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

1977;60:353.
16. Dubin DB. A new simplified method for nipple reconstruction. Plast Surg Forum 1980;3:32.

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Chapter 397
Nipple Reconstruction With The Skate Flap and Modifications
W. R. STAGGERS
L. O. VASCONEZ
R. J. FIX
S. TERKONDA
The skate flap and its modifications, permutations of local flaps fashioned from the reconstructed breast, require
ample donor tissue. A satisfactory nipple reconstruction can be simply and reliably achieved, with minimal donor
defect, in patients with submuscular implants and with varying methods of autologous reconstruction.
INDICATIONS
Nipple reconstruction should be delayed until the reconstructed breast has been allowed to realize its final
position (1, 2). Three to 6 months is usually sufficient to allow the breast to settle, probably decreasing the
risk of retraction or malposition of the reconstructed nipple, which is a frequent problem. Nipple
reconstruction is performed as a second stage and is usually done using local or general anesthesia, the
latter if a modification of the reconstructed or normal breast is required to obtain symmetry.
The method of choice should be carefully considered, assuring adequate soft tissue to obtain the desired
nipple form. If such tissue is lacking, other methods of reconstruction should be undertaken. Over-correction
of flap design will allow for anticipated shrinkage of up to 50 percent (3, 4). Patients who smoke, have
irradiated donor sites, or have medical issues that affect tissue microcirculation deserve special
consideration.
ANATOMY
The skate-flap family consists of a pedicle of epidermis, dermis, and subcutaneous fat centered at the site of the
future nipple. The subcutaneous plexus and subdermal plexus provide the major blood supply to the flap (3).
Intradermal sources
and inosculation provide sustenance to the partial-thickness skin flaps. The thickness of the reconstructed
breast mound is directly affected by the method of reconstruction used and affects the abundance of tissue
available for use.
FLAP DESIGN AND DIMENSIONS
The location of the nipple is marked preoperatively by visually positioning it in a location agreed upon by the
surgeon and patient. This is confirmed by photography that shows even slight abnormalities in position. The
location is verified by triangulating landmarks from the opposite nipple in the operating room. A final position is
ultimately determined by the surgeon during the procedure.
A circle matching the diameter (D) of the desired nipple and areola is drawn about the nipple mark (Fig. 397.1).
Symmetry may be verified by observing the patient in a sitting position from the foot of the patient's bed. The
orientation of the flap is assessed, and scars are positioned to decrease risk to flap vascularity (2, 4, 5, 6, 7, 8).
Minimal tension should be transferred to the breast mound. The base of the flap is at 12 o'clock, if no scarring or

tension exist. A line is drawn perpendicular to the base of the flap, three nipple diameters in length. The central
third of this line will be the future site of the composite flap. The length of the flap is measured as twice the height
(H) of the desired nipple (Fig. 397.1).
A small excess may be added to the flap, to be deepithelialized and incorporated into the nipple. Two lines are
drawn parallel to the proposed composite flap, converging distally. A curved line connects the ends of the base
line to the apex of the composite flap (3) (Fig. 397.2A).
Modified Skate Flap
The nipple and areola are marked, as previously described. The flap limbs are drawn as parallel lines from the
nipple circle, converging at the areolar margin. These are marked at the 3, 6, and 9 o'clock positions (1, 9) (Fig.
397.3A).
Modified Fish-Tail Flap
This variation is demonstrated in Figure 397.4A. The angle between the limbs may vary, according to individual
circumstances, in an effort to assure flap safety (2).
FIGURE 397.1 Normal breast serves as a template for the desired nipple dimensions. Nipple diameter (D) and
height (H) are shown.
[The double-opposing-tab flap variation was designed to help circumvent the problem of surgical scars
frequently found crossing the proposed nipple site (10) (see Chapter 395).]
Quadrapod Flap
The nipple location is identified, as previously described. The areola is marked about the nipple point. A
concentric circle marking the proposed nipple is drawn within the areola circle. Trapezoid-shaped flaps are
marked radiating from the nipple circle to the areola mark (6) (Fig. 397.5A). Care should be taken to avoid scars
that might affect flap vascularity.
Occasionally, there is some concern because of the amount of tissue underlying the breast mound, or when
implants are at risk for exposure. The following modifications minimize the extent of subcutaneous intrusion to
achieve the desired nipple form (4, 7, 8).
H Flap
The nipple and areola are marked. Rectangular tabs are drawn on opposing sides of the nipple disk. The width
of the rectangle is the desired projection (H) and the length is half the desired nipple circumference (C) (4) (Fig.
397.6A). The flaps must avoid scarred areas and should rest on healthy donor tissue.
T Flap
The nipple and areola are marked in a satisfactory position. A T-shaped flap is outlined, as indicated (Fig.
397.7A). Nipple height is determined by varying the length of the transverse limbs of the T. Nipple diameter is

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determined by the width of the vertical limb of the T. The width of the distal transverse limb should be three
nipple diameters long; the proximal transverse limb is two nipple diameters in length (7).
Mushroom Flap
The nipple and areola are marked, with the nipple disk as a circle one-quarter the surface area of the neo-
areola. The width of the nipple disk may be enlarged, if donor-tissue viability is a concern (8) (Fig. 397.8A).
OPERATIVE TECHNIQUE
Local anesthetic with vasoconstrictors is infiltrated into the area of the proposed flap. The wings of the skate flap
are first developed as a medium-thickness split-thickness graft attached to the composite flap. Dissection ends
when the markings outlining the composite flap are reached. The dissection is deepened into the subcutaneous
plane, and the composite flap is carefully elevated to its base. If the breast mound is thin, a layer of muscle may
be included in the flap (Fig. 397.2B); however, this is not recommended when using implants because of the risk
of implant exposure.
The wound is closed by advancing the skin edges toward the nipple with fine absorbable suture. This may
completely close the defect, although the breast must not be deformed in an effort to avoid grafting at the donor
site. The subcutaneous defect is closed in a similar manner (Fig. 397.2C). The wing
tips circumscribe the subcutaneous portion of the flap and are approximated at the base with fine suture. The tip
is then trimmed and sutured into position. If bulk is required, the tip may be deepithelialized and buried in the
nipple (Fig. 397.2D). The nipple base is stabilized by suturing to the donor-site dermis. Full-thickness grafts may
be taken for scar revision from the breast or from another suitable donor site. Grafts are applied in the usual
manner, and petroleum-jelly-impregnated gauze is applied to the graft. A rigid nipple guard may be fashioned
from a 5-cc syringe barrel cut 2 cm in length. The flange is padded with gauze prior to application. Bolster
dressings are applied and may be removed in 4 days.
FIGURE 397.2 A: Skate flap is marked for elevation. B: The flap is elevated gently, with care taken at the base

to avoid vascular compromise. C: Donor defects are closed. Deepithelialized skin may be advanced toward the
nipple. The skate wings circumscribe the pedicle and are secured. D: Tip of the skate flap is deepithelialized and
buried within the nipple or trimmed as needed. Closure is complete. Areola grafting is done if necessary.
FIGURE 397.3 A: Diagram of modified skate flap on the breast. Flaps extend to the neo-areola margin. B: Flap
elevation is complete, with care taken near the flap base to avoid vascular compromise. C: Neo-areola is
deepithelialized and grafted. Donor sites may be closed primarily. D: Tip of the dermal-fat flap may be
deepithelialized and buried if needed. Closure is complete. Optional areolar grafting is shown.
FIGURE 397.4 A: Diagram of modified fish-tail flap on the breast. The angle between flaps may vary according
to local conditions. B: Flaps are elevated, with care taken at the flap base to avoid vascular compromise. Flap
“a” is rotated into position and secured. C: Flap “b” is deepithelialized and passed beneath flap “a.” Flap “b” is
secured and donor defects are closed. D: Completed nipple construct.

FIGURE 397.5 A: Quadrapod flap diagrammed on the breast. B: Intervening trapezoids are removed as partial-
thickness grafts. C: Flap limbs are elevated as partial-thickness grafts. Dissection deepens at the nipple disk. D:
Dissection toward the chest wall is done about the nipple disk as an inverted cone. E: Areola grafting is
necessary to complete the final construct.
Modified Skate Flap
Full-thickness skin grafts are developed at the 3 and 9 o'clock positions. Elevation stops at the nipple circle. The
6-o'clock flap is raised with a generous subcutaneous fat layer and elevated to the 12-o'clock position (Fig.
397.3B). The areola is deepithelialized (Fig. 397.3C). The wing flaps are wrapped about the composite flap and
sutured with fine suture, and donor defects are closed with fine absorbable suture. Areola size is verified and
trimmed, as needed. The composite flap is trimmed and closed in a similar manner (Fig. 397.3D). This harvested
skin or skin from other suitable donor sites may be used to graft the neo-areola and remaining donor defect.
Modified Fish-Tail Flap
Similar principles for flap elevation have been previously described. Full-thickness flaps are raised with a
generous subcutaneous fat pad. Dissection stops at the nipple margin. The dissection is deepened into the
subcutaneous fat. The nipple base must not be undermined further. The tip of flap “a” is inset at the base of flap
“b” (Fig. 397.4B). Flap “b” is marked and deepithelialized to allow passage beneath flap “a.” Flap “b” is then
secured to the base of flap “a” as indicated (Fig. 397.4C). The donor sites are closed with fine suture (Fig.
397.4D). Postoperative dressings and wound care have been previously described.

