Flaps Practical Reconstructive Surgery

28
I Planning and Decision Making in Reconstructive Surgery
Suggested Further Reading
Corm ack GC, Lamberty BGH. A classi cation of fasciocutaneous aps
according to their pattern of vascularity. Br J Plast Surg 1984;
37(1):80–87
Limberg AA. Design of local aps. Mod Trends Plast Surg 1966;2:38–61
Mathes SJ, Nahai F. Classi cation of the vascular anatomy of muscles: ex-
perimental and clinical correlation. Plast Reconstr 1981;67:177–187
Rohrich RJ, Zbar RI. A simpli ed algorithm for the use of the Z-plasty. Plast
Reconstr Surg 1999;103(5):1513–517
Taylor GI, Palm er JH. The vascular territories (angiosomes) of the body:
experimental study and clinical applications. Br J Plast Surg 1987;
40(2):113–141
Thatte MR and Thatte RL. Venous aps. Plast Reconstr Surg 1993; 91(4):
747–51.
Figure Credits
1. Weerda H, ed. Reconstructive Facial Plastic Surgery: A Problem-Solving
Manual. 2nd ed. New York, NY: Thieme; 2015
2. Sherris DA, Larrabee WF. Principles of Facial Reconstruction. 2nd ed.
New York, NY: Thieme; 2010
3. Theissing J, Rettinger G, Werner JA. ENT–Head and Neck Surgery:
Essential Procedures. Stuttgart: Thieme; 2011
4. Pechlaner S, Hussl H, Kerschbaumer F. Thieme. Atlas of Hand Surgery.
Stuttgart: Thieme; 2000
outcomes can be worse, but are not inevitably so, and indeed in
some instances this technique has many advantages and can be
the preferred choice.

Conclusion
Various aps are show n in Fig. 1.56. The choice of any recon-
structive technique is solidly founded in a detailed history and
exam ination of the patient, an understanding of the pathology
as well as the problem s unique to that patient, and a detailed
knowledge of the anatomy. The art of reconstructive surgery
is that a num ber of solutions exist for any one problem , and
the additional reward for the surgeon is the knowledge that
perhaps their choice of technique and its application was
best. What is clear is that an in-depth understanding of the
basic principles of wound healing, grafts, aps, and ancillary
techniques is essential for the key to all reconstruction: good
decision m aking.
Fig. 1.56 Various  aps in the face.1

Microsurgery
Christopher G. Wallace and Fu-Chan Wei
2
29

Microsurgical
Instrumentation
Reproducibly successful and safe microsurgery demands special-
ized instrumentation, meticulous techniques, a clear understand-
ing of key physiological principles, and sound clinical judgement.
Magni cation and Illumination
Magni cation and illum ination can be provided by operating
microscopes or by surgical loupes with an accessory light source
(Table 2.1). Although m icroanastom oses and nerve coaptations
should be performed under the microscope, ap and pedicle har-
vests are m ore conveniently perform ed under loupe m agni ca-
tion (2.53 or 3.53 is usually appropriate).
Microinstruments
Desirable properties provided by good-quality microinstrum ents
include: glare-free under intense illumination, nonmagnetizable,
lightweight, well-balanced, smooth-hinged, ne-tipped, and
atraumatic (Fig. 2.1). A microsurgeon requires:

●
Forceps

●
Needle holder (curved or straight; som e prefer to use for-
ceps instead)

De nitions

● Microsurgery is surgery performed with the aid of an oper-
ative m icroscope. Ophthalm ologists, otologists, neurosur-
geons, and plastic surgeons commonly use microsurgery.

●
Microvascular, m icroneural, m icrolymphatic, and m icrotu-
bular surgery are modi cations of the term microsurgery
that indicate the operated structures.

● Anastom osis: perform ed to adjoin two structures with lu-
mens (e.g., blood vessels).

● Coaptation: perform ed between nonlum inal structures
(e.g., nerves).

●
An anastom osis or coaptation between structures is
end-to-end, end-to-side, or side-to-side according to their
alignm ent.

● Flow is anterograde or retrograde with respect to the struc-
ture’s native direction of content ow.

●
The term ow-through is added to describe the bridging
of a segmental defect to restore ow between structures.

●
A free ap (free tissue transplantation or free tissue transfer)
is an autogenous transplantation (i.e., the tissue donor and
tissue recipient are the sam e individual) of vascularized
tissues.

●
Free tissue transfer has revolutionized the ability of plastic
surgeons to reconstruct tissue defects; it is almost always
performed using microsurgical techniques.
Table 2.1 Operating microscope versus surgical loupes
Operating microscope
Surgical loupes
Magni cation
Adjustable (63 to 403 )
Fixed (23 to 43 most common)
Depth of eld
Adjustable
Fixed and limited
Focus
Adjustable
Fixed focal distance
Light source
Dedicated, adjustable, cool beroptic illumination
Lighting provided by operating room lamps (occasionally have
an attachable or built-in lightsource)
Controls
Foot-paddle or nger-touch
No controllable components
Operating eld
Shared by operator and assistant
Individualized
Documentation
Television monitoring and video recording possible
Not possible
Cost
Expensive
Comparatively inexpensive
Size
Large and clumsy to move between operating rooms
Portable
Weight
E ectively weightless (not borne by operator)
Lightweight but may become uncomfortable after prolonged use
Sterility
Easier to compromise
Easier to maintain
Operator freedom
May compromise posture or positioning of the operator/assistant
Operator/assistant freedom not compromised

30
I Planning and Decision Making in Reconstructive Surgery
a
b
c
Fig. 2.1 Instruments for microvascular surgery. (a) Straight and curved microforceps; (b) spring-handled
microscissors, straight and curved (also, spring-handled needle holder with ne jaws); (c) approximators
(double and single microclamps).

2 Microsurgery
31

●
Scissors (straight or curved; smooth or serrated)

●
Vessel dilators

●
Microvascular clamps (double and single; various clamp
pressures and sizes) w ith clamp appliers

●
Range of nonabsorbable (nylon or polypropylene) mono l-
ament microsutures (8/0 to 11/0). Microneedles (diameter
range 30 to 150 mm; 3/8 circle, half-circle, straight; round-,
spatulate-, taper-tipped). The ideal microsuture has not been
achieved: a needle with a diameter equal to that of its suture.

●
Accessories: bipolar coagulator, microvascular clips, back-
ground (nonadherent, pliable; green or yellow), 10 m L irri-
gation syringe with a short cannula (three useful irrigants:
20 units heparin per 1 mL of normal saline; 2% or 4% lido-
caine; normal saline).
Mechanical devices (e.g., venous couplers) and suture re-
placements (e.g., brin glue and laser-welding) have been advo-
cated for reducing anastomosis time while maintaining patency
rates comparable to traditional suturing techniques. These ad-
vantages can be o set with experience or by practicing m icro-
surgery with sutures in the laboratory.

Microsurgical Technique
Requirements: Experience and the
Correct Disposition

●
Microsurgical experience: the critical factor in uencing
success rates of microvascular surgery. The early learning
curve must be overcome in the laboratory, remembering
that this arti cial setting m akes m icrosurgery easier: per-
fect operator positioning and risk-free (minor or no conse-
quences from failure).

●
Calm , patient, prolonged concentration, dedication,
determ ination.
Planning: Time Dedicated to
Planning Is Time Well Spent

●
Incisions and patient positioning: plan for minimal patient
position changes and, ideally, a two-team approach (one
donor site team, one recipient site team).

●
Insetting: m ust be planned before anastom osis to al-
low accurate judgm ent of pedicle and anastom osis
positioning and pedicle length. Avoid redundancy and
tension.

●
Sensible planning and ap choice avoid unnecessary inter-
positional vein grafts.
Setup and Comfort: Important to
Success

●
Position, in order, the table, the microsurgeon, operating
microscope, assistant, and scrub nurse.

●
Problem s from poor setup introduce stress and reduce
com fort. Aim to reproduce a com fortable, stress-free envi-
ronment (Table 2.2).
Table 2.2 Tips for improving setup and comfort
Problems from poor setup
Useful solutions
Tremor
Stack folded towels under elbows, forearms, and heels of the hands.
Double clamp lying vertically (i.e., not at)
Elevate one clamp corner into the horizontal plane with damp gauze. Secure the opposite
corner with saline-soaked gauze (for weight).
Troublesome backhand suturing
Rotate the clamp so the right side is farther away than the left (for right handers). Secure
with saline-soaked gauze.
Uncomfortable posture
Use an adjustable high-seat. Sit slightly forward with feet apart to form a load-bearing
triangle ending at oor level.
Unfamiliar microscope
Be completely familiar with the microscope and its controls before the operation starts.
Condensation obscuring lenses
Seal the top rim of the operating mask with a strip of surgical tape to redirect warm
expired air away from the lenses.
Lost microsuture
Never let go of the microsuture unless it is securely parked.
Fatigue
Take a break before ap devascularization. Relieve eye strain intermittently by brie y
focusing into the distance.
Assistant/anesthetist/scrub nurse does not understand
the procedure
Maintain a good operative understanding between all team members through clear
communication.
Operating eld ooding (hemorrhage or irrigation)
Before starting anastomoses, place: (1) four clean damp swabs around the operating eld,
(2) one end of a damp swab under the background with the other end dependent and
outside the wound (siphon), (3) an activated low-pressure suction drain distant from and
dependent to the anastomoses.

32
I Planning and Decision Making in Reconstructive Surgery
surgery but might a ect success; debride back to nd the
healthiest available intima.

●
The usefulness of routine preoperative angiography remains
contentious. Normal angiography does not guarantee good
arteries and provides no information on the quality of the
accompanying veins. Abnormal angiography rarely adds
useful information to clinical evaluation.

●
Vein grafts may a ect success. Remem ber to use them in
retrograde position and allow for elongation of the vein
graft with blood ow (Fig. 2.2). Useful when pedicle length
Choosing Recipient Vessels:
Finalize Assessment Under
the Microscope

●
Choose the healthiest available recipient vessels. Famil-
iar vessels with good ow, reasonable diameter, adequate
length, and good size match are preferred.

●
Vessel changes from trauma, irradiation, atherosclerosis, scar-
ring, and advanced diabetes do not preclude microvascular
Fig. 2.2 Interpositional vein grafts. (a) Interpositional vein grafts must be oriented so that venous
valves do not prevent blood ow. (b) Improper alignment of venous valves inhibits the ow of blood
through the artery and causes thrombosis. (c) When an interpositional vein graft is utilized, especially
for the arterial system, its length must be judged so as to allow for dilation-elongation. (d) An over-
ly long vein graft can kink upon restoration of intraluminal blood pressure, impairing blood ow and
causing thrombosis.1
a
b
d
c

2 Microsurgery
33
and its sheath. This can usually be perform ed w ith loupe
m agni cation.

●
Under the operative microscope hereon, cleanly divide the
vessel ends.

●
Always avoid venous valves near the anastomosis site.

●
Sharply dissect away adventitia that overhangs the ves-
sel ends w ith scissors (Fig. 2.3); never bluntly peel it
away w ith two opposing pairs of forceps as this indi-
rectly stretches and can dam age the intim a. The adven-
titia is slightly m obile so dissect it back from the vessel
ends by 2 to 3 m m to avoid subsequent advancem ent
and overhang, but dissect no further so as to avoid
aneurysm form ation. Irrigation w ill reveal rem aining
adventitia encroaching near the vessel lum en; rem ove
it. Never allow adventitia to enter the vessel lum en
during anastom osis.

●
Ensure good recipient arterial pulsatile spurting pressure.
Lower pressures may struggle to support a ap.
is too short, to reach healthier proximal vessels, or to solve
severe size discrepancies. Alternatives: end-to-side anasto-
mosis, proximal donor vessel dissection for advancement,
ap reorientation, or re-insetting. Alternative graft sources:
autogenous artery and synthetic grafts (e.g., polytetra uo-
roethylene and polyurethane; mainly experimental).
Preparing Vessels for
Microvascular Anastomosis:
Atraumatic Technique Is Key

●
Manipulate vessels atraum atically and m inim ally; grasp
only the periadventitia.

●
Maintain exquisite hemostasis to avoid obscuring anatom -
ical planes with blood stains.

●
The key to vessel dissection is advancem ent in the im -
m ediately perivascular plane, between the vessel wall
Fig. 2.3 Preparing the skeletonized vessel for anastomosis. (a) With the approximator in place, the vessel is generally divided
perpendicular to the vessel axis. (b) The cut ends are gently ushed out with heparinized saline. (c,d) Projecting adventitia
is removed along with any remaining connective tissue, completely opening up the circumference of the vessel. The tissue
is pulled past the vessel end with a forceps and cut ush with the edge of the media (visible through the transparent tissue).
a
b
c
d

34
I Planning and Decision Making in Reconstructive Surgery
provides equally high success rates when performed by experts.
The follow ing principles are applicable to most:

●
Reassess vessels under the m icroscope before starting
m icrovascular anastom oses. Debride dam age (e.g., wall
bruising, m edial or intim al intralum inal prolapse, ath-
erosclerosis, intim al clot or brin deposits indicating
possible underlying endothelial dam age) and look for
warnings of impending problem s (e.g., friable vessel
walls, vasospasm ).
Microvascular Anastomosis:
The Technical Principles
The various techniques of anastomosis include: triangulation and
bisecting techniques, and their modi cations (Fig. 2.4); various
orientations (e.g., end-to-end, end-to-side); interrupted, con-
tinuous, and open-loop suturing; and intim a-to- intim a, sleeve,
and hemi-invagination systems of abutting vessel ends. Di erent
techniques are applicable in di erent situations. Each technique
Fig. 2.4 Triangulation technique of anastomosis. (a) The mi-
croneedle is passed through the full thickness of the donor and
recipient vessel ends (this is regarded as the 0-degree position).
(b) Having completed the rst knot, a second knot is completed
at approximately the 120-degree position and gentle traction ap-
plied to open the lumen. (c) A third stay suture is placed at the
240-degree position and upward traction is used to open the lu-
men further so that the front wall sutures can be placed with re-
duced risk of catching the back wall within the knot.
a
b
c

2 Microsurgery
35
vessels should be correctly aligned at the intim al sur-
face. Knots should be sym m etrically spaced and suture
ends cut short to prevent encroachm ent into the lum en
or across neighboring knots. Cut suture ends should be
rem oved.

●
End-to-end anastom oses are perform ed when it is safe to
sacri ce the recipient vessel blood supply to its distal tis-
sues (Fig. 2.5); end-to-side anastom oses preserve donor
vessel continuity.

●
Diameter discrepancies can be overcome by several meth-
ods: (1) dilate the smaller vessel (Fig. 2.6); (2) take slightly
wider bites of the larger vessel; (3) incise the smaller vessel
obliquely (Fig. 2.7); (4) place a short axial “ shmouth” or
wedge incision in the smaller vessel (Fig. 2.8); (5) perform
end-to-side anastom osis for dram atically discrepant ves-
sels (Fig. 2.9); (6) use a smaller side branch of the recip-
ient vessel; (7) allow a smaller donor vein to dilate with
restored blood pressure by perform ing the arterial anas-
tomosis rst.

