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

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suture, and the donor site is closed primarily in layers after limited skin edge undermining, under closed suction drainage
(1, 12).
CLINICAL RESULTS
To date, only a handful of cadaver, anatomical, and clinical application studies have been performed. The results of
these studies, however, corroborate and have contributed to our knowledge of the vascular anatomy of the deep
superior epigastric artery and may make it as useful as its neighbor, the deep inferior epigastric artery. The SEAP flap
can be used for reconstruction of sternal (Fig. 420.1), breast (Figs. 420.2 and 420.3), and abdominal wall defects
without disrupting the muscular continuity of the abdominal wall. Deep superior epigastric artery-based
adipocutaneous flaps offer an attractive alternative in sternal wound coverage. In patients with an intact internal
thoracic artery-deep superior epigastric artery vascular axis, the use of this flap maintains future use of rectus
abdominis or pectoralis major myocutaneous flaps.
The results for SEAP flaps available in the literature are outlined in Table 420.1.
SUMMARY
Our clinical experience indicates that the SEAP flap provides a useful approach for reconstruction of defects of the
anterior chest wall or breast reconstruction, or for abdominal wall reconstructive purposes. CT-based imaging allows
for assessment of the perforators of the SEA. Moreover, MDCT scan improves preoperative planning in salvage
cases. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, with reduced donor site morbidity
related to muscle harvest or laparotomy. From our experience with the DIEP flap, we know that a safe length of a
perforator flap depends on many factors such as perforator diameter, location, and orientation in the soft tissue.
Although tip necrosis is the major complication (1, 12), this can often be treated conservatively without affecting
outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint
between the xiphisternum and the umbilicus or by transverse orientation of the flap.

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FIGURE 420.1 A 76-year-old patient who developed an infected sternal wound postoperatively after coronary bypass
surgery. Despite multiple debridements, the patient developed a chronic fistula. A pedicled SEAP was planned using
an MDCT. A: The wound after debridement and the SEAP flap design based on the CT findings. A dominant SEA
perforator was found at the right side. The flap (20 × 8 cm) was designed parallel to the subcostal area. B: An
anterior incision was used to explore the perforator. C: The RA fascia was incised, and the perforator was freed up to
the main pedicle (SEA). (Continued)

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FIGURE 420.1 (Continued) D-F: The flap was rotated as a propeller to reach the defect. G: Complete wound closure
was done with primary closure of the donor site.

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FIGURE 420.2 A 71-year-old female patient presented with major fat necrosis after a pedicled latissimus dorsi (LD)
flap was used for partial breast reconstruction. A pedicled SEAP flap was planned based on the MDCT exam. A,B:
Preoperative views. C,D: The MCDT images show two large SEA perforators originating from the right pedicle.
(Continued)

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FIGURE 420.2 (Continued) E: A SEAP flap was vertically designed (27 × 7 cm). F: Debridement of the fat necrosis
within the right breast. G: The more distal SEA perforator was dissected. H: The flap was transferred to the defect
with primary closure of the donor site. I: The result at 1 year postoperatively with complete wound healing.

FIGURE 420.3 A 52-year-old patient who developed a large area of fat necrosis after a free DIEP flap breast
reconstruction over the superomedial quadrant of the right side. A pedicled SEAP flap was planned based on
unidirectional Doppler. A: Preoperative view. The amount of the fat necrosis was outlined over the breast, and the
SEAP flap was designed horizontally with an extension under the inframammary fold (IMF) of the contralateral breast.
B: Intraoperative view shows the debridement of the fat necrosis, but the breast skin was severely damaged due to
the previous radiotherapy and the inflammatory reaction after fat necrosis. The Doppler perforator was explored
through the IMF incision. C: The flap was raised and isolated on the found SEA perforator. D: The damaged skin
breast was resected, and the SEAP flap was turned 150 degrees to fit to the defect.
Table 420.1 SUPERIOR EPIGASTRIC ARTERY PERFORATOR FLAPS DESCRIBED IN THE
LITERATURE
Author
Pre-op
imaging
Patient
number
Average
flap
dimension
Donor
site
closure
No.
perforators
per flap
Mean
harvesting
time (min)
Distal
tip
necrosis
Flap
failure
Uemura
(2005)
(11)
Handheld
Doppler
3
22.2 × 6
cm2
Primary
2
Not
specified
1/3
0/3
Mah et
al.
(2008)
(12)
Handheld
Doppler
+ MDCT
3
Not
specified
Primary
Not
specified
“operation
time”: 80
2/3
0/3
Hamdi
et al.
(2009)
(1)
Handheld
Doppler
+ MDCT
7
21.7 × 6.7
cm2
Primary
1
110
(range 55-
120)
2/7
0/7

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Woo et
al.
(2010)
(17)
Handheld
Doppler
+ MDCT
1
20 × 10
cm2
Primary
1
Not
specified
0/1
0/1
Oni et
al.
(2011)
(18)
Handheld
Doppler
1 (2
flaps)
38 × 15
cm2
Primary
Not
specified
Not
specified
0/1
0/1
Ziegler
et al.
(2011)
(15)
Handheld
Doppler
1
12 × 20
cm2
Partial
use of
FTG
1
Not
specified
0/1
0/1
References
1. Hamdi M, Van LK, Ulens S, et al. Clinical applications of the superior epigastric artery perforator (SEAP) flap:
anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg
2009;62:1127e34.
2. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric
systems. Plast Reconstr Surg 1984;73:1e16.
3. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical
applications. Br J Plast Surg 1987;40:113e41.
4. Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003;30:331e42.
5. Miller LB, Bostwick J III, Hartrampf CR Jr, et al. The superiorly based rectus abdominis flap: predicting and
enhancing its blood supply based on an anatomic and clinical study. Plast Reconstr Surg 1988;81:713e24.
6. Hallock GG. The superior epigastric (RECTUS ABDOMINIS) muscle perforator flap. Ann Plast Surg 2005;55:430e2.
7. Geddes CR, Tang M, Yang D, et al. Anatomy of the integument of the trunk. In: Blondeel PN, Morris SF, Hallock
GG, et al., eds. Perforator Flaps, Anatomy, Technique & Clinical Application. St. Louis, MI: QMP, 2006;360e84.
8. Manchot K. Die Hautarterien des Meslichen Korpers. Liezig, Germany: FCW Vogel, 1889.
9. Schmidt M, Tinhofer I, Duscher D, et al. Perforasomes of the upper abdomen: an anatomical study. J Plast Reconstr
Aesthet Surg 2014;67(1):42-47.
10. Offman SL, Geddes CR, Tang M, et al. The vascular basis of perforator flaps based on the source arteries of the
lateral lumbar region. Plast Reconstr Surg 2005;115(6):1651-1659.
11. Uemura T. Superior epigastric artery perforator flap: Preliminary report. Plast Reconstr Surg 2007;120:1e-5e.

12. Mah E, Rozen WM, Ashton MW, et al. Deep superior epigastric artery perforators: anatomical study and clinical
application in sternal reconstruction. Plast Reconstr Surg 2009;123:1719e23.
13. Tai Y, Hasegawa H. A transverse abdominal flap for reconstruction after radical operations for recurrent breast
cancer. Plast Reconstr Surg 1974;53:52.
14. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast
reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008;122:29e38.
15. Ziegler K, Schmidt M, Huemer GM. A pedicled superior epigastric artery perforator (SEAP-) propeller flap for 2-
cavity reconstruction after oncologic rib resection. Microsurgery 2011;31(4):335-336.
16. Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row computed tomography in the planning of abdominal
perforatorflaps. J Plast Reconstr Aesthet Surg 2006;59:594e9.
17. Woo KJ, Pyon JK, Lim SY, et al. Deep superior epigastric artery perforator “propeller” flap for abdominal wall
reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63:1223e6.
18. Oni G, Sharma R, Rao R, et al. Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage. J
Plast Reconstr Aesthet Surg 2011;64:1104e7.

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Chapter 421
Tensor Fasciae Latae Musculocutaneous Flap for Abdominal-Wall
Reconstruction
G. W. CARLSON
The tensor fasciae latae (TFL) musculocutaneous flap is useful to provide soft-tissue coverage and fascial
integrity in abdominal- wall reconstruction. It can definitively repair lower abdominal-wall defects.
INDICATIONS
The TFL musculocutaneous flap is a reliable and versatile method of reconstructing full-thickness defects of
the abdominal wall. It is generally used in contaminated operative fields in which nonabsorbable synthetic
mesh cannot safely be used. In clean cases, such as those seen after tumor resection, it can provide soft-
tissue coverage of synthetic mesh.
ANATOMY
The tensor fasciae latae is a short flap muscle of the lateral thigh, measuring 12 to 15 cm in length. It has a large
fascial extension that inserts on the iliotibial band, approximately one-third of the way down the lateral thigh. The
origin of the TFL muscle is the anterior iliac spine and the greater trochanter of the femur. The muscle serves as
an accessory flexor and medial rotator of the thigh. Occasional knee instability is noted with flap harvest, but
suturing the distal cut margin into the fascia of the vastus lateralis muscle may reduce this complication.
The flap is supplied by the transverse branch of the lateral femoral circumflex vessels, which enter the deep
surface of the muscle approximately 10 cm below the anterior superior iliac spine. The branch usually arises from
the profunda femoral artery, although it may originate from the common femoral artery. The artery divides into
several branches before entering the muscle. Inferior branches course superficial to the fascia lata. These
vessels send perforating branches to supply the overlying skin.
The skin territory is supplied by two sensory nerves: the lateral cutaneous branch of T12, which innervates the
skin overlying the iliac crest, and the lateral cutaneous branches of L2,3, which innervate the skin of the lateral
thigh. Both nerves are easily identifiable and may be included in a sensory flap.
FLAP DESIGN AND DIMENSIONS
The skin territory is large, measuring up to 15 × 40 cm. The center of the flap is a line from the greater trochanter
to the lateral knee at the margin of the biceps femoris muscle. Anteriorly, the flap may include skin over the
rectus femoris muscle. A line drawn from the greater trochanter distally to the head of the fibula marks the
posterior margin of the skin territory. The donor site can be closed primarily, if the flap width is less than 10 cm.
The arc of rotation of the pedicled flap will reach the costal margin, if the tensor muscle is completely detached
from its origin and raised as an island flap. The problem with using the flap in the upper abdomen is that the
distal third of the skin island has a random blood supply and is unreliable. The blood supply to this area is
normally via the superior lateral genicular artery branch of the popliteal artery, which is severed during flap
elevation. If this portion of the flap is used, a delayed procedure is planned before flap elevation.
OPERATIVE TECHNIQUE

