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FIGURE 145.9 (Continued) G and H: Postoperative photographs of the recipient and donor sites. The
arrows indicate the cephalic direction. S, scapular tip.
References
1. Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal artery perforator flap: anatomic basis and
clinical application. Ann Plast Surg 2003;51:23.
2. Mun GH, Lee SJ, Jeon BJ. Perforator topography of the thoracodorsal artery perforator flap. Plast
Reconstr Surg 2008;121:497.
3. Kim JT. Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal
perforator flaps. Plast Reconstr Surg 2005;115:755.
4. Lin CT, Yang KC, Hsu KC, et al. Sensate thoracodorsal artery perforator flap: a focus on its preoperative
design and harvesting technique. Plast Reconstr Surg 2009;123:163.

5. Lin CT, Chen LW. Surgical refinements and sensory recovery of using transverse sensate thoracodorsal
artery perforator flaps to resurface ring-avulsed fingers. Ann Plast Surg 2014;72:299.
6. Lee SH, Mun GH. Transverse thoracodorsal artery perforator flaps: experience with 31 free flaps. J Plast
Reconstr Aesthet Surg 2008;61:372.
7. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional arterial and venous anatomies
of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2008;121:1578.
8. Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical
implications. Plast Reconstr Surg 2009;124:1529.
9. Kim JT, Kim YH. Initial temporary vascular insufficiency in latissimus dorsi and thoracodorsal perforator
flaps. Plast Reconstr Surg 2009;124:e408.
10. Lin CT, Chen LW. Inclusion of extra perforators--A single and efficient measure to prevent vascular
insufficiency in unreliable thoracodorsal artery perforator flaps. J Plast Reconstr Aesthet Surg 2012;65:342.

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Chapter 146
Microvascular Transfer of Anterolateral Thigh Flaps for
Reconstruction of Head and Neck Defects
R. S. ALI
F.-C. WEI
EDITORIAL COMMENT
The ALT flap has become a workhorse flap because of its donor site, which is easily covered by clothing,
and its flap tissue pliability. The reader must be aware of the variability of the blood supply.
The anterolateral thigh (ALT) flap was first described as a free cutaneous flap from the anterolateral aspect of
the thigh, based on a septocutaneous perforator. In fact, the majority of ALT flaps are based on
musculocutaneous perforators. As surgical techniques to dissect musculocutaneous perforators have developed,
the ALT flap has been at the forefront of the “perforator flaps.” Rapid assimilation of the ALT flap into
multidisciplinary head and neck practices attests to its versatility, based on characteristics such as: (a) a large
cutaneous surface area; (b) multiplicity of tissue components that can be included in the flap (skin, fat, fascia,
muscle, nerve, tendon); (c) freedom with which the tissue components can be separated on individual
musculocutaneous perforators or septocutaneous vessels; (d) a long, wide-caliber pedicle; and (e) minimal donor
morbidity.
INDICATIONS
General
The ALT flap, first described by Song et al. (1), is an ideal soft-tissue flap and is used in the reconstruction
of many soft-tissue defects, including those following tumor resection, lower-limb trauma, or congenital
deficiency.
Head and Neck
Indications for ALT flap use in head and neck surgery include the following: external face resurfacing,
intraoral mucosal lining, soft-tissue volume replacement, palate and maxillary reconstruction, filling of dead
space/sinus/cavity, reconstruction of the floor of the mouth, reconstruction of the tongue, reconstruction of
the pharyngoesophagus, and scalp and skull-base reconstruction.
Buccal Mucosa
The cutaneous or fasciocutaneous ALT flap is a moderately thin, pliable flap that is ideal for resurfacing
intraoral defects (Fig. 146.1). The long pedicle allows suitable inset of the ALT flap intraorally, with
tunneling of the pedicle, to allow comfortable microvascular anastomosis to facial or cervical recipient
vessels. The greater surface area of the ALT flap, compared
with the radial forearm flap, along with versatility in tissue design due to the often multiple perforators
supplying the skin paddle, permits the resurfacing of larger defects, multiplanar defects (2), and bilateral
defects (3).

FIGURE 146.1 Thin fasciocutaneous anterolateral thigh (ALT) flap, to resurface extensive defect of right
buccal mucosa. Note large surface area and excellent contour of flap.
An ALT flap with more than one tissue paddle, based on widely separated perforators, is invaluable in the
reconstruction of intraoral defects located in nearby but different sites or on different axial planes (2) (Fig.
146.2). More recently, the double-paddled ALT flap has evolved into harvesting two separate ALT flaps
from one thigh, based on a single source vessel (3). This offers infinite degrees of freedom when
positioning the flaps but requires the preparation of additional recipient vessels and additional
microvascular anastomoses (Fig. 146.3).
Tongue Reconstruction
A thin fasciocutaneous or cutaneous ALT flap is ideal for reconstructing the partial glossectomy defect. The
large cutaneous paddle permits resurfacing of an extensive surface area, and the relatively pliable flap can
be molded to the three-dimensional contours of the tongue (Fig. 146.4).
Total glossectomy requires reconstruction with a flap of large cutaneous surface area and sufficient soft-
tissue volume; the musculocutaneous ALT flap is excellent for reconstructing such defects. Incorporation of
vascularized nerve in the ALT flap (anterior branch of the lateral femoral cutaneous nerve) confers the
additional option of sensory reinnervation (4).
FIGURE 146.2 ALT flap with multiple Doppler-detected perforator signals. A: Two eccentrically aligned skin
paddles are marked, based on widely separate perforators. The flap is raised on a single pedicle and
requires only a single anastomosis. B: Flap design allows more exact inset into the multiplanar defect
involving the right commissure and buccal mucosa, as well as the right lower lip.
Pharyngoesophageal Reconstruction
A rapidly developing indication for use of the ALT flap is in pharyngoesophageal reconstruction. A wide
fasciocutaneous or musculocutaneous ALT flap is raised with supplementary vascularized fascia and tubed
to form a wide-bore, relatively rigid cylinder. The fascial layer augments the water-tight closure requisite to
preparing the neo-pharyngoesophagus. The ALT flap can be raised simultaneously with tumor resection
and recipient-site preparation; furthermore, the neo-pharyngoesophagus may be tubed and prepared with
the flap still in situ on the thigh (Fig. 146.5). The free ALT flap can withstand extended ischemia time,
compared with the free jejunal flap. There is growing evidence that postoperative complications are reduced
by using the ALT flap, with concomitant superior functional outcome (5, 6).

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Maxillary and Palatal Defects
Maxillary tumor resection often results in complex three-dimensional defects requiring multiple skin paddles,
in addition to soft-tissue volume replacement and/or the need to separate compartments or pack
sinuses/dead spaces. The ALT flap harvested with additional vascularized fascia and/or muscle is ideal for
reconstructing such multidimensional defects alone or in combination with a bone flap (Fig. 146.6).
Through-and-Through Cheek Defects
A musculocutaneous ALT flap incorporating a portion of vastus lateralis provides excellent approximation of
the bulk required to reconstruct a full-thickness cheek defect. The musculocutaneous ALT flap may be used
to provide tissue bulk and external skin cover only. If the commissure is involved, the ALT flap may be
folded around the commissure, to provide soft-tissue bulk and intraoral and extraoral skin cover (Fig. 146.7).
If the commissure is not involved, an area of the ALT flap may be deepithelialized, and the flap “posted” into
the oral cavity to provide intraoral coverage. Alternatively, a multiple-paddled ALT flap may be designed,
which can be divided between widely separated perforators, and the separated tissue paddles inset to
provide both intraoral and extraoral coverage (2).
FIGURE 146.3 Widely separated perforators permit planning of a large fasciocutaneous ALT flap (A), which
is then divided between the perforators and raised as two separate ALT flaps (B). C,D: Bilateral intraoral
defects may be reconstructed with two separate flaps harvested from a single thigh.
Mandibular Defects
Oromandibular resections, resulting in significant volume loss, require a large bulky flap for adequate soft-
tissue reconstruction. It has become established practice to reconstruct major oromandibular defects with a
combination of two flaps: a bone/internal lining flap and a soft-tissue/external skin flap (7, 8). The ALT
musculocutaneous flap has been extensively used in conjunction with the fibula osteoseptocutaneous
(OSC) flap (Fig. 146.8). Both flaps can be harvested from the same lower limb, simultaneously with
recipient-site preparation, in a multidisciplinary two-team approach. In recurrent or complex cases with
limited local recipient vessels, the ALT perforator flap may be raised with a length of distal vessel, for use as
a flow-through flap (9) or to “piggy back” a distal flap.

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FIGURE 146.4 A: ALT fasciocutaneous flap raised, with an additional length of sensory nerve proximally
(anterior branch of lateral femoral cutaneous nerve of thigh). B: The large surface-area, pliable flap is used
to reconstruct the mobile, three-dimensional tongue, following partial glossectomy. Sensory reinnervation
may facilitate more rapid return of protective sensation.
Face and Scalp Resurfacing/Craniofacial
Large malformations, tumors, or traumatic defects of the face and scalp may warrant major resurfacing and
necessitate a pliable and robust flap with a large surface area (Fig. 146.9).
Scalp and dura defects necessitate inclusion of vascularized fascia, which can be used to reconstruct the
dura with a watertight seal, in conjunction with a large cutaneous component for resurfacing work.
FIGURE 146.5 A: Wide musculocutaneous ALT flap, raised and tubed, to form a neo-pharyngoesophagus
in situ. B: Skin paddle faces inward, and harvesting an additional width of fascia, to over-sew the suture
line, ensures a watertight, three-layer closure. Muscle component adds extra vascularity to the flap bed and
additional coverage of exposed cervical structures.
FIGURE 146.6 Musculocutaneous ALT flap for reconstruction of the right palate, following excision of a
maxillary tumor. Subsequent bony reconstruction with a free fibula flap was followed by the insertion of
osseointegrated teeth.

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FIGURE 146.7 A: Fasciocutaneous ALT flap designed with a large external skin paddle and a smaller skin
paddle for reconstruction of the buccal mucosa. B: The flap is inset by folding around the full-thickness
defect, to provide internal and external skin coverage and to create a new oral commissure.
Skull Base
A musculocutaneous or cutaneous ALT flap is ideal for use in this vital area, and can be tailored to fill any
dead space and to provide a large surface area of robust skin. The fascial component of a fasciocutaneous
ALT flap may also be used and is especially suitable if the dead space is narrow.
ANATOMY
The area of the anterolateral thigh supplied by the lateral circumflex femoral artery (LCFA) extends from the iliac
crest to the lateral femoral condyle and from the medial border of the rectus femoris to the posterior midline. A
line joining the anterior superior iliac spine (ASIS) to the superolateral margin
of the patella indicates the longitudinal axis of the anterolateral thigh flap, and approximates the intermuscular
septum between the vastus lateralis and rectus femoris (Fig. 146.10).

