Flaps Practical Reconstructive Surgery

628
Dorsalis Pedis Flaps
Loretta Coady-Fariborzian and W inston T. Richards
59

Classi cation
Cutaneous ap; can be harvested with the second metatarsal
bone, metatarsophalangeal joint, and/or extensor tendons to
make a composite graft.

Vascular Pedicle

●
Dorsalis pedis (in ow) is the continuation of the anterior
tibial artery, branches to the arcuate, and terminates at
rst dorsal metatarsal artery; venae comitantes of dorsalis
pedis and/or greater saphenous vein provide out ow;
innervated by super cial peroneal nerve; length of the
pedicle can extend to the anterior tibial artery.

●
Can be used as a proxim ally based pedicle ap to cover
defects of the lower leg/ankle or a free ap to reconstruct
hand (Fig. 59.1) and head and neck acquired defects.

Patient Positioning
Supine

Surface Markings

●
Place tourniquet above ankle.

●
Measure the defect; consider designing the ap 10 to 20%
larger than the defect to account for contraction.

●
Doppler/palpate and mark the dorsalis pedis artery from the
rst web to distal edge of the extensor retinaculum (can be ap-
proximately 9 3 12 cm in an adult) (Fig. 59.2); consider a pre-
operative angiogram to verify adequate in ow and dual blood
supply to foot; dorsalis pedis artery usually comes o the ante-
rior tibial artery, but can come from the peroneal artery (40%).

Raising the Flap
Step 1
Incise skin and fascia starting medially to identify and include the
super cial venous draining system.
Step 2
Ligate the rst dorsal metatarsal artery distally (Fig. 59.3).
Step 3
Elevate ap distally to proximally, taking care to preserve
paratendon.
Step 4
Medial border overlaps the tendons of the extensor hallucis lon-
gus (EHL) and the vein on the medial border of the foot.
Step 5
Lateral border is lateral to the tendon of the extensor digitorum
longus.
Step 6
Artery lies between extensor digitorum longus (laterally) and
EHL (m edially) and lies deep to extensor hallucis brevis (EHBr)
(Fig. 59.4).
Step 7
Include EHBr with ap by dividing the tendon of the EHBr where
it inserts laterally into the tendon of EHL.
Step 8
Keep paratenon intact over tendons; dissect deep to fascia.
Step 9
Suture fascia to skin to avoid shearing of ap o blood supply.
Step 10
The super cial peroneal nerve and the deep peroneal nerve may
be incorporated into the ap or left in situ (Fig. 59.5).
Step 11
Cut extensor retinaculum, proceeding proximally to increase
pedicle length. May rotate ap as pedicle to cover lateral or
medial malleolar or distal leg defects.

59 Dorsalis Pedis Flaps
629
c
Fig. 59.1 (a) Left dorsal hand with third- and fourth-degree burns with
tendon involvement from industrial iron. (b) Dorsalis pedis free ap inset
over acquired defect of dorsal ngers and hand. (c) After planned syndac-
tyly release of digits.
a
b

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III Masterclasses in Reconstructive Flaps
Fig. 59.2 Preoperative markings for dorsalis pedis pedicle or free ap.
Fig. 59.3 Hemostat identi es the rst dorsal metatarsal artery.
Fig. 59.4 Hemostat indicates extensor hallucis brevis under elevated ap.

59 Dorsalis Pedis Flaps
631

●
Extensor hallucis brevis muscle

●
May include deep or super cial peroneal nerve
Identi ed and preserved:

●
Extensor paratendon 6 deep peroneal nerve (lies lateral
to artery)

Clinical Perspectives
Advantages include a thin and pliable ap, useful for reconstruct-
ing dorsal hand and palate defects.
A disadvantage is that the donor site is at risk for break-
down; recom m end reconstructing donor site in two stages
using derm al substitutes such as Integra (Plainsboro, NJ), Matri-
Derm (MedSkin Solutions, Billerbeck, Germ any), or Alloderm
(Acelity, San Antonio, TX) prior to thin split-thickness skin graft
reconstruction.
Step 12
When using as free ap, ligate anterior tibial artery once ade-
quate length is achieved (Fig. 59.6); temporarily occlude in ow
with Ackland clamp and verify in ow to foot.
Step 13
Reconstruct defect with a split-thickness skin graft.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Dorsalis pedis artery

●
Medial super cial vein draining to greater saphenous
Fig. 59.5 Deep peroneal nerve left in situ.
Fig. 59.6 Well-perfused dorsalis pedis free ap prior to harvest.

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III Masterclasses in Reconstructive Flaps
Kleinert JM, Fleming SG, Abel CS, Firrell J. Radial and ulnar artery domi-
nance in normal digits. J Han Surg Am 1989;14(3):504–508
Lee KS, Park SW, Kim HY. Tendocutaneous free ap transfer from the
dorsum of the foot. Microsurgery 1994;15(12):882–885
Macionis V. Ipsilateral second metatarsal island osteocutaneous
ap for lower extremity reconstruction. Plast Reconstr Surg
1998;101(6):1611–1615
McCraw JB, Furlow LT. The dorsalis pedis arterialized ap: a clinical study.
Plast Reconstr Surg 1975;55(2):177–185
Reid CD, Moss LH. One-stage ap repair with vascularised tendon grafts
in a dorsal hand injury using the ”Chinese” forearm ap. Br J Plast
Surg 1983;36(4):473–479
Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm ap
donor-site complications and m orbidity: a prospective study. Plast
Reconstr Surg 1997;99(1):109–115
Ritz M, Mahendru S, Som ia N, Paci co MD. The dorsalis pedis fascial ap.
J Reconstr Microsurg 2009;25(5):313–317
Soutar DS, Scheker LR, Tanner NS, McGregor IA. The radial forearm ap:
a versatile method for intra-oral reconstruction. Br J Plast Surg
1983;36:1–8
Yajim a H, Tamai S, Yamauchi T, Mizumoto S. Osteocutaneous radial fore-
arm ap for hand reconstruction. J Hand Surg Am 1999;24(3):
594–603
Zuker RM, Manktelow RT. The dorsalis pedis free ap: technique of
elevation, foot closure, and ap application. Plast Reconstr Surg
1986;77:93

Flap Variations
Can be harvested with the second m etatarsal bone or m etatar-
salphalangeal joint to make an osteocutaneous ap; may harvest
with extensor tendons to transfer vascularized tendon grafts;
may harvest as a purely fascial ap.

Hints and Tips

●
Obtain preoperative angiogram to determine distalmost
ap elevation point; may start dissection just proximal to
web if rst dorsal metatarsal artery is present; otherwise
must start at level of mid-metatarsals.

●
Keep donor site elevated for 2 weeks.
Suggested Further Reading
Kaufman MR, Jones NF. The reverse radial forearm ap for soft tissue
reconstruction of the hand and wrist. Tech Hand Up Extrem Surg
2005;9(1):47–51

633
Understanding the Rhomboid Flap:
The 20-Degree Rule
Jonathan D. Morton and Rowan Pritchard Jones
60

Introduction
The rhom boid ap is a geometrically designed transposition ap
described by Alexander Limberg. While the ap principles ap-
pear straightforward, the accurate orientation of the ap in prac-
tice can be di cult both to teach and to learn. This chapter is
intended to remedy this.

Task One
It is necessary to be able to draw 30- and 60-degree angles freehand.
Fortunately, this is easy. First draw a right angle: it is obvious when
you have this correct (Fig. 60.1). Now, divide the right angle into
three equal parts. You now have three 30-degree angles, and the
60-degree angle is obviously a composite of two of these (Fig. 60.2).

Task Two
Design and execute a classic Lim berg rhomboid ap. First, draw
a lesion to be excised (Fig. 60.3). Add your m argin of excision
(Fig. 60.4). Now enclose this circle with a rhom bus. A freehand
rhombus is surprisingly di cult to draw accurately. A rhombus is
Fig. 60.1 A right angle.
Fig. 60.2 Three 30-degree angles.
two equilateral triangles placed together. Every line is the same
length. Every angle is 60 degrees. This is much easier to draw.
The line m arked X is the central lim b. Note that the central lim b is
longer than the diam eter of the circle (Fig. 60.5).
Now extend a further length X to the right (or left) and then
at a 60-degree angle, continue this line a further length X down
(or up) parallel to the original rhombus. You have now outlined a
second rhomboid, and this is your ap (Fig. 60.6). Or rather, it is
one of four possible aps, as shown in Fig. 60.7. It resem bles the
TIE Fighter from the Star Wars m ovies. This shows four possible
aps: it is most unlikely that any one of them will be absolutely
correct in a clinical setting.
Next, raise ap num ber 4 outlined in Fig. 60.6. The original
rhomboid has been excised leaving a defect (the primary defect).
The ap (ABCZ) is elevated below the subdermal plexus (mid-fat
plane), creating a secondary defect, also a rhomboid (Fig. 60.8).
Now transpose your ap. C m oves to C’, B m oves to B’, and
A m oves to A’. The A to A’ is critical. This is where m ost of the
tension in the closure lies, as A to A’ closes the secondary defect.
Som e tension also lies at a point between BC– B’C’ (Fig. 60.9); this
may be very important if placed close to a critical structure, for
example an eyelid.
Study Figs. 60.9 and 60.10 very carefully. There are many
depictions of this in the literature. Frequently points Y-A’-B’-C’-Z
are depicted as entirely xed, with 100% of the movement

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Fig. 60.5 Rhombus enclosing excision margin.
Fig. 60.6 The classic Limberg  ap.
Fig. 60.7 Each rhomboid can generate four potential  aps.
Fig. 60.4 Lesion 1 excision margin.
Fig. 60.3 Lesion drawn out.

60 Understanding the Rhomboid Flap: The 20-Degree Rule
635
Fig. 60.8 The  ap raised prior to transposition.
Fig. 60.9 Transposition of the  ap.
attributed to ap transposition. On the other hand, the classic
geometric teaching model, derived from Lister and Gibson’s pa-
per, predicts A and A’ both contributing equally (30 degrees) to
the closure of the secondary defect. This is the teaching m odel
that uses relaxed skin tension line (RSTL) plus line of m axim um
extensibility (LME) (Fig. 60.11).
One of the di culties of planning this ap is that in fact
there are no truly xed points. Z is the closest there is to a xed
point. Speci cally note A’ is not a xed point. Clinical experience
shows that in practice both A and A’ m ove a variable am ount
depending on the clinical situation, but rarely is the m ovement
equal. The line of closure shifts by, on average, about 20 degrees,
hence the 20-degree rule. This subtle but important point is ob-
servable in the papers of both Larrabee et al. and Gunter et al.
(Fig. 60.10).
There are inherent di culties w ith the m odel illustrated in
Fig. 60.11. This model, routinely used to teach trainees, involves
drawing in two LMEs to create a rhomboid, and then predicting
two feasible aps (Fig. 60.11, A and B) from that rhomboid. In the
authors’ experience, it has several signi cant drawbacks. Princi-
pally, trainees grasp the concept, and carry out the task allotted
Fig. 60.10 (a,b) A-A’ moves unequally in wound closure, creating a 20-degree shift in line Y-AA’.
a
b
to them on skills courses, but then seem to be no better equipped
to design a ap correctly in the clinical situation. Second, because
the m odel assum es points A and A’ m oving equally (30 degrees),
the results it gives are adequate but rarely perfect. Third, it is
based around formally drawing a rhomboid, now rarely seen
in clinical practice. Fourth, the need to use both LME and RSTL
causes unnecessary confusion. Finally, there is always a mirror
image rhomboid defect, which in turn o ers another two possi-
ble aps (Fig. 60.11, C and D), and it is di cult for the trainee to
see which rhomboid to use, never mind which ap.
The concept behind the rem ainder of this chapter is to o er
a quick, logical, reproducible, and easily learned m ethod of de-
signing the ap in the clinical situation. The authors believe it
simply re ects what m ost of us do instinctively, but in a way
that fosters genuine understanding rather than just a form ulaic
approach.
So, the rhom boid ap is not a di cult concept, but ap orien-
tation is what causes most trainees (and some seniors) di culty.

636
III Masterclasses in Reconstructive Flaps
Beginning by drawing the rhom boid rst will almost invariably
lead to incorrect orientation. The ap needs to be “designed in
reverse”: the ap position de ned rst and then the rhomboid
drawn in later (or not, as we shall see). Consider what you hope to
achieve. You are generally considering a ap because the primary
defect is too tight to satisfactorily close directly. The ap must
be orientated such that it maximizes usage of lax skin adjacent
to the defect; this both facilitates closure of the secondary defect
and ideally will leave the line of secondary closure sitting in an
RSTL, achieving the optimal cosmetic outcome.

Task Three
Orientation: This m ethod uses the RSTL only along with the
20-degree rule. The RSTL is a line that, in most patients, is
Fig. 60.12 An RSTL bisecting the lesion.
clinically obvious as a skin crease. Envisage a lesion requiring ex-
cision overlying the right mastoid. Draw in the RSTLs, ensuring
that one of your near-parallel lines passes through the center of
the defect (Fig. 60.12).
Next draw two lines, each a little longer than the diam eter of
the proposed excision, each at an angle of 20 degrees to the RSTL,
through the center of the circle. Rem em ber that 20 degrees is a
third of 60 degrees (Fig. 60.13).
Each line is the central lim b to a rhom bus. This gives you two
di erent rhomboids, both potentially viable options (Fig. 60.14).
Continue the central limb X downward by the same length again
Fig. 60.11 The standard geometric teaching model.
Fig. 60.13 Two lines drawn at 20 degrees through the center of the circle.

60 Understanding the Rhomboid Flap: The 20-Degree Rule
637
It follows therefore that when your two central limb op-
tions have been drawn in that each central limb will lead to a
rhomboid, each of these rhom boids will then have two viable
ap options. This potentially gives us four viable ap options
from two rhom boids for each lesion. The four colored squares
(Fig. 60.17) show where each of these aps would derive from.
Contrast this with the four aps, all incorrect, derived from the
single rhom boid (the TIE Fighter in Fig. 60.7) that result if the
rhombus is planned rst. You can see also that it is similar to the
standard model (Fig. 60.11) but with improved angles and (crit-
ically) all the options in one plan. The geometry is shown again
in Fig. 60.18.
(there is no lax skin above the defect, thus ruling out the upper
two ap options) (Fig. 60.15).
This lesion is over the mastoid. While both these options are
feasible, the one on the left will source much looser skin, away
from the hairline; so we shall choose this as our ap option.
We now need to add a 60-degree angle to create the second
limb of our ap of length X again. Again, there are two options
(Fig. 60.16). How do we know which of the two options is correct?
Think of the apex of the ap as an arrowhead. When you
have the correct option (Fig. 60.16), the ap points like an arrow
along the RSTL. If you see this, the ap is correctly oriented. If the
ap points across the RSTL then you have got it wrong.
Fig. 60.15 (a,b) First limb of the  ap drawn in.
a
b
Fig. 60.14 (a,b) Two rhomboid options derive from the two central limbs.
a
b

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III Masterclasses in Reconstructive Flaps
Fig. 60.17 Any of these four areas may be suitable choices, depending on local condi-
tions. Keep this image in your mind to plan your next rhomboid.
Fig. 60.18 The geometry outlined.
a
Fig. 60.16 (a,b) The two options—only one correct—for completing our  ap.
b

60 Understanding the Rhomboid Flap: The 20-Degree Rule
639
borne in m ind. Most aps are draw n as show n in Fig. 60.21.
Note again the ap pointing as an arrow along the RSTL and
the 20/40 angles at the apex relative to RSTL. Anticipate the
standing cutaneous cone, but resist cutting it out until after
ap transposition. Fig. 60.20 illustrates the relative tensions in
closing these aps.

