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

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flap transfer.
FIGURE 348.3 A: Postburn contracture of the elbow crease; elbow extension is blocked. B: Outline of
island fasciocutaneous flap on medial arm, which has been spared from burns. C: The flap elevated as an
island. D: Undersurface of the flap is exposed. Note short segment of septum on which flap is based. E:
One year postoperatively, extension and excellent contour have been achieved. (From Carriquiry, ref. 2,
with permission.)
FIGURE 348.4 Subtotal soft-tissue avulsion of volar surface of the thumb. A distally based cross-arm flap
has been used for coverage. Note the long pedicle that prevents direct contact between the recipient hand

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and donor arm, and the direct closure of the donor site. (From Carriquiry, ref. 2, with permission.)
References
1. Salmon M. Artères de la peau. Paris: Masson, 1936.
2. Carriquiry CE. Versatile fasciocutaneous flaps based on the medial septocutaneous vessels of the arm.
Plast Reconstr Surg 1990;86:103.
3. Kaplan EN, Pearl RM. An arterial medial arm flap: vascular anatomy and clinical applications. Ann Plast
Surg 1980;4:205.
4. Maruyama Y, Onishi K, Iwahira Y. The ulnar recurrent fasciocutaneous island flap: reverse medial arm
flap. Plast Reconstr Surg 1987;79:381.

Chapter 349
Fasciocutaneous Flaps for Elbow Coverage
T. R. HEINZ
L. O. VASCONEZ
EDITORIAL COMMENT
The fasciocutaneous flaps presented in this chapter and in Chapter 350 are excellent for traumatic defects
with exposure of the elbow or elbow joint, as well as for resurfacing following excision of large olecranon
type of ulcerations.
Local fasciocutaneous flaps form an important part of soft- tissue coverage for elbow defects, often following
burns, but also as the result of trauma, tumor, or olecranon bursitis.
INDICATIONS
The options available among fasciocutaneous flaps for elbow coverage are numerous, given the rich
collateral circulation of both the medial and lateral arm, which extends onto the forearm. The ideal flap,
which may be derived from any of these territories, would be thin, pliable, and its donor site either entirely or
partially closed primarily. Local flaps that satisfy these requirements may be derived from the medial or
lateral arm.
ANATOMY
Lateral Arm Fasciocutaneous Flap
The standard lateral arm flap, which has been utilized as a free and pedicled flap, may be used in reverse
fashion for elbow coverage based on the posterior radial collateral artery (PRCA) (1, 2, 3, 4). Reversed lateral
arm flaps for elbow coverage may be raised to at least 8 × 10 cm, based on injection studies with methylene
blue. They are also based on the posterior radial collateral artery system taken, in this instance, as a reversed
pedicle flap with a pivot point at the lateral epicondyle. This well-known flap pedicle is found in the lateral
intramuscular septum and extends at least halfway up the arm proximally, giving off numerous perforators
through the septum based on this vessel (Fig. 349.1). The radial nerve is found immediately adjacent to the
pedicle, and care should be taken during dissection to avoid injury to this nerve.
The venous return in this reversed island pedicle flap is presumably by multiple venae comitantes crossover (3).
Proximally Based Pedicle Lateral Forearm Flap
Careful anatomic studies of the forearm fascial extension of the well-known lateral arm flap have been carried out
(5). This flap is found to divide into anterior and posterior divisions 4 cm proximal to the lateral epicondyle. The
posterior division anastomoses with the interosseous recurrent artery and supplies the circulation about the
elbow, including the joint and skin. The anterior division is of more interest, since it extends along the lateral
forearm extensor surface in the axis of the brachioradialis muscle, for an average of 15 cm (Fig. 349.2). In
cadaver studies, the artery extended from 13 to 18 cm.

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Medial Arm Fasciocutaneous Flap
Flaps based on the medial circulation at the elbow have been studied and described (6). This is a
fasciocutaneous reversed pedicle flap based on the ulnar recurrent artery, which, through a network of
interconnecting fascial systems from perforators on the medial arm, can be harvested nearly up to the axilla. This
provides very substantial flap coverage for anterior/cubital or posterior defects.
FIGURE 349.1 Diagram of distally based lateral arm flap with pedicle lying over lateral epicondyle.
This fasciocutaneous flap is based on the network of the ulnar recurrent artery from the brachial artery, which
travels distally through the larger posterior branch between the two heads of the flexor carpi ulnaris, to join the
superior/inferior ulnar collateral arteries around the medial epicondyle (Fig. 349.3). It is found to travel posterior
to the medial epicondyle and immediately posterior to the ulnar nerve, and must be separated from the nerve
with meticulous dissection. Quite constant in at least 18 dissections is the network of five to six perforators that
anastomose in a subfascial plane along the medial arm to the axilla. The ulnar recurrent artery itself branches
from the ulnar artery just distal to the separation of the radial and ulnar arteries, as they leave the brachial artery
and the antecubital area.
FIGURE 349.2 Layout and plan for proximally based lateral forearm flap based on extension of posterior radial
collateral artery on axis of brachioradialis muscle.

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FIGURE 349.3 Diagram of distally based medial arm flap, supported by septal perforators from ulnar recurrent
artery. The ulnar nerve must be dissected carefully away.
FLAP DESIGN AND DIMENSIONS
Lateral Arm Fasciocutaneous Flap
The midline of the flap should be placed on the longitudinal line between the deltoid insertion down to the lateral
epicondyle of the humerus. A flap at least as large as 8 × 10 cm may be harvested, based on the PRCA. Primary
closure is possible up to a flap width of 6 cm.
Proximally Based Pedicle Lateral Forearm Flap
A thin, proximally based, pedicled fasciocutaneous flap may be harvested from the extensor forearm skin
territories, typically with an elliptical design. It should be especially well suited to the antecubital area, such as for
burn contracture release. The pivot point of this flap is again the lateral epicondyle and the territory immediately
proximal to it. Flap design may be best done in a tongue-shaped fashion with primary closure of the donor site in
most cases where an island is not required. In addition, anatomic and clinical studies have shown the potential
for use of the lateral forearm flap in conjunction with the lateral arm flap, to provide a very substantial flap length,
one that may or may not include the lateral antebrachial cutaneous nerve.
Medial Arm Fasciocutaneous Flap
The island skin margins should lie between the mid anterior and posterior lines of the arm itself. The flap size, on
average, by methylene blue injections in cadaver studies, was 15 × 17 cm; clinically, however, flaps up to 29 × 8
cm have been raised without flap loss.
OPERATIVE TECHNIQUE
Lateral Arm Fasciocutaneous Flap
Flap design and markings are laid out on the involved arm, usually as an ellipse. Dissection is carried out
posteriorly to the
septum, followed by the anterior subfascial dissection, again to the septum. With the septum well delineated, the
proximal pedicle vessels may be divided at the most proximal extent of the flap. Care should be taken to avoid
injury to the radial nerve in this portion of the dissection. The deep fascia of the triceps posteriorly and biceps
anteriorly, is included. Careful dissection allows elevation of the flap from the radial nerve and humerus,
preserving the pedicle in the lateral intramuscular septum down to its pivot point at the lateral epicondyle. Careful
planning should allow coverage of posterior anterior/cubital or even medial defects about the elbow. Sutures may

be used to narrow or close the donor wound, and a skin graft may then be applied. Postoperative splinting of the
limb at 130° to 150° at the elbow is recommended.
Medial Arm Fasciocutaneous Flap
The longitudinal portion of the predesigned flap should be incised through skin, subcutaneous fat, and fascia.
The fascia may then be elevated from anterior and posterior to the septum between the brachialis and triceps
muscles. The perforators that are distributed inferiorly and posteriorly in the subfascial plane may be identified
and traced to the midline of the flap, and then to the pedicle itself, found in the interval between triceps and
brachialis muscles adjacent to the ulnar nerve. The proximal pedicle may be divided at this time, and dissection
of the pedicle itself from proximal to distal is carried out. Again, some care must be taken to avoid injury to the
ulnar nerve that is immediately adjacent to the pedicle; this should be relatively easy. The pedicle may be
dissected to just distal to the medial epicondyle, to allow easier rotation anteriorly or posteriorly, if coverage of
the elbow is required.
The donor site may be primarily closed up to 6 cm or partially skin-grafted. Since the vessel lies deep between
the muscles, even portions of the arm that have been burned and skin-grafted may be used around the pedicle
itself or on the flap itself, given the very rich anastomotic network in the subfascial plane.
SUMMARY
The rich blood supply of the skin and fascia surrounding the elbow and antecubital fossa allows for the safe
design of a variety of fasciocutaneous flaps, either proximally or distally based.
References
1. Culbertson J, Mutimer K. The reverse lateral arm flap for elbow coverage. Ann Plast Surg 1987;18:62.
2. Katsaros J, Schusterman M, Beppu M, et al. The lateral arm flap: anatomy and clinical applications. Ann
Plast Surg 1984; 12:489.
3. Lin S-D, Lai C-S, Chiu C-C. Venous drainage in the reverse forearm flap. Plast Reconstr Surg
1984;74:508.
4. Kincaid C, Banis J. The lateral arm flap. In: Gilbert A, Masquelet A, Hentz A, eds. Pedicle flaps of the
upper limb. Boston: Little, Brown, 1992.
5. Lanzetta M, St. Laurent J-Y, Chollet A. The lateral arm flap: an anatomic and clinical study. Presented at
the Annual Meeting, American Society for Reconstructive Microsurgery, Tucson, AZ, January, 1996.
6. Maruyama Y, Onishi K, Iwahira Y. The ulnar recurrent fasciocutaneous island flap: reverse medial arm
flap. Plast Reconstr Surg 1987;79:381.
7. Cormack G, Lamberty B. The forearm angiotomes. Br J Plast Surg 1982; 35:420.

