Operative Technique in Plastic Surgery – Kevin C.Chung

■ To minimize the risk of pedicle compression and vascular compromise, we
typically prefer to make an incision between the flap pivot point and the
defect for inset (TECH FIG 4A). Skin flaps are elevated along this incision
to achieve sufficient mobility to permit tension-free closure over the
pedicle.
■ Alternatively, the pedicle can be covered with a skin graft.
■ For volar palm defects, the flap can be passed around the ulnar border of
the hand or through the IOM using a wide tunnel.13
■ The flap is inset into the defect and secured with sutures; it can be rotated up
to 180 degrees.
■ The pedicle is carefully rotated at the pivot point to avoid kinking.
■ If a skin bridge has been used, release of the dermis at the pivot point can
facilitate inset.
■ A small-caliber drain can be placed under the flap, away from the pedicle,
if desired (TECH FIG 4B).
■ Narrow flap donor sites are closed primarily.
■ For flap donors site over 4 to 6 cm in width, a split-thickness skin graft
(STSG) is used for closure.
■ Antibiotic-impregnated gauze is applied to the flap incisions and covered
with sterile gauze.
■ The flap skin paddle is left exposed for monitoring in the postoperative
period.
■ Antibiotic-impregnated gauze is placed over the STSG at the flap donor site
and covered with sterile gauze and an elastic bandage to apply gentle
compression and to avoid shear of the STSG.
■ The wrist and hand are immobilized with a well-padded splint.
■ Antegrade PIA Flap
■ The axis of the flap is marked from the lateral epicondyle to the head of the
ulna. The flap is designed at the junction of the middle and distal thirds of the
dorsal forearm.
■ The distal edge of the flap is marked 4 cm proximal to the wrist to avoid
injury to the dorsal sensory branch of the ulnar nerve.
■ The radial aspect of the flap is incised.
■ The flap is raised from radial to ulnar in the subfascial plane toward the IMS

between the EDM and ECU.
■ The PIA and its perforators are visualized.
■ The flap design is confirmed, ensuring the perforators enter the center of the
flap, and then the ulnar incision is made.
■ The flap is raised to the IMS between the EDM and ECU in an ulnar to
radial direction.
■ Distal to the flap, the anastomotic branch of the PIA to the AIA is identified
and ligated.
■ The flap is elevated from distal to proximal, following the pedicle in the
septum between the EDM and ECU.
■ The flap is typically raised as an island flap.
■ The dorsal sensory branch of the ulnar nerve and the PIN are protected at
all times.
■ The flap is inset into the defect; it can be rotated up to 180 degrees.
■ Care is taken to avoid pedicle kinking and compression as the flap is
sutured.
■ The flap donor site is closed primarily or with an STSG.
■ The incisions are covered with antibiotic-impregnated gauze and dry sterile
gauze.
■ The visibility of the flap skin paddle is necessary for flap monitoring.
■ If used, the STSG is dressed with antibiotic-impregnated gauze and covered
with sterile gauze and an elastic bandage.
■ The elbow is immobilized with a well-padded splint, avoiding pressure on
the flap and pedicle.
PEARLS AND PITFALLS
Physical
findings
■ The PIN must be protected throughout flap elevation. The PIA
pedicle is dissected away from the PIN. If branches of the PIN
cross superficial to the PIA and impede flap elevation, the flap can
be converted to a free flap.
■ The PIA flap offers a better skin color match than the radial
forearm flap for defects of the dorsal hand and first web space.
Technique
■ The vena comitantes of the PIA are small. To optimize the chances

of flap survival, a cutaneous vein is raised with the flap to permit
venous supercharging if venous congestion is noted after flap inset.
■ When harvesting a retrograde PIA flap, it is wise to harvest the
PIA and its vena comitantes at least 1 cm proximal to the proximal
flap edge. This also permits supercharging of the flap if there is
poor arterial inflow through the PIA-AIA anastomosis or venous
congestion. Conversion to a free flap is also possible.
■ Often the proximal and distal margins of the flap can be closed
primarily. If the central flap width is over 4–6 cm, depending on
the skin laxity, a skin graft may be required for closure. A sheet
STSG is preferred rather than a meshed STSG for improved donor-
site appearance.4
■ For large defects, the PIA flap can be harvested simultaneously
with an ipsilateral lateral arm flap.14 The two skin paddles are
elevated together.
Postoperative
care
■ Partial or complete flap necrosis is uncommon.5,12 However, the
patient must be counseled preoperatively of the risk of flap
necrosis and the need for a second flap.
Therapy
■ After flap inset, the elbow, wrist, and fingers are moved passively
to evaluate the effect of joint range of motion on the flap. Tension-
free inset is ideal; this permits early range of motion exercises
starting 5 days postoperatively after the donor site graft has taken.
POSTOPERATIVE CARE
■ Flap checks are performed every 2 hours for the first 24 hours postoperatively
and then every 4 hours.
■ Tissue turgor, color, capillary refill, and temperature are monitored.
■ Any change in flap status, indicating possible arterial or venous insufficiency,
should prompt a return to the operating room for flap assessment.
■ Compression by a hematoma or pedicle kinking is a common cause of flap
insufficiency.
■ The patient is typically discharged home on postoperative day 3.
■ The patient returns to clinic on postoperative day 5 to assess the skin graft take
and replace the dressings.
■ The splint is discontinued following this dressing change after confirming
that the flap does not experience undue tension with elbow, wrist, and hand
range of motion.
■ If there are concerns, the splint can be continued for an additional week.

OUTCOMES
■ The PIA flap provides reliable soft tissue coverage for upper extremity defects.
■ Along with the radial forearm flap, it is a valuable option for pedicled flap
coverage of the wrist and hand.
COMPLICATIONS
■ Most of the lymphatic drainage from the hand runs over the volar forearm.
Compared with the radial forearm free flap, the PIA flap disrupts less
lymphatic outflow that results in less edema postoperatively.
■ PIN palsy is rare following PIA flap harvest. Motor functions of the muscles
of the extensor compartment of the forearm are tested postoperatively to
confirm PIN innervation.
REFERENCES
1. Tonkin MA, Stern H. The posterior interosseous artery free flap. J Hand Surg
Br. 1989;14(2):215-217.
2. Balakrishnan G, Kumar BS, Hussain SA. Reverse-flow posterior interosseous
artery flap revisited. Plast Reconstr Surg. 2003;111(7):2364-2369.
3. Kim KS. Distally based dorsal forearm fasciosubcutaneous flap. Plast
Reconstr Surg. 2004;114(2):389-396.
4. Hsu C, Chang J. The posterior interosseous artery flap revisited. Operat Techn
Plast Reconstr Surg. 2003;9(4):173-180.
5. Costa H, Gracia ML, Vranchx J, et al. The posterior interosseous flap: a
review of 81 clinical cases and 100 anatomical dissections—assessment of its
indications in reconstruction of hand defects. Br J Plast Surg. 2001;54(1):28-
33.
6. Costa H, Smith R, McGrouther DA. Thumb reconstruction by the posterior
interosseous osteocutaneous flap. Br J Plast Surg. 1988;41(3):228-233.
7. Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous
reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr
Surg. 1993;92(2):285-293.
8. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-
cutaneous flap of the posterior interosseous artery. Surg Radiol Anat.
1986;8(4):209-215.
9. Büchler U, Frey HP. Retrograde posterior interosseous flap. J Hand Surg
[Am]. 1991;16(2):283-292.
10. Giunta R, Lukas B. Impossible harvest of the posterior interosseous artery

