Operative Technique in Plastic Surgery – Kevin C.Chung

hematoma and minimize pressure on the skin repair.
TECH FIG 1 • A. Anteroposterior radiograph of a 74-
year-old man demonstrating bone sarcoma with soft
tissue mass. B. Axial T1-weighted MRI showing tumor
eroding into femur and abutting sciatic nerve and
popliteal vessels. C. Sagittal MRI showing
craniocaudal extent of tumor. D. Intraoperative
photograph demonstrating soft tissue dissection to
expose tumor, mobilize popliteal vessels and sciatic
nerve, and expose femur in preparation of osteotomy.
E. Intraoperative photograph showing the femur after
tumor resection. F. Allograft femur with ink lines
outlining how the graft will be fashioned to fit the
defect. G. Intraoperative photograph after allograft has
been secured into the native femur. H. Lateral

radiograph of the distal femur 3 weeks after surgery. I.
Lateral radiograph of the distal femur 36 months after
surgery. The allograft has incorporated into the
patient’s femur.
PEARLS AND PITFALLS
Hematoma
■ Dead space after tumor removal should be managed with
drains, muscle flap, free tissue transfer, or a combination of
these techniques.
■ Seroma drainage in the clinic may be necessary.
Wound
breakdown
■ Incisional negative pressure dressings, aggressive dead space
management, and maximizing patients’ nutrition may reduce
wound problems.
■ Patients should be counseled about potential need for
reoperation for wound management.
Positive margins
■ Appropriate preoperative planning is important to minimize
risk of unplanned positive margins.
■ Planned positive margins around critical structures such as
nerves and vessels may be appropriate in certain settings.
Allograft
nonunion/fracture
■ Common complications may be minimized by good cortical
apposition of graft to the native bone.
■ Restrict weight bearing until evidence of bone healing is
observed.
■ Counsel patients that reoperation for nonunion is possible.
POSTOPERATIVE CARE
■ Mobilization and weight bearing depend on the extent of surgery.
■ Extremity elevation is recommended while patient is in bed.
■ Range of motion and therapy may begin after wound healing is sufficient.
■ May administer antibiotics in the perioperative period.
OUTCOMES
■ Oncological outcomes include local recurrence and metastasis. Surveillance

for recurrence should be managed by a multidisciplinary sarcoma team. Local
recurrence is greater when margins are positive.
■ Functional outcomes depend on the extent of tissue resection and patient
overall health status. Most patients will experience some form of disability that
is proportional to the volume of muscle and bone resected.3,4
COMPLICATIONS
■ Allograft nonunion and fracture are relatively common and require additional
surgery to achieve a limb salvage.5
■ Local recurrence occurs in a minority of patients and is more common in
patients with positive margins.
■ Deep infection can occur at any time after surgery and requires aggressive
therapy including surgical debridement and antibiotic therapy to achieve limb
salvage. Removal of implants may be necessary to eradicate infection.
REFERENCES
1. Bacci G, Forni C, Longhi A, et al. Local recurrence and local control of non-
metastatic osteosarcoma of the extremities: a 27-year experience in a single
institution. J Surg Oncol. 2007;96(2):118.
2. Grimer RJ, Taminiau AM, Cannon SR; Surgical Subcommittee of the
European Osteosarcoma Intergroup. Surgical outcomes in osteosarcoma. J
Bone Joint Surg Br. 2002;84(3):395.
3. Nagarajan R, Neglia JP, Clohisy DR, Robison LL. Limb salvage and
amputation in survivors of pediatric lower-extremity bone tumors: what are the
long-term implications? J Clin Oncol. 2002;20(22): 4493.
4. Renard AJ, Veth RP, Schreuder HW, et al. Function and complications after
ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg
Oncol. 2000;73(4):198.
5. Hornicek FJ, Gebhardt MC, Tomford WW, et al. Factors affecting nonunion of
the allograft-host junction. Clin Orthop Relat Res. 2001;(382):87-98.

37
CHAPTER
Femoral Bone Debridement
Robert J. Steffner, David W. Lowenberg, and Sahitya K.
Denduluri
DEFINITION
■ Femoral bone debridement is generally needed for osteomyelitis (acute or
chronic), symptomatic nonunion, and open fracture.
ANATOMY
■ The femur contributes to the hip and knee joints and withstands significant
stress in motion.
■ Vital structures around the femur include the sciatic and femoral nerves, the
superficial and deep femoral artery and vein, and the extensor mechanism for
knee extension.
PATHOGENESIS
■ Open fracture leads to gross contamination, soft tissue stripping, and avascular
bone. Direct inoculation occurs, which will lead to infection in the absence of
prompt surgical care.
■ Hematogenous spread of bacteria to the bone can create osteomyelitis. Acute
infection tends to produce rapid symptoms and the accumulation of purulent
fluid. Chronic infection is more indolent and produces waxing and waning
symptoms. After a week or two of infection, bacteria form a protective
avascular matrix called biofilm. Antibiotics cannot penetrate this layer.
■ Nonunion is a fractured bone that will not heal. Hypertrophic nonunion comes
from too much fracture site motion. Atrophic nonunion is from poor blood
supply and inadequate substrate for bone healing. Infection can also lead to
nonhealing bone and sometimes creates a false joint known as a pseudarthrosis.
■ In all of these instances, surgical debridement is required to promote bone

recovery and healing.
NATURAL HISTORY
■ Neglected open fractures and osteomyelitis can lead to systemic infection and
sepsis, which is life threatening.
■ Chronic infection can produce a nonhealing wound with drainage. This limits
quality of life and can also lead to squamous cell carcinoma at areas of long-
standing skin ulceration.1
■ Nonunion in the femur limits weight bearing and mobilization. Pain is often
present with activity. Quality of life is significantly diminished.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Ask about prior trauma, surgical procedures, and any complications or wound
healing problems.
■ Specifically ask about cellulitis and draining sinus tracts.
■ Assume infection until proven otherwise.
■ Assess impact on the patient’s quality of life.
■ Inquire about recent antibiotic use.
■ Determine host factors such as nutrition, nicotine use, medical comorbidities,
use of immunosuppressive and anti-inflammatory medications, and any prior
radiation exposure to the area of interest.
■ Visually inspect the patient’s thigh. Look for deformity, leg length
discrepancy, and rotational change from the contralateral side.
■ Lab work including WBC, ESR, and CRP can help determine the presence of
infection.
IMAGING
■ Plain radiographs can demonstrate nonhealing bone, erosive cortical changes
seen in acute infection, and sclerotic thickening seen in chronic infection (FIG
1).

FIG 1 • A. AP and lateral (B) radiographs of a distal
femur chronic osteomyelitis in the setting of prior
internal fixation for an open distal femur fracture.
Original hardware removed with exception of a broken
screw. Radiolucent changes (arrows) seen in the
metaphysis of a patient with clinical evidence of a
draining sinus tract.
FIG 2 • A. Coronal and sagittal (B) CT scan of the distal
femur with chronic osteomyelitis demonstrating sclerotic
rim of the bone (involucrum) surrounding a spicule of
the bone (sequestrum, arrow).
■ Full-length, weight-bearing radiographs of the lower extremities show
deformity and leg length discrepancy.

