Flaps Practical Reconstructive Surgery

78
I Planning and Decision Making in Reconstructive Surgery
Lefevre JH, Bretagnol F, Maggiori L, et al. Operative results and quality
of life after gracilis muscle transposition for recurrent rectovaginal
stula. Dis Colon Rectum 2009;52:1290–1295
McCraw J, Kemp G, Given F, et al. Correction of high pelvic defects with
the inferiorly based rectus abdom inis myocutaneous ap. Clin Plast
Surg 1988;15:449–454
McCraw JB, Massey FM, Shanklin KD, et al. Vaginal reconstruction
with gracilis myocutaneous aps. Plast Reconstr Surg 1976;58:
176–183
Muneuchi G, Ohno M, Shiota A, et al. Deep inferior epigastric perforator
(DIEP) ap for vulvar reconstruction after radical vulvectomy: a
less invasive and simple procedure utilizing an abdominal incision
wound. Ann Plast Surg 2005;55:427–429
Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh aps for
immediate reconstruction of pelvic and perineal cancer resection
defects. Plast Reconstr Surg 2009;123:175–183
Saleh DB, Liddington MI, Loughenbury P, et al. Reconstruction of the irra-
diated perineum following extended abdomino-perineal excision
for cancer: an algorithmic approach. J Plast Reconstr Aesthet Surg
2012;65(11):1537–1543
Shibata D, Hyland W, Busse P, et al. Imm ediate reconstruction of the peri-
neal wound with gracilis muscle aps following abdominoperineal
resection and intraoperative radiation therapy for recurrent carci-
noma of the rectum. Ann Surg Oncol 1999;6:33–37
Singer P. Nutritional care to prevent and heal pressure ulcers. Isr Med
Assoc J 2002;4:713–716
Sunesen KG, Buntzen S, Tei T, et al. Perineal healing and survival after anal
cancer salvage surgery: 10-year experience with prim ary perineal
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(VRAM) ap. Ann Surg Oncol 2009;16:68–77
Wang X, Qiao Q, Burd A, et al. Perineum reconstruction with pedicled antero-
lateral thigh fasciocutaneous ap. Ann Plast Surg 2006;56:151–155
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Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and
Operative Approaches. 2nd ed. New York, NY: Thieme; 2006

Current Options for Head and
Neck Reconstruction
Sachin M. Shridharani, Justin L. Bellamy, Justin M. Sacks, and Anthony P. Tufaro
6
79

Introduction
Reconstruction of head and neck defects represents the most
complicated problem that reconstructive surgeons can be called
upon to manage. In fact, the origin of plastic surgery is based in
reconstruction of injuries to the head and neck. This reconstruc-
tion is critical not only to restore function, but also to allow the
patient to interact normally in society. Most of the reconstruc-
tive e orts will be evaluated in the central gaze of everyone who
meets the patient. It is imperative that form and function are
built into every phase of the reconstructive e ort. Simply “ lling
a hole” will not su ce.
Multiple challenges face the reconstructive surgeon and
m ust be considered in form ulating a comprehensive m anage-
m ent plan. Composite tissue defects require m ultiple compo-
nents to restore structure and function. If we approach the
reconstructive e ort by evaluating the challenges, the rst thing
considered is the skin/soft tissue cover. In hair-bearing areas,
alopecia m ay be tolerable when considering the patient’s age,
deform ity, sex, nature of injury, and expectations. Matching the
contour and skin quality of the una ected areas are ideal. This is
not always possible in larger defects, since these soft tissue de -
cits m ay preclude the use of local aps that otherw ise would
have provided excellent color and tissue quality m atch. The cre-
ation of aberrant concavities or convexities is incredibly di -
cult to cam ou age and readily noticeable by observers. While
these contour deform ities m ay be initially inevitable at the rst
stage of reconstruction, the surgeon and the patient m ust be
prepared for secondary procedures. Another challenge that the
head and neck reconstructive surgeon faces is the di culty
w ith restoration of the special senses. For example, injuries to
the eyelid and periorbital tissues m ay comprom ise their func-
tion of protecting vision. Therefore, failures in reconstruction
of these supportive/protective structures can directly lead to
loss of this special sense unique to this facial subunit. Sim ilar-
ly, hearing, taste, and sm ell w ill be disrupted if their protective
soft tissue and skeletal support structures are inappropriately
reconstructed.
The ability to anim ate m ust be considered when planning
reconstruction in the head and neck with emphasis on the face.
Reconstructing the scalp (static structure) often requires nothing
more than local aps or skin grafts. However, large skin grafts
on the face (dynamic structures) may lead to primary versus
secondary contracture, which not only impairs the movement of
the reconstructed area, but also comprom ises anim ation in other
regions of the face.

Assessment
The choice of tissue to reconstruct a given defect is dictated by
patient factors such as age, sex, comorbidities (body mass index/
body habitus, smoking status, etc.), race, and patient expectations.
Factors pertaining to local defects include: size, location, tissues
to be replaced (skin, subcutaneous fat, muscle, bone), static vs.
animated tissue, skin texture, and hair bearing vs. non–hair bear-
ing. Other factors that will a ect the type of reconstruction used
include the etiology of the wound created—traumatic versus on-
cologic. In addition, oncologic defects m ay have the added bur-
den of pre- or postoperative chemotherapy or radiation injury.
These factors m ust be carefully considered when planning for
reconstruction.
Perhaps the most important factors are the “surgeon fac-
tors.” One must consider limitations of the ability to reconstruct
the defect and/or the capabilities of the hospital or institution
where these reconstructive procedures are being performed.
The advantage of local aps is the ability to transfer tissue
of like color, character, and quality. One example of a local ap
that m eets these ideal criteria is the paramedian forehead ap
for nasal reconstruction. However, a di culty arises when larger
volumes of tissue are required or composite defects are present.
Also, the ability to transfer the tissue into the defect is limited by
the arc of rotation of the pedicle. The advantage of distant aps is
the ability to m ove large volum es of tissue including composite
anatomic structures (bones, subcutaneous tissue, skin, etc.). One
example of a distant pedicled ap is the pectoralis major myocu-
taneous ap for oral cavity reconstruction. The disadvantages of
this reconstruction include lim ited arc of rotation and donor site
morbidity. The use of free tissue transfer has revolutionized head
and neck reconstruction. Several advantages exist and include the
ability to harvest large pieces of tissue, reconstruct large compos-
ite defects, and transfer multiple tissue types to the defect with
no concern of arc of rotation. One example of a free tissue transfer
is the free bula osteocutaneous ap for mandible and oor of
mouth reconstruction. The disadvantages are a large donor site
defect often requiring a reconstructive procedure, technically
challenging procedure, and added anesthesia and surgical time
for the patient.
An e ort must be taken to avoid untoward events in the op-
erating theater. Preoperative planning is necessary. Often, this
preparation includes advanced imaging modalities. Computed
tomography (CT), CT angiogram, and standard angiograms are
often necessary to visualize not only the donor vessels, but also
the recipient site and remaining vasculature.

80
I Planning and Decision Making in Reconstructive Surgery
smaller ipsilateral rotation ap based on the super cial temporal
vessels m ay be used. Larger defects m ay also be reconstructed
by employing rotational aps similar to those used for moder-
ate sized defects, or a temporoparietooccipital ap can be used
if the anterior hairline needs to be recreated. Very large defects
up to 30% of the cranium m ay be covered using the three- ap
reconstructive technique as originally described by Orticochea in
1971. This technique is based on the vascular territories of each
ap arm and can cover defects in the frontal or occipital regions
while broadly distributing force. The use of these aps is quite
challenging, and attaining “passive” inset is never as simple as
one may think. The surgeon must be aware that placing undue
tension on any wound closure, particularly inelastic tissue, w ill
result in wound complications, skin necrosis, and poor scarring.
Employing galeal scoring increases the excursion of the scalp soft
tissue. This well-vascularized layer can tolerate cross-hatching, as
well. One must be careful, however, to not use excess electrocau-
tery, as this will result in thermal injury and damage to the small
blood vessels feeding the dermis.
Using fewer, larger aps rather than numerous sm all aps
ensures that vascular integrity is preserved and lim its the like-
lihood of necrosis of any one unit. Donor site defects can often
be closed primarily; however, skin graft may be necessary, high-
lighting the importance of preserving the periosteum during
subgaleal dissection of the scalp ap to ensure graft take. The
overall aesthetic result using the Orticochea ap is often inferior
to that which can be achieved using tissue expansion due to the
resulting unnatural hair orientation. For this reason, consider-
ation should be given to staged reconstruction using tissue ex-
pansion when feasible.
Parietal Defects
Larger parietal defects m ay be addressed with scalp rotation aps
based on the ipsilateral occipital vessels. In cases where patients
have undergone previous posterior neck procedures or neck dis-
section, it is imperative to assess the continuity of the ipsilateral
occipital vessels. This can be achieved with advanced imaging or
simple handheld Doppler. In the case where two aps may be
necessary, one should evaluate the integrity of the ipsilateral
super cial temporal vessels (STV). Flap selection is important
for many di erent reasons. Aesthetic considerations must be
accounted for when deciding the ap to employ and its respec-
tive direction of m ovem ent. Large aps translocated posteriorly
based on the STV will result in an anterior defect that will require
a skin graft. This can result in a nice reconstruction; however, a
poor overall aesthetic can result due to an unsightly donor site in
an onlooker’s central gaze.
In contrast to other scalp locations, Orticochea aps for
large defects of the parietal scalp have poor utility due to the
lim ited ability to mobilize su cient tissue from the contralat-
eral parietal scalp. Here tissue expansion becom es an option
for satisfactory reconstruction of large parietal scalp defects.
Use of large bi-pedicled fronto-occipital aps has also been de-
scribed but this option requires large areas of back-grafting and
rem ains m ost suitable only when single-stage reconstruction is
necessary.

Reconstructive Options
Scalp
For the most part, the scalp represents reconstruction of a static
structure. Important considerations of the defect include: size,
depth, etiology, and nearby mobile structures including brow
and hairline. Many reconstructive options exist to cover scalp
defects. Prior to performing the reconstruction, assessing the
scalp and neck for signs of previous surgery is critical. Violation
of vascular territories or multiple dermal incisions can compro-
mise the reconstructive e ort and result in a wound larger than
the original defect. The reconstructive ladder always begins with
the least complex option. Sm all wounds super cial to the peri-
cranium may be left to heal by way of secondary intention. This
will result in at, hypopigmented, and slightly shiny tissue with
scar alopecia. This reconstructive option may be best employed
in non–hair-bearing regions over convexities. The reconstructive
ladder increases in complexity through the full range of surgical
options: undermining (local tissue rearrangement), local aps,
skin grafts, rotation/advancement aps, local pedicled aps, and
free aps. Local options are somewhat limited due to the inelas-
tic nature of the scalp and lack of redundant tissue. The scalp is
incredibly well vascularized which perm its closure of smaller de-
fects (1–2 cm) with random pattern aps.
Larger defects m ay require scalp rotation aps. These are
technically relatively simple procedures that provide an excel-
lent aesthetic outcome by replacing a hair-bearing defect with
hair-bearing scalp. The use of larger rotation aps (random pat-
tern or based on named pedicle) will require skin grafting or
an alternative reconstruction at the donor site. Often in scalp
reconstruction, secondary revisions are necessary to remove
the skin graft or restore the original hairline. These procedures
should be discussed with the patient prior to all surgeries and
may com m it the patient to having tissue expanders placed.
Nam ed pedicled aps and large random pattern aps, which are
moved in a large arc of rotation, result in a dog ear deformity.
One should resist the temptation to address this skin excess at
the initial reconstructive procedure. It is preferred to place the
dog ear in the posterolateral location on the scalp rather than an-
terocentral. This maneuver preserves anterior hairline and har-
mony of hair grow th direction. After several m onths, the dog ear
deformity or standing cone of skin will often atten on its own;
however, if this is not the case, the defect can be excised with
local anesthesia since the ap will have full neovascularization
and mature venous out ow.
Anterior Defects
Any reconstructive e ort in the area of the anterior hairline will
be di cult to camou age. Even if a hair-bearing ap is used, a
donor site defect may be appreciated nearby. V-Y, V-Y-S, rhom -
boid, subcutaneous, and subgaleal rotation advancement aps
may be employed for defects up to 25 cm 2. In order to avoid
distortion of the anterior hairline and to displace the resulting
dog ear to a cosmetically acceptable lateral location, one large
contralateral rotation ap based on the occipital vessels and a

6 Current Options for Head and Neck Reconstruction
81
back-grafting allow for transposition of the defect to a less cos-
metically sensitive location that may be addressed even more ef-
fectively with tissue expansion at a later time (Fig. 6.1).
Wide underm ining of the tissue to the middle posterior
neck is often necessary for full excursion of the soft tissue. It
is possible to utilize this posterior neck skin by incising down
the m idline and only elevating one half of the posterior neck.
Vertex and Occipital Defects
Due to the relative immobility of this region of the scalp, local
aps may be necessary even for smaller lesions. Rhomboid and
pinwheel aps provide good alternatives for smaller defects when
primary closure is not possible, while double-opposing rotation
advancement aps allow for closure of moderately sized defects.
Additionally, rotation advancement aps from the occiput with
a
b
Fig. 6.1 A 67-year-old man with longstanding history of scalp tumor. (a) The patient. (b) Surface markings for proposed incision
for scalp rotation ap. (c) Scalp rotation ap with Xeroform bolster over split-thickness skin graft utilized to cover donor site defect.
(d) Bolster removed and visible incision/wound at 2 weeks. (continued)
c
d

