Flaps Practical Reconstructive Surgery

328
II Reconstructive Flaps A-to-Z
Fig. 26.8 (continued) (f) The anterior ap is transposed to cover the majority of the triceps tendon. (g) The posterior ap is elevated ready for transposi-
tion. (h) Upon transposition of the posterior ap, the triceps tendon is now completely covered with vascularized (though irradiated) tissue. (i) At closure,
residual dog ears are super cially trimmed and there is only a modest contour irregularity. The di erence in color between the more irradiated anterior
ap and the less irradiated posterior ap is obvious. (j) A region of supraphysiological tension near the lateral epicondyle was released and a full-thickness
skin graft inset to cover this part of the secondary defect. In the absence of supraphysiological tension, both keystone aps are suitably pink with good
capillary return. (k) In the early postoperative period, healing was delayed, likely due to previous irradiation.
f
g
h
i
j
k

26 Keystone Flaps for Reconstruction in the Upper Limb
329
Cormack GC, Lam berty BG. Fasciocutaneous vessels. Their distribution on
the trunk and limbs, and their clinical application in tissue transfer.
Anat Clin 1984;6:121–131
Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and
clinical implications. Plast Reconstr Surg 1996;98:195–210
Kolker AR, Coombs CJ, Meara JG. A method for minimizing donor site com-
plications of the radial forearm ap. Ann Plast Surg 2000;45:329–331
Figure Credits
1. THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal
System, © Thiem e 2005, Illustration by Markus Voll.
2. THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal
System, © Thiem e 2005, Illustration by Karl Wesker.
Suggested Further Reading
Behan FC. The keystone design perforator island ap in reconstructive
surgery. ANZ J Surg 2003;73:112–120
Behan FC, Findlay MW, Lo CH. The Keystone Perforator Island Flap Con-
cept. Chatswood NSW: Elsevier Australia; 2012
Chang SC, Miller G, Halbert CF, et al. Lim iting donor site m orbidity by
suprafascial dissection of the radial forearm ap. Microsurgery
1996;17:136–140
Cormack GC, Lam berty BG. Cadaver studies of correlation between vessel
size and anatom ical territory of cutaneous supply. Br J Plast Surg
1986;39:300–306
Cormack GC, Lamberty BG. Fasciocutaneous vessels in the upper arm: ap-
plication to the design of new fasciocutaneous aps. Plast Reconstr
Surg 1984;74:244–250
Fig. 26.8 (continued) (l,m) Final postoperative result demonstrated good healing and coverage of the triceps despite high-dose radiotherapy. Elbow
motion was good and the patient had no signi cant functional limitations. At this stage, he had been back at work as a truck driver for a few months.
l
m

Keystone Flap Principles, Technique, and
Variations in Head and Neck Surgery
Michael W. Findlay, Sarah N. Bishop, and Gordon K. Lee
27
330

Introduction
Locoregional ap reconstruction has a very long history in head
and neck reconstruction due to the excellent cutaneous blood
supply in this region and the obvious aesthetic bene ts provided
by replacing like with like tissue. The profuse nature of the cutane-
ous vasculature, num erous perforators, and signi cant intercom -
munication between perforator zones ensure ap viability like no
other region in the body. It is possible to achieve outstanding re-
sults with locoregional aps due to the similarity in skin color and
texture a orded by their use. However, the depth of experience
required to deliver reliable, aesthetic locoregional reconstruction
without distorting facial features or impacting symmetry should
not be underestim ated. The outcomes, both functional and aes-
thetic, of any reconstruction in this region will be directly visible
to others and in few places is the need for both aesthetics and
function as paramount. For this reason, it is worthwhile develop-
ing skills in the use of locoregional aps in other areas of the body
before transitioning to this cosmetically sensitive area.
Subunit-based reconstruction o ers optim al aesthetics when
com bined with the close skin color and texture match a orded
by locoregional reconstruction in the head and neck. This adds
an additional facet to the assessment of head and neck defects:
namely, whether single or multiple subunits are a ected. The
ideal reconstruction reconstructs subunits while placing suture
lines at the junction between these subunits. The nal compo-
nent of aesthetic reconstruction then is the restoration of appro-
priate facial contour through selection of the most appropriate
donor tissue and then mobilizing it in such a manner as to restore
this contour. For example, convex areas should be reconstructed
using transposition elements to re-create the convexity. Where a
signi cant volume de cit is present, the priority for reconstruc-
tion is (variably) color m atch, followed by subunit reconstruction
and then volume lling. Such lling is rarely achieved through
locoregional fasciocutaneous reconstruction alone. Depending
on the needs of the patient and planned postoperative course, an
additional deep ap (pedicled or free) can be buried under per-
forator-based locoregional aps and the reliable nature of the lo-
coregional blood supply will ensure the viability of the overlying
ap. In our aged head and neck populations, patients are reticent
to undergo such involved surgery when color match and subunit
reconstruction can be readily achieved by a minimally invasive
approach. The dissection involved in all of these approaches can
bring important neurovascular structures such as the facial nerve
into the surgical eld where they are at potential risk of injury. A
thorough knowledge of the relevant anatomy and relationship of
the facial nerve to other structures is vital.
The keystone ap shape needs to be m odi ed, som etim es
radically, to achieve these desired outcomes in the head and neck
due to the need to respect facial subunits during reconstruction
and the often complex topography of the face and neck. In these
cases, the keystone principles outlined in this section are still
applied, with combinations of creep, advancement, rotation, and
transposition applied while using the sam e surgical technique
as in other areas of the body to ensure progressive mobilization
with minimal endothelial injury to the perforators for the ap.
Therefore, the perforator aps developed are based on keystone
principles, even though they may not bear any immediate resem -
blance to the keystone shape. The development of speci c aps
has occurred as a direct result of the expertise gained in the use
of keystone aps throughout the body and the necessary modi-
cations applied to the keystone design to meet the needs of the
defect. Examples of such aps include the cervicosubmental is-
land (CSI) ap, the superior thyroid artery perforator (STAP) ap,
the facial artery cheek subunit (FACS) ap, and the extended fa-
cial artery cheek subunit (EFACS) ap.
Depending on the size of the defect and its position relative
to the subunit borders, we can then decide what nature and form
the reconstruction can take. Speci cally, the defect can be recon-
structed from within a single subunit, across two subunits, or
from an outside subunit (e.g., neck) that is transferred into the
site. The signi cant redundancy of tissue in the neck can be used
for reconstruction of head and neck defects in a manner analo-
gous to the use of the lower abdominal skin and tissue removed
in abdominoplasty for breast reconstruction. The CSI ap (includ-
ing its anterior and posterior variations) and CSI aps named by
speci c perforators such as the STAP ap all utilize this principle.
Every ap design needs to incorporate suitable vessels. Num er-
ous perforating vessels and super cial veins are present to supply
aps of signi cant size for this purpose as evidenced by vascular
studies for facial transplantation, and following oncological re-
section, it is often possible to nd a number of intact perforators
upon which to base a fasciocutaneous ap.

Vascular Pedicles and
Blood Supply in the Head
and Neck
There has been renewed interest in the arterial and venous
supply to the head and neck with recent vascular studies used
to support composite vascularized allotransplantation (CVA)
for facial reconstruction. These demonstrate that the facial and

27 Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
331
It is uncommon to have to reoperate for residual disease follow-
ing ap-based reconstruction using this cautious, measured ap-
proach, combined with postoperative radiotherapy as required.
However, careful documentation assists with any such reopera-
tion, especially through the use of diagrams that dem onstrate the
type of ap and the method of its m obilization into the primary
defect. Any instruments used in resection of the tumor should
not be used for elevation of the ap.
Step 2: Mark Out Flap, Determine
Mobilization, and Utilize Creep
Maxim izing the use of aesthetic units when m arking out the
ap signi cantly improves the nal appearance. Planning in re-
verse, the ideal is to nish the reconstruction w ith the m ajority
of the suture lines within natural skin creases and/or at the bor-
ders between aesthetic units. Similarly, replacing like with like
by using the tissue from the cosmetic unit to reconstruct defects
within that unit maximizes color match, such as the FACS ap
(Fig. 27.3).
Where defects are too large for intra-unit reconstruction,
consider reconstruction of the entire subunit, rather than leav-
ing a small margin of intact subunit and having suture lines pass
across the subunit. Obviously, such an approach must be bal-
anced against the available tissue, blood vessels, and experience
of the surgeon for ap reconstruction. In determining the nature
of the mobilization, areas of convexity are best suited to transpo-
sition and rotational variants of the keystone ap. Planning dog
ears from transposition to lie over prom inences such as the angle
of the jaw is very helpful for aesthetics and this approach is what
prompted the design of the EFACS ap (a FACS ap with an exten-
sion into the neck inferoposteriorly that is transposed for peri-
auricular reconstruction, leaving the convexity of transposition
over the angle of the jaw). Early suture placement is advisable to
induce creep as this can facilitate defect closure.
Step 3: Determine Degree of
Islanding and Consider Selective
Ligament Release
Full cutaneous islandization of aps provides some bene ts in
the setting of previous radiotherapy—nam ely through the provi-
sion a small, but measureable increase in cutaneous blood sup-
ply (3–5%) and by ensuring even tension to limit single lines of
tension that may a ect the circulation to a speci c part of the
ap. These potential bene ts must be balanced carefully against
the additional scar burden and suturing time. Luckily, most on-
cology cases in the head and neck occur in older patients who
tend to produce minimal scar and have skin creases that readily
mask their appearance. Skin elasticity is greater in younger pa-
tients, and therefore, even tension is easier to achieve without
full islanding in this patient population and thus the additional
scar length can often be avoided.
The face has a well-developed, but often poorly described,
system of retaining ligaments. These demonstrate regular pat-
terns that not only suspend the youthful face, but also determine
super cial temporal arteries supply the m ajority of the face and
anterior scalp and that the facial vessels alone can be used for
facial transplantation. The outstanding intercom m unication be-
tween the vessels in the head and neck improves the safety of
aps raised in this region, even on relatively sm all perforators
thereby making locoregional reconstruction ideal. The keystone
principles strongly encourage the preservation of subcutaneous
neurovascular structures and these abound in the head and neck
w ith the infraorbital and mental nerves being good examples
of conjoint supply to overlying aps due to the additional blood
supply provided by their vasa nervorum . The preservation of
subcutaneous veins is essential to lim it arteriovenous mismatch
and congestion of any aps raised. In the neck, perforators from
the branches of the external carotid artery supply the overlying
neck skin after traversing the platysm a m uscle. Pre-platysm a and
post-platysma plexuses exist that increase collateral ow and,
due to this, aps in the neck are raised deep to the platysma to
ensure the incorporation of these plexuses within the ap.
The transverse cervical arteries (or branches from the dorsal
scapular arteries) supply the posterior triangle of the neck and
can be used as the basis for posteroinferiorly based aps. The
occipital vessels and their branches supply the majority of the
posterior neck skin along with perforators from the dorsal scap-
ular and segmental spinal vessels emerging through the trape-
zius muscle. Flap elevation in the posterior cervical region should
include the fascia over the trapezius to improve reliability, but
the dissection can be similar in di culty to elevation of gluteal
perforator aps due to the sim ilar consistency of the underlying
muscle. The posterior neck tissue is also quite thick and therefore
is best used for reconstruction of the posterior neck rather than
extending more anteriorly into thinner regions of the neck.
Scalp reconstruction must be predicated on the understand-
ing that there are no perforators in this region, only direct vessels.
Therefore, extra care must be taken to ensure that vessels such as
the occipital or super cial temporal branches are incorporated in
any aps rather than being divided during islanding (Figs. 27.1
and 27.2).

Technique in the Head and
Neck
The head and neck region has some speci c needs and challenges
relative to other areas of the body. For this reason, we examine
the di erences in technique in this region to emphasize the im -
portant points.
Step 1: Defect, Pathology, and
Available Vascular Supply for Flap
The importance of ensuring tumor clearance, including adequate
margins, cannot be overemphasized prior to fasciocutaneous de-
fect reconstruction in the head and neck. Frozen sections, delayed
reconstruction until (formal) pathology evaluation (DRAPE), and
the use of temporary skin grafts with later ap reconstruction
are all useful options for the resective and reconstructive team(s).