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FIGURE 397.6 A: H flap diagrammed on the breast. B: Areola is deepithelialized to the margin of the H flap. C:
Deepithelialization of areola completed. D: Flap is elevated as a dermal-fat flap. Dermis about the nipple disk is
incised to allow complete flap elevation. E: Limbs of the H are wrapped about the subcutaneous pedicle and
secured. Areola grafting is required to complete the construct.
Quadrapod Flap
Intervening trapezoids are deepithelialized (Fig. 397.5B). The remaining flaps are elevated as medium-thickness
split-thickness grafts toward the nipple circle (Fig. 397.5C). The flaps are widened to include the intervening
dermis as the nipple disk is approached. The plane of dissection is now deepened into the subcutaneous tissue
and carried as an inverted cone toward the chest wall (Fig. 397.5D). The nipple should easily elevate to the
height of the flap limbs. Dissection may extend to the underlying muscle, if nipple mobility is limited. The areola is
then grafted in the usual manner. A cruciate incision is made, and the nipple is delivered from beneath the neo-
areola graft (Fig. 397.5E). Fine suture is used to join the flap limbs at each corner along the length of the nipple.
The nipple base is secured to the dermis of the neo-areola using fine suture. Postoperative dressings and
wound care have been previously described.
H Flap
The skin between the areola and the flap is deepithelialized (Fig. 397.6B and C). Rectangular flaps are elevated
in the
subcutaneous plane to the nipple circle. The remaining dermis about the nipple circle is incised into the
subcutaneous fat (Fig. 397.6D). The nipple disk is now freely mobile; it is elevated, and the tabs of the H are
wrapped about the base of the elevated nipple. The flaps are fixed to the opposing flap limbs with fine suture
(Fig. 397.6E). A full-thickness skin graft is obtained, and a small cruciate incision is made, through which the
nipple is passed. The graft is sutured into position, and the nipple is secured to the dermis of the neo-areola with
fine suture. Postoperative dressings and wound care have been previously described.
T Flap

The flap is raised as a dermal-fat flap with a generous subcutaneous fat layer. Careful handling is needed to
avoid vascular injury. The remainder of the skin between the neo-areola and the flap is deepithelialized (Fig.
397.7B). The flap limbs are wrapped about the nipple, approximating the subcutaneous layers, and sutured with
fine suture (Fig. 397.7C). The areola is grafted and the nipple secured to the dermis of the neo-areola with fine
suture (Fig. 397.7D). Postoperative dressings and wound care have been previously described.
Mushroom Flap
The areola is incised and elevated as a medium-thickness split-thickness graft to the nipple disk, leaving a thin
layer of reticular dermis in the donor bed (Fig. 397.8B). The neo-areola is then grafted with a full-thickness skin
graft and sutured into position. A small cruciate incision is made over the nipple disk. The flap is delivered
through the wound (Fig. 397.8C-E). A dressing is made of petroleum-jelly-impregnated gauze placed between
the areola graft and flap. A cover dressing is made with layered gauze, with a central hole created to protect the
flap. Soft bulky dressings cover the bolster and remain in place for 6 to 10 days. The undersurface of the
mushroom flap requires no dressing, as the areola graft and dressing preclude adherence. Contraction of the
elevated flap occurs with time, giving a satisfactory projection.
FIGURE 397.7 A: T flap diagrammed on the breast. B: Flap is elevated as a dermal-fat flap, with care taken to
avoid vascular compromise near the flap base. The areola is deepithelialized. C: Flap limbs are wrapped about
the subcutaneous pedicle and secured. D: Areola grafting completes the construct.
CLINICAL RESULTS
Nipple projection and size are well-maintained, although shrinkage may occur. This is overcome by slight
flap oversizing, but may require secondary amputation if a size discrepancy persists after healing is
completed. A generous wedge of subcutaneous tissue should accompany composite flaps to provide
adequate blood supply, and careful handling is necessary to protect the delicate vasculature from injury.
Tensionfree advancement of the donor margins is required to prevent deformation of the breast mound.
Prior periareolar mastectomy and reconstruction may negate the need for marking a neo-areola. Meticulous

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closure of the donor sites will permit tattooing as a next step.
Flattening, malposition, and shrinkage, although improved using current techniques, still continue to occur.
Allowing the breast position to stabilize over 3 to 6 months and slight flap oversizing may help to
compensate for these sequelae. Flaps
with a centrally-attached core are thought to resist radial tension from the breast mound and its deforming
forces on the nipple. The generous size of these flaps offers relatively greater vascular reliability. Scars
should be carefully avoided, as the local blood supply may be adversely affected. Skin grafts are frequently
necessary to cover the denuded neo-areola; these are taken from easily hidden local donor sites.
FIGURE 397.8 A: Mushroom flap diagrammed on the breast. B: Flap is elevated as a partial-thickness flap
to the nipple disk. C: Areola grafting is carried out. The flap is delivered through a cruciate incision in the
areola graft. D: Completed flap shown in cross section. E: Completed mushroom flap ready for dressing.
SUMMARY
The skate flap and its modifications provide reliable methods of producing durable nipples with adequate
projection and length. The procedures are simple, reliable, and produce minimal donor defects.
References
1. Kon M. Latissimus dorsi three-flap nipple reconstruction. Aesthet Plast Surg 1984;8:243.
2. Grotting JC. Reoperation following free flap breast reconstruction. In: Reoperative aesthetic and
reconstructive plastic surgery. St. Louis: Quality Medical Publishing, Inc., 1995.
3. Little JW. Nipple-areola reconstruction and correction of inverted nipple. In: Noone RB, ed. Plastic and

reconstructive surgery of the breast. Philadelphia: BC Decker, 1991;481-490.
4. Hallock GG, Altobelli JA. Cylindrical nipple reconstruction using an H flap. Ann Plast Surg 1993;30:23.
5. Georgiade GS, Reifkohl R, Georgiade NG. To share or not to share. Ann Plast Surg 1985;14:180.
6. Little JW, Munasifi T, McCulloch D. One-stage reconstruction of a projecting nipple: the quadrapod flap.
Plast Reconstr Surg 1983;71:126.
7. Chang WH. Nipple reconstruction with a T flap. Plast Reconstr Surg 1984;73:140.
8. Smith JW, Nelson R. Construction of the nipple with a mushroom-shaped pedicle. Plast Reconstr Surg
1986;78:684.
9. Chang BW, Slezak S, Goldberg NH. Technical modifications for on site nipple areola reconstruction. Ann
Plast Surg 1992;28:277.
10. Kroll SS, Hamilton S. Nipple reconstruction with the double-opposing tab flap. Plas. Reconstr Surg
1989;84:520.

Chapter 398
Transposition and Advancement Skin Flaps
D. P. ARMSTRONG
EDITORIAL COMMENT
One should be aware of these procedures because they are invaluable, especially for scar release of the
axilla. In dealing with hidradenitis of the axilla, the preferred closure would be direct approximation.
Resurfacing of axillary defects following excision of burn scars with contracture release or following excision of
localized disease can be accomplished by the use of local flaps, with or without the concomitant use of split-
thickness skin grafts.
INDICATIONS
Although direct primary closure can be accomplished following excision of localized disease (1, 2), well-
designed local flaps can provide a means of closure of larger defects by redistributing the local tissues to
avoid limitation of motion or distortion of adjacent structures (3, 4, 5, 6, 7, 8, 9, 10, 11, 12). When used in
combination with skin grafts, random-pattern flaps allow the surgeon to transfer skin and subcutaneous
tissue into the axilla in the area of greatest motion while placing the skin graft onto the adjacent chest or
arm in an area requiring no splinting and having little or no influence on axillary flexibility.
FIGURE 398.1 Local axillary flap using skin from the axilla to relieve moderate contractures anteriorly or
posteriorly. A: Design of flaps for elevation. Triangles are areas of scar to be excised. B: After excision of
scar and mobilization of flaps. (From Converse, ref. 5, with permission.)
ANATOMY
The successful use of random-pattern flaps in and around the axilla is made possible by the abundant branches
of the axillary artery and their liberal penetration to the dermal-subdermal plexus.
OPERATIVE TECHNIQUE
Burn Scars and Contractures
The patterns of distribution of scars about the axilla are multiple, and the possibilities for flap reconstruction

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depend on the availability of uninvolved adjacent skin. Local flaps alone (Fig. 398.1) or in combination with split-
thickness skin grafts (Figs. 398.2 and 398.3) are helpful in the correction of burn scar contractures.
FIGURE 398.2 A: Burn scar contracture involving posterior axillary fold. B: Contracture relieved by excision of
the thickest band of scar tissue. C: Medial arm flap elevated. (May be shifted anteriorly, if appropriate.) D: Flap
transposed across the posterior axillary fold, leaving a defect on the arm for repair with a split-thickness skin
graft. (From Converse, ref. 5, with permission.)
Four flap patterns for correction of both anterior and posterior axillary contractures are shown in Figures 398.1,
398.2, 398.3. Figure 398.1 demonstrates the advancement of a double flap from the axillary skin to relieve a
more limited, localized contracture band anteriorly (11). Figures 398.2 and 398.3 demonstrate methods of shifting
transposition flaps into areas of greatest motion, the soft flap bases providing the pivot points for motion within or
adjacent to the axilla. The medial aspect of the arm is often spared from the burn and provides a generous flap
for breaking up a moderate contracture anteriorly or posteriorly, leaving a relatively small defect on the arm for
resurfacing by means of a split-thickness skin graft (11). A superiorly based flap from the skin of the back just
posterior to the posterior axillary fold has been described (Fig. 398.3) (3). This is rotated anteriorly to interrupt
the contracture involving the posterior axillary fold. A similar flap from the anterior chest can be used if burn scars
and flap sites favor this approach.
Hidradenitis Suppurativa and Other Localized Disease
Five specific flaps have been found helpful in resurfacing defects following the excision of hidradenitis
suppurativa, a disease generally localized to a portion of or all of the hair-bearing skin of the axilla. These
principles could be applied in treating other localized tumors. Specific selection of the method of resurfacing
depends on the extent of the disease. Direct primary closure of axillary defects is a well-accepted alternative (1,
2).
Figure 398.4 illustrates a very conservative advancement flap whose base is very broad in relation to flap length
and with the resulting scar positioned to avoid banding with the elevation of the arm (7, 9).
FIGURE 398.3 A: Burn scar of infraaxillary skin extending into axilla. B: S-shaped incision elevating superiorly
based back flap with release of axillary contracture. (Similar anterior flap could be used if more appropriate to the
burn distribution.) C: Flap transposed across posterior axillary fold into axilla. Skin graft to arm defect. (From

