The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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1066
separation and with muscle flaps of the trunk because of
the extensive tissue dissection, and drains may be neces­
sary for up to 4 to 6 weeks. Intraoperative techniques,
such as quilting sutures, fibrin sealant, and postoperative
abdominal binders, may help to prevent or reduce seroma
formation.24
Mediastinitis
Infection may manifest as mediastinitis or empyema. Ster­
nal wound infection after cardiac surgery occurs in approx­
imately 0.5 to 9% of cases. Pairolero and Arnold classified
sternal wounds based on timing of presentation of infec­
tion.25 Type I wounds occur in the first few days postop­
eratively. These wounds may contain incisional dehiscence
with serosanguineous discharge and/or sternal instability.
Type II wounds occur in the first several weeks and may
present with cellulitis, mediastinal purulence, and posi­
tive cultures. Type III wounds occur months to years post­
operatively and are distinguished by draining sinus tracts
and chronic osteomyelitis. Major risk factors for sternal
dehiscence and subsequent infection are obesity, diabetes,
COPD, and bilateral harvest of internal mammary arteries.
The treatment for sternal infection and dehiscence is radi­
cal débridement of all infected tissue, culture-directed an­
tibiotic therapy, and obliteration of dead space. In addition,
chest reconstruction with vascularized tissue, most com­
monly pectoralis myocutaneous advancement, and rectus
abdominis myocutaneous and other flap procedures, such
as latissimus dorsi or omentum, have proved to be effective
treatments and have lowered mortality rates26 (Table 57.1).
Flail Chest (Paradoxical Motion)
Trauma and the ablation of large oncological defects may
require the resection of multiple ribs, leading to disruption
of chest wall integrity and paradoxical chest movement, a
condition known as flail chest. When a flail segment, usu­
ally 5 cm or greater in diameter, loses continuity with the
surrounding chest wall, ventilation becomes progressively
inefficient. Variations include posterior flail segments, an­
terior flail segments, and sternal flail with fracture of bilat­
eral anterior ribs. The segment requires adequate fixation
to restore normal respiratory physiology. Defects, depend­
ing on their size, may be amendable to either a soft tissue
or bony reconstruction. Soft tissue reconstruction is appro­
priate for two-rib and some three-rib (< 5 cm in diameter)
segmental loss without functional consequences. Surgical
stabilization has been shown to decrease mechanical venti­
lator days, improve long-term outcome, and lower the cost
of hospitalization in select patients. Note that restoration
of chest wall integrity after reconstruction may not restore
lung function if underlying pathology such as significant
lung contusion is not addressed.
Autologous tissues such as rib grafts and fascial grafts
have been falling out of favor for restoration of chest wall
stability since the introduction of synthetic mesh. Semi­
rigid chest wall reconstruction can be achieved by suturing
Common Complications and Adverse
Events
Infection
Surgical site infections are common after both chest and
abdominal wall reconstruction. The exact incidence is dif­
ficult to determine, because most series poorly define this
outcome variable. The U.S. Centers for Disease Control and
Prevention (CDC) recommends that surgical site infections
be specified as superficial, deep, or organ space infections.21
Additionally, categorization of the intraoperative level of
wound contamination based on CDC criteria into clean,
clean-contaminated, contaminated, and dirty wounds is
important to appropriately stratify patients by risk of surgi­
cal site infection. In patients with clean-contaminated and
contaminated wounds, a prospective multi-institutional
study evaluating the role of a porcine acellular dermal ma­
trix (ADM) to repair abdominal wall defects reported a 34%
rate of superficial surgical site infections. In contrast, stud­
ies of clean wounds have reported infection rates of 0 to
12%.22 Mesh infections are one of the most serious com­
plications that can occur after both chest and abdominal
wall reconstruction. The exact incidence of this problem is
difficult to discern from the literature because of the use of
poorly defined terms and inconsistent reporting practices.
Mesh infections are reported to occur in 0 to 3.6% of lapa­
roscopic ventral hernia repairs and 6 to 10% of open repairs
using mesh.23 The most common organism infecting mesh
is Staphylococcus aureus, seen in up to 81% of cases; this
suggests skin flora contamination during mesh implanta­
tion. However, gram-negative organisms, such as Klebsiella
and Proteus spp., have been implicated in up to 17% of mesh
infections. Management of mesh infections is complex and
requires patient individualization as well as a knowledge of
bacterial susceptibility for a particular hospital. In general,
control of local sepsis is important, as is preserving native
tissue for eventual reconstruction.
Seroma
Seroma formation can occur after both chest and abdomi­
nal wall reconstruction, particularly in cases involving large
undermined flaps, which create significant dead space. If
symptomatic, seromas can be aspirated percutaneously or
under ultrasound guidance. In most cases, small seromas
will be reabsorbed over time. Resection of a previous her­
nia sac is important to prevent seroma formation. In open
ventral hernia repair, drains are often placed in an attempt
to obliterate the dead space caused by the hernia and tis­
sue dissection. These drains can cause retrograde bacterial
contamination, and seromas can form after drain removal.
Long subcutaneous tunnels, meticulous securing of drain
exit sites with drain sutures that prevent intussusception
of the drain, and meticulous drain exit site wound man­
agement using antibiotic-impregnated dressings should
be used to reduce the risk of retrograde bacterial infection.
Seroma formation is common after abdominal component

1067
Chapter 57 Reconstruction of the Chest and Abdomen
reduces paradoxical movement, inertness that allows tissue
ingrowth, malleability, and radiolucency that does not ob­
struct radiographic evidence of tumor relapse.
Synthetic mesh in general may increase complication
rates when it is placed directly over viscera or when the op­
erative site has been irradiated or contaminated with bac­
teria. Synthetic mesh is contraindicated in contaminated
wounds unless prolonged dependence on a ventilator will
result from not using it.27 In the latter situation, biopros­
thetic mesh is an alternative. Many bioprosthetic meshes
synthetic or bioprosthetic mesh under tension to span the
skeletal defect that follows large chest wall resections. Some
authors also suggest the use of more rigid fixation with poly­
methylmethacrylate or polypropylene mesh for such defects.
Polymethylmethacrylate reconstruction is commonly ad­
vocated to repair large anterior and anterolateral chest wall
contour defects, whereas large defects in flat surfaces on the
anterior and posterior aspect of the chest may be repaired
with prosthetic mesh. The ideal prosthetic material features,
as described by le Roux and Shama,27 include rigidity that
Table 57.1 Thigh-based and torso-based pedicled flaps used in chest and
abdominal wall reconstruction
Flap
Characteristics
ALT flap
Large surface area.
Minimal donor-site morbidity.
Generally will reach the periumbilical area but has been reported to reach up to the costal
margin.
Can reach the ipsilateral posterior superior iliac spine posteriorly and the contralateral fossa
laterally.
Associated fascia may not be reliable for fascial reconstruction.
Pectoralis major flap
May be used as a muscle only or a myocutaneous pedicled flap.
May be elevated as a pedicled flap off the thoracoacromial vessels or as a turnover flap for
sternal defects off the internal mammary vessel perforators.
Major workhorse flap of the chest wall for mediastinitis and sternal nonunion after cardiac
surgery.
Rectus femoris flap
Can be transferred as a muscle flap, myocutaneous flap, or part of a combined thigh flap
based on the lateral circumflex femoral vessel.
Provides a long cylindrical muscle, approximately 6 cm wide, and can support a 12- by
20-cm skin island.
Combined thigh flaps
A “subtotal thigh” flap takes advantage of the versatile lateral circumflex femoral vessel
system and can include rectus femoris, tensor fasciae latae, vastus lateralis, and/or
anterolateral thigh flap tissue.
Nearly the entire abdominal wall skin can be reconstructed with bilateral pedicled subtotal
thigh flaps.
The fascial portion of these flaps can be used to repair fascial defects, but mesh is often
preferred for reconstruction of the musculofascia, with soft tissue flaps used for coverage;
thigh fascia may be less reliable and can tear along its fibers.
Rectus abdominis flap
The skin paddle can be oriented vertically, horizontally, as an extended deep inferior
epigastric artery flap (musculocutaneous flap with lateral skin extension based on the
periumbilical perforators), or as a flag flap (skin from the upper abdomen with extensions
to the inframammary fold and the anterior axillary line)51–54
Useful for defects located at the periphery of the abdominal wall.
Generally should be avoided for large abdominal wall defects when the donor site would
add to the primary defect.
Latissimus dorsi flap
The arc of rotation of the flap allows coverage of superolateral chest and abdominal wall
defects.
Can be used as muscle or a myocutaneous flap.
Source: Adapted with permission from Althubaiti G, Butler CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg 2014;133(5):688e–
701e.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1068
of 2.2 to 16%.28 The presence of untreated dead space and
bronchopleural fistula after lobectomy or pneumonectomy
will usually result in infection. The postoperative mortal­
ity rate of pneumonectomy increases to 25% if the course
is complicated by empyema and to approximately 50% if
bronchopleural fistula is present. Soft tissue flaps are often
used to reinforce the repair after closure of a fistula or to fill
the intrathoracic dead space after drainage of a fluid collec­
tion. Flaps used in bronchopleural fistula closure include
intercostal muscle, pericardial fat, diaphragm, extratho­
racic muscle, omental, and free flaps.
Pedicled flaps commonly used to fill intrathoracic dead
space are described in Table 57.1 and illustrated in Fig.
57.1.26 These flaps can be introduced into the thoracic cavity
through the original wound or through a new, separate tho­
racotomy. For single-stage treatment of empyema without
a bronchopleural fistula, the empyema is drained and the
dead space is irrigated, filled with a muscle flap, and closed.
If the patient is too ill to undergo an extended single-stage
procedure or if the infection is long-standing and resistant,
treatment may begin with a drainage procedure, such as the
Eloesser procedure29 (Fig. 57.2). When bronchopleural fis­
tula is also present, it must be addressed as well.
Hernia
The most common abdominal wall defects faced by recon­
structive surgeons are incisional hernias. The incidence
of incisional hernia is approximately 11% after a midline
laparotomy5 (Fig. 57.3). One in three incisional hernias will
cause symptoms, and approximately 4 percent of patients
undergoing laparotomy will undergo an additional opera­
tion to repair an incisional hernia.30 Patients with hernias
are at risk of developing bowel-related complications such
as enterocutaneous fistulas, obstruction, incarceration,
and strangulation. Functional problems in hernia patients
are available; these include xenogeneic ADM, preferentially
used for chest wall reconstruction. Bioprosthetic meshes
have been shown in animal models to allow tissue ingrowth,
become incorporated and revascularized, and be valuable
for wounds with a high risk of infection or complications.
The main limitations are their high cost, unproven long-term
stability in the chest wall, and theoretic risk of stretching or
laxity with ongoing remodeling. Bioprosthetic mesh may be
a good option for defects that have bacterial contamination
or an increased risk of skin dehiscence with mesh exposure;
the material tolerates cutaneous exposure without the need
for explantation.
Once the synthetic or bioprosthetic material is placed
and secured to the edges of the defect, well-vascularized soft
tissue coverage should be provided to minimize the chance
of exposure and infection. The use of prosthetic mesh su­
tured under tension to re-create semirigid chest wall sta­
bility after repair of large defects has been shown to reduce
ventilator dependence and hospital stay. However, the abso­
lute need for rigid or semirigid skeletal stability reconstruc­
tion of the chest wall after resection has been challenged,
particularly for smaller defects. Arnold and Pairolero25 re­
ported that pulmonary function is not ultimately compro­
mised after major chest wall resection, such as removal of
the entire sternum, if reconstruction is performed without
mesh. Furthermore, the resulting pulmonary insufficiency
after chest wall resection is often less significant than that
after trauma.15
Bronchopleural Fistula and Empyema
Bronchopleural fistula and chronic empyema are two of
the most common conditions necessitating reconstruction
of the pleural space and often occur together. The incidence
of postpneumonectomy stump fistula is 0 to 12%, although
postpneumonectomy empyema has a reported incidence
Fig. 57.1 (a) Pedicled flaps commonly used to fill intrathoracic dead space: pectoralis major muscle (1), serratus anterior muscle (2), latissi­
mus dorsi muscle (3), omental (4), and rectus abdominis muscle (5) flaps. (b) The pectoralis major muscle flap is useful for filling upper chest
defects. The latissimus dorsi muscle flap is more useful for filling lateral defects. The omental flap can be passed over the ribs or through
the diaphragm. (Adapted with permission from Althubaiti G, Butler CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg
2014;133[5]:688e–701e.)
2
3
5
1
4
a
b

1069
Chapter 57 Reconstruction of the Chest and Abdomen
Acquired hernias typically occur after surgical incisions
and thus are commonly referred to as incisional hernias. Epi­
gastric hernias occur from the xiphoid process to the um­
bilicus, umbilical hernias occur at the umbilicus, and hypo­
gastric hernias occur below the umbilicus in the midline.
Although not a true hernia, a bulge can develop after viola­
tion of the rectus fascia, such as after a transverse rectus ab­
dominis muscle flap (TRAM) for breast reconstruction (Fig.
57.4). In this condition, the anterior rectus fascia may be
stretched or completely released with the posterior rectus
fascia intact, resulting in bulging over the rectus abdominis
muscles. There is no fascial ring or true hernia sac. Unless
significantly symptomatic, iatrogenic bulges and diastasis
recti do not generally require surgical reconstruction.
include poor respiratory effort, loss of abdominal domain,
and weak abdominal musculature. Cosmetic problems are
also common concerns of patients with abdominal hernias.
Incisional hernias are notorious for their high recurrence
rate after repair and for their high rate of surgical complica­
tions. One study found that the 5-year reoperation rate was
23.8% after the first hernia repair operation, 35.3% after the
second, and 38.7% after the third.31 The infection rate after
ventral hernia repair is 4 to 16%, and the risk significantly
increases if the patient had a previous infection (41% ver­
sus 12% in one study). Bowel-related complications such as
adhesions, obstruction, erosion, and fistulization are other
known complications of hernia repair, especially with the
use of synthetic mesh.
Diaphragm
Pleural cavity
Pus
Inferiorly based
skin flap
Fig. 57.2 Eloesser procedure. A superiorly or inferiorly based skin flap (as shown here) is created over the area of the chest that needs to be
drained. A window is created in the chest wall by removing a segment from one or more ribs. The skin flap is sutured to the inside of the
pleural cavity (to the diaphragm in this illustration) to create a pleurocutaneous fistula.
a
b
Fig. 57.3 The most common abdominal wall defects faced by reconstructive surgeons are incisional hernias. This patient, a 68-year-old
woman with a history of colon cancer who had a partial colectomy 2 years prior, presented with a 7-cm midline fascial defect of her ab­
dominal wall. The incidence of incisional hernia is approximately 11% after midline laparotomy.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1070
ommended the use of synthetic mesh for grade 1 and bio­
prosthetic mesh for grades 3 and 4 hernias. No consensus
recommendations were made for grade 2 hernias. This grad­
ing system represents an important first step in developing
a classification system to improve reporting and allow ap­
propriate comparative studies to be performed. However,
this grading system has not yet been validated in a large
patient cohort, and further studies are necessary to validate
these results.
Mesh reinforcement of fascial closure is advised for her­
nia defects larger than 74 cm2, and randomized prospective
studies have shown significantly lower early and late hernia
recurrence rates when mesh is used.32 When selecting the
appropriate mesh for a patient, the surgeon must consider
whether the mesh will be in direct contact with the viscera
and whether infection is present or likely. A variety of syn­
thetic mesh products are available for ventral hernia repair.
The ideal mesh has not yet been developed but would cause
minimal or no inflammatory reaction and be chemically in­
ert, resistant to mechanical stress, sterilizable, noncarcino­
genic, hypoallergenic, and reasonably priced. Each of the
commercially available synthetic meshes has some but not
all of these properties. Polypropylene mesh is a semirigid,
hydrophobic, macroporous mesh that allows for ingrowth
of native fibroblasts and incorporation into the surround­
ing fascia. Placing polypropylene mesh in an intraperitoneal
position directly against the bowel is often avoided because
of the risk of bowel adhesions to mesh and enterocutaneous
fistula formation.12
Recently, lighter-weight polypropylene mesh has been
introduced to address some of the long-term complications
of heavyweight polypropylene mesh, particularly adhesions
to bowel. The definition of lightweight polypropylene mesh
was arbitrarily set at less than 50 g/m2, with heavyweight
mesh weighing greater than 80 g/m2. In a randomized con­
trolled trial evaluating lightweight versus heavyweight poly­
propylene mesh for ventral hernia repair, the recurrence rate
was more than two times greater in the lightweight mesh
group (17%, versus 7% for heavyweight mesh; p = 0.05).33
Two recent systematic reviews of the use of ADMs in
abdominal wall reconstruction have echoed the difficulty of
direct comparisons of study results because of differences in
patient variables, techniques, nomenclature, and definitions
of outcomes.34,35 The conclusions of these reviews were that
there is no consensus on risk factors predicting recurrence
or wound morbidity, there is limited consensus on termi­
nology for defect characteristics, and there is no consensus
on terminology for outcomes. Clearly, grading systems, such
as those described earlier, and the need to accurately assess
and report outcomes will be drivers for future studies from
multiple institutions and authors that will help define the
role of ADMs in abdominal wall reconstruction.
Mesh can be placed extraperitoneally in either the pre­
peritoneal space or retrorectus position36 (Fig. 57.5). This
technique was initially described by Stoppa.37 A large piece
Given the wide spectrum of patient characteristics and
defect complexities, no single approach to abdominal wall
reconstruction and in particular ventral hernia repair will
be the best choice for all patients, and comparing different
approaches is difficult. Estimated incidences of hernia recur­
rence have a wide range from 2 to 54%, depending on the
type of repair (mesh, 2 to 36%, versus suture repair alone,
25 to 54%), patient comorbidities, and surgical technique.
The number of prior attempts of hernia repair is predictive
of the relative risk of recurrence. In a study of approximately
10,000 patients, the 5-year reoperative rate was 23.8% after
a primary repair, 35.3% following a secondary repair, and
38.7% after a tertiary repair.31
There is no standard nomenclature system to accurately
stratify ventral or incisional hernias. This has led to the use
of poorly defined, confusing terms such as “complex ven­
tral hernia repair,” “large defects,” and “loss of abdominal
domain.” Recently, a group of ventral hernia surgeons (the
Ventral Hernia Working Group—VHWG)19 attempted to de­
velop a classification system for ventral or incisional hernias.
The resulting grading system takes into account underlying
patient comorbidities and the presence of wound contami­
nation during the repair19 (Table 57.2).
In the VHWG system, grade 1 includes hernias in pa­
tients with a low risk of complications and no history of
wound infection. Grade 2 includes hernias in patients who
smoke, have COPD, are obese, have diabetes, or are immu­
nosuppressed. Grade 3 includes hernias in patients with
a previous wound infection, a stoma, or violation of the
gastrointestinal tract (i.e., hernias in potentially contami­
nated surgical fields). Finally, grade 4 includes hernias in
patients with infected mesh or septic dehiscence of their
wound. Based on this classification system, the VHWG rec­
Fig. 57.4 This 46-year-old woman developed an iatrogenic bulge of
the abdominal wall after elevation of a right-sided transverse rectus
abdominis muscle flap (TRAM) for breast reconstruction. Although
not a true hernia, the anterior rectus fascia may be stretched or com­
pletely released with the posterior rectus fascia intact, resulting in
bulging over the rectus abdominis muscles. There is no fascial ring or
true hernia sac. Unless significantly symptomatic, iatrogenic bulges
and diastasis recti do not generally require surgical reconstruction.
Operative management includes re-creation of the original defect,
repair of fascia, and reinforcement with mesh.

