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

P.1296
Chapter 479
Gluteus Maximus Musculocutaneous Flap
R. L. MILLS
The gluteus maximus musculocutaneous flap has found its place in the surgery of spinal cord-injured patients (1)
(Fig. 479.2), in whom functional loss from use of the muscle is not a consideration.
INDICATIONS
The gluteus maximus muscle is important to posture and gait in normal patients. Clinical or experimental
evidence is not available to indicate how much of a normally functioning gluteus maximus might be
sacrificed without adverse effect. Rather than using a normal muscle, an alternate repair should be sought.
For the ischial area, which is critical to weight bearing, there seems no indication for use of the gluteus
maximus muscle alone, although this has been done. The muscle also has been used for repair of the
trochanter and sacrum with a skingrafted surface.
FIGURE 479.1 Excess muscle is taken beyond the cutaneous incision (for anatomy, see Chapter 487).
ANATOMY
See Chapter 487.
FLAP DESIGN AND DIMENSIONS
The surface design is a simple rotation flap with excess muscle taken to fill space in the wound (see Fig. 479.1).
The incisions are planned so that the flap is as large as possible and will not encroach on pressure points.
Ischial repairs do not require use of skin that does not directly overlie the muscle, except perhaps inferiorly. An
island flap can be designed for ischial repairs, if necessary, to meet the requirements of the case (2, 3).

P.1297
FIGURE 479.2 A: Ischial pressure sore. B: Following repair.
OPERATIVE TECHNIQUE
For ischial repairs, the muscle is elevated from its inferior border, which usually appears as part of the wall of a
soft-tissue defect over the prominence of the ischial tuberosity. The muscle is elevated by dissecting in the
areolar plane (although often somewhat scarred) deep to the muscle and superficial to the sciatic nerve. The
blood supply is protected by being closely attached to the deep surface of the muscle, except near the piriformis
muscle margin, where it emerges from the pelvis.
The incision is made through skin and subcutaneous tissue to the muscle fascia, which is quite thin. The
dissection then bares the muscle surface for several centimeters distal to the skin incision (Fig. 479.1). The
muscle is transected at a point where a mass adequate to fill the deep portions of the wound has been included.
In the lateral part of the wound, it may be necessary to backcut parallel to the muscle fibers to achieve adequate
mobility.
The tip of the flap is drawn into place by suturing the excess muscle into the depths of the wound. If the flap is
suitably designed, the flap donor site can nearly always be closed without a skin graft. The long side of the
surface wound is often shortened by excision of a Burow's triangle, but it is sometimes appropriate to lengthen
the short side by a backcut.
CLINICAL RESULTS
Adequacy of blood supply has not, in my experience, been a problem, even in the presence of scars in the
skin and subcutaneous tissue. Complications such as wound hematoma, seroma, or infection have related
to the nature of the wound rather than to the nature of the flap.
SUMMARY
The gluteus maximus musculocutaneous flap can be reliably used for ischial ulcer repair.
References

1. Minami RT, Mills RL, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast
Reconstr Surg 1977;60:242.
2. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby,
1979;91-103.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;434-437.

P.1298
Chapter 480
Gracilis Muscle and Musculocutaneous Flaps
F. R. HECKLER
The gracilis muscle and musculocutaneous flaps are ideal for covering ischial pressure sores (1, 2). For a
complete discussion of indications, anatomy, flap design and dimensions, and operative technique, see Chapter
441.
INDICATIONS
The ischium lies well within the reach of standard-sized musculocutaneous flaps. Caution is advised in the
use of these flaps in paraplegics with severe muscle atrophy because failure of the skin portion of such
flaps has been a problem. No such problem has been encountered in paralyzed patients who have retained
reasonably normal muscle bulk.
FIGURE 480.1 A: Large bilateral ischial pressure sores in a paraplegic patient. B: After wide excision and
removal of the bony prominences, bilateral gracilis musculocutaneous flaps were used to close the defects.
(Courtesy of Philip Antypas, M.D.)
OPERATIVE TECHNIQUE
The operative procedure is performed with the patient in the lithotomy or prone position, depending on which
gives the best access to the recipient site. The ulcer and inciting bony prominence are removed, and the flap is
transferred and sutured into place over suction drains (3, 4) (Fig. 480.1).
CLINICAL RESULTS

Improper location of the skin-paddle design and subsequent partial separation of the skin and muscle
components of the musculocutaneous unit are, in my opinion, the most common causes of failure in the use
of this flap. In my series of 53 patients with various perineal problems, none of the flaps failed. This success
rate is particularly gratifying because the gracilis musculocutaneous flap seems to have gained some
notoriety for relative lack of reliability.
SUMMARY
The gracilis muscle and musculocutaneous flap can be reliably used for coverage of ischial defects.
References
1. Mathes SJ, Nahai, F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby,
1979;13-31.
2. Mathes SJ, Nahai, F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis:
Mosby, 1982;438-439.
3. Labandter HB. The gracilis muscle flap and musculocutaneous flap in the repair of perineal and ischial
defects. Br J Plast Surg 1980;33:95.
4. Wingate GF, Friedland, JA. Repair of ischial pressure ulcers with gracilis myocutaneous island flaps. Plast
Reconstr Surg 1978;62:245.

P.1299
Chapter 481
Biceps Femoris Flaps
G. R. TOBIN
EDITORIAL COMMENT
With use of this flap as a V-Y advancement, one must be assured that the flap sits comfortably without any
tension in the area of the defect with the hip flexed. Failure to confirm this will create a significant incidence
of dehiscence in patients having this procedure.
The biceps femoris muscle long head provides the basis for several reliable flaps for ischial pressure ulcer
reconstruction. These flaps include musculocutaneous advancement, hamstring V-Y, and turnover muscle flaps
(1, 2, 3) (see Figs. 481.1, 481.2, 481.3, 481.4). Among these and alternative ischial flaps described in this
encyclopedia, the author's first choice is the biceps femoris musculocutaneous advancement flap (3) (see Figs.
481.1, 481.2, and 481.4).
The biceps femoris musculocutaneous unit (4, 5), when used clinically as a transposition flap, resulted in
significant tissue loss, and the flap fell into disrepute (5, 6). These tissue losses occurred because transposition
requires division of distal major vascular pedicles to this segmentally supplied muscle. The advancement
modification described preserves all neurovascular pedicles and results in reliable flap survival (3).
INDICATIONS
The advantages of this flap are as follows: (1) it easily covers large ischial defects; (2) it is highly reliable;
(3) a maximum number of reconstructive options are preserved for recurrent ischial ulcers, and use of the
flap does not preclude subsequent use of alternative flaps, in contrast to most other ischial flaps; and (4) it
transfers both muscle and skin over the ischium, providing greater bulk that protects the membranous
urethra and better balances the pelvis in sitting (3, 7). The muscle component provides greater reliability in
contaminated wounds, presumably because of better vascular perfusion of muscle (8).
ANATOMY
The biceps femoris long head originates on the ischial tuberosity and inserts principally on the fibular head. The
flap vascular supply is from segmental vascular pedicles from profundus femoris vessels, which are
accompanied along an obliquely caudal course by branches of the sciatic nerve (9). Most of these pedicles enter
the muscle belly in its distal half (the anatomic basis for better survival of advancement flaps compared with
transposition flaps) (3).

FIGURE 481.1 A: Biceps femoris musculocutaneous advancement flap with a medial cutaneous pedicle. B: Flap
inset after cephalad advancement, reorientation of vascular pedicles, transection of tendons, and V-Y closure of
donor defect. C: Biceps femoris musculocutaneous advancement flap closure of ischial pressure ulcer. (From
Tobin et al., ref. 3, with permission.)
The overlying thigh skin derives its vascular supply from biceps femoris musculocutaneous perforators (3, 4, 5).
It receives secondary vascular supplies from axial branches of the inferior gluteal artery (when preserved), the
dermal-subdermal plexus of a medial or lateral cutaneous pedicle (when preserved), and musculocutaneous
perforators from the semitendinosus and semimembranosus muscles (when preserved) (3, 10, 11, 12). Flap
innervation is from sciatic nerve motor branches to the biceps femoris and hamstring muscles and from the
posterior cutaneous nerve of the thigh (9).
Hamstring muscles are prime knee flexors, and they function in normal gait to decelerate leg swing immediately
before heel strike, thus contributing to forward momentum of the thigh and upper body (13). In paraplegics,
however, the hamstring muscles are usually either useless or spastic. Accordingly, their division and transfer
leave no functional loss and may relieve knee flexion spasticity or contracture (3). Therefore, when voluntary
knee flexion is present, as in patients with normal innervation or partial spinal cord lesions, I transfer only the
biceps femoris long head with the flap. In complete spinal cord lesions, I include the semitendinosus and
semimembranosus muscles (3).
FLAP DESIGN AND DIMENSIONS
This flap consists of the biceps femoris long head and its overlying musculocutaneous territory, the posterior
thigh skin (Fig. 481.1). The flap is advanced cephalad into the ischial defect on both its neurovascular pedicles
and a wide medial or lateral cutaneous pedicle (3). Also, the flap may be reelevated and readvanced (14).
Subsequently, the cutaneous and muscle components can be independently, sequentially used (1, 10, 15) (Fig.
481.2).
The flap extends vertically from the gluteal to the popliteal creases and transversely from the gracilis muscle to
the fascia lata. Thus it comprises one third of thigh circumference at all levels and provides the largest described
skin paddle for ischial ulcer reconstruction (approximately 45 × 20 cm). Deeply, it includes the long head of the
biceps femoris muscle. In addition, it also may include semitendinosus and semimembranosus muscles if these
units are not required to preserve voluntary knee flexion (3, 11).

