(Trang không có chữ)
Part IV
Head and Neck
(Trang không có chữ)
12
Head and Neck
cases, it bifurcates above the zygomatic arch into ante-
rior and posterior branches (4, 5). The internal caliber at
this level ranges from 1.8 to 2.7 mm. Its length ranges
from 2.5 to 5.0 cm, averaging 3.4 cm.
Figure 12–1
Arterial anatomy
of temporoparietal ap.
1. Super cial temporal a.
2. Middle temporal a.
3. Transverse facial a.
4. Anterior branch
5. Posterior branch
6. Zygomatic arch
7. Zygomatico-orbital a.
TEMPOROPARIETAL FLAP
Arterial Anatomy (Fig. 12–1)
The super cial temporal artery (1), a terminal branch of
the external carotid artery, lies between the deep and
super cial lobes of the parotid gland at its origin and
is covered there by the facial nerve. As it em erges
from between the lobes, it lies lateral to the temporo-
mandibular joint and gives off the middle temporal (2)
and transverse facial arteries (3). At the zygom atic arch,
it blends into the super cial temporal fascia. In 80% of
632
IV.12 HEAD AND NECK: HEAD AND NECK
The temporoparietal fascia free ap is a thin, highly vas-
cularized unit having a consistently reliable pedicle. Its
versatility stem s from its nonbulky, supple property. It
can drape over cartilage stripped of perichondrium and
maintain the de nition of the underlying framework in
ear and nasal reconstruction. Likewise, it can contour
into bony concavities as part of the treatm ent of chronic
osteomyelitis. Temporoparietal fascial free aps have
proven especially useful in hand reconstruction, in si-
multaneously restoring a gliding apparatus for tendons
denuded of paratenon and providing an elastic vascu-
larized surface in wound closure. The scalp donor site
scar is relatively inconspicuous. The operation accom-
modates a two-team approach.
Drawbacks of this ap include alopecia at the donor
site and tedious elevation of the scalp aps. Alopecia is
usually transient and resolves in several months. It may
be prevented by deepening the dissection and not ex-
posing the hair follicles when raising the scalp aps. Re-
dundant wound margins may also be excised.
An osteofascial ap consisting of the outer table of
the frontoparietal calvarium may be transferred by the
super cial temporal pedicle. Because it is vascularized
and contains membranous bone, this ap is appropriate
for bony reconstructions in unfavorable recipient sites,
for example, scarred, irradiated beds, hypoplastic zygo-
m aticomaxillary complex reconstructions in Treacher-
Collins syndrom e, or clinically infected hand defects
requiring grafting to the metacarpals.
Within the past decade, this donor site is still com-
m only reported for clinical use in m icrosurgical recon-
struction.
COMMENT AND INSIGHTS
The m iddle temporal artery (2) arises from the
super cial temporal artery (1) at or just below and su-
per cial to the zygomatic arch. Immediately above the
zygomatic arch, it enters the deep temporal fascia and
arborizes within it. The middle temporal vein accompa-
nies the artery throughout its course.
The superficial tem poral vein, m easuring be-
tween 2.1 and 3.3 m m in diam eter, usually lies ante-
rior to the artery and w ithin 0.8 cm of it. However,
the vein can be as distant as 3 cm away from the ar-
tery. Near the origin of the artery, the superficial
tem poral vein joins the m axillary vein to form the
retrom andibular vein, w hich drains into the external
jugular vein.
The auriculotem poral nerve, a sensory branch
of the trigeminal nerve, lies posterior to the super cial
tem poral vessels and above the super cial tem poral
fascia; it proceeds to innervate the temporal scalp.
TEMPOROPARIETAL FASCIA FLAP
The super cial temporal fascia (temporoparietal fascia)
is a thin, highly vascular layer of connective tissue that
is a component of the super cial musculoaponeurotic
system (SMAS). It is continuous with the galea aponeu-
rotica superiorly, the occipitalis posteriorly, the frontalis
anteriorly, and the deep investing fascia overlying the
parotid gland and the muscles of facial expression infe-
riorly. It lies immediately beneath the hair follicles of
the temporoparietal scalp and is progressively more ad-
herent to the subdermal brofatty layer in which they
lie, as it proceeds from the level of the zygomatic arch
cephalad toward the vertex of the skull. The subdermal
layer of the scalp is also attached to the super cial tem-
poral fascia by numerous sm all vessels. The super cial
temporal fascia overlies the deep temporal fascia and is
separated from it by a loose, areolar plane. The super cial
temporal fascia is 1.4 to 3.8 mm thick in the preauricu-
lar region of children, and 2.2 to 4.2 mm thick in adults.
Its expansion is upward of 14
17 cm. Near the lateral
orbital rim in the frontozygom atic area, the frontal
branches of the facial nerve lie deep to an attenuated
portion of the super cial temporal fascia, thus increas-
ing its vulnerability during dissection.
Incision (Fig. 12–2)
The pulse of the super cial temporal artery is appreci-
ated in the preauricular area by palpation and Doppler
probe. A rhytidectomy incision is outlined to extend
vertically and to bifurcate in lofty “Y” fashion two thirds
of the distance to the apex of the skull at the upper tem-
poral fascia.
TEMPOROPARIETAL FASCIA FLAP
633
Figure 12–2
Incision.
1. Super cial temporal a. and v.
2. Super cial temporal fascia
3. Frontal branch of facial n.
4. Auriculotemporal n.
5. Deep temporal fascia
6. Parotid gland
Exposure of the Fascia and Vessels
(Fig. 12–3)
The super cial temporal vessels (1) are identi ed pretra-
gally. Elevation of the scalp aps begins inferiorly where
the plane between the dermis and super cial temporal
fascia (2) is more easily identi ed. As dissection pro-
ceeds cephalad, separation becomes increasingly dif -
cult because the brous septae and piercing vessels
within the subcutaneous fat connecting the super cial
temporal artery to the overlying scalp are quite dense.
634
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–3
Exposure of the fascia and
vessels.
1. Super cial temporal a. and v.
2. Super cial temporal fascia
3. Frontal branch of facial n.
4. Auriculotemporal n.
This plane is painstakingly developed so that it is
deep enough to avoid exposure of the hair follicles, yet
super cial enough not to injure the super cial tempo-
ral fascia (2). Hemostasis is maintained by liberal use of
the bipolar cautery. When dissecting in the frontozygo-
m atic region, a nerve stimulator m ay help in localizing
the frontal branch of the facial nerve (3). The auricu-
lotemporal nerve (4) is invariably incorporated within
the fascial ap.
Elevation of the Fascia Flap (Fig. 12–4)
After the scalp aps are completely re ected, a template
outlining the required geometry of the ap is applied to
the super cial temporal fascia (2) and is marked. The
super cial temporal fascia is incised and readily ele-
vated along with its pedicle in retrograde fashion. This is
expedited by the loose, areolar plane that separates the
super cial and deep temporal fasciae (2,5).
TEMPOROPARIETAL FASCIA FLAP
635
Figure 12–4
Elevation of the fascia
ap.
1. Super cial temporal a. and v.
2. Super cial temporal fascia
5. Deep temporal fascia
Dissection of the Vascular Pedicle
(Fig. 12–5)
The super cial temporoparietal fascia ap (2) is com-
pletely raised from the deep fascia. To avoid damage to
the branches of the facial nerve, further dissection of
the vascular pedicle (1) in the parotid gland (6) is not
recom mended.
636
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–5
Dissection of the vascular
pedicle.
1. Super cial temporal a. and v.
2. Super cial temporal fascia
6. Parotid gland
BILOBED TEMPOROPARIETAL FASCIA
FLAP
When m ore tissue is required, a bilobed ap consist-
ing of the super cial and deep temporal fascial leaves
m ay be developed on the super cial tem poral arterial
pedicle.
The deep temporal fascia is a dense, semicircular
fascial sheath that invests the tem poral m uscle. At
each margin, this fascial layer ends by attaching to the
periosteum of the frontal, temporal, and parietal bones,
and the upper edge of the zygomatic arch. It m easures
~7 cm in both dimensions. The deep temporal fascia is
supplied by the middle temporal artery.
Elevation of the Super cial Fascia Flap
(Fig. 12–6)
The super cial fascial ap (2) is raised as described in
the section on the super cial temporoparietal fascial
ap.
BILOBED TEMPOROPARIETAL FASCIA FLAP
637
Figure 12–6
Elevation of the super cial fascia ap.
1. Super cial temporal a. and v.
2. Super cial temporal fascia
3. Deep temporal fascia
4. Middle temporal a. and v.
5. Temporalis m.
Elevation of Deep Fascia Flap
(Fig. 12–7)
The deep temporal fascia (3) is lifted off the underlying
tem poralis m uscle (5) and sharply separated below
from its zygom atic attachm ent. The m iddle temporal
vessel (4) originating from the super cial temporal ar-
tery (1) and supplying the deep temporal fascia (3) is
preserved. The double-leaf arrangement is particularly
suited to tendon reconstruction in simultaneously pro-
viding vascularized coverage and an envelope of gliding
surfaces.
638
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–7
Elevation of deep
fascia ap.
1. Super cial temporal a. and v.
2. Super cial temporal fascia
3. Deep temporal fascia
4. Middle temporal a. and v.
5. Temporalis m.
TEMPOROCALVARIAL
OSTEOFASCIAL FLAP
As has already been mentioned, the SMAS is continuous
with the galea through the temporoparietal fascia. The
super cial temporal, occipital, and supratrochlear ves-
sels form a rich, anastomotic network located just above
the galea. As part of this complex, the super cial tem-
poral artery, ~1 to 2 cm beyond the temporal line (a
ridge that begins at the zygomatic process of the frontal
bone coursing upward and backward across the frontal
and parietal bones and ending at the supramastoid crest,
representing the cephalic-most portion of the temporalis
muscle), sends perforators down through the galea and
periosteum. In the frontoparietal region, these perfora-
tors, in turn, anastom ose through the diploë with
branches of the middle meningeal artery, the dominant
blood supply to the calvarium.
Incision and Proposed Bone (Fig. 12–8)
The skin incision and proposed outer table of calvarial
bone are illustrated. The bone is outlined above the
temporal line (6).
TEMPOROCALVARIAL OSTEOFASCIAL FLAP
639
Figure 12–8
Incision and proposed bone.
1. Frontoparietal bone
2. Super cial temporal a. and v.
3. Outer table of calvarial bone
4. Inner table of calvarial bone
5. Super cial temporal fascia
6. Temporal line
Elevation of Osteofascial Flap
(Fig. 12–9)
In harvesting the partial-thickness vascularized bone
ap, care must be taken to incorporate all layers—galea
bearing the overlying super cial temporal vascular net-
work (2), periosteum , and outer table of calvarium (3)—
as a composite. This is accomplished by suturing the
galea and periosteal layers and drilling holes at the pe-
riphery of the bone to prevent shearing at the deep
surface of the galea. On its super cial surface where the
galea is densely adherent to the scalp, dissection neces-
sarily proceeds tediously exposing the hair follicles of
the dermis and preserving the super cial temporal vas-
cular network covering the super cial surface of the
galea. To augment the circulation in a partial-thickness
bone ap, or when full-thickness calvarium is favored,
the deep temporal fascia continuous with the perios-
teum above the temporal line is elevated along with the
super cial temporal fascia (5) as part of the composite
ap, thereby adding contributions from the m iddle
temporal arteries. Moreover, the deep temporal fascia
and its middle temporal arterial system are suf cient to
carry the outer table of calvarium (3).
640
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–9
Elevation of
osteofascial ap.
1. Frontoparietal bone
2. Super cial temporal a. and v.
3. Outer table of calvarial bone
4. Inner table of calvarial bone
5. Super cial temporal fascia
6. Temporal line
FREE SCALP SKIN FLAP
Flap Design (Figs. 12–10, 12–11)
The super cial temporal arterial pedicle m ay be used to
carry overlying scalp in correcting male-pattern bald-
ness and tem poral alopecia cicatrices (bald scars) in
burn and trauma patients. Hair-bearing scalp aps as
small as 2.5
12 cm and as large as 6
35 cm have
been successfully transferred.
FREE SCALP SKIN FLAP
641
Figure 12–10
Lateral view of ap design.
642
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–11
Top view of ap design.
1. Super cial temporal a. and v.
2. Hair-bearing scalp ap
3. Periosteum of calvarial bone
4. Deep temporal fascia
Flap Elevation (Fig. 12–12)
This composite ap consists of the scalp and underlying
super cial temporal fascia bearing the super cial tem-
poral arterial network (1). The recipient vessels are usu-
ally the contralateral super cial temporal artery and
vein. The transplanted scalp bears hair of normal den-
sity that grows in a natural anterior direction. The hair
stream covers the inconspicuous scar. Donor defects up
to 4 cm wide may be closed primarily.
FREE SCALP SKIN FLAP
643
Figure 12–12
Flap elevation.
