Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (Ấn bản 4)

226
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
from spinal nerves T7–T12 and L1 and act to compress and
support the abdominal viscera and to flex and rotate the
trunk. Blood supply is segmental via the lower thoracic inter­
costal vessels, classifying these muscles as type IV.
Vascular anatomy
In 1979, Huger described the cutaneous blood supply to the
abdomen, and this theory was supported by anatomic studies
of Taylor. Huger’s zone I is located medially and supplied by
perforators from the deep epigastric system. Zone II includes
the lower lateral abdomen, which is supplied by the external
iliac system comprising of the superficial inferior epigastric
artery and the superficial and deep circumflex iliac arteries.
Zone III is lateral; this is supplied by the intercostals and
subcostal arteries.23 These three zones have a rich arcade of
anastomosis and choke vessels.
The deep inferior epigastric artery (DIEA) is a branch of the
external iliac artery (Fig. 9.10). It emerges from the medial
Muscles6
The rectus abdominis originates at the pubic symphysis and
pubic crest. It inserts into the xiphoid process and costal car­
tilage of ribs 5–7 (Fig. 9.9). It is innervated by the ventral rami
of spinal nerves T7–T12. Its main action is to flex the trunk and
compress the abdominal viscera. Its blood supply is via the
superior epigastric artery and deep inferior epigastric artery,
which classifies this muscle as Mathes and Nahai type III.
The external oblique originates from the external surface of
the lower eight ribs and inserts into the linea alba, pubic
tubercle, and iliac crest. The internal oblique muscle originates
at the thoracolumbar fascia, iliac crest, and lateral half of
inguinal ligament. It inserts at the inferior border of ribs
10–12, the linea alba, and the pubis. The transversus abdominis
muscle originates from the internal surface of costal cartilage
ribs 7–12, thoracolumbar fascia, iliac crest, and lateral third
inguinal ligament. It inserts at the linea alba, pubic crest, and
pectin pubis. These three layered muscles derive innervation
Fig. 9.9  Superficial and deep anatomy of the abdomen
showing muscular layers and fascial layers with vascular
relationships.
Linea alba
Linea semilunaris
Arcuate line
Anterior rectus sheath
Inguinal ligament
Round ligament
Rectus abdominis
Internal oblique
External oblique
Superior epigastric artery
Deep inferior epigastric
artery
Superficial circumflex
iliac artery
Superficial inferior
epigastric artery
Femoral artery
Femoral vein
Epigastric perforators

227
Abdomen
area of skin along the iliac crest (see Fig. 9.10). Two venae
comitantes parallel the DCIA along its course and drain into
the external iliac vein as a single vessel.25,26
The superficial inferior epigastric artery (SIEA) is a branch of
the proximal femoral artery arising 2–3 cm below the inguinal
ligament. The branching pattern is variable and reported as
either an independent branch, from a common trunk with the
superficial circumflex iliac artery, or from another branch of
the femoral artery such as the external pudendal. The SIEA
was originally reported to be present in only 60% of individu­
als,27 but current anatomic studies support anecdotal evidence
suggesting this artery is more ubiquitous.28 The vessel travels
from its origin superolaterally and pierces Scarpa’s fascia 0.5
to 4 cm above the inguinal ligament midway between the
ASIS and the pubic tubercle. It travels just superficial to the
fascia as it branches medially and laterally to supply the lower
hemi-abdominal skin.29 This vessel and its anastomotic con­
nections do not reliably cross midline. Venous return of the
subcutaneous tissue supplied by the SIEA is via two vessels.
One vein accompanies the SIEA in its course, and a larger
medial vein is almost always present in a more superficial
plane. The medial vein often drains into the saphenous bulb
but may at times be found to join the smaller vein and drain
directly into the femoral vein.22
wall of the external iliac artery and pierces the transversalis
fascia to course along the posterior surface of the rectus
muscle. As the DIEA approaches the arcuate line it divides
into a medial and lateral branch and occasionally a third
branch providing direct blood supply to the umbilicus. The
medial and lateral branches of the DIEA give off perforating
vessels to the fasciocutaneous tissue overlying the midabdo­
men. The dominance of one or the other branch is variable.
There are between four and seven perforators in a given
individual, usually clustered in the periumbilical region.24 At
the level of the umbilicus there are anastomotic connections
to the superior epigastric artery, which is a continuation of the
internal mammary artery in the chest.
The deep circumflex iliac artery (DCIA) originates from the
external iliac artery near the origin of the DIEA. The DCIA
travels along the iliacus muscle giving off a large ascending
branch 1 cm medial to the ASIS. The artery then pierces
the transversalis fascia and travels along the internal lip
of the iliac crest just lateral to a line of attachment of iliacus
to transversalis fascia. Along the medial surface of the iliac
crest there are several periosteal branches. Approaching the
flank, the transverse branch of the DCIA forms anastomotic
connections with the lumbar and iliolumbar arteries. Superfi­
cial perforating branches of the DCIA supply an oval-shaped
Fig. 9.10  Superficial and deep muscular layers showing vascular anatomy from iliac and femoral branches. (a) Lateral row perforators from DIEA, (b) medial row
perforators from DIEA.
Rectus abdominis (cut)
Rectus abdominis
Transversus abdominis
Transversus
abdominis
Internal oblique
Internal oblique
External oblique
External oblique
Transversalis fascia
Transversalis fascia
a
b
Inguinal
ligament
Diaphragm
Internal mammary
artery
Superior epigastric
artery
Deep inferior epigastric artery
Superficial inferior epigastric artery
Superficial
circumflex
iliac artery
Intercostal arteries
(a) Lateral row perforators
(b) Medial row perforators
Parietal peritoneum
Inferior epigastric
artery
Superficial circumflex
artery
Inguinal ligament
Femoral vein
Pubic tubercle
Femoral artery
Femoral nerve

228
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
The superficial circumflex iliac artery is a branch of the
femoral artery and usually emerges near the origin of the
SIEA or shares a common trunk. This vessel passes over
the inguinal ligament superiorly into the abdominal wall
running in the superficial fascia along the iliac crest. It sup­
plies the skin and subcutaneous tissue for 10–20 cm in an area
of the infero-antero-lateral abdominal wall. It is paralleled by
a vein that drains into the greater saphenous vein.
The intercostal arteries travel into the abdomen between the
internal oblique and the transverses abdominis muscle.
Nerves
Sensory and motor innervation to the anterior abdominal wall
is via paired spinal nerves running between the internal
oblique and the transversus abdominis muscles and give rise
to parallel dermatomes of the abdomen. The ventral rami of
T5–T11 and subcostal (T12) provide innervation of the anterior
abdominal wall from the periphery of the diaphragm to
the superior iliac spine. The ilioinguinal nerve passes between
the internal oblique and transversus abdominis supplying the
hypogastric region and iliac crest. The iliohypogastric nerve
innervates skin of the scrotum, labia majora, mons pubis, and
medial thigh.
Pelvis
The pelvis consists of a bowl-shaped arrangement of bones
connecting the trunk to the legs. It contains the intestines,
urinary bladder, and internal sex organs. Paired ilia, ischia,
and pubic bones connect anteriorly at the pubic symphysis
and posteriorly at the sacrum. The muscles of the pelvic floor
provide the inferiormost border of the peritoneal cavity. Below
these are the perineal structures of the male and female
anatomy (Figs. 9.11, 9.12).
Female perineum
The external genitalia are derived from ectoderm. The sex-
specific genital characteristics start to develop in the 7th week
of gestation, appear at the 9th week, and become fully dif­
ferentiated by the 12th week. Estrogen produced by either the
placenta or the fetal ovaries is responsible for female genital
differentiation. The genital tubercle arises from mesenchyme
at the superior end of the cloacal membrane and becomes the
clitoris. The urogenital folds and labial scrotal folds border the
cloacal membrane. These become the labia minora, fusing
posteriorly to form the frenulum, and labia majora, respec­
tively.3 The mons pubis and labia majora are covered by
stratified squamous epithelium with a thick keratinized layer
containing multiple hair follicles. Below the skin of the labia
majora is superficial fatty fascial tissue continuous with the
Camper’s fascia of the abdomen. The deep superficial fascia
of the perineum is referred to as Colles fascia and is the peri­
neal extension of Scarpa’s fascia. The labia minora, clitoris,
urethral, and vaginal opening are covered by stratified squa­
mous epithelium with a thin keratinized layer. There is no
adipose tissue below the labia minora, only elastic and fibrous
connective tissue and multiple eccrine, apocrine, and seba­
ceous glands, which serve to lubricate the surface of this deli­
cate tissue (Fig. 9.13).
The perineum is divided into two adjacent triangles (Fig.
9.14). The anterior urogenital triangle is bound by the pubic
symphysis, the conjoint ramus of the ischium and pubis, and
Fig. 9.11  Cross-section anatomy of male pelvis. (From: Netter; © Elsevier Inc. All rights reserved.)
Urachus
Median (sagittal) section
Apex
Fundus
Body
Trigone
Neck
Pubic symphysis
Fundiform ligament of penis
Suspensory ligament of penis
Inferior (arcuate) pubic ligament
Transverse perineal ligament (anterior
thickening of perineal membrane)
Superficial perineal space
Corpus cavernosum
Corpus spongiosum
Superficial (dartos) fascia of penis and scrotum
Deep (Buck’s) fascia of penis
Prepuce
Glans penis and external urethral meatus
Rectovesical pouch
Rectum
Seminal
vesicle
Prostate
Rectoprostatic
(Denonvilliers’)
fascia
Sphincter
urethrae
muscle
Bulbourethral
(Cowper’s) gland
Bulbospongiosus muscle
Deep perineal (investing or
Gallaudet’s) fascia
Superficial perineal (Colles’) fascia
Buck’s fascia
Septum of scrotum
Navicular fossa
Urinary bladder
Perineal body
Vesical fascia
Perineal membrane

Fig. 9.12  Cross-section anatomy of female pelvis. (From: Netter; © Elsevier Inc. All rights reserved.)
Median (sagittal) section
Uterosacral ligament
Vesicouterine pouch
Rectouterine pouch
(of Douglas)
Cervix of uterus
Posterior part
of vaginal fornix
Anterior part
of vaginal fornix
Rectum
Vagina
Levator ani
muscle
Anal canal
External
anal
sphincter
muscle
Sacral promontory
Ureter
Suspensory ligament of ovary
Uterine (fallopian) tube
Ovary
External iliac vessels
Ligament of ovary
Body of uterus
Round ligament of uterus
(ligamentum teres)
Fundus of uterus
Urinary bladder
Pubic symphysis
Urethra
Deep transverse
perineal muscle
Deep dorsal vein of clitoris
Crus of clitoris
External urethral orifice
Labium minus
Labium majus
Anus
Vaginal orifice
Perineal
membrane
Sphincter urethrae
Superficial transverse perineal muscle
Fig. 9.13  Surface anatomy of female perineum. (From: Netter; © Elsevier Inc. All rights reserved.)
Mons pubis
Anterior commissure of
labia majora
Prepuce of clitoris
Pudendal cleft (groove or
space between the
labia majora)
Glans of clitoris
Frenulum of clitoris
External urethral orifice
Labium minus
Labium majus
Openings of paraurethral
(Skene’s) ducts
Vestibule of vagina
(cleft or space surrounded
by labia minora)
Vaginal orifice
Opening of greater
vestibular (Bartholin’s) gland
Hymenal caruncle
Vestibular fossa
Frenulum of labia minora
Posterior commissure of
labia majora
Perineal raphe
(over perineal body)
Anus

230
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
Fig. 9.14  Female urogenital triangle. (From: Netter; © Elsevier Inc. All rights reserved.)
Suspensory ligament of clitoris
Bulb of vestibule
Perineal membrane
Greater vestibular
(Bartholin’s) gland
Bulbospongiosus
muscle
(cut away)
Superficial
transverse
perineal
muscle
Perineal
body
Clitoris
Bulbospongiosus muscle
with deep perineal (investing
or Gallaudet’s) fascia
partially removed
Superficial perineal space
(pouch or compartment)
Ischiopubic ramus
with cut edge of
superficial
perineal (Colles’)
fascia
Perineal
membrane
Ischial
tuberosity
Sacro-
tuberous
ligament
Gluteus
maximus
muscle
Obturator
fascia
Tendinous arch of
levator ani muscle
Inferior fascia of
pelvic diaphragm (cut)
Levator ani muscle
External anal sphincter muscle
Anococcygeal (ligament) body
Coccyx
Ischioanal fossa
Crus of
clitoris
Ischio-
pubic
ramus
Bulb of
vestibule
Greater vestibular
(Bartholin’s) gland
Perineal membrane
Urethra
Sphincter urethrae
muscle
Perineal membrane
(cut and reflected)
Compressor urethrae
muscle
Sphincter urethrovaginalis
muscle
Vagina
Deep transverse
perineal muscle
Ischiocavernosus muscle

231
Pelvis
the deep transverse perineal muscle spanning the ischial
tuberosities. The posterior anal triangle lies behind a line
drawn between the ischial tuberosities and contains the anus.
The urogenital triangle is divided into a deep and superficial
space. Colles fascia forms the roof of the superficial perineal
space. Laterally, this fascia is firmly attached to the fascia lata
of the thigh at the ischiopubic ramus and defines the perineal
thigh crease. Posteriorly, the fascia surrounds the superficial
transverse perineal muscle and anchors to the inferior fascia
of the urogenital diaphragm.5
The superficial perineal space contains the ischiocaverno­
sus muscle that overlies the crus of the clitoris, the bulbospon­
giosus muscle that overlies the bulb of the vestibule, the
superficial transverse perineal muscles, and the greater ves­
tibular glands. The superficial perineal artery and vein travel
within this space. The inferior fascia of the urogenital dia­
phragm, referred to in some texts as the deep perineal or
Gallaudet fascia, forms the deep margin of this space. The
urethral and vaginal openings pass through here. Posteriorly,
the Gallaudet fascia encases the bilateral perineal muscles and
fuses in the midline to form the perineal body.
Deep to the Gallaudet fascia is the deep perineal space. This
contains the proximal urethra, the external urethral sphincter
muscle, and the deep transverse perineal muscles. The termi­
nal branches of the internal pudendal artery travel within this
space as they make their way to the clitoris. As they exit the
space anteriorly, between the transverse perineal ligament
and the arcuate pubic ligament, they become the dorsal artery
and the deep dorsal vein of the clitoris. The end branch of the
pudendal nerve, the dorsal nerve of the clitoris, travels with
these vessels.
Vascular anatomy
The two main vascular pedicles supplying the female
perineum are the deep external pudendal artery supplying
the anterior labial structures and the internal pudendal artery
supplying the clitoris and posterior labial structures (Fig.
9.15). The deep external pudendal artery is a branch of the
femoral artery. It passes into the subcutaneous plane approxi­
mately 8–10 cm from the pubic symphysis and travels along
the adductor longus. At 4–6 cm from the pubic symphysis the
artery splits into an abdominal branch and a perineal branch.
The latter is called the anterior labial artery and supplies the
superior third of the labia majora. The second major pedicle
arises from the internal pudendal artery supplying the poste­
rior structures and the clitoris. The superficial perineal artery is
a branch of the internal pudendal artery as it arises from
Alcock’s canal along the ischium. The superficial perineal
artery has two branches, the internal posterior labial artery
and the external posterior labial artery. Both supply the pos­
terior two-thirds of the labia minora and majora.30 The internal
pudendal artery continues anteriorly within the deep perineal
space to become the dorsal artery of the clitoris.
The venous drainage of the perineum patterns the arterial
supply. Anteriorly, these vessels drain into the saphenous vein
and then the femoral vein. Posteriorly, the superficial perineal
veins drain into the internal pudendal vein, which drains to
the internal iliac vein.
Innervation to the vulvar structures is via the ilioinguinal
nerve, genitofemoral nerve, and the perineal branch of the
femoral cutaneous nerve of the thigh. The superficial perineal
nerve, a branch of the pudendal nerve, supplies the posterior
two-thirds of the labia, and the terminal branch of the puden­
dal nerve becomes the dorsal nerve to the clitoris.
Male perineum
At the 6–7th week of gestation, testosterone produced by the
fetal testes induces the genital tubercle to elongate to form the
phallus. An ingrowth of ectoderm along the ventral surface
of the penis forms the urethral groove as surface ectoderm
fuses in the midline enclosing the spongy urethra within the
penile shaft. The corpora cavernosa and corpus spongiosum
are developed from mesenchyme within the phallus. The
labioscrotal swellings enlarge and fuse to form the scrotum.
Circular ectodermal invagination at the glans forms the fore­
skin. The foreskin is adherent to the glans penis until birth or
early infancy.3
Descent of the testes into the scrotum begins around the
26th week. Shortly after their descent, the inguinal canal con­
tracts around the spermatic cord. Development of the inguinal
canal involves dissention of the gubernaculum, which origi­
nates at the inferior pole of the gonad. It passes through the
abdominal wall and attaches to the labioscrotal swellings. The
processus vaginalis develops ventral to the gubernaculum
and travels along the same path carrying extensions of the
layers of abdominal wall. These will become the walls of the
inguinal canal. The place where the processus passes through
the transversalis fascia becomes the deep inguinal ring.
Superficial structures of the male perineum include the
penis and scrotum (Fig. 9.16). The penis consists of the root,
body, and glans. The paired corpora cavernosa and ventral
corpus spongiosum are specialized erectile tissue surrounded
by a fibrous outer layer, the tunica albuginea. At the base of
the penis the corpora cavernosa split to become the crura of
the penis and the corpus spongiosum thickens to become the
bulb of the penis. The crura and the bulb, which are sur­
rounded by the ischiocavernosus and bulbospongiosus
muscles, respectively, form the root of the penis and lie in the
superficial perineal space (Fig. 9.17). Also contained in this
space is the proximal spongy urethra, superficial transverse
perineal muscles, superficial perineal vessels, and branches of
the pudendal nerve. The deep perineal space contains the
transverse perineal muscles, the external urethral sphincter,
the bulbourethral glands, and the terminal branches of the
internal pudendal vessels as they travel to become the deep
artery of the penis, the dorsal artery, and the deep dorsal vein
of the penis.5
In men, Colles’ fascia is continuous with the spermatic cord
and dartos fascia encasing the penis and scrotum. The suspen­
sory apparatus of the penis consists of the fundiform ligament,
the suspensory ligament proper, and the arcuate subpubic
ligament. The fundiform ligament is superficial and is an
extension of Scarpa’s fascia running from the level of the
pubic bone around the base of the penis and attaching to the
septum of the scrotum. The suspensory ligament proper is
deep to the fundiform ligament and bridges between the
symphysis pubis and the tunica albuginea of the corpus
cavernosum. The arcuate subpubic ligament runs a similar
course to the suspensory ligament proper. The suspensory
ligaments maintain the base of the penis in front of the pubis
and act as a major point of support for the erect penis during
intercourse.31