The flap dimensions are diagrammed on the lateral leg, not to extend farther than 5 to 8 cm above the knee. An
incision is made through the skin, subcutaneous tissue, and fascia lata at the distal skin border. The fascia is
temporally secured to the overlying dermis with sutures. The anterior and posterior skin borders are incised
distal-to-proximal through the fascia lata. The flap is elevated distal-to-proximal in a plane deep to the fascia lata
overlying the vastus lateralis (Fig. 421.1).
The vascular pedicle is visualized on the deep medial aspect of the muscle 8 to 10 cm below the anterior
superior iliac spine by medial retraction of the rectus femoris muscle. If an island flap is planned, a superior
branch of the lateral femoral circumflex artery must be divided before dividing the muscular insertion on the iliac
crest and its attachments to the gluteus minimus muscle. To increase upward mobility, the origin of the rectus
femoris can be divided. The donor site is most often closed with a skin graft, which is unaesthetic.
CLINICAL RESULTS
Careful patient selection and planning are necessary to avoid complications. Partial flap necrosis occurred
in six of 24 patients, when a TFL flap without vascular delay was used for abdominal-wall reconstruction, in
my experience. Fascial herniation is not an uncommon complication, especially when the flap is used to
reconstruct the upper abdomen.
FIGURE 421.1 Schematic of full thickness TFL flap. The distal end will reach across the lower abdomen for
fascial closure and closure of skin defect.
SUMMARY
The TFL flap can reliably reconstruct full-thickness lower abdominal-wall defects by providing soft tissue
and fascia.

References
1. Nahai F, Hill L, Hester TR. Experiences with the tensor fascia lata flap. Plast Reconstr Surg 1979;63:788.
2. Williams JK, Carlson GW, deChalain T, et al. Role of tensor fasciae latae in abdominal wall reconstruction.
Plast Reconstr Surg 1998;101:713.
3. Gosain AK, Yan JG, Aydin MA, et al. The vascular supply of the extended tensor fasciae latae flap: how
far can the skin paddle extend? Plast Reconstr Surg 2002;110:1655.

Chapter 422
Deep Inferior Epigastric Artery Island Rectus Musculocutaneous
Flap
G. I. TAYLOR
R. J. CORLETT
J. B. BOYD
The rectus abdominis musculocutaneous flap, based on the deep inferior epigastric artery, is an extremely
versatile flap for use as either an island or a free flap.
INDICATIONS
The procedure is speedy, simple, and safe. There is a minimal donor-site defect, especially if the anterior
rectus sheath is repaired as described. This flap may be used to provide muscle only, as a
musculosubcutaneous flap, or as a large skin flap with a variable amount of muscle.
ANATOMY
Contrary to previous views, the major blood supply to the abdomen is from the deep inferior epigastric artery
(DIEA) (1, 2, 3). This artery has an intimate relationship with the rectus abdominis muscle and, in the region of
the umbilicus, provides major perforating vessels that pass directly through the muscle to reach the overlying
skin. Below this level, the DIEA can be dissected from the muscle to provide a vascular pedicle of 10 to 15 cm in
length.
The greatest density of major musculocutaneous perforators emerges from the rectus muscle in the
paraumbilical region, especially from its middle and inner thirds. They radiate like the spokes of a wheel to
communicate with other vessels supplying the abdominal wall. These vessels are directed predominantly upward
and laterally, and as they approach the costal margin, they connect with the lateral intercostal perforators. They
connect with the superior epigastric, the lateral intercostals, the deep circumflex iliac artery (DCIA), the
superficial circumflex iliac artery (SCIA), and the superficial inferior epigastric artery (SIEA). However, the
predominant outflow is directed upward and laterally, parallel to the ribs.
Although the superior epigastric artery (SEA) is currently in vogue for breast reconstruction, in fact, the DIEA
supplies a much larger vascular territory, and this is reflected in the relative diameters of these two arteries
(DIEA: 3.4 mm; SEA: 1.6 mm). The DIEA flap would appear to be the abdominal equivalent of the versatile
latissimus dorsi flap.
FLAP DESIGN AND DIMENSIONS
The deep inferior epigastric flap may be raised in one stage from the groin to the anterior axillary fold. As an
island, it will reach the knee on the same side, the distal third of the opposite thigh, the buttocks, or the pelvic
floor (Fig. 422.1). It will more than adequately repair the genitalia in both sexes. Alternatively, it may be used as a
free flap, giving it many advantages (Fig. 422.2). The flap has a long pedicle with large vessels that are ideal for
microvascular anastomosis.
A large skin flap can be designed on the perforating vessels, provided that the segment of rectus muscle and its
anterior sheath that contain these perforators are preserved. The pedicle can be dissected to its origin from the

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P.1122
external iliac vessels. The flap has a long pedicle with vessels of large diameter (the artery averages 3.4 mm and
there are always two venae comitantes that usually exceed 3 mm in diameter). Muscle may be taken alone and
skin-grafted at the recipient site. Or the muscle can be combined with a large skin flap. Many designs are
available (Fig. 422.3). The donor defect is minimal, and if care is taken when harvesting the graft, the anterior
rectus sheath can be repaired directly in each case.
Because the paraumbilical perforators of the DIEA radiate like the spokes of a wheel, an axial skin flap can be
designed in any direction with its base at the umbilicus. However, the longest flap is planned along a line
between the umbilicus and the inferior angle of the scapula, because this places the flap along the dominant
vascular axis. The width of the flap is determined by a “pinch test,” so that the wound can be closed directly.
OPERATIVE TECHNIQUE
The distal end of the flap is elevated first, and the areolar layer on the deep surface of the subcutaneous fat is
included. This is an important anastomotic layer between the vascular territories incorporated in this flap. The
flap is dissected medially until the lateral border of the rectus sheath is reached. Then it is carefully dissected
from the outer third of the sheath to leave a sufficient fringe of this structure to facilitate direct repair of the donor
defect. During this part of the dissection,
fasciocutaneous perforators that appear from the lateral border of rectus muscle will be divided.
FIGURE 422.1 Left: The various flaps that can be based on the paraumbilical perforators of the DIEA, with the
optimal flap radiating toward the inferior angle of the scapula, parallel to the ribs. Right: Arc of rotation of the
inferior rectus abdominis thoracoumbilical flap (when dissected to the groin).

FIGURE 422.2 Diagram of several of the various combinations that we have used for free transfer designed on
the DIE system and its paraumbilical perforators. A,B: A musculocutaneous flap with varying amounts of muscle.
C,D: Note the versatility as a muscle flap with the potential for segmental reinnervation. E: A
musculosubcutaneous flap.
FIGURE 422.3 The clinical cutaneous vascular territory of the DIEA (center), which extends by means of
captured adjacent arterial territories to the midaxillary line laterally and superiorly to the axilla and crosses the
midline to the lateral border of the opposite rectus muscle. Several of the free skin flap designs that we have
used successfully within this territory are illustrated, based on the perforators emerging through the anterior
rectus sheath.
Next, a disk of the rectus muscle and its sheath is isolated to preserve the cutaneous blood supply. The sheath
and muscle at the upper border of the flap are divided, and the connections between the superior and inferior
epigastric systems are ligated. The sheath is incised medially to leave a 5- to 10-mm fringe to the midline (again,
to aid the donor-site repair). The tendinous intersection adjacent to the umbilicus is detached, and the muscle is
separated easily from its posterior sheath. Next, the lateral border of the rectus muscle is defined from its deep

P.1123
surface. The anterior sheath is divided in this region, just lateral to the major skin perforators, leaving an outer
fringe of rectus sheath 1 to 2 cm wide. Finally, the lower part of the skin flap is divided and the incision in the
anterior rectus sheath is completed, taking care to incise the sheath above the level of the arcuate line.
This isolates the skin flap, which is now attached to the underlying muscle by a disk of the anterior sheath
through which emerge the supplying perforators. This disk will be sited approximately over the middle fifth of the
length of the rectus muscle.
The pedicle is dissected last. This can be achieved through a paramedian incision, but we usually employ a
transverse suprapubic (lipectomy) incision to isolate the pedicle. The anterior abdominal skin is then elevated
from the muscle layers to join the upper dissection. A longitudinal incision is made in the anterior rectus sheath
and the muscle is dissected from its confines. The DIEA and its paired venae comitantes are found plastered to
the undersurface of the muscle.
Near the pelvis, the DIE vessels diverge laterally toward the external iliac vessels. Most of the rectus muscle,
except the disk through which the skin perforators course, can be discarded or left in situ. This requires a careful
dissection of the pedicle, with ligation of multiple branches. Nevertheless, it does provide a large skin flap with a
small amount of muscle and a very long pedicle of 10 to 15 cm. Alternatively, the muscle can be retained in the
flap and simply filleted from its sheath. This latter method is a very quick and simple dissection.
Closure of the anterior rectus sheath above the arcuate line may be unnecessary. However, as an added
precaution to prevent abdominal herniation, we have preserved a cuff of the anterior sheath both medially and
laterally that has allowed us to restore its integrity in every case. As another precaution, we suture the anterior
and posterior sheaths together at the arcuate line (Fig. 422.4).
CLINICAL RESULTS
In a series of over 30 patients, the success rate has been 100 percent, with an average operating time of
4¼ hours. Disadvantages are those of a bulky flap in an obese patient and the possible onset of a late
hernia. However, to date, this latter problem has not occurred.
SUMMARY
The deep inferior epigastric artery island flap has an extensive arc of rotation and offers a viable alternative
to the reliable latissimus dorsi flap. As a free-muscle or musculocutaneous flap, it has almost limitless
possibilities.

