Flaps Practical Reconstructive Surgery

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New York • Stuttgart • Delhi • Rio de Janeiro
Flaps
Practical Reconstructive Surgery
Professor Kayvan Shokrollahi, MSc, LLM, FRCS(Plast)
Consultant Burns, Plastic, and Laser Surgeon
Clinical Lead, Mersey Regional Burns Service
Mersey Regional Burns and Plastic Surgery Unit
Whiston Hospital
Liverpool, England, United Kingdom
Professor Iain S. Whitaker, MA(Cantab), PhD, FRCS(Plast)
Professor of Plastic and Reconstructive Surgery
Reconstructive Surgery & Regenerative Medicine Research Unit
Swansea University Medical School
Honorary Consultant Reconstructive Plastic Surgeon
The Welsh Centre for Burns and Plastic Surgery
Swansea, Wales, United Kingdom
Professor Foad Nahai, MD, FACS, FRCS(Hon), FRCST(Hon)
The Maurice J. Jurkiewicz Chair in Plastic Surgery
Professor of Surgery
Department of Surgery
Emory University
Atlanta, Georgia, USA
with 1401 illustrations

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Library of Congress Cataloging-in-Publication Data
Names: Shokrollahi, Kayvan, editor. | Whitaker, Iain S., editor. | Nahai,
Foad, 1943- editor.
Title: Flaps : practical reconstructive surgery / [edited by] Kayvan Shokrollahi,
Iain S. Whitaker, Foad Nahai.
Other titles: Flaps (Shokrollahi)
Description: New York : Thieme, [2017] | Includes bibliographical references
and index.
Identi ers: LCCN 2016035628| ISBN 9781604067156 | ISBN 9781604067163
(eISBN)
Subjects: | MESH: Surgical Flaps | Reconstructive Surgical Procedures—
m ethods | Microsurgery—methods | Wound Healing
Classi cation: LCC RD119 | NLM WO 610 | DDC 617.9/52—dc23
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Dedicated to the past masters of the art and science of plastic surgery upon whose shoulders we stand;
and also to those now learning, to whom we o er our own shoulders via this book,
so that you may one day stand yet taller and see still further than us.

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vii
Contents
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Menu of Accompanying Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
Section I. Planning and Decision Making in Reconstructive Surgery
Chapter 1
Basic Principles of Reconstructive Surgery and Flaps
Parneet Gill and Kayvan Shokrollahi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 2
Microsurgery
Christopher G. Wallace and Fu-Chan Wei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Chapter 3
Preoperative Im aging for Reconstructive Flap Planning
Warren M. Rozen and Vachara Niumsawatt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Chapter 4
Current Options for Breast Reconstruction Following Mastectomy
Matthew R. Endara and Maurice Y. Nahabedian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Chapter 5
Current Options for Perineal Reconstruction
Sachin M. Shridharani, Raja Mohan, and Justin M. Sacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Chapter 6
Current Options for Head and Neck Reconstruction
Sachin M. Shridharani, Justin L. Bellamy, Justin M. Sacks, and Anthony P. Tufaro . . . . . . . . . . . . . . . . . . . 79
Chapter 7
Current Options for Lower Limb Reconstruction
Sujatha Tadiparthi and Kayvan Shokrollahi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Chapter 8
Recipient Vessels for Microsurgery
Amir Sadri, David M. S. Bodansky, and Kayvan Shokrollahi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Chapter 9
The Internal Mamm ary System as Recipient Vessels for
Breast Microsurgical Reconstruction
Moustapha Hamdi and Mohamed Zulf kar Rasheed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Chapter 10
The Thoracodorsal System as Recipient Vessels for
Breast Microsurgical Reconstruction
Nicolas A. Guay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Chapter 11
Postoperative Monitoring of Microvascular Free Flaps
Zita M. Jessop, Warren M. Rozen, and Iain S. W hitaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Section II. Reconstructive Flaps A-to-Z
Chapter 12
Anterolateral Thigh Free Flaps
Christopher G. Wallace and Fu-Chan Wei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Chapter 13
Anterolateral Thigh Pedicled Flaps
Sachin M. Shridharani, Raja Mohan, and Justin M. Sacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 14
Deep Circum ex Iliac Artery Flaps
Russell J. Corlett and G. Ian Taylor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

viii
Contents
Chapter 15
Deep Inferior Epigastric Artery Perforator Flaps and Super cial Inferior
Epigastric Artery Flaps for Breast Reconstruction
Moustapha Hamdi and Ali M. Ghanem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Chapter 16
Deltopectoral Flaps for Head and Neck Reconstruction
Rowan D. Gillies and Pouria Moradi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Chapter 17
Fibula Osteoseptocutaneous Flaps
Christopher G. Wallace and Fu-Chan Wei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Chapter 18
Gastrocnem ius Muscle Flaps for Lower Lim b Reconstruction
Duncan Atherton, Pouria Moradi, Shehan Hettiaratchy, and Jagdeep Nanchahal . . . . . . . . . . . . . . . . . . 224
Chapter 19
Gracilis Muscle and Myocutaneous Flaps
Cedric Hunter, Gordon K. Lee, and Michael W. Findlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Chapter 20
Groin and Super cial Circum ex Iliac Perforator Flaps
Terence Goh, Kok Chai Tan, and Joon Pio Hong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Chapter 21
Inferior Gluteal Artery Musculocutaneous Flaps
Damien Grinsell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Chapter 22
Jejunal Flap Reconstruction for Circum ferential Pharyngolaryngectomy Defects
Pouria Moradi, Charles A. T. Durrant, and Sim on H. Wood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Chapter 23
Design, Principles, and Variations of Keystone Flaps
Michael W. Findlay, Gordon K. Lee, and Felix C. Behan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Chapter 24
Keystone Flaps for Lower Lim b Reconstruction
Michael W. Findlay, Dominik Duscher, and Gordon K. Lee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Chapter 25
Keystone Flaps for Reconstruction in the Trunk
Michael W. Findlay, Peter C. Neligan, and W illiam M. Kuzon Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Chapter 26
Keystone Flaps for Reconstruction in the Upper Lim b
Michael W. Findlay, Zeshaan N. Maan, and Gordon K. Lee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Chapter 27
Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
Michael W. Findlay, Sarah N. Bishop, and Gordon K. Lee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Chapter 28
Lateral Arm Free Flaps for Head and Neck Reconstruction
Pouria Moradi and Kevin Ho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Chapter 29
Latissim us Dorsi Free Flaps
Sachin M. Shridharani, Adriana G. Ramirez, Raja Mohan, and Justin M. Sacks . . . . . . . . . . . . . . . . . . . . 348
Chapter 30
Latissim us Dorsi Pedicled Flaps
Mohamed Zulf kar Rasheed and Moustapha Hamdi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Chapter 31
Pedicled Om ental Flaps for Sternal Reconstruction
Pouria Moradi, Charles A. T. Durrant, and Simon H. Wood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Chapter 32
Pectoralis Major Muscle Flaps
Sachin M. Shridharani and Devinder P. Singh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Chapter 33
Pectoralis Major Myocutaneous Flaps
Sachin M. Shridharani and Devinder P. Singh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Chapter 34
Gluteal Thigh Flaps
Sarah I. Fernandez and Bruce A. Mast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Chapter 35
Posterior Thigh Perforator Flaps
Sarah I. Fernandez and Bruce A. Mast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Chapter 36
Radial Forearm Fasciocutaneous Flaps
Terence Goh and Chin-Ho Wong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Chapter 37
Rectus Abdom inis Muscle Flaps
Terence Goh and Kok Chai Tan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Chapter 38
Rectus Fem oris Muscle Flaps
Sachin M. Shridharani and Anthony P. Tufaro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Contents
ix
Chapter 39
Scapular Flaps, Parascapular Flaps, Circum ex Scapular Artery Perforator Flaps, and
Scapular Osteocutaneous Flaps
Stuart B. Watson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Chapter 40
Superior Gluteal Artery Perforator Flaps
Phillip Blondeel, Koenraad Van Landuyt, John W. Antonetti, and Richard Young . . . . . . . . . . . . . . . . . . . 434
Chapter 41
Soleus Flaps
Sachin M. Shridharani and Devinder P. Singh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
Chapter 42
Reverse Sural Flaps
Sachin M. Shridharani, Tom S. Potokar, Kayvan Shokrollahi, and Anthony P. Tufaro . . . . . . . . . . . . . . . 460
Chapter 43
Thoracodorsal Artery Perforator Flaps
Phillip Blondeel, Koenraad Van Landuyt, Richard Young, and John W. Antonetti. . . . . . . . . . . . . . . . . . . 469
Chapter 44
Tensor Fascia Lata Perforator-Based Island Flaps
Sang W ha Kim , Jeong Tae Kim, and Youn Hwan Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
Chapter 45
Transverse Myocutaneous Gracilis Free Flaps
Stefan O. P. Hofer and Caroline E. Payne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
Chapter 46
Temporoparietal Fascia Flaps
Terence Goh, Ying Chien Tan, and Kok Chai Tan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Chapter 47
Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
Simon G. Talbot and Julian J. Pribaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
Chapter 48
Free Transverse Rectus Abdominis Musculocutaneous Flaps for Breast Reconstruction
Maurice Y. Nahabedian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
Chapter 49
Trapezius Flaps
Sachin M. Shridharani, Shyam M. Shridharani, and Justin M. Sacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Chapter 50
Ulnar Artery Forearm Fasciocutaneous Flaps
Adrian Sjarif and Pouria Moradi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Chapter 51
Vertical or Oblique Rectus Abdominis Myocutaneous Flaps for Perineal Reconstruction
Charles A. T. Durrant and Simon H. Wood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
Section III. Masterclasses in Reconstructive Flaps
Chapter 52
Meeting the Aesthetic Challenges of Complex Facial Reconstructions
Marc A. M. Mureau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
Chapter 53
Nasal Reconstruction
Lisha McClelland and Nicholas Spencer Jones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Chapter 54
Facial Allo aps for Face Transplantation
Edward W. Swanson, Devin O’Brien Coon, Ryan J. Murphy, Mehran Armand, and
Chad R. Gordon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608
Chapter 55
Facial Artery Perforator Flaps for Perioral Soft Tissue Defects
Stefan O. P. Hofer and Caroline E. Payne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Chapter 56
Facial Artery Musculom ucosal Flaps
Brian M. Parrett and Julian J. Pribaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
Chapter 57
Parascapular Cutaneous Axial Flaps
Bruce A. Mast and Richard B. Nesmith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Chapter 58
Radial Forearm Flaps
Loretta Coady-Fariborzian and W inston T. Richards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
Chapter 59
Dorsalis Pedis Flaps
Loretta Coady-Fariborzian and W inston T. Richards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
Chapter 60
Understanding the Rhom boid Flap: The 20-Degree Rule
Jonathan D. Morton and Rowan Pritchard Jones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633

