Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

the perforators are small. Usually three perforators have been identified between the pubis and the umbilicus.
FIGURE 337.1 The dotted lines outline the groin or iliofemoral flap supplied by the superficial circumflex iliac
artery (SCIA). The abdominohypogastric flap is outlined by the solid line; it is supplied by anterior perforating
branches of the deep inferior epigastric artery and by branches of the superficial inferior epigastric artery (SIEA).
(From Schlenker et al., ref. 1, with permission.)
FIGURE 337.2 The small Doppler probe is used to determine the course of the superficial inferior epigastric
artery. The lower border of the abdominohypogastric flap is designed to include branches of this artery within the
base of the flap. (From Schlenker et al., ref. 1, with permission.)
FIGURE 337.3 A: Shotgun wound to the left forearm with division of the ulnar artery, ulnar nerve, and fracture of

the ulna. The skin defect measured 10 by 15 cm. B: The defect in the forearm was primarily covered completely
with a tubed abdominohypogastric flap. The flap was tubed and the donor and recipient sites were closed. The
flap was divided and inset 3 weeks after the initial injury. C: One month after injury. There is complete healing of
the skin over the forearm. (From Schlenker et al., ref. 1, with permission.)
In contrast to a thoracoabdominal flap that is elevated with the fascia over the serratus anterior muscle, the
abdominohypogastric flap is raised superficial to the muscular fascia. The portion of the flap that covers the
defect can be thinned so that a thickness of 0.5 cm or less of adipose tissue remains beneath the dermis.
CLINICAL RESULTS
We have employed this flap in four cases, all of which have been successful. In three patients the defect
was on the wrist or forearm and in one it was on the dorsum of the hand. In two cases the flap was tubed
(Fig. 337.3) and the skin edges of the donor defect were approximated without the need for a skin graft (1).
In two patients the flap was employed after the groin flap had already been used on the same side.
SUMMARY
The abdominohypogastric skin flap can be reliably used for both hand and forearm coverage.
References
1. Schlenker JD, Atasoy E, Lyon JW. The abdominohypogastric flap, an axial pattern flap for forearm
coverage. Hand 1980;12:248.
2. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
3. Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for recurrent
breast cancer. Plast Reconstr Surg 1974;53:52.
4. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade.
Plast Reconstr Surg 1977;55:416.
5. Davis WM, McCraw JB, Carraway JH. Use of a direct, transverse, thoracoabdominal flap to close difficult
wounds of the thorax and upper extremity. Plast Reconstr Surg 1977;60:526.
6. McGregor IA. Flap reconstruction in hand surgery: the evolution of presently used methods. J Hand Surg
1979;4:1.
7. Schlenker JD, Averill RM. The iliofemoral (groin) flap for hand and forearm coverage: pitfalls, prevention
and alternatives. Orthop Rev 1980;9:57.
8. Shaw DT, Payne RL. One stage tubed and abdominal flaps. Surg Gynecol Obstet 1946;83:205.
9. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.

10. Harii K, Ohmori K, Torii S, et al. Free groin skin flaps. Br J Plast Surg 1975; 28:225.

Chapter 338
Tissue Expansion and Flaps of The Upper Extremity
G. G. HALLOCK
The development of large random flaps for the elimination of local arm defects (1, 2, 3), the augmentation of flaps
prior to their transposition by gradual distension using inflatable silicone balloons (4, 5), and the amelioration of
donor site deformities (6, 7), are all advantages not previously possible without the combination of tissue
expansion with upper extremity flaps.
INDICATIONS
For all practical purposes, the scope of tissue expansion currently remains limited to skin augmentation (8,
9, 10, 11, 12, 13). The following discussion is therefore limited to those named fasciocutaneous flaps that
have a reasonably large territory and a constant, reliable anatomy that facilitate their dissection— the
deltoid, lateral upper arm, and forearm flaps based on the radial or the ulnar artery or on their segmental
perforators (Fig. 338.1). All are versatile microsurgical free tissue donor areas, while the lateral upper arm
and forearm flaps may also be useful for coverage of ipsilateral upper extremity defects. Unless small
dimensions are used, all ultimately require a skin graft of the donor area following transfer (14, 15, 16, 17).
FIGURE 338.1 Versatile fasciocutaneous donor sites of the upper extremity. Shaded areas are suitable for
placement of expanders at the time of flap transfer.
The immediate or delayed placement of expanders to allow later transformation of these defects into more
acceptable linear scars has been particularly valuable for the distal radial forearm flap (7) where the
residual nonaesthetic donor site is the most conspicuous (18, 19). If required, pretransfer expansion may
also create larger flaps.
OPERATIVE TECHNIQUE
For immediate expansion following flap transfer, the remaining medial or lateral skin and subcutaneous tissues
are undermined above the muscle fascia to create a pocket that will accept the dimensions of the expansion
envelope (Fig. 338.2A) (20, 21). Usually a standard rectangular implant whose length exceeds that of the defect

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is satisfactory. Placement over bony prominences or joints is avoided so that mobility will not be impaired during
expansion. The dermis at the defect edge is then carefully closed to the underlying tissues, as any gap will
promote infection and subsequent extrusion of the implant. A remote valve prevents the risk of inadvertent
implant puncture during fluid instillation. The expander can be placed directly under the flap, if pretransfer
augmentation is elected.
FIGURE 338.2 A: Longitudinal curved expander placed in a dorsal pocket immediately after transfer of a radial
forearm flap. B: Measurement of arm circumference allows determination of tissue gain required prior to implant
removal. Note objectionable appearance of typical volar skin graft donor defect. C: Highly vascularized capsule
on undersurface of the expanded dorsal flap, prior to its advancement to cover the skin graft defect depicted in
B. Re-creation of the donor flap defect must await assurance that the augmented tissues will provide adequate
coverage. D: Typical linear scar result following tissue expansion.
Adequate wound healing is mandatory prior to commencing serial expansion and, not uncommonly, this must be
delayed even up to 6 weeks. Then percutaneous saline is instilled on a weekly basis until skin capillary fill
disappears or pain intolerance occurs. If rapid expansion or expansion of an anesthetic area is desired, objective
monitoring of transcutaneous oxygen levels might be desirable for greater safety (22).
The difference in the circumference of the extremities from a given fixed point will determine the available tissue
gain (Fig. 338.2B). When this exceeds coverage requirements, the expander may be removed. In many cases
this requires expander overinflation well beyond the stated allowable volume, but at least twice this amount and
probably more has been reported to be safe (23, 24). Maximum inflation at the time of surgery will yield an
additional 1 to 2 cm in length by way of acute load-cycling or skin stretching (25). A defect should not be created
until confirmation that the expanded flap will provide adequate coverage (Fig. 338.2C), as it may be necessary to
retain the expander for a second period of expansion.
CLINICAL RESULTS
Transforming an upper extremity deformity into a linear scar, or at least minimizing the size of a skin-grafted

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donor defect, have been usual sequelae of the appropriate use of tissue expansion (Fig. 338.2D).
Complication rates are higher in extremity tissue expansion (11, 12, 26), and proper precautions and
attention to wound healing must be adopted, if this concept is to be successful. A minimum of two surgical
stages are required, regardless of whether pretransfer or post-transfer expansion is elected. Pretransfer
expansion also carries additional risks to the flap: if the implant were to become infected, the skin
devascularized or thinned, or this pedicle compromised, the elective transfer might have to be aborted (13).
Caution must be observed with any attempt at extremity tissue expansion. Since the procedure requires a
significant investment of both patient and surgeon time, the hazards as well as the advantages must be
clearly outlined in advance.
SUMMARY
Although no universal flap yet exists that will meet every functional demand of the recipient area, while
simultaneously minimizing the donor site defect, tissue expansion provides added advantages that allow
use of many donor regions with the assurance that a linear scar will be the only residuum.
References
1. Morgan RF, Edgerton MT. Tissue expansion in reconstructive hand surgery: case report. J Hand Surg
1985;10A:754.
2. Mackinnon SE, Gruss JS. Soft tissue expanders in upper limb surgery. J Hand Surg 1985;10A:749.
3. Hallock GG. Tissue expansion techniques in burn reconstruction. Ann Plast Surg 1987;18:274.
4. Hallock GG. Tissue expansion. Contemp Surg 1986;29:34.
5. Leighton WD, Russell RC, Marcus DE, et al. Experimental pretransfer expansion of free flap donor sites: I.
Flap viability and expansion characteristics. Plast Reconstr Surg 1988;82:69.
6. Hallock GG. Free flap donor site refinement using tissue expansion. Ann Plast Surg 1988;6:566.
7. Hallock GG. Refinement of the radial forearm flap donor site using skin expansion. Plast Reconstr Surg
1988;81:21.
8. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 1984;74:482.
9. Austad ED, Thomas SB, Pasyk K. Tissue expansion: dividend or loan? Plast Reconstr Surg 1986;78:63.
10. Sasaki GH, Pang CY. Pathophysiology of skin flaps raised on expanded pig skin. Plast Reconstr Surg
1984;74:59.
11. Manders EK, Schenden MJ, Furrey JA, et al. Soft tissue expansion: concepts and complications. Plast

Reconstr Surg 1984;74:493.
12. Hallock GG. Extremity tissue expansion. Orthop Rev 1987;16:606.
13. Leighton WD, Russell RC, Feller AM, et al. Experimental pretransfer expansion of free-flap donor sites: II.
Physiology, histology and clinical correlation. Plast Reconstr Surg 1988;82:76.
14. Russell RC, Guy RJ, Zook EG, Merrell JC. Extremity reconstruction using the free deltoid flap. Plast
Reconstr Surg 1986;76:586.
15. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical application.
Ann Plast Surg 1984;12:489.
16. Hallock GG. The radial forearm flap in burn reconstruction. J Burn Care Rehabil 1986;7:318.
17. Hallock GG. Soft tissue coverage of the upper extremity using the ipsilateral radial forearm flap. Contemp
Orthop 1987;15:15.
18. Timmons MJ, Missotten FEM, Poole MD, Davies DM. Complications of radial forearm flap donor sites. Br
J Plast Surg 1986;39:176.
19. Fenton OM, Roberts JO. Improving the donor site of the radial forearm flap. Br J Plast Surg 1985;38:504.
20. Hallock GG. Adjuvant use of the suction lipectomy cannula for blunt dissection. Aesthet Plast Surg
1985;9:107.
21. Hallock GG. Suction cannula assisted placement of traction sutures. Ann Plast Surg 1987;18:355.
22. Hallock GG, Rice DC. Objective monitoring for safe tissue expansion. Plast Reconstr Surg 1986;77:416.
23. Shively RE, Bermant MA, Bucholz RD. Separation of craniopagus twins utilizing tissue expanders. Plast
Reconstr Surg 1985;76:765.
24. Hallock GG. Maximum overinflation of tissue expanders. Plast Reconstr Surg 1987;80:567.
25. Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose and ala by load cycling of the
nasal skin and harnessing of extra skin. Plast Reconstr Surg 1986;77:316.
26. Argenta LC, Marks MW, Pasyk KA. Advances in tissue expansion. Clin Plast Surg 1985;12:159.