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Chapter 350
Radial Recurrent Fasciocutaneous Flap for Coverage of Posterior
Elbow Defects
F. C. AKPUAKA
The radial recurrent fasciocutaneous flap on the posterolateral aspect of the lower half of the upper arm is based
on the radial recurrent artery, a constant branch of the radial artery. It is a useful flap for one-stage coverage of
posterior elbow defects, and is superior to other alternatives (1).
INDICATIONS
The coverage of posterior elbow defects is usually difficult and time-consuming. Previously described local,
distant, and free flaps (2, 3, 4, 5, 6, 7, 8, 9), some of which are also one-stage procedures, have the
disadvantages of difficulty of elevation, association with a significant degree of functional muscle loss, and,
with the radial forearm or Chinese flap, complete division of the radial artery at the wrist that may be
associated with a number of local complications (10, 11, 12). The radial recurrent fasciocutaneous flap has
the advantages of decreasing donor site morbidity, preserving elbow flexion and a relative case of elevation
and transfer.
ANATOMY
Very close to its origin, the radial artery gives off the radial recurrent artery, which supplies branches to the
adjacent muscles such
as the supinator, and to the elbow joint. It then runs upward between the brachialis and the brachioradialis
muscles, to anastomose with the profunda brachii artery in the mid-upper arm, supplying these muscles (Fig.
350.1). The radial recurrent artery also supplies the fascia, subcutaneous tissue, and skin over the posterolateral
aspect of the lower half of the upper arm.
FIGURE 350.1 Diagram demonstrating the anatomy of the radial recurrent fasciocutaneous flap and major

arteries. (From Akpuaka, ref. 1, with permission.)
FLAP DESIGN AND DIMENSIONS
The flap, which is a type B fasciocutaneous flap (13), is outlined over the course of the radial recurrent artery,
which runs proximally across the lateral epicondyle toward the posterior border of the deltoid muscle. The base
of the flap is at the elbow joint, and the proximal limit is at the mid-upper arm. The width of the flap depends on
the size of the elbow defect, but the entire flap is taken on the posterolateral aspect of the upper arm (Figs. 350.2
and 350.3).
FIGURE 350.2 Schematic representation of the flap elevated in the upper arm. (From Akpuaka, ref. 1, with
permission.)
FIGURE 350.3 Elevation of a 7 × 6 cm flap. (From Akpuaka, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The incision is begun on the lateral side and carried through the skin to beneath the deep fascia. The flap is
freed by sweeping the finger up and down beneath the fascia, and then transposed over the defect, and sutured
into position (Fig. 350.4). The wound is drained for about 48 hours, using corrugated or suction drains. With
small-dimension tissue requirements, the donor defect can be closed primarily, but with a greater demand for
replacement tissue, it is necessary to apply split-thickness skin grafts at the donor site.

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FIGURE 350.4 Flap sutured into place. (From Akpuaka, ref. 1, with permission.)
CLINICAL RESULTS
A small series of cases, including post-olecranon fracture with wiring, left supracondylar compound fracture,
and severe posttrauma defect, were treated with radial recurrent fasciocutaneous flaps, measuring from 4 ×
4 cm to 7 × 6 cm. Donor sites were both sutured directly and covered by split-thickness skin grafts.
Postoperative healing at the flap and donor sites, as well as elbow movement, were satisfactory. There
were no complications.
SUMMARY
The radial recurrent fasciocutaneous flap is reliable, easy to elevate and transfer, and is associated with
much less donorsite morbidity than other available procedures for posterior elbow reconstruction.
References
1. Akpuaka FC. The radial recurrent fasciocutaneous flap for coverage of posterior elbow defects. Injury
1991;22:332.
2. Abu Jamra FN. Repair of major defects of the upper extremity with a latissimus dorsi myocutaneous flap: a
case report. Br J Plast Surg 1981;34:121.
3. Abu-Dalu K, Muggla M, Schiller M. A bipedicled chest wall flap to cover an open elbow joint in a burned
infant. Injury 1982;12:292.
4. Fisher J. External oblique fasciocutaneous flap for elbow coverage. Plast Reconstr Surg 1985;75:51.
5. Sbitany U, Wary RC. Use of the rectus abdominis muscle flap to reconstruct an elbow defect. Plast
Reconstr Surg 1986;79:988.
6. Grotting J, Walkinshaw M. The early use of free flaps in burns. Ann Plast Surg 1985;15:127.

7. Lendrum J. Alternatives to amputation. Ann R Coll Surg Engl 1980;62:95.
8. Lai MF, Krishna BV, Pelly AD. The brachioradialis myocutaneous flap. Br J Plast Surg 1981;34:431.
9. Nahai F, Mathes SJ. A selective approach to flap selection. In: Mathes SJ, Nahai F, eds. Clinical
application for muscle and myocutaneous flaps. St. Louis: Mosby, 1982.
10. Yang C, Chen B, Gao Y, et al. Forearm free skin flap transposition. N Med J China 1981;61:139.
11. Fatah MF, Davis DM. The radial forearm island flap in upper limb reconstruction. J Hand Surg
1984;9B:324.
12. Timmons MJ, Missotten FEM, Poole MD, et al. Complications of radial forearm flap donor sites. Br J
Plast Surg 1986;39:176.
13. Cormack GC, Lamberty BGH. A classification of fasciocutaneous flaps according to their patterns of
vascularization. Br J Plast Surg 1984;37:80.

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Chapter 351
Brachioradialis Muscle and Musculocutaneous Flap for Coverage
of The Elbow
A. GILBERT
J. RESTREPO
Coverage of the elbow can be difficult. Very few local flaps are safe and chest wall flaps can result in stiffness
since the joint cannot be immediately mobilized. The brachioradialis muscle provides a small but effective local
flap for coverage of the elbow (1, 2, 3).
INDICATIONS
This flap can cover completely the anterior aspect of the elbow, the lateral aspect and, depending on the
length of the muscular belly, the olecranon and posterior aspect of the joint. It has been used in our
experience for the treatment of flexion contractures of the elbow after burns and trauma. We have also used
it as a free neurovascular muscle flap.
ANATOMY
Dissection and injection studies on 50 forearms have revealed the following.
The average length of the muscle, from its insertion on the humerus to its tendinous insertion on the radius is 30
cm (24 to 33 cm). This muscle is the most superficial muscle of the lateral border of the forearm. The average
length of the tendon is 8 cm and the muscular part is approximately 22 cm.
The muscle is innervated by a branch of the radial nerve (C5-C6). There may be one or several branches. Their
main entry point is usually 6 cm distal to the humeral insertion of the muscle. It is important to note that the nerve
pedicle is different from the main vascular hilum.
The blood supply to the muscle consists of a main vascular pedicle and several accessory vessels. The main
pedicle usually branches from the radial recurrent artery (Fig. 351.1) (78%) but may come from the brachial
artery (12%), the radial artery (4%), or the ulnar recurrent artery (2%). This pedicle has an average length of 3.8
cm. The diameter of the direct branch is approximately 1.6 mm, but the radial recurrent artery has a diameter of 2
mm, which makes it a reasonable candidate for free microvascular transfer. The vascular hilum is situated from 6
to 16 cm (average 10 cm) distal to the humeral insertion.
FLAP DESIGN AND DIMENSIONS
The existence of direct musculocutaneous branches makes it possible to transfer the overlying skin with the
muscle belly. Injection studies show that at least the proximal two-thirds of the skin overlying the muscle can be
moved safely. The reasonable size of a proximally based flap would be 15 × 8 cm.

FIGURE 351.1 The arterial supply to the muscle usually comes from the radial recurrent artery.
If the flap is taken as a musculocutaneous flap, the donor defect cannot be closed primarily. For this reason, the
flap is usually used as a muscle flap and subsequently skin-grafted (Fig. 351.2).
OPERATIVE TECHNIQUE
An incision is made directly over the muscular prominence. The fascia is opened and the muscle is dissected
free from its surroundings. A small distal incision is used to cut the tendon, taking care to preserve the cutaneous
branch of the radial nerve. The dissection then progresses very quickly until it reaches the main pedicle. During
this dissection, one or two secondary pedicles must be cut. A few branches of the radial recurrent artery will
need to be transected to allow more mobility to the pedicle.
The muscle is then transferred and sutured over the defect. It is possible to “spread” the muscle, obtaining about
one-third of extra width (Figs. 351.2 and 351.3).
SUMMARY
The brachioradialis muscle can be used with or without the overlying skin to cover anterior and lateral
elbow defects.

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FIGURE 351.2 The muscle is transferred and sutured into the defect.

FIGURE 351.3 A: Flexion contracture of the elbow in an 8-year-old child. B: The contracture is released
and the biceps tendon is lengthened. C: The biceps tendon is covered by the brachioradialis muscle. D:
The muscle can be spread to further cover the defect. E: Elbow extension at 6 months postoperatively. F:
Elbow flexion at 6 months postoperatively.
References
1. Ger R. The coverage of vascular repairs by muscle transposition. J Trauma 1976;16:974.
2. Gilbert A, Restrepo J. Le long supinateur: anatomie et utilisation comme lambeau de rotation musculaire.
Ann Chir Plast 1980;25:72.
3. Lai MF, Krishan BV, Pelly AD. The brachioradialis myocutaneous flap. Br J Plast Surg 1981;34:431.