1071
Chapter 57 Reconstruction of the Chest and Abdomen
Table 57.2 Ventral Hernia Working Group ventral hernia grading scale
Grade 1: low risk
Grade 2: comorbid
Grade 3: potentially contaminated
Grade 4: infected
Low risk of
complications
Smoker
Previous wound infection
Infected mesh
No history of
wound infection
Obese
Stoma present
Septic dehiscence
Diabetic
Violation of the gastrointestinal tract
Immunosuppressed
Chronic obstructive
pulmonary disease
Source: Adapted from Ventral Hernia Working Group; Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: review of the literature and
recommendations regarding the grading and technique of repair. Surgery 2010;148(3):544–558.
Fig. 57.5 Plane of mesh placement. (a) Onlay mesh placement. The mesh is placed superficial to the anterior rectus sheath and the exter­
nal oblique aponeurosis. (b) Intraperitoneal inlay mesh placement. The mesh is placed within the peritoneal cavity deep to the posterior
rectus sheath and transversalis fascia laterally. The mesh is anchored laterally, and the anterior rectus sheaths are closed in the midline.
(c) Retrorectus inlay mesh placement (the Rives-Stoppa technique). The mesh is placed within the posterior rectus sheath deep to the rectus
abdominis muscle. The mesh is anchored to the linea semilunaris, and the anterior rectus sheaths are closed in the midline. (Reproduced
from Losken A, Janis JE. Advances in Abdominal Wall Reconstruction. New York: Thieme Medical; 2013.)
a
b
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1072
shown in long-term studies to have a respectable hernia re­
currence rate of 14% for large incisional hernias. A retrospec­
tive review from the Mayo Clinic with a median follow-up
of 5 years documented a 5% overall hernia recurrence rate
in 254 patients undergoing complex ventral hernia repair
over a 13-year period.38
All attempts should be made to avoid a bridged mesh re­
pair, because there is a clear trend toward higher recurrence
rates compared with when the fascia can be reapproximated
over a mesh repair.39 Understanding all of the approaches for
abdominal wall reconstruction and particularly myofascial
advancement flaps is critically important to determine the
least invasive procedure to provide a long-lasting repair with
an excellent functional outcome for the patient. Ramirez and
colleagues’ description of the surgical technique of compo­
nent separation (CS) facilitates medialization of the rectus
of mesh is placed ventral to the posterior rectus sheath or
peritoneum (Fig. 57.6). This space must first be dissected
laterally on both sides of the linea alba to the linea semilu­
naris. The linea semilunaris is identified by the presence of
the intercostal nerves perforating the lateral border of the
rectus muscle, as well as the lateral reflection of the pos­
terior sheath as it transitions to the anterior sheath. These
neurovascular bundles must be maintained, because they
provide segmental innervation to the rectus complex. The
mesh extends 5 to 6 cm beyond the superior and inferior
borders of the defect. The mesh is secured laterally with
several sutures. These sutures should be placed under phys­
iological tension to help medialize the rectus abdominis
muscles and prevent buckling of the mesh during midline
fascial reapproximation. This approach avoids contact be­
tween the mesh and the abdominal viscera and has been
Fig. 57.6 A ventral hernia repaired with retrorectus mesh reinforcement. This 58-year-old morbidly obese (BMI 42.3) woman with diabe­
tes and a history of exploratory laparotomy complicated by peritonitis and abdominal abscesses and two previous ventral hernia repairs
presented with a 12-cm ventral hernia. (a–c) Bilateral components separation was performed with ventral herniorrhaphy and retrorectus
(d) placement (the Rives-Stoppa technique) of mesh for soft tissue support (e) with complete fascial coaptation (f). The postoperative course
was uncomplicated, as seen at 1 year. (g,h) A latissimus dorsi flap and mastopexy were performed in the interim for right breast cancer.
g
h
a
b
c
d
f
e

1073
Chapter 57 Reconstruction of the Chest and Abdomen
segment of intestine injured (small versus large bowel) and
amount of spillage. Options include aborting the hernia
repair, continuing the hernia repair and repairing the en­
terotomy with local tissue or bioprosthetic mesh using a
primary tissue or bioprosthetic mesh repair, or performing
a delayed repair using mesh in 3 to 4 days. When there is
gross contamination, the use of synthetic mesh is gener­
ally contraindicated. Regardless of the approach taken, it is
important that patients understand preoperatively the risk
of this complication and how it might alter intraoperative
decisions.
The unexpected postoperative appearance of intestinal
contents draining through an abdominal surgical incision
is a devastating event for the patient and the surgical team.
The treatment of patients with enterocutaneous fistulas
musculofascia and thus midline abdominal closure by re­
leasing the external oblique aponeuroses and posterior rec­
tus sheath bilaterally40 (Fig. 57.7).
Although CS will often allow for midline fascial reap­
proximation, which is the optimal situation, occasionally
this will not be possible, particularly for larger hernias, and
the myofascial edges will need to be bridged with mesh.
Data have shown that defect size reduction, especially to
smaller than 150 cm2, leads to the lowest recurrence rates.41
Enterotomy and Enterocutaneous Fistulas
Unintentional intestinal injury during adhesiolysis can be
catastrophic. Appropriate management of an enterotomy
during a hernia repair is controversial and depends on the
Fig. 57.7 The minimally invasive component separation (MICS) technique. (a) Access to the external oblique aponeurosis is achieved through
a small tunnel from the midline to the supraumbilical external oblique aponeurosis. Vertical tunnels are created dorsal and ventral to the
planned release site of the external oblique aponeurosis. Periumbilical perforators and the subcutaneous tissue overlying the anterior rectus
sheath are left undisturbed. (b) The external oblique aponeurosis is then divided from the pubis to above the costal margin. The external
oblique aponeurosis in the upper abdomen is released with electrocautery as muscle is transected at, and superior to, the costal margin.
(c) Scissors are generally used to release the external oblique aponeurosis inferiorly. This MICS approach preserves the attachments of the
subcutaneous tissue (including myocutaneous perforators) to the anterior rectus sheath throughout its course.
Xiphoid process
Costal margin
External oblique muscle
Umbilicus
Linea semilunaris
Rectus abdominis
muscle fibers
Access tunnels to external
oblique aponeurosis for release
superiorly and inferiorly
a
Subcutaneous
tunnel creation
Dissected space
between external
and internal
oblique muscles
Incision of
external oblique
aponeurosis
Intact
myocutaneous
perforators
Line of release superiorly
with diathermy
b
Line of release
inferiorly with scissors
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1074
carbonate, which must be adequately replaced. Diligent
protection of the surrounding skin is one of the most im­
portant and difficult aspects of ECF management. A dedi­
cated enterostomal nurse is essential to the success of
wound management, because destruction of local skin can
seriously affect eventual reconstructive options.
If a fistula is already present, a negative-pressure wound
therapy (NPWT) device can be helpful to isolate a fistula
from the surrounding wound and to allow a skin graft to
heal. In cases of uncontrolled intestinal leakage, a proximal
diverting stoma can be lifesaving. When a proximal diver­
(ECFs) is complex, and most recommendations are based
on expert opinions or single-center retrospective case series
(Fig. 57.8). The underlying cause of an ECF has significant
implications for the prognosis for spontaneous closure or
the need for operative intervention. By definition, an ECF is
an abnormal communication between the bowel lumen and
the skin (Box 57.1).
Causes of ECFs include trauma; foreign body; infectious
disease; malignancy; and, for up to 20% of ECFs, bowel resec­
tion related to Crohn’s disease. Approximately one third of
ECFs will close spontaneously with appropriate wound care,
nutritional support, and medical therapy.42 Several prognos­
tic factors have been linked to nonhealing fistulas. A com­
mon mnemonic to describe these factors is FRIENDS of a
fistula: foreign body, radiation enteritis, inflammatory bowel
disease, epithelialization of the fistula tract, neoplasm, distal
obstruction, and ongoing sepsis. There are three phases of
ECF management (Boxes 57.2 and 57.3).
Once a fistula is identified, four factors must be ad­
dressed simultaneously:
1. Fluid and electrolyte repletion
2. Control of fistula effluent and protection of the sur­
rounding skin
3. Control of infection and drainage of abscesses
4. Nutritional support
Depending on the location of the fistula along the gas­
trointestinal tract and the volume of output, significant
electrolyte disturbances can occur. In particular, proximal
high-output fistulas can result in substantial losses of bi­
Box 57.1
Anatomical classification (based on segment of in­
volved intestines):
•• Gastrocutaneous
•• Biliocutaneous
•• Enterocutaneous
•• Colocutaneous
Output classification (based on volume of effluent
from the fistula):
•• Low output (less than 200 mL/day)
•• Moderate output (200–500 mL/day)
•• High output (more than 500 mL/day)
Etiologic classification
Classification of
Enterocutaneous Fistulas
Box 57.3
•• Control of Sepsis
•• Optimization of nutritional status
•• Wound care
•• Assessment of fistula anatomy
•• Timing of surgery
•• Surgical strategy
SOWATS Management
Algorithm
Box 57.2
•• Recognition and stabilization
•• Anatomical definition and decision
•• Definitive operation
Phases of Enterocutaneous
Fistula Management
a
Fig. 57.8 Enterocutaneous fistula (ECF). An ECF is an abnormal com­
munication between the bowel lumen and the skin. This 46-year-old
man with a history of colon cancer developed an ECF after a partial
colectomy complicated by an iatrogenic duodenal injury. (a) Preop­
eratively. (b) Intraoperative exploration and repair.
b

1075
Chapter 57 Reconstruction of the Chest and Abdomen
steadily decreasing and the wound is healing, surgery should
be avoided, because the fistula might heal spontaneously.
The goals of surgical correction of ECFs include the fol­
lowing:
•• Resect the segment of bowel involved in the fistula
•• Reestablish gastrointestinal tract continuity
•• Cover the anastomosis with well-vascularized soft tissue
•• Provide a stable abdominal wall closure
An autologous tissue graft or bioprosthetic mesh is prefer­
able to synthetic mesh in this population given the heavy
contamination often present as a result of the fistula. Bio­
prosthetic mesh has been used to bridge the fascial defect
in ECF cases with limited success. Although bioprosthetic
meshes are very expensive and likely may not prevent a ven­
tral hernia for a long time in these patients, as mentioned,
that is not the primary goal of ECF repair. In a series of 135
patients with ECFs, Visschers and colleagues43 reported suc­
cessful restoration of gastrointestinal tract continuity in 91%
of patients, with a 9.6% mortality rate, despite fairly early
surgical repair (mean of 53 days from ECF development).
Among 53 patients with concomitant abdominal wall de­
fects, 77% required surgical intervention for closure, and the
mortality rate was 15%. Malnutrition was correlated with
failure of surgical closure and increased mortality rates.
Outcomes
Several case examples are presented in Figs. 57.9–57.12).
sion cannot be achieved because of a foreshortened mesen­
tery or extremely dilated or hostile bowel, appropriate tube
drainage can be helpful.
Nutritional supplementation is one of the most impor­
tant aspects of reducing deaths related to ECFs. Nutritional
requirements should be adjusted accordingly for patients
with proximal high-output fistulas. During initial manage­
ment of an ECF, parenteral nutritional support is preferred.
However, once the sepsis is controlled and the patient is sta­
bilized, enteral feedings are initiated. Enteral feedings pre­
serve the intestinal mucosal barrier, improve immunologic
function, and prevent central-line sepsis.
Initially, an abdominopelvic CT study with oral and in­
travenous contrast is performed. This provides valuable in­
formation about undrained collections, bowel length, and
the integrity of the anterior abdominal wall. An appropri­
ately performed small bowel radiograph series is also help­
ful. In conjunction with our radiology team, we perform an
initial upper gastrointestinal tract radiograph series with
small bowel follow-through using water-soluble contrast
material.
Next, the fistula is cannulated, and the exact anatomy of
the fistula and the remaining small bowel are documented.
If necessary, a barium enema is performed to delineate the
distal anatomy. In difficult cases, these procedures are per­
formed under endoscopic guidance.
Once the entire gastrointestinal tract anatomy is es­
tablished, a general repair plan for the number of anasto­
moses, the amount of bowel requiring resection, and the
amount of remaining bowel is made. If the fistula output is
a
c
b
d
e
Fig. 57.9 Infected sternotomy wound. (a) Two years after débridement and reconstruction of an infected median sternotomy wound with
bilateral pectoralis major muscle flaps, this patient presented with a draining sinus without evidence of gross infection. (b) Computed to­
mography revealed significant destruction and fragmentation of several costal cartilages and a small residual cavity. (c) The median ster­
notomy scar was incised, the sinus tract débrided, the pectoralis muscle flaps retracted, and three consecutive costal cartilages along with
portions of the ribs were débrided. (d) The subsequent defect was obliterated and covered with readvancement of the left pectoralis muscle
flap, and the skin was closed without tension. (e) Final result 2 years after the reconstruction with stable chest and no evidence of infection.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1076
Fig. 57.10 Nonhealing pulmonectomy defect. (a) Residual cavity of the left chest 18 months after pulmonectomy. (b) Demonstrated on
computed tomography. (c) After débridement of the cavity all residual muscles remaining after the previous thoracotomy, including the
latissimus dorsi, serratus anterior, and pectoralis major, were mobilized and completely filled the chest defect. (d,e) Postoperative radio­
graphs demonstrated no evidence of a residual cavity. (f,g) At 4 months after the reconstruction.
a
c
b
d
e
f
g
a
b
c
Fig. 57.11 Infected mesh hernia repair. (a) Two years after repair of a ven­
tral hernia with Gore-Tex synthetic mesh, this patient presented with multiple
draining sinuses. (b) The sinuses and surrounding skin and underlying mesh
were excised en bloc. (c) The abdominal defect was repaired without the use
of synthetic material. (d) Final result 5 months after the reconstruction, dem­
onstrating a stable incision and no evidence of hernia.
d

