Lower Extremity Soft Tissue & Cutaneous Plastic Surgery, 2e

Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Second edition

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Lower Extremity Soft
Tissue & Cutaneous
Plastic Surgery
Second edition
Edited by
G. Dock Dockery DPM, FACFAS
Fellow and Past Board of Directors, American College of Foot and Ankle Surgeons; Fellow, American College of Foot
and Ankle Pediatrics; Fellow, American Society of Podiatric Dermatology; Fellow, American College of Foot and Ankle
Orthopedics and Medicine; Board Certified in Foot and Ankle Surgery, American Board of Podiatric Surgery; Board
Certified in Podiatric Orthopedics, American Board of Podiatric Orthopedics and Primary Podiatric Medicine; Chairman of
the Board and Director of Scientific Affairs, International Foot & Ankle Foundation for Education and Research; Edmonds,
Washington, USA
Mary E. Crawford DPM, FACFAS
Fellow, Past Board of Director and President, American College of Foot and Ankle Surgeons; Fellow, American College
of Foot and Ankle Pediatrics; Board Certified in Foot Surgery and Reconstructive Rearfoot and Ankle Surgery, American
Board of Podiatric Surgery; Instructor, Department of Foot and Ankle Surgery, Swedish Podiatric Surgical Residency
Program, Swedish Medical Center, First Hill Campus, Seattle, Washington; Chair, Board of Medical Advisors, International
Foot & Ankle Foundation for Education and Research, Edmonds, Washington; Private Practice, Ankle and Foot Clinic of
Everett, Everett, Washington, USA
Forewords by
Michael J. Coughlin, MD
Director, Coughlin Foot and Ankle Clinic, St. Alponsus Regional Medical Center, Boise, Idaho; Past President, International Federation of Foot and Ankle
Societies, Rosemont, Illinois, USA
Sigvard T. Hansen, Jr. MD
Professor Emeritus, Department of Orthopaedics and Sports Medicine, University of Washington; Formerly, Director of S.T. Hansen Jr. MD Foot and
Ankle Institute and Foot and Ankle Fellowship Program, Harborview Medical Center, Seattle, Washington, USA
Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto  2012

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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understand­
ing, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any informa­
tion, methods, compounds, or experiments described herein. In using such information or methods they should be mindful
of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recom­
mended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any
injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.
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Contributors
Christopher E. Attinger, MD, FACS
Professor
Department of Plastic Surgery
Georgetown University;
Director
Wound Healing Center
Georgetown University Hospital
Washington, District of Columbia
Bradley W. Bakotic, DPM, DO, FCAP
Assistant Clinical Professor
Barry University School of Podiatric Medicine
Departments of Dermatology and Pathology
Miami Shores, Florida;
Chief Dermatopathologist
Bako Pathology Services
Alpharetta, Georgia
Neal M. Blitz, DPM, FACFAS, ABPS
Chief of Foot Surgery
Department of Orthopedic Surgery
Bronx-Lebanon Hospital Center
Bronx, New York
Peter A. Blume, DPM, FACFAS, ABPS
Assistant Clinical Professor
Department of Orthopedics and Rehabilitation
Yale School of Medicine
New Haven, Connecticut
Carlos A. Charles, MD
Department of Dermatology and Cutaneous Surgery
University of Miami School of Medicine
Miami, Florida
Mark W. Clemens, MD
Assistant Professor
Department of Plastic Surgery
MD Anderson Cancer Center
University of Texas
Houston, Texas
Lawrence B. Colen, MD, FACS
Professor of Surgery
Department of Plastic and Reconstructive Surgery
Eastern Virginia Medical School;
Attending Surgeon
Norfolk Plastic Surgery
Norfolk, Virginia
Mary E. Crawford, DPM, FACFAS, ABPS
Instructor in Foot and Ankle Surgery
Swedish Medical Center
Seattle, WA;
Chair
Board of Medical Advisors
International Foot & Ankle Foundation
Edmonds, Washington;
Private Practice, Ankle and Foot Clinic
Everett, Washington
G. Dock Dockery, DPM, FACFAS, ABPS
Chairman of the Board and Director of Scientific Affairs
International Foot & Ankle Foundation
Edmonds, Washington
Ivica Ducic, MD, PhD, FACS
Professor
Division of Plastic Surgery;
Research Associate
Department of Surgery;
Director
Peripheral Nerve Surgery Institute
Georgetown University Medical Center
Washington, District of Columbia
Anna F. Falabella, MD, CWS
Department of Dermatology and Cutaneous Surgery
University of Miami School of Medicine
VA Medical Center
Miami, Florida
vii
Contributors

viii
Contributors
Tania J. Phillips, MD, FRCPC
Professor of Dermatology
Department of Dermatology
Boston University School of Medicine;
Director
Wound Healing Clinic
Boston Medical Center
Boston, Massachusetts
John S. Steinberg, DPM, FACFAS, ABPS
Associate Professor
Department of Plastic Surgery
Georgetown University School of Medicine
Georgetown University Hospital
Washington, District of Columbia
Eric B. Unger, MD
Department of Plastic Surgery
Georgetown University Medical Center
Washington, District of Columbia
Charles Zelen, DPM, FACFAS, ABPS
Assistant Clinical Professor of Medicine
University of Virginia School of Medicine
Staff Physician
Department of Podiatry and Foot Surgery
Lewis-Gale Clinic
Roanoke, Virginia
Thomas Zgonis, DPM, FACFAS, ABPS
Associate Professor
Department of Orthopedic Surgery
Director
Reconstructive Foot and Ankle Fellowship
University of Texas Health Science Center
San Antonio, Texas
Adolfo C. Fernandez-Obregon, MD
Assistant Clinical Professor
Department of Dermatology
New York Medical College
Valhalla, New York
Dennis N. Gusman, DPM, FACFAS, ABPS
Instructor in Foot and Ankle Surgery
Swedish Medical Center
Seattle, WA;
Private Practice, Auburn Ankle and Foot Clinic
Auburn, Washington
Gary P. Jolly, DPM, FACFAS, ABPS (Deceased 2010)
Director
Graduate Podiatric Medical Education
Director
Fellowship Program in Reconstructive Foot Surgery (PGY-IV)
New Britain General Hospital
New Britain, Connecticut
Christopher J. Lamy, DPM, FACFAS, ABPS
Assistant Clinical Professor
Oregon Health Sciences University
Portland, Oregon
Mark M. Levin, MD
Department of Plastic Surgery
Georgetown University Medical Center
Washington, District of Columbia
May Leveriza-Oh, MD
Dermatology Fellow, Wound Healing
Department of Dermatology
Boston University School of Medicine
Boston, Massachusetts
Andrew J. Meyr, DPM, AACFAS
Assistant Professor
Department of Podiatric Surgery
Temple University School of Podiatric Medicine
Philadelphia, Pennsylvania

Foreword
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery, second
edition, is a thorough review of the principles of operative inter­
vention of the lower extremity. Editors, G. Dock Dockery, DPM and
Mary E. Crawford, DPM have completely updated this textbook, but
have retained the thoughtful approach used in the prior edition, to
patient evaluation and treatment with a special emphasis on the
anatomy of the foot and ankle, and specific surgical techniques for
skin grafts, flaps and soft tissue coverage. These techniques whether
used in a primary operative procedure, or in the case of a revision
surgery are explained in a very understandable fashion using both
simple drawings and intraoperative photographs.
I found the principles elaborated for surgical instrumentation,
dressings, and techniques were applicable for the student and resident
in training; the flaps and soft tissue sections, I believe, are advanta­
geous for the surgeon in practice as well. In many cases, these
techniques receive little attention in routine podiatric and orthopedic
training, and this textbook fills a noted void in this area of
education.
In all cases, the techniques are discussed, illustrated, and explained
in a fashion that is simple and straightforward, making it an excellent
reference textbook for not only the podiatric and orthopedic surgeon,
but for anyone dealing with complex surgical coverage issues.
I found this to be a delightful contribution to our foot and ankle
literature, and the step-by-step manner in which different procedures
are explained, makes it so incredibly easy to read and to understand.
I highly recommend it as a primary reference source for all foot and
ankle surgeons.
Michael J. Coughlin, MD
ix
Foreword
Michael J. Coughlin

Foreword
I am very pleased to have been asked to write a foreword for the
second edition of this book edited by Drs. Dockery and Crawford. I
have practiced foot and ankle surgery in the same community with
these authors and have long recognized that they have special interests
and skills in this area and in these topics.
The fine points of cutaneous diagnosis and treatment are not of
foremost interest to most foot and ankle surgeons, particularly those
who are orthopedically trained. Our skills are focused more on the
musculoskeletal structures. Knowledge about the foot and ankle, as
well as the levels of skill required to manage serious problems, have
increased greatly both in orthopedic and podiatric groups in the past
30 years. Increased interaction between the two groups has helped fuel
this growth, as each has much to offer the other.
Podiatry has long had a greater interest in the skills required to treat
skin-related problems, which are a major part of foot and ankle care.
As noted in this book, the number of diabetic patients is projected to
markedly increase in the near future. These skills will become even
more important, as larger numbers of patients with numerous skin
and digit-related problems present for treatment.
A potential problem with both orthopedic and podiatric practition­
ers is the tendency to get overly excited about major new reconstruc­
tion options and implants and never really adequately learn, or just
ignore, the very important basic principles and techniques of manag­
ing skin wounds. This book can help remedy that problem. The
second edition has been significantly improved over the first with
more extensive illustrations, references and added detail. Additional
chapters, some written by MD plastic surgeons and dermatologists,
expand the book’s scope and sophistication.
I would recommend this as required reading for all surgeons doing
any level of work in the foot and ankle area. I believe it should be
recommended, if not required, reading in training programs in the
foot and ankle, possibly even in plastic surgery.
Sigvard T. Hansen, Jr., MD
xi
Foreword
Sigvard T. Hansen Jr.

Preface
As with the first edition, this edition of Lower Extremity Soft Tissue
& Cutaneous Plastic Surgery is intended to provide a comprehensive
and practical manual of the most commonly performed lower extrem­
ity soft tissue and cutaneous surgical procedures. The text moves
from basic, but very important, information to complex cutaneous
techniques and reconstructive surgeries. The process starts with pre­
operative considerations, cutaneous and microvascular anatomy,
instrumentation and tissue handling, and works its way through
anesthesia, hemostasis and suture materials, wound-healing proper­
ties and techniques. Next, attention is directed toward understanding
and utilizing medical photography and, finally, into the heart of the
subject with specific procedures, each chapter illustrated with color
photography and beautiful drawings.
There has been a tremendous increase in the scope and complexity
of cutaneous surgical procedures performed by lower extremity sur­
geons in the past two decades. This is partly due to increased patient
acceptance of outpatient skin procedures, along with the continued
attainment of precise knowledge and skills in reconstructive and
plastic surgery techniques by all physician specialists. Additionally,
there has been an increase in the cooperative relationships and referral
patterns among plastic surgeons, dermatologic surgeons, podiatric
foot and ankle surgeons, surgical oncologists, orthopedic surgeons and
general practitioners. This process has helped to promote the sharing
of knowledge, training, and information regarding the performance of
simple and complex cutaneous procedures for the lower extremities.
The ultimate goal is to allow the reader the ability to develop
increased self-confidence in approaching lower extremity cutaneous
problems. This book is designed to be thorough in scope by providing
specific and practical information for both the new cutaneous surgeon
and the more experienced practitioner.
G. Dock Dockery DPM FACFAS
Mary E. Crawford DPM FACFAS
Seattle, 2012
xiii
Preface

Abbreviations
ADM – abductor digiti minimi
AHB – abductor hallucis brevis
AHL – abductor hallucis longus
APTT – activated, partial thromboplastin time
CAT – computerized axial tomography
CCD – charge-coupled device
CHF – congestive heart failure
CT – computerized tomography
DIC – disseminated intravascular coagulation
DTM – dermatophyte test medium
EDB – extensor digitorum brevis
EDL – extensor digitorum longus
EHL – extensor hallucis longus
FDB – flexor digitorum brevis
FDL – flexor digitorum longus
FDM – flexor digiti minimi
FHB – flexor hallucis brevis
FHL – flexor hallucis longus
H&E – hematoxylin and eosin
IPJ – interphalangeal joint
LEPS – lower extremity plastic surgery
LET – lidocaine, epinephrine and tetracaine
LME – lines of maximum extensibility
LMM – lines of minimal movement
MCT – medial calcaneal tubercle
MCTD – mixed connective tissue disease
MRI – magnetic resonance imaging
MTPJ – metatarsophalangeal joint
NSAIDS – non-steroidal antiinflammatory drugs
PAS – periodic-Acid Schiff
PB – peroneus brevis
PVD – peripheral vascular disease
PVNS – pigmented villonodular synovitis
PVNT – pigmented villonodular tenosynovitis
RSTL – relaxed skin tension lines
SCC – subcuticular closure
SFA – superficial femoral artery
SLE – systemic lupus erythematosus
SLR – single lens reflex
SWC – standard wound closure
TA – tissue adhesives
TAC – tetracaine, adrenaline or epinephrine and cocaine
TMA – transmetatarsal amputations
USP – United States Pharmacopeia
xv
Abbreviations

Introduction
WHO IS THIS BOOK FOR?
One of the first questions considered in this textbook is: ‘Who is this
book intended for?’ Is it for the student? Is it better suited to the surgi­
cal resident? How about the new practitioner? Or, would it be suited
to the skilled surgeon who has already established a busy and success­
ful practice? The answer is that this book is designed for all of these
doctors. There should be no concern as to whether or not the practi­
tioner is a dermatologist, podiatrist, orthopedist, general practitioner
or even a master plastic surgeon. The only concern is that the physi­
cian be authorized by education, training, licensing and privileges to
be considered a qualified medical provider to perform lower extremity
soft tissue and cutaneous reconstructive and plastic surgery.
WHERE ARE THESE SURGERIES PERFORMED?
Some of the techniques that are outlined and detailed in this book
are very simple procedures that can easily be performed in the prac­
titioner’s clinical setting. In this scenario, there is less formality in the
preparation of the skin and surroundings. The skin may be washed
and then cleansed with a quick-drying antiseptic, such as alcohol,
except in cases where electrocautery procedures are being performed.
The surgical area may then be surrounded with simple sterile drapes
(either disposable or reusable) to provide a sterile field for the proce­
dure. For some of the more involved techniques discussed, it might
be more suitable to have the patient admitted to a surgery center or
same-day-surgery unit at the hospital. In this case, the use of anesthe­
sia, better-equipped surgical theaters, sterile surroundings and assist­
ance may be extremely beneficial to both the patient and the surgeon.
Obviously, the more complex and involved reconstructive procedures
require the most extensively prepared facilities and equipment. The
location of the surgery is not nearly as important as is the periopera­
tive preparation and consideration of all aspects of the procedure and
the potential complications.
PRINCIPLES OF CUTANEOUS SURGERY
One of the major principles of cutaneous surgery is that care should
be taken at all times to protect the patient from any harm, whether
from the clinical or surgical environment, or from external or internal
chemicals and medications. This principle is no different from those
that have always governed good clinical practice. The surgeon and
surgical staff should always be vigilant in the handling of the patient’s
tissue, fluids or blood, as well as the instruments that come into
contact with these entities. There should be no difference in the han­
dling of tissues in a patient with HIV infection or hepatitis compared
with any other condition.
No matter how simple or how complex the procedure planned, the
skin should be handled with the utmost respect and as gently as
possible. In fact, it should be handled as little as possible. One of the
early lessons learned is that living tissue is easily damaged with
improper techniques. Even though normal healthy skin can recover
from most injuries quickly, there is no need to do additional damage
to the tissues by forceful manipulation with tissue forceps or with
inappropriate pressure with tissue retractors. In fact, long-term retrac­
tion, electrocautery and excessive swabbing of the surgical wound
should be avoided whenever practical. Dead spaces should be
properly closed with as few sutures as possible. Incisions should
be closed in layers and should never be closed under tension. Exces­
sive compression or restrictive bandages should also be avoided in
all cases.
By carefully reviewing the principles and techniques within this
surgery text, the practitioner should be able to gain additional insight
and understanding of specific procedures and options that will facili­
tate precision of the surgery and improve the ultimate outcome. The
benefits offered herein should minimize the risk of complications
while significantly improving the quality of patient care. This should
always be our first and final goal for any treatment offered to the
patient.
xvii
Introduction
G. Dock Dockery

