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

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profunda femoris in the perifascial- subcutaneous plane of the skin of the corresponding territories. This explains
the extension of the gluteal flap to the lumbar and thigh areas. Branches of the pudendal artery pierce the
sacrotuberous ligament to enter the muscle. Some of them may be big enough (up to 2 mm in diameter) to cause
confusion with the gluteal pedicles for the inexperienced surgeon.
The gluteus maximus muscle is innervated by the inferior gluteal nerve (L5,S1,S2) (3, 6). This accompanies the
inferior gluteal artery and vein. During flap elevation, this neurovascular pedicle should be preserved to allow
preservation of function.
FLAP DESIGN AND DIMENSION
The flap shape and size will depend on the location and size of the defect. For defects up to 10 cm in diameter,
no skin island or subcutaneous dissection is needed. This variation is called “sliding plication-gluteus maximus
flap” (5). In this variation, the muscle and the skin are elevated en bloc and advanced to the midline (Figs. 468.1,
468.2, 468.3). For perineal defects, the lower fibers of origin of the muscle are detached and advanced to the
depths of the cavity. The overlying skin is then closed independently in the midline. For sacral and
sacrococcygeal defects, adjacent triangular skin islands overlying the corresponding muscles are made (Figs.
468.4, 468.5, 468.6, 468.7, 468.8, 468.9). For large sacrolumbar defects, the triangular skin paddle overlying the
sacral portion of the muscle is extended to the lumbar area on the superficial lumbar fascia (3).
FIGURE 468.1 Modified sliding gluteal plication.
OPERATIVE TECHNIQUE
Preoperatively a standard bowel prep including colon irrigation and antibiotics is administered. In addition, broad-
spectrum antibiotics are administered at surgery and during the perioperative period.
For the moderately sized defects, the initial approach should be the plication sliding type of operation. If a longer
flap is needed and the decision to use a triangular skin island is made, the skin islands are incised first down to
the muscle fibers. From there, a wide subcutaneous dissection is made away from the skin island. Both
approaches then elevate the gluteus maximus along its periosteal origin on the sacrum and coccyx. Dissection is
continued inferiorly to separate the ischiorectal fat from the muscle fibers. From there, dissection is continued to
identify the sacrotuberous ligament. It is in this ligament that branches of the pudendal artery are found. This
should be doubly ligated and divided. The fibers of the gluteus should be “shaved off” from this ligament. This
ligament should not be transected; otherwise, the dissection becomes bloody and the anatomic landmarks are
lost.
The inferior neurovascular bundle is identified next. This is located 1 cm superior to the sacrotuberous ligament
and 5 cm from the lateral border of the sacrum. The superior gluteal artery and vein are located 3 cm above the

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inferior gluteal neurovascular pedicle. After both are identified and protected, the rest of the fibers of origin are
detached. Separation of the gluteus maximus from the medius is another important step of the operation.
However, this is done only if the size of the defect requires extensive mobilization of the gluteus maximus muscle.
Both muscle boundaries are clearly identified close to the insertion of the gluteus maximus on the iliotibial tract,
and separation is usually started there. Some of the fibers of insertion to the iliotibial tract are also detached if
there is too much lateral pull during flap advancement. Partial detachment usually
does not affect the muscle function. At this point, usually the gluteus muscles are ready to be advanced and inset
into the defect. Closure is done to its opposite member with figure-of-eight heavy Vicryl sutures. The donor
defect is closed in a V-Y fashion, and enough subcutaneous dissection should be done to avoid lateral pulling of
the muscle flap (Figs. 468.4, 468.5, 468.6, 468.7, 468.8, 468.9).
FIGURE 468.2 Graphic depiction of the flap.
FIGURE 468.3 Completed repair.

FIGURE 468.4 Outline of the flap and extent of the subcutaneous dissection. Insert shows the orientation of the
gluteal pedicles before and after flap advancement. (From Ramirez et al., ref. 1, with permission.)
FIGURE 468.5 Relationship of the gluteal pedicles, piriformis muscle, sciatic nerve, and “gluteal lid.” Observe
the extensive muscle origin that needs to be detached. (From Ramirez et al., ref. 1, with permission.)
Postoperative care is directed to avoid pressure and shearing forces on the gluteal flap. Our usual routine is for
a 2-week period of bed rest on a Clinatron bed followed by assisted ambulation with full activity by 6 weeks.
CLINICAL RESULTS
The senior author has used variations of the gluteus maximus flap to cover lower trunk midline defects in
over 100 ambulatory patients. In the initial group of patients, functional evaluation was performed, including
gait analysis, step climbing, and manual muscle strength. In a limited group of patients, electromyographic
studies were also performed. These studies showed excellent preservation of muscle function (Figs. 468.10

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and 468.11).
FIGURE 468.6 Detachment of the muscle off the sacrotuberous ligament ischiorectal fat is key for its
advancement. (From Ramirez et al., ref. 3, with permission.)
SUMMARY
The sliding gluteus maximus flap and its variations allow closure of small and truly massive lower trunk
midline defects. This can be done with preservation of muscle function important in the ambulatory patient.
FIGURE 468.7 The four vessels that supply the gluteus maximus muscle. Observe the orientation of the
fibers of the gluteus medius. (From Ramirez et al., ref. 1, with permission.)

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FIGURE 468.8 Separation of the gluteus maximus off the medius is another important step of the operation.
(From Ramirez et al., ref. 1, with permission.)
FIGURE 468.9 The periosteal origin of the muscle is sutured to the opposite member. Closure of the donor
defect in a V-Y fashion. (From Ramirez et al., ref. 1, with permission.)
FIGURE 468.10 A: Intraoperative view of patient prior to modified sliding gluteal plication. B: Postoperative
view of patient following modified sliding gluteal plication.

FIGURE 468.11 A: Preoperative view of patient with large area of scarring from radiation necrosis. B:
Intraoperative view showing triangular flaps incised and approximated in the midline. C: Postoperative view
showing healed flaps. Electromyographic studies show intact neuromuscular function.
References
1. Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus myocutaneous flap: its relevance in
ambulatory patients. Plast Reconstr Surg 1984;74:68.
2. Ramirez OM, Hurwitz DJ, Futrell JW. The expansive gluteus maximus flap. Plast Reconstr Surg
1984;74:727.
3. Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus muscle: experimental and clinical
considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg 1987;40:1.
4. Ramirez OM. The distal gluteus maximus advancement musculocutaneous flap for coverage of
trochanteric pressure sores. Ann Plast Surg 1987; 18:295.
5. Ramirez OM. The sliding plication gluteus maximus musculocutaneous flap for reconstruction of
sacrococcygeal wound. Ann Plast Surg 1990;24:223.
6. Williams PL, ed. Gray's anatomy, 38th ed. New York: Churchill Livingstone, 1995.

Chapter 469
Slide-Swing Skin and Musculocutaneous Flap
J. SCHRUDDE
V. PETROVICI
EDITORIAL COMMENT
The reader should be aware that in the design of the musculocutaneous gluteus flap to cover radiation
ulcers on the sacrum, one poor effect is total defunctionalization of the gluteus maximus, because
innervation accompanies the inferior gluteal artery.
The slide-swing skin and musculocutaneous flap is well suited for coverage of sacral defects (1, 2, 3, 4).
INDICATIONS
None of the numerous other procedures offered over the years produces the advantages of the procedure
described here (5, 6, 7, 8, 9). In recent publications, the use of various rotation flaps is frequently advocated
(10, 11, 12); however, the rotation flap has some disadvantages. It can be used to close only relatively small
bedsores. Extensive supplementary revisions are required when creating and mobilizing rotation flaps,
causing additional scars; and scars, especially in paraplegics, offer little resistance to stress and can be the
starting point for new bedsores.
The slide-swing flap (SSF) is used most often for covering large defects in the sacral region. Its application
extends to chronic fistulas, unstable scars (Fig. 469.3), radiation ulcers (Fig. 469.4), pressure ulcers (Fig.
469.5), and various dysplasias, such as hairy nevi.
ANATOMY
Although the SSF is a random flap, the general direction of blood vessels should be considered in flap design.
The anatomic particulars of the sacral region will influence the operative procedure, keeping in mind that the
sacrum lies directly under the skin. The gluteal region provides great reserves of muscle and skin (see Figs.
469.4 and 469.5). The gluteus maximus muscle can be included with the flap to create a more robust
musculocutaneous flap.
FLAP DESIGN AND DIMENSIONS (SEE CHAPTER 112)
The extent of the subsurface defect is explored by forceps, and the defect boundaries are drawn on the skin.
After the extent of the defect has been determined, the flap can be planned.
In cases of an unfavorable ratio of length to width as in type II SSFs or in cases of very deep ulcers, portions of
the gluteal muscle are included in the flap to ensure a better flap blood supply (Figs. 469.1 and 469.2). If the
defect is located in the upper region of the sacrum, inclusion of the lower portions of the latissimus dorsi in the
flap will improve the results (see Fig. 469.5). Because mistakes in cutting the flap cannot be corrected, precise
design and remeasurement of the flap are of great importance.
OPERATIVE TECHNIQUE

The incisions should be carried down to the muscle layer. Not only the ulcer proper but all scar tissue is excised.
The excision should be carried out en bloc to avoid contact with infected surfaces.
The principles and technique of the slide-swing flap are discussed in more detail in Chapter 112. The donor site
is closed before suturing the flap in place. Suction drainage, for about a week, is introduced to prevent any
hematoma. With this method, two or three ulcers can be treated in one session.
All pressure on the flap must be avoided during the first few postoperative days. After the sutures are removed,
13 to 14 days postoperatively, the patient is permitted freedom of movement; however, sitting on the flap should
not occur until after 5 to 6 weeks.
FIGURE 469.1 The three types of slide-swing skin flaps (see Chapter 103). (From Schrudde and Petrovici, ref.
4, with permission.)
FIGURE 469.2 Geometric principles of the slide-swing flap with exchange of asymmetrical triangles (see Chapter
112). (From Schrudde and Petrovici, ref. 4, with permission.)