1077
Chapter 57 Reconstruction of the Chest and Abdomen
achieved by adhering to basic principles of restoration of
anatomy, stabilization, and adequate soft tissue coverage.
Proper surgical technique and patient selection are essen­
tial to successful and durable outcomes and the avoidance
of complications.
Conclusion
Large, complex chest and abdominal wall defects can be
some of the most challenging problems a reconstructive
surgeon must face, but successful outcomes may be reliably
Fig. 57.12 Traumatic laparotomy hernia. (a) A 42-year-old man after exploration for a gunshot wound to the abdomen and temporary cover­
age with a skin graft that resulted in a defect measuring 48 by 40 cm. (b,c) Four months after removal of the skin graft the defect was recon­
structed using the component separation technique. Complete competency of the abdominal myofascial system was achieved in one setting.
a
b
c
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of the chest and indications for chest wall reconstruction.
Semin Plast Surg 2011;25(1):5–15
2. Martin RD. The management of infected median sternot­
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3. Chase CW, Franklin JD, Guest DP, Barker DE. Internal fixa­
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4. Davison SP, Clemens MW, Armstrong D, Newton ED, Swartz
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Physiol 2001;281(2):C398–C406
11. Miller PA, Mezwa DG, Feczko PJ, Jafri ZH, Madra­
zo BL. Imaging of abdominal hernias. Radiographics
1995;15(2):333–347
12. Franz MG. The biology of hernia formation. Surg Clin
North Am 2008;88(1):1–15, vii
13. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and
long-term results of prosthetic chest wall reconstruction. J
Thorac Cardiovasc Surg 1999;117(3):588–591, discussion
591–592
14. Hanna WC, Ferri LE, McKendy KM, Turcotte R, Sirois C,
Mulder DS. Reconstruction after major chest wall resec­
tion: can rigid fixation be avoided? Surgery 2011;150(4):
590–597
15. Mansour KA, Thourani VH, Losken A, et al. Chest wall
resections and reconstruction: a 25-year experience.
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1725–1726
16. Losken A, Thourani VH, Carlson GW, et al. A reconstruc­
tive algorithm for plastic surgery following extensive
chest wall resection. Br J Plast Surg 2004;57(4):295–302
17. Fabre D, El Batti S, Singhal S, et al. A paradigm shift for
sternal reconstruction using a novel titanium rib bridge
system following oncological resections. Eur J Cardiotho­
rac Surg 2012;42(6):965–970
18. Butterworth JA, Garvey PB, Baumann DP, Zhang H, Rice
DC, Butler CE. Optimizing reconstruction of oncologic
sternectomy defects based on surgical outcomes. J Am
Coll Surg 2013;217(2):306–316
19. Breuing K, Butler CE, Ferzoco S, et al; Ventral Hernia
Working Group. Incisional ventral hernias: review of the
literature and recommendations regarding the grading
and technique of repair. Surgery 2010;148(3):544–558
20. Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of
postoperative venous thromboembolism risk in plastic
surgery patients using the 2005 and 2010 Caprini Risk
score. Plast Reconstr Surg 2012;130(2):343–353

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33. Carlson MA, Ludwig KA, Condon RE. Ventral hernia and
other complications of 1,000 midline incisions. South
Med J 1995;88(4):450–453
34. Janis JE, O’Neill AC, Ahmad J, Zhong T, Hofer SO. Acellu­
lar dermal matrices in abdominal wall reconstruction: a
systematic review of the current evidence. Plast Reconstr
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35. Zhong T, Janis JE, Ahmad J, Hofer SO. Outcomes after ab­
dominal wall reconstruction using acellular dermal ma­
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2011;64(12):1562–1571
36. Losken A, Janis JE. Advances in abdominal wall recon­
struction, New York: Thieme Medical Publishers; 2013
37. Stoppa RE. The treatment of complicated groin and inci­
sional hernias. World J Surg 1989;13(5):545–554
38. Iqbal CW, Pham TH, Joseph A, Mai J, Thompson GB, Sarr
MG. Long-term outcome of 254 complex incisional hernia
repairs using the modified Rives-Stoppa technique. World
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39. Booth JH, Garvey PB, Baumann DP, et al. Primary fascial
closure with mesh reinforcement is superior to bridged
mesh repair for abdominal wall reconstruction. J Am Coll
Surg 2013;217(6):999–1009
40. Rosen M. Atlas of Abdominal Wall Reconstruction. Phila­
delphia: Elsevier; 2012:15–195
41. Itani KM, Hur K, Kim LT, et al; Veterans Affairs Ventral In­
cisional Hernia Investigators. Comparison of laparoscopic
and open repair with mesh for the treatment of ventral
incisional hernia: a randomized trial. Arch Surg 2010;
145(4):322–328, discussion 328
42. Wind J, van Koperen PJ, Slors JF, Bemelman WA. Single-
stage closure of enterocutaneous fistula and stomas in the
presence of large abdominal wall defects using the com­
ponents separation technique. Am J Surg 2009;197(1):
24–29
43. Visschers RG, Olde Damink SW, Winkens B, Soeters PB,
van Gemert WG. Treatment strategies in 135 consecu­
tive patients with enterocutaneous fistulas. World J Surg
2008;32(3):445–453
21. Centers for Disease Control and Prevention. Guideline for
Prevention of Surgical Site Infection, 1999
22. de Vries Reilingh TS, van Geldere D, Langenhorst B, et al.
Repair of large midline incisional hernias with polypro­
pylene mesh: comparison of three operative techniques.
Hernia 2004;8(1):56–59
23. Koch A, Bringman S, Myrelid P, Smeds S, Kald A. Random­
ized clinical trial of groin hernia repair with titanium-
coated lightweight mesh compared with standard poly­
propylene mesh. Br J Surg 2008;95(10):1226–1231
24. Butler CE. Treatment of refractory donor-site seromas
with percutaneous instillation of fibrin sealant. Plast Re­
constr Surg 2006;117(3):976–985
25. Arnold PG, Pairolero PC. Chest-wall reconstruction: an
account of 500 consecutive patients. Plast Reconstr Surg
1996;98(5):804–810
26. Althubaiti G, Butler CE. Abdominal wall and chest wall re­
construction. Plast Reconstr Surg 2014;133(5):688e–701e
27. le Roux BT, Shama DM. Resection of tumors of the chest
wall. Curr Probl Surg 1983;20(6):345–386
28. Goldstraw P. Postpneumonectomy empyema. J R Soc Med
1993;86(10):559–560
29. Thourani VH, Lancaster RT, Mansour KA, Miller JI Jr.
Twenty-six years of experience with the modified eloess­
er flap. Ann Thorac Surg 2003;76(2):401–405, discussion
405–406
30. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk
EG, Jeekel J. Long-term follow-up of a randomized con­
trolled trial of suture versus mesh repair of incisional her­
nia. Ann Surg 2004;240(4):578–583, discussion 583–585
31. Flum DR, Horvath K, Koepsell T. Have outcomes of inci­
sional hernia repair improved with time? A population-
based analysis. Ann Surg 2003;237(1):129–135
32. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk
EG, Jeekel J. Long-term follow-up of a randomized con­
trolled trial of suture versus mesh repair of incisional her­
nia. Ann Surg 2004;240(4):578–583, discussion 583–585
Discussion by Geoffrey G. Hallock
Plastic surgeons often must problem solve for the chest
and abdominal areas after complications occur, often
after procedures performed by other surgeons. Many
adverse events can be mitigated or minimized by an in­
tense understanding of the pertinent basic physiology,
the disease processes, and proper patient selection, as
well as the ideal surgical approach to best avoid or cor­
rect these events. Much of this is outside the realm of
most plastic surgeons, who must therefore depend on
a collegial interaction with oncologic, general, cardio­
thoracic, or other surgeons to achieve the best overall
result for their patients.
Few would argue that an acute respiratory compro­
mise is more of an immediate danger than a high output
enterocutaneous fistula. Suppurative mediastinitis and
bronchopleural fistula or empyema may be rare and may
carry a high risk for mortality, but large ventral hernias
are more common in the usual general reconstructive
practice and thus disproportionately require attention.
Chest stability is important to prevent respiratory
insufficiency, as the chapter shows in detail. Interest­
ingly, the use of internal fixation devices for sternal
stabilization after median sternotomy to accomplish
this goal is one example, with plastic surgeons at the

1079
Chapter 57 Reconstruction of the Chest and Abdomen
­forefront of development of this concept.1 On the other
side of the coin, restoration of an intact and contrac­
tile myofascial support system for the abdominal wall,
whether by component separation or use of mesh, has
also been championed.2
Muscle Flaps
Although the aforementioned nuances are essential,
probably the biggest role for the plastic surgeon for
both the chest and abdomen is to provide appropri­
ate soft tissue closure, which in partial or small defects
may be accomplished simply by a skin graft, use of
relaxing incisions, or recruitment using tissue expan­
sion. However, defects with mesh or fixation device
exposure will instead often demand some form of vas­
cularized tissue coverage. Traditionally in both these
regions of the trunk this has relied on pedicled muscle
flaps. As a group their anatomy is highly reliable, and
the extent of viability is quite predictable. Muscles are
relatively malleable and thus are preferable for fill­
ing three-dimensional voids or even for intrathoracic
transposition, as shown in Fig. 57.1. Unfortunately,
particularly for thoracic defects, sometimes the patient
has undergone thoracotomy incisions that have re­
sulted in transection of the workhorse latissimus dorsi
muscle and even the serratus anterior muscle, making
them unavailable. In other cases the rectus abdominis
muscles have been widely displaced by a huge ventral
hernia, which could limit reach as a muscle flap. Under
these circumstances, a free muscle flap may then be a
solution, but a microsurgical tissue transfer creates a
far greater risk from its inherent complexity, and suc­
cess may be diminished for these patients, who often
have multiple other comorbidities.
It is always preferable to sacrifice only a single mus­
cle when a flap is necessary so remaining unviolated op­
tions will be available later if there is a complication or a
recurrence of the initial problem. There are many varia­
tions of muscle flap harvesting that will allow this. One
example is an old standby that requires the presence of a
segmental blood supply: splitting the chosen muscle so
that most remains not only still available but still func­
tional.3 Another example is to increase the range, as has
been specifically shown for the pectoralis major muscle.
This workhorse muscle, commonly used for closure of
the anterior mediastinum, can as a single muscle cover
the entire median sternotomy incision, including the
difficult epigastric area, if its thoracoacromial pedicle
is lengthened by dissection back to its origin from the
axillary vessels.4 Such a maneuver will simultaneously
avoid the need for the superior-based rectus abdomi­
nis muscle turnover flap, commonly added just for the
subxiphoid region.
Although the rectus abdominis is the only intrin­
sic abdominal muscle routinely used as a local flap for
both the chest and abdominal wall, its sacrifice will fur­
ther compromise abdominal wall function. This choice
should be avoided if the primary defect would thereby
be accentuated. Alternatives include many thigh mus­
cles, with the gracilis muscle especially valuable for
small defects in the inguinal region. However, these
muscles each have their own role, exemplified by har­
vest of the rectus femoris muscle, which may result in
up to 10% or more loss of donor leg strength.5 Our subto­
tal thigh flap, which can include the rectus femoris mus­
cle as well as the tensor fascia lata and vastus lateralis
muscles, ensures thigh skin vascularity as a musculocu­
taneous flap and may with its contralateral twin permit
total abdominal wall reconstruction without resorting
to the perhaps extreme risks of a microvascular anas­
tomoses. Again, however, the effect on lower extremity
function by such a composite should not be overlooked.
Perforator Flaps
Except for the anterolateral thigh flap, no other thigh
or torso-based perforator pedicled flaps were included
in Table 57.1 as alternatives for chest and abdominal
wall skin closure. If a muscle flap of choice is not avail­
able, a backup alternative should always be considered.
Most surgeons recognize that perforator flaps can be
designed almost anywhere in the body as long as there
is an adequate perforator. Muscle does not need to be
included with this form of fasciocutaneous flap. A per­
forator flap that is nourished by musculocutaneous
perforators during their dissection will result in some
diminution of function, for the most part maximum
muscle function preservation is the sine qua non ad­
vantage of the perforator flap genre. Especially for the
abdomen, where denervation of functioning muscle
should be avoided, many surgeons would consider a
perforator flap even as the primary flap option if only a
superficial wound closure is required. Once the location
of the requisite perforator has been established, perfo­
rator flaps can be advanced, rotated, or even turned like
a propeller from adjacent tissues, or transposed as an
island flap on a long pedicle from donor sites far away
or outside the chest or abdomen itself.
Most schemas devised as a guideline to assist in
the selection of the right flap for restoration of the in­
tegument of the abdomen have generally been strati­
fied according to the location of the defect. The use of
perforator flaps is slightly different; “hot zones” where
dominant perforators can usually be found will dictate
which perforasome is the best available. Thus the abdo­
men can accordingly be divided into five different zones,
two of which are mirror images6,7 (Fig. 57D.1).
Probably the most versatile choice is the deep infe­
rior epigastric artery perforator (DIEAP) flap. The per­
forators of the rectus abdominis muscle cluster in the
periumbilical region. These can allow a skin flap to reach

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1080
almost every zone and will be especially straightforward
if used as a propeller flap that can be rotated about its
hub (the perforator), which would then require little if
any deep fascia or muscle dissection.8
Unfortunately, with a large periumbilical wound or
hernia these perforators may have already been com­
promised and often found after component separation
techniques where the dissection did not spare them. The
next best “ideal” soft tissue option may be extrinsic to
the abdomen, as represented by the anterolateral thigh
(ALT) flap pedicled on the lateral circumflex ­femoral
system.9 This flap easily reaches the infr­aumbilical and
upper lateral zones and may reach the periumbilical
zone. If not, a free flap may be the best choice if nei­
ther the pedicled ALT nor DIEAP flap are solutions. A
relatively newer technique is the deep superior epi­
gastric artery perforator (DSEAP) flap, which actually
is a straightforward option for the often frustrating epi­
gastric wound10 (Fig. 57D.2). In a sense it is a mirror
image of the DIEAP flap, taking advantage of the fact
that the rectus abdominis muscle is a type III muscle
with dual opposing major source vessels. Many other
less-well-known and perhaps more difficult perforator
flaps both intrinsic and extrinsic to the abdomen have
been described that could be considered as secondary
or tertiary flap options6 (Table 57D.1).
The perforator flaps that arise within the chest
­region are used less often than their abdominal coun­
terparts. The most important is the internal mammary
artery perforator (IMAP) flap, which is safest if designed
with a transverse orientation and based on parasternal
perforators that usually traverse the second, third, or
fourth intercostal space.11 The size of these perforators
can be quite variable, with the second intercostal space
Fig. 57D.1 Zones of the abdomen determined by location and
preferred perforator flap options for closure. ALT, Anterolateral
thigh; DIEAP, deep inferior epigastric artery perforator; DSEAP,
deep superior epigastric artery perforator. (Reproduced from
Hallock GG. A paradigm shift for soft tissue coverage of the
zones of the abdominal wall using perforator flaps. Plast Recon­
str Surg 2012;130:590–599.)
DIEAP or ALT
DSEAP
DIEAP ALT
ALT
a
b
c
Fig. 57D.2 (a) After median sternotomy for complications of Marfan’s syndrome, this pa­
tient’s subxiphoid area had been skin grafted. An epigastric hernia ensued and was re­
paired with mesh (arrow). A left deep superior epigastric artery perforator (DSEAP) local
flap based on perforator x was outlined for coverage. (b) Total flap necrosis resulted from
venous congestion (a not uncommon problem with perforator flaps), probably caused by
unrecognized excessive tension during closure. (c) A right DSEAP flap was next elevated
with three potential perforators (p) of the rectus abdominis muscle (RA). (d) The success of
the procedure was evident 4 months later. Bilateral upper paramedian scars are visible from
the primary donor site closure for both flaps.
d