Chapter 61
Quaba Flaps
Omar Quaba and Aw f Quaba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
Chapter 62
Spinal Reconstruction with Free Vascularized Bone Flaps
Henri A. H. W inters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
Chapter 63
Muscle-Sparing Latissim us Dorsi Flaps
Kathryn Hamnett and Azhar Iqbal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
Chapter 64
Reconstruction of Full-Thickness Orom andibular Defects
Henri A. H. W inters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
Chapter 65
Principles of Flap Reconstruction for Burns
Shehab Jabir, Quentin Frew, Naguib El-Muttardi, Odhran Shelley, and Peter Dziew ulski . . . . . . . . . . . 664
Chapter 66
Local Perforator Flap Reconstruction in the Surgical Mission Setting
Yvette Godw in, Bernardo Righi, and Enrico Robotti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Chapter 67
Peroneus Brevis Muscle Flaps for Lower Lim b Reconstruction in Burns or Traum a
Dilnath Gurusinghe, David Bell, and Kayvan Shokrollahi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .691
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Contents

xi
About the Editors
Professor Kayvan Shokrollahi is a Burns, Plastic, and Laser Surgeon and clinical lead for the regional burns
centre at the Mersey Regional Burns and Plastic Surgery Unit in Liverpool, England. He is Editor-in-Chief of
the international journal Scars, Burns & Healing, which rem ains the world’s only peer-reviewed scar journal.
He is Associate Editor of the journal Annals of Plastic Surgery, and Chairm an of the noted charity The Katie
Piper Foundation. He graduated from Bristol University with both a Bachelor of Science degree with rst
class honours in Cellular and Molecular Pathology and a degree in Medicine. He went on to graduate with
both a Masters in Clinical Engineering and subsequently a Masters in Law with commendation, having de-
veloped a speci c interest in consent for medical treatment and the ethics and law related to medicine. He
was awarded the Hunterian Professorship of the Royal College of Surgeons in 2007, and has delivered nu-
merous guest and keynote lectures around the world. Professor Shokrollahi has won various prizes, grants,
and scholarships including from the British Association of Plastic, Reconstructive and Aesthetic Surgeons,
Bristol University, the Pathological Society of Great Britain, and The Healing Foundation. He has a strong academic and research inter-
est having published over seventy peer-reviewed articles in the scienti c literature. He has written a number of textbooks including
those currently in press such as the Oxford Specialist Handbook: Burns and Multiple Choice Questions in Plastic Surgery. He has written
dozens of book chapters on a variety of reconstructive, aesthetic, scienti c, and legal subjects relevant to his diverse interests and ex-
pertise. He is an authority in a number of clinical areas including scars and burns, laser treatment in the context of both skin oncology
and scar management, as well as pediatric ear surgery and is current writing the textbook Laser Managem ent of Scars (Springer).
Outside of clinical m edicine, Professor Shokrollahi is an accomplished composer and pianist with his original music and perfor-
mances having reached 153rd in the all-time top 500 Classic FM charts in Europe under the pseudonym Shokolat. His music is widely
available including via digital and online platforms, in addition to CDs and sheet music. In addition, he is a regularly exhibiting artist
and sculptor with art works available internationally through Saatchi Gallery Online.
Professor Iain S. Whitaker is the Professor of Plastic Surgery at the Welsh Centre for Burns and Plastic
Surgery and Swansea University Medical School. He com bines a clinical practice (both acute care and elec-
tive surgery) with the developm ent of an active research program . He is the Director of the Reconstructive
Surgery & Regenerative Medicine Research Unit ( ) and Deputy Editor of Europe’s
largest reconstructive surgery journal, the Journal of Plastic, Reconstructive and Aesthetic Surgery
(JPRAS). After reading m edicine at Cam bridge University (Trinity Hall), Professor Whitaker completed
a sub- internship in Plastic Surgery at Harvard Medical School, followed by plastic, reconstructive, and
aesthetic surgery training in Yorkshire, Wales, Sweden, Australia, and France. During his training Profes-
sor Whitaker was awarded num erous prizes from the British Association of Plastic, Reconstructive and
Aesthetic Surgeons (BAPRAS) and the Royal College of Surgeons. He completed prestigious fellowships in
Melbourne, Australia (The Rowan Nicks Award, Royal Australasian College of Surgeons) and Paris ( European
Association of Plastic Surgeons Young Plastic Surgeon Scholarship).
Professor Whitaker has published over 150 articles, with a Hirsch Index of 30, edited several textbooks, and written in excess of
25 book chapters. He currently sits on the BAPRAS research council and in addition to his role at JPRAS is the Chief Specialty Editor for
Frontiers in Surgery, Associate Editor of the Annals of Plastic Surgery, and is the regenerative m edicine lead for BMC Medicine. In collab-
oration with leading scientists at Swansea University, Professor Whitaker developed a doctoral and postdoctoral career path for plastic
surgeons in Wales, having drawn in millions of pounds of funding from a variety of sources including Welsh Assembly Government,
the Medical Research Council, Royal College of Surgeons, the British Association of Plastic, Reconstructive and Aesthetic Surgeons,
and the ABMU Health Board. His group’s research focuses on stem cell biology in combination with platform technologies such as 3D
printing to solve aesthetic and reconstructive problems safely and e ectively.
In his spare time, now that his own playing days are over, he enjoys following rugby. Professor Whitaker dedicates this book to his
wife and their greatest achievement, their daughter Lara.

xii
About the Editors
Professor Foad Nahai is a graduate of Bristol University in England, and is the Maurice J. Jurkiewicz Chair
in Plastic Surgery and Professor of Surgery at Emory University in Atlanta, Georgia. He is Editor-in-Chief
of Aesthetic Surgery Journal and the current president of the Am erican Association for the Accreditation of
Ambulatory Surgical Facilities. He is past president of the International Society of Aesthetic Plastic Surgery,
past president of the American Society for Aesthetic Plastic Surgery, former director American Board of
Plastic Surgery, and past chairman of the Plastic Surgery Research Council. He has published over 210 peer
reviewed articles, edited or co-edited 9 textbooks, and his writings have covered all aspects of reconstruc-
tive and aesthetic plastic surgery.
Professor Nahai is internationally recognized as an innovator in the eld of plastic surgery where he has
developed and re ned many procedures. His contribution to reconstructive surgery is extensive, including
the Mathes-Nahai classi cation of aps and the original description of the Tensor Fascia Lata ap as well
as numerous re nements and innovations in reconstructive surgery. The most recent book before this that he authored and edited,
published in 2011, is the second edition of his three-volume text entitled The Art of Aesthetic Surgery, and he has used his knowledge
and skills to contribute greatly to the advancement and safety of aesthetic surgery, the focus of the latter half of his career.
Professor Nahai has been invited to lecture and dem onstrate plastic surgical procedures all over the world. In addition to numerous
professional honours and awards, he is listed among the “Best Doctors in America,” and has been named by W Magazine as one of the
top plastic surgeons in the world.

xiii
Menu of Accompanying Videos
These videos have been edited, narrated, and demonstrated by Iain R. Mackay of the Canniesburn Plastic Surgery Unit, Glasgow Royal
In rmary, and Department of Anatomy, Glasgow University, Glasgow, Scotland, United Kingdom. The Canniesburn Plastic Surgery Unit
has pioneered ap surgery over the decades and continues to provide internationally renowned ap and microsurgery training courses.
The videos are best viewed at the presented size and not maximized to full screen.
Video 1: First Dorsal Metacarpal Artery Flap
Video 2: Becker Flap
Video 3: Deltopectoral Flap
Video 4: Distal Fasciocutaneous Flaps of Lower Limb
Video 5: Fibular Flap
Video 6: Gastrocnemius Flap
Video 7: Gracilis Flap
Video 8: Lateral Arm Flap
Video 9: Latissimus Dorsi Flap
Video 10: Pectoralis Minor Flap
Video 11: Pectoralis Major Flap
Video 12: Posterior Interosseous Flap
Video 13: Radial Forearm Flap
Video 14: Scapular Flap
Video 15: Temporal Artery Flap
Video 16: Trapezius Flap