■ CT scan is best for bony detail. It is the modality of choice to identify a nidus
of dead bone (sequestrum) and surrounding sclerotic bone (involucrum) seen in
chronic osteomyelitis (FIG 2).
■ MRI imaging assesses the level of intramedullary bone and soft tissue
involvement with bone infections. This is crucial in determining the extent of
surgical debridement.
NONOPERATIVE MANAGEMENT
■ Nonhealing bone and bone infection in the femur are almost always operative
given the structural importance for weight bearing and ambulation.
■ Exceptions include low-demand patients with minimal symptoms, patients
who adapt well with assist devices, and patients at high surgical risk due to
medical comorbidities.
■ Nonunion patients without infection can try bracing and bone stimulation
devices before surgery.
SURGICAL MANAGEMENT
■ It is important to set patient expectations. Several debridement procedures may
be needed to create a favorable bone and soft tissue bed for reconstructing and
healing. Persistent or recurrent nonunion or infection may happen despite
aggressive surgical management.
Preoperative Planning
■ Address modifiable host factors including smoking cessation, nutrition,
glycemic control, and medication use (anti-inflammatories, corticosteroids,
etc.).
■ In the lower extremity, quantify the degree of limb shortening, malalignment,
and malrotation. Shortening greater than 2 cm and deformity greater than 10
degrees tend to limit a patient’s quality of life.
■ Anticipate the extent of debridement and appropriately plan for bony
stabilization, dead space management, and soft tissue coverage.
■ A reamer-irrigator-aspirator device can assist with intramedullary debridement
in long bone osteomyelitis.2
■ Hold antibiotics for culture. Multiple cultures should be obtained and sent for
aerobic, anaerobic, fungal, and yeast assessment. Cultures will guide
postoperative medical therapy.
■ Send soft tissue and bone for surgical pathology. This will help determine the

presence and chronicity of infection, especially if cultures are negative.
FIG 3 • Illustration of the lateral approach to the femur.
A. The iliotibial band is divided in-line with the skin
incision, and the vastus lateralis is raised off the
intermuscular septum with clips placed on perforating
branches of the profunda femoris artery and vein (B).
Positioning
■ Both lateral decubitus with an axillary roll and supine position with hip bumps
and a leg ramp are acceptable for a lateral approach to the femur.
■ Lateral position is best for the upper half of the femur, and supine position
with leg ramp is best for the distal half of the femur.

■ Use a radiolucent table to allow intraoperative fluoroscopy.
Approach
■ Planned access to the femur is generally through a lateral approach (FIG 3).
Traumatic wounds and prior incisions can sometimes lead to alternative
approaches.
T E C H N I Q U E S
■ Debridement of Chronic Osteomyelitis of the
Distal Femur
■ Patient is positioned supine with an ipsilateral hip bump on a radiolucent
table. A small leg ramp can be added to facilitate intraoperative imaging.
■ Antibiotics are held for culture and then given.
■ Open wounds are prepped with Betadine scrub and paint.
■ Before incision, the involved anatomic location is identified with
intraoperative fluoroscopy.
■ A straight lateral incision is made.
■ Compromised skin is generally characterized as multiply operated, puckered,
and adherent. This skin, in addition to any sinus tracts, should be sharply
excised. Remaining skin should have bleeding edges.
■ The iliotibial band is split in-line with the skin incision, and the vastus
lateralis muscle is raised off the lateral intermuscular septum. The muscle is
retracted upward to identify perforating vascular branches from the deep
profunda artery and vein.
■ Ligating branches with surgical clips preserves branches for possible
microsurgical anastomosis.
■ Using a combination of a microsaw, osteotomes, and high-speed bur, a long
cortical window is created in the lateral femoral cortex. The high-speed bur is
then used from inside-out to widen the elongated ellipse to improve access to
the intramedullary canal (TECH FIG 1A). Irrigating during use of the bur
can limit heat necrosis of the bone.
■ Multiple cultures are obtained from the soft tissue and bone. The bone is sent
for surgical pathology.

■ Aggressive debridement involves excision of all nonviable soft tissue and
bone (TECH FIG 1B), including sequestra (TECH FIG 1C). Surgical tools
for debridement include curettes, rongeurs, osteotomes, high-speed bur, and
fresh surgical blades.
■ Wound irrigation is performed with low-flow cystoscopic tubing. Many
liters of normal saline with antibiotics are advised.
■ An adequately debrided field demonstrates bleeding tissues with normal
color and properties such as contractility.
■ Polymethyl methacrylate (PMMA) is mixed with medications to create filler
for the defect created from the debridement. The medications used, which
may include antibiotics, antifungals, and antiparasitics, should be discussed
before surgery with infectious disease and pharmacy colleagues.
■ Appropriate drug concentrations with PMMA should also be discussed with
a pharmacist.
■ PMMA beads can be made either by hand or with a mold. A line of beads is
placed along a thick monofilament suture. It is important to document the
number of beads being implanted.
■ Pack the dead space with antibiotic beads (TECH FIG 1D).
■ Surgical stabilization should bridge the defect. Options include external
fixation, an antibiotic-impregnated cement intramedullary nail, or a locking
plate coated in antibiotic cement (TECH FIG 1E,F).
■ Final fluoroscopic or radiographic images should be taken to document
implants.
■ Deep drains are utilized to help with dead space management.
■ Remaining soft tissues should be healthy and bleeding. Attempt to isolate
deep fascial layers for a tiered closure. Primary closure should not have a lot
of tension. The surgeon should maintain a low threshold for rotational or free
tissue coverage.

TECH FIG 1 • A. Clinical photograph of an exposed
distal femur with the creation of a long cortical window
with evidence of infected soft tissue within the
intramedullary canal. B. Fluoroscopic image showing
debridement of the femur intramedullary canal with a
curette. C. Photograph of sequestra removed during
debridement of the distal femur. D. Photograph of
cement antibiotic beads placed into the bone defect
after debridement of chronic osteomyelitis. E.
Postoperative AP and lateral (F) radiographs of the
distal femur after debridement, placement of antibiotic
beads, and stabilization of the defect.
PEARLS AND PITFALLS
Hip and
knee
■ In the setting of infection, consider aspirating adjacent joints to
ensure there is no associated septic arthritis.
■ Surgical stabilization should be robust enough to allow joint passive

range of motion during recovery.
Debridement
■ Retained hardware likely has a bacterial biofilm. Efforts should be
made to remove all foreign bodies during the debridement.
Tumor
■ Bone tumors can look like bone infection. If there is any
uncertainty, a biopsy should be performed before debridement.
Bacteria
■ Some microbiology labs can run polymerase chain reaction (PCR)
to identify microbial DNA.
Antibiotic
nail
■ Bone defects can be supported with an antibiotic intramedullary
nail. Inject a chest tube with cement mixed with antibiotics and let
dry with a guide wire inserted into the cement. A small injection
nozzle is often needed. Once dry, bend the guide wire at the top to
facilitate removal of the nail. Bone must be reamed to a diameter
1.5 mm larger than the diameter of the chest tube.
POSTOPERATIVE CARE
■ Dressings can be removed in 48 hours and the patient may shower with soap
and water.
■ Encourage early range of motion of surrounding joints to avoid stiffness.
■ Intravenous medications are tailored to operative cultures and are determined
in consultation with infectious disease specialists. Cultures may not grow
because many patients receive antibiotic therapy before debridement and some
bacteria require special media.
■ Patients with infection are monitored clinically and with serial lab studies
(ESR and CRP). After antibiotics are complete, the patient is observed for a
few weeks for signs of recurrent infection. If there are no concerns,
management of the bone defect can ensue. Many physicians will perform
intraoperative frozen section studies assessing the number of neutrophils per
high-powered field at any subsequent surgeries. It is wise to maintain suspicion
of infection.
■ Persistent or recurrent infection starts the process over again.
OUTCOMES
■ Coagulase-negative Staphylococcus and Staphylococcus aureus are the most
common causes of bacterial osteomyelitis.3
■ Age (60 years and older) and diabetes are risk factors for osteomyelitis.4
■ The most common cause of persistent infection is inadequate debridement.5
Often times, the site of inadequate debridement is the intramedullary canal.