1081
Chapter 57 Reconstruction of the Chest and Abdomen
Fig. 57D.3 Zones of the chest determined by location and pre­
ferred perforator flap options for closure. DSEAP, Deep supe­
rior epigastric artery perforator; IMAP, internal mammary artery
perforator; TDAP, thoracodorsal artery perforator.
DSAEP
IMAP
T
D
A
P
T
D
A
P
Table 57D.1 Zones of the abdomen and perforator flap closure options
Zone
Primary choicesa
Secondary choicesa
Epigastric
DSEAP
AICAP, IMAP
Infraumbilical
ALT, DIEAP
LAP, MCFAP, SCIAP, SIEAP, SPAP, TFL
Lateral abdomen
ALT
LAP, LICAP
Periumbilical
DIEAP
DSEAP, ALT, ALT free flapb
Abbreviations: AICAP, Anterior intercostal artery perforator; ALT, anterolateral thigh; DIEAP, deep inferior epigastric artery perforator;
DSEAP, deep superior epigastric artery perforator; IMAP, internal mammary artery perforator; LAP, lumbar artery perforator; LICAP, lateral
intercostal artery perforator; MCFAP, medial circumflex femoral artery perforator; SCIAP, superficial circumflex iliac artery perforator;
SIEAP, superficial inferior epigastric artery perforator; SPAP, superficial pudendal artery perforator; TFL, lateral circumflex femoral artery
­perforator—ten­sor fascia lata.
Source: Modified from Hallock, GG, A paradigm shift for soft-tissue coverage of the zones of the abdominal wall using perforator flaps, Plast
Reconstr Surg. 130:590-599, 2012.
aLocal flap unless otherwise designated.
bPrimary choice for large defects.
Table 57D.2 Zones of the chest
and perforator flap closure
options
Zone
Primary
choices
Secondary
choices
Axilla and lateral
costal
TDAP
CSAP, LICAP, TAAP
Parasternal and
medial costal
IMAP
AICAP, TAAP
Lower midchest
and xiphoid
DSEAP
AICAP, IMAP
Abbreviations: AICAP, Anterior intercostal artery perforator; CSAP,
circumscapular artery perforator; DSEAP, deep superior epigastric
artery perforator; IMAP, internal mammary artery perforator; LICAP,
lateral intercostal artery perforator; TAAP, thoracoacromial artery
perforator; TDAP, thoracodorsal artery perforator.
perforator usually the largest, and probably historically
the basis of the now archaic deltopectoral flap. The IMAP
flap itself may reach as high as the neck or down to the
epigastrium. Other chest perforator flaps have a rela­
tively minor role12 (Table 57D.2). Lateral intercostal ar­
tery perforator flaps have been useful particularly for
small defects in breast reconstruction. Thoracoacromial
and anterior intercostal artery perforator flaps are an
alternative for the upper and lower chest, respectively,
but their anatomy is extremely anomalous and dissec­
tion difficult. Extrinsic chest perforator flaps may then
be a better option, because the DSEAP flap can reach
the lower midchest, and the thoracodorsal artery per­
forator (TDAP) flap can have a long pedicle as an island
flap to reach the axilla or even lateral clavicular area
(Fig. 57D.3).
Keystone Flap
Another recently introduced flap gaining momentum
as a workhorse flap throughout the body is the key­
stone island flap as described by Behan.13 Some might
consider this also to be a perforator flap theoretically
based on capillary perforators, as championed by Ko­
shima et al.14 The typical design resembles the keystone
of a Roman arch (Fig. 57D.4). These flaps can be quite
large. They would be best designed where numerous
capillary perforators exist, such as over muscles like
the pectoralis major in the chest or external abdominal

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1082
Fig. 57D.4 (a) Thin melanoma of the right midchest, with the proposed wide excision marked. (b) Prototypic keystone flap de­
sign (yellow), with sides (S) tangential to the horizontal extremes of the excision defect (brown), extending at least the vertical
height (H) of the defect, and then connected by an arc. (c) The flap boundaries were incised down to Scarpa’s fascia equivalent,
with a bridge (B) kept in the center of the arc to minimize the risk of dehiscence of the donor site closure.15 In this patient a large
myocutaneous perforator (p) was observed and retained in the leading edge of flap. (d) The healed chest keystone flap 2 months
later that obviated the need for a skin graft.
a
b
c
d
oblique where a thick aponeurosis does not exist. These
flaps do not require the actual dissection of a perfora­
tor. Because unrestricted flap advancement is impera­
tive, the chosen design must overlie the most mobile
skin in the area around the defect, and preferably not
in the vicinity of a joint whose movement could lead to
flap dehiscence.
Conclusion
Chest and abdominal reconstruction is a multifaceted
endeavor. The chapter thoroughly explained a proper
stepwise approach to solve these problems. Many
plastic surgeons realize these complexities but have
concentrated on a small yet important part of this pro­
cess: to complete the necessary soft tissue transplan­
tation. The authors discussed their preferences in this
regard, usually a muscle flap. Muscle flap dissection
is normally relatively straightforward, and anomalies
are not expected, making this a very safe choice. Per­
forator flaps are a valid alternative to the previously
somewhat limited array of possibilities. Although a
skilled microsurgeon should be capable of harvesting a
perforator flap even with diminutive perforators, there
is definitely a learning curve that can be steep during
which the unwary can perhaps cause more harm than
good16 (see Fig. 57D.2).
Determining the presence of an adequate perforator
for a chosen flap is imperative and may be ascertained
preoperatively by computed tomography angiography or
magnetic resonance angiography17 or by direct visual­
ization during flap exploration, which still in all aspects
requires experience. Reliance on a handheld acoustic
Doppler alone can have highly variable consequences.18
Large wounds or those for which there has been prior
surgical attempts at closure with wide skin undermin­
ing may doom local flaps of any kind to failure. The safe
territory for a given perforasome and in turn dimen­
sions of any skin flap can also be variable, although the
availability of laser-assisted indocyanine green imaging
in many institutions has minimized this uncertainty.19
Perforator flaps may now be mainstream,20 but precau­
tions for their use compared with muscle flaps must be
accounted for and appreciated.

1083
Chapter 57 Reconstruction of the Chest and Abdomen
References
1. Roughton M, Agarwal S, Song DH, Gottlieb LJ. Rigid
sternal fixation in the management of pediatric post­
median sternotomy mediastinitis: a 20-year study. J
Plast Reconstr Aesthet Surg 2015;68(12):1656–1661
2. Ramirez OM, Ruas E, Dellon AL. “Components separa­
tion” method for closure of abdominal-wall defects:
an anatomic and clinical study. Plast Reconstr Surg
1990;86(3):519–526
3. Morain WD, Geurkink NA. Split pectoralis major myo­
cutaneous flap. Ann Plast Surg 1980;5(5):358–361
4. Hallock GG. The pectoralis major muscle extended
island flap for complete obliteration of the median
sternotomy wound. Ann Plast Surg 2007;59(6):
655–658
5. Caulfield WH, Curtsinger L, Powell G, Pederson WC.
Donor leg morbidity after pedicled rectus femoris
muscle flap transfer for abdominal wall and pelvic re­
construction. Ann Plast Surg 1994;32(4):377–382
6. Hallock GG. A paradigm shift for soft-tissue coverage
of the zones of the abdominal wall using perforator
flaps. Plast Reconstr Surg 2012;130(3):590–599
7. Hallock GG, Neligan PC. Cutaneous coverage of the
abdominal wall. In: Blondeel PN, Morris SF, Hallock
GG, Neligan PC, eds. Perforator Flaps. 2nd ed. St Louis,
MO: Quality Medical Publishing; 2013:1111–1125
8. Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS.
Deep superior epigastric artery perforator ‘propeller’
flap for abdominal wall reconstruction: a case report.
J Plast Reconstr Aesthet Surg 2010;63(7):1223–1226
9. Wei FC, Jain V, Celik N, Chen HC, Chuang DCC, Lin
CH. Have we found an ideal soft-tissue flap? An ex­
perience with 672 anterolateral thigh flaps. Plast
Reconstr Surg 2002;109(7):2219–2226, discussion
2227–2230
10. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E,
Roche N, Monstrey S. Clinical applications of the su­
perior epigastric artery perforator (SEAP) flap: ana­
tomical studies and preoperative perforator mapping
with multidetector CT. J Plast Reconstr Aesthet Surg
2009;62(9):1127–1134
11. Koulaxouzidis G, Orhun A, Stavrakis T, Witzel C. Sec­
ond intercostal internal mammary artery perforator
(IMAP) fasciocutaneous flap as an alternative choice
for the treatment of deep sternal wound infections
(DSWI). J Plast Reconstr Aesthet Surg 2015;68(9):
1262–1267
12. Blondeel PN. Flap options and technical consider­
ations in the trunk. In: Blondeel PN, Morris SF, Hal­
lock GG, Neligan PC, eds. Perforator Flaps. 2nd ed. St
Louis: Quality Medical Publishing; 2013:1030–1034
13. Behan FC. The keystone design perforator island flap
in reconstructive surgery. ANZ J Surg 2003;73(3):
112–120
14. Koshima I, Narushima M, Mihara M, et al. New thora­
codorsal artery perforator (TAPcp) flap with capillary
perforators for reconstruction of upper limb. J Plast
Reconstr Aesthet Surg 2010;63(1):140–145
15. Stone JP, Webb C, McKinnon JG, Dawes JC, McKenzie
CD, Temple-Oberle CF. Avoiding skin grafts: the key­
stone flap in cutaneous defects. Plast Reconstr Surg
2015;136(2):404–408
16. Hallock GG. Is there a “learning curve” for muscle
perforator flaps? Ann Plast Surg 2008;60(2):146–149
17. Masia J, Navarro C, Clavero JA, Alomar X. Noncontrast
magnetic resonance imaging for preoperative perfo­
rator mapping. Clin Plast Surg 2011;38(2):253–261
18. Hallock GG. Attributes and shortcomings of acoustic
Doppler sonography in identifying perforators for
flaps from the lower extremity. J Reconstr Microsurg
2009;25(6):377–381
19. Komorowska-Timek E, Gurtner GC. Intraoperative per­
fusion mapping with laser-assisted indocyanine green
imaging can predict and prevent complications in im­
mediate breast reconstruction. Plast Reconstr Surg
2010;125(4):1065–1073
20. Hallock GG. If based on citation volume, perforator flaps
have landed mainstream. Plast Reconstr Surg 2012;
130(5):769e–771e

Votive relief from the sanctuary of the hero-physician Aminos. End of 4th century BC. (National
Archaeological Museum, Athens, Greece. © Hellenic Ministry of Culture and Sports/Archeological Receipts
Fund. Photo: Irini Miari.)

1085
Lower Extremity
Reconstruction
Basel Sharaf, Karen Kim Evans, Ali Izadpanah, and Samir Mardini
Lower extremity reconstruction is a multidisciplinary
field requiring coordination of care by multiple special­
ties including trauma surgery, orthopedic surgery, plas­
tic surgery, vascular surgery, podiatry, radiology, physical
therapy, occupational therapy, prosthetics, physical medi­
cine and rehabilitation, psychiatry, and pain management.
Plastic surgeons are commonly asked to provide advanced
expertise in the management of problematic lower extrem­
ity wounds secondary to trauma, vascular disease, diabetic
ulcers, infections, or oncologic resection. The primary goals
of lower limb reconstruction are to preserve function and
limb length, achieve stable bony fixation, and provide du­
rable soft tissue reconstruction to withstand load-bearing
and shearing forces and allow pain-free ambulation. This
chapter reviews reconstructive considerations of the lower
extremity with special emphasis on perioperative plan­
ning, avoidance of complications, and management of un­
favorable results.
Avoiding Unfavorable Results
and Complications in Lower
Extremity Reconstruction
CHAPTER
58
Summary Box
Complications in Lower Extremity Reconstruction
•• Inadequate preoperative planning
○
○Poor medical optimization
○
○Improper wound assessment
○
○Underestimation of zone of injury
○
○Improper assessment of vessel suitability
○
○Poor understanding of patient’s preoperative
function
○
○Missed diagnosis of underlying malignancy,
radiation, or indolent infection
•• Improper flap design
•• Vascular problems
○
○Venous insufficiency
○
○Arterial thrombosis
•• Deep venous thrombosis or pulmonary embolism
•• Recurrent ulceration related to a biomechanical
problem with gait
•• Infection
•• Osteomyelitis
•• Partial flap loss
•• Complete flap loss
•• Bulky flap
•• Noncompliance with postoperative protocol
•• Reconstruction of nonfunctional limb

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1086
Although initial studies in the trauma literature advo­
cated earlier coverage within 72 hours,2 such an approach
is not always necessary and may not always yield optimal
results.3,4 Additionally, the use of negative-pressure wound
therapy (NPWT) has made a positive impact on wound
management, and delayed coverage of the wound has not
resulted in increased flap failure rates.3,5 Although some
wounds can be covered early, other wounds with greater
soft tissue injury may require 7 to 10 days to fully demar­
cate and undergo adequate débridement. In such scenarios,
serial débridement every 48 to 72 hours and appropriate
NPWT management are necessary before definitive cover­
age. Newer technology with NPWT and instillation of fluid
has been shown to decrease length of stay and timing of
closure in lower extremity reconstruction.6 Expeditious cov­
erage of exposed hardware, major vessels, nerves, joint sur­
faces, tendons, and bone is attempted whenever possible to
avoid later complications.
Overview of Surgical Technique
Intraoperative execution of the reconstructive plan by fol­
lowing meticulous surgical technique is paramount. The
surgeon and anesthesia team must pay close attention to
maintenance of patient normothermia, adequate padding
of pressure points, proper patient positioning for the in­
tended flap elevation and inset dressings, effective DVT
prophylaxis, and prospective hemostasis. Examination of
potential flap donor sites for any signs of trauma or previ­
ous surgical intervention that may compromise flap viabil­
ity is important. For foot and lower leg reconstruction, the
ideal flap donor site should be thin enough to later fit into
a shoe. If there was soft tissue infection or osteomyelitis,
a culture-specific antibiotic regimen is paramount to the
immediate and long-term success of any extremity recon­
struction.
Surgical options for lower extremity reconstruction are
local or free tissue transfers. Local flaps include local pedi­
cled fasciocutaneous flaps, such as perforator-propeller flaps
that have been recently popularized as options in lieu of
free flaps.7 These flaps are technically demanding and re­
quire a learning curve. Careful flap selection is key in avoid­
ing complications. Patient age older than 60 years, diabetes,
and peripheral vascular disease are significant risk factors
for perforator–pedicled propeller flap complications in the
lower extremity.8
For lower extremity free tissue transfer, proper flap se­
lection, flap design, careful elevation and recipient vessel se­
lection are prerequisites for success. Free flap failure is gen­
erally higher in lower extremity reconstruction compared
with breast and head and neck reconstruction.9 The most
important consideration to avoid free flap loss is early rec­
ognition of flap compromise, which can be more difficult to
assess in muscle flaps versus skin flaps (Fig. 58.1). Flap loss
rates of up to 28% have been reported. Vascular complica­
tions remain the primary reason for free flap loss. As stated
previously, preoperative assessment of arterial and venous
flow should be confirmed by physical examination and du­
Proper Preoperative Planning
and Patient Selection to Avoid
Complications
Patient Selection
Proper patient evaluation includes several steps:
•• A comprehensive past medical and surgical history
•• Assessment of comorbidities:
○
○Diabetes
○
○Smoking
○
○Peripheral vascular disease
○
○Prior lower extremity trauma
○
○Cardiovascular disease
○
○Hypercoagulability
○
○Deep venous thrombosis (DVT)
○
○Lymphedema
○
○Obesity
○
○ Steroid use
○
○Drug dependency
•• Assessment of the patient’s expectations, motivation for
rehabilitation, psychological status, job requirements,
and level of social support
•• A history of chemotherapy or radiation therapy, which
are equally pertinent and can adversely affect wound
healing and reconstructive outcome
•• Assessment and optimization of the patient’s nutritional
status
•• Preoperative imaging such as computed tomography
angiography (CTA), magnetic resonance angiography
(MRA), or angiography should be assessed
For patients with underlying renal disease or a contrast al­
lergy, it is important to note that a properly executed an­
giogram uses far less intravenous contrast dye than does
CTA. Other indicated vascular studies such as duplex ultra­
sound to assess for venous insufficiency or underlying DVT
should be obtained preoperatively to assess venous out­
flow. Effective communication with other involved services
such as anesthesia, trauma surgery, orthopedic surgery, in­
ternal medicine, and physical therapy is critical. In patients
with severe illnesses and comorbidities, amputation may
be a better option than aggressive attempts at limb salvage,
which can lead to costly medical complications.
Timing of Closure
Accurate wound assessment and adequate débridement are
integral to lower extremity reconstruction. Complex recon­
struction surgery techniques are used to cover bone, tendon,
hardware, or other vital structures. Ensuring that the wound
bed has been adequately débrided, is clean, and shows signs
of granulation tissue is essential to a successful, durable
reconstruction. Deep postdébridement tissue cultures are
helpful to determine whether the wound is ready for closure
and will prevent late osteomyelitis or late infection.1