FIGURE 422.4 A: A hypertrophic ulcerated groin scar with the external iliac-femoral artery reconstruction
outlined, together with the contralateral flap planned for repair. B: A 32 × 11 cm thoracoumbilical flap was
designed from the contralateral side. The tip extended to the midaxillary line. The flap was elevated to
within 5 cm of the midline, at which stage two large perforators were identified. The skin island was raised
with its disk of anterior rectus sheath, and the vascular pedicle was dissected, retaining the rectus muscle
and the perivascular connective tissues down to the pubis. The latter was done to provide good cover for
the reconstructed femoral artery and to introduce a possible lymphatic bridge that, if successful, would drain
the lymphedema to the contralateral normal groin. C: The scar was excised and the flap was tunneled to
the opposite side, using the rectus muscle to fill the deep cleft in the groin and thigh. The skin flap was
sutured in place, and the donor site was closed as a linear scar, with direct repair of the rectus sheath. D:
The result. Note how the flap has assumed the groin contour. There has been no recurrence of infection,
and the swelling of the leg has resolved.
References
1. Taylor GI, Corlett RJ, Boyd JB. The extended deep inferior epigastric flap: a clinical technique. Plast
Reconstr Surg 1983;72:751.
2. Boyd JB, Taylor GI, Corlett RJ. The vascular territories of the superior epigastric and deep inferior
epigastric systems. Plast Reconstr Surg 1984;73:1.

3. Taylor GI, Corlett RJ, Boyd, JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J
Plast Surg. 1984;37:330.

P.1125
Chapter 423
Microvascular and Pedicled Anterolateral Thigh Flap for
Abdominal-Wall Reconstruction
Y. KIMATA
EDITORIAL COMMENT
The anterolateral thigh flap is one of the “newer” flaps that has proven to be extremely valuable when used
as either a pedicled or a free flap. It is becoming a good first option for large defects.
The anterolateral thigh (ALT) flap has been used to reconstruct various types of defects. The indications and
surgical procedures for use of the free or pedicled ALT flap in reconstructing abdominal-wall defects are
discussed.
INDICATIONS
Because of its wide vascular tissue territory, the free or pedicled ALT flap is indicated for reconstruction of
extremely large, full-thickness defects of the upper and lower abdominal wall (1, 2). The cutaneous territory
of the ALT flap may extend from a horizontal line at the level of the greater trochanter to a parallel line just
above the patella, and includes half the surface of the thigh. The lateral border is the lateral intermuscular
septum (3). This vascular territory also includes the iliotibial tract without the tensor fasciae latae muscle.
The strong subcutaneous fascia component (iliotibial tract) of this flap can be used to repair defects of the
peritoneum and the abdominal wall, and the wide vascularized skin component can be used to repair
abdominal skin defects. If the distance or area of an abdominal defect is too great, a pedicled ALT can be
converted to a free flap (4).
ANATOMY
The cutaneous perforators of the ALT flap are usually derived from the descending branch of the lateral
circumflex femoral artery (Fig. 423.1). This descending branch runs downward through the intermuscular space
between the rectus femoris and vastus lateralis muscles and terminates in the vastus lateralis muscle near the
knee joint by branching into several cutaneous perforators at the lateral aspect of the thigh. These cutaneous
perforators can be divided into septocutaneous perforators and musculocutaneous perforators that penetrate the
vastus lateralis muscle. Musculocutaneous perforators requiring complicated dissection procedures are much
more common than are septocutaneous perforators. The perforators are usually near the midpoint of the thigh
(5).

FIGURE 423.1 Diagram showing the territory of the ALT flap.
FIGURE 423.2 A pedicled ALT flap raised as an island and its arc are shown. Pivot point of the flap is indicated
by an asterisk.
The skin of the thigh is supplied by two vascular plexi: the subdermal plexus and the plexus above the deep
fascia. These two plexus systems supply blood to large areas of both the skin and the deep fascia.
FLAP DESIGN AND DIMENSIONS

First, the possibility of using a pedicled ALT flap to repair abdominal defects should be assessed in each patient.
The pivot point of the pedicled ALT flap is approximately 2 cm below the inguinal ligament on the femoral artery
and correlates with the origin of the lateral circumflex femoral artery, which supplies the cutaneous perforators to
the ALT flap. Because a perforator of the ALT flap arises near the midpoint of the thigh, the pedicled ALT flap
can reach 8 cm above the umbilicus; in contrast, the pedicled tensor fasciae latae flap cannot reach either above
the umbilicus or beyond the midline (6). Therefore the pedicled ALT flap can cover the entire groin and the
perineum to the anus, reach the contralateral inguinal area, and extend into the contralateral lower abdomen
(Fig. 423.2). One disadvantage of the pedicled ALT flap for reconstruction of abdominal-wall defects is its limited
range of orientation on the abdominal wall. Although a vertically oriented pedicled ALT flap allows tension- free
placement of the flap pedicle, a horizontally oriented pedicled flap requires a larger skin paddle than does a free
flap.
If the distance or area of an abdominal defect is too great, a pedicled ALT can be converted to a free flap. The
free ALT flap is indicated for reconstruction of upper-abdominal defects and large horizontal defects.
OPERATIVE TECHNIQUE
Because detailed surgical techniques for the ALT flap have been reported (1, 2), some technical aspects of
using these flaps for abdominal-wall reconstruction are described. Because the selection of the perforators is
related to the length of the pedicle, distal perforators near the midpoint of the thigh are preferred. After the
pedicled ALT flap and the fascia lata have been elevated, this island flap and its vascular pedicle are passed
under the rectus femoris and sartorius muscles and moved to the abdominal-wall defect. The flap is sutured
firmly to the margins of the defect.
When a free ALT flap is used, recipient vessels for microanastomosis must be selected carefully. Because they
are easy to dissect and have suitable diameters for microsurgical anastomosis, the inferior epigastric vessels
and gastroepiploic vessels are preferred.
After reconstruction with either a pedicled or a free ALT flap, the patient is restricted to bed rest for 5 days and to
non- weight-bearing status for 14 days.
CLINICAL RESULTS
In a series of 13 patients, nine pedicled ALT flaps and five free ALT flaps were successfully transferred to
repair abdominal- wall defects. However, in two of these patients who underwent resection of the bilateral
rectus abdominis muscles, postoperative pseudohernia was recognized. For these patients, dynamic
reconstruction of the rectus abdominis muscle may be considered.
SUMMARY
The pedicled or free ALT flap enables satisfactory reconstruction of large abdominal-wall defects.
References
1. Koshima I, Fukuda S, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and
neck defects. Plast Reconstr Surg 1993;92:421.
2. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of

head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123:1325.
3. Zhou G, Qiao Q, Chen GY, et al. Clinical experience and surgical anatomy of 32 free anterolateral thigh
flap transplantations. Br J Plast Surg 1991;44:91.
4. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal- wall reconstruction. Plast
Reconstr Surg 1999;103:1191.
5. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral
thigh flap: a report of 74 cases. Plast Reconstr Surg 1998;102:1517.
6. Williams JK, Carlson GW, Howell RL, et al. The tensor fasciae latae free flap in abdominal-wall
reconstruction. J Reconstr Microsurg 2007;13:83.