332
II Reconstructive Flaps A-to-Z
Supratrochlear
nerve
Supraorbital nerve,
lateral branch
Supraorbital nerve,
medial branch
Dorsal nasal artery
Auricilotemporal
nerve
Superficial temporal
artery and vein
Infraorbital artery
and nerve
Transverse
facial artery
Parotid duct
Masseter muscle
Mental branch,
inferior alveolar artery
Mental nerve
Facial artery
and vein
Facial nerve,
marginal mandi-
bular branch
Parotid gland
Facial nerve,
buccal branches
Facial nerve,
zygomatic
branches
Angular artery
and vein
Facial nerve,
temporal
branches
Fig. 27.1 (a) Anterior aspect of face demonstrating the relationship between the mimetic muscles and the important neurovascular structures includ-
ing many (but not all) important perforators and vessels. The subcutaneous plane is relative safe with minimal risk of injuring the facial nerve which is
in the plane deep to the majority of these muscles; however, where the muscles are discontinuous or in regions directly over bone (e.g., the zygomatic
arch), additional care is required to ensure the safety of these important nerves. (continued)
a

27 Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
333
to the new ap position to limit the stigmata of the facial nerve
palsy.
Step 4: Preserve Neurovascular
Structures and Maintain Venous
Drainage
The head and neck contains num erous, important neurovascular
structures that may be injured during locoregional ap surgery.
The facial nerve branches, parotid duct, and sensory nerves, such
as the infraorbital nerve, all have very important roles. The fa-
cial nerve branches are at particular risk due to their often ne,
the pattern of age-related facial soft tissue ptosis. Selective
division of these ligam ents can provide additional ap m obili-
ty to assist in wound closure (selective ligament release [SLR]).
Faced with the option of a more complex ap reconstruction, se-
lective division of these ligam ents, with reconstitution if required
by periosteal anchoring sutures to the facial skin in its new posi-
tion, can provide a highly aesthetic result. It can also be used in
combination with ap reconstruction to maximize ap mobility
(e.g., FACS ap). Full islanding in these cases can be useful, espe-
cially when facial nerve palsy is anticipated postoperatively. The
FACS and EFACS aps combine aesthetic unit reconstruction with
SLR to close the primary defect and, simultaneously, the angle of
the mouth and the alar of the nose can be repositioned relative
Superficial temporal
artery, parietal branch
Superficial temporal
artery and vein
Occipital artery
Greater
occipital nerve
Lesser
occipital nerve
Sternocleidomastoid
Occipital vein
Parotid gland
Great auricular
nerve
External
jugular vein
Branches of parotid
plexus (facial nerve)
Masseter muscle
Facial vein
Mental nerve
(branch of
trigeminal
nerve)
Buccinator
muscle
Parotid duct
Infraorbital nerve
(branch of
trigeminal nerve)
Transverse
facial artery
Angular vein
Auriculotemporal
nerve
Zygomatico-
orbital artery
Supratrochlear nerve
(branch of trigeminal
nerve)
Supraorbital nerve
(branch of trigeminal nerve)
Superficial temporal
artery, frontal branch
Fig. 27.1 (continued) (b) Lateral view of the head demonstrating the main arteries and veins and the course of the branches of the facial nerve. There
are a very large number of perforators throughout this region. Unless very small aps are used, it is not usually necessary to speci cally identify
perforators because there are so many within the head. Note the direct cutaneous vessels over the scalp.1
b

334
II Reconstructive Flaps A-to-Z
Occipital artery,
posterior branch
Posterior
auricular artery
Occipital artery
Facial artery
External carotid artery
Internal carotid artery
Vertebral artery
Subclavian artery
Common
carotid artery
Superior
thyroid artery
Lingual artery
Ascending
pharyngeal artery
Maxillary artery
Superficial
temporal artery
Vertebral artery
Anterior
scalene
Inferior
thyroid artery
Common
carotid artery
Thyrocervical
trunk
Costocervical
trunk
Clavicle
First rib
Internal
thoracic artery
Supreme inter-
costal artery
Deep cervical
artery
Subclavian artery
Axillary artery
Suprascapular
artery
Posterior
scalene
Middle scalene
Tranverse
cervical artery
Dorsal scapular artery
(deep branch)
Superficial cervical artery
(superficial branch)
Ascending
cervical artery
Fig. 27.2 (a) Lateral and (b) anterior views of the
contributions of the various branches of the exter-
nal carotid artery and the marked communication
between the two sides across the midline. These
branches supply the vast majority of the skin of the
head and neck, but have only limited supply to the
posterior triangle of the neck (the region between
the posterior border of the sternocleidomastoid and
the anterior border of the trapezius muscles). Many
cutaneous perforators branch o these vessels to
form a solid foundation for perforator-based aps in
this region. The aps can be named by the perforator
that supplies them, such as superior thyroid artery
perforator (STAP) ap, or by the general region, if
speci c perforators are not targeted or multiple per-
forators are involved, such as the cervicosubmental
island ap. (c) Branches from the subclavian artery
provide the main supply to the posterior triangle of
the neck. A number of nonspeci c and speci c aps
(e.g., suprascapular ap) have been described based
on these vessels. There can be signi cant variation in
the pattern of branching. (continued)
a
b
c

27 Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
335
Fig. 27.2 (continued) (d) The variations in the pattern of branches supply-
ing the posterior triangle of the neck (and upper back). Signi cant variation
can occur, but in general, there is always one or two major vessels in the
posterior triangle supplying perforators to the overlying skin; therefore,
keystone aps in this region should seek to capture these perforators low
in the neck or, alternatively, perforators either coming through or around
the sternocleidomastoid muscle (not shown).2
d
Fig. 27.3 (a) A common pattern of skin defect following surgical excision of skin cancer is demonstrated in the preauricular region. (b) Despite early
institution of creep, the defect will not close primarily. (c) Aesthetic unit reconstruction is sought and a facial artery perforator subunit (FAPS) ap
is outlined with the markings running within facial skin creases and/or at the junction between facial aesthetic subunits. Note that the incision con-
tinues over the orbital rim to ensure that there is signi cant lower lid laxity to minimize the risk of ectropion. (d) Selective ligament release (SLR) is
undertaken to facilitate movement of the ap posteriorly. Here the zygomatic ligament is identi ed in the subcutaneous plane, the skin is put under
tension, blunt dissection ensures that the ligament is nonelastic, and it is divided sharply up near the undersurface of the dermis to release the ap in
this region. (continued)
a
b
d
c

336
II Reconstructive Flaps A-to-Z
Fig. 27.3 (continued) (e) The upper part of the primary defect is now able to be closed due to SLR with the ap now extending beyond the posterior
border of the suture line in the temple—a useful indication that su cient mobilization has occurred in this region. The lower part of the primary defect
still requires mobilization of the lower part of the FAPS ap to facilitate closure. (f) Demonstration of the plane of the dissection with blunt dissection in
the subcutaneous plane, sharp division of facial ligaments through SLR, and preservation of all neurovascular structures including these ne cutaneous
sensory branches from the trigeminal nerve. The use of blunt dissection and SLR in this plane signi cantly minimizes the risk of iatrogenic facial nerve
injury. (g) Identi cation and sharp division of the mandibular ligament to facilitate mobilization of the lower half of the FACS ap. Note the marginal
mandibular branch of the facial nerve, the facial artery, and facial vein all pass behind this retaining ligament; therefore, appropriate care should be
taken when dividing this ligament (under tension near the dermis) to ensure the safety of these important neurovascular structures. (h) Following SLR
of the mandibular ligament, the primary defect is able to be directly closed without signi cant tension and now there is redundant ap at the posteroin-
ferior margin. (i) Anchoring of the ap to the underlying periosteum (pointing to buried periosteal suture) is undertaken to form a hammock/sling near
the inner canthus (taking care not to injure the angular or infratrochlear vessels). When combined with anchoring laterally over the zygoma, vectors
directed upward (inward and outward) respectively support the lower eyelid and suspend the ap. (j) Lateral periosteal anchoring point using a buried
suture ensures appropriate support for the ap (and the lower eyelid to minimize the risk of ectropion). (continued)
e
g
i
f
h
j

27 Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
337
k
l
Fig. 27.3 (continued) (k) Now that the primary defect has been closed and the ap has been suspended by periosteal anchoring, it is possible to de-
termine the level at which to inset the alar of the nose and the angle of the mouth as a static procedure in preparation for postoperative facial nerve
palsy a ecting these branches. This approach, combined with management of the lid (e.g., gold weight or tarsorrhaphy) and the eyebrow (periosteal
anchoring or excisional dermodesis) can minimize the stigmata of facial nerve palsy in a single operation. (l) Posteriorly, the redundant ap tissue is
marked ready for trimming now that most of the important sutures have been placed. (m) Full inset of the ap demonstrating V-Y advancement in the
right submental region. Note that the majority of suture lines are within natural skin creases and/or at the border between facial aesthetic subunits.
(n) Anterior view demonstrating placement within the facial aesthetic subunits and the good contour provided by this reconstruction. In the absence
of gravity, the positions of the angle of the mouth and nasal alar are slightly elevated on the right (operative) side in preparation for the postoperative
facial ptosis associated with facial nerve palsy. This can be controlled to a greater or lesser degree depending on how much ptosis is anticipated.
m
n
branching structure, long passage through the face, and relatively
super cial position in some areas (e.g., over the zygomatic arch).
These are not only important to preserve, but the potential for
facial nerve injury following super cial parotidectomy should ac-
tively be excluded prior to defect reconstruction. Reversed great
auricular nerve can be useful as a biological nerve conduit for the
reconstruction of any segmental defects of facial nerve branch-
es and nerve reconstruction (if necessary) should be undertak-
en prior to ap reconstruction. The principles used to minim ize
injury to the facial nerve include the avoidance of monopolar
diathermy, limited use of muscular blocking agents during an-
esthesia (to facilitate nerve stim ulation if required), recognition
of the landmarks for facial nerve transit (e.g., Pitanguy line), dis-
section in the appropriate plane to minimize inadvertent facial
nerve injury, and placing tissue under tension with blunt dissec-
tion com bined with cutting of nonelastic structures up close to
the skin during ap mobilization. This approach also preserves
the venous drainage where this does not adversely a ect ap
mobilization.
Step 5: Assess Flap Vascularity
Flaps often (but not invariably) becom e hyperem ic upon is-
landization. Occasionally aps can demonstrate the opposite
through the e ects of vessel spasm , but this should have resolved
at or near the completion of suturing of the wound margins. Ide-
ally, bleeding from the suture holes during wound closure should
be m ore profuse from the keystone ap side, compared with the
surrounding non ap skin (the red dot sign) and this can be a use-
ful indicator of a norm al circulation within the islanded ap. If
any region of the ap is not well vascularized, it is important to
check for focal tension (including single lines of tension) and ei-
ther improve mobilization, fully island the ap, and/or consider
the addition of a small skin graft over part of the secondary defect
to reduce the skin tension even further. If a distal region remains
poorly viable, it can either be monitored to determine whether it
improves subsequently or debrided at the time and an additional
smaller skin graft or ap applied. Luckily, this is very uncommon
due to the robust nature of the blood supply to these aps.
Step 6: Strategic Mattress
Suture and Continuous Closure
to Produce Even Physiological
Tension
Strategic mattress suturing is an approach where sutures are
placed progressively to even out tension across the entire ap.

338
II Reconstructive Flaps A-to-Z
the key point of supraphysiological tension lim its the need for an
additional donor defect.
Step 8: Document the Flap
Type, Outline, and Movement to
Facilitate Reoperation if Required
Two of the major changes to head and neck surgery that have
occurred over the past decade include the increased number of
cases (secondary to our aging populations) and increased reop-
erative m anagem ent (including recurrences and new tum ors fol-
lowing successful treatment of the primary/secondary disease).
For this reason, it is essential to have adequate documentation
including a suitable diagram and/or photodocumentation that
demonstrates the nature of the ap used for reconstruction so as
to facilitate management of the patient into the future. Inherent
in this is to undertake procedures that are not only e ective, but
also preserve future reconstructive options where possible (plan
for recurrence and new disease). The subunit approach for this
is particularly useful because not only does it maximize aesthet-
ics, but also the larger ap size can be reused/readvanced should
recurrence occur at the m argins of the ap. Also, often the addi-
tional tissue resected to perm it reconstruction of the subunit as a
whole can provide an additional (small) margin of safety against
local recurrence (Fig. 27.4).
These ensure ap inset under uniform tension, thereby maxi-
mizing the potential for even cutaneous blood ow and drain-
age. Once tension is even, a continuous suture is used to evert the
wound edges to ensure direct derm al to derm al apposition. This
minimizes scar and facilitates wound neovascularization and
presum ably lymphangiogenesis. Comparative to other areas, the
super cial sutures are able to com e out relatively early (if nonab-
sorbables are used) and this lim its cross-hatching. When the area
has been previously irradiated, the authors’ preference is to use
nonabsorbable sutures and leave them in for longer to support
the wound until there is su cient structural stability to limit the
risk of wound dehiscence.
Step 7: Determine Whether
an Additional Small Skin
Graft Is Necessary to Prevent
Supraphysiological Tension
While the use of a ap alone is ideal for aesthetic closure,
supraphysiological tension in aps increases the risk of partial
or complete ap failure. Usually there is excess ap tissue for the
needs of the primary defect closure. This excess can usually be
trim m ed, defatted, and used as a sm all full-thickness skin graft
at the site of maximal tension. The use of local skin for the graft
improves aesthetics and the placement of a sm all sized graft at
a
b
d
c
Fig. 27.4 (a) Left cheek defect near the border of the cheek aesthetic subunit. The central position and inability to be closed primarily are indications
for the importation of expendable tissue from another subunit. (b) A cervicosubmental island ap based on the superior thyroid artery perforator
(black dot) is marked out, crossing the midline with the lower line angling upward to meet the upper line just past the midline. (c) The CSI (perforator)
ap is elevated deep to the platysma muscle to ensure capture of the pre- and post-platysma plexuses. The superior thyroid artery perforator is visible
along with the anterior jugular vein. (d) This CSI ap has not been elevated from anterior to posterior with the superior thyroid artery perforator the
last visible perforator at its anterior border. Now it is ready for transposition into the primary defect. Transposition will re-create the convexity of this
region. (continued)

27 Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
339
reconstructive alternatives to the use of a locoregional perforator
ap. The signi cant neck redundancy with age makes it an obvi-
ous candidate site for head and neck reconstruction and there-
fore its use should be considered very early during reconstructive
planning. In a world that is rapidly aging and in the setting of
increased cancer survival (with recurrence or new tumors), the
need for additional options in head and neck reconstruction has
never been greater. The keystone perforator island ap concept
provides a reliable means to make the most out of the available
local tissue with minimal morbidity and very acceptable aesthet-
ics in most cases (Figs. 27.5 and 27.6).