1
| 1 |
CHAPTER CONTENTS
Introduction
1
Second opinion
1
Informed consent
2
Patient examination
2
History
2
Physical examination
3
Patient preparation
4
Patient expectations
5
INTRODUCTION
The preoperative management of a patient with a surgical problem
involves three parts: the diagnostic work-up, a preoperative eval­
uation and the preoperative preparation. The diagnostic work-up
determines the cause and the extent of the patient’s condition.
The preoperative evaluation is a general assessment of the patient’s
health to identify operative risks that may influence the recovery
period or, ultimately, alter the surgical plan. This evaluation includes
an anesthesia plan that takes into consideration the patient’s overall
medical condition(s), the requirements of the surgical procedure and
the patient’s preferences.
Whether the planned cutaneous procedures are exceptionally minor
or extremely complex, it is crucial to consider that each case is as
important as the next. Because serious complications may occur at any
time, it is necessary to be fully informed as to the exact nature of the
patient’s condition, general health status, mental status and allergies
before entering into the treatment program. In order to be prepared,
it is imperative to have obtained a thorough evaluation preoperatively.
Some practitioners feel that this step is unnecessary, but let me assure
you that having obtained this information early on will be important
if a problem should arise.
Other essential considerations before surgery include determining
if the patient completely understands the following: the proposed
surgical procedures; the risk factors associated with the surgery; the
necessary actions after surgery and the long-term expected results. It
is important to ascertain, before commencing the surgery, if the
patient has planned for the appropriate care and recovery time
and does not plan to take an extended trip or return to work too
soon. Equally crucial is the assurance that the surgeon will be avail­
able during the immediate postoperative recovery period or that a
covering physician, familiar with the type of procedure performed, is
accessible to the patient during this time. Finally, the surgeon can
prepare the patient for the operation by reviewing the procedure,
postoperative medications and immediate expectations following
the surgery.
It is generally assumed that the patient is an established patient and
has a complete chart with the general patient information form
already filled out. However, if the patient is new, and the procedure
is being performed on the first visit (usually not recommended unless
the patient is referred by another physician specifically for the proce­
dure or, the condition is urgent in nature), they should complete the
general patient information sheet prior to being seen by the surgeon.
This form generally contains all of the necessary information regard­
ing the patient’s name, address and contact numbers, and overall
health status. There should also be a listing for a person to contact if
there are any problems or an emergency arises.
In pediatric patients, a parent or a legal guardian must accompany
the child and should always be present during the consultation
and informed consent. If the child is of a relatively mature age, the
child should be included in the discussion. The child’s concerns and
wishes should always be addressed directly and in a manner that is
understandable. For younger patients, creating a child-friendly envi­
ronment with toys and offering stickers or other rewards are helpful.
Encourage the child to bring a favorite toy or personal stereo to the
procedure.
SECOND OPINION
Once the initial discussion and recommendations for treatment have
been completed, it might be advisable to offer the patient a choice of
obtaining another opinion. They are encouraged to get a second surgi­
cal opinion if they need it for their insurance or if they have any
©2012 Elsevier Ltd.
Preoperative patient evaluation
G. Dock Dockery
Chapter
1

2
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Once the informed consent has been discussed with the patient and
there are no further questions or concerns, it is wise to dictate an
extensive progress note for the patient’s chart that clearly outlines the
information that has been given to the patient. At no point should
there be any suggestion as to a guarantee of results or outcomes, as
this will undoubtedly cause a dilemma later, if there should be unsat­
isfactory results.
This informed consent form may be very general (Fig. 1.1) or it may
be specific for only one type of procedure. In other words, a form can
be made-up for each individual procedure, e.g. the rotational flap,
showing the fine points of how it is performed, with drawings or
illustrations outlining the details. Utilizing line drawings representing
the foot or lower extremity, where the surgeon can draw the procedure
onto it, is extremely helpful in showing the patient the actual proce­
dure planned and providing a complete understanding of the pro­
posed surgery (Fig. 1.2).
There is no strict outline that can be followed because of the
multiplicity of treatment options and the diversity of patients. Aes­
thetic surgery, cutaneous lesion excision and major reconstructive soft
tissue surgery, for example, all differ in patient expectations, preopera­
tive assessments required and postoperative follow-up. The more
urgent the treatment, the less detailed the information needed. In
contrast, the more cosmetic the procedure, the more detailed the
amount of information necessary regarding possible risks and expected
outcomes. However, the guidelines reviewed earlier are basic to all
preoperative informed consents and are designed to increase the
patient’s understanding of the expectations and to explain the risks
involved.
Preoperative photographs are very helpful for providing additional
documentation of the pathology present and the extent of planning
by the surgeon. Each photograph should be clearly marked with the
date the photograph was taken and the patient’s information. It is
even considered superior evidence if the patient has signed and dated
the photographs or a form indicating that the photos have been taken.
Patients will frequently forget what the original condition or problem
looked like and the preoperative photograph is an excellent reminder
for them. Furthermore, the preoperative photograph of a tissue lesion
may be very helpful for the dermatopathologist during the histologic
review of a biopsy specimen. Additional information regarding clini­
cal photography is reviewed in Chapter 9.
PATIENT EXAMINATION
This part of the patient information provides the most help when
general health issues and medicolegal situations arise. For this reason,
special attention must be given to obtaining all of the necessary infor­
mation to complete this part accurately. The information provided
from the history and physical examination should be easily found
within the chart and, above all, be very legible.
History
The initial element of the patient examination is the past medical
history. The health status and general information about the patient’s
history is usually obtained in a questionnaire or history form. A clear
determination of the cutaneous or soft tissue problem, its duration,
symptoms and exact location, and any prior treatment, should be
obtained at this time. Any known allergies to topical, systemic or
environmental agents may be determined. Specific questions should
include whether there are allergies to antibiotics, aspirin, latex, iodine,
local anesthetic agents and tapes or adhesives. If an allergy exists, this
information should be clearly printed on the front of the patient’s
questions or concerns about the proposed procedures. We have found
that by offering the patient this choice, it appears to lessen their
anxiety about whether or not they are making the right decision.
When the patient does seek another opinion, we have found that
almost all second opinion surgeons agreed with our diagnosis and
planned treatment. This information is important to document into
the patient chart prior to the surgery.
The easiest method of suggesting that the patient gets a second
opinion is to have a preprinted form available. This form should list
several surgeons in your general area that you are familiar with and
that do similar types of surgery as you. It is a simple matter to circle
one or two doctors on this form that you would recommend that the
patient see for a surgical opinion. The doctor’s full name, medical
degrees, clinic’s address and phone number should be listed. It is also
advisable to list the address and phone number of the local medical
association. Once again, this is reassuring for most patients because
it is offered up front as a source of further information regarding the
surgeon and the procedure being recommended.
INFORMED CONSENT
Once the decision has been made to proceed with surgery, it is neces­
sary to obtain comprehensive informed consent. Informed consent is
much more than just stating the name of the planned procedure and
having the patient sign the appropriate form. It entails providing suf­
ficient information about the nature of the condition, the potential
options or alternative forms of treatment available, the possible risks
or complications and the benefits of treatment. This information
needs to be written in lay terminology, and should be clear and honest
in its presentation. Everything that is discussed must also be on the
printed informed consent form.
Patients given verbal warnings are less able to recall them than those
receiving written information. Additionally, the surgeon should
review the consent form with the patient, rather than delegating this
duty to another member of staff. It is helpful if a family member is
present to witness the consent form. Finally, the patient should be
offered the opportunity to ask any questions or voice any concerns
prior to signing the consent form.
Under the options that are discussed with the patient, it is impor­
tant to explain that they have three choices available: (1) leave the
problem alone with no further treatment provided; (2) attempt con­
servative treatment with physical therapy, medications, injections or
other non-surgical choices; and (3) the surgical option as outlined in
the consent. Each of these options also has potential risks and these
can be briefly discussed. The risk of no further treatment is that the
condition may worsen or, at least, not go away. The risks of conserva­
tive care might include the continuation of the problem, reaction to
treatments or medications or worsening of the condition. The risks of
the surgical procedure should be more specific and should always
include the common complications that might occur as a direct result
of this particular surgery.
The general risks of any surgery such as scarring, nerve damage (pain
or numbness), infection, recurrence or worsening of the condition
should be mentioned at this time. A brief discussion of the anesthesia
that is being contemplated and its most common risks may also be
provided at this time. For cases in which regional or general anesthesia
is being considered, it is best to explain to the patient that a certified
anesthesiologist or nurse anesthetist will review the anesthesia in great
detail prior to the surgery. A very detailed account of this perioperative
period does not significantly increase patient anxiety and has the
advantage of allowing patients a fully informed choice before they
sign the consent form for surgery.

Chapter
Preoperative patient evaluation
3
| 1 |
Today’s Date________________________Time:__________________AM/PM
PATIENT:________________________________________________________
I hereby authorize Dr.____________________________________, and designated associates or assistants selected by said
physician to perform upon me the following surgical procedure(s):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
The purpose of the procedure(s) is to treat the following condition(s):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
I consent to the performance of operations and procedures in addition to or different from those now contemplated,
whether or not arising from presently unforeseen conditions, which the above-named doctor or his associates or assistants may
consider necessary or advisable in the course of the operation.
I consent to the administration of such anesthetics as may be considered necessary or advisable by my doctor, anesthesiologist,
or other qualified party under the direction of a physician.
For the purpose of advancing medical education, I consent to the admittance of observers, and/or the use of medical photography
equipment in the operating room.
I consent to the disposal or pathology review of any tissues or parts, which may be removed.
I have not had any allergic reaction to any drug(s) except:
_________________________________________________________________________________________.Initials_____
I understand and assume all risks, which may exist, as a result of my failure to disclose any medical condition(s) and/or previous
or current use or abuse of alcohol or drugs to the above named physician and realize that this treatment plan could be affected
with such an omission.
I recognize that throughout the course of treatment for my condition(s) I have the responsibility to follow and adhere to my
doctor’s instructions. Initials_____
SPECIAL CONSENT TO OPERATE
A
Figure 1.1  Standard two-page consent form.
chart and other forms and documented within the patient’s chart
records.
Also important is whether or not the patient is on any anticoagu­
lants or agents such as aspirin, non-steroidal antiinflammatory drugs,
immunosuppressive agents, beta blockers or vitamin E that may
hinder normal coagulation and healing. Other related drug questions
should include all drugs and medications that the patient may be
taking, including those purchased without a prescription, such as
vitamins, minerals, cold medications and herbal supplements. Spe­
cific questions should be asked about difficulties with normal healing,
bleeding problems, excessive bruising following minor injuries or
procedures, prior deep vein thrombosis, complications following any
other surgeries and whether or not there were any past problems
resulting from anesthesia.
It is essential to determine medical conditions such as diabetes,
hypertension, heart or vascular disease, kidney disease, gastrointesti­
nal disorders, liver conditions such as hepatitis and cirrhosis and
glaucoma. Further information should include the use of alcohol and
tobacco products and the exact daily use of these items. Patients may
minimize this information and it is best to be very specific in the
questioning and the reason why this information is important for the
well-being of the patient.
Physical examination
The physical portion of the examination includes the vital signs:
resting blood pressure, pulse rate, oral temperature and respiration
rate. The vascular status and neurologic assessment are equally

4
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
With infected or ulcerated lesions a preoperative culture of the wound
may be helpful in determining the source of the infection. It is usually
not necessary to perform other laboratory evaluations before cutane­
ous surgery.
PATIENT PREPARATION
The overall preoperative assessment, including obtaining the medical
history, performing the physical examination and completing the dis­
cussion of the informed consent, should be an opportunity to recog­
nize possible mental or medical problems that can be dealt with prior
to surgery rather than at the last minute. It is also a time where the
diagnosis is confirmed and treatment approaches are fully reviewed
important and should be carefully measured prior to surgery. All
patients undergoing surgery should routinely have this work-up per­
formed. This information is essential in establishing the current
patient health status and it may also expose some unknown primary
medical con­dition that will require referral to the primary care
provider.
The cutaneous condition should be re-examined, measured, photo­
graphed and documented in the chart during the physical examina­
tion. The extent of the proposed procedure may suggest the need for
further diagnostic or preoperative laboratory evaluations, X-rays,
magnetic resonance imaging (MRI) scans or special studies. In cases
where there is a known preoperative medical condition or history of
bleeding problems, it is advisable to obtain a complete blood count
including: measurement of platelet count, a prothrombin time, INR
(international normalized ratio) and partial thromboplastin time.
POSSIBLE RISKS SPECIFIC TO THIS SURGERY
1.____________________________________________________________
Initials_____
2.____________________________________________________________
Initials_____
3.____________________________________________________________
Initials_____
4.____________________________________________________________
Initials_____
PROGNOSIS:_____________________________________________________________
The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility
of complications have been fully explained to me in a language in which I understand. I acknowledge that no guarantees
or assurances have been made as to the end results that may be obtained. Initials_____
ALTERNATIVE TREATMENTS:
___1. No further treatments provided/observation
___5. Medications
___2. Change in occupation or activities
___6. Padding/strapping
___3. Change of shoes/use of shoe inserts
___7. Injections
___4. Periodic care/Physical therapy
___8. Other: _______________
POSSIBLE RISKS INHERENT TO ANY SURGERY:
1. Infection and/or painful inflammation of tissues
2. Delayed or non-healing of incisions and/or operated bones
3. Excessive bleeding, swelling, and/or pain (complex regional pain syndrome)
4. Allergic reaction to suture or other implanted materials
5. Nerve or blood vessel complications (numbness, painful nerve, blood clots)
6. Over or under correction of the deformity
7. Loss of blood supply leading to amputation
8. Need for additional surgery or treatment in the future
9. General medical complications (reactions to anesthesia, loss of life, clot to lung)
10. Return of same condition or development of new problem
SPECIAL CONSENT TO OPERATE
DO NOT SIGN THIS FORM UNLESS YOU FULLY UNDERSTAND EVERYTHING ON IT.
Patient Name (Print):__________________________________________________________
Signature:____________________________________________ Today’s Date:___________
(Patient or person authorized to consent for patient)
Relationship:________________________________________________________________
Witness:________________________________________________
Date:__________
Physician:_______________________________________________
Date:__________
B
Figure 1.1, Continued.

