle is 1 to 2 cm.
For innervation, please refer to Chapter 32.

Patient Positioning
Position the patient supine with the shoulder abducted to
90 degrees and the arm extended on an arm board. Although
not essential, it may be useful to prep the arm and drape it in
the eld.

Surface Markings
1. In planning for surgery, identify and mark the sternal notch,
xiphoid process, midline chest, and coracoid process (see
Fig. 32.2).
2. Identify and mark the clavicle.
3. Identify the middle third of the clavicle. This represents the
location of the underlying dominant vascular pedicle.
4. Palpate the lateral axillary fold. This represents the lateral
extent of the pectoralis major muscle.
5. Draw a line from the coracoid process to the xiphoid process.
This represents the underlying course of the pedicle.
6. The location, size, and shape of the skin paddle can be variably
designed. The cutaneous portion of the ap is usually marked
over the lower medial part of the muscle. An extension can be
taken distally to include the anterior rectus sheath. In wom en,
the ap skin paddle can be designed just above the inframa-
mmary fold so that the scar ultimately rests within the fold,
although the patient will still need to accept som e alteration
in the breast morphology and thus asymmetry. In women
with large ptotic breasts, the lower medial aspect of the skin
overlying the pectoralis major muscle usually is the thinnest
available ap skin paddle.

Raising the Flap
Step 1: Prepare the Chest
Prep the chest widely and drape to include the m idaxillary line,
supraclavicular skin, and subxiphoid abdomen.
33
Pectoralis Major Myocutaneous Flaps
Sachin M. Shridharani and Devinder P. Singh

33 Pectoralis Major Myocutaneous Flaps
385
Step 2: Place the Incision
Depending on clinical indication, ap selection, and defect loca-
tion, the surgical approach to the pectoralis myocutaneous ap
is through an oblique/param edian incision with a distal ellipti-
cal skin paddle extension (Fig. 33.1). It is safest to place the skin
paddle over the muscle itself, as the more the paddle is designed
below the muscle (to increase e ective pedicle length), the more
random its circulation pattern will be.
Step 3: Expose the Muscle
Elevate m edially and laterally based adipocutaneous aps
o the underlying m uscle fascia. Take care not to underm ine
the skin paddle during this step (Fig. 33.2). Som e prefer the
“defensive approach” to raising this ap for head and neck
reconstruction, w hich involves preserving (and thus also delay-
ing) the deltopectoral fasciocutaneous ap in case it m ight be
required in future.
Step 4: Raise the Flap
Identify the lateral border of the pectoralis major muscle and ele-
vate in the subpectoral plane. Identify the vascular pedicle on the
deep surface of the muscle. Take care to preserve and include this
blood supply in the ap when performing the medial myotomy.
Con rm the pedicle is supplying the desired skin paddle.
Step 5: Dissection of the Flap
Carefully dissect the ap in distal to proxim al manner in the sub-
pectoral plane. Preserve the pectoralis minor on the chest wall.
Place the medial myotomy in a manner preserving the medial
portion of the pectoralis major muscle, which is supplied by per-
forators of the internal mammary artery and vein (Fig. 33.3).
Step 6: Increasing Arc of Rotation
Identify and ligate the medial and lateral pectoral nerves as they
enter the deep surface of the m uscle. Carefully dissect the prox-
imal vascular supply and divide the overlying muscle to fully
skeletonize the pedicle, if necessary (Fig. 33.4). In rare circum -
Fig. 33.1 Cadaveric dissection demonstrating surface markings and skin
paddle placement. 1, Skin paddle; 2, alternative defensive approach,
raising the deltopectoral ap rst to access the pectoral ap; 3, oblique
incision to access pectoral ap without the potential for preserving the
deltopectoral ap; and 4, thoracoacromial axis.
Fig. 33.2 Elevation of medially and laterally based adipocutaneous aps
o the underlying muscle fascia.
Fig. 33.3 Placement of the medial myotomy in a manner preserving the
medial portion of the pectoralis major muscle, which is supplied by perfo-
rators of the internal mammary artery and vein.
Fig. 33.4 Cadaveric demonstration of arc of rotation.

386
II Reconstructive Flaps A-to-Z
stances, obtain m axim um rotation by perform ing segmental
ostectomy of the overlying clavicle. If indicated, it is also possible
to skeletonize the vascular pedicle as it travels within the muscle
with intramuscular dissection; this thins the pedicle for insetting
(thereby reducing the characteristic supraclavicular bulge that
occurs when using this ap for head and neck reconstruction)
and can also increase reach.
Step 7: Insetting the Flap
Inset the muscle ap without tension using absorbable sutures.
Step 8: Drain Placement
Place 19-French round channeled drains in the donor site defect.
Bring the drain out through a separate stab incision and secure it
with a standard drain suture.
Step 9: Split-Thickness Skin
Grafting
It is generally possible to advance adequate lateral chest skin to close
the donor site. When the ap is particularly large, however, perform
split-thickness autografting at this stage if primary closure of the
donor site is not possible. One may prefer to remove the nipple from
a particularly large skin paddle and re-inset it onto the chest as a
free nipple graft rather than transfer it to the recipient site.
Step 10: Donor Site Closure
Close the incision in multiple layers and place a donor site drain.

Important Anatomical
Structures
Identi ed and raised with the ap:
1. Overlying skin paddle
2. Required muscle ap
3. Dominant supplying vascular pedicle(s)
Identi ed and preserved:
1. Identify and divide branches of medial and lateral pectoral
nerves
2. Pectoralis minor
3. Lateral thoracic artery

Clinical Perspectives
The pectoralis m ajor ap is a com m only employed ap in
plastic surgery for chest wall and head and neck reconstruc-
tion. It is generally transferred as a pedicled m uscle ap. Vari-
ations include advancement aps, turnover aps, split turnover
aps, and osteocutaneous aps. Other common indications for
the pectoralis m uscle ap include breast reconstruction, breast
augmentation, thoracic reconstruction, tracheopharyngeal re-
construction, pacemaker coverage, intrathoracic defects, and
upper extremity reconstruction (Fig. 33.5).

Flap Variations
1. Pectoralis myocutaneous advancement aps are employed for
midline sternum reconstruction and head and neck recon-
struction. The patients undergoing this type of chest wall re-
construction have generally previously undergone a midline
sternotomy for cardiac surgery. The aps are raised as myocu-
taneous aps o of the underlying chest wall. This ap is a
good option for critically ill patients, because the aps can be
raised expeditiously. Furthermore, the aps are dependable,
because the skin is not separately elevated o the muscle.
2. The pectoralis major osteomyocutaneous ap is well de-
scribed for reconstructing composite defects of the mandible.
This ap is an accepted option for patients who cannot un-
dergo free tissue transfer with defects too large for nonvascu-
larized bone grafts, and for salvage of free tissue transfer. The
fth rib is most commonly harvested for this ap.

Hints and Tips
1. This muscle is generally not transferred as a free tissue transfer
due to a short pedicle length and is generally not used in wom-
en (i.e., aesthetic considerations due to proximity to the breast).
2. The surgeon should wear a headlamp or utilize a lighted
retractor.
3. Automatic vascular clip appliers facilitate e cient hemostasis.
4. The loss of the pectoralis muscle has minimal functional
consequences, especially if any segment of the muscle is pre-
served. It is not entirely dispensable, however, and the sur-
geon should forewarn the patient of some resultant functional
disability. Mobilization of the entire muscle as a standard ap
with division of the insertion will result in the loss of the an-
terior axillary fold, resulting in a possible aesthetic deformity.
Flap modi cations that preserve the anterior axillary fold may
also preserve some muscle function.
5. With respect to innervation, the nomenclature of the medi-
al and lateral pectoral nerves can be slightly confusing. The
names are derived from their brachial plexus anatomy, specif-
ically the nerves originating from the medial and lateral cords,
respectively. The lateral pectoral nerve is located medially on
the chest wall, while the m edial pectoral nerve courses later-
ally. The lateral pectoral nerve has also been referred to as the
“superior pectoral nerve,” whereas the m edial pectoral nerve
has been called the “inferior pectoral nerve.”
6. To extend the arc of rotation of the pectoralis major muscle
ap in head and neck reconstruction, one can perform a seg-
mental ostectomy of the clavicle at the m iddle third. The bony
segment is resected in the subperiosteal plane. This maneu-
ver ensures continuity of the periosteum which will protect

33 Pectoralis Major Myocutaneous Flaps
387
c
a
Fig. 33.5 Clinical case of (a) a 55-year-old man with
exposed internal jugular vein and mandible after
tumor extirpation and neck dissection. (b) Pectora-
lis major myocutaneous ap elevation. (c) Final skin
paddle inset with coverage of critical neck structures.
b