FIGURE 469.3 A: Extensive burn scar area on buttocks of a 3-year-old child, causing a substantial functional
deficit. B: A large type I slide-swing flap (SSF) from the back is planned. C: The flap has been cut and put into
position to estimate how much of the scar area can be excised. (Continued)
FIGURE 469.3 Continued. D: Result after 5 months. E: Final result after three more operations, including
another SSF for coverage of right buttock.

FIGURE 469.4 A: Coverage of the sacrum with deep radiation damage. B: Portions of the gluteal musculature
are included in this musculocutaneous flap. C: The flap inset and the donor site are closed primarily.
FIGURE 469.5 A: Deep soft-tissue defect, 18 × 14 cm, due to pressure necrosis in lumbosacral region. B:
Application of a slide-swing musculocutaneous flap, type I. The lower part of the latissimus dorsi muscle has

been included in the flap. C: The flap inset and the donor site are closed primarily. D: Result 1 year.
The same operative technique can be used in cases of chronic fistulas or radiation ulcers. Preoperative
visualization of fistulas by contrast radiography is obligatory. In patients with radiation ulcers, preoperative
radiographs are helpful in finding osteomyelitic bone.
CLINICAL RESULTS
Marginal or partial necrosis is the main complication. This is most likely to occur when the patient rests lying
on his or her back and exerts pressure on the operated area. If granulation tissue or parts of a fistula have
been left behind, recurrence of the fistula is most likely. Hematomas under the flap should be suctioned off
at once. Healing by secondary intention is frequently observed in operated radiation ulcers, because radical
excision cannot be achieved in all cases.
SUMMARY
The slide-swing skin or musculocutaneous flap can be effectively used for covering defects in the sacral
region.
References
1. Schrudde J. Deckung von Hautdefekten durch gestielte Lappenplastik. Aesthet Med 1963;12:166.
2. Wahle H, Schrudde J, Olivari N. Zur konservativen and operativen Behandlung von Druckgeschwueren
bei Paraplegikem. Z Neurolog Psych 1971;39:653.
3. Olivari N, Schrudde J, Wahle H. The surgical treatment of bedsores in paraplegics. Plast Reconstr Surg
1972;50:477.
4. Schrudde J, Petrovici V. Unfallbedingte Spaetschaedigungen des Hautund Subkutangewebes. Chir Geg
1975;4:2.
5. Conway H, Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia: based on
experience with 1000 cases. Am J Surg 1956;99:946.
6. Dansereau JG, Conway H. Closure of decubiti in paraplegics. Plast Reconstr Surg 1964;33:474.
7. Schmidt-Tintemann U. Die plastische Deckund des sacralen Dekubitus. Langenbecks Arch Chir
1965;309:117.
8. Zellner PR, Meinecke FW. Anzeigetechnik verschiedener plastischer Operationsverfahren bei
Druckgeschwueren. Chir Plast 1966;2:115.
9. Griffith BH. Pressure Sores. In: Grabb WC, eds. Plastic surgery. Boston: Little, Brown, 3rd Ed., 1979;818.

10. Ger R, Levine SA. The management of decubitus ulcers by muscle transposition. Plast Reconstr Surg
1976;58:419.
11. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable sensate flap for the closure of
buttock and perineal wounds. Plast Reconstr Surg 1981;68:521.
12. Scheflan M, Nahai F, Bostwick J. Gluteus maximus island musculocutaneous flap for closure of sacral
and ischial ulcers. Plast Reconstr Surg 1981;68:533.

Chapter 470
Thoracolumbar-Sacral Flap
J. H. BINNS
S. C. VYAS
A thoracolumbar-sacral flap is a large medially based arterialized flap that can be raised without delay from the
posterior thoracic lumbar and gluteal region (1).
INDICATIONS
Large sacral defects may be closed in a single-stage procedure using this flap, and it is particularly useful in
treating recurrent sacral pressure sores in which the more conventional sacral rotation flap has failed.
ANATOMY
The blood supply for this flap is derived from the posterior perforating vessels of the intercostal and lumbar
arteries (Fig. 470.1).
OPERATIVE TECHNIQUE
The defect is stained with methylene blue and then is excised. Any bony prominences are smoothed with an
osteotome, and the flap, previously marked, is elevated. Care is taken not to raise the flap beyond the midline,
and it may be necessary to make a backcut at the proximal part of the flap in the interscapular region. The flap is
rotated into the defect, which may measure as much as 30 × 10 cm, and it is sutured in two layers. Suction
drainage is necessary and should be prolonged for 10 to 14 days.
FIGURE 470.1 A: Outline of flap and defect. B: Raised flap. C: Flap rotated into defect and incision closed in
two layers.
CLINICAL RESULTS
In the absence of infection, the viability of the flap is good, and results in the management of large sacral

defects using this flap have been satisfactory (Fig. 470.2).
SUMMARY
The thoracolumbar skin flap can be used to cover sacral pressure sores.
FIGURE 470.2 A: Sacral sore 15 × 15 cm. B: Postoperative result after 1 year.
Reference
1. Vyas SC, Binns JH, Wilson AN. Thoracolumbar-sacral flaps in the treatment of sacral pressure sores.
Plast Reconstr Surg 1980;65:159.

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Chapter 471
Intercostal Neurovascular Island Skin Flap
R. K. DANIEL
C. L. KERRIGAN
EDITORIAL COMMENT
This is a very innovative flap, particularly because it was hoped that it would provide sensibility to a
paralyzed patient. The difficulty of the operative procedure and the variability of the sensibility results have
decreased its use.
The intercostal island flap has many applications in torso reconstruction (1, 2, 3, 4, 5). It can provide a large skin
area with a permanent blood supply to close defects secondary to radiation or tumor excision. With modifications,
it can be used as a sensory skin flap for paraplegics or as a compound osteocutaneous flap for chest-wall
reconstruction.
INDICATIONS
The clinical applications for torso reconstruction are virtually limitless, as any intercostal bundle on either
side can be selected. Because the length is expandable, the flap can reach
from the nape of the neck to the sacrum and sweep the torso like the hands of a clock, even reaching the
contralateral chest. This flap is our first choice for children with multiple recurrent pressure sores overlying a
prominent lumbar kyphosis.
ANATOMY
The anatomy of the intercostal flap is based on a thorough understanding of the course of an intercostal
neurovascular bundle. For simplification, this course can be divided into four segments (see Fig. 471.1A and B).
From the posterior midline to the anterior midline, the subdivisions consist of the vertebral, costal groove,
intermuscular, and rectus segments. Throughout, the venous system parallels the arterial.
The vertebral segment extends from the aorta to the commencement of the costal groove of the rib and
measures approximately 8 cm long. The segmental intercostal artery arises from the aorta and can be located in
the middle of the interspace. As it continues distally, it approaches the cephalad rib to reach the beginning of the
costal groove. The course of the intercostal nerve parallels the vessel and lies caudal to it. In the proximal
portion of this segment, the artery gives rise to three branches: the dorsal branch, the nutrient branch to the rib,
and the collateral branch that follows the main trunk but assumes a position adjacent to the caudal rib. This
segment is not dissected in an island flap but is dissected for the transfer of a free intercostal flap. This segment
also does not contribute to the length of the flap, because the pivot point for rotation is the juncture of vertebral
and costal groove segments.
The costal groove segment begins at the costal groove and extends to the level of insertion of the abdominal
musculature and diaphragm onto the ribs. It measures approximately 12 cm long. Under protection of the costal
groove, the neurovascular bundle assumes a course deep to the external and internal intercostal muscles but