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FIGURE 146.8 A: Full-thickness oromandibular defect with segmental mandibulectomy and neck dissection. B:
Fibula-osteoseptocutaneous (OSC) flap used to reconstruct the bony defect and internal oral lining. C: Large-
surface-area, bulky musculocutaneous flap raised to reconstruct full-thickness soft-tissue defect and to provide
well-vascularized coverage of the underlying bone flap and metal work. D: Combined fibula-OSC and ALT flaps
inset. ALT flap provides sufficient soft-tissue bulk and large-surface-area skin paddle and is pliable enough to
fold over to form a neo-commissure.
The LCFA usually arises from the profunda femoris but may also arise from the main femoral artery. The LCFA
trifurcates into ascending, transverse, and descending branches and supplies much of the skin and underlying
musculature of the anterolateral thigh, including the tensor fasciae latae and quadriceps femoris muscle mass,
comprising the vastus lateralis, v. intermedius, v. medialis, and rectus femoris.
The vascular pedicle of the ALT flap is usually the descending branch (75% of cases), which is also the largest
and longest of the LCFA branches. In a significant minority of cases, however, the ALT musculocutaneous
perforators may arise from the transverse branch (25% of cases). The descending branch has a length of 8 to 12
cm and runs in the intermuscular septum between the vastus lateralis and rectus femoris. The pedicle of the ALT
flap is therefore readily located, of significant length, has an arterial diameter of 2.1 ± 0.1 mm, and is typically
accompanied by two venae comitantes (d = 1.8−2.3 ± 0.1 mm) (10).
Perforating arteries from the descending branch of the LCFA localize to the middle third of the anterolateral thigh.
A 3-cm circle radius bisecting the longitudinal axis of the anterolateral thigh flap contains the majority (92%) of
Doppler-audible perforators, most (87%) of which lie just lateral to
the longitudinal axis (10) (Fig. 146.10). On average, two to four perforating arteries supply the cutaneous territory
of the ALT flap (11). In general, the blood supply to the ALT flap is via musculocutaneous perforators traversing
through the vastus lateralis (59.2%-84%), giving rise to the ALT musculocutaneous perforator flap. The

remaining (16%-40.8%) flaps are supplied by septocutaneous vessels that pass directly through the
intermuscular septum, to give rise to a septocutaneous flap. Rarely are there no suitable perforators on which to
base an ALT flap (12, 13). In such cases, the skin paddle may be raised with the underlying vastus lateralis
muscle as a carrier, flap design can be altered to that of a medial thigh or tensor fasciae latae flap, or the
contralateral thigh can be explored.
FIGURE 146.9 Large fasciocutaneous ALT flap, inset following resection of an ulcerative incision, with exposed
skull. Flap is thin, pliable, and large enough to provide scalp reconstruction.
The ratio of musculocutaneous perforators to septocutaneous vessels varies considerably and varies with the
location of the skin paddle. Septocutaneous vessels are more prevalent in the proximal thigh, whereas
musculocutaneous perforators predominate in more distally located skin flaps. The distinction between
septocutaneous vessel and musculocutaneous perforator is worth making, because the “true” perforator flap
relies on intricate dissection of the musculocutaneous perforator through the underlying musculature and is the
hallmark of “perforator flap surgery” (14). The septocutaneous ALT flap, raised on shorter, more direct vessels
penetrating the intramuscular septum, presents a more rapid and straightforward dissection.
Variability in the vascular pedicle of the ALT flap and the differential ratio of musculocutaneous perforators to
septocutaneous vessels are well-recognized characteristics of the ALT flap. Perforator-flap harvest relies on
retrograde dissection; therefore, providing that the surgeon is aware of potential vascular variations, there is
seldom any contraindication to raising an ALT flap.
Sensory innervation of the anterolateral thigh is via the lateral femoral cutaneous nerve of the thigh (L2-L3),
which enters the proximal thigh deep to the inguinal ligament and passes over the sartorius proximally, to pierce
the deep fascia 7 to 10 cm inferomedial to the ASIS. The sensory nerve then divides into anterior and posterior
branches; the larger anterior branch passes downward along the longitudinal axis of the anterolateral thigh to
supply the ALT cutaneous-flap territory. Motor innervation of the quadriceps musculature is via the femoral nerve
(L2-L4). The motor nerve to the vastus lateralis (VL) travels superolaterally with the vascular pedicle and is
preserved whenever possible.
FLAP DESIGN AND DIMENSIONS
The ALT flap is marked with the patient supine on the operating table. The readily palpable bony landmarks—the

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ASIS and the superolateral margin of the patella—are identified. A line connecting the ASIS to the superolateral
patella is drawn and bisected with a 3-cm circle radius. A 5- to 8-MHz handheld Doppler probe is used to audibly
identify cutaneous perforators, which are localized to the lateral half of the marked circle. If Doppler volume and
probe pressure are kept constant, louder signals generally correspond to greater flow; therefore, more dominant
perforators can be identified and designated with a larger marking.
A longitudinally orientated skin paddle is designed around the marked perforator(s). A skin paddle of 8 to 10 cm
in width lends itself to direct closure (depending on skin laxity), whereas wider skin paddles will require alternate
closure techniques such as skin grafting. Longer ALT flaps (20-25 cm) are increasingly preferred because they
facilitate longer proximal pedicle dissection, without compromising donor-site closure or cosmesis. The flap may
be designed more distally or extended laterally, as required, providing it includes the selected perforator(s). If
multiple skin paddles are to be harvested from one thigh, each skin paddle is designed around widely separated,
suitable perforators.
OPERATIVE TECHNIQUE
The patient is positioned supine and the whole lower limb circumferentially sterilized and draped. A sandbag
placed under the ipsilateral hip, or tethering the ipsilateral foot to the contralateral side, will keep the limb
internally rotated slightly and presents better access to the lateral aspect of the thigh.
Under loupe magnification, an initial exploratory incision is performed along the medial side of the planned flap.
The ALT flap may be raised in a suprafascial or subfascial plane, depending on which tissue components are
required and the desired thickness of the ALT flap. The cutaneous or fasciocutaneous tissue paddle is elevated
sufficiently, to allow visual confirmation of the presence, position, and size of the perforators. Modification of ALT
flap design may be conducted at this stage, depending on perforator attributes. Once suitable perforators have
been visualized, the flap is elevated by retrograde dissection of the selected perforator(s) to the source vessel in
the intermuscular septum. A small cuff of fascia may be retained around the entry point of the perforator complex
into the cutaneous paddle, to protect against damage or twisting of the perforator vessel.

FIGURE 146.10 Diagrammatic representation of ALT flap, demonstrating bony landmarks [anterior superior iliac
spine (ASIS), patella], longitudinal axis of flap, location of ALT-flap perforators, and relationship to underlying
musculature.
Meticulous intramuscular dissection is the sine qua non of “perforator flap surgery” and mandates scrupulous
hemostasis. Musculocutaneous perforators are dissected by initially “deroofing” or exposing the vessel, by
incising the muscle fibers above the perforator. The perforator is then dissected free of the muscle tissue on
either side, and, finally, the underside of the perforator is freed. Multiple side branches to the adjacent muscle
are encountered and necessitate careful ligation, using hemoclips or coagulation with bipolar diathermy.
Perforator dissection continues proximally until the required length of pedicle is achieved. If the cutaneous flap to
be raised is supplied by more than one perforator and the motor nerve to the vastus lateralis runs between the
perforators and is unable to be preserved, it is incised near its entry point into muscle and repaired directly,
under microscope magnification.
A fasciocutaneous ALT flap is raised in the relatively avascular subfascial plane and allows full exposure of the
intermuscular septum and easy visualization of the perforators. Flap harvest is technically straightforward and
results in a flap that includes the rich vascular network of the deep fascia. The cutaneous ALT flap is raised in
the suprafascial plane and permits harvest of the thinnest possible flap, containing only skin and subcutaneous
tissue (Fig. 146.11).
If an even thinner cutaneous flap is required, the ALT perforator flap may be thinned primarily, before ligation of

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the pedicle. Thinning to a uniform thickness of 3 to 5 mm can
be performed safely under microscope guidance, as long as a small area of tissue (radius: 2-4 cm) surrounding
the perforator is preserved (15). Thinning prior to vascular ligation permits monitoring of flap viability and allows
precise hemostasis.
FIGURE 146.11 Very thin ALT flap can be raised in a suprafascial plane, consisting of only skin, dermis, and
minimal subcutaneous fat. Fascia is incised, to allow dissection of the perforator, but is repaired following flap
harvest, resulting in negligible functional donor morbidity.
The ALT musculocutaneous flap is dissected anterograde, the flap pedicle is identified in the intermuscular
septum, and the vastus lateralis is split along its longitudinal axis, to ensure inclusion of the vascular pedicle.
Musculocutaneous ALT flap harvest may include as much or as little muscle as required by the dimensions of the
defect.
Perforators supplying the skin overlying the muscle may be visualized prior to flap harvest, and the cutaneous
and muscle components can each be tailored to the requirements of the defect (Fig. 146.12A). Alternatively, the
muscle and skin components can be raised en bloc, and skin viability ensured by including the perforator
Doppler signals heard at the beginning of the procedure (Fig. 146.12B).
Incorporating the anterior branch of the lateral femoral cutaneous nerve proximally raises the potential to develop
a sensate ALT flap. Such reinnervation by coaptation of the sensory nerve to the recipient nerve(s) allows
protective sensation to be achieved more rapidly. Additional fascia lata can be rolled to form a tendonlike
structure that can function as a static sling in adjuvant procedures associated with facial resurfacing.
FIGURE 146.12 A: Musculocutaneous ALT flap, in which the skin component has been separated on an
individual perforator. In this way, the flap can be tailored to an individual defect, and the muscle component used
as a soft-tissue filler, to separate compartments or to provide extra bulk where required. B: Musculocutaneous
ALT flap, in which the muscle is raised en bloc with the skin paddle, making sure to include the perforator signals
marked on the flap.