flap: a report of an individualised salvage procedure. Br J Plast Surg.
1998;51(8):642-645.
11. Hu W, Martin D, Foucher G, Baudet J. Le lambeau interosseux anterieur. Ann
Chir Esthet. 1994;39(3):290-300.
12. Fujiwara M, Kawakatsu M, Yoshida Y, Sumiya A. Modified posterior
interosseous flap in hand reconstruction. Tech Hand Up Extrem Surg.
2003;7(3):102-109.
13. Gupta A, Wang A, Baylis W, Breidenbach W. Anterior transposition of the
posterior interosseous artery flap through the interosseous membrane. J Hand
Surg Br. 1997;22(1):32-33.
14. Shibata M, Hatano Y, Iwabuchi Y, Matsuzaki H. Combined dorsal forearm
and lateral arm flap. Plast Reconstr Surg. 1995;96(6):1423-1429.

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51
CHAPTER
Pedicled and Free Groin
Flap
Mark Morris and Kevin C. Chung
DEFINITION
■ A free flap requires the transfer of tissue from one body site to another, with
anastomosis of arterial and venous systems to the recipient site using
microsurgical techniques.
■ A pedicled flap transposes tissue from a donor site to a recipient site while
keeping the tissue partially attached to the donor site. The donor vascular
pedicle is left intact to supply the flap. Pedicled flaps are reliable and do not
require microsurgery.
■ The groin flap was described in 1972 by McGregor and Jackson1 for
reconstruction of soft tissue defects of the hand. This was once a “workhorse”
flap for hand reconstruction; however, with the introduction and advancement
of microsurgery, it has fallen out of favor for many indications. Nevertheless,
there are still many indications for its use.
■ When a pedicled groin flap is used, patients must be counseled that they will
require multiple operations (average 4.6 operations per patient), including flap
division, debulking, and tissue rearrangement for contouring.2
ANATOMY
■ The groin flap is based on the superficial circumflex iliac artery (SCIA).
■ The SCIA arises approximately 2 to 3 cm distal to the inguinal ligament,
either directly from the femoral artery (70%) or from the superficial inferior
epigastric artery (FIG 1).
■ The SCIA passes laterally from its origin and gives a deep branch at the
medial border of the sartorius.
■ The superficial branch then pierces the fascia at the lateral border of the

sartorius and runs 2 to 3 cm distal and parallel to the inguinal ligament,
toward the anterior superior iliac spine (ASIS). This superficial branch
supplies the skin to be used for the flap.
■ After reaching the ASIS, the superficial branch of the SCIA branches further
and anastomoses with branches of the superior gluteal, deep circumflex iliac,
and ascending lateral femoral circumflex arteries.
■ The SCIA pedicle is generally between 0.8 and 1.8 mm in diameter.3
FIG 1 • Vascular and regional anatomy of the groin flap,
which follows the axis of the superficial circumflex iliac
artery.

FIG 2 • Limits of the groin flap.
■ Venous drainage of the flap is split between the superficial circumflex iliac
vein and the venae comitantes of the SCIA. Both of these eventually drain into
the femoral vein, either directly or via the saphenous vein.
■ Flap size is limited to about 13 × 10 cm (FIG 2). The axis of the SCIA is
marked by palpating the femoral pulse, marking the origin 2 to 3 cm distal to
the inguinal ligament and then drawing a line to the ASIS. The flap will follow
this axis.
■ The medial boundary of the flap is about 3 to 4 cm lateral to the femoral
artery (2–3 cm medial to the medial border of the sartorius).
■ The maximum width of the flap that can be primarily closed in most patients
is 10 cm. The flap should be positioned two-thirds superior to the vascular
axis and one-third below the axis. This translates to up to 6 to 7 cm superior to

the axis and 3 to 4 cm inferior to the axis.
■ The lateral portion of the flap should be designed with a 1:1 length-to-width
ratio. This is because the portion of the flap lateral to the ASIS has a random
pattern of vascularization. Therefore, because the width of the flap is limited
to 10 cm, the lateral limit of the flap is then 10 cm lateral to the ASIS.
■ Sensation to the lateral portion of the groin flap is supplied by the lateral
cutaneous branches of the 12th thoracic subcostal nerve (FIG 3).4 This nerve
can be harvested with the flap to provide sensation to the hand, but a sensate
nerve is infrequently used.
■ The 12th thoracic nerve pierces the internal and external oblique muscles and
courses distally over the iliac crest, 5 cm posterior to the ASIS. Do not
confuse the lateral femoral cutaneous nerve, which supplies sensation to the
lateral thigh, for the 12th thoracic nerve.

FIG 3 • The lateral cutaneous branch of the 12th
thoracic nerve enters the graft opposite the vascular
pedicle.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History must include the mechanism of injury.
■ Crush and blast injuries can lead to a much larger zone of injury than
expected by initial examination (FIG 4A,B).
■ In the case of a crush injury, the physician must also assess the patient for
signs of compartment syndrome.
■ Contaminated wounds may require multiple irrigation and debridement
procedures (FIG 4C–E).
■ Medical and social history—such as diabetes mellitus, peripheral vascular
disease, or smoking—does not contraindicate surgery but will affect the
healing potential of the flap and must be discussed with the patient.
■ Assess the vascular status of the remaining limb.
■ Motor and sensory evaluation to assess damage to nerves, tendons, or muscles.
IMAGING
■ Standard radiographs of the hand are done to evaluate for bony injury.
SURGICAL MANAGEMENT
■ Free flaps are generally considered superior to the pedicled groin flap with
today’s microsurgical techniques. However, there are still many good
indications for doing a pedicled groin flap:
■ Complex hand injuries in young children (less than 2 years). Microsurgery in
infants is technically challenging because of the small size of the vessels.
■ In preparation for a toe-to-thumb transfer following thumb or finger loss.
This preserves the recipient vessels for later microsurgery during transfer and
also saves as much stump tissue as possible by providing coverage.

