Operative Technique in Plastic Surgery – Kevin C.Chung

tourniquet).
TECH FIG 1 • Lower leg following adipofascial
excision. Note that a layer of adipose tissue is
preserved over the muscle fascia.
■ Skin grafts are either stapled or sutured in place depending on surgeon
preference.
■ Skin grafts are covered with nonadhesive dressing such as N-Terface
followed by a silver product (eg, Acticoat Ag) to prevent infection. This is
then wrapped with Kerlix gauze and elastic ace wrap.
■ A knee immobilizer is placed in extension.
■ Of note, skin grafting can be delayed for 1 week if there is concern for
problems in graft take (ie, concern for serous drainage or infection).
■ In this scenario, skin grafts are banked, and negative pressure wound
therapy is applied to the circumferential wound.8
■ Staged Excision9,10
■ Similar to the Charles procedure, the leg is prepped and draped
circumferentially.
■ A vertical line is drawn on both the medial and lateral leg, dividing the leg
into anterior and posterior halves.
■ Skin is then incised vertically along the medial or lateral leg depending on
which half is being excised.

■ Adipodermal flaps are lifted in a suprafascial plane, preserving a cuff of
adipose tissue (1–2 cm).
■ The elevation stops at the leg meridian.
■ Soft tissues are then completely debulked from the adipofascial flap down to
muscle.
■ The anterior and posterior flaps are raised, and two drains are placed
underneath.
■ The two flaps are secured to each other at midline using a single layer of 3-
0 nylon sutures.
■ No deep sutures are used.
■ Dressings are applied and the leg is wrapped circumferentially.
PEARLS AND PITFALLS
Hemostasis
■ When performing extremity adipofascial excision, use a sterile
tourniquet, and limit runs to less than 2 hours. Let the tourniquet
deflate to obtain hemostasis prior to placing skin grafts. Excise
proximal to distal. Epinephrine 1:10 000 soaked sponges can assist in
hemostasis.
Skin
harvest
■ In general, it is easier to harvest the skin grafts prior to adipofascial
excision given the difficultly in making a taught convex surface once
the tissue is excised.
■ If excised donor leg skin is hyperkeratotic and poor quality, harvest
skin grafts from contralateral leg or trunk.
Soft tissue
excision
■ Leave a cuff of soft tissue around the ankle and knee (popliteal fossa,
patella) to avoid exposing bone and vascular structures.
■ Be cautious when excising in the posterior calf and lateral upper
lower leg to avoid the sural and common peroneal nerves.
Single vs
staged
■ Consider staged excision in morbid patients who might not tolerate a
complete leg debulking.
Cosmetic
result
■ Appropriately set expectations with patients who these operations
provide extremity debulking at the cost of poor appearance.
POSTOPERATIVE CARE

■ As with any skin graft procedure, patients should be immobilized for 4 or 5
days to allow for graft take. This will almost always involve a hospital
inpatient admission, which can allow for physical/occupational therapy
assistance for mobility, and intravenous pain medication.
■ All patients should be started on deep venous thrombosis prophylaxis such as
subcutaneous heparin or low molecular weight heparin.
■ Consider a 5-day course of intravenous antibiotics such as first-generation
cephalosporin to prevent infection under the grafts.
■ On postoperative day 5, all dressings are removed carefully with narcotic
premedication. Wound care is targeted as needed to areas of healing difficulty.
■ Prior to discharge, we recommend evaluation by occupational therapy and
physical therapy for ambulation. Range-of-motion exercises are very important
at the knee and elbow but are balanced against skin graft take. As soon as
feasible, patients should be attempting full active range-of-motion exercises.
■ Patients often require pressure garments for life to help prevent scar
contractures. Lifelong follow-up with occupational therapy is advised.
OUTCOMES
■ The largest series evaluating quality of life outcomes showed 63% satisfaction
with limb-reducing surgery. 70% of all limb-reducing patients would opt for
the surgery again.11
■ A common problem with the Charles procedure is poor appearance.
■ This results from the absence of subcutaneous tissues (ie, leg looks much
thinner than normal leg).
■ There can also be a large step off at the junction of normal tissue and excised
tissue from lack of contour between these sites (FIG 2).
■ Additionally, the skin grafts can become hyperkeratotic.
COMPLICATIONS
■ These patients are at elevated risk of deep venous thrombosis given
postoperative mobility limitations, diverting all venous blood into the deep
system, and the significant inflammation from extremity excision.
■ Suboptimal skin graft take is the most common complication that often results
from local hematomas and seroma. Meticulous hemostasis along with meshed
grafts can reduce this risk. Also, placing skin graft seems at lower tension
points (avoiding joints) can ensure the highest graft take.
■ Amputation has been reported.12

FIG 2 • Six months postoperatively with complete skin
graft take. Note the hyperkeratotic appearance that is
common following the Charles procedure.
REFERENCES
1. International Society of Lymphology. The diagnosis and treatment of
peripheral lymphedema: 2013 Consensus Document of the International
Society of Lymphology. Lymphology. 2013;46(1):1-11.
2. Tiwari A, Cheng K-S, Button M, et al. Differential diagnosis, investigation,
and current treatment of lower limb lymphedema. Arch Surg. 2003;138(2):152-
161.
3. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am
Coll Cardiol. 2008;52(10):799-806.
4. Casley-Smith JR. Measuring and representing peripheral oedema and its
alterations. Lymphology. 1994;27(2):56-70.
5. Farina R. Elephantiasis of the lower limbs; treatment by dermo-fibro-
lipectomy followed by free skin grafting. Plast Reconstr Surg. 1946.
1951;8(6):430-442.
6. Yeo MS-W, Lim SY, Kiranantawat K, et al. A comparison of vascularized
cervical lymph node transfer with and without modified Charles’ procedure for
the treatment of lower limb lymphedema. Plast Reconstr Surg.
2014;134(1):171e-172e.
7. Sapountzis S, Ciudad P, Lim SY, et al. Modified Charles procedure and lymph
node flap transfer for advanced lower extremity lymphedema. Microsurgery.
2014;34(6):439-447.
8. van der Walt JC, Perks TJ, Zeeman BJ, et al. Modified Charles procedure

using negative pressure dressings for primary lymphedema: a functional
assessment. Ann Plast Surg. 2009;62(6):669-675.
9. Miller TA. A surgical approach to lymphedema. Am J Surg. 1977; 134(2):191-
195.
10. Miller TA. Surgical management of lymphedema of the extremity. Plast
Reconstr Surg. 1975;56(6):633-641.
11. Ogunbiyi SO, Modarai B, Smith A, Burnand KG; London Lymphoedema
Consortium. Quality of life after surgical reduction for severe primary
lymphoedema of the limbs and genitalia. Br J Surg. 2009;96(11):1274-1279.
12. Miller TA. Charles procedure for lymphedema: a warning. Am J Surg.
1980;139(2):290-292.

