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

Chapter 567
Split Gluteal Muscle Flap for Autoprosthesis Buttock
Augmentation
SADRI O. SOZER
O. ERHAN ERYILMAZ
EDITORIAL COMMENT
An excellent procedure, applicable to patients who do not want gluteal implants or buttock augmentation
with fat grafting. Autologous augmentation with the local muscle achieves an excellent result.
INDICATIONS
Recently, there has been an increase in the number of patients seeking buttock augmentation and contour
restoration. Post- bariatric surgery and cosmetic patients seeking circumferential body lifts also seek a way
of avoiding a flattened buttock contour. Gluteal implants have been described with various rates of
complications and difficulties. Lipografting is an effective means of moderately increasing buttock volume.
However, neither of these procedures directly addresses ptosis. Although the procedure described in this
chapter readily addresses the volume deficit, it is especially indicated for those cases where ptosis and
volume are the main concerns. A number of adipocutaneous flaps for gluteal augmentation in different
settings have been described. Most of these flaps originate within the superior gluteal region and maintain
volume in the top half of the buttocks, lacking the ability to reach the midportion of the buttocks. The ideal
flap should be versatile and not vascularly compromised, result in a supragluteal concavity, and give the
maximum projection at the midlevel of the buttocks. We have described a split gluteal muscle flap for
buttock autoaugmentation that achieves these goals (1, 2, 3, 4).
ANATOMY
The gluteal flap is based randomly on superior gluteal artery perforators. Perfusion to the skin overlying the
gluteal region is supplied by 20 to 25 perforating branches of the superior and inferior gluteal arteries, both of
which branch from the internal iliac artery (5, 6, 7, 8). The abundant vascular supply of the gluteal region
provides robust perfusion to surrounding tissue flaps.
FLAP DESIGN
The estimated final scar is marked first. The intersection of the inguinal crease line with the midaxillary line is
Point A (Fig. 567.1A). The cranial endpoint of the intergluteal crease is Point B (Fig. 567.1B). The line is drawn
starting above the Point B extending in a curvilinear fashion to Point A. At the sacrum, the line from the
contralateral side is joined, forming a V and creating an aesthetically pleasing V-shaped crease. This will form a
scar that is slightly arched, follows the skin's tension lines, and is easily concealed by underwear. Use a pinch
test to estimate the amount of possible skin resection (Fig. 567.1C).
The direction of elevation of the ptotic buttocks is cranial and slightly medial. These lines can be continued
anteriorly with abdominoplasty or spiral lift markings given the appropriate indications or meet anteriorly at the
flanks in an isolated buttock lift. A flap originating between the superior and inferior lines is marked within the

P.1534
P.1535
medial two-thirds of the supragluteal tissue marked for excision. The flap is demarcated medially 2 to 3 cm lateral
from the midline. The lateral demarcation of the flap is approximately three-fourths of the distance from the
midline to the posterior axillary line and may range between 5 and 15 cm in width, depending on the patient's
body habitus, buttock contour, and desired result (Fig. 567.1D).
Depending on the patient's contour deformities, liposuction is routinely performed in the flanks, sacrum, and
posterior thigh, following the aesthetic units of the buttocks and accentuating their final contour.
OPERATIVE TECHNIQUE
The marked wedge of supragluteal skin to be excised is resected, leaving the subscarpal fat to aid in lymphatic
drainage. The marked gluteal flap is then de-epithelialized (Figs. 567.1D and 567.2A).
The flap is dissected down to the fascia at a perpendicular angle superiorly, medially, and laterally. The inferior
border of the flap is dissected inferiorly in an oblique angle to the level of the fascia. A pocket is created for
insertion of the flap by undermining the buttock in the plane above the gluteus maximus fascia (Fig. 567.2B). The
fascia at the
superior, medial, and lateral borders of the dermal fat flap is divided. The flap is then raised by partially dividing
the superior insertion of the gluteus maximus muscle to the posterior iliac spine and sacrum. The gluteus
maximus is then split (5 to 6 cm) to allow the flap to rotate caudally 180 degrees (Fig. 567.3).

FIGURE 567.1 Preoperative markings. A: The intersection of the inguinal crease line with the midaxillary line is
Point A. B: The cranial endpoint of the intergluteal crease is Point B. C: Pinch test used to estimate skin
resection. D: The flap is demarcated.
FIGURE 567.2 A: The gluteal flap is deepithelialized. B: A pocket is created for the flap above the gluteus

P.1536
maximus fascia.
FIGURE 567.3 A: The gluteus maximus is divided and rotated into the pocket. B: Rotated position of the gluteus
flap.
The flap is rotated caudally into the pocket and anchored. Securing the de-epithelialized surface upside down
gives the flap a more rounded and implant-like shape. The remaining buttock skin is pulled in the reverse
direction to cover the flap. The patient is then placed in the supine position, and other concurrent procedures
may be performed.
FIGURE 567.4 Preoperative (left) and postoperative (right) views of a patient who underwent autoprosthesis
buttock augmentation with circumferential body lift.

P.1537
CLINICAL RESULTS
Incorporation of the split gluteus maximus muscle facilitates the mobility and rotation of the flap caudally to
reach the gluteal crease and increases the vascular supply to the flap when compared with the dermal fat
flap. There were no cases of total flap loss or necrosis and no cases of any degree of fatty necrosis in our
case series. We did not find any cases of hematomas or seromas, probably because of the lymphatic
drainage, minimal dead space, pressure of the area, and the use of drains. Endpoints considered
aesthetically pleasing include maximum gluteal projection at the midlevel of the buttocks, verified by a
horizontal line from the point of maximal projection of the mons pubis. At the same time, ptosis correction is
verified by elevation of the gluteal mass and the correction of the infragluteal fold to a shorter line with a
downward slope. The oblique dissection increases the length and reach of the flap. The flap can be custom
shaped to each individual's need.
Another advantage of this flap in comparison with others is its caudal reach once it is mobilized, allowing for
maximal projection at the midportion of the buttocks. At the same time, moving the tissue from the area
above the buttocks inferiorly automatically creates a pleasing concavity or the effect of lumbar
hyperlordosis. Significant improvement in the waist contour is achieved by removing the excess skin from
the flanks. The trade-off is a longer scar, which, in our experience, is very well accepted, adds minimal
morbidity, and is well concealed when properly planned (Figs. 567.4 and 567.5).
FIGURE 567.5 Preoperative (left) and postoperative (right) views of a patient who underwent prior buttock
augmentation with round 270-mL silicone implants that resulted in ptosis and a double-bubble appearance.
Implants were removed, and a buttock lift with autoprosthesis augmentation was performed.
SUMMARY
The creation of an autologous buttock implant from a split muscle flap provides additional projection during
autologous buttock augmentation. The flap achieves maximum projection at the midportion of the buttocks
and creates a supragluteal concavity at the same time. The procedure allows for a more substantial
augmentation when compared with fat grafting and, in our experience, is safer than implants and allows for
a lift at the same time. It has proven to be a reliable procedure that can be used in isolated buttock lift with
augmentation, circumferential body lift, and spiral lift.
References
1. Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle flap for autoprosthesis buttock augmentation. Plast