Chapter 424
Internal Oblique Muscle Flap
W. M. SWARTZ
S. S. RAMASASTRY
The internal oblique muscle, based on the deep circumflex iliac artery, may be used as a pedicle flap for
coverage of the groin, pubis, anterior perineum, or greater trochanter (1).
INDICATIONS
Potential uses for this flap include coverage of radiation necrosis ulceration of the pubic area following
vulvectomy or primary coverage of defects following treatment of vulvar cancer. The technique is also
useful for covering the exposed femoral vessels following arterial surgery. When using this flap for coverage
of vascular prostheses in the groin, it is necessary to ensure that the deep circumflex iliac artery is indeed
patent. Arteriograms prior to surgery are helpful. The artery can be seen coursing in an oblique direction
toward the anterior superior iliac spine. This vessel is not expected to be suitable in patients who have
undergone aortoiliac or aortofemoral vascular reconstructions.
ANATOMY
The muscle originates from the lumbosacral fascia, the iliac crest, and the lateral half of the inguinal ligament and
inserts into the rectus sheath and the pubis. The muscle lies between the transversus abdominis muscle and the
external oblique muscle (Fig. 424.1). The primary blood supply to this muscle is the deep circumflex iliac artery
(DCIA). In approximately 80 percent of patients, a separate blood vessel, the ascending branch of the deep
circumflex artery, enters the muscle approximately 1 cm medial to the anterior superior iliac spine. In the
remainder of patients, smaller branches from the DCIA supply the muscle along the border of the iliac crest (Fig.
424.2) (2, 3).
FLAP DESIGN AND DIMENSIONS
The maximum size of the muscle flap is approximately 10 × 20 cm when the muscle is detached from its origin
along the lumbar-sacral fascia. Its arc of rotation based on the DCIA at its origin from the external iliac artery
extends to the greater trochanter, the ipsilateral groin, and the pubis (Fig. 424.3).
OPERATIVE TECHNIQUE
The internal oblique muscle is exposed through an incision approximately 2 cm above the inguinal ligament,
extending beyond the anterior superior iliac spine. The external oblique fascia is incised and the muscle is
immediately identified. Dissection of the muscle is made at first superiorly, dividing the muscle along the direction
of its fibers. Care must be taken not to penetrate the transversus abdominis muscle, since these fibers
interdigitate particularly near the insertion along the rectus border.
Dissection is then continued inferiorly along the rectus sheath, carefully separating the muscle from the
underlying transversus abdominis. At this point, the ascending branch is easily identified on the underside of the
muscle, originating approximately 1 cm medial to the anterior superior iliac spine in the majority of patients.
If this vessel is not identified, then the entire deep circumflex iliac system along the inner border of the ilium must
be kept with the muscle. This is accomplished by identifying the main trunk of the DCIA and then dissecting

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distally along the inner border of the ilium just beneath the transversalis fascia. Following this, the muscle may be
elevated and detached from the inner border of the ilium based on the vascular pedicle alone (Fig. 424.4).
The pedicle is developed as proximally as necessary to provide adequate rotation of the muscle for coverage of
the ipsilateral groin or pubic area. The donor site is closed by suturing the external oblique fascia over a suction
drain and closing the wound directly (Fig. 424.5).
SUMMARY
The internal oblique muscle flap, supplied by the deep circumflex iliac vessels, is an excellent flap for
coverage of lower abdominal or groin defects.
FIGURE 424.1 Internal view of the anatomy of the abdominal wall. The internal oblique muscle lies between
the external oblique muscle and transversus abdominis. Its primary blood supply is the deep circumflex iliac
artery.
FIGURE 424.2 Anatomic variations in the ascending branch of the DCIA. When this branch is absent, the
entire DCIA must be included as the vascular pedicle of the internal oblique muscle.

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FIGURE 424.3 1, Arc of rotation of the internal oblique muscle. 2, The muscle will reach the pubis, 3, the
ipsilateral groin, and 4, the greater trochanter.
FIGURE 424.4 Technique of dissection for the internal oblique muscle flap. Inset: The incision in the groin
is made parallel to and slightly above the inguinal ligament, extending laterally beyond the anterior superior
iliac spine. A: The internal oblique muscle is identified immediately below the external oblique fascia. B:
Dissection is begun superiorly and medially, taking care not to penetrate the fibers of the transversus
abdominis muscle. C: The ascending branch is identified on the underside of the muscle prior to dividing
the muscle from the iliac crest. D: The DCIA is dissected as the pedicle for a rotation flap.

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FIGURE 424.5 A: An 86-year-old patient underwent a right radical groin dissection for palliation during the
treatment of an extensive penile carcinoma. B: Isolation of the internal oblique muscle flap on the DCIA. C:
Muscle flap rotated as a turnover flap to cover groin vessels. Note vessels on underside of muscle. D:
Muscle immediately skin-grafted. Six-month follow-up has shown this wound to remain satisfactorily healed
without hernia or tumor recurrence.
References
1. Ramasastry S, Tucker J, Swartz W, Hurwitz D. The internal oblique muscle flap: an anatomic and clinical
study. Plast Reconstr Surg 1984;73:721.
2. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: experimental work. Plast Reconstr Surg 1979;64:595.
3. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: clinical experience. Plast Reconstr Surg 1979;64:745.

Chapter 425
Component Separation for Abdominal-Wall Defects
V. T. NGUYEN
K. K. AZARI
K. C. SHESTAK
EDITORIAL COMMENT
This modification shows how important it is to understand vascular anatomy and apply those principles to
extend the value of previously described procedures. Including the abdominal perforators increases the
reliability of this reconstructive procedure.
Multiple authors have advocated and published the “components separation” or “separation of parts” procedure
for reconstruction of the anterior abdominal wall. Proposed benefits of this procedure focus on its use of
innervated, vascularized, autologous tissue for the reconstruction of anterior abdominal-wall defects. Additionally,
beyond providing a tensionless closure, the use of these innervated, myofascial flaps helps to recreate the
dynamic nature of the native abdominal wall.
INDICATIONS
At our institution, the separation-of-parts procedure, first advocated in 1990 by Ramirez and colleagues (1),
has become a mainstay for the closure of complicated or recalcitrant midline and paramedian abdominal-
wall defects. For complex reconstructions, patients are addressed by a team approach in conjunction with
our general surgery colleagues. Before embarking on the reconstruction, it is critical to assess whether
significant portions of the abdominal wall are missing, either from the initial disease process or as a result of
prior operative resection. Abdominal computed tomography can greatly assist in the evaluation of the
presence or absence of the rectus muscle complex, particularly in cases of massive midline defects, in
which the recti can be situated at the lateral extremes of the abdomen. These and other aspects have
contributed to a body of literature citing a recurrence rate averaging around 10% to 15% (2, 3, 4).
ANATOMY
The anterior abdominal wall consists of paired rectus and oblique muscles that coalesce in the midline, to create
a dynamic, myofascial sling that resists internal pressure yet provides a stable platform for core movement and
assistance with respiratory excursion. Flexion of the abdominal wall is facilitated mainly by the paired, midline
rectus abdominis muscles, with their origin at the pubic symphysis and their insertion at the xyphoid process and
the fifth through seventh-costal cartilages.
Lateral support of the abdomen is provided by the trilaminar construct consisting of the external oblique, internal
oblique, and transversus abdominis muscles. Bilaterally, these muscles interdigitate toward the midline, to form
the anterior and posterior rectus sheaths, with their corresponding insertion medially into the linea alba or white
line. Above the umbilicus, the aponeuroses of these muscles divide, with the external oblique providing fibers to
the anterior rectus sheath, the transversus abdominis muscle donating its fibers posteriorly, and the internal
oblique splitting to contribute fibers to both anterior and posterior sheaths. However, below the umbilicus at the

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arcuate line, located at the inferior fourth of the rectus sheath, all three aponeuroses run anterior to the rectus
muscle, with only the transversus abdominis fascia providing posterior support.
A neurovascular plane exists within the anterolateral abdominal wall, traversing between the internal oblique and
transversus abdominis muscles. Coursing within this plane is the innervation to the oblique and rectus muscles,
provided by the inferior six thoracic nerves (T7 to T11, and the subcostal nerve T12), and the iliohypogastric and
ilioinguinal nerve branches of L1. This anterolateral configuration allows a relatively avascular and nerve-sparing
plane to exist between the external and internal oblique muscles on either side of the midline.
FIGURE 425.1 Diagrammatic illustration showing elevation of skin flap laterally and development of the plane
between the external oblique and internal oblique. This plane was opened all the way to the posterior axillary
line.
OPERATIVE TECHNIQUE
While in the operating room, the general surgeons are allowed first to define the defect, dissecting out the hernia
sack and reducing its contents back into the abdominal cavity. Once they are satisfied with their lysis of
adhesions and have completed any required intraabdominal procedure, the plastic surgery service assumes
control of the patient for definitive closure of the abdomen.
The procedure is begun by elevating adipocutaneous flaps off the underlying abdominal musculature in a lateral
direction toward the anterior axillary line (Fig. 425.1). Next, the linea semilunaris is noted, along with the insertion
of the external oblique fascia.
Two to 3 cm lateral to the linea semilunaris, a vertically oriented incision is made through the external oblique
fascia and parallel with the linea semilunaris, extending from the inguinal ligament to the level of the costal
margin, and often above the costal margin. This superior extension is critical in cases of defects extending up to
the xyphoid process, to obtain adequate release of tissue for these superior closures. The incision should be
made well lateral to the linea semilunaris, at just medial to the musculofascial junction of the external oblique
muscle itself. In a small number of cases, it has been noted that the fascia of the external oblique, internal
oblique, transverse abdominis muscles, or a combination of these, coalesce a short distance from the lateral
edge of the rectus muscle. In such circumstances, incising directly adjacent to the linea semilunaris risks
inadvertent division of the underlying internal oblique and transversalis fascia, and raises the possibility of
subsequent spigelian-type hernias.

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FIGURE 425.2 Plane of dissection (indicated by dashed line 4) as it proceeds posteriorly to the posterior axillary
line. Dashed line 3 shows plane of dissection to use the medial aspect of the rectus abdominis muscle, giving an
extra 2 cm of tissue at the waist level.
After division of the external oblique fascia, the deep surface of the external oblique muscle is identified, and the
plane between the external oblique muscle and internal oblique muscle is developed (Fig. 425.2). When making
the initial incision in the oblique fascia, the surgeon must be careful not to dissect deep to this layer of external
oblique fascia, to avoid injuring the internal oblique fascia or muscle. Generally, the planes are quite distinct.
The dissection proceeds in this relatively avascular intermuscular plane and is continued in a lateral direction
beyond the area of skin, undermining to at least the level of the midaxillary
line. At this point, the mobility of the innervated rectus abdominis- internal oblique-transversus abdominis muscle
complex is determined. If additional mobility of these structures on either side of the midline is desired, then the
dissection in the intermuscular plane can be continued to the posterior axillary line. In our experience, each
ipsilateral complex can be advanced toward the midline 4 cm in the upper abdomen, 8 cm at the waist, and 3 cm
in the lower abdomen (Fig. 425.3).
FIGURE 425.3 The distances that the innervated complex of rectus abdominis-internal oblique-transversus
abdominis muscles can be moved on one side of the abdomen.

