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

FIGURE 513.1 The anatomy of the extensor digitorum longus and peroneus longus muscles and their
relationship to other structures.
We observed that the vascular distribution of the PL differs from that found by others (2, 3). The PeA was the
sole nutrient only in 4% of the cases dissected by us. Our dissections revealed that the pedicles are composed
of branches from two arteries: the ATA and the PeA. These originate separately from the popliteal artery;
however, it should be pointed out that the anterior tibial artery irrigates practically all the nutrient pedicles.
FIGURE 513.2 A,B: Anatomy of the peroneous longus. Note the pedicles of the PeA and anterior tibial artery
(ATA). F, fibula; M, muscle; P, pedicle of the ATA; Pe, pedicle of the PeA.
Extensor Digitorum Longus
The EDL is found in the anterior compartment of the leg (Figs. 513.1, 513.3, and 513.4). It arises from the lateral
condyle of the tibia, the upper three fourths of the medial surface of the fibula, and the anterior surface of the
interosseous membrane. Together with the extensor digitorum brevis and the expansions of the interosseous
and lumbrical muscles, it inserts in the proximal and distal phalanges of the four lesser toes. The function of the
EDL is to extend the toes and dorsiflex the foot in synergy with the other muscles. Innervation is provided by the
deep peroneal nerve.
The EDL is supplied segmentally by multiple branches that pass laterally from the ATA. Laboratory dissections of
18 cadavers demonstrated that the muscle has eight pedicles in 50% of cases, nine pedicles in 5.5%, 10
pedicles in 22%, 11 pedicles in 5.5%, and 12 pedicles in 17%. All were derived from the ATA. The most proximal
pedicle originates at an average distance of 4.68 cm from the head of the fibula, the most distal at 33.33 cm. It
should be pointed out that the muscle has three or four main superior pedicles with a diameter of 0.75 to 1.0 mm.
They leave the ATA directly, penetrating the superoposterior portion of the muscle belly. Vessels from the ATA

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penetrate the medioinferior aspect of the muscle belly after traversing through the extensor hallucis longus. At
this point, the average diameter is 0.5 mm.
With respect to the distance of the pedicle from the reference point, we found the first pedicle at a distance of
4.68 cm. This finding agrees with the findings of others (4), who reported an average distance of 5 cm. Another
important finding was that there are vessels with a wider lumen on the proximal side of the muscle, which
enables the raising of a musculocutaneous flap with a proximal pedicle of four or five perforators. The use of a
muscle flap based on the inferior pedicles has been reported (4).
Regarding the EDL, in all the cases studied, the single nutrient artery was the ATA, which furnishes a variable
number of branches or pedicles (8 to 12). These findings
differ from those of others (3), who reported 6 to 8 pedicles. Eight pedicles were found in only 50% of the cases
we dissected.
FIGURE 513.3 A,B: The extensor digitorum longus (EDL) and peroneus longus (PL) muscles. Distribution of the
nutrient pedicles. T, tibia; p, nutrient pedicles.
Statistical analysis enabled us to conclude (1) that the origin of the arterial pedicles is from the ATA and PeA; (2)
that the branches from the ATA are more proximal to the intercondyle line in relation to the branches from the
PeA; (3) that the branches originating from the ATA are shorter compared with those from the PeA; and (4) that
the external diameters of the branches from the ATA are not significantly different in cases with a single pedicle
from those with two pedicles, one from the ATA and the other from the PeA.
FIGURE 513.4 A,B: The musculocutaneous flap made up of the extensor digitorum longus and peroneus

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longus. S, skin.
FLAP DESIGN AND DIMENSIONS
The flap is outlined 2 cm from the external malleolus (Fig. 513.5), an average of 7 cm wide. The midline of the
flap should descend vertically over the lateral malleolus. Two other lines are drawn on the anterolateral and
posteromedial surfaces of the leg.
FIGURE 513.5 Design of the musculocutaneous flap.
FIGURE 513.6 A,B: Elevation and rotation of the musculocutaneous flap (F).
OPERATIVE TECHNIQUE
The incision is extended down until the tendon of the extensor digitorum is located at the level of the inferior
extensor retinaculum, between the tendons of the extensor hallucis longus and peroneus brevis muscles. The
dissection proceeds, and the four or five distal pedicles of the EDL are divided. The tendons are divided and the
flap elevated to the lower-third tibial level (Fig. 513.6). The same technique is followed with the tendon of the PL
behind the external malleolus.

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CLINICAL RESULTS
Regarding the PL, disability from loss of foot eversion is minimal. Indeed, the loss of both these muscles is
functionally and aesthetically inconsequential (Figs. 513.7 and 513.8).
SUMMARY
The EDL and the PL muscles can be combined to form a musculocutaneous flap that can be used to cover
lower-third tibial defects.
FIGURE 513.7 A: Patient with a compound fracture and exposed tibia showing the focus of the fracture
distally. B,C: Late result with integration of the musculocutaneous flap and a skin graft over the peroneus
longus. T, tibia; F, musculocutaneous flap; S, skin graft.
FIGURE 513.8 A: Patient with chronic osteomyelitis and bone sequestrum. O, focus of osteomyelitis. B,C:
Musculocutaneous flap in place 45 days postoperatively, with beginning of bone consolidation and
remission of osteomyelitis. F, musculocutaneous flap.

References
1. Maquiera N. Estado atual dos retalhos mio-cutaneous. Presented at the XVIII Congresso Brasileiro de
Cirurgia Plastica, Guarapari, 1981.
2. Mathes SJ, McCraw JB, Vasconez LO. Muscle transposition flaps for coverage of lower extremity defects:
anatomic considerations. Surg Clin North Am 1974;54:1337.
3. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
4. Arnold PG, Hodgkinson DJ. Extensor digitorum turn-down muscle flap. Plast Reconstr Surg 1980;66:599.

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Chapter 514
Extensor Hallucis Longus Muscle Flap
M. PERS
S. MEDGYESI
B. KIRKBY
Situated in the anterolateral compartment just behind the tibialis anterior, the extensor hallucis longus muscle is
often the muscle of choice to cover tibial defects with bare bone (Fig. 514.1). This is so because its belly extends
farther distally than any other muscle, close to the anterior surface of the tibia (1, 2, 3).
ANATOMY
The tendon is easily recognized when the big toe is moved passively. Proximally, the muscle is closely
connected with the tibialis anterior and the extensor digitorum longus. The extensor hallucis longus usually
receives four small branches from the anterior tibial artery that enter its tibial aspect at approximately a 4-cm
interval and a finger's breadth behind the tendon.
FLAP DESIGN AND DIMENSIONS
Because the muscle is rather thin, the size of the defect it covers should not be too large. If the muscle flap turns
out to be smaller than expected, it sometimes can be supplemented with part of the powerful belly of the tibialis
anterior muscle to cover denuded bone in the middle third of the tibia (see Fig. 514.2D). In the lower third, the
peroneus brevis may serve as a supplement (Fig. 514.1).
OPERATIVE TECHNIQUE
The muscle is mobilized by freeing its distal extent from the deep attachments (Fig. 514.2). The muscle must be
isolated by sharp and blunt excision, and finally the tendon is cut as far distally as needed. Great care should be
taken to avoid pressure on the muscle after transfer, especially if it is passed behind the tibialis anterior tendon
to reach the tibia. Sometimes resection of bone may give better space for transfer of the muscle.
CLINICAL RESULTS
Transfer of the extensor hallucis longus muscle was carried out in 16 patients, our largest group of muscle
transfers on the lower extremity. Most of the patients had previously sustained a compound fracture of the
tibia and fibula. Infection was usually present in the soft tissue and bone. A small partial necrosis of muscle
was observed in three patients. Too much tension, rather than infection, was responsible for this problem,
but in one patient, heavy streptococcal infection caused total flap necrosis.
Split-thickness skin grafts on the muscle flaps resulted in primary healing in most of the remaining 12
patients. There have been only minor functional deficits. In some patients, the distal ends of the cut tendon
have been sutured to the tibialis anterior tendon.

FIGURE 514.1 Transposition of extensor hallucis longus muscle. Diagram shows arc of rotation.

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FIGURE 514.2 A: Defect with bare bone located low in the middle third of the anterior surface of the tibia.
Incision marked. B: Tape around extensor hallucis longus muscle located between tibialis anterior in front
and extensor digitorum longus behind. C: The tendon cut. D: The scar has been excised and the muscle
flap transferred. The tibialis anterior muscle provides a supplementary cover to the proximal part of the
defect. E: The defect covered with muscle. F: Skin graft covers the muscle flap.
SUMMARY
The extensor hallucis longus muscle flap is one of the most commonly used muscle flaps for tibial defects.
References
1. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;26:313.
2. Pers M. Muscle flaps in reconstructive surgery. In: Barron JN, Saad MN, eds. Operative plastic and
reconstructive surgery, Vol. 1. London: Churchill- Livingstone, 1981;115-135.

3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;577.

Chapter 515
Peroneus Brevis Muscle Flap
M. PERS
S. MEDGYESI
B. KIRKBY
The peroneus brevis muscle flap is a good alternative to a dorsalis pedis arterial island flap, especially when the
defect is situated just proximal to the lateral malleolus (1, 2, 3).
FIGURE 515.1 Transposition of the peroneus brevis muscle. Diagram shows arc of rotation.
ANATOMY
The muscle is the nethermost of the two muscles in the posterolateral compartment of the leg. It arises from the
lower half of the lateral surface of the fibula and from the intermuscular septa. It lies between the extensor
digitorum longus anteriorly and the flexor hallucis longus posteriorly. The muscle terminates in a short tendon
that runs behind the lateral malleolus and then bends forward to end at the base of the fifth metatarsal bone.
In the area behind the lateral malleolus, the muscle is still fleshy and is crossed by the tendon of the peroneus
longus. A common synovial sheath envelops the two tendons, which are covered by the superior peroneal
retinaculum.
The blood supply is provided by small segmental branches, usually three to four in number, arising from the
peroneal artery. Another set of nutrient vessels coming off the anterior tibial artery supplies the upper part of the
muscle belly.
The nerve supply is from the superficial peroneal nerve, the lower stem of the common peroneal nerve that
winds around the neck of the fibula. The muscle's function, in common with that of the peroneus longus, is to
perform eversion and plantar flexion of the foot.