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A longer ALT flap may be raised, and the extra length deepithelialized and buried, to minimize contour deformities
or fill dead space (Fig. 146.13). This has proved valuable following cervical lymph-node dissection and serves to
protect vital structures in the neck from potential radiotherapy effects (16). A deepithelialized ALT flap is also
suitable for correcting contour deformities, such as hemifacial microsomia (17).
Direct closure of the thigh is possible for defects of less than 8 to 10 cm in width and is generally performed in
two layers (Fig. 146.14). Drainage is not required, and the patient is mobilized on postoperative day 1.
Harvesting of a suprafascial flap entails additional closure of the remaining deep fascia. Musculocutaneous flap
harvest often allows easier closure of the relatively “debulked” thigh. If a wide flap has been harvested that
precludes direct closure of the thigh, a split-thickness skin graft is applied to the muscle or fascial bed of the
residual defect.
CLINICAL RESULTS
The ALT flap has become our workhorse soft-tissue flap for head and neck reconstruction. Since 1999,
between 200 and 300 ALT flaps have been used for head and neck reconstruction each year.
SUMMARY
The ALT flap has demonstrated primacy in microvascular head and neck reconstruction, whether used as a
cutaneous/fasciocutaneous flap for resurfacing, or as a musculocutaneous flap for complex maxillary and
oromandibular defects or total tongue reconstruction. The flap has rapidly established a dominant role in
pharyngoesophageal reconstruction, due to its ease of handling and improved functional outcome.
Microvascular transfer of an ALT flap results in a discrete donor site, with minimal reported functional or
aesthetic morbidity.
FIGURE 146.13 Thick fasciocutaneous ALT flap inset into a left partial glossectomy defect. The remaining
flap is deepithelialized and positioned under the facial and cervical skin flaps, to minimize any contour
defect, following cervical lymph-node dissection. The additional tissue also serves to protect underlying
vascular and neural structures from the potentially harmful effects of radiotherapy. Deepithelialization may
be performed before or after microanastomosis.

FIGURE 146.14 ALT-flap donor site can usually be closed directly for flaps of less than 8 to 10 cm width.
There are rarely any functional sequelae, and the majority of patients express satisfaction with the discrete,
easily hidden donor site.
Favorable anatomic characteristics of the flap include a large cutaneous surface area and reliable
distribution of perforators. Recent advances in surgical technique and instrumentation have encouraged the
development of the double-paddle ALT flap and harvesting of multiple ALT flaps from a single thigh. This
allows bilateral pathologies to be treated simultaneously and has extended the reach of the reconstructive
surgeon to premalignant progressive conditions, such as oral submucosal fibrosis.
References
1. Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous
artery. Br J Plast Surg 1984;37:149.
2. Lin YT, Lin CH, Wei FC. More degrees of freedom by using chimeric concept in the applications of
anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2006;59:622.
3. Chou EK, Ulusal B, Ulusal A, et al. Using the descending branch of the lateral femoral circumflex vessel as
a source of two independent flaps. Plast Reconstr Surg 2006;117:2059.
4. Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head Neck 2004;26:1038.
5. Yu P, Lewin JS, Reece JP, Robb GL. Comparison of clinical and functional outcomes and hospital costs
following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap.
Plast Reconstr Surg 2006;117:968.
6. Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and
functional outcomes study. Plast Reconstr Surg 2005;116:1845.
7. Koshima I, Fukuda H, Soeda S. Free combined anterolateral thigh flap and vascularized iliac bone graft
with double vascular pedicle. J Reconstr Microsurg 1989;5:55.
8. Wei FC, Celik N, Chen HC, et al. Combined anterolateral thigh flap and vascularized fibula

osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg
2002;109:45.
9. Koshima I, Hosoda S, Inagawa K, et al. Free combined anterolateral thigh flap and vascularized fibula for
wide, through-and-through oromandibular defects. J Reconstr Microsurg 1998;14:529.
10. Xu DC, Zhong SZ, Kong JM, et al. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg
1988;82:305.
11. Kawai K, Imanishi N, Nakajima H, et al. Vascular anatomy of the anterolateral thigh flap. Plast Reconstr
Surg 2004;114:1108.
12. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral
thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102:1517.
13. Wei FC, et al. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.
Plast Reconstr Surg 2002;109:2219, discussion: 2227.
14. Wei FC, Celik N. Perforator flap entity. Clin Plast Surg 2003;30:325.
15. Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin
anterolateral thigh flap. Plast Reconstr Surg 1996;97:985.
16. Ao M, Uno K, Maeta M, et al. De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for
dead space filling and contour correction in head and neck reconstruction. Br J Plast Surg 1999;52:261.
17. Ji Y, Li T, Shamburger S, et al. Microsurgical anterolateral thigh fasciocutaneous flap for facial contour
correction in patients with hemifacial microsomia. Microsurgery 2002;22:34.

Chapter 147
Muscle Vascularized Pedicle Flap and Bone
Y. SHINTOMI
K. NOHIRA
Y. YAMAMOTO
L. O. VASCONEZ
EDITORIAL COMMENT
This procedure may open up new possibilities in coverage of difficult defects. However, as pointed out so
aptly by Buncke (2), other methods should be considered that are reliable and involve a single stage.
The introduction of free-tissue transfer and refinements of microvascular techniques have made it possible to
reconstruct difficult defects expeditiously; however, available flap donor sites are often limited by local vascular
anatomy. This chapter presents a unique technique of allowing the custom design of free flaps that fit the tissue
requirements of specific defects. The muscle vascularized pedicle (MVP) flap, which is actually a secondarily
vascularized flap, is developed by implanting a vascular bundle surrounded by a small cuff of muscle into a
selected donor site (1). With extension of the concept of the MVP flap, any tissue, such as bone, tendon, and
nerve, can be revascularized and applied as a source of free tissue transfer (1, 2, 3).
INDICATIONS
When thin flaps are needed for head and neck and upper and lower extremity reconstruction, a free skin
flap can be provided that has a thickness of 1 cm or less. The donor site can be chosen so that it provides
skin of good color, texture, and volume in facial reconstruction. The donor site also can be chosen not only
so that it provides bone of specific contour in maxillary or mandibular reconstruction but also so that it
results in as little morbidity as possible.
ANATOMY
Any muscle vascular pedicle can be used. Especially desirable muscles are those that have large, long vascular
pedicles providing easy microvascular anastomosis in free tissue transfer, such as the latissimus dorsi and
serratus anterior muscle with the thoracodorsal vessels and the rectus abdominis muscle with the inferior
epigastric vessels.
FLAP DESIGN AND DIMENSIONS
The cuff of muscle needed to revascularize the custom tissue should be approximately 10% to 20% of the size of
the flap. The skin of the lateral thoracic, medial arm, and anterior chest are typically good donor-site choices for
facial reconstruction. They are successfully revascularized by implantation of a small cuff of the latissimus dorsi
or serratus anterior muscle with the thoracodorsal pedicle. The iliac bone is a typically good donor site choice for
maxillary or mandibular reconstruction. It can be successfully revascularized by implantation of a small cuff of the
rectus abdominis muscle with the inferior epigastric pedicle.

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OPERATIVE TECHNIQUE
The procedure involves three stages. In the first stage, a pattern of the required flap is designed on the selected
donor site. The flap is undermined with the appropriate thickness, including the subdermal plexus. The selected
vascular bundle, surrounded by a small cuff of muscle, is dissected and implanted into the undersurface of the
flap. A thin silicone sheet occasionally is placed under the implanted vascular pedicle to avoid neovascularization
from the bed. When bone is to be revascularized, the surface of the donor bone that is to be attached with the
selected vascular bundle and a small cuff of muscle is rasped to the cancellous bone layer to provide rapid,
reliable revascularization from the implanted pedicle. Two weeks later, a surgical delay procedure is performed
by circumferentially incising the skin flap or bone on its remaining borders. From 1 to 3 weeks later, in the third
stage, the revascularized tissue then can be transferred as a conventional free flap to the recipient site (Figs.
147.1, 147.2, 147.3, 147.4, 147.5, 147.6).
SUMMARY
A custom-designed secondarily vascularized flap, which can include bone, can be developed by implanting
a vascular pedicle surrounded by a small cuff of muscle into a selected donor site.
FIGURE 147.1 A,B: A 15-year-old boy who sustained multiple flame burns 2 years previously. The
preoperative frontal and lateral appearance of the burn scar. Note the significant right-sided burn scar
contracture, which is pulling the right side of the mouth downward and preventing adequate neck extension.

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FIGURE 147.2 A: The patient in the lateral decubitus position with the skin over the right lateral chest wall
marked in an exact pattern to cover the planned defect. The initial incision will be through the anteromedial
portion of this outline. B: The skin flap elevated at the level of appropriate thickness. The bulks of the
latissimus dorsi muscle and the small sheath of muscle surrounding the thoracodorsal vessels. C: The
positioning of the small muscle sheath to the undersurface of the skin flap. Note that a thin silicone sheet
has already been placed over the underlying remaining subcutaneous tissue and latissimus dorsi muscle.
D: The planned skin flap several days following the delay procedure, at which a complete division of all
remaining skin attachments to the flap was done. Approximately 1 week later, this newly vascularized skin
flap underwent free-tissue transfer to resurface the neck burn scar defect.
FIGURE 147.3 A,B: Anterior and lateral views approximately 1 month following transfer of the flap. Although
the edges of the wounds have not yet completely settled, note the good color and texture match. Also note
the correction of the contracting forces on the right corner of the mouth.

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FIGURE 147.4 A,B: A 27-year-old man with defect of the right mandible following cancer resection.
Mandibular reconstruction with a free muscle vascularized pedicle iliac bone was scheduled.
FIGURE 147.5 A: The left inferior epigastric vascular pedicle surrounded by a small cuff of the rectus
abdominis muscle was designed with the patient in the supine position. B: After a total of 4 weeks from the
first surgery, with one surgical delay procedure to the iliac bone, the revascularized iliac bone was elevated.
Good bleeding was noticed from the incised margin of the revascularized iliac bone. (Continued)
FIGURE 147.5 (Continued) C: View of the muscle vascularized pedicle bone based on the left inferior
epigastric vessels after isolation. D: The revascularized iliac bone was transferred to the defect.

Microvascular anastomosis with the right facial artery and vein was performed.
FIGURE 147.6 A: Anterior view approximately 6 months after transfer of the bone. B: Postoperative
radiograph showing a good bony synthesis of the reconstructed mandible.
References
1. Shintomi Y, Ohura T. The use of muscle vascularized pedicle flaps. Plast Reconstr Surg 1982;70:725.
2. Buncke HJ. The use of muscle vascularized pedicle flaps (discussion). Plast Reconstr Surg 1982;70:735.
3. Shintomi Y, Nohira K, Yamamoto Y, et al. MVP (muscle vascularized pedicle) Flap and Bone. Panel
Discussion, Yokohama: IPRAS, 1995.