P.1300
P.1301
The flap pivots on the entrances of its vascular pedicles into the posterior thigh. It may be advanced cephalad 10
cm without division of any neurovascular pedicle. To date, I have found this maneuver sufficient to cover all
ischial ulcers.
Because of its musculocutaneous vascular supply, the cutaneous portion of this flap may be elevated as an
island (3, 11) (Fig. 481.3); however, I prefer to preserve a wide medial or lateral cutaneous pedicle. A medial
cutaneous pedicle is chosen when a tensor fasciae latae flap has been or may be needed for trochanteric ulcers
(see Fig. 481.1). Alternatively, a lateral cutaneous pedicle that carries the sensory nerves may be designed (Fig.
481.4).
OPERATIVE TECHNIQUE
Procedures to relieve hip flexor spasm either precede flap transfer or are done simultaneously (8). The ulcer is
excised
en bloc (16). The ischial tuberosity is excised, and the ischium is contoured to broaden the pressure point. Total
and subtotal ischiectomies are avoided (7). Specific systemic perioperative prophylactic antibiotics are given.
FIGURE 481.2 A: Biceps femoris turnover muscle flap closure of ischial pressure ulcer. B: Combined hamstring
muscle flap turned over to close an ischial ulcer. Skin-graft application and successful closure followed.

FIGURE 481.3 A: Alternative island cutaneous design of biceps femoris musculocutaneous advancement flap.
B: Island biceps femoris musculocutaneous advancement flap closure of ischial ulcer. (From Tobin et al., ref. 3,
with permission.)
FIGURE 481.4 Alternative cutaneous design of biceps femoris musculocutaneous advancement flap. Lateral
cutaneous pedicle preserved.
The flap cutaneous margins are incised and elevated deep to the underlying fascia. Cutaneous sensory nerves
that lie lateral to the ischial tuberosity are preserved if they are functional. At the muscle-component borders, the
dissection enters the plane deep to the muscles, and neurovascular pedicles are identified and mobilized.
Laterally, the sciatic nerve is the guiding landmark to the deep dissection. The biceps femoris long head is
included in the flap by surgical separation from the short head. Medially, the semitendinosus and
semimembranosus muscles are included in the flap unless they are needed to preserve voluntary knee flexion (3,
11). The flap muscles are transected at origin and insertion tendon junctions. After mobilization, the flap is

advanced into the ischial defect and its neurovascular pedicles are redirected cephalad (see Fig. 481.1). First,
the proximal half of the flap is inset without tension; then the distal flap and cutaneous donor defect are closed by
V-Y technique (17). Skin grafts may be used for the donor defect, but I have not needed them to date.
CLINICAL RESULTS
I have had experience with more than 20 clinical flaps. Clinical experience with biceps femoris
musculocutaneous advancement flaps has been excellent; there have been no partial or complete losses to
date (3). This success rate presumably results from preservation of distal segmental vascular pedicles, as
reports of transposition flaps describe a high partial failure rate (5, 6).
SUMMARY
Biceps femoris musculocutaneous advancement flaps provide a large posterior thigh skin paddle carried on
underlying muscle mass. This flap has proven most reliable and versatile for reconstruction of ischial ulcers.
References
1. Gelb J. Plastic surgical closure of decubitus ulcers in paraplegics as a result of civilian injuries. Plast
Reconstr Surg 1952;9:525.
2. Pappas C, Goldich G, Cundy K, Wong W. Skin flaps vs. muscle flaps: coping with infection in the
presence of a foreign body. Plast Surg Forum 1980; 3:133.
3. Tobin GR, Pompi-Sanders B, Man D, Weiner LJ. The biceps femoris myocutaneous advancement flap: a
useful modification for ischial pressure ulcer reconstruction. Ann Plast Surg 1981;6:396.
4. McCraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories. Plast
Reconstr Surg 1977;60:212.
5. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent and myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
6. McCraw JB. Closure of defects of the lower extremity by myocutaneous flaps. In: Converse JM, ed.
Reconstruction plastic surgery, 2nd ed. Philadelphia: Saunders, 1977;3560-3566.
7. Comarr AE, Bors E. Perineal urethral diverticulum: complications of removal of ischium. JAMA
1958;168:2000.
8. Michaelis L, ed. Orthopedic surgery of the limbs in paraplegia. Berlin: Springer-Verlag, 1965;8012.
9. Brash JC, ed. Neurovascular hila of limb muscles. Edinburgh: Livingstone, 1965;54, 55.
10. Conway H, Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia. Am J

Surg 1956;91:946.
11. Hurteau JE, Bostwick J, Nahai F, Hester R, Jurkiewicz MJ. V-Y advancement of hamstring
musculocutaneous flap for coverage of ischial pressure sores. Plast Reconstr Surg 1981;68:539.
12. Hurwitz DS, 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.
13. Simon SR, Mann RA, Hagy JL, Larsen U. Role of the posterior calf muscles in normal gait. J Bone Joint
Surg 1978;60A:465.
14. Tobin GR, Gordon JA, Smith BA, Schusterman MS. Preserving motor function by splitting muscle and
myocutaneous pedicles. Plast Surg Forum 1980;3:160.
15. Baker DC, Barton FE, Converse TM. A combined biceps and semitendinosus muscle flap in the repair of
ischial sores. Br J Plast Surg 1978;31:26.
16. Guttman L. The treatment and rehabilitation of patients with injuries of the spinal cord. In: MacNalty AS,
Cope Z, eds. British history of World War II surgery. London: His Majesty's Stationery Office, 1953;486-496.
17. Campbell RM, Delgado JP. The pressure sore. In: Converse JM, ed. Reconstructive plastic surgery.
Philadelphia: Saunders, 1977;3787.

Chapter 482
Limberg Skin Flaps
J. G. HOEHN
Trochanteric pressure ulceration is one of the least common ulcers requiring surgical repair (1). Because of
increased awareness on the part of physiatry staffs, reconstructive surgeons are often asked to see small ulcers
in this location (2). Limberg flaps are optional reconstructive choices.
INDICATIONS
Like sacral pressure ulcers and in contrast to ischial pressure ulcers, trochanteric ulcers are often found in
the bedridden patient. Successful use of the Limberg flap for reconstruction of small surgical defects over
the greater trochanter of the femur depends on variables of flap design and technical execution.
FLAP DESIGN AND DIMENSIONS
The basic principles of pressure ulcer management and Limberg flap design were covered in Chapter 465.
Evaluation of the small ulcer must include an accurate determination of the amount and location of undermining.
The cavity may be significant enough in size to dictate the choice of flap. If viable flaps cannot be fashioned from
the ulcer edges, the resultant large surgical defect will require a large flap. Our current choice is a tensor fasciae
latae musculocutaneous flap.
In each fully developed pressure ulcer, bony involvement is presumed and sought. The proximity of the greater
femoral trochanter to the fascial planes of the hip joint facilitates bacterial penetration and the development of
pyoarthrosis. Management of this significant event must be addressed at the outset, since continued drainage
from a retained contaminated joint will compromise any flap (Fig. 482.1).
OPERATIVE TECHNIQUE
Clinical examination is reinforced by a roentgenographic study with contrast material examination (sinogram) to
confirm joint involvement. Preoperative preparation is essentially the same as for sacral ulcers. Attention to hip
joint involvement and its management may require orthopedic consultation.
FIGURE 482.1 A 44-year-old woman with multiple sclerosis and severe flexion contracture of both hips. Pressure
ulcer developed in approximately 4 weeks. A: A pressure ulcer on the right hip with a rhombic excision planned
and the Limberg flap design. Note the orientation of the hip, positioned to account for maximum hip flexion prior
to surgery. The rhombic excision is offset slightly to allow the ultimate skin closure (dotted line) to coincide with

the relaxed skin tension lines (RSTL) of the lateral thigh. The nomenclature coincides with that outlined in
Chapter 465, Fig. 465.1. (Continued)
FIGURE 482.1 Continued. B: Block resection of the ulcer, including the bony base, as a single unit. Note the
increase in size of the defect, relative to part A. C: Closure completed. Note drain exiting through separate
wound.
Severe spasticity may limit patient positioning to the lateral position, enhancing the production of other pressure
ulcers. However, medical control may be difficult, and surgical correction is undertaken with the hips flexed (Fig.
482.1A).
Excision of the small trochanteric pressure ulcer includes limited resection of the greater trochanter of the femur
(Fig. 482.1B). The resultant ostectomy should be smooth and sculptured. The orientation of the Limberg flap to
the defect should allow donor-site closure to fall in or parallel to the midlateral line of the thigh (the LME; d-f in
Fig. 482.1A). Orientation may be in a posterior or superior direction, taking advantage of the convergence of the
lines of maximum extensibility on the trochanteric prominence.
CLINICAL RESULTS
The Limberg flap design has been used in 24 flap transfers (14 patients) to reconstruct small pressure ulcer
defects in 20 years. Ease of execution and minimal postoperative morbidity recommend the flap when the
defect size permits.
SUMMARY
The Limberg flap can be designed to successfully close small trochanteric pressure sores.
References
1. Agris JA, Spira M. Pressure ulcers: prevention and management. Clin Symp 1979;31:3.
2. Hoehn JG, Elliott RA, Stayman JW. The use of Limberg flaps for repairing small decubitus ulcers. Plast
Reconstr Surg 1977;60:548.