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Chapter 339
Microneurovascular Transfer of Rectus Femoris Muscle and
Musculocutaneous Flaps
R. R. SCHENCK
EDITORIAL COMMENT
The use of microvascular free transfer of muscles for restoration of both flexion and extension in the upper
extremity has added a significant new dimension to the functional restoration of the upper extremity. At this
time, the gracilis muscle appears to be the most useful for free transfer.
The rectus femoris muscle can be selected for a free muscle transfer to a patient's forearm, to replace
traumatically destroyed digital flexors (1, 2).
INDICATIONS
The rectus femoris musculocutaneous flap, whose length is ideal for forearm transplant, is particularly
useful where strong motor power is necessary on the flexor aspect of the forearm. The technique offers the
following advantages:
1. The single main arterial supply of the muscle simplifies arterial anastomosis at the recipient site. This is in
contrast to the gracilis muscle that often has two arteries (3, 4, 5, 6).
2. The femoral nerve branch is of adequate length for anastomosis.
3. The muscle is excellent in size and power for replacing lost forearm flexors. It can provide good grasp
and strength. This is in spite of the anticipated 50% reduction in mass commonly observed after free
muscle transfers.
4. There is adequate overlying skin for coverage of the muscle itself at the recipient site, yet primary closure
at the donor site can be effected.
5. The muscle with its tendinous attachments is of appropriate length to reach from the new origin at the
medial epicondyle to the new insertion site at the profundus tendons at the wrist.
6. There is no loss of effective quadriceps action in the donor leg. Complete and powerful knee extension is
retained because of the remaining quadriceps muscle mass.
ANATOMY
The rectus femoris muscle originates from the anterior inferior iliac crest (Fig. 339.1). The neurovascular supply,
consisting of the femoral nerve, artery, and vein, is found more medially.
The portion of the femoral nerve supplying the muscle can be most readily identified approximately 3 cm distal to
the midpoint on Poupart's ligament, between the anterior inferior iliac crest and the lateral margin of the pubis.
The femoral nerve can be identified under the sartorius muscle and traced there to its entry into the
posteromedial margin of the rectus femoris muscle. There are usually two branches at the entry point.

The artery of the rectus femoris may arise from either the profunda femoris or the descending branch of the
lateral circumflex femoral artery.
FLAP DESIGN AND DIMENSIONS
The flap can measure as much as 10 cm wide by 30 cm long. However, it is wise not to include the distal portion
of skin near the knee.
FIGURE 339.1 The anatomy of the donor rectus femoris muscle is diagrammed to show its tendinous origin and
insertion and its easily obtained arterial supply from one source, in contrast to the gracilis muscle, which may
have multiple arteries supplying it. The overlying composite skin to be transferred is not shown in this diagram.
(From Schenck, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The incision outline should be modified in a curvilinear manner near the superior portion of the muscle. The
remainder of the incision encompasses the entire mass of the rectus femoris muscle, but care should be taken
not to include skin that extends laterally or medially beyond the margins of the muscle belly itself (Fig. 339.2B).
The skin incisions are carried down vertically to the muscle fascia. After identifying the femoral nerve and the
artery of the rectus femoris, the accompanying venae comitantes should be noted for later reference. The
tendinous attachments of the rectus femoris are then divided proximally from the anterior inferior iliac crest and
distally through the patellar tendon. Finally, vascular clamps are applied to the artery and vein of the profunda
femoris and the vessels and nerve are divided. A sufficient length of femoral nerve is critical. From 10 to 12 cm of
the nerve's two branches can be obtained when the division is proximal to their common juncture. The donor site
can be closed primarily.
Selection of the proper incision and exposure in the arm will depend on the existing scar and the previous flap
margins. Owing to its location and size, the anterior interosseous artery is a convenient recipient vessel.
However, a portion of a severed ulnar or radial artery, if patent, will serve the purpose just as well.
When the composite rectus femoris flap is transferred to the prepared arm, the proximal tendinous portion is
sutured to the medial epicondylar fascia and the distal portion to the flexor profundus tendons near the wrist (Fig.
339.2C and D). The recipient arteries and nerves will vary according to the individual situation.
Microneurovascular anastomoses should proceed with the vein being repaired first, then the artery. The motor
nerve is repaired last.
When the distal rectus femoris muscle tendon is sutured to the flexor profundus tendons at the wrist, the
transverse carpal ligament is divided in its proximal two-thirds. The wound is closed by suture of the cutaneous
flap. If the composite skin does not fully cover the transferred muscle, a small split-thickness skin graft can be
added. The dressing should be provided with a padded long arm posterior plaster splint for 90° of elbow flexion.
There is marked swelling of the transferred composite muscle-skin flap in the immediate postoperative period.
There is apt to be slower than normal healing of the wound margins, and one should not be misled by the fact

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that the flap margins appear pink and bleed easily. Sutures should not be removed prematurely. Three to 6
months may be required before active motor end plate unit potentials can be noted on electromyography and/or
correlated with clinical contractility (7, 8).
CLINICAL RESULTS
In cases in which the author has personally performed the surgery, there have been no instances of
residual donor defect. In fact, full knee extension has been retained even against gravity or resistance.
There has been no failure of the flap and no functional deficit. There was one instance of delayed healing
at the wrist, when the skin in the suprapatellar area was included with the flap.
FIGURE 339.2 A: The right arm of a 49-year-old man was severely injured in a milling machine, resulting in
loss of all digital flexors by avulsion and the severing of the flexor carpi ulnaris, ulnar nerve and artery,
median nerve, radial artery, and brachioradialis tendon. The two muscles, ulnar nerve, and radial artery
were reapproximated and abdominal pedicle flap coverage was immediately provided. Eleven weeks later,
bilateral sural nerve grafting was performed for both the median and the ulnar nerves. B: The left rectus
femoris is being dissected, the origin being from the anterior inferior iliac crest on the right and the patellar
tendon on the left. The elliptical composite skin flap is shown being taken carefully with the muscle, with its
margins extending no farther than that of the muscle. C: The transferred rectus femoris muscle now lies in
its new functional position, taking origin from the flexor origin at the medial epicondyle and inserting into the
common mass of the flexor profundus tendons, just proximal to the partially divided transverse carpal
ligament. D: The site of insertion of the transferred muscle can be seen, just prior to closure of all wound
margins, using the composite skin. A small split-thickness skin graft (not visible) is necessary on the most
ulnar aspect. (From Schenck, ref. 1, with permission.)
Among five cases reported by other surgeons who have used the rectus femoris muscle for a forearm
composite graft, reinnervation was first detected by electromyography from 3 to 6 months following surgery.
In these five cases, clinically detected reinnervation was also noted within the same 3- month time frame.
These surgeons estimated excursion created by the transplanted muscle as ranging from 2 to 4 cm, and
graded muscle activity at grade 3 or 4.

SUMMARY
The rectus femoris muscle or musculocutaneous flap can be used to replace the function of muscles such
as the forearm flexors. Skin can be included with the flap or the muscle can be covered with a split-
thickness skin graft.
References
1. Schenck R. Free muscle and composite skin transplantation by microneurovascular anastomoses. Orthop
Clin North Am 1977;8:367.
2. Schenck R. Rectus femoris muscle and composite skin transplantation by microneurovascular
anastomoses for avulsion of forearm muscles: a case report. J Hand Surg 1978;3:60.
3. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation with microneurovascular anastomoses for
the treatment of facial paralysis. Plast Reconstr Surg 1976;57:133.
4. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. Plast Reconstr Surg 1976;57:294.
5. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat Volkmann's
contracture. Plast Reconstr Surg 1976; 58:407.
6. McCraw J, Dibbel D, Horton C, et al. Definition of new arterialized myocutaneous vascular territories.
Paper presented at the 55th Annual Meeting of the American Association of Plastic Surgeons, Atlanta, Ga.,
1976.
7. Tamai S, Komatsu S, Sakamoto H, et al. Free muscle transplants in dogs with microsurgical neurovascular
anastomoses. Plast Reconstr Surg 1970;46:219.
8. Kubo T, Ikuta Y, Tsuge K. Free muscle transplantation in dogs by microneurovascular anastomoses. Plant
Reconstr Surg 1976;57:495.