Chapter 148
Principles of Prefabricated Flaps
J. BAUDET
D. MARTIN
EDITORIAL COMMENT
This chapter, by one of our most innovative microsurgery and plastic surgeons, is recommended for
solutions to some of the most difficult reconstructive problems. Preforming a body part before transfer is an
elegant concept, although the vagaries of healing tissue do not always allow perfect results.
Flap prefabrication may be considered a generic description referring to the remodeling, reshaping, or rebuilding
of pedicled or free flaps, in effect, a tailored or customized flap. Using the concept of prefabrication, the area of
the potential flap can be enlarged, a more reliable vascularity can be achieved, and the availability of donor
materials can be maximized before transfer of the flap.
INDICATIONS
Because the use of prefabrication involves a wide variety of complementary or associated surgical
techniques, perhaps the only common denominator is the ability to extend the indications and potentials of
pedicled or free flaps in several donor and recipient body areas. Techniques can include the use of delay
as a preliminary stage for a free flap, thus increasing the survival area by enlargement of the choke vessels
that link vascular territories (1, 2). Flap preexpansion can enhance the available area of a flap, contribute to
better vascularity and safety, and allow easier primary closure at the donor site (3, 4, 5, 6). Induced
neovascularization or preliminary vascular induction can expand the possibilities of tissue use by delaying
or staging transfer until dependable vascularization is achieved (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18,
19, 20, 21, 22, 23, 24). Combinations using several elements of prefabrication make it possible to
reconstruct several anatomic and aesthetic units in sequential procedures done at a single donor site with
the addition of free or pedicled flaps (25, 26, 27).
OPERATIVE TECHNIQUE
Induced Neovascularized Flap
Orticochea (13) was the first to use this principle for reconstruction of the nose. He transferred the superficial
temporal vessels to the retroauricular conchal area, which then was used in a second stage as a pedicled
composite flap. Subsequently, Erol (14) developed the conversion of a thick split-thickness skin graft as a
secondary vascularized flap. The temporoparietal branch or the frontal branch of the superficial temporal vessels
was used in nine patients to prepare vascular pedicled flaps, which then were transferred at least 3 weeks later
for reconstruction of the infraorbital, zygomatic, or buccal regions as well as for nose and ear reconstruction.
Shen (16) reconstructed the helix of the ear after implanting the superficial temporal artery and vein into a long,
thin tube on the neck. The average time between the two operations was 4.5 weeks. He also was the first to
transfer a prefabricated flap with preliminary vascular induction successfully (17). In a first stage, the descending

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branch of the lateral femoral circumflex artery was implanted beneath the skin territory of the lateral aspect of the
thigh. Six weeks later, a 2.6 × 16-cm flap was transferred and revascularized in the neck for treatment of a
severe burn contracture. According to the same principle, a skin territory can be neovascularized by the free
transfer of an arteriovenous pedicle and its surrounding fascia or a muscle cuff done as a first stage (18, 19).
Prefabricated Composite Flap
A total nose reconstruction was prefabricated on the forearm, with incorporation of the radius in the flap as
vascularized bone. In a first stage, the nose was adequately shaped and 1 month later was transferred to the
recipient site, including part of the vascularized radius for support of the nasal spine and reconstruction of the
columella. The eyebrows and upper and lower eyelids were reconstructed in the same patient by a unipedicled
galea and scalp flap plus skin graft (Figs. 148.1, 148.2, 148.3, 148.4, 148.5, 148.6, 148.7).
Reconstruction of Several Anatomic and Aesthetic Units by Prefabrication
A complex reconstruction was carried out in which the first set of microsurgical transfers included an inguinal flap
to the cheek and an osteocutaneous transfer from the dorsum of the foot, including the second metatarsal, to
reconstruct the nose (Figs. 148.8 and 148.9). The eyebrow, both eyelids, orbital cavity, and lips were
prefabricated in situ on the radial artery of the forearm (Figs. 148.10, 148.11, 148.12, 148.13). The whole
prefabricated construct finally was successfully transferred, with the deepithelialized zone of the transfer buried
under the free inguinal flap previously used to reconstruct the cheek. Preserved bovine cartilage was used to
support the lower eyelid, and a split palmaris longus muscle was inserted into the lips for better contour and
definition.
FIGURE 148.1 A,B: Xeroderma pigmentosum of the face in a young female with a history of numerous
destructive basal cell carcinomas and superficial malignant melanomas. Nose, upper and lower eyelids, and both
eyebrows require reconstruction. (From Baudet, ref. 27, with permission.)

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FIGURE 148.2 Marking of cutaneous territory of the left forearm centered on the radial artery designed for
prefabrication of the nose. Rectangle at right center corresponds to the territory of the radius that will be
incorporated in the flap as vascularized bone to ensure support of the nose. (From Baudet, ref. 27, with
permission.)
Another complex reconstruction involved prefabrication of the penis on the forearm. The unit was transferred 1
month later after excellent healing of the neourethra and
good tolerance of the prosthesis had been demonstrated (Figs. 148.14 and 148.15).
FIGURE 148.3 Illustration of the prefabrication; the nose has been modeled and the donor site grafted. (From
Baudet, ref. 27, with permission.)
FIGURE 148.4 One month later. The prefabricated nose is raised with a segment of radius divided into two
segments: one for the support of the nasal bridge, the other for reconstruction of the columella. (From Baudet,
ref. 27, with permission.)

FIGURE 148.5 Appearance of the prefabricated nose before revascularization. (From Baudet, ref. 27, with
permission.)
FIGURE 148.6 A,B: Final result. Note the excellent texture and projection of the recreated nose. Eyebrows and
upper and lower eyelids were reconstructed by a unipedicled galea and scalp flap plus skin graft. (From Baudet,
ref. 27, with permission.)
FIGURE 148.7 Sequelae at the grafted donor site. (From Baudet, ref. 27, with permission.)

FIGURE 148.8 Patient after childhood radiotherapy for an immature angioma. (From Baudet, ref. 27, with
permission.)
FIGURE 148.9 Appearance after the first two microsurgical transfers, an inguinal flap to the cheek and
osteocutaneous transfer from the dorsum of the foot for nose reconstruction. (From Baudet, ref. 27, with
permission.)
FIGURE 148.10 Prefabrication on the radial artery of the foream. Above: An orbital cavity with an ocular
prosthesis already in place; reconstruction of the eyebrow by end-to-side scalp transfer on the radial artery.
Below: Creation of upper and lower lips. (From Baudet, ref. 27, with permission.)

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CLINICAL RESULTS
Preexpansion of flaps is associated with a significant rate of complications (hematoma, seroma, infection,
superficial or full-thickness skin necrosis). Partial thrombosis of the main vascular axis and its branches can
occur in induced neovascularization. When using delay techniques or induced neovascularized expansion,
it is advisable to use silicone sheets or interpositional skin grafting to prevent neoconnections of the flap to
the donor site or adhesions of the vascular carrier to the recipient bed and subsequent tedious and
hazardous dissection at the time of flap transfer.
It is imperative to emphasize that all prefabrication procedures, whether used singly or in combination, must
be
planned meticulously. The surgeon must have not only a wide anatomic knowledge of tissue behavior and
vascularity but also must exhibit technical expertise.
FIGURE 148.11 Appearance of the free transfer after pedicle separation. The deepithelialized zone is
buried under the free inguinal flap previously used to reconstruct the cheek. (From Baudet, ref. 27, with
permission.)
FIGURE 148.12 Immediate postoperative appearance. (From Baudet, ref. 27, with permission.)
SUMMARY
Indications for prefabrication of any sort must be evaluated carefully. Such procedures should be
undertaken only when these techniques are the most suitable, or possibly the only, solution. Nevertheless,

when carefully planned and executed, customized or prefabricated flaps currently may be the most
ambitious and exciting advance in reconstructive plastic surgery.
FIGURE 148.13 Final appearance of this complex reconstruction with four microsurgical transfers, including
a prefabricated free flap. (From Baudet, ref. 27, with permission.)
FIGURE 148.14 Prefabricated penis on forearm of a female transexual patient. Appearance at 1 month.
(From Baudet, ref. 27, with permission.)
FIGURE 148.15 Postoperative view; satisfactory cosmetic result and adequate micturition. (From Baudet,
ref. 27, with permission.)

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References
1. Callegari PR, Taylor GI, Caddy C, Minabe T. An anatomic review of the delay phenomenon. I.
Experimental studies. Plast Reconstr Surg 1992; 89:397.
2. Taylor GI, Corlett R, Caddy C, Zelt RG. An anatomic review of the delay phenomenon. II. Clinical
applications. Plast Reconstr Surg 1992;89:408.
3. Shenaq JM. Pretransfer expansion of a sensate lateral arm free flap. Ann Plast Surg 1987;19:558.
4. Leighton WD, Russel RC, Fellar AM, et al. Experimental pretransfer expansion of a free flap donor site. II.
Physiology, histology, and clinical correlation. Plast Reconstr Surg 1988;82:76.
5. Masser MR. The preexpanded radial free flap. Plast Reconstr Surg 1990; 86:295.
6. Vergote T, Revol M, Servant JM, Banzet P. Lambeaux musculocutanés de grand dorsal expanses micro
anastomosés. Ann Chir Plast Esthet 1993;38:323.
7. Dickerson RC, Duthies RB. The division of arterial blood flow to bone. J Bone Joint Surg Am.
1963;45A:356.
8. Woodhouse CF. The transplantation of patent arteries to bone. J Int Coll Surg 1963;39:437.
9. Hirase Y, Valauri FA, Buncke HJ. Neovascularized bone, muscle and myo osseous free flap: an
experimental model. Plast Reconstr Surg 1988;4:209.
10. Duarte A, Valauri FA, Buncke HE Creating a free muscle flap by neovascularization: an experimental
investigation. J Reconstr Microsurg 1987;4:15.
11. Hirase Y, Valauri FA, Buncke HJ. Neovascularized free cutaneous cartilage flap transfer with
microsurgical anastomosis: an experimental study in the rabbit. Ann Plast Surg 1988;21:342.
12. Hirase Y, Valauri FA, Buncke HJ. Neovascularized free fat flaps: an experimental model. J Reconstr
Microsurg 1988;4:197.
13. Orticochea M. A new method for total reconstruction of the nose: The ears as donor area. Br J Plast Surg
1971;24:225.
14. Erol OO. The transformation of a free skin graft into a vascularized pedicled graft. Plast Reconstr Surg
1976;58:470.
15. Erol OO, Spira M. Development and utilization of a composite island flap employing omentum:
experimental investigation. Plast Reconstr Surg 1980; 65:405.

16. Shen TY. Vascular implantation into skin flap: experimental study and clinical application. A preliminary
report. Plast Reconstr Surg 1981;68:404.
17. Shen TY. Microvascular transplantation of a prefabricated thigh flap. Plast Reconstr Surg 1982;69:568.
18. Khouri RK, Upton J, Shaw WW. Principles of flap prefabrication. Clin Plast Surg 1992;4:763.
19. Khouri RK, Upton J, Shaw WW. Prefabrication of composite free flaps through staged microvascular
transfer: an experimental and clinical study. Plast Reconstr Surg 1991;87:108.
20. Falco NA, Pribaz JJ, Eriksson E. Vascularization of skin following implantation of an arteriovenous
pedicle: implications in flap prefabrication. Microsurgery 1992;13:249.
21. Pribaz JJ, Maitz PKM, Fine NA. Flap prefabrication using the “vascular crane” principle: an experimental
study and clinical application. Br J Plast Surg 1994;47:250.
22. Maitz PKM, Pribaz JJ, Hergrueter CA. Manipulating the prefabricated flap: an experimental study
examining flap viability. Microsurgery 1994; 15:624.
23. Maitz PKM, Pribaz JJ, Duffy FJ, Hergrueter CA. The value of the delay phenomenon in flap
prefabrication: an experimental study in rabbits. Br J Plast Surg 1994;47:149.
24. Khouri RF. Panel discussion on the “prefabricated flap.” Presented at the 11th Congress of the
International Confederation of Plastic, Reconstructive and Aesthetic Surgery. Yokohama, Japan, April 16-21,
1995.
25. Baudet J, River D, Martin D, Boileau R. Prefabricated free flap transfer. In: Swartz WM, Banis J., eds.
Head and neck microsurgery. Baltimore: Williams & Wilkins, 1992.
26. Brent B, Byrd HS. Secondary ear reconstruction with cartilage graft covered by axial random and free
flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141.
27. Baudet J. Prefabrication of facial flaps. In: Rose E., ed. Aesthetic facial restoration. Philadelphia:
Lippincott-Raven, 1998.