1087
Chapter 58 Lower Extremity Reconstruction
flap outcomes to end-to-side anastomosis. However, end-
to-side venous anastomosis was strongly associated with
unplanned reoperation and total flap loss.13 After microvas­
cular anastomosis, if flap perfusion is questionable, the mi­
crovascular anastomosis must be assessed before leaving the
operating room, where most vascular compromise begins.14
In general, venous insufficiency is more common than ar­
terial thrombotic complications in free flap reconstruction of
the lower extremity.15 In a review of 170 free flaps, when the
deep vein system was used in microvascular anastomosis, a
higher risk for DVT measured by the Caprini risk assessment
model was shown to be predictive of flap venous insufficiency
after microsurgical lower extremity reconstruction.16 In our
experience, performing two venous anastomoses is preferred
whenever possible. It is important to assess the back bleed­
ing of the venous system before performing the microsurgi­
cal anastomosis to ensure the pressure in the venous system
is not too high. Our preference is to perform microsurgical
anastomosis to the deep venous system, because usually the
venae comitantes are adjacent to the artery and easily ac­
cessible. A second venous anastomosis to the superficial sys­
tem is recommended, when feasible. Adding a second venous
anastomoses has been shown to decrease the incidence of
flap failure rate by 36% and venous thrombosis rate by 34%
compared with one venous anastomoses.17
One of the most important considerations when per­
forming lower extremity free tissue transfer is assessing the
final wound closure for tightness, potential pedicle compres­
sion, and kinking, which can lead to thrombosis. The flap
design should always be larger than the defect and take in
consideration the coverage of the pedicle outside the zone
of injury to prevent tension and kinking. Use of the implant­
plex ultrasound when venous insufficiency or edema is sus­
pected. Preoperative angiogram, CTA, or MRA are indicated
for virtually every patient.
The recipient vessels should be explored and assessed
for pulsatile flow and suitability for microvascular anasto­
mosis before flap elevation. Because of the nature of the
compartmental trauma of the lower extremity and the re­
sulting thrombogenic zone of injury, selecting vessels proxi­
mal to the zone of injury is preferred whenever possible.
However, this may not always be feasible. Meticulous mi­
crosurgical technique distal to the zone of injury has been
safely performed, with reported success rates up to 97% in
some centers.10 Advantages of using recipient vessels distally
include easier access, technically easier anastomosis, shorter
flap pedicle requirement, no need for vein graft or tunnel­
ing the pedicle, and avoiding crossing the knee joint. Using
the distal recipient vessels is possible, but inset of the flap
is more complex, because the venous outflow must take a
180-degree turn from the flap to the recipient venous out­
flow. It is important to have adequate length to make sure
the pedicle is not kinked.
In general, end-to-side arterial anastomosis has equiva­
lent free flap success rates to end-to-end anastomosis and
should be considered in most extremity reconstruction to
preserve distal arterial supply.11 Most importantly, end-to-
side anastomosis avoids issues with size mismatch. In one
large series, an end-to-side arterial anastomosis technique
was performed in 50% of patients with a single vessel run
off without an increased incidence of foot ischemia or flap
failure rates when compared with the end-to-end arterial
anastomosis technique.12 Similarly, in another large onco­
logic series, end-to-end arterial anastomosis had equivalent
Fig. 58.1 Early signs of venous congestion in a free muscle flap. (a) Preoperative view of a large posterior leg and heel defect. (b) Immediate
postoperative view after free vastus lateralis muscle flap and skin graft. The muscle is soft and pink under the skin graft. (c) Approximately
14 hours postoperatively, the wound shows early signs of venous congestion with purplish muscle, edema, and a darker-colored skin graft.
Any change from the immediate postoperative examination should warrant taking the patient back to the operating room.
a
b
c

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1088
healthy individuals with an active lifestyle. Motor vehicle
accidents, motorcycle accidents, industrial trauma, and
military trauma account for most of these injuries. Some
of these injuries are not only limb-threatening, but also
life-threatening. Limb salvage and reconstruction should
always be considered within the context of the patient’s
overall physiologic state. At initial presentation, stabiliza­
tion of the patient and immediate attention to any life-
threatening injuries is undertaken according to advanced
cardiac life support (ACLS) and advanced trauma life sup­
port (ATLS) guidelines. Focused clinical examinations to
diagnose and assess vascular injury, fracture displacement,
tissue perfusion, limb sensibility, extent of soft tissue com­
promise, and bony injury is a must. CTA has become the
standard of care in assessing lower extremity vascular in­
jury in most institutions. High-resolution vascular images
can be obtained quickly and cost-effectively without the
need to assemble a specialized team for catheter-directed
angiography or its associated morbidity. Fractures are eval­
uated simultaneously.
In our experience with CTA in preoperative planning for
lower extremity trauma and free tissue transfer, up to 64% of
patients with findings of traumatic injury on CT had a docu­
mented normal peripheral vascular examination.20 Signs of
vascular damage include filling arterial defects, extravasation
of contrast, vessel narrowing, or early venous opacification.
able Cook Doppler may be helpful during inset to ensure
that the closure is not compressing the venous outflow. It
is always better to leave portions of the defect open if the
closure is too tight and compressing the pedicle. With the
advent of imaging systems such as SPY (Novadaq), cutaneous
tissue perfusion can easily be assessed; if questionable, the
time to intervene is in the operating room. The application
of proper dressings and splints is important at the end of the
procedure; dressings should be loose with very light com­
pression and splint immobilization to prevent motion but
not compress the microvascular anastomosis or flap itself.
Positional tension and edema can also occur postopera­
tively during dangling or mobility. Institution of a dangling
protocol is important to allow the venous outflow to equili­
brate and allow for dependent high flow.18,19 In general pa­
tients maintain leg elevation for 5 to 7 days before starting a
dangling protocol. Pressure off-loading, limb elevation, and
continuous flap monitoring in the early postoperative pe­
riod and during dangling protocol are important consider­
ations (Fig. 58.2). Hematomas and fluid collections should
be drained in a timely manner to avoid flap compromise.
Trauma
Trauma is a common presentation requiring lower extrem­
ity reconstruction. Trauma victims are generally young and
a
b
c
Fig. 58.2 Prolonged dangling leading to signs of venous congestion. (a) Free anterolateral thigh flap for coverage of a tibial fracture.
(b) Dangling began on postoperative day 3 without compression. Venous congestion is visible. (c) After stopping the dangling protocol
and restarting a couple of days later, the flap is well healed without adverse sequelae.

1089
Chapter 58 Lower Extremity Reconstruction
make the decision to salvage or amputate the injured
limb. The Mangled Extremity Severity Score (MESS) and
Nerve Injury/Ischemia/Soft tissue/Skeletal Injury/Shock/
Age (NISSSA) score are useful scoring systems that help
the surgical team make decisions about limb salvage ver­
sus amputation.22–24 (Tables 58.1 and 58.2). For example,
a MESS of 7 to 10 has been generally proposed to predict
amputation.23 However, current injury scoring systems
should be used as a guide in management, because they
have not been shown to correlate well with eventual func­
tional recovery after limb salvage.25 In a recent systematic
review of some of these scoring systems (MESS, the Limb
Salvage Index [LSI], the Predictive Salvage Index [PSI], and
the Gustilo-Anderson scoring system), a good correlation
between MESS and amputation rate was found in only
25% of published data.25 Ultimately, sound clinical judg­
ment and a multidisciplinary team approach considering
the patient’s limb injury severity, systemic factors, social
factors, rehabilitation potential, and functional recovery
CTA is also valuable in assessing variable vascular anatomy
and in preoperative planning for recipient vessel selection for
free tissue transfer.21 Specialized monitoring systems such
as measurement of intracompartmental pressures and the
performance of fasciotomies in a timely fashion are often
required. Careful examination under anesthesia and serial
assessment of limb perfusion and wound débridement can
better delineate the damaged structures and the final defect
to be reconstructed. In hemodynamically unstable patients,
definitive reconstruction should be delayed and the wound
should be temporized. Fracture reduction, wound débride­
ment, and wound vacuum-assisted closure may be required.
Amputation versus Salvage
The plastic surgeon plays an integral role along with the
orthopedic surgeon in providing insight and expertise on
reconstructive options for lower extremity wounds. Sev­
eral scoring systems have been proposed to help surgeons
Table 58.1 Mangled Extremity Severity Score (MESS) scoring system
Variable
Points
Skeletal/soft tissue injury
Low energy (stab; simple fracture; civilian gunshot wound)
1
Medium energy (open or multiple fracture, dislocation)
2
High energy (close-range shotgun or military gunshot wound, crush injury)
3
Very high energy (above criteria plus gross contamination, soft tissue avulsion)
4
Limb ischemia
Pulse reduced or absent but normal perfusion
1*
Pulseless, paresthesias, diminished capillary refill
2*
Cool, paralyzed, insensate, numb
3*
Shock
Systolic blood pressure always > 90 mm Hg
0
Transient hypotension
1
Persistent hypotension
2
Age
Younger than 30 years of age
0
Between 30 and 50 years of age
1
Older than 50 years of age
2
*Score doubled for ischemia time longer than 6 hours.
Source: From McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extrem­
ity Severity Score (MESS). J Orthop Trauma 1994;8(2):81–87.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1090
anatomically complete disruption of the posterior tibial
nerve in adults, multilevel trauma to the limb with life-
threatening injuries, and crush injury with warm isch­
emia for longer than 6 hours27–29 (Fig. 58.3, Box 58.1).
Oncologic Defects
Preoperative consultation with the reconstructive surgeon,
appropriate preoperative imaging, and multidisciplinary
planning is critical in dealing with oncologic defects of
should dictate limb salvage or primary amputation.26
Every lower extremity trauma is unique and should be
treated accordingly. The main indications for limb sal­
vage include any limb injury in a child and adults with
bony and soft tissue loss with intact sensation. In some
instances, however, determining limb sensibility is diffi­
cult in the acute setting. In such a scenario, débridement,
vascular reconstruction, and bony fixation are indicated
until definitive insensibility is confirmed. Considerations
for primary amputation of open tibial fractures include
Table 58.2 The Nerve Injury, Ischemia, Soft Tissue, Skeletal Injury/Shock/Age
(NISSSA) scoring system
Type of injury
Degree of injury
Points
Description
Nerve injury (N)
Sensate
Dorsal
Plantar partial
Plantar complete
0
1
2
3
No major nerve injury
Deep or superficial peroneal nerve, femoral nerve injury
Tibial nerve injurya
Sciatic nerve injurya
Ischemia (I)
None
Mild
Moderate
Severe
0
1b
2b
3b
Good to fair pulses, no ischemia
Reduced pulses, prolonged capillary refill, Doppler pulses
present
No pulses, prolonged capillary refill, Doppler pulses present
Pulseless, cool, ischemic, no Doppler pulses
Soft tissue/
contamination (S)
Low
Medium
High
Severe
0
1
2
3
Minimal to no soft tissue contusion, no contamination (Gustilo
type 1)
Moderate soft tissue injury, low-velocity gunshot wound,
moderate contamination, minimal crust (Gustilo type 2)
Moderate crush, degloving, low-velocity gunshot wound,
moderate soft tissue injury, may require soft tissue flap,
considerable contamination
Massive crush, farm injury, severe degloving, severe
contamination, requires soft tissue flap (Gustilo type 3B)
Skeletal
Low energy
Medium energy
High energy
0
1
2
Spiral fracture, oblique fracture, no or minimal displacement
Transverse fracture, minimal comminution, small-caliber
gunshot wound
Moderate displacement, moderate comminution, high-velocity
gunshot wound, butterfly fragments
Shock (S)
Normotensive
Transient
hypotension
Persistent
hypotension
0
1
2
Blood pressure normal, always greater than 90 mm Hg systolic
Transient hypotension in field or emergency center
Persistent hypotension despite fluids
Age (A)
Young
Middle
Old
0
1
2
Younger than 30 years of age
Between 30 and 50 years of age
Older than 50 years of age
Total score = (N+I+S+S+S+A)
aNerve injury as assessed primarily in the emergency room.
bScore doubles with ischemia greater than 6 hours.
Source: From McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extrem­
ity Severity Score (MESS). J Orthop Trauma 1994;8(2):81–87.

1091
Chapter 58 Lower Extremity Reconstruction
a
b
c
d
e
f
g
Fig. 58.3 Forefoot reconstruction using local flap options. This 47-year-old man sustained a crush injury to his right foot that resulted in
multiple fractures of the metatarsals and phalanges. (a,b) After the area of soft tissue necrosis in the forefoot and midfoot had fully de­
marcated, he underwent débridement. (c) After partial amputation and wound vacuum therapy. Additional shortening of the proximal
phalanx of the great toe was performed. The metatarsophalangeal joint was preserved and the flexor hallucis brevis muscle attachment was
maintained to allow for a stable sesamoid–plantar–foot complex. The third and fourth metatarsal necks were further shortened. (d,e) Lo­
cal tissue with overlying granulation were elevated to the cover stumps of the first digit proximal phalanx and second and third metatarsal
bone stumps, and the plantar skin was advanced dorsally. (f,g) Early postoperative result after skin grafting. A free flap was not necessary.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1092
ity tumor reconstruction are similar to those of trauma
reconstruction with certain caveats. In tumor reconstruc­
tion, neoadjuvant chemotherapy or radiotherapy may be
required; in such instances delaying the reconstruction to
allow recovery of the tissues from acute radiation injury
can be considered. Considering the radiation zone of injury
to the local tissues and recipient vessels will impact flap
selection and reconstruction. Neoadjuvant irradiation has
not been shown to increase acute wound or microvascular
complications when combined with free flap reconstruc­
tion and is associated with fewer late recipient-site compli­
cations than adjuvant irradiation.30 Radiated tissues within
the wound bed should be replaced with healthy tissues,
and sometimes this requires very large flaps (Fig. 58.4). If
radiated tissue is left behind, there is a high likelihood that
healing will be compromised. Providing durable and pre­
dictable reconstruction is critical to allow for wound heal­
ing and adjuvant chemotherapy, radiotherapy, or both for
locoregional control. Final tumor margins should be con­
firmed before definitive coverage. A short period of tempo­
rary coverage may be needed in certain tumor types until
permanent pathologic margins are confirmed, and only
then is definitive coverage warranted. Patients with cancer
are often malnourished. Nutritional markers such as trans­
ferrin, albumin, and prealbumin are useful in determining
the need for supplemental nutrition before reconstructive
surgery.
the lower extremity. Most lower extremity oncologic re­
sections are electively scheduled, which allows time for
assembling the appropriate team, whether this involves
skeletal or vascular reconstruction, soft tissue coverage,
or a combination of these. The objectives of lower extrem­
Box 58.1
Absolute
•• Posterior tibial nerve transection in adults
•• Crush injury with warm ischemia > 6 hours
•• Total leg amputation in adults
•• Nonreparable devascularization
Relative
•• Life-threatening multisystem trauma
•• Severe ipsilateral foot trauma
•• Unable to rehabilitate
•• Elderly with previous history of advanced
diabetes and/or peripheral vascular disease
Indications for Lower
Extremity Amputation
Source: From Pu Lee LQ, Levine JP, Wei FC. Overview of lower extremity
reconstruction. In: Pu LQ, Levine JP, Wei FC, eds. Reconstructive Surgery
of the Lower Extremity. St Louis, MO: CRC Press, 2013.
a
b
Fig. 58.4 A nonhealing medial defect in a patient after radiation for osteosarcoma. (a) Preoperative view of the nonhealing ulcer in a radi­
ated field. The radiated skin is marked. (b) The ulcer was débrided.
Continued

1093
Chapter 58 Lower Extremity Reconstruction
c
d
e
f
g
h
Fig. 58.4, cont’d (c) A free anterolateral thigh flap was performed to cover this area; however, the radiation injury extended dorsally and
proximally. (d) The patient developed a small nonhealing area along the medial side of the flap near the radiated tissue. (e) This defect
became infected and required further débridement. (f,g) A free latissimus muscle flap was performed to cover the entire radiated field.
(h) Six months postoperative view showing a healed wound after a latissimus dorsi flap and a skin graft.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
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posterior tibial, and peroneal arteries. Any patient with a
history of peripheral vascular disease or abnormal Doppler
foot examinations should undergo a consultation by vascu­
lar surgery and, if needed, restoration of vascular inflow by
interventional or open vascular procedures before defini­
tive flap reconstruction.
Osteomyelitis must be adequately débrided and culture-
directed antimicrobial therapy instituted by infectious dis­
ease specialists. Antibiotic-impregnated beads or cement are
useful adjuncts to systemic therapy to fill and sterilize empty
spaces after débridement; these are typically removed in
2 to 4 weeks.35 In chronic osteomyelitis, a two-stage ap­
proach may be required. Adequate débridement of in­
fected bone and soft tissues is needed first. In some in­
stances when bony continuity is disrupted, placement of
an external fixator may be required. Definitive soft tissue
and bony reconstruction is undertaken after the infection
has been controlled. The patient and caregivers should be
counseled about the need for multiple procedures and the
relatively prolonged recovery necessary. Even after success­
ful reconstruction, late osteomyelitis may develop that ulti­
mately leads to amputation (Fig. 58.6). Patients with lower
­extremity lymphedema should receive aggressive deconges­
Infectious, Diabetic, Vascular, or
Lymphatic Wounds
Patients with infectious, diabetic, vascular, or lymphatic
wounds pose special challenges in lower extremity re­
construction due to the tendency for wound recurrence.
Unlike acute traumatic wounds in younger and healthier
patients, successful reconstruction in these patients can
only be achieved after appropriate multidisciplinary
management of the underlying systemic causes. A multi­
disciplinary team approach to diabetic foot wounds with
plastic surgery, orthopedics or podiatry, vascular surgery,
infectious disease, internal medicine, pedorthotists, and
prosthetists has been shown to decrease major amputa­
tion rates.31–33 Optimal diabetes control (hemoglobin A1C
< 7%), effective wound débridement and care, control of
infection, pressure-relieving strategies such as specialized
orthotic shoes, and lifestyle changes are necessary for a
successful reconstruction.34 Biomechanical correction of
abnormal foot alignment and gait must be corrected before
reconstruction (Fig. 58.5). All patients undergoing lower
extremity reconstruction should be evaluated with preop­
erative pencil Doppler examination at the anterior tibial,
a
b
c
Fig. 58.5 Failure to recognize and correct gait abnormality before reconstruction in a patient with diabetes with a chronic heel ulcer.
(a) Preoperative view of the recalcitrant heel ulcer. (b) A free anterolateral thigh flap was performed for closure. (c) The patient presented to
the clinic 3 months after flap closure with a large defect related to pressure from calcaneal gait, which was unrecognized before flap closure.