Chapter
Preoperative patient evaluation
5
| 1 |
and additional patient education is provided. This helps to build
patient–surgeon rapport and trust, and ensures better outcomes for
everyone involved.
Many minor procedures and most cutaneous surgery can easily be
performed in the clinical setting. More complex cases are referred to
the outpatient surgery suite or hospital operating suites. During the
procedure, the patient is placed on the surgical chair or table in a
comfortable position. The surgical site is prepared by washing any
visible dirt with a detergent. The skin is then cleansed with a quick-
drying antiseptic solution and the lesions are covered with sterile
drapes. The surgical area should not be shaved unless absolutely nec­
essary, as this increases the number of skin bacteria on the superficial
skin surface. If the hair is simply in the way, it can be clipped back
prior to the skin preparation. The skin may be prepared with chlo­
rhexidine solution or 10% povidone-iodine surgical scrub solution.
Prepackaged sterile fenestrated surgical drapes are very useful, but an
appropriate-sized window can be cut into the center of a sterile dispos­
able drape with the same result. Obviously, in more involved cases,
the extent of skin preparation and draping is increased to suit the
complexity of the surgery (See Chapter 7).
PATIENT EXPECTATIONS
The patient’s expectations may vary considerably depending upon the
nature of the condition that they present with. For example, a patient
presenting with a minor cosmetic condition may have unrealistic
comprehension as to the complexity of the treatment and may not
understand that complications can occur in any case. It is imperative
to look closely at the patient’s psychological profile when dealing with
worries about very negligible skin problems. Likewise, it is essential
to be careful in the assessment of patients that are unhappy with previ­
ous surgical care or are obsessive or perfectionist in nature. These
patients frequently have an unrealistic expectation and are more likely
to be unhappy with the final results of surgery. In these examples, it
might be advisable to make sure prior records are obtained, the
patient has a second opinion and has discussed the potential risks
and complications in some detail before proceeding with surgical
scheduling.
Figure 1.2  Drawing of the foot. Areas of concern may be circled or the
proposed surgical procedures may be drawn onto the illustration. This
will help the patient visualize placement of incisions and final scars.
FURTHER READING
Amir, M., Rabbani, M.X., Parvez, M.B., 2009.
Informed consent in elective surgical
procedures: ‘What do the patients think’?
J Pak Med Assoc 59 (10), 679–682.
Armstrong, A.P., Cole, A.A., Page, R.E., 1997.
Informed consent: are we doing enough?
Br J Plast Surg 50 (8), 637–640.
Bloom, R.F., 1994. Preoperative patient
evaluation and preparation for cutaneous
surgery. In: Wheeland, R.G. (Ed.),
Cutaneous Surgery. WB Saunders,
Philadelphia, pp. 12–25.
Chan, Y., Irish, J.C., Wood, S.J., et al., 2002.
Patient education and informed consent in
head and neck surgery. Arch Otolaryngol
Head Neck Surg 128 (11), 1269–1274.
Courtney, M.J., 2001. Information about
surgery: what does the public want to
know? Aust N Z J Surg 71 (1), 24–26.
Dockery, G.L., 1984. Perioperative
management of the infant and child. Clin
Podiatr Med Surg 3, 645–665.
Dockery, G.L., 1997. History and physical
examination in dermatological patients. In:
Cutaneous disorders of the lower extremity.
WB Saunders, Philadelphia, pp. 10–18.
Eedy, D.J., Breathnach, S.M., Walker, N.P.J.,
1996. Surgical dermatology. Blackwell
Science, London, pp. 44–48.
Falagas, M.E., Korbila, I.P., Giannopoulou,
K.P., et al., 2009. Informed consent: how
much and what do patients understand?
Am J Surg 198 (3), 420–435.
Gabriel, M., Pawlaczyk, K., Krasinski, Z., 1999.
Evaluation of general medical awareness
and extent of preoperative explanation of
surgical patients. Przegl Lek 56 (2),
121–125.
Gongal, R., Bhattarai, P., 2005. Informed
consent: is it really understood?
Kathmandu Univ Med J 3 (3), 271–273.
Gorney, M., Martello, J., 1999. The genesis
of plastic surgery claims. A review of
recurring problems. Clin Plast Surg 26 (1),
123–131.
Haller, U., Hepp, H., Reinold, E., et al., 1999.
How much preoperative information?
How can it be documented? Gynakol
Geburtshilfliche Rundsch 39 (4),
181–182.
Ivashkov, Y., Van Norman G.A., 2009.
Informed consent and the ethical
management of the older patient.
Anesthesiol Clin 27 (3), 569–580.
Kerrigan D.D., Thevasagayam R.S., Woods T.O.,
et al., 1993. Who’s afraid of informed
consent? BMJ 306 (6873), 298–300.

6
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
McGillis S.T., Stanton-Hicks U., 1998.
The preoperative patient evaluation:
preparing for surgery. Dermatol Clin
16 (1), 1–15.
Merriman, L.M., Tollafield, D.R. (Eds.), 1995.
Assessment of the Lower Limb. Churchill
Livingstone, London.
Neumann, P.B., 2011. What should be relayed
to your patients. A plastic surgery
intervention is not a visit to the hair dresser
(interview by Dr. Beate Fessler). MMW
Fortschr Med 11; 153 (32–34), 16.
Paci E., Barneschi M.G., Miccinesi G., et al.,
1999. Informed consent and patient
participation in the medical encounter: a
list of questions for an informed choice
about the type of anesthesia. Eur J
Anaesthesiol 16 (3), 160–165.
Peter, F.W., Peter, K., Buttemeyer, R., et al.,
1995. Preoperative patient, education in
plastic surgery. Handchir Mikrochir Plast
Chir 27 (4), 171–174.
Waisel, D.B., Troug, R.D., 1995. The benefits of
the explanation of the risks of anesthesia in
the day surgery patient. J Clin Anesth 7 (3),
200–204.
Whyte, A., 1994. Pre and postoperative
evaluation of patients undergoing
cutaneous surgery. Dermatol Nurs 6 (4),
248–250.
Williams, G.D., 1997. Ambulatory surgery.
Preoperative assessment and health history
interview. Nurs Clin North Am 32 (2),
395–416.

7
| 2 |
CHAPTER CONTENTS
Introduction
7
Epidermis
7
Specialized cells and appendages of the epidermis
8
Dermis
9
Subcutaneous layer
9
Surgical implications
10
Conclusion
10
INTRODUCTION
The degree of complexity of the skin is often overlooked by the
surgeon, but it plays an integral role in the postoperative healing,
or non-healing, following any operative procedure. The intricate
relationship between the layers that make up the epidermis and its
relationship with the dermis create a complex physiological and bio­
chemical organ system that serves many functions in the human body.
The most obvious function of the skin is to serve as a protective barrier
against microorganisms and harmful environmental elements enter­
ing into the more fragile internal organ systems.
The organization of the skin, however, also allows for water equi­
librium, thermal regulation, protection from UV radiation, excretion,
secretion, sensation of temperature and pressure or pain, as well as
endocrine and immunological activities. To appreciate the mechanism
by which the skin can perform these multiple functions, one must
look more closely at the detailed organization of the epidermis, the
dermis and the underlying support system of the subcutaneous tissue
that makes up the complexity of the skin.
EPIDERMIS
The epidermis is a continuous, self-regenerating layer of stratified
squamous epithelium that varies in thickness from 0.4 mm on the
eyelid to 1.5 mm on the palms and soles. The epidermis is organized
into four layers based on distinct structural features or unique func­
tional activities. Each layer becomes more specialized as it ascends
from the deepest to the most superficial layer. The epidermal layers,
or strata, from deep to superficial are the stratum basalis (also called
the stratum germinativum), stratum spinosum, stratum granulosum
and the stratum corneum (Fig. 2.1). The final, most superficial layer
of the stratum corneum is made up of the non-living, terminally dif­
ferentiated keratinocytes, composed of a plasma membrane, filamen­
tous and matrix proteins, and lipids.
The stratum basalis or stratum germinativum, the basal cell layer,
is properly named, as the cells are mitotically active, self-regenerating
progenitor cells present in the deepest layer of the epidermis and
attached to the dermis at the level of the basement membrane. They
are the least differentiated cells, capable of dividing rapidly, and as
they advance towards the skin surface they begin the process of kerati­
nization. The cells are attached by hemidesmosomes to the basement
membrane aligned in a columnar fashion and the cell is dominated
by an ovoid, deeply basophilic nucleus.
As the cells from the basal cell layer advance superiorly to the
stratum spinosum, the cells take on the specialized task known as
keratinization. This is the process by which the cells are committed to
protein synthesis that forms keratin. The shape of the cell becomes
altered and changes from the columnar cell of the basal layer to the
prickle cell of the spinosum layer. The cell is flatter, more ovoid and
begins to orient itself parallel to the most superficial surface as the cell
matures and advances outward. Besides keratinization specialization,
the spinous keratinocytes feature a potent lysosomal system for the
degradation of any foreign material that may penetrate the outer layer.
Lysozyme concentration is 5-fold higher in newborns compared with
adults, which may contribute to the newborn infants’ defence against
invasive bacterial and other infections.
The final living layer of cells advancing towards the skin surface is
the stratum granulosum. This layer, along with the stratum spinosum
and germinativum, make up the living layers of the epidermis, known
as the stratum Malpighii. The cells within the stratum granulosum are
even more specialized than their precursors, with the cells containing
a large number of granules full of keratohyalin. Keratohyalin is a
protein precursor to filaggrin. Filaggrin stabilizes the epidermal struc­
ture by functioning as a glue or cement between the keratinocytes. The
previously seen cellular elements such as the nucleus, mitochondria,
©2012 Elsevier Ltd.
Cutaneous anatomy and its surgical implications
Mary E. Crawford
Chapter
2

8
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Langerhans’ granules and its function is not fully understood, however
it may represent a population of stem cells capable of multiple dif­
ferentiated lineages.
The adnexa, or specialized appendages of the epidermis, play a vital
role in daily homeostasis. These highly specialized structures provide
for regulation of temperature, evaporation and touch or pain stimulus.
The adnexa of the epidermis begin their origin below the epidermis
but travel through the epidermis to the surface and include the hair
follicle, the apocrine and eccrine sweat glands, the sebaceous glands
and the nerves of the epidermis. The hair follicle develops through an
interaction between the epidermis and dermis and is highly sensitive
to light touch.
The sweat glands, both apocrine and eccrine, are preoccupied with
thermoregulation and evaporative heat loss and have both an intra­
dermal and intraepidermal component. The apocrine gland is in great­
est concentration in the axillae, anogenital and areolae areas and also
produces a pheromone secretion. The eccrine gland is present overall
in higher numbers but particularly in the axillae, the palms and soles,
and plays a greater role in thermoregulation than the apocrine sweat
gland. Sebaceous glands are found everywhere except the palms and
soles, and are in very high concentration on the face and scalp. Sebum
is the secretion from the sebaceous gland; it acts as a skin lubricant
and contains lipid droplets and decomposing cell debris. This gland
can be free standing or found in association with hair follicles.
As mentioned previously, the hair follicle can aid in light-touch
perception, but additional sensation input from the environment is
needed to adjust to ever-changing external stimuli. Free nerve endings
are absent in the epidermis, but intraepidermal nerve endings do exist
as Merkel-cell-neurite complexes. These complexes are terminal nerve
branches from the dermis that reside just above the basement mem­
brane on non-myelinated axon terminals and function as receptor
cells of terminal nerve branching (Fig. 2.2).
Golgi apparatus, ribosomes and endoplasmic reticulum all undergo
dissociation forming a homogenous, amorphous substance. As these
cells advance to the surface, dehydration occurs and forms the stratum
corneum.
As stated earlier, the stratum corneum is made up of dead, termi­
nally differentiated keratinocytes that are flattened, polyhedral cells
with absent nuclei. The cells interdigitate in a basket weave-like
pattern to help prevent harmful environmental intrusion, but to also
aid in resistance to water loss. This arrangement of cells allows for the
orderly process of desquamation every 14 days. The lowest layer of
the stratum corneum can be separated into a sublayer known as the
stratum conjuctivum or lucidum. This layer is most pronounced on
the palms and soles where the skin is most thick. This cell layer sepa­
rates itself from the most superficial stratum corneum because of the
presence of Odland bodies within the cells. Odland bodies contain a
large amount of protein-bound lipids. The majority of the stratum
corneum, however, is mostly characterized by cells whose contents are
amorphous.
Specialized cells and appendages
of the epidermis
Before advancing our attention to the dermal layer and its functions,
it is important to discuss the specialized cells and the adnexa found
in the epidermis. There are three specialized cells of neuroectodermal
origin that are important in daily function of the skin: the melanocyte,
the Langerhans’ cell and the indeterminate cell. The melanocyte con­
tains melanin granules giving color to keratinocytes and hair. The
Langerhans’ cells contain no melanin and are thought to be related
to the monocytic cell with phagocytosis properties. The third cell type,
the indeterminate cell, does not possess either melanosomes or
Figure 2.1  Cross-sectional drawing of the epidermis and its component layers.
Macrophage
Venule
Fibroblast
Melanocyte
Stratum Basale
Stratum Spinosum
Stratum Granulosum
Stratum Corneum
Melanocyte
Histiocyte
Dendrocyte
Langerhans′ cell

Chapter
Cutaneous anatomy and its surgical implications
9
| 2 |
and is more vascularized than the reticularis by the subpapillary
plexus, which extends a capillary loop into each papillae. The reticular
dermis is the bulk of the dermis and extends from the subpapillary
plexus to the hypodermis or subcutis. It is primarily composed of type
I collagen with fibers arranged in large interwoven bundles surrounded
by elastic fibers in a vast network. Veins, arteries and nerves occur as
triads in the reticular dermis.
There are specialized cells that are indigenous to the dermis, includ­
ing fibroblasts, macrophages and mast cells, while lymphocytes,
plasma cells and leukocytes will migrate in response to chemical or
mechanical stimuli. Although the cell types found in the papillary
and reticular layers are similar, there appears to be a reduction in the
number of cells seen in the reticularis. Fibroblasts are the principal
cell type seen in the dermis and are responsible for the maintenance
of the structural integrity of the dermis and vital to wound healing
and scar formation. Fibroblasts synthesize the connective-tissue pro­
teins in the dermis for collagen and elastin as well as the ground
substance matrix proteins glycosaminoglycans and glycoproteins.
Macrophages are blood-borne monocytes that phagocytose foreign
material or antigens and also play a vital role in wound healing. Mast
cells are specialized secretory cells located primarily around the sub­
papillary plexus and also in the subcutaneous fat. The mast cells
secrete substances that result in histamine release and vasodilatation.
This attracts blood leukocytes with chemotaxis. Lysosomal granules
of the mast cells are also capable of degradation due to the presence
of acid hydrolases and other enzymes.
The final structural components of the dermis take into considera­
tion the neural and vascular elements found in both the papillary
and reticular dermis. The neural components involve both sensory
and autonomic nerve structures. The autonomic nerve formation
enervates blood vessels, arrector pili units and the apocrine and
eccrine sweat glands. The sensory nerve units supply the hair follicles,
mucocutaneous end organs, Meissner corpuscles and Vater–Pacini
corpuscles. Lymphatic vessels are also prominent components of this
system.
The cutaneous circulation is a complex array of subcutaneous and
dermal vascular channels that supply nutrients and oxygen to both
the epidermis and dermis. The circulatory system arises in the subcu­
taneous layer as a plexus of small arteries and veins. Small bundles of
arterioles ascend from this plexus into the dermis. These small arteri­
oles join with arteriole and venous capillaries and small postcapillary
venules to form a plexus around eccrine and apocrine glands and hair
follicles and the subpapillary dermis. Capillary loops then ascend
from the subpapillary plexus to supply each dermal papilla, which
then supplies the overlying epidermis (Fig. 2.3).
SUBCUTANEOUS LAYER
The structural and vascular support of the skin is derived from the
underlying subcutaneous layer. This layer is comprised of adipocytes
that synthesize large volumes of fat inside each adipocyte cell. These
cells aggregate to form a primary microlobule that then aggregate
again to form a secondary lobule about 1.0 cm in diameter. The vas­
cularity within the subcutaneous layer involves a series of branching
vessels to supply the overlying dermis and each secondary and primary
microlobule.
Large blood vessels found in the major fibrous septa of the subcu­
taneous layer branch upward to supply the dermis, but no capillaries
connect the dermis and the underlying subcutaneous fat. The subcu­
taneous fat is nourished by smaller vessels within the fibrous septa,
giving rise to a complex network of capillaries between the arteriole
and venule surrounding each lobule.
DERMIS
The epidermis and dermis exist in a functional and morphological
relationship and interact in exchanges of inductive biochemical rela­
tionships. This interaction is mediated across the epidermal–dermal
junction or basement membrane. The basement membrane is a
complex multilayer structure derived by substances contributed from
both sections of the skin. While the epidermis is derived from the
embryonic ectoderm, the dermis is derived from the embryonic
mesoderm. The mesoderm gives rise to cells of the dermis, vascular
elements, connective tissue stroma and subcutaneous tissue. As a
composition generalization, the dermis is an intricate connective
tissue network made up of collagen and elastic fibers embedded in a
ground substance matrix that accommodates nerve bundles, sensory
receptors and lymphatic and vascular elements. This structural com­
position assists in sensory perception, water homeostasis, temperature
regulation and protection against mechanical trauma. When assessed
in its entirety, the dermis is made up of 75% collagen. The two distinct
layers of the dermis, the papillary and the reticular dermis, differ in
the collagen matrix formed. The papillary dermis collagen is loosely
arranged in a fine meshwork, while the reticular dermis collagen is
assembled in thick interwoven bundles.
Elastic fibers then surround and border the collagen bundles and
are distributed throughout the dermis, the walls of cutaneous blood
vessels, sheaths of hair follicles and eccrine and apocrine sweat glands.
The elastic fibers impart elasticity to these structures, allowing them
to tolerate deforming forces without irreparable harm. Besides the
collagen and elastic tissue, the connective tissue network is also com­
posed of ground substance that supports the structural components
of the dermis. Ground substance is a matrix that consists of gly­
cosaminoglycans, such as hyaluronic acid, and glycoproteins, such as
fibronectin, produced by fibroblasts. Fibronectin is important in
wound healing and in forming matrix adhesions between collagen
and elastin bundles, and between keratinocytes and the basement
membrane.
The structural elements of the dermis differ either in cellular type
or number, depending on the papillary or the reticular dermis. The
papillary dermis is the region between the basement membrane and
the subpapillary plexus in the reticular dermis. It is made up primarily
of type III collagen in a loose network with large number of fibroblasts
that have an increased proliferative and synthetic capability compared
with fibroblasts of the reticular dermis. The papillary dermis interdigi­
tates with papillae directly with the epidermis through the basal layer
Figure 2.2  Magnification of terminal branches of epidermal nerve fibers.
(Courtesy of Dr Bradley Bakotic)

