Operative Technique in Plastic Surgery – Kevin C.Chung

■ Elbow approach: The muscles causing an elbow flexion contracture
(brachialis, biceps brachii, and BR) are approached via an antecubital incision.
■ Procedures to restore elbow flexion require a technique-specific approach.
■ Forearm approach: The biceps tendon is approached through an antecubital
fossa incision. The entire length of the tendon and portion of the radius under
which the tendon is rerouted must be visualized.
■ Wrist/fingers approach: Procedures to restore wrist and finger function require
a technique-specific approach. The FCU tendon may be approached through a
single longitudinal incision or several stepcut incisions.
■ Free functioning muscle transfers to restore finger flexion require an
extensile approach from the anterior upper arm across the acromion and
lateral clavicle. This provides full visualization of the proposed site of origin
of the transferred muscle as well the adjacent neurovascular structures to be
protected and/or used for vascular anastomoses and nerve coaptation.
E L B O W R E C O N S T R U C T I O N
T E C H N I Q U E S
■ Elbow Release
■ Landmarks: median nerve, radial nerve, lateral antebrachial cutaneous nerve
(LABC), brachial artery, brachialis muscle, biceps brachii muscle, BR
(TECH FIG 1)
■ Depending on the severity of the contracture, a curvilinear or Z-plasty
incision is made and the lacertus fibrosus is identified and divided (TECH
FIG 2A,B).
■ The median nerve/brachial artery is identified and retracted medially and the
LABC is retracted laterally.
■ If fractional lengthening is indicated, then two incisions 1 cm apart are made
with electrocautery at the musculotendinous junction of the brachialis. The
anterior half of the BR is elevated from the humerus while protecting the
radial nerve. The medial half of the biceps tendon is incised distally and the

lateral half proximally to provide lengthening. The release is reinforced with
3-0 braided suture, as needed.
■ If a full release is indicated, then the biceps tendon is Z-lengthened16 (TECH
FIG 2C), the brachialis is divided, and the BR is completely elevated from
the humerus while protecting the radial nerve. The anterior elbow capsule is
incised, if necessary. In long-standing contractures, foreshortened
neurovascular structures will limit full passive elbow extension.
■ The biceps tendon is reapproximated using 3-0 braided suture with the
elbow in 30 degrees of flexion (TECH FIG 2D).
■ The skin is closed in layers (TECH FIG 2E).
TECH FIG 1 • Structures crossing the elbow.

TECH FIG 2 • Approaches to elbow release. A.
Curvilinear approach to the elbow. B. Z-plasty
approach to the elbow. C. Steps in a biceps Z-

lengthening. D. Z-lengthened biceps tendon prior to
reapproximation. E. Wound closure with a Z-plasty at
the elbow (arrow).
■ Restoration of Elbow Flexion
Steindler Flexorplasty (TECH FIG 3)
■ Landmarks: medial epicondyle, median nerve, ulnar nerve, brachial artery,
humerus, biceps brachii muscle, brachialis muscle
■ Fifteen-centimeter medial elbow curvilinear incision is made, and the skin
flaps are elevated above the fascia while protecting the medial antebrachial
cutaneous nerve.
■ The ulnar nerve is retracted medially and the median nerve and brachial
artery are retracted laterally.
■ The flexor-pronator mass is freed from osseous attachments distally. Using
an osteotome, the flexor-pronator origin at the medial epicondyle is elevated
with a 2-cm segment of bone.
■ The humerus is exposed deep to the brachialis. Approximately 5 to 7 cm
proximal to the elbow joint, a bur is used to create a cortical window in the
humerus.17
■ With the elbow in 130 degrees of flexion, the medial epicondyle/flexor-
pronator mass is secured to the humeral corticotomy using a 3.5-mm
compression screw over a washer.

TECH FIG 3 • Steps in a Steindler flexorplasty.
■ The ulnar nerve is transposed anteriorly to prevent tethering and the muscle
is closed over the exposed osteotomy site using absorbable suture.
■ The skin is closed in layers.
Latissimus dorsi Transfer (Pedicled) (TECH FIG 4)
■ Landmarks: thoracodorsal neurovascular bundle, rhomboid muscle, teres
major and minor muscles, acromion, clavicle, biceps brachii tendon
■ Bipolar (moving the muscular origin and insertion) transfer is preferred
because it increases the mechanical efficiency of the transfer and decreases
the chance of vessel twisting/kinking.18
■ Harvest—5-cm wide elliptically oriented skin paddle (8 cm distal to the
axilla) is designed over the midaxis of the muscle and incised with
superolateral and inferomedial extensions.

■ The skin flaps are elevated off of the muscle and the arm is fully abducted
and flexed.
■ The muscle is marked at resting tension using 3-0 silk sutures placed at 5-cm
intervals.
■ The origin of the muscle is released and the muscle is elevated toward the
axilla.
■ The thoracodorsal neurovascular pedicle is identified on the deep surface of
the muscle and dissected to its origin from the axillary artery. All adventitia is
freed from the vessel to prevent tethering during transfer.
■ The LD insertion is released from the bicipital groove of the humerus using
electrocautery.
■ Inset—a curvilinear longitudinal incision is made over the anterior upper
arm with a transverse extension over the acromion and lateral clavicle.
■ The skin flaps are elevated, and a deltopectoral window is created through
which the muscle flap is passed, origin first. Confirmation of the
neurovascular pedicle orientation is mandatory at this juncture.
■ The insertion of the muscle is secured to the acromion and clavicle using two
previously placed suture anchors.
■ With the elbow in 100 degrees of flexion and full supination, the distal
muscle is tubularized and secured to the distal biceps tendon with 2-0 braided
suture or with suture anchors to the radial tuberosity.