xiv
Preface
Flaps are an essential tool in our reconstructive armamentarium,
and a good working knowledge of ap surgery provides the back-
bone of surgical practice through which we restore form and
function. This book and its accompanying videos bring together
the cumulative experience of the leading pioneers and educators in
reconstructive surgery from around the world to demonstrate and
simplify ap surgery, focusing on the most useful and common aps
and the most advanced and cutting-edge methods. The aim is not to
be a ap encyclopedia, but more helpfully to be a source of reference
of reliable and workhorse aps to reconstruct the majority of ana-
tomical defects seen in the course of general and specialist recon-
structive surgery. These are outlined in as safe and e ective a way
as possible and presented in a step-by-step format from planning
to execution. We are excited that many series in this book demon-
strate ap surgery in details heretofore never described.
Overview chapters for each major anatomical area provide a
general approach to reconstruction with a choice of recom mended
aps. Workhorse aps are then presented in greater detail in the
A-Z of aps. Masterclasses are presented at the end of the book,
and this important section is packed with state-of-the-art inno-
vations, personal experiences, and challenging reconstructions
and will m aintain the freshness of each subsequent edition of
the book as techniques evolve and further interesting material
becomes available to our readers.
Our plan to regularly update the inform ation presented
herein is best underscored by Professor Foad Nahai’s recollec-
tions: “My involvem ent w ith this book was cause for re ection.
Re ection and rem iniscence which took m e back to the late
1970s when Stephen Mathes and I, as trainees, laid plans for
the Atlas of Muscle and Musculocutaneous Flaps. We were
encouraged in our e orts by our m entors Maurice Jurkiew icz,
Luis Vasconez, John Bostw ick, John McCraw, and P. G. Arnold,
all of whom were pioneers in the developm ent of m uscle and
m usculocutaneous aps. We have certainly com e a long way
since then. So m uch has changed; so m any new aps, with
m ore sophistication in clinical applications. Flap descriptions
and dissections are m ore detailed, accompanying artwork all in
color w ith complex clinical examples of the aps. In short, when
I compare our initial e orts to describe the blood supply and arc
of rotation of m uscle aps w ith this work I realize how fortunate
I have been to be a part of and to have w itnessed the evolution
of our specialty.”
We hope and expect that you will nd this book and its ac-
companying videos useful to your practice.
Professor Kayvan Shokrollahi, MSc, LLM, FRCS(Plast)
Professor Iain S. W hitaker, MA(Cantab), PhD, FRCS(Plast)
Professor Foad Nahai, MD, FACS, FRCST(Hon)
Join the ap community at:
w w w.thef apbook.com

xv
Thanks also to those editorial assistants that have facilitated
the coordination of the manuscript, including Jamie Howie and
Thomas Hayes, and to project manager Luke Whitmore.
Last but not least we thank our friends, fam ilies, and loved
ones who have supported us through thick and thin.
Many thanks to artist Steve Atherton and the Departm ent
of Medical Illustration of Morriston Hospital for the m asterful
three-dimensional illustration shown on the front cover.
We are grateful to the num erous international experts who have
contributed to this book, many of whom were the rst to de-
scribe or popularize the techniques herein. Especial thanks go to
our publisher, Thieme, whose people have diligently shaped this
book into its nal form . We are particularly grateful to the ac-
cess granted by Thiem e to their considerable and world-class im -
age library, and to the authors and illustrators of those books in
which these illustrations rst appeared, as well as to the beautiful
new illustrations provided by artist Samantha Stutzman.
Acknowledgments

xvi
Contributors
John W. Antonetti, MD
Medical City Dallas
Dallas, Texas
Mehran Arm and, PhD
Member Principal Sta
The Johns Hopkins University Applied Physics Laboratory
Merle A. Tuve Associate Research Professor of Mechanical
Engineering
Faculty of Orthopaedic Surgery
The Johns Hopkins University
Baltimore, Maryland
Duncan Atherton, Bsc, MBBS, MD, FRCS(Plast)
Department of Plastic Surgery
Guys and St Thomas Hospital
London, England, United Kingdom
Felix C. Behan, MBBS, FRCS, FRACS
Adjunct Associate Professor
Consultant Plastic and Reconstructive Surgeon
Department of Surgery
University of Melbourne
Melbourne, Australia
David Bell, MBBS, MD, FRCS(Plast), DipHandSurg (UoM/BSSH)
Mersey Regional Burns Centre
Mersey Regional Burns and Plastic Surgery Unit
Whiston Hospital
Liverpool, England, United Kingdom
Justin L. Bellamy, MD
Plastic and Reconstructive Surgery Resident
Hansjörg Wyss Department of Plastic Surgery
New York University Medical Center
New York, New York
Sarah N. Bishop, MD
Plastic and Reconstructive Surgery Fellow
Mayo Clinic College of Medicine
Rochester, Minnesota
Phillip Blondeel, MD, PhD
Professor and Chairman
Department of Plastic and Reconstructive Surgery
Gent University Hospital
Gent, Belgium
David M. S. Bodansky, BMedSc(Hons), MBChB, MRCS
SHO
Royal Liverpool Hospital
Liverpool, England, United Kingdom
Loretta Coady-Fariborzian, MD, FACS
Clinical Assistant Professor
University of Florida
Section Chief, Plastic and Reconstructive Surgery
Malcom Randall VA Medical Center
Gainesville, Florida
Devin O’Brien Coon, MD, MSE
Chief Resident, Plastic and Reconstructive Surgery
The Johns Hopkins Hospital and University of Maryland
Medical Center
Baltimore, Maryland
Russell J. Corlett, MBBS, FRACS
Consultant Plastic Surgeon
Royal Melbourne Hospital
Melbourne, Victoria, Australia
Charles A. T. Durrant, MBBS, BSc(Hons), MA, FRCS(Plast)
Clinical Lead for Plastic and Reconstructive Surgery
Mountbatten Department of Plastic Surgery
Queen Alexandra Hospital
Portsmouth, England, United Kingdom
Dominik Duscher, MD
Director of Plastic Surgery Research
Section of Plastic and Reconstructive Surgery
Johannes Kepler University
Linz, Austria
Peter Dziew ulski, FFICM, FRCS, FRCS(Plast)
Consultant in Plastic, Reconstructive and Burns Surgery
St. Andrews Centre for Plastic Surgery and Burns
Chelmsford, England, United Kingdom
Naguib El-Muttardi, FRCS(Plast)
Consultant in Plastic, Reconstructive and Burns Surgery
St. Andrews Centre for Plastic Surgery and Burns
Chelmsford, England, United Kingdom
Matthew R. Endara, MD
Plastic and Reconstructive Surgeon
Silver Cross Hospital
New Lenox, Illinois
Presence St. Joseph Medical Center
Joliet, Illinois
Little Company of Mary Hospital
Evergreen Park, Illinois
Ingalls Memorial Hospital
Harvey, Illinois

Contributors
xvii
Sarah I. Fernandez, MD
Division of Plastic and Reconstructive Surgery
University of Florida
Gainesville, Florida
Michael W. Findlay, MBBS, PhD, FRACS, FACS
Plastic, Reconstructive, and Hand Surgeon
The Peter MacCallum Cancer Center
The Neil Hamilton-Fairley Clinical Overseas Research Fellow
Royal Melbourne Hospital Department of Surgery
University of Melbourne
Melbourne, Australia
Clinical Instructor and Stanford Applied Regenerative
Medicine Fellow
Department of Surgery
Stanford University School of Medicine
Stanford, California
Quentin Frew, MRCS
Registrar in Plastic, Reconstructive and Burns Surgery
St. Andrews Centre for Plastic Surgery and Burns
Chelmsford, England, United Kingdom
Ali M. Ghanem, MD, PhD
Academic Plastic Surgery
Barts and the London School of Medicine and Dentistry
London, England, United Kingdom
Parneet Gill, MBChB, MSc, MRCS(Eng)
Plastic Surgery Registrar
Mersey Regional Burns and Plastic Surgery Unit
Whiston Hospital
Liverpool, England, United Kingdom
Rowan D. Gillies, MBBS, FRACS(Plast)
Department of Plastic Reconstructive and Burns Surgery
Royal North Shore Hospital
Sydney Medical School
University of Sydney
Department of Plastic and Reconstructive Surgery
Prince of Wales Hospital
Sydney, Australia
Yvette Godw in, FRCS
Médecins Sans Frontières/Doctors Without Borders (MSF)
London, England, United Kingdom
Terence Goh, MBBS, MRCS, FAMS(Plast)
Consultant
Plastic Reconstructive and Aesthetic Surgery Department
Singapore General Hospital
Singapore
Chad R. Gordon, DO, FACS
Assistant Professor of Plastic Surgery and Neurosurgery
The Johns Hopkins University School of Medicine
Co-Director, Multidisciplinary Adult Cranioplasty Center (MACC)
Co-Director, Face Transplant Program
The Johns Hopkins Hospital
Baltimore, Maryland
Dam ien Grinsell, MBBS, FRACS(Plas)
Consultant Plastic and Reconstructive Surgeon
St. Vincents Hospital Melbourne
Royal Melbourne Hospital
Western Hospital
Melbourne, Australia
Nicolas A. Guay, BSc, MD, FRCS(C)
Corporate Chief and Medical Director of Surgery
William Osler Health System
Toronto, Ontario, Canada
Dilnath Gurusinghe, MBBS(Lond), MRCS(Eng), FRCS(Plast)
Mersey Regional Burns Centre
Mersey Regional Burns and Plastic Surgery Unit
Whiston Hospital
Liverpool, England, United Kingdom
Moustapha Hamdi, MD, PhD
Professor and Chairman
Plastic and Reconstructive Surgery Department
Brussels University Hospital–Vrij Universiteit Brussel (VUB)
Brussels, Belgium
Kathryn Hamnett, MBChB Hons, MRCS (Ed), FRCS(Plast)
Whiston Hospital
Liverpool, England, United Kingdom
Shehan Hettiaratchy, MA(Oxon), DM, FRCS(Plast)
Chief of Service, Plastics Orthopaedics ENT and Major Trauma
Imperial College Healthcare NHS Trust
Honorary Clinical Senior Lecturer
Imperial College
London, England, United Kingdom
Kevin Ho, MB, BS, FRACS(Plast)
Consultant Plastic Surgeon
Prince of Wales and Sydney Children’s Hospitals
Chair of Plastic and Reconstructive Surgery Training
Sydney Children’s Hospital
Sydney, Australia
Stefan O. P. Hofer, MD, PhD, FRCS(C)
Wharton Chair in Reconstructive Plastic Surgery
Professor of Surgery
University of Toronto
Chief, Division of Plastic Surgery
University Health Network
Toronto, Ontario, Canada
Joon Pio Hong, MD, PhD, MMM
Professor
Department of Plastic Surgery
Asan Medical Center
University of Ulsan
Seoul, Republic of Korea
Cedric Hunter, MD
Plastic and Reconstructive Surgery Resident
Stanford University Hospital
Stanford, California