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Chapter 149
Prefabricated Induced Expanded (Pie) Supraclavicular Flap
R. K. KHOURI
P. PELISSIER
EDITORIAL COMMENT
This is an extremely useful technique. By expansion of the skin, the blood supply appears to be augmented.
Flaps that could not be safely transferred previously are now capable of being successfully fabricated and
transferred.
Prefabrication of flaps opens interesting, new possibilities (1, 2, 3, 4, 5). The prefabricated induced expanded
(PIE) supraclavicular flap involves the staged transfer of expanded supraclavicular skin, with a fascial flap used
as a carrier (7, 8). The PIE supraclavicular flap is ideally suited for nasal reconstruction, when a forehead flap
option is not available or when a forehead scar is not desirable.
INDICATIONS
Facial defects are best reconstructed with facial tissue. When this option is not available, the next best
tissue match is supraclavicular skin, which has no practical vascular pedicle that would allow its transfer as
a thin flap. The PIE flap is an ideal alternative for reconstruction of facial units using tissue that
best matches facial tissue. Total cheek, forehead, nasal, and even hemifacial reconstructions are possible
with a single PIE flap. With judicious design, the flap can be made large enough to reconstruct major facial
defects that extend to the contralateral side well beyond the midline.
ANATOMY
When available, the temporoparietal fascia is the preferred carrier. (For details of flap dissection, see Chapters
58 and 96 on temporoparietal fascia flaps.) If the temporoparietal fascia is not available, the next best alternative
is the radial forearm fascial free flap. (See Chapters 202 and 204 for details of flap anatomy.) Any other fascial
flap with a long vascular pedicle is suitable as a carrier.
Although expanded tissue can be transferred only to adjacent sites with traditional skin expansion, the presence
of a long vascular pedicle in the carrier placed over the expander makes it possible to transfer the expanded
tissue as an island flap to distant sites. Furthermore, the angiogenic effect of the expander capsule improves the
neovascularization between the fascia carrier and the expanded skin.
A temporoparietal fascia flap is transferred to a subcutaneous pocket in the ipsilateral supraclavicular fossa, and
a skin expander is simultaneously placed under both the fascia flap and the elevated supraclavicular skin,
thereby precluding the need for microsurgical expertise and eliminating the potential complications associated
with microvascular anastomoses. The PIE flap is a two-staged transfer.
FLAP DESIGN AND DIMENSIONS
The fascia flap can be either a distant microvascular free flap or a pedicled temporoparietal fascial flap. The

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fascia is tacked under the supraclavicular skin, and a skin expander is placed under both fascia and skin. After
adequate expansion, the fascia is incorporated within the capsule of the expander, and the composite
capsulofasciocutaneous flap can be transferred based on the vascular pedicle of the fascia flap.
OPERATIVE TECHNIQUE
In the first stage, an extended superficial temporoparietal fascia flap is dissected (Fig. 149.1). To reach the
supraclavicular fossa, flap dissection must extend cephalically nearly up to the vertex. The vascular pedicle will
need to be dissected inside the parotid gland down to the level of the main trunk of the facial nerve. A thin
subcutaneous pocket is dissected in the supraclavicular area. Superficial undermining of the skin is achieved
through a rhytidectomy-type incision extended to the mastoid hairline and through a counterincision on the
superior aspect of the shoulder (Fig. 149.2). The fascia flap then is transferred inside the supraclavicular pocket
and temporarily tacked to the skin with retention sutures. An expander is placed under both the fascia flap and
the supraclavicular skin. It is important to sandwich the vascular pedicle between Silastic sheets along its entire
length to facilitate its dissection in the second stage.
The expander is gradually inflated starting 10 days later. During the course of the inflation, it is possible to trace
the course of the temporal artery under the supraclavicular skin
with Doppler examination. It is preferable to expand slowly and to gather enough well-expanded skin; this interim
period typically may last 2 to 3 months (Fig. 149.3).
FIGURE 149.1 Temporoparietal fascia flap is raised. The superficial temporal vessels are dissected inside the
parotid gland down to the main trunk of the facial nerve.

FIGURE 149.2 A thin subcutaneous pocket is made in the supraclavicular area using a preauricular incision
extended to the mastoid hairline. To dissect the pocket fully and help with insertion of the fascia and the
expander, a counterincision is made at the level of the acromion. The temporoparietal fascia flap has been
turned down, and the expanders are visible inside the supraclavicular pocket.
FIGURE 149.3 Before the second stage, the supraclavicular skin is well expanded and the temporal artery can
be subjected to Doppler evaluation over the expander.
In a second operative stage, after adequate expansion is achieved, the PIE supraclavicular flap is raised as an
island flap pedicled on the fascia vessels. The vascular pedicle that was sandwiched between Silastic sheets is
readily available and allows flap transfer to the facial defect. With adequate planning, the donor site can be
closed primarily (Fig. 149.4). If required, the pedicle component can be resected at a later date (Fig. 149.5).
CLINICAL RESULTS
Despite a limited degree of overlap between the fascia carrier and the skin paddle, the potent angiogenic
effect of the expander is such that we have not observed any marginal skin flap necrosis. In our experience,
as little as a one to four ratio of overlap between the fascia carrier and the expander allows adequate
perfusion of the skin overlying the entire expander capsule.
Complications may relate to temporoparietal fascia flap elevation or to extrusion of the expander.
Displacement of the Silastic sheets may render the secondary dissection of the pedicle very tedious.
In ten cases, we had only one venous thrombosis in a microvascular free flap; that flap was salvaged by

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timely reexploration. We also experienced two expander exposures, necessitating premature transfer of the
PIE flap. In both these cases, the reconstruction was salvaged at the expense of a larger donor-site defect.
SUMMARY
The PIE flap allows safe pedicle transfer of an expanded thin supraclavicular skin flap to any facial unit. It
uses the principle of carrier-mediated staged transfer, in which the carrier is a fascia flap. If that fascia flap
is a pedicled temporoparietal flap, no microsurgical anastomoses are needed.
FIGURE 149.4 At the second stage, the prefabricated induced expanded (PIE) flap has been dissected and
transferred to the nose. The expanders are removed, and the donor site is closed primarily. Displacement of
the anterior Silastic sheet made it impossible to separate the vascular pedicle safely from the overlying
cervical skin; the latter had to be included in the pedicle and resected at a later stage.
FIGURE 149.5 Frontal view 6 months after the nasal reconstruction.
References
1. Khouri RK, Upton J, Shaw WW. Principles of flap prefabrication. Clin Plast Surg 1992;19:763.

2. Khouri RK, Upton J, Shaw WW. Prefabrication of composite free flaps through staged microvascular
transfer: an experimental and clinical study. Plast Reconstr Surg 1991;87:108.
3. Yao ST. Vascular implantation into skin flap: experimental study and clinical application. A preliminary
report. Plast Reconstr Surg 1981;68:404.
4. Bricout N, Arrouvel C, Banset P. Résultats préliminaires d'une étude éxperimentale sur les lambeaux “à
pédicule vasculaire axial induit.” Ann Chir Plast Esthet 1984;29:376.
5. Hirase Y, Valauri FA, Buncke HJ, Newlin LY. Customized prefabricated neovascularized free flaps.
Microsurgery 1987;8:218.
6. Khouri RK, Ozbek MR, Hruza GJ, Young VL. Facial reconstruction with prefabricated induced expanded
(PIE) supraclavicular skin flaps. Plast Reconstr Surg 1995;95:1007.
7. Olenius M, Dalsgaard CJ, Wilkman M. Mitotic activity in expanded human skin. Plast Reconstr Surg
1988;81:30.
8. Bengtson BP, Ringler SL, George ER, et al. Capsular tissue: a new local flap. Plast Reconstr Surg
1993;91:1073.

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Chapter 150
Partial Face Transplant
B. DEVAUCHELLE
EDITORIAL COMMENT
This was groundbreaking microsurgery with a startling result. This surgery is still considered experimental,
but the obvious improvement in the patient will encourage other centers to follow.
Extended soft-tissue defects of the face are very difficult to reconstruct, especially when multiple anatomic units
like the nose, lips, and chin are missing simultaneously. Under such circumstances, several conventional
autologous tissue transfers are necessary to restore the form and, if possible, the function, of each of the missing
parts of the damaged face. The idea was raised that in such cases, a one-stage reconstruction of the central and
lower face could be achieved by microsurgical transfer of a full-thickness composite tissue allograft harvested on
the cephalic extremity of a brain-dead donor with similar morphologic characteristics.
INDICATIONS
Previous procedures, which often required several secondary corrections, usually led to poor cosmetic and
functional outcomes. The original face of the reconstructed patient had an unattractive appearance with
many scars and several mismatching skin paddles, all of them remaining mostly immobile and devoid of any
future expressive mobility.
The partial face transplant is a full-thickness composite soft-tissue allograft, including all anatomic
components of the nose-lips-chin triangle, harvested down to their skeletal bone support (Fig. 150.1). The
transplant is sensate and aims at restoring all complex motor functions devoted to orality—competent
feeding, intelligible speech, and restoration of the aesthetic appearance of the central and lower face, with
no donor-site morbidity. Furthermore, it allows a one-stage high-quality restoration of an acceptable
aesthetic appearance of the central and lower face. Although the ultimate goal of the procedure is certainly
not to reach an exact restitution of the recipient's previous facial identity, the new face, which is finally
created with the contribution of the graft, restores a real morphologic individuality to the facial image. A
lifelong immunosuppressive treatment remains, at present, a drawback, but is a mandatory medical
requirement to obtain the durable benefit of all the surgical advantages.
ANATOMY
The graft is supplied by the right and left facial arteries and veins that, during their ascending course to the
medial canthi, give rise to a large number of medial and lateral collateral vessels running into the subcutaneous
and submuscular planes. Lateral branches (long and short facial collaterals) are directed to the cheeks, and
medial branches distribute to the submental area (submental vessels), to the lips (upper and lower labial
vessels), and to the nose. All of these collaterals are richly connected with each other and with branches from
adjacent angiosomes. Major right-left anastomoses crossing the midline exist between the labial, submental, and
nasolobar arteries and veins. Thanks to these numerous functional connecting vascular channels, the graft may

