Grabb’s Encyclopedia of Flaps Head and Neck

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FIGURE 135.6 A-C: A large (13 × 25 cm) paddle of skin was used to cover a large wound following a temporal
bone resection. The skin paddle extended beyond the pectoralis major muscle by 8 cm and included the anterior
rectus fascia. D: The donor defect was closed primarily with generous elevation and advancement of the chest
skin and subcutaneous tissue. The donor site seen at 1 year.
FIGURE 135.7 A: An extensive squamous cell carcinoma that invaded the globe and orbital contents was widely
resected. B: The cavity was filled with the soft tissue of the distal portion of a pectoralis major flap. C: The
appearance of the patient at 6 months. (From Ariyan, ref. 4, with permission.)
Temporal Bone Resection
Following resection of the tumor and the temporal bone, the size and extent of the defect are determined and a
paddle of skin of appropriate size is outlined over the vascular axis of the pectoralis major muscle. This flap can
be tunneled under the neck skin on its narrow muscle pedicle to reach the cranial resection and cover the wound

in one stage. This musculocutaneous flap can tolerate a full course of radiation therapy without complications in
the postoperative period.
Mandibular Reconstruction (7, 8, 9, 10, 11)
In patients in whom I employed the pectoralis major musculocutaneous flap incorporating a segment of
underlying rib to reconstruct a jaw (9), the body and symphysis of the mandible were reconstructed with the
attached rib while the floor of the mouth and chin were reconstructed with the overlying double-paddle
musculocutaneous flap (Fig. 135.8). The viability of this rib was confirmed through the use of flourochrome
markers (9).
However, for reconstruction of the entire mandible, the paddle of skin that is needed would require a long
segment of bone along its longitudinal axis. To accomplish this would require elevating the entire pectoralis
major muscle to transport such a paddle of skin and bone, and this would be much too bulky. Under these
circumstances, I prefer to reconstruct the jaw with free bone grafts in the traditional manner and to cover it with a
pectoralis major musculocutaneous flap so that the bone graft is sandwiched within a well-vascularized muscle.
CLINICAL RESULTS
The pectoralis major musculocutaneous flap has been a very reliable and successful flap in my early
experience of 40 consecutive patients (six patients had esophageal reconstructions). In half these patients,
the size of the skin paddle exceeded 150 cm2, with the largest paddle recorded at 13 × 25 cm for a temporal
bone resection (see Fig. 135.6). All the donor sites were closed primarily and healed without complication.
In eight patients, the flap was elevated with double paddles, either in tandem or split side by side (see Figs.
135.1 and 135.2).
FIGURE 135.8 Artist's depiction of pectoralis major flap elevated with underlying segment of rib. Note that
the skin paddle is used for oral lining and the rib is used to bridge the mandibular resection.
There were nine complications in eight patients. There were three cases of separation of the skin paddle
along a portion of the suture line; however, in each instance, the muscle did not separate and the wound
healed without additional surgical treatment. An orocutaneous fistula developed in three patients, two of
whom had oropharyngeal reconstruction with the tip of the skin paddle in the piriform sinus; there was only
one orocutaneous fistula in the six reconstructions of the esophagus (all of which had a full course of
preoperative radiation therapy). Each of these three fistulas closed within 2 weeks without requiring
additional surgery.
There were three cases of partial loss of the skin paddle, one for a jaw reconstruction, one for an orbital
reconstruction, and one in a double paddle. Two were debrided and allowed to close by secondary
contraction, while a third required surgical debridement and secondary closure of the wound. There was no

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case of total loss of a pectoralis major flap.
The patients in this series did not have any evidence of disability from a partial loss of the pectoralis major
muscle, whether the lateral pectoral nerves were cut or left intact. In two patients, both pectoralis major
muscles were used for reconstructions, and these patients had no disability. All six patients with esophageal
reconstructions are able to eat regular or mechanically soft diets without difficulty in swallowing.
SUMMARY
The pectoralis major musculocutaneous flap is very reliable for head and neck reconstruction. There are
few complications and little or no disability from the loss of muscle.
References
1. Ariyan S, Krizek TJ. Reconstruction after resection of head and neck cancer. CINE Clinics. Clinical
Congress of the American College of Surgeons, Dallas, Texas, October 1977.
2. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck.
Plast Reconstr Surg 1979;63:73.
3. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of
defects from excisions of head and neck cancer. Plast Reconstr Surg 1979;64:605.
4. Ariyan S. Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck
construction. Clin Plast Surg 1980;7:89.
5. Ariyan S, Cuono CB. Myocutaneous flaps for head and neck reconstruction. Head Neck Surg 1980;2:321.
6. Sharzer LA, Kalisman M, Silver CE, Strauch B. The parasternal paddle: a modification of the pectoralis
major myocutaneous flap. Plast Reconstr Surg 1981;67:753.
7. Brown RG, Fleming WH, Jurkiewicz MJ. An island flap of the pectoralis major muscle. Br J Plast Surg
1977;30:161.
8. Arnold PG, Pairolero PC. Chondrosarcoma of the manubrium: resection and reconstruction with pectoralis
major muscle. Mayo Clin Proc 1978;53:54.
9. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional
osteomusculocutaneous flap. Plast Reconstr Surg 1980;65:477.
10. Bell MSG, Barron PT. The rib-pectoralis major osteomusculocutaneous flap. Ann Plast Surg 1981;6:347.
11. Green MF, Gibson JR, Bryson JR, Thomson E. A one-stage correction of mandibular defects using a split
sternum pectoralis major osteomusculocutaneous transfer. Br J Plast Surg 1981;34:11.

12. Thomson HG. Reconstruction of the orbit after radical exenteration. Plast Reconstr Surg 1970;45:119.
13. Murray JE, Matson DD, Habal MB, et al. Regional cranio-orbital resection for recurrent tumor with
delayed reconstruction. Surg Gynecol Obstet 1972;134:437.
14. Bakamijian VY, Souther SG. Use of temporal muscle for reconstruction after orbitomaxillary resections for
cancer. Plast Reconstr Surg 1975; 56:171.
15. Sypert GW, Habal MB. Combined cranio-orbital surgery for extensive malignant neoplasms of the orbit.
Neurosurgery 1978;2:8.
16. Holmes AD, Marshall KA. Uses of the temporalis muscle flap in blanking out orbits. Plast Reconstr Surg
1979;63:336.
17. Parsons H, Lewis JS. Subtotal resection of the temporal bone for cancer of the ear. Cancer 1954;7:995.
18. Ward GE, Loch WE, Lawrence W. Radical operation for carcinoma of the external auditory canal and
middle ear. Am J Surg 1951;82:169.
19. Ariyan S, Sasaki CT, Spencer D. Radical en bloc resection of the temporal bone. Am J Surg
1981;142:443.
20. Manktelow RT, McKee NJ, Vettese T. An anatomic study of the pectoralis major muscle as related to
functioning free-muscle transplantation. Plast Reconstr Surg 1980;65:610.
21. Freeman JL, Walker EP, Wilson JSP, Shaw HJ. The vascular anatomy of the pectoralis major
myocutaneous flap. Br J Plast Surg 1981;34:3.
22. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical
correlation. Plast Reconstr Surg 1981;67:177.
23. Meyer R, Kelly TP, Failat ASA. Single bilobed flap for use in head and neck reconstruction. Ann Plast
Surg 1981;6:203.
24. Donegan JO, Whiteley J, Gluckman JL, Shumrick DA. Improved method of harvesting the pectoralis
major myocutaneous flap. Am J Otolaryngol 1981;2:223.

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Chapter 136
Free Groin Flap Reconstruction of Severe Burn Neck Contracture
K. HARII
Reconstruction of a severe burn scar contracture of the neck occasionally requires skin-flap coverage to prevent
recurrence, of the contracture or to reestablish chin prominence. Conventional flaps such as the deltopectoral,
acromiopectoral, and shoulder flap are available for this purpose, but a free skin flap from the groin region is an
alternative because it can provide sufficient skin for coverage of the total anterior neck surface in one operation
(1, 2, 3). The donor scar in the grout can be easily concealed.
ANATOMY
There are dual arterial supplies to the groin flap that consist of the superficial circumflex iliac artery (SCIA) and
the superficial epigastric artery (SEA). Both arteries form complex vascular patterns in nourishing the groin flap.
In a typical case, the separate SCIA and SEA originate directly from the femoral artery, but on some occasions,
their points of origin vary from the profunda femoris, the deep circumflex iliac artery and so on. In 16% of cadaver
dissections, either or both the SCIA and the SEA emerged from arteries other than the femoral artery (1, 4).
In 30% to 50% of cases, the SCIA and SEA together form a single common trunk at their origin, but they are of
separate origin in the remainder of cases. The SCIA is constant, with a reliable anatomic course, but the SEA
occasionally is deficient. Both arteries form a closed vascular network in nourishing the groin skin, and a free
groin flap can therefore be isolated with a pedicle of either of the arteries or the common trunk.
There are two venous drainage systems in the groin. The dominant venous system is usually composed of the
superficial cutaneous veins involving the superficial circumflex iliac vein and the superficial epigastric vein. In
more than 60% of cases, both veins form a common trunk and flow into the saphenous bulb after crossing over
the femoral artery. When both veins are duplicated or branch farther out, the dominant venous
flow usually is maintained by the superficial circumflex iliac vein. The deep veins, such as the venae comitantes
of the two arteries, are additional drainage systems in the groin and can, in some cases in which the superficial
veins do not develop well, be reliable drainage veins.
FLAP DESIGN AND DIMENSIONS
The femoral artery, the inguinal ligament, and the anterosuperior iliac spine are first marked as definite anatomic
landmarks. The base of the flap should be placed over the femoral artery. The center of the flap is positioned a
little higher than the axial line, which is drawn from a point on the femoral artery about 3 cm below the inguinal
ligament to the anterosuperior iliac spine, because the base of the flap can include the origins of both the SCIA
and the SEA (Fig. 136.1).
OPERATIVE TECHNIQUE
All the scar tissue causing the neck contracture is completely excised. If the anterior cervical muscles are
affected by the contracture, they also are excised to minimize recurrence of the contracture. It is important to
create a deep groove along the chin-neck angle, because an obtuse angle may give a poor aesthetic result.