P.1303
Chapter 483
Thigh Transposition and Rotation Skin Flaps
M. B. CONSTANTIAN
EDITORIAL COMMENT
It is now well known that including the underlying fascia corresponding to the tensor fasciae latae territory
will increase the vascularity and safety of this flap.
Defects over the greater trochanter can present some unique problems. If caused by pressure, trochanteric
ulcers may reach sizable proportions and may communicate with a pyarthrosis in the hip or with nearby sacral or
ischial ulcers. Because of proximity to the hip joint and its powerful muscle groups, the trochanteric ulcer cannot
be easily managed without good control of muscle spasticity. Flexion contractures that prohibit joint movement or
positioning must be corrected before ulcer closure. Finally, because balance and positioning depend on the
function and anatomy of the hips, bony excision or disarticulation must be planned intelligently and with
forethought. Management by a number of surgical specialists may be necessary in some circumstances.
INDICATIONS
Because of the common association of bursal and joint abnormalities, trochanteric defects, especially
pressure ulcers, can have a surprisingly benign appearance for all the trouble they can cause. Gentle
probing of a wound that does not respond to conservative care may reveal a long sinus, heterotopic
calcifications, or communication with the hip joint or a nearby bursa. Such abnormalities can be investigated
by sinography and plain radiographs.
Drainage of loculated pus must be carried out prior to ulcer closure. Treatment of an involved hip joint
should be part of the preoperative plan. Unexpected bony manipulation at surgery is a sign of inadequate
diagnosis of the deformity.
If the cephalad extension of the ulcer does not communicate with the hip joint, the problem is one of
readying the wound for closure. If the ulcer communicates with the hip joint, it has been my experience that
conservative measures have not succeeded in controlling the pyarthrosis; the ultimate solution has virtually
always involved resection of the head and neck of the femur. Protracted attempts at conservative treatment
of the joint infection may lead to osteomyelitis of the acetabulum or ilium, a much more profound problem for
which there is no good surgical answer. Patients who develop this degree of bony involvement usually
require proximal disarticulation of the femur, saucerization of the acetabulum and ilium, revision or resection
of the ischium, and closure with a large, anteriorly based thigh flap (1).
ANATOMY
A number of bursae are found near the greater trochanter (Fig. 483.1) and may be involved in a nearby pressure
ulcer or traumatic defect. A large, frequently multiloculated bursa
separates the greater trochanter from the gluteus maximus; a second bursa is located between the gluteus
medius and gluteus minimus muscles; a third bursa appears between the tendons of the gluteus maximus and

vastus lateralis muscles. This is a random flap supplied by branches of the lateral femoral circumflex artery and a
superficial circumflex iliac artery.
FIGURE 483.1 Surgical anatomy of the trochanteric area. Stippled areas represent the major bursae.
FIGURE 483.2 Closure of trochanteric defect with superiorly based transposition flap.
FLAP DESIGN AND DIMENSIONS
A variety of skin and musculocutaneous flaps will reach the trochanteric area. If the defect is a pressure ulcer,
however, the surgeon is wise to select a flap that is large and thus can be advanced a second or third time to
close a secondary (recurrent) ulcer. A superiorly based transposition or rotation skin flap fills these requirements
well (2, 3, 4, 5, 6) (Fig. 483.2).

P.1304
A superiorly based skin flap can be outlined and raised at the level of the deep fascia (Fig. 483.3). The flap is
usually designed with a width of approximately 8 to 10 cm and a length of 20 to 25 cm, and it can be raised
without delay if constructed properly.
The only limitation to the use of such a flap concerns closure of the counter defect, which may require split-
thickness skin grafting if the primary defect is posterior to the trochanter. The more posterior the primary defect,
the larger the flap must be to close it. Frequently, the soft tissues posterior to the ulcer can be advanced several
centimeters anteriorly to meet the margin of the flap. When the trochanteric ulcer is anterior to the greater
trochanter, the flap is planned in the same location but should be curved anteriorly around the ulcer. The width of
the flap is determined, of course, by the size of the defect.
Generally, the anterior border of the flap runs along the anterior border of the tensor fasciae latae muscle. The
general
outline of the flap is in a quartercircle shape, which facilitates closure of the secondary defect. The narrower the
flap, the wider the arc of rotation but the harder it is to close the secondary defect. The wider the flap, the shorter
the arc of rotation but the easier it is to close the secondary defect.
OPERATIVE TECHNIQUE
The patient should lie supine on the operating table with a sandbag or rolled sheet inserted beneath the
ipsilateral buttock to elevate the trochanteric area. A superiorly based skin flap then can be outlined and raised
at the level of the deep fascia (see Fig. 483.3).
When a portion of the greater trochanter presents in the wound, some bony debridement or modification will be
necessary. Even in the case of a trochanteric pressure ulcer, it is not always necessary to excise the entire
greater trochanter. In fact, removal of the trochanter is contraindicated in nonparaplegics, because proper
insertion of the gluteus medius is critical to maintenance of a normal gait. In either case, the greater trochanter
and any other bony projections are merely leveled to provide a smooth surface that will not protrude through
whatever soft tissues are brought to cover them.

P.1305
FIGURE 483.3 A: Trochanteric pressure ulcer. Outline of excision and proposed flap. Dotted line indicates size
of cavity into which ulcer leads. B: Flap elevated, cavity lining excised, trochanter leveled. C: Transfer of flap. D:
Closure.
The secondary defect usually can be closed primarily if the flap is well designed, but it may be covered with a
split-thickness skin graft if necessary. Drainage by means of a large siliconized suction catheter is advisable.
One special point of postoperative care is that the patient should not lie on the contralateral hip because in this
position the operated side tends to flex automatically, placing tension on the wound closure. In the case of
paraplegics or quadriplegics, the patient should be repositioned every 2 to 3 hours, if feasible, alternating
between prone and semiprone positions.
A variation in this flap is the inclusion or addition of the tensor fasciae latae muscle, which, although thin, has a
predictable, proximal, dominant vascular supply. The tensor fasciae latae is routinely uncovered during elevation
of the superiorly based skin flap and thus may be added under direct vision as a separate muscle flap or raised
with the overlying skin as a musculocutaneous flap. If properly done, the donor site may still often be closed
primarily (6).
CLINICAL RESULTS
In a recent review of 50 superiorly based rotation flaps of this design (6), 72% had no complications and
18% had hematoma, defined as any amount of blood requiring at least one aspiration. Wound separation
(10%), partial flap loss (8%), and infection (4%) were less common. Although the superiorly based
transposition flap is generally reliable and well vascularized, the rate of complications in this particular

review indicates the relatively high incidence of wound complications in cord-injured patients with chronic
open wounds.
SUMMARY
The superiorly based thigh transposition flap can be used in conjunction with treatment of underlying
pyarthrosis or sinuses, to cover trochanteric pressure ulcers.
References
1. Constantian MB, Jackson HS. The complex problem. In: Constantian MB, ed. Pressure ulcers: principles
and techniques of management. Boston: Little, Brown, 1980.
2. Barker DE. Surgical treatment of decubitus ulcers. JAMA 1945;129:160.
3. Conway H, Kraissl CJ, Clifford RH, et al. Plastic surgical closure of decubitus ulcers in patients with
paraplegia. Surg Gynecol Obstet 1947;85:321.
4. Kostrubala JG, Greeley PW. The problem of decubitus ulcers in paraplegics. Plast Reconstr Surg
1947;2:403.
5. Blocksma R, Kostrubala JG, Greeley PW. Surgical management of decubitus ulcer in paraplegics: further
observations. Plast Reconstr Surg 1949;4:123.
6. Constantian MB, Jackson HS. The trochanteric ulcer. In: Constantian MB, ed. Pressure ulcers: principles
and techniques of management. Boston: Little, Brown, 1980.

P.1306
Chapter 484
Thigh Bipedicle Advancement Skin Flap
B. H. GRIFFITH
EDITORIAL COMMENT
This bipedicle random flap may, in some instances, be the only solution to the problem. However, first
choice would be a flap with a more secure circulation such as a musculocutaneous or a fasciocutaneous
flap.
Pressure sores in the region of the greater trochanter of the femur were closed for some years by means of
rotation skin flaps (1, 2); however, frequent problems with partial necrosis led to the use of a more reliable means
of closure. A bipedicle flap advanced laterally from the anterolateral thigh has proven extremely useful for the
repair of defects in this area (3, 4).
INDICATIONS
This flap is uniquely suited to the closure of an oval or round trochanteric wound (see Fig. 484.2).
ANATOMY
The blood supply of the thigh bipedicle advancement flap is derived mainly from the superficial circumflex iliac
branch of the femoral artery and the lateral circumflex femoral branch of the profunda femoris artery. They
anastomose with each other and with branches of the deep circumflex iliac artery and send perforating branches
through the tensor fasciae latae, sartorius, and rectus femoris muscles to provide a rich network of vessels in the
subcutaneous tissue and skin. Because the flap is elevated off the underlying muscle fascia, the circulation
depends on the dermal-subdermal plexus fed from both pedicles.
FIGURE 484.1 Thigh bipedicle advancement skin flap for closure of trochanteric pressure sore. The medial edge
of the flap is really farther anterior than can be shown in this two-dimensional diagram. Note the split-thickness
skin graft placed on the anterior thigh to relieve tension on the lateral suture line. Note also the resection of the