1. Super cial temporal a. and v.
2. Hair-bearing scalp ap
3. Periosteum of calvarial bone
4. Deep temporal fascia
SUPERFICIAL CERVICAL FLAP
Arterial Anatomy (Fig. 12–13)
In most cases, the super cial cervical artery (5) arises
directly from the thyrocervical trunk (2), which originates
from the rst portion of the subclavian artery (1) and
almost immediately divides into three branches: the in-
ferior thyroid artery (3), suprascapular artery (4), and
super cial cervical artery (5) itself.
At its inception, the super cial cervical artery lies in
front of the scalenus anterior, phrenic nerve, and brachial
plexus, and behind the sternocleidomastoid and internal
jugular vein. It runs laterally to cross the posterior cervi-
cal triangle. After passing over the brachial plexus and
behind the inferior belly of the omohyoid, it divides into
ascending and descending branches.
The ascending branch (6) runs super cially, giv-
ing off several sm all branches to the skin area of the
posterior cervical triangle and ascending along the
anterior border of the trapezius, where it anastom oses
w ith the descending branch of the occipital artery.
The descending branch (7) of the superficial cervical
artery goes, along w ith the spinal accessory nerve, to
the undersurface of the trapezius as its m ain blood
supply.
The super cial cervical artery measures 1.0 to 1.5 mm
in diameter at its origin.
Innervation of the Posterior
Cervical Triangle
The anterior, middle, and posterior supraclavicular nerves
em erge from the cervical plexus deep to the posterior
margin of the sternocleidomastoid muscle. They course
inferiorly across the triangle and branch out to the
overlying skin. The middle trunk innervates the major-
ity of this skin territory.
644
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–13
Arterial anatomy of the super cial cervical ap.
1. Subclavian a.
5. Super cial cervical a.
2. Thyrocervical trunk
6. Ascending branch
3. Inferior thyroid a.
7. Descending branch
4. Suprascapular a.
Variations of the Super cial Cervical
Artery (Fig. 12–14)
A. In the majority of cases, the super cial cervical artery
independently arises from the thyrocervical trunk (4),
whereas the transverse cervical artery (2) originates
from the second or third portion of the subclavian
artery (5), to supply the muscles near the scapula.
B. In a minority of cases, the super cial cervical artery
(1) arises from the transverse cervical artery (2),
which originates from the thyrocervical trunk (4)
and runs posteriorly to the scapular area.
SUPERFICIAL CERVICAL FLAP
645
Figure 12–14
Variations of the super cial cervical artery (see text for details).
1. Super cial cervical a.
6. Inferior thyroid a.
2. Transverse cervical a.
7. Suprascapular a.
3. Deep branch of transverse cervical a.
8. Vertebral a.
4. Thyrocervical trunk
9. Internal mammary a.
5. Subclavian a.
Harvesting Technique
Flap Design (Fig. 12–15)
The ap is outlined in the posterior triangle of the neck,
which is de ned by the posterior margin of the stern-
ocleidom astoid anteriorly, the anterior m argin of the
trapezius posteriorly, and the middle third of the clavi-
cle inferiorly, centered along the axis of the super cial
cervical artery that is marked from the sternoclavicular
joint to the midpoint of the lateral m argin of the trapez-
ius (between the acromion and the external occipital
protuberance). Depending on skin laxity, aps as large
as 8
15 cm can be transferred without having to skin
graft the donor site.
646
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–15
Flap design.
1. Super cial cervical a.
2. Omohyoid m.
3. Sternocleidomastoid m.
4. Clavicle bone
5. Trapezius m.
6. Spinal accessory n.
7. External jugular v.
8. Supraclavicular n.
9. Thyrocervical trunk
The super cial cervical free ap is fairly thin and its ori-
gin in the neck provides favorable thickness and color
m atch in resurfacing facial defects. As an innervated
ap, it is useful in both offering stable coverage and
restoring sensibility in hand, heel, ankle, and trans-
metatarsal amputation site reconstruction.
Disadvantages of this ap are mainly related to its
anatomy. Pedicle components do not course together in
“comitante” fashion. Instead, the artery, vein, and nerve
enter the ap at different points, making dissection te-
dious and restricting the ap orientation at the recipi-
ent site. The proxim al dissection at the thyrocervical
trunk is fairly deep, necessitating working in a hole.
Moreover, the arterial diameter is smaller when com-
pared with that of other thin, cutaneous, free aps, for
example, the radial forearm free ap.
Donor-site m orbidity includes potential injury to
the great auricular and spinal accessory nerves. Donor-
site closure may result in a widened scar of skin graft in
a fairly conspicuous location.
COMMENT AND INSIGHTS
Identi cation of the Super cial Cervical
Artery (Fig. 12–16)
The anterior skin incision of the ap is made rst, so as
to identify the super cial cervical artery (1), and is car-
ried through platysma and deep fascia. The omohyoid
(2) is divided and the entrance of the super cial cervi-
cal artery to the ap is identi ed. The artery is traced to
its origin at the thyrocervical trunk in the supraclavicu-
lar triangle, bordered by the posterior belly of the omo-
hyoid (2) superiorly, clavicle (4) inferiorly, and
clavicular insertion of the sternocleidomastoid muscle
(3) m edially.
SUPERFICIAL CERVICAL FLAP
647
Figure 12–16
Identi cation of the
super cial cervical artery.
1. Super cial cervical a.
2. Omohyoid m.
3. Sternocleidomastoid m.
4. Clavicle bone
7. External jugular v.
Elevation of the Dorsal Portion of the
Flap (Fig. 12–17)
The dorsal margin of the ap is incised and elevated prox-
imally so as to incorporate the super cial cervical arteri-
ovenous pedicle (1). The plane of dissection is beneath
the supraclavicular fat pad through which course the ar-
tery, vein, and nerves. Care must be taken at this point to
avoid injury to the spinal accessory nerve (6) when divid-
ing the artery as it enters the trapezius muscle (5).
648
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–17
Elevation of the dorsal portion of the ap.
1. Super cial cervical a.
6. Spinal accessory n.
2. Omohyoid m.
7. External jugular v.
5. Trapezius m.
8. Supraclavicular n.
Dissection of the Neurovascular Pedicle
(Fig. 12–18)
The venae comitantes of the super cial and other ve-
nous tributaries within the ap are followed to the ex-
ternal jugular vein (7) that is used as the pedicle. When
taken as a sensory ap, the supraclavicular nerves (8)
may be identi ed by tracing the great auricular nerve
downward as it courses over the sternocleidomastoid
muscle. As it dives behind the midposterior border of
the muscle, the supraclavicular nerves are encountered
arising from the cervical plexus.
SUPERFICIAL CERVICAL FLAP
649
Figure 12–18
Dissection of neurovascular pedicle.
1. Super cial cervical a.
7. External jugular v.
2. Omohyoid m.
8. Supraclavicular n.
5. Trapezius m.
9. Thyrocervical trunk
SUBMENTAL FLAP
Anatomy (Fig. 12–19)
The facial artery (2) arises from the external carotid ar-
tery (1), a little above the level of the greater cornu of
the hyoid bone. It runs upward behind the stylohyoid
(7) and the posterior belly of the digastric (8) to enter
the groove between the submandibular gland (4) and
the medial pterygoid muscle, where it gives off three or
four branches to the gland. It then goes forward to reach
the lower border of the mandible. At the anterior edge
of the m asseter (6), it turns upward around the
mandible toward the medial palpebral commissure.
The subm ental artery (5) is given off from the
facial artery (2) im m ediately after the facial artery
leaves the subm andibular gland (4) and before it turns
upward. It goes forward between the mylohyoid (9)
and platysm a in the subm ental region toward the chin.
At the chin, it turns upward over the base of the
m andible, where it divides into super cial and deep
branches. In its course, the subm ental artery gives off
som e branches to the platysm a and overlying skin. The
diam eter of this artery usually exceeds 1 m m and it is
accompanied by its venae com itantes. The subm ental
artery supplies a skin area of the ipsilateral m ental and
subm ental region.
Venous Drainage
After crossing over the m andible, the facial vein re-
ceives the subm ental vein and then runs obliquely
backward separately from the facial artery, super cial
to the submandibular gland, digastric, and stylohyoid
m uscles. It com m unicates with the external jugular
vein before draining to the internal jugular vein at the
level of the hyoid bone. The subm ental venae com i-
tantes travel with the artery and join the facial vein
proximally.
Innervation
The sensibility of the submental area is supplied by sev-
eral terminal branches of the transverse cutaneous nerve
of the neck, which derives from the cervical plexus.
650
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–19
Anatomy
of the submental ap.
1. External carotid a.
2. Facial a.
3. Parotid gland
4. Submandibular gland
5. Submental a.
6. Masseter m.
7. Stylohyoid m.
8. Digastric m.
9. Mylohyoid m.
Harvesting Technique
Flap Design (Fig. 12–20)
The patient is positioned with the neck extended and
the face turned toward the contralateral side. The ap is
located in the subm andibular and submental regions.
Its superior margin follows the inferior border of the
mandible; its anterior margin can go beyond the mid-
line by 2 or 3 cm ; and the posterior margin is located
perpendicular to the anterior edge of the m asseter
where the facial artery can be palpated. The inferior
m argin depends on the width of the proposed ap.
Usually, the skin defect can be directly closed after re-
m oval of a ap with a width of ~6 cm. The comm on size
of the submental ap is ~6 cm
11 cm.
SUBMENTAL FLAP
651
This is a newly developed ap. According to prelim i-
nary reports of ap anatomy and clinical application,
this ap would be useful in reconstructive surgery of
the head and neck, especially with ipsilateral pedicle
transfer for face and neck defects. A free submental ap
has been reported for reconstruction of a contralateral
facial defect. However, further anatomic investigations
and wider clinical applications are needed.
The skin in the submandibular and submental re-
gions is usually very delicate. It may be hairy in adult
males, and its thickness varies with the individual. The
resultant linear scar under the mandible may be incon-
spicuous and is reported to be acceptable. Direct skin
closure may result in tightness at the front of the neck;
if neck extension is thereby limited, a secondary release
would be required.
There m ay be the risk of injury to the m arginal
m andibular branch of the facial nerve during ap dis-
section, although this can be avoided with care.
Over the past decade, this donor site is still more
commonly reported for clinical use in microvascular re-
construction.
COMMENT AND INSIGHTS
Figure 12–20
Flap design.
1. Submental a. and v.
2. Facial a. and v.
3. Digastric m.
4. Mylohyoid m.
5. Submandibular gland
6. Marginal mandibular branch of
facial n.
7. Mandible
8. Platysma m.
Identifying the Vascular Bundle
(Fig. 12–21)
The inferior margin of the ap is incised through the
platysm a (8), and the facial vein (2) can be visualized at
the posterior portion of the inferior margin under the
platysm a. Keeping the facial vein and platysm a to-
gether with the ap, the lower ap portion is elevated
from the mylohyoid (4) and the anterior belly of the di-
gastric (3), as well as from the surface of the sub-
mandibular gland (5), until the upper edge of the gland
and the submental vessels (1) are identi ed.
652
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–21
Identifying the vascular bundle.
1. Submental a. and v.
4. Mylohyoid m.
2. Facial a. and v.
5. Submandibular gland
3. Digastric m.
8. Platysma m.
Dissection at the Upper Border of the
Flap (Fig. 12–22)
The superior margin of the ap is incised. Special atten-
tion should be paid, when dividing the platysm a, to
avoid injury to the marginal mandibular branch of the
facial nerve (6). After emerging from the parotid gland,
this branch of the facial nerve usually runs along the
lower border of the mandible under the platysma (8)
and crosses the facial vessels (2) to supply the risorius
and the muscles of the lower lip and chin. Sometimes it
appears above the lower border of the mandible or lies
upon the submandibular gland (5).
SUBMENTAL FLAP
653
Figure 12–22
Dissection at the upper border of the ap.
2. Facial a. and v.
6. Marginal mandibular branch of facial n.
3. Digastric m.
7. Mandible
4. Mylohyoid m.
8. Platysma m.
5. Submandibular gland
Elevation of the Flap (Fig. 12–23)
Under direct visualization, the m arginal m andibular
branch of the facial nerve (6) is preserved at the donor
site, and the submental vessels (1) are included in the
ap. The ap is elevated anteriorly to posteriorly, and
the subm ental vessels are then traced to their origin
from the facial vessels (2).
654
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–23
Elevation of the ap.
1. Submental a. and v.
4. Mylohyoid m.
2. Facial a. and v.
5. Submandibular gland
3. Digastric m.
6. Marginal mandibular branch of facial n.
Pedicle Dissection and Flap Completion
(Fig. 12–24)
Through a 3-cm extension incision, the submandibular
gland (5) is separated from the mandible (7), and the fa-
cial artery (2) is dissected out by ligating its trunk over
the mandible going toward the face and its branches to
the gland.
Because the facial vein (2) lies super cially, the ve-
nous pedicle can be of suf cient length, although the
length of the arterial pedicle can attain ~6 cm by further
dissection.