Chapter 340
Microneurovascular Transfer of The Latissimus Dorsi Muscle and
Musculocutaneous Flaps to The Forearm
R. M. BARTON
The latissimus dorsi muscle offers the surgeon a formidable tool in reconstruction, as the muscle offers large
bulk to cover significant defects, or it can be tailored to cover smaller ones. If needed, the overlying skin is
dependable and may be oriented in any direction. The neurovascular pedicle has a predictable anatomic
location, and the vessels have diameters that facilitate microvascular anastomosis.
INDICATIONS
Since the experimental groundwork for the successful transfer of functional muscle units was laid in 1970
(1), several criteria for free muscle transfer have evolved (2). Before restoration of the mechanical function
of the hand and arm, the patient must have supple joints, a stable osseous skeleton, and an identifiable
neurovascular supply. Moreover, free muscle transfer is indicated only when local tendon transfer cannot
provide suitable functional restoration.
ANATOMY
The anatomy of the latissimus dorsi muscle has been well described (3). In nearly all patients, the thoracodorsal
nerve, artery, and vein arise from or enter at a common hilum. The diameters of the artery and vein at their origin
average 2.5 to 3.5 mm, respectively. The thoracodorsal artery then travels to the muscle, giving off one to three
branches to the serratus anterior.
The length of pedicle that can be obtained is 9 cm. The nerve, artery, and vein enter the muscle on its inferior
surface, approximately 2 cm medial to the lateral border and 10 cm inferior to the apex of the axilla. On entrance,
the vessels and nerve bifurcate into transverse and longitudinal bundles. However, in 55% of patients there is no
transverse branch, and the medial aspect of the muscle is supplied by many small branches from the posterior
cord of the brachial plexus and lies proximal to the subscapular artery and vein before joining them in a common
pedicle.
The intramuscular neural anatomy is similar to that of the artery and vein. Knowledge of the vascular and neural
branching pattern makes it possible to take only part of the entire muscle or to split the muscle into two
segments.
FLAP DESIGN AND DIMENSIONS
In transferring functional motor units, it is imperative to assess the amplitude of excursion required for motor
function. For finger flexion the amplitude is at least 7 cm. Helpful technical points include marking the latissimus
dorsi muscle in situ with either indelible ink or suture material at standard intervals, to maintain this length when
the muscle is transferred to the forearm. For restoration of finger flexion, the latissimus dorsi muscle is oriented
with its insertion distally, to be attached to the flexor tendon(s), and its origin is oriented proximally, to be
attached to the medial epicondyle (Fig. 340.1).
Preoperative planning must establish the integrity of the vascular and neural supply. Arteriography may be
necessary. Intraoperative biopsy of the recipient nerve may be helpful to ensure its axonal content. Although the

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thoracodorsal nerve can be taken with an average length of 12 cm, it may be sectioned close to its muscular
entrance to shorten the time for reinnervation.
When exploring the arm, it is helpful to design cutaneous flaps that will cover the musculotendinous junction after
the insertion of the flap. The remainder of the latissimus dorsi muscle can either be transferred with its overlying
skin paddle or grafted with a split-thickness skin graft.
CLINICAL RESULTS
The appearance of muscle function returns in approximately 6 to 12 months. The force of contraction of
transferred muscle has been measured at between 25% and 50% of its original functional strength. The
rate of return of muscular function and its ultimate strength are closely related to the status of the recipient
nerve. Although a pure motor nerve is preferable, a mixed nerve such as the anterior interosseous can be
used.
SUMMARY
The latissimus dorsi muscle can be transferred to the upper extremity as an innervated flap, to restore
function and to provide coverage.
FIGURE 340.1 Transfer of a functional latissimus dorsi to the forearm.
References
1. Tamai S, Komatsu S, Sakamoto H, et al. Free muscle transplants in dogs with microsurgical neurovascular
anastomoses. Plast Reconstr Surg 1970; 46:219.
2. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg
1978;3:416.
3. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.

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Chapter 341
The Multilobed Latissimus Dorsi Myocutaneous Flap
YIXIN ZHANG
DAVIDE LAZZERI
MAOLIN TANG
JIN MEI
EDITORIAL COMMENT
The author demonstrates how to obtain large islands of skin with the latissimus dorsi flap and still achieve
primary closure of the wound. A simpler and possibly more aesthetic effect may be obtained with the muscle
alone covered with a STSG.
INDICATIONS
Although the latissimus dorsi (LD) flap was first described by Iginio Tansini in 1906 as a method to
resurface extensive postmastectomy defects, it was popularized only in 1976 by Olivari for the coverage of
large radiation ulcers of the chest wall (1). Since then, the LD myocutaneous flap has been widely used for
the reconstruction of both postoncologic and posttraumatic defects, becoming one of the most frequently
used flaps in reconstructive surgery (2, 3, 4, 5, 6, 7).
The reliable anatomy of the thoracodorsal and subscapular vessels and the large volume and robust
viability of the muscle tissue make the LD myocutaneous flap versatile with a largesize caliber and long
pedicle. In contrast, the main drawback
of the flap's use for repairing large defects is the relatively small skin paddle size that can be harvested
(width < 8 cm) to enable primary closure of the donor site.
A plethora of modifications of the conventional LD flap harvesting have been reported (8, 9, 10, 11, 12, 13,
14), but none of these methods have provided the enlargement of the skin paddle size while preserving
primary donor site closure; almost all these techniques are restricted to selected obese patients with a
redundancy of skin and subcutaneous fat or to patients with advanced-stage breast cancer. A variation of
the traditional LD myocutaneous flap is herein described that maintains all the advantages of the traditional
LD harvesting method. The LD is design with multiple (two or three) relatively small skin paddles that can
be raised and allowed for primary closure of the donor site (for widths < 8 to 9 cm). The skin paddles can be
tailored and altered to exactly match the shape of the recipient site defect and that can provide coverage for
larger defect sizes that is not possible when using the conventional LD flap design.
ANATOMY
The thoracodorsal artery (TDA) arises from the subscapular artery, enters the deep surface of the LD at the
vascular hilus (at approximately 2.5 cm from the lateral LD edge and 5 cm from the posterior axillary fold), and
divides into transverse and descending branches (15, 16, 17, 18, 19, 20). All along their course, these two
branches give rise to constant cutaneous perforators (18, 19, 20). The subscapular vein and the thoracodorsal
vein may enter separately, adjacent one to another, or more commonly fuse as a common trunk. Medially to the

vein, the thoracodorsal nerve emerges from beneath the axillary vein to join the thoracodorsal bundle.
Schaverien et al. (19) investigated the perfusion of the LD musculocutaneous flap using three- and four-
dimensional computed tomographic angiography and venography (19, 20). The authors found that the upper
transverse (bra line) skin paddle was supplied mostly by the transverse branch of the TDA and that the vertical
and lower transverse skin paddles were supplied mostly by the descending branch of the TDA (19, 20). The
robust vascularity of these three popular locations, that is, the upper transverse, vertical, and lower transverse
areas, strengthened the creative concepts for various flap designs in this area.
FLAP DESIGN AND DIMENSIONS
A paper template having the same size and shape of the defect is created. The defect's global area is split in two
or three small segments of equal or unequal sizes and different shapes that correspond to a number of planned
skin islands. The arrangement, size, and orientation of each part of the template depend on the elasticity of the
skin over each part of the hemiback that is different for every patient. Each skin island is marked on the back
skin of the patient as linking together or splitting apart, taking care that the largest width of each skin paddle
does not exceed 8 cm, which facilitates primary closure of the donor site. The preoperative Doppler examination
is not used as the location of the perforators is known, based on previous investigations of the vascular anatomy
of the TDA and its cutaneous perforator vessels (15, 16, 17, 18, 19, 20). To maximize skin size harvest and avoid
any final tension on the sutures, a pinch test is used for all skin paddle areas in both adducted and abducted
positions of the upper arm. Individual differences in skin laxity between the skin of the upper and lower back
should be always taken into consideration during the flap design because the main goal of the multilobed LD flap
design is to ensure primary closure after harvesting the flap.

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FIGURE 341.1 Above: The removal of a squamous cell carcinoma involving the left occipital region of a 19-
year-old patient resulted in an 11 × 11 cm soft-tissue defect. Center: A left bilobed latissimus dorsi was raised
with both halves measuring 11 × 6 cm and 11 × 5 cm. Below: The skin paddle was then shaped to form a U
shape with the inner sides kissing together. The microvascular anastomoses were performed end-to-end with the
left superficial temporal vessels. Despite the large width of the defect, which measured 12 cm, harvesting a
bilobed skin paddle and orientating these paddles side-by-side enabled us to perform primary closure of the
donor site. (From Zhang YX, et al. A novel design of the multilobed Latissimus dorsi myocutaneous flap to
achieve primary donor-site closure in the reconstruction of large defects. Plast Reconstr Surg 2013;131(5):752e-
758e, with permission.)
OPERATIVE TECHNIQUE
Before raising the flap, the defect is carefully debrided or complete resection of tumor at the recipient site is
ensured. The precise size of the defect that needs coverage is confirmed in the preoperative flap design.
Elevation of the flap is similar to conventional LD flap. Once the LD flap is completely elevated according to the
presurgical multilobed flap design, the skin paddles are tailored before transfer. The sum of the sizes of the skin
paddles corresponds to the defect size and shape as planned preoperatively with the paper templates. The two
or three-skin paddles are always designed with a width less than 8 cm and are stacked side-by-side and
carefully sutured together before inset the flap to avoid any undue perforator stretch that could diminish the
vitality of the cutaneous islands.

Primary closure of the donor site is always considered the primary goal of this modified method. The residual
skin flap of the donor site that is to be elevated off of the LD is elevated at the muscle fascia and advanced to
close the back. Lastly, two suction drains are placed.
CLINICAL RESULTS
In our series, seven of nine flaps were raised as bilobed and the remaining two were harvested as trilobed
flaps. The defects are measured from 11 × 11 cm to 21 × 17 cm (mean area of 213 cm2). The largest skin
area of the bilobed flap was 280 cm2, and the triple flap was 340.5 cm2. Limited undermining of the donor
site allowed tension-free primary closure in all cases. The average hospitalization was 7 days, and patients
were followed for a mean period of 6 months. Seven bilobed flaps and one trilobed flap healed uneventfully.
Partial necrosis occurred in one case in which a three-skin paddle flap was harvested to cover a previously
irradiated defect that resulted from a fibrosarcoma excision. This patient required additional coverage with a
local bilobed flap and healed with no further complications. Clinical cases are illustrated in Figures 341.1,
341.2, 341.3, 341.4, 341.5.
FIGURE 341.2 The flap survived completely, with no complications. An excellent outcome was observed at
9 months postoperatively. (From Zhang YX, et al. A novel design of the multilobed Latissimus dorsi
myocutaneous flap to achieve primary donor-site closure in the reconstruction of large defects. Plast
Reconstr Surg 2013;131(5):752e-758e, with permission.)