xviii
Contributors
Azhar Iqbal, BSc, MBBS, FRCS Glasgow, FRCD(Edin), MSc,
FRCS(Plas)
Consultant Plastic Surgeon
Whiston Hospital
Liverpool University
Liverpool, England, United Kingdom
Shehab Jabir, MRCS
Registrar in Plastic, Reconstructive and Burns Surgery
Department of Plastic Surgery and Burns
Nottingham University Hospitals Trust
Nottingham, England, United Kingdom
Zita M. Jessop, MB BChir, MA(Cantab), MRCS
Clinical Lecturer
Swansea University Medical School
Plastic Surgery Registrar
The Welsh Centre for Burns and Plastic Surgery
Swansea, Wales, United Kingdom
Nicholas Spencer Jones, MD, BDS, FRCS, FRCS(ORL)
Special Professor and Consultant (retired)
Department of Otorhinolaryngology–Head and Neck Surgery
Queen’s Medical Centre
University of Nottingham
Nottingham, England, United Kingdom
Jeong Tae Kim , MD, PhD
Professor
Department of Plastic and Reconstructive Surgery
Hanyang University, College of Medicine
Hanyang University Medical Center
Seoul, Republic of Korea
Sang Wha Kim, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive Surgery
Seoul National University, College of Medicine
Seoul National University Hospital
Seoul, Republic of Korea
Youn Hwan Kim, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive Surgery
Hanyang University, College of Medicine
Hanyang University Medical Center
Seoul, Republic of Korea
William M. Kuzon Jr., MD, PhD
The Reed O. Dingman Professor of Surgery
Section of Plastic Surgery
University of Michigan
Chief of Surgery
Ann Arbor VA Healthcare
Ann Arbor, Michigan
Gordon K. Lee, MD, FACS
Associate Professor
Associate Chief of Clinical A airs
Residency Program Director
Director of Microsurgery
Stanford Plastic and Reconstructive Surgery
Stanford University
Stanford, California
Zeshaan N. Maan, MBBS, MSc, MRCS(Eng)
Plastic and Reconstructive Surgery Resident
Division of Plastic Surgery, Department of Surgery
Stanford University School of Medicine
Stanford, California
Iain R. Mackay, MBChB, FRCS(Plast)
Consultant Plastic Surgeon
Canniesburn Plastic Surgery Unit
Glasgow Royal In rmary
Glasgow, Scotland, United Kingdom
Bruce A. Mast, MD, FACS
The Maurice J. Jurkiewicz Professor of Reconstructive
Plastic Surgery
Chief, Division of Plastic and Reconstructive Surgery
University of Florida College of Medicine
Gainesville, Florida
Lisha McClelland, FRCS
Consultant ENT Surgeon
Queen Elizabeth Hospital
Birmingham, England, United Kingdom
Raja Mohan, MD
Chief Resident
Department of Plastic Surgery
The Johns Hopkins Hospital
Baltimore, Maryland
Pouria Moradi, MBBS, BSc(Med), MRCS(Eng), FRACS(Plast)
Consultant Plastic and Reconstructive Surgeon
Prince of Wales, Royal Hospital for Womens’ and Sydney
Children’s Hospital
Sydney, Australia
Jonathan D. Morton, BSc(Hons), MBChB, FRCS(Ed), MRCGP
Associate Specialist Plastic Surgeon and Mohs Surgeon
Mersey Regional Burns and Plastic Surgery Unit
Whiston and St Helens Hospitals
Liverpool, England, United Kingdom
Marc A. M. Mureau, MD, PhD
Associate Professor
Head, Oncologic Reconstructive Surgery
Department of Plastic and Reconstructive Surgery
Erasmus MC Cancer Institute
University Medical Center Rotterdam
Rotterdam, The Netherlands

Contributors
xix
Ryan J. Murphy, PhD
Senior Professional Sta
Research and Exploratory Development Department
The Johns Hopkins University Applied Physics Laboratory
Laurel, Maryland
Maurice Y. Nahabedian, MD, FACS
Professor and Vice Chairman
Department of Plastic Surgery
Georgetown University
Washington, DC
Foad Nahai, MD, FACS, FRCS(Hon), FRCST(Hon)
The Maurice J. Jurkiewicz Chair in Plastic Surgery and
Professor of Surgery
Department of Surgery
Emory University
Atlanta, Georgia
Jagdeep Nanchahal, BSc, PhD, MBBS, FRCS(Plast)
Professor of Hand, Plastic, and Reconstructive Surgery
Kennedy Institute of Rheumatology
Nu eld Department of Orthopaedics Rheumatology and
Musculoskeletal Sciences
University of Oxford
Honorary Consultant Plastic and Reconstructive Surgeon
Oxford University Hospitals
Oxford, England, United Kingdom
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Professor of Surgery
Division of Plastic Surgery
University of Washington
Seattle, Washington
Richard B. Nesm ith, MD
Plastic and Reconstructive Surgery Resident
University of Florida College of Medicine
Gainesville, Florida
Vachara Nium sawatt, MBBS
Monash University
Clayton, Victoria, Australia
Brian M. Parrett, MD
Attending Plastic Surgeon
Sutter Paci c Medical Foundation
San Francisco, California
Caroline E. Payne, BSc Genetics (Hons), MSc, FRCS(Eng),
FRCS(Plast)
Consultant Plastic and Reconstructive Surgeon
Head of Department
St Bartholomew and Royal London Hospital
London, England, United Kingdom
Tom S. Potokar, MBChB, FRCS(Ed), FRCS(Plast), DA(UK), DTM&H
Consultant Plastic Surgeon and Director Interburns
The Welsh Centre for Burns and Plastic Surgery
Honorary Clinical Associate Professor
Swansea University College of Medicine
Swansea, Wales, United Kingdom
Julian J. Pribaz, MBBS(Melb), FRCS(Edin), FRACS(Plast)
Professor of Surgery
Harvard Medical School
Boston, Massachusetts
Rowan Pritchard Jones, MD, FRCS(Plast), MB ChB(Bris)
Consultant Reconstructive Plastic Surgeon
St Helens & Knowsley NHS Trust
Honorary Clinical Senior Lecturer
Liverpool University
Liverpool, England, United Kingdom
Aw f Quaba, FRCS(Plast)
Consultant Plastic Surgeon
The Spire Murray eld Hospital
Edinburgh, Scotland, United Kingdom
Omar Quaba, MB BChir, FRCS(Plast)
Consultant Plastic Surgeon
Ninewells Hospital
Dundee, Scotland, United Kingdom
Adriana G. Ramirez, MD
General Surgery Resident Physician
Department of Surgery
University of Virginia
Charlottesville, Virginia
Mohamed Zulf kar Rasheed, MBBS, MRCS(Ed), MMed(Surg),
FAMS(Plast)
Consultant
Department of Plastic Reconstructive and Aesthetic Surgery
Singapore General Hospital
Singapore
Winston T. Richards, MD, FACS
Clinical Assistant Professor of Surgery
Division of Acute Care Surgery
Department of Surgery
University of Florida
Gainesville, Florida
Bernardo Righi, MD
Consultant Plastic Reconstructive Surgeon
Department of Plastic and Reconstructive Surgery
Ospedale Papa Giovanni XXIII
Bergamo, Italy
Enrico Robotti, MD
Chief of Plastic Surgery
Department of Plastic and Reconstructive Surgery
Ospedale Papa Giovanni XXIII
Bergamo, Italy
Warren M. Rozen, MBBS, BMedSc, PGDipSurgAnat, MD,
PhD, FRACS
Plastic and Reconstructive Surgeon
Department of Surgery
School of Clinical Science at Monash Health
Faculty of Medicine
Monash University
Monash Medical Centre
Clayton, Victoria, Australia

xx
Contributors
Justin M. Sacks, MD, MBA, FACS
Director of Oncological Reconstruction
Assistant Professor
Department of Plastic and Reconstructive Surgery
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Am ir Sadri, BSc(Hons), MBChB(Hons), MRCS
Registrar in Plastic Surgery
Chelsea & Westminster Hospital
London, England, United Kingdom
Odhran Shelley, FRCS(Plast)
Consultant in Plastic, Reconstructive and Burns Surgery
St Andrews Centre for Plastic Surgery and Burns
Chelmsford, England, United Kingdom
Kayvan Shokrollahi, MSc, LLM, FRCS(Plast)
Consultant Burns, Plastic, and Laser Surgeon
Clinical Lead, Mersey Regional Burns Service
Mersey Regional Burns and Plastic Surgery Unit
Whiston Hospital
Liverpool, England, United Kingdom
Sachin M. Shridharani, MD
Director
LUXURGERY
New York, New York
Shyam M. Shridharani, MD
Section Chief, Spine Surgery
Department of Orthopaedic Surgery
University of Arizona
Tucson, Arizona
Devinder P. Singh, MD
Chief and Medical Director of Plastic Surgery
Anne Arundel Medical Center
Annapolis, Maryland
Adrian Sjarif, BSc, MBBS(Hons), MS, FRACS(Plast)
Plastic & Reconstructive Surgeon
St George Hospital, Kogarah
The Wollongong Hospital, Wollongong
New South Wales, Australia
Edward W. Swanson, MD
Resident in Plastic and Reconstructive Surgery
Department of Plastic and Reconstructive Surgery
The Johns Hopkins University School of Medicine
The Johns Hopkins Hospital
Baltimore, Maryland
Sujatha Tadiparthi, MB BCh, MRCS, MSc, FRCS(Plas)
Consultant Plastic and Reconstructive Surgeon
Department of Plastic and Reconstructive Surgery
Queen Elizabeth Hospital
Birmingham, England, United Kingdom
Simon G. Talbot, MD
Assistant Professor of Surgery
Harvard Medical School
Associate Surgeon
Brigham and Women’s Hospital
Boston, Massachusetts
Kok Chai Tan, MBBS(Monash), FRSC(Eng)
Adjunct Professor Duke-Nus
Associate Professor Nus
Senior Consultant Plastic Surgeon
Plastic Surgery Department
Singapore General Hospital
Singapore
Ying Chien Tan, MBBS, MRCS(Edin), MMed(Surg), FAMS(Plast)
Consultant Plastic Surgeon
The Sloane Clinic Plastic Surgery Centre
Singapore
G. Ian Taylor, AO, MD, FRACS, FRCS, FACS
Professor
Department of Plastic Surgery
Royal Melbourne Hospital
Professor
Department of Anatomy and Neuroscience
University of Melbourne
Melbourne, Australia
Anthony P. Tufaro, MD, DDS, FACS
Associate Professor of Plastic and Reconstructive Surgery,
Oncology and Surgical Oncology
The Johns Hopkins University School of Medicine
Associate Professor of Plastic and Reconstructive Surgery
University of Maryland Shock Trauma Center
Baltimore, Maryland
Koenraad Van Landuyt, MD, PhD, FCCP
Associate Professor
Department of Plastic and Reconstructive Surgery
Ghent University Hospital
St. Lucas General Hospital
Ghent, Belgium
Christopher G. Wallace, MB ChB, MS, FRCS(Plast)
Consultant Plastic, Reconstructive and Aesthetic Surgeon
Department of Plastic Surgery
Royal Devon and Exeter Hospital
Exeter, England, United Kingdom
Stuart B. Watson, MB ChB, FRCS(Plast)
Consultant Plastic Surgeon
Canniesburn Unit
Glasgow Royal In rmary
Glasgow, Scotland, United Kingdom