For donor-site closure, the inferior ap edge should
be underm ined, pulled up toward the superior edge,
with the superior edge kept intact. Tension should be
avoided to prevent distortion of the lower lip.
SUBMENTAL FLAP
655
Figure 12–24
Pedicle dissection and ap completion.
1. Submental a. and v.
6. Marginal mandibular branch of facial n.
2. Facial a. and v.
7. Mandible
5. Submandibular gland
8. Platysma m.
RECIPIENT SITE EXPOSURES
External Carotid Artery and
Its Branches
Incision (Fig. 12–25)
The patient is placed in a supine position, with the neck
extended and the head turned to the contralateral side.
An incision is made transversely at the upper third of
the neck, on the middle portion of a curved line from
the thyroid cartilage to the m astoid process.
656
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–25
Incision.
1. Parotid gland
2. Sternocleidomastoid m.
3. Facial v.
4. External jugular v.
5. Mandibular branch of facial n.
6. Platysma m.
7. Stylohyoid m.
8. Digastric m.
9. Carotid sheath
10. External carotid a.
11. Internal carotid a.
12. Internal jugular v.
13. Superior thyroid a.
14. Superior laryngeal a.
15. Lingual a.
16. Facial a.
17. Hypoglossal n.
Identifying the Super cial Structures
(Fig. 12–26)
The platysma (6) and deep cervical fascia are incised,
the upper and lower skin aps are developed and re-
tracted, and the anterior border of the sternocleido-
mastoid muscle (2) is then identi ed. Attention should
be paid not to injure the m arginal m andibular branch
of the facial nerve (5), which lies below the parotid (1)
and mandible and under the platysma (6), and extends
to supply the risorius and the muscle of the lower lip
and chin.
The facial vein (3) incorporating the communica-
tion between the deep and super cial systems is ideally
suited as a recipient vein.
RECIPIENT SITE EXPOSURES
657
Figure 12–26
Identifying the super cial structures.
1. Parotid gland
4. External jugular v.
2. Sternocleidomastoid m.
5. Mandibular branch of facial n.
3. Facial v.
6. Platysma m.
Exposure of the Carotid Sheath
(Fig. 12–27)
The facial vein (3) is traced distally, ligated or m icro-
clipped. The sternocleidomastoid muscle (2) is mobi-
lized and retracted posteriorly. The carotid sheath (9) is
exposed.
658
IV.12 HEAD AND NECK: HEAD AND NECK
Figure 12–27
Exposure of the carotid sheath.
2. Sternocleidomastoid m.
3. Facial v.
4. External jugular v.
7. Stylohyoid m.
8. Digastric m.
9. Carotid sheath
Dissection of the Carotid Arterial
System (Fig. 12–28)
After the sheath is open, the internal jugular vein (12),
which is usually super cial to the artery, is dissected
and gently retracted with vessel loops. The external
carotid artery (10), which arises from the com m on
carotid artery at about the level of the upper border of
the thyroid cartilage, is easily revealed. However, the
hypoglossal nerve (17) [the 12th cranial nerve, which
crosses the external and internal carotid arteries (10, 11)
at a level a little above the hyoid bone], should be iden-
ti ed and protected before isolating the following three
branches of the external carotid artery.
The superior thyroid artery (13) arises from the
vessel a little above the upper m argin of the thyroid
cartilage and goes anteroinferiorly. The lingual artery
(15) leaves the vessel at the level of the greater horn of
the hyoid bone and runs deep to the hyoglossus muscle.
The facial artery (16) arises a little above the lingual ar-
tery and runs upward.
RECIPIENT SITE EXPOSURES
659
Figure 12–28
Dissection of the carotid
arterial system.
7. Stylohyoid m.
8. Digastric m.
10. External carotid a.
11. Internal carotid a.
12. Internal jugular v.
13. Superior thyroid a.
14. Superior laryngeal a.
15. Lingual a.
16. Facial a.
17. Hypoglossal n.
BIBLIOGRAPHY
Temporoparietal Flaps
Abul-Hassan HS, van Drasek-Ascher G, Acland RD. Sur-
gical anatomy and blood supply of the fascial layers of
the temporal region. Plast Reconstr Surg 1986;77:17
Ahm ed OA, Kolhe PS. Prevention of Frey’s syndrom e
and volume de cit after parotidectomy using the su-
per cial temporal artery fascial ap. Br J Plast Surg
1999;52:256
Altintas M, Aydin Y, Yucel A. Eye socket reconstruction
with the prefabricated temporal island ap. Plast Re-
constr Surg 1998;102:980
Biswas G, Dip NB, Ohani I, Chari PS. The sandwich tem-
poroparietal free fascial ap for tendon gliding. Plast
Reconstr Surg 2001;108:1639
Brandt K, Khouri RK, Upton J. Free aps as ow-
through vascular conduits for sim ultaneous coverage
and revascularization of the hand or digit. Plast Recon-
str Surg 1996;98:321
Brent B, Byrd HS. Secondary ear reconstruction with car-
tilage grafts covered by axial random, and free aps of
temporoparietal fascia. Plast Reconstr Surg 1983;72:141
Brent B, Upton J, Acland RD, et al. Experience with the
tem poroparietal fascial free ap. Plast Reconstr Surg
1985;76:177
Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE. Clini-
cal applications of the subgaleal fascia. Plast Reconstr
Surg 1991;87:615
Chen C-T, Robinson JB, Rochrich RJ, Ansari M. The blood
supply of the reverse temporalis muscle ap: anatomic
study and clinical im plications. Plast Reconstr Surg
1999;103:1181
Chen T-H, Chen C-H, Shyu J-F, et al. Distribution of the
super cial temporal artery in the Chinese adult. Plast
Reconstr Surg 1999;104:1276
Chiarelli A, Baldelli A, DiVincenzo A, Martini G. Utiliza-
tion of the super cial temporoparietal fascia in recon-
structive plastic surgery: a clinical case. Ophthal Plast
Reconstr Surg 1989;5:274
Chowdary RP. Use of temporoparietal fascia free ap in
digital reconstruction. Ann Plast Surg 1989;23:543
Delaere PR, Guelinfkx PJ, Ostyn F. Vascularized tem -
poroparietal fascial ap for closure of a nasal septal
perforation: report of a case. Acta Otorhinolaryngol
Belg 1990;44:47
East CA, Brough MD, Grant HR. Mastoid obliteration
with the tem poroparietal fascia ap. J Laryngol Otol
1991;105:417
Erni D, Lieger O, Banic A. Comparative objective and
subjective analysis of tem poralis tendon and m icro-
neurovascular transfer for facial reanimation. Br J Plast
Surg 1999;52:167
Hallock GG. The extended temporoparietal fascia “non-
free” ap. Ann Plast Surg 1989;22:65
Hing DN, Buncke HJ, Alpert BS. Use of the tem poro-
parietal free fascial ap in the upper extremity. Plast
Reconstr Surg 1988;81:534
Hirase Y, Kojima T, Bang HH. Secondary reconstruction
by temporoparietal free fascial ap for ring avulsion in-
jury. Ann Plast Surg 1990;25:312
Hirase Y, Kojima T, Hirakawa M. Secondary ear recon-
struction using deep tem poral fascia after tem poro-
parietal fascial reconstruction in m icrotia. Ann Plast
Surg 1990;25:53
Im anishi N, Nakajim a H, Minabe T, et al. Venous
drainage architecture of the temporal and parietal re-
gions: anatomy of the super cial temporal artery and
vein. Plast Reconstr Surg 2002;109:2197
Jenkins AM, Finucan T. Primary nonmicrosurgical recon-
struction following ear avulsion using the temporopari-
etal fascial island ap. Plast Reconstr Surg 1989;83:148
Kakibuchi M, Asada Y, Kobayashi S. Expanded free
scalp ap. Br J Plast Surg 1996;49:468
Lee H-B, Hong JP, Kim K-T, et al. Orbital oor and infra-
orbital rim reconstruction after total m axillectomy
using a vascularized calvarial bone ap. Plast Reconstr
Surg 1999;104:646
Marks MW, Friedman RJ, Thornton JW, Argenta LC. The
tem poral island scalp ap for m anagem ent of facial
burn scars. Plast Reconstr Surg 1988;82:257
Matsuba HM, Hakki AR, Romm S, et al. Variations on
the temporoparietal fascial ap. Laryngoscope 1990;
100:1236
Nakajim a H, Im anishi N, Minabe T. The arterial
anatomy of the temporal region and the vascular basis
of various temporal aps. Br J Plast Surg 1995;48:439
Park C, Lew D-H, Yoo W-M. An analysis of 123 tem -
poroparietal fascial aps: anatomic and clinical consid-
erations in total auricular reconstruction. Plast Recon-
str Surg 1999;104:1295
Quirke TE, Fiorillo MA, Sharm a PK. The reverse tem -
poroparietal fascia ap. Plast Reconstr Surg 1998;
101:1338
Rogachefsky RA, Ouellette EA, Mendietta CG, Galpin P.
Free temporoparietal fascial ap for coverage of a large
palmar forearm wound after hand replantation. J Re-
constr Microsurg 2001;17:421
660
IV.12 HEAD AND NECK: HEAD AND NECK
Rose EH. Small ap coverage of hand and digit defects.
Clin Plast Surg 1989;16:427
Rose EH, Norris MS. The versatile temporoparietal fas-
cial ap: adaptability to a variety of composite defects.
Plast Reconstr Surg 1990;85:224
Tellioglu AT, Tekdem ir I, Erdem i EA, et al. Tem poro-
parietal fascia: an anatomic and histologic reinvestiga-
tion with new potential clinical applications. Plast Re-
constr Surg 2000;105:40
Turpin IM, Altm an DI, Cruz HG, Achauer BM. Salvage of
the severely injured ear. Ann Plast Surg 1988;21:170
Upton J, Ferraro N, Healy G, et al. The use of prefabri-
cated fascial aps for lining of the oral and nasal cavi-
ties. Plast Reconstr Surg 1994;94:573
Upton J, Rogers C, Durham-Smith G, Swartz WM. Clin-
ical applications of free temporoparietal aps in hand
reconstruction. J Hand Surg [Am] 1986;11:475
Watanabe T, Iwasawa M, Kushim a H, Kikuchi N. Free
temporal fascial ap for coverage and extensor tendon
reconstruction. Ann Plast Surg 1996;37:469
Yano H, Nishimura G, Kaji S, et al. A clinical and histo-
logic com parison between free tem poroparietal and
scapular fascial aps. Plast Reconstr Surg 1995;95:452
Super cial Cervical Flap
Dassler EH, Anson HJ. Surgical anatomy of the subcla-
vian artery and its branches. Surg Gynec Obstet 1950;
108:149
Freeland AP, Rogers JH. The vascular supply of the cer-
vical skin with reference to incision planning. Laryngo-
scope 1975;85:714
Futrell JW, Rabson JA. Discussion of Colem an JJ, Jur-
kiewicz MJ, Nahai F, Mathes SJ. The platysma musculo-
cutaneous ap: experience with 24 cases. Plast Reconstr
Surg 1983;72:322
Huelke DF. A study of the transverse cervical and dor-
sal scapular arteries. Anat Rec 1958;132:233
Hurwitz DJ, Rabson JA, Futrell JW. The anatomic basis
for the platysm a skin ap. Plast Reconstr Surg 1983;
72:302
Kenyeres M. A new cervical island ap: a preliminary
report. Acta Chir Plast 1982;24:90
Lam berty BGH. The supraclavicular axial patterned
ap. Br J Plast Surg 1979;32:207
Lamberty BGH. The cutaneous arterial supply of cervi-
cal skin in relation to axial skin aps. Anat Clin
1982;3:317
Mathes SJ, Vasconez LO. The cervicohumeral ap. Plast
Reconstr Surg 1978;61:7
Morris RL, Dillm an D, McCabe JS, et al. The transverse
cervical neurovascular free ap. Ann Plast Surg 1983;
10:90
Submental Flap
Barthelemy I, Martin D, Sannajust J-P, et al. Prefabri-
cated super cial temporal fascia ap combined with a
subm ental ap in nom a surgery. Plast Reconstr Surg
2002;109:936
Baudet J, Martin D, Pascal JF, et al. The submental area:
a new donor site. Presented at the 10th Symposium of
the International Society of Reconstructive Micro-
surgery, Munich, Germany, September 19, 1991
Faltaous AA, Yetman RJ. The submental artery ap: an
anatom ic study. Plast Reconstr Surg 1996;97:56
Kim JT, Kim SK, Koshima I, Moriguchi T. An anatomic
study and clinical applications of the reversed sub-
m ental perforator-based island ap. Plast Reconstr
Surg 2002;109:2204
Koshima I, Inagawa K, Urushibara K, Moriguchi T. Com-
bined submental ap with toe web for reconstruction
of the lip with oral commissure. Br J Plast Surg 2000;
53:616
Martin D, Baudet J, Mondie JM, Peri G. A propos du
lambeau cutane sous-m ental en ilot: protocole opera-
toire. Perspectives d’utilisation. Ann Chir Plast Esthet
1990;35:480
Martin D, Pascal JF, Baudet J, et al. The submental is-
land ap: a new donor site. Anatomy and clinical ap-
plications as a free or pedicled ap. Plast Reconstr Surg
1993;92:867
Pistre V, Pelissier P, Martin D, et al. Ten years of expe-
rience with the subm ental ap. Plast Reconstr Surg
2001;108:1576
Sterne GD, Januszkiewicz JS, Hall PN, Bardsley AF. The
subm ental island ap. Br J Plast Surg 1996;49:85
BIBLIOGRAPHY
661
(Trang không có chữ)
A
Abdominal segm ents, pectoralis major ap, 456–460
Achilles tendon
composite anterolateral thigh ap, “tendon” transfer,
246, 246f
gastrocnemius anatomy, 297, 297f
Acromial arterial branch, anatomy, 453–455, 454f, 455t
Adductor canal exposure, posterior leg ap, proximal
popliteal artery elevation, 329, 329f
Adductor m agnus exposure, anterolateral thigh ap,
261, 261f
Allen’s test, radial forearm ap design, 49
Anatom ic snuff box, radial artery in, 113–114, 113f–114f
Angular artery
latissim us dorsi ap, anatomy and variations, 576, 576f
scapular bone-latissimus dorsi osteomuscular ap
identi cation, 596, 596f
muscle division, 597, 597f
Anterior approach
anterolateral thigh ap
comm on and super cial fem oral arteries, 255–257,
255f–257f
deep fem oral artery, 264, 264f
super cial fem oral artery, Hunter’s canal, 258–260,
258f–260f
femoral nerve and femoral vessel sheath exposure,
265, 265f
lateral arm ap, vascular bundle harvesting, 16, 16f
medial arm ap, vascular bundle harvesting, 10, 10f
medial leg ap, 319, 319f
reverse tibial island ap
applications, 318
cross-sectional diagram, 316, 316f, 322, 322f
harvesting, 318, 318f, 321, 321f
posterior tibial vessel exposure, 320, 320f
reverse harvesting pattern, 316, 316f
septocutaneous perforators elevation and identi cation,
319, 319f
tibial ap
anatomy, 311, 311f
applications, 312
harvesting technique, 312–313, 312f–313f, 315, 315f
vascular bundle dissection, 314, 314f
Anterior costal osteocutaneous ap
design, 506, 506f
osteotomy and ap elevation, 508, 508f
vascular bundle identi cation, 507, 507f
Anterior cutaneous nerve, anterolateral thigh (ALT) ap,
236, 236f
Anterior intercostal artery, vascularized rib graft
cartilage resection and vascular bundle identi cation,
504, 504f
incision and rib graft, 503, 503f
intercostal m uscle division, 505, 505f
intercostal space exposure, 504, 504f
osteotomy and rib graft elevation, 505, 505f
Anterior interosseous artery (AIA)
interosseous forearm ap, 72–74, 72f–74f
surgical approach, 79, 79f
Anterior interosseous (dorsal wrist) ap
applications, 76
design, 92, 92f
dorsal approach and vascular pedicle identi cation,
92, 92f
elevation and pedicle dissection, 93, 93f
Anterior tibial artery
arched segm ent exposure, bula resection
incision, 353, 353f
neck exposure, 354, 354f
neurovascular identi cation and dissection,
355, 355f
exposure, 356–358, 356f–358f
Anterolateral thigh (ALT) ap
anatomy, 234–236, 234f–236f
applications, 237
blood supply, 234–235, 234f–235f
Index
Index entries with “f” or “t” following the page m ean that the entry is in a gure or table, respectively.