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Colson et al., ref. 3, with permission.)
Very extensive involvement of the axillary skin may require a larger, posteriorly based sliding flap, as shown in
Figure 398.5, combined with a split-thickness skin graft in the flap bed. Note that the base of the flap is
positioned to avoid limitation of shoulder motion.
The skin and subcutaneous tissue from the anterior and posterior extremes of the wound can be shifted on a
subcutaneous pedicle into the central portion of the defect to aid in complete closure (Fig. 398.6).
Moderate to large axillary defects can be covered by well-designed infraaxillary rotation flaps (Fig. 398.7) with
primary closure of both the defect and the flap bed (4, 6, 7, 9). This flap is based posteriorly and slightly
superiorly and extends toward the submammary fold. The incisions are staggered slightly, as illustrated, to
facilitate closure of the flap bed. Final adjustment of the pivot point superiorly can be made after the chest defect
is closed and the flap is transferred into its axillary position. Encroachment into the flap base must be avoided to
prevent disruption of the blood supply. Hidradenitis tends to occur in slightly obese females who have an
abundance of soft tissue in this location. However, a generous flap can be mobilized in the thin male as well.
Owing to an abundant dermal- subdermal plexus in this area, an average width of 6 to 9 cm at the flap base and
a flap length of 8 to 11 cm have been well tolerated without necrosis.
The Limberg flap is an excellent means of closing axillary defects (10, 11, 12). A posteriorly based flap is
generally used in the male patient, and an anteriorly based flap is used in the female patient (Fig. 398.8). This is
comparable
to the infraaxillary flap described earlier and has the advantage of permitting development of a flap with a width
and length up to 12 cm. The flexibility of the adjacent structures permits rotation of this conservative flap into the
axillary defect.
FIGURE 398.4 A: Left axillary hidradenitis defect following excision with outline of posterolaterally based
advancement flap. B: Result 7 days postoperatively. (From Armstrong et al., ref. 7, with permission.)

FIGURE 398.5 A: Left axillary hidradenitis with outline of proposed area of excision and posteriorly based sliding
flap. B: Defect following excision. Note enlargement of defect. C: Result 2 weeks postoperatively with a skin
graft on the donor site. (From Armstrong et al., ref. 7, with permission.)
FIGURE 398.6 A: Defect of left axilla following excision of hidradenitis. B: Triangular flaps from the extremes of
the wound are shifted centrally on subcutaneous pedicles. C: Closure. (From Lipshutz, ref. 8, with permission.)
FIGURE 398.7 A: Drawing of axillary defect from excision of local hidradenitis and projected flap from the
infraaxillary area. Note that the inferior outline of the flap terminates at a pivot point slightly anterior to the defect
for greatest ease of closure of the flap bed and in order to leave a generous flap base. This flap has an average
width of 6 to 9 cm with a length of 8 to 11 cm. B: Postoperative result.

FIGURE 398.8 A: Limberg flap design. B: Defect after excision in a female patient with an anteriorly based
Limberg flap designed. C: Postoperative result. Note scar anteriorly from recent excision of additional focus of
disease. D: Male patient with proposed area of excision and posteriorly based Limberg flap. E: Large flap well
healed 21ú2 years postoperatively.
Excision of localized hidradenitis disease rarely extends through the axillary fascia, and therefore, the infraaxillary
or Limberg-type flap can be elevated in the same plane of dissection. Careful tissue handling, obliteration of the
dead space, securing of the flap to the base of the defect with absorbable material, and suction or soft rubber
drainage are helpful adjuncts to proper wound healing. Limited shoulder motion during the first postoperative
week generally completes the wound care of this versatile flap pattern.
SUMMARY
Several types of transposition and advancement flaps can be used, depending on the extent of the defect,
for burn contractures and hidradenitis in the axilla.
References
1. Pollack WJ, Vimelli FR, Ryan RF. Axillary hidradenitis suppurativa. Plast Reconstr Surg 1972;49:22.
2. Anderson DK, Perry AW. Axillary hidradenitis. Arch Surg 1975;110:69.

3. Colson P, Gangolphe M, Houot R, et al. Correction des retractions par brûlure de l'aisselle: valeur de
rotations de lambeau dans les cas de gravité moyenne. Ann Chir Plast 1960;5:1.
4. Paletta FX. Hidradenitis suppurativa: pathologic study and use of skin flaps. Plast Reconstr Surg
1963;31:307.
5. Converse JM, ed. Reconstructive plastic surgery, Vol. 4. Philadelphia: Saunders, 1964;1606-1607.
6. Harrison SH. Axillary hidradenitis. Br J Plast Surg 1964;17:95.
7. Armstrong DP, Pickrell KP, Giblin TR, Miller F. Axillary hidradenitis suppurativa. Plast Reconstr Surg
1965;36:200.
8. Lipshutz H. Closure of axillary hidradenitis defects with local triangular flaps. Plast Reconstr Surg
1974;53:667.
9. Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown, 1975; 437-446.
10. O'Brien J, Wysocki J, Anastasi G. Limberg flap coverage for axillary defects resulting from excision of
hidradenitis suppurativa. Plast Reconstr Surg 1976;58:354.
11. Borges A. Choosing the correct Limberg flap. Plast Reconstr Surg 1978; 62:542.
12. Rossi A, Jeffs J. The rhomboid flap of Limberg: a simple aid to planning. Ann Plast Surg 1980;5:494.

Chapter 399
Five-Skin Flap
B. HIRSHOWITZ
A. KAREV
EDITORIAL COMMENT
These multiple, relatively small flaps are reliable even though most of the designs are made through scar
tissue.
The triangular flaps of two Z-plasties and a V-Y advancement flap constitute the five-skin flap. They are best
applied for correction of a web contracture, most frequently caused by burns. Generally, the skin on the
underside of the web is relatively unscarred and is used for advancement into the scarred area for its release.
INDICATIONS
The sites on the body that lend themselves best to the five-skin flap procedure appear to be thumb webs
(see Chapter 327) (1, 2), finger webs, and bridle scars of the axilla (3, 4). In the latter situation, the apex of
the axilla is left intact and in situ, thus avoiding the transfer of unattractive tufts of hair to unusual sites.
FIGURE 399.1 A: The incisional lines. The procedure consists basically of two Z-plasties with an
intervening V-Y advancement. B: Flaps raised. C: The flaps transposed and advanced.
FLAP DESIGN AND DIMENSIONS
The design of the five-skin flap as applied to the axilla is shown in Figure 399.1A. Flap CDE encloses the apex of
the axilla and its tip D lies at the midpoint of the line AB that runs along the ridge of the web. GA and HB
complete the outline of the two Z-plasties; the angles 1 and 2 are about 70 degrees. The incision DF opens into
a triangular defect, into which CDE is advanced.
OPERATIVE TECHNIQUE
In preparing the Z-plasty flaps, the web is incised midway, so that an equal thickness of subcutaneous tissue is
retained on both sides of the web.

FIGURE 399.2 A,B: Preoperative markings of postburn anterior axillary web. The end of the central inverted V
can be seen to lie on the undersurface of the web. This will form the flap to be advanced. The inverted V
encompasses the apex of the axilla, and accordingly, the hair-bearing skin is left undisturbed. C: Immediately
postoperatively. D: One month postoperatively. A fairly normal contour has been obtained. (From Hirshowitz et
al., ref. 4, with permission.)
The part that is advanced and is the only part undermined lies on the underside of the web; thus no change in
position of the axillary apex occurs. The length DF is adjusted for the best fit. Because the ridge of the web is
curved, the angles ADF and BDF are slightly larger than 90 degrees, and some trimming of excess may be
necessary.
SUMMARY
Scar contractures creating a web across the axilla can be released by a procedure that involves the
creation of five flaps: two Z-plasties and a V-Y advancement flap.
References
1. Hirshowitz B, Karev A, Rousso M. Combined double Z-plasty and Y-V advancement procedure for the
repair of thumb web contractures: five-flap technique. Hand 1975;7:291.
2. Rousso M. Brûlures dorsales graves de la main. Reconstruction de la commissure. Technique à cinq
lambeaux. Ire partie: La premiére commissure. Ann Chir 1975;29:475.
3. Glicenstein J, Bonnefous G. La plastie en trident. Ann Chir Plast 1975; 20:257.
4. Hirshowitz B, Karev A, Levy Y. A five-flap procedure for axillary webs leaving the apex intact. Br J Plast
Surg 1977;30:48.