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FLAP DESIGN AND DIMENSIONS
The muscle flap, nearly 10 cm long by 3 cm wide, can be swung forward to cover the upper half of the lateral
malleolus and the adjoining part of the fibula (Fig. 515.1). A split-thickness skin graft provides the epithelial cover
(Fig. 515.2). There will be no functional loss using this muscle flap if the peroneus longus is preserved intact.
OPERATIVE TECHNIQUE
The distal portion of the muscle belly can be felt immediately behind the lower third of the fibula in front of the
Achilles tendon. Access to the muscle is by a longitudinal incision along
the posterior border of the lateral malleolus. The distal 10 to 12 cm of the muscular attachment to the fibula can
be released without compromising the blood supply to the muscle flap.
FIGURE 515.2 The complete “take” of a split-thickness skin graft on the transposed peroneus brevis muscle.
The site of the lesion is ideal for the use of the peroneus brevis muscle flap.
Having cut through the superior peroneal retinaculum, the tendon is isolated. Damage to the peroneus longus
tendon with its peritendineum, situated superficial to that of the brevis, must be avoided. The peroneus brevis
tendon should be transected as far distally as possible.
CLINICAL RESULTS
We used the peroneus brevis muscle flap twice. In both instances, the patient had a complicated fracture of
the lateral malleolus. The first patient was a 72-year-old man with a chronic ulceration, 3 cm long by 3 cm
wide, with an underlying osteitis. The second patient was a 45-year-old woman with a 2-cm-long by 3-cm-
wide ulceration with exposed bone. In both patients, the peroneus brevis flap was successful.
SUMMARY
The peroneus brevis muscle flap can be used to cover defects just proximal to the lateral malleolus.
References

1. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;26:313.
2. Pers M. Muscle flaps in reconstructive surgery. In: Barron JN, Saad MN, eds. Operative plastic and
reconstructive surgery, Vol. 1. London: Churchill- Livingstone, 1981;115-135.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;577.

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Chapter 516
The Muscular, Osteomuscular, and Free Functional Peroneus
Brevis Flap
GOETZ A. GIESSLER
ANDREAS B. SCHMIDT
EDITORIAL COMMENT
As a pedicled flap, it would be a secondary option to the soleus or gastrocnemius flaps. As a free
osteomuscular flap, it is similar to the fibular flap for mandibular reconstruction.
INDICATIONS
The distally pedicled peroneus brevis flap is a versatile flap for small to medium-sized soft-tissue and
osseous defects around the ankle. Proximally based, it covers soft-tissue and combined defects around the
middle third of the lower leg. It can be harvested as a free muscle flap and, together with a segment of
fibula, as a functional or nonfunctional muscle component in this free flap system.
FIGURE 516.1 A distally pedicled peroneus brevis flap. In the center, the pivot perforator is clearly visible
as it courses posteriorly around the fibula.
ANATOMY
The peroneus brevis muscle lies deep and distal to the peroneus longus in the peroneal compartment of the
lower leg. It originates with its proximal half from the lateral fibular face, whereas its distal half has no bony
attachments. Its tendon runs posterior to the lateral malleolus. The dual vascular supply is derived from three to
five perforators from the peroneal vessels entering through the posterolateral septum distally and two to four
perforators from the anterior tibial vessels entering the muscle proximally through the anterior septum. One
perforator is sufficient for muscle perfusion and must be microsurgically isolated for torsion-free rotation. For a
distally pedicled flap, the most commonly used perforator is found 5 to 7 cm proximal to the lateral malleolar tip
(Fig. 516.1). There are no branches to the skin (1, 2). At the syndesmosis, a connection of variable diameter
between the peroneal and the tibialis posterior vessels ( R. communicans cum a. tib. post.) often permits distal

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pediculation of the flap even when the peroneal vessels are damaged. Its single motor nerve enters proximally
and can be separated from the motor nerve to the peroneus longus muscle for up to 8 cm. Both derive from the
superficial peroneal nerve. The peroneus longus can completely maintain eversion and plantar flexion after
harvesting the brevis muscle.
FIGURE 516.2 Distally based peroneus brevis flap with typical dimensions depicting the range of action around
the ankle. Note the subperiosteal dissection off the lateral fibula.
FLAP DESIGN AND DIMENSIONS
The muscle portion has a length of 12 to 18 cm and a width of 3 to 5 cm (Fig. 516.2). The muscle bulk depends
on the patient's mobility and is considerably less in bedridden or plegic patients. An osseous segment can be
harvested underneath the muscle's origin with 2 to 8 cm length and up to one-half of the fibula's diameter in
thickness. All flaps need to be covered with skin grafts. Skin islands are not described with this flap, except when
harvested together with the fibula. The periosteal surface of the flap should always face deep into the wound.
OPERATIVE TECHNIQUE
The patient is placed in a supine or lateral decubitus position with a thigh tourniquet. The peroneus brevis lies
deep to the peroneus longus, which is retracted posteriorly. The brevis is gently released from the peroneus
longus and the anterior intermuscular septum. The motor nerve to the peroneus longus must be identified and
preserved. The muscular peroneus brevis flap is raised by subperiosteal dissection and release from the
posterior septum with ligation of unnecessary perforators. If the pivot point is distal, this dissection is performed
from proximal to distal, usually leaving the tendon of the brevis muscle intact. If rotation is planned proximally, its
tendon is cut at the ankle and the muscle is raised from distal to proximal (Fig. 516.3A and B). For a pure rotation
flap, the proximal perforators do not need to be identified (3).
For an osteomuscular peroneus brevis flap, the muscle remains attached to the fibula for transperiosteal
vascularization for the harvested bone segment. This is only the case at the proximal half of the brevis muscle,
where a semicircumferential fibula segment is cut out with the oscillating saw and raised with the flap (4) (Fig.
516.4A and B). Protective osteosynthetic plating is usually unnecessary. The muscle can also be harvested en
bloc as a free osteomusculofasciocutaneous free fibula flap for complex defects (5) or transferred free on one
perforator and vein (6) (Fig. 516.5). Donor site closure includes suturing the lower leg fascia to prevent
herniation of the peroneus longus.

FIGURE 516.3 A: Anterior tibial defect in its middle third. These defects typically can be closed with proximally
based peroneus brevis muscle flaps. B: Lateral view 6 weeks after flap closure. Note the primary donor site
closure and the appropriate contour of the flap.
CLINICAL RESULTS
In our series, 109 patients with various soft-tissue and skeletal defects were reconstructed with proximally
(n = 10) or distally pedicled (n = 98) or free microvascular (n = 1) peroneus brevis flaps. Eight patients
received a pedicled osteomuscular peroneus brevis flap. In 72.5% of cases, a stable defect closure was
achieved. In 16.5% of patients, secondary wound closure or flaps were necessary, most often due to the
avascular loss of 1 to 3 cm of the distal flap tip. Nine flaps were lost completely (8.3%). Seven of eight
osteomuscular flaps demonstrated stable bony healing (Fig. 516.4B) and full weight bearing was achieved.
No relevant donor site complications were seen (6). Persistent loss of function after peroneus brevis flap
harvest has not been described in the literature (7, 8).
A free microvascular peroneus brevis was harvested as a neurotized functional muscle component in a
composite osteomusculocutaneous flow-through fibula flap (Fig. 516.5A). The flap components were used
to reconstruct extensive radius and soft-tissue defects in a mangled forearm. Here, the peroneus brevis
nerve was coapted to the proper flexor carpi radialis (FCR) motor nerve to counterbalance ulnar abduction,
as all radial abductors were lost in the injury.
Thirteen months later, the arm was fully reconstructed and an active radial abduction of 15 degrees by the
contracting peroneus muscle was achieved (Fig. 516.5B). Donor site complications were absent (5).
FIGURE 516.4 A: Complete harvest of a distally based osteomuscular peroneus brevis flap with a segment
of fibula attached. These vascularized pedicled composite flaps work well for calcaneal defect
reconstruction. B: Healed fibular component of the osteomuscular peroneus brevis flap for a calcaneal
defect reconstruction.
The peroneus brevis can expand the versatility of the peroneal vessel flap system as a third muscular
component in four possible ways: (a) addition of plain muscle bulk in the middle and lower third of the fibula

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if left attached to the bone, (b) as a reinnervated functional muscle, (c) as a distally based muscle
component if released from its origin from the middle third of the fibula and pedicled on its distal segmental
branches from the peroneal vessels, or (d) as a distally pedicled osteomuscular flap permitting individual
placement of a middle fibula segment (5).
SUMMARY
Pedicled or free muscular and osteomuscular peroneus brevis flaps are versatile workhorses to cover
defects in the lower leg and ankle with a very low donor site morbidity and good aesthetic outcome (Fig.
516.6). In distally pedicled flaps, primary trimming of the proximal flap tip for 2 to 3 cm is recommended due
to unreliable vascularization. Together with a fibular segment, it can be harvested as a third functional or
nonfunctional muscle component in the peroneal compound flap system.
FIGURE 516.5 A: Chimeric flap composed of a free osteofasciocutaneous fibula en bloc with the peroneus
brevis flap attached. Note the very long motor nerve to this muscle. B: Successful counterbalance of severe
ulnar abduction by the contracting peroneus brevis (black asterisk) in its flexor carpi radialis function.
FIGURE 516.6 Denervation during harvest and secondary contracture of the skin graft usually results in a
very good shape of the flap. Around the ankle, this often permits wearing of normal shoes.
References

1. Yang YL, Lin TM, Lee SS, et al. The distally pedicled peroneus brevis muscle flap anatomic studies and
clinical applications. J Foot Ankle Surg 2005;44:259-264.
2. McHenry TP, Early JS, Schacherer TG. Peroneus brevis rotation flap: anatomic considerations and
clinical experience. J Trauma 2001;50: 922-926.
3. Pers M, Medgyesi S, Kirkby B. Peroneus brevis muscle flap. In: Strauch B, Vasconez LO, Hall-Findlay EJ,
et al., eds. Grabb's Encyclopedia of Flaps, Vol. 3, 3rd ed. Philadelphia: Wolters Kluwer/Lippincott Williams &
Wilkins, 2009;1408-1409.
4. Giessler GA, Schmidt AB. Muscular and osteomuscular peroneus brevis flaps. Oper Orthop Traumatol
2013;25:131-144.
5. Giessler GA, Schmidt AB. The functional peroneus brevis as a third muscle component in the
osteomyocutaneous fibula free-flap system. J Plast Reconstr Aesthet Surg 2013;66:e137-e140.
6. Schmidt AB, Giessler GA. The muscular and the new osteomuscular composite peroneus brevis flap:
experiences from 109 cases. Plast Reconstr Surg 2010;126:924-932.
7. Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: a new flap for the
lower leg. Plast Reconstr Surg 2001;107:1443-1448.
8. Lorenzetti F, Lazzeri D, Bonini L, et al. Distally based peroneus brevis muscle flap in reconstructive
surgery of the lower leg: postoperative ankle function and stability evaluation. J Plast Reconstr Aesthet Surg
2010;63:1523-1533.