TECH FIG 4 • Steps in a latissimus dorsi transfer for
elbow flexion.
■ Two drains are placed in the donor site and all wounds are closed in layers.
■ The skin paddle is used for postoperative muscle flap perfusion monitoring.
Free Functioning Gracilis Transfer
■ Landmarks: thoracoacromial artery, acromion, clavicle, biceps brachii
tendon, PM, intercostal muscles, adductor magnus, adductor longus
■ Harvest—a longitudinal incision is made 2 cm posterior to the palpable
adductor longus tendon on the medial upper thigh. The gracilis muscle is

identified and freed from surrounding soft tissues.
■ The obturator nerve is identified and dissected proximally toward the
adductor hiatus where it is divided sharply.
■ The medial circumflex femoral artery and vein are dissected to their origin
on the deep femoral vessels between the adductor longus and magnus.
Branches to the adductor longus must be carefully ligated and divided
(TECH FIG 5A).
■ The muscle is marked at resting tension using 3-0 silk sutures placed at 5-cm
intervals.
■ A 4-cm longitudinal incision is made overlying the medial proximal tibia.
The sartorius fascia is divided and the distal gracilis tendon (the most
superior structure of the pes anserinus) is identified and sharply release from
the tibia.
■ Inset—a curvilinear longitudinal incision is made over the anterior upper
arm with a transverse extension 2 cm above the acromion and lateral clavicle.
The distal biceps tendon is exposed while protecting the neurovascular
structures.
■ The thoracoacromial artery (or brachial artery) and cephalic vein are
prepared and the spinal accessory nerve is dissected free from the deep
surface of the anterior trapezius muscle, ensuring maximum length for
transfer (TECH FIG 5B,C). The intercostal nerves are an alternative donor
for motor reinnervation.19
■ The medial circumflex vessels are ligated and the muscle is transferred to the
arm.
■ The muscle position is evaluated relative to the anticipated neurovascular
repairs and the muscle is secured to the acromion and clavicle using two
previously placed suture anchors.
■ The vessel anastomoses and nerve coaptations are performed with 9-0 and
10-0 nylon suture, respectively.
■ With the muscle at resting tension and the elbow flexed to 100 degrees, the
gracilis tendon is woven into the distal biceps tendon with 2-0 braided suture
or secured to the radial tuberosity with suture anchors.
■ The wounds are closed in layers (TECH FIG 5D).
■ An implantable venous Doppler is used to monitor perfusion in combination
with clinical examination.
■ The patient is placed on 81 mg of aspirin daily for 4 weeks.

TECH FIG 5 • A. Free functioning gracilis muscle
transfer harvest. B. Free functioning gracilis transfer
with spinal accessory motor nerve. C. Free functioning
gracilis transfer with intercostal motor nerves. D. Free
functioning gracilis muscle transfer inset and closure.
F O R E A R M R E C O N S T R U C T I O N
■ Biceps Rerouting
■ Landmarks: biceps muscle, brachialis muscle, BR muscle, lacertus fibrosus,
brachial artery and branches, recurrent radial artery, median nerve, radial
nerve, LABC
■ A curvilinear incision is made over the antecubital fossa and the LABC is
identified and protected.
■ The radial nerve is identified between the brachialis and BR and protected.
The brachial artery and median nerve are also identified and gently retracted
for protection. The radial recurrent artery is ligated, if necessary.
■ The lacertus fibrosus is divided and the biceps tendon is traced to the interval

between the BR and PT such that the biceps insertion into the radius is
visualized.
■ The biceps tendon is then divided with a Z-lengthening technique.20
■ The distal biceps tendon is rerouted dorsolaterally around the radial neck
using a curved clamp. The rerouted tendon is then secured to the proximal
biceps tendon in a side-to-side fashion using 3-0 braided with the elbow in 90
degrees of flexion and the forearm in full pronation (TECH FIG 6).
TECH FIG 6 • Biceps tendon rerouting.
■ PT Release/Rerouting

Video p8-c053_02
■ Landmarks: BR, ECRL, ECRB, radius, radial artery, superficial radial nerve
■ Six-centimeter skin incision at the volar radial aspect of the midforearm
(TECH FIG 7A).
■ The forearm fascia is divided and the BR and ECRL are retracted dorsally
(TECH FIG 7B).
■ The superficial radial nerve lies under the BR and should be protected.
■ The PT is detached from the insertion on the radius (the release is complete
at this step). If rerouting is planned, then a 3-cm sleeve of the periosteum is
taken with the PT to ensure adequate length for rerouting (TECH FIG 7C).
■ The PT is mobilized proximally to allow for easy excursion.
■ The IOM is released at the site of reinsertion and the PT is passed from volar
to dorsal though a window in the IOM.
■ The forearm is supinated and the PT is reinserted into the radius. In children,
a 3-0 braided is woven into the PT tendon and passed through two
transosseous drill holes to secure the PT to the radius (TECH FIG 7D). This
is facilitated with the use of a Hewson suture passer.
■ In adults, a suture anchor may be used to secure the PT to the radius.
■ The tourniquet is deflated, hemostasis is ensured, and the incision is closed
in layers.
00:00 / 00:00

TECH FIG 7 • A. Approach for pronator teres
exposure. B. Exposure of pronator teres insertion on
the radius. C. Pronator teres elevation with a strip of
the periosteum. D. Transosseous suture placement
and docking of pronator teres onto dorsal radial shaft.
W R I S T / F I N G E R S
R E C O N S T R U C T I O N
■ FCU to ECRB Tendon Transfer for Wrist
Extension

Video p8-c053_01
■ Landmarks: FCU tendon, ulnar artery, ulnar nerve, ECRB tendon, ECRL
tendon, EDC tendons
■ A 10-cm incision made over the palpable FCU tendon extending proximally
from the pisiform (TECH FIG 8A).
■ The FCU is released from the pisiform, and the muscle/tendon unit is
elevated while protecting the ulnar artery and nerve (TECH FIG 8B).
■ A 6-cm incision is made over the distal dorsal forearm in line with the
middle finger ray. The second extensor compartment is opened sharply, and
the ECRB tendon is identified.
00:00 / 00:00

TECH FIG 8 • A. Markings for FCU to ECRB transfer,
pronator rerouting, and thumb adductor release. B.
FCU muscle/tendon exposure. Ulnar neurovascular
bundle sits just deep to the tendon. C. The FCU to
ECRB transfer was performed in combination with
EPL rerouting. D. Preoperative right wrist extension.
E. Postoperative right wrist extension.
■ A wide subcutaneous tunnel is created to directly connect the FCU muscle to
the proposed intersection with the ECRB tendon.11 In the setting of ulnar
wrist deviation, the FCU is instead woven into the ECRL to achieve radial
balance.
■ With the wrist in 30 degrees of extension, the FCU tendon is interwoven into
the ECRB tendon using an end-to-side Pulvertaft weave with 3-0 braided
suture (TECH FIG 8C).
■ Hemostasis is ensured, and the incisions are closed in layers.
■ The preoperative and postoperative posture of the right wrist is shown in
TECH FIG 8D,E.
■ Free Functioning Gracilis Transfer for Finger

Flexion
■ Landmarks: thoracoacromial artery, acromion, clavicle, intercostal muscles,
adductor magnus, adductor longus, FPL, and FDP tendons
■ See Restoration of Elbow Flexion technique, earlier, for harvest and
proximal inset details. The muscle may also be directly attached to the
humerus via suture anchors if additional distal length is necessary.
■ A pulley is created at the elbow using either the PT or the FCU to optimize
gracilis muscle excursion.21
■ With the muscle tension set at resting length, the elbow at 90 degrees of
flexion, and the MCP joints at 45 degrees of flexion, the gracilis tendon is
woven obliquely through the FDP and FPL tendons in the distal third of the
forearm and secured using 3-0 Ethibond suture. The FPL tendon junction
with the FDP tendons is performed to ensure that the thumb does not flex
prior to the digits (TECH FIG 9).
■ Hemostasis is ensured and the incisions are closed in layers.
■ An implantable venous Doppler is used to monitor perfusion in combination
with clinical examination.
■ The patient is placed on 81 mg of aspirin daily for 4 weeks.