1095
Chapter 58 Lower Extremity Reconstruction
studies and further research will help define proper surgi­
cal treatment algorithms using lymphaticovenous bypass
or vascularized lymph node transfers for the affected limb.
tive therapy or surgical lymphatic reconstruction when fea­
sible.36 Although long-term studies on surgical management
of lymphedema are lacking, promising outcomes from early
a
b
c
d
Fig. 58.6 Medial ankle defect with tibial osteomyelitis from previous tibial fracture infection. (a) Preoperative image with a polymethyl­
methacrylate antibiotic implant placed in the bony defect after tibial débridement. (b) A radiograph showing a large defect in the tibia.
(c) A free gracilis flap and skin graft was used for soft tissue reconstruction. (d) The patient presented 4 months after a healed flap with
cellulitis and infection requiring amputation because of persistent infection.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1096
Thigh
When sufficient local tissues are present, primary closure
or local tissue rearrangement may be sufficient. Indica­
tions for soft tissue coverage include an exposed femoral
neurovascular bundle, infected vascular grafts, and large
Reconstruction of Lower Extremity
Defects by Anatomic Level
From a reconstructive perspective, the lower extremity is
subdivided into upper, middle, and lower anatomic thirds
to help guide with reconstructive options (Fig. 58.7).
Femoral neurovascular bundle
• Sartorius
• Rectus femoris
• Gracilis
• Anterolateral thigh flap
or vastus lateralis
• Rectus abdominus
• Free flap
Upper third tibia
• Medial/lateral gastrocnemius flap
• Pedicled MSAP
Middle third tibia
• Soleus
• Pedicled perforator flaps (peroneal/posterior tibial artery)
• Free flap
Lower third tibia
• Pedicled perforator flaps (peroneal/posterior tibial artery,
anterior tibila artery)
• Reverse sural
• Free flap
Medial/lateral malleolus
• Pedicled perforator flaps
(supramalleolar or posterior
tibial artery)
• Reverse sural
• Free flap
Dorsal foot
• Supramalleolar flap
• Free flap
Knee
• Medial/lateral gastrocnemius flap
• Reverse anterolateral thigh flap
• Pedicled medial sural artery perforator flap (MSAP)
Fig. 58.7 Reconstruction of the lower extremity by regions, showing the different types of flaps used for each region.
Continued

1097
Chapter 58 Lower Extremity Reconstruction
this muscle from the superficial femoral artery system,
because often this vessel is diseased and being bypassed.
If the sartorius muscle is an available option, however, it
can provide coverage for small groin defects. Critical to the
success of the sartorius muscle flap is identification of the
perforators supplying the muscle. This allows the surgeon
soft tissue defects after oncologic resection or extensive
débridement of devitalized tissues. Common local mus­
cle flaps include the sartorius, gracilis, or rectus femoris
muscle. The sartorius muscle is slender and often has been
sacrificed or is unavailable from previous vascular proce­
dures. It is important to assess adequate blood supply to
Achilles tendon
• Pedicled perforator flaps
(supramalleolar or posterior
tibial artery)
• Reverse sural
• Free flap (anterolateral thigh)
or TFL
Hindfoot (heel)
• Medial plantar artery flap
• Lateral calcaneal artery flap
• Free flap
Plantar forefoot
• V-Y medial plantar artery flap
• Free flap
Fig. 58.7, cont’d Reconstruction of the lower extremity by regions, showing the different types of flaps used for each region.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1098
cluded because of injury in high-energy trauma. In such in­
stances, free flap reconstruction is preferred. Microvascular
anastomosis should be performed proximal to the zone of
injury when possible.39 The need for vein grafts or arterio­
venous loop should be planned. The anterolateral thigh flap
and gracilis flap (when a long pedicle is not required) are
often used for this purpose. The latissimus dorsi muscle
is used when a long pedicle is needed and/or the defect is
large. Even though the rectus abdominis muscle provides a
thin flap with a long pedicle, it is avoided due to the donor
site morbidity. End-to-end microvascular anastomosis into
the anterior tibial, posterior tibial, or peroneal vessels is ac­
ceptable when adequate collateral runoff to the distal leg is
confirmed. However, when the posterior tibial vessels are
used, an end-to-side anastomosis is preferred.
Middle Tibial Third
The soleus muscle is the primary local muscle flap for re­
constructing the middle third of the leg. For smaller defects,
propeller flaps based on the posterior tibial artery and pe­
roneal artery are used. For larger defects, a free gracilis
muscle, ALT flap or latissimus dorsi muscle are preferred.
Distal Tibial Third
Pedicled perforator flaps or “propeller” flaps based on the
peroneal and posterior tibial artery can be useful in cov­
erage of smaller defects. However, these flaps are often
fraught with a high partial necrosis rate (more than 11%)
and complication rates (more than 25%).7 The surgeon’s
experience and the clinical context should dictate which
reconstructive modality is best suited for the patient. The
reverse sural artery adipofascial flap is useful in coverage
of lateral ankle and foot wounds. Poor venous outflow and
high partial flap necrosis rates have been reported.40 To cir­
cumvent this problem, especially in elderly patients with
other comorbidities, a flap delay or supercharging the lesser
saphenous vein to a superficial vein are recommended to
minimize venous congestion (Fig. 58.9). It is important to
consider function when selecting the appropriate flap for
lower extremity reconstruction. Simply providing coverage
to the wound without regard to function will yield subop­
timal results. Functional muscle transfer or tendon recon­
struction may be necessary when determining the ideal
flap choice (Fig. 58.10).
to avoid scarifying more than the number of perforators
necessary to mobilize the muscle. The rectus femoris is our
workhorse flap for coverage of larger groin soft tissue de­
fects and coverage of vascular grafts. The muscle is easily
elevated and is supplied by the profunda femoris system.
Knee
The medial and lateral gastrocnemius muscles are impor­
tant flaps for knee and proximal tibial wound coverage.
Disinserting the muscle’s insertion on the distal femur
can extend the reach of this flap to the patella and supra­
patellar area. Scoring the muscle fascia will also help fur­
ther extend flap reach as well. When the gastrocnemius
muscle is not available, the reverse anterolateral thigh flap
or vastus lateralis flap can be used based on retrograde
flow to the descending branch of the lateral circumflex
femoral artery through the profunda system or the lateral
superior genicular system. Supercharging the vein of the
reverse anterolateral thigh flap is often necessary to en­
sure complete survival of the flap.37,38 Another alternative
is the lateral genicular artery flap based on a perforating
branch of the superior lateral genicular artery. When local
flap options are not available, a free flap anastomosed to
branches of the popliteal artery, such as the sural arter­
ies or superior, inferior, or middle genicular arteries, or
anastomosed to branches of the profunda, such as the de­
scending branch of the lateral circumflex femoral artery,
can be used (Fig. 58.8).
Tibial Region
Because of the limited soft tissue laxity in the lower leg,
local tissue options are often limited and may be com­
promised. This, however, should not compromise the ad­
equacy of the débridement or oncologic resection. Free flap
reconstruction can circumvent this problem by providing
well-vascularized tissue for coverage of large wounds in a
hostile bed.
Upper Tibial Third
Like the knee, the proximal third of the leg can be recon­
structed with the medial or lateral gastrocnemius muscle
flaps. The soleus muscle can reach the lower end of upper-
third tibial defects. Often, local muscle flaps may be pre­

1099
Chapter 58 Lower Extremity Reconstruction
a
b
c
d
e
Fig. 58.8 A prosthetic knee joint infection resulting in failed reconstruction related to persistent osteomyelitis. Medial ankle defect with
tibial osteomyelitis from previous tibial fracture infection. (a) This 52-year-old man with nicotine dependence and a history of alcohol
abuse presented with a several day history of an infected and draining left knee arthroplasty. (b) After initial débridement, irrigation, and
resection arthroplasty, an antibiotic cement spacer was placed and wound vacuum-assisted closure (VAC) was initiated. (c,d) After serial
débridements, wash out, and wound VAC, the antibiotic spacer was replaced with antibiotic cement–coated interlocking intramedullary
nails. The prosthesis was covered with a medial gastrocnemius flap and skin graft. (e) Three months postoperatively, despite successful soft
tissue coverage of the antibiotic spacer, a draining fistula tracking into the knee joint developed, with elevated erythrocyte sedimentation
rate and other radiological studies indicating chronic osteomyelitis. This patient eventually required amputation for recalcitrant infection.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1100
a
b
c
d
e
f
g
h
Fig. 58.9 Failure of local flap reconstruction of the distal leg requiring salvage with a free flap. (a) This 47-year-old man had nonunion of
a right calcaneal fracture. He underwent bone grafting and internal fixation. A 2-cm by 9-cm lateral ankle soft tissue defect with exposed
hardware warranted coverage. (b) A reverse sural artery was designed with a pivot point 5 cm superior to the lateral malleolus. (c,d) The
reverse sural flap was elevated in a standard fashion and turned clockwise to cover the defect. (e) The adipofascial tissue carrying the pedicle
was covered with a split-thickness skin graft. (f) On postoperative day 7 exhibited venous congestion. (g) The flap was débrided and (h) the
wound was reconstructed with a free gracilis muscle flap and a skin graft.

1101
Chapter 58 Lower Extremity Reconstruction
a
b
c
d
e
f
g
Fig. 58.10 The importance of considering functional and coverage requirements in lower extremity reconstruction. (a) This 52-year-old
woman presented with a lower extremity wound over the calcaneus and a ruptured Achilles tendon. (b) After serial wound débridements,
culture-directed antibiotic therapy, and vacuum-assisted closure. (c,d) The wound was reconstructed with an anterolateral thigh flap and
TFL fascia. The anterolateral thigh flap was elevated based on a single dominant perforator. The flap was harvested with a cuff of tensor
fascia lata for functional Achilles tendon reconstruction. The fascial cuff is rolled to strengthen the repair. (f,g) At 2 months postoperatively
the wound has healed, with a bulky flap and good plantar flexion. Thinning of the flap in the primary setting would have helped the bulk
issue. The patient was not interested in a debulking procedure.

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1102
anterolateral thigh flap, and the lateral arm flap. The an­
terolateral thigh flap may require debulking if subcutane­
ous tissue thickness is excessive. The medial plantar artery
flap is an ideal local option for plantar heel defects when
available (Fig. 58.11).
Managing Unfavorable Results
and Complications in Lower
Extremity Reconstruction
Reconstructive failures do occur, and the reconstructive
surgeon is often faced with managing unfavorable out­
comes (Box 58.2). It is important to recognize and be pre­
pared to manage potential complications in a timely fash­
ion. Informed consent is an integral part of educating the
patient about the reconstructive journey and sets the stage
for establishing a trusting patient–doctor relationship and
realistic expectations.
Foot
The dorsum of the foot is a low functional unit but requires
higher aesthetic consideration compared with the plantar
surface. Conversely, the plantar surface is of lower aesthetic
importance but higher functional requirements for walk­
ing and withstanding shearing forces. Soft tissue coverage
of the foot requires pliable and thin tissues with minimal
bulk for shoe fitting. Simple techniques with use of Integra
or other bioengineered dermal substitutes to cover tendon
with later skin grafting provide good aesthetic and func­
tional outcomes. Muscle flaps with skin graft provide a du­
rable nonshearing surface; good choices include the gracilis
muscle, vastus lateralis, latissimus dorsi, and others. Fas­
ciocutaneous flaps, on the other hand, provide superior
cosmetic appearance but are of poorer quality for plantar
reconstruction because of the lack of dense connective tis­
sues native to the plantar aspect of the foot.41 Fasciocuta­
neous flap options include the radial forearm free flap, the
a
b
c
Fig. 58.11 Inappropriate flap design and choice. (a) This 62-year-old man sustained a crush injury to his forefoot. The wound was débrided
and allowed to demarcate. Antibiotic beads were placed; after serial débridement and bony fixation of the metatarsal bone fractures, ten­
don, hardware, and bony coverage were required. (b,c) Result 5 months after reconstruction with an anterolateral thigh myocutaneous flap.
A small cuff of vastus lateralis muscle was harvested with the skin paddle based on two perforators, and the rest of the muscle and defect
were covered with a skin graft. Better flap design and selection and primary debulking could have prevented this bulkiness. A suprafascial
harvest would have provided a thinner flap and lessened the need for secondary debulking procedures.

1103
Chapter 58 Lower Extremity Reconstruction
When free flap failure occurs, prolonged healing and
hospital stay, adverse functional and cosmetic morbidities,
and increased health care costs ensue. The patient and the
surgeon should be prepared to deal with this challenging
situation.
Managing Local Flap Complications
Total flap loss after local flap reconstruction is uncommon,
but partial flap necrosis is commonly encountered in clini­
cal practice (Fig. 58.12). Overall complication rates after lo­
cal or regional flap reconstruction were estimated at 18% in
one long-term study.42 This was usually related to unrec­
ognized injury to local muscles such as the gastrocnemius
or soleus muscle. When the suspected zone of injury en­
compasses these muscles, judicious planning is important
Box 58.2
•• Improper wound assessment or
underassessment of the zone of injury and
vessel suitability
•• Inadequate débridement leading to infection or
osteomyelitis
•• Venous insufficiency or arterial thrombosis
•• Fracture nonunion
•• Improper flap selection or design
•• Poor decision-making regarding primary
amputation versus salvage of the injured limb
Most Common Problems
in Lower Extremity
Reconstruction
a
b
c
d
e
Fig. 58.12 Partial failure of a free flap reconstruction and successful management with secondary wound healing. This case demonstrates
marginal necrosis of a free superficial circumflex iliac artery (SCIP) flap to the foot. (a) This young patient suffered an injury to the medial
aspect of the foot, creating a defect with an exposed metatarsopharyngeal joint. (b–d) A free SCIP flap was used to reconstruct the defect.
(e) The flap underwent partial necrosis.
Continued

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1104
consider changing the microsurgical strategy when ap­
propriate.43
A complete free flap loss is a disappointment to the sur­
geon and the patient. The first step in managing this prob­
lem is accurate assessment of the cause of the thrombosis.
When vascular compromise is suspected, prompt explo­
ration with a low threshold for returning to the operating
room is warranted. Nonsurgical venous salvage methods
such as leeching should only be used if surgical revision is
not feasible or fails. Early recognition and intervention is
more likely to salvage the flap. This is more evident in arte­
rial thrombotic complications. During the exploration, at­
tention should be directed to the vascular pedicle, looking
to avoid a failed local reconstruction. If a local muscle flap
has failed, many times the next best option is free tissue
transfer. If pedicled local fasciocutaneous flaps have failed,
the options are excision of marginal necrosis and flap read­
vancement or consideration of other local or free flap re­
construction.
Managing Free Flap Loss
When managing a free flap failure the surgeon should
reevaluate the need for vascularized free tissue transfer,
use a sensitive psychosocial approach to the patient and
family, analyze the cause of the first free flap failure and
f
g
h
i
j
Fig. 58.12, cont’d (f,g) The viable parts of the flap were advanced to cover the critical structures, and a skin graft was used to cover the
remaining part of the defect. (h,i) The foot defect went on to heal. (j) Donor site of the SCIP flap.