superficial to the innermost intercostal muscle and the parietal pleura. In this segment, the vessels give rise to
numerous large musculocutaneous perforators at intervals of 1 to 3 cm. In the distal portion of the segment
corresponding to the midaxillary line, vessels and nerves give off their lateral cutaneous branches that perforate
the intercostal muscle to attain a subcutaneous position. This branch itself subsequently divides into posterior
and anterior branches that travel in a subcutaneous course to supply and innervate the overlying cutaneous
territory.
The intermuscular segment extends from the costal attachment of the abdominal musculature to the lateral
border of the rectus muscle and is approximately 12 cm long. The neurovascular bundle travels in a plane
between the internal oblique and the transversus abdominis muscle. The most confusing anatomy is at the
transition point between the costal groove and intermuscular segments. At this level, the transversus abdominis
and diaphragm are attached to the inner surface of the costal cartilages. The neurovascular bundle is located
between this musculature and the costal cartilage.
The rectus segment corresponds to the width of the rectus muscle and averages 8 cm long. The neurovascular
bundle courses deep to the rectus muscle, where it anastomoses with the epigastric vessels at the muscle
midpoint. From this anastomosis arise perforators to supply the muscle and overlying skin.
FLAP DESIGN AND DIMENSIONS
The maximum dimensions of the cutaneous segment have not been determined. Experimental evidence
suggests that one interspace can support a flap up to 8.6 interspaces wide; thus, flap size is limited by ease of
donor-site closure. Our largest flap to date measures 18 × 12.5 cm. The location of the skin flap may be
anywhere along the course of the intercostal neurovascular bundle. If located over the rectus segment, the blood
supply will come from the deep vessels, the innervation will come from the main intercostal nerve, and the flap
should be elevated in a submuscular plane. If the flap is located over the intermuscular or costal groove
segment, the blood supply will come from the deep vessels, but innervation will come from the lateral cutaneous
branch. Skin flaps that cross the abdominal midline are dependent on somewhat sparse vascular connections
and should not exceed the contralateral rectus segment.
The most dorsal pivot point of the island flap is the lateral border of the sacrospinatus muscles, corresponding to
the posterior angle of the rib. The arc of rotation is 360 degrees, with an average radius of 38 cm. The flap may
be rotated to the adjacent thorax, to the posterior aspect of the shoulder, to the ipsilateral and contralateral
backs, to the posterior midline, and to the sacrum. The longest radius of this arc that we have used is 42 cm,
from T9-10 interspace to the sacrum. It should be noted that superior rotation requires maximum resection of the
rib above to avoid kinking the pedicle.
The approximate recipient-site requirements are determined, and the distance from this site to the pivot point of
the flap is measured. The interspace to be used is chosen (usually T9 or T10), and the length of the pedicle
along the interspace is drawn (see Fig. 471.1A and B). The cutaneous portion of the flap is then centered over
the interspace at the appropriate distance from the pivot point. Sensory flaps are best designed with the patient's
arm at the side so as not to distort the cutaneous interspace relationship.
OPERATIVE TECHNIQUE
Flap elevation is divided into three key steps: (1) isolation of the vascular pedicle, (2) elevation of the cutaneous
paddle, and (3) fusion of the cutaneous paddle and its vascular pedicle (Fig. 471.1).
To isolate the vascular pedicle, an incision is made along the interspace to be used from the posterior pivot point
to the dorsal outline of the flap. The incision is carried down to the fascia, and the skin is retracted superiorly and
inferiorly to expose the ribs above and below the interspace. Scalpel incision is carried down to and through the
rib periosteum on both ribs. A complete and careful subperiosteal dissection of the cephalad rib is carried out

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without damage to the intercostal vessels. The portion of the caudal rib adjacent to the selected interspace is
similarly exposed. The cephalad rib is then excised as far dorsally as possible. The pleural cavity is entered next,
and by sharp dissection, the entire length of the exposed interspace is divided from the interspace above and
from the rib below.
To elevate the skin paddle, the incision around the skin flap is made down to the fascia. When the flap is located
over the rectus segment, the greatest vascularity is ensured if the rectus muscle and the lateral third of its
posterior sheath are elevated with it. The dissection is thus down to, but not through, the peritoneum. With the
flap located over the intermuscular segment, the full thickness of abdominal musculature should be included to
ensure preservation of the vascular network.
FIGURE 471.1 Closure of a sacral ulcer in a paraplegic using an intercostal island flap. A,B: T10 neurovascular
intercostal flap is outlined with the skin paddle overlying the rectus segment and abutting a previous midline
incision. C: The lateral rectus segment is incorporated into the flap before the transversus abdominis. D: The
flap completely isolated with the thorax opened but the peritoneum closed. E: The flap easily reaches the sacral
defect. The skin overlying the pedicle is removed before passage through the tunnel. F: The flap in place
following passage through the interconnecting tunnel.

To join the cutaneous paddle to the proximal portion of its vascular pedicle, the deep surface of the flap is
dissected free from the peritoneum until the diaphragm is encountered. The costal cartilage (if crossing over the
path of the neurovascular bundle) is incised on both sides of the flap and may be left in place. The remaining soft
tissues between the flap and the interspace then are divided.
Flap Insetting
A large subcutaneous tunnel is created from the pivot point of the flap to the recipient defect. This procedure is
facilitated by the use of a tunneler (employed by vascular surgeons for femoral- popliteal bypasses). The flap is
passed gently through the tunnel, being careful not to kink or twist the vascular pedicle. The flap is sutured in
position, and the donor site is closed after placement of a chest tube in the pleural cavity.
CLINICAL RESULTS
In our series of 13 patients, we have used the flap to cover the following sites: (1) sacrum, 8; (2) chest wall,
2; and (3) axilla/shoulder, 3. The etiology of the defects included pressure ulceration, tumor excision,
radiation, and infection. The youngest patient was aged 5 years, the oldest 63. The principal
contraindications have been obesity and chronic pulmonary problems.
The reliability of the flap is excellent, and there has not been significant loss of any flap—a tribute to its
durability. Sensation has been maintained in the island flaps, and, to date, pressure sores have not
recurred in the sacral region. Our initial patient was seen 7 years postoperatively, and skin coverage was
both stable and sensate.
The actual complications are relatively few: intraoperative damage of the neurovascular pedicle and
postoperative compression of the pedicle. The former is prevented by a straightthrough incision into the
pleural cavity above and below the designated interspace rather than by attempting to tease the pedicle out
without penetrating the pleura. Compression is best avoided by creating a broad interconnecting tunnel (8
cm minimum) and proximal resection of the rib, if it is transposed superiorly. Growth of a rib along the
pedicle is inevitable if the periosteum is included, but it is of little consequence. As with any new surgical
procedure, practice dissections in the anatomic laboratory will facilitate clinical execution.
SUMMARY
The intercostal island flap has multiple applications for torso reconstruction. It can be used to provide
sensation to the sacral area in paraplegics, especially children.
References
1. Dibble DG. Use of a long island flap to bring sensation to the sacral area in young paraplegics. Plast
Reconstr Surg 1974;54:220.
2. Daniel RK, Terzis JK, Cunningham DM. Sensory skin flaps for coverage of pressure sores in paraplegic
patients: a preliminary report. Plast Reconstr Surg 1976;58:317.
3. Daniel RK, Kerrigan CL, Gard DA. The great potential of the intercostal flap for torso reconstruction. Plast
Reconstr Surg 1978;61:653.

4. Kerrigan CL, Daniel RK. The intercostal flap: an anatomical and hemodynamic approach. Ann Plast Surg
1979;2:411.
5. Shively RE, Schafer ME, Kernahan DA. The spread of sensibility into previously anesthetic skin following
intercostal flap transfer in a paraplegic. Ann Plast Surg 1980;5:396.
6. Little JW, Fontana DJ, McCulloch DT. The upper quadrant flap. Plast Reconstr Surg 1981;68:175.