48
CHAPTER
Liposuction for Treatment of
Lymphedema
Dung Nguyen and Joseph Baylan
DEFINITION
■ Lymphedema is lymphatic transport alteration/damage resulting in the
accumulation of proteinaceous fluid in the interstitial compartment.
■ Liposuction is the surgical removal of local excess fat from under the skin by
vacuum suctioning using a cannula introduced through small skin incisions.
■ Dry liposuction is performed without the use of local anesthetic or dilute
epinephrine.
■ Superwet liposuction uses a 1:1 mL ratio of infiltrate-to-aspirate for large
volume aspirate removal, decrease blood loss, avoidance of lidocaine toxicity,
and to minimize resultant fluid shifts.
■ The pitting test refers to the amount of depression of the tissue (in millimeters)
after the thumb is pressed as hard as possible on the extremity for 60 seconds.
■ Tissue edema that harbors more fluid will have more pitting and tissue edema
that is mainly hypertrophied fat or fibrous tissue shows little or no pitting.
ANATOMY
■ Vital structures, such as neurovascular bundles and tendons that travel beneath
the skin, can be injured during liposuction.
■ The key anatomical areas to avoid during liposuction in the upper extremity
are the axilla, antecubital region, and the wrist.
■ In the lower extremity, liposuction at the femoral triangle, popliteal fossa, and
ankles should be avoided.
■ Subcutaneous fat is divided into superficial, intermediate, and deep layer.
Distribution of each layer varies depending on anatomical location and
liposuction is carried out in the intermediate and deep layer.

■ Lymphatic capillaries are present in a subdermal plexus, which merge together
into larger lymphatic vessels to form a complex network that carries lymph
through the body. The lymph fluid enters a lymph node basin (ie, inguinal
region, axilla) via several afferent lymph vessels where it is filtered and then
transported toward the lymphatic ducts by efferent lymph vessels. Deep
liposuction in the region of a lymph node basin can disrupt the lymphatic
network and cause neurovascular injury.
PATHOGENESIS
■ Long-term accumulation of lymph fluid causes chronic tissue inflammation
that induces excess differentiation of fat precursors, fat hypertrophy, tissue
fibrosis, and hyperkeratosis.
■ Hypertrophied adipose tissue and tissue fibrosis are late signs of lymphedema.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Candidates for liposuction are those with late stage II (spontaneously
irreversible) to stage III lymphedema (lymphostatic elephantiasis).
■ These patients have been treated and are refractory to complex decompressive
physiotherapy (CDPT) and compression garments.
■ Physical examination:
■ Presence of nonpitting edema on pitting test.
■ Intact skin without open wounds.
■ No erythema or signs of infection.
■ Negative Homans sign, defined as calf pain with extension of the foot.
■ Treatment contract:
■ The success of the surgery relies on the patient being reliable and compliant
with compression garment use 24/7 for life.
■ Patients who wish to proceed with surgery are asked to sign a treatment
contract before surgery.
IMAGING
■ Dual-energy x-ray absorptiometry (DXA) is used to estimate the excess fat,
muscle, and bone tissue in the lymphedema limb.
■ From the DXA scan, measurements are made in grams and transferred to
volumes by density, which is useful in estimating the amount of excess fat to
remove in patients scheduled for liposuction.
SURGICAL MANAGEMENT

■ Preoperative preparation:
■ Optimize nonsurgical therapy to reduce residual pitting edema in the tissue as
much as possible prior to surgery.
■ Patients who have history of deep vein thrombosis (DVT) should get a
baseline venous duplex study.
■ Appropriate preoperative evaluation of cardiopulmonary status is always
indicated prior to any surgical procedure.
■ The patient must be aware of potential complications to include bleeding,
infection, pain, numbness and tingling, contour irregularity, and wound healing
problems.
■ Garments:
■ Two sets of garments are made to match the size of the normal limb (Juzo,
class II 30–40 mm Hg): one set is given to the surgeon to put on the patient
immediately after surgery; the other set, the patient will bring to the first
postoperative clinic appointment.
■ Upper extremity garments include Juzo compression sleeve from wrist to
axilla with shoulder strap and gauntlet.
■ Lower extremity garments include Juzo open toe compression stocking with
adjustable waistband, toe cap, and biker shorts for compression of the thigh
and hip area.
■ Donning device to aid in putting on and removing garments.
■ These garments are not sterilizable in the United States.
T E C H N I Q U E S
■ Anesthesia
■ General endotracheal anesthesia is preferred.
■ Epidural or peripheral nerve blockade performed by a regional anesthesia
team is optional for postoperative pain management.
■ Position
■ The patient is placed in supine position, and the affected extremity is rested
on a hand table or a leg raise, respectively (TECH FIG 1).

■ During surgery, the extremity is raised with the help of an assistant to access
the posterior surface of the limb.
TECH FIG 1 • Positioning of affected extremity prior to
suction-assisted lipectomy.
■ Equipment
■ Sterile tourniquet.
■ Liposuction set to include 3 and 4-mm cannulas.
■ Suction-assisted or power-assisted liposuction machine.
■ Wetting solution containing 20 mL of 1% lidocaine, 1 ampule of 1:1000 (1
mg/mL) epinephrine and 8 mL of sodium bicarbonate (8.4 mEq/L) in 1 L of
lactated ringers.
■ Details of Procedure

Video p7-c048
■ Preoperative antibiotic should be given prior to incision.
■ Piperacillin-tazobactam (Zosyn) is preferred for broad-spectrum antibacterial
coverage, particularly in patients with diabetes or significant comorbidities.
■ After general endotracheal anesthesia is established, the entire affected
extremity is prepped and draped circumferentially in the usual sterile fashion.
Superwet Liposuction
■ Begin with superwet liposuction of the upper arm or thigh. Wetting solution
is used in the proximal limb to minimize bleeding because tourniquet is not
possible in this location.
■ The amount of tumescent infused is the same as the expected amount of
lipoaspirate removed. This is determined preoperatively by DXA scan.
■ Using a no. 11 blade, 5 to 8 stab incisions, 3 mm in length, are made
circumferentially in the proximal half of the arm or thigh.
■ Wetting solution is injected in 1:1 infiltrate: aspirate ratio into the
subcutaneous tissues of the upper arm or thigh using an infiltrating cannula.
Wetting solution is infused until skin turgor is present at the desired location.
■ After 10 to 15 minutes, liposuction is performed in the proximal extremity
circumferentially.
■ We prefer a 4-mm liposuction cannula for large volume liposuction and a 3-
mm liposuction cannula for fine tuning and contouring with suction set at a
medium setting.
■ Start with the limb at rest on the table and begin liposuction of the anterior,
00:00 / 00:00

medial, and lateral surfaces first.
■ The limb is then raised and held by an assistant or placed on a leg raise (for a
lower extremity) to allow liposuction of the posterior limb.
■ Liposuction should be performed in segments to ensure maximal volume
reduction at each location.
■ Avoid liposuction of the axilla or the femoral triangle, respectively, to avoid
inadvertent neurovascular injury.
■ The end point is achieved when no fat is seen in the suction tubing and the
skin is loose and hanging (TECH FIG 2).
TECH FIG 2 • Tumescent liposuction is performed in
the proximal thigh.
Dry Liposuction
■ Dry liposuction is used for the remainder of the limb to avoid bleeding and
excessive swelling of the tissue. This is beneficial in the immediate
postoperative period for easier placement of the compression garment. It also
facilitates quicker recovery as there is less postoperative edema.
■ Place a sterile tourniquet on the proximal extremity with an Esmarch used to
exsanguinate the limb.
■ The tourniquet should be inflated to 175 mm Hg in the arm and 275 mm Hg
in the leg.
■ 10 to 20 skin stab incisions, 3 mm in length, are then made along the length
of the extremity using a no. 11 blade to gain access for circumferential
liposuction.
■ Using a combination of 3 and 4 mm cannulas, gentle circumferential