1105
Chapter 58 Lower Extremity Reconstruction
tracture release, functional muscle transfer, and physical
therapy.
Conclusion
The field of lower extremity reconstruction is multidisci­
plinary and continues to evolve. Today’s limb salvage rates
and reconstructive outcomes are significantly improved
over those of 20 years ago, thanks to the resiliency of the
founding fathers of microsurgery, improved imaging and
diagnostic methods, and wound care. The treating team
should decide on limb salvage versus amputation on a case-
by-case basis. Caring for complex lower extremity wounds
is better suited for centers of excellence with a multidisci­
plinary system approach, microsurgical expertise, and high
surgical volume. Having alternative plans of action, should
the primary reconstructive modality fail, is an integral part
of everyday reconstructive surgery practice. It is important
for surgeons to learn from their failures to prevent flap
losses and unfavorable outcomes. The field of bioprosthet­
ics is rapidly evolving and will likely have a significant im­
pact on lower limb salvage and reconstruction in the next
20 years. Lastly, composite vascularized tissue allotrans­
plantation is in its infancy. The development of new immu­
nosuppressive drugs and advanced protocols will help offer
patients and reconstructive surgeons viable alternatives to
today’s traditional reconstructive methods.
for kinking, twisting, or extrinsic compression from a hema­
toma. Limb venous disease such as DVT or venous refluxing
should be assessed as possible causes of flap failure.
If no technical issue is found, a complete hypercoagu­
lable workup and hematology consultation must be per­
formed before embarking on a second free flap.44–46 Other
rare medical conditions such as heparin-induced throm­
bocytopenia syndrome should be considered. Hypercoagu­
lability should be suspected in patients with early arterial
thrombosis, because arterial thrombosis is much less likely
than venous thrombosis. If a medical cause is discovered
for free flap loss, and local flap options are available, local
flap reconstruction should be considered before a second
free flap (Fig. 58.13). Use of functional amputation such as
a Symes, midfoot amputation, or below-the-knee amputa­
tion should be considered in patients who are medically ill
and cannot undergo a second free flap or when local flaps
are not available.
Other Complications
Other common complications of lower limb reconstruc­
tion include infection, nonunion, and osteomyelitis. Ag­
gressive débridement, use of antibiotic-impregnated
spacer or beads, and culture-specific antibiotics are re­
quired before salvage reconstruction. Increased flap bulk
and contractures can be managed by flap debulking, con­
a
b
c
d
Fig. 58.13 Lateral ankle defect with exposed fibula and peroneal tendons. (a) Preoperatively. (b) A free gracilis flap was performed; how­
ever, the patient developed HIT syndrome and the flap underwent thrombosis and was unable to be salvaged. (c) Local muscles were used
to close over the bone, and Integra dermal substance was used to cover exposed tendons. (d) Split-thickness skin grafting was used, and
the patient went on to heal uneventfully.

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lower extremity distal to the zone of injury: indications
and outcomes over a 25-year experience. Plast Reconstr
Surg 2007;120(4):952–959
11. Tsai YT, Lin TS. The suitability of end-to-side microvascu­
lar anastomosis in free flap transfer for limb reconstruc­
tion. Ann Plast Surg 2012;68(2):171–174
12. Cho EH, Garcia RM, Blau J, et al. Microvascular anasto­
moses using end-to-end versus end-to-side technique in
lower extremity free tissue transfer. J Reconstr Microsurg
2016;32(2):114–120
13. Chang EI, Nguyen AT, Hughes JK, et al. Optimization of
free-flap limb salvage and maximizing function and qual­
ity of life following oncologic resection: 12-year experi­
ence. Ann Surg Oncol 2016;23(3):1036–1043
14. Chen KT, Mardini S, Chuang DC, et al. Timing of presenta­
tion of the first signs of vascular compromise dictates the
salvage outcome of free flap transfers. Plast Reconstr Surg
2007;120(1):187–195
15. Lorenzo AR, Lin CH, Lin CH, et al. Selection of the recipi­
ent vein in microvascular flap reconstruction of the lower
extremity: analysis of 362 free-tissue transfers. J Plast Re­
constr Aesthet Surg 2011;64(5):649–655
16. Kim SY, Lee KT, Mun GH. Postoperative venous insuf­
ficiency in microsurgical lower extremity reconstruc­
tion and deep vein thrombosis potential as assessed
by a caprini risk assessment model. Plast Reconstr Surg
2015;136(5):1094–1102

1107
Chapter 58 Lower Extremity Reconstruction
ous flap in distal leg reconstruction. Plast Reconstr Surg
2009;123(5):1499–1504
41. Hollenbeck ST, Toranto JD, Taylor BJ, et al. Perineal and
lower extremity reconstruction. Plast Reconstr Surg
2011;128(5):551e–563e
42. Pinsolle V, Reau AF, Pelissier P, Martin D, Baudet J. Soft-
tissue reconstruction of the distal lower leg and foot: are
free flaps the only choice? Review of 215 cases. J Plast Re­
constr Aesthet Surg 2006;59(9):912–917, discussion 918
43. Baumeister S, Follmar KE, Zenn MR, Erdmann D, Levin LS.
Strategy for reoperative free flaps after failure of a first
flap. Plast Reconstr Surg 2008;122(3):962–971
44. Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the
hypercoagulable state: a hematologist’s perspective. Plast
Reconstr Surg 2015;136(4):545e–552e
45. Davison SP, Kessler CM, Al-Attar A. Microvascular free flap
failure caused by unrecognized hypercoagulability. Plast
Reconstr Surg 2009;124(2):490–495
46. DeFazio MV, Hung RW, Han KD, Bunting HA, Evans KK.
Lower extremity flap salvage in thrombophilic patients:
managing expectations in the setting of microvascular
thrombosis. J Reconstr Microsurg 2016;32(6):431–444
34. Yan H, Yang M, Lineaweaver WC, Myers RS, Chen H, Zhang
F. Flap reconstruction of distal lower extremity wounds
in diabetic patients. Ann Plast Surg 2011;67(4):426–428
35. Diefenbeck M, Mückley T, Hofmann GO. Prophylaxis and
treatment of implant-related infections by local applica­
tion of antibiotics. Injury 2006;37(Suppl 2):S95–S104
36. Cormier JN, Rourke L, Crosby M, Chang D, Armer J. The
surgical treatment of lymphedema: a systematic review
of the contemporary literature (2004-2010). Ann Surg
Oncol 2012;19(2):642–651
37. Lin CH, Hsu CC, Lin CH, Chen YC, Wei FC. Antegrade ve­
nous drainage in a reverse-flow anterolateral thigh flap.
Plast Reconstr Surg 2009;124(5):273e–274e
38. Lin CH, Zelken J, Hsu CC, Lin CH, Wei FC. The distally
based, venous supercharged anterolateral thigh flap. Mi­
crosurgery 2016;36(1):20–28
39. Kolker AR, Kasabian AK, Karp NS, Gottlieb JJ. Fate of free
flap microanastomosis distal to the zone of injury in lower
extremity trauma. Plast Reconstr Surg 1997;99(4):1068–
1073
40. Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE,
Orgill DP. Risk analysis for the reverse sural fasciocutane­
Discussion by L. Scott Levin
The concepts of careful preoperative planning based on
wound assessment, reconstructive needs, and patient
characteristics are important to avoid reconstructive
failure.
Lower extremity reconstruction is traditionally co­
ordinated between orthopaedics and plastic surgeons.
The so-called orthoplastic approach applies principles
and practices of both orthopaedic and plastic surgery
to clinical problems simultaneously.1–3
Plastic surgeons are often called upon to help
with the management of problematic lower extrem­
ity wounds; however, often the response from a plas­
tic surgeon—particularly those who are uncomfortable
with a microsurgical approach, who are unwilling to
treat a patient because of financial reasons, or who
have a busy cosmetic practice will often suggest care
solutions that are inadequate and often prolong mor­
bidity and hospitalization and increase costs. For this
reason it is essential that physicians from orthopaedics
departments and plastic surgery be trained in complex
microsurgical reconstruction and practice in environ­
ments where there is adequate volume to maintain
skills and to make a living.
Historically, more than 30 years ago the late surgeon
Marko Godina introduced the concept of emergency free
flap. This is only required in rare occasions, such as in
the creation of a fillet free flap of an extremity that is not
suitable for replantation. Although we rarely use emer­
gency free flaps, early coverage has been shown to be
optimal after trauma.4
The Reconstruction Team
The lower extremity team should include psychia­
trists and pain management physicians who can help
the patient cope with limb salvage or limb loss. Recent
military experience suggests that amputees can serve
as patient advocates for trauma patients who are con­
sidering amputation either early or late in their post­
traumatic course.
Anesthesiologists
In terms of communication with other services, the ex­
tremity care team not only should communicate with
the anesthesiologists, but should have anesthesiolo­

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1108
gists familiar with regional blocks and advanced proto­
cols for postoperative pain management.
Podiatry
I do not engage or rely on podiatrists for any reconstruc­
tive needs of the lower extremity. I direct patients to a
podiatrist for nail care and callous trimming. In addition,
they may be helpful in cases of plantar skin care after
free tissue transfer to the sole of the foot. Independent
of whether a muscle or skin flap is used, the modulus of
elasticity and the histology of any free flap is different
than the plantar glabrous skin that contains vertically
oriented septae and compartments of fat. This septae
and fat act as a shock absorber during heel-strike and
toe-off during a gait cycle. Because of this, disparity of
the native tissue to the flap fissuring or callous forma­
tion can occur that may benefit from podiatric input.
Patient Selection
Patient selection includes all of the factors listed but
should also include a history of drug dependency, par­
ticularly since the medical field is trying to decrease
opiate consumption in patients after elective surgery.
One of the most important lessons learned in lower
extremity reconstruction, particularly in the care of a
patient with osteomyelitis, is that the treating surgeon
should enter into a contract with the patient. A defined
time should be determined for how long it will take for
the patient to achieve full function. In the case of chronic
osteomyelitis, the requirements for free transfer and sub­
sequent intercalary bone reconstruction can take weeks
or months, particularly if distraction osteogenesis is used
for bone reconstruction. Defining patient expectations is
important. A surgeon should inform the patient that a
failure can occur and amputation should be considered.
Use of Scoring Systems
In terms of amputation versus salvage, despite a great
deal of literature on scoring systems, they are not
used in my practice. Classifications are used to com­
pare similar patient groups, and I have not found them
helpful in lower extremity reconstruction. Combining
techniques such as the Ilizarov and microsurgery has
resulted in limbs being saved that according to referred
scoring systems would have been amputated.
Although posterior tibial nerve transection in an
adult is a relative indication for limitation, I caution
trauma teams and reconstructive teams on initial in­
sensibility as a criterion for amputation. In fact, there
can be profound neuropraxia in a high energy injury
and subsequent recovery of some nerve function up to
2 to 3 years after the trauma. Many individuals with
diabetes with peripheral neuropathy have no sensibil­
ity and yet can avoid ulceration with proper shoes and
daily skin surveillance.
Avoiding Failure in Free Tissue
Transfer
Preoperative Considerations
When a patient is referred, the first question the sur­
geon must ask is, “Does the patient need a free flap?” If
so, the surgeon should consider these questions:
•• What is the plan?
•• What is the backup plan?
•• What patient morbidities may affect the outcome?
•• Will the management be carried out solo or part of
a team?
•• Who is on the team?
•• Are an experienced partner, new fellows, or junior
residents available? (This has bearing on the pace
and efficiency of the operation.)
•• Will the surgeon remain in town for the first 24 to
48 hours? (It is ill-advised for the primary surgeon
to do a free flap and then be unavailable. Even if
other surgeons will be “covering,” the possibility of a
complication should preclude travel.)
•• Which team member will be harvesting? Is it
his or her first time, or does the individual have
experience?
•• What is the patient’s position on the table? (This
should be determined before the day of surgery and
the operating room team alerted regarding the need
for special tables, bean bags, or other equipment.)
•• Where is the microscope positioned? Is the
operating room team familiar with microscope
setup and draping?
•• Are the light bulbs functional?
•• Are the two teams working simultaneously or
consecutively?
•• Which vessels are selected for vascular inflow and
outflow? If this can be determined ahead of the day
of surgery, this is an advantage.
The workup includes medical, social, and vascular
evaluation (both arteries and veins). The surgeon must
review flap anatomy and the sequence of harvest.
Contingencies should be considered before the op­
eration. Postoperative monitoring (how, where, who)
is important. Options include a surface perforator, im­
plantable system, pulse oximetry, skin paddle, or com­
bination.
If the surgeon will be performing consecutive free
flaps in one day or several in a week, a plan should be
in place for a flap rejection that will necessitate replan­
tation, especially if the surgeon operates at different
hospital locations. Considerations include whether the

1109
Chapter 58 Lower Extremity Reconstruction
primary surgeon is on call and what protocol will be fol­
lowed in a critical emergency case such as a replanta­
tion. The surgeon must have a contingency plan in case
this occurs.
The day of surgery the surgeon must “get his or her
mind right”; this means that the time of the operation is
the only responsibility that day. Surgeons should not be
in a position to feel rushed or under pressure because of
other obligations. They should be rested, nourished, and
well enough to perform at their best. Fatigue is a deadly
ingredient for free flap surgeons.
Flap Harvesting
Things generally go well if the flap is harvested without
trouble and looks good in situ. If the recipient vessels are
good quality, this bodes well. If vessels are fibrotic or in a
scarred bed, this can result in vascular compromise.
Surgical Considerations
Certain surgeons have a preference of which vessel to
sew first, artery or vein. I prefer the artery, and then ob­
serve venous outflow. This allows proper orientation of
veins that are more susceptible to obstruction if malpo­
sitioned or twisted. The length of the vessel after anas­
tomosis is important. Kinking or redundancy should be
avoided. Some surgeons prefer “one way up,” working
from the back wall to the front. Some prefer sutures at
180 degrees and manipulating the vessel. Whether the
surgeon sews end-to-end or end-to-side on the artery is
based on total runoff. The vessel number and caliber help
determine this. If there is a size mismatch the vessels
can be  spatulated. A smaller artery should be coupled
into a larger recipient; a large vein emptying into a small
vein should be avoided if possible. The venous coupler
is a useful tool, but the surgeon should be adept in vein
hand-sewn anastomosis. Certain conditions and vein
characteristics preclude the use of the coupler. Vessel
quality in the individuals with vasculopathy or diabetes
requires special techniques to avoid intima fragmenta­
tion. Larger microneedles are often required to penetrate
calcified vessels. The intima should be tacked where pos­
sible. The surgeon must see every stitch: Blind passes are
a recipe for disaster. Insufflation with an irrigator to see
every stitch with heparinized saline will avoid back wall­
ing. A running stitch is acceptable with large veins, but
usually vessels are sewn in an interrupted fashion. Fixing
leaks rapidly is important. Excessive anastomosis bleed­
ing can contribute to clot formation.
Negative-Pressure Wound Therapy
Negative-pressure wound therapy certainly has taken
its place in the armamentarium of lower extremity
fracture care, but it is no substitute for vascularized tis­
sue transfer either as a pedicle flap or free flap. With­
out adequate wound débridement the patient is at risk
for sepsis, and care must be taken to avoid placing the
negative-pressure sponge directly over a major blood
vessel. Arterial ruptures have been reported with ca­
lamitous results.
Revascularization with Free Flap
Reconstruction
When dealing with the patient with peripheral vascu­
lar disease who requires free tissue transfer, there is
debate whether revascularization should precede free
flap reconstruction or occur at the same time. Some
patients need vascular bypass or angioplasty and as a
result may not require free tissue transfer if the wound
bed granulates. Others have large cavitary defects. In
these patients, I perform vascular reconstruction or by­
pass at the same time as the free tissue transfer.
Access Around the Knee
There are multiple vascular strategies to gain access to
defects around the knee. Despite long pedicles, a lot of
flap is used up getting from the back of the knee to the
front of the knee. I prefer to use the anterior tibial ar­
tery as a turnup pedicle inflow source to provide inflow
and outflow, and the saphenous vein is always helpful if
it is available. The surgeon must use caution with a pa­
tient with the total knee replacement whose prosthetic
has been colonized based on exposure to the outside
world for a period of time. These patients always need
a two-stage explant and reimplantation of the pros­
thetic, and many are plagued by recurrent infection
even in the best of circumstances.
When considering the use of distantly based fascio­
cutaneous flaps, it is imperative that the reconstructive
team be able to perform free flap rescue if the pedicle flap
does not survive. Similarly, if a patient requires free tissue
transfer for limb salvage or reconstruction, in the case of
flap failure, a second flap should be considered unless it
becomes clear that local options can be used. This is the
exception rather than the rule.
With a free tissue transfer around the foot and an­
kle, I do not consider it a complication or failure in re­
construction for the free tissue transfer to require deb­
ulking. Despite tendencies to do thinning of free tissue
transfers such as the anterolateral thigh flap, for most
patients two or three debulkings are necessary to ac­
commodate normal shoe wear.
Closure
Regarding the timing of closure, complex “reconstruc­
tive” surgery techniques are used that can be per­
formed by orthopaedic or plastic surgeons. Quantita­