P.1307
trochanter and a little of the lateral cortex of the femur below it to avoid a new pressure point. (From Griffith, ref.
3, with permission.)
FLAP DESIGN AND DIMENSIONS
The flap consists of skin and the underlying fibroadipose tissue and is basically longitudinally oriented. Its lateral
edge is adjacent to the trochanteric defect, and its medial edge lies just lateral to the anterior superior iliac spine
proximally and to the femoral triangle on the anterior thigh distally. Its size varies with the size of the patient and
the size of the defect to be closed from 10 × 20 cm to 15 × 30 cm. A 2:1 ratio of length to width should not be
exceeded (Fig. 484.1).
When the trochanteric wound is especially large, the proximal pedicle may be somewhat narrower than the distal
pedicle because the distance between the edge of the trochanteric wound and the anterior superior iliac spine
may be short. However, the proximal pedicle should be kept lateral to the iliac spine to avoid having to put a skin
graft directly over the bone.
OPERATIVE TECHNIQUE
The flap is elevated off the underlying muscle fascia and shifted laterally to cover the trochanteric defect. When
used to repair a trochanteric pressure sore, the underlying greater trochanter should, of course, be resected
along with the ulcer, bursa, and any soft-tissue calcifications that may be present (Fig. 484.1). The stump of the
trochanter should be completely covered with a rotation flap of tensor fasciae latae or turnover flaps of fascia lata
or muscle fascia before the bipedicle flap is advanced into the wound.
FIGURE 484.2 A: Large right trochanteric ulcer with exposed bursa and bone. B: After bipedicle advancement
flap with split-thickness skin graft to close the flap donor area. C: Same area 10 years later.
This flap is particularly useful when the trochanteric ulcer is very large and has caused a separation of the
subcutaneous tissue from the underlying tensor fasciae latae muscle, thus making a musculocutaneous flap
impossible. A delay has never been necessary. A split-thickness skin graft must be placed on the anterior thigh
to cover the flap donor site to avoid tension on the important lateral suture line (see Fig. 484.2).
CLINICAL RESULTS
The success rate of this flap in my hands has been in excess of 95% both in the short term (2 weeks) and in
the long run (follow-up of 4 to 25 years). The blood supply by means of the two pedicles is so rich that I
have not had a problem with circulation in the flap.
Continuous wound suction for 2 weeks postoperatively has kept the hematoma rate to under 10%. Sutures
are left in for 2 weeks, and the patient is turned prone to supine alternately on a Stryker frame every 2
hours for 2 weeks before flexion of the hip is permitted. There has been no functional deficit.

SUMMARY
A bipedicle skin flap is a reliable method of closing trochanteric defects.
References
1. Conway H, Griffith BH. Plastic surgical closure of decubitus ulcers in patients with paraplegia: based on
experience with 1000 cases. Am J Surg 1956;91:946.
2. Griffith BH, Schultz RC. The prevention and surgical treatment of recurrent decubitus ulcers in patients
with paraplegia. Plast Reconstr Surg 1961; 27:248.
3. Griffith BH. Pressure sores. In: Grabb WC, Smith JW, eds. Plastic surgery, 3rd ed. Boston: Little, Brown,
1979; Chap. 50;818.
4. Griffith BH, Lewis VL Jr. Pressure sores. In: Goldwyn RM, ed. The unfavorable result in plastic surgery,
2nd ed. Boston: Little, Brown, 1984; Chap. 52;1073-1084

P.1308
P.1309
Chapter 485
Gluteal Thigh Flap for Reconstruction of Lateral Thigh Defects
J. BUNKIS
R. L. WALTON
D. J. HURWITZ
EDITORIAL COMMENT
The axial vessel that accompanies the posterior nerve of the thigh is not always present, thus making an
island flap design difficult or impossible; however, the peninsular flap, with either skin or only fascia as the
base, will be successful and safe, as it is supplied by branches of the cruciate anastomosis.
The gluteal thigh flap provides an excellent source of sensate tissue for defects of the proximal lateral thigh,
particularly those overlying the greater trochanter (1, 2). This flap has advantages in ambulatory patients in that
it allows repair of proximal lateral lower extremity defects without sacrifice of major lower limb muscle units.
INDICATIONS
The gluteal thigh flap can be used to cover most defects over the proximal lateral thigh. The most common
indication for its use in this region is trochanteric pressure sores and exposed total hip prostheses (see Fig.
485.3). It also can be used to reconstruct the lateral thigh or to cover the femur following tumor extirpation
for sarcomas or following localized trauma to the proximal lateral thigh.
This flap is particularly useful in the nonparaplegic patient because it provides a flap with excellent
sensibility without sacrificing important motor units. We have used both peninsular and island designs of
this flap for coverage of trochanteric defects.
ANATOMY
See Chapter 440 (Fig. 485.1).
FLAP DESIGN AND DIMENSIONS
See Chapter 440 (Figs. 485.2 and 485.3B).
OPERATIVE TECHNIQUE
See Chapter 440 (Fig. 485.3).
CLINICAL RESULTS
To date, we have employed the gluteal thigh flap for coverage of 11 lateral thigh defects. One patient
dehisced a wound over a trochanter secondary to an underlying hematoma. Another developed dysesthesia
in an island flap transferred to close a trochanteric defect, presumably as a result of tethering of the

nerve during a tight closure. Other than decreased sensibility in the donor area and occasional temporary
tightness in the thigh (resulting from donor-site closure), no functional deficits were encountered.
FIGURE 485.1 Flap anatomy. The gluteal thigh flap includes the skin, subcutaneous tissue, and femoral
fascia of the posterior thigh region. Note the relationship of the posterior cutaneous nerve to the descending
branch of the inferior gluteal artery. (From Hurwitz et al., ref. 1, with permission.)
FIGURE 485.2 Flap design. The central axis of the flap (halfway between the greater trochanter and the
ischial tuberosity) overlies the extrapelvic course of the inferior gluteal artery. The entire posterior aspect of
the thigh can be incorporated into the flap. (From Hurwitz et al., ref. 1, with permission.)

FIGURE 485.3 A: Left trochanteric pressure sore has been excised with the patient in the prone position.
B: Gluteal thigh flap design. Distal incision has been carried through the femoral fascia, and the distal
neurovascular pedicle has been identified (arrow). (Continued)
FIGURE 485.3 (Continued) C: Flap has been elevated to the inferior border of the gluteus maximus muscle.
More proximal dissection can increase flap length, but care must be taken to avoid placing incisions over
the ischial tuberosity, as to do so may predispose the patient to pressure sores in this area. D: The
interposing skin bridge has been divided and the peninsular flap inset into the trochanteric defect. A split-
thickness skin graft was employed to avoid a tight closure in this thin male patient.
The gluteal thigh flap has proven quite reliable if designed and elevated with care. All the complications
encountered thus far were avoidable and not the result of intrinsic pitfalls in flap anatomy or design.
SUMMARY
The inferior gluteal thigh flap can be used to close trochanteric pressure ulcers and is especially useful in
nonparaplegic patients.
References
1. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable sensate flap for the closure of
buttocks and perineal wounds. Plast Reconstr Surg 1981;68:521.
2. Walton RL. The inferior gluteal thigh flap. In: Mathes SJ, Nahai F, eds. Clinical applications for muscle
and musculocutaneous flaps. St. Louis: Mosby, 1981.

P.1310
Chapter 486
Total Thigh Flap
G. S. GEORGIADE
EDITORIAL COMMENT
This is a useful procedure that was more common in the past. Currently, better management and/or
prevention of pressure sores have decreased its use.
The total thigh flap has been successfully applied to manage difficult recurrent pressure sores for more than 30
years (1, 2, 3, 4, 5). This flap is particularly useful in paraplegic patients with large, multiple, recurrent ulcers or
for large trochanteric ulcers associated with pyarthrosis of the hip joint and widespread osteomyelitis of the femur
and pelvis.

P.1311
FIGURE 486.1 Diagrammatic representation of the steps in the operative procedure.
INDICATIONS
With the development of versatile regional musculocutaneous flaps, the application of the total thigh flap is
currently limited to the patient with ulceration around the hip, sacral, or ischial regions who does not have
available musculocutaneous flaps or whose ulcer is so massive that no regional flap is of sufficient
dimensions to resurface the defect.
The total thigh flap will provide a significant amount of tissue for closure of large defects in the trochanteric
region. The flap may be extended below the knee to cover combined defects in the ischial, trochanteric, and
sacral regions. The flap should be designed so that the thigh muscles can be maximally used. If recurrent
ulceration develops in the same region, the femur may be further shortened and the flap advanced
superiorly for coverage. The thigh flap is a relatively safe procedure, is not technically difficult, and is
reliable when executed properly.

