Core Procedures In Plastic Surgery: Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình

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Operative techniques
back to the nasolabial junction of the non-cleft side
philtral column (Fig. 8.6).
• The height of this rotation incision should be the same as
the height of the non-cleft side philtral column.
• The angle of the backcut is dependent on the width of
columella.
• If the columella is wide, a wider angle can be made.
• The incision across the free border of the lip at CPHL
should be at right angles to the axis of the white skin roll
to facilitate subsequent lip closure.
• After the incision is made, the muscle is freed from the
skin in the subdermal plane for a distance of 2–3 mm
(Fig. 8.7, inset).
• The muscle dissection on the non-cleft side should reach
the nasal floor of the non-cleft side for adequate releasing
of the abnormal muscle insertion to the columellar base.
• Traction on the free border of the lip will determine if the
rotation is adequate, that is, both sides of the Cupid’s
bow at the same level (Fig. 8.8).
• Even if the rotation is inadequate, extending the incision
across the non-cleft-side philtral column should be
avoided, as it will result in a vertically long lip. If the
rotation fails to level the Cupid’s bow, nothing further is
done until after muscle repositioning.
• The C-flap incisions are made on a line that extends from
point CPHL along the junction of skin and mucosa to the
most lateral point of the skin overlying the premaxilla
(Fig. 8.9).
• The incision on the premaxilla then turns superiorly at
the junction of the columellar skin and septal mucosa for
a distance of 5 mm or even longer (Fig. 8.10).
• Blunt-tip tenotomy scissors are used to separate the
medial crura of the cleft side lower lateral cartilage (see
Fig. 8.10).
Operative techniques
Unilateral cleft lip (Video 8.1; Video 8.2)
Alveolar molding: external taping
• The external taping (non-surgical lip adhesion) is the
simplest technique for both presurgical molding of the
maxillary halves and approximation of the alveolus.
• A strip of Micropore tape is placed across the cleft to
approximate the upper lips. The objective of the tape is to
simulate effects of an adhesion cheiloplasty and
reposition the maxillary segments into proper alignment.
Nasoalveolar molding
• Liou’s method utilizes a molding bulb attached to a
dental plate as an outrigger to mold the nose along with
external taping of the lip.
• The device is held to the palate with dental adhesives.
• The force from taping and counterforce from the molding
bulb provide the combined force necessary to bring the
alveolus into proper position.
• The nasal molding and alveolar molding are done at the
same time, taking approximately 3 months.
• Newer devices contain an internal spring.
• Grayson’s method utilizes nasal molding after alveolar
approximation to avoid overstretching the nasal cartilage.
• The appliance consists of an acrylic or resin plate which
fits over the maxillary dental arch (alveolar ridges), an
acrylic retention arm or button, and a nasal stent.
• This technique should be started within the first 2 weeks
after birth; careful monitoring is required every 1–2
weeks for a period of 3–6 months to complete it.
Rotation advancement cheiloplasty for
complete clefts
• The following points and measurements are made, with a
caliper, at the time of surgery:
■ The points of the Cupid’s bow on the epidermis–
vermillion junction line (the white skin roll).
■ The vermillion–mucosa junction line (the red line).
■ This clearly defines the intervening vermillion and also
helps identify the deficient vermillion beneath the
cleft-side Cupid’s bow.
■ The base of the ala and the commissure (see Fig. 8.5).
■ The base of the cleft-side philtral column is difficult to
identify.
■ It is located where the white skin roll changes direction
and where the vermillion first becomes widest, usually
3–4 mm lateral to the converging point of red line and
white skin roll.
Medial incisions
• After the above markings are made, a Mohler’s rotation
incision line is marked as a curving line from CPHL
going upward into the base of columella then turning
Figure 8.6  Preoperative marking: CPHR, IS, CPHL, CPHL′ and CHL as described
in Figure 8.5. The C-flap (C) and C-flap mucosa (CM) are marked. The dotted line
on the lip is the red line, which is the junction between vermillion and mucosa.
Incision lines are shown on the lip extending from point CPHL lateral to the
columella on the skin edge overlying the premaxilla extending superiorly along the
junction line of columella skin and septal cartilage mucosa. The cleft-side base of
the philtral column is also marked (CPHL′). The proposed incision lines are marked
with the rotation incision in a Mohler’s fashion. A small triangular white skin roll
flap is designed above the CPHL′.
Video
8.1
Video
8.2

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• Cleft lip repair
8
Figure 8.7  The orbicularis peripheralis muscle (OP) is
released in a subdermal plane. The abnormally inserted
fibers of the nasalis, depressor septi, and levator muscles
are released from the base of the ala. Inset (B): the muscle
is freed from the skin in the subdermal plane for a
distance of 2–3 mm.
L
CPHL’
L
T
OP
T
A
B
Figure 8.8  (A) Traction on the free border of the lip helps to determine if the rotation is adequate. (B) The muscle dissection on the rotation flap should reach the nasal
floor on non-cleft side.
DA
B
Figure 8.9  The incision lines for C-flap and nasal floor: a transverse incision is made inside the nasal floor at the junction of skin and mucosa leaving ample tissue on
piriform area and premaxilla.
DA
B

141
Operative techniques
• The incision line on the inferior turbinate extends from
the piriform rim inward on the upper and lower edges of
the inferior turbinate for a distance of 1.5 cm, where a
transverse cut is made.
• The inferior turbinate flap (T) is elevated in a retrograde
fashion based on the vestibular skin.
• After elevation of the L and T flaps, the attachments
of the LLC to the maxilla and ULC are released,
allowing easy mobilization of the LLC and the
lateral lip.
• Even in wide clefts, mobilization of the lip and cartilage
is easily accomplished without an extensive dissection
over the maxilla (see Fig. 8.11).
• The lateral lip mucosa is incised and dissected free for
only 2 mm as excessive dissection contributes to scarring
and should be avoided.
• The orbicularis peripheralis muscle is bunched up as a
disorganized mass of fibers with numerous dermal
• This allows mobilization of the C-flap and repositioning
of the downward displaced footplate of the medial crura
of the cleft side lower lateral cartilage.
• The tip of the C-flap (point at CPHL) is rotated medially
to fill in the defect on the columellar base after the
Mohler’s incision (Fig. 8.11).
• An L-flap is marked based on the maxilla, extending on
the free border of the lip to the point where the red line
and white skin roll converge, preserving the vermillion
on the lateral lip.
• The skin incision line on the free border of the lip starts
from point CPHL′ and a triangular shaped small WSR
flap is designed (see Fig. 8.6).
• The width of the WSR flap is exactly the same as the
width of WSR above the point CPHL′.
• The length of the WSR flap is only 1–2 mm.
• The incision line is then continued along the skin–
mucosal junction on the piriform up to the inferior edge
of the inferior turbinate then turning inward to include
an inferior turbinate flap (see Fig. 8.11).
Figure 8.10  (A) The incision line of the C-flap. (B) A blunt-tip scissors is used to
release the foot plate of the medial crura of the cleft side lower lateral cartilage.
A
DB
Figure 8.11  (A) The tip of the C-flap adjacent to CPHL is rotated medially to fill
the defect on columellar base after a Mohler’s incision. (B) The completed
dissection with an elevated turbinate (T) and mucosal flap (L) based on the
maxilla. Markings for the mucosal flap L, based on maxilla and inferior turbinate
flap T. The L-flap based on the maxilla extends to the converging red line and white
skin roll, leaving the vermillion between this point and CPHL’ available for
reconstruction of the deficient vermillion beneath the cleft side of the Cupid’s bow.
C
L
T
OP
A
B

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insertions, by use of a blunt-nosed tenotomy scissors, the
orbicularis peripheralis muscle is dissected along the
edge of the dermis to a line extending from the base of
the ala to the base of the philtral column CPHL′.
• The dissection is continued on a subdermal plane
superiorly under and around the base of the ala.
• This releases the abnormal insertions of the paranasal
muscles including the transverse portion of the nasalis
muscle, the depressor septi, and the levator muscles of
the upper lip and ala.
• The angular artery is used as a landmark for the muscle
dissection around the alar base.
• The extent of dissection should be lateral to the vessel to
assure most of the abnormal muscle insertions to the alar
base are released.
• Release of the muscle from the overlying skin and ala
allows the tethered, bunched-up muscle to be stretched,
effectively elongating the lateral lip.
• The skin will also stretch in a similar manner, gaining
increased vertical height (see Fig. 8.7).
• The orbicularis marginalis (OM) flap is incised along the
free border of the lip to include the orbicularis marginalis
muscle, the vermillion medial to point CPHL′, and the
corresponding mucosa posteriorly.
• The OM flap is elevated to its base beneath the philtral
column (CPHL′) in such a way that the volume of muscle
at its base CPHL′ is similar to the volume of muscle
at the opposite point CPHR on the non-cleft side of
the lip.
• The OM flap is cut squarely and not beveled (Fig. 8.12).
• The LLC is repositioned superiorly and fixed to the ULC
with interrupted polyglactin sutures (Fig. 8.13).
• The T-flap based on vestibular skin is rotated 90° to fill in
the defect on piriform rim.
• Its superior edge is sutured to the piriform edge.
• The T-flap corrects mucosal deficiency and allows
repositioning of the LLC and ala without restriction.
Figure 8.12  (A,B) The incision along the skin edge from CPHL′ to the base of the inferior turbinate and elevation of the OM flap on the lateral lip. The OM flap is elevated to
its base beneath the philtral column (CPHL′) in such a way that the volume of muscle at its base CPHL′ is similar to the volume of muscle at the opposite point CPHR on
the non-cleft side of the lip.
DA
DB
Figure 8.13  (A) The LLC is freed from its fibrous attachments to the maxilla and
ULC. There is no dissection over the maxilla. The LLC is elevated with a traction
suture and fixed to the ULC in an elevated position. The turbinate flap (T) is rotated
into the piriform area. The nostril floor is reconstructed with the L-flap behind the
columella, and the CM flap mucosa is sutured lateral to the maxilla. (B)
Completion of nostril floor reconstruction with advancement of the vestibular skin
rotating the alar base inward. There is good mucosal closure with no open areas for
secondary healing and scar contracture. OP, orbicularis peripheralis muscle.
L
T
CM
CM
OP
OP
L
T
A
B

143
Operative techniques
Closure
• Points CPHL and CPHL′ are approximated with a fine
7–0 absorbable polyglactin suture.
• The excess mucosa opposite points CPHL and CPHL′ on
the free border of the lip is trimmed.
• The vermillion triangular flap should fit into the medial
opening beneath the Cupid’s bow (Fig. 8.16).
• Incisions on the vermillion are closed with continuous
7–0 polyglactin suture.
• The lateral lip buccal mucosa is trimmed and closed with
interrupted fine absorbable sutures.
• The upper edge of the buccal mucosa is sutured to the
C-flap mucosa that bridges the alveolar gap.
• This gives a complete mucosal closure without tension.
• The other tip of the C-flap (the most lateral point of skin
overlying the premaxilla) is brought laterally. No lateral
horizontal skin incision for the lateral advancement flap
is made initially, as now the surgeon can better visualize
how to make appropriate incisions that will eliminate
incisions around the ala.
• If the alar base and the peak of the Cupid’s bow on the
cleft side are still high, an incision is made inside the cleft
side nasal floor.
• If the alar base is already leveled after muscle
reconstruction, a nasal floor incision is made.
• The tip of the advancement flap is sutured to the most
lateral point on the junction of the C-flap and the rotation
flap.
• The suture line on the lateral part of the rotation flap thus
mimics the philtral ridge.
• The L-flap is rotated medially behind the columella and
attached to the perichondrium of the previous incision
behind the columella.
• The inferior edge of the T-flap is sutured to the superior
edge of the L-flap with interrupted 5–0 polyglactin
sutures.
• The C-flap mucosa is rotated laterally and placed below
the L-flap.
• It is attached to the maxilla and sutured to the inferior
edge of the L-flap.
• This gives good mucosal coverage of the nostril floor and
lateral nostril wall without any raw surface or tension.
• The vestibular skin with attached ala is advanced over
the mucosal bridge to the uppermost point of the
previous incision behind the columella.
• The upper free edge of the vestibular skin flap and
bridging T and L flaps are closed with interrupted 5–0
polyglactin sutures.
• This gives a good two-layer closure of the nostril floor
and effectively corrects the tissue deficiency in this area.
• The vestibular skin is advanced as far as necessary to
achieve a slightly over-corrected nostril width.
• This also advances and rotates the ala inward into a
position slightly over-corrected to the opposite side.
• Final positioning and closure of the nostril floor are done
after muscle reconstruction (see Fig. 8.13).
• The muscle is approximated with a 5–0 polydioxanone.
• A key suture is placed in the center of the muscle,
opposite points CPHL and CPHL′ and pulled downward
to level the Cupid’s bow.
• This is to assure the correct placement of each muscle
suture.
• The first stitch is passed through the caudal edge of the
nasal septum, catching the tip of the muscle (which is
originally inserted above and lateral to the cleft side alar
base) in the advancement flap in a mattress fashion and
anchored to the septum.
• This anchoring suture helps to pull the lateral lip
medially and centralize the Cupid’s bow.
• The muscle sutures are placed in such a way that the
lateral muscle is overlapping above the medial muscle to
increase the muscle thickness and simulate a philtral
column.
• The muscle in OM flap is also sutured in a mattress
fashion to avoid any depression in this area after
operation (Fig. 8.14).
• The vermillion flap is marked and incised on the OM
flap, while the OM flap is held under tension.
• A No. 11 blade is laid on the incision line, drawing the
knife across to ensure an accurate cut.
• After the vermillion flap is incised, an incision is made
along or above the red line of the lip beneath the Cupid’s
bow opposite point CPHL, thus opening the lip for
eventual insertion of the vermillion flap after muscle
approximation.
• The width of the vermillion flap should correct the
vermillion deficiency under the Cupid’s bow.
• The tip of the vermillion flap should not cross the natural
lip tubercle (Fig. 8.15).
Figure 8.14  Orbicularis peripheralis muscle closure (with septal anchoring
suture). Inset: Overlapping the lateral muscle on the medial muscle for philtral
column reconstruction.

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• Cleft lip repair
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• It is important to make any necessary minor adjustments
before finishing the operation. The cleft side Cupid’s bow
must be adequately rotated.
• If it is slightly elevated, a small hook is used to place the
Cupid’s bow under tension and a short transverse
incision is made above the white skin roll to release the
Cupid’s bow into its proper position.
• An appropriately sized small triangular skin flap,
1–2 mm in width, is incised from the lateral lip and filled
into the defect above the white skin roll and secured with
fine 7–0 polyglactin sutures (Fig. 8.18).
• This small triangular skin flap is also helpful to improve
the lip pout as it tightens the skin above the white skin
roll.
• Excess skin on the nostril floor is excised as
necessary with careful preservation of the
nasal sill.
• The nasal floor is closed with 5–0 polyglactin sutures
and lip skin is closed with 7–0 polyglactin sutures
(Fig. 8.17).
• The small triangular WSR flap on the lateral lip is directly
approximated to the medial lip to reconstruct the bulging
of the WSR.
• If the WSR on the medial lip is less prominent, a small
horizontal incision can be made slightly above the point;
CPHL and the WSR flap from lateral lip can be inserted
into medial lip for augmentation of the WSR above the
CPHL.
Figure 8.15  The vermillion flap is marked and incised on the OM flap while the OM flap is held under tension. The width of the vermillion flap should correct the vermillion
deficiency under the Cupid’s bow. The tip of the vermillion flap should not cross the natural lip tubercle.
Figure 8.16  Medially, the lip is opened on the red line beneath the Cupid’s bow for insertion of the vermillion flap. The excessive tissue on both medial and lateral lips is
carefully trimmed.

145
Operative techniques
• The LLCs are approximated with 5–0 polydioxanone
mattress sutures for medial rotation of the cleft
side LLC.
• The stitches are placed more laterally on the cleft side
LLC for over-correction. Through-and-through sutures
placed on the medial crura for further support to the
LLCs.
• The most important factor in achieving alar symmetry
is releasing the abnormally attached paranasal
muscles.
• In reconstructing the nostril floor, the alar base is
advanced farther to its proper width compared with the
normal side.
• The alar-facial groove is further accentuated by the
approximation of the lip musculature.
• Mobilization of the alar base on cleft side will
accentuate the vestibular webbing inside the cleft
side nostril and alar transfixion sutures can help
reduce this.
• Two sutures are usually required:
■ The lower suture is used to close the dead space and
tack the vestibular webbing.
■ The upper suture catches the leading edge of the LLC
and helps to support the LLC.
■ Skin dimpling from the sutures disappears 2 weeks
after surgery (see Fig. 8.17).
Adjustments at cheiloplasty
• Making the necessary minor adjustments to achieve a
satisfactory result is the enjoyment and challenge of cleft
surgery. Every cleft is different and always needs minor
adjustments.
Addressing the cleft nasal deformity
• Most surgeons address the cleft nasal deformity at this
stage by releasing the fibrofatty tissue over the nasal tip
and LLC, and repositioning the LLCs through a “semi-
open” approach.
• To release the fibrofatty tissue on the nasal tip and LLC,
dissection is carried out over the LLCs using sharp
scissors.
• The extent of dissection on the cleft side should be lateral
to the groove on the caudal edge of the LLC to correct
this groove.
Figure 8.17  (A) Complete wound closure with columella elongation with the
Mohler’s rotation incision; note the laterally positioned philtral column. (B) Alar
transfixion sutures (ATS) of 5–0 absorbable monofilament are placed with traction
on the LLC. One suture is placed in the vestibular skin. The remaining sutures catch
the leading edge of the LLC, pass through the alar-facial groove and back near the
rim of the ala, and are tied on the inner side. Notching of the skin disappears within
1–2 weeks.
ATS
A
B
Figure 8.18  The skin closure is depicted to show inadequate rotation and peaking
of the Cupid’s bow. A horizontal incision is made above CPHL on the cleft side of
the Cupid’s bow to rotate it down. An appropriately sized triangular flap from the
lateral lip skin is inserted into this defect to correct the deformity.