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1110
tive cultures have been used for burn patients but have
not been a practical measurement in relation to flap
transfer in open fractures.
Postoperative Considerations
Increased vigilance of the anastomosis is required if
there is intraoperative thrombosis or flow cessation. In­
setting without excessive tension is essential. The flaps
swell for a day or so due to reperfusion after ischemia.
Drains should be positioned away from the anastomo­
sis. If there is any question of capillary refill before leav­
ing the operating room, slow or brisk, the anastomosis
should be explored. While flaps “open up,” Doppler sig­
nals should be present and reproducible before leaving
the operating room. Dressings should not be too tight.
The surgeon should cut the dressing to the level of the
flap and leave splints open so flaps can swell if needed.
Controversy exists relative to when a lower extrem­
ity free flap can be dependent. Dependency too early can
result in flap swelling, and thus the subsequent loss of
split-thickness skin graft over muscle flaps. I characteris­
tically wait approximately 2 to 3 weeks before beginning
a dangling protocol, but this is dependent on whether
I use a skin flap or muscle flap. Skin flaps have a higher
tendency to inosculate quicker than muscle flaps with
skin grafts.
Occasionally an external fixator can be applied to
a foot and ankle reconstruction to act as a kickstand
to keep pressure off a free flap, particularly around the
Achilles and posterior heel region.
Postoperative Dressing
Surgical technique includes the postoperative dressing;
particularly when flaps are placed around external fix­
ators, caution must be exercised to avoid placing bulky
dressings between the flap and the fixator. Flaps have a
tendency to swell and if constrained can result in vas­
cular compromise. Thus I prefer to split the dressing
completely to the level of the skin adjacent to the free
tissue transfer. Although seemingly harmless, sheet
cotton or other bandage materials contain a degree of
elasticity that can restrict swelling, resulting in pedicle
compression. Particularly in the upper extremity, such
as in toe-to-hand transfer, any oozing from a wound
can result in a blood cast. This is also a source for con­
striction of vessels.
Perforator and Propeller Flaps
For perforator and propeller flaps, I have found it help­
ful to delay distally based flaps, particularly in patients
with peripheral vascular disease, or to “supercharge” a
proximal vein into the distal saphenous system if the
flap appears congested.
Like other surgeries, results are not always per­
fect, and failure does occur. This chapter suggests
monitoring flaps with Cook Doppler. This is an im­
provement over the laser Doppler but still can be con­
founding, particularly when the venous signal is in­
audible. Care should be taken in using the Cook probe
on very small vessels; the Silastic cuff can shift and
obstruct a small vessel. It may take 10 to 12 hours
for the venous signal from Cook probes to be audible.
Identifying a perforating vessel that can be auscul­
tated with an external handheld Doppler is a failsafe
against uncertainty.
At the completion of the operation, the surgeon
should talk with the patient’s family, describing the op­
eration and reminding them that takebacks do occur.
Proper handoff in the recovery room and intensive care
unit is critical in the postoperative period. Extremity
positioning, elevation, and monitoring systems must
be reviewed. The “midnight run” refers to the operating
surgeon seeing the patient late in the evening for a final
check to make sure no adverse conditions are evolving
that would require a takeback. At this time the surgeon
should check hematocrit, urine output, and patient tem­
perature. When these are optimized flap compromise
is less likely.
Flap Failure or Takeback
If there is any persistent oozing or evolution of a he­
matoma, it should be managed aggressively. If a return
to the operating room is needed, small Fogarty cath­
eters, tissue plasminogen activator (TPA), and new in­
struments should be readily available, and the surgeon
should know how to use Fogarty catheters and to ad­
minister TPA. A sterile Doppler should also be available.
Leeches may be required, so the operating team must
know where they are kept and how to apply them. If
the flap may be in trouble, the surgeon should not hesi­
tate. Time to return to the operating room is critical. An
error of omission is always worse than error of com­
mission. The surgeon must have a high index of suspi­
cion when team members say, “I think it looks okay” or
“the signals are not as strong as they were,” checking
himself or herself if there is any question. The surgeon
must stay calm and follow a series of steps for success­
ful takeback and salvage.
Preoperative considerations for a takeback also re­
quire a plan. The strategy should have been discussed
before leaving the operating room after the initial pro­
cedure. The surgeon should communicate urgency to
the anesthesia team and operating room staff; talk to
nursing staff about what they need to prepare, such as
microinstruments; inform the patient’s family; and doc­
ument the problem in the medical record. The person
who performed the anastomosis should open. Tissue
swelling and hematoma can be difficult to sort through

1111
Chapter 58 Lower Extremity Reconstruction
if the operating surgeon is not opening the takeback.
The surgeon must get to vessels carefully, determining
whether it is a hematoma or thrombosis or whether
there is a twisted Cook probe. If it is a hematoma ob­
structing flow, the lumen should be explored even if
evacuation results in signals and patency returning.
Liberal vein grafting is important if vessel reanastomo­
sis is not possible or a segment is thrombosed with an
organized clot. A vein graft site should be prepped. It
may not be possible to reinset the flap completely. A skin
substitute or a dressing should be used until ischemia
reperfusion swelling subsides. 
At this point the surgeon must talk to the family
again and be realistic about the chances for success. A
plan for a “redo-redo” or “removing the flap and throw­
ing it in the bucket” should be determined in case a
second takeback is necessary. The surgeon and patient
should remain in the operating room for a while so the
surgeon can monitor the flap. Anticoagulation may be
needed; complications from heparin can occur but the
risk may be justified. Informed consent is vital, so the
team must communicate with the patient’s family at all
times. The surgeon should remain vigilant for compli­
cations.
Conclusion
Finally, a microsurgical free flap reconstruction re­
mains the gold standard for coverage of open fractures
against which all other methods must be compared.
However, vascularized composite allotransplantation
does have promise for the future. Its potential success
is dependent on rapid nerve growth, minimal effects
of immunosuppression strategy, and comparison with
ever-increasing sophistication of lower extremity pros­
thetics (Fig. 58D.1, Video 58D.1).
Fig. 58D.1 (a,b) Gustillo 3C motor vehicle accident injury in an 8-year-old child. (c) Emergency bypass from the proximal posterior
tibial artery to the distal posterior tibial artery (emergent leg revascularization). (d) Provisional coverage with skin substitute for
24 hours.
Continued
a
b
c
d

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1112
References
1. Levin LS. The reconstructive ladder. An orthoplastic ap­
proach. Orthop Clin North Am 1993;24(3):393–409
2. Levin LS. New developments in flap techniques. J Am
Acad Orthop Surg 2006;14(10 Spec No.):S90–S93
3. Levin LS. Principles of definitive soft tissue coverage with
flaps. J Orthop Trauma 2008; 22(10 Suppl)S161–S166
4. Godina M. Early microsurgical reconstruction of com­
plex trauma of the extremities. Plast Reconstr Surg
1986;78(3):285–292
e
f
g
j
i
h
Fig. 58D.1, cont’d (e–g) Conversion external fixation with a free myocutaneous latissimus dorsi flap performed on the third postin­
jury day with intramedullary nailing. (h–j) Supplemental bone graft and tibial plating at 4 months; the radiographs show fracture
healing and soft tissue coverage at 7 months.

1113

Microsurgical Treatment of Lymphedema
Deana Saleh Shenaq and David W. Chang
Lymphedema is a chronic and debilitating condition that
involves the accumulation of lymphatic fluid, which leads
to progressive fibrosis and destruction of lymphatic chan­
nels. It can be classified as primary or secondary based on
etiology. Primary lymphedema is regarded as genetically
determined, with expression occurring at birth (Milroy
disease), puberty (lymphedema praecox), or adulthood
(lymphedema tarda). In the United States, cancer treatment
is recognized as the main cause of secondary lymphedema,
whereas worldwide, it is infection with the parasite Wuch­
ereria bancrofti.1
Lymph node dissection for cancer treatment provokes
anatomic and physiologic changes. Lymphatic vessels pos­
sess vigorous potential for regeneration, and studies have
shown that when they are obstructed, a new pathway may
be created, which fills the lymphatic gap in the affected re­
gion.2 If the new pathway fails to transport enough lymph
fluid, lymphedema will slowly manifest. When this occurs,
the accumulated high-protein lymph fluid damages the col­
lecting lymphatic vessels that are a mainstay of lymph trans­
port. On electron microscopy, degeneration of the smooth
muscle cells in the collecting lymphatic vessels can be seen,
and this degeneration appears to progress from proximal to
distal after blockage.3 The lymphatic vessels gradually lose
their ability to transfer lymph fluid, and this decrease in
function corresponds to the stage of lymphedema.
Lymphedema may occasionally develop immediately
after surgery but most often appears after a latent period.
Obesity, postoperative seroma, and radiation represent ma­
jor risk factors for lymphedema, but the underlying cause of
lymphedema is still not fully understood.4
Common symptoms are increased volume and weight of
the limb and increased skin tension. The increased volume
of the affected upper limb impairs manual dexterity and
complicates finding appropriately fitting clothes in addition
to affecting patients’ emotional and mental psyche.
First-line medical therapies for lymphedema include
manual or complete decongestive lymphatic therapy and
compression wrapping, usually administered by a certified
lymphedema therapist. This mixed therapy includes skin
care, compression garments, exercise therapy, and manual
lymph drainage. Although conservative therapy is benefi­
cial to some extent in many cases, considerable training is
required for patients to master the treatment, and they are
expected to continue these rigorous self-care measures for
their entire lives.5
When patients fail nonoperative management, surgi­
cal treatment can be pursued for the following indications:
weight reduction of the affected region, progression preven­
tion, reduction of episodes of infection or inflammation, and
improvement of function and cosmesis. Currently, surgical
interventions can be broadly categorized into physiological
methods and reductive techniques. This chapter focuses on
physiologic treatments, including lymph node transfer and
lymphatic bypass, which aim to restore lymphatic drainage.
Reductive Surgery
Reductive techniques, such as suction-assisted lipectomy
(SAL) or direct excision, remove fibrofatty tissue that has
been generated as a result of continual lymphatic fluid
stasis. With SAL, the patient must always wear a compres­
sion garment after the procedure to prevent recurrence of
lymphedema. It does not address the cause of lymphedema
but treats the sequelae and is often very effective if com­
pression therapy is maintained.
In 1912 Charles6 first described the process of direct
excision of lymphedematous tissue with subsequent skin
grafting for the treatment of scrotal lymphedema. Since
then, excisional procedures have been applied to the ex­
tremities and have been shown to vastly reduce the size of
affected limbs but can have a multitude of complications
CHAPTER
59

SECTION VII RECONSTRUCTIVE SURGERY FOR THE HEAD AND NECK, BODY, AND LOWER EXTREMITY
1114
transplanting them to the affected region as nonvascular­
ized grafts. This technique, however, has had disappointing
results in animal models.14,15 In our practice, we perform
vascularized lymph node transfers in which nodes and sur­
rounding fat are kept intact and transplanted with their
own venous and arterial supply. This method has been
shown to have a greater degree of improvement of lymph­
edema than nonvascularized grafting.
Many theories exist to explain how lymph node transfer
augments lymphatic function. One theory postulates that
the orthotopically placed lymph nodes act as a sponge or
pump to absorb lymphatic fluid and direct lymph into the
vascular network.16 Others believe that the transplanted
nodes induce lymphangiogenesis that bridges lymphatic
pathways.17–19 In general, it has been shown that preserv­
ing the vascular supply during transfer results in greater im­
provement in the degree of lymphedema and in lymphatic
function.20
Avoiding Unfavorable Results
and Complications in the
Treatment of Lymphedema
Preoperative Planning, Counseling,
and Patient Selection
The ideal candidate for lymph node transfer or LVB is one
with moderate secondary lymphedema who is compliant
with physical therapy and is committed to continued ex­
tremity wrapping or wearing a garment postoperatively.
During the initial visit, based on a patient’s clinical stage,
a recommendation is made to proceed with surgery with the
options of LVB, VLNT, or a combination of both. LVB alone
is usually reserved for those patients with mild or stage 1
lymphedema. For severe lymphedema, debulking may be
necessary (Table 59.1).
Preoperatively, our lymphedema therapist evaluates
every patient and performs a quantitative volumetric and
qualitative analysis of the limb and symptoms. Patients are
then also evaluated at 3, 6, and 12 months postoperatively
for signs of improvement. We do not typically perform pre­
operative lymphoscintigraphy studies on patients with
secondary lymphedema from a known cause. Patients who
present with primary lymphedema always undergo confir­
matory lymphoscintigraphy preoperatively to document
lymphatic dysfunction.
In our experience, patients with primary lymphedema
are harder to treat and may not have as favorable outcomes
as those patients with secondary lymphedema. This may re­
sult from the fact that patients with secondary lymphedema
often have scarring and fibrosis that, when released, gives
almost immediate relief of symptoms. Also, these patients
have a normal lymphatic system but were locally damaged
secondarily. Primary lymphedema patients have an abnor­
mal lymphatic system involving lymph nodes or lymphatic
including destruction of remaining lymphatics, reoccurrence
of swelling, aesthetic deformities, and unsightly scars.7
Physiologic Surgery
Lymphovenous Bypass
In lymphovenous bypass (LVB), lymphatic fluid is routed
back to the venous system to increase the region’s capacity
to transport lymph. One of the first attempts at LVB was
described by Jacobson8 in the canine model. To treat fila­
riasis, Sedlécek9 used the saphenous vein for end-to-side
LVB. However, postoperative concerns over venous hyper­
tension in larger-caliber vessels led to the idea of bypassing
venules, which was pioneered by Yamada.10 These proce­
dures can be technically difficult because of the “supermi­
crosurgery” requirement, which involves anastomoses on
vessels smaller than 1 mm.
LVB has been shown to be useful primarily in cases of
mild lymphedema before the initiation of fibrosis. In 1990
O’Brien et al11 reported long-term follow-up on 90 patients,
some of whom received LVB-only and others who had LVB
with adjunctive reductive procedures. In the cohort that re­
ceived LVB-only, subjective improvement occurred in 73%
of patients and objective improvement was documented in
42% of patients, with an average 44% reduction in volume.
At a 4-year follow-up, 74% of patients were able to discon­
tinue conservative treatment completely, and the incidence
of cellulitis decreased by 58%.
In a recent report of the senior author’s experience with
100 patients undergoing LVB (89 upper extremity, 11 lower
extremity), symptom improvement was reported in 96% of
patients, and quantitative improvement was noted by 74%.
The overall mean volume differential reduction at 12-month
follow-up was 42%. This reduction was significantly larger
in patients with earlier stage (stage 1 or 2) versus later stage
(stage 3 or 4) lymphedema as determined by indocyanine
green (61% versus 17%). LVB alone is best indicated for pa­
tients with mild to moderate upper extremity lymphedema
who still have some functioning lymphatic vessels and mini­
mal tissue fibrosis.
Vascularized Lymph Node Transfer
Free tissue transfer of lymph nodes has been the most re­
cent development in the treatment of lymphedema. Au­
tologous or vascularized lymph node transfer (VLNT) was
first pioneered successfully in an animal model by Shesol et
al in 197912 and used clinically for a patient by Clodius et al
in 1982.13 In this procedure, healthy lymph nodes are har­
vested from one region and transferred to another, either
to the original site of injury (i.e., axilla or groin) or within
a lymphedematous limb (i.e., dorsum of lower leg). Vascu­
larized lymph node harvest has been described using the
groin, thoracic, submental, or supraclavicular nodes. The
lymph nodes can be transferred as either a graft or flap.
Some have described mincing the donor lymph nodes and