Chapter 400
Parascapular Fasciocutaneous Flap for Release of Axillary Burn
Contracture
G. G. HALLOCK
EDITORIAL COMMENT
It is always preferable to resurface axillary contractures by using a flap. Where burn contractures are
concerned, the parascapular area is often uninvolved, and this flap can be used with reconstructive
advantages.
The parascapular flap is a true fasciocutaneous flap from the posterolateral chest wall overlying the lateral
border of the scapula. In addition to its widespread use as a free flap, its attributes permit a wide range of utility
as a local pedicled flap, including coverage of the axilla (1, 2, 3, 4).
INDICATIONS
When used as a vascularized flap for axillary reconstruction, the risks of contracture or recurrence, as often
follow skin grafting in this region, are avoided (2). Postoperative splints are unnecessary, early mobilization
of the shoulder joint is unimpeded, and the period necessary for rehabilitation is diminished. The
parascapular flap, as a single-staged alternative, is excellent for resurfacing large defects involving the
posterior axillary web, or after the total axillary obliteration that frequently occurs with significant burn
injuries (2, 3).
ANATOMY
The vascular plexus of the dorsal thoracic fascia has an orientation along the direction of the terminal branches
of the cutaneous branch of the circumflex scapular artery (5). This cutaneous branch first courses through the
triangular space bounded above by the teres minor, below by the teres major, and laterally by the long head of
the triceps muscle, to pierce the deep fascia as a true septocutaneous perforator. Shortly after or sometimes just
before this (6), the branch divides into three distinct branches— ascending, horizontal, or transverse, or
descending—and each, in turn, ramifies on the surface of the fascia (Fig. 400.1) (7, 8). The descending branch
supplying the parascapular flap descends toward the tip of the scapula, paralleling its lateral border, and
represents the central axis of any such flap.
The descending branch departs occasionally from the circumflex scapular vessels, before reaching the triangular
space, and descends beneath to exit below, rather than above, the teres major muscle (5, 6, 7). Although the
circumflex scapular pedicle is more usually located approximately two-fifths of the distance between the spine of
the scapula and the scapular tip (2), this branch can still exit the triangular space anywhere along the middle
third of the lateral border of the scapula.
FLAP DESIGN AND DIMENSIONS
The parascapular flap encompasses that portion of the dorsal thoracic fascia nourished by the descending
branch of the

P.1078
P.1079
cutaneous branch of the circumflex scapular artery. Based at the site of this perforator arising from the triangular
space, the vertical or slightly oblique design of the flap has a caudal orientation that follows a vascular axis
paralleling the lateral border of the scapula.
FIGURE 400.1 Schematic diagram of the usual pattern of the trifurcation of the terminal branches of the
cutaneous branch of the circumflex scapular artery, after it has passed through the triangular space at the lateral
border of the middle third of the scapula. A parascapular flap has been drawn, centered about the descending
branch, with its near vertical axis (dotted line) paralleling the lateral border of the scapula. (The author thanks
Carol Varma, medical illustrator, the Lehigh Valley Hospital, Allentown, PA, for providing the diagram.)
Using an audible Doppler flowmeter or color duplex imaging, as necessary, the location of the origin of the
branch to the parascapular flap can be predetermined (8). The proposed point of rotation or base of the flap
corresponds to this site. Flap design is then centered about this vascular axis, which consistently parallels the
lateral border of the scapula. Flap width should slightly exceed that of the given defect (Fig. 400.2). Flaps up to
30 cm long and 15 cm wide, not exceeding a 3:1 ratio, have proven to be successful (2, 4). If flap width exceeds
about 10 cm (less in more obese patients), primary closure of the donor site will not be possible (3, 4).

FIGURE 400.2 A: A patient with a tight and primarily anterior axillary band preventing full arm abduction.
Unstable, hypertrophic burn scars of the chest and inner arm prevented the selection of alternative local flaps
from these regions, after the anticipated contracture release. B: Large parascapular flap designed on the
posterolateral chest with patient in a lateral decubitus position. C: Contracture after release, with a 25-cm × 12-
cm parascapular flap elevated in situ, (D) then transposed into the large area of axillary-skin deficiency. Flap has
a broad skin base that safely obviates the need for actual identification of the vascular pedicle, (E) to allow
unrestricted arm movement, but resulting in some superior displacement of the cupula. Primary donor-site
closure was possible, with the linear scar partially seen laterally. (Fig. 400.2A and C from Hallock and Okunski,
ref. 2, with permission.)
Using the horizontal (scapular flap) (9) or vertical (ascending scapular flap) (10) branches as alternatives usually
requires a conversion to island flaps, which cannot reach the axilla without almost an 180-degree twist about
their pedicles, a risk totally avoided by the wide base of a pedicled parascapular flap, where rotation into the
axilla follows a shorter, more natural, course (Fig. 400.2). The pedicled version of the parascapular flap could
even reach the side of the face, posterior scalp, shoulder, and upper arm, if desired, with a range similar to the
latissimus dorsi muscle (4). A major bonus is that no muscle need ever be expended.

OPERATIVE TECHNIQUE
With the patient in a lateral position, the anterior chest, axilla, and scapular region can all be exposed
simultaneously. After assessing the demands of the recipient site, the flap borders are correspondingly outlined
(Fig. 400.2). Dissection should begin inferiorly, to include the latissimus dorsi muscle fascia with the tip of the
flap. Retrograde dissection then continues toward the triangular space, being wary of anatomic variations,
especially an aberrant descending branch at the inferior border of the teres major muscle (5, 6, 7). If present, this
muscle may have to be divided, to gain additional length of the vascular pedicle for unimpeded flap transfer.
Otherwise, dissection toward or even along the main vascular pedicle is extended, until insetting can be
achieved without tension. Normally, the length of the flap can easily exceed that required, so that actual
dissection into the triangular space, discrete vessel identification, and possible vascular injury can be totally
avoided (Fig. 400.2).
CLINICAL RESULTS
Small axillary scars are preferably released with Z-plasties, Y-V plasties, local random flaps, etc. (11).
Solitary anterior webs are better treated by an inner-arm (12) or anterior trunk flap; a parascapular flap, if so
used, would destroy or displace the hair-bearing cupula. Of course, if the axilla has been totally obliterated
or predominantly has a posterior axillary contracture, the parascapular flap would be a primary initial
consideration anyway (11). Previous burns or skin grafts of the trunk are not a contraindication to using this
flap, as long as excision-to-fascia techniques were not previously utilized (13).
SUMMARY
The large vessel caliber, anatomic consistency, and length of the vascular pedicle permit the design of a
large local flap, very convenient for providing vascularized skin coverage for the adjacent axilla.
References
1. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: A new cutaneous microsurgical free flap.
Plast Reconstr Surg 1982;69:591.
2. Hallock GG, Okunski WJ. The parascapular fasciocutaneous flap for release of the axillary burn
contracture. J Burn Care Rehab 1987;8:387.
3. Yanai A, Nagata S, Hirabayashi S, et al. Inverted-U parascapular flap for the treatment of axillary burn scar
contracture. Plast Reconstr Surg 1985; 76:126.
4. Kim PS, Lewis VL. Use of a pedicled parascapular flap for anterior shoulder and arm reconstruction. Plast
Reconstr Surg 1985;76:942.
5. Cormack GC, Lamberty BGH. The anatomical vascular basis of the axillary fasciocutaneous pedicled flap.
Br J Plast Surg 1983;36:425.
6. Upton J, Albin RE, Mulliken JB, Murray JE. The use of scapular and parascapular flaps for cheek

reconstruction. Plast Reconstr Surg 1992;90:959.
7. Maruyama Y, Ohsaki M. Anatomical investigations of the cutaneous branches of the circumflex scapular
artery and their communications. Br J Plast Surg 1993;46:160.
8. Hallock GG. Color duplex imaging for identifying perforators prior to pretransfer expansion of
fasciocutaneous free flaps. Ann Plast Surg 1994; 32:595.
9. Dimond M, Barwick W. Treatment of axillary burn scar contracture using an arterialized scapular island
flap. Plast Reconstr Surg 1983;72:388.
10. Maruyama Y. Ascending scapular flap and its use for the treatment of axillary burn scar contracture. Br J
Plast Surg 1991;44:97.
11. Hallock GG. A systematic approach to flap selection for the axillary burn contracture. J Burn Care Rehab
1993;14:343.
12. Budo J, Finucan T, Clarke J. The inner arm fasciocutaneous flap. Plast Reconstr Surg 1984;73:629.
13. Hallock GG. The role of local fasciocutaneous flaps in total burn wound management. Plast Reconstr
Surg 1983;72:388.

Chapter 401
Transposition and Advancement Skin Flaps
J. E. WOODS
EDITORIAL COMMENT
When dealing with postradiation ulcerations, the use of muscle or omentum would be preferable to ensure
healing.
Chest-wall reconstruction may be achieved by many means. Following one of the older dicta of reconstructive
surgery—to use local tissue when available—leads one seriously to consider use of transposition and
advancement flaps as a relatively high priority. Since chest-wall reconstruction is often carried out for radiation
necrosis, bringing in tissue with a relatively unaffected blood supply is appropriate (1).
The flaps to be considered here include laterally and medially based flaps, oblique or transverse flaps, and the
contralateral breast flap (2). In addition, using a reverse abdominoplasty technique, the abdominal skin may be
advanced considerably in conjunction with other techniques or used alone where the defect is only moderate in
size (3).
INDICATIONS
Contrary to common opinion, even very sizable defects, including the absence of ribs, with consequent
concern for flailing, may be repaired using the flaps to be described. Full-thickness flaps with underlying
subcutaneous tissue provide enough substance to minimize flailing without the use of underlying synthetic
mesh, except in unusual circumstances. The possibility of subsequent foreign body-reaction and/or
extrusion is thus minimized.
Even very large laterally based flaps can be elevated without delay with some back-cutting at the lateral
base for greater mobility (see Fig. 401.1). While the laterally based flap is preferable in most instances, if
the area that might serve as its base has been compromised by surgery, radiation, or both, the medially
based flap is most useful. Again, surprisingly large defects can be reconstructed. Like the lateral flap, the
medially based flap may be elevated without delay, providing it does not extend beyond the anterior axillary
line (see Fig. 401.3). Unlike the laterally based flap, however, the donor defect of the medially based flap
cannot usually be closed primarily, and a skin graft is frequently required.
The contralateral breast flap may be an alternative when other flaps are not available (see Fig. 401.5). It is
perhaps more readily tolerated in the debilitated patient than the latissimus dorsi muscle or
musculocutaneous flap, where the procedure is for palliation and a less extensive and briefer procedure is
desirable. However, with all the other options currently available, this flap has not been employed in my
practice for several years. In my experience, the contralateral breast flap can be elevated without delay and
without subsequent necrosis (see Fig. 401.6). However, skin grafting to the donor defect is often necessary.
FLAP DESIGN AND DIMENSIONS
Most commonly, the laterally based flap should be designed as an oblique flap extending downward and
medially, so that rotation or transposition occurs at a favorable angle. It is important that the inferomedial border