Chapter 472
Upper Quadrant Abdominal Musculocutaneous Rib-Skin Flap
J. W. LITTLE III
The intercostal neurovascular island skin flap (1, 2, 3, 4), when sizable or extended toward the midline, is
considered to require surgical delay (2, 3, 4) or double intercostal pedicles (3, 5). The following expanded
transpleural technique broadens and deepens the thoracic pedicle, the abdominal paddle, and the critical
thoracoabdominal transition, thereby speeding elevation and enhancing the circulatory vigor of the flap (6).
The nomenclature emphasizes not the well-recognized intercostal nature of the thoracic pedicle, but the full-
thickness nature of the abdominal paddle, representing, as it were, the virtual entire upper abdominal quadrant,
with rectus muscle and deep epigastric systems included. Through the presence of these latter, impressive
extensions of contralateral upper quadrant and ipsilateral lower-quadrant abdominal wall have been possible.
INDICATIONS
The execution of this flap, involving an open thoracoabdominal approach, must be considered an
exceptional surgical undertaking and is not, therefore, indicated where surface flaps are available and will
do as well. Beyond concerns for acute pulmonary complications and long-term abdominal support, operative
morbidity includes 1 week of considerable postoperative pain. The special virtues of this flap, however,
sensibility and remarkable vascularity through a long pedicle, easily justify its use in special circumstances.
In sensory reconstruction, of course, the pedicle must originate above the sensory level. Such is frequently
possible when treating the dorsal defects of myelodysplastic children, in whom ulcers tend to overlie the
spinal deformities and hence the sensory lesions themselves. It is less often possible in treating the
conventional pressure sores of the acquired paraplegic. The highest pedicle that can cover the sacrum
without insensible extension of its paddle is T8. Microsurgical anastomosis of the intercostal nerve to one
above the level of sensory loss is a possible solution to this problem (3). The T11 pedicle with a modest
inferior extension of the paddle can cover the ischial region and may be indicated for a troublesome ischial
sore in a paraplegic with a sensory level fortuitously falling between T11 and L2-3. For levels below L2-3,
which occur most commonly in myelodysplastic children, the sensory tensor fasciae latae flap carrying the
lateral femoral cutaneous nerve remains the simpler and preferred source of innervated coverage.
In general reconstruction, the flap is most often indicated for large or difficult defects of the low trunk, where
local solutions to sizable problems may be limited. Surely the clearest indication remains the complicated
radiation defect of the lumbosacral or hip region, to which unsurpassed blood supply can be brought quickly
from a remote area to ensure rapid per primam healing (see Fig. 472.3).
ANATOMY (3, 4)
The thoracic course of the major neurovascular bundle is deep within the intercostal space, at points immediately
applied to the parietal pleura; its abdominal course runs between the transversus abdominis and internal oblique
abdominis muscles. Collateral vascular pathways also run within the musculature of the intercostal space.
Innervation of the skin overlying the rectus muscle is by way of the main intercostal trunk, and that of the
abdominal wall lateral to the muscle is through the lateral cutaneous branch that arises from the deep trunk in the
midaxillary line and thereafter follows a subcutaneous course (Fig. 472.1).

FIGURE 472.1 Planned incisions. (From Little et al., ref. 6, with permission.)
Additional points are pertinent (6). The major neurovascular bundle, in passing from the intercostal space to the
abdominal wall, runs deep to the chondral syncytium of the costal margin. The scanty transversus abdominis
muscle arises from the inner surfaces of the cartilages of the lower six ribs, in common with the diaphragm, at
some distance within the costal margin. The deep intercostal vessels anastomose freely with the superior and
inferior deep epigastric systems after perforating from beneath the lateral third of the posterior rectus sheath to
reach the undersurface of the muscle. The perforating vessels of the anterior rectus sheath support an
impressive circulation across the abdominal midline.
FLAP DESIGN AND DIMENSIONS
Extended skin paddles can exceed 25 × 25 cm and are considered limited only by the ability to restore the
abdominal defect. Certainly, no flap has shown even marginal ischemia of any border at any time. The pivot point
of this true island flap occurs at the intersection of the selected interspace with the lateral border of the
sacrospinalis muscle, one hand's breadth off the spine. The arc of rotation of extended flaps is impressive. A T10
pedicle with extended paddle reaches the ipsilateral trochanter and ischium; a T9 pedicle with similar extension
reaches the occiput (Fig. 472.2).
The ninth, tenth, or occasionally other intercostal space is selected as the pedicle for the flap, and spaces above
and below are marked as superior and inferior margins. These relationships should be determined with the
patient's arm at the side, so that the subcutaneous portion of the pedicle will not be displaced but will accurately
overlie the desired interspace and thus carry the appropriate lateral cutaneous nerve. The abdominal paddle is
drawn flush to the midline, centered at the umbilicus in the case of the T10 pedicle, somewhat higher for T9. Its
size is limited only by the requirements of the defect. The pedicle marking then is blended to the abdominal
paddle over the region of the costal margin.

FIGURE 472.2 Arcs of rotation.
OPERATIVE TECHNIQUE
Thoracic incisions are made to fascia and carried at this level to the rib of the selected interspace (the tenth, for
a T10 pedicle) above and to its inferior neighbor (the eleventh) below, where they are deepened through muscle
and periosteum onto rib (Fig. 472.3).
Behind the posterior axillary line, it is neither necessary to include skin and subcutaneous tissue in the pedicle
(the lateral cutaneous nerve does not become superficial until the midaxillary line) nor to divide the latissimus
dorsi muscle, which instead may be retracted intact or used in some other way (as, for example, a reversed
muscle flap (9)). The upper rib is removed subperiosteally from the sacrospinalis muscle to the costochondral
junction, and the thorax is entered through the midportion of the periosteal bed over this extent. The superior
border of the lower rib then is freed subperiosteally; without removing this rib, the superior aspect of its bed is
similarly entered behind the rib.
Now that the pedicle has been completed by rapid, parallel full-thickness cuts into the thoracic cavity, attention is
turned to the abdominal paddle. It is incised along the midline into the underlying rectus sheath and along the
superior and inferior margins through both the anterior sheath and rectus muscle, dividing and ligating the deep
epigastric vessels where encountered. The muscle is lifted bluntly from the underlying posterior sheath from
medial to lateral until perforating vessels are encountered (usually at the junction of the middle and lateral thirds
of the sheath). These vessels are necessary for survival of the undelayed flap across the midline and are spared
by deepening the dissection through the posterior sheath onto the peritoneum just at their appearance.
The remainder of the abdominal dissection is rapidly performed at the level of the intact peritoneum, dividing
skin, subcutaneous tissue, and abdominal wall musculature along the superior and inferior margins of the paddle
until the costal margin is reached. Here the deep dissection of transversus muscle from peritoneum continues
well beneath the costal margin onto the diaphragm. The elevated abdominal paddle is joined to the dissected
thoracic pedicle. The cartilaginous portion of the upper rib is removed, and the upper incision is joined full-
thickness. Below, the J-shaped portion of terminal cartilage crossing the interspace is divided flush with the
lower incision and carried with the flap. This situation occurs regularly when the ninth interspace is used,
including a portion of chondral tenth rib in the flap. It does not occur when the lower tenth interspace is used.
The presence of the main neurovascular bundle deep to this cartilage and of the collateral systems superficial to
it is considered to make its removal hazardous, jeopardizing the surviving length of ambitious flaps. Subsequent
removal from the recipient site with the patient under local anesthesia remains a simple prospect, although no
such removal has been necessary to date. Now the remaining soft-tissue attachments are divided, connecting

paddle to pedicle and incorporating a small portion of diaphragm to ensure total inclusion of transversus
abdominis muscle in this critical transition zone.
The initial design may incorporate paddle extensions across the midline to include the contralateral abdominal
upper quadrant or inferiorly to include the ipsilateral lower quadrant (Fig. 472.1). When crossing the midline to
include the former, the midline fusion is divided deeply at the level of the posterior rectus sheath. The
contralateral anterior rectus sheath is included to carry the additional skin. When taking the lower abdominal
wall, underlying rectus muscle is included, along with that portion of the lateral posterior sheath bearing
perforating intercostal branches. Thus two thirds to three quarters of the abdominal wall can be transferred with
ease and speed. The flap can be raised in less than 1 hour.
FIGURE 472.3 A 19-year-old woman with radiation-treated sacroiliac sarcoma. A: Planned resection. B:
Planned incisions. C: Extended paddle on T10 pedicle with part of secondary defect. D: Contralateral extension
denuded for filler. E,F: Wounds healing without complication (From Little et al., ref. 6, with permission.)
Of course, a considerable abdominal and thoracic wall defect remains in the wake of this elevation. The thoracic
defect is closed in a straightforward manner by approximation of the remaining ribs with heavy intercostal
sutures. It is usually necessary to remove an additional small part of cut proximal rib to ensure that intercostal
closure does not compress the exiting pedicle. The diaphragm is reattached to the closed chest wall, but no
effort is made to close the pleura, sealing the chest instead with a multiple overlapping soft-tissue closure. A
chest tube is inserted.

The abdominal defect is more of a problem because support must be returned to that portion of abdominal wall
between the residual posterior rectus sheath (medial two thirds) and the closed costal margin. This step is
accomplished by splitting off flaps from the remaining abdominal musculature and fascia, including lower external
oblique muscle and fascia and contralateral rectus sheath. Skin closure is accomplished directly after extensive
undermining. The flap then is tunneled subcutaneously to the area of the wound, which is approached now that
the chest and abdominal wounds have been closed. The skin of the pedicle is excised, conserving the
subcutaneous component and its lateral cutaneous nerve. Longitudinal traction on the pedicle does not appear
to be detrimental, as the intact layer of parietal pleura prevents undue tension on the vessels themselves.
CLINICAL RESULTS
Of six flaps raised to or beyond the midline, all have survived entirely without signs of compromise. All
healing was per primam, including three patients treated for extensive radiation defects. All flaps were
sensate, four immediately and two after some delay. No defects have recurred over a 1- to 3-year follow-up.
There have been no complications in this series. All chest tubes were removed during the first week
following an unremarkable pulmonary course in all patients.
Abdominal support has remained satisfactory in all patients. The segmental loss of rectus abdominis muscle
has not been noticed. Vertical shortening of the hemithorax through rib resection and intercostal closure has
produced no postural deformity.
SUMMARY
The upper quadrant abdominal musculocutaneous rib-skin flap is basically an extension of the intercostal
neurovascular island flap. Although it involves a transpleural technique, it is a more robust flap that is
technically less difficult to perform.
References
1. Dibbell DG. Use of a long island flap to bring sensation to the sacral area in young paraplegics: case
report. Plast Reconstr Surg 1974;54:220.
2. Daniel RK, Terzis JK, Cunningham DM. Sensory skin flaps for coverage of pressure sores in paraplegic
patients: a preliminary report. Plast Reconstr Surg 1976;58:317.
3. Daniel RK, Kerrigan CL, Gard DA. The great potential of the intercostal flap for torso reconstruction. Plast
Reconstr Surg 1978;61:653.
4. Kerrigan CL, Daniel RK. The intercostal flap: anatomical and hemodynamic approach. Ann Plast Surg
1979;2:411.
5. Daniel RK. The upper quadrant flap (Discussion). Plast Reconstr Surg 1981;68:183.
6. Little JW, Fontana DJ, McCulloch DT. The upper quadrant flap. Plast Reconstr Surg 1981;68:175.