TECH FIG 9 • Free functioning gracilis muscle for
finger flexion.
PEARLS AND PITFALLS
ELBOW RECONSTRUCTION

Elbow release
■ Electrocautery should be used to decrease bleeding during
myotomy.
■ Identify and protect the radial nerve during BR elevation.
■ In long-standing contractures, the neurovascular structures will
shorten and prevent full passive extension.
■ Z-lengthening of the biceps tendon should be performed over
as long a stretch of the tendon substance as possible.
■ Extreme care should be taken when handling the thin biceps
tendon during repair.
■ Patients with weak flexion may have a functional loss of
elbow flexion power after full release.
Steindler
flexorplasty
■ Small nerve branches to the flexor-pronator muscles and the
medial collateral ligament of the elbow must be protected.
■ Ensure good wrist extension power to counteract the possible
development of a wrist flexion contracture. If active wrist
extension is poor, simultaneous wrist arthrodesis can be
performed.
■ Concomitant ulnar nerve transposition is recommended to
prevent traction on the nerve after muscle transposition.
■ Ensure that the median nerve and brachial artery are free from
compression or traction prior to securely fixing the transposed
medial epicondyle/flexor-pronator mass.
LD transfer
■ High brachial plexus lesions may preclude use of this transfer.
■ Inclusion of a skin island will simplify recipient site closure.
■ The muscle can be debulked to accommodate the upper arm
soft tissue pocket.
■ The neurovascular structures should be assessed repeatedly
during transfer in an effort to avoid kinking/twisting.
Free functioning
gracilis transfer
■ Avoid nerve grafts, if at all possible.
■ If normal (unaffected by the NBPP), the LD transfer results in
better elbow flexion strength than the free gracilis transfer.
■ Delay revision surgery for at least 1 year or after skeletal
maturity.
FOREARM RECONSTRUCTION
Biceps rerouting
■ Overtensioning of the transfer may lead to an elbow flexion
contracture.
■ The tendon may be fragile, and care should be taken to prevent
fraying during handling.
■ It is essential to Z-lengthen the entirety of the tendon to ensure

adequate length for rerouting.
■ The posterior interosseous nerve is at risk during rerouting
because it lies directly on the radius.
■ A concomitant IOM release is recommended if there is no
passive pronation.
■ A BR rerouting in the forearm is recommended in patients
without adequate triceps function, because biceps rerouting
will impart an unopposed flexion force across the elbow.
PT
release/rerouting
■ The superficial radial nerve and radial artery must be protected
throughout the procedure.
■ The periosteal sleeve must be carefully elevated from the
radius to provide adequate length for rerouting and reinsertion
into the radius.
WRIST/FINGERS RECONSTRUCTION
FCU to ECRB
tendon transfer
■ If passive flexion of the wrist to 20 degrees is not possible, the
tension is too great and the muscle weave must be loosened.
■ Avoid lifting the tendons from the wound when performing the
weave because this will result in a lax repair.
■ Ensure that the subcutaneous tunnel through which the tendon
is passed is wide and straight.
■ Wrist arthrodesis is a better option in children with weak wrist
flexors.
Free functioning
gracilis transfer
■ Delay revision or adjunctive procedures for at least 1 year or
after skeletal maturity.
■ In children with weak or absent wrist extension, wrist
arthrodesis may be considered in the future to direct the full
force of flexion to the finger flexors.
POSTOPERATIVE CARE
Elbow Reconstruction
■ Elbow release
■ No immobilization is necessary after a fractional lengthening of the elbow
flexors. Immediate active and passive range of motion is initiated.
■ A full elbow release requires a long-arm orthosis for 4 weeks with initiation
of active and passive range of motion. A nighttime extension orthosis is worn
for 3 months.
■ Steindler flexorplasty

■ The elbow is immobilized in a long-arm orthosis for 6 weeks.
■ After 6 weeks, gentle elbow extension and flexion are initiated under
guidance of a hand therapist.
■ Resistance exercises are introduced at 12 weeks.
■ LD transfer
■ The elbow is immobilized at 100 degrees of flexion in a sling for 6 to 8
weeks. At 4 weeks, the patient is instructed to begin muscle contraction
exercises.
■ At 8 to 10 weeks, active elbow extension and flexion are initiated under
guidance of a hand therapist; re-education of the transferred muscle is often
necessary.
■ Resistance exercises are introduced at 12 weeks.
■ Free functioning gracilis transfer
■ The elbow is immobilized for 6 weeks in a position of 100 degrees of elbow
flexion and the forearm in neutral.
■ Passive range of motion is initiated at 6 weeks, but passive flexion is
restricted beyond 30 degrees for 12 weeks.
■ Re-education of the transferred muscle is necessary and EMG biofeedback is
helpful.22
■ Contraction of the transferred muscle typically begins around 4-6 months
postoperatively.
Forearm Reconstruction
■ Biceps rerouting
■ The arm is immobilized in a long-arm cast with the elbow in 30 degrees of
flexion and maximal pronation.
■ At 4 weeks, passive range-of-motion exercises are initiated and the patient is
transitioned to a long-arm orthosis.
■ At 6 weeks, active elbow extension and flexion are initiated under guidance
of a hand therapist.
■ The orthosis is discontinued at 8 weeks and resistance exercises are
introduced at 10 weeks.
■ PT release/rerouting
■ The forearm is placed in full supination using an above elbow orthosis for 6
weeks.
■ The patient is then allowed unrestricted motion under the supervision of a