chim eric ap
type 1, 249, 249f
type 2, 250, 250f
composite, with “tendon” transfer
design, 246, 246f
lateral portion elevation, 247, 247f
medial portion elevation, 246, 246f
“tendon” formation, 248, 248f
cutaneous ap, 243–244, 243f–244f
fasciocutaneous ap
intram uscular dissection, 242, 242f
perforator detection and design, 238, 238f
perforator veri cation, 241, 241f
vascular pedicle dissection, 242, 242f
“ ow-through” ap, 251–252, 251f–252f
recipient site exposures
adductor m agnus exposure, 261, 261f
anterior approach
com m on and super cial femoral arteries, 255–257,
255f–257f
deep femoral artery, 264, 264f
super cial fem oral artery, Hunter’s canal, 258–260,
258f–260f
deep femoral artery
cross-sectional diagram , 270, 270f
identi cation, 269, 269f
fem oral artery identi cation, 262, 262f
fem oral nerve/vessel sheath exposure, 265–266,
265f–266f
posterior approach
deep femoral artery, 267, 267f
super cial fem oral artery, 261, 261f
sciatic nerve, 268, 268f
super cial fem oral artery, cross-sectional diagram ,
263, 263f
sensate ALT ap
ap elevation, 254, 254f
sensory nerve identi cation, 253, 253f
sensory innervation, 236, 236f
septofasciocutaneous ap, 239–240, 239f–240f
Anterom edial thigh ap
anatomy, 231, 231f
anterior elevation, 232, 232f
completion, 233, 233f
harvesting technique, 232, 232f
innervation, 231
vascular pedicle dissection, 233, 233f
Aponeurosis
composite groin ap
elevation, 170, 170f
exposure, 169, 169f
internal oblique ap exposure, 197, 197f
Arcuate artery, dorsalis pedis ap, 373
Arterial anatomy. See also Blood supply; Venous drainage;
speci c arteries
carotid dissection, 659, 659f
dorsalis pedis ap, 372–373, 372f
rst web space skin aps (lower extremity),
417, 417f
free second toe transfer, 411, 411f
free toe /toe tissue transfers, 399, 399f
interosseous forearm ap, 72–74, 72f–74f
lateral thoracic ap, 509, 509f
pectoralis major ap, 453–456, 454f, 455t
recipient site exposure, 439, 439f, 441, 441f
rectus abdom inis ap, 518–519, 519f
revascularized costal bone graft and intercostal ap,
489, 489f
super cial cervical ap, 644, 644f
temporoparietal ap, 631, 631f
Arteriography, radial forearm ap design, 49
Auriculotemporal nerve, temporoparietal ap,
632, 633f
Axial fasciocutaneous ap, posterior leg ap, 325
Axilla
dissection and identi cation, 29, 29f
recipient site exposure, 28, 28f
scapular ap, pedicle dissection, 611, 611f
Axillary artery
exposure as recipient site, 22–24, 22f
anatomic structure dissection and identi cation,
26, 26f
branch variations, 23, 23f
rst and second parts, 24, 24f
second and third parts, 27, 27f
lateral thoracic ap
accessory lateral thoracic artery dissection,
511, 511f
applications, 510
arterial anatomy, 509, 509f
design and incision, 510, 510f
elevation, 514, 514f
innervation, 509
lateral thoracic artery dissection, 512, 512f
thoracodorsal artery dissection, 513, 513f
venous drainage, 509
B
Basilic predom inance, super cial veins, 45, 45f
Basilic vein
brachial super cial structures, 34, 34f
forearm drainage, 44, 44f
ulnar forearm ap elevation, 71, 71f
Bilobed split latissim us ap
applications, 578
lateral and medial branch marking, 588, 588f
muscle separation, 589, 589f
Bilobed temporal fascia ap
deep fascia ap elevation, 638, 638f
elevation, 637, 637f
Blood supply. See also Arterial anatomy; Venous
drainage
anterolateral thigh (ALT) ap, 234–235, 234f–235f
extensor digitorum brevis ap, 388, 388f
free jejunum transfer, 555–556, 556f
gastrocnemius muscle, 298, 298f
gluteus m axim us ap, 130t, 130, 130f
gracilis ap, 203
greater omentum transfer, 543–544, 543f, 544t
internal oblique ap, 196
664 INDEX
pectoralis major ap, 453–456, 454f, 455t
pectoralis minor ap, 471–472, 471f
rectus abdominis ap, 518–519, 519f
abdominal skin supply, 520, 520f
rectus femoris ap, 219, 219f
serratus anterior ap, 476, 476f
temporoparietal fascia ap, 634, 634f
tensor fasciae latae ap, 213, 213t
Bone grafts
revascularized costal bone graft and intercostal ap,
489, 489f
vascularized bula
applications, 278
cross-sectional diagram, 284, 284f
extraperiosteal exposure, bula lateral aspect, 280, 280f
incision, 279, 279f
osteotomy, 281, 281f
peroneal vessel identi cation, 282, 282f
posterior crural septum approach, 279, 279f
vascular bundle dissection and harvesting completion,
283, 283f
vascularized iliac
anatomy, 181, 181f, 181t
applications, 132
deep circum ex iliac artery anatomy, 179–180,
179f–180f, 179t
applications, 181
dissection, 184, 184f
donor closure, 189, 189f
incision, 182, 182f
inner lip osteotomy, 188, 188f
inner space, DCIA dissection, 185, 185f
middle/outer layer suturing, 190, 190f
outer ilium exposure, 186, 186f
pedicle approach, 183, 183f
whole iliac crest osteotomy, 187, 187f
gluteus m axim us m uscle anatomy, 130, 130f
gluteus m edius approach, 141, 141f
groin aps, 157
inner ilium approach, 143, 143f
neurovascular bundle exposure, 142, 142f
osteotomy, 144, 144f
superior gluteal vessel approach, 140, 140f
vascularized rib graft (posterior intercostal artery)
incision, 490, 490f
intercostal space and rib exposure, 492, 492f
neurovascular bundle identi cation and dissection,
493, 493f
osteotomy and bony graft isolation, 494, 494f
serratus anterior muscle exposure, 491, 491f
Bony segm ent
osteocutaneous groin ap, 166, 166f
radial forearm osteocutaneous ap, 59, 59f
elevation toward vascular bundle, 60, 60f
medial exposure, 61, 61f
reversed posterior interosseous osteocutaneous ap,
87, 87f, 90, 90f
scapular bone-latissim us dorsi osteomuscular ap,
exposure, 598, 598f
scapular osteocutaneous ap, 614–615, 614f–615f
Brachial artery, recipient site exposure, 29–30
anatom ic structure dissection and identi cation,
32, 32f
bifurcation, 95–96, 95f–96f
deep artery and radial nerve exposure, 37, 37f
medial approach, 30, 30f
middle part exposure, 33, 33f
posterior approach, deep and proxim al portions,
36, 36f
proxim al part, 30, 30f
retraction techniques, 38, 38f
Brachial vein, exposure of, 34, 34f
C
Calcaneal tendon, gastrocnemius anatomy,
297, 297f
Carotid artery
dissection, 659, 659f
external and branch exposure, 656, 656f
Carotid sheath, recipient site exposure, 658, 658f
Cartilage resection, vascularized rib graft, 504, 504f
Cephalic predom inance, super cial veins, 45, 45f
Chimeric anterolateral thigh (ALT) ap, 237
type 1, 249, 249f
type 2, 250, 250f
Circum ex scapular artery
anatomy, 605, 605f
com bined scapular and latissim us dorsi aps,
621, 621f
Clavicular segment, pectoralis major ap
applications, 455
dissection and completion, 468, 468f
incision, 465, 465f
interm uscular septum , 466, 466f
myocutaneous donor site patterns, 470, 470f
neurovascular pedicle dissection, 467, 467f
osteomuscular donor site patterns, 469, 469f
Clavipectoral fascia, exposure of, 25, 25f
Cleland’s ligament, super cial palmar arch, 110
Colon separation, free omentum transfer, 546, 546f
Com bined pedicle release, combined scapular and
latissimus dorsi aps, 622, 622f
Com bined scapular and latissim us dorsi aps
circum ex scapular vessels, 621, 621f
conjoined pedicle, teres m ajor division, 622, 622f
design, 619, 619f
elevation and m uscle exposure, 620, 620f
Com bined scapular and parascapular aps
design, 617, 617f
harvesting, 618, 618f
Com bined sternocostal/abdominal segm ents, pectoralis
major ap, 456–460
distal m uscle ap detachm ent and elevation,
458, 458f
incision, 456, 456f
muscle exposure, 457, 457f
neurovascular structure identi cation, 459, 459f
pedicle dissection and ap completion, 460
Com mon fem oral artery, anterolateral thigh ap,
anterior approach, 255, 255f
INDEX 665
Composite anterolateral thigh ap, “tendon” transfer
design, 246, 246f
ap completion, 247, 247f
lateral portion elevation, 247, 247f
medial portion elevation, 246, 246f
“tendon” formation, 248, 248f
Composite groin ap, “tendon” transfer, 168–171,
168f–171f
aponeurosis elevation, 170, 170f
aponeurosis exposure, 169, 169f
design and incision, 168, 168f
Composite serratus-latissim us muscle ap
elevation, 486, 486f
incision, 485, 485f
Composite stom ach/omentum ap
cross-sectional diagram, 551, 551f
posterior stom ach wall exposure, 550, 550f
stom ach clamping, 552, 552f
stom ach excision, 553, 553f
tube prefabrication, 554, 554f
Coracobrachialis m uscle, recipient site exposure, 31, 31f
Costal bone graft and intercostal ap, 489, 489f
Crossover pattern, retrograde deep venous system ,
46, 46f
Cutaneous aps, anterolateral thigh (ALT) ap, 243–244,
243f–244f
Cutaneous perforators, rectus abdom inis ap, 520, 520f
Cutaneous vessels, posterior leg ap, 326, 326f
D
Deep brachial artery, anatomy, 12, 12f
Deep circum ex iliac artery (DCIA)
groin aps, 157
iliac osteocutaneous ap
design, 191, 191f
elevation, 193, 193f
exposure and dissection, 192, 192f
osteotomy, 194–195, 194f–195f
internal oblique ap, 196
elevation, 198, 198f
pedicle dissection, 199, 199f
internal oblique osteom uscular ap, 200, 200f
vascularized iliac bone grafts
anatomy, 179–180, 179f–180f, 179t
applications, 181
dissection, 184, 184f
donor closure, 189, 189f
incision, 182, 182f
inner lip osteotomy, 188, 188f
inner space, DCIA dissection, 185, 185f
m iddle/outer layer suturing, 190, 190f
outer ilium exposure, 186, 186f
pedicle approach, 183, 183f
whole iliac crest osteotomy, 187, 187f
Deep fascia, brachial super cial structures, 34, 34f
Deep fem oral artery
anterior approach, 264, 264f
anterolateral thigh (ALT) ap, 234–235, 234f–235f
cross-sectional diagram, 270, 270f
dissection, 257, 257f
identi cation, 266, 266f, 269, 269f
posterior approach, 267, 267f
Deep inferior epigastric artery (DIEA)
lower transverse rectus abdom inis myocutaneous (TRAM)
ap, 527, 527f
recipient site exposure
dissection, 563, 563f
identi cation of, 562, 562f
incision, 561, 561f
rectus abdominis ap
anatomy, 518–519, 519f
applications, 521
rectus abdominis muscle ap
incision, 522, 522f
m uscle exposure, 522, 522f
Deep inferior epigastric perforator (DIEP) ap
applications, 521
blood supply, 520, 520f
design, 536, 536f
Doppler detection, 535, 535f
harvesting completion, 540, 540f
intram uscular dissection of perforators, 539, 539f
modi cation, 541
harvesting, 542, 542f
m uscle cuff creation, 541, 541f
perforator identi cation and pedicle dissection,
541, 541f
nerve dissection, 539, 539f
opposite side ap elevation, 537, 537f
pedicle identi cation, 538, 538f
perforator identi cation, 537, 537f
perforator selection, 538, 538f
Deep palmar arch system
princeps pollicis artery, 117–121
palmar approach, 117–119, 117f–119f
radial artery anatomy, 109–110, 109f