(Trang không có chữ)

Chapter 473
Paravertebral Osteomuscular Flap
J. C. MUSTARDÉ
EDITORIAL COMMENT
This procedure certainly was one of the earliest ones that gave excellent coverage to patients with
meningomyeloceles. Its major drawback is the possible excessive blood loss encountered during the
procedure in these small children. More recently, posterior advancement of bilateral latissimus dorsi muscle
flaps, with or without relaxing incisions, has proven to be an even more satisfactory procedure. (See
Chapters 475 and 476.)
Most problems arising in the management of babies with spina bifida are due to damage to the spinal cord,
occurring occasionally in later childhood, but most often during, after, and possibly before birth. It is obvious that
the cord is more likely to be damaged in babies who are born with meningomyeloceles (Fig. 473.1), where the
primitive neural tissue of the cord has remained untubed and where its surface is exposed, with failure of
development also of the skin, muscle, bone, and neural coverings that are normally present along the spine.
INDICATIONS
Tubing, followed by dural covering of the neural plaque, presents little problem, but provision of adequate
skin covering that will protect the spinal cord permanently is more difficult to achieve (Fig. 473.2A and B).
Skin flaps in the dorsal region are not readily raised and moved without running into vascular problems, and
they tend to leave scars close to the midline. Apart from this, skin flaps alone can offer little protection to the
underlying cord in the event of blows to the lumbar region in later life.
FLAP DESIGN AND DIMENSIONS
A flap that is raised in the muscles of the paravertebral region and that includes the transverse processes of the
bifid vertebrae will, on being turned over toward the midline (Fig. 473.2C and D) and firmly fixed to its opposite
number by a line of sutures in the lumbodorsal fascia, produce a tunnel that will not only provide permanent
protection for the underlying spinal cord but also will readily accept free skin grafts onto the muscle surface now
exposed on the midline. This does away with the need for raising, and especially for undermining, dorsal skin
flaps (1).
OPERATIVE TECHNIQUE
The neural plaque of the meningomyelocele should be tubed and closed with the dural covering. The
osteomuscular flaps are developed by incising the paravertebral muscle mass and fracturing the transverse
processes (Fig. 473.2). The lumbodorsal muscles are incised down to the tips of the lateral processes (Fig.
473.3A). Then the lumbodorsal muscle mass is grasped by Lane's tissue forceps and turned toward the midline,
thus fracturing the lateral vertebral processes (Fig. 473.3B and C). The paravertebral osteomuscular flap
therefore creates a protective bony canal for the spinal cord. The lumbodorsal muscle mass is included with the
flap to carry the blood supply to the bone (Fig. 473.3D). Because the muscle is left exposed dorsally, it provides
an excellent bed for skin grafts.

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After the muscle layer is brought together in the midline, the skin of the back is closed as far as possible without
any tension. The remaining defect is then skin-grafted (Fig. 473.3E).
CLINICAL RESULTS
An operation of this nature is obviously most effective if it can be carried out within 2 or 3 hours of birth, and
in my experience, the procedure has led, if not to actual recovery of neurologic function, at least to
diminution of the severity of neurologic problems in the developing child.
SUMMARY
The paravertebral osteomuscular flap can be used to close meningomyelocele defects. It provides a
protective bony canal for the newly closed neural plaque. At the same time, the muscular bed permits the
skin defect to be grafted.
FIGURE 473.1 Meningomyelocele in the newborn infant, showing exposed neural plaque.

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FIGURE 473.2 Schematic representation of transverse section through a meningomyelocele. A,B: Tubing
of the neural plaque with closure of dural covering. C,D: Development of the osteomuscular flaps by
incising paravertebral muscle mass and fracturing the transverse processes. (From Mustardé, ref. 1, with
permission.)
FIGURE 473.3 Paravertebral osteomuscular flap used to construct a protective spinal canal. A: The cord
has been tubed and the dural covering closed. The lumbodorsal muscles are being incised down to the tips
of the lateral processes. B,C: The lumbodorsal muscle mass, grasped by Lane's tissue forceps and turned

toward the midline, thus fracturing the lateral vertebrae processes. D: The osteomuscular flaps are being
united from above down (the tubed cord is seen still exposed on the left), followed by union of the muscle
layer superficially. E: Postoperative result showing well-healed skin graft over the reconstructed spine. Note
development of widespread capillary nevus.
Reference
1. Mustardé JC. Plastic surgery in infancy and childhood, 2nd ed. Edinburgh: Churchill-Livingstone, 1979;
Chap. 26.

Chapter 474
Transverse Lumbosacral Back Flap
H. L. HILL JR.
EDITORIAL COMMENT
This flap extends beyond the midline for a considerable distance and maintains its vascularity, thus making
it quite safe for coverage of moderately large sacral sores. The secondary defect almost always requires
skin grafting.
The transverse lumbosacral back flap (TLBF) (1) is presented as a reasonable alternative procedure in the
coverage of medium to large soft-tissue defects of the lower lumbar spine, sacrum, and upper coccygeal areas. It
applies particularly to the treatment of sacral pressure sores.
INDICATIONS
Advantages of this flap include the following: (1) it is a quick and easy procedure, (2) the flap elevation itself
is relatively bloodless, (3) the donor defect is in a non-weight-bearing area, (4) muscle is not sacrificed
(possibly of importance in the ambulatory patient), and (5) surgical options are preserved in cases of
recurrence. (The flap itself may be reelevated and inset in some cases of recurrence.)
The primary disadvantages of the TLBF are relative and should be considered when determining the
surgical options. First, the TBLF is composed of skin (albeit thick) and subcutaneous tissue, consequently
lacking the bulky padding afforded by alternative musculocutaneous flaps. Second, the vascularity of the
flap tip (i.e., the portion covering the defect) is empirically less dependable than that of a musculocutaneous
flap. Finally, the donor defect is large, cannot usually be closed primarily, and, in the occasional patient,
may prove of cosmetic concern.
Candidates for flap coverage of sacral defects are usually those in whom rehabilitation can be anticipated.
Occasionally, though, it can be justified to improve hygiene and facilitate nursing care in an otherwise
chronically nonrehabilitatable person.
ANATOMY
The blood supply to the skin and subcutaneous region between the lower ribs and posterior iliac crest is largely
segmental. It appears that the primary vascular supply is from posterior perforating arteries of the lower
intercostal vessels through the latissimus dorsi muscle and lumbar arteries through the lumbar triangle.
Additional contributors include musculocutaneous perforators from the gluteus maximus muscle inferiorly and
inconsistent paraspinous perforators in the midline and sacrospinalis area (1) (Fig. 474.1A and B).
Closer dissection of the lumbar perforators, especially L3, exposes a medially directed branch, “axially” providing
blood supply to the skin near the midline (2). In the human, transaortic injection of fluorescein in a lumbar artery
intraoperatively fluoresces significantly across the midline (Fig. 474.2A and B). The midline need not be
considered a relatively avascular barrier to flap design (3, 4, 5). Specifically in regard to the transverse
lumbosacral back flap, when the lumbar perforators are preserved, a portion of the flap is probably axial with a
random extension across the midline.