●
Thickness discrepancy can be overcome by taking a full
bite of the thinner vessel rst, then excluding the outer-
most layers of the thicker vessel. Perform this with care;
full-thickness bites cause less disruption to the vessel
layers and for this reason have better patency rates than
partial- thickness bites.

●
Leave the anastom osis alone for at least 10 m inutes after
its initial completion, then check for its patency: (1) di-
rectly by visual inspection and a gentle m ilking patency
test (Fig. 2.10); (2) indirectly by clinical inspection of
the ap; (3) by direct assessm ent prior to closure of the
wound; (4) by indirect clinical assessm ent (of the ap)
after closure of wounds, after application of dressings, af-
ter patient transfer o the operating table to bed, before
letting the patient return to the ap m onitoring unit, and
regularly thereafter.

●
Before wound closure, mark the pathway of the pedicle,
the position of the anastomosis, and the point where the
blood supply enters the ap (this will avoid pinprick tests
of the ap disrupting the pedicle).

●
Whether the artery or vein should be anastomosed rst is
usually a matter of personal preference. It generally makes
sense to perform the more di cult or more deeply posi-
tioned vessel rst. Otherwise, we would advocate to rou-
tinely anastomose the artery rst to reduce ischemia time,
but avoid ap congestion by letting a second (e.g., comi-
tant) vein bleed freely away from the eld. Performing the
artery rst also allows the ap vein to distend and length-
en; the surgeon can then m ore accurately judge how m uch
of the pedicle vein to remove before venous anastomosis
to avoid redundancy and kinking of the vein once the ap
is owing.

●
Whether one perform s one or two venous anastom oses
is case-dependent; if one su ces then two are not re-
quired. Clinical venous insu ciency should prompt, rst,
checking of the prim ary venous anastom osis for paten-
cy and, second, perform ing another venous anastom osis
if the rst venous anastom osis is perfectly patent yet
the ap is congested. If the ap has zonal venous insuf-
ciency, then the second venous anastom osis is better
perform ed on a vein speci cally draining that zone. A
second venous anastom osis is not a replacem ent for a
poor initial one; the rst should be perfected w ith an-
other attempt.

●
Vessel dilation, if required, should be performed gently and
only with vessel dilators.

●
Avoid factors that m ay predispose to throm bosis; these are
addressed in their own section (Thrombogenesis and Anti-
coagulation; Table 2.3).

●
Place the smallest number of sutures that ensures a leak-
proof anastomosis. This is determined mainly by the di-
mensions of the vessels, the suture and needle sizes, the
suturing technique used, whether the vessel is an artery or
vein, and the hemodynamic status of the patient.

●
Regarding knotting, the first throw should be double
to m aintain desired knot tension and the second (and
third, if used) should be single. Tightness should be vi-
sually assessed, not just by feel, and should stop w hen
the vessel ends abut w ith the slightest eversion. The
Table 2.3 Thrombogenic factors
Altered laminar blood ow
Endothelial damage
Hypercoagulability
Twisting/kinking
Too many sutures
Acquired thrombophilic tendency (e.g.,
pregnancy, paraneoplastic Trousseau syndrome,
antiphospholipid antibody syndromes,
hyperhomocysteinanemia from folic acid
de ciency)
Overly tight sutures
Overly tight sutures
Vasospasm
Unused needle passes
External compression
Traumatic vessel handling or dilation
Atherosclerosis
Tearing
Hereditary thrombophilias (e.g., activated
protein C resistance, protein C de ciency,
protein S de ciency, antithrombin III de ciency,
hyperhomocysteinanemia)
Back-walling
Back-walling
Intimal malalignment
Intraluminal placement of inappropriate instruments
Anastomotic tension
Atherosclerosis
Venous valves
A leaking anastomosis simulates intimal damage

36
I Planning and Decision Making in Reconstructive Surgery
Fig. 2.6 If the vessel calibers are nearly equal, then the smaller lumen can
be gently dilated with dilator forceps; no other instrumentation should be
used for this purpose.
Fig. 2.7 Vessel calibers can also be matched by cutting the smaller vessel
end at an oblique angle.
Fig. 2.8 Fish-mouth technique. The front and back walls of the donor vein
are incised to enlarge the anastomotic lumen. This technique can be useful in
an end-to-side anastomosis where the incision in the recipient vein has been
made too large. It is important to smooth o the sharp corners of the vessel
before anastomosis.
Fig. 2.5 After the front wall sutures
have been placed, the approximator
is inverted, rotating the vessels
180 degrees. The vessel ends at this
stage show a typical diamond pat-
tern. (a) The intermediate sutures
are placed as they were in the front
wall. Gentle traction on the nal su-
ture opens up the lumen slightly and
reduces the danger of grasping the
front wall. (b) The end-to-end anasto-
mosis is also used for veins. Traction
perpendicular to the vessel axis places
tension on the thinner-walled veins,
opening up the collapsed lumen.
a
b

2 Microsurgery
37
Fig. 2.9 Acland’s technique of creating an oval opening for end-to-side anastomosis. (a) The
vessel wall is pierced with a microneedle. The wall tissue is elevated on the needle, and the
raised area is excised with scissors. (b) The key sutures are inserted. The rst two sutures are
placed 180 degrees apart. (c) The intermediate sutures are placed in the front wall. (d) The
ap vessel is lateralized with forceps, and the back wall is sutured. Alternatively, the back wall is
sutured before the front wall.
a
b
c
d

38
I Planning and Decision Making in Reconstructive Surgery
blood ow (turbulence and stasis), (2) damaged vascular
endothelium , and (3) alterations in the constitution of
blood (hypercoagulability).

●
Routine laboratory thrombophilia screening is expensive
and has no proven clinical bene t; the patient and family
history are most important.

●
There are several m ethods to reduce vasospasm when en-
countered (Table 2.4).

●
Indications for systemic anticoagulation in microvascular
surgery remain controversial (Table 2.5). No study has
conclusively shown improved patency rates with any an-
ticoagulant. Several large clinical trials have failed to nd
a correlation between anticoagulant use and ap failure.
There exists a risk–bene t ratio between hem orrhage with
anticoagulation and possible thrombogenesis without.
Their use seem s prudent for re-explored free aps. None
are used routinely at our institution.

Microneural Coaptation:
The Technical Principles
The various techniques of microneural coaptation include di erent
orientations (e.g., end-to-end, end-to-side); suturing of di erent
neural layers (e.g., epineural, epiperineurial, perineural fascicular
repair); and incorporation, if necessary, of interpositional conduits
(most commonly nerve grafts). Di erent techniques are applica-
ble in di erent situations. As for microvascular anastomosis, it is
important to reassess the nerve ends under the microscope before
repair so that nerve tissue can be excised, if needed, back to reveal
healthy and unscarred nerve fascicles for repair. End-to-side re-
pairs have their speci c indications and require an epiperineurial
window to be created on the recipient nerve so that nerve regen-
eration can proceed into the recipient from the end of the donor
nerve. Meticulously performed epineural repairs are generally ad-
equate, but some regard epiperineurial repairs as having greater
strength and most would argue that repair of cross-sectionally
large nerves with grouped fascicles, such as in the brachial plexus,
would bene t from matching of fascicular bundles.

Key Physiological
Concepts
Thrombogenesis and
Anticoagulation

●
Throm bus formation is the predeterm inant of ap failure
and is often the result of several factors that a ect one or
more of Virchow’s triad (Table 2.3): (1) altered lam inar
Table 2.4 Reducing the risk of vasospasm
Systemic factors
Local factors
Warm the patient
Choose healthy vessels
Avoid metabolic acidosis/alkalosis
Treat vessels atraumatically
Avoid vasoconstricting inotropes
Minimize vessel manipulation
Hydrate the patient well
Avoid vessel desiccation
Patient should avoid recreational
vasoconstrictors (e.g., ca eine)
Adventitiectomy (causes local
sympathectomy and improves
vessel compliance)
Keep the patient pain-free
Topical drug irrigants (e.g., 2% or
4% lidocaine; 30 mg/mL papaverine,
but causes heparin to precipitate)
Fig. 2.10 Milking patency test for checking a completed anastomosis. (a) The arrow indicates that blood ow should travel from
right to left. The two microforceps have been placed close to each other distal (in terms of ow direction) to the anastomosis
to occlude blood ow. (b) The distal microforceps (on the left) is slid down the blood vessel so as to drain the lumen of content.
(c) The proximal microforceps (on the right) is then released to test if blood will ow through the anastomosis and re ll the
previously drained section of vessel. If re ll occurs, then it can be concluded that blood is able to pass through the anastomosis.
a
c
b

2 Microsurgery
39
we perform all bula osteoseptocutaneous ap osteoto-
mies, perform sim ultaneous osseointegrations of dental
implants (when indicated), and nish bone xations and
soft tissue insets during primary warm ischemia time.

●
Reducing warm ischemia time is more critical for func-
tioning muscle or peristaltic intestinal free tissue transfers
than for nonfunctioning free aps used for coverage.
Reperfusion injury refers to the damage caused when blood
supply is reinstated after a period of ischemia above and beyond
that caused by the ischem ic insult itself.

●
In owing normal leukocytes release pro-in ammatory
factors when they encounter ischemia-damaged tissues:
neutrophil respiratory burst, oxidative stress from free
radical accumulation, and interleukin release attract more
pro-in ammatory cells. Restoration of oxygenated blood
ow thus causes oxidative stress and in ammation instead
of normal function.

●
Many drugs (e.g., heparin, nitrendipine, prostacyclin, uro-
kinase, streptokinase, superoxide dismutase) have been
used experimentally to increase tolerance to ischemia
and/or reperfusion injury, but none have routine clinical
applications.
The no-re ow phenomenon is sometimes witnessed follow-
ing prolonged ischemia and is clinically irreversible: poor ap
perfusion despite adequate arterial input and a patent venous
output (but no venous return).

●
Mechanism s unclear but are associated with intracellular
calcium overload, altered arachidonic acid m etabolism,
and free radical damage (mainly oxygen-derived radicals).
Ischemia-Reperfusion Injury and
the No-Re ow Phenomenon
Primary ischemia time begins with the interruption and ends
with the reestablishment of oxygenated blood supply; this is a
mandatory ischem ia tim e during free tissue transfer. Secondary
ischemia time occurs thereafter if ap circulation is compro-
mised (e.g., occluded anastomosis). Minim izing ischem ia tim e(s)
reduces injury caused by ischemia as well as by reperfusion.

●
Oxygen deprivation (ischem ia) eventually causes cellular
death from, for example: adenosine triphosphate deple-
tion, im balances in transm em brane ion gradients (e.g., cal-
cium), and cell membrane dysfunction.

●
The critical ischem ia time refers to the maximum period of
ischem ia that a tissue can withstand and still remain viable
after revascularization. However, the de nitions of “with-
stand” and “viable” change according to the m ethods of
quanti cation used (e.g., at protein, cellular, m acroscopic,
clinical, and functional levels).

●
Di erent tissues tolerate di erent durations of ischemia
according to their basal metabolic rate, which is a ected
by temperature, among other factors. However, studies
have shown that cooling free aps does not appear to a ect
clinical outcom es as long as ischem ia tim es rem ain below
about 4 hours.

●
Tolerable critical ischemia times for the various tissues are
likely longer than was previously believed. For example, in
our experience, the bula bone can tolerate up to 6 hours
of warm ischemia without detriment to its viability or
fracture healing. This is why, for mandible reconstruction,
Table 2.5 Anticoagulants in microvascular surgery
Drug
Principle mechanisms underlying
potential bene ts
Signi cant risks
Unfractionated heparin
Heparin binds antithrombin III (AT-III). This
exposes the AT-III active site. AT-III then
inactivates the coagulation enzyme factors IIa
(thrombin), IXa, and Xa, which then prevent
brinogen conversion to brin.
Bleeding: heparin activity can be counteracted with protamine
sulphate.
Heparin-induced thrombocytopenia: highly prothrombotic disorder,
mediated by anti-heparin IgG, occurs in 1% of patients receiving
. 5 days IV heparin, rarely occurs within hours in patients recently
exposed to heparin. Monitor platelets daily.
Low-molecular-weight
heparins (LMWHs)
LMWHs also bind AT-III but have greater
anti-factor Xa activity instead of greater anti-
thrombin activity.
Bleeding from LMWHs is pharmacologically irreversible, including
by protamine sulphate. Bleeding is a rarer complication of LMWHs
compared to unfractionated heparin.
Heparin-induced thrombocytopenia is rarer for LMWHs.
Aspirin
Aspirin inhibits the cyclooxygenase enzymes,
which are responsible for thromboxane
synthesis; thromboxanes are responsible for
platelet aggregation; thus aspirin indirectly
inhibits platelet aggregation.
Reye syndrome (rare but often fatal): thus aspirin is contraindicated in
those younger than 16.
Bleeding: pharmacologically irreversible
Peptic ulceration, asthma exacerbation, tinnitus
Dextrans (most commonly
Dextran-40)
Multiple mechanisms: impairs erythrocyte
aggregation, impairs platelet aggregation/
adhesiveness, exerts thrombolytic e ects by
activating plasminogen, improves blood ow
through colloidal hemodilution.
Anaphylaxis, acute renal failure, and pulmonary and cerebral edema
are uncommon but severe side e ects. Bleeding: pharmacologically
irreversible.

40
I Planning and Decision Making in Reconstructive Surgery

Applications of
Microvascular Surgery:
Free Tissue Transfer
Microvascular techniques are m ost com m only employed by
plastic surgeons for free tissue transfer and replantation. Free
tissue transfer involves: (1) com plete detachm ent and devas-
cularization of the ap from the donor site; (2) revascular-
ization of the ap w ith anastom oses to recipient site blood
vessels; and (3) a variable intervening period of ap prim ary
ischem ia tim e.
The conceptual distinction between random and axial pat-
tern ap designs, clari ed by McGregor and Morgan in 1973, co-
incided w ith the early clinical free ap successes (Table 2.6). The
realization that m icrovascular anastom oses could be perform ed
in vessels comparable to the diam eter of m ost axial pattern ap
pedicle vessels resulted in a surge in the num ber and variety
of available free aps. With these early hurdles conquered and
w ith free ap success rates improving worldw ide, the focus of
m icrovascular free tissue transfer shifted during the late 1980s
toward developing re nem ents, and has continued ever since.
Although countless free aps have now been described, a selec-
tion of reliable workhorse aps can satisfactorily address m any
reconstructive challenges w ith acceptable donor site m orbidity
(Table 2.7).