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In the rare instance that additional advancement is needed, the rectus muscle can be elevated off the posterior
rectus sheath in its entirety. Two centimeters of additional advancement can be obtained at each level by using
this maneuver. However, the surgeon must leave the anterior rectus fascia intact to allow secure suture
placement.
The muscles are joined together in the midline with an interrupted closure, by using strong nonabsorbable
suture. During closure of the fascia, peak airway pressures are noted by the anesthesia team. Marked elevations
above baseline may indicate some element of respiratory restriction, necessitating prolonged postoperative
intubation or paralysis or both. A decision should be made as to whether small increases in peak airway
pressures are tolerable to achieve final closure, or if adjunctive maneuvers (e.g., interposition mesh or grafts) are
instead necessary. If, after fascial closure, increases in peak airway pressure occur, in addition to alterations in
systemic function, such as hypotension or diminished urine output or both, one should be cognizant of the
possibility of abdominal compartment syndrome. Release of the fascial closure is necessary to restore
hemodynamic stability, and fascia or mesh/biologic graft should be used to bridge any remaining defect.
Once the surgeon is convinced of a stable fascial closure and stable patient, the skin flaps are then advanced to
the midline and approximated in a layered closure. Three to four suction drains are used routinely, and these are
positioned in the plane between the oblique muscles and beneath the skin flaps on each side of the midline and
brought out through separate stab incisions in the pubic area, lateral abdomen, or both. An abdominal binder is
placed before the patient leaves the operating room.
One obvious drawback of the original procedure is the need for extensive dissection of the skin and
subcutaneous layer laterally, to provide adequate exposure for subsequent external oblique division. Such widely
undermined cutaneous flaps are subject to ischemia and adipocutaneous flap necrosis, risking exposure of the
underlying myofascial closure. To address this issue, other authors developed modified versions of the
separation-of-parts technique (5, 6). As in the original procedure, they used lateral dissection from the defect
edges, to expose the linea semilunaris and to gain access to the external oblique. However, in distinct contrast to
the original technique, the periumbilical perforators of the epigastric system are preserved, via subcutaneous
dissection performed both superior and inferior to the umbilicus, after which these two areas are connected by a
tunnel coursing lateral to the perforators (Fig. 425.4). This allows access to the external oblique for division, from
the inguinal ligament inferiorly to above the costal margin. We advocate the use of this method in patients who
may be at high risk for wound complications, including patients who are significantly obese, patients with
previous abdominal incisions off the midline, and diabetic patients.
On some occasions, medialization of the rectus abdominis edge is under undue tension after components
separation, or the rectus fascia is deemed to be of poor quality. These clinical situations are thought to be a
predisposition to potential reconstructive failure. To achieve the goal of a tension-free and stable closure,
augmentation of components separation with biologic mesh substitutes has been advocated (7). With this
technique, a biologic mesh substitute is placed as a retrofascial underlay and held with interrupted horizontal
mattress sutures. Subsequently, the rectus abdominis fascial edges are reapproximated in a tension-free
manner. Next, another layer of biologic mesh can be added above
the repair; however, in our significant experience with this components-separation technique modification, only
an underlay graft is necessary.

FIGURE 425.4 Illustration showing the technique of periumbilical perforator preservation. Note the dissections
superior and inferior to the umbilicus, which meet laterally, above the external oblique fascia.
Postoperative Management
Suction drains are maintained until the drainage decreases to less than 30 mL per 24 hours for 2 consecutive
days, which is usually at an average of 7 to 14 days. Patients are maintained on nothing-by-mouth status until
the resumption of bowel function. Nasogastric tubes are used if extensive intraabdominal dissection is required
as part of the procedure.
Although not widely practiced at our institution, consideration should be given to those patients with existing
ostomies within the rectus sheath. Division of the external oblique muscle can be achieved via laterally placed
incisions, thus leaving the paramedian ostomy undisturbed or allowing placement of new ostomies or both.
Additionally, the literature supports the practice of various techniques to preserve the periumbilical,
musculocutaneous perforators, citing a reduced incidence of midline wound complications. We have adopted this
practice in many patients.
SUMMARY
Despite some limitations, we believe the components-separation technique to be a powerful method for the
closure of extensive or recalcitrant abdominal-wall defects or both. The ideal reconstruction of the
abdominal wall should adhere to four requirements: (a) prevent visceral eventration; (b) incorporate the
abdominal wall; (c) provide a tensionless repair; and (d) provide dynamic muscle support. These criteria are
fulfilled by the components-separation technique through its translocation of vascularized, and innervated,
rectus-internal oblique-transversus abdominis muscle complexes. Its use of autologous tissue has obvious
benefits, when compared with the use of synthetic mesh, particularly when faced with contaminated or
infected wounds. Furthermore, its superiority over other flap methods of reconstruction rests in its preserved
innervation and lack of significant donor-site morbidity.
References
1. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects:
an anatomic and clinical study. Plast Reconstr Surg 1990;86:519.

2. Ewart CJ, Lankford AB, Gamboa MG. Successful closure of abdominal wall hernias using the components
separation technique. Ann Plast Surg 2003;50:269.
3. Shestak KC, Edington HJ, Johnson JJ. The separation of anatomic components technique for the
reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and
limitations revisited. Plast Reconstr Surg 2000;105:731.
4. Losanoff JE, Richman BW, Sauter ER, Jones JW. “Component separation” method for abdominal wall
reconstruction. J Am Coll Surg 2003:196:825.
5. Sukkar SM, Dumanian GA, Szczerba SM, Tellez MG. Challenging abdominal wall defects. Am J Surg
2001;181:115.
6. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces
superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg 2002;109:2275.
7. Nguyen V, Shestak KC. Separation of anatomic components method of abdominal wall reconstruction:
clinical outcome analysis and an update of surgical modifications using the technique. Clin Plast Surg
2006;33:247.

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Chapter 426
Umbilical Reconstruction Using A Cone-Shaped Flap
Y. ITOH
EDITORIAL COMMENT
In diverse cases where loss of the umbilicus has occurred following an operative procedure or sacrifice of
the umbilicus, this technique offers an excellent method of reproducing an appropriately- shaped and well-
camouflaged neo-umbilicus.
The goals of umbilical reconstruction should be the creation of an umbilicus of sufficient depth and good
morphology, with minimal scarring. The cone-shaped flap is useful for attaining these goals.
INDICATIONS
There have been several reports in the literature on umbilical reconstruction or umbilical plasty using skin
grafts or local
flaps, or both (1, 2, 3, 4, 5). Features common to all these reports concern the planar elements of the
reconstruction, involving grafts or flaps that are combined in a complex fashion. As the umbilicus is a three-
dimensional construction, it is desirable to reconstruct the lateral walls with flaps, so that the umbilicus will
retain its depth over time. It is also desirable to minimize suturing.
The cone-shaped flap technique utilizes a single flap or a combination of two flaps, to form the three-
dimensional structure of a circular cone, with a single or double suture line. Postoperative scarring that
appears on the body surface is in an inconspicuous, single, straight line. The shape generally preferred for
umbilical reconstruction is longitudinal, and attaining such a shape is easier with this procedure. The
technique can be used not only for umbilical defects, but also for protrusion and umbilical herniation (6).
FLAP DESIGNS AND OPERATIVE TECHNIQUE
Type 1 (Fig. 426.1)
Design a triangular flap with its apex oriented in a cranial direction in the umbilical region to be reconstructed or
where the umbilicus is absent. After making a skin incision, the fatty tissue immediately below the flap should be
preserved. To form a conical flap with point D at its apex, bring points B and C together, and maintain the
position of these points with a suture. In addition, stitch point D and line BC together. The subcutaneous fatty
tissue caudal to the site of the flap should be thoroughly removed, and an advancement flap taken toward the
caudal side, to affix point D of the flap to the abdominal wall. Suture points A'-A-BC together with the skin at this
location, so that the umbilicus will have the proper longitudinal length.

