732 • CHAPTER 62
of fl aps for vaginal reconstruction generally allows the
cavity to be maintained without the need for long-term
dilators and stents, the pudendal-thigh fl aps have been
reported to contract somewhat more than other fl ap
reconstructions.
Rectus Abdominis Flap
The inferiorly based rectus abdominis musculocutaneous
fl ap ( Figure 62-2C ) is excellent for fi lling large defects
with accompanying dead space created by extirpative sur-
gery for cancer. 5 It can also be used for vulvar and vagi-
nal reconstruction. The skin island of a rectus abdominis
musculocutaneous fl ap is most versatile when oriented
obliquely on an angle from the umbilicus to the scapula
( Figure 62-5A ). Not only does it provide a long skin pad-
dle, but this design facilitates abdominal wall donor site
closure ( Figure 62-5B ). The muscle fl ap alone is a versa-
tile option that can be used to fi ll the pelvic dead space,
close the pelvic fl oor, or repair intestinal or genitouri-
nary fi stulae. The deep inferior epigastric artery perfora-
tor or superfi cial inferior epigastric artery fl aps may be
used in thin patients requiring less bulk ( Figure 62-2D ).
When performed for complete vaginal reconstruction, it
is important to suspend the blind end of the neovagina to
the sacral promontory.
Vascularized peritoneum may also be transferred with
this fl ap 6 ( Figure 62-2E ). The rectus abdominis muscu-
loperitoneal fl ap has low bulk, and can be useful when
dealing with a nonexenterated pelvis in which there is not
enough room for bulkier musculocutaneous fl aps. Similar
in concept to the Davydov procedure, the peritoneum re-
mucosalizes with vaginal mucosa in 2 to 3 months. The
rectus abdominis musculoperitoneal fl ap is best used for
partial longitudinal vaginal defects. Unfortunately, when
used for circumferential defects of more than two thirds
of the upper vagina, there is an increased risk of severe
stenosis.
Gracilis Flap
The gracilis muscle and myocutaneous fl aps ( Figure 62-2F )
were popularized for vaginal, vulvar, and perineal recon-
struction by McCraw in the mid 1970s. 7 They are useful
when the extirpative defect is large, requiring obliteration
of dead space. However, the distal skin territory of the lon-
gitudinally oriented fl ap is unreliable. Similarly, the distal
third of the gracilis muscle, which is usually the part that
is placed in wound cavities, frequently lacks adequate bulk
and has marginal blood fl ow. Wang et al. described a fascio-
cutaneous thigh fl ap of almost the same skin island as the
gracilis, but with a blood supply which comes from more
proximal (medial) perforators of the external pudendal
artery. 8
Anterolateral Thigh Flap
The anterolateral thigh fl ap ( Figure 62-2G ) based on
the descending branch of the lateral circumfl ex femoral
artery is a versatile fl ap that may be customized to accom-
modate a variety of defects. It may be transferred as a
fasciocutaneous perforator fl ap ( Figure 62-6 ), a vastus
lateralis muscle fl ap, a vastus lateralis musculocutaneous
compound fl ap, or a chimeric fl ap, including the vastus
lateralis and/or rectus femoris muscles. To facilitate the
transfer of the lateral circumfl ex femoral artery fl ap to
the perineum, the fl ap should be passed beneath the rec-
tus femoris and sartorius muscles, thus creating a direct
line from its pivot point as it comes off the profunda
femoris vessels to the perineum ( Figure 62-7 ). The main
disadvantage of this fl ap is the visibility of the donor site
on the anterior lateral thigh.
Gluteal Thigh Flap
Flaps based on the inferior gluteal artery system allows
for a variety of tissue to be transferred to the perineum.
The inferior gluteal muscle may be transferred indepen-
dently or combined with skin as a compound or chimera
fl ap ( Figure 62-8 ). The fasciocutaneous gluteal thigh fl ap
( Figure 62-2H ) is based on the descending branch of the
inferior gluteal artery. It is associated with the posterior
cutaneous nerve of the thigh and has been shown to
provide reliable and sensate skin. 9 The point of rotation
of this fl ap is located 5 cm above the ischial tuberosity
where the inferior gluteal artery emerges from beneath
the piriformis muscle. The central axis of the skin island
is midway between the greater trochanter and the ischial
tuberosity perpendicular to the gluteal crease. The fl ap
length may extend to within 8 cm of the popliteal fossa.
For wounds that have a cavity, a chimera fl ap consisting of
the fasciocutaneous posterior thigh fl ap as well as a por-
tion of the inferior gluteal maximus muscle can be raised
on a single vascular pedicle ( Figure 62-9 ). In this varia-
tion, the descending branch of the inferior gluteal artery
is separated from beneath the gluteal muscle. A portion
of the gluteus maximus muscle is elevated on a separate
branch, allowing independent positioning of the muscle
and skin. 10 The gluteal thigh fl ap provides skin coverage
and adequate soft tissue bulk and, generally, even when
combined with a portion of gluteal muscle, results in no
functional defi cit at the donor site. Although sensation
in this fl ap is generally considered an advantage, adult
patients can have diffi culty with cortical reorganization,
sensing stimuli of the transferred skin paddle as originat-
ing from the posterior thigh.
Gluteal Fold Flap
The gluteal fold fasciocutaneous fl ap ( Figure 62-2 I) is a
sensate fl ap with a neurovascular supply similar to that of
the pudendal thigh fl ap. It is designed with the center of
the fl ap situated along the infragluteal crease. 11 This fl ap
may be “islandized” with its proximal portion just medial
to the ischial tuberosity, extending laterally for approxi-
mately 15 cm in length. The fl ap may then be transposed
anteriorly to reconstruct vulvar defects or posteriorly to
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 733
FIGURE 62-5. (A) Resultant perineal and total vaginal defect following pelvic
exeneration in a 36-year-old woman with recurrent squamous cell carcinoma of
the cervix. (B) Intraoperative skin paddle design of a left oblique rectus abdominis
myocutaneous (ORAM) fl ap. (C) Flap raised on deep inferior epigastric pedicle,
leaving inferior portion of rectus abdominis muscle intact for placement of end
colostomy. (D) ORAM fl ap tubed for vaginal reconstruction with markings for
non-circumferential introital inset before transfer into pelvis. (E) Primary closure
of donor site and laparotomy with placement of ileal conduit and end colostomy.
(F) Inset of neo-introitus and perineum and (G) follow-up at three months
demonstrates no introital stenosis.
A
B
C
D
E
F
G
734 • CHAPTER 62
FIGURE 62-6. (A) Squamous cell carcinoma in situ of the penis and scrotum
of a 66-year-old man. The left-sided anterior lateral thigh fl ap (B) based on fi rst
septocutaneous perforator of the lateral circumfl ex femoral system is dissected and a
Penrose drain is passed under rectus femoris and sartorius muscles (C) after creation of a
tunnel. (D) Flap well healed at postoperative month 6 (penile shaft closed with skin graft).
A
B
C
D
FIGURE 62-7. (A) Vastus lateralis muscle fl ap ( white arrow ) based on descending
branch of the lateral circumfl ex femoral system ( black arrow ). Small island of skin used
as a monitor ( asterisk ). The fl ap is passed medially under rectus femoris and sartorius
muscles (B). Note the improved arc of rotation with its pivot point moved medially.
A
B
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 735
B
A
C
D
FIGURE 62-8. A 61-year-old man sustained a large
gluteal abscess after 12% burn with inhalation injury. After
deep debridement of the abscess (A), an inferior segment of
gluteus maximus muscle was harvested through a counter
incision (B). The inferior gluteal artery pedicle ( white arrow
head ) is shown (C) and the curved white arrow demonstrates
path of transfer of this muscle fl ap. The muscle was secured
to fi ll the defect (D) and the wound was closed with a large
fasciocutaneous rotational/advancement fl ap based on the
perforators of the superior gluteal artery. (E) Six months
postoperatively he is well-healed with good contour (skin
graft of contralateral buttock related to burn injury).
E
736 • CHAPTER 62
FIGURE 62-9. (A) Severe perianal and perineal Crohn’s
disease in a 26-year-old woman with multiple fi stulae,
sinuses, and abscesses. (B) After proctectomy and excision
of all involved soft tissue, (C) a chimeric fl ap was designed
using an inferior portion of gluteus maximus muscle and a
fasciocutaneous posterior thigh fl ap, both based on separate
branches of the left inferior gluteal artery. (D) Muscle fl ap
transposed into pelvic defect. (E) Posterior thigh fl ap passed
under skin bridge and distal portion de-epithelialized to
provide additional bulk for obliteration of defect.
A
B
D
C
E
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 737
reconstruct perianal defects ( Figure 62-10 ). The design
may be either unilateral or bilateral and may be advanced
in a V-Y fashion. 12
TECHNIQUES: VAGINAL
RECONSTRUCTION
The various methods for vaginal reconstruction may be
classifi ed into three categories: stretching techniques,
grafting techniques, and fl ap reconstruction. The choice of
technique depends on the amount of vagina absent, size or
volume of the accompanying defect, available donor sites,
and the patient’s acceptance of donor scar. In most devel-
opmental abnormalities as well as transgender surgery,
the lack of defect precludes most of the bulkier fl aps and
alternate techniques are preferred. On the contrary, after
surgical extirpation, thicker fl aps may be preferred so that
endopelvic dead space can be fi lled. Partial defects of the
vagina are also common following surgery. Rarely are grafts
able to be used in this scenario.
Dilatation or Stretching Techniques
(for Vaginal Agenesis)
In patients with vaginal agenesis, the external genitalia
are essentially normal. Instead of a vaginal cavity, there
is typically a small pouch or dimple that is 1 to 4 cm in
depth. The Frank technique, initially described in 1938,
is the only nonsurgical approach to vaginal construction.
With the use of graduated dilators pressing on and pro-
gressively stretching a severely foreshortened vagina, this
technique can increase both depth and caliber. In 1981,
Ingram reported his experience using a modifi ed bicycle
seat with an integrated dilator that young women would
sit on, providing direct pressure on the incompletely
developed vagina. This technique works best in compli-
ant, motivated patients who have more depth than just a
vaginal dimple. 13 , 14
Another dilation technique that has become very popu-
lar in Europe is the Vecchietti operation, fi rst described
in 1965. It involves the creation of a neovagina via dila-
tation with a traction device attached to the abdomen.
With a combined surgical and dilation approach, a plas-
tic bead with traction sutures attached is placed in the
interlabial space. Via a formal laparotomy, a space is made
between the urethra/bladder and rectum and the traction
sutures are passed extraperitoneally in the abdomen and
anchored to a spring traction device placed on the outside
of the abdomen. More recently, this has been performed
laparoscopically. By applying constant continuous trac-
tion, the Vecchietti method creates a functional vagina
of 10 to 12 cm length in 7 to 9 days. The vaginal cavity
FIGURE 62-9. (continued) (F). Inset of posterior thigh fl ap with primary closure of
groin wounds, and (G) well-healed perineal reconstruction 4 months postoperatively.
F
G
738 • CHAPTER 62
FIGURE 62-10. (A) Resultant defect following extirpation of a perianal squamous
cell cancer in-situ in a 55-year-old woman. Bilateral gluteal fold fl aps were designed
(B) and the right fl ap is shown transposed into defect (C). Final inset of fl aps (D)
demonstrates preservation of buttock contour with tensionless closure of donor sites in
infragluteal folds.
A
B
C
D
created must be maintained with vaginal molds for a num-
ber of months. 15 , 16
Grafting Techniques (for Vaginal Agenesis)
For congenital abnormalities, a simple and often used
surgical procedure is utilization of skin grafts to line
a cavity dissected in the retrovesical space. Although
originally described by Abbe in 1898, McIndoe and col-
leagues popularized its use four decades later, and the
use of skin grafts placed around a stent to create the
neovagina is often referred to as the McIndoe proce-
dure. While originally described with the use of split-
thickness skin grafts, full-thickness grafts are preferred
to decrease contraction of the vaginal cavity. Creating
lining with grafts requires long-term (up to 1 year) use
of a vaginal mold to prevent contraction and strictures.
Despite this, shrinkage and stenosis are common prob-
lems if the patient does not continue intermittent stent-
ing or sexual activity. 17 – 19
Locoregional Flaps
Surgical reconstruction of the vagina using local fl aps
has been reported since the 1800s. These fl aps work
well when the defect is limited. A number of random
and axial pattern skin fl aps can be used, taking advan-
tage of the extensive, interconnecting pudendal blood
supply. Additionally, fl aps incorporating the suprapubic
and infraumbilical skin have been described. The thin-
ness and pliability of these fl aps as well as inconspicuous
donor scars make them attractive options. Williams re-
popularized vulva fl aps in the 1960s and Davydov cre-
ated vaginas from the peritoneum of Douglas’s pouch. 20 , 21
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 739
Recently, the Davydov technique has been modifi ed with
a laparoscopic approach. Flaps of the bladder have also
been described. In all cases, the tissue utilized must be
mobile, nonirradiated, and nonscarred. Similar to graft-
ing, use of periodic postoperative dilation is necessary to
minimize contraction and stenosis.
An alternative option that is excellent for total vaginal
reconstruction is to use the previously described ORAM
fl ap. As shown in (Figure 62-5), the skin paddle of the
ORAM fl ap can be tubed to create a neo-vagina. Once
passed into the pelvis, care must be taken to perform a
non- circumferential inset of the introital region, so as to
prevent future stenosis. In addition, the most cephalad
portion of the neo-vagina should be secured to the sacral
promontory to prevent collapse and/or prolapse.
Intestinal Flap
Reconstruction of the vagina with segments of bowel (ini-
tially described by Baldwin in 1904) allows for creation
of a cavity that does not require persistent dilation for
patency, as well as a mucosa-lined neovagina that creates
natural lubrication. The colon or small bowel (usually
ileum) may be transferred on a vascular pedicle for vagi-
nal reconstruction. 22 , 23 This may be performed through an
open or laparoscopic approach. A 10- to 15-cm segment of
bowel is isolated on its vascular pedicle. It is divided, and a
bowel anastomosis is performed to reestablish continuity
of the bowel. The proximal end of the pedicled segment of
bowel is closed off, and it is then passed into a space that
has been dissected between the urethra and rectum. The
proximal end is fi xed to the sacral promontory to prevent
prolapse ( Figure 62-11 ). The distal end is sutured to the
vaginal remnant or to perineal skin fl aps, with interdigi-
tating fl aps to break up a circular suture line and prevent
stenosis. Vaginal reconstruction with an intestinal fl ap pro-
vides good patency and satisfactory sexual activity. Patients
with this type of reconstruction may complain of excess
mucous production. When colon is used there is also the
potential to develop diversion colitis. Other diseases of the
colon, such as ulcerative colitis or colon cancer have also
been reported to occur in colovaginoplasties. 24 , 25
Free Jejunal Flap
Due to length limitations of the mesenteric vascular arcade,
it is usually necessary to transfer the jejunal segment as a
free fl ap in order to reach the vaginal introitus. A short,
second segment of bowel can be externalized for monitor-
ing through an incision required for vascular access. This
fl ap has been shown to have less excess mucous produc-
tion than other bowel transfers. 26 It is a useful technique
for neovaginal reconstruction in late adolescence or early
adulthood, providing a single-stage operation with good
patient satisfaction. The dimensions of the vaginal cav-
ity are well-maintained, long-term stents and dilators are
not required, and natural lubrication is provided for inter-
course without mucous hypersecretion or excessive odor.
Postoperative Care
Most patients undergoing vaginal, vulvar, or perineal
reconstruction are at high risk for deep venous thrombo-
sis. As such, sequential compression devices and prophy-
lactic anticoagulation should be used perioperatively and
continued as appropriate. Patients are placed on pressure
relieving mattresses with legs adducted and knees bent.
Free fl aps are monitored in specialized nursing units for
48 to 72 hours, after which activity is gradually increased.
The monitoring segment is removed on postoperative days
7 to 10.
Physical therapy is important for instructing the patient
on how to get out of bed without putting pressure on the
operative site. Sitting is limited to 5-minute periods on
special padding. A Foley catheter is maintained until the
patient is ambulating comfortably. Diet is advanced after
the return of bowel function. The patient is discharged
when tolerating a general diet, ambulating, and pain is con-
trolled on oral medication.
TECHNIQUE: RECONSTRUCTION
OF THE MALE GENITALIA
Hypospadias
Hypospadias is a common congenital anomaly occurring
in approximately 1 in 300 newborn males. It is character-
ized by three anomalies of the penis, including an abnor-
mal ventral opening of the urethral meatus; chordee or
an abnormal ventral curvature; and an abnormal foreskin
with dorsal hooding and a ventral defi ciency. Hypospadias
is variable in severity, and the meatal opening may be
located anywhere from the ventral glans to the perine-
um. 27 If the most severe form of hypospadias is associated
with an undescended testes, the infant must be evaluated
for an intersex state with ambiguous genitalia. The goals of
treating hypospadias, and indeed any congenital anomaly
of the penis, are to create a straight penis with a continu-
ous urethra with a meatus ending at the tip of the penis, to
reshape the glans into a more natural conical confi guration,
and to achieve penile skin coverage. The resulting penis
should enable the patient to void while standing, have an
acceptable cosmetic appearance, and be suitable for future
sexual intercourse.
The position of the meatus along with the degree of
chordee, development of the spongiosum, thinness of
urethra, elasticity and thickness of ventral shaft skin,
and depth of glanular groove determine the selection of
approach to repair. More than 300 different techniques
for repair of hypospadias are described, and all are based
on standard principles of reconstructive plastic and uro-
logic surgery, which allow for creation of a tubular ure-
thra, correction of chordee curvature, and coverage of the
urethral tube with well-vascularized skin fl aps that avoid
superposition of suture lines. In the twenty-fi rst century,
almost all hypospadias repairs are performed by pediatric
urologists. Reconstructive plastic surgeons are usually not
involved unless there is a severe deformity or the patient
740 • CHAPTER 62
FIGURE 62-11. (A) Surgical specimen from a 66-year-old
woman who underwent subtotal vaginectomy, hysterectomy,
and bilateral oophorectomy for recurrent colon cancer
invading into vagina. (B) Segment of jejunum isolated on its
vascular pedicle. (C) The pedicled jejunal fl ap is secured to
the vaginal remnant over a dilator, and the vaginal-jejunal
anastomosis (D) is completed. (E) Closed end of jejunum
secured to sacral promontory ( black arrow ) to prevent
prolapse.