COMPLICATIONS
■ The bone that does not heal after debridement, stabilization, and possible
antibiotic therapy should trigger additional workup to examine host factors,
poor vascularity of tissues, presence of unidentified metabolic conditions, and
possible persistent or new infection.
■ Nonhealing bone should also consider the need for more stability
(hypertrophic nonunion) or more biology (atrophic nonunion).
REFERENCES
1. Kerr-Valentic MA, Samimi K, Rohlen BH, et al. Marjolin’s ulcer: modern
analysis of an ancient problem. Plast Reconstr Surg. 2009;123: 184-191.
2. Tosounidis TH, Calori GM, Giannoudis PV. The use of reamer-irrigator-
aspirator in the management of long bone osteomyelitis: an update. Eur J
Trauma Emerg Surg. 2016;42:417-423.
3. Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004;364:369-379.
4. Kremers HM, Nwojo ME, Ransom JE. Trends in the epidemiology of
osteomyelitis: a population-based study, 1969–2009. J Bone Joint Surg Am.
2015;97:837-845.
5. Wagner JM, Zöllner H, Wallner C. Surgical debridement is superior to sole
antibiotic therapy in a novel murine posttraumatic osteomyelitis model. PLoS
One. 2016;11:1-13.

38
CHAPTER
Reconstruction of Femur
Vishwanath R. Chegireddy, Michael J. A. Klebuc, and
Anthony Echo
DEFINITION
■ Femoral shaft bone defects usually result from tumor resection, traumatic loss,
chronic osteomyelitis, congenital skeletal defects, failed allografts, or infected
nonunions.1,2
■ Extensive resection of long bone can lead to large intercalary osseous defects
necessitating reconstruction, which was traditionally achieved with allografts
or allograft prosthetic composites. These allografts were associated with high
rates of complications, including joint instability, fracture of the allograft, and
infection of the allograft.3
■ Vascularized bone flaps are essential for successful bone reconstruction due to
their ability to incorporate into the recipient site and provide early bone
consolidation while maintaining stability of the appendicular skeletal structure.
Owing to its independent blood supply, such a flap is well incorporated into the
recipient bone despite compromised surrounding tissue from previous surgery
or radiation therapy.
■ The advantage of vascularized bone flap over nonvascularized bone grafts is
the intrinsic ability to integrate into the recipient bone similar to standard
fracture healing instead of creeping substitution.
■ The fibula is an ideal vascularized bone flap for femur reconstruction due to its
ease of access for harvest while preserving the stability of the proximal and
distal tibial-fibular syndesmosis despite segmental resection. It has a negligible
influence on knee and ankle joint stability without compromising weight-
bearing ability or function of the lower extremity.
■ The vascularized fibular flap undergoes hypertrophy overtime in response to
continuous pressure load, which translates to remarkable long-term

durability.4–6
ANATOMY
■ The femur is the longest and strongest bone in the body and is subject to large
amounts of axial loading as well as significant rotational angular stresses.
■ The fibula is a long and thin cortical bone with a small medullary component.
In adults, the width of the fibula is 1.5 to 2 cm with a length of 35 cm of which
approximately 25 cm of the fibular diaphysis can be harvested for free tissue
transfer.
■ Vascular supply to the diaphysis of the fibula is via a dominant nutrient
endosteal artery and minor musculoperiosteal branches from the peroneal
artery and veins. These vessels run parallel to the fibula and course between
the flexor hallucis longus (FHL) and tibialis posterior muscle group.
■ The dominant nutrient artery branches 6 to 14 cm from the peroneal artery
bifurcation and enters the fibula posterior to the interosseous membrane. It then
courses into the nutrient foramen located in the middle third of the diaphysis
and further divides into an ascending and descending branch.
■ Musculoperiosteal vessels are derived from the peroneal artery and travel
within the posterolateral septum, through the FHL and tibialis posterior muscle,
giving segmental rise to four to eight branches that supply the muscles in the
anterior compartment, soleus muscle, and lateral leg skin territory. The
majority of the periosteal branches are located in the middle third of the fibula
(FIG 1).
■ Soft tissue defect coverage is achieved with a skin paddle supplied by
perforators traversing through the posterior crural septum with the majority
concentrating at the proximal and distal ends of the fibula. These
fasciocutaneous perforators supply a skin paddle up to 10 × 20 cm in size.7
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Detailed preoperative evaluation is required for patients undergoing extensive
long bone resection and intercalary bone defect reconstruction.
■ A thorough medical history should be obtained to evaluate the peroneal artery
for free fibula graft. Pertinent history includes trauma, deep venous thrombosis,
peripheral vascular disease, lymphedema, or venous insufficiency. Patients
with peripheral vascular disease may not be a candidate for surgery.
■ Physical exam should include an evaluation of knee and ankle joints for range
of motion and laxity, and a foot Allen test with a Doppler probe to access

dorsalis pedis and posterior tibial arteries.
■ Peronea arteria magna is a congenital variant of the arterial inflow to the foot,
which affects about 1% to 8% of the population, where both the anterior and
posterior tibial arteries are hypoplastic or absent with the peroneal artery
serving as the single arterial supply below the knee.
■ Patients with an abnormal vascular exam or a history of trauma to the affected
extremity will need additional preoperative imaging such as an arteriogram,
computed tomography angiogram (CTA), duplex ultrasound, or magnetic
resonance angiography (MRA) to identify atherosclerotic occlusive disease or
congenital anomalies.

FIG 1 • A. Cross-sectional anatomy of four
compartments at midtibial level. B. Vascular supply to
the lower extremity.
IMAGING
■ Preoperative imaging of both the recipient and donor sites should include an
evaluation of:
■ Recipient site:

■ The extent of bone resection, length and diameter of the intercalary defect,
and potential soft tissue defect (FIG 2). This allows the surgeon to determine
the extent of the tumor burden, traumatic bone loss, or chronic osteomyelitis
and plan for reconstructive options.
■ Donor site:
■ Evaluate vascular supply with Doppler ultrasound (anterior tibial, posterior
tibial, and dorsalis pedis arteries), and exclude any fibular deformities.
■ Angiogram to look for vessel patency and flow to the foot.
FIG 2 • A. Anterior and lateral (B) preoperative MRIs
showing a right midfemur chondroblastoma. C. Plain
radiograph of the right femur showing chondroblastoma.
SURGICAL MANAGEMENT
Preoperative Planning
■ Free fibula bone graft can be transferred with a generous skin paddle and
adjacent muscles such as soleus, peroneal muscles, or FHL.
■ Either right or left leg can be used as a donor for fibula flap. The left side is
preferable in most patients because it is the less dominant leg and used less
frequently while driving a vehicle. However, thoughtful planning of vessel
orientation in the recipient site should be considered, when deciding upon
laterality.
■ Prior to incision, anatomical landmarks including the head of the fibula, lateral
malleolus, and anterior and posterior border of the fibula are marked. The
posterior border of the fibula correlates with the posterior intermuscular

septum encasing the vascular supply to the skin paddle (FIG 3).
■ Intraoperative Doppler probe is used to identify perforator vessels to design
the skin paddle centered over the posterior crural septum. Sometimes, the
perforators pass through the FHL and/or soleus muscles and lie posterior to the
septum.
■ Area of fibula bone resection is marked with superior margin 4 cm below the
head of the fibula and inferiorly 6 cm above the lateral malleolus. By
preserving the proximal fibula, the stability of the knee is maintained without
disrupting the attachment of the tibia to the fibula, fibular collateral ligament to
the head of the fibula, and biceps femoris muscle. Also, the common peroneal
nerve courses inferior to the head of the fibula, and identifying this location
can prevent injury during dissection.
Positioning
■ Positioning can allow two surgical teams to work simultaneously, if the
contralateral fibula flap is used (FIG 4):
■ The patient is placed in the supine position on the operative table with the
donor side knee flexed 90 degrees. A roll is placed under the ipsilateral hip to
internally rotate the pelvic girdle and keep the hip and knee flexed.
■ A heel stop can be placed on the operative room table to help knee at 90
degrees, when harvesting in the supine position.
■ The patient can also be placed in lateral decubitus position if donor and
recipient site is in the same limb:
■ A bean bag can help keep the patient in the lateral position.
■ All pressure points should be carefully padded and protected.