232
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
Fig. 9.15  Vascular anatomy of the female perineum. (From: Netter; © Elsevier Inc. All rights reserved.)
Internal pudendal artery
in pudendal canal (Alcock)
Dorsal artery of clitoris
Deep artery of clitoris
Bulb of vestibule
Compressor urethrae
muscle
Artery to bulb of vestibule
Greater vestibular
(Bartholin) gland
Deep transverse perineal muscle
Internal pudendal
(clitoral) artery
Perineal membrane
(cut away)
Perineal artery (cut)
Superficial perineal (Colles) fascia (cut
and reflected) to open superficial perineal space
Inferior rectal artery
Ischiocavernosus muscle
Bulbospongiosus muscle
Superficial perineal space
Perineal membrane
Superficial transverse
perineal muscle
Perineal
artery
Internal posterior
labial artery
External anal sphincter muscle
Note: Deep perineal (investing or Gallaudet) fascia removed from muscles of superficial perineal space.

233
Pelvis
Fig. 9.16  Superficial structures of male perineum and their fascial layers. (From: Netter; © Elsevier Inc. All rights reserved.)
Superficial
inguinal ring
External
spermatic fascia
Cremaster muscle
and fascia
Septum of scrotum
(formed by
dartos fascia)
Superficial
(dartos) fascia
of scrotum
Skin of scrotum
Skin of penis
Superficial fascia
of penis (Colles’ fascia)
Deep (Buck’s)
fascia of penis
Testicular artery
Ductus deferens
Artery to ductus deferens
Genital branch of
genitofemoral nerve
Pampiniform (venous) plexus
Epididymis
Appendix of epididymis
Appendix of testis
Testis (covered by visceral
layer of tunica vaginalis)
Parietal layer of tunica vaginalis
Superficial (dartos) fascia of scrotum
External spermatic fascia
Cremaster muscle and fascia
Internal spermatic fascia
Parietal layer of tunica vaginalis
Epididymis
Testis (covered by visceral layer of tunica vaginalis)
Skin of scrotum

234
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
Fig. 9.17  Male superficial and deep perineal spaces. (From: Netter; © Elsevier Inc. All rights reserved.)
Pubic symphysis
Superior
pubic
ramus
Inferior
(arcuate)
pubic
ligament
Deep dorsal
vein of penis
Ischiopubic ramus
Urethra
Perineal
membrane
Pubic bone
Transverse perineal ligament (anterior
thickening of perineal membrane)
Dorsal artery and nerve of penis
Deep artery of penis
Urethral artery
Duct of bulbourethral (Cowper’s) gland
Artery of bulb of penis
Deep perineal (investing or Gallaudet’s) fascia over
ischiocavernosus, bulbospongiosus, and
superficial transverse perineal muscles (cut away)
Superficial perineal (Colles’) fascia (cut away)
Superficial transverse perineal muscle
(cut and reflected)
Ischial tuberosity
Inferior views
Perineal
body
External
anal sphincter
muscle
Dorsal artery and nerve of penis
Deep artery of penis
Urethral artery
Bulbourethral (Cowper’s) gland
Artery of bulb of penis
Perineal membrane (cut edge)
Internal pudendal artery
and dorsal nerve of penis
Internal pudendal artery and perineal branch
Sphincter
urethrae
muscle
Urethra
Deep transverse
perineal muscle
Levator ani muscle
Perineal membrane
Deep transverse perineal muscle
Deep perineal (investing
or Gallaudet’s) fascia
Corpus cavernosum (crus of penis)
and deep (Buck’s) fascia of penis
Ischiocavernosus muscle
Superficial perineal (Colles’) fascia
(closes superficial perineal space)
Urinary bladder
Prostate
Obturator internus muscle
Ischiopubic ramus
Sphincter urethrae muscle
Bulbourethral (Cowper’s) gland
Ischiocavernosus muscle
Bulb of penis (corpus spongiosum) and
deep (Buck’s) fascia of penis
Bulbospongiosus muscle
Frontal section, anterior view of perineum: schema

235
Pelvis
structures. It divides into two branches at the level of the
spermatic cord to become the internal anterior scrotal artery
supplying the base and dorsum of the penis, ventral scrotum,
perineal fat, and anteromedial spermatic–scrotal fascia. The
external anterior scrotal artery supplies the lateral scrotum.
The superficial perineal artery is a terminal branch of the inter­
nal pudendal artery. Its course takes it superficial to the
superficial transverse perineal muscle and lateral to the bul­
bocavernosus muscle. It has three branches. The internal
posterior scrotal artery supplies the dorsal scrotum and raphe.
The external posterior scrotal artery supplies the posterior-
lateral spermatic cord fascia. The transperineal arteries provide
anastomotic connection to the anterior vessels. The third
arterial supply is the funicular artery, a branch of the deep
inferior epigastric artery that crosses just below the inguinal
ligament and supplies the anterior perineum, giving off ter­
minal branches to the cord.32 The deep structures of the
penis are supplied by the dorsal artery and the deep artery of
The scrotum supports and encases the testicles (see Fig.
9.17). The dartos fascia, which lies just under the skin, is a
thin musculofascial layer that regulates the temperature
of the testicles by contracting and relaxing, bringing the
scrotum closer or further from the ambient heat of the
body. The cremaster muscle originates at the inferior internal
oblique muscle, inguinal ligament, pubic tubercle, and
pubic crest. It inserts into the investing fascia of the sper­
matic cord and testes. Its function is to retract the testicles.
It is innervated by the genital branch of the genitofemoral
nerve.5
Vascular anatomy
There are three main arterial pedicles to the male perineum
(Fig. 9.18). The deep external pudendal artery is a branch of the
femoral artery and supplies the anterior perineum. It courses
from the saphenous hiatus and provides supply to anterior
Fig. 9.18  Vascular anatomy of the male perineum.
Glans penis
Deep external pudendal
artery
Femoral artery
Femoral vein
Saphenous hiatus
Spermatic cord
Ischial tuberosity
Internal pudendal artery
Inferior rectal
artery and vein
External posterior
scrotal artery
Internal posterior
scrotal artery
Superficial perineal artery
Scrotum
Inguinal crease
Bulbospongiosus
muscle
Ischiocavernosus
Levator ani
External anal sphincter
Transverse perineal
Gluteus maximus

236
SECTION II
CHAPTER 9 • Comprehensive trunk anatomy
the penis, which are terminal branches of the pudendal
artery.
Venous drainage parallels the arterial supply. Venous
supply of the penile shaft is variable and can drain via the
deep external pudendal system or toward the infraumbilical
system of the superficial inferior epigastric or superficial
external pudendal veins.31
Bonus images for this chapter can be found online at

Fig. 9.1 Mathes and Nahai Classification of the vascular anatomy of muscle.
Type I, single vascular pedicle; type II, dominant pedicle(s) plus minor pedicles;
type III, two dominant pedicles; type IV, segmental pedicles; type V, dominant
pedicle plus secondary segmental pedicles. (From: Mathes SJ, Nahai F.
Classification of the vascular anatomy of muscles: experimental and clinical
correlation. Plast Reconstr Surg. 1981; 67(2):177–187.)
1. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67:177–187. Original article defining variation in muscle perfusion
as it relates to reconstructive surgery.
2. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141. Sentinel article laying groundwork for angiosome
theory.
3. Moore KL, Persaud TVN. Before We Are Born: Essentials of Embryology
and Birth Defects. 5th ed. Philadelphia: WB Saunders; 1998. Used as
cardinal reference for embryologic origins of trunk and perineum.
4. Lockwood TE. Superficial fascial system (SFS) of the trunk
and extremities: a new concept. Plast Reconstr Surg. 1991;87:
1009–1018.
5. Moore KL, Agur AM. Essential Clinical Anatomy. 2nd ed. Baltimore:
Lippincott Williams & Wilkins; 2002. Textbook of anatomy for general
structure and surface anatomy.
6. Olson TR, Pawlina W. ADAM Student Atlas of Anatomy. Baltimore:
Williams & Wilkins; 1996. Atlas of anatomy for general structure and
muscular anatomy.
Access the complete reference list online at

236.e1
References
References
1. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67:177–187. Original article defining variation in muscle perfusion
as it relates to reconstructive surgery.
2. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141. Sentinel article laying groundwork for angiosome
theory.
3. Moore KL, Persaud TVN. Before We Are Born: Essentials of
Embryology and Birth Defects. 5th ed. Philadelphia: WB Saunders;
1998. Used as cardinal reference for embryologic origins of trunk and
perineum.
4. Lockwood TE. Superficial fascial system (SFS) of the trunk
and extremities: a new concept. Plast Reconstr Surg. 1991;87:
1009–1018.
5. Moore KL, Agur AM. Essential Clinical Anatomy. 2nd ed. Baltimore:
Lippincott Williams & Wilkins; 2002. Textbook of anatomy for general
structure and surface anatomy.
6. Olson TR, Pawlina W. ADAM Student Atlas of Anatomy. Baltimore:
Williams & Wilkins; 1996. Atlas of anatomy for general structure and
muscular anatomy.
7. Baek S, Biller HF, Krespi YP, et al. The lower trapezius island
myocutaneous flap. Ann Plast Surg. 1979;5:108–114.
8. Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius
musculocutaneous flap from pedicled to free flap: anatomical basis
and clinical applications based on the dorsal scapular artery. Plast
Reconstr Surg. 2004;113:1580–1590.
9. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous
scapular flap for mandibular and maxillary reconstruction. Plast
Reconstr Surg. 1986;77:530–545.
10. dos Santos LF. The vascular anatomy and dissection of the free
scapular flap. Plast Reconstr Surg. 1984;73:599–602.
11. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi
musculocutaneous flap without muscle. Plast Reconstr Surg.
1995;96:1608–1614.
12. Seneviratne S, Duong C, Taylor GI. The angular branch of the
thoracodorsal artery and its blood supply to the inferior angle of
the scapula: an anatomical study. Plast Reconstr Surg.
1999;104:85–88.
13. Balogh B, Piza-Katzer H, Ritschl P, et al. Modifications of the
paraspinous muscle flap: anatomy and clinical application. Plast
Reconstr Surg. 1996;97:202–206.
14. Jones GE, ed. Bostwick’s Plastic and Reconstructive Breast Surgery. 3rd
ed. St. Louis, MO: Quality Medical Publishing; 2010.
15. Terzis JK. Pectoralis minor: a unique muscle for correction of facial
palsy. Plast Reconstr Surg. 1989;83:767–776.
16. MacQuillan A, Horloc N, Grobbelaar A, et al. Arterial and venous
anatomical features of the pectoralis minor muscle flap pedicle.
Plast Reconstr Surg. 2004;113:872–876.
17. Cuadros CL, Driscol CLW, Rothkopf DM. The anatomy of the lower
serratus anterior muscle: a fresh cadaver study. Plast Reconstr Surg.
1995;95:93–97.
18. Taylor GI, Palmer JH. The vascular territories of the anterior chest
wall. Br J Plast Surg. 1986;39:287–299.
19. Friedrich W, Lierse W, Herberhold C. Myocutaneous vascular
territory of the thoracoacromial artery. A topographical and
morphometric study of the arterial vascularization of the pectoralis
major myocutaneous flap. Acta Anat (Basel). 1988;131:284–291.
20. Yii NW, Cronin K. Vascular anatomy of the serratus anterior muscle
(letter). Plast Reconstr Surg. 2005;116:680–682.
21. Struthers J. Anatomical and Physiological Observations, Part 1.
Edinburgh: Simpkin, Marshall; 1854.
22. Worseg AP, Kuzbari R, Hubsch P, et al. Scarpa’s fascia flap:
anatomic studies and clinical application. Plast Reconstr Surg.
1997;99:1368–1380.
23. Huger WE. The anatomic rationale for abdominal lipectomy. Am
Surg. 1979;45:612–617.
24. El-Mrakby HH, Milner RH. The vascular anatomy of the lower
anterior abdominal wall: a microdissection study on the deep
inferior epigastric vessels and the perforator branches. Plast
Reconstr Surg. 2002;109:539–543.
25. Bergeron L, Tang M, Morris SF. The anatomical basis of the deep
circumflex iliac artery perforator flap with iliac crest. Plast Reconstr
Surg. 2007;120:252–258.
26. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex
iliac vessels as the supply for free groin flaps. Plast Reconstr Surg.
1979;64:595–604.
27. Taylor GI, Daniel R. The anatomy of several free flap donor sites.
Plast Reconstr Surg. 1975;56:243–253.
28. Rozen WM, Chubb D, Grinsell D, et al. The variability of the
superficial inferior epigastric artery (SIEA) and its angiosome: a
clinical anatomical study. Microsurgery. 2010;30:386–391.
29. Hester TR, Nahai F, Beegle PE, et al. Blood supply of the abdomen
revisited, with emphasis on the superficial inferior epigastric artery.
Plast Reconstr Surg. 1984;74:657–666.
30. Giraldo F, Mora MJ, Solano A, et al. Anatomic study of the
superficial perineal neurovascular pedicle: implications in
vulvoperineal flap design. Plast Reconstr Surg. 1997;99:100.
31. Li CY, Agrawal V, Minhas S, et al. The penile suspensory ligament:
abnormalities and repair. BJU Int. 2007;99:117–120.
32. Giraldo F, Mora MJ, Solano A, et al. Male perineogenital anatomy
and clinical applications in genital reconstructions and male-to-
female sex reassignment surgery. Plast Reconstr Surg.
2002;109:1301–1310.