82
I Planning and Decision Making in Reconstructive Surgery
By staying super cial to the trapezius m uscle, it is easier to
m obilize this tissue. Furtherm ore, placing the patient’s neck
in neutral or slight extension will facilitate increased ability to
close the wound.
In the occipital region, rotation advancement aps can read-
ily be designed to cover m oderately sized defects while Ortico-
chea aps have been classically used to cover larger defects of the
occiput. Again, however, tissue expansion provides superior re-
sults and should be employed whenever possible. In cases where
deeper vital structures are exposed, trapezius aps versus tra-
pezius myocutaneous aps can be employed especially for high
posterior cervical wounds and all other wounds posterior to the
external auditory canal.
Total versus Subtotal Scalp
In instances of total or subtotal scalp defects, options include
large sheet skin grafts which may be best placed on dermal sub-
stitutes a ording the scalp a slightly greater durability. In cases
where there is loss of periosteum and/or calvarium requiring
cranioplasty, reconstruction is best achieved employing free tissue
transfer. These aps can be muscle-only with skin graft, myocu-
taneous, adipocutaneous, fasciocutaneous, and even omentum.
There are advantages and disadvantages of each of these aps.
The most common aps used for reconstructing large scalp de-
fects include: latissimus dorsi, radial forearm, and anterolateral
thigh (Fig. 6.2).
It should be noted that while initially the latissimus dorsi
ap with skin graft seems like the ideal option, problems may
arise within months to years. Harvest of the aps requires divid-
ing the thoracodorsal nerve leading to denervation of the muscle.
This results in long-term atrophy of the m uscle. This m uscle loss
over an alloplastic cranioplasty can eventually result in hard-
ware exposure. The radial forearm ap is an ideal reconstructive
Fig. 6.1 (continued) (e) Final healed wound at 6 months.
e
option for smaller full-thickness defects. The anterolateral thigh
ap also provides excellent, supple soft tissue for small and large
defects. The ap can sustain radiation therapy and protect al-
loplastic cranioplasty hardware. The disadvantage of the ap is
noticed in corpulent patients. The excess subcutaneous fat re-
quires m eticulous thinning of the ap at the tim e of inset and/or
liposuction as a secondary procedure.
Upper Face
The upper face in m ost ethnic groups is comprised of even col-
ored skin overlying a convex skeletal support sca old. In lighter
skinned patients, defects even at the level of the pericranium can
heal nicely by secondary intention. A shiny, tight, and fair-skinned
scar often appears consistent with the native skin. This is most
classically noted in healing by secondary intention of the donor
site for a paramedian forehead ap. In darker skinned individuals,
color match m ay not be as optim al. Therefore, advancem ent aps
are ideal for central defects of the forehead; in particular, unilat-
eral advancem ent aps are typically used for param edian or lat-
eral forehead. In addition, central defects of the forehead m ay be
readily closed by w idely undermining adjacent tissue super cial
to frontalis muscle. This is particularly e ective in older patients
who have skin redundancy. The resultant dog ear deformity can
often be addressed by extending the incision into the hairline.
Larger full-thickness defects of the forehead often require sheet
skin grafting (Fig. 6.3).
The forehead is considered a single aesthetic subunit; there-
fore, the skin graft will appear as a patch. Color matching be-
comes progressively more di cult as one harvests skin caudal to
the nipple line. Large defects resulting from repeat surgery, on-
cologic resection, and/or traum atic avulsion wounds m ay require
a thin, pliable, fasciocutaneous ap. This free tissue transfer is
often needed to cover hardware or skeletal defects.

6 Current Options for Head and Neck Reconstruction
83
Fig. 6.2 A patient with history of scalp malignancy invading into the
cranium. (a) Cutaneous manifestations of scalp malignancy. (b) Resect-
ed cutaneous scalp malignancy. (c) Resultant cutaneous defect with re-
moved pericranium. (d) Super cial temporal artery and vein harvested.
(e) Titanium mesh cranioplasty. (f) Surface landmarks including border
of scapula and palpable latissimus dorsi (LD) muscle. (g) Access incision
for muscle harvest with wide exposure of muscle. (continued)
a
c
b
d
e
f
g

84
I Planning and Decision Making in Reconstructive Surgery
Fig. 6.3 A patient with history of forehead malignancy invading into the pericranium. (a) Cutaneous manifestations of scalp malignancy.
(b) Resected cutaneous scalp malignancy. (continued)
a
b
Fig. 6.2 (continued) (h) Harvested LD muscle with ped-
icle. (i) LD muscle inset with split-thickness skin graft
placed on muscle. (j) Primarily closed donor site.
h
i
j

6 Current Options for Head and Neck Reconstruction
85
d
Fig. 6.3 (continued) (c) Resultant cutaneous defect with re-
moved pericranium and dermal replacement placed over skull.
(d) Split-thickness sheet skin graft placed over matured dermal
replacement. (e) Patient at 3-month follow-up visit.
c
e
Defects in the temporal region m ay require high cervicofa-
cial rotation or advancem ent aps by recruiting tissue from the
lateral cheek and neck. For larger defects, bilateral advancement
aps m ay be necessary to avoid excessive tension on the closure.
Beware that advancement aps tend to narrow with tension on
the subcutaneous tissue and dermis requiring that the surgeon
design a ap wider than the defect to compensate. Composite tis-
sue defects of the inferior portion of the temporal region may
require local and distant pedicled aps. A classic example of a
local ap option is advancem ent of scalp tissue based on the su-
per cial temporal artery and vein. The resultant defect in the
posterolateral scalp may require skin grafting. The temporalis
muscle independent of the skin can also be m obilized and ro-
tated into defects in this region, the orbit, and the oral cavity. An
example of a distant ap is use of the pedicled pectoralis major
myocutaneous ap.
Free tissue transfer options exist for reconstruction of de-
fects in this region. The latissim us dorsi, radial forearm, scapular
ap, parascapular ap, and anterolateral thigh ap are all well-
described ap options (Fig. 6.4). Consideration for defect loca-
tion, pedicle length, and required intraoperative repositioning
maneuvers may dictate which ap is most appropriate.

86
I Planning and Decision Making in Reconstructive Surgery
a
b
c
Fig. 6.4 A patient with history of cutaneous malignancy involving the
forehead and periorbital region. (a) Cutaneous manifestations of malig-
nancy. (b) Resultant cutaneous defect after tumor extirpation. (c) Tem-
plate of cutaneous defect placed over forearm. (d) Raised radial forearm
ap. (continued)
d

6 Current Options for Head and Neck Reconstruction
87
Large Defects, Anterior Lamella
The anterior lam ella is composed of skin and orbicularis oculi.
Various rotational aps have been described to cover defects that
include the anterior lamella. The semicircular rotational ap, a
superiorly based musculocutaneous ap rst described by Tenzel
and Stewart, is ideal for defects of 40 to 60% of the eyelid. The
ap starts at the lateral canthus and extends in a semicircle with
the plane of dissection deep to the orbicularis m uscle. A selective
lateral canthotomy on the upper lateral canthal tendon releases
the ap for advancem ent and reapproxim ation with the tarsal
plate. Care should be taken to preserve the anterior canthal ten-
don during the selective canthal release, and canthoplasty should
be performed to reconstruct the lateral canthus. For some larger
lower lid defects, a periosteal ap may be used to provide fur-
ther lateral support. A m edially based rectangular ap is raised
from the anterior crest of the lateral orbital rim and re ected
180 degrees into the lower lid defect. The periosteal ap is an-
chored to the lateral aspect of the residual tarsus to function as
the posterior lam ella while the sem icircular ap form s the ante-
rior lamella.
The Cutler-Beard or bridge ap is a lower eyelid bridge ap
ideal for broad, shallow upper eyelid defects and may even allow
coverage of total eyelid reconstruction. A horizontal incision is
made 5 m m inferior to the lower eyelid m argin to preserve eye-
lid blood supply. Vertical incisions are extended inferiorly to the
fornix and inferior orbital rim to form a biplanar ap. Maximal
mobilization of the ap includes relaxing incisions in the capsu-
lopalpebral fascia to allow this ap to be passed under the eyelid
margin to form a bridge with the upper eyelid defect. Once the
Middle Face
Eyelid
Eyelid reconstruction requires special attention to the restoration
of function in an e ort to preserve vision. The delicate anatomy
a ords function. For example, the lateral canthus provides bony
stabilization of the eyelid during m ovem ent while the complex
anatomical interplay at the medial canthus drives the lacrimal
pump. Furthermore, the lower eyelid is under the vertical forces
of gravity on the cheek and midface which tend to adversely
a ect the position of lower lid reconstruction. This lower eyelid
descent is further exacerbated by vertical scar contracture lead-
ing to cicatricial ectropion.
Small Defects
Super cial anterior lam ellar defects m ay be closed with
full-thickness skin graft. Donor skin is best taken from the upper
eyelid; however, supraclavicular, preauricular, postauricular, and
lateral cervical skin also make e ective donor sites. Harvesting
medial eyelid skin should be avoided to prevent lagophthal-
mos. Full-thickness defects up to 30 to 40% of the eyelid m ay
be repaired by direct closure. Excision of lesions should involve
full-thickness incisions perpendicular to eyelid margin and ex-
tending to the superior tarsal margin in order to prevent postop-
erative notching. Lateral cantholysis can be perform ed to reduce
tension on the closure, which if unaddressed may produce me-
chanical ptosis. Exact approximation of the wound is critical to
avoid eyelid inversion that can cause corneal irritation.
Fig. 6.4 (continued) (e) Patient at 1-week follow-up visit. (f) Patient at 4-month follow-up visit.
e
f

88
I Planning and Decision Making in Reconstructive Surgery
bridge in 4 to 6 weeks. The Hughes procedure is best suited for
medial or lateral defects; thus in cases of centrally located con-
junctival defects, oral mucosal grafts from the upper lip, lower
lip, or buccal mucosa are an alternative for reconstruction.
When the ipsilateral eyelid skin is unavailable for transpo-
sition, a tarsoconjunctival graft from the contralateral eyelid can
be used. Again, a horizontal incision matched 1:1 in length to the
defect is made 4 mm from the lid margin to preserve donor eyelid
vascular integrity. Parallel vertical incisions are extended to the
tarsal plate border. The graft is dissected from the levator apo-
neurosis and Müller muscle and inset into the defect. The donor
site is left to reepithelialize.
Ear
The outer ear is composed of skin closely adherent to an under-
lying cartilaginous fram ework. The surface anatomy of the ear
consists of the helix, antihelix, scapha, concha, tragus, antitragus,
and lobule. These structures must be preserved or reconstructed
to maintain the inherent anatomy and contour of the ear.
Small to medium sized defects in the conchal bowl can be
reconstructed with a skin graft and generally do not require lo-
cal aps. Reconstruction of the ear lobule generally is performed
in staged manner by employing tubed aps from the mastoid/
postauricular skin. Small defects in the skin of the helical rim can
be repaired with excision of a triangular wedge and direct approx-
imation. If the defect is small but direct approximation cannot be
performed, the remaining helix can be reconstructed with local
chondrocutaneous aps; in this instance, the remaining helical
rim is dissected o the scapha and advanced. Large defects of the
helical rim can be covered with a tubed ap or postauricular ap
(Fig. 6.5). This is a staged procedure in which division and inset are
performed 2 to 3 weeks after the initial transposition of the ap.
Sm all cartilage defects in the helical rim can be repaired us-
ing cartilage grafts taken from the contralateral ear. Large helical
defects missing cartilaginous components can be reconstructed
using cartilage grafts from the ribs. These grafts can be sculpted
to conform to the missing helical rim and covered with a ped-
icled temporoparietal fascia ap based on the super cial tem -
poral artery. Alloplastic frameworks such as those composed of
high-density polyethylene can also be used to repair cartilagi-
nous defects in the ear, obviating the need for donor cartilage.
Alloplastic implants should be covered with vascularized tissue
such as a temporoparietal fascia ap. The goal of reconstruction
following total auriculectomy for an invasive cutaneous malig-
nancy is to provide vascularized soft tissue coverage of the ex-
posed bone and tissue. Alternatively, a prosthetic ear can yield
excellent aesthetic results. Osseointegrated appliances can also
be constructed and are favored in bone that has not been previ-
ously irradiated.
Cheek
Local Flaps
The age of the patient and size of defect are important consid-
erations for reconstruction of cheek defects. Older age a ords
greater skin laxity and often allows for easier coverage of wounds
without placing traction or tension on adjacent structures, such
conjunctiva has been sutured in place, a cartilage graft is har-
vested from the at scaphoid ear and implanted anterior to the
conjunctiva to recapitulate tarsal function while avoiding corneal
irritation. The superior edge of the cartilage graft is sutured to
the levator aponeurosis to maintain lid function, and the skin
and m uscle ap is sutured in place. Typically after 6 weeks, the
ap m ay be divided 2 m m below the desired upper lid border
followed by excision of the projecting skin and muscle. The re-
maining conjunctiva is folded anteriorly and sutured to the skin
to form a conjunctival border. To prevent ectropion or eyelid m al-
position of the donor site, lower lid lateral canthoplasty is usually
necessary.
Another option for broad defects near the lid m argin rst de-
scribed by Mustardé is the pedicled lower lid-sharing ap. Unlike
the bridge ap, this ap allows for primary closure of the lower
lid and transfers eyelashes to the upper lid; however, the ap re-
quires a shallower upper lid defect. A 5-mm full-thickness vertical
incision is m ade in the lower lid at the lateral limbus. A horizontal
inferior incision is then made parallel to the lid m argin below the
marginal artery until adequate mobilization is achieved to reach
the upper lid defect. The ap is rotated superiorly such that the
lateral lower lid tarsal plate m ay be sutured to the medial upper
lid tarsal plate. Again, ap division typically occurs at 6 weeks
and the remainder of the ap is rotated into the defect. The donor
site is closed by lateral advancement and the lower lid margins
are reapproxim ated taking care to realign the gray line and lash
line. Selective lateral canthotomy and canthoplasty should be
performed if there is excess tension to avoid malposition.
Several periorbital rotational aps for reconstruction of de-
fects with large volum e loss have been described, including the
temporal forehead ap, the forehead ap, and the glabellar ap. It
should be noted that m ost periorbital aps would result in m is-
matched skin quality and thickness.
Large Defects, Posterior Lamella
The posterior lam ella is form ed by the tarsal plate and conjunctiva
and makes direct contact with the globe. Reconstruction of the
posterior lamella must preserve or reestablish the conjunctival
layer in order to prevent corneal irritation. The tarsoconjunctival
ap, also known as a tarsal extension ap or Hughes procedure, is
a transposition ap wherein the upper border of the tarsal plate
is used to reconstruct posterior lamellar defects of the upper or
lower eyelid. A horizontal incision is made in the conjunctiva
4 mm superior to the eyelid parallel to the margin to match defect
length in a 1:1 ratio. The incision is extended superiorly to the
tarsal plate edge and Westcott scissors are used to dissect the tar-
sal ap from the levator aponeurosis and Müller muscle, enabling
ap transposition into the defect. For upper eyelid defects, the
ap is secured to the periosteum of the orbital rim with suture
and the tarsal plate is sutured in place. For lower eyelid defects,
the ap is secured m edially and laterally to the residual tarsus
and inferiorly to the conjunctiva and lower lid retractors.
Once the conjunctiva is repaired, the rem aining anterior
lamellar defect is repaired using a skin and muscle ap or
full-thickness skin graft. For upper lid reconstruction, the eye is
sutured closed and a bolster dressing is left in place for 1 week.
The Hughes procedure for lower lid reconstruction e ectively
sutures the lid closed and requires a second stage to split the ap

6 Current Options for Head and Neck Reconstruction
89
a
b
c
d
Fig. 6.5 A patient with history of left ear cutaneous malignancy. (a) Cutaneous manifestations of ear malignancy. (b) Resected
cutaneous ear malignancy. (c) First stage of ear reconstruction by employing posterior auricular ap. (d) Second stage of ear
reconstruction by dividing and insetting ap and skin grafting resultant donor site defect.
as the lower eyelid. The most commonly employed ap for central
and upper medial cheek defects is the cheek rotation advance-
ment ap (Fig. 6.6). This reconstructive option may be designed
posteriorly as described by Stark and Kaplan and is a modi ca-
tion of the Mustardé’s reverse cervicofacial advancem ent ap.
This ap requires m oving excess skin of the jowls onto the face.
Alternatively, an anteriorly designed ap mobilizes the neck skin
onto the face. When indicated, the incision may be continued
onto the clavicular region or chest to increase the arc of rotation.
Ectropion from downward traction on the lower eyelid may be
avoided by using either periosteal sutures or an anchoring device
such as a Mitek anchor. Placing the incision around the sideburn
can prevent rotation of hair-bearing skin onto the cheek in fem ale
patients.