10
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
entirely devoted to wound healing to demonstrate the significant role
the skin plays in intraoperative and postoperative management. The
ability of the skin to regenerate itself is at times nothing less than
remarkable. The initial event in wound healing is hemorrhage fol­
lowed by a clot of fibrin meshwork to establish hemostasis. A mitotic
burst of the germinatival cells occurs at the periphery of the wound
and becomes migratory as mitosis increases. So the cells may properly
migrate, polymorphonuclear leukocytes and lymphocytes invade the
wound in a predictable timed sequence and phagocytose and debride
the wound.
The cells of the stratum germinativum continue migrating over the
clot, until like cells are encountered and close the defect. Fibroblasts
in the dermis synthesize a new matrix along with collagen, and elastin
fibers and blood vessels reconstitute themselves by budding into the
dermis. Any disruption of this sequence of events, whether mechanical
or chemical disruption, will result in a delay or absence of wound
healing and increased operative complications.
The vascular supply to the dermis is of critical importance to the
surgeon during preoperative planning. The cutaneous vessels ulti­
mately originate from named source vessels below. Each source vessel
supplies a three-dimensional vascular territory of tissue from bone to
skin termed an angiosome. Adjacent angiosomes form vascular con­
nections between territories by way of reduced caliber (choke) vessels
or similar caliber (true) vessels. The cutaneous vessels originate either
directly from the source arteries or as terminal branches of muscular
vessels. As these vessels traverse toward the skin, they form extensive
subdermal and dermal plexuses. The dermis contains horizontally
arranged superficial and deep plexuses, which are interconnected with
communicating vessels oriented perpendicular to the skin surface.
Cutaneous vessels ultimately anastomose with other cutaneous vessels
to form a continuous vascular network within the skin. This extensive
horizontal network of vessels allows for random skin-flap survival.
The mapping of various angiosomes of the foot and leg will be dis­
cussed in later chapters pertaining to random skin-flap designs.
CONCLUSION
With the surgeon aware of the complexities of the skin and its surgical
implications, many of the cutaneous surgical procedures can be
undertaken with improved final outcomes and decreased complica­
tions. It behoves all surgeons to consider the intricate relationship of
the skin and its components not only when performing any surgery,
but in particular, when performing skin flaps and grafts. Evaluating
the quality of the skin and determining the relaxed skin tension lines
and the location of angiosomes will help the surgeon plan the proce­
dure for optimal results.
The subcutaneous layer plays additional vital roles in daily function.
The deposits of fat act as shock absorbers, protecting and supporting
vital organs. The adipose tissue also acts as an insulator for heat, and
the metabolic burning of its stores of triglycerides serves as fuel for its
thermogenic function. Energy is efficiently stored in the form of tri­
glycerides and is released as fatty acids when necessary.
SURGICAL IMPLICATIONS
Understanding the complex morphological and biochemical compo­
sition of the epidermis and the dermis allows the surgeon to enhance
surgical outcomes with fewer wound complications. Chapter 10 is
Figure 2.3  Drawing of the cutaneous vascular network demonstrating
the relationship and connection of the deep and superficial vascular
plexuses.
Epidermis
Papillary
dermis
Subcutaneous
fat
Superficial
vascular
plexus
Deep
vascular
plexus
Reticular
dermis
FURTHER READING
Braverman, I.M., Yen, A., 1977. Ultrastructure
of the human dermal microcirculation II.
The capillary loop of the dermal papillae.
J Invest Dermatol 68, 42–52.
Chu, A., Eisinger, M., Lee, J.S., 1982.
Immunoelectron microscopic identification
of Langerhans cells using a new antigenic
marker. J Invest Dermatol 78, 177–180.
Clemens, M.W., Attinger, C.E., 2010.
Angiosomes and wound care in the diabetic
foot. Foot Ankle Clin 15 (3), 439–464.
Dale, B.A., 1985. Filaggrin, the matrix protein
of keratin. Am J Dermatopathol 7, 65–68.
Dockery, G.L., 1997. Anatomy of the skin. In:
Cutaneous disorders of the lower extremity.
WB Saunders, Philadelphia, pp. 1–8.
Domonkos, A.N., 1971. Cutaneous structure
and pathology. In: Andrews’ diseases of the
skin, sixth ed. WB Saunders, Philadelphia,
pp. 1–16.
Downing, D.T., Strauss, J.S., 1974. Synthesis
and composition of surface lipids in
human skin. J Invest Dermatol 62,
228–244.
Downing, D.T., Strauss, J.S., 1982. On the
mechanism of sebaceous secretion. Arch
Dermatol Res 272, 343–349.
Eady, R.A., 1988. The basement membrane.
Arch Dermatol 124, 709–712.
Fitzpatrick, T.B., Eisen, A.Z., Wolff, K.,
et al., 1987. Dermatology in general
medicine. McGraw-Hill, New York,
pp. 93–455.

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Cutaneous anatomy and its surgical implications
11
| 2 |
Frances, D., Robert, L., 1984. Elastin and
elastic fibers in normal and pathological
skin. Int J Dermatol 23, 166–179.
Habif, T.P., 1990. Principles of diagnosis and
anatomy. In: Clinical dermatology. A color
guide to diagnosis and therapy, second ed.
Mosby, St Louis, pp. 1–10.
Holbrook, D., Wolff, K., 1987. Structure and
development of the skin. In: Fitzpatrick,
T.B., Eisen, A.Z., Wolff, K., et al. (Eds.),
Dermatology in General Medicine.
McGraw-Hill, New York.
Jakubovic, H.R., Ackerman, A.B., 1992.
Structure and function of skin:
development, morphology, and physiology.
In: Moschella, S.L., Hurley, H.J. (Eds.),
Dermatology, third ed. WB Saunders,
Philadelphia, pp. 3–87.
Katz, S.I., 1984. The epidermal basement
membrane zone-structure, ontogeny, and
role in disease. J Am Acad Dermatol 11,
1025–1037.
Katz, S.I., 1988. The skin as an immunologic
organ. Arch Pathol Lab Med 112, 231–234.
Katz, A.M., Rosenthal, D., Sauder, D.N., 1991.
Cell adhesion molecules: structure, function
and implication in a variety of cutaneous
and other pathologic conditions. Int J
Dermatol 30, 153–160.
Lavker, R.M., Sun, T.T., 1983. Epidermal
stem cells. J Invest Dermatol 81, 121–127.
Leffell, D.J., Rachal, M., 1994. Microanatomy,
structure and function of the skin. In:
Wheeland, R.G. (Ed.), Cutaneous
Surgery. WB Saunders, Philadelphia,
pp. 32–45.
Mackenzie, I.C., Zimmerman, K., Peterson, L.,
1981. The pattern of cellular organization
in human epidermis. J Invest Dermatol 76,
459–461.
Masuda, T., Ikida, S., Tajima, K., 1986. Neuron
specific enolase (NSE): a specific marker
for Merkel cells in human epidermis.
J Dermatol 13, 67–69.
Matoltsy, A.G., 1976. Desmosomes, filaments,
and keratohyaline granules: their role in
stabilization and keratinization of the
epidermis. J Invest Dermatol 65, 124–142.
Matoltsy, A.G., 1976. Keratinization. J Invest
Dermatol 67, 20–25.
McCarthy, D.J., 1986. Cutaneous anatomy.
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Podiatric Dermatology. Williams & Wilkins,
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Pouillot, A., Dayan, N., Polla, A., et al., 2008.
The stratum corneum: a double paradox.
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Robertshaw, D., 1983. Apocrine sweat glands.
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Lymphatics of the skin. Int J Dermatol 25,
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131–142.

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CHAPTER CONTENTS
Introduction
13
Angiosomal circulation to the foot and ankle
13
Posterior tibial artery angiosomes
14
Anterior tibial artery angiosomes
15
Peroneal artery angiosomes
16
Cutaneous circulation of the skin and superficial
fascia
16
Mechanisms of anastomosis
17
Compromised vascular states
17
Incision planning
18
Venous and lymphatic drainage
18
Conclusion
19
INTRODUCTION
Chapter 2 of this edition provided a comprehensive description of the
structural anatomy of the skin and superficial fascia of the lower
extremity. It is the intended emphasis of this chapter to build from
that material and present a closer look at the vascular anatomy sup­
plying these structures.
From a functional perspective, the vascular components of the cuta­
neous system are integral to its role in temperature maintenance,
blood pressure regulation and immunological function. In addition,
its role as part of the larger wound healing process has obvious impli­
cations that should be fully appreciated by all surgical specialties.1–15
Though the vascular components are also required for the basic meta­
bolic duties of the skin, these demands in fact only represent a small
portion of the total potential cutaneous circulation.1
From a clinical anatomic perspective, the macrovascular supply
to the lower extremity may best be appreciated in terms of the
angiosomal and cutaneous circulations. The angiosomal circulation
can be thought of as the named arteries that physically transport the
blood into the foot and to the level of the deep fascia. The cutaneous
circulation would then be comprised of the unnamed perforators and
arterioles found within the superficial fascia and skin. These branches
arise from the underlying named arteries of the angiosomal circula­
tion. This cutaneous circulation therefore serves as a transition from
the macrovascular supply of the angiosomes to the diffusion physiol­
ogy of the capillaries and microcirculation.
All surgeons must possess an active awareness of the vascular supply
to a given target tissue in the perioperative period. The physiology and
pathophysiology of the angiosomal and cutaneous circulations should
have an impact on the choice of procedure, incision planning and
postoperative course.
ANGIOSOMAL CIRCULATION
TO THE FOOT AND ANKLE
G. Ian Taylor first originated the concept of angiosomes in human
anatomy to describe a three-dimensional block of tissue supplied by
a single source artery incorporating all surgical layers including bone,
muscle, fascia, subcutaneous tissue and skin.1,2,16–19 Attinger and
colleagues20–22 further developed this principle with their work specifi­
cally examining the foot and ankle, eventually illustrating six foot
angiosomes originating from three primary source arteries (Table 3.1).
The concept of a single source artery supplying a unit of tissue is
important when considering angiosomal principles of the lower
extremity because this region represents a peninsular end-organ. All
vascular supply to the foot and ankle enters through the popliteal
fossa and the terminal branches of the popliteal artery: the anterior
tibial, posterior tibial and peroneal arteries. In addition, there are
anastomotic communications between these terminal branches within
the foot and ankle, which gives the entire macrocirculation redun­
dancy in case one of the named arteries is damaged or occluded.
©2012 Elsevier Ltd.
Vascular anatomy and its surgical implications
Andrew J. Meyr, John S. Steinberg, Christopher E. Attinger
Chapter
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14
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
aspect of the heel to the lateral glabrous junction. This territory
extends as far distally as the junction of the heel and medial instep.
Medial plantar angiosome
The posterior tibial artery then bifurcates into the medial plantar and
lateral plantar arteries within the flexor retinaculum. The medial
plantar artery supplies an angiosome encompassing the medial instep
Posterior tibial artery angiosomes
The posterior tibial artery supports three angiosomes in the foot
through its branches and terminal bifurcation: the medial calcaneal,
medial plantar and lateral plantar arteries. Before terminal bifurcation
however, the posterior tibial artery directly supplies the medial lower
leg from the anterior crest of the tibia to the midline of the calf. The
specific posterior border of this territory is represented by the central
raphe of the Achilles tendon. Anterior and posterior branches bifur­
cate from five or six perforating arteries through the flexor hallucis
longus muscle, soleus muscle or the intramuscular septum dividing
the superficial and deep posterior compartments of the lower leg
(Fig. 3.1).
Additionally, the posterior tibial artery supplies two important anas­
tomotic connections before termination. The first is the posterior
medial malleolar artery at the level of the medial malleolus. This
branch directly anastomoses with the anterior medial malleolar artery,
which is a branch of the anterior tibial artery. It provides direct com­
munication between the posterior tibial and anterior tibial source
arteries, in addition to supplying the tissue overlying the medial
malleolus. The second important anastomoses are a series of com­
municating branches running proximal to the ankle joint and deep to
the flexor hallucis longus that anastomose with similar communicat­
ing branches of the peroneal artery. These provide direct communica­
tion between the posterior tibial and peroneal source arteries, in
addition to supplying the posterior perimalleolar area.
Medial calcaneal angiosome
The medial calcaneal artery branches from the posterior tibial artery
proximal to the flexor retinaculum and supplies a region encompass­
ing the entire plantar aspect of the heel (Fig. 3.2). To fully appreciate
the breadth of this territory, the heel is divided into medial, posterior,
lateral and plantar portions. The specific boundaries of this angio­
some are from the posterior and medial heel (an area covering the
Achilles tendon insertion and tarsal tunnel), across the entire plantar
Table 3.1  The angiosomes of the foot
Angiosome
Medial
calcaneal
Medial
plantar
Lateral
plantar
Dorsalis pedis
Lateral
calcaneal
Anterior
perforating
Source artery
Posterior
tibial artery
Posterior tibial
artery
Posterior tibial
artery
Anterior tibial
artery
Peroneal artery
Peroneal artery
Boundaries
Posterior heel
covering the
Achilles tendon
insertion.
Proximally to the
junction of the
heel and medial
instep.
Proximally to the
junction of the
heel and lateral
plantar midfoot.
Encompassing
entire dorsal foot
from the ankle joint
to the forefoot.
Posterior heel
covering the
Achilles tendon
insertion.
Encompassing a general
area about the distal
interosseous membrane
and anterolateral ankle.
Medial heel
covering the
area of the
tarsal tunnel.
Medially to an
arc 2–3 cm above
the medial
glabrous junction.
Medially to the
midline of the
plantar foot.
Medially to an arc
2–3 cm above the
medial glabrous
junction.
Entire plantar
heel to the
medial glabrous
junction.
Entire plantar
heel to the
lateral glabrous
junction.
Laterally to the
midline of the
plantar foot.
Laterally to the
lateral glabrous
junction.
Laterally to the
lateral glabrous
junction.
Lateral heel
covering the area
to the base of the
fifth metatarsal.
Distally to the
junction of the
heel and
medial instep.
Distally to the
edge of the
plantar forefoot.
Distally
encompassing
the entire
forefoot.
Figure 3.1  Posterior tibial artery angiosome. The posterior tibial artery
(1) serves as the primary source artery for three angiosomes in the foot
through its branches and terminal bifurcation: the medial calcaneal (2),
lateral plantar (3) and medial plantar (4) arteries. Prior to terminal
bifurcation, the posterior tibial artery directly supplies the medial lower
leg from the anterior crest of the tibia to the midline of the calf. Anterior
and posterior branches bifurcate from five or six perforating arteries
(*) through the superficial and deep posterior compartments of the
lower leg.
1
2
3
4