SECTION II • Trunk Surgery
10 
Reconstruction of the chest
David H. Song and Michelle C. Roughton
SYNOPSIS
■ Chest wall reconstruction frequently requires both bony and soft-tissue
support.
■ Skeletal support is accomplished with mesh, acellular dermal matrix,
or autogenous material.
■ Soft-tissue coverage can be achieved with local muscle flaps,
omentum, or local tissue rearrangement.
■ Proper treatment of mediastinitis includes debridement, rigid sternal
fixation when possible, and soft-tissue coverage.
■ Intrathoracic reconstruction is indicated for difficult empyemas and
bronchopleural fistulas. Commonly latissimus is used for space filling
and reinforcement of ischemia-prone areas.
Access the Historical Perspective section online at

Introduction
Chest wall reconstruction can be generalized to include skel­
etal support and soft-tissue cover. Skeletal support to prevent
open pneumothorax and prevent or reduce paradoxic chest
wall motion is usually required when the defect exceeds 5 cm
in diameter. Generally, this corresponds to those defects
exceeding a two rib resection. This rule of thumb, however, is
somewhat region dependent (Table 10.1). Posterior chest wall
defects may tolerate up to twice the size of those in the anterior
and lateral chest due to scapular coverage and support.1,2
Furthermore, without truly rigid chest wall reconstruction,
i.e., methyl methacrylate, titanium, or rib graft, some para­
doxic chest wall motion is expected and is usually well toler­
ated in patients without underlying pulmonary disease.3
Options for skeletal support include various mesh prod­
ucts including polytetrafluoroethylene (PTFE, Gor-Tex),
polypropylene, Mersilene (polyethylene terephthalate)/
methyl methacrylate,4 titanium, and acellular dermal matrix
(Fig. 10.1). Furthermore, use of tensor fascia lata (TFL) and
thoracolumbar fascia as both graft and flap reconstruction has
been described. Little data exists as to outcome comparisons
between these options. However, in a retrospective review of
197 patients, PTFE and polypropylene appear to be equivalent
in complications and outcomes.1 Another smaller retrospective
review of 59 patients prefers Mersilene-methyl-methacrylate
sandwich (MMM) to PTFE due of decreased paradoxic chest
wall motion.5 Yet another group retrospectively evaluated 262
patients and, despite an increased risk of wound complica­
tions, prefers rigid to pliable mesh (MMM), especially for
larger resections.6 As alloplastic implants tend towards an
increased infection rate when compared to autogenous mate­
rial or acellular dermal matrix, the authors prefer to avoid all
alloplastic mesh when possible.
Chest wall reconstruction frequently requires some form of
soft-tissue coverage as many of these defects result from full-
thickness resections. Reconstructive goals include wound
closure with maintenance of intrathoracic integrity, restora­
tion of aesthetic contours, as well as minimization of donor
site deformity.
Recruitment of local muscles with or without overly­
ing skin is often the first line of reconstructive treatment.
These muscles include pectoralis major, latissimus dorsi,
serratus anterior, rectus abdominus, and external oblique.
The omentum may also be used. Commonly, the ipsilateral
latissimus muscle is divided during thoracotomy incisions,
and the authors encourage early communication between
surgeons if there are multiple teams.
Pectoralis major
Pectoralis major, a muscle overlying the superior portion of
the anterior chest wall, is the workhorse for chest wall recon­
struction, especially for defects of the sternum and anterior
chest. Its main function is to internally rotate and adduct the
arm. Additionally, this muscle serves as the foundation for
the female breast, and when absent, such as in Poland syn­
drome, reconstruction may be indicated for aesthetic reasons
  Access video content for this chapter online at expertconsult.com

238
SECTION II
CHAPTER 10 • Reconstruction of the chest
(Fig. 10.2). It originates from the sternum and clavicle and
inserts along the superomedial humerus in the bicipital
groove. Its dominant pedicle is the thoracoacromial trunk,
which enters the undersurface of the muscle below the clavicle
at the junction of its lateral and middle third. Segmental blood
supply is derived from internal mammary artery (IMA)
Table 10.1  Chest wall regions
Anterior
Between anterior axillary lines
Lateral
Between anterior and posterior axillary lines
Posterior
Between posterior axillary lines and the spine
Fig. 10.1  Implantable mesh products including polypropylene, polytetrafluorethylene (PTFE, Gore-Tex), and acellular dermal matrix.
A
B
C
Fig. 10.2  Left sided Poland’s syndrome. With tissue expander and acellular dermal matrix (ADM), placed through a lateral transverse incision. (Courtesy of Dr. Roughton.)
A
B
C
D

239
Introduction
paddle. Donor site deformity including scar placement
and loss of anterior axillary fold may be aesthetically
displeasing.7
Latissimus dorsi
Latissimus dorsi, a large, flat muscle covering the mid and
lower back is often recruited for chest wall reconstruction
perforators. It will easily cover sternal and anterior chest wall
defects as an island or advancement flap. It can also be turned
over, based on the IMA perforators, and, with release of its
insertion, cover sternal, mediastinal, and anterior chest wall
defects. As a turnover flap, the anterior axillary fold may be
preserved. In order to place the muscle intrathoracically, a
portion of the second, third, or fourth rib will be resected (Fig.
10.3). The muscle may be harvested with or without a skin
Fig. 10.3  Pectoralis anatomy and flap reach, standard and as turnover.
A
B
C
D
E

240
SECTION II
CHAPTER 10 • Reconstruction of the chest
hernia, and at times, mesh reinforcement of the abdominal
wall is necessary. Caution is also advised for patients with
prior abdominal incisions as the skin perforators or intra­
muscular blood supply may have been previously violated.7
(See Fig. 10.7.)
External oblique
External oblique is a broad, flat muscle that originates from
the lateral lower eight ribs and inserts onto the iliac crest and
linea semilunaris. It easily covers lower anterior chest wall
especially when significant bulk and mobility is required. It
is easily placed into the chest for intrathoracic space-filling. It
is known as the climbing muscle and adducts, extends, and
internally rotates the arm. It originates from the thoracolum­
bar fascia and posterior iliac crest and inserts into the superior
humerus at the intertubercular groove. Superiorly it is attached
to the scapula, and care must be taken to carefully separate
this muscle from the serratus at this point to avoid harvesting
both muscles. Its dominant blood supply is the thoracodorsal
artery, which enters the undersurface of the muscle 5 cm from
the posterior axillary fold.8 Segmental blood supply is derived
from the posterior intercostal arteries as well as the lumbar
artery. Based upon its thoracodorsal pedicle, the muscle can
easily reach the ipsilateral posterior and lateral chest wall
including those defects involving anterior chest wall, sternum,
or mediastinum. It can also be turned over and based upon
the lumbar perforators. In this fashion, it can reach across the
midline and back again. Again, it can be moved intrathoraci­
cally with rib resection. Donor site morbidity can include
shoulder dysfunction as well as unattractive scarring.9
However, our experience suggests these concerns are minimal.
Also, transposition of this muscle can blunt or obliterate the
posterior axillary fold resulting in some asymmetry.7 We
advise caution in patients who have undergone previous
thoracotomy and modified radical mastectomy as the muscle
or blood supply may have been divided. Muscle sparing
thoracotomy incisions may be helpful in preoperative plan­
ning. (See Figs. 10.4 & 10.5.)
Serratus anterior
Serratus anterior is a thin broad multi-pennate muscle lying
deep along the anterolateral chest wall. It originates from the
upper eight or nine ribs and inserts on the ventral-medial
scapula. It functions to stabilize the scapula and move it
forward on the chest wall such as when throwing a punch. It
has two dominant pedicles including the lateral thoracic and
the thoracodorsal arteries. Division of the lateral thoracic
pedicle will increase the arc posteriorly, and similarly division
of the thoracodorsal will increase the arc anteriorly. The
muscle will reach the midline of the anterior or posterior
chest. More commonly, however, it is used for intrathoracic
coverage, again requiring rib resection. An osteomyocutane­
ous flap may be harvested by preservation of the muscular
connections with the underlying ribs. Donor site morbidity is
related to winging of the scapula and can be avoided if the
muscle is harvested segmentally and the inferior three or four
slips are harvested.7 (See Fig. 10.6.)
Rectus abdominus
Rectus abdominus is a long, flat muscle that constitutes the
medial abdominal wall. It originates from the pubis and
inserts onto the costal margin. It can easily cover sternal and
anterior chest wall defects and can also fill space within the
mediastinum. It has two dominant pedicles, the superior
and inferior epigastric arteries and functions to flex the
trunk. With division of the inferior pedicle, the muscle will
cover the mediastinum and the anterior chest wall. It can be
harvested with an overlying skin paddle, and usually the
resulting cutaneous defect can be closed primarily. When
taken with overlying fascia, there is a risk for resultant
Fig. 10.4  Muscle sparing thoracotomy. (From: Ferguson MK. Thoracic Surgery
Atlas. Edinburgh: Elsevier©; 2007.)
Latissimus dorsi
Serratus anterior
Serratus anterior
A
B
C

241
Introduction
Fig. 10.5  Latissimus anatomy and arc of rotation standard and turn over.
A
B
C
D
Thoracodorsal
artery

242
SECTION II
CHAPTER 10 • Reconstruction of the chest
resected. Furthermore, when transposing the omentum over
the costal margin, by necessity a portion of the abdominal
fascia must be left open to allow egress. This area is prone to
hernia.7 (See Figs. 10.9–11.)
Key points
■ Skeletal chest wall support may be achieved with mesh,
acellular dermal matrix, or autogenous material such as
tensor fascia lata. The former is more prone to infection.
Rigid skeletal support prevents paradoxic chest wall
motion although this is usually well tolerated.
■ Pectoralis muscle is the workhorse for sternal and
anterior chest wall defects.
■ Latissimus muscle is known for its bulk and ability to
reach intrathoracic defects. Caution is advised for
patients with previous thoracotomy incisions as it may
have been divided. Less commonly the thoracodorsal
vessels will have been clipped during modified radical
mastectomy.
■ Serratus muscle is less bulky than the latissimus but will
function to cover lateral chest wall defects and some
intrathoracic needs.
■ Rectus abdominus is an excellent choice for sternal and
anterior chest wall defects, especially the lower two-
thirds. Furthermore, it can be used to fill space within the
mediastinum.
■ External oblique is well positioned for a rotational flap
and easily covers lower anterior defects.
■ The omentum can reach almost any chest wall defect. Its
greatest advantage is its pedicle length, which can be
extended by dividing the arcades.
Patient selection/approach to patient
The importance of a multidisciplinary approach to chest wall
reconstruction cannot be underestimated. These patients,
whether suffering from malignancy, infection, or trauma, are
often also plagued with cardiac or respiratory insufficiency,
diabetes, obesity, malnutrition, tobacco use, and generalized
deconditioning. Thorough workup including pulmonary
function testing, physical therapy and nutritional assessment,
smoking cessation, and preoperative control of blood sugar,
outcomes may be optimized. Furthermore, communication
between referring surgeon and reconstructive plastic surgeon
is crucial to properly define preoperative reconstructive
expectations as well as incision planning with caution to spare
chest wall musculature if required. Occasionally preoperative
imaging may be used to confirm suspected vascular injury to
commonly used muscle pedicles, e.g., thoracodorsal vessels
during mastectomy.
Acquired chest wall deformities are commonly the result
of iatrogenic injury. Chest wall wound infections, mediastini­
tis, osteoradionecrosis (ORN), refractory empyemas, and
bronchopleural fistulae can all necessitate a reconstructive
surgeon. The surgeon is generally well prepared to reconstruct
any defect with utilization of the workhorse flaps described
above, combined with general principles of thorough debride­
ment and skeletal stabilization. Common chest wall recon­
structive problems are described below.
defects as a rotational flap and has a segmental blood supply
from the posterior intercostal arteries, which enter the muscle
at the midaxillary line. It functions in situ as an important
strength layer of the abdominal wall, and thus its harvest
tends to be a second-line option when the latissimus is
not available. A similar flap can be made with overlying
soft tissue leaving the muscle intact as well.7 (See Fig. 10.8 –
external oblique anatomy and arc of rotation.)
Omentum
The omentum comprises visceral fat and blood vessels that
arises from the greater curve of the stomach and is also
attached to the transverse colon. This flap can easily cover
wounds in the mediastinum and anterior, lateral, and poste­
rior chest wall. It has two dominant pedicles, the right and
left gastroepiploic arteries. The greatest benefit of this flap is
the pedicle length that can be easily elongated with division
of internal arcades. The flap is mobilized onto the chest or
into the mediastinum from a tunnel through the diaphragm or
over the costal margin. Caution is again advised for patients
with prior laparotomy incisions as the omentum may have
significant intra-abdominal adhesions or have been previously
Fig. 10.6  Serratus anatomy and arc of rotation.
Thoracodorsal
artery
Subclavian artery

242.e1
Historical perspective
Historical perspective
Throughout history, the ability to perform surgical resections
has been limited by their survivorship. Chest wall resections,
in particular, were difficult given the intimate relationship of
the chest to vital structures beneath – the heart, lungs, and
great vessels. In particular, sequelae, such as pneumothorax,
were challenging for surgeons in the era preceding positive
pressure ventilation and closed chest drainage.
Despite adversity, however, and as early as 1906, the latis­
simus dorsi was used for chest wall coverage following radical
mastectomy.10 This was similarly performed by Campbell in
1950.11 The earliest use of fascia lata grafts appears in 1947.12
Axially based flaps regained popularity in the 1970s, and in
1986 Pairolero and Arnold published their series of 205
patients managed with muscle flaps purporting their safety
and durability.13

243
Patient selection/approach to patient
Fig. 10.7  Rectus anatomy and arc of rotation.
A
B
Superior
epigastric
artery
Inferior
epigastric
artery
Fig. 10.8  External oblique anatomy and arc of rotation.
A
B
C

244
SECTION II
CHAPTER 10 • Reconstruction of the chest
common benign tumor is osteochondroma and is resected
only when symptomatic. The most common primary malig­
nant tumors are sarcomas, chondrosarcoma from the bony
structures, and desmoid tumors from the soft tissue. Sarcoma
resection is recommended to include a 4 cm margin of normal
tissue and thus will almost always necessitate significant
chest wall reconstruction16 (Figs. 10.12 & 10.13). Over half of
Chest wall tumors
Basic science/disease process
Primary tumors of the chest wall comprise only 5% of thoracic
neoplasms.14 Half of these are considered benign.15 The most
Fig. 10.9  Omentum anatomy.
Original
incision
Incision
Omentum
Left gastroepiploic vessels divided
Omentum
A
B
C
Fig. 10.10  Omentum is passed through cruciate incision in
diaphragm under the left lobe of the liver.
Omentum passing
through diaphragm
into thoracic cavity
Left lobe of liver
Stomach
Incision in diaphragm

245
Chest wall tumors
malignant chest wall lesions represent metastatic disease,
with breast and lung cancers being the most common.17
Diagnosis/presentation/patient selection
For relief of symptoms including pain, ulceration, and foul
odor, and occasionally for disease control, even metastatic
lesions may necessitate resection. (See Fig. 10.14.)
Treatment/surgical technique
Like other neoplasms, metastatic tumors are resected with a
margin of normal tissue, and thus they too will frequently
require skeletal support as well as recruitment of soft tissue
in the form of pedicled or free flaps.
Outcomes
Not all metastatic resections are palliative. The 5-year survival
rate following resection of chest wall recurrence of breast
cancer is reported to be as high as 58%.18
Fig. 10.11  Omentum arc of rotation.
A
B
Fig. 10.12  Multipe recurrent osteosarcoma. Initial reconstruction included ipsilateral latissimus, free contralateral latissimus. Third recurrence, resection involved 6 ribs and
the previously implanted mesh. Reconstructed with free anterolateral thigh (ALT) flap to the deep inferior epigastric artery/deep inferior epigastric vein (DIEA/DIEV).
(Courtesy of Dr. Song.)
C
D