388
II Reconstructive Flaps A-to-Z
the underlying pedicle and subclavian artery and vein. This
technique allows for passage of the pedicle without tethering
or compression when insetting the ap. Stabilize the resulting
osseous defect with a spanning, locking, reconstruction plate.
7. The pectoral branch of the thoracoacromial pedicle has been
described as a recipient vessel for free tissue transfer to the
thorax. Similarly, perforators from the internal mammary ar-
tery and vein have been utilized as recipient vessels for free
ap breast reconstruction.
8. The internal mammary artery perforators are useful for
designing local islanded aps; these are often rotated as
propeller aps to reach the sternum, neck, and trachea (e.g.,
for tracheoesophageal stula closure).
Suggested Further Reading
Ariyan S. The pectoralis major myocutaneous ap: a versatile ap for
reconstruction in the head and neck. Plast Reconstr Surg 1979;
63:73–81
Ariyan S. Further experiences with the pectoralis major myocutaneous
ap for the imm ediate repair of defects from excisions of head and
neck cancers. Plast Reconstr Surg 1979;64:605–612
Ethier JL, Trites J, Taylor SM. Pectoralis m ajor myofascial ap in head and
neck reconstruction: indications and outcomes. J Otolaryngol Head
Neck Surg 2009;38:632–641
Green MF, Gibson JR, Bryson JR, Thomson E. A one-stage correction
of mandibular defects using a split sternum pectoralis major
osteo-musculocutaneous transfer. Br J Plast Surg 1981;34:11–16
Krespi YP, Wurster CF, Sisson GA. A longer muscle pedicle for pectoralis
myocutaneous ap. Laryngoscope 1983;93:1360–1361
Kroll SS, Goepfert H, Jones M, Guillam ondegui O, Schusterm an M. Anal-
ysis of complications in 168 pectoralis m ajor myocutaneous aps
used for head and neck reconstruction. Ann Plast Surg 1990;
25:93–97
McLean JN, Carlson GW, Losken A. The pectoralis major myocutaneous
ap revisited: a reliable technique for head and neck reconstruction.
Ann Plast Surg 2010;64:570–573
Mehta S, Sarkar S, Kavarana N, Bhathena H, Mehta A. Complications of the
pectoralis major myocutaneous ap in the oral cavity: a prospec-
tive evaluation of 220 cases. Plast Reconstr Surg 1996;98:31–37
Netter FH. Atlas of Human Anatomy. 2nd ed. East Hanover, NJ: Novartis;
1997
Phillips JG, Falconer DT, Postlethwaite K, Peckitt N. Pectoralis m ajor
m uscle ap with bone graft in intra-oral reconstruction. Br J Oral
Maxillofac Surg 1990;28:160–163
Shah JP, Haribhakti V, Loree TR, Sutaria P. Complications of the pectoralis
m ajor myocutaneous ap in head and neck reconstruction. Am
J Surg 1990;160:352–355

389

Introduction
The gluteal thigh ap is a versatile ap that can be used to ll soft
tissue defects involving the ipsilateral ischium , the perineum ,
and the sacrum. As such, it is of particular utility in patients with
pressure ulcers or oncologic defects of the perineum.

Vascular Pedicles
The gluteal thigh flap is supplied by the term inal branch of
the inferior gluteal artery. This artery passes below the un-
dersurface of the gluteus m axim us m uscle, and term inates as
a sm all direct cutaneous artery in an anastom otic plexus at
the level of the m edial fem oral circum flex artery. Variations
in arterial anatomy include absence of the descending inferior
gluteal artery, in w hich case the cutaneous branch arises
from the m edial circum flex fem oral artery or from another
thigh perforator.

●
Mean arterial caliber: 1.33 mm

●
Flap dimensions: varies, but can be up to 12 to 15 cm in
width and up to 30 cm in length

●
Sensory innervation: posterior femoral cutaneous nerve

Patient Positioning
The patient is positioned prone, with adequate padding over
bony prominences and catheters. Ensure that the endotracheal
tube is adequately secured. In cases in which the ap is being
raised for coverage of an anterior defect (i.e., an abdominoperi-
neal resection), the patient must be repositioned supine for ap
inset. Alternatively, the patient may be placed in an exaggerated
lithotomy position for both ap harvest and inset, although this
may limit the size of the ap that can be harvested.

Surface Markings
With the patient in the prone position, the gluteal crease is
marked. The ap dim ensions are designed to ll the expected
defect and the ap is centered over a line midway between the
greater trochanter and the ischial tuberosity, perpendicular to
the gluteal crease. The distal extent of the ap can be to within
8 cm of the popliteal fossa. Ideally, the width of the ap should
be designed to ll the defect but also allow primary donor site
closure (varies depending on patient body habitus), although
donor site skin grafting can also be planned.

Raising the Flap
Incision through skin and subcutaneous tissue exposes the un-
derlying muscle. Superiorly, the caudal portion of the gluteus
maximus is exposed. Inferiorly, the incision is carried down
through the fascia lata and investing fascia of the posterior thigh
musculature, and the ham string muscles are visualized. Begin-
ning at this most distal aspect of the ap, the ap is elevated in
continuity with the skin paddle such that the ap is elevated o
the ham string m uscles. Of note, the term inal branch of the infe-
rior gluteal artery is encountered at the distal aspect of the ap
and may require ligation.
The attachm ents of the gluteus m axim us to the fem ur are
released to m obilize the ap and allow it to reach the defect,
up to the level of the greater trochanter. Further elevation of
the ap exposes several deep fem oral perforators, w hich are
ligated as they are encountered. To prevent shearing, tempo-
rary tacking sutures are placed between the skin and fascia
lata. Superiorly, above the biceps fem oris, the sciatic nerve is
identi ed and preserved. Depending on the extent of m obility
needed, the inferior portion of the gluteus m axim us (below
the lower border of the piriform is) m ay also be taken as a
myocutaneous ap.
Once fully mobilized as needed for the particular reconstruc-
tive need, the ap is rotated into position, as seen in Fig. 34.1.
It is important to ensure during inset that there is no twisting or
kinking of the pedicle, and that the ap remains viable—appearing
without evidence of ischemia or venous congestion.
At least one closed-suction drain is placed beneath the ap to
avoid uid accumulation.

Donor Site Closure
Closure of the donor site is done in layers to m inimize tension on
the wound edges. The donor site may typically be closed primar-
ily, and a closed-suction drain is left in place to prevent seroma
formation. If tension-free primary closure is not possible, then
skin grafting will be required.
Gluteal Thigh Flaps
Sarah I. Fernandez and Bruce A. Mast
34

390
II Reconstructive Flaps A-to-Z
Fig. 34.1 (a) A posterior gluteal thigh ap is advanced and rotated to ll a defect on the contralateral buttock. (b) The same patient after inset of the
gluteal thigh ap and closure of the donor site.
a
b

Important Anatomic
Structures
Identi ed and raised with the ap:

●
Skin paddle

●
Fascia lata (should be secured to the skin with temporary
tacking sutures to avoid shearing)

●
Posterior cutaneous nerve of the thigh

●
The inferior portion of the gluteus maxim us m uscle (to
the level of the piriformis) m ay be harvested in the gluteal
thigh ap as a myocutaneous ap if additional bulk is
needed or to facilitate an adequate arc of rotation
Identi ed and preserved:

●
Posterior thigh compartment muscles

●
Sciatic nerve

●
Pudendal vessels (superior and medial to ischial tuberosity)
Suggested Further Reading
Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior
gluteal artery perforator aps. Plast Reconstr Surg 2007;120(6):
1551–1556
Hurwitz D, Swartz W, Mathes S. The gluteal thigh ap: a reliable, sensate
ap for the closure of buttock and perineal wounds. Plast Reconstr
Surg 1981;68(4):521–532
Unal C, Ozdem ir J, Yirmibesoglu O, et al. Use of inferior gluteal artery
and posterior thigh perforators in managem ent of ischial pressure
sores with lim ited donor sites for ap coverage. Ann Plast Surg
2012;69(1):67–72
Windhofer C, Brenner E, Moriggl B, et al. Relationship between the
descending branch of the inferior gluteal artery and the posteri-
or femoral cutaneous nerve applicable to ap surgery. Surg Radiol
Anat 2002;24(5):253–257

391

Introduction
The posterior thigh perforator ap can be successfully used
in the absence of a patent inferior gluteal artery. These aps
are ideal for closure of ischial wounds, especially in patients
w hose inferior gluteal artery m ay have already been sacri ced
(Fig. 35.1). A notable advantage to this ap is its potential re-
use w ith re-elevation, longer back-cut, and readvancem ent or
rotation w hile preserving the proxim al fem oral perforators.
This is of particular advantage in patients w ith recurrent
pressure ulcers.