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• Cleft lip repair
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• Efforts have been made to eliminate the external scar as
with traditional rotation-advancement or straight-line
closures.
• The authors’ preference is still a modified rotation
advancement cheiloplasty similar to the technique used
in incomplete cleft lips.
Bilateral cleft lip (Video 8.3)
• The technical details for repair of a bilateral complete
cleft lip and nasal deformity are given below, followed by
modifications used for the major anatomic variants of
bilateral cleft lip.
• The steps are portrayed as they proceed, which often
requires turning attention from the lip to the nose, then
back to the lip again, and ending with the final touches to
the nose.
• Some leeway in the sequence of the procedure is possible
but, in general, this is not advisable, until considerable
experience is gained in these procedures.
Bilateral, complete cleft lip and palate
Markings
• The anatomic points are designated using the standard
anthropometric initialisms, as in the unilateral cleft
patient.
• With the nostrils held upward with a double-ball
retractor, the philtral flap is drawn first.
• Its dimensions are determined by the child’s age at repair
(usually 5–6 months), and less so by ethnicity.
■ The length of the philtral flap (sn-ls) is set at 6–7 mm
(normal male 11.4 ± 1.3 mm at 6–12 months); usually it
is the same as the cutaneous prolabium.
■ If the prolabial element is overly long, the philtral flap
should be shortened appropriately.
■ The width of the philtral flap is set at 2 mm at the
columellar–labial junction (cphs-cphs) and 3.5–4 mm
between the proposed Cupid’s bow peaks (cphi-cphi)
(normal male 6.7 ± 1.0 mm at 6–12 months).
■ The sides of the philtral flap should be drawn slightly
concave in anticipation of slight bowing with growth.
• Flanking flaps are drawn which will be de-epithelialized
and will come to lie beneath the lateral labial flaps in an
effort to simulate elevation of philtral columns.
• The proposed Cupid’s bow peaks are carefully noted on
the lateral labial elements, and marked just atop the
white roll above the vermillion-cutaneous junction.
• Curvilinear lines are drawn at the juncture of the alar
bases and lateral labial elements. (Fig. 8.20).
Labial dissection
• First, all labial lines are lightly scored, the philtral
flanking flaps are de-epithelialized, the extra prolabial
skin is discarded, and the philtral flap is elevated
(including subcutaneous tissue) up to the anterior nasal
spine.
Rotation advancement cheiloplasty for
incomplete clefts
• The incomplete cleft lip is sometimes surprisingly
difficult to reconstruct.
• The rotation incision and muscle dissection is made
similar to complete clefts in a Mohler’s fashion. The
C-flap is raised similar to complete clefts. The incision on
the advancement flap is made along the cleft edge. The
WSR flap is also designed (Fig. 8.19).
• The technique and extent of muscle dissection is similar
to complete clefts. Less muscle dissection tends to leave
the abnormal muscle insertions to the alar base, which
will cause the lateral and downward displacement of the
alar base in secondary deformities. The OM flap is raised
as in complete clefts.
• The local tissue on the nasal septum and piriform
area is turned over and sutured to each other,
matching the height of the nasal floor on non-cleft
side nostril.
• Muscle reconstruction is performed as in complete clefts,
using an anchoring suture to the septum for centralizing
Cupid’s bow. Overlapping mattress muscle sutures are
used to reconstruct the philtral column.
• Nasal correction is performed as in complete clefts with a
rim incision on non-cleft side nostril and reversed U
incision (semi-open) on cleft side. The cartilage
dissection, cartilage repositioning, alar transfixion sutures
are the same.
Microform cleft lip
• Surgical correction of microform cleft lip has received
less attention in the literature because of its minor
deformity.
Figure 8.19  Markings for incision lines in incomplete clefts with incision made
along the free edge of the skin.
Video
8.3

147
Operative techniques
the premaxillary periosteum to construct the posterior side of
the central gingivolabial sulcus (Fig. 8.23).
Labial closure
• Advancement of the lateral labial elements during closure
of the sulci is critical.
• A back-cut is made at the distal end of the sulcal incision,
and each sulcus is closed while the labial flap is being
pulled mesially with a double hook.
• The lateral white-roll-vermillion-mucosal flaps are
incised; however, stop these incisions about 2–3 mm short
of the tattooed lateral Cupid’s bow peak-points.
• The lateral labial elements are disjoined from the alar
bases, and the basilar flaps are freed from the piriform
attachments by incision along the lower section of the
cutaneo-mucosal junction.
• The mucosal incisions are extended distal along the
gingivolabial sulcus to the premolar region.
• With a double-hook on the muscular layer, the lateral
labial elements are widely dissected off the maxillae in
the supraperiosteal plane.
• The non-dominant ring finger is held on the infraorbital
rim (to protect the globe) as the dissection is further
extended over the malar eminence (Fig. 8.21).
• Extensive release of the lateral labial segments is a critical
maneuver so as to minimize tension at the muscular and
cutaneous closure.
• The orbicularis oris bundles are dissected in the
subdermal and submucosal plane for 1 cm, or a little
further if necessary (Fig. 8.22).
Alveolar closure
The lateral nasal mucosal flaps are released from beneath the
inferior turbinates, the medial nasal mucosal flaps are ele­
vated from the premaxilla, and the nasal floors are closed.
The premaxillary mucosal incisions are continued on each
side and vertical incisions are made in the facing gingiva of
the lesser segments.
The alar base flaps are advanced medially and the inner
edge is sutured to the anterior edge of the constructed nasal
floors.
The thin strip of vermillion is trimmed off the premaxillary
mucosa and the remaining mucosal flange is secured high to
Figure 8.20  Markings for synchronous repair of bilateral cleft lip and nasal
deformity. Open circles denote tattooed dots. Anthropometric points: nasion;
pronasale (prn); highest point of columella nasi (c); subnasale (sn); ala nasi (al);
crista philtri superior (cphs); crista philtri inferior (cphi); labiale superius (ls);
stomion (sto).
prn
c
sn
cphs
cphi
ls
al
sto
Figure 8.21  Lateral labial elements dissected off maxilla in supra-periosteal plane,
extending over the malar eminences.
Figure 8.22  Dissection of orbicularis oris muscle bundles in subdermal and
submucosal planes.

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• Cleft lip repair
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• The excess vermillion-mucosa is successively trimmed
from each flap, and the flaps are accurately aligned to
form the median raphe.
• Nasal dissection and positioning the lower lateral
cartilages
• The slumped/splayed lower lateral cartilages are
visualized through bilateral rim incisions (“semi-open”
approach).
• Fibrofatty tissue is dissected off the anterior surface of
and in between the cartilages:
• This is aided by elevation with a cotton-tipped applicator
on the mucosal underside.
• Dissection is continued across the dorsal septum to
expose the upper lateral cartilages (Fig. 8.25).
• With direct visualization, a horizontal mattress suture of
5–0 polydioxanone (1/2 circle cutting needle) is placed
between the genua and left untied.
• The advanced lateral labial mucosa forms the anterior
wall of the central gingivolabial sulcus.
• The orbicular bundles are apposed (end-to-end),
inferiorly-to-superiorly, using simple polydioxanone
sutures.
• Prior to completion of the muscular closure, a
polydioxanone suture is placed on each side through the
maxillary periosteum in the region of the origin of the
depressor alae nasi and left untied.
• A polypropylene suture suspends the uppermost
muscular elements to the periosteum of the anterior nasal
spine (Fig. 8.24A).
• Construction of the median tubercle begins with
placement of a fine chromic suture, about 3 mm medial
to the tattooed lateral Cupid’s bow peak-point, joining
the white-roll-vermillion-mucosal flaps in the midline
(Fig. 8.24B).
Figure 8.23  (A) After completion of gingivoperiosteoplasty, redundant premaxillary vermillion trimmed. (B) Remaining premaxillary mucosal flange sutured to periosteum
forming posterior wall of anterior gingivolabial sulcus.
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Figure 8.24  (A) Apposition of orbicularis oris from inferior-to-superior; uppermost suture placed through periosteum of anterior nasal spine. (B) Lateral white-roll-
vermillion-mucosal flaps trimmed to construct median tubercle and Cupid’s bow.
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Operative techniques
Figure 8.26  Positioning dislocated and splayed lower
lateral cartilages: (A) Apposition of genua with interdomal
mattress suture; (B) suspension over ipsilateral upper
lateral cartilage with inter-cartilaginous mattress suture.
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Figure 8.25  Lower lateral cartilages exposed through rim incisions. Cotton-tipped
applicator elevates nostril and helps display genua.
• Another mattress suture is inserted through each upper
lateral cartilage and then through the ipsilateral lateral
crus.
• Often it is possible to place a second suture to suspend
the lateral crus to the upper lateral cartilage.
• Holding an intranasal cotton-tipped applicator, beneath
the genu and tenting the nostril roof, facilitates the
insertion and tying of these sutures (Fig. 8.26).
• The C-flap on each side of the columellar base is trimmed
to 3–5 mm in length (Fig 8.27A).
• The alar bases are advanced medially, rotated
endonasally, and sutured side-to-end to the C-flaps.
• Next, the tips of the alar base flaps are trimmed to
complete closure of the sills.
• A “cinch suture” of polypropylene is placed through the
dermis of each alar base, passing under the philtral flap,
and tied to narrow the inter-alar dimension (al-al) to less
than 25 mm (normal male 26 ± 1.4 mm at 6–12 months).
• The maxillary periosteal sutures, placed earlier, are
brought above the muscular layer, inserted through the
alar bases (superficial to the “cinch suture”) and tied.
• This suture simulates the depressor alae nasi and also: (1)
forms the cymal shape of the sills; (2) prevents alar
elevation with smiling; (3) minimizes postoperative nasal
widening (see Fig. 8.27B).
Final touches
• Fashioning a philtral dimple seems just beyond the
surgeon’s skill, nevertheless, it is worth trying.
• One way to simulate this depression is to suture the
dermis in the lower one-third of the philtral flap down to
the orbicularis layer.
• The tip of the philtral flap is inset into the handle of the
Cupid’s bow.
• The leading edge of the lateral labial flaps should not be
trimmed before apposition to the philtral flap.
• A little extra lateral labial tissue helps to simulate the
columns.
• There should be no tension at the philtral closure, which
is done with fine, interrupted dermal and percutaneous
sutures.
• The cephalic margin of the labial flaps must be trimmed,
corresponding to the position and cymal configuration of
the sills (Fig. 8.28).
• Closure of the labial flaps to the sills proceeds
laterally-to-medially.
• After anatomic positioning of the lower lateral cartilages,
it is obvious that there is redundant domal skin in the
soft triangles and in the upper columella.
• This extra skin is excised in a crescentic fashion from the
leading edge of the rim incisions and extending inferiorly
along each side of the columella (see Fig. 8.28).
• This resection narrows the nasal tip, defines and tapers
the midcolumella, and elongates the nostrils.

150
•
• Cleft lip repair
8
Late presentation of bilateral complete
cleft lip/palate
• Rather than attempt labial closure over a protrusive
premaxilla, consider ostectomy and set-back. There are
two alternatives: (1) premaxillary set-back and nasolabial
repair or (2) premaxillary set-back and palatoplasty.
• The second alternative, premaxillary set-back,
gingivoperiosteoplasties, and palatoplasty, is the safer
procedure.
• It is recommended if the child is nearing age 1 year or
older when speech is the first priority.
• Bilateral nasolabial repair on a solid maxillary foundation
is scheduled later.
Bilateral incomplete cleft lip
• One-quarter of all double labial clefts are incomplete cleft
lip; most are symmetrical.
• Of all the bilateral variants, this is the most easily
repaired.
• The design and execution are the same as for the bilateral
complete form, including adjustments based on expected
nasolabial changes with growth.
• There are two technical considerations that need to be
underscored.
• Construction of the median tubercle:
• Usually formed using the lateral white-roll-vermillion-
mucosal flaps, in the rare instance of a bilateral lesser-
form (<50% of cutaneous labial height) and a prominent
central white roll, the prolabial vermillion-mucosa may
be utilized as the central segment.
• Columellar length:
• If columellar length is normal for the infant’s age and the
lower lateral cartilages are in nearly normal position, it
may be unnecessary to position the cartilages and sculpt
the tip. (Fig. 8.30, Table 8.2).
• Apposition of the genua also accentuates the extra lining
(oblique webbing) in the lateral vestibules.
• Lenticular excision on the cutaneous side of the
intercartilaginous junction flattens this lateral ridge (see
Fig. 8.28, inset).
• Immediately postoperative nasolabial anthropometry is
documented and placed in the child’s record (Fig. 8.29).
• The constructed columella (sn-c) is usually 5–6 mm,
(normal male 4.7 ± 0.8 mm at 5 months).
• After the measurements, a strip of 14 inch Xeroform®
gauze is wrapped around a 19 G silicone tubing and a
1 cm segment is inserted into each nostril.
• These vented “stents” are removed after 48 h.
• Prolonged nostril splinting is difficult to maintain, likely
to damage the sills, and unnecessary.
A
B
Figure 8.27  (A) Columellar flaps shortened and alar bases trimmed. Note bilateral
sutures in maxillary periosteum below alar bases – these sutures were inserted prior
to completion of muscular closure. (B) Alar base flaps rotated endonasally and
secured (side-to-end) to C-flaps. Interalar distance narrowed with cinch suture.
Right maxillary periosteal suture to alar base has been tied – note cymal
configuration (depression) of lateral sill.
Table 8.2  Intraoperative anthropometry. Fast-growing features
made smaller and slow-growing dimensions made larger than
normal age/sex-matched values
Intraoperative
Patient
(6 months)
Normal
(6–12 months)
n-sn
20.0a
27.0 ± 1.7
al-al
24.5a
26.5 ± 1.4
sn-prn
12.3a
9.1 ± 1.2
sn-c
6.0a
4.3 ± 0.9
cphs-cphs
2.0
NA
cphi-cphi
5.0a
6.7 ± 1.0
sn-ls
7.0a
11.4 ± 1.3
sn-sto
14.5
15.8 ± 1.5
ls-sto
7.0a
4.4 ± 1.0
Normal values expressed as norm ± SD. aValues outside SD. NA, not available.

151
Complications and outcomes
• Parents are instructed in suture-line care and how to keep
the nostrils clean.
• Antibiotic ointment is often placed on the suture
line after it is cleaned, keeping it from drying out or
crusting.
• Postsurgical molding with silicone nasal conformers has
been used in many centers to support the lower lateral
cartilages during the healing phase and to prevent
contracture and nasal stenosis.
• If used, the parents are instructed to use the conformers
full-time for 6 months to 1 year if possible.
• Success in nasal conformer use depends more upon the
cooperation of the parents rather than the compliance of
the patients.
• After bilateral lip repair, Dr Mulliken utilizes a Logan
bow, which is taped to the cheeks to protect the labial
repair and to hold an iced-saline sponge over the wound
for 24 h postoperatively.
• Percutaneous sutures are removed 5–6 days
postoperatively under general anesthesia using mask
induction and insufflation.
• After suture removal, a 12 inch transverse Steri-Strip®
(3M Health Care, St Paul, Minnesota) can be trimmed
and placed over the labial scars to aid healing.
• If placed, the tape is typically changed as needed for 6
weeks.
• After adequate healing has occurred, the parents are
instructed how to perform digital massage to hasten scar
maturity and counseled about the importance of
application of sun-block ointment (Fig. 8.32, Table 8.3).
Complications and outcomes
• A symmetrical balanced lip is the goal of cleft lip repair.
Patient and parental satisfaction is largely dependent
upon psychosocial adaptation.
• Complications can include lip asymmetry, infection,
dehiscence, and hypertrophic scarring.
Asymmetrical bilateral (complete/incomplete)
cleft lip
• Symmetry, the first principle of bilateral labial repair,
should be foremost in mind when planning and
executing closure of an asymmetrical variant.
• An algorithm for timing and techniques for repair of
asymmetrical bilateral cleft lip is shown in Figure 8.31.
Postoperative considerations
• A soft nipple with good flow is used with bottle-feeding.
• Feeding is started as soon as the baby desires.
Figure 8.28  Crescentic excision of expanded domal skin
and lining extended into upper columella. Cyma-shaped
resection of superior margin of lateral labial elements to fit
curve of the alar base and sill. Lenticular excision of lateral
vestibular web (inset).
Figure 8.29  Completed bilateral complete cleft lip/nasal repair. Pronasale (prn);
highest point of columella nasi (c); subnasale (sn); ala nasi (al); crista philtri
superior (cphs); crista philtri inferior (cphi); labiale superius (ls); stomion (sto).
prn
c
sn
cphs
cphi
ls
al
sto

152
•
• Cleft lip repair
8
Figure 8.30  (A) Bilateral symmetrical incomplete cleft lip. (B) Markings for synchronous closure at age 6 months. (C) Following nasolabial repair. (D,E) Appearance at age
1.5 years.
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• It is not uncommon to have notching at the height of
Cupid’s bow on the cleft side as well as vermillion
irregularities.
• Symmetry is the one major advantage of a bilateral
complete cleft lip as compared to a unilateral complete
cleft lip.
• Any nasolabial asymmetry following closure and further
distortions with growth will become increasingly obvious
before the child attends school.
• In a study of 50 consecutive non-syndromic children
(median age 5.4 years), the revision rate was 33% for
those with bilateral complete cleft lip/palate as compared
to 12% for those with bilateral complete cleft lip/alveolus
and intact secondary palate
• The most common labial revision was resuspension of
prolapsed anterior gingivolabial mucosa. This problem
has since been minimized by trimming prolabial
vermillion and securing the remaining mucosa to the
premaxillary periosteum.
Table 8.3  Immediate postoperative anthropometry documents
under-corrected fast-growing features and over-corrected
slow-growing features compared with normal values
Intraoperative
Patient
(7 months)
Normal
(6–12 months)
n-sn
20.0a
26.9 ± 1.6
al-al
24.5
25.4 ± 1.5
sn-prn
10.5
9.7 ± 0.8
sn-c
6.0a
4.7 ± 0.8
cphs-cphs
1.5
NA
cphi-cphi
4.5a
6.5 ± 1.1
sn-ls
5.5a
10.7 ± 1.1
sn-sto
11.2a
16.0 ± 0.8
ls-sto
6.2
5.3 ± 1.4
Normal values expressed as norm ± SD. aValues outside SD. NA, not available.