90
I Planning and Decision Making in Reconstructive Surgery
a
b
c
d
Fig. 6.6 A patient with history of invasive malignancy involving right
lower eyelid and cheek. (a) Cutaneous manifestations of eyelid and
cheek malignancy (anteroposterior view). (b) Cutaneous manifesta-
tions of eyelid and cheek malignancy (oblique view). (c) Surface mark-
ings for proposed incision for cheek advancement ap. (d) Resultant
cutaneous defect. (e) Widely undermined cheek advancement ap.
(continued)
e

6 Current Options for Head and Neck Reconstruction
91
f
g
Fig. 6.6 (continued) (f) Appearance of raised ap with
appropriate venous drainage. (g) Flap inset. Patient
at 5-month follow-up visit: (h) anteroposterior view.
(i) oblique view, and (j) lateral view.
i
h
j

92
I Planning and Decision Making in Reconstructive Surgery
discarding adjacent normal tissue within the subunit may allow
positioning of scars in creases between subunits and control con-
tour distortion often attributed to pincushioning. Consideration
should be given to staged reconstructions as these generally al-
low for more controlled excision, soft tissue sculpting, and inset
of supporting cartilage.
Covering
Sm all defects will heal by secondary intention or can be resur-
faced with full-thickness skin graft. Large, deep defects require
local ap reconstruction. Depending on the location, size, and
a ected nasal subunit, several aps are described: bilobed aps
(Fig. 6.7), two-stage nasolabial aps, and bishop-mitre ap are
among the commonly employed local aps. For larger defects,
defects require lining replacement, or those located within the
infratip/columella, a paramedian forehead ap is ideal. The skin
quality, size, and vascularity of the forehead ap make it ideal for
nasal resurfacing.
The vertical param edian forehead ap, based on the supra-
trochlear vessels, allows for excellent ap reach and can be em -
ployed to reconstruct virtually any nasal defect with minimal
visible scarring (Fig. 6.8). The param edian ap is traditionally
performed in two stages, although a three-staged approach al-
lows greater soft tissue excisional sculpting with secondary car-
tilage support grafting. Other forehead ap options include the
median forehead, oblique, Gillies up-and-down, horizontal fore-
head, Sickle, and Converse scalping aps. However, these aps are
all associated with increased donor site scarring or limited mo-
bility when compared to the vertical paramedian forehead ap.
Lining
Many options are available to reconstruct the intranasal lining
and are brie y reviewed. Small defects can be managed using a
hinge-over ap by turning over adjacent skin of residual nose or
cheek; however, these aps tend to be poorly vascularized, thick,
occlude the airway, and are di cult to mold with cartilage grafts.
A second nasolabial or forehead ap may be used. The facial artery
myomucosal ap described by Pribaz et al. can be used to transfer
intraoral mucosa to ll isolated intranasal mucosal loss. Compos-
ite skin grafts for small defects, or combined with full-thickness
graft extension for larger defects, have been described to provide
both cover and lining. Burget and Menick have re ned a tech-
nique rst described by Gillies for saddle nose deformities that
utilizes a skin graft on the raw surface of the forehead ap to
simultaneously create lining while maintaining a patent airway.
A technique termed prelamination (or prefabrication) constructs
the nose on the forehead prior to ap transfer. Six weeks before
transfer, a composite skin graft (full-thickness graft with carti-
lage pieces positioned within the subcutaneous layer) is secured
on the deep surface of the forehead ap. However, this technique
provides only limited rim support.
Folded aps, with or without full-thickness lining extensions,
have been described wherein the forehead ap is folded in on it-
self to provide intranasal lining. Secondary cartilage support may
be added later by placing an incision at the nostril m argin. Intra-
nasal lining grafts have been described and m ay allow for primary
cartilage grafts for support and shape. Smaller defects can be
Many small to moderate sized defects may be reconstructing
using the submental artery ap. This ap can readily reach the
cheek and the donor defect is well hidden, though the implicit
hair grow th pattern in this region m ay be a signi cant consider-
ation in men.
Free Tissue Transfer
Several free tissue transfer options exist to cover large defects on
the cheek. Skin color often may not be m atched to the native skin
and the patient should be made aware of this fact in the preop-
erative planning phase. Small, thin adipocutaneous aps, such as
the radial forearm ap, m ay be ideal for sm aller defects of the
cheek. The anterolateral thigh ap results in acceptable aesthetic
outcomes in patients who require larger soft tissue reconstruc-
tion. Particularly in darker skinned individuals where color vari-
ation is less pronounced, the scapular and parascapular aps can
ll even the largest of cheek defects while providing satisfactory
donor and recipient site aesthetics. In through-and-through de-
fects, single aps may be folded on themselves to provide both
external epiderm al coverage and intraoral lining. The epidermis
will mucosalize when inset into the intraoral cavity. For greater
exibility during the inset, scapular and parascapular aps may
both be harvested on the transverse and descending branches of
the circum ex scapular artery, respectively, to provide indepen-
dent internal and external coverage.
Unlike the scapular and parascapular aps, utilizing the an-
terolateral thigh ap allows for simultaneous tumor extirpation of
the head and neck and concom itant ap harvest since the patient
may be positioned in the supine position. This m akes this ap
an excellent choice for patients who require a shorter operation.
Suprafascial dissection allows for a thinner ap to be tailored for
cheek reconstruction. Furtherm ore, excess subcutaneous fat m ay
be trimmed when necessary without ap compromise. If bulk is
needed, as in lateral cheek reconstruction, a portion of the vastus
lateralis may be harvested. When bony defects accompany the
cheek defect, the bular osteocutaneous ap can be used to re-
construct the intraoral lining adjacent to the bony defect while
the anterolateral thigh ap lends bulk and volum e to the external
cheek.
Nose
Principles
The nose is composed of nine anatom ical/aesthetic subunits: dor-
sum, tip, columella, paired ala, paired soft triangles, and paired
sidewalls. For each subunit, three layers potentially must be re-
constructed when involved: super cial (epiderm al cover), m iddle
(cartilage/bony support), and deep (intranasal mucosal lining).
To ensure an aesthetically successfully reconstruction, the nose
must be reconstructed on a stable platform . Therefore, composite
wounds that involve the cheek or upper lip should have integrity
rst reestablished. Super cial composite defects m ay be repaired
simultaneously; however, larger defects susceptible to shift due
to tension, edema resolution, or scar contracture should have the
nasal reconstruction delayed. When possible, the contralateral
nasal subunit should be used as a template to reproduce a normal
appearance. When reconstructing convex subunits (ala and tip),

6 Current Options for Head and Neck Reconstruction
93
reconstructed using a bipedicled ap of residual vestibular lining.
Ipsilateral septal mucosa may be used for larger defects. Alterna-
tively, a composite ap of bilateral septal mucosa with adjacent
cartilage and bone can be transposed through the piriform aper-
ture to line the upper nose and vestibule while providing central
bridge support. For massive, irradiated, or composite defects, free
ap reconstruction m ay be indicated. Skin quality match is poorer
than regional aps; however, free tissue transfers can be used to
reconstitute the nasal oor, vault, and columella and reestablish
the cheek and lip followed by a forehead ap at a later time. When
a microvascular ap is used for nasal reconstruction, the septal
partition is not restored to prevent airway obstruction.
Support
When absent, support structures must be replaced to main-
tain normal shape under the forces of scar contraction, edema
resolution, and tension. Additionally, cover and lining must
be thin and vascular to maximize the contour aesthetics of the
support grafts without compromising the airway. To maximize
the aesthetic outcom e, the support structure should be fully
reestablished before ap pedicle division. Depending on donor
availability and defect requirements, support may be restored
using septal, ear, or rib cartilage. If bone is necessary, rib or split
calvarial grafts may be used.
Lower Face
Lips
Reconstruction of lip defects must approximate both the form
and function of the premorbid state. Various local aps are avail-
able for smaller defects while larger defects may require free
tissue reconstruction. Intermediate-sized defects can be recon-
structed using either technique; however, local aps generally
Fig. 6.7 A patient with history of cutaneous malignancy involving right nasal lobule-dorsum junction. (a) Cutaneous defect
after tumor extirpation. (b) Bilobe ap inset. Patient at 3-month follow-up visit: (c) anteroposterior view and (d) oblique view.
a
b
d
c

94
I Planning and Decision Making in Reconstructive Surgery
Fig. 6.8 A patient with history of cutaneous malignancy involving multiple aesthetic sub-
units of right side of nose. (a) Cutaneous manifestations of nose malignancy (anteroposterior
view). (b) Cutaneous manifestations of nose malignancy (lateral view). (c) Cutaneous mani-
festations of nose malignancy (oblique view). (d) Resultant cutaneous defect with removed
cartilage. (e) Replaced cartilage framework. (f) Raised left-sided paramedian forehead ap.
(g) Flap inset. (continued)
a
b
c
d
e
f
g

6 Current Options for Head and Neck Reconstruction
95
Fig. 6.8 (continued) (h) Patient at 6-week follow-up. (i) Flap division. (j) Flap inset and primary closure of donor site. Patient at 5-month follow-up visit:
(k) anteroposterior view, (l) lateral view, and (m) oblique view.
k
l
m
h
i
j
achieve superior functional outcomes. The optimal results are
seen where maximal local tissue is preserved prior to introduc-
ing free tissue transfer.
Many defects less than one-quarter of the upper lip or one-
third of the lower lip can be closed prim arily with some exci-
sion of the white roll and vermillion border, allowing movement
of the native labial edges. Various local aps are also used to
close these sm aller defects, including V-to-Y arrangem ents and
stair-stepping incisions.
Larger defects that cannot be closed primarily require the
use of more extensive local tissue rearrangement or tissue trans-
fer. Often these defects may involve cheek, requiring combined
reconstruction e orts. When possible, it is ideal to split these
dual reconstructions into a separate lip reconstruction and cheek
reconstruction using their respective techniques. If a single ap is
desired for combined coverage, an Abbé or lip switch can be used.
Occasionally cheek advancem ent aps, particularly the Webster,
Bernard, and Karapandzic ap techniques, m ay provide su cient
tissue to close cheek and lip defects in continuity and avoid com -
plications microstom ia often seen in prim ary closure. Cheek ad-
vancement aps are best suited for lower lip defects, as upper lip
defects have less available tissue and are further lim ited by the
potential for distortion of the nose. Older patients with increased
cheek laxity make ideal candidates.
Karapandzic aps cam e into favor because they resulted in
vascularized and innervated lip reconstruction with greatest po-
tential for preserved sphincter function. This technique does not
increase lip tissue mass, however, and may not be appropriate if
the resultant oral opening will be too small. Generally, defects
compromising up to two-thirds of either lip can be reconstructed