FIGURE 426.1 Diagram of type 1 procedure. A triangular flap is formed into a conical flap and advanced toward
the caudal side. (From Itoh, Arai, ref. 6, with permission.)
FIGURE 426.2 Diagram of type 2 procedure. A rhombic flap is formed into a conical flap, and the donor site is
closed with sutures from the end to the center, with the flap buried subcutaneously. An incision perpendicular to
the suture line is carried out, and the reconstructed umbilicus is formed. (From Itoh, Arai, ref. 6, with permission.)
Type 2 (Fig. 426.2)
Design a rhombic flap in the umbilical region to be reconstructed or, in the absence of the umbilicus, a triangular

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flap with the left and right sides adjacent to the umbilical region. As in the type 1 procedure, separate the flap
from the surrounding tissue, while preserving continuity at the bottom of the flap. Deeply resect the
subcutaneous fatty tissue at point D, and affix point D to the abdominal wall. Close the donor site directly with
sutures, from the ends to the center, with the conical flap buried subcutaneously. An incision should be made
directly above and perpendicular to the sutured region, to hold the upper end of the incision together with point A
of the buried flap. Suture the
bottom end to point BC of the flap, to form an umbilicus with its major axis pointing upward (Figs. 426.3 and
426.4).
FIGURE 426.3 Case 1. A 40-year-old female patient with endometriosis of the umbilicus. A: A triangular flap is
designed in the upper region of the tissue defect. B: Reconstructed umbilicus 2 weeks postoperatively.
CLINICAL RESULTS
Both types of the procedure were used in 9 patients, all with good results. With the type 1 technique, the
possibility of longitudinal hypertrophic scarring is greater. However, with patients requiring flaps within the
umbilical area, the type 1 procedure may be desirable, as postoperative scarring can be aligned with the
longitudinal furrow that is formed at the bottom of the umbilicus.
FIGURE 426.4 Case 2. A 21-year-old female patient presenting with a cicatrized umbilical defect

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subsequent to omphaloceleplasty at birth. A: The umbilical region with old scarring. B: A rhombic flap is
designed. C: Reconstructed umbilicus 10 months postoperatively. (From Itoh, Arai, ref. 6, with permission.)
SUMMARY
Umbilical reconstruction can be carried out by forming a circular cone with a flap that is anchored to the
abdominal wall. The procedure depends on a three-dimensional structure with a single or double suture
line; the reconstructed umbilicus retains its depth over a long period of time.
References
1. Baroudi R. Umbilicoplasties. Clin Plast Surg 1975;2:431.
2. Borges AF. Reconstruction of the umbilicus. Br J Plast Surg 1975;28:75.
3. Kirianoff TG. Making a new umbilicus when none exists. Plast Reconstr Surg 1978;61:603.
4. Apfelberg DB, Maser MR, Lash H. Two unusual umbilicoplasties. Plast Reconstr Surg 1979;64:268.
5. Jamra FA. Reconstruction of the umbilicus by a double V-Y procedure. Plast Reconstr Surg 1979;64:106.
6. Itoh Y, Arai K. Umbilical reconstruction using a cone-shaped flap. Ann Plast Surg 1992;28:335.

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Chapter 427
Expansion of Vaginal Lining by Graduated Dilation
T. R. BROADBENT
EDITORIAL COMMENT
The reader may wonder why this procedure is included in a compendium of flaps. It is, however, an early
example of what is now called tissue expansion. The editors think that simple dilation of the congenitally
absent vagina may be an equally effective treatment as any other to expand the hypoplastic vaginal
mucosa.
The tissues of the vaginal area are soft and distensible. This is clearly evident in the dilated, stretched tissues at
the time of a normal delivery. It is reasonable to assume that these same tissues could be stretched, elongated,
or dilated with gradual external pressure, and such is the case.
INDICATIONS
Almost all patients with congenital vaginal atresia, with tissues unscarred by trauma, tumor, or previous
surgery, should first be treated by dilation (1). Surgical construction of a vagina can certainly be done by
skin grafting (2, 3), but it involves hospitalization, discomfort, and scarring of graft donor area and vaginal
tract. Of prime concern is the difficult hygiene problem of offensive odor that is present for life. Every patient
with an absent vagina is entitled to construction of a vaginal tract by dilation, a painless office and home
nonoperative procedure. Should this fail, surgery and grafting are always available.
ANATOMY
The external genitalia are normal in these patients, including the labia and secretions from Bartholin's glands.
Sexual intercourse is therefore quite possible and quite normal, requiring no artificial lubrication. However, a
lubricant is recommended for the first month of sexual activity.
TECHNIQUE
At some time in the management of the patient with an absent vagina, a consultation with her and her partner or
family is important. Everyone must understand the procedure and the goals. It is of equal importance to have a
private consultation with the patient, during which her anatomy can be discussed and, by palpation and with a
mirror, she can see the normal anatomy, but with the absence of a vagina. Between the rectum and urethra and
between the labia, there is always a dimple—soft, pink, and shiny—where the vaginal opening should be (Fig.
427.1). Once this is identified, the patient will know where to put pressure with the dilators.
Beginning with the smallest dilator and with adequate lubrication (Fig. 427.2) gentle pressure is placed on the
dimple in a pulsing in-and-out fashion (Fig. 427.3). Pain should not be produced, but there should be enough
pressure to make it discernible if the tissue is to be stretched. Bleeding should not be produced; an unpleasant,
uncomfortable, or bleeding episode should always be avoided. At the time of the first visit,
the physician can move from the first to at least the third or even perhaps the fourth dilator within a half hour.

FIGURE 427.1 Congenital vaginal agenesis. Note dimple between normal labia where vaginal orifice would
normally be.
FIGURE 427.2 Set of graduated dilators. (Courtesy of McGhan Medical, 700 Ward Drive, Santa Barbara, CA
93111.)
It is then important to have the patient herself put this dilator in and out of the very new and shallow vagina, so
that she knows it will work, that something positive has happened. The patient then is quite aware of the fact that
with a little more effort, more can happen (Figs. 427.4 and 427.5).
The patient should be lying on her back with a large pillow under her shoulders and a small pillow under her hips
to tilt the vagina forward and to bring her arms far enough down so that the dilator can be pushed in the right
direction. If the dilator is tilted backward, it will be pushing toward the rectum. This will not only be uncomfortable,
but it will be only partially successful in stretching the vaginal area. If the dilator is tilted too far anteriorly, it will be
pressing on the urethra and, again, can cause irritation and be less effective in producing a vaginal tract.
After the first visit, the patient is instructed to carry out the mechanical dilation by pressure 15 minutes twice a
day. This is to be done with a clock, for the time always seems longer than it really is. In the evening, after
having completed this exercise, the patient is instructed to place the largest dilator that can be accommodated
into the vagina and then to assume a sitting position on a hard surface. This can be a desk top or a hard chair.
There is never any difficulty in obtaining diameter in the vagina, only in obtaining depth. Sitting on the dilator with
pressure up into the vaginal tract helps a great deal to achieve this. To sit on the dilator on a soft cushion would
defeat the purpose, since there would not be any pressure directed through the dilator into the dome of the
vaginal tract. The patient is instructed to do the dilation in an in-and-out and side-to-side fashion 15 minutes
twice a day and to sit on a dilator 10 minutes a day.

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FIGURE 427.3 Vaginal agenesis. Progressive pressure dilation with a no. 3 dilator. A: Dilator placed on vaginal
orifice dimple. B: Dilator pushed into the tissue.
A vaginal tract that will accommodate satisfactory sexual activity can be formed in 6 to 8 weeks, although most
patients are advised that it may take 3 months. Once sexual activity has been assumed, the dilators no longer
need to be used. Since these patients are somewhat anxious about the effectiveness of sexual activity, they are
advised to use some external lubrication to begin with. Most do so only a few times, and all patients have
discontinued use of a lubricant after 1 month.
The dilators are washed with ordinary soap and water after each use, and normal bathing is all that is required
as far as care of the genitalia is concerned. The patient should be encouraged to check with her physician
whenever she has any concerns to ensure a gradual, progressive program.
CLINICAL RESULTS
Fourteen of 15 patients with congenital atresia of the vagina have had a vagina successfully constructed by
progressive graduated dilation. One failure represented a patient unwilling to spend the time or effort to
accomplish what would have been possible. All patients have appeared to be normal adult females in body
habitus and secondary sexual characteristics, with development of the breasts, vulvar labia, and body hair
pattern.
FIGURE 427.4 Vaginal agenesis. Progressive pressure dilation with a no. 5 dilator. A: Placement of dilator.
Note that it should not angle posteriorly to the rectum or anteriorly to the urethra. B: Dilator pressed into
new vaginal tract.

FIGURE 427.5 Vaginal agenesis. Progressive pressure dilation with a no. 6 dilator. A: Before entry. B:
After entry into new dilated vaginal tract. The patient is ready for sexual activity.
The success of the procedure rests heavily on the willingness of the physician to spend enough time with
the patient, to educate her about her own anatomy, and to gain her confidence in a very private matter. The
patient must be assured of success by partial successful dilation during the first visit when the dilators are
used. Motivation is important, and anticipated sexual activity is the prime motivator.
Dilation is started 3 months before anticipated use of the vagina. Patients and parents often want to start
earlier because of their emotional stress over the absence of a vagina. In addition, no one knows when
marriage or use of the vagina may be imminent. However, disappointment is likely if the vagina is not used
once dilated. Sexual activity continues the dilation; without it, manual dilation one or two times a week is
probably indicated, although this remains to be proven. Recoil of a dilated vagina may not occur or, if it
does, may not be significant. At any rate, redilation of an unused vagina has been observed to be very easy
and rapid.
These patients do not have a hygiene problem with odor and dryness (such as with a skin-grafted vagina),
and the mucosa looks normal and pink and is soft and resilient. There have been no contractures, and
although the vaginal vault can look a bit flat or shallow, sexual intercourse has been satisfactory. A large
vaginal speculum can be passed into the vaginal tract after the dilation described above.
SUMMARY
Expansion of the vaginal lining by graduated dilation is probably the simplest and most effective way to
permit normal sexual intercourse in patients with congenital vaginal atresia.
References
1. Broadbent TR, Woolf RM. Congenital absence of the vagina: reconstruction without operation. Br J Plast
Surg 1977;30:118.
2. Castanares S. Plastic construction of the artificial vagina in congenital total absence. Plast Reconstr Surg
1963;32:368.
3. McIndoe AH. The treatment of congenital absence and obliterative conditions of the vagina. Br J Plast
Surg 1950;2:254.