Clinical Perspectives
Perforator-based reconstruction in the head and neck must be
precisely tailored to match the needs of the defect. In this way
every reconstruction has di erent demands. Wide local excision
is often combined with neck dissection in which subplatysmal
aps are elevated and important cutaneous perforators or their
parent vessels may be ligated. Luckily, the ability to raise key-
stone and related perforator island aps in the head and neck in-
creases the available options for reconstruction. In the majority
of cases, a free tissue transfer and a pectoralis major ap are still
Fig. 27.4 (continued) (e) The CSI ap is inset and the secondary defect has
been closed directly within a skin crease. The convexity produced by the
transposition sits directly over the angle of the mandible. Any mild dog
ears will settle down well in this region.
e
Fig. 27.5 A facial artery cheek subunit (FACS) ap for closure of a paroti-
dectomy (with neck dissection) defect. (a) Following super cial parotidec-
tomy, a 4 3 12 cm defect is present in the preauricular region on the right
side. The neck skin is able to be closed directly and is therefore not includ-
ed within the defect analysis. The right facial artery is intact. (b) A FACS
ap is marked out to make most use of skin creases for incisions and the
native cheek tissue to reconstruct missing cheek (like for like). A small
area of V-Y closure is possible under the chin and in the temporal region.
(c) Islandization is performed and selective ligamentous release allows for
closure of the primary defect and the ap is then anchored to the underly-
ing periosteum to form a sling under the lower eyelid. (continued)
a
b
c

340
II Reconstructive Flaps A-to-Z
d
e
g
f
Fig. 27.5 (continued) (d) The upper preauricular triangle of tissue can be transposed to increase the vertical length of the scar and the angle of the
mouth and the alar of the nose can be anchored to the ap in anticipation of some facial muscle weakness as a result of the surgery. Following full closure
(e), the ap drapes naturally over the contour of the face to improve aesthetics, as best seen on the anterolateral view (f). Early postoperative view
(g) demonstrates good contour and a scar that is slowly settling despite recent surgery.
a
b
Fig. 27.6 Left lateral neck defect with exposed mandibular border. (a) Cutaneous defect following excision of invasive squamous cell carcinoma and
level 2–4 neck dissection in an elderly man who was not t for free tissue transfer reconstruction. (b) The design of an omega variant perforator ap for
reconstruction of the defect. This utilizes remaining blood supply from the superior thyroid artery of the contralateral neck. (continued)

27 Keystone Flap Principles, Technique, and Variations in Head and Neck Surgery
341
d
c
e
f
g
Fig. 27.6 (continued) (c) Upon islandization in the subplatysmal plane, the ap is sutured to itself in an omega variant. (d) The ap can then be pro-
gressively stretched to produce even physiological wound tension and suitable draping for the neck. The procedure took less than 1 hour to complete.
(e) Lateral view demonstrating good contour of the anterior neck, despite the initial size of the primary defect. (f,g) Early postoperative views at 3 days
showing good neck position and movement that was well tolerated by the patient despite his proximity to his surgery.

342
II Reconstructive Flaps A-to-Z
Siemionow M, Agaoglu G, Unal S. A cadaver study in preparation for facial
allograft transplantation in humans: part II. Mock facial transplan-
tation. Plast Reconstr Surg 2006;117:876–885
Siemionow M, Kulahci Y. Facial transplantation. Semin Plast Surg
2007;21:259–268
Soga S, Pomahac B, Mitsouras D, et al. Preoperative vascular map-
ping for facial allotransplantation: four-dim ensional computed
tom ographic angiography versus m agnetic resonance angiography.
Plast Reconstr Surg 2011;128:883–891
Wilson JL, Rozen WM, Ross R, et al. The superior thyroid artery perfora-
tor ap: anatomical study and clinical series. Plast Reconstr Surg
2012;129:641–646
Figure Credits
1. THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal
System, © Thieme 2005, Illustrations by Karl Wesker.
2. THIEME Atlas of Anatomy, General Anatomy0 and Musculoskeletal
System, © Thieme 2005, Illustrations by Markus Voll.
Suggested Further Reading
Behan FC, Findlay MW, Lo CH. The Keystone Perforator Island Flap Concept.
Chatswood NSW: Elsevier Australia; 2012
Behan FC, Rozen WM, Kwee MM, et al. Oncologic clearance with preser-
vation of reconstructive options: literature review and the ‘delayed
reconstruction after pathology evaluation (DRAPE)’ technique. ANZ
J Surg 2012;82:780–785
Behan FC, Rozen WM, Wilson J, et al. The cervico-subm ental keystone
island ap for locoregional head and neck reconstruction. J Plast
Reconstr Aesthet Surg 2013;66:23–28
Imanishi N, Nakajima H, Kishi K, et al. Is the platysma ap musculocu-
taneous? Angiographic study of the platysma. Plast Reconstr Surg
2005;115:1018–1024
Mesic H, Kirkeboen KA, Bains R. The importance of a skin bridge in pe-
ripheral tissue perfusion in perforator aps. Plast Reconstr Surg
2012;129:428e–434e
Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous
attachm ents in the temple and periorbital regions. Plast Reconstr
Surg 2000;105:1475–1490; discussion 1491–1498

343
Lateral Arm Free Flaps for Head and
Neck Reconstruction
Pouria Moradi and Kevin Ho
28

Classif cation
The lateral arm free ap is a type B Mathes and Nahai
fasciocutaneous ap, which was popularized by Katsaros et al.
in 1984.

Vascular Pedicle
The ap is supplied by the radial collateral artery and venae
com itantes. The radial collateral artery originates from the pro-
funda brachii artery and passes posteriorly around the humerus,
descending on the lateral aspect of the humerus in the lateral
intermuscular septum between the brachialis and lateral head of
the triceps muscle (Figs. 28.1 and 28.2).
The length of the pedicle is 7 to 8 cm with a diam eter of
2.0 to 2.5 mm. This pedicle length may be increased up to 12 to
14 cm by dividing the middle collateral artery and dissecting to
the profunda origin or by siting the skin paddle distally.

Patient Positioning
Patient is in the supine position with the elbow exed and shoul-
der adducted across the body (Fig. 28.3). This position m ay be
secured by a crepe bandage around the wrist attached to the
opposite side of the operating table. The entire arm is prepped to
the axilla including the shoulder. A sterile tourniquet or Esmark
bandage may be used for the procedure and must be placed high
up in the arm . The tourniquet usually interferes with proximal
dissection, and therefore must be removed at the latter part of
ap harvest.
Fig. 28.1 Schematic diagram of the position of the radial collateral artery
relative to the lateral humeral intermuscular septum, radial nerve, and
anastomosis with the radial recurrent artery.1
Fig. 28.2 Applicable anatomy for the lateral arm  ap: 1, deltoid muscle;
2, biceps muscle; 3, triceps muscle; 4, brachialis muscle; 5, brachioradialis
muscle; 6, deep brachial artery; 7, middle collateral artery; 8, radial collat-
eral artery; 9, posterior branch; 10, anterior branch.1

Surface Markings
The axis of the ap is marked from the deltoid insertion to the
lateral epicondyle. Note that in the arm with skin excess that the
septum may curve posteriorly in the midpoint with gravity, which
can be easily palpated (Fig. 28.4). The ap is commonly designed
over the lower third of the arm, with the distal limit being 5 cm dis-
tal to the lateral epicondyle over the brachioradialis muscle. Prox-
imally, the ap may extend 2 cm above the deltoid insertion. The
maximum width is usually limited by what can be closed primarily
and aps up to 8 cm wide are usually easily closed (Fig. 28.5).

344
II Reconstructive Flaps A-to-Z
Fig. 28.3 Supine position with the hand secured with a crepe bandage to
the opposite side of the operating table.
Fig. 28.4 Palpation of the lateral intermuscular septum slightly posterior
to the axis of the humerus.
Fig. 28.5 Surface markings of the lateral arm  ap: axis of the humerus 
(white arrow); lateral intermuscular septum (white arrowhead).

Raising the Flap
Step 1
The posteroinferior edge of the ap is incised rst as the fas-
cia over triceps is more readily appreciated than that over the
brachialis anteriorly. The dissection continues deep to the fas-
cia over the lateral head of the triceps (Fig. 28.6). The fascia is
elevated anteriorly toward the lateral intermuscular septum. The
pedicle is identi ed in the septum (Fig. 28.7).
Step 2
The ap is then incised along its anterior border, with the fas-
cia over the brachialis and brachioradialis incised and elevated
posteriorly until the lateral intermuscular septum and pedicle
are reached. The posterior cutaneous nerve of the forearm may
be visualized and is often divided (Fig. 28.8).
Step 3
The artery and vein at the distal aspect are ligated. Staying deep
to these vessels, the septum is divided freeing the ap from
the hum erus as the dissection continues proxim ally (Figs. 28.9
and 28.10).
Step 4
A proximal incision is extended from the ap and a plane is
developed between the triceps and the deltoid muscles, which
exposes the pedicle and the radial nerve. The radial nerve pierc-
es the septum and courses along the brachioradialis. The lateral
bers of the triceps m uscle m ay be divided o the humerus to
allow better exposure to the pedicle. Note that the posterior cuta-
neous nerve of the arm is associated with the pedicle and always
removed with the ap (Fig. 28.11). This nerve may be used to
innervate the ap.
Step 5
The radial nerve is identi ed anterior to the pedicle and is care-
fully retracted and dissected o the pedicle (Fig. 28.12).
Fig. 28.6 Posterior incision of the lateral arm  ap with identi cation of 
the fascia (held by forceps).

28 Lateral Arm Free Flaps for Head and Neck Reconstruction
345
Fig. 28.7 Anterior dissection in a subfascial plane over the lateral head
of the triceps until the pedicle is visualized in the intermuscular septum.
Fig. 28.8 Anterior dissection in a subfascial plane, with the posterior cu-
taneous nerve of the forearm identi ed (blue arrow) and distal pedicle
(white arrow).
Fig. 28.10 Close up of the pedicle being dissected o  the humerus.
Fig. 28.9 Distal pedicle ligated and intermuscular septum is divided
allowing the pedicle to be lifted o  the humerus.
Fig. 28.11 Proximal dissection between triceps and deltoid muscles reveals
the pedicle with the posterior cutaneous nerve of the arm (blue arrow) and
the radial nerve (white arrow).
Fig. 28.12 The radial nerve (white arrow) is carefully dissected o  the 
pedicle and posterior cutaneous nerve of the arm (blue arrow).

346
II Reconstructive Flaps A-to-Z

Flap Variations

●
Osseocutaneous f ap: The lateral arm ap can also be har-
vested as an osseocutaneous ap. A posterolateral wedge
of humerus with a small muscular cu (2 mm) of lateral
head of triceps and brachioradialis (distally) or brachialis
(proximally) with periosteum is harvested under the sep-
tum and pedicle in the distal third of the arm . A unicortical
portion of bone approximately 1 to 1.5 cm wide and 12 cm
long can be harvested. As a rule, bone cannot be harvested
greater than one-third the caliber of the humerus without
risk of postoperative pathological fracture.