FIGURE 136.1 Anatomic landmarks: F.A., femoral artery; I.G., inguinal ligament; A.L., axial line; arrow A, point on
femoral artery 3 cm below the inguinal ligament; arrow B, the anterosuperior iliac spine. (From Harii, ref. 3, with
permission.)
During preparation of the recipient site, exposure of a suitable artery and vein is required. The facial artery and
vein at the mandibular angle are generally preferred, but if the facial vessels are not available, the superficial
cervical, lingual, or other vessels are used.
Following preparation of the recipient site, a groin flap of the required size is isolated. The flap then is elevated
from the lateral margin toward the femoral artery. At the lateral border of the sartorius muscle, a terminal
cutaneous branch of the SCIA is clearly observed piercing the sartorius fascia to the skin. To secure a blood
supply in the distal part of the flap, the branch should be included in the flap with a piece of the sartorius fascia.
The dissection then proceeds toward the medial border of the sartorius muscle, and here the root of the SCIA
should be identified (2).
After dissection of the medial border of the sartorius fascia, the flap is further elevated toward the femoral artery,
tracing the root of the SCIA. On reaching the lateral wall of the femoral artery, the SCIA is usually observed
originating from the femoral artery itself or one of the major branches. The SEA also is dissected after the root of
the SCIA has been exposed. The venae comitantes of the two arteries should be preserved.
The base of the flap finally is incised to dissect the superficial cutaneous veins. The flap is thus elevated as an
island flap with the nutrient vessels composed of the SCIA, the SEA (or the common trunk of both arteries), the
venae comitantes of the two arteries, and the superficial cutaneous veins; however, one artery and one vein that
appear optimal for microvascular anastomoses are finally selected.
The isolated groin flap is then transferred to the recipient defect and fixed with several marginal sutures.
Microvascular anastomoses between flap and recipient vessels then are performed. After observation of good
vascular return to the flap, both the donor and recipient sites are closed. The skin defect in the groin is
approximated as directly as possible, but a skin graft may be required (Fig. 136.2).
CLINICAL RESULTS
The main drawbacks of the free groin flap are the complex vascular anatomy of the groin and the short and

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small stalk of the pedicle vessels, which sometimes make the operation difficult.
SUMMARY
A free groin flap is an alternative for release of neck scar contractures when standard flaps are not
available.
FIGURE 136.2 An 8-year-old boy with burn scar contracture of the neck. A,B: Preoperative views. The
entire contracture was released by excision of all scar tissue and contracted cervical muscles. C:
Completely elevated groin flap. Note the pedicle vessels. Anastomoses were carried out between the
superficial circumflex iliac artery, the superficial cutaneous vein, and the right facial vessels. D,E: Two
months postoperatively, the patient's neck extension is complete. There has been no recurrence of the
contracture. (From Harii, ref. 3, with permission.)
References
1. Harii K, Ohmori K, Torii S, Sekiguchi J. Microvascular free skin flap transfer. Clin Plast Surg 1978;5:239.

2. Harii K. Microvascular transfer of free skin flaps. In: Wilson JSP, ed. Operative surgery, 3d ed. London:
Butterworth, 1981;83.
3. Harii K. Microvascular free tissue transfers. World J Surg 1979;3:29.
4. Taylor GI, Daniel RK. Anatomy of several free-flap donor sites. Plast Reconstr Surg 1975;56:243.

Chapter 137
Lateral Intercostal Microvascular Flap for Release of Neck Scar
H. A. BADRAN
EDITORIAL COMMENT
This is another alternative that would be far down on the editors' list of recommendations because of the
difficult dissection and the poor color match for neck skin. In severely burned patients with only selected
areas that are free of scarring, however, this flap might prove useful.
This is a sizable neurovascular skin flap from the anterolateral abdomen, based on the lateral cutaneous branch
of any one of the lower three posterior intercostal vessels or the subcostal artery. It can have varying forms and
a wide spectrum of applications, including use for posttraumatic scarring of the face, neck, and extremities, to
correct facial contour deformities, and in breast and penile reconstruction (Fig. 137.1).
INDICATIONS
Lateral intercostal flaps share indications with other upper-quadrant flaps (1, 2, 3, 4, 5, 6, 7, 8) but without
the need for delay or the inclusion of intercostal or abdominal musculature. The flaps are innervated by the
lateral cutaneous nerve, which contains between two and four fascicles for total flap supply. A vascularized
rib segment may be incorporated for an osteocutaneous flap (9), and the flap may be deepithelialized (10).
Other advantages of the flap include its large size (up to 25 × 20 cm), its long pedicle (8-15 cm), easy
anastomosis of relatively large-diameter intercostal vessels (1.5-2.0 mm), and relative thinness. There is a
choice between several pedicles, and the flap can be defatted and beveled without compromising its
vascularity; primary tailoring minimizes the need for future revisions. The donor defect is closed directly,
even in larger flaps, because of the redundancy of the abdominal skin.
ANATOMY
For purposes of description, the posterior intercostal artery, which is a branch of the thoracic aorta, can be
divided into four segments: vertebral, costal groove, intermuscular, and rectus sheath segments (7). The
vertebral segment gives off a nutrient branch to the rib, a spinal branch, and a collateral branch. In the
intermuscular segment, the artery gives off mainly muscular and intermuscular branches. In the rectus sheath
segment, the vessel terminates by anastomosing with the epigastric system. In the costal groove segment, the
vessel gives off the following branches.
The lateral cutaneous branch arises near the anterior end of the costal groove and is accompanied by a vein of
similar diameter lying above and a nerve below. The lateral cutaneous bundle courses obliquely in the intercostal
space deep to the internal and external intercostal muscles and under cover of the slip of origin of the external
oblique. It leaves the intercostal space at the anterior border of this slip and emerges to the subcutaneous tissue
lying on the superior slip, 1 to 2 cm in front of the anterior border of the latissimus dorsi muscle. At this point, the
artery has an internal diameter of 0.5 to 1.0 mm.
The bundle courses for a short distance superficial to the muscle fascia, to which it is firmly attached, before
dividing into a smaller posterior and a larger anterior branch. Early division of the lateral cutaneous bundle may

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occur in 40% of cases. In these instances, the posterior division exits in the normal position described for the
lateral cutaneous bundle. On the other hand, the anterior division continues deeply between the slips of the
external oblique to emerge several centimeters anterior to the point of emergence of the posterior division. Injury
of this anterior division in the depth of the intercostal space, or mistaking it for the anterior continuation of the
posterior intercostal bundle, could lead to flap loss. In 5% of cases, the two divisions of the lateral cutaneous
branch arise separately from the posterior intercostal artery.
Periosteal branches arise directly or from the muscular branches of the vessel. These branches supply the
anterior and posterior periosteum and are located well protected within its layers. These vessels can support a
vascularized rib segment without the need for an endosteal supply (9).
FIGURE 137.1 Severe post-burn contracture of the neck. A: Preoperative view. B: Postoperative view showing
the large dimensions of the flap.
Musculocutaneous branches usually anastomose with the musculocutaneous branches of the thoracodorsal
system before emerging to the subcutaneous tissues. This is a hemodynamic basis for inclusion of ribs and
latissimus dorsi muscle together in one vascularized unit.
FLAP DESIGN AND DIMENSIONS
The flap is outlined within the skin territory supplied by the artery with the patient standing. The point of pedicle
exit into the subcutaneous plane can be roughly marked at the intersection of the anterior border of the
latissimus dorsi and the lower border of the rib, corresponding to the bundle selected, usually the tenth or
eleventh.
With the chosen pedicle lying in the center, the skin territory of the flap can extend to incorporate four intercostal
spaces in the vertical dimension, and from the lateral border of the rectus abdominis anteriorly to the lateral
border of the sacrospinalis posteriorly. The posterior border of the flap should lie at least 5 cm behind the
posterior axillary line to ensure that the lateral cutaneous branch of the lower three posterior intercostal arteries
and the subcostal artery are included in the flap (Fig. 137.2).
OPERATIVE TECHNIQUE

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The part of the flap posterior to the pedicle is elevated first with the muscle fascia to protect the vessels (Fig.
137.3A). Once the lateral cutaneous branch is identified, it is traced back to its origin from the posterior
intercostal artery in the intercostal space. The slip of origin of the external oblique
from the same rib is detached, and the latissimus dorsi and intercostal muscles are divided (Fig. 137.3B). For the
desired pedicle length, the bundle then is dissected out from the subcostal groove in a posterior direction. To do
this, the periosteum is incised on the lower border of the rib and is reflected down (Fig. 137.3C). It is again
incised in the area of the roof of the costal groove. In this way, the delivery of the intercostal bundle is facilitated
by pulling the incised edge of the periosteum down.
FIGURE 137.2 Diagram of surface anatomy of the flap. P.A.L., posterior axillary line; L.D., latissimus dorsi;
P.I.V., posterior intercostal vessels; R, rib; L.C.B., lateral cutaneous branch; P.D., posterior division; A.D.,
anterior division; E.O., external oblique.