●
Believed to progress as follows: (1) endothelial cellular swell-
ing; (2) in ammatory vasoconstriction; (3) impaired ap
microcirculation; (4) stasis; (5) platelet aggregation; (6) mi-
crocirculatory thrombosis; (7) intravascular leakage into the
interstitium; (7) progressive ischemia; and (8) ap failure.
Healing of the Successful
Anastomosis

●
Immediately after anastomosis: a platelet layer covers de-
nuded endothelium but does not progress to brin depo-
sition and thrombosis if it is not exposed to the media and
the lumen is not injured.

●
Between 24 and 72 hours: the platelet layer gradually
dislodges.

●
Within 5 days: a pseudointima forms.

●
Within 1 to 2 weeks: new endothelium covers the
anastom osis.

●
Endothelial regeneration depends on the presence or ab-
sence of injury to the subendothelium.

●
Only endothelial dam age: endothelium reconstituted
by surrounding cells within 7 to 10 days.

●
Subendothelium also dam aged: regeneration occurs by
di erentiation and migration of myoendothelial cells
from the cut vessel ends.

●
Other layers of the vessel will regenerate through bro-
blast proliferation, collagen deposition, and myointimal
thickening at the anastomosis site.
Table 2.6 Development of microvascular free tissue transfer: historical milestones
Milestone
Pioneers (location)
Performed
Published
Successful human arterial repair (femoral artery, nonmicrovascular)
Murphy (U.S.)
1896
1897
Experimental triangulation technique of vascular anastomosis
(nonmicrovascular)
Carrel (France)
1901
1902
Operation in humans performed under microscope magni cation
(otological)
Nylen (Sweden)
1921
1923
Successful human jejunal free ap (nonmicrovascular)
Seidenberg et al. (U.S.)
1957
1959
Successful experimental microvascular anastomoses (minimum 1.4 mm
diameter)
Jacobson & Suarez (U.S.)
1960
1960
First series of human free tissue transfers (21 free intestinal aps in 21
patients, of which 16 were successful; all nonmicrovascular using an
anastomotic stapling device)
Nakayama et al. (Japan)
Not stated, but
pre-Aug 1963
1964
Successful replantation of completely amputated arm (nonmicrovascular)
Malt and McKhann (U.S.)
1962
1964
Successful replantation of completely amputated thumb (microvascular)
Komatsu and Tamai (Japan)
1965
1968
Partially successful microvascular free ap (dermolipomatous groin ap)
Antia and Buch (India)
1966
1971
Successful microvascular free ap of whole digit (second toe, Yang; great
toe, Cobbett)
Yang (China); Cobbett (UK)
1967; 1968
1979; 1969
Successful microvascular free ap (non-skin-bearing; omentum ap)
McLean and Buncke (U.S.)
1969
1972
Successful microvascular free ap (skin-bearing; groin ap)
Daniel and Taylor (Australia)
1973
1973

2 Microsurgery
41
advantages: reduced ap bulk, improved ap insetting, design,
and choice). Therefore, a perforator ap can be de ned as one that
is based on a pedicle that has been skeletonized from its intramus-
cular course (excluding the muscle) by retrograde intramuscular
dissection (e.g., anterolateral thigh free ap based on a vessel that
traverses the vastus lateralis muscle). If the same ap is based on
a pedicle that has no intramuscular course, there is no donor site
morbidity to be spared (muscle is anatomically excluded), intra-
muscular dissection is not required, and it is not a perforator ap
by this de nition (e.g., anterolateral thigh free ap based on a sep-
tocutaneous vessel).
Chimeric Flaps
A ap with separate components that share a common source
vessel is a chimeric ap. Their key advantage is that the individual
components are freely mobile with respect to one another, making
it possible to reconstruct a compound or composite defect with a
ap based on only one arterial and one venous anastomosis.
Supramicrosurgery (or
Supermicrosurgery) Technique
The key advantage of supramicrosurgery in free tissue transfer is
that donor site morbidity is theoretically reduced by not breach-
ing the deep fascia and not touching the underlying muscle during
ap harvest because suprafascially transected (or immediately

Re nements in Free Tissue
Transfer
Patient Selection Criteria
In the modern era, there is no generic absolute contraindication to
free ap surgery. The impact of age, tobacco smoking, obesity, di-
abetes, peripheral vascular disease, di cult anatomy (e.g., small
extrem ity vasculature in poliomyelitis patients and in infants),
previous trauma or radiation therapy, and various noncompliant
psychiatric disorders has all been debated. The microsurgeon
should be alert to these factors as indicative of possibly increased
risk of infection, donor site complications, free ap failure, and
anesthetic problems. Absolute contraindications to a speci c free
ap choice (e.g., ap pedicle disruption) or to microvascular free
tissue transfer (e.g., unacceptable anesthetic risk) may be en-
countered on a case-by-case basis.
Improving Flap Design and
Reducing Donor Site Morbidity
Perforator Flaps
The de nition of a perforator ap remains controversial. The pri-
mary reason why perforator aps were revolutionary was that do-
nor site morbidity could be reduced by excluding an unnecessary
component, almost always a muscle, from their harvest (other
Table 2.7 Six workhorse free aps
Anterolateral
thigh
Radial forearm
Fibula bone
Gracilis muscle
Rectus abdominis
muscle
Latissimus dorsi
muscle
Dominant
vascular
pedicle
Descending branch
of lateral circum ex
femoral artery
Radial artery
(ensure ulnar
artery dominant
hand)
Peroneal artery
Branch to gracilis
from medial
circum ex femoral
artery
Deep inferior
epigastric artery
(IEA)
Thoracodorsal artery
(TA)
Tissue
components
that can be
included
(commonly)
Skin/fat, fascia/
fascia lata, vastus
lateralis muscle,
lateral femoral
cutaneous nerve
Skin/fat, fascia,
palmaris longus
tendon, medial/
lateral cutaneous
nerve of the
forearm, radius
bone segment
Skin/fat/fascia
(preferably),
bula, lateral sural
cutaneous nerve,
soleus muscle
segment
Skin/fat/fascia,
anterior branch
of obturator
nerve (motor and
sensory), gracilis
muscle
Skin/fat, fascia,
rectus abdominis
muscle, 10th or 11th
intercostal nerve
sensory branch,
segmental motor
innervated
Skin/fat, fascia, one
or more ribs with
intercostal muscle,
split latissimus dorsi
(LD), chimeric, motor
innervated (note:
proximal pedicle
extension to the
subscapular artery
and its branches
dramatically
increases useful ap
components)
Examples
of common
modi cations
Chimeric, ow-
through, sensate,
functioning
muscle, perforator
ap
Chimeric, ow-
through, distally/
proximally based,
sensate, perforator
ap
Chimeric, ow-
through, sensate,
double-barreled
Chimeric,
functioning muscle
Transverse
rectus abdominis
myocutaneous
(RAM) ap, vertical
RAM ap, sensate,
deep IEA perforator
ap; super cial IEA
perforator ap
Chimeric, functioning
muscle, sensate,
perforator ap

42
I Planning and Decision Making in Reconstructive Surgery
blood pressure monitoring (systolic . 100 mm Hg), and pulse
oximetry. Ideally, free ap patients should be monitored in an
intensive care setting until both patient and ap are stable for
routine ward monitoring. The earlier a vascular compromise is
recognized, the better is the chance of reversing the problem(s).
The m ajority of throm bi occur within the rst 2 days, and salvage
rates reduce progressively the later the thrombosis occurs.
Clinical Observation

●
Improves with experience: capillary re ll time, ap tem-
perature, ap color, bleeding color (by dermal scratch or pin-
prick distant from the pedicle). All sections of the ap should
be individually assessed: one area might be healthy, whereas
another is reversibly failing. Regular reassessment is neces-
sary to appreciate the progress of a ap, particularly in re-
sponse to interventions: improving, no change, worsening.

●
Arterial and venous compromise can occur simultaneously
and one may lead to the other:

●
Signs of failing arterial in ow: increasing pallor, drop-
ping temperature, reducing tissue turgor, slowing cap-
illary re ll, and slowing dermal bleeding.

●
Signs of failing venous out ow: increasingly reddish/
purplish tinge, increasing temperature, increasing tis-
sue turgor, darkening, and quickening pinprick bleeding.
Monitoring Buried Flaps
These can be m onitored m ore easily with an exteriorized skin
island (can later be removed under local anesthetic). When a skin
island is absent, implantable monitoring devices (e.g., implant-
able Doppler probe) have been used to directly assess anastomot-
ic patency; however, a patent anastomosis does not necessarily
equate with a healthy ap distal to the anastomosis. Similarly, an
exteriorized skin island does not always re ect the status of the
buried portion of the ap.
Other Methods
These include invasive (e.g., m icrodialysis, implantable tissue ox-
ygenation probe), noninvasive (e.g., pulse oximetry, near-infrared
spectroscopy, photoplethysmography, computed thermography,
transcutaneous oxygen m easurem ent), and various ultrasono-
graphic techniques (e.g., laser Doppler owmetry, color Doppler,
high- and low-frequency Doppler).

Addressing Failing
Free Flaps
The m ost successful m icrosurgical team s prevent the struggling
free ap from transforming into an irreversibly failing one. Time
is of the essence: detect vascular compromise early, diagnose the
contributing problems accurately, and reverse each problem ex-
pertly and expediently.
subfascially transected) pedicle vessels can be anastomosed suc-
cessfully. The diameter of such vessels is almost always less than
1 mm, making anastomoses more challenging, and such pedicles
are very short, making ap inset more troublesome.
Endoscopic Techniques
Som e free aps have been harvested with endoscopic assistance,
notably the gracilis, rectus abdominis, and latissimus dorsi mus-
cles; the om entum ; and jejunum . Their key advantage is im-
proved patient satisfaction with donor site cosmesis.
Innervated Flaps
It is possible to restore a variable quality of cutaneous sensation
to free aps by microneural coaptation of a ap sensory nerve to
a recipient site sensory nerve. Functioning free muscle transfer
implies the use of an innervated m uscle ap to replace lost m us-
cle function by coaptation to a recipient motor nerve.
Free Style Flaps
One can design a free ap in alm ost any desirable cutaneous ter-
ritory, identify a pedicle supply to that territory with a handheld
Doppler probe, and then trace that pedicle along any anatom ical
course, until its source vessel, with retrograde dissection tech-
niques. The key advantage of freestyle free aps is increased
exibility when choosing donor skin and subcutaneous tissue
characteristics.
Flap Prefabrication: Vascular Induction
and Prelamination
Vascular induction involves introducing a new blood supply into
a chosen volume of tissue by: (1) transferring a pedicle into that
volume of tissue; (2) neovascularization of that tissue by the
transferred pedicle; and (3) transfer of that tissue based only on
its implanted vascular pedicle. This m ethod allows the design of
free aps in more discrete regions of the body or in areas of skin
excess, and the creation of new aps in areas that do not have
de ned axial vessels.
Prelam ination involves the addition of one or m ore extra lay-
ers of tissue to an existing ap, for example, by skin grafting or
by implanting the donor site with mucosa or cartilage, to create a
customized multilayered free ap. Prelamination is one method
to precustomize free aps for reconstructing compound or com -
posite head and neck defects.

Monitoring Patients and
Free Flaps
Patients who undergo free ap surgery require at least the fol-
lowing continuous monitoring: total uid input and urinary
catheter output (aim for 0.5 to 1.0 m L/kg/hr), core temperature
(normal), cardiac monitoring including peripheral intra-arterial

2 Microsurgery
43

Future Applications of
Microsurgery
The re nem ent of free tissue transfer and of m icrosurgical tech-
niques continues to improve the results of increasingly complex
reconstructions. Microsurgical techniques will be required for
vascularized composite allotransplantation and composite vas-
cularized tissue-engineered constructs in the future.
Suggested Further Reading
Chubb DP, Rozen WM, Whitaker IS, Acosta R, Grinsell D, Ashton MW. The
e cacy of clinical assessment in the postoperative monitoring of
free aps: a review of 1140 consecutive cases. Plast Reconstr Surg
2010;125(4):1157–1166
Chubb DP, Rozen WM, Whitaker IS, Ashton MW. Introduction of the im -
plantable Doppler system did not lead to an increased salvage rate
on comprom ised aps: a multivariate analysis. Plast Reconstr Surg
2011;127(2):1020–1021
Hanasono MM, Butler CE. Prevention and treatment of thrombosis in
m icrovascular surgery. J Reconstr Microsurg 2008;24(5):305–314
Jokuszies A, Herold C, Niederbichler AD, Vogt PM. Anticoagulative strate-
gies in reconstructive surgery—clinical signi cance and applicabil-
ity. Ger Med Sci 2012;10:Doc01
Koshim a I, Inagawa K, Urushibara K, Moriguchi T. Paraum bilical perfora-
tor ap without deep inferior epigastric vessels. Plast Reconstr Surg
1998;102(4):1052–1057
Mardini S, Tsai FC, Wei FC. The thigh as a model for free style free aps.
Clin Plast Surg 2003;30(3):473–480
Mathy JA, Pribaz JJ. Prefabrication and prelamination applications in current
aesthetic facial reconstruction. Clin Plast Surg 2009;36(3):493–505
McGregor IA, Morgan G. Axial and random pattern aps. Br J Plast Surg
1973;26(3):202–213
Rickard RF, Hudson DA. A History of vascular and microvascular surgery.
Ann Plast Surg 2014;73(4):465–472
Wang WZ, Baynosa RC, Zam boni WA. Update on ischem ia-reperfusion
injury for the plastic surgeon: 2011. Plast Reconstr Surg 2011;
128(6):685e–692e
Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator aps: what
is a true perforator ap? Plast Reconstr Surg 2001;107(3):874–876
Whitaker IS, Oboum arzouk O, Rozen WM, Naderi N, Balasubramanian SP,
Azzopardi EA, Kon M. The e cacy of medicinal leeches in plastic
and reconstructive surgery: a systematic review of 277 reported
clinical cases. Microsurgery 2012;32(3):240–250
Figure Credits
1. Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. Stutt-
gart: Thieme; 2000
Patient factors include:

●
Keep the patient warm and pain-free, hemodynamically
optimize the patient, correct hypovolemias with uid chal-
lenges, avoid vasoconstrictors, and avoid blood replace-
ment unless there is a clear indication for its use.
Flap factors include:

●
Remove compressive or constrictive dressings/casts, cor-
rect unfavorable patient positioning, and nonhemorrhagic
uid collections and constrictive skin sutures that can be
safely released at the bedside should be addressed.
Pharmacologic factors include:

●
In the setting of failing aps, most would advocate antico-
agulant administration (see above), but no drug will de n-
itively correct a technically failed anastomosis.

●
Live leeches (Hirudo m edicinalis with antibiotic prophylax-
is) or chemical “leeching” (topical heparin com bined with
dermal punctures) can be used to relieve mild venous con-
gestion that is not worsening.
Return to operating room:

●
Justi able for any patient who can safely tolerate a further
general anesthetic and has a struggling free ap that does
not improve with bedside maneuvers.

