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

CHAPTER 41 — Latissimus Dorsi Flap 463.e1
A
B
C
Figure 41.10  (A) A 43-year-old man after a crush injury to the dorsum of the right foot, with exposed tendon. (B) A latissimus dorsi flap
is elevated with its skin paddle and its neurovascular pedicle dissected, as described in the section on flap harvesting, with the patient
positioned in the lateral decubitus position. (C) Appearance after primary defect coverage with a free latissimus dorsi flap. The monitoring
island has been removed and the muscle skin grafted.
CASE 41.5  Soft Tissue Coverage of a Large Dorsal Foot and Ankle Defect with a Free
Latissimus Dorsi Muscle Flap and a Skin Graft

463.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
A
B
C
D
E
A 54-year-old woman presented after left modified radical mas-
tectomy. She underwent a breast reconstruction. Scapular fat
fascia is harvested in addition to the conventional latissimus flap
to achieve the goal of sufficient volume. Overcorrection of the
desired breast size by 15–20% is strongly recommended. An
excellent aesthetic result is achieved after left extended latissi-
mus dorsi flap reconstruction with inferolateral placement of the
skin island.
CASE 41.6  Breast Reconstruction with a Pedicled Extended Latissimus
Dorsi Myocutaneous Flap
Figure 41.11  (A) A 54-year-old woman, after a left modified radical mastectomy. (B) Myocutaneous flap after elevation and rotation
through the left axillary tunnel. (C) The left latissimus dorsi myocutaneous flap is rotated into the left breast defect. (D) Partial inset of the
flap. (E) Postoperative result.

CHAPTER 41 — Latissimus Dorsi Flap 463.e3
CASE 41.7  Pedicled Latissimus Muscle Transfer for Restoration of Biceps Function
Figure 41.12  (A) Severe injury of the right upper arm of a 24-year-old woman with avulsion of the palmar aspect of biceps muscle.
Brachial artery and median nerve are lacerated and had to be repaired after insufficient primary care in a minor trauma center. (B) Intra­
operative view of a neurovascular pedicled latissimus dorsi flap to cover the defect and restore biceps function. (C) Postoperative result
1 year after latissimus dorsi transfer. The patient has no limitations in her personal activities. (D) Postoperative result 1 year after latissimus
dorsi transfer. The patient has no limitations in her personal activities. (E,F) Postoperative result 1 year after latissimus dorsi transfer. The
patient is able to play tennis.
C
B
A
E
F
D

463.e4 PART 4 — CONVENTIONAL WORKHORSE FLAPS
FURTHER READING
Barlett SP, May LW, Yaremchuk MJ. The latissimus dorsi muscle: a fresh
cadaver study of the primary neurovascular pedicle. Plast Reconstr
Surg 1981;67:631–6.
Cabanie H, Garbe JF, Guimberteau JC. Anatomical bases of the thora­
codorsal axillary flap with respect to its transfer by means of micro­
vascular surgery. Anat Clin 1980;2:65–73.
Cavadas
PC,
Teran-Saavedra
PP.
Combined
latissimus
dorsi-
thoracodorsal artery perforator free flap: the “razor flap.” J Reconstr
Microsurg 2002;18:29–31.
Friedrich W, Herberhold C, Lierse W. Vascularization of the myocuta­
neous latissimus dorsi flap. Acta Anat 1988;131:97–102.
Heitmann C, Guerra A, Metzinger SW, et al. The thoracodorsal artery
perforator (TDAP) flap – anatomical basis and clinical application.
Ann Plast Surg 2003;51:23–9.
Kim JT, Koo BS, Kim SK. The thin latissimus dorsi perforator based
free flap for resurfacing. Plast Reconstr Surg 2001;107:374–82.
Koshima I, Saisho H, Kawada S, et al. Flow-through thin latissimus dorsi
perforator flap for repair of soft tissue defects in the legs. Plast
Reconstr Surg 1999;103:1483–90.
Lin CH, Wei FC, Levin LS, et al. Donor-site morbidity comparison
between endoscopically assisted and traditional harvest of free latis­
simus dorsi flap. Plast Reconstr Surg 1999;104:1070.
Papp C, McCraw JB. Autogenous latissimus breast reconstruction. Clin
Plast Surg 1998;25:261.
Rowsell AR, Eisenberg DN, Taylor GI. The anatomy of the subscapular-
thoracodorsal arterial system: study of 100 cadaver dissections. Br J
Plast Surg 1984;37:574–6.
Rowsell AR, Eisenberg N, Davies DM, et al. The anatomy of the thora­
codorsal artery within the latissimus dorsi muscle. Br Plast Surg
1986;39:206–9.
Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of latissimus
dorsi donor site. Plast Reconstr Surg 1986;78:336.
Slavin SA. Improving the latissimus dorsi myocutaneous flap with tissue
expansion. Plast Reconstr Surg 1994;93:811.
Spinelli HM, Fink JA, Muzaffar AR. The latissimus dorsi perforator
based fasciocutaneous flap. Ann Plast Surg 1996;37:500–6.
Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi
myocutaneous flap. Ann Plast Surg 1981;7:272–80.
Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular
neurovascular anatomy of the latissimus dorsi muscle: the basis for
splitting the flap. Plast Reconstr Surg 1981;67:637–41.

464
Iliac Flap
James S. Brown
42 
INTRODUCTION
The iliac crest provides a good source of bone and is uni­
versally accepted as a donor site for non-vascularized grafts.
Its role as a vascularized graft for head and neck reconstruc­
tion has very much decreased in popularity since Hidalgo
described the fibula flap for mandibular reconstruction in
1989.1 There is no doubt that the excellent depth and width
of the bone as well as the natural curvature can be an
advantage, but the donor site is often quoted as much less
favorable to either the fibula or scapula. It has a definite
role in the reconstruction of the maxillary defect especially
when combined as a myo-osseous flap with internal oblique
in Class III defects involving the orbital floor.
Initially, the flap was raised on the superficial circumflex
vessels but now the deep circumflex artery and vein are
routinely used. This author prefers always to include the
ascending branch to the internal oblique to ensure a dual
blood supply through these vessels and the deep circumflex
Iliac crest
bone flap
Anterior superior
iliac spine
Internal iliac
artery
Femoral artery
Rectus femoris
Sartorius
Deep circumflex
iliac artery
Iliacus
Lateral femoral
cutaneous nerve
Pectineus
Ilio-inguinal
nerve
Internal oblique
flap harvest site
Iliohypogastric
nerve
Internal
oblique
Iliopsoas
Inguinal ligament
Transverse
abdominis
Iliacus
Ascending
branch of deep
circumflex
iliac artery
Perforators
supplying skin in
osteomyocutaneous
flap
Figure 42.1  Iliac flap.
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION E  —  LOCAL AND FREE FLAPS IN THE PELVIS, GROIN, AND BUTTOCK

CHAPTER 42 — Iliac Flap
465
vein and either passes over or under the artery. If the
pathway is over the artery, it is possible to achieve more
length to the vein but this is not generally advised if the vein
passes inferior to the artery.
The author’s favorite use of this flap is with internal
oblique, as described by Urken2 after the relationship of the
internal oblique muscle was explained by Ramasastry et al.3
It is possible to use a skin island either raised with external
oblique, internal oblique, and transversalis but this makes
the flap very heavy and bulky for orofacial reconstruction,
and the introduction of the skin island as a perforator flap
by Kimata et al.4 has increased the options and versatility of
the flap. The site, size and position of the perforators has
been mapped by Bergeron et al.5 and these are generally
situated superior to the iliac crest by 4 cm and between 5
and 11 cm posterior to the ASIS.5 It is possible to check for
these with color flow Doppler and handheld Doppler tech­
niques for planning the position of the skin island and to
ensure a reasonable size of perforator vessel. Kimata et al.
succeeded in raising 7 out of 10 flaps, and so there is a
reasonable chance that this chimeric option may not be
available. It is not known at this time whether the color flow
Doppler or arteriography will accurately predict the usabil­
ity of this option.
COMMON ANATOMIC VARIANTS
• The DCIA may arise from the external iliac very close
to the inguinal ligament, which will need to be released
from the ASIS to ensure access for the dissection.
• The ascending branch may be absent, in which case the
supply to the internal oblique will be through multiple
smaller branches and can still be harvested.
• There may be a separate run-off of the ascending branch
from the external iliac, which may require an additional
set of anastomoses although I have transferred the flap
safely without this additional surgery.
Minor:  superficial circumflex iliac artery (SCIA)
Length: 3 cm (range 2–4 cm)
Diameter: 1.5 mm (range 1–2 mm)
The DCIA and SCIA communicate in the region of
the iliac crest. The SCIA supplies a small segment of iliac
crest bone, usually at the ASIS. The SCIA predominantly
supplies the skin anterior and superior to the ASIS and
may be used to support a larger skin paddle than may
be reliably supplied by the DCIA alone, or may provide
vascular supply for an independent and/or additional skin
paddle.
VENOUS DRAINAGE OF THE FLAP
(See Figs 11.6, 11.8)
Primary:  deep circumflex iliac vein
Length: 9 cm (range 8–10 cm)
Diameter: 3.6 mm (range 2–5 mm)
The deep circumflex iliac venous system parallels the course
of the artery before merging with either the femoral vein or
iliac artery (DCIA). The length of the pedicle is reasonable
but can be lengthened by not including the anterior supe­
rior iliac spine (ASIS) and making the anterior cut more
posterior/lateral to the origin of the pedicle.
The skin component can be harvested as a perforator flap
based on the deep circumflex iliac artery or as a osteocuta­
neous flap including iliac bone and the abdominal skin
overlying the perforators, which can be placed with more
flexibility often combined with internal oblique muscle to
add a chimeric option for more complex mandibular and
maxillary defects. This is a valid alternative for patients with
arterial disease or abnormal lower limb anatomy, which may
preclude a fibula option.
FLAP ANATOMY (see Fig. 42.1 and Figs 11.3,
11.6, 11.8, 11.9 and 11.10)
ARTERIAL SUPPLY OF THE FLAP (see Fig. 42.1
and Figs 11.6, 11.9 and 11.10)
Dominant:  deep circumflex iliac artery (DCIA)
Length: 6 cm (range 5–7 cm)
Diameter: 2.8 mm (range 2–3 mm)
The DCIA is the dominant supply to this flap, which
includes the ascending branch, which is the main supply to
the internal oblique muscle. The DCIA arises from the
external iliac artery superior to the inguinal ligament and
passes inferior to the internal oblique muscle in the fascia
separating this muscle from the iliacus. The artery gives off
the ascending branch at a variable distance from the exter­
nal iliac to the ASIS (65% within 1 cm and 15% between 2
and 4 cm), and in some cases may not be obvious. This is
quoted as high as 20% but in the author’s experience, this
is much lower, at between 5% and 10%. Occasionally, I have
found that the ascending branch and accompanying vein
arise separately from the external iliac system (<5%). There
will be communicating branches to the internal oblique
from the DCIA, but it is worth soft clamping the ascending
system to check that the internal oblique muscle is still sup­
plied. One of my colleagues anastomosed both sets of
vessels, but this will depend on the number of recipient
options and an alternative soft tissue flap may be required.
The DCIA then lies between the transversalis and iliacus
but does not persist in this position starting 2 cm below the
iliac crest ridge before passing superiorly over the crest at a
variable distance from the ASIS. The DCIA pierces the trans­
versus abdominis muscle approximately 6–9 cm from the
ASIS and terminates by anastomosing with the iliolumbar,
superior gluteal, and intercostal systems. It is essential when
harvesting this flap to maintain the ascending branch to the
internal oblique to ensure supply to the bone through this
muscle if a long bone harvest of >10 cm is required. Main­
taining the internal oblique with its blood supply will ensure
a better supply to the distal segment of bone if an osteotomy
is required to shape the mandible or maxilla. The deep
circumflex iliac vein (DCIV) accompanies the artery initially
as venae comitans but these usually merge to leave a single
vein draining in to the external iliac vein. The vein tends to
pass inferiorly as the dissection approaches the external iliac

466
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• The perforator flap with internal oblique offers a chime­
ric flap option for complex cases.
DISADVANTAGES
• There is a higher flap failure in some series, which is
related to the potential for vessel spasm and the smaller
vessels when compared to fibula, scapula, and radial artery.
• There is a higher potential for bleeding and the abdomi­
nal contents can be damaged if due care is not taken with
the flap harvest technique.
• Although hernia formation has been cited as a disadvan­
tage of this flap, this is unlikely with careful closure and
the use of mesh to support the abdominal wall.
• The donor site morbidity can be reduced by raising a split
iliac crest only including the abdominal cortex but the
iliac deformity is well tolerated and the thickness of the
bone important in the primary site.
• Sensory loss of the lateral thigh is a potential problem if
the lateral femoral cutaneous nerve is injured. However,
if this does happen it is generally well tolerated.
• Gait disturbance may also occur, particularly when large
bony and muscle components are harvested.
PREOPERATIVE PREPARATION
If the patient has a clear medical history and examina­
tion of the abdomen is normal, then there are no particu­
lar investigations that are required prior to using this
flap option. In general, this author would be less inclined
to use an iliac crest reconstruction in a patient that is obese
but this simply makes the harvest more difficult, and use of
bone and internal oblique ensures a flap of normal size
as adipose tissue is not included. Any form of perforator
and certainly the composite option for such patients, is to
be avoided. I have noted that elderly patients have more
problems with this donor site but that is true for all the
bone harvest donor sites with perhaps scapula being the
best tolerated.
It is important to establish that there has been no history
of previous surgery to the donor site such as appendicec­
tomy or hernia repair, as there may be damage or fibrosis
affecting the pedicle. This donor site should be avoided for
patients with a history of deep vein thrombosis, as there are
reconstructive options such as scapula, which are less likely
to result in this complication. In general, a history of periph­
eral vascular disease does not preclude this donor site but
in such circumstances, appropriate imaging of the vessels
and establishing normal undamaged vessels is essential.
Some suggest that patients with chronic obstructive pulmo­
nary disease may have a higher risk of incisional hernia
formation due to postoperative coughing.
FLAP DESIGN
ANATOMIC LANDMARKS (Figs 42.2, 42.3)
The ASIS, the pubic tubercle, the line of the inguinal liga­
ment, the curve of the iliac crest, the costal margin, and the
position of the iliac vessels will help guide the surgeon in
planning the incision and skin island if required.
the external iliac vein. The two venae comitantes usually
diverge superiorly from the artery to coalesce and form the
deep circumflex iliac vein (DCIV) approximately 1–4 cm
(average 2 cm) from either the femoral or external iliac artery
or, more frequently, the external iliac vein beneath the ingui­
nal ligament. The DCIV receives contributions from the super­
ficial system, which will allow drainage of the SCIA territory by
the DCIV. The DCIV is usually 2–5 mm in diameter.
Secondary:  superficial circumflex iliac vein
Length: 3 cm (range 2–4 cm)
Diameter: 2.5 mm (range 2–3 mm)
Additional venous drainage of the skin component of the
flap may be provided via the paired venae comitantes that
accompany the SCIA.
FLAP INNERVATION (See Fig. 42.1, and Figs 11.9
and 11.10)
Sensory:  the sensory innervation to skin overlying the iliac
crest primarily comes from T12.
The ilio-inguinal nerve (L1) crosses the DCIA and pro­
vides sensation to the groin. The genital and femoral
branches of the genitofemoral nerve (L1, 2) confer sensibil­
ity to the mid-inguinal region and the genital regions,
respectively. The lateral femoral cutaneous nerve (L2, 3)
courses along the inner surface of the iliacus muscle and
penetrates the deep fascia of the thigh about 2 cm infero­
medial to the ASIS, providing sensation to the anterior
thigh. The DCIA usually crosses over the lateral femoral
cutaneous nerve near the ASIS and every effort should be
made to preserve the nerve during flap dissection. It may
be possible to create a sensate flap based on this nerve, but
this technique is not commonly practiced.
Motor:  this flap does not provide for motor reinnervation.
FLAP COMPONENTS
The iliac crest is an excellent source of cancellous bone with
a dual blood supply directly to the bone from the DCIA and
via the internal oblique through the ascending branch. The
best use of the flap is with internal oblique muscle to provide
a natural oral lining or grafted muscle. A composite flap
without a perforator option is now less commonly used but the
perforator option allows versatility in a truly chimeric flap with
bone muscle and skin for complex orofacial reconstructions.
ADVANTAGES
• Excellent bone stock with options for full facial and
dental rehabilitation.
• Two-team operating.
• The ability to close the skin directly without grafting when
using a composite flap.
• The donor site scar is in a favorable position and can be
covered easily.
• The natural contour of the bone is favorable for ipsilat­
eral mandibular and maxillary reconstruction.
• The internal oblique muscle epithelializes leaving a
natural looking result suitable for implant placement.

