Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 76-year-old man underwent resection of a right flank sarcoma.
An external oblique myocutaneous flap was harvested based on
intercostal vessels and pedicled to reconstruct the defect. The
superficial inferior epigastric vessels were isolated and brought
with the flap in case there was a need to transfer as a free flap
or if there was congestion of the flap. These vessels were not
used. At the donor site the upper and lower abdominal skin flaps
were elevated and the tissues were brought together primarily.
The patient healed and was able to return to normal activities.
CASE 36.3  Large Flank Defect Reconstructed with a Pedicled External Oblique
Myocutaneous Flap
Figure 36.8  (A) Preoperative view of the patient showing the mass in the right flank. (B) Intraoperative view showing a 15 × 12 cm defect
in the right flank. Part of the defect will be closed primarily. (C) External oblique flap designed on the lower abdomen based on the inter­
costal vessels. (D) Flap margins are incised; the superficial inferior epigastric artery (if present) and vein can be harvested with the flap.
In this case the artery and vein were present and were preserved in case there was a need to augment inflow or outflow to the flap or if
this flap were to be converted to a free flap. (E) The flap is elevated from medial to lateral under the external oblique and over the internal
oblique muscle. (F,G) A tunnel is created to the defect and the flap is transferred. (H) Patient at 1 year following the reconstruction.
A
B
C
D
E
F
G
H
(Case courtesy of Samir Mardini.)

CHAPTER 36 — Omentum, Superior Epigastric, a nd External/Internal Oblique Flaps
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7. Kuzbari R, Worseg A, Burggasser G, et al. The external oblique
muscle free flap. Plast Reconstr Surg 1997;99(5):1338–45.
8. Ramasastry SS, Granick MS, Futrell JW. Clinical anatomy of the
internal oblique muscle. J Reconstr Microsurg 1986;2(2):117–22.
9. Upton J, Mulliken JB, Hicks PD, et al. Restoration of facial contour
using free vascularized omental transfer. Plast Reconstr Surg 1980;
66(4):560–9.
10. Jurkiewicz MJ, Nahai F. The omentum: its use as a free vascularized
graft for reconstruction of the head and neck. Ann Surg 1982;
195(6):756–65.
11. Gallagher J, Webb A, Ilankovan V. Gastro-omental free flaps in oral
and oropharyngeal reconstruction: surgical anatomy, complica­
tions, outcomes. Br J Oral Maxillofac Surg 2002;40(1):32–6.
12. Vyas RM, Prsic A, Orgill DP. Transdiaphragmatic omental harvest.
Plast Reconstr Surg 2013;131(3):544–52.
13. Reade CC, Meadows WM, Bower CE, et al. Laparoscopic omental
harvest for flap coverage in complex mediastinitis. Am Surg 2003;
69(12):1072–6.
14. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruc­
tion with the omentum: indications, complications, and results.
Ann Plast Surg 2001;46(3):242–9.
15. López-Monjardin H, de-la Peña-Salcedo A, Mendoza-Muñoz M,
et al. Omentum flap versus pectoralis major flap in the treatment
of mediastinitis. Plast Reconstr Surg 1998;101(6):1481–5.
16. Maloney CT, Wages D, Upton J, et al. Free omental tissue transfer
for extremity coverage and revascularization. Plast Reconstr Surg
2003;111(6):1899–904.
17. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric
system. Plast Reconstr Surg 1988;82(5):815–32.
18. Schmidt M, Tinhofer I, Duscher D, et al. Perforasomes of the
upper abdomen: an anatomical study. J Plast Reconstr Aesthet Surg
2014;67(1):42–7.
19. Hamdi M, Van Landuyt K, Ulens S, et al. Clinical applications of
the superior epigastric artery perforator (SEAP) flap: anatomical
studies and preoperative perforator mapping with multidetector
CT. J Plast Reconstr Aesthet Surg 2009;62(9):1127–34.
20. Wettstein R, Weiser M, Schaefer DJ, et al. Superior epigastric artery
perforator flap for sternal osteomyelitis defect reconstruction.
J Plast Reconstr Aesthet Surg 2014;67(5):634–9.
21. Szychta P, Anderson WD. Islanded pedicled superior epigastric
artery perforator flaps for bilateral breast augmentation with mas­
topexy after massive weight loss. J Plast Reconstr Aesthet Surg
2011;64(12):1677–81.
22. Hallock GG. The superior epigastric (RECTUS ABDOMINIS)
muscle perforator flap. Ann Plast Surg 2005;55(4):430–2.
23. Schlenz I, Burggasser G, Kuzbari R, et al. External oblique abdomi­
nal muscle: a new look on its blood supply and innervation. Anat
Rec 1999;255(4):388–95.
24. Yang D, Morris SF, Geddes CR, et al. Neurovascular territories of
the external and internal oblique muscles. Plast Reconstr Surg
2003;112(6):1591–5.
25. Moschella F, Cordova A. A new extended external oblique muscu­
locutaneous flap for reconstruction of large chest-wall defects. Plast
Reconstr Surg 1999;103(5):1378–85.
26. Dumanian GA, Heckler FR, Bernard SL. The external oblique
turnover muscle flap. Plast Reconstr Surg 2003;111(7):2344–8.
27. Shpitzer T, Neligan PC, Gullane PJ, et al. The free iliac crest and
fibula flaps in vascularized oromandibular reconstruction: com­
parison and long-term evaluation. Head Neck 1999;21(7):639–47.
28. Seify H, Jones G, Sigurdson L, et al. Endoscopic harvest of four
muscle flaps: safe and effective techniques. Ann Plast Surg 2002;
48(2):173–9.
29. Baumann D, Butler C. Lateral abdominal wall reconstruction.
Semin Plast Surg 2012;26(01):40–8.
30. Ramasastry SS, Tucker JB, Swartz WM, et al. The internal oblique
muscle flap: an anatomic and clinical study. Plast Reconstr Surg
1984;73(5):721–33.
31. Neligan PC. Head and neck reconstruction. Plast Reconstr Surg
2013;131(2):260e–269e.
Expert Commentary 
Bien-Keem Tan, FRCS
The omentum is composed of highly vascularized fatty connec-
tive tissue containing “milky spots,” which are collections of
macrophages and lymphocytes. These attributes make the
omentum the abdomen’s “policeman.”
Its pliability and long pedicle allow the tissue to conform to
a three-dimensional defect. I agree with the authors that its size
may vary with the size of the patient and I have noticed that in
thinner patients, such flaps can be thin and flimsy.
The authors prefer to raise the omental flap based on the
right gastroepiploic vessels as their caliber is larger. I agree with
this observation. In addition, lymph nodes found in this area
can be harvested as a vascularized lymph node flap for the
treatment of chronic lymphedema of the extremities. Great care
must be taken when dissecting the right gastroepiploic artery
near its origin at the gastroduodenal artery to avoid injury to
the head of the pancreas.
In chest defect reconstruction, I prefer to base the flap on
the left gastroepiploic vessels as length is gained when the
vessel is mobilized superiorly along the greater curve of the
stomach. The risk of devitalizing the stomach is low because
of its collateral circulation from the short gastrics, as well as
the right and left gastric arteries. A hole through the diaphragm
is a more direct passage and I prefer this route to gain flap
length. If flap reach is adequate, a subcutaneous tunnel is
performed to avoid a communication between the chest and
abdominal cavities.
Attention must be paid when handling the omentum as the
vessels are fragile. All divided vessels must be securely ligated.
I avoid cautery alone as it is not reliable. A leaking vessel may
cause an expanding hematoma.
The authors have highlighted the risk of abdominal hernias
since the pedicled flap has to be passed through a fascial gap.
Careful design of the gap can minimize this risk. I prefer the
right subcostal region because the liver prevents herniation of
bowel. For lateral abdominal defects, the exit could be created
adjacent to the linear semilunaris by component separation.
The resultant oblique passage between the separated muscle
layers of the lateral abdominal wall makes it less prone to
hernia.
REFERENCES
1. McLean DH, Buncke HJ. Autotransplant of omentum to a large
scalp defect. Plast Reconstr Surg 1972;49(3):268–74.
2. Horch RE, Horbach T, Lang W. The nutrient omentum free flap:
revascularization with vein bypasses and greater omentum flap in
severe arterial ulcers. J Vasc Surg 2007;45(4):837–40.
3. Santos Costa S, Blotta RM, Mariano MB, et al. Aesthetic improve­
ments in Poland’s syndrome treatment with omentum flap. Aes­
thetic Plast Surg 2010;34(5):634–9.
4. Bayles SW, Hayden RE. Gastro-omental free flap reconstruction of
the head and neck. Arch Facial Plast Surg 2008;10(4):255–9.
5. Boyd JB, Taylor GI, Corlett R. The vascular territories of the supe­
rior epigastric and the deep inferior epigastric systems. Plast
Reconstr Surg 1984;73(1):1–16.
6. Oni G, Sharma R, Rao R, et al. Bilateral superior epigastric pedicle
perforator flaps for total chest wall coverage. J Plast Reconstr
Aesthet Surg 2011;64(8):1104–7.

416
Rectus Abdominis Flap
Marcus Castro Ferreira  |  Luis Henrique Ishida  |  Lincoln Saito Millan
37 
INTRODUCTION
The rectus abdominis muscle (RAM) flap and its variations
are some of the most important flaps used in reconstructive
surgery. Its popularity is explained by the location of its skin
island in the inferior abdomen, which results in a skin resec­
tion similar to that of conventional abdominoplasties, espe­
cially in women undergoing breast reconstruction.
The RAM flap was first described by Holmstron in 1979,
who based the flap on its inferior pedicle, the deep inferior
epigastric artery (DIEA). The RAM flap gained popularity
with the work of Hartrampf, with its utilization as a pedicled
flap based on its superior pedicle, the superior epigastric
artery (DSEA), in breast reconstructions.
With the objective of reducing the sequelae resulting
from harvesting it from the abdominal wall, Koshima in
1989, proposed its use with complete preservation of the
rectus muscle and its innervation, a flap that is now termed
the deep inferior epigastric artery perforator (DIEP) flap.
Currently, the DIEP is considered the gold standard in
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION C  —  LOCAL AND FREE FLAPS IN THE ABDOMEN
Figure 37.1  Rectus abdominis flap.
Rectus
abdominis
Anterior
rectus
sheath
Deep inferior
epigastric artery
Superficial
inferior
epigastric
artery
Superior
epigastric
artery
Superficial
circumflex
iliac artery
Femoral
artery
Superficial
inferior
epigastric
artery
Lateral
and
medial
branches
of deep
inferior
epigastric
arteries
Sensory
branch of
intercostal
nerve
Lateral
cutaneous
branches of
intercostal
nerves
External
iliac
artery

CHAPTER 37 — Rectus Abdominis Flap
417
intercostal space into the musculophrenic artery and the
superior epigastric artery. It then emerges beneath the
chest wall along the posterior and medial aspect of
the muscle. The superior epigastric vessels run inferiorly
deep to rectus abdominis and superficial to the fibrous
layer that forms the posterior leaflet of the rectus sheath.
Within this layer they ramify to widely anastomose with the
inferior epigastric artery.
When a cutaneous component is harvested such as in a
musculocutaneous flap or a perforator flap, the deep infe­
rior epigastric vessels provide a more robust blood supply.
The superficial inferior epigastric artery also contributes to
the blood supply of the anterior abdominal skin.
Minor:  subcostal and intercostal arteries
Length: 2 cm
Diameter: 0.5–1 mm
Branches from the thoracic aorta, inferior vena cava, and
intercostal pedicles run immediately below each corre­
sponding rib. At the anterior portion of each costal arch,
the vascular pedicles, associated with the intercostal nerves,
perforate the transversalis fascia, in its lateral aspect. These
pedicles anastomose with the superior epigastric artery and
vein within the deep surface of the rectus muscle. Although
there is a real vascular anastomosis between these vessels,
they play a smaller role in the nourishment of the rectus
muscle.
Minor:  superficial superior epigastric artery and the
superficial circumflex artery
Both arteries play a small role in the nourishment of the
rectus flap and no focus will be given to those vessels in this
chapter.
VENOUS DRAINAGE OF THE FLAP
(See Fig. 11.8)
Veins accompany the arteries and are present in pairs.
Primary:  deep inferior epigastric vein
Length: 6 cm (range 4–8 cm)
Diameter: 4 mm (range 2–5 mm)
Primary:  deep superior epigastric vein
Length: 3 cm (range 2–4 cm)
Diameter: 2.5 mm (range 1.5–3 mm)
Secondary:  superficial inferior epigastric vein
Length: 6.4 cm (range 3.5–10 cm)
Diameter: 2.1 mm (range 1–3 mm)
This drains to the saphenous bulb and cooperates in skin
drainage of the anterior abdomen.
FLAP INNERVATION (See Fig. 11.9)
Sensory:  The 7th–12th intercostal nerves enter the RAM
at various points and divide into motor and sensory branches.
breast reconstructions in which large flaps are required (see
Ch. 16).
FLAP ANATOMY (Figs 11.2, 11.3, 11.8, 11.9,
37.1 and 37.3)
ARTERIAL SUPPLY OF THE FLAP (Figs 11.3
and 37.1)
The rectus muscle exhibits double nourishment (type III
Mathes/Nahai) and is supplied superiorly by the superior
epigastric artery, a branch of the internal thoracic artery,
and by the deep inferior epigastric artery, a branch of the
external iliac artery. These two vessels comprise an intramus­
cular anastomotic network with each other above the level
of the umbilicus. This vascular system also anastomoses with
the intercostal branches. Along its course, these arteries
emit perforating branches that supply the overlying skin.
Dominant:  deep inferior epigastric artery
Length: 7 cm (range 6–8 cm)
Diameter: 3.5 mm (range 3–5 mm)
The inferior epigastric artery is a branch of the external
iliac artery. It arises superior to the inguinal ligament and
passes superomedially in the layer superficial to the perito­
neum but deep to the transversalis fascia. Medially it passes
deep to the conjoint tendon. At the level of the arcuate line
(4–6 cm above the pubic bone), it passes superiorly and
superficially to perforate the posterior leaflet of the rectus
sheath. Clinically the arcuate line is important as the site of
entry of the inferior epigastric artery into the rectus sheath.
The DIEA enters the rectus muscle in its lateral third and
divides into a medial and lateral branch. These branches
provide perforators to the skin at various locations. Within
the rectus sheath, the inferior epigastric artery passes supe­
riorly and ramifies to anastomose with the superior epigastric
artery. It lies within the neurovascular plane of the transver­
salis fascia and transversus abdominis aponeurosis.
Two types of perforating vessels from the medial and
lateral branches are visible:
1. Perforators with a straight and perpendicular intramus­
cular path located in the intermuscular septum in the
direction of the subcutaneous tissue. In this case the
intramuscular course of the vessel is short and perpen­
dicular to the muscle fibers.
2. Perforators with an oblique intramuscular course. The
perforating vessel crosses two or more septa on its way
to the subcutaneous tissue, making dissection difficult
but increasing pedicle length. In the lateral row, 79.2%
of the vessels display a rectilinear course, whereas in the
middle row only 18.2% of the vessels present this pattern.
Dominant:  deep superior epigastric artery
Length: 3 cm (range 2–4 cm)
Diameter: 1.5 mm (range 1–2.5 mm)
The superior epigastric artery is a continuation of the
internal mammary artery, which branches at the sixth

418
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• This muscle does not function well as a functional muscle
transfer since its excursion is minimal and its innervation
is segmental.
PREOPERATIVE PREPARATION
Preoperative evaluation is of fundamental importance. A
detailed history and physical examination can reveal impor­
tant aspects of the surgical procedure. Previous abdominal
or pelvic surgeries can damage the vascularization of the
flap. Previous irradiation of the internal thoracic vessels can
diminish its blood flow. If one suspects injury of the pedi­
cles, additional studies should be performed.
One should be aware of prior abdominal scars, especially
transverse ones, which can indicate previous injury to the
pedicle. For instance, the Kocher (subcostal) incision
usually divides most of the rectus muscle, so that the
superiorly based RAM flap may be contraindicated, though
Doppler ultrasonography may be used to check the integrity
of the pedicles.
Prior undermining of the skin flap of abdominoplasties
is a relative contraindication. Although reports in the litera­
ture mention that patients with prior abdominoplasties have
been subjected to harvesting of myocutaneous RAM flaps
without complications, we do not recommend it. If one still
wants to use an abdominal skin flap, a thorough history and
discussion with the previous surgeon may aid in determin­
ing the level and extent of dissection during the abdomino­
plasty. CT angiography can help determine availability and
location of perforators. Also, careful delay procedures can
be helpful.
In obese patients, fat necrosis is a major probability when
the superiorly based pedicled form is utilized. Supercharg­
ing and superdraining, microsurgical inferiorly based flaps
or delay procedures can be indicated in this situation.
If the proposed flap requires dissection of its perforators,
prior location of the pedicles with duplex ultrasound or CT
angiography is recommended. Handheld unidirectional
Doppler can be used, although its sensibility and specificity
are lower. Although not mandatory, knowledge of the ped­
icles’ exact location permits a speedier and accurate dissec­
tion of the flap.
A detailed physical examination should be performed in
every patient. One should look for abdominal muscle weak­
ness or herniations that should be dealt with intraopera­
tively. At this time, the cutaneous island flap planning
begins. If the patient has enough skin laxity to allow a trans­
verse skin island (especially in patients who have been preg­
nant), the transverse rectus abdominis muscle – TRAM flap
is our first choice. Otherwise, a vertical skin island must be
used with the vertical rectus abdominis muscle – VRAM
flap.
Patients in whom the internal mammary artery has been
used for cardiac revascularization should not use a superi­
orly based flap. Although there is an anastomosis of the
costomarginal artery with the superior epigastric artery,
distal to the internal mammary artery, that may supply the
rectus muscle, there are not currently sufficient data to show
that this vessel can nourish the whole flap, particularly when
a large skin island is included.
The sensory branches join the perforators that supply the
overlying skin.
Motor:  Segmental motor branches of the 7th–12th inter­
costal nerves.
FLAP COMPONENTS
The flap can be dissected as a pure muscle flap; as a seg­
mental muscle flap with preservation of part of the muscle;
as a myocutaneous flap with a transverse, oblique, or vertical
skin island flap; as a myocutaneous flap with muscle preser­
vation; or as a perforator flap, with preservation of the
muscle and its innervation.
The 7th, 8th, 9th, and/or 10th ribs can be included in a
rectus abdominis flap. They are nourished by the 7th, 8th,
and 9th intercostal vessels, which join the costomarginal
artery along the inferior border of the costal margin. The
costomarginal artery then forms an anastomosis with the
superior epigastric artery along the deep surface of the rectus
abdominis muscle. This flap is useful in three-dimensional
reconstructions of bony and soft tissue defects of the face.
ADVANTAGES
• The position of this flap’s skin island in the inferior
abdomen, especially in women who have already been
pregnant, is advantageous. Dissection of the flap can lead
to a skin resection similar to a conventional abdomino­
plasty, resulting in not only a well -placed scar but also an
improvement in body contour.
• Since the flap is dissected in the supine position,
reconstruction of defects in the anterior trunk as well
as the upper and lower extremities can be performed
without a change in position during the procedure.
• The vascular anatomy is uniform and reliable. The pedicle
is long and has large diameter vessels, simplifying micro­
vascular anastomoses.
• If it is transferred based on its superior pedicle, the whole
length of the pedicle included in the rectus muscle will
greatly increase its rotational arc.
• The design of the skin island is very versatile. It can be
transverse, vertical, and/or oblique.
• In large three-dimensional defects, the flap can be folded
on itself, providing good coverage particularly in complex
head and neck resections.
• A muscle flap, without a skin island, can be harvested
through a low transverse abdominal incision
DISADVANTAGES
• Weakening of the abdominal wall after flap harvest
may be seen with variations of the flap that include a
significant part of the anterior rectus sheath. If only a
small part of the anterior fascia and the abdominal wall
layers is closed appropriately, weakening of the abdominal
wall and bulgings or hernia will be less likely to happen.
• The removal or denervation of the RAM can create a
slight functional deficit, especially upon flexing the trunk.
However, utilizing the perforator form of the flap mini­
mizes this deficit (see Ch. 57).
• In obese patients, the myocutaneous form of the
rectus flap is very likely to be bulky for resurfacing
objectives.