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FLAP DESIGN AND DIMENSIONS
The TLBF is designed so that its vascular pedicle is preserved along the lateral aspect of the paraspinous
muscles on either side (Fig. 474.3A). It is extended across the midline several centimeters lateral to the
contralateral perforators, which are usually identified and located. The limit of the lateral extent of this flap is
unclear, although it is routinely safe 2 to 3 cm lateral to the opposite paraspinous border. There has been at
least one instance in which marginal necrosis occurred with this length, but routinely, such flaps do well. (One
early patient had a significant flap loss which, in retrospect, was obviously due to elevation past the vascular
pedicle.) It might be recommended that fluorescein determinations of flap viability be carried out at the
appropriate time in questionable flaps.
Flap width should be such that most of the lower lumbar skin is included. This prevents the secondary defect
from extending over the pressure-bearing area of the sacrum.
FIGURE 474.1 A: Vascular supply of the lumbosacral skin. B: The existence of a vascular supply across the
midline has been confirmed by experimental, cadaver, and clinical investigations. (From Hill et al., ref. 1, with

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permission.)
FIGURE 474.2 A,B: Area of fluorescence outlined on the lumbosacral area of a patient injected transabdominally
in a lumbar artery while undergoing abdominal aneurysmectomy. (From Hill et al., ref. 1, with permission.)
OPERATIVE TECHNIQUE
The involved tissue is excised, and limited removal of the underlying bone is performed (Fig. 474.4A). The flap is
usually elevated from the tip to the base, resorting to blunt dissection as the pedicles are approached, identified,
and preserved. To enhance rotation, the flap may be backcut for 2 to 3 cm (probably more, because theoretically
it may survive as an island). On backcutting, the vascular pedicles obviously must be included in the flap.
Following flap rotation and inset, one or two large suction drains are used. The wound is closed in two layers.
The donor defect is covered with a meshed split-thickness skin graft.
Postoperative care usually includes removal of drains at 3 to 5 days and avoidance of weight-bearing on the flap
for about 2 weeks.
FIGURE 474.3 A: Paraplegic with pressure sore (flap outlined). B: Two weeks postoperatively. (From Hill et al.,
ref. 1, with permission.)
CLINICAL RESULTS
Complications directly relating to surgery have been gratifyingly few, despite contamination of the initial
wound and the relative debilitation of the patients. Partial flap loss is unusual.

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SUMMARY
Approximately one fourth of all pressure sores are sacral, particularly in paralyzed or bed-ridden patients.
Recurrence is all too frequent. The TLBF is a reliable surgical alternative in these usually sick and
debilitated patients.
FIGURE 474.4 A: Large sacral pressure sore following debridement. B: Three weeks postoperatively.
(From Hill et al., ref. 1, with permission.)
References
1. Hill HL, Brown RG, Jurkiewicz MJ. The transverse lumbosacral back flap. Plast Reconstr Surg
1978;62:177.
2. Daniel RK. The anatomy and hemodynamics of the cutaneous circulation and their influence on skin flap
design. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown, 1975;111-131.
3. Baroudi R, Pinotti JA, Edwald MK. A transverse thoracic abdominal skin flap for closure after radical
mastectomy. Plast Reconstr Surg 1978;61:547.
4. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction following total mastectomy with a transverse
abdominal island flap: anatomic and clinical observations. Plast Reconstr Surg 1982;69:216.
5. Davies D, Adendorff D. A large rotational flap raised across the midline to close lumbosacral defects. Br J
Plast Surg 1977;30:1663.

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Chapter 475
Bilateral Latissimus Dorsi Musculocutaneous Advancement Flaps
for Closure of Meningomyelocele Defects
J. B. MCGRAW
J. O. PENIX
EDITORIAL COMMENT
The reader is advised to refer also to Chapters 436 and 439 for alternative methods of closure.
One of every 800 infants is born with spina bifida cystica. The disease includes a number of conditions in which
epithelium-lined sacs filled with cerebrospinal fluid (CSF) are in free communication with the spinal subarachnoid
space; there is usually associated maldevelopment of the spinal cord, some paralysis of the lower limbs and
sphincter, and a variable sensory deficit.
Obtaining good coverage of the meninges is a lifesaving measure that prevents major complications and
preserves
maximum function. The main challenge presented by the spina bifida defect is to repair the dura adequately and
to create a durable surface cover without functional loss and without excessive traumatization of very small,
newborn infants.
INDICATIONS
Eighty-five percent of patients with spina bifida cystica have a myelomeningocele, with protrusion of the
meningeal membranes through a defect in the vertebral column and with nerve elements found within the
sac. These patients almost always have an associated motor and sensory deficit of the lower limbs, rectum,
and bladder.
Fourteen percent of spina bifida cystica patients have a meningocele with no nerve elements in the sac and
no associated paralysis. Rarer forms of the disease are syringomyelocele and myelocele, expressed as
dilatations of the central canal of the cord and an incomplete closure of the neural groove.
All forms of the disease can be associated with other congenital anomalies, including hydrocephalus,
clubfoot, dislocation of the hip, absent ribs, exstrophy of the bladder, prolapse of the uterus, Klippel-Feil
deformity, congenital heart disease, and umbilical hernias. Previous options for closure included primary
repair, skin grafts, or more complex repairs using rotation skin flaps or the “reversed” latissimus dorsi
muscle flap.
Primary repair is rarely possible and is associated with a high incidence of wound dehiscence. Skin grafting
of the meninges is frequently complicated by poor graft take, early or late breakdown of the graft, the
associated meningitis, and death. Rotation flaps can provide durable coverage but at the expense of
significant blood loss, an extensive and lengthy procedure, and large donor-site skin grafts. The “reversed”
latissimus dorsi muscle flap offers a tedious dissection and unpredictable variability of the vascular pedicles;
it also compromises latissimus dorsi muscular function, which is important to these paraplegic patients in
transfer activities.

FLAP DESIGN AND DIMENSIONS
Excellent soft-tissue coverage can be obtained by using bilateral latissimus dorsi musculocutaneous
advancement flaps (1); CSF shunts can be employed within 5 days of initial surgery; and discharge within 2
weeks can be reasonably expected. When a myelomeningocele defect occurs in the lower sacral area, bilateral
latissimus dorsi advancement flaps are insufficient to provide total muscular coverage of the meninges.
Advancement flaps of external oblique muscle or turnover flaps of gluteus maximus muscle then can be used to
supplement the latissimus dorsi in these patients (2).
For cervical and high thoracic defects, bilateral trapezius musculocutaneous flaps can be advanced in much the
same way as latissimus dorsi units. The muscles are exposed through a midline thoracic incision and are
elevated from the paraspinous and rhomboid muscles. The lower margins of the origins are then divided, and the
units can easily be advanced into the midline.
OPERATIVE PROCEDURE
The goals of the neurosurgical part of the procedure are straightforward. Neural elements are freed from
cutaneous elements, a subarachnoid space is developed, and a watertight dural closure is obtained. The
CSF is drained through an incision in the epidermal-arachnoid junction. Then, using sharp dissection, a
circumferential incision of the dura is completed, and the epidermal-arachnoid membrane is excised flush
with the neural plaque, taking care to remove all epidermal tissue from the plaque.
At this point, an anatomic arachnoid surface is created by folding the neural plaque inward, along the axis of
the spine, and closing it with 4-0 chromic catgut. The dura mater is dissected laterally to the dura-dermis
fusion line, or the “ junctional zone.”
After the dura is circumferentially separated from the dermis, it is elevated away from the underlying
lumbosacral fascia, dysplastic paraspinal muscles, and posterior bony elements. It is closed in the axis of
the spine using a running suture of 4-0 chromic reinforced with a layer of running 4-0 Prolene. If a
significant kyphosis that will complicate or jeopardize the flap closure is present, it should be partially
removed.
Dissection of the bilateral latissimus dorsi musculocutaneous flaps is begun just lateral to the paraspinous
muscles by separating the thoracolumbar fascia from the overlying latissimus dorsi muscles. The plane
between the paraspinous muscular fascia and the posterior edge of the latissimus dorsi muscle is often ill
defined in the area of the deformity, but it can be identified superiorly in the region of the trapezius muscle.
The separation between the latissimus dorsi and external oblique muscles is identified, and a submuscular
plane of dissection is developed between the two muscles.
Care should be taken to avoid dissecting beneath the external oblique muscle, because a peritoneal
perforation can result. The posterior perforating vasculature of the latissimus dorsi muscle is divided when
encountered approximately 6 cm lateral to the midline.
Separating the origin of the latissimus dorsi muscle from the iliac crest will give additional exposure of the
anterior muscle. The dissection then can be continued on the deep surface of the latissimus dorsi muscle
until the anterior margin of the muscle is encountered and completely released from its fascial attachments
to the skin and chest wall.
Once this dissection is completed bilaterally, the two musculocutaneous units will advance to the midline for
closure. Closure should be carried out in three layers: muscle, fascia, and skin. The midline closure of the
latissimus dorsi muscle is carried out with 3-0 Vicryl rather than a less substantial suture. The deep fascia
and subcutaneous layers are closed with 4-0 Vicryl (Fig. 475.1).

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CLINICAL RESULTS
The usual operative time for harvesting bilateral latissimus dorsi musculocutaneous advancement flaps is 1
hour or less, with an average blood loss of only 30 to 35 ml. These flaps are unmatched in reliability, and
the dissection is straightforward. Although there is some controversy regarding the timing of the coverage,
in our experience, the best results are obtained when medical and surgical interventions are carried out
within the first 24 hours of life. Because of the age and size of these patients, anesthesia, monitoring, and
core body temperature maintenance are essential to the success of the procedure.
In our unit, this operative procedure has been performed 147 times without a mortality. This is a significant
improvement over an observed mortality of 3% to 7% with skin grafts and random skin flaps.
SUMMARY
Local musculocutaneous advancement flaps offer a safe, simple, and effective closure of myelomeningocele
defects in the newborn infant. These procedures have proven to be lifesaving, decreasing mortality and
morbidity without adding any long-term disability.