●
Carefully assess the ap systematically, correcting each
encountered problem and reassessing after each correc-
tion: (1) anastom oses and, if used, vein grafts (e.g., twist-
ing, kinking, nonretrograde; Fig. 2.2); (2) the entire m ain
pedicle; (3) the insetting and folding of the ap; (4) the
intervening vessels connecting ap components; and
(5) non ap components causing external compression.

●
Apply lidocaine for vasospasm, redo nonpatent or doubtful
anastomoses (e.g., redundant, tensioned), try to improve
ap circulation with subtle ap repositioning, reroute the
pedicle, reinset the ap if necessary, supercharge the ap
if required, and consider thrombolysis (but be aware of its
contraindications and prevent system ic adm inistration by
allowing the ap to drain the thrombolytic out with the
circulation).

44
Preoperative Imaging for Reconstructive
Flap Planning
Warren M. Rozen and Vachara Nium sawatt
3

Doppler Ultrasound
The Doppler probe has been used to identify perforator loca-
tion for m any years. Doppler ultrasound allows the identi ca-
tion of a perforator’s axis and dim ensions, adding to safety and
predictability in ap harvest. It has been used to design new
perforator-based aps and to modify the approach to existing
perforator aps, particularly in the setting of the “freestyle” per-
forator ap. Doppler ultrasound has been used in the setting of
both local aps and free tissue transfers. The most common de-
vice to incorporate Doppler ultrasound principles that is used by
reconstructive surgeons is the portable, handheld unidirectional
Doppler owm eter (Fig. 3.1). This device provides an audible or
visible waveform when contacting a vessel with intraluminal
ow. With technological advances, the multidirectional nature of
ap was able to be mapped, and, from this, color duplex ultra-
sound was introduced, to be able to map not only location but
directional ow (Fig. 3.2). The presence of both/either an artery
or vein can be highlighted, and the dominance of either can be
established. More recently, four-dimensional ultrasound has also
been introduced to show ow changes over time.
Technique
Sonographic conductive gel is applied, and the probe is placed
at an angle (usually 45 degrees) to the skin plane to maximize
de nition of the vertical orientation of the perforator in relation

Introduction
Reconstructive aps, both pedicled and free, have undergone
signi cant advances over the past three decades, with microsur-
gical free ap transfer survival rates approaching 98% in most
reported series. While advances since then have included im-
provements in the operating microscope, suture materials, ap
options, and postoperative monitoring, there is widespread ap-
preciation of attributing much of the success to advances in pre-
operative planning, intraoperative assessment, and postoperative
monitoring with im aging techniques. Preoperative im aging prior
to undertaking a soft tissue ap has become a vital tool for sur-
geons. Doppler ultrasound has long been established, computed
tomographic angiography (CTA) and magnetic resonance angi-
ography (MRA) have been more recently introduced widely, and
stereotactic im age guidance and digital infrared therm ographic
photography are newer advances. All of these may have their
place in preoperative planning, and have each been shown to be
e ective options as tools in reconstructive ap planning. With
the increased popularity of perforator aps, in which sm aller
vessels are dissected during ap harvest, im aging has becom e all
the m ore imperative. With substantial interindividual variability
of vascular anatomy, whether by congenital variation or changes
resulting from a vascular, traumatic, or neoplastic insult, these
modalities can rapidly and noninvasively aid ap planning and
potentially improve ap-related, donor site– related, and overall
patient outcomes.
Fig. 3.1 Conventional ultrasound (a) and color duplex ultrasound (b) of the anterior abdominal
wall vasculature, with the deep inferior epigastric vessels (arrows) demonstrated immediately
adjacent to the pedicle origin on the external iliac artery (EIA) and vein (EIV).1

3 Preoperative Imaging for Reconstructive Flap Planning
45
Guidelines

●
Conductive gel applied to the skin surface.

●
Probe is placed at 45 degrees to the skin plane.

●
Move the probe backward and forward system atically
during scanning.

●
Scan from a di erent horizontal plane to increase its accuracy.

Computed Tomographic
Angiography
The advent of “objective” im aging m odalities heralded a new
phase in preoperative imaging, in which all cutaneous perfora-
tors within the volume of a planned ap can be demonstrated on
a single three-dimensional software reformat, facilitating a sub-
stantial reduction in interobserver variability. Computed tomo-
graphic (CT) angiography, especially multidetector CT (MDCT),
has allowed for a noninvasive vascular imaging modality with
high spatial and temporal resolution. MDCT angiography al-
lows for precise evaluation of the origin, course, and relations of
small-diameter vessels to the surrounding anatomical planes and
structures (Fig. 3.3).
Heo et al. demonstrated that MDCT angiography provides an
accurate vascular map of the perforators of the lateral circum ex
femoral artery. The entire course, branching pattern, and anatom-
ical variation of the perforators, as well as the presence of any vas-
cular anomalies, can be accurately identi ed. These bene ts have
held true for published reports of perforator territories throughout
the body. For the deep inferior epigastric artery perforator (DIEP)
Fig. 3.2 Color duplex ultrasound of the abdominal wall vasculature,
demonstrating a perforator of the deep inferior epigastric artery (DIEA)
pedicle, with both the super cial and deep course able to be mapped rel-
ative to the point of perforation of the anterior rectus sheath. (a) The
subcutaneous course of a perforator is demonstrated, super cial to the
anterior rectus sheath (asterisk). (b) The subfascial and intramuscular
course of a perforator is demonstrated (arrow), deep to the anterior rec-
tus sheath (asterisk).1
to the probe. Angling of the probe in too parallel of an orientation
relative to the skin can increase the chance that an axial vessel
or a more proximal source vessel will be mistaken as a cutane-
ous perforator. The probe is then moved backward and forward
in a systematic way across the skin surface to map for signals.
When an audible signal is heard, the location of maximal ow is
marked, and then scanned from a di erent direction to increase
accuracy.
Given the relative operational simplicity of the Doppler
ultrasound, its relative inexpensive nature, and ability to be
perform ed by the operating surgeon either pre- or intraop-
eratively, this m odality has becom e the m ost com m only used
preoperative planning technique, at least until recent tim es. It
is worth noting that the literature does report substantial inac-
curacy w ith the use of the Doppler probe, particularly w here
used w ith inexperience on the part of the surgeon, or in pa-
tients w ith excess subcutaneous fat. Examples of this have been
highlighted throughout the body. In the anterolateral thigh
(ALT) ap, for example, Doppler ultrasound has w idely been
reported as show ing a low accuracy. Lin et al. and Tsukino et
al. m apped the thigh w ith Doppler, and found that Dopplered
perforators were identi ed w ithin 1 cm of the actual cutaneous
perforator location between 43% and 87% of the tim e. Further-
m ore, it was highlighted that the Doppler probe can only pro-
vide detail of the position of the perforators but not speci cs of
their deeper course. Certainly color duplex and scanning laser
Doppler im aging improve both accuracy and usability; however,
w ith these advancing techniques, experienced radiologists are
increasingly required, lim iting one of the greatest bene ts of
Doppler: the ability to be both perform ed and reported by the
operating surgeon.
Key Points

●
Use of handheld device which is simple to operate.

●
Accuracy dependant on patient body habitus and operator
experience.

●
Lower sensitivity and speci city when compared to CTA
and MRA.
Fig. 3.3 Computed tomographic angiographic images of the abdominal
wall for perforator ap planning. (a) Three-dimensional volume-rendered
technique (VRT) software reconstruction, with coronal view demonstrat-
ing musculocutaneous perforators emerging from the rectus sheath
into the subcutaneous fat. (b) Oblique view, highlighting the cutaneous
course of the perforators on VRT reconstruction. (c) Maximum intensity
projection (MIP) axial software reconstruction, highlighting the subcuta-
neous and intramuscular course of the paraumbilical perforators.
a
b
c

46
I Planning and Decision Making in Reconstructive Surgery
Study Range
In each patient, the scan range necessarily needs to include the
surgical eld, and thus this needs to be clearly known by both
the surgeon and radiologist. The position of the patient on the CT
scanning table should be equivalent to the nal position adopted
in the operating room. This can avoid positional distortion, com -
pression due to positioning, and distortion due to garments. The
scan should also only include the area of interest for the surgeon,
in order to avoid unnecessary radiation.
Contrast Medium
There are side e ects and idiosyncratic reactions from the use of
contrast m edia. Renal function and a potential for contrast aller-
gy are the more common, and can be checked prior to the scan
with a thorough history and/or investigations. CTA is performed
using an injection of 120 mL of iodinated contrast medium (320
mg of iodine/m L) at a ow rate of 4 m L/s by using the bolus track-
ing technique described above. For most preoperative planning
scans, the use of an oral contrast medium is not required.
Image Interpretation
A range of speci c anatomical data points can be obtained using
this scanning technique:

●
Location and characteristics of perforators: The images ob-
tained after appropriate software reconstruction allow for
determining the number of perforators and their emer-
gence from deeper planes.

●
Location of the vascular pedicle: the ap pedicle (both ar-
tery and vein) can be identi ed. The suitability and poten-
tial variations can be observe and taken into consideration
prior to surgery.

●
Vessel caliber: in most available CT software programs,
there are built-in program s that allow the m easurem ent of
vessels: both diameter and length.

●
Course of the perforators and vascular pedicle: CTA allows
for identi cation of anatom ical structures surround-
ing each part of the vessel of choice (e.g., bone, m uscle,
deep fascia, and super cial fascia), and can dem onstrate
these vessel relations in m ultiple planes (axial, coronal,
and sagittal). This facilitates preoperative planning of the
penetration pattern of the particular vessel: true “virtual
surgery.”
Key Points

●
CTA combines the use of multiplanar CT scanning with IV
contrast to identify vascular anatomy.

●
Both arterial and venous phases can be performed by
optimizing scan delay times, timed using bolus tracking
from the time after infusion of IV contrast.

●
CTA can be di cult to distinguish arterial from
venous vasculature.

●
By selecting arterial versus venous tim ing, vessel
characteristics can be better demonstrated.
ap, preoperative CTA is currently considered, in reported series
from multiple international centers, as the gold standard in preop-
erative planning for DIEP aps. These studies have demonstrated
that CTA is signi cantly more accurate than other imaging modali-
ties, for both perforator mapping (location and course) and demon-
strating all of the other vascular pedicle characteristics sought.
Rozen et al. have demonstrated that the use of preoperative CTA
in DIEP ap can reduce operative learning curve, operative time,
and abdominal wall morbidity as well as increasing ap reliability.
In order to improve the accuracy of CTA, the use of high-quality
software reconstruction is imperative. These three-dim ensional
reconstructions can be achieved using computer software that
performs multiplanar reconstructions. Volume-rendered tech-
nique (VRT) and maximum-intensity projection (MIP) recon-
structions are widely used for this purpose and can be achieved
with a wide variety of commercially available software programs.
MIP reconstructions are optim al for dem onstrating the vascular
pedicle and relationship to other surrounding structures, particu-
larly for the intram uscular course of perforators. VRT reconstruc-
tions assign color to data points which display a two-dimensional
representation of the three-dimensional data set. This technique
is particularly useful for perforator ap m apping as the subcu-
taneous course of perforators can be clearly distinguished. This
allows for the generation of perforator location m aps: a single
map of all the regional vessels and their locations.
Technique
The technique for patient scanning varies depending on the
region of the body being examined. Patient factors also need to
be taken into consideration including body habitus, morbidity
(e.g., renal function), and contrast allergy. Thus, several adjust-
ments may be necessary, but in most circumstances, the follow-
ing techniques can be applied.
Scanning
The tim ing of the scan is essential to m axim ize either arterial or
venous phase scanning, with this timing able to highlight the re-
spective vascular anatomy. There are some authors who advocate
arterial phase scanning, arguing that there are always concomi-
tant veins with every arterial perforator, and thus identifying the
artery is uniformly su cient. Others advocate a venous phase
scan, arguing that ap compromise is more often a venous issue,
and thus the veins are more important to demonstrate preopera-
tively. We prefer the rst approach.
There are two methods of scanning that can achieve this
arterial phase timing, with both methods using a bolus-tracking
technique to identify lling of the appropriate vessels with con-
trast as a means to initiate scanning.

●
The rst technique, after identifying contrast lling of the
central aorta, uses an extensive delay before scanning which
can use known delay times based on the regional vessel of
choice. When using a 64-row multidetector row scanner,
a 25- to 35-second delay is commonly used for the DIEA.

●
Both techniques require consideration of the inherent
delay of the particular scanner (approximately 4 seconds).

3 Preoperative Imaging for Reconstructive Flap Planning
47
Technique
There are several unique contraindications to the use of MRA,
including: severe obesity, implanted de brillator or pacemaker
devices, implanted ferromagnetic devices, and cochlear implants.
There are also other relative contraindications including: the
presence of arti cial heart valves, implanted drug infusion ports,
implanted nerve stimulators, arti cial limbs or metallic joint
prostheses, metal pins, screws, plates, stents, or surgical staples.
MRA scanning protocols follow the sam e philosophy as used
and described for CTA techniques, with a view to identifying all
the m ain perforators and related vascular pedicles and their m ain
anatomical features. Higher strength magnets are typically as-
sociated with greater image quality and contrast resolution: the
authors have used a 1.5-tesla GE Echospeed HDx (General Elec-
tric, Milwaukee, WI) scanner and a 3-tesla Siem ens Magnetom
Trio (Siemens Medical Solutions, Erlangen, Germany) scanner. In-
travenous contrast is achieved w ith 30 mL of gadolinium -based
contrast m edia, with varying agents used in di erent centers;
the authors have used Magnevist (Dimeglum ine Gadopentetate;
Schering, Bergkamen, Germany).
Key Points

●
Similar applications for vascular mapping as CTA.

●
Not associated with ionizing radiation exposure, lower
risk of allergy to contrast, and postulated lower risk of
nephrotoxicity.

●
Has been suggested to be associated w ith nephrogenic
systemic brosis; however, this has also been disputed.

●
Expensive and may not be available in all centers.

●
High speci city similar to CTA but potentially lower
sensitivity.

●
CTA has been used for preoperative imaging, particularly
for perforator aps, in many international centers, and has
been widely reported as the gold standard.