OPERATIVE TECHNIQUE
Patients undergoing this procedure should be monitored with extreme care because of vasomotor instability.
Substantial blood loss should be anticipated, and transfusion should be initiated at the onset of surgery.
The incision is marked on the midlateral aspect of the femur and extends from the trochanteric region to the level
of the knee. The incision is begun superiorly and is extended inferiorly along the femur and then circumferentially
around the knee just above the patella or below the patella if a longer flap is required (Fig. 486.1A). The popliteal
vessels are identified in the popliteal fossa and are ligated. After the tibial and peroneal nerves are ligated and
divided, the dissection is carried along the lateral intermuscular septum, located along the lateral border of the
long head of the biceps muscle, and is extended superiorly. The incision along the lateral muscular septum is
relatively avascular and provides a cleavage plane between the biceps femoris muscle and the vastus lateralis
muscle. The quadriceps and hamstring muscles are divided, and the dissection is extended subperiosteally,
completely freeing the femur from the muscle mass of the thigh (Fig. 486.1B). By remaining in close proximity to
the femur, the superficial femoral artery, the essential blood supply to the thigh flap, is avoided (Fig. 486.1C-K).
In patients not requiring resection of the femoral head, acetabulum, or pelvis for control of osteomyelitis, a
segment of femur 8 to 12 cm below the greater trochanter is preserved to provide adequate stability and balance
when the patient is in the sitting position.
If disarticulation is necessary, the subperiosteal dissection is extended to the level of the greater trochanter. The
gluteus maximus muscle is retracted superiorly, and the external rotator muscles are divided, exposing the hip
joint. The disarticulation is accomplished at the joint level after incising the joint capsule, retracting the femoral
head laterally, and then ligating and transecting the ligamentum teres. At the subperiosteal level, the dissection is
extended by releasing all the muscular attachments to the femur. The entire femur and the portion of the lower
extremity to be discarded are now detached from the thigh flap (Fig. 486.1H-J).
The dissection as described is altered when there is extensive osteomyelitis or pyarthrosis of the hip joint.
Extensive resection of the affected bone, including the acetabulum and ischium, is often necessary as part of the
dissection.
The distal end of the flap is then rotated into the defect, and the deeper layers are sutured, progressively
approximating the flap to the underlying musculature in multiple layers. Two suction drains are inserted into the
depths of the wound for a period of 4 to 6 days.
CLINICAL RESULTS
The most common postoperative problem is hematoma, especially in patients requiring extensive resection
of the pelvis. Postoperative infection is also common and is probably due to fecal contamination of the
wound. Sinus tracts are frequent in patients with pyarthrosis and osteomyelitis of the hip joint. Partial wound
separation is also common, and secondary wound closure may be necessary. Recurrent urinary tract
infections, hydronephrosis, and acute pyelonephritis are constant possibilities during the postoperative
period.
SUMMARY
The thigh flap is useful when regional musculocutaneous flaps are not available for the management of
extensive tissue necrosis in the paraplegic patient.

References
1. Georgiade N, Pickrell K, Maguire C. Total thigh flaps for extensive decubitus ulcers. Plast Reconstr Surg
1956;17:220.
2. Berkas EM, Chesler MD, Sako Y. Multiple decubitus ulcer treatment by hip disarticulation and soft-tissue
flaps from the lower limbs. Plast Reconstr Surg 1961;27:618.
3. Spira M, Hardy SB. Our experience with high thigh amputations in paraplegics. Plast Reconstr Surg
1963;31:344.
4. Steiger R, Curtiss P. The use of a total thigh flap procedure for chronic infection of the hip joint. J Bone
Joint Surg 1968;50:1429.
5. Royer J, Pickrell K, Georgiade N, et al. Total thigh flaps for extensive decubitus ulcers: a 16-year review of
41 total thigh flaps. Plast Reconstr Surg 1969;44:109.

P.1313
Chapter 487
Gluteus Maximus Muscle and Musculocutaneous Flaps
R. L. MILLS
The gluteus maximus muscle flap is used to repair defects centered over the trochanter, such as typical pressure
sores, although use of the gluteus musculocutaneous flap is limited because of other more suitable repairs.
ANATOMY
The gluteus maximus muscle arises from the posterior part of the ilium, the posterior surface of the lower sacrum,
and the side of the coccyx. It passes downward and laterally to insert into the iliotibial band and the gluteal
tuberosity of the femur. Its blood supply is from the superior and inferior gluteal arteries that emerge from the
pelvis through the greater sciatic foramen above and below the piriformis muscle (Fig. 487.1). Both arteries
arborize on the inferior surface of the muscle before penetrating to supply the muscle and overlying skin. The
superior gluteal artery passes beyond the gluteus maximus to supply the gluteus medius and minimus muscles.
The inferior gluteal artery extends beyond the muscle to supply much of the posterior thigh skin.
FIGURE 487.1 Vascular supply of gluteus muscle.
Use of the muscle or a musculocutaneous flap designed to repair trochanteric defects takes advantage of a rich
blood supply from the inferior gluteal artery and the vascular contribution to the area from the medial and lateral
femoral circumflex and first perforating arteries (the cruciate anastomosis of Henry) (1). In a defect centered over
the trochanter (such as a typical pressure sore), a portion of the gluteus muscle passes beyond (distal and
posterior to) the defect with its blood supply intact.
FLAP DESIGN AND DIMENSIONS
That portion of the gluteus that passes beyond the defect with its blood supply intact and with or without its
overlying skin can be rotated laterally and cephalad to cover the trochanter. The surface design can be circular
as a rotation flap (Fig. 487.2) or rectangular if a skin graft is anticipated. A distally based muscle flap of the
inferior half of the gluteus muscle can be turned over to cover trochanteric defects (2).

FIGURE 487.2 Rotation flap design.
OPERATIVE TECHNIQUE
The dissection usually begins from within the defect where the margin of the muscle can be seen after excision
of the tissue lining the defect (3). The insertion of the muscle is carefully freed from the femur. The perforating
vessels will be found just behind the insertion in fatty tissue. Some of these may be divided, if necessary, to gain
additional mobility of the flap. A distally based muscle flap depends on the cruciate anastomosis, since the
inferior gluteal artery must be divided proximally in the reflection of the flap. The muscle is covered with a skin
graft to complete the repair.
CLINICAL RESULTS
Experience with this variant of the gluteus musculocutaneous flap is limited because of other suitable
repairs.
SUMMARY
The gluteus muscle and musculocutaneous flap can be used for coverage of trochanteric pressure sores. It
can be based proximally on the inferior gluteal blood supply or distally on the cruciate anastomosis.
References
1. Henry AK, ed. Extensile exposure, 2nd ed. Edinburgh: Churchill- Livingstone, 1970.
2. Becker H. The distally based gluteus maximus muscle flap. Plast Reconstr Surg 1979;63:653.
3. Minami RT, Mills RL, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast
Reconstr Surg 1977;60:242.

P.1314
Chapter 488
Vastus Lateralis Muscle Flap
R. L. MILLS
EDITORIAL COMMENT
The vastus lateralis is a good muscle to fill in defects along the trochanter or ischium. It should be kept in
mind following excision of deep pressure sores in these areas.
The vastus lateralis is not suitable for musculocutaneous flaps. Its most common use has been in muscle flaps
for trochanteric pressure-sore repairs in patients with spinal cord injuries (see Fig. 488.2). It is available for
defects of whatever cause in the middle and upper thigh and hip region that need to be filled with vascular
tissue, where a subsequent skin graft as cover would be satisfactory (1).
FIGURE 488.1 Vastus lateralis muscle with location of vascular pedicle.
FIGURE 488.2 Trochanteric defect repaired with vastus lateralis muscle flap with skin graft.
ANATOMY
The vastus lateralis muscle arises from a broad aponeurosis that is attached to the intertrochanteric line, to the
anterior and inferior borders of the greater trochanter, to the lateral lip of the gluteal tuberosity, and to the upper
half of the linea aspera. It inserts through a flat tendon into the lateral border of the patella, blending with the
quadriceps femoris tendon.
The blood supply is from the lateral femoral circumflex vessels that enter the medial edge of the muscle

approximately a hand's breadth below the greater trochanter (Fig. 488.1). The overlying skin is part of the tensor
fasciae latae vascular territory.
OPERATIVE TECHNIQUE
The medial border of the muscle is exposed through a longitudinal incision along a line between the anterior
superior iliac spine and the lateral border of the patella. The muscle is beneath the fascia lata, which is incised
along the same line. The vastus is then separated from the rectus femoris, taking care to avoid the
neurovascular bundle. If necessary, the origin also may be divided if it facilitates placing the muscle into the
defect to be repaired. The superficial surface of the muscle is most suitable for accepting a skin graft (Fig.
488.2). The muscle is sutured to the margins of the defect and covered with a skin graft of intermediate
thickness.
CLINICAL RESULTS
With use of the vastus lateralis muscle flap, complications are unusual. The use of a normal muscle does
not seriously affect use of the leg because the other parts of the quadriceps continue to act as strong knee
extensors. An occasional skin graft has failed and required secondary replacement. Vascularity of the
muscle is dependable. Some atrophy of the muscle can be expected, and there is a difference of opinion as
to the implications of this problem with regard to durability of repair. Many of these repairs have stood up
well over many years in paraplegic patients.
SUMMARY
The vastus lateralis muscle flap can be used to cover trochanteric pressure sores. The muscle must be
covered with a split-thickness skin graft, as this flap does not have an associated cutaneous territory.
Reference
1. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;482-483.