●
Neurosensory f ap: can be raised with the posterior cuta-
neous nerve of the arm or the posterior cutaneous nerve
of the forearm.

●
Poster ior cutaneous ner ve of the ar m is the primary
sensory branch of the lateral arm ap. It arises from the
Step 6
Dissection continues proxim ally to the level of the deltoid in-
sertion, w ith the m iddle collateral artery identified and of-
ten divided to allow for m ore proxim al dissection to w here
the pedicle originates from the profunda brachii artery
(Fig. 28.13).
Step 7
The ap is then divided and prepared for m icrovascular anasto-
mosis (Fig. 28.14).
Step 8
The donor site is closed in layers with a suction drain left in situ
(Fig. 28.15).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Subcutaneous tissue and skin of the lateral arm

●
Posterior cutaneous nerve of the arm
Identi ed and preserved:

●
Radial nerve

Clinical Perspectives
Main application is for a thin vascularized fasciocutaneous ap in
head and neck and upper limb reconstruction. However, it can be
also used as a reversed ap for elbow coverage.
Fig. 28.13 Proximal dissection with middle collateral artery (blue arrow)
and the radial collateral artery (vertical white arrow).
Fig. 28.14 Lateral arm free  ap with its artery (A), two venae comitantes (V),
and the posterior cutaneous nerve of the arm (N).
Fig. 28.15 Primary closure of the donor site in layers with a suction drain
left in situ.

28 Lateral Arm Free Flaps for Head and Neck Reconstruction
347
as such this ap may be prone to congestion. It is suggested
to perform an additional venous anastomosis where possi-
ble to augment the drainage of this ap.

Hints and Tips

●
Beware of the bowing of the intermuscular septum in lax
or obese arms.

●
Position the paddle distally if greater pedicle length is
required.
Suggested Further Reading
Cuthbertson JH, Mutimer K. The reverse lateral upper arm ap for elbow
coverage. Ann Plast Surg 1987;18:62
Katsaros J, Schusterm ann M, Beppu M, Banis J Jr, Acland RD. The lateral
upper arm ap: anatomy and clinical application. Ann Plast Surg
1984;12:489
Mathes SJ, Nahai F. Reconstructive surgery: principles, anatomy, & tech-
nique. New York: Churchill-Livingston; 1997
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York: Thiem e; 2006
radial nerve superior to the origin of the profunda bra-
chii artery, and pierces the lateral head of the triceps
and enters the cutaneous territory of the ap at the level
of the deltoid insertion. Dissection through the m uscle
is recommended to attain adequate nerve length.

●
Poster ior cutaneous ner ve of the forea r m also aris-
es from the radial nerve and pierces the deep fascia
slightly anterior to the intermuscular septum in the
distal third of the arm and courses super cial to the
brachioradialis. This nerve is generally divided during
the elevation of the ap but can be included in the ap
if the skin territory is below the level of the epicondyle
or if a vascularized nerve graft is required.

●
Fascial f ap: The ap can be harvested without a skin pad-
dle, on the deep fascia only, creating a thin fascial ap.

●
Vascularized tendon: A strip of vascularized triceps ten-
don may be taken with the ap.

●
Musculocutaneous f ap: A 2-cm strip of the lateral head of
triceps may be included with the ap.

●
Tissue expansion: to increase the available cutaneous
paddle

●
Reverse pedicled f ap: for elbow coverage. Note that ve-
nous drainage is via retrograde venae comitantes ow and

348
dimensions of the muscle typically measure 38 cm length, 20 cm
width, and 0.8 cm thickness. The muscle is located super cial
to all other muscles of the back with the exception being on its
superomedial margin. At this location, the trapezius muscle par-
tially covers the LD. The LD muscle originates from multiple ana-
tomic sites: the spinous processes of T7-12, L1-5, and sacrum and
the posterior and m iddle portion of the iliac crests (thoracodorsal
aponeurotic fascia). A small percentage of the LD muscle bers
also originate from the external surface of ribs 8 to 12. The LD’s
triangular base converges into a single tendon as it courses to-
ward its insertion: lesser tubercle and intertubercular groove of
the proxim al hum erus. The LD m uscle courses anteriorly to ap-
proach its point of insertion by spiraling 180 degrees around the
teres major. This anterior course takes place in the axilla and with
the teres m ajor and subscapular m uscles creates the posterior ax-
illary line. The LD functions primarily to extend and adduct at the
shoulder and medially rotate the arm. In addition, the LD assists
in pulling the shoulder downward and posteriorly.
The LD is a robust and well-vascularized ap. The thoraco-
dorsal artery and vein are the dom inant blood supply to the
LD m uscle. The posterior intercostals/lum bar perforators con-
stitute a secondary blood supply. The thoracodorsal artery is
classically the inferior continuation of the subscapular artery
arising from the third portion of the axillary artery. At 2 to 3 cm
from the origin of the subscapular artery, the vessel divides
into the circum ex scapular artery and thoracodorsal artery.
In 3% of the population the thoracodorsal artery has been found
to branch directly from the axillary artery or the lateral tho-
racic artery. The thoracodorsal artery enters the m uscle at its
the undersurface 4 cm distal to the inferior scapular border and
2.5 cm lateral to the m edial border of the latissim us m uscle and
reliably divides into two or three m ajor branches. The distance
from the origin of the subscapular artery and its entrance into
the LD m uscle distally is an average of 8.7 cm . The rst bifur-
cation of the thoracodorsal artery is into the lateral and m edial
branches. In 14% of cadaveric studies, there is no identi able
m edial branch and the m uscle is supplied solely o the lateral
branch. The m edial branch courses parallel to the upper m uscle
border at a distance of 3.5 cm . The slightly larger lateral branch
runs parallel and m edial to the lateral border of the m uscle at
a distance of 2.1 cm . There are three vessels that create the col-
lateral blood supply: (1) thoracodorsal artery prior to entering
the LD sends one to three branches to the serratus anterior
m uscle that penetrate the m uscle along the course of the long
thoracic nerve; (2) circum ex scapular artery; and (3) dorsal
scapular artery. A signi cant degree of collateral circulation
exists between the thoracodorsal branches and the secondary
segm ental perforators w ith cutaneous vessels arising in close

Classi cation
Mathes-Nahai (m uscle): The latissim us dorsi (LD) m uscle is a fan-
shaped muscle classi ed as a type V muscle ap.

Vascular Pedicle
The latissim us dorsi m uscle is a broad, at, triangular-shaped
muscle located in the posterior lower trunk (Fig. 29.1). The
Latissimus Dorsi Free Flaps
Sachin M. Shridharani, Adriana G. Ram irez, Raja Mohan, and Justin M. Sacks
29
Fig. 29.1 Overview of the latissimus dorsi muscle and its blood supply:
1, axillary artery; 2, subscapular artery; 3, thoracodorsal artery; 4, circum-
ex scapular artery; 5, lateral branch of thoracodorsal artery; 6, medial
branch of thoracodorsal artery; 7, latissimus dorsi muscle; 8, teres major
muscle.1

29 Latissimus Dorsi Free Flaps
349
association w ith the lateral and m edial branches of the thoraco-
dorsal artery.
Venous drainage of the ap generally follows the arterial
supply. There are two regions of preferential venous return:
(1) inferior and medial parts of the muscle, intercostals, and lum -
bar venous systems; and (2) superior part, thoracodorsal system,
and the circum ex scapular vein. The thoracodorsal artery has
a single venae comitantes. The relevance for noting this distinc-
tion is to explain the occurrence of venous comprom ise with a
muscle-only ap of the inferior portion of the LD m uscle. Delinea-
tion of the venous drainage is unnecessary if a m usculocutaneous
ap is raised, since the subcutaneous network adequately drains
the muscle.

●
Mean arterial caliber of the thoracodorsal artery: 2–4 m m
(3 mm)

●
Mean venous caliber of the thoracodorsal vein: 2–5 m m
(3.5 mm)

●
Length: The length of the pedicle is 6.5–12 cm (8.5 cm)

●
Motor innervation: The thoracodorsal nerve arises from
the posterior cord of the brachial plexus and is the motor
innervation for the LD muscle. The nerve is inferolateral to
the vascular pedicle and divides into a lateral and m edical
branch 1.3 cm proximal to the muscle.

●
Sensory innervation (Fig. 29.2): The lateral cutaneous
branches of the intercostal nerves from the ventral rami
of T4-T12 and the lateral branches of the posterior rami
T7-T12 provide segmental sensory innervation to the over-
lying skin. To preserve sensation in a myocutaneous ap or
the thoracodorsal artery perforator (TDAP) ap, the T7-T8
branches should be preserved.

Patient Positioning
Position the patient in the lateral decubitus position with tar-
get muscle side up. It is possible to have the patient in a prone
or even a supine position with a 45-degree lateral tilt; however,
the lateral decubitus position allows for access to the vascular
pedicle as well as the chest wall. If placed in lateral decubitus
position, the arm must be elevated, resting it in a leveled posi-
tion on a Mayo stand. Avoid abduction of the arm greater than
90 degrees assuring no impingement on the upper trunk of the
Fig. 29.2 Anatomic distribution of the sensory nerves of the skin on the latissimus dorsi muscle.1

350
II Reconstructive Flaps A-to-Z
brachial plexus. The elbow should also be exed with padding
below the medial condyle of the humerus to protect from ulnar
nerve injury during long cases. If a free tissue transfer is planned
to the upper or lower extremity, the ap is usually harvested
from the contralateral side. Pad and protect all pressure points
and bony prominences. A donor site for possible skin grafting is
also prepped and draped.

Surface Markings
Mark the patient in the standing position due to distortion of
the muscle territory when prone or in lateral decubitus position.
With the patient standing, surface markings are made over the tip
of the scapula and anterior and posterior axillary lines; mark the
anterior and posterior borders of the LD muscle. Mark an incision
line over the back extending from the axilla or the posterior ax-
illary fold. Continue the m ark inferiorly and m edially over the LD
muscle. The length of m uscle required dictates the length of the
incision. If a skin paddle is required, m ark the requisite cutaneous
territory over the proposed muscle ap. The orientation of the
skip paddle is typically transverse or oblique. The skin paddle can
be as large as 12 3 25 cm in length and still be closed primarily. In
some cases, the donor site cannot be closed and a split-thickness
skin graft has to be used. Transcutaneous Doppler can assist in
determining if the skin paddle is over a perforator vessel from
thoracodorsal system.

Raising the Flap
Step 1: Identify the Skin Paddle
Determine the landmarks of the skin paddle if utilizing a myocu-
taneous ap. The proximal two-thirds of the muscle contains a
larger number of myocutaneous perforators.
Step 2: Position the Patient
Place the patient in the lateral decubitus position, with shoulder
abducted and all pressure points padded (Fig. 29.3).
Step 3: Identify the Defect
Identify the defect that needs to be covered and template out the
size. Con rm that the skin paddle will be su cient to reconstruct
the defect. If the defect requires a skin paddle greater than 10 to
12 cm in one dimension, a split-thickness skin graft donor site
should be identi ed and prepped.
Step 4: Initial Skin Incision
Make the initial skin incision starting at the posterior axillary fold
and running posteroinferiorly toward the iliac crest and 3 to 5 cm
posterior to the medial border of the latissimus dorsi muscle.
The length of the incision depends of the size of the desired m us-
cle ap. Dissect through the skin and subcutaneous tissue and
maintain a hemostatic eld (Fig. 29.4).
Step 5: Secure the Skin Paddle
When raising the skin paddle with the muscle, it is important
not to shear the skin paddle. Suture the skin paddle to the mus-
cle fascia with absorbable stiches to avoid shearing injury to the
myocutaneous perforators.
Step 6: Identify the Latissimus
Dorsi Muscle
Raise anterior and posterior skin aps super cial to the LD m us-
cle fascia. Continue dissection until all borders of the LD m uscle
are visualized.
Fig. 29.3 Surface landmarks including border of scapula and palpable LD muscle.