hand therapist.
Wrist/Fingers Reconstruction
■ FCU to ECRB tendon transfer
■ The wrist is immobilized in 30 degrees of extension for 4 weeks.
■ After 4 weeks, gentle range-of-motion exercises are begun and an orthosis is
worn for an additional 4 weeks.
■ Free functioning gracilis transfer
■ The arm is immobilized for 4 weeks with the elbow at 90 degrees of flexion,
the wrist in neutral, and the fingers in at least 45 degrees of flexion at the
MCP joints and interphalangeal joints.
■ At 4 weeks, a custom orthosis is created and a passive stretching program is
initiated under the guidance of a hand therapist.
■ Upon spontaneous muscle contraction, the patient is directed to attempt
active flexion of the fingers.
■ Therapy should continue for up to 1 year.
■ Re-education of the transferred muscle is necessary and EMG biofeedback is
helpful.22
■ Contraction of the transferred muscle typically begins around 4-6 months
postoperatively.
OUTCOMES
Elbow Reconstruction
■ Elbow release: fractional lengthening will increase elbow extension by 40 to
60 degrees, with minimal loss of elbow flexion power.23–25
■ A full elbow release will increase elbow extension by 50 degrees but leads to
a 19-degree loss of active flexion.25 Many patients are able to accomplish
tasks that were difficult before surgery.
■ Steindler flexorplasty: Al-Qattan26 reports that patients can expect 110 degrees
of active elbow flexion against resistance, with a mean postoperative elbow
flexion contracture of 35 degrees.
■ LD transfer: Most patients will achieve M4 elbow flexion strength after
transfer, with a mean arc of flexion of 90 to 140 degrees.18,27
■ Free functioning gracilis transfer: El-Gammal et al. report an average arc of
elbow flexion of 104 degrees. Elbow flexion power increased an average of 3.8
grades,28 and 79% of patients achieve at least M4 elbow strength.29 Average

passive elbow range of motion significantly decreased from 147 to 117
degrees.28
Forearm Reconstruction
■ Biceps rerouting: Rühmann and Hierner reported an average increase in
pronation of 87 degrees (range 70 to 100 degrees). Active pronation to neutral
was achieved in 91% of patients and 46% were able to pronate 30 degrees or
more.30 Results are less favorable in those with limited preoperative passive
supination31 or active pronation.
■ PT release/rerouting: PT release results in approximately 50 degrees of
decreased forearm pronation.32 PT rerouting results in an improvement of
active supination between 45 and 90 degrees.23,33 Over time, there may be
attenuation at the insertion site, leading to loss of supination.34
Wrist/Fingers Reconstruction
■ FCU to ECRB tendon transfer: Transfer results in an average gain in wrist
extension of approximately 47 degrees.35 Al-Qattan14 reported that average
wrist extension muscle strength increased from 0 to 4 on a modified MRC
system for motor grading. All patients, regardless of gains in wrist extension,
discontinued use of a wrist orthosis.35
■ Free functioning gracilis transfer: Terzis and Kostopoulos reported a
postoperative mean MRC grade of 3.17 and 4.00 when innervated by the
intercostal or spinal accessory nerve, respectively.36 In a series by Chim et
al.,21 the youngest patients in their series (ages 6 and 8) developed elbow joint
flexion contractures. Many patients require secondary procedures to optimize
finger flexion and hand function.
COMPLICATIONS
Elbow Reconstruction
■ Elbow release: neurovascular injury, weakening of elbow flexion, recurrent
contracture
■ Steindler flexorplasty: neurovascular injury, nonunion of fusion site, elbow
flexion contracture, wrist flexion contracture
■ LD transfer: hematoma/seroma, muscle nonfunction or ischemic failure, loss
of muscle tension, clavicle fracture, elbow flexion contracture, compartment
syndrome

■ Free functioning gracilis transfer: neurovascular injury, muscle nonfunction or
ischemic failure, clavicle fracture, elbow flexion contracture
Forearm Reconstruction
■ Biceps rerouting: neurovascular injury, persistent supination or pronation
contracture, tendon rupture
■ PT release/rerouting: neurovascular injury, persistent pronation or supination
contracture, attenuation of the reinsertion site
Wrist/Fingers Reconstruction
■ FCU to ECRB tendon transfer: neurovascular injury, attenuation of the
transfer, limited finger release resulting from weak finger extensors or tight
finger flexors.
■ Free functioning gracilis transfer: neurovascular injury, muscle nonfunction or
ischemic failure, adhesions, bowstringing across the elbow, elbow flexion
contracture
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paralytic supination contracture of the forearm in tetraplegia due to trauma. J
Bone Joint Surg Am. 1994;76(3):398-402.
32. Strecker WB, Emanuel JP, Dailey L, et al. Comparison of pronator tenotomy
and pronator rerouting in children with spastic cerebral palsy. J Hand Surg
[Am]. 1988;13(4):540-543.
33. Bunata RE. Pronator teres rerouting in children with cerebral palsy. J Hand
Surg [Am]. 2006;31(3):474-482.
34. Sakellarides HT, Mital MA, Lenzi WD. Treatment of pronation contractures
of the forearm in cerebral palsy by changing the insertion of the pronator radii
teres. J Bone Joint Surg Am. 1981;63(4):645-652.
35. van Alphen NA, van Doorn-Loogman MH, Maas H, et al. Restoring wrist
extension in obstetric palsy of the brachial plexus by transferring wrist flexors
to wrist extensors. J Pediatr Rehabil Med. 2013;6(1):53-57.

36. Terzis JK, Kostopoulos VK. Free muscle transfer in posttraumatic
plexopathies: part III. The hand. Plast Reconstr Surg. 2009;124(4): 1225-1236.

56
CHAPTER
Section XIV: Lower
Extremity
Rotationplasty of the Lower
Extremity
Samer Attar, Robert J. Steffner, and Terrance D. Peabody
DEFINITION
■ Rotationplasty of the lower extremity is a reliable and durable reconstructive
option in the setting of bone loss in the lower extremity due to tumor, infection,
or trauma.
■ With resection of the bone around the knee joint, the rotated tibia is attached to
the remaining femur.
■ With appropriate preoperative education and proper patient selection, it is a
functional alternative to an above-knee amputation or endoprosthetic
reconstruction—especially in the skeletally immature patient.
ANATOMY
■ The distal limb is rotated 180 degrees. This technique permits the rotated ankle
joint to function as a knee joint for prosthetic fitting (FIG 1).
■ The stump can fit into a modified below-knee prosthesis that is end-bearing, as
opposed to ischial-bearing prostheses for above-knee amputations.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Historically, rotationplasty has been described in the management of femoral
bone loss from tuberculosis, proximal femoral focal deficiency, and
sarcomas.1,2
■ Indications for rotationplasty