The Modif ed Rhomboid
Flap and the SPIRO Flap
In 1987 Quaba and Sommerlad described two modi cations
of the Limberg ap. Initially, they declined to formally excise a
rhomboid defect, leaving it as a circle. This is shown in Fig. 60.19,
where the rhomboid is faintly shown for reference only. This now
is generally called the m odi ed rhom boid ap and transposing
the ap will create a small standing cutaneous cone (or dog ear),
equivalent to one apex of the rhom boid. The ap tip will need
trim m ing. The second m odi cation was simply to m ake the ap
smaller, presumably as con dence grew after the rst modi -
cation. Here the lim b of the ap m ay be as little as two-thirds
the diam eter of the circular defect, and this is referred to as the
SPIRO (square peg in round hole) ap. The ap is undersized rel-
ative to the defect, and therefore, the whole of the ap is used,
without trimming of the tip. The standing cutaneous cone is also
proportionately smaller, and tissue wastage is minimized. The
ap relies to a signi cant extent on skin stretch. In essence these
two aps di er only in degree. This variant of the Limberg ap
has now become the norm; it is very liberating (in terms of plan-
ning) to avoid the rhomboid.
Attention needs to be draw n to the increased tension be-
tween the tip of the ap and the prim ary defect (Fig. 60.20), as
this can have unintended consequences on surrounding struc-
tures. There is no clear distinction between these aps, and in
practice, m ost surgeons simply plan the ap large enough so
that it w ill close the defect w ithout undue tension and keep
wastage to a m inim um . This to som e extent com es w ith ex-
perience, and other factors such as skin fragility need to be
Fig. 60.19 Modi ed rhomboid  ap; the tip of the  ap will need trimming, 
as will a small standing cutaneous cone.
Fig. 60.20 Relative closure tensions in SPIRO  ap (upper) and modi ed rhomboid (lower).

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III Masterclasses in Reconstructive Flaps
Fig. 60.21 SPIRO  ap; the smaller size of the  ap means that none of the 
ap is trimmed, and the standing cutaneous cone created will be minimal.
scar from standing cutaneous cone correction is both less
predictable and nonlinear. Almost always the opposite ap
(which feels distinctly counterintuitive) is best: utilize lax skin
medially, and chase the standing cutaneous cone out laterally.
This leaves a discreet and predictable linear scar m edially—
such as over the cheek, malar, or lateral canthal regions—and
the standing cutaneous cone correction either in the hairline
or well away from the central face.

Conclusion
Planning a rhomboid ap seems to be one of those concepts that
continue to vex trainees long into their career. Many fear being
asked about it in their exit examinations at the culmination of
training. Once the concept is fully grasped, suddenly it seem s
easy, but conveying that knowledge to the trainee can be extraor-
dinarily di cult. The authors don’t believe the historical choice
of teaching model has helped. The authors expect that this new
model, the 20-degree rule, will provide a far easier way to over-
com e the barrier and allow trainees to easily plan these aps in
the clinical situation.
Suggested Further Reading
Borges AF. Choosing the correct Lim berg ap. Plast Reconstr Surg 1978;
62:542–545
Bray DA. Clinical applications of the rhomboid ap. Arch Otolaryngol 1983;
109:37–42
Gunter JP, Carder HM, Fee WE. Rhomboid ap. Arch Otolaryngol 1977;
103:206–211
Larrabee WF Jr., Trachy R, Sutton D, Cox K. Rhomboid ap dynamics. Arch
Otolaryngol 1981;107:755–777
Limberg AA. Mathematical principles of local plastic surgery procedures
on the surface of the human body. Leningrad: Medgis; 1946
Limberg AA. Design of local aps. In: Gibson T, ed. Modern Trends in
Plastic Surgery. 2nd ed. London: Butterworths; 1966
Lister GD, Gibson T. Closure of rhomboid skin defects: the aps of Lim berg
and Dufourmentel. Br J Plast Surg 1972;25:300–314
Quaba AA, Sommerlad BC. “A square peg into a round hole”; a m odi ed
rhomboid ap and its clinical application. Br J Plast Surg 1987;40:
163–170

Flap Choice:
Guiding Principles
The nal section will help with ap choice (i.e., which of the
available four options to use). The following four considerations
in decision making are illustrated in Fig. 60.22.
1. Skin laxity: Obviously enough skin laxity to permit movement is
required. With the mastoid defect, only one of the four possible
ap options exhibited su cient laxity to allow easy closure. But,
as shown, up to four aps may be possible for any given defect.
Supposing each has laxity, how do you choose which is best?
2. Tension 1 landmarks: The A-A’ closure (secondary defect) removes
most of the tension of wound closure but not all. Some tension re-
mains between the tip of the ap and the primary defect, unless
the ap is oversized. It follows that with undersized (SPIRO-type)
aps there may be considerable tension at this point. You need a
clear idea of the direction of pull from closing both primary and
secondary defects. Will this pull on or distort important landmarks,
such as the eyelid? If so, then either the ap size or its orientation
will need adjusting, or an alternative method must be found.
3. Dependency 1 pin cushioning: Dependent aps are more
likely to become and stay pu y; try and keep the pedicle
below the ap wherever possible. This usually rules out two of
the ap options quite quickly. But look at all four and become
familiar with drawing them. You must be able to predict the
outcome before you start operating.
4. Scar versus standing cutaneous cone: Closing the secondary
defect leaves a linear scar in an RSTL. Trainees generally site
this scar (which is very predictable) away from the central
face. Flap transposition creates a standing cutaneous cone at
the opposite pole; this always requires correction, particularly
if sited over a promontory such as the malar prominence. The
Fig. 60.22 The four key considerations for  ap planning.

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Quaba Flaps
Om ar Quaba and Aw f Quaba
enter the overlying skin 0.5 to 1 cm proxim al to the correspond-
ing metacarpophalangeal joint (MCPJ). The ap is usually de-
signed as an ellipse with limits from metacarpophalangeal level
to the wrist crease. Width varies from 1 to 3.5 cm. Axis of rotation
corresponds to site where recurrent perforating branch of dorsal
metacarpal vessel enters the skin.

Patient Positioning
Patient is positioned supine with an arm board. The ap is raised
using tourniquet control. Complete exsanguination is avoided to
aid visualization of the pedicle.

Raising the Flap
Step 1
The skin is incised on one side of the ellipse down to paratenon
(Fig. 61.2). The ap is undermined with care, starting proximally.
Sm all vessels em erging between the extensor tendons m ay be
encountered and can be sacri ced (Fig. 61.3).
Step 2
The pedicle is identi ed distal to the intertendinous connec-
tion of the corresponding interm etacarpal space. Once the ped-
icle has been identi ed, the incision is continued onto the other
side. Super cial veins are ligated as necessary and the ap is
completely islanded (Fig. 61.4).

Classi cation

●
Cutaneous distally based direct perforator ap from sec-
ond, third, or fourth dorsal metacarpal vessels (or perfora-
tors from the deep palmar arch)

Vascular Pedicle

●
Direct perforator from second, third, or fourth dorsal meta-
carpal artery

●
Arising just distal to juncturae tendineae and coursing
from distal to proximal within the skin (Fig. 61.1)

Anatomy and Surface
Markings
The ap is raised on second, third, or fourth interm etacarpal
spaces. Perforators arise distal to intertendinous connections to
61
Fig. 61.1 Flap demonstrating perforator arising from dorsal metacarpal
vessels. Note perforator arises distal to juncturae tendineae (black arrow)
and that perforator is not skeletonized.
Fig. 61.2 Exploratory incision on one side of  ap.

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III Masterclasses in Reconstructive Flaps

Clinical Perspectives
The ap is ideal for resurfacing soft tissue defects in the region of the
dorsal proximal phalanx (including MCPJ and proximal interphalan-
geal joint) with exposed tendon, bone, or joint. The main indications
for the ap are trauma, deep burns, and web contractures.

Flap Variations
Maruyam a published his reverse axial dorsal m etacarpal artery
ap at the same time as Quaba (same issue of the same jour-
nal). It involves a lengthier dissection and a ords little advan-
tage in terms of reach. Pelissier and colleagues described the
extended distally based dorsal m etacarpal artery ap. This ap
is essentially a reverse dorsal metacarpal artery ap based on
dorsopalmar anastomoses at the level of the web spaces. This
extends the distal reach of the ap. The foot counterpart of the
Quaba ap is that described by Early and Milner and is particu-
larly useful for releasing hyperextension contractures of the toes
(Figs. 61.6 and 61.7).
Fig. 61.3 Flap is undermined from proximal to distal. Note small vessels
emerging between the extensor tendons, which can be sacri ced.
Fig. 61.4 Once pedicle is identi ed, the  ap is islanded.
Fig. 61.5 Long-term result from previous patient for correction of web
space contracture with a completely islanded  ap transposed 180 de-
grees. Donor site was closed directly.
Step 3
The ap is rotated (up to 180 degrees) to cover the defect
(Fig. 61.5).
Step 4
The donor site is grafted or closed directly (in the case of a
narrow ap).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Skin and subcutaneous tissue

●
Single recurrent direct perforator (arising distal to junctu-
rae tendineae)
Identi ed and preserved:

●
Paratenon

●
Branches of super cial radial nerve and dorsal ulnar nerve
Fig. 61.6 Hyperextension contracture of toes secondary to burns with
perforator  ap based on perforator arising from dorsal metatarsal vessels.

61 Quaba Flaps
643

●
Do not try to tunnel the ap into palm as there is increased
risk of ap necrosis.

●
Do not extend the proxim al m argin of the ap beyond the
wrist crease.

●
The ap is more reliable on the radial side.

●
The ap can be raised on scarred skin (with care) (Figs. 61.7,
61.8, and 61.9).

●
Doppler is not reliable at identifying the perforator.

●
The scar on the dorsum of the hand can be a signi cant
cosmetic de cit, especially when closure is achieved under
tension.
Suggested Further Reading
Bharathwaj VS, Quaba AA. The distally based islanded dorsal foot ap. Br
J Plast Surg 1997;50(4):284–287
Earley MJ, Milner RH. A distally based rst web ap in the foot. Br J Plast
Surg 1989;42(5):507–511
Maruyama Y. The reverse dorsal m etacarpal ap. Br J Plast Surg
1990;43(1):24–27
Pelissier P, Casoli V, Bakhach J, Martin D, Baudet J. Reverse dorsal digi-
tal and metacarpal aps: a review of 27 cases. Plast Reconstr Surg
1999;103(1):159–165
Quaba AA, Davison PM. The distally-based dorsal hand ap. Br J Plast Surg
1990;43(1):28–39

Hints and Tips

●
Do not attempt to skeletonize the pedicle as the connective
tissue surrounding the perforator m ay contain a num ber of
veins that can be easily damaged.
Fig. 61.7 Flap raised and inset into defect following release of contracture.
Fig. 61.8 Example of a  ap raised on scarred skin in a burn contracture patient.
Fig. 61.9 Two-month postoperative result of the same patient in Fig. 61.8.

644
Spinal Reconstruction with Free
Vascularized Bone Flaps
Henri A. H. W inters
62
superiority in terms of mechanical quality, quantity, and donor
site morbidity. To establish the suitability of the bula for vascu-
larized transfer, a preoperative vascular analysis of the peroneal
vessels should be perform ed in all cases by angiography or du-
plex ultrasonography.
Surgical procedures include anterior, anterolateral, lateral, or
posterior spinal approaches of the cervical, cervicothoracic, tho-
racic, thoracolumbar, lumbar, or lumbosacral spine. For each of
these regions, approaches and choice of acceptor vessels should
be very carefully planned, as the combination is crucial to suc-
cess. Planning is crucial and should involve the whole team. It is
of the greatest importance that the exact procedure is discussed
in detail, including the approach, the size and position of the bony
fragment, and the choice of acceptor vessels, preferably including
a plan B. We make use of 3D imaging and use a 3D printed mod-
el of the patient’s spine to plan the exact shape and size of the
defect, to judge the possibility/need of using a single or double
strut bula, and to determ ine the position where the bula strut
is going to be docked. Sometimes the optimal approach for the
selected spinal segment is not the same as the optimal approach
for the preferred acceptor vessels. This calls for compromise and
should be discussed during the planning session. Angiography or
computed tom ography angiography of acceptor vessels is rarely

Introduction
The use of free vascularized bone grafts is a well-accepted and
frequently used surgical technique in the reconstruction of large
skeletal defects. Free vascularized bone grafts maintain their cel-
lular viability as a result of restoration of endosteal and perios-
teal blood ow. Therefore, revascularized bone grafts participate
actively in bony union and provide fast and reliable periosteal
grow th and healing, comparable to fracture healing under physi-
ological conditions. The advantages of vascularized over nonvas-
cularized bone grafts include rapid consolidation, resistance to
infection, hypertrophic reaction guided by m echanical load, and
tolerance of therapeutic levels of radiation.
In spinal surgery, the use of vascularized bone grafts seems
to be less common than in reconstruction of the extremities. It
may be that spinal surgeons are not aware of, or fam iliar with,
the possibility of reconstruction with vascularized bone, or are
not convinced of its superiority compared to more convention-
al techniques. It may also be that surgeons are reluctant to use
vascularized bone in spinal surgery because of the problems and
di culties expected in selecting acceptor vessels and perform -
ing microanastomoses in places that are hard to reach. In spite of
the superior quality of vascularized bone in the reconstruction of
skeletal bony defects, reports on use of vascularized bone for spi-
nal reconstructive surgery are limited. In this chapter, the author
will share his experience in over 40 cases of spinal reconstruction
with free vascularized bone grafts.
In our institution, free vascularized bone grafts are used for
the reconstruction of complex primary or secondary defects and/
or loss of structural integrity of one or m ore spinal segments that
require adequate, long-term, mechanical stability. The indications
include progressive symptomatic spinal deformities, trauma,
(chronic) infections, and vertebral corporectomies for primary
or metastatic spinal tumors. Additional anterior and/or posterior
instrumentation is necessary to ensure initial stability (Fig. 62.1).
For the reconstructive surgeon, this eld of surgery brings
many challenges concerning choice of ap, planning of the oper-
ative procedure, technical aspects of inserting and securing the
graft, and especially selection and dissection of recipient vessels
and revascularization. The techniques used for instrumentation
and xation of the spine do not di er signi cantly from other forms
of spinal surgery and are therefore not included in this chapter.