Chapter 517
Peroneus Longus Muscle Flap
M. PERS
S. MEDGYESI
B. KIRKBY
The peroneus longus muscle can be used to fill cavities in the upper lateral part of the tibia (see Fig. 517.2). It
can be used as an alternative to the coleus to cover smaller defects on the middle anterior surface of the leg (1,
2, 3). This relatively thick muscle has been satisfactorily used to fill a 6-cm defect in the tibial condyle.
ANATOMY
The peroneus longus muscle is located in the upper half of the anterolateral side of the leg in the superficial
muscle layer. It arises from the head and upper part of the shaft of the fibula, the deep surface of the fascia, and
the intermuscular septa. The relatively thick muscle belly terminates in a long tendon in the middle of the calf
(Fig. 517.1). The peroneal artery gives off perforating branches to this muscle, usually three in number. The
function of the muscle is eversion and plantar flexion of the foot.
OPERATIVE TECHNIQUE
To approach the muscle, an incision is made on the anterolateral surface of the leg. After dividing the tendon, the
flap can safely be dissected to the upper third of its length (Fig. 517.2).
CLINICAL RESULTS
If the peroneus brevis (and tertius) is intact, foot eversion should not be impaired after peroneus longus
transfer. We used this relatively thick muscle to fill a 6-cm defect in the tibial condyle. The patient had
sustained a comminuted fracture with subsequent osteitis. Several curettings of the cavity and transfers of
bone chips had been undertaken without success. The patient had no loss of function. We have had no
further opportunity to use this muscle.
SUMMARY
The peroneus longus muscle can be used to cover defects in the upper third of the leg.

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FIGURE 517.1 Transfer of the peroneus longus muscle. Diagram shows arc of rotation.
FIGURE 517.2 A: Cavity in the lateral condyle of the tibia following osteitis. B: The peroneus longus
muscle mobilized. C: The muscle flap ready to enter the cavity in the bone. D: Percutaneous transfixation

suture keeps muscle in position; suction drainage and no dressing; small split-thickness skin graft to
residual skin defect over transposed muscle.
References
1. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg
1973;313:1973.
2. Pers M. Muscle flaps in reconstructive surgery. In: Barron JN, Saad MN, eds. Operative plastic and
reconstructive surgery, Vol. 1. London: Churchill- Livingstone, 1981;115-135.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982;565.

Chapter 518
Free Groin Flap
D. SERAFIN
C. H. MANSTEIN
EDITORIAL COMMENT
Although the groin flap was the first unit applicable to transfer by microvascular surgery, the difficulty in
execution has led to a choice of free muscle or musculocutaneous units.
Historically, the groin flap was one of the first flaps used in microsurgical composite-tissue transplantation (1, 2).
Once the anatomic basis for this flap was established, demonstrating a self-contained arteriovenous system (3),
the flap was first employed as an alternative to the abdominal tubed pedicle flap. The next logical step was to
transplant this vascularized donor tissue to a distant recipient site.
INDICATIONS
The greatest advantage of the vascularized groin flap is in the concealment of the donor deformity, even by
a brief bathing suit. A defect up to 10 cm wide can easily be closed primarily. Flaps of greater dimension
require a split-thickness skin graft to cover the donor defect, negating the primary advantage for selecting
this flap as donor tissue.
A portion of the iliac crest may be included with the cutaneous portion if a segment of bone is required in
reconstruction. Viability of the bone is maintained through its periosteal circulation. If the medial portion of
the flap is excluded, the groin flap consists of non-hair-bearing tissue suitable for reconstruction in exposed
areas.
The vascularized scapular flap (see Chapter 573), with its long vascular pedicle and vessel size of
adequate external diameter, has replaced the vascularized groin flap as the donor tissue of choice when
cutaneous cover alone is required in reconstruction.
ANATOMY
The vascular anatomy of the groin flap is well documented (3, 4, 5). Unfortunately, considerable vascular
variability has contributed to unacceptably high flap failure rates (6). Anatomic dissections support these clinical
observations.
The vascular basis for the vascularized groin flap is the superficial circumflex iliac artery. The external diameter
of this vessel is approximately 1 mm. It arises as a separate branch from the femoral artery approximately two to
three finger breadths inferior to the intersection of the femoral artery and inguinal ligament. The arterial length is
usually quite short, often less than 1 cm (Fig. 518.1).
Frequently, a short distance from its origin from the femoral artery, the superficial circumflex iliac artery sends a
muscle branch to the sartorius muscle. The artery then continues as a direct cutaneous artery laterally to
terminate in multiple branches inferior to the anterior superior iliac spine. From this point laterally, the arterialized
flap becomes a random one. It is not uncommon to find that the superficial circumflex iliac artery is duplicated,

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takes origin from a common trunk with the superficial inferior epigastric artery, or takes origin from the lateral
circumflex femoral artery. Occasionally, the artery may be totally absent. When this occurs, the dominant blood
supply to this cutaneous region is often from branches of the superficial inferior epigastric artery.
The venous drainage is more constant than the arterial blood supply. Frequently, small venae comitantes
accompany the superficial circumflex iliac artery. Most often, however, these veins are too small in external
diameter to be used in reestablishing venous continuity. The superficial drainage vein of the flap is most
frequently employed. It has an external diameter of 1.5 to 2.5 mm and a length of 2 to 3 cm. It most frequently is
found entering the termination of the greater saphenous vein just prior to its junction with the deep femoral vein
in the fossa ovalis. Close to its junction to the saphenous vein, a valve system is almost always present.
Although the lateral cutaneous nerve of the thigh is often transected during dissection, the vascularized groin flap
has not been successfully employed as a neurosensory flap.
FLAP DESIGN AND DIMENSIONS
Prior to flap dissection, a line corresponding to the course of the superficial circumflex iliac artery is outlined on
the skin approximately 2.5 cm inferior to and parallel to the inguinal ligament. This line serves as a central axis of
the flap. The flap then is outlined approximately 10 cm wide and 25 to 30 cm long. If a greater length of the flap is
required, then a previous delay of the random portion is indicated.
FIGURE 518.1 Intraoperative photograph demonstrating origin of the superficial circumflex iliac artery from a
common trunk (instrument left). Note the short arterial length, often less than 1 cm. The superficial drainage vein
of the flap (instrument right) is more constant than the arterial blood supply. Note that the superficial drainage
vein joins the termination of the greater saphenous vein just prior to its junction with the deep femoral vein in the
fossa ovalis.
OPERATIVE TECHNIQUE
By first determining the feasibility of transfer with a medial exploratory incision, there is the additional advantage
of easy access to the contralateral groin with a minimum of dissection, reducing the length of the operative
procedure. A medial curvilinear incision is first made overlying the femoral artery and vein (7) (Fig. 518.2A). A
deeper dissection exposes first the superficial drainage vein at its junction with the saphenous bulb in the fossa
ovalis. The dissection then is continued laterally and superiorly to the femoral artery, where the origin of the
superficial circumflex iliac artery is identified (Fig. 518.2B). This medial dissection takes approximately 1 to 1½
hours. Because of the frequent finding of vascular variability, this maneuver allows assessment of the suitability

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of the vasculature prior to transfer and minimizes lost time. If the medial dissection reveals that the donor
vasculature is unsuitable for anastomosis, then the other groin can be explored.
FIGURE 518.2 A: Intraoperative photograph demonstrating medial curvilinear incision used to assess the quality
of the donor vasculature. B: Illustration depicting the superficial circumflex iliac artery as visualized through a
medial curvilinear incision.
Once the flap has been deemed suitable for transfer and the vasculature is carefully dissected from the
surrounding tissue through the medial incision, dissection then is begun laterally and proceeds in a medial
direction (Fig. 518.3A). This portion of the dissection is quite rapid. Dissection proceeds in a loose areolar plane
just anterior to the fascia lata of the thigh and the inguinal ligament. As the fascia overlying the sartorius muscle
is encountered, dissection may proceed deep to this
structure, where the muscular branch is identified and then ligated (Fig. 518.3B). Frequently, however, this is not
necessary because this muscular branch is well visualized through the medial incision, making inclusion of the
fascia overlying the sartorius unnecessary.
FIGURE 518.3 A: Intraoperative photograph demonstrating lateral dissection. B: Illustration depicting the lateral
dissection beneath the fascia overlying the sartorius muscle. Note the vessel branch of the superficial circumflex
iliac artery.