CHAPTER 37 — Rectus Abdominis Flap
419
CHEST WALL AND BREAST RECONSTRUCTION
The most commonly employed design of the skin portion
of the flap is the transverse lower abdominal skin flap,
similar to the skin resection of an abdominoplasty. The
superior margin of the skin island is usually 2 cm above the
umbilicus (in order to include the periumbilical perfora­
tors) and the inferior margin is above the pubic hairline.
When the lower abdominal skin is harvested as a myocutane­
ous flap based on blood supply traversing the rectus muscle
with inclusion of the muscle in the flap, this is called a
transverse rectus abdominis myocutaneous (TRAM) flap.
This design permits dissection of a thick flap, since it is a
region that usually accumulates some excess fat, and it
confers a pleasing aesthetic result to the donor area. Varia­
tions in flap design depend on the type of flap dissection
utilized.
SUPERIORLY BASED UNIPEDICLED
MYOCUTANEOUS FLAP
This kind of flap dissection provides a reliable blood supply
to the ipsilateral skin and part of the contralateral skin.
However, the remaining contralateral skin island should be
resected to achieve abdominal symmetry.
SUPERIORLY BASED BIPEDICLED
MYOCUTANEOUS FLAP
If a large amount of tissue is required, the flap based on
both RAMs may be employed. In this case a larger flap can
be designed because there will be two vascular pedicles
nourishing the flap. If necessary, the flap can be designed
more proximally, although it should be borne in mind that
in this case the resulting scar will also be higher up. We
recommend that this bipedicled flap is not used as a routine
since its morbidity to the donor site is higher than the uni­
pedicled one.
FREE MYOCUTANEOUS FLAP BASED ON
THE DIEA (See Ch. 57)
When this type of reconstruction is employed, its vascular­
ization is abundant and reliable, permitting the use of the
entire inferior abdominal skin.
OTHER RECONSTRUCTIONS (Fig. 37.3)
In other types of reconstructions, the flap design will depend
on the defect to be repaired. Flaps with vertical or oblique
skin islands can be utilized or even separate distinct skin
islands, based on perforator pedicles. If the design is
oblique, it is possible to utilize the skin portion above the
rib cage that has the advantage of being thinner and conse­
quently more suitable for modeling the flap. This flap is
designed transversely over the anterior portion of the lower
costal margin laterally all the way to the level of the midaxil­
lary line. On the other hand, if volume is necessary, a major
or minor portion of the rectus muscle can be included in
the flap, always bearing in mind the fact that about 20–30%
of the muscle volume is usually lost due to denervation of
the muscle. If the planned flap is purely muscular, it can be
dissected through a paramedian incision placed longitudi­
nally and centered over the rectus muscle with a lateral
extension in the caudal portion that aids in exposure of the
DIEA, or alternatively, via a low transverse incision, followed
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 37.2)
The RAMs are located in the anterior abdomen with their
medial limits situated in the midline, except in multiparous
women who present with diastasis of the rectus muscles,
separating them from the midline. The superior limit is the
rib cage, as the muscle arises from the fifth, sixth, and
seventh costal cartilages and the inferior limit is its insertion
at the pubis (see Fig. [4815]). Palpation of the contracted
muscle easily determines its location in thin patients.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The design and size of the flap vary greatly depending on
the surgical technique utilized and the characteristics of the
donor and recipient areas. Therefore, each transfer will be
explained individually.
Our preference is to include periumbilical perforators
in the design of the skin paddle whenever possible.
These perforators are larger and provide better supply to
the skin of the abdominal wall. However, in some cases,
in order to preserve a majority of periumbilical perfora­
tors, a supraumbilical incision should be used as the
superior margin of the flap. Closure of the donor site in
that situation may not allow for the inferior incision to
be placed immediately above the pubic hairline. In those
situations, the inferior incision is placed higher in the
abdomen, in a visible location and can be improved in a
future procedure through re-advancing the superior
abdominal flap and repositioning the scar lower in the
abdomen. The other alternative is to place the superior
incision lower than the umbilicus and sacrifice some of
the periumbilical perforators, allowing for a more aes­
thetically pleasing incision line.
Figure 37.2  Anatomic landmarks.
5th, 6th and 7th costal
cartilages
Midline
Anterior iliac spine
Xiphoid
Umbilicus
Pubic
symphysis

420
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Skin Island Dimensions: Vertical Skin Flap
Length: 25 cm (range 23–29 cm)
Width: 6 cm (range 4–8 cm)
Thickness: 2.5 cm (range 1–6 cm)
These dimensions are based on what would allow primary
closure of the donor site.
MUSCLE DIMENSIONS
Length: 25 cm (range 23–29 cm)
Width: 6 cm (range 4–8 cm)
Thickness: 1.5 cm (range 0.7–2 cm)
BONE DIMENSIONS
Length: 10 cm (range 3–15 cm)
Width: 2 cm (range 2–6 cm, multiple costal cartilages)
Thickness: 2 cm (range 1–3 cm)
The 7th–10th cartilages can be raised with the flap.
FLAP MARKINGS
Figure 37.3 shows different kinds of skin design that can be
changed depending on the defect to be reconstructed and
availability of tissue in the donor site. It may be transverse,
vertical, or oblique.
PATIENT POSITIONING
The supine position is ideal for dissecting the flap. During
breast reconstructions, it is often necessary to raise the
back of the patient to analyze the shape of a breast recon­
struction, or to place the patient in a semi-Fowler position
by undermining of an abdominal flap and dissection of the
muscle flap below it.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The placement of the skin island may differ slightly if a
pedicled flap is to have an extended reach; otherwise, the
principles are similar and the designs described can be used
for both pedicled and free flaps.
For a free flap, usually, the pedicle is the DIEA. Although
not impossible to perform a free flap based on the DSEA,
it is very impractical, since the access to the thoracic internal
vessels and the DSEA itself is not easy compared with the
access to the DIEA.
FLAP DIMENSIONS
Skin Island Dimensions: Lower Abdominal Skin
Flap
Length: 13 cm (range 10–20 cm). Maximum to close pri­
marily: 20 cm
Width: 25 cm (range 20–40 cm)
Thickness: 2.5 cm (range 1–6 cm)
These dimensions are based on what would allow primary
closure of the donor site. Usually the upper incision is made
first, the upper abdominal wall flap is mobilized, then the
patient is placed in a sitting position and the placement of
the lower incision is confirmed. If the source of blood
supply to the skin flap is through the DIEA artery when a
TRAM flap is harvested, the majority of skin can be utilized.
If the TRAM flap is based on the superior epigastric vessels,
zone IV must be discarded and zone II’s blood supply evalu­
ated intraoperatively.
Figure 37.3  Flap marking. Different kinds of skin design that can be changed on the defect to be reconstructed.

CHAPTER 37 — Rectus Abdominis Flap
421
Once the muscle is isolated, it is sectioned, carefully isolat­
ing and ligating the DIEA. Usually, when performing a
pedicled rectus muscle or myocutaneous flap based on the
superior epigastric vessels and there is no plan to super­
charge the deep inferior epigastric vessels, the DIEA is
located at the lateral edge of rectus sheath and divided.
When additional blood flow is required or needed and the
surgeon plans to augment blood inflow or venous outflow
through supercharging either the artery or the vein, the
DIEA and DIEV can be dissected to the level of the inguinal
ligament and divided. This approach permits an increase of
3–6 cm in pedicle length and the DIE vessels can serve as
an optional source of flap vascularization if an additional
anastomosis is performed between the divided DIE vessels
and the recipient site. From this point on, the flap is ele­
vated and any remaining adhesions are cut. A tunnel in the
subcutaneous plane is utilized to transfer the flap to the
thorax.
In the majority of cases, the subcostal (T8) and the 6th
or 7th intercostal arteries represent the minor pedicles of
the superiorly based flap. Usually, the subcostal pedicle is
the largest pedicle of these segmental minor pedicles and
presents 2–3 cm length and a diameter between 0.5 and
1 mm. This vessel enters the midportion of the deep surface
of the rectus muscle at the level of the sixth and seventh
costal cartilages and anastomoses with the superior epigas­
tric vessels. Normally, the subcostal pedicle associated with
the motor nerve is divided in order to permit an adequate
arc of rotation to the anterior chest. In the situation of prior
ligation of the internal mammary artery (coronary revascu­
larization), care must be taken to preserve the minor pedi­
cles and especially the subcostal artery in order to maintain
the retrograde flow to the superior epigastric artery. In
general, our experience has demonstrated that the rectus
muscle associated with a transverse or longitudinal superior
skin island survives when transposed based on minor pedi­
cles. However, the conventional superiorly based TRAM flap
using the minor pedicles should be avoided as the vascular
flow may be unpredictable.
At the beginning of flap dissection, the umbilicus is cir­
cumscribed as a circle. Usually, the skin is incised down to
the rectus abdominis muscle fascia in order to perform
complete isolation of the umbilicus. After donor site
closure and inferior traction of the superior abdominal
flap, the new point of the umbilicus is calculated. For this
purpose, a vertical incision passing through this point and
equal in length to that of the original umbilicus is per­
formed. The skin is incised and small ellipses of full-thick­
ness skin and fat of the superior abdominal flap are
resected on either side of the vertical line to re-create the
gap in which to inset the horizontal dimension of the
umbilicus. After hemostasis, the umbilicus is exteriorized
and the 6-o’clock position of its stalk is plicated inferiorly
with nonabsorbable sutures on the rectus fascia, and the
edges of the navel are sutured to the skin with 5-0 nylon
sutures.
MUSCLE FLAP
If only a muscle flap is to be dissected, it can be performed
by a median, paramedian, or even a low transverse incision
with the abdominal flap undermined to expose the muscle
to evaluate the ease of closure and tension on the closure
of the donor area. In order to prevent dislocations, it is
important to ensure that these maneuvers are possible
based on the placement of the patient on the operating
table and by fixation of the trunk and arms on the operat­
ing table.
ANESTHETIC CONSIDERATIONS
The recommended form of anesthesia for this kind of
surgery is general anesthesia because of the potentially long
duration of the surgery and muscle relaxation required
when dissecting the rectus muscle.
TECHNIQUE OF FLAP HARVEST
(Fig. 37.4)
SUPERIORLY BASED PEDICLED TRAM FLAP
The dissection begins with a superior incision followed by
undermining of the upper abdomen. Above the level of
the superior incision, extensive undermining laterally to
the rectus muscles should not be performed in order to
protect the nourishment of the abdominal skin flap. The
patient is then placed in a sitting position and by caudal
traction of the upper abdomen; the inferior limit of the
flap is marked. The lower skin incision is completed and
the skin of the flap is undermined from lateral to medial
above the plane of the external oblique and its aponeuro­
sis. Skin and subcutaneous tissue are lifted off the external
oblique muscle up to the lateral border of the rectus
abdominis muscle on both sides of the abdomen. Nor­
mally we start the elevation of the flap on the contralat­
eral side of the abdomen first in order to determine the
location of the perforators, which would aid in defining
the exact location of the vessels on the ipsilateral side.
Once a perforator vessel is found, the subcutaneous fat
around it is immediately dissected through the fascia. The
anterior rectus sheath through which the perforator
passed is opened, and we continue to search for other
perforators. In the DIEP flap dissection, the perforator
vessel is dissected from the rectus muscle fibers through a
longitudinal direction split.
This dissection extends up to the lateral margin of the
RAM. After the medial and lateral aspect of the anterior
rectus sheath is completely exposed, the anterior fascia is
incised on its medial and lateral aspect to expose the under­
lying rectus muscle. The lateral aspect is easily determined
by the location of the largest perforator previously identi­
fied. However, the medial aspect is calculated in order to
preserve the maximum extension of the fascia to perform
an adequate and tension-free abdominal wall closure. Nor­
mally the medial incision is situated 1.5–3 cm from the
medial aspect of the rectus muscle. The muscle can then be
approached starting from these perforators, thereby sparing
an amount of fascia that will simplify closure of the abdomi­
nal wall.
The rectus muscle is undermined from its posterior
sheath by blunt dissection in this loose areolar tissue plane.
At the tendon’s intersection, the muscle adheres to the
anterior aponeurosis, so dissection becomes more difficult.

422
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A
B
C
D
Figure 37.4  (A–D) Monopedicled TRAM flap. (A) Monopedicled skin territory. (B) Superiorly based TRAM flap. (C) Monopedicled TRAM flap
and dissection prior to flap molding. (D) Donor site closure and flap molding.

CHAPTER 37 — Rectus Abdominis Flap
423
E
F
G
H
(E–H) Bipedicled TRAM flap. The flap can be split into two flaps. (E) Bipedicled TRAM flap skin territory. (F) Superiorly based
bipedicled TRAM flap. (G) Bipedicled TRAM flap dissection. (H) Donor site closure and flap molding.
Figure 37.4, cont’d

424
PART 4 — CONVENTIONAL WORKHORSE FLAPS
medium flaps only where we observe more predictable
results.
SENSORY REINNERVATION OF THE FLAP
Although spontaneous recovery of some sensory return may
occur without coaptation of a sensory branch of the flap
nerve, the fourth intercostal nerve responsible for eroge­
nous sensation can be anastomosed to sensory nerve
branches of the flap.
FUNCTIONAL MUSCLE TRANSFER
Due to its segmental motor innervation, dependent on mul­
tiple nerves, and its short excursion, the use of the rectus
flap as a functional muscle does not have clear indications
in clinical practice.
MUSCLE-SPARING FLAP
This can be defined as a flap with maximal preservation of
both lateral and medial portions of the remaining rectus
muscle. One might surmise that split muscle harvest results
in less bulk of muscle folding on itself and may contribute
to less potential venous outflow obstruction. Additionally,
using abdominal flaps that minimize the amount of rectus
abdominis muscle and anterior rectus sheath harvested may
result in improved abdominal strength and contour. It is
also possible to split the muscle between the medial and
lateral row vessels for reconstruction of two separate defects
or for creation of a valve-like mechanism. However, the
preserved muscle must retain its vascularization and inner­
vation. For this purpose, after the anterior surface of the
muscle is exposed, it is important to detect the course of the
DIEA or DSEA through Doppler analysis in order to main­
tain the vascularization. Non-innervated and poorly vascu­
larized muscle segments lack the ability to contract, and
finally atrophy. Conversely, innervated muscle segments will
contract on stimulation and maintain muscle width and
volume.
The innervation and blood supply to the remaining
rectus muscle are derived from the laterally based intercos­
tal nerves and vessels. Regularly, these minor pedicles enter
the deep surface of the lateral muscle or central segment in
association with the 7th–12th intercostal nerves. Thus,
during flap dissection the lateral margin of the muscle is
preserved along with its innervation. In association with
prior location of the DIEA and DSEA through Doppler, it
is also possible to preserve the medial portion of the muscle.
The remainder of the flap elevation technique is unchanged.
In addition to these technical details and Doppler examina­
tion, care must be taken with muscle-sparing procedures as
the technique is associated with an increased risk of vascular
pedicle injury and muscle denervation.
PEDICLED FLAPS BASED ON THE DIEA
In the inferiorly based flap, the superior rectus muscle is
usually divided at the costal margin. Based on its inferior
pedicle, the arc of rotation of the inferior pedicled flap
takes place at the level of the pubis, and the rectus muscle
will reach the groin, perineum, and inferior trunk. This
(C-section incision). The muscle is dissected according to
the previous description.
FREE FLAP
The muscle is divided superiorly and inferiorly. As free flaps
utilize the deep inferior epigastric artery as the main pedicle,
the superior epigastric pedicle is ligated proximally. The
DIEA is dissected to the level of the inguinal ligament. The
two venae comitantes will become one vein near the exter­
nal iliac vein.
PERFORATOR FLAP (See Ch. 57)
The main difference when dissecting perforator flaps is the
intramuscular dissection of the perforator pedicles. When
they are identified, the anterior rectus margin is opened
vertically. The pedicles are dissected to their depth, ligating
the muscle branches that originate from the main pedicle.
If more than one perforator pedicle is needed, the small
muscle segment between the pedicles should be sectioned.
Injury to the nerves of the muscles that cross transversely
should be avoided. Dissection continues to the deep inferior
epigastric artery and the pedicle is ligated as soon as suffi­
cient length is achieved. The donor site closure is performed
as standard technique.
FLAP MODIFICATION/FLAP HANDLING
DELAY OF THE FLAP
A surgical delay has been suggested to increase flap reli­
ability in high-risk patients as an alternative to microsurgi­
cal augmentation or supercharging, or even free TRAM
flap transfer. Delay of a superiorly based TRAM flap can
be performed on an outpatient basis under general anes­
thesia. The procedure should be done at least 2 weeks
before the reconstruction, whether the reconstruction is
immediate or delayed. The type of technique varies from
small bilateral incisions and ligature of the deep inferior
epigastric artery and veins, to complete skin incisions and
flap elevation (zones 2–4), in addition to ligature of both
inferior vascular pedicles. Usually we prefer ligature of
both deep inferior epigastric arteries and veins bilaterally
accessed from an inferior flap incision before flap
transfer.
THINNING OF THE CUTANEOUS PORTION OF
THE FLAP
Based on the need at the recipient site, thinning of the
DIEP flap may be required in order to optimize the final
contour. For this purpose, the thinning technique should
be based on knowledge of perforator vascular territories in
order to avoid vascular compromise. Particular care must
be taken when thinning larger flaps because the course of
the small vessels is often unpredictable and they may be
injured during the thinning process. Avoiding injury to
these vessels is critical; therefore, we prefer not to thin
very large flaps in the primary setting and perform thin­
ning procedures in the primary setting for small and