■ Congenital bone loss or deficiency
■ Sarcomas of the lower extremity
■ Trauma
■ Failed arthroplasty
■ Skeletally immature patient or active adult patient
■ Contraindications
■ Pre-existing nerve damage or ankle stiffness
■ Sciatic nerve involvement in tumor requiring its resection
■ Physical examination
■ The soft tissues proximal and distal to the area of tumor must be intact and
free of disease.
■ The ankle joint must be inspected for any contractures or limitations to
motion.
■ The dorsalis pedis and posterior tibialis pulses must be inspected for flow.
■ Ankle extension, ankle flexion, and extensor hallucis longus motor strength
must be documented.
■ A sensate foot with 5/5 motor strength and full ankle range of motion is ideal.
IMAGING
■ Limb lengths of both lower extremities are obtained.
■ Bone age should be approximated as the nonoperative limb will continue to
grow.
■ In malignant bone tumors about the knee undergoing resection, the distal
femoral and proximal tibial growth plates are usually removed.
■ When the patient reaches skeletal maturity, the rotated tibiotalar joint of the
operative limb should be located at the center of rotation of the knee of the
nonoperative limb.
■ The projection of growth of the nonoperative limb must be taken into
consideration at the time of surgery. Therefore, in a skeletally immature
individual, the operative leg must be longer than the nonoperative femur.
■ In the setting of sarcoma, magnetic resonance imaging determines where to
resect the femur with an adequate margin, whether the joint is contaminated,
and whether vascular structures are contaminated.
■ If there is joint invasion, an extra-articular resection should be performed.
■ If tumor infiltrates or encases vessels, vascular resection with anastomosis
should be considered.

■ The tibial and peroneal nerves should be intact and free of disease as they
will be required to power ankle motion.
FIG 1 • Limb after rotationplasty, allowing the rotated
ankle joint to function as a knee joint for prosthetic
fitting.
SURGICAL MANAGEMENT
■ Operative intervention must focus on the creation of appropriate flaps, wide
resection of bone and soft tissue margins, and stable fixation of the remaining
femur to the rotated tibia.
Preoperative Planning
■ Extensive discussions with the patient and family are essential prior to
performing a rotationplasty. The options of an amputation vs internal prosthesis

must be reviewed in addition to explaining their respective risks/benefits.
■ Imaging is reviewed to determine levels of resection of the femur and tibia in
order to:
■ Achieve a sound oncologic margin
■ Account for a projected center of rotation of the rotated tibiotalar joint to be
at the same level of the nonoperative knee when the patient reaches skeletal
maturity
Positioning
■ The patient is placed supine on a radiolucent table.
■ The entire lower extremity from the pelvis to the foot must be prepped and
draped.
■ This setup provides vascular access and enables internal fixation to the level of
the hip joint if needed.
■ Intraoperative fluoroscopy is recommended in order to aid placement of
hardware.
Approach
■ The skin incision must be planned to accommodate the disproportion between
thigh and calf circumference.
■ Circumferential incisions are commonly made at acute angles to each other to
account for this thigh/calf discrepancy (FIG 2).
■ A longitudinal incision is then drawn to connect the proximal and distal
circumferential flaps. This line is placed ideally to expose a plane for tumor
resection and neurovascular dissection.3–6

FIG 2 • Intraoperative outline of incision in the right
lower extremity of a pediatric patient with a distal femur
osteosarcoma.
T E C H N I Q U E S
■ Incision
■ Skin and subcutaneous tissues are incised and raised as flaps along the
circumferential thigh and calf tissues and the longitudinal line connecting
them (TECH FIG 1A,B).
TECH FIG 1 • A. Incision with thick skin flaps. Note
the circumferential incisions placed at oblique angles
in order to accommodate the difference in thigh and
calf diameter during rotation and closure of the
wounds. B. The rhomboid incision should have an

anterior axis that is about 5 to 10 cm longer than the
intended length of the bone resection. The bone
resection itself should be located at the proximal and
middle thirds of the more proximal incision.
■ Nerves
■ The peroneal nerve is identified deep to the biceps tendon coursing laterally
around the proximal fibula. It is dissected free of the surrounding soft tissue
and followed proximally into the posterior thigh until its bifurcation with the
tibial nerve (TECH FIG 2A).
■ The tibial nerve is traced distally through the popliteal space and distal to the
proposed osteotomy site. It is also dissected proximally until the sciatic nerve
is identified and traced above the level of the proposed femoral osteotomy.
■ Alternatively, the sciatic nerve may be identified proximally and traced
distally through its bifurcation into the tibial and peroneal nerves (TECH
FIG 2B).
TECH FIG 2 • A. The peroneal nerve is dissected
more proximally to the location where it joins the tibial
nerve at the bifurcation. The tibial nerve can then be
dissected distally into the popliteal space. B. Sciatic
nerve (arrow) dissected from surrounding soft tissues.
■ Vessels
■ Transection of the pes anserinus and medial gastrocnemius tendons reveals
the popliteal artery and vein. They are traced distally to the trifurcation.
Proximally, they are delivered posteriorly away from the femur, and the
dissection should stop proximal to the proposed femoral osteotomy site.7
■ The vessels must be free and untethered from all surrounding soft tissues
from proximal to distal to prevent kinking and tension when the tibiotalar
joint is rotated (TECH FIG 3).

■ In the setting of vascular involvement with tumor, the vessels can be
resected and the remnants anastomosed. However, this technique possesses a
higher risk and higher potential for complications.
TECH FIG 3 • Femoral vessels (arrow) dissected from
surrounding soft tissues.
■ Osteotomies
■ Once the neurovascular structures are dissected and freed, attention should
be turned to the femoral and tibial osteotomies.
■ Steinmann pins can aid in rotation of the limb (TECH FIG 4A).
■ Proximal to the level of bone resection, a pin can be placed anterior to
posterior with the patella directed straight anteriorly.
■ Distal to the tibial resection, a second pin is placed in the medial tibia
perpendicular to the femoral pin.
■ The surrounding soft tissues are then incised down to the proposed
osteotomy sites.
■ Distally, the patellar tendon, the cruciate and collateral ligaments, the knee
menisci, and the posterior knee capsule are incised and released at the level
of the tibial insertion.
■ Proximally, the quadriceps, hamstring, and adductor musculature are
incised down to the level of the femoral osteotomy site.

TECH FIG 4 • A. Steinman pin placed anterior to
posterior in the proximal femur and medial to lateral in
the distal tibia. B. Intercalary specimen with resected
proximal tibia.
■ Attention must always be paid to maintaining tumor margin and protecting
neurovascular structures during these steps.
■ The femur and tibia can then be osteotomized with an oscillating saw, and
the specimen is passed off the field (TECH FIG 4B).
■ Marrow Margin
■ A femoral bone marrow margin should be sent to pathology for a frozen
section. It should be confirmed that this margin is negative prior to
proceeding with reconstruction.
■ During this wait time, the wound can be irrigated. The continuity of the
vessels and nerves should be examined and should be tension-free (TECH
FIG 5).