246
SECTION II
CHAPTER 10 • Reconstruction of the chest
Mediastinitis
Basic science/disease process
Mediastinitis occurs in 0.25–5% of patients undergoing
median sternotomy.19–21 Historically, mortality approached
50% in these patients.9 Sternal wound infections may be clas­
sified into three distinct types as described by Pairolero (Table
10.2).22 Type I wounds occur in the first several postoperative
days and are usually sterile. This is consistent with early bony
nonunion and may represent the earliest stage of infection
and perhaps even the portal of entry for skin flora. Type II
infections, occurring in the first several weeks postoperatively,
are consistent with acute deep sternal wound infection includ­
ing sternal dehiscence, positive wound cultures, and cellulitis.
Type III infections, presenting months to years later, represent
chronic wound infection and uncommonly represent true
mediastinitis. They are usually confined to the sternum and
overlying skin and may be related to osteonecrosis or persis­
tent foreign body.
Speculation exists that dehiscence of the sternum precedes
infection of the deeper soft tissues within the mediastinum.
Fig. 10.13  Radiation-induced rhabdomyosarcoma of anterolateral chest wall,
resection of ribs 3–5, and adherent right middle lobe (RML). Reconstruction with
porcine acellular dermal matrix (ADM) and latissimus myocutaneous flap and skin
graft. (Courtesy of Dr. Roughton.)
A
B
C
Table 10.2  Classification of infected sternotomy wounds
Type I
Type II
Type III
Occurs within first
few days
Serosanguineous
drainage
Cellulitis absent
Mediastinum soft
and pliable
Osteomyelitis and
costochondritis
absent
Cultures usually
negative
Occurs within first
few weeks
Purulent drainage
Cellulitis present
Mediastinal
suppuration
Osteomyelitis
frequent,
costochondritis
rare
Cultures positive
Occurs months to
years later
Chronic draining sinus
tract
Cellulitis localized
Mediastinitis rare
Osteomyelitis,
costochondritis, or
retained foreign body
always present
Cultures positive
(Adapted from Pairolero and Arnold. Chest wall tumors. Experience with 100
consecutive patients. J Thorac Cardiovasc Surg. 1985;90:367–372.)

247
Mediastinitis
10.15),27 will require adequate drainage and debridement.
Quantitative tissue culture facilitates this debridement.
If tissue culture is positive, >10 organisms per cm3 of tissue,
indicating deep sternal wound infection rather than early
sternal dehiscence, early debridement is encouraged and
should be performed urgently. A thorough debridement
includes the removal of sternal wires and extraneous foreign
bodies including any unnecessary pacing wires and chest
tubes (Fig. 10.16). Sharp debridement of necrotic and/or
purulent tissue is performed until remaining tissue appears
healthy and bleeding .28,29 Radical sternectomy is not indicated,
and sternal salvage should be attempted if the bone is viable.
This may be determined by bleeding from the marrow and
the presence of hard, crunchy cortical bone. Topical antimi­
crobials such as silver sulfadiazine and mafenide creams are
employed to gain and maintain bacteriologic control of the
wound. Subatmospheric pressure wound therapy may be
utilized to increase wound blood flow and expedite granula­
tion tissue, thereby decreasing dead space.30,31 This has been
shown to decrease the number of days between operative
debridement and definitive closure of sternal wounds. 20
Fixation of the sternum or residual sternal bone is
crucial for bony healing. Furthermore, this fixation pre­
vents paradoxic motion of the anterior chest wall and may
improve many complications seen with sternal nonunion
such as chronic chest wall pain and abnormal rubbing or
Like other fractures in the body, such as the lower extremity
and the mandible, sternal instability may perhaps encourage
infection rather than result from it.23
Diagnosis/patient presentation
Preoperative risk factors for the development of mediastinitis
include older patients, chronic obstructive pulmonary disease
(COPD), smoking, end stage renal disease (ESRD), diabetes
mellitus (DM), chronic steroid or immunosuppressive use,
morbid obesity including large, heavy breasts, prolonged
ventilator support (>24 h), concurrent infection, and reopera­
tive surgery. Other variables include off midline sternotomies,
osteoporosis, use of left internal mammary artery (LIMA) or
right internal mammary artery (RIMA), long cardio-pulmonary
bypass runs (>2 h), and transverse sternal fractures.24,25 A high
index of suspicion is encouraged for any patient with sternal
instability or “click”. However, firm diagnosis of mediastinitis
or deep sternal wound infection is made by isolation of an
organism from mediastinal fluid or tissue and observing chest
pain or fever associated with bony instability.26
Treatment/surgical technique (Video 10.1 )
Consistent with fundamental plastic surgery principles, treat­
ment of infection, including that of the mediastinum (Fig.
Fig. 10.14  Sternal metastases from breast cancer, resection, and vertical rectus
abdominus myocutaneous [FLAP] (VRAM) flap coverage. (Courtesy of Dr. Song.)
A
B
C

248
SECTION II
CHAPTER 10 • Reconstruction of the chest
Fig. 10.15  Management of sternal wounds. Split thickness skin graft
(STSG).
Sternal wound with
• Instability or "click"
• Both bony dehiscence
Evaluation of wound/
debridement/
tissue sampling
+ Topical
antimicrobial
therapy
Quantitative tissue
culture >105
Quantitative tissue
culture <105
Inadequate
remaining viable bone
Adequate remaining
viable bone
Adequate soft-
tissue coverage
Inadequate soft-
tissue coverage
Defect in upper
or midsternum
Both upper and
lower poles
Both
Or
Omentum
+ STSG
Defect in
lower pole
Sternal plating
Pectoralis major
muscle flap
+/- STSG
Rectus abdominus
myocutaneous or
muscle flap +/- STSG
Primary closure
Fig. 10.16  Thorough debridement requires
removal of necrotic tissue and foreign bodies.
(Courtesy of Dr. Song.)
A
B

249
Empyema and bronchopleural fistula
can be used. This may be harvested with a skin island and
allow chest wound closure.35 Skin grafting, if required, may
be employed for closure of either the sternal wound or flap
donor site.18
Empyema and bronchopleural fistula
Basic science/disease process
Empyema is defined as a deep space infection between the
layers of visceral and the parietal pleura. Empyema and
bronchopleural fistulas often are found in concert and plague
pneumonectomy and partial pneumonectomy defects. The
chest cavity, unlike most other regions in the body, is rigid
and non-collapsible. Thus deep space infections, such as
empyemas, are unlikely to heal without collapse of dead
space or filling of the cavity. Older techniques, such as open
chest drainage and the use of Eloesser flaps, designed to
decrease intrathoracic dead space, (Fig. 10.20) have fallen out
of favor.
clicking sensations.32 For adults, titanium plates are used
(Fig. 10.17).
Occasionally, sternal dehiscence occurs early in the postop­
erative course, consistent with type I sternal wound infections.
This is secondary to mechanical failure of wire closure rather
than infection. The wounds are sterile and should proceed
to rigid sternal fixation. More commonly, however, patients
will present with sternal nonunion in a delayed fashion.
In the absence of infection, the residual viable bone can be
plated directly. Importantly, a paradigm shift has occurred in
the authors’ institution such that patients who are deemed
high risk for mediastinitis and sternal dehiscence are plated
prophylactically.33,34 Several plating systems exist all designed
to facilitate ease of application as well as emergent chest
re-entry.
Once rigid fixation is achieved, soft-tissue closure must be
addressed. As very limited soft tissue exists over a normal
sternum, residual local tissue following debridement of
mediastinitis will often prove inadequate for plate coverage.
Thus muscle flap coverage is indicated. When the wound
involves the upper two-thirds of the sternum, pectoralis major
muscle advancement or turnover flaps are easily harvested
and are the first line therapy for wound closure (Fig. 10.18).
Caution is advised for turnover flaps when the ipsilateral IMA
has been harvested for coronary artery bypass graft (CABG).
Furthermore, emergent chest re-entry will, by definition,
devascularize this turnover flap. Additionally, when the lower
sternal pole lacks coverage, the pectoralis may be inadequate
based on its limited arc of rotation. For these cases, the rectus
abdominus muscle flap is a better choice (Fig. 10.19). It may
be used despite LIMA or RIMA harvest based upon the eighth
intercostal artery, its minor pedicle. If the rectus is unavailable
secondary to previous surgery, a pedicled omental flap should
be considered for soft-tissue sternal coverage. Finally, if the
omentum has been previously resected or the patient has had
multiple prior abdominal operations, the latissimus dorsi flap
Fig. 10.17  Rigid fixation is crucial for sternal union.
A
Fig. 10.18  Bilateral pectoralis advancement flaps. Muscle sutured together in
midline. (Courtesy of Dr. Roughton.)
B

Fig. 10.19  Oblique rectus abdominus myocutaneous flap for inferior pole sternal
coverage. (Courtesy of Dr. Roughton.)
A
B
C
Fig. 10.20  Eloesser flap. Skin flap sewn to parietal pleura.
Proposed inverted
“U” incision
Ribs to be resected
Tongue flap
Tongue flap
Ribs resected
Completed procedure
with tongue flap sewn down
Left lung
Diaphragm
Parietal pleura
Drained empyema
cavity
Skin flap attached to
base of empyema
cavity
Skin flap
A
B
C
D
E

251
Osteoradionecrosis
Fig. 10.21  Bronchopleural fistula with latissimus muscle
introduced intrathoracically for reinforcement.
Stapled bronchus
Middle lung lobe retracted
Latissimus dorsi muscle
The bronchial stump, created after pneumonectomy, can
also become a reconstructive challenge. If it dehisces, by defi­
nition, a bronchopleural fistula is created. This phenomenon,
a massive air leak between the large airways and the chest
cavity, is unlikely to resolve without the interposition of
healthy tissue in the form of flap coverage.36 (See Fig. 10.21.)
Surgical technique
The omentum, latissimus dorsi, serratus anterior, pectoralis
major, and rectus abdominus muscles have all been described
for space filling and reinforcement of the bronchial stump.37,38
An often encountered problem with intrathoracic space filling
is the sheer volume required to totally obliterate the thoracic
cage. This can be overcome with thoracoplasty (meaning
partial rib/cage collapse) or with the use of multiple flaps.39
As a single flap, however, the latissimus muscle is often the
preferred choice given its volume.
Outcomes
Outcomes following muscle flap transposition are reported
as quite successful with 73% resolution or prevention of
infection in Arnold and Pairolero’s retrospective review of
100 patients with severe intrathoracic infections.28 Several
smaller and more recent studies report even higher rates of
success.26,40,41 In fact, prophylactic use of the latissimus muscle
for reinforcement of the bronchial stump in high-risk patients
is the standard of care in some centers.42
Osteoradionecrosis
Basic science/disease process
The use of adjuvant radiation therapy is becoming increas­
ingly common in the treatment of both breast and lung cancer.
As such, osteoradionecrosis (ORN) of the ribs is becoming an
increasing problem for reconstructive surgeons. Radiation
injury and tissue damage may not become clinically apparent
for months to years after exposure, especially in tissues with
slow cell turnover such as bone. Although the mechanism is
poorly understood, radiation leads to an increased production
of cytokines, collagen deposition, and scarring within affected
tissues, as well as vascular damage leading to relative hypoxia
(Figs. 10.22 & 10.23). The severity of radiation-induced necro­
sis is related to several factors including total dose, dose per

252
SECTION II
CHAPTER 10 • Reconstruction of the chest
Fig. 10.22  (A) Osteoradionecrosis of ribs following chest wall radiation for breast cancer. (B,C) Following radical resection, serratus thoracoabdominal flap is planned and
inset. Note all incisions kept supraumbilical to preserve lower abdominal donor site for future autologous breast reconstruction. (Courtesy of Dr. Gottlieb.)
A
B
C
Fig. 10.23  Osteoradionecrosis following chest wall radiation for breast cancer treated with omentum and skin graft. (Courtesy of Dr. Roughton.)
A
B
C
D

253
Traumatic chest wall deformities
Fig. 10.24  Judet struts. (From: Surgical Stabilization of Severe Flail Chest, Fig. 7,
reproduced with permission from CTSNet, Inc. © 2010. All rights reserved.)
fraction, frequency of administration, and whether it is com­
bined with chemotherapy. Smaller doses per fraction appear
to be better tolerated.43 Note that this entity may be difficult
to diagnose radiographically and demands a high level of
clinical suspicion.
Treatment/surgical technique
Some advocate hyperbaric oxygen (HBO) therapy for ORN.
However, for ORN of the mandible, a prospective, random­
ized, placebo-controlled trial showed the HBO group actually
fared worse than their counterparts.44 Anecdotally, the authors
have not found this therapy to be essential or especially
helpful and do not routinely pursue it. Management of ORN
of the chest wall consists of wide local excision and recon­
struction. In addition to osteonecrosis, radiation damage also
affects overlying soft tissues creating hyperpigmentation,
decreased pliability, and even ulceration. However, note that
this decrease in chest wall pliability may make skeletal rein­
forcement unnecessary for borderline sized defects. Recruit­
ment of healthy tissue in the form of local myocutaneous flaps
is recommended for coverage of resultant chest wall defects
and any skeletal reinforcement as indicated.
Osteomyelitis
Basic science/disease process
Chest wall osteomyelitis most commonly results from
contiguous spread of infection, either from pneumonia or
empyema. Hematogenous spread is also possible. Infectious
etiology tends to be bacterial, with mycobacterial and fungal
sources less likely. It frequently coexists with ORN as well.
Diagnosis/patient presentation
Osteomyelitis produces symptoms including fever, chest
pain, and localized swelling of the chest wall.45
Treatment/surgical technique
Similar to osteomyelitis of other areas of the body, antibiotics
and surgical excision are recommended. Chest wall recon­
struction should proceed similarly to other areas of resection
with rigid support when indicated and soft-tissue coverage in
the form of local muscle flaps. In an infected field, however,
the authors strongly discourage use of prosthetic material.
When skeletal stabilization is indicated, autogenous material
or acellular dermal matrix is preferred.
Traumatic chest wall deformities
Basic science/disease process
Chest trauma results from both penetrating and blunt injuries,
which damage underlying bony and soft tissues. This may
occur with or without further injury to vital organs or great
vessels within the thoracic cage.
Diagnosis/patient presentations
Severe paradoxic chest wall motion, in the form of flail chest,
may be seen following significant chest trauma. This results
from multiple adjacent rib fractures, broken in two or more
places, creating a flail segment.
Patient selection/treatment/surgical technique
Patients with traumatic chest wall deformities should initially
be stabilized according to Advanced Trauma Life Support
(ATLS) protocol. Chest tubes and positive pressure ventilation
should be initiated as indicated. For patients with respiratory
compromise, rigid fixation of the flail segment may be indi­
cated. This is accomplished traditionally with the use of
mini-plates, thicker titanium recon bars, or Judet struts (Fig.
10.24). Significant loss of chest wall, seen in massive crush
injuries, should be managed again with rigid support to the
remaining viable chest wall and concomitant soft-tissue
coverage.
Outcomes
Traditionally patients were treated with expectant manage­
ment; however, rib plating has been shown to reduce ventila­
tor dependence and ICU stay as well as incidence of
pneumonia in patients with flail chest.
Secondary procedures
Chest wall reconstruction has been, over the last three decades,
very successful. Cases of failure commonly result from inad­
equate control of infection or residual tumor burden. In either
case, an aggressive resection is often indicated and the use of
a second flap. Another unfortunate complication of skeletal
chest wall reconstruction is infection of alloplastic mesh
products. In these cases, removal of the infected prosthesis
and use of acellular dermal matrix, autologous fascia, or even
contralateral ribs may be indicated.