Chapter 428
Vaginal Mucosal Flaps
A. WEISS JR.
Vaginal mucosal flaps can be very useful in reconstruction of the female perineum following vulvectomy (1). This
procedure is frequently used in the treatment of Bowen's disease, which most commonly occurs in women under
50 years of age (2, 3). The resulting introital stenosis can be quite disabling sexually. The standard vulvectomy
procedure currently in vogue requires a clitorectomy for closure. This produces a further loss of sexual response.
The use of vaginal mucosal flaps obviates the need for clitorectomy and provides a technique for treatment and
prevention of introital stenosis that has been much more satisfactory than the standard method of treatment
using skin grafts (4, 5).
INDICATIONS
Vaginal mucosal flaps have several advantages over skin grafts:
1. Amputation of the clitoris is not required in order to establish a satisfactory bed for a graft.
2. A split-thickness skin graft dressing requires an indwelling catheter for periods of 7 to 10 days, which is
not required in this procedure.
3. The period of immobilization is reduced to only a few hours.
4. The perineum does not require fastidious cleansing, since these local tissues are fairly resistant to the
bacteria encountered in that area.
5. The donor site is not a source of pain or scar formation because it is in a graft, and it is well camouflaged
because it is hidden within the vagina.
6. Late complications of maceration and abnormal changes in the graft are not present because the
mucosal tissue is normally accustomed to this environment.
Because this flap is well innervated and vascularized, it frequently has excellent sensitivity, and it has been
found to be most useful in the reconstruction of the perineum following vulvectomy.
ANATOMY
The blood supply of this flap originates primarily from the vaginal arteries that enter the lower lateral region of the
vaginal wall. These arteries anastomose freely with the uterine and rectal plexi. The veins follow a similar pattern
of distribution. As a result of this excellent vascular supply, survival of this flap is not a problem.
The nerve supply is derived from the branches of S2, S3, and S4 by means of the internal pudendal nerve. It
likewise enters from a lower lateral distribution, which in these patients frequently produces a flap that retains
excellent sensibility.
FLAP DESIGN AND DIMENSIONS
The planning of the flap is easily accomplished, since the blood supply is excellent and the tissue is very elastic.
Up to one-half of the vaginal circumference may be used with primary closure, and the remaining tissue
subsequently will stretch to provide a normal functional vagina.
Flaps measuring up to 6 cm in width and 12 cm in length have been moved without difficulty. The base of the flap

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is best placed as near the introitus as possible to allow for maximal rotation. The flap, when taken almost to the
cervix, will easily reach and resurface the entire clitoral area (Fig. 428.1).
OPERATIVE TECHNIQUE
The operative procedure is most easily performed with the patient in the lithotomy position. The use of
epinephrine 1:200,000 injected locally has been found to reduce the intraoperative bleeding significantly without
any decrease in flap survival. If present, an old scar should be completely excised and the original deformity
recreated in secondary procedures. Care must be taken not to damage the urethral sphincter.
It is important to elevate some of the submucosa of the vaginal wall with the flap, since the blood supply
originates from within the submucosal layer. The base of the pedicle should not be extensively dissected in order
to preserve adequate blood supply to the flap. The vaginal flap is then rotated and sutured into place. Closure is
almost always possible without tension, since the flap tissues are very distensible (Fig. 428.2).
A topical antibiotic ointment, such as bacitracin, is then applied three times daily for 10 days, at which time
dilations of the introitus are begun. Either a biologic or prosthetic dilator may be used with success.
FIGURE 428.1 A: Lithotomy position demonstrating the stenosed introitus secondary to scar contracture. B: The
scar must be excised to recreate the original deformity. A Foley catheter is frequently used to protect the urethra.
The flap is demonstrated. C: The flap sutured into the defect, relieving the stenosis and allowing for more normal
contour. Note that the clitoris is easily covered with a flap of this size.

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FIGURE 428.2 Final result. A: The stenosis is released and there is no evidence of contracture or tension
around the area. B: The exposed vaginal mucosal flap results in relatively normal appearing labia.
CLINICAL RESULTS
Long-term follow-up has shown a normal-appearing introitus without any recurrence of stenosis.
SUMMARY
Vaginal mucosal flaps have several advantages over standard methods for coverage of vulvectomy
wounds.
References
1. Weiss AW Jr. A new method of perineal reconstruction following vulvectomy. Plast Reconstr Surg
1980;65:824.
2. Abell MR, Gosling JRG. Intraepithelial and infiltrative carcinoma of vulva: Bowen's type. Cancer
1961;14:318.
3. Rutledge RN, Sinclair M. Treatment of intraepithelial carcinoma of the vulva by skin excision and graft. Am
J Obstet Gynecol 1968;102:806.
4. Delgado G. Plastic procedures in cancer of the lower genital tract. Am J Obstet Gynecol 1978;131:775.
5. Shaw W. Shaw's textbook of operative gynecology, 4th Ed. New York: Churchill-Livingstone, 1976.

Chapter 429
Medial Thigh Skin Flaps for Repair of Vaginal Stenosis
A. I. PAKIAM
Vaginal stenosis can vary from the simpler introital strictures to those which are deeper and involve large
segments of the vagina. The minor problems can be safely dealt with by local transposition flaps with good
results (1). However, the more extensive varieties, which can amount to a virtual obliteration of the canal, present
a far greater challenge to the ingenuity and technical capabilities of the surgeon.
INDICATIONS
In the Western world, most severe cases of vaginal stenosis are due to trauma to the pelvis and perineum,
overzealous repair of the anterior and posterior vaginal walls for the treatment of cystocele and/or rectocele
(especially if severe infection is a complication), and stenosis following radiotherapy and/or surgery for
neoplasia.
Conversely, in the underprivileged parts of the world, vaginal stenosis is more likely to be due to tropical
diseases such as severe lymphogranuloma and also may follow prolonged obstructed labor and poor
obstetrical management. Female circumcision is practiced in many parts of the world to cure infertility or to
punish infidelity (2). The result of this may be vulval adhesions of varying severity. In some Middle Eastern
countries, the deliberate insertion of crude rock salt into the vagina results in virtual obliteration of the cavity
by severe scarring. Several methods are available to treat vaginal stenosis.
Dilation
Conservative treatment by continual dilation has succeeded in creating a useful skin-lined pouch.
Nonoperative therapy has the advantage of unscarred tissue (3, 4).
Split-Thickness Skin Grafts
If skin grafts are to be used, the scar excision must be complete to achieve any degree of success. A
second stage is often necessary because of the severe bleeding encountered. Thick split-thickness skin
grafts are placed some 7 to 10 days later, after the initial packing has been removed. Even under ideal
conditions, the “take” of the graft is difficult to achieve, owing to problems of immobilization. Indeed, if the
initial graft succeeds, the problem of having to wear a dilator continually to prevent subsequent graft
contracture makes great demands on the patient. The eventual result is often inadequate and disappointing
(5, 6, 7, 8, 9).
Full-Thickness Grafts
This method diminishes subsequent graft contracture, and the use of a dilator may be avoided. However,
graft survival is more difficult to achieve technically, owing to the same problems that beset thinner skin
grafts.
Local Flaps
The problems associated with grafts can be overcome by the use of bilateral, partially deepithelialized
medial thigh flaps. Groin flaps, although tempting because of their axial pattern of vasculature, may distort
the external genitalia (10, 11, 12, 13, 14, 15, 16, 17, 18, 19).
FLAP DESIGN AND DIMENSIONS

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The flaps are proximally based, and the proximal part is deepithelialized with a skin-graft knife. Sufficient normal
skin is
left at the tip of the flap to cover the defect created by dissection of each lateral vaginal wall. The dimensions of
the flap vary according to the defect. A typical flap measures 15 cm in length and 5 to 6 cm in width.
FIGURE 429.1 A: Illustration showing the flap being migrated into the subdermal tunnel. B: The distal surface
(with intact skin) is sutured to the vaginal lateral wall defect. Kinking of the deepithelialized base must be
avoided.
The deepithelialized portion of the flap aids in maintaining the viability of the tip of the flap. Indeed, a completely
deepithelialized local flap may be extremely useful in the repair of vesicovaginal or rectovaginal fistulas, since the
dermis provides a greatly needed blood supply to the repaired area.
OPERATIVE TECHNIQUE
The patient is placed in the lithotomy position, and excision of the scar from the lateral walls of the vagina is
carried out. Dissection is avoided over the anterior and posterior walls in order to avoid damage to the urethra,
bladder, and rectum, particularly if the cause of the stenosis has been an overzealous repair of a cystocele
and/or a rectocele.
The flaps are rotated through 180 degrees and inserted through a subdermal tunnel into the vaginal cavity,
where they are sutured. Care is taken to ensure that there is no dangerous kinking of the flap and that the tunnel
through which it is migrated is not tight (Fig. 429.1). The donor site is closed in layers after wide undermining,
with a gap left at the base of the flap, in order to avoid constriction. A later secondary adjustment to the base of
the flap to remove the dog-ear and relieve intertrigo has so far not been necessary (Figs. 429.1 and 429.2).
FIGURE 429.2 A: Operative views showing the design of the thigh flaps and the deepithelialized portion at the
base of the flap on the left thigh. B: Postoperative view 6 months later showing a cavity that will admit two