CHAPTER 42 — Iliac Flap
467
external oblique, internal oblique, and transversalis muscle
is no longer routine practice, as this makes the skin island
very bulky with little choice about its placement in relation
to the bone. If skin is also required, a perforator skin island
is planned and I would use color flow Doppler to establish
the presence of a reasonably sized perforator artery in a
favorable position and follow this up with a handheld
Doppler in the operating room. The perforators have been
mapped and are shown to arise from 5–11 cm posterior to
the ASIS and about 4 cm above the crest. In a series of 10
cases of perforator iliac crest flaps, Kimata reported only
seven successfully harvested.4
It is preferred to keep the ASIS with its attachments
including the inguinal ligament and not include them in
the flap, unless a long span of mandible is being recon­
structed and the additional length is required.
SPECIAL CONSIDERATIONS
FLAP DESIGN BASED ON RECIPIENT REQUIREMENTS
The ipsilateral donor site is preferred for the mandible
with the crest forming the lower border and the pedicle
emerging posteriorly in relation to the defect (Fig. 42.2B).
Ipsilateral harvest is also preferred for the maxilla with
the crest forming the alveolar part of the reconstruction
and the pedicle arising posteriorly. The natural curvature
of the iliac crest helps to reduce the need for multiple oste­
otomies. If a perforator flap is being planned, then the
ipsilateral donor site is ideal for external skin require­
ments using internal oblique intraorally. If there is a very
large intraoral defect requiring skin as a reconstruction,
GENERAL THOUGHTS ABOUT FLAP DESIGN
The position of the internal oblique is planned to decide
how posterior the muscle will be harvested, which relates to
the position of the bone cuts. The use of a composite flap
including a skin island with similar sized harvest of the
Figure 42.2  (A) Anatomic landmarks. 1. Anterior superior iliac spine. 2. Inguinal ligament. 3. Pubic tubercle. 4. Symphysis pubis. 5. Superficial
inguinal ring. 6. Deep inguinal ring. 7. Femoral artery. 8. Femoral vein. 9. Femoral canal. 10. Femoral nerve. 11. Inguinal hernia incision. 12.
Femoral hernia incision. 13. Saphenous opening. 14. Long saphenous vein. 15. Femoral triangle. (B) Outline of osteotomies on iliac crest bone
needed for ipsilateral hemi-mandible reconstruction. (A: After Lumley JSP. Surface anatomy. 3rd ed. Elsevier, Churchill Livingstone; 2002.)
1 2
3
4
6
7
5
8
15
9
11
12
14
13
10
A
Mandible outline (for
ipsilateral hemi-mandible
reconstruction)
Anterior superior
iliac spine
B
Figure 42.3  External anatomy showing surrounding musculature,
inguinal ligament, and inguinal blood vessels. The flap outline and medial
extension needed to dissect the pedicle are indicated by a broken line.
External oblique
muscle
Iliac crest
Gluteus minimus
muscle
Gluteus maximus
muscle
Tensor fascia
lata muscle
Flap outline
Flap axis
Anterior superior
iliac spine
Superficial circumflex
iliac artery
Inguinal ligament
Superficial inferior
epigastric artery
Spermatic cord
Femoral artery
Greater saphenous
vein
Femoral vein

468
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP MARKINGS (Fig. 42.3)
ASIS, iliac crest, internal oblique muscle, costal margin, iliac
vessels, inguinal ligament, and proposed skin island make
up the usual skin marking. The incision is placed 2 cm
above the inguinal ligament and iliac crest, from the iliac
vessels to the distal proposed bone cut. The skin island posi­
tion depends on the result of the color flow Doppler, and
handheld Doppler studies but is usually positioned from
5–11 cm posterior to the ASIS and 4 cm above the iliac
crest.
PATIENT POSITIONING
The iliac crest flap is best harvested with the patient in the
supine position. The placing of a role or bolster under the
hip may improve access but the technique describes uses the
abdominal approach and so elevation of the hip may not be
an advantage. It is essential to remember that the bolster is
moved from time to time in order to avoid a pressure sore.
ANESTHETIC CONSIDERATIONS
Free tissue transfer from the iliac crest donor site may result
in an increased potential for blood transfusion as there is
sometimes prolonged oozing from the donor site. There are
no specific factors in relation to pharmacological therapeu­
tics to aid blood flow through the flap but routine pre-
and postoperative deep vein thrombosis prophylaxis is
essential.
TECHNIQUE OF FLAP HARVEST
(Figs 42.4–42.6)
After establishing the likely position of the perforator(s),
make the incision 2 cm above the line of the inguinal liga­
ment and the iliac crest to include the extra skin. The
external oblique muscle lies under the fat layer with fibers
in the direction of “hands in pockets,” or angled from the
costal margin to the pubic tubercle. This is the correct plane
to identify any perforators relating to the planned skin
island and preserve them. At this stage, the perforators can
be followed through the external oblique, internal oblique,
and transversalis to join either the DCIA or ascending
branch. The rest of the exposure is now done to show the
costal margin posterior planned bone cut, and the position
of the iliac vessels. If the internal oblique alone is being
raised, there is no need to look for perforators prior to
exposing the external oblique as above.
Once the perforators have been dissected and protected,
the external oblique is incised in the same plane as the skin
incision (2 cm above the inguinal ligament and the iliac
crest). This muscle is very easily blunt dissected from the
internal oblique as there is only some fat between these
layers with virtually no intervening vessels. The fibers of the
internal oblique run at right angles to the external oblique
and so this muscle is very easily identified. Once again, this
muscle should be exposed widely to the costal margin, iliac
crest, rectus sheath, and the position of the iliac vessels, and
then the planned harvest marked.
then a contralateral donor site may be preferred to allow
easier placement of the skin island at a cost of increased
osteotomies to accommodate the adverse shape of the
ilium. If extraoral skin and intraoral skin are required, then
an alternative flap or combined flap option may be the best
option.
In tibial reconstruction the direction of the vascular pedicle
and limited length of the straight portion of the iliac crest
bone suggest that the ipsilateral crest is used if the recipient
artery is to be the anterior tibial artery and the contra­
lateral crest is used if the recipient artery is to be the posterior
tibial artery.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
Pedicled bone vascularized iliac flaps have been performed
for the treatment of acetabular problems. The design and
outline of pedicled flaps from this region would allow for a
wide arc of rotation by designing the marks of the flap as
far as possible from the origin of the vessels. In addition, a
long bone flap is usually required to reach the posterior
acetabulum.
FLAP DIMENSIONS
Skin Island Dimensions
Length: 15 cm (range up to 20 cm), maximum to close
primarily: 20 cm
Width: 8–10 cm (range up to 20 cm), maximum to close
primarily: 12 cm
Thickness: variable, depending on the amount of subcuta­
neous adipose tissue
Muscle Dimensions
Length: 10 cm (range 10–15 cm)
Width: 6 cm (range 6–8 cm)
Thickness: 1 cm (range 0.5–1 cm)
Bone Dimensions
Length: 7 cm (range up to 16 cm)
Height: 4 cm (range 2–7 cm)
Thickness: 1 cm (range 1–1.5 cm, full-thickness bone)
The iliac crest flap can supply a large quantity of bone,
up to 16 cm in length. For mandibular reconstruction,
a height of about 2.5 cm is appropriate. The thickness of
the bone harvested depends on whether the flap is raised
as a unicortical, split-thickness bone flap, or a full-thickness
bone flap that includes both cortices and the medullary
bone. In most cases, the full thickness of the iliac crest is
harvested as a thinner flap will reduce the options for
implant-retained prosthetic oral rehabilitation. I am not
aware of a comparative series observing the donor site
outcome with and without the full-thickness harvest,
although it is logical to assume that keeping the outer cortex
will be an advantage in donor site morbidity. If skin
is required, a flap can be 6–12 cm in width and 15–20 cm
in length (average 8 × 18 cm) in order to permit primary
donor site closure.

CHAPTER 42 — Iliac Flap
469
Figure 42.4  Dissection of flap with transversalis fascia, internal and
external oblique muscles, and iliacus muscles cut. The broken line
on the iliac bone indicates the proposed osteotomy.
Cut transversalis
fascia
Internal oblique
muscle
External oblique
muscle
Osteotomy line
Iliacus muscle
Anterior superior
iliac spine
Deep circumflex
iliac artery
Inguinal ligament
Spermatic
cord
Femoral artery
and vein
Greater saphenous
vein
Exposed iliac bone
Figure 42.5  Split-thickness iliac crest osseomyocutaneous flap dis­
sected and isolated on the deep circumflex iliac artery pedicle.
External oblique,
internal oblique, and
transversus abdominis
muscles (cut)
Iliacus muscle
Anterior superior
iliac spine
Deep circumflex
iliac artery and venae
comitantes
Inguinal ligament
Iliacus muscle
(cut)
Internal iliac artery
and vein
Iliac crest bone flap
Ascending branch
(tied)
SKIN PADDLE
Figure 42.6  (A) Layered closure of iliac crest flap donor site including approximation of iliacus muscle to transversus abdominis muscle and
transversalis fascia. (B) Next, the internal and external oblique muscles and muscular aponeuroses are sutured to the gluteal, tensor fascia
lata, and sartorius muscles.
A
B
Exposed bone
Iliacus muscle
Anterior superior
iliac spine
Transversus
abdominis muscle
Internal and
external
oblique
muscles
Gluteus muscles
and tensor fascia
lata muscle
External oblique
aponeurosis
The marking runs from the planned posterior position
directly over the planned posterior bone cut extending as
far as the costal margin. The width of the muscle may be
harvested as far as the interconnection with the rectus
sheath but the thinness of the muscle usually limits the
medial extension. The line then descends back toward
the iliac crest and extends anteriorly to the position of the
iliacs. It is best to start the sharp dissection of the internal
oblique muscle in a more posterior position as all three
abdominal muscles (external, internal oblique, and trans­
versalis) become thinner medially. Sharp dissect through
the internal oblique until the white fascial plane between
internal oblique and transversalis is identified. Expose
this fascia along a reasonable length and then incise the
fascial plane to reveal the fibers of the transversalis muscle
running horizontally on the abdominal wall. It is very impor­
tant to ensure that the fascia remains attached to the under­
surface of the internal oblique, as the ascending branch

470
PART 4 — CONVENTIONAL WORKHORSE FLAPS
lies between the fascia and the internal oblique muscle.
Leaving the fascia, which is adherent to both muscle layers
on the transversalis, may compromise the pedicle required
for a good blood supply to the internal oblique. Once
anterior to the planned harvest of internal oblique, con­
tinue the sharp division of the muscle toward the iliac
vessels. Usually the ascending branch or branches are
evident on the under surface of the internal oblique muscle
and act as a natural guide toward the exposure of the
DCIA/V.
It is usually straightforward to identify the ascending
branch on the under surface of internal oblique and dissect
this anteriorly toward the main pedicle of the DCIA/V. If
there is no clear ascending branch that can be dissected,
then open the incised internal oblique anteriorly, and the
pedicle lies within the fascia underlying the internal oblique
and anterior to the free edge of transversalis. The next stage
of the harvest is to establish the DCIA/V pedicle from its
origin at the iliacs toward the ASIS. It is important to remem­
ber that the DCIV usually starts to separate superiorly from
the DCIA as the iliacs are approached. The vein can pass
over the iliac artery or inferior to the artery before joining
the iliac vein. The DCIV passing above the iliac artery allows
an easier dissection and slightly more length to the vein. At
this point, the pedicle can be exposed between the planned
anterior bone cut and the iliacs and any branches coming
off the pedicle ligated. At this stage, the position of the
lateral cutaneous nerve of the thigh will become evident
passing either over or under the pedicle. If this nerve passes
over the pedicle, then it is possible to deliver the pedicle
under the nerve after the pedicle has been released from
its iliac origin. There is a small part of the internal oblique
attached to the iliac crest and inguinal ligament that does
not require harvest, which can be separated from the
ascending branch to allow repair of this part of the muscle.
In order to do the bone cuts, the transversalis muscle is
incised posteriorly as far as the planned posterior bone cut.
This allows the peritoneal fat and contents to be retracted
to expose the iliacus muscle on the abdominal side. This
muscle should then be incised through to the abdominal
side of the ilium about 2–3 cm below the height of the iliac
crest (Fig. 42.4). If the plan is to split the iliac crest, then
no lateral dissection is required and the bone cuts can be
planned and harvested from the abdominal side. For a full-
thickness iliac crest harvest, it is necessary to sharp dissect
gluteus maximus and medius and tensor fascia lata from the
lateral aspect of the iliac crest. If the ASIS is included in the
bone harvest, the insertion of sartorius and the inguinal
ligament have to be separated through sharp dissection
from the bone. As far as possible, efforts are made to keep
the ASIS intact and to harvest the bone flap more posteri­
orly to reduce morbidity and increase the length of the
pedicle. For a full-thickness iliac crest, the anterior bone cut
must be made from the lateral or nonabdominal side after
lifting a thin area of periosteum to protect the pedicle. This
anterior vertical bone cut is made through the full thickness
of the iliac crest and the saw can be seen on the abdominal
side important in planning the horizontal bone cut. The
posterior bone cut can be made in the planned position to
the depth required and now both the anterior and posterior
bone cut extensions should be visible from the abdominal
side. Both these bone cuts should be angled to allow the
in-fracture of the graft toward the abdominal side. It is pre­
ferred to perform the horizontal bone cut from the abdomi­
nal side as the natural curve of the ilium is toward the
operator, improving access and visibility. This cut simply
connects the posterior and anterior bone cuts to complete
the bone harvest.
If a partial-thickness bone graft is planned, then after
protection of the main pedicle, a bone cut is made from the
crest to the depth required, ensuring that the bone cut
leaves the lateral cortical plate intact (Fig. 42.4). It is then
necessary to make a bone cut along the crest, leaving a small
lateral cortex intact. This cut is carried to a depth compat­
ible with the thickness of the ilium to the depth required.
The posterior bone cut is made leaving the lateral cortex
intact and then the horizontal cut made to join the anterior
and posterior cuts.
It is now possible to push the bone graft through to the
abdominal side and complete the dissection to free the
pedicle completely from the fascia while it remains attached
to the iliac vessels. Our practice is to allow the flap to recover
as there is often marked spasm of the pedicle after the
prolonged dissection. Meticulous care is required at this
point to ensure that all bleeding points are cauterized
and Surgicel is used to reduce the ooze from the cut-bone
surface.
FLAP HARVEST WITHOUT
INTERNAL OBLIQUE
This was originally described by Taylor6 before Ramasastry
investigated the internal oblique option popularized by
Urken.2,3 The skin markings are similar without the need to
include internal oblique and the incision in a similar place.
In this technique, a perforator flap can also be raised start­
ing with the planned skin island. If an adequate perforator
is seen and can be followed this should lead to the DCIA,
which is then exposed and dissected forward to the iliac
origin. If no perforator is planned, then the internal oblique
is incised 2 cm above the inguinal ligament and the pedicle
found in the fascia between the ASIS and the iliac vessels.
Helpful markers are the iliac vessels themselves and the free
edge of the transversalis muscle. Once the pedicle has been
identified dissection can proceed anterior and posterior to
reach the ASIS and the iliac vessels. The ascending branch
is usually found close to the ASIS but can come off the
DCIA/V at any point between the iliacs and the ASIS. In
some cases, there is no obvious ascending branch and in
other cases (5%) the ascending branch has a separate origin
from the iliac vessels. Once the pedicle has been safely dis­
sected the bone cuts are made in a similar way to that
described above. It is more difficult to work out the correct
anatomy without raising internal oblique, and this factor as
well as the improved blood supply to the bone is the main
reason for preferring the technique described by Urken and
confirmed in this chapter.
SHAPING OF THE NEO-MANDIBLE
There are now programs available to make models of the
recipient and donor sites so that bone plates and templates
can be prepared preoperatively to speed up the process