CHAPTER 37 — Rectus Abdominis Flap
425
it is necessary to include flap tissue that lies beyond the
well-perfused zones to achieve optimal results without com­
plications. This situation is frequently observed in thin
patients who have a limited quantity of abdominal tissue or
who have a midline abdominal scar, in which perfusion is
restricted to the ipsilateral hemi-flap. In these situations,
providing a second vascular pedicle through “charged tech­
niques” may improve the blood supply to an additional
volume of tissue included in the flap.
In the “supercharged” procedure, the DIE vessels, the
superficial epigastric vessels, or the superficial circumflex
iliac vessels can be anastomosed to recipient vessels in the
axilla. In the “turbocharged,” “recharged,” and “parasite”
flaps, both deep inferior epigastric vessels are anastomosed
together to form a loop. In theory, the use of microvascular
techniques for tissue transfer in pedicled flaps can offer
greater flap perfusion and decreased donor site morbidity.
However, additional study of larger groups of patients is
necessary to verify this trend.
FREE MICROVASCULAR TRANSFER OF THE
RECTUS FLAP BASED ON THE DEEP
SUPERIOR EPIGASTRIC ARTERY
The flap can be transferred based on the DSEA as a free
flap. This procedure is similar to that for a conventional
superiorly based flap dissection. It is important to release
the rectus muscle insertion at the xiphoid junction and to
identify the DSE vessels deep to the costal margin at the
medial edge of the posterior rectus sheath. In order to
increase the superior pedicle length, it is necessary to
perform a more proximal dissection, and, in some situa­
tions, costal cartilage division is required for a better dissec­
tion of the internal mammary vessels.
PEDICLE EXTENSION OF THE
SUPERIORLY BASED FLAP
The origin of the muscle can be transected and the 7th and
8th ribs can be removed in order to extend the length of
the superiorly based pedicle.
PEDICLE EXTENSION OF THE
INFERIORLY BASED FLAP
In the inferiorly based flap, it is possible to increase the
extension of pedicle length through a wide dissection near
the inguinal region. After complete flap dissection, the
fibers of muscle origin are divided from the pubic bone.
The DIE vessels are mobilized to the level of the inguinal
ligament in the groin region.
METHOD OF ROTATION AND INSET OF A
SUPERIORLY BASED OR INFERIORLY BASED FLAP
Depending on the defect location, the rectus abdominis
flap has two arcs of rotation. In superiorly based flaps, the
superior epigastric artery represents the critical point of
rotation and it usually occurs at the costal margin and the
flap normally reaches the anterior thorax. In inferiorly
based flaps, the inferior epigastric artery represents the
rotation can be extended by division of the rectus muscle
fibers in the pubis and mobilization of the inferior epigas­
tric artery to the level of the inguinal ligament.
HARVEST OF THE TRANSVERSE SUPERIOR
SKIN ISLAND AND THE SUBMAMMARY
PORTION OF THE FLAP
Usually the entire central abdominal wall receives vascular
contributions from the paired rectus muscles. Thus multiple
options of skin designs are possible for a rectus musculocu­
taneous flap. The transverse superior skin island or the
submammary portion of the flap is typically located at the
epigastric and subcostal regions. The skin territory dimen­
sion is determined by the ability to achieve direct donor site
closure. Although the skin island may be extended across
the abdominal wall, the flap vascularization is unpredictable
between the midclavicular and anterior axillary lines, espe­
cially on the contralateral side of the abdomen. The flap
can be based on the inferior or superior pedicle, and dis­
section is similar to the conventional TRAM flap. In the
inferiorly based flap the superior muscle is divided at the
costal margins and the DSEA is divided at the superior limit
of the skin island at the deep medial surface of the rectus
muscle. In the superiorly based flap, the inferior rectus
muscle can be divided at the pubis if a large amount of
muscular tissue is required. Otherwise, the rectus muscle
can be divided near the inferior limit of the skin island as a
conventional inferior TRAM flap.
SPLITTING OF THE FLAP BETWEEN THE LATERAL
AND MEDIAL ROW PERFORATORS
Some authors have described splitting the muscle between
the medial and lateral row vessels for reconstruction of two
separate defects or for creation of a valve-like mechanism
(vagina reconstruction or bladder neck reconstruction).
THE RECTUS FLAP WITH VASCULARIZED RIB
The RAM flap can be combined with vascularized 7th, 8th,
9th, and/or 10th costal cartilages. These cartilages are nour­
ished by costomarginal and musculophrenic arteries,
branches of the deep superior epigastric artery. A large
paramedian incision is made to expose the rectus muscle.
A standard approach to raising the rectus muscle based on
the DIEA is used. The margins of the rectus sheath sur­
rounding the ribs are incised down to periosteum and peri­
chondrium. The ribs are cut using either a sagittal saw or
knife. Care must be taken to avoid pleural injury. This tech­
nique is used mostly in three-dimensional reconstructions
of the face.
SUPERCHARGED FLAP (SUPERIORLY OR
INFERIORLY BASED, ARTERIES OR VEINS)
Variations of the conventional flap, based on either the
deep superior or the deep inferior epigastric vessels, are
commonly used for reconstruction. The DIE vessels are the
dominant blood supply, and perfusion of the flap is least
reliable in the zones farthest from the pedicle. Occasionally

426
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Inferiorly based
• Coverage: perineum, vagina, groin, and lower extremity
• Reconstruction: breast, perineum, groin, and lower
extremity
• Components: muscle, musculocutaneous or cutaneous
FREE FLAP – INDICATIONS
• Coverage: head and neck, upper and lower extremities
• Components: muscle, musculocutaneous or cutaneous
• Functional muscle: head and neck and extremities
VARIATIONS OF THE FLAP
• Musculocutaneous: transverse superior skin island design,
transverse inferior skin island design, vertical superior
skin island design
• Cutaneous (perforator flap): transverse inferior skin
island design, vertical inferior skin island design
TYPICAL INDICATIONS
PEDICLED FLAP
One of the major indications of the superiorly based pedi­
cled myocutaneous RAM flap is breast reconstruction. The
location of the donor area and the large amount of soft
tissue provided are the main advantages of this kind of
reconstruction.
The flap is transferred to the thorax through a subcutane­
ous tunnel at the inframammary sulcus. The excess of soft
tissue is resected and the flap can be molded with nylon
stitches. De-epithelialization is performed if necessary.
FREE FLAPS
Free TRAM flaps or DIEPs are frequently used for breast
reconstruction. The vascular anastomosis is usually per­
formed with the internal mammary or thoracodorsal vessels.
Alternatively, the internal mammary perforators, the lateral
thoracic and thoracoacromial vessels can be used. These
flaps usually have an easier inset when compared with the
superiorly based ones, because the only limitation for their
positioning is their vascular pedicles. Molding is performed
in a similar way to the superiorly based flaps.
Soft tissue deformities can also be reconstructed with
free myocutaneous RAM flaps. Frequently the skin over
the rectus muscle is thick, making this flap useful in
contour deformities. The possibility for different designs
of the skin island of this flap makes it suitable for three-
dimensional reconstructions because it can be folded on
itself. This characteristic is specifically useful in complex
facial defects.
In lower limb reconstructions, the muscular segment of
the RAM flap is useful for obliteration of dead spaces of
exposed bone, and its cutaneous segment can cover a soft
tissue defect.
ATYPICAL INDICATIONS
PEDICLED FLAP
Due to their broad rotational arc and the possibility of
pedicled transfer in a proximal and caudal direction,
point of rotation and it usually occurs at the pubic bone,
and normally the flap can reach the inferior trunk and
perineum. By releasing the rectus muscle from its bony
attachments (pubis and costal cartilages), it is possible to
extend the arc of rotation.
DONOR SITE CLOSURE AND
MANAGEMENT
The donor site closure is performed as a standard tech­
nique. The closure is usually accomplished with interrupted
figure-of-8 nonabsorbable sutures reinforced with a running
suture. An onlay mesh is utilized when a complete secure
closure cannot be accomplished. Usually, mesh reinforce­
ment is indicated for a bipedicled TRAM flap. For this
purpose, five regions located near the bony sites are dis­
sected and marked: the pubic symphysis inferiorly, the ante­
rior superior iliac spines laterally, and the lower costal
cartilages superiorly. Two longitudinal incisions are made
3–5 cm apart on the anterior sheath of the rectus muscle
above the umbilicus. Normally, we do not perform lateral
relaxing incisions in order to avoid vascular interruption to
the medial fascia. In a monopedicled TRAM flap, the oppo­
site anterior rectus fascia is plicated vertically to the size of
the contralateral defect to reposition the umbilicus. A mesh
is applied over most of the abdominal wall and fixed under
tension with interrupted nonabsorbable sutures to the five
bony sites. After the mesh is anchored in place, it is approxi­
mated circumferentially to the external oblique fascia with
running sutures. We recommend the use of suction drains.
They may be removed after about 1 week, when the drain­
age volume is lower than 30–50 mL every 24 h.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• When closing the donor area, placing sutures so that they
unite the undermined skin flap to the rectus aponeurosis
reduces “dead space,” diminishing the incidence of
hematomas or seromas.
• Extra plication of the aponeurosis of the rectus muscle
achieves a better body contour for the patient.
• During closure of the anterior rectus sheath, the internal
and external oblique aponeurosis can be clearly seen as
two separate layers, particularly below the arcuate line.
Often the internal oblique layer is retracted and missed
during the closure process. It is imperative that the
surgeon include both layers during closure of the ante­
rior rectus sheath below the arcuate line.
FLAP USAGE
PEDICLED – INDICATIONS
Superiorly based
• Coverage: anterior and lateral thorax, abdomen, and pos­
terior trunk
• Components: muscle, musculocutaneous or cutaneous

CHAPTER 37 — Rectus Abdominis Flap
427
reconstructed breast has a better shape than the opposite
one, so that a pexy or breast reduction is needed to provide
symmetry.
In breast reconstructions, pedicled flaps can cause loss of
definition of the reconstructed mammary sulcus, due to the
passage of the muscle pedicle through the subcutaneous
path. Microsurgical flaps achieve a better definition of the
mammary sulcus.
DONOR SITE
When a transverse design of the skin island is used in women
with abdominal laxity, an improvement of the contour of
the abdomen is expected because the excess of soft tissue is
resected.
UNTOWARD/UNFAVORABLE OUTCOMES
GENERAL
The RAM flap is very safe as long as one respects its vascular
anatomy. Small necrosis of the flap are usually related to
insufficient venous drainage and are located at the margins
of the flap. Total flap losses are related to technical prob­
lems with the vascular anastomosis rather than problems
with the dissection of the flap.
The presence of small hard nodules in the subcutaneous
tissue of the flap is related to fat necrosis. They are more
common in breast reconstructions with superiorly based
pedicled flaps.
DONOR SITE
Small areas of necrosis of the abdominal flap and poor
umbilical scarring rarely occur, and are probably related to
extensive undermining or aggressive dissection. They are
usually treated with minor local debridement and dressings.
Seromas in the undermined areas are rare due to the use
of suction drains. However, if they should occur, they can
be treated by needle aspiration or surgical drainage.
LONG-TERM OUTCOMES
GENERAL
The RAM flap is sometimes heavy. In the long term there
may be a variable degree of ptosis that may require reposi­
tioning of the flap.
When the RAM flap is used in contour restoration, one
must bear in mind that the muscle segment of the flap will
atrophy by about 20–30% due to denervation.
BREAST RECONSTRUCTION
Surgeries for remolding or repositioning of the flap with or
without reduction or pexy of the opposite breast are eventu­
ally necessary. The flap tends to grow proportionally to the
patient’s weight gain but there is generally less tendency to
ptosis than in the normal breast.
Postoperative radiotherapy can reduce the size of the
reconstructed breast; therefore, it is recommended that
treatment be concluded before procedures to achieve sym­
metry are scheduled.
Approximately half the patients undergoing breast recon­
struction utilizing the myocutaneous flap achieve some
spontaneous return of sensibility. This return increases if
the perforating form of the flap is dissected, even more if
upper trunk defects, such as thoracotomy dehiscences or
large thoracic resections, can be treated with a superiorly
based pedicled flap based on its proximal pedicle.
Inferiorly based RAM flaps have a distal rotation arc favor­
able to reconstructions of the inguinal, pelvic, and hip
regions. Peritoneal tissue can be transferred with the flap,
which may be useful in vaginal reconstructions.
FREE FLAP
Association of vascularized ribs with the RAM flap can be
useful in maxillary reconstructions.
POSTOPERATIVE CARE AND
EXPECTED OUTCOMES
GENERAL
When the lower abdominal skin is included with the flap,
as with breast reconstructions, positioning the patient in a
semi-Fowler position reduces skin tension on the donor
area. Excessive efforts, chiefly those that increase abdomi­
nal pressure such as lifting or carrying weight, should be
avoided for at least 1 month. Drains are kept in place for
about 3 days and hospitalization is for about 5 postoperative
days.
RECIPIENT SITE
In breast reconstructions the use of a surgical brassiere is
recommended for about 1 month to avoid excessive tension
on the vascular pedicle and to provide a suitable shape to
the flap.
In lower extremity reconstructions, the patient must keep
the reconstructed limb elevated for 1 or 2 weeks and, after
this period, is encouraged to maintain the elevation when
resting. The use of a compressive stocking helps the dimin­
ishment of edema and bulkiness of the flap.
DONOR SITE
In breast or facial reconstructions, the patient is encouraged
to ambulate on the first postoperative day. Abdominal
binders are recommended for 1 month. In lower extremity
reconstructions, the patient can ambulate for short dis­
tances after 7 days.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
The RAM flap has a very constant and reliable anatomy. The
most frequent problems are related to partial necrosis with
superiorly based pedicled flaps or abdominal wall closure
defects, especially when including large quantities of muscle
with the flap.
BREAST RECONSTRUCTION
The flap can be shaped with sutures and resections, thus
achieving an excellent fit to the new breast. Usually the

428
PART 4 — CONVENTIONAL WORKHORSE FLAPS
perforator flaps, with preservation of muscles and local
innervation, seems to reduce these complaints.
CONCLUSIONS
Rectus abdominis muscle flaps have a privileged position,
especially in multiparous patients. Nevertheless, the poten­
tial sequelae at the donor site are of some concern. Several
changes in flap design have been proposed, with the objec­
tive of reducing these sequelae. To date, utilization of the
DIEP flap has demonstrated a more suitable form for trans­
fer of skin from the abdominal region.
But the RAM flap still has its role when a considerable
amount of bulk tissue, including muscle, is necessary.
sensory reinnervation by microsurgical nerve anastomosis is
performed.
DONOR SITE
Hernias or bulges are not uncommon (Fig. 37.5). A careful
closure of the aponeurotic layers can diminish these prob­
lems. Reinforcement with a nonabsorbable mesh must be
used whenever there is tension on the sutures.
The RAM and its aponeurotic margin possess three main
functions: tensing the abdominal wall, maintaining its con­
tents, and providing the first 30° of flexion when passing
from the supine to the sitting position. One can expect
patient complaints related to these two functions resulting
from flaps that utilize the muscle, especially in patients
who engage in intense physical activity. The utilization of
Figure 37.5  Young female patient presenting with bulge after vertical rectus abdominis muscle (VRAM) harvest.
A
B
C

CHAPTER 37 — Rectus Abdominis Flap
429
Figure 37.6  (A) Defect after ECC resection. (B) Flap marking. (C) Flap inset. (D) Primary closure of donor site. (E) External view. (F) Internal
view.
A
B
C
E
D
F
This patient presented with a full-thickness defect in the face
after espinocelular carcinoma resection. A VRAM flap was
designed with two skin islands. Long-term follow-up shows a nice
external contour.
CASE 37.1  Large Composite Facial Defect Reconstructed with a Free VRAM Flap

430
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 37.7  (A) Advanced BCC. (B) Defect after BCC resection exposing skull base. (C) Flap marking (the rectangle shows the area
where the periumbilical perforators are most likely found). (D) The flap harvest with the deep inferior epigastric vessels over the forceps.
(E) Flap inset and vessel anastomosis. (F) Immediate postoperative status. (G) Long-term follow-up. (H) Donor site with minimal
morbidity.
A
B
C
D
E
F
G
H
This patient presented with an advanced basal cell carcinoma.
The resection exposed the skull base and resulted in a large skin
defect. A VRAM flap was performed with minimal donor site
morbidity, as seen at long-term follow-up.
CASE 37.2  Skull Base and Lateral Facial Composite Defect Reconstructed with a Free
VRAM Flap

CHAPTER 37 — Rectus Abdominis Flap
431
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expertconsult.inkling.com
Expert Commentary 
Brian T. Carlsen, MD
The rectus abdominis flap can be used as a pedicle flap, based
on either primary or secondary (superior or inferior) pedicle or
as a free flap, based on the deep inferior epigastric vessels.
Over time the flap has gradually evolved, initially into a muscu-
locutaneous flap, and finally into the perforator flap (DIEP) that
has become the gold standard for breast reconstruction.
The rectus abdominis muscle flap is intermediate in size
(between gracilis muscle and latissimus dorsi muscle) and has
a large vascular pedicle. For these reasons it remains a work-
horse flap for the reconstructive microsurgeon for reconstruc-
tion of soft tissue defects in select situations. In recent years it
has seen decreasing application in favor of other muscle flaps
or perforator flaps. The significant disadvantage of donor site
morbidity, primarily abdominal bulge or hernia formation,
appropriately limits its application for many surgeons. As a
general rule, many surgeons prefer the gracilis muscle flap over
the rectus abdominis flap for reconstruction of soft tissue
defects where a muscle-only flap is desired due to the favorable
donor site scar and limited morbidity attributed to the gracilis
muscle flap. Still, the rectus flap can be harvested with the
patient in the supine or lateral position and safe harvest can be
rapidly completed, which, in some situations, can tip the
balance in favor of the rectus flap over other muscle-only flaps
due to patient and/or wound factors.
The intercostal nerves segmentally innervate the rectus
muscle. This has limited its application as a functional muscle
transfer; however, it may offer a unique advantage in some
special reconstructive scenarios. Targeted muscle reinnerva-
tion (TMR) where muscle signals are used to amplify motor
nerve signals for prosthetic control (or neuroma control) after
amputation. TMR typically uses residual, local, nonfunctional
muscles for control; however, free tissue transfer can provide
additional myoelectric signals when local options are lacking.
The rectus abdominis muscle, with its single vascular pedicle
but segmental innervation, could provide a unique application
for TMR application and expand its utility in the armamentarium
of the reconstructive surgeon.
This patient underwent a radical groin lymphadenectomy dissection. A pedicled VRAM flap was used to cover the defect with bulk
tissue and protect the exposed vessels.
CASE 37.3  Groin Defect Reconstructed with an Inferiorly Based Pedicled VRAM Flap
Figure 37.8  (A) Patient after groin lymphadenectomy. (B) VRAM flap inset to cover the defect. (C) Immediate postoperative.
A
B
C