FIGURE 475.1 A: Meningomyelocele defect in a newborn infant. B: After closure of the dura mater. C:
Dissection of the latissimus dorsi musculocutaneous flaps is begun just lateral to the paraspinous muscles
by separating the thoracolumbar fascia from the overlying latissimus dorsi muscles. The posterior
perforatory vasculature of the latissimus dorsi will need to be divided. D: The latissimus dorsi
musculocutaneous flap is advanced to the midline. E: Final result. Note that the dog-ears are setting well.
References
1. McCraw JB, Penix JD, Baker JW. Repair of major defects of the chest wall and spine with the latissimus
dorsi myocutaneous flap. Plast Reconstr Surg 1978;62:197.
2. Ramirez DM, Ramasastry SS, Granick MS, et al. A new surgical approach to closure of large lumbosacral
meningomyelocele defects. Plast Reconstr Surg 1987;80:799.

Chapter 476
Bilateral Interconnected Latissimus Dorsi-Gluteus Maximus
Musculocutaneous Flaps for Closure of Large Lumbosacral
Meningomyelocele Defects
S. S. RAMASASTRY
O. M. RAMIREZ
EDITORIAL COMMENT
The extension of the latissimus dorsi into the gluteus is more reliable than if one were to extend it laterally.
Consequently, this is a useful extension for the closure of very large and low meningomyeloceles.
To overcome the problems of significant flap complications, increased operating time, and blood loss, the en bloc
advancement of bilateral interconnected latissimus dorsi and gluteus maximus musculocutaneous units without
lateral relaxing incisions and back cuts can achieve primary closure of large lumbosacral meningomyelocele
defects (1).
INDICATIONS
Primary wound healing can be achieved in most small thoracolumbar and lumbosacral meningomyelocele
defects with wide undermining of the wound edges and direct closure of the wound. (In a series of 130
patients (2), it was discovered that only 25% required more elaborate closure techniques.)
Large meningomyelocele defects can be difficult to repair, however, and are associated with problems of
wound breakdown and infection (3). We recommend a technique of closure for defects 5 cm or greater in
width, where wide undermining of the skin only is fraught with significant wound complications. The
procedure has been used instead of previously described methods such as advancement flaps, bipedicle
flaps, rotation flaps, the paraspinous musculoosseous Mustardé technique (4) (see Chapter 473), and the
latissimus dorsi musculocutaneous flap described by McCraw et al. (5) (see Chapter 475).
This technique is preferable to earlier ones for the following reasons: (1) no relaxing incisions or backcuts
are used; (2) no skin grafts are needed; (3) the blood supply of the intervening skin between the latissimus
dorsi and gluteus maximus muscles is more reliable; (4) the inclusion of the gluteus maximus muscle as a
musculocutaneous unit provides significant superomedial advancement, facilitating closure of large defects
in the low thoracolumbar and lumbosacral areas without tension; and (5) transfer of the gluteus maximus
muscle should not cause any functional deficit. In addition, this composite muscle flap provides good soft-
tissue padding over the neural repair.
The only contraindication is the decision by the neurosurgeon not to intervene surgically in a child with
severe neurologic deficit (one patient in our series of 18 patients) or multiple severe congenital anomalies.
ANATOMY
The anatomic details of the latissimus dorsi and gluteus maximus muscles and their relevance to reconstructive
surgery have been well described (6, 7, 8) (Fig. 476.1). The basis for our technique, using latissimus dorsi-
gluteus maximus musculocutaneous flaps as a single unit, derives from injection studies of the gluteal arterial

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system in 20 adult and 2 neonatal cadavers. A rich anastomotic network exists between the vasculature of the
skin overlying the gluteus maximus and the latissimus
dorsi muscles (7). Adequate skin circulation of the lumbar area skin between the latissimus dorsi and gluteus
maximus musculocutaneous territories is maintained if dissection of both these muscles is done in continuity,
even if paraspinous perforators are sacrificed (Fig. 476.2).
FIGURE 476.1 The latissimus dorsi and gluteus maximus muscles shown with the major vascular pedicles: the
thoracodorsal artery and the superior and inferior gluteal arteries. (The paravertebral and perforating vessels are
not shown.)
OPERATIVE TECHNIQUE
During the initial neurosurgical closure of the dural defect, undermining of the skin should be avoided (Fig.
476.3). Following the dural repair, flap elevation is begun by incising the thoracolumbar fascia over the
paraspinous muscles and carrying the dissection under the latissimus dorsi to its free border laterally. The
perforating vessels are cauterized and divided in the process.
FIGURE 476.2 Cross-sectional illustration showing the rich anastomoses between the latissimus dorsi vessels
and the superior gluteal vessels supplying the lumbar skin, maintained by submuscular dissection without skin
undermining. GMM, gluteus maximus muscle; LDM, latissimus dorsi muscle.
The entire latissimus dorsi then is based on the thoracodorsal vessels, which should be preserved. The
latissimus dorsi muscle is then freed from its attachments to the external oblique and serratus posterior muscles
by sharp dissection. The gluteus maximus muscle is detached from the iliac crest and sacrum, and the dissection
is carried into the plane between the gluteus maximus and medius. Care should be taken to preserve the gluteal

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vessels (Fig. 476.4).
The quadratus lumborum muscle is often poorly developed in the infant, and retroperitoneal structures, including
the ureter, must be safeguarded. No lateral relaxing incisions or backcuts are made. The submuscular dissection
of the flap is carried all the way to the posterior or midaxillary line, as needed (Fig. 476.5). The flaps meet in the
midline with minimal tension and can be approximated in three layers (Fig. 476.6).
CLINICAL RESULTS
This technique has been used in the last 3 years in 18 thoracolumbar and lumbosacral defects that could
not be repaired by direct primary closure. Primary reconstruction was carried out in the 18 patients
immediately following neurosurgical management of the meningomyelocele. Blood loss was less than 20 ml
in all patients, and blood transfusion was not necessary.
All reconstructions were completed in one stage, with no complications. Good healing was noted at 14
months' mean follow-up, and there has been no deterioration of neurologic function. There was one death
following correction of Fallot's tetralogy in the late postoperative period. No flap was lost, and no wound
infections or disruptions were noted.
Potential disadvantages associated with dissection of such an extensive nature are significant blood loss
and prolonged operating time. The use of electrocautery and meticulous dissection with attention to
hemostasis have eliminated significant blood loss and the need for blood transfusion in all our patients.
SUMMARY
A new method for reconstruction of large thoracolumbar and lumbosacral meningomyelocele defects
involves the medial advancement of latissimus dorsi and gluteus maximus musculocutaneous units and
reapproximation in the midline. This permits primary closure of the defect in three layers. The flaps are
based on the thoracodorsal and superior gluteal vessels and the intervening thoracolumbar fascia. They
provide tension- free, durable, and viable soft-tissue coverage over the dural repair. The flaps do not alter
the nerve supply of the muscles and merely redefine the muscle origins.
FIGURE 476.3 Preoperative appearance of a meningomyelocele lesion and the neural closure (schematic).

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FIGURE 476.4 The submuscular dissection of the latissimus dorsi and gluteus maximus musculocutaneous
units bilaterally. Dotted line indicates the area of undermining at the submuscular level beneath the
latissimus dorsi (LDM) and gluteus maximus muscles (GMM).
FIGURE 476.5 Schematic illustration showing the approximation of the latissimus dorsi (LDM) and gluteus
maximus (GMM) musculocutaneous units in the midline (seen through a cutaneous window for clarity). No
back cuts are made in the skin.

FIGURE 476.6 A: A 14-hour-old full-term infant was referred with a 10 × 8-cm lumbosacral
meningomyelocele. The child had flaccid paralysis of both lower extremities and no anal wink. B: The
exposed neural plate was dissected free, and the dura was repaired, obtaining a watertight closure. The
kyphos was resected, and a small portion of abnormal skin around the myelorachischisis was excised. The
technique as described was used to obtain a three-layer closure of the soft-tissue defect in a stepwise
fashion. C: Mobilization of bilateral compound musculocutaneous flaps. D: Appearance of the repair at the
end of the operation. The child's postoperative course was complicated by upper respiratory infection that
delayed placement of the ventriculoperitoneal shunt. The back wound healed uneventfully, and the child
was discharged on postoperative day 21. E: Appearance of the repair at 6 months.
References
1. Ramirez OM, Ramasastry SS, Granick MS, et al. A new surgical approach to closure of large lumbosacral
meningomyelocele defects. Plast Reconstr Surg 1987;80:799.
2. Patterson, TJ, Till K. The use of rotation flaps following excision of lumbar myelomeningoceles: an aid to
closure of large defects. Br J Surg 1959;46:606.
3. Luce EA, Walsh J. Wound closure of the meningomyelocele defect. Plast Reconstr Surg 1985;75:389.
4. Mustardé JC. Meningomyelocele: the problem of skin cover. Br J Surg 1969;53:36.