FIG 4 • A,B. Preoperative radiograph and clinical
photograph, respectively, of a 12-year-old boy who
sustained a bomb-blast injury to the left upper extremity.
C–E. Images after left hand radical debridement, open
reduction and internal fixation of the left thumb
metacarpal using K-wires, and left index finger
metacarpal transposition to the small finger and fixation
with K-wires.
■ Dorsal or palmar soft tissue defects involving multiple digits
■ Degloving injury to all fingers
■ Circumferential thumb soft tissue defect
■ First stage of an osteoplastic thumb reconstruction
■ High-voltage electrical burns with a hand surviving on collateral circulation.
In some cases, a hand may survive based on collateral blood supply when
both ulnar and radial arteries have thrombosed in the forearm. The extensive
zone of injury affects available recipient vessels, and dissection of these
vessels may inadvertently lead to hand necrosis.5
■ Advantages to the pedicled groin flap are that it is thin and nearly hairless, it is
reliable, flap elevation is quick, and the donor site can be closed primarily in

most cases.
■ Disadvantages of the pedicled groin flap are that it is a mandatory two-stage
operation, the patient’s hand is connected to his or her groin for 3 to 4 weeks
(which leads to stiffness in the shoulder, elbow, and wrist, especially in older
patients), and there is a high risk of injury to the lateral femoral cutaneous
nerve with subsequent loss of sensation in the lateral thigh or a painful
neuroma.
Preoperative Planning
■ The following is a rough guideline for skin requirements for reconstruction in
an adult male:
■ Thumb (circumferential)
• Distal to the metacarpophalangeal joint: 9 × 8 cm
• Distal to the thenar crease: 13 × 12 cm
■ Palmar hand: 12 × 10 cm
■ Dorsal hand: 12 × 10 cm
■ Finger (circumferential): 7 × 10 cm
■ Assess for any scars in the groin.
■ Use a Doppler probe to confirm the location of the SCIA.
Positioning
■ The patient is positioned supine on the operating table with a hand table in
place.
■ A bump is placed under the ipsilateral hip to better visualize the elevation of
the random portion of the flap lateral to the ASIS.
■ The operative extremity and ipsilateral groin are prepped and draped widely.
■ A tourniquet is placed on the upper extremity.
Approach
■ The wound must be thoroughly debrided back to healthy tissue.
■ Keep in mind the above-mentioned limits of the flap when designing the groin
flap.
■ Bone fixation and nerve reconstruction can be performed at the same time as
the groin flap; however, tendon reconstruction should be delayed until passive
joint range of motion is re-established for rehabilitation purposes.
■ The surgeon must decide on whether or not to attempt an innervated flap prior

to elevating the flap, as the lateral cutaneous branch of the 12th thoracic nerve
will have to be harvested if this is desired.
T E C H N I Q U E S
■ Pedicled Groin Flap
Flap Design
■ Mark the inguinal ligament from the pubic tubercle to the anterior superior
iliac spine (ASIS).
■ Palpate the femoral pulse.
■ Mark the origin of the superficial circumflex iliac artery (SCIA) off of the
femoral artery, 2 to 3 cm distal to the inguinal ligament (TECH FIG 1).
■ Draw another line perpendicular to the first line, 2 to 3 cm inferior to the
inguinal ligament. This marks the axis of the SCIA. This can be confirmed
with a Doppler probe.
■ Make a template of the defect and transfer it to the groin within the limits of
the graft discussed earlier.
Flap Harvest
■ Elevate the flap starting at the superolateral margin.
■ The incision is taken down to the level of the external oblique aponeurosis.
The flap is elevated in this plane from lateral to medial (TECH FIG 2A).
■ If an innervated flap is desired, the surgeon must identify the lateral
cutaneous branch of the 12th thoracic nerve. This nerve pierces the internal
and external oblique muscles and descends 5 cm posterior to the ASIS.
Harvest the nerve at this time as it enters the lateral portion of the flap.
■ Elevate the lateral and inferior margins of the flap.
■ The inferior portion of the flap is elevated superficial to the fascia lata.
■ The random portion of the flap is elevated to the ASIS.
■ The lateral borders of the sartorius and fascia lata are identified inferior to
the ASIS.

TECH FIG 1• Markings for a pedicled groin flap.
■ Elevate the axial portion of the flap.
■ An incision is made longitudinally over the fascia lata and sartorius fascia.
The flap is now elevated in this deeper plane to include this layer of
sartorial fascia medial to the ASIS (TECH FIG 2B). This is critical
because the SCIA is superficial to the fascia over the sartorius. Elevating
the sartorial fascia protects the SCIA. This also prevents the fascia from
tethering and kinking the vessel, which could cause flap necrosis. The
SCIA does not need to be isolated for the pedicled flap.
■ Identify and ligate the deep branch of the SCIA. It will arise at the medial
border of the sartorius. The deep branch is very short and should be ligated
within the substance of the sartorius to avoid injury to the SCIA.
■ Identify and protect the lateral femoral cutaneous nerve as it arises beneath
the inguinal ligament, near the medial border of the sartorius.
■ Divide any connections between the inguinal ligament and fascia lata.
■ The flap can be elevated 2 to 3 cm medial to the medial border of the
sartorius.
■ Close the flap donor site.
■ Close from medial to lateral in layers.
■ A drain is not usually required if adequate hemostasis was attained. The

closure is tight and should compress the bed sufficiently, so fluid collection
under the flap is not a concern.
■ Undermining skin flaps and hip flexion will assist with closure. The bump
can also be removed from under the hip.
Flap Placement and Division
■ Thin the flap to match the thickness of the recipient site.
■ The random portion of the flap lateral to the ASIS can be made thin safely
because the flap relies on the subdermal plexus in this location.
■ Leaving excess fat increases vascular demands of the flap.
■ The 12th thoracic nerve can now be repaired to an available digital nerve
from the recipient hand if an innervated flap is planned.
■ Inset the flap to the recipient site using 3-0 nylon interrupted sutures (TECH
FIG 3A,B).
■ Flap division generally occurs after 3 weeks (TECH FIG 3C–F).
■ The surgeon can passively move the patient’s shoulder, elbow, and hand
while still under anesthesia after division.
■ This will break up adhesions and facilitate recovery of motion
postoperatively.

TECH FIG 2• A. The flap is elevated from lateral to
medial, superficial to the external oblique aponeurosis.
B. The sartorius fascia is raised with the SCIA pedicle

as the flap is elevated from lateral to medial.
TECH FIG 3• A,B. Images after the groin flap has
been inset to the left hand. C–F. Postoperative images
after flap division.
■ Free Groin Flap
Flap Design
■ Follow the same steps as for a pedicled flap to plan and elevate the free flap,
except that the medial portion of the flap must also be elevated.
■ The free flap can be harvested from the contralateral or ipsilateral groin.
■ Free groin flap is seldom performed because of the short pedicle and
variability of the pedicle origin.
■ Identify and dissect out the SCIA and concomitant vein. Cutaneous veins
may have to be used if there is no concomitant vein.
■ Identify suitable arterial and venous sites of anastomosis in the hand,
depending on the location of injury.
Flap Harvest
■ Divide the vascular pedicle.

