Grabb’s Encyclopedia of Flaps Head and Neck

Centre de Chirugie de la Main-Urgences Mains
Hôpital Nanterre
Paris, France
F. E. Pratt, MD (Retired)
Sacramento, California
J. J. Pribaz, MD
Children's Hospital, Boston
Associate Professor/Chief, Hand and
Microsurgery
Department of Surgery/Division of
Plastic Surgery
Brigham and Women's Hospital
Boston, Massachusetts
J. M. Psillakis, MD
Professor of Plastic and Reconstructive Surgery
University of Sao Paulo, Brazil
Barueri, Brazil
C. L. Puckett, MD, FACS
University of Missouri Hospital and Clinics
Professor and Head
Division of Plastic and Reconstructive Surgery
University of Missouri
Columbia, Michigan
C. Radovan, MD
(Deceased)
S. S. Ramasastry, MD
University of Illinois at Chicago Medical Center
Cook County Hospital
Mount Sinai Hospital
Chicago, Illinois
O. M. Ramirez, MD, FACS
Professor, Greater Baltimore Medical Center
The Johns Hopkins University
School of Medicine
Franklin Square Hospital, Baltimore
Plastic and Aesthetic Surgery
Lutherville-Timonium
Baltimore, Maryland

Y. Ramon, MD
Department of Plastic Surgery
Rambam Medical Center, Haifa
Haifa, Israel
V. K. Rao, MD, MBA
University of Wisconsin Hospital and Clinic
University of Wisconsin Medical School
Madison, Wisconsin
D. A. Campbell Reid, MD, FRCS
Consultant Plastic Surgeon
Plastic and Jaw Department
Fulwood Hospital
Fulwood, Sheffield, United Kingdom
R. S. Reiffel, MD, FACS
White Plains Hospital
St. Agnes Hospital
Westchester Medical Center
White Plains, New York
J. F. Reinisch, MD, FACS
Head, Division of Plastic Surgery
Childrens Hospital Los Angeles
University Hospital
Associate Professor of Clinical Surgery,
University of Southern California School of Medicine
Division of Plastic Surgery
Childrens Hospital Los Angeles
Los Angeles, California
A. J. Renard, MD, FACS
Sarasota, Florida
J. E. Restrepo, MD
Clínica Soma
Medellin, Columbia
Ryan Reusche, BSc
Medical Student
University of Miami
Miller School of Medicine
Miami, Florida
C. A. Rhee, MD

Levittown, New York
M. Ribeiro, MD
Plastic Surgery Unit
Department of Surgical Oncology I
Portuguese Institute of Oncology
Porto, Portugal
D. Richard, MD
Centre Hospitalier D'Agen
Agen, France
R. A. Rieger, MBBS, FRCS, FRACS
Adelaide, Australia
R. Roa, MD
President of the Chilean Burn Association
Assistant Professor
Medical School, Universidad de los Andes
Santiago, Chile
G. A. Robertson, MD
Victoria Hospital, Winnipeg, Manitoba
Manitoba Clinic
Winnipeg, Manitoba, Canada
J. F. R. Rocha, MD
Laboratoire d'Anatomie de l'UER
Biomedicale de Saint Peres
Hôpital Trousseau
Paris, France
C. Rodgers, MD, FACS
Rose Medical Center
Swedish Hospital
Porter Hospital
Littleton Hospital
Denver, Colorado
E. Roggendorf, Dr.sc.med.
(Deceased)
M. C. Romaña, MD
Hôpital d'Enfants Armand-Trousseau, Paris
Consultant Surgeon
Department of Orthopaedic

and Reconstructive Surgery for Children
Hôpital Trousseau
Paris, France
T. Romo III, MD
Director of Facial Plastic
and Reconstructive Surgery
Department of Otolaryngology
Head and Neck Surgery
Lenox Hill Hospital
The Manhattan Eye, Ear and Throat Hospital
New York, New York
E. H. Rose, MD
Assistant Clinical Professor (Plastic Surgery)
The Mount Sinai Medical School
Attending Staff, The Mount Sinai Medical Center
and Lenox Hill Hospital
Founder and Director
The Aesthetic Surgery Center
New York, New York
M. Rousso, MD
Senior Lecturer of Surgery
Hadassah Hebrew University, Jerusalem
Head of Hand Surgery and Day Care Surgery
Misgav Ladach General Hospital
Jerusalem, Israel
R. T. Routledge, MD, FRCS (Retired)
Chief of Plastic Surgery Department
Frenchay Hospital
Bristol, United Kingdom
Warren M. Rozen, MD
Consultant Plastic Surgeon and Senior Lecturer
Monash Plastic Surgery Research Group,
Department of Surgery
Monash University
Clayton, Victoria, Australia
J. Peter Rubin, MD
UPMC Endowed Professor and Chair
Department of Plastic Surgery
Director, Life After Weight Loss Body Contouring
Program

University of Pittsburgh
Pittsburgh, Pennsylvania
R. C. Russell, MD, FACS, FRCS
Plastic Surgery
Memorial Hospital
St. John's Hospital
Southern Illinois University School of Medicine
Springfield, Illinois
Illini Hospital
Pittsfield, Illinois
R. F. Ryan, MD, FACS (Retired)
Emeritus Professor of Surgery (Plastic Reconstructive)
Tulane Medical School
New Orleans, Louisiana
Perido Bay Country Club
Pensacola, Florida
F. J. Rybka, MD, FACS
Mercy Hospital
Sutter Hospital
Professor of Plastic Surgery, University of California, Davis
Carmichael, California
M. N. Saad, MD
Honorary Consultant Plastic Surgeon
Wexham Park Hospital, Slough
Consultant Plastic Surgeon
The Thames Valley Nuffield Hospital, Slough
The Princess Margaret Hospital
Berks, United Kingdom
Tunc Safak, MD
Professor
Plastic and Reconstructive Surgery Department
Hacettepe University Hospital
Ankara, Turkey
Michel Saint-Cyr, MD
Professor of Plastic Surgery
Mayo Clinic
Rochester, Minnesota
H. Saito, MD, PhD
Fukui Medical University

Fukui, Japan
S. Sakai, MD
Associate Professor
Department of Plastic and Reconstructive Surgery
St. Marianna University School of Medicine
Myamae-ku, Japan
R. H. Samson, MD
Sarasota Memorial Hospital
Columbia Doctors Hospital
Vascular Associates of Sarasota
Sarasota, Florida
J. R. Sanger, MD, FACS
Medical College of Wisconsin
Milwaukee, Wisconsin
J.R. Ramón Sanz, MD
Head of Department of Plastic and Reconstructive Surgery
“Marqués de Valdecilla” University Hospital
Santander, Spain
G. H. Sasaki, MD, FACS
St. Luke Medical Center
Huntington Memorial Hospital
Arcadia Methodist Hospital
Plastic and Reconstructive Surgery
Pasadena, California
K. Sasaki, MD
Chief Professor of Nihon
University School of Medicine
Department of Plastic and Reconstructive Surgery
Nihon University School of Medicine, Oyaguchi
Itabashi-ku, Tokyo, Japan
R. C. Savage, MD, FACS
Assistant Clinical Professor, Division of Plastic Surgery
Harvard Medical School
Needham Medical Building
Needham, Massachusetts
H. Schaupp, MD (Retired)
University ENT Hospital
Frankfurt-am-Main, Germany

L. R. Scheker, MD
Christine M. Kleinert Institute
for Hand and Microsurgery
Assistant Clinical Professor of Plastic
and Reconstructive Surgery
University of Louisville
Louisville, Kentucky
R. R. Schenck, MD, FACS
Associate Professor and Director
Section of Hand Surgery
Senior Attending,
Departments of Plastic and Orthopaedic Surgery
Rush-Presbyterian-St. Luke's Medical Center
Chicago, Illinois
J. D. Schlenker, MD
Advocate Christ Medical Center
Little Company of Mary
Palos Community
Holy Cross
Illinois Valley Community Hospital
Chicago, Illinois
Andreas B. Schmidt, MD
Section Chief
Plastic and Hand Surgery
Asklepios Clinic
Bad Toelz, Germany
J. Schrudde, MD
University of Köln
Köln, Germany
M. A. Schusterman, MD, FACS
Clinical Associate Professor of Plastic
and Reconstructive Surgery
Baylor College of Medicine
Houston, Texas
S. P. Seidel, MD
Cullman Regional Medical Center
Woodland Community Hospital
Walker Baptist Medical Center
Seidel Plastic Surgery

Cullman, Alabama
D. Serafin, MD, FACS
Professor, Chief of Plastic Reconstructive
Maxillary Oral Surgery
Duke University Medical Center
Durham, North Carolina
Jose Maria Serra-Mestre, MD
Hospital Quirón Barcelona
Institute of Aesthetic and Plastic Surgery
Barcelona, Spain
José Maria Serra-Renom, MD
Hospital Quirón Barcelona
Institute of Aesthetic and Plastic Surgery
Barcelona, Spain
R. E. Shanahan, MD, FACS
Emeritus Staff, The Toledo Hospital
Emeritus Clinical Associate Professor of Surgery
Medical College of Ohio at JOCTPC
Toledo, Ohio
L. A. Sharzer, MD, FACS
Albert Einstein College of Medicine
Montefiore Medical Center
Westchester Square Hospital
Beth Israel Hospital
New York, New York
W. W. Shaw, MD, FACS
Professor, Chief, Division of Plastic Surgery
UCLA School of Medicine
Los Angeles, California
R. W. Sheffield, MD, FACS
Cottage Hospital
Santa Barbara, California
A. Shektman, MD
Wellesley, Massachusetts
S. M. Shenaq, MD, FACS
The Methodist Hospital, Texas Medical Center
St. Luke's Episcopal Hospital, Texas Medical Center

Texas Children's Hospital, Texas Medical Center
Ben Taub General Hospital, Texas Medical Center
Veteran's Administration Hospital, Texas Medical Center
Institute for Rehabilitation and Research, Texas Medical
Center
Diagnostic Center Hospital, Texas Medical Center
Poly Ryan Memorial
Richmond, Texas
Northeast Medical Center Hospital
Humble, Texas
Professor of Surgery, Division of Plastic Surgery
Baylor College of Medicine
Houston, Texas
G. H. Shepard, MD
Riverside Regional Hospital Medical Center
Mary Immaculate Hospital
Newport News, Virginia
M. M. Sherif, MD
Associate Professor
Department of Plastic and Reconstructive Surgery
Aim Shams University
Cairo, Egypt
K. C. Shestak, MD
Division of Plastic Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Y. J. Shin, MD
Department of Plastic Surgery
College of Medicine
Chungnam National University
Jung-ku, Taejeon
South Korea
Y. Shintomi, MD
Director of Soshundo Plastic Surgery
Soshundo Plastic Surgery Hospital
Sapporo, Japan
G. F. Shubailat, MD, FRCS, FACS
Member of the Senate, Jordan Parliament
CEO and Chairman of the Board, Chief of Plastic Surgery
Amman Surgical Hospital