Chapter
Vascular anatomy and its surgical implications
15
| 3 |
significant series of anastomoses with the dorsalis pedis artery in the
metatarsal interspaces. The most important of these is formed in the
proximal first interspace, although similar connections are typically
found in the other proximal and distal interspaces.
Anterior tibial artery angiosomes
The anterior tibial artery supplies the anterior aspect of the leg
and the dorsalis pedis angiosome of the foot. In the leg, the area
overlying the anterior compartment is supplied from the anterior
tibial crest to the fibula. Several anastomotic connections are formed
just proximal to the level of the ankle joint. As previously described,
the anterior medial malleolar artery supplies the tissue overlying the
medial malleolus and connects with the posterior tibial source artery.
Also at this level, the lateral malleolar artery supplies the tissue overly­
ing the distal extent of the fibula and anastomosis with the anterior
perforating branch of the peroneal artery.
Dorsalis pedis angiosome
The dorsalis pedis artery represents the continuation of the anterior
tibial artery distal to the level of the ankle joint. The dorsalis pedis
angiosome encompasses the entire dorsal aspect of the foot through
the variable medial tarsal, lateral tarsal, arcuate and dorsal metatarsal
arteries (Fig. 3.6).
These arteries contribute to important anastomoses with the other
terminal arterial branches of the foot. As described earlier, there
are anastomoses along the medial border of the foot between the
through its superficial and deep terminal branches. The boundaries of
this angiosome are the junction of the heel and medial instep proxi­
mally, the midline of the plantar foot laterally, an arc 2–3 cm above
the medial glabrous junction medially, and the proximal edge of the
plantar forefoot distally (Fig. 3.3). While this angiosome may encom­
pass the tissue of the hallux, this area is usually primarily supplied by
the lateral plantar angiosome.
The superficial branch of the medial plantar artery provides dorsal
anastomoses with the dorsalis pedis artery and the first dorsal meta­
tarsal artery through cutaneous branches, and also lateral anastomoses
with the first plantar metatarsal artery through deeper branches. The
deep branch of the medial plantar artery provides lateral anastomoses
with the first plantar metatarsal artery and the distal lateral plantar
artery about the neck of the first metatarsal.
Lateral plantar angiosome
Following bifurcation, the lateral plantar artery travels through the
central plantar compartment to form the important deep plantar arch
with its four plantar metatarsal arteries extending distally to the digits.
The boundaries of this angiosome are the junction of the heel and
lateral plantar midfoot proximally, the lateral glabrous junction later­
ally, the midline of the plantar foot medially and the entire forefoot
distally (Fig. 3.4). Again, this angiosome usually provides vascular
supply to the hallux, but this area may also be supplied by the medial
plantar or dorsalis pedis angiosomes (Fig. 3.5).
In addition to the previously described anastomoses with the
medial plantar angiosome, the lateral plantar artery forms a very
Figure 3.2  Medial calcaneal angiosome. The primary source artery of the
medial calcaneal angiosome (A) is the posterior tibial artery by way of the
medial calcaneal artery branches (1). The boundaries of this angiosome
are the posterior and medial heel (an area covering the Achilles tendon
insertion and tarsal tunnel), across the entire plantar aspect of the heel
to the lateral glabrous junction, and as far distally as the junction of the
heel and medial instep.
1
A
Figure 3.3  Medial plantar angiosome. The primary source artery of
the medial plantar angiosome (B) is the posterior tibial artery by way of
the superficial (1) and deep (2) branches of the medial plantar artery. The
boundaries of this angiosome are the junction of the heel and medial
instep proximally, the midline of the plantar foot laterally, an arc 2–3 cm
above the medial glabrous junction medially, and the proximal edge of
the plantar forefoot distally.
1
2
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Lateral calcaneal angiosome
The lateral calcaneal artery travels along the peroneal tendons giving
off several small calcaneal branches as it courses toward the base of
the fifth metatarsal. Again, to fully appreciate the boundaries of this
territory, the heel is divided into medial, posterior, lateral and plantar
portions. The specific boundaries of this angiosome are from the
posterior and lateral heel (an area covering the Achilles tendon inser­
tion and the lateral heel to the base of the fifth metatarsal), across the
entire plantar aspect of the heel to the medial glabrous junction. This
territory extends as far distally as the junction of the heel and lateral
plantar midfoot (Fig. 3.7).
There are anastomoses with the lateral tarsal arteries of the dorsalis
pedis angiosome distally, and although it is not necessarily a true
anastomosis, it should be noted that the majority of the heel is sup­
plied by two overlapping source arteries: the posterior tibial and pero­
neal arteries.
Anterior perforating peroneal angiosome
The anterior perforating peroneal artery supplies a general area about
the distal interosseous membrane and the anterolateral ankle. This
is the specific region of the supramalleolar tissue flap. Anastomotic
communication exists with the anterior lateral malleolar artery of the
anterior tibial angiosome.
CUTANEOUS CIRCULATION OF THE SKIN
AND SUPERFICIAL FASCIA
From this clinical anatomic perspective, these angiosomes represent
the macrocirculation transporting blood to the level of the deep fascia
in all areas of the foot and ankle. We can then view the cutaneous
Figure 3.4  Lateral plantar angiosome. The primary source artery of the
lateral plantar angiosome (C) is the posterior tibial artery by way of the
lateral plantar artery (1). This artery forms the deep plantar arch (2) with
its plantar metatarsal artery branches before anastomosing in the
proximal first interspace. The boundaries of this angiosome are the
junction of the heel and lateral plantar midfoot proximally, the lateral
glabrous junction laterally, the midline of the plantar foot medially, and
the entire forefoot distally.
1
2
C
Figure 3.5  Hallux with varying angiosomal supply. The angiosomal
supply to the hallux can be provided by the lateral plantar angiosome,
medial plantar angiosome, dorsalis pedis angiosome, or combinations of
these angiosomes.
(Reprinted from Attinger, C.E., Evans, K.K., Bulan, E., et al. 2006. Angiosomes
of the foot and ankle and clinical implications for limb salvage: reconstruction,
incisions, and revascularization. Plast Reconstr Surg Jun 117 (7 Suppl), 261S–293S.)
superficial cutaneous branches of the medial plantar artery and the
medial tarsal branches dorsally. The dorsalis pedis artery terminally
bifurcates in the proximal first interspace as it forms an important
anastomosis with the lateral plantar artery at the distal extent of the
deep plantar arch. In the same way, there are often anastomoses
between the dorsal and plantar metatarsal arteries in several locations
(proximal and distal perforating arteries) in their respective inter­
spaces. Anastomoses are also present between the proximal lateral
tarsal arteries and the calcaneal and perforating branches of the pero­
neal artery.
Peroneal artery angiosomes
The peroneal artery supplies the tissue of the posterolateral aspect of
the lower leg from the midline of the posterior calf to the fibula along
the anterior edge of the lateral compartment. At the level of the lateral
malleolus, the peroneal artery bifurcates into its terminal branches
forming the final two angiosomes of the foot: the anterior perforating
and lateral calcaneal arteries.

Chapter
Vascular anatomy and its surgical implications
17
| 3 |
circulation as the blood supply to the skin and subcutaneous tissue
following perforation of the deep fascia. Taylor1 describes the deep
fascia as an ‘enveloping body suit’ covering the entire human frame,
similar to the way that Bonica describes this layer as a ‘second skin’23,24
forming a developmental boundary between the superficial structures
derived from the ectoderm (skin, superficial fascia) and the deeper
structures derived from mesodermal tissue (muscles, tendons, joints,
bones). Cutaneous arteries must penetrate through this layer in order
to supply the skin and superficial fascia. This can occur either directly
from the underlying source arteries, or indirectly from source artery
branches supplying deeper tissues such as muscle. So conceptually,
the cutaneous circulation to the skin and superficial fascia is from
cutaneous perforators that arise from the deeper angiosomal macro­
circulatory source arteries.
Cutaneous perforators pierce the deep fascia at fixed intervals
depending on the specific anatomy of the location. This tends to
occur at sites where the skin is fixed to the deep fascia such as skin
crease lines, over intermuscular septae, near retinacular components,
close to muscular insertions, and along the course of cutaneous
nerves. Once the cutaneous arteries enter the superficial fascia, they
organize into distinct layers forming a ‘body carpet’,1 or plexuses on
the undersurfaces of the subcutaneous fat and dermis. Each cutaneous
perforator can then be thought of as supplying a three-dimensional
unit of skin and superficial fascia with distinct layers and interconnec­
tions to adjacent cutaneous perforators. The cutaneous circulation
of the lower extremity can be appreciated as these continuous plexuses
that form uninterrupted horizontal layers within the skin and
superficial fascia from cutaneous perforator to cutaneous perforator
(Fig. 3.8). Capillary loops then arise from the subdermal plexus
and provide a transition to the diffusion physiology of the
microcirculation.25–28
Mechanisms of anastomosis
Anastomosis within the angiosomal circulation occurs deep to the
deep fascia between adjacent source arteries, just as anastomosis
within the cutaneous circulation occurs superficial to the deep fascia
between adjacent cutaneous perforators. Both processes are regulated
by the mechanisms of arterial-to-arterial connections, and allow
neighboring angiosomes to share a common blood supply if one
source artery is disrupted. The cutaneous vessels are under additional
control of the sympathetic nervous system. Connections are open or
closed as needed for the function of temperature regulation.
Direct arterial-to-arterial connections serve simply as a shunt where
blood can pass from one angiosome to another through communicat­
ing arteries. Indirectly, choke vessels are found at the junction of
angiosomal boundaries, but are normally closed and do not allow
communication. The delay phenomenon explains how choke vessels
can serve as safety conduits in the setting of source artery disruption,
and allow the source artery from another angiosome to provide blood
flow beyond its immediate border.16,21,22 When the source artery to an
angiosome has been disrupted, the choke vessels at the angiosomal
boundary respond to the stress by opening and allowing communica­
tion. In this way, a threatened angiosome can be supplied by an
adjacent source artery.
COMPROMISED VASCULAR STATES
The source artery supplying a given angiosome can become compro­
mised because of acute or chronic conditions. As a peninsular end-
organ, the lower extremity is particularly susceptible to the chronic
Figure 3.6  The dorsalis pedis angiosome. The anterior tibial artery serves
as the primary source artery for the dorsalis pedis angiosome in addition
to supplying the tissue of the anterior leg from the anterior crest of the
tibia to the fibula. The dorsalis pedis angiosome (D) encompasses the
entire dorsal aspect of the foot through the variable dorsalis pedis (1),
medial tarsal (2), lateral tarsal (3), arcuate (4) and dorsal metatarsal
arteries. The reader can also appreciate the anterior perforating branch
of the peroneal artery (5) penetrating the distal interosseous membrane
in this figure.
1
5
2
3
4
D
Figure 3.7  Lateral calcaneal angiosome. The peroneal artery (1) serves as
the primary source artery for two angiosomes in the foot through its
terminal bifurcation: the anterior perforating (2) and lateral calcaneal (3)
branches. Prior to terminal bifurcation, the peroneal artery supplies the
lateral lower leg from the posterior midline of the calf to the fibula. The
boundaries of the lateral calcaneal angiosome (E) are the posterior and
lateral heel (an area covering the Achilles tendon insertion and the lateral
heel to the base of the fifth metatarsal), across the entire plantar aspect
of the heel to the medial glabrous junction, and distally to the junction
of the heel and lateral plantar midfoot.
1
2
3E

18
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
manifestations of peripheral vascular disease. Impairment can occur
within the specific source artery, but disease at a site more proximal
along the vascular tree will also affect distal angiosomes. The superfi­
cial femoral artery is the most commonly affected in the lower extrem­
ity, and those with diabetes are particularly at risk for the type 1
pattern of disease with involvement of the superficial femoral artery
and infra­popliteal trifurcation.11,29–31 Direct and indirect affects on the
angiosomal supply of the foot can be expected depending on the
specific location and severity of the disease.
Physicians should also appreciate the potential for diffusion abnor­
malities with microvascular dysfunction in the setting of diabetes and
other chronic conditions.32–45 Surgeons are strongly encouraged to
perform a thorough macro- and microvascular evaluation prior to the
initiation of any surgical intervention. This evaluation is detailed in
Chapter 1 of this edition, and the reader is further referred to other
sources.46–54
Additionally, Attinger and colleagues21,22 developed a physical exam­
ination technique of angiosome patency utilizing a handheld Doppler
device and finger applied occlusion. This method not only provides
the surgeon with information regarding angiosome source artery flow,
but also the direction of that flow. For example, the source artery for
the dorsalis pedis angiosome on the dorsum of the foot is the dorsalis
pedis artery, anatomically a continuation of the anterior tibial artery
distal to the ankle. Flow through the dorsalis pedis artery may arise
directly antegrade from the anterior tibial artery, but it may also arise
Figure 3.8  Cutaneous perforator continuous plexus. Figures A and B
demonstrate the continuous nature of the cutaneous circulation as
interconnected and uninterrupted horizontal layers within the skin and
superficial fascia from cutaneous perforator to cutaneous perforator.
(Reprinted with permission from Taylor, G.I., Palmer, J.H. 1987. The vascular
territories (angiosomes) of the body: experimental study and clinical applications.
Br Plast Surg 40, 113–141.)
A
B
Skin
Cutaneous
perforators
Source
artery
Deep
fascia
Horizontal
plexuses
indirectly antegrade from the peroneal artery through the anterior
perforating branch or lateral calcaneal artery, or from the posterior
tibial artery through the lateral plantar artery, depending on the spe­
cific anastomosing patterns of the arterial-to-arterial connections. This
system of evaluation presents the surgeon with a specific and detailed
map of the vascular anatomy of a given surgical site, whether it is the
ankle, heel, plantar aspect of the foot or dorsum of the foot. A review
of the angiosome source arteries with their potential arterial–arterial
connections is provided in Figure 3.9.
INCISION PLANNING
Exact incision placement represents a compromise between target
tissue exposure, skin tension lines (with considerations for scar forma­
tion and joint contracture), adjacent neurological structures and vas­
cular supply. From an entirely vascular perspective, an incision within
a given angiosome is safe if a palpable pulse or triphasic Dopplerable
signal is present from the source artery supplying that angiosome.21,22
In situations of abnormal flow, extreme care must be taken to appreci­
ate not only which angiosomes are deficient, but also where collateral
anastomotic flow is coming from. An incision through an angiosome
without a viable source artery should not disrupt the essential col­
lateral flow from adjacent angiosomes.
When an incision is required at the junction of two angiosomes,
the ideal location from a vascular perspective is along the exact
border of both. Then each side of the incision has adequate flow
from the respective source arteries. An example of this concept is
illustrated by the extensile lateral approach used for open reduction
of calcaneal fractures.55 The proper location for the inferior arm of
this incision is precisely at the lateral glabrous junction of the heel,
which is directly at the boundary of two angiosomes. An incision,
which has been displaced more superiorly into the lateral heel, puts
the tissue between the lateral glabrous junction and the incision at
risk for dehiscence and necrosis (Fig. 3.10). Attinger and colleagues21,22
have made similar recommendations for incision placement at angio­
some boundaries for other locations, and with multiple incisions in
the foot and ankle.
VENOUS AND LYMPHATIC DRAINAGE
Although not usually the focus of surgical vascular anatomy, a brief
description of the venous56–60 and lymphatic61–65 drainage of the foot
and ankle will be reviewed here and should be considered in preop­
erative planning. The venous and lymphatic systems are organized in
a similar manner to the arterial system, but naturally the flow moves
from distal to proximal, and from superficial to deep. Comparable
horizontal plexuses are formed within the skin and subcutaneous
tissue, and the venous and lymphatic vessels generally travel with
arterioles and arteries. In addition to his work with the arterial angio­
somes, Taylor has also described the anatomy of the venosomes, or
three-dimensional blocks of tissue served by a single source vein.56 A
simple rule of thumb is that wherever there is an artery, there are
adjacent venous and lymphatic vessels.
The reverse of this statement is not true however, and often impor­
tant veins and lymphatics travel without arteries within the superficial
fascia. These drainage systems rely more heavily on the cutaneous
circulation for proximal flow, and distinct superficial and deep venous
and lymphatic systems are found. For example, the majority of the
drainage from the dorsum of the foot and plantar heel occurs through