variations, 112, 112f
Deep peroneal nerve, dorsalis pedis ap, 373, 373f
Deep plantar artery, free toe/toe tissue transfers, 399, 399f
Deep superior epigastric artery, rectus abdominis ap,
518–519, 519f
Deep temporal fascia, elevation, 637–638, 638f
Deltoid arterial branch, anatomy, 453–455, 454f, 455t
Deltoid ap
anatomy, 3–4, 3f–4f
harvesting technique, 5–7
ap design, 5, 5f
ap elevation, 6, 6f
pedicle dissection, 7, 7f
pedicle identi cation, 7, 7f
innervation, 4, 4f
Digital artery and nerve, incision and exposure sites,
124–125, 124f–125f
Disarticulation
dorsalis pedis osteocutaneous ap, second TMT joint and
ap completion, 384, 384f
free proxim al interphalangeal joint transfer,
433, 433f
Dissection
adductor m agnus exposure, 261, 261f
666 INDEX
ALT perforator fasciocutaneous ap, vascular pedicle,
242, 242f
anterior tibial ap, vascular bundle, 314, 314f
anterolateral septofasciocutaneous ap, 240, 240f
anterom edial thigh ap, 233, 233f
carotid arterial system, 659, 659f
deep circum ex iliac artery
iliac osteocutaneous ap, 192, 192f
vascularized iliac bone grafts, 184–185, 184f–185f
deep inferior epigastric artery, 563, 563f
deep inferior epigastric perforator ap
intram uscular dissection of perforators, 539, 539f
modi ed pedicle dissection, 541, 541f
nerve dissection, 539, 539f
dorsalis pedis ap
distal border, 378, 378f
proxim al dissection, 380, 380f
dorsalis pedis osteocutaneous ap, neurovascular
structures, 383, 383f
en bloc second and third toe transfers, vascular system ,
436, 436f
extensor digitorum brevis ap, pedicle dissection,
389–390, 390f
femoral artery, anterolateral thigh ap, 257, 257f
bula resection, neurovascular bundle, 355, 355f
rst web space skin aps (lower extremity)
plantar aspect, 418, 418f
venous and arterial systems, 417, 417f
free big toe transfer
rst dorsal m edial artery, 406, 406f
super cial veins, 404, 404f
vascular pedicle, 407, 407f
free jejunum transfer, pedicle dissection, 559, 559f
free proxim al interphalangeal joint transfer, neurovascular
bundle, 432, 432f
free second toe transfer
rst dorsal m edial artery, 412, 412f
metatarsophalangeal joint, vascular systems,
434, 434f
pedicle dissection, 413, 413f
plantar side, 414, 414f
super cial veins, 410, 410f
glutei m axim us/m edius septum exposure, 153, 153f
gracilis myocutaneous ap, 210, 210f
intercostal neurovascular bundle, 493, 493f
internal oblique ap, 199, 199f
intram uscular
ALT perforator fasciocutaneous ap, 242, 242f
thoracodorsal artery perforator (TAP) ap,
603, 603f
lateral intercostal skin ap, vascular pedicle,
498, 498f
lateral thigh ap, vascular pedicle, 229–230, 229f–230f
lateral thoracic ap
accessory lateral thoracic artery, 511, 511f
lateral thoracic artery, 512, 512f
thoracodorsal artery, 513, 513f
latissim us dorsi ap
lateral border dissection, 581, 581f
neurovascular pedicle dissection, 582, 582f
lower transverse rectus abdom inis myocutaneous
(TRAM) ap, pedicle dissection, 531, 531f
modi ed wrap-around ap (lower extrem ity)
neurovascular pedicle, 423, 423f
plantar dissection, 424, 424f
pectoralis major ap
muscle ap completion, 468, 468f
neurovascular pedicle, 467, 467f
pedicle dissection, 460, 460f
peroneal vessels, bular osteocutaneous ap, 290, 290f
posterior leg ap
popliteal fossa identi cation and dissection, 343, 343f
vascular pedicle, 327, 327f
radial forearm ap, 49, 49f
rib-latissim us dorsi osteomyocutaneous ap, 594, 594f
scapular triangular space, 610, 610f
sensate anterolateral thigh (ALT) ap, 254, 254f
serratus anterior costo-osteom uscular ap, vascular
pedicle, 488, 488f
serratus anterior myocutaneous ap, vascular pedicle,
484, 484f
subm ental ap
pedicle dissection, 655, 655f
upper border, 653, 653f
super cial cervical ap, neurovascular pedicle, 649, 649f
super cial circum ex iliac artery, 160, 160f
medial-to-lateral procedure, 162, 162f
temporoparietal fascia ap, vascular pedicle, 636, 636f
tensor fasciae latae (TFL) ap, 217, 217f
tibioperoneal trunk
arteries, 346, 346f
vascular bundle, 349, 349f
vascular bundle, vascularized bula bone graft, 283, 283f
wrap-around ap (lower extrem ity)
neurovascular pedicle, 420, 420f
plantar dissection, 421, 421f
Distal dissection
gracilis myocutaneous ap, 210, 210f
latissimus dorsi ap, 583, 583f
posterior leg ap, popliteal artery exposure, 334, 334f,
340, 340f
Distal elevation
dorsalis pedis ap, 379, 379f
medial plantar ap, 395, 395f
posterior leg ap, cutaneous vessel identi cation,
326, 326f
tensor fasciae latae ap, 215, 215f
Distal gracilis exposure, gracilis m uscle ap, 207, 207f
Distal interphalangeal (DIP) joint, free toe/toe tissue
transfers, 401–402
Distal muscle ap, pectoralis m ajor, 458, 458f
Distal perforating artery, free toe/toe tissue transfers,
399, 399f
variations, 400, 400f, 400t
Distal phalanx, m odi ed wrap-around ap (lower extremity),
medial ap elevation, 426, 426f
Donor closure
dorsalis pedis osteocutaneous ap, 384, 384f
en bloc second and third toe transfers, 437, 437f
iliac bone grafts, 189, 189f
INDEX 667
modi ed wrap-around ap (lower extrem ity),
429, 429f
Donor enhancement, lower transverse rectus abdom inis
myocutaneous (TRAM) ap, 529, 529f
Doppler owm eter
composite anterolateral thigh ap, “tendon” transfer,
246, 246f
deep inferior epigastric perforator ap, 535, 535f
inferior gluteal artery perforator ap, 148–149, 148f
musculocutaneous perforator veri cation, 241, 241f
superior gluteal artery perforator (S-GAP) ap, 145, 145f
perforator identi cation, 146, 146f
thoracodorsal artery perforator (TAP) ap, 600, 600f
Dorsal approach
free big toe transfer incisions, 403, 403f
princeps pollicis artery, deep palm ar arch origin, 120–121,
120f–121f
super cial cervical ap, 648, 648f
wrap-around ap (lower extrem ity), neurovascular pedicle
dissection, 420, 420f
wrist ap
design, 92, 92f
dorsal approach and vascular pedicle identi cation,
92, 92f
elevation and pedicle dissection, 93, 93f
Dorsal arterial system , free toe /toe tissue transfers, 399, 399f
Dorsalis pedis artery
anatomic variations, 374, 374f
anatomy, 372–373, 372f
extensor digitorum brevis ap, 389
free pulp ap elevation, 430, 430f
recipient site exposure, 438, 438f
Dorsalis pedis ap
applications, 376
arterial anatomy, 372–373, 372f
FDMA variations, 375, 375f, 376t
variations, 374, 374f
innervation, 373
osteocutaneous ap, second metatarsal
design, 381, 381f
donor site closure, 384, 384f
lateral elevation, 382, 382f
m edial elevation, 381, 381f
m etatarsophalangeal joint, disarticulation, 382, 382f
neurovascular proxim al dissection, 383, 383f
TMT joint, disarticulation and ap completion, 384, 384f
skin ap
design, 377, 377f
distal border dissection, 378–378f
distal elevation, 379, 379f
elevation completion, 380, 380f
proxim al dissection, 380, 380f
vascular bundle, m edial elevation and identi cation,
379, 379f
tendinocutaneous ap, extensor tendons
completion with tendons, 387, 387f
design, 385, 385f
lateral elevation, 386, 386f
vascular bundle, m edial elevation, 385, 385f
venous drainage, 373, 373f
Dorsalis pedis tendinocutaneous ap, extensor tendons
completion, 387, 387f
design, 385, 385f
lateral elevation, 368f, 386
vascular bundle, m edial elevation, 385, 385f
Dorsal m etatarsal veins, free second toe transfer,
410, 410f
Dorsum region, neurovascular pedicle dissection,
423, 423f
E
En bloc second and third toe transfers
donor closure, 437, 437f
harvesting completion, 437, 437f
vascular dissection, 436, 436f
Extensor digitorum brevis ap
anatomy, 388, 388f
applications, 389
blood supply, 388, 388f
incisions, 389, 389f
innervation, 388, 388f
muscle ap completion, 392, 392f
muscle insertions and origin, detachm ent,
391, 391f
neurovascular pedicle exposure, 390, 390f
Extensor hallucis brevis m uscle
extensor digitorum brevis ap, 392, 392f
free big toe transfer, vascular pedicle identi cation,
405, 405f
free second toe transfer, 411, 411f
Extensor hallucis longus m uscle, recipient site exposure,
438, 438f
Extensor tendons, dorsalis pedis tendinocutaneous ap,
385, 385f
Extraperiosteal exposure, vascularized bula bone graft,
280, 280f
F
Facial artery, subm ental ap, 650, 650f
Facial palsy, extensor digitorum brevis ap, 389
Fem oral artery, anterolateral thigh ap
dissection, 257, 257f
identi cation, 260, 260f, 262, 262f
Fem oral nerve exposure, anterior approach, 265, 265f
Fem oral vessel sheath, anterior exposure, 265, 265f
Fibula-adjacent tissue transfer
applications, 278
bula anatomy, 278, 278f
peroneal artery anatomy, 275–276, 275f–276f
variations, 277, 277f
Fibula anatomy, 278, 278f
Fibula bone graft
applications, 278
cross-sectional diagram, 284, 284f
extraperiosteal exposure, bula lateral aspect,
280, 280f
incision, 279, 279f
osteotomy, 281, 281f
peroneal vessel identi cation, 282, 282f
668 INDEX
posterior crural septum approach, 279, 279f
vascular bundle dissection and harvesting completion,
283, 283f
Fibula resection, anterior tibial artery arched segm ent
artery exposure, 355, 355f
incision, 353, 353f
neck exposure, 354, 354f
neurovascular identi cation and dissection, 355, 355f
Fibular osteocutaneous ap
applications, 278
completion, 291, 291f
cross-sectional diagram, 292, 292f
design, 289, 289f
posterior crural approach, 289, 289f
Fibular osteom uscular ap
applications, 278
soleus m uscle transfer
cross-sectional diagram, 296, 296f
exposure techniques, 293, 293f
harvesting completion, 295, 295f
incision, 293, 293f
neurovascular structures, splitting and identi cation,
294, 294f
osteotomy, 295, 295f
First dorsal m edial artery (FDMA)
dorsalis pedis ap, 373, 375f
distal border dissection, 378, 378f
osteocutaneous ap, second m etartasal,
381, 381f
free big toe transfer
dissection, 406, 406f
vascular pedicle identi cation, 405, 405f
free pulp ap elevation, 430, 430f
free second toe transfer
anatomy, 411, 411f
dissection, 412, 412f
metatarsophalangeal joint, 434, 434f
free toe/toe tissue transfers, 399, 399f
applications, 401–402
variations, 400, 400f, 400t
MTP joint anatomy, 431, 431f
variations, 375, 375f, 376t
First web space skin aps (lower extrem ity)
design, 416, 416f
dissection, m odi ed wrap-around ap, 425, 425f
elevation technique, 418, 418f
plantar aspect dissection, 418, 418f
venous and arterial dissection, 417, 417f
Flap thinning, anterolateral thigh cutaneous ap,
244, 244f
Flap transfer, hybrid radial forearm ap, 65, 65f
Flexor carpi ulnaris, ulnar forearm ap, 69, 69f
Flexor digitorum brevis m uscle, m edial plantar ap,
393–394
Flexor digitorum super cialis, radial forearm dissection,
70, 70f
Flexor hallucis longus, proxim al tibial artery exposure,