Planning
In the rst two cases we performed, an iliac crest ap was used.
Thereafter, the bula was used as ap of choice because of its
Fig. 62.1 Complete stability, despite dislocation of posterior instrumen-
tation 8 years postop in a case of neuro bromatosis.

62 Spinal Reconstruction with Free Vascularized Bone Flaps
645
In most cases, additional stability is created—independent
of the level—with instrum entation through a separate dorsal ap-
proach. This can be done at the same time as the anterior oper-
ation, or at an earlier stage. The two-step method has m ultiple
advantages: the patient does not have to be turned during the
operation, operating tim e is signi cantly reduced, and there is
less risk of abundant blood loss, hemodynamic instability, etc.
Unfortunately, this is not always possible, especially in tumor
cases, where the resection necessitates ventral and dorsal ap-
proaches in one stage. Technique of the dorsal xation is beyond
the scope of this chapter, as we aim to focus on the microsurgical
reconstructive procedure, with special emphasis on surgical ap-
proach and acceptor vessels. In contrast to the reconstruction of
bone defects in the extrem ities and the head and neck region, the
use of vascularized bone grafts in spinal reconstruction encom -
passes additional technical di culties in relation to selection of
recipient vessels at di erent anatomical locations of the cervical,
thoracic, and lumbosacral spine.
Cervical Spine
Because of the relative proximity and good quality of the recipi-
ent vessels in the cervical area, microsurgical revascularization of
free aps rarely presents any di culties. Facial, superior thyroid,
or transverse cervical vessels are the most used acceptor vessels
in the neck. In this region the exposure of the vertebral corpora is
the bigger problem . An anterolateral approach is favored to reach
vertebrae and acceptor vessels from C3 down. For high defects
(C1, C2) a combined dorsal and lateral approach is often pre-
ferred, in between, combined with a transoral approach. In these
cases, the graft is inserted and xated through a dorsal approach,
but the anastomoses are performed through a separate anterior
incision (submandibular) (Fig. 62.4).
called for, but can be useful in cases of severe m alform ation or
extensive previous surgery.

Surgical Technique
The reconstructive surgeon participates in the spinal approach
to the extent that the recipient vessels are selected and dissected
as early in the operation as possible. Both arterial and venous
recipient vessels are selected and, if necessary, dissected care-
fully. These vessels are then guarded throughout the duration
of the surgical procedure. This applies in particular when inter-
costal or lum bar vessels are selected as acceptor vessels, as they
are easily damaged during the operation. Simultaneous with
the subsequent orthopedic/neurosurgical part of the operation,
the reconstructive surgeon can harvest the bula ap from the
leg. In many cases the patient will be in a lateral position. This
by no means causes any di culty in the dissection of the ap. We
always include the exor hallucis longus muscle in the ap. This
simpli es the dissection, improves the out ow, and reduces the
risk of postoperative ection contracture of the great toe. The ap
is left attached to its vascular pedicle until the m om ent of actual
transfer. The size of the spinal defect is accurately m easured and
the bula is osteotomized accordingly. If needed, the bula can
be folded in a double-, triple-, or quadruple-barrel construct to
increase the graft strength (Figs. 62.2 and 62.3).
When osteotom izing and folding the bula, som etim es a
small (1 cm) segment of bula needs to be removed to facilitate a
smooth bend in the vascular pedicle. Depending on the position
of the selected recipient vessels, the bular graft will be placed
with the vascular pedicle ending in the direction of the recip-
ient vessels. Fixation of the bula can be just press- t, simple
screws, or more complex instrumentation. If additional anterior
spinal instrumentation is applied, it should be done prior to per-
forming the vascular anastomoses in order to eliminate the risk
of kinking or compression of the vascular pedicle during instru-
mentation. Either end-to-end or end to-side arterial and venous
anastomoses are performed using an operating microscope or
4.53 ocular loupes.
Fig. 62.3 Osteotomy in vascularized bula, to follow contour of lumbar
spine.
Fig. 62.2 Double-barrel bula with exor hallucis longus.

646
III Masterclasses in Reconstructive Flaps
Fig. 62.5 Pancoast tumor, necessitating resection of cervicothoracic
vertebrae.
The catch with this technique is that the duration of ap
ischemia may become an issue without very careful planning
and preparation, because the patient has to be turned after ap
insertion and xation, in order to perform the anastomoses
through an anterior approach. It may be wise to prepare the
acceptor vessels in an earlier stage, at the very start of the oper-
ation, so no time is lost in dissecting the acceptor vessels at the
time of anastomosis, even though this may mean turning the
patient one m ore tim e. The alternative is to perform the whole
operation with the patient in a lateral position.
Cervicothoracic and Thoracic
Spine
In the cervicothoracic region, a combination of anterior cervical
approach and sternotomy can be used to reach from level C3 to
T5. For levels under T5, the heart and the aorta get in the way, so
in these cases another approach should be considered. After per-
forming the sternotomy, with or without a cervical extension, the
spine is reached through the mediastinum. The distance between
sternum and spine is surprisingly short, thus giving an excellent
accessibility. In addition, the internal thoracic artery and vein are
available as recipient vessels. They are easy to dissect and provide
good quality, diameter, and adequate length to reach any thorac-
ic defect. Furtherm ore, they are well away from the area of the
ablative surgery, lessening the risk of intraoperative damage. In
these cases, there is no need to dissect the acceptor vessels in an
early stage of the operation, albeit dissection before the actual
ap transfer is strongly advised. We consider this approach a
major improvem ent for treatm ent of anterior spinal disorders of
the high thoracic region.
For cervicothoracic or high thoracic defects, the Shaw-
Paulsen approach is a good alternative. The patient is placed in
a lateral position, the scapular muscles (trapezius and rhom -
boid) are detached from the ribs, starting at the spine, and
the arm , including the scapula and all of its dorsal m uscles, is
Fig. 62.4 High cervical reconstruction; consolidation and incorporation
of vascularized bula graft 1 year postoperative.
rotated forward. The rst and second ribs are then removed, cre-
ating good access to the cervicothoracic and thoracic spine down
to T7-8. The vascular pedicle can be anastomosed end to side
with the subclavian artery and vein, as these vessels are easily ac-
cessible and close to the spine. Also, the internal thoracic vessels
can be reached through this approach and be brought to the ap
(Figs. 62.5 and 62.6).
The approach to the mid and lower thoracic region is a chal-
lenge (Fig. 62.7). An intercostal thoracotomy provides reasonable
access to the spine, but the reconstructive surgeon is confronted
with a relatively deep cavity through a relatively narrow open-
ing. This can make it di cult to reach the target recipient vessels
with standard microsurgical instruments. Long, 21-cm micro
needle-holders and micro forceps are of great value in this type
of surgery. In some cases, we were not able to use the operating
microscope due to the limited accessibility, necessitating the use
of high-power (4.53 ) ocular loupes to perform the vascular anas-
tomoses. Here (partial) removal of one or two ribs can greatly
enhance the accessibility. Recipient vessels will most likely be in-
tercostal arteries and veins, or azygos/hemi-azygos veins. In cases
of spinal or paraspinal tumors, the azygos and/or hemi-azygos
veins can be displaced by, or included in, the tumor and, there-
fore, may not be usable for microvascular reconstruction, making
it extremely di cult to nd suitable receptor vessels. We have
demonstrated that the thoracic duct can be a valuable alternative
for the venous recipient in these cases. Despite the successful use

62 Spinal Reconstruction with Free Vascularized Bone Flaps
647
of the thoracic duct in this one case, we do not advocate its use as
a standard venous receptor vessel.
Lower Thoracic and
Thoracolumbar Spine
Approaches to the lower thoracic and upper lumbar vertebrae are
through a thoraco-phrenico-laparotomy. This is likely to be the
most di cult region for microvascular anastomosis. Intercostal or
lumbar vessels are the rst choice as acceptor vessels, but are often
di cult to reach and easily damaged. In this region creativity and
ingenuity are called for. The aorta and vena cava are di cult to
expose at the same time. Through a right-sided approach, the vena
cava can be reached and used in an end-to-side fashion, but the
artery will be too deep to reach properly. For a left-sided approach,
this is the other way around. The superior and inferior mesenteric
vessels can be used for end-to-side anastomosis, or minor branches
can be used for end-to-end anastomosis. However, even though
we did not encounter this in our series, there is a risk of inducing
intestinal ischemia and necrosis. In one patient we performed an
end-to-side anastomosis to the right renal artery and used an end-
to-side anastomosis to the vena cava for venous out ow. If no local
acceptor vessels can be found, there is a possibility to construct an
arteriovenous loop from the greater saphenous vein. This is dis-
sected from the leg, to as low as the ankle, and then anastomo-
sed to the femoral artery in an end-to-side fashion. This loop can
be brought up to the desired level and, after insetting the graft,
divided and used for revascularization of the graft. We have used
this technique several times, albeit not for spinal reconstruction.
Fig. 62.7 Axial vascularized bula strut in a case of neglected progressive
spinal deformity.
Fig. 62.8 Slot in lumbar vertebrae before insertion of vascularized bula.
Fig. 62.6 Reconstruction of defect with double-barrel vascularized bula.
Lumbar Spine
For lower lum bar vertebrae, up to S1, the anterior approach ac-
cording to Brau is an excellent way to create good exposure of
the anterior spine and of the com m on iliac vessels (Figs. 62.8 and
62.9). These vessels are well situated for revascularization of the
ap by end-to-side anastomosis. In this approach, the skin is in-
cised transversely over the rectus abdom inis muscle belly, and
the rectus m uscle is m obilized to facilitate the dissection. As we
normally need a w ider exposure, we adapted this technique in
the way that a param edian longitudinal skin incision is m ade.
The dissection continues through the rectus sheath, m obilizing
the lower part of the rectus and nally keeping it retracted to the

648
III Masterclasses in Reconstructive Flaps
strength is also desired. The bula is superior in axial strength;
provides up to 30 cm of bone; is easily accessible in the prone,
supine, and lateral positions; has a low donor site morbidity; and
can easily be harvested simultaneously with the spinal surgery.
Therefore, after starting out with vascularized iliac crest grafts in
the rst two cases, we changed to the bula as our ap of choice.
In most cases, we used single- or double-barrel bular grafts, but
triple- and even quadruple-barreled bulas have been used to
improve axial strength of the reconstruction. However, by using
multibarrel bular grafts, there is a risk of pushing the m ost pos-
terior bular strut into the spinal cord. For stabilizing procedures,
where no vertebrae have been completely resected, this risk is
absent.
Complex spinal surgery often implies wide surgical exposure
and long-lasting procedures with extensive blood loss. As a result,
these patients are susceptible to hypotherm ia and poor peripheral
circulation, with an increased risk of deep venous thrombosis.
We found venous thrombosis in the deep peroneal veins of the
already raised bular ap in three patients. In all three patients,
there had been an extensive period of tim e (3 to 8 hours) between
the dissection of the bular ap and the actual transfer, leaving
the ap attached to the lower leg by its vascular pedicle only. We
have never experienced deep venous thrombosis in more than
200 bular aps used for mandibular reconstruction in head and
neck surgery, albeit, in many of those cases, there has also been a
period of many hours between dissection and transfer of the ap.
Even though there is no proof of the e cacy of these m easures,
we try to minimize the risk of deep venous thrombosis by keep-
ing the donor site covered and warm and by raising the ap as
close to the moment of actual transfer as possible. Fortunately, in
these three cases, throm bectomy was perform ed easily and suc-
cessfully and all three aps showed good ow after transfer and
vascular anastomosis.

Postoperative Monitoring
Postoperative monitoring is important to prove the viability of the
ap after revascularization. Immediate postoperative revascular-
ization can be demonstrated by selective angiography, gadolin-
ium-enhanced magnetic resonance imaging (MRI), three-phase
technetium -99m bone scintigraphy, positron emission tomogra-
phy (PET) studies, single-photon emission computed tomography
(SPECT), or the use of a skin paddle. From these techniques, only
the use of a skin paddle has been proven to be a reliable indi-
cator of the postoperative viability of the ap. Monitoring the
postoperative vascularization of free aps in anterior spinal re-
construction with the use of a skin paddle is simply not possible
in most cases. For reconstructions of the cervical spine, it may
be possible to include a small skin paddle that can be sutured
into the neck for the purpose of monitoring, but for anterior re-
constructions at the thoracic or lum bar spine, the use of a skin
paddle is impossible. We have performed bone scans and SPECT
scans in several patients early in the series, but, apart from giving
only information about one moment in time, they proved to be
di cult to interpret in the spinal region, rendering us uncertain
in most cases. As these patients are always in the intensive care
unit in their early postoperative days, perform ing these scans was
lateral side, as described in the original article by Brau. Because
the dissection stays completely extraperitoneal, uid loss and
the risk of abdominal complications stay low. The bula is po-
sitioned in such a way that the pedicle is at the distal end of the
graft. This brings the pedicle very close to the comm on iliac ves-
sels for end-to-side anastom osis. Access is excellent, as the dis-
tance from anterior abdom inal wall to the com m on iliac vessels
is relatively small.
The use of a pedicled, vascularized iliac crest graft, based on
the iliac branches of the iliolumbar artery, is a valuable alterna-
tive technique for reconstructive procedures in the lumbosacral
area. This technique has been described by the author, but is be-
yond the scope of this chapter.

Discussion
Instead of combining dorsal instrumentation with a lateral/
ventral approach for vascularized reconstruction of the spine, the
whole procedure can be performed through a dorsal approach
only. To gain access to the thoracic vertebrae and perform a vas-
cularized reconstruction by this posterior approach only provides
a formidable challenge. The onsets of two to three ribs have to
be removed to gain exposure. The reconstructive surgeon should
partake in the posterior surgical approach from the beginning, in
order to dissect and preserve the intercostal vessels that are se-
lected as recipient vessels. Size and quality of intercostal vessels
can be inadequate, especially if a long pedicle is needed. The vein
can be thin-walled and adherent to the rib, m aking it di cult
to dissect. The complete resection and reconstruction will have
to be performed maneuvering around the myelum, making this
approach extremely di cult. We have performed this technique
in one case, but do not advocate the use of this approach in com -
bination with microsurgical reconstruction.
For anterior spinal reconstruction, a substantial volume and/
or length of bone is needed in most cases. High compression
Fig. 62.9 Perfect exposure of acceptor vessels in anterior approach (Brau).