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FIGURE 341.3 Above: A 15-year-old female patient was involved in a work accident and sustained a
degloving injury of the scalp 7 years before presentation to our clinic. She presented with a tumor in the
context of the chronic wound. A biopsy of the wound had revealed squamous cell carcinoma. Excision of the
cancer, including the involved skull bone and débridement of the wound, left a 17 × 17-cm defect with
epidural exposure. Center, below: The defect was covered with a right trilobed latissimus dorsi flap. Skin
paddles measured 16 × 6.5 cm, 17 × 6 cm, and 16 × 6 cm, respectively, and were tailored to the shape of
the defect at the recipient site before the inset of the flap. The right superficial temporal artery and vein
were used as recipient vessels. (From Zhang YX, et al. A novel design of the multilobed Latissimus dorsi
myocutaneous flap to achieve primary donorsite closure in the reconstruction of large defects. Plast
Reconstr Surg 2013;131(5):752e-758e, with permission.)

FIGURE 341.4 The patient healed uneventfully, and the final results of the recipient sites at 2 months
postoperatively were excellent. (From Zhang YX, et al. A novel design of the multilobed Latissimus dorsi
myocutaneous flap to achieve primary donor-site closure in the reconstruction of large defects. Plast
Reconstr Surg 2013;131(5):752e-758e, with permission.)
SUMMARY
The main drawback of the LD myocutaneous flap for the repair of large defects is the relatively small skin
paddle size that can be raised to allow primary closure of the donor site. A novel design of the flap using
multiple separate skin paddles is described, with each paddle nourished by an independent perforator, to
repair very large defects while maintaining primary donor site closure. The total area of the defect is split
into two or three-skin paddles and marked on the back skin so that the largest width of each paddle does
not exceed 8 cm. After harvesting the flap, several smaller skin paddles are transferred and rejoined at the
recipient site while the donor site is closed primarily in all cases. The multilobed myocutaneous LD flap is a
new modification of the conventional LD design, which enables a customized reconstruction of large defects
to all types of patients and direct closure of the donor site.
FIGURE 341.5 The patient healed uneventfully, and the final results of the donor site at 2 months
postoperatively were excellent. (From Zhang YX, et al. A novel design of the multilobed Latissimus dorsi
myocutaneous flap to achieve primary donor-site closure in the reconstruction of large defects. Plast
Reconstr Surg 2013;131(5):752e-758e, with permission.)

References
1. Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr
Surg 1980;65(5):686-692.
2. Spear SL, Boehmler JH, Taylor NS, et al. The role of the latissimus dorsi flap in reconstruction of the
irradiated breast. Plast Reconstr Surg 2007;119:1-9.
3. Munhoz AM, Montag E, Fels KW, et al. Outcome analysis of breast-conservation surgery and immediate
latissimus dorsi flap reconstruction in patients with T1 to T2 breast cancer. Plast Reconstr Surg
2005;116:741-752.
4. Hierner R, van Loon J, Goffin J, et al. Free latissimus dorsi flap transfer for subtotal scalp and cranium
defect reconstruction: report of 7 cases. Microsurgery 2007;27:425-428.
5. Rinker B, Valerio IL, Stewart DH, et al. Microvascular free flap reconstruction in pediatric lower extremity
trauma: a 10-year review. Plast Reconstr Surg 2005;115:1618-1624.
6. Pacella SJ, Vogel JE, Locke MB, et al. Aesthetic and technical refinements in latissimus dorsi implant
breast reconstruction: a 15-year experience. Aesthet Surg J 2011;31:190-199.
7. Button J, Scott J, Taghizadeh R, et al. Shoulder function following autologous latissimus dorsi breast
reconstruction. A prospective three year observational study comparing quilting and non-quilting donor site
techniques. J Plast Reconstr Aesthet Surg 2010;63:1505-1512.
8. Hokin JA. Mastectomy reconstruction without a prosthetic implant. Plast Reconstr Surg 1983;72:810-818.
9. Papp C, McCraw JB. Autogenous latissimus breast reconstruction. Clin Plast Surg 1998;25:261-266.
10. Germann G, Steinau HU. Breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr
Surg 1996;97:519-526.
11. Clough KB, Louis-Sylvestre C, Fitoussi A, et al. Donor site sequelae after autologous breast
reconstruction with an extended latissimus dorsi flap. Plast Reconstr Surg 2002;109:1904-1911.
12. Bailey SH, Saint-Cyr M, Oni G, et al. The low transverse extended latissimus dorsi flap based on fat
compartments of the back for breast reconstruction: anatomical study and clinical results. Plast Reconstr
Surg 2011;128:382e-394e.
13. Li BH, Jung HJ, Choi SW, et al. Latissimus dorsi (LD) free flap and reconstruction plate used for
extensive maxillo-mandibular reconstruction after tumour ablation. J Craniomaxillofac Surg 2012;40(8):e293-
e300.
14. Munhoz AM, Montag E, Arruda E, et al. Immediate locally advanced breast cancer and chest wall

reconstruction: surgical planning and reconstruction strategies with extended V-Y latissimus dorsi
myocutaneous flap. Plast Reconstr Surg 2011;127:2186-2197.
15. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631-636.
16. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637-641.
17. Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi myocutaneous flap. Ann Plast Surg
1981;7:272-280.
18. Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal artery perforator flap: anatomic basis and
clinical application. Ann Plast Surg 2003;51:23-29.
19. Schaverien M, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional arterial and venous anatomies
of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2008;121(5):1578-1587.
20. Schaverien M, Wong C, Bailey S, et al. Thoracodorsal artery perforator flap and Latissimus dorsi
myocutaneous flap--anatomical study of the constant skin paddle perforator locations. J Plast Reconstr
Aesthet Surg 2010;63:2123-2127.

Chapter 342
Microvascular Free Gracilis Muscle and Musculocutaneous Flap to
The Forearm
R. T. MANKTELOW
R. M. ZUKER
EDITORIAL COMMENT
The description of the use of this flap revealed a whole new area in rehabilitation of the injured upper
extremity. It continues to be an extremely useful technique to this date.
There are many muscles that can be transferred from one location in the body to another through the use of
microvascular techniques. The gracilis is the first muscle that was transferred in this manner (1, 2). It remains
one of the most useful muscles for microvascular transfer. The muscle is easy to remove, can be reliably
transferred on its pedicle, produces no functional loss, and leaves an incisional scar on the upper medial portion
of the thigh, where it is easily hidden. The potential for transferring a muscle and having it function provides
exciting reconstructive possibilities to the surgeon.
INDICATIONS
The muscle may be used for coverage of soft-tissue defects, for functional reconstruction in replacing
missing skeletal musculature, and for facial reanimation in facial paralysis. When used for soft-tissue flap
coverage, it may be transferred alone and a skin graft applied directly to the muscle, or it may be transferred
with an overlying cutaneous island as a musculocutaneous flap (1, 2, 3, 4). The gracilis muscle is well
suited for small and medium-sized soft-tissue defects that cannot be adequately handled by simpler flap
techniques. It will conform well to irregular contours, can be split longitudinally at both ends to allow
placement into cavities and awkward spaces, and can be transferred in part or in whole. When one is
transferring only a part of it, the transferred muscle will remain viable as long as the anterior margin of the
muscle is transferred.
The muscle has been used for replacement of major muscular defects that result in significant functional
loss (1, 2, 5, 6). The commonest site of these defects is the forearm, usually in the flexor aspect. However,
the muscle has also been used to replace the extensor musculature of the forearm, the anterior
compartment of the upper arm, and the anterior compartment of the lower leg (see Chapter 521). This
procedure is complicated and the time for functional recovery is prolonged. The procedure should not be
used when simpler techniques of tendon transfer are available.
ANATOMY
The gracilis muscle is one of the superficial muscles on the medial aspect of the thigh. The proximal half of the
muscle has a strap muscle configuration and the distal half a pennate configuration. It is broad above and tapers
to a long, thin tendon below. Depending on the size of the individual, the muscle in an adult is 25 to 30 cm in
length, with an additional 10 to 12 cm of tendon. The origin is the body of the pubis and its inferior ramus and the
adjacent ramus of the ischium. The muscle passes distally between the adductor longus and the adductor

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magnus, and ends in a tendon that passes medial to the condyle of the femur and inserts in the tibia just below
the tibial tubercle.
The tendon lies between the sartorius and the semitendinosis. There is a single motor nerve, which is a branch
of the obturator. This is composed of from two to six fascicles and enters the muscle obliquely (Figs. 342.1 and
342.2) just proximal to the dominant vascular pedicle. The nerve lies under the adductor longus. There are
usually two or three vascular pedicles. The superior pedicle is dominant and, in almost all cases, the muscle will
survive entirely on the superior pedicle alone. The artery in this pedicle is 1 to 2 mm in diameter, and there are
two venae comitantes, one of which is usually larger than the artery.
OPERATIVE TECHNIQUE
Donor Site
Exposure of the gracilis is facilitated by abduction and external rotation of the hip with the knee flexed (Fig.
342.3). The gracilis muscle lies posterior to a line that is drawn from the adductor longus tendon to the tibial
tubercle. When the knee is flexed, the muscle may be relaxed and sag posterior to this line.
FIGURE 342.1 The gracilis muscle lies in the medial thigh. The pedicle exits from the deep portion of the anterior
surface in the proximal quarter of the muscle.
An incision is carried through the skin immediately posterior to this line, and the dissection carried through the
superficial thigh fascia to the muscle. The skin is elevated and the muscle is identified by separating the
surrounding subcutaneous tissue from the muscle, and the anterior and posterior borders of the muscle are
cleared.
The pedicle is identified by separating the adductor longus from the gracilis muscle. The pedicle will be found 8
to 12 cm from the muscle origin and will pass under the adductor longus muscle. The assistant can retract the
adductor longus and display the pedicle. There are side branches from the venae comitantes and the artery to
the adductor longus. If these are divided, it is possible to develop a 6 cm length of pedicle.
Dissection is then carried proximally and distally and the muscle is completely separated from its bed. Distally,
there will usually be a second and often a third vascular pedicle entering the anterior border of the muscle at a
distal point.
The incision is then carried as far distal as necessary to separate the muscle completely. If the tendon is
required, a transverse incision is placed in the distal thigh, and the tendon is identified, retracted, and divided.
The tendon should be divided first and the origin second, in order that the pedicle will not be pulled out of the
thigh.