be revascularized on a single vascular pedicle.
FIGURE 150.1 Schematic anatomic drawing of the nose-lips-chin allograft. Preoperative virtual three-
dimensional model of the first partial human face allograft.
Sensitive nerves to the graft arise from the infraorbital (V2) and mental (V3) nerves on both sides. These nerves
leave the corresponding bone foramina on the maxilla and the mandible, and then enter the soft tissues of the
mid and lower face; they then quickly divide into small rami distributed to the skin. Due to this early spread in the
small terminal rami, the main stem of the maxillary (V2) and inferior alveolar (V3) nerves need to be exposed by
an endo-osseous dissection, in order to obtain, after deep subperiosteal elevation of the graft, large proximal
nerve stumps suitable for reliable microsurgical anastomoses.
FIGURE 150.2 Anatomic specimen of a partial face transplant. The dissected allograft, shown from its outer (A)
and inner (B) aspects, is elevated on both facial vascular pedicles containing all the muscles of orofacial
expression with their intact motor-nerve supply, V2 and V3 sensitive nerves, the whole nasal pyramid, and a
large patch of anterior oral mucosa.
Motor nerves to the graft originate from the terminal zygomatic, buccal, and mandibular branches of the facial
nerves, which arise from the parotid area, run laterally above the masseteric fascia, then reach [deep to the
superficial muscular aponeurotic system (SMAS) layer] the levator and depressor muscles of the lips. Depending
on the extent of the graft, they need to be dissected separately at their exit from the parotid gland or, otherwise,
inside the gland or more proximally on the cervico- and temporofacial trunks of the facial nerves.
FLAP DESIGN AND DIMENSIONS
The partial central and lower face allograft is a full-thickness composite tissue transfer, which includes the exact

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amount of skin necessary to close the recipient's cutaneous defect, the underlying subcutaneous fat, the four
sensitive nerves to these integuments, all perioral muscles with their intact segmental motor nerve supply, the
missing cartilage of the nose, the inner lining of both nasal vestibules, and a large patch of anterior and lateral
oral mucosa (Fig. 150.2). If necessary, the graft may be enlarged laterally by including the cheeks, with the
corresponding buccinator muscles, buccal nerves, and the anterior portion of Bichat's fat pads.
A brain-dead donor is selected according to strong morphologic and immunologic criteria. Ideally, the anatomic
requirements include a similar range of age (within the same decade), the same color and texture of skin, and a
comparable overall body habitus. The donor and the recipient should also share the same blood group and have
several (as many as possible) positive human leukocyte antigen (HLA) cross-match tests.
OPERATIVE TECHNIQUE
Graft Harvesting
The face transplant is elevated on both right and left facial vessels exposed on the basilar border of the
mandible. The contour of the skin flap is designed very precisely, following a sterile, rigid pattern, previously
fabricated on the recipient, in order to match exactly the dimensions and shape of the defect to be repaired. After
the circumferential skin incision, a deep
subcutaneous dissection is made laterally on both sides of the graft, in order to expose the proximal heads of the
levator and zygomatic muscles superiorly, and the risorius and platysma muscle sheets inferiorly. Below the
lower border of the mandible, the latter is incised in order to expose the facial artery, the facial vein, and the
mandibular branch of the facial nerve, which usually crosses the pedicle at that point. Buccal and zygomatic
branches are then identified on the outer surface of the masseteric fascia and of Bichat's fat pad. Stensen's
parotid duct is ligated and not included in the composite tissue transfer.
Along the infraorbital segment of the skin incision, the orbicularis oculi muscle is divided between its preseptal
and preorbital parts. The lower orbital septum is then transected in order to expose and to cut the maxillary nerve
in the proximal portion of the infraorbital groove. Thereafter, the upper part of the graft is elevated from the
maxilla through a subperiosteal plane dissection, allowing inclusion inside the medial part of the transfer of the
intact periosteal attachments of all levator muscles to the upper lip, which are inserted on the anterior surface of
the bone. When the proximal heads of the zygomatic and levator anguli oris muscles are cut more laterally, they
are tagged individually on small silicone markers, in order to identify them and to prevent their retraction inside
the graft fatty tissue. On the dorsum of the nose, the integuments are elevated from the nasal bones under the
deep surface of the nasalis muscle. Then, the lateral nasal cartilages are incised along their bone attachments,
and the whole nasal pyramid is separated from the bony piriform aperture with a simple, sharp blade, descending
the frontal section of the nasal septum and of the mucosae of both nasal cavities.
Along the inferior skin incision line, the depressor muscles to the lower lip are freed from their mandibular
insertions. Then, the mental foramina are exposed through a subperiosteal approach, and a small cortical bone
window is drilled on the lateral side of each of them, in order to expose and transect the main stem of the inferior
alveolar nerve inside the distal part of the mandibular canal. The transplant elevation finally ends with a sharp
breakdown of the oral mucosa, occurring centrally along the upper and lower vestibular sulci close to the gingiva
and laterally on the cheek inner lining in front of the opening of the parotid duct. At the end of the harvesting
procedure, the graft remains pedicled on both right and left facial blood vessels, which are dissected from the
submandibular gland and traced proximally down to the large neck vessels, in order to obtain the longest and
most extensive donor blood vessels for revascularizing the transplant. If a lower suprahyoid skin extension is
included in the graft design, care is taken during this dissection not to damage the thin submental blood vessels
that are responsible for the supply of that area.

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After harvest, the facial graft is irrigated with 500 mL of ILG-1 organ preservation solution at 4°C, and then
placed in double plastic bags and in a standard icebox. After multiorgan procurement, the donor's nose-lips-chin
triangle is cautiously reconstructed, using a custom-made, carved, and colored silicone mask inside a plaster
cast molded on the face before any incision and at the very beginning of the procedure.
Recipient Allograft
The recipient's face is prepared to receive the graft after a tracheotomy is performed. An extended facial
dissection is then performed in order to obtain regular, healthy skin edges around the soft-tissue defect, to
remove deep scar tissue, and to isolate each anatomic structure to be joined to those dissected and individually
tagged on the graft. Superficial muscle dissection attempts to individualize all remaining stumps of the elevator
and depressor muscle bellies and the segmental motor branches of the facial nerves. Deeply, terminal sensitive
branches of the maxillary and mandibular nerves are exposed at the origin of their supraperiosteal course and
prepared for further microsurgical anastomoses at the point at which they leave the infraorbital or mental
foramina. Blood vessels selected to revascularize the transplant are usually the right and left facial vessels
carefully exposed in the submandibular area or in the neck.
After a complementary microsurgical preparation performed on a bed of iced sponges, the graft is transferred to
the recipient's face and secured along one edge of the skin defect by several temporary stitches.
Revascularization is then carried out by anastomosing donor and recipient facial vessels on one side of the
transplant (Fig. 150.3). When the clamps are released, the whole composite allograft rapidly recovers a normal
color and volume. Due to the right-left vascular anastomoses running mostly in the labial networks, active
bleeding is also quickly observed on the free end of the contralateral vessels. Further repair includes,
sequentially, the circumferential closure of the oral vestibule; the clockwise suture of mental and infraorbital
sensitive nerves that start from the responsible facial pedicle; and, finally, the anastomoses of the contralateral
facial artery and vein.
Facial mimic muscles are sutured in layers, with an attempt to join them individually whenever possible. If not
possible, an approximation is made by joining together the buccinator mass deeply and vectorial groups of
levator muscles superficially. On the lower edge of the transplant, the depressor muscles of the lower lip are
reinserted on the periosteum of the mandibular border. To reanimate the face, several motor-nerve coaptions are
conducted in a termino-terminal or termino-lateral fashion, depending on the location of injuries on the available
facial nerve branches. Final inset of the transplant then includes the ascending repair of both nasal vestibules,
the upper periosteal suspension of the deep graft layer on the recipient facial skeleton, the lower closure of the
nasal SMAS
layer, and, finally, subcutaneous and skin suture. Silkworm guts are used to drain the subcutaneous space by
capillarity, and the wounds are lightly dressed with short sterile skin closure strips (Steri-Strips) only. Silicone
drains are inserted in both nasal fossae to maintain their permeability and to ensure hemostasis. The whole graft
is left uncovered for postoperative monitoring.

FIGURE 150.3 Early revascularization of the first partial face transplant. Facial artery anastomosis on the right
side of the graft, 30 seconds after clamp release. Note the uniform recovery of normal skin perfusion on the
nearly whole allograft surface.
CLINICAL RESULTS
The first partial face transplantation was carried out in Amiens, France, on November 27, 2005, to
reconstruct the central and lower face of a 38-year-old woman who had suffered, 6 months previously, a
severe dog bite that amputated her distal nose, both lips, chin, and adjacent parts of the cheeks (Fig.
150.4). The donor's face was harvested and transplanted according to the previously described technique,
and a standard immunosuppressive treatment was instituted to prevent graft rejection. The initial
postoperative course was uneventful. No surgical complication occurred, wound healing was rapid, and
immunosuppression well tolerated. Nevertheless, the patient developed, at week 3 (W3) and month 7 (M7),
two moderate rejection episodes that were easily controlled by increasing corticosteroid doses. Immediate
anatomic integration and psychologic acceptance of the face transplant were excellent.