Chapter 352
Extensor Carpi Radialis Longus Muscle Flap for Anterior Elbow
Coverage
R. V. JANEVICIUS
EDITORIAL COMMENT
For defects in which muscle coverage is preferable, this is a most useful flap.
The extensor carpi radialis longus muscle, when elevated as an island flap, can cover large areas about the
elbow joint, with minimum donor-site morbidity (1). It can be used alone or in conjunction with the brachioradialis
muscle, to cover significant defects around the antecubital fossa.
INDICATIONS
Small defects about the elbow and antecubital fossa area can often be reconstructed with brachioradialis or
flexor carpi ulnaris muscle flaps. When these muscles are not available, or when larger areas require
coverage, the extensor carpi radialis longus (ECRL) muscle flap is indicated. Although it can be raised as a
musculocutaneous unit (2), I prefer its use as a pure muscle flap, as its arc of rotation will be far greater,
and donor-site morbidity will be minimal. The ECRL is a useful muscle for coverage about the elbow,
including coverage of the radial and median nerves and the humerus, after trauma or tumor resection.
ANATOMY
The ECRL originates from the lower third of the lateral supracondylar ridge of the humerus, and inserts into the
base of the index finger metacarpal. As it courses distally, it lies deep and ulnar to the brachioradialis and
superficial to the extensor carpi radialis brevis (ECRB). Its muscle belly ends at the junction of the proximal and
middle thirds of the forearm, its tendon then passing distally, superficial to the ECRB tendon. Its tendon then
passes deep to the abductor pollicis longus and extensor pollicis brevis, then through the second dorsal
compartment with the ECRB tendon, to insert into the dorsal base of the index metacarpal.
The ECRL is a Mathes type II muscle. Its proximal dominant vascular supply arises from the radial recurrent
artery 80% of the time, directly from the radial artery 10% of the time, and directly from the ulnar artery 10% of
the time (3). The proximal vascular pedicle arises within 4 cm of the antecubital crease. Minor pedicles occur
distal to this point.
Motor innervation of the ECRL arises from the radial nerve and enters the muscle proximally close to the
proximal vascular pedicle.
Wrist extension occurs by synergistic contraction of the ECRL, ECRB, and extensor carpi ulnaris (ECU) muscles.
When the ECRB and ECU are present, the ECRL is an expendable muscle, as evidenced by its utility in tendon
transfers for median- and ulnar-nerve palsies (4, 5). Moreover, its successful use in tendon transfers has
demonstrated the predictability of its proximal vascular anatomy.
FLAP DESIGN AND DIMENSIONS
Because of its single dominant proximal vascular pedicle, the ECRL muscle arc of rotation is approximately 4 cm

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distal to the antecubital crease. Disinserting the muscle from the index metacarpal will allow radial and ulnar
transposition, but limited antecubital and elbow coverage. Disoriginating the muscle from the humerus and
fashioning a pure island flap, will allow for a more extensive arc of rotation and more proximal coverage.
OPERATIVE TECHNIQUE
The defect about the antecubital fossa and/or olecranon is defined and measured (Fig. 352.1). The ECRL is
harvested via a longitudinal incision, extending distally from the soft-tissue defect, and overlying the midportion of
the ECRL. The brachioradialis muscle is retracted radially to facilitate exposure. The ECRL is disinserted from
the index metacarpal and elevated off the ECRB (Fig. 352.3). Dorsal traction as one dissects proximally will
reveal the minor vascular pedicles.
The proximal dominant vascular pedicle should be identified approximately 4 cm distal to the antecubital crease.
The radial nerve will be encountered in this area and must be carefully preserved (Fig. 352.2). Minor distal
pedicles, distal to 4 cm beyond the antecubital crease, may be safely ligated.
FIGURE 352.1 A 5-cm margin with an underlying muscle-group resection is outlined. (From Janevicius and
Greager, ref. 1, with permission.)
The origin of the muscle is detached from the humerus to create a pure island flap. Neural branches from the
radial nerve may be divided to denervate the muscle and diminish bulk within the antecubital fossa. The muscle
is transposed and covered with a split-thickness skin graft (Fig. 352.4). The donor site is closed primarily.

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FIGURE 352.2 The resection exposes a 15-cm segment of the radial nerve, as well as the distal humerus. (From
Janevicius and Greager, ref. 1, with permission.)
FIGURE 352.3 The ECRL has been disinserted. (From Janevicius and Greager, ref. 1, with permission.)
CLINICAL RESULTS
A biopsy-proven malignant fibrous histiocytoma of the distal arm was resected with 5-cm margins, and an
underlying muscle-group resection included removal of the brachialis and
brachioradialis muscles (Fig. 352.1). This resulted in a defect exposing the radial nerve for a distance of 15
cm, as well as the distal humerus (Fig. 352.2). The ECRL was elevated and fashioned as a pure island flap
(Fig. 352.3), then rotated 180° to fill the defect and to cover the exposed radial nerve and humerus (Fig.
352.4).

FIGURE 352.4 The ECRL island flap has been rotated 180°. (From Janevicius and Greager, ref. 1, with
permission.)
FIGURE 352.5 Full extension is demonstrated postoperatively. (From Janevicius, Greager, ref. 1, with
permission.)
Thirty months postoperatively, the patient has normal elbow flexion and extension (Figs. 352.5 and 352.6),
normal radial nerve and hand function, and a stable skin graft. He has continued to work full time in his
previous job as a jackhammer operator.
FIGURE 352.6 Full flexion is present. (From Janevicius, Greager, ref. 1, with permission.)

SUMMARY
The extensor carpi radialis longus muscle is well suited for reconstruction about the antecubital fossa.
Substantial defects can be covered, resulting in minimal donor-site morbidity.
References
1. Janevicius RV, Greager JA. The extensor carpi radialis longus muscle flap for anterior elbow coverage. J
Hand Surg 1992;17A:102.
2. Ohtsuka H, Imagawa S. Reconstruction of a posterior defect of the elbow joint using an extensor carpi
radialis longus myocutaneous flap: case report. Br J Plast Surg 1985;38:238.
3. Parry SW, Ward JW, Mathes SJ. Vascular anatomy of the upper extremity muscles. Plast Reconstr Surg
1988;81:358.
4. Burkhalter WE. Median nerve palsy. In: Green DP, ed. Operative hand surgery, 2nd ed. New York:
Churchill Livingstone, 1988;1499-1534.
5. Omer GE. Ulnar nerve palsy. In: Green DP, ed. Operative hand surgery, 2nd ed. New York: Churchill
Livingstone, 1988;1534-1554.

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Chapter 353
Microvascular Free Transfer of A Compound Deep Circumflex
Groin and Iliac Crest Flap to The Upper Extremity
G. I. TAYLOR
R. J. CORLETT
EDITORIAL COMMENT
This classic description, which opened the door to free bone grafting, continues to present a problem from
the standpoint of adding skin to the flap. The relative positioning and thickness of the skin flap limit its
usefulness as a compound flap. As will be seen in some of the other chapters in which this flap is used
purely as an osseous flap, it continues to be an excellent choice.
The composite deep circumflex iliac flap provides a large bloc of bone, and in some situations advantage may be
taken of its curvature (1, 2, 3). In the upper limb, it would seem most appropriately suited for stabilization of the
various joints, viz., the shoulder, elbow, or wrist, particularly if there is associated extensive soft-tissue loss.
Our experience with the use of the deep circumflex iliac osteocutaneous flap in the upper extremity is limited. It
does provide a large amount of bone. However, the curvature of the crest and the associated soft-tissue bulk
make it a less attractive solution for those problems that involve a long segmental defect of the radius, ulna, or
humerus. In these situations we have found that the fibula is the flap of choice (3). Our experience with the flap is
restricted to two cases that required skin and bone replacement at the wrist and at the elbow joint (Figs. 353.1
and 353.2).
See Chapter 208.

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FIGURE 353.1 A: A 62-year-old patient with the dorsal and radial part of his hand ablated. The defect included
the first metacarpal, the proximal phalanx of the thumb, the scaphoid, the trapezium, and the radial styloid
process. There was an associated oblique fracture of the lower end of the radius. The dorsal skin, the radial
wrist extensors, the extensor tendons of the thumb, and the ligamentous structures of the wrist were lost. A
composite iliac crest muscle and skin flap was raised, based on the deep circumflex iliac artery. The skin flap
measured 8 3 4 cm and the bone 14 3 3 cm. The wrist was arthrodesed, using the vascularized bone graft to
bridge the skeletal defect between the dorsal surface of the radius, the remaining carpal bones, the second
metacarpal, and the tip of the terminal phalanx of the thumb. An osteotomy of the bone graft was performed at
the level of the first metacarpophalangeal joint, to obtain the correct position of the thumb. Postoperatively, the
patient developed a wound infection and subsequently a small portion of the distal bone graft was lost. Following
debridement of this area of bone and grafting with a split-thickness skin graft, the graft healed without further
complication. B: Radiograph of the result at 12 months. C, D, E, F: The graft has provided a stable wrist, the
hand is in good alignment, and there is an excellent range of movement of the fingers at the
metacarpophalangeal and proximal interphalangeal joints. The thumb, although foreshortened, has remained
stable and has required no further surgical intervention.