Amman, Jordan
M. Siemionow, MD, PhD, DSc
Professor of Surgery
Director of Plastic Surgery Research
Department of Plastic Surgery
Cleveland Clinic
Cleveland, Ohio
Özlem Karataş Silistireli, MD
Private Practice
Alsancak, Konak/Izmir
Turkey
C. E. Silver, MD
Professor of Surgery
Albert Einstein College of Medicine
Chief of Head and Neck Surgery
Montefiore Medical Center
Bronx, New York
R. P. Silverman, MD
Chief, Division of Plastic Surgery
University of Maryland Medical Center
Baltimore, Maryland
Laura Sita-Alb, MD
Department of Plastic Surgery and Reconstructive
Microsurgery
Emergency District Hospital
Cluj Napoca, Romania
F. A. Slezak, MD
Professor of Surgery
Northeastern Ohio Universities College of Medicine
Department of Surgery
Summa Health Systems
Akron, Ohio
C. J. Smith, MD
Swedish Hospital
Providence Hospital
Northwest Hospital
Seattle, Washington
E. Durham Smith, MD, FRACS

Senior Associate, University of Melbourne
Melbourne, Victoria, Australia
R. J. Smith, MD
(Deceased)
J. W. Snow, MD
St. Vincent's Hospital
Jacksonville, Florida
B. C. Sommerland, FRCS
Great Ormond St. Hospital for Children, London
St. Andrew's Hospital, Billeriay, Essex
Consultant Plastic Surgery
The Old Vicarage
Writtle
Chelmsford, United Kingdom
Erhan Sönmez, MD, PhD
Chief, Department of Hand Surgery
Department of Plastic, Reconstructive and
Aesthetic Surgery
Associate Professor of Plastic, Reconstructive and Aesthetic
Surgery
Ataturk Research and Training Hospital
Izmir, Turkey
J. T. Soper, MD
Professor, Department of Gynecological Oncology
Duke University
Division of Gynecologic Oncology
Duke University Medical Center
Durham, North Carolina
M. Soussaline, MD
Institut Gustave Roussy Villefrief
Clinique Ste. Genevieve
Plastic and Cosmetic Surgery Department
American Hospital
Paris, France
D. Soutar, MD
Clinical Director, Consultant Plastic Surgeon
Honorary Senior Lecturer, University of Glasgow
Plastic Surgery Unit
Canniesburn Hospital

Bearsden
Glasgow, Scotland, United Kingdom
Sadri Ozan Sozer, MD, MBA
Associate Professor of Plastic Surgery
Texas Tech Medical School
President
El Paso Cosmetic Surgery
El Paso, Texas
M. Spinner, MD
Cedarhurst, New York
M. Spira, MD, FACS
Chief of Plastic Surgery, St. Luke's
Episcopal Hospital
Baylor College of Medicine
Houston, Texas
R. K. Srivastava, MD
Athens Regional Medical Center
Athens, Georgia
D. A. Staffenberg, MD, FACS
Professor and Vice Chair
Department of Plastic Surgery
New York University Langone Medical Center
New York, New York
W. R. Staggers, MD
Thomas Hospital, Fairhope, Arizona
South Bladwin Hospital, Foley, Arizona
Thomas Hospital Medical Office Center
Fairhope, Arizona
R. S. Stahl, MD, MBA
Associate Chief, Department of Surgery,
Yale-New Haven Hospital
Clinical Professor of Surgery, Yale University School
of Medicine
Yale New Haven Hospital
New Haven, Connecticut
R. B. Stark, MD, FACS (Retired)
New York, New York

D. N. Steffanoff, MD (Retired)
Cathedral City, California
H.-U. Steinau, MD
Department of Plastic Surgery, Burn Center
BG-Universitätsklinik Bergmannsheil
Bochum, Germany
M. Steiner, MD
Burn and Plastic Surgery Unit
Hospital del Trabajador de Santiago
Santiago, Chile
H. R. Sterman, MD
Albert Einstein College of Medicine and
Montefiore Medical Center
Holy Name Hospital
Teaneck, New Jersey
T. R. Stevenson, MD
Professor and Chief
Division of Plastic Surgery
University of California Davis Medical Center
Sacramento, California
W. Stock, MD
Ltd. Arzt f. Plast. Chirugie
Chirurgische Klinik
München, Germany
M. F. Stranc, MD
Head of Plastic Surgery Section, Health
Sciences Center
Victoria Hospital
Manitoba Clinic
Winnipeg, Canada
W. E. Stranc, MD
Victoria Hospital
Winnipeg, Manitoba, Canada
Berish Strauch, MD, FACS
Professor and Emeritus Chairman
Department of Plastic Surgery
Albert Einstein College of Medicine
Montefiore Medical Center

New York, New York
V. V. Strelzow, MD, FACS, FRCS(C)
Irvine, California
J. H. Sullivan, MD
Clinical Professor, University of California
San Francisco, California
Yoo Joon Sur, MD, PhD
Research Fellow, Division of Plastic
Surgery
Mayo Clinic, Rochester, Minnesota
Associate Professor,
Department of Orthopedic Surgery
College of Medicine, The Catholic University
of Korea
Seoul, South Korea
I. Suzuki, MD
Associate Professor
Department of Plastic and
Reconstructive Surgery
St. Marianna University School
of Medicine
Myamae-ku, Kawasaki, Japan
W. M. Swartz, MD, FACS
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Amir H. Taghinia, MD
Department of Plastic Surgery
Children's Hospital
Boston, Massachusetts
E.-P. Tan, FRCS(Ed), FRACS
Gordon, New South Wales, Australia
Maolin Tang, MD, PhD
Professor
Director
Department of Anatomy
Wenzhou Medical University
Wenzhou University Town, People's Republic of
China

M. J. Tavis, MD, FACS
(Deceased)
G. Allan Taylor, MD, FRCS(C)
Assistant Professor of Surgery
University of Ottawa Medical School
Chief, Division of Plastic Surgery
Ottawa Civic Hospital
Ottawa, Ontario, Canada
G. I. Taylor, MD
Royal Melbourne Hospital
Melbourne, Australia
H. O.B. Taylor, MD
Plastic Surgery Resident
Harvard Plastic Surgery Program
Boston, Massachusetts
B. Teimourian, MD, FACS
Attending Surgeon, Suburban Hospital
Bethesda, Maryland
S. Terkonda, MD
Instructor, Division of Plastic Surgery
University of Alabama at Birmingham
University Hospital
Birmingham, Alabama
J. K. Terzis, MD
Sentara Hospitals
International Institute of Microsurgical Research
Eastern Virginia Medical School
Norfolk, Virginia
M. R. Thatte, MS, MCh (Plastic)
Consultant Plastic Surgeon
Mumbai Hospital Institute of Medical Sciences
Shushrusha Citizen's Co-Operative Hospital
Dadar, Mumbai, India
R. L. Thatte, MD
Consultant Plastic Surgeon, Bhatia Hospital
Mumbai, India

H. G. Thomson, MD, FACS
Toronto, Ontario, Canada
Dalia Tobbia, MB, BA, MD
Medical Fellow
Division of Reconstructive Microsurgery
Department of Plastic and Reconstructive Surgery
Chief, Center for Tissue Engineering
Chang Gung Memorial Hospital
College of Medicine, Chang Gung University
Taoyuan, Taiwan
G. R. Tobin, MD, FACS
Professor and Director, Division of Plastic Surgery
University of Louisville Hospitals
Department of Surgery
University of Louisville
Louisville, Kentucky
M. A. Tonkin, MD
Clinical Associate Professor and Head, Hand and Peripheral
Nerve Surgery, Royal North Shore Hospital of Sydney
Department of Hand Surgery
The Royal North Shore Hospital of Sydney
St. Leonards, New South Wales, Australia
B. A. Toth, MD
Pacific-Presbyterian Medical Center
Assistant Clinical Professor, University of California
San Francisco, California
H. Tramier, MD
Service d'Orthopedie-Traumatologie-Chirurgie Pediaturgie
Centre Hospitalier, Aubogne Cedex
Marseille, France
G. Trengove-Jones, MD
Sentara Norfolk General Hospital
Sentara Leigh Hospital
De Paul Hospital
Childrens Hospital of the King's Daughters
Department of Plastic Surgery
Eastern Virginia Medical School
Norfolk, Virginia
W. C. Trier, MD, FACS (Retired)

Seattle, Washington
T.-M. Tsai, MD
Jewish Hospital
Suburban Hospital
Alliant Hospitals
University Hospital
Clark County Hospital, Indiana
Shriners Hospital, Lexington, Kentucky
Audubon Hospital
Caritas Hospital
Christine M. Kleinert Institute for Hand and Micro Surgery
Louisville, Kentucky
M. Tschabitscher, MD
Department of Microsurgical and Endoscopic Anatomy
Medical University of Vienna
Vienna, Austria
John Bradley Turner, MD
Chief Resident
Division of Plastic and Reconstructive Surgery
University of Kentucky
Lexington, Kentucky
Y. Ullmann, MD
Deputy Head, Department of Plastic
and Reconstructive Surgery, Rambam Medical Center
Faculty of Medicine (Bruce)
Haifa, Israel
S. Unal, MD
Department of Plastic Surgery
The Cleveland Clinic Foundation
Cleveland, Ohio
J. Unanue, MD
Centre Hospitalier Ter de Villeneuve Sur Lot
Villeneuve Sur Lot, France
Joseph Upton, MD
Department of Plastic Surgery
Children's Hospital
Boston, Massachusetts
M. L. Urken, MD, FACS

Professor and Chairman, Department
of Otolaryngology
Mt. Sinai Medical Center
New York, New York
E. J. Van Dorpe, MD
Plastic Surgery Department
Onze Lieve Vrouw
Kortrijk, Belgium
F. Van Genechten, MD
Saint Augustinus-Saint Camillus Hospital,
Antwerp, Belgium
Virga Jesse Hospital, Masself, Belgium
Henry C. Vasconez, MD
Division Chief
William S. Farish Endowed Chair
Division of Plastic and Reconstructive Surgery
University of Kentucky
Lexington, Kentucky
Luis O. Vasconez, MD, FACS
Professor of Surgery and Vice Chairman
Department of Surgery (Emeritus)
University of Alabama-Birmingham
Birmingham, Alabama
T. R. Vecchione, MD
Associate Clinical Professor of Surgery,
Division of Plastic Surgery USSD
Senior and Past Chief of Staff, Children's Hospital
of San Diego
Senior and Past Chief of Plastic Surgery, Morcy Hospital
Senior and Past Chief of Plastic Surgery,
Sharp Memorial Hospital
San Diego, California
Professor R. Venkataswami, MS, MCh, FAMS, FRCS (EDIN), DSC (Hon)
Emeritus Professor, Dr. M.G.R. Medical University
Chennai, India
R. J. J. Versluis, MD
Department of Otorhinolaryngology and
Head and Neck Surgery
Kennemer Gasthuis Deo

Haarlem, The Netherlands
L. Vidal, MD
Department of Plastic and Reconstructive Surgery
C.H.U.-Hôpital Du Tondu
Groupe Pellegrin-Tondu
Bordeaux, France
C. Vlastou, MD
Director, Department of Plastic
and Reconstructive Surgery
Diagnostic and Therapeutic Center of Athens “HYGEIA”
Athens, Greece
V. E. Voci, MD, FACS
Presbyterian Hospital
McRoy Hospital
Voci Center Cosmetic Plastic Surgery, P.A.
Charlotte, North Carolina
Gaston Memorial Hospital
Gastonia, North Carolina
H. D. Vuyk, MD
Department of Otolaryngology, Head and Neck Surgery
Gooi-Nord Hospital
Blaricum, The Netherlands
S. C. Vyas, MD
Oakwood Hospital
Dearborn, Michigan
M. Wada, MD
Higasishinagawa Clinic
Tokyo, Japan
M. S. Wagh, MS, MCh
Lecturer in Plastic Surgery
LTMG Hospital
Mumbai, India
R. L. Walton, MD, FACS
Plastic Surgery
University of Chicago
University of Chicago Hospitals
Chicago, Illinois