96
I Planning and Decision Making in Reconstructive Surgery
Airway compromise may result from a loss of airway stability
and tongue support necessitating tracheostomy. Malocclusion of-
ten develops as a result of a shift in the position of the mandible
following mandibulectomy. Mandibular reconstruction following
ablative surgery optimally preserves speech, swallowing, and air-
way integrity. It restores lower facial aesthetics and enables sub-
sequent dental reconstruction. The gold standard in mandibular
reconstruction is microvascular tissue transfer, though a variety
of pedicled aps and nonvascularized bone grafts exist (pectoralis
major osteomyocutaneous ap). The functional and aesthetic re-
sults obtained with microvascular tissue transfer are superior to
those obtained with nonvascularized bone grafts or pedicled tis-
sue transfers; however, microvascular reconstruction requires lon-
ger operative times and may not be possible in the elderly or those
with comorbidities. Smaller mandibulectomy defects may be
reconstructed with nonvascularized grafts and metal plates, but
such defects are rare. In most patients, mandibulectomy defects
involve a large segment of the bony mandible, the internal oral
lining, and/or the external skin. Free tissue transfer provides su -
cient bony and soft tissue coverage with a reliable vascular supply.
In general, vascularized bone aps are used to reconstruct mandi-
bulectomy defects greater than 5 to 6 cm and composite defects.
Vascularized bone aps have high bone union rates because the
aps heal by primary bone healing, similar to how fractures heal.
In contrast, nonvascularized bone grafts heal by osteoconduction.
The mainstay of mandibular reconstruction is the free bula
ap as it has the widest application (Fig. 6.9). This ap provides
up to 25 cm of bone, which is su cient to reconstruct any man-
dibular defect. Furthermore, the shape of the bula is relatively
consistent, and since the bone receives both an interosseous and
segmental blood supply, osteotomies can be made at intervals to
conform sections of the bone to a locking reconstruction plate
modeled on the resected mandible. In addition, a skin paddle
may be harvested to provide soft tissue coverage. Harvest of the
central bula is well tolerated provided 5 cm of proximal and dis-
tal bula are preserved in situ for tibial stability. The length and
caliber of the pedicle vessels are su ciently large to be anasto-
mosed to vessels in the neck. The free bula ap does not pro-
vide su cient mandibular height relative to a dentate mandible,
which may be problematic when dental implants are planned for
occlusal rehabilitation. A “double barrel ap” or vertical distrac-
tion of the ap has been described to compensate for this limita-
tion. Secondary ap sources for mandible reconstruction include
the iliac crest, scapula, and radial forearm . The iliac crest ap pro-
vides the most bone and has a contour that resembles the natural
mandible; however, it has a short vascular pedicle, lacks segmen-
tal perforating vessels thereby limiting its use in osteotomies, and
can be associated with signi cant donor site morbidity. The free
scapular ap can provide up to 14 cm of bone while supplying a
large quantity of soft tissue perfused by a single vascular pedicle.
It is ideal for through-and-through defects, but its location may
inhibit simultaneous tumor resection and graft harvest. The ra-
dial forearm ap provides 10 to 12 cm of bone while providing
a large pedicle and a large, thin, and pliable skin paddle that is
ideal for intraoral lining. The bone is thin and may not allow for
multiple osteotomies, and the limited height is suboptimal for
implant use. To prevent fracture of the radius at the donor site,
keel-shaped osteotomy and preplating have been described.
with this technique. Several approaches have been described.
The usual principles of rotational aps apply: hide the sem icir-
cular incisions in the nasolabial fold when possible and only cut
mucosa as necessary to complete the intraoral repair. Defects
involving the entire lower lip can be reconstructed using an ex-
tended form of the Karapandzic ap, wherein cheek extensions
are formed from the main lip elements to enhance the lip stock.
The nonextended Karapandzic ap can also be used for near-total
or total lower lip defects; however, secondary lip balancing, in-
cluding Abbé aps from the remaining lip, will frequently
be required. The gingivolabial sulcus is often compromised by the
Karapandzic procedure and must be addressed separately.
While aesthetic considerations are largely sim ilar, functional
considerations for upper and lower lip reconstruction di er and
should impact ap selection accordingly. The upper lip functions
more as a hanging barrier and therefore simply restoring struc-
ture greatly restores function. While it is possible to reconstruct
very large upper lip defects using multistaged tissue rearrange-
ments, free tissue transfer is quite e ective. The radial forearm
ap provides excellent coverage without resulting in microstomia
as seen in local tissue rearrangements, while a super cial tempo-
ral artery-based ap can be used to recapitulate hair-bearing skin
of the upper lip.
On the contrary, the lower lip reconstruction has the added
layer of complexity in that it must attempt to prevent drooling
and food loss while providing a dynamic seal with the upper lip.
For this reason, innervation of a radial forearm free ap by co-
aptation of a sensory nerve to the inferior alveolar nerve may
provide a more functional reconstruction, though satisfactory
sensory return may occur w ithout coaptation. In order to main-
tain the anatomic location of the lower lip, a radial forearm ap
may be suspended using the palmaris longus tendon attached to
the m axilla, m odiolus, or any rem aining orbicularis oris m uscle.
Dynam ic suspension can som etim es be obtained by placing ten-
don grafts between the cheek wound boundaries under tension
with the forearm ap atop as to allow tension and ap movement
with the cheeks. Other described aps include the scapular ap,
lateral arm ap, anterolateral thigh ap, and groin ap. The grac-
ilis free ap has also been described if a functional sphincter is
desired, as this ap’s motor nerve can be coapted to branches of
the facial nerve to provide coarse motor control. Unfortunately,
the resultant bulky m ovement may only impart m inim al func-
tional improvement.
Mandible
The mandible plays a key role in mastication, deglutition, pho-
nation, and structural stabilization of the airway. The most com-
mon indication for mandibular reconstruction is ablative surgery
for neoplastic processes of the oral cavity and/or oropharynx.
Extirpative surgery includes enucleation, marginal resection, and
segmental resection. Functional losses and aesthetic deformity
depend on the size and location of the mandibular defect. Defects
in the posterior body or ramus of the mandible are generally better
tolerated than defects in the anterior mandible, which are associ-
ated with signi cant deformity and loss of function. Mastication
and deglutition are often compromised following mandibulecto-
my due to loss of structural support for the tongue and larynx.

6 Current Options for Head and Neck Reconstruction
97
Fig. 6.9 A patient with history of invasive malignancy involving right
lower eyelid and cheek. (a) Resected mandibular segment with subto-
tal glossectomy. (b) Resultant bony defect in mandible. (c) Harvest of
free bula bone ap. (continued)
b
a
c

98
I Planning and Decision Making in Reconstructive Surgery
Fig. 6.10 A patient with history of left-sided tongue malignancy. (a) View
of tongue malignancy. (continued)
a
d
Fig. 6.9 (continued) (d) Inset of bone ap with miniplate xation. (e) View of skin paddle used as monitoring segment and for oor of mouth
reconstruction.
e
Oral Cavity
The oral cavity includes the tongue, oor of the m outh, alveolar
ridges, retromolar trigone, palate, and buccal m ucosa. Oral tum or
resection results in a functional and aesthetic defect in the face
and mouth. Defects involving any of these structures can com -
promise speech, chew ing, swallowing, and breathing. The goal of
reconstruction is to not only restore aesthetics, speech, and swal-
lowing but also re-create an alveolar ridge suitable for dental re-
habilitation so that chewing can be restored.
The radial forearm free ap is an excellent option for recon-
structing thin m ucosal defects, such as those in the oor of the
mouth, buccal area, and palate, and for reconstructing the tongue
after partial glossectomy (Fig. 6.10). The lateral arm ap, which is
supplied by the posterior radial collateral vessels, and the antero-
lateral thigh ap may also be appropriate choices provided they
have a thin layer of su cient subcutaneous fat. For larger defects
requiring resection of the overlying skin, a chimeric anterolateral
thigh ap can often be employed to reconstruct both the oropha-
ryngeal and cutaneous structures (Fig. 6.11).
For full-thickness cheek defects, the radial forearm ap or
other fasciocutaneous aps can be folded in on themselves to pro-
vide an internal and external lining. Total and near-total glossec-
tomies require bulky aps to potentially restore swallowing; for

6 Current Options for Head and Neck Reconstruction
99
Fig. 6.10 (continued) (b) Partial glossectomy specimen. (c) View of resultant defect. (d) Proposed incision for radial forearm ap. (e) Raised ap. (continued)
c
b
d
e

100
I Planning and Decision Making in Reconstructive Surgery
f
Fig. 6.10 (continued) (f) Donor site at 6 months. (g) View of patient’s tongue at 6-month follow-up.
g
Fig. 6.11 Patient with history of oropharyngeal cancer. (a) On-table preoperative photograph. (b) Tumor extirpation with resultant oropharyngeal
defect. (continued)
a
b

6 Current Options for Head and Neck Reconstruction
101
Fig. 6.11 (continued) (c) Proposed anterolateral
thigh markings and perforator location. (d) Chi-
meric ap with neo-oropharynx and skin paddle.
(e) Flap inset.
e
c
d

102
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Dado DV, Angelats J. Upper and lower lip reconstruction using the step
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example, the rectus abdom inis m uscle ap or the anterolateral
thigh ap plus a portion of the vastus lateralis m uscle can pro-
vide adequate bulk for reconstructing large tongue defects.
Speech and swallowing are key functional outcom es that m ust be
considered when reconstructing glossectomy defects.
The resection of more locally advanced oral cancers that in-
vade the maxilla or mandible can result in composite defects. The
pedicled pectoralis major muscle ap can be used in these situa-
tions. In many patients, however, this ap’s bulk, lack of pliability,
and limited reach still make it a second choice behind free aps in
oral cavity reconstruction.

Conclusion
Head and neck reconstruction can pose a di cult challenge for
the plastic and reconstructive surgeon; however, employing ba-
sic surgical principles and understanding the pertinent anatomy
will lead to positive surgical outcomes. As the surgeon’s arsenal
of options increases and technology improves, patients demand
higher quality reconstruction incorporating restoration of func-
tion and optimal aesthetic outcom es. In this chapter, the authors
presented the goals of assessment and ap options for recon-
struction of several defects in the head and neck region. Sever-
al recommended options are highlighted in the aforementioned
sections. Careful consideration should be placed on the size and
extent of the defect as well as the state of the surrounding tissues.
Once these factors are taken into consideration, the appropriate
procedure can be chosen to reconstruct the defect to supply ex-
cellent form and function. The subsequent chapters in this text
expand upon the aps mentioned in this chapter and guide the
reader through comprehensive anatomy and surgical techniques.
Suggested Further Reading
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379–393
Bocchi A, Baccarani A, Bianco G, Castagnetti F, Papadia F. Double V-Y
advancement ap in the m anagement of lower lip reconstruction.
Ann Plast Surg 2003;51:205–209
Burget G, Menick F. Aesthetic Reconstruction of the Nose. St. Louis:
Mosby; 1993
Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty
and blood supply. Plast Reconstr Surg 1989;84:189–202
Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast
Reconstr Surg 1985;76:239–247
Calhoun KH. Reconstruction of small- and medium -sized defects of the
lower lip. Am J Otolaryngol 1992;13:16–22
Chandler DB, Gausas RE. Lower eyelid reconstruction. Otolaryngol Clin
North Am 2005;38:1033–1042
Chang KP, Lai CS, Tsai CC, Lin TM, Lin SD. Total upper lip reconstruction
with a free temporal scalp ap: long-term follow-up. Head Neck
2003;25:602–605
Clairmont AA. Versatile karapandzic lip reconstruction. Arch Otolaryngol
1977;103:631–633
Codner MA. Reconstruction of the eyelids and orbit. In: B. Achauer, ed.
Plastic Surgery: Indications, Operations, and Outcomes. Vol. 3. St.
Louis: Mosby; 2000:1425–1454
Converse JM. Reconstruction of the nose by the scalping ap technique.
Surg Clin North Am 1959;39:335–365
Crow ML, Crow FJ. Resurfacing large cheek defects with rotation aps
from the neck. Plast Reconstr Surg 1976;58:196–200
Cutler NL, Beard C. A m ethod for partial and total upper lid reconstruc-
tion. Am J Ophthalm ol 1955;39:1–7

6 Current Options for Head and Neck Reconstruction
103
Rashid M, Hanif MS, Illahi I, Aslam R, Hameed S, Masood T. Reconstruc-
tion of lip defects with the karapandzic technique. J Coll Physicians
Surg Pak 2003;13:219–222
Reinert S. The free revascularized lateral upper arm ap in maxillofacial re-
construction following ablative tum our surgery. J Craniomaxillofac
Surg 2000;28:69–73
Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis of the abbe
ap. Laryngoscope 2001;111:382–386
Serletti JM, Tavin E, Moran SL, Coniglio JU. Total lower lip reconstruction
with a sensate composite radial forearm -palm aris longus free ap
and a tongue ap. Plast Reconstr Surg 1997;99:559–561
Shestak KC, Roth AG, Jones NF, Myers EN. The cervicopectoral rotation
ap—a valuable technique for facial reconstruction. Br J Plast Surg
1993;46:375–377
Smith B, Obear M. Bridge ap technique for large upper lid defects. Plast
Reconstr Surg 1966;38:45–48
Spinowitz AL, Stegm an SJ. Partial-thickness wedge and advancement ap
for upper lip repair. J Dermatol Surg Oncol 1991;17:581–586
Stark RB, Kaplan JM. Rotation aps, neck to cheek. Plast Reconstr Surg
1972;50:230–233
Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle ap
technique. Ophthalmology 1978;85:1164–1169
Tenzel RR. Reconstruction of the central one half of an eyelid. Arch Oph-
thalmol 1975;93:125–126
Terashi H, Kurata S, Hashimoto H et al. Free composite graft for lip recon-
struction after tumor excision. Ann Plast Surg 1996;36:582–585
Upton J, Albin RE, Mulliken JB, Murray JE. The use of scapular and
parascapular aps for cheek reconstruction. Plast Reconstr Surg
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Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined anterolat-
eral thigh ap and vascularized bula osteoseptocutaneous ap in
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Reconstr Surg 2002;109:45–52
Weinzweig N, Jones NF, Shestak KC, Moon HK, Davies BW. Orom andibu-
lar reconstruction using a keel-shaped m odi cation of the radial
forearm osteocutaneous ap. Ann Plast Surg 1994;33:359–369;
discussion 369–370
Wells MD. Scalp reconstruction. In: Mathes SJ, ed. Plastic Surgery. Vol. 2.
Philadelphia: Elsevier Saunders; 2006:607
Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC. Use of free
thin anterolateral thigh aps combined with cervicoplasty for
reconstruction of postburn anterior cervical contractures. Plast
Reconstr Surg 2002;110:39–46
Yoshimura Y, Nakajima T, Nakanishi Y, Yoneda K. Secondary correction of
bilateral cleft lip deformity with simultaneous abbe ap and nasal
repair. J Craniom axillofac Surg 1998;26:17–21
Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction of scalp defects
with free aps in 30 cases. Br J Plast Surg 1998;51:186–190
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New York: Raven; 1995:99–117
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Avoiding ectropion by using the m itek anchor system for ap xa-
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Current Options for Lower Limb
Reconstruction
Sujatha Tadiparthi and Kayvan Shokrollahi
7
104

Introduction
Managem ent and reconstruction of lower lim b traum a have
changed dramatically over the last century. The First World War
(1914–1918) was a turning point in history with regard to wound
management and trauma surgery. Whereas limb amputation
was the predominant method of treatment prior to World War I,
advances in antibiotics, aseptic techniques, anaesthesia, wound
care, fracture m anagem ent, and soft tissue reconstruction have
led to the modern era of limb salvage and functional reconstruc-
tion. Recent developm ents in skeletal xation and soft tissue
coverage with free tissue transfer and local fasciocutaneous aps
and increasing use of negative pressure therapy have contributed
signi cantly to higher limb salvage rates.
Providing a stable skeletal xation and coverage with
well-vascularized soft tissue in an expeditious manner has
remained the gold standard throughout for lower limb recon-
struction. However, over time, the goal posts have moved beyond
achieving a healed wound with good soft tissue cover. Minim iz-
ing the donor site morbidity, optimizing the patient’s long-term
functional status, and maintaining a good aesthetic appearance
have also become important aspects of reconstruction (Fig. 7.1).