●
CTA has a high accuracy, with perforators smaller than
1.0 mm readily detected, and as low as 0.3 mm reported.
Guidelines1

●
Scan type: Helical multi-detector row CT angiography

●
Slice thickness: 64 detector row 3 0.6 mm collimator width

●
Helical detector pitch: 0.9

●
Gantry rotation speed: 0.37 s

●
Tube potential: 120 kV

●
Tube current: 180 mA

●
Contrast: Omnipaque 350 100 mL IV injection 4 mL/s

●
Scanning range: Various according to body region of interest

●
Scanning direction: audocranial

●
Bolus tracking: Varies according to body region of interest

●
Image reconstruction: 1 mm/0.7 mm overlapping axial images

Magnetic Resonance
Angiography
Magnetic resonance angiography (MRA) has progressed from
its initial use for brain or solid organs to a feasible technique for
vascular study. Even the very peripheral and small diameter vas-
culature can be evaluated. While ow voids can facilitate MRA
use for m apping vasculature, and certainly this has been used
in reconstructive surgery, the more commonly reported and
used technique is to use contrast m edium as m eans to creating
the necessary contrast for angiography. In ap reconstruction
planning, MRA has been shown to have a higher sensitivity and
speci city in evaluating vessels, particularly course and size, than
Doppler/color duplex and even CTA in som e series. This is not
uniform , and has not been our experience to date, but certainly
suggests that this is a fascinating and evolving technique.
MRA has also been suggested as having an improved risk
pro le, when compared with CTA, as it is not associated with
ionizing radiation, and has a potentially less toxic intravenous
contrast m edium when compared to CTA. Gadolinium , however,
is not a benign agent, and others have suggested that its use may
in fact be just as nephrotoxic. MRA of the abdominal wall, which
demonstrates the location and evaluation of deep inferior epigas-
tric vessels and its perforators, is shown in Fig. 3.4.
In the literature, the accuracy of identifying cutaneous perfora-
tors has been reported to be as high as 97% to 100%, with perforators
as small as 0.8 mm in diameter able to be accurately detected. Lo-
renz et al. have used MRA in the planning of bular free aps, and
were able to identify congenital anomalies that would not have been
detected without the use of MRA. Despite having a high degree of
accuracy (particularly high speci city) in identifying perforators of
greater than 1 mm in size, it does not identify all perforators (lower
sensitivity). Some authors, such as Rozen et al., found that MRA has
a lower sensitivity in identifying perforators when compared to CTA.
1 The authors have m odi ed this from data in Rozen et al. (2010).
Fig. 3.4 Magnetic resonance angiogram of the abdominal wall, demon-
strating the location and evaluation of perforator vessel in a patient un-
dergoing DIEP ap breast reconstruction. (a) The widest perforator vessel
is initially identi ed in the MIP reconstruction (arrow), in this case in the
right anterior abdominal wall. (b) The intramuscular course of the perfo-
rator vessel is evaluated in the sagittal curve-MIP as well as the anastomo-
sis of the perforator (arrow) with the super cial vasculature. (c) Coronal
MIP reconstruction in which the course of the deep inferior epigastric
artery can be observed.2
a
b
c

48
I Planning and Decision Making in Reconstructive Surgery
There are three techniques that have been described in the
literature: (1) ducial marking and the articulated arm technique;
(2) “soft touch” registration; and (3) Z-touch surface matching
registration. Each of these techniques uses a di erent technique
to register the scan data to real-time patient landmarks. As such,
these techniques are similar to each other, superimposing radio-
logical images with the patient prior to the operation. The radio-
logical images are input into computer software programs, and
the resultant scan data can be visualized in a multiplanar fash-
ion on the screen. The images are calibrated with the patient by
an identi cation of known bony landmarks: so-called registra-
tion. Markers ( ducial) or a wand (a wireless handheld device) is
placed on the patient’s body and data transmitted via infrared to
a digital station, which displays real-time localization on a screen.
Fiducial Marking and Articulated
Arm Technique

●
Preoperative im aging is perform ed within 24 hours of the
operation (to reduce any change in patient’s physique/hab-
itus that may cause discrepancy in ducial marker posi-
tion).

●
Preoperative CTA or MRA

●
Fiducial markers are placed on the patient’s bony
landmarks.

●
CTA or MRA scan obtained.

●
Thin axial images exported as “digital imaging and com-
munications in medicine” (DICOM) le format and are
load onto the stereotactic navigation software. The imag-
es are three-dimensionally reconstructed, demonstrat-
ing the anatomy in coronal, sagittal, and axial planes.

●
At operation:

●
The patient is placed in sam e position as in the CT/MR
scanner.

●
A reference star is attached rmly to the patient using
a Velcro strap.

●
Digitizer, which is mounted to the navigation station, is
placed focusing on the patient.

●
Localization of perforators is done by slow maneuver-
ing of the pointer to each perforator as displayed on the
navigation station (Fig. 3.5).

●
Each perforator is then marked on skin.
Guidelines2

●
Field strength: 1.5 to 3.0 teslas

●
Image acquisition: TIM (Total Imaging Matrix Technology)

●
Slice resolution thickness: 0.8 mm coronal acquisition slices

●
In-plane resolution: 0.9 3 0.8 3 0.8 mm

●
IV contrast: Magnevist (dimeglumine gadopentetate,
Schering)

●
Contrast infusion: 30 mL IV 2 mL/s, Care Bolus Technique

●
Contrast bolus tracking: Varies according to body region of
interest

●
Scanning range: Varies according to body region of interest

●
Body m atrix coil: Varies according to body region of interest

Stereotactic Image–
Guided Surgery
The use of navigation techniques to accurately m ap anatom ical
structures was pioneered in the late 1800s and has been m odi-
ed extensively since then to becom e com monplace in som e sur-
gical specialties. It is particularly heavily utilized in the eld of
neurosurgery. The concept in stereotaxy is to accurately localize
anatomical structures within the human body, and use scanned
data to map these structures in real-time. It was recognized that
this can be achieved by recreating a three-dimensional construct
using three planes designated X (horizontal), Y (coronal), and Z
(sagittal). The technique was coined “stereotactic navigation.” In
ap reconstructions, this concept has been used in combination
with both CTA and MRA images (Fig. 3.5). This has allowed for the
real-time localization of the vascular pedicle and its perforators.
While preoperative imaging with CTA and MRA has been as-
sociated w ith the term “virtual surgery,” stereotactic navigation
has taken this to a new level, as the vessels can be speci cally
mapped in real tim e through the patients’ tissues. This technique
further allows for intraoperative application. The surgeon can
thus have real-tim e visual guides when dissecting out perforators
and be able to navigate through the surrounding tissues safely,
which may yet translate to lower patient morbidity and improved
outcomes.
Fig. 3.5 Stereotaxy. (a) Navigation station for registra-
tion and localization of patient data, by means of du-
cial point registration, utilizing a stereotactic pointer,
reference star, and ducial marker for the abdominal
wall donor site. (b) Three-dimensional multiplanar
reconstruction images, as seen on BrainLAB Vector Vi-
sion Cranial software, demonstrating coronal, sagittal,
and axial planes during stereotactic navigation of a com-
puted tomography angiogram of the abdominal wall
vasculature.3
2 The authors have m odi ed this from data in Rozen et al. (2009).

3 Preoperative Imaging for Reconstructive Flap Planning
49

●
Markers or wireless handheld devices to transmit information
to the navigation system are noninvasive and easy to use.

●
Potential to be used during the operation, such that the
surgeon can have real-time visual guides when dissect-
ing out perforators and able to navigate through the sur-
rounding tissues in a “virtual surgery” fashion, improving
operative safety.
Guidelines

●
In the ducial marking technique, navigation markers are
placed on xed bony landmarks, such as the anterior supe-
rior iliac spines (ASIS) and greater trochanters.

●
CTA or MRA is performed with the same protocol as men-
tioned in previous sections.

●
Thin axial im ages are load into the stereotactic nav-
igation software. The images are reconstructed in a
three-dimensional and multiplanar fashion.

●
At operation:

●
Patient is placed in the same position as during the
radiological scan.

●
Again, in the ducial marking technique, the markers
are placed on the same landmarks as used during scan-
ning for calibration (“registration”).

●
For soft touch and Z-touch techniques, markers are not
required. Instead calibration is performed using the
wireless handheld devices.

●
In all three techniques: Localization of perforators is
done by maneuvering the pointer to each perforator as
displayed on the navigation station.

Dynamic Infrared
Thermography
The term dynam ic infrared therm ography, or DIRT, was coined by
De Weerd et al. to describe the technique of infrared therm og-
raphy in which a thermal challenge (warm or cold) is applied
to a particular body region, and the degree, rate, and pattern of
temperature change toward equilibrium (room temperature) are
registered with the infrared camera. An analysis of the rate and
pattern of rewarming is then used as an indicator of the underly-
ing skin and subcutaneous tissue perfusion.
The use of infrared thermography in medicine was initially
adapted from the principle that an increase in body temperature
causes a higher am ount of radiation to be em itted. This is thus a
phenomenon observed in the presence of increased vascularity,
which is a hallmark of many pathological changes such as in am -
mation or neoplasms with increased metabolic activity, and, in
particular, the presence of higher ow and larger caliber cutane-
ous vessels. This is the basis for the use of DIRT in reconstructive
ap planning.
The use of DIRT in assessing and mapping perforators in pre-
operative ap reconstructions has been explored relatively wide-
ly to date, with eight high-quality publications that include six
prospective clinical studies reported. All these studies use a sim -
ilar type of DIRT camera and analytical software. Theuvenet et al.
In the literature, the use of a stereotactic device can provide
accurate inform ation regarding perforator position, potential-
ly in excess of CTA or MRA imaging alone. Rozen et al. has used
this technique to identify perforators of the DIEP and ALT aps,
and showed a 100% correlation in DIEP and 98.4% in ALT perfo-
rators with a discrepancy of location reaching 2 mm in location
of the actual perforators. These studies highlighted that the use
of CT-guided stereotaxy with ducial m arkers is not only a reli-
able and accurate method for preoperative ap planning, but can
be associated with the additional bene ts of surgeon safety and
operative mapping.
Soft Touch Registration and
Z-Touch Surface Matching
Registration
These two techniques utilize a wireless handheld device that col-
lects data points on the patient’s skin. In the soft touch technique,
the registration is m ade by using a “soft touch pointer,” equipped
with two navigation points attached to the device. The two nav-
igation points signal its position, which is picked up by an over-
head digitizer. The digitizer, which is mounted to the navigation
station, detects the m ovem ent of the two navigation points and
displays the information on the monitor.
Z-touch provides a touchless registration, through automatic
recognition of laser re ections by infrared cameras. This device
is swept over the skin of the patient with a visible laser detect-
ing surface contours, and the inform ation is transmitted directly
to the navigation system via infrared signal. These make patient
registration potentially quicker and easier by simply touching the
patient’s skin with either a pointer or a laser.
Because both devices register CTA and MRA images without
frames or markers, scans taken only for registration purposes can
be avoided, helping to reduce costs. However, these systems are
more di cult to use and are time-consum ing to operate and set
up. Furtherm ore, the use of surface landmarks with the handheld
device is felt to be less accurate than ducial marker registration.
Most of the surface m atching registration failed the registration
process in reported series, despite using multiple points, includ-
ing the sam e landm arks used with success during ducial m arker
registration.
Key Points

●
Image-guided stereotaxy provides precise demonstration
of the position of anatomical structures within the human
body in real time.

●
The principle is to superimpose preoperative im ages with
the patient in real time, using navigation technology.

●
Stereotaxy can provide a high degree of accuracy in both
sensitivity and speci city with a maximal discrepancy in
location of up to 2 mm.

●
Can be expensive and time consuming to set up.

●
Three techniques have been explored in ap reconstruction.

●
Fiducial marking and the articulated arm technique.

●
Soft touch registration.

●
Z-touch surface matching registration.

50
I Planning and Decision Making in Reconstructive Surgery

●
The therm al scale provided by the m anufacturer is able
to quantify increasing thermal activity and represent it in
color, from blue to red.

●
A series of single-frame images 10 seconds apart are taken
over a 5-minute period of rewarming to achieve this and
can highlight the precise location of perforators compared
to adjacent body landmarks.
Key Points

●
DIRT can be used as an alternative or in conjunction with
other diagnostic techniques to m ap and characterize per-
forators during ap design using the presence of hot spots.

●
DIRT has a similar sensitivity and speci city for perforator
localization as CTA when compared to operative ndings.

●
DIRT provides a qualitative assessment of perforators by
assessing true in vivo ow, which can provide additional
information when combined with CTA in ap planning:
able to optimally select the best ap, design the ap, and
aid dissection.
used DIRT in the evaluation of cadavers for the marking of perfo-
rators in the planning of harvesting free aps. The skin and sub-
cutis were dissected from the underlying fascia and muscle; and
31 out of 36 perforators that were detected by DIRT were located
during dissection. A further 16 living volunteers were evaluated
w ith cooling, exsanguination, and the use of tourniquet to eval-
uate perforator location. After the tourniquet was released, ther-
mographic hot spots were detected with DIRT.
Five publications (Itoh [1995], Salmi [1995], Zetterman
[1999], Kalra [2007], and De Weerd [2009]) evaluated the use of
DIRT to detect perforators in abdominal wall–based free aps.
Whitaker et al. provided a clear comparison of DIRT to other mo-
dalities, particularly CTA, highlighting the bene ts and pitfalls of
each modality. Chijiwa et al. used infrared thermography to create
a facial map of perforators to enable planning of aps of the face.
In all of these studies, the subjects’ skin was cooled and allowed
to rewarm while the thermal images were recorded. Two of these
publications (Salmi [1995] and Kalra [2007]) further analyzed the
use of DIRT to evaluate DIEA perforators intraoperatively, with
both reporting a decrease in temperature of 3.4 6 1.05°C of the
whole ap from the reference point (p , 0.05) detected by DIRT,
after ligation of the pedicles during ap harvest. De Weerd et al.
also observed the rate and pattern of rewarming of the hot spots
to represent quality of the perforators. A hot spot (reperfusion)
that produces a rapid rewarming for a larger area is preferable for
ap reconstruction.
Technique

●
A range of techniques have been described to optimize
digital thermographic photography. Over the last 20 years,
there have been calls for increased standardization of pro-
cedures, including changes in patient preparation (cold
challenges) and body positioning for im age recording.
Ammer has described a total of 24 body positions and
90 regions of interest, with the construction of a clinical
database of reference therm ographic im ages designed as
a reference tool. Ammer showed that such standardization
can have a signi cant in uence on the accuracy of m ea-
surements obtained from DIRT images. Despite this, there
is currently no widely accepted system or standardized
values from which any standardized thermal pro les of the
human body can be matched.

●
There is similarly a range of therm al infrared cameras avail-
able. One with which we have achieved good outcomes is
the Therm o Tracer TH 7800 (NEC Avio Infrared Technolo-
gies, Tokyo, Japan).

●
Thermal im ages are only begun after 10 m inutes of a cold
challenge using a water pack at 5°C. This creates a broad
cold region, with progressive vascular lling able to show
the presence of hot spots (Fig. 3.6).

●
These hot spots con rm the presence of all of the dom -
inant perforators, and the sequence of lling can give an
idea as to the relative dominance of each.