liposuction of the limb down to the wrist or ankle is performed to remove the
excess fibrofatty deposits.
■ Liposuction near the wrist and ankle should be done cautiously and with the
smaller cannula to prevent excessive tissue trauma.
Irrigation
■ All incision sites are irrigated with bacitracin solution (50 000 units/L) and
cleaned.
■ Apply antibiotic ointment to skin.
■ With large volume of fat and lipoaspirate removed, there will be a noticeable
reduction in the limb size and increased skin laxity in the extremity after
liposuction is completed (TECH FIG 3).
Compression Garment Application
■ The most challenging part of the operation is application of a clean custom
compression garment, which is made preoperatively using the unaffected
extremity as a sizer for the garment.
■ We have found the most effective method is to be starting at the great toe
and having an assistant lift the extremity while pulling force is being applied
proximally to allow for the garment to span from the toes to the proximal
thigh.
■ Use of a donning device is also helpful to get the garment pass the hand or
foot. The incisions are left open to drain through the sleeve.
■ The tourniquet is then released once the garment is pulled to the level of the
proximal thigh and secured.
■ The entire extremity is additionally lightly wrapped with 6-in. Bias wrap to
absorb the drainage.
■ Total tourniquet time should be 120 minutes or less.
■ There is typically minimal blood loss.

TECH FIG 3 • Liposuction is performed in segments.
There is noticeable excess of skin envelope of the
thigh and leg with reduction of large adipose volume.
A. Dry liposuction is performed below the midthigh
under tourniquet. B. Large volume of fibrofatty tissue
is removed.
PEARLS AND PITFALLS
Patient selection
■ The ideal patient is one who has isolated nonpitting edema and
can be compliant with 24/7 postoperative compression
garment.
Approach
■ Use a systematic approach to liposuction by complete
liposuction of each section of the extremity at a time.
■ Avoid liposuction at the axilla, the femoral triangle, or at the
joints.
Tourniquet time
■ Allocate appropriate tourniquet time to each segment of the
limb to avoid spending too much or inadequate time in one
area.
■ Avoid liposuction at the axilla, the femoral triangle, or at the
joints.
Compression
garment
application
■ Use a donning device to aid in garment placement.

FIG 1 • A. 69-year-old female with 5 years history of
right leg lymphedema status post hysterectomy, lymph
node dissection, and postoperative radiation therapy.
Preoperative DXA scan calculates 6150 mL of edema in
the right leg. B. Results 1.5 years after liposuction of
6300 mL of fat from the right leg. C. 68-year-old female
with 10 years history of left lower extremity
lymphedema status post radical hysterectomy, pelvic
lymph node dissection, and postoperative radiation
therapy for cervical cancer. Preoperative DXA scan
calculates 2583 mL of edema in the left leg. D. Results
at 1 year after 3300 mL of fat tissue removed by
liposuction.
POSTOPERATIVE CARE
■ Due to the large amount of fluid (sometimes in excess of 10 L, depending on
severity of lymphedema) removed from liposuction, overnight observation is
indicated due to potential fluid shifts and for pain control.
■ Patients are kept on an IV antibiotic for 24 hours and are discharged with a 2-
week course of cephalexin (Keflex) or trimethoprim-sulfamethoxazole
(Bactrim DS) for penicillin allergic patients.
■ Prescription for oral narcotics is given for pain control.
■ Patients are encouraged to ambulate regularly.
■ Compression garment is to stay on 24/7 and may change the Bias wrap as
needed when soiled.

FOLLOW-UP
■ First postoperative appointment is on postoperative day 3, and the patient is
asked to bring the second premade garment set to clinic to be changed by the
surgeon.
■ Patients are instructed to change their garment daily thereafter and to wear it
24/7.
■ Subsequent visits are every 3 months in the initial 1 to 1.5 years with each
visit adjustments to the garments are made as the edema improves.
■ Once complete reduction is achieved, the patient is seen annually.
OUTCOME
■ In patients who can remain compliant with 24/7 compression garment use,
complete volume reduction can be achieved after 1.5 years and maintained
long term (FIG 1).
COMPLICATIONS
■ Blistering, particularly at the ankles, for which Mepilex may be used to protect
areas of sensitive skin as needed
■ Infection
■ Contour irregularity
■ DVT
■ Paresthesias
REFERENCES
1. Bernas M. Assessment and risk reduction in lymphedema. Semin Oncol Nurs.
2013;29(1):12-19.
2. Brorson H. From lymph to fat: complete reduction of lymphoedema.
Phlebology. 2010;25(suppl 1):52-63.
3. Chang CJ, Cormier JN. Lymphedema interventions: exercise, surgery, and
compression devices. Semin Oncol Nurs. 2013;29(1):28-40.
4. Damstra RJ, Voesten HG, Klinkert P, Brorson, H. Circumferential suction-
assisted lipectomy for lymphoedema after surgery for breast cancer. Br J Surg.
2009;96(8):859-864.
5. Greene AK, Maclellan RA. Operative treatment of lymphedema using
suction-assisted lipectomy. Ann Plast Surg. 2016;77(3):337-340.
6. Maclellan RA, Greene AK. Lymphedema. Semin Pediatr Surg. 2014;
23(4):191-197.

49
CHAPTER
Section VII: Burns
Acute Management:
Tangential Excision and
Skin Grafting
Yvonne Karanas
DEFINITION
■ Tangential excision of a wound is defined as the sequential removal of eschar
in thin layers until healthy tissue is reached. Punctate bleeding of the
underlying wound bed signals the presence of viable tissue and the end point of
excision.
■ Tangential excision can be applied to any eschar of the skin in order to
minimize the amount of tissue removed and preserve underlying viable tissue.
It is most commonly used in burn surgery.
■ This procedure was first described by Janecovic in the 1970s and has been
adopted worldwide by burn and plastic surgeons.1
■ A split-thickness skin graft is a piece of skin removed from the body for the
purpose of covering a wound in another location. The outer portion of the skin
composed of the epidermis and some portion of the dermis is “split” from the
remaining underlying dermis. Enough dermis is left in the “donor site” for re-
epithelialization.
■ A full-thickness skin graft is a piece of skin containing the “full thickness” of
the epidermis and the dermis. Like a split-thickness graft, this piece of skin is
removed from the patient and then transplanted to another site for wound
closure or to add additional skin after contracture release. Unlike a split-
thickness skin graft, no dermis is left behind so the wound must be closed
primarily.