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FIGURE 137.3 Diagram of operative technique. A: Reflection of posterior part of the flap to expose the lateral
cutaneous branch between the slips of origin of the external oblique. B: The branch is traced back into the
intercostal space. The slip of origin of the external oblique is detached, the latissimus dorsi is cut, and the
intercostal muscles are divided. C: Delivery of the posterior intercostal bundle out of the subcostal groove. The
periosteum (Per.) is incised at the lower border of the rib and again at the roof of the groove, to facilitate the
delivery. D: Diagram of osteocutaneous flap. The posterior intercostal bundle is left in place in the subcostal
groove of the harvested rib segment and is dissected out only for the desired pedicle length from the portion of
the rib posterior to that segment.
This step is better done under loupe magnification and can be time consuming. Care should be taken to identify
and coagulate the periosteal branches arising directly from the
vessels to the periosteum of the undersurface of the groove; their injury could lead to troublesome bleeding.
Dissection between the point of exit of the branch from the mother vessels to its emergence in the subcutaneous
level should be done with utmost care because of the possibility of branching anomalies.
Anteriorly, the posterior intercostal bundle is dissected to just beyond the lateral cutaneous branch, ligated, and
cut. The lateral cutaneous nerve can be stripped from the main nerve for the desired length. Dissection then
proceeds carefully to free the lateral cutaneous bundle from the fascia on the slip of origin of the external oblique

on which it lies. This step is also better done under loupe magnification. The rest of the flap borders then are
incised down to and including the muscle fascia. The flap is quickly elevated and its circulation tested before the
pedicle is clamped.
In cases of osteocutaneous flaps, raising the skin portion of the flap is initially done in the usual fashion. The
lateral intercostal branch then is traced into the intercostal space as usual, but the posterior intercostal bundle is
not dissected out and is kept in the costal groove. The rib is harvested based on the periosteal blood supply
given by the artery while inside the groove. At the posterior end of the harvested rib segment, the posterior
intercostal vessels are dissected out of the groove and traced for the desired length (Fig. 137.3D).
SUMMARY
The varying forms possible in using the lateral intercostal flap and its advantageous properties make it
useful in a wide variety of applications.
References
1. Badran HA, El-Helaly M, Safe I. The lateral intercostal neurovascular free flap. Plast Reconstr Surg
1984;73:17.
2. Esser JFS. Biological or artery flaps of the face. Monaco: Institut Esser de Chirurgie Structive, 1931.
3. Dibbel DG. Use of long island flaps to bring sensation to the sacral area in young paraplegics. Plast
Reconstr Surg 1974;54:200.
4. Daniel RK, Terzis JK, Cunningham DM. Sensory skin flaps for coverage of pressure sores in paraplegic
patients: a preliminary report. Plast Reconstr Surg 1976;58:317.
5. Daniel RK, Kerrigan CI, Gard DA. The great potential of the intercostal flap for torso reconstruction. Plast
Reconstr Surg 1978;61:653.
6. Little JW, Fontana DJ, McCulloch DT. The upper quadrant flap. Plast Reconstr Surg 1981;68:175.
7. Kerrigan CL, Daniel RK. The intercostal flap: anatomical and hemodynamic approach. Ann Plast Surg
1979;2:411.
8. Drever JM. Total breast reconstruction with either of two abdominal flaps. Plast Reconstr Surg
1977;59:185.
9. Badran HA, Safe I, El Fayoumy S. Simplified technique for isolating vascularized rib periosteal grafts. Plast
Reconstr Surg 1990;86:1208.
10. Badran HA, Yousef MK, Shaker A. Management of facial contour deformities with deepithelialized lateral
intercostal free flaps. Ann Plast Surg 1996;37:94.

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Chapter 138
Microvascular Free Transfer of A Deepithelialized Groin Flap to
The Cheek
L. A. SHARZER
Soft-tissue augmentation with autogenous dermis and fat is a well-known and well-accepted technique.
Composite dermal fat segments may be transferred as grafts (nonvascularized) (1, 2, 3, 4), as pedicle flaps
(vascularized) (5, 6, 7), or as free flaps (microvascular) (8, 9, 10, 11, 12). Nonvascularized grafts undergo 40% to
50% resorption and must therefore be overcorrected at the time of transfer. Even then, resorption is
unpredictable and the ultimate outcome uncertain. Because flaps retain their circulation, the volume transferred
is the volume that remains, barring excessive generalized weight gain or weight loss. Free flaps, in general, allow
greater leeway in flap design and donor-site choice than pedicle flaps, and this is true for deepithelialized free
flaps as well.
INDICATIONS
The most common indications for deepithelialized free-flap transfer are Romberg's hemifacial atrophy,
congenital or acquired hemifacial microsomia, and contour defects related to trauma or cancer surgery.
ANATOMY
The deepithelialized groin flap based on the superficial circumflex iliac vessels is particularly well suited to
contour reconstructions and has been my flap of choice.
FIGURE 138.1 Soft-tissue defect outlined on the cheek.
FLAP DESIGN AND DIMENSIONS
The flap should be designed to the exact recipient-site requirements (Figs. 138.1 and 138.2). The flap outline will
often be quite irregular, as there may be projections into the temporal, malar, or mental regions. Recipient
vessels are planned in advance, so they can be oriented on the flap template. In general, it is best to use vessels

in the neck such as the facial artery and vein or other branches of the external carotid artery. In this way, if the
planned-for vessels are found to be unsuitable, the vascular pedicle will be located where it can be anastomosed
(with a vein graft, if necessary) to another neck vessel.
FIGURE 138.2 Pattern of required flap transferred to the groin. (Solid line is at the inguinal ligament; broken line
is along the course of superficial circumflex iliac artery.)
FIGURE 138.3 Dissected flap has been transferred to the face. (White vessel loops mark the external carotid
artery and its branches.)
The flap template then is transferred to the groin area, where the flap outline is marked. The flap pedicle is
oriented toward the takeoff of the superficial circumflex iliac artery, and the long axis of the flap lies along the
course of the artery two fingerbreadths below the inguinal ligament. It is helpful to tattoo key points of the flap to
aid in orientation after the flap is elevated.

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FIGURE 138.4 Anteromedial portion of revascularized flap has been deepithelialized.
FIGURE 138.5 A: Preoperative appearance of acquired hemifacial microsomia. B: Postoperative appearance
following flap transfer.
OPERATIVE TECHNIQUE
Donor Site
The flap is elevated as a standard free groin flap. My preferred technique is a lateral to medial elevation after
preliminary identification of the superficial circumflex iliac artery and vein through an incision over the femoral
artery. It is best not to deepithelialize any portion of the flap until it has been revascularized at the recipient site.
The donor site is always closed primarily. It is often necessary to excise dog-ears at both medial and lateral ends
of the defect because of the irregularity of flap design.
Recipient Site
A preauricular incision is made and extended into the submandibular area if necessary. A cheek flap is elevated,
as for a face-lift. If the proposed recipient vessels are in the neck, epinephrine may be infiltrated in the cheek
area to aid in hemostasis. Epinephrine should not be used anywhere near the recipient vessels. The recipient
vessels are identified and marked with vessel loops, but they are not divided until the flap has been transferred.