●
Thermographic im ages are taken beginning 1 minute af-
ter removal of a cold challenge. Arterial perforators are
rewarmed in a pattern that highlights their relative domi-
nance and distribution.
Fig. 3.6 DIRT. (a) Computed tomographic angiogram (CTA) of the ab-
dominal wall vasculature, highlighting the location of deep inferior epi-
gastric artery (DIEA) perforators. (b) Digital thermographic photograph
of the abdominal wall of the same patient, demonstrating concordance
in localizing perforators. The thermographic image was taken 1 minute
after removal of a cold challenge. Arterial perforators have preferentially
rewarmed the skin in a pattern that highlights their distribution. The scale
on the right demonstrates increasing thermal activity from blue to red.4
a
b

3 Preoperative Imaging for Reconstructive Flap Planning
51
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324–325

●
DIRT is performed by the surgeon, eliminating the need for
third-party reporting.

●
DIRT provides an accurate, inexpensive method for perfo-
rator mapping in ap planning.

●
DIRT can additionally be used for postoperative ap
monitoring.
Guidelines

●
DIRT camera: Thermo Tracer TH 7800 (NEC Avio Infrared
Technologies, Tokyo)

●
Period of cooling: 10 minutes

●
Cooling technique: ice-water pack, cooled to 5°C

●
Rewarming technique: exposure to ambient temperature
(passive)

●
Photographic technique: single frame images, taken 10 sec-
onds apart over complete period of rewarming (approxi-
mately 5 minutes)

●
Scale: thermal scale is supplied with cam era software for
quantitative analysis of hot spots
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Itoh Y, Arai K. Use of recovery-enhanced thermography to localize
cutaneous perforators. Ann Plast Surg 1995;34(5):507–411
Kalra S, Dancey A, Waters R. Intraoperative selection of dom inant per-
forator vessel in DIEP free aps based on perfusion strength using
digital infrared thermography – pilot study. J Plast Recon Aesthet
Surg 2007;60(12):1365–1368

52
psychosocial e ects of the various options. Cederna et al. investi-
gated whether or not the type of reconstruction performed, autol-
ogous versus prosthetic, had an e ect on psychosocial outcomes.
They were not able to dem onstrate a statistically signi cant dif-
ference in body image or overall satisfaction between the two
options. However, in patients having autogenous reconstruction
with the transverse rectus abdominis musculocutaneous (TRAM)
ap, patients reported increased satisfaction with the look and
feel of their reconstructed breasts. Thus postmastectomy recon-
struction can provide excellent results in term s of patient satis-
faction and quality of life regardless of the option selected.

Assessment
Selecting the appropriate operation to achieve a desirable cos-
metic and functional outcom e in breast reconstruction patients
is dependent upon a variety of factors. These factors can be cat-
egorized as patient-related, cancer-related, and surgeon-related.
Patient factors include breast size, volume, and contour as well
as body weight and habitus. Included in this category is an as-
sessment of patient expectations. Oncologic factors include tu-
mor size, cancer stage, previous or future adjuvant therapies,
and whether the reconstruction should be immediate or delayed.
Surgeon-related factors are based on the fact that not all surgeons
perform the same reconstructive procedures. Most surgeons will
have an inherent bias toward one or more procedures that may
be based on technical abilities and experience.
The initial consultation is usually the rst opportunity for
surgeons and patients to meet. A pertinent history and physical
exam ination is perform ed with docum entation of several im-
portant details that include facts related to the cancer, past med-
ical and surgical history, and documentation of body mass index.
A physical examination of the breasts and possible donor sites is
necessary. A review of the options, risks of the procedures, and
recovery times is performed. It is recommended that patients re-
view photographs of the surgeon’s work and understand what
constitutes a good, average, and poor outcom e. Well-educated
patients with realistic expectations will facilitate the reconstruc-
tive process and hopefully improve patient satisfaction.

Reconstructive Options
The options for breast reconstruction following mastectomy are
diverse. Some procedures are relatively simple whereas others are
more complex. Although patients m ay have sim ilar characteris-
tics, each is unique when all factors are taken into consideration.

Introduction
Breast reconstruction following mastectomy has become an inte-
gral part of the management algorithm for women diagnosed with
breast cancer. This paradigm shift has been globally appreciated
and due in part to several oncologic and reconstructive advance-
ments. Prior to 1990, the prevailing thought was that immediate
breast reconstruction was not safe and should be avoided. The
reasons for this included the risk of local recurrence, interference
and delay with adjuvant therapies, and compromised surveil-
lance. These concerns have been addressed and studied in numer-
ous clinical trials, and it is now well documented that immediate
reconstruction does not delay the administration of adjuvant ra-
diotherapy or chemotherapy and that there are no signi cant dif-
ferences in the rates of local recurrence, local-regional recurrence,
or distant metastasis. Clinical studies have also demonstrated that
the ability to detect a recurrence in a reconstructed breast is not
compromised and that survival rates are not adversely a ected by
performing breast reconstruction. Current recommendations are
that the majority of women diagnosed with breast cancer are can-
didates for immediate breast reconstruction.
The bene ts of breast reconstruction following m astectomy
are becoming increasingly appreciated. Breast reconstruction
can improve a wom an’s sense of identity and self-esteem . Wom -
en undergoing m astectomy are at risk of experiencing a variety
of negative emotions that include feelings of mutilation, altered
body image, diminished self-worth, loss of femininity, decrease
in sexual attractiveness and function, anxiety, depression, hope-
lessness, guilt, shame, fear of recurrence, and abandonment.
Although the decision of whether or not to pursue breast re-
construction is personal, it is prudent for healthcare providers
to explain that breast reconstruction has been shown to have a
signi cantly positive impact on patients’ quality of life and psy-
chosocial well-being following mastectomy.
When discussing and reviewing oncologic and reconstructive
options, surgeons and healthcare providers should have an in-
depth understanding of the risks and bene ts associated with each.
In patients deciding between breast conservation therapy (BCT)
and mastectomy with reconstruction, it is important to review
the relative pros and cons. Although BCT is the most commonly
performed therapeutic maneuver, there are aesthetic sequelae
that may be undesirable. Although most patients following BCT
will have acceptable cosmetic outcomes, it has been demonstrated
that skin-sparing mastectomy with immediate breast reconstruc-
tion can enhance cosmetic outcomes with equivalent quality of life
when compared to breast conserving surgery.
Once the decision to pursue m astectomy with reconstruc-
tion has been m ade, the healthcare team should review potential
Current Options for Breast Reconstruction
Following Mastectomy
Matthew R. Endara and Maurice Y. Nahabedian
4

4 Current Options for Breast Reconstruction Following Mastectomy
53
breast cancer. The reconstruction can be performed in one or
two stages based on breast characteristics, patient preference,
and surgeon recommendation. It can be performed using tissue
expanders and implants as well as silicone gel or saline- lled
devices. Although prosthetic reconstruction seems simple and
straightforward, there are m any important details that m ust be
appreciated in order to achieve predictable and reproducible
outcomes.
Deciding on the speci c technique for prosthetic reconstruc-
tion requires appreciation of oncologic and anatom ic factors. A
decision regarding nipple-areolar–sparing mastectomy (NSM) or
skin-sparing mastectomy (SSM) must be made. In general, the
criteria for candidates for NSM include:

●
Tumors , 2.5 cm in diameter

●
Tumors . 3.0 cm from the nipple-areolar complex

●
No previous radiation

●
No tobacco use

●
No angiolymphatic invasion
Single-stage reconstruction with a permanent implant is gen-
erally performed on women with mild to moderate volume breasts
in the setting of NSM but can also be performed in women with
larger breasts in the setting of SSM. Two-stage reconstruction is
performed more often in the setting of immediate and delayed re-
construction and can be useful for women with a variety of breast
sizes and volumes. Delayed reconstruction is usually recommend-
ed for women who are morbidly obese, use tobacco products, and
have mastectomy skin aps of questionable viability. The use of
acellular dermal matrices has been very helpful in both one- and
two-stage prosthetic reconstructions.
The most common method of prosthetic reconstruction is
the two-stage technique (Fig. 4.1). A tissue expander is placed in
The goal of the reconstructive surgeon should be to o er an
option that has a high probability of success. This underscores
the importance of appropriate dialogue regarding the risks and
complications associated with a given procedure in a given
patient. Reconstructive techniques are categorized as prosthet-
ic or autologous. The indications for each are listed in Table 4.1.
A review of the various options is provided.
Expander/Implant Reconstruction
Breast reconstruction using prosthetic devices is arguably the
most com m on reconstructive option selected by wom en with
Table 4.1 An algorithm for deciding upon prosthetic or
autologous reconstruction
Factor
Autologous
Prosthetic
A, B, C, D cup
Yes
Yes
Unilateral / bilateral
Yes
Yes
Elderly (. 65 years)
Yes
Yes
Immediate (no RT)
Yes
Yes
Immediate (preop RT)
Yes
Maybe
Immediate (postop RT)
No
Yes
Delayed (no RT)
Yes
Yes
Delayed (previous RT)
Yes
No
Morbid obesity (BMI . 40)
Maybe
Maybe
Active tobacco use
No
No
Abbreviations: BMI, body mass index; RT, radiation therapy.
Fig. 4.1 The two-stage technique of prosthetic reconstruction with partial muscle coverage is illus-
trated. The upper two-thirds of the tissue expander is in the subpectoral position. The lower one-third
of the tissue expander is in the subcutaneous position.

54
I Planning and Decision Making in Reconstructive Surgery
Fig. 4.2 The tissue expanders are removed and replaced with permanent implants at the second stage.
the subpectoral position at the tim e of mastectomy followed by
serial expansion over the next several weeks. Once the expansion
is complete, the device is exchanged for a perm anent implant. In
patients who do not require postoperative adjuvant therapy, the
exchange will typically occur after 3 m onths (Fig. 4.2). In patients
who require postoperative radiation therapy, decisions regarding
device exchange or conversion to a ap must be made. This de-
cision will be based on quality of the tissues and patient prefer-
ence. When converting to an implant, the exchange is typically
performed 6 to 12 weeks follow ing radiation therapy (Fig. 4.3).
This is during the subacute phase of tissue healing, which pre-
cedes the development of permanent brosis. It is theorized that
Fig. 4.3 (a) Algorithm that includes reconstructive pathways based on the indications for
adjuvant therapies. (continued)
a

4 Current Options for Breast Reconstruction Following Mastectomy
55
Free Flaps
Lumbar perforator
DCIA (Rubens)

TR AM/ DIEP/ SIEA
Gracilis/ TUG
Gluteus/GAP
Rectus abdominis
Latissimus
dorsi flap
Latis
dors
Pectoralis
major flap
Intercostal artery
perforator (ICAP) flap
IV
IIIIIIIIIIIIIIIIII
I
III
Rectus abdominis
(TRAM) flap
Fig. 4.3 (continued) (b) Breast reconstruction options.1
b

56
I Planning and Decision Making in Reconstructive Surgery
during this interval, permanent and dis guring changes related
to the radiation therapy may be reduced.
An alternative to the two-stage method is one-stage recon-
struction in which a permanent implant is placed at the tim e of
the m astectomy (Fig. 4.4). One-stage reconstruction is typical-
ly reserved for wom en with sm all to m oderate breast volum e,
although it can be performed in women with larger breasts as
well. Usually these are women who have also decided to have
nipple-sparing mastectomy. In the majority of patients, the
one-stage technique avoids the need for secondary procedures
assuming that patient and device selection protocols have been
optimized. The technical aspects of the procedure may be facili-
tated using acellular dermal matrix, which will be discussed.
One of the controversies in regard to prosthetic reconstruc-
tion is focused on device location. The two options for device
placement include total muscle coverage and partial muscle cov-
erage. Total muscle coverage includes the pectoralis major and
occasionally includes the superior rectus abdominis or serratus
anterior muscles (Fig. 4.5). Advocates of this approach will cite
less infection and seroma, whereas critics will cite a more fre-
quent comprom ise in the cosmetic appearance because of lower
pole constriction with subsequent superior displacement of the
device.
The alternative to total muscle coverage is partial muscle
coverage. With this technique, the pectoralis major m uscle (up-
per two-thirds) and the lower mastectomy skin ap (lower one-
third) cover the device (Fig. 4.1). The bene ts include improved
control of the lower pole with enhanced projection but the draw-
backs include the possibility of rippling and wrinkling due to thin
mastectomy skin ap or device exposure in the event of delayed
healing.
In response to the shortcom ings of standard partial m uscle
coverage, surgeons have used bioprosthetic mesh or acellular
derm al matrix (ADM) (Fig. 4.6). These ADMs will provide addi-
tional tissue support to the lower mastectomy skin ap. It wall
also secure the inferior edge of the pectoralis m ajor muscle and
anchor it to the infram amm ary fold (Fig. 4.7). The biology of
these acellular dermal m atrices is that they w ill repopulate with
host broblasts and blood cells. They have regenerative proper-
ties that make them attractive for this purpose.
Speci c bene ts of ADM include increased initial expan-
sion, more rapid postoperative expansion, compartmentaliza-
tion of the prosthetic device, and prevention of “window-shad-
ing.” Although most studies have demonstrated that the risk of
infection is not increased using ADM, some have dem onstrated
slightly higher rates of infection. In a recent meta-analysis, it was
demonstrated to not increase rates of infection, explantation, or
reconstructive failure in 916 reconstructions using partial mus-
cle coverage and ADM compared to 3,814 reconstructions using
total muscle coverage or partial muscle coverage without ADM.
There was noted to be a higher rate of serom a form ation in the
ADM group (4.3% versus 8.4%, p 5 0.03). Figs. 4.8 and 4.9 dem on-
strate a patient before and after bilateral m astectomy and two-
stage prosthetic reconstruction using ADM.
Complications follow ing prosthetic breast reconstruction in-
clude but are not limited to capsular contracture, device rupture,
device extrusion, and device malposition. Other complications in-
clude infection, skin ap necrosis, and delayed healing. Adjuvant
Fig. 4.4 The one-stage technique of prosthetic reconstruction is illustrated.
A permanent implant is placed in the partial subpectoral position.

4 Current Options for Breast Reconstruction Following Mastectomy
57
Fig. 4.5 This  gure illustrates the total muscle coverage technique. Note that the device is complete-
ly covered by the pectoralis major muscle. The inferior origin of the muscle has not been released.
Fig. 4.6 A sheet of acellular dermal matrix is depicted. The material has polarity with a dermal and basement
membrane side. The dermal side is seen in this photograph.

58
I Planning and Decision Making in Reconstructive Surgery
radiation, obesity, tobacco use, and compromised vascularity can
increase the risk of complications. Salvage of a failing prosthetic
reconstruction is dependent upon prompt diagnosis and early in-
tervention. On average, prosthetic failure will increase at a rate of
1% to 2% per year.
Autologous Reconstruction
There have been signi cant advancem ents with autologous re-
construction over the past several years. During the 1970s, use of
the latissim us dorsi ap was described, and wom en were o ered
Fig. 4.7 This  gure illustrates the appearance of the partial muscle coverage technique using 
acellular dermal matrix (ADM). Note that the inferior origin of the pectoralis major muscle has
been released and secured with the ADM.
Fig. 4.8 Preoperative photograph of a woman prior to bilateral skin-sparing mastectomy.