CHAPTER 42 — Iliac Flap
471
of preparing the graft with appropriate osteotomies and
shaping (see Chapter 4). If the internal oblique muscle is
included with the harvest, there is no need for closing oste­
otomies, which makes shaping this particular donor site very
easy and quick. It is possible to do this on the donor site
prior to division of the pedicle, but with iliac crest we are
usually happy to carry out any reshaping required on the
table prior to revascularization of the flap.
If the condyle has been resected, then bone is required
to reach the glenoid fossa with the pedicle so positioned to
reduce the risk of kinking. As a result, it is often necessary
to place the distal part of the graft into the fossa and bring
the pedicle out at the distal osteosynthesis site. With the iliac
free flap the crest can be used as the body reconstruc­
tion with the bone inferior to the ASIS placed into the
fossa to allow the pedicle to come out at the angle near
the ASIS. It is not our practice to use rib and cartilage as a
non-vascularized adjunct or to reconstruct the temporo­
mandibular joint (TMJ) with a prosthesis. The proximal
reconstruction is placed as close to the fossa as possible
and supported with a reconstruction plate to maintain
that position. The use of intermaxillary fixation with elastic
traction support is also helpful in the immediate post­
operative period to maintain the condylar position. The use
of stereolithographic modeling and pre-bent plates is very
useful with the loss of the condyle to help achieve a good
result.
FLAP MODIFICATION/FLAP HANDLING
BONE COMPONENT
“SPLIT” ILIAC CREST
In our practice, the iliac crest is rarely split as the bone thins
rapidly from the crest reducing the options for an implant-
retained dental prosthesis. The donor site morbidity is reduced
as the outer cortex is left intact but choosing this donor site is
related to the thickness and height of the reconstruction
required. This would be a reasonable option in lateral man­
dibular defects where dental rehabilitation is not planned and
with reconstructing some edentulous mandibles.
MULTIPLE SEGMENT OSTEOTOMIES
OF THE ILIAC BONE
If the internal oblique is part of the reconstruction, it is impor­
tant to have this muscle attached along the length of the
reconstruction so that there is definite blood supply to any
distal segment after shaping osteotomies. Closing osteotomies
are not necessary with the iliac crest because there is far more
cancellous bone and because the natural curve of the ilium
allows far less displacement of the segments. Unlike the fibula
a single anterior osteotomy is often sufficient to reconstruct
the anterior mandible from premolar to premolar.
MUSCULAR COMPONENT
ILIAC CREST WITH INTERNAL OBLIQUE AND
PERFORATOR SKIN AND ILIAC CREST WITH
INTERNAL OBLIQUE
These are the two versions of the flap preferred by the
author. This flap is often chosen when the main defect is
loss of the mandible in the dentate jaw, where both height
and width are required to restore form. In this situation, the
oral defect is often relatively small and can be reconstructed
with the internal oblique providing an ideal epithelialized
muscle very similar to oral mucosa. This facilitates the prep­
aration and placement of implants, which can obviate the
need for further mucosal or palatal grafting. The use of the
internal oblique in maxillary reconstruction provides an
ideal lining for the reconstructed palate and the lateral
nasal wall. The muscle also helps to obdurate the sinus
defect following the resection and reduce the risk of infec­
tion and flap breakdown and poor healing.
SKIN COMPONENT
SUPERCHARGING THE SKIN ISLAND WITH INFLOW
FROM THE SCIA
Several modifications have been employed to increase the
size and reliability of the skin paddle associated with the iliac
crest flap by including vascular inflow from the SCIA system.
In order to increase the reliable size of the skin paddle of
the iliac crest flap, the blood supply to the flap can be aug­
mented by including and revascularizing the SCIA. During
the harvest of the flap, the ascending branch can be har­
vested with enough length to allow for primary anastomosis
to the SCIA. Another alternative is to anastomose the SCIA
to a separate recipient vessel at the recipient site.
PERFORATOR-BASED OSTEOMYOCUTANEOUS OR
OSTEOCUTANEOUS FLAP
Kimata4 was the first to report a series of osteocutane­
ous perforator flaps for mandibular reconstruction and
establish the principle of a DCIA perforator flap that can
also be raised with internal oblique as described above. The
relevant anatomy and prevalence of perforator vessels was
researched by Bergeron5 reporting their presence in 11 cm
out of 12 specimens with a mean of 1.6 (range 0–5) perfora­
tors per case and a mean size of 0.7 mm (range 0.5–1.8 mm).
These perforators were positioned between 5 and 11 mm
posterior to the ASIS and 4 cm above the crest.
DONOR SITE CLOSURE AND
MANAGEMENT (Fig. 42.6)
Meticulous closure of the iliac crest donor site is essential
to reduce the risk of incisional hernia. In the method
of harvest described, the inguinal canal is not encoun­
tered and in our experience, herniation related to the inguinal
ligament has not been seen in our standard harvest tech­
niques. More commonly, there is a risk of incisional hernia­
tion of abdominal contents in the region of the harvested
bone.
The first layer of closure is the remnant of transversalis
fascia sutured to the cut edge of iliacus. The anterior part
of the internal oblique overlying the iliac vessels is repaired
up to the site of internal oblique harvest. This shows the
defect left by the internal oblique and the loss of the bone
graft. We use Mersilene mesh or equivalent, which is cut into
the shape of the lost internal oblique muscle and secured
to the rest of the internal oblique with PDS suture. Holes
are drilled in the residual bone defect to ensure that the

472
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• The iliac crest has also been used for maxillary recon­
struction because of the large height and depth of bone
provided to restore facial contour in both palatal and
total maxillary defects while providing an ade­quate
base for dental implant placement. The internal oblique
muscle or skin paddle lines the nasal and oral cavity.
• The iliac crest bone flap is commonly used for tibial
reconstruction.
ATYPICAL INDICATIONS FOR THE USE
OF THIS FLAP
PEDICLED BONE FLAPS FOR HIP RECONSTRUCTION
Pedicled vascularized iliac crest bone grafts based on the
DCIA vessels have been utilized in a few adults and some
children with large acetabular defects. The grafts molded to
the femoral head have demonstrated long-term stability.
Treatment of ischemic necrosis of the femoral head would
similarly seem efficacious with this technique. Anatomic con­
siderations suggest that vascular pedicle position and length
are the most limiting facets of the pedicled iliac crest flap in
this application. In cadaver studies, the ascending branch of
the DCIA and the lateral femoral cutaneous nerve were sac­
rificed in order to gain additional pedicle length, which mea­
sured 12–14 cm. The nerve should be preserved in clinical
cases to avoid untoward sensory symptoms. An increase in the
bone length or passage of the vascular pedicle inferior to the
anterior inferior iliac spine is required for access to the pos­
terior acetabular wall, the latter of which could risk compro­
mise of the pedicle in the prosthetic elements. This suggests
that pedicled iliac crest flaps will most reliably reach the
anterior and superior acetabular rims.
POSTOPERATIVE CARE
GENERAL
Routine monitoring of the free flaps may be accomplished
by the clinical exam and a handheld Doppler if a skin
paddle is present. An implantable Doppler ultrasound
probe (Cook–Swartz probe) placed around the arterial and
venous pedicles distal to the anastomoses may be helpful to
monitor completely buried flaps.
RECIPIENT SITE
Tube feeds are generally used for 1 week after mandibular
reconstruction while mucosal incisions heal. Oral rinses
with saline are begun as soon as feasible.
DONOR SITE
Attentive postoperative management, including 3–5 days of
bed rest with the thigh flexed, is indicated. Closed suction
drains are maintained until their outputs are <30 mL/day
individually, as the site is prone to seroma formation. Ambula­
tion is begun on the 3rd to 5th postoperative day with gradu­
ally increasing activity. Physical therapy may be required
initially. Utilization of abdominal binders and other support
garments may increase patient comfort and serve as a
mesh can be secured to the bone edge where the internal
oblique has been harvested. A suction drain is then placed
at this layer and the external oblique closed. It is a sensible
option to place a catheter in this layer for a bupivacaine
infusion to run over the first few days to help with pain
control and allow earlier mobilization. The skin can then
be closed in one or two layers.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• Including internal oblique muscle does not increase the
overall bulk of the flap in the long term and greatly facili­
tates the dissection while ensuring a dual blood supply to
the bone.
• Meticulous care is required during the dissection of the
pedicle from the iliac origin to the ASIS. There are small
branches entering the muscle that require securing with
ligaclips to ensure there is no compromise to the pedicle.
• It is easier to perform the distal and horizontal bone cuts
from the abdominal side especially if there is a fairly long
mandibular defect that requires reconstruction. Make
sure the angle of the bone cuts will allow infracture of the
cut bone toward the abdominal side.
• The use of unipolar or the Harmonic scalpel when away
from the pedicle or the ascending branch will greatly
reduce the overall blood loss with this harvest
FLAP USAGE
FREE FLAP
HEAD AND NECK
Mandibular and maxillary reconstruction with osseous,
osteocutaneous, bone and internal oblique muscle, or
osseomyocutaneous flaps.
UPPER EXTREMITY
Can be potentially used as an osseous flap for humeral
reconstruction, although this has not been critically assessed.
LOWER EXTREMITY
Tibial reconstruction with osseous, osteocutaneous, or
osseomyocutaneous flaps.
TYPICAL INDICATIONS FOR THE USE
OF THIS FLAP
FREE MICROVASCULAR TRANSFER OF THE ILIAC FLAP
• The iliac crest is probably most commonly used for man­
dibular reconstruction. Hemi-mandibular reconstruction is
best accomplished using a flap from the ipsilateral iliac crest
due to the curvature of the bone. This donor site provides
an ideal reconstruction for the dentate mandible.
• Anterior mandibular re-construction typically requires
one open osteotomy to recreate the curvature of the jaw
in this region, and the height of the bone allows for an
implant-retained fixed bridge prosthesis favored in the
dentate mandible.

CHAPTER 42 — Iliac Flap
473
osseocutaneous flaps, such as the incidence of radial frac­
ture and motor-sensory disturbance associated with osseo­
cutaneous radial forearm flaps and the incidence of gait
anomalies and lower extremity pain during ambulation
after fibular flap harvest. All composite harvest sites can
cause severe complications in a small group of patients and
this is more common in the elderly.
LONG-TERM OUTCOMES
GENERAL
Vascularized flaps in general demonstrate excellent reliabil­
ity over time and the iliac crest flap is no exception.
Long-term follow-up demonstrates successful bony heal­
ing, osseointegration, and stability at the recipient site.
Although data are somewhat limited, experience in the
pediatric population suggests that the iliac crest bone grows
adequately with the child, provided untoward adjuvant/
neoadjuvant therapies such as radiation are not applied. In
this regard, issues of non-union, malunion, and osteoradio­
necrosis appear to occur with the same or slightly lower
frequency than other bone flaps, but as these sequelae are
multifactorial in origin, attributing superiority of one flap
over another in this regard is not warranted.
DONOR SITE
Most patients will adapt well to any sensory disturbance but
there can be ongoing gait disturbance in a small group of
patients.
CONCLUSIONS
MANDIBULAR RECONSTRUCTION
This is a first choice for reconstruction of the anterior man­
dibular defect in a dentate case with minimal loss of soft
tissue. A single osteotomy is required as the shape of the hip
is favorable and internal oblique muscle harvest ensures an
excellent dual blood supply. The height and thickness of the
bone ensure good support of the chin and an option for
implants if required.
MAXILLARY RECONSTRUCTION
An excellent choice for Class III defects and especially those
crossing the midline.7 Including internal oblique ensures a
good blood supply and the muscle allows epithelialization
for the oral cavity and nasal lining. Implants can be used for
an upper denture if needed and the long-term result for
orbital support is optimized.
reminder to avoid heavy lifting or straining. Patients should
be advised to anticipate a 4–6 week recovery in most cases.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
Flap failure rates with the iliac crest donor sites are slightly
higher than the fibula, scapula, and radial options. The
reason for this is mainly technical. The harvest of this flap
is a more technically demanding procedure requiring
meticulous attention to the dissection of the pedicle. In the
author’s opinion the harvest technique with internal oblique
described by Urken facilitates this dissection and may reduce
failure rates and provide better donor site outcomes. The
DCIA is smaller than the other options above and the
pedicle length is shorter than the radial and fibula options.
The incorporation of internal oblique provides a dual blood
supply to bone with a higher proportion of cancellous bone
allowing excellent adaptation to the recipient bone and a
low incidence of non-union in a successful flap. This also
will allow open osteotomies easily carried out on the lateral
side of the graft with a low risk of non-union.
DONOR SITE
The donor site cosmesis is generally very good. Functional
morbidity is minimized when the iliac crest is harvested as a
split-thickness bone flap. The contour deformity is significantly
more noticeable when taken as a full-thickness bone flap.
UNTOWARD OUTCOMES
GENERAL
As the iliac crest has a shorter pedicle length it is important
to ensure a good option of recipient artery and vein espe­
cially in maxillary reconstruction. For anterior mandibular
defects, it may not be possible to reach the internal jugular
vein for anastomosis and so ensuring there is an option
using the common facial is important. The facial artery is
usually in a good position for any mandibular defect recon­
struction. In maxillary reconstruction, the facial artery and
vein are kept in continuity and used as recipients without
the need for vein grafts in most cases. If muscle is used for
the soft tissue reconstruction then the use of the Cook–
Swartz implantable Doppler for the vein is useful as the
muscle is not a reliable monitor used alone.
DONOR SITE
Outcomes for the overall donor site morbidity of iliac
crest flaps appear comparable with those seen with other

474
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 42.7  (A) Intraoperative view showing anterior mandible resection through visor access. (B) View showing segment of mandible
removed and part of the oral floor. (C) Postoperative view showing a healed flap. (D) Panorex showing the mandible reconstructed with
a vascularized iliac flap. (E) Osseointegrated implants are placed. (F) Panorex showing implants in place. (G,H) AP and lateral facial views
showing reasonable facial profile and height. (I) Oral view showing complete dental rehabilitation.
A
D
G
E
F
H
I
B
C
A 45-year-old woman with a mandibular SCC underwent resec-
tion of the anterior mandible and part of the floor of the mouth.
She was reconstructed with iliac crest and internal oblique
muscle and the muscle was skin grafted (we do not currently
perform a skin graft over the muscle. We allow the muscle to
mucosalize). Osseointegrated implants were placed and eventu-
ally a retained prosthesis for oral rehabilitation.
CASE 42.1  Central Mandibular Defect with Minimal Soft Tissue Resection Reconstructed
with a Composite Iliac and Internal Oblique Flap and a Skin Graft

CHAPTER 42 — Iliac Flap
475
CASE 42.2  Central and Lateral Mandibular Defect and Extensive Intraoral Soft Tissue
Resection Reconstructed with a Free Iliac Bone Flap and Free Radial Forearm Flap
Figure 42.8  (A) Early Panorex following reconstruction with an iliac free flap. (B) Following implant placement and prosthesis. (C,D) Facial
views showing reasonable facial profile and height. (E) Oral view showing complete dental rehabilitation.
A
B
C
D
E
A 52-year-old woman following extensive mandibular recon­
struction and soft tissue intraoral resection reconstructed with
a combination of iliac crest and radial forearm flap through
to implant-retained prosthesis. Postoperative radiotherapy was
required.

476
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 54-year-old man with adenoid cystic carcinoma of the right
maxilla required an extensive maxillectomy crossing the midline
and maintaining the orbit with orbital floor resection. He has
undergone an implant-retained prosthesis and is now 4 years
post-surgery.
CASE 42.3  Class IIID Maxillectomy Defect Reconstructed with Free Iliac Crest Flap with
Internal Oblique Muscle
Figure 42.9  (A) Preoperative AP view of a patient with an adenoid cystic carcinoma of the right maxilla. (B) Preoperative CT scan showing
the adenoid cystic carcinoma. (C) Intraoperative view showing open osteotomy to shape bone to facial profile and cross the midline. A
separate non-vascularized graft has been used for nasal support. (D,E) Early postoperative view soon after radiotherapy showing main­
tenance of facial profile and orbital support. (F,G) At 4 years post-treatment, there is reasonable stability of the reconstruction with full
oral rehabilitation with implant retention.
A
B
C
D
E
F
G

CHAPTER 42 — Iliac Flap
477
Access further reading online at http://
expertconsult.inkling.com
REFERENCES
1. Hidalgo DA. Titanium miniplate fixation in free flap mandible
reconstruction. Ann Plast Surg 1989;23:498–507.
2. Urken ML, Vickery C, Weinberg H, et al. The internal oblique-iliac
crest osseomyocutaneous free flap in oromandibular reconstruc­
tion. Report of 20 cases. Arch Otolaryngol Head Neck Surg 1989;
115:229–349.
3. Ramasastry SS, Granick MS, Futrell JW. Clinical anatomy of the
internal oblique muscle. J Reconstr Microsurg 1986;2:117–22.
4. Kimata Y, Uchiyama K, Sakuraba M, et al. Deep circumflex iliac
perforator flap with iliac crest for mandibular reconstruction. Br J
Plast Surg 2001;54:487–90.
5. Bergeron L, Tang M, Morris SF. The anatomical basis of the deep
circumflex iliac artery perforator flap with iliac crest. Plast Reconstr
Surg 2007;120(1):252–8.
6. Taylor GI. Reconstruction of the mandible with free composite iliac
bone grafts. Ann Plast Surg 1982;9:361–76.
7. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface:
introducing a new classification. Lancet Oncol 2010;11(10):
1001–8.
Expert Commentary 
Roberto Puxeddu, MD, FRCS (Eng.)
The iliac crest osteocutaneous or osteomusculocutaneous
flap represents a generous flap allowing for complex options
either in terms of shape, length, and transfer of composite
tissue. When Taylor in Australia and Sanders with Mayou in
England identified the deep circumflex iliac vessels as being
able to supply the bone, muscles, and skin in the region of
the lower abdomen, they basically identified a “backbone”
for complex reconstruction in the oral cavity and maxilla.
The pedicle is not extremely long but very constant and of
adequate caliber, allowing for reliable anastomoses. By
knowing the anatomy of the region and the tricks of the
harvesting, and by using the ultrasonic piezoelectric scalpel,
the peritoneum is very rarely violated, so that the intimidating
aspects of the flap and the apparent difficulties become
minimal.
The flap offers adequate amount of skin that is usually
enough for the majority of soft tissue of intraoral defects that
follow segmental mandibulectomy and or maxillectomy. The
same skin can also be used for external reconstruction for
through-and-through defects, leaving the external and inter-
nal oblique and the transversus muscles exposed for a sec-
ondary re-epithelialization.
In trained hands, the muscles can be reduced at a minimal
cuff close to the pedicle that runs between the insertion of
the three muscles and the iliacus. At this level, the vessels
can be easily felt at palpation during the blunt dissection of
the peritoneum, allowing for a fast and easy recognition of
the limit of the dissection.
The bone is heavily vascularized by the periosteum, and
even after multiple osteotomies, it maintains a generous vas-
cular supply that allows integration of free bone chips.
Although the bone of the iliac crest is considered to be
inadequate in cases of long segmental mandibulectomies,
I personally harvested and reconstructed angle-to-angle
defects without major problems.
The thickness and the variable height of the bone trans-
plant usually allow for osseointegrated implants even after
radiotherapy. The iliac flap in the form of an osteocuta­
neous or osteomusculocutaneous flap, although somehow
neglected, still represents a rewarding tool that is excellent
for use in major head and neck reconstruction.