■ Anastomose the SCIA to the appropriate vessels, depending on the location
of the defect. An end-to-side anastomosis is recommended for the artery in
order to not devascularize the recipient site. End-to-end anastomosis of veins
is performed.
■ The 12th thoracic nerve can now be repaired to an available nerve from the
recipient hand if an innervated flap is planned (TECH FIG 4).
■ Inset the flap to the recipient site using 3-0 nylon interrupted sutures.
TECH FIG 4• The SCIA and vein are anastomosed
proximally, while a digital nerve or two can be repaired
to a branch or branches of the 12th thoracic nerve.
PEARLS AND PITFALLS

Positioning
■ Place a bump under the ipsilateral hip to allow better visualization.
Technique
■ A full-thickness flap is raised. Thinning is done before inset.
Leaving fat on the abdominal wall will make closure more
difficult.
■ If the lateral femoral cutaneous nerve prohibits flap elevation, the
surgeon can divide it to elevate the flap further and then repair the
nerve. This nerve is usually not in the way when harvesting a
pedicle flap because one does not need to skeletonize the pedicle
medial to the sartorius fascia.
Postoperative
care
■ The upper limb should be immobilized for 2 or 3 days, until the
patient is comfortable with the position of the extremity and the
flap. This is important to do prior to waking the patient up from
anesthesia so the patient does not inadvertently reach for the
endotracheal tube and damage the flap.
■ If the groin closure is very tight, patients may need to be
immobilized with the hip in flexion. This can be done by placing
pillows under the knee for a few days.
■ If there is marginal necrosis of the flap, wait for 2 to 3 days to let
the necrosis demarcate as the initial postoperative swelling
subsides. The patient should then return to the operating room for
excision of necrotic portions and flap advancement and reinset.
Waiting longer than 2 or 3 days risks further complications and
failure of the flap.
■ The groin scar is closed under tension and will spread. Leave
sutures in place until it is time for flap division, 3 to 4 weeks later.
POSTOPERATIVE CARE
■ The open area near the pedicle is kept moist with bacitracin ointment twice
daily and is covered with Xeroform gauze.
■ Passive and active range of motion should start early under the supervision of
a hand therapist.
■ Compression bandages should be applied for bulky flaps.
■ Surgery for thinning the flap should be delayed for at least 3 to 6 months.
OUTCOMES
■ Arner and Moller6 retrospectively studied 44 pedicled groin flaps for coverage
of hand and forearm soft tissue defects.

■ Local complications (partial flap necrosis, infection, and seroma) occurred in
11 patients (25%).
■ Defatting was subsequently required in 38 (86%) patients, and 4 patients
(9%) required secondary revisions of donor sites.
■ Goertz et al.2 treated 85 patients with pedicled groin flaps and prospectively
collected data on these patients. Forty-nine patients were later interviewed and
examined, with mean follow-up of 9 years. Mean hospital stay was 29 days.
Patients each required a mean of 4.6 operations (including thinning of the flap,
deepening of the interdigital fold, stump, and flap revisions).
■ One flap loss occurred.
■ Of the 49 patients interviewed, 82% would undergo the procedure again.
■ Mean Disabilities of the Arm, Shoulder, and Hand score was 23.
■ The Vancouver Scar Scale showed close to normal height and vascularity of
the flap (0.2 and 0.3, respectively), but pigmentation was slightly abnormal
(0.8) and pliability was rated between “supple” and “yielding” (1.5).
COMPLICATIONS
■ Flap necrosis
■ Infection
■ Shoulder and elbow stiffness
■ Scarring
REFERENCES
1. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:
3-16.
2. Goertz O, Kapalschinski N, Daigeler A, et al. The effectiveness of pedicled
groin flaps in the treatment of hand defects: results of 49 patients. J Hand Surg
Am. 2012;37(10):2088-2094.
3. Hsu W, Chao W, Yang C, et al. Evolution of the free groin flap: the superficial
circumflex iliac artery perforator flap. Plast Reconstr Surg. 2007;199(5):1491-
1498.
4. Joshi BB. Neural repair for sensory restoration in a groin flap. Hand.
1977;9(3)221-225.
5. Al-Qattan MM, Al-Qattan AM. Defining the indications of pedicled groin and
abdominal flaps in hand reconstruction in the current microsurgery era. J Hand
Surg [Am]. 2016;41(6):917-927.
6. Arner M, Moller K. Morbidity of the pedicled groin flap: a retrospective study

of 44 cases. Scand J Plast Reconstr Surg Hand Surg. 1994;28(2):143-146.

52
CHAPTER
Free Anterolateral Thigh
Flap
John R. Lien and Kevin C. Chung
DEFINITION
■ The anterolateral thigh flap is a versatile free flap that is often harvested as a
fasciocutaneous flap, supplied by the descending branch of the lateral femoral
circumflex artery (LFCA).
■ It can be harvested also as a cutaneous or musculocutaneous flap with the
vastus lateralis, with the option of an innervated flap with inclusion of the
lateral femoral cutaneous nerve (LFCN).
ANATOMY
■ The LFCA arises from the profunda femoris artery and divides into three
branches (ascending, transverse, descending) deep to the sartorius and rectus
femoris muscles (FIG 1).
■ The descending branch of the LFCA courses distally along the medial border
of the vastus lateralis, supplying perforators of the anterolateral thigh.
■ Perforators supplying the anterolateral thigh are either of the following:
■ Musculocutaneous, which pass through the vastus lateralis muscle
■ Septocutaneous, which travel along the septum between the vastus lateralis
and rectus femoris
■ The LFCN passes under the inguinal ligament and pierces the deep fascia to
innervate the skin of the anterolateral thigh.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with a history of peripheral vascular disease, active nicotine use, or
generally poor health are not candidates for free tissue transfer.
■ Obese patients may have a very thick flap and require primary thinning or

secondary debulking procedures.
■ Examine the donor site for scarring and obtain a thorough history to include
previous injury or surgery to the thigh.
■ We do not routinely obtain preoperative angiography.
SURGICAL MANAGEMENT
■ Anterolateral thigh flap is indicated for large soft tissue defects, though it is
versatile and can be used for smaller defects if needed.
■ A two-team approach can be used to decrease surgical time.
■ Flap vascular pedicle can be long (12 cm), allowing for anastomosis outside of
zone of injury, if necessary.
■ Flap dimensions are generally limited to 35 cm long and 15 cm wide on a
single dominant perforator, though multiple perforators are preferred in large
flaps.
■ Limiting the width of the flap to 8 cm generally permits primary donor-site
closure.
Preoperative Planning
■ Preoperative Doppler exam is used to confirm the presence of a perforator.
■ If one is not detectable, consider the contralateral thigh or a different type of
flap.
Positioning
■ Supine with a bump under the right hemipelvis, or lateral decubitus position
■ Drape out the entire lower limb for leg manipulation.
■ Ensure the anterior superior iliac spine (ASIS) and patella are included in the
operative field.
Approach
■ A suprafascial approach to flap harvest achieves a thinner flap design, though
it is more technically challenging.
■ Subfascial flap harvest is technically easier to identify the vascular anatomy
but will result in a bulkier flap.