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FIGURE 150.4 Anatomic and functional results of the first partial facial composite tissue allograft. After a
dog-bite trauma, the patient completely lacked the distal nose, both lips, and chin (A). One year after
transplantation, she has recovered her static rest face image (B) and also a dynamic, perfectly symmetric
smile (C).
From this inaugural experience, it was determined that, functionally, the patient was able to eat and drink
almost normally at the end of the first postoperative week. Rehabilitation training was started at day 1,
repeated twice a day, and tried to create, very early, an intimate functional sensory relationship between the
sensate autologous tongue and the “dead” deep surface of the lips on the graft. Facial static and dynamic
exercises were mainly focused on the restoration of lip suspension and mouth occlusion.
Sensation of the graft recovered quite rapidly and was probably favored by the positive neurotrophic effects
of the immunosuppressive drugs. Assessed by the progression of the Tinel sign and by repeated heat-cold
and Semmes-Weinstein testing, sensitive recovery began around the infraorbital and mental areas at the
end of M1 and occurred more quickly for epicritic than for discriminative sensitivity. Later, the reinnervated
area reached the lateral part of the lips at M2 and thereafter involved the whole surface of the transplant at
M4. The oral mucosa of the graft also became sensate over the same interval of time, since at the end of
M2, routine mucosal biopsies performed for immunologic monitoring needed to be done under local
anesthesia.
Motor recovery was slower but became progressively more effective. Dynamic motions were first observed

on the upper lip and arose from transmission of contractions generated in the healthy proximal stumps of
the repaired levator and zygomatic muscles (M3). Thereafter, real autonomous contractions of the
transplanted muscle bellies, causing natural skin wrinkling, became obvious from M4 on. Of course, these
phenomena occurred as results of a complex random biological process, which probably involved both
intramuscular neurotization taking place in the areas of muscle repair and intraneural axonal regeneration
spreading through the motor-nerve coaptation sites. A paralytic sagging of the lower lip remained present
until W20, and hypertonic and hypotonic areas may have also coexisted temporarily inside the face graft.
Nevertheless, complete active, then passive, lip occlusions were achieved at M6 and M8, respectively, and
a perfect symmetric smile was restored at M10. Over the same period, other relevant facial expressive
motions involving the antagonistic depressor muscles, as in fear, pain, and hesitation, also recovered
progressively.
The partial face transplant is fully sensate and contains, in exact anatomic position, all the functional muscle
vectors responsible for delicate lip movements involved in feeding, speech, and facial expression. After
revascularization, the allograft immediately recovers its form, volume, and contour, therefore allowing a one-
stage reconstruction of several neighboring anatomic units within a severely damaged face, with highly
natural curves, nearly inconspicuous transitions between autologous and heterologous tissue, and no
additional scars to the surrounding skin. There is no donor-site morbidity in the recipient body and, thanks
to the rapid sensitive nerve recovery, the neurologic reintegration of the transplant into the brain cortex
seems to favor a relatively rapid psychologic acceptance of the new face inside the body scheme.
Technically, face transplant is a long and serious procedure requiring two teams of experienced
microsurgeons able to carry out, simultaneously and in perfect time planning, operations on the brain-dead
donor and on the recipient patient. For the recipient, facial reconstruction would obviously be delayed until a
compatible and adequate donor becomes available. Additionally, after successful surgery, a lifelong
immunosuppressive treatment is mandatory, to prevent allograft rejection until a hypothetic state of
tolerance is achieved. Well-known side effects of the drugs commonly used for this purpose include, in
addition to potential negative alterations of renal and hepatic functions, an increased risk of viral, microbial,
and fungal infections; of skin cancer (×15); and of lymphoma (1%). At the present time, the lifelong results
of a facial transplant cannot be predicted; in cases of early or late failures (acute or chronic rejections), the
transplantectomy site would then need to be reconstructed secondarily by another graft or by conventional
autologous tissue transfer.
SUMMARY
Although the ultimate goal of the procedure is certainly not to reach exact restitution of the recipient's facial
identity, the new face that is recreated with the contribution of the graft restores a real morphologic
individuality.
References
1. Devauchelle B, Badet L, Lengelé B, et al. First human face allograft: early report. Lancet 2006;15:368.
2. Monaco AP, Maki T, Hale D, et al. The enigma of tolerance and chimerism: variable role of T cells and
chimerism in induction of tolerance with bone marrow. Transplant Proc 2001;33:3837.

3. Dakpe S. Image d'une transplantée faciale: à propos de l'intégration neurologique d'une allotransplantation
du triangle nez-lèvres-menton. Thèse pour le doctoral en medicine No. 71, Oct. 2006. Université de Picardie,
France.
4. Giraux P, Sirigu A, Schneider F, Dubernard JM. Cortical reorganization in motor cortex after hand graft of
both hands. Nat Neurosci 2001;4:691.
5. Dubernard JM, Lengelé B, Morelon E, et al. First human face transplantation at 18 months' follow-up. N
Engl J Med 2007;357:2451.

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Chapter 151
Facial Transplantation— The Anatomic Basis
M. SIEMIONOW
G. AGAOGLU
S. UNAL
EDITORIAL COMMENT
Increasing numbers o composite allotransplantation of the face are being performed throughout the world. Anyone who is interested in
facial transplantation will be well served by studying the descriptive anatomy of the donor and the recipient dissections as outlined in
this chapter.
Lifelong immunosuppression therapy, due to serious side effects, is the main obstacle to routine use of composite tissue allografts. When
the subject is a candidate for face transplantation, there are ethical, social, and psychologic issues to be considered. In addition, the
technical aspects of face transplantation have to be outlined. To mimic the clinical scenario of a facial transplantation procedure, we have
performed a mock facial transplantation by harvesting a total facial-scalp flap from donor cadavers and transferring the flap to recipient
cadavers.
INDICATIONS
Since the first successful hand allograft transplantation in France in 1998 (1), composite tissue allograft transplantation has opened a
new era in the field of reconstructive surgery. However, the final cosmetic and functional outcomes of currently available reconstructive
procedures for severe soft-tissue defects of the face are not optimal. Face transplantation is a promising alternative to the
conventional reconstructive procedures. Successful partial face transplantation cases have been reported in France and in China (2,
3, 4). We have designed a cadaveric facial allograft transplantation model (5, 6) to support application of facial allografts, as a new
treatment option for reconstruction of facial defects in patients with severe facial deformities due to burn, trauma, and cancer ablation.
ANATOMY
In donor cadavers, a full facial-scalp flap was elevated to include the entire facial skin and the scalp. The flap also incorporated the
superficial muscular aponeurotic system (SMAS) of the face; the parotid gland; the inferior and superior tarsal plates; and the great
auricular, facial, supraorbital, infraorbital, and mental nerves. This composite facial-scalp flap is based bilaterally on the external carotid
arteries, including superficial temporal and facial arteries, and on the external jugular and facial veins.
FLAP DESIGN AND DIMENSIONS
The flap was designed to include the entire facial skin and the scalp, including both ears, based on the external carotid arteries and
external jugular and facial veins. The mean horizontal-vertical dimensions for the total facial-scalp flaps were 57 × 30 cm, and the mean
surface area was 1,192 cm2. The mean horizontal and vertical dimensions for facial flaps without scalp were 33 × 28 cm, and the mean
surface area was 675 cm2.
OPERATIVE TECHNIQUE
Mock Facial Transplantation: Technique of Donor Facial-Scalp Flap Harvesting
A midline vertical incision from mentum to suprasternal notch was performed to the depth of the platysmal layer (Fig. 151.1A). From the
lower end of the vertical incision, horizontal incisions were extended bilaterally, to be met posteriorly in the neck midline at the scalp
hairline. With the cadaver in the left lateral position, the incision was extended vertically in the midline to the vertex of the scalp.
In the subplatysmal plane, the flaps were elevated from medial to lateral and caudal to cranial, exposing the strap muscles at the midline
and the sternocleidomastoid muscle (SCM) more laterally. The caudal portions of the external jugular
veins (EJVs) were found bilaterally underneath the platysmal layer, ligated, transected, and incorporated into the skin-platysmal flap. The
great auricular nerves were both identified on the lateral edges of the SCM and incorporated into the flap.
The scalp-flap dissection was performed in the subgaleal plane, with the cadaver turned to the left lateral and right lateral positions. The
supraorbital rims were reached, and the supraorbital nerves were traced down to their exit from the supraorbital foramen and transected.
Then, the external ear canals were reached and transected to incorporate the ears within the flap.

In the neck, the SCM was cut close to its clavicular and sternal insertions, and the carotid sheath underneath was exposed. The omohyoid
muscle was cut at its tendinous junction, to better expose the caudal portion of the carotid sheath. The carotid sheath was incised and the
carotid artery, along with the internal jugular vein, was dissected cranially to reach the carotid bifurcation. After the bifurcation of the
common carotid to internal and external carotid arteries, the external carotid artery was transected, to become the arterial pedicle of the
flap.
At this point, the attachments of the stylohyoid and digastric muscles on the hyoid bone were cut, to get a better exposure of the underlying
structures. The ascending pharyngeal, the superior thyroid, and the lingual arteries were ligated close to their branching from the external
carotid, and the dissection was further carried cranially. The hypoglossal nerve was also exposed and transected. The facial artery,
branching from the anteromedial side of the external carotid artery, was carefully dissected in a cranial direction as it entered the
submandibular gland. The artery was traced and separated from the gland with a tedious dissection, and the gland was not incorporated in
the platysmal skin flap (Fig. 151.1B).
Then, the second venous pedicle of the flap, the facial vein, was also isolated from the surrounding soft tissue and the submandibular
gland. After dissection of the vein toward its entrance to the internal jugular vein, it was ligated and transected, leaving sufficient pedicle to
become the second venous pedicle of the flap. After the mandibular border was reached at the midline, the dissection was continued
cranially underneath the SMAS, to reach the lips. The vermilion of the lips was incorporated within the flap, as the sub-SMAS dissection
was deepened to incise the gingivobuccal mucosa. Through intraoral incision, the mental nerves were exposed, traced, and incorporated
within the flap.
After keeping the facial artery intact, the external carotid artery was further traced cranially behind the ramus of the mandible as it continued
deep to the parotid gland. The gland was incorporated within the flap. Before becoming the superficial temporal artery, the external carotid
gives off the occipital, the maxillary, the transverse facial, and the middle temporal branches, each of which was ligated and transected
sequentially.
In the cheek flap dissections continued in a sub-SMAS plane, a fashion similar to a face-lift dissection was used. Intraoral incision was
circumferentially carried onto the upper gingivobuccal sulcus, and the soft tissues were sharply incised. Through the upper gingivobuccal
incision, in the subperiosteal plane, the infraorbital nerve was explored, traced, and included in the flap.
On both sides, the upper and lower palpebral fornix conjunctival incisions were performed in a circumferential manner just at the tarsal
margins and joined with the sub-SMAS flap dissection plane, in order to incorporate the upper and lower lids within the flap. At the midline,
the nasal soft tissue was elevated, leaving the osseocartilaginous framework behind, and the elevation of the total facial-scalp flap was
completed (Fig. 151.1C and D).
Technique of Recipient Facial Skin Harvesting as a “Monoblock” Full-Thickness Skin Graft
Incisions were made in a fashion similar to that described previously. The entire skin of the neck, face, and scalp was incised and elevated
as a “monoblock” full-thickness skin graft in a plane above the platysma, SMAS, and galea, respectively (Fig. 151.2A and B). The great
auricular nerve was identified at the posterior border of the SCM muscle, dissected from the surrounding tissue, and the maximal access to
the nerve was preserved. Through the upper and lower gingivobuccal incisions, the vermilion of the upper and lower lips was excised with
the entire facial skin. At the infraorbital and mental regions, both the infraorbital and mental nerves were explored and dissected from their
surrounding tissue, respectively, until an adequate length of the nerves was achieved for future coaptation. The upper and lower
circumferential conjunctival incisions were performed at the tarsal margins and were joined with the facial skin dissection plane,
incorporating the upper and lower lids. At the supraorbital rims, the supraorbital nerves were explored and traced down to the supraorbital
foramen, until adequate length was obtained.
Next, the arterial and venous pedicles were dissected and prepared for the future anastomoses. External jugular veins were bilaterally
explored under the platysma and were prepared to serve as one of the recipient venous pedicles. SCM muscle was retracted laterally, and
the carotid sheath was reached and incised. The external carotid artery was dissected, separated from the internal carotid artery, and
prepared as the recipient's arterial pedicle. The facial vein was identified at its entrance into the internal jugular vein and dissected to obtain
adequate length to serve as the second venous pedicle in the recipient.
Technique of Donor Facial-Scalp Flap Transplantation into Recipient Facial-Scalp
The inset of the donor flap began with markings of the regions at which the donor facial-scalp flap would be anchored against gravity.
These anchoring sites included the mandibular and zygomatic ligament regions, preauricular area, mastoid fascia, temporalis fascia, and
frontal bone. The harvested facial-scalp flap was transferred from the donor to the recipient site, and the sequence of flap inset was as
follows. First, the supraorbital, infraorbital, and mental nerves of the facial flap were approximated to their respective nerves in the recipient.
Next, the flap was sutured to the marked regions at the level of the mandibular and zygomatic ligaments bilaterally (Fig. 151.3A). This was
followed by anchoring the flap into the preauricular regions, to the mastoid fascia behind the ears, and to the temporalis fascia at the
temporal region (Fig. 151.3B). At the frontal region, the flap was fixed to the frontal bone with 4-0 Prolene sutures passed through the
cortical bone tunnels created by the electric drill (Fig. 151.3C).
Next, the upper and lower gingivobuccal and conjunctival incisions were closed. The vascular pedicles, consisting of the external carotid