FIG 3 • Intraoperative marking of anatomical landmarks
for an ipsilateral fibula harvest in the lateral decubitus
position: head of the fibula, lateral malleolus, and
anteroposterior fibular border.
FIG 4 • If the contralateral fibula flap is desired, the
patient can be placed in a supine position, which allows
two teams to work simultaneously for recipient
preparation and donor site harvest.
Approach
■ Plastic surgeons and orthopedic surgical team will need to work together to
coordinate resection of the affected femur segment and reconstruction of the
subsequent intercalary defect. Preservation of potential recipient vessels is of
the upmost importance.

■ Reconstruction of long femoral intercalary defects with vascularized fibula
alone is not sufficient due to inadequate stability and fragility of the bone to
tolerate early weight bearing. The Capanna method is ideal in this scenario,
using a femoral allograft as a peripheral shell and telescoping the free fibula
graft through the allograft segment.7
■ Reconstruction of smaller intercalary defects up to 13 cm can be achieved with
double-barrelled fibular flap, keeping the arterial blood supply intact while
performing an osteotomy in the fibula flap.
■ Initial exposure by the plastic surgeon serves to protect the recipient vessels
for microvascular anastomosis at a later point. Although any artery or vein of
adequate caliber can be utilized as the recipient vessel, the descending branch
of the lateral femoral circumflex artery and vein is the preferred vessel because
of its location.
■ If extensive soft tissue defect is anticipated due to trauma or tumor/chronic
osteomyelitis resection, then a skin paddle can be harvested with the fibular
flap by sharing the same vascular pedicle, which helps with early detection of
flap compromise and provides tension-free skin closure of recipient site.
T E C H N I Q U E S
■ Free Fibula Flap
■ After the bone tumor or chronic osteomyelitis resection by the orthopedic
surgical team, the dimensions of the intercalary bone defect are measured
(TECH FIG 1A).
■ Prior to flap harvest, a sterile tourniquet is placed on the midthigh while
avoiding compression over the fibular head and common peroneal nerve.
■ By tracing the anatomical landmarks, a midlateral vertical incision is made
over the fibula, and skin flaps are elevated at the level of the fascia.

TECH FIG 1 • A. Right femoral intercalary defect
remaining after the tumor resection. B. Exposure of
peroneus longus and soleus at the midtibial level. C.
Dissection around the fibula and lateral muscle

compartment. Dissection proceeds proximally to
identify and protect the superficial peroneal nerve. D.
Dissection anterior to the fibula through the anterior
intermuscular septum and protecting the deep
peroneal nerve and anterior tibial vessels. E. After the
distal fibula osteotomy, the peroneal vessels located
between FHL and tibialis posterior muscle groups
should be ligated distally. F. Adequate fibula length is
freed, and proximal osteotomy is performed carefully
while protecting the pedicle vessels. G. Isolated fibula
graft with intact peroneal vessels.
■ Dissection is carried through the investing fascia of the lateral compartment,
anterior to the posterior intermuscular septum (TECH FIG 1B–D):
■ Care should be taken to preserve fasciocutaneous perforators traveling
through the posterior intermuscular septum if a skin island is needed for
osteocutaneous flap.
■ During proximal dissection, identify and preserve the common peroneal
nerve traversing around the head of the fibula to become the superficial
peroneal nerve.
■ The peroneal muscles are dissected off the anterior surface of the fibula and
reflected anteriorly to expose the anterior intermuscular septum. The septum
is incised to gain access to the anterior compartment and reflect extensor
digitorum and hallucis muscles to identify and preserve anterior tibial vessels
and deep peroneal nerve.
■ The interosseous membrane is incised to enter the deep posterior
compartment, and the peroneal vessels are located between tibialis posterior
and flexor hallucis longus (FHL) muscles.
■ After adequate length of the fibula is marked for reconstruction, towel
clamps are used to apply lateral traction on the proximal and distal fibula
while osteotomizing with an oscillating saw or Gigli saw. If possible, a strip
of periosteum overlying the osteotomy site should be included to overlap the
osteotomy sites at the recipient site.
■ Prior to performing osteotomy, a microvascular clamp can be applied to the
peroneal artery distal to the osteotomy site to ensure adequate supply to the

foot and then divided (TECH FIG 1E):
■ The vascular pedicle is dissected starting distally and carried proximally up
to the origin of tibioperoneal trunk and ligated with approximately 2 to 6
cm of pedicle length.
■ Next, the peroneal vessels are identified proximally and distally, and
dissection is propagated circumferentially around the fibula while staying
medial to the vessels using a large right-angle clamp. The vascular pedicle
should be maintained during dissection.
■ After the fibula graft is fully mobilized with the pedicle (TECH FIG 1F,G),
the tourniquet is released. One should see robust arterial inflow and venous
outflow and healthy back bleeding from both the periosteum and
intramedullary canal.
■ An osteomuscular flap can also be harvested in similar fashion to include
soleus and FHL muscles. This can aid in filling the dead space in patients
with extensive soft tissue defect.
■ If the distal osteotomy is close to lateral malleolus, a screw fixation to the
tibia can be utilized to prevent valgus deformity and ankle instability, which
is more important in a pediatric patient.
■ Capanna Method
■ The Capanna technique combines a vascularized fibula graft with massive
allograft to reconstruct large defects of the femur to provide structurally
competent reconstruction with vascular perfusion and osteogenic capability
to achieve lower rates of infection, fracture, and nonunion.8
■ The free fibula graft can be harvested in similar fashion mentioned earlier:
■ The allograft is cut to match the resected defect, and the medullary canal of
the allograft is enlarged with a reamer to create a space for fibula graft
(TECH FIG 2A).
■ A bur is used to create a window in the allograft to accommodate the
vascular pedicle without external compression (TECH FIG 2B).

TECH FIG 2 • A. In the Capanna technique, the
allograft is cut to match the femur defect size, and the
fibula is telescoped into the intramedullary canal of the
allograft. Care should be taken to accommodate the
vascular pedicle. B. The Capanna technique using a
femoral allograft. C. Microvascular anastomosis
between the recipient vessels (descending branch of
the lateral femoral circumflex artery and vein) and the
flap vessels (peroneal artery and vein).
■ The fibula is telescoped into the intramedullary canal of the allograft and
delivered into the recipient site. This is anchored to the femur proximally and
distally with compression plates and screws. During this step, care is taken to
prevent any damage to the nutrient vessel.
■ Standard microvascular anastomosis is performed between the recipient

vessels and peroneal artery and accompanying venae comitantes (TECH FIG
2C):
■ Additionally, several fat grafts can be placed around the pedicle in an effort
to prevent compression.
■ A well-padded posterior leg splint is applied to keep the foot in extension to
prevent an equinus deformity.
■ Double Barrel Fibula Technique
■ This technique can be useful for reconstruction of smaller femur defect
without the use of an allograft:
■ Larger defects will not be able to be reconstructed with a single fibula in a
double-barreled fashion; both fibulas would need to be harvested which is
not usually recommended.
■ The fibula graft is harvested in similar fashion as described previously. This
technique provides a graft that doubles the cross-sectional area of the flap but
only requires single arterial and venous anastomosis (TECH FIG 3).
■ At the site of the proposed osteotomy, the vascular pedicle is carefully
elevated off the bone flap in the subperiosteal plane with an elevator over a
segment of 2 to 3 cm, which will allow a malleable retractor to be placed to
protect the pedicle.
■ The graft is osteotomized at the midpoint, with care taken to preserve the
peroneal vessels.