CHAPTER 37 — Rectus Abdominis Flap 431.e1
FURTHER READING
Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg 1994;32(1):32–8.
Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and
blood flow in free transverse rectus abdominis myocutaneous and
deep inferior epigastric perforator flaps. Plast Reconstr Surg
2000;106(6):1295–9.
Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
morbidity of free DIEP flaps and free TRAM flaps for breast recon­
struction. Br J Plast Surg 1997;50(5):322–30.
Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior
epigastric and the deep inferior epigastric systems. Plast Reconstr
Surg 1984;73(1):1–16.
Codner MA, Bostwick J 3rd, Nahai F, et al. TRAM flap vascular delay
for high-risk breast reconstruction. Plast Reconstr Surg 1995;96(7):
1615–22.
Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg 1982;69(2):
216–25.
Ishida LH, Gemperli R, Longo MV, et al. Biomechanical analysis of
sutures used for mesh fixation in the donor area after removal of the
rectus abdominis muscle. J Plast Reconstr Aesthet Surg 2010;63(12):
e807–10.
Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical
perforator-based flaps. Ann Plast Surg 1992;29(1):12–17.
Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus
abdominis muscle. Br J Plast Surg 1989;42(6):645–8.
Kroll SS, Marchi M. Comparison of strategies for preventing
abdominal-wall weakness after TRAM flap breast reconstruction.
Plast Reconstr Surg 1992;89(6):1045–51, discussion 1052–3.
Mathes SJ, Nahai F. General principles. In: Mathes SJ, Nahai F, editors.
Reconstructive surgery: principles, anatomy and technique. New
York: Churchill Livingstone; 1997. p. 3–161.
Munhoz AM, Duarte GG, Fells K, et al. The use of a deep inferior
epigastric perforator flap (DIEP) in a case of severe breast asymmetry
secondary to radiation therapy during childhood. Breast J 2007;13(1):
76–82.
Munhoz AM, Ishida LH, Sturtz GP, et al. Importance of lateral row
perforator vessels in deep inferior epigastric perforator flap harvest­
ing. Plast Reconstr Surg 2004;113(2):517–24.
Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP
flap in total vaginal reconstruction after pelvic exenteration. Plast
Reconstr Surg 2013;132(6):1020e–7e.
Salgado CJ, Orlando GS, Herceg S, et al. Pfannenstiel incision as an
alternative approach for harvesting the rectus abdominis muscle for
free-tissue transfer. Plast Reconstr Surg 2000;105(4):1330–3.
Taylor GI, Corlett RJ, Boy d JB. The versatile deep inferior epigastric
(inferior rectus abdominis) flap. Br J Plast Surg 1984;37(3):330–50.

e112
INTRODUCTION
In 1904, Wiilstein, in Germany, reported the first case of a
jejunal flap. He used the jejunum as a pedicled flap to
reconstruct the thoracic esophagus. In 1907, Roux, in
France, described a successful staged reconstruction of the
esophagus using the jejunum. The most common compli­
cation was necrosis of the most cephalad portion of the
flap. As a result, pedicled jejunal flaps were generally
restricted to esophageal defects below the inferior pulmo­
nary vein.
In 1959, the jejunal free flap was the first reported suc­
cessful free tissue transfer in humans. Seidenberg, without
using the microscope, transplanted a loop of jejunum to the
neck in a patient who had undergone a pharyngoesopha­
gec­tomy. The jejunum has many anatomic advantages: it is
tubed and lubricated, and has peristaltic activity; it also has
a reliable blood supply. It is used for reconstruction of
various defects, including the esophagus and vagina.
REGIONAL ANATOMY
SMALL INTESTINE
The small intestine extends from the pylorus to the ileocecal
valve. It is composed of 3–7 m of duodenum, jejunum, and
ileum (Fig. 38.1). After the first 25 cm of duodenum, the
remaining intestine is divided between jejunum and ileum;
the proximal two-fifths is jejunum and the distal three-fifths
is the ileum. Because the duodenum is a retroperitoneal
structure and the jejunum is intraperitoneal, the beginning
of the jejunum is easily recognized at the ligament of Treitz.
The jejunum and ileum are attached to the posterior
abdominal wall by the mesentery and are arranged in a
series of loops.
MESENTERY
The mesentery is fan-shaped and consists of two layers of
peritoneum containing jejunum and ileum, blood vessels,
nerves, lymph nodes, and fat (Figs 38.1, 38.2). The mesen­
tery is attached superiorly to the posterior abdominal wall
along an oblique line running from the left side of the
Jejunum Flap
Hung-Chi Chen  |  Stefano Spanio di Spilimbergo  | 
Karen Kim Evans  |  Samir Mardini
38 
body of the second lumbar vertebra to the right sacroiliac
joint. This line of attachment is called the “mesenteric
root.” The average length of the mesentery is 20 cm,
being longer in the middle than at the proximal and
distal ends.
JEJUNUM
The jejunum measures approximately 4 cm in external
diameter and 2.5 cm in internal diameter. The jejunal intes­
tinal wall is an important anatomic unit, distinguishing it
from proximal stomach and duodenum and distal ileum.
The jejunal wall contains thick circular folds extending into
the lumen, perpendicular to the long axis. Unlike the
stomach rugae, which disappear on distention, these circu­
lar folds are fixed. They decrease in number and size, pro­
gressing distally toward the ileum, and function to retard
the passage of the food and to increase the surface area for
absorption. Proximally, the circular folds are thicker and
more numerous, the muscle layer is thicker, and the vascu­
larity of the jejunal wall is greater. In the distal ileum, circu­
lar folds are absent and the circular muscle layer is thinner.
In addition, the ileum diameter is smaller (external diam­
eter 3.5 cm; internal diameter 2 cm) and the wall thickness
is considerably less (Fig. 38.3).
The intestinal walls are composed of:
• The serous layer formed of visceral peritoneum and sub­
serous connective tissue
• The muscularis externa, consisting of a thin outer longi­
tudinal layer and a thick inner circular layer
• The submucous layer consisting of nerves, blood vessels,
and lymphatics in loose connective tissue
• Mucous membrane, which lines the jejunum and is also
present in circular folds containing the intestinal villae,
which are more concentrated and longer in the proximal
jejunum.
The physiologic functions of the jejunum are chyme
transport, digestion, absorption of nutrients, and produc­
tion of gut-derived enzymes and hormones. Motility of the
jejunum comprises two basic types of automatic movement:
circumferential segmental contraction and peristalsis. After
transplantation, however, the jejunal segment has a more
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION C  —  LOCAL AND FREE FLAPS IN THE ABDOMEN

CHAPTER 38 — Jejunum Flap
e113
Figure 38.1  (A) The small intestine extends from the pylorus to the ileocecal valve. It is composed of 3–7 m of duodenum, jejunum, and ileum,
as the greater omentum is lifted. After the first 25 cm of duodenum, the remaining intestine is divided between jejunum and ileum: the proximal
two-fifths is jejunum and the distal three-fifths is the ileum. (B) Because the duodenum is a retroperitoneal structure and the jejunum is intra­
peritoneal, the beginning of the jejunum is easily recognized at the ligament of Treitz, which is labeled as the inferior duodenal fold in the
drawing. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Greater omentum (turned up)
Transverse colon (turned up)
Transverse mesocolon
Left colic (splenic) flexure
Right colic (hepatic) flexure
Small intestine (jejunum and ileum)
Ascending colon
Cecum
Small intestine
(covering descending colon)
Sigmoid colon
Urinary bladder
Mesenteric Relations of Intestines
Transverse
colon (elevated)
Transverse mesocolon
Superior duodenal fold
Superior duodenal fossa
Left colic (splenic) flexure
Paraduodenal fossa
Inferior duodenal fossa
Inferior duodenal fold
Mesentericoparietal recess (fossa)
Superior mesenteric artery
in root of mesentery
Inferior mesenteric artery and vein
Abdominal aorta
A
B

e114
PART 4 — CONVENTIONAL WORKHORSE FLAPS
BLOOD SUPPLY OF THE JEJUNUM
The superior mesenteric artery arises from the anterior
surface of the abdominal aorta, approximately 1  cm
inferior to the celiac trunk, and supplies the entire
small bowel and half of the large bowel (Fig. 38.2). It
courses in the mesentery toward the iliac fossa, where
it forms an anastomosis with the ileocolic artery, one of
its own branches. From the right side of the superior
mesenteric artery arise, in descending order, the middle
colic, right colic, and ileocolic arteries. The jejunal and
ileal arteries arise from the left side of the superior
mesenteric artery. Generally, the jejunal arteries are
longer and fewer in number than the ileal arteries (see
below).
varied motility, resulting in anterograde, retrograde, and
peristaltic propulsion.
The clinical, reconstructive significance of jejunal anatomy
lies in the intrinsic suitability of the jejunum for flap forma­
tion, because it has its own series of independent vascular
territories.
ARTERIAL ANATOMY OF THE REGION
All blood supply of the small intestine and large intestine
comes from the superior mesenteric artery and inferior
mesenteric artery, both of which are direct branches of the
abdominal aorta below the celiac artery. All arteries and
veins run within the mesentery, along with lymphatic vessels
and nerves (Fig. 38.2).
Figure 38.2  Arteries of the small intestine. The superior mesenteric artery arises from the abdominal aorta and gives rise to the jejunal and
ileal arteries. The jejunal arteries arise from the left side of the superior mesenteric artery and are approximately 12–15 in number. The jejunal
branches course in the mesentery toward the jejunum. The anastomotic loops (arcades) branch off the jejunal arteries and give rise to the vasa
recta, which are straight, terminal branches that supply the jejunum. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Common hepatic artery
Supraduodenal artery
Gastroduodenal artery
Posterior superior pancreaticoduodenal artery
Right gastro-omental (gastroepiploic) artery
Anterior superior pancreaticoduodenal artery
(Common portion)
Posterior
Anterior
Inferior pancreaticoduodenal
arteries
Anastomosis (inferior
pancreaticoduodenal to
1st jejunal artery)
Right colic artery
Ileocolic artery
Superior mesenteric artery
Anterior cecal artery
Posterior cecal artery
Appendicular artery
Jejunal and ileal (intestinal) arteries
Anastomotic loops (arcades)
Straight arteries (arteriae rectae)
Celiac trunk
Splenic artery and vein
Dorsal pancreatic artery
Inferior pancreatic artery
Superior mesenteric
artery and vein
Middle colic artery (cut)

CHAPTER 38 — Jejunum Flap
e115
NERVES IN THE REGION
The nerve supply of the jejunum is both extrinsic and intrin­
sic. The extrinsic supply is autonomic, from the pregangli­
onic parasympathetic, and postganglionic sympathetic
branches of the celiac plexus. These nerves enter the
jejunum through the mesentery along branches of the large
VENOUS ANATOMY OF THE REGION
The veins that supply the jejunum and ileum accompany
arterial branches of the same name and drain into the supe­
rior mesenteric vein. There are often two venae comitantes
for each mesenteric artery. The walls of the veins within the
mesentery route are thin and fragile (Fig. 38.4).
Figure 38.3  Cross-sectional structure of jejunum (A) and ileum (B). The jejunal wall has many circular folds as compared to the ileum. These
folds retard the passage of food and increase the surface area of absorption. Proximally, the circular folds are thicker and more numerous,
the muscle layer is thicker, and the vascularity of the jejunal wall is greater. In the distal ileum, circular folds are absent and the circular muscle
is thinner. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Mesentery
Anastomotic loop (arcade)
of jejunal arteries
Straight arteries (arteriae rectae)
Serosa (visceral peritoneum)
Longitudinal muscle layer
Circular muscle layer
Submucosa
Mucosa
Circular folds (valves of Kerckring)
Solitary lymphoid nodule
Mesentery
Anastomotic loops (arcades)
of ileal arteries
Straight arteries (arteriae rectae)
Serosa (visceral peritoneum)
Longitudinal muscle layer
Circular muscle layer
Submucosa
Mucosa
Circular folds
Solitary lymphoid nodules
Aggregate lymphoid nodules (Peyer’s patches)
Barium radiograph of jejunum
Barium radiograph of ileum
A
B

e116
PART 4 — CONVENTIONAL WORKHORSE FLAPS
be deceiving because there is an obligate relationship
between the position of the main mesenteric vessels and the
arcade and thus between the arcade and the segment of
jejunum.
The blood supply network to the jejunum is a highly
organized branching network composed of multiple, con­
secutive, tiered vascular loops called arcades. The primary-
order arcades run parallel to one other within the layers
of the mesentery (Figs 38.2, 38.5). These parallel vessels
divide in two branches, one ascending and one descend­
ing, which course parallel to the intestine. These branches
then unite with the adjacent branches coming from the
closest jejunal arteries, thus forming an anastomotic
arcade. The second-tier arcade is then formed off the
primary arcade loop. In the same way, smaller vessels
arising from the secondary arcades can form arcades of
third or fourth order.
From the last arcade (which is the last arch parallel to the
intestine) arise the vasa recta, which form the direct and
final blood supply to the jejunum. The vasa recta are termi­
nal vessels measuring approximately 4–6 cm (Figs 38.2,
38.5). One to two vasa recta supply a distinct area of jejunum
(approx. 1 cm per vasa recta unit), thus the blood supply to
the jejunum is described as segmental. These small vessels
encircle the bowel and then circumferentially traverse only
half of the intestine wall, between the muscle and the
mucosa, forming a dense submucosal plexus. The least,
although adequately, vascularized part of the bowel wall is
along the antimesenteric border, 180° from the mesenteric
attachment.
vessels. The intrinsic nervous system is formed by the myen­
teric plexus of Auerbach, between the muscle layers and the
submucosal plexus of Meissner. Fibers from the Auerbach
plexus supply the muscularis externa, whereas Meissner’s
plexus supplies the muscularis mucosa. Reflex arcs, involv­
ing afferent stimuli from the mucosal surface, and efferent
motor activity within the myenteric plexus, seem to be
responsible for the autonomous movements of the jejunum,
when isolated from its extrinsic nerve supply. Such move­
ments, however, are not significantly reduced by a complete
myotomy.
FLAP ANATOMY
ARTERIAL SUPPLY OF THE FLAP
The jejunum has its own series of independent vascular ter­
ritories, corresponding to loops. These loops or segments,
measuring up to 25 cm in length, are usually supplied by a
single arteriovenous pedicle and maintain at least some
autonomous cephalocaudad motility (Fig. 38.2).
JEJUNAL ARTERY
Length: 5 cm (range 4–6 cm)
Diameter: 2.0 mm (range 1.5–2.5 mm)
The overall length of the pedicle varies between 15 and
20 cm, considering the course of the vessels within the
mesentery. The overall length of the pedicle may
Figure 38.4  Veins of the small intestine. The jejunal veins accompany the arteries in the mesentery. They all drain eventually to the middle
colic vein and into the superior mesenteric vein. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Hepatic portal vein
Left gastric vein
Splenic vein
Superior mesenteric vein
Jejunal and ileal (intestinal) veins
Anastomotic loops
Straight veins (venae rectae)
Right
gastric vein
Middle colic
vein (cut)
Right
colic vein
Ileocolic vein
Transverse colon (elevated)
Transverse mesocolon
Superior mesenteric artery and vein
Jejunal and ileal (intestinal) vessels
Relations of superior
mesenteric vein and artery
in root of mesentery

CHAPTER 38 — Jejunum Flap
e117
and esophageal reconstruction, and minimize complica­
tions because of the low number of suture lines.
• Flap harvest is quick and simple.
• Jejunum diameter approximates that of the esophagus.
• As a free flap, the vascular pedicle can be lengthy (up to
15–20 cm), with vessels of suitable external diameter
(artery 1.5–2.5 mm; vein 2–4 mm).
• The jejunum can be considered relatively sterile and is
relatively free of intrinsic disease.
• The jejunum maintains its mucosa at long-term follow-up.
There is no metaplasia/dysplasia that can be seen in the
residual esophagus such as after the gastric pull-up
procedure.
• The accompanying mesentery can be employed to cover
vital neck structures and can provide a suitable bed for
skin grafting if needed.
• The length of jejunum available for transplantation
ranging 7–25 cm, based on only one pedicle.
• As a pedicled flap, the jejunum can replace the whole
esophagus; however, in adult patients, it is necessary to
supercharge the flap.
• A portion of the jejunal segment may be split along its
antimesenteric border, creating a vascularized patch,
which is suitable for reconstruction of partial circumfer­
ential defects or for providing oral lining.
• When used as a buried flap, monitoring can be under­
taken by exteriorizing a segment.
• The pedicled jejunum flap is ideal for vaginal reconstruc­
tion because it is mucosalized and tubular.
DISADVANTAGES
• In experimental models, the jejunal flap may be more
susceptible to harmful effects of ischemia. Clinically, an
ischemia time of around 2 h has not shown adverse
effects.
• The length of the pedicle may be deceiving because
there is an obligate relationship between the position
of the main mesenteric vessels and the arcade and thus
between the arcade and the segment of jejunum.
• There is a mortality rate between 2.4% and 5% when
using jejunal flaps for reconstruction of esophageal
Depending on the length of the jejunum flap to be trans­
ferred, the vascular arches to be harvested must be carefully
dissected toward the main jejunal branch off the superior
mesenteric artery.
VENOUS DRAINAGE OF THE FLAP (Fig. 38.4)
Primary:  jejunal veins accompany arterial branches of the
same name
Length: 5 cm (range 4–6 cm)
Diameter: 2 mm (range 3–4 mm)
The veins within the mesentery are thin and fragile and
the utmost care has to be taken during dissection, especially
when the mesentery has an abundance of fat (Fig. 38.4).
FLAP INNERVATION
Sensory:  There is no true sensory innervation of this flap.
Bowel wall distention causes pain because of the overlying
visceral peritoneum which has proprioceptor pain fibers.
This reflex arc does not appear to be intact after
transplantation.
Motor:  Afferent stimuli from the mucosal surface elicit
efferent motor activity within the myenteric plexus, which
is responsible for the autonomic peristalsis. The trans­
planted jejunum shows episodes of peristalsis and quies­
cence. The peristaltic wave follows the luminal distention of
the jejunal segment. This peristalsis is not coordinated to
distal esophageal motility when transferred to the
esophagus.
FLAP COMPONENTS
The jejunum is harvested with its mesentery, which contains
the vessels that supply it and the lymph nodes that drain it.
ADVANTAGES
• The tubed nature of the jejunum and its peristaltic activ­
ity provide functional benefits when used for pharyngeal
Figure 38.5  The vascular arcades within the mesentery. (A) Arcades of primary, secondary, and third order. (B) Close-up view of the terminal
branches called vasa recta.
Arcade of third
order
Arcade of
second order
Arcade of primary
order
Vasa recta
B
A