A
B
D
C
E
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 741
has had repeated complications or failures. Complications
include urethrocutaneous fi stulae, stricture, meatal dysto-
pia, meatal stenosis, urethral diverticula, hair in the ure-
thra, and persistent curvature. Multiple failed surgeries can
lead to a condition with a scarred and dysfunctional penis
dubbed the “hypospadias cripple” requiring more complex
reconstructive intervention. 28
Urethral Reconstruction
The male urethra is 17.5 to 20 cm long and extends from
the internal urethral orifi ce in the urinary bladder to the
meatus at the end of the penis. It is divided into three por-
tions: the prostatic, membranous, and penile or cavernous
urethra. The epithelium of the urethra starts off as tran-
sitional cells as it exits the bladder. At the membranous
portion it turns into pseudostratifi ed columnar epithelium,
then stratifi ed squamous epithelium near the external
meatus.
Urethral problems include loss of part or all of the
urethra, urethral stenosis and strictures, and urethral
sinuses and fi stulae. Like hypospadias repair, urologists
care for most straightforward urethral problems but a
plastic surgeon may be necessary for complicated cases.
Injuries involving the urethral meatus may cause steno-
sis. Mild stenosis can be treated with repeated dilatations.
Stenosis unresponsive to dilation may require z-plastys or
other interpolations of adjacent skin into the constricting
band. Occasionally, persistent strictures require an open
approach with urethrotomy and graft placement to widen
the lumen. Urethral fi stulae may involve the skin, bowel,
or vagina. Most urethral fi stulae are due to trauma or sur-
gery, especially after radiation. Frequently, these will close
with urinary diversion. Persistent fi stulae may require
operative closure and reinforcement with a nonscarred,
nonirradiated local/regional or distant fl ap. Distal cavern-
ous urethral loss may be repaired using the principles of
hypospadias surgery.
Techniques of more proximal cavernous urethral recon-
struction continue to evolve. Many methods of restoring
urethral continuity and establishing a normal urethral
lumen have been devised. Autologous skin or mucosal
grafts and local/regional fl aps have produced dependable
long-term results. The decision regarding which one of the
various methods available for urethral reconstruction must
be individualized. Factors used in choosing the appropriate
option include the location and dimension of the injured
or diseased urethra, quality of the urethral bed, availabil-
ity of local or regional tissue, and quality and availability
of distant tissue.
Grafts may be harvested from the oral mucosa, bladder
mucosa, or skin. For success, they require a perfect wound
bed to achieve a dependable result. Even a small loss of a
graft will result in stricture.
Loco-regional fl aps of skin or bladder mucosa have the
advantage of bringing their own blood supply, thereby not
relying on the quality of bed on which they are placed.
Scrotal fl aps for urethral reconstruction should be avoided
because the coarse pubic hair is not tolerated well and
leads to urinary stones. Occasionally, a pedicled appendix
is used for proximal urethral reconstruction. Injury and
scarring from prior surgery or trauma may preclude using
local or regional fl aps. In addition, reconstructing the prox-
imal male urethra may push the limits of some of these
techniques.
When grafts and regional fl aps are inappropriate, inad-
equate or unavailable, free tissue transfers may be the best
option. Appendix, tailored intestinal segment, or a long,
thin skin fl ap that is tubed (eg, radial forearm or ante-
rior lateral thigh) may be considered for the treatment of
extensive urethral abnormalities when the alternative is
chronic supravesical diversion. 29 , 30
General Postoperative Care
Again, this is a high-risk population for deep venous
thrombosis. As such, sequential compression devices and
prophylactic anticoagulation should be used periopera-
tively and continued as appropriate. If a graft is used for
urethral repair, a large bore catheter is left in place for
2 to 3 weeks as a stent. If circumferential replacement
with a graft is necessary, then stenting may be required
9 to 12 months. In patients undergoing repair with a fl ap, a
small caliber catheter is used to minimize pressure on the
fl ap. Extensive repairs or reconstruction should have the
urine diverted with a suprapubic tube.
Patients undergoing free fl ap urethral reconstruc-
tion are monitored in a specialized unit for a minimum
48 hours. After 2 days of bed rest, gradual mobilization
with the assistance of physical therapy begins. The urinary
fl ow remains diverted through the suprapubic tube. When
the patient is comfortable with the care of the fl ap and
donor site, he is discharged with the suprapubic tube in
place. Three to 4 weeks postoperatively, if healing appears
adequate, a retrograde urethrogram is performed. If no
fi stula is seen, the bladder catheter in the neourethra is
removed and the suprapubic tube is clamped, allowing the
patient to void. If the patient voids successfully, the supra-
pubic tube is removed 1 week later.
Penile Reconstruction
The history of total penile reconstruction has paralleled the
history of fl ap development in plastic and reconstructive
surgery. The multistage tube pedicle fl ap reconstruction
has given way to the axial pattern skin fl aps and muscle
fl aps. These procedures have subsequently yielded the
state-of-the-art neurosensory fasciocutaneous radial fore-
arm free fl ap. 31 Recently, as knowledge and experience
has been gained with various perforator fl aps of the lower
abdomen and thigh, the popularity of pedicle fl aps is start-
ing to reemerge.
Ideally, the reconstructed phallus (or constructed
neophallus in transsexuals) should fulfi ll several cri-
teria to be functionally and psychologically satisfy-
ing. It should be aesthetically acceptable with a shaft
742 • CHAPTER 62
of adequate length and glans with defi ned shape and
meatus. It should contain a neourethra that can be anas-
tomosed to the patient’s residual native urethra. As such,
the patient should be able to void while standing. It
should have close to normal tactile and erogenous sensi-
tivity, and it should be able to accommodate a stiffener
(prosthetic or autologous). The girth should be adequate
for sexual function, but not too large to preclude intro-
mission. While multiple techniques have been described
to meet these objectives, the authors’ preferred method
of penile construction is the neurosensory radial forearm
free fl ap.
This fl ap is a modifi cation of the original radial fore-
arm free fl ap design described by Chang and Hwang. 32 It
incorporates a centrally based T-shaped portion of skin
that will make up the neourethral lining in continuity
with the neoglans ( Figure 62-12A ). Two strips of skin,
each 1-cm wide, are de-epithelialized on either side of
the neourethral lining from the proximal edge of the fl ap
to within 3-cm of the distal portion ( Figure 62-12B ). The
dimensions of the fl ap are usually 15 3 17 cm; however,
the distal width can be tapered to accommodate a nar-
rower wrist, and the urethral portion may be extended
proximally to accommodate a urethral anastomosis in the
perineum. This design provides for the maximal dimen-
sion of the neophallus, places the urethra over the most
hairless and reliable portion of the fl ap, as well as creates
the appearance of a glans. Most importantly, it avoids a
concentric suture line at the meatus, decreasing the risk
of distal neourethral stenosis.
Preoperatively, an Allen test is performed to assure
suffi cient vascularization of the hand through the ulnar
artery. The fl ap is outlined on the nondominant volar
forearm. The fl ap, dissected under tourniquet, is based
B
FIGURE 62-12. Neophallus construction with neurosensory radial forearm free fl ap.
(A) Design on forearm. (B, C) Central urethra with fl anking de-epithelialized strips enables
multiple layer closure for creation of urethral tube. (D) The dorsal side is closed and the
neoglans is folded back and secured with mattress sutures.
A
C
D
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 743
on the radial artery and its venae comitantes. If necessary,
the fl ap may be based on the ulnar artery. The cephalic
vein is also included in the fl ap and dissection is car-
ried far enough proximally so that the venae comitantes
coalesce into a single vein. If this dissection is continued
more proximally, the coalesced venae comitantes join the
cephalic vein via the profundus cubitalis vein, which is a
valveless vein connecting the superfi cial (cephalic) and
deep (venae comitantes) venous systems of the forearm.
This added dissection makes it possible for one large cali-
ber vein to drain both venous systems. 33 Additionally, the
author creates a distal radial-cephalic arteriovenous fi stula
to improve the venous outfl ow. The superfi cial branch of
the radial nerve must be identifi ed and preserved as it
pierces beneath the brachioradialis tendon and courses
close to the cephalic vein at the wrist. The medial and
lateral antebrachial cutaneous nerves are included in the
fl ap and dissected several centimeters proximal to the
skin paddle, then tagged and divided.
The neophallus is fashioned while still in continuity
with the vascular supply. Full-thickness transverse inci-
sions are then made connecting the distal portion of the
centrally placed neourethral skin with the radial and
ulnar edges of the fl ap. The portion of the fl ap forming
the central neourethra is “tubed” over a 12-French silas-
tic urinary catheter and closed in layers ( Figure 62-12C ).
The fl ap is then turned over and the dorsal skin is closed.
The wings of the neoglans are trimmed to the appropri-
ate shape and rolled back on the shaft. The distal portion
of the shaft that will be under the rolled-back neoglans
is de-epithelialized. The neoglans is then secured in its
rolled-back position with full-thickness nylon mattress
sutures ( Figure 62-12D ).
If the patient has a relatively small forearm with a sig-
nifi cant amount of subcutaneous fat, then one of the two
suture lines on the shaft may not be able to be closed
without undo tension. In this situation, the outer layer
of the volar suture line may be opened and a full-thick-
ness graft placed, allowing the dorsal suture line to be
closed primarily for aesthetic concerns ( Figure 62-13 ).
During fl ap elevation, a second surgical team pre-
pares the pubic site with recipient vessels and nerves.
Approximately, 20-cm of saphenous vein is harvested
from the thigh and is left attached to the femoral vein
at the fossa ovalis. The divided end of this saphenous
vein is then anastomosed to the femoral artery to create
a temporary loop arteriovenous fi stula. This is allowed
to fl ow for at least 20 minutes until the fl ap is ready for
transfer. The incision used for the saphenous vein harvest
is connected to the fl ap recipient bed incision to prevent
compression, torquing, or kinking of the vein grafts.
For reconstruction of a genetic male, a degloving inci-
sion is made if a portion of the native phallus exists. If
there is no remnant, a W-shaped incision is made over the
pubic symphysis. The dorsal penile branches of the puden-
dal nerve are isolated. If the nerves are not apparent, often
in cases of trauma, dissection is continued toward the
perineum and the pudendal nerves are identifi ed as they
emerge from the Alcock canal and travel along the inferior
ramus of the pubis.
In transsexuals, inverted V incisions are made in the
superior portion of the labia majora and they are retrodis-
placed inferiorly for creation of a neoscrotum. The medial
aspects of the labia majora are secured together, creating a
neoscrotal median raphe. Transsexuals then undergo vagi-
nectomy and an anterior vaginal fl ap is combined with a
portion of the labia minora to fashion a tubed extension
of the native urethra. The skin of the clitoris is removed
and both clitoral nerves are identifi ed and isolated on ves-
sel loops in preparation for neurorraphies to the antebra-
chial cutaneous nerves of the fl ap ( Figure 62-14 ).
FIGURE 62-13. Full-thickness skin graft (FTSG)
placed on ventral surface of neophallus in patients where
subcutaneous tissue prevents closure without tension.
FIGURE 62-14. Neophallus recipient site. Yellow vessel
loops around clitoral nerves in female to male transsexuals.
Vein loop in left groin.
744 • CHAPTER 62
When both the construct and recipient site prepara-
tion are complete, the neophallus is detached from the
arm and secured to the recipient site with tacking sutures.
The Foley catheter in the neourethra is placed into the
bladder and the balloon is infl ated. The neourethra is then
anastomosed to the native urethra in an end-to-end spat-
ulated fashion in two layers using 4-0 absorbable suture.
The saphenous vein loop is divided and the microvascu-
lar anastomoses are performed, followed by the epineural
neurorraphies. The remaining wounds about the proximal
shaft of the neophallus and femoral vessels are closed over
closed suction drains.
A suprapubic catheter is placed to allow drainage
away from the healing neourethra. The catheter in the
neourethra is capped. A thick split-thickness skin graft
is applied to the donor site on the arm. A loose dressing
is applied to the neophallus and it is supported within a
bottomless Styrofoam cup, secured to the lower abdo-
men with foam tape.
Postoperative Care
Routine free fl ap monitoring is performed as previously
described with mobilization after 48 hours. The Styrofoam
dressing is removed and the fl ap is gently supported with
a loose mesh garment. The urinary fl ow remains diverted
through the suprapubic tube. When the patient is com-
fortable with the care of the fl ap and donor site, he is
discharged with the suprapubic tube in place. Three to
4 weeks postoperatively, if healing appears adequate, a ret-
rograde urethrogram is performed. If no fi stula is seen, the
bladder catheter is removed and the suprapubic tube is
clamped. If the patient voids successfully, the suprapubic
tube is removed 1 week later. When adequate protective
sensation is gained in the fl ap, the patient is eligible for
insertion of a prosthesis to allow for intromission. Most
patients report the ability to achieve orgasm on stimula-
tion of the neophallus within 9 months ( Figure 62-15 ).
Scrotal Reconstruction
The scrotum and vulva are derived from the same embryo-
logic tissue. The differences are that the scrotum descends
farther than the vulva and fuses to form the median raphe
and the vulva forms the vaginal introitus. In addition, the
testicles migrate down to fi ll the scrotum. Scrotal skin
loss may occur secondary to congenital anorchia, Fournier
gangrene, burn, traumatic loss, or tumor resection.
Reconstruction is guided by what tissue is injured or lost.
Small to moderately sized skin defects may be treated
conservatively, by allowing the wounds to heal by sec-
ondary intention. Common treatment of the surgically
or traumatically created defects frequently involves
either split-thickness skin grafting or burial of the testes
in subcutaneous medial thigh pockets with delayed scro-
tal reconstruction.
FIGURE 62-15. (A, B) Final neophallus construction (transsexual) after minor
revisions, insertion of infl atable prosthesis, and professional tattoo of veins and glans.
A
B
RECONSTRUCTION OF THE PERINEUM AND GENITALIA • 745
When there is a remnant of scrotal skin left, the authors’
preferred technique is a two-stage reconstruction with the
use of tissue expansion to create the scrotal sac. 34 In the fi rst
stage, a small tissue expander is placed beneath the deep
Dartos fascia of the residual scrotal or perineal skin at the
base of the penis. The expander is then gradually fi lled to
at least a 150-mL capacity over several months. The sec-
ond stage involves removal of the expander through an
inverted V incision at the penoscrotal junction. The tes-
tes are mobilized (or testicular prosthesis is inserted) and
secured to the inferior portion of the neoscrotal sac as in
an orchiopexy. The incisions are then closed in a V-Y fash-
ion, allowing the neoscrotal sac to move inferiorly and to
hang in a natural position.
In complete absence of the scrotum, a variety of regional
fl aps can be used for reconstruction. The appearance of testi-
cles may be created with the fat of a pudendal or medial thigh
fl ap or with the use of silicone prosthesis. Due to the thick-
ness of most fasciocutaneous fl aps, it is diffi cult to recreate
the texture of the original scrotum, in addition to problems
with color match.
COMPLICATIONS
All tissue transfer techniques, whether grafts or fl aps, have
the inherent potential complication of partial or complete
loss with possible infection and resultant contraction and
stenosis. All of the techniques have risks of injuring the
rectum or urinary tract. The complications of the intra- or
transabdominal procedures are similar to any intra-abdom-
inal procedure, including infection, formation of adhesions,
and bowel obstruction. Of all the pedicled fl aps, the rectus
myocutaneous fl ap seems to have the lowest overall com-
plication rate. 35
All grafts and fl aps are at risk for partial or complete
failure. Even a small area of ischemia of the tissue trans-
ferred will result in stricture and possible fi stula. Most fi s-
tulae close spontaneously, those that do not may require
secondary surgery. Mild strictures may be amenable to
dilatation. Severe but localized strictures may be treated
with internal urethrotomy followed by a short period of
self-catheterization. Extensive strictures from poor take of
a graft or a marginally perfused fl ap will most likely need
revisional surgery.
The most common complications are related to the
proximal urethral anastomosis, including sinuses, fi stulae,
and strictures. Most fi stulae close spontaneously. Proximal
urethral anastomotic suture line strictures may be treated
with internal urethrotomy. One or two neodymium-YAG
lasers or cold knife urethrotomies, followed by a short
period of self-catheterization, often results in a stabilized
widely patent urethra. Occasionally, recurrent proximal
urethral suture line complications require surgical correc-
tion with local fl aps or buccal mucosal grafts. All of our
patients were ultimately able to stand to void. Meatal
stenosis has not been problematic in these patients since
a circumferential meatal suture line is avoided. Urethral
stone formation has not been observed in these patients,
despite the hair present on the forearm. It is presumed
that the fi ne hair on forearm skin does not have the same
propensity to form stones as that of the thick, coarse hair
on scrotal skin. Erosion and extrusion of penile prosthe-
ses has been described. It has been found that if prosthe-
sis placement is delayed until protective sensation has
returned the risk of prosthetic erosion and extrusion can
be minimized. 36
The greatest drawback of the radial forearm fl ap is the
unsightly donor site ( Figure 62-16 ). The thicker the graft
used to close it, the better the aesthetics. Functional dis-
ability of the donor extremity has been rare, although the
authors have had one patient with a radial nerve palsy
that resolved and one patient with postoperative carpal
tunnel syndrome that required release. Considering the
high quality of penile construction possible with the
radial forearm fl ap, the resultant donor site scar is usu-
ally well tolerated by patients. Some patients may not
be the candidates for the radial forearm fl ap, and others
may refuse it as a donor site. In these instances, alternative
methods of penile reconstruction are possible and should
be considered. 37 - 40
For vaginal reconstruction, there is no single technique
that is successful in all patients. Skin graft techniques are
attractive because they are straightforward to perform.