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CLINICAL RESULTS
Disadvantages of the vascularized groin flap include primarily the variability of the donor arterial vasculature
and the short length of the arterial pedicle. The short vascular pedicle length makes an end-to-side
anastomosis to a recipient artery quite difficult without the use of an interpositional vein graft. This
necessitates an additional anastomosis, with the added potential for thrombosis.
FIGURE 518.4 A: Defect on the medial aspect of a patient's right knee subsequent to excision of a
melanoma. B: Postoperative result following successful vascularized groin flap.
The flap may be quite thick, particularly in obese patients. Even in lean patients, the medial aspect of the
flap often contains an excessive amount of adipose tissue that contributes to problems related to flap
placement and positioning (Fig. 518.4).
Finally, flap failure and morbidity statistics are significantly higher than with other cutaneous composite
tissue used in microsurgical composite-tissue transfer. In an unpublished
series consisting of approximately 90 patients, the failure rate of the vascularized groin flap was
approximately 24% (8). This is approximately three to four times greater than flap failure rate statistics for
other vascularized tissue employed at present in reconstruction of extensive defects. Today, an acceptable
flap failure rate following microsurgical composite- tissue transfer should be in the range of 4% to 6%.
SUMMARY
The vascularized groin flap was the first cutaneous donor tissue employed in microsurgical composite-
tissue transfer; however, transfer in many large series has been characterized by significant flap morbidity
and failure.
References
1. Kaplan EN, Buncke HJ, Murray DE. Distant transfer of cutaneous island flaps in humans by microvascular
anastomoses. Plast Reconstr Surg 1973;52:301.
2. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses: a clinical technique.

Plast Reconstr Surg 1973;52:111.
3. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
4. Taylor GI, Daniel RK. The anatomy of several free-flap donor sites. Plast Reconstr Surg 1975;56:243.
5. Harii K, Ohmori K. Free skin flap transfer. Clin Plast Surg 1978;3:111.
6. Serafin D, Georgiade NG, Smith DH. Comparison of free flaps with pedicled flaps for coverage of defects
of the leg or foot. Plast Reconstr Surg 1977;52:492.
7. Serafin D, Georgiade NG. Microsurgical composite tissue transplantation. Am J Surg 1977;133:752.
8. Serafin D. Unpublished data. 1977.

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Chapter 519
Microvascular Free Transfer of A Latissimus Dorsi Muscle and
Musculocutaneous Flap
R. M. BARTON
L. O. VASCONEZ
The microvascular transfer of the latissimus dorsi muscle, with or without overlying skin, is perhaps the most
reliable of all free-tissue transfers for the lower extremity, particularly involving wounds of the distal third of the
tibia (1, 2, 3). The latissimus dorsi muscle is the largest muscle that can be transferred, and in most people, it
can be sacrificed without significant loss of strength of the upper extremity. When taken with an overlying skin
paddle less than 9 cm wide, the cutaneous defect can be closed primarily.
INDICATIONS
Several aspects of the latissimus dorsi make it amenable to free transfer to the lower extremity. The
vascular pedicle is long, averaging 9 cm in length, with vessels of comparable size to those in the leg (2.5-
4.0 mm). In nearly all patients, the nerve, artery, and vein arise in a common hilum. In addition, the length of
the pedicle will often allow microsurgical anastomoses outside the zone of injury without the need for vein
grafts.
ANATOMY
Studies of the intramuscular anatomy have demonstrated branching of the artery and vein into transverse and
longitudinal segments, thus allowing harvesting of only part of the muscle for smaller defects (4) or splitting of the
muscle to provide coverage for two defects (5). The latissimus dorsi has been transferred to restore motor
function to the leg. If used for this purpose, careful preoperative planning is necessary to ensure that the motor
nerve in the leg can be identified and is long enough to permit neural coaptation near the vascular pedicle of the
flap (Fig. 519.1).
FLAP DESIGN AND DIMENSIONS
The latissimus dorsi muscle can be reliably transferred using its entire bulk. When skin islands are included, they
should be placed over musculocutaneous perforators, their location being determined by Doppler examination. In
general, these perforators are more numerous over the proximal two thirds of the muscle. The “extended”
latissimus dorsi flap, which may include the thoracolumbar fascia and overlying skin, is less reliable without a
delay procedure.
The choice of ipsilateral or contralateral muscle may depend on the most favorable positioning of the patient in
order to approach the medial or lateral aspect of the leg.
OPERATIVE TECHNIQUE
Occasionally, the zone of injury in the leg is so extensive that vein grafts are required to ensure that the
microsurgical anastomoses are located in an area of uninjured vessels. A helpful
technique, if exposure of the recipient vessels is difficult, is to attach the reversed segment of vein graft to the
artery and vein as a loop. It is then much easier to divide the distal end of the loop and attach the muscle. In this

way, the flap will not obscure exposure of the proximal anastomoses.
FIGURE 519.1 The latissimus dorsi muscle can be used as a free-muscle transfer for coverage of defects in the
lower leg. The muscle then is covered with a split-thickness skin graft. Alternatively, a musculocutaneous flap
can be used, but it is often unacceptably bulky.
An alternative method has been used in rare circumstances to place the anastomoses outside the zone of injury.
This method involves using the dorsalis pedis artery and saphenous vein as recipient vessels distal to the defect
in the leg. This approach should be used with caution because of the potential of proximal vascular compromise.
Although these vessels may be patent, the flow characteristics may not be sufficient to support the flap.
When transferring the muscle as a motor unit, it is helpful to take the tendinous insertion that will permit easier
coaptation with the distal tendons in the leg. It is also advisable to place temporary sutures in the latissimus dorsi
muscle at regular intervals before removing it from its donor site as a guide to restore the correct resting length
when transferred to the leg.
Two problems encountered in patients with lower extremity trauma are hypercoagulability and increased spasm
of the vessels. The phenomenon of hypercoagulability is poorly understood, but some form of prophylactic
anticoagulation should be considered. A technique that has been helpful in minimizing vascular spasm is the
application of 2% lidocaine (without epinephrine) prior to dissection of the periadventitial tissues. The use of a
tourniquet, vessel loops instead of vessel clamps, and meticulous hemostasis also may help to prevent spasm.
End-to-side anastomoses have been shown to be as reliable as end-to-end repairs and are absolutely necessary
for patients with one-vessel legs or for those in whom the blood flow to the distal extremity is tenuous. A
technique has been described in which the thoracodorsal artery is harvested with a short segment of the
subscapular artery in a T configuration. Although this requires an additional anastomosis, it has the theoretical
advantage of not placing the suture line at the point of turbulent flow of the branch.
CLINICAL RESULTS
In many patients, the latissimus dorsi muscle with overlying skin produces a flap that is much bulkier than
required, particularly for wounds of the distal leg. To produce a more cosmetically acceptable

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reconstruction, the muscle alone has been transferred, and a skin graft is applied after it has been tailored
to the defect (Fig. 519.2). Postoperative edema of the flap is maximal at 3 to 5 days and begins to subside
over the next several weeks. The leg should be elevated during the initial postoperative phase and should
be wrapped with a compressive dressing when dependent. In noninnervated flaps, atrophy will gradually
reduce the muscle bulk by approximately 25% to 50%.
The timing of free-flap transfer to reconstruct major wounds of the lower extremity has been a subject of
considerable discussion. Many surgeons believe there is a “golden period” of about 2 weeks from the time
of injury when complications such as flap failure and recurrent infections will be at a minimum. If
reconstruction during this period is not possible, it has been recommended that free-flap transfer be delayed
at least 6 weeks; however, this is a subject for more critical analysis.
FIGURE 519.2 A: A 7-year-old girl sustained a severe burn and crush injury to the ankle in a three-wheeler
accident. Initial attempts at tangential excision and grafting were unsuccessful. B: Ultimately, a major
debridement was required, leaving her with an open ankle joint and exposed tibia and fibula. C: A latissimus
dorsi muscle flap was harvested through a short vertical incision along the posterior axillary line and

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transferred to the right-ankle area with anastomoses to the anterior tibial artery and vein. The muscle flap
was covered with split-thickness skin grafts. D: At 1 month, the muscle flap and skin grafts have healed with
no evidence of infection. E,F: One year postoperatively, the patient has resumed all normal activities. She
lacks some ankle motion but has not required a fusion. She is pain free. G: The donor scar is virtually
undetectable.
SUMMARY
The latissimus dorsi is a large, dependable flap that fulfills many of the requirements for lower extremity
reconstruction. Its versatility is demonstrated by the ability to provide coverage of large defects, or it can be
tailored for smaller ones. A skin paddle can be included with orientation in any axis. The vascular pedicle is
long enough to bridge the zone of injury, and it provides vessels of large size. In addition, the muscle can be
reinnervated to restore muscle function.
References
1. May JW, Gallico GG, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the
distal lower extremity. N Engl J Med 1982;306:253.
2. Serafin D, Voci VE. Reconstruction of the lower extremity: microsurgical composite-tissue transplantation.
Clin Plast Surg 1983;10:55.
3. Harii K. Reconstruction of the lower leg. In: Buncke HJ, Furnas DW, eds. Symposium on clinical frontiers
in reconstructive microsurgery. St. Louis: Mosby, 1984.
4. Bartlett SP, May JW, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:531.
5. Tobin GR, Schusterman BA, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.