TECH FIG 3 • In the double-barrelled fibula repair, free
fibula is harvested with the peroneal vessels intact.
The graft is then osteotomized at the midpoint and
folded.
PEARLS AND PITFALLS
Flap inset
■ The goal is to maximize bone-to-bone contact between the recipient
bone ends and fibula flap.
■ Opposition and stability can be achieved by making wedges, steps,
or another method that articulates the bone ends together. Creating
adequate opposition helps with bone healing while minimizing the
number of screws placed into the fibula flap for fixation.
Vascular
pedicle
■ Any fixation needs to consider the vascular pedicle of the flap. The
plate should not be placed over the vascular pedicle. In some cases,
the screws placed within the bone flap may need to be unicortical.
The plastic surgeon should be actively involved with the fixation
and inset of the flap.
Vascular
variations
■ Peronea arteria magna is a congenital variant of the arterial inflow
to the foot, where both the anterior and posterior tibial arteries are
hypoplastic or absent with the peroneal artery serving as the single
arterial supply below the knee.

Injury to
common
peroneal
nerve
■ The nerve courses inferior to the head of the fibula and should be
identified during proximal dissection to prevent injury.
Careful
dissection
of skin
perforators
■ Preserve the posterior intermuscular septum, which carries
perforators to the skin paddle.
POSTOPERATIVE CARE
■ Monitor donor site for signs and symptoms of vascular insufficiency or
compartment syndrome.
■ Assess the drains daily and remove if output is less than 20 to 30 cc/day.
■ Monitor the flap postoperatively with clinical exam and using Doppler probe
every hour for the first 24 hours. Flap monitoring should continue until
discharge to check microanastomotic patency and skin island perfusion.
■ An internal implantable Doppler can be utilized to monitor a bone flap without
a skin paddle.
■ No ambulation for 2 weeks postoperatively. Afterward, start with partial
weight bearing with crutches until full weight bearing when bone union is
achieved.
■ If an osteocutaneous flap used for reconstruction fails due to vessel
thrombosis, the skin island can be debrided or allowed to heal secondarily. The
bone graft can remain in place, and hyperbaric oxygen therapy can be utilized
to increase the chance of bone revascularization.
OUTCOMES
■ Limb functionality varies depending on trauma, tumor, or infectious etiology.
■ Patient counseling is crucial: numerous revision procedures (8.7 per patient)9
common for best results
■ 64% of lower extremity flap complications resolve conservatively; 36%
require additional bone grafting or flap revisions.10
■ Full bone healing: 86% of patients
■ Ambulation: all patients (100%) at an average 9.59 to 14.3 months11

■ Joint stiffness (40%) and pain (18%) are frequent.9
■ Return to work: 63.5% of patients with primarily salvaged limbs12
COMPLICATIONS
■ General complications:
■ Wound infection (9.6%–23.2%)9,11,13,14
■ Bleeding (6.7%)6
■ Delayed wound healing or dehiscence (10.0%)6
■ Cosmetically unpleasant scar
■ Recipient site:
■ Flap failure (3.8%–5.8%)12,14 due to compromised flap perfusion (eg,
anastomotic thrombosis)
■ Minor necrotic areas (11.5%)14 due to temporary interruptions of the vascular
supply
■ Bone nonunion (15.5%–31.0%)12,13
■ Osteomyelitis (8.6%–17.3%)12,13
■ Revision surgery and need bone for grafting
■ Amputation as ultima ratio (3.9%–7.3%)12,13
■ Donor site:
■ Knee/ankle instability with secondary pseudoarthrosis (2.0%)9
■ Prevention: sparing 6 cm at the proximal and 6 cm at the distal end of the
fibula in order not to violate the connective structures:
■ Inability to flex the great toe due to extensive dissection of FLH
■ Loss of sensation of peroneal nerve (10.0%)9
■ Skin graft failure after donor site closure
■ Because of the improvements of microsurgical training and techniques, the use
of autologous tissue for lower extremity reconstructions is continuously
increasing and offers lower complication rates compared to allografts.6
ACKNOWLEDGMENTS
Thank you to D. Zavlin, MD, and Michael J. A. Klebuc, MD, of Houston
Methodist Hospital and Weill Cornell Medicine, Houston, Texas, for their help in
preparing this chapter.
REFERENCES
1. Bickels J, Meller I, Henshaw RM, Malawer MM. Reconstruction of hip
stability after proximal and total femur resections. Clin Orthop Relat Res.

2000(375):218-230.
2. Friesecke C, Plutat J, Block A. Revision arthroplasty with use of a total femur
prosthesis. J Bone Joint Surg Am. 2005;87(12):2693-2701.
3. Getty PJ, Peabody TD. Complications and functional outcomes of
reconstruction with an osteoarticular allograft after intra-articular resection of
the proximal aspect of the humerus. J Bone Joint Surg Am. 1999;81(8):1138-
1146.
4. Capanna R, Campanacci DA, Belot N, et al. A new reconstructive technique
for intercalary defects of long bones: the association of massive allograft with
vascularized fibular autograft. Long-term results and comparison with
alternative techniques. Orthop Clin North Am. 2007;38(1):51-60.
5. Malizos KN, Zalavras CG, Soucacos PN, et al. Free vascularized fibular grafts
for reconstruction of skeletal defects. J Am Acad Orthop Surg. 2004;12(5):360-
369.
6. Zaretski A, Amir A, Meller I, et al. Free fibula long bone reconstruction in
orthopedic oncology: a surgical algorithm for reconstructive options. Plast
Reconstr Surg. 2004;113(7):1989-2000.
7. Chen ZW, Yan W. The study and clinical application of the osteocutaneous
flap of fibula. Microsurgery. 1983;4(1):11-16.
8. Bakri K, Stans AA, Mardini S, Moran SL. Combined massive allograft and
intramedullary vascularized fibula transfer: the capanna technique for lower-
limb reconstruction. Semin Plast Surg. 2008;22(3):234-241.
9. Pelissier P, Boireau P, Martin D, Baudet J. Bone reconstruction of the lower
extremity: complications and outcomes. Plast Reconstr Surg.
2003;111(7):2223-2229.
10. Innocenti M, Menichini G, Baldrighi C, et al. Are there risk factors for
complications of perforator-based propeller flaps for lower-extremity
reconstruction? Clin Orthop Relat Res. 2014;472(7):2276-2286.
11. Weichman KE, Dec W, Morris CD, et al. Lower extremity osseous oncologic
reconstruction with composite microsurgical free fibula inside massive bony
allograft. Plast Reconstr Surg. 2015;136(2):396-403.
12. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes
and complications of reconstruction and amputation for type IIIB and IIIC
fractures of the tibia. Plast Reconstr Surg. 2008; 122(6):1796-1805.
13. Harris AM, Althausen PL, Kellam J, et al. Complications following limb-
threatening lower extremity trauma. J Orthop Trauma. 2009; 23(1):1-6.
14. Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower

extremity using free flaps. Arch Plast Surg. 2013;40(5):575-583.