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FIGURE 353.2 A: A 53-year-old woman suffered a shotgun injury to the region of her right elbow. There was
loss of the distal 5 cm of her humerus, the proximal 2 cm of the olecranon, the attached triceps muscle and
tendon, and an 8 cm gap in the ulnar nerve, together with loss of the overlying skin (see Fig. 353.2F). B: A
segment of iliac crest was chosen, using the anterior portion of the contralateral hip to simulate the lost segment
of the distal humerus ( dotted lines). The curvature of the crest was designed to fit the curvature of the articular
surfaces of the head of the radius and the olecranon. Various soft-tissue attachments to the iliac crest were used
to reconstruct the elbow joint capsule and ligaments. A segment of attached inguinal ligament provided the ulnar
collateral ligament ( A) and a flap of thick periosteum was elevated to reconstruct the radial collateral ligament (
B). A fringe of fascia lata ( C) reconstructed the anterior joint capsule. The loose areolar layer on the surface of
the external oblique muscle at its attachment to the crest offered a convenient gliding layer for joint articulation.
The blade of the ilium was sculptured to resemble the lower end of the humerus. (Continued)

FIGURE 353.2 (Continued) C: The flap was detached (shown here with a model of the deficient distal humerus),
secured to the distal humerus, and revascularized to the brachial artery and its vena comitans. The triceps
mechanism was reconstructed with tendon grafts to the remaining olecranon. The ulnar nerve was repaired with
three sural nerve cable grafts, and the skin defect closed with a flap. The elbow was immobilized at 90° D, E:
The postoperative course was uneventful. At 6 weeks gentle mobilization of the elbow commenced. At 8 weeks
there was a range of elbow movement of 25° to 30°, and the preoperative range of supination and pronation had
been regained. The elbow is painless and stable. F: Preoperative angiogram. G, H: Postoperative radiographs
at 8 weeks.
References
1. Taylor GI, Townsend P, Corlett RJ. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps. Plast Reconstr Surg 1979;64:745.
2. Taylor GI, Townsend P, Corlett RJ. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: experimental work. Plast Reconstr Surg 1979;64:595.
3. Taylor GI. The current status of free vascularized bone grafts. Clin Plast Surg 1983;10:185.

Chapter 354
Thoraco-Epigastric Skin/Fascia Flap to The Arm
V. L. LEWIS JR.
Flaps based on the midline of the body have played an important role in reconstructive plastic surgery. Webster
(1) in 1937 designed a flap based on the superior epigastric artery. Braun et al. (2) and Cannon and Trott (3)
oriented epigastric flaps transversely for application to the upper extremity. Tai and Hasegawa (4) recognized the
contribution of the superior epigastric perforators to the transverse flap, and successfully designed longer flaps
for chest wall coverage.
With the success and versatility of the thoracoepigastric flap, it is interesting that a recently proposed schema for
upper extremity reconstruction makes no mention of it (5). However in upper extremity trauma, the demonstration
that microsurgical reconstruction could be done early (6, 7) and the development of criteria for wound closure (8)
have undoubtedly decreased the frequency of use of pedicled thoracoepigastric flaps.
INDICATIONS
The thoracoepigastric flap has been successfully used to cover losses from burns (9, 10), penetrating
trauma (11, 12), extravasation, and pressure injuries. The flap has been applied to the arm, elbow, forearm,
wrist, and hand by adjusting the level at which it is designed. The flap can be applied to the anterior,
medial, and posterior arm, and dorsal and volar forearm, wrist, and hand.
The flap may be applied immediately to traumatic defects for coverage of blood vessels, nerves, or tendons,
if the wound is completely debrided and bacterial counts low. In repair of dirty wounds and burns, it is most
successfully applied secondarily. Secondary defatting can be safely performed.
ANATOMY
Early reports on medially based thoracoepigastric flaps focused on length-to-width ratios, emphasizing short
lengths and wide bases (2, 13). The work of Milton (14) initiated the idea that it was more important that a flap be
designed to contain expectable vessels than that it be designed to certain rigid ratios. The observation of Brown
et al. (11) that, in an upper abdominoplasty, no bleeding is encountered from the rectus sheath to the latissimus
border suggested that the epifascial blood supply of the abdomen radiated from perforators in the rectus
abdominus muscle.
The work of Taylor et al. (15) and Boyd et al. (16) definitively clarified the anatomic basis of the transverse
thoracoepigastric flap (Fig. 354.1A). Boyd et al. reported, “The deep epigastric arcade forms the abdominal
portion of a ventral vascular railroad, linking the subclavian and external iliac arteries.” The deep inferior
epigastric artery supplies blood to the majority of major perforating vessels leaving the rectus abdominus muscle
and running laterally to the area of the latissimus dorsi muscle. These vessels are in the plane above the fascia,
making flap elevation in the subfascial plane mandatory.
The superior epigastric artery, though smaller than the inferior epigastric, contributes to the upper abdominal and
thoracic flap (16). Derived primarily from the internal thoracic (internal mammary) artery (17), it also receives
contributions from (1) terminal branches of the intercostals (18), (2) the superficial inferior epigastric (11), and (3)
meets the inferior epigastric in a complex of spiral vessels within the rectus muscle (19). Damage to the internal
thoracic artery by trauma, operation or radiation, significantly reduces reliability of the flap.

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FLAP DESIGN AND DIMENSIONS
The flap includes skin, subcutaneous tissue, and muscular fascia of the lateral thoracic and upper abdominal
areas. The base is the lateral border of the rectus sheath, and the undelayed lateral border is the posterior
axillary line, or anterior edge of the latissimus dorsi muscle. Both delayed and undelayed extensions beyond this
line are described (10, 12, 20). With delay, the flap has been extended to within 5 cm of the dorsal midline (20,
21).
The upper limit of the flap base is the areola in men or the inframammary fold in women. However, upward (10)
and downward (22) movement of the base, in accordance with the principle of known perforator inclusion, is
possible. The flap width is in accordance with defect size, but widths of 10 to 15 cm are usual (23), and a width
of 30 cm reported (12) (Fig. 354.1B). The length of the flap from the lateral rectus border to the posterior axillary
line averages 20 to 25 cm in the adult, varying with gender and size of the torso. It is not necessary to raise the
full length of the flap if a shorter flap will cover the defect. Davis et al. (20) found that a 16-cm donor defect could
be closed in a chubby individual, and a 10-cm defect in a thin person.
The rotation point of the thoracoepigastric flap has been described as the lateral margin of the rectus abdominis
fascia, near the underportion of the flap base (20). The rotation point is not the lower portion of the base,
because upward flap mobility is gained when the abdominal wound is closed by reversed abdominoplasty
advancement. A key to closure is cited (20) as being release of the dense fascia overlying the iliac crest.
FIGURE 354.1 A: Vascular anatomy of the thoracoepigastric flap. B: Dimensions and limits of undelayed flap.

When applied to the upper extremity, the flap usually isn't rotated. If it is rotated, without a delayed random
extension, the flap will reach the upper axilla and the anterior chest wall. With a delayed addition, it will reach the
apex of the axilla and clavicle (21, 23).
OPERATIVE TECHNIQUE
The flap is elevated in a lateral to medial direction, with division of approximately ten muscular intercostal
perforating vessels, mostly over the serratus anterior muscle. Depending on the design and width of the flap,
elevation exposes the serratus anterior, external oblique and pectoralis major muscles. Elevation of the flap from
the posterior axillary line medially is in the subfascial plane. The random delayed portion over the latissimus is
raised superficial to the fascia. The lateral border of the rectus abdominis sheath is determined by palpation
before the flap is elevated, and is marked on the skin. No elevation is carried out medial to this line (Fig. 354.1).
The perforating vessels that support the flap may or may not be visible when this point is reached. These
vessels must never be divided. Doppler identification may, if necessary, be used to protect the perforating
vessels. The viability of the flap is assessed with fluorescein if there is any concern.
The flap is placed over the defect on the upper extremity, either the anterior or posterior surface, and sutured in
two layers. If the donor defect cannot be closed, it and the inner surface of the flap base may be covered with
meshed skin graft or membrane dressing.
Active wrist and hand motion are maintained with physiotherapy. If necessary, wrist dorsiflexion is maintained
with a volar splint. The upper extremity may be supported with a sling or shoulder immobilizer.
The pedicle is divided in stages, beginning at 14 to 21 days postoperatively. The guidelines for this are primarily
historic and empirical (3). Division is begun at the later time if the flap lacks a border on the arm consisting of
normal, well-vascularlized soft tissue (13). Division of the pedicle is accomplished in two or three stages by
measured quarters or thirds, with the division completed in 7 to 10 days. The axial vessels are identified and
ligated as part of the division. When there is doubt about the adequacy of the blood supply to the flap from the
arm, the flap base may be clamped with a noncrushing clamp and fluorescein given.
The divided flap margin is not inset into the arm, but allowed to contract and form a contour, making surgical
inset usually unnecessary and preventing marginal necrosis. At flap division, the graft is removed from the flap
base and bed, and remaining flap returned to its bed.
CLINICAL RESULTS
With proper design, and undamaged blood supply, the thoracoepigastric flap has proved highly reliable in
upper extremity reconstruction (Fig. 354.2A and B). Combining the results of reports that listed number of
cases (9, 11, 12, 20), of 25 flaps transferred, 23 succeeded. Experience with the flap in chest wall and
breast reconstruction is also good. Flap reliability decreases with damage to the longitudinal blood supply,
and undelayed extension beyond the posterior axillary line. Abdominal scars that have not damaged the
perforating vessels (i.e., midline laparotomy scars) have not influenced flap survival.
Wide flap donor defects covered with skin grafts, though unsightly, are acceptable in limb salvage (Fig.
354.2C). Immobilization of the shoulder while the flap heals has not resulted in stiffness that could not be
resolved by physical therapy. However, arthritis or preexisting stiffness might relatively contraindicate this
flap choice.
SUMMARY

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The thoracoepigastric flap, which has been expanded due to recent understanding of the blood supply, can
provide coverage for large areas of the arm and forearm.
FIGURE 354.2 A: Electrical burn defect. B: Extended thoracoepigastric flap coverage of defect. C: Long-
term follow-up of coverage. (From Lewis and Cook, ref. 10, with permission.)
References
1. Webster JP. Thoracoepigastric tubed pedicles. Surg Clin North Am 1937;17:145.
2. Braun JB, Cannon B, Graham WC, et al. Direct flap repair of defects of the arm and hand. Ann Surg
1947;122:706.
3. Cannon B, Trott AW. Expeditious use of direct flaps in extremity repairs. Plast Reconstr Surg 1949;4:415.
4. Tai Y, Hasegawa H. Transverse abdominal flap for reconstruction after radical operations for recurrent
breast cancer. Plast Reconstr Surg 1974;53:52.
5. Hallock GG. A schema for local flap selection in the upper extremity: a hypothesis. Ann Plast Surg
1990;25:479.