254
SECTION II
CHAPTER 10 • Reconstruction of the chest
1. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term
results of prosthetic chest wall reconstruction. J Thorac Cardiovasc
Surg. 1999;117(3):588–592. The authors review their experience with
nearly 200 patients requiring chest wall reconstruction over 15 years.
Mesh is utilized (polypropylene and polytetrafluoroethylene) for skeletal
support, and over half of the patients required muscle transposition for
soft-tissue coverage. Wound healing was complete for 95% of patients,
although 24% experienced local cancer recurrence.
6. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall
resection and reconstruction with and without rigid prosthesis. Ann
Thorac Surg. 2006;81(1):279–285.
7. Zenn MR, Jones G. Reconstructive Surgery: Anatomy, Technique, and
Clinical Applications. St Louis (MO): Quality Medical Publishing;
2012. This textbook detailing nearly all commonly used flaps in plastic
surgery continues to be an excellent reference for relevant anatomy, flap
selection, and arc of rotation.
13. Pairolero PC, Arnold PG. Thoracic wall defects: surgical
management of 205 consecutive patients. Mayo Clin Proc.
1986;61(7):557–563.
19. Jurkiewicz MJ, Bostwick TJ, Bishop JP, et al. Infected median
sternotomy wound: successful treatment with muscle flaps. Ann
Surg. 1980;191(6):738–743.
20. Sarr MG, Gott VL, Townsend TR. Mediastinal infection after cardiac
surgery. Ann Thorac Surg. 1984;38:415–423.
23. Gottlieb LJ, Pielet RW, Karp RB, et al. Rigid internal fixation of the
sternum in postoperative mediastinitis. Arch Surg.
1994;129(5):489–493.
28. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
infected median sternotomy wound: a treatment algorithm utilizing
vacuum-assisted closure followed by rigid plate fixation. Ann Plast
Surg. 2006;56(6):680–685. This paper contains a treatment algorithm for
mediastinitis, emphasizing debridement, the use of sub-atmospheric
pressure, rigid fixation, and soft-tissue coverage.
33. Song DH, Lohman RF, Renucci JD, et al. Primary sternal plating in
high-risk patients prevents mediastinitis. Eur J Cardio-Thor Surg.
2004;26:367–372. This is a case-controlled study of prophylactic sternal
plating in high-risk patients. The group who was plated experienced no
mediastinitis while 14.8% of the control group, closed with wire,
developed mediastinitis.
38. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account of
their use in the management of 100 consecutive patients. Ann Surg.
1990;211(6):656–660. The authors detail a 73% success rate with
treatment and prevention of intrathoracic infection following muscle
transposition into the chest of high-risk patients.
Access the complete references list online at

254.e1
References
References
1. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term
results of prosthetic chest wall reconstruction. J Thorac Cardiovasc
Surg. 1999;117(3):588–592. The authors review their experience with
nearly 200 patients requiring chest wall reconstruction over 15 years.
Mesh is utilized (polypropylene and polytetrafluoroethylene) for skeletal
support, and over half of the patients required muscle transposition for
soft-tissue coverage. Wound healing was complete for 95% of patients,
although 24% experienced local cancer recurrence.
2. Hasse J. Surgery for primary, invasive, and metastatic malignancy
of the chest wall. Eur J Cardiothor Surg. 1991;5:346–351.
3. Mansour K, Thourani VH, Losken A, et al. Chest wall resections
and reconstruction: a 25-year experience. Ann Thorac Surg.
2002;73:1720–1726.
4. Lardinois D, Muller M, Furrer M, et al. Functional assessment of
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grafts for chest wall reconstruction. J Int Surg. 2006;19:353–360.
6. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall
resection and reconstruction with and without rigid prosthesis. Ann
Thorac Surg. 2006;81(1):279–285.
7. Zenn MR, Jones G. Reconstructive Surgery: Anatomy, Technique, and
Clinical Applications. St Louis (MO): Quality Medical Publishing;
2012. This textbook detailing nearly all commonly used flaps in plastic
surgery continues to be an excellent reference for relevant anatomy, flap
selection, and arc of rotation.
8. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled
descending branch muscle-sparing latissimus dorsi flap for breast
reconstruction. Plast Recon Surg. 2009;123(1):13–24.
9. Russell RC, Pribaz JJ, Zook EG , et al. Functional evaluation of
latissimus dorsi donor site. Plast Recon Surg. 1986;78(3):336–344.
10. Tansini I. Sopra il mio nuovo processo di amputazione della
mammilla. Gazz Med Ital. 1906;57:141.
11. Campbell DA. Reconstruction of the anterior thoracic wall. J
Thoracic Surg. 1950;19:456.
12. Watson WL, James AG. Fascia lata grafts for chest wall defects. J
Thorac Surg. 1947;16:399.
13. Pairolero PC, Arnold PG. Thoracic wall defects: surgical management
of 205 consecutive patients. Mayo Clin Proc. 1986;61(7):557–563.
14. Perry RR, Venzon D, Roth JA, et al. Survival after surgical resection
for high-grade chest wall sarcomas. Ann Thorac Surg.
1990;49(3):363–368.
15. Graeber GM, Snyder RJ, Fleming AW, et al. Initial and long-term
results in the management of primary chest wall neoplasms. Ann
Thorac Surg. 1982;34(6):664–673.
16. King RM, et al. Primary chest wall tumors: factors affecting
survival. Ann Thorac Surg. 1986;41(6):597–601.
17. Pairolero PC, Arnold PG. Chest wall tumors: experience with 100
consecutive patients. J Thorac Cardiovasc Surg. 1985;90(3):367–372.
18. Faneyte IF, Rutgers ETh, Zoetmulder FAN. Chest wall resection in
the treatment of locally recurrent breast carcinoma. Cancer.
1997;80(5):886–891.
19. Jurkiewicz MJ, Bostwick TJ, Bishop JP, et al. Infected median
sternotomy wound: successful treatment with muscle flaps. Ann
Surg. 1980;191(6):738–743.
20. Sarr MG, Gott VL, Townsend TR. Mediastinal infection after cardiac
surgery. Ann Thorac Surg. 1984;38:415–423.
21. Prevosti LG, Subramainian VA, Rothaus KO, et al. A comparison of
the open and closed methods in the initial treatment of sternal
wound infections. J Cardiovasc Surg. 1989;30:757–763.
22. Pairolero PC, Arnold PG. Management of recalcitrant median
sternotomy wounds. J Thorac Cardiovasc Surg. 1984;88:357–364.
23. Gottlieb LJ, Pielet RW, Karp RB, et al. Rigid internal fixation of the
sternum in postoperative mediastinitis. Arch Surg.
1994;129(5):489–493.
24. Golosow LM, Wagner JD, Felley M, et al. Risk factors for predicting
surgical salvage of sternal wound-healing complications. Ann Plast
Surg. 1999;43:30–35.
25. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep
sternal wound complications: incidence, risk factors and mortality.
Eur J Cardio-Thor Surg. 2001;20:1168–1175.
26. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for
prevention of surgical site infection, 1999. Centers for disease
control and prevention (CDC) hospital infection control practices
advisory committee. Am J Infect Control. 1999;27:97–132.
27. Roughton MC, Song DH. Sternal wounds. In: Marsh I, Perlyn C,
eds. Decision Making in Plastic Surgery. St Louis (MO): Quality
Medical Publishing; 2009.
28. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
infected median sternotomy wound: a treatment algorithm utilizing
vacuum-assisted closure followed by rigid plate fixation. Ann Plast
Surg. 2006;56(6):680–685. This paper contains a treatment algorithm for
mediastinitis, emphasizing debridement, the use of sub-atmospheric
pressure, rigid fixation, and soft-tissue coverage.
29. Agarwal JP, Ogilvie M, Wu LC, et al. Vacuum-assisted closure for
sternal wounds: a first-line therapeutic management approach. Plast
Recon Surg. 2005;116(4):1035–1040.
30. Argenta LC, Morykwas MJ. Vacuum assisted closure: a new
method for wound control and treatment: clinical experience. Ann
Plast Surg. 1997;38(6):563–576.
31. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum
assisted closure: a new method for wound control and treatment:
animal studies and basic foundation. Ann Plast Surg.
1997;38(6):553–562.
32. Yuen JC, Zhou AT, Serafin D, et al. Long-term sequelae following
median sternotomy wound infection and flap reconstruction. Ann
Plast Surg. 1995;35(6):585–589.
33. Song DH, Lohman RF, Renucci JD, et al. Primary sternal plating in
high-risk patients prevents mediastinitis. Eur J Cardio-Thor Surg.
2004;26:367–372.
This is a case-controlled study of prophylactic sternal plating in high-risk
patients. The group who was plated experienced no mediastinitis while
14.8% of the control group, closed with wire, developed mediastinitis.
34. Lee JC, Raman J, Song DH, et al. Primary sternal closure with
titanium plate fixation: plastic surgery effecting a paradigm shift.
Plast Recon Surg. 2010;125(6):1720–1724.
35. Nahai F, Rand RP, Hester TR, et al. Primary treatment of the
infected sternotomy wound with muscle flaps: a review of 211
consecutive cases. Plast Recon Surg. 1989;84(3):434–441.
36. Jadczuk E. Postpneumonectomy empyema. Eur J Cardio-Thor Surg.
1998;14:123–126.
37. Iverson LI, Young JN, Ecker RR, et al. Closure of bronchopleural
fistulas by an omental pedicle flap. Am J Surg. 1986;152(1):40–42.
38. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account of
their use in the management of 100 consecutive patients. Ann Surg.
1990;211(6):656–660. The authors detail a 73% success rate with
treatment and prevention of intrathoracic infection following muscle
transposition into the chest of high-risk patients.
39. Rand RP, Maser B, Dry G, et al. Reconstruction of irradiated
postpneumonectomy empyema cavity with chain-linked coupled
microsurgical omental and TRAM flaps. Plast Recon Surg.
2000;105(1):183–186.
40. Okumura Y, Takeda S, Asada H, et al. Surgical results for chronic
empyema using omental pedicled flap: long-term follow-up study.
Ann Thorac Surg. 2005;79:1857–1861.
41. Meyer AJ, Krueger T, Lepori D, et al. Closure of large intrathoracic
airway defects using extrathoracic muscle flaps. Ann Thorac Surg.
2004;77:397–405.
42. Abolhoda A, Bui TD, Milliken JC, et al. Pedicled latissimus dorsi
muscle flap: routine use in high-risk thoracic surgery. Tex Heart Inst
J. 2009;36(4):298–302.
43. Stone HB, Coleman CN, Anscher MS, et al. Effects of radiation on
normal tissue: consequences and mechanisms. Lancet Oncol.
2003;4:529–536.
44. Annane D, Depondt J, Aubert P, et al. Hyperbaric oxygen therapy
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45. Bishara J, Gartman-Israel D, Weinberger M, et al. Osteomyelitis of
the ribs in the antibiotic era. Scan J Infect Dis. 2000;32(3):223–227.

SECTION II • Trunk Surgery
11 
Reconstruction of the soft tissues of
the back
Gregory A. Dumanian and Vinay Rawlani
SYNOPSIS
■ Reconstruction of the soft tissues of the back at first may seem to be
a daunting task compounded by large wounds, unfamiliar and
segmental anatomy, radiation, hardware, and difficulties with
postoperative positioning.
■ Many of the conditions treated require significant coordination
with surgical colleagues. The conditions may be unfamiliar to the
plastic surgeon and without parallels elsewhere in the body, an
example being pseudomeningoceles filled with cerebrospinal fluid
(CSF).
■ The goal of this chapter is to provide the reader with real-life solutions
to difficult problems involving back wounds.
Introduction
The back is 18% of the total body surface area; however,
until recently, reconstruction of the back was neglected
in plastic surgery texts. From the nape of the neck, to the
anterior axillary lines, to the inferior gluteal crease, the only
area well known to the plastic surgeon is the buttocks for
the treatment of pressure sores. What changed the equation
were the advances made in spine surgery and instrumenta­
tion. In decades past, spinal fusions were often performed
by removing discs and scraping the endplates of vertebral
bodies. These procedures were not limited by the sur­
rounding soft tissues. This changed with improvements in
surgical hardware that allowed for longer constructs for
spinal stability. Simultaneous anterior and posterior spine
exposures for rigid fixation greatly stripped and elevated the
surrounding soft tissues, and correspondingly pushed the
soft tissues past the point where wound healing would be
automatic. In response to the need created by our surgical
colleagues, surgical procedures to reliably close the back were
developed.
Patient presentation
Midline back wounds
When a spine surgeon calls to discuss new drainage from a
midline spine wound, the thought process for treatment
should be methodical and thorough. When was the last pro­
cedure performed, and did the procedure involve the place­
ment of hardware? What type of hardware is present, and is
it locally prominent or is it low profile? Did the spine surgeons
place hardware on the anterior or lateral aspect of the verte­
bral bodies, or rather was it only posterior? Have there been
any dural tears that were repaired, and do the spine surgeons
have any evidence of a CSF leak? After obtaining an under­
standing of what was done, an evaluation of wound healing
issues is necessary. Is the patient markedly malnourished and
catabolic? Is obesity and dead space management the problem?
Has the patient been radiated for a spinal cord metastasis with
the associated stiff and edematous soft tissues? Next, an
examination of the patient is often telling of what needs to be
done. Continued soiling of dressings with fluid and dieback
of wound edges often point to deep fluid collections emerging
from around the spinal hardware. Further understanding of
the time course of the drainage also points to the underlying
pathology. Early postoperative episodes of drainage less than
4–6 weeks after the spine surgery are typically successfully
treated with repeat surgery and soft-tissue reconstruction
with hardware preservation. However, drainage that has been
only partially treated with a small debridement or treated
solely with IV antibiotics only to resurface months later is
more difficult to treat. In fact, a chronic hardware infection
defined as bacteria in association with hardware greater than
6 months after placement is typically not a situation that
plastic surgery can definitively treat without hardware
removal.
Much can be learned with the simple examination of a
patient’s spine X-ray in terms of the existence and location of

256
SECTION II
CHAPTER 11 • Reconstruction of the soft tissues of the back
Fig. 11.1  Lumbar incision draining serous fluid 2 weeks after lumbar fusion.
Fig. 11.2  A subcutaneous hematoma was identified. The deep muscle closure was
opened, and there was no purulence or fluid present. The muscles were reclosed,
and a subatmospheric pressure dressing applied.
hardware. Do the plain films demonstrate hardware immedi­
ately deep to the wound or drainage areas? Plain films of the
spine are also obtained to reveal the length of the construct
when present, degenerative spine disease, and the presence or
absence of fusion. CT and MRI scans are helpful when looking
for fluid collections, pseudomeningoceles, and inflammation
of the soft tissues. A key issue is if fluid collections are above
or below the standard back muscle closure or fascial plane.
If fluid or a hematoma is seen deep to the musculature, a
deep hardware infection is more likely. Unfortunately, the
spinal hardware causes artifacts in both CT and MRI scans,
lowering their ability to demonstrate fluid collections with
high accuracy.
Non-midline back wounds
While midline wounds are either due to pressure sores or
spine procedures, non-midline wounds represent a much
more heterogeneous collection of etiologies and therefore
require a wide range of solutions. Much like acquired wounds
elsewhere in the body, wounds of the non-midline back are
due to poor wound healing after access incisions of the chest
cavity or retroperitoneum, necrotizing infections, or tumor
excision. Traumatic injuries are uncommon. A working
knowledge of the conditions facing the thoracic surgeon is
important in these instances. Thoracotomy incisions some­
times break down in the face of an empyema, persistent air
leaks, radiation, and malnutrition. Desmoid tumors, soft-
tissue sarcomas, and even neglected skin cancers can leave
large defects of the back. For these patients, a more standard
thought process and wound management often suffices. The
wounds are typically flat and often allow skin grafting. When
flaps are needed to cover bone or prosthetic material, the same
muscles that are used to cover the midline spine are often
available and easier to mobilize to the lateral back due to the
lateral placement of their pedicles. The lateral tissues, being
more mobile than the midline tissues, are easier to transpose
for adjacent tissue transfers. Free flaps are facilitated as they
have larger inflow vessels available nearby, such as the axil­
lary artery, than exist for midline reconstructions.
Patient treatment
Local wound care
For superficial relatively painless wounds without exposed
hardware, local wound care with dressings is a relatively
risk-free way to achieve wound closure. Draining midline
incisions tend to have wide areas of undermining along the
length of the closure. These tunnels can typically be opened
in the office with a local injection of anesthesia and finger
fracturing of the incision. A long wound without tunnels with
a saucer shape typically heals faster than small wounds with
a fishbowl shaped internal wound, due to the improved
ability to cleanse the surface of the internal wound. Therefore
tunnels should be opened along old incision lines. All necrotic
tissue should be debrided. All non-absorbable sutures, such
as braided polyester, should be removed. Obtaining local
wound control with wide exposure of the wound is a tried
and tested method for the first step in healing. Patients are
often unaware of the real size of the wound and must be
prepared for the resulting appearance of the surgical site after
opening of the tunnels.
Much depends on the patient’s home situation. Dressings
can be simple wet-to-wet saline dressings, with showering
twice a day to cleanse the surface of the wound. Subatmo­
spheric pressure dressings can be employed, but the tubing is
sometimes difficult to place under back bracing devices (Figs.
11.1–11.3). This does well for obese patients with thick subcu­
taneous tissues, who otherwise tend to dehisce suture lines
due excessive weight and suture pull-through. After a wound
has granulated, if it is painful, then delayed primary closure
or skin grafts can be performed if the wound is sizeable.
However, the risks of these secondary closure procedures
often outweigh the benefits. The subcutaneous tissue stiffens
during the time of obtaining local wound control, and it is
difficult to re-elevate and close without a fairly sizeable
procedure.