The biggest disadvantage is the tendency to contract or
shrink over time and long-term use of molds is frequently
required. Lining made from skin, whether from grafts or
fl aps, all have the problem of dryness, desquamation, and
the tendency to be malodorous. A common disadvantage
of musculocutaneous fl aps is excess bulk. Pudendal fl aps
that are placed through the perineal route for total vaginal
reconstruction tend to shorten and or prolapse. To prevent
shortening and prolapse of fl aps placed transperineally, a
simultaneous laparoscopic suspension may be performed
FIGURE 62-16. Forearm donor site closed with split-
thickness skin graft.
746 • CHAPTER 62
to suspend the blind end of the neovagina to the sacral
promontory. 41 Patients frequently have sexual dysfunction
due to psychological reasons, fl ap shortening, and diffi culty
with lubrication. 42
OUTCOMES
A successful outcome is achieved if the realistic goals of
the surgeon and patient are met. This is best achieved by
using a multidisciplinary approach. It should include a pre-
operative urogenital workup in cases of congenital defor-
mities and psychological counseling for many patients,
both pre- and postoperatively. The specifi c reconstructive
option should be tailored to provide the best chance to
maintain or restore function, improve quality of life, have
acceptable aesthetics, and minimal morbidity. Appropriate
follow-up should ascertain functional success as well as
emotional health. Outcome measurements should iden-
tify whether the urologic, gynecologic, and sexual goals
are met. Serial postoperative visits should evaluate the aes-
thetic appearance of the reconstructed tissues, the regular-
ity and ability to control urine production, the ability to
have regular pain-free intercourse if desired, as well as the
patient’s own satisfaction with the appearance and func-
tion of the reconstruction. If all of these outcomes are met,
the result may be deemed successful.
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28. van der Werff, JFA, van der Meulen, JC. Treatment mo-
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age of the radial artery forearm free fl ap: use of the profun-
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of total penile reconstruction with sensate osteocutaneous
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63
Lower Extremity Reconstruction
Amir H. Tahernia, MD / Lawrence S. Levin, MD, FACS
INTRODUCTION
Lower extremity defects are encountered following
trauma, ablative oncologic procedures, and in the setting
of infection. When discussing lower extremity recon-
struction, it is helpful to divide the limb into anatomic
components: upper leg (thigh to knee), knee, and lower
leg (knee to foot). Each area due to its composition and
function, presents different reconstructive challenges.
The primary goal is to restore form and function of the
reconstructed limb. The operative approach must be tai-
lored to each patient, as limb defects arising from trauma
will have different reconstructive demands to those fol-
lowing oncologic resection. As such, planning and com-
munication between the ablative and reconstructive
team is essential, with goals established early by the cli-
nician and the patient.
PATIENT EVALUATION
Trauma
Lower extremity injury with open high-energy soft tis-
sue wounds is frequently encountered in trauma centers
and often requires the input from reconstructive plastic
surgeons. In the setting of severe limb injury, the ques-
tion of limb salvage versus primary amputation is the
most important early decision. Several authors have
attempted to use scoring systems to help decide between
limb reconstruction and amputation. These include the
Mangled Extremity Severity Score, the Limb Salvage
Index, and the Predictive Salvage Index. Studies have
shown that although these indices may serve as a use-
ful classifi cation of wound severity, they do not reliably
predict which limbs should undergo amputation. The
primary factors infl uencing the outcome in leg injuries
are the degree of soft tissue damage, the presence or
absence of plantar sensation, and the severity of vascu-
lar injuries. From this, absolute and relative indications
for indications for primary limb amputation have been
proposed. Absolute indications include complete disrup-
tion of posterior tibial nerve in adults and crush injury
with warm ischemia time longer than 6 hours. Relative
indications include serious associated polytrauma, severe
ipsilateral foot trauma, anticipated protracted course to
obtain soft tissue coverage and fracture healing, and mas-
sive bone loss.1
The most important determinants of outcome after
open fractures are wound size, degree of soft tissue dam-
age, and the amount of contamination. The severity of
open wounds has been further classifi ed in a landmark
paper by Gustillo. Several clinical studies have confi rmed
the utility of the Gustillo classifi cation as a prognostic tool
for recovery of open tibial fractures. Using this classifi ca-
tion as a guide, the reconstructive team can determine the
appropriate method of limb salvage.
Gustillo Classifi cation of Open Fractures of the Tibia
I—Open fracture with a wound ,1 cm
II—Open fracture with a wound .1 cm without exten-
sive soft tissue damage
III—Open fracture with extensive soft tissue damage
IIIA—III with adequate soft tissue coverage
IIIB—III with soft tissue loss and periosteal stripping
and bone exposure
IIIC—III with arterial injury needing repair
As with any trauma patient, those who have sustained
lower limb injury need to be assessed according to the
Advanced Life Trauma Support protocol. Extremity
injuries are best treated by a multidisciplinary team that
involves orthopedic, plastic, and vascular surgeons. A recent
study has shown that this team approach has led to lower
complication rates and need for revisional surgery.2
c h a p t e r
750 • CHAPTER 63
Tumor
The objectives of reconstruction of the lower extrem-
ity following cancer resection are to provide adequate
wound coverage to allow for subsequent adjuvant ther-
apy, to preserve functional capability, and to optimize
the aesthetic outcome. As a rule, any extremity that can
be preserved with a good potential for function should
be salvaged. Currently, there are many effective pros-
thetic devices, but none of them can replicate the func-
tion of the human hand or foot. As a result, surgeons
and patients are willing to go to great lengths to salvage
affected extremities. Limb salvage rates approach 90% in
many studies. This is a testament to technical advances in
reconstructive surgery, as well as newer, more effective
adjuvant therapies. 3
Infection
Perhaps the most benign of the three indications, lower
extremity wounds due to infectious complications are
often the most diffi cult to manage. Osseous tissues are less
vascular than the surrounding soft tissue and thus more
resistant to antibiotic therapy, which relies on a healthy
blood supply to reach the affected tissues. Management
of such injuries requires adequate determination of the
offending agent, in this case the specifi c organism, and
precise tailoring of the pharmacologic therapy. Frequent
cultures and serial debridements are invaluable in the
management of such wounds. Grossly infected bone
often needs to be debrided back to healthy tissue in
order for the overlying soft tissue to heal. Nowhere is
the adage, “Don’t put a new roof on a burning building,”
more true than with bony infection.
PATIENT PREPARATION
In all three clinical settings, there are instances where
preoperative radiographs are indicated. In the instance
where a free fl ap is contemplated, the issue of “zone of
injury” as it relates to the vascular status of the affected
limb must be addressed. The zone of injury refers to the
infl ammatory response of the soft tissues that extend
beyond the gross wound and results in perivascular
changes. These changes include increased friability of
vessels and increased perivascular scar tissue, which can
contribute to higher anastomotic failures. Therefore,
when performing free vascularized bone or soft tissue
transfer, it is best to avoid this zone. This is accomplished
by extensive proximal dissection of the recipient vessels
as well as use of interposition venous conduits. A meticu-
lous clinical examination in combination with Doppler
mapping will likely be suffi cient to assess the adequacy
of recipient vessels for microvascular anastomosis.
However, there are times when either CT angiography
or formal angiography is necessary to better prepare the
reconstructive surgeon. The use of angiography should
be determined on a case-by-case basis.
TREATMENT
Although treatment concepts for the traumatized lower
extremity did not change much until the major wars,
several early principles of treatment were proposed.
Pierre-Joseph Desault (1738–1795) introduced deep
incisions for drainage and debridement of devitalized
tissue and Louis Ollier (1830–1900) introduced plaster
casting for fracture stabilization. By the end of World
War I, the concept of treating open wounds with dress-
ings and casts was the mainstay of treatment of lower
extremity wounds. Osteomylelitis was a frequent compli-
cation and prompted surgeons to perform more aggres-
sive debridement prior to application of a cast.
After World War II, the use of skin grafts for cov-
erage of complicated lower extremity wounds was
introduced. Following this period, wound closure was
attempted before the appearance of granulation tissue
and this led to lower infectious complications. Over the
past 40 years, signifi cant advances have been made in
the management of soft tissue and skeletal defi ciencies.
Wounds, which would have resulted in amputation, can
now be salvaged with free tissue transfer as well as a
variety of local fl aps.
Today, wounds can be examined along a spectrum
of reconstructive modalities, regardless of the location.
Using a “reconstructive ladder” the clinician can formu-
late an effective approach for coverage based on the exist-
ing defect. This is particularly useful in the management
of lower extremity defects as management at different
levels of the limb mandate different restorative measures
( Figure 63-1 ). The initial management of open fractures
consists of emergent debridement of devitalized tissue
as well as skeletal stabilization. Thorough debridement
is essential prior to any reconstructive endeavor, as any
nonviable tissue that remains can lead to failure of the
reconstruction.
Timing of Reconstruction
Traditionally, coverage of complicated lower extremity
wounds was delayed until the tissue edema had subsided
and the wound had stabilized. The issue of delayed ver-
sus early reconstruction has been examined closely. In
the 1980s, Byrd and colleagues4 noted that complications
were higher if wounds were not covered in the early
phase defi ned as 6 days from the time of injury. Godina
demonstrated that with radical debridement and cover-
age of wounds within 72 hours, the incidence of non-
union and osteomyelitits decreased. Most studies show
a signifi cantly lower failure rate in patients in whom
free fl ap reconstruction is performed within 3 days of
injury as compared with fl aps performed at a later date.
Godina5 noted a failure rate less than 1%, 12%, and 10%
when free fl aps were performed within 3 days, 3 days
to 3 months, and longer than 3 months after injury. It
is thought that in the setting of a delayed reconstruc-
tion, wounds enter a subacute or chronic phase where
LOWER EXTREMITY RECONSTRUCTION • 751
FIGURE 63-1. The reconstructive ladder. STSG, split-thickness skin graft;
HBO, hyperbaric oxygen therapy; VAC, vacuum-assisted closure. (Reprinted with permission
from Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg.
2001;108(4):1029–1041; quiz 1042.)
Non-definitive
2nd look
Yes
No
Elective reconstruction
Angioplasty/bypass
Soft
tissue
management
Aesthetic
2° closure
1. 1° closure
2. 2° closure
3. STSG
Meshed–unmeshed
4. Local/rotational flap
5. Transplant
A. Coverage
B. Function
C. Flow through
Bead pouch
Saline/adaptic dressing
Porcine allograft
Wound VAC
Requirement for
granulation tissue
–consider HBO
Vascular supply
Emergent
reconstruction
bypass graft
Coverage
STSG/flap
6. Debulking
A. Staged excision
B. Tissue expanders
C. Free tissue
Compromised
Definitive
Debridement
Not adequate
No
Yes
there is increasing infl ammation and bacterial coloniza-
tion, which may hinder reconstructive efforts. Therefore,
the current approach is to perform early coverage with
vascularized tissue to reduce complications and lead to
shorter hospitalizations.
Methods of Bone Stabilization
and Reconstruction
In the setting of lower extremity trauma, bony injury falls
into two categories: (1) those with adequate bone stock
in need of stabilization and (2) those where signifi cant
bone loss has occurred and stabilization with hardware
alone would be inadequate. Bone fi xation may be of two
general types: internal fi xation with plates, rods, and/
or screws placed within or on top of the bone or exter-
nal fi xation with percutaneous pins held together with
hardware outside the leg. Although possible for smaller
wounds, casting larger wounds with exposed bone is not
an appropriate method of skeletal stabilization.
Plate fi xation requires exact opposition and compres-
sion of bones by plates and screws. The hardware must
be covered with soft tissue. The periosteum is critical for
bone healing and one of the problems with use of plate
fi xation in the setting of trauma is the need for further
periosteal stripping prior to plate fi xation. This devascu-
larization in addition to what may have been sustained
as a result of the trauma can lead to suboptimal bony
union. Several studies have shown increased complica-
tion rates, including infection and nonunion, when plates
are used in severe leg injuries. As such, for high-energy
tibial fractures, the safest choice for skeletal stabilization
is external fi xation. The advantage of this method is that
in addition to providing stability, it is able to hold the
bony segments out to their anatomic length, which is of
particular importance when a large segment of bone may
be missing. The main disadvantages of external fi xation
are complications associated with hardware, the most
common of which is pin tract infection. The longer the
pins stay in place, the more chance of infection and this
may limit the duration of fi xator placement. Ideally, the
external fi xator should remain until union has occurred,
but in certain cases this needs to be balanced with the
risk of infection.6
Intramedullary nailing of tibial fractures is a method
also applied in the management of open tibial fractures.
Studies have shown it to result in high union rates and few
infections in the setting of low energy wound. In grossly
contaminated wounds (Gustillo IIIA or IIIB), intramedul-
lary nailing is associated with increased risk of infection
and hardware exposure. In these wounds external fi xa-
tion is still the best choice for skeletal stabilization.3
Complicated lower extremity wounds can be accom-
panied by signifi cant bone loss mandating reconstruction.
752 • CHAPTER 63
Options for skeletal reconstruction include autogenous
bone grafts, vascularized bone transfer (pedicled or free),
and the Ilizarov technique. The size of the bony defect will
determine the ideal reconstructive approach. For defects of
the tibia less than 6 cm, bone grafts have been shown to be
an acceptable option assuming there is adequate soft tis-
sue coverage. Although alloplastic bone graft can be used,
it is fraught with a relatively high infection rate. As such,
cancellous autografts are preferred. The bone grafts are
typically placed following placement of antibiotic spacers
and 4 to 6 weeks after soft tissue reconstruction to allow
for the transferred tissue to further sterilize the wound. An
intact fi bula facilitates bone grafting, as it may act as a strut
to keep the extremity at length.7,8
Vascularized bone transfers have been described using
iliac crest and scapula but by far the most commonly
harvested bone is the fi bula. Vascularized bone transfer
can be performed based on a preserved vascular pedicle
( Figure 63-2 ) or as a free fl ap with microvascular anas-
tomosis ( Figure 63-3 ). The fi bula can be transferred with
or without an overlying skin paddle. The bone has great
strength and is able to provide adequate length in many
FIGURE 63-2. Arc of rotation of a pedicled fi bula
osteoseptocutaneous fl ap.
FIGURE 63-3. Harvested free fi bular fl ap with pedicle
and skin island.
circumstances. To provide more stability and bulk, the
bone may be folded on itself. In doing so, the fracture rates
and time to full weight bearing is diminished.9
Bone transport or distraction techniques provide an
alternative for bony reconstitution. This method was fi rst
described by Codvilla10 and popularized by Ilizarov. This
can be used for defects less than 10 cm. The technique
requires debridement of the fractured ends with pin
placement near the bone ends on either side of the gap.
A corticotomy is made high on the tibia and serves as the
source of regenerate after the bone is distracted with trans-
fi xation pins on an external frame.
Acute shortening of the bone can also be done using
the Ilizarov method. This allows for subsequent length-
ening with distraction performed at 1 mm/day. Typically
a latency period of 7 days where no distraction is per-
formed is followed as protocol. Acute shortening is espe-
cially useful in cases of nerve or vascular repair. One
of the advantages of the Ilizarov method is that during
the distraction period the soft tissue is also transported
over the length of the defect, allowing for closure of
soft tissue defects without the need for fl aps or grafts.
Theoretically, no limit exists regarding bone loss that can
be fi lled using this technique. The length and alignment
of the bone are maintained throughout treatment, allow-
ing improved extremity function and ambulation. Levin
and colleagues11 have reported on using a combination
of distraction with microsurgical free tissue transfer to
provide an additional option for extremity reconstruc-
tion. Disadvantages of the Ilizarov method include joint
deformities, nonunion, and pin site infections.
LOWER EXTREMITY RECONSTRUCTION • 753
Soft Tissue Reconstruction
With any lower extremity reconstruction, three tenets
are essential: (1) adequate preparation of wound bed,
including debridement and control of infection prior to
coverage; (2) stabilization and management of associ-
ated orthopedic injuries; and (3) overall assessment of
the patient’s suitability for reconstruction and rehabilita-
tion. As a reconstructive adjunct, a vacuum-assisted clo-
sure (VAC) device can be used to optimize the wound
bed and minimize dressing changes in preparation for
reconstruction. In the lower extremity, muscle and fas-
ciocutaneous fl aps remain primary choices for soft tissue
coverage with free fl aps being the fi rst-line for the distal
third of the leg. For free fl ap reconstruction, it is impor-
tant to anastomose vessels outside the zone of injury and
reconstruct the soft tissue fi rst followed by restoration of
skeletal support.12
In the lower extremity reconstruction, the workhorse
fl aps for soft tissue coverage are the latissimus, serra-
tus, rectus, and gracilis muscles, and more recently the
anterolateral thigh fl ap has gained popularity. The latis-
simus dorsi fl ap has the advantage of a large amount of
bulk to fi ll dead space ( Figure 63-4A–C ). Over time, the
fl ap loses bulk, which aids in restoring normal contour to
the leg. For coverage of massive lower extremity wounds,
the latissimus dorsi can be coupled to the serratus ante-
rior using a single thoracodorsal pedicle. The latissimus
muscle also has the added advantage of having a relatively
long pedicle, anywhere from 9 to 11 cm, allowing for ves-
sel anastomosis to occur well outside the zone of injury.
For smaller defects, the gracilis muscle is an ideal choice.
The gracilis is relatively easy to harvest with minimal
donor site or functional morbidity ( Figure 63-5A,B ). The
anterolateral thigh fl ap is based on one or two perfo-
rators arising from the descending branch of the lateral
femoral circumfl ex artery. It is a fasciocutaneous fl ap
with a large skin paddle ( Figure 63-6A,B ). The donor
site can be closed primarily or skin grafted if a large fl ap
is harvested.