A. Wangermez, MD
Centre Hospitalier D'Agen
Agen, France
P. H. Warnke, MD
Department of Oral and Maxillofacial Surgery
University of Kiel
Kiel, Germany
H. Washio, MD, FACS
Attending Staff, Plastic Surgery
St. Luke's-Roosevelt Hospital Center
New York, New York
J. T. K. Wee, MD
(Deceased)
Fu-Chan Wei, MD
Distinguished Chair and Professor
Chang Gung University, Medical College
Chang Gung Memorial Hospital
Taipei, Taiwan
A. J. Weiland, MD
The Hospital for Special Surgery
New York, New York
N. Weinzweig, MD, FACS
Associate Professor of Plastic Surgery and Orthopaedic Surgery
University of Illinois
Cook County Hospital
Associate Professor of Plastic Surgery and Orthopaedic Surgery
University of Illinois
Division of Plastic Surgery
Chicago, Illinois
A. W. Weiss Jr., MD
St. Luke's Hospital
Associate Professor of Surgery, College of Human Medicine
Michigan State University
Saginow, Michigan
M. R. Wexler, MD
Head, Department of Plastic and Aesthetic Surgery
Hand Surgery and the Burn Unit
Professor of Plastic Surgery

Hebron University
Hadassah Medical Center
Department of Plastic and Aesthetic Surgery
Hadassah University Hospital
Jerusalem, Israel
W. White, MD
(Deceased)
Jeremy Wilson, MD
Consultant Plastic Surgeon
Department of Surgical Oncology
Peter MacCallum Cancer Centre
Victoria, Australia
J. S. P. Wilson, FRCS
The Cromwell Hospital
London, United Kingdom
C. Windhofer, MD
Department of Plastic and Reconstructive Surgery
Hospital of Barmherzige Brüder
Salzburg, Austria
M. S. Wong, MD
Assistant Professor
Division of Plastic Surgery
University of California, Davis
Sacramento, California
J. E. Woods, MD, PhD, FACS
Emeritus Staff
Division of Plastic and Reconstructive Surgery
Mayo Clinic
Rochester, Minnesota
A. P. Worseg, MD
Department of Plastic and Reconstructive Surgery
Wilhelminen Hospital
Vienna, Austria
E. F. Worthen, MD (Retired)
Monroe, Louisiana
Y. Yamamoto, MD, PhD
Assistant Professor, Department of Plastic

and Reconstructive Surgery
Hokkaido University School of Medicine
Sapporo, Japan
Chong Jin Yeo, MBChB (Glasg), MRCS(Glasg), M.Med(Surg)
Consultant
Head of Hand and Microsurgery Section
Department of Orthopaedic Surgery
Tan Tock Seng Hospital
Singapore
Janet H. Yueh, MD
Department of Orthopedic Surgery
Beth Israel Deaconess Medical Center
Boston, Massachusetts
N. W. Yii, MD
Division of Plastic Surgery
Wexham Park Hospital
Slough, Berkshire, United Kingdom
M. Young, MD
Grossman Burn Center at Sherman Oaks Hospital
Sherman Oaks, California
N. J. Yousif, MD
Froedtert and Memorial Lutheran Hospital
Milwaukee, Wisconsin
P. Yugueros, MD
Mayo Medical Center
Division of Plastic and Reconstructive Surgery
Mayo Clinic
Rochester, Minnesota
L. S. Zachary, MD, FACS
Division of Plastic Surgery
University of Chicago
Chicago, Illinois
S. Zenteno Alanis, MD
Chief of Service
Department of Plastic and Reconstructive Surgery
Hospital General de Mexico
Mexico City, Mexico

F. Zhang, MD, PhD
Professor
Division of Plastic Surgery
University of Mississippi Medical Center
Jackson, Mississippi
Yixin Zhang, MD, PhD
Professor
Chief, Division of Reconstructive Microsurgery
Assistant Chief, Department of Plastic and Reconstructive
Surgery
Ninth People's Hospital
Shanghai Jiao Tong University School of Medicine
Shanghai, People's Republic of China
He-Ping Zheng, MD
Professor
Clinical Anatomic Center
Fuzhou General Hospital of PLA
Fuzhou, Fujian, People's Republic of China
Lin Zhu, MD
Research Fellow
Department of Plastic Surgery
Mayo Clinic
Rochester, Minnesota
Assistant Professor of Plastic Surgery
Peking Union Medical College Hospital
Beijing, China
E. G. Zook, MD, FACS
Memorial Medical Center and St. John's Hospital
Southern Illinois University School of Medicine
Institute for Plastic Surgery
Springfield, Illinois
R. M. Zuker, MD, FRCS(C), FACS
Head, Division of Plastic Surgery
The Hospital for Sick Children
Professor of Surgery, Department of Surgery
University of Toronto
Head, Division of Plastic Surgery
The Hospital for Sick Children
Toronto, Ontario, Canada

Dedication
To my over 150 resident trainees. You have made me a better plastic surgeon, teacher, and mentor. I hope I
have done the same for you.
Berish Strauch, MD, FACS
To my wife, Diane; my daughters, Cristina, Nessa, and Rachel; and to my grandchildren, Francesca and Elisa,
for their continued support and joy they have given me throughout the years.
Luis O. Vasconez, MD, FACS
This textbook is dedicated to the memory of my late father, Dr. Marvin J. Herman, who passed away during the
time that this book was being prepared. He was an inspiration to his family, including his invaluable personal and
professional influence on me, his friends, and the hundreds of students, dentists, and physicians whom he
trained in his 50 years as a physician, administrator, and professor.
Charles K. Herman, MD, FACS
To my sons, Brodie and Teddy: who find joy and passion in learning new things. To my wife Britt: who is clearly
out of my league yet somehow puts up with me every day. Even on May 18th last year, when I forgot our
wedding anniversary. To my parents, Ching and Emily: who continue to question and change existing paradigms.
Bernard T. Lee, MD, MBA, MPH, FACS

Preface
This fourth edition of Grabb's Encyclopedia of Flaps is exceptional in several regards. It is the 25th anniversary
edition of the textbook, which attests to the popularity and pertinence of this classic reference. In the 25 years
since the first edition was published, our encyclopedia has evolved along with the field of plastic and
reconstructive surgery itself. Evolution of the encyclopedia has mirrored the evolution of the flaps used to
reconstruct anatomical defects. As our understanding of the anatomy and physiology of flaps has matured, the
flaps described within these pages have become increasingly elegant and clinically useful.
In the third edition, we introduced perforator flaps that had begun to augment the traditional pedicle-based flaps
that had been the mainstay of reconstructive surgery. At the time of publication of this new edition, many of these
flaps have begun to replace the traditional options and change the reconstructive ladder. A more sophisticated
knowledge of perforator anatomy has led to more versatile flap designs that have the added benefit of limiting
donor site morbidity. These pages contain perforator flaps utilized in virtually all areas of the body. Perforator
anatomy has been applied to locoregional flaps, such as expanded applications of “propeller” flaps. The novel
concept of vascularized lymph node flap transfer has been introduced into this edition. New neurotized and
composite flaps have been described in many anatomic locations, including the hand.
A significant amount of time was dedicated to updating and colorizing the artwork in this volume. For the first
time, the textbook is being printed in color, which greatly enhances the impact of the drawings and clinical
photographs. Not only have the new chapters been printed with color figures, but the drawings contained in the
older chapters were also colorized and, in many cases, redrawn. We feel strongly that the improved quality of the
artwork has strengthened the visual appeal of the textbook and its clinical utility.
As the most recent seven years of plastic surgery literature was perused and 32 new chapters added, we editors
were faced with the challenge of selecting which chapters to retain in print format and which to transfer to
electronic online format only. We felt that it was important to include older but less commonly used flaps, even if
only in an online format, because one of the strengths of this textbook has always been its comprehensivity and
the historical perspective that it instills in the reader. The four editors of the encyclopedia collectively have over
100 years of clinical experience. Therefore, the editorial comments that reflect our clinical experience have been
updated and augmented and remain a unique and valuable component of the book.
We would like to thank the editorial staff at Wolters Kluwer Health, particularly Brendan Huffman, for their
assistance and dedication in preparing this new edition. We are deeply appreciative of the contributions of the
authors of the individual chapters, the majority of whom are the originators of the novel flaps contained in these
pages. As a result of the hard work put into preparing this new edition, we believe that the fourth edition carries
on the tradition of its predecessors while delivering the most current, complete, and relevant reference available
to date in the field of plastic and reconstructive surgery.
Berish Strauch, MD, FACS
Luis O. Vasconez, MD, FACS
Charles K. Herman, MD, FACS
Bernard T. Lee, MD, MBA, MPH, FACS

Preface to the Third Edition
Since our last edition of Grabb's Encyclopedia of Flaps, major evolutionary changes have occurred in the field of
reconstructive plastic surgery. The explosion of perforator flap sites and the techniques of harvesting the pedicle
without extensive sacrifice of the underlying muscles are well represented in this new edition.
In the last ten years, the field of transplantation has also been further advanced by plastic surgeons. Face and
hand allotransplantation represents some of the most exciting advances in all of medicine, and we have tried to
provide a glimpse of this emerging field with the inclusion of two articles on facial transplantation. What was once
science fiction has now become reality and may one day even become commonplace.
The changes in the reconstructive ladder are evident in all arenas. With the widespread success of
microsurgery, many defects are currently reconstructed with the most complex free tissue transfers as the
primary option, jumping straight to the top of the ladder. On the other hand, negative pressure devices have
revolutionized wound care management and, in many cases, has supplanted tissue coverage, moving many
potential defects rapidly down the ladder.
More than 12,000 citations in the literature on flaps were reviewed, and 43 new Chapters were added to this
third edition. Many of the older Chapters were revised or brought up to date. The new edition includes flaps, both
pedicle and microvascular, for reconstruction of the face, orbits, lips, and nose. The latest techniques in nasal
reconstruction, including local mucosal flaps as well as providing total reconstruction of the nasal support and
lining with microvascular forearm flaps, have been added. Use of innervated muscle for tongue reconstruction is
presented. In the hand volume, many new flaps have been added for reconstruction of the palm, the fingers, and
the metacarpals. Breast surgery articles, including the use of medial and lateral pedicles, are new to this edition.
A major inclusion has been the addition of the multiple perforator flaps used for breast reconstruction. Articles on
reconstruction of the chest and abdomen have been chosen, as have the latest techniques for lower extremity
reconstruction.
In adding all of these new choices, the editors were faced with a dilemma. How do we keep the concept of an
encyclopedic atlas, while still staying within the confines of hard copy pages and costs of printing? The decision
was made to keep all of the previous articles but to list some of the lesser used flaps by Chapter title and author
only in the printed text so that the reader is aware of these choices. In the online edition, all of the articles, new
and old, are presented with full text and illustrations. Of course, editorial opinions at the beginning of the
Chapters have been maintained to help the reader make prudent reconstructive decisions. To access these
complete aricles, go to
The third edition of this encyclopedia would not have been possible without the dedication provided by Dr. R.D.
(Lee) Landres. In addition, we would like to thank the editorial staff at Lippincott Williams & Wilkins. To all the
authors who contributed new Chapters or provided revisions of their original Chapters in a timely fashion, we
extend our thanks, as we are deeply indebted to them.
Berish Strauch, MD, FACS
Luis O. Vasconez, MD, FACS
Elizabeth J. Hall-Findlay, MD
Bernard T. Lee, MD, MBA, MPH, FACS