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6. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg
1986;78:285.
7. Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg 1988;13A:22.
8. Breidenbach WC. Emergency free tissue transfer for reconstruction of acute upper extremity wounds. Clin
Plast Surg 1989;16:505.
9. Hallock GG, Dingeldein GP. The thoracoepigastric flap as an alternative for coverage of the burned elbow.
J Burn Care Res 1982;3:393.
10. Lewis VL, Cook JQ. The nondelayed thoracoepigastric flap: coverage of an extensive electric burn defect
of the upper extremity. Plast Reconstr Surg 1980;65:492.
11. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade.
Plast Reconstr Surg 1975;55:416.
12. Kalisman M, Wexler MR, Yeshua R, et al. Comparison between the early use of skin flap and skin graft
for the correction of large tissue loss at the elbow. Ann Plast Surg 1978;1:474.
13. Kelleher JC, Sullivan JG, Barbak GJ, et al. Use of a tailored abdominal pedicle flap for surgical
reconstruction of the hand. J Bone Joint Surg 1970;51A:1552.
14. Milton SM. Pedicled skin-flaps: the fallacy of the length:width ratio. Br J Surg 1970;57:502.
15. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J
Plast Surg 1984;37:330.
16. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and deep inferior
epigastric systems. Plast Reconstr Surg 1984;73:1.
17. Moore KL. Clinically oriented anatomy. Baltimore: Williams and Wilkins, 1984;75.
18. Kerrigan CL, Daniel RR. The intercostal flap: an anatomical and hemodynamic approach. Ann Plast Surg
1979;2:411.
19. Scheflan M, Dinner MI. The transverse abdominal island flap: Part I. Indications, contraindications, results
and complications. Ann Plast Surg 1983;10:24.
20. 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.
21. Cronin TD, Upton J, McDonough JM. Reconstruction of the breast after mastectomy. Plast Reconstr

Surg 1977;59:1.
22. Seitchik SM, Granick MS, Soloman MP, et al. Post-traumatic upper extremity wound coverage utilizing
the extended deep inferior epigastric flap. Ann Plast Surg 1992;28:465.
23. Bostwick J, Vasconez LO, Jurkiewicz M. Breast reconstruction after a radical mastectomy. Plast Reconstr
Surg 1978;61:682.

Chapter 355
Medial Arm Flap
E. N. KAPLAN
R. PEARL
V. R. HENTZ
EDITORIAL COMMENT
The attractiveness of the thin, pliable skin and of a most acceptable donor site on the inner aspect of the
arm would make this flap a favorite one. Unfortunately, the blood supply is quite variable, particularly as it
relates to the ulnar collateral artery. In a great number of cases, that artery is not present and the flap would
be random and thus less reliable.
The physical quality, location, and blood supply of medial arm skin make it useful for reconstructive procedures
in various clinical situations. The thinness, pliability, and hairlessness of the skin commend it as an excellent
choice for resurfacing of the face, neck, and hands (1, 2, 3, 4).
INDICATIONS
The medial arm flap has been used for rotation into the axilla for release of burn and radiation scar
contractures, for augmentation of soft-tissue defect of the chest, and for treatment of upper arm
lymphedema. As a distant flap, it provides excellent coverage for the contralateral upper extremity,
especially the thumb, as well as for much of the head and neck region. As a free flap, this tissue may be
transferred to any recipient site requiring less than 20 × 12 to 15 cm of thin, pliable, hairless tissue (Fig.
355.1).
ANATOMY
Vascular
In addition to the direct cutaneous blood supply, there is an overlapping with the musculocutaneous perforators
from the biceps and triceps (1, 3). Although one could use the musculocutaneous flow as the basis for flap
design, the supplying muscles would need to be included, and this would obviate the thin and pliable quality of
the flap and could produce unacceptable functional deficits. The use of the fascia, however, as the primary
vascular source may obviate the need for inclusion of direct cutaneous arteries (1, 4, 5, 6) (Fig. 355.2).
Arterial
The brachial artery is the continuation of the axillary artery beyond the teres major. The artery courses in the
intermuscular septum between the biceps and the triceps (Fig. 355.3).
The profunda artery is a musculocutaneous artery that is usually the first branch off the brachial. It arises 2 to 3
cm beyond the teres major and passes posteriorly between the humerus and the triceps to accompany the radial
nerve. The branches from the profunda brachii supply the triceps, then perforate into the skin. Small (0.1 to 0.3
mm) cutaneous branches perforate the muscular fascia at 2- to 3-cm intervals, to supply the skin of the posterior

P.951
two-thirds of the arm.
The superior ulnar collateral artery is an axial cutaneous vessel that arises 4 to 6 cm beyond the pectoralis
major and courses distally through the subcutaneous tissue to enter the medial arm skin 6 to 12 cm beyond the
pectoralis (Fig. 355.4). The arterial diameter is from 0.8 to 1.5 mm. In 60% of dissections this artery originates
from the profunda artery, and in 20% it originates directly from the brachial artery. In the other 20% there is a
double system with a direct cutaneous vessel exiting from both the brachial artery and the profunda artery. In this
latter situation the vessel size is inadequate for free flap transfer but can be used for local or distant pedicle
flaps.
The biceps musculocutaneous artery arises 6 to 8 cm distal to the pectoral muscle. After penetrating the biceps
muscle, two or three major perforating vessels vascularize the anterior arm skin. The size of these vessels is
variable.
The inferior ulnar collateral artery is an axial cutaneous artery that arises 5 to 10 cm from the elbow and may
form collaterals either around the elbow or with the superior ulnar collateral artery. In 6 out of 16 dissections, a
0.4 to 0.6 mm direct cutaneous artery supplied the skin of the distal third of the arm.
FIGURE 355.1 A: Medial arm skin can be used for replacement of local axillary or elbow skin. Tissue deficiency
caused by burn contracture, injury, radiation, and infection has been corrected. B: The thin, pliable inner arm
skin is ideal for resurfacing the contralateral hand and fingers.

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FIGURE 355.2 The vascular territories of the medial arm are depicted. The primary supply is from the direct
cutaneous vessels. The remainder of the arm is supplied by musculocutaneous perforators.
FIGURE 355.3 This was the most common pattern of vascular anatomy. The superior ulnar brachial collateral
artery was a branch of the brachial artery. It can also branch off the profunda artery (or both). (From Hentz et al.,
ref. 1, with permission.)
Venous
Venous drainage tends to follow the superior ulnar collateral or other branches into the paired brachial veins on
each side of the brachial artery. However, there is separate venous drainage through the cephalic and/or basilic
veins.
FLAP DESIGN AND DIMENSIONS
The proximally based medial arm flap can be designed to extend from the midanterior to midposterior line. A flap
of this extent will require a skin graft for the donor site, but narrow flaps can be primarily closed (Fig. 355.5). The
flap will consistently survive to three-quarters the length of the upper arm (20 to 30 cm), but can extend to the
elbow if a delay procedure is first performed.
Preoperative flap planning includes both identification of the superior ulnar collateral artery, using the Doppler
flowmeter, and marking of the large subcutaneous veins (Fig. 355.4B). The flap is centered along the axis of the
superior ulnar brachial cutaneous collateral artery, as determined by Doppler, and includes at least one large
superficial vein.

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FIGURE 355.4 A: The relation of the brachial collateral artery is depicted. The branch typically is found 4 to 6
cm beyond the axillary fold. B: A Doppler (presurgical) evaluation can often identify the artery and its course.
These relationships were confirmed intraoperatively. (From Hentz et al., ref. 1, with permission.)
OPERATIVE TECHNIQUE
Flap Elevation
The skin boundaries are incised down through and including the areolar plane overlying the muscular fascia.
The deep plane of elevation includes the areolar fascia to protect the superior brachial collateral artery.
Dissection on the muscular fascia can be rapid until the point of penetration of the vessel into the skin, beginning
distally at the flap tip, as determined by the Doppler study (about 6 to 10 cm from the anterior axillary fold). Care
is taken to avoid the intermuscular septum that contains the ulnar and median nerves and the brachial artery.
Protection is facilitated by marking the brachial artery course between biceps and triceps. Proximal to the point
where the superior ulnar collateral artery penetrates the skin, the dissection requires more care, so as not to
transect this direct
cutaneous artery as it exits the intermuscular septum. The dissection is terminated as soon as enough elevation
has been completed to allow transfer to the recipient site. Although this flap can be elevated as an island flap,
only minimal increase in arc of rotation is achieved, while markedly increasing the difficulty of the dissection and
the risk to the vascular pedicle.
FIGURE 355.5 The preferred method for distant flap design and elevation includes tubing of the base and
grafting of the bed for large flaps. In this patient a delay procedure was performed.
Flap Delay
Flap delay increases survival potential for the distal quarter of the proximally based arm flap (7). This distal area
is independent territory and is supplied by the inferior ulnar collateral system and by musculocutaneous