Microvascular Soft Tissue Reconstruction
When confronted with a lower extremity wound where
the location of injury and extent of tissue loss mandates
free tissue transfer, certain critical considerations need to
be made prior to reconstruction. One of the controversial
issues is the use of angiography in lower extremity recon-
struction. A good clinical examination corroborated with
ultrasonography is a reliable enough assessment to pro-
ceed with a microvascular anastomosis. There are certain
situations where we feel that a vascular road map (for-
mal angiography, CT angiography, or MR angiography)
would be a useful tool for preoperative planning. One of
these circumstances is the extremity that has undergone
a vascular reconstruction at another facility and is then
transferred for soft tissue reconstruction. In this situation,
one would need to confi rm beyond the clinical examina-
tion, the reconstructed vascular anatomy of the leg prior
to embarking on free tissue transfer. The other clinical
scenario where angiography is warranted is in the setting
of a Gustillo IIIC wound (associated vascular injury).13
With respect to the technical aspects of microvascular
anastomosis, the posterior and anterior tibial arteries are
the most common recipient vessels. The arterial anasto-
mosis enjoys more success when it is performed in an
FIGURE 63-4. (A–C) Large posterior calf defect covered with myocutaneous
latissimus dorsi fl ap.
A
B
C
754 • CHAPTER 63
end-to-side fashion, whereas the venous anastomosis is
usually performed end to end to one or preferably both
of the venae commitantes. Superfi cial veins are more
prone to spasm and as such are avoided in microvascular
reconstruction, except in the situation where supercharg-
ing of a fl ap is desired. In this setting, if the fl ap has an
available venous perforator, an additional venous anasto-
mosis can be done to decrease the potential for venous
congestion. Venous congestion is known to be a common
cause of early fl ap failure and mandates a return to the
operating room.
The role of microsurgery in the amputee is another
area worth mentioning. Once amputation is inevitable,
the main objective of surgery is to preserve a functional
stump. Free tissue transfer is a valuable tool in preserv-
ing length and restoring contour of the lower limb stump.
Parts from the amputated limb such as the calcaneal-
plantar unit and classic free fl aps such as the latissimus
dorsi, scapula, and anterior lateral thigh fl aps can be used
to achieve stable and rapid rehabilitation of the patient.
The “free fi llet” fl ap principle was described as part of
“spare part” preservation.14 This allows for the use of tis-
sue in the absence of additional donor site morbidity. This
strategy can be applied on the basis of an immediate use
of fl aps and a multistaged reconstruction with banking of
free fl aps.
FIGURE 63-5. (A) Patient with exposed hardware following open reduction
and internal fi xation of the ankle. (B) Postoperative photograph 16 months following
debridement and coverage with a free gracilis muscle fl ap with a split-thickness
skin graft.
A
B
FIGURE 63-6. (A) Patient with a degloving injury to the medial aspect of foot.
(B) Wound bed following debridement and coverage with a free anterolateral thigh fl ap.
A
B
LOWER EXTREMITY RECONSTRUCTION • 755
Site-specifi c Soft Tissue Reconstruction
In the thigh, the need for pedicled or free fl ap reconstruc-
tion is minimal. Given the large amount of local muscle
and skin, wounds can be closed either primarily or muscle
can be covered with a split-thickness skin graft. In cases
where the defects are very large or femoral vessels are
exposed, a pedicled rectus abdominis muscle (based on the
inferior epigastric vessels)—with or without the overlying
vertical pattern of skin—can be used. For smaller defects
the gracilis (medial femoral circumfl ex) or tensor fascia
lata (ascending branch of the lateral femoral circumfl ex)
can be rotated into the wound.
As a general rule, the area around the knee can be
covered with local rotational fl aps. Special consideration
must be given to preserving the knee extensor mecha-
nism. Techniques have been described where either one
or both gastrocnemius muscles (sural artery) have been
used for both coverage of knee wounds and restoration
of the extensor mechanism. There are instances, however,
where free tissue transfer may be necessary due to defect
size. An area of particular interest with regard to knee
reconstruction is in the setting of a failed knee arthro-
desis where a free fi bula can be transferred to achieve
joint fusion.
For coverage of the defects around the upper third of
the tibia, the main rotational fl aps include both lateral
and medial heads of the gastrocnemius, proximally based
soleus (peroneal artery), and tibialis anterior (anterior
tibial artery). The medial head of the gastrocnemius
allows for a longer advancement as compared with
the lateral head. The pedicle is the medial sural artery.
Advancement is facilitated by release of the origin of the
muscle from the femoral condyle and scoring of the fas-
cia. When harvesting the lateral head of gastrocnemius,
care should be taken not to injure the peronreal nerve.
The soleus muscle based proximally can be reliably car-
ried to a point about 5 cm above its tendinous insertion.
The tibialis anterior is important in dorsifl exion of the
foot and is not considered expendable. Nonetheless by
maintaining its origin and insertion, the muscle might
be raised as a bipedicled fl ap and transposed to cover a
neighboring defect.
For coverage of middle tibial wounds, the soleus and
gastrocnemius are the main reconstructive options.
Other fl aps include the fl exor digitorum longus (poste-
rior tibial artery), the extensor digitorum longus (ante-
rior tibial artery), the extensor hallucis longus (anterior
tibial artery), and the tibialis anterior (anterior tibial
artery). The fl exor digitorum longus is a small and its
use is reserved for coverage of small defects or in con-
junction with other fl aps. There is minimal donor site
morbidity as the fl exor digitorum brevis can supplement
toe fl exion. The extensor digitorum longus and extensor
hallucis longus are also small and are used for coverage
of wounds less than 5 cm in diameter. In the setting of
large wounds where local fl aps are inadequate, free tissue
transfer must be considered.
Due to insuffi cient soft tissue available for transposi-
tion, local fl aps have a limited role in coverage in the area
of the distal leg and ankle. As such, free fl aps are the fi rst
choice for reconstruction. However, for small defects in
this area there are some local muscle and distally based
superfi cial fl aps that can be used. Attinger and colleagues15
have described several of these, including such the medial
plantar artery fl ap. It is important to realize that these
are only for small defects and in the right patient they
may prevent the use of a free fl ap. Therefore, a careful
evaluation of the wound will allow one to decide on the
best course of action. The sural fl ap as a fasciocutane-
ous fl ap has been used in coverage of the lower third of
the leg. It is supplied from its distal aspect by perfora-
tors from the medial superfi cial sural artery. Because of
the reverse orientation of the fl ap, venous congestion can
compromise fl ap viability. For this reason, the fl ap can
be supercharged with a microvascular anastomosis per-
formed between the greater saphenous vein within the
fl ap and the lesser saphenous vein. In attempts to redirect
blood fl ow and decrease the risk of fl ap necrosis and other
complications, several authors have described sural fl ap
delay procedures as an additional method for improving
fl ap survival ( Figure 63-7A–C ).16,17
The goal of reconstruction of the foot is functional:
to restore weight bearing during ambulation. Important
components to achieve this goal include stable and
well-contoured bony support, and a sensate and durable
plantar surface. The overall soft tissue contour should
allow the use of regular foot apparel or a reasonable
orthotic device. Otherwise, a normal gait cycle may not
be possible. Donor site morbidity should be minimal.
Unfortunately, attaining all of these goals in one reconstruc-
tion is not always possible. Bulky fl aps may be durable but
insensate and clumsy. Innervated fl aps may offer sensibility
with less than optimal durability or donor site morbidity.
Cases are therefore individualized to each patient’s needs
and desires. When embarking on a foot reconstruction,
it is critical to assess the potential soft tissue defect, the
amount and location of remaining bone, the expected
plantar sensation, and the vascular status of the limb after
the ablative portion of the procedure. Actual fl ap choices
will be guided by the fi ndings. The vascular supply to the
foot is assessed fi rst. If the patient has a history of vascular
disease, claudication, or rest pain, or if pulses are not pal-
pable on physical examination, a preoperative arteriogram
is obtained. Poorly vascularized distal extremities may best
be served by amputation or reconstruction in concert with
a revascularization procedure. Bony support of the foot
should be addressed next. If the areas of the fi rst metatar-
sal head and calcaneus are uninvolved, minimal bony work
should be required because these are the normal weight-
bearing areas. Bony prominences should be recontoured
to allow the distribution of forces over as wide an area as
possible.
The choice of soft tissue coverage must be individual-
ized for the particular case. Considerations in fl ap selec-
tion include defect size, required bulk, surface durability,
756 • CHAPTER 63
and sensory reinnervation. These considerations should be
prioritized because any particular fl ap rarely can satisfy all
possible needs. For skin defects with exposure of vital struc-
tures such as tendon, bone, or joint spaces, an innervated
free fasciocutaneous fl ap is preferred. Examples of this type
of fl ap include the radial forearm fl ap ( Figure 63-8A,B ) and
the lateral arm fl ap. These fl aps provide well-vascularized,
thin, pliable soft tissue that facilitates restoration of foot
contour with durable sensate skin. This allows patients to
wear normal shoes. When larger, more complex defects are
anticipated, a muscle free fl ap is a good choice to fi ll the
dead space and accomplish reconstruction with a healthy
pad of tissue. Skin grafting is required, and although no
nerves are reanastomosed, patients may be functional
from proprioceptive feedback and some protective sensa-
tion from the defect bed and surrounding skin. Regardless
of the fl ap procedure performed, patient education in
meticulous foot care is imperative. Patients need to inspect
their feet frequently and recognize any incipient problems.
Special footwear should be prescribed following plantar
resurfacing.
Cross-Leg Flaps
Prior to the advent of free tissue transfer, when local tis-
sue was not an option for lower extremity wound cov-
erage, the cross-leg fl ap was the treatment of choice for
coverage, particularly in the elderly patient. Currently
there are limited indications. The patient who is not a
free fl ap candidate and is immobilized for other reasons
may be a candidate. Cross-leg fl aps are transferred as
fasciocutanoeus fl aps with a 3:1 length-to-width ratio.
A recent analysis of cross-leg fl aps by Dawson indicated
a high morbidity. In a review of 99 patients local fl ap
necrosis was identifi ed in 40% and infection in 28%.
Soft Tissue Expansion
Although tissue expansion has enjoyed good results
in coverage of defects in the chest and head and neck
regions, its use in the lower extremities has been associ-
ated with high rates of infection and implant extrusion.
Its primary use in the lower extremity is to resurface
areas of unstable soft tissue or unsightly scar. If used in
the lower extremity, expanders are placed in a subcu-
taneous pocket above the muscular fascia. In the foot
and ankle region, the use of expanders is almost always
avoided. Proximal placement is associated with higher
success rates. It has been shown that lateral expansion
of defects has a decreased failure rate when compared
with advancement in a longitudinal vector. Overall, the
role of tissue expansion in lower extremity reconstruc-
tion is limited. Its use should be tailored to patients on
an individual basis.
FIGURE 63-7. (A) Patient with bilateral necrotic heel ulcers and planned coverage
with bilateral sural artery fl ap. Flaps are designed with the pivot point of the pedicle
5 cm above the lateral malleolus. (B,C) Delay of the fl ap is used to decrease the
incidence of venous congestion. The fl ap is elevated and secured back into the wound
bed. At 3 weeks, the fl aps are re-elevated and transposed into position for coverage of
heel wound.
A
B
C
LOWER EXTREMITY RECONSTRUCTION • 757
FIGURE 63-8. (A) Donor site in a patient with a nonhealing wound of the heel
covered with a free radial forearm fl ap. (B) Recipient site of the radial forearm free fl ap
2 weeks after free tissue transfer.
A
B
Vacuum-assisted Closure
Over the past decade, VAC devices have improved treat-
ment of open wounds. The device applies continuous
subatmospheric pressure causing decreased tissue edema
and decreased wound circumference. It has been shown
to promote granulation tissue in the wound bed by virtue
of increased blood fl ow and decreased bacterial counts.
It is an ideal bridging therapy to defi nitive reconstruc-
tion of the lower extremity. Pribaz et al. showed that for
complicated wounds, including Gustillo III defects, VAC
can decrease the need for free fl ap coverage. They dem-
onstrated rapid production of granulation tissue over
exposed bone, tendon, and hardware with subsequent
coverage with skin grafts or delayed primary closure.
Although this study demonstrated encouraging results
with VAC and skin graft, negative pressure therapy will
not replace the role of vascularized tissue transfer in the
management of complex lower extremity wounds.
Oncologic Wounds
Wide tumor resection in the lower extremity can expose
neurovascular structures or bone devoid of its perios-
teum and can require coverage of allografts or internal
metal prostheses. Often, the surrounding soft tissues are
infl exible and cannot be mobilized to provide adequate
wound coverage, especially when local tissues have been
previously irradiated. In these cases, creative solutions
using distant fl aps to restore form and function are
required. When amputation is inevitable, preparation of
the wound bed for an external prosthesis becomes the
main objective of the reconstruction. And most impor-
tant, it is imperative that the reconstructive plan facili-
tates a rapid recovery so that patients can quickly receive
any required additional adjuvant treatment modalities
and resume their activities of daily living.
Surgery is infrequently used alone for treatment of
soft tissue sarcomas of the extremities and is often per-
formed between courses of systemic chemotherapy. It
is imperative that the surgery, not interfere with the
administration of chemotherapy. Previous studies have
shown that neoadjuvant chemotherapy does not usually
complicate a microsurgical tissue transfer, and similarly,
microsurgical tissue transfers do not usually interfere
with the subsequent delivery of adjuvant chemotherapy.
When compared with the use of local tissues alone or
primary wound closure, microsurgical tissue transfer
allows for better wound healing when used in associa-
tion with adjuvant chemotherapy.
Over the last decade, microsurgical techniques have
been increasingly utilized to reconstruct bone and soft tis-
sue tumors in the lower extremity. Specifi cally, with the
emphasis placed on limb salvage after compartment resec-
tion rather than amputation, microsurgical techniques
have allowed the orthopedic oncologist and reconstruc-
tive surgeon to work together, resulting in limb preser-
vation. Specifi cally, in soft tissue sarcoma, where entire
compartments are resected, microsurgical transplantation
replaces components of both muscle and skin to maintain
limb contour and aid in healing. For example, a large ante-
rior compartment resection for a malignancy may expose
the tibial cortex. Microsurgery is the only reconstructive
option for wound closure. A fl ap such as the latissimus
dorsi muscle could be used to cover the tumor defect.
This muscle can also be innervated to assist in dorsifl exion
of the foot.18
The radiated wound, encountered in the treatment
of soft tissue sarcomas, has a high incidence of wound
complications after attempted primary closure. Radiated
wounds generally have a poor vascular supply, making
surgery through these wounds diffi cult and prone to
breakdown. Importing well-vascularized tissue into the
758 • CHAPTER 63
wound results in more rapid wound healing and may
improve local circulation in radiated areas. For this rea-
son, many centers have adopted the policy that imme-
diate microsurgical reconstruction be performed after
tumor extirpation.19 The results of immediate microsur-
gical transfers in these cases have been well substantiated
and have led to decreased hospital time, decreased costs,
decreased morbidity, and increased rate of limb salvage,
as well as high patient satisfaction. The traditional treat-
ment for high-grade sarcomas of bone, such as osteosar-
coma, was amputation before the advent of free-tissue
transfer. Limb salvage surgery has become a viable alter-
native for many patients due, in part, to the development
of more effective perioperative chemotherapy. The suc-
cess of limb salvage in these patients primarily depends
on wide resection margins and the addition of periopera-
tive chemotherapy.
The current management of soft tissue sarcomas or
osteogenic sarcomas stresses more conservative resec-
tion and limb-sparing operations. Local fl aps generally
do not provide adequate coverage, and free tissue trans-
fer is often the only option. This type of resection cre-
ates complex composite defects of bone and soft tissue
that require the use of composite fl aps in the reconstruc-
tive process, such as an osteocutaneous fi bula fl ap for an
intercalary bone defect that also has an accompanying
overlying skin defect. A recent study looked at one cen-
ter’s experience with free fi bula transfer for long bone
defects after sarcoma resection and showed high rates of
union and good functional outcomes. Although vascu-
larized fi bula fl aps may never achieve the native size or
shape of a tibia, they can hypertrophy under a mechani-
cal load. This is in contrast to allograft, which can restore
size and shape similar to that of resected bone, but essen-
tially acts as a dead spacer for years before bone for-
mation occurs at the graft-host junction. With a lower
infection rate and better bony union rate than allograft,
reconstruction with a free fi bula fl ap produces a better
result than allograft in long bone sarcoma patients who
undergo wide en bloc excisions. There are also defects
following cancer resection, which large combined soft
tissue and skeletal defects. In this setting a double-free
fl ap may be needed to achieve skeletal support with sta-
ble soft tissue coverage.20,21
Approaching these cases with a multidisciplinary team
facilitates the planning of the surgical resection, onco-
logic treatment, and reconstruction timing. Operative
details such as incisions, design of skin fl aps, exposure,
and preservation of the recipient site vessels should be
carefully planned with the ablative surgeon. It is usually
possible to establish the soft tissue and bony require-
ments of the wound early in the operation and to begin
the fl ap harvest concurrent with the tumor resection. If
oncologic margins are not predictable, then it is best to
complete the resection before beginning dissection of
the free fl ap fl aps are indicated to cover neurovascular
structures (particularly if radiated), bone devoid of
periosteum, and allografts or tumor prostheses that can-
not be covered with local tissues. Sometimes blood sup-
ply to local fl aps may be compromised or vessels may be
taken during tumor resection.
Secondary Reconstruction
Patients who undergo secondary reconstruction can be
divided into two groups. The fi rst includes those who
undergo tumor resection and develop acute wound com-
plications such as skin fl ap necrosis in the early postop-
erative period. These patients may require debridement
and free fl ap coverage within the fi rst or second postop-
erative week. It is safe to let questionable areas demarcate
before surgery. Patients who present later with impend-
ing allograft or prosthesis exposure should undergo sur-
gery as soon as possible to avoid infection of the implant
or allograft.