Preface to the Second Edition
In the last ten years, evolutionary changes in the use of flaps in reconstructive plastic surgery have resulted in
increased flap reliability, as well as in more definitive reconstruction of particular defects. Currently, there is much
less dependence on the use of flap delays and on random skin flaps. The reconstructive surgeon is now
provided with a choice not only of skin flaps, but also of composite flaps which may contain skin and muscle,
muscle alone or, in cases where bony defects are also involved, associated bone flaps. There is no longer a
requirement for empirical questions about whether or not a particular flap will have an adequate blood supply.
We presently think in terms of reliable flaps with a known blood supply and a determinate reliability. Where this is
not yet possible, the reconstructive surgeon is likely to consider a free microvascular flap.
Another important change is our independence from the so-called reconstructive ladder, according to which
surgeons followed the precept of using the simplest method and then advancing to a more complex one.
Nowadays, the objective should always be to utilize the best method first, the one that will fulfill the requirements
of the reconstruction, even though it may be the most complex, for example, a microvascular composite flap.
It was impossible for the authors to have included every flap that has been described since the first edition. In
fact, considerable care has been taken in choosing proven and reliable flaps. Over 10,000 citations in the
literature on flaps were reviewed and 120 new and revised chapters were added to the second edition. A
considerable number of chapters describing procedures that have not been proven clinically reliable have been
deleted. The editors have also added appropriate editorial comments that should be helpful to the reader
wherever these seemed indicated.
Undertaking publication of the second edition of the encyclopedia would not have been possible, had it not been
for the dedication and immense help provided by the editorial assistance of Dr. R. D. (Lee) Landres. We would
also like to thank the editorial staff at Little, Brown and Company, whose work on this second edition has been
taken over by Lippincott-Raven Publishers. Additionally, our sincere thanks to all the authors who contributed
new chapters or revision of the original chapters in a timely fashion. We are indebted to them.
B. S.
L. O. V.
E. J. H.-F.

Preface to the First Edition
An important and very broad area of plastic surgery entails the coverage of defects throughout the body. These
defects are usually covered by flaps, of which we now have a great variety. For approximately 50 years, from the
introduction of the tubed flap until the middle 1960s, most flaps were tubed. Although we realized that blood
supply was important for survival of the tubed flap, it was not until the end of the 1960s that we began to pay
attention to the distinct arterial and venous supplies of different flaps. Axial flaps, musculocutaneous flaps,
fasciocutaneous flaps, and microvascular free flaps were introduced in the decade of the 1970s. These were
rapidly used in great numbers, with clinical applications throughout the body. The concept of “delay” of flaps has
just about been abandoned. It is extremely advantageous that we now have a multitude of flaps that can be
applied for the coverage of particular defects.
A flap can be designed and made with an adequate dimension with the knowledge of its exact blood supply; one
needs only proper execution to be assured of a consistent, satisfactory, and acceptable result. This great
number and variety of the flaps that differ not only in their design, but also in their type, as far as the blood
supply is concerned, is “wonderful” for the experienced surgeon, but it also may present a quandary for the
student plastic surgeon. The young surgeon may not have the clinical experience of having performed many and
different flaps for a similar defect. There is usually no problem with execution of the procedure, but the clinical
judgment that some learn by previous clinical errors may be supported by consideration and proper description
of available options.
This Encyclopedia attempts to provide choices for the closure of particular defects throughout the body.
Recognized experts described how to execute a particular flap, and each flap is presented in a uniform format,
emphasizing the indications and anatomy, including the blood supply, surgical technique, complications, and
safeguards. Selected editorial comments are included as a guide to the reader.
The multiauthored format has been chosen to give each author, often the originator of the flap, an opportunity to
explain the procedure, and in each Chapter the editors have rewritten only to maintain the uniform format, always
attempting to keep the authors' information unchanged.
This Encyclopedia is intended to serve as a stimulus to experienced surgeons to refresh their memories about a
multitude of options for particular defects so that they may choose what, in their judgment, will give a safe,
predictable, and acceptable result. This work also will show the student of plastic surgery the numerous options
and will teach him or her to choose the most appropriate one and to consider a great many factors that can play
a role in what we call “clinical judgment.” Once the proper choice is made, this Encyclopedia will refresh
knowledge of the clinical aspects of flap execution, as well as the blood supply and the safeguards.
This Encyclopedia tends to encompass defects throughout the body and is divided into three volumes. For the
reader who wants an increased knowledge of a particular flap, selected references are included at the end of
each Chapter.
We hope that this work will be helpful to all, including the most experienced surgeons, reinforcing with certainty
that a good number of options have been considered and that the best were chosen.
Dr. William Grabb dreamed of a sequel to his book on skin flaps. He had organized and outlined the book and
had chosen an initial group of contributors. His foresight encompassed the tremendous influence that
microvascular and musculocutaneous flaps would have on the availability of usable flaps. He asked Berish
Strauch and Luis O. Vasconez to join him as associate editors, to guide the sections on microvascular and
musculocutaneous flaps, respectively. The decision to go forward with the Encyclopedia was made in 1981
during the annual meeting of the American Society of Plastic and Reconstructive Surgeons in New York.
Dr. Grabb's untimely death in 1982 halted progress on the work for over nine months. The two associate editors

P.xlii
finally decided that the concept of the Encyclopedia was too important to plastic surgery for the project not to be
completed.
Advice was sought from Lauralee Lutz in Ann Arbor. Lauralee had served as Dr. Grabb's administrative secretary
and in-house editor. Her advice resulted in bringing aboard Dr. R. D. (Lee) Landres in New York to help with the
editing of the Encyclopedia. All the contributors were contacted, and the Chapters began to be produced.
The enormity of the task soon became apparent, and Dr. Elizabeth Hall-Findlay, who had worked previously with
Drs. Strauch and Vasconez, was asked to join the two editors.
Multiauthored textbooks are often disorganized and repetitive. Faced with well over 400 Chapters written in
several languages and with various styles, we made a decision: Each Chapter was to be reorganized into a
similar format—with an introduction, a section on anatomy, and a section on flap design and dimensions,
followed by operative technique and clinical results. In general, line drawings were to be the main figures, with
some case illustrations. Details of history and research results were to be be omitted. Interested readers would
be encouraged to refer to original publications, with each Chapter followed by a relevant but not overbearing list
of references. We knew we were into at least three volumes and
did not want the work to be burdened with unnecessary detail. Despite the rewriting and uniform organization,
there was a serious attempt to keep the authors' information unchanged.
This work has already traveled extensively. It has originated from all over the world. The Chapters were initially
rough-edited and placed on computer disks by Dr. Landres. The disks were sent to Dr. Hall-Findlay in Banff,
Alberta, in the Canadian Rocky Mountains. There they were edited directly off the disks, and appropriate
illustrations and references were chosen. Most of the Chapters spent some time deep in the mountains at one of
the most beautiful sites in the world—Lake O'Hara Lodge. There, care had to be taken not to lose any of the text
or “work in progress” if the electric generator failed. Further work and refinements always seemed to take ten
times longer than expected.
Drs. Vasconez and Strauch reviewed the editorial changes as they progressed and, as well, solicited and
received new Chapters as delays became prolonged. Meetings were held in Banff, where we closeted ourselves
away with “the book,” reviewing text and illustrations and discussing editorial comments.
The editors at Little, Brown and Company in Boston have been invaluable in seeing the project to completion.
Fred Belliveau had organized and supervised the project from its inception. Curtis Vouwie helped during the
seemingly never-ending delays, and Susan Pioli has both encouraged and prodded the work to completion.
Although the delays resulted in criticisms of being out of date, we felt that many of these Chapters have stood
and will stand the test of time. We tried to keep up with the Chapters, without adopting the unproven. Of
necessity, we stopped inclusions of new Chapters in 1987. We hope that the book will not only be
comprehensive, but also useful to surgeons in reviewing options when faced with routine or unusual problems or
defects.
We can never thank everyone who has been involved in helping, directly or indirectly, with the Encyclopedia.
Drs. Strauch, Vasconez, and Hall-Findlay wish to express in common their appreciation to Dr. Lee Landres, who
has worked tirelessly for the past seven years on this work. Dr. Hall-Findlay wishes to recognize and thank
Cheryl Low and Lynn Enderwick, who helped with many endless secretarial chores while, at the same time,
handling patients and managing the office. Checking references accurately would not have been possible
without the help of Merle Duncan, librarian at the medical library of the University of Calgary. Patricia Velasquez,
Elke Berthold, Doris Freytag, Liesbeth Heynen, and Vickilynn Norton have all helped by being loving and
devoted nannies to Jamie, David, and Elise. Dr. Hall-Findlay's mother, Betty Hall, and her in-laws, Jim and Edith

Findlay, helped immeasurably with child care during their many visits to Banff, so that work on the Encyclopedia
could go on. Don Findlay cannot be thanked enough for his understanding and patience.
B. S.
L. O. V.
E. J. H.-F.

Introduction: The History of Vascularized Composite-Tissue
Transfers
R. A. CHASE
The compelling drive of human beings to reconstruct deficient or missing parts and the desire of victims to
undergo such reconstruction are best appreciated by recognizing the early development and use of pedicle-flap
transfers long before the advent of anesthesia. Imagine the tolerance a patient must have had to undergo nasal
reconstruction using a forehead pedicle flap without anesthesia. The seminal work of Sushruta (1) in the pre-
Christian era must have resulted in meager success; however, the basic principle behind the “Indian flap” is so
sound that the procedure is still used in contemporary surgery.
From those early developments, at first slowly, and then like a wild fire in the last four decades, the world has
witnessed enormous progress in tissue-transfer surgery. The latter-day developments in anesthesia, antibiotics,
hematology, instrumentation, and wound-healing research have given surgeons devoted to reconstruction the
opportunity to achieve results that would have been considered miraculous only four decades ago. When
immunologic barriers to risk-free transplantation are breached, a whole new wave of applications of existing and
developing reconstructive strategies will break upon the world.
PEDICLE TRANSFERS
It is interesting to note, at least from what can be gleaned from recorded history (2), that the first successful
transfer of human tissues to heterotopic sites was done by what we now call pedicle techniques. Such transfers
are never even transiently, deprived of blood supply. Thus, on a trial-and-error basis, it should not be a surprise
that the success of the Hindu Sushruta (1) during the pre-Christian era depended on the use of pedicle flaps of
tissue in the face and forehead.
The designation of “Indian flap” for nasal reconstruction has survived, and its use in contemporary surgery
testifies to its practicality. It appears to have taken centuries for the principle and procedure itself to travel from
its origin in India to Europe—first to the Brancas in Italy, who became known in the fifteenth century for use of the
technique and the principle to develop new and imaginative reconstructive procedures. Tagliacozzi in the
sixteenth century made use of the printing press to disseminate knowledge of the techniques abroad through his
celebrated De Curtorum Chirurgia (3) published in 1597.
Nonetheless, the procedures lay dormant for about 200 years until a newspaper, the Madras Gazette, and the
Gentleman's Magazine (4) reported the Indian method for nose reconstruction in 1794. Among others, Carpue
(5) in England and von Graefe (6) in Germany further developed the technique in Europe. Zeis, in his 1830
description of the procedure (7), displayed illustrations suggesting the dusky appearance of the flap early after
surgery. Warren was the first in the United States to publish this technique in 1837 (8). It appeared in the Boston
Medical and Surgical Journal (now the New England Journal of Medicine).
The pedicle flap principle, initiated by trial and error in pre-Christian history, was established and refined in the
nineteenth century and formed the fundamental basis for the spectacular developments in the modern decades
of surgery.
I shall mention a few landmarks in the development of tissue transfers during the nineteenth and twentieth
centuries. In 1829, Fricke of Hamburg published a book describing many alternate facial flaps (9). Shortly
thereafter, Tripier, Malgaigne (10), Burrow, Estlander, von Graefe (6), Abby, Denonvilliere, Rosenthal,
Dieffenbach, and Zeis (2)—to name the principals— added further innovations in the shift of tissues to adjacent
areas within the face for reconstruction.