P.1316
Chapter 489
Tensor Fasciae Latae Musculocutaneous Flap
T. R. STEVENSON
F. NAHAI
A pressure sore centered at and involving the greater trochanter is amenable to closure with a tensor fasciae
latae musculocutaneous flap (1, 2, 3). Skin flaps alone often do not provide stable coverage of this sore.
ANATOMY
The tensor fasciae latae (TFL) is a short, flat muscle of the lateral thigh 12 to 15 cm long. It is invested by two
layers of the iliotibial tract that is continuous with the fascia lata. The muscle serves as an accessory flexor and
medial rotator of the thigh.
The anterior aspect of the outer lip of the iliac crest, the lateral surface of the anterior superior iliac spine, and
the deep surface of the fascia lata give origin to the TPL. At its origin, the TFL lies between the gluteus medius
and sartorius muscles, superficial to the vastus lateralis and lateral to the origin of the sartorius. The muscle
blends with and inserts into the fascia lata in the middle third of the thigh.
The TFL is nourished by a single major vessel that is predictable in location: the transverse branch of the lateral
femoral circumflex artery (Fig. 489.1). The branch usually arises from the deep femoral artery, although it may
originate from the common femoral artery. It emerges from beneath the rectus femoris muscle, anterior to the
vastus lateralis. The artery enters the muscle on its deep (medial) surface 6 to 8 cm from the anterior superior
iliac spine. The vessel is 2 to 3 mm in diameter at its origin. Venous drainage is accomplished by venae
comitantes measuring 1.8 to 2.5 mm in diameter and closely associated with the major artery.
On entering the TFL, the artery branches into vessels that run parallel to the muscle fibers and send perforators
to the skin. A descending artery continues beyond the muscle to supply skin of the anterolateral midthigh and
part of the lower thigh. Skin overlying the muscle is supplied by numerous musculocutaneous perforators. Axial
musculocutaneous perforators extend a considerable distance beyond the muscle, increasing the TFL skin
territory.
The motor nerve to the TFL is an inferior branch of the superior gluteal nerve (L4 and L5). It emerges between
the gluteus maximus and gluteus medius muscles and pierces the deep surface of the muscle.
The skin territory of the TFL is supplied by two sensory nerves. The lateral cutaneous branch of the twelfth
thoracic nerve exits between the internal and external oblique muscles in the anterior axillary line. It descends
across the iliac crest approximately 6 cm behind the anterior superior iliac spine. This nerve supplies skin over
the iliac crest and upper portion of the TFL. The lateral cutaneous nerve of the thigh is a branch of the second
and third lumbar nerves. It enters the thigh below the inguinal ligament, passes 1 to 2 cm medial to the anterior
superior iliac spine, and runs in a plane on the surface of the sartorius. It provides sensibility to the skin of the
anterolateral thigh.
FLAP DESIGN AND DIMENSIONS
The TFL musculocutaneous flap commands a skin territory of up to 600 cm2 (15 ×14 cm), representing a skin
area three times as large as the surface of the muscle. A line 10 to 15 cm
long drawn on the skin over the iliac crest, beginning at the anterior superior iliac spine and passing posteriorly,

marks the origin of the TFL muscle. The skin territory extends at least 2 cm above this line. The lower border of
the skin territory is 8 cm above the lateral femoral condyle. A line drawn from the greater trochanter distally to the
head of the fibula marks the posterior margin of the skin territory. Anteriorly, the skin island can be carried to a
line overlying the midportion of the rectus femoris muscle. The skin, muscle, and underlying fascia are elevated
as a unit based on the dominant vascular pedicle. The pedicle determines the point of rotation and is located 6 to
8 cm below the anterior superior iliac spine.
FIGURE 489.1 Fascial anatomy and potential areas of coverage of the tensor fasciae latae musculocutaneous
flap.
OPERATIVE TECHNIQUE
The ulcer and its bursa are excised. The prominence of the greater trochanter is removed with an osteotome. A
TFL flap is outlined (Fig. 489.2), raised, and rotated posteriorly over the defect (Fig. 489.2B). The donor site is
closed primarily, or a split-thickness skin graft is applied. The patient is allowed to bear weight on the flap 3
weeks postoperatively (Fig. 489.2C).
The first step in raising the TFL flap is outlining the desired skin island. An incision is made through the skin,
subcutaneous tissues, and fascia lata at the distal skin border. Temporary sutures are placed between the
dermis and the fascia lata to prevent dislodging the skin. The anterior and posterior skin borders are incised
distal to proximal through the fascia lata. The dissection is carried from the distal end of the flap proximally in a
plane deep to the fascia lata overlying the vastus lateralis. If the unit is to be used as a rotation flap to cover the
greater trochanter, the vascular pedicle need not be identified. The tissues are dissected proximally until enough
is raised for rotation into the defect.
If an island flap is planned, the vascular pedicle must be identified. The plane deep to the fascia lata and TFL is
followed proximally until the vessels are seen entering the TFL 6 to 8 cm below the anterior superior iliac spine.
Just before it enters the TFL, the lateral femoral circumflex artery gives off a superior branch to the gluteus
minimus muscle. This branch may be divided. Once the pedicle is identified, the skin incisions are completed and

the origin of the TFL muscle is dissected free of the iliac crest. The TFL muscle is also released from its
attachments to the gluteus minimus muscle. The donor site of the TFL musculocutaneous flap is closed primarily
or, if too large for direct closure, covered with a split-thickness skin graft.
CLINICAL RESULTS
Complications have occurred with the use of this procedure. Infection in the operative site is treated by
drainage and systemic antibiotics. Necrosis of the distal portion of the flap may result if the skin-island
length exceeds the design limits. If bleeding of the dermis is sluggish at the time of operation, fluorescein is
given and ultraviolet light is used to assess skin circulation. Any areas that do not fluoresce are excised.
Use of the TFL muscle in a flap results in little functional deficit. The muscle is a minor accessory flexor and
medial rotator of the thigh, and its loss is well tolerated.
SUMMARY
The TFL flap will reliably cover an excised trochanteric pressure sore. A recurrence of the sore can be
anticipated if prolonged and excessive pressure is applied to the site.
FIGURE 489.2 A: Outline of tensor fasciae latae musculocutaneous flap. B: Elevation and beginning
rotation of tensor fasciae latae musculocutaneous flap. C: Healed tensor fasciae latae musculocutaneous
flap seen 3 months postoperatively.

References
1. Hill H, Nahai F, Vasconez L. The tensor fascia lata musculocutaneous free flap. Plast Reconstr Surg
1978;61:517.
2. Nahai F, Silverton J, Hill H, Vasconez L. The tensor fascia lata musculocutaneous flap. Ann Plast Surg
1978;1:372.
3. Nahai F, Hill H, Hester TR. Experiences with the tensor fascia lata flap. Plast Reconstr Surg 1979;63:788.

Chapter 490
Proximal Tfl (Gluteus Medius-Tensor Fasciae Latae)
Musculocutaneous Flap
J. W. LITTLE III
J. R. LYONS
The proximal TFL flap is recommended for the repair of uncomplicated defects around the trochanter. It is based
on the forgotten proximal portions of the tensor fasciae latae muscle and its neighboring gluteus medius muscle,
providing closure through the principle of rotation advancement.
It uses an area previously unused in the musculocutaneous repair of pressure sores, an area that remains
unavailable to other pressure-sore sites. It transfers a bulky muscle pad of gluteus medius to the exact ostectomy
site and presents a secondary defect that is readily closed from a remote and unscarred secondary area. Its use
spares other flaps of the region and retains in reserve such major reconstructive units as the traditional tensor
fasciae latae musculocutaneous (1, 2, 3, 4, 5) and vastus lateralis (6, 7) muscle flaps for future needs.
INDICATIONS
We consider it our flap of choice for closure of uncomplicated primary and secondary defects of the
trochanter (see Fig. 490.3). In this role it surpasses the thin, conventional TFL flap by bringing in a
considerable muscle pad where desired and by rarely, if ever, requiring a skin graft. We continue to use the
conventional TFL flap where tandem defects exist over the ischium or sacrum. We prefer the vastus
lateralis system to obliterate a complex dead space, especially where the hip joint has been involved.
ANATOMY
The narrow tensor fasciae latae muscle arises from a short segment of the outer lip of the iliac crest immediately
behind the anterior superior iliac spine. It descends vertically some distance before inserting into the tough
iliotibial tract of the lateral thigh. Immediately deep and posterior arises the broad gluteus medius, whose origin
occupies essentially the entire sweep of the outer crest as well as the posterior half of the external iliac wing
below the crest. Finally, deep to both arises the gluteus minimus from the anterior half of the remaining iliac wing
to insert, with the medius, into the superior aspect of the greater trochanter of the femur (Fig. 490.1).
The blood supply of the tensor fasciae latae muscle and fascia is well described (3, 4). The lateral circumflex
femoral artery of the profunda femoral system gives off a major ascending branch that terminates as the
dominant pedicle to the tensor fasciae latae muscle, passing between the rectus femoris and vastus lateralis
muscles to reach the tensor some 8 cm below the anterior superior iliac spine. Immediately before entering the
muscle, the artery divides into descending, transverse, and ascending branches. The descending branch
supplies an impressive territory, including the distal fascia lata and lateral integument of the thigh. The
transverse branch, which immediately gives off a small branch to the gluteus minimus, nurtures the main belly of
the muscle, and the ascending branch feeds the upper muscle and a segment of iliac crest. The blood supply of
the gluteus medius is by way of the deep branch of the superior gluteal artery of the internal iliac system. Both
the tensor fasciae latae and the gluteus medius muscles are innervated by the superior gluteal nerve.
Apparent inconsistencies arise when considering the anatomy of the tensor fasciae latae muscle, causing
confusion in its classification (4). We prefer to think of this strange little mongrel as sharing anatomic traits,