perforators that must be transected. Theoretically, the distal quarter can be carried as a random dermal flap at
the end of the arterial flap, without a delay procedure. However, we do not have sufficient case numbers to
estimate the risk for distal flap loss. Therefore, we have adopted a conservative attitude.
Flap Transfer and Inset
When the flap is to be used at a distant site, such as the hand or face, the distal end is configured and inset to fit
the defect, and the proximal flap is tubed. Local flaps to the axilla or elbow are directly transposed and inset. The
donor site is either grafted or closed directly, depending on flap width and other local conditions.
Flap Takedown
When the flap is used as a pedicled distant flap, we recommend an assessment of the adequacy of flap
vascularization from the recipient site, prior to takedown. After application of a tourniquet, the flap is evaluated
both clinically and with fluorescein. One week prior to flap transection, the superior ulnar brachial collateral artery
can be identified and ligated at the pedicle base.
Free Flap
If the flap is being used as a free flap, the superior ulnar brachial collateral artery must be identified where it exits
the brachial artery, 4 to 6 cm distal to the pectoralis insertion. The medial brachial cutaneous nerve can also be
included, to create a neurovascular flap that runs with this tissue. If the nerve can be sutured to an available
sensory nerve at the recipient site, it allows protective sensation (Fig. 355.6).
FIGURE 355.6 The anatomic relations of the superior brachial collateral artery are shown. This dissection is
essential for free flap transfer. Note the vessel in the intermuscular septum and its course under the ulnar nerve.
This flap serves as an alternative to the use of the dorsum or the first web space of the foot in patients requiring
a neurosensory flap. Its advantages are the ability to close the donor site primarily, the lack of functional
sequelae associated with skin grafts of the foot, and the inconspicuous location of the donor site. The main
disadvantages are the inconsistent location and variable size of the superior ulnar collateral artery. Moreover, in
those areas that require sensation, the medial brachial cutaneous nerve may not be as efficacious as the
common plantar nerve (8).
The design of the flap is the same as in the pedicle technique, with inclusion of one of the subcutaneous veins
for providing venous drainage if the venae comitantes are not chosen for anastomosis. The anterior incision is
deepened to the biceps muscle and the fascia of this muscle is included in the flap. The lateral aspect of the
brachial artery is identified and the profunda brachii artery noted approximately 4 cm distal to the pectoralis major
insertion. If a second large vessel is seen, 1 to 2 cm more distally, this is the superior ulnar collateral artery, and
it can be followed distally as it supplies the medial arm skin. Unfortunately, its course is usually under the ulnar
nerve. Care must be taken to identify and preserve the ulnar nerve.

P.954
In those situations in which the superior ulnar collateral artery is a branch of the profunda artery, there will
usually not be a direct artery from the brachial artery. Instead, a large branch will exit from the profunda artery
toward the medial skin, which can be identified by following the profunda brachii artery distally. In those rare
situations where there is both a direct cutaneous artery from the brachial artery, as well as a superior ulnar
collateral artery from either the profunda or the brachial artery, a free flap is less feasible because of vessel size.
Preoperative angiograms can obviate this uncertainty and allow better definition of the supplying vascular
system. Whether the extremely large basilic veins or smaller venae comitantes are chosen, venous drainage is
determined by the size of the recipient vessels.
FIGURE 355.7 A: A 12-year-old girl with axillary burn contracture. A proximally based arterial arm flap measuring
3 by 12 cm (less than three-fourths of the arm length) was elevated and transposed into the axilla in one stage.
B: A skin graft is used on one or both sides of the flap, depending on the flap and defect size.
CLINICAL RESULTS
In over 30 applications of this flap, there has been no loss of flap length due to vascular compromise. When
we have limited the length of the flap to three-quarters the length of the upper arm (Fig. 355.7), only one
partial slough occurred, and this was at the time of pedicle division. In this case, neither superior ulnar
collateral artery identification, assessment of flap vascularization, or ligation was performed, prior to
detaching the flap from its direct arterial supply.
By incorporating the superior ulnar brachial collateral artery, the flap may be transferred as a proximally
based undelayed flap extending three-quarters the length of the arm with complete reliability. If the artery is
not identified or is inadvertently injured, the rich fascial network can sustain the flap. In addition, the skin
can be transferred as a free flap from the same vascular system. The major limitation of this tissue as a
pedicled flap is the need for shoulder immobilization. For distant transfer, the major drawback of this flap as
a free flap is the inconsistent and occasionally small size of the donor vessel.
Medial arm skin has proved to be thin, pliable, and hairless, and the flap dependable. However, in
comparison with surrounding recipient site skin, medial arm skin has sometimes been inappropriate in color.
SUMMARY
The medial arm flap can provide thin, pliable coverage from the axilla to the hand. It can be used as a direct,
distant, or free flap, depending on the recipient site. By including the medial brachial cutaneous nerve, the
free flap can also provide protective sensation.

References
1. Hentz VR, Pearl RM, Kaplan EN. Use of the medial upper arm skin as an arterialized flap. Hand
1980;12:241.
2. Kaplan E, Buncke H, Murray D. Distant transfer of cutaneous flaps in humans. Plast Reconstr Surg
1973;52:301.
3. Song R, Song Y, Yu Y, et al. The upper arm free flap. Clin Plast Surg 1982;9:27.
4. Budo J, Finucan T, Clarke J. The inner arm fasciocutaneous flap. Plast Reconstr Surg 1984;73:629.
5. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr
Surg 1973;52:111.
6. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.
7. May H. Plastic and reconstructive surgery, 3rd Ed. Philadelphia: FA Davis, 1971.
8. Daniel R, Terzis J, Schwarz G. Neurovascular free flaps. Plast Reconstr Surg 1975;56:13.

Chapter 356
Lateral Trunk Flaps
E. G. ZOOK
R. C. RUSSELL
EDITORIAL COMMENT
The technique described in this chapter gives excellent coverage for large defects. The major drawback is
the extensive scarring at the donor site.
Lateral trunk flaps traditionally are random pattern flaps from the lateral aspect of the chest wall or abdomen.
They were designed for reconstruction of large wounds of the upper extremity, especially above the elbow (1, 2,
3, 4, 5). With the advent of axial pattern and musculocutaneous flaps, their importance has diminished (6).
However, they are effective flaps that should be maintained for the patient in whom the more advanced types of
flaps are impossible.
INDICATIONS
These flaps have the advantage of not requiring sacrifice of a muscle to resurface the upper arm, as do the
latissimus dorsi and pectoralis major flaps. They also have the advantage of containing only skin and fat
where bulk is not wanted. However, because of the limited length that can be constructed, in most
instances they require that the arm be held close and relatively immobile against the chest wall until the flap
can be divided.
Flank flaps are rarely indicated, since the groin flap is much safer and dependable for covering the hand
and lower arm. For the forearm, the anterior abdominal flap leaves the arm in a much more comfortable and
physiologic position during immobilization.
Recently, axial pattern flaps have been described that come from the lateral trunk. These are the scapular
flap (7), based on the circumflex scapular artery, and the parascapular flap (8), based on the cutaneous
parascapular artery. Although described as free flaps, they should reach to the upper arm or deltoid area.
ANATOMY
Since these flaps are essentially random pattern when raised to a length necessary to reach the arm (9), it is
essential that they have a wide base. The blood supply of the lateral chest and abdomen comes from branches
of the terminal portions of the intercostal perforating arteries, and the thoracoepigastric, internal mammary, and
rectus vessels.
FLAP DESIGN AND DIMENSIONS
If the length of these flaps exceeds the width by more than one-half, a delay is advisable prior to transferring the
flap, but not absolutely necessary (10). As in any flap, accurate planning is essential, but here it is critical
because there is small margin for error if an adequate flap is to be available and its survival assured. A piece of
nonexpandable cloth should be used to simulate the flap design, to assure that its base will not be under tension
and that its length and width will be of the proper dimensions to cover the defect. The flap can be based

anteriorly (Fig. 356.1) or posteriorly (Fig. 356.2), depending on whether the defect is on the anterior or posterior
aspect of the arm.
When the defect occurs on the surface of the upper arm that is adjacent to the chest wall, an H-type of flap can
be designed, elevated from the chest wall, and attached to the borders of the defect on the arm. After
appropriate delays, these flaps can be divided from the trunk and turned to resurface the inner aspect of the
upper arm. In the meantime, they will protect vessel grafts, nerve repairs, and so forth (Fig. 356.3).
CLINICAL RESULTS
It is rare that the donor site can be closed primarily (6); it usually requires a split-thickness skin graft. This
creates a large scar on the lateral chest wall that is a particularly significant defect in the female patient.
Fortunately, most of these injuries occur in men.
SUMMARY
The lateral trunk flap can be used effectively under appropriate circumstances to cover defects of the upper
arm.
FIGURE 356.1 A: A necrotic nonhealing wound is seen on the medial aspect of the upper arm. B: A flap
large enough to cover the defect is designed with its base anteromedially. The flap is approximately twice
as wide as it is long, to ensure adequate circulation.
FIGURE 356.2 A: A defect on the posterior aspect of the upper arm is best covered by a posteriorly based
lateral trunk flap, as outlined here. B: The flap will be sutured into place with half-buried horizontal mattress
sutures tied over dental rolls.