Assessment of Patients
with an Acute Lower
Limb Injury
Patients with lower extremity injuries caused by high-energy
traum a often have concom itant injuries that are potentially life
threatening. In a patient with m ultisystem injuries, the patient
Fig. 7.1 Timeline of important events throughout history related to lower limb reconstruction.1

7 Current Options for Lower Limb Reconstruction
105
Fig. 7.2 Algorithm for appropriate management of lower extremity wounds.
needs to be stabilized and life-threatening injuries should be
given priority. Therefore, in the acute phase, simultaneous as-
sessment and treatment should be undertaken according to ad-
vanced trauma life support (ATLS) principles (Fig. 7.2).
Once stabilized, focus can then turn to the lower lim b
injury. Accurate preoperative evaluation of the patient w ith a
lower extrem ity wound is essential in developing a successful
treatm ent plan. The decision to salvage the lim b is dependent
not only on the nature of the injury but a variety of other patient
factors coexisting com orbidities, risk factors such as sm ok-
ing and body m ass index, occupation/socioeconom ic factors,
compliance/m otivation, social support, and level of m obility
prior to the injury. Consideration of these factors is critical for
success of the reconstruction as well as the rehabilitation of
the patient. Therefore, a thorough history should be taken and
physical exam ination of the lim b should be perform ed to assess
the extent of the injury, the tissues involved, and suitability
of the lim b for salvage. Important aspects of the history and

106
I Planning and Decision Making in Reconstructive Surgery
displacement of the bony fragments, bone loss, and seg-
mental injury.

●
Depending on the nature of the injury, specialized monitor-
ing may also be required, such as compartment pressures
in suspected compartment syndrome and handheld Dop-
pler for pulses that are not palpable.
Scoring Systems
A variety of systems have been developed for the assessment of
lower limb injuries. Some are classi cations used to grade the
extent of the injury, whereas others are scoring systems used to
identify patients who would bene t from primary limb amputa-
tion rather than salvage.
The m ost widely used system to describe the severity of open
tibial fractures is the Gustilo-Anderson classi cation (Table 7.1).
First described in 1976 and later m odi ed in 1986, this system
is applied after debridement of the wound. Although the Gust-
ilo-Anderson classi cation has been criticized for not including
certain criteria such as nerve damage, it does provide a simple
and standardized system for easier communication among clini-
cians, as well as a means of classi cation for audit and research
purposes. Gustilo type IIIB and type IIIC fractures most frequent-
ly require major soft tissue reconstruction.
The decision to amputate or salvage a severely injured lower
extremity can be challenging. Failed e orts at limb salvage are as-
sociated with increased complications (including mortality) and
higher hospital costs. Scoring systems have been developed to
quantify the severity of the injury and help assist the surgeon in
making the initial decision whether to salvage or amputate the in-
jured limb. Published lower extremity injury severity scoring sys-
tems include the Mangled Extremity Severity Score (MESS); the
Predictive Salvage Index (PSI); the Limb Salvage Index (LSI); the
Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock,
and Age of Patient (NISSSA) Score; and the Hannover Fracture
Scale-97 (HFS-97). Recent studies evaluating the clinical utility
of lower extremity injury severity scoring systems have criticized
the retrospective design and small sample sizes used to develop
the scores, heavy reliance on neurological examination ndings at
initial presentation, and lack of sensitivity of the scoring systems.
Ischemia, contusion, stretch, or compression can cause transient
neurological injury, and any acute sensory impairment may not
exam ination in the assessm ent of a patient w ith a lower lim b
injury are outlined here.
History
Patient factors include:

●
Age

●
Occupation

●
Comorbidities: diabetes, peripheral vascular disease, car-
diovascular, and respiratory disease

●
Smoking status

●
Body mass index

●
Tetanus status

●
Level of mobility and independence preinjury, available
social support during the rehabilitation phase
Trauma-related factors include:

●
Timing of injury

●
Mechanism of injury: high or low energy

●
Degree of contamination

●
Duration and severity of any crush injury
Physical Examination

●
Location and size of wounds

●
Degree of contamination

●
Soft tissue injury/defect

●
Exposure of vital structures such as bone, tendon, joint,
nerves/vessels, or metalwork

●
Vascular status and presence of pulses

●
Limb sensation and presence of nerve injury

●
Signs of compartment syndrome
Investigations

●
In a patient with multiple injuries, a “trauma series”—
radiographs of chest, pelvis, and cervical spine—are in-
dicated initially as per ATLS guidelines to exclude any
life-threatening injuries.

●
Radiographs of the lim b should then be perform ed to as-
sess extent of the bony injury: degree of comminution and
Table 7.1 Gustilo open fracture classi cation
Gustilo grade
De nition
I
Open fracture, clean wound, wound , 1 cm in length
II
Open fracture, wound . 1 cm in length without extensive soft tissue damage, aps, or avulsion
IIIA
Open fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture; however, there is adequate
periosteal coverage of the fracture bone
IIIB
Open fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture; there is extensive soft tissue
loss and periosteal stripping and exposure of bone
IIIC
Type III fracture associated with an arterial injury requiring repair, regardless of the soft tissue damage
Source: Data from Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classi cation of type III open fractures.
J Trauma 1984;24:742–746.

7 Current Options for Lower Limb Reconstruction
107
such as MESS, NISSA, and Hanover Fracture scales, are heavily
dependent on initial plantar sensation and should be used cau-
tiously in decision m aking. The m ain indications for amputation
are sum marized in Table 7.2.

Timing of Debridement
and Reconstruction
Historically, serial debridement and second-look procedures
with delayed soft tissue coverage were the widely accepted
means of treating lower limb injuries. However, the need for sev-
eral anesthetic procedures, high incidence of nonunion and os-
teomyelitis, and prolonged length of hospitalization and time to
recovery resulted in poor outcomes, and these multiple debride-
ments were deemed unnecessary.
Work published by Godina in 1986 changed this practice and
popularized the concept of “early” soft tissue coverage. Godina’s
retrospective data revealed clearly how radical debridement and
early wound coverage with vascularized tissue within 72 hours af-
ter the injury resulted in fewer ap failures (0.75%), reduced wound
infection rates (1.5%), shorter time to bone healing (6.8 months),
and shorter hospitalization time compared with reconstructions
between 72 hours and 3 months and those beyond 3 months. Nu-
merous studies including the LEAP study have advocated early soft
tissue cover within 7 days as there is clear evidence that delayed
reconstruction leads to poor outcomes with higher rates of wound
infection, wound healing problems, free ap loss, and delayed
bone union. Beyond this acute phase, the complication rates in-
crease signi cantly as the wound becomes colonized and there is
increasing presence of friable granulation tissue.
Gopal and colleagues advocated the concept of “ x and ap”
within 24 hours whenever possible. They demonstrated a lower
rate of deep wound infection (3%) in cases that underwent imme-
diate debridement and reconstruction in a single stage compared
re ect the nal neurological de cit. These scoring systems should
be used cautiously as they are not necessarily good predictors
of limb salvage or amputation or of the likely functional recov-
ery after successful limb salvage. Decisions regarding amputation
should therefore be made on an individual basis for each patient
after an accurate clinical assessment of the injury and collabora-
tion between experienced orthopedic and plastic surgeons.

Indications for
Amputation and
Limb Salvage
After assessment of the patient and his or her injuries by senior
plastic and orthopedic surgeons, it is important to determine if
reconstruction of both the bony and soft tissue defects and limb
salvage are feasible. The decision regarding limb salvage can be
challenging, and indications for amputation m ay vary am ong dif-
ferent surgeons and units depending on their training and pre-
vious experiences. When reconstruction is planned, ensuring a
satisfactory functional outcome is the main criterion and not just
achieving a healed wound. Francel and colleagues compared out-
com es of patients who underwent lim b salvage with those who
had primary amputation. Patient satisfaction after reconstruction
and limb salvage was 96% despite 66% having a decreased range
of motion and only 28% of patients returning to work at 2 years.
In contrast, 68% of amputees returned to work within 2 years.
Therefore, patients should be fully inform ed that even though
reconstruction is possible, there are long-term implications for
their functional status and it m ay take m onths to years for return
to normal weight bearing and employment. Both the patient and
family should also be involved in the discussions throughout to
make an inform ed decision regarding lim b salvage or amputation.
Traditionally, an insensate foot at initial presentation was
thought to be an absolute indication for amputation due to
likelihood for poor functional outcom e with lim b salvage. Loss
of plantar sensation leads to loss of some positional sense and
chronic injury to the plantar aspect of the foot. In a study ex-
am ining the initial treatment decision m aking in severe lower
lim b injuries, tibial nerve dysfunction was the m ost important
factor resulting in limb amputation, ranking even higher than
lim b ischem ia. However, loss of plantar sensibility on initial pre-
sentation is no longer thought to be an absolute indication for
lim b amputation as this may be temporary from neurapraxia
or reversible ischem ia of the peripheral nerves. The LEAP study
assessed long-term outcomes in patients who were insensate at
presentation. Of those who had an insensate foot at initial pre-
sentation, 55% had norm al plantar sensation at 2 years as well
as physical and psychosocial scores similar to those who had an
initial amputation for an insensate foot. Therefore, initial plan-
tar sensory status is not always prognostic of long-term plan-
tar sensory status or functional outcom es and should not be a
component of lim b salvage decision-m aking algorithm. Altered
plantar sensation requires surgical exploration of the tibial nerve
at the tim e of debridem ent. Structural continuity of the nerve
should prompt an expectant approach rather than a decision
to amputate. As m entioned earlier, many of the severity scores,
Table 7.2 Indications for amputation and limb salvage
Indications for
limb salvage
• Limb injury in a child
• Adults with reconstructible bony and soft tissue
loss with intact sensibility
Absolute
indications for
amputation
• Avascular limb with a warm ischemia time
greater than 4 to 6 hours
• Unstable patient with severe life-threatening
polytrauma (life before limb)
Relative
indications for
amputation
• The presence of life-threatening comorbidities
that preclude prolonged salvage procedures
• Multiple levels of injury or segmental tibial
fractures
• Segmental bone loss greater than a third of the
length of the tibia
• Segmental muscle loss across more than two
compartments (especially involving the posterior
compartment)
• Insensate limb
• Severe ipsilateral foot trauma
• Projected long course for reconstruction and
recovery

108
I Planning and Decision Making in Reconstructive Surgery
must also be provided to cover the m etalwork to minimize
infection rates.

●
De nitive coverage of the defect w ith vascularized soft tis-
sue is recommended within 7 days of the injury, as compli-
cations are higher after this acute period with increasing
wound contamination, presence of friable granulation tis-
sue, perivascular soft tissue edema, and eventually brosis.

●
Managem ent of complex lower lim b injuries should be in
a tertiary center by a multidisciplinary team with the in-
volvement of orthopedics, plastic surgery, radiology, mi-
crobiology, physiotherapy, and psychology.

Principles of
Reconstruction
Reconstruction should only be attempted when the patient is
physiologically stable, local vascularity is ensured, the wound has
been thoroughly debrided and is free of infection, and stable skel-
etal xation has been achieved. A range of reconstructive options
are available for lower limb defects. Choosing the most appropri-
ate method of reconstruction requires good clinical judgment and
an accurate assessment of the defect after initial debridement. For
the initial reconstruction, the procedure that is likely to give the
best chance of success should be undertaken to avoid the devastat-
ing consequences of a failed reconstruction resulting in increased
soft tissue loss, nonunion, osteomyelitis, and even amputation.
For wounds w ith a well-vascularized bed and no exposure of
vital structures, resurfacing of the defect with skin grafts or heal-
ing by secondary intention is su cient. Wounds with exposed vi-
tal structures, including bone, tendons, major nerves, and blood
vessels, require coverage with either a local fasciocutaneous or
muscle ap or free tissue transfer. Flap selection is based on size
and location of the defect, ap constituents required, presence
of metal work, accessibility and vascularity of the local tissues,
available donor sites and recipient vessels for free tissue transfer,
and patient factors such as presence of comorbidities and tness
for anesthesia, patient preference, level of motivation, compli-
ance, and socioeconomic factors. Local aps are suitable for use in
small defects resulting from low-energy trauma and in patients
who are not suitable for complex reconstruction with prolonged
anesthesia. Free aps are preferred for defects too large for cover
by local aps, and where the vascularity of the local tissues is
compromised by the injury.
NPWT has been shown recently to play a useful role in pa-
tients with defects with exposed vital structures that are not
suitable for complex reconstruction and when local ap options
are not available. The device stimulates the formation of granula-
tion tissue at the wound site, which can either be left to heal by
secondary intention or skin grafted.

Options for Reconstruction
of Lower Limb Defects
With the leg topographically divided into thirds (Fig. 7.2), the
common local reconstructive options include the following.
to those performed within 24 to 72 hours (10%) and longer than
72 hours (30%). The use of external xators was also associated
with pin tract infections and increased rates of non- and malunion,
and posed practical di culties in gaining access for reconstruc-
tion. Although single-stage debridement with immediate soft tis-
sue reconstruction may be suitable for a stable patient with an
acute noncontaminated wound, it may not be possible in unstable
patients with grossly contaminated wounds or in units that lack
the adequate resources or experienced sta to perform immedi-
ate reconstruction. Any complex reconstruction is best performed
under elective conditions by experienced orthoplastic teams once
the patient is stabilized and appropriately investigated.
Godina’s work pioneered a com bined orthopedic and plas-
tic surgery approach to achieve an optimal outcome in terms of
wound coverage and bone healing. This collaboration between
the two specialties has become the standard, achieving consis-
tently high lim b salvage rates. Recom m endations for the success-
ful treatment and reconstruction of open lower lim b fractures are
set out by the joint working committee of the British Association
of Plastic Surgeons and British Orthopaedic Association. An algo-
rithm for the management of lower limb wounds is presented in
Fig. 7.2, and the salient points of the guidance are outline here:

●
Immediate surgical exploration is recommended where
there is a devascularized limb, gross contamination of the
wound, compartment syndrome, or in the presence of mul-
tiple injuries. In grade IIIC injuries, urgent surgical explo-
ration with an on-table angiography is recommended to
prevent any unnecessary delays, as well as the use of a shunt
for prompt revascularization and to minimize ischemic time.