■ Allograft is broadly defined as a tissue graft from another human being. In
burn care and surgery, it refers to human cadaver skin used to provide
temporary wound coverage.
■ TBSA is Total Body Surface Area and refers to the amount of skin on the body
that is burned.
ANATOMY
■ Burns and traumatic injuries can result in partial-thickness and full-thickness
injuries. These terms refer to the depth of the injury into the skin.
■ Partial-thickness injuries involve the epidermis and some portion of the
dermis.
■ Full-thickness injuries involve the epidermis and the entire dermis and can
even include the subcutaneous fat.
PATHOGENESIS
■ Full- or partial-thickness skin necrosis may occur with trauma, burn injury,
and severe soft tissue infections.
■ There are approximately 486 000 burn injuries per year in the United States
with 40 000 requiring hospitalization.2
■ Worldwide, the magnitude of the problem is even greater.
NATURAL HISTORY
■ Burns or traumatic injuries may initially appear as superficial injuries, but with
time (72–96 hours), they may progress to full-thickness injuries.
■ Judicious early debridement and serial wound care preserve all viable tissue
while preventing wound infection.
■ When the wound evolution is complete, areas of full-thickness and partial-
thickness burns should be clearly delineated. Definitive surgical treatment may
then be performed as needed.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Full-thickness injuries may present as white, yellow, or brown leathery,
insensate areas that lack capillary refill. With time, they will progress to a black
eschar (FIG 1).
■ Partial-thickness injuries may be superficial with pink, moist, sensate tissue
that has capillary refill.
■ Deep partial-thickness burns may be cherry red in color, lack capillary refill,

have decreased sensation, and may be dry. These burns are often described as
“indeterminate thickness” as it is often unclear initially whether they will
require surgical treatment or not.
■ Burns and traumatic injuries may result in wounds that are a combination of
different depths of injury (FIG 2).
FIG 1 • Lower extremity full-thickness necrosis from a
severe soft tissue infection.
NONOPERATIVE MANAGEMENT
■ Partial-thickness burns may be managed with wound care alone.
■ In general full-thickness skin, necrosis requires surgical treatment. It may be
managed conservatively in select situations, for example, small wounds that
are less than 1% TBSA on the torso. A large burn is commonly defined as a
burn greater than 20% TBSA.
■ Wound care may be performed once or twice daily with silver sulfadiazine to
soften and debride the eschar and prevent infection. Eventually the eschar will
separate from the underlying wound bed; however, this process may take
weeks or even months and lead to poor scarring and contractures.
■ For large wounds, an expectant management strategy carries a high risk of
wound infection.
■ Surgical treatment remains the standard of care for large full-thickness
wounds.

FIG 2 • A. Contact ankle burn with second-degree and
third-degree components in a paraplegic patient. B.
Flame burn to the thigh with mainly third-degree burns
and small patches of second-degree burns.
SURGICAL MANAGEMENT
Preoperative Planning
■ Equipment for Tangential Excision
■ Watson Knives (FIG 3A)
■ Weck/Goulian Knives (FIG 3B)
■ Epinephrine solution
■ Equipment for Skin Grafting
■ Dermatome electric or air powered
• Guards of different widths (FIG 3C)
■ Mineral Oil
■ Tumescent solution: I L crystalloid, 1 cc (1:1000) epinephrine, 0.25%
Marcaine (30 cc)
■ Klein Infiltration Pump—allows for high-volume infusion of tumescent
solution in a rapid fashion
■ Tangential excision is performed using a variety of knives designed for this
purpose, or a dermatome may be used.
■ The choice of instrument is based on the location of the wound and the size
and thickness of the eschar. Small burns or burns in delicate areas such as the
hands, face, or feet are excised with a Weck knife. Larger, thicker burns on the
extremities or trunk are excised with a Watson knife. The depth of the excision

can be set by adjusting the guard on the Weck knife or on the Watson knife
itself.
■ The Weck knife has three guards that can be placed over the blade to control
for the depth of excision: 0.012, 0.010, and 0.008 in. The selection of the
thickness of the excision is based on the surgeon’s perception of the depth of
the wound and the thickness of the skin in that region. The narrower guards of
the Weck knife are used for less deep burns and areas of thin skin such as the
dorsum of the hand, foot, or nose (FIG 3D).
■ The Watson knife can be adjusted manually for thinner or thicker excisions.
The knife is opened to its widest for large deep back burns, whereas more
superficial leg burns would be treated with the knife only partially opened.
Video p7-c014_01
■ Skin grafts are harvested using a dermatome which can be electric or air
powered.
■ A mesher is used to place holes in the skin, so that it can be stretched to cover
a larger surface area (FIG 3E).
00:00 / 00:00

FIG 3 • A. Watson Knife. B. Weck knife with guards. C.
Dermatome with 1″, 2″, 3″, 4″ guards. D. Weck knife
with guard loaded on blade. E. Skin being meshed in a
2:1 fashion.
Positioning
■ The patient is positioned to access the eschar and available donor sites. If
necessary, the patient may be repositioned during the operation. For most
lower-extremity wounds, the patient can be placed in the supine position.
■ A plan to keep the patient warm during surgery should be formulated prior to
the OR and implemented on arrival. Common strategies to maintain the
patient’s temperature include warming the room and all IV fluids, covering all
nonoperative body parts with warm blankets and placing a heating pad or
warming blanket under the patient.
T E C H N I Q U E S
■ Tangential Excision
■ Direct the blade of the knife at the skin in approximately a 30 degree angle
to engage the eschar in the blade.
■ Decrease the angle so that the blade is parallel to the skin through the
remainder of the excision.

■ Gentle pressure is applied as the blade is moved back and forth to slice off
the eschar at a uniform depth. The motion of the blade is akin to playing the
violin where the bow is slid back and forth across the strings.3
■ Excise the most dependent portion of the eschar first, so that the bleeding
will not obscure the remaining areas that require excision.
■ This process should be repeated until the entire wound has healthy tissue
present with punctate bleeding.
Video p7-c014_02
■ Each area should be tangentially excised until a viable wound bed is
obtained before moving to the next area. This will minimize blood loss and
ensure that entire wound bed is adequately excised.
■ After initial excision, the entire wound bed should be assessed to assure
punctate bleeding is present throughout. If immediate skin grafting is
planned, any areas of questionable viability should be excised again in the
same method until the surgeon is satisfied with the appearance of the wound
bed. If allograft is planned for areas of questionable viability, then these
wounds can be left to see if they will survive. These areas can then be re-
excised at the next surgical session as needed (TECH FIG 1).
■ Epinephrine-soaked sponges are used for hemostasis followed by
electrocautery to any bleeding that has not subsided.
00:00 / 00:00