P.1143
fingers for a distance of 10 cm. Note the linear scar on the medial side of the left thigh, after the wound was
closed primarily.
CLINICAL RESULTS
Patients operated on have demonstrated stenoses close to the introitus. The length of the stenosed
segment has varied between 1 and 2.5 cm, the narrowest of which would barely admit the tip of a hemostat.
All patients have achieved good results, the longest follow-up being 3 years, with no recurrence noted. The
use of dilators has not been necessary.
SUMMARY
Medial thigh skin flaps can be used to repair vaginal stenoses, especially those near the introitus.
References
1. Pakiam AI. Repair of posttraumatic vaginal stenosis using local thigh flaps. Br J Plast Surg 1980;33:54.
2. Iregbulem LM. Postcircumcision vulval adhesions in Nigerians. Br J Plast Surg 1980;33:83.
3. Frank RT. The formation of an artificial vagina without operation. Am J Obstet Gynecol 1938;35:1053.
4. Woolf RM. Congenital absence of the vagina: reconstruction without operation. Br J Plast Surg
1977;30:118.
5. Abbé R. New method of creating a vagina in a case of congenital absence. Med Rec NY 1898;54:836.
6. Counsellor VS. Congenital absence of the vagina. JAMA 1948;136:861.
7. McIndoe AH, Bannister JB. An operation for the cure of congenital absence of the vagina. Br J Obstet
Gynaecol 1938;45:490.
8. McIndoe AH. Treatment of congenital absence and obliterative conditions of the vagina. Br J Plast Surg
1950;2:254.
9. Whitely JM, Parrott MH, Rowland W. Split-thickness skin graft technique in the correction of congenital or
acquired vaginal atresia. Am J Obstet Gynecol 1964;89:377.
10. Conway H, Stark RB. Construction and reconstruction of the vagina. Surg Gynecol Obstet 1953;97:573.
11. Simmons RJ, Millard DR. Reconstruction of a functioning vagina following radiation therapy for cancer of
cervix. Surg Gynecol Obstet 1961;112:761.

12. West JT, Ketcham AS, Smith RR. Vaginal reconstruction following pelvic exenteration for cancer or
postirradiation necrosis. Surg Gynecol Obstet 1964;118:788.
13. Williams EA. Congenital absence of the vagina: a simple operation for its relief. Br J Obstet Gynaecol
1964;71:511.
14. Williams EA. Vulva-vaginaplasty. Proc R Soc Med 1970;63:40.
15. Song IC, Cramer MS, Bromberg BE. Primary vaginal reconstruction after pelvic exenteration. Plast
Reconstr Surg 1973;51:506.
16. Morley GW, Lindenauer SM, Youngs D. Vaginal reconstruction following pelvic exenteration: surgical and
psychological considerations. Am J Obstet Gynecol 1973;116:996.
17. Schellhas HF, Fidler JP. Vaginal reconstruction after total pelvic exenteration using a modification of the
Williams' procedure. Gynecol Oncol 1975;3:21.
18. Magrina JF, Masterson BJ. Vaginal reconstruction procedures following radical pelvic surgery. J Kansas
Med Soc 1981;82:61.
19. Magrina JF, Masterson BJ. Vaginal reconstruction in gynecological oncology: a review of techniques.
Obstet Gynecol Surg 1981;36:1.

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Chapter 430
Vulvoperineal Fasciocutaneous Flap for Vaginal Reconstruction
F. GIRALDO
EDITORIAL COMMENT
These are good flaps for vaginal reconstruction based, we believe, on the same vessels as the pudendal
flaps described by Joseph and Wee (Chapter 431).
Partial or complete vaginal reconstruction for both acquired and congenital abnormalities is a challenging
problem. In recent years, flaps based on the terminal vessels of the internal pudendal artery have been useful (1,
2, 3, 4, 5, 6). A recently-designed pedicled vulvoperineal fasciocutaneous flap, supplied by the external branches
of the superficial perineal vessels, has been used successfully for the reconstruction of congenital vaginal
agenesis (7).
INDICATIONS
The vulvoperineal flap has been used for vaginoplasty in the Mayer-Rokitansky syndrome. There are
potential applications for partial and complete vaginal reconstruction in other congenital anomalies,
including testicular feminization and masculinized adrenogenital syndromes, as well as in cases of male-to-
female transsexualism. The flap is reliable and can also be used for reconstruction of acquired perineal and
vaginal defects secondary to trauma or postoncologic resection. Important advantages include flap security
and reliability, with well-established vascularization beneath the lateral border of the labia majora, and a
sensitive flap due to the innervation of its posterior two-thirds.
It is not indicated for reconstructive purposes when its design is laterally extended to the inguinal fold, in
those cases in which malignant neoplasia affects the vulva or lower vagina and there is the presence or
possibility of lymphatic spreading.
The vulvoperineal flap can be based on a deepithelialized or adipofascial pedicle; an island flap is not
advocated because of
the difficult dissection and isolation of the superficial perineal artery in the fat of the ischiorectal space.
ANATOMY
The perineal region is a relatively neglected area anatomically and requires further definitive clarification. A
cadaveric study (8) of the blood supply to the skin and fascia of the anterior perineal region, labia major, and
adjacent labial integuments (Fig. 430.1) in 15 female cadavers led to some new and specific findings. The two
principal pedicles providing the major blood supply to the anterior perineal region include an anterior pedicle—
the deep external pudendal artery (DEPA), which issues from the femoral artery. This vessel crosses from the
deep plane to a subcutaneous location, piercing to the longus adductor muscle aponeurosis about 8 to 10 cm
from the pubis symphysis. It then runs along the surface of the adductor muscle aponeurosis, giving off both
abdominal and perineal branches 4 to 6 cm distant from the pubis symphysis. The perineal branch or anterior
labial artery goes medially to nourish the soft tissues of the superior third of the labia majora and adjacent

integuments.
Another principal pedicle is a posterior pedicle—the superficial perineal artery (SPA), a direct branch of the
internal pudendal artery, which emerges from Alcock's canal at the ischium. The SPA divides into an internal
branch, the internal posterior labial artery, constantly present and closely related to the bulboclitoridean muscle,
and an external branch, the external posterior labial artery, located near the ischioclitoridean muscle root and
coursing through the anterior perineal region under the lateral border of the labia majora.
A supraaponeurotic intralabial plexus is integrated by multiple anastomoses between the different arterial
afferences included in the stromal tissue of the labia majora and immediately adjacent skin, over the adductor
and perineal aponeuroses.
FIGURE 430.1 Afferent vessels to the perineal region. 1 = deep external pudendal artery (DEPA); 2 = abdominal
branch of the DEPA; 3 = perineal branches of the DEPA; 4 = superficial perineal artery (SPA); 5 = external
branch of the SPA; 6 = internal branch of the SPA; 7 = supraaponeurotic intralabial plexus; 8 = perineal
superficial transverse artery; 9 = adductor musculocutaneous perforators; 10 = abdominal-wall vascular
anastomosis; 11 = perineal aponeurosis; 12 = adductor aponeurosis. (From Giraldo et al., ref. 8, with
permission.)
The course of the superficial perineal nerve closely follows the internal branch of the SPA. When it crosses over
the perineal superficial transverse muscle, it divides into subcutaneous rami, which sensitively innervate the
posterior two-thirds of the labia majora.
FLAP DESIGN AND DIMENSIONS
The vulvoperineal fasciocutaneous flap is designed in a vertical, rectangular fashion, centered over the lateral
border of the labia majora, nourished by the terminal vessels of the SPA, and posteriorly based on the anterior
perineal triangle base (perineal superficial transverse muscle) between the anus and the ischial tuberosity. This
design allows for a perfectly-defined vascularization system following the major axis of the flap—the lateral
border of the labia majora—which is formed principally by the anastomotic circuit between the external branches
of the SPA (external posterior labial arteries) and the perineal branches of the DEPA (external anterior labial
arteries).
The posterior half of the flap (under the ischiopubic bony rami) is integrated by the superficial and medial (Colles'
fascia) perineal aponeuroses, including the SPA and subcutaneous rami of the superficial perineal nerve,
presenting a fasciocutaneous pattern of vascularization. The anterior half of the flap (over the ischiopubic bony
rami) includes the adductor aponeurosis as a “continuation” of the perineal aponeurosis and supraadjacent soft
tissues, presenting a direct cutaneous pattern of vascularization (Fig. 430.2).

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Following the classification of fasciocutaneous flaps established by Cormack and Lamberty (9), we defined two
types of vulvoperineal flaps. Type A, one-third of all our anatomic dissections, is vascularized by small
perforators at its base, arising from the SPA orientated with the long axis of the flap, with
a predominantly vertical direction of the intralabial plexus at the deep fascia level. In Type B flaps, two-thirds of
all our anatomic dissections, the blood supply depends on a simple, sizeable, and consistent external posterior
labial artery arising from the superficial perineal vessels (Fig. 430.3).
FIGURE 430.2 Diagram of anatomy and design of the vulvoperineal flap. DEPA = deep external pudendal artery;
SPA = superficial perineal artery; VPF = vulvoperineal flap in a vertical-rectangular orientation centered on the
lateral border of the labia majora. The anterior half contains the adductor aponeurosis and the posterior half, the
perineal aponeurosis (refer to text).
FIGURE 430.3 Diagram of types of vulvoperineal fasciocutaneous flaps (refer to text).
Although we have utilized vulvoperineal flaps measuring 8 to 9 × 3 cm for complete vaginal reconstruction in the
Mayer- Rokitansky syndrome, larger flaps are available, always bearing in mind the experience of authors who
have reported similar perineal artery flaps.
OPERATIVE TECHNIQUE
The technique is basically the same as originally reported (7, 10), apart from a few important modifications (Fig.
430.4). After establishing a sterile field and inserting a Foley catheter in the bladder, the first step consists of a
2.5- to 3.0-cm U-shaped incision in the vestibular mucosa and submucosal compact tissue across the region of
the dimple, 1 cm under the urethral meatus, and extended transversely to the labia minora.