Reconstr Surg 2012;129:766-776.
2. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast
Surg 2005;29:133-137; discussion 138-140.
3. Sozer SO, Agullo FJ, Palladino H. Autologous augmentation gluteoplasty with a dermal fat flap. Aesthet
Surg J 2008:28;70-76.
4. Sozer SO, Agullo FJ, Palladino H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation.
Aesthetic Plast Surg 2008:31;120-125.
5. Foster RD, Anthony JP, Mathes SJ, et al. Flap selection as a determinant of success in pressure sore
coverage. Arch Surg 1997;132:868-873.
6. Ichioka S, Okabe K, Tsuji S, et al. Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral
pressure ulcers. Plast Reconstr Surg 2004;114:906-909.
7. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure
sores. Plast Reconstr Surg 1993;91:678-683.
8. Park C, Park BY. Fasciocutaneous V-Y advancement flap for repair of sacral defects. Ann Plast Surg
1988;21:23-26.

P.1538
Chapter 568
Ipsilateral Gracilis Musculocutaneous Flap
G. F. SHUBAILAT
Use of the gracilis musculocutaneous flap in reconstruction of the ipsilateral ankle and lower leg region adds yet
another alternative to the limited choice of methods available (1).
INDICATIONS
The ipsilateral gracilis musculocutaneous flap can be used to cover ankle and foot defects in certain thin,
young patients. The operation is in two stages only. The other limbs and trunk are spared. Only the knee
joint is immobilized for 3 weeks, with no resultant stiffness in selected patients. Easy nursing care is
possible with the use of this flap.
ANATOMY
The detailed anatomy of the gracilis muscle is described in Chapter 441 (2).
FLAP DESIGN AND DIMENSIONS
In thin, young patients, if the knee can be fully flexed, the anterior arc of rotation can reach the anterior, medial,
and posterior aspects of the lower leg and ankle (Fig. 568.1).
FIGURE 568.1 A gracilis musculocutaneous flap applied to an ipsilateral ankle defect.
CLINICAL RESULTS

Hematoma formation under the flap, causing circulatory embarrassment, is best prevented by adequate
drainage. Partial loss of the distal end of the flap due to ischemia can be avoided if the viability of the flap is
confirmed by fluorescein. Infection, if it occurs, is usually secondary to inadequate circulation in the flap.
SUMMARY
An ipsilateral gracilis musculocutaneous flap occasionally can be used to cover ankle and foot defects in
selected thin, young patients.
References
1. Shubailat GF, Ajluni NJ, Shahateet MA. Repair of a lower leg defect with an ipsilateral gracilis
myocutaneous flap. Plast Reconstr Surg 1979; 64:560.
2. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.

P.1539
Chapter 569
Gastrocnemius Musculocutaneous Cross-Leg Flap
C. L. PUCKETT
J. F. REINISCH
Because of its low surgical and psychological morbidity, the ipsilateral gastrocnemius musculocutaneous flap has
been offered as a superior alternative to the standard cross-leg skin flap for coverage of defects of the middle
third of the lower extremity. This flap, along with other local muscle flaps and free flaps, has significantly reduced
the need for cross-leg skin flaps in recent years; however, the gastrocnemius flap can be used in a cross-leg
manner when other means of local tissue reconstruction are unavailable or rejected by the patient (1).
INDICATIONS
Its basic indication is any situation in which one would have formerly used a standard cross-leg skin flap.
Examples include (1) large tissue defects where local flaps have been destroyed or, by themselves, would
not provide sufficient coverage, (2) inadequate expertise or facilities for microsurgical reconstruction, and
(3) previous free-flap failure or poor recipient vessels for free-tissue transfer.
The gastrocnemius musculocutaneous flap can provide coverage for defects in the middle third of the leg;
however, its use as a cross-leg flap expands its range of coverage to include most of the lower extremity,
including the foot (Fig. 569.1). Its large size and its predictable vascularity allow it to cover most of the
opposite extremity without extreme positioning.
FLAP DESIGN AND DIMENSIONS
Because of proximity, the medial gastrocnemius flap is selected for cross-leg transfer. This flap carries the skin
over the muscle as well as distal skin to a point 5 cm proximal to the medial malleolus. The width of the flap
extends from the posterior midline to the medial border of the tibia (see Fig. 569.2A).
OPERATIVE TECHNIQUE
A plane between the gastrocnemius muscle and the underlying soleus muscle is developed, exposing the
plantaris tendon, which is left intact. The medial head of the gastrocnemius is separated from the lateral head
and the distal skin is elevated with its deep fascia intact to provide vascularity to the skin (Fig. 569.2B). The
saphenous vein is protected. The vascular pedicle of the flap enters proximally and is not visualized.
Because the flap is too bulky to be tubed, skin grafts are required to cover both the donor defect and the
exposed undersurface of the flap. The flap is inset, and the legs are secured either with pins (Fig. 569.2C) or
plaster. The flap can be divided between 1½ and 4 weeks following surgery. The fluorescein test is useful in
determining the time of division. Occasionally, a partial division (delay) of the pedicle under local anesthesia is
necessary before final division.
SUMMARY
Despite the advent of free-flap transfer and a variety of muscle flaps, we find the cross-leg gastrocnemius
flap a valuable occasional adjunct in lower extremity reconstruction.

FIGURE 569.1 Gastrocnemius cross-leg flap for coverage of the opposite foot.
FIGURE 569.2 Coverage of a chronic nonhealing wound following gunshot wound to lower extremity. A:
Outline of medial gastrocnemius flap. B: Elevation of the flap including the underlying medial head of the
gastrocnemius muscle and deep fascia. The soleus muscle and cut edge of the lateral head are seen in the
base of the wound. C: Coverage of the defect of the opposite leg and crossleg pin fixation.
Reference
1. Furnas DW, Anzel SH. Two consecutive repairs of the lower limbs with a single gastrocnemius
musculocutaneous cross-leg flap. Plast Reconstr Surg 1980;66:137.