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Chapter 520
Free Muscle Flaps With Split-Thickness Skin Grafts for Contoured
Closure of Difficult Wounds
J. W. MAY JR.
R. C. SAVAGE
A virtual explosion in available free-flap donor sites has occurred over the last decade (1, 2). Most recently, the
emphasis shifted from mere survival of free-tissue transfer to consideration of reconstructive and aesthetic
refinements. The purpose of this chapter is to summarize the advantages that free-muscle flaps with split-
thickness skin grafts provide in dealing with difficult wounds.
INDICATIONS
Recently, experimental and clinical evidence has firmly established the usefulness of local and distant
muscle-flap coverage of chronic bony wounds compared with the historical options of random skin flaps,
cross-leg flaps, and tubed pedicle “jump” flaps (3, 4, 5, 6, 7, 8). It has been hypothesized that vascularized
muscle flaps provide improved oxygen transport in concert with the direct delivery of host defense
mechanisms, including phagocytes, immunoglobulins, and the complement system (7). This combination of
factors and the ability to cover virtually any wound after thorough debridement are probably responsible for
the recent improvement in the coverage of these difficult bony wounds.
The use of free muscle flaps, covered with a thick split-thickness skin graft from the buttock area, has many
cosmetic and reconstructive advantages (9, 10) (Fig. 520.1). The dissection of the donor muscle alone is
easier, and the problems of location and design of the skin paddle over the muscle are avoided. When the
muscle is grafted, there is no problem fitting the skin paddle to the recipient site without tension. Free
muscle flaps can be tailored more effectively than free muscle-skin flaps in awkward locations, for example,
heels (Fig. 520.2), and in wounds with unusual three-dimensional characteristics. Moreover, a muscle flap
alone can more readily conform to fill all the recipient-site interstices. This elimination of dead space,
combined with the delivery of well-vascularized tissue, effectively decreases bacterial counts and
encourages the use of muscle flaps, especially compared with free skin flaps.
The latissimus dorsi muscle has become the “workhorse” of free-tissue transfer, for it satisfies most of the
ideal donor-site characteristics (9, 11, 12, 13, 14). The entire latissimus dorsi muscle, for example, can be
taken through a relatively short incision, most of which is concealed in the axilla (8). It possesses a long,
flexible vascular pedicle of wide internal diameter. It is a broad, flat, pliable muscle with potential for durable
coverage of defects of enormous size, yet its internal vascular anatomy allows for splitting the muscle (15)
and for use of only part of the muscle when flaps of smaller size are required (16). In addition to the
latissimus, the gracilis and rectus abdominis muscles also have many similar advantages, particularly for
smaller wounds.
OPERATIVE TECHNIQUE
See the appropriate chapters of the various muscle flaps for details of dissection, etc. (Chapters 519, 521, and
530).

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FIGURE 520.1 Sequence of operative steps in transfer of free latissimus dorsi muscle flap with split-thickness
skin graft. (From May et al., ref. 8, with permission.)
FIGURE 520.2 A: Chronic draining wound of the left heel in a 35-year-old man who had a severely comminuted
fracture of his os calcis. B: Contoured hemilatissimus dorsi muscle flap ready for transfer after further
debridement of the heel. The subscapular-circumflex scapular T anastomosis was performed to the posterior
tibial artery. An end-to-end venous repair was effected to the greater saphenous vein. Postoperatively, the
patient was monitored clinically as well as with internal thermocouple monitors. An early venous thrombosis
necessitated reoperation with anastomosis of the vein to the vena comitans of the posterior artery. (Continued)

FIGURE 520.2 (Continued) C: Tailored muscle flap with split-thickness skin graft 6 months postoperatively. The
patient walks without pain and has had no further drainage. D: Comparison with opposite heel 6 months
postoperatively.
CLINICAL RESULTS
Thirty-five consecutive free latissimus dorsi muscle flaps covered with thick split-thickness skin grafts from
the buttock area have been performed at the Massachusetts General Hospital, with the most common
application being acute and chronic bony wounds of the distal lower extremity (Fig. 520.3). We have had a
single flap loss due to infection 10 days postoperatively.
FIGURE 520.3 A: Deep chronic wound, lower lateral right thigh. B: Latissimus dorsi muscle flap prepared
for transfer, after femur debridement. Local thigh muscle flap reconstruction was not available because the
zone of trauma had created marked anterior and posterior fibrosis. The thoracodorsal artery was repaired
end-to-side to the popliteal artery, its vein end-to-end to a posterior popliteal vein. The postoperative course
was uneventful except for a small donor-site seroma. C: Muscle flap and split-thickness skin graft 8 months
postoperatively. The patient walks without assistance and is drainage free. D: Note the flexibility of healed
transfer 8 months postoperatively.
Skin-graft “take” on transferred muscle flaps is usually excellent. We have had only three partial graft losses

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requiring regraft procedures under local anesthesia in a series of
35 patients. Two of these failures were related to temporary venous obstruction of the flap.
When properly designed and inset, the muscle flap and skin graft should not require secondary debulking
operations, so commonly needed following free-skin flap and skin-muscle flap transfers. Muscle flaps
undergo a variable amount of shrinkage owing to both true atrophy and edema resolution. Experimental
studies suggest that denervated muscle atrophies at a rate of 1% per day for approximately 60 days (17,
18, 19, 20). It is our subjective clinical impression that free-muscle flaps, especially in a dependent location,
undergo less than a 60% total volume reduction. In a single case of a muscle flap in a nondependent
location, rapid shrinkage of more than 60% of the flap was seen within 2 months. These shrinkage factors
must be considered in determining appropriate flap contouring at the initial procedure.
Proponents of skin-muscle flaps feel that a major advantage is the availability of a “skin marker” for
postoperative color monitoring. Experienced observers of muscle flaps should be able to detect obstructive
color changes by means of a “window” left at the edge of the skin graft. If any question arises, a small
portion of the muscle can be cut and observed for bleeding. Furthermore, recent advances in thermocouple
temperature monitoring have been accurate in forecasting vessel occlusion (21).
SUMMARY
Free-muscle flaps with skin-graft coverage have added reconstructive and aesthetic refinements to the
reconstructive surgeon's armamentarium. These flaps allow durable closure of difficult wounds with superior
contour characteristics and minimal functional and cosmetic morbidity at the donor site.
References
1. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
2. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.
3. Stark WJ. The use of pedicled muscle flaps in the surgical treatment of chronic osteomyelitis resulting from
compound fractures. J Bone Joint Surg 1946;28B:343.
4. Ger R. Muscle transposition for treatment and prevention of chronic posttraumatic osteomyelitis of the
tibia. J Bone Joint Surg 1977;59B:784.
5. Serafin D, Georgiade N, Smith D. Comparison of free flaps with pedicled flaps for coverage of defects of
the leg or foot. Plast Reconstr Surg 1977;59:492.
6. Chang N, Mathes S. A comparison of the effect of bacterial inoculation in musculocutaneous and random
pattern flaps. Plast Surg Forum 1981;4:18.
7. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical
correlation. Plast Reconstr Surg 1982;69:815.

8. May JW Jr, Gallico GG III, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of
the distal lower extremity. N Engl J Med 1982;306:253.
9. May JW Jr, Lukash FN, Gallico GG III. Latissimus dorsi free muscle flap in lower extremity reconstruction.
Plast Reconstr Surg 1981;68:603.
10. Gordon L, Buncke HJ, Alpert BS. Free latissimus dorsi muscle flap with split-thickness skin graft cover: a
report of 16 cases. Plast Reconstr Surg 1982;70:173.
11. Maxwell GP, Stueber K, Hoopes JE. A free latissimus dorsi myocutaneous flap. Plast Reconstr Surg
1978;62:462.
12. Maxwell GP, Manson PN, Hoopes JF. Experience with 13 latissimus dorsi myocutaneous free flaps. Plast
Reconstr Surg 1979; 64:1.
13. Watson JS. The free latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1979;64:299.
14. Serafin D, Sabatier RE, Morris RL, Georgiade NG. Reconstruction of the lower extremity with
vascularized composite tissue: improved tissue survival and specific indications. Plast Reconstr Surg
1980;66:230.
15. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.
16. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle. A fresh cadaver study of the
primary neurovascular pedicle. Plast Reconstr Surg 1981;67:631.
17. Tower SS. Atrophy and degeneration in skeletal muscle. Am J Anat 1935;56:1.
18. Guttman E. Effect of delay of innervation on recovery of muscle after nerve lesions. J Neurophysiol
1948;11:279.
19. Sunderland S, Ray LJ. Denervation changes in mammalian striated muscle. J Neurol Neurosurg Psychol
1950;13:159.
20. Guttman E, Selena J. Morphological changes in the denervated muscle. In: Guttman E, ed. The
denervated muscle. Prague: Czechoslovak Academy of Sciences, 1962.
21. Cohn K, May JW Jr. Thermal energy dissipation: a laboratory study to assess patency in blood vessels.
Plast Reconstr Surg 1982;70:475.

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Chapter 521
Microvascular Free Gracilis Muscle and Musculocutaneous Flap
R. T. MANKTELOW
R. M. ZUKER
The gracilis muscle may be used for coverage of soft-tissue defects, for functional reconstruction in replacing
missing skeletal musculature, and for facial reanimation in facial paralysis. When used for soft-tissue flap
coverage, it may be transferred alone and a skin graft may be applied directly to the muscle, or it may be
transferred with an overlying cutaneous island as a musculocutaneous flap. The gracilis muscle is well suited to
small and medium-sized soft-tissue defects that cannot be adequately handled by simpler flap techniques. It will
conform well to irregular contours (Fig. 521.1), can be split longitudinally at both ends to allow placement into
cavities and awkwardly shaped spaces, and can be transferred in part or in whole. When transferring only a part
of it, the transferred muscle will remain viable as long as the anterior margin of the muscle is transferred.
FIGURE 521.1 A: Following a sequestrectomy of osteomyelitis in the distal third of the tibia, a deep hole and
irregular soft-tissue defect are present. B: Gracilis muscle and defect. C: Muscle is revascularized, split into
separate leaves, and inserted into the defect. D: Gracilis muscle with split-thickness skin graft applied directly,
seen 1 year postoperatively.
ANATOMY, FLAP DESIGN AND DIMENSIONS
See Chapter 342.
OPERATIVE TECHNIQUE
See Chapter 342.
Prior to removal of the muscle, the recipient site should be prepared so that ischemia time is minimized. The
margins of the defect are excised back to healthy, viable tissue and the skin is elevated in order that the muscle