FIGURE 356.3 A: A defect high on the medial aspect of the upper arm with a vein graft of the brachial
artery that must be protected. B: An H-type flap is designed so that one flap will cover the posterior portion
of the defect and the other the anterior portion. The wound can be closed completely, protecting the vein
graft. (Continued.)
FIGURE 356.3 (Continued). C: The bases of the flaps have been delayed; they are now divided and the
flap is elevated. D: The defect of the chest wall after the flaps are released and the arm moved away from
the chest. E: One year later, a durable and satisfactorily cosmetic coverage of the arm.
References
1. Brown JB, Cannon B, Graham WC, et al. Direct flap repair of defects of the arm and hand. Ann Surg
1945;122:706.
2. Brown JB, Cannon B, Graham W, et al. Restoration of major defects of the arm by combination of plastic,
orthopedic and neurological procedures. Plast Reconstr Surg 1947;4:337.

3. Cannon B. Some recent developments in plastic surgery. Surg Clin North Am 1974;167:1106.
4. Cannon B, Trott AW. Expeditious use of direct flaps in extremity repairs. Plast Reconstr Surg 1974;5:415.
5. Zook EG, Bennett JB. Primary trunk flap coverage of traumatic upper arm defects. J Trauma 1974;14:102.
6. Maxwell GP, Manson P, Hoopes JE. Reconstruction of traumatic defects utilizing arterialized cutaneous
muscle, myocutaneous and free flaps. Am Surg 1979;45:215.
7. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:601.
8. Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new cutaneous microsurgical free flap. Plast
Reconstr Surg 1982;69:591.
9. Gilbert DA. An overview of flaps for hand and forearm reconstruction. Clin Plast Surg 1981;9:129.
10. Lewis VL, Cook JQ. The non-delayed thoracoepigastric flap: coverage of an extensive electrical burn
defect of the upper extremity. Plast Reconstr Surg 1980;65:492.

Chapter 357
Latissimus Dorsi Functional Transfer to The Arm
W. Y. HOFFMAN
L. O. VASCONEZ
With its vascular supply and innervation left intact, the latissimus dorsi can be transferred to the arm for
restoration of either flexion or extension at the elbow (1, 2, 3, 4, 5, 6, 7, 8, 9). A skin island may be included in the
design of the flap for coverage of the additional bulk from the muscle transfer or for closure of soft-tissue defects.
INDICATIONS
It is important to assess the strength of the latissimus preoperatively: the muscle may have been weakened
by the same process that affected the arm, such as brachial plexus injury or poliomyelitis. Preoperative
conditioning has been used to strengthen the latissimus. In some neurologic disorders, it is well to consider
the function of the latissimus in stabilizing the hip for gait. Other operations on the upper extremity, such as
joint fusion or tendon transfer, should be incorporated in the overall reconstructive plan.
OPERATIVE TECHNIQUE
Incisions are required over the latissimus posteriorly, in the axilla over the elbow anteriorly, over the olecranon
for extension and flexion, and over the coracoid process if the insertion of the muscle is transferred. The lateral
portion of the muscle may be used in order to diminish bulk or to preserve normal latissimus function.
The serratus anterior branches and sometimes the circumflex scapular vessels must be ligated to allow sufficient
mobilization of the muscle that is converted into an island. The muscle is then passed under the pectoralis
tendon to reach the arm.
For flexion, the divided origin of the muscle is sutured to the distal biceps tendon; for extension, to the triceps
tendon. Including a rim of the thoracodorsal fascia with the muscle and fixation to the radial tubercle or the
olecranon process will make this juncture more secure.
The insertion of the latissimus on the humerus has been transferred to the proximal biceps or triceps tendon for a
more direct line of pull. By extending the muscle with strips of fascia lata, finger flexion can also be restored.
Muscle tension is critical in this procedure, as in any functional muscle transfer. Measuring the distance between
two or more sutures placed in the muscle before its division may provide a guide to reestablishing physiologic
muscle length. Overcorrection is preferred, bringing the arm to 90° to 100° for flexor repairs and to full extension
for extensor repairs.
CLINICAL RESULTS
The results of this operation have been satisfactory. If the latissimus has normal function preoperatively, a
fair degree of strength is achieved, with one patient reportedly lifting 15 pounds. If the muscle is weakened
before surgery, there is still substantial functional gain from being able to position the hand upward for
working and eating.

SUMMARY
The latissimus dorsi muscle, with or without skin, can be transferred with its neurovascular supply left intact,
to restore flexion or extension to the elbow.
References
1. Schottstaedt ER, Larsen LJ, Bost FC. Complete muscle transposition. J Bone Joint Surg 1955;37A:897.
2. Hovnanian AP. Latissimus dorsi transplantation for loss of flexion or extension at the elbow. Ann Surg
1956;143:493.
3. Axer A, Segal D, Elkon A. Partial transposition of the latissimus dorsi: a new operative technique to restore
elbow and finger flexion. J Bone Joint Surg 1973;55A:1259.
4. Zancolli E, Mitre, H. Latissimus dorsi transfer to restore elbow flexion. J Bone Joint Surg 1973;55A:1265.
5. Landra AP. The latissimus dorsi musculocutaneous flap used to resurface a defect on the upper arm and
restore extension to the elbow. Br J Plast Surg 1979;32:275.
6. Bostwick J III, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plant Reconstr Surg
1979;63:31.
7. Tobin GR, Man D, Meadows K, et al. Split latissimus dorsi motor transfer (Abstract). J Bone Joint Surg
1981;5:104.
8. Steven PJ, Neale HW, Gregory RD, Kreikin JG. Latissimus dorsi musculocutaneous flap for elbow flexion.
J Hand Surg 1982;7:25.
9. Brones MF, Wheeler ES, Lesavoy MA. Restoration of elbow flexion and arm contour with the latissimus
dorsi myocutaneous flap. Plast Reconstr Surg 1982;69:329.

Chapter 358
Tissue Expansion in Conjunction With Flaps of The Upper
Extremity
G. G. HALLOCK
EDITORIAL COMMENT
This is an attractive concept in an effort to enlarge the surface area of an available flap. However, the recoil
phenomenon of expanded flaps should not be forgotten.
Pre- or posttransfer tissue expansion, as an adjunct to upper-extremity flaps, can augment the potential available
surface area for wound coverage, and can minimize donor-site morbidity by permitting only a solitary linear scar.
INDICATIONS
Major advantages not previously possible without a combination of tissue expansion and the increased
anatomic knowledge of reliable upper-extremity flaps (Fig. 358.1), include pretransfer augmentation of
reliable flap territories, and the amelioration of donor-site morbidity (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11). These
developments were possible only after the commercial introduction of medical-grade inflatable silicone
balloons, now used commonly for chronic and gradual tissue distension.
The current scope of tissue expansion in the upper extremity remains limited to skin augmentation (12, 13,
14, 15). Of the numerous reliable fasciocutaneous flaps that have been identified in the upper limb and are
available for local flap transfer, many are limited in size (Fig. 358.1). Unless restricted to relatively small
dimensions or taken strictly as fascial flaps, all the known donor areas have previously required a skin graft
to maintain skin integrity following flap harvesting.
The immediate or delayed placement of tissue expanders adjacent to existing defects, now allows the
secondary transformation of the defect into a more acceptable linear scar. This has been particularly
valuable for the more distal radial forearm flap, in which a conspicuous unaesthetic or unstable skin graft
over the flexor tendons has heretofore been considered a major detriment (Fig. 358.2B). Under elective
conditions, pretransfer expansion not only increases the potential flap surface area, but also allows primary
closure of the donor site at the time of flap transfer, thereby avoiding any need for a skin graft (Fig. 358.3).
OPERATIVE TECHNIQUE
Immediate tissue expansion can begin at the time of flap transfer, or expander placement can follow total wound
healing, although this is more inconvenient (Fig. 358.2). Any remaining skin and subcutaneous tissue adjacent to
the donor site are undermined above the muscle fascia and preferably under the deep fascia to preserve all
collaterals to the residual fascial plexus in the area. The pocket created should be made through as narrow an
opening as possible. This can be done either by blind dissection with a blunt instrument (e.g., a cervial dilator or
liposuction cannula) (16), or more carefully and sharply under direct endoscopic guidance (17). The dimensions
of the cavity should approximate those of the chosen expander envelope to ensure no edge infolding. Normally,
a standard rectangular implant should prove satisfactory, when its length exceeds that of the defect. Sometimes,
a custom-designed implant may be more appropriate, to minimize the total required number of expanders (Fig.