CHAPTER 42 — Iliac Flap 477.e1
FURTHER READING
Akyurek M, Conejero A, Dunn R. Deep circumflex iliac artery perfora­
tor flap without iliac crest. Plast Reconstr Surg 2008;122(6):1790–5.
Brennan PA, Pratt C, Brown JS. Reconstruction of the total maxillec­
tomy defect using a pedicled coronoid flap and deep circumflex iliac
artery free flap. Br J Oral Maxillofac Surg 2008;46(5):423–4.
Brown JS. Deep circumflex iliac artery free flap with internal oblique
muscle as a new method of immediate reconstruction of maxillec­
tomy defect. Head Neck 1996;18(5):412–21.
Brown JS. Reconstruction of the maxilla with loss of the orbital floor
and orbital preservation: a case for the iliac crest with internal
oblique. Semin Plast Surg 2008;22(3):161–74.
Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with
internal oblique muscle for immediate reconstruction after maxil­
lectomy. Br J Oral Maxillofacial Surg 2002;40:183–90.
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: intro­
ducing a new classification. Lancet Oncol 2010;11(10):1001–8.
Clement JL. A growing acetabular graft. Results of 10 cases of trans­
plantation of the epiphysis of the iliac crest including a vascular
pedicle. Chirurgie 1991;117:745–50.
Daniel RK. Mandibular reconstruction with free tissue transfers.
Ann Plast Surg 1978;1:346–71.
David DJ, Tan E, Katsaros J, et al. Mandibular reconstruction with vas­
cularized iliac crest: a 10-year experience. Plast Reconstr Surg 1998;
82:792–801.
Forrest C, Boyd B, Manktelow R, et al. The free vascularised iliac crest
tissue transfer: donor site complications associated with eighty-two
cases. Br J Plast Surg 1992;45:89–93.
Huang GK, Shen YL, Miao H. Microvascular free transfer of iliac
bone based on the deep circumflex iliac vessels. J Microsurg 1980;
2:113–20.
Jewer DD, Boyd JB, Manktelow RT, et al. Orofacial and mandibular
reconstruction with the iliac crest free flap: a review of 60 cases and
a new method of classification. Plast Reconstr Surg 1989;84:
391–403.
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66(9):1256–62.

478
Groin Flap and Superficial
Circumflex Iliac Artery
Perforator Flap
Isao Koshima  |  Kensuke Tashiro  |  Samir Mardini  |  Fu-Chan Wei
43 
INTRODUCTION
The groin flap, nourished by the superficial circumflex iliac
artery (SCIA), is historically important because it was the
first successful free flap. With its concealed donor site, this
flap was especially popular in children and young women.
However, it is less commonly used nowadays due to the
anatomic variations in the course and size of the pedicle
vessels that make flap elevation difficult. With the recent
development of perforator flaps, the major pedicle vessels
of musculocutaneous and fasciocutaneous flaps could be
left in place at the donor site and the flap could be har­
vested based on branches of these vessels only, thus minimiz­
ing donor site morbidity while preserving reliable blood
supply with the flap. Additionally, musculocutaneous flaps
could be replaced with cutaneous perforator flaps of the
same skin territory, by dissecting the perforator vessels away
from the muscle fibers that they traverse, and allowing for
preservation of maximal function at the donor site. Simi­
larly, fascia could be left in place at the donor site where it
would have been included with the flap in standard fascio­
cutaneous flaps.
All these modifications are performed today, without a
significant decrease in the skin territory size and blood
supply included with the flap. This concept of perforator
flaps has been applied to the development of the superficial
circumflex iliac artery perforator (SCIP, skip) flap, which is
based on a perforator with a small segment of the superficial
circumflex iliac vessel. This chapter covers both the tradi­
tional groin flap and the SCIP flap and discusses modifica­
tions of both these flaps.
FLAP ANATOMY
ARTERIAL SUPPLY OF THE FLAP (see Figs 43.1 and
43.2 and Figs 11.3, 11.6, 11.8, 11.9 and 11.10)
The region of the groin and the surrounding areas (lower
abdomen and upper thigh) are supplied by the superficial
circumflex iliac artery (SCIA), the superficial inferior
epigastric artery (SIEA), the deep circumflex iliac artery
(DCIA), and the lateral circumflex femoral artery (LCFA).
The SIEA supplies the lower abdominal area, the DCIA sup­
plies the superior lateral area of the anterior superior iliac
spine (ASIS), and the LCFA supplies the anterolateral thigh
region. The SCIA is present in 98% of cases and is usually
at least 1 mm in diameter. In some cases, if the SCIA is small
and the SIEA is large, the SIEA can be used to supply the
same region. The SCIA is the main supply to the region and,
unless it is absent or too small, it is the vessel of choice for
harvesting the region of the groin.
Figure 43.1  Groin flap and superficial circumflex iliac artery perfora­
tor flap.
Rectus
sheath
Deep branch
of SCIA
Superficial
branch of SCIA
Perforator of deep
branch of SCIA
Superficial
circumflex iliac
artery (SCIA)
Femoral artery
Rectus femoris
Sartorius
Vastus lateralis
Tensor fasciae
latae
Iliopsoas
Lateral femoral
cutaneous nerve
Terminal branch
of SCIA
Pectineus
Lateral cutaneous
branch of subcostal
nerve (T12)
Perforator of
superficial
branch of SCIA
Lateral cutaneous
branch of
iliohypogastric
nerve (L1)
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION E  —  LOCAL AND FREE FLAPS IN THE PELVIS, GROIN, AND BUTTOCK

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap
479
originates from a common trunk with the SIEA (one-third
of cases). It gives off a superficial branch that is located
proximally over the deep fascia of the sartorius muscle and
distally in the fatty tissue. It gives off a few perforators (0.3–
0.5 mm caliber) at the middle portion of the anteromedial
groin region.
The deep branch of the SCIA system runs in a supero­
lateral direction beneath the deep fascia of the sartorius
muscle through the inguinal ligament. After penetrating
Dominant:  superficial circumflex iliac artery (SCIA)
Length: 2 cm (range 1.5–3 cm)
Diameter: 1.5 mm (range 0.8–2 mm)
The SCIA takes off from the anterolateral aspect of the
superficial femoral artery approximately 3 cm below the
inguinal ligament and runs laterally approximately two fin­
gerbreadths below and parallel to the inguinal ligament. It
Figure 43.2  (A) Schematic drawing of the perforator of the superficial circumflex iliac artery as related to the SCIP flap. D, deep branch of
the superficial circumflex iliac artery; P1, perforator of the deep branch; S, superficial branch of the superficial circumflex iliac artery; P2, per­
forator of the superficial branch; T, distal terminal of the deep branch; M, sartorius muscle. (B) Schematic drawing of the SCIP flap, G. A short
segment of the deep branch, D, of the superficial circumflex iliac system was used as the pedicle. (C) Schematic drawing of the perforator of
the superficial circumflex iliac system, demonstrating harvest of the SCIA perforator flap. A, femoral artery; V, femoral vein; F, free groin per­
forator flap; D, deep branch of the superficial circumflex iliac artery; S, superficial branch of the superficial circumflex iliac artery; P1, perforator
of the superficial branch; P2, perforator of the superficial branch; M1, sartorius muscle; M2, tensor fascia lata muscle. (Reproduced with permis­
sion from Koshima et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004;
113:233–40.)
S
P2
P1
M
D
T
A
P1
M
D
T
G
B
P1
S
V
A
D
M2
P2
F
M1
C

480
PART 4 — CONVENTIONAL WORKHORSE FLAPS
included in this flap. The sartorius muscle may be included
based on perforators of the SCIA that supply the upper
portion of the muscle. In cases with penetration of the SCIA
through the sartorius muscle, flap elevation is easier if part
of the sartorius muscle is included.
ADVANTAGES
Groin Flap and SCIP Flap
• Minimal donor site morbidity
• Donor site is easy to conceal
• A large cutaneous vein is available as a venous drainage
system
• Reliable blood supply
• Lateral portion of the flap can be thin
SCIP Flap
• Deeper and longer dissection of the SCIA system to the
femoral artery, as in the groin flap, is unnecessary
• Only the dominant perforator and a short length of the
superficial or deep branch is required to nourish the
flap
• Flap elevation time is short
• Thinning of the flap may be done with primary defatting
• Thinning to create a customized adiposal flap with volume
reduction may be done in one stage
DISADVANTAGES
Groin Flap and SCIP Flap
• Bulky, particularly in the medial aspect of the flap
• Short pedicle and small vessels
• Significant anatomic variation of the vessels
• Presence of pubic hair, particularly in the medial aspect
of the flap
SCIP Flap
• Supermicrosurgery is necessary to dissect and to anasto­
mose the smaller and short pedicle vessels
• There is an anatomic variation of the SCIA system: when
the pedicle perforators of the free SCIP flap are hypoplas­
tic or smaller (<1.0 mm), smaller recipient vessels are
necessary for anastomosis.
PREOPERATIVE PREPARATION
Designing and marking the course of perforators are
essential components of a successful perforator flap trans­
fer. The high degree of anatomic variation within the
SCIA system is widely known, and contributes to the per­
ception that SCIP flap surgery is particularly difficult. The
SCIA system is sometimes hypoplastic or missing, requir­
ing the reconstructive strategy to be altered during
surgery, so it is important to know preoperatively which
artery is dominant in this region. Prior knowledge of any
hypoplasia or hyperplasia in the SCIA, SIEA, and DCIA
systems within a groin region promotes the ease and safety
of SCIP flap surgery.
Preoperative color Doppler ultrasound (US) evaluation
is very useful for planning the SCIP flap. CT angiograms are
not suitable for delineating the course of the superficial and
the deep fascia at the lateral border of the sartorius
muscle, the deep branch enters the suprafascial layer to
give off several perforators (0.5–0.8 mm caliber) in the
anterolateral portion of the groin region.
When a superficial branch is long and large, the deep
branch is usually short and small. Sometimes, in cases in
which the superficial branch is absent, only the long and
large deep branch can be detected. The distal terminals of
the superficial and deep branch sometimes connect to the
perforators from the deep circumflex iliac system, deep
inferior epigastric system, and the lateral circumflex femoral
system.
VENOUS DRAINAGE OF THE FLAP (see Fig. 43.2
and Figs 11.6 and 11.8)
The region of the groin is drained by two main systems:
superficial and deep. The superficial circumflex iliac vein
(SCIV) and the superficial inferior epigastric vein (SIEV)
constitute the superficial system, and the venae comitantes
of the different arteries constitute the deep system. The
SCIV and SIEV are usually located superficial to Scarpa’s
fascia. In many cases, these two veins join to form one large
vein (2.5 mm diameter) that can be used for anastomosis.
Additional veins in the regions are perforating veins of con­
comitant veins of the DCIA, and perforating veins of the
transverse branch of the LCFA system.
Primary:  superficial circumflex iliac vein
Length: 3 cm (range 2–4 cm)
Diameter: 1.8 mm (range 1.5–2 mm)
Secondary:  concomitant vein of the SCIA system
Length: 2.5 cm (range 2–3 cm)
Diameter: 1 mm (range 0.5–1.5 mm)
These veins are significantly smaller than the superficial
system. They can be anastomosed directly to a recipient vein
or they can be connected to the superficial system if the
venous system does not seem to drain the flap adequately.
Usually one concomitant vein is present, and sometimes
there are two. Veins from the surrounding systems can be
used as secondary drainage of the flap as long as the flap
encompasses these veins.
FLAP INNERVATION (Figs 43.1 and 11.10)
Sensory:  The region of the groin is supplied by T12 and
L1 segmentally. Although not commonly performed, using
the lateral cutaneous branch of T12 allows a sensate flap to
be harvested.
Motor:  The flap cannot include any motor potentials;
however, if the sartorius muscle flap is included, the motor
nerve to the muscle can be included with the flap (this is
rarely performed).
FLAP COMPONENTS
The fascia lata or fascia of the abdominal wall, adipose
tissue, iliac bone, or lateral femoral cutaneous nerve can be

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap
481
The surgeon can plan the design and axis of the flap to
allow for inclusion of the SIEA in case the SCIA cannot be
found or is too small.
DIFFERENCES IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
Dissection of the pedicled flap does not require visualiza­
tion of the pedicle or extensive dissection of the pedicle,
as long as the arc of rotation is adequate. In order to
increase the arc of rotation, pedicle dissection can be
performed.
FLAP DIMENSIONS
Skin Island Dimensions
Length: 15 cm (range 10–20 cm)
Width: 10 cm (range 5–15 cm), maximum to close primar­
ily: 10 cm
Maximal dimension: posterior margin, 10 cm lateral to
anterior superior iliac supine.
Superior border: umbilical level.
Inferior border: 10 cm below the inguinal ligament
Muscle Dimensions
A small segment of sartorius muscle proximally can be har­
vested with this flap if necessary.
Bone Dimensions
Length: 4 cm (range 3–8 cm)
Width: 2 cm (range 1–3 cm)
The iliac bone can be harvested based on the SCIA;
however, it is better harvested based on the deep circumflex
iliac vessels.
FLAP MARKINGS (Fig. 43.3)
GROIN AND SCIP FLAP
The ASIS and pubic tubercle are marked and a line is
drawn connecting the two landmarks. A line is drawn two
fingerbreadths (approx. 3 cm) below and parallel to the
inguinal ligament. This is the line of the vascular pedicle.
The superficial femoral artery is palpated in the femoral
triangle.
The flap is centered over this line and can be extended
5–10 cm lateral to the ASIS. The width can be up to 10 cm,
with primary closure being possible.
SCIP FLAP
The SCIA perforator exits around the medial aspect of the
anterior superior iliac spine. The flap is marked lateral and
medial to the perforator with more of the extension
laterally.
PATIENT POSITIONING
The preferred position is supine. There is no need to place
a bump below the hip as the anatomy may become distorted
and the pedicle may be under tension during harvest.
deep branches of SCIA system, owing to the short perforator
length of the major vessels in this lesion. The handheld
Doppler system is similarly inferior to color Doppler US in
preoperative identification of SCIP flap perforators because
it cannot provide precise information on the subcutaneous
tissue layer.
Male patients need hair trimming around the groin
region. There is no age limitation but the flap is best suited
for young females and children.
FLAP DESIGN (Fig. 43.3)
ANATOMIC LANDMARKS
The pubic tubercle, anterosuperior iliac spine, inguinal
ligament, and femoral artery are marked. Color Doppler
US examination confirms the course of the SCIA, which
runs parallel to and 2–3 cm below the inguinal ligament.
If a SCIP flap is to be harvested, the dominant perfora­
tor of the superficial and deep branches of the SCIA
system is usually located at the cross-point 3 cm medial
to the anterior superior iliac spine along the course of
the SCIA.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Wide flaps should be avoided in patients with thick adipose
tissue, as donor site problems may occur.
In designing a SCIP flap, the point of the ASIS should
be included in the design of the flap. The flap can be
extended beyond the ASIS toward the back in a superolat­
eral direction.
If a very large flap is to be harvested, it is beneficial to
include the SIEA system. Other dominant arterial systems
such as the DCIA or deep inferior epigastric artery (DIEA)
can carry the groin region in cases in which the SCIA system
is hypoplastic.
After locating the vessels supplying the flap, the skin
paddle size and design should be adjusted based on the
location and size of the vessels. This applies more to the
SCIP flap in which the perforator is preferably centered
within the flap markings. Larger flaps can be harvested if
the artery is large, dominant, and pulsatile.
A different version of the flap, the lateral islanded
groin flap, is harvested from the more lateral aspect of
the groin. The purpose is to extend the pedicle length
and to harvest a thinner flap. The medial marking of the
flap begins lateral to the femoral triangle and extends
laterally. A T-shaped incision is made with the T lying on
its side.
The osteocutaneous groin flap based on the SCIA is
designed as described for the standard groin flap; however,
a segment of iliac bone is included in the design. The ASIS
is preferable left at the donor site to minimize contour
deformities.
SPECIAL CONSIDERATIONS
In defects of the extremities with small recipient vessels, the
SCIP flap or the groin flap can both provide vessels with a
suitable match in size.