●
In patients in whom immediate surgical exploration is not
warranted, treatment should be within 24 hours. Admin-
istration of intravenous antibiotics, thorough debridement
of devitalized and contaminated tissue under tourniquet
control (to allow identi cation and preservation of neuro-
vascular bundles), wound lavage, assessment of the extent
of soft tissue injury and degloving, and stabilization of frac-
tures within 24 hours of injury are recom m ended. Wound
debridement within the rst 24 hours and administration
of broad-spectrum antibiotics within 3 hours have been
shown to signi cantly reduce rates of infection. However,
no signi cant di erence in outcomes has been observed in
terms of infection, time to union, nonunion rates, number
of surgical procedures, admissions, inpatient stay, time to
weight bearing, walking speed, and time to return to work,
regardless of whether the wounds were debrided within
6 hours or within 24 hours.

●
A spanning external xator is a convenient technique for
skeletal stabilization after primary debridement when de-
nitive closure is not provided. The position of the pin sites
for the external xator should be determined by collabo-
ration between the orthoplastic team s so that any future
reconstructive options are not compromised and exposure
for soft tissue reconstruction and microsurgical repair is
maintained. If de nitive skeletal xation and soft tissue
cover is not provided in a single stage, negative pressure
wound therapy (NPWT) should be used as temporary
wound cover. If there is minimal contamination and the
fractures are stabilized by internal xation, de nitive cover

7 Current Options for Lower Limb Reconstruction
109
fasciocutaneous aps can be feasible. Distally based fasciocuta-
neous aps based on the perforators from the peroneal or poste-
rior tibial arteries are an option providing the defect is of sm all
to moderate size following a low-energy injury and there is no
degloving of the tissues that may compromise the vascularity of
these aps. These fasciocutaneous aps can be islandized to al-
low greater arc of rotation and better cosmesis. The distally based
(reverse) sural ap is a versatile fasciocutaneous ap that allows
the harvest of up to 14 cm from the posterior calf and can be used
to cover defects over the ankle, distal leg, and foot.

Imaging Before
Reconstruction
In severe lower limb injuries, recipient vessels in the zone of
trauma m ay be transected, crushed, or thrombosed. Failure to
identify the extent of injury to the recipient vessels can have di-
sastrous consequences to any reconstruction with local aps or
free tissue transfer (Lutz et al). Accurate assessment of the extent
of the injury, the vascular tree, and patency of the recipient ves-
sels can facilitate in the planning of the soft tissue reconstruction
and coordination with the orthopedic team.
Computed tomography (CT) angiography is widely accepted
as the best imaging tool for lower limb injuries as it allows ex-
cellent three-dimensional volumetric analysis of vessels to assess
the patency of vessels and quality of ow, anatom ical variations,
and atherosclerosis, and unlike conventional angiography it pro-
vides inform ation on the venous systems, surrounding soft tis-
sues, fractures, and metallic hardware. It is also quicker, cheaper,
less invasive, and ensures less radiation exposure. In contrast,
conventional angiography requires arterial puncture and can be
complicated by bleeding, hem atom a, arteriovenous stula, false
aneurysm, and thrombosis and has largely fallen out of favor.
Compared to CT angiography, magnetic resonance (MR) angiog-
raphy is more tim e consum ing, provides inferior visualization
of surrounding bony structures and atherosclerosis, is more
sensitive to motion artifacts, and is of limited use in patients
with hardware or other metallic implants or who su er from
claustrophobia.
The role of prereconstruction im aging is controversial.
While som e surgeons consider im aging to be unnecessary
whenever pulses are clinically palpable, others argue that va-
sospasm , soft tissue edem a, and vasoconstriction after injury
can m ake palpation of pedal pulses challenging, thus m aking
clinical assessm ent unreliable. Recent studies have highlighted
the importance of investigation w ith CT angiography prior to
reconstruction for lower lim b traum a. In a retrospective re-
view of 68 patients w ith Gustillo and Anderson IIIB injuries
who underwent free ap reconstruction, a vascular injury on
CT angiography was noted in 26.5% of patients w ith palpable
pulses. Furtherm ore, in a study of 76 patients w ith lower lim b
injuries, Duym az and colleagues reported traum atic arterial oc-
clusion in 28.9% (n 5 22), anatom ical variation in 5.2% (m ost
com m only a hypoplastic anterior tibial artery), and atheroscle-
rotic occlusive disease in 7.9%. Of the 22 patients w ith arterial
injury on CT angiography, 14 had either norm al palpable pulses
or audible Doppler signals (64%). CT angiography can help w ith
Knee and Proximal Third
Leg Wounds
Proxim al third leg injuries, including those involving the knee,
can often be treated su ciently by transposing local m uscle
aps. Free tissue transfer is not commonly needed unless local
ap options are not available or the defect is extensive requiring
coverage with a large well-vascularized tissue.
The rst choice for the knee and upper third of leg defects
remains the gastrocnemius ap, which is taken as a muscle-only
ap with an overlying skin graft. The medial head of the gastroc-
nemius is preferred as it is longer and broader. However, either
the m edial or lateral head or both can be used (without causing
any functional de cit) depending on the location and size of the
defect, any preexisting wounds, and previous scars. To increase
the arc of rotation and gain additional length for wound coverage,
the proxim al tendon can be divided taking care to preserve the
pedicle and scoring the muscular fascia longitudinally and trans-
versely. When the lateral gastrocnemius head is used, ap rota-
tion m ay be lim ited by the bular head and care should be taken
to avoid injury to the common peroneal nerve.
Other local options or upper third of leg include the distally
based anterolateral thigh ap with retrograde ow based on a
collateral circulation arising from the geniculate vessels with
anastomoses to the descending branch of the lateral circum ex
femoral system. Proximally based Ponten-type fasciocutaneous
aps can also be used. These fasciocutaneous aps have the ad-
vantage of being easier to elevate for secondary procedures, such
as insertion of knee prosthesis, compared to the gastrocnemius
muscle ap.
Middle Third Leg Defects
As in the case of m id-third defects, m uscle aps such as the gas-
trocnem ius muscle and hem isoleus muscle aps can be used for
coverage of wounds involving the m iddle third of the leg. The so-
leus is a powerful muscle that plays an important role as a venous
pump, in plantar exion of the foot, and in maintaining posture
while standing. The hemisoleus ap maintains some of these
muscle functions and can be a useful option in patients not suit-
able for complex free ap reconstruction.
Although the local options are useful, high-energy wounds in
the mid-leg area are often associated with a large zone of injury,
and in such situations, free aps are more reliable.
Lower Third Leg and
Ankle Defects
Free tissue transfer is often the preferred m ethod of reconstruc-
tion of defects in the distal third of the leg and ankle due to the
limited availability of local tissues. An important consideration is
to match the thickness of the ap with that of the defect. Other-
wise a bulky free ap that does not match the thinner, native tis-
sue of the lower leg can compromise the function and aesthetics
of a reconstruction.
In patients who are not candidates for free ap recon-
struction, depending on the size and location of the wound,

110
I Planning and Decision Making in Reconstructive Surgery
anastom oses should be to the deep veins accompanying the ar-
tery used for the anastom osis. In situations where there is poor
venous drainage, anastom oses to a super cial vein or retrograde
venous ow can be considered.
To avoid the zone of trauma, Godina emphasized the useful-
ness of a posterior approach with a midline posterior muscle split
and the creation of a tunnel from the anterior compartment to
the posterior and end-to-side anastomoses to the posterior tibial
vessels.

Reconstruction with
Free Tissue
The proven success of free tissue transfer has m ade this the cor-
nerstone in the management of complex high-energy lower ex-
trem ity wounds. Indications for m icrovascular tissue transfer for
reconstruction following lower extremity trauma include large
defects, high-energy injuries, middle and distal third tibial and
ankle wounds, large segmental bone loss, osteomyelitis, and non-
unions. Free tissue transfer provides healthy, well-vascularized
tissues where there are no locoregional options and aids fracture
healing.
Choice of ap for reconstruction is an individualized process
and is determined by several factors including size and location
of the wound, type of tissue de cit, components to be replaced,
degree of dead space to be lled, length of the pedicle required,
characteristics of the recipient site, need for intraoperative po-
sitioning, availability of donor sites, patient preferences, and
anticipated aesthetic result. Other important considerations for
free ap surgery include the available facilities and the skill and
experience of the operating surgeon.
For lower limb defects, latissimus dorsi, gracilis, anterolateral
thigh, scapular, and parascapular aps currently remain the m ain
choices for reconstruction. The latissimus dorsi muscle is a large,
broad, and at muscle with a long vascular pedicle. The latissimus
dorsi free ap is suitable for large defects and it can be raised in
com bination with the serratus m uscle if the defect is particularly
extensive. The rectus abdom inis free ap also has a long vascular
network and provides a large amount of tissue, although its width
is narrower than the latissimus dorsi. The rectus abdominis ap,
although previously used commonly, has fallen out of favor due
to the donor site morbidity with potential abdominal hernia or
weakness. The gracilis ap is a good option for smaller defects
and its donor site morbidity is minimal with a well-hidden scar
and no functional de cit. The anterolateral thigh (ALT) ap has
become the main choice in many units for reconstruction of low-
er lim b defects. The bene ts of this ap have been w idely report-
ed and include a long pedicle with large-caliber vessels, abundant
tissue, potentially a sensate ap, chim eric ap options, m inim al
donor site morbidity, two-team approach in the supine position,
and potential for inclusion of fascia or muscle within ap tendon
reconstruction or to ll dead space.
Microsurgical reconstruction is versatile, and extrem es of
age and smoking are not contraindications. Free tissue transfer
can be perform ed safely and successfully both in children and
the elderly with good long-term results with careful preoperative
reconstructive planning by reliably identifying arterial injury,
venous throm bosis, possible recipient vessels, level of healthy
recipient vessels out of the zone of injury, atherosclerosis, and
the assessm ent of the donor site.
Angiographic evaluation of limb vascularity is now indicated
in these situations:

●
High-energy lower limb trauma

●
Loss of one or more peripheral pulses

●
Neurologic de cit secondary to the injury

●
Compound fracture of the extremity that has undergone
either external or internal reduction

●
History of peripheral vascular disease or diabetes with
abnormal ankle-brachial index

Choice of Recipient
Vessels
Selection of appropriate recipient vessels is a crucial step in suc-
cessful free tissue transfer. The anterior tibial artery, due to its
m ore anterior and super cial location, is the m ost com m only
injured vessel in lower lim b traum a w ith injury rates of 32 to
64% being reported in literature. Posterior tibial and peroneal
vessel injury is less com m on w ith rates of 2 to 32% and 16 to
27% reported, respectively. The high incidence of vessel injury
further advocates the importance of im aging to delineate the
anatomy and plan the reconstruction. Posterior tibial vessels are
often the recipient vessel of choice as they are less often dam -
aged due to the posterior location and the protection o ered by
the tibia.
In high-energy injuries, the “zone of injury” (which refers
to the soft tissue in ammatory response to the trauma) can ex-
tend beyond the visible wound leading to increased vessel fria-
bility and perivascular scar formation resulting in microvascular
throm bosis. In order to avoid complications, extensive proxim al
dissection of the recipient pedicle should be undertaken and mi-
crosurgical anastomosis performed in a “safe zone,” where re-
cipient vessels have not been damaged by the initial trauma and
appear healthy, pliable, and demonstrate good ow. If the zone of
injury is extensive, a free ap with a long pedicle m ay be required
or the use of interpositional vein grafts may be necessary to allow
proximal anastomoses to the recipient vessels.
Park and colleagues developed an algorithm for the selec-
tion of recipient vessels in free tissue transfer for lower extrem -
ity injuries. In their study, site of injury and vascular status of
the lower lim b were the m ost important factors in recipient
vessel selection. According to their algorithm , if the anterior
tibial vessels were patent w ith good ow on CT angiography,
end-to-end anastom osis was preferred due to easier access
to these vessels and their expendable nature. However, if the
anterior tibial vessels are dam aged by the traum a or there is
a large size m ism atch, end-to-side anastom osis to the PTA is
recom m ended to allow ow through and m aintain lim b perfu-
sion. When these options were lim ited, the authors also high-
lighted the usefulness of distal anastom oses reliant on reverse
arterial ow via com m unicating branches between the dorsalis
pedis artery and the plantar arch in the rst webspace. Venous

7 Current Options for Lower Limb Reconstruction
111
less pleasing. Muscle aps do, however, conform better to defects
and provide bulk to obliterate any dead space. In contrast, fascio-
cutaneous aps provide more robust and aesthetic wound cover,
are easier to monitor in the postoperative period, are easier to
elevate for secondary procedures, can provide thinner soft tissue
cover, and are easier to thin if deemed too bulky. Often the deci-
sion regarding the choice of ap is dependent on the preference
of the patient and surgeon, size and location of the wound, and
length of the pedicle required as well as the need for secondary
procedures. In some cases, chimeric aps, such as an anterolateral
thigh ap that includes a segm ent of vastus lateralis m uscle, are
invaluable as they incorporate the biological bene ts of muscle
apposition, ll dead space, and provide robust soft tissue cover.