Contributors
xxi
Fu-Chan Wei, MD, FACS
Distinguished Chair Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital
Chang Gung University Medical College
Taipei, Taiwan
Iain S. Whitaker, MA(Cantab), PhD, FRCS(Plast)
Professor of Plastic and Reconstructive Surgery
Swansea University Medical School
Honorary Consultant Plastic and Reconstructive Surgeon
The Welsh Centre for Burns and Plastic Surgery
Swansea, Wales, United Kingdom
Henri A. H. Winters, MD, PhD
Head of Resident Training Program
Chair of the Amsterdam Center for Complex Bone Defects
Department of Plastic Reconstructive and Hand Surgery
VUMC University Teaching Hospital
Amsterdam, The Netherlands
Chin-Ho Wong, MBBS(S’pore), MRCS(Ed), MMed(Surg),
FAMS(Plast)
Director
W Aesthetic Plastic Surgery
Visiting Consultant
Department of Plastic Reconstructive and Aesthetic Surgery
Singapore General Hospital
Singapore
Simon H. Wood, MBBS, FRCS(Plast)
Consultant Plastic Surgeon
Charing Cross Hospital
Imperial College Healthcare NHS Trust
London, England, United Kingdom
Richard Young, MA, BM, BCh, FRCS, FRCS(Plast)
Consultant Plastic, Reconstructive and Aesthetic Surgeon
Chelsea and Westminster Hospital
London, England, United Kingdom

(Trang không có chữ)

I
Section I
Planning and Decision Making
in Reconstructive Surgery

(Trang không có chữ)

3

Principles of Wound
Healing
Wound healing is a complex biological response, involving a de-
ned, regulated sequential cascade, with coordinated cellular
activity including phagocytosis, chemotaxis, mitogenesis, and
extracellular m atrix component synthesis. Three overlapping
phases are traditionally described: in ammatory, proliferative,
and remodeling (Fig. 1.1). It is important that these activities
occur in an ordered manner for successful wound healing to take
place.
Phases of Wound Healing
In ammation
The primary sequence of events is initiated by injury to the tissue,
causing hemorrhage with initial vasoconstriction and activation of
the coagulation cascade. This is followed by release of in ammatory
mediators, leukocytes, erythrocytes, and platelets. Platelets release
vasoactive amines, including serotonin, and cytokines, including
platelet-derived growth factor (PDGF), transforming growth factor-
beta (TGF-b), and epidermal growth factor (EGF). Granulation tissue
production commences. Hematoma and brin bind to the wound,
attracting platelets and supporting broblast migration.
The coagulation and complem ent cascades enable the m igra-
tion of leukocytes and m onocytes within hours, closely followed
by macrophages after 24 to 36 hours via the process of margin-
ation and diapedesis. Debris is phagocytosed and removed from
the wound by the polymorphonuclear cells (PMNs). Epitheliali-
zation results in migration of epithelial cells across the wound,
w ith the leading edge losing its basement mem brane adhesion
and attening out.
By 48 to 72 hours macrophages are the predominant cell
types, producing grow th factors for the production of the ex-
tracellular membrane (ECM) by broblasts and angiogenesis
following proliferation of sm ooth m uscle and endothelial cells.
Chemo-attractants for macrophages include immunoglobulin G
(IgG) fragm ents; complem ent, collagen, and elastin breakdown
products; and cytokines, such as PDGF, TGF-b, and leukotriene B4.
Lymphocytes are attracted by interleukin-1 (IL-1), IgG, and com-
plement products and are the last cells to enter the wound during
the in ammatory phase.
Proliferation
By day 7 the wound is predom inated by broblasts, migrating
through the ECM into the wound following stim ulation by cyto-
kines. Fibroblasts synthesize type I and type III collagen, to form
the foundation of the wound ECM. New blood vessel form ation
occurs by the action of platelets releasing cytokines to attract
macrophages and PMNs. The m acrophages release angiogenic
substances such as tumor necrosis factor-alpha (TNF-a ), vascu-
lar endothelial grow th factor (VEGF), and basic broblast grow th
factor (bFGF). These actions result in angiogenesis.
1
Basic Principles of Reconstructive
Surgery and Flaps
Parneet Gill and Kayvan Shokrollahi
Fig. 1.1 Following the initial injury, the three phases of wound healing are shown: in ammatory, proliferative, and remodeling.

4
I Planning and Decision Making in Reconstructive Surgery

●
Wound oxygenation

●
Radiation

●
Denervation
General factors that a ect wound healing include:

●
Age

●
Sm oking

●
Nutritional status

●
Vitamin de ciency 1 zinc de ciency

●
Temperature

●
Inherited conditions, such as, pseudoxanthoma elasticum,
Ehlers-Danlos

●
Acquired conditions, such as, diabetes mellitus, autoim -
mune in ammatory conditions
Structure and Function of the Skin
The skin is composed of epidermis and derm is (Fig. 1.2). The ve
layers of the epidermis are the stratum corneum, stratum granu-
losum, stratum lucidum, stratum spinosum, and stratum basale.
Epiderm is is strati ed squam ous epithelium with m ainly kerati-
nocytes, but also Langerhans cells, Merkel cells, and melanocytes.
The derm is accounts for 95% of the thickness of the skin
and is split into the super cial papillary dermis and the deeper
reticular derm is, separated by the vascular plexus (Fig. 1.2a). The
Remodeling
By day 21, a steady state of collagen synthesis and breakdown
is reached following remodeling of the ECM. TGF-b promotes
matrix accumulation by decreasing the activity of the m atrix
metalloproteinases (MMPs), which are produced by broblasts,
macrophages, and granulocytes. Fibronectin acts as a sca old for
collagen deposition and is involved in wound contraction, cell
interaction and migration, collagen matrix deposition, and re-
sultant epithelialization. As the wound matures, type I collagen
replaces type III and the amount of bronectin reduces. Stromal
ground substance consisting of proteoglycans and glycosami-
noglycans (GAGs) is vital in creating a hydrated environment to
enable cell mobility and binding. Rem odeling occurs increasing
tensile strength of the wound to 80% of normal between 3 and
8 weeks.
Factors that A ect Wound
Healing
Local factors that a ect wound healing include:

●
Infection

●
Handling of wound by surgeon

●
Local tissue ischemia
Fig. 1.2 (a) Structure of the skin. Skin consists of epidermis 
and dermis, leading into the layers of subcutaneous tissue 
and muscle. Within the layers are vascular plexi, shown as 
listed. (1) Subpapillary vascular plexus; (2) dermal vascular 
plexus; (3) subdermal vascular plexus; (4) segmental vascular 
plexus. (b) Composition of free skin grafts. Skin grafts can be 
classi ed as full thickness or split thickness.1
Anterior
fascia
Epidermis
a
b
Full-thick-
ness graft
(>0.5 mm)
Epidermis
Thin split-
thickness graft
(0.2 – 0.3 mm)
Thick split-
thickness graft
(0.4 – 0.5 mm)
Dermis
Subcuta-
neous
tissue
Muscle
1
2
3
4
Dermis
Subcuta-
neous
tissue
Muscle
Posterior
fascia
Segmental artery

1 Basic Principles of Reconstructive Surgery and Flaps
5

●
Free tissue transfer

●
Miscellaneous, such as, cell culture, vacuum -assisted clo-
sure (VAC)
Reconstructive Menu
The reconstructive menu is a m ore recent, sophisticated option,
as the reconstructive ladder encourages the simplest option
rather than the most optimal reconstruction. Any item can be
chosen from the m enu, allowing personal preference and the
most suitable reconstruction to be used for each individual case.
The aim s of reconstruction are both functional and cosm etic.
Scars should be placed in lines of election (Langer lines) or paral-
lel to them to enable settling of the scar into wrinkles over time
(Fig. 1.3a). The nasolabial fold, glabellar wrinkle pattern, lateral
canthal “crow’s feet,” and forehead wrinkles are preferable areas
to place scars. The use of a natural junction line distracts the eye
from the scar and can be used e ectively, such as, the base of the
alar, the vermilion border, and the lower eyelid below the line of
the eyelashes (Fig. 1.3b).
Facial Subunits
The face can be divided into six m ajor aesthetic subunits: fore-
head, eyes/eyebrows, nose, cheek, lips, and chin (Fig. 1.4). These
can be further divided into additional anatomical subunits
(Figs. 1.5, 1.6, and 1.7). These are important when considering
reconstruction as defects a ecting more than 50% of a subunit
may produce a superior result if the whole subunit is replaced
instead of the defect alone.
Direct Closure
The aims of direct closure include:

●
Place scar in Langer lines if possible (Fig. 1.3)

●
Adequate debridement of traumatic wounds
derm is consists of collagen, elastin bers, ground substance, and
the vascular plexus. The skin appendages including the hair fol-
licles, eccrine glands, apocrine glands, and the sebaceous glands
are found in the dermal layer (Fig. 1.2a).
For the blood supply to the skin, deep vessels arising from the
aorta divide to form the m ain arterial supply to the head, neck,
trunk, and limbs before feeding into the vascular plexus of the
fascia, subcutaneous tissue, and skin. Fasciocutaneous and m us-
culocutaneous perforators connect the deep vessels to the skin.
The vascular plexus is divided into six layers (Fig. 1.2a):
1. Subfascial plexus
2. Prefascial plexus
3. Subcutaneous plexus
4. Subdermal plexus
5. Dermal plexus
6. Subepidermal plexus
An angiosome is a composite block of tissue that is supplied
by a named artery. Angiosomes were rst described by Manchot
in 1889 and later by Taylor and Palm er. The vessels that pass be-
tween the anatomical territories of the angiosomes are called
choke vessels.