e118
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 38.6  Abdominal wall anatomic landmarks. (1) spleen; (2)
liver; (3) gallbladder; (4) duodenum; (5) appendix; (6) root of small
bowel mesentery. For the open approach, a standard midline incision
is made from xiphoid to pubic tubercle. In this illustration, one can
see the approximate location of the root of the mesentery (6), and the
end of the duodenum (4), which marks the beginning of the jejunum
at the ligament of Treitz. (With permission from Lumley JSP. Surface
anatomy. 3rd ed. Philadelphia: Churchill Livingstone; 2002.)
1
2
3
4
5
6
defects. This rate is similar to using gastric pull-up and
colonic interposition.
• Fistula rates continue to range between 1.8% and 30%.
• The patient will require either a laparotomy or laparoscopy-
assisted approaches to the abdomen, which carry their
own inherent risks.
PREOPERATIVE PREPARATION
A thorough history and physical examination are per­
formed, including previous intra-abdominal surgeries, med­
ications that may interfere with coagulation, nutrition, and
pulmonary status. No special preoperative studies are neces­
sary. If intra-abdominal aortic vascular occlusive disease is
suspected, an angiogram may be obtained, although this is
rarely, if ever, necessary. Standard bowel preparation and
bowel perioperative antibiotics are given. In general, obese
patients have a fattier mesentery, which makes vessel dissec­
tion more precarious.
Contraindications to surgery are the presence of ascites,
chronic intestinal diseases such as Crohn’s disease, and pre­
vious extensive jejunum harvestings. Harvest of jejunal flaps
can be done more than once.
FLAP DESIGN
ANATOMIC LANDMARKS
Standard midline laparotomy or laparoscopy-assisted inci­
sions are used (Fig. 38.6). Intra-abdominally, the ligament
of Treitz in the left upper quadrant of the abdominal cavity
marks the beginning of the jejunum. The superior mesen­
teric artery arises from the anterior surface of the abdomi­
nal aorta, approximately 1 cm inferior to the celiac trunk,
and the jejunal and ileal arteries arise from the left side of
the superior mesenteric artery.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Depending on the location of esophageal resection, the
patient can be evaluated for a free or a pedicled flap.
As a free flap, the jejunum is generally used for microsur­
gical tissue transplantation to replace any part of the
esophagus or hypopharynx. As a pedicled flap, it can be
used to reconstruct the more distal, thoracic esophagus
(interposition-like graft) or the vagina. The free jejunal
flap is harvested from the second or third loop, whereas
the fourth loop is usually used for a pedicled flap. This is
because more length of pedicle can be obtained from the
more distal jejunum by unfurling the bowel loops and
elongating the arcades. For supercharging the pedicled
flap, the third or second jejunal artery is used. If only a
patch is required, the antimesenteric border of the
jejunum can be opened and used reliably as a patch
esophagoplasty.
SPECIAL CONSIDERATIONS
JEJUNUM AS A CONDUIT (Case 38.2)
The jejunum is generally used as a conduit for circumferen­
tial reconstruction of esophageal, hypopharyngeal, and
vaginal defects (Fig. 38.7). There is no size mismatch
between the cervical esophagus and jejunum, so no special
design of the segment is required.
However, for oropharyngeal resection, the jejunum must
be tailored to match the much larger oropharynx (Fig.
38.8). The options are:
• Adapt the diameter of the hypopharynx.
• Adapt the shape of the jejunum through several maneu­
vers such as fish-mouth-type opening: the antimesenteric
border of the jejunum is opened enough to create a
better size match. The problem with this technique is the
possibility of kinking.
• Double-barreled jejunum: the jejunum is folded and a
side-to-side jejunostomy using a gastric stapling device is
performed on the antimesenteric border. This is per­
formed on the proximal aspect of the flap.
After radical surgery for cancer, a pedicled segment of
jejunum can be utilized as a pouch to reconstruct the vagina:
the upper end of the conduit is closed and the lower end is
sutured at the perineum to the remnant of vagina.
JEJUNUM AS A PATCH
The jejunum can be used as a patch if there is a partial
defect of the hypopharynx, a mucosal defect of the oral
cavity, after esophagoplasty or after release of a focal stric­
ture. When the jejunum is used for non-circumferential
reconstruction, similar to a patch flap, it is split along the
antimesenteric border. This patch can be transferred as
either a pedicled or free flap (Fig. 38.9).

CHAPTER 38 — Jejunum Flap
e119
Figure 38.8  Different ways to adapt the diameter of the hypopharynx and the jejunum. (A) The hypopharynx can be modified to fit the diameter
of the jejunum. (B) The double-barreled jejunum.
Jejunum
Hypopharynx
A
Distal jejunum
Base of tongue
Oversewn proximal
end of jejunum
Jejunojejunostomy
B
Figure 38.7  (A) The standard flap is depicted as a jejunal conduit. (B) Jejunal conduit placed for cervicoesophageal reconstruction.
A
Esophageal defect
Jejunal
conduit
B
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
As a free flap, the second or third loop is usually har­
vested, based on the second or third jejunal artery. For a
pedicled jejunum, the fourth jejunal loop is harvested and
the fourth jejunal artery functions as the distal vascular
pedicle to the mobilized jejunal conduit. The third jejunal
artery is ligated and divided close to its origin from the
superior mesenteric artery for supercharging. The mesen­
tery of the jejunum is then divided at the serosal border
between the second and third jejunal arteries, allowing
the conduit to completely unfurl. This straightens the
sinusoid turns in the small bowel caused by a naturally
foreshortened mesentery.
FLAP DIMENSIONS
Any length of jejunum 7–25 cm may be transferred on
one vascular pedicle. The bowel lumen diameter is
3–5 cm.

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 38.9  Jejunum as a patch. The jejunum can be used for non-
circumferential reconstruction, similar to a patch flap. It is split along
the antimesenteric border to expose the mucosa. This patch can be
transferred as either a pedicled or free flap.
Jejunal patch
FLAP MARKINGS
Abdominal incisions are marked (Figs 38.6 and 38.10). After
identification of the jejunum segment, the proximal and
distal ends must be marked so that the segment is trans­
ferred in the same isoperistaltic anatomic orientation.
PATIENT POSITIONING
The patient is placed in the supine position. In cases of
esophageal reconstruction, two teams work simultaneously:
one team prepares the neck recipient site, while the abdom­
inal team harvests the jejunum.
ANESTHETIC CONSIDERATIONS
The patient is given general endotracheal anesthesia.
TECHNIQUE OF FLAP HARVEST
HARVESTING JEJUNUM AS A FREE FLAP
(Fig. 38.10)
Either a midline laparotomy or laparoscopy-assisted inci­
sions are made (Fig. 38.10A). After reflecting the transverse
colon and stomach superiorly, the ligament of Treitz is iden­
tified in the left upper quadrant (Fig. 38.10B,C). The small
bowel is followed to approximately 40–60 cm below the liga­
ment of Treitz (Fig. 38.10D), where the vascular arcades are
evaluated by transillumination (Fig. 38.10E). A segment of
jejunum is selected and measured longer than the defect.
Exact tailoring of flap length will be performed later during
inset. The jejunal segment is centered on a proximal jejunal
artery and vein of suitable diameter.
The site of jejunal transection is marked either by sutures
or marking solution both proximally and distally (Fig.
38.10F). It is mandatory to remember to identify the proxi­
mal portion of the jejunal segment (we usually mark the
proximal end with one suture and the distal end with two
sutures), in order to perform the inset in an isoperistaltic
position. With the bowel marked, the mesentery is scored
using electrocautery, from the bowel margin toward the
center to expose the vascular pedicle. The mesentery is
completely divided on each side and the vasa recta are then
selectively clamped, ligated, and transected.
Mesentery and vascular arcades are clamped and tran­
sected on either side of the donor vascular pedicle. In this
manner, a fan-shaped segment of mesentery attached to the
jejunal segment is dissected and attached only to the donor
vascular pedicle and the jejunum more distally.
Special care must be taken in patients with extensive
mesenteric fat to avoid damage to branches of the mesen­
teric vessels. Vessel loops are not recommended because
they produce spasm and trauma to the pedicle vessels.
The bowel is then clamped using atraumatic bowel
clamps both proximally and distally at sites previously
marked (Fig. 38.10G). The jejunal segment is isolated on a
single jejunal artery and vein; it is observed for adequate
perfusion and peristalsis. Harvest of the bowel is performed
using standard intestinal stapling devices, and intestinal
continuity is reestablished using either side-to-side or end-
to-end closure (Fig. 38.10H).
Under loupe magnification, the donor jejunal artery and
vein, arising from the superior mesenteric vessels at the root
Figure 38.10  (A) After opening the abdomen, the greater omentum is encountered. (B) The greater omentum is reflected to reveal the small
bowel. (C) The greater omentum and transverse colon are reflected to reveal the ligament of Treitz. (D) The jejunal segment is identified and
mesentery containing the arteries and veins is noted. (E) The jejunal mesentery is transilluminated to determine the course of the vessels. Dis­
section of the vasa recta and arcades is begun down to the main jejunal branch. (F) The site of the jejunal transaction is marked either by
sutures or marking solution both proximally and distally. It is mandatory to remember to identify the proximal portion of the jejunal segment
(we usually mark the proximal end with one suture and the distal end with two sutures), in order to perform the inset in an isoperistaltic posi­
tion. With the bowel marked, the mesentery is scored using electrocautery, from the bowel margin toward the center to expose the vascular
pedicle. The mesentery is completely divided on each side and the vasa recta are then selectively clamped, ligated, and transected. (G) The
bowel is then clamped and observed for peristalsis and perfusion. (H) Harvest of the bowel is performed using standard general surgery,
stapling devices or hand-sewn techniques, and intestinal continuity is reestablished using either side-to-side or end-to-end closure. (I) Under
loupe magnification, the donor jejunal artery and vein, arising from the superior mesenteric vessels at the root of the mesentery, are identified
and dissected free from the surrounding tissues. (J) When the recipient site dissection is complete, the jejunal segment is harvested from the
abdomen after dividing its blood supply at its origin from the superior mesenteric vessels. The jejunal artery at the donor site is tied and suture
ligated. (A, B and C, reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)

CHAPTER 38 — Jejunum Flap
e121
D
E
F
G
J
I
H
Falciform ligament
Left lobe of liver
Right lobe of liver
Stomach
Gallbladder
Greater omentum
overlying transverse
colon and small intestine
(jejunum and ileum)
A
Greater omentum (turned up)
Transverse colon (turned up)
Transverse mesocolon
Left colic (splenic) flexure
Right colic (hepatic) flexure
Small intestine
(jejunum and ileum)
Ascending colon
Cecum
Small intestine (covering
descending colon)
Sigmoid colon
Urinary bladder
B
Mesenteric Relations of Intestines
Transverse
colon (elevated)
Transverse mesocolon
Superior duodenal fold
Superior duodenal fossa
Left colic (splenic) flexure
Paraduodenal fossa
Inferior duodenal fossa
Inferior duodenal fold
Mesentericoparietal recess (fossa)
Superior mesenteric artery
in root of mesentery
Inferior mesenteric artery and vein
Abdominal aorta
C

e122
PART 4 — CONVENTIONAL WORKHORSE FLAPS
If further length for the arterial anastomosis is needed,
the intestinal artery can be mobilized from its arcade using
an operative microscope; tributaries are usually ligated
using ligaclips (Fig. 38.11). Microsutures such as 8-0 or 9-0
polypropylene (Prolene) are used to tie off the main vessel
trunk and reverse flow down the marginal vessel back to the
main trunk. This technique can provide 2–3 cm of extra
length; however, care must be taken to avoid devasculariza­
tion of the graft during detachment of the artery.
If warm ischemia time is prolonged, the detached jejunal
segment can be cooled by a double-lumen glass tube placed
within the bowel lumen. Cooled saline (4°C) is run continu­
ously through the tube. This technique is useful during
further pedicle dissection under the microscope. The intes­
tine segment is continuously moistened with Ringer’s lactate
solution and covered with laparotomy sponges.
HARVESTING JEJUNUM AS PEDICLED FLAP FOR
ESOPHAGEAL RECONSTRUCTION (Case 38.3)
Due to the arc of rotation, the more distal jejunum is more
appropriate for a pedicled flap for esophageal reconstruc­
tion. Usually, the fourth loop is chosen, based on the fourth
jejunal artery, which functions as the distal vascular pedicle
to the mobilized jejunal conduit. The third jejunal artery is
ligated and divided close to its origin from the superior
mesenteric artery in order to retain length for supercharg­
ing. The mesentery of the jejunum is then divided to the
serosal border between the second and third jejunal arter­
ies, allowing the conduit to completely unfurl. This straight­
ens the sinusoid turns in the small bowel caused by a
naturally foreshortened mesentery (Fig. 38.12).
If a longer segment is needed, the second jejunal artery
is divided. If more length is needed, one or more of the
secondary arcades must be dissected and ligated. These
secondary arcades resemble truncated cones with relatively
narrow proximal bases, longer sides, and wider distal bases.
Once they are divided along the proximal bases, consider­
able lengthening and unfurling of the redundancy of the
bowel can occur. In addition, the disparity between intesti­
nal and mesenteric lengths is decreased.
Before one divides any point of the arcade, however, it is
important to ensure that the blood supply after division will
be adequate. It is useful to temporarily clamp the vessels
prior to division to ensure blood supply. The deep arcades
with large secondary arcades should be divided first; division
is avoided when the reverse is true – that is, the proximal
vessel is large and the secondary vessels are small. When an
adequate length of jejunum has been prepared, the jejunal
limb is brought through a hole made in the mesocolon and
gastrocolic ligament, toward the neck. In addition, a micro­
anastomosis must be performed to augment arterial and/
or supercharge the venous return for a total esophageal
reconstruction.
HARVESTING PEDICLED JEJUNAL FLAP FOR
VAGINAL RECONSTRUCTION (Case 38.4)
The fourth loop of jejunum is chosen for vaginal reconstruc­
tion. Prior to committing to any loop of intestine, the
surgeon should attempt to move the segment to the recipi­
ent area and get an idea of the arc of rotation and the
Figure 38.11  How to gain additional length of the pedicle by dis­
section of adjacent arcades.
Vein
Artery
A
Vein
Artery
B
Vein
Flow
Artery
C
of the mesentery, are identified and dissected free from the
surrounding tissues (Fig. 38.10I). Careful dissection of
the jejunal vein is essential as the wall is thin and fragile.
The dissection begins from the superior mesenteric vessel
toward the mesenteric border of the jejunal segment, at the
sites of future proximal and distal bowel transection. We
reserve dissection of the artery and vein at its proximal end
until the end of the flap harvest when the flap is completely
ready for transfer and the recipient site is prepared. This
allows for immediate clamping and transection and transfer
of the flap if problems related to bleeding occur. When
the recipient site dissection is complete, the jejunal segment
is harvested from the abdomen after dividing its blood
supply at its origin from the superior mesenteric vessels
(Fig. 38.10J). The jejunal artery at the donor site is doubly
ligated and a stick tie is placed.

CHAPTER 38 — Jejunum Flap
e123
long segment of jejunum (up to 25 cm) and mesentery is
harvested. Excess portions of jejunum are separated from
the mesentery and discarded, leaving a portion of mesen­
tery. This mesentery, separated from the jejunum, can be
used in variety of ways: as a soft tissue flap for coverage, for
protecting the carotid vessels in the neck, filling dead space,
and providing coverage over the intestinal anastomosis or
the vascular pedicle.
A FREE OR PEDICLED JEJUNAL PATCH
The jejunum can be split to be used as a patch for pharyn­
geal or esophageal reconstruction, or as lining for the oral
cavity. The jejunum is first divided along the antimesenteric
border, cut to size and shape, and sutured into the defect
(Fig. 38.13).
FREE JEJUNUM AS A DIVERSIONARY CONDUIT
FOR SWALLOWING
In patients with severe dysphagia, such as those with exten­
sive corrosive disease and a nonfunctioning epiglottis, a
diversionary conduit can be helpful to allow swallowing
(Fig. 38.14). Indications for this procedure include severe
pharyngoesophageal and epiglottis injuries. This technique
can be used in patients with stroke who, after prolonged
and exhausted rehabilitative effort, continue to fail to
swallow. The senior author (H-CC) introduced this tech­
nique, which allows patients to restore alimentation
through the mouth while maintaining a patent oral
airway.
feasibility of the transfer. The harvest is similar to harvesting
pedicled jejunum for head and neck reconstruction (see
above). A 15 cm section of jejunum is isolated and trans­
posed to the pelvis with one end closed in two layers to form
the upper blind pouch. The perineum is approached simul­
taneously through the open abdominal cavity and transvagi­
nally to create a space for the neovagina. The distal end of
the pedicled jejunum is sutured carefully in two layers to the
remnant of the native vagina. An obturator is used to prevent
postoperative stricture formation.
FLAP MODIFICATIONS/FLAP HANDLING
SUPERCHARGING A PEDICLED JEJUNUM
(Case 38.3)
An additional anastomosis between one of the pedicles of
the jejunum and a vessel at the recipient site augments the
arterial inflow and/or venous outflow. This is usually done
in the setting of a pedicled jejunum flap for more proximal
esophageal reconstruction. As the fourth jejunal vessels are
supplying the pedicled flap, the second or third vessels can
be anastomosed to appropriate recipient vessels (superior
thyroid, thoracoacromial, usually the pectoral branch, trans­
verse cervical, or internal mammary).
THE JEJUNUM-MESENTERIC FREE FLAP
The jejunum can be harvested with a segment of mesentery
and transferred as a free flap. With this technique, a very
Figure 38.12  Pedicled jejunum. (A) The more distal jejunum is more appropriate for a pedicled flap for esophageal reconstruction. (B) The
third jejunal artery is ligated and divided close to its origin from the superior mesenteric artery in order to retain length for supercharging. The
mesentery of the jejunum is then divided to the serial border between the second and third jejunal arteries, allowing the conduit to completely
unfurl. This straightens the sinusoid turns in the small bowel caused by a naturally foreshortened mesentery.
A
B

e124
PART 4 — CONVENTIONAL WORKHORSE FLAPS
contracture by disrupting the circular muscle of the jejunum.
The proximal end of the jejunum is then sutured to the oral
mucosa, with the buccal side slightly higher than the gingi­
val side. The jejunum is inset in an isoperistaltic direction.
After inset, revascularization is performed to suitable recipi­
ent vessels in the neck. The lower end of the jejunal segment
is then anastomosed end-to-end or end-to-side (whichever
is appropriate) to the cervical esophagus or the upper end
of the thoracic esophagus. The patient must re-learn how
to swallow by forcing food into the conduit (Fig. 38.14).
JEJUNUM FOR VOICE RECONSTRUCTION
After total pharyngolaryngectomy, a free jejunum flap can
be used for esophageal reconstruction combined with voice
reconstruction (Fig. 38.15). The jejunal flap is divided in
two parts with a common vascular pedicle. The first part is
used for esophagus reconstruction and the second part for
creation of a voice tube. The upper end of the voice tube is
joined to the cervical esophagus in an end-to-side manner
with a shunt size of 0.5 cm in diameter. The lower end is
anastomosed to the proximal end of the trachea stump in
an end-to-end fashion or to the side of the trachea in an
end-to-side fashion. When the patient wants to speak, he or
she places a finger on the tracheostoma, occluding air
outflow, and the air is diverted to the voice tube. The air
flows from the trachea through the TE shunt, and then into
the pharynx for articulation.
SPECIAL INSTRUMENTS
Standard general and microsurgical instruments are used.
The MacCollum–Dingman breast dissector (Padgett Instru­
ments Inc., Kansas City, MO) can aid in dissecting the sub­
sternal space if a pedicled jejunum is to be used.
A curvilinear incision is made on the left side of the neck,
below the mandibular margin and extending to the clavicle.
Musculocutaneous flaps are raised subplatysma for place­
ment of the pedicled jejunum. An oral incision is made in
the lower left gingivobuccal sulcus behind the second pre­
molar tooth and extending 3 cm mesially. Care is taken not
to injure the mental nerve. Approximately 0.5 cm of the
lower anterior cortex is burred and contoured to allow
space for the transferred jejunal segment. A 1 cm incision
is made on the antimesenteric border of the jejunum to
increase the circumference of the anastomosis between the
jejunal flap and the oral mucosa. This helps to prevent
Figure 38.13  A free jejunal patch flap was used to reconstruct a
non-circumferential esophageal defect.
Figure 38.14  Diversionary conduit created from the anterior gingi­
vobuccal sulcus to the distal aspect of the cervical esophagus. The
proximal part of the esophagus is either left as is or diverted to the
skin. In this illustration, the stricture allows for adequate drainage of
the saliva. It is safer to divert the proximal aspect to the skin in order
to avoid choking if fluid or solid food is misdirected to the posterior
aspect of the oral cavity during feeding.
Figure 38.15  Jejunum for voice reconstruction. The jejunal flap is
divided in two parts with a common vascular pedicle. The first part
is used for esophagus reconstruction and the second part is used for
creation of a voice tube.