TECH FIG 1 • Contact ankle burn after tangential
excision and hemostasis.
■ In the extremities, tourniquet control can be used while performing
tangential excision.
■ A sterile tourniquet can be applied to the normal skin or even injured tissue
proximally on the extremity.
■ The extremity is elevated and the brachial or popliteal artery compressed
prior to inflation of the tourniquet. In general, exsanguination is not
performed as the wounds may be contaminated or infected.
■ Excision then proceeds as outlined above. Given the inflated tourniquet,
bleeding is not the end point of excision. The surgeon must become adept
in assessing the underlying wound bed in the absence of bleeding. The
dermal tissue should be glistening white and the fat a moist light yellow
without hemorrhage. All thrombosed blood vessels should be excised.
Once excision is completed, the tourniquet is deflated and the wound bed
reassessed. Areas that do not bleed should be re-excised as outlined above.
■ Skin Grafting
■ Split-thickness skin grafts are harvested using a dermatome.
■ In general, 0.012-in. thickness is the standard setting for harvesting a split-
thickness skin graft.
■ Thinner grafts may be used for large burns or when wound contraction is
desired as is the case for fingertip injuries or plantar heel wounds.
■ Thicker grafts can be harvested for areas of functional importance and

where graft contracture should be minimized.
■ The hands, face, feet, and genitalia are a few examples where thicker split-
thickness grafts or full-thickness grafts would be utilized.
■ Harvesting a skin graft is ideal when the donor surface is flat.
■ This can be achieved both by positioning the patient and manipulating the
tissue with pressure and traction.
■ For these reasons, the thighs are the preferred donor site for harvesting a skin
graft.
■ Local anesthetic can be injected prior to skin graft harvest for postoperative
pain control.
■ Other areas can be made smooth and flat by “tumescing” the underlying
tissue similar to the technique used for liposuction.
■ This involves inflating or swelling the subcutaneous tissues with liquid.
■ A solution consisting of lactated ringers, local anesthetic, and epinephrine
is injected into the subcutaneous tissue of the area of the planned harvest.
■ The amount of solution required is assessed for adequate “tumescence” by
manual palpation to see if it is indurated and filled with fluid such that it is
smooth and all bony prominences are now obscured.
■ Care must be taken to ensure the injection is subcutaneous and not within
the deeper tissues.
■ Tumescence is commonly performed over the back and chest where the ribs
are palpable and the anterior lower extremities where the tibia is prominent.
■ If injected too deeply in the extremities, compartment syndrome could
ensue.
■ The tumescent solution also aids with hemostasis from the epinephrine effect
and postoperative pain control from the local anesthetic.
■ Mineral oil is applied to the skin and dermatome immediately prior to
harvesting to allow the dermatome to slide more easily along the skin.
■ Once the donor site has been prepared, the dermatome is turned on and
applied to the skin at approximately a 45-degree angle.
■ Light to moderate pressure is applied and the skin engaged by the
dermatome.
■ Once the graft is visible in the dermatome, the angle of harvest can be
decreased to roughly 30 degrees.
■ Under physician control, gentle forward pressure is applied to the
dermatome along the entire length of the skin being harvested.

■ The dermatome is then disengaged from the skin by angling it up akin to a
“plane taking off from the tarmac.” The motor is engaged until the
dermatome is off of the skin.
Video p7-c014_03
■ After the skin grafts are harvested, topical epinephrine-soaked sponges can
be applied to the donor site wound bed for hemostasis.
■ Grafts can be kept on the technician’s table in moist saline soaked gauze
until the surgeon is ready to apply them.
■ The grafts can be applied as sheet grafts or meshed grafts. Sheet grafts
contract less than meshed grafts, and their appearance is better. Grafts can be
meshed 1:1 up to 9:1 as needed. Narrow mesh allows for fluid egress while
minimizing the mesh appearance of the healed graft. Wider meshing allows
for coverage of large wounds with minimal amounts of intact skin. The wider
the graft is meshed, the longer the time to healing and the more wound
contracture there will be. Widely meshed grafts can be difficult to work with
as it may be challenging to identify the dermal side of the graft.
■ Grafts should be placed with the dermal side in contact with the underlying
wound bed. The surgeon should try to avoid having seams or joining areas
over joints.
00:00 / 00:00

TECH FIG 2 • Meshed skin graft secured in place with
staples.
■ For the lower extremity, there are two techniques that facilitate grafting.
■ The first is to wrap the grafts circumferentially around the leg so that the
seam is on the anterior surface of the leg.
■ The second is to place one long strip vertically on the posterior side of the
leg.
■ The remaining grafts can then be placed on the anterior, medial, and lateral
sides.
■ Both of these techniques minimize the amount of stapling or suturing that
needs to be done to the posterior surface of the leg. Technically, this makes
the surgery easier and allows it to proceed more expeditiously.
■ The grafts can be secured with surgical staples (TECH FIG 2), sutures, and
tissue glue or Steri-Strips/Hypafix (Smith & Nephew, London, UK) dressing
tape.
■ Skin staples are the traditional method of fixation for large grafts.
■ Smaller grafts can be sutured in place obviating the need and pain of staple
removal.
■ In recent years, Artiss fibrin sealant (Baxter, Westlake Village, CA) has
become available and can be used to adhere grafts to the underlying wound
bed.
• Artiss is used in conjunction with staples, but these can be removed at the
completion of grafting and when the Artiss has dried or alternatively a few
critical staples may be left in place to be removed later.
■ Steri strips or other adhesive tapes can also be used on grafts that border

the normal skin.
PEARLS AND PITFALLS
Technique
■ If the Watson, Weck/Goulian blade is held in a too vertical position, it
will incise the skin like a standard knife and can injure underlying
structures.
■ Care should be taken over the Achilles tendon, malleoli, and the
patella as overzealous excision will quickly result in tendon and bone
exposure.
Tumescent
technique
■ Care must be taken to ensure the injection is subcutaneous and not
within the deeper tissues.
■ If injected too deeply in the extremities, compartment syndrome could
ensue.
Excision
■ Adequate excision is the key to a successful outcome. It is critical that
the surgeon ensure that all nonviable tissue has been excised prior to
skin grafting.
POSTOPERATIVE CARE
■ For larger grafts or in larger wounds, the grafts are covered with nonadherent
gauze and silver impregnated dressings for antimicrobial protection. In the
contaminated wound, the dressings are left in place for 72 hours, and then daily
dressing changes are instituted. Early changing of bandages in these high-risk
wounds helps identify infections and promote aggressive treatment to salvage
skin grafts. Pseudomonas infection is a common culprit in these scenarios and
can be treated effectively with mafenide solution-containing dressings. Smaller
or less contaminated burns can be left in the postoperative dressing for 5 to 7
days, and then wound care can begin with any moisture-containing products.
We commonly use Xeroform and Bacitracin. There is currently no conclusive
data to support the use of systemic antibiotics after a skin graft procedure is
performed.
■ The vacuum-assisted closure (VAC) device can also be used to secure skin
grafts during the early postoperative period. The VAC is placed in the
operating room and left on for 5 to 7 days postoperatively depending on the
surgeon’s comfort with the cleanliness of the wound. After removal, standard
daily dressing changes are instituted. The VAC is extremely helpful in getting

grafts to adhere to a wound bed that has concavities or irregularities. The VAC
provides excellent fixation of the grafts so that movement of the extremity will
not shear the grafts. This feature makes it an excellent choice for children who
may not be compliant with immobilization instructions. In addition, the VAC
provides a less painful wound environment often giving patients a break from
the daily pain of wound care. In order to place the VAC, there must be a 1- to
2-in. border of the normal skin around the wound for tape placement (FIG 4).
■ Grafts that cross joints should be immobilized with splints to prevent shearing
of the grafts.
■ Bolsters can be used to present movement of the graft and promote adherence
of grafts in convex and irregular wound beds.
■ Physical therapy with ambulation and range of motion is instituted on
postoperative day 5 when the grafts should be adherent. For larger wounds and
grafts, compression garments are worn once the wound is healed.
FIG 4 • VAC dressing in place.