Chapter
Vascular anatomy and its surgical implications
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Figure 3.9  Source artery anastomoses chart. Anastomosis within the angiosomal circulation occurs deep to the deep fascia between adjacent source
arteries, just as anastomosis within the cutaneous circulation occurs superficial to the deep fascia between adjacent cutaneous perforators. Both
processes are regulated by the mechanisms of arterial-to-arterial connections, and allow neighboring angiosomes to share a common blood supply if
one source artery is disrupted.
Anterior
Tibial Artery:
- Dorsalis Pedis
Angiosome
- Anterior and posterior lateral
malleolar arteries
- Lateral tarsal arteries and the
perforating and calcaneal branches
- Posterior communicating branches
- Dual angiosome heel coverage
- Anterior and posterior medial
malleolar arteries
- Medial plantar artery and the dorsalis
pedis/first dorsal metatarsal arteries
along the medial glabrous junction
- Lateral plantar artery and dorsalis pedis
artery in the proximal first interspace
- Dorsal and plantar metatarsal arteries
in the respective interspaces
Peroneal Artery:
- Lateral Calcaneal
Angiosome
- Anterior Perforating
Angiosome
Posterior Tibial Artery:
- Medial Calcaneal
Angiosome
- Medial Plantar
Angiosome
- Lateral Plantar
Angiosome
Popliteal Artery
Anastomoses
Anastomoses
Anastomoses
Figure 3.10  Incisions at the junction of two angiosomes. (A) When an incision is required at the junction of two angiosomes, the ideal location is
along the exact border of both so that each side of the incision has adequate flow from the respective source arteries. An appropriate example of this
concept is illustrated by the extensile lateral approach used for open reduction of calcaneal fractures. The proper location for the inferior arm of this
incision is precisely at the lateral glabrous junction of the heel, which is directly at the boundary of two angiosomes. (B) An incision which has been
displaced superiorly into the lateral heel puts the tissue between the lateral glabrous junction and the incision at risk for dehiscence and necrosis.
(Reprinted from Attinger, C.E., Evans, K.K., Bulan, E., et al. 2006 Jun. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions,
and revascularization. Plast Reconstr Surg 117 (7 Suppl), 261S–293S.)
A
B
the superficial system via greater and lesser saphenous veins.14,57,58 If
a surgical procedure is contained solely within the skin and superficial
fascia, then the arterial supply to the region originates from deeper
sources, but the expected venous drainage will be nearly entirely con­
tained superficially. This concept becomes increasingly important
when surgical procedures involve advanced reconstructions with
various flaps (see Ch. 23).
CONCLUSION
The intended emphasis of this chapter is to provide the foot and ankle
surgeon with a clinical appreciation for the specific vascular anatomy
of the lower extremity and an appreciation of how angiosomal
anatomy can directly influence the outcomes of surgical procedures.

20
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
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Vascular anatomy and its surgical implications
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42. Boyko, E.J., Ahroni, J.H., Stensel, V.L.,
2001. Tissue oxygenation and skin blood
flow in the diabetic foot: responses to
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43. Khodabandehlou, T., Zhao, H., Vimeux,
M., et al., 1997. The autoregulation of the
skin microcirculation in healthy subjects
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et al., 2007. Impaired skin microvascular
reactivity in painful diabetic neuropathy.
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et al., 2005. Manifestations of cutaneous
diabetic microangiopathy. Am J Clin
Dermatol 6 (4), 225–237.
46. Sumpio, B.E., Lee, T., Blume, P.A., 2003.
Vascular evaluation and arterial
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Podiatr Med Surg 20 (4), 689–708.
47. Jaff, M.R., 2002. Lower extremity arterial
disease. Diagnostic aspects. Cardiol Clin 20
(4), 491–500.
48. Principato, R., 1997. Peripheral vascular
disease and its evaluation. Clin Podiatr
Med Surg 14 (2), 265–280.
49. Bassiouny, H.S., 1995. Noninvasive
evaluation of the lower extremity arterial
tree and graft surveillance. Surg Clin North
Am 75 (4), 593–606.
50. Sykes, M.T., Godsey, J.B., 1998. Vascular
evaluation of the problem diabetic foot.
Clin Podiatr Med Surg 15 (1), 49–83.
51. Bashir, R., Cooper, C.J., 2003. Evaluation
and medical treatment of peripheral
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52. Neville, R.F., 2001. Vascular reconstructive
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53. Rose, S.C., 2000. Noninvasive vascular
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arterial occlusive disease: Part II –
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54. Gerhard-Herman, M., Gardin, J.M., Jaff,
M., et al., 2006. American Society of
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55. Bernirschke, S.K., Sangeorzan, B.J., 1993.
Extensive intra-articular fractures of the
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56. Taylor, G.I., Caddy, C.M., Watterson, P.A.,
et al., 1990. The venous territories
(venosomes) of the human body:
experimental study and clinical
implications. Plast Reconstr Surg 86 (2),
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57. White, J.V., Katz, M.L., Cisek, P., et al.,
1996. Venous outflow of the leg: anatomy
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venous plexus. J Vasc Surg 24 (5),
819–824.
58. Imanishi, N., Kish, K., Chang, H., et al.,
2007. Anatomical study of cutaneous
venous flow of the sole. Plast Reconstr Surg
120 (7), 1906–1910.
59. Ghali, S., Bowman, N., Khan, U., 2005.
The distal medial perforators of the lower
leg and their accompanying veins. Br J
Plast Surg 58 (8), 1086–1089.
60. Imanishi, N., Kishi, K., Chang, H., et al.,
2008. Three-dimensional venous
anatomy of the dermis observed
using stereography. J Anat 212 (5),
669–673.
61. Kamath, D., Rapaport, D., DeConti, R.,
et al., 1997. Redefining cutaneous
lymphatic flow: the necessity of
preoperative lymphoscintigraphy in
the management of malignant
melanoma. J Fla Med Assoc 84 (3),
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62. Ryan, T.J., Mortimer, P.S., Jones, R.L., 1986.
Lymphatics of the skin. Neglected but
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411–419.
63. Ryan, T.J., 1989. Structure and function
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(2 Suppl), 18S–24S.
64. Ryan, T.J., Curri, S.B., 1988. Blood vessels
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65. Daroczy, J., 1983. The structure and
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FURTHER READING
Clemens, M.W., Attinger, C.E., 2010.
Angiosomes and wound care in the
diabetic foot. Foot and Ankle Clinics
15 (3), 439–464.
Taylor, G.I., Corlett, R.J., Dhar, S.C., et al, 2011.
The anatomical (angiosome) and clinical
territories of cutaneous perforating arteries:
development of the concept and designing
safe flaps. Plast Reconstr Surg 127 (4),
1447–1459.

23
| 4 |
CHAPTER CONTENTS
Introduction
23
Skin properties
23
Contour lines
23
Lines of minimal movement and relaxed skin
tension lines
24
Incision planning
24
Incision making
25
INTRODUCTION
Surgical planning is the preoperative method of pre-visualizing a
surgical intervention, in order to predefine the surgical steps and
furthermore, any bone segment repositioning in the context of the
final outcome. It is without question that surgeons must have detailed
knowledge of the surgical principles, as well as surgical anatomy,
of the areas in which they will be operating. This comprehension
is also necessary for planning the local and regional anesthesia
required to work efficiently and to carry out the procedures safely.
Knowledge of the lower extremity cutaneous and surgical anatomy is
of prime importance since this is the location in which the surgery is
performed.
There are only a few important features that must be understood
and handled with care when discussing most cutaneous surgery. In
contrast, the lower extremity anatomical structures beneath the skin
are much more complex and varied, and it is imperative that there is
a detailed knowledge of these structures in order to prevent irreparable
harm. It is a lack of understanding of the underlying structures that
causes many serious complications involving the nerves, blood vessels
and tendons. Therefore, it is crucial that new surgeons take every
opportunity to improve their expertise of surgical anatomy by dissect­
ing cadavers as well as reviewing textbooks and taking surgical tech­
niques workshops provided by their surgical societies. Similarly,
experienced surgeons must never become too cavalier in their surgical
techniques that they forget the many complexly arranged elements
involved in cutaneous reconstruction.
As soon as the surgeon has a good understanding of the general
anatomy, as well as the cutaneous anatomy, it becomes much easier
to plan and execute skin-related procedures. These skin procedures
rely on the knowledge of the anatomical structures that lie directly
below where the incisions will be performed. In the following section,
the discussion will center on the surgical importance of skin proper­
ties such as contour lines, lines of maximum extensibility, relaxed skin
tension lines, incision planning and, finally, incision-making tech­
niques. Many of these surgical planning principles will be discussed
in other chapters and greater details will be provided when necessary
for individual procedures.
SKIN PROPERTIES
Contour lines
The contour lines are seen around prominent areas of the foot and
ankle, including the toenails, the toes, the contours of the first and
fifth metatarsals, the long extensor tendons, lateral peroneal tendons
and the Achilles tendon to the heel. Other examples include the
boundary of the medial and lateral ankle with the foot and leg. These
lines divide the foot into functional units. During surgery on the foot
and ankle, it is important that these contour lines be maintained as
much as possible in order to reduce visible deformity.
Contour lines can also be effectively used to camouflage surgical
scars, especially when combined with other techniques such as use of
lines of maximum extensibility (LME) of skin and relaxed skin tension
lines (RSTL). The functional units can be further divided into subu­
nits. Thus, the toes can be divided into two sides, the dorsum and the
plantar surfaces. Similarly, the forefoot is divided into the dorsum and
plantar surfaces. The ankle is generally divided into the anterior and
posterior, medial and lateral units and so on. In general, when using
random pattern flaps and grafts, it is best to try to use skin from the
same functional unit or subunit if possible. For example, if a defect is
located on the plantar surface, it is best to use plantar skin for the
repair.
©2012 Elsevier Ltd.
Surgical principles
G. Dock Dockery
Chapter
4

24
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
incision placed parallel to or within the RSTLs will result in less
tension on the wound due to underlying anatomical structures. Inci­
sions with little or no tension generally heal with a lesser degree of
scarring. When it is not possible to stay parallel to the RSTLs, it is best
to place the incision obliquely across the RSTLs. Unfortunately, in foot
and ankle surgery, it is not always practical or advisable to do this,
and in some cases the incision is best placed perpendicular to the
RSTLs to obtain the best surgical exposure and least amount of harm
to the underlying and surrounding tissues.
To best identify the RSTLs on the foot and ankle region, the area is
simply taken through a normal passive or active range of motion and
the crease lines that form in the skin may be observed (Fig. 4.3). In
other parts of the foot, where motion is less, the RSTLs may be repro­
duced by pinching the skin between the thumb and forefinger and
observing the crease lines that form. This same maneuver works in
flexible joints without putting them through the range of motion
process (Fig. 4.4).
INCISION PLANNING
We have determined that it is best to place a surgical incision within
the RSTLs and that, when this is not possible, the next best position
for the incision is oblique to the RSTLs. In order to obtain the best
surgical exposure, however, the incision may need to be placed at right
angles to the RSTLs or direction of muscle/tendon pull over joints.
Surgical incisions that cross over joints are more prone to scar forma­
tion and subsequent scar contracture. If the incision is curved as it
crosses over the joint, there is a tendency to reduce the excessive scar­
ring that might occur with a straight linear scar.
It is equally important to consider the structures underlying the skin
when planning surgical incisions. The obvious structures include the
muscles, tendons, nerves and blood vessels. Incisions placed parallel
with the longitudinal neurovascular and muscle-tendon structures
reduce the risk of injury to these entities and, therefore, reduce the
overall postoperative complications. As was pointed out earlier, it may
not be possible to comply with this principle all of the time due to
accessibility of underlying structures. For example, on the anterior
ankle, the tendons, blood vessels and lymphatic systems all run in a
Lines of minimal movement and relaxed
skin tension lines
The lines of minimal movement (LMM) are similar to those described
as RSTLs. The LMM indicate that very little motion occurs along that
line and usually runs perpendicular to the LMEs. The RSTLs are related
to the underlying musculature and osseous structures and are associ­
ated with creases that develop in the skin with normal flexion and
extension, especially on the lateral and anterior region of the ankle.
The skin reveals its greatest ability to stretch and relieve tension in a
direction perpendicular to the RSTLs along the lines of maximum
extensibility (Fig. 4.1). The RSTLs are not exactly identified on the foot
and ankle, and many different guidelines have been developed as
surgeons have searched for an ideal guide for elective skin incisions.
Many surgeons prefer Langer’s lines. These lines were described by Karl
Langer in 1861,1 an anatomy professor, from cadavers in rigor mortis.
However, in 1951, Kraissl2 published his preferred anatomic lines
oriented perpendicular to the action of the underlying muscles. Later,
the best model was based on a description by Borges and Alexander
in 1962,3 in which relaxed skin tension lines follow furrows formed
when the skin is relaxed and are produced by taking the part through
a range of motion (Fig. 4.2).
Skin tension is important in incisional and wound healing. An inci­
sion that is oriented such that tension across it is maximal, will result
in a stretched, hypertrophic scar. This occurs when an incision is
placed perpendicular to the RSTLs and the skin has minimal move­
ment available along the lines of minimal movement. In contrast, an
Figure 4.1  The long axis of a semi-elliptical (fusiform) excision should
follow the relaxed skin tension lines (RSTLs) to close the defect without
tension. Excising the lesion following the lines of maximum extensibility
(LME) might seriously jeopardize the closure and increase the scar size
and thickness.
LME
RSTL
Position of excision
Figure 4.2  Relaxed skin tension lines on the foot (as described by Borges and Alexander 19623).