4 Current Options for Breast Reconstruction Following Mastectomy
59
ap. Advantages of pedicled aps include its relative simplicity,
lesser time requirement, and good to excellent outcomes. The
disadvantages of the TRAM ap are related to donor site. Total or
subtotal muscle sacri ce may compromise abdominal function
and increase the risk of a hernia or bulge.
The latissimus dorsi ap (LD ap) is an excellent option for im-
mediate or delayed autologous reconstruction. This ap is some-
what limited because it is usually insu cient in terms of volume
and is often performed in conjunction with an implant or tissue
expander. It remains a good option alone for smaller breasts or for
partial breast reconstruction, in addition to salvage. For smaller
defects, especially if muscle cover is not needed over a prosthe-
sis, then the thoracodorsal artery perforator ap (TAP ap), which
spares the LD muscle, is an alternative in some circumstances.
Other advantages of autologous reconstruction include the
variety of donor sites. Although the donor site options for free
tissue transfer are greater than with pedicled aps, the preferred
donor site for both is usually the abdomen. Speci c advantag-
es of the abdom en include the availability of a large volum e of
well-vascularized tissue, the ability to adequately shape the ap
to mimic the natural breast, and an abdominoplasty-type ap-
pearance. Overweight or obese women may be at an increased
risk for complications regardless of the type of ap performed.
Multiple variants of abdominal free ap are currently in use.
Most techniques are based on the deep inferior epigastric vascu-
lar system as the source vessels (free TRAM and DIEP aps) with
the exception being the super cial inferior epigastric system (SIEA
ap). The classic free TRAM technique usually involves removal of
the entire width of the rectus abdominis muscle with its overlying
skin and fat. This technique, although reliable, is functionally similar
to the pedicle TRAM ap because the continuity of the rectus
abdominis muscle is disrupted, placing the patient at an increased
risk of abdominal weakness and contour abnormality.
the option of using their own tissues to create a new breast.
During the 1980s, the transverse rectus abdom inis m usculocuta-
neous (TRAM) ap revolutionized autologous breast reconstruc-
tion based on the improved cosmetic appearance of the breast
and the abdom en. During the 1990s, m icrovascular m usculocu-
taneous free tissue transfer began to gain m om entum prim arily
to improve ap vascularity and to minimize morbidity. During
the 2000s, microvascular perforator ap reconstruction made
signi cant strides primarily to reduce the m orbidities associated
w ith the donor sites.
The advantages of autologous reconstruction make this an
ideal option for some patients. Fortunately, there are multiple donor
sites available such that if one donor site is insu cient, another may
be considered. Available donor sites include the abdomen, gluteal
region, posterior thorax, and the inner and lateral thigh. Autologous
reconstruction, when successful, will last forever and usually im-
prove over time. In patients who have had radiation therapy prior to
breast reconstruction, autologous options are usually preferred be-
cause of the high failure rates associated with prosthetic devices in
the setting of radiation therapy. In patients who will have radiation
therapy following reconstruction, it is important to appreciate that
radiation therapy can have deleterious e ects. In these patients,
prosthetic devices are usually placed at the time of mastectomy and
before the radiation therapy in order to optimally expand the skin.
Recognizing that radiation therapy can have deleterious e ects on
all types of reconstruction, it is important to appreciate that the ra-
diated device can be exchanged for a ap when necessary whereas
a radiated ap is permanent and cannot be exchanged.
When evaluating a wom an for autologous reconstruction,
there are several important points to consider. These include tim -
ing, pedicle versus free, m usculocutaneous versus perforator, and
the donor site. Pedicled options for breast reconstruction are lim -
ited to the TRAM ap and the latissimus dorsi m usculocutaneous
Fig. 4.9 Postoperative photograph following two-stage bilateral breast reconstruction using prosthetic
devices and ADM.

60
I Planning and Decision Making in Reconstructive Surgery
The popularity of the DIEP ap has grown in recent years due
to its excellent donor site pro le. Although donor site morbidity
may be minimized with the DIEP ap, debate continues over the
actual improvement in activities of daily living when compared
to the muscle-sparing free TRAM. There is also concern regarding
the risk–bene t ratio. Because these perforator aps are based on
one or two perforators, there may be an increased risk of vascular
complications that include fat necrosis and failure. In addition, the
surgical skill and time required to perform these perforator aps
are generally greater than those of the musculocutaneous free or
pedicle aps. Comparative studies have demonstrated that the
MS-2 and MS-3 aps are equivalent in terms of muscle strength
and abdominal contour in the unilateral setting. In bilateral
In response to these donor site complications, several modi -
cations have been made. The muscle-sparing free TRAM techniques
remove only the portions of the muscle required to ensure the mus-
culocutaneous perforators are preserved, without the need to re-
move the entire muscle. A classi cation system has been previously
described that distinguishes between the various muscle sparing
(MS) techniques based on the degree and location of muscle har-
vest. The MS-0 free TRAM incorporated the entire width of the re-
cuts muscle (Fig. 4.10). The MS-1 free TRAM preserves the lateral
or medial segment of the rectus abdominis muscle (Fig. 4.11).
The MS-2 free TRAM preserves the medial and lateral seg-
ments of the rectus abdominis muscle (Fig. 4.12). The MS-3 or
DIEP ap preserves the entire muscle (Fig. 4.13).
Fig. 4.10 An MS-0 free TRAM  ap is harvested, incorporating the entire width of the rectus abdominis muscle.
Fig. 4.11 An MS-1 free TRAM  ap is harvested preserving the lateral aspect of 
the rectus abdominis muscle.

4 Current Options for Breast Reconstruction Following Mastectomy
61
Fig. 4.12 An MS-2 free TRAM is depicted that includes only the central segment of
the rectus abdominis muscle. The lateral and medial segments of the muscle are pre-
served in situ.
Fig. 4.13 An MS-3 or DIEP  ap is harvested that includes no muscle. All three segments (medial, central, 
and lateral) of the rectus abdominis muscle are preserved.

62
I Planning and Decision Making in Reconstructive Surgery
comprom ise abdom inal function because there is no fasciotomy
of the anterior rectus sheath and there is no myotomy of the rec-
tus abdom inis m uscle. Thus it is a true “abdom inoplasty ap.”
Limitations of this ap are that the super cial inferior epigastric
vessels are not present or of suitable caliber in the m ajority of
patients. In addition, the perfusion capacity of these vessels is
generally less than the deep system, often limiting the SIEA to a
hemi- ap. This ap is ideal in women of moderate body habitus,
with suitable vessels, who desire bilateral reconstruction.
The decision as to whether to perform a m usculocutaneous
ap (free TRAM) or a perforator ap (DIEP, SIEA) is based on spe-
ci c patient factors as well as surgeon experience. The algorithm
currently in use by the senior author is based on breast volume
requirement, quantity of abdom inal fat, and the number and cal-
iber of the perforators (Table 4.3).
Although the nal assessment of perforator quality and
number is made at the time of harvest, ancillary procedures can
be performed preoperatively to assist with the decision. Com -
puted tomographic angiography, magnetic resonance angiogra-
phy, and duplex ultrasound have been used for this purpose and
have demonstrated high rates of e cacy. Of these modalities,
CTA appears to be the most feasible at identifying and localizing
perforators through the anterior abdominal wall and is becoming
increasingly performed (Fig. 4.17).
Another modality that is currently in use is uorescent
angiography or SPY (LifeCell Corporation, Branchburg, NJ).
cases, the MS-3 techniques confer a slight advantage (Table 4.2).
Figs. 4.14 and 4.15 demonstrate a patient following bilateral DIEP
ap reconstruction.
The nal abdominal free ap is the super cial inferior epi-
gastric artery (SIEA) perforator ap (SIEP) (Fig. 4.16). This ap
is included in the category of perforator ap; however, the vas-
cular pedicle does not perforate a muscle; rather, it traverses in
the subcutaneous layer. The bene t of this ap is that it does not
Table 4.2 The morbidities associated with free TRAM and
DIEP aps
Factor
DIEP
Free TRAM
Fat necrosis
7.3%
7.1%
Venous congestion
4.5%
2.7%
Flap failure
2.7%
1.8%
Abdominal bulge
Unilateral
4.5%
5%
Bilateral
6.5%
21%
Sit-ups
Unilateral
100%
97%
Bilateral
95%
83%
Fig. 4.14 Preoperative photograph prior to autologous reconstruction.

4 Current Options for Breast Reconstruction Following Mastectomy
63
Fig. 4.15 Postoperative photograph following bilateral breast reconstruction with DIEP
aps.
Fig. 4.16 A photograph of a hemi SIEA  ap is shown. There is no incision into the anterior rectus 
sheath.

64
I Planning and Decision Making in Reconstructive Surgery
areas of su cient and insu cient perfusion. Relative perfusion
gradients can be calculated to aid in determining optimal perfu-
sion (Fig. 4.18). Poorly perfused areas can be identi ed intraop-
eratively and excised to m inim ize the incidence of fat necrosis,
partial ap necrosis, and delayed healing (Fig. 4.19).
In cases where the abdomen is not a suitable donor site, al-
ternative donor sites are considered. These include the gluteal
and inner thigh regions (Fig. 4.20). The gluteal region includes
the superior gluteal artery perforator (SGAP) and the inferior
gluteal artery perforator (IGAP) aps. The challenge with these
aps is that they can be more di cult because the vascular ped-
icle has less length and caliber. In some patients, donor site con-
cerns related to abnormal contour can be problematic. The SGAP
can scallop the upper buttock and the IGAP can result in delayed
healing or postoperative pain due to the proximity of the sciatic
nerve.
The transverse upper gracilis m usculocutaneous (TUG)
ap (also known as TMG, transverse myocutaneous gracilis) is
another option for women who lack su cient abdominal tissue
or who prefer the inner thigh as the donor site. This ap usually
provides 300 to 600 g of tissue and is useful for women with mild
to moderate volume requirements. Some surgeons feel that this
ap is more malleable than the abdominal or gluteal aps that can
facilitate insetting and shaping of the breast. The main disadvan-
tage of this ap is its propensity toward donor site complications
that include lymphedem a, seroma, and delayed healing. Reports
in the literature are as high as 25%. Once healed, however, the ul-
timate appearance of the donor site appears to be satisfactory to
This is being used intraoperatively to help discern tissue perfu-
sion characteristics and to assist with de ning vascular territo-
ries. Fluorescent angiography utilizes an intravenous injection of
indocyanine green (ICG) dye and illum ination of the ap with an
806 nm laser that w ill stim ulate the ICG to uoresce. This uores-
cence is captured using cameras and computers then electroni-
cally formatted and illustrated on a computer monitor. The cap-
tured perfusion patterns on the skin surface will help delineate
Table 4.3 An algorithm for selecting abdominal aps
based on volume, quantity, and perforator number and
caliber
Factor
Free TRAM
DIEP
SIEA
Breast volume requirement
, 800 mL

1 /2

1

1 /2
. 800 mL

1

1 /2

2
Abdominal fat
Mild2 moderate

1 /2

1

1 /2
Severe

1

1 /2

2
Perforators . 1.5 mm
0

1

2

2
. 1

1 /2

1

1 /2
Fig. 4.17 A CT angiogram demonstrating patency of the inferior epigastric vascular system.

4 Current Options for Breast Reconstruction Following Mastectomy
65
Fig. 4.18 An intraoperative image of  uorescent angiogram demonstrating the perfusion charac-
teristics of an abdominal  ap. Zone 4 is poorly perfused.
Fig. 4.19 The lateral region of the abdominal  ap to be excised based on the  uorescent angiography measurements.

66
I Planning and Decision Making in Reconstructive Surgery
Fig. 4.20 An SGAP  ap is harvested from the upper gluteal region.
patients as it is the same incision pattern as with traditional me-
dial thigh lifts. Autologous fat transfer is out of the scope of this
text, but is worthy of mention as it certainly has a role for general
reconstruction as well as “space lling” and general contouring.
Disadvantages include the multiple treatment sessions required,
inconsistent and unpredictable results, and the potential for tu-
mor recurrence-simulating rm areas of fat necrosis.

Decision Making
Decisions regarding reconstructive options can be di cult for patients
because of the various options and the di erence in recovery times.
Those patients who desire a quick recovery with minimal downtime
as well as those with insu cient donor sites for autologous recon-
struction are usually good candidates for prosthetic reconstruction.
In women who wish to avoid having prosthetic material implanted
into their body and who have su cient donor site tissue, autologous
reconstruction may be preferred. Although volume requirements
are a signi cant factor, it is important to realize that autologous or
prosthetic reconstruction can be safely and e ectively performed in
women with a variety of breast sizes and shapes (Table 4.1).
The need for adjuvant therapy is another consideration when
deciding upon breast reconstruction. Surgeons must explain
that some adjuvant therapies can be associated with additional
morbidities. In patients who have had radiation therapy prior to
mastectomy, autologous reconstruction may be preferred if the
quality of the breast skin is suboptimal. These patients may be
prone to further morbidity in the setting of prosthetic reconstruc-
tion that includes capsular contracture, infection, and premature
removal of the device. In patients who will receive radiation ther-
apy following the mastectomy, prosthetic reconstruction is usu-
ally preferred in this author’s practice. This is because autologous
reconstruction may be adversely a ected by the radiation. These
changes can include fat necrosis and shrinkage that tend to progress
over time. The concept of “delayed-immediate” reconstruction has
been popularized for these reasons. Following the mastectomy,
a tissue expander is inserted in the partial or complete muscu-
lar space. Following the radiation therapy, the temporary tissue
expander is removed and exchanged for a ap or implant based on
the degree of soft tissue damage and patient preference.

Conclusion
Although options for breast reconstruction following mastectomy
have expanded, the decision-making process can be di cult.
Having a diverse skill set can facilitate this process by being able
to o er all options based on the patients’ physical characteris-
tics and expectations. Optimal patient outcomes can be achieved
with proper patient selection. It is important for surgeons to un-
derstand not only the reconstructive options but also when best
to apply them and to properly counsel patients regarding these
options and possible outcomes.