FIG 5 • Six days after excision and grafting. The graft is
pink and adherent.
OUTCOMES
■ With experience, skin graft take should consistently be above 80% (FIG 5).
Long-term outcomes from skin grafting depend on the severity of the injury,
length of time to healing, and patient participation in therapy. Hypertrophic
scarring, contractures, pigment changes, itching, and pain are long-term
sequelae of the disease process and the treatment. Often, surgical release of
contracture is necessary to regain full function after tangential excision and
skin grafting.
COMPLICATIONS
■ Graft loss (partial or total) remains the main complication.
■ Causes:
■ Inadequate excision of the underlying wound bed
■ Hematoma
■ Seroma
■ Graft shear
■ Infection
■ Contracture
REFERENCES
1. Janzekovic Z. A new concept in the early excision and immediate grafting of
burns. J Trauma. 1970;10:1103-1108.
2. Burn Incidence and Treatment in the United States: 2016.

3. Mosier MJ, Gibran NS. Surgical excision of the burn wound. Clin Plast Surg.
2009;36(4):617-625.

50
CHAPTER
Reconstruction of
Contractures: Z-Plasty, Skin
Grafting, and Flaps
Xiangxia Liu
DEFINITION
■ Scar contracture is the result of tightening of the skin during and after the
wound healing process.
■ The continuous and progressive contraction of the scar will cause the
impairment of appearance and significant dysfunction of the affected area.
■ In the lower extremities, especially around the knee and ankle joint, the
contracture scar can cause significant restriction in movement and, therefore,
should be treated as soon as possible.
■ There are many surgical interventions to treat scar contracture, including Z-
plasty technique for mild scar contracture, skin grafting for a larger area of skin
defects after the releasing of the contraction, and a skin flap, especially around
the knee and ankle joint area or when there are any bone, tendon, nerve, and
blood vessel exposure.
ANATOMY
■ The scar contractures in the lower extremities usually only affect the
superficial fascia layer. Sometimes there will be exposed bone, tendons, nerves,
and vessels after scar resection or revision.
■ Lateral femoral circumflex artery (LFCA) arises from the deep femoral artery;
it goes deep to the rectus femoris muscle and divides into three branches: the
ascending, transverse, and descending branch. The Anterolateral thigh flap
(ALT) is designed base on the perforator of the descending branch of LFCA
(FIG 1A).
■ Pedicled reverse-flow ALT flap is a useful tool to repair the defects around the

knee joint. The descending branch of LFCA will communicate with the arteries
around the knee joint, which perfuses the pedicled reverse-flow ALT flap (FIG
1B).
■ Perforator flaps based on the peroneal artery or posterior tibial artery (FIG
1C) are powerful tools to repair the defects around the ankle joint and the heel
(FIG 1D).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history and physical examinations will help us to determine whether a
simple Z-plasty can release the contracture or skin grafting or a flap is needed
(FIG 2).
FIG 1 • A. Arising from the produnda femoral trunk, the

lateral circumflex femoral artery (LCFA) gives three
branches: ascending, transverse, and descending
branch. The descending branch of LCFA travels deep
with the space between the rectus femoris muscle and
the vastus lateralis muscle. As traveling distally, it
distributes the perforators, in most cases
musculocutaneous perforators to the flap. B. The distal
communicating artery between the descending branch
of LFCA and the lateral superior geniculate artery is the
anatomic basis for the reversed ALT flap. C. Through its
course in the leg, the posterior tibial artery usually gives
two to four major septocutaneous perforators; these
perforators arise from between the soleus and the flexor
digitorum longus muscle or between the flexor digitorum
longus muscle and the medial aspect of tibial bone. The
distance between the lowest perforator and the medial
malleolus ranges from 3.5 to 8.2 cm.1 D. The
perforators of peroneal/fibular artery arise from between
the soleus and the peroneus longus/brevis muscle.
They are usually located within 2 cm from posterior
border of fibular bone and are closer to the fibular bone
proximally than distally.
IMAGING
■ Preoperative radiography can help to distinguish simple and complex scar
contracture, especially if an underlying skeletal abnormality is suspected.
■ CT and MRI scanning play an important role in the evaluation of skin cancer.
■ An MRI can well identify the relationship among the tumor, calcaneus bone,
and Achilles tendon in the case of Marjolin ulcer, an aggressive squamous cell
carcinoma presenting in an area of chronic inflammatory scar tissue (FIG 3).
SURGICAL MANAGEMENT
Indications

■ Z-plasty is designed to elongate a less contracted linear scar or to break a scar
tension line.
■ Skin grafting is an option when the primary closure is impossible and there is
a lack of adjacent tissue for coverage.
FIG 2 • A. For a superficial nonhypertrophic scar on
right arm with minimal contracture, the simple technique
of Z-plasty will release the contracture scar and break
the tension line. B. For this patient, skin grafting is
needed to replace the unwanted hypertrophic scar on
the dorsum of the right foot and to release the dorsal
contracture of the second, third, and fourth toes. C.
Both the Z-plasty and skin grafting are needed to fully
release the contracture bands of the left ankle and foot.
■ Flap should be applied when there is an exposure of the bone, nerve, blood
vessel, and other tissues, which are unsuitable for skin graft.
Preoperative Planning
■ Prepare the donor site for skin grafting.
■ Use Doppler ultrasonography to confirm the perforator before the operation.
■ Pathological study of the chronic ulcer in the scar area before the surgery is
important.
Positioning
■ The patient is placed supine on the operating room table with the entire lower
extremity prepared into the field.
■ The ipsilateral or contralateral thigh is prepared into the field in the event that

a split-thickness skin graft is needed.
■ The scalp is another option for harvesting thin split-thickness skin grafts if
the patients do not want to leave a visible scar on the donor site.
FIG 3 • A. Cauliflowerlike tumor on the right heel. B.
MRI shows the tumor has a close relationship with the
calcaneus bone and the Achilles tendon. A flap would
be needed to cover this defect after tumor resection
because there will be an exposure of both the bone and
tendon.
■ The groin is prepared in the event that a full-thickness skin graft is needed.
■ A prone position will be helpful when the procedure is related to the posterior
aspect of lower extremity.
■ A lateral decubitus position will facilitate the exploration of the perforator of
peroneal artery.
Approach
■ Make the incision on the medial margin of ALT flap first as this will facilitate
the exploration of perforators in the medial thigh in case that there is no
perforator available in the lateral side.
T E C H N I Q U E S
■ Z-Plasty
■ Draw the center line on the part of the scar with the most contracture.
■ Make a paired and paralleled limb line on each side of the center line

(TECH FIG 1A).
■ Try to set the angle around 60 degrees between the center line and limb
lines.
■ Cut the skin along the designed lines.
TECH FIG 1 • A. Multiple Z-plasties marked on a
contracture band. B. The flap is elevated superficial to
the deep fascia. C. The paired Z-plasty flaps are
transposed initially.
■ Release the subcutaneous bands.
■ Elevate the flap superficial to the deep fascia (TECH FIG 1B).
■ Transpose the paired skin flaps (TECH FIG 1C).
■ Trim the dog ears and overly abundant subcutaneous tissues.
■ Place several sutures in dermal layer of the key areas.
■ Close the wound accordingly.
■ Skin Grafting
Preparation of the Recipient Site
■ Release the contracture bands of the scar (TECH FIG 2A).