Chapter
Surgical principles
25
| 4 |
for soft and non-tender scar formation, even with complex rotational
flaps and advancement flap procedures.
INCISION MAKING
The first few decisions in making the incision are on its placement,
orientation and length. If the incision location is improperly chosen,
then the exposure to the surgical condition may be limited. Similarly,
if the orientation of the incision around bone or structural promi­
nences is incorrect, the resultant scar may be problematic. Finally, if
the incision is too short then the surgeon may require more extensive
vertical linear pattern, but the RSTLs run transversely across the middle
of the joint. The surgeon then must decide which of the principles of
skin incision are to be violated. In all cases, the best choice is that
which achieves adequate visualization and surgical access to the
tissues rather than final scar formation.
Incision planning on the foot and ankle and lower leg require
preoperative considerations of skin characteristics, underlying ana­
tomical structures and the ultimate goal of wide exposure. However,
incisional planning for the plantar foot must also take into account
other factors, including pressure points, weight-bearing areas, and the
increased thickness of the plantar foot skin. There is an increased risk
of scar formation on the plantar foot unless several issues are addressed
during the planning stage. The first consideration is the placement of
the incision away from prominences and direct weight-bearing. This
alone will reduce the potential for increased scarring and scar tender­
ness. Another consideration is the increased time needed to heal
incisions placed on the plantar foot. It has been shown that the
plantar foot scars can be minimized by careful planning of the inci­
sion placement and protection from motion and weight-bearing for
a minimum of 3 weeks. Careful attention to these details will allow
Figure 4.3  Reproduction of relaxed tension lines (RSTLs) with motion.
(A) The RSTLs are not easily identified on the foot and ankle in a relaxed
position. (B) The RSTLs around the foot and ankle can easily be visualized
by dorsiflexion of the foot.
A
B
Figure 4.4  Reproduction of relaxed tension lines (RSTLs) with pinch test.
(A) Pinching the skin perpendicular to the RSTL shows decreased skin
movement. (B) Pinching the skin within the RSTL gives rise to a linear
crease formation. By pinching the skin between the two angles, or
oblique to the RSTL, an irregular or S-shaped pattern may be produced.
A
B

26
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 4.5  Incision making. (A) It is advisable to draw the planned
incision with a skin-marking pen. Cross-hatching allows the incision
edges to be realigned properly after completion of the surgery. Nerves
and other anatomical structures are outlined for clarity. (B) Complex flaps
or other incisions may be drawn out for accuracy of placement.
A
B
Figure 4.6  Skin tension for incision placement. It is helpful to apply
tension to the skin on either side of the planned incision to help separate
the tissue layers and maintain control of the incision depth.
Figure 4.7  Incision technique. Start the incision with the tip of the
scalpel and carry the incision to the end using the cutting belly of the
blade and completing the incision with the tip of the scalpel.
Figure 4.8  Incision technique. (A) Incorrect. A biased or skived incision
may lead to poor healing and increased scar formation. (B) Correct. The
incision is vertical and has greater potential for normal healing.
A
B
retraction for proper visualization, which may result in skin tears or
increased damage to the skin edge from the retraction instruments.
In almost all cases, it is advisable to draw the projected incision line
with a skin-marking pen. This allows for a much better visual picture
of what the actual incision will look like and will guide the surgeon
to a more accurate placement of the incision. Additionally, cross-
hatching the marked incision line provides a nice guide to realign the
skin edges at final closure of the incision (Fig. 4.5). Even skilled sur­
geons will routinely draw the skin incision placement prior to per­
forming the procedure, especially when planning flaps or complex
incisions.
The choice of surgical scalpel blade is based upon the location of
the incision and the type of planned procedure. A No. 10 scalpel blade
is frequently used for linear incisions on relatively flat surfaces or in
larger skin areas. The No. 15 scalpel blade, because it is shorter and
has a smaller radial arc, is more commonly utilized in curvilinear and
circular incisions and in areas where greater control of the blade is
warranted. The No. 11 scalpel blade may be used for small or intricate
incisions and many surgeons prefer the even smaller mini-Beaver
blades for toes or detailed excisions. Once the blade is selected, it is
useful to apply tension on either side of the incision line to separate
the tissues and to allow control of the incision depth (Fig. 4.6).
The initial incision should be made perpendicular to the skin
surface and with one full-length swipe of the scalpel blade. This

Chapter
Surgical principles
27
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single-pass incision is best accomplished by starting the incision with
the tip of the scalpel blade held in a vertical position perpendicular
to the skin and then rolling onto the belly of the blade for the main
portion of the incision and then completion of the incision with the
tip of the blade again (Fig. 4.7). Multiple passes of the scalpel blade
during the initial incision or cutting on a bias should be avoided at
all times.
As the incision is being performed, care must be taken to assure
that the surgical blade maintains its position and does not slip or be
allowed to skive the skin and deep-tissue layers (Fig. 4.8). Slippage
frequently occurs when: the skin is thick, the adjacent skin tension is
lost or when a dull scalpel blade is being used. The biased transdermal
incision is often made when: the surgeon is in an awkward position
during the procedure, the incision is performed around prominent
locations or around a significant curvature or when the operator is
inexperienced. Both the slippage laceration and the biased skived
incision can lead to wider scars, improper apposition of skin edges on
closure or possible wound-healing problems.
REFERENCES
1. Langer, K., 1978. On the anatomy and
physiology of the skin. I. The cleavability
of the cutis. Translated from Langer, K.
(1861). Zur anatomie und physiologie
der haut. I. Uber die spaltbarkeit
der cutis. Sitzungsbericht der
mathematisch-naturwissenschaftlichen
Classe der Kaiserlichen Academie der
Wissenschaften. Br J Plast Surg 31 (1),
3–8.
2. Kraissl, C.J., 1951. The selection of
appropriate lines for elective surgical
incisions. Plast Reconstr Surg 8 (1),
1–28.
3. Borges, A.F., Alexander, J.E., 1962. Relaxed
skin tension lines, Z-plasties on scars, and
fusiform excision of lesions. Br J Plast Surg
15, 242–254.
FURTHER READING
Andermahr, J., Jubel, A., Elsner, A., et al., 2007.
Cleavage lines and incisions in foot
surgery. Orthopade 36 (3), 265–268,
270–272.
Borges, A.F., 1984. Relaxed skin tension lines
(RSTLs) versus other skin lines. Plast
Reconstr Surg 73, 144–150.
Borges, A.F., Alexander, J.E., 1962. Relaxed skin
tension lines, Z-plasties on scars, and
fusiform excision of lesions. Br J Plast Surg
15, 242–254.
Cox, H.T., 1962. The cleavage lines of the skin.
Br J Plastic Surg 29, 234–240.
Dockery, G.L., Christensen, J.C., 1986. Design
of skin flaps for use on the lower extremity.
Clin Podiatr Med Surg 3, 563–577.
Gillespie, P.H., Banwell, P.E., Hormbrey, E.L.,
et al., 2000. A new model for assessment
in plastic surgery: knowledge of relaxed
skin tension lines. Br J Plast Surg 53 (3),
243–244.
Gusman, D., 1995. Wound closure and special
suture techniques. J Am Podiatr Med Assoc.
85, 2–10.
Hussain, T., Al-Mutairi, H., Al-Zumel, S., et al.,
2004. Modified obtuse-angled lateral
exposure of the calcaneum. Foot and Ankle
Surg 10 (3), 145–148.
Kraissl, C.J., 1951. The selection of appropriate
lines for elective surgical incisions. Plast
Reconstr Surg 8 (1), 1–28.
Kuwada, G.T., 1995. Plantar incisional
approaches, current perspectives. J Am
Podiatr Med Assoc 85, 15–21.
Langer, K., 1978. On the anatomy and
physiology of the skin. I. The cleavability
of the cutis. (Translated from Langer, K.
(1861). Zur Anatomie und Physiologie der
Haut. I. Uber die Spaltbarkeit der Cutis.
Sitzungsbericht der Mathematisch-
naturwissenschaftlichen Classe der
Kaiserlichen Academie der Wissenschaften,
44,19. Br J Plast Surg 31 (1), 3–8.
Miller, S.J., 1986. The art of making an
incision. Clin Pod Med Surg 3, 223–233.
Monaco, A., Grumbine, N.A., 1986. Lines of
minimal movement. Clin Podiatr Med Surg
2, 241–247.
Namikawa, A., Sakai, H., Motegi, K., et al.,
1986. Cleavage lines of the skin. Bibl Anat
27, 1–60.
Stegman, S.J., 1976. Guidelines for placement
of elective incisions. Cutis. 18 (5),
723–726.
Storm, T.R., Lee, M.S., 2001. Plastic and
reconstructive surgery. In: Banks, A.S.,
Downey, M.S., Martin, D.E., et al. (Eds.),
McGlamry’s Comprehensive Textbook
of Foot and Ankle Surgery, third ed.
Lippincott Williams & Wilkins,
Philadelphia, pp. 1487–1521.
Tatla, T., Lafferty, K., 2002. Making your mark
again in surgery. Ann R Coll Surg Engl
84 (2), 129–130.
Viera, M.H., Amini, S., Konda, S., et al., 2009.
Do postsurgical interventions optimize
ultimate scar cosmesis. G Ital Dermatol
Venereol 144 (3), 243–257.
Wilhelmi, B.J., Blackwell, S.J., Phillips, L.G.,
1999. Langer’s lines: to use or not to
use. Plast Reconstr Surg 104 (1),
208–214.

29
| 5 |
CHAPTER CONTENTS
Tissue handling
29
The operating room
29
Surgical instruments
30
Instrument stand
30
Scalpel handles and blades
30
Tissue-handling forceps
32
Scissors
32
Tissue retractors
34
Artery forceps or mosquito hemostats
36
Needle holders/drivers
37
Punches
38
Miscellaneous instruments
38
Hand signals in surgery
39
TISSUE HANDLING
The general principle of tissue handling is very simple: be gentle at all
times. This involves the initial approach of injecting the skin and
deeper layers, marking the skin incision, draping the surgical area,
making the incision and the careful use of retractors and other surgical
instruments used during the procedure. The use of gauze sponges
should be limited, and lavage and suction are preferred for removal
of blood and fluids in the surgical site. When gauze sponges are used,
the mechanism should be one of dabbing the wound gently rather
than wiping or rubbing.
Keeping the tissue layers moist during the procedure is very impor­
tant, and the use of frequent cool sterile flush and suction is encour­
aged. When sterile flush is used, it should be gently applied since
forceful sprays of solution may spread tissue layers unnecessarily and
cause tissue emphysema. This forceful flushing technique is reserved
for wound irrigation in the presence of debris, foreign body particles
or infection.
As we get into the use of specific instruments for cutaneous proce­
dures, we will discuss their individual applications and techniques
available. Overall, it is important to be attentive to the application of
sterile drapes and the use of towel clamps to secure them. It is more
than just frustrating when the surgical assistant or nurse accidentally
damages the patient’s skin with the towel clamps. On the same subject,
tourniquets need to be properly placed, padded and monitored to
prevent additional skin damage. Whenever possible, it is best to avoid
tourniquet use.
As will be pointed out subsequently, the use of new, sharp,
knife blades using the proper technique will make a clean and even
incision. The use of skin retractors is recommended in place of
handling the tissues with skin forceps or pick-ups. Manual hand-held
retractors are suggested rather than self-retaining retractors and sharp
retractors are preferred over the blunt retractors in most cases. Finally,
gentle tissue handling is essential during the process of incision
closure.
THE OPERATING ROOM
The operating room must obviously be large enough for the patient,
surgeon, assistant and all necessary surgical and emergency supplies
needed for the procedure. The room must be well ventilated and
adequately illuminated, and it should have a variety of mobile lighting
units that may be readily adjusted by the surgeon or assistant during
the surgery, while maintaining sterility.
The operating table for the patient may be either an adjustable
surgical chair or electronic flat operating table. Either unit should be
easily adjusted in height by the surgeon, for either sitting or standing,
and it should have an adjustable head support and be able to be
repositioned with the head or foot elevated. The entire surgical
table should be easily placed into the Trendelenburg’s position
with the patient’s head down in case of an emergency. It is also
advisable to have either attached armrests or detachable side exten­
sions to support the patient’s arm to receive intravenous solutions or
medications.
©2012 Elsevier Ltd.
Basic instruments and tissue handling
G. Dock Dockery
Chapter
5

30
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
SURGICAL INSTRUMENTS
Surgical instrumentation for plastic and soft tissue reconstruction is
highly specialized, even although there may be several different instru­
ments with the same function. The majority of skin procedures may
be performed with just a few key instruments, although most surgeons
prefer to use a wide variety of small plastic surgery instruments during
a complex procedure. Eventually, each surgeon develops a fondness
for particular instruments for specific procedures. It is best for cutane­
ous surgeons to become familiar with a variety of plastic surgery
instruments, as well as their functions, in order to broaden the scope
of tools available.
Instrument stand
The most common instrument stand used for basic plastic surgery
procedures is a stainless steel dressing tray, frequently referred to as a
Mayo stand (Fig. 5.1). This mobile support stand has an upper tray
for supporting the instruments and a wide base for stability. When the
instrument tray is wheeled into the surgery room, it can be positioned
over the patient or the surgical site, without resting on the patient.
This transportable adjustable tray makes access of the surgical instru­
ments more efficient for the assistant as well as the surgeon. There are
two basic formats of providing a sterile field for the sterile instru­
ments. The most common is simply to drape the instrument tray with
sterile Mayo stand covers and the other is to use autoclavable reusable
instrument pads that have small grooves for holding the instruments
in place.
Scalpel handles and blades
Generally, the term scalpel refers to both the handle and the cutting
blade. The one-piece reusable scalpel is not very popular today and
has been replaced with other styles of handheld scalpels with one-use
disposable blades. The most commonly used scalpel handle is the
Bard–Parker. The standard handles are the No. 3, No. 4 and No. 7
(Fig. 5.2). Of these handles, the No. 3 is most frequently used in foot
and ankle surgery and it can be ordered with or without an imprinted
ruler on one side of the handle (Fig. 5.3). The author prefers the
handle with the ruler because it is useful for measuring the size of
lesions, incisions or for planning skin flaps. For the smaller mini-
blades, the 316 inch diameter, rod-shaped mini-handles use a simple
draw-in collet locking mechanism which, when tightened with the
fingers, grips the mini-blade securely. The surgeon has maximum
control of this style scalpel with a comfortable, cross-knurled pencil-
grip design (Fig. 5.4).
All of the scalpels described may be held in two basic positions for
making an incision. In general, the scalpel is held between the thumb
and index finger with the middle finger supporting the handle from
below, also called the ‘pencil grip’ (Fig. 5.5). The second position is
similar, but with the scalpel held with the first three fingers, allowing
the handle to be positioned in a lower attitude (Fig. 5.6). The pencil
grip position allows for firm control of the scalpel while making
precise or intricate incisions. The lower position is useful when much
longer incisions are needed.
Disposable scalpel blades, constructed of high-quality surgical
stainless steel, are available in a variety of sizes and shapes (Fig. 5.7).
The No. 15 blade is suitable for most plastic surgery procedures;
however, there are many instances when other sizes of blades will be
more useful. For example, for a large incision on the posterior leg, a
No. 10 blade, with its larger and more rounded design, might be more
suitable. Likewise, for a much smaller incision or skin flap on a toe,
Figure 5.1  Mayo stand. (A) Typical Mayo instrument stand that may be
placed close to the surgery site. (B) With sterile drape and surgical
instruments.
A
B
Figure 5.2  Bard–Parker scalpel handles. From top to bottom, No. 7,
No. 4 and No. 3 handles.

Chapter
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31
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Figure 5.3  Close-up of No. 3 handle with engraved ruler on side.
Figure 5.4  The Beaver mini-handle with cross-knurled pencil-grip design.
Figure 5.5  The standard position to hold the scalpel handle for best
control while making precision cuts.
Figure 5.6  The alternate position to hold the scalpel handle for making
longer incisions.
Figure 5.7  Surgical blades: No. 10, No. 15, No. 11 and Beaver mini-
blade 64.
Figure 5.8  Disposable plastic scalpels: No. 10. Sizes 11 and 15 are also
commonly available.
the No. 11 blade or Beaver mini-blade No. 64 or 67, might be prefer­
able. Although not in common use today, several different styles of
sterile disposable plastic scalpel holders with non-removable blades
of standard sizes are available (Fig. 5.8).
As pointed out in earlier chapters, the surgical blade is designed
to cut skin and soft tissues. The most effective method of making
the incision is to begin with the tip of the blade, for accuracy,
and then to use the sharpest portion of the belly of the blade for
the incision, with completion of the cut utilizing the tip once again
(Fig. 5.9).