can be tucked under the skin edges to provide a good skin-muscle junction.
The recipient vessels are evaluated under magnification. If dealing with an area of injury such as in the lower leg,
it is important that the recipient vessels be proximal to the zone of injury. Otherwise, there is a strong tendency to
vasospasm in the artery. In this location, end-to-side repairs are preferred, since the tendency to vasospasm is
much less. Venous repairs to the venae comitantes are preferable and can be done in an end-to-side or end-to-
end fashion.
The muscle is loosely tacked in place so that there will be no inadvertent shearing of the pedicle during the
anastomoses. The artery and vein are positioned. Either can be repaired first, depending on the access to each.
The deepest vessel is usually repaired first.
Repair of the largest vena comitans will usually provide a very adequate venous outflow tract. When patency is
ensured, the muscle is then sutured under the skin margins with mattress sutures. The muscle may be trimmed
proximally and distally as well as along the posterior margin.
One of the interesting features of the gracilis is the ease with which it may be stretched transversely to fill a
defect that is wider than the muscle (Fig. 521.1). The usual 6-cm width of muscle can easily be spread to 9 to 10
cm following removal of some of the perimysium. A split-thickness skin graft is applied to the muscle and loosely
tacked about the margins. A “window” (1 × 1 cm) is placed in the dressing and in the underlying skin graft,
allowing for direct visualization of the muscle.
Fifty percent or more of the muscle bulk will atrophy. This provides a good-contour reconstruction of the anterior
tibia, providing adequate padding without any excess bulk (Fig. 521.1D). The muscle will maintain sufficient
pliability to tolerate the shear stresses produced by accidental bumps and blows to the anterior shin.
The flap is rarely used as a musculocutaneous flap. The reasons for this are that the skin usually provides
excess bulk and most situations are best handled with a split-thickness skin graft applied directly to the muscle.
See Chapter 342.
CLINICAL RESULTS
See Chapter 342.
SUMMARY
The gracilis can be used as a muscle or musculocutaneous flap to cover and fill defects of the lower
extremity. It is usually used as a muscle flap and then covered with a split-thickness skin graft.

Chapter 522
Deep Inferior Epigastric Artery Rectus Musculocutaneous Free
Flap
G. I. TAYLOR
R. J. CORLETT
J. B. BOYD
FIGURE 522.1 A: A 21-year-old motorcyclist presented with a severe compound injury of his left leg. The skin
defect extended from the knee to the ankle and was almost circumferential in the distal leg. There was an
associated comminuted fracture of the distal tibia. Angiography revealed a patent posterior tibial artery. B: After
repeated debridement of the wound and stabilization of the fracture with an external fixation device, the defect
was closed with a free deep inferior epigastric artery thoracoumbilical flap. The flap measured 52 × 11 cm and
included the entire rectus muscle. Note how thin the distal portion of the flap is in this obese patient. C: The flap
was transferred to the leg and revascularized by end-to-side anastomoses to the posterior tibial vessels.
Cancellous iliac bone grafts were packed around the fracture, and the skin flap was oriented longitudinally from
the knee to the ankle. Additional split-thickness skin grafts were placed over the revascularized muscle. The
donor site was closed directly in all layers, including the anterior rectus sheath. D: The flap healed without
complication, and the tibia was united at 3 months. See Chapter 422 and Figure 422.1, in Chapter 522.

Chapter 523
Microvascular Free Rectus Abdominis Muscle Flap for Lower
Extremity Reconstruction
T. BENACQUISTA
B. STRAUCH
EDITORIAL COMMENT
This is a workhorse and standard unit that, along with the latissimus, is one of the most commonly used
muscles for reconstruction of the lower extremity. An advantage of the rectus abdominis is that the patient
can be maintained supine for both the donor and recipient portions of the procedure. In addition, a long and
large pedicle is provided, and the amount of muscle will cover large defects.
The rectus abdominis muscle flap has been used in the reconstruction of defects of the head and neck, chest
and abdominal walls, perineum, and upper and lower extremities. It can be transferred either as a pedicled flap or
as a microvascular free flap.
INDICATIONS
As a microvascular free flap to the lower extremity, this flap has gained enormous popularity. Harvesting of
the rectus abdominis flap can be carried out rapidly and easily, and is usually accomplished simultaneously
with exploration of the leg for recipient vessels. In addition, its vascular pedicle is quite constant, with a
large-caliber artery, two sizeable venae comitantes, and of sufficient length to reach most recipient vessels
without requiring the use of a vein graft (1).
The majority of free flaps for lower-extremity reconstruction are used to cover large wounds sustained from
trauma, especially those with Gustilo type IIb and IIc tibial fractures (2). While some traumatic leg wounds
can be closed with pedicled muscle flaps such as the gastrocnemius flap (upper third of the leg) or soleus
flap (middle third of the leg), or with local fasciocutaneous flaps, most high-energy wounds require
microvascular free flaps for adequate coverage (see Figs. 523.2 and 523.3).
Local flaps are inadequate, in that they are located in the area of injury, or are of sufficient bulk or length to
reach the defect (3). Traumatic wounds of the lower third of the leg also require free-flap closure, as there is
little or no local tissue in the distal leg. The rectus abdominis muscle, along with the latissimus dorsi muscle,
has become a workhorse in treating these traumatic leg wounds, as well as wounds of the ankle or foot.
In the treatment of chronic osteomyelitis, free vascularized muscle flaps have also made a significant
difference in obtaining stable, closed wounds in the lower extremity. Before the advent of free muscle flaps,
the available treatment modalities, including debridement and closure with secondary intention, as well as
local flap closure, resulted in high recurrence rates (4, 5).
Limb salvage after excision of aggressive neoplasms is another indication for the use of free muscle flaps.
Their use has been reported (6) to avoid amputation after excision of sarcoma in the lower extremity; seven
of the 10 reported flaps were rectus abdominis flaps.
Perhaps the most challenging area of lower-extremity reconstruction is in patients with peripheral vascular
disease. The addition of microvascular free-tissue transfer for revascularization of the extremities has led to

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increased limb salvage in this very complex patient population. Patients with diabetes and complex open
wounds of the leg and foot have also benefited from free muscle flap closure of the wounds (6, 7, 8, 9).
ANATOMY (FIG. 523.1)
The rectus abdominis muscle is a segmental muscle originating from the symphysis pubis and pubic crest, and
inserting into the fifth, sixth, and seventh costal cartilages. It usually has three inscriptions and is enclosed in its
rectus sheath, except for the area below the arcuate line.
The rectus muscle is a type III muscle, with a dual blood supply from the superior epigastric artery (which arises
from the internal mammary artery) and from the inferior epigastric artery. The latter is the larger of the two and is
the vessel used for microvascular transfer of the muscle. The superior epigastric artery is used for pedicled
reconstructions of the breast and chest area.
The inferior epigastric artery arises from the external iliac artery just above the inguinal ligament. It then travels
upward
and medially toward the muscle, to enter on its lateral aspect below the arcuate line. It remains on the
undersurface of the muscle, and divides into 2 to 3 branches that travel craniad above the rectus sheath, to
anastomose with the superior epigastric vessels at the level of the umbilicus.
FIGURE 523.1 Anatomy of the rectus abdominis muscle.
The average arterial length of the inferior epigastric pedicle is about 10 cm, and the diameter of the artery is
about 2 to 3 mm. It is accompanied by two venae comitantes that average 3 mm in diameter.
OPERATIVE TECHNIQUE

A two-team approach is used to decrease operating time. A preoperative angiogram determines the recipient
artery. The best choice is usually the posterior tibial artery, if it is available and uninjured (Fig. 523.2). This
allows for the easiest positioning of the patient—supine and in a frog-leg position. It also allows the saphenous
vein to serve as a recipient vein, if the venae comitantes are inadequate. In patients with peripheral vascular
disease, a preoperative angiogram and the vascular surgeon's bypass will determine the recipient vessel of
choice. Even a prosthetic vascular bypass graft has served as a recipient vessel for the free muscle flap (10).
FIGURE 523.2 Chronic open lower-extremity wound with open tibial- fibula fracture following multiple
debridements.
A paramedian incision is made, and the rectus abdominis muscle is dissected from its pubic origin to the rib
insertion, preserving the rectus fascia to obtain a strong abdominal-wall closure and to prevent hernia formation.
Endoscopic harvest of the rectus abdominis muscle has been shown to be possible in a cadaver and may be the
means of decreasing donor-site morbidity (11). Only a part of the muscle may be necessary, and a segmental
rectus abdominis free flap (Fig. 523.3) can be harvested for smaller wounds, especially about the foot and ankle
(12).
The tendinous portion of the muscle is included, as it is useful in providing coverage for the pedicle during
insetting of the flap. The muscle can be inset using either bolsters, if intact skin is present, or it is sutured to leg
fascia. A split-thickness skin graft is used to cover the muscle. Musculocutaneous flaps are rarely used in lower-
extremity reconstruction, as they are usually too bulky, and muscle covered with split-thickness skin graft has
been found to be as durable.
Postoperatively, the leg is maintained in an elevated position. An external fixator allows for the best management
of the extremity, as no splinting is necessary, and thus no external pressures are placed on the pedicle or the
flap.
Monitoring of the flap is at the microsurgeon's preference. The initial bulkiness soon subsides and can be
flattened more quickly with the use of an Ace bandage wrap, once the skin graft has healed. Over time, the
contour of the flap improves

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dramatically, due to atrophy of the muscle. At times, revision of the flap may be necessary, especially around the
ankle or foot, if shoe fit is affected (Figs. 523.2 and 523.3).
FIGURE 523.3 Result 1 year after transfer of rectus abdominis free flap. No revisions were performed to obtain
this smooth contour.
CLINICAL RESULTS
Most series report success rates of 90% or better in the transfer of the rectus abdominis muscle to the lower
extremity, although these series usually group many muscle flaps together, as well as other types of free-
tissue transfers. These success rates are quite consistent for microvascular tissue transfers to wounds
resulting from trauma, chronic osteomyelitis, or after excision of malignant neoplasms (2, 3, 4, 5, 6).
Not unexpectedly, lower success rates have been reported when treating wounds resulting from peripheral
vascular disease. The management of these patients is complicated by their concomitant medical problems,
especially diabetes, decreased healing secondary to ischemia and the sequelae of diabetes, and the
uncertain recipient vessels. A 73% success rate with freeflap transfer has been reported in 30 patients with
atherosclerosis and complex lower-extremity wounds (9). In another series of 10 patients, an 80% limb-
salvage rate was achieved (8), and a 93% limb-salvage rate was reported in a series combining free-tissue
transfer with distal revascularization (7).
SUMMARY
The rectus abdominis muscle is easily dissected and highly reliable, with a consistent and large-caliber
pedicle, and it is ideally suited to lower-extremity reconstruction. There is a high rate of limb salvage when it
is used in microvascular free-tissue transfer, to cover defects of the lower extremity resulting from trauma,
osteomyelitis, excision of malignant neoplasm, and peripheral vascular disease.