The second group of patients requires reconstruction
several months or years after primary tumor resection.
Some of the patients in this group present with chronic
unstable soft tissue coverage, wound dehiscence, pros-
thesis infection, and prosthesis failure or limb growth
that compromises soft tissue. Although free tissue trans-
fer adds extra time and technical complexity to the
tumor operation, it may also lead to a decrease in ampu-
tation rates by decreasing wound complications. In addi-
tion, it allows the oncologic surgeon to obtain adequate
margins of resection, which may favorably infl uence
amputation rates by contributing to a decrease in local
recurrence.
With respect to wound location following tumor extir-
pation, much of the reconstructive options implemented
are based on the same principles and options, which guide
lower extremity reconstruction secondary to trauma. In
the lower third, although local options exist for small
defects, free tissue transfer is often the best choice for
both soft tissue and bony reconstruction as needed. In the
middle third of leg, the pedicled gastrocnemius based on
the sural artery and the soleus muscle based on the per-
oneal promixally and posteior tibial distally, can be used.
For the knee, the gastrocnemius combined with a skin
graft has remained a reliable method to reconstruct the
knee and popliteal regions. In some situations, a microsur-
gical tissue transfer around the knee and popliteal region
may be needed. A microvascular tissue transfer should be
considered when the defects are too large for local fl aps,
when local tissue fl aps are not available due to previous
surgery or injury, or when patients have received previous
radiation to the local donor sites. An anterior lateral thigh
fl ap, a rectus abdominis muscle fl ap with a skin graft, a
latissimus dorsi muscle fl ap with skin graft, or a compos-
ite latissimus dorsi and serratus anterior muscle fl ap based
on the subscapular system can provide adequate coverage
to reconstruct these defects.
LOWER EXTREMITY RECONSTRUCTION • 759
Orthopedic Sepsis
Osteomyelitis is now a treatable disease. The classic
treatment of osteomyelitis includes thorough debride-
ment of infected bone and necrotic tissue, appropriate
antibiotic therapy and, if necessary, subsequent closure
of the resultant dead space with well-vascularized tissue.
The management of dead space after sequestrectomy
relies heavily on the technique of free tissue transfer.
Free muscle fl aps provide coverage for the debrided bone
and soft tissue, obliterate dead space, improve vascular-
ity, and enhance leukocyte function. Advances in skeletal
reconstruction and fi xation have improved the treatment
of patients with osteomyelitis and large (.6 cm) segmen-
tal bone defects. In the past, despite successful treatment
of osteomyelitis, some patients required amputation due
to chronic nonunions. Now, once the bone infection is
treated, vascularized bone transplants or bone lengthen-
ing using the Ilizarov technique facilitate reconstruction
and provide structural stability for limb function.
Local muscles were traditionally used to treat chronic
osteomyelitis, and free fl aps have been described more
recently for this use. Local gastrocnemius and soleus
muscle fl aps are still used to cover smaller wounds on
the upper and middle thirds of the leg, respectively.
However, local muscle fl aps will not reliably cover
defects larger than 25 cm 2 or those on the distal third
of the leg, ankle, or foot. For these defects, free muscle
transfers are preferred. The advantages of using the free
muscle fl aps, such as the latissimus dorsi, serratus ante-
rior, and rectus abdominis, instead of local pedicled mus-
cle fl aps, such as the gastrocnemius muscle, are that free
fl aps provide greater bulk (fi lling larger wounds), have
longer pedicles (increasing fl exibility in muscle position-
ing), and carry larger diameter vessels (facilitating the
microanastomoses).
Postoperative Management
Monitoring free tissue transfer is essential to assure
transplant success. Many different monitoring devices
and techniques have been used with varying levels of
success. There is no ideal fl ap monitoring system, but
improving the existing monitoring techniques and a bet-
ter understanding of the information they give will help
improve the salvage rate in cases that develop complica-
tions. Clinical evaluation remains the gold standard by
which all methods of monitoring need to be compared.
This involves observing skin color, temperature, capillary
refi ll, and bleeding characteristics. Changes are often ini-
tially subtle and, by the time they are clinically apparent,
salvage of the fl ap may be impossible because of irrevers-
ible tissue damage.
One common practice is routine monitoring of
patients using an implantable Doppler probe. This
is usually done in the intensive care unit for the fi rst
24 hours when postoperative problems most frequently
occur after free tissue transfer. With the implantable
device, we are able to continuously monitor free fl aps
and any change in signal prompts an immediate evalu-
ation. The device is usually left in place until the fi fth
postoperative day.
COMPLICATIONS
Acute complications occur usually in the fi rst 48 hours and
include venous thrombosis, arterial thrombosis, hematoma,
hemorrhage, and excessive fl ap edema. Arterial insuf-
fi ciency can be recognized by decreased capillary refi ll,
pallor, reduced temperature, and the absence of bleeding
after pinprick. This complication can be caused by arterial
spasm, vessel plaque, torsion of the pedicle, pressure on
the fl ap, technical error with injury to the pedicle, a fl ap
harvested that is too large for its blood supply, or small ves-
sel disease (due to smoking or diabetes). Management of
arterial compromise requires prompt surgical intervention
to restore the blood fl ow.
Pharmacological intervention includes vasodilators, cal-
cium blockers, and anticoagulants for fl ap salvage present-
ing with arterial insuffi ciency. Venous outfl ow obstruction
should be suspected when the fl ap has a violaceous color,
brisk capillary refi ll, normal or elevated temperature,
and produces dark blood after pinprick. Venous insuffi -
ciency can occur due to torsion of the pedicle, fl ap edema,
hematoma, or tight closure of the tissue over the pedicle.
Venous outfl ow obstruction can result in extravasation of
the red blood cells, endothelial breakdown, microvascu-
lar collapse, thrombosis in the microcirculation, and fl ap
death. Given the irreversible nature of the microcircula-
tory changes in venous congestion that occur even after
short periods of time, the surgeon must recognize venous
compromise as early as possible. These complications can
occur alone or in any combination.
Clinical observation and patient monitoring should
alert the surgeon to complications. The surgeon must
then decide between conservative and operative inter-
vention. There is frequently little downside but signifi -
cant benefi t to re-exploration in the operating room.
However, conservative treatment may be helpful; include
draining the hematoma by the bedside and/or release of
a few sutures to decrease pressure. In cases of venous
congestion, leeches may be helpful if insuffi cient venous
outfl ow cannot be established, despite a patent venous
anastomosis. The leeches inject a salivary component
(hirudin) that inhibits both platelet aggregation and the
coagulation cascade. The fl ap is decongested initially as
the leech extracts blood and is further decongested as
the bite wound oozes after the leech detaches. The donor
site should be given the same attention as the recipient
site during the postoperative period. Complications of
the donor site include hematoma, seroma, sensory nerve
dysfunction, and scar formation.
760 • CHAPTER 63
REFERENCES
Flap Failure
Occasionally, free fl aps fail despite early return to the
operating room for vascular compromise. Options for
management include the performance of a second free tis-
sue transfer, noting the technical or physiologic details that
led to initial failure. Most of the time, free tissue transfers
fail due to technical errors in judgment, which can include
fl ap harvest, compromise of the pedicle during the harvest,
improper microvascular technique during anastomosis,
improper insetting resulting in increased tissue tension and
edema, and postoperative motion of the extremity result-
ing in pedicle avulsion. Although rare, avulsion does occur.
The next decision made by the operating surgeon regard-
ing the management of the patient is based on several fac-
tors. Obviously, if a patient requires a free fl ap in the fi rst
place, a second free fl ap should be considered.
If a decision is made not to redo the fl ap, it could be left
in place using the Crane principle in hopes that underlying
granulation will be suffi cient such that skin grafting can be
performed once the necrotic fl ap is removed. The Crane
principle is based on the fact that a local fl ap or a free
tissue transfer that necroses in part or totally can act as a
biological dressing or eschar over a wound bed. If there is
no infection, then the eschar can be left on the wound bed
with hopes that some healing can occur underneath the
eschar. This would be in the form of granulation tissue that
may form under the eschar. Ultimately, the eschar could
be removed and, with an appropriate granulation bed, the
wound can be skin-grafted, thus obviating the need for
another free tissue transfer. By observing the wound, if
such a bed is not produced, then a second fl ap must be
considered. Some prefer not to leave the necrotic fl ap in
place because the fl ap can become a source of sepsis and
further compromise local tissues. Necrotic, nonviable fl aps
should be removed, and a temporary wound dressing, such
as a bead pouch or wound VAC, should be used.22
Occasionally, when fl aps fail in severely compromised
extremities, consideration can be given to amputation in
that the morbidity of a second free tissue transfer and per-
haps the resultant extremity state renders the extremity
less favorable for salvage and more favorable for amputa-
tion. If a second free fl ap is considered, obvious errors
that lead to fl ap compromise need to be recognized. It
may be prudent to obtain an arteriogram, evaluate the
coagulation profi le, and research other issues that lead
to failure.
A recent comprehensive study looking at over 580 free
fl aps performed for lower extremity reconstruction
revealed a failure rate of 8.5%.23 This study spanned over
25 years with 18% of those patients going on to ampu-
tation. The remainder was salvaged with secondary free
fl aps, local fl aps, and skin grafting. The most common
causes of fl ap failure included venous thrombosis, infec-
tion, and arterial thrombosis. In this study, the research-
ers noted a signifi cantly higher rate of failures in the fi rst
half of the study period with signifi cant improvements in
outcome in the latter period. The improved success rate
seen in the second half of the study period was attrib-
uted to a more critical selection of free fl ap candidates,
improved understanding of the physiology surrounding
acute trauma and a more sophisticated multidisciplinary
team organization.24
OUTCOMES
The fi nal stage of the reconstructive ladder involves the
issue of aesthetic restoration of the limb. Not infrequently,
patients are traumatized by scars, skin grafts, and bulky
free fl aps, and consideration should be given to the psy-
chological comfort of the patient in addressing these
issues. The reconstructive ladder could involve the use of
staged excision of scars, scar revision, dermabrasion, and
tissue expanders to expand the normal skin, recruiting
dermal and epidermal elements, followed by transposition
of these expanded skin segments to stage out or elimi-
nate unsightly scars. In some instances, even free tissue
transplantation can be performed for aesthetic recontour-
ing of limbs, which can be of major psychological benefi t
to patients and may even allow further reconstruction, if
necessary.
1. Heller L, Levin LS. Lower extremity microsurgical recon-
struction. Plast Reconstr Surg. 2001;108(4):1029.
2. Zenn M, Levin LS. Microsurgical reconstruction of the lower
extremity. Semin Surg Oncol. 2000;19(3):272.
3. Pederson W. Limb salvage. Plast Reconstr Surg. 1991;1:125.
4. Heitmann C, Levin LS. The orthoplastic approach for
management of the severely traumatized foot and ankle.
J Trauma. 2003;53:379.
5. Godina M. Early microsurgical reconstruction of com-
plex trauma of the extremities. Plast Reconstr Surg. 1986;
78(3):285.
6. Levin LS, Aponte RL, Nunley JA. Soft tissue coverage for
the foot and ankle. Foot Ankle Clin. 1999;8:1.
7. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular
osteoseptocutaenous fl ap: Anatomic study and clinical
application. Plast Reconstr Surg. 1986;78(2):191.
8. Malizos KN, Nunley JA, Goldner RD, et al. Free vascularized
fi bula in traumatic long bone defects and in limb salvage fol-
lowing tumor resection: Comparative Study . Microsurgery.
1993;14:368.
9. Heller L, Levin LS. Bone and soft tissue reconstruction. In:
Bucholz RW, Heckman JD, eds. Rockwood and Green’s Frac-
tures in Adults. Philadelphia: Lippincott Wilkins & Wilkins;
2001:415–462.
10. Gustillo RB, Merkow RL, Templeman D. The management
of open fractures. J Bone Joint Surg Am. 1990;72(2):299.
LOWER EXTREMITY RECONSTRUCTION • 761
11. Ong SY, Levin LS. Lower limb salvage in trauma. Plast
Reconstr Surg. 2010;125(2):582.
12. Parrett N, Matros E, Pribaz J. Lower extremity trauma: trends
in the management of soft-tissue reconstruction of open
tibia-fi bula fractures. Plast Reconstr Surg. 2006;117(4):1315.
13. Basheer M, Wilson SM, Lewis H, Herbert K. Microvascu-
lar free tissue transfer in reconstruction of the lower limb.
J Plast Reconstr Aesthet Surg. 2008;61(5):525.
14. Levin LS. Microsurgical autologous tissue transplantation.
Tech Orthop. 1995;10:134.
15. Pinsolle V, Reau AF, Pelissier P, et al. Soft tissue reconstruc-
tion of the distal lower leg and foot: Are free fl aps the only
choice? Review of 215 cases. J Plast Reconstr Aesthet Surg.
2006;59(9):912.
16. Follmar KE, Baccarani A, Baumeister SP, et al. The distally
based sural fl ap. Plast Reconstr Surg. 2007;119(6):138e.
17. Baumesiter SP, Spierer R, Erdmann D, et al. A realistic com-
plication analysis of 70 sural artery fl aps in a multimorbid
patient group. Plast Reconstr Surg. 2003;11(2):129.
18. Corderio PG, Neves RI, Hidalgo DA. The role of free tissue
transfer following oncologic resections in the lower extrem-
ity. Ann Plast Surg. 1994;33:9.
19. Barwick WJ, Goldberg JA, Scully SP. Vascularized tissue
transfer for clusre of irradiated wounds after soft tissue sar-
coma resection. Ann Surg. 1992;216:591.
20. Hoy E, Granick M, Benevenia J, et al. Reconstruction of
musculoskeletal defects following oncologic resection in
76 patients. Ann Plast Surg. 2006;57(2):190.
21. Chen CM, Disa JJ, Lee HY, et al. Reconstruction of
extremity long bone defects after sarcoma resection with
vascularized fi bula fl ap: a 10 year review. Plast Reconstr Surg.
2007;119(3):915.
22. Khouri RK, Shaw WW. Reconstruction of the lower extrem-
ity with microvascular free fl aps: A 10 year experience with
304 consecutive cases. J Trauma. 1989;29:1086.
23. Heller L, Kronowitz S. Lower extremity reconstruction .
J Surg Oncol. 2006;94:479.
24. Culliford AT 4th, Spector J, Blank A, et al. The fate of lower
extremities with failed free fl aps: a single institution’s expe-
rience over 25 years. Ann Plast Surg. 2007;59(1):18.
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c h a p t e r
Pressure Sores
Lisa C. Moody, MD / Wesley T. Myers, MD / John D. Bauer, MD / Linda G. Phillips, MD
INTRODUCTION
Pathogenesis
Pressure sores result from ischemia of the soft tissue as a
consequence of prolonged pressure, shearing forces, fric-
tion, moisture, decreased mobility, decreased sensation,
and spasticity. Lindan 1 demonstrated that areas of greatest
pressure are found over bony prominences. In the prone
position, the knees and chest are the areas of greatest pres-
sure. In the supine position, the buttock, heels, and occiput
carry the highest pressure. The ischial tuberosities are at
greatest risk for developing pressure sores in the sitting
position because pressures can reach as high as 300 mm Hg
( Figure 64-1 ). When external pressure is greater than
end-capillary bed pressure (32 mm Hg), there is a decline
of blood fl ow to the tissue and ischemia results. Dinsdale 1
proved that constant pressure of 70 mm Hg applied for
2 hours leads to irreversible ischemia and tissue loss.
Muscle is the most sensitive to ischemia and necrosis of
muscle can occur before there are overlying skin changes.
Shea 1 classifi ed pressure sores based on tissue depth and
pathophysiologic changes. Although there have been
some modifi cations over the years, it remains the most
accepted pressure sore classifi cation system ( Table 64-1 ).
Stage I pressure sores are confi ned to the epidermis and
are defi ned by acute infl ammation and present as an
area of nonblanchable erythema. Typically, stage I pres-
sure sores can be reversed by eliminating pressure. Stage
II pressure sores have breakdown to the dermis with
acute and chronic infl ammation and usually possess
more defi ned borders than stage I pressure sores. Wound
care and behavioral modifi cation to reduce contributing
pathophysiologic factors usually allows stage II pressures
to heal without the need for surgical intervention. Stage
III pressure sores extend through the subcutaneous fat
but do not violate the deep fascia. They can involve fat
necrosis caused by thrombosis of small vessels, undermin-
ing, and tunneling with thickened epidermal edges in the
periphery of the wound. Stage IV pressure sores entail
destruction of the deep fascia, muscle, and bony struc-
tures and can be complicated by extensive undermining,
necrosis of all tissue layers, involvement of the joint, and
osteomyelitis.
PATIENT EVALUATION AND SELECTION
A thorough history and physical examination is impera-
tive in the evaluation of patients presenting for treat-
ment of their pressure sores. Recognition of medical
comorbidities, risk factors, and behaviors that contrib-
uted to the development of the pressure sore are neces-
sary in order to make changes for optimization of the
patient prior to surgery. Diabetes, malnutrition, vitamin
defi ciencies, spasticity, joint contractures, urinary and
bowel incontinence, infection, anemia, smoking, spinal
cord injury, and prolonged pressure in the area—all can
contribute to development and progression of pressure
sores. Spasticity is common among patients with spinal
cord injuries and is a contributing factor to pressure sore
development and wound dehiscence postoperatively.
Higher spinal cord injuries result in an increased inci-
dence of muscle spasticity. Muscle spasticity increases
shearing and friction forces and makes transfers more
diffi cult. Patient compliance with lifestyle modifi ca-
tion is one of the most important factors to a success-
ful reconstruction. Patient should shift weight every
10 minutes when sitting and every 1 to 2 hours when
lying down, keep skin clean and dry, and invest in pres-
sure reducing devices such as air mattresses, air-fl uidized
beds, and ROHO cushions.