62 Spinal Reconstruction with Free Vascularized Bone Flaps
649
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quite a burden for patient and personnel. Therefore, we decided
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of obstructed or absent blood ow. However, in cases of early ap
failure, it is highly questionable if these patients—after just hav-
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Therefore, the clinical consequences of m onitoring may be very
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bone grafts. Orthop Clin North Am 2007;38:23–35

650
Muscle-Sparing Latissimus Dorsi Flaps
Kathryn Hamnett and Azhar Iqbal
63

Surface Markings
1. Using indelible ink, mark the patient standing wearing a stan-
dard brassiere (Fig. 63.3).
2. Draw in back brassiere strap.
3. Patient removes the brassiere.
4. Mark the posterior midline.
5. Mark the tip of the scapula.
6. Mark the posterior iliac crest.

Classi cation

●
Mathes-Nahai type I

Vascular Pedicle
The latissim us dorsi (LD) m uscle itself is supplied by the trans-
verse and descending branches of the thoracodorsal artery with
segmental supply from the posterior intercostals and lumbar
paravertebral vessels. Most commonly the main thoracodorsal
pedicle has two branches—the transverse and descending—
although there may be more than two branches at varying dis-
tances from the anterior border of the muscle. There always
appears to be a constant vessel anteriorly. This distribution of
branches allows splitting of the muscle to provide blood supply
from the descending branch to the skin paddle and fat pockets
and a thin anterior strip of latissimus dorsi muscle (Fig. 63.1).
The skin paddle does not need to be on the perforator providing
there is a good fascial bridge. The rem aining m uscle is supplied by
the segm ental supply and transverse branch of the m ain pedicle;
hence function and form of the latissimus dorsi are preserved.

●
Vascular supply: descending branch of thoracodorsal
artery and perforators

●
Arc of rotation: 25 to 30 cm

●
Venous drainage: thoracodorsal vein

●
Innervation: branches of the thoracodorsal nerve along
the anterior descending with m inor contributions from
the fascial plexus and from the scapular–parascapular axis

Patient Positioning

●
Order in unilateral breast reconstruction: supine; lateral;
supine

●
Order in bilateral breast reconstruction: supine; left lateral;
right lateral; supine

●
The patient should be positioned supine with ipsilateral
arm abducted at the shoulder with elbow extended on a
thin arm board. The contralateral arm is held adducted us-
ing a folded pad around the wrist and tucked under the
buttocks.

●
The patient is turned to lateral with ipsilateral arm abducted
at the shoulder and exed at the elbow in Carter-Braine arm
support (Fig. 63.2) and nally supine again with both arms
adducted at the shoulder and extended at the elbow secured
at the wrist.
Fig. 63.1 Overview of the latissimus dorsi muscle and its blood supply:
1, axillary artery; 2, subscapular artery; 3, thoracodorsal artery; 4, circum-
ex scapular artery; 5, lateral branch of thoracodorsal artery; 6, medial
branch of thoracodorsal artery; 7, latissimus dorsi muscle; 8, teres major
muscle.1

63 Muscle-Sparing Latissimus Dorsi Flaps
651
Fig. 63.2 Positioning of the patient lateral with ipsilateral arm abducted
at the shoulder and resting in a Carter-Braine support.
Fig. 63.3 Appropriate surface markings.

Raising the Flap
For breast reconstruction, the mastectomy defect is rst re-
created, the pedicle and anterior edge of the latissimus dorsi
muscle are identi ed, and a pocket is created through which the
ap will “tunnel.”
Step 1: Prepare the Field
Use aqueous povidone iodine from table edge to table edge and
prepare the upper arm to the elbow when the patient is in the
lateral position.
Step 2: In ltration
Use 60 to 100 m L of a m ixture of 40 m L 0.5% levobupivacaine and
1:1,000 adrenaline diluted in 1,000 mL saline in 60-mL syringes
attached to pink spinal needles to hydro-dissect the posterior
plane deep to the super cial fascia; this aids to identify the
fascial layer intended to be kept with the skin. Do not in ltrate
directly under the skin paddle as this may cause vasospasm and
use minimally along the future suture line.
7. Ask the patient to “push the fists in to the hips and
cough” and m ark the accentuated anterior border of the
latissim us dorsi m uscle usually form ing the posterior
axillary fold.
8. Draw a line 7 cm posterior to the anterior border of the latis-
simus dorsi and shade it obliquely. This is the “danger zone”
w ithin which the descending branch of the thoracodorsal
vessel lies.
9. Design a skin paddle as a transverse ellipse extending from
2 cm lateral to the posterior m idline to the anterior border of
the latissimus dorsi muscle. This should be designed in order
to leave a scar that lies within the boundaries of the brassiere
strap. Gently pinch the skin in the longitudinal direction to
ensure the defect left will close with minimal tension in nat-
ural skin folds. This usually is no more than 8 cm. The ellipse
should be horizontal and slightly asym m etrical with greater
fullness in its lower pole. This will give improved breast
shape when the ap is transposed anteriorly 180 degrees.
The lower aspect posteriorly becomes the upper pole of the
breast anteriorly.
Although the ap is taken into an ellipse toward the pos-
terior m idline to avoid a dog ear on the back, this corner m ay
need to be discarded or de-epithelialized due to less reliable
blood supply.
10. Mark the extent of the posterior dissection to include the ex-
tended fat pads and shade obliquely.
11. Preoperatively select appropriate implants. As a rule of
thumb, the authors believe that a good breast shape requires a
minimum of 500 mL of volume. The standard muscle-sparing
latissimus dorsi provides approximately 250 mL but some of
this is taken up in the axilla; therefore, a supplementary im -
plant should be chosen accordingly. On average the authors
use anatomical implants 340 mL XM2; the largest used has
been 530 mL XM3.

652
III Masterclasses in Reconstructive Flaps
and perpendicular to the areolar tissue, “cut the air” layer with
a gentle side-to-side sweeping motion without digging the tip
of the monopolar into the delicate fat layer. Do not leave any fat
on the deep surface of the super cial fascia as this must stay
with the ap.
Using the sam e technique and staying in the sam e plane,
raise the skin aps along the full length of the superior border
of the skin paddle. It is essential that this plane is adhered to,
as the deep fat layer tends to be signi cantly thinner anteriorly.
Complete superiorly at the premarked tip of the scapula.
Inferiorly the super cial fascia and deep fat layer will taper
out as the posterior iliac crest is approached. Approximately 8 to
10 cm of inferior fat harvest should provide adequate coverage of
the implant in its superior pole. The posterior boundary of skin
ap dissection is 2 cm from the midline.
Step 4: Dissecting the Fascial Flap
from the Underlying Structures
Extend the dissection of the skin and fascial ap and then raise
o the deep structures that compose the thoracolumbar fascia
toward the midline and the latissimus dorsi as dissection is con-
tinued laterally. A layer of fascia may be lifted from the latissimus
dorsi, but the muscle itself is preserved (Fig. 63.4).
The inferior border of the trapezius m ay dictate where to
conclude the superomedial extent of the fascial ap (Fig. 63.5).
If required, fat deep to trapezius can occasionally be har-
vested, sim ilar to the traditional extended latissim us dorsi ap.
Leave fat around the tip of the scapula as a gliding surface for the
scapula to avoid sti ness. Avoid cutting into the scapula bursa
(Fig. 63.6). Small intermuscular perforators should be identi ed
and addressed with bipolar diathermy. Dissection is continued
anteriorly until the danger zone, which is within 7 cm of the an-
terior border of the latissimus dorsi anterior edge.
Step 3: Dissecting the Skin Flaps
in the Subsuper cial Fascial Plane
Following initial incision with a blade, the superior and inferior
skin aps are raised. The “glistening white” subsuper cial plane
between the “white fascia and yellow fat” junction is identi-
ed and raised o the underlying fat using m onopolar 30:30
blend. Keeping the monopolar tip parallel to the deep fat layer
Fig. 63.4 The ap, including the fascia, is dissected o the underlying
musculature.
Fig. 63.5 The edge of trapezius indicates the extent of superomedial
dissection.
Fig. 63.6 Leave fat around the tip of the scapula as a gliding surface for
the scapula to avoid sti ness, and avoid cutting the scapular bursa.

63 Muscle-Sparing Latissimus Dorsi Flaps
653
Fig. 63.7 The oblique bers become almost vertical, indicating the site of
the descending branch within the muscle.
Fig. 63.8 Lift the anterior edge of the LD and free it along its entire length.
Please note the alteration in the direction of the latissimus
dorsi (LD) m uscle bers, which changes from oblique to become
vertical anteriorly (Fig. 63.7). The authors nd that this corre-
sponds to the zone supplied by the descending branch and this
characteristic can also be useful to split along the bers when the
pedicle is mobilized.
Very gentle handling of the ap is observed during this part
of the dissection. Do not over aggressively apply the swab to
bleeding points on the ap as this could disrupt the sm all cap-
illaries. At this point, muscle paralysis by the anesthetist and
lowering the monopolar to 20:20 blend aid this dissection, which
otherwise becomes di cult due to muscle twitching. Use of tra-
ditional or harmonic scalpel dissection m ay remove muscle con-
traction problems.
Step 5: Identi cation of the
Descending Branch and Raising
the Muscle Strip
Once the skin or fascial ap is raised up to the danger zone, the
next step is to identify the boundaries of the strip of muscle that
contains the vascular pedicle and needs to be included. This is
done by lifting the anterior edge of the muscle along its entire
length (Fig. 63.8) and locating the descending branch on the deep
surface by carefully sweeping o the underlying serratus fascia.
Often the descending branch is directly visible and becom es
more prom inent as it is traced proxim ally toward the hilum . If
not, the following can aid identi cation:

●
Fatty streak sign—the vessels run within the fatty yellow
streak on the deep surface.

●
Transillumination by tilting the overhead light to the
posterior of the patient and visualized by standing anterior
to the patient (Fig. 63.9).

●
Pulsations can be palpated.

●
Sterile intraoperative Doppler.
If there is more than one branch, then only include those
within 4 to 6 cm of the main branch. Inclusion of branches outside
of this boundary will result in unnecessary expenditure of muscle.

654
III Masterclasses in Reconstructive Flaps
Fig. 63.9 Transilluminate the descending branch (pointed out with the bipolar forceps).
Once the descending branch or branches are identi ed, only
the segment of muscle directly enveloping it are harvested. Com -
mence division of this strip of muscle from inferior to superior
to minim ize risk of dam age to the pedicle. The vertical bers
mentioned earlier can be split from the main body oblique bers.
It m ay not actually be necessary to go all the way to the bifur-
cation because transposition may be possible before that point
(Fig. 63.10).
To avoid a bulge at the pivot point, skin undermining may
need to be adjusted and a m inimal back cut in the fascial part
of the ap above the superiormost perforator of the descending
branch m ay be used (4 to 7 cm below the apex of the posterior
axillary fold). This is the area where a fascial bridge may theoreti-
cally contribute minor vascular contributions from the parascap-
ular/scapular territory. The ap is orientated and delivered via a
subcutaneous tunnel to the mastectomy defect (Fig. 63.11).
Please note the main nerve supply and transverse branches
are still intact and the ap can be sutured to the peripheral
mastectomy defect for smooth contour using 2-0 PDS (Ethicon,
Somerville, NJ). Once an appropriate implant is chosen, the skin
island can be inset under reasonable tension because this ap
is fairly robust apart from the very medial edge, which can be
de-epithelialized and buried to give medial fullness.
Step 6
Deliver the ap.
Step 7: Close the Donor Defect
A single size 10 Blake drain (Ethicon) is inserted exiting though
the axillary skin. Around 6 to 8 four-strand quilting sutures are
inserted using dyed 2-0 PDS. The wound is closed in the super-
cial fascial layer with 2-0 PDS. A continuous deep subcuticular
barbed suture (e.g., V-lock) closes the wound. Steri-Strips (3M, St.
Paul, MN) and a water-resistant dressing are applied. Postoper-
atively, keep the patient warm, pain free, and well hydrated and
keep drains until clear serous drainage and/or less than 40 mL
per day.

Important Anatomical
Structures
The descending branch in our experience has been constant. Per-
forming the anterior dissection under the LD rst should be done
if previous surgery or radiotherapy has taken place, and the pro-
cedure adapted accordingly. The nerve is not dissected separately
to the vascular pedicle. It may be necessary on occasion to release
the fascia superior to the tendon of the latissim us dorsi in order
to increase the reach when transposing the ap anteriorly.

Clinical Perspectives
The m uscle-sparing LD ap in conjunction with a breast implant
is an excellent option for breast reconstruction (Figs. 63.12 and
63.13). It is particularly useful in bilateral reconstruction in
athletic women with little abdominal pannus and in whom it is
preferable not to sacri ce the latissimus function. A larger ap
dimension can be attained with multiple perforator inclusion to
provide more tissue in this particular group.
Using only a slip of LD preserves the rest of the m uscle as a
fallback for a salvage procedure. It also maintains the aesthetic

63 Muscle-Sparing Latissimus Dorsi Flaps
655
Fig. 63.11 (a) Prepare to deliver the ap through the preraised axillary tunnel to the breast pocket. (b) The ap is delivered via a subcutaneous tunnel
to the mastectomy defect.
a
b
Fig. 63.10 A strip of LD muscle is harvested with the ap.

656
III Masterclasses in Reconstructive Flaps
a
Fig. 63.12 (a) Delayed breast reconstruction in an athletic patient. (b) Right delayed and left immediate breast reconstruction in a patient who
skis at 2 years and 4 weeks, respectively.
b
contour of the posterior axillary fold and m inim izes the under-
arm bulk from tunneling. There is a signi cantly lower rate of
seromas than in traditional LD reconstruction.
Alone it may be suitable for total and partial breast recon-
struction. The authors, however, do not recomm end expending
Fig. 63.13 One year following a muscle-sparing LD and anatomical im-
plant for immediate left breast reconstruction following nipple-sparing
mastectomy through an inframammary fold incision.
this ap for partial reconstruction under usual circumstances,
as it should be kept as an option for total breast reconstruction.