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Care must be taken to avoid injury to the marginal mandibular branch of the facial nerve.
After completion of donor- and recipient-site dissections and observation of the flap for adequacy of circulation,
the flap is transferred to the face and held in place with a few sutures while the vascular anastomoses are
carried out. I prefer to perform the arterial anastomosis first because this decreases ischemia time and allows a
longer period of observation of the arterial anastomosis.
Once the flap has been revascularized, it is oriented in its new position. Key sutures are placed in the dermis of
the flap and brought out through the facial skin to be tied later over a bolster. The cheek flap then is placed
without tension over the free flap to determine how much of the free flap may be deepithelialized (Figs. 138.3 and
138.4). Often, the added bulk of the soft tissue from the flap makes the facial skin inadequate, and a portion of
free-flap skin must be left intact. Even if it is not necessary to leave a portion of flap skin intact, it is desirable to
leave at least a small patch to serve as a monitor of circulation during the postoperative period. This can later be
removed, leaving a linear scar. A tight closure of facial skin over the free flap should be avoided. The dermis
should be anchored to facial fascia or periosteum of the zygoma to avoid “drooping” later on. Deepithelialization
is then carried out and the wound is closed over suction drains (Fig. 138.5).
CLINICAL RESULTS
Complications that may arise from any free groin flap transfer, such as vascular thrombosis, are possible
with this procedure. Two complications, in particular, must be anticipated. The recipient vascular anatomy is
frequently anomalous in congenital cases, and it is important to identify the common carotid and the carotid
bifurcation before dividing any vessels. The internal and external carotid arteries may be small and
confused with branches of the facial or superior thyroid arteries. The other complication is sagging of the
flap if it is not well anchored to fascia or periosteum.
SUMMARY
Deepithelialized groin flaps are a safe, reliable operation for autogenous soft-tissue augmentation of the
cheek.
References
1. Thompson N. The subcutaneous dermis graft: a clinical and histological study in man. Plast Reconstr Surg
1960;26:1.
2. Leaf N, Zarem HA. Correction of contour defects of the face with dermal and dermal fat grafts. Arch Surg
1972;105:715.
3. Sawhney CP, Banerjee TN, Chakravarti RN. Behavior of dermal fat transplants. Br J Plast Surg
1969;22:169.
4. Scheussler WW, Steffans DN. Dermal grafts for correction of facial defects. Plast Reconstr Surg
1949;4:341.

5. Converse JM, Betson RJ. A twenty-year follow-up of a patient with hemifacial atrophy treated by a buried
de-epithelialized flap. Plast Reconstr Surg 1971;48:2.
6. Dey DL. Hemifacial atrophy: repair with a buried flap. Aust N Z J Surg 1974;44:379.
7. Neumann CG. The use of large buried pedicle flaps of dermis and fat. Plast Reconstr Surg 1953;11:315.
8. Fujino T, Tanino R, Sugimoto C. Microvascular transfer of a free deltopectoral dermal fat flap. Plast
Reconstr Surg 1975;55:428.
9. Harashina T, Nakajima T, Yoshimora Y. A free groin flap reconstruction in progressive facial hemiatrophy.
Br J Plast Surg 1977;30:14.
10. Wells JH, Edgerton MT. Correction of severe hemifacial atrophy with a free dermis-fat flap from the lower
abdomen. Plast Reconstr Surg 1977; 59:223.
11. O'Brien BM, Russell RC, Morrison WA, Sully L. Buried microvascular free flaps for reconstruction of soft-
tissue defects. Plast Reconstr Surg 1981;68:712.
12. Shintomi Y, Ohura T, Honda K, Iida K. The reconstruction of progressive facial hemiatrophy by free
vascularized dermis fat flaps. Br J Plast Surg 1981;34:398.

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Chapter 139
Microvascular Transfer of A Scapular/Parascapular Flap to The
Cheek
T. BENACQUISTA
B. STRAUCH
EDITORIAL COMMENT
The use of scapular/parascapular flaps in this area is quite effective, not only for the correction of cheek
skin deformities but also for the augmentation of subcutaneous tissue, especially in patients with Romberg's
disease or hemifacial microsomia.
The use of scapular and parascapular microvascular free flaps in cheek reconstruction is gaining more popularity
(1, 2). These fasciocutaneous flaps have great versatility, allowing for good contour in many types of cheek
defect and in cases of facial asymmetry. The flaps also have been used in the lower extremity and hand.
INDICATIONS
When used as fasciocutaneous flaps, these free-tissue transfers can fill in large cheek defects after trauma
or tumor ablation. When deepithelialized, the flaps can be used in the correction of facial asymmetry.
Advantages in these cases include reliability, appropriate bulk for the cheek, and lack of atrophy; the latter
characteristic is not found in muscle flaps (1, 2). The color match of scapular and parascapular flaps may be
troublesome when they are used with skin to fill in cheek defects, but the excellent contour that can be
achieved may outweigh this shortcoming.
These free flaps not only provide sufficient bulk for cheek defects but have a quite constant and reliable
pedicle, with a long pedicle length (7-8 cm) and wide-caliber vessels (2-3 mm). If bone is required in the
reconstruction, the flap can be taken with the lateral border of the scapula. About 10 to 14 cm of bone can
be harvested, depending on the amount required by the individual patient (3).
The major disadvantage is patient positioning during flap harvesting and closure of the donor site.
Dissection of the vascular pedicle can be tedious because of the numerous muscular and bony branches
that must be divided. Also, the donor site does not have a cutaneous sensory nerve, and there is no
possibility for a sensate flap.
ANATOMY
The cutaneous flaps are supplied by the circumflex scapular artery, which emerges from the scapular artery
about 4 cm from its origin from the axillary artery (4). The circumflex
scapular artery emerges from the triangular fossa on the back at the edge of the lateral border of the scapula.
This space is formed by the long head of the triceps and the teres major and minor muscles (5) (Fig. 139.1). The
artery then terminates into two fasciocutaneous branches, one oriented transversely (scapular flap [6]) and one
oriented vertically (parascapular flap [7]).

FIGURE 139.1 Vascular anatomy of the scapular region.
Before dividing into terminal branches, the circumflex scapular artery gives off several branches to the lateral
border of the scapula in its superior portion. These branches supply the periosteum of the lateral border of the
scapula and the attached muscles, thus allowing bone to be harvested with the flap.
FLAP DESIGN AND DIMENSIONS
Because of the orientation of the fasciocutaneous branches, the flaps can be designed as an ellipse, either
horizontally (scapular flap) or vertically (parascapular flap). More commonly, the flap is designed in an oblique
configuration between these two orientations to allow easier primary skin closure of the back and a better
cosmetic result (Fig. 139.2).
Depending on the laxity of the skin, up to 10 cm of skin width can be harvested and closed primarily. Much larger
widths can be harvested with a good blood supply; however, the resultant defect must be skin grafted, or
preoperative skin expansion must be planned. The length that can be harvested depends on the patient's size
and can be up to 30 cm. Combinations of cutaneous flaps are possible for larger defects. Even the latissimus
dorsi muscle, with or without a cutaneous paddle, may be harvested on the thoracodorsal pedicle if more bulk is
necessary; this is rare for defects limited to the cheek. A combination of the two cutaneous territories as two
separate paddles can be useful in through-and-through defects to provide both external skin coverage and inner-
mouth lining.

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FIGURE 139.2 Dorsal aspect of the scapular area with schematic outlining of the various technical possibilities:
scapular or parascapular flaps, oblique orientation or in combination.
OPERATIVE TECHNIQUE
The patient is placed in a lateral decubitus position with the side of the cheek defect facing upward using the
ipsilateral back for the harvest site, which allows a two-team approach to the procedure, although the work
space may be somewhat cramped. The team at the head will prepare the cheek to receive the flap and will
dissect out the recipient vessels. In cases of facial asymmetry due to hemifacial microsomia or Romberg's
disease, a skin flap is raised via a preauricular incision on the affected side to the extent of the deficiency to
accommodate a deepithelialized scapular or parascapular flap.
The incision can be extended into the neck if the facial artery and vein or other neck vessels are to be used as
recipient vessels, or it can be limited to the preauricular region with a better cosmetic result if the superficial
temporal artery and vein are used as recipient vessels (8). Because the superficial temporal vein is quite fragile,
this may not always be possible.
If there is an ablative portion to the procedure, the patient is usually placed first in a supine position, as most
head and neck surgeons are not amenable to operating with the patient in a lateral decubitus position. In this
case, once the ablation is completed, the vessels in the neck are prepared for the anastomoses, and the patient
then is turned onto the side. After the flap has been harvested, it is best to detach it, put it aside, and close the
donor defect. This should be done as expediently as possible because the flap is ischemic during this period.
The wound then is dressed, and the patient can return to a supine position without reprepping and draping.

FIGURE 139.3 Outline of the parascapular flap, and the measurement procedure (D, D1) to determine the
emergence of the pedicle, as shown.
The location of the triangular fossa is palpated just lateral to the scapula. If it is not palpable, it can be located
using the following measurements. The triangle is located at distance D1 = (D − 1)/2, where D is the distance
between the middle part of the spine and the tip of the scapula (7) (Fig. 139.3).
As mentioned, the flap is usually oriented in an oblique direction from the shoulder toward the middle of the back.
Dissection starts at the distal end of the flap, and a fasciocutaneous flap is raised off the underlying muscle
fascia. With an oblique orientation, this is usually the latissimus dorsi muscle. Fascial extensions can be
harvested to fill in subtle deficiencies in cases of facial asymmetry (1).
As the dissection is carried proximally, the borders of the omotricipital space are identified, the teres major first
laterally and the teres minor medially. Once these are identified, the pedicle is usually visible. At this point, the
upper incision can be made and the long head of the triceps will be seen. The pedicle is traced back into the
triangle toward the cirumflex scapular artery or to the scapular artery, depending on the length of pedicle
required. The dissection should be carried out as bloodlessly as possible because blood staining the tissues in
this area makes for a frustrating experience, especially when dissecting the periosteal branches.
FIGURE 139.4 Clinical case. A 35-year-old woman with a history of an enlarging left-cheek mass, which was

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adherent to the skin but without invasion of buccal mucosa. Pathology showed dermatofibrosarcoma
protuberans.
Once the flap is transferred to the face and revascularized, it is sculpted to fit the defect. Preoperative fabrication
of a facial moulage may help to obtain better results (2). The flap should be anchored to bone whenever possible
to prevent descent over time, especially when very large flaps are being used. If flap deepithelialization is
required and the flap is to be placed under a facial skin flap, a lateral skin paddle may be constructed for
postoperative monitoring (Figs. 139.4, 139.5, 139.6, 139.7, 139.8).
FIGURE 139.5 Defect of the entire left cheek after tumor resection.
FIGURE 139.6 Markings drawn for a very large parascapular flap in an oblique orientation shaped to fit the
defect.