FIG 1 • Anterolateral thigh flap anatomy.
T E C H N I Q U E S
■ Flap Design
■ Draw a line from the anterosuperior iliac spine (ASIS) to the superolateral
border of the patella. This represents the intermuscular septum between the
rectus femoris and vastus lateralis muscles (TECH FIG 1).
■ Use a portable Doppler device to identify the perforator around the midpoint
of this line.
■ 80% of perforators are found within 3 cm of this point.1

■ Design the flap dimensions based on the recipient site defect.
■ We generally design the perforator to be centrally located in the flap.
■ For large flaps, we attempt to incorporate multiple perforators.
TECH FIG 1 • Flap design and identification of
perforator. A line from the anterosuperior iliac spine
(ASIS) to the superolateral patella (SLP) represents
the intermuscular septum between rectus femoris and
vastus lateralis. Perforators are identified with a
Doppler ultrasound probe.
■ Flap Harvest
■ Under loupe magnification, incise the medial margin of the designed flap.
■ Suprafascial dissection
■ Deepen the medial incision to the deep fascia, and continue lateral
dissection above the deep fascia.
■ Using tenotomy scissors, carefully separate the subcutaneous fat from
underlying deep fascia. If possible, preserve cutaneous nerves overlying the
fascia.
■ Continue dissection from medial to lateral and identify the marked
perforator piercing though the fascia at the level of the intermuscular
septum.
■ Incise the lateral margin of the flap and dissect from lateral to medial until
the same perforator is visualized.
■ Leave a cuff of deep fascia around the perforator, and dissect retrograde
toward its origin until adequate pedicle length and caliber is achieved.
■ Septocutaneous perforators allow for uneventful dissection along the

intermuscular septum. However, the majority of the time perforators are
musculocutaneous and pierce the muscle. To allow for safer dissection, the
vastus lateralis is retracted laterally to visualize the descending LFCA, which
can be dissected down to the perforator through the vastus lateralis muscle by
separating the muscle fibers using scissors and bipolar cautery.
■ Subfascial dissection (TECH FIG 2A)
■ Deepen the medial incision through the thigh fascia, exposing the rectus
femoris muscle.
■ Continue dissection laterally under the deep fascia until the intermuscular
septum between rectus femoris and vastus lateralis is visualized.
■ Retract the rectus femoris medially to visualize the descending branch of
the lateral femoral circumflex artery (LFCA) and its perforating branches.
■ The perforators may be musculocutaneous, traveling through the vastus
lateralis, or septocutaneous, passing directly through the intermuscular
septum.
■ For septocutaneous vessels, dissection is performed from distal to proximal
through the septum until adequate pedicle length and caliber is achieved.
Leave a fascial cuff around the perforator (TECH FIG 2B).
■ For musculocutaneous skin perforators, expose the point of exit from the
muscle. Spread transversely over the vessel and divide the overlying muscle
fibers. Ligate any intramuscular branches of the perforator, and continue
retrograde dissection up to the descending LFCA until adequate pedicle
length and caliber is achieved.
■ If additional pedicle length is needed, continue retrograde dissection up the
descending LFCA. During proximal dissection of the descending LFCA, take
care to preserve the motor branches of the femoral nerve to the vastus
lateralis.

TECH FIG 2 • A. Elevation of flap. Subfascial
elevation allows for identification of the descending
branch of the LCFA (D). Perforator is highlighted in
yellow. RF, rectus femoris; VL, vastus lateralis. B.
Completion of flap elevation. The perforator is
dissected proximally, and the pedicle is dissected up
the descending LFCA.
■ Flap Thinning
■ If the flap is too bulky for the recipient site (hand/wrist), one can perform
flap thinning at the time of harvest, as opposed to debulking at a later date.
For beginners, we do not recommend primary flap thinning as inadvertent
perforator injury can result in flap necrosis.
■ Perform flap thinning after elevation but prior to transection of the vascular
pedicle.
■ Preserve a 3-cm radius cuff of full-thickness adipose tissue around the
perforator.
■ Thin the flap by removing the deep fat tissue, which is characterized by wide
and flat lobules.
■ Removing this deep layer of fat should result in flap thickness of 5 to 6 mm.
■ Donor-Site Closure
■ Obtain adequate hemostasis of the donor site.
■ Reapproximate vastus lateralis muscle edges in cases of intramuscular
dissection.
■ Primary closure is usually possible when the flap width is limited to 8 cm.
■ Place a suction drain to minimize risk of hematoma.
■ If the donor-site width is more than 8 cm, the wound is unlikely to close
primarily. Perform split-thickness skin grafting.
PEARLS AND PITFALLS

Flap
dissection
■ Avoid unnecessary traction during flap elevation by dissecting
around the perforator from the medial border and then lateral border,
as opposed to elevating the entire flap from the medial border.
■ If the skin perforators are too small to safely perform an
intramuscular dissection, consider the use of the operating
microscope, or elevate the flap in a myocutaneous fashion by
incorporating a cuff of muscle around the intramuscular pedicle.
■ Maintain the position of the flap during dissection. Traction on the
perforator(s) from the weight of the flap may cause injury or
vasospasm.
■ If there is concern for vasospasm, bathe perforators in topical
lidocaine.
Flap
thinning
■ Inexperienced surgeons should avoid aggressive one-stage flap
thinning due to the risk of perforator injury and flap necrosis.
Hemostasis
■ Meticulous dissection during flap harvest is necessary particularly
with musculocutaneous perforator dissection, as hasty division of
muscular perforator branches will retract and be difficult to ligate.
Flap inset
■ Avoid twisting of the pedicle by preserving a cuff of fascia and
allowing the pedicle to fall into its normal orientation before final
inset.
POSTOPERATIVE CARE
■ Avoid compressive bandages on the flap.
■ Flaps are checked hourly with Doppler ultrasound for the first 48 hours
postoperatively and then every 4 hours for the next 48 hours.
■ The patient is kept hydrated with intravenous fluids and kept on thrombosis
prophylaxis therapy (low molecular weight heparin) while hospitalized.
■ Drain is removed once output is appropriate, typically less than 30 mL/d.
■ If a skin graft was applied to the donor site, bed rest is instituted until the graft
takes.
■ Secondary debulking of the flap is delayed until 6 to 9 months postoperatively.
OUTCOMES
■ Good results are reported with 96% overall survival rate of 672 flaps.2
■ Donor-site morbidity is generally minimal. Anterolateral thigh numbness may
result from sensory nerve division but can be avoided by careful preservation
of suprafascial nerve branches.

COMPLICATIONS
■ General complications related to free tissue transfer such as flap necrosis and
hematoma are possible.
■ Flap necrosis can occur from overaggressive flap thinning and perforator
injury.
REFERENCES
1. Kimata Y, Uchiyama K, Ebihara S, et al. Anatomic variations and technical
problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr
Surg. 1998;102:1517-1523.
2. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? An
experience with 672 anterolateral thigh flaps. Plast Reconstr Surg.
2002;109:2219-2226.