Hints and Tips
If the patient does not have a brassiere with them, note that the
bra line is usually in line with anterior inframammary fold.
Suggested Further Reading
Brackley PTH, Mishra A, Sigaroudina M, Iqbal A. Modi ed muscle spar-
ing latissim us dorsi with implant for total breast reconstruction –
Expanding the boundaries. J Plast Reconstr Aesthet Surg 2010;
63(9):1495–1502
Delay E, Gounot N, Bouillot A, et al. Autologous latissimus breast recon-
struction; a 3 year clinical experience with 100 patients. Plast
Reconstr Surg 1998;102:1461–1478
Delay E, Gratadour A, Jorquera F, et al. Imm ediate autologous latissimus
breast reconstruction after skin sparing mastectomy. Eur J Plast
Surg 1999;22:111
Mojallal A, Saint-Cyr M, Wong C, Veber M, Braye F, Rohrich R. Muscle-
sparing latissim us dorsi ap: Vascular anatomy and indications in
breast reconstruction Ann Chir Plast Esthet 2010;55(2):87–96
Wong C, Saint Cyr M. The pedicled descending branch muscle-sparing
latissim us dorsi ap for trunk and upper extrem ity reconstruction.
J Plast Reconstr Aesthet Surg 2010;63(4):623–632
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

657

Surgical Techniques
Fibula
In the author’s center, three di erent techniques are used to re-
construct through-and-through orom andibular defects with one
free vascularized bula ap:
A. Single skin paddle, with an orocutaneous fold. In these
cases, the skin paddle runs in continuity from intraoral to
extraoral. The author uses this technique in cases where
the orbicularis oris m uscle is a ected. Often a tendon graft
is used to support the skin paddle at the oral aperture
(Fig. 64.1).
B. Single skin paddle with a de-epithelialized bridge be-
tween the intraoral and extraoral component. This is
used in cases where a strip of orbicularis muscle and lip
can be preserved. The strip of orbicularis/lip rides on the
de-epithelialized bridge of the skin paddle (Fig. 64.2).

Introduction
Through-and-through defects, consisting of mandible, intraoral
lining, and external skin provide the reconstructive surgeon with
a serious challenge. Most surgeons will use more than one ap
to obtain satisfactorily functional and cosmetic outcome. One
can im agine that the use of a second free ap will be m ore tim e
consum ing and m ore expensive. Also, two donor sites m ight be
more invalidating and have m ore donor site m orbidity than one.
Therefore, our primary choice for reconstruction of a through-
and-through oromandibular defect is one double-paddle bula
ap only. In cases where the bula ap is not an option, athero-
sclerosis of the leg being the most common cause, our second
choice is a free vascularized iliac crest in com bination with a
groin ap. This does necessitate the use of two aps and two re-
vascularizations, but the aps can be raised from the same donor
site, through the same incision and primary closure of the donor
site is possible in most cases.
64
Reconstruction of Full-Thickness
Oromandibular Defects
Henri A. H. W inters
b
a
Fig. 64.1 (a,b) Reconstruction of oor of mouth and external skin with a
continuous skin ap.

658
III Masterclasses in Reconstructive Flaps
the author starts the dissection from the dorsal side. The skin is
incised and the incision is deepened to a subfascial level. The so-
leus muscle is freed from the fascia and the posterolateral sep-
tum comes in to view.
The perforators of the skin paddle are located on this side
of the septum and can easily be seen (Fig. 64.4). Normally, there
will be perforators in the caudal part of the ap, and they will
run on the septum, into the exor hallucis longus muscle, often
giving o a muscle branch to the soleus at the point where they
disappear into the exor hallucis muscle. These muscle branches
can be clipped and cut. The author leaves the exor hallucis m us-
cle in the ap, as this m akes the dissection easier and does not
have a negative e ect on the donor site morbidity. The soleus is
then freed from the bula from distal to proxim al. The perfora-
tors in the cranial part of the ap can either run on the septum,
perforate the origin of the soleus muscle and go straight into the
C. Two completely separate skin paddles, each with its own
perforator(s). This gives m ore freedom of placement
(Fig. 64.3).
Methods A and B are often used for central defects, where
the complete, or almost complete, lower lip has to be resected.
Method C is used m ore often for lateral defects, where m ore
mobility of the ap is needed for proper positioning.
The dissection of a double skin paddle bula ap is not nec-
essarily very di cult; however, the anatomy of the proximal
perforators can vary signi cantly from those in the lower half of
the lower leg. When a double skin paddle bula ap is needed,
the proxim al perforator(s) will supply the proxim al skin paddle,
which is norm ally used for the external defect. The author be-
lieves it is important to get a clear view of the availability and
localization of the perforators in an early stage of the operation.
Therefore, in contrast with several descriptions of this operation,
Fig. 64.2 Continuous skin paddle with de-epithelialized skin bridge for the lower lip to ride on.

64 Reconstruction of Full-Thickness Oromandibular Defects
659
Fig. 64.3 Fibula ap with two separate skin paddles.
Fig. 64.4 Septal skin perforators of bula ap seen from dorsal approach.
peroneal vessels, or run into the soleus muscle and follow a ceph-
alad course through the muscle, converging with other muscle
branches and skin perforators to nally reach the peroneal ves-
sels high in the lower leg. They might even run up to the popliteal
vessels, necessitating a separate anastom osis (in fact, leaving a
separate ap, albeit from the same donor site). Normally, these
musculoseptal cutaneous perforators are located above the ori-
gin of the exor halluces longus muscle, where the soleus muscle
is m ore attached to the bula. The m ost e cient way to dissect
them out of the soleus is from the deep (anterior) aspect of the
muscle, that is, from the inside (Fig. 64.5).
Blind inclusion of a soleus m uscle cu does not guarantee
that these perforators are preserved, especially not when they
originate from higher up. When a single skin paddle is needed,
the cranial perforators (from above the origin of the exor) are
rarely needed and can be discarded when the usual septal per-
forators or musculoseptal perforators through the exor hallu-
cis longus muscle are present, even if a big skin paddle—running
up to the knee—is needed. For a double-paddle ap, however,
these perforators supply the proxim al skin ap. They are ade-
quate and reliable, but in order to include this type of perforator,
it has to be dissected out of the soleus m uscle, all the way up

660
III Masterclasses in Reconstructive Flaps
Fig. 64.5 Skin perforators on inner aspect of soleus muscle.
Fig. 64.6 Fibula ap with separate vascularization of skin paddle, necessitating separate anastomosis.
to its vascular origin. The author has had to perform a separate
anastomosis in several cases where these perforators originated
cranially o the bifurcation of the peroneal and posterior tibial
arteries and thus could not be included in the vascular pedicle of
the bula ap (Fig. 64.6). The author strongly believes that the
misapprehension of this con guration has in the past led to ap
failure, giving the skin paddle of the bula ap a bad reputation.
In case of a double paddle bula ap, the distal skin paddle
is relatively xed to the bula by the septum and the relatively
short perforators. It is well suited for intraoral reconstruction.
The proxim al skin island has a large range of m otion due to the
long descending perforator(s), and is therefore ideal for covering
external defects.
Iliac Crest 1 Groin Flaps
When a bula ap is not available, the iliac crest ap is our sec-
ond choice for the reconstruction of m andibular defects. The
internal oblique abdom inal m uscle is included in the ap and
used for reconstruction of the oral lining. In case of a through-
and-through defect, the iliac crest ap is com bined w ith a
groin ap for reconstruction of the external defect (Figs. 64.7
and 64.8).
The dissection is started w ith the groin ap. This ap is com-
pletely dissected, but the vascular pedicle is left intact. Then the
iliac crest is raised in combination with the internal oblique ab-
dominal muscle. If possible, use only a bicortical iliac crest graft,

64 Reconstruction of Full-Thickness Oromandibular Defects
661
Fig. 64.7 Iliac crest ap and groin ap raised through same approach.
Fig. 64.8 Result of combined iliac crest and groin aps.
leaving the anterior superior iliac spine and the outer table of
the iliac crest intact (Fig. 64.9). This reduces donor site morbidity
and still provides adequate bone for mandibular reconstruction
in m ost cases. The iliac crest ap is transferred rst, followed by
the groin ap. Two revascularizations are needed. The donor site
can generally be closed primarily.

Discussion
Although through-and-through defects of the oral cavity are not
com m on, these represent a signi cant challenge for the recon-
structive surgeon. Because of the need for intraoral soft tissue
lining, external skin, and bone, it is often thought that multiple
aps are required. However, we feel that a single free vascular-
ized bula ap is su cient in most cases using either of the three
described techniques (the double paddle, de-epithelized skin
bridge, or orocutaneus fold).
One can imagine that postoperative morbidity, especially of
the donor site, is lower if only one ap is used, though if a larger
single skin paddle is harvested, wound healing might be more
of an issue compared with two sm aller donor sites. Using a skin
graft on the donor site is correlated with higher early donor site
morbidity. Because we plan our skin paddles in a longitudinal
way, most of the defects can be primarily closed, so the author
feels that a double paddle skin ap creates no m ore donor site

662
III Masterclasses in Reconstructive Flaps
morbidity than a single paddle, thus decreasing operating tim e
and donor sites, which will also reduce costs.
Algorithms concerning ap choice for reconstruction of oro-
mandibular defects have been described in several publications.
In these algorithms the double paddle technique for complex de-
fects is only mentioned by Baumann et al. The other physicians
prefer the use of more than one ap when reconstructing an oro-
mandibular through-and-through defect.
If the bula ap is not available, the author’s second choice
for through-and-through defects is a combination of myo-osseous
iliac crest ap and groin ap. We prefer this combination to the use
of an osteomyocutaneous iliac crest ap, because in our hands, the
skin paddle of the iliac crest ap is not always reliable and has a
very limited mobility, compared to the groin ap, even though it is
partially the same area of skin. The groin ap and the iliac crest ap
can be raised through the same incision and the donor site can be
closed primarily in most cases. So, even though two aps are used,
there is in fact only one donor site, an advantage for our patients.
Suggested Further Reading
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Surg 2010;48(4):245–252
Balasubram anian D, Thankappan K, Kuriakose MA, Duraisamy S, Sharan R,
Mathew J, et al. Reconstructive indications of simultaneous double
free aps in the head and neck: a case series and literature review.
Microsurgery 2012;32(6):423–430
Bardot J, Jallut Y, Zanaret M, Legre R, Magalon G. [Mandibular reconstruc-
tion using an iliac crest free ap vascularized by the deep circum -
ex iliac vessels. A clinical study apropos of 30 cases]. Ann Chir
Plast Esthet 1994;39(4):442–447
Baumann DP, Yu P, Hanasono MM, Skoracki RJ. Free ap reconstruction
of osteoradionecrosis of the mandible: A 10-year review and defect
classi cation. Head Neck 2011;33(6):800–807
Carbiner R, Jerjes W, Shakib K, Giannoudis PV, Hopper C. Analysis of the
compatibility of dental implant systems in bula free ap recon-
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Chang YM, Wallace CG, Tsai CY, Shen YF, Hsu YM, Wei FC. Dental im-
plant outcom e after prim ary implantation into double-barreled
bula osteoseptocutaneous free ap-reconstructed mandible. Plast
Reconstr Surg 2011;128(6):1220–1228
Fig. 64.9 Bicortical bone segment of iliac crest ap; reduction of donor site morbidity.
Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of the m andible
with osseous free aps: a 10-year experience with 150 consecutive
patients. Plast Reconstr Surg 1999;104(5):1314–1320
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Osseointegrated implants: a comparative study of bone thickness
in four vascularized bone aps. Plast Reconstr Surg 1993;92(3):
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Gaggl AJ, Burger H, Chiari FM. A combined super cial inferior epigastric
artery ap and vascularized iliac crest ap in the reconstruction
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2011;40(2):162–168
Garvey PB, Chang EI, Selber JC, Skoracki RJ, Madewell JE, Liu J, et al.
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Hidalgo DA, Pusic AL. Free- ap mandibular reconstruction: a 10-year
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rator locations and clinical application for pedicled perforator aps.
Plast Reconstr Surg 2008;122(1):161–170
Sullivan MJ, Carroll WR, Baker SR, Crompton R, Smith-Wheelock M.
The free scapular ap for head and neck reconstruction. Am J
Otolaryngol 1990;11(5):318–327
Takushim a A, Harii K, Asato H, Momosawa A, Okazaki M, Nakatsuka T.
Choice of osseous and osteocutaneous aps for mandibular recon-
struction. Int J Clin Oncol 2005;10(4):234–242
Urken ML, Buchbinder D, Weinberg H, Vickery C, Sheiner A, Biller HF.
Primary placement of osseointegrated implants in microvas-
cular mandibular reconstruction. Otolaryngol Head Neck Surg
1989;101(1):56–73

664
Principles of Flap Reconstruction for Burns
Shehab Jabir, Quentin Frew, Naguib El-Muttardi, Odhran Shelley, and Peter Dziew ulski
65
for only 1.8% of all cases. Data from our own institution pub-
lished recently indicated that out of a total of 8,776 burns pa-
tients admitted for operative treatment over a 12-year period,
only 55 locoregional aps in 52 patients (0.59%) and 26 free aps
in 23 patients (0.26%) were performed. It is clear from these data
that locoregional and free ap utilization in burn reconstruction
is not always the norm in burn reconstruction surgery. The vast
majority of burns requiring operative intervention may ade-
quately be treated with split skin grafting.