also be oblique (Figs. 401.1 and 401.2), so that even with very large flaps, the donor defect can be closed with
some mobilization of the skin at the inferior perimeter with a V-Y closure. If the medial border of the flap is not
directed obliquely in the inferior and lateral direction, primary closure is impossible and skin grafting becomes
necessary, obviating one of the special advantages of this very useful flap. To enlarge or extend this flap, a
portion of the external oblique muscle may be included, where appropriate.
The medially based upper abdominal or thoracoepigastric flap differs from the lateral flap in that it is essentially
an axial flap based on perforators from the superior epigastric artery by means of the rectus muscle. It is for this
reason that the flap is designed in a transverse orientation, taking full advantage of the medial blood supply. The
flap is designed with a width to fit the defect and a length to reach it.
OPERATIVE TECHNIQUE
The laterally based flap (Figs. 401.1 and 401.2) is incised down to fascia as marked and elevated to the anterior
axillary line. As the flap is developed more laterally where large penetrating vessels are seen, these may be
spared, although this is essentially a random flap with a favorable base (width) to length ratio. Once elevated,
the flap is rotated into the defect with mobilization of the inferior and lateral defect skin, as necessary, and with
some back-cutting, if needed.
FIGURE 401.1 Design of flap. A: Flap is oblique, and medial incision also must be oblique if closure without skin
grafting is to be accomplished. Incorrect design is shown in upper right inset. Not only is it impossible to close the
donor defect without grafting, but the flap will not reach as high. B: Flap rotated into position. To gain more
length, some limited back-cutting of the base is permissible. C: Closure of the defect is possible by closing the V-
shaped defect in part B to form a Y or T.

FIGURE 401.2 A: Radiation necrosis of chest wall following radical mastectomy and radiation therapy. B: Defect
after excision of affected area showing design of flap. Note oblique medial border (patient's head is to the right).
C: Reconstruction of defect and closure of donor defect without skin grafting. D: Final result.
FIGURE 401.3 A: Chest-wall defect and design of medially based transverse upper abdominal or
thoracoepigastric flap based on medial perforators. B: Flap rotated into defect. C: Defect closed by
advancement of donor defect edges and split-thickness skin grafting.

FIGURE 401.4 A: Advanced radiation necrosis and recurrent cancer of chest wall. B: Chest-wall defect and flap
design. C: Immediate postoperative result showing lateral skin-grafted donor area. D: Late postoperative result.
The medially based flap (Figs. 401.3 and 401.4) is elevated with the underlying fat down to fascia from its lateral
extreme toward the midline, with the dissection stopping about 2 cm from the midline in order to avoid damaging
its perforating blood supply. The dissection approaching this area is done very carefully with blunt and scissor-
spreading dissection. The flap is rotated into place and sutured appropriately. The skin edges of the donor
defect are mobilized, advanced to minimize the open area, and sutured to the underlying fascia. A split-thickness
skin graft is used to cover the remaining defect, with bolus dressing for graft immobilization (Fig. 401.4).
FIGURE 401.5 A: Advanced radiation necrosis of shoulder and upper chest wall rendering upper extremity
painful and useless. B: After shoulder disarticulation and closure of defect with opposite breast. In this case,
breast flap was delayed. Nipple-areola complex was removed.
Since the operative technique for the contralateral breast flap is straightforward, no description is given (Figs.
401.5 and 401.6) (see Chapter 404).
CLINICAL RESULTS
For the contralateral breast flap, disadvantages include the appearance, the transfer of tissue at risk for
cancer, and the unaesthetic donor site. In one instance, after successful use of the breast flap, the nipple-
areola complex and underlying remnant of breast tissue were removed at a subsequent time at the patient's

request.
FIGURE 401.6 A: Large local recurrence of breast cancer after mastectomy. B: Defect after removal of
recurrence. View from left lateral aspect. C: Closure of defect with combination of undelayed contralateral
breast and laterally based oblique flaps, with closure of all defects without skin grafting. D: Final result. This
patient was last seen at 3 years without evidence of recurrence.
SUMMARY
Musculocutaneous flaps with their flexibility and reliability would appear to be a first choice in many cases of
definitive chest-wall reconstruction. However, in some patients undergoing palliative resections for recurrent
breast cancer, the lesser procedures described herein may be successfully used, even for very large
defects. Properly designed and executed primarily for purposes of wound management, the laterally based
oblique and medially based transverse thoracoepigastric flaps may be expected to achieve success with
minimal significant morbidity.
References
1. Brown JB, Fryer MP, McDowell F. Application of permanent pedicle blood-carrying flaps. Plast Reconstr
Surg 1951;8:335.
2. Woods JE, Arnold PG, Masson JK, et al. Management of radiation necrosis and advanced cancer of the
chest wall in patients with breast malignancy. Plast Reconstr Surg 1979;63:235.
3. Lewis JR. Use of a sliding flap from the abdomen to provide cover in breast reconstructions. Plast
Reconstr Surg 1979;64:491.

Chapter 402
Contralateral Transverse Thoracoabdominal Skin Flap
R. L. BAROUDI
EDITORIAL COMMENT
The vascular supply is now better understood to come from the contralateral musculocutaneous perforating
branches. It is imperative that as one elevates the flap, several of the perforators be maintained to ensure
flap reliability.
A transverse thoracoabdominal skin flap is rotated 90 degrees to cover the defect resulting from radical
mastectomy. It avoids the need for skin grafts for closure of the donor area, and the flap can be mobilized and
directly rotated without delay. Also, it provides good cover for a future mammaplasty.
INDICATIONS
Use of this flap should be selective, and it should not be used to close all postmastectomy wounds. Patients
on whom I have used it were principally those with stage III tumors (79 percent) and those with tumors
located in the outer quadrant (35 percent). However, some patients were closed by this procedure even
without fitting these qualifications because of the greater ease of repair after wide tumor resection.
ANATOMY
One peculiarity of this flap is that it crosses the midline. The blood circulation within the flap is not clear when
examined in the light of current knowledge about the vascularization of skin flaps. However, a careful review of
the literature permits some tentative hypotheses without much experimental substantiation (1, 2, 3, 4).
The flap does not resemble the axial type of flap but is more like a random flap. The pedicle receives flow from
the lateral branches of the segmental arteries at the T6 to T10 level and from the supraumbilical and
infraumbilical plexus formed by the perforating musculocutaneous branches that originate in the arcade of the
upper and lower deep epigastric arteries (Fig. 402.1).
Still unclear is the manner in which the lateral branches of the segmental arteries are joined to those on the
subaponeurotic plane of the epigastric arcade. The subaponeurotic and subdermal anastomotic network that
joins the arcades of the superior and inferior epigastric arteries to the navel must be very important to the
circulatory dynamics of the flap (5).
My conclusion is that the circulatory system that supplies the flap is based on the direct flow it receives from the
segmental branches, from the subdermal and the subaponeurotic infraumbilical plexus at the side of the pedicle,
and from the whole subdermal system of the areas adjacent to the pedicle. The subdermal and subaponeurotic
plexus, in turn, must be fed by the arcade of the deep epigastric branches of the same side. The superficial and
deep anastomoses of the contralateral side also permit the blood flow to cross the midline to serve the biologic
requirements of the flap (6).
FLAP DESIGN AND DIMENSIONS
The tumor area and the areola, as well as incision lines, are marked within the oncologic safety margin (Fig.

P.1081
402.2). The excision lines resemble a triangle with convex sides. The base of the triangle is along the
inframammary sulcus, and the other two convex sides are united at a vertex below the clavicle (the distance
varying according to the individual patient). The thoracoabdominal skin flap is outlined, also in a triangular shape
(Fig. 402.2B). The length of the flap may vary from 30 to 40 cm and its base from 20 to 25 cm. Its maximum
length-to-width ratio is 2:1, and its size is limited by two transverse parallel lines. One of these lines passes along
the inframammary sulcus; the other passes through the navel. The distal end of the flap is situated at the
contralateral hypochondrium. The lower edge, which begins very close to the navel, is convex and longer than
the upper edge. The flap reaches from one hypochondrium to the other, passing through the epigastric region
(Fig. 402.2B) (7, 8, 9, 10).
FIGURE 402.1 Schematic diagrams of flap circulation from the lateral branches of T6 to T10 segmental arteries
and from the adjacent plexus and epigastric arteries.
OPERATIVE TECHNIQUE
Mobilization of the thoracoabdominal flap is shown in Figure 402.3. The incisions are perpendicular to the skin
plane, and dissection is done at the level of the aponeurosis, from the distal end back to the base of the flap.
The dissection and rotation are tested repeatedly and delicately until the flap end reaches the highest part of the
surgical wound (Fig. 402.3D) (9).
To prepare for closure of the donor area, the subcutaneous tissue covering the anterolateral wall of the
abdomen is dissected almost to the inguinal fold. The umbilical pedicle is sectioned at its base during this
dissection. Suturing of the rotated flap is done in two layers over various drains.
CLINICAL RESULTS
In all patients, the mastectomy was performed according to oncologic safety limits, whatever the location of
the tumor in the breast quadrants. The position of the resultant defect on the thorax varied with the location
and size of the resection, and thus the width and length of the flap also varied, as it did with patient biotype
(longer for tall patients and shorter for short patients). In tall patients with tumors in the upper outer
quadrant of the breast, the length of the flap was about 40 cm, and in shorter patients, the length was about
24 to 30 cm.