482
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Flap elevation is difficult but feasible in the lateral decu­
bitus position.
ANESTHETIC CONSIDERATIONS
If necessary, a small flap can be elevated under local anes­
thesia. Epidural or lumbar anesthesia is sufficient for flap
elevation.
TECHNIQUE OF FLAP HARVEST
GROIN FLAP (Fig. 43.4)
PEDICLED GROIN FLAP
The dissection is begun on the lateral aspect and continued
medially. On the lateral aspect of the flap, the incisions are
made down to the fascia lata, the inguinal ligament, and the
external oblique, and the dissection is carried medially
superficial to these fascial structures. As the dissection pro­
ceeds medially, the sartorius muscle becomes visible under
the fascia. Care is taken to visualize the pedicle as the dis­
section approaches the lateral border of the sartorius
muscle. The flap is dissected deep to the fascia of the sarto­
rius muscle in order to avoid injury to the deep branch of
Figure 43.3  Flap markings. (Reproduced with permission from
Lumley JSP. Surface anatomy. 3rd ed. Churchill Livingstone; 2002.)
1
2
3
4
6
7
5
8
15
9
11
12
14
13
10
1. Anterior superior iliac spine
2. Inguinal ligament
3. Pubic tubercle
4. Symphysis pubis
5. Superficial inguinal ring
6. Deep inguinal ring
7. Femoral artery
8. Femoral vein
9. Femoral canal
10. Femoral nerve
11. Inguinal hernia incision
12. Femoral hernia incision
13. Saphenous opening
14. Long saphenous vein
15. Femoral triangle
Figure 43.4  Step-by-step procedure for groin flap. (Redrawn from
Strauch B, Yu H-L. Atlas of microvascular surgery. 2nd ed. Thieme
Medical Publishers; 2006.)
A
B
C
Lateral femoral
cutaneous nerve
Superficial circumflex
iliac artery and vein

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap
483
centralize the pedicle. If the pedicle is found to be too small
or absent, the surgeon can resort to using the SIEA or
change to the other side. If the vessels are present and of
adequate size, the flap is dissected from lateral to medial as
described for pedicled groin harvest (see above).
Once the dissection reaches the medial aspect of the
sartorius muscle in the subfascial plane, attention is then
paid to the pedicle identified earlier from the medial aspect
of the flap. With the pedicle in full view medially and the
medial aspect of the sartorius in view from the lateral aspect,
the two are communicated by incising the fascia medial to
the sartorius muscle. It is critical that the deep branch
of the SCIA is included. This vessel usually runs on the
undersurface of the fascia of the sartorius. Sometimes it
perforates the sartorius muscle, and in those cases a segment
of the muscle can be included. Care is taken to ligate all
branches supplying the sartorius muscle.
SCIP FLAP (Fig. 43.2)
Preoperative color Doppler US examination is useful to
confirm the course of the SCIA and location of perforators.
The dominant perforator of the superficial and deep
branches of the SCIA system is usually located at the cross-
point 3 cm medial the ASIS and along the course of the
SCIA. The flap is outlined to include this point and the area
over the ASIS. The first incision is made through the supe­
rior or inferior border of the outline to detect the deep and
superficial branch and the perforators. Although both
branches have usually dominant perforators, in some cases
in which the superficial branch is short or absent, the long
and large deep branch can be detected. When a superficial
branch is very long and large, the deep branch is usually
short and small. Therefore, the perforator of either domi­
nant branch can be selected as a pedicle of the SCIP flap.
During suprafascial flap elevation from the distal side,
several perforators of the SCIA system can be easily identi­
fied under lower magnification with a loupe. The dominant
perforator is dissected deeply to the level of the superficial
or deep branch of the SCIA system. The cutaneous vein in
the adiposal layer is included as a venous drainage system
for the flap, because the concomitant vein of the SCIA is
sometimes too small (<0.5 mm in diameter) to anastomose.
After dissection of the perforator and SCIA system, the
other border of the flap is incised to elevate it as an island
flap. If necessary, thinning, except around the perforator, is
possible with removal of fatty tissue with scissors. The key
point for this operation is bloodless flap elevation to detect
and preserve the perforators and both SCIA branches. The
flap can be elevated on a single perforator.
Finally, the SCIA, concomitant vein (usually one, some­
times two), and superficial circumflex iliac cutaneous vein
are ligated. The proximal and distal portions of the perfora­
tor division of the SCIA system are transected, and a free
groin perforator flap with a perforator and small segment
of SCIA and concomitant vein (0.8–1 mm diameter at the
proximal transected end) and the cutaneous vein (1.5 mm)
is transferred (Fig. 43.2B,C). As the vascular dissection for
the proximal SCIA system is not necessary, the flap can be
elevated within a short time, usually about 30 min. Usually,
the donor defect can be closed directly but sometimes a
split-thickness skin graft is required.
Figure 43.5  Step-by-step procedure for free groin flap. The remain­
ing part of the procedure is performed as demonstrated in Figure
43.4. (Redrawn from Strauch B, Yu H-L. Atlas of microvascular surgery.
2nd ed. Thieme Medical Publishers; 2006.)
A
B
the SCIA. Once the medial aspect of the muscle is encoun­
tered, flap dissection is stopped. Only if necessary, the flap
is dissected medially beyond the medial aspect of the fascia
of the sartorius muscle. If this is necessary, the flap is har­
vested as if it were a free flap (see below).
FREE GROIN FLAP (Fig. 43.5)
The dissection can be performed from lateral to medial or
it can be started medially. Our preference is to begin the
dissection by identifying the SCIA and SCIV medially at
their takeoff and entry points into the superficial femoral
artery and vein. The vessels are identified by incising the
medial aspect of the flap. The vessels are identified before
fully committing to the skin island design. Once the vessels
are identified, the markings of the flap may be changed to

484
PART 4 — CONVENTIONAL WORKHORSE FLAPS
artery and/or bilateral internal jugular veins. Because of the
limitation of the skin territory of pedicled flaps, large full-
thickness cervical defects involving the pharyngoesophagus
have been repaired with an extended latissimus dorsi mus­
culocutaneous flap, a combined deltopectoral and pectora­
lis major musculocutaneous flap, a pectoralis major or
latissimus dorsi musculocutaneous flap with a free intestinal
transfer, or a radial forearm flap. These methods have some
disadvantages, including partial necrosis of the extended
latissimus dorsi musculocutaneous flap and technical diffi­
culties because of multiple donor sites. To overcome these
disadvantages, a free combined SCIP–anterolateral/antero­
medial thigh flap using the lateral circumflex femoral
system was developed. This flap, consisting of two neighbor­
ing flaps with a single vascular source, is useful for recon­
struction of large cervical defects.
The SCIA and the perforators of the lateral circumflex
femoral system are included in order to harvest both
territories and repair cervical skin defects involving the pha­
ryngoesophagus. Although it appears to be similar to
“Siamese” flaps, this flap is a new concept because it consists
of two adjacent flaps that are simultaneously elevated with
pedicles that are anastomosed as a “bridge” flap. The advan­
tages of this combined flap are that simultaneous elevation
of the flaps during tumor resection is possible and vascular­
ization of this large flap is ensured. This combined flap is
unique in that the skin territory of the main flap, the
anteromedial thigh flap, is extended with an additional
FLAP MODIFICATION/FLAP HANDLING
THIN SCIP FLAP
A conventional groin flap with thick fatty tissue cannot be
thinned safely at the initial operation because of the axial
nature of the SCIA and its location in the subfascial plane
in the medial aspect of the flap. However, resection of a
considerable amount of fatty tissue in a groin perforator
flap (SCIP) is easily performed by performing fat resection
away from the perforator.
SCIP FLAP WITH ADDITIONAL ADIPOSE TISSUE
The deep adiposal tissue around the inguinal ligament
and lower abdominal region can be vascularized with a
single SCIA perforator. The adiposal flap can be used for
augmentation of facial depressive deformity and breast
augmentation.
COMBINED SCIP–ANTEROLATERAL THIGH (ALT)
FLAP (Fig. 43.6)
Defects following radical resection of recurrent laryngeal
carcinomas are often difficult to deal with because of previ­
ous irradiation, radical neck dissection, and resulting large
defects involving the esophagus and the common carotid
Figure 43.6  Combined SCIP flap–anteromedial thigh flap. (A) Schema of the reconstruction. T, transverse cervical artery; E, external jugular
vein; L, lateral circumflex femoral artery; F, superficial circumflex iliac artery. (B) After the middle portion of the flap was de-epithelialized for
folding and the anteromedial thigh flap was rolled up, the flap was transferred. O, pedicle vessels of the medial thigh flap, which originated
directly from the femoral system. (Reproduced with permission from Koshima et al. Extended anterior thigh flaps for repair of massive cervical
defects involving pharyngoesophagus and skin: an introduction to the “mosaic” flap principle. Ann Plast Surg 1994;32:321–43.)
A
L
T
F
E
B
O
F

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap
485
Figure 43.7  (A,B) Combined SCIP flap–iliac bone osteocutaneous
flap. Cutaneous portion over the iliac crest can be vascularized
with a SCIA perforator. This method is essential in cases with
hypoplastic or no perforators of the deep circumflex iliac system.
Anastomosis is performed between the ascending branch of the
deep circumflex iliac artery and the vessels of the SCIP or groin
flap. C, distal portion of the SCIA with a perforator; R, ascending
branch; D, deep circumflex iliac artery. (Reproduced with permission
from Koshima et al. Sequential vascularized iliac bone graft and a
superficial circumflex iliac artery perforator flap with a single source
vessel for established mandibular defects. Plast Reconstr Surg 2004;
113:101–106.)
R
D
C
R
D
C
A
B
vascular anastomosis between the vascular pedicle of the
neighboring flap and the distal end of the axial lateral cir­
cumflex femoral system.
COMBINED SCIP OR GROIN FLAP WITH
VASCULARIZED ILIAC BONE GRAFT BASED ON
THE DCIA (Fig. 43.7)
The cutaneous portion of the iliac osteocutaneous flap
based on the deep circumflex iliac artery often shows partial
skin necrosis, because some cases have hypoplastic perfora­
tors of the deep iliac system. To salvage this disadvantage,
the pedicle of the SCIP flap from the superficial circumflex
iliac system can be anastomosed to the ascending branch of
the deep circumflex iliac vessel. This combined osteocuta­
neous flap has excellent blood circulation of the cutaneous
portion.
SCIP OSTEOCUTANEOUS FLAP
The deep branch of the SCIA system sends a perforator to
the ASIS. To include this bone branch in the SCIP flap, we
can harvest SCIP osteocutaneous flap for bone defect recon­
struction such as head and neck reconstruction, hand
reconstruction, or penile reconstruction.
SPECIAL INSTRUMENTS
Supermicrosurgery instruments may be needed when the
vessels are <1 mm in diameter.
DONOR SITE CLOSURE AND
MANAGEMENT
Direct closure is preferable. Drains are placed when some
bleeding exists or extensive dissection and injury to lym­
phatics have occurred. For the SCIP adiposal flap, quilting
fixation sutures are used to close the dead space.
If the flap is wider than 10 cm, primary closure may not
be possible, and a skin graft is used. Flexion of the hip is
helpful.
If the flap is used as a pedicled tubed flap for upper
extremity reconstruction, the distal aspect is closed primar­
ily and a wet dressing, a temporary biologic dressing, or a
skin graft is placed near the pedicle. This proximal aspect
is then managed after division of the flap.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• To avoid flap necrosis in cases with a hypoplastic SCIA
system, the SIEA can be included.
• In order to avoid injury to the lateral femoral cutaneous
nerve, the nerve is identified and preserved.
• Vascular dissection should be carried out under complete
hemostasis using electric cautery and loupe magnifica­
tion, particularly when performing the SCIP flap.
• If the vessels are not present or are too small, the SIEA is
identified (if present) and the design of the flap is altered
slightly (see Ch. 57).
• The flap is harvested deep to the sartorius fascia in order
to avoid injury to the pedicle which penetrates the fascia
lateral to the muscle.
• The pedicled groin flap can be preconditioned by clamp­
ing the base of the flap between two fingers or by placing

486
PART 4 — CONVENTIONAL WORKHORSE FLAPS
PEDICLED SCIP FLAP FOR PENILE RECONSTRUCTION
The flap is harvested in its maximum size. The flap is trans­
ferred to genital area through tunnel. The proximal side of
flap is folded to make urethra which connect to perineal
urethra. The distal side of flap is folded to make grans. The
outer layer of penis is covered contralateral pedicled SCIP
flap or split thickness skin graft. This technique overcomes
some problems of conventional penile reconstruction; low
frequency of urethral fissula or urethral stricture, minimum
donor site morbidity.
FREE SKIN APONEUROSIS FOR RECONSTRUCTION OF
A SOFT TISSUE DEFECT AND UNDERLYING TENDON
A segment of external oblique fascia is harvested based on
the superficial circumflex iliac artery and included in the
flap. The fascia is tubed and used to reconstruct a tendon
defect and the groin flap skin and fat are used for soft tissue
coverage.
POSTOPERATIVE CARE
GENERAL
The patient may need up to 1 week’s stay in the hospital,
depending on the type of reconstruction performed.
RECIPIENT SITE
As with the care of any free flap, monitoring takes place
every hour, and care is taken not to compress the pedicle of
the flap. Any evidence of disturbance to the vascularity of
the flap requires immediate attention and flap reexploration
whenever necessary. If the reconstruction is performed for
an upper or lower extremity defect, a splint is usually placed
in order to immobilize the area temporarily and provide
protection to the flap. Care is taken not to compress the
area of the flap or proximal to it.
When a pedicled tubed groin flap is used for upper
extremity reconstruction, the sutures alone are usually ade­
quate to maintain the blood supply. There is no need for
any form of rigid fixation.
DONOR SITE
Postoperative temporary seroma in the donor subcutaneous
space sometimes occurs in cases with a SCIP adiposal flap.
Quilting fixation sutures to close a dead space can help to
avoid this complication.
There is no need for immobilization of the donor groin
region. However, hip flexion, knee flexion, and head of bed
elevation can decrease tension on the groin incision, par­
ticularly when a wide flap is harvested.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
When designed properly, the blood supply to the groin flap
and SCIP flap is excellent and the flap is expected to do
a rubber band around the base of the flap for a few
minutes every several hours. This can be performed
beginning 1 week prior to the planned division.
FLAP USAGE
PEDICLED
Island flaps for lower abdomen, proximal thigh, penile, peri­
neal, urethral, vaginal, and other genital reconstructions.
FREE FLAP
• Head and neck facial augmentation using the adiposal
flap, facial skin defect, intraoral lining, scalp defect, etc.
• Trunk or breast augmentation with the groin or SCIP
adiposal flap
• Upper extremity skin defect reconstruction using the
adiposal flap for soft tissue augmentation
• Lower extremity skin coverage, using the adiposal flap for
soft tissue augmentation or soft tissue and tendon
reconstruction.
TYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
PEDICLED TUBED GROIN FLAP OR SCIP FLAP FOR
UPPER EXTREMITY RECONSTRUCTION
The flap is raised from lateral to medial based on its respec­
tive blood supply. The defect in the upper extremity is
covered and the lateral aspect of the donor site is closed.
The part under the pedicle of the flap is temporarily closed.
The flap is divided 2–3 weeks later and contoured to fit the
defect. Some debulking of the flap can be performed at that
stage; however, this should be done nonaggressively.
FREE GROIN OR SCIP FLAP FOR SOFT TISSUE
COVERAGE OR AS A BURIED FLAP FOR SOFT TISSUE
AUGMENTATION
The flap is raised in the standard fashion. If a long pedicle
is required, the island flap based laterally is preferable. The
defect is prepared and the flap is transferred to reconstruct
the defect. Debulking is performed 3–6 months later and
can be performed either with direct excision of tissue or
using an orthopedic shaver.
PEDICLED GROIN OR SCIP FLAP FOR ABDOMINAL
WALL OR PERINEAL RECONSTRUCTION
The flap is harvested in the standard fashion from lateral to
medial and transferred to the defect. A tunnel is avoided
and direct incisions connecting the flap and the defect are
preferable.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
FREE GROIN LYMPH NODE TRANSFER FOR UPPER OR
LOWER EXTREMITY LYMPHEDEMA
The flap is designed in the standard fashion; however, only
a small area around the femoral triangle is included (see
Ch. 8).

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap
487
DONOR SITE
The scar may become wide with time and can be revised if
the patient desires.
SCIP FLAPS
From 1991 to 2011, we have treated 79 patients with defects
in extremities, with SCIP flaps: 23 island pedicled flaps and
56 free flaps. The recipient sites were 35 in face and man­
dible; 13 in the legs; 11 in penile and urethra reconstruc­
tion. The complications included five cases of partial
necrosis and three cases of total necrosis.
CONCLUSIONS
The groin flap is a reliable and old flap that has been used
mainly for soft tissue defects. It has played a significant role
in upper extremity reconstruction both as a free flap and as
a pedicled flap. The SCIP flap, with a short pedicle of the
SCIA system, has the potential to replace the groin flap for
certain indications.
ACKNOWLEDGMENTS
The superficial circumflex iliac artery perforator flap was
presented at the 10th Annual Meeting of the Japan Society
of Cranio-Maxillo-Facial Surgery held in Tokyo in November
1992, at the Third to Fifth International Courses on Perfora­
tor Flaps, in Munich, Glasgow, and Taipei in 1999, 2000, and
2002, respectively, and at the First and Second Congresses
of the World Society of Reconstructive Microsurgery in
Taipei and Heidelberg in October 2001 and June 2003,
respectively.
very well. The reconstruction is often bulky, requiring a
secondary procedure for optimal aesthetic outcomes.
For soft tissue augmentation, the results are excellent and
long lasting. As a reconstructive option for defects requiring
facial skin replacement, the color match is a problem and
serial excisions or tissue expansion of the surrounding skin
with eventual excision of the groin flap skin yields optimal
results.
DONOR SITE
The donor site looks excellent and is well concealed with
clothing.
UNTOWARD OUTCOMES
GENERAL
This flap has minimal morbidity and outcomes are
excellent.
Bulky flaps are expected when the groin flap is used,
particularly near the medial aspect of the flap. When the
SCIP flap is used, more aggressive debulking can be per­
formed during the primary procedure.
DONOR SITE
Subcutaneous temporary seroma in the donor site and
sometimes sensory loss on the lateral thigh region may
occur. Widening of the scar can occur with wide flap harvest.
A very unlikely result of harvesting this flap may be lymph­
edema of the lower extremity if more than three nodes are
taken. Therefore, unless the procedure is performed as a
lymph node transfer, including nodes in the dissection is
avoided.
LONG-TERM OUTCOMES
GENERAL
Excellent outcomes are expected at the donor and recipient
sites.