Pedicled Fasciocutaneous
versus Free Flaps
In 1981, Ponten rst introduced the concept of including the fas-
cia to increase ap vascularity and enable a ap length-to-width
ratio of 3:1 compared to the 1:1 ratio of skin aps without fascia.
Since Ponten’s description, a variety of fasciocutaneous aps of
greater complexity and based on perforators have been described
in literature for small to mid-sized defects. Local fasciocutaneous
aps o er the advantage of a quicker, simpler, and more cost-
e ective m ethod of reconstructing defects without any distant
donor site morbidity. They are useful in patients su ering from
multiple traum a or signi cant com orbidities who would not be
suitable for prolonged and complex free ap reconstruction.
The use of local fasciocutaneous aps, however, has been
associated with a higher rate of wound complications and less
favorable functional and aesthetic results compared with free
tissue transfer. Erdm ann and colleagues report their experience
of distally based islandized fasciocutaneous aps for 61 cases
of lower limb trauma with an overall complication rate of 7.6%.
However, 20% of the Gustillo and Anderson IIIB cases (5 out of
25) su ered complete ap loss and 16% developed chronic osteo-
myelitis leading to nonunion (4 out of 25). Results from the LEAP
study also con rm a signi cantly higher complication rate of
44% with local fasciocutaneous aps compared to 23% with free
aps. Wound infection and wound necrosis were more frequent,
with local fasciocutaneous aps being 4.3 times more likely to
develop wound complications requiring operative intervention
compared to free aps. These high complication rates may be ac-
counted by the presence of peripheral vascular disease or crush
or extensive degloving of the soft tissues in high-energy trauma
with damage to the perforators ( aps within the zone of injury).
In addition, the reach of the ap and size of the defect that can be
reconstructed are often dependent on the size and location of the
perforator. Placement of the external xator should be judicious
so that use of local aps is not compromised.
Use of local fasciocutaneous aps m ay therefore be best re-
stricted to sm all defects resulting from low-energy trauma and
in patients who are not suitable for complex free ap recon-
struction. The aps should be planned outside the zone of injury
where there is no degloving, the perforators are intact, and vas-
cularity has not been compromised.
evaluation for tness for prolonged anesthesia and adequate
perioperative monitoring. Smokers also have been shown to
have similar anastom otic patency rates and free ap survival as
nonsm okers, although they have a higher rate of wound healing
problems.

Fasciocutaneous and
Muscle Flaps
Traditionally, muscle aps were preferentially used for cover-
age of lower limb defects following trauma. Experimental ev-
idence suggested that soft tissue aps not only provide wound
cover to prevent wound desiccation and infection, but the bio-
logical characteristics of the tissues in a ap play an important
role in fracture healing. Muscle aps in particular may be a rich
source of vascularity for the delivery of oxygen, growth factors,
and cells such as leukocytes and stem /osteoprogenitor cells that
are essential for healing and grow th at the fracture site. This is
an important consideration especially in tibial fractures where
vascularity is signi cantly reduced secondary to periosteal strip-
ping and disruption of the endosteum and nutrient vessels. A
study of blood ow at the ap–wound interface dem onstrated a
rapid increase in muscle blood ow in the rst 24 hours which
then plateaued, whereas a gradual and steady increase was seen
over the 6-day study period with fasciocutaneous aps. Bacteri-
al counts correlated with rates of blood ow with a rapid fall in
the rst 24 hours in muscle aps. However, similar rates of both
blood ow and bacterial counts were observed at the end of the
6-day study period in both types of aps. In contrast, Harry and
colleagues with experiments on a murine model found that at all
time points the vascular density was greater in fasciocutaneous
tissue in apposition with a periosteally stripped fracture than
muscle. Despite this, fracture repair was still more rapid in the
muscle group.
Regardless of these experimental ndings, clinical studies
have not shown any measurable di erence in outcomes between
muscle or fasciocutaneous aps. Yazar et al. performed a retro-
spective review of open tibial fractures treated with either free
muscle (n 5 98) or free fasciocutaneous aps (n 5 79) and found
no signi cant di erence in ap survival, time to bony union, or
rate of postoperative infection or chronic osteomyelitis. Functional
outcomes were also similar, with patients in both groups being
able to walk unaided at 2 years. Other clinical studies comparing
fasciocutaneous with muscle aps have also demonstrated stable
wound coverage with equal functional and quality-of-life out-
comes with both types of ap and no di erence in time to bony
union, even in the presence of infection. Therefore, fasciocutane-
ous aps can be as reliable and e ective as muscle aps for cover-
ing for lower limb defects.
There are di erences in the applicability of muscle and fas-
ciocutaneous aps that should be given consideration in the
clinical setting. Muscle aps lead to more donor site morbidity,
can be m ore challenging to monitor in the postoperative peri-
od, can be di cult to elevate for secondary procedures such as
bone grafting, and require skin grafts for coverage, which can
make them susceptible to minor trauma and can be aesthetically

112
I Planning and Decision Making in Reconstructive Surgery
compliance, with a risk of pressure sores or throm boem bolism as
a result of the immobility.
Amputation should be o ered if there are no reconstructive
options available or the patient prefers not to pursue them. Wher-
ever possible, the decision to amputate should be taken by two
senior surgeons to give absolute reassurance for both the patient
and their family that an amputation is unavoidable. The level of
amputation is an important consideration with implications for
future mobility and employment prospects. If the knee is sal-
vageable, a transtibial amputation should be performed, ideally
maintaining a stump of at least 6 cm to allow usage of a prosthe-
sis. The work of ambulation is signi cantly reduced in transtibial
amputation (25% energy and oxygen consumption) compared to
above knee amputation (65%), which can translate into function-
al capacity, especially in older age groups. In long-term follow-up
studies, those with above knee amputations tended to aban-
don their prostheses and preferred to mobilize in a wheelchair,
whereas those with below knee amputations adapted better and
achieved a quality of life comparable to their peers.

Conclusion
Management and reconstruction of severe lower limb injuries re-
main formidable challenges. Successful management requires an
accurate assessment of the patient as a whole as well as the injury
itself, a con dent decision regarding the feasibility of limb salvage,
adequate surgical planning, and collaboration between experienced
orthopedic and plastic surgeons. Ensuring a thoroughly debrided
wound, stable fracture xation, and expeditious soft tissue coverage
are the cornerstones of achieving infection-free fracture union.
Although a stable skeleton and adequate soft tissue cover are
the primary goals, with the evolution of limb reconstruction, the
aims have progressed to ensuring a functional limb, minimizing
donor site morbidity, and ensuring a good aesthetic appearance.
Treatment of these complex injuries by a multidisciplinary team
with an orthoplastic approach should be the standard of care in
order to optimize patient outcomes.
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Negative Pressure
Wound Therapy
NPWT is a useful and safe temporary m easure during the early
period while an external xator is in situ and de nitive cover is
to be provided. It serves to keep the wound clean, provides es-
sential coverage of wounds to avoid desiccation where there is
exposed bone or tendon, and reduces the frequency of dressing
changes. However, NPWT should not be used as a substitute for
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Recent studies have demonstrated the important role NPWT
can play in patients who are not suitable for complex reconstruc-
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unstable, and patients who are unlikely to comply with postop-
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the successful use of NPWT in 71 out of 75 patients w ith lower
limb wounds with exposed tendon, bone, or metalwork in whom
complex reconstruction was not possible. The sponge dressings
were changed every 48 hours with continuous subatmospheric
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stim ulate granulation tissue at the wound site to cover the ex-
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intention or be skin grafted.

Free Flap Loss and
Amputation
Failure of free tissue following reconstruction for lower lim b
traum a defects has been observed in 8% of cases. The failure rate
has been shown to be higher when there are large bone defects,
vascular trauma, or if vein grafts are used. In the event of free ap
loss, the reason for the failure should be determined: whether it
is due to problem s with the ap itself (intim al dam age through
traction or poor ap design) or due to the recipient site or recip-
ient vessels (e.g., poor in ow/out ow, ongoing infection). If the
failure was due to underlying problems with the ap, a second
free ap may be considered. Other possible donor sites should be
explored and a second free ap that is easy to harvest w ith a pre-
dictable vascular supply should be chosen. The decision to either
pursue limb salvage or consider amputation should be discussed
with the patient. In a study of failed free ap reconstructions for
extrem ities (n 5 59), 63% were treated with conservative mea-
sures, 29% had second free aps, 5% had regional aps, and 3%
underwent amputation. The average time between rst and sec-
ond free aps was 12 days.
The cross-leg ap is a potential last resort option when
limb salvage with a free ap is not possible. They are raised as
fasciocutaneous aps based on the post descending branch of the
popliteal artery with length-to-width ratio of 3:1 to 4:1. These
aps are associated with signi cant donor site morbidity, have
high complication rates (28% wound infection, 40% local ap ne-
crosis), and require a period of immobility necessitating patient

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Recipient Vessels for Microsurgery
Am ir Sadri, David M. S. Bodansky, and Kayvan Shokrollahi
8
115

Introduction
Recipient vessel selection and access are just as important to re-
constructive outcom e as is ap selection. This chapter aim s to
provide the reader w ith an overview of the common recipient
arteries and veins used for microvascular anastomosis. This is
not meant to be a rigid descriptive guide as the defect location
usually predetermines which recipient vessels are most suitable.

Upper Limb
Brachial Artery
Diameter: 4.3–4.5 mm
Anatomy
The brachial artery begins at the lower border of the teres m ajor
as a continuation of the axillary artery. It is the dominant supply
to the upper limb and bifurcates at the neck of the radius into the
radial and ulnar arteries.
The brachial artery has a relatively super cial course. In the
arm, the vessel lies between the coracobrachialis and biceps ante-
riorly, anterior to the medial intermuscular septum, and the medial
head of triceps posteriorly (Fig. 8.1). In the upper third of the arm,
the ulnar nerve and basilica vein lie medial to the brachial artery.
The brachial artery gives m uscular branches and nutrient ar-
tery to the humerus. It also gives rise to the profunda artery in
the proximal third of the arm , which travels with the radial nerve
in the spiral groove. Finally the brachial artery gives rise to the
superior and inferior ulnar collateral arteries.
Fig. 8.1 Brachial artery: 1, Coracobrachialis m.; 2, short head of the biceps m.; 3, pectoralis major m.; 4, triceps m.; 5, teres
major m.; 6, latissimus dorsi m.; 8, brachial artery; 9, brachial vein; 10, deep brachial artery; 11, median nerve; 12, ulnar
nerve; 13, radial nerve; 14, musculocutaneous nerve.1

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I Planning and Decision Making in Reconstructive Surgery
At the wrist, the artery reaches the dorsum of the hand by
passing between the tendons of the abductor pollicis longus and
extensor pollicis brevis and can be palpated in the anatomical
snu box.
Access
The surface anatomy of the radial artery can be delineated by a
line drawn from the midpoint of the antecubital fossa to the in-
sertion of the exor carpi radialis (Figs. 8.5 and 8.6). Dissection
at a desired position along this line will provide access for anasto-
mosis to radial artery. Dissection through skin, fat, and deep fas-
cia will reveal the radial artery in the distal third (Fig. 8.7). Care
is required to protect the branches of the super cial radial nerve,
Access
The brachial artery and its perforating branches are com m only
used as recipient vessels. Care must be taken to preserve its
integrity. End-to-end anastomosis to one of its perforating
branches or end-to-side to the brachial artery is possible. The ba-
silic and cephalic veins are in close proximity and can provide
venous drainage.
The brachial artery is palpated and longitudinal incision in
the medial aspect of the arm can be m ade (Fig. 8.2). Dissection
through skin, subcutaneous tissue, and deep fascia will expose
the biceps muscle belly anteriorly and the triceps posteriorly. The
vessels lie between these two muscles to the m edial intram us-
cular septum. The medial cutaneous nerve of the arm must be
protected as dissection proceeds through the skin and subcuta-
neous tissue.
The medial intermuscular septum can be incised to enter the
posterior compartment of the arm and access the ulnar collateral
artery as it travels with the ulnar nerve.
Radial Artery
Diameter: 2.3–2.8 mm
Anatomy
The brachial artery bifurcates in the forearm at the level of the
radial neck, medial to the biceps tendon, and lateral to the median
nerve, into the radial and ulnar arteries (Fig. 8.3). The radial artery,
smaller in diameter compared to the ulnar artery, passes obliquely
and laterally to lie beneath the belly of brachioradialis. As it travels
down the forearm, it lies beneath the brachioradialis and on top
of the pronator teres, supinator, radial side of the exor digitorum
super cialis, and exor pollicis longus (Fig. 8.4). In the distal third
of the forearm, the radial artery becomes very super cial, lying just
beneath the deep fascia. At this point it lies between the tendons of
brachioradialis laterally and exor carpi radialis medially. The radial
artery is accompanied by venae comitantes in its entire course.
Fig. 8.2 Medial arm incision for brachial artery.1
Fig. 8.3 Anatomy of the antecubital fossa: 1, Radial artery; 2, ulnar artery;
3, super cial palmar arch; 4, radial recurrent artery; 5, common interosse-
ous artery; 6, brachioradialis m.; 7, pronator teres m.; 8, exor carpi radialis
m.; 9, palmaris longus m.; 10, exor digitorum super cialis m.; 11, bicipital
aponeurosis; 12, exor carpi ulnaris.1

8 Recipient Vessels for Microsurgery
117
Fig. 8.5 Incision for radial artery.1
Fig. 8.4 Approach the brachial artery: 1, Brachial artery and vein; 2, me-
dian nerve; 3, biceps muscle; 4, brachioradialis muscle; 5, pronator teres
muscle; 6, brachialis muscle; 7, triceps muscle; 8, bicipital aponeurosis.1
which lie lateral to it in this region. In the proximal two-thirds
of the forearm, the artery lies beneath the belly of the brachi-
oradialis (Fig. 8.8). This needs to be retracted laterally to reveal
the artery. Venous drainage can be either to the cephalic vein or
a venae comitantes. It is important to perform an Allen test pre-
operatively to ensure that the radial artery is not the dominant
supply to the hand before anastomosis, particular if end-to-end
anastomosis is considered.
Ulnar Artery
Diameter: 2.5–3.0 mm
Anatomy
In the upper half of the forearm, the ulnar artery is sandwiched
between the exor digitorum super cialis and profundus
(Fig. 8.9). It is crossed by the median nerve which com es to lie
lateral to the artery and separated from it by the ulnar head of
pronator teres. In the distal half of the forearm, the ulnar artery
lies between the exor carpi ulnaris medially and the exor digi-
torum super cialis laterally (Fig. 8.10). It is accompanied by two
venae comitantes with the ulnar nerve on its medial side.
At the wrist, the ulnar artery is covered by the skin and car-
pal ligament and lies lateral to the pisiform (Fig. 8.11).
Access
Being the dominant supply to the hand, the ulnar artery is not
routinely used for microvascular anastomosis. However, if re-
quired, one of its branches or an end-to-side anastomosis can
be used.
The surface landmark of the ulnar artery is a line from the
medial epicondyle of humerus to the pisiform (Fig. 8.12). Access
in the distal half of the forearm is easier as the artery is covered
by less soft tissues. An incision along the line outlined previously
and dissection through the deep fascia and re ecting the exor
carpi ulnar will reveal the ulnar artery beneath. The artery is
found lateral to the nerve.