32
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
between the thumb and index finger (two-finger technique) or the
thumb, index finger and the middle finger (three-finger technique) for
finer tissue manipulation and control (Fig. 5.11). The pick-ups are
available with or without teeth. The forceps with teeth are preferable
for picking up tissue rather than by using the atraumatic style of
forceps. It is a misconception that the pick-ups without teeth are truly
atraumatic. It requires light pressure between the tips of toothed
forceps to hold tissue securely, but it takes considerably more pressure
between the tips of smooth or non-toothed pick-ups to hold the same
tissue at the same tension. Therefore, there is more potential damage
to the tissues being held by the forceps with no teeth. The most com­
monly used toothed forceps are the Brown–Adson tissue forceps,
which have seven teeth on each side of the prongs (Fig. 5.12). The
Adson tissue forceps have one tooth on one side and two teeth on the
other side of the prongs of the forceps. They are frequently referred to
as one-two or rat-tooth pick-ups due to this configuration of teeth.
The fine Adson forceps are used during flap handling and for skin
closure; however, care must be exercised with these forceps in most
situations owing to the potential for tissue damage. It is common to
see the Adson forceps used to handle suture material.
Other tissue forceps include the Adson, Hudson and iris forceps
with serrated tips rather than teeth. All of these pick-ups must be
handled gently to avoid tissue crush injury and are best used as retrac­
tors, rather than as grasping forceps. Another useful pick-up for cuta­
neous procedures is the fine-point splinter forceps. They also come
with extra-fine and super-fine tips and may be used for bipolar elec­
trosurgical coagulation of small vessels during the initial stages of the
surgery.
Scissors
Scissors are very useful in plastic and reconstructive surgery and a wide
variety of scissors are available (Fig. 5.13). Scissors are usually held
with the thumb and middle finger in the finger loops and the index
finger is placed under the rings or along the shaft of the scissor for
stability (Fig. 5.14). Each type of scissors has been designed for a
specific purpose and scissors designed for one purpose should not be
used for another purpose. The four main functions of scissors are for
cutting tissue, dissecting/undermining, suture removal and bandage
removal.
A
B
Figure 5.9  Photograph showing precise incision technique from tip to
belly to tip of blade.
C
Figure 5.10  Assorted tissue forceps. From top to bottom: long 1–2
Adson; Brown-Adson; short 1–2 Adson; fine serrated Hudson; fine
smooth splinter forceps.
Tissue-handling forceps
These pick-ups or tissue forceps are designed to grasp or pick up tissue
during the surgery. They are made in several different styles of tips and
in different lengths (Fig. 5.10). Tissue forceps are generally held

Chapter
Basic instruments and tissue handling
33
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Skin and tissue-cutting scissors are usually very fragile and are
designed to sever tissue cleanly, even at the tips. They may be curved
or straight and have sharp or blunt tips (Fig. 5.15). Straight scissors
allow more exact straight-line cutting, while curved scissors provide
an advantage in curved cuts and for removing small tissue attach­
ments. The very small iris and tenotomy scissors are best used for fine
or intricate work. These delicate scissors should never be used to cut
sutures or bandages, as this will greatly reduce the lifespan of these
scissors.
Dissecting scissors are typically used for the undermining of subcu­
taneous layers and deep tissues, have longer shanks and are usually
blunt, but they may be either curved or straight in design (Fig. 5.16).
The fine Metzenbaum scissors are commonly used for dissection pur­
poses and may be used to cut lighter capsule and small fibrous tissue
connections. The sturdier Mayo scissors are used to cut ligaments,
larger fibrous bands and thick capsular tissues. In the deep layers, and
in subcutaneous dissection, the dissection scissors may be used by
either direct visualization cutting or by placing the closed scissors into
the tissue layer and spreading the blades apart. This allows a control­
led blunt dissection to occur, which provides better visualization for
further tissue cutting within the new layer.
Stitch or suture scissors may be straight or curved, but are usually
blunt to prevent damage to adjacent tissues during the suture cutting
process (Fig. 5.17). Spenser stitch scissors have a small hook on one
side to allow easy positioning of the scissors against the suture to be
cut. In many cases, the standard 412-inch operating scissors with one
sharp and one blunt point are used as suture scissors (Fig. 5.18).
Bandage scissors, as a rule, are the least sophisticated of the scissors.
The typical style is the Lister bandage scissors, with angulated blades
and a large blunt end to allow slipping between the patient and the
bandage (Fig. 5.19). The heavy-duty utility and bandage scissors is
another popular model with serrated blades and needle destroyer (Fig.
5.20). It is best to use the bandage scissors on the outermost layers of
wound bandaging or cast padding, and then carefully remove the deep
dressing covers without cutting them. In some instances, however, the
deeper bandage layers may be difficult to unwrap due to dried blood
or serous drainage, and in this case, the bandage scissors may be useful
in freeing the dressings. It is tempting to use any scissors that are
available when bandages need to be removed, but it is wise to refrain
from using non-bandage scissors for this heavy-duty job.
Figure 5.11  Pick-up techniques. (A) Holding tissue forceps in two
fingers. (B) Holding tissue forceps with three fingers for fine control of
the tips.
A
B
Figure 5.12  Close-up of the Brown–Adson 7 × 7 tissue forceps.
Figure 5.13  Assorted scissors.

34
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Tissue retractors
Tissue retractors are used to assist the surgeon in exposure of underly­
ing structures, while protecting adjacent important structures. A variety
of different styles of tissue retractors are available (Fig. 5.21). The two
basic types of retractors are the hand-held and the self-retaining forms.
The hand-held retractors allow an assistant to move tissue out of the
way of the surgical instruments and protect the vital structures during
the procedure. The advantage to the hand-held retractors is that the
assistant can easily and quickly reposition them for added exposure
and, at the same time, adjust the tension or force on the tissues as
needed. The obvious disadvantage is that the surgeon needs the help
of another person, the assistant, in order to have good retraction with
these instruments. The advantage of the self-retaining retractors is that
the surgeon can position this retractor without assistance. The disad­
vantages of the self-retaining retractors are that they may cause tissue
damage by being placed in the incision with too much tension, or
they may be left in place for an extended time. Therefore,
A
B
Figure 5.14  Correct holding position for cutting scissors. (A) Standard
position with index finger under the rings. (B) With the index finger
along the shaft for greater stability. (C) Using the tissue scissors to
remove a skin lesion.
C
Figure 5.15  Skin and tissue scissors, sharp and blunt, curved and
straight.
Figure 5.16  Dissection scissors: Mayo and Metzenbaum.

Chapter
Basic instruments and tissue handling
35
| 5 |
Figure 5.17  Suture scissors. Spencer scissors with a hook on one blade
and straight suture scissors below.
Figure 5.18  Standard 4 12-inch operating scissors may also be used to
cut sutures.
Figure 5.19  Lister bandage scissors.
it is recommended that the self-retaining retractor be repositioned
regularly to prevent the constant pressure of the retractor from being
isolated to a small area. At the same time, the tension should be
adjusted to the minimal amount that allows for adequate exposure.
Skin hooks and regular retractors are preferred in most plastic
surgery procedures, since they allow for precise tissue manipulation
during the procedure and, because of their design, do not crush tissue
during retraction. They may have single, double or triple prongs with
sharp or blunt tips. The double-pronged skin hooks provide better
holding power, even though the single-pronged skin hooks are used
more frequently. Sharp-tipped hooks are preferable to the blunt tips
for better ability to perform skin eversion and for maintaining better
visualization. Most skin hooks range from 412 to 6 inches in length
with an assortment of different sized hooked tips available. The deli­
cate Tyrell skin hook has a 1.5 mm diameter, single hook on the tip
(Fig. 5.22), while the slightly larger Freer has a 2 mm diameter, single
or double hook and the Frazier skin hook is 2.5 mm in diameter. The
Figure 5.20  Comparison of utility and Lister bandage scissors.
Figure 5.21  Several different styles of tissue retractors, both hand-held
and self-retaining are available.

36
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 5.22  Fine delicate Tyrell skin hook, for delicate flaps.
Figure 5.23  Close-up of Wiener skin hook tip, for most retraction
purposes.
Figure 5.24  Senn tissue retractor. (A) Full view of two instruments.
(B) Close-up of sharp and blunt tips.
A
B
Figure 5.25  The 6-inch blunt Ragnell tissue retractors are commonly
used in soft tissue surgery.
Figure 5.26  Rigid rake tissue retractor. They may have two or three
prongs that are blunt or sharp.
standard Wiener skin hook has a 3.5 mm diameter, single hook on
the tip (Fig. 5.23).
Regular tissue retractors range from 5 to 612 inches in length. The
most common style is the double-ended Senn retractor, 612 inches in
length, with three sharp or blunt curved prongs on one end and an
angled blade on the other end (Fig. 5.24). The Ragnell retractor is also
a double-ended retractor, 6 inches in length, with one 4 mm by 8 mm
angled blade on one end and a 6 mm by 15 mm angled blade on the
other end (Fig. 5.25). The rigid rake retractor, 6.5 inches in length,
may have either two or three blunt or sharp prongs on one end only
(Fig. 5.26).
The two most common self-retaining retractors used in plastic pro­
cedures are the 4-inch, cross-action three or four-pronged sharp or
blunt self-retaining retractor (Fig. 5.27), the 4-inch, two by three and
the three by four blunt or sharp pronged, Weitlaner self-retaining
retractor (Fig. 5.28).
Artery forceps or mosquito hemostats
The most common hemostat used in plastic surgery is the Halsted
5-inch, straight or curved tip mosquito (Fig. 5.29). The straight-tipped
forceps, with the regular or delicate teeth, is the most versatile
hemostat, although the curved-tipped forceps are very useful for blunt
undermining and for clamping small blood vessels during procedures.
Other types of artery forceps include the 312-inch Hartman mosquito
hemostat and the larger 512-inch curved or straight Kelly or Crile
forceps (Fig. 5.30). The larger and heavier forceps are cumbersome
and have little application in most plastic surgical procedures, except
when a strong hold is needed, such as with large muscle or fascia
transfers.

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37
| 5 |
Figure 5.27  Small self-retaining three-pronged sharp retractor.
Figure 5.28  Weitlaner self-retaining retractor.
Figure 5.29  Curved and straight Halsted 5-inch mosquito hemostat
forceps.
Figure 5.30  Curved and straight Kelly or Crile forceps.
Needle holders/drivers
Needle holders, or needle drivers, come in a variety of styles and sizes
(Fig. 5.31). The selection of needle holder from this large choice of
instruments depends upon the nature of the procedure and the opera­
tor’s preference. They should be comfortable as well as functional.
Needle holders are available with smooth or cross-serrated jaws that
are capable of holding a large assortment of different sized needles.
In general, the smooth jaws are useful with small, delicate, needle sizes
and the cross-serrated tips are designed to allow for a firm grip on the
needle or suture. The cross-serrated tips, however, may cause damage
to the suture material, such as the braided types and may damage the
needle, especially at the tip.
The Olsen–Hegar needle holder has the advantage of having scissors
directly behind the jaws, which saves time if an assistant is not present
during the procedure. The disadvantage of the driver and scissor com­
bination is simply that it is harder to master the combination of
instruments. The most multipurpose driver is the 5-inch Mayo-Hegar
needle holder (Fig. 5.32). It is supplied with the smooth, standard
cross-serrated or the carbide inlay tips. The author prefers the newer
tungsten-carbide inserts and feels that they provide a better grip on
Figure 5.31  Assorted needle drivers.

38
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Miscellaneous instruments
Although there are numerous other instruments that may be used
during reconstructive and plastic surgery procedures, the ones dis­
cussed earlier are the most common and the most popular. Some
specialized instruments have found a place in the cutaneous surgeon’s
toolbox. Tissue and periosteal elevators, such as the Freer and Sayre,
may be used to undermine tissue, aid in dissection of tissue planes or
in removing tissues firmly adhered to bone (Fig. 5.34). Single and
double-ended bone rasps are also occasionally needed for removal of
bone irregularities or spurs (Fig. 5.35). Bone-cutting forceps and
Rongeur bone forceps are useful when large bone needs to be cut or
removed (Fig. 5.36).
Small malleable retractors may be useful in some situations, such
as retracting larger structures or passing beneath small tendons (Fig.
5.37). In addition, incision closure may be facilitated by using an
automatic skin stapler (Fig. 5.38). This skin stapling process in many
cases will be much faster than standard suture techniques and is fre­
quently used in situations where strength of the closure material is an
issue. For longer cases, the staples make the tedious final closure go
much faster (Fig. 5.39). The staple removal system is also easy to use
and the patients tend to report very little discomfort during the staple
removal process.
It can be very advantageous to work with a specialized small surgical
instrument company and get to know their representatives. They can
often work with the surgeon to make a wide variety of instruments
available that make precision skin surgery easier and often they can
order special instruments that are not readily available with many
Figure 5.32  Needle holder showing proper hand position. (A) Finger and
thumb control. (B) Hand control. Both types of needle holders can be
held in the hand-control position.
A
B
Figure 5.33  Disposable punch biopsy units. (A) Individually packaged for
convenience. (B) Close-up of 4 mm disposable punch unit.
A
B
small or medium-sized needles, and tend to grasps suture firmly
without causing fraying or tearing. The hand-controlled needle holders
may be faster to maneuver, but they take a little practice to use them
comfortably. The longer-handled needle drivers are useful in placing
deep sutures and the larger instruments with heavy jaws are more
practical in holding larger needles for suturing fascia or tendons.
Punches
Punches used for biopsies of skin lesions are usually of the sterile
packaged disposable type, which have one-time usage stainless barrels
and plastic handles (Fig. 5.33). They are preferred over the reusable
Keyes punch biopsy units since they provide the advantage of always
being clean and sharp. Punches are available in a wide variety of
diameter sizes, at 2.0, 3.0, 3.5, 4.0, 4.5, 5.0 and 6.0 mm. The most
common are the 3.0 mm and the 4.0 mm diameter punch for lower
extremity biopsies; however, using two 2.0 mm diameter punches is
becoming much more popular than using one 4.0 mm punch of the
same lesion (see Ch. 13).

Chapter
Basic instruments and tissue handling
39
| 5 |
holder/driver (Fig. 5.48); retractors, both sharp (Fig. 5.49) and blunt
(Fig. 5.50) and a straight periosteal elevator (Fig. 5.51). Many other
hand signals are used to indicate ligature suture ties, bone cutters,
saline flush, gauze sponge, specific power equipment and to indicate
continuing or to stop.
instrument companies, such as small self-retaining retractors and spe­
cialized scissors (Figs 5.40–5.43).
HAND SIGNALS IN SURGERY
Since much of soft tissue and plastic surgery of the lower extremity is
performed under local anesthesia or with mild sedation, many of our
patients are able to communicate during the surgical procedures. They
also hear the conversation of the operating room personnel and physi­
cians. Much of this normal operating room conversation may be
misunderstood or create a great deal of unnecessary anxiety in some
patients. A ‘4 by 4’ may be interpreted as a piece of lumber, a ‘mos­
quito’ may be seen as an insect or the word ‘rake’ might bring visions
of the garden to mind.
In order to decrease much of the uneasiness of this technical termi­
nology and to put the patient more at ease, it is recommended that
the surgeon and the surgical scrub assistant learn to communicate
much of the normal jargon with non-verbal hand signals. There are
standard recommendations for requesting surgical instruments and
supplies using hand signals but the surgical team that works together
frequently may make up their own signals for everything needed
during the operation.
The most commonly requested instruments include: the scalpel or
knife (Fig. 5.44); the tissue forceps (pick-ups) (Fig. 5.45); the scissors
(Fig. 5.46); the mosquito (hemostat) forceps (Fig. 5.47); the needle
Figure 5.34  Periosteal elevators.
Figure 5.35  Bone rasps. Single-roll and cross-hatch styles.
Figure 5.36  Rongeur bone forceps.
Figure 5.37  Small malleable retractor and ruler.
Figure 5.38  Skin stapling system (3M Corporation).

40
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 5.39  Skin stapler. (A) Close-up of skin stapler loaded with multiple skin staples. (B) Single staples may be applied to skin for wound closure. In
some cases, it may be useful to have an assistant hold the skin edges in slight eversion while the staples are being placed in the incision. (C) The first
staple has been placed and new staple is ready to go. (D) 3M staple removal unit. (E, F) Staple removal unit in action and the staple being removed.
This removal process causes little discomfort for most patients.
A
B
C
D
E
F

Chapter
Basic instruments and tissue handling
41
| 5 |
Figure 5.40  Low profile self-retaining wound retractor.
Figure 5.41  Small four-pronged self-retaining retractor.
Figure 5.42  Small Alm self-retaining retractor.
Figure 5.43  (A) Ultra-fine super-cut Jamison scissor. (B) Close-up of
ultra-fine scissor tips.
A
B
Figure 5.44  Scalpel or knife. The thumb and the first two fingers as the
surgeon simulates a cutting motion.