153
Complications and outcomes
Figure 8.31  Algorithm for correction of asymmetrical bilateral cleft lip (complete/incomplete) and contralateral incomplete or lesser-form cleft. DFO, dentofacial
orthopedics; GPP, gingivoperiosteoplasty. (Modified from Yuzuriha et al. 2008.)
Greater side
Lesser side
Minor-form
Incomplete
Complete
DFO
Labial adhesion and GPP
Synchronous bilateral
nasolabial repair
Incomplete
Complete
DFO
Labial adhesion and GPP
Rotation-advancement
Incomplete
Lesser side: delayed double unilimb Z-plasty
Rotation-advancement
Lesser side: immediate/delayed lenticular
labial excision and nasal correction
Complete
DFO
Labial adhesion and GPP
Incomplete
Microform
Mini-microform
Type of repair

154
•
• Cleft lip repair
8
Figure 8.32  (A) Bilateral complete cleft lip/palate. (B) Following synchronous nasolabial repair at 6 months. (C,D,E) At 4 months postoperative. Note columella/tip
projection, hint of a philtral dimple, and normal columellar-labial angle.
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Further reading
Barillas I, Dec W, Warren SM, et al. Nasoalveolar molding
improves long-term nasal symmetry in complete
unilateral cleft lip-cleft palate patients. Plast Reconstr
Surg. 2009;123(3):1002–1006.
This paper demonstrated that the lower lateral and septal
cartilages are more symmetric in patients with nasoalveolar
molding compared with the surgery-alone patients.
Furthermore, the improved symmetry can be maintained at
9 years of age.
Cutting CB, Grayson BH, Brecht L, et al. Presurgical
columellar elongation and primary retrograde nasal
reconstruction in one-stage bilateral cleft lip and nose
repair. Plast Reconstr Surg. 1998;101:630–639.
The article describes the prototype of a nasoalveolar molding
appliance in preparation for synchronous nasolabial repair
by Cutting’s technique. The authors underscore that
expansion of nasal lining is as important as stretching
columellar skin. The principle of primary positioning the
lower lateral cartilages is applied as described in this
chapter; however, the technique differs.
Farkas LG, ed. Anthropometry of the Head and Face. 2nd ed.
New York: Raven Press; 1994.
Grayson BH, Garfinkle JS. Nasoalveolar molding and
columellar elongation in preparation for primary
repair of unilateral and bilateral cleft lip and palate. In:
Losee JE, ed. Comprehensive Cleft Care. New York:
McGraw Hill; 2009:701–720.
Lee CT, Garfinkle JS, Warren SM, et al. Nasoalveolar
molding improves appearance of children with

155
Further reading
Mulliken JB, Burvin R, Farkas LG. Repair of bilateral
complete cleft lip: Intraoperative nasolabial
anthropometry. Plast Reconstr Surg. 2001;107:307–314.
Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft lip:
Review, revisions, and reflections. J Craniofac Surg.
2003;14:609–620.
Mulliken JB, Burvin R, Padwa BL. Binderoid complete cleft
lip/palate. Plast Reconstr Surg. 2003;111:1000–1010.
The authors define a rare subset of patients who have
complete cleft lip/palate, nasolabiomaxillary
underdevelopment, and orbital hypertelorism. One-half of
the patients have a bilateral complete deformity,
characterized by a diminutive single-toothed premaxilla.
Necessary modifications in primary repair and in secondary
correction of the hypoplastic soft tissue and skeletal elements
are described.
Noordhoff MS, Huang CS, Wu J. Multidisciplinary
management of cleft lip and palate in Taiwan. In:
Bardach J, Noordhoff MS, Chen PK. Unilateral
cheiloplasty. In: Mathes ST, ed. Plastic Surgery. Vol 4.
Philadelphia: WB Saunders; 2006.
Salyer KE, Genecov E, Genecov D. Unilateral cleft lip-nose
repair: A 33-year experience. J Craniofac Surg.
2003;14(4):549–558.
A 33-year experience in over 750 patients with a proven
method of repair for primary unilateral cleft lip-nose is
presented in this paper. Approximately 35% of them needed
a minor revision in preschool age and most of them received
an aesthetic rhinoplasty after growth was completed. This
long-term experience showed that with primary nasal
reconstruction, self-esteem was enhanced in cleft patients.
Wong JY, Oh AK, Ohta E, et al. Validity and reliability of
craniofacial anthropometric measurements of 3D
digital photogrammetric images. Cleft Palate Craniofac J.
2008;45:232–239.
Yeow VK, Chen PKT, Chen YR, et al. The use of nasal
splints in the primary management of unilateral cleft
nasal deformity. Plast Reconstr Surg.
1999;103(5):1347–1354.
This paper shows that postoperative nasal splinting in the
primary management of the unilateral cleft nasal deformity
serves to preserve and maintain the corrected position of the
nose after primary lip and nasal correction, resulting in a
significantly improved aesthetic result. The authors
recommend that all patients undergoing primary correction
of complete unilateral cleft deformity use the nasal retainer
postoperatively for a period of at least 6 months.
Yuzuriha S, Oh AK, Mulliken JB. Asymmetrical bilateral
cleft lip: Complete or incomplete and contralateral
lesser defect (minor-form, microform, or mini-
microform). Plast Reconstr Surg. 2008;122:1494–1504.
This paper focuses on a subgroup of asymmetrical bilateral
clefts that present with a lesser-form variant that is
contralateral to a complete or incomplete cleft lip. The lesser
forms are defined based on extent of disruption at the
vermilion–cutaneous junction: minor-form, microform, and
mini-microform. These designations determine the methods
of repair and correlate with frequency and types of revisions
that are usually necessary.
bilateral cleft lip-cleft palate. Plast Reconstr Surg.
2008;122:1131–1137.
This study provides further proof of the principle of primary
nasal correction. Photogrammetry was used to document
columellar length in patients with bilateral cleft lip/palate
who had nasal repair by the two-stage forked flap method
versus primary nasal correction after nasoalveolar molding;
both groups were compared to age-matched controls.
Measurements to age 3 years showed nearly normal
columellar length in the primary repair group without need
for further nasal procedures, whereas secondary operations
were recommended for all children who had forked flap
columellar lengthening.
Liou EJ, Subramanian M, Chen PKT, et al. The progressive
changes of nasal symmetry and growth after
nasoalveolar molding: a three-year follow-up study.
Plast Reconstr Surg. 2004;114(4):858–864.
This paper revealed that in patients with unilateral complete
cleft lips, the nasal asymmetry was significantly improved
after nasoalveolar molding and was further improved after
primary cheiloplasty. However, after surgery, the nasal
asymmetry significantly relapsed in the first year
postoperatively and then remained stable and well afterward.
The authors recommend (1) narrowing down the alveolar
cleft as well as possible by nasoalveolar molding; (2)
overcorrecting the nasal vertical dimension surgically;
and (3) maintaining the surgical results using a nasal
conformer.
Lo L-J, Wong F-H, Mardini S, et al. Assessment of bilateral
cleft lip nose deformity: A comparison of results as
judged by cleft surgeons and laypersons. Plast Reconstr
Surg. 2002;110:733–741.
Millard Jr DR, ed. The unilateral deformity. Cleft Craft: The
Evolution of Its Surgery. Vol I. Boston: Little, Brown;
1976.
Millard Jr DR. Cleft Craft: The Evolution of Its Surgery. Vol II.
Boston: Little, Brown; 1977.
One definition of a “classic” is a great book that is often
cited, but seldom read. In his conversational style of writing,
Millard recounts the history of bilateral cleft lip repair as if
he was an observer. The novice may find the organization of
the book a little difficult to follow. Nevertheless, reading
Millard’s text is analogous to watching a master-surgeon in
the operating room. The more experienced the visitor, the
more gained by the experience.
Mohler L. Unilateral cleft lip repair. Plast Reconstr Surg.
1995;2:193–199.
This paper introduced a modification of the original
rotation-advancement technique by changing the direction of
the rotation incision to the “mirror-image of the noncleft
side philtral column” that resulted in a more natural looking
lip.
Morris HL, ed. Multidisciplinary Management of Cleft Lip and
Palate. Philadelphia: WB Saunders; 1990:18–26.
Mulliken JB, Martinez-Perez D. The principle of rotation
advancement for repair of unilateral complete cleft
lip and nasal deformity: technical variations and
analysis of results. Plast Reconstr Surg.
1999;104:1247–1260.

©2014, Elsevier Inc. All rights reserved.
Chapter
9 
Cleft palate
• This fusion proceeds from anterior to posterior, which
helps to understand the spectrum of clefts of the
secondary palate.
• The levator palatini and other pharyngeal muscles are
derived from the fourth branchial arch and are
innervated by cranial nerve X (vagus). The sole exception
to this is the tensor palatini muscle, which arises from the
first branchial arch and is innervated by cranial nerve V
(trigeminal).
• The incidence of otitis media effusion has been found to
be 96–100% in cleft palate patients.
• It is estimated that there is a 20–30% incidence of pure
tone hearing loss in cleft palate patients by audiography.
• It has long been suggested that closure of the palate
reduces risk of permanent hearing loss
Preoperative considerations
Sub-mucous cleft palate
• Sub-mucous cleft palate occurs when the palate has
mucosal continuity but the underlying levator palatini
muscle is discontinuous across the midline and
longitudinally oriented, similar to the muscle anatomy in
overt clefts of the palate (Fig. 9.1).
• Calnan’s classic triad is diagnostic of this condition:
■ A midline clear zone (zona pellucida).
■ A bifid uvula.
■ A palpable notch in the posterior hard palate.
■ With contraction of velar musculature, a distinct
midline muscle diastasis may be seen (see Fig. 9.1).
• The significance of a sub-mucous cleft may be difficult to
assess clinically; the child with sub-mucous cleft palate is
often undiagnosed in infancy.
• It has been reported that 45–55% of patients with
isolated sub-mucous cleft palate are symptomatic
This chapter was created using content from
Neligan & Losee, Plastic Surgery 3rd edition,
Volume 3, Pediatric Plastic Surgery, Chapter 25,
Cleft Palate, William Y. Hoffman.
SYNOPSIS
■ Normal speech is the primary goal of cleft palate repair; minimizing
effects of maxillary growth is also important but ultimately
secondary.
■ Cleft palate repair prior to 1 year of age (ideally 9–10 months)
results in better speech outcomes than later repairs.
■ The levator veli palatini muscle is longitudinally oriented in the cleft
palate patient. Realignment of the muscle to a transverse and
posterior position in the soft palate is the key to a successful
functional result.
■ Eustachian tube function is abnormal in cleft patients due to
abnormal position of the tensor veli palatini muscle; this must be
addressed in every cleft palate patient, usually with ventilating
tubes.
Brief introduction
• The failure of fusion of the frontonasal and maxillary
processes gives rise to the cleft of the primary palate,
which includes the lip, alveolar process, and the hard
palate anterior to the incisive foramen.
• This results in a cleft in the typical location between the
premaxilla and the lateral maxilla, on either one or both
sides.
• The lateral palatal shelves fuse later than the primary
palate, around 7–8 weeks’ gestation, as they rotate from
vertical to horizontal orientation.

157
Preoperative considerations
• Nasal airways have been used for the same purpose with
reported success rates of 80–90%.
• If these conservative measures fail, surgical management
of the airway may be required.
• A tongue–lip adhesion has been used as an alternative to
tracheostomy and is generally effective.
• More recently, mandibular distraction osteogenesis has
been used in neonates with success in averting
tracheostomy.
• Palatoplasty in children with Pierre Robin sequence must
be carefully timed with growth of the child, particularly
the mandible, as closure of the palate narrows the
effective area for respiration and can lead to respiratory
distress.
■ If the mandible attains reasonable size in the first year
of life, palate repair can still be performed safely
before 1 year of age.
■ In the rare patient who has previously undergone
tracheostomy, the palate should be repaired before
decannulation.
■ The risk of airway compromise after palatoplasty
reaches 25%, with an emergent tracheostomy or
reintubation rate of 11% at one institution.
Syndromes
• Cleft palate without associated cleft lip has been reported
to be associated with a syndrome in as many as 50% of
cases, while cleft lip and palate together have an
incidence of syndromes of about 30%.
• Van der Woude syndrome is associated with a mutation
in the interferon regulatory factor 6 (IRF6) gene; this is an
autosomal dominant syndrome associated with lower lip
sinus tracts (“lip pits”), and has variable penetrance
including the full range of cleft lips as well as palates.
• Velocardiofacial syndrome is associated with a 22q
chromosomal deletion, detected by fluorescent
immunohybridization (FISH). These children have a
characteristic “bird-like” facial appearance, soft palate
dysfunction, developmental delay, and various cardiac
conditions.
• The same deletion gives rise to DiGeorge syndrome with
associated B-cell and immune dysfunction.
• Infants with profound developmental delay and severely
shortened life span projection should have surgical
intervention delayed or should undergo palatoplasty
under special circumstances only.
• Palate repair in severely disabled children can lead to
altered airway status and obstructed upper airway in
those with neuromuscular delay.
Growth
• At birth the average weight is the same for cleft and
unaffected newborns. However, cleft infants have been
shown to exhibit poor weight gain in early infancy.
• After repair of the palate, average growth returns to
normal compared with unaffected children by the age of
4 years.
with regard to speech, serous otitis media, or
hearing loss.
• However, an infant identified with sub-mucous cleft
palate need not routinely undergo repair because a
significant number of individuals with sub-mucous cleft
palate will not develop velopharyngeal insufficiency.
• Rather, these patients should be closely monitored with
serial speech evaluations and audiometric surveillance.
• Patients who present with velopharyngeal insufficiency
and sub-mucous cleft palate on examination require full
evaluation, including speech evaluation and endoscopy.
• Even in the absence of obvious findings on clinical
examination, anatomic abnormalities are found in most
patients (>90%) at the time of surgery.
• Corrective surgical technique for sub-mucous cleft palate
is focused on anatomic correction of the velar muscle
diastasis.
• Although pharyngeal flaps and sphincter pharyngoplasty
have been proposed as primary means of treatment, most
surgeons focus on repair of the abnormal levator muscle
position.
• The Furlow double opposing Z-plasty (see below) is an
ideal procedure for these patients because there is no
width discrepancy to overcome.
Pierre Robin sequence
• Pierre Robin described the triad of micrognathia,
glossoptosis, and respiratory distress.
• 60–90% of patients diagnosed with Pierre Robin sequence
have cleft palate.
• Infants with Pierre Robin sequence also have increased
incidence of associated anomalies, particularly cardiac
and renal problems.
• Newborns with Pierre Robin sequence may have severe
respiratory and feeding difficulty because of the posterior
displacement of the tongue.
• Initial treatment consists of placing the child prone and
use of gastric lavage feeding tubes to push the tongue
forward.
Figure 9.1  Sub-mucous cleft palate – note bifid uvula and thinning of central
palate. On palpation there is a notch in the posterior hard palate rather than a
posterior nasal spine.