References
1. Reath DB, Taylor JW. Free rectus abdominis muscle flap: advantages in lower extremity reconstruction.
South Med J 1989;82:1143.
2. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10 year
experience with 304 consecutive cases. J Trauma 1989;29:1086.
3. Yaremchuck MJ. Acute management of severe soft tissue damage accompanying open fractures of the
lower extremity. Clin Plast Surg 1986; 13:621.
4. Eisenschenk A, Kern O, Lehnert M, Weber U. Free vascularized muscle flap transplantation in the
treatment of chronic osteomyelitis. Chir Organi Mov 1994;79:139.
5. Gayle LB, Lineaweaver WC, Oliva A, et al. Treatment of chronic osteomyelitis of the lower extremities with
debridement and microvascular muscle transfer. Clin Plast Surg 1992;19:895.
6. Heiner J, Rao V, Mott W. Immediate free tissue transfer for distal musculoskeletal neoplasm. Ann Plast
Surg 1993;30:140.
7. Cronenwett JL, McDaniel MD, Zwolak RM, et al. Limb salvage despite extensive tissue loss: free tissue
transfer combined with distal revascularization. Arch Surg 1989;124:609.
8. Greenwald LL, Comerota AJ, Mitra A, et al. Free vascularized tissue transfer for limb salvage in peripheral
vascular disease. Ann Vasc Surg 1990;4:244.
9. Serletti JM, Deuber MA, Guidera PM, Herrera HR. Atherosclerosis of the lower extremity and free tissue
reconstruction for limb salvage. Plast Reconstr Surg 1995;96:1136.
10. Berman BA, Zamboni WA, Brown RE. Microvascular anastomosis of a rectus abdominis free flap into a
prosthetic vascular bypass graft. J Reconstr Microsurg 1992;8:9.
11. Bass LS, Karp NS, Benacquista T, Kasabian AK. Endoscopic harvest of the rectus abdominis free flap:
balloon dissection of the fascial plane. Ann Plast Surg 1995;34:274.
12. Reath DB, Taylor JW. The segmental rectus abdominis free flap for ankle and foot reconstruction. Plast
Reconstr Surg 1991;88:824.

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Chapter 524
Lower-Extremity Muscle Perforator Flaps
G. G. HALLOCK
The lower extremity is noteworthy as a challenging milieu for achieving wound healing and, even more, for
obtaining even a facsimile of the original appearance. Although musculocutaneous flaps from this region were
soon abandoned in favor of thinner muscle-only flaps, the same skin territories once again have become useful
as muscle perforator flaps (Fig. 524.1), relying on the identical musculocutaneous perforators, but now without
inclusion of the muscle. Not only is muscle function thereby preserved, but a superior aesthetic result with similar
tissue also is possible, whether used as a local/regional flap or as a microsurgical tissue transfer.
FIGURE 524.1 Muscle perforator flap territories of the lower extremity. The sural territory can be further
subdivided into medial and lateral sural, depending on the source artery of the respective musculocutaneous
perforators. (Common names in brackets under standard nomenclature. AP, artery perforator; am, adductor
magnus; g, gracilis; s, soleus; vl, vastus lateralis; tfl, tensor fasciae latae.)
INDICATIONS
Often, the selected donor site of a lower-extremity muscle perforator flap can be from the ipsilateral limb,
which limits morbidity to the same extremity (1). The only prerequisite needed to sustain any cutaneous flap
is that an adequate perforator (diameter 0.5 mm or greater or visibly pulsatile) can be found, allowing the
creation of free-style local or free flaps (2) that do not necessarily rely on a named source vessel. However,
to be more realistic, the precise localization of such a perforator can be quite variable, as anomalies tend to
be the norm. For this reason, some guidelines for the harvest of the more commonly used lower-extremity
muscle perforator flaps, all characterized by some anatomic consistency, are appropriate, as these are

valuable alternatives, not just for the lower extremity. They have a versatile role throughout the body.
ANATOMY
Lateral Circumflex Femoral (Vastus Lateralis) Perforator Flap
Of interest, most described “freestyle free flaps” have focused on musculocutaneous perforators found in the
anterolateral thigh region (2) (Fig. 524.2). Although Song et al. (3) originally described a septocutaneous flap
from this same area, they noted that only a musculocutaneous perforator was present on occasion. They may
then have recorded the first “true” muscle perforator flap, although not yet called this. Rather, according to the
standards set by the Canadian system (4), the proper nomenclature for this or any perforator flap should state
the source vessel to the given territory and, secondarily, the muscle traversed by the chosen perforator(s) for
further clarification, if necessary. Thus this rendition would now be called the lateral circumflex femoral artery
perforator-vastus lateralis, LCFAP-vl flap. However, the original name, as introduced by Song et al. (3), as the
“anterolateral thigh flap,” understandably remains more established.
FIGURE 524.2 Perforators to the LCFAP-vl (i.e., “anterolateral thigh”) flap can often be found within a circle with
a radius of 3 cm, centered at point “P” on a line drawn between the anterior superior iliac spine (ASIS) and the
superior lateral border of the patella. If absent, sometimes superior to this can be found a superior cutaneous
perforating artery (SC).
Many advocates (5, 6) have stressed that the LCFAP-vl flap may be the “ideal” soft-tissue flap. More has been
written about this versatile donor site than about any other muscle perforator flap (7). Certainly, at the least, it
represents a “gold standard” with which all other alternative cutaneous flaps must be compared.
FLAP DESIGN AND DIMENSIONS
A line is drawn from the anterior superior iliac spine to the superior lateral border of the patella (Fig. 524.2) (8, 9).
This coincides with the lateral intermuscular septum between the vastus lateralis and rectus femoris muscles. At
the midpoint of this line, a circle with a radius of 3 cm is drawn. All quadrants of this circle are scanned, by using
an audible Doppler. Most often, in the posterior inferior sector, a perforator can be identified (8, 9). The desired
LCFAP-vl flap boundaries can be centered about this perforator, although an eccentric design will accordingly
adjust the length of the desired vascular pedicle.

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OPERATIVE TECHNIQUE
The medial border of the LCFAP-vl flap is first incised down to the fascia lata. Identification of all perforators is
easiest if the bloodless subfascial plane is entered, but a suprafascial dissection will preserve all fascia at the
donor site. In about 15% of cases, a large septocutaneous branch is encountered exiting within the lateral
intermuscular septum (5), but usually dissection must proceed over the vastus lateralis muscle before an
adequate perforator is found. If the flap is very long, including a second, more distal, perforator, this better
ensures perfusion to that area as well. The inclusion of multiple large perforators, if available, also provides a
safety factor, in case one is inadvertently injured, and eliminates the risk of twisting about a single perforator.
Once all perforators have been selected, the flap can be redesigned, if necessary. The remaining boundaries
can then be incised. The usual tedious intramuscular dissection of each perforator requires ligation or
coagulation of all muscle side branches. This is usually continued back to the septum between the vastus
lateralis and rectus femoris muscles, and to their origin from the descending branch of the lateral circumflex
femoral vessels, which commonly resides there. Further proximal dissection ceases once attainment of a local
flap has been accomplished, or if the pedicle length or caliber or both are sufficient for use as a free flap. Donor-
site closure, if larger than 8 to 10 cm, will require a skin graft.
Among the advantages of the LCFAP-vl flap are the following:
1. The skin territory is immense: a huge flap, sometimes including almost the entire anterior thigh, can be raised
(although “turbocharging” perforators unrelated to the pedicle of the flap may be necessary to ensure total
viability) (10);
2. Too long a vascular pedicle is sometimes a problem, but certainly vein grafts can usually be avoided when
used as a free flap. If large side branches are maintained, a vascular “flow through” is another option (11),
especially to “turbocharge” another perforator, or add another flap as a “sequential” flap;
3. Large-caliber vessels: even before reaching the lateral circumflex femoral vessels proper, vessel diameters
that approach macrosurgery are obtainable;
4. Consistent anatomy: even though the exact site or type of perforator to this region can be extremely variable,
almost always at least one adequate perforator will be found;
5. A supine position allows two-team flap harvest, sometimes even if the recipient site is the ipsilateral extremity;
6. As a consequence of the long potential vascular leash, a local flap can reach up to the umbilicus, groin,
perineum, or trochanter and, if distal-based, even to the knee (12);
7. Combined flaps are possible, joining with vascularized fascia, nerve, muscle, and other thigh
cutaneous/adiposal flaps, with numerous options as chimeric or conjoined flaps (5).
Among the disadvantages of the flap are the following:
1. Problems of contour: the flap is difficult to raise in an obese patient, and then can be very bulky, although
immediate thinning has been described (13);
2. The donor-site scar: even a long, vertical scar of the thigh may be unacceptable, especially for women;
3. Absence of an adequate perforator: in the rare situation that no anterolateral thigh perforator can be found in
the usual site, a prominent medial thigh perforator may exist for an alternative flap (14). A better option, if
present, is to look for a superior cutaneous perforator artery (15), which will be found 5 to 8 cm above the
midpoint of the line drawn from the ASIS to the superior lateral border of the patella (Fig. 524.2). One must be
aware that this perforator does not necessarily arise from the descending branch of the lateral circumflex