■ Make multiple zigzag incisions along the cutting edge of the wound to lessen
the tension of the scar (TECH FIG 2B,C).
■ Remove the scar tissues in the wound.
■ Control bleeding with bipolar electrocautery.
■ Make a template of the defect.
Harvesting the Skin Grafts
■ Use the tumescent fluid to flatten the surface of donor site and reduce
bleeding.
■ Use a power-driven (TECH FIG 3A) or freehand dermatome to harvest the
split-thickness skin grafts from the thigh or scalp.
■ Choose the width and the thickness of the harvested grafts by adjusting the
dermatome (TECH FIG 3B,C).
■ A simple way to assess the thickness is by passing a no.15 blade between
the guard and the blade.
■ Install and lock a new disposable blade.
■ Make a 30- to 45-degree angle between the handle and the surface of the
skin (TECH FIG 3D).
■ Apply gentle downward pressure, and advance the machine slowly during
the harvesting (TECH FIG 3E).
■ Assess the thickness of the cut during harvesting by observing the grafts
through the guard and the wound of donor site.
■ Angle the machine upward, and lift off from the donor site when the harvest
is complete.
■ Cover the donor site with petroleum jelly gauze (TECH FIG 3F) or
Melgisorb (Mölnlycke Health Care, Gothenburg, Sweden) combined with
Mepilex (Mölnlycke Health Care, Gothenburg, Sweden).
■ Put the grafts on petroleum jelly gauze with the dermal side facing up
(TECH FIG 3G). A graft tends to fold over on itself, and this will help to
keep it extended.
Placing and Securing the Grafts
■ Place the grafts on the wound.
■ Keep the dermal side downward, and attach to the wound directly. The
dermis has a shiny appearance and sticky sensation.
■ Tailor the grafts to the wound and staple the key area.
■ Adding a suture at the tip of a small full-thickness skin graft and holding it

against the index finger can help to trim the grafts with scissor (TECH FIG
4A,B).
■ Secure the grafts with suture, surgical staple, or fibrin glue (TECH FIG 4C),
flushing beneath the grafts with normal saline before dressing.
■ Place a petroleum jelly gauze directly on the grafts (TECH FIG 4D), and
top that with a single layer of moistened gauze.
■ Next, apply a circumferential wrap/tie-over bolster/negative pressure
technique (TECH FIG 4E).
■ A splint is applied to immobilize the extremity.
TECH FIG 2 • A. The contracture band is completely
released. B,C. Zigzag incisions (arrows) are made
along the cutting edge of the wound to minimize the
scar contracture later on.

TECH FIG 3 • A. Aesculap model dermatome. B.
Width is adjustable with 10 individual 8.0-mm cutting
flaps. C. Cutting thickness varies from 0.2 to 1.2 mm
in lockable 0.1 mm increments. The thickness reading
indicates the maximal thickness the surgeon can
harvest; grafts may be thinner depending on the
pressure applied on the handle. D. The device is held
at 30- to 45-degree angle between the handle and the
surface of the skin. E. Split-thickness skin grafts being
harvested from scalp. F. The donor site is covered
with petroleum gauze. G. The harvested skin grafts
are placed on the petroleum jelly gauze with dermal
side facing up, which will facilitate placement in the
wound.

TECH FIG 4 • A. A stitch is placed in the tip of the
graft. B. Placing the graft on the dorsal of index finger
and holding with thumb and middle finger helps with
trimming. C. Graft in place and secured with staples.
D. Petroleum jelly gauze is placed on the graft. E.
Wrapped before splinting.
■ Skin Grafting Combined with Acellular
Allodermal Matrix
■ The recipient site is prepared by excising the scar as previously described.
■ Acellular allodermal matrix is used to cover the defect (TECH FIG 5A,B).
■ Split-thickness skin grafts are harvested and placed as described (TECH FIG
5C).
TECH FIG 5 • A. Premeshed acellular allodermal
matrix. B. Placement of the matrix. C. Placement of
split-thickness skin graft.
■ Flaps

Using an Expanded Flap to Repair a Contracture Scar
■ Release the contracture scar.
■ Harvest the expanded flap (TECH FIG 6A,B).
■ Transpose and inset the expanded flap (TECH FIG 6C).
■ Close the recipient and donor sites (TECH FIG 6D).
Using a Flap and Skin Graft
■ In this patient, a pedicled reverse-flow ALT flap was used to reconstruct an
ulcer of the scar in the knee area.
■ The lesion is excised (TECH FIG 7A,B).
■ The ALT (ALT) flap is designed, including the pivot point (TECH FIG 7C).
■ The flap is elevated, rotated, and inset (TECH FIG 7D–G)
■ Split-thickness skin graft is used to cover the donor site, and the recipient
and donor sites are closed (TECH FIG 7H).
Using a Skin Flap to Repair a Heel Wound
■ In this patient, lateral lower leg skin flap based on the perforator of peroneal
vessel was used to repair a Marjolin ulcer on the heel.
Stage 1: Tumor Resection
■ A 2 cm margin is marked.
■ Dissection plan is under the deep fascia.
■ The periosteum of calcaneus under the tumor is resected (TECH FIG 8).
■ The wound is packed with iodine gauze.
■ The second stage of reconstructive surgery is delayed until the negative
margin is confirmed by the final pathology report.
Stage 2: Wound Repair
■ Perforator investigation
■ Mark the head of the fibula, lateral malleolus, and fibula bone.

TECH FIG 6 • A. Scar contracture of the popliteal
fossa with tissue expander placed on the lateral
aspect of the thigh. B. Inferior-based flap design. C,D.
Contracture scar excised and flap transposed.
TECH FIG 7 • A. Chronic ulcerative scar on the
anterior aspect of the right knee with limited knee
extension function. B. Excise the lesion completely. C.
Design of the ALT flap and the marking of pivotal
point. D. Flap monitor is used during the surgery. E.
The ALT flap is incised and elevated. F. The

perforator. G. The flap is rotated into place to repair
the defect. H. Skin graft is used to cover the donor
site, and both sites are closed.
■ Make an incision at the posterior margin of the flap, usually 3-5 cm
posterior to fibula bone and between 6 and 15 cm above the lateral
malleolus.
■ Dissect under the deep fascia, from posterior to anterior toward the fibula.
■ Identify any perforators coming out from the septum (TECH FIG 9A,B).
■ Flap elevation and coverage
■ The incision is complete all around the flap.
■ Elevate the flap under the deep fascia.
■ Microclamp the perforators that are going to be ligated.
■ Release the tourniquet and observe the flap perfusion.
■ If flap perfusion is good, all the perforators, other than the selected one, are
ligated.
■ If flap perfusion is not satisfactory, wait for about 15 minutes.
■ If perfusion is still not good, an adjacent perforator should be reopened and
the perfusion reassessed until a satisfactory vascularity of the flap is
guaranteed.
■ Rotate the flap and cover the wound (TECH FIG 9C).
■ Donor site closure with skin grafting
■ Temporarily staple the flap to the margin of the wound, and measure the
defect of donor site and the uncovered one.
■ Use power-driven dermatome to harvest the split-thickness skin grafts from
the thigh.
■ Tailor the skin grafts to the wound and staple it (TECH FIG 9D).
■ Soft bulky dressing is put on the flap.
■ The distant part of the flap is exposed without dressing for flap monitoring.