257
Patient treatment
operating room. Alternatively, a subatmospheric pressure
dressing may be applied.
For those deep wounds judged amenable to re-closure, a
radical incision and drainage is performed. This should
involve the surgical excision of scarred tissues where possible
to reveal supple soft tissues with pulsatile bleeding. Scar
tissue, though it bleeds, does not bleed in a pulsatile fashion
due to the small size of the vessels that developed during
prior wounding. Pulsatile bleeding at wound margins has
been shown to correlate with wound healing in problematic
incisions, such as distal foot amputations. Tissues with a
pseudobursa should be excised, as this too represents scar
tissue. Tissue that is stiff is unyielding and does not conform
well, and so the tissues should be removed until they are soft
to palpation. Pulsatile irrigation with saline is gentle to tissues
that cannot be removed and cleanses surface bacteria.
An interesting issue is the removal of non-viable elements
such as hardware and bone graft. While plastic surgery teach­
ing emphasizes the removal of all non-vascularized surfaces,
in this case the hardware acts to stabilize the wound. An
orthopedic principle is that the most effective way to fight
infections is to have rigid bone fixation. Therefore hardware
that is well fixed should remain in place in early hardware
infections. This is done both to stabilize the wound for
improved healing, as well as to avoid the surgery involved
with removing and replacing hardware. Long-term mainte­
nance of the hardware as well as clinical and radiographic
evidence of fusion is well documented in patients that were
returned to the operating room for washouts within 6–8
weeks after placement. As stated previously, hardware colo­
nized after 6 months is defined as a chronically infected
foreign body, and salvage of this hardware is much less likely
in the long-term. Another issue is the endogenous and exog­
enous bone graft placed to achieve a fusion. In the absence of
definitive studies, it seems reasonable to remove a non-
incorporated and easy to remove graft, but to leave in place
a graft that has, in any way, begun to stick to the local tissues
due to inosculation. Loose hardware should be removed and
replaced in a secure fashion if deemed necessary.
Wound “shape” is an important concept for reconstruction
of the soft tissues of the back and is especially true for the
depth of the wound. The back has lordotic and kyphotic
regions in the normal condition, and these contours can be
dramatically changed with pathology. These curves make
postoperative positioning difficult when the surgical incision
involves the most prominent portion of the back. The depth
of the procedure performed by spine surgeons is also impor­
tant. For example, a patient with a laminectomy has a deeper
wound than when the spinous processes are intact. Also,
spinal hardware serves to create a local prominence in contra­
distinction to the depth of the surgical dissection. A prime
reason for persistent fluid collections is the 3D space between
a laminectomy and the adjacent vertically oriented bars.
Crosslinks between the bars further prevent soft tissues from
collapsing into the space immediately over the midline.
Finally, laterally placed hardware can be poorly covered by
soft tissue and be the originators of pressure sores. This is
especially common when hardware inserts into the posterior
superior iliac spines for pelvic fusions. Therefore in the treat­
ment of wounds of the spine, the 3D shape should be evalu­
ated and converted as much as possible to a 2D wound.
Prominent hardware should be exchanged for something with
Fig. 11.3  Subatmospheric pressure dressing used to aid in delayed primary
closure of the skin flaps.
Operative debridement
Patients with persistently draining wounds after spine surgery
associated with hardware should be evaluated critically for
an operating room debridement. Secondary indications for a
debridement include unexplained fevers and fluid collections
seen on imaging scans. The patient should be readied for
surgery with large intravenous lines and in a warm operating
room. The large exposed surface areas can allow the patient
to rapidly cool, with the associated coagulopathies and
increased blood loss that occurs. Blood should be available for
a transfusion. Due to the segmental nature of the vascularity,
surgery does not typically expose large blood vessels, but
rather many small ones, and the blood loss is rather constant
throughout the case.
The maneuvers in the operating room are a critical step in
the treatment of patients with postsurgical back wounds. A
thorough incision and drainage should be performed for
patients with unexplained or purulent drainage through their
incision. The entire length of the incision should be opened as
wide as necessary to explore for purulence and drain fluid
collections. The erector spinae muscle closure should be
reopened for cultures and to evaluate for liquefying hemato­
mas. In addition, the surgeon should know at the beginning
of the debridement whether a laminectomy was performed at
the original spine surgery, in order to prevent injury to the
spinal cord and dura during the incision and drainage. If this
is the case, the spine team should be available to assist in
opening the wound.
At this point, the surgeon will need to make a decision as
to the quality of the tissues. Non-purulent benign fluid collec­
tions in the subcutaneous tissues with no purulence deep to
the musculature can be reclosed over drains, or else closed
secondarily with a subatmospheric pressure dressing (see
above, local wound care). Purulent and deep collections
require additional decisions. If the local wound is so purulent
as so preclude an immediate re-closure, then all non-viable
tissue should be debrided and the wound irrigated and left
open for local wound care. This can be done with dressing
changes over several days until the second trip to the

258
SECTION II
CHAPTER 11 • Reconstruction of the soft tissues of the back
Flap closure
Principles
The first step in reconstruction is a timely debridement, as has
been emphasized already. The second step is local wound
control with a radical debridement of all stiff and scarred
tissue. For the reconstruction, the surgeon should never rely
on scar tissue as a positive factor for wound healing. The more
completely the old scar can be excised and replaced with
non-scarred new soft tissues, the better the reconstruction.
Finally, the procedure with the highest chance for success and
with the lowest morbidity should be selected for the patient.
a lower profile (Figs. 11.4–11.7). Incomplete corrections of
spine deformities should be revised in patients to better
re-create the natural contours. The deeper the hole, the more
a flap should be “dropped into” the defect, rather than tissue
simply slid towards the midline. Teamwork between the
spine and the soft-tissue surgeons is often necessary to appro­
priately treat problems of wound shape and contour.
The status of the CSF and dura is also critical for treatment
of certain back wounds. The dura is opened and closed in a
planned fashion in numerous instances, including the treat­
ment of spinal cord malignancies, untethering of the spine for
patients with a history of cord lipomas and spina bifida, and
treatment of pseudomeningoceles. Unplanned tears of the
dura also occur in laminectomy procedures. The low-pressure
CSF leaks and the continuing fluid build up push the soft
tissue away from the leakage site and thereby prevent soft-
tissue collapse of the space. The CSF fluid in fresh postopera­
tive cases can also become infected, and exists in association
with surgical wounds of the back. Treatment of patients with
CSF leaks will be discussed later in this chapter.
Fig. 11.4  Purulent drainage from a back wound 2 weeks after posterior spinal
fusion.
Fig. 11.5  Prominent hardware with exudate between the bars. Crosslinks create a
hardware “cage” to prevent soft tissue from collapsing to the depth of the surgical
dissection.
Fig. 11.6  Hardware revised to be less prominent in conjunction with erector spinae
muscle flaps.
Fig. 11.7  Healed wound in this patient after optimizing both the hardware
architecture and the soft tissues.

259
Patient treatment
of the muscle that then descends laterally towards the more
lateral neck, thoracic, and lumbar areas. It is in this groove
that segmental blood vessels enter the lateral and deep aspects
of the longissimus and iliocostalis muscles. Continuation of
these blood vessels is superficial to the skin and the latissimus
muscle in the thoracolumbar area. While the surgeon is elevat­
ing the skin flaps, the perforators and dorsal sensory nerves
going up to the skin can often be identified and preserved to
maintain skin vascularity. To lessen the chance of marginal
skin perfusion and to limit a future potential seroma cavity,
undermining should not be overdone.
The thoracolumbar fascia is incised, much like the develop­
ment of any standard bipedicled flap, in order to mobilize the
erector spinae muscle and/or overlying skin to the midline.
When the original dissection is superficial to the fascia and
the fascia remains attached to the muscle, this facilitates the
later closure and the fascial release is critical to the movement
of the muscle. Occasionally the fascia remains attached to the
skin during the initial elevation. In this case, muscle mobiliza­
tion is facile, but the skin is more difficult to close in the
midline. Therefore an incision of the fascia along its length
allows the skin to move medially and to provide the excess
for debridement and re-closure. The dissection up until this
point is rather easy and bloodless, but only moves the muscle
an estimated 30% of its potential. Complete mobilization of
the muscle requires a dissection along the deep aspect of the
erector spinae (Fig. 11.9). Again with tension applied to the
tissue with retractors, cautery dissection of the deep and
medial attachments of the erector spinae will mobilize the
muscle and detach it from the lateral aspects of the transverse
processes of the spine. It will by necessity divide the medial
row of blood vessels entering the paraspinous muscles, but
the prior dissection to identify the lateral vessels entering the
muscle will suffice to preserve vascularity. One technique is
to have the fingers of the non-dominant hand in the lateral
groove at the site of the lateral perforators while bluntly elevat­
ing the medial aspect of the muscle with the thumb and index
finger. The medial muscle elevation is a powerful means to
allow the paraspinous muscles to “unfold” like an accordion
to be advanced towards the midline (Figs. 11.10 & 11.11). The
muscle changes shape from being a round muscle mass to
being more elliptical. Advancement of the muscle is a
Central questions to be answered relate to the presence or
absence of a fusion, and the vertebral levels involved.1 When
an instrumented fusion has been performed, the erector
spinae musculature function is no longer necessary, and the
muscles are completely expendable in terms of a reconstruc­
tion. The fusion rods prevent postoperative motion and, when
the erector spinae muscles are re-approximated in the midline,
they tend to stay in place. Spine patients without fusions still
require the function of the erector spinae musculature when
healing is completed for flexion and extension of the spine.
These patients do better with flaps that are “dropped into”
the defect, rather than with erector spinae muscles that are
closed side to side and that would dehisce with back flexion.
Possible flap choices for spine closure
Erector spinae muscle flaps
The erector spinae muscles, also called the paraspinous
muscles,2 are expendable after a previous spine fusion and no
longer functional for spine extension and flexion. The dissec­
tion of these muscles proceeds in a stepwise fashion in order
to move them towards the midline. This flap is appropriate
from the high cervical area to the low lumbar area, but it will
not adequately cover an occipito-spinal fusion, and nor will
it be sufficient for low lumbosacral lumbosacral soft-tissue
coverage. One must be careful in its use when a lateral
approach to the spine has been made, because the muscle can
be transected for access.
First, skin flaps are elevated superficial to the thoracolum­
bar fascia (Fig. 11.8). With a retractor putting tension on the
soft tissues, the granulation tissue is entered using a cautery
and a blunt plane is elevated with finger dissection. The latis­
simus muscle and trapezius muscle should stay attached to
the skin. The dissection is easiest inferior in the lumbar area
where the muscle is round and large, and most confusing
superiorly where the muscle is thinnest and becomes attached
to the undersurface of the trapezius. The erector spinae
muscles have a convex shape, and there is a rounded aspect
Fig. 11.8  Cross-section of lumbar spine area. Skin flaps are elevated to expose the
thoracolumbar fascia and to reach the region of the lateral pedicle entering the
erector spinae muscles. The thoracolumbar fascia is incised to allow a medial
movement of the muscles.
Necrotic tissue
Fascia
Incise fascia
Lateral perforator
Medial perforator
Cutaneous
perforator
Exposed instrumentation
Longissimus
Iliocostalis
Spinalis
Fig. 11.9  A dissection is then performed to release the medial and deep
attachments of the erector spinae muscles to the spine and transverse processes.
The lateral blood supply is approached from the deep aspect of the muscle.
Raise
flaps

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SECTION II
CHAPTER 11 • Reconstruction of the soft tissues of the back
the latissimus can reach the lower lumbar area. An advantage
of the latissimus is being able to be “dropped in” to a hole,
and so it is useful for patients that have not been fused, or for
more lateral defects. The muscle can reliably carry a skin
paddle, and this often helps in the inset of the flap. Caution
should be made for patients that have had thoracotomy inci­
sions, as the muscle is often divided. The latissimus muscle is
a good but second-line flap for the coverage of midline back
wounds. In comparison to the paraspinous flaps, the latissi­
mus flap can only cover a spine wound 10–12 cm in length,
while the erector spinae flaps can cover practically the entire
length of the spine. The dissection required to elevate the
latissimus muscle takes more time and effort than for the
erector spinae. While the morbidity of flap elevation is low,
there is a long-term potential functional loss, especially for
those patients who may need to utilize crutches or wheel­
chairs. The latissimus muscle is a good choice for a radiated
wound of the midback, where the patient has not been fused,
and the erector spinae musculature is in the field of radiation
(Fig. 11.14A–C).
Patients undergoing latissimus flaps should have a thor­
ough debridement of their wounds. The flap dissection is best
begun in an area where the anatomy has not been distorted
by prior incisions. For instance, flaps based on paraspinous
perforators should begin in the axilla with the identification
of the muscle and division of the thoracodorsal pedicle. It is
easier than one would expect to be in the wrong plane and to
divide these small paraspinous perforators when the dissec­
tion is begun in the midline wound.
The orientation and design of the skin paddle should be
done carefully. For flaps based on the thoracodorsal pedicle,
a skin paddle oriented with its long axis perpendicular to the
midline will result with the skin paddle vertically oriented.
Closure of the donor site initially oriented perpendicular to
the spine does not make the midline spine any more difficult
to close due to added tension. Another helpful skin paddle is
a V-Y design (Fig. 11.15A–D) with the latissimus muscle and
overlying skin advanced medially along the submuscular
loose areolar plane. This flap can be re-elevated and moved a
second time if necessary.
Trapezius muscle flap
The trapezius flap is useful for high cervical wounds because
the paraspinous musculature is of limited mobility and size
different process from simply releasing the thoracolumbar
fascia and “rolling” the dorsal aspect of the muscle towards
the midline.
With the skin and muscle flaps so created, it is now quite
easy to distinguish stiff and inflamed tissue from more normal
soft tissue. The medial aspect of the skin, subcutaneous tissue,
and paraspinous muscles is sharply debrided. The muscles
are brought together in the midline (Fig. 11.12), and any extra
tissue can be imbricated to help fold the soft tissue into crev­
ices between vertically oriented hardware bars (Fig. 11.13A–F).
Drains are left both deep and superficial to the erector spinae
closure and are kept until the drainage is minimal. When the
closure of the erector spinae muscles is of good quality, there
is no need for a second overlying muscle flap using the tra­
pezius or the latissimus muscles.
Latissimus muscle or myocutaneous flap
The latissimus muscle is a well-known and understood flap.3
Based on the thoracodorsal pedicle, the muscle can be moved
superiorly up to the level of the top of the scapula. Based on
its minor perforators that also supply the paraspinous muscles,
Fig. 11.10  Cadaver dissection of the erector spinae muscles at the lumbar level.
Fig. 11.11  Release and medial movement of the muscles.
Fig. 11.12  The muscles are approximated in the midline. The erector spinae
muscles unfurl, changing shape from circular to elliptical.
Extend
flaps