4 Current Options for Breast Reconstruction Following Mastectomy
67
Johnson CH, van Heerden JA, Donohue JH, et al. Oncological aspects of
im mediate breast reconstruction following mastectomy for malig-
nancy. Arch Surg 1989;124:819–823; discussion 823–824
Jugenburg M, Disa JJ, Pusic AL, et al. Impact of radiotherapy on breast re-
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Ann Plast Surg 2008;60:244–250
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476–477
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m ediate autologous breast reconstruction compared to breast con-
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with breast cancer. Cancer 1991;67:1097–1117

68
I Planning and Decision Making in Reconstructive Surgery
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thesis: a single surgeon’s 15-year experience with 69 patients. Plast
Reconstr Surg 2010;125:1074–1084
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17–21
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chosocial outcom es in breast reconstruction: one-year postoper-
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Study. Plast Reconstr Surg 2000;106:1014–1025; discussion
1026–1017
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SIEA, DIEP, and muscle-sparing TRAM aps for breast reconstruc-
tion. Plast Reconstr Surg 2008;122:702–709
Zienowicz RJ, Karacaoglu E. Implant-based breast reconstruction with
allograft. Plast Reconstr Surg 2007;120:373–381
Figure Credits
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Reconstr Aesthet Surg 2010;63:289–297
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ning of deep inferior epigastric artery perforator aps: magnetic
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thetic breast reconstruction versus complete submuscular cover-
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2009;124:1735–1740
Sbitany H, Serletti JM. Acellular dermis-assisted prosthetic breast recon-
struction: a systematic and critical review of e cacy and associated
m orbidity. Plast Reconstr Surg 2011;128:1162–1169
Schoeller T, Huem er GM, Wechselberger G. The transverse m usculocuta-
neous gracilis ap for breast reconstruction: guidelines for ap and
patient selection. Plast Reconstr Surg 2008;122:29–38
Schoeller T, Wechselberger G. Breast reconstruction by the free transverse
gracilis (TUG) ap. Br J Plast Surg 2004;57:481–482
Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing the func-
tional impact of SIEA, DIEP, and muscle-sparing free TRAM aps on
the abdom inal wall: Part II. Bilateral reconstruction. Plast Reconstr
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Selber JC, Samra F, Bristol M, et al. A head-to-head comparison between
the muscle-sparing free TRAM and the SIEA aps: is the rate of ap
loss worth the gain in abdominal wall function? Plast Reconstr Surg
2008;122:348–355

Current Options for Perineal
Reconstruction
Sachin M. Shridharani, Raja Mohan, and Justin M. Sacks
5
69

Introduction
Wounds of the perineum pose challenging problems for the
plastic and reconstructive surgeon. Besides matching the quality
of native tissue, many other considerations must be taken into
account. One such consideration is the need to restore durable
tissue to the perineum due to daily “wear and tear.” Individuals
spend much of their lives in seated and lying positions, which
directly apply pressure to the soft tissue encasing the pelvis/
perineum. Perineal defects and wounds requiring reconstruction
are generally associated with malignancy and result from extir-
pative resection. The wounds that result from these conditions
are generally in irradiated beds and are in a location subject to
ischem ia, pressure, and shear forces. In addition, wounds also
result from direct trauma and long-term pressure necrosis phe-
nomenon. These factors make it more challenging to reconstruct
these defects successfully. However, there are multiple options
that can be implemented depending on the type of defect, and
this chapter delineates how to assess such wounds and recon-
struct them.

Assessment
When devising an algorithm on how to reconstruct perineal de-
fects, there are certain considerations that m ust be accounted
for prior to attempting any type of ap or procedure. A thorough
review of m edical com orbidities should be performed—
especially as it relates to obesity, diabetes, im munosuppression,
malnutrition, and smoking history. All of the aforem entioned
factors can impair wound healing and lead to worse outcomes
for the patient. Furtherm ore, every patient’s nutritional status
should be optim ized preoperatively to m inim ize wound healing
complications.
A thorough history of the patient’s prior radiation therapy
and chemotherapy course must be obtained. Patients in need of
future radiotherapy are candidates for ap coverage of perineal
defects as bringing in autologous tissue into these defects w ill
optimize wound healing. Alternatively, the persistent presence of
open wounds will often preclude or delay time-critical neoadju-
vant therapies. Depending on the extensive nature of the onco-
logic resection, other surgical specialties may need to be involved
such as procedures involving reconstruction of the urological
system. Preoperative planning and communication are of para-
mount importance to avoid costly m istakes that m ay preclude a
reconstructive option. For example, the location of the planned
gastrointestinal ostomy may be placed in the proposed rectus
abdominis ap. The patient’s preoperative ambulatory status is
very important. Two of the m ajor workhorses of perineal recon-
struction are the vertical rectus abdominis myocutaneous ap
(VRAM) (Figs. 5.1 and 5.2) and the anterolateral thigh ap (ALT)
(Fig. 5.3). Both are pedicle aps and both can compromise ambu-
latory function with trauma being in ected upon the abdominal
wall and thigh, respectively. Mobility and immobility can both be
disadvantageous in any form of reconstruction. Immobility can
comprom ise the reconstruction from pressure necrosis and local
ischemia. On the other hand, m obility increases the risk of dehis-
cence and tissue shearing.
Reconstruction with local or distant aps is better suited for
patients who have failed treatment with conservative measures.
Free tissue transfer for perineal defects is reserved for cases with
very extensive skin and subcutaneous tissue defects without any
available local options. These are extremely rare situations. Mul-
tiple scars, the presence of stulas, or poor tissue quality m ay
prevent the use of local or pedicled options. Pedicled aps and
free tissue transfer are recom mended for patients with irradiated
or infected wounds. Distant pedicled aps and free tissue transfer
provide recruitment of uninjured, healthy, vascular tissue not in
the zone of injury that can withstand the negative e ects of ra-
diation therapy when regional options are not available. Infected
wounds should be appropriately treated with aggressive opera-
tive debridem ent and species-speci c directed antibiotic therapy
prior to performing the nal reconstruction. Irradiated or infect-
ed wounds rarely heal by secondary intention.
Fig. 5.1 Vertical rectus abdominis myocutaneous  ap.1

70
I Planning and Decision Making in Reconstructive Surgery

Reconstructive Options
After the initial assessment is made and careful consideration
given, the reconstructive surgeon needs to formulate a plan that
will lead to optimal healing. Often in the case of perineal defects
that have been previously irradiated, it is important to recruit
local well-vascularized tissue. In very rare cases, especially in
smaller wounds, it is possible to close the wound primarily. The
next simplest option is to use rotational aps or V-Y advance-
ment aps for very sm all defects. However, based on size, cavi-
tary defects of the wound, and previous or future irradiation, it
is not appropriate to close these defects prim arily as they will
dehisce. In instances where the defect is too large for primary
closure, previously irradiated, or a secondary procedure, local
muscle-only, myo-, fascio-, or adipocutaneous pedicled aps are
the next best option to reliably reconstruct the defect. As with
most radiated wound beds, vascularized, healthy tissue confers
the optimal chance of wound healing.
There are m ultiple options to reconstruct perineal defects.
The most commonly used aps include:

●
Gracilis myocutaneous ap

●
Rectus abdominal ap (vertical/oblique)

●
Posterior thigh ap

●
Groin ap

●
Pudendal (Singapore) ap

●
Rectus femoris ap

●
Vastus lateralis ap

●
Anterolateral thigh ap

●
Deep inferior epigastric ap

●
Radial forearm ap
The choice of ap depends on the size, depth, and location
of the defect. After assessing these three factors, the best ap
can be chosen to close the defect. An algorithm proposed in a
recent review suggested di erent options depending on the
size of the defect. The algorithm was as follows: sm all defects
(less than 20 cm 2), local transposition aps; m edium -size de-
fects (20 to 60 cm 2), gluteal thigh or pedicled gracilis ap; and
larger defects (greater than 60 cm 2), vertical rectus abdom inis
myocutaneous (VRAM)/oblique rectus abdom inis m usculocu-
taneous (ORAM). Fig. 5.4 demonstrates a simple algorithm on
how to approach these defects. No random ized controlled tri-
als have been perform ed to assess which types of aps have
Fig. 5.2 Identi cation of the vascular pedicle: 1, rectus abdominis mus-
cle; 2, sheath of rectus; 3, deep inferior epigastric artery; 4, arcuate line.1
Fig. 5.3 Perforator detection and  ap design: 1, anterior superior iliac 
spine; 2, patella.1

5 Current Options for Perineal Reconstruction
71
Perineal wound
( If unavailable )
(develops complications)
Free flaps
Small wound
( < 20 cm2)
Primary closure,
local transposition
flaps
Larger ( > 20 cm2),
irradiated or
infected wounds
Local, pedicled
myocutaneous or
adipocutaneaous
flaps
Fig. 5.4 How to approach the perineal defects.
Fig. 5.5 Harvested and islandized pedicled anterolateral thigh myocutaneous  ap.
superior outcom es. A retrospective review, however, found sig-
ni cantly greater complications w ith thigh aps as opposed to
rectus-based aps.
For wounds that are super cial, groin or thigh aps are rec-
ommended because they do not contain as much soft tissue or
bulk as myocutaneous or some fasciocutaneous aps. Speci cally
for females, the anterolateral thigh (ALT) ap (Fig. 5.5) is an ex-
cellent choice for perineal defects that require the reconstruction
of the posterior vaginal wall when the cavitary defect is not as
large. The advantage of gluteal thigh aps (Fig. 5.6) is they can be
sensate and do not cause much dysfunction at the donor site. The
Singapore ap (pudendal thigh ap) can also be innervated and is
meant for smaller defects.
Myocutaneous aps such as the gracilis (Figs. 5.7 and 5.8) or
rectus abdominis are indicated for more extensive defects requir-
ing greater soft tissue bulk for coverage.
The vertical or oblique rectus abdominis myocutaneous
ap contains enough soft tissue to create a neovagina or recon-
struct the pelvic oor. These aps can also contain skin pad-
dles with relatively larger surface areas. Employing the rectus
abdom inis muscle or myocutaneous ap does not preclude the
use of a stoma. The risk of using such aps is the development of
a postoperative hernia or bulge as well as abdom inal wall weak-
ness. Careful examination of the abdom inal wall for previous op-
erations is critical prior to proceeding with this abdominal ap.
If the patient has a ventral hernia or has undergone m ultiple pre-
vious abdominal wall operations, use of the thigh-based ALT ap
is an excellent option to recruit well-vascularized skin, adipose,
fascia, and m uscle tissue into the perineal defect (Figs. 5.9, 5.10,
5.11, and 5.12).
The gracilis myocutaneous ap is a great option to employ
when the surgeon is faced with a patient who has a rectovaginal
stula. The gracilis muscle can function as a barrier between the
vagina and the rectum and obliterate dead space. If a skin defect
is noted due to resultant traum a or extirpation, this ap can be
advanced as a V-Y myocutaneous ap or fashioned as a rotational
island ap. It can be harvested unilaterally or bilaterally depend-
ing on the extent of the defect. A bilateral ap assists to restore
the form of the vagina. In addition, the muscle can be simply har-
vested and a split-thickness skin graft placed over the muscle.

72
I Planning and Decision Making in Reconstructive Surgery
Fig. 5.7 Anatomy of the gracilis  ap: 1, gracilis muscle; 2, sartorius mus-
cle; 3, adductor longus muscle; 4, rectus femoris muscle; 5, pectineus 
muscle; 6, femoral artery; 7, deep femoral artery; 8, branch to the gracilis.1
Fig. 5.6 Flap design: 1, gluteus maximus muscle; 2, direct cutaneous
branch of inferior gluteal artery and vein; 3, hamstring muscle; 4, sciatic
nerve; 5, piriformis muscle; 6, inferior gluteal artery, vein, and nerve; 
7, ischial tuberosity; 8, superior gemellus muscle, internal obturator 
muscle, and inferior gemellus muscle; 9, quadratus femoris; 10, adductor
brevis and magnus muscle; 11, posterior femoral cutaneous nerve.1
More inform ation about these aps is detailed in the respective
chapters found in this textbook.
In addition to the aforem entioned aps, other lower ex-
trem ity aps m ay be employed: anterolateral thigh ap,
groin ap, rectus fem oris ap (Fig. 5.13), and tensor fascia
lata ap (Figs. 5.14 and 5.15). Note that the use of any lower
extrem ity ap requires a thorough vascular exam and possibly
preoperative im aging (computed tom ography [CT] or m agnetic
resonance im aging [MRI]) to visualize the vessel anatomy.
Many of these thigh aps are also useful for m edial thigh de-
fects but can result in donor site m orbidity—that is, weak ter-
m inal extension of the knee joint and slight exion contracture.
These aps are often utilized when larger defects are present.
For example, an anterolateral thigh ap m ay be harvested w ith
a portion of vastus lateralis in order to obliterate dead space in
the perineal defect.
Free aps and pedicle perforator aps also have a role, how-
ever limited, within perineal reconstruction. They are being used
more often in order to reduce donor site morbidity. For exam -
ple, instead of harvesting a rectus abdominis ap, a deep inferi-
or epigastric artery ap or super cial inferior epigastric artery
perforator ap may be utilized for larger defects; however, these
are di cult and tedious dissections. Often the perineal defect
will require obliteration of dead space and it is appropriate to
recruit muscle. A radial forearm free ap is yet another option
that can be employed for reconstruction or creation of a phallus
(Figs. 5.16 and 5.17).

Complications
The perineal region can be problem atic w ith regard to wound
healing. Close postoperative m onitoring and providing the pa-
tient w ith clear postoperative instructions are param ount in
m axim izing the success of reconstruction. Any pressure on the
ap can result in ischem ia or necrosis resulting in tissue loss;
therefore, allow ing the patient to sit in the postoperative set-
ting is prohibited until the ap is declared as viable and wound
healing has occurred. Our recom m endation is sem i-fowlers
position for 6 weeks postoperatively w hen sitting w ith am bu-
lation being recom m ended on postoperative day 1. Although
am bulation is encouraged postoperatively, exercise and ex-
trem e m ovem ent can cause dehiscence of the ap skin edges.

5 Current Options for Perineal Reconstruction
73
Fig. 5.8 Incisions: 1, gracilis muscle; 2, adductor longus muscle; 9, semitendinosus muscle.1
Fig. 5.9 Intraoperative photo of patient with history of low rectal cancer necessitating abdomino-
perineal resection/low anterior resection.

74
I Planning and Decision Making in Reconstructive Surgery
Fig. 5.10 Resultant soft tissue defect of perineum after tumor extirpation. Forceps indicating intact pos-
terior vaginal wall mucosa.

5 Current Options for Perineal Reconstruction
75
Fig. 5.11 Tunneling of pedicled myocutaneous anterolateral thigh  ap in a subrectus femoris, subsartorius, and subcu-
taneous plane demonstrating pedicle length and robust nature of  ap.
Fig. 5.12 Flap inset.

76
I Planning and Decision Making in Reconstructive Surgery
Fig. 5.13 Incision planning for rectus femoris muscle harvest.
Fig. 5.14 Anatomy of tensor fasciae latae  ap: 1, tensor fasciae latae; 
2, rectus femoris muscle; 3, sartorius muscle; 4, femoral artery; 5, deep 
femoral artery; 6, lateral circum ex femoral artery; 7, ascending branch; 
8, descending branch.1
Fig. 5.15 Flap design: 1, tensor fasciae latae; 2, rectus femoris muscle; 
3, vastus lateralis muscle; 4, ascending branch; 5, iliotibial band; 6, lateral
cutaneous nerve of thigh; 7, cutaneous branch of T12 nerve; 8, gluteus 
muscle; 9, iliac bone.1