TECH FIG 5 • Depiction of the limb after extra-articular
resection of the distal femur before rotation of the
limb.
■ Rotation/Reconstruction
■ Reconstruction involves external rotation of the tibia by 180 degrees. If a
medial tibial pin was placed, it should be perpendicular to the femoral pin
from the lateral direction once rotation is complete (TECH FIG 6A–C).
■ The vessels and nerves should coil in a relaxed fashion with no excessive
tension. Any kinking or tension of neurovascular structures suggests adherent
soft tissues that should be released (TECH FIG 6D–F).
■ The lateral aspect of the femur and medial aspect of the tibia are then
exposed to permit compression plating fixation of the femoral-tibial junction.
Fixation of six to eight cortices on either side of the junction is ideal if the
remaining bone allows. Alternative methods of fixation are intramedullary

rods or external fixators.
■ Intraoperative fluoroscopy aids final images documenting limb alignment
and positioning of hardware (TECH FIG 6G,H).
■ Flow to the foot must be documented prior to closure by palpation and/or
Doppler ultrasound of the dorsalis pedis and posterior tibialis pulses.

TECH FIG 6 • A. Rotation of the distal limb. B. Tibial
pin (arrow) is medial, and the foot is anterior. C. When
the tibia has been rotated externally, the pin extends
from lateral to media, exactly 180 degrees from its
original position. The osteotomy is fixed with a
compression plate and screws. The vessels coil

medially. D. The neurovascular structures should be
relaxed and tension-free. Continuity of the sciatic
nerve (white arrow) and femoral vessels (black arrow).
E. View of the lower extremity after rotation. F. Close-
up view of the coiled vessels and nerves (arrow). G.
Intraoperative fluoroscopic radiographs of
compression plate fixation between the remaining
proximal femur and rotated distal tibia. H. AP view.
Lateral view.
■ Closure
■ Drains are placed per surgeon discretion.
■ A layered closure is then performed. The quadriceps fascia is usually sutured
to the gastrocnemius musculature and deep fascia of the calf. The hamstring
fascia is sutured to the pretibial fascia (TECH FIG 7).
■ A bulky dressing is ideal to maximize padding and minimize swelling. The
internal fixation should be rigid, so no cast is usually needed.
TECH FIG 7 • Extremity after closure and before
dressing applied.
PEARLS AND PITFALLS

Indications
■ Indicated in skeletally immature or active individuals. Preoperative
education of the patient and family with literature, photos, and
communication with patients who have undergone rotationplasty is
beneficial.
Preoperative
planning
■ Plan the length of the operative limb so that at skeletal maturity, the
rotated tibiotalar joint of the operative limb should be located at the
center of rotation of the knee of the nonoperative limb.
Approach
■ Angle circumferential incisions to account for discrepancies in
thigh and calf circumference.
Technique
■ Vessels and nerves should be coiled in a relaxed fashion with no
tension.
■ Use landmarks or pins to approximate rotation of the tibiotalar joint
to 180 degrees.
■ Confirm vascular flow after rotation and fixation.
POSTOPERATIVE CARE
■ The status of the limb must be followed closely with frequent neurovascular
and compartment checks.
■ Mobilization out of bed with assistive devices is encouraged as soon as
possible Active motion of the hip and ankle should be promoted as well.
■ If there is a nerve palsy, an ankle-foot orthosis may be placed, and the foot and
ankle should be passively ranged to prevent a contracture until motor function
returns.
■ Adequate wound healing usually occurs in 2 to 6 weeks. At that point,
provisional prosthetic fitting may begin. However, no weight bearing through
the prosthesis should be allowed until clinical and radiographic healing is
evident at the femoral-tibial junction (FIG 3).
■ Once healing has occurred, activities as tolerated are allowed with a
prosthesis.
OUTCOMES
■ Rotationplasty provides local recurrence rates comparable to other forms of
wide resection such as limb salvage and amputation.
■ Gait velocity and the energy cost for mobility are improved compared to a
transfemoral amputation.

■ Rotationplasty permits participation in recreational and sports activities due to
an end-bearing prosthesis, whereas endoprosthetic reconstruction has
limitations due to concerns over prosthetic wear and loosening.
■ Psychosocial problems due to the cosmetic appearance of a rotated limb are
not usually reported.
■ Psychosocial issues can be avoided through preoperative education of the
patient and family with literature, photographs, and interactions with patients
who have had rotationplasties.
FIG 3 • Radiographs of the hip at 6 months postop. A.
AP view. B. Lateral view.
■ No adverse events have been reported with regard to the ability to pursue an
education or career or develop and maintain relationships.
■ There are no phantom pains or neuromas reported due to nerve continuity
unlike in amputations.
■ Rotationplasty is a reliable, predictable, and durable reconstructive option in
the active or skeletally immature patient with a malignant bone tumor about the
knee. Functionally, it can be equivalent or better than a transfemoral
amputation, and it has comparable oncologic outcomes.8–16
COMPLICATIONS
■ Ischemia and vascular compromise can occur—especially in the setting of

vascular resection with anastomosis.
■ Transient or permanent nerve palsy can lead to soft tissue contractures or a
delay in rehabilitation with a prosthesis.
■ Delayed or incomplete wound healing may require debridement with soft
tissue coverage.
■ Infection.
■ Fracture nonunion.
■ Hardware failure.
■ Compartment syndrome.
■ Rotational malalignment.
REFERENCES
1. Van Nes CP. Rotation-plasty for congenital defects of the femur. J Bone Joint
Surg Br. 1950;32(1 suppl):12-16.
2. Salzer M, Knahr K, Kotz R, Kristen H. Treatment of osteosarcomata of the
distal femur by rotation-plasty. Arch Orthop Trauma Surg. 1981; 99(2
suppl):131-136.
3. Gebhart MJ, McCormack RR Jr, Healey JH, et al. Modification of the skin
incision for the Van Nes limb rotationplasty. Clin Orthop Relat Res.
1987;216:179-182.
4. Ossendorf C, Exner GU, Fuchs B. A new incision technique to reduce
tibiofemoral mismatch in rotationplasty. Clin Orthop Relat Res. 2010;468(5
suppl):1264-1268.
5. Fuchs B, Sim FH. Rotationplasty about the knee: surgical technique and
anatomical considerations. Clin Anat. 2004;17(4 suppl):
345-353.
6. Anderson M, Green WT, Messner MB. Growth and predictions of growth in
the lower extremities. J Bone Joint Surg Am. 1963;45:
1-14.
7. Mahoney CR, Hartman CW, Simon PJ, et al. Vascular management in
rotationplasty. Clin Orthop Relat Res. 2008;466(5 suppl):
1210-1216.
8. Agarwal M, Puri A, Anchan C, et al. Rotationplasty for bone tumors: is there
still a role? Clin Orthop Relat Res 2007;459:76-81.
9. Sawamura C, Hornicek FJ, Gebhardt MC. Complications and risk factors for
failure of rotationplasty: review of 25 patients. Clin Orthop Relat Res.
2008;466(6 suppl):1302-1308.