FIGURE 139.7 Parascapular flap has been raised. The donor site required skin grafting to close the defect.
FIGURE 139.8 Postoperative appearance at 6 months.
CLINICAL RESULTS
All series reporting the use of scapular/parascapular free flaps in head and neck reconstruction are quite
favorable. Some authors state that this is their first choice for reconstruction of major defects in this area (1,
2, 3, 8, 9, 10). In a series of 28 patients, Upton et al. reported little less than half requiring secondary
procedures to achieve better contour (2). Another series of 57 patients reported excellent contour using the
flap with fascial extensions (1), with revisions performed in about a third of patients and no significant
sagging or atrophy reported over time.
SUMMARY
Scapular/parascapular flaps are excellent for cheek reconstruction and may be the best choice for this
purpose. The flaps are vigorous and have constant vascular anatomy, good pedicle length, and large
vessel caliber. Although there is no long-term atrophy, patients may require flap revision to achieve the best

results.
References
1. Siebert JW, Anson G, Longaker MT. Microsurgical correction of facial asymmetry in 60 consecutive cases.
Plast Reconstr Surg 1996;97:354.
2. Upton J, Albin RE, Mulliken JB, Murray JE. The use of scapular and parascapular flaps for cheek
reconstruction. Plast Reconstr Surg 1992;90:959.
3. Swartz WM, Banis JC, Newton D, et al. The osteocutaneous scapular flap for mandibular and maxillary
reconstruction. Plast Reconstr Surg 1986;77:530.
4. Strauch B, Yu HL. Atlas of microvascular surgery: anatomy and operative approaches. New York: Thieme
Medical Publishers, 1993.
5. dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg
1984;73:599.
6. Barwick WJ, Goddkind DJ, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69:779.
7. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: a new cutaneous microsurgical free flap.
Plast Reconstr Surg 1982;69:591.
8. Longaaker MT, Siebert JW. Microvascular free-flap correction of severe hemifacial atrophy. Plast
Reconstr Surg 1995;96:800.
9. Chandrasekhar B, Lorant JA, Terz JJ. Parascapular free flaps for head and neck reconstruction. Am J
Surg 1990;116:160.
10. Sullivan MJ, Carroll WR, Baker SR. The cutaneous scapular free flap in head and neck reconstruction.
Arch Otolaryngol Head Neck Surg 1990; 116:600.

Chapter 140
Microvascular Free Transfer of Omentum to The Cheek
S. K. DAS
M. A. LESAVOY
EDITORIAL COMMENT
The major problem of free omentum to the face for contour restoration is the late sagging of the omentum.
For this reason, other procedures are being used, such as those described in preceding chapters,
especially deepithelialized skin flaps.
The search for ideal tissue to reconstruct contour deformity in the face still goes on. Various autogenous and
synthetic materials have been tried.
INDICATIONS
Omentum is one of the satisfactory alternatives for reconstruction of contour defects produced by facial
atrophy (Romberg's disease) (1, 2, 3, 4); hemifacial microsomia (5, 6), or trauma. Correction of the
underlying bony defect is necessary first, followed by soft-tissue reconstruction.
ANATOMY
The size of the omentum is not a problem, and it has been shown that omentum is almost always present, with
an average length of 25 cm and an average width of 33 cm. Omental size can be predicted from the sex, height,
and weight of the patient (7, 8). Only in rare cases of total lipodystrophy is omental fat, as well as mesenteric fat,
totally absent (9).
The structure and vascular anatomy of the omentum make it suitable for use in facial reconstruction (3, 8). The
fatty structure gives it pliability and softness, and the distribution of omental vessels helps divide the omentum
into vascular units. The right gastroepiploic vascular pedicle length ranges from 9 to 12 cm, and the size of the
vessels ranges from 1.5 to 3 mm for artery and 2.5 to 3.5 mm for vein. The length of the pedicle permits the
selection of donor vessels far away from the recipient site and allows for minimal size discrepancy with recipient
vessels, such as the facial, superior thyroid, and superficial temporal vessels.
The unique vasculature of the omentum, in the form of parallel vessels ranging between two and eight in number
running distally from the gastroepiploic arch, allows the omentum to be split into units with an artery and vein
surrounded by a segment of omentum. Thus, one can augment a specific portion of the face by placing strips of
omentum one upon the other.
FLAP DESIGN AND DIMENSIONS
A clever technique has been devised (3) using the unique vasculature of omentum in an attempt to counter the
gravitational sag of omental transfer over time and the accumulation of bulk along the dependent mandibular
margin. The face is divided into three sections (Fig. 140.1): a frontotemporal area above the line drawn from the
tragus to the lateral canthus of the eye, a zygomaticomaxillary area above a line drawn from the tragus to the
lateral commissure of the mouth, and a mandibular area above a line drawn from the lobule of the ear along the

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inferior border of the mandible.
Usually, the base of the omentum with the gastroepiploic arch is placed vertically and along the preauricular area
and the omentum is spread as a fan anteriorly and medially.
OPERATIVE TECHNIQUE
The most common recipient vessels are the facial, because of easy access and corresponding vessel size. The
superficial temporal artery is an excellent alternative, but one should be aware that in some cases of hemifacial
atrophy the superficial temporal vessels can be atrophic or hypoplastic.
The face is explored through a preauricular face-lift type of incision, with extension below the mandibular area.
The skin flap is raised as in a face-lift, but the attachment of the skin to deeper tissue (dermis to premuscular
fascia) along the three lines mentioned above is kept intact. The recipient vessels, the facial or the superficial
temporal vessels, are exposed and the anastomoses are performed.
The distal omentum is split into several tongues or peninsulas and is placed in the already dissected pockets as
required to correct the deformity. Usually, a slight overcorrection is recommended. Pull-out bolster sutures (Fig.
140.2C) are placed through the distal end of the tongues of omentum over forehead, supraorbital area,
zygomaticofrontal area, nasolabial
area, and mandibular area. The skin flap is closed, and a drain is placed over the most dependent part
(postauricular).
FIGURE 140.1 Three compartments of the face divided by three lines (see text). (From Upton et al., ref. 3, with
permission.)

FIGURE 140.2 A,B: Preoperative photographs of a patient with left hemifacial atrophy. C: Immediately after skin
closure, showing various bolster suture fixations of omentum. D,E: Postoperative follow-up photographs, 1 year
later. (From Das, ref. 8, with permission.)
CLINICAL RESULTS
In most cases, reoperation and revision of excess omentum are necessary. The reason for this is generally
overaugmentation, with the expectation of resorption; however, because this flap is vascularized
immediately, the amount of resorption is less than one would expect. Other possible complications related to
this procedure occur from harvesting the omentum through a laparotomy.
The success rate with this flap for facial reconstruction has been high, and surgeons using the procedure
are consistently satisfied. The difficulty with late gravitational sagging over the mandibular area has been
minimized through the modifications described.
SUMMARY
The omentum, through microvascular transfer, has provided a good flap for reconstructing contour
deformities of the face.
References
1. Harii K. Free omental transfer. In: Transactions of the Sixth International Congress of Plastic and

Reconstructive Surgery. Paris: Masson, 1976;61.
2. Harii K. Clinical application of free omental flap transfer. Clin Plast Surg 1978;5:273.
3. Upton J, Mulliken JB, Hick PD, Murray JE. Restoration of facial contour using free vascularized omental
transfer. Plast Reconstr Surg 1980;66:560.
4. Zuo SL. Reconstruction of facial atrophy defect by transplantation of free great omentum: case report
(Author's translation). Chung Hua Kou Chiang Ko Tsa Chih 1981;16:14.
5. Rheiner P, Montandon D. Correction d'une hemiatrophic faciale par transfert libre de l'épiploon. Helv Chir
Acta 1980;47:141.
6. Wallace JG, Schneider WJ, Brown RG, Nahai FM. Reconstruction of hemifacial atrophy with a free flap of
omentum. Br J Plast Surg 1979;32:15.
7. Das SK. The size of the human omentum and methods of lengthening it for transplantation. Br J Plast Surg
1976;29:70.
8. Das SK. Use of the omentum in reconstructive surgery. In: Barron J, Saad M, eds. Manual of operative
plastic and reconstructive surgery. Edinburgh: Churchill-Livingstone, 1980.
9. Personal communication with Dr. M. Jurkiewicz, 1988.