P.xliv
Hamilton of Buffalo reported the first successful cross-leg flap in 1854 (12). He also was the first to apply the
principle of delay to flap transfer. In 1868, Prince published A New Classification and a Brief Exposition of
Plastic Surgery (12) with examples of applications of pedicle-flap techniques in plastic surgery. At the
Practitioner's Society of New York in 1891, Shrady used an open jump flap cut from one arm and carried after
vascularization by the contralateral index finger to fill a cheek contour defect (13). Shortly thereafter, in 1896, the
renowned William Stewart Halsted (14) first “waltzed,” by end-over-end transfer, a flap from the abdomen up to
the neck of a burn victim. He was the first to use the term waltzed.
In pedicle-transfer surgery, aside from studies of the delay phenomenon (11, 15, 16), effects of drugs and
radiation (17), and thinning of the flap (18), the refinements during this era were confined largely to the carrying
pedicle itself. In 1849, Jobert of Paris, in his two-volume textbook Chirurgie Plastique (19), described “the
temperature changes in skin flaps and the reinnervation of flaps” and noted that “the size of the pedicle should
be proportional to the size of the flap.”
The renowned Sir Harold Gillies stated, “In general, a flap should not be larger than the width of its carrying
pedicle.” In 1920, he added a rider: “A longer flap could be raised if the flap contained in its base a larger
vascular pedicle such as the superficial temporal artery” (20).
Gillies' book, Plastic Surgery of the Face (21), is a classic in the field and, together with that of John Staige
Davis, ushered in the modern era of plastic surgery. Both were based on lessons learned from current works and
publications early in the
twentieth century, such as those of Vilray Blair (22), and experiences during World War I. Gillies himself had
been stimulated and influenced by Morestin, whom he had visited in France. The war experience was very
influential on many great contributors to plastic surgery—V. H. Kazanjian, Ferris Smith, R. H. Ivy, Eastman
Sheehan, and Sterling Bunnell, to name a few.
As noted by Khoo Boo-Chai (23), John Wood in 1863 had described a flap that, in 1869 (24), he called a “groin
flap.” He commented on the importance of incorporating known vessels— in his patients, the superficial
epigastric vessels.
John Staige Davis, reporting World War I experiences, expanded the uses of pedicle flaps (2, 25) and later with
William German et al. (26) explored the vascular anatomy of the skin and subcutaneous tissues important in
designing such flaps.
John Roberts of Philadelphia pointed to lessons learned in the war and applicable to reparative surgery using
pedicle flaps on the hand (27). In 1919, Albee described the surgical construction of an osteoplastic finger
substitute using a pedicle flap and a bone graft (28). Also in 1919, at the clinic day of the American Orthopaedic
Association at Jefferson Hospital in Philadelphia, P. G. Skillern presented a patient from Polyclinic Hospital in
whom a double-pedicle “strap” flap was used for coverage of the dorsum of the right hand (29). Steinler's books
appeared in 1923 and 1925 (30, 31), at the same time Allen Kanavel's book (32) was published, and later Marc
Iselin's Atlas (33, 34) and Cutler's The Hand (35).
In 1931, Jacques Joseph, using illustrations of Manchot from 1889, justified and published illustrations of
deltopectoral flaps as vascular-pattern flaps (36, 37). The deltopectoral flap was later popularized and used
imaginatively by V. Y. Bakamjian, as described in his papers starting in 1965 (38, 39). McGregor and Jackson
showed its use in hand surgery (40).
A debate between S. H. Milton (41) and P. M. Stell (42) raged in the early seventies on the appropriate base for
random flaps. By then, the classification of flaps according to the nature of the pedicle had begun to crystallize.
McGregor and Morgan had hinted at it in 1960 (43). Ten years later, McGregor and Jackson proposed that one

could outline self-contained vascular territories (44). They referred to work by Shaw, who, together with Payne,
had described such a flap based on the superficial epigastric arterial and venous system (45). The technique
was developed for care of the wounded during World War II. Other developments in tissue transfer in hand
surgery were described in the volumes on hand surgery in World War II (see below).
General plastic surgery as a discipline made enormous strides during this war. For example, at the beginning of
the war, there were only four fully experienced plastic surgeons in Great Britain: Gillies, McIndoe, Mowlem, and
Kilner. This nucleus of surgeons and their trainees established plastic surgical centers throughout Great Britain,
and each made major contributions to the field.
In the United States, Fomon's 1939 The Surgery of Injury and Plastic Repair (46) and Barsky's Principles and
Practice of Plastic Surgery (47) appeared at the beginning of World War II. During the war, Ivy and a group of
plastic surgical luminaries wrote two manuals on plastic and maxillofacial surgery for use by military surgeons
(48). Plastic surgical centers such as the one at Valley Forge General Hospital were spawning grounds for
consolidation of reconstructive strategies. James Barrett Brown, Sheehan, McDowell, Tanzer, Littler, and
Cannon exemplify what could be an enormous list of contributors. Books by Sheehan (49), Ivy (50), Kazanjian
and Converse (51), May (52), New and Erich (53), Padgett and Stephenson (54), Pick (55), and Smith (56),
among others, were published after experiences during the war.
McGregor et al. described the anatomic basis for a flap based on the superficial circumflex iliac vessels (57), the
classic McGregor or groin flap. The groin flap has been a mainstay in reconstructive hand surgery (58, 59). The
terms random and axial were applied to flaps in McGregor and Morgan's paper in 1973 (60, 61).
Early in the twentieth century, the carrying pedicle for random or chance axial pedicle flaps was large and flat. It
was refined to a closed tube independently by the Russian Filatov in 1917 (62) and by Gillies at about the same
time (20, 63, 64). Pedicle flaps with identifiable blood vessels had become the rule wherever possible.
Sterling Bunnell's second edition of Surgery of the Hand (65) drew heavily from experiences in hand centers
during World War II. It was filled with a variety of types of pedicle flaps, as well as his additional technical
modifications of the tubed-pedicle flap technique.
William L. White put together an organized review of flap grafts (66) for a meeting that he organized and chaired
in Pittsburgh in 1959.
With waltzing, jumping, and tubing, the transfer of tissues from place to place in endless combinations (67),
including composites of skin, fascia, muscle (68), and bone, was firmly established (69).
ISLAND PEDICLE FLAP
Since the turn of this century, further refinement of the carrying pedicle had reached the point where flaps are
transferred regularly on vascular and neurovascular bundles. The principle of transfer without an intact
epithelialized skin pedicle was initiated by Robert Gersuny, of Vienna. In 1887, he published a description of the
transfer of a composite flap of soft tissue from the neck to the oral lining of the cheeks (70) carried on a very
narrow pedicle of dermis and subdermal vessels from the periosteum of the mandible. This was a one-stage
transfer of a pedicle flap without an intact skin pedicle and without specifically identifiable blood vessels.
In August of 1882, Theodore Dunham, of New York, excised a large epidermoid cancer of the cheek and eyelid.
He raised a flap from the forehead, and in his publication (71) said, “This flap was so cut as to contain traversing
its pedicle and ramifying in it, the anterior temporal artery.” Three days after the first procedure, Dunham
dissected out the vascular pedicle and buried it beneath the skin of the cheek. The skin pedicle was returned to
its donor site. This was the first recorded two-stage island pedicle flap preserving the transferred blood supply
intact.

P.xlv
However, it was Monks in 1898 who repaired the defect resulting from an excision of a lower eyelid epithelioma
and who first reported a one-stage island pedicle flap (72). He illustrated the procedure that same year in the
Boston Medical and Surgical Journal. Shelton Horsely beautifully illustrated the use of a forehead flap carried
on temporal vessels in a paper in the Journal of the American Medical Association in 1915 (73).
J. F. S. Esser, publishing in the New York Journal of Medicine in 1917 (74), pointed out that during his care of
wounded soldiers in Austria, he often used flaps from the neck directly under the jawline near the external
maxillary artery. These flaps had no skin pedicle, but a carrying arm consisting of soft tissue that contained the
external maxillary artery. Said Esser, “I called them ‘island flaps' because after being placed in the facial defect
resulting when scars are removed, they give the effect of a free transplantation.”
There was renewed interest in the island pedicle flap for a variety of uses in the sixties (75, 76, 77, 78, 79, 80).
For example, temporal arterial island flaps found a place in eyebrow reconstruction and for coverage of difficult
areas requiring a permanently transferred blood supply.
In this contemporary period of hand surgery, the biologic or island pedicle flap described earlier was first applied
to the hand. Erik Moberg (81), discussing a paper by Donal Brooks on nerve grafting (82) at the annual meeting
of the American Orthopaedic Association at Bretton Woods, New Hampshire, in 1954, suggested that
neurovascular flap techniques were useful in restoring stereognosis to the hand. He showed some exemplary
cases. Littler discussed uses of the neurovascular island 2 years later, and Tubiana et al. (79, 80), Frackelton
and Teasley (83), Holevich (84), Hueston (85), O'Brien (86), Lewin (87), Peacock (78), Winsten (88), and many,
many others (89) published ingenious applications of the versatile techniques. Littler reviewed the development
in detail during his Monk's Lecture delivered in Boston in 1982 (90).
The versatile island flap (91) could be used as part of a carrier for a nerve transfer to innervate an intact but
anesthetic digit tip. It could be used to bring cover and blood supply to a badly damaged devascularized finger. It
was useful in transferring composite parts of useless digits to restore others, including whole joints. Many hand
surgeons have pointed to its efficacy in the restoration of protective and useful sensibility and blood supply in
osteoplastic thumb reconstruction (92, 93, 94, 95, 96, 97, 98, 99, 100).
MUSCLE AND MUSCULOCUTANEOUS FLAPS
The first published, planned muscle flap was that of Louis Ombredanne of Paris in 1906 (101). He described a
pectoralis minor flap for breast reconstruction, turning down the humeral insertion of the pectoralis minor to
recreate a breast mound following mastectomy.
Tanzini introduced a latissimus dorsi muscle flap for breast reconstruction in 1906 (102). The first true
musculocutaneous flap was that described in detail in 1912 by Professor Stefano d'Este and published in a
monumental paper on chest-wall reconstruction after mastectomy (103). He used the latissimus dorsi and
showed the anatomy of both a musculocutaneous flap and an axial flap of skin alone from the same area.
Illustrated examples were shown.
The roots, then, were well set at the beginning of the century for refinement of the principles of the modern
muscular and musculocutaneous flaps that have become so popular and important in the current era. The
interest in muscle and musculocutaneous flaps was renewed when Neal Owens in 1955 suggested the use of a
compound neck pedicle composed of the sternocleidomastoid muscle overlying platysma, subcutaneous tissue,
and skin in the reconstruction of major facial defects (104).
Ralph Ger, of Capetown, showed the virtue of muscle transfer for coverage of difficult areas in the distal lower
limb in a seminal paper in 1966 (105). Shortly thereafter, Miguel Orticochea, of Bogota, Columbia, described the
musculocutaneous flap method (106). He presented the technique, using a gracilis musculocutaneous flap as a