P.1082
FIGURE 402.2 A: The base of the triangle is along the inframammary sulcus, and the other two convex
sides are united at the vertex below the clavicle. The thoracoabdominal skin flap is also triangular in shape.
The distal end of the flap is situated at the contralateral hypochondrium. B: The dotted area indicates the
undermining necessary to close the flap donor site by direct suture.
Thirty-four patients were treated. In 15 patients, seromas occurred. These were drained for 1 or 2 weeks
with no residual effect. Postoperative care was routine, and no special surgical treatment was needed.
Some flap necrosis occurred in 10 patients. In 6 of these, the necrosis prolonged healing time. Both
superficial and deep necrosis was observed, principally at the free ends of the flaps. In all these patients,
there had been more tension in the sutures and more excessive dissection of the flaps. In the six instances
of deep necrosis, the maximum extension was 8 cm from the end of the flap and across the entire width. All
these patients were reoperated. Necrotic material was excised, and the area was covered with a split-
thickness skin graft. Superficial necrosis occurred in 4 patients, slightly affecting the epithelium and the
dermis at the flap end. They healed by secondary intention.

FIGURE 402.3 A: Triangular area of demarcation surrounding the tumor with oncologic safety margin. B:
Typical appearance of the wound area immediately after tumor resection of the breast. C: The flap
elevated. D: Cranial traction on the flap. Evaluation of the amount of undermining and umbilical pedicle
amputation that must be done at this stage. E: Suture of the skin flap is done in two layers. F:
Postoperative result.
Suture dehiscence occurred at the flap end in 11 patients. This varied in length from 2 to 10 cm and
occurred where the tension was greater or after early removal of stitches. Seven of these patients were
resutured, and four healed by secondary intention. No hematomas were noted in the surgical area. None of
these patients developed any major or primary infection.
The site of the tumor and the patient's biotype are of major importance to the results, because they
determine the requirements for longer or shorter flaps. Upper outer quadrant tumors in tall patients required
greater undermining and longer flaps, and all cases of deep necrosis that occurred were in this group. Four
of these patients were tall and two were average in height. The size of the tumor was not a limiting factor in
the closure of defects.
SUMMARY
The transverse thoracoabdominal skin flap can be used for the large chest defects that result after a radical
mastectomy, especially when skin also must be excised.
References
1. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965;36:173.
2. Haddad CM. Ensaios sobre a rede arterial da parede anterolateral do abdome (Estudo radiologico). Rev
Assoc Med Bras 1969;110:225.
3. Smith PJ, Foley B, McGregor LA, Jackson IT. The anatomic basis of the groin flap. Plast Reconstr Surg
1972;49:41.
4. Brown RG, Vasconez LO, Jurkiewicz JM. Transverse abdominal flap and the deep epigastric arcade. Plast
Reconstr Surg 1975;55:416.
5. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg 1973;26:202.
6. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;2:3.
7. Veronesi U, Lovo GF. Tecnica operatoria dell'exereci di metastasi mammarie interne isolate, in paziente
operate di mastectomia radicale. Tumori 1963;49:443.
8. Spadafora A. Cierre de brechas producidas por mastectomias amplias. Prensa Med Argent 1964;51:552.

9. Baroudi R, Pinotti JA, Keppke EM. Radical mastectomy: new technique for closing wound areas.
Panminerva Med 1967;9:463.
10. Tai Y, Hasegawa H. A transverse abdominal flap for breast cancer. Plast Reconstr Surg 1974;53:52.

Chapter 403
Bipedicle Skin Flaps
L. C. ARGENTA
E. C. DUUS
EDITORIAL COMMENT
The use of bipedicled skin flaps is limited because of the lack and siting of tissues; most of the time,
secondary skin grafting is required.
Bipedicle flaps of skin and subcutaneous tissue are easily developed on the thorax and are simple solutions to
coverage of many superficial defects (1, 2, 3). Because of the multiple systems supplying blood to the chest wall,
such flaps may be oriented equally well in a vertical or horizontal direction depending on the needs of the patient.
When properly designed, bipedicle flaps are robust flaps, allowing mobilization of well-vascularized tissue.
However, because of their design, they are limited as to the distance they can be moved.
INDICATIONS
Vertically oriented bipedicle flaps lend themselves extremely well to defects of the sternum. The
juxtaposition of two bipedicle flaps, one from each side of the defect, is especially useful for the closure of
large defects. Such flaps may be used in combination with underlying synthetic material such as Marlex or
homologous muscle flaps. Most defects of the anterior chest wall are best closed with transversely based
flaps.
ANATOMY
The blood supply to the skin and subcutaneous tissues of the chest wall is derived from branches of the lateral
thoracic, internal mammary, superior epigastric, thoracoachromial, and intercostal arteries (Fig. 403.1). An
understanding of the distribution of these vessels is important so that as many of these vessels as possible may
be incorporated into the flap.
The lateral thoracic arteries are tributaries of the second portion of the axillary artery, which descends to the
anterior and lateral portions of the chest, turning around the free edge of the pectoralis. Multiple perforators
supply the overlying skin. In the female patient, this tends to be a significantly more substantial vessel than in the
male patient.
The internal mammary artery gives off the anterior intercostal vessels. The upper six intercostal spaces are
supplied by two such anterior intercostal vessels. The perforating branches of these vessels supply the overlying
skin, with the second, third, and fourth being dominant.
The superior epigastric artery anastomoses with the internal mammary artery and supplies the area of the rectus
sheath and overlying skin. The pectoral branch of the thoracoacromial supplies the pectoral muscles, and its
perforators supply the overlying skin. Posterior intercostal arteries send branches to the posterior and lateral
chest wall, to the breast, and to the overlying skin and subcutaneous tissue.

FIGURE 403.1 The blood supply of the chest wall. Multiple discrete arteries and their tributaries supply the
thoracic wall. A considerable amount of overlapping of vessels allows safe development of transversely or
vertically based flaps on the chest wall.
FIGURE 403.2 Most defects of the anterior and posterior chest wall are best closed with transversely based
flaps. Defects of the midsternum are expeditiously covered with bilateral flaps on either side of the defect. These
are best based in the vertical direction.
FLAP DESIGN AND DIMENSIONS
The anterior and lateral chest walls are usually best covered with a transversely based flap, taking advantage of
the transverse orientation of the intercostal vessels. Defects of the midsternum are best covered with vertically
oriented bipedicle flaps (Fig. 403.2).
Obviously, the quality of tissue adjacent to the defect is critical. The inclusion of heavily irradiated, scarred,
inflamed, or traumatized tissue with the advancement flap invites failure. The presence of such tissue is best

treated with distant vascularized flaps.
The flap should always be at least 25 percent, and preferably 50 percent, larger than the defect. The larger flap
allows overlap of the defect so that some contact may be made with adjacent vascularized tissue. Since all
bipedicle flaps include some random area, a flap width of at least half the length of the flap is recommended.
OPERATIVE TECHNIQUE
The success and ease of mobilization of this flap largely depend on the initial relaxing incision that is made
parallel to the defect. To avoid tension and kinking of the flap, the relaxing incision should be at least twice as
long as the defect. Curving the relaxing incision, with the concave side toward the defect, facilitates mobilization
of the flap.
Undermining may be done bluntly or sharply at the level of the fascia. While inclusion of the fascia may preserve
additional blood supply, it limits mobilization. As many perforating vessels as possible are left intact, as long as
the transposition can be accomplished. When the flap is transposed to the defect, extension of the relaxing
incision or even judicious backcutting of the flap may be required.
If there is any suspicion of compromise after transposition, fluorescein should be used. If significant areas of the
flap fail to fluoresce, the flap should be returned to its donor site for 5 to 7 days as a delay procedure.
After transposition of the bipedicle flap, the donor defect should always be closed with a split-thickness skin
graft. At times, undermining of adjacent tissue may give the illusion that the defect may be closed primarily.
However, the resultant tension may prove disastrous, with subsequent necrosis or dehiscence of the flap.
SUMMARY
Bipedicle skin flaps, either vertically or transversely oriented, can be used to close chest-wall defects.
References
1. Starzynski T, Snyderman R, Beattie EJ. Problems of major chest-wall reconstruction. Plast Reconstr Surg
1969;44:525.
2. Martini N, Starzynski T, Beattie E. Problems in chest-wall resection. Surg Clin North Am 1969;49:313.
3. Gingrass R. Flaps for chest wall reconstruction. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little,
Brown, 1975;447-458.