Vascular Pedicle
The posterior thigh perforator ap is supplied by perforators
from the profunda femoris artery. These perforators supply
the m uscles of the thigh including the gracilis, biceps fem oris,
and adductor muscles, and give o multiple septocutaneous
and musculocutaneous perforators, supplying a zone that runs
from the inferior gluteal fold to 8–10 cm proximal to the lateral
femoral condyle.

●
Mean arterial caliber: 0.7 mm

●
Mean venous caliber: 0.8 mm

●
Pedicle length: 30 mm (from deep fascia)

Patient Positioning
The patient is placed in the prone position, w ith care taken to
ensure that all bony prom inences and catheters are adequately
padded.

Surface Markings
With the patient in the prone position, the femoral artery is
identi ed with a handheld Doppler and marked. The perfora-
tors from the femoral artery are similarly identi ed and marked.
A skin paddle that w ill ll the defect and that encompasses the
35
Posterior Thigh Perforator Flaps
Sarah I. Fernandez and Bruce A. Mast
Fig. 35.1 A posterior thigh perforator  ap is ideal for closure of ischial pressure ulcers, as in this patient.

392
II Reconstructive Flaps A-to-Z
perforators is then designed and marked. For ischial wounds, the
ap is designed with a long medial incision that gently curves
to the midline and stops approximately 6 to 8 cm from the
popliteal fossa.

Raising the Flap
Incision is made along the medial edge of the previously marked
ap. The incision is carried down through the fascia and the ap
is elevated from medial to lateral, keeping the investing m uscular
fascia in continuity with the skin paddle. Multiple small perfo-
rators from the ham strings will require ligation. The dissection
is carried laterally, to identify the lateral segmental perforators
from the femoral artery, which are preserved (Fig. 35.2).
At this point the ap is rotated and advanced toward the
defect, and a back-cut along the inferolateral edge of the ap
is m ade to allow the ap to be inset into the defect. This back-
cut is m ade only to the extent required to allow rotation and
advancem ent of the ap into the defect, ensuring m axim um
preservation of the perforators supplying the ap (Fig. 35.3).
Doppler is used to con rm a signal from the perforators w ithin
the ap. Once again, it is critical to ensure that rotation and
inset occur in such a m anner as to avoid comprom ise of the
vascular pedicle.
A closed-suction drain is placed beneath the ap to avoid
uid accumulation.

Postoperative Care
Due to their location, these aps are particularly susceptible
to pressure dam age. This is exacerbated by the fact that they
are typically used to repair wounds in patients w ith lim ited
m obility. Postoperatively, patients are placed on air- uid m at-
tresses w ith frequent turning to m inim ize pressure on the ap.
Sitting is avoided for at least 3 weeks to avoid pressure over
the ischium . Closed suction drains rem ain in place until out-
put is m inim al. Patients should be counseled on avoiding pres-
sure to the operative site once discharged and often require
an air- uid bed to be delivered to the hom e to allow optim al
postoperative care.
Fig. 35.2 Elevating the posterior femoral perforator  ap: elevation proceeds 
from medial to lateral, with the  ap being raised o  the underlying muscle. 
Note the back-cut at the inferior aspect of the  ap, which will allow the  ap 
to be rotated and advanced into the ischial pressure ulcer. In this patient, 
the gracilis muscle was divided inferiorly and rotated superiorly to provide 
additional soft tissue coverage to the wound.

35 Posterior Thigh Perforator Flaps
393
Fig. 35.3 (a) The  ap is completely elevated and ready to be inset. The femoral perforators are visible at the lateral aspect of the  ap. (b) The posterior
thigh perforator  ap is inset into the defect and sutured into place.
a
b
Suggested Further Reading
Rubin JA, Whetzel TP, Stevenson TR. The posterior thigh fasciocutaneous
ap: vascular anatomy and clinical application. Plast Reconstr Surg
1995;95:1228–1239
Unal C, Ozdem ir J, Yirmibesoglu O, et al. Use of inferior gluteal artery
and posterior thigh perforators in managem ent of ischial pressure
sores with lim ited donor sites for ap coverage. Ann Plast Surg
2012;69(1):67–72
Windhofer C, Brenner E, Moriggl B, et al. Relationship between the de-
scending branch of the inferior gluteal artery and the posterior
femoral cutaneous nerve applicable to ap surgery. Surg Radiol
Anat 2002;24(5):253–257

394

Classi cation

●
Type C fasciocutaneous ap

Vascular Pedicle
The radial forearm flap encompasses all of the skin covering
the entire forearm . The brachial artery bifurcates into the ra-
dial and ulnar arteries at the elbow crease. The radial artery
courses between the brachioradialis and the pronator teres in
the upper forearm and lies in the lateral interm uscular sep-
tum between the flexor carpi radialis and the brachioradialis
in the lower forearm . Septocutaneous perforators supply the
overlying skin in the proxim al forearm , and direct cutaneous
perforators from the radial artery supply the overlying skin
in the distal forearm . The radial artery continues under the
abductor pollicis longus and extensor pollicis brevis tendons
as the deep palm ar arch w here it joins up w ith the ulnar artery
(Fig. 36.1).
The radial forearm ap is drained by a super cial venous
system and a deep venous system. The super cial system is
drained by the cephalic vein, which courses on the radial border
of the ap to join the basilic vein. This can be included to improve
venous drainage of the ap. The deep system is usually based on
the two accompanying venae comitantes to the radial artery. This
is especially crucial in distally based aps.

●
Mean arterial caliber: 1.5 to 2.0 mm

●
Mean venous caliber: 1.0 to 1.5 m m ; cephalic vein: 1.5 to
2.0 mm

●
Length: 20 cm

●
Sensory innervation: Lateral antebrachial cutaneous nerve
(radial half of ap), medial antebrachial cutaneous ap
(ulnar half of ap)
Radial Forearm Fasciocutaneous Flaps
Terence Goh and Chin-Ho Wong
36
Fig. 36.1 Blood supply to the radial forearm  ap. The radial forearm  ap is supplied by septocutaneous 
perforators from the radial artery in the distal forearm.

36 Radial Forearm Fasciocutaneous Flaps
395

Patient Positioning
The patient is positioned in the supine position with the arm
extended and supinated on an arm board. A sterile tourniquet
is placed in the upper arm.

Surface Markings
1. Mark the proximal wrist crease to determine the distal extent
of the ap.
2. Mark the radial and ulnar borders to determine the width of
the skin paddle.
3. Mark the super cial cephalic vein and the super cial veins of
the hand.
4. Mark the radial artery, which can be palpated just lateral to
the exor carpi radialis (FCR) (Fig. 36.2).

Raising the Flap
Step 1: Skin Markings
Preoperatively, the Allen test is performed to ensure adequate
collateral supply to the hand via the ulnar artery. The radial
Fig. 36.2 Distal dissection of the radial forearm  ap. The radial artery lies 
between the brachioradialis and the  exor carpi ulnaris. 1, Radial artery and 
its venae comitantes; 2, brachioradialis muscle; 3, cephalic vein; 4,  exor 
carpi radialis muscle; 5,  exor digitorum super cialis muscle; 6, palmaris
longus muscle; 7,  exor carpi ulnaris muscle; 17, median nerve.1
artery is palpated and marked along with the cephalic vein.
The needed dimensions of the ap are drawn (Fig. 36.3).
Step 2: Skin Incision and
Suprafascial Flap Harvest
The skin and derm is are incised over the planned skin m arkings,
beginning with the ulnar border. The ap is raised in the supra-
fascial plane until the radial border of the exor carpi radialis
(FCR) is reached. Further dissection is deferred until the radial
artery is secured distally.
The radial border of the ap is then incised (Fig. 36.4).
Dissection is perform ed initially w ith a pair of dissecting scis-
sors to identify branches of the super cial radial nerve and
the lateral antecubital nerve (arrow heads), w hich are locat-
ed above the deep fascia. The cephalic vein is also identi ed
and preserved. The dissection is perform ed in the suprafascial
plane m edially until the brachioradialis (BR) tendon (arrow ) is
reached.
Step 3: Securing the Distal End of
the Radial Artery Pedicle
The distal incision, along the proxim al wrist crease, is m ade down
to the deep fascia (Fig. 36.5). The super cial veins are ligated.
The radial artery and the venae com itantes (arrow heads) are
found immediately below the fascia. It is mobilized circumferen-
tially and then ligated. The distal pedicle of the radial forearm is
sutured to the distal edge of the skin edge and used as a traction
suture (Fig. 36.6).
Step 4: Dissecting the Radial
Artery Pedicle
Gentle traction on the suture presents the inferior surface
of the pedicle (asterisk) for bottom -up dissection (Fig. 36.7).
The transverse fibrous bands (arrow ) seen at the base of the
tunnel are the deep layer of the deep fascia. Its attachm ents
to the deep fascia covering the BR laterally and the FCR m e-
dially at the conjoint area (arrow heads) m ust be preserved
to m aintain the integrit y of the facial com partm ents of the
forearm .
The roof of the tunnel located between the pedicle and
the subcutaneous tissue is the super cial layer of the deep
fascia. This layer (arrow heads) is cut and lifted w ith the ap
(Fig. 36.8).
The deep layer of the deep fascia is preserved so that it
covers the FCR on the ulna side and the BR on the radial side so
as to maintain proper function of the exor tendons. There are
branches from the pedicle passing through the deep layer of the
deep fascia to supply the underlying bone and the underlying
muscle. These are ligated with hemoclips (Fig. 36.9).
Preservation of the branches of the perforators to the bone
enables harvesting of a segment of radial bone.