158
•
• Cleft palate
9
Speech
• The primary goal of palatoplasty is normal speech.
• Patients can grow and even thrive, despite feeding
difficulties, but speech cannot be normalized if the palate
is not repaired.
• The ability to partition the oropharynx and nasopharynx
is crucial for normal speech production.
• The palate elevates during production of any sounds
requiring positive pressure in the oropharynx; the
levator palatini is primarily responsible for this
movement (Fig. 9.2).
• Speech is a complex issue, and many factors may
influence speech development in a child with a cleft
palate.
• In addition to the importance of the palate itself, speech
development may be influenced by motor or neurologic
developmental delay (often seen in syndromes), by
hearing, and by environmental stimuli.
• If palate function is not corrected, velopharyngeal
insufficiency results, with speech that is hypernasal, often
with hoarse quality due to difficulty in directing airflow
through the mouth.
• When complete closure cannot be anatomically or
functionally obtained, compensatory mechanisms for
sound production are learned.
• These are maladaptive patterns that interfere with global
intelligibility and include glottal stops and pharyngeal
fricatives.
• Two crucial aspects of palatoplasty are important in
optimal speech outcome: (1) surgical technique and (2)
timing of palate repair.
• Most would agree that the best speech results are
correlated with closure of the palate near the time of the
infant beginning language acquisition, which for the
normal-developing child is before 12 months of age.
• Despite the absence of hard evidence supporting earlier
palate repairs, a growing body of opinion seems to
support palate repair around 9–10 months of age for
children with apparently normal development.
• Very early repair of the palate (6 months or younger) has
been proposed by some surgeons, primarily as a means
of improving feeding; however, long-term results are
lacking for any large cohort of these patients.
Maxillary growth
• Palatoplasty has been shown to detrimentally affect
maxillary growth.
• Many children with repaired cleft palate display typical
findings of transverse maxillary deficiency requiring
orthodontic widening of the maxilla once permanent
teeth have erupted.
• There may be a sagittal growth deficiency as well;
whereas 35–40% of children will develop an anterior
crossbite, as many as 15–20% of children with cleft palate
go on to require a Le Fort I maxillary advancement in
some series.
• Although it might seem preferable to wait until a more
advanced age for palate repair, given the growth effects
• Children with orofacial clefting stabilize and continue
normal growth to at least 6 years of age, with no
statistically significant differences in height and weight
when compared to unaffected children.
• In later childhood, however, the average weight and
height of children with cleft palate appears to diminish
compared with those of control subjects.
Feeding and swallowing
• Oral intake is divided into two separate activities:
generation of suction force (negative intraoral pressure)
and swallowing.
• For negative intraoral pressure to be produced, the velum
seals off the pharynx posteriorly; the lips close anteriorly,
and negative pressure is produced by moving the tongue
away from the palate and by opening the mandible
which effectively increases the intraoral volume within a
closed system.
• If the individual is unable to close the nasopharynx or to
generate a seal of the lips, or if the palate is not intact at
the point of contact with the tongue, negative pressure
cannot be produced.
• In the cleft palate infant, the communication between the
oropharynx and nasopharynx prevents a seal of the
tongue against the palate, and negative pressure cannot
be generated. Suckling is therefore not productive, and
breast-feeding is ineffective.
• Swallowing involves a coordinated, complex interaction
of the tongue and pharynx and is dependent on
neuromuscular control and rhythmic coordinated
contraction of the tongue and pharynx.
• Children with clefts generally do not have difficulty
with swallowing and aspiration unless intrinsic
neuromuscular abnormality of the tongue or pharynx
is present.
• When the palate has an open cleft, food may reflux into
the nasal passage.
• Nasal reflux is irritating to the nasal mucosa and can
predispose to sinusitis and ulceration.
• In the older child, a persistent communication
through a fistula in the palate may result in
regurgitation of food through the nose, which is
socially unacceptable.
• Most infants with clefts are unable to breast-feed. Infants
who are unable to breast-feed because of cleft palate have
a number of options for feeding including nipples,
crosscutting of standard nipples, long soft nipples that
place the liquid at the posterior tongue, and special flow
bottles.
• All of these techniques are effective, and selection is
generally by personal preference and the baby’s
acceptance of the method.
• Other key considerations are elevated head positioning
during feeding and careful observation of feeding time
and volume ingested.
• Weight gain and skeletal growth confirm success of the
feeding regimen. Once the palate is successfully closed
surgically, special feeding methods are generally
unnecessary.

159
Anatomical considerations
Figure 9.2  (A) In the lateral cephalogram, the soft palate or
velum (“V”) is shown at rest (above left) and during speech,
making contact with the posterior pharyngeal wall (“PW”)
(above right). (B) This line drawing shows the air flow
during normal speech (left), with the velum making contact
with the posterior pharynx to direct air out the mouth. If the
velum is too short or movement is inadequate (right), air can
escape through the nose during speech, creating
velopharyngeal insufficiency (VPI).
A
B
V
V
PW
PW
on the maxilla, it is far more difficult to establish normal
speech in older children after cleft repair than to correct
occlusion with a combination of orthodontic treatment
and orthognathic surgery.
Anatomical considerations
• It is critical to understand the normal anatomy of the
levator palatini muscle and the derangement of this
anatomy that occurs in all clefts of the palate, including
sub-mucous cleft palate (Fig. 9.3).
• Normally, the levator muscle forms a transverse sling
across the posterior half of the soft palate, and
contraction causes the soft palate to move superiorly and
posteriorly, contacting the posterior pharyngeal wall for
velar closure, usually at the level of the adenoid pad.
• In addition to being discontinuous across the cleft, the
levator muscle runs more or less longitudinally along the
cleft margin before it inserts aberrantly into the posterior
border of the hard palate.
• This results in ineffective contraction and inability to
close the palate against the posterior pharyngeal wall.
• Air escape through the nose during speech produces a
characteristic hypernasal quality.
• In addition, there is abnormal fusion with the tendon of
the tensor veli palatini muscle, which impairs its function
and contributes to cleft otopathology.
• Although the primary palate and the secondary palate
form at different stages of embryonic development, cleft
palate is most commonly seen in combination with
cleft lip.
• The alveolar portion of the cleft lies between the
maxillary lateral incisor and canine tooth roots resulting
in malposition of the maxillary lateral incisor and cuspid
in both the deciduous and permanent dentition.
• The maxillary lateral incisor on the cleft side is absent in
80–90% of cleft patients.
• Unilateral complete cleft palate is characterized by direct
communication between the entire length of the nasal
passage and oropharynx.
• The nasal septum is deviated and buckled toward the
cleft side.
• Absence of a portion of the inferior piriform aperture and
hypoplasia of the lateral nasal bony platform at the
maxillary wall contribute to the cleft nasal deformity:
• The nasal base is depressed, the ala collapses, and the
floor widens.
• The unilateral complete cleft is a full-thickness palatal
defect of nasal mucosa, bony palate, velar musculature,
and oral mucosa and all of these deficiencies must be
addressed during the cleft palate repair or later at the
time of alveolar cleft bone grafting.
• In the bilateral complete cleft lip and palate, the
premaxillary segment containing the central and
lateral incisor tooth roots is discontinuous from the
alveolar arch.

160
•
• Cleft palate
9
• The lateral segments often collapse inward and lingually,
resulting in “locking out” of the premaxilla.
• Preoperative management with presurgical infant
orthopedics (PSIO) may help prevent or treat lateral
segment collapse and correct the anterior position of the
premaxilla.
• Kernahan proposed a standardized reporting form to
distinguish the variable presentations of cleft lip and
palate, shown in Figure 9.4.
• The greater palatine neurovascular bundle emerges
through the greater palatine foramen through the lateral
posterior hard palate.
• Circumferential freeing of the palatal attachments around
the pedicle and gentle stretching of the pedicle out of the
foramen are essential to obtain a tension-free closure of
the oral flap.
• In general, the goal is to obtain complete nasal and oral
closure from front to back.
• In wide clefts, this may not be possible, particularly on
the nasal surface.
• The most difficult area for closure, around the junction of
the hard and soft palate, is the most common location for
fistulas.
Operative techniques
General technical considerations
• The use of a RAE endotracheal tube facilitates placement
of the Dingman gag without kinking the tube.
Figure 9.3  (A) Normal anatomy: the levator veli palatini muscle can be seen forming a sling across the soft palate; the tensor veli palatini is shown coming around the
hamulus to fuse with the levator. (B) Cleft palate: the muscles are seen running more or less parallel with the cleft margin.
A
B
Aponeurosis
Hamulus
Tensor muscle
Levator muscle
Uvulus muscle
Aponeurosis
Hamulus
Tensor muscle
Accessory muscle
Levator muscle
Figure 9.4  Kernohan’s classification of clefts allows for standardized reporting of
the severity of both cleft lip and palate.
9
10
11
Hard
palate
Soft
palate
Nose
1
2
3
5
6
7
4
8
Lip
Nasal floor
Alveolus
Hard
palate

161
Operative techniques
■ Circumferential dissection with release of the
periosteum behind the greater palatine vessels.
■ The nasal tissue is released and left open: some
authors have proposed providing nasal lining either
with septal flaps, or with buccal mucosa (Fig. 9.7).
■ The soft palate is addressed with repair of the cleft
margins and transverse closure of the levator muscle.
• Advantage:
■ Providing increased length for the palate and places
the levator muscle in a more favorable position.
• Disadvantages:
■ Large open areas are left anteriorly and on the nasal
surface; as these close by contraction, a good deal of
the length gain is lost.
■ The contraction of the oral mucosal defects results in
loss of maxillary width anteriorly.
■ Flattening of the arch.
■ Closure anteriorly is a single layer of nasal mucosa
only, which gives rise to a higher fistula rate than in
other techniques.
Two-flap palatoplasty
• Bardach and Salyer originally described a technique of
freeing mucoperiosteal flaps from the cleft margins only,
arguing that the arch of the cleft would provide the
length needed for central closure.
• The more extensive two-flap palatoplasty is a
modification of the Langenbeck technique, extending the
relaxing incisions along the alveolar margins to the edge
of the cleft.
• The Dingman gag, the most commonly used instrument
for exposure, compresses the tongue and causes ischemia:
■ If it is used for longer than 2 h, significant
postoperative tongue swelling can occur.
• Lidocaine 0.5% and epinephrine 1 : 200 000 are infiltrated
into the palate 7–10 min before incision.
• A rolled towel under the shoulders will extend the neck;
it is important to ensure that the child does not have any
syndromes that predispose to cervical spine anomalies.
• The use of curved needle holders facilitates suture
placement without obstruction of vision.
von Langenbeck
• Bernhard von Langenbeck introduced the use of
mucoperiosteal flaps to close clefts of the secondary
palate in the late 1800s.
• The initial description of the technique involved a simple
approximation of the cleft margins with a relaxing
incision that began posterior to the maxillary tuberosity
and followed the posterior portion of the alveolar ridge.
• Intravelar veloplasty, or repair of the levator palatini
muscle, as described below, is added today to reproduce
the normal muscle sling (Fig. 9.5).
V-Y pushback (Veau–Wardill–Kilner)
• The essence of the pushback repair is the central V
incision on the hard palate that is then closed in a
straight line, creating length on the oral side of the
closure (Fig. 9.6). This involves:
Figure 9.5  von Langenbeck repair. (A) Relaxing incisions
are made behind the alveolar ridge, creating bilateral
bipedicle flaps for midline closure. The greater palatine
vessels must be preserved. (B) The cleft margins are
incised in a manner to leave adequate nasal mucosa for
complete closure. (C) Closure of the nasal mucosa and
muscle repair. (D) Final appearance.
A
B
C
D

162
•
• Cleft palate
9
Figure 9.6  Pushback repair. (A) Design of anterior “W”
incision. (B) Elevation of bilateral mucoperiosteal flaps
based on palatine vessels. The levator veli palatini muscles
are freed from the posterior border of the hard palate. (C)
The muscles are repaired across the midline of the soft
palate. (D) The “Y” closure creates additional length but
also leaves large raw areas bilaterally.
A
B
C
D
• The flaps are designed entirely dependent on the
circulation from the palatine vessels
• In a complete unilateral cleft, the flap from the greater
(medial) segment can be shifted across the cleft and
closed directly behind the alveolar margin.
• This virtually eliminates fistulas in the anterior hard
palate.
• The soft palate closure is accomplished with a straight-
line closure in the typical two-flap technique.
• Intravelar veloplasty is an essential part of this closure
(Fig. 9.8).
Vomer flaps
• There is confusion about the terminology applied to
anterior closure of the nasal mucosa in complete cleft lip
and palate.
A
B
Figure 9.7  (A) Buccal mucosal flap. Kaplan advocated use of this flap to elongate the nasal mucosa. (B) Flap transposed into the nasal surface. In some situations,
bilateral flaps can be used with the second flap lining the oral surface.

163
Operative techniques
• The original vomer flap is described as inferiorly based;
an incision is made high on the septum, and the flap is
reflected downward to provide a single-layer closure on
the oral side.
• A high number of patients with maxillary retrusion,
presumably from injury to the vomer-premaxillary
suture, as well as a high fistula rate and changed to a
two-layer anterior closure.
• Similar problems have not been found with superiorly
based vomer flaps.
• It involves:
■ Reflecting the mucosa from the septum near the cleft
margin.
■ Dissecting only enough to close the nasal mucosa of
the opposite side.
■ In bilateral cleft palate, this requires a midline incision
along the septum, and two flaps are reflected in each
direction.
■ Results in a two-layer closure of the hard palate
mucosa, with low fistula rates and less effect on
maxillary growth.
Double opposing Z-plasty (Furlow)
• Furlow first described his technique for palate closure in
the 1980s, adapting the Z-plasty principle to palatal
closure.
• A Z-plasty is developed on both the oral and
nasal surfaces of the soft palate but in opposite
directions.
Figure 9.8  Two flap palatoplasty. (A) The incisions are
similar to the Langenbeck repair but meet the cleft margin just
behind the alveolar ridge. (B) Mucoperiosteal flaps are
developed on both sides with preservation of the greater
palatine vessels. (C) The levator veli palatini muscle is freed
from the posterior border of the hard palate and sutured
across the midline. (D) Final closure. It is often possible to
close much of the lateral incision and minimize raw areas.
A
B
C
D
• For both of the Z-plasties, the central limb is the cleft
margin, and the posteriorly based flap is designed to
include the levator muscle.
• Furlow recommended that the posteriorly based oral flap
be on the left side for a right-handed surgeon because the
elevation of the muscle from the nasal mucosa is the most
difficult part of the dissection (Fig. 9.9).
• This technique addresses closure of the soft palate in a
manner that provides complete nasal and oral closure as
it re-establishes the levator sling (intravelar veloplasty).
• The chief problem may arise in very wide clefts, in which
the distance to be traversed by the Z-plasty may be
excessive.
• Alternatively, relaxing incisions have been described to
allow the flaps to advance.
• Another alternative is to extend the relaxing incision
along the lateral border of the soft palate to allow oral
closure and to use acellular dermal matrix for any nasal
defects.
• A third alternative is to employ a straight line for closure
in wide cases, reserving the Z-plasty as a secondary
procedure if needed for speech.
Two-stage palate repair
• The problem of maxillary growth after cleft palate repair
has led some surgeons to advocate a two-stage approach
to palatoplasty, with earlier repair of the soft palate only
and later repair of the hard palate.
• The general protocol:

164
•
• Cleft palate
9
• Children with Pierre Robin sequence and any other
children with syndromes that may affect breathing must
be observed closely, even in an ICU setting.
• There are inevitably raw surfaces which may ooze for
12–24 h.
• Bleeding can be reduced by surgery that takes less than
90–120 min because the epinephrine will still have some
effect during emergence from anesthesia.
• Light pressure on the hard palate repair at the conclusion
of the procedure will often control bleeding as well.
• The author has found that application of ice packs to the
posterior neck is almost always effective in stopping
postoperative bleeding in recovery or on the ward.
• Postoperative feeding is generally limited to liquids for
10–14 days, to prevent particulate matter lodging in the
areas that are left open at the end of the procedure.
• The parents must learn to time feeding for 30 min or so
after analgesic administration.
• Arm splints may be used as well to prevent children from
putting their fingers, or more likely foreign objects, in
their mouth.
Complications and outcomes
• Fistula formation is a source of nasal regurgitation of
fluids and may be a source of persistent nasal air loss
even in the face of a functioning soft palate.
• Use of the Furlow repair was shown to markedly reduce
fistulas relative to the V-Y pushback or von Langenbeck
■ Repair of the soft palate at the same time as the cleft
lip repair, around 4–6 months.
• The hard palate is obturated and repaired at about 4–5
years of age.
• Earlier ages have subsequently been proposed for hard
palate repair, usually around 18–24 months.
• The rationale for this approach has been that the hard
palate cleft narrows during the time between procedures,
requiring less dissection and thus resulting in less
maxillary growth disturbance.
Postoperative considerations
• Postoperative hypoxemia is not uncommon, but generally
resolves after 24–48 h.
• The use of a traction suture in the tongue during
the immediate period after extubation may avoid the
need for utilizing any oral devices for maintaining the
airway.
• Some centers use nasal trumpets routinely to improve
ventilation.
• Monitoring with continuous pulse oximetry and
minimizing narcotic use will help to avoid catastrophic
problems.
• Acetaminophen 15 mg/kg alternating with ibuprofen
10 mg/kg will usually give adequate pain relief.
• Any patient who has had prolonged surgery (over 2 h)
with the mouth gag in place should be observed for at
least 48 h for tongue edema.
Figure 9.9  Furlow double opposing Z-plasty. (A) The oral
flap design is shown with the posteriorly based flap on the
left side. If necessary the relaxing incisions can be continued
up to the cleft margin behind the alveolus, similar to the two
flap palatoplasty (Fig. 9.7) for the hard palate closure. (B)
The left sided oral flap is raised with the levator muscle, the
right sided flap above the muscle. The reverse pattern is
planned for the oral side. A vomer flap is shown closing the
nasal mucosa anteriorly. (C) The nasal flaps are transposed
and the anterior oral mucosa closed. (D) The final
appearance after transposition of the oral flaps.
A
B
C
D