TECH FIG 8 • A. Cauliflowerlike tumor on the right
heel. B. The defect after the excision surgery.
TECH FIG 9 • A. One week after the initial excision
surgery, a flap based on the perforator of peroneal
artery is elevated. The blue dot shows the location of

the perforator. B. The perforator is seen arising
between the soleus and peroneus brevis muscle. C.
Flap rotation to cover the area of the Archilles tendon
and calcaneus bone exposure. D. Donor site is
covered by split-thickness skin graft. No active suction
drainage is placed around the perforator.
PEARLS AND PITFALLS
Z-
plasty
■ Flap angle of 60 degrees will get maximal elongation (FIG 4).
■ The angles should set up to be a little more than 60 degrees when there is
a severe contracture of the scar line because as the contracture scar is
released, the angles tend to go sharper than designed.
■ Place the lateral limbs parallel to the line in which the new central line
will lie.
■ Always cut the center line before cutting the limb.
■ In scarred tissues, raise a thick flap that includes a layer of subcutaneous
tissue to ensure adequate blood supply.
■ In multiple Z-plasty, the designed flaps may not always interdigitate to
each other perfectly.
Skin
grafting
■ Make sure the defect is suitable for skin grafting before harvesting the
graft.
■ Kirschner wire fixation can help in patients with severe contracture
deformity (FIG 5).
■ The formula for tumescent fluid: 500 mL lactated Ringer solution plus 1
mL/1 mg epinephrine.
■ Harvest 5%–10% more grafts than the template because the graft always
tends to shrink.
■ Always keep the grafts moist.
■ It is important to keep the dermal side downward and attach to the wound
directly. False orientation will lead to a complete necrosis of the grafts.
■ Inadequate wound preparation always contributes to the failure of skin
grafting.
Flaps
■ Locate the perforators by using ultrasound Doppler preoperatively to help
dissection during the surgery.
■ Always explore the perforator under tourniquet control before elevating

the flap.
■ Modify the design of the flap based on the perforators discovered during
surgery.
■ Although the perforators that are identified by ultrasound preoperatively
may be good, sometimes better ones will be uncovered during the
dissection.
■ Placing a drain near the perforator that can compress the vessel or putting
excessive compression over the pedicle of the flap will jeopardize the
blood supply of the whole flap.
FIG 4 • A. The angle of a Z-plasty should be about 60
degrees, as shown on this congenital constriction ring
of right lower leg. Black = center line; blue = limb lines.
B,C. Immediately after Z-plasty, the constriction ring
had been excised.

FIG 5 • A. Dorsal contracture of the second, third, and
fourth toe of the right foot. B. Placement of K-wire
fixation before the placement of acellular dermal matrix
and split-thickness skin graft.
POSTOPERATIVE CARE
■ A soft dressing is applied to the wound of Z-plasty. There is no need to restrict
the mobility of patients with simple Z-plasty reconstruction.
■ Dressing is applied to provide compression over the skin graft site.
■ Tie-over bolster technique or negative pressure wound therapy may be
helpful to increase the take rate of the grafts.
■ The lower leg and foot cast or splint should be applied if the skin graft site is
near to the knee or ankle.
■ The cast or splint can be removed after about 2 weeks. If the tie-over bolster
technique was applied, remove the bolster carefully to avoid the shear injury
to the grafts.
■ After the flap surgery, mark the location of flap’s pedicle where the perforators
enter the flap and avoid pressure over it.
■ Postoperative flap monitoring is vital for the reconstruction.
■ Capillary refill time is still a secure and practical way to monitor the flap.
■ A cast or splint on the surgical site would be helpful if there is a skin grafting
at the same time.
■ The postoperative scar care, such as pressure garments and silicone gel, should
be applied to all patients for a better functional and aesthetic result.
OUTCOMES
■ Outcome photos for the cases in this chapter are shown in FIG 6.
COMPLICATIONS
■ Potential causes of skin graft loss

FIG 6 • Case outcomes. A. Two-year follow-up of split-
thickness skin grafting in the patient in TECH FIG 4. B.
One-year follow-up of skin graft combined with acellular
dermal matrix in the patient in TECH FIG 5. C. Six-month
follow-up of expanded thigh flap to repair a contracture
scar in the patient in TECH FIG 6. D. One-year follow-up
of an ALT flap in the patient in TECH FIG 7 shows a
pliable flap and full extension of the knee. E. Three-
month follow-up of the patient in TECH FIG 9, who
underwent skin flap repair of a Marjolin ulcer on the
heel. F. Ten-year follow-up of the patient in FIG 4, who
underwent Z-plasty for a congenital constriction ring.
FIG 7 • A. Epidermolysis of skin graft. B. Partial
necrosis of skin graft caused by hematoma underneath.
C. The distal part of an expanded flap became necrotic.
■ Infection
■ Hematoma/seroma
■ Poor vascularization
■ Irradiation

■ Other complications
■ Epidermolysis of skin graft (FIG 7A)
■ Partial necrosis of the skin grafts (FIG 7B)
■ Partial necrosis of an expanded flap (FIG 7C)
ACKNOWLEDGMENTS
The author thanks Drs. Xunxun Lin and Wenjun He for their help in
preparation of FIG 1.
REFERENCE
1. Hung LK, Lao J, Ho PC. Free posterior tibial perforator flap: anatomy and a
report of 6 cases. Microsurgery. 1996;17:503-511.

51
CHAPTER
Soft Tissue Reconstruction
with Propeller Flaps
Adam Jacoby, John T. Stranix, and Pierre B. Saadeh
DEFINITION
■ Propeller flaps represent one of the most recent technical advances in
perforator flap dissection.
■ Propeller flaps are especially useful alternatives to microvascular free tissue
transfer when reconstructing distal lower extremity defects.
■ The perforator propeller flap can provide soft tissue coverage on all parts of
the body despite its original and most common use for lower extremity defects.
Its adipocutaneous composition and ability to be rotated up to 180 degrees
provide an excellent source of thin pliable tissue along with a faster and
relatively simpler dissection compared with free flap harvest.
■ To be considered a “propeller,” the flap must rotate between 90 and 180
degrees around its perforating vessels.
ANATOMY
■ Propeller flaps can be classified based on pedicle anatomy, either the type of
pedicle supplying the flap or the pedicle position.
■ Island propeller flaps are skeletonized along the perforator vessels and allow
up to 180 degree rotation with relative protection from pedicle kinking.
■ Nonskeletonized propeller flaps can be either skin- or muscle-based pedicled
flaps where the dominant perforator is not skeletonized. Although operative
times are shorter and there is less risk of perforator injury from dissection
with nonskeletonized flaps, pedicle kinking is more likely—especially when
rotated greater than 90 degrees (FIG 1).
■ Propeller flaps can also be classified as a central axis propeller (pedicle in the
middle of the flap) or an eccentric axis propeller (at its periphery).