Chapter 404
Breast Flaps
R. P. GINGRASS
EDITORIAL COMMENT
We agree with the author's assessment that the usefulness of these breast flaps is limited.
Given the great variety of musculocutaneous, muscle, and skin flaps developed in recent years, the role of the
breast flap for chest-wall reconstruction is limited.
INDICATIONS
The breast flap may still have a place in reconstruction of an anterior defect in a woman with radiation
necrosis and/or recurrent cancer after mastectomy (1). An appropriate candidate might well be an older
woman with a chronic, painful, ulcerating wound who is not concerned about the aesthetic deficiency of the
transposed breast (2, 3, 4). Another indication might be in a woman who wants a minimum of additional
scars that cannot be covered easily. These include those which result from flaps taken from the chest,
upper abdomen, back, and arm. One additional use of the flap is as a fall-back procedure if an initial flap
reconstruction fails, especially if an open chest wound is present.
The breast flap has several advantages over other flap techniques. It is comparatively uncomplicated and
can be done expeditiously. The flap usually has a good blood supply that is not jeopardized. Scarring is low
on the anterior chest wall, thereby allowing the woman to wear clothes that expose the upper anterior chest,
back, and abdomen. The cyclops breast deformity can be decreased by judicious thinning of the transposed
breast and by excision of the nippleareola complex, which can be replaced appropriately on the remaining
breast mound.
OPERATIVE TECHNIQUE
The incision for the breast flap is usually made in the inframammary crease and is extended as far laterally in the
crease as is necessary to allow the flap to rotate into the defect without tension (Fig. 404.1). The flap is
undermined over the pectoralis and serratus fascia, again only as far laterally and superiorly as necessary. If the
defect is large and lateral, and/or the donor breast is small, the breast flap may be transposed as well as rotated.
This requires a split-thickness skin graft to close the lateral donor site.
A variety of modifications can be used, depending on the size and location of the defect and of the donor breast.
Extended coverage can be obtained by one or several incisions on the deep surface of the breast to allow the
skin component to be advanced further laterally. A bibbed flap can be created by an additional skin incision from
the crease toward the areola or beyond, with excision of the nipple-areola complex (2, 4, 5, 6) (Fig. 404.2).
If the defect is small and medial or the donor breast is large, only the medial portion of the breast may be needed
(7) (Fig. 404.3). If the breast is very large or ptotic, there may be sufficient tissue in the inferior quadrants to use
as a medially based pedicle flap (7, 8). This creates a long, narrow flap, and a delay procedure may be
necessary. In either case, the remaining breast can be rotated into the defect created at the donor site to
minimize the deformity and avoid the cyclops problem. A little ingenuity on the part of a thoughtful breast surgeon

with experience in reconstruction, reduction mammaplasty, and mastopexy should minimize the donor-site
deformity.
For a larger defect, or in a patient with a small breast, additional skin beyond the breast may be needed (Fig.
404.4). The skin beneath the inframammary crease can be included, either as part of the rotation flap or by
creation of a transposition flap (2, 9, 10) (Fig. 404.5). The skin beyond the midline may be necessary for an
extensive lateral defect (Fig. 404.6), but a delay procedure may be wise.
SUMMARY
The breast flap may occasionally be the procedure of choice for closing chest-wall defects.
FIGURE 404.1 A: Incision for the breast flap. The superolateral end is determined by rotating the breast
into the defect and extending the incision just high enough to allow the flap to cover the defect without
tension. B: Breast flap rotated into the defect. The shaded area can be closed primarily if this does not
cause tension on the flap. If tension results, a split-thickness skin graft is necessary.
FIGURE 404.2 Breast-splitting incision (solid line) creating a bilobed flap. The medial component can
thereby be advanced further laterally to the patient's right. For even further advancement, the nipple-areola
area can be excised and the incision extended superiorly (broken line).
FIGURE 404.3 For a very small medial defect, a transposition flap from the medial portion of the breast may
be all that is necessary.

FIGURE 404.4 For a large or lateral defect, or in a patient with a very small breast, the skin beneath the
inframammary crease may need to be included with the breast to provide sufficient skin to cover the defect.
FIGURE 404.5 In selected patients, a transposition flap including the inframammary skin may be more
appropriate than the usual rotation flap.
FIGURE 404.6 For an extensive lateral defect, the breast flap can be extended across the midline. A delay
procedure is strongly recommended.
References
1. Gingrass R. Flaps for chest wall reconstruction. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little,
Brown, 1975.
2. Maier HC. Surgical management of large defects of the thoracic wall. Surgery 1947;22:169.
3. Pierce GW, Wiper T, Magladry G, et al. Reconstruction of a large defect on the entire thickness of the
chest wall. Am J Surg 1961;102:720.
4. Rees TD, Converse JM. Surgical reconstruction of defects of the thoracic wall. Surg Gynecol Obstet
1965;121:1066.

5. Urban JA. Radical excision of the chest wall for mammary cancer. Cancer 1951;4:1263.
6. Whalen WP. Coverage of thoracic wall defects by a split breast flap. Plast Reconstr Surg 1953;12:64.
7. Latham WD. Operative treatment for postradiation defects of the chest wall. Am Surg 1966;32:700.
8. Pickrell KL, Kelly JW, Mazzoni FA. The surgical treatment of recurrent carcinoma of the breast and chest
wall. Plast Reconstr Surg 1948;3:156.
9. Davis JS, ed. Surgery: its principles and practice. Philadelphia: Blakiston, 1919. Chap. 23.
10. Bennett JE, Carter D. The surgical management of extensive necrosis after Radiation therapy. In:
Transactions of the Third International Congress of Plastic Surgery. Amsterdam: Excerpta Medica,
1964;113.

Chapter 405
Deepithelialized Turnover Deltopectoral Flap
A. G. LEONARD
The standard deltopectoral flap (1) can be modified to cover chest-wall defects. The end of the flap is
deepithelialized and then turned over like the pages of a book (2, 3). In medial defects, the procedure can be
completed in one stage; however, in lateral defects, the flap pedicle is returned after 3 weeks.
INDICATIONS
The classic deltopectoral flap can be used in reconstruction of defects of the anterior chest wall (4),
although this may give rise to difficulty with twisting of the pedicle to reach the defect. If the chest-wall
excision has been full-thickness, skeletal support may be required, and the dermis of a deepithelialized flap
can be used to provide this (5). The flap may be planned simply to turn over into the defect after removal of
its epithelium. If the defect is located medially, a one-stage reconstruction can be achieved. However, if the
defect is located more laterally, a longer flap is required, and division and return of the pedicle are
preferred. Where the former is possible, it has the advantage of retaining the blood supply to the flap in
patients in whom the surrounding tissues have been irradiated. If the flap is deepithelialized using the drum
dermatome, this allows use of the removed skin to graft the undersurface of the flap, thus reducing the
amount of skin to be taken from a distant site.
ANATOMY
See Chapter 127.
FIGURE 405.1 A: Plan of a one-stage reconstruction of a medially located defect. B: A longer deltopectoral flap
with a distal deepithelialized paddle for reconstruction of a laterally located defect.
FLAP DESIGN AND DIMENSIONS
If the contralateral breast is large and pendulous, the flap should be planned preoperatively with the patient
sitting up to avoid inclusion of a large amount of breast tissue in the flap. In any case, the flap should be planned
slightly longer than might at first be apparent to allow for some shortening when it is turned over (Figs. 405.1A
and 405.2).
Where the defect is placed so far laterally that extension of its medial margin to the midline would require
sacrifice of a large area of normal skin, it is preferable to use a longer flap, with division and return of the pedicle
at 3 weeks (Figs. 405.1B and 405.3). It also may be preferable to use this technique in a medially located defect
in a patient with a very large contralateral breast, in whom the medial part of the flap will be very thick.

OPERATIVE TECHNIQUE
Medially Located Defects
After creation of the defect by excision of radionecrotic ulcer or extirpation of tumor, the medial margin of the
defect should be extended at least to the midline or, if there is a great thickness of subcutaneous fat, to the
contralateral border of the sternum (Figs. 405.1A and 405.2). In the latter case, care should be taken not to
damage the perforating branches of the internal mammary artery.
The flap is then raised in the usual way, with dissection carried medially until the perforating branches of the
internal mammary artery are seen. It can conveniently be deepithelialized using the drum dermatome. It is then
turned over like a page of a book to lie in the defect, where it is sutured in place (6). The previously removed
skin is used to graft the exposed undersurface of the flap, and the secondary defect is grafted with split-
thickness skin taken from a distant site.
FIGURE 405.2 A: Preoperative view of a radionecrotic ulcer on the left side of the chest, with the third rib
exposed in the depth of the wound. B: The ulcer has been excised with the full thickness of the chest wall where
necessary. The medial margin of the excision extends to the midline, and the deltopectoral flap is outlined on the
right side of the chest. C: The deepithelialized deltopectoral flap is turned over like a page of a book to lie in the
defect. D: Postoperative view of the repair.

FIGURE 405.3 Postoperative result in a two-stage repair after division and return of the pedicle.
Laterally Located Defects
In this case, only a paddle at the end of the flap, of an area corresponding to the defect, is deepithelialized,
planning on division and return of the pedicle at 3 weeks (Figs. 405.1B and 405.3).
CLINICAL RESULTS
Where the defect is medially located, the one-stage technique provides a rapid reconstruction with skeletal
support provided by the flap dermis and retention of the vascular axis. Where this is not possible, the two-
stage technique provides a satisfactory reconstruction at the expense of longer hospitalization. Paradoxical
movement of the reconstructed segment is minimal except on deep inspiration, but this has not reduced
exercise tolerance in normal activities.
SUMMARY
The deltopectoral skin flap can be deepithelialized and turned over to cover chest-wall defects in either one
or two stages.
References
1. Bakamjian VY. A two-stage method of pharyngeal reconstruction with a primary pectoral skin flap. Plast
Reconstr Surg 1973, 1965:36.
2. Dinner MI, Anderson R, Kay PP. Repair of defect of anterior chest wall with a turnover dermal-fat
deltopectoral flap. Plast Reconstr Surg 1978;61:115.
3. Leonard AG. Reconstruction of the chest wall using a deepithelialized “turn-over” deltopectoral flap. Br J
Plast Surg 1980;33:187.
4. Robinson DW. The deltopectoral flap in chest wall reconstruction. Br J Plast Surg 1976;29:22.
5. Tamoney HJ, Stent PA. Dermal graft for chest wall repair. Surg Gynecol Obstet 1964;118:289.
6. Pakiam AI. The reversed dermis flap. Br J Plast Surg 1978;31:131.