165
Further reading
Cutting C, Rosenbaum J, Rovati L. The technique of muscle
repair in the soft palate. Operative Techniques Plast Surg.
1995;2:215–222.
Denny AD, Talisman R, Hanson PR, et al. Mandibular
distraction osteogenesis in very young patients to
correct airway obstruction. Plast Reconstr Surg.
2001;108:302–311.
This clinical series correlates airway measurements before
and after distraction with functional outcomes. The authors
conclude that distraction improves tongue base position such
that airway space is effectively increased.
Emory Jr RE, Clay RP, Bite U, et al. Fistula formation and
repair after palatal closure: an institutional perspective.
Plast Reconstr Surg. 1997;99:1535–1538.
The authors report an 11.5% post-palatoplasty fistula rate.
Local flaps are advocated to repair these lesions.
Furlow Jr LT. Cleft palate repair by double opposing
Z-plasty. Plast Reconstr Surg.1986;78:724.
Furlow describes his palatoplasty in the context of a
22-patient case series. Optimistic speech outcomes are
reported.
Huang MH, Lee ST, Rajendran K. A fresh cadaveric study of
the paratubal muscles: implications for eustachian tube
function in cleft palate. Plast Reconstr Surg.
1997;100:833–842.
Cadaveric dissections were performed to clarify possible
ramifications of palatal clefting on eustachian tube function.
Functional hypotheses are drawn from morphological
findings.
Kaplan EN. The occult submucous cleft palate. Cleft Palate J.
1975;12:356–368.
Robin P. Glossoptosis due to atresia and hypotrophy of the
mandible. Am J Dis Child. 1934;48:541–547.
Rohrich RJ, Byrd HS. Optimal timing of cleft palate closure.
Speech, facial growth, and hearing considerations. Clin
Plast Surg. 1990;17:27–36.
technique; however, the width of the cleft is an important
factor to consider.
• Normal speech is the primary goal of cleft palate repair.
■ In the majority of studies in which some form of
muscle repair is utilized, good speech results are
obtained about 85–90% of the time.
■ Syndromic patients will always have poorer results for
a variety of reasons, but their good outcomes may be
in the 50–60% range.
• Normal maxillary growth is the secondary goal of palate
repair.
■ Avoidance of large raw surfaces on the hard palate
will improve maxillary growth long term, and
minimizing scar tissue will have a salutary effect
as well.
■ Fistula formation requiring additional procedures will
increase scar tissue and often decrease maxillary
growth.
■ The need for maxillary advancement is highly variable,
from 10–40% in non-syndromic cleft patients.
■ Syndromic patients have a higher rate of maxillary
hypoplasia, which may well be genetically determined.
Further reading
Bardach J. The influence of cleft lip repair on facial growth.
Cleft Palate J. 1990;27:76–78.
Chen PK-T, Wu J, Hung KF, et al. Surgical correction of
sub-mucous cleft palate with Furlow palatoplasty. Plast
Reconstr Surg. 1996;97:1136–1146.
Sleep apnea is a recognized adverse outcome of pharyngeal
flaps performed for velopharyngeal insufficiency (VPI). This
report demonstrates that Furlow palatoplasty is a reliable
alternative to pharyngeal flaps for the correction of VPI in
the context of submucous cleft palate.

©2014, Elsevier Inc. All rights reserved.
Chapter
10 
Lower extremity reconstruction
• Extremity salvage is a long and complex process, thus
patient education, motivation, and compliance along with
family support will be critical during physical and
psychological recovery.
• Although early amputation and prosthetic treatment was
thought to offer the potential of faster recovery and lower
cost, recent reports have provided different views.
• The Lower Extremity Assessment Project, or LEAP
study showed no significant difference in outcome at
2 years.
Preoperative considerations
• The primary goal of surgical reconstruction of the lower
extremity wound is to restore or maintain function.
• Although evaluations such as Mangled Extremity
Severity Score (MESS), the Predictive Salvage Index, and
the Limb Salvage Index can assist the team in making a
decision for amputation, it must not be used as a sole
criterion and the decision to amputate must be
individualized for each patient.
• Whether acute or chronic, evaluation of lower extremity
wounds and the eligibility for soft tissue reconstruction
begins with vascular status evaluation.
• If clinical and diagnostic examination reveals inadequate
perfusion and the value of reconstruction is minimal,
amputation should be individually decided.
• An amputated or avulsed tissue should never be
disregarded, especially in acute traumas, unless severely
contaminated or lacking vascular structure.
• The skin harvested from the degloved or amputated part
can be utilized as biologic dressings to permanent skin
grafts.
• The leg length can be preserved using soft tissue
distal from the zone of injury as fillet pedicled or free
flaps.
This chapter was created using content from
Neligan & Song, Plastic Surgery 3rd edition,
Volume 4, Lower Extremity, Trunk and Burns,
Chapter 5, Reconstructive surgery: lower extremity
coverage, Joon Pio Hong.
SYNOPSIS
■ The reconstructive surgery for the lower extremity has evolved
from a staged approach to proving best solutions for functional
and cosmetic outcome.
■ This chapter covers the classical approach with a gradual change
of principle that advocates a one-stage elevator approach.
■ Special considerations should be given to overcome the complexity
of lower extremity reconstruction, such as diabetes and chronic
infection.
■ Finally, introduction of perforator flaps, the use of multiple flaps by
combination, and supermicrosurgery will help you design and
widen the reconstructive choice for the lower extremity.
Brief introduction
• Lower extremity reconstruction following severe trauma,
cancer ablation and chronic infections remains
challenging, as multiple structures including bone,
muscle, vessels, nerves and skin may be involved.
• In the recent years, the management of lower extremity
has evolved with numerous new techniques and
innovations leading to greater salvage opportunities.
• If the extremity cannot be salvaged, the next goal is to
maintain maximal functional length with good soft tissue
coverage on the stump to bear the prosthesis for
functional gait.

167
Anatomical/technical pearls
best form and function rather than a sequential climb up
the ladder (Fig 10.1B).
• Based on the reconstructive elevator, method of
reconstruction should be chosen based on procedures that
result in optimal function as well as appearance.
• The initial evaluation of the lower extremity wound
involves visual and manual examination. Neurological
evaluation as well as vascular and skeletal evaluation is
made to develop a plan for reconstruction.
• After the decision is made to reconstruct the lower
extremity, the first preoperative evaluation should start
with vascular status.
• Physical examination of palpable pulse, color, capillary
refill, and turgor of the extremity allows assessment of
initial status and Doppler examination can provide
additional information.
• The use of preoperative arteriography for lower extremity
reconstruction is considered when physical/Doppler
exam reveals inconclusive vascular status or chronic
vascular disease is suspected.
• The use of computed tomographic angiography may
obtain vascular information of the recipient region
without the risk of complications from arterial puncture
of the groin and also can provide vascular information of
the donor flap facilitating the planning and the surgical
procedure.
• Nerve injuries that are irreversible may require special
considerations.
• Peroneal nerve injuries result in foot drop and loss of
sensation of the dorsum of the foot. Thus lifelong
splinting or tendon transfers may be required.
• Complete loss of tibial nerve function results in loss of
plantar flexion and is an absolute contraindication for
reconstruction.
• The loss of plantar sensation can be devastating and may
hinder the need for reconstruction although it is not an
absolute contraindication.
• An algorithm of approach is outlined in Figure 10.2.
Anatomical/technical pearls
Skin grafts and substitutes
• Autologous skin grafts are used in a variety of clinical
situations.
• The split-thickness grafts are usually used as the first line
of treatment where wounds cannot be closed primarily or
undue tension is suspected.
• In the extremity often with complex wounds, bone
exposure and/or avascular beds, infected wounds,
wound with dead space and poorly coagulated beds, skin
grafts should be avoided.
• A skin substitute is defined as a naturally occurring or
synthetic bioengineered product that is used to replace
the skin in a temporary, semi-permanent or permanent
fashion.
• Temporary epidermal replacements may be beneficial in
superficial to middermal depth wounds.
• Amputated bones can be banked or used as a flap to
reconstruct the leg.
• Once the wound is evaluated to have good vascular
supply, stable skeletal structures and a relatively clean
wound, soft tissue coverage is then considered.
• The concept of reconstructive ladder was proposed to
achieve wounds with adequate closure using a stepladder
approach from simple to complex procedures (Fig. 10.1A).
• Although still valued and widely taught, in the era of
modern reconstructive surgery, one must consider not
only adequate closures but form and function.
• Thus a simpler reconstructive option may not necessarily
produce optimal results, which is especially true for
lower extremity coverage, where consequences of
inadequate coverage will lead to complications such as
additional soft tissue loss, osteomyelitis, functional loss,
increased medical cost and even amputation.
• The reconstructive elevator requires creative thoughts
and considerations of multiple variables to achieve the
Figure 10.1  The reconstructive elevator requires creative thoughts and
considerations of multiple variables to achieve the best form and function rather
than a sequential climb up the ladder. This paradigm of thought does not eliminate
the concept of reconstructive ladder but replaces it as a ladder of wound closure
and makes its mark in the field where variety of advanced reconstructive procedures
and techniques are not readily available. Based on the reconstructive elevator,
method of reconstruction should be chosen based on procedures that result in
optimal function as well as appearance.
Reconstructive ladder
Reconstructive elevator
Complex
Simple
Complex
Simple
Free flaps
Distant flaps
Local flaps
Skin grafts
Direct closure, secondary intension
Free flaps
Distant flaps
Local flaps
Skin grafts
Direct closure, secondary intension,
negative pressure wound therapy
B
A

168
•
• Lower extremity reconstruction
10
■ Vertical rectus abdominis muscle or myocutaneous flap
using the deep inferior epigastric artery.
■ The gracilis muscle or myocutaneous flap based on the
medial femoral circumflex artery may lack muscle bulk
but is a good option when the dead space is not
extensive.
• Now with increased knowledge of perforator and
perforator based flaps, basically any perforator can be
chosen as a source of vascular supply to the skin flap and
be rotated to cover a defect.
• When the use of local flaps is not feasible due to the
complexity of the wound, free tissue transfer is indicated.
• The midthigh wound, due to the anatomical character
where femur is surrounded by a thick layer of soft tissue,
rarely requires reconstruction using free tissue transfer
and often is sufficiently reconstructed by skin graft or
local flap.
• Local muscle or musculocutaneous flaps based on the
lateral or medial femoral circumflex artery can be used
when available.
• Any perforator can be chosen as a source of vascular
supply to the skin flap and rotated to cover a defect.
• If the patient has undergone massive resection or has
special considerations such as postoperative radiation
therapy, it may warrant free tissue coverage.
• Examples: EZ-derm and Mediskin (Brennen Medical-
LLC, St Paul, MN), and Biobrane (UDL Laboratories Inc,
Rockford, Illinois)
• In deeper wounds, dermal replacements are of primary
importance.
• Examples: Allograft, Alloderm (Life Cell Corporation,
Woodlans, TX), Integra (Integra Life Sciences, Plainsboro,
NJ), and Apligraf (Organogenesis Inc, Canton, MA).
Approach by location (local flaps)
Thigh
• The thigh can be divided into three parts: the proximal
thigh, midthigh, and the distal thigh (supracondylar
knee) regions.
• The medial portion of the proximal thigh can be
especially challenging due to the location of vital
structures and the likely formation of dead space.
• Local lower extremity muscle or myocutaneous flap
options include:
■ Using the flaps based from the lateral circumflex
femoral artery such as tensor fascia lata, vastus
lateralis, and rectus femoris flaps.
Figure 10.2  Algorithm of approach for soft tissue
reconstruction of lower extremity.
Yes
Bypass graft
Angioplasty
Debridement and
establish bone stability
Vascular supply
Amputation
Amputation
No
Complete disruption of
posterior tibial n. Ischemic leg
(ischemic time greater than 6 hours)
Serial debridement
Negative pressure
Wound therapy
Conservative wound care
Negative pressure wound therapy
Hyperbaric oxygen therapy
Inadequate
Adequate
Inadequate
wound bed
Adequate
wound bed
Inadequate
wound bed
Adequate
wound bed
Skin graft
Cross leg flap
Elective
reconstruction

169
Anatomical/technical pearls
significant daily distances, thus maintaining good quality
of life.
• Though the ideal stump length below the knee is more
than 6 cm, any length of tibia should be preserved.
• If adequate soft tissue exists, the stump may be closed
primarily and where local tissue is inadequate,
microsurgery allows preserving maximal length of the
stump.
• If the tissue distal to the amputation is usable, a fillet flap
can be performed.
• Other flaps such as muscle, musculocutaneous,
fasciocutaneous and perforator flaps can be used.
• Muscle flaps may have a tendency to heal slowly and to
shrink due to muscle atrophy, while skin flaps may
provide better contour and sensibility.
Debridement
• Bony stability is first established using external or
internal fixation devices.
• An external device is usually preferred if there is
significant bone loss or bone devascularization and may
facilitate coverage procedure.
• Debridement must cover devitalized soft tissue and bone
and be performed until fresh bleeding is noted.
• Multiple stages of debridement may be needed to achieve
adequate wound bed prior to soft tissue coverage.
• The vacuum-assisted closure can be used to optimize the
wound bed and minimize dressing changes until
definitive reconstruction.
Timing of reconstruction
• Regardless of the degree of contamination and extent of
injury when indicated for salvage, there is no need to
delay definitive coverage provided that the general
condition of the patient and the status of the wound
allow it.
• General consensus favors early aggressive wound
debridement and soft issue coverage.
• Ideally, the wound is covered in the first 5–6 days after
injury at the acute phase of the wound.
• Godina further demonstrated that radical debridement
and coverage within 72 h results in best outcome where
only 0.75% of flaps fail, 1.5% are infected, and 6.8 months
are needed for union of the bone.
• The common idea behind early intervention is that it
minimizes the risk for increasing bacterial colonization
and inflammation leading to complications.
• Acute coverage by day 5–7 is generally accepted as
having a good prognosis in terms of decreased risk of
infection, flap survival, and fracture healing.
Selection of recipient vessel
• Many lower extremity wounds resulting from trauma are
high-energy injuries with a substantial “zone of injury.”
• This thrombogenic zone is known to extend beyond what
is macroscopically evident, and failure to recognize the
• The wounds of the distal thigh (supracondylar knee) can
be very difficult due to the limit of rotation from
previously described local muscle or musculocutaneous
flaps from the thigh.
• Pedicled medial gastrocnemius muscle or
musculocutaneous flap from the lower leg can be
extended to cover this region.
• Extensive or complex defects may require free tissue
transfer or coverage using a perforator based rotation/
advancement skin flap.
Lower leg
• The traditional planning for reconstruction of the lower
extremity has been approached according to the location
of the defect.
• Divided into thirds, gastrocnemius muscle flap for
proximal third, soleus muscle flap for middle third and
free flap transfer for the distal third of the leg.
• Like the reconstructive ladder concept, this traditional
approach can be useful but the surgeon must
individualize each wound and choose the initial
procedure that can yield the best chance of success and
avoid morbidity.
Microvascular free tissue transfer
• Workhorse flaps for soft tissue coverage include muscle
or musculocutaneous flaps such as latissimus dorsi,
rectus abdominis, and gracilis.
• The perforator flap, where a skin flap is based on a single
or multiple perforators, such as the anterolateral thigh
flap or thoracodorsal artery perforator flap have been
added on to the list.
• Whichever flap you select, the guidelines for lower
extremity reconstruction using free flaps remain the same:
■ Anastomose the vessel outside the zone of injury.
■ Make end-to-side arterial anastomosis and end-to-side
or end-to-end venous anastomosis.
■ Reconstruct the soft tissues first and then restore the
skeletal support.
Primary limb amputation
• Absolute indications include: anatomically complete
disruption of the posterior tibial nerve in adults and
crush injuries with warm ischemia time greater than 6 h.
• Relative indications include: serious associated
polytrauma, severe ipsilateral foot trauma, and
anticipated protracted course to obtain soft tissue
coverage and tibial reconstruction.
• In these cases where limb salvage is not possible,
attempts should be made to salvage as much limb length
as possible.
• Every effort should be made to save the functional knee
joint as below-knee amputation results in far superior
ambulatory outcome and up to 2–3-fold more full
mobility compared to above knee amputation.
• The energy consumption is far less for below-knee
amputation and this allows these patients to walk