488
PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 35-year-old gender identity disorder patient (female-to-male)
desired sex reassignment surgery. At a previous operation, the
patient received bilateral mastectomy, hysterectomy, removal of
the ovaries, and metaoidioplasty, resulting in a new urethral
ostium at the clitoris. There was no urethral fistula.
Bilateral SCIP flaps were designed on the lateral sides of the
anterior superior iliac spine bilaterally. The island SCIP flaps
were outlined on the lateral lumbar back regions to reach the
medial genital region, without transection of the pedicle vessels.
The flap included the perforator near the iliac spine at the base
of the flap. The left SCIP flap, 22 cm in length and 5 cm in
width, was designed for the urethra, and the right SCIP flap,
13 cm in length and 10 cm in width, was for outer surface wrap-
ping around the reconstructed urethra.
CASE 43.1  Penile Reconstruction with Bilateral Pedicled SCIP Flaps
Figure 43.8  (A) A 35-year-old gender identity disorder (female-to-male) patient with previous mastectomy, hysterectomy, ovarian resec­
tion, and metaoidioplasty. Preoperative appearance.(B) SCIP flap design, 13 cm in length, 10 cm in width, for penile shaft. (C) SCIP flap
design, 22 cm in length, 5 cm in width, for urethra. (D) Elevated right SCIP flap with primary thinning. (E) Elevated left SCIP flap with
primary thinning. (F) Elevated bilateral thin SCIP flaps. Long urethral tube was created with the left thinned flap. (G) Operative schema.
Urethral tube flap was wrapped by right SCIP thin flap to create a penis in one stage. (H) Postoperative appearance with no additional
operative procedure. At 7 months after surgery.
A
B
C
D
E
F
H
G

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap
489
A 26-year-old man had an arteriovenous malformation with fre-
quent phlegmon and severe pain on the medial aspect of the
right foot. After a complete resection of this lesion, the medial
tarsal artery and concomitant vein were prepared as the recipi-
ent vessels.
The flap was obtained from the left groin region. Superficial
and deep branches of the SCIA system were present, and
the deep branch had a dominant perforator near the ASIS. The
dominant perforator, involving a short length (3 cm) of the
SCIA and concomitant vein, which was a transected segment of
the deep branch, was selected as a pedicle of the flap. A free
SCIP flap, 15 × 9 cm in size, was transferred and the deep branch
was anastomosed to the medial tarsal artery and concomitant
vein. The donor defect was closed directly.
The postoperative course was smooth and no complications
occurred. At 4 months after surgery, there was no reappearance
of the malformation, no pain, and no dysfunction in walking.
CASE 43.2  Medial Ankle Soft Tissue Defect Reconstructed with a SCIP Flap
Figure 43.9  (A) A 26-year-old man had an arteriovenous malformation with severe pain in the foot. (B) Outline of the SCIP flap. (C)
Elevated flap. (D) Flap after harvest, shows the perforator of the deep branch. (E) At 1 month after transfer. (Reproduced with permission
from Koshima et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004;
113:233–40.)
A
D
B
C
E

490
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Access Figures 43.10 and 43.11, as well as case
examples 43.3 and 43.4 and further reading
online at
Expert Commentary
Joon Pio (JP) Hong, MD, PhD, MMM
Although one of the first flaps to be used, the groin flap had
lost its popularity due to the thickness, short pedicle, and
possible complications involved with lymphedema. But as
new modifications were being introduced as shown in this
chapter, applications of the SCIP flap are slowly increasing.
To date, 23 articles related to the SCIP flap can be found in
PUBMED since 2013. In these reports, and according to
personal experience, the SCIP flap is one of the thinnest flaps
that can be harvested in our body. The territory that can be
supplied by a single perforator can be as large as 10 × 20 cm,
according to this chapter. These dimensions allow for cover-
age of a wide range of defects and makes this the flap of
choice unless the defect is huge. Most of all, the donor site
morbidity is minimal to none and the scar is better than most
flaps.
There are still challenges to using this flap. The issues
related to a short pedicle (2–5 cm) can be overcome by
finding recipient vessels superficial within the defect or in
a superficial plane adjacent to the defect. Perforator-to-
perforator supermicrosurgery approach helps to overcome
the short pedicle issue as well. As for beginners, it would
be easier to use this flap where the recipient pedicles are
located relatively shallow to the defect such as dorsum of
feet and hand and lower third of the leg and forearm. Another
problem for beginners can be the small diameter of the
pedicles. Instruments such as dilators are valuable, as it they
can expand the arterial diameter up to more than 1 mm in
most of the vessels. Another challenge related to the harvest
of this flap is minimizing damage to the lymphatic drainage
system in order to avoid ending up with lymphorrhea and/or
lymphedema of the lower extremity. Adequately clipping and
coagulating lymph ducts is essential in order to avoid having
lymphorrhea.
It is exciting to work with a flap that allows speedy harvest,
minimal donor site morbidity, allows combining various
tissues and most all a thin flap for resurfacing. The SCIP flap
as a modified version of the groin flap holds much promise
for reconstructive surgery.

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap 490.e1
A 30-year-old female patient had a history of a motorcycle acci-
dent, in which she sustained an injury to the right lower leg (Fig.
43.10A). The patient had an open wound and an Achilles tendon
defect. She was treated at another hospital by skin grafting the
wound and then referred to our center for further management.
The plan was to release the scar contracture, fill in the defect
with vascularized soft tissue, and repair the Achilles tendon.
A vascularized composite adipocutaneous flap with external
oblique fascia was harvested based on the superficial circumflex
iliac artery (Fig. 43.10B). The fascia was tubed to form an inter-
position graft between the proximal and distal aspects of the
native tendon. Figure 43.10C shows the flap after harvest; the
external oblique fascia and the pedicle of the flap are marked
with arrows.
Figure 43.10D is a posterior view of the patient 10 years post-
operatively standing on her forefoot. The patient is able to
sustain plantar flexion against resistance, demonstrating the
strength of the tendon repair.
CASE 43.3  Achilles Tendon and Soft Tissue Defect Reconstructed with a Free Groin with
External Oblique Fascia
Figure 43.10  (A) This young woman had a history of a motorcycle accident in which she sustained an injury to the right lower leg, which
was treated with a skin graft. The patient was left with discontinuity of the Achilles tendon and severe scarring. (B) A groin flap was
designed, including external oblique fascia. (C) Flap after harvest. (D) The patient 10 years postoperatively, demonstrating a well-healed
wound and reasonable function of plantar flexion of the foot.
A
B
C
D

490.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
CASE 43.4  Soft Tissue Deficit in the Lower Leg Reconstructed with Free Groin Flap
Figure 43.11  (A) The patient had an injury to the tibial region, which was reconstructed with a skin graft placed directly over the peri­
osteum of the tibia. She presented with a complaint of discomfort and an unattractive contour. (B) A groin flap was marked based on the
superficial circumflex iliac vessels. (C) Elevation of flap. (D) Postoperative result.
A
B
C
D
The patient is a young female who was involved in an automobile
accident 1 year prior to her visit to our institution. She had a skin
graft placed directly over the periosteum of the tibia. She pre-
sented with a complaint of discomfort and an unacceptable
contour (Fig. 43.11A). A groin flap was marked based on the
superficial circumflex iliac vessels (Fig. 43.11B). This flap was
elevated from lateral to medial and the vessels were exposed
medially (Fig. 43.11C).

CHAPTER 43 — Groin Flap and Superficial Circumflex I liac Artery Perforator Flap 490.e3
FURTHER READING
Acland RD. The free iliac flap: a lateral modification of the free groin
flap. Plast Reconstr Surg 1979;64(1):30–6.
Angrigiani C, Grilli D, Sisbert J. Latissimus dorsi musculocutaneous flap
without muscle. Plast Reconstr Surg 1995;96:1608.
Cheng MH, Chen HC, Wei FC, et al. Devices for ischemic precondition­
ing of the pedicled groin flap. J Trauma 2000;48(3):527–52.
Chuang D, Colony LH, Chen HC, et al. Groin flap design and versatil­
ity. Plast Reconstr Surg 1989;84:100–7.
Chuang D, Jeng SF, Chen HT, et al. Experience of 73 free groin flaps.
Br J Plast Surg 1992;45(2):81–5.
Cobb AR, Koudstaal MJ, Bulstrode NW, et al. Free groin flap in hemi­
facial volume reconstruction. Br J Oral Maxillofac Surg 2013;51(4):
301–6.
Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular
anastomoses. Plast Reconstr Surg 1973;52:111–17.
Goertz O, Kapalschinski N, Daigeler A, et al. The effectiveness of ped­
icled groin flaps in the treatment of hand defects: results of 49
patients. J Hand Surg [Am] 2012;37(10):2088–94.
Goh TL, Park SW, Cho JY, et al. The search for the ideal thin skin flap-
superficial circumflex iliac artery perforator flap – a review of 210
cases. Plast Reconstr Surg 2015;135(2):592–601.
Green R, Rahman KM, Owen S, et al. The superficial circumflex iliac
artery perforator flap in intra-oral reconstruction. J Plast Reconstr
Aesthet Surg 2013;66(12):1683–7.
Harii K, Ohmori K, Torii S, et al. Free groin skin flaps. Br J Plast Surg
1975;28:225–37.
Harii K. Discussion of “The free iliac flap (a lateral modification of
the free groin flap)” by Dr. Acland RD. Plast Reconstr Surg 1979;
64:257–8.
Hong JP, Choi DH, Suh H, et al. A new plane of elevation: the super­
ficial fascial plane for perforator flap elevation. J Reconstr Microsurg
2014;30(7):491–6.
Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac
artery perforator flap and supermicrosurgery technique for lower
extremity reconstruction: a new approach for moderate-sized defects.
Ann Plast Surg 2013;71(4):380–3.
Hsu WM, Chao WN, Yang C, et al. Evolution of the free groin flap: the
superficial circumflex iliac artery perforator flap. Plast Reconstr Surg
2007;119(5):1491–8.
Iida T, Mihara M, Yoshimatsu H, et al. Versatility of the superficial cir­
cumflex iliac artery perforator flap in head and neck reconstruction.
Ann Plast Surg 2014;72(3):332–6.
Iida T, Narushima M, Yoshimatsu H, et al. A free vascularised iliac bone
flap based on superficial circumflex iliac perforators for head and
neck reconstruction. J Plast Reconstr Aesthet Surg 2013;66(11):
1596–9.
Iida T, Yoshimatsu H, Hara H, et al. Reconstruction of large facial
defects using a sensate superficial circumflex iliac perforator flap
based on the lateral cutaneous branches of the intercostal nerves.
Ann Plast Surg 2014;72(3):328–31.
Jeng SF, Wei FC, Noordhoff MS. The composite groin fascial free flap.
Ann Plast Surg 1995;35(6):595–600.
Kimura N, Saitoh M. Free microdissected thin groin flap design with
an extended vascular pedicle. Plast Reconstr Surg 2006;117(3):
986–92.
Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based
flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:
678.
Koshima I, Nanba Y, Nagai A, et al. Penile reconstruction with bilateral
superficial circumflex iliac artery perforator (SCIP) flaps. J Reconstr
Microsurg 2006;22(3):137–42.
Koshima I, Nanba Y, Tsutsui T, et al. Sequential vascularized iliac bone
graft and a superficial circumflex iliac artery perforator flap with a
single source vessel for established mandibular defects. Plast Recon­
str Surg 2004;113:101–6.
Koshima I, Soeda S. Inferior epigastric skin flap without rectus abdomi­
nis muscle. Br J Plast Surg 1989;42:645.
Koshima I, Yamamoto H, Moriguchi T, et al. Extended anterior thigh
flaps for repair of massive cervical defects involving pharyngoesopha­
gus and skin: an introduction to the “mosaic” flap principle. Ann
Plast Surg 1994;32:321.
Koshima I. A new classification of free combined or connected tissue
transfers: introduction to the concept of bridge, Siamese, chimeric,
mosaic, and chain-circle flaps. Acta Med Okayama 2001;55:329.
McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:
3–16.
Muresan C, Dorafshar AH, Rodriguez ED. A reappraisal of the free
groin flap in aesthetic craniofacial reconstruction. Ann Plast Surg
2012;68(2):175–9.
O’Brien BM, McLeod AM, Hayhurst JW, et al. Successful transfer of a
large island flap from the groin to the foot by microvascular anasto­
moses. Plast Reconstr Surg 1973;52:271–8.
Salmon M. The lower limb. In: Taylor GI, Tempest M, editors. Arteries
of the skin. London: Churchill Livingstone; 1988. p. 38–41.
Smith PJ, Foley I, McGregor IA, et al. The anatomical basis of the groin
flap. Plast Reconstr Surg 1972;49:41–7.
Sonmez E, Nasir S, Safak T, et al. Free groin flap applications in the
pediatric population. J Reconstr Microsurg 2010;26(4):259–64.
Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast
Reconstr Surg 1975;56:243–53.
Wei FC, Chen HC, Chuang CC, et al. Reconstruction of Achilles tendon
and calcaneus defects with skin-aponeurosis-bone composite free
tissue from the groin region. Plast Reconstr Surg 1988;81(4):
579–89.

e157
INTRODUCTION
The gluteus maximus (GM) flap was initially described as a
turnover muscle flap for sacral coverage, in 1974. During
the following years, musculocutaneous GM flaps became
the gold standard in the treatment of pressure ulcers
because of their ability to fill dead space and to provide
well-vascularized tissue to the ulcerated, often contaminated
defect. The flap was expanded to several variations and was
used successfully for reconstruction of sacral, ischial, tro­
chanteric, and perineal defects. Even today, the use of GM
myocutaneous flaps is still the first choice of many surgeons
for decubitus ulcers of the sacral and ischial regions in
paraplegic patients. Microsurgical transfer of a myocutane­
ous gluteal flap was first described by Fujino et al.1 in 1975
and, a few years later, Le Quang2 introduced the inferior
gluteus maximus free flap for breast reconstruction.
However, the use of GM muscle free flaps has been limited
due to the short pedicle and high donor site morbidity.
Since the advent of perforator flaps, harvesting flaps from
the gluteal region, without inclusion of GM muscle, as a
superior gluteal artery perforator (SGAP) flap or an inferior
gluteal artery perforator (IGAP) flap, has supplanted GM
muscle flaps in most reconstructions because of the reduced
donor site morbidity. Fasciocutaneous flaps seem to be suit­
able to cover pressure sore defects with a similar outcome
to that of muscle flaps. Koshima et al.3 first described the
pedicled SGAP flap for use in pressure sore treatment.
Allen4 has popularized the use of gluteal perforator free
flaps in breast reconstruction. Surgeons adept at the use of
perforator flaps are rarely in favor of using gluteus muscle
flaps and limit their use to patients with lower extremity
paralysis that renders these muscles expendable. Although
perforator flaps provide a better reconstructive option due
to a longer pedicle with a better flap mobility and reduced
donor site morbidity, some surgeons continue to use gluteus
muscle flaps in patients who are paralyzed and when the
techniques of perforator flaps have not been mastered.
Techniques of gluteus maximus muscle flaps, as well as
perforator-based flaps, are summarized below.
FLAP ANATOMY
The gluteus maximus, which is the superficial muscle of the
buttock, is a thick muscle (see Fig. 44.1 and Figs 13.1 and
58.1). Its function is to extend the hip and to rotate the
thigh laterally. The origin of the GM muscle involves the
posterior gluteal line of the ilium, the aponeurosis of
the erector spinae, the dorsal surface of the lower part of
the sacrum, the side of coccyx, and the sacrotuberous liga­
ment. The upper portion inserts into the iliotibial tract and
the deep fibers of the inferior portion insert on the gluteal
tuberosity of the femur. The GM muscle is completely
invested by the deep fascia of the lower limb, which splits
into two luminae around the GM muscle; the deep layer is
thickened and contains the gluteal vessels and nerve. The
piriformis muscle lies under the GM muscle. It is a pyramid-
shaped muscle that arises from the 2nd–4th sacral segments
and exits the pelvis through the greater sciatic foramen to
insert into the top of the greater trochanter. The piriformis
muscle acts as a lateral rotator of the hip. The sacral plexus
is formed largely on the pelvic surface of the piriformis
muscle. The sciatic nerve emerges under the piriformis
muscle but may occasionally pass through it.
ARTERIAL SUPPLY OF THE FLAP (See Fig. 58.1
and Fig. 13.3)
The GM muscle is type III (Mathes and Nahai classifica­
tion5), which has two dominant pedicles: the superior and
inferior gluteal vessels. Usually the IGA is dominant over the
SGA and supplies approximately two-thirds of the muscle.
Dominant:  superior gluteal artery (SGA)
Length: 2.5 cm (range 2–3 cm)
Diameter: 2.5 mm (range 2–3 mm)
The SGA is a terminal branch of the internal iliac artery
and exits the pelvis through the greater sciatic foramen.
After its exit, the SGA divides into deep and superficial
branches. The superficial branch continues above the piri­
formis muscle into the gluteus maximus muscle. The intra­
muscular length of these vessels is 4–5 cm, depending on
the thickness of the gluteal muscle. The superficial branch
gives off perforating vessels (average of four) that go on to
supply the upper portion of the gluteus muscle and overly­
ing fat and skin. The perforator vessels pass in superior and
lateral directions.
Dominant:  inferior gluteal artery (IGA)
Length: 9 cm (range 8–10 cm)
Diameter: 3 mm (range 2.5–3.5 mm)
The IGA is a terminal branch of the internal iliac artery
and exits the pelvis through the greater sciatic foramen. The
artery accompanies the greater sciatic nerve, internal
pudendal vessels, and the posterior femoral cutaneous
nerve. The IGA pierces the sacral fascia and exits the pelvis
caudal to the piriformis muscle. It gives several perforators,
Gluteus Flap
Moustapha Hamdi 44 
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION E  —  LOCAL AND FREE FLAPS IN THE PELVIS, GROIN, AND BUTTOCK