53
CHAPTER
Revascularization and
Replantation of Digits
Mark Morris and Kevin C. Chung
DEFINITION
■ Revascularization refers to the repair of injured structures and restoration of
circulation to a digit that has been incompletely amputated. Restoration of
vascularity to the incompletely severed digit is necessary to prevent necrosis.
■ Replantation refers to the reattachment of a digit that has been completely
amputated (FIG 1).
■ Revision amputation refers to shortening a digit by debriding nonviable tissue
and protruding bone in order to provide coverage of a digit that is not
amenable to revascularization or replantation.
ANATOMY
■ Each digit has a radial and ulnar proper digital artery. Each vessel is
accompanied by a respective radial or ulnar proper digital nerve. Digital nerves
are sensory only. In the digits, the artery is dorsal to the nerve (FIG 2A).
■ There are three major palmar arches that arise from the digital arteries. The
proximal, middle, and distal arches are located at the level of the C1 pulley, at
the level of the C3 pulley, and just distal to the flexor digitorum profundus
(FDP) insertion, respectively.
■ Four palmar and four dorsal branches extend from each digital artery.
■ The dorsal veins are larger than the palmar veins. Veins do not reliably travel
with the arteries and nerves.
■ Grayson ligament originates from the flexor tendon sheath and inserts on the
skin. It lies palmar to the neurovascular bundle.
■ Cleland ligament originates from the periosteum and inserts on the skin. It lies
dorsal to the neurovascular bundle (FIG 2B).

■ The flexor tendons travel within the flexor sheath. There is a series of five
annular and three cruciform pulleys in which the flexor tendons pass through.
The pulleys are discrete thickenings of the fibro-osseous sheath.
■ Odd-numbered annular pulleys (A1, A3, A5) are located over the joints of the
finger (metacarpophalangeal, proximal interphalangeal, and distal
interphalangeal [DIP], respectively). Even-numbered annular pulleys (A2, A4)
are located over the proximal and middle phalanges, respectively.
■ The A2 and A4 pulleys are important in preventing bowstringing and should
be preserved if possible.
FIG 1 • A–C. Complete amputation of the thumb. This
injury required replantation. D–F. Partially amputated
long and ring fingers. This injury required
revascularization.
FIG 2 • A. Neurovascular anatomy of the digit. B. Axial
cut of the digit, showing the relationship of Cleland and

Grayson ligaments to the neurovascular bundle. The
digital nerve is palmar to the artery.
■ The flexor digitorum superficialis (FDS) splits into two slips at Camper
chiasm and inserts as two slips into the midportion of the middle phalanx.
■ The FDP tendon passes between the two slips of FDS at Camper chiasm and
inserts at the proximal base of the distal phalanx.
■ The extensor digitorum communis (EDC) sends a tendon to each digit. The
index finger also contains the extensor indicis proprius (EIP), and the small
finger also contains the extensor digiti minimi (EDM). The EIP and EDM
tendons are ulnar to their respective EDC tendon.
PATHOGENESIS
■ Amputation can be caused by sharp or blunt dissection, crush injury, or
avulsion injury.
■ Sharp amputations have a narrow zone of injury and are thus better suited for
replantation or revascularization (FIG 3A).
■ Crush and avulsion injuries have a larger zone of injury, which may preclude
replantation or revascularization (FIG 3B).

FIG 3 • A. Clean-cut amputation of the thumb. B–D.
Crush-avulsion injury of the ring finger with a wide zone
of injury secondary to the hand being caught in a gear
mechanism, precluding successful replantation.
NATURAL HISTORY
■ Mean survival rate after replantation is 86% reported by highly experienced
surgeons and hospitals.1
■ Clean-cut amputations have a better survival rate (92%) than crush-cut (80%)
or crush-avulsion injuries (75%).
■ Mean two-point discrimination after replantation is 7 mm.
■ Ninety-eight percent of patients are able to return to work after digit
replantation.1

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The history must include the mechanism and timing of injury. Crush injuries
may preclude replantation depending on the degree of tissue damage.
■ Ischemia time and method of transport must be evaluated. In general, warm
ischemia time of less than 6 hours and cold ischemia time of less than 12 hours
are desired for replantation.
■ Delayed replantation has been shown to have success, however. In a study of
delayed and suspended replantation of digits and hands, Woo et al.2 studied 28
digital and 4 hand amputations that underwent delayed or suspended
amputation (mean cold ischemic time 15 hours 48 minutes). In this series, 24
of 28 digits and all 4 hands survived (88% survival rate). Case reports exist
with successful replantation after warm ischemia times of 42 hours and cold
ischemia times of 94 hours.3,4
■ Transportation method of an amputated digit is important. The digit should not
be placed directly on ice but should rather be wrapped in gauze moistened with
normal saline or lactated Ringer’s and placed into a plastic bag, which is then
placed in an ice slush.
■ A psychological and mental health history is important, as patients will require
significant compliance with rehabilitation protocols.
■ Medical history including diabetes mellitus, peripheral vascular disease,
hypercoagulability, or smoking is not a contraindication to revascularization or
replantation but will affect the healing potential of the digit(s) and must be
discussed with the patient.
■ The surgeon must examine the extremity to assess the number of digits
injured, vascularity and sensation of partially amputated digits, wound
contamination, and type of injury sustained.
■ Several classifications exist for fingertip amputations. Two commonly used
classifications are by Allen and Tamai.
■ Allen5 (FIG 4A)
• Type I: Only the pulp of the finger is involved. No suitable vessel for
anastomosis.
• Type II: Pulp and nail loss. Preserves half of the nail bed. No dorsal vein
available for anastomosis.
• Type III: Partial loss of the distal phalanx in addition to pulp and nail loss.
High incidence of hook-nail deformity if nail bed is not ablated.

• Type IV: Amputation proximal to nail fold. Dorsal vein usually available for
anastomosis.
■ Tamai6 (FIG 4B)
• Zone 1: Fingertip to the base of the nail
• Zone 2: Between the base of the nail and the DIP joint
FIG 4 • Classification of fingertip amputations. A. Allen
classification. B. Tamai classification.
■ Red line sign—a red streak along the lateral border of a digit suggests
hemorrhage from an avulsed branch of the digital artery after a traction injury.
■ Ribbon sign—coiling of a digital artery at the amputation site. This also results
from a traction injury (FIG 5). If replantation or revascularization is attempted,
vein grafting will be required.
IMAGING
■ Standard radiographs of the injured extremity and the amputated parts should
be performed, in order to better understand the extent of injury and to plan
fixation (FIG 6).

NONOPERATIVE MANAGEMENT
■ There is no role for nonoperative management in digit amputations or
dysvascular partial amputations.
■ Occasionally, revision amputation can be performed in the emergency
department, but this is often better done in the operating room with appropriate
anesthesia, sterile conditions, lighting, and equipment.
FIG 5 • The red line sign and ribbon sign are both signs
of artery avulsion from a traction injury. If these signs
are present, a vein graft should be attempted rather
than direct repair, as the vessel walls have been
injured.