Chapter 570
Gastrocnemius Musculocutaneous V-Y Advancement Flap
P. C. LINTON
The gastrocnemius musculocutaneous V-Y advancement flap can be used to reconstruct the Achilles tendon
while simultaneously closing an overlying skin and soft-tissue defect (1).
INDICATIONS
The massive gastrocnemius musculocutaneous V-Y advancement flap is clearly not a flap for all
applications. The major indication would be in those few patients in whom restoration of active ankle plantar
flexion must be combined with reconstruction of a significant soft-tissue defect. The patient whose case is
presented had a 4.5 × 7 cm skin and Achilles defect and good passive ankle flexion (see Fig. 570.3).
ANATOMY
The blood supply to the skin of the entire posterior calf to 5 cm above the medial malleolus and 7 cm above the
lateral malleolus is primarily from vessels that perforate the fascia of the underlying medial and lateral
gastrocnemius muscles (2). Distal to the muscle bellies, these perforators run superficial to the Achilles tendon.
The muscles are each supplied by a single neurovascular pedicle arising from the popliteal artery high in the
popliteal space and entering the proximal muscle belly just distal to their tendinous origins on the femur. This
neurovascular bundle is stretchable to at least 4.5 cm when the muscle origins are detached (3), allowing distal
mobilization of the functioning musculocutaneous unit, simultaneous reconstruction of Achilles tendon integrity,
active ankle plantar flexion, and soft-tissue coverage in the distal posterior ankle.
FIGURE 570.1 Schema of operation. (From Linton, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The technique consists of detachment of the proximal gastrocnemius origins, separation of the distal confluence
of soleus-gastrocnemius at the proximal Achilles tendon, advancement of the musculocutaneous unit over the
soleus bed, and distal tendon repair (Figs. 570.1 and 570.2).
The area of the distal square or rectangular defect is transferred to the proximal V-shaped donor defect, and
because of the excess tissue here, primary closure should be possible as a V-Y. The skin island must be tacked

P.1541
to the fascia with particular care distally in the tendinous region because it is here that the greatest risk of
devascularization exists. To facilitate closure, the proximal portion of the skin island should be designed as a
long, narrow V, taking care to start the point of the V at or distal to the popliteal flexion crease in order to prevent
flexion contracture. Access to the neurovascular pedicle and muscle origins proximally should be through a Z
incision in the popliteal area for the same reason (Fig. 570.3C).
Following surgery, the knee should be splinted at 90 degrees to relieve all tension on the neurovascular leash
and on the Achilles repair. Gradual knee extension is allowed after soft-tissue healing has occurred.
FIGURE 570.2 Operative design. (From Linton, ref. 1, with permission.)

P.1542
FIGURE 570.3 A,B: Preoperative defect. C: Flap raised on its neurovascular pedicles. D,E: Postoperative result
with 20 degrees of active range of motion. (From Linton, ref. 1, with permission.)
CLINICAL RESULTS
In my patient, nearly 6 months elapsed before full knee extension was achieved. No complications or
functional deficits resulted, and at 1 year the patient was walking with virtually no limp (1).
SUMMARY
The gastrocnemius musculocutaneous V-Y advancement flap can be used simultaneously to reconstruct
defects of the Achilles tendon and overlying skin and soft tissue.
References
1. Linton PC. The combined medial and lateral gastrocnemius musculocutaneous V-Y island advancement
flap. Plast Reconstr Surg 1982;70:490.
2. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular pedicles.
Plast Reconstr Surg 1977;60:3.
3. Dibbell DG, Edstrom LE. The gastrocnemius myocutaneous flap. Clin Plast Surg 1980;7:45.

Chapter 571
Microneurovascular Free Transfer of A Dorsalis Pedis Flap to The
Heel
L. A. SHARZER
Skin coverage of weight-bearing areas such as the heel is a controversial problem in reconstructive surgery. It is
well known that coverage with skin grafts may be adequate and well tolerated in the intelligent, motivated patient.
Nevertheless, many patients require flap coverage. It was previously shown that the provision of sensation to the
insensate heel can prevent recurrent breakdown (1, 2, 3, 4).
INDICATIONS
Most reports of the dorsalis pedis neurovascular island flap involve reconstruction of the hand (5, 6, 7). In
these, a two-point discrimination of 10 to 20 mm is usual. The dorsalis pedis flap has been used in lower-
extremity reconstruction of the same leg as an island flap (8, 9) or in the opposite leg as a free flap. Only
one author has discussed its use as a free neurovascular flap to a weight-bearing area of the other foot (7).
The three patients achieved a 10- to 20-mm two-point discrimination.
ANATOMY
The vascular anatomy is described in Chapter 548.
Cutaneous sensation is supplied to the dorsal foot skin by means of the superficial peroneal nerve. The
superficial peroneal nerve, one of the two terminal branches of the common peroneal nerve, arises high in the
leg between the tibialis and the peroneus longus muscles. It passes distally between the extensor digitorum
longus and the peronei to the distal third of the leg, where it pierces the deep fascia on its way to the dorsum of
the foot. Whereas it is rarely necessary to dissect a very long nerve pedicle, it is possible to do so. This is
particularly useful if the recipient-site nerve is far from the heel. In the distal third of the leg, the superficial
peroneal nerve bifurcates to form the medial and intermediate dorsal cutaneous nerves (Fig. 571.1A). These
nerves cross the ankle joint superficial to the extensor retinaculum. It is here that they are encountered during
the elevation of the flap.
FLAP DESIGN AND DIMENSIONS
The vascular anatomy and technique of elevation of the dorsalis pedis flap are as described in Chapter 548. A
few considerations are necessary when the flap is being used to provide sensory skin over the heel (Fig. 571.1).
Pretransfer delay of the flap is rarely necessary for a dorsalis pedis flap used in this manner. The defects are
often not large enough to require an augmented flap, and the weight-bearing area is almost always of a size that
can be covered by an undelayed flap. If the entire plantar defect is larger than the flap, the non-weight-bearing
areas usually can be covered by skin grafts.
Preoperative arteriography is routine and should be performed on both the donor and recipient legs. It is
important to assess the quality, location, and patency of the dorsalis pedis artery as well as the collateral
circulation. In the recipient leg, the location, continuity, and patency of all vessels must be determined. Mere
presence of pulses may be unreliable because of reverse flow by means of plantar anastomoses.
Generally, the posterior tibial artery and the sural nerve are the recipient structures of choice. They are located

P.1543
near the heel, allowing relatively short pedicles. The vessels are of good caliber, and the nerve is a pure sensory
nerve. Furthermore, the sensory consequences of sural nerve division are not serious. The nerve can be traced
high in the leg, if necessary, to reach a normal fascicular pattern.
FIGURE 571.1 A: Outline of neurovascular dorsalis pedis flap (solid line, dorsalis pedis artery; broken line,
superficial draining veins; x's, superficial peroneal nerve). B: Dissected flap. (Hemostat points to vascular
pedicle and probe to nerve pedicle.) C: Deep aspect of flap. (Note the nerve and vascular pedicles.) D: Note the
long vascular pedicle and very long nerve pedicle that can be obtained.
OPERATIVE TECHNIQUE
Elevation of a neurovascular dorsalis pedis flap begins similarly to a standard dorsalis pedis flap (Fig. 571.1B-D).
When the distal incision is made, the terminal branches of the superficial peroneal nerve are found as they cross
to the toes and are divided. As the lateral portion of the flap is elevated, these nerve branches may be used as a
guide to locate the one or two main trunks of the superficial peroneal nerve proximally in the foot.
After making the distal, medial, and lateral incisions of the flap, the medial portion is dissected toward the
vascular pedicle and the distal portion toward the penetrating branch of the dorsalis pedis artery. As the lateral
portion of the flap is elevated, the nerves are usually found at the proximal lateral corner. Further dissection of
the proximal edge of the flap toward the vascular pedicle is then limited, depending on the length of the nerve
required. The skin only may be incised and then with a longitudinal incision made proximally in the leg. The leg
skin is then elevated off the extensor retinaculum to allow as much proximal dissection of the superficial peroneal
nerve as required. Once adequate length has been obtained and the nerve is divided, the remainder of the flap
dissection can proceed (Fig. 571.1D). The retinaculum is divided, and the vascular pedicle is traced into the