e158
PART 4 — CONVENTIONAL WORKHORSE FLAPS
• Thick muscle and subcutaneous tissue allow for ade­
quate coverage of bony prominences and filling of
defects.
• When harvested as a free flap, a sufficient amount of soft
tissue with a constant vascular pedicle can be used for
breast reconstruction, leaving a well-concealed scar on
the donor site.
DISADVANTAGES
• Raising a GM flap requires a muscle transection, which
may lead to important blood loss. Furthermore, dissec­
tion of the pedicle under the muscle is tedious because
of multiple side branches and fragile veins. Bleeding in
that area can be difficult to control.
• In the case of a free transfer of a GM musculocutaneous
flap, the superior gluteal vessels are short and can result
in the need to use an intertransposition vein graft to
reach the recipient vessels.
• An area of numbness over the posterior surface of the
thigh is possible due to sacrifice of the posterior cutane­
ous nerve of the thigh during dissection of an inferior
gluteal musculocutaneous flap.
• The skin paddle cannot be >10 cm if the donor site is to
be closed primarily.
• The patient’s position during flap harvesting can compli­
cate simultaneous work by a second team of surgeons.
• The firmer consistency of gluteal fat makes it more dif­
ficult to mold the flap, especially for breast reconstruc­
tion. Additional minor secondary corrections might be
necessary to obtain the desired shape.
• At the donor site, a contour deformity or asymmetry can
occur in unilateral harvesting and may necessitate a sec­
ondary correction of the contralateral side.
• Although there is no functional advantage of sparing GM
muscle in paralytic patients, harvesting part of the GM
can result in functional weakening of hip extension in
ambulating patients.
ADVANTAGES OF GLUTEAL PERFORATOR FLAPS
OVER GLUTEUS MAXIMUS MUSCLE FLAPS
Some of the above-described disadvantages are reduced by
harvesting the flap based only on the perforators. The
gluteal perforator flap has the following advantages:
• Donor morbidity after raising gluteal perforator flaps is
the lowest that can be offered to the patient today. This
itself will lead to a shorter hospital stay and therefore
reduced costs.
• A better intraoperative exposure, less blood loss, and a
longer vascular pedicle compared with its myocutaneous
predecessor (Fig. 44.1). The length of the pedicle gives
the flap an impressive mobility and allows for easy tissue
transposition without tension.
• The possibility of including a sensate branch of the nervi
clunium superiores within a gluteal perforator free flap
provides better quality and quantity of sensation to the
flap.
• In the case of a pedicled flap, the tissues used in the
gluteal perforator flap come from a further distance from
the ulcer or wound and, as such, they are less inflamed,
usually more than the SGA, under the inferior portion of
the gluteus maximus muscle to nourish the skin and subcu­
taneous tissue. Perforators that nourish the medial and infe­
rior parts of the buttock have short intramuscular length
(3–5 cm), whereas the perforators that nourish the lateral
part of the buttock have a longer intramuscular course
(4–6 cm). The IGA descends into the posterior cutaneous
surface of the thigh together with the posterior femoral
cutaneous nerve, in 90% of the cases.
Minor:  first perforator off the profunda femoris artery,
which courses superiorly to the insertion of the gluteus
maximus on the femur.
VENOUS DRAINAGE
Veins usually accompany the arteries. The superior gluteal
vein (SGV) receives multiple tributaries from other pelvic
veins at the level of entering the pelvis. Veins accompanying
the IGA are larger but are fragile and prone to bleed easily
during dissection.
Primary:  venae comitantes of the SGA
Length: 2.5 cm (range 2–4 cm)
Diameter: 3 mm (range 2–4 mm)
Primary:  venae comitantes of the IGA
Length: 8 cm (range 7–10 cm)
Diameter: 3 mm (range 2.5–4 mm)
Secondary:  none.
FLAP INNERVATION
Sensory (See Figs 13.3 and 58.1):  cluneal nerves (nervi
clunium superiores) – direct branches off the spinal cord
(L1–S3) – can be iden­tified at the superior edge of the flap
above the muscle fascia.
Motor:  the inferior gluteal nerve (IGN) nerve enters the
deep surface of the gluteus maximus, but it is not of recon­
structive use and is usually left intact.
FLAP COMPONENTS
For small sacral pressure sores, a pure skin rotation flap
design may be sufficient. For larger pressure sores, a segment
of GM muscle is incorporated, based on the SGA as a mus­
culocutaneous flap. A bone component from the sacral
region can be incorporated; however, the donor site mor­
bidity does not justify its use.
The gluteal flap can also be raised as a skin-fat perforator
flap or as a compound flap (skin and muscle), where a
segment of GM muscle is harvested based on a muscular
branch from the main pedicle or as a side branch from the
perforator.
ADVANTAGES
• Due to its abundant blood supply, the GM muscle flap
provides a generous amount of well-vascularized soft
tissue.

CHAPTER 44 — Gluteus Flap
e159
the inferior gluteal crease in the case of an inferior gluteal
flap, whereas it is oriented obliquely from the sacrococcy­
geal junction to the anterior superior iliac spine for a supe­
rior gluteal flap (Fig. 44.3). This orientation of the skin
paddle minimizes distortion of the anatomy upon donor site
closure.
In the case of a perforator flap, a fusiform skin island is
drawn over the perforators, ideally centered on selected
perforators. The main perforators are localized by a hand­
held 5–8 MHz Doppler probe in an area above or under the
piriform muscle, for SGAP or IGAP flaps, respectively (Fig.
44.3C). Currently, we are using a new method for perforator
mapping with a 64-slice spiral computed tomography (CT)
scan (Figs 44.4, 44.5). This provides more accurate informa­
tion concerning the vascular network and perforators.
Choice of the perforator depends not only on the strength
of the Doppler signal or the findings of the CT scan but also
on the location of the perforator. Choosing the most
remotely located perforator from the SGA exit will provide
a longer pedicle, which is more suitable for microanastomo­
sis (Figs 44.4, 44.5).
less edematous, and less prone to dehiscence. The inset
of the flap is always tension-free and the donor defect can
always be closed primarily.
PREOPERATIVE PREPARATION
Preoperative bowel preparation is performed on patients
who are undergoing this procedure for breast reconstruc­
tion. However, a temporary intestinal stoma may be required
to avoid wound contamination in complicated cases of large
sacral defects. Wound culture and bone biopsy are necessary
for chronic cases with signs of osteomyelitis. Spasticity con­
tractures and vascular disease that can compromise the flap
or wound healing and nutritional factors must first be
managed. Intrinsic factors in bed sore physiopathology
include sensory loss, diminished muscle strength or mobility,
incontinence, infection, anemia, protein malnutrition, and
advancing age. Obviously, if possible, these factors must be
considered and corrected before surgery. Antibiotic therapy
is given at the beginning of surgery and continued at least
for 24 h postoperatively. Depending on perioperative wound
culture, antibiotics should be adjusted if necessary.
FLAP DESIGN
ANATOMIC LANDMARKS (See Fig. 44.2)
The initial points marked are the posterior superior iliac
spine (PSIS), the prominence of the greater trochanter (T)
of the femur, the superior edge of the greater trochanter,
and the coccyx (C). The location where the SGA exits the
suprapiriform foramen is marked on the skin at the proxi­
mal one-third of a line connecting the posterior superior
iliac spine and the apex of the greater trochanter. Figure
44.2 shows the territories of the superior gluteal and the
inferior gluteal flaps and their relationships with the above-
mentioned landmarks.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Since the gluteus maximus is a type III muscle, it can be
harvested based on either the superior or the inferior
gluteal artery. For free tissue transfer, usually a small part of
the muscle is taken along with an overlying island of skin
and subcutaneous tissue. The skin paddle is oriented along
Figure 44.1  (A) The pedicle length of the SGAP flap and (B) gluteus maximus musculocutaneous flap.
A
B
Figure 44.2  Flap design of the superior gluteal flap (red line) and
the inferior gluteal flap (blue line) based on either the SGA or IGA
vessels and their relationship with the anatomic landmarks. PSIS,
posterior superior iliac spine; C, coccyx; T, greater trochanter. (With
permission from Standring S, editor. Gray’s anatomy. 40th ed. Elsevier,
Churchill Livingstone; 2008.)
PSIS
C
T

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 44.3  Gluteal flap design. (A) The design of the superior gluteal flap for pressure sores. The flap can be designed as a rotation flap
(black line), as an island transposition flap (red line), or as a V-Y advancement (blue line). (B) The design of the inferior gluteal flap as a trans­
position or V-Y advancement flap (black line); the gluteal thigh flap is marked in blue. (C) Patient positioning during harvesting of an SGAP free
flap for breast reconstruction. The dotted lines delineate the area where the main perforators of the SGA can be expected (see text for more
details). PSIS, posterior superior iliac spine; C, coccyx; T, greater trochanter.
A
B
C
Figure 44.4  CT angio scan shows clearly the location of the perforator when it raises from the gluteus muscle (A).

CHAPTER 44 — Gluteus Flap
e161
FLAP DIMENSIONS
Skin Island Dimensions
Length: 22 cm (range 20–30 cm)
Width: 8 cm (range 5–15 cm)
The flap can be designed up to 30 cm in length and
8–15 cm in width, depending on skin laxity and ability to
close the donor site with the least possible tension. Posterior
thigh skin can be carried on the inferior gluteal artery for
a distance of 15 cm below the inferior gluteal crease. The
angiosomes of the gluteal region are large with few vessels
nearby (inferior gluteal, parasacral, tensor lata). Thus, a
perforator flap can be safely raised on just one perforator.
Muscle Dimensions
Length: 15 cm (range 10–20 cm)
Width: 10 cm (range 8–15 cm)
FLAP MARKINGS
In pressure sore patients, pedicled superior gluteal flaps are
marked in prone position. The skin paddle is designed
depending on the type of flap transfer (Fig. 44.3A).
Inferior gluteal flaps are marked as shown in Figure
44.3B. When a gluteal thigh flap is marked, the central axis
of the flap is midway between the greater trochanter and
the ischial tuberosity and perpendicular to the inferior
gluteal crease. The IGA descends toward the posterior
aspect of the thigh accompanied by the posterior femoral
cutaneous nerve.
In free gluteal flaps, markings are done on the patient in
the standing position. If the patient has redundant sagging
skin, it might be advisable to mark the patient in the lateral
or ventral decubitus. First, the position where the superior
or the inferior gluteal artery enters the buttock is deter­
mined according to bony landmarks, as previously explained.
Then, the skin incision is planned. An ellipse of appropriate
dimension is marked on an area containing the superior
gluteal artery or along the inferior gluteal crease, depend­
ing on the type of flap chosen. The surgeon should make
sure that the patient has sufficient skin laxity to allow closure
after flap harvest.
SPECIAL CONSIDERATIONS
SGAP FREE FLAP FOR BREAST RECONSTRUCTION
In the case of a superior gluteal free flap, a skin paddle of
24 × 9 cm is usually placed obliquely with a horizontal ori­
entation at the lateral aspect to produce a scar that is easy
to conceal in a bathing suit. Also, we add a small fishtail
at the medial tip of the flap to avoid dog-ear formation
in the median gluteal crease (Fig. 44.3). The flap is also
designed longer to be able to shape the breast in the form
of a hammock, taking care to reconstruct both the ante­
rior axillary fold and the full width of the inframammary
crease.
The oblique/horizontal axis of the flap provides a tension-
free closure with buttock lift and minimal contour defor­
mity. The flap island can be designed much higher on the
buttock than traditionally described, to allow for the scar
line to ultimately rest at the junction of the aesthetic units
of the lower back and the upper buttock. This essentially
results in only the medial half of the flap being centered
over the GM muscle. A careful Doppler examination is
then mandatory to ensure inclusion of SGA perforators
in the flap. In the case of the inferior gluteal free flap, a
transverse skin ellipse is marked on the ipsilateral gluteal
crease.
SGAP PEDICLED FLAP FOR PELVIC RECONSTRUCTION
There exist many ways in which the gluteus maximus can be
used as a local flap. It is most often designed as a large rota­
tion or advancement flap. In that case, the whole gluteal
skin can be mobilized en bloc with the muscle. A posterior
thigh skin extension can also be harvested based on the
descending branch of the inferior gluteal artery.
In sacral pressure sore treatment, triangular-shaped flaps
can sometimes be used combined with V-Y advancement.
However, a transposition flap is preferable in order to use
remote, healthier skin to close the defect. The axis of the
skin island can be positioned in any direction over the iden­
tified perforators but will be strongly influenced by skin
tension during donor site closure. This means that for larger
flaps a horizontal or slightly oblique (from mediocaudal to
laterocranial) position is preferred.
Figure 44.5  CT scan used to plan a free SGAP flap. The most remotely located perforator (C) from the SGA exit will provide a longer
pedicle, which is more suitable for microanastomosis.

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
the area identified by the preoperative Doppler where the
perforator pierces through the fascia, the muscle fascia is
incised and the dissection continues on top of the muscle.
The individual perimysia septi that run parallel to the
muscle fibers and connect with the overlying fascia are tran­
sected one by one (Fig. 44.6B).
Once a suitable perforator is encountered (the more
lateral the perforator, the longer the pedicle), muscle fibers
around it are split longitudinally to expose the perforator
(Fig. 44.6C). Wide exposure and a bloodless dissection are
two extremely important key points in the dissection of any
type of perforator flap. The epimysium is then cut on both
sides parallel to the perforator, ligating all the different side
branches carefully. The dissection continues down to the
deep layer of the GM fascia. This is a strong and often thick
distinctive structure through which the vessels perforate. If
the size and length of the perforators are acceptable super­
ficial to this fascia, the vessels can be cut if a free flap is
harvested. More often, larger or longer vessels are pre­
ferred, so the fascia is then opened and dissection is contin­
ued below the anterior fascia (Fig. 44.6D). After clearing off
the loose fat tissue around these vessels, the main gluteal
vessels are exposed. The flap skin is then incised inferiorly
and medially and the skin paddle is lifted from the underly­
ing muscle (Fig. 44.6E). Beveling is done to obtain a larger
amount of subcutaneous tissue mainly at the inferior border
of the flap. The pedicle is finally transected and the flap is
transferred to the thorax. The gluteus maximus muscle is
left intact. The donor site is closed primarily (Fig. 44.6F).
SUPERIOR GLUTEUS MAXIMUS MUSCLE FREE FLAP
The position of the superior gluteal vessels can be identified
using a handheld Doppler. The upper part of the skin
paddle is incised first. Dissection through subcutaneous
tissue is done with subcutaneous beveling to incorporate an
appropriate amount of fat in the flap (Fig. 44.7A). The
cephalad edge of gluteus maximus is delineated and incised.
The plane between gluteus maximus and gluteus medius is
opened, thus permitting identification of the superior
gluteal vessels on the undersurface of gluteus maximus. The
lateral part of the upper gluteus maximus muscle is then
incised at about 5 cm from the greater trochanter. This
allows caudal eversion of the flap and visualization of the
superior gluteal vessels as they emerge above the piriformis
muscle (Fig. 44.7B). The artery and vein are accompanied
by the superior gluteal nerve, which should be preserved as
it is the motor supply to the gluteus medius, gluteus minimus,
and tensor fascia lata muscles. Once fully dissected, the
vascular pedicle has an approximate length of only 2–3 cm
(Fig. 44.7C).
INFERIOR GLUTEAL ARTERY PERFORATOR FREE FLAP
Harvesting the flap begins laterally after the skin is incised
superiorly and inferiorly (Fig. 44.8A,B). Maximum beveling
is done superiorly over the inferior part of the buttock,
while direct incision toward the deep fascia is done caudally.
The posterior cutaneous nerve of the thigh is identified and
preserved (Fig. 44.8B). Perforator dissection is done in a
similar way to the SGAP. However, the intramuscular course
of the IGA is longer. After opening the deep fascia under
the GM muscle, care must be taken not to damage motor
branches. Depending on the position of the perforator, the
In the case of perforator flaps, the preoperative markings
are adjusted, depending on the location of the perforators.
The patient is positioned lying on the operative table (Fig.
44.3C). A line is drawn between the PSIS and the coccyx
(PSIS-C). The position of the piriform muscle is located by
connecting the middle of the PSIS-C line with the superior
edge of the greater trochanter (T) of the femur. The rela­
tively constant anatomy of the superior gluteal artery and
the presence of a low number of perforators that cross the
fascia perpendicularly make it rather easy to preoperatively
identify the location of the perforators by unidirectional
Doppler flowmetry or spiral CT scanner.
The flap is then drawn, as described above, depending
on the indications.
PATIENT POSITIONING
In the case of decubitus surgery, the patient will be placed
in prone position during the whole procedure.
For unilateral breast reconstruction with a free flap, the
patient is positioned in lateral decubitus with the ipsilateral
buttock selected as a donor site (Fig. 44.3C). The ipsilateral
arm is free-draped. The hip is slightly flexed and can be
extended later to ease the tension on the donor site during
closure. The upper thorax is rotated back in semi-supine
position in order to allow a two-team approach.
In the case of bilateral breast reconstruction, the patient
is placed initially in supine position to prepare the recipient
vessels and then turned to prone position to harvest the
flaps and close the donor sites. A second supine reposition­
ing is then done to perform microanastomosis and flap
shaping.
ANESTHETIC CONSIDERATIONS
Usually the gluteus maximus flap is performed under
general anesthesia. The patient should be completely para­
lyzed during muscle or perforator dissection. However, a
pedicled flap can be raised under regional anesthesia if
the patient is felt to be unable to withstand general anesthe­
sia. Arterial hypotension is usually recommended during
wound debridement and flap harvesting in order to reduce
blood loss.
TECHNIQUE OF FLAP HARVEST
FREE FLAP
SGAP FREE FLAP
Dissection of perforator flaps is usually done under 3.53
loupe magnification. The upper part of the skin paddle is
incised first. Harvesting of the perforator flap starts latero-
cranially. The nervi clunium superiores can be identified at
the superior edge of the flap, above the muscle fascia (Fig.
44.6A). If these nerves are large enough for microanasto­
mosis, they can be dissected and included to obtain a sensate
free flap. The dissection proceeds above the muscle fascia
parallel to the direction of the gluteus maximus muscle
fibers from lateral to medial. When the dissection approaches