39
CHAPTER
Soft Tissue Coverage of the
Thigh—Pedicled Rectus
Flap
Brock Lanier and Alex Wong
DEFINITION
■ Soft tissue defects of the thigh can involve critical anatomy including the
neurovascular structures of the femoral triangle (i.e. common femoral artery,
common femoral vein, and femoral nerve) and/or bone.
■ Prior infection, radiation, trauma, tumor resection, or other pathologies can
render local or pedicled flaps from the thigh unusable for reconstruction. In
such scenarios the pedicled rectus flap is a reliable workhorse for thigh defects.
■ The rectus flap is very versatile. It can be used as a pedicled muscle or
myocutaneous flap. The available flap dimensions can range from a small
segment of muscle to a large flap incorporating an extended skin component.1
ANATOMY
■ The rectus abdominis muscle spans the vertical length of the abdominal wall.
It originates from the pubis, inserts at the fifth to seventh costal cartilage, and is
situated in pairs along the paramedian axis of its anterior wall. It is a Mathes
and Nahai type III muscle with two codominant vascular pedicles: the superior
epigastric artery and the inferior epigastric artery (FIG 1).
■ In order to use the pedicled rectus flap for thigh reconstruction, the superior
epigastric artery is transected and the flap is rotated maintaining the blood
supply from the inferior epigastric artery.
■ Perforating branches from the inferior epigastric artery are concentrated
around the umbilicus. As such, the periumbilical area should be incorporated
into the design of any myocutaneous flap’s skin paddle.
■ If the periumbilical perforators to the skin are utilized, an almost infinite

number of skin paddle designs are possible. Large (size) skin paddles can be
transposed to the thigh defect if needed.2
FIG 1 • VRAM clinical anatomy. The rectus abdominis
muscle originates from the pubis and inserts at the fifth
to seventh costal cartilage. It has codominant vascular
pedicles: the superior epigastric artery and the inferior
epigastric artery. The VRAM skin paddle must include
periumbilical skin perforators.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Most soft tissue defects involving the thigh are associated with either trauma
or cancer.
■ Focused examinations of the abdomen and lower extremity should be
performed:
■ The abdominal examination should evaluate for previous surgical scars, the

presence of abdominal wall hernias, and skin laxity if a myocutaneous flap is
being considered:
• Transverse midabdominal laparotomy scars indicate that the rectus
abdominis was likely transected.
• Low transverse scars associated with prior cesarean sections may or may
not have violated the inferior epigastric pedicle.
■ Check the neurovascular status of the lower extremities. Trauma or surgery,
particularly vascular surgery, involving the external iliac artery or common
femoral artery, may have compromised the inferior epigastric pedicle.
IMAGING
■ Imaging is not mandatory but can be considered if the patient’s physical exam
is concerning regarding the integrity of the inferior epigastric artery.
■ CT angiography can assess the pedicle and can concurrently evaluate the
abdominal wall for occult hernias and other pathologies.
■ MR angiography and ultrasonography are other modalities that can also be
considered.
NONOPERATIVE MANAGEMENT
■ Nonoperative treatment of soft tissue defects of the proximal thigh is limited,
especially when critical structures of the femoral triangle or osseous structures
of the lateral thigh are exposed.
■ Temporary coverage using vacuum-assisted wound care devices can be
considered depending on the contents of the wound.
SURGICAL MANAGEMENT
■ Surgical management decisions include timing (immediate vs delayed
reconstruction) and choice of the flap.
■ Flap options include local pedicled flaps of the thigh such as the anterolateral
thigh flap, tensor fascia lata flap, gracilis flap, and sartorius flap.
■ Free flaps are also an option if appropriate regional options do not exist.
T E C H N I Q U E S
■ Flap Design

■ The size and depth of the soft tissue defect should be defined following
tumor resection or wound debridement.
■ Critical landmarks include the symphysis pubis and the anterior superior
iliac spine (ASIS), which defines the inguinal ligament.
■ The origin of the inferior epigastric artery is at the halfway point of the
distance between the symphysis pubis and the ASIS.
■ The paramedian location of the rectus abdominis muscle is marked.
■ If desired, a template of the defect can be constructed (e.g., using wrapping
paper from sterile gloves) to facilitate creation of the design of the skin
paddle. It is suggested that the length of the muscle and the size of the skin
paddle be slightly larger than the defect.
■ The donor site of muscle flaps will almost always close primarily.
■ The donor site of skin paddle of a myocutaneous flap should be assessed
during flap design. A pinch test can ensure that the donor site will be able
to close primarily.
■ In pedicled flaps such as the rectus abdominis, the pivot of the flap about its
vascular pedicle should be considered during flap design (TECH FIG 1).
■ Typically, the flap will rotate externally to reach a lateral thigh defect and
internally to reach a medial thigh defect. A sterile towel or laparotomy pad
can be used to simulate the arc of rotation of the flap about its pivot point
to ensure adequate length of the flap during flap design.
TECH FIG 1 • Lateral view of the abdomen and right
thigh, demonstrating proximal anterolateral thigh full-
thickness defect with exposed femur. The extended
vertical rectus myocutaneous (eVRAM) flap has been

marked incorporating the flap’s periumbilical
perforators into its design.
■ Flap Harvest
■ For a muscle flap without skin island, the approach may be via a paramedian
incision directly over the muscle or a low transverse abdominoplasty
incision.
■ Once the anterior rectus sheath is exposed, it is entered sharply in the
middle of the muscle and reflected medially and laterally to expose the
muscle.
■ For smaller defects of the thigh, a segment of the muscle can be harvested,
leaving the remaining muscle supplied by the superior epigastric artery.
■ For a myocutaneous flap (TECH FIG 2A), the skin paddle must be in
continuity with the anterior rectus sheath to incorporate perforating vessels.
■ At the medial and lateral surface, the fat and skin can be elevated 1 to 3 cm
off of the anterior sheath to allow for the donor site to be closed directly.
■ To complete harvest, the muscle is circumferentially dissected off of the
posterior rectus sheath (TECH FIG 2B).
■ Below the arcuate line, the posterior sheath is thin because it consists only
of transversalis fascia.
■ Neurovascular bundles associated with intercostal nerves are controlled
with either suture ties or clips.
■ The inferior epigastric pedicle is identified at the inferolateral aspect of the
muscle approximately 4 cm cranial to the origin.
■ The flap’s pedicle can be dissected back to its external iliac origin to
maximize the arc of rotation.
■ Care should be taken not to exert excessive tension or pressure on the
pedicle during the dissection.
■ The cranial aspect of the muscle is transected at the costal margin, taking
particular attention to identifying the superior epigastric artery.
■ The caudal aspect of the muscle can also be divided from the pubic origin
for additional length.