261
Patient treatment
however, these are morbid in terms of shoulder stabilization.
The occipital artery supplies the superior aspect of the flap
and can be use to cover small cervical wounds.
The most common trapezius flap elevation is based upon
the main pedicle supplied by the branches of the transverse
cervical artery. The dissection begins with identification of the
distal and inferior triangular aspect of the trapezius where it
at that level. In addition, the trapezius flap may have a vari­
able blood supply. The superficial branch of the transverse
cervical artery (superficial cervical artery (SCA)) and/or the
deep branch of the transverse cervical artery (dorsal scapular
artery (DSA)) are the main pain pedicles. Segmental thoracic
perforators can supply a “turnover” trapezius flap, analogous
to what is more routinely done for the pectoralis muscle;
Fig. 11.13  (A) Patient with a long thoracolumbar fusion with drainage 3 weeks after a posterior spinal fusion. Note the erythema of the staple line. (B) Complete opening
of the superficial and deep tissues reveals an infected fluid collection surrounding the hardware. A crossbar is visible. (C) The wound is radically debrided to reveal the
entire spinal hardware construct. The hardware seems solidly fixed to the bone. (D) Dissection deep to the thoracolumbar fascia to the lateral border of the erector spinae
muscles. A large nerve traveling through the muscle to the overlying skin is spared. (E) Dissection on the deep aspect of the erector spinae muscles to the level of the
lateral perforators. (F) Erector spinae muscles closed in the midline.
A
B
C
D
E
F

262
SECTION II
CHAPTER 11 • Reconstruction of the soft tissues of the back
Fig. 11.14  (A) A 26-year-old man had a recurrent desmoid tumor removed from his thoracic spine area. There is exposure of the spinous processes. There is no hardware
present. (B) A skin paddle slightly less wide than the defect and oriented at a right angle to the long axis of the wound is drawn out. (C) Final inset of the Latissimus
Myocutaneous Flap. The flap donor site is oriented perpendicular to the long axis of the defect so that closure of the donor site will not make the recipient site more difficult
to close.
A
B
C
A
B
Fig. 11.15  (A) A 57-year-old female with a complex history of back surgery, revisions, and flaps. She has already had erector spinae flaps and a left latissimus flap for
closure. She presents with a new area of exposed hardware due to a pressure sore. She is not yet fused, and removal of the hardware is not possible. (B) The area of the
pressure sore is at a kyphotic area of the lumbosacral spine. The optimal way to treat this condition is to correct the spinal deformity at the same time as improving the soft
tissues. (C) A myocutaneous latissimus flap with the skin paddle advanced in V-Y fashion is elevated after debridement. (D) Closed incisions. As might be anticipated,
several months later she presented with a new pressure sore at the same spot. She subsequently underwent successful correction of the spinal deformity and a
readvancement of the V-Y flap for coverage.
C
D

263
Patient treatment
dissection is easy. The main pedicle is encountered and, with
this vessel under direct view, the lateral aspect of the muscle
is divided. Movement of the flap is tested, and the lateral
muscle division is extended if greater mobility is required for
wound coverage. The higher the dissection continues, the
higher the morbidity due to shoulder drop but the greater the
arc of rotation of the muscle.
Because of its sizeable donor site morbidity for the shoul­
der, the indication for the trapezius flap is in a non-fused
patient with a radiated deep back wound where the erector
spinae have been involved in the field of radiation. As the
muscle is typically turned 90° for inset, the length of midline
coverage by the trapezius is usually short, and either a com­
bination of two trapezius flaps or else the trapezius flap with
erector spinae flaps should be planned for long wounds.
just overlaps the latissimus muscle, because the crossing
muscle fiber directions of the two muscles are quite distinct
in this area. The main branch enters the muscle approximately
7–8 cm lateral to the midline and at the level of the spinous
process of C7 on its deep aspect.4 A skin paddle overlying the
muscle can be taken to help with the inset. The more cephalad
and larger the skin paddle, the better the reliability (Fig.
11.16A–D), as the skin overlying the caudal trapezius is often
supplied by the angular branch of the thoracodorsal system.
Further cephalad and lateral to the elevated skin paddle, the
upper back skin is elevated off the trapezius. The deep dis­
section is then performed, with the muscle elevated off the
paraspinous musculature and the rhomboids, taking care to
elevate the pedicle. The medial attachments are thickest, and
then a plane between the two muscle groups is reached where
Fig. 11.16  (A) A 60-year-old patient with painful metastatic neuroendocrine tumors to the cervical spine area. The tumors have been radiated, precluding closure with skin
grafts. (B) Wound after tumor excision. (C) Incised myocutaneous trapezius flap. The skin paddle was oriented at the inferior aspect of the muscle. (D) Trapezius flap during
inset with 180° twist. The superficial dorsal scapular artery was not included with this flap, resulting in mild hypoperfusion of the skin paddle. The donor site was closed in
the vertical midline.
A
B
C
D

264
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CHAPTER 11 • Reconstruction of the soft tissues of the back
postoperative placement on a pressure relief air fluidized bed
will allow the patient to lie directly on the flap without causing
a pressure injury to the tissues. It is suspected that compres­
sion of the flap directly onto the wound bed has beneficial
effects in helping the wound to seal.
Omentum
The primary criterion for using a pedicled omental flap includes
scarred, irradiated, divided, and otherwise unusable back
musculature suitable for local flap transfer in a patient in need
of soft-tissue coverage of thoracolumbar spinal instrumenta­
tion (Fig. 11.18A–C).7 The second criterion includes extremely
deep wounds, such as those of patients with coverage needs of
both anterior and posterior instrumentation, and for patients
in whom the abdominal cavity is already entered for exposure.
Absolute contraindications to the use of a pedicled omental
flap include a history of intra-abdominal malignancy and
a previously resected omentum. Relative contraindications
include morbid obesity and the potential for intra-abdominal
adhesions from previous laparotomies. The zone of coverage
for an omental flap is from the lumbosacral recess inferiorly
up to the level of the midscapula superiorly.
Close coordination is required between the spine and the
plastic surgery teams. Typically, a posterior spinal instrumen­
tation for stabilization is performed before the omental flap is
harvested. The abdomen is entered either through an upper
midline incision, a Kocher, or a right paramedian incision.
After entering the peritoneal cavity and identifying the
omentum, dissection begins by liberating the omentum and
transverse colon such that they can be lifted out of the
abdominal cavity. Traction on the tissues will aid in demon­
strating the fusion plane between the omentum and the
transverse mesocolon. The omentum can be dissected from its
attachments to the transverse colon with a minimum of sharp
dissection; blunt dissection is adequate. The dissection, if
performed in the correct planes, should be avascular and not
require the ligation of vessels. It is critical to not confuse the
transverse colon blood supply with an omental vessel. Inclu­
sion of the middle colic vessels with the flap may potentially
devascularize the colon. Performed correctly, the entire colon
from the hepatic flexure to the splenic flexure can be mobilized
away from the omentum and stomach. Attention to detail
should be made when putting traction on the left side of
the omentum. Adhesions to the spleen can cause bleeding
from the splenic capsule, and in the worst case require a
splenectomy.
Next, a decision is made regarding whether to base the flap
on the right or left gastroepiploic artery. The right-sided vessel
is usually larger; the left is used when the spine exposure
includes a left flank incision. The omentum is mobilized off
the stomach by taking down the short gastric vessels. One
should not attempt to travel great distances for each tie, as
this tends to shorten the reach of the flap. The gastroepiploic
vessel courses 1–2 cm from the edge of the stomach and
should not be encroached by the ties. The stomach should be
decompressed with a nasogastric tube, and this tube should
remain in place for several days so that gastric distension will
not cause any of the vessel ligatures on the greater curve to
pull off. After compete mobilization of the gastroepiploic
vessel off the stomach, it can be followed to the area where it
emerges as the gastroduodenal artery (a branch off the hepatic
Superior gluteal artery
The superior gluteal artery flap technique is the most chal­
lenging of all of the reconstructive soft-tissue procedures for
the spine, but it is a necessary and useful procedure.5 The flap
should not be attempted unless the surgeon has had signifi­
cant experience with perforator flaps and the surgical man­
agement of sacral pressure sores. A line is drawn between
the superior-lateral aspect of the sacrum and the posterior-
superior iliac spine. From a point that bisects this line, a
second line is drawn toward the greater trochanter. This
second line represents the path of the superior gluteal artery
and is the long axis of the flap. A skin paddle is designed that
encompasses the Doppler signal of the perforator of the
superior gluteal artery and is oriented laterally towards the
greater trochanter (Fig. 11.17A–F). This will be the lateral most
tissue to be captured by the superior gluteal artery perforator.6
To improve the reliability of the tissue, a strip of gluteus
muscle oriented underneath the skin paddle can be taken
along with the perforator. This is a different orientation than
the skin paddle used for closure of sacral pressure sores,
where extra skin is taken medial to the Doppler signal. The
superior border of the skin is incised, and the skin flap elevated
until the perforator from the superior gluteal artery is seen to
be entering the skin paddle. Medial to this, the gluteus muscle
is split to aid in the dissection of the pedicle. These patients
typically have some motor dysfunction, and their gluteus
muscles are thin and atrophic. With the pedicle under full
view, the remainder of the skin paddle can be incised and the
flap dissection completed. If there is difficulty with identifica­
tion of the SGA perforator, additional muscle should be ele­
vated with the skin paddle, or a decision made to dissect the
other buttock. Medially, any muscle along the pedicle will
resist the 180° flip required of the pedicle for the flap to reach
the midline. Muscle found around the pedicle that impedes
this 180° turn should be excised so that there is no tension on
the flap to reach the lumbosacral spine. The skin paddle is
de-epithelialized and will be able to cover the dura. The donor
and recipient sites are closed over drains. Avoidance of a
three-way incision with a small skin bridge and tunneling of
the flap under this area also assists in the final closure. Alter­
natively, the flap may be transferred as a propeller flap with
the skin paddle designed lateral to the perforator and rotated
180° medially into the defect. Given the difficulty of this flap
and its perforator in general, caution is advised with the
propeller design.
The buttocks are an area not typically reached by the spine
surgeons. Both buttocks should be prepped into the field, in
case there is an injury to the pedicle. In patients with buttock
weakness preoperatively, the stronger side should be used.
Caution should be observed with regard to patients who are
markedly obese, and those with prior pressure sore proce­
dures. A complete pressure relief bed is necessary for 10–14
days after the procedure to prevent pressure on the pedicle as
it runs from the lateral sacrum towards the midline. Drains
are often required for several weeks in the donor site. The
procedure does not cause much pain or dysfunction
long-term.
Closed suction drainage between the base of the wound
and the flap should be maintained until less than 30 cc a day
emerges in the bulbs. The more drains, the better, and for large
procedures even 4–6 bulbs have been required. Furthermore,

265
Patient treatment
A
B
C
D
E
F
Fig. 11.17  (A) Radiograph of low lumbar fusion of a patient with drainage 3 weeks after spinal fusion. (B) Intraoperative view after debridement of fusion site. (C) Incised
skin paddle for left superior gluteal artery perforator (SGAP) flap. The staple marks the audible Doppler signal of the SGAP perforator to the skin. (D) Vascular pedicle to the
superior gluteal artery perforator flap. Muscle around the pedicle must be minimized to allow for a facile flip of the flap to the midline. (E) The skin paddle is
de-epithelialized and placed to fill the lumbosacral recess. (F) Closed incisions.

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CHAPTER 11 • Reconstruction of the soft tissues of the back
The 12th rib is identified by palpation after elevating the latis­
simus muscle and skin off the rib cage. Lateral to the paraspi­
nous muscles, the 12th rib is excised, the periosteum opened,
and the omental flap will be immediately identifiable (Fig.
11.19A & B). The only confusion would be if Gerota’s fascia
were entered and the perirenal fat mistaken for the omental
flap. The integrity of blood flow through the pedicle is assessed
with a Doppler probe. Multiple drains are used in the
closure in order to avoid seroma formation and problematic
fluid collections. When skin is not available for coverage
of the omentum, a negative pressure suction dressing is
applied immediately onto the flap and a delayed skin graft
performed.
Adjacent tissue transfers/perforator flaps
Adjacent tissue transfers without a defined blood supply and
perforator flaps are two ends of a spectrum of possible recon­
structions of the soft tissues of the back. In adjacent tissue
transfers such as V-Y, transposition, and rotation flaps, the
thick soft tissues of the back will create large dog ears, and
artery/celiac plexus just inferior to the pylorus and still
superior to the transverse colon mesentery). The artery and
vein should not be skeletonized, so that the surrounding soft
tissue can help prevent unexpected tension on the vessels
during the tunneling process. Sutures can also be used in this
area to prevent tension and thrombosis of the pedicle.
The passage of the omentum toward the spinal column
requires creativity and knowledge of anatomy of the gastro­
duodenal artery and its relationship to the attachments of the
colon to the retroperitoneum. The most straightforward
means to tunnel the omentum to the spine is to mobilize the
hepatic flexure and right colon toward the midline. This is an
avascular plane, and the mobilization of the colon is greatly
simplified by the prior elevation of the omentum off the colon.
The line of lateral peritoneal reflection (the white line of Toldt)
is incised, exposing the retroperitoneum. The omental flap is
then positioned behind the colon in the right paracolic gutter.
The right kidney and Gerota’s fascia is mobilized medially,
and the omentum is “parked” on top of the 12th rib, which is
confirmed by palpation. The abdomen is then closed in stan­
dard fashion and the patient re-prepped in the prone position.
Fig. 11.18  Diagram of a pedicled omental flap for coverage of the spine.
A
B
C
Right gastroepiploic artery
Omental flap is passed behind hepatic flexure of colon
Left gastroepiploic
artery divided
Gastric branches
divided
Greater omentum
Right kidney
12th rib