CHAPTER 38 — Jejunum Flap
e125
coverage. External compression can compromise the
blood supply.
• Suction saliva from the patient’s mouth for the first 3 days.
Saliva accumulation can cause distention of the jejunal
segment.
• Take care to transfer the appropriate length of jejunum. A
segment that is too long and redundant will cause dyspha­
gia. After revascularization, the jejunal segment will elon­
gate and necessitate proper tailoring.
• Do not dissect the proximal end of the jejunal vessels until
the flap is almost completely harvested and the recipient
site is prepared. If bleeding occurs during dissection of
the proximal jejunal vessels, the flap would be ready for
transfer.
FLAP USAGE
PEDICLED
• After total esophagectomy, when stomach or colon are
not available for pull-up. Supercharging is necessary in
adult patients
• Reconstruction of the thoracic esophagus, as an intra­
posed flap between the stomach and the cervical
esophagus
• Reconstruction for the short gut syndrome
• Vaginal reconstruction
• Closure of enteric-cutaneous fistula by splitting the
jejunum along the antimesenteric border and removing
the mucosal layer to create a seromuscular flap
FREE FLAP
• Cervical esophagus, as a conduit
• Hypopharynx, as a conduit
• Urethral substitution, as a conduit
• Vaginal reconstruction, as a pouch
• Repair of esophageal stricture, as a patch
• Intraoral mucosal lining, as a patch
INDICATIONS BY REGION
• Head and neck: cervical esophagus, hypopharynx, intra­
oral lining
• Trunk: the whole esophagus or the thoracic esophagus as
interposed flap, vagina, urethra
TYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
ESOPHAGEAL RECONSTRUCTION
When considering reconstructive options for esophageal
defects, the following factors should be considered:
• Location and length of the defect
• Previous attempts at reconstruction and the reasons for
failure
• Past history of other abdominal surgeries
• Previous radiation therapy
• Wound-healing problems
• Swallowing goals
DONOR SITE CLOSURE AND
MANAGEMENT
After harvesting the segment of jejunum, the transected
intestine is reanastomosed by standard general surgery
principles. The two ends are either hand sewn or stapled
end-to-end or end-to-side. Hand-sewn anastomoses are typi­
cally performed in a two-layer fashion: an interrupted
mucosal-muscularis 3-0 Vicryl suture and a 3-0 silk inter­
rupted imbricating serosal suture. The mesentery is reap­
proximated with a running suture to prevent herniation.
The abdomen is then closed in layers: peritoneum, fascia,
and skin sutures. Two large drains are usually placed, one
for each side of the abdomen cavity, and appropriate dress­
ings are applied.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• Decrease the ischemia time. Recipient vessel exposure and
preparation of the defect should be completed prior to
dividing the flap pedicle. The jejunal flap is placed in the
appropriate position in the neck. The mesentery is placed
in a position where the pedicle vessels can reach the
recipient vessels. Several 5-0 chromic sutures are placed
securing the mesentery to surrounding structures. This
prevents movement and traction on the pedicle during
flap inset. The vein is anastomosed first, clamps are
released, and then the arterial anastomosis is performed.
If the arterial anastomosis is performed first, we prefer
not to release the vascular clamps until both the artery
and vein anastomoses are completed. Note that damage
to the intima can occur if the vascular clamp is in place
for a prolonged period.
• Choose a large recipient vein. A large branch off the internal
jugular or the external jugular is a good recipient vessel.
The jejunum vein can also be sutured in an end-to-side
fashion to the internal jugular vein if the above two
options are not available.
• Watertight closure should be done at the junction of the jejunal
segment and pharynx. Use a two-layered closure. Ensure
proper positioning after surgery to prevent hyperexten­
sion of the neck and subsequent tearing of the sutures.
After the procedure, avoid violent coughing, which can
damage the closure.
• Avoid stricture at the junction between the jejunum and the
smaller thoracic esophagus. Increase the diameter of the
esophagus by making a small cut at the thoracic esopha­
gus. Use manual sutures instead of a stapling device. Insert
two intraluminal drains for stenting and drainage.
• Place drains in the neck prior to closing skin. Non-suction
drains are used on the side of the recipient vessels and
bulb suction drains are used on the opposite side.
• Avoid intestinal leak. Use excess mesentery to seal off the
upper and lower anastomotic sites. Primary healing is
important for future function. A leak will cause inflam­
mation and later stricture. In addition, it will prolong
hospitalization and delay timing for radiation therapy.
• Avoid tight closure of the neck wound. If necessary, a local flap
(deltopectoral or pectoralis major flap) can be used for

e126
PART 4 — CONVENTIONAL WORKHORSE FLAPS
We usually choose the transverse cervical artery as the
recipient artery, because it is anatomically distant from pos­
sible sites of bowel leakage, and we have found that these
vessels are in good condition. Other choices for arterial
anastomosis are the superior thyroid artery, and the lingual
or the facial artery. The lingual and facial arteries are not
usually employed because they are much smaller than the
jejunal artery and far from the recipient vein.
Using an operating microscope, the recipient and donor
vessels are irrigated with heparin solution, and standard
end-to-end or end-to-side microsurgical anastomosis is made
with 9-0 or 10-0 interrupted nylon sutures. Following anas­
tomosis, the clamps are removed to check the patency of
the vessels and pulsation within the mesentery as well as
bleeding from the cut edges of the bowel. Visible disordered
peristalsis, spontaneous and mechanically induced, should
be present within the flap, and the color of the mucosa
should rapidly become pink. The proximal anastomosis
between the bowel and the cervical esophagus is carried out
with a two-layer suture technique. The jejunum is observed
for about 10 min, before reducing its length, in order to
avoid any redundancy.
Repair of Esophageal Stricture Using
Free Jejunal Patch Flap
First, the esophageal stricture is removed and the defect size
is calculated. A larger segment of jejunum is harvested. The
jejunum is split along the antimesenteric border and tai­
lored to match the defect size, discarding the rest of the
harvested intestine. The patch is fixed with a few sutures to
the border of the defect. The vascular anastomosis is per­
formed and the patch is sutured in place (Fig. 38.13).
When the esophageal defect is short and starts from
the hypopharynx, the free jejunal flap is the first choice
for reconstruction. When the defect starts from the oro­
pharynx, the free colon transfer, or a double-barreled
jejunum flap, can be used to match the large circumfer­
ence of the defect. The jejunum has superior swallowing
function due to its intrinsic peristalsis. If the defect is
partial circumference, we suggest using a free jejunal
patch flap. Of note, in patients with vascular disease, the
small bowel vasculature may be spared, in contrast to
the colonic vessels, which may have more evidence of
atherosclerosis.
For replacement of the entire esophagus, alternatives are
the gastric pull-up or a pedicled colon. If the stomach or
colon is not available, the esophagus can be reconstructed
with a pedicled jejunum. A segment up to 30–40 cm is
mobilized on the fourth jejunal artery and additional micro­
vascular anastomosis is performed at the neck vessels,
according to the supercharging technique, to provide
better nourishment to the distal part of the transposed
intestine.
After total pharyngolaryngectomy, the jejunum can be
used to reconstruct the cervical esophagus, a tracheo-
esophageal fistula is created, and a one-way valve prosthesis
is inserted for voice rehabilitation. If a prosthesis is not
favored for use, two segments of jejunum can be used to
reconstruct the cervical esophagus and to create a voice
tube. If a prosthesis is not chosen for voice reconstruction,
we prefer a free ileocolon flap over having two jejunal seg­
ments for reconstruction of esophagus and voice. The colon
is used for esophageal reconstruction and the ileum is used
for creation of a voice tube. The ileocecal valve functions as
a one-way valve to prevent reflux of saliva and fluids into the
trachea. These techniques are used for patients who are
expected to have long-term survival.
Reconstruction of the Cervical Esophagus or
Hypopharynx Using Free Jejunum (Case 38.1)
The jejunal segment, isolated on its mesenteric pedicle, is
transferred to the neck when the recipient vessels have been
isolated by the team performing the tumor resection. The
abdomen is subsequently closed. The transplantation of the
jejunal segment is performed by the microsurgical team,
who will additionally close the neck wound.
Before the microsurgical anastomosis, the jejunal segment
is tacked in place with several 4-0 nylon sutures to prevent
it from falling from the field or placing undue stretch on
the microsurgical anastomosis. The bowel must be placed
in an isoperistaltic position.
It is important to note that the length of the pedicle may
be deceiving due to the intertwined relationship between
the position of the main mesenteric blood vessels and the
arcade and thus between the arcade and the segment of
jejunum. Additional length can be obtained by resecting
bowel from the edge of the mesentery, thus in effect length­
ening the overall pedicle (Fig. 38.16).
We first perform the venous anastomosis. This is
usually end-to-end to a branch of the internal jugular vein
and/or end-to-end to the external jugular vein. The venous
anastomosis is performed before the arterial, because perfu­
sion will engorge and enlarge the mesenteric vein, making
anastomosis technically challenging.
Figure 38.16  Lengthening the pedicle. How to move and lengthen
the pedicle by resecting distal or proximal bowel.
Lines of division
for moving
pedicle up
Lines of division
for moving
pedicle down

CHAPTER 38 — Jejunum Flap
e127
• The cervical bowel anastomosis is completed in two layers.
• Trim the jejunum to eliminate redundancy.
• In the abdomen, the distal part of the jejunum is anasto­
mosed to the posterior wall of the stomach in a retrocolic,
retrogastric manner with a circular stapler.
• In the absence of a stomach, a Roux-en-Y anastomosis is
performed.
Reconstruction of the Thoracic Esophagus with
Pedicled Jejunum Interposition
Resection and reconstruction of the thoracic esophagus
occur through a thoracotomy. The right thoracic cavity is
opened through the 3rd and 7th intercostal spaces, with a
longitudinal midaxillary skin incision. The affected portion
of esophagus is resected or, in cases of atresia, the length
of the defect is grossly measured. The wound is closed
temporarily.
The abdomen is opened, the jejunum is harvested based
on the 3rd or the 4th jejunal vessels, and the bowel is
divided in two different sites. The terminal vessels are
divided along the distal part of the free jejunum until ade­
quate length of pedicle is obtained. The devascularized
bowel is discarded and the transplant is prepared. The vas­
cular pedicle reaches a sufficient length to connect the
transplant to the neck when approximately 30 cm of
jejunum are sacrificed.
After restoring the bowel continuity, the vascular pedicle
is passed posterior to the transverse colon and stomach into
the esophageal hiatus of the diaphragm and into the right
thoracic cavity. Finger dissection is used to dilate the hiatus.
A pyloroplasty could be useful to prevent reflux. The
abdomen is closed and the thorax is opened again.
The length of the graft is adjusted to bridge the gap. Both
upper and lower end-to-end esophagojejunostomies are
performed with two layers. When the distal esophagus must
be excised, as in cases of peptic stricture, a jejunogastros­
tomy is done distally. The thorax is closed with a chest drain­
age tube.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
PEDICLED JEJUNUM IN THE TREATMENT OF
SHORT GUT SYNDROME
In patients with short gut syndrome, where large segments
of small bowel have been resected due to ischemic disease,
Crohn’s disease, etc., the absorptive capacity of the small
bowel is severely limited. If the patient has at least 35 cm
of jejunum, a 10 cm long pedicled jejunum can be har­
vested and reversed in an antiperistaltic fashion. The
jejunal segment is harvested and placed in the same posi­
tion but in the antiperistaltic fashion. This can theoreti­
cally decrease the transit time and increase the absorptive
capability of the bowel. The ideal segment length to be
reversed seems to be 10 cm, because shorter segments
may be inefficient in slowing transit time, whereas longer
segments may create a clinical bowel obstruction syn­
drome. In addition, to achieve optimal benefit, the
reversed segment should be located in the most distal part
of the jejunum.
Reconstruction after Total Esophagectomy Using
Pedicled Jejunum
In adult patients, additional microanastomosis must be per­
formed to ensure adequate perfusion to the distal bowel
(Case 38.3).
After isolating the jejunum on the fourth jejunal artery,
the bowel is transferred through a hole made in the meso­
colon and gastrocolic ligament, up into the chest. For the
thoracic portion, there are three possible routes: the subcu­
taneous, substernal, and posterior mediastinum. The short­
est route is the posterior mediastinal. However, if leakage
occurs in the mediastinum, there will be serious complica­
tions. The substernal route is slightly longer than the poste­
rior mediastinal and most commonly used because of good
aesthetics and relatively low risk. The longest is the subcuta­
neous route, which is used only in special conditions
because there is obvious bulging of the anterior chest. This
route is safer due to easier detection of leakage and easy
drainage.
Technical Steps for a Substernal Route
• Divide the insertion of the strap muscle and sternocleido­
mastoid muscle.
• The xiphoid process is rongeured until two fingers pass
easily at the lower part of the substernal space to expand
the thoracic inlet.
• The initial 4–5 cm beneath the lower sternum is dissected
with the fingers, through the abdominal incision.
• The breast dissector is inserted into the substernal recess
to dilate the space. We used the MacCollum–Dingman
breast dissector (Padgett Instruments Inc.).
• Gentle finger dissection continues from above (neck)
and below (abdominal) until the tunnel is cleared.
• Insert one large gauze through the substernal space, then
three large gauzes tied together.
• The pedicled jejunum is then passed into the tunnel from
the abdominal incision, to reach the neck region.
Technical Steps for the Subcutaneous Route.  The subcuta­
neous route is used rarely in difficult cases. To allow good
positioning of the jejunum and to avoid any compression
on the vascular pedicle, especially the vein, utmost care has
to be paid at certain sites.
• Ensure that the jejunum passes through the transverse
mesocolon without tension. Mobilize a sufficient length of
intestine to relieve tension on the jejunal mesentery and
anchor the mesocolon to prevent downward slippage.
• Consider resection of the xiphoid to decrease the angula­
tion as the segment passes over it.
• Ensure that the upper portion of the subcutaneous tunnel
is generous. Dilate the tunnel at least three or four times
the diameter of the graft.
After the Substernal or Subcutaneous Tunnel Has Been
Made
• The microvascular anastomosis is performed to augment
venous outflow and increase perfusion to the neck vessels
or the internal mammary vessels.
• In children, this additional anastomosis is not necessary.

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
sides of the head to ensure this position. It is of the utmost
importance to avoid tight dressings or circumferential tra­
cheostomy ties around the neck wound as this flap is very
sensitive to blood supply. In addition, it is important to avoid
violent coughing with frequent aspiration of the airway.
For esophageal reconstruction, strict NPO status is main­
tained for the first 1–2 weeks. Liquids are started on post­
operative day 9 at the earliest and up to 14 days in some
patients with medical illnesses that may cause delayed
healing. Diet is then advanced as tolerated over the next 3
weeks.
RECIPIENT SITE
USE OF A MONITORING SEGMENT OF JEJUNUM
An exteriorized segment of jejunum can be used for buried
esophageal reconstruction. We usually use the distal 2 cm
of the jejunal flap and suture it gently to the skin. This
segment is covered by a moist sponge to be checked accord­
ing to the protocol. On the 8th postoperative day, that
segment is excised under local anesthesia at the patient’s
bed and the wound closed.
A barium swallow is performed on the 30th postoperative
day.
MONITORING A BURIED JEJUNAL FLAP AT ANY SITE,
PEDICLED OR FREE
For buried flaps with no option of exteriorizing, implant­
able monitoring devices are used. The internal Doppler
device is easy to use and interpret.
It is important to know that all implantable devices have
a false-positive rate. If there is any question about the moni­
toring probe, color duplex ultrasonography is a noninvasive,
inexpensive, and rapid confirmatory test. In the hands of an
expert radiologist, ultrasound can show the blood flow in
the pedicle and other smaller vessels within the tissues of
the buried flap.
DONOR SITE
The donor site is treated as any other laparotomy site. The
drains are removed after 3–4 days. Enteral nutrition
(through a nasogastric tube or in some cases through a
jejunostomy) is started on the second operative day. Usually,
by the 4th postoperative day the patient is receiving almost
90% of nutritional support by the enteral method.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
For esophageal reconstruction, a liquid diet is started from
the 9th postoperative day, semi-liquid diet from the 12th
day, and a soft diet (rice, porridge) from the 30th day.
During the following 2–3 months, >94% of our patients can
tolerate a solid diet.
FOR DIFFERENT INDICATIONS
• For vaginal reconstruction: sexual activity can recommence
6 weeks after the reconstruction.
The main limitation of this technique is the very short
length of remnant small bowel, which may not allow the
sacrifice of a 10 cm segment for reversal. When this proce­
dure is feasible, the results are sufficiently good to offer this
as an alternative in selected patients with short bowel, thus
curtailing the cost of long-term parenteral nutrition and the
complications of immunosuppression after an intestine
transplantation.
This technique has only been adopted in adults.
VAGINAL RECONSTRUCTION (Case 38.4)
After vaginectomy, the vagina can be reconstructed with the
jejunum as a free or pedicled flap. As a free flap, a 25 cm
segment of jejunum is harvested; 10 cm are discarded to
provide the lengthening of the pedicle. The upper end of
the conduit is closed with a two-layer suture in a pouch-like
design. It is then positioned in the recipient site, with the
open end toward the perineum. The recipient vessels could
be the superficial femoral or the deep inferior epigastric
vessels.
As a pedicled flap, a 15 cm segment of jejunum is har­
vested based on the fourth jejunal vessels. Unlike the free
jejunum for vagina reconstruction, the pedicled flap does
not need to discard any part to elongate the pedicle. After
making a pouch, closing the upper (proximal) end of the
intestine segment, the flap is inset in the defect, approach­
ing the area from the abdominal cavity and from a trans­
perineal route.
URETHRAL RECONSTRUCTION
A free jejunal flap is an option for urethral reconstruction
following cancer extirpation. After resection, a much larger
segment of jejunum is harvested. To functionally lengthen
the vascular pedicle and provide temporary external moni­
toring, a large segment is discarded and up to 6 cm of
intestine is left attached to the vascular pedicle as an exter­
nal monitoring segment. The jejunum flap is tailored and
plicated along its antimesenteric border with polylactic
sutures down to the diameter of a 16 Fr Foley catheter. The
flap is inset in an antiperistaltic way, anastomosing the proxi­
mal bowel end to the proximal native urethra. Microanas­
tomosis is usually performed to the superficial femoral
vessels. A suprapubic tube is placed for urinary diversion
and for access for antegrade urethrography, which is per­
formed after 3 weeks, to reveal if the urethra is patent and
the lumen adequate.
POSTOPERATIVE CARE
GENERAL
Initially, the patient is kept in the intensive care unit, moni­
toring urine output, fluid status, and the flap. The nursing
staff are instructed to check the flap every hour for the first
3 days and then, from the 4th to the 7th day, every 2 h. Any
change in color, temperature, mucus production, or peri­
stalsis in the monitoring segment must be immediately
reported to the surgeon.
For the first 3 days, the patient is instructed to keep the
neck in a “neutral” position to minimize tension on the
vessel and bowel anastomosis. Sandbags are placed on both