CHAPTER 44 — Gluteus Flap
e163
Figure 44.6  Dissection of SGAP free flap. (A) The flap is first incised cranially and laterally. Note the dissection of the nervi clunium supe­
riores. (B) Subfascia dissection near the area where the perforator is expected. (C) Splitting the muscle along the epimysium and dissecting
the perforator. (D) Opening the deep layer of the GM fascia. (E) Dissecting the main pedicle under the deep fascia and the flap is completely
harvested. (F) The donor site is closed primarily.
Incised muscle
fascia
Perforator
Nervi clunium superiores
A
B
C
D
E
F
pedicle length varies between 7 cm and 13 cm (Fig. 44.8C).
Closure of the donor site is done by undermining the pos­
terior skin of the thigh, which is lifted and fixed higher to
the GM fascia (Fig. 44.8D).
INFERIOR GLUTEUS MAXIMUS MUSCULOCUTANEOUS
FREE FLAP
The precise location of the inferior gluteal vessels can be
identified with a Doppler. The lower incision is made first,
beginning caudally, and dissection is carried down to the
GM fascia. The fasciocutaneous extension of the IGA can
be found just below the lower border of the GM muscle and
just lateral to the ischial tuberosity. Running with these
vessels is the posterior cutaneous nerve of the thigh (Fig.
44.9A). Once this neurovascular bundle is identified and
ligated, the medial aspect of the lower gluteal incision is
completed (Fig. 44.9B). The superior skin is incised down
to the GM fascia. Beginning laterally, a GM muscle segment
approximately 4 × 8 cm is dissected (Fig. 44.9C). The flap is
elevated superiorly. The medial aspect of the inferior gluteus
muscle is then incised carefully, observing the inferior
gluteal pedicle. The posterior cutaneous nerve of the thigh
is usually transected. The muscle is divided superior to the
pedicle, which is then dissected toward its origin as it
emerges inferior to the piriformis muscle. A total pedicle
length of 8–10 cm is usually obtained (Fig. 44.9D). Care
must be taken to avoid injury to the inferior gluteal nerve.
After dividing the vessels, the flap is transferred. The medial
and lateral GM muscle segments are approximated to cover
the sciatic nerve.

e164
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 44.7  Dissection of superior gluteus maximus musculocutaneous free flap. (A) The lateral part of the upper gluteus maximus muscle
is incised. (B) The superior gluteal artery is dissected between the gluteus maximus and gluteus medius muscles. (C) Dissection of the main
pedicle under the gluteus maximus muscle.
Superior gluteal artery
and vein
Gluteus medius muscle
Piriformis muscle
Gluteus maximus muscle
Gluteus medius muscle
Gluteus maximus muscle
Superior gluteal artery
and vein
Gluteus medius muscle
Piriformis muscle
Gluteus maximus muscle
Gluteus maximus muscle
A
B
C

CHAPTER 44 — Gluteus Flap
e165
PEDICLED MUSCULOCUTANEOUS FLAP
The gluteal rotation skin flap consists of skin and subcutane­
ous fat of essentially the entire buttock. It is based inferiorly.
The gluteal fascia is included to cover the sacrum after the
bone has been smoothed. If the muscle is included, it is
incised along the superior edge, then inferior and lateral
borders but without undermining the subcutaneous tissues.
The muscle is elevated in the plane overlying the gluteus
medius muscle. The SGA and veins emerge from the supe­
rior edge of the piriformis muscle. The GM elevation is
continued in a superomedial direction. Detachment of the
GM muscle from its origin medially is performed as widely
as necessary to allow the musculocutaneous rotation. A skin
graft can be necessary over the muscle to close part of the
PEDICLED FLAP
PEDICLED GLUTEAL PERFORATOR FLAPS
The position of the gluteal vessels can be identified using a
handheld Doppler. The more lateral the perforator is
located, the longer the pedicle is obtained to reach the
defect easily. The flap is dissected and transferred as a trans­
position flap but it is designed in such a way that it can be
converted to a rotation flap if no perforators are found (Fig.
44.10A). Dissection of the perforator flap is similar to the
free version but is usually done to the posterior fascia of the
GM muscle (Fig. 44.10B). The flap is then advanced or
rotated 90° to cover the defect and the donor site is closed
primarily (Fig. 44.10C).
Figure 44.8  Dissection of the IGAP free flap. (A) After incising the skin, the posterior cutaneous vessels and nerves are identified. (B) The
perforator is identified. (C) The GM is split and the perforator is dissected into the main pedicle. (D) The closure of the donor site.
Muscle
fascia
The posterior
cutaneous
nerve of the
thigh and
vessels
A
B
C
D

e166
PART 4 — CONVENTIONAL WORKHORSE FLAPS
in an inferomedial direction to cover ischial defects. The
donor site is closed by V-Y advancement (Fig. 44.12C).
FLAP MODIFICATION/FLAP HANDLING
PERFORATOR FLAP
Including a segment of the GM in a pedicle gluteal perfora­
tor flap (compound flap) is rarely done. However, this
may be necessary if a radical debridement of the bed sore
cannot be achieved or if a cavity needs to be filled. The GM
muscle fascia is included only in the region around the
flap donor site and take the tension off the important suture
line over the sacrum (Fig. 44.11).
The GM musculocutaneous transposition flap is har­
vested by incising the skin and subcutaneous tissue down to
the GM fascia (Fig. 44.12A). The skin around the island is
undermined. The superior half of the GM is detached from
its insertion on the femur and iliotibial tract. The muscle,
along with the attached island of skin and subcutaneous
tissue, is elevated in a superomedial direction, exposing the
piriformis muscle. The SGA and veins are exposed and
preserved. The superior half of the gluteal muscle is left
attached only to the superior gluteal vessels (Fig. 44.12B).
The flap is advanced to cover the sacral defects or rotated
Figure 44.9  Dissection of the inferior GM musculocutaneous free flap. (A) Lower incision is made and the posterior cutaneous nerve and
vessels are identified. (B) The posterior cutaneous nerve and vessels are identified and ligated. (C) The lateral part of the inferior GM muscle
is incised. (D) The GM is elevated and the inferior gluteal vessels are dissected. The sciatic nerve is preserved. A total pedicle length of 8–10 cm
is usually obtained.
Piriformis
muscle
Sciatic
nerve
Quadratus
femoris
muscle
Gluteus
maximus
muscle
Hamstring
Ischial
tuberosity
A
C
B
D

CHAPTER 44 — Gluteus Flap
e167
perforator. A direct defatting of the SGAP flap can be safely
done away from the surrounding area where the perforator
enters the flap.
GLUTEUS MAXIMUS MUSCLE FLAP
In a GM flap, a varied amount of GM muscle is included in
the flap, depending on the indications. A larger muscle
segment is used in pedicled flaps for bed sore coverage in
paraplegic patients, whereas a limited piece is taken in the
case of a free flap for breast reconstruction. However, the
GM muscle is an important extensor and lateral rotator of
the hip. Thus, it is indispensable in ambulatory patients. A
variation of the GM flap is useful for closure of lower trunk
midline defects. The sliding GM musculocutaneous flap
preserves the integrity and function of the muscle unit in
non-paralyzed patients (Fig. 44.13A). In this technique the
muscle and skin are elevated en bloc and advanced to the
midline (Fig. 44.13B). Bilateral triangular skin islands over­
lying the corresponding GM muscle are marked. A wide
subcutaneous dissection is made away from the skin island.
The GM is detached from its periosteal origin on the sacrum
and coccyx on both sides. Dissection is continued inferiorly
to separate the ischiorectal fat from the muscle fibers. The
muscle is also freed from the sacrotuberous ligament, which
should be preserved while the branches of pudendal artery
are ligated within it. Separating the GM muscle from the
medius is only done if the size of the defect requires exten­
sive mobilization of the GM muscle.
More recently, a similar technique has been described to
avoid dissecting the GM in non-paraplegic patients. A bilat­
eral sliding V-Y fasciocutaneous flap can be designed, simi­
larly to the above-described technique but without harvesting
the GM (Fig. 44.14). This technique can be used for sacral
bed sores <6 cm in diameter.
When the superior GM flap is used to cover a lumbosacral
defect, the skin paddle is extended to the lumbar area based
on the superficial lumbar fascia vascular network. On the
other hand, the inferior GM flap can be extended over the
posterior surface of the thigh by including the cutaneous
branch of the IGA, which accompanies the posterior cutane­
ous nerve of the thigh.
GLUTEAL THIGH FLAP
The flap is based on the inferior gluteal vessels with an
extension on the posterior thigh aspect (Fig. 44.3B). The
flap can be used as a rotation flap to cover ischial or tro­
chanter defects. When the flap is completely islanded, it can
reach higher defects on the gluteal region.
DONOR SITE CLOSURE AND
MANAGEMENT
Donor site closure begins by undermining of the skin edges.
The undermining is done mainly on the distal skin flap to
achieve a limited buttock lift. Undermining over the iliac
crest is avoided if possible, as this will interrupt important
periosteum-to-skin attachments and increase the risk of
postoperative seroma formation. Deep sutures are placed
on the superficial scarpa-like fascia, and skin closure is
Figure 44.10  Dissection of the SGAP pedicled flap. (A) A trans­
position flap is designed around the Doppler-located perforator. The
flap can be converted to a rotation flap if no perforator is found. (B)
The SGAP flap is dissected and transposed to the defect. (C) Closure
of the wound in a V-Y way.
A
B
C

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
performed by a layer of resorbable subdermal and then
subcuticular stitches. Two drains are left in the donor site.
A dry dressing is used to protect the wounds.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
FREE FLAPS
• The gluteal vessels should be dissected as far as possible
up to their exit from the pelvic cavity in order to obtain
adequate length and diameter to perform comfortable
vascular anastomoses.
• Meticulous dissection under the deep fascia is required
to avoid vessel damage, which is difficult to control in this
area and may lead to a major blood loss.
PEDICLED FLAPS
• When the flap is designed as a transposition flap for sacral
defects, it is better to harvest the skin paddle on a healthy
tissue as a transposition flap. This allows the surgeon to
replace the ulcer in most cases with undamaged tissue
from a distant untraumatized zone.
• Subcutaneous tunneling of a de-epithelialized portion of
the flap should be avoided to prevent compression and
fat necrosis of the tunneled portion of the flap.
• In perforator flap surgery, wide exposure of the perfora­
tor is mandatory during dissection and is easily obtained
by splitting the GM fibers longitudinally. The muscle
Figure 44.11  A rotation GM musculocutaneous pedicled flap for
sacral defects. The GM muscle is incised (dotted line).
Figure 44.12  Dissection of a superior GM transposition musculocutaneous pedicled flap for sacral defects. (A) A transposition flap is
designed. (B) The GM muscle is incised (dotted lines) to include a segment of the GM and superior gluteal vessels. (C) Closure in V-Y.
A
B
C

CHAPTER 44 — Gluteus Flap
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Figure 44.13  (A) Bilateral sliding GM musculocutaneous flaps. (B) The GM flaps are incised and then sutured in the midline.
A
B
Figure 44.14  Bilateral V-Y fasciocutaneous flaps. (A) The skin is dissected (dark colored area) over the GM fascia until large perforators
are encountered. (B) The flaps are advanced in a V-Y fashion. The GM muscles are left intact.
A
B

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
axis. The dissection is identical to the SGAP for sacral pres­
sure sores, but the flap is now rotated counter clockwise. By
maximally splitting the gluteus maximus muscle, an impor­
tant cranial displacement can be obtained, providing cover­
age up to L1–T12.
Free Flap
Breast Reconstruction.  The free gluteus flap is a valuable
second choice for autologous breast reconstruction after
the abdominal free flap. It is indicated in patients with an
asthenic body habitus or with excessive abdominal scarring
(Fig. 44.18). An increasing number of patients present for
breast reconstruction or autologous breast augmentation
following liposuction of the abdomen or abdominoplasty.
ATYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Ischial and Trochanteric Defects
The GM muscle flap is used very rarely for ischial or tro­
chanteric ulcers, such as in the case of absent perforators
due to previous local fasciocutaneous flap and other failed
locoregional flaps.
Only an IGAP flap can cover ischial and trochanteric
defects without sacrificing the GM muscle or placing the
incision line over the pressure points. The IGAP flap is a
useful tool for ischial bed sores but we still believe that flaps
from the posterior surface of the thigh are less difficult to
dissect. However, the IGAP flap should be considered in
tetraplegic patients who suffer from severe contractures.
The use of gluteal tissue avoids tension in the thigh–buttock
junction, which can be seen with the use of the posterior
thigh perforator flap or gluteal thigh flaps.
POSTOPERATIVE CARE
GENERAL
Free flap patients spend the first night in the recovery unit
and are then transferred to the wards. Regular clinical moni­
toring of the flap is done by trained nursing staff. Patients
receive standard intravenous (IV) fluids. We use Nootropil
(piracetam) 12 g/24 h IV for 5 days and as a solution 20%
orally 25 cc q.i.d. for another 5 days. This drug has been
shown to increase the viability of the distal portion of skin
flaps due to an increase in the capillary blood flow.
Pain is related to the amount of sacrificed muscle in
ambulating patients. Hospital stay varies from 5 to 7 days
(socialized medical system). In perforator flaps the pain is
minimal and breast reconstruction patients are usually self-
mobilizing within 24 h.
The dressing is changed daily at the donor site. The drain
is removed when it gives less than 30 cc/24 h. After harvest­
ing a free gluteal flap, a garment dressing can be used for
4 weeks at the donor site, which helps to decrease seroma
incidence. After harvesting a pedicled gluteal flap for pelvic
reconstruction, the patient is nursed in a special bed with a
fluidized mattress for 3 weeks during a rehabilitation
program, in order to reduce pressure on the flap. At 3 weeks
postoperatively, the patients follow a restricted protocol,
starting to sit up for 15 min three times per day and increas­
ing the length and frequency gradually.
fascia should be left on the GM muscle in order to avoid
seroma formation.
FLAP USAGE
PERFORATOR FLAP
When gluteal perforator flaps are raised as either free or
pedicled flaps, the skin paddle is designed mostly in fusiform
shape. It can be completely raised as an island around the
most lateral perforator to create the longest pedicle possible.
With pedicled perforator flaps, the upper border of the flap
is designed as the edge of an imaginary rotation flap, into
which the flap could be converted if no suitable perforator
is encountered during the dissection. The main movement
of the flap is transposition. Rotation of the flap up to 90°
applies minimal torsion to the vascular pedicle, which is of
no concern. However, more rotation can be done when the
perforator is dissected long enough within the muscle.
PEDICLED GLUTEUS MAXIMUS FLAPS
Harvesting a unilateral gluteus maximus flap based on the
superior gluteal artery provides adequate tissue for coverage
of sacral defects up to 6 cm. The flap is usually transferred
as a rotation flap with a 25–40° arc of rotation. The pivot
point is in the medial third of the base. There is no need
for delay. In GM musculocutaneous pedicled flaps, section­
ing of the lateral insertion of the GM on the greater tro­
chanter, partially or totally, provides a larger arc of rotation.
Bilateral flaps are required for larger sacral defects up to
10–12 cm. The flaps are then advanced in V-Y fashion.
The superior gluteus maximus flap can also be used less
frequently for trochanteric defects as a salvage solution if
the tensor fascia lata flap is not available. Finally, it can be
used to cover ischial defects but based on the inferior gluteal
vessels.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Pedicled Flap
Sacral Defects.  A gluteus pedicled flap, both perforator
based or muscle based, is an excellent tool to cover large
sacral and gluteal defects (Fig. 44.15). The SGAP is particu­
larly suited to reconstruct large sacral midline defects in one
stage, especially in the non-plegic patient (Fig. 44.16).
Dorsal Lower Trunk Defects.  Wounds in the lower dorsal
trunk and/or lumbar area can be secondary to acute trauma,
of congenital origin (i.e., myelomeningocele) or a conse­
quence of chronic internal (exposed osteosynthesis mate­
rial) or external pressure (pressure sores). Deep defects
with exposure of vital structures over and around the lumbar
spine have always been troublesome to cover. Most fre­
quently, local fasciocutaneous flaps, paraspinal muscle flaps,
or the pedicled turn-over latissimus dorsi muscle flap
together with a gluteal flap have been used to deal with this
problem. Nowadays, the extended SGAP provides a more
reliable solution (Fig. 44.17). The conventional design of
the skin island as described above can be extended more
laterally or laterodistally to increase the length of the flap