Chapter 141
Free Deltoid Flap
J. D. FRANKLIN
R. D. GOLDSTEIN
For details of anatomy, flap design and dimensions, operative technique, and clinical results, see Chapter 320.
This chapter shows one indication for the flap—coverage of a defect in the cheek (FIg. 141.1).
FIGURE 141.1 A: A 36-year-old woman prior to wide excision for a neck dissection for nodular level IV 1.2 mm
thick melanoma. B: The donor site for the flap is 20 × 12 cm at its greatest dimensions. C: Early postoperative
appearance. D: Result, 1 year later. Note that the donor site was closed primarily, because the flap was taken
more down on the shoulder on the inferior portion of the arm, rather than on the shoulder.

Chapter 142
Scapular and Parascapular Flaps
J. BAUDET
T. NASSIF
J. L. BOVET
B. PANCONI
For details of anatomy, flap design and dimensions, operative technique, and clinical results, see Chapter 321.
This chapter illustrates the use of the parascapular flap for release of a scar contracture in the neck (Fig. 142.1).
FIGURE 142.1 A: Sequelae of burn with contracture of the right side of the neck. B: Satisfactory release of skin
contracture after transfer of a parascapular flap. Z-plasties are planned for the anterior part. (Clinical case
courtesy of Dr. J. Fissette et al., Department of Maxillofacial Surgery and Plastic Surgery, and Professor A.
Castermans, Hopital de Baviere, Liege, Belgium.)

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Chapter 143
Thoracodorsal Artery Perforator (Tdap) Flap
C. ANGRIGIANI
EDITORIAL COMMENT
This is a reasonably reliable flap, with consistent anatomy. The donor site can usually be closed, and the
scar is not objectionable. It is a flap that should be used more frequently than it is.
This flap was originally described in 1995 as a method for diminishing the volume of the conventional latissimus
dorsi myocutaneous flap (1). Various methods had been previously described to split the muscle, either
longitudinally or transversely, to diminish flap bulk (2, 3). The same area of skin and subcutaneous tissue island
can be harvested without the muscle, using the perforator-flap technique.
The thoracodorsal artery perforator (TDAP) flap is another example of the independence of the skin paddle from
the underlying muscle from the standpoint of irrigation.
INDICATIONS
The TDAP, as well as its predecessor, the latissimus dorsi musculocutaneous flap, can be used as an
island or as a free transferred flap. It is indicated when a thin, large flap with a long vascular pedicle is
necessary. It is used as an island for resurfacing of axillary, shoulder, or ipsilateral breast, or anterior thorax,
lesions.
As a free flap, it is indicated whenever a large area of skin and subcutaneous tissue is necessary, and a
long and large
vascular pedicle is preferred (for example, for large ankle and lower-leg lesions or cranial lesions when the
anastomoses are performed to the neck vessels).
FIGURE 143.1 The thoracodorsal artery runs under the deep surface of the latissimus dorsi muscle, where
it bifurcates into two main branches: horizontal and descending branches. Both branches give off cutaneous
branches that pierce the muscle. The larger ones come off the descending branch at 6 to 8 cm inferior to
the axillary crease and 1 to 2 cm to the border of the muscle.
As the skin island can be designed in any direction, the TDAP flap is a very convenient way to harvest skin
from the lateral thoracic wall and the inframammary area; this is an excellent donor area, with low morbidity

and acceptable aesthetic results, and is easy to close directly.
ANATOMY
The vascular anatomy of this flap has been studied extensively. The thoracodorsal artery originates from the
subscapular artery. It runs under the deep surface of the latissimus dorsi, where it bifurcates into two main
branches: horizontal and vertical (or descending) branches. Both branches give off cutaneous branches, which
pierce the muscle and distribute in the subcutaneous tissue; the larger ones arise from the descending branch at
6 to 8 cm inferior to the axillary crease and 1 to 2 cm posterior to the anterior border of the muscle (Fig. 143.1).
This main cutaneous artery frequently surrounds the anterior border of the muscle or pierces it through a few
anterior fibers. In summary, the thoracodorsal artery consistently gives off several cutaneous branches through
the muscle, although the first one may be attached to the anterior border (Fig. 143.2).
FIGURE 143.2 Anatomy of the course of cutaneous vessels.
FLAP DESIGN AND DIMENSIONS
The flap is designed with the patient in a standing position. The arm is abducted 90 degrees. An assistant holds
the elbow, and the patient is asked to adduct the arm against opposition. The anterior border of the latissimus
dorsi is clearly observed and is marked. A point is marked over this line at 7 cm below the axillary crease. A 2-cm
radial circumference centered at this point is marked. This is the approximate location of the proximal cutaneous
branch of the thoracodorsal artery. A Doppler probe is applied, and the vessel is precisely located.
From this point, a 25-cm-long ellipse skin paddle is designed with the longitudinal axis placed in any direction.
The cutaneous vessel that irrigates the flap does not need to be in the center. Usually, the flap is designed in an
oblique anterior position for better donor-area closure. No relation exists between the flap design and the limits of
the underlying muscle: the flap may be designed almost completely beyond the anterior border of the muscle.
OPERATIVE TECHNIQUE
The patient is positioned in a lateral decubitus position with the arm in 90-degree abduction and 90-degree
elbow flexion. Once the operative field is prepared, the dermis is infiltrated with lidocaine (Xylocaine) 1% with
epinephrine where the skin will be incised. The skin incision starts at the inferior border of the flap. The anterior
border of the latissimus dorsi is exposed, and dissection continues superiorly above the deep fascia with optical
magnification. The cutaneous vessels are identified, and careful dissection is performed between the muscle

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fibers to the main pedicle, which is completely exposed. The muscle branches are coagulated or clipped and
sectioned. The muscle nerve is preserved.
The cutaneous perforator can be easily dissected from the muscle fibers because it is surrounded by fatty tissue.
It is not advisable to perform this procedure as a muscle-sparing technique, because a greater risk of damaging
the vessels exists.
CLINICAL RESULTS
Seventy-five patients were operated on by using TDAP flaps (42 male and 33 female patients). Patient ages
ranged from 2 to 78 years. Thirty-five cases used islands and 40 used free flaps. In 26 cases, the muscle
was used as an independent unit. The island flaps were used mainly for burn scar-contracture release at
the mammary or axillary area, or for shoulder resurfacing after tumor resection. The free flaps were used for
cranial-vault coverage and knee, ankle, and elbow coverage.
Five flaps were lost. In three cases, the skin island was lost, and the muscle was eventually used as a free
muscle flap and skin grafted. In two cases, the flap was lost after having been transferred, because of
technical problems at the anastomosis. In three cases, the perforator was not found or was destroyed
during flap elevation. Considering that in more than 50 specimen dissections done in injected cadavers, the
cutaneous branches of the thoracodorsal artery were consistently found, we believe that technical error was
the main factor for flap loss.
SUMMARY
The thoracodorsal perforator flap is very reliable; the cutaneous branches of the thoracodorsal are a
constant finding (the skin paddle of the traditional latissimus dorsi musculocutaneous flap is consistently
irrigated by these branches). The flap allows a better “handling” of the skin island and the underlying
muscle.
References
1. Angrigiani C, Grilli D, Sebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr
Surg 1995;96:1608.
2. Godina M. The tailored latissimus dorsi free flap. Plast Reconstr Surg 1987;80:304.
3. Hayashi A, Maruyama Y. The “reduced” latissimus dorsi musculocutaneous flap. Plast Reconstr Surg
1989;84:290.

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Chapter 144
Free Anterolateral Thigh Flaps for Reconstruction of Head and
Neck Defects
I. KOSHIMA
EDITORIAL COMMENT
This chapter describes another source of tissue for your reconstructive efforts in the head and neck area.
The solution is especially attractive, inasmuch as it does not require changing the position of the patient.
The anterolateral thigh flap is based on the septocutaneous or muscle perforators of the lateral descending
branch of the lateral circumflex femoral system. It is useful for reconstruction of defects in the head and neck and
in the extremities.
INDICATIONS
This flap is suitable for coverage of defects in the head and neck regions, such as the oral floor with or
without tongue and hypopharyngeal defects, and also the cervical esophagus with the anterior cervical wall
(1). It is also suitable for reconstruction of scalp defects. Even in infected cranial full-thickness defects
involving the dura, one-stage reconstruction is possible using an anterolateral thigh fasciocutaneous flap
because the dural defect can be replaced with the vascularized fascia lata. The fasciocutaneous flap is also
suitable for the repair of large, full-thickness defects of the lip. Instead of the oral orbicular muscle, the
vascularized tensor fascia lata can be used to suspend the lower or upper lip. In obese patients, the flap
can be made thinner with primary defatting (1).
The main advantage is that, with the use of the vascular system of this flap, massive complex defects in the
head and neck can be easily reconstructed in one stage with combined “chimeric” flaps with the same
vascular source. The flap can be combined with other flaps or tissue (chimeric combined flap), such as the
paraumbilical flap (rectus abdominis musculocutaneous flap), vascularized iliac bone or fibula, rectus
femoris muscle, or sartorius muscle (2). In addition, this flap can be connected with other adjacent flaps
(“mosaic” flaps), such as the connected anterolateral thigh-groin flap and/or anterolateral thigh-medial thigh
flap (3).
ANATOMY
The lateral circumflex femoral system is composed of three main branches: the ascending branch, which passes
through the intermuscular space between the sartorius and vastus lateralis muscles and terminates in the outer
cortex of the iliac bone; the transverse branch, which terminates in the tensor fasciae latae muscle; and the
(lateral) descending branch, which runs downward through the intermuscular space between the rectus femoris
and the vastus lateralis muscles and finally terminates in the vastus muscle near the knee joint. The perforator of
the anterolateral thigh flap usually is derived from the transverse branch or the descending branch, and the
proximal perforator is situated around the proximal third of the thigh through the lateral longitudinal line of the
thigh. Usually, a few cutaneous perforators are found passing through the intermuscular septum or the vastus