CHAPTER 38 — Jejunum Flap
e129
dysphagia occurs at a rate of 4% and is usually a result of
redundancy of the reconstructed esophagus. Occasionally,
it is necessary to shorten a tortuous jejunum.
DONOR SITE
All the authors describe a low incidence of abdominal com­
plications (up to 2.5%), consisting of minor wound-healing
complications or adhesive bowel obstruction. We have
encountered two cases of intestinal adhesion in the past 200
cases. This is not to underestimate the inherent risks associ­
ated with laparotomy such as bleeding, infection, fistula,
adhesions, etc.
LONG-TERM OUTCOMES
GENERAL
The long-term durability of jejunum for esophageal recon­
struction is well established. After the initial healing, peri­
stalsis will be always present, even if decreased over time.
The reduction of peristalsis over time improves the initial
dysphagia. In addition, the jejunum mucosa retains its
original features with no metaplasia. There are long-term
studies (between 5 and 32 years) by Saeki (Japan) and Ring
(USA) who reported successful results after the use of
pedicled jejunum for total esophagectomy or thoracic
esophagus.
For esophageal reconstruction in children, most children
show some evidence of growth delay. Although some studies
have questioned this, growth disturbances are likely related
to sacrifice of the proximal jejunum in an early stage of life,
especially in patients with atresia. In all studies, the jejunum
remains disease free, without peptic ulceration. Dilatation
of the cervical jejunum creating a cervical pouch was
observed in 38%. The motility was normal in 92% of the
patients with a reported normal eating time. Half of the
patients were unable to vomit. All these referred symptoms
are related to the peristaltic activity of the jejunum, which
is slower than in the normal esophagus.
CONCLUSIONS
In conclusion, the jejunal flap is an anatomically suitable
and versatile body part for reconstruction of a variety of
defects, particularly circumferential defects of the esopha­
gus, vagina, and urethra. It has excellent and reliable blood
supply and good functional outcomes. The flap dissection
and inset can be easily learned.
• For urethral reconstruction: normal urinary control returns
after 4 weeks. Sexual activity depends on the surgical time
of the eventual neophallus reconstruction.
DONOR SITE
The abdominal wound usually heals uneventfully. The
enteral nutrition starts with a low-rate infusion on the 2nd
postoperative day. The skin sutures are removed on the 14th
postoperative day.
UNTOWARD OUTCOMES
GENERAL
The worst complication is flap loss. The failure rate in our
series is 2.4%. The flap loss usually occurs within the first 3
postoperative days. Other complications such as arrhythmia
(30%), wound infection (26%), pneumonia (23%), and
pleural effusion (23%) are the most common untoward
outcomes. Problems with stricture, redundancy of jejunum,
and impaired deglutition also occur, but their incidence
compares favorably with other methods of reconstruction.
These problems seem to be related to the experience of the
surgeon.
ESOPHAGUS RECONSTRUCTION
Leaks/fistula are the most common complication and occur
at a rate of 4.8% at the cervical anastomosis. Fistula forma­
tion is significantly more common in patients who have
been treated with preoperative radiation therapy. Around
40% of patients affected by a leak or fistula heal after con­
servative treatment with neck drainage and local wound
care. The other 60% of patients require surgical interven­
tion with reanastomosis and either coverage or obliteration
of the fistula with well-vascularized tissue.
Strictures occur at a rate of 5.2%, usually at the distal
esophageal anastomosis. These are identified by endoscopy
or radiologic procedures. Strictures may be due to fibrosis
of the distal anastomosis or may result from kinking of
elongated bowel segment. Endoscopic dilatation may
provide some relief in cases of fibrosis. Other strictures can
be released with V-Y plasty.
Initial, postoperative dysphagia is usually due to residual
dyskinetic peristalsis. Uncoordinated peristalsis may result
in delayed emptying of the jejunal segment, particularly
with solid foods. The motility decreases with time, a mecha­
nism that may be responsible for the clinically improved
swallowing in most patients over time. After 2–3 weeks,

e130
PART 4 — CONVENTIONAL WORKHORSE FLAPS
CASE 38.1  Cervical and Thoracic Esophageal Defect Reconstructed with a Free Jejunum
Flap and a Pedicled Colon Flap
A 52-year-old woman who had a corrosive injury from swallowing a lye-based fluid. She had significant damage to her esophagus and
pharynx.
Figure 38.17  (A) First-stage procedure. The skin incision is marked in the neck for exploration of the pharynx. The plan is to reconstruct
the pharynx and cervical esophagus with a free jejunal flap. (B) View of the patient after the first-stage reconstruction. The lower end of
the free jejunal flap is open to an external skin orifice. (C) Second-stage reconstruction performed at 2 months. This delay is to allow time
to prove that there was no choking on swallowing so that it would be safe for second-stage reconstruction. (D) Second stage: a pedicled
colon was used for reconstruction of the thoracic esophagus. (E) Esophagogram showing smooth passage of the contrast medium from
the mouth to the free jejunal flap, then (F) through the pedicled colon segment to the intestine in the abdomen.
A
B
C
D
E
F

CHAPTER 38 — Jejunum Flap
e131
Figure 38.18  (A) Following resection of the tumor there was a defect of the pharynx, cervical esophagus, and upper trachea. The patient
required a tracheostomy and reconstruction of the circumferential esophageal defect. (B) A free jejunum flap was used for reconstruction
of the pharynx and cervical esophagus. (C) The patient at 1 year follow-up. (D) An esophagogram of the patient at 1 year showing smooth
passage of contrast medium from the mouth through the jejunal flap to the thoracic esophagus.
A
B
C
D
A 51-year-old man with hypopharyngeal cancer.
CASE 38.2  Pharyngeal and Cervical Esophagus Defect Reconstructed with a Free Jejunum
Flap
A 35-year-old woman who sustained injury to her cervical and
thoracic esophagus after swallowing a corrosive agent. She had
been reconstructed with a colon segment, which failed. She was
then transferred to our unit for treatment. She required recon­
struction of the entire esophagus, which was to be performed
with a pedicled jejunal flap with distal revascularization.
CASE 38.3  Cervical and Thoracic Esophageal Defect Reconstructed with a Pedicled
Supercharged Jejunum Flap
Figure 38.19  (A) Marking on the patient demonstrating the design of the flap. The jejunum will be pedicled based on the fourth jejunal
vessels. The distal part of the flap will be inset in the neck and augmentation of arterial inflow and venous outflow will be performed by
anastomosing the second jejunal vessels to the pectoral branch of the thoracoacromial trunk and the cephalic vein. Other vessels can be
used such as the internal mammary artery, superior thyroid artery, or transverse cervical artery. Other veins would include the external
jugular or a branch of the internal jugular vein. If the length of donor and recipient vessels does not allow for primary anastomoses, vein
grafts may be used. (B) This figure demonstrates the tortuosity of the jejunum and difficulty in reaching beyond the lower part of the chest.
Division of the mesentery is required and the proximal portion of the jejunum would then be based on blood supply through the marginal
arcade. In order to reach the neck safely, augmentation of arterial inflow and venous outflow is necessary. (C) Photograph of the jejunum
after division of the blood supply from the second and third jejunal vessels. The second and third loops receive their blood supply through
the marginal arcade. After this division, this distal portion of the jejunum flap can be pedicled to reach the neck. As can be seen in this
figure, the blood supply to the superior aspect of the jejunum is suboptimal before revascularization in the neck. (D) An esophagogram
at 1 year showing contrast medium passing through the pedicled jejunal flap without obstruction to flow.
A
C
B
D

e132
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 30-year-old woman who had a history of cervical cancer and wide reconstruction 3 years prior to presentation. She was scheduled
for reconstruction with a pedicled jejunal flap.
CASE 38.4  Vaginal Reconstructed with a Pedicled Jejunum Flap
Figure 38.20  (A) This figure demonstrates the segment of jejunum after preparation and prior to transposition into the pelvis. The jejunum
flap was then pedicled to the pelvis. The proximal segment was oversewn and the distal opening was anastomosed to the proximal stump
of the vagina. (B,C) Follow-up at 3 years showing patency of the neovagina.
A
B
C
Expert Commentaries 
John J. Coleman III, MD
This excellent chapter on the jejunal free and pedicled autograft
by Hung-Chi Chen and colleagues is very complete and has
excellent illustrations that are particularly relevant to the technical
aspects of the procedure. I will elaborate on those I think most
important and add several personal differences.
When correctly dissected, the pedicle can be 15–20 cm. In
some cases, this is too long, and careful dissection along the
primary jejunal branch of the superior mesenteric will allow short-
ening of the pedicle. The arterial and venous branches are closely
apposed with frequent crossing veins between the comitantes,
which require clipping to allow separation choice, of the appropri-
ate vena comitans for anastomosis and positioning in the neck.
This is best done in the abdomen but in obese patients or other
technically difficult situations can be done with the microscope
after division. In those cases where extra pedicle length is desir-
able, the artery and vein can be ligated without the use of clamps
by passing sutures and then suture ligating the stump. After the
division of the bowel into the graft segment and the proximal and
distal segments it is useful to observe the segments for 10–20 min
to ensure the adequacy of their perfusion. If the stapled ends
remain well vascularized enteroenterostomy is performed. If not,
they are trimmed until viable as is the graft.
As mentioned, the transverse cervical vessels are an excellent
choice for anastomosis particularly in patients who have had
previous neck dissection or irradiation. It has been our practice
to perform the most difficult pharyngeal or esophageal anasto-
mosis first, so for an oropharyngeal resection it would be at the
base of the tongue, or for a post-sternal esophageal lesion the
distal anastomosis. With this done, the microvascular anastomo-
sis is performed and when perfused the flap is tailored, fixed in
position, and the distal anastomosis performed. This can usually
be done within the acceptable ischemia time of 1.5–2 h.
When tracheostomy is performed, the tracheostomy tube is
sutured to the chest wall and neck with four interrupted 2-0
proline sutures to avoid tracheostomy tape. In all cases, the
patient is sent to the ICU with a sign to be posted on his bed
stating “Nothing around the neck.”
Despite the sensitivity of the small bowel to radiation, the
jejunum in the neck can tolerate full-dose adjuvant radiotherapy.
We avoid delaying radiation even if a fistula is present, since we
have observed spontaneous closure during therapy.
Michael J.A. Klebuc, MD
The authors should be complimented on this chapter that clearly
describes the anatomy of the jejunal flap and illustrates its clinical
utility in reconstruction of the esophagus, oropharynx, vagina, and
urethra. Additionally, they provide the reader with many of the
technical pearls that can make the difference between success
and failure. At our Reconstructive Surgery Institute, the jejunum
is frequently employed as a supercharged flap for restoration of
the thoracic and cervical esophagus. The supercharged jejunal
flap has a series of advantages in contrast to the colonic interposi-
tion. The diameter of the jejunum closely parallels that of the
native esophagus; the flap maintains antegrade peristalsis follow-
ing transfer and is less prone to developing stretch and redun-
dancy over the long term.
When utilizing the supercharged jejunum for long segment
esophageal reconstruction, a partial resection of the sternal body,
sternoclavicular joint, and first rib is often performed in an effort
to prevent compression near the thoracic inlet. Care is taken to
avoid disruption of the ligamentous attachments of the first rib to
the clavicle to prevent a secondary tenting deformity. The left
internal mammary artery and vein are preferentially utilized as
recipients over the left transverse cervical vessels. The mammary
vessels are lengthy and their exploration does not carry the risk
of thoracic duct injury. Transillumination during flap harvest often
proves very beneficial for visualization of the vascular anatomy.
The second vascular arcade is routinely divided and utilized for
microvascular anastomosis. The third vascular arcade will be
ligated and divided in an effort to unfurl the flap. These vessels
should be temporarily occluded with a microvascular clamp prior
to division to verify inflow from the fourth arcade. The mesentery
between the second and third arch is divided up to the serosal
border. This is delayed until the time of flap transfer, as it pro-
duces relative ischemia in the distal segment. A sterile sleeve
ultrasound cover is then used to deliver the jejunal flap through a
retrosternal tunnel reducing sheer while protecting the vascular
pedicle. Additional technical tips and tricks are well described
within the body of this chapter. However, one further

CHAPTER 38 — Jejunum Flap
e133
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Expert Commentaries (Continued)
consideration is how long to maintain the external monitoring
segment. It is my personal preference to retain the monitoring
segment for 4–6 weeks. If the monitoring segment is removed
early in the postoperative period and the patient becomes aci-
dotic or metabolically compromised, then there is a high likelihood
that endoscopy will be utilized to evaluate the viability of the flap.
This can lead to disruption of the esophago-jejunal anastomosis
and potential occlusion of a patent microvascular anastomosis.
Additionally, if a postoperative fistula develops, the mucosa can
be removed from the monitoring segment and it can be employed
as a vascularized patch. If the monitoring segment is to be left
for this period of time, it is important to keep it well lubricated
with petrolatum-based dressings to prevent serosal tears and
bleeding. The authors also describe the use of the jejunum for
reconstruction of the vagina, urethra, and oropharynx. Jejunal flap
vaginal reconstruction is infrequently performed at our center. The
technique produces significant vaginal discharge and relatively
high rates of prolapse and stricture. Additionally, the jejunum
remains a tertiary option for the urethral reconstruction. The role
of the jejunum in reconstruction of the cervical esophagus and
pharynx has also largely been supplanted by fasciocutaneous
flaps such as the anterior lateral thigh and radial forearm flap.
Fasciocutaneous flaps appear to offer the benefits of improved
tracheoesophageal speech and swallowing as compared with
free jejunal reconstructions.

e134
INTRODUCTION
The trapezius muscle, with its unique triangular shape
and great length, extends from the occiput down to the
12th thoracic vertebra and consists of descending, trans­
verse, and ascending parts; its complexity renders a system­
atic description challenging. Since the upper trapezius
Trapezius Flap
Franz Haas  |  Andreas Weiglein  |  Neal D. Futran
39 
myocutaneous flap was first published by McCraw et al.1 and
Demergasso and Piazza2 in 1979 and the lower trapezius
myocutaneous flap by Baek et al.3 and Mathes and Nahai4
in 1980, the pedicled trapezius flap has been a standard
procedure in head and neck reconstruction. In 1981, the
trapezius muscle was classified as a type II pattern of circula­
tion (one dominant vascular pedicle plus minor pedicles)
according to Mathes and Nahai.5
Figure 39.1  Trapezius flap.
Rhomboid major
Transverse cervical artery
(from thyrocervical trunk)
Trapezius
Spinal
accessory
nerve (XI)
Deltoid
Dorsal scapular artery
(from thyrocervical trunk)
Scapula
Latissimus dorsi
Perforating
intercostal arteries
Rhomboid major
Infraspinatus
Teres
minor
Teres major
Erector spinae
Posterior cutaneous
branches of dorsal rami
of spinal nerves
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION D  —  LOCAL AND FREE FLAPS IN THE BACK

CHAPTER 39 — Trapezius Flap
e135
• The levator scapulae muscle originates from the transverse
processes of the 1st–4th cervical vertebrae and inserts into
the superior angle of the scapula. It supports the function
of the descending (superior) part of the trapezius in
elevating the scapula.
• The rhomboid minor muscle originates from the spinous
processes of the 6th and 7th cervical vertebrae and inserts
into the medial border of the scapula above the spine of
the scapula. It supports the function of the trapezius in
retracting and elevating the scapula.
• The rhomboid major muscle originates from the spinous
processes of the 1st–4th thoracic vertebrae and inserts
into the medial border of the scapula below the spine
of the scapula. Similar to the rhomboid minor, it supports
the function of the trapezius in retracting and elevating
the scapula.
ARTERIAL ANATOMY OF THE REGION
(Figs 39.1–39.4 and Fig. 11.7)
The posterior muscles of the neck are mainly supplied
by arteries branching off the subclavian artery either directly
or indirectly via the thyrocervical trunk. Only the descend­
ing (superior) part of the trapezius is supplied by branches
of the occipital artery, which is the largest posterior branch
of the external carotid artery. The surgically more impor­
tant parts of the trapezius are supplied by two either direct
or indirect branches of the subclavian artery. The compli­
cated vascular anatomy and the difficult and often misused
vascular terminology have caused problems in the planning
and harvesting of trapezius flaps. For this reason, special
emphasis is placed here on the vascular supply of the trans­
verse (middle) part (= upper trapezius flap) and the ascend­
ing (inferior) part (= lower trapezius flap) of the trapezius
muscle. The transverse (middle) part of the trapezius is
supplied by the superficial cervical artery (SCA; superficial
branch of the transverse cervical artery). The ascending
(inferior) part of the trapezius is supplied by the dorsal
scapular artery (DSA; deep branch of the transverse cervical
artery). Minor intercostal perforators add to the blood
supply of the most inferior part of the trapezius.
The SCA arises from a common trunk with the dorsal
scapular artery in 30% (in these cases forming the trans­
verse cervical artery) with a superficial (superficial cervical
artery) and a deep branch (dorsal scapular artery), with the
suprascapular artery in 22% or with both the dorsal scapular
and the suprascapular arteries in 24%. These trunks may be
branches of the thyrocervical trunk in the great majority of
the cases or of the subclavian artery. In the remaining 24%,
the superficial cervical artery arises independently from
either the thyrocervical trunk (22%) or the subclavian
artery (2%). The SCA usually has an ascending and a
descending branch. In any case, the artery lies deep to the
trapezius muscle and superficial to the levator scapulae and
rhomboids.
The DSA arises from a common trunk with the superficial
cervical artery in 30% (see above) or the suprascapular
artery (4%), or with both the dorsal scapular and the supra­
scapular arteries in 24%. In the remaining 42%, it originates
directly from the subclavian artery (37%), the thyrocervical
trunk (1%), the internal thoracic artery (1%), or the
Since then, different opinions on the vascular anatomy of
all flap modifications have led to confusion and technical
problems during flap harvesting. To avoid any misunder­
standings in flap planning and elevation, all flaps related to
the trapezius discussed below are defined by their supplying
arteries.
REGIONAL ANATOMY (Figs 39.1–39.4 and
Figs 11.1, 11.4 and 11.7)
The trapezius muscle is the most superficial muscle on the
posterior aspect of the neck and thorax. The underlying
layer is composed of the levator scapulae, the major and
minor rhomboid muscles, and the latissimus dorsi below the
7th thoracic vertebra.
The trapezius is divided into three parts: the descending
or superior part, the transverse or middle part, and the
ascending or inferior part. The descending (superior) part
originates at the external occipital protuberance, the supe­
rior nuchal line, and the nuchal ligament down to the
spinous process of C7 and inserts into the lateral third of
the clavicle. This part mainly acts to elevate the scapula. The
transverse (middle) part originates at the spinous processes
of the 1st–5th thoracic vertebrae and inserts into the
acromion. This part mainly acts to retract the scapula.
The ascending (inferior) part is attached proximally to the
spinous processes of the 6th–12th thoracic vertebrae and
inserts into the spine of the scapula. This part mainly acts
to depress the scapula.
Only the transverse (middle) part (= upper trapezius
flap) and the ascending (inferior) part (= lower trapezius
flap) of the trapezius are widely used in reconstructive
surgery.
The anatomy of the underlying muscles is important for
harvesting trapezius flaps.
Figure 39.2  Harvested trapezius muscle (cadaver study) with an
X-ray of the muscle after injection of the SCA, DSA, and intercostal
perforator artery with radio opaque dye.