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I Planning and Decision Making in Reconstructive Surgery
Fig. 8.7 Exposure of the distal radial artery: 1, Radial artery and vein;
2, super cial branch of radial nerve; 4, brachioradialis m.; 5, exor carpi
radialis m.; 9, exor pollicis longus m.1
Fig. 8.6 Incision for antecubital fossa.1

Lower Limb
Popliteal Artery
Diameter: 7–9 mm
Anatomy
The popliteal artery is the continuation of the fem oral artery
as the latter enters the opening in the adductor magnus. The
popliteal artery continues in the thigh in a mediolateral and
downward direction toward the popliteal fossa. It trifurcates at
the level of the soleus into the anterior, posterior tibial artery and
the peroneal artery.
Within the popliteal fossa, the artery is the deepest structure
lying posterior to the popliteal vein on top of which is the tibial
nerve. The popliteal artery gives muscular, genicular, and a sural
artery before passing beneath the soleal arch and trifurcating.
Access
The popliteal artery can be accessed through the fossa with the
patient prone. A step incision is made with the transverse limb
in the crease of the popliteal fossa. The skin aps are raised.
The short saphenous vein will be encountered next. This can be
prepared for venous drainage. The medial and lateral heads of
gastrocnemius are retracted. The popliteal artery is the deepest
structure once the tibial nerve and popliteal vein have been re-
tracted. One of the genicular branches of the popliteal artery can
be used for arterial anastomosis into the chosen ap. Care should
be taken to preserve the sural nerve and its branches.
Alternatively, the popliteal artery can be approached from the
medial aspect of the thigh, although this is m ore di cult. The patient
is placed supine, w ith hip abducted and knee exed. A longitudinal
incision is made along the junction between the vastus medialis
and sartorius (Fig. 8.13). Dissection through subcutaneous fat
should preserve the long saphenous vein which can be used for
venous drainage. The deep fascia is incised and the vastus m e-
dialis and sartorius are retracted to reveal the popliteal artery

8 Recipient Vessels for Microsurgery
119
Fig. 8.11 Exploration of the ulnar artery at the wrist: 1, Flexor carpi
ulnaris m.; 2, exor digitorum super cialis tendons; 3, pisiform; 4, super-
cial part of the exor retinaculum; 5, palmaris brevis m.; 6, palmar fascia;
7, hypothenar m.; 8, ulnar artery; 9, ulnar nerve; 10, deep branch of the
ulnar nerve; 11, ulnar palmar digital artery of little nger.1
Fig. 8.9 Exploration of the proximal half of the ulnar artery: 1, Ulnar ar-
tery and vein; 2, ulnar nerve; 3, exor carpi ulnaris m.; 4, exor digitorum
super cialis m.; 5, exor digitorum profundus m.1
Fig. 8.10 Exploration of the distal half of the ulnar artery: 1, Ulnar artery and
vein; 2, ulnar nerve; 3, exor carpi ulnaris m.; 4, exor digitorum super cialis
m.; 6, dorsal cutaneous branch of ulnar nerve; 7, pronator quadratus m.1
Fig. 8.8 Exposure of the proximal radial artery: 1, Radial artery and vein;
2, super cial branch of radial nerve; 3, recurrent radial artery; 4, brachi-
oradialis m.; 5, exor carpi radialis m.; 6, pronator teres m.; 7, supinator
m.; 8, bicipital aponeurosis.1

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I Planning and Decision Making in Reconstructive Surgery
In the upper third of the leg, the artery lies between the tibialis
anterior and extensor digitorum (Fig. 8.16); in the middle third it
lies between the tibialis anterior and the extensor halluces longus
(Fig. 8.17). In the distal third of the leg near the ankle, the exten-
sor halluces longus tendon crosses over it from lateral to medial
(Fig. 8.18). The artery is accompanied by a pair of venae comitantes.
Access
The surface m arkings of the anterior tibial artery correspond to
a line from the bular head to the midpoint between the mal-
leoli (Fig. 8.19). With the patient supine, an incision is m ade a
ngerbreadth lateral to the tibial crest. The deep fascia is incised,
and the tibialis anterior is retracted medially and the extensor
halluces longus retracted laterally to reveal the vessel. Care is re-
quired to protect the deep peroneal nerve, which runs with the
artery. The venae comitantes can be used for venous drainage.
(Figs. 8.14 and 8.15). Again one of its genicular branches can be
used for anastomosis.
Anterior Tibial Artery
Diameter: 6 mm
Anatomy
The anterior tibial artery branches o the popliteal artery at
the soleal arch and passes between the two heads of tibialis
anterior over the superior edge of the interosseus m em brane to
enter the anterior compartm ent of the leg. It descends down the
interosseus m em brane in an oblique direction to lie on top of
the tibia as it passes over the ankle and becom es the dorsalis
pedis artery.
Fig. 8.12 Incision for access to the ulnar artery.1
Fig. 8.13 Hunter’s canal incision.1

8 Recipient Vessels for Microsurgery
121
Fig. 8.16 Proximal third of tibialis anterior artery: 1, Anterior tibial artery
and vein; 2, deep peroneal nerve; 3, peroneus longus m.; 4, peroneous
brevis m.; 5, extensor digitorum longus m.; 6, tibialis anterior m.; 7, inter-
osseous membrane.1
Fig. 8.17 Middle third of tibialis anterior artery: 1, Anterior tibial artery
and vein; 2, deep peroneal nerve; 3, peroneus longus m.; 5, extensor
digitorum longus m.; 6, tibialis anterior m.; 7, interosseous membrane;
8, tibia; 9, extensor hallucis longus m.1
Fig. 8.14 Hunter’s canal: 1, Super cial femoral artery and vein; 2, saphenous
artery, vein, and nerve; 3, roof of adductor canal; 4, sartorius m.; 5, vastus
medialis m.; 6, gracilis m.; 7, adductor magnus m.; 8, adductor longus m.1
Fig. 8.15 Hunter’s canal with fascial roof removed: 1, Super cial femoral ar-
tery and vein; 2, saphenous artery, vein, and nerve; 4, sartorius m.; 5, vastus
medialis m.; 6, gracilis m.; 7, adductor magnus m.; 8, adductor longus m.1

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I Planning and Decision Making in Reconstructive Surgery
Access
The patient is positioned supine with the hip exed and ab-
ducted and the knee slightly bent. The artery can be palpated
midway between the calcaneus and the medial m alleolus, and
a longitudinal incision is made 1 cm posterior to the medial edge
of the tibia (Figs. 8.23 and 8.24). Dissection through deep fascia
will reveal the tibialis posterior and exor digitorum muscles an-
teriorly and the soleus posteriorly. These muscles are retracted
and the posterior tibial artery and venae comitantes can be seen
running with the tibial nerve. Alternative venous drainage can be
provided using the long saphenous vein which courses anterior
to the medial malleolus super cial to the deep fascia.
Dorsalis Pedis Artery
Diameter: 2–3 mm
Posterior Tibial Artery
Diameter: 2.5–3.0 mm
Anatomy
The posterior tibial artery begins at the soleal arch as a branch
of the popliteal artery and descends in the deep posterior com -
partm ent of the leg. The artery runs deep to the gastrosoleal
complex. In the upper third of the leg the artery lies on the
tibialis posterior (Fig. 8.20), in the m iddle third on the exor
hallucis longus m uscle belly, and in the distal third on the tibia
(Fig. 8.21). In the distal third of the leg where the artery is m ost
super cial, it is covered by skin and fascia and runs parallel to
the m edial border of the Achilles tendon. With the artery run
two venae com itantes.
At the level of the medial malleolus, the posterior tibial ar-
tery lies posterior to the tendons of tibialis posterior and exor
digitorum longus (Fig. 8.22). Posterior to the artery is the tibial
nerve. The posterior tibial artery terminates as it enters the
plantar aspect of the foot by bifurcating into the medial and
lateral plantar arteries.
Fig. 8.19 Incision for anterior tibial artery.1
Fig. 8.18 Distal third of tibialis anterior artery: 1, Anterior tibial artery
and vein; 2, deep peroneal nerve; 5, extensor digitorum longus m.; 6, tib-
ialis anterior m.; 7, interosseous membrane; 8, tibia; 9, extensor hallucis
longus m.; 10, bula.1

8 Recipient Vessels for Microsurgery
123
Fig. 8.22 Exposure of the posterior tibial artery at the medial ankle:
1, Posterior tibial artery and vein; 2, tibial nerve; 3, Achilles tendon;
4, laciniate ligament; 5, tibialis posterior tendon; 6, exor digitorum
longus tendon; 7, exor hallucis longus tendon; 8, medial malleolus;
9, tuberosity of navicular bone; 10, abductor hallucis m.1
Fig. 8.23 Incision for the posterior tibial artery.1
Fig. 8.20 Exposure of the proximal part of the posterior tibial artery:
1, Tibial nerve; 2, posterior tibial artery and vein; 3, gastrocnemius m.;
4, soleus m.; 5, tibialis posterior m., 6, exor digitorum longus m.; 7, tibia.1
Fig. 8.21 Exposure of the distal part of the posterior tibial artery: 1, Tibial
nerve; 2, posterior tibial artery and vein; 4, soleus m.; 6, exor digitorum
longus m.; 7, tibia; 8, exor hallucis longus; 9, Achilles tendon.1

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I Planning and Decision Making in Reconstructive Surgery
Access
The artery can be easily palpated on the dorsum of the foot and
a longitudinal incision made over it course (Fig. 8.26). A short
dissection through subcutaneous tissue will reveal the artery and
care should be taken to protect the super cial peroneal nerve.
Anatomy
The dorsalis pedis artery is the continuation of the anterior
tibial artery as it crosses over the ankle to enter the dorsum of
the foot. The artery runs with the super cial peroneal nerve and
just lateral to the extensor hallucis longus tendon (Fig. 8.25). The
artery bifurcates at the rst intermetatarsal space into the rst
dorsal metatarsal artery and the deep plantar artery.
Fig. 8.25 Identi cation of the dorsalis pedis artery: 1, Extensor hallucis
brevis m.; 2, extensor hallucis longus tendon; 3, inferior extensor retinac-
ulum; 5, dorsalis pedis artery, vein, and deep peroneal nerve; 6, lateral
tarsal artery and vein; 7, tarsal branch of deep peroneal nerve.1
Fig. 8.26 Incision for the dorsalis pedis artery.1
Fig. 8.24 Incision at the medial malleolus for the posterior tibial artery.1

8 Recipient Vessels for Microsurgery
125

Head and Neck
Superf cial Temporal Artery
Diameter: 1.8–2.7 mm
Anatomy
The super cial temporal artery (STA) is the term inal branch of
external carotid artery. It begins in the substance of the parotid
gland, behind the neck of the mandible, and crosses over the
posterior root of the zygomatic process of the temporal bone
(Fig. 8.27). At 5 cm above this process it divides into frontal
(diameter 2 mm) and parietal branches (diameter 1.8 mm).
As it crosses the zygom atic process, it is covered by the
auricularis anterior muscle and by a dense fascia; it is crossed by
the temporal and zygomatic branches of the facial nerve and one
or two veins and is accompanied by the auriculotemporal nerve,
which lies immediately behind it.
Access
The super cial temporal vessels are approached through a longi-
tudinal preauricular incision. Dissection through subcutaneous
and super cial to the deep fascia will reveal the artery. Palpation
of arterial pulsation will aid the direction of dissection. Dissec-
tion more proximally in the course of the STA will reveal a higher
caliber vessel.
It is important to note that the STA is sandwiched between
the auriculotemporal nerve posteriorly and the super cial tem -
poral vein (STV) anteriorly.
Facial Artery
Diameter: 2.5 mm
Anatomy
The facial artery branches from the external carotid artery
superior to the lingual artery. It then runs upward beneath the
posterior belly of the digastric and the stylohyoid muscle and
the subm andibular gland. It then winds round the m andibular
margin, reaching the face at the anterior inferior angle of the
masseter m uscle. Its pulsation is readily palpable 3 cm m edial to
mandibular angle (Fig. 8.28).
Access
Palpate the facial artery as it passes over the mandible and m ark
its position. Access can be obtained through a short transverse
Fig. 8.27 Anatomy of the external carotid artery: 5, posterior branch; 6, zygomatic arch;
7, zygomatico-orbital artery.1

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I Planning and Decision Making in Reconstructive Surgery
incision along the inferior m argin of the m andible. Dissection
through platysma should reveal the artery. Care must be taken
not to damage the marginal mandibular branches of facial nerve
(Fig. 8.29).
Access to the facial artery can also be gained through a
facelift incision when performing a free functional muscle trans-
fer in facial palsy patients.
Superior Thyroid Artery
Diameter: 1.5–3.0 mm
Anatomy
The superior thyroid artery is the rst branch of the external
carotid artery. It arises just below the greater cornu of the hyoid
bone within the superior carotid triangle. It passes toward the
midline beneath the om ohyoid, sternothyroid, and sternohyoid
muscles and term inates in the upper part of the thyroid gland.
Its branches are the infrahyoid, middle sternocleidomastoid,
superior laryngeal, and the cricothyroid arteries.
Access
A transverse incision in the neck at the level of the superior border
of thyroid cartilage is made. Dissection through fat and platysma
Fig. 8.28 Facial artery anatomy: 1, External carotid artery; 2, facial artery; 3, parotid gland; 4, submandibular
gland; 5, submental artery; 6, masseter m.; 7, stylohyoid m.; 8, digastric m.; 9, mylohyoid m.1
Fig. 8.29 Access for the facial artery and super cial structures: 1, Parotid
gland; 2, sternocleidomastoid m.; 3, facial vein; 4, external jugular;
5, mandibular branch of facial nerve; 6, platysma m.1