P.1544
anterior tibial vasculature as far proximally as necessary. The donor site is closed with a skin graft.
After transfer, the flap is usually tacked in place and the vascular anastomoses are carried out either end-to-side
or end-to-end. The sural nerve is divided as far distally as possible, at a point where normal fascicular structures
are noted. The superficial peroneal nerve is divided so that it will fit comfortably without redundancy or tension,
and a careful microscopic anastomosis is carried out.
Postoperative management requires continuous elevation of the flap, which generally means that the patient
remains in the prone position for the first postoperative week. Dependency of the leg is not allowed for 3 weeks,
and partial weight bearing is begun at 6 weeks and is increased as tolerated. The evolution of sensibility in the
flap is assessed by following an advancing Tinel's sign.
SUMMARY
The dorsalis pedis free flap can provide stable skin coverage over the heel with protective tactile sensation
(Fig. 571.2).
FIG. 571.2. A: Recurrent breakdown of the heel. B: Postoperative appearance of the heel covered by
dorsalis pedis neurovascular free flap.
References
1. Snyder GB, Edgerton MT. The principles of the island neurovascular flap in the management of ulcerated
anesthetic weight-bearing areas of the lower extremity. Plast Reconstr Surg 1965;36:518.
2. Kaplan I. Neurovascular island flap in the treatment of trophic ulceration of the heel. Br J Plast Surg
1969;22:143.
3. Maquiera NO. An innervated full-thickness skin graft to restore sensibility to finger tips and heels. Plast
Reconstr Surg 1974;53:568.
4. Lister GD. Use of an innervated skin graft to provide sensation to the reconstructed heel. Plast Reconstr
Surg 1978;62:157.
5. Daniel RK, Terzis JK, Midgley RD. Restoration of sensation to an anesthetic hand by a free neurovascular
flap from the foot. Plast Reconstr Surg 1976;57:275.
6. Ohmori K, Harii K. Free dosalis pedis sensory flap to the hand with microneurovascular anastomoses.

Plast Reconstr Surg 1976;58:546.
7. Robinson DW. Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg
1976;29:209.
8. Kobus K, Licznerski A, Stepniewski J, Charles W. Management of island and free dorsalis pedis flaps in
surgery of the lower extremities. Acta Clin Plast 1980;22:138.
9. McCraw JB, Furlow LT. The dorsalis pedis arterialized flap: A clinical study. Plast Reconstr Surg
1975;55:177

P.1545
Chapter 572
Free Parietotemporalis Fascial Flap
J. UPTON
C. M. RODGERS
The anatomy, flap design, and operative technique of this flap are described in Chapter 318.
INDICATIONS
Our most common use has been to provide stable coverage with minimal bulk over localized defects in the
extremities in difficult regions. In the lower extremity, the free parietotemporalis fascial flap can be used for
coverage of small pretibial defects, exposed Achilles tendons, and exposed extensor tendon and/or bone in
the dorsum of the foot (Fig. 572.1).
FIGURE 572.1 A: Professional ballet dancer who, while performing in December 1981, ruptured his Achilles
tendon. Following a primary repair with tendon graft by an orthopedic surgeon, his wound dehisced,
became infected, and failed to heal. By the fall 1982, he was unable to walk because of pain. Following
multiple debridements, his wound healed spontaneously. B: Reconstruction consisted of thorough excision
of scar tissue and release of the Achilles tendon from the peroneus longus and brevis tendons as well as
from the posterior joint capsule. The superficial temporal vessels of the flap were joined end-to-side into the

posterior tibial artery and end-to-end into one vena comitans. Then the vascularized flap was wrapped
completely around the Achilles tendon, obliterating a potential space and providing external coverage. The
areolar side of the flap faced the Achilles tendon as a gliding surface. A split-thickness skin graft completed
the external skin coverage. C,D: Within 6 weeks, the patient had regained enough motion to ambulate
without assistance. In 5 months, he was teaching in a professional dance studio.

Chapter 573
Free Scapular Flap
L. FONSECA DOS SANTOS
A. GILBERT
The scapular flap, based on the cutaneous branches of the subscapular artery, has become a favored donor site
for free vascularized tissue transfer (1, 2, 3, 4, 5, 6, 7).
INDICATIONS
The free scapular flap has the advantages of strong skin and a thin subcutaneous pedicle. It is especially
good for defects about the heel and ankle.
ANATOMY
The subscapular artery, a branch of the axillary artery, divides rapidly into an inferior branch, the thoracodorsal
artery, and a posterior branch, the circumflex scapular artery (Fig. 573.1). It runs between the teres major and
minor to reach the lateral side of the scapula. The circumflex scapular artery divides into several branches. The
first of these vascularizes the subscapular muscle and runs between the muscle and the deep side of the
scapula.
FIGURE 573.1 The circumflex scapular artery as it arises from the axillary artery and emerges between the teres
major and minor muscles.
There are then two branches that supply the supraspinatus and infraspinatus and the teres major and minor.
This whole vascular system gives a rich blood supply to the lateral side of the scapula. Finally, the subscapular
artery takes a downward turn and goes toward the tip of the scapula along its lateral side, turning into bony
muscular and cutaneous branches.
The main branch to the skin starts from the circumflex scapular artery at the level where it reaches the side of the

P.1547
scapula. Then it extends over toward the infraspinatus to divide shortly into two or three branches.
The subscapular artery was always present in our anatomic studies of 70 cases. In one clinical case, the artery
could not be found. Its diameter varies between 0.8 and 2.0 mm from the lateral side of the scapula. If the trunk
of the circumflex scapular artery is used, the diameter can reach 3 mm. The artery is usually accompanied by two
veins, of which only one has a significant diameter (2-3 mm).
The circumflex scapular artery usually emerges at a point two fifths of the distance between the spine of the
scapula and its lower angle. The artery can be felt quite easily in thin patients, or it can be identified with a
Doppler probe.
FLAP DESIGN AND DIMENSIONS
The flap is then drawn horizontally or diagonally, with the pedicle on its lateral extremity (Fig. 573.2). The pedicle
is located on the lateral side of the flap for two reasons: (1) the cutaneous branches run toward the midline and
(2) the subcutaneous fat in the axillary area is very thick. The cutaneous territory of this flap is not yet well
defined. It extends at least to the midline of the back and has been successfully raised to a length of 30 cm.
OPERATIVE TECHNIQUE
The arm is maintained in 90 degrees of abduction during elevation of the flap. The flap is elevated just above the
fascia of the infraspinatus muscle. Once half the flap is raised, the vascular pedicle can be identified as it
emerges at the lateral edge of the muscle. At this point, it is still possible to modify the lateral part of the incision
to correct a possible error in planning.
FIGURE 573.2 The flap outlined in the lower scapular region.