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FIGURE 342.2 The vascular pedicle consists of an artery and two venae comitantes. The nerve enters the
muscle more obliquely proximal (on the left side) to the vascular pedicle.
If a cutaneous flap is desired with the muscle, care must be taken to place the flap directly over the muscle belly.
There is usually one identifiable perforator that is approximately opposite the vascular pedicle. There are few, if
any, perforators over the distal muscle belly. Our cadaver dissections have shown that there are significant
interfascial vessels at this level that appear to provide the dominant blood supply to the skin of the middle and
distal portion of the thigh.
Although the flap is reliable anteriorly and posteriorly in the proximal thigh, it is not reliable distal to 15 cm from
the muscle origin, although it may occasionally survive in the middle third of the thigh. A musculocutaneous flap
should not be used if the patient is obese, because of the difficulty in positioning the flap on the underlying
gracilis muscle. The skin flap is not well attached to the muscle and should be tacked anteriorly and posteriorly
to the gracilis muscle, in order that there is no shearing of the perforating vessels. The flap should be evaluated
for the adequacy of circulation when the muscle and skin are separated and while the pedicle is still attached.
The procedure involved in preparing the muscle for functional reconstruction is identical to that used when the
muscle is prepared for coverage, except that the motor nerve is also taken with the muscle.
FIGURE 342.3 The location of the gracilis is outlined in the medial thigh. The key structure to identify in the
anterior border is the adductor longus tendon, which is easily palpated at its origin from the pubic tubercle.
Recipient Site
The structures at the recipient site that must be prepared are the sites of origin and insertion for the muscle, a
motor nerve, and a vascular pedicle. Care must be taken to raise suitable skin flaps that will adequately cover
the muscle, to allow good muscle gliding. This is particularly important in the distal half of the muscle and at the
point where the tendon is sutured to the recipient vessels. Preparation of the recipient site is frequently tedious,
as the dissection usually involves an area of considerable scar tissue subsequent to muscle loss.

A pure motor nerve must be selected so that good reinnervation can be obtained. In the forearm, the anterior
interosseous nerve is the first choice, although other branches of the median and ulnar nerves may be used.
Good muscle function cannot be expected without a normal motor nerve and a good nerve repair.
The muscle is not transferred until the recipient site is completely prepared (Fig. 342.4). The usual ischemia is
less than 2 hours, although our experience in laboratory investigations suggests that an ischemia time of up to 3
hours is not harmful. When the muscle is separated from the thigh, it is positioned in the forearm and tacked into
place. The muscle is then stretched out to its maximum expected size, and the relative positions of the muscle
pedicle and the recipient vessels are identified. The vascular repairs are positioned in such a way that the nerve
repair can be placed as close as possible to the muscle. The duration of muscle denervation will, to some extent,
determine the degree of muscle atrophy, and this is directly proportional to the distance of the nerve repair from
the neuromuscular junction. It is usually possible to do a nerve repair within 2 to 3 cm of the muscle. There is
considerable connected tissue about the gracilis motor nerve, and this should be stripped back to allow a good
fascicle-to-fascicle apposition with 11-0 nylon sutures.
The tension selected for the insertion of the muscle is important in the determination of eventual muscle function.
If the muscle is being used to replace forearm flexors and there is some extensor and intrinsic function, the
position of the fingers following a transfer will indicate the adequacy of the tension. When the gracilis tendon is
sutured to the four profundus tendons, it will provide sufficient flexion so that the fingers are in slightly more
flexion than in a position of function.
FIGURE 342.4 A: The muscle should not be removed from the thigh until all structures in the forearm are
prepared to receive it. B: The patient has the gracilis muscle transplanted to the forearm to replace the long
flexors of all fingers. The muscle will stretch to allow full finger extension. C: Contraction of the muscle provides
almost full finger flexion.
When adequate antagonistic muscles are not present, the technique of determining muscle tension is different.
Prior to the removal of the gracilis from the leg, sutures reinforced with marking ink are placed at 5 cm intervals
along the muscle belly when it is stretched to its maximum. This position is obtained by abducting the thigh and
extending the knee.
Following the transfer of the muscle to the forearm, and with revascularization and nerve repair, it is firmly
attached to the medial epicondyle with multiple mattress sutures. The tendon is then stretched distally toward the
hand until the suture marks are once again 5 cm apart. This indicates the maximum length to which the muscle is
normally stretched, and it should be placed within the forearm in such a way that when the wrist and fingers are
extended the muscle will be stretched to approximately this location. Appropriate suture repair can be done
between the flexor digitorum profundus tendons and the gracilis tendon with the fingers flexed, so that there will
not be undue tension on the repair.

P.916
Care must be taken in suturing the muscle into its bed, so that the pedicle is not kinked. Good skin closure over
the distal portion of the muscle and tendon-to-tendon juncture is important, to allow tendon gliding and to allow a
tenolysis, if this should be necessary.
A window is placed in the dressing and in the underlying skin graft; this allows direct visualization of the muscle.
CLINICAL RESULTS
We have used the gracilis muscle as a free tissue transfer in 49 cases. In 24 cases the entire muscle was
taken; in the others only a portion was taken for facial paralysis reconstruction. In all cases, all muscle was
adequately perfused by the proximal pedicle. Occasionally the distal portion of the muscle will take a few
minutes to develop a red color following revascularization, indicating that the blood supply may be very
marginal distally.
The muscle has been used to motor extremities in 20 cases. It should be limited to those cases where there
is a major functional deficit. The procedure is complex, and there are many areas where errors can be made
that will result in inadequate function. These include, particularly, the vascular anastomosis, the selection of
an adequate nerve and good nerve repair, and the positioning of the muscle under adequate tension. The
return of muscle function appears to be improved with an exercise program that is given to the patient once
reinnervation occurs. The results of muscle transplantation to the forearm have shown that the gracilis has
a functional potential of providing up to 50% of normal grip strength and a full range of finger excursion (Fig.
342.4B and C)
SUMMARY
The gracilis is an excellent muscle to use for major functional deficits of either the flexor or the extensor
aspect of the forearm. The procedure is complex and requires particular care in planning and execution.
References
1. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. Plast Reconstr Surg 1976;57:294.
2. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg
1978;3:416.
3. Orticochea M. The musculocutaneous flap method. Br J Plast Surg 1972; 25:106.
4. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous
flaps. Plast Reconstr Surg 1976;58:176.
5. Manktelow RT. Free muscle flaps. In: Green DP, ed. Operative hand surgery, 2nd Ed. New York: Churchill
Livingstone, 1988;861-876.
6. Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg 1984;9A:32.

(Trang không có chữ)

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Chapter 343
Microneurovascular Free Transfer of Pectoralis Major Muscle and
Musculocutaneous Flaps
Y. IKUTA
The pectoralis major muscle, with or without skin, can be used as a microneurovascular transfer to replace
muscles such as the powerful forearm flexors (1, 2, 3, 4).
ANATOMY
The pectoralis major muscle has three origins—clavicular, sternal, and abdominal. In the first it arises from the
medial half of the clavicle; in the second it arises from the anterior part of the sternum to the seventh rib; and in
the last it arises from the anterior layer of the rectus abdominal muscle sheath and terminates at the lateral lip of
the bicipital groove of the humerus (Fig. 343.1) (5).
It is a broad and flat fan-shaped muscle, innervated by the medial and lateral pectoral nerves extending from the
medial and lateral cords that arise from the brachial plexus. The function of this muscle is to adduct the upper
arm and to provide medial rotation. Deprivation of the muscle will result in some limiting of motor function, but to
a degree that is very slight and will not interfere with daily life.
The main blood supply of the pectoralis major muscle is from the pectoral branch of the thoracoacromial artery
that arises from the proximal portion of the axillary artery. The supply enters the undersurface of the muscle just
lateral to the midclavicular line that corresponds to the upper border of the pectoralis minor muscle.
A branch of the thoracoacromial artery passes through the clavicular head of the pectoralis major muscle,
becomes the cutaneous branch at the infraclavicular triangle, and ramifies outward to the acromial and deltoid
areas of the shoulder (6).
The internal mammary artery that is a branch of the subclavian artery runs along the posterior aspect of the
cartilages of the first to sixth ribs, distributes perforating branches through the intercostal spaces, and nourishes
the pectoralis major muscle and its overlying skin. Among the skin flaps in which these arteries serve as a
pedicle, the deltopectoral flap is well known and, of course, it can also be used as a musculocutaneous flap (6).
FIGURE 343.1 The design of the pectoralis major musculocutaneous flap (right). The undersurface of the

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muscle with its thoracoacromial blood supply (left).
OPERATIVE TECHNIQUE
When the flap is to be used as an island or free musculocutaneous flap, it is raised from the acromion to the
xiphoid, about 6 to 8 cm wide and about 30 cm long (5). In either case, the lateral border of the pectoralis major
muscle is first identified and is then separated from the distal aspect of the sternum toward the proximal aspect;
one must exercise care to isolate vessels to retain as the pedicle.
If the muscle is to be used as a musculocutaneous flap, it must be kept in mind that the location of the nipple will
become slightly deviated, and difficulty may be encountered in preparing the flap because of the fatty tissue of
the breast.
Figure 343.2 shows the procedures for identifying the pectoralis major muscle. At first the origin of the right
pectoralis major muscle is released and detached from the chest wall. The four nerve branches of the muscle are
identified. By electrically stimulating each of the branches, it is possible to determine the area served by each.
This method is useful when it is desirable to limit the amount of muscle transfer or to use it for more than two
separate applications (7).
FIGURE 343.2 A: The outer border or abdominal part of the right pectoralis major muscle is released (the head
is to the left). B: By electrical stimulation applied to each of the branches, it is possible to confirm the area
served by each. (From Ikuta et al., ref. 2, with permission.)
Figure 343.3 shows the transplanted pectoralis major muscle in the forearm, as well as the postoperative results.
SUMMARY
The pectoralis major muscle flap can be transferred with or without skin to replace muscles such as the
forearm flexors, where considerable exertion is required. There is minimal donor site morbidity.