femoral vessels.
Lateral Circumflex Femoral (Tensor Fasciae Latae) Perforator Flap
On rare occasions, when no perforator can be found in the anterolateral thigh, dissection even more superiorly
along the lateral intermuscular septum will reveal a perforator emanating via the tensor fasciae latae (TFL)
muscle, which will allow another alternative thigh flap design (Fig. 524.3). Although described by Kimura (16) as
a microdissected thin free flap, the major attribute of this lateral circumflex femoral artery perforator- tensor
fasciae latae (i.e., LCFAP-tfl flap) is as a local flap for trochanteric wounds (17). The advantage as a perforator
flap is that muscle function is preserved, which may be critically important for the ambulatory patient. But also the
muscle itself can then be used as a backup flap for recidivism, common with patients with pressure sores in this
area.
FLAP DESIGN AND DIMENSIONS
A line “x” drawn from the anterior superior iliac spine to the superior lateral border of the patella coincides with
the lateral intermuscular septum superiorly between the tensor fasciae latae and rectus femoris muscles (Fig.
524.3) (17). A second line “y,” perpendicular to this, is drawn from the pubis to the prominence of the greater
trochanter. A rectangle is then constructed with sides 4 cm both above and below the “y” axis, and another pair
parallel to the “x” axis, corresponding to the anterior prominence of the greater trochanter and the septum itself.
This area is scanned by an audible Doppler, and a minimum of two perforators consistently can be found (17).
Any flap boundaries must encompass this perforator, usually in an ellipsoid shape, with the major axis paralleling
the “x” axis, to facilitate direct donor-site closure, if less than 9 cm wide.
FIGURE 524.3 A perforator to the LCFAP-tfl (i.e., tensor fasciae latae) flap will be found within a rectangle with
one long side corresponding to a line drawn between the anterior superior iliac spine (ASIS) and the superior
lateral border of the patella, and a parallel side tangent to the anterior prominence of the greater trochanter (G).
The remaining sides connect the previous pair 4 cm above and below a line drawn from the pubic tubercle (PT)
to the greater trochanter (G).
OPERATIVE TECHNIQUE
The patient can be placed in a lateral decubitus or supine position. The distal edge of the flap is incised first
down to the fascia lata. A suprafascial dissection then continues superiorly until an ideal perforator is
encountered. The rest of the flap boundaries may then be incised to create an island flap. At this point, rotation

P.1412
may be possible as a local flap. If necessary, the perforator can be followed through the tensor fasciae latae
muscle back to its origin from the ascending branch of the lateral circumflex femoral vessels, to extend reach and
pedicle mobility, or to transfer as a free flap.
Among the advantages of this flap are the following: (a) the vascularized fascia lata may be combined as a
composite flap, if thick fascia is needed at the recipient defect (18, 19); and (b) a local flap is the preferred option
for trochanteric wounds.
Among the disadvantages are (a) the short pedicle: a pedicle length of 9 to 10 cm can be obtained only if
dissection is completely back to the lateral circumflex femoral vessels. This is half the length possible with the
LCFAP-vl flap; (b) a difficult dissection is involved: the usual tedious intramuscular
dissection of any perforator flap is even more difficult involving the narrow window offered through the TFL; (c)
pedicle fragility: the vascular pedicle is subject to tension, if stretched to reach a trochanteric defect, a risk
enhanced by the forces of gravity if the patient is kept in a supine position.
Medial Circumflex Femoral (Gracilis) Perforator Flap
The gracilis musculocutaneous flap fell into disfavor because the usually longitudinally oriented skin paddle
proved to be unreliable. Recent studies of the requisite gracilis musculocutaneous perforators have found
usually one to three that arise from the proximal muscle in its midportion, with injection studies demonstrating
staining of a skin area that actually parallels the groin crease (20, 21, 22). The anatomy otherwise is already
extremely well known to the experienced surgeon, which facilitates creation of a medial circumflex femoral artery
perforator— gracilis (i.e., MCFAP-g) flap. Moderate-sized flaps can be raised from the medial groin, and this
donor site can easily be concealed by clothing, even if a skin graft is needed (23, 24).
FLAP DESIGN AND DIMENSIONS
A line drawn from the pubic tubercle to the medial condyle of the femur along the medial thigh corresponds to the
course of the often palpable or visible adductor longus muscle (Fig. 524.4). At a point 10 ± 2 cm below the pubic
tubercle at the posterior edge of this muscle, the medial circumflex femoral pedicle enters the undersurface of the
gracilis muscle (21, 22). A semicircle with a radius of 7 cm, centered at that point and overlying the gracilis
muscle, will include all possible perforators (20, 21, 22), which can be localized with an audible Doppler. The
majority will be found in the upper half of that semicircle. The flap design must include these perforators, with a
major axis paralleling the groin crease, staying toward the posterior thigh as much as possible, as this seems to
be more reliably captured than the thigh skin anterior to the adductor longus muscle.

FIGURE 524.4 A line is drawn from the pubic tubercle (PT) to the medial condyle of the femur (F). Centered at a
point “P” on this line about 10 cm below the PT, a perforator to the MCFAP-g (i.e., medial groin) flap will often be
found in a semicircle with a radius of 7 cm, as depicted.
OPERATIVE TECHNIQUE
The donor limb is abducted with a bump under the flexed knee readily to expose the medial thigh. The distal
boundary of the flap is incised first through the subcutaneous tissue and deep fascia to expose the gracilis
muscle. The fascia is retracted cephalad over the gracilis muscle, to ascertain the presence of an adequate
perforator. If one is found, the remaining flap boundaries are incised. Posteriorly, the flap can be raised at the
level of the Scarpa fascia, to immediately thin it, until the posterior border of the gracilis muscle is reached. The
remainder of the dissection must then be done in a subfascial plane, to ensure inclusion of all reasonable gracilis
perforators, remembering that an inverse relation exists between perforator diameter and number (22). The usual
intramuscular dissection is completed back to the medial circumflex femoral vessels.
Often, a sizeable septocutaneous branch between the adductor longus and gracilis muscles will be seen and
should be retained. A branch of the greater saphenous vein will always be found anterior to the gracilis muscle
and should be saved as an alternate venous outflow source in the event of later venous congestion. The MCF
pedicle can be dissected under the adductor longus muscle back to the profunda femoris vessels as far as
needed.
Among the advantages: (a) this is a local flap, and groin and perineum coverage is possible (25); (b) because
any donorsite residue can be easily hidden by clothing, probably the aesthetic result is the best for any
perforator flap; (c) as a chimeric flap, skin branches often diverge from major muscular branches, to allow
simultaneous and independent transfer of both a cutaneous and gracilis muscle flap (26); (d) as a sentinel flap,
inclusion of a small perforator flap with a gracilis muscle flap allows constant monitoring of the latter relying on
capillary refill of the former (27); (e) the patient's supine position can allow a two-team flap harvest, especially if
the recipient site is the contralateral extremity; and (f) the consistent anatomy allows the approach to the gracilis
muscle and MCF pedicle already to be routine for the experienced surgeon.
Among its disadvantages, (a) the limited length of the short pedicle, even though slightly longer than for a strictly
gracilis muscle flap, restricts reach as a local flap, and can make the anastomosis of a free flap awkward; (b)
anomalies involving the frequency of diminutive perforators or even the total absence of perforators are relatively

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common, in which cases, this option will have to be abandoned; and (c) even in thin women, bulkiness or medial
thigh fat deposits or both can be significant, although this could be a positive attribute for breast reconstruction.
Medial Sural (Gastrocnemius) Perforator Flap
The medial gastrocnemius musculocutaneous flap has long been abandoned, not only because of its excessive
bulk but also because of the significant donor defect that accrued.
Instead, as a muscle flap only, it has become a workhorse flap for coverage about the knee. However, if the
same cutaneous territory is now taken as a muscle perforator flap, a reasonably thin local flap can achieve the
same purpose, often leaving only a linear calf scar if less than 8 cm in width. Not only is muscle function
preserved, but the muscle also remains as a “lifeboat” if any further problems are found (28). Even in the most
obese individual, this can be a source of a relatively thin free flap, rivaled perhaps only by the forearm flaps, but
in this case, no major limb vessel must be sacrificed. Based on the medial sural vessels, the medial sural artery
perforator flap (i.e., MSAP flap) has been found always to be possible (29, 30, 31). This is in contradistinction to
a lateral sural artery perforator flap where, not infrequently, no adequate musculocutaneous perforator can be
found emanating from the lateral gastrocnemius muscle head (31). Unlike the other perforator flaps from the
lower extremity, the MSAP flap can be accessed with the patient in either a prone or a supine position (32).
FLAP DESIGN AND DIMENSIONS
With the thigh abducted at the hip, and knee flexed and externally rotated, a line is drawn along the medial leg
from the midpoint of the popliteal crease to the midpoint of the medial malleolus (Fig. 524.5) (29, 33). A first major
perforator usually can be found with an audible Doppler within the distal half of a circle with a radius of 2 cm,
centered at a point along this line 8 cm from the popliteal crease (29, 33). A second major perforator may be
within a circle with a radius of 3 cm, whose center is on this line 15 cm from the popliteal crease (33). Some
variation will be found in taller individuals. A flap designed on the first perforator will require the least dissection
to reach the larger-caliber medial sural vessels that arise from the popliteal at the knee joint. This option may be
a preferable choice if it is needed as a free flap (34). If the second perforator is chosen, the vascular pedicle can
be longer, to allow extended reach as a local flap for knee coverage (29, 35).
FIGURE 524.5 A line is drawn from the midpoint of the popliteal crease (PC) to the prominence of the medial
malleolus (M). If present, the first perforator to the MSAP flap (i.e., medial calf) will be within the distal half of a
circle with a radius of 2 cm found 8 cm from the popliteal crease. A second perforator may be present within a