TECH FIG 2 • A. Examples of skin paddle designs of
VRAM and extended VRAM. B. Dissected extended
VRAM in situ at the donor site.
■ Flap Inset and Completion
■ According to the location of the soft tissue defect, the flap can be rotated or
tunneled to the defect (TECH FIG 3A).
■ With the flap in situ at the recipient site, its vascular status should be
assessed before inset.
■ The pedicle can be checked to ensure there is minimal twisting and no
acute turns compromising flow.
■ For myocutaneous flaps, the skin paddle’s cutaneous Doppler signal sites
should be examined and can be marked with ink or small suture (e.g., 5-0
polypropylene) to facilitate postoperative monitoring.
■ The flap is inset in layers using suture and/or staples. A skin graft can be
applied if appropriate (TECH FIG 3B).
■ The anterior rectus sheath donor site is repaired directly with sutures (e.g.,

no. 1 PDS).
■ When a skin paddle is incorporated into the flap, mesh is usually required
to minimize tension on the repair.3
TECH FIG 3 • A. Rotation of VRAM flap demonstrates
that it can reach past midthigh. Final intraoperative
lateral view appearance of the abdomen and right
thigh with the eVRAM donor site closed primarily and
the flap inset after de-epithelization and tunneled
through the subcutaneous space.
PEARLS AND PITFALLS

Artery
preservation
■ In the setting of large soft tissue defects involving the proximal
thigh, it is essential to ensure that the origin of the inferior epigastric
artery has been preserved.
■ Radical resections involving the ipsilateral common femoral artery
or external iliac artery will likely compromise the flap’s pedicle. The
need for vascular reconstruction of these vessels should alert the
reconstructive surgeon.
Flap design
■ The flap can be trimmed and customized to a smaller size during
inset. It cannot be enlarged once it has been dissected.
■ For this reason, a larger flap is recommended (longer rectus and/or
larger skin paddle). Consider a 20% larger design than what is
suggested by the initial measurements of the soft tissue defect.
POSTOPERATIVE CARE
■ The abdominal donor site can be dressed with a sterile occlusive dressing (e.g.,
gauze, adhesive tape, or topical liquid bonding product).
■ The dressing for the flap depends on the type of the flap (muscle with or
without skin graft, skin paddle) and preference of the surgeon.
■ Pedicled flaps to the proximal thigh are at risk with early postoperative
motion. A short period of immobilization, especially for flaps with overlaying
skin grafts, should be considered.
■ Flap checks examining the color, turgor, temperature, and/or Doppler signal
should be performed in accordance with institutional standards. Many
protocols call for hourly flap checks during postoperative day 1, every 2 hours
on postoperative day 2, and every 4 to 6 hours thereafter.
OUTCOMES
■ The pedicled rectus abdominis flap has a constant blood supply, making it a
safe and reliable option for small to large soft tissue defects of the proximal
thigh (FIG 2).
COMPLICATIONS
■ Obesity, smoking, uncontrolled diabetes, and prior abdominal surgery are
factors that have been associated with an increased risk of complication.4
■ Intraoperative vascular complications related to twisting or kinking of the
pedicle during inset
■ Acute venous insufficiency is rare but can occur in patients with a dominant
superficial venous system. If this is encountered, then the flap can be returned

to its native position, and its inset can be postponed for a few days allowing for
the delay phenomenon to occur.
■ Partial flap necrosis may occur at the distal aspect of the skin island in
myocutaneous flaps.5
■ Postoperative hematoma or seroma5
■ Donor site bulge or hernia (12%)5
FIG 2 • Result 1 year postoperatively, demonstrating the
postoperative appearance of the healed eVRAM donor
site and flap.
REFERENCES
1. Gottlieb ME, Chandrasekhar B, Terz JJ, Sherman R. Clinical applications of
the extended deep inferior epigastric flap. Plast Reconstr Surg.
1986;78(6):782-792.
2. Lee MJ, Dumanian GA. The oblique rectus abdominis musculocutaneous flap:
revisited clinical applications. Plast Reconstr Surg. 2004;114(2):367-373.
3. Küntscher MV, Mansouri S, Noack N, Hartmann B. Versatility of vertical
rectus abdominis musculocutaneous flaps. Microsurgery. 2006; 26(5):363-369.
4. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for
immediate reconstruction of pelvic and perineal cancer resection defects. Plast
Reconstr Surg. 2009;123(1):175-183.
5. Parrett BM, Winograd JM, Garfein ES, et al. The vertical and extended rectus
abdominis myocutaneous flap for irradiated thigh and groin defects. Plast
Reconstr Surg. 2008;122(1):171-177.

40
CHAPTER
Soft Tissue Coverage of
Thigh—Free Flaps
Ulrich Kneser and Thomas Kremer
DEFINITION
■ Soft tissue defects of the thigh requiring free flap reconstruction are rare,
because of a sufficient soft tissue envelope that frequently allows other
reconstructive options such as split-thickness skin grafting, local random
pattern, or pedicled flaps.
■ Exposure of functional structures such as neurovascular bundles, tendons, or
bone may require reconstruction using free microvascular tissue transfer.
ANATOMY
■ Anatomy of the thigh is characterized by a sufficient number of strong
muscles:
■ Anterior:
• The quadriceps muscle (medial, lateral, and vastus intermedius muscle as
well as rectus femoris muscle)
• The sartorius muscle
■ Medial:
• The adductor muscles (gracilis, adductor magnus, adductor longus, adductor
brevis, and pectineus muscle)
■ Posterior:
• Biceps femoris muscle
• Semitendinosus muscle
• Semimembranosus muscle
■ Perfusion of the thigh is maintained by the femoral artery and its branches:
■ Profunda femoris artery (with medial circumflex and lateralis artery)

■ Descending genicular artery
■ Popliteal artery
■ Peripheral branches of the inferior gluteal artery for the proximal dorsum
■ Major nerves of the thigh are:
■ The femoral nerve (quadriceps, sartorius, and pectineus muscle)
■ Obturator nerve (adductor muscles)
■ Sciatic nerve (posterior muscles of the thigh)
■ Venous drainage of the thigh is provided by deep veins and the saphenous
vein.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Defects at the thigh may results from trauma, infection, or oncologic resection.
Each of these entities should be evaluated and requires special focus during
patient examination.
■ Patients with traumatic soft tissue defects of the thigh should be asked for the
mechanism of injury. This may help to identify the true extent of the defect and
concomitant trauma consequences.
■ Infections of the thigh should be evaluated for dynamics, systemic
consequences (eg, fever, fatigue), pain, prior antibiotic treatment, as well as
potential causes and infectious portals of entry.
■ The major goal in patients after oncologic resection is to evaluate prognosis,
prior treatment, and adjuvant treatment options, since this information strongly
influences therapeutic as well as reconstructive choices.
■ Additional important factors influencing reconstruction are patients’ demands:
patients who were ambulating normally prior treatment may require more
extensive reconstructive attempts than patients who are chair- or even bed-
bound.
■ Inspection of the thigh in patients suffering from soft tissue loss should assess
the extent and depth of the defect as well as exposed functional structures.
Additionally, the surroundings of the defect should be carefully evaluated:
scarring, tension, and former incisions should be noted. Prior radiation therapy
may lead to wound healing disturbances and subsequent postoperative
morbidity and should therefore be taken into account.
■ When free flap reconstruction is required, potential donor vessels should be
evaluated. The distance from these vessels to the most distant part of the defect
should be measured and significantly influences flap choices. In some patient,
even more invasive strategies such as arteriovenous loops or bypasses may be

necessary.
■ Patients should be asked for varicosity or prior venous surgery (such as venous
stripping or bypass surgery).
IMAGING
■ Photographs of the defect should be performed including the complete thigh as
well as detailed pictures focusing on the defect.
■ Conventional x-rays of the femur in two perpendicular views (anteroposterior
and lateral) may show concomitant fractures or nonunions in traumatic cases,
osteomyelitis after infection, or oncologic osseous lesions in oncologic
patients.
■ Magnetic resonance imaging and computed tomography may reveal the real
extent of the defect or sequelae of infection of the bone as well as soft tissue.
However, both options should not postpone onset of treatment in special
patients such as cases with necrotizing infections.
■ Radiologic examination of donor vessels is required in patients prior to
microsurgery for thigh defects. MRI or CT angiographies are sufficient in most
cases. The advantage of conventional angiographies in these patients is that
endoluminal interventions are possible, if necessary.
■ Doppler or duplex ultrasound is indicated to evaluate the superficial venous
system and for venous mapping if vein grafts may be required.
SURGICAL MANAGEMENT
■ Indications for free flap reconstruction at the thigh are relatively rare. Most
cases can be managed using local random pattern or pedicled flaps as well as
split-thickness skin grafting. However, extensive defects with exposure of
functional structures such as bone, neurovascular bundles, or tendons may
require free tissue transfer.
■ Another reason for microsurgical flap transplantation is radiation therapy.
Tissues from distant donor sites that are not radiated may improve the healing
capacity of irradiated wound beds. This is especially important because soft
tissue sarcoma of the limbs most commonly occur at the thigh.1 Here, defect
reconstruction using free flaps can even be indicated when primary wound
closure would be possible with tension. In these patients, complications rates
can be reduced when reconstruction with nonradiated flaps is applied.
■ Any reconstructive attempt should only be started when wounds are
sufficiently debrided. No signs of infection or devitalized tissue should be