10. Gottsauner-Wolf F, Kotz R, Knahr K, et al. Rotationplasty for limb salvage in
the treatment of malignant tumors at the knee: a follow-up study of seventy
patients. J Bone Joint Surg Am. 1991;73(9 suppl):1365-1375.
11. Fuchs B, Kotajarvi BR, Kaufman KR, Sim FH. Functional outcome of
patients with rotationplasty about the knee. Clin Orthop Relat Res.
2003;415:52-58.
12. Rödl RW, Pohlmann U, Gosheger G, et al. Rotationplasty: quality of life after
10 years in 22 patients. Acta Orthop Scand. 2002;73(1 suppl):85-88.
13. Hillmann A, Rosenbaum D, Gosheger G, et al. Rotationplasty type B IIIa
according to Winkelmann: electromyography and gait analysis. Clin Orthop
Relat Res 2001;384:224-231.
14. Hopyan S, Tan JW, Graham HK, Torode IP. Function and upright time
following limb salvage, amputation, and rotationplasty for pediatric sarcoma of
bone. J Pediatr Orthop. 2006;26(3 suppl):405-408.
15. McClenaghan BA, Krajbich JI, Pirone AM, et al. Comparative assessment of
gait after limb-salvage procedures. J Bone Joint Surg Am. 1989;71(8
suppl):1178-1182.
16. Hillmann A, Rosenbaum D, Schroter J, et al. Electromyographic and gait
analysis of forty-three patients after rotationplasty. J Bone Joint Surg Am.
2000;82(2 suppl):187-196.

57
CHAPTER
Section XV: Breast
Poland Syndrome
Patrick J. Buchanan and Paul S. Cederna
DEFINITION
■ Poland syndrome is a developmental defect characterized by varying degrees
of unilateral pectoralis major aplasia, thoracic skeletal defects, breast
hypoplasia or aplasia, and ipsilateral syndactyly.1,2
■ A congenital unilateral absence of the sternocostal head of the pectoralis major
muscle is pathognomonic for this congenital anomaly.
ANATOMY
■ There are two predominant variations of Poland syndrome: simple form (mild)
and complex form (severe).
■ The simple form is the most common and is characterized by the absence of
the sternocostal head of the pectoralis major muscle and effacement of the
ipsilateral axillary fold.
■ The clavicular head of the pectoralis major muscle remains as a thin
triangular muscle bundle that attaches the humerus to the inferomedial third of
the clavicle.
■ The ipsilateral breast is hypoplastic or aplastic.
■ The ipsilateral nipple-areolar complex is typically smaller in diameter and
displaced laterally and superiorly toward the axilla (FIG 1).
■ The complex form is characterized by the absence of the sternocostal head of
the pectoralis major muscle, ipsilateral rib and/or sternal hypoplasia or
absence, and other ipsilateral muscular abnormalities (FIG 2).
■ The clavicular head of the pectoralis major muscle may be diminutive.
■ The ipsilateral latissimus dorsi, trapezius, pectoralis minor, serratus anterior,
external oblique, and/or rectus abdominis muscles may be abnormal.

• The pectoralis minor muscle is commonly hypertrophic.
• Absence of the serratus anterior muscle results in a winged scapula.
FIG 1 • Simple form of Poland syndrome depicting an
ipsilateral breast anomaly with a smaller and
superolaterally displaced nipple-areolar complex.
• Insertion of the ipsilateral rectus abdominis muscle is displaced cranially.
■ The sternum is foreshortened and bifid with a pectus excavatum appearance.
■ The ipsilateral scapula is small and cranially displaced, causing an internal
shoulder rotation when compared to the contralateral side.
■ The ipsilateral anterior second through fifth ribs are thin, short, and devoid of
their superolateral cartilage.
PATHOGENESIS
■ To date, no definitive cause of Poland syndrome has been elucidated.
■ However, there are theories identifying developmental and familial causes.
■ Developmentally, in the 6th week of gestation, there is an interruption of the
subclavicular arterial branches causing maldevelopment of the tissues
supplied by these vascular pedicles
■ Currently, geneticists believe Poland syndrome is rarely inherited; however,
there is documentation of a 1% inheritance pattern from affected individuals.
NATURAL HISTORY
■ The true incidence and etiology of Poland syndrome still remains unknown;
however, it tends to occur more on the right side, 2 to 3:1, is more common in

males, 2:1, and is estimated to occur 1 in 20 000 to 30 000 live births.3
■ The most common presentation is that of a patient with a unilateral absence of
the sternocostal head of the pectoralis major muscle with hypoplastic or absent
breast parenchyma.1
FIG 2 • Complex form of Poland syndrome showing
ipsilateral axillary webbing, ipsilateral rib and sternal
hypoplasia, ipsilateral trapezius, serratus anterior,
rectus abdominis, and external oblique muscle
abnormalities.
■ The vast majority of patients with Poland syndrome present with concerns
about the shape and appearance of their chest or abnormal breast
development.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The surgeon must be acutely aware of the social impact of Poland syndrome
on the patient and their parents.
■ Patients with the simple form of Poland syndrome may be aware of their
abnormality earlier than their family, as it can remain unannounced until early
adolescence, as muscle and breast development occur.
■ Early in childhood, parents may notice a slight chest asymmetry.
■ Adolescent children with Poland syndrome spend an inordinate amount of
time trying to conceal their asymmetry from their parents and others.
■ The severe form, on the contrary, is readily known during infancy by the
parents, as the chest wall is grossly asymmetric.

■ In all patients, there will be a noticeable soft tissue deficiency of the affected
side of the chest due to volume loss from the partial or complete absence of the
pectoralis musculature.
■ The noticeable asymmetry often leads to adverse psychosocial sequelae.
■ Patients often report an adverse impact on their social functioning, emotional
well-being, and psychological health.
IMAGING
■ Diagnostic imaging is available but usually not necessary in cases other than
the most severe variants.
■ Ultrasonography will show an absence of a portion of the pectoralis major
muscle and asymmetry of the rib cage.4
■ Mammography is typically not used as an imaging modality for Poland
syndrome; however, absence of the pectoralis major muscle can be
incidentally discovered on the mediolateral oblique view of a hypoplastic
breast.4
■ A CT scan can be used for presurgical planning to confirm the presence of
the latissimus dorsi muscle and to better define the structural chest wall
deformity.5
■ MRI may be useful to better define the patient’s anatomy as it offers a
multiplanar view without the ionizing radiation of a CT scan.5
■ Both color-coded duplex sonography and contrast-enhanced magnetic
resonance angiography allow for the evaluation of selected arteries and
vessels.5
DIFFERENTIAL DIAGNOSIS
■ Unilateral accentuated thelarche
■ Unilateral amazia
■ Unilateral amastia
NONOPERATIVE MANAGEMENT
■ Because reconstruction is rarely ever performed to restore a severe functional
deficit, providing reassurance to the patient and their family is an important
aspect of care that should not be overlooked by the surgeon.
■ Removable external breast prostheses help correct the appearance of a female
patient’s chest and breast in clothing.
SURGICAL MANAGEMENT