P.1318
functions, and vascular supplies with both the lateral group of femoral muscles acting at the hip (glutei) and the
anterior group of femoral muscles acting at the knee (sartorius, quadriceps). We consider the tensor as squarely
occupying that common vascular territory joining the internal and external iliac systems as they anastomose
about the hip. Seen this way, both the superior and inferior rami of the deep branch of the superior gluteal artery
anastomose freely with the terminal ascending branch of the lateral circumflex femoral artery through the region
of the tensor and minor gluteus muscles. Certainly, when separating the tensor along its posterior border from
the gluteus medius, rich vascular connections must be divided. It is this generous collateral flow around the hip,
we contend, that allows inclusion of a major portion of gluteus medius muscle as a true nutritive
musculocutaneous extension of the anteriorly supplied tensor fasciae latae muscle in the flap to be described.
FLAP DESIGN AND DIMENSIONS
The flap can measure from 15 cm or more in width to 20 cm in length, with its base falling along a line joining the
greater trochanter to the estimated pedicle of the TFL some 8 cm below the anterior superior iliac spine. This
latter determination also
represents the pivot point of the flap, which can be shifted laterally by backcutting (through skin and fat only)
along the base toward the trochanter. The arc of rotation includes the entire hip and trochanteric region anterior
to the gluteus maximus muscle.
FIGURE 490.1 Bony origins and insertions of TFL and gluteus muscles. (From Little and Lyons, ref. 5, with
permission.)
After appropriate preparation of the wound and ostectomy of the trochanter, the flap is outlined (Fig. 490.2).
Beginning at the posterior superior margin of the defect, a rotation arc is inscribed, rising to the height of the iliac
crest and dropping back inferior to its anterior superior iliac spine to end near the estimated location of the
pedicle of the tensor fasciae latae some 8 cm below.
This flap has not been performed on an ambulatory patient. Whereas the tensor itself remains expendable, the
gluteus medius is quite important to normal gait. As a potent thigh abductor, it pulls the pelvis toward the
trochanter of the weight-bearing leg, preventing pelvic collapse on the unsupported side while that leg is raised.
As a medial rotator, it then swings the pelvis forward as the step is executed. Although the gluteus minimus
remains to continue these functions, total loss of the gluteus medius component would likely create a

P.1319
Trendelenburg gait. For this reason, the conventional TFL flap is preferred in the ambulatory patient.
OPERATIVE TECHNIQUE
The incision is made through skin, fat, and dense gluteal aponeurosis onto muscle. Beginning anteriorly, the
narrow tensor fasciae latae is divided from the crest. A finger is now introduced around the anterior border of
gluteus medius, between its thin muscle sheet and the underlying deeply situated gluteus minimus. This sheet is
progressively divided until its thicker portion is reached over the posterior wing. Usually, the division of medius
can now swing inferiorly toward the defect. When the defect is large or posteriorly located, however, greater
portions of posterior deeper medius are included, up to but not beyond the overlapping free edge of gluteus
maximus. Anteriorly, a distinct plane exists between the gluteus medius muscle fibers and underlying dense
fascia of the gluteus minimus. Posteriorly, the gluteus medius itself must be cut across. It is here that multiple
significant branches of the superior gluteal artery are routinely divided on their way to anastomosis with the
lateral circumflex femoral system.
FIGURE 490.2 Planned incision. (From Little and Lyons, ref. 5, with permission.)
No muscles are divided beyond the anterior border of the tensor. Subcutaneous dissection proceeds with care
as the level of the anterior pedicle is approached, although the vessels themselves are not sought. The lateral
femoral cutaneous nerve, if encountered, is spared for later possible reinnervation. Rotation is now attempted
and occasionally must be aided by backcutting through skin and subcutaneous tissue alone. With rotation
complete, layered closure is performed over multiple drains.
The secondary defect resulting from this rotation transposition is a crescent-shaped area of exposed gluteus
minimus fascia anteriorly and a cut surface of gluteus medius muscle posteriorly. Rapid undermining (to the
umbilicus, if necessary) and direct advancement of the skin of the lower abdominal quadrant across the iliac
crest achieve closure. If the dense fascia over the crest has been lifted with the abdominal flap, this is advanced
and secured to the exposed fascia of the gluteus minimus with heavy sutures near the margin of the rotated flap,
allowing tension-free closure of skin and fat. Should a skin graft be required to close a portion of the defect after
advancement (an unlikely occurrence), it would lie protected in the concavity between crest and trochanter.

FIGURE 490.3 A 43-year-old woman with multiple sclerosis. A: Primary trochanteric sore with posterior
extension showing the flap design and the proposed secondary defect that will be closed by abdominal
advancement. B: Early postoperative result. (From Little and Lyons, ref. 5, with permission.)
Because the vascular pedicle has not been disturbed, the entire traditional tensor fasciae latae
musculocutaneous flap remains available for later requirements, as do virtually all useful axial flaps of the region
that have been described.
CLINICAL RESULTS
This flap has been used in eight paraplegic patients over the past 2 years (Fig. 490.3), with all flaps
surviving entirely and healing per primam. There have been no recurrences to date. Moreover, there have
been no wound or other complications in this small series.
SUMMARY
The proximal TFL flap, which includes a portion of the gluteus medius muscle, is used to close
uncomplicated defects around the greater trochanter. Its use does not preclude later use of the standard
TFL flap for the same area if necessary.
References
1. Nahai F, Silverton JS, Hill HK, Vasconez LO. The tensor fascia lata musculocutaneous flap. Ann Plast
Surg 1978;1:372.
2. Nahai F, Hill HL, Hester TR. Experiences with the tensor fascia lata flap. Plast Reconstr Surg
1979;63:788.
3. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby,
1979;63-85.
4. Nahai F. The tensor fascia lata flap. Clin Plast Surg 1980;7:51.
5. Little JW III, Lyons JR. The gluteus medius-tensor fasciae latae flap. Plast Reconstr Surg 1983;71:366.

6. Mathes SJ, Vasconez LO, Jurkiewicz MJ. Extensions and further applications of muscle flap transposition.
Plast Reconstr Surg 1977;60:6.
7. Minami RT, Hentz VR, Vistnes LM. Use of vastus lateralis muscle flap for repair of trochanteric pressure
sores. Plast Reconstr Surg 1977;60:364.

Chapter 491
Upper Transverse Rectus Abdominis Flap: The Flag Flap
R. DE LA PLAZA
EDITORIAL COMMENT
This is an excellent flap, with the donor site often hidden in the submammary area and with a long arc of
rotation, since it is based on the deep inferior epigastric vessels. The flap can easily reach the region of the
trochanter or as low as the distal third of the thigh.
This flap is a reverse of the lower transverse rectus abdominis (TRAM) flap (1, 2, 3, 4). The rectus muscle
represents a flagpole, and the skin of the upper abdomen, a flag, q.e.d., “flag flap.”
INDICATIONS
The flap is most useful for coverage of large defects in the superior abdomen, the flanks, hips, trochanteric
area, and above-the-knee amputation stumps. It can also be utilized for the anterior, internal, and lateral
aspects of the thighs, almost down to the knee and the perineal region (Fig. 491.1E).
ANATOMY
The blood supply of the flap is ensured by the inferior epigastric artery, a branch of the external iliac, which has a
caliber of 2 to 3 mm. The inferior epigastric vessel enters the distal third of the rectus abdominis muscle on its
posterior surface, where it is easily seen as it courses superiorly in a cephalic direction. Just above the
umbilicus, the artery anastomoses in what appears to be a wide network of vessels with similar branches from
the superior epigastric. This epigastric arcade is known to send perforating vessels segmentally and penetrates
the anterior rectus sheath to supply the overlying skin (Fig. 491.1B). There are also connections between the
epigastric arcade and the segmental intercostal vessels. Most of them are divided as the flap is freed for transfer.
The inclusion of a portion of the anterior rectus sheath throughout the extent of the muscle seems to be
important, in light of recent studies of the anastomotic network at the level of the fascia. The flap procedure could
be carried out using only a portion of the rectus muscle; we have done this in some cases, but only up to the
umbilicus. Above the umbilicus, the division of the muscle would enter the zone of anastomosis of both arterial
systems, making hemostasis more difficult and damaging flap irrigation. Nevertheless, the most caudal part of the
muscle can be left in place, up to where it penetrates the arteriovenous pedicle. Given the great
musculocutaneous mass of the flap, great care must be taken not to produce extreme traction on the pedicle,
which could lead to its rupture, avulsion, or elongation, with subsequent stenosis.
FLAP DESIGN AND DIMENSIONS
The flap consists of an island of skin outlined and elevated from the upper abdomen, and extending to the
submammary fold in females (Fig. 491.1A). Laterally, the island can safely extend to the anterior axillary line on
the ipsilateral side of the rectus muscle chosen and to the lateral edge of the contralateral rectus. Skin flaps of
25 to 30 cm long by 12 to 20 cm wide can be taken, depending on the amount of abdominal laxity that will allow
primary closure. The cutaneous island can be amplified with a caudal extension in the middle zone, providing

P.1321
P.1322
P.1323
more skin and modifying the form of the island, thus allowing a better adaptation to certain types of defects.
It is helpful to mark out a symmetrical area to the opposite anterior axillary line, keeping in mind that a good
portion of that skin will be discarded. Theoretically, all the skin marked from one to the other axillary line could be
utilized in its entirety by taking both rectus muscles; however, this alternative would be very rare and we have
had no experience with it. Utilization of the two halves, with their corresponding muscles, might occasionally be
indicated, particularly in the reconstruction of very extensive defects in the perineal region.
OPERATIVE TECHNIQUE
An incision is made at the lower edge of the flap, continuing to the opposite anterior axillary line. Dissection of
the skin of the lower abdomen follows. This can be done bluntly to some extent, but attention must be paid to the
segmental perforators that need to be divided between ligature clips, rather
than by electrocautery. If necessary, the umbilicus is transected and taken with the abdominal flap, or
circumscribed and later exteriorized at the proper level, as in a reverse abdominal dermolipectomy. Incision of the
remaining edges of the flap is carried out.

FIGURE 491.1 A: Superior and inferior epigastric arteries and their anastomosis in the rectus abdominis muscle.
B: Incision of the skin island and outlining of the contralateral area for excision to close the donor defect. C: The
flag flap with skin island and musculovascular pedicle. D: Closure of the defect by upward abdominal stretching.
E: Arc of rotation of the flag flap.