Urinary and bowel incontinence can precipitate the
development of pressure sores by sustaining a moist
64
764 • CHAPTER 64
environment and leading to skin maceration. Contamination
of pressure sores with urine and fecal contents can also
lead to wound infection. Pressure sores can be complicated
by osteomyelitis of the underlying bone, which is usually
polymicrobial. Anemia can be an indicator of poor nutri-
tion or chronic blood loss and should be worked up and
corrected.
Contraindications for surgical reconstruction of pres-
sure sores include critically ill patients who are unable to
tolerate general anesthesia, sepsis, wound bacterial load
greater than 10 5 colony-forming units or the presence of
beta-hemolytic streptococci, osteomyelitis, malnutrition,
inability of the patient to tolerate prone positioning, fail-
ure to control spasticity, and unwillingness of patients to
alter behaviors that contributed to the development of
pressure sores. Patients who use tobacco products should
be counseled regarding smoking cessation. Smoking leads
to peripheral vasoconstriction and decreases tissue oxygen-
ation. Continued tobacco use can lead to fl ap failure.
10
100
20
60
80
80
40
FIGURE 64-1. Pressures over the ischial tuberosities in
a patient sitting with the feet supported. (With permission from
Lindan O, Greenway RM, Piazza JM. Pressure distribution on the surface
of the human body: Evaluation in lying and sitting positions using a “bed
of springs and nails.” Arch Phys Med Rehabil. 1965;46:378.)
TABLE 64-1. Pressure Sore Stages
Stage I
Stage II
Stage III
Stage IV
Depth
Limited to epidermis
Through epidermis and
into dermis
Extends through
subcutaneous fat
down to but not
through deep fascia
Full-thickness skin loss
with damage to deep
fascia, muscle, and
bony structures
Clinical Signs
Nonblanchable erythema;
acute infl ammatory
response
Mixture of acute and
chronic infl ammatory
response
Fat necrosis,
undermining, and
tunneling
Extensive undermining
and necrosis of all
layers of tissue
PATIENT PREPARATION
Stage III and stage IV pressure sores are indications for sur-
gical reconstruction provided that the preoperative evalu-
ation is clear. In diabetics, glucose and hemoglobin A1C
levels should be checked and optimized. Hyperglycemia
slows wound healing and increases the risk of wound
dehiscence and infection. Malnutrition can be assessed
by serum albumin, pre-albumin, and transferrin levels. An
albumin level greater than 3.5 is a predictor in optimiz-
ing wound healing and preventing dehiscence. Vitamin C,
vitamin A, copper, magnesium, iron, and zinc are essen-
tial for wound healing and should be supplemented when
defi ciencies exist.
Treatment of muscle spasticity should be implemented
prior to surgery. The most common medical treatments for
muscle spasms include baclofen, diazepam, and dantrolene.
Botulinum toxin is an emerging treatment for spasticity and
has been shown to be effective in reducing localized spas-
ticity of the upper and lower limbs with minimal adverse
effects. The lasting effects of the botulinum toxin treat-
ment for muscle spasticity are approximately 3 months. 2
A chart review of 28 patients with spinal cord injury
receiving botulinum toxin type A (doses 10–119 Units per
muscle) demonstrated improvement for 56% of patients
in ambulation, 71% of patients in positioning, and 78% of
patients in upper-extremity function. 3 A decrease in pain
was reported in 83.3% of patients receiving botulinum
toxin injections. 3 Splinting and physical therapy can also
be benefi cial in treating contractures. For those patients
who fail medical treatment, surgical alternatives can be
explored, and include surgical rhizotomy, amputation, and
contracture release.
Wound biopsies should be sent for quantitative tis-
sue cultures preoperatively. Infection is defi ned as greater
than 10 5 organisms and should be treated with appropri-
ate antibiotics prior to surgery. Urinalysis and urine cul-
tures should also be included in the preoperative workup.
Paraplegic and quadriplegic patients typically require rou-
tine catheterization for urinary retention that predisposes
them to urinary tract infections.
If suspected, a workup for osteomyelitis should be
instituted. Bone biopsy is the gold standard for diagnos-
ing osteomyelitis. Plain x-rays may demonstrate periosteal
PRESSURE SORES • 765
changes and heterotopic new bone formation, but only
have a 54% sensitivity and a 68% specifi city. 4 In addition,
it can take many weeks for changes to become apparent
on x-ray. A negative bone scan rules out osteomyelitis.
False-positives on a bone scan can result from trauma, sur-
gery, degenerative joint disease, malignancies, and infl am-
matory bone conditions. If plain fi lms are normal, the
sensitivity and specifi city of a bone scan for the diagnosis
of osteomyelitis is 94% and 95%, respectively. 4 MRI is an
accurate test in the diagnosis of osteomyelitis with a 90%
sensitivity and 79% specifi city and can detect changes as
early as 3 to 5 days. 4 Osteomyelitis is treated with appro-
priate antibiotics and surgical debridement. Treatment fail-
ure is likely to occur without surgical debridement.
In addition to optimizing the patient medically and
avoiding pressure at the site of the pressure sore, local
wound care can be provided for those with contraindi-
cations to surgical interventions. Sharp, enzymatic, and
mechanical debridement can be performed at the bedside.
Debridement of the pressure sore removes necrotic tis-
sue, decreases the bacterial count, and converts a chronic
wound into an acute wound that promotes wound heal-
ing and the development of a granulated tissue bed. Daily
wound cleansing should be performed with a neutral, non-
irritating, nontoxic solution such as mild soap and sterile
water. Antiseptic agents such as iodine should be avoided. If
infection is suspected, obtain a tissue biopsy and quantita-
tive culture, treat with appropriate antibiotics, and initiate
local dressing changes with topicals such as Dakin solution,
silver sulfadiazine, or mafenide acetate to decrease the
bacterial count. A bacterial count of 10 5 colony-forming
units per gram of soft tissue or any level of beta-hemolytic
streptococci can impair wound healing. 5 Topical antibiotics
should be discontinued once bacterial balance is reestab-
lished. Moist dressings are most appropriate for pressure
sores because they promote faster epithelialization than
leaving the wound exposed to air. Negative pressure dress-
ings are an alternative treatment that can be used in grades
III and IV pressure sores that fail conventional nonsurgical
therapy. Negative pressure wound therapy removes exu-
dates and debris, controls bacterial colonization, and pro-
motes tissue perfusion and formation of granulation tissue,
but it will not replace large tissue losses.
Once patients are optimized medically, operative plan-
ning and preparation can proceed. It is imperative to iden-
tify the unique reconstructive needs of each individual.
The goal is to provide soft tissue coverage of the pressure
sore defect, while maintaining as many options as possible
for future use. The recurrence rate of pressure sores has
been reported to be as high as 91%. 6 If a patient is ambula-
tory, a reconstructive procedure should be chosen that will
preserve function.
TECHNIQUE
Surgical interventions for pressure sores include debride-
ment of necrotic tissue and its bursa, ostectomy to decrease
bony prominences, and defi nitive closure of the defect with
viable soft tissue. General anesthesia with endotracheal
intubation is the most appropriate induction for patients
undergoing surgery for pressure sore reconstruction. It is
essential to have a defi nitive airway due to the position-
ing required for adequate exposure of the operative sites.
Succinylcholine should be avoided in the fi rst few months
after spinal cord injury.
Prone jack-knife positioning is used for adequate expo-
sure of sacral and ischial pressure sores and lateral decu-
bitus positioning is utilized for adequate exposure of
trochanteric pressure sores.
Debridement
Debridement should be performed prior to designing the
fl ap. Once all nonviable tissue is removed, the defect is
typically larger than anticipated. The superfi cial changes of
pressure sores can be deceiving in predicting the extent of
involvement beneath the surface. In the absence of infec-
tion, debridement and reconstruction can be performed in
a single operation.
Ostectomy
Bony prominences within the pressure sore are signifi cant
contributors to recurrence. Therefore, partial ostectomy
is frequently recommended for ischial, trochanteric, and
sacral pressure sores. Conversely, total unilateral ischiec-
tomy is contraindicated because it leads to pressure over
the contralateral ischial pressure and resultant tissue loss
on the contralateral side. Similarly, bilateral total ischiecto-
mies place pressure on the perineum and leads to perineal
ulceration and urethral fi stulae.
Ischial Coverage
The most common location of pressure sore occurrence
is the ischium. Reconstructive options for ischial pressure
sores include fl aps based on the gluteus maximus muscle,
inferior gluteus thigh fl ap, gracilis fl ap, V-Y hamstring
fl ap, tensor fascia lata fl ap (expanded or delayed), and the
rectus abdominis fl ap.
The entire gluteus maximus fl ap is an excellent fi rst
approach for ischial pressure sore coverage because it pro-
vides a large skin paddle with large muscle and soft tissue
bulk while allowing primary closure of the donor site with
minimal tension. In addition, this fl ap can be re-elevated
or rotated for local recurrence and preserves all other local
fl aps for future use. The inferior gluteus maximus island fl ap
is a good choice for patients who are ambulatory because it
preserves function. The blood supply to the inferior gluteus
maximus island fl ap comes from the inferior gluteal artery
and venae comitantes with the pedicle running deep to the
gluteal muscle, inferior to the piriformis muscle. The infe-
rior gluteus maximus fl ap originates from the gluteal line
of the sacrum and ilium and inserts into the greater tuber-
osity of the femur and iliotibial band of the fascia lata. The
skin paddle should be made as large as possible despite the
size of the defect and is centered over the gluteal crease
766 • CHAPTER 64
between the ischial tuberosity and the greater trochanter.
The medial edge of the skin paddle should abut the lateral
edge of the pressure sore. The skin is then incised and the
muscle divided distally with several centimeters of muscle
exposed beyond the skin island fl ap. The muscle should
then be divided superiorly and laterally to mobilize the
inferior half of the gluteus maximus muscle. The muscle
is then rotated medially and inset over drains. Lastly, the
donor site is closed primarily ( Figure 64-2 ). 7
The inferior gluteus thigh fl ap is an effective fl ap for
ischial pressure sore coverage and can be re-advanced in
the future should the pressure sore recur. The blood supply
to this fl ap is provided by the descending terminal branch
of the inferior gluteal artery. A line drawn perpendicular
to the gluteal crease and equidistant between the ischial
tuberosity and the greater trochanter marks the central
axis of the inferior gluteus thigh fl ap where the inferior
gluteal artery continues down to the posterior thigh. The
fl ap is centered over the posterior thigh and should be less
than 12 cm if primary closure is desired. The distal end of
the fl ap can be extended to within 8 cm of the popliteal
fossa. Skin incisions are made at the distal end of the fl ap
fi rst. Dissection is carried down to the deep fascia to iden-
tify the posterior femoral cutaneous nerve. The posterior
cutaneous femoral nerve should be located at the distal
tip midline, and confi rms that the fl ap is centered over the
vascular pedicle. The descending branch of the inferior glu-
teal artery is then ligated and the fl ap is elevated to gluteal
crease, rotated into the defect and inset over drains. The
donor site is closed primarily ( Figure 64-3 ). 8 The fl ap does
not include muscles, preserving function, but not provid-
ing bulk for a large defect.
The gracilis fl ap is typically a last choice for ischial
pressure coverage because these fl aps tend to be small
(Figure 64-4). The gracilis fl ap is supplied by the ascending
branch of the medial circumfl ex femoral artery and venae
comitantes. The gracilis muscle originates from the pubic
tubercle and inserts into the medial condyle of the tibia.
The gracilis muscle can be found 2 cm posterior and paral-
lel to a line drawn from the pubic tubercle to the medial
FIGURE 64-2. Inferior gluteus maximus island fl ap
for ischial pressure sore coverage. (With permission from
Scheufl er O, Farhadi J, Kovach S, et al. Anatomical basis and clinical
application of the infragluteal perforator fl ap. Plast Reconstr Surg.
2006;118:1389–1400.)
FIGURE 64-3. Inferior gluteus thigh fl ap for ischial
pressure sore coverage. (Above left) Pre-operative view;
(above right) 21 months post-op; (below left) fl ap design
(below right) intraoperative view. (With permission from Kim YS,
Lew DH, Roh TS, et al. Inferior gluteal artery perforator fl ap: a viable
alternative for ischial pressure sores. J Plast Reconstr Aesthet Surg.
2009;62:1347–1354.)
condyle of the femur. The fl ap should be designed with an
8 3 15 cm skin island centered over the proximal third of
the gracilis muscle. A majority of the musculocutaneous
perforators supply the skin overlying the proximal third
of the gracilis muscle. A small incision is fi rst made over
the medial aspect of the knee to identify the tendinous
insertion of the gracilis. A suction drain is then positioned
around the tendon and upward traction is applied. This
allows visualization of the gracilis muscle as it travels prox-
imally and permits confi rmation of skin island position
over the proximal third of the gracilis. The skin incisions
are made and the gracilis muscle is identifi ed superiorly
and inferiorly. Temporary sutures may be used to keep the
FIGURE 64-4. Gracilis fl ap for ischial pressure sore
coverage. (A) Flap design; (B) elevation of fl ap. (With permission
from Bagdatli D, Kara IG. Proximally located partial skin-paddle
necrosis in the gracilis musculocutaneous fl ap. J Plast Reconstr
Aesthet Surg. 2009;62:424–425.)
A
B
PRESSURE SORES • 767
skin island adherent to the muscle. The insertion of the
gracilis is then divided and the fl ap is elevated superiorly
while ligating branches of the superfi cial femoral artery as
necessary. The muscle is rotated into the defect and inset
over drains. 9
The V-Y hamstring fl ap is another option for ischial
pressure sore coverage. This myocutaneous fl ap is based
on the biceps femoris, semimembranosus, and semitendi-
nosus. The blood supply to this fl ap is derived from the
perforating branches of the profunda femoris artery. The
profunda femoris artery passes through the adductor mag-
nus to enter each of the muscles on their posterior aspect.
The semimembranosus, semitendinosus, and the long head
of the biceps femoris all originate from the ischial tuberos-
ity. The short head of the biceps femoris originates from
the linea aspera of the femur. The biceps femoris is the
largest hamstring muscle and travels most lateral to insert
into the head of the fi bula. The semitendinosus and semi-
membranosus both travel medial to the biceps femoris and
insert into the medial condyle of the tibia. The base of the
fl ap should be designed as the same width of the ischial
defect. A V-shaped incision is made from medial and lat-
eral borders of the defect distally. The biceps femoris, sem-
itendinosus, and semimembranosus are divided distal to
apex of the skin island. The fl ap is elevated and the origin
of the short head of the biceps femoris is divided at the
linea aspera. The origins of the three hamstring muscles
are detached from the ischium allowing mobilization of
the fl ap to cover the defect. The fl ap is inset over drains
and sutured in place ( Figure 64-5 ). The donor site is closed
primarily. The V-Y advancement fl ap can be modifi ed to
maintain function of the lower extremity by only utilizing
the long head of the biceps femoris for advancement into
the defect.
The tensor fascia lata fl ap is not as reliable in the distal
portion of the fl ap, which is essential for ischial pressure
sore coverage. If the tensor fascia lata fl ap is going to be
used for ischial pressure sore coverage, the fl ap should be
delayed or expanded. Delay involves a fi rst-stage incision
and primary closure of the periphery of the fl ap without
elevation followed by a second-stage fl ap elevation and
rotation. Lastly, the rectus abdominis fl ap can be tunneled
through the groin for ischial pressure sore coverage.
Sacral Coverage
The V-Y gluteus maximus rotation or advancement fl ap is
the major reconstructive option used for coverage of sacral
pressures sores. Both fl aps can be advanced past the mid-
line and therefore a contralateral fl ap can be used. Bilateral
gluteus maximus fl aps are used for large sacral defects and
are usually approximated at the midline. The gluteus max-
imus fl aps provide large bulk and can be re-advanced in
the future for recurrence. Ambulatory function can be pre-
served by solely advancing the superior half of the gluteus
maximus muscle instead of performing complete muscle
advancement. The blood supply to the V-Y gluteus maxi-
mus advancement fl ap is provided by the superior gluteal
FIGURE 64-5. V-Y hamstring fl ap for ischial pressure sore coverage.
(A) Musculocutaneous fl ap attached by its vascular pedicles. (B) Flap inset over ischial
pressure sore.
A
B
768 • CHAPTER 64
artery and the venae comitantes and enters the deep sur-
face of the gluteus maximus at the level of the piriformis
muscle. The dominant vascular pedicle enters the muscle
at the lateral edge of the sacrum. The gluteus maximus
muscle originates from the gluteal line of the ilium and
sacrum and inserts in the greater tuberosity of the femur
and the iliotibial band of the fascia lata. The superior and
inferior boundaries of the muscle are the posterior supe-
rior iliac spine and the ischial tuberosity, respectively. The
skin island is centered over the medial portion of the mus-
cle and abuts the sacral wound. The skin island should be
designed as large as possible to allow for re-advancement
should the pressure sore recur. Oblique incisions across the
buttocks are made with the base of the triangle abutting
the wound and the apex located laterally. The superior and
inferior aspects of the gluteus maximus muscle are elevated
with blunt dissection and carefully separated from the glu-
teus medius underneath. The muscle is then divided at the
origin. The piriformis muscle is a good landmark for the
midportion of the gluteus maximus muscle and identifi es
the point where the superior and inferior gluteal arteries
enter the gluteus maximus. The muscle is elevated over the
sacrum and inset over drains into the defect. The muscle
is sutured to the contralateral gluteus maximus. The donor
site is closed in a V-Y fashion ( Figure 64-6 ).
Trochanteric Coverage
Trochanteric pressure sores usually have extensive bursa
formation and undermining despite nominal skin changes.
This is worsened by uncontrolled muscle spasticity and
contractures. The most common fl aps used for recon-
struction of trochanteric pressure sores are the tensor
fascia lata (TFL) musculocutaneous fl ap with or without
V-Y modifi cation and the vastus lateralis fl ap. The V-Y
modifi cation provides use of the proximal, more vascu-
larized tissue for coverage. The TFL fl ap permits eleva-
tion of a large skin island despite the size of the muscle.