Reconstructive Techniques
Options
Reconstructive Ladder
This is a stepwise progression from the simplest options for re-
construction to those that are more complex:

●
Secondary intention healing

●
Primary closure

●
Graft—split skin, full thickness skin, or composite

●
Tissue expansion

●
Local tissue transfer

●
Distant tissue transfer
a
Fig. 1.3 (a) Langer lines. Scars are placed in lines of election as shown. (continued)

6
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.3 (continued) (b) Use of resting skin tension lines to plan reconstruction using direct closure and local  aps.1
b

●
Atraumatic technique

●
Minimize dead space

●
Tension-free closure

●
Opposition of skin edges without overlap (Fig. 1.8)

●
Evert skin edges (Fig. 1.8)

●
Use nest suture possible for tension

●
Excise dog ears
The methods of direct closure include:

●
Simple interrupted (Figs. 1.8 and 1.9)

●
Subcutaneous with buried knot (Figs. 1.8 and 1.9)

●
Subcuticular (Fig. 1.10)

●
Vertical mattress (Figs. 1.11 and 1.12)

●
Horizontal mattress (Fig. 1.13)

●
Continuous (Fig. 1.14)
The standard suture technique can be described as a deep
buried subcutaneous suture or a simple interrupted skin suture
(Figs. 1.8 and 1.9). The aim of the buried subcutaneous suture is
to eliminate dead space at the base of the wound to reduce the
risk of hematoma, seroma, or infections. The simple interrupted
skin suture aim s to evert the wound edges by ensuring an equal
Inferior border of eyebrow
and superior orbital rim
Continuation of
lower lid margin
Lateral
orbital rim
Continuation of
upper lid margin
Inferior
orbital rim
Nasojugal groove
Upper and lower
lid lacrimal
puncta
Fig. 1.5 Subunits of the eye.2
Hairline or
superior
border of
frontalis m.
Orbital rim
Nasofacial
groove
Melolabial
fold
Preauricular
crease
Labio mental
crease
Fig. 1.4 The major subunits of the face.2

1 Basic Principles of Reconstructive Surgery and Flaps
7
Dorsal
Side wall
Tip
Soft triangle
Columellar
Alar
Fig. 1.6 Subunits of the nose.2
Philtral ridge
Melolabial-fold
Vermilion borders
Labio mental
crease
Fig. 1.7 Subunits of the lips and chin area.2
Epidermis
Dermis
Subcutaneous
Fig. 1.8 Simple interrupted and buried deep dermal suture. This  gure 
shows opposition of the wound edge with eversion.2
Fig. 1.9 Simple suture techniques. (a) Placement of a subcutaneous suture with a buried knot. (b) Placement of an 
interrupted suture with equal distances from the wound edge in order to achieve eversion. (c) Successfully completed 
wound closure.3
“bite” is taken at each wound edge with a simple loop knotted at
one side of the wound (Fig. 1.9c). Inverted wound edges do not
heal adequately.
A subcuticular suture is used to close a wound edge with-
out leaving external tracking marks. It consists of a single run-
ning suture, which starts at one end of the wound, traversing the
wound at the level of the dermis to the other end of the wound
(Fig. 1.10). The subcuticular suture can be left free at either end
and trimmed upon review or can be buried.
The vertical m attress suture is used to evert wound edges
while reducing dead space. The distance from the wound edge
must be equal in both the deeper and super cial “bite” to avoid
a step deformity (Fig. 1.11). The half-buried vertical m attress su-
ture can also be used to close a wound by passing deep from one
wound edge into the other and exiting super cially by forming a
loop, which is knotted on the side of entry (Fig. 1.12).
The horizontal mattress suture is used to evert wound edges
by taking the tension and spreading it along the wound edge by
taking horizontal “bites” (Fig. 1.13). It is ideal for closing fragile
skin as well as areas under a large amount of tension; however,
the blood supply to the tissue between the suture may become
compromised if tied too tightly.

8
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.11 Vertical mattress suture. (a) Placement of suture at 
equal points from wound edge. (b) Completed wound closure.3
Fig. 1.10 Subcuticular suture.3
Fig. 1.12 Half-buried vertical mattress suture. (a) Placement 
of suture with start and  nish points on same side of wound. 
(b) Completed wound closure.3

1 Basic Principles of Reconstructive Surgery and Flaps
9
enabling wound closure minus the dog ear. This acts to lengthen the
scar further but produces a attened and more pleasing scar.
Skin Grafts
A dermatome or Watson knife is used to shave a layer of epider-
mis, with a varying am ount of derm is (Fig. 1.16a-e). The graft
is transferred to a distal site, where it establishes a new blood
supply with the bed of the wound (Fig. 1.16f). The graft can be
unmeshed or meshed to enable drainage of underlying hemato-
ma and coverage of a larger area. The bed should be free of in-
fection, ischemia, or foreign bodies in order to ensure good take.
A bolster dressing is often applied to reduce shearing and
hem atom a between the graft and wound bed (Figs. 1.16g and
1.17). The split skin graft is trimm ed to size and sutured to the
wound edges leaving the suture ends tied long. The graft m ay
also be quilted to the underlying bed if desired (Fig. 1.17a). Jelo-
net gauze and a dressing such as pro avine-soaked wool or foam
dressing are used to compress the graft, w ith the tie-over com -
pleted by tying the long ends of the sutures across it (Fig. 1.17b).
Fig. 1.14 Simple continuous suture. (a) Placement of suture 
with bites taken at equal distance from wound edge. (b) Com-
pleted wound closure.3
A simple continuous over and over suture is a quick method
to close a wound but can bunch up and strangulate the wound
edges if tied too tightly. The sutures should be placed at equal
distances away from the wound edge to encourage eversion of
the wound edges (Fig. 1.14).
Before wound edges are sutured, it is vitally important that any
debris or nonviable tissue is adequately debrided in order to avoid
infection and any risk of debris tattooing. Wound edges should be
opposed into their “normal” position by using landmarks to aid
placement. Where there has been tissue loss, assessment should
be made about whether the wound can be left to heal by second-
ary intention, whether primary closure is adequate or whether
new tissue needs to be recruited either as a skin graft or ap.
Dog ears result when excess tissue remains at either end of a
wound during direct closure. These unsightly swellings produce an
unsatisfactory result and can improve over time but are easily man-
aged by formal dog ear excision (Fig. 1.15). Initially the direction of
the relaxed skin tension lines is noted and creating an equilateral
triangle shortens the wound edge. An incision is made at the shorter
edge that meets the wound before the resultant ap is draped across
the wound to highlight the remaining excess. The excess is excised,
Fig. 1.13 Horizontal mattress suture placement.

10
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.15 Excision of dog ears. (a) Initial situation with direction of RSTL
marked. (b) Shortening the lower wound edge by creating an equilater-
al triangle. (c) Incision at shorter edge meeting wound. (d) Extension of 
resulting  ap over wound to show excess edge. (e) Excision of dog ear to 
enable desired wound closure.2
Full-thickness graft
Thick split-thickness graft
(0.4–0.5 mm)
Thin split-thickness
graft (0.2–0.3 mm)
Epidermis
Dermis
Subdermis
(Fat)
Muscle
Fig. 1.16 Free skin grafts. (a) Skin grafts can be full thickness or 
varying levels of split thickness.3 (continued)
a
A split skin graft leaves some dermis at the donor site, where-
as a full thickness skin graft takes the full derm is; therefore, the
donor site needs to be directly closed or grafted. Fig. 1.18 shows a
picture of a patient following split skin graft to the anterior scalp
following excision of a lesion.
Skin Graft Classi cation

●
Autograft: same individual

●
Allograft: same species

●
Isograft: genetically identical donor

●
Xenograft: another species
Skin Graft “Take”

●
Adherence

●
Imbibition

●
Revascularization

●
Remodeling
The graft im m ediately adheres to the wound bed due to
the presence of brin. During the rst 48 hours the skin graft
begins to swell due to absorption of uid. Vessel ingrow th
into the skin graft occurs around day 4 either by inosculation,
revascularization, or neovascularization. The histological ar-
chitecture of the graft returns to that of norm al skin during
rem odeling.
The donor site heals by epithelializing from the margins and
from the derm al rem ains such as the appendages. Healing occurs
over 1 to 2 weeks.
The donor sites for split skin grafts are the thigh, medial up-
per arm, buttock, and hypothenar em inence; and for full thick-
ness skin grafts, the pre- or post-auricular area, supraclavicular
area, groin, medial upper arm, and cubital crease.
Reasons for skin graft failure include the following:

●
Hematoma

●
Infection

●
Serom a

●
Shear

●
Inappropriate wound bed

●
Error in placement
a
b
c
d
e

1 Basic Principles of Reconstructive Surgery and Flaps
11
b
c
e
d
Fig. 1.16 (continued) (b) Photograph showing lesion on left leg marked with margin of 6 mm. (c) Photograph showing markings for split skin graft from 
left thigh. (d) Photograph showing a split skin graft being taken. (e) Photograph showing a split skin graft on a swab. (f) Photograph showing split skin
graft being applied to defect. (g) Photograph showing bolster dressing over graft.
f
g