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Chapter 406
Omental Flap
R. S. STAHL
M. J. JURKIEWICZ
EDITORIAL COMMENT
Taking the omentum may be costly; this should be considered for reconstructive purposes only when other
skin or musculocutaneous flaps are nor available.
In no discipline have the recent advances in the knowledge of surgical anatomy and technique enabled more
bold and aggressive extirpation of tumor, infection, and radionecrosis than in chest-wall reconstruction. With the
use of regional muscle flaps, omental transposition, and free-tissue transfer, most restrictions on chest-wall
surgery have been eliminated (1, 2, 3, 4, 5, 6). The use of pedicled omentum has proven a reliable method of
reconstruction of difficult thoracic defects with highly revascularized tissue and minimal morbidity (7, 8, 9, 10, 11,
12, 13, 14).
INDICATIONS
The omentum has many utilitarian virtues: it readily accepts skin grafts, has an extended range, and leaves
a minimal donor defect. The omentum typically brings highly vascularized tissue to necrotic, irradiated,
malignant, or infected wounds with extreme reliability. Its rich lymphatic supply offers the theoretical
advantage of increased resistance to infection and malignancy. Indeed, recurrence of tumor in wounds
covered with omentum usually occurs at the margins (13).
Not only does the omentum offer an effective means of reconstruction in curative procedures, but it
improves the quality of life in patients with the ulcerated, foul, weeping, miserable wounds of terminal
disease. For example, it can be used in reconstruction of excisional defects in many lesions of the chest
wall: primary tumors, recurrent breast carcinomas, or progressive radionecrosis. It offers a reliable means of
breast reconstruction or infected sternal dehiscence repair when other tissues, such as the latissimus dorsi
or pectoralis major, are unavailable or inadequate.
ANATOMY
The greater omentum, having developed from the dorsal mesogastrium, is supplied by the right and left
gastroepiploic arteries. These vessels, arising from the gastroduodenal and splenic arteries, respectively, join
along the greater curvature of the stomach to form the gastroepiploic arch. This arch typically gives rise to the
right, middle, and left omental arteries, as well as multiple short omental vessels. Each of the omental arteries
then contributes to another vascular arcade in a more dependent portion of the omentum (15). Knowledge of the
five major variants of the vascular arcade (16) allows for preservation and utilization of collateral blood flow in
selective division and lengthening for more distant pedicle applications (see Fig. 406.3).
FLAP DESIGN AND DIMENSIONS
The omentum will reach the nipple in 75 percent of patients, the level of the sternal angle in 40 percent of

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patients, and the inguinal ligament in 10 percent of patients after lysis of its colonic attachments only (17) (Fig.
406.1). The omentum has been applied in the treatment of wounds of the back and flank by passing it through
retroperitoneal tunnels, further extending its range (18). With attention to the vascular anatomy, the omentum
may be divided and lengthened to reach the skull, the midleg, and the midforearm. However, progressive
sacrifice of “tip size” corresponds with lengthening, making free
microvascular transfer a more practical means of using omentum for distant wounds.
FIGURE 406.1 Colonic attachments of omentum lysed as initial step of omental mobilization.
OPERATIVE TECHNIQUE
Prior to operative treatment, the difficult wound should be biopsied for appropriate microbiologic and
histopathologic examinations. Such information will, of course, dictate proper antibiotic coverage, as well as
appropriate width of resection.
The operative strategy in omental chest-wall reconstruction consists of assessing and mobilizing the omentum
prior to manipulating the contaminated thoracic wound or committing to an extensive resection. After a thorough
peritoneal exploration by means of a transverse abdominal incision, the first assistant places the omentum on
traction, while the surgeon begins lysing its relatively avascular attachments to the colon. Since there is usually
less fusion of the leaves of the omentum to the tail and body of the pancreas, most surgeons advocate beginning
omental mobilization on the left. It is also important to avoid injuring diverticula coli, appendices epiploica, and the
transverse mesocolon and middle colic vessels. Immediate ligature of vessels, with avoidance of the use of
electrocautery, prevents injuries to these delicate vessels and resultant damage to the gastroepiploic arcade by
hematoma formation.
If the range of omental mobilization is not adequate, several steps may be taken to extend this. Division of gastric
attachments and one of the gastroepiploic vessels is the simplest and most commonly used method of omental
elongation (Fig. 406.2). Care must be taken not to distort the gastroepiploic vessels during division and ligation
of the omental attachments to the stomach. The short vessels between the gastroepiploic system and the
stomach may be individually clamped and ligated as far distally as the antrum and duodenum. Furthermore, the
right and left gastroepiploic vessels should be alternately occluded to determine competence of the arch. The
right gastroepiploic artery is usually the larger and more pulsatile of the two; consequently, the left gastroepiploic
vessel is usually sacrificed. The final option for augmenting omental range consists of selective omental division,
described in the discussion of anatomic considerations (Fig. 406.3).

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FIGURE 406.2 After division of gastric attachments, the omentum may be based on either the right (A) or the left
(B) gastroepiploic vessel, markedly extending omental range.
Having achieved adequate omental length, a generous tunnel is created in the subcutaneous space for passage
of the omental flap through the laparotomy incision, through a separate incision in the rectus sheath, or between
ribs adjacent to the recipient site. The latter two choices are thought to diminish chances of herniation. Many
surgeons place the pedicle through the body wall just to the left of the falciform ligament in an effort to prevent
herniation as well. Care should be taken during this transposition of the flap to avoid twisting the pedicle or
distorting the duodenum or antrum. The placement of tacking sutures from the omentum to the margins of the exit
wound helps to prevent extrusion and excess mobility of the flap.
Once omental range and position are deemed adequate and the omentum is placed in its tunnel readily
accessible to its recipient site and covered with a moist pad, the abdominal wound is closed and attention is
turned to the chest-wall lesion. A generous resection of all necrotic, infected, irradiated, or malignant tissue is
performed. It is especially important to resect involved costal cartilages widely.
Chest-wall rigidity may be restored by suturing one or two layers of Prolene mesh to the inner surface of the rib
cage after placement of chest tubes (19). This material seems to tolerate contamination relatively well. For larger
full-thickness defects, rib grafts are added to provide bony support, preventing paradoxical motion as well as an
unnatural chest-wall contour (Fig. 406.4).
After the omentum is sutured to the wound margins, covering Prolene, rib grafts, and chest tubes, meshed split-
thickness skin is applied directly to the omental surface, allowing for the transudation of fluid that typically occurs
postoperatively. The procedure is then concluded with the application of a moist but noncompressive dressing.
CLINICAL RESULTS
Surprisingly few complications arise from use of the omentum for the foregoing purposes, in spite of the
need for invasion of the peritoneal cavity, the advanced, contaminated wounds for which its application is
often reserved, and the debilitated state of many patients in whom it is used.

FIGURE 406.3 Knowledge of omental vascular anatomy allows for pedicle lengthening with preservation of
blood supply.
FIGURE 406.4 A: Ulcerated, irradiated chest-wall recurrence of carcinoma of the breast. B: Prolene mesh
is sutured to margins of full-thickness chest-wall resection after placement of chest tubes. For larger
wounds, rib grafts may be added to restore contour and prevent paradoxical motion. (From Jurkiewicz,
Arnold, ref. 11, with permission.) C: Healed wound after placement of omentum (plus meshed skin graft)
over Prolene mesh.
Most sequelae and complications of use of the omentum are minor and resolve with expectant treatment.
These include a brief gastric ileus, partial omental or skin-graft separation or loss, and occasional
recurrence of infection. Periodically, elevation of the flap, debridement, and reinsetting may be required,

P.1087
although most of these marginal wounds rapidly granulate and epithelialize.
Possible complications of pedicled omental reconstruction include incisional hernia formation and omental
migration of the peritoneal exit site. As with any intraabdominal procedure, a finite risk of adhesive bowel
obstruction exists, although this has not seemed a prominent problem. Lysis of omental adhesions has been
reported as the cause of cecal volvulus in the mortality of one patient who underwent pedicled omental
chest-wall reconstruction (12). However, adherence to the principles outlined earlier should prevent most
complications.
SUMMARY
The omentum is especially useful in managing wounds of the chest wall, where dependable, adequate
coverage of vital organs and vessels is essential.
References
1. Starzynski TE, Snyderman RK, Beattie EJ. Problems of major chest-wall reconstruction. Plast Reconstr
Surg 1969;44:5.
2. Martini N, Starzynski TE, Beattie EJ. Problems in chest wall resection. Surg Clin North Am 1969;49:313.
3. Woods JE, Arnold PG, Masson JK, et al. Management of radiation necrosis and advanced cancer of the
chest wall in patients with breast malignancy. Plast Reconstr Surg 1979;63:235.
4. Leonard AG. Reconstruction of the chest wall using a deepithelialized “turn over” deltopectoral flap. Br J
Plast Surg 1980;33:187.
5. Dingman RO, Argenta LC. Reconstruction of the chest wall. Ann Thorac Surg 1981;32:202.
6. Arnold PG. Reconstruction of the sternum and anterior chest wall: aesthetic considerations. Clin Plast
Surg 1981;8:389.
7. Kiricuta I, Goldstein MB. Das Omentum als Ersatzmaterial der blasenwand bei durchstrahlen verursachten
Blasenscheidenfisteln. Krebsarzt 1961;16:202.
8. Kiricuta I. L'emploi du grand épiploon dans la chirurgie du sein cancereux. Presse Med 1963;71:1.
9. Dupont C, Menard Y. Transpositions of the greater omentum for reconstruction of the chest wall. Plast
Reconstr Surg 1972;49:263.
10. Arnold PG, Hartrampf CR, Jurkiewicz MJ. One-stage reconstruction of the breast using the transposed
greater omentum. Plast Reconstr Surg 1976;57:520.
11. Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruction of the chest wall.