FIGURE 343.3 A: A 6-year-old boy with characteristic findings of Volkmann's contracture. All flexor muscles
were excised at a previous operation. B: The insertion of the pectoralis major muscle is sutured to the
medial epicondyle of the humerus, and the muscular origin is sutured to the flexor tendons of the fingers
and thumb. C: The vessel (A and V) and nerve (N) anastomoses are shown by turning over the muscle flap.
PMM, pectoralis major muscle; AIN, anterior interosseous nerve; MN, median nerve; UN, ulnar nerve. D,E:
Five months postoperatively finger sensation is almost normal and there is powerful active flexion of the
thumb and the four fingers.
References
1. Clark JMP. Reconstruction of biceps brachii by pectoralis muscle transplantation. Br J Surg 1946;34:180.
2. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe
Volkmann's contracture. Plast Reconstr Surg 1976;58:407.
3. Shanghai Sixth People's Hospital. Free muscle transplantation by microsurgical neurovascular
anastomoses: report of a case. Clin Med J 1976;2:47.
4. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg
1978;3:416.
5. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck.
Plast Reconstr Surg 1979;63:73.
6. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979;317-
335.

7. Manktelow RT. Muscle transplantation. In: Serafin D, Buncke HJ, eds. Microsurgical composite tissue
transplantation. St. Louis: Mosby, 1979; 369-391.

Chapter 344
The Free Radial Artery Forearm Flap With Innervated Pronator
Quadratus
DAMIEN GRINSELL
PRADYUMNA HERLE
EDITORIAL COMMENT
This refinement in the radical forearm flaps for lip reconstruction allows for functional muscle transfer with
the innervated pronator quadratus flap.
INDICATIONS
This novel variant of the radial artery forearm flap is potentially a solution whenever a reconstructive
solution requires both skin and/or mucosal coverage and functional muscle. We have mainly utilized this
flap for reconstruction of large lip defects, typically greater than 80% loss of the lower lip or greater than
50% loss of the upper lip. Other documented uses of this flap have been limited to only one other series in
which the flap was utilized for reanimation of the paralyzed face (1).
ANATOMY
Vascular Anatomy
Main pedicle: Radial artery, venae comitantes of radial artery
Pedicle length: 18 cm (range 15 to 22 cm)
Artery diameter: 3 mm (range 2.5 to 3.5 mm)
Venae comitantes diameter: 1.5 mm (range 1 to 2 mm)
The supply of the radial artery to the skin portion of the flap via fasciocutaneous branches in the septum
between brachioradialis and flexor carpi radialis is well documented.
The pronator quadratus muscle derives its main vascular supply from the anterior interosseus artery. This
flap, however, relies on the secondary supply of the muscle by branches from the radial artery. There are five
to six branches given to the muscle perpendicular to its longitudinal axis. The branches are approximately 14 mm
long and spaced at 1-cm intervals. Muscle survival is based off the rich anastomoses between these
perpendicular branches and the branches of the anterior interosseous artery within the muscle, as established
by cadaveric dye studies by Lee et al. (2, 3).
Neurologic Anatomy
Main pedicle: Anterior interosseous nerve
Pedicle length: 7 to 8 cm
Sensory nerve: Lateral cutaneous nerve of the forearm
The neurologic supply of the pronator quadratus is derived from the anterior interosseus nerve, and maximal

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neurologic pedicle length of 7 to 8 cm can be achieved with intraneural dissection from fibers to the flexor pollicis
longus, which arise 60 mm from the proximal border of the muscle (3).
FLAP DESIGN AND DIMENSIONS
Flap Design
Refer to Figure 344.1.
Dimensions
Skin island
Length: 10 cm
Width: 5 to 10 cm
Pronator quadratus muscle
Length: 6 cm
Width: 3.5 cm
Axis
The axis for the flap is essentially the radial artery. The artery can be palpated in the distal portion of the forearm
and followed proximally with a Doppler for precise position.
FIGURE 344.1 Outline of flap design.
Skin Paddle Markings
Based on previously documented descriptions of the radial forearm free flap, almost all the skin of the forearm
except for a 4- to 5-cm strip on the posterior aspect of the forearm and ulnar subcutaneous border can be raised
safely with the radial forearm flap (4). In our practice, we have not encountered indications with the need for such
large skin flaps. The shape of the tissue taken can be taken to a template based on the reconstructive defect. In
our experience, skin flaps of dimension 8 to 10 cm can be taken and closed primarily when the procedure is
combined with prior tissue expansion (Fig. 344.2).
OPERATIVE TECHNIQUE
Step 1: Lateral Edge of Flap
The lateral edge of the skin flap is elevated in a suprafascial plane until the superficial radial nerve piercing the
deep fascia behind the brachioradialis tendon is identified. The deep fascia is then entered medial to the nerve

to ensure the nerve is not taken with the flap and the flap is raised subfascially over the brachioradialis tendon.
The septum between the brachioradialis and flexor carpi radialis is thus reached from the lateral side. Attention
now is focused on the medial side of the flap.
Step 2: Medial Edge of Flap
The medial margin of the flap is raised suprafascially from the fascia overlying the palmaris longus, flexor
digitorum superficialis, and flexor carpi radialis tendons. Once the dissection reaches the lateral margin of the
flexor carpi radialis, the septum in which the vascular bundle to the flap is contained is reached from the medial
side. At this point, the fascia is incised to become subfascial. The flexor carpi radialis and other long flexor
tendons (palmaris longus, flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus) and the
median nerve are retracted medially to expose the superficial surface of the pronator quadratus. At its superior
margin is the entry of the anterior interosseous neurovascular bundle. The nerve is identified and traced
proximally. Intraneural dissection can be performed to separate it from the FPL (Flexor Pollicis Longus) nerve
bundles if extra length is required. Once adequate nerve pedicle length is achieved, the anterior interosseous
nerve branch to the pronator quadratus is ligated and delivered gently to rest on the superficial surface of the
pronator quadratus The muscle is then elevated from the underlying bones of the forearm and distal radioulnar
complex in a subperiosteal plane in an ulnar to radial direction. Remaining in a subperiosteal plane protects the
main vascular pedicle and branches to the muscle, which lie on the superficial surface of the muscle. A periosteal
extension can be included proximally if further length or width to the muscle is required.
FIGURE 344.2 Skin paddle with tissue expander in situ.
Step 3: Dissection of Vascular Pedicle
The distal end of the radial artery and venae comitantes in the septum between brachioradialis and flexor carpi
radialis are found and the vessels are ligated here. Applying gentle upward traction on the combined skin and
muscle flap, any adhesions between the flap and surrounding tissue are divided and pedicle length is developed
by following the radial artery and venae comitantes proximally as far as needed towards the brachial artery. The
superficial radial nerve is avoided by dissecting carefully on the lateral side of the pedicle.
The lateral cutaneous nerve is found entering the flap when dissecting the proximal edge of the flap and followed
suprafascially to provide a sensate basis for this flap.
CLINICAL RESULTS
The composite radial forearm free flap with palmaris longus sling represents the workhorse for one-stage
reconstruction of large lip defects (5, 6, 7). While the technique of the suspension technique has been
refined over time, improving functional and aesthetic outcomes as a result (5, 6, 7, 8, 9, 10, 11, 12, 13, 14),
the use of static slings is not without its faults. Many series have demonstrated unsatisfactory oral
competence particularly during dynamic activities (7, 10, 15). Static slings in reconstruction may droop and
loosen over time secondary to loss of orbicularis oris function (10, 11, 16, 17, 18, 19). Functional muscle
flaps therefore offer a potential solution to these limitations of static reconstructive techniques.
Functional flaps, especially the gracilis muscle flap, have been increasingly gaining popularity (5, 15). The

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gracilis flap inset requires precise trimming of length and width and coaptation with the branches of the
facial nerve for function (20). The gracilis flap, however, has a notoriously unreliable skin flap and usually
requires coverage by skin grafts or other reconstructive techniques externally and mucosal flaps, for
example, facial artery musculomucosal (FAMM) flaps, posteriorly (20, 21, 22). The gracilis muscle is also
very large, and it can be difficult to achieve the subtle movements required for lip function (15).
We have utilized this flap in a series of three patients for complex lip reconstructions. Our study revealed
that muscle flicker recovered within 4 to 7 months postoperatively and function as a dynamic structure to
achieve oral competence was achieved in all cases, thus offering a promising new tool in approaching
complex lip reconstruction (Figs. 344.3, 344.4, 344.5).
SUMMARY
This flap combines the advantages of the cutaneous coverage of the radial forearm flap with the
functionality of having sphincteric muscle action in a one-step procedure. This represents a potential new
standard for reconstruction of near total lip defects to allow for sphincteric function as well as adequate skin
and mucosal coverage and adequate aesthetic quality. Minimal donor site morbidity is noted.
FIGURE 344.3 Defect in patient one in series.

FIGURE 344.4 Result in first patient in series.
FIGURE 344.5 Result in patient two of series.
References
1. Tzou CH, Aszmann OC. Reanimation of the paralyzed face: radial forearm-pronator quadratus muscle flap.
JAMA Facial Plast Surg 2013;15:388-390.
2. Fontaine C, Millot F, Blancke D, et al. Anatomic basis of pronator quadratus flap. Surg Radiol Anat
1992;14:295-299.
3. Lee JC, Lim J, Chacha PB. The anatomical basis of the vascularized pronator quadratus pedicled bone
graft. J Hand Surg [Br] 1997;22:644-646.
4. Soutar DS. Flaps and reconstructive surgery. In: Wei FC, Mardini S, eds. Saunders (Elsevier), 2009;320-
338.