cross-leg flap with success.
Typically, the empirical but logical use of muscle alone (107) and muscle with overlying skin led to possible
application of that principle throughout the body (108, 109, 110, 111, 112, 113). For example, after sporadic
reports of muscle flaps and musculocutaneous flaps, McCraw and Dibbell outlined possible independent
myocutaneous flaps (114); then, fasciocutaneous flaps (115, 116) were launched (117, 118, 119). Muscles with
nutrient vessels are usable as pedicles to carry substantial skin and soft tissue. As an example, the rectus
abdominis muscle with its superior epigastric vascular leash may be used to carry a large transverse segment of
soft tissue (120), that is axial on its ipsilateral and random on its contralateral side, from the lower abdomen to
the breast area.
Credit goes to Elliott and Hartrampf for championing this remarkable transfer of tissue (121). Muscle and
musculocutaneous flaps have found multiple uses in upper limb surgery, and even intrinsic muscles are useful as
muscle or musculocutaneous carriers (122). Hentz et al. (123) showed the use of the abductor digiti minimi as a
musculocutaneous flap within the hand.
FREE COMPOSITE-TISSUE TRANSFER WITH IMMEDIATE
REVASCULARIZATION
Once the pedicle for transfer was refined to require only blood vessels with or without sensory nerves, the only
remaining deterrent to unlimited anatomic transfer of composite tissues was the length of vascular tether. It
followed predictably that the next advance would be an assault on that deterrent. The answer would come from
refinements of techniques described by Carrell at the turn of the century (124, 125), made possible by the advent
of the operating microscope.
Stimulated by the possibilities offered by microsurgery reported by Jacobson and Suarez from Burlington,
Vermont (126), Buncke and Schultz (127) worked tirelessly with methods to improve sutures and instruments.
Their influence on Berish Strauch, Avron Daniller, Donald Murray, and others in our Stanford laboratories
resulted in rat renal transplant developments and rat limb replants.
Clinically, Komatsu and Tamai's thumb replantation in 1968 (128) ushered in the new era of digit replantation
(129, 130, 131, 132). Buncke et al. reported their one-stage Nicoladoni thumb reconstruction, transferring a big
toe to the thumb position in monkeys (133), and Cobbett soon thereafter reported a successful clinical case of
such a free digital toe-to-hand transfer (134). The procedure is now well established in hand surgery (135, 136,
137).
Berish Strauch and Donald Murray (138), stimulated by the work of Harry Buncke, worked out and reported the
transfer of groin skin flaps to the neck in rats.
With that background, and with knowledge of Goldwyn, Lamb, and White's experiments (139) and the
vascularized island experiments of Krizek et al. (140), Kaplan, Buncke, and Murray attempted and reported a free
flap from the groin to an intraoral site in 1971 (141). The flap survived for 21ú2 weeks, but it failed to heal to the
poorly vascularized recipient bed. Rollin Daniel, after hearing the paper reporting the case, was stimulated to
persevere. When the opportunity arose, he and Ian Taylor tried again and reported the first successful free-flap
transfer in 1971 (142).
There followed a rash of reports of free groin flap transfers in hand surgery (143, 144, 145, 146, 147, 148, 149).
The clear advantages of such free flaps are that they supply skin and soft-tissue cover with permanent arterial
blood supply and sometimes sensibility in a single stage. Subsequent tendon grafts then may restore extension
function. The flap may be a composite of skin and soft tissue with tendons to eliminate the need for later tendon
grafting, or it may carry bone as well (150). Morrison et al. have introduced us to the wraparound free composite
flap in thumb reconstruction (151)—a modification that Lister, Steichen, and others have

P.xlvi
used to restore a thumb tip and nail. Free microvascular transfers apply to any part or composite of parts whose
viability may be maintained by isolated vessels (152, 153, 154).
FREE FUNCTIONAL MUSCLE AND MUSCULOCUTANEOUS FLAPS WITH
IMMEDIATE REVASCULARIZATION
The first reported attempts to free transfer skeletal muscle were those of Noel Thompson (155), who startled
those attending the Fifth International Congress of Plastic and Reconstructive Surgery in Melbourne in 1971 by
showing a technique of free transfer of the palmeris longus or intrinsic foot muscles (the extensor digitorum
brevis) to the face (156) without surgical revascularization. After transfer, the patients regained function through
muscular neurotization. In 1975, Gerhard Freilinger, of Vienna, did similar free muscle grafts (157), innervating
them with nerve grafts from the contralateral facial nerve.
Meanwhile, Tamai and colleagues had been experimenting with free muscle transfers with microvascular and
microneural anatomoses in dog rectus femoris muscles (158). They showed survival of the transferred muscles
with an interval of denervation atrophy followed by recovery of innervation at about 3 months. They suggested
the use of such transfers in humans.
Harii et al. reported free gracilis muscle transfers to the face using microvascular and microneural
revascularization and innervation techniques with success (159). They suggested that the principle of free
revascularized and reinnervated muscle transfers “would find broad use in recontructive surgery.”
Ralph Manktelow, of Canada, having seen some examples of free vascularized muscle transfers at the Sixth
People's Hospital in Shanghai and having carried out some animal experiments in his laboratory, started to build
a series of free, revascularized, and reinnervated muscle transfers in the upper limb of selected patients. In 1978,
at the annual meeting of the American Society for Surgery of the Hand, Manktelow and McKee reported their
experience with free musculocutaneous transfers, using a gracilis muscle in one patient and a pectoralis muscle
in another, transferred to restore finger flexion (160). The feasibility and growing reliability of these free muscle
and musculocutaneous transfers (161, 162, 163), as prophetically stated by Harii et al. (159), obviously will have
a “wide range of applications in reconstructive surgery.”
It has taken the perseverance and faith of a Harry Buncke (164), the energetic aggressiveness of a Bernie
O'Brien (165), the patience and technical expertise of Tamai and Harii (166), the organization of the Kleinert
(167), Kutz (168), and Lister groups, and the ever-growing list of young microsurgeons (169) to take the early
work of Jacobson and Suarez and to place it firmly in the armamentarium of reconstructive surgeons. These
pioneers found their greatest pleasure in doing what people said could not be done (170).
Work with venous flaps and arteriovenous flaps is moving from the laboratory to clinical application, one more
step toward broadening the armamentarium of the reconstructive surgeon.
There appear to be inexhaustible imaginations among surgeons developing new and innovative flaps for use in
every part of the body. Progressive liberation from the large carrying pedicle to the refined vascularized and
innervated island flaps to vascularized free flaps has opened the way for near-infinite variations in flap design.
New additions to these volumes cover the broad spectrum of composite-tissue transfers in reconstructive
surgery. The elders in the field look with a mixture of amazement and envy at surgeons active in the development
of new strategies to deal with old problems. In facial, neck, intraoral, esophageal, breast, upper and lower limb,
abdominal-wall, genital, and anal reconstruction, there have been new reconstructive techniques added to those
in the first edition of this encyclopedia.
The advent of anesthesia opened the way for a flood of new operative procedures in the second half of the 19th
century. The evolution of microsurgery in this century has been responsible for the current plethora of new

techniques. It is my firm belief that the next wave of innovations will emerge as a result of progress in the related
field of transplantation. Solutions for the residual immunologic problems in transplantation will prepare the way
for a torrent of procedures based on knowledge of techniques developed by surgeons devoted to the field of
composite-tissue transfer.
Meanwhile, exhaustive studies of gross and microscopic vascular anatomy, exemplified by Taylor's mapping of
neurovascular territories (171), coupled with anatomic studies to clarify the spectacular advances in imaging,
feed into the growing armamentarium available to today's reconstructive surgeons.
References
1. Wallace AF. History of plastic surgery. J R Soc Med 1978;71:834.
2. Zies E. The Zeiss index and history of plastic surgery, 900 B.C. to 1863 A.D., Vol. 1. Baltimore: Williams &
Wilkins, 1977.
3. Tagliacozzi G. De curtorum chirurgia per institione, Vol. 2. Venice: 1597.
4. Gentleman's Magazine. London, October 1974;891.
5. Carpue JC. An account of two successful operations for restoring a lost nose from the integuments of the
forehead. London: 1816.
6. von Graefe CF. Rhinoplastik. Berlin: 1818.
7. Zeis E. Handbuch der Plastischen Chirurgie. Berlin: 1818.
8. Warren JM. Boston Med Surg J 1837.
9. Fricke JCG. Die Bildung neuer Augenlider (Blepharoplastik) nach Zerstorungen und dadurch hervorge-
brachten Auswartswendungen derselben. Hamburg: 1829.
10. Malgaigne JF. Manuel de médecine operatoire. Brusells: 1834.
11. Hamilton FH. Elkoplasty: on ulcers treated by anaplasty. NY J Med 1854.
12. Prince D. Plastics: a new classification and a brief exposition of plastic surgery. Philadelphia: Lindsay
and Blakiston, 1868.
13. Shrady G. The finger as a medium for transplanting skin flaps. Med Rec 1891.
14. Halsted W. Plastic operation for extensive burn of neck. Johns Hopkins Hosp Bull 1896.
15. Blair VP. The delayed transfer of long pedical flaps in plastic surgery. Surg Gynecol Obstet 1921;3:261.
16. Hoffmeister FS. Studies on timing of tissue transfer in reconstructive surgery. Plast Reconstr Surg

P.xlvii
1957;19:283.
17. Patterson TIS, Berry RJ, Wiernik G. The effect of x-radiation on the survival of skin flaps in the pig. Br J
Plast Surg 1972;25:17.
18. Colson P, Houot R, Gangolphe M, et al. Utilisation des lambeaux degraisses (lambeaux-greffes) en
chirurgie reparatrice de la main. Ann Chir Plast 1967;12:298.
19. Jobert AJ. (de Lamballe). Traité de chirurgie plastique. Paris: Bailliere, 1849.
20. Gillies HD. Present-day plastic operation of the face. J Natl Dent Assoc 1920;1:3.
21. Gillies HD. Plastic surgery of the face. London: Frowde, 1920.
22. Blair VP. Surgery and diseases of the mouth and jaws. St. Louis: Mosby, 1912.
23. Boo-Chai K. John Wood and his contributions to plastic surgery: the first groin flap. Br J Plast Surg
1977;30:9.
24. Wood J. Fission and extroversion of the bladder with epispadias with the results of 8 cases treated by
plastic operations. Med Chir Trans 1869;2:85.
25. Davis JS. The use of the pedunculated flap in reconstructive surgery. Ann Surg 1918;68:221.
26. Germany W, Finesilver EM, Davis JS. Establishment of circulation in tubed skin flaps. Arch Surg
1933;26:27.
27. Roberts JB. Salvage of the hand by timely reparative surgery. Ann Surg 1919;70:627.
28. Albee FH. Synthetic transplantation of tissues to form a new finger. Ann Surg 1919;69:379.
29. Skillern PG Jr. A surgical clinic at Polyclinic Hospital. Int Clin 1919;3:75.
30. Steindler A. Reconstructive surgery of the upper extremity. New York: Appleton, 1923.
31. Steindler A. A textbook of operative orthopedics. New York: Appleton, 1925.
32. Kanavel AB. Infections of the hand, 5th ed. Philadelphia: Lea & Febiger, 1925.
33. Iselin M. Chirurgie de la main: plaies, infections, chirurgie reparatrice. Paris: Masson, 1933.
34. Iselin M. Surgery of the hand, wounds, infections and closed tramata. Philadelphia: Blakiston, 1940.