396
II Reconstructive Flaps A-to-Z
Fig. 36.3 Skin markings. The distal limit of the  ap is the proximal wrist crease, and the radial and ulnar borders will determine the 
width of the  ap.2
Fig. 36.4 Suprafascial  ap harvest. The ulnar border of the  ap is  rst incised (not shown here) and then the radial border is incised. 
The super cial radial nerve and the lateral antecubital nerve (arrowheads) are identi ed and spared. The dissection is commenced 
medially until the brachioradialis tendon (arrow) is reached.2

36 Radial Forearm Fasciocutaneous Flaps
397
Fig. 36.5 Identi cation of the radial artery pedicle. The distal incision is made along the proximal wrist crease to identify the radial 
artery, which lies between the FCR and BR (arrowheads). It is mobilized circumferentially and ligated. The pedicle is sutured to the 
ap, such that gentle traction on the suture presents the  ap for a bottom-up dissection.2
Fig. 36.6 Surgical anatomy of the distal radial artery: 1, radial artery and its venae comitantes; 2, super cial branch of the radial 
nerve; 3, lateral antecubital nerve; 4, deep fascia of the forearm; 5, super cial layer of the deep fascia; 6, deep layer of the deep fascia; 
and 7, the conjoin of the deep and super cial layer of the deep fascia. This structure must be preserved to maintain the continuity of 
the deep layer of the deep fascia and the fascia over the FCR and BR. This in turn is important in maintaining proper functioning of 
the  exor tendons and in providing a good bed for skin grafting.2

398
II Reconstructive Flaps A-to-Z
Fig. 36.7 Traction on suture for bottom-up approach. Traction on the suture ensures that the pedicle (asterisk) is raised with the  ap 
and enables dissection of the  ap, while preserving the deep layer of the deep fascia (arrow).2
Fig. 36.8 Preservation of the deep fascia. The deep fascia covers the BR laterally and the FCR medially at the conjoined area 
(arrowheads) and must be preserved to maintain the integrity of the fascial compartments of the forearm.2

36 Radial Forearm Fasciocutaneous Flaps
399
Step 5: Proximal Dissection of the
Radial Artery
Proximally, the pedicle is located in the lateral intermuscular sep-
tum between the BR and the FCR (Fig. 36.10). These muscles are
retracted to reveal the pedicle. If a ap of a greater longitudinal
dimension is required, care is taken to include the septocutane-
ous vessels supplying the ap proximally. The cephalic vein is also
dissected proximally to a length adequate for microanastomosis
(Fig. 36.11).
Step 6: Closure of the Donor Site
The donor site is closed with a full-thickness skin graft taken from
the groin (Fig. 36.12). The proximal forearm is closed primarily
using Monocryl 3-0.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Radial artery and venae comitantes

●
Cephalic vein (optional)
Identi ed and preserved:

●
Super cial radial nerve (can be included if neurotization of
the skin paddle is intended)

●
Lateral antecubital nerve

●
Deep layer of the deep fascial overlying the FCR and BR

●
Flexor carpi radialis

●
Brachioradialis

●
Palm aris longus (can be included if a tendon sling is
required)

●
Radius (40% can be included in an osteocutaneous ap)

Clinical Perspectives
The radial forearm ap is a robust fasciocutaneous ap that is ide-
al for reconstruction of defects that require thin pliable skin. The
ap can be employed as a pedicle ap that is proximally based to
resurface forearm defects up to the elbow and as a distally based
ap for defects up to the thumb and metacarpals. The ap can
be also be harvested as a free ap for reconstruction of defects
in the head and neck region and upper and lower extremities.
Specialized use of the ap includes neurotization for a sensate
ap. Inclusion of the perforators that supply the radius allows
harvesting of an osteocutaneous ap for penile reconstruction.
The palm aris longus can also be included in the ap harvest to
provide a static sling.
Fig. 36.9 Ligation of deep perforators to the radius. There are deep branches from the pedicles, which supply the underlying bone 
and muscle. These are ligated with ligaclips.2

400
II Reconstructive Flaps A-to-Z
Fig. 36.10 Dissection of the proximal pedicle. The pedicle is located in the intermuscular septum between the BR and FCR. These 
muscles are retracted to reveal the pedicle.2
Fig. 36.11 Radial forearm  ap. The cephalic vein can be included with the  ap harvest to provide a separate venous drainage.

36 Radial Forearm Fasciocutaneous Flaps
401
Fig. 36.12 Closure of the donor site. The donor site is closed with a full-thickness skin graft taken from the groin.

Radial Forearm Flap for
Tongue Reconstruction
The patient is a 60-year-old mam with a 2 3 3 cm squamous cell
carcinom a of the left hemitongue (Fig. 36.13a). He underwent
wide excision of the left hemitongue and reconstruction with
a radial forearm free ap. The radial forearm ap was inset to
reconstruct the left hemitongue.
Microanastomosis of the ap was completed under m icro-
scope assistance (Fig. 36.13b). The radial artery (arrow) was
anastomosed end-to-end to the superior thyroid artery and the
venae com itantes to the branch of the internal jugular vein. The
cephalic vein was anastomosed to the external jugular vein.
The patient’s recovery was uneventful. Fig. 36.13c shows the
ap fully healed at 6 months, and Fig. 36.13d shows the well-
healed donor site of the left forearm.

Hints and Tips
1. The siting of the pedicled radial forearm skin ap depends
on the location of the defect to be resurfaced. For a proximal
defect, the skin paddle is positioned m ore distally to allow an
adequate arc of rotation and, for distal defects, the skin paddle
is placed more proximally.
2. Placement of the ap too radially will cause the donor site to
be visible when the hand is in its natural position.
3. The distally based radial forearm ap is based on retro-
grade perfusion through the deep palm ar arch and its venae
com itantes. The skin paddle is sited proxim ally, but the sur-
geon has to be m indful that the perforators are fewer in the
proxim al forearm . As the ap is based on reverse ow of
the venae com itantes, the cephalic vein should be includ-
ed w ith the ap and anastom osed to provide extra ap
drainage. There is a risk of partial ap loss due to venous
congestion.
4. The ap is raised in the suprafascial plane to preserve the
fascia over the tendons to reduce adhesion formation and to
improve the skin graft take.
5. The radial forearm can be raised as a fascial only ap when
thin fascia is required for tendon reconstruction and skin is
not required.
6. The palmaris longus tendon can be harvested for reconstruc-
tion of eyelid or lip defects. Vascular connections between
the radial artery and the tendons must be preserved.
7. The super cial branch of the radial nerve may be included in
the ap harvest to provide a sensate ap or as a vascularized
nerve ap.
8. Preservation of the branches of the perforators to the bone
enables harvesting of a segm ent of radial bone. If the radius
is harvested as vascularized bone, less than 40% of the cross
section of the radius should be harvested to reduce the risk
of fracture.
9. The radial forearm ap can be used as a ow-through ap
w here the distal vessel can be used to provide a recipi-
ent for a second free ap or to bridge segm ental arterial
defects.
10. Primary closure of the donor site is possible with the use of
transposition aps supplied by perforators from the ulnar
artery.