FIG 6 • A,B. Radiographs of a patient who sustained a
crush injury to the right hand, with multiple
devascularized digits.
SURGICAL MANAGEMENT
■ Patients undergoing revascularization or replantation should also be consented
for possible revision amputation, as a final decision to revascularize or replant
a digit will be made after all structures are carefully evaluated in the operating
room.
■ Indications for replantation:
■ Thumb
■ Multiple digits
■ Partial hand (through-palm amputation)
■ Through wrist or forearm
■ Almost any part in a child
■ Individual digit distal to the FDS tendon
■ Contraindications to replantation:
■ Severely crushed or mangled digit
■ Multilevel amputation
■ Concomitant life-threatening injuries

■ Severely atherosclerotic vessels
■ Patients who are unable to comply with a postoperative rehabilitation
program
■ Prolonged warm ischemia time (relative; see discussion in history and
physical section)
■ Individual finger amputation in an adult at a level proximal to the FDS
insertion (controversial; limited function in a replanted digit at this level may
negatively affect overall hand function)
■ The sequence of repair is as follows:
■ Debridement and identification of injured and intact structures. Place
vascular clips on the arteries. This will help with later identification. In
addition, if the tourniquet needs to be let down prior to arterial repair, the field
will remain dry.
■ Bone shortening and/or fixation
■ Extensor tendon repair
■ Flexor tendon repair
■ Vein repair while still under tourniquet. This is a deviation from the classic
teaching (arteries before veins), because many surgeons find it easier to repair
veins in a bloodless field.
■ Arterial repair
■ Nerve repair
■ Skin closure/coverage
Preoperative Planning
■ Antibiotics and tetanus prophylaxis are given as soon as possible upon
presentation to the emergency department.
■ Regional anesthesia provides increased peripheral vasodilation.
■ Amputated digits are transported to the operating room, and initial preparation
begins as soon as possible.
■ This can be done while the anesthesia team is evaluating the patient and
inducing anesthesia.
■ The surgical team can use a back table to start dissecting the amputated part
to identify all the parts that will be connected.
Positioning
■ The patient is placed supine on the operating table.
■ The operative extremity is placed on a hand table.

■ A brachial tourniquet is applied.
Approach
■ Debridement and careful identification of structures is the key first step.
■ Keep track of each structure as it is identified by writing a count sheet or
having the circulating nurse do so.
■ Each structure is tagged with a suture or a clip for future identification.
■ Duration of surgery is decreased by repairing “structure by structure” rather
than “digit by digit.” Repair the same structure on each digit rather than
completing all aspects of replantation on one digit at a time.
■ A two-team approach can be used to save time. One team prepares the
amputated digit(s) while the other team prepares the patient.
■ Vein, artery, and nerve repairs are performed under the operating microscope.
Microsurgical instruments are used.
■ Never discard amputated parts until the surgery is over. Amputated parts are a
useful source of autologous materials when needed such as nerve grafts,
vascularized skin flap, tendons, bone, and vessels.
T E C H N I Q U E S
■ Preparation of Amputated Digits and Stumps
■ The amputated digits are brought to the operating room as soon as possible.
One team will prepare the amputated digits while the other team prepares the
patient.
■ The parts are cleaned on a sterile prep table.
■ Contaminated edges of the amputated digits and stumps are debrided, and
arteries, nerves, and veins are identified.
■ Vascular clamps can be placed on arteries at this time for identification and
later hemostasis.
■ Midaxial incisions are made on the radial and ulnar sides of the digit to
further expose neurovascular structures (TECH FIG 1).
■ Flexor and extensor tendons are identified.
■ Bone is shortened with a rongeur or a microsagittal saw to facilitate the
vessel repair to obviate the use of vein graft and nerve graft. Bone should be

shortened if much tissue debridement was required. Shortening will facilitate
tension-free anastomosis and skin closure.
■ Amputated digits should be kept cool until they are ready to be replanted.
TECH FIG 1 • A,B. Midlateral incisions are made on
either side of the amputation to assist in visualization,
identification, and repair of neurovascular structures.
■ Bone Fixation
■ Bone fixation can be accomplished using many different methods, including
longitudinal K-wires, crossed K-wires, intraosseous wiring, tension band,
intramedullary screws, and plate and screws.
■ Parallel longitudinal K-wires are fast and easy and have good success rates.
■ In the amputated digit, two 0.045 K-wires are placed longitudinally into the
bone in retrograde fashion.
■ The wire should exit the tip of the digit just palmar to the nail.
■ Advance the wire until just the tip is showing through the proximal end of
the bone, ready to be advanced into the bone from the stump.
■ Align the bones from the amputated part of the digit and its stump.
■ Take care to restore proper rotational alignment.
■ Advance the K-wires into the proximal bone and confirm location with

radiographs (TECH FIG 2).
TECH FIG 2 • A–C. Parallel K-wire fixation was used
in this case of thumb replantation.
■ Tendon Repair
■ Extensor tendons are repaired with two 4-0 nonabsorbable sutures in
horizontal mattress fashion.
■ In-depth discussion of flexor tendon repair can be found in a separate
chapter in this text.
■ We typically use a looped 4-0 Supramid suture to complete a six-strand
repair of flexor tendons, followed by a running epitendinous 6-0 Prolene
suture.
■ Both flexor digitorum superficialis (FDS) and flexor digitorum profundus
(FDP) can be repaired; however, it is not necessary to repair the FDS if this
will impede tendon gliding if the FDS is shredded and too traumatized.
■ If the amputation is distal to the FDS insertion, extensor and flexor tendon
repair can be disregarded and the distal interphalangeal (DIP) joint can be
fused.
■ Vein Repair

■ Ideally, two veins are repaired for each artery that is repaired.
■ Research has shown a significantly better survival rate after two venous
anastomoses per digit compared with one. However, there was no
difference in this study between none and one vein repaired.7
■ Another study also showed no difference in survival rates between distal
digit replantations with and without venous anastomosis.8
■ We recommend venous repair whenever possible, despite the findings of
the later study.
■ Venous repair prior to arterial repair allows for this most difficult task to be
performed in a bloodless field and perhaps doing this critical procedure when
the surgeon is still fresh, rather than at the end of the case when fatigue sets
in.
■ Because the veins are thin, the surgeon needs to take minimal bites of the
vessel wall to prevent folding in of the adventitia. Side branches can be
clipped to lengthen the vein so that it can reach to the other end.
■ Irrigate the lumen of the vein with heparinized saline using a 30-gauge
blunt-tipped needle to keep it open.
■ Fewer sutures are required for venous repair than arterial repair because of
the low-pressure flow.
■ If vein grafts are required, appropriate-sized donor grafts (1–2 mm) can be
harvested from the volar wrist.
■ Artery Repair
■ Arteries have been previously clamped when structures were identified
earlier. The tourniquet can be let down at this time. Vascular clamps will
control bleeding.
■ Both digital arteries should be repaired when possible, to maximize survival
rates.
■ Damaged ends of arteries are sharply debrided back to normal intima until
one gets a robust spurt from the artery, which indicates suitable resection of
the traumatized vessel.
■ Vein grafts are used if there is any defect after debridement.
■ Vein grafts must be rotated 180 degrees with respect to flow, because of the
valves that are present.
■ For proper size match, vein graft from the volar wrist is used.