lateralis muscle. Even in cases with no septocutaneous perforators, there are cutaneous perforators penetrating
the vastus lateralis muscle (1, 2, 3, 4, 5, 7, 8) (Fig. 144.1).
FIGURE 144.1 Diagram of the surgical anatomy of the anterolateral thigh. The lateral circumflex femoral system
is composed of the ascending branch (A), the transverse branch (T), the lateral descending branch (L), and the
medial descending branch (M). Perforators (arrowheads) of the anterolateral thigh flap usually are derived from
the lateral descending branch (or directly from the transverse branch). (From Koshima et al., ref. 1, with
permission.)
FLAP DESIGN AND DIMENSIONS
The anterolateral thigh flap commands a skin territory of up to 600 cm2 (30 × 20 cm), almost the same area as
the tensor fasciae latae musculocutaneous flap. The upper border of the skin territory is the line through the iliac
crest, and the lower border is the level of the lateral femoral condyle. The posterolateral skin territory is a
longitudinal line drawn from the greater trochanter distally to the fibular head. The anteromedial margin of the
skin territory is a line placed through the midportion of the rectus femoris muscle.
The skin, lateral femoral cutaneous nerve, fascia lata, rectus femoris muscle, and vastus lateralis muscle are
elevated as a unit based on the skin perforator. The main pedicle perforator is located at the proximal third of the
longitudinal line through the intermuscular space between the rectus femoris and vastus lateralis muscles. Other
small perforators are located in the middle third of the lateral aspect of the thigh. Clinically, preoperative
stereoangiograms or simple angiograms and Doppler audiometry are essential to determine the locations of the
perforators and vascular variations of the lateral circumflex femoral system; however, using the Doppler is
sometimes unreliable in cases in which the descending branch runs downward near the lateral skin surface of
the thigh because the sound of the descending branch is enhanced rather than the perforators.
The skin territory can be extended with the use of connected (supercharged or mosaic) flaps (6). An upper
extension is possible with the combined anterolateral thigh flap-groin flap, -vascularized iliac bone graft, -rectus
abdominis musculocutaneous flap, or -latissimus dorsi musculocutaneous flap. A medial extension can be made
with the combined anterolateral thigh flap-medial thigh flap-saphenous flap. A posterior extension is also possible

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with the anterolateral thigh flap-posterior thigh flap (Fig. 144.2).
OPERATIVE TECHNIQUE
With the patient in the supine position, flap elevation is begun simultaneously with tumor resection or recipient-
bed preparation in the head and neck region; the donor area is relatively distant compared with other flaps, and
early recipient-site preparation reduces operating time.
The first incision is made through the longitudinal line at the middle of the anterior aspect of the thigh (the middle
on the rectus femoris muscle). Lateral skin is elevated subfascially through the incision with a pair of retractors,
and the septocutaneous or musculocutaneous artery can be seen (Fig. 144.3). The septocutaneous artery
comes through the intermuscular septum between the rectus femoris and vastus lateralis muscles. The
musculocutaneous artery penetrates the vastus lateralis muscle. If the pedicle perforator is absent in the lateral
septum (extremely rare), it is often located at the medial intermuscular septum between the rectus femoris and
sartorius muscles. It often emerges at the juncture of the rectus femoris, sartorius, and vastus medialis muscles
in the midthigh.
Before raising the skin flap, with transection of several muscle branches and retraction of the rectus femoris
muscle medially, the pedicle is dissected and traced proximally, from the descending or transverse branch up to
the division of the rectus femoris muscular branch. If possible, the rectus muscle branch is preserved to maintain
muscle vascularization. The branch of the femoral nerve running parallel to or across this vascular system must
be separated carefully. Usually, the
operating time required for tumor resection is longer than that for dissection of the flap pedicle vessels.
FIGURE 144.2 Schema of flap design and dimensions. The lateral half of the thigh usually can provide a single
dominant perforator for the anterolateral thigh flap. The flap can be combined with other adjacent flaps or tissues
with the same vascular source (chimeric combined flaps). The flap territory can be extended superiorly or
inferiorly by using connected “mosaic” or supercharged flaps. A, anterolateral thigh flap; B, iliac bone graft; M,
rectus femoris muscle; P, paraumbilical flap; L, lateral circumflex femoral system (LCFS); D, descending branch

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of LCFS; A2, connected anterolateral thigh-groin flap; I, superficial circumflex iliac vessels; A3, connected
anterolateral thigh-saphenous flap; S, saphenous vessels.
When tumor resection is completed, the skin flap is outlined to include the perforator in the anterolateral thigh
region. After an incision through the outline, the flap is elevated from the distal portion, as the amount of bleeding
from this portion is small. When a fasciocutaneous flap is required, the flap is raised subfascially. In obese
patients, a thin anterolateral thigh flap can be created by removal of a considerable amount of fatty tissue.
Regarding the creation of a thin flap: After the island flap pedicled by only one perforator is raised over the
fascia, the flap can be made thinner by excising the subcutaneous fatty tissue with scissors (Fig. 144.4).
Because the subdermal plexus of the capillary vessels is preserved, the peripheral region of the flap can be as
thin as necessary, and only a thin layer of superficial fat (approximately 5 mm thick) is retained to protect the
subdermal plexus. Resection of the fatty tissue about 2 cm around the perforator is impossible because of
potential damage to the pedicle perforator. Relatively large
flaps (up to 30 cm long and 20 cm wide usually can survive with only a single perforator.
FIGURE 144.3 Cross-sectional schema of flap elevation (right thigh). The septocutaneous perforator (sometimes
penetrating the vastus lateralis muscle) can be seen through the first incision, which is made through the
longitudinal line at the middle of the anterior aspect of the thigh. E, rectus femoris muscle; S, vastus lateralis
muscle. (From Koshima et al., ref. 1, with permission.)

FIGURE 144.4 Diagram of method for obtaining a thin anterolateral thigh flap. With preservation of the
subdermal plexus, a thin flap can be obtained primarily by removing a considerable amount of fatty tissue. (From
Koshima et al., ref. 1, with permission.)
The donor site is closed primarily or, if too large for direct closure it is covered with a mesh skin graft. Even with
a split-thickness skin graft on the bare muscle, there is no deficit in walking.
CLINICAL RESULTS
Regarding complications, sensory disturbance in the distal portion of the flap is the result of sacrificing the
lateral femoral cutaneous nerve. In cases with a small perforator less than 0.8 mm in caliber, the skin
territory is limited to a maximum of 20 × 10 cm. Use of the rectus femoris muscle with this flap results in little
functional deficit. In some patients, the rectus femoris muscle has a single vascular source with no collateral
routes; therefore, when the muscle is preserved in the donor leg, the feeding artery also should be
preserved.
SUMMARY
The anterolateral thigh flap ideally can reconstruct defects in the head and neck regions and, when
combined or connected with other flaps from the same vascular source, is especially useful for complicated
facial defects.
References
1. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and
neck defects. Plast Reconstr Surg 1993;92:421.
2. Koshima I, Yamamoto H, Hosoda M, et al. Free combined composite flaps using the lateral circumflex
femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric
flap principle. Plast Reconstr Surg 1993;92:411.

3. Koshima I, Yamamoto H, Moriguchi T, Orita Y. Extended anterior thigh flaps for repair of massive cervical
defects involving pharyngoesophagus and skin: an introduction to the “mosaic” flap principle. Ann Plast Surg
1994;32:321.
4. Song YG, Chen GZ, Song YL. The free thigh flap: a new concept based on the septocutaneous artery. Br
J Plast Surg 1984;37:149.
5. Koshima I, Fukuda H, Utsonomiya R, Soeda S. The anterolateral thigh flap: variations in its vascular
pedicle. Br J Plast Surg 1988;42:260.
6. Koshima I. Reply (see ref. 3). Ann Plast Surg 1994;33:462.
7. Xu DC, Zhong S, Kong J, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg
1988;82:305.
8. Zhou G, Qiao, Q, Chen GY, et al. Clinical experience and surgical anatomy of 32 free anterolateral thigh
flap transplantations. Br J Plast Surg 1991;44:91.