402
II Reconstructive Flaps A-to-Z
Fig. 36.13 Reconstruction of tongue. (a) A patient with a left tongue squamous cell carcinoma. (b) The microanastomosis with 
the radial artery anastomosed end-to-end to the superior thyroid artery. The venae are anastomosed end-to-end to a branch of the 
internal jugular vein and to the external jugular vein. (continued)
a
b

36 Radial Forearm Fasciocutaneous Flaps
403
Fig. 36.13 (continued) (c) A well-healed tongue reconstruction at 6 months. (d) The donor site of the left forearm.
c
d

404
II Reconstructive Flaps A-to-Z
Suggested Further Reading
Bashir MA, Fung V, Kernohan MD, et al. "Z-plasty" modi cation of ul-
nar-based fasciocutaneous ap for closure of the radial forearm ap
donor defect. Ann Plast Surg 2010;64(1):22–23
Chacha B, Soin K, Tan KC. One stage reconstruction of intercalated defect
of the thumb using the osteocutaneous radial forearm ap. J Hand
Surg Br 1987;12(1):86–92
Corm ack GC, Lamberty BGH. A classi cation of fasciocutaneous aps
according to their patterns of vascularization. Br J Plast Surg
1984;37:80–87
Hsiao HT, Leu YS, Lin CC. Tongue reconstruction with free radial forearm
ap after hemiglossectomy: a functional assessment. J Reconstr
Microsurg 2003;19(3):137–142
Hsieh CH, Kuo YR, Yao SF, et al. Primary closure of radial forearm ap
donor defects with a bi-lobed ap based on the fasciocutaneous
perforator of the ulnar artery. Plast Reconstr Surg 2004;113(5):
1355–1360
Lamberty BGH, Cormack GC. The forearm angiosomes. Br J Plast Surg
1982;35:420–429
Lin JY, Cheng MH, Wei FC, et al. Proximal forearm ap based on a sep-
tocutaneous vessel from the radial artery. Plast Reconstr Surg
2006;117:955–960
Reid CD, Moss LH. Radial forearm vascularised tendon. One-stage ap
repair w ith vascularised tendon grafts in a dorsal hand injury
using the "Chinese" forearm ap. Br J Plast Surg 1983;36(4):
473–479
Saint-Cyr M, Mujadzic M, Wong C, et al. The radial artery pedicle perfora-
tor ap: vascular analysis and clinical implications. Plast Reconstr
Surg 2010;125(5):1469–1478
Serletti JM, Tavin E, Moran SL, et al. Total lower lip reconstruction with a
sensate composite radial forearm -palm aris longus free ap and a
tongue ap. Plast Reconstr Surg 1997;99(2):559–561
Song C, Wong M, Wong CH, et al. Modi cations of the radial forearm ap
phalloplasty for fem ale-to-m ale gender reassignment. J Reconstr
Microsurg 2011;27(2):115–120
Taylor GI, Ham FJ. The free vascularized nerve graft. A further experimental
and clinical application of microvascular techniques. Plast Reconstr
Surg 1976;57(4):413–426
Villaret DB, Futran NA. The indications and outcomes in the use of osteocu-
taneous radial forearm free ap. Head Neck 2003;25(6):475–481
Wong CH, Lin JY, Wei FC. The bottom -up approach to the suprafascial har-
vest of the radial forearm ap. Am J Surg 2008;196:60–64
Yamauchi T, Yajima H, Kizaki K, et al. Sensory reconstruction in sensate ra-
dial forearm ap transfer. J Reconstr Microsurg 2000;16(8):593–595
Yang GF, Chen BJ, Gao YZ. The free forearm ap. Chin Med J 1981;61:139–142
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
2. Wong CH, Lin JY, Wei FC. The bottom -up approach to the suprafascial
harvest of the radial forearm ap. Am J Surg 2008;196:60–64

Rectus Abdominis Muscle Flaps
Terence Goh and Kok Chai Tan
37
405
the deep inferior epigastric supplies the inferiorly pedicled rectus
aps or the free muscle aps. The 7th to 12th intercostal arteries
are minor pedicles that supply the ap via a segmental distri-
bution. The perfusion from these minor pedicles is not adequate
enough to perfuse the ap reliably for transfer.
The deep inferior epigastric artery is the dominant inferior
pedicle and also the larger of the two dominant pedicles. Free tissue
transfer of the rectus muscle ap should be based on this pedicle.

●
Mean arterial caliber: 1.5 to 2.5 m m. The deep inferior epi-
gastric artery branches from the anteromedial aspect of
the external iliac artery.

Classi cation

●
Mathes-Nahai type III

Vascular Pedicle
The rectus abdom inis m uscle is supplied by two dom inant pedi-
cles, which are the superior epigastric artery and the deep inferior
epigastric artery (Fig. 37.1). The superior epigastric vessel sup-
plies the proximally based pedicled transposition aps, whereas
Fig. 37.1 Blood supply to the rectus abdominis muscle. The rectus abdominis
muscle is supplied by the superior epigastric artery and the deep inferior epigastric
artery. The deep inferior epigastric artery is the dominant blood supply to the ap.
1, External iliac artery; 2, deep inferior epigastric artery (DIEA); 3, superior epigastric
artery; 4, internal mammary artery; 5, musculophrenic artery; 6, posterior sheath
of rectus; 7, arcuate line; 8, rectus abdominis muscle; 9, lateral branch of DIEA;
10, medial branch of DIEA.1

406
II Reconstructive Flaps A-to-Z
3. Mark the paramedian incision, which lies two to three nger-
breadths lateral to the linea alba (Fig. 37.2).

Raising the Flap
Step 1: Skin Markings
A paramedian incision is planned for the harvest of the rectus
abdominis ap (Fig. 37.2). The rectus abdominis muscle is ap-
proximately 30 3 10 cm, originates from the xiphoid and costal
margin, and inserts into the symphysis pubis and pubic crest. It
is bounded medially by the linea alba and laterally by the linea
semilunaris. The pedicle (deep inferior epigastric artery) is
located at the inferolateral edge of the rectus abdominis muscle.
Step 2: Skin Incision
The param edian incision is used. The skin incision is m ade and
deepened through dermis and subcutaneous tissue straight to
the anterior rectus sheath (Fig. 37.3). There is minimal under-
mining of the subcutaneous tissue to preserve the cutaneous
blood supply (Fig. 37.4).
Step 3: Incision of the Anterior
Rectus Sheath
The anterior rectus sheath is incised vertically with the use of a
diathermy with care not to cut the underlying muscle (Fig. 37.5),
from the costal margin to as far inferiorly as required. At the ten-
dinous intersections, dissection is slowed (Fig. 37.6) to m inim ize

●
Mean venous caliber: 2.0 to 3.0 m m . There are normally
two accompanying venae comitantes with one vein being
larger. These two veins converge to form a larger vein that
drains into the external iliac vein.

●
Length: 7 to 12 cm, if this is traced to the origin from the
external iliac artery.

●
Nerve supply

●
Motor: Segm ental nerves from the 7th to the 12th in-
tercostal nerves enter the deep surface of the muscle at
its mid to lateral aspect.

●
Sensory: The lateral cutaneous nerves from the 7th to
the 12th intercostal nerve also provide sensation to the
skin territory of the rectus abdominis muscle.
The superior and deep inferior system s anastom ose at the
periumbilical area through a system of choke vessels as described
by Taylor. The most common variant is the dual system (60%),
followed by the single vessel (29%), and the remainder (11%) exist
as multiple smaller branches.

Patient Positioning
The patient is positioned in the supine position. The abdom en is
exposed from the xiphoid to the pubis.

Surface Markings
1. Mark the linea alba, which divides the two rectus abdominis
muscles, and the linea semilunaris.
2. Mark the entire length of the rectus abdominis muscle and
the tendinous intersections.
Fig. 37.2 A paramedian incision is made about two ngerbreadths lateral to the linea alba.

37 Rectus Abdominis Muscle Flaps
407
Fig. 37.3 The skin incision is made with a no. 15 blade and deepened with a monopolar diathermy.
Fig. 37.4 The skin incision is deepened with a diathermy. There is minimal undermining done.
Fig. 37.5 The anterior rectus sheath is incised with care not to injure the underlying rectus
abdominis muscle.

408
II Reconstructive Flaps A-to-Z
dissection. The underside of the rectus abdominis is peeled o
from the posterior rectus sheath with the intercostal vessels and
nerves on the posterior aspect of the muscle. This is to ensure that
the inferior epigastric pedicle is kept with the muscle (Fig. 37.10).
Step 5: Division of the Superior
End of the Rectus Abdominis
Muscle
Division of the proxim al end of the rectus is done at the tendinous
intersection to m inim ize bleeding (Fig. 37.11). Additional muscle
length can be obtained by dividing the muscle more proxim ally
at the costal origins. The cut ends of the muscle are oversewn
trauma to the rectus abdominis muscle and the epigastric vessels
(which can com e to lie quite super cially). The anterior rectus
sheath is peeled o the rectus abdom inis m edially to the linea
alba (Fig. 37.7) and laterally to the linea semilunaris. This exposes
the entire width of the rectus muscle (Fig. 37.8). Skin perforators
(arrow) from the deep inferior epigastric perforator are identi ed
and ligated (Fig. 37.9).
Step 4: Dissection of the Muscle
O the Posterior Rectus Sheath
Once the anterior surface of the rectus muscle is exposed, the
rectus muscle is undermined from its posterior sheath by blunt
Fig. 37.6 At the tendinous intersections between the rectus abdominis muscle and the anterior
rectus sheath, extra precaution is taken to separate the sheath from the muscle and to prevent
injury to the pedicle, which can come to lie super cially.
Fig. 37.7 There is a clear avascular plane between the rectus abdominis and the anterior rectus sheath.