12
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.17 Bolster dressing to  x a split skin graft. (a) Placement 
of sutures at graft edge. (b) Tie-overs being performed over 
pro avine-soaked wool to complete wound closure.3
Fig. 1.18 A healed split skin graft at anterior scalp following excision of 
a skin lesion.2
Tissue Expansion
Tissue expansion uses mechanical means to increase the surface
area of tissue by using an expander. The expander is inserted
via an incision next to the defect site and in ated via a port
over weekly intervals (Fig. 1.19a,b). Once the desired am ount is
reached, the expander is removed, the defect is excised, and the
skin can be used for local reconstruction (Fig. 1.19c,d).
Creep and stress relaxation principles apply to tissue expan-
sion. Creep is the plastic deformation of tissue in response to a
constant stress over tim e. Stress relaxation refers to the decrease
in force required to stretch the skin to a given length over time.
Tissue expanders can be used in a range of clinical scenarios
including reconstruction following excision skin grafts and exci-
sion of lesions (Fig. 1.20). The advantages of tissue expansion are:

●
Good color, texture, and hair match

●
No donor site

●
Sensate

●
Reliable
The disadvantages of tissue expansion are:

●
Infection

●
Extrusion/rotation/rupture of expander

●
Hematoma or seroma

●
Pain

●
Unsightly

●
Failure to achieve adequate expansion
Flaps
A ap is a unit of tissue with various compositions that carries its
own blood supply when transferred from a donor site to a recip-
ient site. Flaps are classi ed according to the ve Cs, as follows:

●
Circulation

●
Composition

●
Contiguity

●
Contour

●
Conditioning
Circulation

●
Random: no directional blood supply, not based on any
vessel, such as, most local aps on face. Length to breadth
ratio in face is 1:6, but 1:1 in lower limb.

●
Axial: named artery along axis, such as, groin ap on su-
per cial external iliac vessels or deltopectoral ap on per-
forators of internal mammary artery.

●
Fasciocutaneous: from deep arteries to fascia.

●
Musculocutaneous: perforators reach skin through muscle.

●
Venous: venous pedicles.
Composition

●
Cutaneous

●
Fasciocutaneous

●
Fascial

1 Basic Principles of Reconstructive Surgery and Flaps
13
Defect
closed
Expanders removed,
defect excised
Incision for
expanders
Area
of
defect
Expanders in
position
Fig. 1.19 (a–d) Use of the tissue expansion technique with two expanders to produce adequate skin coverage of a scalp defect.
a
b
c
d

●
Musculocutaneous

●
Muscle only

●
Osseocutaneous

●
Osseous
Contiguity

●
Local aps: the tissue lies adjacent to defect.

●
Regional aps: the tissue is taken from same region of
body as defect, such as, head and neck.

●
Distant pedicled aps: the tissue is taken from a distant
part of the body but remains attached via a pedicle.

●
Distant free aps: the tissue is completely detached and
anastomosed to vessels close to defect.
Contour
Methods of transferring aps into defect:

●
Advancement

●
Transposition

●
Rotation

●
Bilobed

●
Interpolation

●
Crane principle: the Crane principle is the transformation
of an ungraftable bed into one that will accept a skin graft.
Initially, a ap is placed into the defect to enable vascu-
larization. The super cial portion is then replaced into its
original position, leaving a subcutaneous portion, which
can be grafted.

14
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.20 Tissue expansion technique. (a) A large lesion on scalp. (b) Tissue expanders in situ following excision. (c) Closure of scalp
following removal of tissue expanders. (d) Healed wound.2
c
d
a
b
The Cormack and Lamberty Classi cation of Fasciocutaneous
Flaps (1984)
Type A: Multiple nonnamed fasciocutaneous vessels enter base of 
ap, such as, Ponten lower limb  aps.
Type B: Single fasciocutaneous vessel, which runs along axis of  ap, 
such as, scapular and parascapular  aps, fasciocutaneous  aps 
based on perforators of the lower limb.
Type C: Multiple small perforating vessels that reach the  ap from 
a deep artery along a fascial septum between muscles, such as, 
radial forearm  ap and lateral arm  ap.
Type D: Fasciocutaneous  aps that contain bone, such as radial 
forearm  ap with a segment of the radius, the lateral arm  ap 
raised with a segment of the lateral supracondylar ridge of the 
humerus.
The Mathes and Nahai Classi cation of Muscle and
Musculocutaneous Flaps (1981)
The classi cation is as follows (Fig. 1.21):
Type 1: Single vascular pedicle, such as, gastrocnemius, tensor 
fascia lata, and abductor digiti minimi.
Type 2: Single dominant and smaller minor pedicles that enter the 
muscle near its origin or insertion point, such as, trapezius, 
gracilis, soleus.
Type 3: Multiple dominant pedicles arising from a separate region-
al artery, such as, rectus abdominis, gluteus maximus.
Type 4: Multiple segmental pedicles, such as, sartorius, tibialis 
anterior, long  exors and extensors of the toes.
Type 5: One dominant and secondary segmental vascular pedicles, 
such as, latissimus dorsi, pectoralis major.
The Thatte and Thatte Classi cation of Venous Flaps (1993)
Type 1: Single venous pedicle
Type 2: Venous  ow-through  aps, supplied by a vein that enters 
from one side of  ap and exits from the other
Type 3: Arterialized venous  aps
(continued)

1 Basic Principles of Reconstructive Surgery and Flaps
15
Fig. 1.21 The Mathes and Nahai classi cation of muscle and musculocutaneous   aps.
Conditioning
Delay is a preoperative m aneuver to increase flap survival.
The delay phenom enon develops the flap by transferring it
in m ore than one stage to ensure its vascular safet y. At the
first stage division of part of the vascular supply or drainage
is carried out, followed by definitive raising of the flap at 1
to 3 weeks.
Delay is thought to work by:

●
Disruption of transverse vessels

●
Reorientation of the vessels longitudinally along ap

●
Opening of choke vessels

●
Vasodilation due to in ammatory mediators and sympa-
thectomy

●
Reactive hyperemia secondary to relative ischemia and
oxygen-free radicals

●
Tolerance to hypoxia

●
Inter ap shunting hypothesis
Local Flaps
Advancement Flaps
Advancement aps are local aps that move forward from a
donor site to the recipient site, without rotation or lateral move-
ment, relying on skin elasticity (Fig. 1.22).

●
Single pedicle: excess skin at the base of the ap can be
excised as two triangles (Burrow’s) (Figs. 1.23 and 1.26e,f),
with a cutback (Fig. 1.24), or incorporated with a z-plasty
(Figs. 1.25 and 1.26c,d).

●
Bipedicle: elevate ap leaving it pedicled at either end and
advancing it into the defect (Figs. 1.27 and 1.28).

●
V-Y: based on the laxity of the subcutaneous pedicle can
be advanced with closure of the tail (Figs. 1.26a,b, 1.29,
and 1.30).

●
Y-V: used to break up a scar in burns contracture or
Dupuytren’s closure. Adjacent Ys are drawn perpendicular
to the scar axis; following incision, the triangular aps are
advanced into the longitudinal limbs.
Transposition Flaps
A transposition ap is usually a rectangular or square ap, which
moves laterally from a pivot point to close the defect. The length
from the pivot point to the apex of the ap should be equal to or
greater than the length from the pivot point to the apex of the
defect farthest from the ap.

●
Limberg ap/rhomboid ap (Figs. 1.31, 1.32, 1.34, 1.35,
1.36, and 1.37)
Fig. 1.22 Use of advancement  ap for reconstruction on the face. The 
pink shaded areas represent the defect to be reconstructed with the direc-
tion of movement of the advancement  ap indicated by the black arrows. 
The resultant scars are shown.1

16
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.24 (a,b) Single pedicle advancement  ap with cutbacks to enable 
further movement.1
a

b
“Cuts back”
Fig. 1.26 Advancement  aps for nasal reconstruction. (a,b) A long Rieger
V-Y advancement  ap. (c,d) A long Rieger  ap with z-plasty modi cation. 
(e,f) A U-shaped advancement  ap with excision of Burrow’s triangles.1
Fig. 1.25 (a,b) Single pedicle advancement  ap with z-plasty modi ca-
tion to enable further movement.1
Fig. 1.27 Bilateral advancement  aps to close defect on fore-
head. (a) The forehead defect with markings for the  ap. (b)
Wound closure with resultant scars.2
a
b
Fig. 1.23 (a,b) Single pedicle advancement flap with excision of Bur-
row’s triangles at base.1

1 Basic Principles of Reconstructive Surgery and Flaps
17
Fig. 1.29 V-Y advancement  ap. (a) A contracted scar can be lengthened 
by making a V-shaped incision, mobilizing the  ap, and advancing it in 
the direction of the arrow. (b) Shows how the  ap is mobilized. (c) The
resulting defect is closed as a Y.1
Fig. 1.30 Modi cation of the V-Y advancement  ap. (a) The V-shaped
incision below the defect site. (b) The  ap is mobilized and advanced into 
the defect. (c) Closure of the donor site.1
Fig. 1.28 Bilateral advancement  aps to close defect on forehead. (a) The forehead defect with markings for the  ap. (b) Wound closure with resultant 
scars. (c) Healed wounds.2
c
a
b
Fig. 1.31 Rhomboid  ap of Limberg. (a) The  rst  ap incision is an extension of the 
axis B-D and the second incision (E-F) is made parallel to G-A. (b) The  ap is mobilized. 
(c) The resulting closed defect.1
Fig. 1.32 Two opposing Limberg  aps. (a) The  ap is mobi-
lized. (b) The resulting closed defect.1
Fig. 1.33 Dufourmentel  ap. (a) Flap incisions shown. (b) The  ap is mobilized. (c) The
resulting closed defect.1
Fig. 1.34 Inferiorly based Limberg  ap. (a) The left temple 
defect with markings for the  ap. (b) The resulting closed
defect.1