present.
■ In some cases, vacuum-assisted closure (VAC) therapy can be performed to
prepare wounds for soft tissue reconstruction.
Preoperative Planning
■ Different parameters influence the choice for various reconstructive options:
■ The aim of reconstruction (eg, palliative vs curative intention, limb salvage
vs major amputation; ability to walk or just to sit)
■ Structures or functions requiring reconstruction, extent of the defect (eg, soft
tissue loss, bone damage, muscle function, nerve injury)
■ Perfusion of the wound bed (eg, in patients with peripheral arterial disease,
after radiation therapy)
■ The patients’ individual needs and compliance as well as concomitant
diseases
■ Donor site morbidity
■ Adjuvant therapy options or further surgery
■ Another important information is the distance from potential donor vessels to
the most distant part of the defect. If this distance is too long, the risk of partial
flap loss (“where you need it most”) is increased. In these cases, arteriovenous
loops or vessel interpositional grafts should be considered.
■ Patients with atherosclerosis should be evaluated by angiography and should
be presented to vascular surgeons or interventional radiologists prior to
surgery.
■ If multidisciplinary approaches are required (eg, osseous internal fixation, soft
tissue reconstruction and/or vascular surgical interventions), a detailed
preoperative discussion is required. The sequence and extent of different
surgical steps, postoperative care, and operative strategy has to be considered.
Here, interdisciplinary extremity boards similar to oncologic tumor boards
have been shown to be very efficient.
Positioning
■ Patient positioning depends on donor vessels, flap choice, as well as additional
surgical interventions (eg, osteosyntheses, vascular surgery, harvest of vein
grafts).
■ Supine positioning allows:
■ Common flaps: anterolateral thigh flap, gracilis flaps, rectus abdominis
myocutaneous flaps, tensor fascia lata flaps, vastus lateralis flaps, lateral arm

flap, forearm flaps
■ Donor vessels: femoral artery and vein in the groin and adductors canal
■ Lateral decubitus position (FIG 1A,B):
■ Common flaps: flaps from the subscapular system
■ Donor vessels: femoral artery and vein in adductor canal
■ In some patients, it is not possible to perform the complete procedure in one
position (eg, when internal osseous fixation is required). Here, intraoperative
repositioning may be necessary.
Approach
■ The surgical approach to defects at the thigh is defined by defect localization
as well as extent and cannot be discussed here in detail.
■ Recipient vessels at the thigh predominantly are the femoral vessels. These can
best be approached in the groin and the adductors canal.
■ In patients with unfavorable defect localization, microvascular anastomoses
can be performed to arteriovenous loops (that can be performed in the same
procedure or separately in prior procedures) or interpositional vein grafts.
■ If different approaches to the defect, vessels, and bone have to be combined,
the surgeons should carefully discuss operative incisions in advance to prevent
skin malperfusion.
FIG 1 • The lateral decubitus position of patients allows
exposure of the thigh and femoral vessels, if the
contralateral leg is placed backward. A. Care has to be
taken for the upper arm that has to be prevented from
any compression to prevent compartment syndromes in
lengthy procedures. B. Flaps from the subscapular

system can easily be harvested.
T E C H N I Q U E S
Video p7-c040
■ Approach to the Groin
■ The femoral artery and vein can easily be identified in the groin (TECH FIG
1). These vessels arise from the external iliac artery and course under the
inguinal ligament into the thigh. Here, the artery can usually be found by
palpation. The femoral vein is located medial to the artery, whereas the
femoral nerve courses laterally.
■ The course of the vessels across the thigh is between the vastus medialis
muscle (laterally) and the adductor muscles. Distally, the sartorius muscle lies
superficial to the vessels.
■ Major arterial branches in the groin are the deep femoral artery, the
superficial epigastric, and the circumflex iliac artery. The saphenous vein can
likewise be identified in the groin.
■ The skin incision is performed distal to the inguinal ligament over the
vessels that were previously identified by palpation or Doppler probe. During
subcutaneous preparation, the saphenous vein should be identified and
preserved.
■ Because the femoral vessels lie on the muscles in the groin, these structures
00:00 / 00:00

can easily be dissected. For safety reasons, the major branches should be
identified (especially the deep femoral artery) and secured using vessels
loops.
■ After dissection of the femoral artery and vein over several centimeters, an
adventitiectomy should be performed to prepare the vessels for anastomosis
that is usually performed in an end-to-side fashion.
TECH FIG 1 • A. The femoral vessels can be exposed
in the groin. Here, the femoral vein (A) is visualized
caudal to the inguinal ligament. Dissection was
performed to the entry of the saphenous vein. (B)
Here, the saphenous vein is pulled cranially (left) to
form an arteriovenous loop through an end-to-side
anastomosis (C) to the femoral artery (D) in the groin.
B. Illustration of the femoral vessels in the groin.
■ Approach to the Adductor Canal
■ The anatomical borders of the adductor canal are:
■ Dorsally: adductor longus muscle (TECH FIG 2A)
■ Ventrally: vastoadductor membrane between the tendons of the vastus

medialis and adductor longus muscles (see TECH FIG 2A)
■ Medially: adductor magnus muscle
■ Laterally: vastus medialis muscle
■ The femoral vein is located under (“deep”) the femoral artery.
■ Additional structures in the adductor canal are the saphenous nerve and the
descending genicular artery.
■ The approach to the femoral artery and vein is possible in supine as well as
lateral decubitus position.
■ The skin incision is performed at the medial thigh (TECH FIG 2B). During
subcutaneous dissection, the saphenous vein can be found and prepared for
anastomosis.
■ After incision of the fascia of the thigh, the descending genicular artery can
be identified (TECH FIG 2C). This structure can be used as a guide into the
adductor canal, and the femoral artery and vein can easily be found. Both
vessels are then dissected (TECH FIG 2D).
■ Care has to be taken to preserve the femoral vein behind (deep) to the
femoral artery. Several arterial and venous branches arise from the femoral
vessels in the adductor canals. Some of these generally seem to be sufficient
for anastomosis. However, the authors recommend ignoring these vessels
because complication rates are significantly higher when compared to direct
end-to-side anastomoses to the “big” femoral vessels.

TECH FIG 2 • A. Illustration of the adductor canal. B.
The adductor canal is exposed through a medial skin
incision. C. After subcutaneous dissection and incision
of the fascia, the descending genicular artery can be
identified (arrow). D. This structure guides into the
adductor canal, and the femoral artery can be
identified and dissected as well as the femoral vein.
Here, the saphenous vein is anastomosed to the
femoral artery to create an arteriovenous loop (arrow).
■ Dissection of the Saphenous Vein
■ The saphenous vein collects the blood of the dorsum of the foot and courses
superficially at the lower leg. Around the knee, it courses dorsal to the medial