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5. Martin T, Sury F, Goga D, et al. Reconstruction of large defects of the lips and commissure using a
composite radial forearm palmaris longus free flap associated with a lengthening temporalis myoplasty. Ann
Plast Surg 2012;69:169-172.
6. Jeng SF, Kuo YR, Wei FC, et al. Total lower lip reconstruction with a composite radial forearm-palmaris
longus tendon flap: a clinical series. Plast Reconstr Surg 2004;113:19-23.
7. Cinar C, Arslan H, Ogur S. Reconstruction of massive lower lip defect with the composite radial forearm-
palmaris longus free flap: empowered static and partial dynamic reconstruction. J Craniofac Surg
2007;18:237-241.
8. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial
forearm-palmaris longus free flap. Plast Reconstr Surg 1991;88:209-214.
9. Serletti JM, Tavin E, Moran SL, et al. Total lower lip reconstruction with a sensate composite radial
forearm-palmaris longus free flap and a tongue flap. Plast Reconstr Surg 1997;99:559-561.
10. Sakai S, Soeda S, Endo T, et al. A compound radial artery forearm flap for the reconstruction of lip and
chin defect. Br J Plast Surg 1989;42:337-338.
11. Sasaki K, Adachi K, Sekido M. Transverse fascial suspension with muscle bow traction: advantages for
full-thickness lip reconstruction involving the oral commissure using free flap. J Plast Reconstr Aesthet Surg
2012;65:e193-e196.
12. Carroll CM, Pathak I, Irish J, et al. Reconstruction of total lower lip and chin defects using the composite
radial forearm—palmaris longus tendon free flap. Arch Facial Plast Surg 2000;2:53-56.
13. Ozdemir R, Ortak T, Kocer U, et al. Total lower lip reconstruction using sensate composite radial forearm
flap. J Craniofac Surg 2003;14:393-405.
14. Kuzon WM Jr, Jejurikar S, Wilkins EG, et al. Double free-flap reconstruction of massive defects involving
the lip, chin, and mandible. Microsurgery 1998;18:372-378.
15. Langstein HN, Robb GL. Lip and perioral reconstruction. Clin Plast Surg 2005;32:431-445, viii.
16. Mandrekas AD, Page R, O'Neill TJ. Upper lip reconstruction with a radial forearm free flap. J Craniofac
Surg 1994;5:105-107; discussion 108-109.
17. Furuta S, Sakaguchi Y, Iwasawa M, et al. Reconstruction of the lips, oral commissure, and full-thickness
cheek with a composite radial forearm palmaris longus free flap. Ann Plast Surg 1994;33:544-547.
18. Shinohara H, Iwasawa M, Kitazawa T, et al. Functional lip reconstruction with a radial forearm free flap
combined with a masseter muscle transfer after wide total excision of the chin. Ann Plast Surg 2000;45:71-

73.
19. Kushima H, Iwasawa M, Kiyono M, et al. Functional reconstruction of total lower lip defects with a radial
forearm free flap combined with a depressor anguli oris muscle transfer. Ann Plast Surg 1997;39: 182-185.
20. Gurunluoglu R, Glasgow M, Williams SA, et al. Functional reconstruction of total lower lip defects using
innervated gracilis flap in the setting of high-energy ballistic injury to the lower face: preliminary report. J
Plast Reconstr Aesthet Surg 2012;65:1335-1342.
21. Ueda K, Oba S, Nakai K, et al. Functional reconstruction of the upper and lower lips and commissure
with a forearm flap combined with a free gracilis muscle transfer. J Plast Reconstr Aesthet Surg
2009;62:e337-e340.
22. Ninkovic M, Spanio di Spilimbergo S, Kim Evans KF. Lower lip reconstruction using a functioning gracilis
muscle free flap. Semin Plast Surg 2010;24:212-218.

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Chapter 345
Free Fibular Transfer
A. GILBERT
The free fibular transfer has revolutionized the reconstruction of long bone defects. Originally (1) the fibula was
harvested by a posterior incision (2). I have found, however, that the lateral approach has several advantages
(3).
INDICATIONS
Between 1975 and 1983, this approach was used 160 times with the following indications: for posttraumatic
reconstruction in the upper and lower limb (6 and 43 times, respectively), for necrosis of the femoral head
(63 times), for congenital pseudarthrosis (31 times), and for tumors (17 times). There were four cases of
transfer with skin and two cases of transfer with the soleus muscle.
ANATOMY
The vascular anatomy of the fibula has been well described (4). The length of the fibula varies between 30 and
40 cm, with an average of 34 cm.
There are two types of vascularization to the fibula, provided primarily by the peroneal artery. One source is the
nutrient artery, usually unique and branching 6 to 14 cm from the origin of the peroneal artery. The nutrient artery
enters the bone in its middle third, usually at mid-diaphysis. It then divides into an ascending and a descending
branch into the bone. Periosteal vascularization comes from a series of branches from the peroneal artery and
the anterior tibial artery. These branches may be direct periosteal branches or musculoperiosteal arteries.
In my experience, the peroneal artery is seldom absent. In only one out of 160 clinical cases was it replaced by a
direct branch from the posterior tibial artery to the bone.
OPERATIVE TECHNIQUE
The lateral approach has simplified free bone transfer and shortened operating time, so that harvesting takes
between 30 and 50 minutes. The fibula may be harvested through a lateral approach in a patient who is supine,
prone, or in a lateral position. The knee is slightly bent to relieve tension on the muscles (Fig. 345.1).
A line is drawn joining the head of the fibula and the lateral malleolus (Fig. 345.2A). At the middle of this line, a
point will indicate the approximate location of the nutrient vessel. This point should be included in the graft.
The incision is slightly longer than the graft. After incision of the superficial aponeurosis, the dissection is
directed straight toward the bone shaft, pushing the peroneal muscles and the musculocutaneous nerve forward
and the soleus backward (Fig. 345.2C). The bone is reached quickly and the dissection then becomes
extraperiosteal, but without keeping the musculotendinous cuff on the anterolateral two-thirds of the fibula.
Detachment continues forward up to the interosseous membrane, which is incised, and downward to the flexor
hallucis longus. The graft is then measured and the bone sectioned at both ends, using a Gigli saw, although the
peroneal artery has not yet been properly identified (Fig. 345.2D).

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FIGURE 345.1 A,B: Schematic representation of the main steps in harvesting the fibula via the lateral approach.
FIGURE 345.2 The operative technique. A: The fibula is drawn on the skin and the middle third is preserved. B:
After the peroneus longus is retracted anteriorly, the fibula is well exposed. C: After the muscles are detached
from the bone, the aponeurosis is divided anteriorly. D: After the distal and proximal ends of the fibula are cut
with the Gigli saw, the distal end of the peroneal vascular bundle is ligated. At this point, the proximal vessels
can be identified and the peroneal artery transected just distal to the bifurcation.
The graft can then be easily removed, taking the vascular bundle with it. This bundle is first located and tied at
the distal portion of the graft, and the dissection continues toward the origin of the peroneal artery, keeping a
minimal muscular cuff.
Using the dissection technique described and working under visual control, one can reach the peroneotibial
bifurcation very quickly. The fibula is then isolated on its pedicle and the tourniquet is released, with testing for

good bone vascularization. When the recipient site is ready, the pedicle (which has been kept in place) is
sectioned just below the bifurcation.
The muscles are reinserted on the interosseous membrane with a few sutures, and the leg is closed on a suction
drain. If the patient is in satisfactory condition, he can stand with his full weight on the grafted side after 3 to 4
days.
Variations in Technique
Recently, several modifications of the described bone transfer have been proposed. It has been shown that the
transfer may include the soleus muscle, vascularized by its main pedicle, which depends on the peroneal artery
(5).
It is also possible to take some skin with the fibula, either using the musculocutaneous branches of the peroneal
artery (6), or as I have done in several cases, using only the direct cutaneous branches arising at the junction of
the middle and distal thirds of the fibula.
CLINICAL RESULTS
Monitoring of the bone is difficult when it is not transferred with skin or muscle. Bone scans do not seem to
be completely reliable, nor do arteriograms. In this series there has been no case of postoperative infection,
but this does not mean that there were no failures. When there is no muscle with the bone, vascularization
failure does not produce massive necrosis, but a nonvascularized bone graft is simply the result.
Very few complications were found at the donor site in adult patients. In six cases, there was a clinical
absence of big toe extension. In children under 9 years of age, valgus deformity of the ankle occurs if the
fibula is not reconstructed. I try always to reconstruct the donor bone using a corticoperiosteal tibial bone
graft (Fig. 345.3). In 11 cases the graft resorbed or did not heal properly, and it was necessary to do a
secondary procedure to obtain healing.
SUMMARY
Transfer of a vascularized fibula has become a well-established procedure for reconstruction of long bone
defects. The use of a lateral approach to the donor site has greatly simplified the procedure.
FIGURE 345.3 A,B: A 5-year-old girl with congenital pseudarthrosis who had had several previous

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operations. C: Immediate postoperative result. (Continued)
FIGURE 345.3 (Continued) D: Result at 3 months. E: Result at 1 year. Note the reconstruction of left
(donor) fibula.
References
1. Taylor G, Miller G, Ham F. The free vascularized bone graft: a clinical extension of microvascular
techniques. Plast Reconstr Surg 1975;55:533.
2. Weiland A, Daniel R. Microvascular anastomoses for bone grafts in the treatment of massive defects in
bone. J Bone Joint Surg 1979;61:98.
3. Gilbert AA. Free transfer of the fibular shaft. Int J Microsurg 1979;1:100.
4. Restrepo J, Katz D, Gilbert A. Arterial vascularization of the proximal epiphysis and the diaphysis of the
fibula. Int J Microsurg 1980;2:48.
5. Baudet J, Panconi B, Caix P, et al. The composite fibula and soleus transfer. Int J Microsurg 1982;4:10.
6. Chung-Wei C, Wang Y. The study and clinical application of the osteocutaneous flap of fibula.
Microsurgery 1983;4:11.