37 Rectus Abdominis Muscle Flaps
409
Fig. 37.8 The rectus abdominis muscle is lifted gently to expose the plane between the posterior
rectus sheath and the underside of the muscle belly.
Fig. 37.9 Skin perforators from the deep inferior epigastric artery travel through the rectus sheath
to supply the overlying skin. These perforators are ligated.
with Vicryl 2-0 sutures (Ethicon, Somerville, NJ) to ensure hemo-
stasis (Fig. 37.12).
Step 6: Exposure of the Deep
Inferior Epigastric Pedicle
The inferior epigastric pedicle lies inferior to the arcuate line and
lateral to the rectus abdominis muscle. The appearance of adipose
tissue, which invests the pedicle, suggests that the pedicle is close by
(Fig. 37.13). Dissection is slowed down. Dissection through the fat
pad will reveal the deep inferior epigastric pedicle. There is usually
one artery with two accompanying venae comitantes (Fig. 37.14).
The inferior edge of the rectus abdominis muscle is detached from
its insertion to the symphysis pubis and the pedicle is ligated.
Step 7: Completion of the Muscle
Harvest
The harvested m uscle has an in situ length of 30 3 10 cm but
because of shrinkage after harvest, the ap unit can provide cov-
erage for defects up to 20 3 8 cm. A sm aller tailored m uscle ap
can also be harvested with just a perforator from the inferior

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II Reconstructive Flaps A-to-Z
Fig. 37.11 The superior end of the muscle is divided at the tendinous intersection to mini-
mize bleeding. Ligation of the superior epigastric artery is done.
Fig. 37.10 Separation of the rectus abdominis from the posterior rectus sheath. (a) The
intercostal vessels and nerves are elevated with the rectus muscle. This is the plane of dissec-
tion so that the branches from the deep inferior epigastric artery to the ap are preserved.
(b) The arrow points to the deep inferior epigastric pedicle that traverses on the underside
of the muscle ap.
a
b

37 Rectus Abdominis Muscle Flaps
411
Fig. 37.12 Division of the muscle. (a) Both ends of the cut muscle are overrun with 3-0 Vicryl
as a hemostatic stitch. (b) Similarly, the cut edge of the ap is also overrun with Vicryl 3-0
suture. (c) Hemostatic running sutures reduce postoperative bleeding and provide a rigid
edge for stitching.
a
b
c

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II Reconstructive Flaps A-to-Z
Fig. 37.13 The deep inferior epigastric pedicle is located at the inferolateral edge of the rectus
muscle. It is usually invested in adipose tissue. The dissection slows down once the adipose tissue
is noted.
Fig. 37.14 The deep inferior epigastric pedicle can be traced until it branches from the external iliac
artery. This provides a pedicle length of approximately 6 to 10 cm.
epigastric artery. The underside of the muscle is shown here
with the deep inferior epigastric pedicle running in the middle
of the ap. A pedicle length of 10 cm can usually be obtained by
dissecting it down to the external iliac artery (Fig. 37.15). There
is usually a single artery (arrow) accompanied by two venae
comitantes (arrow). The diameter of the artery averages 2 mm.
Step 8: Closure of the Donor Site
Closure of the anterior rectus sheath is important to prevent ab-
dominal bulge and hernia. This is done either with interrupted
Prolene 1-0 sutures (Ethicon) or with continuous Prolene
1-0 sutures. Closure is done over a Jackson-Pratt drain. Skin clo-
sure is done with Vicryl 2-0 and Vicryl 3-0 (Fig. 37.16).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Intercostal nerves. The intercostal nerves are sacri ced
with the harvest of the rectus abdominis muscle ap.
These can be used to neurotize the ap to provide a func-
tional muscle ap.

37 Rectus Abdominis Muscle Flaps
413
Fig. 37.15 The underside of the rectus abdominis muscle ap is shown with the deep infe-
rior epigastric pedicle.
a
Fig. 37.16 Skin closure. (a) The anterior rectus sheath is closed securely with Prolene 1-0
and 2-0 sutures with care not to catch the posterior rectus sheath. (b) Skin closure is com-
pleted with Vicryl 3-0 sutures and Prolene 4-0 to the dermis.
b

414
II Reconstructive Flaps A-to-Z

Reconstruction of Tibia
Osteomyelitis with Rectus
Abdominis Muscle Flap
The patient is a 30-year-old m an with chronic osteomyelitis af-
fecting the distal third of the tibia (Fig. 37.17a–c). The surgical
plan is for debridement of the infected bone and coverage with a
rectus abdominis m uscle ap and split skin graft. In view of the
scarred limb, the plan was to explore the posterior tibia artery
proximally and distally to assess the suitability for use as a recip-
ient vessel.
Microanastomosis of the ap was completed under the oper-
ating microscope. The deep inferior epigastric artery (arrow ) was
anastomosed end-to-end to the posterior tibia artery and the ve-
nae comitantes to the respective venae comitantes of the poste-
rior tibia artery (Fig. 37.17d). The ap is inset over the defect and
split skin graft is laid over the muscle. Penrose drains were used.
The patient’s recovery was uneventful. Fig. 37.17e shows the
well-healed donor site and Fig. 37.17f shows the ap fully healed
at the 6-month follow-up.
Identi ed and preserved:

●
Anterior rectus sheath. Minimal rectus sheath is harvested
so as to allow tension-free closure of the donor site defect.
Preservation of the anterior sheath particularly below the
arcuate line will reduce incidence of bulge and abdominal
hernia. A synthetic mesh or acellular dermal matrix can be
used for sheath closure if there is excessive tension.

●
External iliac artery. The deep inferior epigastric artery is
ligated just as it branches from the external iliac artery.

Clinical Perspectives
The rectus abdom inis m uscle ap can be raised as a pedicled ap
or a free ap. As a pedicled ap for regional use, it can be em -
ployed for reconstruction of the anterior chest wall or for defects
in the groin and perineal region. As a free ap, it can be used for
reconstruction of head and neck and upper or lower limb defects.
Modi cation of the ap harvest enables the use of this ap for
breast reconstruction, functional muscle transfer for facial reani-
mation, and vagina reconstruction.
Fig. 37.17 Chronic osteomyelitis. (a) Chronic os-
teomyelitis of the right tibia has led to multiple
discharging sinuses and scarring of the overlying
skin. (b) Anterior view of the right leg. (c) Inset
of the rectus ap: the deep inferior epigastric ar-
tery was anastomosed end-to-end to the posterior
tibial artery and the venae comitantes was anas-
tomosed end-to-end to the posterior tibial venae
comitantes. (continued)
a
b
c

37 Rectus Abdominis Muscle Flaps
415

Hints and Tips
1. This is one of the m ost versatile aps in reconstructive m icro-
surgery. This is due to its central location and the dual supply,
which enables it to be used as a pedicled or free ap. As a
pedicled ap, the rectus abdominis can reach superiorly up to
the upper manubrium to reconstruct sternal defects and infe-
riorly to reconstruct proxim al thigh or groin defects, as well
as defects of the pelvis, vagina, and perineum centrally. The
size of the muscle bulk is substantial and a skin paddle can
be included with the ap. The ap can also be neurotized for
functional muscle transfer.
2. Midline scars are not a contraindication for use of the rectus
abdominis muscle ap. Good preoperative planning allows the
general surgeon to assess the abdominal cavity via a midline
incision while preserving the rectus m uscle. It is also crucial
to site the ostomy site on the contralateral abdominal wall.
3. The presence of a Kocher subcostal incision over the rectus
muscle is an absolute contraindication for use of an ipsilat-
eral superiorly based rectus muscle ap. Prior harvest of the
internal mam m ary artery for cardiac bypass surgery is a rel-
ative contraindication for use of a superiorly based rectus
abdominis ap if there is a contralateral rectus muscle. The
muscle has been shown to survive reliably via transposition
based on the eighth intercostal vessels.
4. Previous surgery involving the external iliac vessels is a con-
traindication to the use of the inferiorly based rectus m uscle
ap unless patency of the inferior epigastric artery is con-
rmed with preoperative arteriography. Prior pelvic surgery
through a Pfannenstiel incision will generally not preclude the
Fig. 37.17 (continued) (d) The rectus abdominis ap was inset over the
defect with tie-over tulle-gras (TG) bolsters over Penrose drains. (e) The
donor site scar has healed well without any bulge or herniation. The skin
graft donor site over the right thigh has also epithelized. (f) Six months
after the operation, the reconstructed limb has healed well and the
patient is ambulating without assistance.
d
e
f