P.1548
FIGURE 573.3 A: Unstable scar of the heel in a 42-year-old woman. B: Immediately after resection and
coverage with the scapular flap. C,D: Two months postoperatively the flap is thin and does not need defatting.
The rest of the incision is completed. The flap remains attached only to its vascular pedicle. This dissection is
the most delicate part of the surgery, because there are multiple branches and the difficulty increases with depth.
The dissection progresses slowly, each branch being tied separately. Vascular clips can be used to gain time.
Up to the appearance of the subscapular branch, the pedicle measures about 6 to 8 cm. Beyond that, the
dissection requires a wider area that is rarely justified.
The donor site can be closed primarily, undermining the edges if necessary. A suction drain is left in place.
CLINICAL RESULTS
Between 1979 and 1982, 32 free scapular skin flaps have been performed (Fig. 573.3).
SUMMARY
The free scapular skin flap has become an ideal donor site for reconstruction of leg and ankle defects.
References
1. Fonseca dos Santos L. Le lambeau scapulaire et l'artère cutanée scapulaire. Paris: Mémoires de la
Laboratoire Anatomique de la Faculté du Médicine, 1980.

2. Hamilton SG, Morrison W. The scapular free flap. Br J Plast Surg 1982;35:2.
3. Mayou B, Whitby D, Jones B. The scapular flap: anatomical and clinical study. Br J Plast Surg 1982;35:8.
4. Marcondez-Nassif T, Vidal L, Bovet JL, Baudet J. The parascapular flap: a new cutaneous microsurgical
free flap. Plast Reconstr Surg 1982;69:591.
5. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982;69:601.
6. Urbaniak J, Koman L, Goldner R, et al. The vascularized cutaneous scapular flap. Plast Reconstr Surg
1982;69:772.
7. Barwick W, Goodkind D, Serafin D. The free scapular flap. Plast Reconstr Surg 1982;69:778.

P.1549
Chapter 574
Microneurovascular Free Inferior Gluteal Artery Perforator (Igap)
Fasciocutaneous Flap for Achilles Tendon Defects
C. PAPP
C. WINDHOFER
The fasciocutaneous infragluteal (FCI) free flap is a viable option in repair of acute rupture of the Achilles tendon
with combined skin, soft-tissue, and tendon defects. When used for reconstruction, it provides protection against
rerupture and allows full weight-bearing, with good range of motion of the ankle.
INDICATIONS
Repair of an acute rupture of the Achilles tendon usually undergoes an uneventful course. However, some
cases may be complicated by infection or rerupture with soft-tissue loss. In these cases, there is often a
need for secondary reconstruction (1, 2, 3, 4, 5). The fasciocutaneous infragluteal free flap is sensate,
giving the patient the advantage of avoiding skin breakdown due to repetitive trauma in the region (6).
The FCI free flap described is not used only for Achilles tendon reconstruction. We also obtain acceptable
results when it is used as a free flap for breast reconstruction or augmentation (7). We also have used it as
a free flap for defects of the lower extremity. It can be used as a transposition flap to reconstruct defects in
the gluteal and perineal regions, as well as for vaginal reconstruction. The length of the vascular pedicle
(up to 18 cm) and the ability to raise subcutaneous tissue with the skin island make the FCI an attractive
alternative for reconstruction with these indications.
ANATOMY
The blood supply of the FCI flap is an end branch of the inferior gluteal artery (IGA). It is important to note that
the blood supply of this flap does not perforate the gluteal muscle at any point. The IGA supplies the skin of the
posterior thigh region, the majority of the blood supply to the lower two thirds of the gluteus maximus muscle, and
it supplies perforators to the overlying skin (8). The inferior gluteal artery perforator (IGAP) flap is supplied by
these perforators (9, 10). The fasciocutaneous posterior thigh flap, described by Hurwitz et al. (11), is also
supplied by the descending branch of the IGA. One branch of this vessel, which courses around the lower border
of the gluteus maximus muscle and ascends to the subcutaneous and fascial tissue of the gluteal crease region,
provides the blood supply of the FCI. An epifascial and subdermal vascular plexus supplied by this cutaneous
branch ensures optimal vascularization of both the subcutaneous and fascial structures in the flap area (12, 13).
Sensory innervation of the inferior gluteal region is provided by the inferior cluneal nerves, branches of the
posterior femoral cutaneous nerve. These nerves course around the lower border of the gluteus maximus muscle
together with the cutaneous branch of the IGA. On the basis of 118 anatomic preparations, we were able to show
the close relation between
the femoral cutaneous nerve and the descending branch of the IGA. The nerve formed a loop around the vessel
in 29% of the dissections. The descending branch of the IGA was present in 91%, and the cutaneous branch
was a constant finding. When the descending artery was absent, this cutaneous branch came from the medial or
lateral femoral circumflex artery of the thigh or from a perforator of the deep femoral artery (13).

Another anatomic consideration that is vital to this flap is the fascial network in the area. The sheets of the
gluteal fascia and the fascia lata of the thigh converge at the gluteal crease. Where these fascial structures
meet, the so-called “raphe” is fixed to the ischial tuberosity by the ischiocutaneous ligament. The subcutaneous
tissue is firmly anchored between the dermis and the gluteal fascia. Vertical tension is maintained right through
the fascia to the intramuscular septa of the gluteus muscle. This special architecture of the connective tissue
makes the skin of this region particularly resistant to mechanical stress (8).
FLAP DESIGN AND DIMENSIONS
The most important landmark for designing the flap is the gluteal crease. The flap is positioned over the crease
in a transverse fashion (Fig. 574.1). The dimensions of the skin island depend on the dimensions of the soft-
tissue defect over the Achilles tendon.
The FCI can be safely raised up to 26 × 8 cm. It is important to include the gluteal fascia, as well as the proximal
portion of the fascia lata. Temporary flap design should be done preoperatively with the patient in the standing
position. A duplex Doppler ultrasound preoperatively can be obtained, to confirm the presence of the descending
branch of the IGA. The position of the vessel can be marked on the skin. This allows the surgeon to redesign the
flap intraoperatively, if necessary.
OPERATIVE TECHNIQUE
With the patient in a prone position, the first step is to perform debridement of the Achilles defect. This allows
precise definition of the extent of the defect before reconstruction is initiated. After this is done, the flap can be
harvested. If necessary, the flap can be redesigned, based on the vessel that was located by ultrasound
preoperatively. When harvesting the flap, the first step in finding the vessels and sensory nerve is to incise the
lateral margin. A lateral-to-medial dissection is the safest approach. At this point, the skin, subcutaneous tissue,
and fascia are dissected en bloc from the gluteal muscle. The gluteal muscle fibers run obliquely, and the
descending branch of the IGA supplying the flap, as well as the nerve, can be found at the inferomedial border of
the muscle.
FIGURE 574.1 Flap design in the left gluteal crease region after incision of the skin. Vessel loop winds around
the posterior femoral cutaneous nerve on the lower border of the flap. Marking the nerve avoids injuring it in
further preparation. m, Medial aspect of the left gluteal crease.
As the fascia is dissected from the muscle fibers, care must be taken to include the intramuscular septae within
the fascial layer of the flap. This provides additional fascial thickness and strength for the tendon repair. During
the dissection of the fascia from the muscle, the myocutaneous perforators from the IGA are encountered and
may be ligated.
When the border of the gluteus muscle is reached, care is taken in dissection of the neurovascular supply. Once
the neurovascular structures are identified, the medial and inferior margins of the flap are incised to raise the flap