Flaps in Burn
Reconstruction
The m ain indications and drivers for ap reconstruction in burns
are tissue cover of exposed and nonvascularized tissue such as
bone or tendon, and improving functional and cosmetic out-
com es through use of tissues of superior quality to skin grafts
for color match, pliability, contour, and sensation. Therefore, aps
are often the treatment of choice if adequate skin and tissue are
locally available. Local aps are very useful for burn reconstruc-
tion and can even be fashioned from scarred skin. Care m ust be
taken to include a good amount of subcutaneous tissue in aps
incorporating scar tissue, as the normal dermal blood supply may
not be present. Advancement aps are generally safer in such cir-
cumstances but do not o er the same amount of release.
A Z-plasty is a transposition ap commonly used in burn
reconstruction. It lengthens scars and changes their direction
allowing the surgeon to place the resultant scars in the lines of
minimal skin tension. The am ount of length increase depends on
the angle of the ap tip with the optimal angle being 60 degrees.
Multiple serial linear Z-plasties can be used to lengthen scars
without using large aps and the need for large amounts of lax
surrounding skin. Multiple combination Z-plasties such as the
four- ap and the ve- ap Z-plasty lengthen and reorient scars to
a greater degree than a simple Z-plasty and are useful for releas-
ing three-dimensional contractures such as the rst web space in
the hand. Z-plasties can also be used to reorientate and reposition
anatomical structures such as the earlobe. Fasciocutaneous trans-
position aps are also useful in the release of joint contracture,
particularly if the ap skin is scarred, as their blood supply is more
reliable. See Figs. 1.51, 1.52, and 1.53 in Chapter 1 of this book.
Advancement aps have less undermining and therefore a
more robust blood supply but use adjacent tissue m obilized from
the sides to produce scar lengthening. A Y-V advancem ent is the
most com m on application and, when used serially along a linear
scar band, can produce very satisfactory lengthening, and is often
used as a series of m ultiple aps. This technique has advantages

Introduction
The skin is the largest organ in the human body, accounting for
approximately 2 m 2 in an average adult. Burn injuries may range
from trivial wounds that heal with no intervention to those that
require prolonged supportive care and lifelong surgical correc-
tion. Even relatively sm all burns m ay have devastating lifelong
functional and aesthetic sequelae. The aphorism “a burn is for
life” is true for the majority of burn patients. Flaps in all their
forms may be utilized for burn reconstruction both in the acute
phase following burn debridement and for postburn reconstruc-
tion. They provide a num ber of advantages over conventional skin
grafting in terms of the quality and durability of primary cover-
age achieved and the complexity of possible reconstructions.
In this chapter we provide a comprehensive approach to ap
reconstruction in the burn patient. Apart from a general and an-
atomical approach to the application of local and free aps, other
factors such as the ideal timing for reconstruction, monitoring
regimens, and m ethods to avoid failure of aps utilized in burn
patients are covered. This chapter focuses on general principles,
as the relevant aps are described in detail earlier in this book.

Epidemiology
In 2004 it was estimated that the worldwide incidence of re-related
injuries was 1.1 per 100,000 population. The highest incidence was
in Southeast Asia and the lowest in the Americas. In the United
Kingdom, it is estimated that there are approximately 250,000
burn injuries per annum. Approximately 175,000 of these attend
emergency departments, while around 13,000 require admission.
Of these burn patients, around 1,000 have burns severe enough to
require uid resuscitation and about 300 of them do not survive.
Apart from incidence, a number of other epidemiological
metrics have been investigated in relation to burn injuries includ-
ing prevalence, accidental versus intentional injuries, mecha-
nism of injury (scalds, electrical burns, or chem ical burns, am ong
others), and populations at risk. However, very lim ited data exist
on the numbers of patients with burn injuries requiring surgical
intervention. Data on the types of intervention performed such as
skin grafting, local aps, and free tissue transfer are also sparse.
In a study by Platt et al., 604 out of 1,699 patients admitted over
a 5-year period required operative treatment of their burns. Out
of these 604 patients, 582 (96.4%) were satisfactorily treated with
skin grafts, 13 (2.1%) required local aps, and only 9 (1.5%) re-
quired free aps. In a sim ilar study by De Lorenzi et al., 2,400 burn
patients were treated operatively between 1976 and 1996. Again,
only 39 patients required free aps for reconstruction accounting

65 Principles for Flap Reconstruction for Burns
665
(late) depending on clinical need—the degree of obstruction
caused to what are considered essential functions. For example,
release of microstom ia and synechial neck contractures would
fall within the urgent category as they severely restrict essential
activities such as feeding. Contractures of the axilla maybe classi-
ed as requiring release for improved function, whereas restoring
facial aesthetics may be performed much later.
Flaps in general (locoregional or free aps) are indicated in
acute primary reconstruction when debridement of the burn
injury results in a signi cant soft tissue de cit that rst results
in a wound bed that is unsuitable for skin grafting and sec-
ond may leave vital structures such as nerves, tendons, bone,
and blood vessels exposed. Hence, the depth of the defect is a
more important consideration than the area of the defect per se.
Locoregional perforator-based aps are chosen when the burn is
restricted to an isolated area with the surrounding tissue being
una ected and of good quality (Fig. 65.1).
The locoregional ap should be designed incorporating
the tissue proxim al or lateral to the burn injury but not tissue
immediately distal to it to reduce the possibility of including
a damaged source or perforator vessel within the ap. Tension
should be avoided, and where possible, the donor site should
be closed primarily without employing a graft for an optimal
functional and aesthetic outcome. Free aps are employed when
there are insu cient quantities of local tissue for a locoregional
ap; when there is a need to import fascia, bone, or nerve tissue
for a complex (possibly single stage) reconstruction; and when
the burn wound extends to involve surrounding tissue precluding
locoregional aps from being used (Figs. 65.2 and 65.3).
This is most com m only the scenario in burns a ecting the
extrem ities (which is discussed in more detail below). These
regions have very limited quantities of soft tissue, which pre-
cludes the use of local pedicled aps (while skin grafting is not
suitable over exposed bone/tendon due to the risk of contrac-
ture). Furtherm ore, free tissue transfer to areas of the upper
limb and lower limb enable salvage of these limbs without the
resultant negative sequelae of local donor site morbidity in cases
where locoregional aps may be used (Fig. 65.4).
Free tissue transfer enables the import of good-quality
una ected healthy tissue for coverage of extensive deep burns.
The primary disadvantage of free aps in acute prim ary recon-
struction, however, is the need for a lengthy operation in a rel-
atively unstable patient (especially those with large total body
surface area burns requiring ventilatory and circulatory support).
In terms of secondary reconstruction, aps are indicated
following contracture release that results in large tissue de cits
that are unsuitable for grafting (discussed in m ore detail below).
Grafting in such circumstances may cause a recurrence of the
contracture (although adm ittedly less severe). It is important to
consider the anatom ical location of the contracture as the release
of a large contracture, say over the cervical region or knee, re-
quires tissue in excess of that required to purely bridge the de cit
as the ap in these regions must permit mobility in addition to
providing coverage. Locoregional aps and free aps comprising
contractured tissue m ay be used, but it is essential to ensure that
the dermal vascular supply to this tissue including the pedicle
and source vessel is not damaged so signi cantly that the subse-
quent ap fails.
over Z-plasty as the ap edges are not undermined, mitigating
the risk of ap necrosis at the tips.
Axial pattern aps have a speci c blood supply based on a
nam ed or unnamed vessel, do not have length–width ratios, and
are generally m ore reliable than random pattern aps. They can
be planned and raised in injured and uninjured skin and can
be based on either a direct cutaneous or fasciocutaneous blood
supply.
Traditionally such aps have incorporated fascia or muscle
and have been based on nam ed vessels. Recent advances in un-
derstanding of vascular anatomy and physiology have led to the
developm ent of the perforator-based aps which are based on
known or ad hoc perforating vessels reaching the skin through
the musculocutaneous, septocutaneous, or direct cutaneous
routes. The perforators can be identi ed for planning purposes
using a handheld 5-MHz vascular Doppler. These aps have be-
come very popular due to their versatility, thinness, pliability,
and availability in all areas of the body and particularly the head
and neck region and the hand. Perforator aps can be dissected
and m obilized in a num ber of ways including advancement (V-Y),
transposition, and rotation (propeller). Thinning of the ap can
be undertaken at the tim e of harvest as well as usually leaving a
cu of tissue/fat around the vascular pedicle.
The use of microvascular reconstruction after burn injury
has been lim ited in the past and m ainly reserved for closure of
complex wounds (often electrical and chemical burns) in the
acute setting and for replacem ent of m issing parts or complex
contracture reconstruction. In addition to being a higher risk
procedure, m any free aps were bulky and required signi cant
revision surgery. Since the advent of perforator aps with the
ability to thin them , the indications for m icrovascular burn re-
construction have signi cantly increased and with the addition
of preoperative ap thinning, both function and cosm esis have
improved. Pre-expansion of aps has allowed larger aps to be
harvested with primary closure of donor sites and prefabrication
has allowed three-dim ensional reconstruction of parts prior to
transfer. Tissue expansion remains a useful technique in burn
care, but is outside the remit of this chapter.

Indications for Pedicled/
Perforator Flaps and Free
Flap Transfer in Burn
Reconstruction
For the sake of simplicity, burn reconstruction can be categorized
into primary acute reconstruction and secondary postburn re-
construction. Prim ary acute reconstruction incorporates im m e-
diately critical procedures required to reduce infection, encour-
age wound healing, and preserve as much function as possible. It
includes the debridem ent of devitalized tissue and provision of
coverage for exposed vital structures such as bone, nerves, ten-
dons, and vessels. Postburn reconstruction, on the other hand,
consists of procedures perform ed following burn wound healing.
For the purpose of prioritization, these procedures may be cat-
egorized as urgent (immediate), essential (early), and desirable

666
III Masterclasses in Reconstructive Flaps

Anatomical and
Regional Basis of Burn
Reconstruction
Head and Neck
Scalp
The prim ary treatm ent for large areas of postburn alopecia con-
sists of a combination of tissue expansion followed by advance-
ment or rotation aps. In situations where large full-thickness
scalp defects exist with exposed bone, free tissue transfer may be
In summary, pedicled locoregional and free tissue transfer
should be considered for burn reconstruction when:

●
There is failure of less complex reconstructive m ethods
such as split-thickness or full-thickness skin grafts in
achieving adequate healing of the burn wound.

●
There is exposure of underlying/deep vital structures such
as bone, tendons, and neurovascular structures that neces-
sitate good quality tissue coverage.

●
There is an absolute need to com bine reconstruction with
cosmetic appearance, such as the facial structures or the
female breast.

●
Unsalvageable deep burns are present.

●
Resurfacing is needed following release of scar contractures.
a
c
Fig. 65.1 (a) Debridement of a caustic soda burn to the dorsum of left
hand following delayed presentation lead to the exposure of the extensor
tendons of the hand. In such a scenario either a loco-regional ap or free
ap is the ideal option to enable smooth gliding of the underlying tendons
following reconstruction. (b) In this patient a pedicled reverse radial fore-
arm ap was used to reconstruct the ensuing tissue defect. (c) The donor
site was closed primarily.
b

65 Principles for Flap Reconstruction for Burns
667
a
b
Fig. 65.2 (a) A chemical burn to the right lower leg. This defect encompasses two important anatomical zones; the ankle, which is essential for mobility,
and the lower third of the shin which is relatively de cient in soft tissue. In such a case a large free ap is the best option, however it is essential that the vas-
cular anastomoses are performed away from the zone of injury (note the thrombosed greater saphenous vein on the proximal aspect of the burn wound).
(b) A large anterolateral thigh ap was used to cover the defect in a single stage with a meshed split thickness skin graft to bridge the exposed tissue.
b
employed to cover these defects. Hair transplantation often has a
supplementary role.
Face
Facial resurfacing following excision of unstable or unsightly scars
is undertaken using the concept of aesthetic units. Full-thickness
skin grafts are commonly used for smaller areas, whereas larger
defects may be reconstructed with either locoregional or free
aps. Locoregional aps from the neck, supraclavicular area, and
shoulder have all been described for facial resurfacing as has free
tissue transfer from m ore distant sites. Flap reconstruction is fre-
quently employed when there is signi cant and unsalvageable
loss of local facial soft tissue to enable any sort of reconstruction
a
Fig. 65.3 (a) A full thickness burn to the dorsum of the left foot following
delayed presentation of a scald burn. Following debridement of the burn,
exposed tendons and the lack of soft tissue options necessitated recon-
struction with a free ap. (b) A free ALT ap was used to reconstruct the
defect. The ap after 8 months following the injury.

668
III Masterclasses in Reconstructive Flaps
Ear
Partial, subtotal, and total ear loss is not uncommon follow ing
burn injury and reconstruction can be particularly challenging.
Common defects include helical rim loss that can be reconstructed
with a posterior auricular tube pedicle.
Greater degrees of loss require replacement of cartilage and
underlying skin. Traditional use of adjacent skin for formation of
a subcutaneous pocket to bury a cartilaginous framework can be
limited by surrounding scar and tissue loss. Temporoparietal fascial
aps can be used to cover a cartilaginous framework followed by
skin grafting. The cartilage is harvested from the costochondral area.
In the circumstance of total loss with severe damage to local tissues
including the temporoparietal fascia, autologous reconstruction
may not be possible and osseointegrated implants combined with
a prosthesis are often an excellent method of reconstruction.
Breast
The breast and the nipple-areolar complex (NAC) are frequently
injured in burns involving the anterior chest wall. Burn scarring
of the breast can impair function and cause dis gurement, par-
ticularly in prepubescent females. Absence of a nipple is notice-
able; deformity of the breast can a ect one or both breasts and
can a ect part of or the whole breast. It can involve developm ent
of the breast mound leaving discrepancies in shape, size, and po-
sition of the mound and can also a ect the NAC in a similar way.
Deform ity can be classi ed by assessing scar contracture
within and without the anatomical boundaries of the breast
giving rise to intrinsic and extrinsic contracture. Burn scar that
crosses the inframammary fold area results in a loss of de nition
and attening of the fold. Complete scar entrapment of the breast
can prevent breast grow th and m im ic hypoplasia or aplasia. If the
injury has been deeper, leading to partial or total gland destruc-
tion, then true breast hypoplasia or aplasia m ay be present. Breast
symmetry is also a very important aesthetic consideration.
Assessm ent of a patient with postburn breast deform ity
must address all the issues above to form ulate a treatm ent plan
that will restore breast size, shape, NAC, and symmetry.
Tim ing of reconstruction of the breast is usually delayed until
a year or more after wound healing to allow for scar maturation
and increased scar pliability. It is usually best to reconstruct the
burned prepubescent breast following breast development in
early adulthood. If the release of the contracture is ill tim ed, the
postpubertal development and grow th of the breast parenchyma
can alter the shape and size of the reconstructed breast quite
signi cantly. In severe cases, staged procedures may be required
throughout puberty to optimize the aesthetic result.
The main principles used in the reconstruction of the burnt
breast include release of scar contractures, resurfacing of unsightly
or painful scar, replacem ent of missing parts or breast volume and
NAC, and the reestablishment of symmetry. The many reconstruc-
tive techniques required to improve breast cosmesis after burn in-
clude simple contracture releases, Z-plasty, skin grafting, nipple
reconstruction, breast augmentation with an implant-expander,
replacement of lost breast volume with autologous fat transfer or
with free tissue transfer, and reduction or mastopexy of the con-
tralateral unburned breast to achieve symmetry.
of complex facial features such as the nose, cheeks, and other
facial soft tissue contours.
Neck
Neck contractures are com m on and, if signi cant, are a priority
for reconstruction in order to allow for safe intubation for general
anesthesia. The neck can be thought of as two separate aesthetic
units: the horizontal (submental, from the chin to the hyoid) and
vertical (from the hyoid to the sternal notch). These can be ad-
dressed separately or together; however, it is important to pay
attention to the junctional area to preserve or reconstruct the
cervicomental angle, blunting of which is a characteristic feature
of neck contracture.
Linear or band contractures can be dealt with using
Z-plasties, Y-V plasties, or local aps. Larger areas can be dealt
with using tissue expanded perforator or locoregional aps that
allow primary donor site closure. If the majority of the neck is
involved or with recurrent contracture, excision of platysma
muscle in conjunction with the scar release is thought to reduce
the risk of recurrent contracture. Following contracture release,
skin grafts or dermal skin substitutes may be used to resurface
the area. However, they m ay result in recurrent contracture and
therefore are not commonly used. The ideal option for treatment
in such cases includes either pre-expanded perforator aps in the
shoulder area or thin perforator-based free aps. Bulky aps used
for neck contracture have to undergo multiple ap thinning revi-
sion procedures to make them look acceptable.
Fig. 65.4 Salvage of the index and middle nger following an electrical
burn with an ALT free ap.