170
•
• Lower extremity reconstruction
10
• Large and composite diabetic wounds must be
aggressively debrided, including the necrotic bone,
and covered with well-vascularized tissue.
Coverage after tumor ablation
• As with any reconstructive procedure, the aim of
reconstruction after tumor ablation is to maintain quality
of life by preserving function and achieving acceptable
appearance.
• In addition, coverage must be able to withstand adjuvant
therapy with radiation therapy and/or chemotherapy
and play a role in achieving long-term local control of
disease.
• Skin grafts are always an option especially for very
extensive defects where flap coverage is not available.
• For wounds scheduled for postoperative radiation
therapy or located over joints and high friction regions,
skin graft should be avoided and be reconstructed with a
durable flap.
• Special consideration should be made to preoperative
radiation therapy where skin would become fibrotic and
ischemic around the cancer and thus will not allow local
coverage.
• Various flaps from omentum, muscle with skin graft,
musculocutaneous, and perforator flaps can be used for
reconstruction depending on location, size, depth,
adjuvant therapy, function, and cosmetic appearance
(Fig. 10.4).
true extent of this zone is cited as a leading cause of
microsurgical anastomotic failure.
• Isenberg and Sherman demonstrated that clinical
presentation of recipient vessel (vessel wall pliability and
the quality of blood from transected end of vessel) was
more important than the distance from the wound.
• Based on these findings, one of the most important
factors in selecting the recipient vessel may be the
vascular quality itself.
Special considerations
Osteomyelitis
• Osteomyelitis often follows severe open leg fractures
with massive contamination or devascularized soft tissue
and bone. Inadequate debridement or delayed coverage
of the wound increases the chance for osteomyelitis and
early debridement remains to be the key to prevention.
• To achieve the goal of infection control and the
restoration of function, treatment principles for chronic
osteomyelitis are debridement including the complete
resection of involved bone, flap coverage with
vascularized tissue, and brief course of antibiotic
treatment.
• Although there has been controversy in selecting the type
of flap for coverage, muscles have shown experimentally
to have increased blood flow and antibiotics delivery,
increased oxygen tension, increased phagocytic activity,
and decreased bacterial counts in wounds reconstructed
with muscle flaps rather than fasciocutaneous flaps.
• Clinically, complete debridement and obliteration of dead
space are the most important steps to treat osteomyelitis
and the type of flap seems less crucial.
■ Bone defects can be managed with vascularized bone
flap, secondary bone grafting, bone distraction
lengthening or a combination of these techniques.
■ Not all chronic osteomyelitis can be salvaged. As with
the indication for amputation, legs with nerves too
damaged after osteomyelitis should not be salvaged.
Diabetes
• Patients with diabetes require additional concerns from
chronic renal failure, nutrition to blood sugar control and
are best approached by a multidisciplinary team.
• Patients will frequently have chronic bacterial
colonization, osteomyelitis, complex wounds, bone
deformity, local wound ischemia and vascular disease.
• When patients with diabetes are required to undergo a
reconstructive procedure of the extremity, vascular status
must be evaluated to ensure success.
• Any vascular problems must be addressed first and
corrected. If not correctable, the surgeon may be faced
with a high risk of failure.
• One must consider the probability of successful
reconstruction, based on eliminating the underlying
problems of the diabetic wound and also take into
account long-term ambulation after reconstruction
(Fig. 10.3).
Figure 10.3  Algorithm for diabetic foot reconstruction.
Systemic condition
and wound evaluation
Small/shallow
Large/deep
Simple
Complex
Reliable
Unreliable
Free flap
Bypass surgery
Conservative
care
Skin graft/
local flap
Evaluate
vascular status
Surgical
(salvage) care
Failure
No benefit
Failure
Amputation
Out patient program
Failure

171
Operative techniques
• The potential advantages of using expanded skin in the
lower extremity include improved contour, coverage with
like tissue, and improved aesthetic result.
• However, use in the lower extremity has been associated
with high rate of infection and extrusion of the implant.
• The technique can be reserved for unstable soft tissues or
scars of moderate size.
• The implant is placed suprafascially in the subcutaneous
pocket in the lower extremity and application on the
ankle and foot region must be avoided.
• Transverse expansion has a lower failure rate compared
to longitudinal advancement.
• For avoidance of wound dehiscence, neurapraxia,
and fat necrosis, expansion should proceed slowly,
stopping before the onset of pain or, if it is
measured, before intraexpander pressure exceeds
40 mmHg.
• Flap prefabrication with tissue expansion may have a role
in select reconstructions of the lower extremity.
Operative techniques
Muscle/musculocutaneous flaps
Tensor fascia lata
• The tensor fascia lata is a small, thin and short muscle
with a long fascial extension from the iliotibial tract of the
facia lata to the lateral aspect of the knee.
Exposed prosthesis
• The traditional method to manage exposed hardware
includes irrigation, debridement, antibiotics, and likely
removal of hardware.
• Factors such as location of the hardware, infection (type
of bacteria and duration of infection), duration of
exposure of hardware, and hardware loosening should be
considered as important prognostic factors for successful
management of exposed hardware.
• If hardware is clinically stable, time of exposure is less
than 2 weeks, infection is controlled, and the location of
the hardware is for bony consolidation, then it may
increase the likelihood of salvage of hardware using
surgical soft tissue coverage.
• Exposed vascular grafts present life- and limb-threatening
complications. It should be managed with early
debridement and muscle flap coverage to salvage the
graft.
• Local muscle flaps such as gracilis, sartorius, and tensor
fascia lata are very useful in providing adequate coverage
for exposed groin synthetic vascular prosthesis.
• If the defect is extensive and inferiorly based, a vertical
rectus abdominis musculocutaneous flap can be
considered.
Soft tissue expansion
• The use of tissue expansion in the lower extremity has
not been successful as in other areas of the body, such as
the breast and scalp.
Figure 10.4  (A) A patient with soft tissue sarcoma of the knee region was noted. (B,C) After wide excision including the bone, a hemi-gastrocnemius muscle was elevated
to resurface the knee joint. (D) Long-term results show good contour with acceptable function and appearance.
A
B
C
D

172
•
• Lower extremity reconstruction
10
• The skin overlying the muscle and fascia lata can be
harvested as a unit with the flap and can extend to
within 10 cm above the knee.
• The marking begins by identifying the major landmarks:
the anterior superior iliac spine, lateral condyle of femur,
and the pubic tubercle.
• A line from the anterior superior iliac spine straight
down the thigh to a point 10–12 cm above the knee
joint, presents the anterior border of the flap and a
parallel line 12–15 cm posterior to the first line is drawn
straight down the thigh, curving anteriorly as it crosses
posterior to the lateral epicondylar area to meet at the
same point.
• The skin island can be designed within this long strip,
according to the needs and distance to the recipient
defect.
• The distal margin of the flap is entered, carrying the
incision through the fascia lata and dissecting deep to the
fascia lata and iliotibial tract.
• The pedicle is located approximately 10 cm below the
anterior iliac spine along the line drawn.
• One must modify the flap when composite tissues are
taken for reconstruction.
Rectus femoris
• The rectus femoris is located superficially on the middle
of the anterior thigh, extending between the ilium and
patella.
• It is a central muscle of the quadriceps femoris extensor
muscles group and acts to extend the leg at the knee.
• The muscle originates with two tendons, one from the
anterior inferior iliac spine and one from the acetabulum
and inserts to the patella.
• It is a thigh flexor and a leg extensor important in
stabilizing the weight-bearing knee, thus is not
considered expandable.
• It has a type II pattern of circulation (the dominant
pedicle is the descending branch of the lateral circumflex
femoral artery with minor pedicles from the ascending
branch of the same vessel as well as from muscle
branches of the superficial femoral artery) and can reach
to cover the inferior abdomen, groin, perineum and
ischium.
• Motor innervation is from the femoral nerve, and muscle
branches enter adjacent to the dominant pedicle.
• This motor innervation and the adequate dimension of
the flap allow it to be used as a functional muscle flap
(Fig. 10.6).
• The intermediate anterior femoral cutaneous nerve (L2–3)
provides sensation. The skin perforators are most reliable
over the midanterior two-thirds of the muscle itself in the
central strip up to 12 × 20 cm.
• A longitudinal incision is marked from 3 cm below the
anterior superior iliac spine to just above the superior
margin of the patella.
• With the anterior thigh muscle contraction, the lateral
border of the vastus medialis and the medial border of
the vastus lateralis is visualized, creating a depression
of skin.
• The muscle originates 5–8 cm anterior of the
external lip of the anterior superior iliac crest
immediately behind sartorius and inserts to the
iliotibial tract.
• It abducts, medially rotates, and flexes the hip, acting to
tighten the fascia lata and iliotibial tract but is an
expendable muscle.
• Its flat shape, excellent length, and reliable type I
circulation pattern (dominant pedicle is the ascending
branch of the lateral femoral circumflex artery and venae
comitantes) make it useful in many reconstructive
scenarios, both as a pedicled flap for local and regional
coverage and as a free, composite unit that incorporates
skin, muscle, and iliac bone.
• Motor innervation is from the superior gluteal nerve
entering the deep surface between the gluteus medius
and gluteus maximus. Sensation is derived from T12
which innervates the upper skin territory and the lateral
femoral cutaneous nerve of the thigh (L2–3) innervates
the lower skin.
• When based on the dominant pedicle, located 8–10 cm
below the anterior superior iliac spine, the anterior
arc of location will reach the abdominal areas, groin,
and perineum while the posterior arc can reach the
greater trochanter, ischium, perineum, and sacrum
(Fig. 10.5).
• The flap can also be advanced superiorly as a V-Y flap to
cover trochanteric wounds.
Figure 10.5  Tensor fascia lata flap elevation. When based on the dominant
pedicle, located 8–10 cm below the anterior superior iliac spine, anterior arc of
location will reach the abdominal areas, groin, and perineum while the posterior arc
can reach the greater trochanter, ischium, perineum, and sacrum.
Tensor fascia lata
Branch from
superior gluteal
nerve
“Transverse”
branch of lateral
femoral circumflex
artery to TFL
Vastus lateralis
Rectus femoris

173
Operative techniques
together above the patella in an effort to preserve full
knee extension.
Biceps femoris
• This large, well-vascularized posterior muscle of the mid
and lateral thigh is useful for the coverage of ischial
pressure sores.
• The muscle has two heads: the long head originates on the
ischial tuberosity and the short head originates on the linea
aspera of femur and both insert onto the head of fibula.
• The long head extends the hip, and both heads flex the
leg at the knee and thus is not expandable.
• The pattern of circulation is type II (the long head has
dominant and minor pedicles from the first and second
perforating branches of the profunda femoris artery,
respectively, and the short head receives the second (or
third) perforating branch of the profunda and a minor
source from the lateral superior geniculate artery) and
can be turned over to cover the ischial regions based on
the dominant pedicle.
• The long head derives its motor innervations from the
tibial division of the sciatic nerve, the short head from the
peroneal division of the sciatic nerve. The postcutaneous
nerve of the thigh (S1–3) supplies the sensation.
• The entire skin of the posterior thigh can be elevated and
advanced in V-Y fashion as a musculocutaneous unit.
• The upper base of the skin flap is horizontally marked
along the buttock crease and the apex just above the
popliteal fossa.
• The relatively short pedicles make the flap unsuitable for
wide rotation flaps but serve well in sliding the muscle
proximally along the femur towards the pelvis.
• The medial thigh skin may also be left uncut, preserving
skin as a rotation advancement modification of the flap.
• With the skin island isolated, the tendon is divided
distally and the dissection proceeds from the distal thigh
towards the ischium, freeing the muscle on its deep
aspect from the femur and from the adductor group of
muscles medially, until enough mobility is attained so
that the defect can easily be filled.
• The flap should be inset and sutured with the patient in a
jack-knife position and the hips flexed to prevent
dehiscence of the flap.
Gracilis
• Located on the medial thigh extending between the pubis
and the medial knee, it is a thin and flat muscle which
lies between the adductor longus and sartorius muscle
anteriorly and the semi-membranous posteriorly.
• It originates on the pubic symphysis and inserts into the
medial tibial condyle.
• The gracilis function is a thigh adductor but is
expandable from the compensation made from abductor
longus and magnus muscle.
• The muscle has a type II circulation pattern (the
dominant pedicle is the terminal branch of the medial
circumflex femoral artery and one or two minor pedicles
arise as branches of the superficial femoral artery) and
• The tendon of the rectus femoris can be easily noted
below the depression and above the patella.
• The skin island should be designed on the middle-third
of the thigh as the majority of the perforators are located
in this region.
• Incision at the distal edge of the skin island, along the
axis allows the rectus femoris muscle to be identified and
separated from the vastus medialis and lateralis.
• The skin island is then incised circumferentially down to
the fascia of the muscle.
• The rectus is elevated from distal to proximal and from
medial to lateral so that the pedicle and nerve can be
identified and protected medially along the underside of
the muscle.
• The dominant pedicle enters the posterior medial muscle
at a variable distance of 7–10 cm below the symphysis
pubis and care must be given to preserve the motor
branches from the femoral nerve to the adjacent vastus
lateralis and tensor fascia lata.
• The donor area should be repaired by careful suturing of
the tendinous fascia of the vastus medialis and lateralis
Figure 10.6  Rectus femoris muscle flap elevation. It is a type II pattern of
circulation (the dominant pedicle is the descending branch of the lateral circumflex
femoral artery with minor pedicles from the ascending branch of the same vessel as
well as from muscle branches of the superficial femoral artery) and can reach to
cover the inferior abdomen, groin, perineum and ischium.
Rectus femoris
Pectineus
Adductor longus
Vastus medialis
Vastus lateralis
Lateral circumflex
artery (descending
and transverse
branches)

174
•
• Lower extremity reconstruction
10
• Tendinous insertion of semi-membranous and semi-
tendinosus muscle can be indentified posterior to the
gracilis.
• Traction on the tendon will highlight the proximal outline
of the muscle and allow accurate estimation of the
location.
• This is an important step to minimize faulty elevation of
the skin component, as the medial thigh is mobile and
makes it easy to incorrectly predict the skin position over
the muscle.
• Dissection of the anterior and posterior skin borders then
proceed proximally, approximately half the length of the
muscle, whereby the distal tendon is divided and the
distal muscle elevated.
• During the elevation of the middle and distal third of the
flap, one or two minor perforators from the superficial
femoral artery will be identified and ligated.
• Retraction of the adductor longus muscle will expose the
major pedicle passing over the deep adductor magnus,
approximately 10 cm below the pubic symphysis.
Soleus
• The soleus is a very broad, large bipenniform muscle
lying deep to the gastrocnemius muscle.
• The muscle has two muscle bellies, medial and lateral,
separated by a midline intramuscular septum in the
distal half.
• The lateral belly originates from the posterior
surface of the head of the fibula and posterior
surface of the body of the fibula and the medial belly
originated from the middle-third of the medial border
of the tibia.
• Both bellies of the soleus insert into the calcaneus bone
through the Achilles tendon.
• It contributes to the plantar flexion of the foot. Soleus is
expandable, taken that at least one head of gastrocnemius
is intact with function.
can reach to cover the abdomen, ischium, groin,
and perineum as a muscle or musculocutaneous
flap (Fig. 10.7).
• Motor innervation is from the anterior branch of the
obturator nerve and enters the gracilis on its deep medial
surface immediately superior to the entry of the
dominant pedicle.
• The motor nerve allows gracilis to be used as a functional
muscle flap for facial reanimation and upper extremity.
• The sensory innervation is from the anterior femoral
cutaneous nerve (L2–3), which provides sensation to the
anterior medial thigh.
• When skin is harvested with the gracilis muscle, the flap
is generally oriented longitudinally and centered over the
proximal third of the muscle, where the majority of the
musculocutaneous perforators are located.
• A proximal transversely oriented skin flap is optional and
the bulky fat of the medial thigh makes this flap suitable
for breast reconstruction.
• The symphysis pubis and the medial condyle of the
femur are major landmarks.
• The muscle extends the full length of the medial thigh
and averages about 6 cm in width proximally and tapers
to about 2–3 cm in the distal third of the muscle.
• Although the width may be narrow, the muscle can be
fanned out to provide coverage over larger defects.
• With the patient in lithotomy position and slight
extension of the knee allows the gracilis to be seen and
felt, and it tends to be more posterior than expected.
• For muscle elevation, an incision is made 2–3 cm
posterior to the line drawn connecting the symphysis
pubis and medial condyle of the knee.
• The muscle is identified posterior to the adductor longus.
• If a skin flap is planned, the skin territory should be
designed on the proximal part of the inner thigh.
• Usually, the dissection is easily approached by distal
incision identifying the tendon of the gracilis posterior to
the saphenous vein and the distal sartorius muscle.
Figure 10.7  Gracilis muscle flap elevation. It is a type II
circulation pattern (the dominant pedicle is the terminal branch
of the medial circumflex femoral artery and one or two minor
pedicles arise as branches of the superficial femoral artery) and
can reach to cover the abdomen, ischium, groin, and perineum as
a muscle or musculocutaneous flap.
Medial femoral
circumflex artery
Adductor longus
Adductor brevis
Branch from
obturator nerve
Abductor magnus
Sartorius
Semi-membranous
Gracilis
Gracilis
tendon (cut)

175
Operative techniques
• The lateral reversed hemisoleus has a tenuous blood
supply through minor perforators from the peroneal and
a shorter arc of rotation.
• The distal half of the muscle can be reversely transposed
based on minor segment pedicles and cover the distal
third of the leg.
• The medial border of the tibia is the landmark for medial
exposure and the fibula itself is the landmark for lateral
exposure.
• A line can be drawn 2 cm medial to the medial edge of
tibia or laterally along the fibula.
• Subcutaneous neurovascular structures are identified and
preserved, and the posterior compartment fascia is
opened.
• The plane between the soleus and gastrocnemius is
usually well-defined superiorly, but sharp scalpel
dissection is needed to separate the tendons and
maintain the gastrocnemius contributions to the
Achilles tendon.
• The pattern of circulation is type II (with dominant
pedicles from the popliteal, posterior tibial and
peroneal arteries and the minor pedicles rise from
the posterior tibial and peroneal arteries supplying
the distal, medial and lateral bellies, respectively),
and can cover the middle and lower-third of the leg
(Fig. 10.8A).
• Motor nerve is derived from the posterior tibial and
popliteal nerves.
• The arc of rotation for a proximally-based soleus flap
after division of minor pedicles and elevation of the
distal two-thirds of the muscle can cover the middle-third
of the tibia.
• Hemisoleus flaps may improve the arc of rotation
and preserve soleus function while sacrificing flap
coverage area.
• The medial reversed hemisoleus pivots around the most
superior distal minor perforator of the posterior tibial
artery, approximately 7 cm above the malleolus.
Figure 10.8  Soleus muscle flap elevation. (A) It is a type II circulation pattern (with dominant pedicles from the popliteal, posterior tibial, and peroneal arteries and the
minor pedicles rise from posterior tibial and peroneal arteries supplying the distal, medial and lateral bellies, respectively) and can cover the middle and lower-third of
the leg. (B–D) A patient with chronic osteomyelitis of the middle-third of the tibia is reconstructed using a hemi-soleus flap.
A
B
C
D