e136
PART 4 — CONVENTIONAL WORKHORSE FLAPS
costocervical trunk (3%). In cases in which the dorsal scapu­
lar artery is a direct or indirect branch of the subclavian
artery, it pierces through the brachial plexus. In any case,
the DSA lies deep to the levator scapulae and rhomboids.
In between the minor and major rhomboid, it always gives
rise to the branch to the ascending (inferior) part of the
trapezius (trapezius branch of the dorsal scapular artery).
The DSA terminates in a descending branch under the
rhomboid major muscle.
VENOUS ANATOMY OF THE REGION
In general, the arteries in the neck are accompanied by two
veins. These venae comitantes drain into a large vein cross­
ing the neck horizontally, the so-called “transverse cervical
vein.” This main collector of the neck drains into the venous
angle.
The veins of the trapezius muscle accompany the arteries
until they cross the anterior border of the muscle. Then,
their courses differ from those of the arteries and form one
(55%), two (42%), or more (3%) so-called transverse cervi­
cal veins. In the majority of cases, these veins pass the bra­
chial plexus laterally and terminate in the external jugular
vein (80%). In the remainder, they terminate in the subcla­
vian vein (12%) or in both the external jugular and the
subclavian vein (8%).
NERVES IN THE REGION (Figs 39.1, 39.3, 39.4
and Fig. 11.7)
The trapezius muscle is supplied by the spinal accessory
nerve (11th cranial nerve). It also receives proprioceptor
fibers via a branch of the cervical plexus. The spinal acces­
sory nerve (11th cranial nerve) crosses superficial to the
SCA in 60% and deep in 33%. In the remaining 7%, one
artery runs superficial and one deep to the nerve. The
nerve accompanies the SCA superiorly and the trapezius
branch of the DSA inferiorly. The levator scapulae and the
rhomboids are supplied by the dorsal scapular nerve (DSN)
from the brachial plexus. The dorsal scapular nerve pierces
through the middle scalene muscle and runs deep to levator
scapulae and the rhomboids, thus accompanying the
descending branch of the DSA.
FLAP ANATOMY (Figs 39.1–39.7 and Fig. 11.7)
With the complex vascular supply of the whole trapezius
muscle and the surrounding area, any classification or
description of flap types is difficult. Mathes and Nahai stated
that the trapezius muscle has one dominant (descending/
deep branch of the transverse cervical artery or, respectively,
the dorsal scapular artery) pedicle and some minor vascular
pedicles (type II). According to our findings from hundreds
of cadavers and those of most other authors, there are at
least two dominant pedicles (the SCA and the DSA) and
some minor pedicles (the occipital artery and the intercos­
tal perforators) with respect to the whole muscle. In prac­
tice, the whole muscle is never harvested as one flap, so, as
such, this is not relevant to reconstructive surgery. The
various flaps utilize only parts of the trapezius muscle, as a
vessel carrier.
The clearest and most logical way to classify flaps is to
define them by their vascular pedicle. A subdivision into
upper or lower flaps is no longer necessary, and categorizing
them into vertical or transverse flaps, according to the skin
island, does not lead to misunderstandings.
According to the vascular supply of the trapezius muscle,
a trapezius flap can be elevated on four different pedicles
and we refer to them here as four types:
• Type 1. A trapezius flap based on the occipital artery. This
usually includes the superior descending part of the
muscle and a transverse skin island.
• Type 2. A trapezius flap based on the SCA (superficial
branch of the transverse cervical artery). Parts of the
middle transverse fibers (upper flap) of the muscle are
included. The skin island may be planned to be transverse
or vertical. The flap can be harvested as myocutaneous or
osteomyocutaneous (including a part of the scapular
spine; Fig. 39.6) based on the ascending branch, or as a
myocutaneous flap based on the descending branch of
the SCA.
• Type 3. A trapezius flap based on the DSA (deep branch
of the transverse cervical artery). Parts of the inferior
ascending (lower flap) fibers are included (Fig. 39.7).
The skin island is planned to be vertical in a myocutane­
ous flap or the muscle is elevated without skin.
• Type 4. A trapezius muscle flap based on the intercostal
arteries in a turnover technique.
In some publications it is not clear whether more than
one pedicle artery is included (DSA and SCA or SCA and
occipital artery) to ensure vascularization. If an island flap
is correctly prepared, there is no need to include two arter­
ies and a large muscle cuff. When the flap is elevated this
way, most of the muscle function or the accessory nerve itself
will be sacrificed.
The trapezius muscle plays two important roles in shoul­
der function: stabilizing and moving the scapula on the one
hand and elevating the shoulder on the other. It is of the
utmost importance to preserve as much function as possible
to minimize donor site morbidity. Careful dissection and
elevation as an island flap are essential.
Myocutaneous perforators, except those from the inter­
costal arteries, are extremely thin and rare, so that, in our
opinion, perforator flaps cannot be recommended. The
donor site should always be closed directly. Skin grafts in the
shoulder region, especially over the acromion and the spine
of the scapula, can lead to deforming scars and functional
problems.
Flap elevation based on the SCA or on the DSA (arterial
supply classification types 2 and 3 as described above) is
useful in clinical practice, and so it is given particular atten­
tion in the following description.
The myocutaneous flap based on the occipital artery
(arterial supply type 1), as first published by McCraw, is
rarely indicated in the era of microsurgical procedures. Dis­
advantages such as time loss, very bulky tissue, and a donor
site that is difficult to close directly prevented it from becom­
ing a standard procedure.
A turnover muscle flap of the ascending (lower) part
(arterial supply type 4) needs further clinical evaluation.
Our anatomic investigations showed constant intercostal

CHAPTER 39 — Trapezius Flap
e137
Figure 39.3  Lateral view of the right trapezius muscle after elevation
of the lateral aspect of the muscle. (A) Cadaver dissection.
(B) Descriptive diagram of (A).
Spinal accessory
nerve (XI)
Superficial branch
of the transverse
cervical artery
Deep branch of
the transverse
cervical artery
Dorsal scapular
nerve
A
B
perforators, mostly around the fifth and sixth intercostal
spaces, which should allow defect coverage of the middle
and lower part of the thoracic spine and even the upper
part of the lumbar spine.
ARTERIAL SUPPLY OF THE FLAP (Figs 39.1 and
39.2 and Fig. 11.7)
The lower trapezius muscle can be classified as a type V
muscle according to Mathes and Nahai,5 having one domi­
nant pedicle and secondary segmental vascular pedicles. The
lengths of the feeding vessels (SCA, intercostal arteries, DSA)
given below are not the pedicle lengths, but the lengths of
the dominant vessels until they divide into the first branches.
TRAPEZIUS FLAP BASED ON THE SCA
Dominant:  superficial branch of the transverse cervical
artery
Length: 4.7 cm (range 4.5–4.9 cm)
Diameter: 4.0 mm (range 3.8–4.2 mm)
The SCA divides into a descending (inferior) branch and
an ascending (superior) branch. The descending branch
runs medial to the scapula and superficial to the levator
scapulae muscle and the rhomboid muscles. The descend­
ing branch is accompanied by the spinal accessory nerve.
The ascending branch runs down to the spine of the scapula.
Minor:  posterior intercostal arteries
Length: 3.1 cm (range 1.7–4.5 cm)
Diameter: 0.7 mm (range 0.5-0.9 mm)
Our cadaver dissections showed constant intercostal arter­
ies supplying the lower part of the trapezius muscle between
the third and sixth intercostal spaces. To our knowledge,
there is very little clinical experience with flaps based on
intercostal branches. We also see rare indications to perform
these flaps in a turnover procedure to cover defects in the
lower and middle part of the thoracic spine.
In any case, as described by Ogawa et al.6 when large
pedicled flaps based on the SCA or even DSA are created,
microvascular augmentation can be helpful when an anas­
tomosis is created between the recipient site and the inter­
costal perforators.
TRAPEZIUS FLAP BASED ON THE DSA
Dominant:  deep branch of the transverse scapular artery
Length: 5.83 cm (range 5.20–6.46 cm)
Diameter: 3.3 mm (range 2.95–3.65 mm)
This branch runs deep to the levator scapulae and the
minor rhomboid muscles. The flap-feeding vessel (trapezius
branch) appears between the minor and major rhomboid
muscles, and lies deep to the trapezius and superficial to the
rhomboid major muscle.
Minor Pedicles:  posterior intercostal arteries
Minor pedicles of the ascending (lower) part of the
trapezius muscle constantly branch off from the dorsal
intercostal vessels from the third to the sixth intercostal
spaces.
The lower trapezius muscle can be classified as a type V
muscle according to Mathes and Nahai,5 having one domi­
nant pedicle and secondary segmental vascular pedicles.
VARIATION OF ARTERIAL ORIGIN (Fig. 39.5,
Table 39.1)
Frequent changes in the anatomic nomenclature of the
arteries in the posterior cervical triangle (lateral cervical
region), coupled with lack of knowledge of the gross
anatomy and incorrect use of the nomenclature of these
arteries, have presented difficulties in musculocutaneous
flap planning. In particular, the term “transverse cervical
artery” (A. transversa colli, cervicis) and its associated
branches (the superficial branch, superficial cervical artery;
and the deep branch, dorsal scapular artery) have been
used frequently over the past several decades with different
meanings.
An investigation of these arteries in 498 sides of necks
showed the following results. The superficial cervical artery,
the dorsal scapular artery, and the suprascapular artery
arose from the subclavian artery either as direct branches
or from trunks. A cervico-dorsal trunk gave origin to
the superficial cervical and dorsal scapular arteries, a

e138
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 39.4  Section in a sagittal plane medial to the scapula margin.
T1
T6
T12
Superior nuchal line
External occipital protuberance
Posterior triangle of neck
Sternocleidomastoid muscle
Trapezius muscle
Spine of scapula
Infraspinous fascia
Deltoid muscle
Teres minor
muscle
Teres major
muscle
Latissimus dorsi muscle
External
oblique muscle
Lumbar triangle (Petit) with
internal oblique
muscle in its floor
Iliac crest
Lateral
Medial
Serratus posterior inferior muscle
Digitations of external oblique muscle
Lower digitations of serratus
anterior muscle
Latissimus dorsi muscle (cut)
Spinous processes
of thoracic vertebrae
Teres major muscle
Teres minor muscle
Infraspinatus muscle
Spine and
Acromion of scapula
Supraspinatus muscle
Rhomboid major muscle
Rhomboid minor muscle
Levator scapulae muscle
Splenius capitis muscle
Accessory nerve (XI)
Posterior cutaneous branches
(from medial and lateral branches of
dorsal rami of thoracic spinal nerves)
Thoracolumbar fascia over deep
muscles of back (erector spinae)
cervico-scapular trunk gave rise to the superficial cervical
and suprascapular arteries, a dorsoscapular trunk provided
origins for the dorsal scapular and suprascapular, and
a cervico-dorsoscapular trunk gave origin to the superficial
cervical artery, the dorsal scapular artery, and the supra­
scapular artery. Each of these trunks, in turn, arose
from either the subclavian artery or the thyrocervical
trunk.
The superficial cervical artery supplies the middle (trans­
verse) part of the trapezius and travels with the accessory
nerve. It is a direct branch from either the thyrocervical
trunk (22%) or the subclavian artery (2%). More com­
monly, the superficial cervical artery arises from trunks, i.e.
cervico-dorsal trunk (30%), cervico-scapular trunk (22%),
or cervico-dorsoscapular trunk (24%).
The dorsal scapular artery supplies the lower (ascending)
part of the trapezius and travels with the dorsal scapular
nerve. It is a direct branch from the subclavian artery (37%),
the thyrocervical trunk (1%), the internal thoracic artery
(1%), or the costocervical trunk (3%). More commonly,

CHAPTER 39 — Trapezius Flap
e139
Figure 39.6  Elevated osteomyocutaneous flap based on the ascending branch of the superficial scapular artery. (A) Schematic drawing: SCA,
superficial cervical artery; SAN, spinal accessory nerve; DSA, dorsal scapular artery; DSN, dorsal scapular nerve. (B) Cadaver dissections.
SCA
DSA
Levator scapulae muscle
DSN
Rhomboid minor
muscle
Rhomboid major
muscle
Latissimus dorsi
muscle
Trapezius muscle
SAN
A
B
Figure 39.5  The most frequent origin (30%) of the dorsal scapular
artery (DSA) is from a common trunk with the superficial cervical
artery (SCA). This trunk, usually called the transverse cervical artery,
may come from the thyrocervical trunk (TT) (16%) or directly from the
lateral part of the subclavian artery (SA) (14%).
SCA
SA
TT
DSA
the dorsal scapular artery arises from trunks, i.e. cervico-
dorsal trunk (30%), dorsoscapular trunk (4%), or cervico-
dorsoscapular trunk (24%).
The suprascapular artery supplies the supra- and infraspi­
natus muscles and travels with the suprascapular nerve. It is
a direct branch from the subclavian artery (12%), the thy­
rocervical trunk (27%), or the internal thoracic artery
(11%). The suprascapular artery arises from trunks, includ­
ing the cervico-scapular trunk (22%), the dorsoscapular
trunk (4%), and the cervico-dorsoscapular trunk (24%).
This labeling convention necessitates omitting the term
“transverse cervical artery,” since this term has been mislead­
ing and misused over the years, and, even if used in its
genuine sense, this artery is found in the minority of cases.
The anatomic findings proved a constant blood supply of
the lower trapezius muscle via the dorsal scapular artery as
the main vessel, regardless of the origin of this artery.
However, the arc of rotation of the lower trapezius flap
changes depending on the origin of its artery.
VENOUS DRAINAGE OF THE FLAP
TRAPEZIUS FLAPS BASED ON THE SCA AND THE DSA
Primary:  the usually double accompanying veins are
slightly larger in diameter and of the same length as the
respective artery.
The termination is in the transverse cervical vein, which
eventually drains into the venous angle. Proximally, at the
level of the anterior border of the trapezius muscle, the
veins generally run separate from the arteries. They can
build a single vein, two veins, or rarely three, all of which
are called transverse cervical veins, and they can drain into
different systems (external cervical vein, subclavian vein, or
both) in the posterior triangle of the neck. This variability
is only important for the pedicled flap based on the SCA,

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 39.7  Elevated myocutaneous flap based on the dorsal scapular artery. (A) Schematic drawing: SCA, superficial cervical artery; SAN,
spinal accessory nerve; DSA, dorsal scapular artery; DSN, dorsal scapular nerve. (B) Cadaver dissections.
SCA
DSA
Levator scapulae muscle
DSN
Rhomboid minor
muscle
Rhomboid major
muscle
Latissimus dorsi
muscle
Trapezius muscle
SAN
A
B
C

CHAPTER 39 — Trapezius Flap
e141
because the course of the veins and their relationship to the
brachial plexus and the accessory nerve can limit their arc
of rotation.
FLAP INNERVATION (Figs 39.1, 39.3, 39.4 and
Fig. 11.7)
Sensory:  trapezius flap based on the SCA
It is possible to preserve partial innervation of the skin
island using acromial branches of the cervical plexus.
Sensory:  Trapezius flap based on the DSA
No axial sensory nerve is available for this flap, but to
recover some sensibility, if necessary, it could be possible to
include one or more posterior cutaneous branches of inter­
costal nerves in the skin island.
There is no useful way to restore sensibility by including
a sensory nerve in a flap based on the DSA.
Motor:  spinal accessory nerve (cranial nerve XI)
The trapezius flaps are not suitable for functional
muscle reconstruction because of their central role in
shoulder function. Harvesting the whole muscle would
cause unacceptable donor site morbidity. It is of greatest
importance to elevate the flap (including a part of the
muscle) in such a way as to preserve as much function as
possible.
FLAP COMPONENTS
TRAPEZIUS FLAP BASED ON THE SCA
The trapezius flap based on the SCA is usually harvested as
a myocutaneous flap. If needed, a segment of the scapular
spine (10 × 2 cm) can be included for an osteomyocutaneous
flap. To avoid shoulder instability, at least 2 cm of the acro­
mion (lateral part) should be left intact. When a skin island
is not indicated, the muscle alone can be transferred.
TRAPEZIUS FLAP BASED ON THE DSA
The trapezius flap based on the DSA is usually indicated as
a myocutaneous flap. In rare cases, a muscle flap without
skin can be performed.
ADVANTAGES
Trapezius Flap Based on the SCA
• The pedicled myocutaneous trapezius flap based on the
SCA provides a fast and easy procedure to reconstruct
defects of the hypopharynx, oropharynx, and upper
esophagus.
• The island flap is thin and pliable with a limited arc of
rotation according to the anatomic situation.
• The flap, transferred as an osteomyocutaneous flap, is
an alternative to free tissue transfer for reconstruction
of combined defects. After ablative surgery, the mandi­
ble and the floor of the mouth can be reconstructed.
• The donor site of the flap is in the same operative field
and often, especially after neck dissection, the vascular
pedicle has already been dissected.
• Short operating time, acceptable donor site morbidity
(preserved accessory nerve and primary closure), and
minimal bulk contribute to a good result.
Trapezius Flap Based on the DSA
• The myocutaneous island flap is a reliable, thin, and
pliable flap, allowing a wide arc of rotation.
• It is especially suitable for problematic ipsi- or contralat­
eral defects in the occipital and dorsal neck region and
over the thoracic spine, which this flap can cover without
microsurgery.
• For soft tissue defects in the lower face and anterior neck,
it is also a good alternative to other flaps, and the donor
site morbidity is low.
• A free flap based on the DSA can be dissected with a very
long pedicle.
DISADVANTAGES
Trapezius Flap Based on the SCA
• In one-third of individuals, the accessory nerve passes
between the pedicle artery and vein, so that one vessel
Table 39.1  Origins of the arteries and trunks in
the posterior cervical triangle
SCA
DSA
SSA
Origin from a vessel
Thyrocervical trunk
22
37
12
Subclavian artery
2
1
27
Internal thoracic artery
0
1
11
Costocervical trunk
0
3
0
Origin from a trunk
Cervico-dorsal trunk (30%)
Thyrocervical trunk
16
16
–
Subclavian artery
13
13
–
Internal thoracic artery
1
1
–
Cervico-scapular trunk (22%)
Thyrocervical trunk
17
–
17
Subclavian artery
3
–
3
Internal thoracic artery
2
–
2
Dorsoscapular trunk (4%)
Thyrocervical trunk
–
3
3
Subclavian artery
–
1
1
Cervico-dorsoscapular trunk (24%)
Thyrocervical trunk
20
20
20
Subclavian artery
3
3
3
Internal thoracic artery
1
1
1
Data are expressed as percentages. SCA, superficial cervical
artery; DSA, dorsal scapular artery; SSA, suprascapular artery.