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358.2A).
Implantation over bony prominences or joints is avoided, so that mobility will not be impaired during the period of
expansion. The access incision to underlying tissues must be carefully closed, preferably in several layers, to
minimize the risk of dehiscence leading to implant infection or exposure, and invariably resulting in extrusion. A
remote valve, rather than an intrinsic one, prevents the risk of inadvertent implant puncture during later fluid
instillation. Although the port can be left totally external (18), internal placement at least theoretically lessens the
risk of contamination or damage over a long course of expansion, even if retrieval can be more difficult.
Totally elective flap transfers allow for consideration of pretransfer expansion. Great care must be observed in
placement of the expander, to protect against damage to the perforators responsible for flap viability. Color
duplex imaging, a repeatable, rapid, noninvasive diagnostic modality, can identify the
presence of cutaneous perforators, their caliber, and flow. This allows for the construction of a preoperative map,
ensuring the retention of essential perforators during undermining of the territory, just prior to insertion of the
expansion envelope (Fig. 358.3). Direct dissection of the pocket, with endoscopic visualization to avoid the
perforators, would be the most minimally invasive approach.
FIGURE 358.1 Diagram of the described fasciocutaneous flap territories of the upper extremity, according to
their source vessels. All are versatile for local transfer; many are possible candidates for consideration as free
flaps. Shaded regions in inset demonstrate suitable areas for expander placement adjacent to the vascular
pedicle of a radial forearm flap, which cannot be undermined to ensure flap viability, whether pre- or posttransfer
expansion is selected. (Modified from Hallock, ref. 29, with permission.)
Adequate wound healing prior to the beginning of serial expansion is necessary; a delay of even up to 6 weeks is
possible. Normal saline is then instilled on a convenient schedule, frequently once or twice a week, via
percutaneous injection into the remote port, until skin capillary refill disappears or pain intolerance occurs.
Accelerated expansion (19) or expansion of an anaesthetic region may be more safely controlled with monitoring
by laser Doppler flowmetry (20).
Accrued tissue gain in the extremities is readily approximated as a difference in their circumferences from a
given, fixed point (Figs. 358.2B and 358.3B). Once desired coverage requirements are exceeded, the expander

P.958
can be removed. In clinical practice, this may demand overinflation well beyond the vendor's maximum allowable
volume. However, safety has been validated beyond twice these amounts in in vitro experiments (21), and
confirmed in humans (22). Maximal inflation again at the time of final envelope removal will yield an additional 1
to 2 cm in all dimensions, by acute load cycling or skin stretching (23, 24).
No defect should be reconstructed until advancement of the expanded flap confirms that adequate coverage is
possible. Occasionally, it may be necessary to retain the expander for a second course of expansion, if
achievement of the initial goal proves to be incomplete (25).
CLINICAL RESULTS
Although an actual gain in epidermal surface area can be measured during chronic expansion, concurrent
subcutaneous fat atrophy occurs with flap thinning; this can sometimes be used to advantage, if bulk is not
essential at the recipient site (13, 26).
Complication rates can be relatively high in extremity tissue expansion, and more precautions and
meticulous tissue handling are essential, if success is to be achieved. Pretransfer expansion has additional
risks, specific to the flap itself, including skin necrosis from flap thinning, implant extrusion, or infection. In
addition, obligatory capsule formation around the implant and adjacent edema, can compromise
identification of the vascular pedicle, risking devascularization, and can even lead to aborting an elective
transfer (8). A minimum of two surgical stages is always required, whether it is pretransfer or posttransfer
expansion that is selected.
Since the technique requires a significant time investment by both patient and surgeon, all potential hazards
must be clearly and fairly outlined in advance. Simpler methods of acute tissue expansion, such as
presuturing (27), wide undermining (28), or use of skin-stretching devices may be more suitable (24).
FIGURE 358.2 A: Diagrammatic blueprint of custom-designed envelope with remote valve, intended to
circumscribe the apex of a triangular- shaped, skin-grafted radial forearm free flap donor site, which

otherwise would have required two rectangular expanders. B: Comparison of forearm circumferences
allows estimation of tissue gain prior to implant removal. Note protrusion of remote valve positioned on the
dorsal right hand for convenient access for injections (arrow). The inflated right forearm expander surrounds
a contour depression after flap harvest. This defect was annoying to the patient, even though most of the
remaining extremity had previously also been skin-grafted for burns. C: Flattening and reduction of some of
the skin-grafted area of the forearm, providing the desired improvement in appearance 8 months following
the commencement of posttransfer delayed expansion. (From Hallock, ref. 10, with permission.)
FIGURE 358.3 Mapping the location and caliber of all perforators through the lateral intermuscular septum
of the arm, as identified by color duplex imaging. The area within the dots was considered safe for
undermining, for placement of an expander, to allow pretransfer expansion of a lateral arm free flap, with no
risk of damage to the nutritive perforators within the cross-hatched zone.
SUMMARY
The augmentation of reliable flap territories, and the amelioration of donor-site deformity, are major
advantages of tissue expansion, used as an adjunct to random, local skin flaps for upper-limb defects.
References
1. Morgan RF, Edgerton MT. Tissue expansion in reconstructive hand surgery. 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. Extremity tissue expansion. Orthop Rev 1987;16:606.

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4. Ogawa Y, Kasai K, Doi H, Takeuchi E. The preoperative use of extra-tissue expander for syndactyly. Ann
Plast Surg 1989;23:552.
5. Hallock GG. Color duplex imaging for identifying perforators prior to pretransfer expansion of
fasciocutaneous free flaps. Ann Plast Surg 1994;32:595.
6. Masser MR. The pre-expanded radial free flap. Plast Reconstr Surg 1990;86:295.
7. Shenaq SM. Pretransfer expansion of a sensate lateral arm free flap. Ann Plast Surg 1987;19:558.
8. 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.
9. Hallock GG. Free flap donor site refinement using tissue expansion. Ann Plast Surg 1988;6:566.
10. Hallock GG. Refinement of the radial forearm flap donor site using skin expansion. Plast Reconstr Surg
1988;81:121.
11. Hallock GG. Complications of fasciocutaneous flaps including donor site treatment. In: Hallock GG, ed.
Fasciocutaneous flaps. Boston: Blackwell Scientific, 1992;157-171.
12. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 1984;74:482.
13. Austad ED, Thomas SB, Pasyk K. Tissue expansion: dividend or loan? Plast Reconstr Surg 1986;78:63.
14. Manders EK, Schenden MJ, Furrey JA, et al. Soft-tissue expansion: concepts and complications. Plast
Reconstr Surg 1984;74:4933.
15. Cohen BE, Ruiz-Razura A. Acute intraoperative arterial lengthening for closure of large vascular gaps.
Plast Reconstr Surg 1992;90:463.
16. Hallock GG. Adjuvant use of the suction lipectomy cannula for blunt dissection. Aesth Plast Surg
1985;9:107.
17. Eaves FF, Price CI, Bostwick J, et al. Subcutaneous endoscopic plastic surgery using a retractor-
mounted endoscopic system. Perspect Plast Surg 1993;7:1.
18. Dickson WA, Sharpe DT, Jackson IT. Experience with an external valve in small volume tissue
expanders. Br J Plast Surg 1988;41:373.
19. Pietila JP, Nordstrom REA, Virkkunen PJ, et al. Accelerated tissue expansion with the “overfilling”
technique. Plast Reconstr Surg 1988;81:204.

20. Hallock GG, Rice DC. Increased sensitivity in objective monitoring of tissue expansion. Plast Reconstr
Surg 1993;91:2217.
21. Hallock GG. Maximum overinflation of tissue expanders. Plast Reconstr Surg 1987;80:567.
22. Hallock GG. Safety of clinical overinflation of tissue expanders. Plast Reconstr Surg 1997.
23. 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.
24. Mackay DR, Saggers GC, Kotwal N, Manders EK. Stretching skin: undermining is more important than
intraoperative expansion. Plast Reconstr Surg 1990;86:722.
25. Sellers DS, Miller SH, Demuth RJ, Klabacha ME. Repeated skin expansion to resurface a massive thigh
wound. Plast Reconstr Surg 1986;77:654.
26. Pasyk KA, Argenta L, Hassett C. Quantitative analysis of the thickness of human skin and subcutaneous
tissue following controlled expansion with a silicone implant. Plast Reconstr Surg 1988;81:516.
27. Liang MD, Briggs P, Heckler FR, Futrell JW. Presuturing—a new technique for closing large skin defects:
clinical and experimental studies. Plast Reconstr Surg 1988;81:694.
28. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic
properties of skin. Plast Reconstr Surg 1993;92:260.
29. Hallock GG. Territories of fasciocutaneous flaps by source and subtype. In: Hallock GG, ed.
Fasciocutaneous flaps. Boston: Blackwell Scientific, 1992;181-193.

Chapter 359
Skin Expansion
C. RADOVAN
EDITORIAL COMMENT
This chapter was written and accepted before the deaths of both Dr. Grabb and Dr. Radovan. There has
been subsequent work on tissue expansion that has further defined the indications, technique, and
complications. The reader should refer to the additional bibliography.
Two points should be emphasized when using skin expanders for breast reconstruction. The first is that the
expander should be placed much lower than the contralateral inframammary line, so that the skin will be
expanded where it is needed and not superiorly under the clavicle. Second, if one is to avoid “recall” or
recontraction of the expanded tissue, the expander should be left for a prolonged period of time after it is
fully expanded—no less than 3 months.
Skin expansion is a significant development in plastic surgery and expanders have been used clinically since
1976 (1, 2, 3, 4). The postmastectomy chest skin and scar are intermittently and gradually expanded, providing
the skin envelope needed for the new breast.
After skin expansion, the temporary expander is replaced by a smaller mammary implant, creating a smaller
breast mound within the larger skin envelope. This tends to mimic a natural breast, with forward teardrop
projection.
INDICATIONS
The most applicable defect for tissue expansion is the deformity following modified radical mastectomy.
However, various postmastectomy deformities can be reconstructed regardless of the thickness of the skin
flap or the shape of the scar.
The procedure is attractive to patients, even though it is performed in two stages; neither stage is
considered a major surgical procedure.
OPERATIVE TECHNIQUE
First Stage
All breasts are reconstructed subcutaneously through a small 5-cm subaxillary incision, either through the lateral
tail of the old mastectomy scar or through a new oblique incision. It is important to position the inframammary
border of the pocket at the same horizontal level as the opposite breast. Preserving the inframmamary line and
expanding the skin into a larger envelope give the breast a natural fold when the implant is finally placed in the
pocket.
The pocket is developed mainly by blunt scissor or finger dissection and is preferably about 3 cm wider in
circumference than the base of the expander. A small subcutaneous pocket is developed posterior to the incision
for placement of the reservoir dome.
The round, extra-large expander is initially filled with 50 to 100 cc of normal saline through the connecting tube.