29 Latissimus Dorsi Free Flaps
351
Step 7: Latissimus Muscle
Elevation
Elevate the middle portion of the muscle from the chest wall by
dissecting between the latissimus dorsi and serratus anterior
muscles starting at the lateral border. Continue dissection toward
the inferomedial muscle origin (thoracolumbar fascia) until de-
sired amount of muscle is elevated. It will be necessary to ligate the
branches from the intercostals and lumbar arteries posteriorly and
perforating branches from the chest wall proximally (Fig. 29.5).
Step 8: Identi cation of Vascular
Pedicle
Identify the thoracodorsal neurovascular bundle on the under-
side of the LD muscle 2 to 3 cm medial of its lateral border. Ligate
one or two branches to the serratus anterior. Identify the circum -
ex scapular artery arising 2 to 3 cm from the origin of the sub-
scapular vessels. Stop dissection once the axillary artery and vein
are reached (Fig. 29.6).
Step 9: Completion of Harvest
Divide the muscle near its insertion. Assure protection of the
neurovascular pedicle underneath during division of the muscle.
Step 10: Donor Site Closure
Close the donor site back defect in a m ultilayer fashion over closed
suction drains. Typically, the authors advocate for using absorb-
able suture to close the super cial fascia and dermis. Assure that
the closure is tension-free to avoid skin necrosis (Fig. 29.7).
Fig. 29.4 Access incision for muscle harvest with wide exposure of muscle.
Fig. 29.5 Harvested LD muscle with pedicle.

352
II Reconstructive Flaps A-to-Z
Fig. 29.6 Dissection of the neurovascular bundle: 1, latissimus dorsi muscle; 2, serratus anterior
muscle; 3, teres major muscle; 6, axillary artery and vein; 7, subscapular artery and vein; 8, thoraco-
dorsal artery, vein, and nerve; 9, circum ex scapular artery and vein; 10, branch to serratus anterior;
13, pectoralis major muscle.1
Fig. 29.7 Primarily closed donor site.

29 Latissimus Dorsi Free Flaps
353

Postoperative Management
The patient may ambulate immediately. The patient should not
lift anything heavy for 3 weeks. Monitor the donor site daily for
any signs of hematoma and seroma. Leave drains in place until
the drain output is less than 20 m L/day for three consecutive
days. In the event that the patient develops a postsurgical seroma,
the surgeon should m anage this collection conservatively with
needle aspiration and compression garments.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Required muscle ap

●
Dominant supplying vascular pedicle(s)
Identi ed and preserved:

●
Thoracodorsal nerve

Flap Variations
1. The latissimus dorsi ap can be harvested as a muscle-only,
myocutaneous, osteomyocutaneous, or perforator ap. Free
aps commonly contain one pedicle but may be based on
more than one. Num erous com binations exist incorporating
the surrounding components of the subscapular system to
produce a chimeric ap. The latissimus dorsi ap can be har-
vested with the serratus m uscle and fascia, with vascularized
bone primarily a rib or part of the scapula, or with a scapular
or parascapular ap on a common pedicle.
2. The reverse latissim us dorsi myocutaneous ap can be based
on either the medial dorsal perforators or the lateral dorsal
perforators of the posterior intercostal arteries. Classically
the major vascular pedicle has been described using the 9th,
10th, and 11th intercostal vessels preferred for their larger
caliber. Consideration and use of this pedicled ap are jus-
ti ed on rare occasion as dissection of the vascular pedicle
causes signi cant morbidity through the paraspinous m us-
cles. It is used to cover defects of the contralateral m idthorax
and inferior thoracic lumber region.
3. The myocutaneous latissim us dorsi ap is harvested with a
circumferential skin incision outlining the desired amount of
skin that will accompany the ap (Fig. 29.8).
4. The pedicled myocutaneous ap transfer can be used for
breast or chest wall reconstruction. A tunnel is made across
the apex of the axilla preserving an island of undisturbed
tissue between the donor and recipient site. This allows for
de nition of the lateral walls of the chest and avoids disrupt-
ing the lymphatic network in the area. Drains should be in-
serted, as a common complication with latissimus dorsi aps
is formation of a seroma in the donor site.
5. Thoracodorsal artery perforator (TDAP) ap produces a thin
sensate island ap w ith maximum of 25 cm in length and
14 cm in width. Sensory innervation is provided via the sev-
enth or eighth lateral cutaneous branch of the intercostal
nerve or the seventh or eighth lateral cutaneous branch of
the dorsal ram i. Doppler owm eter allows for the location
of the cutaneous perforators running 2 to 3 cm posterior
from the lateral border of the muscle. From the neurovas-
cular bundle, the proximal perforator is a slightly larger
diameter vessel in comparison to more distal perforators.
The cutaneous branches circumvent the lateral border of the
muscle and should be considered when planning the loca-
tion of the initial incision. Anatom ical variability exists and
it may be necessary to dissect beyond the lateral border. The
neurovascular bundle is traced back until the main trunk of
the thoracodorsal is reached.
6. The rib–latissimus dorsi osteomusculocutaneous ap can be
used for coverage of bony defects involving the long bones
of the lower extremities or in facial reconstruction involving
the m andible. In lower leg amputees, this ap can serve as
an option in those needing extension of their distal stump
to attain a better tting prosthetic. Typically, the 9th or 10th
rib is selected for the chim eric ap. A maximum of 12 cm of
bone is possible to include (Fig. 29.9).
7. The use of a scapula–latissim us dorsi osteom usculocuta-
neous ap has been described prim arily in reconstruction
of signi cant bone and soft tissue defects of the lower ex-
trem ities. When raising a chim eric osteom uscular ap that
includes the lateral segm ent of the scapula, the angular
artery should be identi ed and incorporated into the con-
joined vascular pedicle. Its origin is from the thoracodorsal
artery in 50% of cases or from a serratus branch in the re-
m aining 50%. The resultant pedicle is proxim al to the divi-
sion of the circum ex scapular and thoracodorsal arteries
to the origin of the subscapular artery from the axillary
artery. The teres m ajor m uscle origin on the lateral edge of
the scapula is detached, as are the infraspinatus and sub-
scapularis. The dim ensions of the osteotom ized bone piece
can be a m axim um of 5 3 2 cm . The integrity of the infe-
rior segm ent of the scapula is preserved to avoid a w inged
scapula.
8. Both of the osteomusculocutaneous aps have been reported
in reconstruction of the infraorbital rim and hard palate.
9. In a thinned musscle ap, a muscle-only latissimus dorsi
ap is raised in the traditional fashion. Prior to transfer, up
to one-third of the thickness of its super cial bers can be
resected without compromising the blood ow located on
the underside of the muscle and deep throughout the re-
mainder of their course.
10. The bilobed split latissim us dorsi ap results in two work-
ing aps to be used simultaneously. Splitting the muscle
also produces less bulk. During the harvest of the ap, the
medial and lateral branches of the thoracodorsal artery and
vein are identi ed and the neurovascular pattern de ned on
the underside of the muscle. The muscle and skin are divided
along the neurovascular pattern.
11. The lateral split latissim us dorsi ap is based on the lateral
branch of the thoracodorsal vessels. The m edial branch of the
thoracodorsal nerve is isolated and preserved to maintain in-
nervation to the rest of the muscle.

354
II Reconstructive Flaps A-to-Z
a
b
Fig. 29.8 (a) Flap design: 1, latissimus dorsi muscle; 2, serratus anterior muscle; 3, thoracodorsal
artery, vein, and nerve; 4, axillary artery and vein; 5, subscapular artery; 6, teres major muscle.
(b) Flap incision and exposure of the muscle: 1, latissimus dorsi muscle; 2, serratus anterior muscle;
6, teres major muscle.1

29 Latissimus Dorsi Free Flaps
355
Fig. 29.9 (a) Flap design and proposed rib. (b) Dissection and osteotomy of the rib: 1, latissimus dorsi muscle; 2, intercostalis muscle; 3, ninth rib; 4, pleura.1
a

b

Clinical Perspectives
The latissim us dorsi m uscle ap is a widely applicable ap op-
tion for coverage of defects involving any com bination of soft
tissue, m uscle, and bone. It is well known as the workhorse ap
of the upper extremity and trunk, including the breast, thoracic,
and abdominal wall. It has additional applications in head and
neck reconstruction, esophageal repair, and reanimation of facial
palsy. Part of its appeal is the reliability of its long pedicle and
large caliber vessels as well as its super cial location and easy
dissection. Another bene t of the latissimus dorsi ap is a negli-
gible functional de cit postoperatively to the patient. It is usually
transferred as a pedicled muscle ap. Variations are discussed
above. Prior to reconstruction, stabilize and debride the wound.
Optimize the patient’s nutrition. Investigate preoperative vascu-
lar status and rule out prior shoulder trauma or surgeries as this
may compromise the source blood supply (Fig. 29.10).

Hints and Tips
1. Make all attempts to primarily close the donor site. Skin grafts
are unsightly in this anatom ic region. Furtherm ore, second-
ary contracture can cause disruption of norm al anatom ic
function.
2. The surgeon should wear a headlamp and loupes.
3. Automatic vascular clip appliers facilitate e cient hemostasis.
4. Placing progressive tension sutures or quilting sutures will
decrease the chance of seroma formation.
5. Palpation of the tip of the scapula provides orientation for
the path of the LD m uscle and the insertion of the serratus
anterior m uscle helping to delineate the two during m uscle
harvest.
6. Seromas refractory to percutaneous drainage should be taken
to the operating room for serom a capsule excision, debride-
ment, and primary closure.

356
II Reconstructive Flaps A-to-Z
a
c
e
b
d
Fig. 29.10 A patient with history of scalp malignancy invading into the cranium (the same patient as illustrated in Figs. 29.3, 29.4, 29.5, and 29.7). (a)
Cutaneous manifestations of scalp malignancy. (b) Resected cutaneous scalp malignancy. (c) Resultant cutaneous defect with removed pericranium.
(d) Superf cial temporal artery and vein harvested. (e) Titanium mesh cranioplasty. (f) LD muscle inset with split-thickness skin graft placed on muscle.
f

29 Latissimus Dorsi Free Flaps
357
Suggested Further Reading
Allen R, Dupin C, Dreschnack P. The latissimus dorsi/scapular bone ap
(the “latissimus/bone ap”). Plast Reconstr Surg 1994:94:988
Barwick W, Goodkind D, Serain D. The free scapular ap. Plast Reconstr
Surg 1982;69:779
Bostwick J III, Nahai F, Wallace J, Vasconez L. Sixty latissimus dorsi aps.
Plast Reconstr Surg 1979;63:31
Bostwick J III, Sche an M, Nahai F, Jurkiewicz M. The “reverse” latissimus
dorsi muscle and m usculocutaneous ap: anatomical and clinical
considerations. Plast Reconstr Surg 1980;65:395–399
Fisher J, Bostwick J III, Powerll R. Latissimus dorsi blood supply after tho-
racodorsal vessel division: the serratus collateral. Plast Reconstr
Surg 1983;72:502
Hallock G. Permutations of combined free aps using the subscapular
system . J Resonstr Microsurg 1997;13:47
Kim J, Koo B, Kim S. The thin latissimus dorsi perforator-based free ap
for resurfacing. Plast Reconstr Sug 2001;107:374
Kim P, Lewis V Jr. Use of a pedicled parascapular ap for anterior shoulder
and arm reconstruction. Plast Reconstr Surg 1985;76:942
Maxwell G, Leonard L, Manson P, Hoopes J. Craniofacial coverage using the latis-
simus dorsi myocutaneous island ap. Ann Plast Surg 1980;4:410–421
Maxwell G, Stueber K, Hoopes J. A free latissimus dorsi myocutaneous
ap. Plast Reconstr Surg 1978;62:462
McCraw J, Penix J, Baker J. Repair of m ajor defects of the chest wall and
spine with the latissimus dorsi myocutaneous ap. Plast Reconstr
Surg 1978;62:197
Olivari N. Use of thirty latissimus dorsi aps. Plast Reconstru Surg 1979;
64:654
Quillen C, Shearin J Jr, Georgiade N. Use of the latissim us dorsi myocuta-
neous island ap for reconstruction in the head and neck area. Plast
Reconstr Surg 1978;62:113
Rowsell A, Godfrey A, Richards M. The thinned latissim us dorsi free ap:
a case report. Br J Plast Surg 1986;36:210
Schneider W, Hill H Jr, Brown R. Latissimus dorsi myocutaneous ap for
breast reconstruction. Br J Plast Surg 1977;30:277–281
Spinelli H, Fink J, Muza ar A. the latissim us dorsi perforator-based fascio-
cutaneous ap. Ann Plast Surg 1996;37:500
Tobin G, Moberg A, DuBou R. The split latissim us dorsi myocutaneous
ap. Ann Plast Surg 1981;7:272
Urbaniak J, Koman L, Goldner R. The vascularized cutaneous scapular ap.
Plast Reconstr Surg 1982;69:772
Watson J, Craig R, Orton C. The free latissim us dorsi myocutaneous ap.
Plast Reconstr Surg 1979;64:299
Yam am oto Y, Sugihara T, Kawashima K, Qi F. An anatomic study of the
latissim us dorsi-rib ap; an extension of the subscapular combined
ap. Plast Reconstr Surg 1996;98:811
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006