365, 365f
“Flow-through” technique, anterolateral thigh ap, 237,
251–252, 251f–252f
Forearm aps
anterior interosseous (dorsal wrist) ap
design, 92, 92f
dorsal approach and vascular pedicle identi cation,
92, 92f
elevation and pedicle dissection, 93, 93f
ap elevation accomplishing, 71, 71f`
hybrid radial forearm ap
harvesting and venous dissection, 65, 65f
transfer, 66, 66f
innervation, 47, 47t
interosseous forearm ap
arterial anatomy, 72–74, 72f–74f
posterior interosseous nerve, 75–76, 75f
posterior interosseous ap
approach to PIA, 79, 79f
design, 77, 77f
pedicle dissection, 81, 81f
radial ap elevation, 78, 78f
ulnar portion elevation, 80, 80f
radial artery anatomy, 40, 41f
variations, 40, 42f
radial forearm, 48, 48f
design, 49, 49f
distal dissection, 49, 49f
harvesting completion, 54, 54f
penile reconstruction, 55, 55f, 57, 57f
proxim al side dissection, 52, 52f
ulnar distal side dissection, 50, 50f
ulnar proxim al side dissection, 51, 51f
urethral creation, 56, 56f
radial forearm osteocutaneous ap
bony segment proposal, 59, 59f
medial bony segm ent exposure, 61, 61f
osteotomy
vascular bundle and bony segm ent ap elevation,
60, 60f
radial forearm tendinocutaneous ap
completion, 64, 64f
proposed tendons, 63, 63f
radial side dissection, 52, 52f
retrograde deep venous system , 46, 46f
reversed posterior interosseous ap
completely raised ap, 85, 85f
design, 82, 82f
distal pedicle dissection, 84, 84f
hand transfer, 86, 86f
radial elevation and PIA approach, 83, 83f
reversed posterior interosseous osteocutaneous ap
bony exposure, 90, 90f
elevation and pedicle approach, 88, 88f
interosseous m em brane exposure, 89, 89f
proposed bony segment, 87, 87f
ulnar osteotomy, 91, 91f
reversed radial forearm island ap, 58, 58f
super cial venous variations, 45, 45f
ulnar artery anatomy, 40, 41f
variations, 40, 43f
ulnar forearm , radial aspect dissection,
70, 70f
INDEX 669
ulnar forearm ap
design, 67, 67f
distal and proxim al neurovascular dissection,
68, 68f
venous drainage, 44, 44f
Fourth lum bar artery iliac ap
anatomy, 175, 175f
harvesting and design criteria, 176, 176f
osteotomy and ap completion, 178, 178f
vessel identi cation, 177, 177f
Free big toe transfer
dorsal/plantar aspects, incisions, 403, 403f
FDMA dissection, 406, 406f
MTP joint disarticulation, and harvesting,
408, 408f
plantar side dissection, 408, 408f
super cial vein dissection, 404, 404f
vascular pedicle identi cation, 405, 405f,
407, 407f
Free jejunum transfer
anatomy, 555, 555f
applications, 556
blood supply, 555–556, 556t
division and pedicle dissection, 559, 559f
emptying and clamping, 558, 558f
incision, 557, 557f
jejunum restoration, 560, 560f
Free om entum transfer
colon separation, 546, 546f
incision, 545, 545f
omentum delivery, 545, 545f
pedicle isolation, 547, 547f
Free pulp ap
design, 430, 430f
elevation techniques, 430, 430f
Free scalp skin ap
design, 641, 641f–642f
elevation, 643, 643f
Free second toe transfer
arterial anatomy, 411, 411f
rst dorsal m edial artery dissection,
412, 412f
incision, 409, 409f
metatarsophalangeal (MTP) joint
incision and skin island design,
434, 434f
osteotomy and harvesting completion,
435, 435f
vascular dissection, 434, 434f
MTP joint disarticulation and harvesting, 415, 415f
pedicle dissection, 413, 413f
plantar side dissection, 414, 414f
proxim al interphalangeal (PIP) joint
disarticulation, osteotomy, and harvesting
completion, 433, 433f
incision and skin island design, 431, 431f
neurovascular bundle dissection, 432, 432f
super cial vein dissection, 410, 410f
Free toe tissue transfers
applications, 401–402
arterial anatomy, 399, 399f
variations, 400, 400f, 400t
G
Gastrocnemius muscle
anatomy, 297–298, 297f, 298t
blood supply, 298
innervation, 298
lateral ap
harvesting completion, 304, 304f
incision, 303, 303f
medial ap
harvesting techniques, 302, 302f
incision, 299, 299f
m edial head, neurovascular bundle identi cation,
300, 300f
m uscle isolation, 301, 301f
neurovascular structures, popliteal fossa, 299, 299f
microvascular transfer, applications, 298
myocutaneous ap, applications, 298
posterior leg ap, m edial head exposure, 335, 335f
soleus exposure, 293f, 293
tibioperoneal trunk, m edial head exposure, 345, 345f
Gluteal thigh ap
applications, 132
design, 136, 136f
distal elevation, 137, 137f
Gluteus m axim us ap
anatomy, 129–132
elevation completion, 139, 139f
inferior gluteal artery perforator ap (I-GAP ap),
148–150
design and Doppler detection, 148–149, 148f
elevation and perforator identi cation, 149, 149f
elevation completion, 150, 150f
intram uscular dissection, 150, 150f
muscle detachment, 138, 138f
muscle ap
anatomy, 129, 129f–130f
applications, 132
blood supply, 130, 130f, 130t
innervation, 131, 131f
recipient site exposure, 151–153
maximus/m edius septum exposure, 152, 152f
superior gluteal artery, 151, 151f
vessel exposure, 153, 153f
superior gluteal artery perforator (S-GAP) ap, 145–147
applications, 132
design and Doppler detection, 145, 145f
intram uscular/pedicle dissection, 147, 147f
lower portion elevation, 146, 146f
upper portion elevation and perforator identi cation,
146, 146f
superior gluteus myocutaneous ap
design, 133, 133f
elevation completion, 135, 135f
upper lateral edge exposure, 134, 134f
vascular pedicle approach, 134, 134f
thigh ap
applications, 132
670 INDEX
distal elevation, 137, 137f
inferior gluteal vessels, 136, 136f
vascularized iliac bone graft, 140–144
gluteus m edius approach, 141, 141f
incision, 140, 140f
inner ilium approach, 143, 143f
neurovascular bundle exposure, 142, 142f
osteotomy, 144, 144f
Gluteus maximus muscle
anatomy, 129, 129f–130f
blood supply, 130, 130f, 130t
ap, applications involving, 132
innervation, 131, 131f
septum exposure, 152, 152f
Gluteus medius approach
septum exposure, 152, 152f
vascularized iliac bone grafts, 141, 141f
Gracilis ap
anatomy, 203, 203f
applications, 204
blood supply, 203
innervation, 204, 204t
muscle ap
completion, 208, 208f
distal gracilis exposure, 207, 207f
incisions, 205, 205f
vascular pedicle approach, 206, 206f
myocutaneous ap
design, 209, 209f
elevation and completion, 211, 211f
vascular pedicle approach and distal dissection,
210, 210f
Greater om entum extension
blood supply dam age, 549, 549f
route tailoring, 548, 548f
Greater om entum transfer
anatomy, 543, 543f, 543t
applications, 544
blood supply, 543–544, 544t
Greater saphenous vein
anterolateral thigh ap, exposure of, 256, 256f
saphenous ap
harvesting completion, 310, 310f
identi cation, 308, 308f
Groin aps
anatomy, 155–156, 155f–156f
applications, 157
composite aps, “tendon” transfer, 168–171, 168f–171f
osteocutaneous ap, 166, 166f
venous drainage, 156, 156f
H
Ham string exposure, posterior leg ap, 332, 332f
Hand aps
deep palm ar arch system
princeps pollicis artery, 117–121, 117f–121f
radial artery anatomy, 109–110, 109f
digital artery and nerve, 124, 124f–125f
recipient site exposures, anatom ic snuff box, radial artery,
113–114, 113f
reversed posterior interosseous ap transfer, 86, 86f
super cial palmar arch
incision and exposure, 122–123, 122f–123f
ulnar artery anatomy, 110–112, 110t, 111f–112f
Harvesting techniques
anterior tibial ap, 312–313, 312f–313f, 315, 315f
anterom edial thigh ap, 232, 232f
deep inferior epigastric perforator ap, 540, 540f
modi cation, 542, 542f
deltoid ap, 5–7
en bloc second and third toe transfers, 437, 437f
bular osteom uscular ap, soleus transfer, 295, 295f
free big toe transfer, 408, 408f
free jejunum transfer, 557, 557f
free metatarsal phalangeal joint, 435, 435f
free proxim al interphalangeal joint transfer, 433, 433f
hybrid radial forearm ap, 65, 65f
iliac ap, 176, 176f
lateral arm ap, 14–17
lateral gastrocnem ius m uscle ap, 304, 304f
lateral thigh ap, 228, 228f
lateral thoracic ap, 510, 510f
latissimus dorsi ap, 584, 584f
medial arm ap, 9–11
medial gastrocnem ius m uscle ap, 302, 302f
medial leg ap, 318, 318f, 321, 321f
medial plantar ap, 394, 394f
medial thigh ap, 224, 224f
modi ed wrap-around ap (lower extrem ity),
prefabricated aps, 429, 429f
myocutaneous pectoralis m ajor ap, 462, 462f
osteomyocutaneous pectoralis m ajor ap, 464, 464f
pectoralis minor ap, 472, 472f, 475, 475f
posterior arm ap, 19–21
posterior leg ap, 325, 325f
radial forearm ap, 54, 54f
rectus abdominis muscle ap, 524, 524f
reverse anterior tibial island ap, 316, 316f
saphenous ap, 307, 307f, 310, 310f
scapular ap, 613, 613f
serratus anterior ap, 482, 482f
subm ental artery, 650, 650f
super cial cervical ap, 646, 646f
thoracodorsal artery perforator (TAP) ap, 604t, 604f
wrap-around ap (lower extrem ity), 421, 421f
Hunter’s canal, super cial femoral artery, anterior approach
to, 258–259, 258f–259f
Hybrid radial forearm ap
harvesting and venous dissection, 65, 65f
transfer, 66, 66f
I
Iliac bone anatomy, 181f, 181t
Iliac bone grafts
applications, 132
deep circum ex iliac artery anatomy, 179–180, 179f–180f
applications, 181
dissection, 184, 184f
donor closure, 189, 189f
incision, 182, 182f
INDEX 671
inner lip osteotomy, 188, 188f
inner space, DCIA dissection, 185, 185f
middle/outer layer suturing, 190, 190f
outer ilium exposure, 186, 186f
pedicle approach, 183, 183f
whole iliac crest osteotomy, 187, 187f
gluteus maximus m uscle anatomy, 130, 130f
gluteus medius approach, 141, 141f
inner ilium approach, 143, 143f
neurovascular bundle exposure, 142, 142f
osteotomy, 144, 144f
superior gluteal vessel approach, 140, 140f
Iliac crest, osteotomy
inner lip, 188, 188f
whole layer, 187, 187f
Iliac ap
design and incision, 164, 164f
fourth lum bar artery
anatomy, 175, 175f
harvesting and design criteria, 176, 176f
osteotomy and ap completion, 178, 178f
vessel identi cation, 177, 177f
super cial circum ex iliac artery identi cation, 165, 165f
Iliac osteocutaneous ap, deep circum ex iliac artery
design, 191, 191f
elevation, 193, 193f
exposure and dissection, 192, 192f
osteotomy, 194–195, 194f–195f
Iliacus sutures, iliac bone grafts, 189, 189f
Iliofem oral ap, super cial circum ex iliac artery
artery identi cation and dissection, 160, 160f
design, 158, 158f
elevation completion, 161, 161f
identi cation of SCIA, 163, 163f
lateral-to-m edial procedure, 159, 159f
m edial-to-lateral procedure, 162, 162f
Ilium inner space, deep circum ex iliac artery dissection,
185, 185f
Inferior gluteal artery, gluteus m axim us m uscle, 130, 130f
Inferior gluteal artery perforator ap (I-GAP ap), 148–150
design and Doppler detection, 148–149, 148f
elevation, 149–150, 149f–150f
intram uscular dissection, 150, 150f