The blood supply to the TFL fl ap is provided by the lat-
eral femoral circumfl ex artery, which is a branch of the
profunda femoris artery. The lateral femoral circumfl ex
artery enters the tensor fascia lata muscle 10 cm below
the anterior superior iliac spine and can have up to three
branches that divide the TFL into upper, middle, and
lower thirds. The tensor fascia lata originates from the
anterior superior iliac spine and inserts in the iliotibial
tract of the fascia lata. A line is drawn from the anterior
superior iliac spine running anterolaterally to the distal
thigh. The posterior portion of the V is drawn from the
apex of the anterolateral line to the posterior perimeter
of the trochanteric pressure sore. The fl ap should be
large enough to cover the trochanteric defect. The fl ap
is then elevated from the apex progressing proximally.
Dissection may continue up to the vascular pedicle. The
fl ap is then rotated superiorly and posteriorly and inset
over drains into the defect. The donor site is then closed
primarily. 10 The tensor fascial lata fl ap can be re-elevated
and re-advanced in the future for local recurrence. If the
TFL has been advanced multiple times, consideration can
be given to the vastus lateralis fl ap ( Figure 64-7 ).
FIGURE 64-6. (A) Stage III sacral pressure sore. (B) V-Y gluteus maximus
fl ap. (C) The musculocutaneous fl ap is then mobilized to the sacral defect. (D) The
musculocutaneous fl ap is sutured into place with underlying drains. The donor site is
closed primarily. (E) Postoperative result.
A
B
C
E
D
PRESSURE SORES • 769
The vastus lateralis is a muscle fl ap that must be used
in combination with the TFL fl ap or a split-thickness skin
graft because this fl ap does not have an associated cuta-
neous territory. In fact, the overlying skin is part of the
tensor fascia lata territory. The blood supply to the vas-
tus lateralis is the lateral femoral circumfl ex artery. The
vastus lateralis originates from the greater trochanter,
the gluteal tuberosity and the linea aspera and inserts
into the lateral border of the patella. An incision is made
along a line from the anterior superior iliac spine to the
lateral border of the patella. The fascia lata is then incised
along the muscle. The vastus lateralis is then separated
from the rectus femoris. The origin can then be divided if
needed. The muscle is sutured over the defected and cov-
ered with a split-thickness skin graft or tensor fascia lata
fl ap. This fl ap is particularly useful if a girdle stone proce-
dure is performed, as the muscle can be used to obliterate
the dead space.
FIGURE 64-7. Tensor fasciae lata perforator fl ap for
trochanteric pressure sore coverage. (With permission from
Ishida L, Munhoz A, Montag E, et al. Tensor fasciae latae perforator
fl ap: minimizing donor-site morbidity in the treatment of trochanteric
pressure sores. Plast Reconstr Surg. 2005;116:1346–1352.)
COMPLICATIONS
Long-term sequelae of pressure sores include wound infec-
tion, osteomyelitis, septic hip joints, and malignant degen-
eration of a chronic wound into squamous cell carcinoma.
Local wound infections are managed with appropriate anti-
biotics and local wound care. Osteomyelitis requires appro-
priate antibiotics and debridement of the involved bone
as discussed previously. If the hip joint becomes infected,
then proximal femoral head resection (Girdlestone arthro-
plasty) with soft tissue coverage is recommended for elim-
inating infection.
Postoperative complications include seroma, hema-
toma, wound infection, wound dehiscence, fl ap necrosis,
and recurrence. Seromas are usually avoided by placing
drains during surgery. Drains should be left in place until
output decreases to 20 to 30 mL over 24 hours. If a seroma
forms after removal the drains then percutaneous drain-
age is recommended. Hematomas predispose patients to
other complications and should be evacuated immedi-
ately. Wound infections should be treated with appropri-
ate antibiotics and local wound care. Wound dehiscence,
fl ap necrosis and recurrence should be treated with local
wound care in addition to controlling spasms and optimiz-
ing the patient medically. If the pressure sore recurs and
becomes large enough, another reconstructive surgery may
be necessary.
OUTCOMES ASSESSMENT
Ultimately, a satisfactory outcome is determined by a
closed, healed ulcer that does not recur. This apparently
simple concept however requires a complex, careful,
multidisciplinary approach. Only a combination of medi-
cal optimization, nutritional support, control of muscle
spasticity and contractures, pressure relief, local wound
care and surgical relief will lead to better outcomes and
patient and physician satisfaction. Specifi c metrics for out-
come assessment include absence of recurrence, duration
until recurrence, and occurrence of surgical or nonsurgical
complications.
REFERENCES
1. Bauer J, Phillips LG. MOC-PSSM CME article: Pressure
sores. Plast Reconstr Surg. 2008;121(1 Suppl):1–10.
2. Sheean G. Botulinum toxin treatment of adult spasticity: a
benefi t-risk assessment. Drug Saf. 2006;29(1):31–48.
3. Marciniak C, Rader L, Gagnon C. The use of botulinum
toxin for spasticity after spinal cord injury. Am J Phys Med
Rehabil. 2008;87(4):312–317; quiz 318–320, 329.
4. Chihara C, Segreti J. Osteomyelitis. Dis Mon. 2010;56(1):
6–31.
5. Levi B, Rees R. Diagnosis and management of pressure ul-
cers. Clin Plast Surg. 2007;34(4):735–748.
6. Evans GR, Dufresne CR, Manson PN. Surgical correction
of pressure ulcers in an urban center: is it effi cacious? Adv
Wound Care. 1994;7(1):40–46.
7. Scheufl er O, Farhadi J, Kovach SJ, et al. Anatomical basis and
clinical application of the infragluteal perforator fl ap. Plast
Reconstr Surg. 2006;118(6):1389–1400.
8. Kim YS, Lew DH, Roh TS, et al. Inferior gluteal artery per-
forator fl ap: a viable alternative for ischial pressure sores.
J Plast Reconstr Aesthet Surg. 2009;62(10):1347–1354.
9. Bagdatli D, Kara IG. Proximally located partial skin-paddle
necrosis in the gracilis musculocutaneous fl ap. J Plast Recon-
str Aesthet Surg. 2009;62(3):424–425.
10. Ishida LH, Munhoz AM, Montag E, et al. Tensor fasciae
latae perforator fl ap: minimizing donor-site morbidity in the
treatment of trochanteric pressure sores. Plast Reconstr Surg.
2005;116(5):1346–1352.
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c h a p t e r
Lymphedema
Richard W. Dabb, MD
INTRODUCTION
Lymphedema is a process of failure of lymphatic drain-
age resulting in the abnormal swelling of the subcutaneous
compartments of the body with protein-rich interstitial
fl uid. This swelling results in a chronic disability with
impaired immunity, susceptibility to infection, impaired
wound healing, and subcutaneous fi brosis ( Figure 65-1 ).
Regardless of the etiology, it is an exceptionally debilitat-
ing clinical problem, which in most cases seems to elude
surgical treatment. Of all areas facing the reconstructive
surgeon, lymphedema may be the most frustrating and
diffi cult to approach with an anticipation of a successful
result.
Interstitial fl uid contributes to the nourishment of
tissue. Ninety percent of the fl uid enters the venous
capillaries, the remaining 10%, which is composed of
high-molecular-weight protein and water held by osmotic
pressure, enter into the lymphatic capillaries. This fl uid is
transported by pre-collector lymphatic vessels to larger
lymphatic vessels and ultimately to the thoracic duct.
The superfi cial lymphatics drain into subdermal channels
which parallel the superfi cial venous system. Other large
molecules and particulate matter enter the lymphatic sys-
tem due to its unique valve-like openings between the
cells. Lymphatic drainage is infl uenced by the contraction
of skeletal muscle, arterial pulsation, and contraction of
smooth muscle in lymphatic trunks themselves. The lym-
phatic trunk consists of an endothelial layer, a smooth mus-
cle layer, and a loose adventitial layer. Recent discovery of
genes responsible for lymphatic development are adding
to a better understanding of both the anatomic develop-
ment of lymphatics and their pathogenesis. 1 The inter-
ruption in the development of the lymphatic system from
blood endothelial cells in the evolution of the lymphatic
plexus has been now described. The reality, however, is
that we know very little about the regional anatomy of
lymphatics and are rather unaware of how phenomenally
dynamic and complex is the process of lymph fl ow. Until
the recent work of Suami in Melbourne, Australia, there
had been no defi nitive study of lymphatic anatomy for
close to 100 years. 2 All anatomic textbook references since
then are based on initial anatomic studies performed nearly
a century ago. This work shows that there may be, indeed,
only two major lymph nodes draining the upper extremity.
This could explain the unfortunate cases of lymphedema
following sentinel node biopsy.
PATIENT EVALUATION
Classically, lymphedema has been categorized as “primary
lymphedema,” which is genetically determined, or “second-
ary lymphedema” which has been caused by some inciting
event. Primary lymphedema may present in several forms.
Milroy disease, or congenital hereditary lymphedema comes
from an autosomal dominant with incomplete penetrance.
It is associated with a genetic mutation on chromosome 5
and may be associated with cholestasis or an intestinal
lymphangiectasia secondary to VEGFR3 tyrosine kinase
receptor defi ciency specifi c for lymphatic vessels. Meige
disease, or lymphedema praecox, usually presents during
puberty and constitutes 60% to 80% of all cases of primary
lymphedema. This follows an autosomal dominant pattern
with association with the FOXC2 and VEGFR3 genes.
This often presents as a unilateral process and may have
associated syndromes such as pulmonary hypertension,
cerebrovascular malformations, distichiasis, and the yellow
nail syndrome. Lymphedema tarda presents in midlife, and
represents 10% of primary lymphedema. It is related to the
FOXC2 gene and the lymphatics show hyperplastic, tortu-
ous vessels with absent or incompetent valves.
Secondary lymphedema is an acquired process. The eti-
ology is usually secondary to destruction of the lymphatic
65
772 • CHAPTER 65
system by either infectious disease, parasitic or bacterial,
or by cancer and its associated treatment. Filariasis is by
far the most common etiologic agent of lymphedema
worldwide. There are millions of people suffering and due
to the infestation with Wuchereria bancrofti. Medical ther-
apy centers on the use of anti-helminthics (diethylcarbam-
azine and Mectizan). Most cases observed in the West are
secondary to lymphadenectomy and associated radiation.
In addition, lymphedema may develop secondary to meta-
static obstruction of lymphatics.
Heffel and Miller 3 present a paradigm concept that
lymphedema may present following an insult depend-
ing on where one is positioned in the preexisting state
of lymphatic anatomy and function. The presentation of
secondary lymphedema then is based on one’s ability to
compensate for trauma and ablation of certain lymphatics
depending on one’s preexisting location in this paradigm.
This concept certainly is consistent with the presenta-
tion of a patient with classic spontaneous appearance of
lymphedema in midlife following the most minor trauma.
However, it may not necessarily apply in all situations, and
creates a certain negativity to approach the clinical prob-
lem surgically.
With obstructive lymphedema, there is massive dila-
tation of the lymphatics that remain distal to the injury.
This leads to valvular incompetence and has associ-
ated progressive fi brosis of the lymphatic walls. Fibrin
thrombi accumulate within the lumen of the remaining
FIGURE 65-2. Residual inguinal node seen on
lymphoscintigraphy with fi brosis above and dilatation below.
Thirty-year-old woman following radical hysterectomy, node
dissection, and radiation.
FIGURE 65-1. Chronic lymphedema.
lymphatics, progressively obliterating lymphatic chan-
nels. Spontaneous lymphatic-venous shunts may develop
and lymph nodes also become progressively fi brotic
( Figure 65-2 ). The protein-rich fl uid causes an increased
infl ammatory reaction in the subcutaneous tissue.
Macrophage activities increased elastic fi bers are destroyed
along with increasing fi brosis. Fibroblasts migrate into the
interstitium and deposit collagen, leading to nonpitting
edema. Local immunologic control is suppressed by this
process leading to associated chronic infections and pos-
sible malignant degeneration with lymphangiosarcoma.
Lymphangiosarcoma is quite rare, occurring in less than
0.5% of patients with long-term lymphedema and is usu-
ally fatal. As the process progresses, the skin becomes
thickened. Ultimately, it takes on a verrucous appear-
ance, develops cracks which leads to further infection.
Lymphorrhea may develop.
The process of ablation of lymphatics following
proximal trauma has been poorly understood. There are
many unanswered clinical questions, such as: Why does
a replanted extremity usually not exhibit lymphedema?
Why does it take so long for the clinical onset of lym-
phedema following lymph node ablation? The work of
Koshima et al., 4 showing the progressive proximal to distal
LYMPHEDEMA • 773
Patient presents with lymphedema
Complete History and Physical Examination
Independent physical therapy evaluation
with 2 weeks of outpatient therapy and education
Venous ultrasound
Positive for
venous disease
Negative for
venous disease
Dilated lymphatics
Residual nodes
Negative for
functional lymphatics
Lymphatic-venous
anastamoses
Lymphoscintigraphy
Lymph node –
venous anastamosis
Continuation of daily maintenance therapy and
prophylaxis
FIGURE 65-3. Treatment algorithm.
fi brosis of lymphatics, may give logic to the selection of
appropriate candidates for lymphatic-venous bypass.
PATIENT PREPARATION
A patient that presents with lymphedema may be managed
based upon a treatment algorithm ( Figure 65-3 ). A careful
history and physical examination may immediately differ-
entiate between “primary” and “secondary” lymphedema.
Patients with true primary lymphedema are referred to
physical therapy for careful evaluation and instruction
( Figure 65-4 ).
Conservative therapy needs to be approached at several
levels. There needs to be encouragement for a healthy life-
style, including weight loss, exercise, avoidance of minor
trauma, and possibly avoidance of restrictive clothing.
The patient is encouraged to carry prophylactic antibiot-
ics and to take them immediately in the presence of the
most minor trauma. The use of benzopyrones (Coumarin
and fl avenoids), agents that effect protein absorption into
the vascular system, is controversial. Comfrey, a common
weed, has been reported to increase lymphatic fl ow when
prepared as a tea or a wet compress. Occasionally diuretics
are indicated. The use of manual compression with low
stretch compression bandages and meticulous skin care is
encouraged and taught to the patient. Proper fi tting com-
pression garments can only be obtained when an optimal
result has been obtained by proper wrapping techniques
prior to measurement. Endermologie 5 may be effective
FIGURE 65-4. Congenital lymphedema before and after compression.
774 • CHAPTER 65
to reduce edema and improve the vascularity of the skin.
Improvement by conservative modalities of therapy may
obviate the need for surgery. Improvement with therapy,
however, may also be considered as a positive indicator
that one might be a more likely to be a surgical candidate
for lymphatic-venous bypass.
The patient with presumed “secondary” lymphedema
is referred for venous ultrasound. One must rule out
venous insuffi ciency, prior deep vein thrombosis, and iliac
compression disease. If the venous system is competent,
the patient is then referred for lymphoscintigraphy. The
results of response to therapy, venous ultrasound, and
lymphoscintigraphy will dictate the possibility for surgi-
cal therapy. The goal of surgery is always presented to the
patient as a goal of improvement of their status and not
a “cure.”
If diagnostic venous ultrasound demonstrates venous
insuffi ciency or venous hypertension, the patient is advised
to continue conservative modalities since they are not a
candidate for lymphatic-venous anastomosis. Following
the venous ultrasound, lymphoscintigraphy is obtained.
Patients who are suspected of having lymphedema should
not be subjected to lymphangiography. Lymphangiography
was the standard for evaluation of lymphatics for many
years; however, the infl ammatory reaction to the remain-
ing lymphatics may obliterate any remaining vessels.
Lymphoscintigraphy, on the other hand, seems to have
no deleterious effect on lymphatics. This test helps defi ne
the anatomy and patency of lymphatics, dynamics of fl ow
with possible reversal of fl ow, the severity of an obstruc-
tive process, and the presence of residual lymph nodes. If
there is no obvious lymphatic activity of the extremity, the
pursuit of lymphatic-venous anastomosis is abandoned.
Several alternative results from lymphoscintigraphy may
be obtained which would encourage the physician to pro-
ceed with the procedure. The presence of lymphatics with
delayed transit, obstructive lymphedema with dilated lym-
phatics, and localized areas of obstructive lymphedema are
all possible indicators that could benefi t from surgery. The
presence of a residual lymph node may warrant an attempt
at lymph node-venous anastomosis rather than a more dis-
tally oriented lymphatico-venous anastomosis.
Prior to lymphatic-venous anastomosis, the patient is
encouraged to maximally wrap the extremity and obtain
as much result from compression as possible for approxi-
mately 2 weeks prior to the surgery. If the patient is unable
to do this himself, he is referred to a physical therapist
for daily treatment. Immediately prior to surgery, the
patient is given an appropriate systemic antibiotic, usually
a cephalosporin and an aspirin suppository. One hour prior
to anesthesia, technetium sulfur colloid is injected into the
web spaces of the involved extremity.
TREATMENT
The indications for surgery include failed conservative ther-
apy with associated diminishing function, recurrent lymp-
hangitis (more than three episodes a year) and increasing
skin changes with lymphedema. Lack of tolerance with the
maintenance regimen seems to be the most common rea-
son for a patient to seek a surgical intervention. Surgery
should be entertained when the patient understands that
continued postoperative conservative management will be
necessary, but may be made easier than prior to surgery.
A reasonable goal is to continue wraps and compression at
night, but to be able to abandon the compression garment
during daily activity.
Surgery may be divided into “physiologic” versus “exci-
sional” procedures. Excisional procedures would include
sequential liposuction, staged subcutaneous excision, and
total subcutaneous tissue and skin excision. These proce-
dures have signifi cant problems with wound healing and
certainly have certain indications when a more physiologic
approach cannot be obtained.
The Charles procedure involves the excision of all
subcutaneous tissue, including muscle fascia and cover-
age with a skin graft. This procedure has a high morbidity
and is usually reserved for the most recalcitrant of cases.