176
•
• Lower extremity reconstruction
10
• The dissection starts at the medial edge of the
gastrocnemius muscle and plantaris can be
easily noted below the gastrocnemius and above
the soleus.
• The midline muscular raphe is located, and with finger
dissection, the underlying soleus muscle is separated
from the gastrocnemius proximally and distally.
• The musculotendinous raphe is then separated sharply.
• Distally, the thick tendinous layer is sharply dissected
free from the remaining calcaneal tendon.
• The transaction of the origin of the muscle allows
increased freedom.
• If a tunnel is made over the lateral proximal leg, care
must be given not to violate the deep peroneal nerve.
• For proximally based flaps, distal perforators are
divided in the deep plane, and the tendon is divided
distally.
• The dominant pedicle is usually located on the
upper third of the muscle for both bellies of the
soleus.
• Identification and dissection of the midline raphe allow a
hemisoleus flap to be developed (see Fig 10.8B–D).
Gastrocnemius
• The most superficial muscle of the posterior calf, the
gastrocnemius has two heads, medial and lateral, which
form the distal boundary of the popliteal space.
• Each head can be used as a separate muscle or
musculocutaneous unit, based on its own pedicle.
• The medial head originates from the medial condyle of
the femur and the lateral from the lateral condyle of the
femur and both heads insert to the calcaneus through the
Achilles tendon.
• It contributes to the plantar flexion of the foot and either
or both heads of the gastrocnemius are expandable if the
soleus is intact.
• The pattern of circulation is type I (the medial muscle is
supplied by the medial sural artery and the lateral
muscle is supplied by the lateral sural artery) and
provides reliable coverage to the upper third of the tibia,
suprapatellar thigh, and knee regions (Fig. 10.9).
• Motor innervation derives from branches of the tibial
nerve.
• The sensation to the skin overlying the medial head is
from the saphenous nerve and that to the lateral and
distal skin overlying the lateral head is from the sural
nerve.
• The arc of rotation of the medial head after complete
elevation can cover the inferior thigh, knee, and upper
third of the tibia.
• When origin of the muscle is divided, an extended arc of
rotation by 5–8 cm can be achieved to extend to the
upper part of the knee.
• The lateral head can be elevated to cover the
suprapatellar region, knee and proximal third of
the tibia.
• It also can be extended with the division of the
muscle origin. Both heads can be inferiorly rotated,
based on the vascular anastomosis across the raphe
between the two muscle heads to reach the middle
third of the leg.
• A skin paddle can be designed based on the perforating
vessels with dimension of 10 × 15 cm for the medial and
8 × 12 cm for the lateral head.
• A line is drawn either 2 cm medial to the medial edge of
the tibia or along the posterior midleg.
• If the muscle alone is employed, a midline posterior
incision affords excellent access to both heads.
• During elevation, care is taken to protect the
neurovascular structures, especially the more superficial
saphenous and sural nerves.
• In the proximal third, medial surface of the medial head
is easily separated from the soleus.
Figure 10.9  Gastrocnemius flap elevation. It is a type I circulation pattern (the
medial muscle is supplied by the medial sural artery and the lateral muscle is
supplied by the lateral sural artery) and provides coverage to the upper-third of the
tibia, suprapatellar thigh, and knee regions.
Medial sural artery,
nerve, and vein
Lateral sural nerve,
vein, and artery
Common
peroneal nerve
Medial head of
gastrocnemius (cut)
Lateral head of
gastrocnemius (cut)
Small saphenous
vein and sural
cutaneous nerve
retracted
Soleus
Gastrocnemius
insertion (cut)

177
Operative techniques
Fasciocutaneous/perforator flap
• A perforator flap is defined as a flap based on a
musculocutaneous perforating vessel that is directly
visualized and dissected free of surrounding muscles and
an adequate pedicle length is achieved.
• This kind of flap that may be based on any perforator,
“freestyle free flap”, allows the freedom of flap selection
from anywhere on the body.
• Although this is a very useful flap, it provides limited
coverage.
• Further advancement by Koshima et al. where the flap
and the pedicle is taken above the fascia as a perforator
flap, truly allows the donor site to have minimal
morbidity.
• Anastomosis can be difficult with the vessel’s diameter
<1 mm, hence this technique is known as
supermicrosurgery.
• Hong and Koshima have also stretched the boundary of
microsurgery opening the possibility of using perforators
as recipient vessels, and introduced the concept of “free
style reconstruction”.
• Since the basic approach may be similar, the
septocutaneous and perforator flaps will be discussed
together when necessary.
Groin/SCIP (superficial circumflex iliac perforator)
• The groin flap may be elevated extending between the
femoral vessels and the posterior iliac spine.
• The dominant pedicle is the superficial circumflex iliac
artery, and venae comitantes and superficial circumflex
iliac vein (Fig. 10.10).
• The pedicle is very short, i.e., up to only 3 cm.
• Koshima defined that the SCIP flap is different
from the groin flap in that it is nourished by only a
perforator of the superficial circumflex iliac system
(Fig. 10.11).
• The T12 sensory innervation is at the lateral margin of
the flap away from the pedicle, precluding use as a
sensate flap.
• The long axis of the flap is centered over a line parallel
and 3 cm inferior to the inguinal ligament with a flap
width of 6–10 cm.
• The flap can be used as a free or pedicled flap.
• For pedicled flaps, the dissection should proceed from
lateral to medial and distal to proximal.
• Elevation is begun in a plane superficial to fascia lata and
when the sartorius muscle is visualized, the flap is
elevated deep to the fascia and superficial to the muscle.
• The perforator flap is elevated suprafascially until a
sizable perforator is located and is used either as a
pedicled or free flap.
• The groin flap as a septocutaneous flap provides a large
amount of skin and soft tissue and may need debulking
where excess tissue is not needed.
• The donor site is well tolerated and well hidden, but the
pale skin and frequent hair growth of the donor site
make for a poor match, particularly with head and neck
reconstructions.
A
B
Inguinal ligament
Superficial
circumflex
iliac artery
Sartorius
Saphenous vein
Superficial
circumflex
iliac artery
and vein
Sartorius
fascia
Figure 10.10  Groin flap elevation. The dominant pedicle is the superficial
circumflex iliac artery (A), and venae comitantes and superficial circumflex iliac
vein (B).
Medial thigh/anteromedial perforator and
gracilis perforator
• The medial thigh flap located at the midthigh: the
dominant blood supply for this fasciocutaneous flap is
the anterior septocutaneous artery and venae comitantes
from the superficial femoral artery and vein at the apex
of the femoral triangle (Fig. 10.12).
• The coverage extends to the abdomen, groin, and
perineum.
• The saphenous vein may be elevated with the flap for
improved venous drainage.
• The sensory innervations are from the medial anterior
cutaneous nerve of the thigh (L2–3).

178
•
• Lower extremity reconstruction
10
• When the flap is moved proximally to the groin, a
perforator from the gracilis muscle is found originating
from the profunda femoris vessel or the medial femoral
circumflex vessel.
• All these flaps can be elevated as a perforator-based
flap and named a medial thigh perforator flap,
anteromedial thigh perforator flap, and gracilis
perforator (medial circumflex femoral artery perforator)
flap, respectively.
• For the medial thigh septocutaneous flap, the dominant
pedicle is typically located at the apex of the femoral
triangle approximately 6–8 cm below the inguinal
ligament and is bordered medially by the adductor
longus and laterally by the sartorius.
• A proximal incision is made to locate the vessels at the
apex of the femoral triangle. The remainder of the flap is
then incised and elevated subfascially.
Lateral thigh/profunda femoris perforator
• The lateral thigh flap located along the lateral aspect of
the thigh between the greater trochanter and the knee can
be based on the three perforating branches of the
profunda femoris (Fig. 10.13).
• The first perforator arises just below the insertion of the
gluteus maximus and flaps based on this perforator are
• When the flap is based more anteriorly, it is termed the
anteromedial thigh flap and is based on a branch of the
lateral femoral circumflex artery emerging from the
lateral border of the sartorius.
• Minor pedicles are contributed by musculocutaneous
perforating vessels of the sartorius and gracilis muscles.
Figure 10.11  The SCIP flap is nourished by only a perforator of the superficial
circumflex iliac system. A large dimension of skin from the inguinal region can be
sufficiently supplied by a single perforator.
A
B
Figure 10.12  The medial thigh flap located at the midthigh. The dominant blood
supply for this fasciocutaneous flap is the anterior septocutaneous artery and venae
comitantes from the superficial femoral artery and vein at the apex of the femoral
triangle.
Perforating branch to
fasciocutaneous flap
Superficial femoral artery
Gluteus
Profunda femoral
artery (deep)
IIiotibial tract
Vastus lateralis
Biceps femoris
3rd perforating
branch of profunda
femoral artery
Figure 10.13  The lateral thigh flap. It is located along the lateral aspect of the
thigh between the greater trochanter and the knee and can be based on the three
perforating branches of the profunda femoris.

179
Operative techniques
• The perforator frequently dissected is usually located on
the midpoint of the line drawn between anterior superior
iliac spine and superior lateral border of the patella.
• The perforator branches are identified with Doppler near
the midpoint of this line.
• According to our clinical experience, about 90% of
perforators are found within 3 cm diameter drawn at the
midpoint of the line.
• The skin flap is designed to include the perforator and
then elevated from the medial border.
• The flaps can be as large as 35 × 25 cm, based on a single
perforator.
• The incision is made through the deep fascia and raised
subfascially until the intermuscular septum between the
rectus femoris and vastus lateralis muscle is reached.
• Now with increased knowledge of the perforator flap
anatomy, flaps can be easily elevated suprafascially
taking just a small cuff of fascia.
• At that point, the descending branch of the lateral
femoral circumflex is explored along with the perforator
to the skin flap.
• The flap can be harvested, either as a perforator flap
including only the perforator branch to the skin or
combined with the vastus lateralis muscle, as a
musculocutaneous flap.
• The skin paddle may be defatted according to the need
up to 3–4 mm thickness, except for the portion which the
perforator branch enters (Fig. 10.15).
• The motor branch of the femoral nerve running medial to
the descending branch of the lateral circumflex femoral
artery should be preserved.
• To elevate as a sensate flap, a branch of the lateral
femoral cutaneous nerve should be included. The donor
site can be primarily closed depending on the laxity of
the skin.
Sural
• The sural flap is located between the popliteal fossa and
the midportion of the leg over the midline raphe between
the two heads of the gastrocnemius muscle.
• It is one of the longest fasciocutaneous flaps of the lower
leg based on the direct cutaneous artery (sural artery
branch) in the upper central calf and extending to the
Achilles tendon distally.
• The lesser saphenous vein provides venous drainage.
• It can cover defects of the knee, popliteal fossa, and
upper-third of the leg.
• When used distally based on a reverse flow through
anastomoses between the peroneal artery and the
communicating vascular network of the medial sural
nerve, it can reach difficult areas of defects in the lower
leg and the ankle and heel region (Fig. 10.16).
• It is innervated by the medial sural cutaneous nerve
(S1–2).
• The flap is raised from distal to proximal, in the plane
beneath the deep fascia and above the gastrocnemius
muscles.
• The sural nerve and lesser saphenous vein are divided
distally and elevated with the flap.
used for proximally based flaps to reach the trochanteric
and ischial areas.
• The third perforator arises between the vastus lateralis
and biceps femoris muscles, midway between the greater
trochanter and lateral condyle of the femur, and the flaps
based on the second or third perforator are for use as a
microvascular transplantation because of the long
pedicle.
• The flap is innervated from the lateral cutaneous nerve of
the thigh (L2–3).
Anterolateral thigh perforator (Video 10.1)
• The anterolateral thigh perforator flap is one of the most
widely used perforator flaps.
• The skin can be elevated from a septocutaneous or
musculocutaneous perforator.
• Numerous perforators are found along the region of
intermuscular septum between the vastus lateralis and
rectus femoris.
• These perforators usually drain into the descending
branch of the lateral femoral circumflex artery, then
proximally to lateral circumflex artery, then to the
profunda femoris artery (Fig. 10.14).
• When perforators are traced to the source vessel, it allows
the pedicle to have long length and thicker diameter.
• Innervation of the anterolateral thigh region is from the
lateral femoral cutaneous nerve (L2–3).
Anterolateral thigh
flap isolated on lateral
branch of descending
lateral femoral circumflex
artery and lateral femoral
cutaneous nerve
Figure 10.14  The anterolateral thigh flap. Numerous perforators are found along
the region of intermuscular septum between the vastus lateralis and rectus femoris.
These perforators usually drain into the descending branch of the lateral femoral
circumflex artery, then proximally to lateral circumflex artery, then to the profunda
femoris artery.
Video
10.1

180
•
• Lower extremity reconstruction
10
• The patient is positioned in a lateral decubitus position
with the upper arm in 90° abduction and 90° flexion at
the elbows.
• The lateral border of the latissimus is palpated and
marked.
• Doppler can be useful to identify potential perforators for
the flap.
• Once perforators are identified, a flap can be designed
based on the perforator.
• Although larger flap dimensions have been reported, flap
dimensions under 255 cm2 within its vascular territory
should be safe from partial necrosis.
• Incision is made from the anterointerior border of the flap
allowing the identification of the anterior border of the
latissimus dorsi muscle.
• The dissection is performed between the fat and deep
fascia covering the muscle.
• This plane is easy to dissect as it is in a loose areolar
plane.
• The pedicle should be visualized and protected in the
popliteal fossa, with continued dissection of the pedicle
for free tissue harvesting.
• For free tissue transplantation, proximal superficial
veins should be dissected and preserved for possible
anastomosis because the venae comitantes are
small.
Tap (thoracodorsal artery perforator)
• The vascular territory lies on top of the latissimus dorsi
muscle.
• The main perforators are located along the course of the
descending branch of thoracodorsal artery or from the
lateral branch.
• The most proximal perforator reaches the subcutaneous
tissue in a point located 2 or 3 cm posterior to the
lateral edge of the muscle and 8 cm below the posterior
axillary fold.
Figure 10.15  (A, B) The deep fat portion of the anterolateral thigh can be debulked to obtain a thinner pliable flap. (C,D) The patient with soft tissue defect of the ankle
region is seen with excellent contour after reconstruction without further debulking.
A
B
C
D

181
Operative techniques
• While dissecting for the perforator, care should be given
when dissecting the proximal portion as direct cutaneous
or perforators adjacent to the anterior borders are easily
missed.
• After a suitable perforator is identified, the design of the
flap, in accordance with the defect and pedicle, can be
made.
• Perforators can be isolated or taken with a muscle cuff
reaching down to the main pedicle.
• Total pedicle length depends on the location of perforator
and the intramuscular course of the pedicle. Pedicle
length can be acquired up to 14–18 cm (Fig. 10.17).
Compound flaps
• A compound flap consists of multiple tissue components
linked together in a manner that allows their
simultaneous transfer.
• These separate components can be maneuvered and
placed in a three-dimensional manner to achieve an ideal
one-stage reconstruction.
Figure 10.16  The sural flap. It is located between the popliteal fossa and the
midportion of the leg over the midline raphe between the two heads of the
gastrocnemius muscle. It is one of the longest fasciocutaneous flaps of the lower
leg based on the direct cutaneous artery (sural artery branch) in the upper central
calf and extending to the Achilles tendon distally.
Figure 10.17  Thoracodorsal artery perforator flap. The main perforators are located
along the course of descending branch (DB) of thoracodorsal (TD) artery or from
the lateral branch. The most proximal perforator reaches the subcutaneous tissue in
a point located 2 or 3 cm posterior to the lateral edge of the muscle and 8 cm
below the posterior axillary fold.
A
B
DB of TD
artery

182
•
• Lower extremity reconstruction
10
• According to Hallock’s classification, the subdivisions of
compound flaps are those with a solitary source of
vascularization and those with combinations of sources of
vascularization (Fig. 10.18).
• Those with a solitary source include composite flaps,
defined as multiple tissue components, all served by the
same single vascular supply, and thereby consisting of
dependent parts.
• Those flaps with combinations of sources of
vascularization include conjoined flaps and chimeric
flaps.
• Conjoined flaps are defined as multiple flap territories,
dependent because of some common physical junction,
yet each retains its independent vascular supply.
• The chimeric flaps are defined as multiple flap
territories, each with an independent vascular supply,
and independent of any physical interconnection,
except where linked by a common source vessel
(Fig. 10.19).
Supermicrosurgery
• The supermicrosurgery technique is defined as
microsurgical anastomosis of vessels, with a diameter
<0.8 mm.
• This technique, although reported frequently on
lymphaticovenous shunting to treat lymphedema and
Figure 10.18  Classification of compound flaps.
Composite
Conjoined
Chimeric
Figure 10.19  The chimeric flaps defined as multiple flap territories, each with an
independent vascular supply, and independent of any physical interconnection
except where linked by a common source vessel. Example of complex extremity
reconstruction is shown using a chimeric approach. The source vessel of the
descending branch of the lateral femoral circumflex artery feeding the vastus
lateralis and the anterolateral thigh perforator flap. A gracilis is connected using a
branch from the source vessel.
A
B
Gracilis
Vastus lateralis
Anterolateral thigh
perforator flap
Descending branch of
lateral femoral circumflex
C
sporadically in soft tissue reconstruction with specific
indications, is a relatively new concept for lower
extremity reconstruction.
• For the lower extremity soft tissue reconstruction, one of
the applications can be seen in the perforator-to-
perforator anastomosis approach.