perforator identi cation, 149, 149f
Inferior gluteal nerve, 131, 131f
Inferior gluteal neurovascular bundle, gluteal thigh ap,
138, 138f
Inferior lateral peroneal artery, anterior tibial ap, 311, 311f
Inner ilium approach
iliac bone grafts, 143, 143f
osteotomy, inner table, 195, 195f
Innervation
anterom edial thigh ap, 231, 231f
deltoid ap, 4, 4f
dorsalis pedis ap, 373, 373f
extensor digitorum brevis ap, 388, 388f
forearm ap, 47, 47t
gastrocnemius muscle, 298, 298f
gluteus maximus m uscle, 129, 129f, 131, 131f
gracilis ap, 204, 204t
lateral arm ap, 13, 13t
lateral thigh ap, 227
lateral thoracic ap, 509
latissim us dorsi ap, 572f–573f, 576
m edial arm ap, 8–9
m edial plantar ap, 393
m edial thigh ap, 223, 223f
pectoralis major ap, 453–455, 454f, 455t
pectoralis minor ap, 472
posterior arm ap, 18, 18t
posterior cervical triangle, 644, 644f
posterior leg ap, 323, 323f
rectus abdominis ap, 520, 520f
rectus femoris ap, 219, 219t
serratus anterior ap, 476
submental ap, 650
tensor fasciae latae (TFL) ap, 213, 213t
sensory nerve identi cation, 216, 216f
Intercostal artery
anterior, vascularized rib graft
cartilage resection and vascular bundle identi cation,
504, 504f
incision and rib graft, 503, 503f
intercostal muscle division, 505, 505f
intercostal space exposure, 504, 504f
osteotomy and rib graft elevation, 505, 505f
posterior
revascularized costal bone graft and intercostal ap,
489, 489f
vascularized rib graft
incision, 490, 490f
intercostal space and rib exposure, 492, 492f
neurovascular bundle identi cation and dissection,
493, 493f
osteotomy and bony graft isolation, 494, 494f
serratus anterior muscle exposure, 491, 491f
Intercostal m uscles, vascularized rib graft, division of, 505,
505f
Intercostal neurovascular bundle
posterior costal osteocutaneous ap, 501, 501f
vascularized rib graft, 492, 492f
Intercostal skin ap, lateral
anatom ic variations, 499, 499f
design, 495, 495f
intercostal space exposure, 496, 496f
neurovascular bundle exposure, 497, 497f
posterior elevation, perforating bundle identi cation,
495, 495f
vascular pedicle dissection and ap elevation, 498, 498f
Intercostal space
lateral intercostal skin ap, 496, 496f
vascularized rib graft
anterior intercostal artery, 492, 492f
posterior intercostal artery, 504, 504f
Interior ilium approach, vascularized iliac bone grafts,
143, 143f
Intermuscular septum , pectoralis m ajor ap identi cation,
466, 466f
Internal oblique ap
anatomy, 196, 196f
672 INDEX
applications, 196
blood supply, 196
elevation, DCIA ascending branch identi cation,
198, 198f
incision, 197, 197f
muscle exposure, 197, 197f
pedicle dissection, 199, 199f
Internal oblique osteomuscular ap, composite pattern,
200, 200f
Interosseous forearm ap
arterial anatomy, 72–74, 72f–74f
posterior interosseous nerve, 75–76, 75f
Interosseous membrane, reversed posterior interosseous
osteocutaneous ap, 89, 89f
Interphalangeal joint disarticulation, m odi ed wrap-around
ap (lower extremity), 427, 427f
Intramuscular dissection
ALT perforator fasciocutaneous ap, 242, 242f
deep inferior epigastric perforator ap, perforators,
539, 539f
inferior gluteal artery perforator ap, 150, 150f
superior gluteal artery perforator (S-GAP) ap, pedicle
dissection and, 147, 147f
thoracodorsal artery perforator (TAP) ap,
603, 603f
J
Jejunum
division, 559, 559f
emptying and clamping, 558, 558f
restoration, 560, 560f
Joint transfer. See Vascularized joint transfer
L
Lateral approach
arm ap
anatomy, 12, 12f
harvesting technique, 14–17
ap design, 14, 14f
pedicle dissection, 17, 17f
innervation, 13, 13t
dorsalis pedis osteocutaneous ap, 382, 382f
dorsalis pedis tendinocutaneous ap, 386, 386f
gastrocnemius muscle ap
harvesting completion, 304, 304f
incision, 303, 303f
intercostal skin ap
anatom ic variations, 499, 499f
design, 495, 495f
intercostal space exposure, 496, 496f
neurovascular bundle exposure, 497, 497f
posterior elevation, perforating bundle identi cation,
495, 495f
vascular pedicle dissection and ap elevation,
498, 498f
leg skin ap
cross-sectional diagram, 288, 288f
design, 285, 285f
ap completion, 287, 287f
peroneal vessel, perforator traced to, 286, 286f
reversed ap pattern, 287, 287f
septum approach, perforator identi cation,
285, 285f
posterior leg ap, proxim al popliteal artery,
341–343, 341f–343f
thigh ap
anatomy, 226–227, 226f, 227t
anterior portion elevation, 228, 228f
harvesting technique, 228, 228f
innervation, 227
posterior portion elevation, 229, 229f
vascular pedicle dissection, 229–230,
229f–230f
thoracic ap
accessory lateral thoracic artery dissection,
511, 511f
applications, 510
arterial anatomy, 509, 509f
design and incision, 510, 510f
elevation, 514, 514f
innervation, 509
lateral thoracic artery dissection, 512, 512f
thoracodorsal artery dissection, 513, 513f
venous drainage, 509
thoracoumbilical ap, 532, 532f
tibioperoneal trunk
incision, 350, 350f
neurovascular structure identi cation and dissection,
352, 352f
soleus exposure, 351, 351f
Lateral circum ex femoral artery (LCFA)
anterolateral thigh (ALT) ap, 234–235, 234f–235f
chim eric ALT ap, 249–250, 249f–250f
“ ow-through” ap, 251–252, 251f–252f
musculocutaneous perforator veri cation,
241, 241f
perforator fasciocutaneous ap, vascular pedicle
dissection, 242, 242f
anterom edial thigh ap, 232, 232f
rectus femoris ap, 219, 219f
tensor fasciae latae ap, 213
vascular pedicle dissection, 217, 217f
vastus lateralis myocutaneous ap, 245, 245f
Lateral crural septum, proxim al tibial artery exposure,
363, 363f, 365, 365f
Lateral cutaneous nerve
anterolateral thigh (ALT) ap, 236, 236f
tensor fasciae latae (TFL) ap, 213, 216, 216f
Lateral cutaneous perforator, revascularized costal bone graft
and intercostal ap, 489, 489f
Lateral interm uscular septum, posterior leg ap, 342, 342f
Lateral pectoral nerve
clavipectoral fascia exposure, 25, 25f
pectoralis major ap, 453–456, 454f, 455t
Lateral plantar artery, exposure and bifurcation with m edial
plantar artery, 442–443, 442f–443f
Lateral split latissim us dorsi aps
incision, 590, 590f
lateral branch identi cation, 591, 591f
muscle detachment, 592, 592f
INDEX 673
Lateral tarsal artery, dorsalis pedis ap, 373
Lateral thoracic artery
pectoralis major ap, 453–456, 454f, 455t
pectoralis minor ap, 473, 473f
serratus anterior ap, 476
Lateral-to-m edial approach, super cial circum ex iliac
artery ap, 159–161, 159f–161f
Latissim us dorsi aps. See also Combined scapular and
latissim us dorsi aps
anatomy, 571
angular artery anatomy and variations,
576, 576f
applications, 578
bilobed split ap
lateral/medial branch m arking, 588, 588f
m uscle separation, 589, 589f
blood supply, 571, 572f
composite serratus-latissim us m uscle ap,
485–486, 485f–486f
distal portion elevation, 583, 583f
exposure, 580, 580f
harvesting completion, 584, 584f
incision, 579, 579f
innervation
sensory nerve anatomy, 577, 577f, 577t
thoracodorsal nerve, 576, 576f
lateral border dissection, 581, 581f
lateral split ap
incision, 590, 590f
lateral branch identi cation, 591, 591f
m uscle detachm ent, 592, 592f
myocutaneous ap
design, 585, 585f
elevation, 587, 587f
incision and m uscle exposure, 586, 586f
neurovascular dissection, 582, 582f
osteomyocutaneous ap, applications, 578
perforator anatomy, 574, 574f
rib-latissim us dorsi osteomyocutaneous ap
design and rib selection, 593, 593f
elevation completion, 595, 595f
rib dissection and osteotomy, 594, 594f
scapular bone-latissimus dorsi osteom uscular ap
angular artery identi cation, 596, 596f
bony exposure, 598, 598f
m uscle division and angular artery visualization,
597, 597f
osteotomy, 599, 599f
subscapular artery variations, 575, 575f
thoracodorsal neurovascular bundle variations,
574, 574f
thoracodorsal vessel anatomy, 572, 574f
Ligament of Treitz, free jejunum transfer,
555, 555f
Lower abdom inal ap, design, 172, 172f
Lower transverse rectus abdom inis myocutaneous
(TRAM) ap, 525f, 526
DIEA identi cation, 527, 527f
harvesting, 528, 528f
m odi ed technique
elevation and pedicle dissection, 531, 531f
m uscle division, 530, 531
M
Mam m ary artery, revascularized costal bone graft and
intercostal ap, 489, 489f
Medial approach
anterolateral septofasciocutaneous ap, 239, 239f
arm ap
anatomy, 8–9, 8f
harvesting technique, 9–11
design, 9, 9f
vascular bundle
anterior approach, 10, 10f
posterior approach, 10, 10f
innervation, 8–9
dorsalis pedis ap, 379, 379f
dorsalis pedis tendinocutaneous ap, vascular bundle
elevation, 385, 385f
gastrocnemius muscle ap
harvesting techniques, 302, 302f
incision, 299, 299f
m edial head, neurovascular bundle identi cation,
300, 300f
m uscle isolation, 301, 301f
neurovascular structures, popliteal fossa,
299, 299f
leg ap
anterior elevation and septocutaneous perforator
identi cation, 319, 319f
applications, 318
cross-sectional diagram , 322, 322f
harvesting technique, 318, 318f, 321, 321f
posterior elevation and tibial vessels, 320, 320f
posterior tibial artery anatomy, 317, 317f
m odi ed wrap-around ap (lower extremity),
426, 426f
plantar ap
anatomy, 393, 393f
applications, 394
distal elevation, 395, 395f
harvesting technique, 394, 394f
innervation, 393
neurovascular bundle exposure, 396, 396f
vessel completion, 397–398, 397f–398f
posterior leg ap
m iddle popliteal artery, 331, 331f
proximal popliteal artery, 328–330, 328f–330f
proximal artery incision, 30, 30f
radial forearm osteocutaneous ap, bony segm ent
exposure, 61, 61f
thigh ap
anatomy, 223, 223f
elevation, 225, 225f
harvesting technique, 224, 224f
vascular pedicle identi cation, 224, 224f
tibioperoneal trunk
artery identi cation and dissection, 346, 346f
incision, 344, 344f
soleus exposure, 345, 345f
674 INDEX
Medial cutaneous nerve, exposure of, 34, 34f
Medial fem oral cutaneous nerve, saphenous ap, 306
identi cation, 308, 308f
Medial m alleolus, posterior tibial artery exposure,
440, 440f
Medial pectoral nerve, pectoralis m ajor ap, 456
Medial plantar artery, exposure and bifurcation with lateral
plantar artery, 442–443, 442f–443f
Medial tarsal artery, dorsalis pedis ap, 373
Medial-to-lateral procedure, super cial circum ex iliac
artery ap, 162, 162f
Median artery, super cial palm ar arch variations,
111, 111f
Median nerve, brachial artery exposure, 32, 32f
Median vein
absence of, 45, 45f
forearm drainage, 44, 44f
Metacarpophalangeal (MCP) joint, free toe/toe tissue
transfers, 401–402
Metatarsophalangeal (MTP) joint
arterial anatomy, 431, 431f
dorsalis pedis osteocutaneous ap, 382, 382f
free big toe transfer, 408, 408f
free second toe transfer
disarticulation, 415, 415f