416
II Reconstructive Flaps A-to-Z
use of this ap. The deep inferior epigastric vessels are rarely
violated in gynecologic surgery. However, adhesions between
the deep surface of the inferior rectus m uscle and the pelvic
viscera may be present.
5. Dissection of the deep inferior epigastric artery pedicle to its
source vessel (external iliac artery) will provide an additional
2 cm of pedicle length. The size of the artery and vein will also
be larger.
6. During the dissection of the rectus muscle o the posterior
sheath, care must be taken inferior to the arcuate line of
Douglas (Fig. 37.10) as the peritoneum is only separated by
the thin fascia transversalis.
7. The morbidity from the harvest of the rectus muscle is usually
acceptable due to the paired nature of this muscle and the
contributory strength of the oblique and transversalis m uscle.
Som e patients report dim inished m uscle strength and the in-
ability to do sit-ups. However, with time, most of the patients
report little or no negative impact on activities of daily living.
Suggested Further Reading
Bakri K, Mardini S, Evans KK, et al. Workhorse aps in chest wall re-
construction: the pectoralis m ajor, latissim us dorsi, and rectus
abdominis aps. Semin Plast Surg 2011;25(1):43–54
Brooks D, Buntic RF. Partial muscle harvest: our rst 100 cases attempt-
ing to preserve form and function at the donor site. Microsurgery
2008;28(8):606–611
Bunkis J, Walton RL, Mathes SJ. The rectus abdominis free ap for lower
extremity reconstruction. Ann Plast Surg 1983;11(5):373–380
Koshim a I, Soeda S. Inferior epigastric artery skin aps without rectus
abdominis muscle. Br J Plast Surg 1989;42:645
Koshim a I, Tsuda K, Hamanaka T, et al. One-stage reconstruction of
established facial paralysis using a rectus abdominis m uscle
transfer. Plast Reconstr Surg 1997;99(1):234–238
Mushara eh R, Macari G, Hayek S, Elhassan B, Atiyeh B. Rectus abdom inis
free-tissue transfer in lower extremity reconstruction: review of
40 cases. J Reconstr Microsurg 2000;16(5):341–345
Netscher DT, Eladoumikdachi F, Goodman CM. Rectus abdominis
m uscle aps used successfully for median sternotomy wounds
after ipsilateral internal mamm ary artery ligation. Ann Plast Surg
2001;47(3):223–228
O’Shaughnessy KD, Rawlani V, Hijjawi JB, et al. Oblique pedicled paraum -
bilical perforator-based ap for reconstruction of complex proxi-
m al and mid-forearm defects: a report of two cases. J Hand Surg Am
2010;35(7):1105–1110
Piza Katzer H, Balogh B. Experience with 60 inferior rectus abdominis
aps. Br J Plast Surg 1991;44:438–443
Shukla HS, Hughes LE. The rectus abdominis ap for perineal wounds.
Ann R Coll Surg Engl 1984;66(5):337–339
Soltanian CG, Zochowski K, Chepla J, et al. The rst m uscular branch of
the deep inferior epigastric artery: an anatomical study and clinical
applications. Plast Reconstr Surg 2012;129(2):463–468
Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric
(inferior rectus abdominis) ap. Br J Plast Surg 1984;37:330–350
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

417
2. Draw a straight line from the anterior superior iliac spine
(ASIS) to the midpoint of the patella.
3. Mark the incision line as a “lazy S” or wide zigzag centered on
the straight line connecting the ASIS and patella (Figs. 38.2
and 38.3).

Classi cation

●
Mathes-Nahai type II muscle ap

Vascular Pedicle
The rectus fem oris m uscle is a bipennate and fusiform -shaped
muscle (Fig. 38.1). It is a central muscle of the quadriceps exten-
sor muscle group lying between the vastus lateralis and medialis
muscles. It originates from the anterior inferior iliac spine and
the groove above the acetabulum and inserts on the patella. The
descending branch of the lateral circum ex femoral artery (LCFA)
is the dom inant blood supply to the rectus fem oris m uscle. The
LCFA is a direct branch o the profunda femoris (deep femoral)
artery. There are two minor pedicles to this muscle. The ascend-
ing branch of the LCFA and venae com itantes supply the proxim al
portion of the muscle. Muscular branches of the super cial fem -
oral artery (SFA) and venae comitantes supply the distal third of
the muscle.

●
Mean arterial caliber of descending branch of LCFA:
2.1 m m

●
Mean venous caliber of LCFA venae comitantes: 2.3 mm

●
Length: the length of the pedicle is 5 cm

●
Motor innervation: The muscular branch from the femoral
nerve enters the muscle on its medial aspect in the proxi-
mal portion of the muscle. It is found adjacent to the dom -
inant vascular pedicle.

Patient Positioning
The patient is placed in the supine position for harvest of the
rectus fem oris ap. The hip joint should be in neutral position.
The knee joint can be extended; alternatively, a stack of tow-
els m ay be placed in the popliteal fossa to create slight knee
exion.

Surface Markings
1. Place the patient in the supine position with the hip joint in a
neutral position and the knee extended or slightly exed.
Rectus Femoris Muscle Flaps
Sachin M. Shridharani and Anthony P. Tufaro
38
Fig. 38.1 Anatomic diagram of the rectus femoris  ap: 1, femoral ar-
tery; 2, profunda femoris artery; 3, lateral circum ex femoral artery; 
4, descending branch; 5, ascending branch; 6, rectus femoris muscle.1

418
II Reconstructive Flaps A-to-Z
Step 4: Elevation of Skin Flaps
Elevate medial and lateral adipocutaneous aps at the level of the
muscle fascia. Extend the aps to the medial and lateral borders
of the muscle (Fig. 38.4b).
Step 5: Identifying Critical
Structures
Perform meticulous dissection at the proximal medial border of the
incision and identify the sartorius muscle as it passes from lateral
to medial. Preserve this anatomic region. The vascular pedicle (de-
scending branch of LCFA) is located by retracting the sartorius muscle
medially. Furthermore, preserving this region will protect muscular
branches of the femoral nerve. The LCFA and its descending branch
are located approximately 10 cm distal to the ASIS (Fig. 38.4c).
Step 6: Raising the Flap
Carefully incise the fascia between the medial and lateral edge of
the rectus fem oris and its adjacent m uscles: vastus m edialis and
vastus lateralis, respectively. The tensor fascia lata (TFL) is located
lateral to the rectus femoris proximally.

Raising the Flap
Step 1: Prepare the Limb
Prep the anterior surface of the lower extrem ity from the lower
abdominal wall to the tibial tuberosity. Drape the extremity so
the entire anterior surface of the thigh is exposed. The surgeon
must plan for the possible need of skin graft for the m uscle it-
self or the donor site. Therefore, prep and drape the contralateral
thigh in the same manner.
Step 2: Surgical Planning
The rectus fem oris m uscle can be m obilized in its near entire-
ty once it is disinserted o the patella. Ensure that the muscular
portion of the ap will reach the defect.
Step 3: Incision
Incise the previously marked “lazy S” or zigzag line through skin
and subcutaneous fat. Continue the dissection until the overlying
muscle fascia is visualized. Obtain meticulous hemostasis during
this portion of the procedure (Fig. 38.4a).
Fig. 38.2 Incision planning for rectus femoris muscle harvest.1
Fig. 38.3 A straight line is drawn from the anterior superior iliac spine to the superior midpoint of the patella. This line 
acts as the central axis for the planned rectus femoris  ap. A line is drawn 10 cm distal to the ASIS to mark the pivot 
point of the  ap and location of the pedicle.

38 Rectus Femoris Muscle Flaps
419
Fig. 38.4 A 51-year-old man. (a) The initial incision is made through the dermis, subcutaneous tissue, and super cial 
fascia. The deep/overlying rectus femoris muscle fascia is visible. (b) Medial and lateral adipocutaneous  aps are raised 
at the level of the muscle fascia and extended to the medial and lateral borders of the muscle. (c) The muscle fascia is 
incised and the cleavage plane between adjacent muscles is visible. (continued)
a
b
c

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II Reconstructive Flaps A-to-Z
Fig. 38.4 (continued) (d) The rectus femoris is dissected free medially from the vastus medialis and deep from the 
underlying vastus intermedius. (e) The rectus femoris is dissected free laterally from the vastus lateralis and deep 
from the underlying vastus intermedius. (f) A Penrose drain is placed around the muscle to demonstrate the freed 
attachments from surrounding muscle. (continued)
d
e
f

38 Rectus Femoris Muscle Flaps
421
g
Fig. 38.4 (continued) (g) The muscle is disinserted from the patella. (h) The muscle is re ected proximally and underly-
ing fascia is visible. (i) A subcutaneous tunnel is created proximally to reach the groin defect. (continued)
h
i

422
II Reconstructive Flaps A-to-Z
j
k
l
Fig. 38.4 (continued) (j) The muscle  ap is carefully delivered into the defect. (k) Su cient length of muscle 
is demonstrated. (l) The donor site is closed primarily with a closed-suction drain. A skin graft is required for 
recipient site coverage, and a drain is placed deep to the muscle  ap.