P.1550
completely on its neurovascular pedicle. During the medial dissection, it is important to avoid injuring the bursa
over the ischial tuberosity while elevating the ischiocutaneous ligament, and lifting the perimysium of the ischial
crural musculature laterally. In our experience, resection of the bursa over the ischial tuberosity leads to long-
term problems in sitting.
Once the skin and subcutaneous tissues of the flap are completely free from the surrounding tissue, the pedicle
can then be further dissected. To isolate the pedicle, the gluteal muscle is retracted superiorly, and the vessel is
dissected free to the level of the infrapiriform foramen. At this point, the artery and vein can be divided. Below the
foramen, in most cases, a more prominent branch of the inferior gluteal artery to the gluteus maximus originates.
This branch can be ligated before it perforates the muscle. Ligating the branch allows one to achieve an
additional 2 to 3 cm of pedicle length. The mean length of the vascular pedicle prepared in our institution was 16
cm.
When dissecting the vascular pedicle at the inferomedial border of the gluteus muscle, the posterior femoral
cutaneous nerve runs with the vessel. As our anatomic investigations have shown, the posterior femoral
cutaneous nerve beneath the gluteus maximus muscle often forms tight loops around the vessels supplying the
flap or around a branch of these vessels. This often requires a microscopic division of the epineurium, so that the
vascular pedicle can be pulled through this gap. As the posterior femoral cutaneous nerve courses to the
posterior thigh, it gives off the inferior cluneal nerves, branches that provide sensation to the flap (Fig. 574.2).
During incision of the subcutaneous tissue, care should be taken to avoid injury to the posterior femoral
cutaneous nerve, but the vessel to the posterior thigh is ligated as the dissection proceeds.
It should be noted that, in 118 anatomic preparations investigated, a variant of the blood supply was observed in
only 10 cases. In these instances, the cutaneous branch to the fascia was supplied either by a circumflex femoral
artery or by a perforator of the deep femoral artery. Such variations, however, were not encountered in any of
our 110 operative cases. After the flap is harvested, the wound is carefully repaired in layers. The flap is
transferred, and the Achilles tendon is reconstructed first. The fascial part of the flap is rolled into a tube and
sutured in a circular fashion to the distal and proximal edges of the tendon stump. This wraparound method
enables stability in both partial and total Achilles tendon reconstructions.
The arterial anastomosis is performed end-to-side, and the veins are usually anastomosed end-to-end. This
prevents circulatory problems in the foot, particularly in older patients with peripheral vascular disease. The
cluneal branch from the posterior femoral cutaneous nerve is coapted to a branch of the sural nerve to restore
sensation. Finally, the skin and subcutaneous tissue are sutured in place.
FIGURE 574.2 Raised FCI flap with neurovascular pedicle (*), in relation to gluteus maximus muscle (arrows,

lower border of the muscle). The posterior femoral cutaneous nerve is looped and isolated from the vascular
pedicle. m, Medial aspect of the gluteal crease.
CLINICAL RESULTS
In our series, 13 patients underwent repair of the Achilles tendon defect with the FCI. In 11 of our 13
patients, the Achilles tendon was reconstructed with good function of the ankle joint. One diabetic patient
required below-the-knee amputation, because of gangrene elsewhere in the extremity. Despite the need for
amputation, the Achilles-tendon repair was able to tolerate full weight. The second patient without a full
recovery was an obese female, who had arthritis of the knee and hip joint. Despite full weight bearing of the
Achilles tendon and acceptable motion in the ankle joint, total recovery did not take place, because of pain
in the other joints of the leg. The other patients have returned to work, with no restrictions in activities of
daily living. It is also worth mentioning that seven patients are able to pursue sporting activities, such as
climbing, jogging, cycling, and tennis, without restrictions. Minor complications, such as donor-site seroma,
were managed conservatively and did not affect final outcome.
FIGURE 574.3 Donor-site scar in the left gluteal crease, 66 months after flap raising.
In six patients, sensory innervation of the flap was accomplished by coaptation to the sural nerve. In the
other cases, the patients reported deep sensation of pressure. After a mean follow- up period of 66 months,
recipients were able to recognize stress caused by pressure (Fig. 574.3).
To achieve a better aesthetic result, we performed liposuction in nine patients, to contour the flap. We
believe that primary liposuction is possible in younger patients with healthy vessels; otherwise, a delay of 4
to 6 months is warranted. Three patients in our group were satisfied with the flap, despite the bulkiness,
and they declined liposuction. In the other two cases, liposuction was not required because of satisfactory
aesthetic results.
SUMMARY
In our experience, the FCI, based on the end branch of the descending branch of the IGA, has been a viable
option for functional and sensate Achilles-tendon repair, when soft-tissue reconstruction is also necessary.
It has a dependable anatomy and reproducible results.
References