267
Patient treatment
External oblique flap
Patients with huge lower lateral thoracic and lumbar wounds
can be closed with pedicled external oblique turnover flaps.11
These patients will have large radiated wounds where the
remaining soft tissues could not be expected to accept a skin
graft, or where there was a prosthetic material used for recon­
struction of the posterior abdominal wall. These large, flat
flaps can be thought of as an interface to help with healing of
skin grafts to the wound bed. Done either unilaterally or
bilaterally, the muscle is exposed with wide elevation of the
abdominal skin, done through an oblique incision paralleling
the dermatomes. Then, the insertion of the muscle is divided,
just as it fuses with the anterior rectus fascia. Much like a
components separation procedure, the external oblique is
bluntly elevated towards the posterior axillary line off the
internal oblique, to the point where segmental vessels enter
the muscle. The muscle is flipped on itself 180° to cover the
defect and to subsequently be skin grafted. When the flap is
done unilaterally, the corresponding muscle imbalance of
the anterior abdomen may cause an unusual contour of the
abdominal wall.
Tissue expansion
Tissue expansion can be preferable to other solutions for
reconstruction of the soft tissues of the back in certain
instances. Those situations are more for pediatric cases than
for adults and include the closure of wounds for giant con­
genital nevi excisions. Rarely, the soft-tissue defects in children
before spine surgery will be amenable to a planned prior
tissue expansion. The indications for tissue expansion are
scarred local tissues, laterally displaced muscles, and a need
for spinal instrumentation (Fig. 11.20A–D). The largest
expanders possible should be placed immediately adjacent to
the area that will require coverage, and the long axis of the
expander should be oriented in a superior-inferior direction
to allow for a medial sliding of the expanded tissue with a
minimum of back-cuts and transposition flaps. Incisions for
placement should be made radially to the closest edge of the
expander to decrease the chance of extrusion of the implant
through this newly placed scar. Ports should be placed over
bony prominences to facilitate their palpability.
Free flap coverage of the back
Soft tissues
The erector spinae muscles are able to cover practically the
length of the spine. However, patients exist that are not can­
didates for this procedure. Scarred erector spinae muscles
from previous advancements or neuromuscular conditions
such as polio cannot be moved to the midline. Eector spinae
flaps are also not possible in patients who have received wide
field radiation. One can feel on preoperative examination of
these patients a woody non-yielding of the soft tissues even
6 cm from the midline. These situations are best treated with
free flaps, especially when the defect is longer than 12 cm,
preventing the use of a transposition of the latissimus or
trapezius muscle (and when the omental flap is not possible).
The difficulty with free flap coverage of the spine is finding a
suitable donor vessel.12 Possibilities include the superior
gluteal artery pedicle and intercostal vessels. A long saphe­
nous vein graft anastomosed to the common femoral artery
donor sites will typically need to be covered with skin grafts.
Keystone-style flaps are particularly useful advancement
flaps of the back. A broad base to a keystone ensures incorpo­
ration of perforators; however, mobility requires release of the
deep fascia. Perforator flaps, on the other hand, will allow
transposition and insets in a more facile manner, and are
especially useful in the iliolumbar and scapular areas.8–10 Typi­
cally perforators of the thoracic and lumbar areas are located
within 10 cm of the midline and will often exist lateral to the
spinal erector muscles. However, the stresses on the soft
tissues of the back with movement in and out of bed and with
position changes will make the delicate nature of perforator
flaps difficult to protect. In addition, these rearrangements of
skin will do better with flat lateral wounds, rather than poten­
tial 3D wounds of the midline spine.
Fig. 11.19  (A) A paraplegic patient had an anterior and posterior fusion, all from
the posterior approach. The spinal cord was tied off for access anteriorly. A deep
infected fluid collection resulted, with the anterior and posterior hardware acting as
a solid “cage”. It was anticipated that flaps from the back would not be able to fill
this deep hole. (B) The omentum has been harvested from an anterior approach
and parked under the 12th rib. From the back, the 12th rib was excised and the
omentum pulled posteriorly. The flap successfully filled the 3D space created by
the hardware “cage”.
A
B

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CHAPTER 11 • Reconstruction of the soft tissues of the back
and with good results. Certain patient subpopulations exist
where vascularized bone is preferable. In these patients, more
rapid incorporation of the bone graft due to its viable osteo­
cytes reduces the chance for construct failure and infection. It
is difficult to define exactly who should receive vascularized
bone flaps, as the success rates of non-vascularized autograft
and allograft are high. Fusions longer than three vertebral
bodies in length, previous failed reconstructions, a history of
radiation, esophagocutaneous fistula onto the fusion site, and
active osteomyelitis may all be indications for a free fibula flap
to the anterior spinal column.14,15 In the cervical esophagus,
after stabilization of the posterior spine, the anterior construct
is readied using a bone template of extra fibula taken from the
flap. The flap is made ischemic after being preshaped on the
leg according to the template and then placed into a trough
created within the anterior vertebral bodies to accept the
fibula flap. The trough must be slightly wider than the bone
flap so that there will be no shear force or compression of the
can provide both inflow and outflow when divided for a
lower trunk defect, and a long cephalic vein graft tied to the
external carotid can bring inflow for an upper trunk flap. A
latissimus dorsi flap can be harvested in the prone position
with proper prepping and draping (Fig. 11.21A–C).13 Free
flaps are for defects that are both long and wide. Multiple
position changes of the patient are required, and the long vein
grafts when used are prone to twists and spasm. Some allow
the vein graft loop to “mature” for a period of time to ensure
that spasm will not cause a flap loss. While possible, this
makes the final anastomosis to the arterial pedicle more dif­
ficult due to size mismatches, adds a separate operative pro­
cedure, and is generally not necessary.
Bone
The vertebral bodies of the spine are typically reconstructed
with cages and bone grafts when corpectomies are performed,
A
B
Fig. 11.20  (A) Lateral photo of a young child with a significant congenital spine defect. (B) Previous attempts at correction have produced numerous scars. A well-cared-
for pressure sore is at the apex of the deformity. (C) Bilateral subcutaneous tissue expanders placed on the posterior trunk. (D) Healed incision after spine correction and
advancement flap closure with expanded skin flaps.
C
D

269
Patient treatment
Fig. 11.21  (A) A 73-year-old man with a history of polio who has had a hardware instrumentation and
prophylactic closure of his spinal fusion with erector spinae flaps. Due to the fibrotic nature of his muscles,
an infected fluid collection developed. This situation was remedied with a free flap to the back. He is in the
lateral decubitus position at the time of his first debridement. (B) A myocutaneous latissimus flap is elevated
and anastomosed to a long saphenous vein graft loop with inflow from the right common femoral artery and
outflow through the saphenous vein to the common femoral vein. The skin paddle facilitates a solid inset of
the flap. (C) Long-term result.
A
B
C
pedicle running along the side of the bone. Narrowing of the
diameter of the fibula is often necessary. The bone is stabilized
with kick plates superiorly and inferiorly, and vascular anas­
tomosis is then performed to the external carotid or the
transverse cervical vessels. The prior spine stabilization makes
the neck, by definition, less mobile, and therefore the vascular
repairs may be best done with loop magnification. In the
thoracic area, vascular inflow is either end to end from a
segmental lumbar vessel or off a saphenous vein patch of the
aorta fashioned by vascular surgery.
Vascularized bone reconstruction of the spine
A straightforward means of bringing vascularized bone to the
anterior aspect of the thoracic spine is with a pedicled rib flap.
For patients undergoing both anterior and posterior fusion of
the spine with an associated thoracotomy for access, a pedicled
rib based on its intercostal neurovascular bundle can be har­
vested. Unlike vascularized fibula flaps, the vascularized rib
brings viable osteocytes but no structural support to the spine.
The rib graft can either be placed next to or within
the metal cage that is used for structural replacement of the
vertebral body.16 The rib area near the costal cartilage is the
actual bone that is used for the flap. The curved rib along the
axillary line is excised, creating the neurovascular pedicle that
is necessary for the rib flap to be positioned without tension.
Flap selection by region
Cervical region
The cervical spine area is more often instrumented from the
anterior rather than the posterior approach. Wounds of the
anterior cervical spine are uncommon, and when they occur
can be in association with esophageal injuries. Wounds of the
posterior cervical spine are more common. Etiologies of these
wounds include pure soft-tissue defects without involvement
of the spine, pressure sores, complications after laminectomy
for radiated cancer excisions, and complications after place­
ment of hardware for fusions. Soft-tissue defects without spine
involvement are treated depending on the size and location
of the defect either with skin grafts or adjacent tissue transfers.
Pressure sores tend to be treated conservatively with pressure
relief. Laminectomies are performed for spinal cord pressure
from metastases, and the wound beds are typically radiated.

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CHAPTER 11 • Reconstruction of the soft tissues of the back
Fig. 11.22  This 50-year-old female has a recurrent fluid collection in the low
lumbar spine after fusion. The initial plan is to perform a superior gluteal artery
flap.
Fig. 11.23  The latissimus muscle can reach the lower lumbar spine, but only with
extensive dissection, and the muscle that reaches the area is small and unable to
fill the space well.
Trapezius pedicled flaps are the preferred treatment for these
patients, as the erector spinae muscles are stiff and immobile
from the cancer treatment. The more laterally placed trapezius
muscles are typically pliable and non-radiated, allowing them
to be mobilized and “dropped in” to the defect. The erector
spinae muscles also tend to dehisce in the midline from neck
flexion in the absence of spinal hardware. Complications after
placement of hardware have been discussed earlier. In most
cases, the erector spinae muscles can be mobilized to the
midline with both superficial and deep releases. The cervical
muscles are thin, located underneath the trapezius muscle,
and become smaller as they insert on the occiput. In the cervi­
cal region, the trapezius and skin should be elevated as one
unit to then identify the paraspinous muscles, and these
planes can be confusing. Beginning inferiorly where the tra­
pezius has a unique triangular shape and then proceeding
superiorly is a technique for being in the correct plane.
Thoracic region
Like the cervical region, defects of the thoracic area include
pure soft-tissue defects without involvement of the spine,
pressure sores, complications after laminectomy for radiated
cancer excisions, and complications after placement of hard­
ware for fusions. Soft-tissue defects without spine involve­
ment are treated depending on the size and location of the
defect either with skin grafts or adjacent tissue transfers. The
scapular and parascapular flaps can be helpful in closing
some of these soft-tissue defects without spine involvement.
In these cases, the donor site should be oriented perpendicular
to the long axis of the wound to facilitate closure.17 Alterna­
tively, when closure of the donor site aids in the closure of the
wound, the flap can be half the width of the wound and a
pure 180° flip of the flap based on an underlying perforator
will allow closure of both the wound and the donor site.
Pressure sores tend to be treated conservatively with pressure
relief. However, in some instances, a true spine correction for
deformity is what is required to definitely treat the wound.
Laminectomies are performed for spinal cord pressure from
metastases, and the wound beds are typically radiated. Latis­
simus flaps based on the paraspinous perforators are ideal for
allowing the muscle to be “dropped in” these defects, and
thereby not manipulating the radiated and stiff erector spinae
muscles. Myocutaneous latissimus flaps have easier insets
with the overlying skin paddle sewn to the adjacent midline
skin of the back.
Wounds of the thoracic back after spine surgery and place­
ment of hardware are best treated with erector spinae flaps.
There is no need for a “double muscle” closure with further
mobilization of a latissimus flap if the erector spinae muscles
come together normally. Rarely, the 3D shape of the wound is
sizeable and requires modification of the spinal hardware.
Even more rarely, after transection of the spine or corpectomy,
the wound will be extremely deep. In these circumstances, the
pedicled omental flap is ideal for filling the defect and helping
achieve closure. These unusual circumstances often require
either erector spinae flaps or latissimus flaps to aid in the
closure.
Lumbar region
The high lumbar area is the optimal area for re-closure with
erector spinae flaps. The muscles are largest in this area and
exist in a lordotic area of the back that is protected from pres­
sure. The lateral perforators are easy to visualize as they enter
the muscle. The only difficulty in this area is management of
the often-thick subcutaneous tissue. Seromas can be problem­
atic after elevation of the skin in order to mobilize the underly­
ing muscle. Allowing the drains to stay for a prolonged period
of time, as well as quilting sutures from the subcutaneous
tissue down to the muscle bed, is helpful in preventing this
postoperative aggravation. Other flaps are also possible for the
lumbar area. Turnover latissimus flaps can reach this area, but
only with some difficulty (Figs. 11.22 & 11.23). Sliding of myo­
cutaneous latissimus flaps elevated from the lower lumbar
area and transposed medially provides thick coverage of the
spine, but only at the expense of a skin grafted donor site.18 The
omentum will also reach this area with some ease.
The inferior region of the lumbar spine is best covered with
superior gluteal artery based flaps as described below. Often,

271
Special clinical situations
a gluteal flap will be combined with erector spinae flaps for
coverage of a longer lumbar and lumbosacral defect. Another
problem area is the posterior superior iliac spine, which is a
site where bone grafts are harvested. Fluid collections, hema­
tomas, and scar tissues develop from procedures on this area.
Lateral dissection of the erector spinae muscles can be made
confusing and difficult in this area that has had prior surgical
exploration for bone grafts.
Lumbosacral region
The recess between the sacrum and the inferior aspect of the
spine is best filled with a superior gluteal artery based flap.
The erector spinae muscles are thin and laterally displaced in
this area, precluding their use. Omental flaps require position
changes in the operating room and bowel dissection. Random
pattern skin flaps of the lumbar tissue or perforator based
flaps are possible but are difficult to inset and control in an
area that is subjected to high shear forces with position
changes. Finally, while latissimus flaps can be mobilized to
reach this area, there are many wounds that are simply too
big for the latissimus muscle to reach and fill the entire cavity
(Fig. 11.24).
Patients undergoing a full sacrectomy for tumors can
undergo bilateral gluteus myocutaneous flaps if the superior
and/or inferior gluteal arteries are preserved during the
sacrectomy. For these patients, the plastic surgery team can
mobilize the gluteus maximus off the sacrum, exposing the
pedicles to the muscle and the sacrotuberous ligaments. The
spine surgeon can then perform the tumor excision. Closure
of the gluteus muscles in the midline, as in the case of a
pressure sore, can be done with V-Y advancement of the skin
paddles if necessary. Finally, for low rectal tumors with
invasion into the sacrum, a transabdominal flap based on
the inferior epigastric artery is feasible. The oblique rectus
abdominis musculocutaneous (ORAM) flap, using a skin
paddle based in an oblique direction off the periumbilical
perforators and using only the lower aspect of the rectus
muscle, can easily bring non-radiated skin to the lumbosacral
Fig. 11.24  The latissimus flap can be mobilized to reach this wound. However, the
wound is large and it would be difficult for the latissimus flap to reach and fill this
wound. This wound is better treated with a superior gluteal artery perforator flap for
the lumbosacral recess, and bilateral erector spinae flaps for the lumbar area.
area.19 The vertical rectus abdominis myocutaneous (VRAM)
is another common design to achieve wound closure, but
requires the harvest of more muscle.20 These abdominal flaps
need to be harvested in the supine position and parked adja­
cent to the sacrum. After sacrectomy, the flap can be retrieved
from the posterior approach and inset.
For the majority of patients with lumbosacral defects, the
tissue near the trochanter can be elevated with the blood
vessels in continuity with the superior gluteal artery for soft-
tissue coverage (Fig. 11.25A–D). This can be done as a pure
perforator flap, or else with a strip of gluteus muscle under
the skin paddle (which is de-epithelialized). As the flap is
typically flipped 180°, the skin paddle will rest over the dura.
To re-emphasize, this is a different design from the superior
gluteal artery perforator (SGAP) flaps that are for sacral pres­
sure sores. The proximal aspect of the pedicle must be dis­
sected free of any muscle, as the muscle will obstruct the
pedicle from being flipped towards the midline. Patients with
longer wounds extending to the midlumbar area may need
additional mobilization of the erector spinae muscles to the
midline.
Patients undergoing this procedure do not complain of
significant buttock morbidity after flap harvesting. Most of
these patients have chronic lower spine dysfunction and
buttock weakness before surgery, and so they are not used to
robust gluteus maximus muscles for ambulation. In fact, the
muscle atrophy typically present facilitates dissection. If the
patients have any elements of motor strength imbalance, then
the “stronger” side should be used for the flap elevation as
that side has more to give if additional weakness were to
develop.
Wounds of the lateral back
Soft-tissue reconstruction of the lateral back has certain special
characteristics. In the thoracic area, if the rib cage is intact,
most wounds are closeable with local wound care, latissimus
flaps, parascapular/scapular flaps, serratus flaps, or posterior
movement of a perforator flap from tissues in the anterior
axillary line area. If the ribs are involved, then a decision
about possible reconstitution of the pleural line needs to be
made. Most authorities recommend that three or more ribs are
reconstructed with a prosthetic patch, and this patch then
needs to be covered with soft tissues. However, when the rib
defect is located under the scapula, then the scapula serves to
protect and camouflage any defect and larger rib resections
are tolerated.
The lateral lumbar area in adults is protected typically by
its lordotic shape, and the only structure that needs to be
reconstructed is the posterior aspect of the abdominal wall.
All other wounds can be closed with local wound care, skin
grafts, or transfer of the latissimus muscle. In rare instances,
which are radiated and require vascularized soft tissue for
closure, an external oblique pedicled flap is possible.
Special clinical situations
Prophylactic closure of back incisions
Spine teams have noted the efficacy of muscle flap closure for
open spine wounds, and this has led to the introduction of