Chapter 346
Transposition Skin Flap to The Elbow
M. B. CONSTANTIAN
Defects requiring flap coverage over the extensor surface of the elbow can be reconstructed with an anteriorly
based transposition flap (1, 2). Pressure ulcers often occur over the olecranon, commonly in patients who lie
prone for long periods and prop themselves up on their elbows.
ANATOMY
Branches of the arteries that anastomose around the elbow joint supply this transposition flap: the middle and
radial collateral and muscular branches of the deep brachial artery, the recurrent radial artery, the posterior ulnar
recurrent artery, and the superior and inferior ulnar collateral (supratrochlear) arteries.
FLAP DESIGN AND DIMENSIONS
The flap should be designed large enough for the defect, remembering that its rotational arc does not easily
exceed 4 to 6 cm and that the base cannot safely be backcut to ease closure. The usual undelayed flap
dimensions are 8 to 12 cm in length and 6 to 9 cm in width. Flaps that are larger should be delayed.
OPERATIVE TECHNIQUE
If the olecranon bursa is involved (and it usually is), it must be completely excised. Joint involvement changes
management and should be established preoperatively by probing and sinography. If a pyarthrosis exists, the
joint may need to be curretted, resected, or arthrodesed. Flap closure over closed irrigation and suction
catheters is an alternative management method for early pyarthrosis, and may succeed in experienced hands.
Treatment of joint or bursa must be adequate. Failure to correct such abnormalities is the commonest cause of
postoperative seroma, flap loss, infection, and ulcer recurrence.
The flap should be raised at the level of the deep fascia overlying the lateral head of the triceps and the proximal
ends of the brachioradialis and extensor carpi radialis longus muscles. Drainage is advisable beneath the inset
flap if bony modification has been necessary. A split-thickness skin graft is needed for the donor defect (Fig.
346.1).
CLINICAL RESULTS
As with many procedures, the success rate is high if each step is executed correctly. Aside from flap loss,
the commonest complications are based on inadequate diagnosis or treatment of bursa or joint
abnormalities that may lead to seroma, ulcer recurrence, or pyarthrosis. The surgeon may wish to use the
brachioradialis muscle that lies beneath the flap as an additional or alternate source of vascularized tissue
in the case of a pyarthrosis. Of course, a brachioradialis muscle flap is not advisable in quadriplegics, for
whom this may be the only voluntary forearm muscle for transfer.
SUMMARY
A transposition skin flap should be considered as one of the alternatives for coverage of an elbow defect,
especially over the olecranon.

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FIGURE 346.1 Local transposition flap for closure of ulcer over olecranon. The secondary defect must be
grafted with a split-thickness skin graft.
References
1. Constantian MB, Jackson HS. Ulcers in less common sites. In: Constantian MB, ed. Pressure ulcers:
principles and techniques of management. Boston: Little, Brown, 1980.
2. Hentz VR, Pearl RM, Kaplan EN. Use of medial upper arm skin as an arterialized flap. Hand 1980;12:241.

Chapter 347
Cephalic Venous Flap
R. L. THATTE
M. R. THATTE
EDITORIAL COMMENT
This flap has limited clinical applications and, although the popularity of flow-through venous flaps has not
entirely waned, it would not be the editors' first choice.
The cephalic venous island flap is a fasciocutaneous flap in the upper half of the radial side of the forearm (1).
Based near the elbow, it has been shown to survive with only the cephalic vein as the feeding and draining
vessel. All other structures, skin, subcutaneous tissue, and fascia are divided. The exact mechanism of the
survival of venous flaps remains a matter for conjecture (2, 3, 4).
INDICATIONS
In the present state of its development the flap is useful to cover defects on the medial and posterior
surfaces of the elbow like a standard fasciocutaneous flap. However, because it is based on a single vein
as an island it is far easier to transpose.
FLAP DESIGN AND DIMENSIONS
The cephalic vein is marked on the lower two-thirds of the upper extremity after raising the tourniquet to occlude
the venous flow. The tourniquet is then released. The arm is exsanguinated and the tourniquet is raised up to
250 mm Hg. A longitudinal flap is then marked along the forearm 5 cm on either side of the cephalic vein up to
about the middle of the forearm, with its base at the elbow (Fig. 347.1).
OPERATIVE TECHNIQUE
The flap is cut along the longitudinal axis (i.e., AB and DC) as a fasciocutaneous flap, and the distal end (i.e.,
BD) is then cut after clamping and ligating the distal cephalic vein. The tourniquet is then released, obvious
bleeders are cauterized and 100 units of heparin per kilogram of body weight are injected intravenously. After
securing further hemostasis, the flap is then converted into an island (Fig. 347.2) by cutting across skin,
subcutaneous tissue, and fascia (along AC; see Fig. 347.1) without severing the cephalic vein or its medial
cubital tributary. (The medial cubital vein, however, may not be constant and is not a mandatory part of the flap
design.) Neither of the veins are teased off of the flimsy soft envelope. The fasciocutaneous island hanging by
the cephalic vein can now be transposed across the elbow medially or posteriorly as required.
CLINICAL RESULTS
As mentioned earlier, the flap is in its initial stages of development and is presented for its unique ability to
survive on venous circulation alone without any apparent arterial input. We have used it in four cases for
defects created by releasing contractures of the elbow on the medial side without any loss of flap. Because
a flap was used, postoperative splinting was not needed.

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P.929
SUMMARY
A fasciocutaneous island flap based only on cephalic venous circulation in the upper half of the forearm is
presented in its early stages of development.
FIGURE 347.1 A: Schematic drawing of flap design. CV, cephalic vein; BV, basilic vein; MC, median cubital
vein. B: Flap raised retaining only its venous connections. C: Flap transposed through 90° with only
proximal veins intact.
FIGURE 347.2 A: Preoperative view showing the right elbow with a post-burn flexion deformity, in a 29-
year-old man. B: The contracture was complicated by myositis ossificans. The elbow was fixed at 90°.
(Continued)

FIGURE 347.2 (Continued) C: The exposure by a long ulnar midneutral incision. The anterior block of bone
was exposed by retracting all anterior structures and securing the ulnar nerve (arrow). A clear plane of
dissection was available between the normal bone and the mature myositic bone mass, which was shelled
out (5 × 5 cm). D: Once the scar tissue was excised, complete flexion of the elbow was possible, but
extension was restricted by scar tissue straddling the medial side. The cephalic venous flap was then
marked distal to the defect. E: The flap is attached to the body by (1) the cephalic vein, (2) the median
cubital vein, and (3) the accessory cephalic vein. (Only the cephalic vein is necessary for survival of the
flap.) F: The flap transposed into the defect.
References
1. Thatte RL, Thatte MR. Cephalic venous flap. Br J Plast Surg 1987;40:16.
2. Baek SM, Weinberg H, Song Y, et al. Experimental studies in the survival of venous island flaps without
arterial inflow. Plast Reconstr Surg 1985;75:88.
3. Thatte RL, Thatte MR. A study of the saphenous venous island flap in the dog without arterial inflow using
a non-biological conduit across a part of the length of the vein. Br J Plast Surg 1987;40:11.
4. Chavoin JP, Rogue D, Vachaud M, et al. Island flaps with an exclusively venous pedicle: a report of eleven
cases and a preliminary haemodynamic study. Br J Plast Surg 1987;40:149.

Chapter 348
Superior Medial Arm Flap
C. E. CARRIQUIRY
EDITORIAL COMMENT
The value of this chapter is the clear anatomy that the author outlines, so that the physical approach to the
medial arm flap is possible. The flap is reliable as well.
The skin of the medial arm is thin, hairless, and barely pigmented, making it very suitable for coverage of the
hand, face, neck, or flexor creases. Proper utilization of the direct septocutaneous branches of the brachial artery
allow elevation of safe fasciocutaneous flaps. These can vary in size, design, orientation, pedicle position, and
method of transfer, to meet a wide variety of clinical requirements.
INDICATIONS
Medial-arm septocutaneous flaps can be used for release of axillary and elbow-crease contractures, and
can be deepithelialized for contour improvement of the anterior axillary wall and for subclavicular depression
after mastectomy. As cross-arm flaps, they are useful for hand and digit coverage, particularly of the thumb,
and for thenar-web reconstruction. They can also be utilized in the rare case of Tagliacotian nasal
reconstruction.
ANATOMY
The brachial artery gives off three to four septocutaneous branches (1, 2) that enter the medial arm septum at
variable intervals. The uppermost branch origin is usually adjacent to the lower border of the pectoralis major
tendon (Fig. 348.1), while the lowermost vessel emerges 2 to 4 cm above the medial epicondyle. On reaching
the deep subcutaneous plane on top of the fascia, the septocutaneous vessels ramify into a few branches (see
Fig. 348.1), which are interconnected by means of longitudinally oriented vessels, sometimes adjacent to the
cutaneous nerves. This vascular arrangement allows safe elevation of longitudinal flaps that stretch along the
whole length of the medial arm. They may be based on either the upper or lower septocutaneous perforator (Fig.
348.2).
Venous drainage is adequate through the venae comitantes of the septocutaneous arteries, although the basilic
vein may also be included in some flaps.
The territories supplied by the superior ulnar collateral and the recurrent ulnar vessels overlap, to a considerable
extent, with that of the brachial septocutaneous branches. Flaps based on the former (3, 4) will not be described
here.

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FIGURE 348.1 The skin of a latex-injected arm has been raised at the subfascial plane from lateral to medial
midlines and the fascia has been removed, so that three large septocutaneous perforators can be appreciated in
detail. They emerge at the medial septum, just behind the brachialis muscle, and arborize in the deep
subcutaneous fat. Longitudinal ramifications arise from the transverse trunks and course parallel to the axis of
the arm. Note the position of the uppermost vessel, close to the pectoralis major insertion, and the most distal
vessels at about 4 cm above the medial epicondyle. (From Carriquiry, ref. 2, with permission.)
FIGURE 348.2 A-C: Diagrammatic representation of the septocutaneous vessels of the medial arm as the basis
for fasciocutaneous flaps. Flaps can be raised either distally (B) or proximally (C). One or more perforators must
be severed to mobilize the flap; their territories are captured by the remaining pedicle. (From Carriquiry, ref. 2,
with permission.)
FLAP DESIGN AND DIMENSIONS