■ The reconstructive options for patients presenting with chest wall deformities
from Poland syndrome depend on several key factors, including anatomical
severity, gender, patient preferences, and associated anomalies.
■ The timing and number of reconstructive stages is also of paramount
importance.
■ A tissue expander can be placed early to gradually expand the affected side to
decrease the amount of noticeable asymmetry as the contralateral breast
developmentally matures.
■ Fat grafting can be initiated early to camouflage the asymmetry until the
definitive reconstructive procedures are performed.
■ Tissue expander-based reconstruction is ideal for the female patient with a
hypoplastic and fibrotic breast or a patient with an aplastic breast.
■ The latissimus dorsi muscle transfer can be used with any of the reconstructive
approaches.
■ It is the best method to reconstruct the anterior axillary fold.
■ It can be performed on any patients, male or female, with a robust latissimus
dorsi muscle.
■ The surgeon should discuss with the patients that harvesting of the latissimus
dorsi muscle can create asymmetry in their back.
■ Customized chest wall implants may be adjunctively needed in women and are
often the treatment of choice in men.6
■ Author preference is for a custom silicone chest wall prosthesis.
■ The advantages of the customized chest wall implant reside in its ease of
fabrication and insertion.
• There is a relatively low morbidity for this technique compared to flap
reconstruction.6
■ Disadvantages include implant migration, contour irregularities, patient
reported discomfort, and potentially palpable or visible edges.6
■ The endoscopic approach is typically performed in two stages when using a
tissue expander and latissimus dorsi muscle transfer
Preoperative Planning
■ Documenting the presence or absence of the serratus anterior and latissimus
dorsi muscles is necessary, because this may affect desired reconstruction.
■ The degree of pectoralis major muscle hypoplasia is also critical to
determining the most appropriate reconstructive option for the patient.

■ The sternal notch-to-acromion, acromion-to-olecranon, and olecranon-to-ulnar
styloid distances are measured and compared to the contralateral side, in cases
of notable skeletal abnormality.
■ In women, the size of the breast and position of the nipple complex are
assessed, particularly in regard to the contralateral, normal side.
■ In the occasional male who seeks muscular strength improvement due to
absence of the pectoralis musculature, objective testing of strength of the upper
extremity via comparison to the contralateral side is needed.1
■ Male patients often lift weights in an attempt to increase the bulk of their
affected chest.
■ Weight lifting typically causes the pectoralis minor and the clavicular head of
the pectoralis major muscle to become more hypertrophic (FIG 3).
FIG 3 • Male patient with Poland syndrome showing
hypertrophy of the ipsilateral pectoralis minor and
clavicular head of the pectoralis major muscles.
Positioning
■ The traditional latissimus dorsi muscle transfer harvest is performed by
positioning the patient in a semilateral decubitus position with the ipsilateral
arm elevated on an arm sling.
■ TECH FIG 1A shows the intraoperative positioning for muscle harvest.
■ TECH FIG 1B depicts the large incisional scar that can be expected from
this traditional approach.
■ Alternatively, the latissimus dorsi muscle harvest and implant placement can
be performed via a single axillary incision with the patient’s ipsilateral arm

extended cranially.
Approach
■ Reconstructive options include the use of tissue expansion with implants,
latissimus dorsi muscle transfers, customized chest wall implants, fat grafting,
and rarely, free tissue transfers.1,7–10
■ Frequently, contralateral procedures are performed after definitive
reconstruction of the affected side to achieve better symmetry.
■ Symmetry procedures include, but are not limited to, contralateral breast
reduction, mastopexy, repositioning of the nipple-areolar complex (NAC),
and reducing the size of the NAC.
■ Both implant-based and latissimus dorsi muscle transfer reconstructions can be
performed with an endoscopic approach to minimize scarring.7
T E C H N I Q U E S
■ Tissue Expansion with Implants
■ The fibrotic breast tissue requires radial scoring prior to tissue expander
placement to allow for adequate expansion.11
■ The degree of muscle coverage of the expander is dependent on the extent of
pectoralis major muscle absence.
■ Partial superior coverage will be achievable in some patients.
■ Subglandular or subcutaneous placement is necessary when the pectoralis
major muscle is notably hypoplastic or fully absent.
■ Expansion is performed as necessary, followed by permanent implant
placement, similar to breast reconstruction.
■ This technique can be performed in stages separated by many years.
■ The tissue expander can be placed early to allow for gradual expansion as
the contralateral breast grows, prior to permanent implant placement.
■ Latissimus Dorsi Muscle Transfer
■ Most often, a skin paddle is not required and, as such, a single incision can
be used.

■ A dorsal incision above the lateral border of the latissimus dorsi muscle,
approximately 6 to 10 cm long, is one option to gain access to the
muscle12,13 (see TECH FIG 1A,B).
■ An endoscope can also be used to gain access to the muscle with a single,
5- to 6-cm incision placed within the axilla7 (TECH FIG 1C).
■ The skin/soft tissue is elevated off of the fascia overlying the latissimus
muscle to expose the borders of the entire muscle. The muscle is divided
distally and the fascial and muscular attachments to the chest wall are
divided, elevating the muscle toward the axilla12,13 (see TECH FIG 1).
TECH FIG 1 • A. Traditional open approach to
latissimus dorsi muscle harvest with the patient
positioned in a lateral decubitus with the ipsilateral
arm extended at 90 degrees on an operative armrest.
B. Surgical scar created after a traditional, open
harvest of the latissimus dorsi muscle for Poland
syndrome reconstruction. C. Endoscopic approach
with the patient in a supine position and the ipsilateral
arm extended at 90 degrees allowing for a 5- to 6-cm
incision placed within the apex of the axilla.
■ The ipsilateral chest skin is undermined through the axillary incision or
through a periareolar approach.
■ The chest and previous axillary dissection planes are then joined.
■ The mobilized latissimus dorsi muscle is then transferred.
■ Release the insertion of the latissimus dorsi muscle and suture it anteriorly
near the bicipital groove, on the humerus, to recreate the anterior axillary
fold.
■ The origin, lumbosacral fascia, is affixed to the lateral border of the sternum.