358
Latissimus Dorsi Pedicled Flaps
Moham ed Zulf kar Rasheed and Moustapha Ham di
30

Classi cation

●
Mathes-Nahai type V

Vascular Pedicle and
Innervation

●
Dom inant pedicle: thoracodorsal (TD) artery and its vena
com itante

●
Artery diameter: 2.0 to 4.0 mm

●
Vein diameter: 2.5 to 4.5 mm

●
Length: 8.0 to 10.0 cm (may be extended to 15.0 cm if
harvested at the subscapular artery)

●
Secondary segm ental pedicles: four to six perforating ves-
sels from the lumbar and posterior intercostal arteries and
their venae comitantes

●
Motor innervation: thoracodorsal nerve (C5-7)

●
Cutaneous sensory innervation: posterior branch of lateral
intercostal nerves and lateral branch of posterior intercos-
tal nerves

Anatomy
The latissim us dorsi (LD) is a large, fan-shaped, super cial m us-
cle of the back. It has a broad aponeurotic origin from the spi-
nous processes of T7 to S5 vertebrae and the posterior aspect
of the medial half of the iliac crest via the thoracolumbar fascia
(Fig. 30.1). The m uscle bers course superolaterally past the tip
of the scapula, then spiral around the teres major at the posterior
axillary fold before converging as a tendon that inserts into the
oor of intertubercular groove of the humerus.
The dom inant vascular pedicle of the LD is the thoracodorsal
(TD) artery. This is the terminal branch of the subscapular artery,
along with the circum ex scapular artery.
Shortly before entering the LD muscle, the TD artery gives
o one or two branches to the serratus anterior (SA). The SA
branch is clinically important for the following reasons. First, it
allows the SA to be raised with the LD as a chimeric ap based on
the thoracodorsal artery. Second, even if the TD artery is ligated
proximal to the origin of the branch to the SA (e.g., after axil-
lary dissection), the LD may still be perfused by retrograde ow
through the SA branch. Third, if the SA branch (rather than the
main TD vessel) had previously been used as a recipient vessel for
Fig. 30.1 Surgical anatomy of the latissimus dorsi muscle.

30 Latissimus Dorsi Pedicled Flaps
359
along the free edge of the muscle, continuing along the poste-
rior axillary fold to its tendinous insertion into the hum erus
at the axilla. The superior border of the LD muscle is drawn as
a line from its humeral insertion, past the tip of the scapula,
extending to the midline of the back.
3. Perforator mapping: This is generally not needed for the
classical LD myocutaneous ap but is perform ed when plan-
ning for the thoracodorsal artery perforator (TDAP) and
muscle-sparing latissim us dorsi (MS-LD) aps. Exam ination
with a handheld Doppler ultrasound is performed in the
lateral position with the shoulder abducted 90 degrees and
exed 90 degrees. Perforators are concentrated at the anterior
aspect of the muscle, within 5 cm from its anterior border
at a level 8 to 13 cm caudal to the posterior axillary crease.
Occasionally, a septocutaneous perforator from the TD artery
passes around the anterior border of the LD. Multidetector
computed tom ography (CT) angiography and m agnetic res-
onance (MR) angiography are other modalities that may be
used for perforator mapping.
4. Skin paddle: The design of the skin paddle varies depending
on the clinical application; generally, it is an ellipse that over-
lies the m uscle. As described previously, the m ajority of per-
forators are located in the anterior aspect of the m uscle. Part
of the skin paddle should therefore overlie this area to cap-
ture these perforators. Moreover, if the surgeon anticipates
the possibility of harvesting a TDAP ap, the skin paddle
should be sited even m ore anteriorly, beyond the anterolat-
eral edge of the LD m uscle toward the lateral infram am m ary
fold. This design ensures that any possible septocutaneous
perforators from the descending branch of the TD artery are
included.
The orientation of the ellipse depends on the type of recon-
struction and defect to be covered. In breast reconstruction, the
authors’ preference is for an ellipse that is directed inferolaterally.
This design incorporates a back fold for m aximal ap volume and
results in an aesthetic scar that parallels the relaxed skin tension
lines. The incision may be oriented slightly horizontally to be
concealed under the patient’s brassiere strap (Fig. 30.3). In head
and neck reconstruction, an oblique skin paddle oriented parallel
to and along the anterior edge of the LD provides maximum reach
and easy access to the pedicle (Fig. 30.4).
The width of the skin ellipse is lim ited to 8 to 10 cm to fa-
cilitate primary closure; this can be con rmed with a pinch test.
Typical ap dimensions are:

●
Skin: length 18 cm, width 8–10 cm

●
Muscle: length 35 cm (22–42 cm ), width 20 cm (14–26 cm )

Patient Positioning
The LD ap is usually elevated with the patient in the lateral posi-
tion with the ipsilateral shoulder abducted 90 degrees and exed
90 degrees. The ap may also be elevated in the prone position,
particularly when harvesting bilateral LD aps.
Following closure of the donor site, the patient is reposi-
tioned accordingly for ap inset (e.g., supine/sitting in breast
reconstruction).
a previous ap, then the option of elevating the LD ap based on
the TD pedicle remains available.
The TD artery runs under the deep surface of the LD and
enters the substance of the muscle approximately 10 cm below
its tendinous insertion. Shortly after, it bifurcates into a trans-
verse (horizontal) branch and descending (vertical) branch, both
of which supply num erous perforators to the overlying skin. The
descending branch courses parallel to the lateral border of the
LD muscle, 2 cm from its edge, while the transverse branch runs
3.5 cm parallel to the superior border of the LD. This vascular
division allows the LD ap to be raised as a split bilobed ap, or as
a m uscle-sparing LD ap (e.g., the lateral border of the LD based
on the descending branch).

Surface Markings
1. Bony landmarks (Fig. 30.2): With the patient in standing po-
sition, palpate and mark the following bony landmarks: the
midline of the back medially, the iliac crest inferiorly, and the
tip of the scapula superiorly.
2. Margins of the LD muscle: The patient is asked to press both
hands rmly against the hips to tense the LD muscle, mak-
ing it m ore palpable. The anterior border of the LD m uscle is
marked from its origin at the m id portion of the iliac crest,
Fig. 30.2 Preoperative markings: surface markings of the latissimus dorsi:
skeletal landmarks (black markings), midline of back, posterior iliac crest,
angle of scapula; latissimus dorsi muscle (blue markings), anterior and
superior edges; thoracodorsal artery and its descending and transverse
branches (red dashed markings); trapezius muscle (green dashed markings),
lower bers lie super cial to the latissimus dorsi muscle; skin paddle de-
sign, the skin paddle can be designed with its axis inferolaterally (yellow
solid markings) or inferomedially (yellow dashed markings).

360
II Reconstructive Flaps A-to-Z
Fig. 30.3 (a,b) Preoperative photographs of a patient undergoing delayed breast reconstruction with the latissimus dorsi ap and implant with con-
tralateral mastopexy.
a
b

Raising the Flap
Step 1: Con rm the Integrity of
the TD Pedicle
The integrity of the thoracodorsal artery pedicle should be con-
rmed prior to raising the latissim us dorsi ap. This is especially
so after previous axillary dissection and radiation therapy where
the pedicle may have been damaged.
During an immediate breast reconstruction, the thoracodor-
sal pedicle may be explored through an existing axillary incision
that had been created for the axillary dissection or sentinel node
biopsy.
In a delayed breast reconstruction whereby an axillary inci-
sion is not available, an anterior approach is used to explore the
thoracodorsal pedicle. The anterior aspect of the ap is incised
down to the muscular fascia. The surrounding (anterior) skin is
undermined o the m uscular fascia until the anterior edge of the
latissimus dorsi muscle is reached. If part of the skin paddle was
designed to lie beyond the anterior border of the LD muscle, then
this is gently elevated o the m uscular fascia until the anterior
edge of the LD m uscle is reached. The anterior edge of the LD
muscle is retracted posteriorly and dissected o the serratus an-
terior (Fig. 30.5).
The pulsations of the descending branch of the thoracodorsal
artery are palpable 2 cm from the lateral edge of the latissimus
dorsi muscle, and are followed proximally to the thoracodorsal
artery proper. The serratus anterior branch, which runs on the
super cial surface of the serratus anterior muscle, may also be
followed proximally to its origin from the TD artery. When the
integrity of the thoracodorsal artery pedicle is con rm ed, the
surgeon may proceed to elevate the latissimus dorsi ap.
Step 2: Complete the Skin Island
The incision is completed circum ferentially to completely island
the skin paddle (Fig. 30.6). This incision is bevelled outward
to include more subcutaneous tissue to capture the maximum
number of perforators.
Step 3: Undermine Super cial to
the Latissimus Dorsi Muscle
The surrounding skin aps are elevated o the LD m uscle
(Fig. 30.7). In most reconstructions, the plane of undermining is
on the muscle. In breast reconstruction, the plane of dissection is
usually just below Scarpa’s (super cial thoracic) fascia in order to
include the deep subcutaneous fat on the muscle. This maximizes
ap volume and smooths the contour of an underlying implant,
particularly after a denervated muscle has atrophied. The latis-
simus dorsi is undermined to its boundaries: the midline of the

30 Latissimus Dorsi Pedicled Flaps
361
Fig. 30.4 (a,b) Latissimus dorsi musculocutaneous ap with the skin paddle oriented obliquely, paral-
lel to the muscle bers, can a ord long reach and easy access for pedicle dissection.1
a
b

362
II Reconstructive Flaps A-to-Z
Fig. 30.5 The anterior aspect of the ap is incised to fascia, bevelling outward. The surrounding anterior skin aps are elevated, exposing the free lateral
edge of the latissimus dorsi muscle. (a) The latissimus dorsi muscle is retracted with hooks and elevated o the serratus anterior. (b) The descending
branch of the thoracodorsal artery is palpated 2 cm from the lateral edge of the latissimus dorsi muscle. This is traced proximally to the thoracodorsal
artery.
a
b
back medially, the iliac crest inferiorly, the free lateral edge of the
LD muscle laterally, and the tendinous insertion superiorly. If less
muscle is required, the extent of underm ining is reduced appro-
priately to minimize dead space and seroma. Superomedially, the
LD is released from the lowermost bers of the trapezius which
overlap it super cially; this prevents its inadvertent inclusion in
the LD ap.
Step 4: Dissect Under the
Latissimus Dorsi Muscle
Elevate the anterior edge of the LD muscle o the underlying SA
muscle (Fig. 30.8). At this juncture, the two muscles interdigitate,
and care needs to be taken not to inadvertently include the SA
muscle bers in the ap. The two muscles may be di erentiated by
the direction of the muscle bers; the long bers of the latissimus
dorsi run vertically while the serratus anterior muscle bers follow
the direction of the ribs. Once past, the plane becomes well de ned
and dissection proceeds smoothly aided by posterior retraction of
the LD. Medially, perforators from the posterior intercostal and
lumbar arteries are encountered; these are ligated with hemoclips.
Step 5: Detach the Aponeurotic
Origin of the Latissimus Dorsi
Muscle
The inferior origin of the LD muscle is released by detaching its apo-
neurosis from its attachments to the iliac crest caudally and the
spinous processes of the vertebrae via the thoracolumbar fascia me-
dially (Fig. 30.9). This may be achieved using monopolar diathermy
with an extended tip aided by gentle traction on the muscle. If less
muscle is required, the muscle is split or cut accordingly and the
raw edges hemostased and overrun with absorbable sutures.
Step 6: Elevate the Latissimus
Dorsi Muscle O Its Deep Surface
The LD is elevated o its deep surface in a caudal to cranial direc-
tion (Fig. 30.10). Apply gentle upward traction on the latissim us
dorsi muscle and keep the dissection close to the chest wall as the
pedicle that runs within the muscle becomes more super cial
proximally. Posterior intercostal artery perforators are encoun-
tered as they course from the chest wall into the latissimus dorsi
muscle and are ligated w ith hemoclips.
The descending branch of the TD artery is identi ed run-
ning within the muscle 2 cm parallel to its anterior border. This
is traced proximally to the TD artery proper and its bifurcation.
The branch to the serratus, which runs on the super cial surface
of the serratus anterior muscle, is also traced proximally to its
origin from the thoracodorsal artery.
The angle of the scapula is reached, beyond which the latis-
simus dorsi muscle needs to be carefully released from the teres
major m uscle. Doing so exposes the thoracodorsal artery pedicle,
which lies laterally.
Step 7: Pedicle Dissection
The thoracodorsal artery is dissected until the origin of the
circum ex scapular artery (Fig. 30.11). Branches from the
Fig. 30.6 The incision is completed circumferentially and the skin paddle
islanded.