35. Cutler CW Jr. The hand: its disabilities and diseases. Philadelphia: Saunders, 1942.
36. Gibson T, Robinson DW. The mammary artery pectoral flaps of Jacques Joseph. Br J Plast Surg
1976;29:370.
37. Joseph J. Nasenplastik und sonstige Gesichtsplastik nebst einem Anhang ueber Mammaplastik und
einige weitere Operationem aus dem Gebiete der ausseren Korper Plastik. Leipzig: Verlag von Curt
Kapitzsch, 1931.
38. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Sutg 1965;36:173.
39. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive
surgery of the head and neck. Br J Plast Surg 1971;24:174.
40. McGregor IA, Jackson IT. The extended role of the deltopectoral flap. Br J Plast Surg 1970;23:173.
41. Milton SH. Pedicled skin flaps: the fallacy of the length-width ratio. Br J Surg 1970;57:502.
42. Stell PM. The viability of skin flaps. Ann R Coll Surg Engl 1977;59:236.
43. McGregor I. Flap reconstruction in hand surgery: the evolution of presently used methods. J Hand Surg
1979;4B:1.
44. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
45. Shaw DT, Payne RL. One-stage tubed abdominal flaps: single-pedicle tubes. Surg Gynecol Obstet
1946;83:205.
46. Fomon S. The surgery of injury and plastic repair. Baltimore: Williams & Wilkins, 1939.
47. Barsky AI. Principles and practice of plastic surgery. Philadelphia: Saunders, 1938.
48. Ivy RH. Manual of standard practice of plastic and maxillofacial surgery. Philadelphia: Saunders. 1942.
49. Sheehan JE. General and plastic surgery with emphasis on war injuries. New York: Hoeber and Harper,
1945.
50. Ivy RH, Curtis L. Fractures of the jaws. Philadelphia: Lea & Febiger, 1945.
51. Kazanjian VH, Converse JM. The surgical treatment of facial injuries. Baltimore: Williams & Wilkins,
1949.
52. May H. Reconstructive and reparative surgery. Philadelphia: Davis, 1947, 1958.

53. New GB, Erich JB. The use of pedicle flaps of skin in plastic surgery of the head and neck. Springfield,
Ill.: Charles C. Thomas, 1950.
54. Padgett EC, Stephenson KL. Plastic and reconstructive surgery. Springfield, Ill.: Charles C. Thomas,
1948.
55. Pick JF. Surgery of repair: principles, problems, procedures, Vols. 1 and 2. Philadelphia: Lippincott,
1949.
56. Smith F. Plastic and reconstructive surgery. Philadelphia: Saunders, 1950.
57. Smith PJ, Foley B, McGregor IA, et al. The anatomical basis of the groin flap. Plast Reconstr Surg
1972;49:41.
58. Heath PM, Jackson IT, Cooney WP, et al. Simultaneous bilateral staged groin flaps for coverage of
mutilating injuries of the hand. Ann Plast Surg 1983;11:462.
59. Lister GD, McGregor IA, Jackson IT. The groin flap in hand injuries. Injury 1973;4:229.
60. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg 1973;26:202.
61. Smith PJ. The vascular basis of axial pattern flaps. Br J Plast Surg 1973;26:150.
62. Filatov VP. Plastic procedure using a round pedicle. Surg Clin North Am 1959;39:277.
63. Gillies HD. The tubed pedicle in plastic surgery. NY Med J 1920;11:1.
64. Webster JP. The early history of the tubed pedicle flap. Surg Clin North Am 1959;39:261.
65. Bunnell S. Surgery of the hand, 2d ed. Philadelphia: Lippincott, 1948.
66. White WL. Flap grafts to the upper extremity. Surg Clin North Am 1960;40:389.
67. Holevich J. Our technique of pedicle skin flaps and its use in the surgery of the hand and fingers. Acta
Chir Plast 1960;24:271.
68. Hokin JAB. Mastectomy reconstruction without a prosthetic implant. Plast Reconstr Surg 1983;72:810.
69. Gilles H. Autograft of amputated digit. Lancet 1940;1:1002.
70. Gersuny R. Plastischer Ersatz der Wangenschleimhaut. Zentralbl Chir 1887;14:706.
71. Dunham T. A method for obtaining a skin flap from the scalp and a permanent buried vascular pedicle for
covering defects of the face. Ann Surg 1893;17:677.

72. Monks GH. The restoration of a lower eyelid by a new method. Boston Med Surg J 1898;139:385.
73. Horsley JS. Transplantation of the anterior temporal artery. JAMA 1915;64:408.
74. Esser JFS. Island flaps. NY Med J 1917;106:264.
75. Chase RA. Expanded clinical and research uses of composite tissue transfers on isolated vascular
pedicles. Am J Surg 1967;114:222.
76. Kuei SJ, Chen EC, Li SY. The use of temporal artery pedicle skin flaps in the repair of facial burns and
other deformities. Chin Med J 1964;83:65.
77. Murray JF, Ord JVR, Gavelin GE. The neurovascular island pedicle flap: an assessment of late results in
sixteen cases. J Bone Joint Surg 1967;49A:1285.
78. Peacock EE. Reconstruction of the hand by the local transfer of composite-tissue island flaps. Plast
Reconstr Surg 1960;25:298.
79. Tubiana R, DuParc J. Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone
Joint Surg 1961;43B:474.
80. Tubiana R, DuParc J, Moreau C. Restauration de la sensibilité au niveau de la main par transfert d'un
transplant cutané heterodigital muni de son pedicule vasculo-nerveux. Rev Chir Orthop 1960;46:163.
81. Moberg E. Nerve-grafting in orthopedic surgery. J Bone Joint Surg 1955;37A:305.
82. Brooks DM, Seddon HJ. Pectoral transplantation for paralysis of the flexors of the elbow. J Bone Joint
Surg 1959;41B:36.
83. Frackelton WH, Teasley JL. Neurovascular island pedicle: extension in usage. J Bone Joint Surg
1962;44A:1069.
84. Holevich J. A new method of restoring sensibility to the thumb. J Bone Joint Surg 1973;45B:496.
85. Hueston J. The extended neurovascular island flap. Br J Plast Surg 1965;18:304.
86. O'Brien B. Neurovascular pedicle transfers in the hand. Aust NZ J Surg 1965;35:1.
87. Lewin ML. Sensory island flap in osteoplastic reconstruction of the thumb. Am J Surg 1965;109:226.
88. Winsten J. Island pedicle to restore stereognosis in hand injuries. N Engl J Med 1963;268:124.
89. Rose EH. Local arterialized island flap coverage of difficult hand defects preserving donor digit

sensibility. Plast Reconstr Surg 1983;72:848.
90. Littler JW, George H. Monks lecture: man's thumb, nature's special endowment. Harvard Medical School,
October 2, 1982.
91. Chase RA. Atlas of hand surgery, Vol. 1. Philadelphia: Saunders, 1973.
92. Chase RA. An alternate to pollicization in subtotal thumb reconstruction. Plast Reconstr Surg
1969;44:412.
93. Dykes ER. Reconstruction of the thumb. Hawaii Med J 1967;27:33.
94. Floyd WE. Reconstruction of the thumb. J Med Assoc Ga 1968;57:425.
95. Greeley PW. Reconstruction of the thumb. Ann Surg 1946;124:60.
96. McGregor IA, Simonetta C. Reconstruction of the thumb by composite bone-skin flap. Br J Plast Surg
1964;17:37.
97. Reid DAC. The neurovascular island flap in thumb reconstruction. Br J Plast Surg 1966;19:234.
98. Suzuki T, Takahashi T, Chang S, et al. Reconstruction of the thumb. Jpn Med J 1967;41:1013.
99. Woudstra ST. Reconstruction of the thumb. Arch Chir Med 1967;19:29.
100. Murray JF, Ord JVR, Gavelin GE. The neurovascular island pedicle flap: an assessment of late results
in sixteen cases. J Bone Joint Surg 1967; 49A:1285.
101. Teimourian B, Adham MN. Louis Ombredanne and the origin of muscle flap use for immediate breast
mound reconstruction. Plast Reconstr Surg 1983;72:905.
102. Tanzini. Sporo il nito nuova processo di aupertozione della menuelle. Riforma Med 1906;22:757.
103. d'Este S. La technique de l'amputation de la mamelle pour carcinome mammaire. Rev Chir 1912;45:164.
104. Owens N. A compound neck pedicle designed for the repair of massive facial defects: formation,
development and application. Plast Reconstr Surg 1955;15:369.
105. Ger R. The operative treatment of the advanced stasis ulcer. Am J Surg 1966;111:659.
106. Orticochea M. The musculocutaneous flap method: an immediate and heroic substitute for the method
of delay. Br J Plast Surg 1972;25:106.
107. Minami RT, Hentz VR, Vistnes LM. Use of vastus lateralis muscle flap for repair of trochanteric pressure
sores. Plast Reconstr Surg 1977;60:364.

P.xlviii
108. Carroll RE, Kleinman WB. Pectoralis major transplantation to restore elbow flexion to the paralytic limb.
J Hand Surg 1979;4A:501.
109. Chase RA, Nage DA. Cosmetic incisions and skin, bone, and composite grafts to restore function of the
hand. In: American academy of orthopaedic surgeons instructional course lectures. Chap. 6. St. Louis:
Mosby, 1974.
110. Hovnanian AP. Latissimus dorsi transplantation for loss of flexion or extension of the elbow. Ann Surg
1956;143:493.
111. Jackson IT, Pellett C, Smith, JM. The skull as a bone graft donor site. Ann Plast Surg 1983;11:527.
112. Stern PJ, Neale HW, Gregory RO, et al. Latissimus dorsi musculocutaneous flap for elbow flexion. J
Hand Surg 1982;7:25.
113. Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow flexion. J Bone Joint Surg 1973;55A:1265.
114. McCraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories.
Plast Reconstr Surg 1977;60:212.
115. Barclay TL, Sharpe DT, Chisholm EM. Cross-leg fasciocutaneous flaps. Plast Reconstr Surg
1983;72:843.
116. Fonseca JLS. Use of pericranial flap in scalp wounds with exposed bone. Plast Reconstr Surg
1983;72:786.
117. Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown, 1975.
118. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
119. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
120. Bunkis J, Walton RL, Mathes SJ, et al. Experience with the transverse lower rectus abdominis operation
for breast reconstruction. Plast Reconstr Surg 1983;72:819.
121. Elliott LF, Hartrampf CR. Tailoring of the new breast using the transverse abdominal island flap. Plast
Reconstr Surg 1983;72:887.
122. Reisman NR, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for palmar wrist
pain. Plast Reconstr Surg 1983;72:859.