65 Principles for Flap Reconstruction for Burns
669
of the scar aps based on the Z-plasty principle, and resurfacing
the area with local or free aps after partial or total excision of
the scar. Adjacent fasciocutaneous aps, medial and lateral arm
aps, or proximally based aps on the radial, ulnar, and posterior
interosseous circulations can be used to reconstruct defects cre-
ated following release of antecubital fossa contractures.
Techniques that avoid exposure of the super cial course of
the antecubital structures include scar release and reconstruc-
tion above and below an island of skin over the antecubital fossa
itself with a combination of aps and grafts.
Wrist contractures are common following burns to the area,
with one large study describing an incidence of over 20% with the
most com m on contractures lim iting wrist extension and wrist
exion. Linear bands respond well to Z-plasty but more extensive
wrist contractures will require incision or excision and grafting
providing that no deep tendon or neurovascular structures are
exposed. More complex reconstruction using local, regional, or
distant aps is required when deep structures are exposed, es-
pecially after electrical injuries. With severe exion contractures,
the division of the exor carpi radialis tendon may be required.
Hand
Hand burns have a signi cant impact on function and subsequent
scarring can signi cantly impair activities of daily living. Hand
reconstruction after burn is challenging and multifaceted; how-
ever, there are a number of common secondary deformities and
contractures that can present to the plastic surgeon.
Adduction deformities of the ngers and thumb in the form of
web space contractures and exion deformities of the ngers due
to palmar surface contractures can be managed with Z-plasties.
Larger defects may be treated with excision and full-thickness skin
grafts, although they are prone to contracture. Hence either re-
gional aps (in cases where there might be adequate locoregional
tissue for reconstruction) or free tissue should be considered in
such defects. The dorsal skin of the hand, on the other hand, is
very thin and pliable and therefore more prone to deeper inju-
ries involving or exposing tendons and joints. In such cases, thin
pliable regional aps or thin perforator free aps should be used.
When digits are irreparably damaged or amputated, preser-
vation of the opposition function of the thumb/ ngers to provide
pinch grip is essential. Preservation of length during acute care is
vital, particularly for the thum b. Thumb length restoration can be
achieved by rst web space deepening, dorsal rotation aps, pha-
langization of the rst metacarpal, pollicization (if an existing n-
ger is available), distraction osteogenesis (if the scar allows), and
in severe cases, microsurgical reconstruction with toe transfer.
Lower Limb
Lower limb burn sequelae include contractures in the inguinal
and popliteal regions limiting function and movement. Exposure
of neurovascular structures, bone, and joints particularly at the
knee and ankle can also be problematic. Scarring on the foot can
cause signi cant functional impairm ent and lead to problem s
with foot wear and walking. Early rehabilitation e orts must
concentrate on weight bearing, mobilization, and ambulation.
Upper Limb
The m ain goal of postburn upper lim b reconstruction is to restore
function. A variety of local, regional, and free ap options may
be employed to bridge soft tissue defects following burns/scar
excision depending on considerations such as the exact site of
reconstruction, movements required, and the size and depth of
the soft tissue defect. The general preference here is to use aps
in preference to skin grafts for resurfacing due to the superior
tissue quality o ered by aps. This enables better gliding m ove-
ments of underlying structures involved with hand function. It is
essential to bear in m ind that apart from soft tissue coverage, an
adequately functioning upper limb requires release of any tendon
and ligament adhesions.
Axilla
Axillary contractures are common as in the acute phase adduc-
tion of the upper lim b is position of com fort and positioning and
splintage are di cult. Reconstruction of axillary contractures
is perform ed to restore full shoulder abduction follow ing scar
maturation and scar m anagem ent. Low-grade contractures can
usually be managed with nonsurgical m ethods such as physical
therapy, scar massage, and splintage but these are not e ective
for more severe contractures. Axillary contractures can be classi-
ed according to their extent and involvement of the anterior and
posterior axillary folds.
Isolated, single-band contractures can be managed with a
variety of local aps including the Z-plasty and Y-V plasty. The
exact choice is based on the type of contracture to be released in-
cluding the size, location, and shape of the contracture and resul-
tant defect following release, using if possible unburned tissue.
The ve- ap Z-plasty is a useful technique for these contractures
and usually provides a reliable and consistent release. Care must
be taken when using aps to avoid positioning hair-bearing ax-
ially skin outside the borders of the axillary fold particularly
anteriorly.
Once both anterior and posterior folds are involved and in
cases where the whole axilla is scarred, aps are usually not con-
sidered a rst-line option. This is because they often produce a
hanging bulge in the axilla due the e ects of gravity. In these cir-
cumstances, split skin grafts or dermal substitutes are preferred
as they contour better to the domelike shape of the axilla. In gen-
eral, such defects are too big for resurfacing with a full-thickness
graft, although som e degree of recurrence can occur despite
postoperative scar management, splintage, and physical therapy.
If the preference is for ap reconstruction, aps used in such cir-
cumstances include the parascapular, lateral and posterior arm,
and perforator aps.
Antecubital Fossa
Scar contracture of the antecubital fossa can lim it function signi -
cantly with a 50% reduction of the range of m otion of the elbow
reducing the function of the upper extremity by approximately
80%. Surgical options include incision or excision of the scar and
split-thickness or full-thickness skin graft coverage, realignment

670
III Masterclasses in Reconstructive Flaps
The glabrous skin on the plantar surface of the foot over the
metatarsal heads and heel takes the weight of the body and should
be reconstructed using sensate and m echanically durable tissue.
Free muscle ap with skin grafts or a sensate perforator-based
skin ap may be required if local options are not available.

Timing of Flap
Reconstruction in
the Burn Patient
The tim ing of ap reconstruction in the burns patient is divided
rst into acute prim ary reconstruction and secondary post-burn
reconstruction. The exact tim e within which ap reconstruction
is performed is more of an issue in the case of (1) acute primary
reconstruction and (2) free tissue transfer. This is due to two
reasons. First, patients undergoing secondary post-burn recon-
structions are generally physiologically stable and have achieved
a good degree of wound healing and possibly scar maturation,
making the exact timing of ap surgery less relevant. Second,
local ap procedures can be performed in a m uch more time e -
cient manner than free ap surgery thus placing a lesser physio-
logical burden on the potentially unstable burn patient.
A number of studies have investigated timing of reconstruc-
tion with free tissue transfer in burn patients. The vast m ajority of
studies suggest early reconstruction within the rst 1 to 10 days
with free tissue transfer following adequate debridement. Par-
ticular attention has been focussed on reconstruction between
5 and 21 days by a German group who suggest that ap failure
was highest when performed during this period after a burn
injury. Their hypotheses for this increased failure rate include an
increased infection rate at the recipient site, augmented intra-
vascular thrombogenicity, and ampli ed posttraumatic vascular
a ectation during this time period. However, in our own unit, we
found that free ap survival had no relationship to timing. All our
aps survived regardless of the time from the initial burn injury
within which they were performed.
Furthermore, we believe that the problems presented in the
hypotheses above continue to remain considerable issues before
and after this period of 5 to 21 days. Thus, it is needless to say that
clear evidence for this particular question is not currently avail-
able, with much of the evidence con icting in nature and of poor
overall quality. We feel that the key to reducing the impact of the
above-mentioned factors is adequate early initial debridement
prior to free tissue transfer. A comprehensive initial debridement
performed soon after the initial injury down to bleeding healthy
tissue will ensure removal of necrotic tissue that may act as both
a nidus for infection and a stimulant to factors that a ect blood
ow and vessel consistency.
On the other hand, when it com es to cases that require a ap
solution for secondary postburn reconstruction, timing may be
less relevant than in acute cases but nonetheless important. It
is essential to allow an adequate period of time for the scars to
have matured. Mature scars provide better quality skin with a
softer texture that lends itself more readily to surgical manipu-
lation than immature scars. The ideal time span for scar matura-
tion is based on the individual concerned through an appropriate
Hip, Knee, and Lower Leg
Limited abduction of the hip is a common complication of ingui-
nal contractures that can usually be released with local aps or
alternatively skin grafts with or without the addition of a dermal
regeneration template. Perforator aps can also be used for this
indication. Burn scar contractures around the popliteal fossa and
knee limit the extension and exion of the leg. The treatment
approach is similar to other joints described above. Deeper burns
to the knee area can leave the patellar and the joint exposed or
open necessitating ap reconstruction. Local ap options include
fasciocutaneous aps, gastrocnemius muscle aps, and more re-
cently the sural artery perforator (SAP) ap.
Exposed tibia is not uncommon following burn injury and
healing. A possible option includes burring the exposed bone and
application of topical negative pressure followed by a skin graft
once a graftable bed is achieved. However, the better alternative in
such cases would be the use of local pedicled aps such as a fascio-
cutaneous aps, perforator aps, gastrocnemius, sural artery ap,
or a free ap. Unfortunately, local aps are not always available
due to the injury a ecting all tissues in and around the lower limb.
Ankle and Foot
The thinness of the skin around the ankle and the limited avail-
ability of local tissue make this a challenging area to reconstruct.
Scarring can result in contractures of the ankle and can impair
ambulation. The Achilles tendon is particularly vulnerable to
injury by a deep burn and exposed tendon is comm only seen
though rupture is less com m on. Exposed Achilles tendon may
need topical negative-pressure wound therapy, adipofascial turn-
over ap covered by a split-thickness skin graft, a perforator ap,
or free ap reconstruction. Posterior contractures can lead to
shortening of the tendo-Achilles and plantar exion can be prob-
lematic to correct. If prolonged they may require tendon length-
ening in addition to ap cover. Anterior contractures can occur
if splintage or compliance is not adequate allowing scar contrac-
ture. Surgical intervention m ay be required in di cult cases not
responding to maximal ancillary therapies.
Deep burns on the plantar or dorsal surfaces of the foot
can lead to signi cant and functionally impairing contractures
resulting in characteristic deformities including dorsi exion,
plantar exion, and claw toes.
Dorsal foot skin is thin and pliable, akin to the skin on the
extensor surface of the hand, to allow mobility. This means that
deeper burns with subsequent scar and contracture are common.
Characteristic dorsal foot burn scar deformity includes dorsi ex-
ion at the m etatarsophalangeal joint with exion of the inter-
phalangeal joints leading to a claw toe deformity. Reconstruction
requires release and resurfacing with a full-thickness graft. Alter-
natively, a distally based lateral supramalleolar adipofascial ap;
reverse ow fasciocutaneous island aps based on the peroneal,
anterior tibial, and posterior tibial arteries; or a distally based
medial plantar ap m ay be used. If aps are used, they should
ideally be either inherently thin or thinned intraoperatively to
avoid problems with footwear. If contractures are severe and
longstanding, division of the extensor tendons and temporary
K-wiring to maintain joint position may be required.

65 Principles for Flap Reconstruction for Burns
671
aps performed in our unit for burn injuries had their recipient
vessels examined under a m icroscope prior to performance of the
anastomosis. However, if there is any question of vessel integrity
proximally or distally to the immediate site of anastomosis,
where visual microscopic assessment would not be possible, one
should consider angiography.
Another local factor that has an enormous impact on free ap
success is adequate debridement of devitalized tissue. Necrotic
burned tissue provides an ideal medium for bacterial (and
occasionally fungal) colonization, produces leukotoxins and sys-
temic immunosuppressants, and may act as a barrier to of tissue.
The literature suggests that inadequate debridement m ay play an
important role in free ap failure. Particularly in electrical inju-
ries, one m ust be cognizant of the possibility of deeper muscle
injury. A high index of suspicion with meticulous assessment of
muscle viability is essential to identify devitalized muscle. Ade-
quate debridem ent consists of excision of necrotic tissue until a
viable bleeding bed of tissue is reached.
Apart from these global and local factors that need to be
addressed to ensure ap success, meticulous postoperative mon-
itoring is essential to identify any problems early. In our experi-
ence, the earlier problem s are identi ed and hence recti ed the
greater the chance of a successful outcom e. Furthermore, there
is no alternative to clinical monitoring of the ap by individu-
als trained in ap monitoring. We feel that in cases suggesting
clinical arterial comprom ise in the presence of a Doppler signal,
precedence should be given to the clinical picture over that of the
Doppler signal and if necessary the patient should be returned to
the operating theatre for re-exploration.
Finally, the importance of a multidisciplinary team approach
to ensuring free ap success cannot be overemphasized. Coop-
eration between the entire team (including the m edical/surgical
team, psychologist, nutritionist, nursing sta , physiotherapist,
and occupational therapist) is essential in order to ensure preop-
erative, intraoperative, and postoperative success.
Suggested Further Reading
Baumeister S, Köller M, Dragu A, Germann G, Sauerbier M. Principles of
microvascular reconstruction in burn and electrical burn injuries.
Burns 2005;31:92–98
Cerkes N, Erer M, Sirin F. The combined scapular/ parascapular ap for the
treatment of extensive electrical burns of the upper extremity. Br J
Plast Surg 1997;50:501–506
Chick LR, Lister GD, Sowder L. Early free- ap coverage of electrical and
therm al burns. Plast Reconstr Surg 1992;89:1013–1019
Chowdary RP, Chernofsky MA, Okunski WJ. Free temporoparietal ap in
burn reconstruction. Ann Plast Surg 1990;25:169–173
De Lorenzi F, van der Hulst R, Boeckx W. Free aps in burn reconstruction.
Burns 2001;27:603–612
Gokalan L, Ozgur F, Mavili E, Gursu G. Reconstruction of post-burn face
deform ities. Ann Burns Fire Disasters. Available at
.m edbc.com /annals/review/vol_10/num _2/text/vol10n2p110.htm .
Accessed November 3, 2015
Grotting J, Walkinshaw M. The early use of free aps in burns. Ann Plast
Surg 1985;15:127–131
Hunt JL, McManus WF, Haney WP, Pruitt Jr BA. Vascular lesions in acute
electric injuries. J Trauma 1974;14:461–473
Jabir S, Frew Q, El-Muttardi N, Dziewulski P. A system atic review of
the applications of free tissue transfer in burns. Burns 2014;40:
1059–1070
Jabir S, Frew Q, Magdum A, El-Muttardi N, Philp B, Dziewulski P. Micro-
vascular free tissue transfer in acute and secondary burn recon-
struction. Injury 2015;46:1821–1827
exam ination, although it has been variously described in the lit-
erature as between 6 and 24 months.