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Chapter 145
Sensate Thoracodorsal Artery Perforator Flap
CHENG-TA LIN
LEE-WEI CHEN
EDITORIAL COMMENT
When sensibility recovery is critical (i.e., for the hands and feet), this may be the flap to go to.
INDICATIONS
The sensate thoracodorsal artery perforator flap is used when recovery of sensibility to recipient sites is
required. The flap can be used for the reconstruction of hands and feet because recovery of sensibility is
important to these locations. The flap is also an option for the reconstruction of breasts and phalluses.
ANATOMY
The blood supply of the flap is from the skin perforators of the thoracodorsal vessels, which run underneath the
latissimus dorsi muscle. The thoracodorsal vessels bifurcate into two large branches, the transverse and
descending branches. In the flap, the perforators derived from the descending branch are preferred because
they are closer to the lateral intercostal
nerves and more constant than those of transverse branch (1, 2). There are two types of skin perforators from
the descending branch (3). First is musculocutaneous perforator, which directly pierces the latissimus dorsi
muscle. Second is septocutaneous perforator, which does not penetrate muscle. The septocutaneous perforator
courses laterally between the latissimus dorsi muscle and serratus anterior muscle (Figs. 145.1 and 145.2).

FIGURE 145.1 Color Doppler sonography is useful to identify the thoracodorsal artery perforators and the
intercostal artery perforators in real time, which helps the design and harvesting of flaps. It also differentiates
different types of perforators, assesses the quality and size of perforators, and delineates the relationship
between perforators and surrounding structures. The arrows indicate the deep fascial layer. L, latissimus dorsi
muscle; Sc, septocutaneous; Mc, musculocutaneous; I, intercostal artery perforator; Sa, serratus anterior muscle;
R, rib; A, axillary artery; T, thoracodorsal artery.
The flaps incorporate the posterior rami of lateral cutaneous branches of intercostal nerves (Figs. 145.3 and
145.4). The lateral cutaneous branch originates from the costal groove segment of the intercostal neurovascular
bundle and emerges from the intercostal space. It penetrates the intercostal muscle and serratus anterior muscle
and separates into an anterior and a posterior ramus. The posterior ramus courses medially, passes along the
lateral border of the latissimus dorsi muscle, and disperses to the subcutaneous tissue. The main trunk of the
posterior ramus always contains two or three fascicles (4).
There are two types of relationships between the intercostal nerves and the thoracodorsal artery perforators.
The conjoint relationship is when a posterior ramus courses above the latissimus dorsi muscle; its main trunk or
branch may travel with a thoracodorsal artery perforator and reach the subcutis together (Fig. 145.4). The
separate relationship means the main trunk or branch of a posterior ramus enters the subcutis at different
location from the thoracodorsal artery perforators (Fig. 145.5). The incidence of which the conjoint relationship
can be found varies from 38.1% to 63.6% (4, 5).

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FIGURE 145.2 Photograph showing the septocutaneous (Sc) and musculocutaneous (Mc) perforators. Using
electrocautery for subfascial dissection helps to create a bloodless surgical field. The arrow indicates the
cephalic direction.
FIGURE 145.3 The lateral cutaneous branch of the intercostal nerve bifurcates into an anterior and a posterior
ramus. The posterior ramus courses along latissimus dorsi muscle and innervates the skin over the muscle. D,
deep fascia; I, intercostal nerve; T, thoracodorsal artery; P, thoracodorsal artery perforator; L, latissimus dorsi
muscle; S, serratus anterior muscle; Lc, lateral cutaneous branch of intercostal nerve; Ar and Pr, anterior and
posterior rami.
FLAP DESIGN AND DIMENSIONS
Before flap harvest, we prefer using color Doppler sonography to map the locations of thoracodorsal artery
perforators and intercostal artery perforators (Fig. 145.1). The location of an intercostal artery perforator helps to
identify the approximate course of an intercostal nerve because of their concomitant relationship (Figs. 145.5 and
145.6). There are four reasons that oblique or transverse designs of flap orientation are preferred than vertical
designs. First is the horizontal distribution of the dermatomes of intercostal nerves. Second is the prevention of
breast distortion caused by the tension line of skin closure. Third is the more acceptable transverse donor site
scar (5, 6). Fourth is the oblique-transverse axis of the perforasome of the thoracodorsal artery perforators (7, 8).
The perforator and nerve can be placed into the lateral one-third or central area of the flap. The flap width
depends on the size of the recipient wound and primary closure of the donor wound. A flap width that does not
exceed 8 to 9 cm allows primary wound closure in most cases. The flap length relies on the quality and quantity
of selected perforators and the design of the flap. The circulation of the flap is adequate in flaps up to 15 cm in
length and marginal in flaps with lengths between 20 and 25 cm (9, 10).

FIGURE 145.4 Photograph showing the bifurcation of the lateral cutaneous branch of the intercostal nerve
(arrowhead). The conjoint relationship (asterisk) between a musculocutaneous perforator (Mc) and a posterior
ramus (I) is demonstrated. The arrow indicates the cephalic direction.
OPERATIVE TECHNIQUE
The patient is held in lateral decubitus position with arm abduction on the operating table. Flap elevation is
begun from inferomedial to superolateral in the subfascial plane under loupe magnification, and the
thoracodorsal artery perforators are identified. We proceed with the subfascial dissection laterally, and the
posterior rami are identified in the deep subcutaneous tissue over the lateral border of latissimus dorsi muscle.
The posterior ramus is liberated from surrounding tissue by using blunt tip dissectors or scissors. It is traced
laterally to the bifurcation of the lateral cutaneous branch and severed here to preserve the continuity of anterior
ramus. Intramuscular dissection is performed to free the perforators from muscular tissue, and the perforators are
irrigated with 2% lidocaine to prevent vasospasm. The thoracodorsal nerve is routinely preserved (Figs. 145.7
and 145.8).
In the preparation of the recipient wound, it is important to have a recipient sensory nerve. First, we try to find a
proximal sensory nerve stump around the recipient wound. The length of the posterior rami can reach 7 to 8 cm.
We attempt to coapt the nerve outside the zone of injury, and end-to-end epineural nerve coaptation by using 10-
0 nylon is preferred. Second, we do not sever an intact sensory nerve for nerve coaptation when a recipient
nerve stump is unavailable. Using end-to-side anastomosis to a nearby intact sensory nerve is an alternative
option.
FIGURE 145.5 Photograph shows the separate relationship between a musculocutaneous perforator (Mc) and a
posterior ramus (I). The asterisk marks the concomitant intercostal artery perforator. The arrow indicates the
cephalic direction.

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FIGURE 145.6 Photograph shows the concomitant relationship between the posterior ramus of the lateral
cutaneous branch (I) and the intercostal artery perforator (Ia). The arrow indicates the lateral direction.
CLINICAL RESULTS
In our first series, we assessed the postoperative tactile sensation in 10 patients using free sensate
thoracodorsal artery perforator flaps (the sensate group) for hand or foot reconstructions (4). The data of
the other 10 patients who underwent reconstructions with nonsensate thoracodorsal artery perforator flaps
(the nonsensate group) were reviewed and compared with the sensate group. The results showed better
tactile sensation recovery at the flap center in the sensate group at 6 months and 12 months after
operation. The difference in tactile sensation between the two groups at the flap periphery was not
significant at 6 months after the operation. Nevertheless, it was better in the sensate group at 12 months
after the operation.
In our second series, we evaluated 11 patients who underwent free sensate thoracodorsal artery perforator
flaps to resurface fingers (5). We assessed the tactile sensation and two-point discriminative sensation after
operation. Ten patients (90.9%) acquired protective to normal tactile sensation, and nine patients (81.8%)
gained fair to normal discriminative sensation at 1 year after operation.
The flap may not be suitable for certain subsets of patients. First are patients with documented peripheral
neuropathies. Second are patients with very extensive injury around the recipient wound. Third are patients
who need postoperative radiation therapy to the recipient site because radiation may decrease the recovery
of sensation (4). Fourth are obese patients. The flaps always need thinning to reduce their bulkiness in
obese patients. The intercostal nerve will interfere with the flap thinning in the separate relationship, and
intrafat
dissection is required to thin the flap (Fig. 145.9). The thinning procedure is easier in patients with the
conjoint relationship, which facilitates the reconstruction of shallow defects in obese patients (5).

FIGURE 145.7 A: The patient underwent tumor ablative surgery at left side of the ankle. B: Preoperative
design at the left side of the back showing the thoracodorsal artery perforator (P) and intercostal nerve (I).
(Continued)

FIGURE 145.7 (Continued) C: Intraoperative photograph demonstrates the conjoint relationship (asterisk).
D and E: The flap was elevated and thinned without injury to the perforator and nerve. The recipient nerve
was a branch of the sural nerve. F: Postoperative appearance. The arrows indicate the cephalic direction.

FIGURE 145.8 A and B: A case involving crush and thermal burn injury to the right hand and forearm. C:
Preoperative design showing two separate skin paddles based on different perforators (P1 to P4). The
larger skin paddle with two intercostal nerves (I) was used for the palm and hand reconstruction, and the
smaller paddle was used for thumb resurfacing. D: The thoracodorsal nerve (arrowhead) was preserved.
(Continued)

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FIGURE 145.8 (Continued) E: The flap was elevated. The recipient nerves were superficial branches of the
radial nerve. F and G: Postoperative photographs show thumb extension and flexion. H: Donor site
appearance. The arrows indicate the cephalic direction. T, thoracodorsal artery; S, scapular tip; Ab and Pb,
anterior and posterior borders of the latissimus dorsi muscle.
SUMMARY
The sensate thoracodorsal artery perforator flap is an option for soft-tissue reconstruction and restoration of
sensibility. It is associated with minimal donor site morbidity.