FIGURE 491.2 A 30-year-old female with a large tissue defect after excision of a liposarcoma on the upper
lateral aspect of the thigh and subsequent radiotherapy and radionecrosis. A: Preoperative outline of flag flap
and area to be covered on the thigh. B: The flap sutured in position, leaving part of the muscle pedicle
exteriorized. This was covered by a mesh skin graft. In this case, the pedicle was not completely covered,
because of the intense radiation damage to the skin in Scarpa's triangle. The donor area was closed primarily,
as in a reverse dermolipectomy. C: Appearance 1 month after division of the pedicle and adaptation of the skin
edges.
Flap elevation begins on the contralateral side and continues up to the midline linea alba. The skin flap on the
side of the carrier muscle is elevated to the lateral edge of the rectus muscle. At this point, the superior end of
the incision is made down to the costal margin and includes the anterior rectus sheath and the muscle insertion.
The linea alba is preserved, and the anterior rectus sheath is divided longitudinally on the ipsilateral side of the
midline, in a rectangular shape up to the lateral edge of the muscle. The underlying muscle is freed from the
posterior sheath by blunt and sharp dissection.
The abdominal flap is elevated, exposing the anterior rectus sheath, a portion of which (approximately 3 to 4 cm

wide) is included along the line of the perforating vessels. The underlying rectus muscle is lifted, completely
freeing its medial and lateral attachments. The segmental intercostal vessels are divided between ligatures, as
far as necessary. The superior portion of the rectus muscle and sheath is completely divided, with suture ligation
of the upper epigastric vessels. The flap is now free and ready to be transferred to the surgical defect (Fig.
491.1C).
In cases in which defects are situated above the inguinal folds, the pedicle will remain inside the abdominal wall.
When this limit is passed, the flap and pedicle will be exteriorized through an incision in the inferior region of the
abdomen or in the actual inguinal fold. Care must be taken not to section the inferior superficial abdominal
vessels (the superficial epigastric artery, external pudendal artery, and superficial circumflex iliac artery).
Protecting these vessels is necessary, to provide a blood supply to the upper abdominal skin, thus preventing
ischemia and necrosis. Burying the pedicle in the subcutaneous tissue under the skin of the thigh or hip may also
cause flap ischemia, due to compression. As an alternative, the pedicle may be covered with a mesh skin graft
taken from the contralateral cutaneous area that was discarded.
Although there is no significant potential for the development of a hernia in the upper abdomen, as the posterior
rectus sheath is intact, Marlex mesh or a dermal graft taken from the discarded cutaneous area can be used to
avoid epigastric softening or bulging. The mesh or dermal graft is inserted into the gap from the costal margin
along the medial and lateral remnants of the anterior rectus sheath, down to the inferior border. We have never
had a problem below the semicircular line. Most of the time, the muscle turns at that level and maintains the
integrity of this segment of the abdominal wall. The upper abdominal skin has previously been undermined, and
it is relatively simple to close the wound primarily by a reverse type of abdominal lipectomy (Fig. 491.1D). Suction
drainage is placed on both sides of the abdomen.
The patient is encouraged to ambulate during days 3 to 4 postoperatively, although the flap is closely observed
for venous congestion.
CLINICAL RESULTS
Partial or total flap necrosis is improbable; vascularization of the flag flap is excellent, and substantially
better than that of the TRAM flap because: (a) the deep inferior epigastric artery has a caliber two or three
times that of the upper artery; and (b) the flow of blood through an arterial system of larger caliber to
another of lesser caliber causes an increase in the pressure and speed of blood circulation (5), and thus
better flap perfusion. The opposite is true for the TRAM flap.
The possibility of hernia development is minimal as the posterior rectus aponeurotic sheath is preserved,
and the anterior sheath is not resected below the semicircular line. Other complications, such as hematoma
and infection, are similar in incidence to those of other procedures in this area (Fig. 491.2).
SUMMARY
The upper transverse rectus abdominis flap, with its wide arc of rotation, has numerous applications over a
wide area and is provided with more secure vascularization than the TRAM flap.
References
1. DeFranzo AJ, Nesmith RL. Reconstruction of large soft tissue defects of the lower torso with rectus
abdominis musculocutaneous flaps. Eur J Plast Surg 1990;13:26.

2. De la Plaza R, Arroyo JM, Vasconez LO. Upper transverse rectus abdominis flap: the flag flap. Ann Plast
Surg 1984;12:410.
3. Drever JM. The epigastric island flap. Plast Reconstr Surg 1977;59:343.
4. Rodrigo Cucalon M, Vinue J, Esarte J, et al. Reconstruction de los grandes defectos de la pared
abdominal con colgajos miocutaneous. Cir Plast Ibero- Latinamer 1987;13:111.
5. Bernoulli D. Hydrodinamyca, 1738. Bernoulli's equation is easy to find in modern texts on hydrodynamic
physics.

Chapter 492
Inferiorly-Based Rectus Muscle Flap in Flank Wound Coverage
B. M. GREENBERG
EDITORIAL COMMENT
For illustrations, refer to Chapter 434.
The rectus muscle flap lends itself to either superior or inferior transfer on the superior epigastric or inferior
epigastric vascular system, respectively (1).
INDICATIONS
The inferior rectus myocutaneous flap is indicated for coverage of ipsilateral defects within the lower
abdominal wall, groin, hip, and flank. Closure of large wounds in the lower back and flank in ambulatory
patients has been problematic (2, 3). Local muscle transfers, such as superior and inferior gluteal flaps, risk
the loss of hip extension and may limit ambulation (4). Substantial soft-tissue coverage to fill large
volumetric defects is often required (5).
The rectus muscle is easily mobilized and tunneled to a flank defect, thus restoring contour without undue
bulk. The muscle and skin component maintains a robust blood supply, because the flap can be based on
the dominant inferior epigastric system in an axial pattern. The rectus island flap is wellsuited for
posterolateral flank defects and has also been used for perineal reconstruction (6), closure of difficult
wounds of the upper thigh (7), and wounds of the posterior superior iliac spine (8).
ANATOMY
Skin perfusion is maximal periumbilically, based on 1- to 2-mm perforators. The flap-skin island should not be
dissected past the midline, but may be planned within 2 to 3 cm lateral to the palpable edge of the rectus muscle.
Inferiorly, it is advisable to maintain the inferior edge of the flap above the inguinal ligament.
FLAP DESIGN AND DIMENSIONS AND OPERATIVE TECHNIQUE
The inferiorly-based rectus island flap is hardy, and its excellent arc of rotation makes it a viable option when
planning the closure of a complex open wound of the pelvis, perineum, or flank. The flap can be utilized without
its accompanying skin paddle, if the added bulk of fatty tissue is a detriment to transfer or would result in an
unacceptable cosmetic outcome. In the case of muscle requirements alone, a skin graft can be applied following
transfer. The use of a liberal subcutaneous tunnel may shorten the distance of transfer. Additionally, isolating the
inferior system will facilitate coverage by lengthening the flap and increasing the arc of rotation.
The size of the defect in three dimensions, following any needed debridement, should be measured prior to flap
design. A decision to incorporate a skin island as part of the dissection will depend on the nature and depth of
the defect, the adiposity of the patient, and aesthetic considerations.
The rectus muscle should be harvested in its entire width, to incorporate the maximal number of perforating
vessels. (Denervation atrophy has been shown to result in a nonworking muscle, in any case.) The flap is raised,
identifying and preserving the inferior epigastric pedicle. Careful attention to bipolar coagulation of the muscle,

P.1325
both proximally and distally, should be paid, to obviate against later recipient-site hematoma. Small branch
vessels should be tied with fine silk, when adjacent to the proximal pedicle, to prevent injury. Identification and
ligation of the superior epigastric artery is necessary, after determining the length of muscle required. A tunnel,
passing over the lateral aspect of the inguinal ligament, may facilitate inset into flank wounds.
The donor site is usually reconstructed with Marlex mesh, which is sutured into position with 0-Tevdek under
moderate tension, after releasing the lateral portion of the external oblique muscle. Generally, suction drains are
used in both donor and recipient sites.
SUMMARY
The hardiness of the rectus island flap is well-suited for posteriolateral flank defects. Flap robustness and
an excellent arc of rotation make it a viable option when planning the closure of a complex open wound of
the pelvis, perineum, or flank.
References
1. Bentivegna PE, Greenberg BM. Use of an inferiorly based rectus muscle flap in flank wound coverage.
Ann Plast Surg 1992;22:261.
2. Hill L, Brown RG, Jurkiewicz MJ. The transverse lumbosacral back flap. Plast Reconstr Surg 1978;62:177.
3. McGraw JB, Arnold PG, eds. Atlas of muscle and musculocutaneous flaps. Norfolk, VA: Hampton Press,
1986;265-295.
4. Ger R, Levine SA. The management of decubitus ulcers by muscle transposition. Plast Reconstr Surg
58:419, 428.
5. Taylor GE, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical technique. Plast
Reconstr Surg 1983;72:751.
6. Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous
flaps. Plast Reconstr Surg 1988;81:62.
7. Gottlieb ME, Chandrosekhar B, Terz JJ, et al. Clinical applications of the extended deep inferior epigastric
flap. Plast Reconstr Surg 1986;78:782.
8. Lineaweaver WC, Buncke GM, Bentivegna PE, Buncke HJ. Subtransversalis passage of a rectus
abdominis island flap for treatment of osteomyelitis of the posterior superior iliac spine. Ann Plast Surg
1989;22:539.