Reducing Complications
and Flap Failure Rates in
Burn Patients
Flap failure is m ore of a problem in free tissue transfer than in
pedicled perforator aps. Hence much of the discussion in this
section focuses on reducing complications and failure rates in
free aps. The most common causes of free ap failure in burn
patients is arterial thromboses followed by venous thromboses,
with studies suggesting that the free ap failure rate is signi -
cantly higher for prim ary acute burn reconstruction (11.5%) than
secondary postburn reconstruction (1.4%). The global release
of in ammatory mediators promoted by the zone of necrosis
together with local factors such as tissue edema, vessel damage,
and contamination of the wound site with bacterial pathogens
all contribute to reduce the chances of free ap success in the
acute phase.
The global release of in amm atory m ediators in a patient af-
icted with an acute burn injury may impact on their physiologi-
cal stability. The extent of this impact is dependent usually upon
age and medical comorbidities. This in turn has a knock-on e ect
on free ap success, although the extent of this knock-on e ect
is uncertain. Hence it is essential that any decision regarding free
tissue transfer to treat a burn wound defect is made together
with input of the critical care/anesthetic team. This enables pre-
operative optimization of the patient’s physiological state prior
to the operative insult.
Apart from correcting the global impact of deranged physi-
ology, assessment of conditions at the site of ap reconstruction
is also essential to ensure free ap success. The quality of blood
vessels used to perform the anastomoses is of prime importance.
A number of studies have attempted to determine the pathologi-
cal vessel wall changes caused by electrical and therm al injuries.
They include dam age to the tunica m edia and endothelium , vas-
cular occlusion, aneurysm formation or thrombosis, segmental
narrowing of major extremity vessels, and a marked decrease in
the density of sm all nutrient vessels. Hence it is essential to per-
form the anastomoses away from the zone of injury. In situations
where there is insu cient pedicle length to achieve this, an in-
terpositional vein graft maybe employed.
In addition, there may be a role for preoperative vascular
imaging in these patients. Investigations such as computed to-
mography angiography and m agnetic resonance angiography
may provide key inform ation such as caliber and patency of all
major extremity arteries, density of collateral in ow, recipient
vessel caliber, and integrity, including global vascular integrity
of the a ected extremity. Some studies, however, have argued
against preoperative angiography citing it as unreliable in as-
sessing vessel status following burn injuries and favor intraop-
erative visualization under the m icroscope. They argue that this
is the most reliable indicator of patency and vessel integrity. In
our experience, we never came across a situation where we felt
angiography was necessary prior to free tissue transfer. All free

672
III Masterclasses in Reconstructive Flaps
Platt AJ, McKiernan MV, McLean NR. Free tissue transfer in the manage-
m ent of burns. Burns 1996;22:474–476
Ponte´n B, Erikson U, Johansson SH, Olding L. New observations on tissue
changes along the pathway of the current in an electrical injury.
Case report. Scand J Plast Reconstr Surg 1970;4:75–82
Sauerbier M, Ofer N, Germann G, Baumeister S. Microvascular recon-
struction in burn and electrical burn injuries of the severely
traumatized upper extremity. Plast Reconstr Surg 2007;119:
605–615
Zelt RG, Daniel RK, Ballard PA, Brissette Y, Heroux P. High voltage elec-
trical injury: chronic wound evolution. Plast Reconstr Surg
1988;82:1027–1041
Koul AR, Patil RK, Philip VK. Early use of m icrovascular free tissue transfer
in the management of electrical injuries. Burns 2008;34:681–687
Lo LJ, Yang JY, Wei FC. Free ap transfer in burn reconstruction. Changgeng
Yi Xue Za Zhi 1991;14:8–14
National Burn Care Review. Standards and Strategy for Burn Care; A review
of burn care in the British Isles. Available at
association.org/downloads/NBCR2001.pdf. Accessed July 4, 2016
Ofer N, Baumeister S, Megerle K, Germann G, Sauerbier M. Current con-
cepts of microvascular reconstruction for lim b salvage in electrical
burn injuries. J Plast Reconstr Aesthet Surg 2007;60:724–730
Pan CH, Chuang SS, Yang JY. Thirty-eight free fasciocutaneous ap trans-
fers in acute burned-hand injuries. Burns 2007;33:230–235

673
Local Perforator Flap Reconstruction in the
Surgical Mission Setting
Yvette Godw in, Bernardo Righi, and Enrico Robotti
not readily available by allowing limb salvage surgery for open
fractures. Islanded perforator aps can be applied as a one-stage
reconstruction resulting in a shorter hospital stay and early
ambulation.
The elastic nature of these composite aps decreases con-
tracture recurrence rate and the aps expand as the children
grow. This compares favorably both functionally and cosmetically
to the common method of contracture release in the developing
world: serial episodes of thick split skin graft (SSG) application
and the marked donor site morbidity (Fig. 66.1).

Introduction
Local perforator aps are a versatile source of vascularized tis-
sue. This chapter highlights the planning, technical issues,
and considerations necessary to enhance ap success when
performing these aps in a mission setting. In the develop-
ing world, we apply local perforator aps to ungraftable, com -
plex defects and also as interpositional aps after the release
of contractures. These aps can impart functional bene ts to
patients in countries where prosthetics and rehabilitation are
66
Fig. 66.1 Unacceptable donor site morbidity from the harvest of thick
split-thickness grafts in burn victims: Dermal injury is marked. Unhealed donor
sites are evident on a calf 3 months after thick split skin graft harvest with an
electric dermatome.

674
III Masterclasses in Reconstructive Flaps
may be sent to other countries. The ideal reconstruction for this
population is therefore a single-stage procedure with minimal
donor site morbidity, minimal rehabilitation necessary, maximal
functional outcome, and minimal complications. Local perfora-
tor aps t these criteria by allowing the importing vascularized,
composite, elastic tissue to address complex defects.

The User’s Guide
The user’s guide presented in Table 66.1 is based on the authors’
experience of second-wave surgery treating civilians in a post
con ict environment. Considerations and lessons learned when
performing local perforator aps in this context are demonstrated.

The Mission and the Post-
Con ict Setting
The post-con ict population has certain characteristics. The inju-
ries presenting are chronic wounds that have received m inim al,
or no, primary treatment. Injuries of poverty follow those of war:
acute domestic injuries are neglected because families cannot pay
for treatment or none is available. Neglected wounds progress to
ungraftable areas, scar tissue, and severe contractures. For the
adult patients, the primary goal is return to function and work, so
they can support their families. For children, future grow th must
be considered in their reconstructive plan. Population mobility
has to be factored into patient care as refugees displace locally or
Table 66.1 A user’s guide for local perforator ap reconstruction in the post-con ict setting
Environment
Kit
We highly recommend the visiting surgeon brings the following minimal equipment
• Handheld Doppler
• Loupes
• Stevens tenotomy scissor or a ne curved mosquito for perforator dissection
• Graft knife and blades
Anesthetic support

• Assess local capabilities
• Optimize the patient for success with good pre-, intra-, and postoperative care
Patient selection

• Timing: single or staged reconstruction? Inpatient or only day case?
• Patient characteristics: Realistic expectations? Compliance? Smoker?
• Translator: Patients’ understanding and compliance will depend on clear instruction and explanation
Planning
Break some rules

• Raise ap in the zone of trauma if necessary
• May need to include scarred skin/graft/ burn scar as part of the ap substance
Don’t burn bridges

• Consider beyond “your” ap: respect donor sites
• Avoid using potential stump tissue if amputation is a future possibility
• Check your patient’s relocation options. Imminent refugee transfer to a country where free tissue
transfer is available could give better functional and cosmetic outcome.
Do perforator aps early in the mission

• You want to be present if revision is necessary. Don’t leave the local team with an ungraftable
defect.
Don’t show o

• Optimize chance of ap success.
• Keep the best blood supply: As many perforators as it takes/skeletonize just what’s needed/island
only if you have to, and consider “perforator plus” pattern
• If a ap based on an axial, more robust blood supply will serve as well as a perforator ap (and taking
the axial vessel does not cause a signi cant donor de cit); use the ap with the more certain blood
supply
Techniques
Meticulous hemostasis

• Avoid hematoma or hemorrhage
• Increased risk of reactionary hemorrhage on the ward: Hot environment. Elevation may not be
complied with. Analgesia inadequate; pain and elevated blood pressure. Patient supervision on the
ward may be minimal.
Don’t be proud

• If on table venous congestion: Return the ap and delay inset 48 hours. Donor sites are few in these
patients. The patient can’t a ord your failure.
Don’t delegate, supervise every step yourself • Make any plaster of Paris splints yourself
• Monitor the patient from the operation table, through recovery, and to the ward
• Make sure elevation happens (without constriction from some improvised sling or bandage by
inexperienced sta ) and that bed rest is understood by the sta and patient
• Write clear postoperative orders as you would at home
• Do the rst dressing change yourself

66 Local Perforator Flap Reconstruction in the Surgical Mission Setting
675
transfer if the patient is expatriated to a country where this is
available.
Basic Operative Technique
The free style local perforator ap technique is used. Local do-
nor tissue of a suitable quality and function is chosen to meet
the reconstructive needs. With the patient in the operative po-
sition, using a handheld acoustic Doppler ultrasound device (8
MHz), local perforators are identi ed. A preliminary ap design is
marked based around the m ost suitable perforator: selection in-
volves nding a strong Doppler signal at suitable location within
the ap to allow perfusion to the ap tip and ap transposition.
A “plan B” ap is also marked based on a second best option of
perforator.
Through an exploratory incision, the quality and positional
suitability of the perforators are con rmed intraoperatively be-
fore committing to the nal ap dimensions, borders, shape,
and orientation (“cut as you go,” freestyle, or ad hoc technique).
A pulsatile arterial perforator of good caliber with venae comi-
tantes, and in a position that allows tension-free transposition
and inset, is ideal.
The quality of the substance of the ap and the degree of pre-
vious trauma to the donor site and vessels dictate the ap design
The 10 subheadings chosen may seem routine considerations in
our regular practice but they carry a di erent emphasis during
second-wave surgery. The complexity, and severity, of the cases
presenting will be greater than at home, yet facilities are less
available. A reconstruction must maximize function and have
longevity, while keeping surgical complications to a minimum,
irrespective of the complexity of the case. The simplest surgical
option on the reconstructive ladder may not be the best function-
ally or aesthetically. Three factors of surgical planning become
more challenging in the mission setting: timing, facilities, and a
missing rung of the reconstructive ladder. Without a microscope
and adequate postoperative support on the ward, there will be no
free tissue transfers.

Raising the Flaps
Table 66.2 outlines the planning and technical di erences of rais-
ing perforator aps in developed world facilities as compared to
during second-wave surgery. The only ap options may be within
the anatomic zone of the injury. Donor sites are chosen respect-
fully without burning bridges for future reconstructive options.
Local perforator aps leave main axial vessels intact so neither
jeopardize the circulation of a limb nor prevent future free tissue
Table 66.2 Raising freestyle local perforator aps in post-con ict environments compared to the developed world
Developed world
Areas of con ict
Flap design
Flap design
Choose a perforator outside of the zone of trauma.
If perforator options are within the zone trauma, “cut as you go” ap
design
Choose best caliber vessel that still allows ap transposition
Keep as many perforators as possible without hindering transposition
Consider “perforator plus” design
Design the ap in virgin tissue.
Flap can contain cutaneous scar.
Partial-thickness, mature cutaneous, and subcutaneous scar or graft can
be carried on an intact adipofascial base. Postoperative epidermolysis may
result: the outcome was not compromised.
Full-thickness scar, extending through all layers of the ap, including fascia,
should be raised with caution. If full-thickness scar traverses the complete
ap width, blocking all choke vessels, another ap design/orientation
should be considered.
Technical considerations
Technical considerations
Mobilize/skeletonize the perforator only as much as necessary.
Same applies
Island the ap only enough to avoid torque on the pedicle and tension at
inset following transposition.
Same applies
Donor site closure: Don’t undermine burn tissue or put under extensive
tension to get primary closure.
Same applies
Postoperative planning
Postoperative planning
Apply well-padded dressings to avoid any pressure on the pedicle and
unnecessary movement.
Surgeon to supervise this step in theatre and on the ward. Family may be
the only caretakers on the ward.
Limb elevation for 48 hours as inpatient
Can proceed as day case: Daily review and compliance by the family.
Keep the patient warm, well hydrated, and comfortable with su cient
analgesia for the rst few postoperative days.
Biggest obstacle if done as a day case. Daily review is mandatory for the
rst 4 postoperative days.
Refrain from nicotine
Little chance of compliance with this request.

676
III Masterclasses in Reconstructive Flaps
and the number of perforators kept. Rather than considering rais-
ing a perforator ap in a zone of trauma, or having scar tissue with-
in the ap, a relative contraindication, we would urge carefully
applying the “cut as you go” technique to maximize the vascular
input. Existing scar tissue within the ap substance and around
the perforators can be easily visualized intraoperatively (Fig. 66.2).
Choosing a perforator in the zone of trauma and designing a
ap containing scar tissue has two implications for the surgeon:
(1) the ap perfusion may be jeopardized by raising a ap on
a previously traumatized vessel; and (2) choke vessels within
the substance of the scarred ap may not open once the ap is
islanded, even if the perforator selected is adequate (Fig. 66.3).
Fig. 66.2 (a) Posterior tibial artery perforator surrounded by scar tissue in a lower limb missile injury with a compound fracture. (b) A perforator ap
raised in the zone of injury contains scar tissue within the distal edge along with embedded pieces of shrapnel (indicated by tip of forceps).
a
b
Fig. 66.3 (a) The slow evolution of vascular insu ciency and patchy ne-
crosis within a ap raised in the zone of trauma of a previous missile injury.
Mild congestion began on the third postoperative day and progressed to
patches of partial-thickness tissue loss over 6 days. The perforator was pat-
ent, with a good Doppler signal, throughout the period of development
of patchy necrosis. (b) The ap was debrided as the end of the mission
approached and it could not be left as a problem in evolution. The un-
derside shows patches of vascular thrombosis corresponding to area of
tissue where choke vessels had not opened to support the tissues due to
previous damage sustained at the original injury.
a
b