■ For vein grafting in the palm, vein graft from the forearm has suitable size
match.
■ Artery ends are approximated in a tension-free manner, but without
redundancy of the vein graft. This can be done with vascular approximating
clamps (TECH FIG 3).
■ A microsurgical dilator is used to dilate the arterial lumen and assess blood
flow by transiently releasing the vascular clamp on the stump side.
■ If there is inadequate blood flow, evaluate for reversible causes such as
vasospasm, cold, acidosis, hypotension/hypovolemia, or mechanical
constriction.
■ Vasospasm can be treated by irrigating with papaverine solution (diluted
1:20 with normal saline).
■ Irrigate the lumen with heparinized saline using a 30-gauge blunt-tipped
needle.
■ We recommend the use of a background to help with visualization.
■ A bolus of 5000 units of intravenous heparin is given prior to anastomosis. A
heparin drip is then initiated at 1000 units per hour.
■ Suture size depends on the size of the vessel being repaired. In general, 11-0
nylon suture is used in the distal digit, 10-0 nylon suture is used in the
proximal digit, and 9-0 nylon suture can be used in the palm.
■ Interrupted sutures are placed circumferentially, with care to avoid capturing
the back wall with the needle.
■ Each bite of the needle should be 1 to 2 times the thickness of the arterial
wall.
■ Leave one limb of each of the initial sutures long. The suture ends can be
used later to manipulate the vessel in a minimally traumatic manner.
■ Release the vascular clamps and observe for pulsations and a water-tight
seal.

TECH FIG 3 • A vascular approximating clamp is used
to bring the arterial ends together in a tension-free
manner.
■ Nerve Repair
■ The severed ends of the nerve are sharply cut using microsurgical scissors or
a no. 11 blade against a wooden tongue depressor.
■ Nerve ends are approximated in a tension-free manner.
■ If tension-free repair is not possible, primary nerve grafting is performed.
The medial or lateral antebrachial cutaneous nerves can be harvested from
the ipsilateral extremity.
■ Alternatively, other amputated digits that are not candidates for
replantation can be used to provide nerve graft of appropriate caliber.
■ Fascicles are aligned and epineural repair is performed using three or four 9-
0 or 10-0 nylon sutures.
■ Closure
■ Obtain hemostasis prior to skin closure. Hematoma will place pressure on
vascular repairs and can result in failure of the replant.
■ Interrupted 4-0 nylon sutures are used to close the skin (TECH FIG 4). Take

care to avoid constriction of underlying structures.
■ Skin grafts or flaps are used as needed.
TECH FIG 4 • Same patient as in FIG 1. Postoperative
images after thumb replantation (A-C) and long and
ring finger revascularization (D,E).
PEARLS AND PITFALLS
Preparation
■ Make a tally sheet for the structures that are injured in each digit as
you debride and identify structures. This will help the case go
smoother and will help with dictation postoperatively.
■ Prioritize the functional goals of the patient for replantation. If
multiple digits are amputated and some are not replantable, the
salvageable digits should be placed in the most functional position—

ie, if the thumb is not salvageable, replant a finger in the thumb’s
position.
Technique
■ Duration of surgery is decreased by repairing “structure by structure”
rather than “digit by digit.” Repair the same structure on each digit
rather than completing all aspects of replantation on one digit at a
time.
■ All anastomoses should be tension-free. Bone shortening or vein
grafting should be performed to accomplish this.
Treatment
of venous
congestion
with
leeches
■ If an inadequate number or quality of venous anatomoses are
performed, venous congestion may occur in the digit. If this occurs,
the nail can be removed and medical leeches (Hirudo medicinalis)
can be placed postoperatively. They should be changed every few
hours and continued for 7 days.
■ Patients should be treated with a third-generation cephalosporin
while leeches are in use as prophylaxis against Aeromonas
hydrophila, which is a symbiotic gram-negative rod in the leech gut.
POSTOPERATIVE CARE
■ The postoperative dressing should not be circumferential or constricting.
■ Xeroform gauze is applied to the incisions.
■ A well-padded plaster splint is applied, with the tips of the digits exposed to
monitor for vascular status.
■ Temperature probes or pulse oximeters can be applied to the fingertips for
monitoring.
■ The splint is changed after 1 or 2 days in case a blood cast forms. If there is
excessive bleeding, the clotted blood on the dressings and splint will solidify
and cause circumferential constriction.
■ Color, warmth, and capillary refill are monitored by the surgeon and nursing
staff.
■ The patient’s room should be kept above 72°F (22°C). We alternatively use a
Bair hugger to cover the extremity and keep it warm.
■ Bed rest is maintained for at least 2 or 3 days, or longer if the vascular status is
tenuous.
■ No caffeine, chocolate, or nicotine is permitted.
■ A bolus of 50 mL Dextran 40 is given in the operating room, followed by a
maintained rate of 20 mL/h while the patient is still hospitalized.
■ The patient is maintained on low molecular weight heparin or unfractionated
heparin for 5 days. Low molecular weight heparin has been reported to be as

effective as unfractionated heparin but with fewer adverse effects.9
■ Aspirin 325 mg daily is started postoperatively and continued for 6 weeks.
■ Anxiolytics can be provided to the patient so he or she does not
unintentionally harm the repair secondary to anxiety.
■ Thorazine 25 mg orally every 8 hours can be used as both an anxiolytic and a
peripheral vasodilator.
OUTCOMES
■ Sebastin and Chung1 performed a systematic review of the outcomes of
replantation of distal digital amputation (FIG 7). Thirty studies were included
in the review.
■ Mean survival rate after replantation was 86%.
FIG 7 • A,B. Five months after bilateral long and ring
finger revascularization. C–E. Ten months after left
thumb replantation.
■ There was no difference in survival of replanted digits based on Tamai
classification of zone I or zone II.
■ Clean-cut amputations had significantly better survival rates than crushed
amputations (92% for clean-cut, 80% for crush-cut, and 75% for crush-
avulsion).

■ Repairing a vein improved survival in both zone I and II replantation (zone I
with venous repair 92% survival vs 83% without repair. Zone II with venous
repair 88% survival vs 78% without repair).
■ Mean two-point discrimination after replantation was 7 mm.
■ Ninety-eight percent of patients were able to return to work.
■ Yu et al.10 performed a meta-analysis to investigate nonsurgical factors
associated with survival rates of digital replantation.
■ Ischemia time (over or under 12 hours) had no significant correlation with
survival rate.
■ Clean-cut injuries had better outcomes than crush and avulsion injuries.
■ The thumb had a better chance of survival than did the small finger (OR
2.09), while there were no significant differences between other digits.
■ The chance of survival was higher in digits that were transported cold when
compared to those transported at room temperature (OR 4.89).
COMPLICATIONS
■ Pulp atrophy (14%)
■ Nail deformity (24%)
■ Failure of replant (14%)
■ Venous congestion
■ Infection
■ Cold intolerance—Almost all patients experience this. Cold intolerance is
expected to improve over the first 2 years but may never resolve.
■ Stiffness—Tenolysis should be delayed for at minimum 3 months
postreplantation.
■ Malunion
■ Nonunion
REFERENCES
1. Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation
of distal digital amputation. Plast Reconstr Surg. 2011;128:723-737.
2. Woo SH, Cheon HJ, Kim YW, et al. Delayed and suspended replantation for
complete amputation of digits and hands. J Hand Surg Am. 2015;40(5):883-
889.
3. Baek SM, Kim SS. Successful digital replantation after 42 hours of warm
ischemia. J Reconstr Microsurg. 1992;8:455-458.
4. Wei FC, Chang YL, Chen HC, Chuang CC. Three successful digital