18
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.36 Photographs of inferiorly based Limberg  ap. (a) Shows the lesion at the left zygomatic area with markings for the  ap. (b) Shows
wound closure with resultant scars. (c) The postoperative result.2
a
b
c
Fig. 1.35 Superiorly based Limberg  ap. (a) The left temple 
defect with markings for the  ap. (b) Wound closure with re-
sultant scars.2
a
b

1 Basic Principles of Reconstructive Surgery and Flaps
19
Fig. 1.37 Photographs showing an inferiorly based Limberg  ap to manage a squamous cell carcinoma (SCC) of the left temple. (a) SCC left temple. 
(b) Excision margins and Limberg  ap markings. (c) Closure of  ap.
b
a
c

●
Dufourmentel ap (Fig. 1.33): These aps are similar in
concept but vary in geometry, with the angles measuring
120 degrees and 60 degrees in the Limberg/rhomboid ap,
whereas in the Dufourmentel ap they measure 150 de-
grees and 30 degrees.
Transpositional aps can also be based on a pedicle, such
as, param edian forehead ap or nasolabial ap (Fig. 1.38). These
aps are used to reconstruct defects on the nose.
Rotation Flaps
A semicircular ap rotates tissue into defect about a pivot point
(Fig. 1.39). The ap circumference should be 5 to 8 tim es the
width of the defect. Tissue redistribution enables direct closure
of the donor site. A backcut can be used to move the pivot point
to reduce tension (Fig. 1.40).
Bilateral rotation aps are useful to close large defects by
using the combination of rotation from both aps to meet in the
middle of the wound (Figs. 1.41, 1.42, and 1.43).
Large rotation aps can be used on the forehead and cheek
for large defects; however, extensive dissection of the ap has to
be performed to get an adequate range of movement to the ap
(Figs. 1.44, 1.45, and 1.46).
Bilobed Flaps
Bilobed aps are two transpositional aps, with the rst trans-
posed into the primary defect and the second transposed into the
secondary defect produced by the rst ap (Figs. 1.46 and 1.47).
The resultant tertiary defect should be sm all enough to close
directly. There may also be some variants to the bilobed ap
including the need to excise a Burrow’s triangle, incorporate a
z-plasty, or undermine extensively to close the donor site defect
(Fig. 1.48).
Bilobed aps can be based superiorly (Fig. 1.49), inferiorly,
medially, or laterally (Fig. 1.50) when used to reconstruct defects
on the nose.
Interpolation Flaps
Interpolation aps move about a pivot point but the pedicle has
to pass above or below the intervening skin to reach the defect as
the donor and recipient sites are not adjacent.
Fig. 1.38 The paramedian forehead  ap is based on the supratrochlear 
artery and the nasolabial  ap is based on the facial artery.3

20
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.40 Transfer of a too small rotation flap is aided by a backcut. (a) The backcut 
to lengthen flap. (b) Mobilization of flap and closure of defect D. (c) The resulting
closed defect.1
Fig. 1.39 Rotation  ap. (a) The  ap is marked and rotat-
ed into defect D after excision of a Burrow’s triangle B. 
(b) The resulting closed defect.1
Fig. 1.42 Bilateral scalp rotation  aps used to close scalp defect. (a) Shows the defect right scalp post excision of lesion. (b) Wound closure. (c) Post-
operative scars.2
a
b
c
Fig. 1.41 Ying-yang or O-to-Z  ap to close scalp defect.2
a
b

1 Basic Principles of Reconstructive Surgery and Flaps
21
Fig. 1.43 Photograph showing ying-yang rotational  aps to manage an SCC left forearm. (a) Lesion marked right volar forearm with bilateral rotation 
aps. (b) Closure of  aps in an ‘O-to-Z’ fashion.
a
b
Fig. 1.44 Large rotation  ap used to close forehead defect. (a) Shows the defect post excision of lesion. (b) Elevation of large rotation 
ap. (c) Flap inset. (d) Postoperative scars.2
a
c
b
d

22
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.46 Bilobed  ap. (a) Shows the defect as D and the
two limbs of the bilobed  ap marked as L1 and L2. The angle 
between L1 and L2 is equal to the angle between D and L1. 
The limb closest to D (L1) is about two-thirds the size of D 
and the limb away from D is two-thirds the size of L1. (b) The
movement of the limbs. (c) Mobilization of the surrounding 
skin to enable closure of the secondary defects. (d) The  ap 
inset.1
Fig. 1.47 Superiorly based bilobed flap. (a) The defect and flap markings. (b) The
flap inset.1
Fig. 1.45 Cheek rotation  ap. (a) Shows the defect left cheek post excision of lesion with  ap marked out. (b) Wound closure. (c) Postoperative scars.2
a
b
c

1 Basic Principles of Reconstructive Surgery and Flaps
23
Fig. 1.48 Variants of the bilobed  ap. (a,b) Excision of a Burrow’s triangle. (c,d) Incor-
poration of a z-plasty. (e,f) Shows extensive undermining.1
Fig. 1.49 Bilobed  ap reconstruction of nasal defect. (a) Nasal defect. (b) The markings of a superiorly based 
bilobed  ap. (continued)
a
b

24
I Planning and Decision Making in Reconstructive Surgery
Fig. 1.50 Laterally based bilobed  ap for  nasal re-
construction. (a) The defect with  ap marked out. 
(b) Inset of  ap. (c) Postoperative  appearance.2
a
c
b
Fig. 1.49 (continued) (c) Flap elevation. (d) Inset of the
bilobed  ap. (e) Post operative scarring.2
c
e
d

1 Basic Principles of Reconstructive Surgery and Flaps
25
Five-Flap Plasty
Two opposing z-plasties with a v-y advancement in the center,
aka a jumping man ap (Fig. 1.55); can be used to release rst
web space contractures and epicanthal folds.
Regional and Free
Fasciocutaneous, Muscle, and
Perforator Flaps
Fasciocutaneous Flaps
These aps are elevated based on the deep fascia and its vessels.
The circulation is based on the vascular pedicles entering the
deep surface to form a vascular plexus within the fascial plane,
and they can be raised as local or free aps including perforator
aps (Fig. 1.56).
Muscle Flaps
Muscle aps have good vascularity and are usually substan-
tial in nature. This allows for reconstructions that are reliable
and can ll in dead space or cover larger areas, and accept skin
grafts. Overlying skin can be included as m usculocutaneous
Z-Plasty
Transposition of two triangular aps to increase the length of a
scar, break up a straight line scar, or realign a scar (Figs. 1.51,
1.52, and 1.53). The angle of the z-plasty determ ines the potential
gain in length (Table 1.1). All three limbs should be equal in
length, with the central limb along the original scar. The desired
direction of the scar should be m arked and the lateral limbs are
joined from the ends of the central limb to the desired direction
of the scar.
W-Plasty
Technique of excision of a scar w ith an interdigitating triangular
zig-zag design (Fig. 1.54). It does not lengthen the scar but can
be used to break up or reorient a linear scar or to treat a trap
door scar.
Four-Flap Plasty
Two interdependent z-plasties that can be designed with di er-
ent angles in order to elongate an area of tissue. The outer aps
become the inner aps and the inner aps become the outer
aps following transposition. Thus ABCD becomes CADB, aka the
CADBury ap.
Fig. 1.51 Simple z-plasty. (a) Shows excision of the scar and use of z-plasty 
with a 45-degree angle to lengthen tissue. The triangular  aps labeled 1 
and 2 are transposed on each other as shown. (b) A 60-degree angle is used 
to enable more lengthening to take place.1
Fig. 1.52 Multiple z-plasties. (a) Shows the use of multiple z-plasties 
 following excision of the scar. (b) The transposition of multiple  aps as 
numbered to lengthen the tissue overall.1
Fig. 1.53 Z-plasty. (a) Planning of the z-plasty with 60-degree angles before excising the scar. (b) Elevation and transpo-
sition of the  aps. (c) The inset and resultant lengthening of the scar.3

26
I Planning and Decision Making in Reconstructive Surgery
the m uscles of the rectus abdominis enables a free ap abdom -
inal ap reconstruction sparing the m uscle and m inim izing do-
nor m orbidity. Chapter 3 describes the latest im aging techniques
for planning of perforator aps in free ap reconstruction as well
as for other local and ad-hoc perforator aps such as propeller
aps.

Nonsurgical and
Adjunctive Wound
Healing Techniques
Negative Pressure Wound
Therapy
Negative pressure wound therapy (NPWT) uses a vacuum dress-
ing applied at a controlled pressure over a wound to promote
healing. A ller is used to t the contour of the wound (usually
sponge) and a transparent lm is used to form a seal over the
wound. A vacuum tube is connected to the transparent lm. It
draws out uid and reduces the size of the wound. There is a con-
siderable volume of published evidence for the value of negative
pressure wound therapy, although this is generally lower- level
evidence. Nevertheless, it is in widespread use and usually forms
one part of the armamentarium of the reconstructive surgeon.
Secondary Intention Healing
If left long enough, many wounds will heal if the environmen-
tal and systemic factors are permissive. Functional and aesthetic
aps, and they can be raised as local or regional pedicled aps,
or as free aps.
Free Flaps
Free aps are in e ect autotransplants, where tissues are trans-
ferred from one anatomical location to another using micro-
surgery to reestablish circulation in order to maintain ap
viability. Free aps have revolutionized reconstructive surgery.
The principles of m icrosurgery are discussed in depth in a sub-
sequent chapter, and numerous free aps are described within
this text.
Perforator Flaps
Perforator aps developed as a way of sparing tissues, for instance
avoiding the sacri ce of a m uscle, while still using the overlying
skin and subcutaneous tissue for reconstruction. Hence the del-
icate dissection of the deep inferior epigastric vessels between
Fig. 1.54 Closure of a large forehead donor site using a w-plasty
in a patient with a stable hairline produces a pretrichial forehead 
lift  closure.2
Table 1.1 Angle of the z-plasty determines potential gain
in length
Angle
Gain in length %
30°
25%
45°

 50%
60°
75%
75°

100%
90°
125%