30 Latissimus Dorsi Pedicled Flaps
363
this often allows adequate reach while still helping to protect the
pedicle from avulsion.
Step 9: Subcutaneous Tunnel
In breast reconstruction, a subcutaneous tunnel to the chest is
made high in the axilla (Fig. 30.13). The chest wall lateral to the
inframammary fold is not violated to preserve this key anatomic
landmark. It is important that the tunnel be dissected su ciently
widely to accommodate the ap or venous congestion may occur.
A pair of Ellis forceps is introduced from the chest through
the tunnel into the back, and the distal edge of the latissim us
dorsi muscle is grasped. The Ellis forceps is pulled with one hand
while the other hand pushes the ap, guiding it gently into the
chest. Excessive traction m ust not be applied as this m ay shear
the perforators that supply the skin paddle or dam age the pedicle.
Ensure that the ap is not rotated as pedicle kinking will result in
venous congestion.
thoracodorsal artery that supply the teres major muscle are
ligated. The branch to the serratus anterior usually needs to be
ligated to allow adequate reach. The circum ex scapular artery
is preserved to m aintain vascularity of the scapula. In the event
that additional pedicle length is required, the circum ex scapular
artery m ay be ligated and the subscapular artery dissected prox-
imally to its origin from the axillary artery.
The latissimus dorsi muscle is denervated by carefully tran-
secting the thoracodorsal nerve which runs alongside the vascu-
lar pedicle. This prevents anim ation deformities and m igration of
the breast implant.
Step 8: Disinsert the Latissimus
Dorsi
The latissim us dorsi m ay need to be disinserted to increase reach
(Fig. 30.12). Rather than transecting the tendinous insertion
completely, the authors prefer a partial release where possible as
Fig. 30.7 The surrounding skin aps are dissected o the latissimus dorsi caudally (a) and cephalically (b). The plane of undermining is usually just
under Scarpa’s fascia to include the deep subscarpal fat with the ap (arrow). Undermining extends until the iliac crest inferiorly, the midline of the back
medially, the edge of the latissimus dorsi laterally, and the tendinous insertion superiorly. Note that the lower bers of the trapezius, which is the only
muscle super cial to the latissimus dorsi, are identi ed and preserved.
a
b
Fig. 30.8 The plane deep to the latissimus dorsi muscle is developed,
particularly caudally. Posterior and lumbar intercostal perforators en-
countered are ligated.
Fig. 30.9 The aponeurotic origin of the latissimus dorsi muscle is de-
tached o the iliac crest.

364
II Reconstructive Flaps A-to-Z
a
b
Fig. 30.10 The ap is exteriorized and dissection of the deep surface of the latissimus dorsi proceeds in a caudal to cephalic direction. Posterior inter-
costal artery perforators encountered are ligated. (a) Proximally, beyond the tip of the scapula, the latissimus dorsi muscle (LD) is released from the
teres major muscle (TM). The thoracodorsal artery pedicle (TDA) is identi ed by following the descending branch of the thoracodorsal artery proximally.
(b) The serratus anterior (SA) also leads to the thoracodorsal artery.
Fig. 30.11 Dissection of the thoracodorsal pedicle. The thoracodorsal (TD)
nerve is transected.
Fig. 30.12 The tendinous insertion of the latissimus dorsi muscle may be
partially or fully detached.
Step 10: Closure of Donor Site
Meticulous hem ostasis is perform ed. Absorbable 1-0 quilting su-
tures are applied to anchor the skin aps down to the underlying
bed to obliterate dead space, reducing the risk of seroma. The in-
cision is closed in layers over a drain, and dressings are applied
(Fig. 30.14). The m astectomy site is temporarily dressed to m ain-
tain sterility. The patient is ready to be repositioned supine for
ap inset.
Step 11: Flap Inset (Breast
Reconstruction)
The patient is repositioned supine in the sitting position for ap
inset. The pectoralis major m uscle has been released inferiorly
and a submuscular pocket created to accommodate an implant.
The upper edge of the latissim us dorsi muscle is sutured to the
pectoralis major muscle. The lower edge of the latissimus dorsi
muscle is sutured to the chest wall at the infram am m ary fold
inferiorly and laterally. Drains are inserted and the skin paddle
inset (Fig. 30.15).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Skin paddle

●
Subcutaneous fat (between Scarpa’s fascia and the m uscle
fascia): when more volume and a smoother contour is de-
sired (e.g., in breast reconstruction)

●
LD muscle: complete muscle, partial muscle, muscle spar-
ing (lateral based on descending branch, medial based on
transverse branch), no muscle (TDAP ap)

●
Thoracodorsal pedicle

30 Latissimus Dorsi Pedicled Flaps
365

●
Circum ex scapular artery: Preserve this vessel, which
maintains vascularity of the scapula and allows the
scapular/parascapular aps to be raised in the future.

Clinical Perspectives
Applications of the pedicled latissim us dorsi m usculocutaneous
ap include:

●
Chest wall/pleural/axillary/shoulder/trunk resurfacing and
reconstruction

●
Breast reconstruction with or without implant (extended
LD ap, subsequent fat injection)

●
Partial breast reconstruction (pedicled TDAP or muscle-
sparing LD aps)

●
Head and neck reconstruction

●
Chim eric ap from the subscapular system—latissimus
dorsi, serratus anterior, scapular, parascapular aps

●
Composite tissue: muscle, musculocutaneous, osteomus-
culocutaneous aps

●
Functional upper extremity reconstruction (innervated LD
ap)

●
Cardiomyoplasty

Hints and Tips

●
In cases of previous axillary dissection or irradiation, the tho-
racodorsal vessels may be compromised. Identify and con-
rm the integrity of the main pedicle before committing to
the LD ap. This may be done through an axillary incision if
available, or through an anterior approach when raising the
LD ap.

●
Design the skin paddle according to the patient’s anatomy
and reconstructive requirements.

●
Avoid inadvertently including the SA m uscle where it
interdigitates with the anterior border of LD muscle.

●
Apply buried 4-0 absorbable sutures between the skin
island dermis to the surrounding LD muscle to protect the
perforators from shear and traction.
Fig. 30.13 The subcutaneous tunnel is made high in the axilla, wide
enough to accommodate the ap. (a) Ellis forceps grasping the distal latis-
simus dorsi muscle to gently pull the ap into the chest. (b) The surgeon
will use their other hand to gently guide the ap into the tunnel from the
back. (c) Ensure that there is no twisting or tenting of the pedicle.
a
c
b
Fig. 30.14 The donor site after closure.
Identi ed and preserved:

●
Serratus anterior m uscle: Avoid inadvertently including
the SA m uscle where it interdigitates with the anterior
edge of the LD.

●
Trapezius muscle: Avoid inadvertently including the low-
erm ost bers of the trapezius, which lies super cial to
the superom edial aspect of the latissimus dorsi m uscle
(at T7-T12).

366
II Reconstructive Flaps A-to-Z
Fig. 30.15 (a–d) Many variations of ap inset exist. Here, the superior lateral edge of the latissimus dorsi muscle is sutured to the lower edge of the
pectoralis major muscle, the implant placed below the muscle, and the muscle sutured to the chest wall laterally before the skin paddle is inset.
a
b
c
d

●
To prevent accidental traction or avulsion of the pedicle,
do not disinsert the latissimus dorsi tendon until the ap
is ready to be transferred.

●
Complete tendon disinsertion is often not required; partial
tendon disinsertion usually provides su cient reach while
protecting the pedicle from traction and avulsion.

●
The m ost com m on complication of LD ap harvest is donor
site seroma. Strategies to reduce the risk of seroma forma-
tion include minimizing dead space by lim iting the extent
of undermining, raising muscle-sparing LD or TDAP aps,
using quilting sutures to bed down skin aps, and drain
insertion.
Suggested Further Reading
Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous ap
without m uscle. Plast Reconstr Surg 1995;96:1608–1614
Barlett SP, May LW, Yaremchuk MJ. The latissimus dorsi m uscle: a fresh
cadaver study of the primary neurovascular pedicle. Plast Reconstr
Surg 1981;67:631–636
Barnett GR, Gianoutsos MP. The latissim us dorsi added fat ap for natural
tissue breast reconstruction: report of 15 cases. Plast Reconstr Surg
1996;97:63–70
Barton FE Jr, Spicer TE, Byrd HS. Head and neck reconstruction with the
latissim us dorsi myocutaneous ap: anatom ic observations and
report of 60 cases. Plast Reconstr Surg 1983;71(2):199–204
Bostwick J, Nahai F, Wallage JG. Sixty latissim us dorsi aps. Plast Reconstr
Surg 1979;63:31–41

30 Latissimus Dorsi Pedicled Flaps
367
Rowsell AR, Eisenberg N, Davies DM, Taylor GI. The anatomy of the tho-
racodorsal artery within the latissim us dorsi muscle. Br Plast Surg
1986;39(2):206–209
Schwabegger A, Ninkovic M, Brenner E, Anderl H. Seroma as a common do-
nor site morbidity after harvesting the latissimus dorsi ap: observa-
tions on cause and prevention. Ann Plast Surg 1997;38(6):594–597
Schwabegger AH, Harpf C, Rainer C. Muscle-sparing latissimus dorsi
myocutaneous ap with maintenance of muscle innervation, func-
tion, and aesthetic appearance of the donor site. Plast Reconstr Surg
2003;111(4):1407–1411
Sinna R, Delay E, Garson S, Delaporte T, Tousson G. Breast fat grafting
(lipomodelling) after extended latissimus dorsi ap breast recon-
struction: a preliminary report of 200 consecutive cases. J Plast Re-
constr Aesthet Surg 2010;63(11):1769–1777
Tanzini I. Sopra il mio nuovo processo di amputazione della mamm ella.
Gaz Med Ital 1906;57:141
Tobin GR, Moberg A, Ringberg A, Netscher D. Mandibular-facial recon-
struction with segmentally split serratus anterior composite aps.
Clin Plast Surg 1990;17(4):663–672
Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi myocu-
taneous ap. Ann Plast Surg 1981;7(4):272–280
Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neuro-
vascular anatomy of the latissimus dorsi muscle: the basis for split-
ting the ap. Plast Reconstr Surg 1981;67:637e–641e
Woo E, Tan BK, Koong HN, Yeo A, Chan MY, Song C. Use of the extended V-Y
latissimus dorsi myocutaneous ap for chest wall reconstruction in
locally advanced breast cancer. Ann Thorac Surg 2006;82(2):752–755
Woo E, Tan BK, Lim CH. Treatm ent of recalcitrant air leaks: the com -
bined latissimus dorsi-serratus anterior ap. Ann Plast Surg
2009;63(2):188–192
Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow exion.
An appraisal of eight cases. J Bone Joint Surg Am 1973;55(6):
1265–1267
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
Chachques JC, Jegaden O, Mesana T, Glock Y, Grandjean PA, Carpentier
AF, et al. Cardiac bioassist: results of the French m ulticenter car-
diomyoplasty study. Asian Cardiovasc Thorac Ann 2009;17(6):
573–580
Fisher J, Bostwick J, Powell RW. Latissim us dorsi blood supply after tho-
racodorsal vessel division: the serratus collateral. Plast Reconstr
Surg 1983;72:502–511
Germann G, Steinau HU. Breast reconstruction with the extended latissi-
m us dorsi ap. Plast Reconstr Surg 1996;97:519
Hallock, Geo rey G. Metachronous aps from the sam e subscapular axis.
Plast Reconstr Surg 2002;109(7):2424–2430
Hamdi M, De Frene B. Pedicled perforator aps in breast reconstruction.
Sem in Plast Surg 2006;20:73e–78e
Hamdi M, Van Landuyt K, Hijjawi JB, et al. Surgical technique in pedicled
thoracodorsal artery perforator aps: a clinical experience with
99 patients. Plast Reconstr Surg 2008;121(5):1632–1641
Hamdi M, Van Landuyt K, Monstrey S, et al. Pedicled perforator aps
in breast reconstruction: a new concept. Br J Plast Surg 2004;57:
531e–539e
Hamm ond DC. Latissim us dorsi ap breast reconstruction. Plast Reconstr
Surg 2009;124(4):1055–1063
Heitm ann C, Guerra A, Metzinger SW, et al. The thoracodorsal artery per-
forator ap: anatomic basis and clinical application. Ann Plast Surg
2003;51(1):23–29
Heitm ann C, Pelzer M, Kuentscher M, Menke H, Germ ann G. The
extended latissimus dorsi ap – revisited. Plast Reconstr Surg
2003;111:1697–1701
Maxwell JP, McGibbon BM, Hoopes JE. Vascular considerations in the use
of a latissimus dorsi myocutaneous ap after mastectomy with an
axillary dissection. Plast Reconstr Surg 1979;64:771–780
Mutaf M, Sensoz O. Use of a pedicled parascapular ap com bined
w ith latissim us dorsi m uscle for coverage of the forearm and re-
construction of elbow exion. Plast Reconstr Surg 1994;93(4):
868–871
Quillen CG. Latissimus dorsi myocutaneous aps in head and neck recon-
struction. Plast Reconstr Surg 1979;63(5):664–670
Rowsell AR, Eisenberg DN, Taylor GI. The anatomy of the subscapular-
thoracodorsal arterial system : study of 100 cadaver dissections. Br
J Plast Surg 1984;37(4):574–576

368
Pedicled Omental Flaps for Sternal
Reconstruction
Pouria Moradi, Charles A. T. Durrant, and Sim on H. Wood
31

Classif cation
The om ental ap has a Mathes and Nahai type III circulation.
There are two dom inant pedicles. The rst is the right gastro-
epiploic artery and vein branch from the gastroduodenal artery
and vein. The other dominant pedicle, the left gastroepiploic
artery and vein, rises from the splenic artery and vein.
The use of the om entum for reconstruction of the chest wall
has been well described. It is a reliable, well-vascularized ap
that can generally be harvested with minimal morbidity, which
does require an abdominal laparotomy, or can be harvested
laparoscopically.