1. Deiler S, Pfadenhauser A, Widmann J, Stützle H. Tensor fasciae latae perforator flap for reconstruction of
composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg 2000;106:342.
2. Sylaidis P, Fatah MFT. A composite lateral arm flap for the secondary repair of a multiply ruptured Achilles
tendon. Plast Reconstr Surg 1995;96:1719.
3. Inoue T, Tanaka I, Imai K, Hatoko M. Reconstruction of Achilles tendon using vascularised fascia lata with
free lateral thigh flap. Br J Plast Surg 1990;43:728.
4. Lee IW, Yu IC, Shieh SJ, et al. Reconstruction of the Achilles tendon and overlying soft tissue using
antero-lateral thigh free flap. Br J Plast Surg 2000;53:574.
5. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of Achilles tendon and calcaneus defects
with skin-aponeurosis-bone composite free tissue from the groin region. Plast Reconstr Surg 1988;81:579.
6. Papp C, Todoroff BP, Windhofer C, Gruber S. Partial and complete reconstruction of Achilles tendon
defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg 2003;112:777.
7. Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap
(FCI). Ann Plast Surg 2007;58:131.
8. Lanz T, Wachsmuth W. Praktische anatomie, Bein und Statik, vol. I/part 4. Berlin: Springer Verlag, 1938.
9. Allen RJ. Perforator flaps in breast reconstruction. In: Spear SL, Little JW, Lippman ME, et al., eds.
Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven, 1998.
10. Guerra AB, Allen RJ, Levine JL, Erhard HA. Inferior gluteal artery perforator flap. In: Blondeel PN, Morris
SF, Hallock GG, et al., eds. Perforator flaps: anatomy, technique and clinical applications. St. Louis: Quality
Medical Publishing, 2006.
11. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable, sensate flap for closure of buttock
and perineal wounds. Plast Reconstr Surg 1981;68:521.
12. Frick A, Baumeister RGH, Wiebecke B. Microvasculature of the inferior gluteal flap. Eur J Plast Surg
1993;16:30.
13. Windhofer C, Brenner E, Moriggl B, and Papp C. Relationship between the descending branch of the
inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery. Surg Radiol Anat
2002;24:253.

Chapter 575
Scapular and Parascapular Flaps
J. BAUDET
T. NASSIF
J. L. BOVET
B. PANCONI
See Chapter 321 and Figures 575.1 and 575.2 for details.
FIGURE 575.1 A: Unstable scar on a forefoot amputation. B: Excellent padding after a parascapular flap
transfer.
FIGURE 575.2 A: Repetitive ulceration of the Achilles tendon area despite an attempt at resurfacing by a local
flap. B: Early postoperative result using a parascapular flap prior to a defatting procedure.

P.1552
Chapter 576
Microneurovascular Skin and Osteocutaneous Free Radial Artery
Flap
E. BIEMER
W. STOCK
The radial artery flap can be used as a free flap to cover defects in the foot and lower extremity. It provides thin,
pliable skin that can provide sensation through anastomoses with the antebrachial cutaneous nerves. By
incorporating a portion of vascularized radius, the flap also can be used as a free osteocutaneous flap (Fig.
576.1).
FIGURE 576.1 A: Total foot amputation that was successfully replanted. (Continued)
FIGURE 576.1 (Continued) B,C: An area of local necrosis at the heel was covered by a free radial artery
sensitive flap, which allows the patient to work full time as a dentist.

P.1553
Chapter 577
Microvascular Composite Serratus Anterior and Rib Flap for Tibial
Composite Bone and Soft-Tissue Defect
C. H. LIN
Lower-extremity bone defects may result from direct traumatic open fractures, tumor resections, and debridement
of osteomyelitic lesions and nonunions. For small bone defects with adequate soft-tissue coverage, the bone gap
can be bridged with conventional cancellous bone grafts or bone substitutes. However, when the segmental
bone defects are larger than 6 cm, with or without soft-tissue defect, they often require either microsurgical
vascularized bone flaps or Ilizarov bone-transplantation techniques to achieve a functional limb.
INDICATIONS
The fibula flap is generally accepted as the most suitable vascularized bone graft for the reconstruction of
composite segmental long-bone defects (1, 2, 3, 4, 5). The vascularized iliac bone flap has an undesirable
curvature, limited length (usually less than 10 to 12 cm), and unreliable skin paddle (6). Regarding its
clinical application, the iliac flap is used for less extensive composite bone and soft-tissue defect
reconstruction. Two situations may preclude the application of fibular and iliac flaps: one situation is that of
patients with severely traumatized limbs who have either bilateral tibia-fibula fractures or a contralateral limb
that was amputated during trauma; the other situation is when the iliac bone is used for conventional bone
grafting or extensive composite defect (7, 8).
The serratus anterior rib flap has the versatility of providing extensive bone length of more than 15 cm, and
accompanying serratus anterior muscle or latissimus dorsi muscle; thus the rib flap can afford composite
bone and soft tissue for lower-extremity defect reconstruction in a one-stage procedure (Fig. 577.1).
ANATOMY
With the periosteal blood supply originating from the serratus anterior muscle, the rib maintains viability for
segmental bony-defect reconstruction. The two main terminal branches
of the subscapular artery consist of a serratus anterior branch providing the circulation to the serratus anterior
muscle and the rib flap, and the other branch, the thoracodorsal artery, to the latissimus dorsi muscle, providing
the required soft tissue for defect obliteration or coverage (9, 10, 11, 12, 13).

P.1554
FIGURE 577.1 A 17-year-old boy sustained bilateral tibia-fibular fracture with composite defect. A: Serratus
anterior myocutaneous flap and ribs 5 and 7 harvested. B: Right leg-rib hypertrophy, 10-year follow-up. C: Left
leg-ribs, 10-year follow-up. D: Anterior view of reconstructed legs after 10 years. (From Lin et al., ref. 7, with
permission.)
FLAP DESIGN AND DIMENSIONS
Regarding the maintenance of serratus anterior muscle function, the upper four ribs should be preserved; thus
the flap will be designed along the fifth to the eighth ribs, as long as 20 cm from the nipple line to the scapula. A
serratus anterior myocutaneous flap, with a skin paddle 7 cm wide and 20 cm long, is preferable, and the skin
paddle can be used for coverage of the pedicle and wound. Because the rib is composed of thin and
membranous bone, the strength to withstand weight bearing may be inadequate. This mandates harvesting two
alternative ribs (ribs 5 and 7, or 6 and 8), or three ribs with one rib accompanied by two alternative neighboring
ribs (ribs 5, 7, and 8, or 5, 6, and 8), to increase the cross-sectional area and to meet the needs of lower-limb
reconstruction (1, 7).
OPERATIVE TECHNIQUE
The patient is placed in a decubitus position, either on the same side or the contralateral side, depending on the
location of the defect and recipient vessel, to allow a simultaneous, two-team approach. First, the serratus