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arteries and facial veins, were approximated to their respective recipient vessels (Fig. 151.3D). The great auricular nerves and the external
jugular veins of the facial flap were approximated to their respective nerves and
vessels in the recipient for future nerve coaptation and vascular anastomoses. There was no attempt to perform vessel or nerve repair,
because vessels are collapsed in cadavers and lack elasticity and turgor, and nerves easily become dried during flap harvesting. Finally,
the skin incisions were closed, and the inset of the flap was completed.
FIGURE 151.1 Dissection of the facial-scalp flap. A: Through a midline incision, the flap is elevated in a subplatysmal plane, including the
external jugular vein in the flap. B: Elevation of the facial-scalp flap showing the arterial network of the flap. (1, common carotid artery; 2,
external carotid artery: 3, superficial temporal artery: 4, facial artery: 5, lower border of mandible.) C: Harvested total facial-scalp flap. D1:
Inverted surface of the harvested total facial-scalp flap showing sensory nerves, and arterial and venous pedicles. (1, mental nerve; 2, facial
artery; 3, superficial temporal artery; 4, external carotid artery; 5, facial vein; 6, external jugular vein. D2: (left). 1, supraorbital nerve; 2,
infraorbital nerve (right).

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FIGURE 151.2 A: Elevation of the facial skin of the recipient cadaver above the superficial muscular aponeurotic system (SMAS)-platysmal
plane as “monoblock” skin graft. In the neck, the skin is elevated above the platysmal plane (B, above). The total facial-scalp skin in the
recipient cadaver harvested as a “monoblock” full-thickness skin graft (right, above).
EXPERIMENTAL RESULTS
Mock Facial Transplantation
In our cadaver studies, in the donor cadavers, the mean harvesting time of the total facial-scalp flap was 235.62 minutes. The mean
length of the supraorbital, infraorbital, mental, and great auricular nerves was 1.5, 2.46, 3.02, and 6.11 cm, respectively. The mean
length of the external carotid artery, facial, and external jugular veins was 5, 3.15, and 5.78 cm, respectively. In the recipient cadavers,
the mean harvesting time of facial skin as a “monoblock,” full-thickness graft was 47.5 minutes (Table 151.1). The mean time for the
preparation of the arterial and venous pedicles and sensory nerves for the future anastomoses and coaptation was 30 minutes. The
mean time for the facial flap anchoring was 22.5 minutes. The total mean time of mock facial transplantation without vessels and nerve
repair was 320 minutes (Table 151.2). The sequence of the mock facial transplantation is presented in Table 151.3.
So far, two partial face transplantations have been performed, the first one in France and the second one in China. The first patient
was a woman, aged 38 years, who had suffered amputation of the central and lower face, including nose, upper and lower lips, chin,
and adjacent parts of the cheeks (2). The transplantation procedure consisted of bilateral facial arteries and vein anastomoses,
mucosal repair of the oral and nasal vestibules, bilateral coaptation of the infraorbital and mental nerves, joining of mimic muscles with
motor nerve suture on the mandibular branch of the left facial nerve, and skin closure.

FIGURE 151.3 A: Anchoring procedure of the facial-scalp flap in the recipient cadaver. Fixation to the mandibular ligament region (left,
above). (1, platysma; 2, mandibular border; 3, mentum). B: Facial flap fixation to the temporalis fascia region and suturing of the
auricular cartilages of the external ears. C: Flap anchoring to the frontal bone by the suture passing through the tunnel created in the
cortical bone (left, below). D: The vascular pedicles of the donor facial flap are approximated to their respective vessels in the
recipient for future vascular anastomoses. (1, recipient's external carotid artery; 2, donor's external carotid artery: 3, donor's superficial
temporal artery; 4, donor's facial artery).
TABLE 151.1
SUMMARY OF THE HARVESTING TIME AND VASCULAR PEDICLE AND NERVE LENGTH IN THE DONOR
CADAVERS
Cadaver
no.
Facial flap
harvesting
time in the
donor
(min)
Facial skin
graft
harvesting,
time in the
recipient
(min)
External
carotid
artery
pedicle
length
(cm)
Facial
vein
pedicle
length
(cm)
External
jugular
vein
pedicle
length
(cm)
Supraorbital
nerve
length (cm)
Infraorbital
nerve
length
(cm)
Mental
nerve
length
(cm)
Great
auricular
nerve
length
(cm)
1
250
—
5.1
2.8
5.8
1.7
2.4
3.2
6.4
2
280
—
4.8
3.3
6.7
1.5
2.2
3.6
6.1
3
220
—
5.6
3.5
6
1.3
2.5
3.1
5.7
4
240
—
4.9
3.2
5.2
1.4
2.4
2.9
6.3
5
235
—
4.5
3.6
5.3
1.4
2.1
2.5
6.4
6
220
—
5.1
3.2
6.2
1.7
2.8
2.8
5.9
7
210
—
5.2
2.7
5.7
1.6
2.5
3
5.4
8
230
—
4.8
2.9
5.4
1.4
2.8
3.1
6.7
Mean
235.62 ±
47.5 ±
5.0 ±
3.15 ±
5.78 ±
1.50 ± 0.15
2.46 ±
3.02 ±
6.11 ±

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21.94
3.53
0.32
0.32
0.5
0.25
0.31
0.42
TABLE 151.2
TOTAL MEAN TIME NEEDED FOR PREPARATION OF THE RECIPIENT'S DEFECT AND INSET OF THE DONOR
FACIAL FLAP TO THE RECIPIENT CADAVERS
Surgical procedure
Cadaver
no. 1
Cadaver
no. 2
Mean
time
Facial skin graft harvesting in the recipient (min)
50
45
47.5 ±
3.53
Preparation of the arterial and venous pedicles and nerves for anastomoses
and repair (min)
30
30
30 ± 0
Inset of the donor facial flap into the recipient (min)
25
20
22.5 ±
3.53
Facial flap harvesting time from the donor cadavers (min)
210
230
220 ±
14.14
Total time for mock facial transplantation (min)
315
325
320 ±
7.07
TABLE 151.3
MOCK FACIAL TRANSPLANTATION PROCEDURE
Sequence of Procedures
1.
Transfer of the donor facial flap into the recipient's facial defect
2.
Coaptation of the supraorbital, infraorbital, and mental nerves
3.
Anchoring of the flap at the region of the mandibular and zygomatic ligaments
4.
Anchoring of the flap to the preauricular region, mastoid fascia, and temporal fascia
5.
Anchoring of the flap to the frontal bones
6.
Closure of the upper and lower gingivobuccal incisions
7.
Closure of the upper and lower conjunctival incisions
8.
Anastomoses of the external carotid arteries between the donor and recipient
9.
Anastomoses of the facial veins between the donor and recipient
10.
Coaptation of the great auricular nerves
11.
Anastomoses of the external jugular veins between the donor and recipient
12.
Closure of the skin incisions

The initial postoperative course of the first clinical case was reported to be uneventful. No surgical complications occurred. Anatomic
and psychologic integration and recovery of sensation were excellent. The 4-month outcome revealed the feasibility of the procedure
and was considered successful, with respect to appearance, sensibility, and acceptance by the patient. The clinicopathologic findings
from the skin and oral mucosa of the patient during the first 8 months were also reported (3). The patient developed clinical rejection
episodes at days 20 and 214 postgraft, which disappeared after increasing the dose of immunosuppressants. Pathologic changes
suggestive of rejection were more severe in the oral mucosa than in the facial skin. Close clinicopathologic monitoring of the facial skin
and oral mucosa was considered the most reliable way to detect rejection in the setting of human facial tissue allotransplantation.
The second partial face transplantation, according to media reports, was performed in a Chinese hunter, aged 30 years, who was
disfigured after being attacked by a bear (4). In this case, the defect included nose, upper lip, and cheek. The hospital reported: “The
operation is considered successful and the patient is in good condition.” However, currently, there is no more information available on
this patient's follow-up. The long-term results of the reported cases of partial facial transplantations will be critical, to assess the future
applications of partial or total face transplantation.
SUMMARY
Total facial-scalp flaps from donor cadavers were harvested and transferred to recipient cadavers. In the donors, the time of facial-
scalp flap harvesting was measured, as well as the length of the arterial and venous pedicles and sensory nerves, which were
included in the facial flaps. In the recipients, the time of facial skin harvest as a “monoblock,” full-thickness graft was measured, as
were the anchoring regions for the inset of the donor flaps and the time sequences for the vascular pedicle anastomoses and nerve
coaptations (7).
References
1. Dubernard JM, Owen E, Herzberg G, et al. Human hand allograft: report on first 6 months. Lancet 1999;353:1315.
2. Devauchelle B, Bodet L, Lengete B, et al. First human face allograft: early report. Lancet 2006;368:203.
3. Kanitakis J, Badet L, Petruzzo P, et al. Clinicopathologic monitoring of the skin and oral mucosa of the first human face allograft:
report on the first eight months. Transplantation 2006;82:1610.
4.
5. Siemionow M, Unal S, Agaoglu G, et al. What are alternative sources for total facial defect coverage? A cadaver study in preparation
for facial allograft transplantation in humans—part I. Plast Reconstr Surg 2006; 117:864.
6. Siemionow M, Agaoglu G, Unal S. Mock facial transplantation: a cadaver study in preparation for facial allograft transplantation in
humans—part II. Plast Reconstr Surg 2006;117:876.
7. Siemionow M, Agaoglu G. The issue of facial “appearance and identity transfer” after mock transplantation: a cadaver study in
preparation for facial allograft transplantation in humans. J Reconstr Microsurg 2006; 22:329.