incision and skin island design, 434, 434f
osteotomy and harvesting completion, 435, 435f
vascular dissection, 434, 434f
Microvascular transfer, gastrocnemius musle, applications,
298
Modi ed wrap-around ap (lower extremity)
design, 422, 422f
donor closure, 429, 429f
rst web dissection, 425, 425f
interphalangeal joint, ap elevation, 427, 427f
medial ap elevation, distal phalanx, 426, 426f
neurovascular pedicle dissection, dorsum of foot,
423, 423f
phalanges osteotomy, 428, 428f
plantar dissection, 424, 424f
prefabricated ap, 429, 429f
Motor nerves, tensor fasciae latae ap, 213
Muscle cuff, deep inferior epigastric perforator ap,
541, 541f
Muscle detachment technique
bilobed split latissim us ap, 589, 589f
combined sternocostal/abdom inal segments, pectoralis
major ap, 458, 458f
extensor digitorum brevis ap, 391, 391f
gluteal thigh ap, 138, 138f
lateral split latissim us dorsi aps, 592, 592f
pectoralis m inor ap, 474, 474f
scapular bone-latissim us dorsi osteomuscular ap,
597, 597f
serratus anterior ap, 482, 482f
thoracoumbilical ap, 534, 534f
Muscle mobilization, serratus anterior ap,
480, 480f
Musculocutaneous nerve, brachial artery exposure,
32, 32f
Musculocutaneous perforator
lateral ALT perforator fasciocutaneous ap,
241, 241f
veri cation, ALT perforator fasciocutaneous ap,
241, 241f
Myocutaneous aps
anterolateral thigh, 234–235, 234f–235f, 237
extensor digitorum brevis ap, 389
gastrocnemius m uscle, applications, 298
gracilis muscle
design, 209, 209f
elevation and completion, 211, 211f
vascular pedicle approach, distal dissection,
210, 210f
latissimus dorsi ap
applications, 578
design, 585, 585f
elevation, 587, 587f
incision and muscle exposure, 586, 586f
lower transverse rectus abdominis myocutaneous
(TRAM) ap, 525f, 526
DIEA identi cation, 527, 527f
harvesting, 528, 528f
pectoralis m ajor ap
clavicular segm ent, 470, 470f
design, 461, 461f
harvesting, 462, 462f
rectus abdominis ap
deep inferior epigastric artery, 527, 527f
donor site enhancem ent, 529, 529f
harvesting completion, 528, 528f
lower transverse rectus ap, elevation, 525f, 526, 526f
patterns of, 524–526, 525f
rectus femoris
design, 222, 222f
elevation, 222, 222f
serratus anterior ap
design, 482, 482f
vascular pedicle dissection and elevation, 484, 484f
tensor fasciae latae ap
design, 214, 214f
distal elevation, 215, 215f
sensory nerve identi cation, 216, 216f
vascular pedicle dissection and elevation, 217, 217f
vastus lateralis, 245, 245f
N
Nerve dissection, deep inferior epigastric perforator ap,
539, 539f
Neurovascular pedicle
anterior tibial ap, elevation and identi cation, 313, 313f
deltoid ap, 4, 4f, 4t
dorsalis pedis osteocutaneous ap, proxim al dissection,
383, 383f
extensor digitorum brevis ap, 389
bula resection, neurovascular identi cation and
dissection, 355, 355f
free proxim al interphalangeal joint transfer, dissection,
432, 432f
intercostal, identi cation and dissection, 493, 493f
INDEX 675
lateral intercostal skin ap
design, 495, 495f
intercostal bundle exposure, 497, 497f
latissim us dorsi ap
dissection, 582, 582f
thoracodorsal bundle, 574, 574f
medial gastrocnemius m uscle ap, 299–300,
299f–300f
medial plantar ap exposure, 396, 396f
modi ed wrap-around ap (lower extrem ity), dissection,
423, 423f
pectoralis major ap
dissection, 467, 467f
identi cation, 459, 459f
posterior costal osteocutaneous ap, identi cation, 501,
501f
recipient site exposure, 31, 31f
serratus anterior ap, identi cation, 479, 479f
soleus m uscle splitting, 294, 294f
super cial cervical ap, dissection, 649, 649f
tibioperoneal trunk, lateral identi cation and dissection,
351, 351f
ulnar forearm ap, 68, 68f
vascularized iliac bone grafts, 142, 142f
wrap-around ap (lower extrem ity),
420, 420f
Neurovascular sheath, dissection and identi cation,
35, 35f
O
Osteocutaneous ap
anterior costal
design, 506, 506f
osteotomy and ap elevation, 508, 508f
vascular bundle identi cation, 507, 507f
applications, 47
dorsalis pedis ap, second m etatarsal
design, 381, 381f
donor site closure, 384, 384f
lateral elevation, 382, 382f
m edial elevation, 381, 381f
m etatarsophalangeal joint, disarticulation,
382, 382f
neurovascular proxim al dissection, 383, 383f
TMT joint, disarticulation and ap completion,
384, 384f
bular ap
applications, 278
completion, 291, 291f
cross-sectional diagram , 292, 292f
design, 289, 289f
posterior crural approach, 289, 289f
groin ap, 166, 166f
bony segment, 166, 166f
osteotomy and elevation, 167, 167f
posterior costal ap
design, 500, 500f
intercostal neurovascular bundle identi cation,
501, 501f
osteotomy and ap elevation, 502, 502f
radial forearm
bony segment proposal, 59, 59f
m edial bony segment exposure, 61, 61f
vascular bundle and bony segment ap elevation,
60, 60f
scapular ap
design and bony segm ent, 613–614, 614f
elevation and bone exposure, 615, 615f
osteotomy, 616, 616f
Osteofascial ap, applications, 632
Osteomyocutaneous aps
bular ap
applications, 278
soleus m uscle transfer
cross-sectional diagram , 296, 296f
exposure techniques, 293, 293f
harvesting completion, 295, 295f
incision, 293, 293f
neurovascular structures, splitting and identi cation,
294, 294f
osteotomy, 295, 295f
pectoralis major ap
clavicular segm ent, 469, 469f
design, 463, 463f
harvesting, 464, 464f
rib-latissim us dorsi ap, 593, 593f
scapular bone-latissimus dorsi osteom uscular ap
angular artery identi cation, 596, 596f
bony exposure, 598, 598f
m uscle division and angular artery visualization,
597, 597f
osteotomy, 599, 599f
tensor fasciae latae (TFL), 218, 218f
Osteotomy
anterior costal osteocutaneous ap, 508, 508f
deep circum ex iliac artery, iliac osteocutaneous ap,
194–195, 194f–195f
bula resection, 355, 355f
bular osteocutaneous ap, 290, 290f
bular osteom uscular ap transfer, 295, 295f
fourth lum bar artery iliac ap, 178, 178f
free metatarsophalangeal joint, 435, 435f
free proxim al interphalangeal joint transfer,
433, 433f
iliac crest layer
inner lip, 188, 188f
whole layer, 187, 187f
m odi ed wrap-around ap (lower extremity), 428, 428f
osteocutaneous groin ap, 167, 167f
posterior costal osteocutaneous ap, 502, 502f
radial forearm osteocutaneous ap, 62, 62f
reversed posterior interosseous osteocutaneous ap,
91, 91f
rib-latissim us dorsi osteomyocutaneous ap,
594, 594f
scapular bone-latissimus dorsi osteom uscular ap,
599, 599f
scapular osteocutaneous ap, 616, 616f
serratus anterior costo-osteom uscular ap, 488, 488f
vascularized bula bone graft, 281, 281f
676 INDEX
vascularized iliac bone grafts, 144, 144f
vascularized rib graft, 494, 494f
posterior intercostal elevation, 505, 505f
Outer ilium exposure, vascularized iliac bone grafts,
186, 186f
P
Palm ar approach, princeps pollicis artery, deep palmar arch
origin, 117–119, 117f–119f
Palm ar digital artery, super cial palm ar arch, 110
Parascapular ap. See also Combined scapular and parascapular
flap
anatomy, 605, 605f, 605t
design, 612, 612f
harvesting, 613, 613f
Pectoral arterial branch, anatomy, 453–455, 454f, 455t
Pectoralis m ajor ap
anatomy, 453, 454f, 455t
applications, 455
blood supply, 453
clavicular segment, 464–470
dissection and completion, 468, 468f
incision, 465, 465f
interm uscular septum identi cation, 466, 466f
myocutaneous ap pattern, 470, 470f
neurovascular pedicle dissection, 467, 467f
osteomuscular ap pattern, 469, 469f
com bined sternocostal/abdom inal segm ents, 455–460
distal m uscle ap detachment and elevation, 458, 458f
incision, 456, 456f
muscle exposure, 457, 457f
neurovascular structure identi cation, 459, 459f
pedicle dissection and ap completion, 460
innervation, 453, 566
myocutaneous ap
design, 461, 461f
harvesting, 462, 462f
osteomyocutaneous ap
design, 463, 463f
harvesting, 464, 464f
Pectoralis m inor ap
anatomy, 471, 471f
applications, 472
blood supply, 471–472, 472f
dom inant pedicle assessment, insertion detachm ent,
474, 474f
harvesting completion, 475, 475f
incision, 472, 472f
innervation, 472
lateral thoracic vessel dissection, 473, 473f
Pedicle dissection
ALT perforator fasciocutaneous ap, 242, 242f
anterior interosseous (dorsal wrist) ap, 93, 93f
anterolateral septofasciocutaneous ap, 240, 240f
anterolateral thigh cutaneous ap, 243, 243f
anterom edial thigh ap, 233, 233f
deep circum ex iliac artery, vascularized iliac bone grafts,
183, 183f
deep inferior epigastric perforator ap, 538, 538f
modi cation, 541, 541f
deltoid m uscle, 7, 7f
extensor digitorum brevis ap, 389–390, 390f
free jejunum transfer, 559, 559f
free second toe transfer, 413, 413f
gracilis muscle ap, 206, 206f
internal oblique ap, 199, 199f
lateral arm ap, 17, 17f
lateral intercostal skin ap, vascular pedicle, 498, 498f
lateral thigh ap, 229–230, 229f–230f
lower transverse rectus abdominis myocutaneous (TRAM)
ap, 531, 531f
medial arm ap, 11, 11f
medial thigh ap, 224, 224f
om entum isolation, 547, 547f
pectoralis m ajor ap, 460, 460f
pectoralis m inor ap, insertion detachm ent, 474, 474f
posterior arm ap, 21, 21f
posterior interosseous ap, 81, 81f
posterior leg ap, 327, 327f
rectus femoris muscle ap, 220, 220f
reversed posterior interosseous ap, 84, 84f
reversed posterior interosseous osteocutaneous ap,
88, 88f
scapular ap, axilla pedicle, 611, 611f
serratus anterior costo-osteomuscular ap, 487, 487f
serratus anterior myocutaneous ap, vascular pedicle,
483, 483f
subm ental ap, 655, 655f
super cial cervical ap, neurovascular pedicle, 649, 649f
superior gluteal artery perforator (S-GAP) ap, pedicle
dissection and, intramuscular dissection and,
147, 147f
superior gluteal myocutaneous ap, 134, 134f
tensor fasciae latae (TFL) ap, 217, 217f
wrap-around ap (lower extrem ity), neurovascular,
420, 420f
Pedicle identi cation, deltoid m uscle, 7, 7f
Penile reconstruction
fabrication cross-sectional diagram , 57, 57f
radial forearm ap
fabrication completion, 57, 57f
harvested ap preparation, 55, 55f
Perforator identi cation
anterolateral fasciocutaneous thigh ap, 238, 238f
anterolateral septofasciocutaneous ap, 239, 239f
anterolateral thigh cutaneous ap, 243, 243f
anterolateral thigh ap, 234–235, 234f–235f
composite anterolateral thigh ap, “tendon” transfer
lateral portion elevation, 247, 247f
m edial portion elevation, 246, 246f
deep inferior epigastric perforator ap, 537, 537f,
538, 538f
intramuscular dissection, 539, 539f
m odi cation, 541, 541f
inferior gluteal artery perforator ap, 149, 149f
lateral intercostal skin ap, 495, 495f
lateral leg skin ap, 285, 285f
peroneal vessels, 286, 286f
latissimus dorsi ap, 574, 574f
m usculocutaneous perforator, 241, 241f
INDEX 677