anterior branch and the subscapular artery are dissected for upper serratus anterior muscle-belly and long
thoracic-nerve preservation. The rib is elevated from the lowest to the uppermost rib in continuity, with the
overlying serratus anterior muscle. One rib or alternative ribs are dissected subperiosteally to the required length
and cut with meticulous care, to prevent injury to the pleura. The intercostal muscle is cut, the intercostal vessels
and nerve are clipped, and the rib is taken with a cuff of intercostal muscle and carried down to the
perichondrium, where it is dissected off the underlying parietal pleura. In cases of extensive soft-tissue defect,
the thoracodorsal artery and the accompanying partial or entire latissimus dorsi muscle can be elevated based
on the upstream subscapular artery.
Because the serratus anterior-rib flap has an unfavorable curvature and is thin, the recipient site requires an
external fixator for stability. The curved rib requires an osteotomy at its midpoint, and its proximal and distal ends
are fixed with screws to the tibial stumps. It is not uncommon that a split-thickness skin graft is needed for
covering the serratus anterior and latissimus dorsi muscle, and the remaining skin defect.
CLINICAL RESULTS
Transferred bone or bone-graft hypertrophy is a time-related phenomenon; various factors are involved in
the speed and extent (14, 15, 16), including the native bone-framework structural deformity and integrity at
the recipient site, the nature of the grafted bone, and functional stress. Patients should be encouraged to
pursue early partial weight-bearing with an external fixator, thus exposing the bone graft to stress, to
promote bone union, remodeling, and hypertrophy. The rib-bone hypertrophy increases gradually after bone
and osteotomy union. After the bone develops adequate hypertrophy, usually around 6 to 8 months, the
external fixator can be replaced with a protective brace until 18 to 24 months postoperatively, to prevent
stress fracture.
The incidence of stress fracture in rib flaps was 14.3% (three of 21 flaps). Theoretically, the occurrence of
stress fracture is length related; however, our series revealed no correlation with graft length. The other
interesting point was that all stress fractures occurred in patients having two bone struts. One possible
reason is that the longer or one-strut bone grafts or both might have had more protection: stress fractures
occurred when patients fell, were running, or were getting out of the bathtub, without wearing the protective
brace. Therefore the nature of patient activity and brace protection are critical in the postoperative care of
these bone grafts. Finally, 18 of 22 patients (81.8%) could walk without crutches at a 2-year follow-up.
Sixteen of 18 patients had primary reconstruction with a serratus anterior-rib flap, and the other two patients
had rib-flap failures and required secondary surgical procedures and Ilizarov bone transportation
techniques.
The viability of the vascularized bone flap will determine the healing and hypertrophy of the bone, and the
final functional results. An optimal vascularized composite-tissue procedure should provide reliable, high
success-rate transfer, adequate bone length and cross-sectional area, and minimal donor-site morbidity and
should be versatile enough that the flap can be transferred as an isolated bone flap or with accompanying
soft tissue (1, 7, 14, 15, 16). The fibular flap is the surgery of choice for lower-extremity bony-defect
reconstruction. The serratus anterior-rib is an alternative method.
The limitations of the vascularized serratus anterior-rib bone grafts in lower-extremity reconstruction are (a)
ribs are curved rather than straight; and (b) limited cross-sectional area is present to withstand body-weight
load. For lower-extremity reconstruction, one rib graft is too weak to support body weight. Theoretically, two
or three sections of ribs should be used to provide more strength and to support axial weight-bearing. This
relatively increases chest-wall morbidity (3). The ribs are of membranous bone and have less mechanical
strength than the cortical straight fibula (4). Inferior functional results compare well with those of other
composite flaps. Overall bone union and bone hypertrophy take a long time, which affects the patient's daily

P.1555
life quality and the length of the period back to work (5). The rate of overall recipient- and donor-site
complications is higher than with other vascularized bone transfers (1, 7, 17, 18). The most common and
noteworthy complication that develops in elevating this flap is pleural injury. This is another reason why the
clinical application of vascularized rib grafts has not been carried out extensively. Because of all these
reasons, transfer indications should be highly selective and restricted. The serratus anterior-rib flap is still
rarely used for lower-extremity bone defect reconstruction.
SUMMARY
The subscapular artery provides a sizable long pedicle that carries the serratus anterior branch for the
serratus anterior-rib flap and the thoracodorsal artery for the latissimus dorsi muscle flap. This arterial
system allows many composite segments to be transferred for segmental bone defects, extensive soft-
tissue coverage, and for three-dimensional dead-space obliteration simultaneously in a one-stage
composite reconstruction. Recently, our major indication for the serratus anterior-rib flap for lower-extremity
reconstruction has been bilateral composite tibia-fibular bone or extensive composite bone and soft-tissue
defects.
References
1. Lin CH, Wei FC, Chen HC, Chuang DCC. Outcome comparison in traumatic lower-extremity reconstruction
by using various composite vascularized bone transplantation. Plast Reconstr Surg 1999;104:984.
2. Yaremchuk MJ, Brumback RJ, Manson PN, et al. Acute and definitive management of traumatic
osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987;80:1.
3. Banic A, Hertel R. Double vascular fibulas for reconstruction of large tibial defects. Microsurgery
1993;9:421.
4. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and
clinical application. Plast Reconstr Surg 1986;78:191.
5. Wei FC, El-Gammal TA, Lin CH, Ueng WN. Free fibula osteosepto-cutaneous graft for reconstruction of
segmental femoral shaft defects. J Trauma 1997;43:784.
6. Hierner R, Wood MB. Comparison of vascularized iliac crest and vascularized fibula transfer for
reconstruction of segmental and partial bone defects in long bones of the lower extremities. Microsurgery
1995;16:818.
7. Lin CH, Wei FC, Levin LS, et al. Free composite serratus anterior and rib flaps for tibial composite bone
and soft tissue defect. Plast Reconstr Surg 1997;99:1656.
8. Lin CH, Yazar S. Revisiting the serratus anterior rib flap for composite tibial defects. Plast Reconstr Surg
2004;114:1871.

9. Serafin D, Villareal-Rios A, Georgiade NG. A rib-containing free flap to reconstruct mandibular defect. Br J
Plast Surg 1977;30:263.
10. Ariyan S. The viability of rib grafts transplanted with a periosteal blood supply. Plast Reconstr Surg
1980;65:140.
11. Buncke HJ, Furnas DW, Gordon L, Achauer BM. Free osteocutaneous flap from a rib to the tibia. Plast
Reconstr Surg 1977;59: 799.
12. Ohsumi N, Shimamoto R, Tsukageshi TT. Free composite latissimus dorsi muscle-rib flap not containing
the intercostal artery and vein for reconstruction of bone and soft tissue defects. Plast Reconstr Surg
1993;94:372.
13. Moscona RA, Ullman Y, Hirshowitz B. Free composite serratus anterior muscle-rib-flap for reconstruction
of a severely damaged foot. Ann Plast Surg 1988;20:167.
14. Cierny G, Zorn KE, Nahai F. Bony reconstruction in the lower extremity. Clin Plast Surg 1992;19:905.
15. De Boer HH, Wood MB. Bone changes in the vascularized fibular graft. J Bone Joint Surg 1989;71B:374.
16. Nusbickel FR, Dell PC, Andrew MP, Burgess AR. Vascularized autografts for reconstruction of skeletal
defects following lower extremity trauma: a review. Clin Orthop 1989;243:65.
17. Bruck JC, Bier J, Kistler D. The serratus anterior osteocutaneous free flap. J Reconstr Microsurg
1990;6:209.
18. Laurie SWS, Kaban LB, Mulliken JB, Murray JE. Donor-site morbidity after harvesting rib and iliac bone.
Plast Reconstr Surg 1984;73:933.