Vascular Pedicle
The om entum possesses a rich arterial arcade with two dom inant
vessels, right and left omental branches, which descend from the
gastroepiploic artery, along the greater curvature of the stomach.
The ap is isolated on the right om ental artery and the right
gastroepiploic artery (Fig. 31.1).

Patient Positioning
The patient is supine on the operating table. This allows exposure
of the abdomen and also the sternal defect (Fig. 31.2).

Raising the Flap
Step 1
An upper midline laparotomy incision is used and the omentum
identi ed (Fig. 31.3) and delivered in to the operative eld.
Step 2
The greater curvature of the stom ach and the right and left gas-
troepiploic vessels are identi ed. The om entum is then turned
up superiorly, allowing access to the posterior attachments to the
transverse colon (Fig. 31.4). The omentum is subsequently freed,
with the perforating vessels ligated and divided. This then allows
the om entum to be isolated on its attachm ents to the greater
curvature of the stomach.
Fig. 31.1 Illumination of the omentum allows excellent visualization of the vascular arcade. Right
gastroepiploic artery (arrow).

31 Pedicled Omental Flaps for Sternal Reconstruction
369
Fig. 31.2 View from above of the planned incision and the sternal defect.
Fig. 31.3 Following an upper laparotomy, the omentum is easily identi ed (arrow).

370
II Reconstructive Flaps A-to-Z
Fig. 31.4 The omentum  ipped superiorly, with the posterior attachments to the transverse colon 
identi ed (arrow).
Step 3
The omentum is then dissected free o the stomach, beginning
on the left side and m arching across to the right, ligating branch-
es entering the om entum . The left and m iddle gastroepiploic ar-
tery and their branches are am ong the vessels that are ligated.
The ap is then isolated on the right gastroepiploic pedicle
(Fig. 31.5).
Step 4
Once the right gastroepiploic pedicle has been isolated, the ap
is transposed superiorly over the skin to check for adequate ap
length (Fig. 31.6).
Step 5
Once the surgeon is happy with the mobilization of the ap, an
incision is m ade in the anterior origin of the diaphragm, allowing
a tunnel for the transposed omentum (Fig. 31.7).
Step 6
Once an adequately sized tunnel is created, the ap is delivered
through the diaphragm into the sternal defect (Figs. 31.8 and 31.9).
Step 7
The om entum is then inset into the sternal defect with split skin
graft coverage with or without a vacuum -assisted closure device
(Fig. 31.10).
Fig. 31.5 Ligating the vascular connections o  the greater curvature of 
the stomach (arrow).

31 Pedicled Omental Flaps for Sternal Reconstruction
371
Fig. 31.6 The omental  ap transposed over the skin superiorly to check for adequate  ap coverage of the sternal defect.
Fig. 31.7 View of the tunnel created through the diaphragm.

372
II Reconstructive Flaps A-to-Z
Fig. 31.8 The omentum being carefully pulled up into the sternal defect.
Fig. 31.9 The entire length of the omentum delivered through the tunnel.
Fig. 31.10 The omentum inset into the sternal defect with split skin graft 
coverage.

31 Pedicled Omental Flaps for Sternal Reconstruction
373
Step 8
The donor site is closed, and a drain is inserted under the
omental ap.

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Om entum , which carries with it fat, connective tissue,
and lymphatics

●
Right or left gastroepiploic artery and its perforators to
the omentum

Clinical Perspectives
In 1963, Kiricuta was the rst to use the omentum for reconstruc-
tion of soft tissue defects in various body surfaces. Following his
description, in 1972, Dupont and Menard promoted widely the
use of the greater om entum for reconstruction of the chest wall.
Also in 1972, Buncke and McLean published the results of the rst
successful clinical microsurgical reconstruction. They utilized the
omentum to cover a large scalp defect, and with this, the era of
microsurgical reconstruction was born.
The om ental ap has also been used to treat chronic vesico-
vaginal stulas; to ll the irradiated pelvis with well-vascularized
tissue; in the abdom inal cavity for a variety of reasons such as
reinforcement of intestinal anastomosis, plication of perforated
ulcers, packing of liver lacerations, and wrapping of injured
spleen; as a useful adjunct in reconstruction for hemifacial
atrophy; and for posterior trunk reconstruction.

Flap Variations
The om ental ap can be raised o the right or left gastroepiploic
vascular bundle, depending on the rotation required, or it can be
transferred as a free ap.

Hints and Tips
Care m ust be taken when m obilizing the om entum o the splenic
exure, as you can easily avulse the left gastroepiploic vessel.
Suggested Further Reading
Dupont C, Menard Y. Transposition of the greater omentum for recon-
struction of the chest wall. Plast Reconstr Surg 1972;49(3):263–267
Fix RJ, Vasconez LO. Use of the om entum in chest wall reconstruction.
Surg Clin North Am 1989;69(5):1029–1046
Giordano PA, Gri et J, Argenson C. Pedicled greater omentum transferred
to the spine in a case of postoperative infection. Plast Reconstr Surg
1994;93(7):1508
Hoballah, J, Mohan, C, Nazzal, M, Corson, J. The use of om ental aps in
abdominal aortic surgery: a review and description of a simple
technique. Ann Vasc Surg 1998;12(3):292–295
Hultm an CS, Carlson GW, Losken A, et al. Utility of the omentum in the
reconstruction of complex extraperitoneal wounds and defects:
donor-site complications in 135 patients from 1975 to 2000. Ann
Surg 2002;235(6):782–795
Kiricuta I. [The use of the great omentum in the surgery of breast cancer].
Presse Med 1963;71:15–17
Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, & Tech-
nique. New York: Churchill Livingstone; 1997
McLean DH, Buncke HJ Jr. Autotransplant of omentum to a large scalp
defect, with microsurgical revascularization. Plast Reconstr Surg
1972;49(3):268–274
Reade CC, Meadows WM Jr, Bower CE, Lalikos JF, Zeri RS, Wooden WA.
Laparoscopic omental harvest for ap coverage in complex m edias-
tinitis. Am Surg 2003;69(12):1072–1076
Turner-Warwick RT, Wynne EJ, Handley-Ashken M. The use of the om ental
pedicle graft in the repair and reconstruction of the urinary tract.
Br J Surg 1967;54(10):849
Wallace J, Schneider W, Brown R, Nahai F. Reconstruction of hemifacial at-
rophy with a free ap of omentum . Br J Plast Surg 1979;32(1):15–18

374
Pectoralis Major Muscle Flaps
Sachin M. Shridharani and Devinder P. Singh
32
Dominant
The pectoral branch of the thoracoacrom ial artery is considered
to be the dominant blood supply to the pectoralis major muscle.

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

●
Mean venous caliber of associated venae comitantes: 3.0 mm

●
Length: The length of the pedicle is 4 cm, but can be
increased slightly based on ap design

Classif cation
Mathes-Nahai (muscle): The pectoralis muscle is a at, fan-shaped
muscle classi ed as a type V muscle ap.

Vascular Pedicle
See Fig. 32.1.
Fig. 32.1 Anatomy for pectoralis major  ap: 1, clavicular segment; 2, sternocostal segment;
3, abdominal segment; 4, axillary artery; 5, thoracoacromial artery; 6, pectoral branch;
7, deltoid branch; 8, acromial branch; 9, clavicular branch; 10, lateral thoracic artery.1

32 Pectoralis Major Muscle Flaps
375
Secondary Segmental
Vascular Pedicles
The internal m am m ary perforating arterial branches through rst
to sixth intercostal spaces (medial) are considered to be second-
ary segmental vascular pedicles to the pectoralis major muscle.

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

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

●
Length: The length of the pedicle is 1 to 2 cm.
The pectoral branch of lateral thoracic artery is considered to be
one of the secondary segmental vascular pedicles to the pectora-
lis major muscle.

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

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

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

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

●
Length: The length of the pedicle is 1 to 2 cm.
Innervation
Motor
The pectoralis m ajor adducts and m edially rotates the arm .
In addition, it has dual motor innervation. The lateral pectoral
nerve originates from the lateral cord of the brachial plexus and
is located lateral to the axillary artery. It enters the muscle on its
deep surface in close proximity to the dominant vascular pedicle.
It innervates the clavicular and sternal heads of the muscle.
The medial pectoral nerve originates from the m edial cord of
the brachial plexus and lies medial to the axillary artery. It passes
between the axillary artery and vein to enter the pectoralis minor
muscle on its deep surface; it supplies the pectoralis minor mus-
cle and then two or three branches pass into the pectoralis major
to supply the posterolateral portions of the muscle.
Sensory
The second through seventh intercostal nerves provide segm en-
tal sensory innervation to the overlying skin of the pectoralis
major muscle.

Patient Positioning
Position the patient supine with the shoulder abducted to
90 degrees and the arm extended on an arm board. Although not
essential, it m ay be useful to prep the arm and drape it in the
eld. If planning for a pectoralis midline advancement ap (see
Variations section, below), be prepared to place the patient’s arm
against their body, adduct the shoulder, and extend the arm at
the elbow joint when closing the midline.

Surface Markings
1. In planning for surgery, identify and mark the sternal notch,
xiphoid process, and midline chest (Fig. 32.2).
2. Identify and mark the clavicle.
Fig. 32.2 Chest wall surface markings.

376
II Reconstructive Flaps A-to-Z
3. Identify the middle third of the clavicle. This represents the
location of the underlying dominant vascular pedicle.
4. Palpate the lateral axillary fold. This represents the lateral
extent of the pectoralis major muscle.
5. Draw a line from the superolateral aspect of the lateral axillary
fold to the xiphoid process.

Raising the Flap
Step 1: Prepare the Chest
Prep the chest widely and drape to include the m idaxillary line,
supraclavicular skin, and subxiphoid abdomen.
Step 2: Placing the Incision
Depending on clinical indication, ap selection, and defect
location, the surgical approach to the pectoralis muscle ap is
through either a midline sternal incision (Fig. 32.3) or a verti-
cal paramedian incision. Additionally, one may make an incision
from the coracoid process running along the deltopectoral groove
and the lateral border of the pectoralis major toward the xiphoid
(Fig. 32.4).
Step 3: Sternal Debridement
Carefully assess the quality and viability of the sternal wound.
Debride infected or necrotic sternal bone back to healthy bleed-
ing tissue. This may require retrosternal subperiosteal dissection
to protect anterior mediastinal contents such as the internal
mammary vessels.
Step 4: Exposing the Muscle
Elevate adipocutaneous aps o the underlying muscle fascia.
For a turnover ap, use rack retractors and Bovie electrocau-
tery extension tip to undermine the skin widely o the anterior
surface of the muscle. For myocutaneous advancement aps,
preserve the skin–muscle junction.
Step 5: Raising a Turnover Flap
with Disinsertion
Identify and preserve the medial intercostal perforating blood
supply based on the underlying internal mammary vessels.
Through the midsternal access, disinsert hum eral attachment of
the muscle. In rare cases of di cult exposure, m ake a counter in-
cision in the axilla to provide access to this muscular attachment
for division. Identify, ligate, and divide the cephalic vein in the
deltopectoral groove. Raise the muscle ap o the chest wall, the
subpectoral place, in a lateral to medial direction. Take care to
preserve the pectoralis minor muscle.
Step 6: Dissection of the
Turnover Flap
Divide clavicular attachments of the muscle in a lateral to me-
dial manner. At the middle third of the clavicle, identify, ligate,
Fig. 32.3 A 60-year-old woman status post coronary artery bypass graft with sacri ce of the left 
internal mammary vessels. Open chest after wound infection and sternal dehiscence.