183
Further reading
• Bone transfer mechanism can be an alternative to free
bone transfer of bone defects longer than 6 cm.
Complications and outcomes
• Complications of lower extremity reconstruction include
flap loss, infection, dehiscence, and wound related
complications, wound recurrence, and amputation.
• To achieve optimal motion of tendons of the lower
extremity, secondary tenolysis procedure may be needed.
• The risk for adhesion may increase when the skin graft is
performed over granulated tissue directly above the
tendons and may warrant flap coverage.
• Patients after recovery frequently show scars, depression,
bulky flaps, and donor site morbidities.
• Although complete restoration is nearly impossible, a
reasonable endpoint should be set and efforts to
minimize scars and achieve good contours should be
made.
• Debulking by surgical excision or liposuction can
improve the contour of the flap and fat grafts can be
added to elevate depressed scars.
• Scar revision by Z-plasties or expanders can help to
alleviate scars not only physical but psychological.
Further reading
Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of
outcomes of reconstruction or amputation after
leg-threatening injuries. N Engl J Med.
2002;347(24):1924–1931.
The authors from Carolinas Medical Center performed a
multicenter, prospective, observational study of 569 patients
with severe leg trauma and evaluated the sickness-impact
profile, a multidimensional self-reported health status to
determine the long-term outcomes after amputation or limb
reconstruction. They report that at 2 years, there was no
significant difference in scores for the Sickness Impact
Profile between the amputation and reconstruction groups.
They advise patients with limbs at high risk for amputation
may undergo reconstruction and will have results in
2- years equivalent to those of amputation.
Chen KT, Mardini S, Chuang DC, et al. Timing of
presentation of the first signs of vascular compromise
dictates the salvage outcome of free flap transfers. Plast
Reconstr Surg. 2007;120(1):187–195.
Chung KC, Saddawi-Konefka D, Haase SC, et al. A cost-
utility analysis of amputation versus salvage for
Gustilo type IIIB and IIIC open tibial fractures. Plast
Reconstr Surg. 2009;124(6):1965–1973.
The authors from the University of Michigan Health System
evaluated the cost following amputation and salvage using
the data presented in a study from the Lower Extremity
Assessment Project. The authors extracted relevant data on
projected lifetime costs and analyzed them to include
discounting and sensitivity analysis by considering patient
age. They report amputation is more expensive than salvage,
• With an evident pulse on the perforating artery, it can
be successfully used as a recipient vessel to supply a
sizable flap.
• This approach will allow an increase in the selection of
recipient pedicles.
• By using a perforator-to-perforator anastomosis
approach, less time is consumed to secure the recipient
vessel, to elevate the flap by taking just a short segment
of the perforator pedicle, and minimizes any risk for
major vessel injury or can utilize collateral circulation
without apparent flow of major vessels while having
acceptable flap survival.
Postoperative considerations
• During the postoperative period, the patient as a whole
and the flap should be closely monitored.
• Monitoring flaps, especially free flaps in the first 24 h is
essential due to the majority of thrombosis occurring at
this time.
• It is also important to monitor hemodynamic and
pulmonary function as adequate hydration and
oxygenation are critical to flap survival.
• Limiting range of motion may be needed for flaps
covering the joints as extension or flexion may increase
the tension of the pedicle.
• There is no ideal method of flap monitoring but recent
techniques such as tissue oxygen measurement,
implantable Doppler device, laser Doppler flowmetry,
and fluorescent dye injections may assist the judgment
made from clinical evaluation which remains as the “gold
standard” of monitoring.
• Emergent re-exploration should be performed once
pedicle compromise is noted.
• Although there are no clinical reviews that conclusively
show any agents that increase flap survival rate, most
microsurgeons use some form of prophylactic
antithrombotic treatment such as heparin, dextran and
aspirin or in combinations with other agents.
• The routine use of dextran should be carefully
approached due to allergic reaction and pulmonary
edema.
• Thrombolytics such as urokinase can be used when flow
is not immediately re-established after pedicle
rearrangement or revision anastomosis.
• Leeches have a role in the postoperative care for a
jeopardized flap. By injecting a salivary component called
hirudin, which inhibits platelet aggregation and
coagulation cascade, leeches can decongest flaps by
extracting blood directly and indirectly through persistent
oozing after it detaches.
• The use of leeches for 5–7 days can sometimes help
salvage the flaps that do not resolve, despite
re-exploration of the venous flow.
• Bone grafts are usually placed 6 weeks after soft tissue
reconstruction to allow time for transferred tissue to
settle in and sterilize the wound.
• Cancellous autografts or vascularized bone transfers can
be chosen depending on length of the bone gap.

184
•
• Lower extremity reconstruction
10
protocol for primary amputation can be properly
developed.
Ong YS, Levin LS. Lower limb salvage in trauma. Plast
Reconstr Surg. 2010;125(2):582–588.
The authors from the Duke University Medical center
review the approach to lower limb salvage. They state that
the primary goal of limb salvage is to restore or maintain
function based on proper patient selection, timely
reconstruction, and choosing the best procedure which
should be individualized for each patient. Aggressive
debridement and skeletal stabilization, followed by early
reconstruction, are the current standard of practice and give
better results than the more traditional approach of repeated
debridements and delayed flap cover. For reconstruction,
they state that free tissue transfer remains the best choice for
large defects, but local fasciocutaneous flaps are a reasonable
alternative for smaller defects and cases in which free flaps
are deemed not suitable.
Wei FC, Celik N. Perforator flap entity. Clin Plast Surg.
2003;30(3):325–329.
The authors from the Chang Gun Memorial hospital state
that the perforator flap is not a new concept in microsurgery
but there is still confusion and that studies about the
differences between these flaps and the conventional flaps,
including donor site morbidity and long-term follow-ups,
are increasing in literature. Better accuracy in
reconstruction, including the use of only cutaneous tissue,
minimization of the morbidity, and preserving the same
survival rate in free flaps are reassurances to microsurgeons
to perform perforator flaps. They believe that in the near
future, with refinements in the techniques and instruments,
perforator flaps will be the first choice flap.
independently of varied ongoing prosthesis needs, discount
rate, and patient age at presentation. Moreover, amputation
yields fewer quality-adjusted life-years than salvage. Salvage
is deemed the dominant, cost-saving strategy.
Godina M. Early microsurgical reconstruction of complex
trauma of the extremities. Plast Reconstr Surg.
1986;78(3):285–292.
Gottlieb LJ, Krieger LM. From the reconstructive ladder to
the reconstructive elevator. Plast Reconstr Surg.
1994;93(7):1503–1504.
Hong JP. The use of supermicrosurgery in lower extremity
reconstruction: the next step in evolution. Plast
Reconstr Surg. 2009;123(1):230–235.
Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III
open tibia fractures with late debridement. J Orthop
Trauma. 1995;9(2):121–127.
Lange RH. Limb reconstruction versus amputation decision
making in massive lower extremity trauma. Clin
Orthop Relat Res. 1989;243:92–99.
This study from the University of Wisconsin describes the
absolute and relative indications for primary amputation
of limbs with open tibial fractures. Absolute indications
include: anatomically complete disruption of the posterior
tibial nerve in adults and crush injuries with warm
ischemia time greater than 6 h. Relative indications
include: serious associated polytrauma, severe ipsilateral
foot trauma, and anticipated protracted course to obtain
soft tissue coverage and tibial reconstruction. However, he
states that individual patient variables, specific extremity
injury characteristics, and associated injuries must all be
weighed before a decision can be reached and further
prospective studies are necessary before a well-defined

©2014, Elsevier Inc. All rights reserved.
Chapter
11 
Chest reconstruction
• Mediastinitis occurs in 0.25–5% of patients undergoing
median sternotomy.
• Historically, mortality approached 50% in these patients.
• Sternal wound infections may be classified into three
distinct types as described by Pairolero and Arnold
(Table 11.1).
■ Type 1: wounds that occur in the first several
postoperative days and are usually sterile.
■ Type 2: infections which occur in the first several
weeks postoperatively.
■ Consistent with acute deep sternal wound infection,
including sternal dehiscence, positive wound cultures,
and cellulitis.
■ Type 3: infections that present months to years later.
■ Represent chronic wound infection and uncommonly
represent true mediastinitis.
■ Usually confined to the sternum and overlying skin
and may be related to osteonecrosis or persistent
foreign body.
• Although each mechanism carries individual nuances,
they will all require adequate debridement and, when
possible, replacement of like with like.
• Fundamentally, the chest wall must be restored for the
protection of underlying viscera, maintenance of
respiratory mechanics, and base for the upper limb and
shoulder.
• Chest wall reconstruction can be generalized to include
skeletal support and soft tissue cover.
• Skeletal support to prevent paradoxic chest wall motion
is usually required when the defect exceeds 5 cm in
diameter.
• Generally, this corresponds to those defects exceeding a
two rib resection. (Table 11.2).
• Posterior chest wall defects may tolerate up to twice the
size of those in the anterior and lateral chest due to
scapular coverage and support.
This chapter was created using content from
Neligan & Song, Plastic Surgery 3rd edition,
Volume 4, Lower Extremity, Trunk and Burns,
Chapter 10, Reconstruction of the chest, David H.
Song and Michelle C. Roughton.
SYNOPSIS
■ Rigid chest wall support may be achieved with mesh, acellular
dermal matrix, or autogenous material such as tensor fascia lata.
Of these, alloplastic mesh is most prone to infection.
■ Soft tissue coverage can be achieved with local muscle flaps.
■ Proper treatment of mediastinitis includes debridement, rigid sternal
fixation when possible, and soft tissue coverage.
■ Pectoralis muscle is the workhorse for sternal and anterior chest
wall defects.
■ Latissimus muscle is known for its bulk and ability to reach
intrathoracic defects. Caution is advised for patients with previous
thoracotomy incisions as it may have been divided.
■ Serratus muscle supplies less bulk than the latissimus but will
function to cover lateral chest wall defects and some intrathoracic
needs.
■ Rectus abdominus is an excellent choice for sternal and anterior
chest wall defects, especially the lower two-thirds. Furthermore, it
can be used to fill space within the mediastinum.
■ The omentum can reach almost any chest wall defect. Its greatest
advantage is its pedicle length, which can be extended by dividing
the arcades. It does, however, require a laparotomy for harvest.
Brief introduction
• Common etiologies for chest wall defects include tumor
resection, deep sternal wound infections, chronic
empyemas, osteoradionecrosis and trauma.

186
•
• Chest reconstruction
11
• Anecdotally, patients who have undergone radiation and
have decreased chest wall compliance will tolerate larger
resections without skeletal replacement due to an overall
fibrosis of their viscera.
• Options for skeletal support include various mesh
products including PTFE (Gore-Tex®), polypropylene,
Mersilene (polyethylene-terephthalate)/
methylmethacrylate, and acellular dermal matrix
(Fig. 11.1). Furthermore, use of TFL as both graft and
flap reconstruction has been described.
• Chest wall reconstruction almost always requires some
form of soft tissue coverage as very few defects will close
primarily. Reconstructive goals include wound closure
with maintenance of intrathoracic integrity, restoration of
aesthetic contours, as well as minimization of donor site
deformity.
• Recruitment of local muscles with or without overlying
skin is often the first-line of reconstructive offense,
including: pectoralis major, latissimus dorsi, serratus
Figure 11.1  Implantable mesh products including polypropylene, PTFE (Gore-Tex®), and acellular dermal matrix.
A
B
C
Table 11.1  Classification of infected sternotomy wounds
Type I
Type II
Type III
Occurs within first
few days
Serosanguineous
drainage
Cellulitis absent
Mediastinum soft
and pliable
Osteomyelitis and
costochondritis
absent
Cultures usually
negative
Occurs within first
few weeks
Purulent drainage
Cellulitis present
Mediastinal
suppuration
Osteomyelitis
frequent,
costochondritis
rare
Cultures positive
Occurs months to
years later
Chronic draining
sinus tract
Cellulitis localized
Mediastinitis rare
Osteomyelitis,
costochondritis, or
retained foreign
body always
present
Cultures positive
Table 11.2  Regions of the chest wall
Anterior
Between anterior axillary lines
Lateral
Between anterior and posterior axillary lines
Posterior
Between posterior axillary lines and the spine
anterior, and rectus abdominus. The omentum may also
be used.
• Commonly, the ipsilateral latissimus muscle is
divided during thoracotomy incisions and the
authors encourage early communication between
surgeons if there are multiple teams in order to mitigate
against routine division. Muscle sparing thoracotomies
help to preserve both the latissimus and serratus
muscles while providing adequate intrathoracic access
(Fig. 11.2).
Preoperative considerations
• The importance of a multidisciplinary approach to chest
wall reconstruction cannot be underestimated. These
patients, whether suffering from malignancy, infection, or
trauma, are often also plagued with cardiac or respiratory
insufficiency, diabetes, obesity, malnutrition, and
generalized deconditioning.
• Acquired chest wall deformities are commonly the result
of iatrogenic injury. Usually encountered in conjunction
with cardiac or thoracic surgery, wound infections,
mediastinitis, osteoradionecrosis, refractory empyema
and bronchopleural fistulas, can all necessitate chest wall
reconstruction.
• Utilizing the workhorse flaps described below, combined
with general principles of thorough debridement and
skeletal stabilization, the surgeon is generally well
prepared to reconstruct any deficit. Common chest wall
reconstructive problems are described below.
• Preoperative risk factors for the development of
mediastinitis include: older patients, COPD, smoking,
ESRD, DM, chronic steroid or immunosuppressive use,
morbid obesity including large, heavy breasts, prolonged
ventilator support (>24 h), concurrent infection and
reoperative surgery. Other variables include off midline
sternotomies, osteoporosis, use of LIMA or RIMA, long
cardiopulmonary bypass runs (>2 h), and transverse
sternal fractures.
• Empyema is defined as a deep space infection between
the layers of visceral and parietal pleura.
• The chest cavity, unlike most other regions in the body, is
rigid and non-collapsible. Thus, deep space infections,

187
Operative techniques
• Radiation damage also affects overlying soft tissues,
creating hyperpigmentation, decreased pliability,
and even ulceration. Thus, recruitment of healthy
tissue in the form of local myocutaneous flaps is
recommended.
Operative techniques
Mediastinitis/sternal wound infection
• If tissue culture is positive, >105 organisms/cm3 of tissue,
indicating deep sternal wound infection rather than early
sternal dehiscence, early debridement is encouraged and
should be performed urgently.
• A thorough debridement includes:
■ Removal of sternal wires and extraneous foreign
bodies including any unnecessary pacing wires and
chest tubes (Fig. 11.3).
■ Debridement of necrotic and/or purulent tissue until
remaining tissue appears healthy and bleeding.
■ Radical sternectomy is not indicated and sternal
salvage should be attempted if the bone is viable. This
may be determined by bleeding from the marrow and
the presence of hard, crunchy cortical bone. Topical
antimicrobials such as silver sulfadiazine and mafenide
creams are employed to gain and maintain
bacteriologic control of the wound.
• Subatmospheric pressure wound therapy (e.g. V.A.C.™)
may be utilized to increase wound blood flow and
expedite granulation tissue, thereby decreasing dead
space.
• This has been shown to decrease the number of days
between operative debridement and definitive closure of
sternal wounds, from 8.5 to 6.2 days, as well as the
number of flaps required per patient, 1.5–0.9.
• It is now standard practice for the treatment of
mediastinitis at many institutions.
• Fixation of the sternum or residual sternal bone is
crucial for bony healing, preventing paradoxic motion
of the anterior chest wall, and improvements in chest
wall pain and/or sternal rubbing or clicking sensations
(Fig. 11.4).
• Sternal dehiscence occurs early in the postoperative
course, consistent with type 1 sternal wound infections,
and is secondary to mechanical failure of wire closure
rather than infection.
• The wounds are sterile and surgeons should proceed to
immediate rigid sternal fixation.
• Once rigid fixation is achieved, soft tissue closure must
be addressed.
• When the wound involves the upper two-thirds of the
sternum, pectoralis major muscle advancement or
turnover flaps are easily harvested and are the first-line
therapy for wound closure (Fig. 11.5).
• Caution is advised for turnover flaps when the ipsilateral
internal mammary artery (IMA) has been harvested
for CABG.
• When the lower sternal pole lacks coverage, the pectoralis
may be inadequate, based on its limited arc of rotation.
such as empyemas, are unlikely to heal without collapse
of dead space or filling of the cavity.
• As adjuvant radiation therapy is becoming increasingly
common in the treatment of both breast and lung
cancer, osteoradionecrosis (ORN) of the ribs is
becoming an increasing problem for reconstructive
surgeons.
• Management of ORN of the chest wall consists of surgical
excision and reconstruction.
• Again, should more than two ribs be resected from the
anterior chest wall, skeletal support will traditionally be
required.
Figure 11.2  Muscle sparing thoracotomy. (From Ferguson MK. Thoracic Surgery
Atlas. Edinburgh: Elsevier©; 2007.)
Latissimus dorsi
Serratus anterior
Serratus anterior
A
B
C