The result can be functional, but has signifi cant drawbacks
secondary to the skin changes associated with the skin
grafts. The Thompson procedure involves the excision of
subcutaneous tissue and the burying of de-epithelialized
dermal fl aps in the muscle. The original goal was to create
a lymphatic communication from the subcutaneous tis-
sue to the “uninvolved” muscle compartment. The staged
subcutaneous excision originally described by Sistrunk in
1918 and Homans in 1936 was revitalized by Miller in
1998. Seventy percent of Miller’s cases showed reason-
able results at 8 years. Liposuction as an adjunct to other
modalities of treatment has also been suggested. This may
be used for proximal reduction of a successful lymphatic
venous bypass. The author would prefer to utilize conser-
vative measures when a physiologic operation cannot be a
performed.
The concept of local fl aps such as omental transposition
and entero-mesenteric bridges has been attempted with no
demonstrated long-term benefi ts. It is has occasionally been
observed that a free fl ap, placed in a heavily radiated bed,
may also somewhat improve the associated lymphedema.
The author’s preference of treatment, beyond conserva-
tive therapy, is lymphatic-venous or lymph node-venous
anastomosis. At the moment, this seems to give the most
improvement at the least cost of deformity to the patient.
The experience of the author along with Koshima (pro-
posed “supermicrosurgery”) has given patients improve-
ment for longer than 5 years.
Lymphatic-Venous Anastomosis
Under general anesthesia, the arm or leg is mapped with
a gamma probe looking for dominant lymphatic chan-
nels and confi rming residual lymph nodes that may have
been observed on lymphoscintigraphy preoperatively.
Areas are considered for exploration when they have a
discreetly higher signal than the surrounding background.
Once these areas have been assessed, Lymphazurin
LYMPHEDEMA • 775
dye is injected into the web spaces of the extremity
( Figure 65-5 ).
Dissection is initiated under the microscope at high
magnifi cation through the skin and into the subcutaneous
layers. Meticulous dissection follows in the subcutaneous
compartment looking for dyed lymphatics that were ini-
tially detected by the gamma probe. Potential recipient
veins are dissented simultaneously. The dissection process
is facilitated by “plucking” the adjacent fat from around
these tiny vessels.
Once the appropriate lymphatics and veins are isolated
in a region of dissection, the anastomoses are then per-
formed. End-to-side anastomoses are preferred when pos-
sible ( Figure 65-6 ). For the smaller lymphatics, a sleeve
anastomosis is most frequently used ( Figure 65-7 ). A spe-
cialized set of microsurgical instruments and vasodilators
( Figure 65-8 ) are used. Most anastomoses are performed
with 11-0 nylon sutures. At least three anastomoses per
patient are attempted. Closure of the wound consists of a
simple 5-0, subcuticular, polydioxanone suture followed
by a skin adhesive. The patient is splinted in a position
of function for the fi rst 48 hours. The cases are usually
limited to 4 hours of surgery and are performed as an
outpatient. Improvement may be observed in the fi rst
24 hours. The patient is instructed to elevate the arm or
leg for the fi rst 48 hours, not to wear compression during
this period of time, and to restrict vigorous exercise for at
least 6 weeks. At approximately 1 week postoperatively,
the patient may return to basic maintenance therapy,
which includes evening wraps. Most patients are able to
abandon their compression garment during the day. The
patient is kept on antibiotics for approximately 1 week
following surgery.
FIGURE 65-5. Injection of lymphazerin dye.
FIGURE 65-6. Lymphatic venous anastomosis.
FIGURE 65-7. Sleeve anastomosis.
Internal sutures
bringing lymphatic
“sleeve” into vein
Vein
Lymphatic
776 • CHAPTER 65
COMPLICATIONS
Complications may be frequent but are limited to local
wound related problems. None of the cases performed by
the author experienced immediate postoperative com-
plications. Only one patient experienced worsening of
the lymphedema beyond the preoperative status 6 weeks
following the procedure.
OUTCOMES
Sequential excision under fl aps and lymphatic-venous
anastomosis gives the most promising results presently
with 70% improvement in long-term results reported.
Re-evaluation of the anatomy of the lymphatic system, as
described by Suami, 2 and a better understanding of the
pathophysiology of the process as shown in the work of
Koshima et al. 4 justifi es the goal to develop more discreet
bypass procedures. The optimal timing of these opera-
tions is to be determined. Improved visualization with
more exact diagnostic mapping than lymphoscintigraphy
or intraoperative gamma probe assessment would signifi -
cantly improve the outcomes for bypass procedures. There
may be a role for robotic surgery with the elimination of
tremor. Microsurgical lymph node transfer, stem cell ther-
apy, preemptive bypass may all theoretically change the
outcome of these patients in the future.
The author has performed 36 lymphatic-venous
bypasses over the past 5 years in the upper and lower
extremity. There were no immediate postoperative com-
plications. All patients were evaluated postoperatively at
3 months and then annually. Seventy percent were found
to have some improvement in their swelling and discom-
fort of the extremity. Neurotrophic symptoms, secondary
to the swelling, seemed to have signifi cant, immediate
improvement. Two patients experienced an episode of
lymphangitis, requiring antibiotics 1 year following sur-
gery. One patient, who underwent a lymph node-venous
bypass in the groin, experienced worsening of her lym-
phedema after initial improvement at 6 weeks. She refused
further evaluation or reoperation. It is the author’s opinion
that measurements of the extremity serve little purpose
in judging the merits of the operation because of the sig-
nifi cant variation that occurs normally with temperature,
amount of activity prior to measurement, and compliance
to daily management.
The patients were given a scale from 1 to 10 to rate
the procedure as to their level of expectation prior to
surgery. Seventy percent of patients favorably related a
value of 7 to the procedure at 1 year. They related that
they could wrap the extremity for a much shorter period
of time at night. Two patients related totally normal
function with no need for any maintenance therapy, and
rated the procedure a 10. The patient who reported the
increased swelling at 5 weeks feels that the procedure
should never have been done and that the procedure
made her worse.
Not all cases of lymphedema present with the con-
ventional, circumferentially, “swollen extremity.” There
are cases where a single drainage region of the extrem-
ity may be involved, such as a single anatomic compart-
ment. Areas of extensive radiation, such as the abdominal
wall, vulva, and breast may be involved in the process and
respond to therapy ( Figure 65-9 ). This procedure has the
greatest chance of a signifi cant improvement for acquired
lymphedema in a properly selected patient. The pres-
ent success rate may be secondary to being able to bet-
ter identify functional lymphatics, intraoperatively, with
the gamma probe and also related to the emphasis on
FIGURE 65-8. Instruments for micro-lymphatic surgery.
LYMPHEDEMA • 777
FIGURE 65-10. Pre- and postoperative lymphatic venous bypass three times
at 5 years’ post-lymphatic surgery. Sixty-fi ve-year-old woman with 12-year history
of lymphedema following radical mastectomy, axillary node dissection, and radiation
therapy. She does not wrap or use compression garments.
FIGURE 65-9. Localized lymphedema of the anterior compartment secondary to a
“tight” cast. Thirty-six-year-old man with four hospitalizations for lymphangitis in 1 year.
Three lymphatic venous anastomosis in the area of involvement gave complete resolution
of symptoms for longer than 10 years.
778 • CHAPTER 65
1. Alitalo K, Tammela T, Petrova T. Lymphangiogenesis in devel-
opment and human disease. Nature. 2005;438:946–953.
2. Suami H. Mapping the human lymphatic system. Unpub-
lished, Department of Anatomy and Cell Biology, Taylor
Lab, University of Melbourne, Australia.
3. Heffel DF, Miller TA. Lymphedema of the extremity. In:
Achauer BM, Eriksson E, Guyuron B, et al. Plastic Surgery,
Indications, Operations, and Outcomes. Philadelphia: Mosby;
2000:4463–4464.
4. Koshima I, Kawada S, Moriguchi T, et al. Ultrastructural
observations of lymphatic vessels in lymphedema in human
extremities. Plast Reconstr Surg. 1996;97:397–405.
5. Campisi C, Boccardo F, Zella H, et al. Techniques in the
treatment of peripheral edema: clinical preliminary results
and perspectives. Eur J Lymphol. 2002;X:35–36.
REFERENCES
long-term follow-up with continued maintenance therapy
and prophylaxis. When successful, this procedure offers
physiologic improvement without the obvious wound-
related problems of excisional, debulking procedures.
There seems to be no correlation between duration of
onset of lymphedema or whether it is the upper or lower
extremity as to clinical improvement following surgery
( Figure 65-10 ).
c h a p t e r
Foot and Ankle Reconstruction
Mark Warren Clemens, MD / Christopher E. Attinger, MD
INTRODUCTION
Improvements in surgical technique combined with the
introduction of novel wound care modalities has helped
reverse the antiquated notion of amputation as the optimal
treatment for complex lower extremity wounds. Infection
as well as changes in blood supply, sensation, immune sta-
tus, and biomechanics renders the foot and ankle suscep-
tible to breakdown. Traditionally, the inability to salvage
an injured foot usually led to amputation. This carries
dramatic sequelae for the amputee because it mandates a
lifetime dependence on prosthetic devices or a wheelchair-
bound existence. In addition, it shortens life expectancy
and places the other limb at increased risk for amputa-
tion. Reconstructive surgeons continue to be called upon
to address wounds that result from trauma and/or infec-
tion. The fi rst task is to convert the existing wound into
a healthy wound. Most wounds can then be closed using
simple soft tissue techniques such as delayed primary clo-
sure, skin grafts, or local fl aps. However a signifi cant por-
tion of wounds require more sophisticated techniques that
mandate an intimate knowledge of the local angiosomes,
arterial blood supply, and fl ap anatomy. All reconstruc-
tions must be biomechanically sound and most require a
multiteam approach to avoid recurrent breakdown.
PATIENT EVALUATION AND SELECTION
A careful medical history should be obtained to evaluate
the most likely disease states that directly affect wound
healing. Attention should be focused on diseases that may
negatively affect arterial infl ow into and venous outfl ow
from the wound. Close attention should be paid to the
immune system, hematological system, and to nutri-
tion, all of which can affect wound healing. The presence
of autoimmune diseases (such as rheumatoid arthritis,
pyoderma gangrenosum, systemic lupus erythematosus,
scleroderma, etc) may cause infl ammatory wounds that
initially require medical management rather than surgical
care. Optimizing these wound types with medical man-
agement fi rst will then allow wounds to go through the
normal stages of healing. It should be noted that the medi-
cations used to treat autoimmune diseases (ie, steroids or
chemotherapy) can also contribute to poor wound heal-
ing. The nutritional status also affects wound healing and
should be assessed (optimal is albumin .3.0 g/dL and/
or total lymphocyte count .1500). Smoking signifi cantly
decreases local cutaneous fl ow and should be documented
and addressed with the patient. Finally, a complete list of
medications and drug allergies should be obtained. Given
the complexity of various diseases affecting the healing
process, multiple medical specialists may be called in to
assist in the patient’s medical management and help opti-
mize his or her medical condition, so that the wound has a
better chance of healing.
PRINCIPLE ETIOLOGIES OF
LOWER EXTREMITY WOUNDS
Before considering wound debridement, the surgeon has
to determine the etiology of the wound, any history of pre-
viously administered wound therapies, and the patient’s
overall medical condition. A thorough history should be
obtained from the patient, family, friends, emergency med-
ical technicians, and/or referring doctor to help determine
the etiology of the wound. In addition, the origin and age
of the wound should be determined. If the wound is trau-
matic in origin, it should be defi ned in terms of high impact,
low impact, repetitive, temperature related, caustic, radia-
tion induced, type of bite, presence of drug abuse, and so
on. The patient’s tetanus immunization status should be
obtained, and the patient should be re-inoculated if revac-
cination is indicated. In chronic wounds, the age of the
66
780 • CHAPTER 66
wound is important, because longstanding wounds can be
malignant (Marjolin ulcer). Previous topical therapy to
the wound should be delineated because certain topical
agents can contribute to the wound’s chronicity (eg, caus-
tic agents such as hydrogen peroxide, 10% iodine, Dakin
solution) ( Figure 66-1 ).
Diabetes is of particular concern to the reconstructive
surgeon. Seven percent of all Americans have documented
diabetes mellitus and 15% of them eventually develop a
foot ulcer during their lifetime. Almost 15% of the health
care budget of the United States goes toward manage-
ment of diabetes, with 25% of diabetic hospital days for
the treatment of diabetic foot ulcers. Two thirds of all the
major amputations performed per year in the United States
are performed in diabetics. 1 With a team approach, more
than 97% of these limbs can be salvaged. Salvage not only
allows the patient to maintain quality of life but it is also
far less expensive for the health care system than major
amputations (ulcer $7,500; toe amputation $22,705; foot
amputation $42,675; leg amputation $51,280).
Diabetic peripheral polyneuropathy is the major cause
of diabetic foot wounds. More than 80% of diabetic foot
ulcers have some form of neuropathy present. The neu-
ropathy is a consequence of chronically elevated blood
sugars that cause vascular and metabolic abnormalities.
FIGURE 66-1. The chronicity of wounds can be
perpetuated by applying a caustic agent to the wound
surface. Hydrogen peroxide, alcohol, 10% iodine, etc all
negatively affect the healing process. This stump was treated
with hydrogen peroxide for 1 year and never healed.
Chronic hyperglycemia leads to the glycosylation of col-
lagen with subsequent loss of elasticity in connective tis-
sues. This is most evident in the Achilles tendon, which
looses its fl exibility and the foot can no longer dorsifl ex
beyond neutral. This loss of motion places a high pres-
sure for a prolonged period during the push-off phase of
gait both at the arch/midfoot and underneath the meta-
tarsal heads. The excess pressure at the midfoot can lead
to Charcot collapse, while at the forefoot it can lead to
ulceration at the plantar metatarsal heads. This problem is
compounded by concomitant hypoesthesia in neuropathic
patient, which robs the patient of the early warning signs
of resultant pain.
The surgeon tests the elasticity of the Achilles tendon
by evaluating the patient’s ability to dorsifl ex the supi-
nated foot. If the patient can dorsifl ex the foot more than
15 degrees with the leg straight and bent, then the tendon
has suffi cient plasticity. If the foot can only be dorsifl exed
when the leg is bent, then the gastrocnemius portion of the
Achilles tendon is tight. If the foot cannot dorsifl ex when
the leg is straight or bent, then both the gastrocnemius
and soleus portions of the Achilles tendon are tight. Open
or percutaneous release of the Achilles tendon decreases
forefoot pressure in the equinovarus foot during gait suf-
fi ciently to allow for healing of plantar forefoot ulcers in
an average of 6 weeks ( Figure 66-2 ). The release results
in a permanent decrease in push-off forces, which has to
been shown to decreasing ulcer recurrence rate fourfold at
7 months and twofold at 27 months (40%). Unless correc-
tion of underlying biomechanical abnormalities that led to
soft tissue breakdown is part of the treatment plan, debrid-
ing and good wound care is usually futile.
Hyperglycemia can also affect the body’s ability to
fi ght infection. As a result of this depressed immune
state, diabetics are especially prone to streptococcal and
staphylococcal skin infections. Deeper infections tend to
be polymicrobial, with gram-positive cocci, gram-negative
rods, and anaerobes being frequently present on culture.
Postoperative complication rates correlate directly with
the level of postoperative hyperglycemia.
Up to 60% of diabetics with nonhealing ulcers have
concurrent macrovascular disease. The arteries below the
popliteal trifurcation are most commonly involved while
the smaller arteries of the foot and ankle are often spared.
For this reason, distal bypass in the diabetic patient is
frequently possible. Noninvasive arterial studies, includ-
ing ankle-brachial indices, should be performed in every
diabetic, and results less than 0.9 should be referred to a
vascular surgeon for evaluation. Ankle-brachial indices can
be misleading in the diabetic because vascular calcifi cation
decreases the compressibility of the vessels. Some there-
fore feel digital arterial toe pressures greater than 40 mm
Hg or tissue oxygen levels (T C O 2 ) higher that 40 mm Hg
may be more reliable indicators of the quality of blood fl ow
in diabetics. If there is any question, the patient should be
seen by a vascular surgeon who is trained in distal revascu-
larization techniques.
FOOT AND ANKLE RECONSTRUCTION • 781
Atherosclerotic disease is a common cause of nonhealing
foot ulcers, especially when in combination with diabetes.
Hypercholesterolemia, hypertension, and tobacco use are
major risk factors for atherosclerosis. The etiology of the
ischemia has to be diagnosed. If the arteries are not palpa-
ble, the Doppler signal over the posterior tibial artery, the
dorsalis pedis artery, and the anterior perforating branch
of the peroneal artery should be evaluated. A triphasic
Doppler signal indicates normal blood fl ow, a biphasic sig-
nal indicates adequate blood fl ow, and a monophasic sig-
nal warrants further investigation. If the quality of fl ow is
questionable, a formal noninvasive arterial Doppler evalu-
ation has to be performed. If the fl ow is inadequate, the
patient should then be referred to a vascular surgeon who
specializes in endovascular techniques and in distal revas-
cularizations. Debridement should be delayed in a stable
wound with dry gangrene and inadequate blood fl ow, until
blood fl ow has been corrected ( Figure 66-3 ). Premature
debridement of a de-vascularized wound may cause future
loss of potentially salvageable tissue. However, immediate
debridement is called for when wet gangrene, ascending
cellulitis from a necrotic wound, or necrotizing fasciitis
FIGURE 66-2. A 39-year-old obese diabetic patient had bilateral lateral plantar
metatarsal ulcers secondary to equinovarus deformity (above). Both the gastrocnemius
and soleus portions of the Achilles tendon were tight. The left Achilles was released
percutaneously, and the left foot healed in 6 weeks with conservative wound care of the
ulcer (below). The right forefoot ulcer healed similarly within 5 weeks after Achilles tendon
release. Correcting the biomechanical abnormality was all that was required for healing
to occur.