38 Rectus Femoris Muscle Flaps
423
Step 13: Addressing the
Donor Site
Draw attention to the new donor site defect. Place at least one
round, channeled 15-French closed suction drain in the space
where the rectus femoris was anatomically situated. Bring
the drain out of the skin lateral or m edial to the patella. In a
tension-free manner, close as much of the incision as possible.
Depending on location and use of the m uscle ap, there will be
a need for skin graft coverage. If the muscle ap is buried, this
consideration is unnecessary.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required muscle and patellar tendon cu
Identi ed and preserved:

●
Sartorius

●
Muscle branches of motor nerve

Flap Variations
This ap can be used as a myocutaneous ap and as a free tis-
sue transfer (Fig. 38.5). In instances where the surgeon plans
on employing a myocutaneous ap, lim it the skin territory to
the area between the sartorius and TFL at the upper third of the
thigh. The m aximum dim ensions of the skin island are 10 cm
width 3 30 cm length. The myocutaneous ap can be unreliable
when patients are obese secondary to perforator unreliability
and in the distal third of the thigh, in general. Furtherm ore, there
can be wound complications and the donor site often requires
skin grafting.
The ap can also be used as a free tissue transfer. The ves-
sel caliber and pedicle length are conducive for successful
microvascular anastom osis. This ap is not com m only employed,
however, due to donor site morbidity. The rectus femoris muscle
is a key muscle in the quadriceps group. Removal of this muscle
will lead to weaker knee terminal extension.

Clinical Perspectives
The rectus femoris m uscle ap is utilized to reconstruct defects
of the lower abdomen, groin, perineum, ischium, and contra-
lateral groin. A rectus femoris ap is preferable to a TFL ap in
reconstructions of the lower abdominal wall as the latter needs
to pivot more laterally and has a less reliable skin island. It is a
hearty muscle ap with reliable blood supply. In addition, the
muscle is well described as a free tissue transfer for patients
Step 7: Isolating the Muscle
Medially and Deep
Beginning on the distal m edial edge of the m uscle, continue to
separate the rectus femoris from the vastus medialis. Continue
the dissection to the deep aspect of the m uscle so that it is free
from the underlying vastus intermedius (Fig. 38.4d).
Step 8: Isolating the Muscle
Laterally
Complete circumferential isolation of the distal rectus femoris
muscle by total elevation of the muscle from the vastus lateralis
(Fig. 38.4e).
Step 9: Disinsertion of the Muscle
Now that the m uscle is free circum ferentially, isolate its ten-
dinous insertion on the patella. Leave a 1-cm cu of tendon
on the m uscle ap and transect the tendon at this point. This
w ill free the m uscle from its bony attachm ent. Place an Allis
clamp on the tendon and use it as a handle for Step 10, next
(Fig. 38.4f).
Step 10: Mobilizing the Muscle
In a distal to proximal manner, completely free the rectus femoris
in the loose areolar plane from all surrounding m uscles. Avoid
injury to the m uscular branches of the femoral nerve. Carefully
isolate and ligate sm all vascular perforators to the m uscle. The
dissection proceeds to where the sartorius muscle crosses over
the anterior portion of the muscle. This landmark is approxi-
mately 10 cm distal to the ASIS and represents the location of the
vascular pedicle (Fig. 38.4g–i).
Step 11: Insetting the Flap
Placing sutures through the muscle can often lead to muscle and
vascular injury. Furthermore, there is a tendency for the muscle
to tear as sutures are tied. Therefore, use the distal preserved pa-
tellar tendon cu to inset the muscle ap. The cu of tendon can
withstand large- and small-caliber sutures with varying tensions
placed on the insertion (Fig. 38.4j–l).
Step 12: Stabilizing the Patellar
Tendon
It is advised to suture the vastus lateralis tendon to the vastus
medialis tendon with the rem nant of the rectus fem oris tendon
interposed between the two adjacent tendons. The authors em -
ploy multiple 2-0 braided polyester sutures. In addition, reap-
proximate the fascia of the distal third of the vastus lateralis to
the vastus medialis.

424
II Reconstructive Flaps A-to-Z
Fig. 38.5 (a) Rectus femoris myocutaneous  ap design: the skin territory is 
limited to the area between the sartorius and TFL at the upper third. The max-
imum cutaneous  ap size is 10 cm 3  30 cm. (b) Flap elevation: 1, rectus femo-
ris muscle; 2, sartorius; 5, lateral circum ex femoral artery; 7, femoral nerve.1
a
b
requiring functional muscle transfer— facial reanimation and up-
per extremity. See the case shown in Fig. 38.6.

Hints and Tips
1. Cross-hatching fasciotomy of the deep surface of the muscle
will increase the length and width of the muscle ap. Per-
form this maneuver with a no. 15 blade and avoid cutting into
the muscle. Furthermore, this maneuver optimizes skin graft
take if the m uscle is being used as a turnover ap (Fig. 38.6b).
2. Disinserting the origin of the muscle o the anterior inferior
iliac spine and acetabulum rim will allow for islandizing the
ap and increased m obility for m edial thigh/groin and lower
abdominal wall wound coverage.
3. As the surgeon increases his/her experience w ith the ap, it
is not always necessary to m ake a full anterior thigh incision.
Make the proxim al incision halfway dow n the thigh. Iden-
tify the rectus fem oris and its m edial and lateral borders.
Create an adipocutaneous tunnel directly over the m uscle.
This tunnel should proceed distal until the tendinous in-
sertion is visualized. Use a lighted retractor to retract the
newly created adipocutaneous ap. Make a lim ited counter
incision proxim al to the proxim al edge of the patella. Under
direct visualization, locate the rectus fem oris tendon and
transect this tendon leaving a 1-cm cu . Pull the m uscle
proxim ally to visualize the correct tendon. Refer to Steps 6
to 10.
4. Severe atherosclerotic disease may compromise the blood
supply a orded by the lateral circum ex branch of the

38 Rectus Femoris Muscle Flaps
425
a
Fig. 38.6 The same clinical case as Fig. 38.4. (a) Resultant defect in the groin of a 51-year-old
man who previously underwent revision axial artery to femoral artery bypass and femoral artery 
to femoral artery bypass. The patient developed a postoperative hematoma, wound dehiscence, 
and bypass graft exposure. (b) The underlying fascia is cross-hatched for increased width and inset.
(c) The donor site is closed primarily and skin graft placed onto the muscle  ap.
b
c

426
II Reconstructive Flaps A-to-Z
Ger R, Duboys E. The prevention and repair of large abdom inal-wall de-
fects by m uscle transposition: a prelim inary comm unication. Plast
Reconstr Surg 1983;72:170–178
Koshim a I, Moriguchi T, Soeda S, Hamanaka T, Tanaka H, Ohta S. Free
rectus femoris muscle transfer for one-stage reconstruction of es-
tablished facial paralysis. Plast Reconstr Surg 1994;94:421–430
Madariaga J, Duboys EB, Stern JT. Use of contralateral rectus fem oris ap:
an alternative for covering exposed femoral vessels of the thigh.
J Surg Oncol 1989;41:206–209
Peters W, Cartotto R, Morris S, Jewett M. The rectus fem oris myocutane-
ous ap for closure of di cult wounds of the abdomen, groin, and
trochanteric areas. Ann Plast Surg 1991;26:572–576
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and
Operative Approaches. 2nd ed. New York, NY: Thieme; 2006
femoral artery. This can be identi ed in at-risk patients by
preoperative angiogram.
Suggested Further Reading
Arnold PG, Witzke DJ. Management of failed total hip arthroplasty with
muscle aps. Ann Plast Surg 1983;11:474–478
Bell MS, Earnshaw PH. Rectus femoris myocutaneous aps for trochanteric
ulcers. Can J Surg 1981;24:496–497
Bhagwat BM, Pearl RM, Laub DR. Uses of the rectus fem oris myocutane-
ous ap. Plast Reconstr Surg 1978;62:699–701
Freedman AM, Gayle LB, Vaughan ED, Ho man LA. One-stage repair of the
anterior abdominal wall using bilateral rectus femoris myocutane-
ous aps. Ann Plast Surg 1990;25:299–302
Ger R. The surgical managem ent of decubitus ulcers by muscle transposi-
tion. Surgery 1971;69:106–110