5. McCraw JB, Fenix JO, Baker JW. Repair of major defects of the chest wall and spine with the latissimus
dorsi myocutaneous flap. Plast Reconstr Surg 1978;62:197.
6. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979;91-
103, 369-391.
7. Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;5, 7-9, 13, 20, 24, 66-69, 114-115, 317, 352-360, 460-465, 470-471.
8. Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus muscle: experimental and clinical
considerations relevant to reconstruction in ambulatory patients. Plast Surg Forum 1984;7:27.

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Chapter 477
Thigh Transposition Skin Flap
B. H. GRIFFITH
EDITORIAL COMMENT
This is a very good, hardy flap. The procedure should be done with the patient severely flexed at the hip.
Otherwise, the surgeon has a false sense of security. As soon as the patient sits up in bed or in a
wheelchair, excessive tension will be brought to bear on the area of closure, with possible early breakdown.
For closure of small pressure sores in the ischial area, excision of the ulcer, the bursa, and the entire ischium
and primary closure with approximation of the local muscles, subcutaneous tissues and skin, plus postoperative
wound suction, may be satisfactory. If the ischial defect is large, however, simple approximation is inadequate
(1). The deep hole must be filled, and this is best done with muscle (1, 2, 3, 4, 5). The biceps femoris sometimes
augmented with the semitendinosus or semimembranosus, has generally proven to be the best muscle.
Exposure of these thigh muscles necessitates a large wound. The thigh transposition flap evolved to solve the
problems of exposure and coverage (3, 4, 5).
INDICATIONS
The principal use for this flap is the closure of an ischial pressure sore (Fig. 477.2). It is also useful for the
closure of ulcers between the ischial area and the trochanter (Fig. 477.3).
ANATOMY
The blood supply for this random flap is from the inferior gluteal artery and anastomoses between it and the
posterior branch of the obturator and the medial circumflex femoral arteries by means of perforators that come
through the adductor magnus and gracilis muscles.
FLAP DESIGN AND DIMENSIONS
This is a large flap consisting of skin and the underlying fibroadipose tissue of most of the posterior thigh (Fig.
477.1). Its upper edge is at and lateral to the ischial defect. Its base is on the posteromedial thigh, its distal free
edge along a line running longitudinally down the thigh from a point just medial to
the posterior edge of the greater trochanter. It extends distally on the thigh to a few centimeters above the
popliteal fold.

FIGURE 477.1 Schematic drawing of thigh transposition skin flap used for closure of an ischial pressure sore.
The flap is wide, large, and based on the posteromedial edge of the thigh. Its elevation affords excellent access
to the muscle used to obturate the large hole made by total ischiectomy. A split-thickness skin graft is used
distally on the thigh to avoid tension on the upper wound edge. (From Griffith, ref. 5, with permission.)
FIGURE 477.2 A: Large right ischial pressure sore. B: Thigh transposition flap 1 week postoperatively with
Hemovac drains in place. C: Final result.
The width of the pedicle, that is the transverse dimension of the flap, is usually about twice the length from base
to free margin. Depending on the size of the patient, it may measure 20 × 10 cm to 30 × 15 cm (see Fig. 477.1).
Basing the flaps on the lateral edge of the thigh not only provides a less abundant blood supply but also makes
the superomedial edge of the flap very difficult to suture along the gluteal fold. A separation of the wound often
results if this is done (4, 5).

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FIGURE 477.3 A: Large ulcer between the ischial area and the trochanter. It occurred following ischiectomy,
biceps flap, and thigh transposition flap. B: Repair using the thigh flap a second time.
OPERATIVE TECHNIQUE
The flap is raised off the fascia covering the hamstrings. After the ischiectomy has been completed and the
muscle flap has been turned into the defect, the skin flap is advanced laterally (superiorly) and sutured in place
with a double-layer closure. A split-thickness skin graft is usually needed to cover the distal flap donor site to
avoid tension on the proximal suture line (see Fig. 477.1).
CLINICAL RESULTS
The reported 97% success rate (4) has been maintained; however, I have seen late recurrences of ischial
ulcers in paraplegic patients who have been sitting up in their wheelchairs for extended periods. On
occasion, the very large size of the flap has permitted its use a second time.
Flexor muscle spasms must be relieved in paraplegics before this flap can be used safely. Otherwise, the
wound may be violently torn apart by the spasms. The use of continuous wound suction for 2 weeks
postoperatively has virtually eliminated the problems of postoperative hematoma and secondary sinus
formation that I used to see when I depended unrealistically on “pressure dressing” postoperatively. The
patient is kept on a Stryker frame or Circolectric bed and turned, front to back, alternately every 2 hours for
2 weeks postoperatively to prevent flexion of the hips and to facilitate general care. Infection is kept to a
minimum by antibiotics. Necrosis of these flaps has been a negligible problem, even though they are
elevated and advanced without a preliminary delay.
There is no deficit from the use of this flap. The accompanying muscle flap(s) presumably could be
troublesome in patients with intact spinal cords but are not troublesome in paraplegics, for whom the flap is
usually employed.
SUMMARY
The thigh transposition flap gives good exposure for transfer of the biceps muscle into an ischial defect as
well as supplying good, stable cover.

References
1. Blocksma R, Kostrubala JG, Greeley PW. The surgical repair of decubitus ulcers in paraplegics: further
observations. Plast Reconstr Surg 1949;4:123.
2. Bors E, Comarr AE. Ischial decubitus ulcer. Surgery 1948;24:680.
3. Gelb J. Plastic surgical closure of decubitus ulcers in paraplegics as a result of civilian injuries. Plast
Reconstr Surg 1952;9:525.
4. Conway HC, Griffith BH. Plastic surgical closure of decubitus ulcers in patients with paraplegia: based on
experience with 1000 cases. Am J Surg 1956;91:946.
5. Griffith BH. Pressure sores. In: Grabb WC, Smith JW, eds. Plastic surgery 3rd ed. Boston: Little, Brown,
1979; Chapter 50; 818.

Chapter 478
Scrotal Flap
I. KAPLAN
M. BEN-BASSAT
EDITORIAL COMMENT
The scrotum will cover small adjacent defects, particularly if they are traumatic; however, for recurrent
pressure sores, the success rate is much lower and the procedure is of only temporary value.
Experience in the treatment of ischial pressure sores in paraplegics has led to the frustration of repeated
breakdown of scars and flaps despite excision of the ischial tuberosity. In a small series of patients, the use of
rotation flaps from the scrotum provided very gratifying results (1, 2, 3).
INDICATIONS
The advantages of the scrotum as cover for these defects are numerous. The scrotum in paraplegics is
usually large and pendulous, and there is almost no limit to the amount of tissue available, as half or even
more of the scrotum can be used, with closure of the donor site presenting no problem (Fig. 478.1).
ANATOMY
Because of the presence of the dartos muscle, the scrotum provides a highly vascular and thick covering ideal
for a weight-bearing area. Existing anatomic relationships make the scrotum an excellent choice.
FIGURE 478.1 A: Scrotal flap used to repair an ischial ulcer that had repeatedly broken down after several
attempts at repair with other rotation flaps. Note that in this patient the ischial tuberosity was not resected. B:
The result 5 years later. (From Kaplan, ref. 1, with permission.)

FIGURE 478.2 A: A 24-year-old man who had been injured in a car accident 5 years before with damage to the
spinal cord at the D7-8 level. He had a deep ulcer measuring 10 × 12 cm in the right groin. In addition, he had
multiple smaller ulcers all around the pelvis and over the sacral area, the left and right trochanteric areas, and
both ischial areas. Following correction of his anemia and hypoalbuminemia, the ulcer was debrided. It became
apparent that the ulcer was extremely large. Laterally, the cavity abutted on the femoral vessels, and distally, it
reached almost to the adductor canal. The pubic ramus was involved, the cavity extending behind the penile
shaft. An adductor muscle flap was rotated from its proximal insertion to cover the femoral vessels. Following this
procedure, a large medial cavity remained that we judged could not be adequately covered with a skin flap
alone. B: A rotation flap of the scrotum was used, bringing the right testicle into the defect to fill the dead space.
Suction drainage was continued for a week. A large amount of sterile fluid, probably lymph, was discharged by
means of the drain, but after the drain removal, the discharge ceased. C: Healed result at 14 days. The patient
can now undergo closure of his other sores. (From Taube et al., ref. 3, with permission.)
CLINICAL RESULTS
The etiology of these groin ulcers is not quite understood. We surmise that prolonged pressure of a urine
bottle over the anesthetic region is largely contributory.
SUMMARY
The versatility of the scrotal flap is now established through its use in sores of the ischium, pubis, and
inguinal area. In one patient, the testicle also was used as a space filler (Fig. 478.2).
References