123. Chase RA, Hentz VR, Apfelberg D. A dynamic myocutaneous flap for hand reconstruction. J Hand Surg
1980;5A:594.
124. Carrel A. La technique operatoire des anastomoses vasculaires et la transplantation des viscere. Lyon
Med 1920;98:859.
125. Carrel A. Results of the transplantation of blood vessels, organs and limbs. JAMA 1908;51:1662.
126. Jacobson JH, Suarez EL. Microsurgery in the anastomosis of small vessels. Surg Forum 1960;11:243.
127. Buncke HJ, Schulz WP. Total ear reimplantation in the rabbit utilizing microminiature vascular
anastomoses. Br J Plast Surg 1966;19:15.
128. Komatsu S, Tamai S. Successful replantation of a completely cut-off thumb. Plast Reconstr Surg
1968;42:374.
129. Chen ZW, Meyer VE, Kleinert HE, et al. Present indications for replantation as reflected by long-term
functional results. Orthop Clin North Am 1981;12:849.
130. Gelberman RH, Urbaniak JR, Bright DS, et al. Digital sensibility following replantation. J Hand Surg
1978;3A:313.
131. Weiland AJ, Daniel RK, Riley LH. Application of the free vascularized bone graft in the treatment of
malignant or aggressive bone tumor. Johns Hopkins Med J 1977;140:85.
132. Vilkki S. Replantation studies on clinical replantation surgery with reference to patient selection,
operative techniques and postoperative control. Acta Univ Tamperensis (A) 1983;156.
133. Buncke HJ, Buncke CM, Schulz WP. Immediate Nicoladoni procedures in the rhesus monkey, or hallux-
to-hand transplantation, utilising microminiature vascular anastomoses. Br J Plast Surg 1966;19:332.
134. Cobbett JR. Free digital transfer: report of a case of transfer of a great toe to replace an amputated
thumb. J Bone Joint Surg 1969;51B:677.
135. Buncke HJ, McLean DH, Geroge PT, et al. Thumb replacement: great toe transplantation by
microvascular anastomosis. Br J Plast Surg 1973;26:194.
136. O'Brien BM, MacLeod AM, Sykes PJ, et al. Microvascular second toe transfer for digital reconstruction.
J Hand Surg 1978;3A:123.
137. Ohtsuka H, Torigai K, Shioya N. Two toe-to-finger transplants in one hand. Plast Reconstr Surg
1977;60:51.
138. Strauch B, Murray DE. Transfer of composite graft with immediate suture anastomosis of its vascular

pedicle measuring less than 1 mm in external diameter using microsurgical techniques. Plast Reconstr Surg
1967; 40:325.
139. Goldwyn RM, Lamb DL, White WL. An experimental study of large island flaps in dogs. Plast Reconstr
Surg 1963;31:528.
140. Krizek TJ, Tani R, Desprez JD, et al. Experimental transplantation of composite grafts by microsurgical
vascular techniques. Plast Reconstr Surg 1965;36:538.
141. Kaplan EN, Buncke HJ, Murray DE. Distant transfer of cutaneous island flaps in humans by
microvascular anastomoses. Plast Reconstr Surg 1973; 52:301.
142. Taylor GI, Daniel RK. The free flap: composite tissue transfer by vascular anastomosis. Aust NZJ Surg
1973;43:1.
143. Ohmori K, Harii K, Sekiguchi J, et al. The youngest free groin flap yet? Br J Plast Surg 1977;30:273.
144. Daniel RK, Terzis JK. Reconstructive microsurgery. Boston: Little, Brown, 1977.
145. Daniel RK, Weiland AJ. Free tissue transfers from upper extremity reconstruction. J Hand Surg
1982;7A:66.
146. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: experimental work. Plast Reconstr Surg 1979;64:595.
147. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: clinical work. Plast Reconstr Surg 1979;64:45.
148. Baudet J, LeMaire JM, Guimberteau JC. Ten free groin flaps. Plast Reconstr Surg 1976;57:577.
149. Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free
flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141.
150. Swartz WM. Immediate reconstruction of the wrist and dorsum of the hand with a free osteocutaneous
groin flap. J Hand Surg 1984;9A:18.
151. Morrison WA, O'Brien BM, MacLeod, AM. Thumb reconstruction with a free neurovascular wrap-around
flap from the big toe. J Hand Surg 1980;5A:575.
152. Van Genechten F, Townsend PLG. Free composite-tissue transfer in a compound hand injury. Hand
1983;15:325.
153. Taylor GI, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical technique. Plast
Reconstr Surg 1983;72:751.

154. Fisher J, Cooney WP. Designing the latissimus dorsi free flap for knee coverage. Ann Plast Surg
1983;11:554.
155. Thompson N. Treatment of facial paralysis by free skeletal muscle grafts. In: Transactions of the fifth
international congress of plastic and reconstructive surgery. Melbourne: Butterworth, 1971.
156. Smith JW. A new technique of facial animation. In: Transactions of the fifth international congress of
plastic and reconstructive surgery. Melbourne: Butterworth, 1971.
157. Freilinger G. A new technique to correct facial paralysis. Plast Reconstr Surg 1975;56:44.
158. Tamai S, Komatsu S, Sakamoto H, et al. Free muscle transplants in dogs with microsurgical
neurovascular anastomoses. Plast Reconstr Surg 1970; 46:219.
159. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation with microvascular anastomoses for the
treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
160. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg
1978;3A:416.
161. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe
Volkmann's contracture. Plast Reconstr Surg 1976; 58:407.
162. Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg
1984;9A:32.
163. Terzis JK, Dykos RW, Williams HB. Recovery of function in free muscle transplants using
microneurovascular anastomoses. J Hand Surg 1978; 3A:37.
164. Bunke HJ. Cobbett JR, Smith JW, et al. Techniques of microsurgery. Sommerville, NJ: Ethicon, 1969.
165. O'Brien BM, Miller GDH. Digital reattachment and revascularization. J Bone Joint Surg 1973;55A:714.
166. Tamai S, Hori Y, Tatsumi Y, et al. Hallux-to-thumb transfer with microsurgical technique: a case report
in a 45-year-old woman. J Hand Surg 1977; 2A:152.
167. Kleinert HE, Kasdan ML, Romero JL. Small blood vessel anastomosis for salvage of severely injured
upper extremity. J Bone Joint Surg 1963; 45A:788.
168. Kutz JE, Dimond M. Replantation in the upper extremity. Surg Rounds 1982;14:9.
169. Strauch B. Microsurgical approach to thumb reconstruction. Orthop Clin North Am 1977;8:319.
170. Ikuta Y. Free flap transfer: historical review, surgical procedures and some clinical cases. Hiroshima J
Med Sci 1976;25:29.

171. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories of the skin and muscles: anatomic
study and clinical implications. Plast Reconstr Surg 1994;94:1.

Chapter 1
Scalp Flaps and The Rotation Forehead Flap
E. F. WORTHEN
EDITORIAL COMMENT
Skin expanders are currently quite popular and effective in correcting scalp defects. The principles of flap
transfer, as demonstrated in this chapter, are also applicable to expanded skin.
The table of contents for this text reveals a dizzying array of skin flap titles. Names ascribed to flaps over the
years have resulted in a confusing adulteration as each designer seeks to single out a particular flap from all the
rest. In this preliminary chapter, an attempt is made to define the true distinctions in the nomenclature of skin
flaps.
“A flap is a flap is a flap,” as one might well paraphrase Gertrude Stein. All skin flaps share the common feature
of a transferable segment of skin with a pedicle of continuing blood supply. Flaps may be local or distant
(depending on the proximity of the donor site to the defect), random or axial (a distinct vascular stem is
identifiable in the axial as opposed to an anastomosing dermal network in the random), peninsular or island (the
skin bridge is preserved over the pedicle in the peninsular). Anatomic location may identify a flap [groin,
scapular, transverse rectus abdominus myocutaneous (TRAM), and so on]. Imaginative and picturesque names
have been used to describe the shape of flaps like clouds in the sky (e.g., banana peel, seagull, pinwheel). Flaps
may be designated by ethnic origin (Indian flap); others, perhaps with a thought toward posterity, bear the name
of the designer.
Scalp flaps, whenever possible, should be local flaps because of the singularity of the hair-bearing surface.
Massive defects may require the use of distant skin, but a compromised aesthetic result is inevitable. For this
reason, the remainder of this chapter is confined to consideration of local flaps (Fig. 1.1). While axial and island
flaps may be used for specialized needs, only basic peninsular flaps are discussed.
FIGURE 1.1 Types of local scalp flaps.
INDICATIONS
The choice between use of a transposition flap or a rotation flap is most often influenced by the size and
nature of the defect. When the defect is large enough, a simple transposition flap ensures the greatest
margin of safety because of direct, straight-line flow of the blood supply. A skin graft will be needed to close
the flap donor site. When the defect is small and closure of the secondary wound by primary suture is
possible, the rotation flap facilitates the adjustment of tension and uneven wound margins.

P.3
ANATOMY
A peninsular scalp flap is a segment of cutaneous cover composed of a full thickness of epidermis and dermis
with an independent territory of vascularity consisting of a subdermal plexus with afferent arterial supply and
efferent venous drainage. The scalp is a unique and specialized integument in which hair shafts penetrate a
thick dermis into a highly vascular subcutaneous layer densely bound to a base of flat, rigid aponeurosis. This
base, the galea aponeurotica, is the tendinous apparatus through
which the frontalis and occipitalis muscles activate the scalp. This motion is a gliding action of the galea over the
underlying pericranium allowed by a gossamer webbing of loose areolar strands in the subaponeurotic layer.
This latter plane is essentially avascular, rendering the scalp independent of the pericranium beneath it and
thereby facilitating flap transfer.
FIGURE 1.2 Pattern of blood supply of the scalp with points of penetration from the deeper tissues located at the
lower end of each vessel. These vessels from anterior to posterior are supratrochlear, supraorbital, superficial
temporal, posterior auricular, and occipital.
The arteries of the scalp and their accompanying veins originate peripherally and ascend to the dome in bilateral
fashion (1) (Fig. 1.2); thus, it is preferable to base scalp flaps peripherally. In the younger patient, there is
widespread anastomosis of the end vessels at the vertex, which provides greater latitude of safety in flap design,
even permitting retrograde flaps based on this rich vascularity at the vertex. This latter advantage is not enjoyed
by the older patient in whom arteriosclerosis diminishes these end vessels. One may surmount even this
obstacle by including a large artery in the base of the flap together with delay of the flap. This has been
demonstrated with the transfer of postauricular skin on a pedicle extending across the dome to the contralateral
superficial temporal vessels (2). Successful microvascular replantation in which the entire scalp and one ear
survived on a singular artery and vein reanastomosis has been reported (3, 4).
DESIGN OF THE PENINSULAR FLAP
The forehead and scalp constitute a single anatomic unit differentiated only by the location of the hairline.
Preservation of this hairline in a normal configuration is a primary consideration because it creates the frame of
the upper face in the frontal and temporal areas. Disruption and asymmetry of this frame are to be avoided.
The rigidity of the scalp does not lend itself to some of the more popular and useful flaps, such as the rhomboid
flap, which require plasticity of the surrounding tissue for closure of the donor site. For this reason, one is limited
to transposition, interpolation, or rotation flap design (see Fig. 1.1). During the following discussion, one must
bear in mind that although geometry offers a worthwhile foundation for understanding basic flap design, it is best
replaced with an artistic eye once the basic tenets have been mastered.
Transposition Flaps